RU2631561C1 - Method for treating acute widespread purulent peritonitis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: intra-abdominal sanation and intestinal peritoneal-intestinal lavage is carried out with the use of ozone under the control of intra-abdominal pressure. At the same time, sanation of the abdominal cavity is carred out with 1500-2000 ml of ozonized physiological solution with an ozone concentration of 3-6 mg/l and 500-800 ml of ozone-oxygen mixture with an ozone concentration of 15-20 mg/l. Intestinal lavage is carried out with 200-400 ml of ozonized physiological solution with an ozone concentration of 3-4 mg/l under the control of intra-abdominal pressure.

EFFECT: method allows to prevent a critical increase in intra-abdominal pressure, has a pronounced sanative and biostimulating effect, accelerates recovery of motor-evacuator function of the gastrointestinal tract, reduces the intensity of bacterial contamination of the abdominal cavity and intestines, reduces endogenous intoxication, and does not cause adverse reactions.

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Description

The invention relates to medicine and can be used in the surgical treatment of acute disseminated purulent peritonitis (ARHP).

It is known that the only radical method of treatment of ARHP is surgical. The main tasks of surgical intervention for ARH are: source removal, intraoperative rehabilitation and rational drainage of the abdominal cavity, intestinal decompression using a nasogastrointestinal probe.

One of the main stages of surgical intervention for peritonitis, which directly affects the final result of treatment, is the rehabilitation of the abdominal cavity. The main tasks when washing the abdominal cavity are its mechanical cleansing and bactericidal effect on the microflora of peritoneal exudate in order to reduce the degree of bacterial contamination. Intraoperative washing of the abdominal cavity allows mechanical removal of microorganisms and toxic substances contained in the exudate and on the surface of the inflamed peritoneum. To achieve adequate abdominal sanitation, 8-12 liters of sterile saline are usually used. An objective criterion for the quality of remediation measures are the results of bacteriological studies of peritoneal flushing. With full washing of the abdominal cavity, the number of microbial bodies in 1 ml of exudate decreases by several orders of magnitude (from 10 ^8-12 to 10 ^2-3 CFU / ml) (Savelyev BC, Gelfand BR, Filimonov MI Peritonit M. - M .: Litterra, 2006 .-- 208 p.).

Antiseptic solutions are used to reduce the volume of washing liquid and achieve the necessary therapeutic effect. For sanitation of the abdominal cavity, the most commonly used antiseptics are aqueous solutions of chlorhexidine 0.02% in a volume of 1.0-1.5 liters and furatsilin 1: 5000 in a volume of 2.0-3.0 liters. However, chlorhexidine has a negative toxic effect on the body. There are reports of the acquisition of a fairly rapid resistance of microorganisms to a solution of furatsilin, and for some types of bacteria (Pseudomonas aeruginosa, Proteus, etc.) it is a nutrient medium (Nifantiev O.E., Popov AE. Sanitation of the abdominal cavity with diffuse purulent peritonitis / / Clinical Surgery. - 1988. - No. 1 - S. 64-68).

The lack of effectiveness of the used antiseptics prompts the search for more effective and non-toxic antibacterial drugs. In this regard, reports on the antibacterial and biostimulating effect of ozone synthesized in gas-discharge chambers deserve attention. The following properties of ozone are distinguished, which are used in medical practice: bactericidal, fungicidal, virusocidal, spore destruction, improvement of blood supply. In addition, ozone cleans wounds well and accelerates their healing due to improved oxygen supply to the tissues and enhanced metabolic processes (Peretyagin S.P. On the multifactorial mechanism of the therapeutic effect of ozone // Ozone in Biology and Medicine: Mater. 5 All-Russian Scientific and Practical Conf. - N.-Novgorod, 2003 .-- S. 6-7).

