RU2653685C1 - Method of draining forearm phlegmon - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery, and can be used in the treatment of patients with superficial and deep phlegmons of the forearm. Method of draining phlegmon of forearm includes opening the purulent focus, necrectomy, sanitation and draining the wound. Active drainage is carried out through two silicone tubes. 5 mm diameter lead tube is used which is perforated along the length of the wound by 4 rows of circumferentially spaced holes, each 3 mm in diameter, applied along the tube 5 mm in staggered order. Outflow tube with a diameter of 8 mm along the length of the wound is perforated with 5 rows of oval shaped circular holes, each 6 mm long and 2 mm wide, staggered along the tube 7 mm. Leading and outgoing silicone tubes are laid on the bottom of the wound parallel to each other at a distance of at least 10 mm between each other so that the perforations on them are staggered relative to each other. Proximal ends of the leading and outgoing silicone tubes are withdrawn through two spaced from opposite corners of the wound at a distance of at least 3 cm of each puncture cut and fixed to the skin. Then edges of the wound are brought together and fixed by gluing the Suprasorb F film bandage, after which the Cellona lining synthetic cotton wool is applied over the wound as a bandage. Active drainage of the wound is performed with a perfusor for 12 hours at intervals of 6 hours. In this case, a washing liquid is introduced through the leading silicone tube: medicinal preparations of dioxidine – 50 ml, pepsin – 20 mg and cefotaxime – 2 g dissolved in 2,000 ml of a 0.9 % sodium chloride solution. In each interval between the drains, the wound is bandaged, for which purpose the edges are treated with an antiseptic solution and brought together. Wound is fixed by gluing the Suprasorb F film bandage, and the Cellona lining synthetic cotton wool is applied over the wound as a bandage. After reaching the inflammatory type of the cytogram of the wound being separated from the wound, the administration of pepsin and cefotaxime is stopped, and introduction of a solution of dioxidine in the same concentrations and regimes is continued until a clean washing liquid separates from the discharge silicone tube. Drainage tubes are then removed.

EFFECT: method is easy to implement, effective, allows to drain both deep and superficial phlegmons of the forearm and practically excludes the development of postoperative complications in the long term.

1 cl, 2 ex

Description

The invention relates to medicine, namely to surgery, and can be used in the treatment of patients with superficial and deep phlegmons of the forearm.

The problem of treating purulent diseases of soft tissues, and in particular phlegmon of the forearm, remains one of the most complex and socially significant problems of modern surgery. The main method of treating this disease is surgical, including opening the purulent foci, draining the purulent cavity to ensure an adequate outflow of exudate. Inflammatory and degenerative processes that occur in tissues during prolonged wound healing, as a rule, lead to pronounced cicatricial changes in the area of surgical intervention, cosmetic defects, a decrease in the functional ability of the limb and the quality of life of patients.

Despite the fact that there are many different methods of drainage, the results of treatment often remain unsatisfactory, which confirms the need to develop highly effective methods of drainage of phlegmon of the forearm.

Conducted a search in the scientific, medical and patent literature, various methods of draining purulent wounds were found.

The USSR copyright certificate No. 1457933 (publ. 02.15.1989, Bull. No. 6) protected "Method of purulent wounds drainage and device for its implementation." Perform mechanical cleaning of a closed wound from purulent necrotic masses and blood clots. To do this, the ends of the tube are brought out, fixed to the skin with elastic shells. When the openings of the tube are occluded by the contents of the wound, the tube is reciprocated. The disadvantages of this technique are its lack of effectiveness, due to passive drainage of the purulent-inflammatory process in the stage of pronounced purulent exudation in the wound, the absence of outflow during hermetic closure of the wound cavity through the lumen of a single drainage tube in the absence of a pressure difference with the environment, which leads to the accumulation of exudate, intensive reproduction of bacteria in the focus of inflammation and disease progression with the development of purulent-septic complications and lengthening the term Eden.

