RU2467706C1 - Method for preventing and treating exudative-inflammatory complications following median sternal incision - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely cardiosurgery, and can find application for preventing and treating exudative-inflammatory wound complications following median sternal incision. Substance of the method consists in inserting active pericardial and mediastinal drainages throughout one-three days following median sternal incision. Prolonged incision is ensured by inserting a dead-end end-perforated sterile microdrainage polyvinylchloride tube through a lumen of the pericardial drainage in an oblique sinus of pericardium. Thereafter, the pericardial drainage is removed. A through perforated microdrainage polyvinylchloride tube perforated in a middle one-third is sutured to a head section of the mediastinal drainage brought out through a counteropening in epigastrium. Thereby the tube is inserted in full-length afterbreast. To this end, three ends of both microdrainage tubes are attached to vacuum aspirators.

EFFECT: use of the given invention provides faster repair processes in an incisional wound and reduced risk of postoperative exudative-inflammatory complications.

4 dwg, 1 tbl, 2 ex

Description

The invention relates to medicine, namely to cardiac surgery, in particular to methods for the prevention and treatment of exudative-inflammatory wound complications after median sternotomy.

A known method for assessing the duration of drainage of subcutaneous tissue in reconstructive surgery of hernias of the anterior abdominal wall using lavsan nets. The essence of this method consists in prolonged active vacuum drainage of the deep layers of the surgical wound with an estimate of the amount and biochemical properties of the discharge (the ratio of creatinine exudate and blood serum of the patient), based on the dynamics of which they decide to remove the drains (UA 12027, published January 16, 2006 g.).

The known method is not acceptable for the prevention and treatment of exudative-inflammatory wound complications after median sternotomy.

The closest in its features adopted for the prototype is the method known in cardiac surgery, which consists in actively draining the oblique sinus of the pericardium and anterior mediastinum with perforated drainage tubes to control postoperative bleeding and exudation, followed by their removal and sealing drainage contrapertures with provisional sutures after 1-3 days after the median sternotomy (Burakovsky V.I., Bokeria L.A. Cardiovascular surgery / Hand. for doctors. M., 1996).

The disadvantages of the prototype include the lack of effective control of the process of wound exudation in the deep layers of the sternotomy wound after removal of drainage in the immediate postoperative period (postpericardial syndrome or postoperative aseptic pericardial effusion).

The objective of the invention is to provide an effective method for the prevention and treatment of exudative-inflammatory complications in cardiac surgery after median sternotomy, which allows to accelerate reparative processes in the surgical wound and reduce the risk of exudative-inflammatory complications in the postoperative period.

The problem is solved using the proposed method for the prevention and treatment of exudative-inflammatory complications in cardiac surgery, including the placement of pericardial and mediastinal drainages, and for extended drainage through the pericardial drainage into the oblique sinus of the pericardium, a blind, perforated sterile microdrainage tube is perforated at the end, after which removed outside, and a perforated through the middle third of the through sterile microdrainage tube is hemmed to the head to the end of the mediastinal drainage discharged through contrapertures in the jugular notch, after which the mediastinal drainage is removed through contrapertures in the epigastrium, thereby installing a tube for the entire length of the sternum, and finally the three ends of both microdrainage tubes are connected to vacuum aspirating devices.

Thus, through the installed sterile microdrainage vacuum aspiration system, consisting of perforated microdrainage PVC pipes, during the immediate postoperative period without violating the patient's activation and recovery process, effective prevention and control of exudation processes in the pericardial cavity and anterior mediastinum are performed, which allows to accelerate reparative processes in the surgical wound and reduce the risk of exudative-inflammatory complications in the postoperative period.

In addition, in the postoperative period, in addition to the threat of cardiac tamponade, the natural evolution of the exudative wound process greatly increases the risk of nonunion of the superficial layers of the sternotomy wound, instability of the sternum osteosynthesis, anterior purulent mediastinitis with the addition of bone-chondral infection and other serious complications. Along with the difficulties of timely and reliable diagnosis, the treatment of these complications is associated with technical difficulties, high costs of treatment, a long stay of the patient in a medical institution, and the proposed method will eliminate these shortcomings.

