RU2328292C1 - Method of maxillofacial phlegmons treatment - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: operative intervention follows intravenous single dosing of 0.03% sodium hypochlorhyd solution in amount 1:40 to amount of circulating blood. During operation cavity is sanitised with 0.06 % sodium hypochlorhyd solution. Operative intervention is followed with daily intravenous introduction of 0.03% sodium hypochlorhyd solution within two days once a day in the same amount and continued sanitation of cavity with 0.06 % sodium hypochlorhyd solution. Within the second phase of wound process wound is applied with ointment Soderm once a day before secondary suturing. The third phase includes removal of sutures and gel Contractubex infriction in a cicatricial tissue.

EFFECT: increased efficiency of treatment and prevention of inflammatory process progressing owing to antioxidant and detoxicative properties in various phases of wound process.

1 ex

Description

The invention relates to medicine, namely to surgical dentistry and maxillofacial surgery, and can be used in the treatment of phlegmon.

In recent years, despite the advent of modern diagnostic and treatment equipment and pharmacological preparations, there has been a steady increase in the number of progressive phlegmons of the maxillofacial region (FMP), spreading to several cellular spaces, often complicated by such formidable conditions as contact mediastinitis, cavernous sinus thrombosis meninges, sepsis, as well as atypical and low-symptom phlegmon (Bazhanov N.N. et al., 2006; Kozlov V.A., 2006). Purulent-inflammatory processes are accompanied by significant intoxication, which leads to disruption of homeostasis, disruption of the vital organs and systems of the patient (Zabelin A.S., Rainauli A.V., 2003; Durnovo E.A., 2005). In this regard, the problem of treating patients with phlegmons of HMF causes increased interest of clinicians and researchers in the active search for new technologies for the treatment of this nosology and their introduction into practice (Ladyaev S.V., 2004; Agapov B.C. et al. 2005).

There is a method of treating phlegmon of the maxillofacial region (Platonova V.V., 1999), including opening a purulent foci and draining, conducting antibacterial, detoxification therapy, while in complex treatment, the wounds are washed daily with sodium hypochlorite solution in the 1st phase of inflammation, their treatment low-intensity laser radiation from 1 postoperative day until discharge from the hospital with the simultaneous intramuscular administration of the immunomodulator dalargin for 5 days.

The disadvantages of this method.

1. The need for expensive equipment.

2. The technical complexity of selecting the individual optimal parameters of helium-neon and infrared laser radiation, taking into account the biological response of the vessels of the microvasculature both in the focus of inflammation and in the body as a whole.

3. The need for training personnel to perform laser treatment of wounds.

4. The absence of the general effect of sodium hypochlorite on the state of endogenous intoxication, which is expressed with phlegmons of the nose.

Despite these shortcomings, the discussed method is currently the main one and is recommended for wide clinical use.

The closest analogue adopted for the prototype is a method of treating phlegmon of the maxillofacial region, which sees the inclusion in the scheme of traditional treatment of phlegmon of the maxillofacial region of indirect electrochemical oxidation of the patient’s blood with a 0.03% sodium hypochlorite solution by intravenous injection into a peripheral or central vein at a speed 40-50 drops per minute. The appointment of an average of 2-3 infusions of a 0.03% sodium hypochlorite solution in a dose of 200-400 ml is recommended (Shargorodsky A.G., Zabelin A.S., Fedorova A.G. Baranovsky V.A., 1998).

The disadvantages of the prototype.

1. Lack of data on the nature of the effect of the recommended doses of sodium hypochlorite and their multiplicity on the functional balance of the pro / antioxidant system. At the same time, the fact of the prooxidant action of sodium hypochlorite is not taken into account.

2. The recommended doses of sodium hypochlorite and the frequency of their administration are not scientifically substantiated, which would maintain the main detoxifying effect of the drug with minimized antioxidant load.