The USSR copyright certificate No. 1806771 (publ. 04/07/1993, Bull. No. 13) protected "Method of purulent wounds drainage and device for its implementation." For drainage use a drainage tube made of elastic material, made corrugated in a spiral. In the middle of the tube, a linear incision is applied to the half of the length of the wound cavity through an internal spiral. The purulent cavity is opened, cleaned, washed, and then a tube is placed on its bottom in the closed state of the coils of the spiral. The ends of the tube are removed through separate punctures and connected to a drip infusion system. In the process of wound regeneration, the spiral is stretched every 12 hours for the outer sections of the tube and rotated over the protruding parts of the tube by one step of the corrugation spiral, on the one hand, clockwise, on the other, counterclockwise. In the absence of a detachable tube is removed. The disadvantages of this technique are its lack of effectiveness, since tubular drainage in the form of a spiral has a traumatic compression effect on the functional structures of the forearm, such as tendon flexors and extensors, which can lead to the development of cicatricial contractures.

In the work of Kanshin N.N. The principles of closed aspiration-washing treatment of contaminated and festering wounds // Surgery. - 1989. - No. 6. - P. 112-115 describes a technique for draining purulent wounds. To remove wound exudate, a double-lumen tube is used, through the small channel of which a washing antiseptic is introduced. Through a large channel, the contents are removed from the cavity. The disadvantage of this technique is its lack of effectiveness, since antibacterial drugs mainly contact the tube walls and interact surprisingly little with wound tissues and microflora, which lengthens the treatment time and increases the frequency of complications (Blueman D. The use of larval therapy to reduce the bacterial load in chronic wounds / D. Blueman, C. Bousfield // J Wound Care. - 2012 May. - Vol. 21, N 5. - P. 244-53).

In the work of Kholamkhanov K.X., Gadzhiev H.A. The method of active drainage and activity control of the inflammatory process of postoperative wounds // Sat. articles of the International scientific and practical conference Actual problems of medicine of the XXI century, April 28, 2014, Ufa: Aeterna, 2014. - P. 12-13 describes a method for draining purulent wounds using a perforated silicone tube. The method is as follows. Both ends of the silicone tube are led out through additional cuts-punctures at a distance of 3-5 cm from the corners of the wound, and the perforations are left completely at the bottom of the wound. The wound is sutured, both ends of the tube are fixed to the skin with a ligature. A cap is put on one end of the tube, and an accordion is put on the other. From time to time, 1-2 times a day, the plug and accordion are removed, the ferritin level is examined in the exudate obtained from the drain, 50-100 ml of an antiseptic solution is injected through the end of the tube where the plug was installed, an accordion is put on the opposite end of the tube, and it is forced to manually stretch it, removing contents from a postoperative wound. Then the accordion is removed, washed, and the cap and accordion are again put on both ends of the tube. The disadvantage of this method is its lack of effectiveness, since the method does not provide adequate continuous active drainage of the surgical wound, which contributes to clogging of the drainage with blood clots and fibrin, and as a result, leads to the development of purulent-septic complications

In the work of Yu.Z. Lifshits, Vasetskiy A.M., Zaichenko P.A., Doskuch O.A. Successful treatment of a patient about phlegmon of the right forearm using the negative pressure method // Clinical Surgery - 2015, No. 3, p. 77-78 describes the method of draining the phlegmon of the forearm. For local treatment of wounds, the negative pressure method using the VOUNDEX system is used. At the same time, 3 VAC dressings are changed at intervals of 72 hours with a constant negative pressure of 120 mm Hg. Each change of the VAC dressing was accompanied by the application of adaptive guiding sutures to the edges of the wound due to a decrease in tissue edema. On the 9th day of treatment, autodermoplasty was performed and a vacuum dressing was applied in a constant gentle mode of negative pressure. Bandage exposure - 78 hours. The total duration of treatment is 32 days. The disadvantage of this method is its complexity, duration of treatment, and the inability to judge its effectiveness by the result of a single observation.

Closest to the claimed technical solution is the method of drainage phlegmon of the forearm, described in the work of A. Shafirov Justification of the tactics of surgical treatment of deep phlegmon of the forearm (clinical anatomical study): author. dis. Cand. honey. Sciences, Rostov-on-Don, 2005, 28 pp. This method is selected for the prototype. The method involves opening a purulent focus, necrectomy, sanitation of a purulent cavity with antiseptic solutions, wound drainage, ultrasound treatment (cavitation) of a wound in a 0.05% aqueous chlorhexidine solution and daily irrigation with ozonized solutions.

