Peritonitis: treatment

With regard to diffuse peritonitis, then, once this diagnosis is made, the preparation for surgery should be immediately started. Urgent forced training is required , which should be performed within 1.5-2 hours. The preparation includes puncture and catheterization of the subclavian vein, as well as transfusion therapy in full under the control of CVP and diuresis.

The initial therapy for the recovery of BCC is carried out by colloids (mainly solutions of hydroxyethyl starch-plasmasterol, 6 and 10% HAES sterile, and also solutions of plasma and albumin), it is not advisable to introduce crystalloids, since they require 3 times more volume by volume colloids.

In total, during the preparation for surgery, a patient with peritonitis should receive at least 1200 ml of fluid, including 400 ml of colloids, 400 ml of fresh frozen plasma or albumin and 400 ml of a complex saline solution. Transfusion therapy should continue during anesthesia and intensive care in the postoperative period.

Technical features of performing operations in patients with peritonitis.

1. The method of choice is lower-medial laparotomy, which provides not only adequate access for revision and surgical intervention, but also the possibility to freely continue the incision if necessary.
2. Aspiration of pathological effusion from the abdominal cavity.
3. Restoration of normal anatomical relationships between the abdominal and pelvic organs with separation of fissures sharply.
4. Mandatory audit of the abdominal organs, including appendix, intestine loops, subhepatic and subdiaphragmatic spaces, even with an obvious "gynecological" (uterus, appendage) focus for identifying and eliminating secondary changes. In the absence of a purulent-destructive focus in the abdominal cavity, an opening of the gland box and revision of the pancreas are shown to exclude destructive pancreatitis.
5. Performing a "gynecological" stage or volume - extirpation of the uterus or removal of the appendages. The principle is the principle of mandatory complete removal of the source of destruction.
6. Execution of the "intestinal" stage:
   • Separation of fissures between the loops of the small intestine (acute route), careful revision of the walls of the abscess cavity, i.e. Determination of the degree of destructive changes in the intestinal wall and its mesentery and their elimination (small defects of the serous and muscular layer of the intestine are eliminated by imposing the approaching gray-serous or serous-muscular sutures in the transverse direction with the Vicril No. 000 on the atraumatic intestinal needle). For prevention of intestinal obstruction, improvement of evacuation and repair conditions, and also in the large adhesive process between the loops of the small intestine at the end of the operation, a transnasal intubation of the small intestine with a probe should be performed.
   • Conducting appendectomy in the presence of secondary purulent-infiltrative changes in the appendix.
7. Thoroughly sanitize the abdominal cavity with a physiological solution (5 L) with the addition of a solution of dioxidine (10 ml of 10% solution per 400 ml of physiological solution). In recent years ozonized solutions have been widely used for this purpose: at the end of the lavage of the abdominal cavity, 3 liters of ozonated isotonic solution (ozone concentration 6 mg / l) cooled to a temperature of 10-12 ° C are introduced into the last for 10-15 minutes. After the sanation, complete removal (aspiration) of any sanitizing solution is shown. If, for some reason, long-term epidural anesthesia is not used or planned, a 0.5% solution of novocaine (200 ml) should be introduced into the mesentery of the small intestine.
8. Drainage of the abdominal cavity should be adequate to ensure complete removal of pathological substrate from the abdominal cavity throughout the time of resolution of the inflammatory process. With peritonitis, it is advisable to use only active aspiration-flushing drainage. The average duration of drainage in patients with peritonitis is 4 days. Criteria for cessation of drainage are the improvement of the patient's condition, the restoration of bowel function, the coping of the inflammatory process in the abdominal cavity. Correctly conducted aspiration-washing drainage (arrangement of tubes, careful monitoring of their function), i.e. Complete removal of pathological exudates from all parts of the abdominal cavity for 4 days, frees us from using program laparotomy in the postoperative period. The following methods of introducing drainage pipes are often used:
   • the main drainage is always inserted transvaginally (through the open dome of the vagina after the extirpation of the uterus or by the back of the colpotomy with the preserved uterus) - it is advisable to use two drains 11 mm in diameter;
   • in addition to transvaginal, transabdominal through the counter-lines in the mesogastric and epigastric regions, 2-3 additional drainages with a diameter of 8 mm are carried out to the sites of greatest destruction (the optimal mode of discharge in the apparatus for draining the abdominal cavity is 30-40 cm of water).
9. For reliable prophylaxis of postoperative event and postoperative hernias, it is advisable to sew the front abdominal wall with separate sutures from kapron or caproag through all layers in two floors (peritoneum - aponeurosis and subcutaneous tissue - skin).
10. For the prevention of bacterial-toxic shock during surgery and postoperative purulent-septic complications (wound infection, septic thrombophlebitis, sepsis), all patients at the time of the cutaneous incision were shown one-step introduction of antibiotics acting on the main pathogens, with the continuation of antibacterial therapy in the postoperative period. We use the following antibiotics:

