RU2625742C1 - Method for therapeutic approach selection for patients with acute desctructive pancreatitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: serotonin concentration in the serum is determined daily by high-performance liquid chromatography, the severity of the patient's condition is assessed on the APACHE II scale, and intraperitoneal pressure is additionally measured if intraabdominal pressure rises by 1-2 degrees within the second day after admission to the intensive care unit (ICU), and decreases without further increase by day 4-5; on the 2nd day blood serotonin decreases to 23 ng/ml, and then increases to day 4-5 day with the subsequent tendency to normalization; on the 2nd day, the APACHE II scale is increased to 17 points or higher, then decreases by day 4-5 without subsequent increase - a relatively favorable course is predicted; in case if intra-abdominal pressure increases by 1-2 degrees on day 2 of admission to the ICU, then decreases by day 4-5 and again rises to 2-3 degrees without a tendency towards normalization; serotonin rises more than 500 ng/ml on the second day, then on day 4-5 it decreases to 21-23 ng/ml; if on day 2nd day the APACHE II scale rises to 17 points, then decreases by day 4-5 with subsequent increase - a severe course of acute destructive pancreatitis is predicted.

EFFECT: method allows to predict serious complications in a timely manner, improve treatment effectiveness.

6 dwg, 1 tbl, 2 ex

Description

The invention relates to medicine, namely to general surgery, and can be used to select the tactics of managing a patient with acute destructive pancreatitis.

The problem of diagnosis and treatment of acute destructive pancreatitis remains a very important and relevant topic in modern surgery. The frequency of acute destructive pancreatitis (ARP) in the structure of surgical pathology is steadily increasing and among forms of acute pancreatitis reaches 15-20% [Boyko VV, Krivoruchko IA, Shevchenko RS, Smanilo PM, Pesotsky ON , 2002].

It should be noted that acute pancreatitis itself is one of the most frequent nosological forms among surgical diseases of the abdominal cavity and takes third place, second only to acute appendicitis and acute cholecystitis (Buyanov V.M., Ognev Yu.V., Kubyshkin V.A. , 1979; Boger M.M., 1984; Alperovich B.I., Kazantsev N.I., Merzlikin N.V., 1991; Viskunov V.G., 1995; Vinnik Yu.S., 2000; Ivacheva N. A., 2005).

The presence of a staged disease course, the speed of transformation of edema into pancreatic necrosis, as a rule, is directly proportional to the severity of the disease, the development of complications and inversely proportional to the reversibility interval, during which an effective therapeutic “break” of the pathological process is possible (Vashenko R.V., Tolstoy A.D. ., Kurygin A.A., Sytko Yu.M., Krasnogorov VB Acute pancreatitis and pancreatic injuries: a guide for physicians. S.-Pb .: publ. "Peter", 2000). Properly selected treatment tactics allows you to get a favorable outcome even with the most severe acute destructive pancreatitis, reduce the degree of development of complications, and reduce mortality in this category of patients.

Despite the successes achieved in the diagnosis of acute destructive pancreatitis (ACP), the improvement of surgical intervention technologies, including the use of minimally invasive surgical treatment methods, as well as the constant expansion of the possibilities of drug provision, the mortality rate for this pathology over the past decades has been consistently high and reaches 15-45% [ Gelfand B.R. et al., 2005; Saveliev B.C. et al., 2007; Lysenko M.V. et al., 2010].

The most important tasks in the diagnosis of NDP, determining the choice of therapeutic tactics at different stages of the development of the abdominal inflammatory process, are an objective assessment of the severity of the patient's condition (including the severity of intoxication syndrome) and prediction of the outcome of the disease (Filimonov MI et al., 2000; Gelfand B.R. et al., 2003; Afanasyev A.N. et al., 2008; Savelyev BC, 2009).

Conducted research on patent and scientific medical literature revealed a significant number of security documents that protect various methods for predicting the course of acute pancreatitis and its complications.

