Method for treating endotoxicosis cases accompanying pyoseptic small pelvis diseases

FIELD: medicine.

SUBSTANCE: method involves carrying out epidural block at the level of Th VII-VIII with lidocaine being introduced. Catheter end is caudally moved 1.5-2 cm behind needle bevel, in carrying out epidural block. 1.5% lidocaine solution is administered 6 times a day. Indirect electrochemical blood oxidation is carried out by introducing sodium hypochlorite. 0.06% sodium hypochlorite solution is intravenously introduced in the amount of 400 ml at a rate of 60 drops per 1 min once a day. Enterosgel is additionally introduced in nasogastric way in concentration of 15 g per 100 ml of water 8 h after lesion focus treatment but before starting epidural block repeating the treatment later in 8 h. Intestine peristalsis being observed, enterosgel is introduced per os.

EFFECT: enhanced effectiveness of treatment; early motor and evacuation intestine functions recovery.

 

The invention relates to medicine, namely to resuscitation.

The problem of correction of endotoxemia resulting from the deregulation of detoxication systems and accompanying many chronic inflammatory diseases (including pelvic) has received considerable attention by many authors (Ershov A.A. Differentiated methods of efferent therapy in various stages of endogenous intoxication. Materials 2, proc. Moscow society of gemafereza. - M., 1994, - p.23; Lebedev, R.N., Poltronova T.V. Some aspects of the pathogenesis and treatment of multiple organ failure. Intensive therapy - 1995 - No. 3 - s-88; Saved CENTURIES Syndrome of endogenous intoxication diagnosis and comprehensive treatment. - Abstract. disect. the honey. Sciences. Grodno, 1990; lot S., Tikhomirova NI, OLGA Oleynikova. and others - Obstetrics and gynecology, 1998 - No. 6 - p.50-51).

When purulent-septic diseases the risk of developing multiple organ failure, primarily suppression of liver detoxification function, inefficient korrelirovanno the endotoxicosis very high, so it is very important to recover in the short term hepatic metabolism and may partially replace some of the functions, thereby to neutralize the vicious chain of maladaptive reactions of the organism as a whole. This confirms the need for their the belt comprehensive intensive therapy combination of known methods of detoxification with the aim of increasing the effectiveness of each. (Kulakov, VN, Serov V.N., Abubakirov A.M. and other Intensive care in obstetrics and gynecology. - M, - 1998, - s).

There is a method of treatment of patients with endotoxemia, accompanied by liver failure, based on the use of hemosorption undertaken against a background of epidural block segments of the spinal cord Innervate hepatopancreatobiliary zone (Chester A.N., Sokolovsky B.C., Slepushkin E, patent RU No. 2056865 from 27.03.96. Bull. No. 9, M. CL. 6 And 61 M 1/36 "Method of treatment of hepatic failure in patients with endo - and exogenous toxicosis").

The authors proposed a correction of endotoxemia by conducting hemosorption on the background epidural block segments of the spinal cord Th VII-VIII solution trimekainom 1,5% - 10.0 ml, and an epidural catheter was performed cranial 1.5-2 cm

The disadvantage of this method is that the methods are quite aggressive detoxification method, which involves the creation in vitro of the "third" circulation, heparinisation in large enough doses (200-300 mg/kg of body weight), complex equipment, expensive consumables. This method is carried out when reaching giperwolemicescoy hemodilution, which requires a significant infusion of funds (gemodez, reopoliglyukin, dry and native plasma, concentrated glucose solutions) often is orticosteroids and agonists (to maintain stable hemodynamics).

The catheter is held in the epidural space of the cranial that provides autonomic blockade typical for hepatic-pancreaticoduodenal area and does not capture the pelvic organs.

Used trimekain 1,5% - 10.0 ml anesthetic short period of action, which often cause allergies.

There is a method of treatment of endogenous intoxication by the use of sodium hypochlorite solution in the complex of intensive therapy. The influence of sodium hypochlorite on the level of endogenous intoxication in patients with inflammatory diseases of the pelvic organs. Tikhomirova NI, Machova O., Herald intensive care 2002, No. 1, - pp.62-66.

The authors have introduced the sodium hypochlorite into the Central vein, drip dose was 400.0 ml of a 0.06% solution in patients with inflammatory diseases of the pelvic organs in combination with traditional therapy, including intravenous, detoxication, antibacterial and immunocorrective therapy. However, a full detoxification during endotoxemia severe to achieve in practice it is not possible. This is confirmed by the results of the authors: the reduction of one of the most important indicators of endotoxemia - LEAH is only the 7th day, you cannot avoid such postoperative complications as paresis of the intestine and dynamic intestinal obstruction.

