UA144440U - METHOD OF CONDUCTING THE POSTOPERATIVE PERIOD AFTER VIDEO-ASSISTED RESECTIONS IN PATIENTS WITH PULMONARY TUBERCULOSIS - Google Patents

Abstract

A method of conducting the postoperative period after video-assisted resections in patients with pulmonary tuberculosis, according to which after performing video-assisted lung resection, the pleural cavity is drained with two drains, the upper of which is directed towards the dome of the pleural cavity. Before suturing the minithoracotomy access and draining the hemothorax, perineural blockades of the intercostal spaces of the minithoracotomy, the intercostal space above and below the surgical wound, and the intercostal space of the thoracoport with Ropivacaine 0.075% solution are performed. After erection of the ribs and suturing of the intercostal spaces through the thoracoport, a final videothoracoscopic audit of the hemothorax cavity is performed and the lower drainage is installed, the drainages are connected to active aspiration, and a chest X-ray is performed immediately in the intensive care unit.

Description

The useful model belongs to medicine, namely to thoracic phthisiosurgery, and can be used in clinical practice in the management of the postoperative period after video-assisted resections in patients with pulmonary tuberculosis.

Surgical methods of treating patients with pulmonary tuberculosis are an important and effective link in the fight against this pathology. At present, wide thoracotomy remains the most frequent approach for surgical interventions on the organs of the chest cavity, but the techniques used in this process continue to be improved (see Iueg A., Khadam

Z. Rovioregaime Sage apa Sotriisayop5 Ayeg Tpogasis Zygdegu // Riipsiriez apa Rgasiise oi

Sagaioipogasis of Zygdegu, Og. Missing! Rigeiepregu. 2013. Mo. 3. R. 1-15.).

Application of video-assisted thoracic surgical interventions (MATo-mideo avviviy

Togasis zygdegu) is an alternative to wide thoracotomy in many diseases, and especially in the treatment of various forms of pulmonary tuberculosis. MAT - operative interventions with the use of minithoracotomy up to 7 cm are effective, convenient, minimally traumatic methods of treatment of patients with tuberculous impressions of the lungs. The performance of this type of surgical intervention is accompanied by insignificant blood loss, a better cosmetic effect compared to a wide thoracotomy, provides satisfactory visibility in the hemothorax cavity, which allows you to determine the real boundaries of the pathological process, carry out comfortable manipulations, and, as a result, allows you to perform a typical lung resection with separate processing of structural elements of the lung and reduce the likelihood of postoperative complications. All this makes it possible to carry out earlier mobilization of the patient and expand the indications for the use of MAT5 in elderly patients and patients with limited vital functions, and also contributes to reducing the length of stay of the patient in the hospital, and, accordingly, reducing the cost of treatment.

The postoperative period is an extremely important stage of surgical treatment of patients of any profile. Phthisiosurgery is no exception. Unfortunately, the medical literature mainly describes the methods of postoperative management of thoracic patients, without taking into account the specifics of the operated pathology, namely pulmonary tuberculosis. Today, it is a proven fact that the effectiveness of surgical treatment of pulmonary tuberculosis depends not only on adequate preoperative preparation, the correct choice of the volume of surgical intervention, but also on proper management of the postoperative period, since pain syndrome, hemodynamic and respiratory disorders are the main predictors of complications and lethality

There is a well-known method of managing the early postoperative period in patients with medium and high perioperative risk who were operated on for pulmonary tuberculosis, which involves disintubation of the trachea in the operating room and ensuring the patient's semi-sitting position, inhalation of humidified oxygen, removal of chest drains after 12-24 hours in the absence of signs of bleeding, control of water balance, since fluid overload is quite dangerous (see Guide to clinical anesthesiology / under the editorship of B.J. Pollard.

M.: MEDpresso-inform, 2006. 912 pp.).

