Method for estimating enteric detoxication in the cases of generalized peritonitis

FIELD: medicine.

SUBSTANCE: method involves studying lactoferrin content in blood serum and peritoneal exudates in postoperative period every day during the first three days. Lactoferrin concentration in blood serum being concurrently reduced by 0.02 mcmole/l or less and increasing lactoferrin concentration in peritoneal exudates by 0.04 mcmole/l or more, enteric detoxication is considered to be effective.

EFFECT: high quality of estimation.

2 tbl

 

The invention relates to medicine, in particular to anesthesiology and critical care medicine.

The urgency of the problem of widespread peritonitis is no doubt, as this nosology remains among the leading causes of death in emergency surgery and medicine critical States. At the moment very promising is the use of so-called methods intracorporal detoxification, i.e. methods of introducing into the cavity of the body of drugs, absorbing and removing those components that can cause deterioration due to endogenous intoxication. The most significant is the way of enterosorption, that the introduction of different methods of sorbents into the lumen of the gastrointestinal tract with subsequent evacuation of contents. One of the phases of the pathogenesis of widespread peritonitis is the translocation of organisms and endotoxins, that is, the migration of pathogenic microorganisms through the wall of the bowel and vascular endothelium in the system splanchnicectomy blood and peritoneum. This factor is capable of supporting a syndrome of endogenous intoxication and explain the severity of the patient even when the effective rehabilitation of surgical infection. The method of enterosorption and enteral detoxification allowed very efficient to cope with endogenous intoxica the iej, as the main direction of toxins is the transport of toxins from the intestinal lumen into the bloodstream and the peritoneum, if we are talking about widespread peritonitis.

There is currently no clean way to assess the effectiveness of using the method of enterosorption in disseminated peritonitis, in particular, no data on the relationship between indicators of biochemical parameters of blood serum, intestinal chyme and peritoneal exudate, as well as to assess the possibility of correction of the phenomenon of translocation of endotoxins from the abdominal cavity into the bloodstream in the dynamics of enteric detoxification.

There is a method of evaluating the effectiveness of intensive therapy of the syndrome of intestinal failure [Popov FT, Tamazashvili T.SH., Shestopalov A. the Syndrome of intestinal failure in surgery. - M.: Medicine. - P.93-108]. In patients with widespread peritonitis, acute intestinal obstruction conducted a comprehensive assessment of multiple symptoms (radiography of abdominal cavity organs, electrogastrography, the study of biochemical parameters of blood) in the dynamics of intensive therapy on the basis of this complex has been evaluated the effectiveness of therapy of the syndrome of intestinal failure.

The disadvantage of this method is the fact that the development of the syndrome of multiple organ failure in common is th peritonitis (that is, failure of the liver, kidney), which contributes to the formation of the changes of biochemical parameters, that is, there is not only the intoxication from the gut lumen, but also a component of endogenous intoxication due to ineffectiveness own organs of detoxification. The complex is quite difficult to implement, since radiography of abdominal cavity organs requires the vertical position of the patient, electrogastrography give false-positive results in the presence of a drainage tube into the abdominal cavity.

There is a method of determining the effectiveness of enterosorption syndrome intestinal failure [Gelfand BYR, Filimonov M.I., Yusufov OG, Podocin PV, Nasibov S.M., Kulaev A.I Enterosorption syndrome intestinal failure // Anesthesiology and resuscitation. - 1997. No. 3. - P.34-36]. The essence of the method consists in the study of biochemical parameters of metabolism (urea nitrogen, total bilirubin, cholesterol, albumin, creatinine, total protein and triglycerides) in the intestinal contents and blood serum; increasing the concentration of these indicators is an indication for enterosorption through nasointestinal probe.

The disadvantage of this method is the use of biochemical parameters of intestinal chyme not only mikroorganismen origin, but also of microbial origin. In addition, the fact that research and CPA is in chyme and blood does not allow to speak about the phenomenon of translocation and efficacy of enterosorption on the correction of the above-mentioned phenomena.

Closest to the claimed method is test effectiveness evaluation of enterosorption, based on biochemical indicators of toxicity in the blood and peritoneal exudate [Belyakov N.A. (as amended) Enterosorption. L., 1991. - S-135]. The essence of the method consists in the measurement of the concentration of molecules of average weight (MSM) in the serum and peritoneal exudate and by increasing the concentration of MSM in the exudate believed illustrates the use of enterosorption.

The disadvantage of this method is the use of models and evidence only in the experiment, in clinical practice, studies have not been conducted. In addition, MSM are not the only molecules sources of endogenous intoxication in translocation syndrome in patients with peritonitis.

The objective of the invention is to improve the assessment of the effectiveness of enteral detoxification with widespread peritonitis by examining the content of lactoferrin in the serum and peritoneal exudate. On the basis of the received data is considered effective or ineffective conduct of enteral detoxification (enterosorption through nasointestinal probe). Lactoferrin is more specific and reliable marker for evaluating enteral detoxification, as it determines the process flow endogenous into the paths and explains the state hematopathology barrier.

This object is achieved by the fact that patients with the widespread peritonitis simultaneously examine the contents of lactoferrin in the serum and peritoneal exudate in the postoperative period and at the same time reducing the concentration of LF in the serum of less than 0.02 µmol/l and the concentration of LF in peritoneal exudate more than 0.04 µmol/l consider enteral effective detoxification.

The novelty of the method:

1. The study LF produce both in the serum and peritoneal exudate. Determining the level of LF at the same time in the blood and exudate may explain the fact that damage to the blood-tissue interfaces of the barrier on the border, “the blood - peritoneum or the so-called hematopathology barrier, as well as the direction of movement of LF and endotoxin bacteria from the abdominal cavity into the systemic circulation.