Currently, methods of ozone therapy (OT) are successfully used in the complex treatment of peritonitis. Ozonized physiological saline (OGF) is used to rinse the abdominal cavity during surgery after eliminating the source of peritonitis. In the postoperative period, multiple abdominal lavage is also performed. It was found that, unlike many antiseptics, the side toxic effect of FGM is minimal. The effect of OFR with an ozone concentration of 5-8 mg / l on a healthy peritoneum within 10-15 minutes does not cause morphological changes in it (Bulynin V.I., Glukhov A.A. Treatment of peritonitis using ozone and hydropressive technologies // Surgery. - 1999. - No. 7. - S. 9-11). An important stage in performing surgical intervention for ARHP is intestinal decompression, which helps to restore intraorgan hemodynamics and peristalsis in the postoperative period. Decompression intestinal intubation helps to eliminate intra-abdominal hypertension, removes stagnant contents and reduces intoxication, improves intestinal microcirculation, creates favorable conditions for performing surgical intervention, and in the postoperative period there is the possibility of enteral lavage (Petrov V.P., Kuznetsov I.V., Domnikova A.A. Intubation of the small intestine in the treatment of patients with peritonitis and intestinal obstruction // Surgery. - 1999. - No. 5. - S. 41-44).

Experimental and clinical studies of recent decades have convincingly shown a steady increase in interest in the pathological increase in intra-abdominal pressure (IAP) and intra-abdominal hypertension syndrome (SIAH) in critically ill patients. If there is a slight increase in IOP to 15 mmHg, usually observed during a number of diagnostic and surgical procedures and surgical procedures (pneumoperitoneum placement, mechanical ventilation, suturing of the laparotomy wound), as well as some types of metabolic disorders (grade 3-4 obesity) ), does not have a significant negative effect on the functions of vital organs and systems, then the achievement of the WBI level of 15 mm Hg and above is accompanied by serious circulatory disorders of the abdominal and pleural cavity, retroperitoneal space, which can lead to reperfusion damage to the microcirculation bed of the life support organs with subsequent violation of their functions up to complete extinction (Gelfand B.R. et al., 2008, Sukovaty B.S. . et al., 2010; Zubritsky V.F. et al., 2010, Timerbulatov V.M. et al., 2012, Schein M., 2002, Malbrain ML, et al., 2006, Manu LNG., et al ., 2005, Mentula P., et. Al., 2010).

Various treatment forms of ozone have been successfully used in the treatment of ARHP. Sanitation of the abdominal cavity with dissolved ozone is carried out according to the following scheme: during the operation, after eliminating the source of peritonitis, the abdominal cavity is washed with a solution of furatsilin 1: 5000, in the volume of 2.0-3.0 liters and OF in the volume of 2.0-3.0 liters with a concentration ozone 3-6 mg / l (depending on the degree of purulent-inflammatory changes in the peritoneum). The disadvantage of this method is that when conducting uncontrolled intra-abdominal and enteral lavage as a result of the introduction of a solution, there is a risk of an increase in intra-abdominal pressure, up to the development of intra-abdominal hypertension syndrome.

The aim of the present invention is the prevention of intraperitoneal hypertension.

In the proposed method for the treatment of acute disseminated purulent peritonitis (ORGP), including intra-abdominal debridement and intestinal peritoneal-intestinal lavage using ozone under the control of intra-abdominal pressure, abdominal sanitation is carried out with 1500-2000 ml of ozonized physiological saline (OGF) with an ozone concentration of 3-6 mg / l and 500-800 ml of ozone-oxygen mixture (ACS) with an ozone concentration of 15-20 mg / l, and intestinal lavage is carried out with 200-400 ml of OGF with an ozone concentration of 3-4 mg / l under the control of intra-abdominal pressure (IAP).

The technical result of the invention is the prevention of critical increases in intra-abdominal pressure, due to the combination of intra-abdominal rehabilitation and intestinal lavage using therapeutic forms of ozone in the form of an ozone-oxygen mixture (ACS) and ozonized physiological saline (RB) under the control of intra-abdominal pressure.

