RU2228758C1 - Method for applying membrane dialysis in the cases of pyoinflammatory diseases - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves surgically treating purulent focus. Membrane capsule is set having medicament and tubular microirrigator unit for substituting spent dialysate on wound bottom. The membrane capsule is filled with highly osmotic 15% chitosane ascorbate solution to 1/3 of its volume and changed every day. The chitosane ascorbate has molecular mass of 15±5 kD and is deacetylized not less than to 96%. EFFECT: accelerated wound healing; short time of sojourn in hospital. 1 tbl

Description

The invention relates to medicine, can be used in surgery.

A known method of draining purulent foci of soft tissues using rubber and PVC tubes of various sizes and diameters, rubber (glove) graduates and gauze swabs (Wounds and wound infection / Edited by M.I. Kuzin, B.M. Kostyuchenok. - M. : Medicine, 1990). This technique has the following disadvantages: low efficiency due to rapid occlusion of the lumen of the drainage tubes with tissue detritus, a short hygroscopic effect of the gauze swab, ischemia, traumatic edema, sensitization of the tissues of the drained area, loss or displacement of the drainage during prolonged use in the postoperative period, and also large losses protein and electrolytes with flowing wound discharge.

A known method of active drainage and local chemotherapy using directed diffusion of drugs through a semipermeable membrane by membrane osmosis and dialysis (Grakov BS and other Semipermeable membranes in the treatment and prevention of surgical infection. - Krasnoyarsk: Publishing house of Krasnoyarsk University, 1988) consisting in laying on the bottom of the wound a capsule from a semipermeable membrane 2/3 filled with a highly osmolar dialysate solution (33% dextran solution with a molecular weight of 70 ± 15 kDa).

The method allows to avoid the disadvantages of tubular drains, however, it has low efficiency due to the mismatch of the membrane performance and progressively increasing concentration of toxic substances in the exudate.

The objective of the invention: optimization of the method of wound membrane dialysis, reducing the healing time of wounds, stopping the phenomena of endotoxemia, reducing the duration of patients in hospital.

The problem is solved by filling the membrane capsule with 1/3 osmotically active 15% solution of chitosan ascorbate (molecular weight 15 ± 5 kDa and a degree of deacetylation of at least 96%), with daily replacement.

The method is as follows: for patients with purulent-inflammatory diseases, after necrectomy and sanitation of the purulent foci, a membrane capsule is filled intraoperatively on the bottom of the wound, filled to 1/3 with a 15% solution of chitosan ascorbate so that the maximum contact of the membrane with the wound surface is achieved. A tubular microirrigator with perforations for changing spent dialysate is enclosed in the membrane cavity. In the postoperative period, as the membrane capsule is filled, the osmotically active 15% solution of chitosan ascorbate is replaced. It is known that the performance of membrane dialysis depends on the osmotic pressure in the capsule, which is determined by the formula: P = C: M, where P is the osmotic pressure, mOsmol; C is the amount of substance in solution, mg / l; M is the molecular weight of the substance. Therefore, if a 33% dextran solution with M = 70 ± 15 kDa provides a pressure of 4.7 mOsmol, then such a pressure can create a 7% solution of chitosan ascorbate. The use of a 15% solution of chitosan ascorbate for membrane dialysis allows you to create the osmotic pressure of 10 mOsmol, which is necessary for massive dehydration of the pathological focus, and increase the duration of the functioning of the membrane capsule by filling it with highly osmotic dialysate to 1/3 of its volume.

Wound membrane dialysis using a 15% solution of chitosan ascorbate was performed in 19 patients, and dialysis with a 33% solution of dextran in 20 patients with various forms of purulent-inflammatory diseases. Including: with post-injection abscesses, with suppuration of postoperative wounds of the abdominal and chest walls, as well as with non-clostridial phlegmon of the trunk and limbs.

Surgical allowance of purulent wounds was carried out immediately upon admission of patients to the hospital. The operations were performed under intravenous anesthesia. The purulent foci and sagging were opened, sanitation with a 3% solution of hydrogen peroxide was carried out, and, if necessary, counter-formation was formed. The indication for wound dialysis was the impossibility of complete excision of non-viable tissues with the proximity of nerve and vascular trunks or with the threat of a large anatomical defect. With non-clostridial phlegmon, dialysis was preceded by excision of all affected fiber and fascia.

In all cases of wound drainage, a Sigma semipermeable cellulose membrane drainage device with a lumen diameter of 2.7 cm, a wall thickness of 0.2 mm, and a pore diameter of up to 12 kDa was used. A dialysis solution of chitosan ascorbate was prepared on the basis of a 15% chitosan solution (15 kDa) with the addition of ascorbic acid (4.5 mg per gram of chitosan). Then, a daily dose of an antibacterial drug, antiseptic and anesthetic was added to the solution of the obtained chitosan ascorbate. Antibacterial drugs were prescribed according to antibioticograms. The dialysis solution was replaced as the membrane capsule was filled, in most cases once a day. In the case of using a 33% solution of dextran, dialysate had to be replaced at least 3 times a day, due to the limited volume of the membrane capsule and the short osmotic activity of the solution.

