RU2454187C1 - Method of early dialysis of purulent wounds in case of type 2 diabetes mellitus - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to purulent surgery, and can be used for treatment of purulent diseases of soft tissues at the background of type 2 diabetes mellitus. For this purpose surgical processing of purulent focus with further application of membrane bandage is performed. Bandage consists of external polypropylene layer, adjoining wound surface and two layers of cellulose and polyakrylate. 15 minutes before application on wound surface bandage is soaked with mixture of acerbin and sodium chloride 0.9% solutions with ratio 1:4. Replacement of bandage is carried out 1 time per day during entire stationary treatment until epithelisation phase starts.

EFFECT: method makes it possible to ensure efficient treatment of purulent wounds at the background of type 2 diabetes mellitus due to facilitation of process of migration and intercellular interaction of macrophages and fibroblasts, stimulating vessel regeneration and formation of granulation tissue.

2 tbl, 1 dwg, 2 ex

Description

The invention relates to medicine, namely to surgery and endocrinology, can be used to treat purulent diseases of soft tissues against type 2 diabetes mellitus.

Known ointment for healing burns and infected wounds (RF patent No. 2174389, A61K 9/06, 38/43, A61P 17/02; 10.10.2001), which consists in local application on the surface of trophic ulcers and long-term non-healing purulent wounds of the composition with the following ratio, wt.%: collagenase 160-200 E; gentamicin sulfate 0.08-0.1; polyethylene oxide-400 66.0-68.0; polyethylene oxide-1500 16.5-17.0; glycerol 10.0-10.1.

Also known is a method of treating trophic ulcers and long-term non-healing purulent wounds (RF patent No. 2160135, A61N 5/06, A61K 38/43; 12/10/2000), which consists in topical application of trophic ulcers and long-term non-healing purulent wounds to the composition in the following ratio, wt.%: pepsin 2.0-4.0; ascorbic acid 4.0-8.0; hydroperite 0.1-0.2; methyluracil 4.0; polyglucin up to 50.0. The disadvantages of these methods are:

1) the antibacterial and necrolytic activity of these compositions is significantly reduced, since the optimum pH level at which pepsin is active is not achieved;

2) with these methods of local treatment, the wound surface is rapidly alkalized with wound and the enzymes are active for a short period of time, since there are no buffer additives that maintain the acid-base balance at a certain level;

3) there are no substances that have a cytoprotective effect on regenerating tissues;

4) with these methods of local treatment of wounds do not reach the optimal level of humidity.

The closest set of essential features to the proposed one is the method of membrane dialysis of purulent-inflammatory diseases (RF patent No. 2228758, A61K 31/722; 05/20/2004), which consists in the fact that after surgical treatment of the purulent lesion, a membrane is installed on the bottom of the wound a capsule with a medicinal composition and a tubular microirrigator for changing spent dialysate. 1/3 of the membrane capsule is filled with a highly osmotic 15% solution of chitosan ascorbate with a molecular weight of 15 ± 5 kDa and a deacetylation degree of at least 96%, with its daily replacement.

However, this method of membrane dialysis of purulent-inflammatory diseases does not allow to create the optimal humidity and pH on the wound surface, necessary for healing in conditions close to natural.

The objective of the proposed method is to increase the effectiveness of the treatment of purulent diseases in type 2 diabetes.

The problem is solved due to the fact that a membrane dressing is used as a membrane product, consisting of an external polypropylene layer adjacent to the wound surface, two layers of cellulose and polyacrylate, which is impregnated with a mixture of solutions of acerbine and sodium chloride 15 minutes before application to the wound surface , 9% in a ratio of 1: 4, a dressing change is performed 1 time per day during the entire inpatient treatment until the onset of the epithelialization phase. The method is as follows: for patients with purulent diseases of the soft tissues in the purulent-necrotic phase against the background of type 2 diabetes mellitus, surgical treatment is performed (opening an abscess, phlegmon, performing secondary surgical treatment, necrectomy). Purulent discharge, necrotic tissue within the visible viable, hypergranulation, pyogenic capsule are removed. The wound is washed with a solution of hydrogen peroxide 3% and antiseptic (plavecept solution 0.02%, chlorhexidine solution 0.05%). A membrane dressing is installed in the postoperative wound, consisting of an external polypropylene layer adjacent to the wound surface, two layers of cellulose and polyacrylate, which are impregnated with a solution of acerbine and sodium chloride 0.9% in a ratio of 1: 4 15 minutes before application to the wound surface. Acerbine solution is a mixture of benzoic, salicylic and malic acids in water-based propylene glycol. This dressing has the properties of a semipermeable membrane, which allows it to be used for transmembrane wound dialysis against type 2 diabetes mellitus. The external polypropylene layer prevents the penetration of microorganisms into the wound, hydrophilic, does not adhere to the wound surface, and maintains a moist environment of the wound. The optimal amount of moisture on the wound surface is provided by the absorption properties of cellulose and polyacrylate. Polyacrylate has a greater affinity for wound exudate, which contains protein, toxins, detritus, microorganisms than solutions of electrolytes and acids. This allows membrane dialysis of purulent wounds, providing continuous, for 24 hours, circulation in the wound of a mixture of solutions of acerbine and sodium chloride 0.9% in a ratio of 1: 4. Under the influence of salicylic and benzoic acids, a necrolytic effect is manifested in cleansing the wound surface from necrotic tissues and fibrin. Malic acid is both an inducer and an obligatory participant in the Krebs cycle, ensuring the efficiency of energy metabolism in damaged tissue, is involved in the removal of carbon dioxide and maintaining water balance, due to which it has a stimulating effect on wound healing processes. This mixture of solutions of acerbine and sodium chloride 0.9% in a 1: 4 ratio, having a pH of 2.8, prevents the alkalization of the wound surface, purposefully changing the acid-base state, creating optimal conditions for the wound process. Subsequently, the dressing was changed once a day, pre-treating the skin edges of wounds with alcohol-containing antiseptics, and the wound surface itself with a 0.9% sodium chloride solution at all stages of the wound process. The duration of treatment was the entire period of inpatient treatment until the onset of the epithelialization phase. An active cleansing process, a moist environment and targeted correction of the pH of the wound process facilitate the migration and intercellular interactions of macrophages and fibroblasts, stimulate vascular regeneration and the formation of granulation tissue.