The method is as follows. In contrast to the abdominal lavage technique proposed by A. Glukhov, postoperative abdominal sanitation is carried out according to the following scheme: 1500-2000 ml of RPF are injected into one of the proximal tubular drains, and up to 500 are insufflated towards the flow of the solution through one of the distal drains -800 ml of ACS (with an ozone concentration of 15-20 mg / l) using a polymer container. After the simultaneous introduction of FGF and ACS, all the drains are squeezed for 10-15 minutes. After the procedure, the contents of the abdominal cavity passively or actively flow through the drains into the collection tanks. Remediation procedures are carried out for 2-4 days in the amount of 4-6 sessions.

The ozone-oxygen mixture and the ozonized physiological saline solution are obtained on the ozone-therapeutic unit UOTA-60-01 (Medozon, Moscow). In this case, take into account the short half-life of ozone (in 30 minutes, the ozone concentration decreases by more than 50%). The introduction of gaseous ozone with a concentration of 15-20 mg / l into the abdominal cavity allows you to maintain a high ozone content in the sanitizing solution.

For antibacterial and detoxification effect, enteric lavage of OGF is performed using a nasogastrointestinal probe. OGFs with an ozone concentration of 3-4 mg / L in a volume of 400-600 ml are fractionally injected into the intestinal tube and intestinal contents are actively aspirated after 5-10 minutes of exposure. Enteral lavage OFR is performed daily for 2-4 days until the restoration of effective intestinal motility. Intestinal ozone dialysis not only effectively eliminates bacterial contamination and reduces the toxicity of intestinal contents, but also accelerates the restoration of the motor-evacuation function of the gastrointestinal tract, improves blood circulation and reduces tissue hypoxia.

The measurement of IOP is carried out according to the method of M. Cheatham et al. (1998), using a Foley urinary catheter connected in series through a tap to a syringe and a low-pressure monitoring device URiMND-10-01. Manometry begins in the preoperative period with the establishment of a urinary catheter.

The essence of the invention lies in the fact that intra-abdominal and intestinal lavage is carried out under continuous monitoring of IOP. In this case, a certain algorithm of medical manipulations is observed. First perform intestinal lavage OFR. This action is preceded by a measurement of IAP. Intestinal lavage is carried out according to the following scheme: after aspiration through the intestinal probe for 3-5 minutes, 200-400 ml of OPF with an ozone concentration of 3-4 mg / l are fractionally injected with a Janet syringe and after 5-10 minutes of exposure the intestinal contents are aspirated. Intestinal lavage is carried out 2 times a day under the control of VBD. The procedure is performed at an IAP level of no higher than 12 mm Hg, which avoids intra-abdominal hypertension with its negative consequences. Intestinal lavage is carried out from 3 to 4 days before the restoration of active intestinal peristalsis and relief of acute phenomena of functional intestinal failure.

Intraperitoneal ozone reorganization begins 20-30 minutes after intestinal lavage under the control of IAP. The invention is illustrated in figure 1.

In one of the proximal tubular drains (2) from a container (1), 1500-2000 ml of RPF (3) with an ozone concentration of 3-6 mg / l are injected in a jet, and up to 500- are insufflated towards one of the distal drains (4) 800 ml of ACS (with an ozone concentration of 15-20 mg / l) using a polymer container (5). The rate of intraperitoneal administration of FGF and ACS is determined by the level of IOP, the value of which should not exceed 12 mm Hg. (the higher the IOP, the lower the rate of administration). After the introduction of the sanitizing solution, all the drains are squeezed for 10-15 minutes, and then the contents of the abdominal cavity passively and actively (aspiration with an electric suction pump or with a Janet syringe) flows through the drains into collection containers. During rehabilitation lavage, the level of IAP did not exceed the initial digital values by no more than 4-8 mm Hg, which avoids the development of intra-abdominal hypertension. Intra-abdominal lavage OFR and ACS spend 2 times a day for 2-4 days. An indication for the termination of sanitation ozone intra-abdominal lavage is: a decrease in bacterial infection of peritoneal exudate to 10 ⁴ CFU / ml or the absence of microflora growth; serous effusion from the abdominal cavity without fibrin; restoration of the motor function of the gastrointestinal tract (reduction in the amount of discharge through the gastric tube to 100-150 ml); leveling signs of endotoxemia (the severity of the condition of patients on a SOFA scale of 4 points, a decrease in LII to 1.5 srvc. units); decrease in IAP to 6-8 mm Hg

