Method for treatment of pleuropulmonic complications in patient suffering from pancreatonecrosis

FIELD: medicine.

SUBSTANCE: claimed method includes paracentesis of pleural cavity and exudate removing by at least tree hours before surgical aggression singly and then additionally over at least one day after surgical aggression. Interval between paracentesis must be not less than one day. After exudate removing during each paracentesis 2000 Units of contrical and 30 mg of mexidole are administered intrapleurally.

EFFECT: method for treatment of increased effectiveness due to improving of ventilation-perfusion ratio and reducing of amylasemia in pleural cavity exudate.

1 ex, 1 tbl

 

The invention relates to medicine, namely to methods for treating pleuropulmonary complications in patients with pancreonecrosis that in 100% of cases are accompanied pleuropulmonary complications.

There is a method of treatment pleuropulmonary complications, namely pancreatic pleuritis (Vigilon, Allstudent. "Emergency pancreatology". - SPb.: Peter. - 1994. - S) consisting in doing after surgery, puncture of pleural cavity and the removal of the pleural effusion.

The disadvantages of this method is the lack of effectiveness of the procedure being performed, so as pleural cavity punctured after surgery and only when functionally significant pleural effusion, i.e. when the already significant decrease in vital capacity of the lungs, oxygenation of the blood and the cases of violation of ventilation-perfusion relationships.

In addition, in 70% of cases are observed persistent recurrence of pleural effusion, which require multiple repeated puncture of the pleural cavity. A high percentage of recurrent pleurisy causes costly monitoring of the pleural cavities, including frequent chest x-rays and ultrasound. Often pleural effusions are infected (hematogenous or lymphogenous route), resulting in empyema of the pleural cavity, which must be drained from n the number of points. Drains require careful care and 9-15% lead to abscess of the chest. Empyema is often complicated by residual cavities, otcharovanie that require operative treatment of thoracotomies access, often ending decorticate lung.

The present invention is easy to use, requires no additional equipment and devices, securely and effectively solves the problem of treatment pleuropulmonary complications in patients with pancreonecrosis.

The technical result consists in increasing the effectiveness of treatment. Using the proposed method, including multiple puncture sequential introduction into the pleural cavity multicomponent drug solution, consisting of a protease inhibitor - kontrikala (20000 units) and a synthetic inhibitor of free radical processes (membranoprotector) - Mexidol (300 mg), reduces in the pleural cavity, the level of pancreatic enzymes (primarily - amylase), kallikrein and products of lipid peroxidation (POL). This eliminates endotoxic bronchospastic effect and spasm of the pulmonary veins, causes a reduction of pressure in the pulmonary artery and reduces the amount of internal-lung bypass, thereby improves ventilation-perfusion from the osenia in the lungs, which lead to fast and reliable relief of pancreatic pleural effusion.

The possibility of multiple puncture intrapleural injection multicomponent drug solution, including contrical and Mexidol, as before the surgery and in the postoperative period, allows to increase the effectiveness of the treatment.

Multiple puncture introduction multicomponent drug solution into the pleural cavity, including contrical and Mexidol, provides improved ventilation-perfusion relationships in the lungs and, very importantly, has a long therapeutic effect for at least 24 hours. Reducing amylasemia, kallikrein and POL in the exudate pleural cavity protects the pleura and alveolararterial lung membranes from destruction, warns embolization and thrombosis pulmonary arterioles reduces pulmonary hypertension, reduces arteriovenous shunt, arterial hypoxemia.

The proposed method for the prevention and treatment of safe, simple, and available for use by the surgeon of any qualification.

This technical result is achieved in that in the method of treatment pleuropulmonary complications in patients with pancreonecrosis, consisting in running for 3 hours before surgery advanced single puncture of the pleural cavity and removal is pleural effusion, and not less than one day after the operation performed additional puncture of the pleural cavity with an interval of not less than one day, and with each puncture and after removal of the pleural effusion in the pleural cavity sequentially injected 20000 units kontrikala and 300 mg of Mexidol.

The method of treatment pleuropulmonary complications in patients with pancreonecrosis is as follows.

For the preparation of solutions for injection into the pleural cavity under sterile conditions bred 20000 units kontrikala in 20 ml of water for injections and take a 20 ml syringe, in another syringe 300 mg (6 ml 5%) of Mexidol diluted in 10 ml of physiological solution and also take a 20 ml syringe.