The main disadvantages of this method are: - no attention is paid to the prevention and treatment of pain syndrome, as it is the trigger of many life-threatening complications; - features of hemothorax drainage, which increases the risk of underexpansion of the lung, are not covered; - the use of active aspiration immediately after the end of the surgical intervention is not provided for; - X-ray control of the state of the thoracic cavity organs is not provided for the purpose of timely diagnosis of early postoperative complications; - early removal of drains is recommended, which reduces control and increases the risk of postoperative complications; - the need to control the water balance is emphasized, but it is not specified which control methods are the most effective and safe.

A known method of prolonged subpleural anesthesia, which consists in establishing a thoracoport in the M intercostal space on the side of the damage along the posterior inguinal line, through the suprasternal fossa near the root of the lung on the side of the main damage, a polyvinyl chloride catheter is inserted, through which a 2-hour infusion of 0.25 905 novocaine is carried out at a rate of 10 drops per minute, analgesia is repeated three times within 5 days (see

Method of prolonged subpleural anesthesia: pat. 2284817 Rossiyskaya

Federation, MPKU AbIK 31/245, AbIR 23/02, AbIV 17/00. / Degtyarev O.L. (VI); applicant and patent holder O.L. Degtyarev (High School). Mo 2005106453/14; statement 10.03.2005; published 10.10.2006, because Bull. Mo 28. 2 b.).

But the disadvantages of this method include: - Claude-Bernard-Horner syndrome is often diagnosed on the side of the injury after the start of the novocaine infusion, which requires a reduction or termination of the anesthetic infusion; - the presence of a catheter in the pleural cavity is an additional source of infection, since its contamination by hospital microflora can cause infectious complications of a local and systemic nature and, in the future, will require a long-term appointment of antibacterial therapy; - the method does not pay attention to the prevention of other postoperative complications.

The method of prevention of residual pleural cavities and pleural empyema after segmental, polysegmental, combined resections, lobectomies in patients operated on for tuberculosis of the lungs and pleura is the closest in terms of technological essence to the claimed method, according to which during these operations drainage of the pleural cavity is carried out two drains, the lower drain with 3-4 lateral openings near the proximal end is inserted into the MI-MII intercostal space along the posterior axillary line, its length in the pleural cavity is 15-20 cm, the upper drainage with 2-3 lateral openings at the proximal the ends are introduced into the II intercostal space along the mid-axillary line, its proximal end is brought to the dome of the pleural cavity, hemmed and fixed with one or two catgut sutures to the soft tissues along the intercostal space and the parietal leaf of the pleura, and it is removed after 5 -9 days (see Method of prevention of residual pleural cavities and pleural empyema after segmental, polysegmental, combined of resections, lobectomies in patients operated on for tuberculosis of the lungs and pleura: pat. 77847 Ukraine. MO and 201210861; statement 17.09.2012; published 25.02.2013, Bull. Mo 4 (book 1). 8 p.).

However, this method has the following disadvantages: - no attention is paid to the prevention of pain syndrome, which is the trigger for many life-threatening complications; - the introduction of upper drainage through a separate aperture in the 1st-5th intercostal space along the mid-axillary line contributes to an increase in pain syndrome and can be an additional source of infectious contamination by hospital microflora and lead to local and systemic complications;

Zo - after reducing the ribs and suturing the intercostal spaces, the lack of final video-assisted thoracoscopic revision does not contribute to timely diagnosis and elimination of possible bleeding from the thoracotomy wound and other complications; - after the surgical intervention, the lack of connection of drains to active aspiration increases the frequency of residual pleural cavities and lung underexpansion; - there are no measures for early diagnosis, prevention and elimination of lung underexpansion.

All of the above leads to an increase in the frequency of postoperative complications, such as intrapleural bleeding, long-term underexpansion of the lung, residual pleural cavity, an increase in the intensity of the pain syndrome and the terms of use of narcotic analgesics, delay in the early mobilization of the patient, an increase in the average length of stay of the patient in the hospital, which, as a result, reduces the overall effectiveness of the patient's treatment.