The proposed method is illustrated by drawings, where:

figure 1 - depicts a U-shaped horizontal provisional sealing skin seam of drainage contrapertures;

figure 2 - shows the drainage of the pericardium and anterior mediastinum according to the standard method with the removal of the conductor in the jugular notch for subsequent through drainage of the chest cavity;

figure 3 to the sterile part of the conductor is hemmed perforated in the Central part of the "through" microdrainage, which, when pulled up and removed through the counter-hole in the epigastrium of the sternal drainage, is automatically brought into the chest cavity. Through the lumen of the removed pericardial drainage, “blind” microdrainage is started;

figure 4 shows a General view of the microdrainage vacuum aspiration system.

The proposed method is as follows:

1. At the end of the operation, before metallography of the sternum, a short (10-15 cm) segment of a polyvinyl chloride diameter tube similar to a subsequently installed microdrainage is sewn to the upper end of the mediastinal drainage 1 for subsequent through drainage of the sternum, conductor 2, which is brought out from the inside out through the counter-opening in the jugular tenderloin, sealed at the end and fixed to the skin with a horizontal sealing U-shaped seam 3 (figure 1). Mediastinal drainage tubes 1 and pericardial drainage tubes 4 with a diameter of 13-15 mm are routinely removed through contrapertures in the epigastrium (Fig. 2) with fixation by sutures 3 similar to those described above.

2. Before removal of drainage tubes 1, 4 from the mediastinum and pericardial cavity on the 1-3rd day of the postoperative period, aseptic conditions are carried out by clotting by aspiration with a sterile catheter (not shown in the figure). Through the lumen of the pericardial drainage 4 into the oblique sinus of the pericardium, a “blind” sterile microdrainage PVC tube 5 perforated at the end is inserted of a smaller diameter; then, controlling its position, the thick pericardial drainage 4 is carefully removed outside. Pulling over the protruding part of the conductor 2, expose its sterile section hidden under the skin of the jugular notch, to which an end-to-end seam is perforated through the sterile polyvinyl chloride tube 6 pre-perforated in the middle third of the entire length of the chest cavity (Fig. 3). Thus, instead of the sternal drainage 1 removed through the counterperture in the epigastrium, a sterile through perforated microdrainage 6 is installed in the anterior mediastinum through the contraperture in the jugular notch along the entire length of the deep layers of the sternotomy wound.

3. The ends of the sterile micro-drainage vacuum-aspiration system consisting of micro-drainage polyvinyl chloride tubes 5 and 6, brought out through three contra-holes in the jugular notch and epigastrium, are fixed with previously sealed horizontal provisional U-shaped skin sutures 3. All three ends of both micro-drainage hollow pipes and 6 are connected to aspirating devices that create a high level of vacuum (100 ml Johnson & Johnson J-Vac tank, 20-50 ml disposable syringes, etc., not shown in Fig. cauldron). Upon reaching the required vacuum after application of an aseptic dressing, the procedure is considered completed. A general view of a sterile microdrainage vacuum aspiration system is shown in FIG.

If necessary, reorganization from fibrin clots or replacement of sternal drainage, which is carried out under aseptic conditions similar to the procedure described above, is possible. The presence of drainage of the anterior mediastinum, if necessary, allows the introduction of solutions of antiseptics and antibiotics into the retrosternal space. Pericardial and sternal microdrainages are removed no earlier than 3-5 days with a progressive decrease in the volume of evacuated serous exudate to a slight (up to 40-50 ml / day) after the control echocardiographic study for hydropericardium. Depending on the timing, the provisional skin horizontal U-shaped seams can be tightened or completely removed.

The proposed method for the prevention and treatment of exudative-inflammatory complications after median sternotomy eliminates the "hidden" cavities and accelerates the repair processes in the pericardial space and in the anterior mediastinum, which allows you to effectively deal with exudative-inflammatory postoperative complications. In addition, the method is convenient, simple, affordable, relieves patients of a number of additional manipulations and procedures, does not interfere with their activation and does not increase the length of stay in a cardiosurgical hospital.

Using this method allows you to achieve a better cosmetic effect after median sternotomy. With the manifestation in the early stages of a deep wound infection (anterior purulent mediastinitis), along with a reliable high diagnostic value, the drainage system from a preventive one can easily be turned into a treatment one with the possibility of establishing flow-aspiration lavage drainage of retrosternal space. Given the cheapness and ease of replacing drainage and aspiration elements, the system can function effectively indefinitely without the need for additional devices and manipulations.