A known method for predicting the course of acute destructive pancreatitis, which uses generally accepted indicators of the dynamics of the development of the inflammatory process and intoxication, such as body temperature, the number of white blood cells, shift of the leukocyte formula to the left, the presence of toxic granularity of neutrophils, leukocyte intoxication index, level of amylase and blood lipase, level urine diastases, the phenomena of multiple organ failure, assessing the severity of the condition according to the APACHE II and SAPS II scales [Savelyev BC, Kiriyenko A.I. Clinical Surgery National leadership. Volume 2. - Moscow. - 2009. - 209-217 p.].

The method has the following disadvantages: the laboratory and physiological parameters considered reflect the dynamics of the development of the disease and intoxication after the fact. By their values, one can only judge what is happening to the patient at the moment, but one cannot predict his condition in the coming days. At the same time, an increase in body temperature, blood leukocyte level, leukocyte intoxication index can be caused not only by acute pancreatitis, but also by developing purulent complications, pneumonia, and exacerbation of chronic diseases. It is also important to note that the use of detoxification and antibacterial therapy can significantly reduce the values of blood leukocytes and the patient’s body temperature, despite the progression of destructive processes.

A known method for predicting the development of generalized complications in acute destructive pancreatitis (RF patent No. 2393771, 07/10/2010), including the detection of stimulated oxidase activity of peripheral blood neutrophilic granulocytes, characterized in that the assessment is carried out at the stage of purulent complications, determining the relative number of peripheral formazan-positive neutrophils blood (% FPK) in the load modified HCT test with opsonized zymosan, and provided that their values above 18% determine a high Shade risk of generalized complications.

The method has the following disadvantages: the laboratory peripheral blood parameters considered do not allow to predict the development of generalized complications in the aseptic phase of acute destructive pancreatitis, as well as the further course of acute destructive pancreatitis.

A known method for the diagnosis of destructive pancreatitis (RF patent No. 2427837, 08.27.2011) by examining blood serum, characterized in that they examine the level of C-reactive protein and 2-macroglobulin in the patient’s blood serum upon admission to the hospital, determine the ratio of CRP concentrations and MG, while the coefficient of CRP / MG above 2 corresponds to acute destructive inflammation of the pancreas, and the coefficient of CRP / MG below 2 indicates a decrease or absence of the inflammatory process in the pancreas.

The method has the following disadvantages: the considered laboratory parameters do not reflect the dynamics of the disease and do not allow to predict the severity of acute destructive pancreatitis. By their values, one can only judge what is happening to the patient at the moment, but one cannot predict his condition in the coming days. At the same time, an increase in the level of C-reactive protein does not allow to differentiate the inflammatory response of infectious and non-infectious genesis (autoimmune and rheumatic disorders, myocardial infarction, malignant tumors, postoperative period).

A known method for assessing the severity of the general condition of a patient with acute destructive pancreatitis and predicting the outcome of the disease (RF patent No. 2568601, 11/20/2015) by studying the biological environment of the body, including a daily study in patients from the first day of treatment, the content of low and medium molecular weight substances and oligopeptides in plasma, red blood cells and urine, followed by the calculation of the coefficient of detoxification, determined by summing the ratios of the sum of the contents of substances of low and medium molecular weight in plasma and erythrocytes to the content of low and medium molecular weight in the urine and the ratio of total content of oligopeptides in plasma and erythrocytes to content in urine oligopeptides predict adverse disease course at a value of more than 3.5 detoxification coefficient u.ed.

The method has the following disadvantages: a daily intake of biological environments of the body is required, a large number of indicators difficult to summarize in routine clinical practice, and the lack of a clear link between a certain probability of an adverse outcome and the possibility of enhancing intensive care.

There is a method of determining indications for surgical intervention in acute pancreatitis (patent No. 2272569, 03/27/2006), which provides for receiving punctate from retropancreatic fiber, characterized in that a 20 cm gauge needle is inserted into the patient under the control of a 3.5 MHz ultrasound transducer with a puncture nozzle 0.64 mm with mandrin and upon reaching the fiber behind the pancreas, the mandrin is removed and active aspiration is carried out, 0.1-0.2 ml of discharge is obtained, a native preparation is prepared from it, microscopic examination is performed e and if leukocytes of 40 or more are detected in it, the phase of purulent-destructive pancreatitis is ascertained in the field of vision and a conclusion is drawn on the need for surgical intervention.