Technique intrapleural puncture differs from classic and execute it in the seventh intercostal space on signedmessage line. After preparation of the solution for 3 hours before operations are performed anesthesia conventional needle through the introduction of a 0.5% solution of novocaine at the top of the eighth rib, after the failure in the pleural cavity, the needle changing the needle with a diameter of 1.5 mm with a blunt end so as not to injure the tissue of the lung, which is held in the pleural cavity. Initially evacuated effusion from pleural cavity, then through the same needle successively introduced 20000 units kontrikala 20 ml of water for injection and 300 mg of Mexidol in 10 ml of physiologically is one solution. After the operation, not less than a day and at intervals of not less than one day perform puncture of the pleural cavity, removal of the pleural effusion and with each puncture enter 20000 units kontrikala and 300 mg of Mexidol.

After the introduction of the drug solution is distributed in the pleural cavity and surrounds the root of the lung.

The way has proved highly effective, cheap, easy to perform and eliminates the disadvantages in the above prototype.

After the introduction of drugs into the pleural cavity of the proposed method all the patients showed a reduction in the frequency of respiratory movements (NPV), increased vital capacity (VC), tidal volume (UP), reserve volume inspiratory (ROVD), expiratory reserve volume (ROWID) and average flow rate during expiration (SOS), also significantly increased blood oxygenation (SpO2).

Observations showed that in 90% of patients for reliable edema pleurisy was sufficient to perform the puncture of the pleural cavity with the introduction of drugs by the proposed method prior to surgery and once after the operation.

Table 1 presents the performance of the ventilation-perfusion lung function, characterizing the effectiveness of the treatment pleuropulmonary complications in patients with pancreonecrosis.

Clinical example: patient K., 57 years old, he enrolled in MUS KB No. 25 26.02.2002. in the 1630with complaints of acute pain in the upper abdomen "zoster" nature, bloating, nausea, repeated vomiting, shortness of breath. Sick considers itself within 3 days after receiving abundant fatty foods with alcohol suddenly developed severe pain in the epigastrium and left upper quadrant, radiating to the left of the rib-vertebral angle. Last night was joined by high body temperature up to 39°With, became evident weakness, dryness in the mouth, bloating. Took analgesics and antispasmodics - no effect. Taken by ambulance to the hospital.

Objectively: a serious condition. HELL 80/40 mm Hg, pulse 126 1 min NPV - 28 per minute. Chest left behind in breathing. In the lungs the right breathing hard, left, listens only on the top. Percutere shortening of sound left to the V ribs. Skin pale belly with spots of Mondorf. Nasolabial triangle of cyanolichen. The sclera of the eye is slightly icterina. Tongue dry, lined with brown patina. Belly swollen, tense and sharp pain in the upper sections, and on the right flank. Peristalsis is not defined, positive symptom Shchetkina-Blomberg, CERTE, Mayo-Robson. During the day the chair was gone, almost gases do not leave, diuresis drastically reduced.

Biochemical analyses were determined hepatopathy Art. I thee is the input. The hemostasis was observed activation of blood coagulation by the type of stage I of DIC due to plasma factors.

Investigation of ventilation-perfusion lung function (apparatus "ETON-SPIRON"): VC was 3,35 l TO 2.9 litres, Police - 1.25 l, ROWID - 1,15 l, SOS - 2,45 l SpO2was 82% (hemoximetry "NONIN 950". Conclusion: a significant reduction in pulmonary ventilation capacity due to impaired patency of small bronchi. Restrictive plus malabsorptive obstructive type.

On chest x-rays was determined by liquid in the rib-diaphragmatic sinus to the left to the V ribs.

Ultrasound imaging of the chest: fluid in the pleural cavity left up to 550 ml.

Abdominal ultrasound: Pancreonecrosis. Swelling of the retroperitoneal tissue. The liquid in the packing bag and the abdominal cavity. Changes hepatorenal structures of the I century Biliary hypertension.

Clinical diagnosis of Infected pancreatic necrosis. Ametabolic. Peritonitis. Obstructive jaundice. Pancreatogenic shock. Pancreatic pleural effusion on the left.

The forecast severity by Ranson was 4 points of senior (age over 55 years, blood glucose is 14.8 mmol/l, leucocytes - 20×109, Alt - 1.15 mmol/l) + 6 clinical syndromes (pain + gastroenterolgy syndrome + hemodynamic syndrome + hepatorenal syndrome + respiratory syndrome + peritoneal shall syndrome).

After an 8-hour training in intensive care the patient is removed from pancreatogenic shock. 3 hours before the operation the patient was performed pleural puncture to the left VII intercostal space at signedmessage line, evacuated 450 ml light serous fluid. Amylase it was 47 mg/SL, gidroperekisi lipids and 18.2 mmol/l (in the peripheral blood - amylase 35 mg/SL, gidroperekisi lipids of 14.5 mmol/l). Introduced into the pleural cavity by the method described above consistently 20000 units kontrikala and 300 mg of Mexidol. The breath left (hard) began to listen to all fields. The NPV decreased to 22 minutes Improved ventilation-perfusion lung function, VC was 3,85 l TO 3.4 liters, Police - 1.55 l, ROWID - 1,42 l, SOS - 2,95 l, SpO2- 88%. Noted a significant improvement in the ventilation of small bronchi.