The invention is illustrated by the following examples.

Example 1. Patient P., 56 years old, was admitted to the Department of Cardiac Surgery 10/16/07 with a diagnosis of CHD: 2-leaf aortic valve. Critical valve stenosis of the aortic orifice, calcification 3 tbsp., 4 f.c. NK IIAst, 3 f.k. (NYHA). Type II diabetes mellitus, cf. Art. severity, subcompensation. Alimentary-constitutional obesity III tbsp. The indication for surgery was symptomatic critical aortic stenosis. 10/19/07 in a planned manner, the aortic valve was prosthetized with a mechanical prosthesis MedInzh-2/23 in conv. IR, FHKP (myocardial ischemia - 90 min, IR - 100 min, operation duration - 250 min). Blood loss on the 1st day amounted to 120 ml on 10/20/07, 22 hours after the operation, drainage was removed according to the method described above with the installation of a micro-drainage vacuum aspiration system in the pericardial cavity and retrosternal space, the patient was transferred from the intensive care unit, and early activation began. Microdrainage functioned for 5 days. 10/26/07 they were removed, the rate of serous-sucrose discharge: 150-95-80-80-50 ml (total - 455 ml). The sternotomic wound healed by primary intention, the sternum osteosynthesis was stable. With control echocardiography, the minimum separation of pericardial leaves behind the side wall of the left ventricle. 10.31.07 patient in satisfactory condition was discharged.

Example 2. Patient Sh., 63 years old, was admitted to the cardiac surgery department 04.09.07 with a diagnosis of Multifocal atherosclerosis. Ischemic heart disease. Unstable angina IIIB class (Braunwald). Postinfarction cardiosclerosis (m / o MI of posterior localization from III / 07 and VI / 07). Stenosing coronary sclerosis. NK IIAst, 3 f.k. (NYHA). Atherosclerosis BCA. Condition after stenting of the mouth of the left ICA (08/10/07). Type II diabetes mellitus, secondarily insulin-demanding, severe, in Art. subcompensation. In connection with the acute coronary syndrome, on September 5, 07, an attempt was made to X-ray endovascular recanalization of the PCA, and September 10, 07, an urgent operation was performed: Autovenous coronary artery bypass grafting of the PMA, VTK OA, ZMZHA in conv. IR and PCF (myocardial ischemia - 56 min, IR - 113 min, operation duration - 285 min). Blood loss for 1 day amounted to 150 ml. September 11, 07, 24 hours after the operation, the drains were removed according to the described method with the installation of a microdrainage vacuum aspiration system in the pericardial cavity and in the retrosternal space, the patient was transferred from the intensive care unit, activation began. Microdrainage functioned for 6 days. 09/17/07 they were removed, the rate of serous-sucrose discharge: 150-120-70-50-50-50-30 ml (total - 470 ml). Despite the persistent cough syndrome during the hospital period (right-sided / lobar pleuropneumonia) and the risk of instability of the osteoporotic sternum, the sternotomy wound healed by first intention, the sternum osteosynthesis was stable. With pleural punctures from September 14 and September 17, 07, up to 300 and 400 ml of serous discharge were evacuated on the right. During the control echocardiography, no separation of pericardial leaves was revealed. 09/25/07 the patient was discharged.

These examples illustrate the effective prevention of wound complications in patients of an older age group with severe cardiac pathology and with a host of concomitant diseases, the totality of which classifies these patients as at high risk for the development of postoperative sternomediastinitis. One of the main preventive factors was the prolonged vacuum-suction drainage of the pericardial cavity and chest cavity with the evacuation of up to 500 ml of exudate, which eliminated favorable conditions for exudative-inflammatory processes in the area of the operation.

The table provides summary data on the outcomes of treatment of patients undergoing median sternotomy according to the described method in comparison with traditional management without prolonged drainage.

