RU2699967C1 - Method for complex treatment of enteral insufficiency in children with severe thermal trauma - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to pediatric surgery and burn injury medicine, and can be used for complex treatment of enteral insufficiency in children with severe thermal trauma. That is ensured by intubation of proximal gastrointestinal tract from the day of hospital admission to the background of standard treatment in the acute period of burn disease. Then enterosorbent "Polysorb MP" is introduced in amount of 0.1 gram per 1 kg of patient's body weight 4 times a day. Prior to introduction, the calculated dose of the preparation is dissolved in drinking water. In the period of burn shock, the preparation is introduced through a nasogastric tube followed by oral introduction of the preparation. Enterosorption is followed by daily sessions of intravenous laser irradiation of blood with an ALT "Matrix-VLOK" device at wave length 635 nm, power 4.0 mW for 20 minutes. Therapeutic course is 10 days from the day of hospital admission.

EFFECT: method provides restoration of function of gastrointestinal organs, prevention of developing intestinal insufficiency syndrome and its complications, reduced level of endogenous intoxication, unloading of detoxification organs in children with severe thermal trauma.

1 cl, 1 tbl, 5 dwg, 1 ex

Description

The invention relates to medicine, in particular to pediatric surgery and combustiology, and can be used for the complex treatment of enteric insufficiency in children with severe thermal injury.

A known method of treating endogenous intoxication in a burn disease by carrying out hyperbaric oxygenation (RF patent No. 2122847), methods of treating a burn disease by carrying out intravenous laser blood irradiation (RF patent No. 2196603, RF No. 2155608).

The disadvantage of this method (No. 2122847) is the many contraindications for performing hardware procedures, namely: epilepsy, polyps and inflammation of the nose and nasopharynx, acute respiratory infections, purulent wounds, the need for logistics. The treatment methods (No. 2196603 and No. 2155608) apply to adults and do not take into account the anatomical and physiological characteristics of the child's body. Moreover, the methods are aimed exclusively at reducing the level of endogenous intoxication, not taking into account changes in the digestive tract.

The closest analogue prototype to the proposed method is the treatment of burn disease in children using plasmapheresis (patent No. 2362591 of the Russian Federation)

The disadvantage of the prototype is:

- contraindications for plasmapheresis: various types of bleeding, renal and hepatic insufficiency, bleeding disorders, gastric and duodenal ulcer, low level of protein in the blood

- the need for logistics.

The present invention is aimed at restoring the function of the organs of the gastrointestinal tract by affecting enterocytes and preventing the development of intestinal insufficiency syndrome and its complications, reducing the level of endogenous intoxication, unloading the detoxification organs of children with severe thermal injury.

The technical result is achieved by the fact that from the day the child enters the hospital against the background of standard treatment for a burn disease, the proximal sections of the gastrointestinal tract are intubated and the intestinal pressure is reduced, then the Polysorb MP enterosorbent is administered at the rate of 0.1 gram per kilogram of patient’s body weight, 4 times a day, general course 10 days from the date of admission to the hospital; moreover, before taking, the calculated dose of the drug is diluted in drinking water, and during the period of burn shock, the drug is administered through a nasogastric tube, followed by oral administration of the drug, accompanying enterosorption with daily sessions of intravenous laser blood irradiation with the ALT Matrix-VLOK 635 nm wavelength ., with a capacity of 4.0 mW., for 20 minutes, for 10 days.

Enterosorption is a method of eliminating toxic substances that enter the body with food and liquid, and toxins that form directly in the body during various pathological processes. The method has several advantages - universal accessibility, non-invasiveness, physiology, ease of use, lack of complications associated with extracorporeal detoxification. Enterosorption has proven itself in case of a burn disease (Osadchaya O.I., Boyarskaya A.M., Slesarenko S.V.), while reducing the level of endogenous intoxication, contributing to the early restoration of enterocyte function and the prevention of complications associated with gastrointestinal dysfunction.

Laser therapy is a method of the influence of quantum energy on blood in the vascular bed. Intravenous laser blood irradiation (VLOK) is also used in case of a burn disease; it improves the rheological properties of blood, trophism and microcirculation of tissues subject to ischemia.

The proposed method is the first to prevent the development of intestinal insufficiency syndrome (SKN) and reduce endogenous intoxication in children with thermal injuries by affecting the functional state of the small intestine (reducing the depth of acute enteric insufficiency syndrome), confirmed by clinical and laboratory (level of permeability marker of intestinal wall, dynamics markers of endogenous intoxication, microbial landscape) and pathological data on the state of the intestinal wall and detoxification organs.

