RU2468760C1 - Method of treating abdominal sepsis of bile origin, complicated by coagulopathy - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgery, and can be used in treatment of patients with abdominal sepsis of peritoneal origin, complicated by coagulopathy. For this purpose performed is laparotomy with intraoperational introduction of double-lumen nasogastric probe into small intestine lumen below Treitz ligament) for active aspiration of intestinal contents. After that, sodium hypochlorite solution is introduced into abdominal cavity once and wound edges are sutured tightly to drainages. Immediately after that, intravenous infusion and intestinal dialysis with application of sodium hypochlorite are performed. 0.04% solution of sodium hypochlorite is used for sanitisation of abdominal cavity through drainage tubes and for intravenous infusions, 0.06% solution being used for intestinal dialysis. In post-operative period sanitisation of abdominal cavity, intestinal dialysis and intravenous infusions with sodium hypochlorite are performed one time per day during 1-3 days in dose 15 ml/kg.

EFFECT: method ensures efficient treatment of said pathology, and makes it possible to reduce manifestations of inflammatory reaction, as well as to prevent further development of coagulopathy due to considerable reduction of level of platelet aggregation as a result of activation of all links of coagulation link of hemostasis with sodium hypochlorite with specific sequence of actions.

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Description

The invention relates to medicine and can be used in surgery in the treatment of abdominal sepsis of peritonial origin, complicated by coagulopathy.

Along with improving medical equipment, the use of high technology in operations in the hepatobiliary region is often a source of iatrogenic damage with the development of biliary peritonitis (GP) [3]. Accidental damage to the extrahepatic bile duct (HPV) is one of the most serious complications in surgical gastroenterology.

There is an expression of S.P. Fedorov [1934] on this score, who said that: “In no one area does the surgeon have to be in such a predicament as during operations on the biliary tract, and nowhere can one damage the patient the smallest mistake made during surgery. "

According to the data of [4], the incidence of HPV damage in case of open cholecystectomy is 0.1-0.8%, while in case of laparoscopic cholecystectomy during the development of the method and the accumulation of experience, their number increases to 3%.

It is well known that iatrogenic damage to the HPV is not uncommon, but its consequences are a difficult test for both the patient and the surgeon. Damage to IDV diagnosed during surgery is repaired by an experienced surgeon without any special consequences. When iatrogenic damage to ALV is diagnosed on the 2nd-3rd day and in a later period, the patient manifests symptoms of abdominal sepsis of biliary origin complicated by coagulopathy.

The problem of gastrointestinal tract is becoming especially relevant against the background of the global trend of increasing the number of patients with cholelithiasis (cholelithiasis), which affects 10 to 15% of the world's population [7].

Large-scale epidemiological studies of the last two decades have led to the understanding that the actual prevalence of cholelithiasis in people in the older age group reaches 30% and is closely correlated with the epidemic growth of other "diseases of civilization" occurring with profound metabolic disorders: atherosclerosis, metabolic syndrome and sugar type 2 diabetes [2].

In the last decade, works have been published containing information on the universality of the triggering mechanism in the development of abdominal sepsis with peritonitis (in general) and biliary (in particular), based on which the leading role belongs to the systemic inflammatory response syndrome, when the intestine is involved in the pathological process with the development of enteric insufficiency in a violation of motor, secretory-resorptive and barrier functions, which serves as one of the triggers of endotoxemia [9]. Against the background of these disorders, there is a change in the quantity and quality of intraluminal and parietal microflora, translocation of toxins and microorganisms into the bloodstream and into the lumen of the abdominal cavity [17]. As the pathological process progresses and the severity of enteric insufficiency increases, endogenous and exogenous toxins, microbial bodies, and catabolism products damage blood cells and vascular endothelium, which are responsible for the production of various anticoagulants, antiplatelet and fibrinolytic compounds [8]. In patients with peritonitis, the time of fibrinolysis increases sharply, which is most likely due to an increased level of cortisol and the presence of bacterial lipopolysaccharides in the blood [10]. Entering the circulating blood, cortisol and bacterial endotoxins inhibit the intracellular activity of the plasminogen activator. The mechanism of such inhibition of fibrinolysis is mediated through stimulation of prostaglandins production by bacterial lipopolysaccharides, which leads to an increase in the concentration of glucocorticoids, in particular, cortisol. Cortisol, in turn, inhibits the function of plasminogen activator - a serine protease that converts plasminogen into plasmin. The same authors indicate the appearance in the blood of patients with peritonitis fibrinogen B, which indicates a clear tendency to hypercoagulation. In the anticoagulant component of the hemostasis system in patients with advanced peritonitis, there is a decrease in the concentration of active AT-III and plasminogen and an increase in the level of PDP, which is associated with the modifying effect of reactive oxygen species on protein molecules of AT-III.

Thus, blood coagulation disorders with peritonitis at the first stage of development are hypercoagulative in nature, and subsequently can go into the phase of hypocoagulation with the development of DIC.

Based on the foregoing, early correction of coagulopathy is an important condition for the successful treatment of abdominal sepsis with peritonitis.

