Method for treating surgical endotoxicosis

FIELD: medicine, surgery.

SUBSTANCE: the present innovation deals with treating "surgical" endotoxicosis, peritonitis, in particular. For this purpose one should apply powder product of table beet obtained out of sublimated raw material. Since the 1st d after operation one should perform enteral introduction of homogenized aqueous suspension of the product at 20 g dry matter/300 ml drinking water of 18-22 C into nasointestinal probe, after intraoperational washing small intestine. Introduction should be carried out thrice daily, 3-5 d/course. The method provides simultaneous enterosorption, stimulation of intestinal motor system and nutritive support.

EFFECT: higher efficiency of therapy.

23 cl, 8 dwg, 1 ex, 5 tbl

 

The invention relates to medicine, namely to surgery, and can be used for surgical treatment of endotoxemia by enterosorption with the use of pectin containing drugs.

Method of enterosorption used for detoxification of the body, with three or four single dose of enterosorbent in a few days, can achieve the effect equal to the procedure of hemosorption. The method is non-invasive, has no complications associated with extracorporeal detoxification, and more physiological. Currently there are a number of chelators for the treatment of diseases of the digestive system, including 1%aqueous solution of pectin (“Clinical application of enterosgel in patients with disorders of the digestive system”. New approaches to therapy. Guidelines for doctors. Edited by Prof. Ivea, Unicel, Assoc. Abbatacola, Moscow, 2000, pp.5-8). Particularly noteworthy vysokodispersnye hydrophilic powder sorbents because of their relatively greater absorptive surface and good yield in solution.

The disadvantages of the known sorbents following: not all known sorbents suitable for long-term administration in the intestine through nasointestinal probe according to their physical form (no need fluidity), which leads to the obturation of the probes and the violation of their function, know the local chelators do not stimulate intestinal motility when it paresis, including postoperative, making it difficult evacuation of related toxins naturally, not have a probiotic nutritional properties, i.e. do not affect the majority endotoxicosis, especially surgical, enteral insufficiency. The combination of these disadvantages complicates and lengthens the treatment of patients with syndrome surgical endotoxemia.

The prototype of the invention is a method of detoxification in case of peritonitis by intraoperative removal of toxic content of the small intestine through nasointestinal probe laundering her to clean water and subsequent passive siphon drainage ulcer on the background of enterosorption. For enterosorption used coal fibrous sorbent “Biosorb” stabilized starch gel. “Biosorb” is used in a dose of 0.3 g per 1 kg of body weight per 100 ml of gel. The gel is prepared at the rate of 2 g of starch per 100 ml of water. After the introduction of the sorbent drainage clamped for 1 hour. The procedure is repeated after surgery, every 6 hours. This marked reduction of intoxication and toxicity intestinal discharge. On the 4th day after surgery was noted decrease in the number of intestinal detachable with 2400±300 ml to 500±200 ml, which was associated with the normalization of the passage through the gut (VII. Detoxification therapy for peritonitis, “Polifakt-alpha”, Minsk, Bela is I, 1997, s-70).

The disadvantages of the prototype are: the absence of stimulation of intestinal motility, which requires passive siphon drainage ulcers, frequent (every 6 hours) introduction of the sorbent with a squeeze of drainage at each session for 1 hour, i.e. the termination of the decompression of the colon for 4 hours. In addition, the used sorbent mixture does not have sanitation in intestinal flora and nutritive effect.

The objective of the invention is to improve the known method of surgical treatment of endotoxemia by simultaneously enterosorption, stimulation of intestinal motility and nutritional support in the early postoperative period in terms of enteral insufficiency.

For this task we used the pectin containing powder product beetroot from sublimated raw material, 20 g in 300 ml of drinking water temperature of 18-22 degrees Celsius. The solution was introduced in nasointestinal probe bolus, 3 times day, a course of 5-7 days, from the first day after the operation, on the background of common postoperative therapy.

Powder product beetroot is prepared according to THE 9199-013-00353158-97 (developed for the first time), certificate for product # P. Optimal preservation of the composition and properties of raw materials, high water absorption and sorption activity, physical fitness vysokodisperstnogo orosco provide technology using sublimation, protected by patents No. 2136182 and No. 2154969 issued by Rospatent.

Analysis of a sample of dry preparation beet
Name of indicatorSample beet
Mass fraction of carbohydrates, %67,9
Mass fraction of cellulose, %6,3
Mass fraction of lignin, %6,8
Mass fraction of pectin, %0,7-1,0
Amino acids, wt.%** 
Lysine*0,30
Histidine*0,25
Arginine*0,35
Asparagina acid0,65
Threonine *0,24
Serine0,31
Glutamic acid**2,79
Proline0,34
Glycine0,25
Alanine0,47
Cystine0,07
Valine 0,33
Methionine*0,09
Isoleucine0,25
Leucine0,32
Tyrosine0,21
Phenylalanine*0,19
Iodine, %0,36
Betaine, %0,469
*irreplaceable 
**The products contain 17 amino acids, including 2,2-2,79 wt.% glutamic.

