RU2844677C1 - Method of treating complicated form of erysipelatous inflammation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to surgery, and can be used for treating complications of erysipelas in the form of phlegmon or abscess accompanying a circulatory injury of the posterior surface of leg. A necrectomy is performed within healthy tissues; purulent leaks are opened by longitudinal incisions followed by wound sanitation with antiseptics. That is followed by a local decompression of the posterior surface of the shin with long incisions, then the wound is covered with vacuum dressings for 48 hours.

EFFECT: method enables the shortest possible wound sanation, stimulates the immune processes in the wound and provides the regeneration ensured by the combined use of the surgical techniques and the vacuum dressing.

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Description

The invention relates to medicine, namely to surgery, and can be used in the treatment of complicated forms of erysipelas - phlegmonous and necrotic. It is known that erysipelas is an acute infectious and immunological disease with damage to the skin, subcutaneous tissue and deep tissues in complicated forms and is accompanied by immunological disorders. Modern ideas about erysipelas have also changed the etiological factors of erysipelas. Studies have shown the presence of an association of pathogenic pathogens in the discharge during erysipelas - streptococcus, staphylococcus, gram-negative flora and other pathogens, especially in complicated forms - abscess, phlegmon and necrosis of soft tissues. To date, the treatment of complicated forms of erysipelas remains one of the urgent problems of surgery and immunology. This is due to both the high frequency of occurrence of this pathology and not always satisfactory results. According to statistics, the incidence of erysipelas is 1 to 2 per 1000 adults. Among purulent-septic diseases, erysipelas accounts for up to 15% of patients in hospital treatment. In recent years, there has been an increase in the number of complicated forms of erysipelas and an increase in disability and deaths in this regard. Currently, the leading role in the pathogenesis of erysipelas has been established in the imbalance of cellular and phagocytic links of immunity. Taking this into account, methods of treating erysipelas based on the use of drugs with immunomodulatory and immunostimulating action are actively introduced into clinical practice. However, most of the proposed drugs have a wide range of side effects, and therefore their use in the clinic is very limited.

Analogues

A method for treating patients with erysipelas using a combination of timoptin as an immunomodulator is known (RU Patent No. 2039563). The disadvantage of the method is the duration of treatment and the need to continue the administration of the drug in an outpatient setting after discharge from the hospital. It should be noted that thymus-based drugs are contraindicated in patients with severe leukopenia caused by active death of neutrophils in the inflammation focus. Such conditions occur with phlegmon, extensive purulent-necrotic wounds. In addition, they are not effective in complicated forms of erysipelas, abscesses and phlegmon, when there are gross disturbances in the immune system.

There is also a known method for treating infected wounds, including erysipelas, which consists of applying crushed shungite mineral to the wound surface. previously diluted with drinking water (RU Patent No. 2307659). which has a biostimulating effect. The disadvantages of this method of treatment are the high risk of secondary infection, as well as the need for frequent dressing changes up to 3 times a day.

Another method of treating patients with erysipelas is described in the article by N. M. Kovaleva "Complex treatment of patients with erysipelas using dimexide" (Klin, Surgery. 1981 - No. 1. - Pp. 20-22). For this, applications of a 50% solution of dimexide in combination with sodium benzylpenicillin (2,000,000 U), 1% solution of diphenhydramine (2 ml), 0.5% solution of novocaine (30 ml) and 3% solution of prednisolone (1 ml) are used. The disadvantages of this method are low efficiency and duration of treatment.

A method for treating complicated forms of erysipelas is also known (patent No. RU2546039C1), which includes intramuscular administration of the immunomodulatory drug Derinat and local treatment with titanium glycerosolvate aquacomplex. The course of treatment is up to 20 days. The disadvantages of the method are the long treatment periods and the high cost of the drugs.

Prototype

As a prototype, we took the method for treating the purulent-necrotic form of erysipelas, patent No. RU2343855C1 dated 20.01.2009, authors Khasanov A.G., Sufiyarov I.F., Ibragimov R.K.

The essence of the prototype method is that in destructive forms of erysipelas, local action is performed with a helium plasma flow in the coagulation mode at a current of 30 A, at a distance of 15 cm from the wound, with an exposure of 40 sec/cm ² . After this, the resulting dry coagulation scab is excised within the viable tissues. Then autodermoplasty of the wound surface is performed according to Tirsch. According to the authors, this treatment ensures the interruption of the complicated course of the 2nd phase of inflammation, acceleration of the scarring phase, complete restoration of the skin as a result of one surgical intervention, and prevention of relapse.