The disadvantage of the prototype is its lack of effectiveness, due to the limited functionality of the method - only for deep phlegmon, the complexity of the technique due to the need for specialized equipment for its implementation, as well as the possibility of the development of long-term postoperative complications, such as peripheral nephritis, parasthesia, myofascial pain, contracture, etc., the number of which according to the author is 10% of the number of treated patients.

The task of the invention is to develop a highly effective method of drainage phlegmon forearm.

The technical result manifested in the implementation of this method is to simplify the method, expand its functionality when draining both deep and superficial phlegmons of the forearm, as well as increase efficiency by reducing the development of long-term postoperative complications.

The technical result is achieved by opening a purulent lesion, performing a necrectomy, debridement and active drainage of the wound through two silicone tubes: a lead and a discharge. The lead silicone tube with a diameter of 5 mm along the length of the wound is punched with 4 rows of holes arranged in a circle, each with a diameter of 3 mm, deposited along the tube through 5 mm in a checkerboard pattern. An outlet silicone tube with a diameter of 8 mm along the length of the wound is punched with 5 rows of oval-shaped holes located in a circle, each 6 mm long and 2 mm wide, deposited along the tube through 7 mm in a checkerboard pattern. The lead and outlet silicone tubes are laid on the bottom of the wound parallel to each other at a distance of at least 10 mm from each other so that the perforations on them are staggered relative to each other. The proximal ends of the lead and outlet silicone tubes are removed through two wounds punctured at a distance of at least 3 cm from each other at opposite angles and fixed to the skin. The edges of the wound are brought together and fixed by sticking a film dressing on Suprasorb F wounds, after which, over the wound, a ZELLON synthetic cotton lining is applied as a bandage. Active drainage of the wound is performed using perfuser for 12 hours with an interval of 6 hours. At the same time, a washing liquid is introduced through the lead-in silicone tube - medicines dissolved in 2000 ml of a 0.9% sodium chloride solution: dioxidine - 50 ml, pepsin - 20 mg, cefotaxime - 2 g. Wound dressing is performed in each interval between drains, for which its edges are treated with an antiseptic solution and brought together, the wound is fixed by gluing a film dressing on Suprasorb F wounds, lining synthetic cellulose CELLON is applied over the wound as a dressing. After reaching the inflammatory type of the wound detachable cytogram, the administration of pepsin and cefotaxime is stopped, and the introduction of a solution of 50 ml of dioxidine in 2000 ml of a 0.9% sodium chloride solution using perfusion for 12 hours at an interval of 6 hours is continued until the discharge from the discharge silicone tube begins clean flushing fluid. After the start of the clean wash liquid from the silicone outlet tube, both drainage silicone tubes are removed.

Detailed description of the method.

In the position of the patient lying on his back after treatment of the surgical field with antiseptic solutions, conduction anesthesia of the brachial plexus is performed. Using a scalpel, cut the skin and underlying soft tissues in the projection of the purulent cavity, open the purulent focus, perform necrectomy, debride the wound with hydrogen peroxide 3%, then with an aqueous solution of chlorhexidine 0.5%. Measure the length of the wound.

