RU2766294C1 - Method of treating peritonitis - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention relates to medicine, namely to surgery, and can be used in emergency surgery for the most accurate prediction of the clinical outcome of peritonitis. That is ensured by scoring: patient's age, presence of malignant neoplasm, type of peritoneal exudate and presence of organ failure not related to peritonitis. In addition, the presence of organ failure (on a qSOFA scale) not associated with peritonitis is assessed, and the presence of sepsis or septic shock is stated. Result of peritonitis is predicted depending on the threshold value in the prediction system, which is 10 points. If the score is less than 10 points, a favorable outcome of peritonitis is predicted, and after the abdominal sanitation and drainage are completed, infusion, antibacterial and symptomatic therapy is performed. If value is 10 points and more, an unfavorable outcome of peritonitis is predicted, and after the completion of the abdominal sanitation and drainage, an intensive infusion, intensive antibacterial and intensive symptomatic therapy is performed.EFFECT: method provides selecting the optimal therapeutic approach in the postoperative period due to the most accurate assessment and ranking (in points) of sepsis and septic shock, as well as ranking (in points) of organ failure not related to peritonitis.1 cl, 4 tbl, 2 ex

Description

The invention relates to medicine and can be used in emergency surgery with the most accurate prognosis of treatment outcome.

The prognosis of the results of treatment of peritonitis is one of the most important factors affecting its outcome.

Known used in the treatment of peritonitis is a method for scoring the prognosis of the outcome of peritonitis according to the prognostic scale APACHE II [Knaus W.A., Draper E.A., Wagner D.P., Zimmerman J.E. APACHE II: a severity of disease classification system. Critical Care Medicine. 1985; 13(10): 818-829. doi: 10.1097/00003246-198510000-00009].

The assessment of severity according to the APACNE II system is based on the fact that when examining a patient, his physiological characteristics, neurological status, laboratory blood parameters are evaluated on a special scale in points.

The APACHE II score uses the worst-case values in the first 24 hours of hospital admission. The total score for the patient is the sum of the physiological parameters (from 0 to 4 points for each), except for the Glasgow Coma Score (GCS), for which the score in the prognostic system is 15 minus GCS. The total scores are added to the scores for age (from 0 to 6) and scores for the assessment of chronic diseases for patients with organ failure (from 2 to 5, depending on the need and urgency of surgical treatment).

The points are summed up, and the final amount gives an idea of the possibility of a fatal outcome. If on the APACNE II scale less than 10 points, then the probability of septic complications is 18.2%, mortality is 0%. If the scores are in the range of 10-19, then the probability of septic complications is 24.6%, mortality is 15.8%.

If the scores are in the range of 20-29, then the probability of septic complications is 27.7%, mortality is 21.3%. If the patient scores 30 or more, then the probability of septic complications is 37.5%, mortality is 75%.

The scale is not suitable for a rapid assessment of the prognosis of peritonitis because it is general clinical, not focused on peritonitis, has low sensitivity in assessing the outcome of treatment in patients with peritonitis, and does not determine the tactics of surgical treatment.

There is a method of scoring the outcome of peritonitis on the scale of the index of the abdominal cavity (IBP) [Saveliev B.C., Filimonov M.I., Podachin P.V., Burnevich S.Z., Yusufov S.G. The choice of treatment tactics for widespread peritonitis. Annals of Surgery. 1998; 6:32-36].

The basis of the integral assessment of the degree and nature of damage to the abdominal organs - the index of the abdominal cavity - were five groups of factors. Particular attention should be paid to the third group of factors characterized by the formation of an adhesive process in the abdominal cavity due to the imposition and organization of fibrin films on the loops of the small intestine, which is an important mechanism for the regression of peritonitis phenomena. The criteria for intraoperative assessment of the nature of the lesion of the abdominal organs in a patient are: the prevalence of peritonitis (1 or 3 points), the nature of the exudate (1, 3 or 4 points), the imposition of fibrin (1 or 4 points), the condition of the intestine (3 or 4 points), suppuration or necrosis of the surgical wound (if present - 3 points), eventration (if present - 3 points), non-removed devitalized tissues (if present - 3 points). The above scores are summed up. The value of IOP more than 13 points is a factor of unfavorable prognosis and, accordingly, can serve as one of the indications for a staged relaparotomy in a programmed mode. If the value of the index of the abdominal cavity is below 10 points, it can serve as a strong justification for terminating the regimen of staged interventions. Most of the parameters of this scale can only be assessed intraoperatively, which excludes the assessment of the prognosis of a patient with peritonitis throughout his treatment in a hospital. In addition, this scale does not take into account the severity of the patient's condition and the adaptive capabilities of a person.

The closest analogue of the invention (prototype) is used in the treatment of peritonitis method for predicting the outcome of peritonitis on the scale of the Mannheim Peritonitis Index (MIP) [binder MM, WachaH., Feldmann U., et al. The Mannheim peritonitis isindex. An instrument for the intraoperative prognosis of peritonitis. Chirug. 1987; 58(2):84-92].