All patients received a central venous catheter, a nasogastric tube for decompression of the intestine, examination of burn surfaces with their subsequent treatment and dressings impregnated with furatsillin and novocaine solutions in a 1: 1 ratio. The volume of infusion support was calculated using the Parkland formula. On the first day after the injury, potassium preparations were not included in the infusion therapy. Anesthesia was performed with narcotic analgesics every 6 hours, followed by a switch to non-narcotic analgesics. All children received oxygen therapy (moistened oxygen through the nasal cannula), inotropic support was carried out, in the form of continuous infusion of a dopamine solution, at a dose of 3-5 μg / kg / min through a drug dispenser. Of the affected children, 2 groups were formed (main and control), similar in age, sex, area and depth of damage. The main group consisted of 35 children, the control group of 36 children. For children from the main group, the Polysorb MP enterosorbent was added to the treatment regimen at the rate of 0.1 gram per kilogram of the patient’s body weight. Before taking the calculated dose of the drug was diluted in drinking water, in the period of burn shock, the drug was administered through a nasogastric tube due to the difficulty of independent drinking by patients, followed by switching to oral administration of the drug. The frequency of taking the drug was 4 times a day, the total course of taking the drug was 10 days from the date of admission to the hospital. From the 1st day of being in the intensive care unit, intravenous laser blood irradiation was performed with the ALT Matrix-VLOK 635 nm wavelength, 4.0 mW power, for 20 minutes, daily for 10 days.

Described in the works of Professor A.A. Zhidovinova (2007), bacterial translocation, which is the main mechanism for the development of endotoxemia in multiple organ failure and intestinal failure syndrome, was proved by us when modeling a burn disease in an experiment. As a result, mice subjected to thermal injury suffer from histological damage to the intestinal mucosa, an increase in its permeability, stasis ischemia in the vessels, laboratory changes in the number and pathogenicity of bacteria in the lumen of the gastrointestinal tract, and conditions are created for the penetration of bacteria, their metabolic products, and other toxic substances through the mucous barrier of the intestinal wall into the systemic circulation.

In dynamics, hematologic intoxication indices (leukocyte intoxication index (LII), nuclear intoxication index (LII), hematological intoxication index (GUI), leukocyte shift index (LIS) - see Fig. 1-4), the state of the microbial landscape, sCD level were monitored -14, the clinical picture and pathomorphological changes in the intestinal wall (see Fig. 5).

When studying intoxication indices in patients on the 1st day, there was no statistical, significant difference between the indices of the main and control groups. LII was 2.22 ± 0.27 cu in the main group and 2.29 ± 0.33 cu in the control group (see Fig. 1). Both indicators were 1.5 times higher than the upper limit of the norm for this indicator. The index of NII in the main group was 0.123 ± 0.013 cu and 0.13 ± 0.011 cu in the control group and also exceeded the upper limit of normal by 1.5 times (see Fig. 2). Also, an increase in LIS was recorded, this index was 3.06 ± 0.31 cu in the main group and 3.16 ± 0.22 cu in the control group, with an upper limit of 2.5 cu (see Fig. 3). The most significant increase was noted in GPI, which amounted to 4.62 ± 0.25 cu in the main group and 4.76 ± 0.37 cu in the control group (see Fig. 4). These GUI indicators exceeded the threshold value by almost 6 times, by the end of the first day. When studying the dynamics of intoxication indices on day 3, there was a decrease in the value of LII in both groups compared with the values on the first day after a burn injury. However, these values still exceeded their upper limit of normal and amounted to 1.73 ± 0.3 cu in the main group and 1.97 ± 0.23 cu in the control group (see Fig. 1). When studying the dynamics of NII, in contrast to other intoxication indices studied in the work, an increase of this indicator to a value of 0.135 ± 0.018 cu was noted. in the main group and 0.143 ± 0.021 cu in the control group (see Fig. 2). The leukocyte shift index also showed a downward trend to its upper limit of normal and was 2.38 ± 0.016 cu in the main group and was equal to 2.45 ± 0.024 cu in the control group (see Fig. 3). The most rapid decrease in the intoxication index was observed in the hematological indicator of intoxication, its value in both groups decreased almost 3 times, but still exceeded its normal values (see Fig. 4). When studying intoxication indices on the 7th day, the following changes were noted. . LII continued its downward trend and was equal to 1.23 ± 0.21 cu in the main group and 1.52 ± 0.23 cu in the control group (see Fig. 1). YII in the control group reached its peak value and was equal to 0.18 ± 0.12 cu, which was significantly higher compared to the main group, where this index was 0.148 ± 0.015 cu (see Fig. 2). Indicators of ISL and GUI in both groups continued the downward trend that had begun (see Figs. 3-4). LIS in both groups did not go beyond its norm and was equal to 1.71 ± 0.2 cu in the main group and 1.85 ±, 3 c.u. in the control group. GPI, unlike ISL, did not return to normal values and was equal to 1.63 ± 0.17 cu in the main group, against 1.92 ± 0.26 cu in the control group (P <0.05). When studying intoxication indices on the 10th day, the following trends were revealed. LII in the main group reached its minimum value from the moment of burn injury and was significantly lower compared with the LII in the control group (1.08 ± 0.2 cu and 1.5 ± 0.12 cu, respectively ) (P <0.05) (see Fig. 1). Despite the rise recorded on the 7th day, by the 10th day it showed a tendency to decrease and amounted to 0.127 ± 0.013 cu in the main and 0.15 ± 0.016 c.u. in the control group (P> 0.05) (see Fig. 2). It should be noted that the values of LII in both groups fell within the normal range, while the LII in both groups exceeded the upper limit of the satisfactory state and corresponded to the moderate state of severity. The leukocyte shift index and hematological intoxication indicator also showed a tendency to decrease in their indicators and reached their minimum values during the study (see Fig. 3-4). LIS in the main group was 1.64 ± 0.2 cu and 1.82 ± 0.17 cu in the control group (P> 0.05). These LIS values, as well as LII indicators, were within the normal range, in contrast to GUI indicators. The GPI index in the main group was equal to 1.54 ± 0.28 cu and 2.3 ± 0.4 cu in the control group (P <0.05), both GUI values are almost 2 times the upper limit for this indicator (see Fig. 2).