In recent years, to prevent intravascular thrombosis in surgery, covalent antiplatelet agents (platelet inhibitors) [20] and sodium hypochlorite have been used, which, when interacting with amino groups of free amino acids, peptides, and proteins, forms N-chloroamino acids [16]. The latter, during the oxidation of sulfur-containing protein groups, modify the plasma platelet membrane [19], which leads to inhibition of the functional activity of platelets [12].

In this regard, it is justified to include in the complex therapy of coagulopathy in case of abdominal sepsis of bile origin sodium hypochlorite (a salt of hypochlorous acid), which is an evolutionary product of neutrophilic granulocytes.

Thus, despite the relevance of the problem presented, abdominal sepsis of biliary origin continues to remain practically outside the field of view of surgeons, and the few studies that take place are narrowly targeted and not sufficiently systematic. All this served as the reason for the development of a new method for the treatment of abdominal sepsis of biliary origin complicated by coagulopathy, which is distinguished by its reliability, accessibility and unburdened economically.

To study hemostasiopathies, we used a set of tests characterizing the state of the procoagulant, platelet, and fibrinolytic units of the hemostatic system, as well as the unit of blood coagulation and fibrinolysis inhibitors, which will allow us to evaluate both the kinetic and dynamic (structural) aspects of coagulation.

Currently, the central link of a multicomponent comprehensive treatment program for all forms of peritonitis is: laparotomy to eliminate the source of peritonitis, programmed sanitation of the abdominal cavity, the use of all means of eliminating enteric insufficiency syndrome (intestinal dialysis), as well as rational drainage of the abdominal cavity [1, 9] .

However, quite often, due to repeated surgical aggression, patients develop secondary immunodeficiency [9].

Despite the continuous improvement of surgical technologies, intensive care methods, success in creating new antibacterial drugs, mortality in peritonitis remains high, reaching 20-40% or more [17].

The widespread introduction in clinical practice of active methods of drainage and sanitation of the abdominal cavity with peritonitis in combination with extracorporeal detoxification methods, which allow prosthetic functions of the affected organs to be prosthetized, prevent the mortality of patients in the early stages of the disease.

One of the common methods of detoxifying the body in the treatment of abdominal sepsis is hemosorption [11, 18]. The method allows eliminating endogenous substances from blood during extracorporeal perfusion of blood through activated carbon columns. The inclusion of hemosorption in the complex treatment of patients with peritonitis has significantly improved treatment results and reduced mortality by 6-11% [6].

The disadvantages of hemosorption include obligatory blood heparinization, the possibility of eliminating biologically active substances from the blood (enzymes, hormones, mediators of immune reactions), as well as trauma to blood cells (red blood cells) when passing through carbon sorbents. Depending on the “aggressiveness” of carbon sorbents, platelets, proteins (fibrinogen), and peptides that are a material substrate of the body’s immune systems can be adsorbed on them [18]. These factors can contribute to disruption of the blood coagulation system.

Optimization of detoxification therapy methods with leveling deficiencies are the most important components of the treatment of peritonitis.

Plasmapheresis is accepted as the closest analogue to the treatment of abdominal sepsis with peritonitis of any etiology [13]. The method is based on the removal of a plasma containing toxins, with adequate replacement by various infusion media (crystalloids, colloids, donor plasma, albumin). The plasmapheresis procedure consists in the separation of blood into cellular elements (red blood cells, white blood cells, platelets, etc.) and plasma, i.e. the liquid part of the blood in which pathological and metabolic components are dissolved - carriers of the causes of diseases. The plasma is separated from the cellular elements and removed together with toxins and pathological elements, in the body it is replaced with various sterile solutions, and the purified cellular elements are returned to the patient. As a result of plasmapheresis, the blood is released from toxins and other harmful substances that accumulate in the body. With the help of plasmapheresis, not only blood, but also all tissues are purified.

The disadvantages of this method are: the problem of adequate plasma substitution, since the removal of plasma from the body negatively affects the state of humoral and cellular immunity, which is already susceptible to significant changes in purulent-inflammatory processes.

The objectives of the invention are to improve the results of treatment of abdominal sepsis of biliary origin, by optimizing antibacterial, detoxification, immuno-and hemostasis-correcting therapy using sodium hypochlorite.

The essence of the invention is that after laparotomy and sanitation of the abdominal cavity are performed, a double-lumen nasogastric tube for active aspiration of intestinal contents is intraoperatively introduced into the lumen of the small intestine below the Treitz ligament, then a solution of sodium hypochlorite is once injected into the abdominal cavity as a bactericidal agent and the wound edges are sutured tightly. before drainage, immediately after this, intravenous infusion and intestinal dialysis using sodium hypochlorite are performed, while for the rehabilitation of the abdominal 0.04% sodium hypochlorite solution is used through the drainage tubes and for intravenous infusions, and 0.06% solution for intestinal dialysis, after which, in the postoperative period, abdominal sanitation, intestinal dialysis and intravenous sodium hypochlorite infusions are performed once for 1 -3 days at the rate of 15 ml / kg.