Active drainage of the wound is performed through two silicone tubes: the lead tube with a diameter of 5 mm and the lead tube with a diameter of 8 mm. The lead silicone tube is perforated along the length of the wound in 4 rows of holes arranged in a circle, each with a diameter of 3 mm, deposited along the tube through 5 mm in a checkerboard pattern. The silicone outlet pipe is perforated along the length of the wound with 5 rows of oval-shaped holes arranged in a circle, each 6 mm long and 2 mm wide, drawn along the tube through 7 mm in a checkerboard pattern. The lead and outlet silicone tubes are laid on the bottom of the wound parallel to each other at a distance of at least 10 mm from each other so that the perforations on them are staggered relative to each other. The proximal ends of the lead and outlet silicone tubes are discharged through two wound punctures that are at least 3 cm apart from the opposite corners of the wound. Each proximal end of the lead and outlet silicone tubes is fixed to the skin with a U-shaped suture with a thread In calves or 1/0. The edges of the wound are brought together and fixed by gluing a film dressing on Suprasorb F wounds manufactured by Lohmann & Rauscher (Austria), after which, on top of the wound, CELLON lining synthetic wool manufactured by Lohmann & Rauscher (Austria) is applied as a bandage. Active drainage of the wound is carried out using a perfuser, for example, a pump of the syringe infusion model 2016 of AITECS company (Lithuania), with a constant rate of injection of washing liquid 170 ml / hour for 12 hours with an interval of 6 hours. At the same time, a washing liquid is introduced through the lead-in silicone tube - medicines dissolved in 2000 ml of a 0.9% sodium chloride solution: dioxidine - 50 ml, pepsin - 20 mg, cefotaxime - 2 g. Wound dressing is performed in each interval between drains, for which its edges are treated with an antiseptic solution - an aqueous solution of chlorhexidine 0.5% and brought together, the wound is fixed by gluing a film dressing on wounds Suprasorb F manufactured by Lohmann & Rauscher (Austria), lining synthetic cotton wool CELLONA pr is applied over the wound duction company Lohmann & Rauscher (Austria). This wash liquid is administered until the inflammatory type of the cytogram is separated from the wound. The inflammatory type of cytogram is determined according to the method described in the work Kuzin M.I., Kostyuchenok B.M. Wounds and wound infection - ed. 2nd. - M .: Medicine, 1990 .-- 592 p. In this case, cytological imprints are obtained according to the method of Pokrovskaya and Makarov (Kuzin M.I., Kostyuchenok B.M. Wounds and wound infection - ed. 2nd. - M .: Medicine, 1990. - 592 p.). After the inflammatory type of the cytogram of the discharge from the wound is reached, the administration of pepsin and cefotaxime is stopped, and the administration is carried out with a perfuser, for example, a syringe infusion pump model 2016, manufactured by AITECS (Lithuania), with a constant injection rate of 170 ml / hour for 12 hours with an interval of 6 hours dissolved in 2000 ml of a 0.9% sodium chloride solution, 50 ml of dioxidine is continued until a clean wash liquid leaves the silicone outlet pipe. After the start of the drainage of the clean wash fluid from the silicone drain tube, the active drainage of the wound is stopped, and both drain silicone tubes are removed.

The practical feasibility of the proposed method is confirmed by examples from clinical practice.

Example 1: a patient R-s, 46 years old, was admitted to the surgical department of the Peschanokop central district hospital of the Rostov region with a diagnosis of deep phlegmon of the anterior surface of the forearm. The diagnosis is confirmed by objective examination and laboratory diagnostic methods. Patient R-ov was performed drainage phlegmon forearm according to the claimed method.

In the position of the patient R-s lying on his back after treatment of the surgical field with antiseptic solutions, conduction anesthesia of the brachial plexus was performed. Using a scalpel, the skin and underlying soft tissues were cut into the projection of the purulent cavity, the purulent focus was opened, and necrectomy was performed. Wound sanitation was carried out using hydrogen peroxide 3%, then with an aqueous solution of chlorhexidine 0.5%. Measured the length of the wound. The following value was obtained - 7 cm.