• combinations of penicillins with beta-lactamase inhibitors, for example, ticarcillin / clavulanic acid (timentin) 3.1 g;

Or

• cephalosporins of III generation, for example, cefotaxime (claforane) 2 g or ceftazidime (fortum) 2 g in combination with nitroimidazoles (clion, metrogyl) 0,5 g;

Or

• Meropenem (meronem) in a dose of 1 g or tienam in a dose of 1 g. Features of postoperative management of patients with peritonitis.

1. The use of adequate analgesia in the postoperative period. Often, long-term epidural anesthesia is used in all patients who do not have absolute contraindications to this method of anesthesia. It is known that epidural blockade is not only an anesthetic method, but also a therapeutic method. Epidural blockade allows you to maintain independent breathing in the postoperative period in full. In view of the absence of pain in the wound and abdominal cavity, the patients actively turn in bed, early sit down, breathe deeply, actively cough up phlegm, while the introduction of narcotic analgesics, especially at 3-4 h intervals, in weakened patients can cause respiratory depression and complications in the form of hypostatic or aspiration pneumonia:
   • is performed with minimal medicinal effect;
   • reduces spasm of peripheral vessels;
   • improves blood flow in the kidneys, stimulates diuresis;
   • significantly improves the motor-evacuation function of the gastrointestinal tract;
   • has antiarrhythmic action;
   • improves the psychoemotional state;
   • selective action on blood circulation, prolonged epidural anesthesia in case of its use for several days after severe operations is a measure of prophylaxis of thrombosis of the pelvic vessels and lower limbs and thromboembolic complications in the postoperative period;
   • economically advantageous, which is important in modern conditions.

If there are contraindications to the use of the method of prolonged epidural anesthesia, anesthesia should be carried out with narcotic analgesics during the first three days, introducing them at various intervals (4-6-8-12 hours). To potentiate the action and reduce the need for drugs, they should be combined with antihistamines and sedatives. It should be borne in mind that the joint appointment of narcotic and non-narcotic analgesics is inexpedient. It is an established fact that the analgesic effect of drugs against the background of the use of analgin and its derivatives is sharply reduced due to the opposite mechanisms of action.

2. The leading role in the outcome of the disease is played by antibacterial therapy. If the causative agent of the disease is known, then directed therapy is performed. However, in the vast majority of cases empirically used broad-spectrum antibiotics, acting on the main pathogens (anaerobes, gram-negative enterobacteria and Gram-positive microorganisms). Treatment is carried out with the maximum single and daily doses, the duration of treatment is 7-8 days.

In clinical practice for the treatment of peritonitis successfully used the following drugs or their combinations:

• monotherapy with beta-lactam antibiotics with beta-lactamase inhibitors - TIC / KK (timentin) in a single dose of 3.1, daily dose of 12.4 g;
• cefalosporins III generation in combination with nitroimidazoles, for example, cefotaxime (klaforan) + metronidazole or ceftazidime (fortum) + metronidazole (cefotaxime in a single dose of 2 g, daily - 6 g, course - 48 g, ceftazidime in a single dose of 2 g, daily - 6 g, the course - 48 g, metronidazole in a single dose of 0.5 grams, daily - 1.5 grams, exchange rate - 4.5 g);
• combinations of lincosamines and aminoglycosides, for example, lincomycin + gentamycin (netromycin) or clindam-zinc + gentamicin (netromycin) (lincomycin in a single dose of 0.9 g, daily - 2.7 g, exchange rate - 18.9 g; clindamycin in a single dose 0,9 g, diurnal - 2,7 g, course - 18,9 g, gentamycin in a daily dose of 0, 24 g, a course - 1.68 g, netromycin in a daily dose of 0.4 g, course - 2 g intravenously) ;
• monotherapy with time-delay, for example: meronem in a single dose of 1 g, daily - 3 g, course - 21 g; tienam in a single dose of 1 g, daily - 3 g, the course - 21 g.