The technical result of the invention is to increase the effectiveness of treatment as a result of a sequential algorithm of a complex of ongoing manipulations: a) laparotomy; b) a single intraoperative sanitation of the abdominal cavity with a sodium hypochlorite solution, which has a powerful bactericidal effect without the use of multiple programmed sanations; c) active aspiration of the small intestinal contents to improve blood supply to its wall, create favorable conditions for the normal functioning of the mucous membrane and maintain its structural integrity, followed by intestinal dialysis of sodium with hypochlorite in order to oxidatively detoxify the decay products and achieve optimal sanitation of the intestinal lumen; e) intravenous administration of sodium hypochlorite to achieve antiaggregation, anticoagulant, antihypoxic and immunomodulatory effects.

This allows you to achieve a good antibacterial, detoxifying, anticoagulant and immunomodulating effect, reducing the number of postoperative complications, reducing the hospitalization of patients and reducing the cost of treatment.

The method is as follows: after a laparotomy and sanitation of the abdominal cavity, a double-lumen nasogastric silicone tube of the ZKS-21 type is carried out intraoperatively into the lumen of the small intestine below the Treitz ligament and 40–50 cm in length and the intestinal contents are actively aspirated. To do this, a 0.9% sodium chloride solution is introduced into the intestinal lumen using intestinal lavage at a rate of up to 10 ml / min using the Infusomat perfusion pump using the infusion channel of the probe. The probe is squeezed for 20-30 minutes, and then open and create a free outflow. The procedure is repeated 2-3 times to clean water. Next, in the abdominal cavity as a bactericidal agent, a 0.04% sodium hypochlorite solution is once poured and the wound edges are sutured tightly to drainage. After that, intravenous administration of a 0.04% sodium hypochlorite solution and intestinal dialysis using a 0.06% sodium hypochlorite solution are performed. In the postoperative period, abdominal sanitation, intestinal dialysis and intravenous infusion of sodium with hypochlorite are carried out once a day for 1-3 days at the rate of 15 ml / kg. Sodium hypochlorite is obtained by electrolysis of a 0.9% solution of sodium chloride in an EDO-4 apparatus. The concentration of sodium hypochlorite solution is determined by iodometric titration.

Thus, the distinctive essential features of the claimed method are:

1. The use of sodium hypochlorite according to the strictly proposed scheme.

2. The use of sodium hypochlorite as a natural product of neutrophilic granulocytes.

3. The introduction of sodium hypochlorite is carried out not only intracorporeally (intravenous indirect electrochemical oxidation of the blood), but also extracorporeally (into the abdominal cavity and lumen of the small intestine).

4. In the postoperative period, the use of sodium hypochlorite in drainage tubes for sanitation of the abdominal cavity, for intestinal dialysis and for intravenous infusions is carried out once a day for no more than 1-3 days.

5. The volume of injected sodium hypochlorite solution in all cases is determined at the rate of 15 ml / kg.

To evaluate the effectiveness of the proposed method of treatment, both experimental and clinical studies were conducted.

Experimental studies were performed on 30 outbred male dogs, weighing 17.1 ± 1.2 kg, divided into 3 groups:

- 30 animals were included in the 1st intact group for determining laboratory parameters of the norm;

- the second control group included the same 30 animals that created a model of 24-hour biliary peritonitis [14], the essence of which was that previously on the outer surface of the hind femur the dogs created a focus of soft tissue destruction by subcutaneous injection of 10% a solution of calcium chloride at the rate of 0.25 ml / kg 48 hours after the creation of the site of destruction of the animals in the abdominal cavity through the installed catheter, pharmacy bile is injected three times every 8 hours at the rate of 1.5 ml / kg of body weight. Mortality of animals was recorded every 12 hours after the creation of the model for 3 days (a three-day mortality criterion), after which they were considered conditionally surviving. When creating a model of 24-hour biliary peritonitis, no animals died.

After that, 30 animals with 24-hour biliary peritonitis in accordance with the tasks were divided: into comparison group No. 1 using hemosorption; comparison group No. 2 using plasmapheresis and an experimental group using sodium hypochlorite, which included 10 animals, respectively. The procedures were repeated once a day for 3 days. Observations were carried out on days 1, 3, 7, and 30 after the start of treatment.

A bacteriological blood test in the portal vein showed bacteremia (Escherichia coli), which indicates the presence of symptoms of abdominal sepsis in animals with a 24-hour biliary peritonitis model due to translocation of microorganisms from the lumen of the small intestine into the portal vein system. At the same time, C-reactive protein (CRP) was studied in animals by ELISA as a marker of the systemic inflammatory response syndrome, which was sharply increased to 642 ± 36 ng / ml versus 18 ± 4 ng / ml in intact animals.

Expanded hemostasiograms in control animals with 24-hour biliary peritonitis revealed a significant increase in platelet count relative to intact animals (p <0.05), increased aggregation properties of platelets (p <0.05), significant shortening of blood coagulation time (VSC) and activated partial thromboplastin time (APTT) (p <0.05), elongation of prothrombin time (PTV) (p <0.05) and thrombin time (TB) (p <0.01), increased fibrinogen content (FG) (p < 0.01) and the concentration of soluble fibrin-monomeric com plexes (RFMC) (p <0.01), a decrease in antithrombin III (AT III) (p <0.05) and an increase in the time of spontaneous euglobulin lysis (SEL) of the clot (p <0.05).