To study the influence of the proposed method, 48 patients with purulent diseases of the soft tissues treated with type 2 diabetes mellitus were treated. The diagnosis was established on the basis of medical history, the clinical picture of the disease, and laboratory data. All patients after surgical treatment (opening abscesses, phlegmon, performing secondary surgical treatment of wounds, necrectomy) received complex conservative therapy (antibacterial, anti-inflammatory, painkillers, antispasmodics, antiplatelet agents, insulin therapy), but the local treatment of the wound process was different, as a result of which there were divided into two groups. The first control group included 20 patients, the local treatment of which was the use of a tubular membrane made of synthetically modified cellulose filled with a solution of chitosan ascorbate. The second group - the study consisted of 28 patients, the proposed method was applied locally.

The age of patients ranged from 41 to 72 years, including 22 men and 26 women.

Patient groups were comparable by gender, age, disease duration, severity and the presence of concomitant pathology, types of surgical and conservative treatment (Table 1)

Table 1 The distribution of patients in clinical groups by the nature of the disease Nosology Groups 1 (n = 20) 2 (n = 28) Abscesses 2 (4.2%) 3 (6.25%) Carbuncle 2 (4.2%) 2 (4.2%) Phlegmon 8 (16.7%) 8 (16.7%) Erysipelas, necrotic phlegmonous
forms 3 (6.25%) 6 (12.5%) Suppuration of post-traumatic and postoperative wounds 5 (10.4%) 9 (18.75%)

The effectiveness of the methods of treatment was evaluated taking into account the general condition of the patient, body temperature, general and biochemical blood tests (level of red blood cells, hemoglobin, leukocytes, total protein, urea, creatinine, bilirubin), monitoring of carbohydrate metabolism, wound appearance, and purulent cleansing periods - non-necrotic masses, the nature and amount of discharge, the presence of skin hyperemia and infiltration of the wound edges, pH of the wound surface (measured with a Hi 99181 pH meter), time of appearance and nature of granulations. Comparative characteristics of the dynamics of the wound process in patients of groups 1 and 2 are presented in table 2.

table 2 The dynamics of the course of the wound process in patients of groups 1 and 2 Symptoms 1 group
day, (M ± m) 2 group
day, (M ± m) one 2 3 The disappearance of perifocal edema 4.2 ± 0.8 3.1 ± 1.1 Complete cleansing of wounds from purulent-necrotic masses 9.1 ± 1.2 6.4 ± 1.3 * The emergence of single granulations 6.6 ± 1.6 4.2 ± 0.7 * The appearance of epithelization of the edges of the wound 8.1 ± 1.1 6.0 ± 1.2 * Filling wounds with mature granulation tissue 11.6 ± 1.8 8.2 ± 1.9 Signs of the onset of epithelization (day) 27 ± 1.8 16 ± 4 * % of patients who have epithelization 75% (15) 85.7% (24) Index L.N. Popova 4.8 ± 0.23 6.7 ± 0.41 * Note: * - significance of differences compared with indicators of the first group of patients (P <0.05)

From table 2 it can be seen that in the 2nd group of patients, wound cleansing, the appearance and filling of granulations of the wound surface, as well as the appearance of epithelization occur earlier.