Active drainage of the wound was performed through two silicone tubes: the lead tube with a diameter of 5 mm and the lead tube with a diameter of 8 mm. The leading silicone tube along the wound length of 7 cm was perforated in 4 rows of holes arranged in a circle, each with a diameter of 3 mm, deposited along the tube through 5 mm in a checkerboard pattern. An outlet silicone tube along the wound length of 7 cm was perforated in 5 rows of oval-shaped holes located in a circle, each 6 mm long and 2 mm wide, drawn along the tube through 7 mm in a checkerboard pattern. The lead and lead silicone tubes were laid on the bottom of the wound parallel to each other at a distance of 12 mm from each other so that the perforations on them were staggered relative to each other. The proximal ends of the lead and outlet silicone tubes were brought out through two 3.5 cm each puncture incision, separated from the opposite corners of the wound, after which the proximal end of each tube was fixed to the skin with a U-shaped suture with 1/1 Vikri thread. The edges of the wound were brought closer together and fixed by gluing a film dressing on Suprasorb F wounds manufactured by Lohmann & Rauscher (Austria), after which, on top of the wound, CELLON lining synthetic wool manufactured by Lohmann & Rauscher (Austria) was applied as a bandage. Active wound drainage was performed using a perfusion pump of a syringe infusion model 2016 manufactured by AITECS (Lithuania), with a constant rate of injection of washing liquid 170 ml / hour for 12 hours with an interval of 6 hours. At the same time, a washing liquid was introduced through a lead-in silicone tube — drugs dissolved in 2000 ml of a 0.9% sodium chloride solution: dioxidine - 50 ml, pepsin - 20 mg, cefotaxime - 2 g. Wound dressing was performed in each interval between drains, for which its edges were treated with an antiseptic solution - an aqueous solution of chlorhexidine 0.5% and brought together, the wound was fixed by gluing a film dressing on Suprasorb F wounds manufactured by Lohmann & Rauscher (Austria), and ZELLON synthetic cotton lining was applied over the wound production company Lohmann & Rauscher (Austria). This wash liquid was injected until the inflammatory type of the cytogram was separated from the wound. The inflammatory type of cytogram was determined according to the method described in the work of Kuzin M.I., Kostyuchenok B.M. Wounds and wound infection - ed. 2nd. - M .: Medicine, 1990 .-- 592 p. In this case, cytological imprints were obtained according to the method of Pokrovskaya and Makarov (Kuzin M.I., Kostyuchenok B.M. Wounds and wound infection - ed. 2nd. - M .: Medicine, 1990. - 592 p.). On the 5th day after the start of active drainage, the inflammatory type of the wound discharge was achieved, which was determined by the following indicators: leukocytes in the field of view - 9%, leukocyte destruction - 65%, neutrophils - 45%, lymphocytes - 9%, monocytes - 1% macrophages - 17%, polyblasts - 28%; microflora is found in moderate amounts intracellularly, in a state of incomplete incomplete phagocytosis. After that, the administration of pepsin and cefotaxime was stopped, and the perfusion injection of the pump of the syringe infusion model 2016 manufactured by AITECS (Lithuania) with a constant injection rate of 170 ml / hour for 12 hours with an interval of 6 hours diluted in 2000 ml of a 0.9% solution sodium chloride 50 ml of dioxidine continued. On the 8th day after the start of active drainage, a clean wash liquid began to flow out of the silicone outlet pipe. Active drainage of the wound was stopped, both drainage silicone tubes were removed. On the 12th day of hospital stay, the patient R-s was discharged from the hospital in satisfactory condition.

In the long term, postoperative complications in the patient R-s were not recorded.

Example 2: patient M-ko, 34 years old, was admitted to the surgical department of the central district hospital in Salsk, Rostov Region, with a diagnosis of superficial phlegmon of the anterior surface of the forearm. The diagnosis is confirmed by objective examination and laboratory diagnostic methods. Patient M-Ko was performed drainage phlegmon forearm according to the claimed method.

In the position of the patient M-ko lying on his back after processing the surgical field with antiseptic solutions, conduction anesthesia of the brachial plexus was performed. Using a scalpel, the skin and underlying soft tissues were cut into the projection of the purulent cavity, the purulent focus was opened, and necrectomy was performed. Wound sanitation was carried out using hydrogen peroxide 3%, then with an aqueous solution of chlorhexidine 0.5%. Measured the length of the wound. The following value was obtained - 10 cm.