The revealed hemostasiological abnormalities in animals with abdominal sepsis of biliary origin are a reflection of a systemic inflammatory reaction, the manifestation of which is damage to blood cell membranes and endothelial dysfunction in the form of activation of the vascular-platelet hemostasis, moderate activation of the coagulation hemostasis internal pathway and an increased content of all plasma coagulation factors indicating hypercoagulation and inhibition of blood fibrinolytic activity according to him "the path due to the inhibition of cell and tissue activator of plasminogen to plasmin transformation and development of the prothrombotic state, which is characteristic of disseminated intravascular blood stage koagulopatin consumption.

Given the above, it can be argued that the urgent correction of coagulopathy is one of the main requirements for the successful treatment of abdominal sepsis of biliary origin.

In the process of treating abdominal sepsis of biliary origin in the comparison groups No. 1 and No. 2, despite the relief of the inflammatory process, there was no early coagulation link of hemostasis. As a rule, correction occurred on the 7-10th day after the start of treatment.

In the treatment of animals of the experimental group, starting from 1 day, there was a significant decrease in platelet count and inhibition of platelet aggregation activity up to 3 days relative to intact animals (p <0.05). At the same time, as in the comparison groups, these indicators came to the initial values on the 10th day. The effect obtained in the experimental group of animals can be due to direct oxidative modification of sodium hypochlorite of platelet membranes, leading to disruption of the intracellular signal transmission system or its indirect effect through oxidized proteins on amino, imino, and sulfhydryl groups in the platelet membrane. The mechanism of this effect of sodium hypochlorite, apparently, is associated with its effect on parts of the phospholipid membrane of platelets, where the receptor apparatus of cells is located, with oxidative modification of which there is a difficulty in intracellular signal transduction and thereby the formation of fibrinogen bridges between cells.

It is well known that against the background of endothelial dysfunction and platelet dysfunction, the activation mechanism of coagulation and thrombosis processes is triggered. A study of the animals of the experimental group showed a significant lengthening of VSC up to 7 days (p <0.001) and APTT in the first three days (p <0.05), relative to intact animals, which indicates the inhibitory effect of sodium hypochlorite on the phase of formation of the fibrin polymer through an obstacle to the polymerization of fibrin monomers, which it transforms into an inactive form and direct oxidative inactivation of V, VIII, IX, and XI coagulation factors that inhibit thrombin formation. At the same time, the animals showed a significant lengthening of the PTV for 7 days (p <0.05) and shortening of the TV, which only on the 1st day remained reliably high relative to the animals of the intact group (p <0.05). Such changes in the PTV index may be due to the oxidative modification of sodium by hypochlorite VII, V, X, and II of blood coagulation factors responsible for the implementation of the “external” pathway and inhibition of the prothrombin formation mechanism. It is also impossible to exclude the possibility of the effect of sodium hypochlorite on the pro- and anticoagulant activity of the endothelium, when, under the influence of oxidized blood lipoproteins, the expression of TFPi synthesis can occur, which binds to factor Xa, and thus inhibits the formation of prothrombinase. Shortening of TB can indicate inhibition of the “external” and “internal” pathways of the coagulation link of hemostasis. In the treatment of animals of the experimental group, a significant increase in the content of FG and RFMC is still observed, reaching their maximum values on the 1st day, which came to the initial values only on the 7th day (p> 0.05). At the same time, hyperfibrinogenemia can be characterized as stimulation of sodium by hypochlorite of the body's protective reaction aimed at the synthesis of fibrinogen in the liver and the deposition of fibrin in the abdominal cavity. This assumption is explained, on the one hand, by the mechanical properties of FG, which create the primary fibrous skeleton, and on the other, by its chemical properties, due to its high sorption activity. At the same time, high concentrations of RFMCs may be due to a violation of the conversion of FG to insoluble fibrin due to the entry of sodium hypochlorite into the hydroxylation reaction with a soluble fibrin monomer and its transformation into an inactive form. Probably, two events take place here - irreversible destruction of sodium by the hypochlorite of part of fibrinogen, leading to a loss of the ability to form full-fledged fibrin under the influence of thrombin, and the manifestation of a kind of antithrombin activity on the part of modified fibrinogen.

In the study of pro- and anticoagulant blood activity in animals of the experimental group, a drop in AT III activity was observed already on the 1st day (p <0.05), which remained low on the 7th day and did not reach the initial figures. It is known that AT III, being a physiological inhibitor of blood coagulation and, to a lesser extent, fibrinolysis, responds to activation of the procoagulant link in the hemostatic system and is complexed with activated factors. The data obtained, apparently, are the result of oxidation of sodium by the hypochlorite of the reactive portion of the proteinase inhibitor, as a result of which the enzyme loses its ability to inactivate the elastase secreted by neutrophil stimulated, which not only destroys the connective tissue, but also inhibits AT III activity. At the same time, the animals showed further inhibition of the time of SEL cell clot, reaching its maximum values on the 1st day, relative to the rate of intact animals (p <0.05), which, apparently, is associated with continued inhibition of the activity of the cell and tissue activator of plasminogen to plasmin transformation .