Clinical example: patient K., 58 years old, was admitted on February 26, 2013 to the COCH with clinical signs of peritonitis of unknown origin. WBD was 22 mm Hg. After preoperative preparation, a median laparotomy was performed, the diagnosis of gangrenous-perforated appendicitis complicated by widespread fibrinous-purulent peritonitis was established. The patient underwent appendectomy, the stump of the process is immersed in purse-string and Z-shaped sutures. Sanitation of the abdominal cavity with sterile nat. solution and drainage by tubular drains. The laparotomic wound is sutured in layers. In a bacterial study of effusion from the abdominal cavity and intestinal probe, 2 types of microorganisms were seeded: E. coli - 10 ⁸ CFU / ml and Enterococcus fasselifavus 10 ⁸ CFU / ml, while sensitivity to all antibiotics was noted. The level of IAP in the first 3 days after surgery ranged from 16 to 20 mm Hg. On the 4th day after the operation, against the background of moderate intestinal paresis and fever up to 38 ° C, suppuration of the postoperative wound was revealed. WBD - 23 mm Hg On the 5th day, the postoperative period was complicated by subcutaneous eventation. The patient underwent relaparotomy, revealed a picture of progressive peritonitis: in the abdominal cavity there is a turbid effusion up to 600 ml in volume, the intestinal loops are edematous, hyperemic, their diameter is increased to 40-45 mm, peristalsis is weakened. Performed nasogastrointestinal intubation of the small intestine, sanitation of the abdominal cavity OFR (with an ozone concentration of 6-8 mg / l, in a volume of 2000 ml), rerenalization of the abdominal cavity, postoperative wound sutured. In the postoperative period, fractional lavage of OGF and ACS and intestinal lavage were performed daily according to the above scheme under the control of VBD. Subsequently, the postoperative period was uneventful. On the 1st day, WBD was 18-19 mmHg, on the 2nd day, 14-15 mmHg, on the 3rd 12 mmHg On the 4th day, active intestinal motility appeared, along the probe with 300 ml of light gastric discharge, with safety drains 100-150 ml of serous effusion, and VBD was 8-10 mm Hg. On day 10, the sutures were removed from the postoperative wound and the patient was discharged from the COCH. In a bacterial study of effusion from the abdominal cavity and intestinal probe, microorganisms were not sown. The given example shows the effectiveness of ozone intra-abdominal sanitation and intestinal lavage and the importance of monitoring IAP in the postoperative period in patients with advanced peritonitis for the timely detection of YAG, possible postoperative complications and the development of the correct tactics of patient management.