3. The effectiveness of treatment with sodium hypochlorite is recommended to be evaluated on the basis of only indicators of endogenous intoxication (leukocyte, hematogenetic, pulse-leukocyte-temperature index of intoxication, the level of medium molecular peptides, etc.), as well as the dynamics of local symptoms of the disease. The authors did not analyze the state of the antioxidant system of blood under the influence of sodium hypochlorite, which plays a key role in the outcome of the purulent-inflammatory process of any localization.

The objectives of the invention are to increase the effectiveness of treatment of phlegmon of the maxillofacial region, reducing the length of hospital stay of patients, reducing the frequency of complications and obtaining good local cosmetic and functional results.

The essence of the invention is the inclusion in the complex of traditional treatment as a detoxifying agent, intravenous (iv) drip of 0.03% sodium hypochlorite solution at a dose of 1:40 to the volume of circulating blood (BCC), which is administered once before surgery, then 1 time per day for 2 days of the postoperative period, after opening the purulent lesion during the first phase of the wound process, the purulent wound is treated with 0.06% sodium hypochlorite solution, in the second phase of the wound process, an antioxidant-based ointment is used deleterious enzyme superoxide dismutase "Soderm" until the time of early imposition of secondary sutures, and in the third phase - gel Kontraktubeks.

The technical result of the invention is to increase the treatment effect due to the combined overall effect of sodium detoxifier hypochlorite in a dose that minimizes its prooxidant load and preserves the detoxification properties of the drug and its local use in the first phase of the wound process, in the second phase - Soderm ointment, and in the third phase - Kontraktubeks gel, at the same time provide an urgent general protective detoxification and local antioxidant effect. This allows you to achieve an early positive effect and thus prevent the progression of the inflammatory process in other cellular spaces, predict the dynamics of endogenous intoxication and reduce treatment time.

The method is as follows. After the final diagnosis is established - phlegmon of the FOA, a 0.03% solution of sodium hypochlorite in a volume of 1:40 bcc at a rate of 30-40 drops / min is injected intravenously once before the operation. During surgical treatment, phlegmon conduct a radical opening of the purulent focus, revision of the concerned cellular spaces, their rehabilitation with 0.06% sodium hypochlorite solution and drainage. In the wound, gauze napkins are left, abundantly saturated with a 0.06% sodium hypochlorite solution. The operation is completed by removing, according to indications, a “causal” tooth. In the postoperative period, a 0.03% sodium hypochlorite solution is still administered intravenously in the same amount for another 2 days, and at the same time locally in the first phase of the wound healing process, the wound is treated daily with a 0.06% sodium hypochlorite solution, and in the second During the phase, gauze wraps with Soderm ointment, the main active ingredient of which is human superoxide dismutase, are applied to the wound once a day, before the application of early secondary sutures. After removal of the sutures, Kontraktubeks gel is rubbed into the scar tissue 2-3 times a day for 4 weeks.

The use of the recommended dose of a 0.03% sodium hypochlorite solution minimizes the prooxidant load of the drug: excessive activation of lipid peroxidation and the associated risk of damage to cell membranes; the ability of the hypochlorite anion when interacting with catalase to inhibit it by oxidation and thereby activate peroxidase activity; its ability to oxidize sulfur-containing and aromatic amino acid residues.

The recommended dose of a 0.03% sodium hypochlorite solution and the frequency of its administration preserve its positive multidirectional effects: reduction of endogenous intoxication by inactivation of medium and large toxic molecular compounds actively excreted by excretory organs; moderate, and not excessive, lipid oxidation in lipoproteins, leading to a change in the permeability of cell membranes, which is crucial in reducing the resistance of microflora to antibiotics.

Thus, the salient features of the claimed method are as follows.

1. The use of a 0.03% sodium hypochlorite solution at a rate of 1:40 of bcc as a detoxifying drug in / in.

2. Complex use of iv administration of a 0.03% sodium hypochlorite solution at a rate of 1:40 bcc for the general correction of homeostasis and local sequential, taking into account the phases of the wound healing process, the use of a 0.06% sodium hypochlorite solution, Soderm ointment and Gel Contractubex.