The method has the following disadvantages: it is invasive, which entails technical difficulties, possible complications, and also assumes the presence of a qualified ultrasound doctor with experience in performing punctures. In some situations, there are significant difficulties for performing a puncture (persistent intestinal paresis with overstretched loops, severe organ disorders), which can be considered a contraindication for this method.

There is a method of choosing the tactics of treating patients with acute destructive pancreatitis (RF patent No. 2497119, 10.27.2013) by examining the patient’s blood and assessing the condition using a questionnaire scale, characterized in that the concentration of procalcitonin (PCT) in the blood serum is determined by quantitative enzyme-linked immunosorbent assay and additionally assess the severity of the patient's condition on the SAPS scale, if the level of PCT does not exceed 2 μg / l, and the assessment on the SAPS scale does not exceed 5 points, choose a conservative treatment tactic using full integrated polices intensive therapy if the severity of the patient's condition on a scale greater than 5 SAPS scores, along with the complex of intensive therapy, therapeutic exercise and diagnostic laparoscopy; if the PCT level exceeds 2 μg / l, and the rating on the SAPS scale does not exceed 5 points, a mini-access operation is chosen in the case of a local infection process, and open laparotomy in the case of a common process, if the rating on the SAPS scale exceeds 5, choose surgical intervention, while in the case of a local infection process, a puncture-draining operation is performed, then a mini-access operation, and in the case of a common process, a puncture-draining operation, then an open laparotomy.

This method is chosen by us for the prototype.

The prototype method has the following disadvantages: the determination of the level of PCT serum is justified for predicting the development of a systemic inflammatory reaction in the early stages of the development of NDP. The development of purulent complications in case of PDP occurs against the background of deep immunosuppression, due to a compensatory anti-inflammatory reaction that naturally arises on the systemic inflammatory response. In addition, this method requires expensive equipment (immunochemiluminescent analyzer) and reagents. Published works that cite very high false-positive values of procalcitonin in patients with respiratory distress syndrome, acute lung diseases, hemodynamic injuries, severe trauma without bacterial infection (Lapillone A., Basson E., Monneret G. et al. // Lancet. - 1998. - Vol. 351. - P. 1211-1212), in addition, the method for determining the level of PCT serum has another drawback - low specificity (48%) (Turner D., Hammerman C., Rudenssky B., Schlesinger Y., Schimmel MS // Acta pediatr. 2006. Dec; 95 (12); 1571-6).

The objective of the invention is to improve the effectiveness of treatment of patients with acute destructive pancreatitis by predicting the severity of acute destructive pancreatitis.

The problem is solved in that in the claimed method for the treatment of patients with acute destructive pancreatitis, the serotonin concentration is determined daily in high blood liquid chromatography, the severity of the patient's condition is assessed using the APACHE II scale, and the abdominal pressure is additionally measured if on the 2nd day from receipt in the intensive care unit (ICU), the intra-abdominal pressure rises within 1-2 degrees (up to 20 mmHg), and then decreases by 4-5 days without further of increase; on the 2nd day, the concentration of blood serotonin decreases to 23 ng / ml, and then by the 4-5th day it rises with a subsequent tendency to normalize this indicator (100-120 ng / ml); on the 2nd day, the APACHE II score increases to 17 points and higher, then decreases to 4-5 days without a subsequent increase - a relatively favorable course of acute destructive pancreatitis is predicted with conservative therapy; in the event that on the 2nd day from admission to the intensive care unit (ICU), the intra-abdominal pressure rises within 1–2 degrees (up to 20 mmHg), then decreases to 4–5 days and again rises to 2– 3 tbsp. (more than 25 mm RT. Art.) without a tendency to normalize; on the 2nd day, the concentration of blood serotonin rises more than 500 ng / ml, then on the 4th-5th day it decreases to 21-23 ng / ml; if on the 2nd day the APACHE II score rises to 17 points, then decreases by 4-5 days with a subsequent increase, a severe course of acute destructive pancreatitis is predicted, requiring early decompression interventions on the retroperitoneal tissue.

The technical result obtained when solving the problem is expressed in obtaining an objective assessment of the severity of the general condition of the patient with acute destructive pancreatitis and the selection of adequate patient treatment tactics based on predicting the outcome of the disease. At the same time, conditions are provided for establishing at an early stage an unfavorable course of the disease in patients and the timely adoption of adequate therapy measures in the shortest possible time.

