Peritonitis - Treatment

As for diffuse peritonitis, as soon as this diagnosis is made, preparation for surgery should be started immediately. Urgent forced preparation is necessary, which should be carried out within 1.5-2 hours. Preparation includes puncture and catheterization of the subclavian vein, as well as full transfusion therapy under the control of central venous pressure and diuresis.

Initial therapy for the restoration of the BCC is carried out with colloids (mainly solutions of hydroxyethyl starch - plasmasteril, 6 and 10% HAES-steril, as well as solutions of plasma and albumin); it is not advisable to administer crystalloids, since to increase the BCC, they are required in volume 3 times greater than colloids.

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

Technical features of performing operations on patients with peritonitis.

1. The method of choice is lower midline laparotomy, which provides not only adequate access for revision and surgical intervention, but also the ability to freely continue the incision if necessary.
2. Aspiration of pathological effusion from the abdominal cavity.
3. Restoration of normal anatomical relationships between the organs of the abdominal cavity and pelvis with acute separation of adhesions.
4. Mandatory revision of abdominal organs, including the appendix, intestinal loops, subhepatic and subdiaphragmatic spaces, even with an obvious "gynecological" (uterus, appendages) focus to identify and eliminate secondary changes. In the absence of a purulent-destructive focus in the abdominal cavity, opening the omental bursa and revision of the pancreas is indicated to exclude destructive pancreatitis.
5. Performing the "gynecological" stage or volume - extirpation of the uterus or removal of appendages. The main principle is the mandatory complete removal of the destructive focus.
6. Carrying out the "intestinal" stage:
   • Separation of adhesions between loops of the small intestine (acutely), 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 applying converging serous-serous or serous-muscular sutures in the transverse direction with vicryl No. 000 on an atraumatic intestinal needle). To prevent intestinal obstruction, improve the conditions of evacuation and reparation, as well as in the case of an extensive adhesion process between loops of the small intestine, transnasal intubation of the small intestine with a probe should be performed at the end of the operation.
   • Conducting appendectomy in the presence of secondary purulent-infiltrative changes in the appendix.
7. Thorough sanitation of the abdominal cavity with a physiological solution (5 l) with the addition of a dioxidine solution (10 ml of a 10% solution per 400 ml of physiological solution). In recent years, ozonized solutions have been widely used for this purpose: after washing the abdominal cavity, 3 l of an ozonized isotonic solution (ozone concentration 6 mg/l), cooled to a temperature of 10-12°C, are introduced into the latter for 10-15 minutes. After sanitation, complete removal (aspiration) of any sanitizing solution is indicated. If for some reason long-term epidural anesthesia is not used or is not planned, it is advisable to introduce a 0.5% solution of novocaine (200 ml) into the mesentery of the small intestine.
8. Abdominal drainage should be adequate to ensure complete removal of pathological substrate from the abdominal cavity throughout the entire period of resolution of the inflammatory process. In peritonitis, it is advisable to use only active aspiration-washing drainage. The average duration of drainage in patients with peritonitis is 4 days. The criteria for stopping drainage are improvement of the patient's condition, restoration of bowel function, and relief of the inflammatory process in the abdominal cavity. Correctly performed aspiration-washing drainage (location of tubes, careful monitoring of their functioning), i.e. complete removal of pathological exudate from all parts of the abdominal cavity for 4 days, frees us from the use of programmed laparotomies in the postoperative period. The following methods of inserting drainage tubes are often used:
   • the main drains are always inserted transvaginally (through the open vaginal dome after extirpation of the uterus or by means of a posterior colpotomy with the uterus preserved) - it is advisable to use two drains with a diameter of 11 mm;
   • In addition to transvaginal, transabdominally through counter-openings in the mesogastric and epigastric regions, 2-3 additional drains with a diameter of 8 mm are inserted to the sites of greatest destruction (the optimal vacuum mode in the apparatus for drainage of the abdominal cavity is 30-40 cm H2O).
9. For reliable prevention of postoperative eventration and postoperative hernias, it is advisable to suture the anterior abdominal wall with separate sutures made of nylon or caproag through all layers in two levels (peritoneum - aponeurosis and subcutaneous tissue - skin).
10. To prevent bacterial-toxic shock during surgery and postoperative purulent-septic complications (wound infection, septic thrombophlebitis, sepsis), all patients are shown a single-stage administration of antibiotics at the time of skin incision, which act on the main pathogens, with 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

• third generation cephalosporins, for example, cefotaxime (claforan) 2 g or ceftazidime (fortum) 2 g in combination with nitroimidazoles (klion, metrogyl) 0.5 g;

