RU2341269C1 - Method of surgical endotoxicosis treatment - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: powdered sublimated table beet and powdered sublimated apples are premixed in ratio 1:1. Then 40 g mixture is processed with 300 ml drinking water, heated to temperature 70-90 degrees, then cooled to 18-20 degrees and homogenized. Homogenized aqueous suspension is dissolved in 900 ml anolyte of mineralised 0.5 g/l NaCl with pH rabged 2.2-5.5. After that end suspension is introduced orally dosed 400 ml 3 times a day within 3-5 days.

EFFECT: allows for higher efficiency of surgical endotoxicosis treatment.

2 cl, 7 tbl, 2 ex

Description

The invention relates to medicine, namely to surgery, and can be used to treat surgical endotoxemia complicated by intestinal insufficiency by detoxification by the method of enterosorption using pectin-containing drugs (PSP).

With surgical endotoxemia and intestinal failure, colonization of the small intestine with large intestinal microflora develops, which enhances portal and systemic toxemia and bacteremia. The prognosis of the disease especially worsens against the background of intestinal insufficiency, when the barrier function of the intestinal wall is disrupted and the microflora penetrates into the abdominal cavity. Enterosorption (ES) binds toxic contents, including microbes, in the lumen of the small intestine.

The method of enterosorption, with three to four times the intake of enterosorbent for several days, allows you to achieve an effect equal to the hemosorption procedure. The method is non-invasive, has no complications associated with extracorporeal detoxification, and is more physiological. Currently, a number of enterosorbents are used to treat the pathology of the digestive system, including 1% aqueous solution of pectin ("Clinical use of the drug Enterosgel in patients with pathology of the digestive system." New approaches to therapy. Guidelines for doctors. / Ed. By Prof. I.V. Maeva, Yu.N. Shevchenko, Associate Professor A.B. Petukhova - M., 2000, p. 5-8). Particularly noteworthy are highly dispersed hydrophilic powder sorbents because of their relatively larger sorbent surface and good fluidity in the solution for administration into the intestine through a nasointestinal probe.

The disadvantages of treatment methods using sorbents are as follows: not all known sorbents are suitable for long-term administration into the intestine through a nasointestinal probe in its physical form (lack of proper fluidity), which leads to obstruction of the probes and impaired function; known enterosorbents do not stimulate intestinal motility in case of paresis, including postoperative, which makes it difficult to evacuate related toxins naturally; do not possess probiotic and nutritive properties, do not prevent translocation of intestinal microflora; those. do not affect concomitant endotoxemia, especially surgical, intestinal failure. The combination of these shortcomings complicates and lengthens the treatment of patients with syndromes of surgical endotoxemia and intestinal failure.

The prototype of the invention is a method for the treatment of surgical endotoxemia in peritonitis. To do this, use powdered pectin-containing product (PSP) of table beets prepared from freeze-dried raw materials. From the first day after the operation, a homogenized aqueous suspension of the product is introduced into the small intestine at the rate of 20 g of dry matter per 300 ml of drinking water with a temperature of 18-22 ° C through a nasointestinal probe. Preliminarily, the small intestine is washed intraoperatively from the contents during the placement of the nasointestinal probe. The introduction of the sorbent is carried out 3 times a day, a course of 3-5 days. The method due to the properties of the sublimate of table beet provides simultaneous enterosorption, stimulation of intestinal motility and nutritional support (Pat. No. 2245159 of the Russian Federation, IPC A61K 35/78, A61P 41/00. Method for the treatment of surgical endotoxemia. B. S. Briskin, D. A. Demidov, T.P. Gazina. / MGMSU. Publish. January 27, 2005. Bull. No. 3).

The disadvantage of the prototype is: the preservation of translocation of intestinal microflora in the early stages of treatment due to the instability of aqueous suspension and the solution according to the concentration of pectin and the pH of the recovery medium, which complicates the dissociation of protopectins to replenish the utilized pectins and limits the enterostimulating, nutritional and antiseptic properties of the administered drug.

The objective of the invention is to increase the effectiveness of the treatment of surgical endotoxemia. The technical result consists in stopping translocation of intestinal microflora in the early postoperative period in conditions of intestinal failure.

This is achieved due to the fact that the homogenized aqueous suspension additionally contains sublimated apple powder in a ratio of 1: 1, while using 40 g of dry matter per 300 ml of drinking water, heated to a temperature of 70-90 degrees, after which it cooled to 18-20 degrees homogenized suspension is dissolved in 900 ml of anolyte mineralized NaCl 0.5 g / l with a pH in the range of 2.2-5.5, the final suspension is administered 400 ml 3 times a day for 3-5 days.