The creation of a general and local urgent protective barrier to an increase in endogenous intoxication and free radical oxidation helps to prevent the progression of the inflammatory process into other cellular spaces of the MND and the occurrence of postoperative complications of a purulent-septic nature, shorten the treatment time, and obtain a good local cosmetic and functional result.

The theoretical background of the claimed method is the literature on the nature and mechanisms of action of a 0.03% sodium hypochlorite solution when administered intravenously at a rate of 1:40 to the volume of the patient’s circulating blood, Soderm ointment and Contractubex gel.

Sodium hypochlorite is not a foreign substance for the human body and is formed in insignificant amounts under natural conditions when a phagocyte comes into contact with a xenobiotic; hypochlorite, hypobromide and hypoiodide are released on the contact area of the first, which destroy the protective structure of the xenobiotic, providing phagocytosis. Based on the mechanism of bactericidal action, the scope of sodium hypochlorite is wide enough: treatment of endo- and exotoxicoses of various etiologies, increased microflora resistance to antibiotics, hypercoagulation syndrome, hyperglycemia, etc. It has a multidirectional effect, effectively inactivating high concentrations of bilirubin, urea in the blood, almost the entire complex of "medium molecules", has a direct and indirect anti-aggregation effect on platelets, immunomodulating and bactericidal action (Pe Trosyan E.A., Belyakov N.A., Petrosyan N.E., 2004; Fedorovsky N.M., 2004).

Soderm ointment contains the antioxidant enzyme superoxide dismutase and nanocluster silver as an antibacterial component of a wide spectrum of action. Superoxide dismutase neutralizes excess oxygen free radicals, which are the main factor causing tissue damage in various inflammatory pathologies. Ointment stimulates reparative processes in the wound at the epithelialization stage and is used in the treatment of thermal burns, reducing the toxic effect caused by their action (Paramonov B.A., Galenko-Yaroshevsky V.P., Turkovsky I.I. et al., 2005).

Gel Kontraktubeks has fibrinolytic, anti-inflammatory (due to the presence of onion extract), antithrombotic (due to the presence of heparin), and keratolytic effect (due to the presence of allantoin). Stimulates cell regeneration without hyperplasia (Russian Medicines Register, 2004. - p.450).

To evaluate the effectiveness of this method of treatment, preliminary studies were conducted in 5 patients with phlegmons of two or three fiber spaces of HMO to study the effect of various doses of iv administration of a 0.03% sodium hypochlorite solution (1:10, 1:20, 1:40 BCC ) on pro- and antioxidant activity of blood and endogenous intoxication. As a result of the studies, it was found that the iv administration of a 0.03% sodium hypochlorite solution at a rate of 1:40 of BCC has a minimized prooxidant effect while maintaining the main detoxification effect and is optimal.

The complex use of iv administration of a 0.03% sodium hypochlorite solution at a rate of 1:40 of BCC, in accordance with the described method of treatment, in 10 patients with phlegmons of two to three cellular spaces, the HFV minimized the prooxidant load of the drug, reduced endogenous intoxication, and corrected the imbalance systems of pro / antioxidants and thus create a common and local urgent protective barrier to an increase in free radical oxidation and endogenous intoxication, which prevented the progression of acute pus but the inflammatory process in other cellular spaces Chloe, the occurrence of complications of purulent-septic and hemostasiological nature, reduce the time of treatment of patients by 2 days in comparison with the prototype, get a good local functional and cosmetic results.

Example. Patient M., 21 years old (medical history No. 1989), was admitted to the maxillofacial hospital of the Clinical Dental Clinic - Krasnodar Regional Dental Center (KSP-KKSC) at 12-00 on 20.10.2006 with a diagnosis of odontogenic phlegmon of the submaxillary region, pterygoid -maxillary, periopharyngeal spaces on the right.