The clinical course of acute pancreatitis is often complicated by the development of multiple organ failure, which characterizes the severity of the pathology and makes the prognosis of patient recovery dubious. It was noted that in some cases, multiple organ failure develops as a result of intra-abdominal hypertension (intra-abdominal hypertension (YAG), when intra-abdominal pressure reaches 12 mm Hg). Multicenter epidemiological studies over the past 5 years have revealed that YAG is detected in 65% of patients with urgent surgical abdominal pathology. Moreover, YAG syndrome (SIAH) develops in 8, 2% of cases of YAG [Gubaydullin P.P. Disorders in the oxygen transport system and ways of their correction in patients with intraperitoneal hypertension in the perioperative period (2005), dis ... Dr. med. sciences .; Khripun A.I. (1999). Prevention and treatment of paralytic ileus in conditions of widespread peritonitis (clinical and experimental research), dis ... Dr. med. sciences. M .; Malbrain ML, Chiumello D, Pelosi P, et al (2005) Incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: a multiple-center epidemiological study. Crit Care Med 33: 315-322].

Intraabdominal hypertension leads to impaired function of many vital organs located in the abdominal cavity and adjacent to it (multiple organ failure develops). As a result, intra-abdominal hypertension syndrome develops (SIAH; English abdominal compartment syndrome). Syndrome of intra-abdominal hypertension is a persistent increase in intra-abdominal pressure (IOP) - more than 20 mm RT. Art., which is associated with newly arising organ failure / dysfunction - with abdominal perfusion pressure (APD) of less than 60 mm Hg. Art. or without it.

To date, no one doubts the participation of serotonin in the implementation of the motor-evacuation function of the gastrointestinal tract. The main part of serotonin is found in enterochromatofin cells of the intestinal epithelium, mainly in the crypt region. Serotonin is intracellularly synthesized from L-tryptophan and stored in secretory granules [Minami M. Pharmacological aspects of anticancere drug-induced emesis with emphasis on serotonin release and vagal nerve activity / M. Minami, T. Endo, M. Hirafuji // Pharmacol. Ther. - 2003. - Vol. 99, N 2. - P. 149-165]. Serotonin is also present in serotonergic neurons of the small intestine nervous system.

On the basis of experimental and clinical studies, it was found that, in pathological conditions in the body, smooth muscle dysfunction resulting from a violation of the interaction of serotonin with its receptors leads to impaired endogenous vasomotorism, impaired microcirculation, local and regional hypoxia, tissue damage and necrosis.

In the future, smooth muscles are unable to perceive nerve impulses due to pronounced metabolic and intracellular electrolyte disturbances. All this leads to a stretching of the intestinal loops and an increase in intracavitary pressure, leading to damage to both the entire digestive system and other functional systems of homeostasis [Simonenkov A.P. Prevention and treatment of serotonin deficiency in surgical patients / A.P. Simonenkov, V.D. Fedorov // Surgery. - 2003; Number 3. - S.76-80. Simonenkov A.P. The use of serotonin adipate to restore impaired smooth muscle function in surgical and therapeutic patients / A.P. Simonenkov, V.D. Fedorov, V.M. Klyuzhev et al. // West. Int. ter. - 2005. - No. 1. - S. 53-57].

An objective assessment of the severity of the patient's condition and determining the likelihood of an unfavorable outcome of the disease course present certain difficulties. To date, there are several approaches to solving this problem. One of them is the use of the widespread integrated scale for assessing the severity of the state of APACHE II. The APACHE system was created to stratify patients at the risk of nosocomial mortality, currently using the modified APACHE system - APACHE II. It includes 12 physiological parameters, each of which was evaluated in the range from 0 to 4 points depending on the degree of deviation from the norm. The total number of points is the sum of physiological parameters, with the exception of the Glasgow Coma Score (GCS -Glasgow Coma Score), for which the number of points in the APACHE II system is 15 minus GCS. For evaluation, the worst values are used in the first 24 hours from the moment of admission to the ICU. The total number of “physiological” points is summed up with points for age (from 0 to 6) and points for evaluating chronic diseases for patients with organ failure (from 2 to 5, depending on the need and urgency of surgical treatment). The prognostic value of the scale is most significant during the first 32 hours from the moment a patient enters the intensive care unit. This scale showed high sensitivity (97%) and low specificity (49%). APACHE was designed to stratify patient groups based on the risk of death.