3. Infusion therapy.

The volume of infusions is individual and is determined by the nature of CVP and the magnitude of diuresis. The data of our own studies suggest that the amount of liquid administered, provided that the kidney function is preserved, should be 35-40 ml / kg of body weight per day. When the body temperature rises by 1 degree, the amount of liquid administered per day should be increased by 5 ml / kg of body weight. Thus, the total amount of fluid administered per day with a normal urination of at least 50 ml / h on average is 2.5-3 liters.

For correction of polyorganic disorders in the postoperative period, both the volume of infusions and the quality of infusion media are important.

The introduction of colloids (400-1000 ml / day) - mainly solutions of hydroxyethyl starch-plasmastheryl, 6% and 10% of HAES-sterile, protein preparations (solutions of fresh frozen plasma and albumin) at the rate of 1-1.5 g of native protein per 1 kg of body weight (with a severe course of the process, the protein dose can be increased to 150-200 g / dry.); The remaining volume is replaced by crystalloids. Fresh (not more than 2 days of storage) erythrocytic mass is used for severe anemia (Hb 80-70 g / l and below).

In severe disease, the amount of fluid administered can be increased to 4-6 l (hypervolemia regimen) with regulation of urination (forced diuresis). The latter is carried out by the method of VK Gostishchev et al. (1992): we inject 1000 ml of crystalloids, 500 ml of a 3% solution of sodium bicarbonate and 400 ml of reopolyglucin, then 40-60-80 mg of lasix, then 1000-1500 ml of protein preparations (albumin, plasma, amino acid solutions) with hourly diuresis.

Data on the main infusion media are presented in Table 9 of this monograph.

4. Stimulation of the intestine.

In the absence of a sufficient effect, the use of other means enhancing the motor skills (proserine, calimin, ubretide) is indicated.

Correction of hypokalemia also plays an important role in the treatment of intestinal paresis. I would like to pay special attention to the following rules when prescribing potassium preparations:

• It is possible to administer potassium preparations only under the control of its content in the blood serum;
• It is impossible to use potassium preparations undiluted in connection with the danger of developing fibrillation of the ventricles and cardiac arrest (the principle of dilution: to 500 ml of the basic solution it is necessary to add not more than 1.5-2 g of potassium, and just before consumption);
• extremely carefully apply potassium preparations in patients with impaired renal function, since the damaged kidney drug is not excreted;
• take into account the potassium content in other potassium-containing preparations (for example, fresh frozen plasma, gemodeze, etc.).

Usually, in the first hour, we add 0.8-1 g of potassium, then gradually in a dose of 0.4 g / h. The average daily dose of potassium preparations in patients with peritonitis, according to our data, is 6-8 g.

5. The use of protease inhibitors significantly altering the proteolytic activity of the blood, eliminating hemocoagulation disorders, potentiating the action of antibiotics. Daily doses of the Gordox 300 000-500 000 units, kontrikala - 800 000-1 500 000 units and tracerol 125 000-200 000 units.
6. Heparinotherapy is used in all patients in the absence of contraindications. The average daily dose of heparin is 10 thousand units. Per day (2.5 thousand units> 4 times subcutaneously) with a gradual decrease and cancellation of the drug with an improvement in the patient's condition and coagulogram and aggregatogram indicators. It is more effective to prescribe prolonged low-molecular analogues of heparin-fractasiparin by 0.4 ml once a day or kleksana in a dose of 20 mg (0.2 ml) once a day.
7. Treatment with glucocorticoids. Currently, there are polar opinions about the need for hormones. Clinical experience indicates that the appointment of prednisolone in a daily dose of 90-120 mg with a gradual decrease and cancellation of the drug after 5-7 days significantly improves the course of the postoperative period.
8. To normalize the aggregation, microcirculation and accelerate the reparative processes, all patients are also shown the use of disaggregants (antiplatelet agents). In the composition of infusion therapy include rheopolyglucin, apply also kurantil (trental). The latter is included in the infusion medium on an average of 100-200 mg / day, and if necessary (the inability to apply direct anticoagulants) the dose can be increased to 500 mg / day. With a gradual introduction of the drug.
9. We apply hepatic therapy (essential, karsil, antispasmodics) and cardiac (cardiac glycosides, drugs that improve myocardial trophism) disorders. To improve the function of the brain, nootropil or cerebrolysin is used.
10. Symptomatic therapy includes the appointment of vitamins, drugs that improve metabolic processes in cells and tissues and regulate redox processes.
11. According to the indications, extracorporeal methods of detoxification are used.

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