RU2491885C1 - Functional preoperative diagnostic technique in postoperative complications in patients underwent replacing hernia repair for postoperative hernias - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, specifically surgery and functional diagnostics. The supine heart rate is recorded and represents a baseline test, while the standing heart rate measured is an orthostatic test for 30 sec. The regulatory system activity index (RSAI) is described in points 1 to 10. An increase of this value relates to the deteriorating body adaptive possibilities; the RSAI value of 3-10 points enables predicting the postoperative wound complications.

EFFECT: method enables predicting the postoperative complications following the replacing hernia repair for postoperative hernias.

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Description

The method relates to medicine, namely to surgery, can be used in the diagnosis of postoperative wound complications in patients with postoperative hernias. The method can be used in everyday practice of abdominal surgery to assess the degree of tension of regulatory systems, predicting postoperative complications.

There are indirect scales for assessing the risk of wound postoperative complications: according to the concomitant pathology, the frequency of repeated operations and the analysis of background conditions (Podergin A.V. Failures of hernia repair with plastic polypropylene mesh / A.V. Podergin, V.L. Halzov // Herniology. - 2007. - No. 2. - P.22-24 .; Langer C. A. Prognosis factors in incisional hernia surgery: 25 years of experience. / CA Langer, A. Schaper. T. Liersh [et al.] // Hernia . - 2005. - No. 9, - P.16-21).

The selection of prevention methods is usually carried out empirically, based on averaged data on the number and quality of complications in a particular pathology (A. Timoshin, Results of surgical treatment of postoperative ventral hernias / A.D. Timoshin, A.L. Shestakov, E. A. Galota // Herniology. - 2007. - No. 2. - S.33-36).

Approximately the recommendations for antibiotic prophylaxis and antimicrobial treatment of complications are also formed, without a deep individual assessment of the patient’s health status and assessment of the adaptive capabilities of his body’s regulatory systems (Abdominal surgical infection: clinic, diagnosis, antimicrobial therapy: Practical Guide / Edited by BC Savelyev, B. R. Gelfand. - M.: Litterra, 2006 .-- 168 p.).

There is a need for a reliable mathematically verified scale capable of predicting the risk of postoperative complications, based on the preoperative state of health of the patient and the identification of its subclinically occurring pathological processes. A method to assess the adaptive capabilities of the body has existed for a long time, cardiointervalography was developed in the 60s of the last century by a group of Soviet scientists working in space medicine under the guidance of Professor P.M. Baevsky (Baevsky R.M. The problem of assessing and predicting a functional organism and its development in space medicine / R.M. Baevsky // Advances in physiological sciences. - 2006. - T.37. - No. 3. - P.42-57) .

For half a century of existence, the method has received worldwide recognition and has been successfully applied in various fields of medicine, it is based on the analysis of assessing heart rate variability. (Wayne A.M. Vegetative disorders. / AM Wayne - M .: MIA - 2003. - 400 p.).

The proposed method was developed using the well-known method of studying rhythm variability (HRV) (V. M. Mikhailov. "Heart rate variability: experience of the practical application of the method", 2002, p. 4. http://www.neurosoft.ru/eng/product /book/hrv-2/chapter4.aspx).

The HRV method consists in recording the parameters of the patient's sinus heart rhythm, in particular, before and after performing various functional tests, such as orthostatic, a test with deep controlled breathing, an isometric exercise test, a test with physical activity (bicycle ergometry), etc. The sinus node of the heart , as a special apparatus for regulating physiological processes with a universal form of constant response during normal functioning, forms heart rhythm values that are adequate to a particular situation. The concept of “rhythm value” includes not only heart rate, duration of RR intervals, but also their sequence (Baevsky R.M. The problem of evaluating and predicting a functional organism and its development in space medicine / R.M. Baevsky // Successes in physiological sciences. - 2006. - T.37. - No. 3. - S.42-57).

The heart rate serves as an indicator of deviations that occur in the regulatory systems of the body, therefore, the study of HRV is of great diagnostic value. Since there are practically no such functional states or diseases in which the mechanisms of vegetative regulation would not be involved, the scope of the HRV analysis method is very large. This is due to the fact that the method is quite simple, relatively cheap, affordable, non-invasive method for assessing autonomic regulation.