Were used pectin-containing powder products of table beets and apples from freeze-dried raw materials. Powdered beetroot product is prepared according to TU 9199-013-00353158-97, the drug has an enterostimulating, nutritive and antiseptic effect, however, the antiseptic effect is slow due to the low rate of release and dissociation of beet pectin in an aqueous medium. The freeze-dried apple powder product is made according to TU 9199-004-11520791-99, the drug has an antiseptic effect due to the rapid isolation and dissociation of apple pectin in an aqueous medium. Product Certificate No. 77.72.10.916.P.05042. The use of a mixture of these drugs in a ratio of 1: 1 is optimal, as it provides a higher antiseptic effect, compared with the prototype, without reducing the sorption, enterostimulating and nutritional properties of the beetroot preparation.

The amount of the mixture, equal to 40 g of dry matter per 300 ml of drinking water, ensures the homogenization of the suspension. The temperature of drinking water of 70-90 degrees provides a quick exit of beet and apple pectins from the powder into the solution. The proportion of the ingredients of the mixture and the temperature regime allow to obtain a 2-3% aqueous solution of pectins from both pectin-containing products. Dissolution of the obtained homogenized suspension in 900 ml of anolyte of mineralized NaCl 0.5 g / l allows to obtain optimal fluidity for bolus administration through a nasointestinal probe and distribution over the small intestine, a pH in the range of 2.2-5.5 is optimal for dissociation of protopectins. The final homogeneous suspension, with a daily volume of 1200 ml, is administered 400 ml 3 times a day for 3-5 days. The duration of the course is determined by the achieved therapeutic effect.

The method is as follows. Intraoperatively establish a nasointestinal probe and remove the gastric and intestinal contents, the probe is washed to clean wash water. From the first day after surgery, enteric therapy is started. The sublimates powders of beetroot and apples are mixed in a 1: 1 ratio, treated with 40 ml of a mixture of 300 ml of drinking water at a temperature of 70-90 ° C, kept to cool to 18-20 ° C at room temperature, and homogenized by mixing. For introduction into the intestine, a homogenized suspension of the obtained product is diluted in 900 ml of anolyte of mineralized NaCl 0.5 g / l with a pH in the range of 2.2-5.5, and a temperature of 18-22 ° C. Anolyte is obtained (for example, at the Stel installation manufactured by NPO Ekran (Moscow, RF)).

The resulting final homogenized suspension is administered through a nasointestinal probe in 400 ml portions 3 times a day. The course of treatment is 3-5 days. The course of treatment is stopped after the disappearance of signs of intoxication and restoration of intestinal motility. After this, the nasointestinal probe is removed and natural nutrition begins. Complications and side effects of the method, except for diarrhea, were not noted. Diarrhea stopped on its own a day after discontinuation of the drug.

In the clinic, the proposed method was used in the treatment of 60 patients with diffuse peritonitis with concomitant intestinal insufficiency. All patients underwent urgent surgical interventions with the elimination of the primary focus, rehabilitation and drainage of the abdominal cavity. In the preoperative and postoperative periods, detoxification and antibacterial therapy was performed. All patients were examined clinically, laboratory, instrumental. After surgery, patients were treated in the intensive care unit. From the first day in combination with conventional intensive care, he applied the proposed method of treatment. The control group consisted of 50 similar patients. He conducted only generally accepted intensive therapy with decompression of the intestine through a nasointestinal probe. Groups were formed by the pair sampling method.

During intraoperative cultures in 48.31% of patients, the abdominal cavity was not infected. In 51.69% of patients, the abdominal cavity was infected (Table 1), with only 20.11% of them contacting due to perforation of the hollow organs, and in the remaining 79.89% by translocation from the intestine, which indicates a violation barrier function of the intestinal wall and translocation of microflora through it.

Table 1. The presence of microflora in the abdominal cavity due to translocation Type of microflora n = 150 Frequency of occurrence,% No growth ** 115 48.31 E. coli fifty 21.0 Staphilococcus 13 5.46 Streptococcus 8 3.36 Klebsiella 7 2.94 Serratia 6 2,52 Candida 6 2,52 Enterobacter 5 2.10 Pseudomonas four 1.68 Citrobacter four 1.68 Proteus 3 1.26 Acinetobacter one 0.42 Corinebacterium one 0.42 Chriseobacterum one 0.42 Ocrobacterum one 0.42 Morganella one 0.42 Mafnia one 0.42 Burkharderia one 0.42

The treatment results were evaluated by the dynamics of severity using the SAPS scale (Le Gall GR, 1984), leukocyte intoxication index (LII), medium molecular weight substances (SCMM) in blood plasma, duration of nasointestinal intubation, resolution rate of intestinal paresis, mortality, and dynamics of indicators crops from nasointestinal probes.