Summing up the obtained data on hemostatic disorders in animals with abdominal sepsis of bile origin, it can be noted that it affects all parts of the system. In this case, we can speak of a pronounced thrombophilic orientation of changes in hemostasis. This is evidenced by a true (including non-hemoconcentration) increase in platelet count, shortening of platelet aggregation time, increase in fibrinogen and RFMC concentration, inhibition of plasma anticoagulant activity, expressed in a decrease in antithrombin III activity, and lengthening of euglobulin lysis time. At the same time, the observed lengthening of PTV and TB indicates a possible transition of the process to the stage of consumption coagulopathy. Such a change in the hemostatic system in the absence of correction can lead to the development of thrombosis in the early or late postoperative period, or go into a detailed clinical picture of DIC blood.

The proposed method for the treatment of abdominal sepsis of biliary origin, complicated by coagulopathy, reduces the degree of prethrombosis by reducing sodium hypochlorite level of one of the most dangerous risk factors for thrombosis - platelet aggregation, through direct oxidative membrane-acting action; the indirect action of sodium hypochlorite on plasma proteins and amino acids; activation of the “external” and inhibition of the “internal” pathway of the coagulation link of hemostasis with a tendency to hypercoagulation changes; reducing the severity of laboratory signs of ICE blood due to inhibition of fibrinogenesis and fibrinolysis; interruption of the polymerization of fibrin monomers and the full formation of a fibrin clot.

Thus, the advantage of the antiplatelet effect of sodium hypochlorite is apparently that, being an inhibitor of prostaglandin synthetase (cyclooxygenase), it inhibits the formation of thromboxane A ₂ (a potent stimulator of irreversible aggregation) and does not inhibit the production of prostacyclin by the endothelium of the vascular wall.

The lethality of animals in the treatment of abdominal sepsis of bile origin complicated by coagulopathy was 2 times lower in the experimental groups than in the comparison groups.

Based on the obtained experimental data, it follows that:

1. Abdominal sepsis of bile origin is characterized by a persistent increase in platelet aggregation activity, moderate activation of the internal pathway of the coagulation link of hemostasis with simultaneous inhibition of the external pathway, which indicates a hypercoagulative orientation of changes in the hemostatic system, which, at the same time, is a factor of high thrombogenic risk requiring hemocorrection.

2. The proposed method for the treatment of abdominal sepsis of biliary origin, complicated by coagulopathy, provides: a decrease in the degree of prethrombosis by inhibiting the aggregation activity of platelets, both due to the direct membranotropic action of sodium hypochlorite and its indirect effect on plasma proteins and amino acids, as well as a decrease in the severity laboratory signs of ICE blood due to interruption of the polymerization of fibrin monomers and the formation of fibrin clots.

The results made it possible to conduct clinical testing on 40 patients with damage to the extrahepatic bile ducts (VLP), after various operations (endoscopic, open, reconstructive, etc.), in which the diagnosis was made late, for 3-5 days with symptoms of abdominal sepsis biliary origin. All patients were divided into 4 groups:

- a control group (n = 10) that was undergoing traditional therapy: debridement laparotomy, abdominal drainage, infusion therapy (hemodez), antibiotic therapy, etc .;

- comparison group No. 1 (n = 10), whose patients underwent hemosorption using carbon sorbents of SKN;

- comparison group No. 2 (n = 10), the patients of which performed plasmapheresis on the apparatus PF-05;

- the experimental group (n = 10), whose patients performed a set of measures, including sodium hypochlorite.

In all the studied groups, therapeutic measures were repeated every 24 hours for 3 days. Patients were observed on days 1, 3, 7, and 30.

In the process of testing the method in patients of all studied groups there was an early relief of the inflammatory process in the abdominal cavity and a significant improvement in the general condition. Clinical signs of endogenous intoxication (weakness, lethargy, loss of appetite, sleep disturbance, headaches) disappeared after the first treatment sessions.

However, biochemical blood tests carried out against the background of the proposed methods of treatment revealed significant differences.

So, in the comparison group No. 1 and No. 2 in patients after the course of treatment, signs of hypocoagulation were observed, while in the experimental group where sodium hypochlorite was used, there was a decrease in the severity of laboratory signs of DIC blood due to normalization of fibrinogen concentration and RFMC, increasing the activity of AT-III, reducing the activity of thrombin in the circulating blood, activating the anticoagulant system of the blood.

Example 1: Medical record inpatient No. 2972. Patient S., 74 years old, was taken to the II emergency surgical department with a diagnosis of cholecysto-choledocholithiasis, acute calculous cholecystitis, abdominal sepsis of biliary origin.