In accordance with the modern understanding of the pathogenesis of the development of acute pancreatitis, this is a pathological process, during the evolution of which there is a change in phases and periods that have important pathomorphological and pathophysiological features. This must be taken into account in the diagnostic and medical process. From these positions, two main phases of the disease are considered: 1st - the phase of toxemia, 2nd - the phase of destructive complications. The first phase is the toxemia phase, lasts 7-10 days from the onset of the disease, two periods are distinguished in it. The period of acute hemodynamic disturbances - occurs on the 1-2 day from the onset of the disease. The period of "early" multiple organ failure - from 4-5 on the 7-10th day of illness. The second phase is the phase of destructive complications (7-10th day from the onset of the disease).

In the course of our clinical studies and observations, it was found that the greatest complications and operational-tactical errors occurred in patients with IOP values exceeding 20 mmHg, the severity of the condition on the APACHE II scale is more than 17 points, and the concentration of blood serotonin is 500 ng / ml

In FIG. Figures 1-6 show graphs of a temporary change in the measured indicators of IAP, blood serotonin concentration, and APACHE II indicators, depending on which the patient is assigned to one of two possible groups:

1st group - a group of patients with a relatively favorable course of acute destructive pancreatitis, with the possibility of conservative therapy;

Group 2 - a group of patients with severe acute destructive pancreatitis requiring early decompression interventions on the retroperitoneal tissue.

Considering the many-sided and pronounced pathological effect of intra-abdominal hypertension on perfusion of the abdominal cavity organs and splanchnic blood flow, the effect of low concentrations of serotonin in the blood on the motor-evacuation function of the gastrointestinal tract, it seems quite reasonable and advisable to predict the severity of the course in patients with acute destructive pancreatitis based on the measurement of indicators of IAP, concentration blood serotonin, calculating the APACHE II rating scale [Anesthesiologist Pocket Guide. Ed. Gologorsky V.A. and Gelfand B.R. M., 1998, p. 150].

In our opinion, these three indicators and the nature of their changes are necessary and sufficient for predicting the severity of the course of the disease and choosing the most optimal therapeutic tactic, which will allow to avoid operational tactical errors.

Thus, we came to the conclusion to use these indicators as basic criteria in choosing the right treatment tactics.

Information on the use of these indicators in predicting the severity of acute destructive pancreatitis in the available scientific and medical literature has not been identified.

A detailed description of the method and examples of its clinical implementation

In patients with acute destructive pancreatitis, from the moment of admission to the intensive care unit and intensive care unit (ICU), serotonin concentration is determined daily in the blood serum by high-performance liquid chromatography, the severity of the patient's condition is assessed using the APACHE II scale, and the abdominal pressure (IOP) is additionally measured. To measure intra-abdominal pressure according to the generally accepted method (gold standard), an urethral catheter installed in the bladder is used. Measurement of IOP is carried out according to the generally accepted method [Malbrain ML (2004) Different techniques to measure intra-abdominal pressure (IAP): time for a critical reappraisal. Intensive Care Med 30: 357-371]. The degree of intra-abdominal hypertension (HBV) is determined in accordance with the gradation of M.L. Malbrain et al. (2005).

Determine the concentration of serotonin in blood serum by high performance liquid chromatography (HPLC) with electrochemical detection on a Chromsystems semi-automatic chromatograph test 999SER.

The necessary indicators for calculating the APACHE II rating scale are obtained from the table where each indicator (for example, blood pressure) has a point, as a result, all the patient's points are summed up, and according to a pre-existing template they are assigned one or another percentage. This percentage indicates the risk of death.

Based on the analysis of the obtained indicators of IOP, blood serotonin concentration, APACHE II indicators on the 2nd day, 4-5th day and 7th day from admission to the intensive care unit and intensive care unit (ICU), the severity of acute destructive pancreatitis is predicted and the patient is referred to one of two possible groups:

1st group - a group of patients with a relatively favorable course of pancreatic necrosis, with the possibility of conservative therapy;

Group 2 - a group of patients with severe pancreatic necrosis requiring early decompression interventions on the retroperitoneal tissue.