Table The method of maintaining sternotomy wounds: Traditional technique (n = 166) Extended drainage method (n = 245) Average age 53.8 ± 8.0 55.6 ± 11.2 IR duration, min 108 ± 32 97 ± 51 The total duration of drainage, days 2.2 ± 0.5 7.7 ± 2.1 The total volume of discharge by standard drainage, ml
284 ± 86 235 ± 103 (+ 412 ± 173 ml on microdrainages on average -
in 5 days) Clinically significant exudative. pericarditis N = 16 (9.6%) N = 1 (0.4%) Insolvency of the surface layers of the wound N = 35 (21.1%) N = 12 (4.9%) Postoperative Mediastinitis N = 10 (6%) N = 6 (2.5%) Osteomyelitis of the sternum N = 5 (3%) N = 3 (1.2%) Postoperative hospital day 18.4 ± 6.5 12.5 ± 3.4

In total, using the proposed method 245 patients were operated on. The average duration of the functioning of the pericardial-mediastinal microdrainage system was 5.4 ± 2.1 days. Over 5 days, the average amount of exudate evacuated by microdrainage was 412 ± 173 ml. The maximum amount of exudate evacuated by a vacuum-aspiration microdrainage system in a 44-year-old woman after prosthetics with a mechanical prosthesis for critical mitral stenosis was about 7000 ml in 14 days. Of course, the accumulation during the next postoperative period of even 500 ml of aseptic serous-hemorrhagic exudate can serve as soil for the emergence of a variety of exudative-inflammatory complications. Significant separation of the pericardial leaves, which required additional percutaneous drainage after the described method of prolonged suction drainage, was observed in only one patient K., 52 years old, 21 days after the aortic valve prosthesis was replaced with a mechanical prosthesis (7 days after discharge) against an overdose of indirect anticoagulants and congestion up to 500 ml of hemorrhagic exudate. It should be noted that hypocoagulation bleeding occurred for a fairly short time and was accompanied by severe pain, probably due to ruptures of adhesions in the pericardial cavity. Superficial exudative-inflammatory complications requiring surgical treatment and secondary suturing were noted in 12 patients (4.9%). Postoperative serous-fibrinous or purulent mediastinitis of types III and V (according to R.M. El Oakley and J.E. Wright, 1996) with concomitant instability of sternum osteosynthesis was noted in 6 patients (2.5%). In all these cases, a reorganization restotomy was performed with simultaneous or delayed sternal rheosteosynthesis and through mediastinal drainage through the described method with a positive result. Everywhere, there was a lack of a cavity in the anterior mediastinum (exudate and granulations were localized between the edges of the sternum cut), as well as almost complete obliteration by adhesions of the pericardial cavity. Osteomyelitis of the sternum was noted by the authors in 3 cases (1.2%). The maximum period of functioning of the aspiration-washing microdrainage system was 28 days for patient P., 58 years old, who underwent aortic valve replacement surgery, twice - a regularotomy for bleeding and mediastinitis (multiresistant strains of microorganisms), and a high risk of sternum osteomyelitis. In all cases, a positive treatment effect was achieved. Almost all patients of the study group with deep wound complications had severe underlying and concomitant pathology, long periods of surgery, IR, prolonged stay in ICU, prolonged mechanical ventilation. The average length of stay in a cardiac surgical hospital after surgery was 10.5 ± 5.4 days. Both in the main and in the control group of patients, the main risk factors for the development of wound complications were obesity, diabetes mellitus, prolonged surgery and postoperative blood loss, which required a restotomy.

The given examples confirm that the task set - the creation of an effective method for the prevention and treatment of exudative-inflammatory complications in cardiac surgery after median sternotomy, which allows to accelerate reparative processes in the surgical wound and reduce the risk of exudative-inflammatory complications in the postoperative period - has been solved.

Claims (1)

A method for the prevention and treatment of exudative-inflammatory complications in cardiac surgery, including the placement of active pericardial and mediastinal drainages during the first to third days after median sternotomy, characterized in that for prolonged drainage through the pericardial drainage lumen, a sterile microperforated blind perforated at the end of the pericardium is inserted at the end polyvinyl chloride tube, after which the pericardial drainage is removed to the outside, and through sterile perforated in the middle third A micro-drainage polyvinyl chloride tube is sutured to the head end of the mediastinal drainage discharged through the counter-hole in the epigastrium, thereby setting the tube to the entire length of the chest cavity, and finally the three ends of both micro-drainage tubes are connected to vacuum aspirating devices.

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