On admission: complaints of dull aching, severe pain in the right hypochondrium and epigastrium, persistent, without irradiation, nausea, bitterness and dry mouth, general weakness. Objectively: the patient’s condition is severe, the tongue is covered with white coating, the mucous membranes are dry, the abdomen is painful on palpation, the right half of the anterior abdominal wall is tense, the symptoms of Ortner, Kerr, Mussi are positive, pronounced peritoneal symptoms on the right. Temperature 39.1, pulse 96 beats / min. Data from instrumental and laboratory studies: ultrasound signs of fluid accumulation in the subhepatic space and its spread along the right flank to the pelvis. An increase in the number of red blood cells, hemoglobin, hematocrit by 15-20% compared with normal values, an increase in the number of leukocytes by 140%, LII according to Kalf-Kalif 11 times. When examining the parameters of a detailed hemostasiogram in a patient, there was a significant decrease in the functional activity of platelets according to the degree of aggregation to 8.36 ± 4.16 s versus 17.00 ± 1.00 s in the control (p <0.05); lengthening of the kaolin-mullet time index to 50.9 ± 4.1 s versus 43.0 ± 1.0 s (p <0.05), which indicates a tendency to hypocoagulation in the 1st phase of blood coagulation. At the same time, an increase in the concentration of fibrinogen to 5.42 ± 0.45 g / L was observed versus 2.08 ± 0.10 in the control (p <0.005) and RKMF to 12.8 ± 2.1 mg / L against 8.7 ± 1.1, which indicates the presence of active thrombin in the circulating blood. In the examined patients, activation of the TB index up to 12.0 ± 0.81 s versus 17.1 ± 0.5 s in the control (p <0.05), pronounced inhibition of the time of spontaneous euglobulin clot lysis up to 326.0 ± 31.6 min against 189.00 ± 13.0 min in the control (p <0.005 ) and hagemandependent clot lysis up to 185.0 ± 2.82 min versus 18.0 ± 0.2 min in the control (p <0.005), which indicates the depletion of anticoagulant and inhibition of fibrinolytic potentials of the hemostasis system. Analysis of the results obtained in a patient with abdominal sepsis of biliary origin indicates pronounced hemostasiological disorders, which can be regarded as the II (transitional) stage of the ICE blood process, requiring urgent hemocorrection.

Under intubation anesthesia, a median laparotomy was performed. A large amount (up to 800 ml) of bile exudate with an admixture of fibrin and pus was found in the abdominal cavity. Last deleted. An infiltrate consisting of a duodenum, a large omentum and a gall bladder was found in the subhepatic space. When separating the infiltrate revealed a perforated hole in the neck of the gallbladder through which bile enters. The bubble is small in size, the walls are sealed, purple in color with a touch of fibrin. The hepatoduodenal ligament is edematous, compacted, and is imbibed with bile. Cholecystectomy and intraoperative abdominal sanitation with furacilin solution (1: 5000) were performed, after which the abdominal cavity was drained with sterile wipes. Through punctures in the right iliac and hypochondrium, drainage of the pelvic cavity and subphrenic space was performed. Immediately after rehabilitation, intestinal dialysis was performed using a 0.06% sodium hypochlorite solution using a double-lumen nasointestinal probe. After that, up to 400 ml of a 0.04% sodium hypochlorite solution was poured into the abdominal cavity. The laparotomic wound was sutured before drainage. At the same time, an intravenous infusion of up to 250 ml of a 0.04% sodium hypochlorite solution was carried out. The introduction of sodium hypochlorite through the drainage tubes, intravenously and into the lumen of the small intestine was repeated three times every 24 hours.

A day after the course treatment, up to 200 ml of hemorrhagic fluid was allocated from the abdominal cavity through the drainage tubes. Against the background of the treatment, a rapid improvement in the patient's condition was noted: normalization of body temperature, the appearance of peristalsis. On the 7th day after the operation, the drains were removed. By the 10th day, normalization of the number of leukocytes was noted. After the course treatment, normalization of the concentration of fibrinogen and RFMC, an increase in the activity of AT-III, a decrease in the activity of thrombin in the circulating blood in terms of TB to 16.6 ± 1.43 s were compared with the control (p <0.05) and, respectively, compared with the original value (p <0.01); activation of the blood anticoagulation system (SEL) up to 153.0 ± 11.4 min (p <0.01) compared to the initial value. The above changes in the parameters of the hemostasiogram after treatment are considered as manifestations of the resolution of DIC blood. The patient on the 20th day was discharged in satisfactory condition for outpatient treatment.