The reason for the cessation of dialysis and removal of the membrane capsule was the absence of signs of purulent inflammation, clinical and laboratory manifestations of endogenous intoxication syndrome. Removing the membrane drainage device was technically simple and painless after releasing it from dialysate.

In the first seven days, clinical, biochemical blood tests were performed daily and the serum luciferase index (LI) was determined.

It was revealed that patients already at admission to the hospital showed a high level of endogenous intoxication. The leukocyte intoxication index (LII) was equal to 1.9 ± 0.21 units, leukocytosis 16.7 ± 2.4 × ^{10 9} / L. Malondialdehyde (MDA) increased to 9.84 ± 0.91 μmol / L. LI was 0.50 ± 0.09 cu, which corresponds to an average degree of intoxication. During the first days after the operation, a decrease in total blood toxicity was noted, the number of leukocytes decreased, but the differences in these terms were not statistically significant. In the water-electrolyte balance, shifts appeared in the form of hyperkalemia and hypocalcemia (table).

By the fifth day, LI of serum was equal to 0.22 ± 0.03 cu (P <0.05). By 5 days, leukocytosis decreased to 7.5 ± 1.1 · 10 ⁹ / L (P <0.05). LII remained elevated. Indicators of lipid peroxidation decreased, MDA - 6.34 ± 0.83 μmol / L. Indicators of potassium, sodium, calcium remained within normal limits.

The efficiency of using wound dialysis with a 15% solution of chitosan ascorbate turned out to be very high in all cases. Anesthetic effect was noted in the very first hours after the start of dialysis, the removal of edema by the end of 2-3 days. By day 6-7, in 74.6% of patients, the wounds had completely cleared of necrotic tissue, and secondary sutures were applied on day 7-8. In 36.8% of patients, wounds were sutured tightly, and drainage was carried out through contraception.

The average duration of treatment of patients in the hospital using a 15% solution of chitosan ascorbate for membrane drainage was 16.7 ± 2.3 days. The average hospital bed in the comparative group (20 patients) was 23.3 + 2.4 days.

Thus, the use of wound membrane dialysis using a 15% solution of chitosan ascorbate allows optimization of wound dialysis, in which dialysate must be replaced once a day; carry out early relief of the phenomenon of endotoxemia (within 4-5 days); reduce the healing and full recovery of patients by an average of 7 days. The achieved positive effect is explained by the prolonged maintenance of the concentration gradient of toxic metabolites on different sides of the semipermeable membrane and the continuous absorption of wound discharge in combination with the elimination of toxins. Which, ultimately, leads to a massive outflow of wound discharge while maintaining high molecular weight reparative factors, local dehydration, restoration of microcirculation and drug delivery directly to the pathological focus.

Clinical example

Patient V., 43 years old, medical history No. 4831. Was admitted to the City Clinical Hospital No. 7 on 08/14/02, 9 days after the disease with a diagnosis of post-injection abscess of the anterior surface of the left thigh. Upon admission to the hospital, the condition was assessed as moderate and caused by the underlying disease. Body temperature 39.0 ° C. Locally, edema, infiltration, and hyperemia along the middle third of the anterior surface of the left thigh with a diameter of up to 20 cm were locally observed. In the center, there was a fluctuation plot with a diameter of up to 10 cm. On 14.08.02, an autopsy and surgical treatment with drainage by membrane drainage were performed. A 15% solution of chitosan ascorbate with antimicrobial and anesthetic substances was introduced into the drainage cavity: cefotaxime - 2 g, sodium ethazole - 10% - 5 ml, trimecain - until a 0.5% solution of anesthetic in the drainage was obtained. An aseptic dressing is applied. At the indicated dose, the preparations were introduced into the drainage once a day along with the gel. The initial microflora is Pseudomonas aeruginosa in combination with golden hemolytic staphylococcus in the amount of 4 · 10 ⁷ per 1 g of tissue. By the fourth day of treatment, the wound 2 times decreased in size, cleared of necrotic tissue and covered with bright red fine-grained dense granulations. The presence of edema was noted only along the edge of the wound up to 1 cm. Bacterial contamination with Staphylococcus aureus was 2 · 10 ³ per 1 g of tissue. On the 6th day of treatment, crops from the growth wound did not give microflora. 08.21.02, the membrane drainage was removed, and the wound was covered with primary deferred sutures. 08/25/02 was discharged from the clinic with a healed wound.

The advantages of the proposed method compared to others are more effective and early detoxification, long-term preservation of the drainage properties of the device used, elimination of protein and electrolyte losses through the wound surface, non-invasiveness of the installation and replacement of the membrane device, as well as minimal economic and technical costs.

Claims (1)

Method of wound membrane dialysis of purulent-inflammatory diseases, including surgical treatment of purulent foci, installing a membrane capsule with a medicinal composition and a tubular microirrigator to replace spent dialysate on the bottom of the wound, characterized in that the membrane capsule is 1/3 filled with a highly osmotic 15% ascorbate solution chitosan with a molecular weight of 15 ± 5 kDa and a degree of deacetylation of at least 96%, with its daily replacement.