The best sanation and detoxification effects in the main group (28 patients) were obtained with the combined use of OGF and ACS, which is obviously associated with an improvement in the mechanical purification of the peritoneum and a local increase in the concentration of active oxygen, which has a universal bactericidal effect and the ability to neutralize toxic metabolic products. The use of OGF and ACS for peritoneal lavage significantly reduces the bacterial contamination of the peritoneum, which largely determines the success of treatment of endogenous intoxication syndrome and a decrease in the number of intra-abdominal and wound suppurative inflammatory complications in the postoperative period by 23.7% and mortality by 18.2%. However, the results showed that bacteriological studies are the indicator that allows you to fairly objectively evaluate the effectiveness of peritoneal lavage. Based on quantitative bacteriological control, it is possible to objectively judge the degree of infection of the abdominal cavity, to indicate the need for relaparotomy with the subsequent decision to extend peritoneal lavage, or to give an opinion on the completion of this manual. It must be borne in mind that the intestine with peritonitis becomes the main source of infection of the abdominal cavity with anaerobic and aerobic microflora and therefore even the most effective sanitation of the abdominal cavity without the use of techniques aimed at combating intestinal intoxication is often insufficient. With intubation and decompression of the intestine, followed by lavage of FGM, it is possible not only to reduce IAP and intestinal pressure by removing stagnant toxic intestinal contents, but also to accelerate the relief of endotoxemia. It must be borne in mind that SFR contains a rather high concentration of dissolved oxygen (pO ₂ is 850–920 mm Hg). Therefore, the use of this therapeutic form of ozone has not only a pronounced debilitating effect, but also helps to reduce hypoxia of the intestinal wall, the restoration of microcirculation and intestinal function. The effectiveness of enteral lavage was evaluated by clinical signs, flow rate and nature of the discharge by the enteral probe, as well as microbiological analysis of intestinal contents taken before and after the procedure. After 1–2 days of enteric lavage of FGD, peristaltic murmurs usually appear. At the same time, the amount of separated contents in the naso-intestinal probe was clearly reduced, the intestinal contents lost an unpleasant odor and became light. On days 2-3, in 86% of patients adequate peristalsis was restored and by the end of 3-4 days an independent stool appeared. The flow rate of intestinal discharge was reduced to 150-200 ml, which, together with other signs of restoration of intestinal motility, was an indication for removal of the enteral probe. Along with this, a rapid decrease in the concentration of microorganisms in the intestinal contents was noted. On the 2-3rd day of the postoperative period, the titer of microbial bodies (E. coli, Klebsiella spp., Proteus spp., Pseudomonas spp., Acinetobacter and other gram-negative bacteria) decreased by 2-3 orders of magnitude, and in 68% of observations, the sowing of the discharge on the nasointentinal probe does not exceed 10 ³ CFU ml of intestinal contents. In the control group (56 patients), in which intestinal lavage was performed with physiological saline of sodium chloride in the same volumes, the recovery of the motor-evacuation function of the gastrointestinal tract was slower. In addition, on the 3-4th day, a high titer of the content of microorganisms was maintained, amounting to 10 ⁵ -10 ⁶ CFU / ml.

Thus, the proposed method for the treatment of OGRP through the use of therapeutic forms of ozone in the form of OGF and ACS during intraperitoneal and enteral lavage under the control of IOP monitoring allows to obtain a distinct therapeutic effect, preventing the development of intraperitoneal hypertension.

The proposed method provides a reduction in endogenous intoxication, reliable sanitation of the peritoneum and helps restore intestinal functions.

The proposed method has the following advantages:

1) has a pronounced debridement and biostimulating effect;

2) accelerates the restoration of the motor-evacuation function of the digestive tract;

3) reduces the intensity of bacterial contamination of the abdominal cavity and intestines;

4) provides a decrease in endogenous intoxication;

5) is cost-effective and does not cause adverse reactions;

6) can be successfully used in the treatment of patients with ARHP.

Claims (1)

A method for the treatment of acute disseminated purulent peritonitis, including intra-abdominal sanitation and intestinal peritoneal-intestinal lavage using ozone under the control of intra-abdominal pressure, characterized in that the abdominal sanitation is carried out in 1500-2000 ml of ozonized physiological solution with an ozone concentration of 3-6 mg / l and 500 -800 ml of ozone-oxygen mixture with an ozone concentration of 15-20 mg / l, and intestinal lavage spend 200-400 ml of ozonized physiological solution with an ozone concentration of 3-4 mg / l under the control of intraperitoneal the detection.

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