The scoring system of the prototype represents an assessment of eight risk factors for a patient with peritonitis: age (if over 50 years old - 5 points), gender (female - 5 points, male 0 points), organ failure (if any - 7 points), the presence of malignant neoplasms (if present - 4 points), the duration of peritonitis for more than 24 hours (4 points), the prevalence of peritonitis (diffuse - 6 points), the location of the primary focus (colon - 4 points), the type of peritoneal exudate (cloudy-purulent - 6 points; fecal putrefactive - 12 points). The scores are added up and totaled. IIP values can range from 0 to 47 points. MIP provides for three degrees of severity of peritonitis. With an index of less than 21 points (I degree of severity) - mortality is 2.3%, from 21 to 29 points (II degree of severity) - 22.3%, more than 29 points (III degree of severity) - 59.1%. The disadvantage of the Mannheim peritonitis index is: insufficient prognosis accuracy, the scale is not able to predict the prognosis in a particular case, the practical application of this scale remains unsatisfactory for deciding on the tactics of treating a particular patient. MPI can only be used in patients with the same cause of peritonitis to evaluate treatment outcomes and conduct research. The scale does not allow assessing the patient's prognosis in dynamics, does not take into account the pathophysiological processes (systemic inflammatory response, sepsis, septic shock) occurring in a patient with peritonitis.

The technical problem to be solved by the present invention is to create a method for the treatment of peritonitis, including the most accurate method for predicting its outcome.

The technical result of the invention is the possibility of choosing the optimal treatment tactics in the postoperative period by evaluating and ranking (in points) sepsis and septic shock, as well as ranking (in points) organ failure not associated with peritonitis.

The essence of the invention is expressed in the totality of essential features, in which a method for the treatment of peritonitis, including a prognosis of treatment, in which the age of the patient, the presence of a malignant neoplasm, the type of peritoneal exudate and the presence of organ failure associated with peritonitis are estimated in points, differs from the closest analogue in that additionally the presence of sepsis or septic shock is established, and the presence of organ failure associated with peritonitis is assessed using the qSOFA scale, while the result of peritonitis is predicted depending on the threshold value of 10 points in the prognosis system, in which age up to 60 years is estimated with a value of 0 points, from 61 to 70 years old 3 points, from 71 to 80 years old 4 points, over 80 years old 5 points, malignancy 5 points, purulent exudate 3 points, fecal exudate 5 points, sepsis 5 points, septic shock 7 points, comorbidity 4 points , moreover, when receiving less than 10 points - forecast a favorable outcome of peritonitis and after the completion of sanitation and drainage of the abdominal cavity, infusion, antibacterial and symptomatic therapy is carried out, while the operational benefit ends with suturing the abdominal wall "tightly", and with a value of 10 points or more, an unfavorable outcome of peritonitis is predicted and after sanitation and drainage of the abdominal cavities, carry out intensive infusion, intensive antibacterial and intensive symptomatic therapy, and the abdominal cavity is most often not sutured “tightly” with the formation of a laparostomy for further staged sanitation relaparotomies.

The method for the treatment of peritonitis includes a prognosis of the outcome of treatment with an assessment in points of the age of the patient, in the system of which for the first time exactly those risks of death are displayed, which are directly based on the modern pathogenetic concept of the transition of peritonitis to abdominal sepsis, which is the cause of high mortality among patients with peritonitis.

The method allows to evaluate the prognosis for each patient in dynamics, throughout his stay in the hospital, which largely determines the tactics of surgical treatment of the patient and the tactics of his management in the intensive care unit. In addition, the method allows to identify the progression of the inflammatory process and thereby helps to correct the ongoing therapy up to solving the problem of the need for ralaparotomy on demand.

The prediction system is presented in table 1. The probability of death depending on the peritonitis prediction score is illustrated in table 2. Tables 3 and 4 explain examples of the implementation of the method and the achievement of its technical result.

The method of treatment of peritonitis is as follows.

The patient is admitted to the emergency department of the hospital. At the level of the emergency department, the patient is examined by a surgeon who collects an anamnesis: time since the onset of the disease, comorbidities. The surgeon makes a preliminary diagnosis.

A complex of examinations is carried out: a general blood test with a leukocyte formula; a biochemical blood test should include a standard set of indicators and a general urine test. Evaluate 1) the age of the patient: up to 60 years old - 0 points, 61-70 years old - 3 points, 71-80 years old - 4 points, over 80 - 5 points; 2) The presence of a malignant neoplasm - 5 points; 3) Exudate: purulent - 3 points, fecal - 5; 4) Systemic inflammatory response; Sepsis - 5 points, Septic shock - 7 points; 5) Organ failure not associated with peritonitis (comorbidity), 4 points. Sepsis is fixed by 2 or more points of the qSOFA scale of organ dysfunctions.