2. The research produced in the postoperative period. Damage hematopathology barrier is closely related to the scheduled readjustments of the abdominal cavity, so as surgical aggression is an important factor in the deterioration of the patient with widespread peritonitis. The determination LF carried out daily during the first three days of the postoperative period.

3. The calculation of the concentration of LF in biological fluids ensures the in mmol/l (concentration, and not in the weight values). It aims at comparative characteristics between respondents in different biological environments

4. The simultaneous achievement of changes in the level of LF in the serum of less than 0.02 µmol/l and in peritoneal exudate more than 0.04 µmol/l is the hallmark of effective enteral detoxification. Data critical values of LF in the exudate and blood obtained during studies of patients with widespread peritonitis, the above values of LF assumed development of adverse outcome of widespread peritonitis.

The method consists in the following. The study of biochemical parameters is performed in the postoperative period (surgical interventions regarding widespread peritonitis suggest a radical reorganization and removal of the primary site of infection in the abdominal cavity). To determine the LF using peritoneal exudate and blood. Peritoneal exudate receive or operations to the readjustment of the abdominal cavity with antiseptic solutions, or during diagnostic laparoscopy, or from drains, which completes the operation. In any case, a prerequisite is the absence of additional impurities (saline solution, hydrogen peroxide solution, furatsilina) when is abore exudate. Exudate centrifuged with a speed of 2500 rpm for 3-5 minutes After which the upper portion (exudate without cellular elements) take in a volume of 3 ml, and then subjected to study, or freeze in domestic refrigerator for further studies. Blood for research taken from catheterized Central vein (with the obligatory washing of the lumen of the catheter Autocraft to avoid impurities in the form of infusion media), followed by centrifugation under the same conditions as the exudate. Subsequent research and storage did not differ from those for peritoneal exudate. Note that the blood and exudate were taken at the same time. In the following were performed enzyme-linked immunosorbent assay serum and exudate on the LF content.

The use of lactoferrin and diagnostics damage hematopathology barrier (barrier the blood - peritoneum) is explained by the fact that LF is the product of the synthesis and secretion by peritoneal macrophages. Under favorable for the process of peritonitis in peritoneal cavity hematopathology barrier cope with the increased secretion of LF, there is no phenomenon of translocation, i.e. transition of endotoxins and LF as a marker of translocation from the abdominal cavity in the system krovatki unfavorable course of the process hematopathology barrier fails, that is, endotoxins, bacteria, and LF is able to penetrate the blood-tissue interfaces barrier and get into the blood system, which greatly impairs the process of inflammation and syndrome of endogenous intoxication. The control is carried out daily during the first three days of the postoperative period, because this period of time the most dangerous for the development of increased translocation through hematopathology barrier.

PRIMER

Patient B., no history 156, hospitalized 13.02.2003 in the Department of emergency surgery of the city clinical hospital №1 with a diagnosis of perforated duodenal ulcer, acute widespread peritonitis. In case of emergency surgery: laparotomy, closure of the perforated holes, sanation of abdominal cavity, nasointestinal drainage, overlay laparostomy. Nearest postoperative period in the intensive care unit. According to LF in the peritoneal exudate and blood considered is shown holding enteric detox

Table 1

The dynamics of the concentration of LF in the exudate and serum, mmol/l
Day123
LF blood0,050,040,02
LF exudate0,020,020,03

EXAMPLE 2

Patient N., no history of the disease 1858, hospitalized 13.05.2002 in the General surgery Department of the city clinical hospital №29 with a diagnosis of a ruptured ulcer dvenadcatiperstnoj intestine, widespread peritonitis. In case of emergency surgery: laparotomy, gastrectomy in Vitebsk, nasointestinal drainage, laparostomy. The LF of the peritoneal exudate and serum on the first day of the postoperative period, it was decided to add to the complex therapy of enteric detoxification. With this aim through nasointestinal probe conducted 3 sessions of enterosorption sorbent “Enterosgel”, session duration 1 hour, the volume of the sorbent 1 g/kg body weight.

Table 2

The dynamics of the concentration of LF in the exudate and serum, mmol/l
Day123
LF blood0,050,040,08
LF exudate0,020,020,01

On the third day according to the LF noted the inefficiency of holding enterosorption, which was confirmed by the increase in the concentration of LF in the monitored blood and decrease in LF in peritoneal exudates. Ineffective conduct of enterosorption became the indication to change the complex of intensive therapy: strengthening antibacterial therapy, adding extracorporeal detoxification session of plasmapheresis.

The condition of the patient in the dynamics improved, he was transferred to the Department of public profile on day 7 of therapy and successful closure laparostomy.

Thus, evaluation of the effectiveness of enteral detoxification using detect changes in the concentration of lactoferrin in blood and peritoneal exudate can improve the quality of estimating enteric detoxification due to specific and reliable marker that allows to optimize the selected treatment regimen to increase the effectiveness of therapy of peritonitis.

A method of evaluating the effectiveness of enteral detoxification with widespread peritonitis, including the study of blood and peritoneal exudate, characterized in that the patients with the widespread peritonitis simultaneously examine the contents of lactoferrin in the serum and peritoneal fluid in the postoperative period daily during the first three days and at the same time reducing the concentration of LF in the serum of less than or equal to 0.02 µmol/l and the concentration of LF in peritoneal exudate more than or equal to 0.04 mmol/l is considered the t enteral effective detoxification.



 

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