Complaints of the patient: pain and swelling in the submandibular region on the right, limited and painful opening of the mouth, pain when swallowing on the right, increased body temperature, chills, general weakness, lack of appetite, sleep disturbance, reduced ability to work. From the anamnesis it was established that a week ago there were pains of a constant nature, aggravated by biting in the region of the second molar of the lower jaw on the right, 3 days ago there was a swelling in the submandibular region on the right, limitation of opening the mouth and pain when swallowing on the right, general weakness, body temperature increased, these symptoms progressively progressed. He first applied for medical help on October 20, 2006 to the outpatient surgical department, where he was examined by a dentist surgeon and sent for hospitalization in the maxillofacial hospital. Complaints about other organs and systems does not show, considers himself a practically healthy person. Not subjected to surgical interventions, sexually transmitted diseases, tuberculosis, AIDS, hepatitis denies.

Objectively. The condition of the patient of moderate severity, body temperature 38.9 ° C, pulse 97 beats / min, blood pressure 120/65 mm Hg An examination of organs and systems revealed no pathology. There were no signs of dehydration and a decrease in the volume of circulating blood.

Local status. The face is asymmetric due to swelling in the submandibular region and in the region of the angle of the lower jaw on the right. The skin over the swelling in the submandibular region is hyperemic, it is difficult to fold. On palpation, a dense, sharply painful infiltrate is determined in the submandibular region on the right and at the angle of the lower jaw on the right. The opening of the mouth is sharply limited (up to 1.5 cm between the central incisors of the upper and lower jaws). The pterygo-maxillary fold on the right is swollen, hyperemic, infiltrated, and painful on palpation. Palatine arches and the side wall of the pharynx on the right are swollen, hyperemic, displaced to the midline of the pharynx, and palpation is sharply painful. The tongue is hyperemic and swollen, shifted to the left. The second lower molar on the right is changed in color, has a deep carious cavity, its vertical percussion is painful, the tooth has II degree mobility. The mucous membrane along the transitional fold in the region of the second and third molars of the lower jaw is hyperemic on the right, swollen, slightly painful on palpation.

Clinical and laboratory data: erythrocytes - 4.92 × 10 ¹² / l; hemoglobin - 160 g / l; color indicator - 0.98; leukocytes - 13.5 × 10 ⁹ / l: eosinophilic granulocytes - 1%, neutrophilic granulocytes: stab - 11%, segmented - 75%, lymphocytes - 10%, monocytes - 3%; ESR - 45 mm / hour. Pro- / antioxidant system: growth of TBA-reactive products by 80%, the content of erythrocyte SH-groups is reduced by 21%; blood catalase activity decreased by 29%, SOD activity increased by 42%. Endogenous intoxication index increased by 75%.

After clinical and laboratory examination, the diagnosis was confirmed, the patient was assigned a treatment plan:

- autopsy phlegmon under general anesthesia,

- Conducting traditional therapy with the on / in the introduction of a 0.03% sodium hypochlorite solution in a volume of 1:40 bcc.

Before surgery, an intravenous drip of 100 ml of a 0.03% sodium hypochlorite solution (1:40 bcc) was performed.

After carrying out a preoperative anesthesiological aid for a patient under mask anesthesia with external access from an incision in the submandibular region, interested cellular spaces were opened, and purulent discharge was obtained. A necrectomy and antiseptic treatment of a purulent wound with a 0.06% sodium hypochlorite solution was performed. Hard drainages and napkins moistened with 0.06% sodium hypochlorite solution were left in the wound. The wound is closed with an antiseptic dressing. The second lower molar on the right was removed.

After the phlegmon was opened, the patient was in the intensive care unit, where he received the necessary traditional therapy in combination with intravenous infusions of a 0.03% sodium hypochlorite solution once within 2 days after the operation in a volume of 100 ml (1:40 BCC).