The criteria for inclusion of the patient in the 1st group include:

1) if on the 2nd day from admission to the intensive care unit (ICU), the intra-abdominal pressure rises within 1-2 degrees (up to 20 mm Hg), and then decreases by 4-5 days without further increase;

2) if on the 2nd day the concentration of blood serotonin decreases to 23 ng / ml, and then increases by 4-5 days with a subsequent tendency to normalize this indicator (100-120 ng / ml);

3) if on the 2nd day the APACHE II scale indicator rises to 17 points and higher, then decreases to 4-5 days without a subsequent increase.

The criteria for inclusion of the patient in the 2nd group include:

1) if, on the 2nd day from admission to the intensive care unit (ICU), the intra-abdominal pressure rises within 1-2 degrees (up to 20 mmHg), then decreases to 4-5 days and rises again to 2-3 Art. (more than 25 mm Hg) without a tendency to normalize;

2) if on the 2nd day the concentration of blood serotonin rises above 500 ng / ml, then on the 4th-5th day it decreases to 21-23 ng / ml;

3) if on the 2nd day the APACHE II score rises to 17 points, then decreases by 4-5 days with a subsequent increase.

The performance of the claimed method is confirmed by the following clinical examples.

Clinical example 1

Patient Sh-ova, 75 years old, medical history from 09/17/15, was admitted by ambulance to the surgical department, from where she was transferred to the intensive care and intensive care unit (ICU) with a diagnosis of acute destructive pancreatitis. On admission, the patient’s condition is of moderate severity, the skin is pale pink in color, covered with cold sweat. There is hard breathing in the lungs on both sides, no wheezing. NPV 19 per minute. Blood pressure 100/80 mm Hg, heart rate 90 per minute. The tongue is dry, coated with a gray coating, the abdomen is not swollen. On palpation, the abdomen is painful in all departments, mainly in the upper sections. The positive symptoms of peritoneal irritation are determined. Percussion in the sloping places of the abdomen is determined by dullness, auscultation of peristalsis is sharply weakened. In the general analysis of blood leukocytosis 15.2 × 10 ⁹ / l, in a biochemical blood test hyperamylasemia (1978 U / l). According to the ultrasound study: there is free fluid in the abdominal cavity up to 500 ml, effusion in the stuffing bag, the presence of diffuse changes in the pancreatic parenchyma.

Serotonin concentration was determined daily in blood serum by high performance liquid chromatography, the severity of the patient's condition was assessed using the APACHE II scale, and intraperitoneal pressure was measured.

On the 2nd day from admission to ICU, the rate of intra-abdominal pressure of 20 mm RT. Art., the concentration of blood serotonin 23 ng / ml, indicator ARANE II 17 points. September 21, 2015 (on the 4th day), the concentration of blood serotonin 78 ng / ml, an indicator of intra-abdominal pressure of 16 mm RT. century, the ARANE II indicator is 11 points, which, based on our methodology, indicated the possibility of conservative therapy and a relatively favorable prognosis of acute destructive pancreatitis. Intensive conservative treatment was carried out (prolonged epidural analgesia, antibacterial drugs, proteolysis inhibitors, sandostatin analogs, detoxification therapy, infusion therapy with water-salt and glucose-electrolyte solutions with forced diuresis). Against the background of the ongoing therapeutic measures, the general condition of the patient stabilized, the phenomena of pancreatogenic peritonitis stopped, the indices of the cardiovascular and respiratory systems stabilized. The patient was transferred from ICU to the specialized department, where multicomponent conservative therapy was continued. The outcome is recovery.