The basis of a useful model is the task of creating a method of managing the postoperative period after video-assisted resections in patients with pulmonary tuberculosis, in which perineural blockades of the intercostal spaces of the minithoracotomy, the intercostal space above and below the surgical wound, and the intercostal space of the thoracoport are performed before suturing the minithoracotomy access and draining the hemithorax. with Ropivacaine solution 0.075 95, a microirrigator is introduced through the front corner of the wound to the dome of the hemothorax as an upper drainage, after bringing the ribs together and suturing the intercostal spaces through a thoracoport, a final video thoracoscopic revision of the hemothorax cavity is performed and a lower drain is installed, the drains are connected to active aspiration, and an inspection X-ray of the chest cavity organs are performed immediately in the intensive care unit, as a result of which an increase in the overall effectiveness of the treatment of this category of patients is achieved due to a decrease in the frequency of postoperative complications, such as intrapleural cro current, long-term underexpansion of the lung, residual pleural cavity, reduction of the duration of use of narcotic analgesics, acceleration of the term of early mobilization of patients and reduction of the length of stay in the hospital.

The task is solved by the fact that in the method of conducting the postoperative period after video-assisted resections in patients with pulmonary tuberculosis, which consists in the fact that after video-assisted lung resection, the pleural cavity is drained with two drains, the upper one of which is directed in the direction of the dome of the pleural cavity, according to the useful model, before suturing the minithoracotomy access and draining the hemithorax, perform perineural blockades of the intercostal spaces of the minithoracotomy, the intercostal space above and below the surgical wound, and the intercostal space of the thoracoport solution

Ropivacaine 0.075 95, a microirrigator is introduced through the front corner of the wound to the dome of the hemothorax as an upper drainage, after bringing the ribs together and suturing the intercostal spaces through the thoracoport, a final videothoracoscopic revision of the hemothorax cavity is performed and a lower drain is installed, the drains are connected to active aspiration, and an inspection X-ray of the chest cavity organs is performed immediately in the intensive care unit.

Carrying out perineural blockades of the intercostal spaces of minithoracotomy, intercostal space above and below the surgical wound and intercostal installation of a thoracoport with a solution of Ropivacaine 0.075 95 with a total volume of 15 ml, has anesthetic and analgesic effects, helps to eliminate the intensity of postoperative pain, prevention of respiratory disorders, etc. associated with pain, contributes to the reduction of the duration of the use of narcotic analgesics, as well as to the acceleration of the patient's activation, which leads to a reduction of the patient's stay in the hospital.

Drainage with a microirrigator in the direction of the dome of the hemothorax through the front corner of the wound, due to the absence of a counter-aperture for drainage, reduces the overall trauma, helps to reduce the intensity of the pain syndrome and the likelihood of developing infectious complications of a local and systemic nature.

Conducting the final videothoracoscopic revision of the hemothorax after reduction of the ribs and suturing of the intercostal spaces through the thoracoport before drainage ensures control of the final hemostasis, the anatomical location of the lobes and structures of the lung roots, contributes to the prevention and rapid elimination of complications.

The use of active aspiration of the contents of the hemithorax contributes to the achievement of rapid expansion of the lung by filling the entire space of the pleural cavity with lung parenchyma, reducing the probability of the formation of a residual pleural cavity, and has diagnostic value in the control of hemostasis and aerostasis.

Performing an X-ray examination of the organs of the chest cavity immediately in

From the intensive care unit, it is possible to control the state of the pleural cavity by assessing the state of the hemithorax, the lung pattern, the contour of the lung and the possible appearance of pathological shadows that may indicate hemorrhagic complications, which, in turn, allows you to quickly apply all possible measures to combat complications.

Thus, the use of all these measures makes it possible to reduce the frequency of postoperative complications, such as residual pleural cavity, long-term underexpansion of the lung, intrapleural bleeding, shorten the duration of the use of narcotic analgesics, speed up the early mobilization of patients, and, as a result, shorten the patient's stay in the hospital and increase the overall efficiency of treatment of patients.

