RU2441673C1 - Means of drainage of pleural cavity during acute empyema - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to the area of medicine, namely to thoracic surgery, and may be applied for drainage of pleural cavity, for example, during acute empyema. The way includes the insertion of tube drainage into pleural cavity. This includes formation of cutaneous-subcutaneous-muscular channel in thoracic soft tissues from skin to intercostals muscles. Inside it the additional drainage is installed near the tube drainage.

EFFECT: improvement of treatment results for patients with acute empyema by the way of prevention of thoracic wall phlegmon formation during drainage.

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Description

The invention relates to medicine, namely to surgery, and can be used to prevent the formation of phlegmon of the chest wall when performing drainage of the pleural cavity in patients with acute pleural empyema.

To date, there is a known method for drainage of the pleural cavity in patients with acute pleural empyema, namely, in the intercostal space in the soft tissues of the chest wall, from the skin to the parietal pleura, usually using a special tool - a trocar, a channel is formed through which into the pleural a special tube is introduced into the cavity (tubular drainage), through which pus is removed from the pleural cavity into an aspiration vessel under the fluid layer (T.E. Ostroverkhov, Yu.M. Bomash, D.N. Lubotsky “Surgery and topographic an Atom. ”- Moscow:“ Medicine ”, 1972 - p. 434-444). The disadvantage of this method is the fact that a small part of the purulent exudate moves in a narrow space between the walls of the canal formed in the soft tissues of the chest wall and tubular drainage. Since the gap in which the pus moves is narrow, the pus often penetrates into the soft tissues and cellular spaces of the chest wall and can cause inflammation with the development of such a serious complication as phlegmon of the chest wall.

Technical result: improved treatment results for patients with acute pleural empyema by preventing the formation of phlegmon of the chest wall when performing drainage of the pleural cavity.

This problem is solved by forming along the tubular drainage with the help of dissection (blunt tissue separation) the cutaneous-subcutaneous muscle channel from the skin to the intercostal muscles and installing additional drainage made, for example, of glove rubber, near the tubular drainage. Through the formed channel and drainage from glove rubber, pus flows freely into the dressings, not lingering in the soft tissues of the chest wall.

The method is as follows. After performing standard drainage of the pleural cavity and introducing tubular drainage into the pleural cavity, the surgeon, using a dissector or Billroth clamp, performs dissection (blunt separation) of the soft tissues along the tubular drainage so that a cutaneous-subcutaneous muscle channel is formed from the skin to the intercostal muscles with a diameter of exceeding the diameter of the tubular drainage by 0.5-1.0 cm. The intercostal muscles do not undergo dissection, which ensures the integrity of the pleural cavity. After that, additional drainage from glove rubber is introduced into the formed channel along the tubular drainage and a bandage is applied. In the postoperative period, pus that enters the soft tissues of the chest wall along the tubular drainage flows out of the glove rubber along the formed channel into the dressings, without lingering in the soft tissues of the chest wall and without getting into the cellular spaces of the chest wall. Standard tools are used, for example, tubular drainages made of rubber or silicone with a diameter of 10-12 mm, trocars of the corresponding diameter, standard Billroth clamps or dissectors, glove rubber drains are usually made from sterile medical latex gloves.

Examples of specific performance.

Example 1

Patient J., 54 years old, medical history No. 1286, 2009. Diagnosis at admission: Acute parapneumonic total empyema of the pleura on the left with bronchial fistula.

Hospitalization on an emergency basis. Complaints of weakness, cough with purulent sputum, pain in the lower chest on the left. The condition is serious. The patient is lethargic, dynamic. Body temperature 38.8 degrees. The skin is pale. Shortness of breath 24 respiratory movements per minute. Pulse 102 beats / min, rhythmic. HELL 130/70 mm Hg Heart sounds are clear. The abdomen is involved in the act of breathing, not painful. On the chest radiograph there is a total blackout of the left pleural cavity with a horizontal upper level of fluid and enlightenment above the level. After a short preoperative preparation, the patient underwent emergency drainage of the right pleural cavity. In the lower part of the cavity, in the 8 intercostal space, a tubular drainage is installed along the posterior axillary line. A cutaneous-subcutaneous muscular canal from the skin to the intercostal muscles was formed along the tubular drainage using dissection. A glove rubber drainage was installed along the channel next to the tubular drainage from the skin to the intercostal muscles. Passive suction. In the postoperative period, a large amount of pus and air was separated into the vessel for aspiration by drainage. The blindfold also soaked pus profusely. At the same time, there were no signs of suppuration in the soft tissues of the chest wall - edema, hyperemia, fluctuation. Against the background of intensive treatment, the condition progressively improved, intoxication manifestations decreased. On the 8th day from receipt on fluoroscopy, the lung was straightened. In the future, the condition of the patient with a persistent tendency to recovery. Drainages are removed on the 23rd day, after the complete cessation of purulent exudation. After removing the drainage, the wound healed by secondary intention without any signs of purulent inflammation. On the 27th day with clinical recovery, the patient was discharged for outpatient aftercare with a pulmonologist at the place of residence.