Example 2: Medical record of inpatient No. 31747. Patient Sh., 80 years old, was taken to the II emergency surgical department with a diagnosis of cholelithiasis, acute calculous cholecystitis, diffuse biliary peritonitis. On admission: complaints of aching, severe pain in the upper abdomen, nausea, vomiting, general weakness. Objectively: the patient’s condition is severe, the tongue is covered with white coating, the mucous membranes are dry, the abdomen is painful on palpation, the right half of the anterior abdominal wall is tense, the symptoms of Ortner, Kerr, Mussi are positive, pronounced peritoneal symptoms on the right. Temperature 38.7 ° С, pulse 90 bpm. Data from instrumental and laboratory studies: with diagnostic laparoscopy in the lower floor of the abdominal cavity, an adhesive process is observed that limits the examination. Throughout the right flank there is a cloudy gray-yellow exudate, up to 100 ml in size with fibrin layers in the area of the liver gate. Clinical and laboratory diagnostics revealed pronounced hemoconcentration, an increase in the number of leukocytes by 120%. When examining the parameters of a detailed hemostasiogram in a patient, there was a significant decrease in the functional activity of platelets according to the degree of aggregation to 6.2 ± 3.78 s versus 17.00 ± 1.00 s in the control (p <0.05); lengthening the index of kaolin-cephalin time to 55.6 ± 5.5 s versus 43.0 ± 1.0 s (p <0.05), which indicates a tendency to hypocoagulation in the 1st phase of blood coagulation. At the same time, an increase in the concentration of fibrinogen to 6.23 ± 0.62 g / L was noted versus 2.08 ± 0.10 in the control (p <0.005) and RKMF to 13.9 ± 3.2 mg / L against 8.7 ± 1 , 1, which indicates the presence of active thrombin in the circulating blood. In the examined patients, activation of the TB index up to 10.5 ± 1.18 s versus 17.1 ± 0.5 s in the control (p <0.05), pronounced inhibition of the time of spontaneous euglobulin clot lysis up to 387.0 ± 40.0 min versus 189.00 ± 13.0 min in the control (p <0.005) and hagemandependent clot lysis to 198.5 ± 4.43 min against 18.0 ± 02.0 min in the control (p <0.005), which indicates depletion of anticoagulant and inhibition of fibrinolytic potentials of the hemostatic system. Analysis of the results obtained in a patient with abdominal sepsis of biliary origin indicates more pronounced hemostasiological disorders compared with the previous patient, which can be regarded as the II (transition) stage of the ICE blood process, requiring urgent hemocorrection.

Under intubation anesthesia, a median laparotomy was performed. Intraoperatively: in the abdominal cavity up to 200 ml of turbid biliary exudate with fibrin, odorless. The gallbladder is perforated in the body area. A cholecystectomy and sanitation of the abdominal cavity with furatsillin solution (1: 5000) were performed, after which the abdominal cavity was drained with sterile wipes, and the pelvic cavity and subphrenic space were drained. Immediately after rehabilitation, intestinal dialysis was performed intraoperatively using a 0.06% sodium hypochlorite solution using a double-lumen nasointestinal probe. After that, 400 ml of a 0.04% sodium hypochlorite solution was poured into the abdominal cavity as a bactericidal agent. Laparotomic wound sutured to drainage. At the same time, an intravenous infusion of 250 ml of a 0.04% sodium hypochlorite solution was carried out. In this case, the introduction of sodium hypochlorite intravenously and into the lumen of the small intestine was repeated three times every 24 hours at the rate of 15 ml / kg.

A day after the course treatment, up to 200 ml of hemorrhagic fluid was allocated from the abdominal cavity through the drainage tubes. Against the background of the treatment, an improvement in the patient's condition, the normalization of the number of red blood cells, hemoglobin, hematocrit were noted. By the 3rd day, the pulse was 70-80 beats / min, body temperature 37.0 ° С, intestinal motility appeared. On the 9th day drainage was removed. By the 10th day, normalization of the number of leukocytes was noted. In the study of indicators of the expanded hemostasiogram in a patient, normalization of the concentration of fibrinogen and RFMC, an increase in the activity of AT-III, a decrease in the activity of thrombin in the circulating blood in terms of TB, both relative to the control (p <0.05) and the initial data (p <0, 01); activation of the anticoagulant system of blood (SEL). The revealed changes in the parameters of the hemostasiogram after a course of treatment are considered by us as manifestations of the resolution of DIC blood. The patient was discharged in satisfactory condition for outpatient treatment on the 22nd day.

Thus, according to the strictly proposed scheme, the use of sodium hypochlorite in the treatment of abdominal sepsis of bile origin, complicated by hemostasiopathy (intraperitoneal, intravenous, and into the lumen of the small intestine), made it possible to reduce the manifestations of the inflammatory reaction at an earlier date, correct hemostasiological disorders, reduce mortality, and reduce the incidence of postoperative complications from the wound and reduce the length of hospital stay by an average of 3.2 ± 0.4 days relative to patients of the group eniya №1, to 2.1 ± 0.3 days relative to the comparison group №2 patients and 7.9 ± 0.4 days in patients with relatively conventional method of treatment that exhibits high medical and social efficiency of the proposed method (table).

Table Comparative efficacy of treatment of abdominal sepsis of biliary origin complicated by hemostasiopathy Suggested treatments Number of patients Number of bed days, days Mortality,% Complications of the wound,% Traditional treatments 10 26.8 ± 1.1 twenty thirty Comparison Group No. 1 10 22.1 ± 0.9 10 twenty Comparison Group No. 2 10 21.0 ± 0.4 10 10 Experienced group 10 18.9 ± 0.6 - -

The proposed method of treatment has a fairly significant economic effect. So, for example, the cost of 1 bed-day for inpatient treatment of a patient only from compulsory medical insurance funds is 450 rubles [The approved tariff for medical care provided in the system of compulsory medical insurance, Krasnodar, 2011]. When using the traditional method of treating abdominal sepsis of biliary origin complicated by hemostasiopathy, the patient remains in the hospital for 26.8 days for 12060 rubles, while in the experimental group where the proposed method of treatment is used, only 8505 rubles, i.e. the effectiveness of treatment of one patient is 3555 rubles.