HRV method is used in the diagnosis of arterial hypertension, coronary heart disease, diabetic autonomic neuropathy (Analysis of heart rate variability when using various electrocardiographic systems / Baevsky R.M., Ivanov G.G., Chireykin L.V., Gavrilushkin A.P. , Dovgalevsky P.Ya., Kukushkin Yu.A., Mironova T.F., Prilutsky D.A., Semenov A.V., Fedorov V.F., Fleishman A.N., Medvedev M.M. // Herald of Arrhythmology, No. 24 dated 02.03.2002, p. 65; V. M. Mikhailov “Heart rate variability: experience of the practical application of the method”, 2002).

However, until now this method has practically not found its application in surgery (I. Piksin. Neural network prediction of early postoperative complications in abdominal surgery. / I. N. Piksin, A. A. Solomakha. Bulletin of the Mordovian State University named after N.P. Ogareva. - 1997. - No. 2-3. - S.112-115.).

The aim of the proposed method is to conduct preoperative diagnosis of the occurrence of postoperative complications in patients after prosthetic hernioplasty for postoperative hernias by measuring the activity of regulatory systems with a vegetative tester.

The goal is achieved by recording cardiointervalography in the supine position (background test) and in the standing position (orthostatic test) for 300 seconds, the indicator of the activity of regulatory systems (PARS) is scored from 1 to 10, an increase in this number corresponds to a worsening of the adaptive capacity of the body , and upon receipt of a PASR value of 3-10 points, wound complications are predicted in the postoperative period.

When PARS indications corresponding to greater than or equal to 3-10 points, individualized tactics of patient management are used (choice of the method of antibiotic prophylaxis with a white blood cell implant, choice of the method of alloplasty, drainage of the abdominal wall).

(Kuznetsov A.V. Antibacterial activity of extracorporeally prepared leukemia in an In vitro experiment / A.V. Kuznetsov, S.P. Belogorodtsev, Yu.V. Kuznetsov // International Conference "Fundamental Problems of Lymphology and Cell Biology" Novosibirsk October 28-29 2008 - S.208-210.

Kuznetsov Yu.V. Extracorporeal antibiotic-immunocorrection as a prophylaxis of infection in the field of surgical intervention when using polypropylene mesh prostheses in patients with postoperative ventral hernias / Yu.V. Kuznetsov, B.S. Dobryakov, E.N. Fedin, A.V. Kuznetsov // Herniology. - 2008. - No. 3 (19). - S.24-25.

Kuznetsov A.V. The possibility of using a leukocyte implant in herniology / A.V. Kuznetsov, S.N. Belogorodtsev, Yu.V. Kuznetsov. G.V. Seledtsova // Bulletin of the ISU. Series: Biology, Clinical Medicine - 2009. - Volume 7. - Issue 3. - P.104-106.

Kuznetsov A.V. Management of patients with seromas after hernia repair in the early postoperative period / A.V. Kuznetsov, V.V. Shestakov, B.A. Alekseev // Bulletin of the East Siberian Scientific Center of the Siberian Branch of the Russian Academy of Sciences 2011, No. 1, part 2, P.75-80.

Kuznetsov A.V. Management of patients with seroma after prosthetic hernioplasty "INLAY" / A.V. Kuznetsov // Bulletin of Novosibirsk State University. Series: Biology, Clinical Medicine 2011, - Volume 9, - Issue 3. - C.1 72-177.

Kuznetsov A.V. The choice of the alloplasty method for large hernial defects / Yu.V. Kuznetsov // Bulletin of NSU. Series: Biology, Clinical Medicine 2011. - Volume 9. - Issue 2. - P.186-191.

Kuznetsov A.V. A new method of intraoperative antibiotic prophylaxis in herniology / A.V. Kuznetsov, I.Yu. Bravve, B.S. Dobryakov, B.V. Alekseev, V.V. Shestakov, S.N. Belogorodtsev, Yu.V. Kuznetsov

// Issues of the pathogenesis of typical pathological processes (Proceedings of the 111th All-Russian Scientific and Practical Conference with International Participation, Novosibirsk 2011. - P.143-145.