An improvement in the motor-evacuation functions of the intestine was noted, an earlier resolution of paresis occurs. The average duration of paresis when using PSP was 3.5 days, with ES UAO-A 3.8 days, and in the control group 5 days, ES reduces the time of nasointestinal intubation from 5.2 days to 3.8 days in the 2nd group and up to 4.2 days in the 3rd group. After removal of the probe during ES ESP, there was no need for additional drug stimulation of the intestine.

Comparative characteristics of enterosorption of PSP and carbon sorbent UAO-A in the treatment of peritoneal surgical endotoxemia and intestinal failure are set forth in tables No. 2-7.

The data obtained illustrate the greater effectiveness of the proposed method compared with the prototype and the generally accepted method for the treatment of surgical endotoxemia and intestinal failure and demonstrate its antiseptic properties.

Table 2. Dynamics of severity of the condition of patients by SAPS Day The control ES PSP ES UAO-A M ± m M ± m M ± m 1st 7.9 ± 0.43 7.8 ± 0.54 8.0 ± 0.54 2nd 7.8 ± 0.54 6.8 ± 0.34 7.6 ± 0.57 3rd 7.1 ± 0.76 5.9 ± 0.65 6.7 ± 2.7 4th 6.0 ± 0.39 4.2 ± 0.56 5.2 ± 0.55 5th 5.1 ± 0.21 3.4 ± 0.76 4.2 ± 0.89 6th 3.9 ± 0.54 2.7 ± 0.21 3.2 ± 0.38 7th 2.4 ± 0.87 1.9 ± 0.11 2.0 ± 0.87 When p≤0,05

Table 3. Characterization of septic postoperative complications Complications The control ES PSP ES UAO-A n-50 n-60 n-40 Pneumonia 13 (26%) 4 (6.6%) 5 (12.5%) Delirium 9 (19%) 6 (10%) 6 (14%) Infectious Toxic Shock 6 (12%) 1 (2.3%) 2 (5%) Abdominal abscesses 4 (8%) 1 (2.3%) 2 (5%) Suture failure 3 (5.4%) 1 (2.3%) 1 (3.2%) Suppuration of wounds 17 (34%) 6 (10%) 6 (14.5%) Eventration 3 (6%) - 1 (2.5%) Intestinal fistula 2 (4%) 1 (2.3%) 2 (5%) Heart attack 8 (16%) 1 (1.6%) 3 (7.5%)

Table 4. Comparative mortality * Toxic stage Control n-43 ES PSP n-50 ES UAO-A n-35 Is dead % Is dead % Is dead % four 8 one 1,6 four 10 Terminal stage Control n-3 ES PSP n-4 ES UAO-A n-1 Is dead % Is dead % Is dead % 3 6 3 5 one 2,5 * There were no deaths in the reactive stage of peritonitis.

Table 5. Dynamics of a decrease in the microflora of the small intestine in ES PSP (% occurrence) The nature of microflora Initial data Crop Duration 1 day 2 days 3 days E. coli 48.0 46.0 29.0 26.0 Pseudomonas 10.0 4.0 3,5 4,5 Klebsiella 6.5 15.4 26.0 22.1 Enterbacter 7.5 7.8 10.0 10.0 Acinetobacter 7.2 6.8 2.0 5,0 Kluyvera 3.9 - - - Citrobacter 2.1 3.6 5,4 1,2 Proteus - 4,5 9.0 8.1 Providencia 1.01 3,7 - - Morganella 2.09 2.1 - - Cedecea - - - 3.9 Hafia - - 2.7 1.7 Enterococcus 2.6 0.9 3.9 6.0 St. aureus 4.8 - 2.7 2,3 Streptococcus - - 2.7 - Candida 4.4 4.2 3,1 9.2 No growth 6.9 - 5.7 18.9 Microbial associations 20,0 26.0 19.8 7.9 Monocultures 73.1 74 74.5 73,2