Analysis of the level of sCD-14, as the main marker of intestinal failure and bacterial translocation, indicates that throughout the acute period of a burn disease, its level in the serum of patients goes beyond the normative parameters (2-4 ng / ml). On the first day, this indicator in the control group was 6.65 ± 0.64 ng / ml (P <0.05). At the end of 3 days, the level of sCD-14 reached its peak value and amounted to 9.71 ± 1.57 ng / ml. In the future, there is a gradual decrease in sCD-14, on the 7th day the values were 7.03 ± 0.52 ng / ml. On the 10th day of burn disease, the content of sCD-14 was twice as high as laboratory standards and was 6.79 ± 0.72 ng / ml. Against the background of ongoing enterosorption according to the above scheme in the main group, sCD-14 indices were several times lower (see Fig. 5). Thus, the prevention of the development of enteric insufficiency in children with burn disease has been experimentally proved.

The dynamics of the clinical picture of the main and control groups are presented in table 1.

On the seventh day, in the structure of the wall of the small and large intestine, against the background of modeling a burn injury in the experiment, edema and plethora were observed in the lamina propria, infiltration of the interstitial space by cells of the lymphocytic macrophage series and eosin by abundant leukocytes, a “sludge” phenomenon was observed in the capillaries. In their own plate of the mucous membrane, in the crypt region, diffuse eosinophilia and proliferation of connective tissue were noted. Submucosal heterogeneous structure. In the muscle membrane, dissociation of smooth muscle fibers was observed, especially around the nerve plexuses. The fibers have lost the correct orientation of the layers. On the tenth day, stasis of small vessels remained, and cell infiltration continued. Small hemorrhages were noted in the mucosa of the small intestine. On the fourteenth day there is a slight reverse development of the process: a decrease in infiltration and edema. At the same time, but against the background of complex treatment according to the described scheme, starting from the first day, changes in the intestinal wall and enterocytes were significantly less pronounced and were manifested mainly by edema, tissue infiltration and eosinophilia. By the fourteenth day, the condition of the intestinal wall did not fundamentally differ from the healthy one.

In the study of fecal biocenosis in patients by the end of 1 day, changes were observed only in 4 patients (11.1%) from the control group, in the form of a decrease in the number of E. Coli with normal properties (10 ⁵ -10 ⁶ ), which was associated with dysbiosis I degree. In the main group, microbiocenosis shifts were not observed. In studies conducted on the 10th day, I degree dysbiosis was already detected in 19 patients (52.7%) from the control group and in 6 patients (17.1%) from the main group. Dysbacteriosis of the II degree was observed in 9 patients (25%) from the control and in 1 patient (2.8%) from the main group, in the form of a decrease in lactobacilli (10 ⁵ ), bifidobacteria (10 ⁷ ), E. Coli with normal properties, an increase amounts of E. colic hemolytic properties. In half of the patients from the control group with II degree dysbacteriosis, a moderate increase in Proteus was determined (10 ⁴ -10 ⁵ ). Dysbacteriosis of the III degree was diagnosed in 4 patients (11.1% of cases) from the control group with a significant decrease in lactobacilli and bifidobacteria (less than 10 ⁵ ), an increase in E. Coli with reduced enzymatic activity (10 ⁸ ), E. Colic hemolytic activity (10 ⁷ ), an increase in representatives of the genus Pantonea, Citrobacter, Proteus (10 ⁵ -10 ⁶ ) and the appearance of fungi of the genus Candida were noted.