On the next day after surgery, the general condition of the patient is satisfactory. He independently moves around the department, takes liquid food. No new complaints, notes a decrease in pain when swallowing. Evening body temperature is 37.6 ° C, and morning temperature is 37.1 ° C. Hemodynamics is stable. Pulse 85 beats / min. HELL 112/76 mm Hg Vesicular breathing, without extraneous noise. The abdomen is soft, painless on palpation. The boundaries of the liver are normal. Sleep and physiological functions are normal.

Local status. The skin around the wound is slightly hyperemic and tense. Opening of the mouth improved slightly, swelling and hyperemia of the lateral wall of the pharynx and pterygo-maxillary folds decreased. From the wound - serous-purulent, hemorrhagic discharge in moderation. Drainages are functioning. Antiseptic treatment of the wound with a 0.06% sodium hypochlorite solution was carried out, napkins moistened with a 0.06% sodium hypochlorite solution were left in the wound, an aseptic dressing was applied. Appointments are being fulfilled. Clinical and laboratory data: red blood cells - 4.75 × 10 ¹² / l; hemoglobin - 155 g / l; color indicator - 0.96; leukocytes - 9.8 × 10 ⁹ / l: eosinophilic granulocytes - 1%, neutrophilic granulocytes: stab - 7%, segmented - 68%, lymphocytes - 18%, monocytes - 6%; ESR - 22 mm / hour. Pro / antioxidant system: the number of TBA-reactive products decreased by 15%, the content of SH-groups of red blood cells decreased by 25%; catalase activity increased by 10%; SOD activity decreased by 12%. The endogenous intoxication index decreased by 25%.

In the next day, a positive dynamics was noted in the patient's condition. On the 5th day, the exudative phenomena in the wound are presented by serous-hemorrhagic discharge, the wound cleansed of necrotic tissue and granulation islands appeared on its surface. Hard drains were removed from the wound, wipes with Soderm ointment under an antiseptic dressing were applied to the wound surface. Positive dynamics of the state of the pro / antioxidant system of the body was noted, manifested in a decrease in TBA-reactive products by 45-50%, an increase in the content of SH-groups by 15%, a marked increase in the activity of catalase and a decrease in the activity of SOD. The endogenous intoxication index decreased by 55%.

On the 8th day of inpatient treatment, the patient notes a significant improvement in health. Active Vesicular breathing. Hemodynamics is stable. Evening body temperature is 36.8 ° C, and morning temperature is 36.4 ° C. Pulse 72 beats / min. HELL 110/70 mm Hg The abdomen is soft, painless on palpation. The appetite is good. Sleep and physiological functions are normal.

Local status. The opening of the mouth is free, in full. The skin around the surgical wound of normal color, painless on palpation. Fresh juicy granulations are determined in the wound, and edge epithelization along the wound edge. After antiseptic treatment under local infiltration anesthesia (Sol. Lidocaini, 2% - 5 ml), layer-by-layer suturing of a granulating wound was performed (early secondary sutures were applied). An antiseptic dressing is applied.

Clinical and laboratory data: red blood cells - 4.3 × 10 ¹² / l; hemoglobin - 150 g / l; color indicator - 0.97; leukocytes - 6.4 × 10 ⁹ / l: eosinophilic granulocytes - 1%, neutrophilic granulocytes: stab - 3%, segmented - 61%, lymphocytes - 27%, monocytes - 8%; ESR - 12 mm / hour. Pro / antioxidant system: the number of TBA-reactive products decreased by 62%; the content of SH-groups of red blood cells increased by 12%; the erythrocyte catalase activity level increased by 11%, and the SOD activity did not significantly change.

In the next day, the general condition of the patient is satisfactory. No complaints. The condition of the postoperative wound had a positive trend. Secondary seams are wealthy. The wound healed by primary intention and was carried out under an antiseptic dressing.

On the 14th day, the sutures were removed, the edges of the wound were epithelized. The patient was prescribed to independently apply the "Contractubex" gel to the scar area for 4 weeks 2-3 times a day.