Clinical example 2

Patient Peninsula, 45 years old, medical history from 09/22/15, was admitted on an emergency basis with a diagnosis of acute calculous cholecystitis. Upon admission, the patient's condition is moderate, the skin is pale pink in color. There is hard breathing in the lungs on both sides, no wheezing. NPV 17 per minute. Blood pressure 130/80 mm Hg, heart rate 89 per minute. The tongue is dry, coated with a gray coating, the abdomen is not swollen. On palpation, the abdomen is soft, painful in the epigastrium and right hypochondrium. Percussion over the entire surface of the abdomen is determined by tympanitis, auscultation is sluggish peristalsis. In the general analysis of blood leukocytosis 17.2 × 10 ⁹ / l, in a biochemical study of blood hyperamylasemia (1854 U / l). According to the ultrasound study: there is free fluid in the abdominal cavity up to 200 ml, effusion in the stuffing bag, the presence of diffuse changes in the pancreatic parenchyma.

Serotonin concentration was determined daily in blood serum by high performance liquid chromatography, the severity of the patient's condition was assessed using the APACHE II scale, and intra-abdominal pressure was measured.

On the 2nd day from admission to the intensive care unit and intensive care unit (ICU), the intra-abdominal pressure indicator was 18 mm Hg, the blood serotonin concentration was 512 ng / ml, the ARANE II indicator was 17 points.

On the 5th day (September 27, 2015), the rate of IAP decreased to 13 mmHg. Art., then again increased to 2-3 Art. (26 mmHg) without a tendency to normalize. Blood serotonin level is 21 ng / ml. The APACHE II scale dropped to 12 points, then rose again to 27.

Based on our methodology, the tactics of performing early decompression interventions on the retroperitoneal fiber was chosen due to the risk of severe acute destructive pancreatitis. A laparoscopic cholecystectomy, dissection and drainage of enzymatic streaks, pancreatic necrosecrectrectomy, and abdominal drainage were performed. In the postoperative period, the concentration of blood serotonin is 22 ng / ml, the indicator of intra-abdominal pressure is 13 mm Hg, the index of ARANE II is 11 points.

On September 30, 2015, to stabilize the patient's condition, he was transferred to the specialized department of further treatment, where multicomponent conservative therapy, stage dressings were continued, and a flushing system was installed. The outcome is recovery.

The proposed method for the treatment of patients with acute destructive pancreatitis was tested by us on 113 patients. Our treatment results showed a decrease in the number of complications by 20.7%, a decrease in overall mortality by 11.4%. The measurement data of the studied parameters in the clinical groups studied by us are presented in the table.

The proposed method has the following advantages:

1. Allows with high accuracy to identify patients with severe acute destructive pancreatitis, requiring early decompression interventions on the retroperitoneal tissue.

2. It allows to improve the results of treatment of patients with acute destructive pancreatitis, to reduce the number of complications and mortality due to timely adequate treatment tactics.

The inventive method for choosing the tactics of treating patients with acute destructive pancreatitis was tested on sufficient clinical material, showed the effectiveness of the application and can be recommended for use in specialized surgical hospitals.

Claims (1)

A method for choosing the tactics of treating patients with acute destructive pancreatitis by examining the patient’s blood and assessing the condition using a questionnaire scale, characterized in that upon admission to the intensive care unit and intensive care unit (ICU), serotonin concentration is determined daily in the blood serum by high performance liquid chromatography, and the severity of the patient’s condition is assessed on the APACHE II scale and additionally measure the abdominal pressure, if on the 2nd day from admission to the ICU, the intra-abdominal pressure rises within 1-2 Degree to 20 mm Hg and then for 4-5 days with no further increase is reduced; on the 2nd day, the concentration of blood serotonin decreases to 23 ng / ml, and then by the 4-5th day it rises with a subsequent tendency to normalize this indicator - 100-120 ng / ml; on the 2nd day, the APACHE II score increases to 17 points and higher, then decreases to 4-5 days without a subsequent increase - choose the tactics of conservative therapy; if on the 2nd day from admission to the ICU, the intra-abdominal pressure rises within 1-2 degrees to 20 mm Hg, then decreases by 4-5 days and again rises to 2-3 degrees - more than 25 mm Hg .st., without a tendency to normalize; on the 2nd day, the concentration of blood serotonin rises above 500 ng / ml, then on the 4th-5th day it decreases to 21-23 ng / ml; if on the 2nd day the APACHE II scale indicator rises to 17 points, then decreases by 4-5 days with a subsequent increase - the tactics of performing early decompression interventions on the retroperitoneal tissue is chosen.

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