The disadvantage of this method is that not considered enterline the component of endotoxemia, because the gastrointestinal tract (GIT) itself becomes a source of endotoxemia, because, when disturbed motility of the intestinal wall loses its protective properties and thus the conditions for the penetration of toxins into the blood from the intestinal lumen.

Closest to the claimed technical solution is "Indirect electrochemical oxidation of blood (NAHAC) on the background of epidural blockade typical for hepatic-pancreaticoduodenal area (GPDS) in the intensive therapy of acute purulent peritonitis in the clinic of gynecology" I. Vorobyov, Picotin SHE, Chester A.N., Chester S.N. Abstracts of the VIII all-Russian Congress of anesthesiology and resuscitation. Omsk, 2002, s. The authors propose to stimulate the detoxification functions of the liver by increasing the blood flow and microcirculation GPDS through the creation of epidural blockade segments of the spinal cord at the level of Th VII-VIII lidocaine 1% - 10,0 combined with NEHOC sodium hypochlorite 0.1% in the Central vein.

The main disadvantage of this method is that not considered enteric component of endotoxemia. Because the digestive tract during endotoxemia and severe in patients with purulent-septic diseases of the pelvic organs itself becomes a source of endotoxemia. In the loss of the protective properties of the intestinal wall and penetration of toxins and productivityis in the blood, mainly in the portal vein, compounded by the liver and the severity of endotoxemia, especially when restoring microcirculation, as the effect of epidural blockade.

Use 1% - 10.0 lidocaine, which requires an increase in the multiplicity of the introduction into the epidural catheter anesthetic by means of the low concentration of the anesthetic solution, and consequently, reducing the time of anesthetic action.

Level Th VII-VIII captures the hpda organs and does not capture the pelvic area surgical aggression.

Use 0.1% solution of sodium hypochlorite, which is more aggressive than 0,06% solution for red blood cells, in a greater degree reduces the level of blood glucose.

The objective of the proposed method for the treatment of endotoxemia with purulent-septic diseases of the pelvic organs is to increase the effectiveness of treatment, due to the intensification of detoxification, early recovery of motor-evacuation function of the intestine, preventing respiratory complications, reduced length of hospital stay.

This object is achieved in that in the treatment of endotoxemia with purulent-septic diseases of the pelvic organs perform epidural blockade at the level of Th VII-VIII with lidocaine 1.5 percent to 10.0 ml. Indirect electrochemical oxidation of the blood is performed with the introduction of vnutrepenialnymi sodium 0,06% - 400,0 mil Additional 8 hours after surgery, but before performing epidural blockade, nasogastric enter enterosgel 15 grams per 100 ml of water, followed by re-introductions 8 hours, and when restoring intestinal motility enterosgel administered orally. When performing epidurally blockade the end of the catheter is introduced Caudalie. Sodium hypochlorite 0,06% - 400,0 ml injected at a rate of 60 drops per minute 1 per day intravenously.

The novelty of the method

- Additional 8 hours after surgery, but before performing epidural blockade, nasogastric enter enterosgel 15 grams per 100 ml of water, followed by re-introductions 8 hours, and the appearance of intestinal peristalsis enterosgel administered orally.

- When performing epidural blockade the end of the catheter is introduced Caudle.

- Sodium hypochlorite 0,06% 400,0 ml injected at a rate of 60 drops per minute 1 per day intravenously at the height of action of epidural block.

Effective detoxification is achieved by the fact that the creation of epidural blockade of the abdominal cavity in the early postoperative period is accompanied by disclosure of the microcirculation, increasing blood flow to tissues in the zone of operations, as well as parenchymal organs, including the liver. From revascularizing organs and tissues in the SHS will in the blood products of autolysis, where they are oxidized to inactive metabolites with sodium hypochlorite.

Epidural blockade is carried out at the level of "hepatic" segments of the spinal cord, but the end of the catheter is Caudalie to anesthetic due to the high specific weight of spread down, grasping the underlying segments of the spinal cord Innervate the organs of abdominal cavity and small pelvis (intestines and area of operation), which is important for our proposed method.

Enterosorbent enter to create epidural blockade of the abdominal cavity because, when executed then the blockade revealed microcirculation in organs of the abdominal cavity, which prevents absorption from the intestines of substrates such as fatty acids, peptides, phenols, ammonia, and NEHOC at the height of EB promotes oxidation in the blood products of autolysis and toxic substances, emissions which occur as a result of surgical aggression. This leads to a decrease of endotoxemia in General and creates optimal conditions for regeneration of hepatocytes.