Or

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

1. Use of adequate pain relief in the postoperative period. Often use long-term epidural anesthesia in all patients who do not have absolute contraindications to this method of pain relief. It is known that epidural block is not only a method of anesthesia, but also a therapeutic method. Epidural block allows to maintain independent breathing in the postoperative period in full. Due to the absence of pain in the wound and abdominal cavity, patients actively turn in bed, sit up early, breathe deeply, actively cough up sputum, while the introduction of narcotic analgesics, especially at intervals of 3-4 hours, in weakened patients can cause respiratory depression and complications in the form of hypostatic or aspiration pneumonia:
   • carried out with minimal medicinal influence;
   • reduces spasm of peripheral vessels;
   • improves blood flow in the kidneys, stimulates diuresis;
   • significantly improves the motor-evacuation function of the gastrointestinal tract;
   • has an antiarrhythmic effect;
   • improves psycho-emotional state;
   • selectively affecting blood circulation, long-term epidural anesthesia, when used for several days after major surgeries, is a preventive measure against thrombosis of the vessels of the pelvis and lower extremities 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, pain relief should be carried out with narcotic analgesics during the first three days, introducing them at different intervals (4-6-8-12 hours). To potentiate the effect and reduce the need for narcotics, they should be combined with antihistamines and sedatives. It should be borne in mind that the combined administration of narcotic and non-narcotic analgesics is inappropriate. It is an established fact that the analgesic effect of narcotics against the background of the use of analgin and its derivatives is sharply reduced due to the opposite mechanisms of action.

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

In clinical practice, the following drugs or their combinations are successfully used to treat peritonitis:

• monotherapy with beta-lactam antibiotics with beta-lactamase inhibitors - TIK/KK (timetin) in a single dose of 3.1, daily dose - 12.4 g;
• third-generation cephalosporins in combination with nitroimidazoles, for example, cefotaxime (claforan) + 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, course - 48 g; metronidazole in a single dose of 0.5 g, daily - 1.5 g, course - 4.5 g);
• combinations of lincosamines and aminoglycosides, for example, lincomycin + gentamicin (netromycin) or clindamycin + gentamicin (netromycin) (lincomycin in a single dose of 0.9 g, daily - 2.7 g, course - 18.9 g; clindamycin in a single dose of 0.9 g, daily - 2.7 g, course - 18.9 g; gentamicin in a daily dose of 0.24 g, course - 1.68 g; netromycin in a daily dose of 0.4 g, course - 2 g intravenously);
• monotherapy with meronem, 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, course - 21 g.

3. Infusion therapy.

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

For the correction of multiple organ dysfunctions 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) is indicated - mainly solutions of oxyethyl starch-plasmasteryl, 6 and 10% HAES-steryl, 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 (in severe cases 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) erythrocyte mass is used in case of severe anemia (Hb 80-70 g/l and below).

In severe cases of the disease, the amount of fluid administered can be increased to 4-6 liters (hypervolemia mode) with regulation of urination (forced diuresis). The latter is carried out according to the method of V.K. Gostishcheva et al. (1992): we administer 1000 ml of crystalloids, 500 ml of 3% sodium bicarbonate solution and 400 ml of rheopolyglucin, then 40-60-80 mg of lasix, then 1000-1500 ml of protein preparations (albumin, plasma, amino acid solutions) with hourly monitoring of diuresis.

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

4. Stimulation of the intestines.

If there is no sufficient effect, the use of other motility enhancing agents (proserin, kalimin, ubretide) is indicated.

In the treatment of intestinal paresis, correction of hypokalemia also plays an important role. We would like to draw special attention to the observance of the following rules when prescribing potassium preparations:

• Potassium preparations can be administered only under control of its content in the blood serum;
• Potassium preparations cannot be used undiluted due to the risk of developing ventricular fibrillation and cardiac arrest (dilution principle: no more than 1.5-2 g of potassium must be added to 500 ml of the main solution, and immediately before use);
• use potassium preparations with extreme caution in patients with impaired renal function, since the drug is not excreted by damaged kidneys;
• take into account the potassium content in other potassium-containing preparations (for example, fresh frozen plasma, hemodesis, etc.).

Usually, in the first hour we introduce 0.8-1 g of potassium, then gradually at 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. Use of protease inhibitors that significantly change the proteolytic activity of the blood, eliminate hemocoagulation disorders, and potentiate the action of antibiotics. Daily doses of Gordox are 300,000-500,000 U, Contrikal - 800,000-1,500,000 U, and Trasylol 125,000-200,000 U.
6. Heparin therapy 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 reduction and withdrawal of the drug when the patient's condition and coagulogram and aggregogram parameters improve. More effective is the administration of prolonged low-molecular analogues of heparin - fraxiparin at 0.4 ml once a day or clexane at a dose of 20 mg (0.2 ml) once a day.
7. Treatment with glucocorticoids. There are currently polar opinions on the need to use hormones. Clinical experience shows that prescribing prednisolone in a daily dose of 90-120 mg with a gradual reduction and withdrawal of the drug after 5-7 days significantly improves the course of the postoperative period.
8. To normalize aggregation, microcirculation and accelerate reparative processes, all patients are also shown the use of disaggregants (antiaggregants). Rheopolyglucin is included in the infusion therapy, and curantil (trental) is also used. The latter is included in infusion media at an average of 100-200 mg / day, and if necessary (impossibility of using direct anticoagulants), the dose can be increased to 500 mg / day with gradual introduction of the drug.
9. We use therapy for liver (Essentiale, Karsil, antispasmodics) and cardiac (cardiac glycosides; drugs that improve myocardial trophism) disorders. Nootropil or Cerebrolysin is used to improve brain function.
10. Symptomatic therapy includes the administration of vitamins, drugs that improve metabolic processes in cells and tissues and regulate oxidation-reduction processes.
11. Extracorporeal detoxification methods are used according to indications.

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