The proposed method is tested in the Department of Anesthesiology and Intensive Care CSTO them. N.N. Silishcheva (Astrakhan) for 35 patients from the main group who received treatment according to the above scheme. The following are test results:

Example. Patient C., 8 months old, with a diagnosis of “Burn of boiling water IIIA-IIIB degree of the head, neck, trunk, upper and lower extremities, S = 48%. Shock of the first degree. " Upon admission to the CSTO, the condition is serious. In the mind. It reacts negatively to the examination with a cry of moderate intensity. Temperature on low-grade figures. The skin and visible mucous membranes outside of burn wounds and dressings are clean, with a pale tint. Spasm of peripheral vessels. In the lungs, auscultation breathing is carried out in all fields, vesicular, no wheezing. NPV - 40 per minute. Heart sounds are rhythmic, muffled. Heart rate - 148 per minute. HELL - 90/60 mm. Hg CVP - 0 cm. The abdomen is at the level of the costal arches, soft on palpation. The liver and spleen are not enlarged. Intestinal motility is weakened, inconsistent. There is no discharge from the nasogastric tube. There was no chair at admission. Urinates through a urinary catheter, the rate of urine output is 2 ml / kg / hour. The weight of the child is 9 kg. In therapy: oxygen therapy, the introduction of Polysorb MP 0.9 grams diluted in drinking water into a nasogastric tube for 3 days, then orally, infusion support - 10% glucose solution with added insulin, 0.9% NaCl solution, freshly frozen plasma, reopoliglukin solution, trental, Contrical at age dosages, dopamine (5 μg / kg / min), 10% calcium chloride solution, 0.25% novocaine solution, heparin solution (subcutaneously), antibiotic therapy (cefotaxime, gentamicin), anesthesia. Ligation of burn wounds was performed: removal of necrotic tissues (exfoliated epidermis), application of furatsillin-novocaine dressings. From the day of admission to the intensive care unit, intravenous laser blood irradiation sessions were performed with the Matrix-VLOK ALT device with a wavelength of 635 nm., Power 4.0 mW., For 20 minutes daily for 10 days. Dynamics of indicators of endogenous intoxication: LII at admission was 2.24 cu, on day 3 - 1.99 cu, on day 7 - 1.23 cu, on day 10 - 1.03 cu. e. NII at admission 0.13 cu, on the 3rd day - 0.142 cu, on the 7th day - 0.137 cu, on the 10th day - 0.119 cu GPI upon receipt of 4.62 cu, on the 3rd day - 3.13 cu, on the 7th day - 1.63 cu, on the 10th day - 0.9 cu LIS upon receipt of 3.11 cu, on the 3rd day - 2.41 cu, on the 7th day - 1.86 cu, on the 10th day - 1.32 cu Clinically, there was a slight bloating, nausea, loss of appetite up to 3 days, and starting from 4 all the symptoms gradually stopped, stool, appetite, and peristalsis returned to normal. No microbial landscape shifts were noted. The level of sCD-14 throughout the course of the disease did not exceed the maximum allowable values, by the 7th day it was 2.8 ng / ml., By the 10th day it was 2.3 ng / ml. Creatinine and urea did not increase.

The proposed method achieves the restoration of the function of the organs of the gastrointestinal tract by affecting enterocytes and preventing the development of intestinal insufficiency syndrome and its complications, reducing the level of endogenous intoxication, unloading the detoxification organs in children with severe thermal injury.

Claims (1)

A method for the complex treatment of enteric insufficiency in children with severe thermal injury by administering drugs, characterized in that from the day of admission to the hospital against the background of standard treatment in the acute period of a burn disease, the proximal sections of the gastrointestinal tract are intubated, then the Polysorb MP enterosorbent is administered at the rate of 0.1 grams per kilogram of patient’s body weight, 4 times a day, with a general course of 10 days from the day of admission to the hospital; moreover, before taking the calculated dose of the drug is diluted in drinking water, and in the period of burn shock, the drug is delivered through a nasogastric tube followed by oral administration of the drug, accompanying enterosorption with daily sessions of intravenous laser blood irradiation with the ALT Matrix-VLOK 635 nm wavelength, capacity of 4.0 mW, for 20 minutes, for 10 days.

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