Glutamine is a Central nitrogen metabolism, as a precursor for the synthesis of purine and pyrimidine, is the chief of plastic and energy material for growing cells, enterocytes, lymphocytes and macrophages. Glutamine transport vehicle for the transfer of ammonia into non-toxic form of peripheral tissues to the kidneys for excretion in the liver to form urea. A large part of it is metabolized in the mucosa of the small intestine instead of glucose, fatty acids or ketones, saving them for other vital organs.

The product contains biologically active substances 2%, including 0,7-1,0% pectin (capacity protopectin up to 20%, allowing you to fill disposed of pectins in dissocial and in the aquatic environment), betaine, flavonoids, iodine, potassium, sodium, calcium, magnesium, manganese, iron, zinc, copper, Nickel, cobalt, chromium, lead, cadmium, mercury, arsenic is not detected), beta-carotene, vitamins B1, B3, FR, RR, H, C, K, meso-Inositol.

Sorption activity determined: a large absorptive surface due to the physical form vysokodisperstnogo powder, hydrophilicity to 1:20 due to sublimation, the presence of lignin, pectin and protopectin. Pectins, forming a hydrophilic gel, stimulate bowel motility, including when it paresis. Nutritional capabilities are defined by the nutritional value of carbohydrates, proteins, and vitamins, trace elements.

Pectins are probiotics, dissociate into short-chain fatty acids (acetate, propionate, butyrate) have a cytoprotective effect against entero - and colonocytes, create conditions for the preservation and restoration of native microflora. The aqueous suspension has a high fluidity and is easily introduced into nasointestinal probes, starting with a diameter of 0.5 cm, without filling them.

The method is as follows. Intraoperative set nasointestinal probe and removed gastric and small bowel contents, the probe is washed to clean the wash water. From the first day after the operation start of enteral therapy. To do this, prepare a water ot the ect powder product beetroot rate of 20 g per 300 ml of drinking water temperature of 18-22 degrees Celsius. After homogenization of the solution injected bolus syringe Jean in nasointestinal probe and probe cover clip for 30 minutes. The procedure is repeated three times a day for 3-5-7 days. The course of treatment after the disappearance of signs of intoxication and restore intestinal motility. After that nasointestinal remove the probe and start the natural diet. Complications and side effects of the method, in addition to diarrhea, not marked. Diarrhea stopped yourself through the day after discontinuation of the drug.

In the clinic the proposed method has been applied in the treatment of 60 patients spilled peritonitis of different etiology in toxic and terminal stages with concomitant enteral insufficiency of different severity. All patients were examined clinical, laboratory and instrumental. After surgery, patients were treated in the ICU. From the first day in combination with conventional intensive therapy they applied the proposed method of treatment. The control group consisted of 50 similar patients. They were only common in the intensive therapy with decompression of the bowel through nasointestinal probe. To compare the effectiveness of the proposed method with the prototype of the 40 patients had similar enterosorption carbon sorbent, WO-a Group formed by the method of steam in the sample.

The results of the treatment were assessed by the dynamics of the severity of the condition scale SAPS (Le Gall G.R., 1984), leukocyte index of intoxication (LII), substances average molecular weight (VSM) in plasma, duration nasointestinal intubation, speed resolution of paresis of the intestine, mortality.

Clinical example. Patient C., 34 years old, medical history, No. 6118 received 3 Department of surgery GCB No. 50 27.03.2002 year with a referring diagnosis: penetrating stab wound of the abdomen, peritonitis, the next day from its receipt. Admission: General condition, pulse 120 in 1 minute, A.D. 105 and 70 mm RT. post, shortness of breath, acrocyanosis, abdomen tense, the breath is not involved, symptom Shchetkina positive in all departments, to review the chest x-ray pathology is not found on the overview image of the abdominal cavity - pneumatosis intestinal, multiple small bowel arches, free gas in the abdominal cavity is not found. After preoperative preparation urgently operated. Operation No. 386 - primary surgical treatment of wounds of the abdominal wall, laparotomy, suturing wounds of the small bowel and omentum, maintenance and drainage of the abdominal cavity, nasogastric and nasointestinal intubation. Operations: in the abdominal cavity to 800 ml of dark blood and intestinal contents, deposits of fibrin in a bet there is a real and visceral peritoneum in all departments of the abdominal cavity, two carved defect of the small intestine and omentum, paresis of the small intestine. Postoperative diagnosis: penetrating wound of the abdomen, injury to the small intestine and omentum, hemoperitoneum, diffuse fibrinous peritonitis, paresis of the small intestine. Through nasointestinal probe evacuated 2.5 l stagnant content. For postoperative treatment the patient was transferred to the intensive care unit. During the initial examination: weight status by SAPS 8,0, LEAH 8,5, VSM 600. From the first day after surgery, with 28.03.2002 year, made enterosorption and interosculate on the proposed method for 4 days. From operative wound complications no, 2 days appeared liquid, beet-colored stools, on the 3rd day of removed non-functioning drainage from the abdominal cavity, initiated activation. On the 5th day of the severity of the condition SAPS 2,0, LEAH 4,5, VSM 300. Paresis of the intestine was resolved, remove the probes from the stomach and small intestine, the patient was transferred to 3 Department of surgery, started regular meals, table 1 surgical. On day 7, 15 translated Desk. On the 8th day surgical wounds healed by first intention, removed the skin sutures. When the control ultrasound on 3-5-7 day of complications from abdominal cavity no. 10 days in a satisfactory condition prescribed under the supervision of a surgeon of the clinic.