Kuznetsov A.V. Features of the early postoperative period with herniotomy with a different position of the mesh prosthesis / A.V. Kuznetsov, Yu.V. Kuznetsov, B.S. Dobryakov, B.V. Alekseev, V.V. Shestakov, A.V. Borodach, E.N. Fedin // Bulletin of experimental and clinical surgery, - 2011, - volume IV, - No. 1. - S.17-20.

Kuznetsov A.V. Evaluation of the appropriateness of vacuum drainage with prosthetic plastic "sublay" in the treatment of postoperative hernias / A.V. Kuznetsov, I.Yu. Bravve, B.S. Dobryakov, A.V. Borodach, V.V. Shestakov, B.V. Alekseev, E.N. Fedin // Science, education, medicine: materials of the annual All-Russian Scientific and Practical Conference (2011; Samara). All-Russian scientific-practical conference "Science, education, medicine" Samara: media "REAVIZ". - 2011. - S.336-339.

Kuznetsov A.V. The course of the early postoperative period after prosthetic allojernoplasty at various positions of the mesh prosthesis / A.V. Kuznetsov, I.Yu. Bravve, B.S. Dobryakov, V.V. Shestakov, A.V. Borodach, B.V. Alekseev, Yu.V. Kuznetsov // Actual issues of emergency and reconstructive surgery (Collection of scientific and practical works, dedicated to the 80th anniversary of MI Gulman. Krasnoyarsk) - S.203-205.

Kuznetsov A.V. Preclinical study of leukocyte implant for antibiotic prophylaxis in herniology / A.V. Kuznetsov, B.S. Dobryakov, V.V. Shestakov // Bulletin of NSU. Series: Biology, Clinical Medicine 2012, Volume 10, Issue 1, S.167-171).

The day before the operation, the electrical potentials of the heart rhythm are recorded at rest (lying on the back for 300 seconds) and when transferred to an upright position (orthostatic test standing for 300 s). Next, the hardware method is used to analyze the duration of RR intervals from the previously obtained electrocardiogram of both samples. Then a sequential series of one hundred digital codes corresponding to the values of the measured durations of the RR intervals is formed, and it is subjected to mathematical analysis, including statistical, histographic, correlation, and spectral processing. Based on the results of mathematical analysis, codes are generated in points corresponding to five indicators: the total effect of regulation, the function of automatism, autonomic homeostasis, the stability of regulation and the activity of subcortical nerve centers. For a general characteristic of the indicator of activity of regulatory systems (PARS), combining the scores of these indicators, form a code corresponding to the integrated indicator of activity of regulatory systems, the value of which is determined in conditional scores from 1 to 10.

PARS allows us to differentiate different degrees of tension of regulatory systems and evaluate the adaptive capabilities of the body (P.M. Baevsky, 1979, 1984).

Criteria taken into account when calculating PARS:

A. The total effect of regulation in terms of heart rate (PE).

B. The total activity of regulatory mechanisms by mean square deviation is SD (or by total spectrum power - TR).

B. Vegetative balance on a set of indicators: Ying, RMSSD, HF, IC.

D. Activity of the vasomotor center that regulates vascular tone, according to the power of the spectrum of slow waves of the 1st order (LF).

D. Activity of the cardiovascular subcortical nerve center or suprasegmental levels of regulation by the power of the spectrum of slow waves of the second order (VLF).

PARS values are expressed in points from 1 to 10. Based on the analysis of PARS values, the following functional conditions can be diagnosed:

Norm (PARS = 1-2). The state of the optimal (working) voltage of regulatory systems, necessary to maintain the active balance of the body with the environment.

The voltage state of regulatory systems (PARS = 3-4), when the body requires additional functional reserves to adapt to environmental conditions. Such conditions arise in the process of adaptation to work, during emotional stress or when exposed to adverse environmental factors.

Overvoltage condition (PARS = 5-6). regulatory systems, which is associated with active mobilization of defense mechanisms, including increased activity of the sympathetic-adrenal system and the pituitary-adrenal system.

The state of depletion (PARS = 7-8) or overvoltage of regulatory systems, for which the nature of the insufficiency of protective and adaptive mechanisms, their inability to provide an adequate response of the body to environmental factors. Here, excessive activation of regulatory systems is no longer supported by the corresponding functional reserves, characteristic signs of pathology appear. Specific changes clearly prevail over non-specific ones.