The concentration and volume of injected anesthetic small, which prevents the toxic effect of the drug.

Enterosgel does not cause "clogging" of the intestinal villi and in combination with the positive effect of epidural block on the motility of the digestive tract helps to prevent secondary poisoning, the reduction gas is obrazovaniya, mild stimulation of bowel function and its decontamination.

The use of epidural block and enterosgel allows you to renounce the use of anticholinesterase funds (neostigmine) indirectly prevents the development of broncho-pulmonary complications due to more early activation of patients and the lack of negative effect of neostigmine methylsulfate.

The method is based on the comprehensive elimination of toxins endovascular and encounterable, antihypoxic, hepatoprotective effect.

The mode of combined treatment within 2-4 days of reliable, sufficient and confirmed clinical practice.

The method is as follows.

Patients with endotoxicosis severe accompanying purulent-septic diseases of the pelvic organs, on the first day of the postoperative period (8 hours after readjustment of the focus) on the background of traditional treatment comprehensive treatment, consisting in the sequential use of epidural blockade segments of the spinal cord in combination with electrochemical oxidation of blood and enterosorption.

Do this as follows: conduct pre infusion preparation by sequential introduction of Central vein catheterized solutions reopoligliukina 400,0 ml of ringer's solution 400,0 mil

Then spend nasaga the Central or urogastrone probe the intubation and aspiration of gastric contents with a syringe Janet, followed by gastric lavage with cold boiled water volume of 2 L. After the evacuation of the wash water in the tube is inserted a solution of enterosgel 100 ml, prepared at the rate of 1 tablespoon of enterosgel (15 g), mashed with 2 tablespoons of boiled water with the addition of water to 100 ml. Probe compress and remove.

Next, after processing the surgical field to the patient in position on the side" under local anaesthesia, catheterization of the epidural space standard Teflon catheter firms "Braun", "Portex" at the level of Th VII-VIII, which corresponds to the line connecting the lower corners of the blades. The catheter is pushed Caudalie 1.5-2 cm per slice needle and fixed with plaster all over. To prevent kinking of the catheter is in place out of his skin obkladyvaetsya with sterile towels and gauze ball with craniolateral side. The end of the catheter displaying in the subclavicular region. Then, in the position of a patient lying on their back input lidocaine solution of 1.5% - 10.0 ml epidural catheter. After a latent period of local anesthetic after 10 minutes begin intravenous infusion of sodium hypochlorite 0,06% - 400,0 ml at 60 drops per 1 min. Produced monitoring: AD, BH, HR, SapO2, diuresis.

The rate of introduction into the epidural anesthetic block - 6 times per day, i.e. after 4 hours.

Enterosgel is inserted through 8, moreover, with the emergence of distinct peristalsis go on active oral administration.

The sodium hypochlorite used 1 time per day.

The course lasts on average 3 days.

Complex application of indirect electrochemical oxidation of blood and enterosorption in combination with prolonged epidural blockade of the abdominal cavity and small pelvis significantly increase the total elimination of endotoxins and products of autolysis of the vascular bed and out of the intestines, eliminates the use of neostigmine methylsulfate in the postoperative period, reduces the cooldown of intestinal peristalsis, reduces flatulence, indirectly prevents the development of pulmonary complications (due to refusal from the use of neostigmine methylsulfate and early activation of patients) does not require sophisticated equipment and expensive supplies, just in technical execution.

Example.

Sick f VA 40 years, with a diagnosis of bilateral purulent tubal-ovarian tumors with perforation, septic omentitis, right anterolateral parametritis, abscess Red pocket, endometritis on the Navy background. After removing the uterus with appendages, resection of omentum, abdominal drainage through the vaginal stump, drainage of abscess small pelvis on Pirogov, under ATN, was admitted to the intensive care unit.