The method is recommended for widespread use in practical health care.

LITERATURE

1. Bagnenko SF, Belotserkovsky BZ, Briskin BS and others. Peritonitis: A Practical Guide / Ed. Savelyeva B.C., Gelfanda B.R. - M .: Litterra, 2006 .-- 205 p.

2. Vovk E.I. Gallstone disease in the 21st century: what's new? // Therapist. - 2011. - No. 2. - S. 58-65.

3. Gallinger Yu.I. Laparoscopic cholecystectomy: experience of 3165 operations // Endoscopic surgery. - 2007. - No. 2. - C.3-7.

4. Halperin E.I., Vetshev P.S. Guide to biliary tract surgery. - M .: Vidar M, 2009 .-- 568 p.

5. Gostishchev V.K., Sazhin V.P., Avdenovenko A.JI. - Peritonitis. M .: Medicine, 1992 .-- 224 p.

6. Gostishchev VK, Fedorovsky NM, Differentiated approach to the treatment of intoxication syndrome in surgical sepsis // Actual problems of modern surgery. - Astrakhan, 1992. - S.15-16.

7. Grigoryeva I.N., Malyutina S.K., Voevoda M.I. The role of hyperlipidemia in gallstone disease // Experimental and clinical gastroenterology. - 2010. - No. 4. - S. 64-68.

8. Dale M.M., Fan T.P.D., Foreman J.K. Guidelines for immunopharmacology. - M .: "Medicine", 1998. - 332 p.

9. Eryukhin I.A., Gelfand B.R., Filimonov M.I., Efimenko N.A., Podachin P.V. Abdominal surgical infections // Surgical infections. Edited by Yuryukhin I.A., Gelfand B.R., Shlyapnikova S.A. - M .: Publishing house "Literra", 2006. - S.410-515.

10. Kruchinsky N.G. The mechanisms of hemostasiopathy formation under conditions of low-level radiation exposure. Abstract. diss. ... doctors honey. sciences. - SPb., 2004 .-- 42 p.

11. Lopukhin Yu.M., Molodenkov M.I. Hemosorption. - M .: Medicine, 1985 .-- 287 p.

12. Murina M.A., Fesenko O.D., Sergienko V.I. et al. Antithrombotic activity of N, N-dichlortaurin in vivo in a model of thrombosis in mice // Bull. expert. biol. - 2002. - No. 7. - S. 44-47.

13. Neymark II, Ovchinnikova V.A. // West. surgery. - 1996. - No. 1. - S.86-90.

14. Petrosyan E.A., Sergienko V.I., Kade A.Kh., Petrovsky A.N. et al., Method for modeling biliary peritonitis / RF Patent No. 2175784 from 10.11.2001., BI 2001, No. 31.

15. Popova T.S., Tamazashvili T.Sh., Shestopalov A.E. Parenteral and enteral nutrition in surgery. - M., 1996 .-- 221 p.

16. Roshchupkin D.I., Murina M.A., Kravchenko N.N., Sergienko V.I. Selectivity of the covalent action of biochloramine antiplatelet agents on platelet-rich plasma // Biophysics. - 2007. - No. 3. - S. 527-533.

17. Savelyev B.C., Lubyansky V.G., Petukhov V.A. Dysmetabolic consequences of intestinal insufficiency syndrome in abdominal surgery // Annals of surgery. - 2005. - No. 6. - S. 39-42.

18. Fedorovsky N.M. Indirect electrochemical detoxification. - M .: Medicine, 2004. - P.52-53.

19. Kim C, Park E., Quinn M.R., Schuller-Levis G. The production of superoxide anion and nitric oxide by cultured murine leukocytes and the accumulation of TNF-alpha in the conditioned media is inhibited by taurine chloramine // Immunopharmacology. - 1996. - Vol. 34. - No. 2. - P.89-95.

20. Savi P., Zachayus J. L., Delesque-Touchard N. et al. The active metabolite of Clopidogrel disrupts P2Y12 receptor oligomers and partitions them out of lipid rafts // Proc. Natl. Acad. Sci. USA - 2006. - Vol. 103. - No. 29. - P.11069-11074.

Claims (1)

A method for the treatment of abdominal sepsis of biliary origin complicated by coagulopathy, including laparotomy, sanitation of the abdominal cavity, characterized in that after laparotomy is performed intraoperatively into the lumen of the small intestine below the Treitz ligament, a double-lumen nasogastric tube is used to actively aspirate the intestinal contents, then as an abdominal cavity once pour in a solution of sodium hypochlorite and suture the edges of the wound tightly to drainage, immediately after that perform intravenous infusion and intestinal dialysis using sodium hypochlorite, while for the sanitation of the abdominal cavity through drainage tubes and for intravenous infusions, a 0.04% solution of sodium hypochlorite is used, and for intestinal dialysis, a 0.06% solution, after which in the postoperative period, abdominal sanitation, intestinal dialysis and intravenous infusion of sodium with hypochlorite are carried out once a day for 1-3 days at the rate of 15 ml / kg.