Disruption of adaptation (PARS = 9-10). or the state of “breakdown” of adaptive mechanisms when special pathological deviations dominate and the ability of adaptive mechanisms to self-regulation is partially or completely impaired.

200 patients, aged 35-55 years (87 men, 113 women), without severe concomitant pathology and diseases of the nervous system who were admitted to the surgical department in a planned manner, operated on for postoperative median hernias MW3-4R0-2 according to the SWR classification, were prospectively examined ( Chevrel IP, Rath AM Classification ofincisional hernias of the abdominal-wall // Ibid. 2000. - Vol.4. Nol. - P.1-7) by the method of implantation of a polypropylene mesh prosthesis.

Using a computer electrocardiograph to study heart rate variability (Neurosoft, Russia), preoperatively recorded while lying down (background test) and standing (orthostatic test) for 300 s. The analysis was performed using the standard Polyspectrum program (Neurosoft LLC, Russia). The hardware activity was used to evaluate the activity of regulatory systems (PARS) according to the method of P.M. Baevsky. According to the results of this indicator, a breakdown was carried out into groups (Table 1.).

Table 1. Grouping according to received PARS value before surgery PARS value groups Number of patients Norm (1-2 points) - group No. 1 49 Voltage (3-4 points) - group No. 2 63 Overvoltage (5-6 points) - group No. 3 46 Depletion (7-8 points) - group No. 4 25 Disruption of adaptation (9-10 points) - group No. 5 17

The results are presented as mean values indicating standard deviation. Statistical processing was performed using the Mann-Whitney test for nonparametric distribution.

Of the 200 patients operated on with a diagnosis of postoperative ventral hernia, we observed 22 cases of infection in the field of surgical intervention (IOCH). Also, 20 cases of wound complications were revealed in which no microflora were sown and it is impossible to directly attribute them to the IOS, however, the term for eliminating these consequences exceeded 30 days, which is always accompanied by secondary infection, and we also included them in the study group.

Table 2. Complications obtained in groups with different PARS values Complication Group 1 Group 2 Group 3 Group 4 Group 5 Norm Voltage Overvoltage Exhaustion Failure adaptation (1-2) (3-4) (5-6) (7-8) (9-10) (n = 49) (n = 63) (n = 46) (n = 25) (n = 17) Suppuration - - - four 6 Divergence of wound edges - one one 2 3 Ligature fistula - - - 2 2 Scar infiltrate - - one one 2 Edge skin necrosis - - 2 2 - Seroma 2 four 6 one - Total (% of all patients) 2 (1%) 5 (2.5%) 10 (5%) 12 (6%) 13 (6.5%) % complications in the group 4.1% 7.9% 21.7% 48% 76.5%

The state of normal or satisfactory adaptation was observed in 49 patients, which is 24.5%) of all examined patients. Complications were observed in 2 patients - subcutaneous tissue gray, which is only 4.1%. In a state of functional tension, which was encountered in 31.5% of cases (63 patients), complications were detected in 7.9% of patients. The state of overvoltage or the state of unsatisfactory adaptation (5-6 points) in 46 patients (23% of cases) revealed 21.7% of wound complications in this group. The state of depletion of regulatory systems (7-8 points) in 25 patients (12.5%) led to the identification of 48% of complications in this group. In 17 patients (8.5%) with a failure of adaptation (9-10 points), wound complications were received in 76.5% in the group. An increase in the total number of complications was noted in direct proportion to the deterioration of the PARS indicator.

The largest number of patients (112 patients - 56%) before the operation were in a normal or subnormal (stress) state of the body's adaptive capabilities. This category of patients accounted for only 3.5% of cases of wound complication.

The remaining 96.5% of cases of complications occurred in patients with established maladaptation of varying severity - overstrain, exhaustion, failure of adaptation.

A clear increase in the total number of complications was found to be directly proportional to the deterioration of the adaptive capabilities of the patient's regulatory systems according to PARS data. According to the number of complications in a particular group, the difference between the group with normal PARS values (4.1%) and adaptation failure (76.5%) is 72.4%.