And the history of the disease: sick for 2 weeks, last week hyperthermia to 39.5°With chills. Was treated independently. When arriving at the clinic of gynecology in a serious condition caused by endotoxicosis severe water and electrolyte disorders. Conscious, inhibited, dinamica. Skin with dark-greenish-gray tint, t - 38,6°C. Breathing hard shade, BH - 24 in 1 min. Hemodynamics with a tendency to hypotension, AD - 80/50 mm Hg, tachycardia of 110 beats per 1 minute of the Tongue dry, white furred. Abdomen moderately swollen, painful, sluggish peristalsis, hypogastruridae positive symptoms of peritoneal irritation. Laboratory: leukocytosis (23×109/l) with a left shift formula, LEAH 5,8 UE. Biochemical parameters: hypolipoproteinemia (total protein of 56.5 g/l), moderate hyperbilirubinemia (30.4 μmol/l), increased activity of the neurotransmitter enzymes, mainly AST (1.26 µkat/l), hyperfibrinogenemia (5.9 g/l), reduced PETIT (78%).

Catheterized Central Vienna, CVP - negative.

Preoperative preparation included the traditional, infusion, symptomatic and antibiotic therapy.

In the early postoperative period in the intensive care unit 2 was conducted prolonged artificial ventilation mode normogastria within 4 hours.

On the background of basic therapy, including antibacte the territorial (cephalosporins, 3rd generation + metrogylum), infusion therapy at a rate of 40 ml/kg of body weight, antispasmodics, antioxidants (tocopherol), the patient had evidence of severe endotoxemia: shortness of breath, tachycardia, tachypnea, nausea, enlarged liver (+1.5 cm from the edge of the costal arch), LEAH 6,2 UE, increasing at 3 times the level of peptides of low and medium molecular weight (Prism), moderate hyperbilirubinemia (28.7 μmol/l), increased activity of the neurotransmitter enzymes (AST 1.04 µkat/l)

8 hours after the operation was performed intubation of the stomach, followed by evacuation of stagnant content number 400,0 ml, stomach washed with cold boiled water; after the evacuation of the wash water in the probe entered the enterosorbent (enterosgel 15 grams dissolved in 100 ml of water).

The probe was removed.

The patient laid on his side, and in this position he performed the catheterization of the epidural space at the level of Th VII-VIII standard Teflon catheter firm "Braun". In the position lying on their back in the catheter entered the lidocaine solution of 1.5% to 10.0 ml.

The patient noted a decrease abdominal pain, feeling of heat in the abdomen and legs.

In subclavian vein started the infusion of sodium hypochlorite solution of 0.06% - 400,0 ml at 60 drops per 1 min. the Solution prepared with the apparatus of the EDO - 4 scheme.

Epidural block anesthetic was administered every 4 hours to maintain neuro-autonomic blockade.

After 8 hours p is after the first injection of sorbent auscultation started listens isolated intestinal noises. Re-probed stomach - stagnation was not, which was confirmed by partial recovery of bowel function. The stomach is washed and then entered the second portion of sorbent.

Later, 8 hours after the second injection of sorbent appeared distinct peristalsis, the patient nausea disappeared and the usual dose of sorbent was given orally. Laboratory: LII-5,2 UE, leukocytosis 14×109/HP

The decrease in the level of bilirubin to 18.7 µmol/l, AST - 0.89 µkat/L.

Thus, the treatment was carried out for 3 days.

In the dynamics of the patient significantly improved the General condition became more active, recovered peristalsis, began to depart gases, the size of the liver returned to normal, decreased fatigue, appetite. The laboratory also reported a positive trend: the decline of LEAH to 2.4 UE, leukocytosis to 8.7×109/l, bilirubin up to 9.7 µmol/l, Prism up to standards.

On the 4th day he removed the DL, the patient was transferred to the recovery room of the gynecology Department.

Thus the proposed method for the treatment of endotoxemia and severe in patients with purulent-septic diseases of the pelvic organs is affordable and safe method of treatment that does not require complicated equipment, expensive consumables and infusion media. In the combined use of enterosorption and NEHOC on phoneb significant positive dynamics laboratory and clinically confirmed, reduced duration of hospital stay.

The proposed method is used in the treatment of 14 patients.

Method for the treatment of endotoxemia with purulent-septic diseases of the pelvic organs, including the execution of epidural blockade at the level of Th VII-VIII with lidocaine and indirect electrochemical oxidation of blood by the introduction of sodium hypochlorite, characterized in that it further through 8 h after recovery of the hearth, but before performing epidural blockade, nasogastric enter enterosgel 15 g per 100 ml of water, followed by re-introduction after 8 h, and the appearance of intestinal peristalsis enterosgel administered orally; when performing epidural blockade the end of the catheter is introduced Caudalie 1.5-2 cm slice of the needle, this injected 1.5%lidocaine solution 6 times per day, and the sodium hypochlorite 0,06%400 ml injected at a rate of 60 drops per minute 1 per day intravenously.



 

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