In group 1 patients, a shift in the acid-base equilibrium of the wound surface to the alkaline side was revealed, which was maximum in the inflammatory phase, pH 9.2. Upon the transition of the wound process to the phase of regeneration and epithelization, the reaction remained slightly alkaline pH 8.1 and 7.3, respectively (Fig. 1). Fig. 1 shows a comparative characteristic of pH-metry in groups 1 and 2, where 1, 2 are groups of patients, A is the phase of inflammation, B is the phase of regeneration, C is the phase of epithelization. In group 1, in 15 patients (75%), wound epithelization occurred on 27 ± 1.8 days, in the remaining 5 patients there were no signs of epithelization. The wound healing rate (L.N. Popova index) averaged 4.8 ± 0.39%. In the second group of patients, in the regeneration phase, the pH of the wound surface changed to 6.8, which was most optimal for the activity of fibroblasts and epithelial cells. In 24 patients (85.7%), epithelization occurred on day 16 ± 4. The wound healing rate was 6.7 ± 0.41%.

Clinical examples

Example 1

Extract from the medical history No. 3016

Received May 26, 2010

Date of discharge: June 7, 2010

Patient K., 58 years old.

Diagnosis: Phlegmon of the right thigh.

Con .: Type 2 diabetes mellitus, moderate, decompensation stage.

From the anamnesis: considers himself ill for 4 days, sought medical help and an ambulance team was taken to the Municipal Clinical Hospital № 7, was hospitalized in a purulent surgical department № 2.

On admission: sharp edema, moderate hyperemia in the middle third of the right thigh along the front-outer surface, with palpation - sharply painful infiltration, without clear boundaries with softening areas. In an emergency, the patient underwent surgical treatment - opening the phlegmon of the thigh with two cuts of 7.0 cm and 10.0 cm, removal of clearly non-viable soft tissues under general anesthesia. The wound was washed with a solution of hydrogen peroxide 3% and an antiseptic with a solution of plivacept 0.02%. Subsequently, membrane dressings were applied to the wounds, consisting of an external polypropylene layer adjacent to the wound surface, two layers of cellulose and polyacrylate, which were soaked 15 minutes before application to the wound surface with a mixture of acerbine and sodium chloride 0.9% in a ratio of 1: 4 . The dressing was changed 1 time per day during the entire inpatient treatment period. On the 5th day of the postoperative period, edema, redness and infiltration of the surrounding soft tissues decreased significantly, granulation appeared in the bottom of the wounds. After 12 days, the wounds were reduced, filled with granulations, epithelization began from the edges of the wounds. The patient was discharged for outpatient follow-up care by a surgeon at the place of residence until the wounds healed.

Example 2

Extract from the medical history No. 3174

Date of receipt 01.06.2010

Date of discharge 06/13/2010

Patient P., 49 years old.

Diagnosis: Festering hematoma of the right lower leg.

Con .: Type 2 diabetes mellitus, moderate, decompensation stage.

From the anamnesis: considers herself a patient for 15 days, applied for medical help at the clinic at the place of residence, was sent to the Municipal Clinical Hospital No. 7, was hospitalized in a purulent surgical department No. 2. On admission: on the outer surface of the right lower leg in the upper third of the swelling, moderate hyperemia, palpation is determined by local hyperthermia, infiltration 8.0 × 5.0 cm with clear boundaries, softening areas. In an emergency, the patient underwent surgical treatment - opening the suppurating hematoma under local anesthesia with a single cut of 7.0 cm. The wound was washed with a solution of hydrogen peroxide 3% and an antiseptic with a solution of chlorhexidine 0.05%. A membrane dressing was installed in the postoperative wound, consisting of an external polypropylene layer adjacent to the wound surface, two layers of cellulose and polyacrylate, which were impregnated with a mixture of acerbine and sodium chloride 0.9% in a ratio of 1: 4 15 minutes before application to the wound surface. The change of this dressing was carried out 1 time per day during the entire inpatient treatment period. On the 3rd day of the postoperative period, redness and infiltration of the surrounding soft tissues passed, granulations appeared in the bottom of the wound. On day 12, the wound is completely epithelized. The patient in satisfactory condition was discharged from the hospital. The proposed method allows: to improve the effectiveness of treatment by purposefully changing the pH of the wound surface, which creates unfavorable conditions for the growth and reproduction of microorganisms, helps to cleanse the wound surface from purulent-necrotic tissues, and allows to stimulate the processes of regeneration and epithelization, thereby reducing the treatment time for this category of patients.

Claims (1)

A method for wound dialysis of purulent wounds in type 2 diabetes mellitus, including surgical treatment of a purulent foci, applying a membrane product with a medicinal composition to the wound surface, characterized in that the membrane dressing is used as a membrane product, consisting of an external polypropylene layer adjacent to the wound surface, two layers of cellulose and polyacrylate, which is soaked 15 minutes before application to the wound surface with a mixture of solutions of acerbine and sodium chloride 0.9% in a ratio of 1: 4, dressing change perform 1 time per day during the entire inpatient treatment until the onset of the epithelialization phase.

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