Comparative characteristics of enterosorption SRP and ug is arodnym sorbent, who And in the treatment of peritoneal surgical endotoxemia set forth in tables №№1-5 (p.11-12), charts 1, 2 (p.13) and graphs 1-6 (p.14, 15).

Our data illustrate that greater efficiency of the proposed method in comparison with the prototype and the generally accepted method of surgical treatment of endotoxemia, including the background of enteral insufficiency.

Table No. 1
Causes of peritonitis in groups of examined patients.
Causes of PeritonitisControl n-50ESPSP n-60ES WO-And n-40
Acute appendicitis16 (32%)9(15%)11(27,5%)
Perforating ulcer of a stomach and 12-p. intestine.9(18%)13 (21,6%)10 (25%)
Injury of abdominal organs10 (20%)3 (5%)1 (2,5%)
Acute cholecystitis3 (6%)6 (10%)3 (7,5%)
Perforation of the small intestine1 (2%)1 (1,66%)1 (2,5%)
Perforation of the colon2 (4%)4 (6,6%)3 (7,5%)
Window4 (6%)12 (20%)4 (10%)
Postoperative peritonitis2 (4%)3 (5%)2 (5%)
Purulent gynecological diseases1 (2%)1 (1,6%)1 (2,5%)
Intestinal fistula1 (2%)5 (8,3%)2 (5%)
Other1 (2%)3 (5%)2 (5%)
Only50 (100%)60 (100%)40 (100%)
Table No. 2
The distribution of patients by stage of peritonitis
The stage of peritonitisControl n-50ESPSP n-60The group with ES. Who-And n-40All patients n-150
Jet4 (8%)6(10,1%)14(was 9.33%)
Toxic43 (86%)50 (83,3%)35 (87,5%)128(85,3%)
Terminal3 (6%)4 (6,6%)1 (2,5%)8 (5,33%)
Only506040150

Table No. 3
The nature of the contents of the abdominal cavity in the examined patients.
The nature of the contentControl n-50ESPSP n-60ES WO-And n-40Just n-150
Serous-fibrinous10 (20%)6 (10%)8 (20%)24 (16%)
Purulent-fibrinous39 (78%)52 (86.6 per cent)27 (62,5%)118 (78,66%)
Gall- 1 (1,66%)2 (5%)3 (2%)
Fecal1 (2%)1 (1,66%)3 (7,5%)5 (3,33%)
Table No. 4
The dynamics of the severity of the condition of the surveyed patients on SAPS.
DayThe control groupESPSPES WO-
1st7,9±0,437,8±0,548±0,54
2nd7,8±0,546,8±0,347,6±0,57
3rd7,1±0,765,9±0,656,7±0,27
4th6,0±0,394,2±0,565,2±0,55
5th5,1±0,213,4±0,764,2±0,89
6th 3,9±0,542,7±0,213,2±0,38
7th2,4±0,871,9±0,112±0,87
Table No. 5
Comparative mortality in different stages of peritonitis*
Toxic stage
Control n-43ESPSP n-50ES WO-And n-35
Died%Died%Died%
4811,6410
End-stage
Control n-3ESPSP n-4ES WO-And n-1
died%died%Died%
3635 12,5
*In the reactive stage of peritonitis deaths was not.

1. Method of surgical treatment of endotoxemia using nasointestinal decompression through the probe, enterosorption and stimulate intestinal motility, characterized in that enterline enter gomogenizirovannogo aqueous suspension of the powder beetroot, made with sublimation.

2. The method according to claim 1, characterized in that is used 20 g of dry matter per 300 ml of drinking water 18-22°in the form of a homogeneous suspension.

3. The method according to claims 1 and 2, characterized in that the aqueous suspension of the powder is injected 3 times a day course of 3-5 days.



 

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