Table 6. Dynamics of a decrease in the microflora of the small intestine in ES UAO-A (% occurrence) The nature of microflora Initial data Crop Duration 1 day 2 days 3 days E. coli 50,0 55.0 49.0 48.0 Pseudomonas 13.6 3,7 5,0 8.4 Klebsiella 4.3 15.6 17 22.0 Enterbacter 3.0 4.8 3.0 - Acinetobacter 3.2 1,2 2.1 1.4 Kluyvera 1.4 1,2 1,5 - Citrobacter - - 2.7 1,1 Proteus - 3,5 5,0 5.7 Pasteurella 3,1 1,6 1,0 1,1 Burkholderia 2.6 1.4 - - Cedecea 0.5 2.1 1,0 0.4 Serratia 0.9 1,2 2.1 2.0 Enterococcus 7.1 2,4 2.0 - Staphylococcus 5,0 1,5 - - Streptococcus 2.1 0.7 - - Candida 3.2 5.3 8.2 10.0 No growth 2,4 3,1 8.3 12.0 Microbial associations 28.3 5.5 28.7 25.0 Monoculture 69.3 91.4 63.0 63.0

Table 7. The dynamics of the microflora of the small intestine in patients of the control group (% occurrence) The nature of microflora Initial data Crop Duration 1 day 2 days 3 days E. coli 30,0 48.0 51.0 50,0 Pseudomonas 15.0 12.0 10.0 12.0 Klebsiella 9.0 12.0 12.0 17.0 Enterbacter 10.0 10.0 - - Acinetobacter 10.0 - - - Kluyvera - 4.0 - - Proteus 18.0 4.0 15.0 17.0 Serratia - 2.0 2.0 - Enterococcus - 10.0 3.0 - Staphylococcus 8.0 - 2.0 3.0 Candida - 2.0 5,0 6.0 No growth 8.9 6.0 2.0 1,0 Microbial associations 21.1 20,0 - 43.0 Monoculture 70.0 74.0 98.0 56.0

Clinical example 1.

Patient M., 34 years old, medical history No. 6118, was admitted to the 3rd surgical department G.K.B. No. 50 03/27/2006 with a directive diagnosis: penetrating stab wound to the abdomen, peritonitis, a day after receiving it. At admission: general condition is serious, pulse 120 in 1 minute, A.D. 105 and 70 mmHg. column, shortness of breath, acrocyanosis, the stomach is tense, does not participate in breathing, Shchetkin’s symptom is positive in all departments, pathology was not found on the chest x-ray, chest pneumatosis in the overview of the abdominal cavity, multiple small intestinal arches, no free gas in the abdominal cavity . After preoperative preparation, it is urgently operated. Operation No. 386 - primary surgical treatment of wounds of the abdominal wall, laparotomy, suturing wounds of the small intestine and omentum, sanitation and drainage of the abdominal cavity, nasogastric and nasointestinal intubation. On the operation: in the abdominal cavity up to 800 ml of dark blood and small intestinal contents, plaque of fibrin on the parietal and visceral peritoneum in all parts of the abdominal cavity, two cut defects in the small intestine and omentum, paresis of the small intestine. Postoperative diagnosis: penetrating wound of the abdomen, wounds of the small intestine and omentum, hemoperitoneum, diffuse fibrinous peritonitis, paresis of the small intestine. 2.5 l of stagnant contents were evacuated through a nasointestinal probe, the small intestine was washed to “clean water”. When sowing detachable from the nasointestinal probe, the growth of mixed microflora with a predominance of colonic.

For postoperative treatment, the patient was transferred to the intensive care unit. At the initial examination: the severity of the condition according to SAPS 8.0, LII 8.5, SCMM 600. From the first day after the operation, from March 28, 2006, they started enterosorption according to the proposed method, within 3 days. The sublimates powders of beetroot and apples were mixed in a 1: 1 ratio, treated with 40 ml of a mixture of 300 ml of drinking water at a temperature of 70-90 ° C, kept to cool 18-20 ° C at room temperature, the mixture was homogenized by mixing. For introduction into the intestine, a homogenized suspension of the obtained product was diluted in 900 ml of a weakly mineralized, weakly acidic aqueous solution of anolyte of mineralized NaCl 0.5 g / l with a pH in the range of 2.2-5.5, and a temperature of 18-22 ° C. The resulting final homogenized suspension was administered through a nasointestinal probe in 400 ml portions 3 times a day. From 2 days a liquid beetroot stool appeared. The course of enteral treatment was stopped after the disappearance of signs of intoxication and restoration of intestinal motility. After this, the nasointestinal probe was removed and natural nutrition began. Mild diarrhea stopped on its own a day after discontinuation of the drug.