Urgently performed laparoscopic examination of the abdominal cavity. Verified positive form of pancreatic necrosis. Conversion to upper median laparotomy. Revealed diffuse enzymatic peritonitis, ametabolic, purulent fusion of tissues of the pancreas in the area of its tail and parapancreatic klekotki with the transition to the mesentery of the colon. The pancreas was administerable. Made cryogenic on the pancreas. Parapancreatic fiber is widely trenirovka is and the drains of Penrose and 2-translucent drains through the gastrocolic ligament and additional lobotomise incision with subsequent formation of a flow-through system drainage stuffing bags. Stuffing the bag marsiliana. Imposed cholecystostomy. Conducted nasointestinal probe to the ileocecal angle. Drained the umbilical vein and the inguinal lymph node on the right for subsequent injections of drugs. Thoracic lymphatic duct drained with the purpose of in vitro electrochemical detoxification of the lymph.

Postoperative diagnosis: Infected pancreatic necrosis. Abscess retroperitoneal space. Diffuse enzymatic peritonitis. Pancreatogenic shock. Pancreatic pleural effusion on the left.

24 hours after surgery has been performed puncture of the left pleural cavity in the seventh intercostal space, evacuated 120 ml light serous fluid, and (by the above method) was introduced 20000 units kontrikala and 300 mg of Mexidol. On the 3rd day after the operation began to listen vesicular breathing with both sides in all fields. The chest on the left side when breathing has ceased to be outdone, the NPV is 22 minutes of Ventilation-perfusion lung function has undergone significant improvement, VC increased to 4,45 l TO 3.9 l, Police - 2,15 l, ROWID - 1,73 l, SOS - 3,65 l, SpO2- 94%. Marked patency of small bronchi is almost the norm. Control radiographs and ultrasound of the chest data for pneumonia or pleurisy is not received.

Since 4 days General condition began to improve. Purulent% the SS in mud and retroperitoneal tissue has been limited. Control radiographs and ultrasound of the chest pleuropulmonary complications were not observed, so the NPV was 20 min, VC increased to 4.62 l TO 4.1 l) Police Department - 2,34 l, ROWID - 1,79 l, SOS - 3,94 l, SpO2- 95%. The patient activated mode, normalized sleep, appetite. Diuresis fully recovered. The independent chair. 7 day phenomenon hepatoprotective were cropped. Hemostasis by this time come fully to normal. On the 15th day after the first operation performed planned sequestrectomy through bursectomy. Further postoperative period without features.

Drainage from the gallbladder removed on 22 days. She recovered. The patient is in satisfactory condition on the 34th day of hospital stay was discharged under the supervision of a physician at the place of residence.

The method reduced the development pleuropulmonary complications, such as pleural effusion, patients pancreonecrosis from 74% to 32%, and the mortality associated with it - from 22.5% to 16.7%.

Norma
Table 1.

Dynamics of ventilation-perfusion lung function after conducting intrapleural injections kontrikala and Mexidol in patients with pancreonecrosis with pleuropulmonary complications (pancreatic-pleurisy) (N-28).
IndicatorsBefore the treatmentAfter the treatment
Respiratory rate, %/min16±224±220±1*
Vital capacity, l4,5±0,33,3±0,23,9±0,1*
Tidal volume, l0,6±0,20,3±0,050,5±0,05*
Reserve volume inspiratory, l1,9±0,11,3±0,11,7±0,1*
Reserve volume expiratory, l1,9±0,11,3±0,11,5±0,1
Average flow rate during exhalation, l/sec3,9±0,32,7±0,23,6±0,3*
Blood oxygenation, %96±284±293±2*
Notes:
* reliable differences with values obtained before treatment;
- norm obtained from averages 20 untrained people (aged 18-24 years).

The method of treatment pleuropulmonary complications in patients with pancreonecrosis consisting in doing after surgery, puncture of pleural cavity and removal of the pleural effusion, ex is different, however, no less than 3 hours before the operation is conducted additionally a single puncture of the pleural cavity and removal of the pleural effusion, and no less than one day after the operation performed additional puncture of the pleural cavity with an interval of not less than one day, and with each puncture and after removal of the pleural effusion in the pleural cavity sequentially injected 20000 IU kontrikala and 300 mg of Mexidol.



 

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