The method is performed as follows.

A tuberculosis patient undergoing video-assisted lung resection is subjected to perineural blockade of the intercostal spaces of the minithoracotomy, the intercostal space above and below the surgical wound, and the intercostal installation of a thoracoport with Ropivacaine 0.075 95 solution in a total volume of 15 ml before suturing the minithoracotomy approach and draining the hemothorax.

The hemithorax is drained as follows: upper drainage - a microirrigator is inserted through the front corner of the wound with stable fixation of its proximal end in the dome of the hemothorax, after reduction of the ribs and suturing of the intercostal spaces through the thoracoport, a final video thoracoscopic inspection of the hemothorax cavity is performed and a lower drain is installed. After suturing the minithoracotomy wound, drains are connected to active aspiration. X-ray examination of the chest cavity is performed immediately in the intensive care unit, and if there are signs of underexpansion of the lung or residual pleural cavity, an artificial pneumoperitoneum is applied.

We give concrete examples of the implementation of the method.

Example 1 (according to the closest analog method).

Patient P., 42 years old, medical history No. 2743, was hospitalized in the department of surgical treatment of tuberculosis and non-specific lung diseases complicated by purulent-septic infections of the State Institution "National Institute of Phthisiology and Pulmonology named after F.G.

Yanovsky National Academy of Medical Sciences of Ukraine" with a diagnosis of "VDTB of the upper lobe of the left lung (multiple tuberculomas)".

After additional examination, a decision was made to perform a left-sided thoracotomy, resection of the upper lobe of the left lung. Intraoperatively, after upper lobectomy of the left lung with separate treatment of the structural elements of the lobe root, the pleural cavity was drained with two drains: the upper drain was installed through a separate aperture in the 5th intercostal space along the mid-axillary line on the left, with suturing and fixing it in the dome of the pleural cavity with two with catgut sutures to the soft tissues along the intercostal space and the parietal sheet of the pleura, the lower drainage was inserted into the 1st intercostal space along the posterior axillary line.

In the postoperative period, in the intensive care unit, the patient was found to have postoperative intrapleural bleeding in the volume of 500 ml of hemorrhagic exudate with hemoglobin - 71 g/l, which was eliminated by the use of conservative hemostatic therapy and transfusion of three doses of fresh frozen plasma of group A (II). On the second day, after a chest X-ray, the patient was diagnosed with underexpansion of the operated lung, in connection with which the patient was transferred to active aspiration, an artificial pneumoperitoneum with a volume of 1500 ml was applied, after which the discharge of air through the drains was observed for 8 days. Also, the patient had a pain syndrome of pronounced intensity, in connection with which narcotic analgesics were prescribed, which were canceled on the 6th day after the operation.

Activation of the patient took place on the 5th day of the postoperative period in the intensive care unit.

The upper drain was removed on the 11th day, and the lower one on the 13th day of the postoperative period. The patient was discharged from the hospital in a satisfactory condition after 21 days.

Example 2 (according to the claimed method).

Patient O., 46 years old, medical history No. 4162, hospitalized in the department of surgical treatment of tuberculosis and non-specific lung diseases complicated by purulent-septic infections of the State Institution "National Institute of Phthisiatry and Pulmonology named after F.G.

Yanovsky National Academy of Medical Sciences of Ukraine" with a diagnosis of "VDTB. Fibro-cavernous tuberculosis of the upper lobe of the right lung". After further examination, a decision was made to perform MAT5 resection of the upper lobe of the right lung.