Example 2

Patient U. 53 years old, medical history No. 133, 2010. Diagnosis at admission: Acute metapneumonic subtotal empyema of the pleura on the right with bronchial fistula.

Hospitalization on an emergency basis. Complaints of pain in the chest on the right, shortness of breath, weakness, cough with purulent sputum. The condition is serious. The temperature is 39.5 degrees. The skin is pale. Respiration is increased to 28 respiratory movements per minute. The pulse is 112 bpm, rhythmic. HELL 110/70 mm Hg Heart sounds are clear. The abdomen is involved in the act of breathing, soft, not painful. On radiographs, subtotal dimming of the right hemithorax with a horizontal upper border and enlightenment above it.

Upon admission to the patient, emergency drainage of the right pleural cavity was performed. In the 8 intercostal space on the left, a tubular drainage is installed along the rear axillary line. A cutaneous-subcutaneous muscular canal was formed along the tubular drainage from the skin to the intercostal muscles. A glove rubber drainage was introduced along the channel next to the tubular drainage from the skin to the intercostal muscles. Passive suction.

In the postoperative period of 3 days, the abundant separation of pus and air was guarded for drainage, as well as the abundant separation of pus in dressings outside the tubular drainage for glove rubber drainage. At the same time, there was no signs of suppuration in the soft tissues of the chest wall (skin hyperemia, swelling, crepitus, and fluctuation in the subcutaneous tissue) on the dressings of the skin around the drains — the usual physiological coloration. Against the background of intensive therapy, the condition stabilized. On the 4th day with fluoroscopy, the lung is straightened, there is no fluid in the pleural cavity. In the future, the patient's condition with stable positive dynamics. The purulent discharge in the drainage ceased, on the 20th day the drainage was removed. After removing the drainage, the wound covered itself with a scab and healed under the scab without suppuration. On the 26th day, the patient was discharged for outpatient aftercare with a pulmonologist at the place of residence with recovery.

Example 3

Patient Z., 44 years old, medical history No. 1134, 2004. Diagnosis at admission: Acute parapneumonic subtotal empyema of the pleura on the left with bronchial fistula.

Emergency hospitalization by the ambulance team. Complaints of weakness, pain in the chest on the right, cough with the separation of a large amount of purulent sputum. The condition is serious, the patient is lethargic, inhibited. The skin is pale. The temperature is 38.5 degrees. Respiratory rate 22 per minute. Pulse 96 beats / min, rhythmic. HELL 130/80 mm Hg Heart sounds are clear. The abdomen is soft, not painful. On the roentgenogram, subtotal dimming of the left hemithorax with a horizontal upper border and enlightenment is higher than the level.

On admission, the pleural cavity on the right is drained by a tubular drainage installed in the 8th intercostal space along the rear axillary line on the left. The proposed method of drainage for that period has not yet been developed, therefore, after installing the tubular drainage, an aseptic dressing was applied, passive aspiration from the pleural cavity was started. In the postoperative period of 2 days, an abundant separation of pus and air was protected by drainage, while the dressings around the tubular drainage remained dry, the pus did not separate in them. Moreover, by the middle of the first day of treatment, hyperemia of the skin had formed around the drainage, with palpation in the soft tissues of the chest wall around the drainage fluctuation and crepitus were determined. With each coughing movement of the patient, the skin around the drainage floated under the pressure of pus and air, which entered the soft tissue of the chest wall along the tubular drainage. The patient was diagnosed with phlegmon of the chest wall. Under general anesthesia, the phlegmon was opened with two cuts located below the drainage, each 8 cm long. When opening the phlegmon from the soft tissues of the chest wall, up to 400 ml of pus was released. Soft tissues are drained by glove rubber drains. In the postoperative period, bandaging and washing of the empyema and phlegmon cavities with antiseptic solutions were performed. Against the background of intensive therapy, the condition stabilized. On the 2nd day with fluoroscopy, the lung is straightened, there is no fluid in the pleural cavity. The drainage of the pleural cavity was removed after the cessation of the separation of pus through the drainage from the pleural cavity on the 23rd day. However, for a long time, pus separation by glove drains from the cavity of the phlegmon of the chest wall was preserved, the temperature and intoxication phenomena persisted. It was possible to achieve recovery and discharge the patient for outpatient aftercare only for 52 days. When discharge is recommended aftercare by the surgeon at the place of residence, dressings.

Observational data indicate that a method for drainage of the pleural cavity with the formation of a cutaneous-subcutaneous muscle channel along the skin to the intercostal muscles along with tubular drainage from glove rubber along with a tubular drainage of glove rubber has been proposed to ensure continuous and timely evacuation of purulent exudate from pleural empyema cavity into the soft tissue of the chest wall, which, in turn, eliminates the formation of phlegmon of soft tissue of the chest wall. The proposed method for draining the cavity of acute pleural empyema is the most effective and safe way to prevent phlegmon of soft tissues of the chest wall in patients with acute pleural empyema.

Claims (1)

A method of draining the pleural cavity in acute pleural empyema by introducing a tubular drainage into the pleural cavity, characterized in that a cutaneous-subcutaneous muscle channel is formed along the skin to the intercostal muscles along the chest wall in soft tissues, inside which an additional drainage is installed next to the tubular drainage.