Septic shock with the need for vasopressor support to achieve mean arterial pressure >65 mmHg and blood lactate >2 mmol/l. in the absence of hypovolemia. The main factors affecting the outcome of treatment of patients with peritonitis are age, the nature of the exudate, the presence of sepsis and the severity of concomitant diseases. Organ failure assessment by qSOFA (quick Sequential Organ Failure Assessment) includes: respiratory rate ≥22; systolic pressure ≤100 mmHg Art.; impairment of consciousness on the Glasgow Coma Scale (normal if GCS is 15 points). Organ failure is fixed at 2 or more points on qSOFA. Sepsis is understood as the presence of an infection (peritonitis) in combination with organ failure due to this infection (qSOFA 2 or 3).

After examination by an anesthesiologist, the patient is taken to the emergency operating room, where surgery is performed. During the operation, the following are assessed: the prevalence of peritonitis, the presence of a malignant neoplasm, the nature of the exudate.

Next, scores are calculated according to the peritonitis prediction system - table 1. The probability of death depending on the score of the combined method for assessing the severity of peritonitis - table 2.

When a value of less than 10 points is obtained, a favorable outcome of peritonitis is predicted and after the completion of sanitation and drainage of the abdominal cavity, infusion, antibacterial and symptomatic therapy is carried out, while the surgical aid ends with suturing the abdominal wall "tightly".

With a value of 10 points or more, an unfavorable outcome of peritonitis is predicted, and after the completion of sanitation and drainage of the abdominal cavity, intensive infusion, antibacterial and symptomatic therapy is carried out. The abdominal cavity is most often not sutured “tightly” with the formation of a laparostomy for further staged sanation relaparotomies.

Example 1. Patient K, 77 years old with a diagnosis of perforation of a stomach ulcer, was admitted to the emergency department of an emergency hospital 48 hours after the perforation. On examination, pain in the anterior abdominal wall, pronounced muscle tension, a positive symptom of Shchetkin-Blumberg are determined. Assessment of organ failure by qSOFA includes: NPV 22 - 1 point, systolic blood pressure - 130 mm Hg. - 0 points, GCS - 15 - 0 points. Total: 1 point - no organ failure. After examination by an anesthesiologist, the patient was sent to the emergency operating room, where a laparotomy, ulcer closure, debridement and drainage of the abdominal cavity were performed. During the operation, an assessment of the lesion in the abdominal cavity was carried out: widespread peritonitis, absence of a malignant neoplasm, purulent exudate. Evaluation of SPP scores for this patient is shown in Table 3. Infusion, antibacterial, symptomatic therapy was carried out. The patient was discharged 10 days after admission in a satisfactory condition.

Example 2. Patient G, 73 years old with a diagnosis of perforated duodenal ulcer, widespread peritonitis, with concomitant coronary artery disease, hypertension, progressive angina pectoris, renal failure was admitted to the emergency department of an emergency hospital. From the history of pain in the abdomen disturb during the day. On examination, pain and muscle tension throughout the abdomen, a positive Shchetkin-Blumberg symptom. Assessment of organ failure by qSOFA includes: NPV 24 - 1 point, systolic blood pressure - 100 mm Hg. - 1 point, Glasgow Coma Scale - 14 - 1 point. Total: 3 points - signs of organ failure. After examination by an anesthesiologist and short-term preparation in the ICU, the patient was sent to the emergency operating room, where a laparotomy, suturing of the perforated ulcer, debridement and drainage of the abdominal cavity were performed. During the operation, an assessment was made: widespread peritonitis, the presence of a malignant neoplasm was not detected, the exudate was serous-fibrous. The calculation of SPP scores for this patient is shown in Table 4. Infusion, antibacterial, symptomatic therapy, and nutritional support were carried out in the ICU. The patient's death was declared 5 days after admission. Cause of death - Purulent intoxication, sepsis, multiple organ failure.

Claims (1)

A method for the treatment of peritonitis, including a prognosis of treatment, in which the age of the patient, the presence of a malignant neoplasm, the type of peritoneal exudate and the presence of organ failure associated with peritonitis are evaluated in points, characterized in that the presence of sepsis or septic shock is additionally established, and the presence of organ failure associated with peritonitis, assessed on the qSOFA scale, while the result of peritonitis is predicted depending on the threshold value of 10 points in the prognosis system, in which age up to 60 years is estimated as 0 points, from 61 to 70 years 3 points, from 71 to 80 years 4 points, older than 80 years 5 points, the presence of a malignant formation 5 points, purulent exudate 3 points, fecal exudate 5 points, sepsis 5 points, septic shock 7 points, comorbidity 4 points, and if less than 10 points, a favorable outcome of peritonitis is predicted and after completion of sanitation and drainage of the abdominal cavity, conducting t infusion, antibacterial and symptomatic therapy, while the operational benefit ends with suturing the abdominal wall "tightly", and with a value of 10 points or more, an unfavorable outcome of peritonitis is predicted, and after the completion of sanitation and drainage of the abdominal cavity, intensive infusion, intensive antibacterial and intensive symptomatic therapy is carried out , and the abdominal cavity is not sutured with the formation of a laparostomy for further staged sanation relaparotomies.