There are no complications from the side of the surgical wound. On the 4th day, non-functioning drainages from the abdominal cavity were removed, activation began.

Intestinal paresis resolved, nasogastric and nasointestinal probes removed. General condition according to SAPS 2.0, LII 4.5, VSMM 300. The patient was transferred to 3 surgical departments, nutrition was started, table 1 was surgical. On the 7th day, it was transferred to the usual fractional food - 15 table. On day 8, the surgical wound healed by first intention, skin sutures were removed. With dynamic ultrasound on 3-5-7 days there are no complications from the abdominal cavity. On the 10th day in a satisfactory condition, the patient was discharged under the supervision of a polyclinic surgeon.

Clinical example 2. Patient D., 33 years old, medical history No. 3196, was admitted to the 1st surgical department G.K.B. No. 81 DZ of Moscow on March 28, 06, with a diagnosis of acute appendicitis, peritonitis widespread 30 hours after the onset of the disease. On admission: the general condition is severe, the pulse is 116 beats per 1 min, blood pressure is 100/70 mm Hg, the abdomen is swollen, tense, does not participate in breathing, and symptoms of peritoneal irritation throughout the abdomen are determined. An emergency laparotomy was performed - a gangrenous altered appendix was removed, in the abdominal cavity up to 1 liter of turbid, with colibacillary odor, purulent exudate in all departments, swollen, paretic intestinal loops with fibrin. The abdominal cavity is sanitized by washing with an aqueous solution of chlorhexidine and saline and draining. Nasointestinal intubation was performed, up to 2 liters of stagnant intestinal contents were evacuated, the small intestine was washed to “clean water”. The operation is completed by ligature laparostomy for programmed sanitation of the abdominal cavity. The severity of the condition according to the SAPS scale is 7.8, LII - 9.6, VSMM 500. When seeding from the nasointestinal probe, the mixed microflora grows with a predominance of large intestine.

A day later, programmed sanitation of the abdominal cavity was performed. In the postoperative period, the next day after programmed rehabilitation, enterosorption was started according to the method described above. The sublimates powders of beetroot and apples were mixed in a 1: 1 ratio, processed per 40 g of the mixture with 300 ml of drinking water at a temperature of 70-90 ° C, kept to cool to 18-20 ° C at room temperature, and the mixture was homogenized by mixing. For introduction into the intestine, a homogenized suspension of the obtained product was diluted in 900 ml of a weakly mineralized, weakly acidic aqueous solution of anolyte of mineralized NaCl 0.5 g / l with a pH in the range of 2.2-5.5, and a temperature of 18-22 ° C. The resulting final homogenized suspension was administered through a nasointestinal probe in 400 ml portions 3 times a day. On the first day of enterosorption, a moderate retrograde outflow of the sorbing mixture was noted (up to 100-150 ml). The course of enteral treatment was stopped after the disappearance of signs of intoxication and restoration of intestinal motility. After this, the nasointestinal probe was removed and natural nutrition began. Diarrhea is not noted.

On the 2nd day, distinct intestinal noises appeared, gases began to escape, there was the first stool. The condition of the abdominal cavity has improved, with ultrasound there is no exudate in it, the loops of the small intestine are peristaltized. On the 5th day, inoculation of the contents from the nasointestinal probe did not give microflora growth, the nasointestinal probe and drains were removed. The general state of moderate severity - on the SAPS scale - 5.2, LII - 4.4, SCMM 300. On the 6th day he was transferred to the surgical department, nutrition began naturally, table 1 was surgical. On the 12th day, the surgical wound healed by first intention, skin sutures were removed, transferred to fractional nutrition, table 15. He was discharged on April 12, 2006 in a satisfactory condition under the supervision of a polyclinic surgeon.

Claims (2)

1. A method of treating surgical endotoxemia using enterosorption and stimulation of intestinal motility by enteral administration of a homogenized aqueous suspension of freeze-dried beetroot powder, characterized in that the homogenized aqueous suspension additionally contains sublimated apple powder in a 1: 1 ratio; 40 g of the mixture are treated with 300 ml of drinking water heated to a temperature of 70-90 °, then cooled to 18-20 ° and homogenized, a homogenized aqueous suspension is diluted in 900 ml of mineralized anolyte 0.5 g / l NaCl with a pH in the range of 2, 2-5.5. 2. The method according to claim 1, characterized in that the final suspension is administered in 400 ml 3 times a day for 3-5 days.