Intraoperatively, after establishing one thoracoport in the 1st intercostal space along the posterior axillary line, a minithoracotomy was performed in the 1st intercostal space along the middle axillary line

From the line, a MAT resection of the upper lobe of the right lung was performed. Before suturing the minithoracotomy approach and draining the hemothorax, perineural blockades of the intercostal spaces of the minithoracotomy, the intercostal space above and below the surgical wound, and the intercostal installation of a thoracoport with Ropivacaine 0.075 95 solution in a total volume of 15 ml were performed. Drainage of the hemithorax was carried out as follows: upper drainage - a microirrigator was installed through the front corner of the wound with stable fixation of its proximal end in the dome of the hemothorax, and after reduction of the ribs and suturing of the intercostal spaces through a thoracoport, a final video thoracoscopic inspection of the hemothorax cavity was performed and a lower drain was installed. Immediately after suturing the wound, the drains were transferred to active aspiration. An X-ray examination of the chest cavity was performed immediately in the intensive care unit, underexpansion of the right lung in the apex area was revealed, in connection with which an artificial pneumoperitoneum with a volume of 1500 ml was applied.

On further control X-rays, the pulmonary pattern filled all sections of the hemothorax. The postoperative period was uneventful. There was no discharge of air through the drains, active aspiration was stopped on the 3rd day after the operation. Less intensity of the pain syndrome was noted, the use of narcotic analgesics was stopped on the 3rd day of the postoperative period. The activation of the patient was noted on the 3rd day after the operative period. The upper drain was removed on the 4th day, and the lower one on the b day after the operative period. The patient was discharged from the hospital in a satisfactory condition after 12 days.

We carried out a retrospective analysis of 28 cases of management of the postoperative period after MAT5 resections in patients with pulmonary tuberculosis. The proposed method of managing the postoperative period after MAT of lung resections was used in 11 patients, in 17 patients the management of the postoperative period was carried out according to the prototype method (archive data). The results are shown in the table.

Table

Comparative assessment of the effectiveness of the use of 2 methods of managing the postoperative period after video-assisted resections in patients with pulmonary tuberculosis

The method of conducting the postoperative period after video-assisted resections in patients with

MoMo oh, pulmonary tuberculosis

Clinical indicators - s/n Method that - -

The closest analogue is claimed (11 (17 patients) patients)

The patient's stay in the hospital 1. Hospital admission 13, 20.3 (days)

The frequency of postoperative complications is long-term underexpansion of the lung, 2. (tr underexpansion 1(91 95) Z (17.6 95) residual pleural cavity, intrapleural bleeding) (95)

Duration of drug use 3. | R! In and 2.20x0.04 5.20x0.08 analgesics (day)

Early mobilization of the patient up to 3 days (5 4. NE of the whole d days (6 80,053.5 277151.3 patients from the group)

Total effectiveness of treatment (965) 777,909.77... 1... 824 7:

Thus, in comparison with the closest analogue, the method claimed allows: - to reduce the frequency of postoperative complications such as long-term underexpansion of the lung, residual pleural cavity, intrapleural bleeding by 8.5 95; - reduce the duration of use of narcotic analgesics by 3,020.04 days; - speed up the terms of early patient mobilization (up to 3 days) in 52.3:22.2 90 patients; - reduce the length of stay of patients in the hospital by 7.2 days; - increase the overall effectiveness of treatment by 8.5 95.

The claimed method is simple to perform and can be performed in the thoracic departments of phthisiatric, phthisiopulmonary hospitals at the city, regional, and state levels.

Claims (1)

USEFUL MODEL FORMULA The method of conducting the postoperative period after video-assisted resections in patients with pulmonary tuberculosis, according to which, after video-assisted lung resection, drainage of the pleural cavity is carried out with two drains, the upper one of which is directed in the direction of the dome of the pleural cavity, which differs in that before suturing the minithoracotomy access and drainage hemothorax is performed by perineural blockade of the intercostal spaces of minithoracotomy, intercostal space above and below the surgical wound and intercostal installation of a thoracoport with Ropivacaine solution 0.075 9o, a microirrigator is introduced through the front corner of the wound to the dome of the hemothorax as upper drainage, after reduction of the ribs and suturing of the intercostal spaces through a thoracoport a final videothoracoscopic inspection of the hemothorax cavity and a lower drain are installed, the drains are connected to active aspiration, and an inspection X-ray of the chest cavity is performed immediately in the intensive care unit. Zo