Active drainage of the wound was performed through two silicone tubes: the lead tube with a diameter of 5 mm and the lead tube with a diameter of 8 mm. The leading silicone tube along the wound length of 10 cm was perforated in 4 rows of holes arranged in a circle, each with a diameter of 3 mm, deposited along the tube through 5 mm in a checkerboard pattern. A silicone outlet pipe along the wound length of 10 cm was perforated with 5 rows of oval-shaped holes arranged in a circle, each 6 mm long and 2 mm wide, drawn along the tube through 7 mm in a checkerboard pattern. The lead and lead silicone tubes were laid on the bottom of the wound parallel to each other at a distance of 12 mm from each other so that the perforations on them were staggered relative to each other. The proximal ends of the lead and outlet silicone tubes were brought out through two 3.5 cm each puncture incision, separated from the opposite corners of the wound, after which the proximal end of each tube was fixed to the skin with a U-shaped suture with 1/1 Vikri thread. The edges of the wound were brought closer together and fixed by gluing a film dressing on Suprasorb F wounds manufactured by Lohmann & Rauscher (Austria), after which, on top of the wound, CELLON lining synthetic wool manufactured by Lohmann & Rauscher (Austria) was applied as a bandage. Active wound drainage was performed using a perfuser - an infusion syringe pump model 2016 manufactured by AITECS (Lithuania), with a constant rate of injection of washing liquid 170 ml / hour for 12 hours with an interval of 6 hours. At the same time, a washing liquid was introduced through a lead-in silicone tube - drugs dissolved in 2000 ml of 0.9% sodium chloride solution in doses: dioxidine - 50 ml, pepsin - 20 mg, cefotaxime - 2 g. This washing liquid was injected until the inflammatory type of cytogram was reached detachable from the wound. The inflammatory type of cytogram was determined according to the method described in the work of Kuzin M.I., Kostyuchenok B.M. Wounds and wound infection - Vol. 2. - M .: Medicine, 1990 .-- 592 p. In this case, cytological imprints were obtained according to the method of Pokrovskaya and Makarov (Kuzin M.I., Kostyuchenok B.M. Wounds and wound infection - 2nd ed. - M .: Medicine, 1990. - 592 p.). On the 3rd day after the start of active drainage, the inflammatory type of the wound discharge was achieved, which was determined by the following indicators: leukocytes in the field of view - 8%, leukocyte destruction - 69%, neutrophils - 49%, lymphocytes - 8%, monocytes - 1% macrophages - 16%, polyblasts - 26%; microflora is found in moderate amounts intracellularly, in a state of incomplete incomplete phagocytosis. After that, the administration of pepsin and cefotaxime was stopped, and the perfusion injection of a syringe infusion model pump 2016 manufactured by AITECS (Lithuania) with a constant injection rate of 170 ml / hour for 12 hours with an interval of 6 hours of a 0.9% solution dissolved in 2000 ml sodium chloride 50 ml of dioxidine continued. On the 7th day after the start of active drainage, clean wash liquid began to flow out of the silicone outlet pipe, after which both silicone drainage pipes were removed. On the 11th day after the operation, the patient M-ko was discharged from the hospital in satisfactory condition.

In the long term, postoperative complications in the patient M-ko were not recorded.

Using the proposed method in the district hospitals of Peschanopsky and Salsky districts of the Rostov region, drainage of deep (12 cases) and superficial (8 cases) forearm phlegmons was performed in 20 patients. In no case of the development of complications in the long term was recorded.

Thus, the proposed method of draining the phlegmon of the forearm is simple to implement, effective, allows you to drain both deep and superficial phlegmon of the forearm and virtually eliminates the development of postoperative complications.

Claims (1)

A method of draining the phlegmon of the forearm, including opening a purulent foci, necrectomy, debridement and wound drainage, characterized in that they carry out active drainage through two silicone tubes: a lead tube with a diameter of 5 mm, which is perforated along the length of the wound with 4 rows of holes located in a circle, each with a diameter of 3 mm, deposited along the tube through 5 mm in a checkerboard pattern, and the outlet one - with a diameter of 8 mm, which is perforated along the length of the wound with 5 rows of oval-shaped holes located in a circle, each 6 mm long and 2 mm wide, nan staggered along the tube through 7 mm; the lead-in and outlet silicone tubes are laid on the bottom of the wound parallel to each other at a distance of at least 10 mm from each other so that the perforations on them are staggered relative to each other, the proximal ends of the lead-in and outlet silicone tubes are led out through two wounds spaced from opposite corners at a distance of at least 3 cm each cut-puncture is fixed to the skin, then the edges of the wound are brought together and fixed by gluing a film dressing on Suprasorb F wounds, after which they are applied over the wound to a bandage Cellona lining synthetic cotton; active wound drainage is performed using perfuser for 12 hours with an interval of 6 hours, while the washing fluid is injected through the lead silicone tube: drugs dissolved in 2000 ml of 0.9% sodium chloride solution: dioxidine - 50 ml, pepsin - 20 mg and cefotaxime - 2 g; in each interval between drains, the wound is ligated, for which its edges are treated with an antiseptic solution and brought together, the wound is fixed by gluing a film dressing on Suprasorb F wounds, Cellona lining cotton wool is applied over the wound as a dressing; after the inflammatory type of the cytogram of the wound is removed, the administration of pepsin and cefotaxime is stopped, and the administration of the dioxidine solution in the same concentration and modes is continued until the clean washing fluid leaves the silicone discharge tube, after which the silicone drainage tubes are removed.