Criticism of the prototype

The disadvantages of the prototype are the impossibility of its use in case of extensive lesions, circular lesions of the limb, phlegmons and abscesses, as well as when the fascia and muscles are involved in the purulent-necrotic process.

Purpose of the invention

The aim of the invention is to develop a method for treating complicated forms of erysipelas, such as phlegmonous, gangrenous-necrotic, to obtain accelerated wound cleansing from purulent-necrotic tissues, to stimulate the body's immunoreactive forces, to ensure accelerated regeneration and healing of wounds after surgical treatment. The stated goal is achieved by the fact that on the day of admission, surgical treatment of the purulent focus is performed with economical necrectomy within healthy tissues, with simultaneous opening of purulent leaks by longitudinal incisions of the affected part of the limb with subsequent thorough sanitation of the wound with antiseptics.

The essence of the invention

Complex treatment of complicated forms of erysipelas includes intravenous infusion and detoxification therapy with broad-spectrum antibiotics until the results of culture are obtained, followed by transfer to antibiotics obtained based on the results of culture for sensitivity, alternation of intravenous ultraviolet irradiation with intravenous laser irradiation, transfusion of protein solutions. The operation consists of the following: surgical treatment of the purulent focus on the affected part of the limb is performed, then necrectomy is performed within healthy tissues. Then, in the affected part of the limb, purulent leaks are opened with longitudinal incisions, followed by thorough sanitation of the wound with antiseptics. In the presence of putrefactive phlegmon caused by non-clostridial anaerobic infection, lampas longitudinal incisions are performed along the entire length of the affected limb. In case of circular soft tissue lesions of the leg, when soft tissue necrosis of the anterior-inner surface of the leg is accompanied by lesions of the posterior surface of the leg in the form of phlegmon or abscess, along with necrectomy, local decompression of the posterior surface of the leg is performed with longitudinal incisions. If it is necessary to perform several incisions, a distance of 3 cm is left between the incisions to prevent ischemic disorders and skin necrosis. The wounds are carefully sanitized with antiseptics. Then, after treatment and sanitization of the wound with antiseptics, vacuum dressings are applied to the wound for 48 hours, this allows aspiration of exudate from the wound, stimulates the formation of granulation tissue, protects the wound from external bacterial contamination and accelerates the healing of the wound process. The used device for vacuum therapy of wounds VivanoTec (Atmos, Germany) generates controlled negative pressure of a constant value applied to the wound surface.

After removing the vacuum dressing, splenodioxidine applications are applied to the wound.

Example No. 1.

Patient M., 55 years old.

Diagnosis: Erysipelas of the right shin, phlegmonous-gangrenous form. Has been ill for 7 days. Upon examination, on the anterior-inner surface of the right shin, against the background of pronounced edema and hyperemia, there is an area of necrosis measuring 8 × 6 cm. On the back surface of the shin, the skin is hyperemic, crepitus is determined by palpation. In blood tests, leukocytes are 23 × 10 /l, leukocyte intoxication index is 4.8, procalcitonia is 18.2 units. On the day of admission, surgical treatment was performed - necrectomy within healthy tissues and opening of putrefactive phlegmon of the back surface of the shin with two longitudinal incisions. About 50 ml of purulent exudate with a sharp putrid odor was released. The wounds were sanitized with antiseptics and left open. Immediately after the surgery, vacuum dressings were applied to the wound for 2 days. Given the severe intoxication and the presence of sepsis markers in the blood tests, the complex treatment included intravenous infusion and detoxification therapy with broad-spectrum antibiotics until the culture results were obtained, followed by transfer to antibiotics obtained based on the sensitivity results of the culture, alternating intravenous ultraviolet irradiation with intravenous laser irradiation, and transfusion of protein solutions. After removing the vacuum dressings, splenodioxidine applications were applied to the wound daily. On the 7th day, the wound was completely cleared of necrotic tissue and covered with granulation tissue. In the blood tests, leukocytes are 9.1 × 10 / l, procalcitonin is 1.2 units, and the leukocyte intoxication index is 0.9. On the 10th day, secondary sutures were applied to the wound on the back of the leg. The wound after necrectomy was closed with a free skin graft according to Tirsch. The skin for the graft was taken from the thigh. All transplanted skin flaps took root. The wounds healed. He was discharged on the 18th day.

Example No. 2. Patient K., 48 years old.

Diagnosis: Erysipelas of the left leg, bullous-necrotic form, complicated by phlegmon of the right leg.