Clinical and laboratory data: red blood cells - 4.48 × 10 ¹⁹ / l; hemoglobin - 145 g / l; color indicator - 0.96; leukocytes - 6.2 × 10 ⁹ / l: eosinophilic granulocytes - 1%, neutrophilic granulocytes: stab - 2%, segmented - 58%, lymphocytes 32%, monocytes - 7%; ESR - 10 mm / hour. Normalization of all indicators of the pro / antioxidant system was noted, with the exception of slight excesses of blood peroxidase activity. The endogenous intoxication index exceeded the norm by 12%.

October 4, 2006 the patient in satisfactory condition with full recovery was discharged from the hospital. At the control examination after 1 month in the area of the operation there is a soft movable linear scar that does not differ in color from the surrounding skin.

Thus, the inclusion in the regimen of traditional phlegmon of the maxillofacial region of single infusions of a 0.03% sodium hypochlorite solution in a volume of 1:40 BCC before surgery and within 2 days of the postoperative period with the aim of stopping endogenous intoxication syndrome, as well as the use of for local treatment of a purulent wound in the first phase of the wound healing process of a surgical wound with a 0.06% sodium hypochlorite solution, in the second phase before applying the early secondary sutures - Soderm ointment, and in the third phase - Kontraktubeks gel allows App end reduce the time of treatment of patients by an average of 2 days, which reflects not only the high medical and social efficiency of the method, but also it has an economic effect.

So, for example, the cost of 1 bed-day for an inpatient only from the compulsory medical insurance funds is 930 rubles (the approved tariff for medical care provided in the compulsory medical insurance system according to KSP-KKSC, 2006) Therefore, within 2 days of treatment costs are 1860 rubles. The cost of 400 ml of 0.9% sodium chloride solution is 22.50 rubles. On average, for one patient with phlegmon of the maxillofacial region according to the method developed by us, 6 bottles are required, that is, 6 × 22.50 rubles. = 135 rubles. The cost of ointment "Soderm" (10 g) is 75 rubles.

Thus, one patient has a cost savings of 1,600 rubles. In the maxillofacial hospital KSP-KKSTS, where the work was carried out, at least 1000 patients with this pathology are treated annually, which in general can save budget funds of about 1.6 million rubles. The method allows to increase the effectiveness of treatment of phlegmon of the maxillofacial region and is recommended for widespread use in practical health care.

Literature

1. Agapov B.C., Orazvaliev A.I., Pimenova I.A. Local treatment of odontogenic phlegmon. // Materials of the VII All-Union. scientific forum. "Dentistry 2005". - M., 2005 .-- P.15-16.

2. Bazhanov N.N., Aleksandrov M.T., Cherkesov I.V. Comparison of the most widely used antiseptics and multicomponent ointments for the treatment of patients with odontogenic phlegmon of the maxillofacial region. // Materials of the International Conference. people surgeons and dentists. - St. Petersburg., 2006. - P.16-18.

3. Durnovo E.A. A comparative analysis of the functional activity of blood neutrophils and the oral cavity of patients with a purulent-inflammatory process in the oral cavity. // Dentistry. - 2005. - No. 3. - S. 29-33.

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Claims (1)

A method of treating phlegmon of the maxillofacial region, including opening a purulent foci, intravenous administration of a 0.03% sodium hypochlorite solution, characterized in that sodium hypochlorite is administered once intravenously before the operation, during the operation and after it, the cavity is sanitized 0.06% -sodium hypochlorite solution, then after the operation, the same solution is also administered intravenously daily once a day for 2 days, in the second phase of the wound healing process, the Soderm ointment is applied once a day to the secondary suturing, and in the third phase, after removing the sutures, the Contractubex gel is rubbed into the scar tissue, and the sodium hypochlorite solution is injected at a rate of 1:40 to the volume of the patient’s circulating blood.