With visible homogeneity and preservation of the patient’s health state, based on the standard scheme of preoperative examination (general blood and urine tests, standard general clinical studies), using cardiointervalography, one can identify non-differentiable clinically different state of the patient’s adaptive capabilities, giving a clear correlation with the frequency of possible wound complications in postoperative period. The data obtained as a result of studying the adaptive capabilities of the body's regulatory systems allow predicting the occurrence of postoperative complications and, accordingly, determining individualized tactics of patient management - choosing the tactics of preoperative preparation, tactics of the operation (antibiotic prophylaxis, choosing the method of plastic surgery, drainage, etc.) and treatment in the early postoperative period.

Thus, on the basis of the data obtained, it can be concluded that the preoperative state of the patient’s autonomic nervous system affects the risk of developing postoperative complications. Examination of PARS data before surgery allows us to synergize the incidence of complications after surgery.

An example of the method

Patient N., 46 years old, was admitted to the clinic 03.01.10, with a diagnosis

postoperative ventral hernia MW3R0 (according to Chavrel 1999).

Evaluation of the rhythmogram and type of sinus rhythm regulation:

VRS-Express

Sample: Orthostatic sample

The duration of the recording of heart rate is 5 min (300 s). Registered ORS complexes: 582.

The current functional state is very poor (-10).

The body's adaptive reserves are significantly reduced (9).

The final result of PARS is 9 (the computer gives out).

Figure 1 - issued by the computer visual total result of the PARS value.

Background recording

The position of the patient when recording: lying. The duration of the recording of heart rate is 5 min (300 s). QRS complexes registered: 629.

Rhythm. Average heart rate: 126 bpm. - increased heart rate (tachycardia).

Figure 2 - computer-generated visual result of the rhythmogram.

Figure 3 is a computer-generated visual spectrogram result.

Table 3. Temporal Spectral Analysis Scorecard Temporary Analysis Indicators Spectral Analysis Indicators Parameter Value Parameter Value R-R min, ms 461 TP, ms ^ 2 133 R-R max, ms 492 VLF, ms ^ 2 117 RRNN, ms 476 LF, ms ^ 2 fifteen SDNN, ms 8 HF, ms ^ 2 0.58 RMSSD, ms 2 LF norm, n.u. 96.3 pNN50,% 0 HF norm, n.u. 3.73 CV,% 1.68 LF / HF 25.8 Spectrum structure % VLF 88.3 % LF 11.2 % HF 0.436 BH 1 / min 44 Krs 18.5

Figure 4 - the final diagram of the visualization of the ratios of LF and HF.

Medical and physiological interpretation of HRV indicators

Evaluation of the rhythmogram and type of sinus rhythm regulation

The rhythmogram of heart rate variability corresponds to the 3rd class. This variant of the rhythmogram and the structure of heart rate variability indicate pathological stabilization of the modulation of the heart rhythm with the transition of its regulation from the reflex, vegetative level of leadership to a lower - humoral - metabolic, which is not able to quickly provide homeostasis.

Spectrogram and spectral analysis score

The total power of the spectrum of neurohumoral modulation is sharply reduced.

The state of neurohumoral regulation is characterized by a low level of vagal, sympathetic and humoral-metabolic (cerebral ergotropic) effects in the modulation of heart rhythm. The balance of the autonomic nervous system is characterized by a predominance of activity of the sympathetic part of the autonomic nervous system. Cardiorespiratory synchronization saved. The current functional state is sharply reduced (-10). Adaptation reserves of regulatory systems 9 points.

Conclusion: the probability of wound complications is 75%. It is necessary to carry out antibiotic prophylaxis, preoperative preparation. Intraoperatively, it is necessary to use deep methods of prosthetic hernioplasty (“sublay” or “underlay”). Drainage-free management of an operational wound. Dynamic monitoring of the wound after surgery.

Claims (1)

A method for the functional preoperative diagnosis of postoperative complications in patients after prosthetic hernioplasty for postoperative hernias, including recording a cardiac rhythmogram and assessing heart rate variability, characterized in that, recording a cardiointervalogram in the supine position - background test - and in the standing position - orthostatic test - during 300 s, the indicator of activity of regulatory systems (PARS) is estimated in points from 1 to 10, an increase in this number corresponds to a deterioration in hell ptatsionnyh of the organism and in obtaining the PARS 3-10 scores predict receipt of wound complications in the postoperative period.

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