The patient has been unwell for 4 days, when for no apparent reason swelling, hyperemia, and pain in the left shin appeared. Outpatient treatment was ineffective. The pain intensified, the temperature became hectic, the swelling increased, and bullae appeared. Upon examination, there was a 3x5 cm necrotic area on the anterior-outer surface of the left shin, with pronounced swelling and hyperemia around it, measuring 15x19 cm, crepitus is detected by palpation. Blood analysis showed hemoglobin - 80 g/l, leukocytes - 24x10/l, procalcitonin - 36 units, leukocyte intoxication index - 6.2. On the day of admission, surgical treatment was performed - necrectomy. opening of putrefactive phlegmon with two longitudinal lampast incisions. The wound was carefully sanitized with antiseptics, a vacuum device was installed on the wound for a period of 2 days. During daily dressings, starting from the 3rd day, a uniform layer of splenodioxidine was applied to the wound surface. On the 4th day, the pain in the postoperative wounds significantly decreased, no purulent discharge was noted, the walls and bottom of the wound were covered with granulation tissue. In the blood test, leukocytes decreased - 11.2 × 10 / l, leukocyte intoxication index - 1.8. procalcitonin - 5.6 units. In smears-prints from the wound, the number of neutrophils significantly decreased, the number of which continued to decrease in the following days. Already from the 5th day, fibroblasts appeared in the smears, in the following days their number progressively increased.

On the 9th day, free skin grafting was performed on the wound and secondary sutures were applied. The patient was discharged in satisfactory condition on the 15th day.

Example No. 3.

Patient T., born in 1963.

Diagnosis: Erysipelas of the right foot, bullous-necrotic form, complicated by necrosis of soft tissues of the anteromedial surface of the right shin. On admission, complaints of severe pain in the right shin, an increase in body temperature to 40 °, weakness. The patient considers himself 4 days old, when for no apparent reason redness appeared on the anterior surface of the shin and a high temperature. The next day after the onset of the disease, fluid formations appeared on the shin. Outpatient treatment was ineffective. One day before admission, a blackened area appeared on the shin, the pain intensified, the temperature became hectic. On examination, redness of the anterior surface of the leg from the upper third to the lower third with transition to the medial and lateral surfaces is determined, in some places there are bullae with hemorrhagic contents, in the middle third of the leg with transition to the medial surface there is a necrotic area measuring 6 × 4 cm. In blood tests, leukocytes are 21 × 10 / l, procalcitonin is 11.1 units, leukocyte intoxication index is 4.9. The patient was prescribed complex treatment according to accepted standards. On the day of admission, surgical treatment was performed - necrectomy within healthy tissues with excision of necrotic fascia. The wounds were sanitized with antiseptics and vacuum dressings were applied for 2 days. From the 3rd day, the wound was treated with daily applications of splenodioxidine. Already on the 6th day after the operation, the walls and bottom of the wound were covered with granulation tissue. In smears, the number of neutrophils significantly decreased and fibroblasts appeared, the number of which rapidly increased in the following days.

Body temperature returned to normal on the 4th day from the start of treatment, local skin changes subsided on the 10th day of treatment.

Positive dynamics were noted in general clinical analyses, the leukocyte intoxication index decreased to 1.0 on the 5th day, leukocytes to 9.1×10/l, procalcitonin - 2.1. On the 8th day, free skin grafting was performed on the granulating wound of the shin. All flaps took root. The patient was discharged on the 13th day in a satisfactory condition.

The technical result obtained from the implementation of the method is the acceleration of all phases of the wound process, complete restoration of the skin in a short time. The proposed method of treatment helps to limit the inflammatory process in a short time and prevents necrotic changes in the skin, and thereby leads to a decrease in tissue swelling and allows you to prepare the wound surface for local NPWT therapy with subsequent wound treatment with splenodioxidine applications.

The method used allows to increase the effectiveness of treatment, accelerated cleansing of the wound from purulent-necrotic tissues and microflora is achieved, the combined use of spleen homogenate with dioxidine against the background of a sluggish course of the inflammatory process and a decrease in reparative processes, contributes to an increase in local immunity, leads to a significant increase in active forms of cellular elements, suppression of pathogens of the wound process, development of a lymphocytic reaction and an increase in regeneration phenomena.

Claims (2)

1. A method for treating complications of erysipelas in the form of phlegmon or abscess in case of circulatory damage to the back of the leg, including performing necrectomy within healthy tissues, opening purulent leaks with longitudinal incisions, followed by sanitation of the wound with antiseptics, characterized in that local decompression of the back of the leg is additionally performed with longitudinal incisions, after which vacuum dressings are applied to the wound for a period of 48 hours. 2. The method according to paragraph 1, characterized in that a distance of 3 cm is left between the longitudinal cuts.