Clinical practice indicates that in some cases after surgical intervention it is necessary to perform drainage abdominal cavity.
This method is used to remove liquid contents that accumulate in hollow organs, wounds and ulcers.
The procedure ensures the creation of favorable conditions for the recovery of the body after surgery.
Surgical methods for treating abdominal organs are always accompanied by the risk of serious complications.
To avoid negative consequences, it is necessary to carefully prepare for the operation. No less important is post-operative care for the sick.
Upon completion of the operation, sanitation of the cavity and drainage are performed to drain intra-abdominal fluid or pus.
Drainage is effective means rehabilitation of the patient after surgical treatment purulent or fecal peritonitis, as well as other diseases.
In some cases, this method is used for preventive purposes to avoid relapse of the pathology.
The accumulation of biological fluids in the abdominal cavity, which are called effusion or exudate, is considered a sign that an inflammatory process is occurring in the body.
Actually, as a result of inflammation of the peritoneum, effusion is released. These fluids contain dead cells, minerals and pathogenic microbes.
If measures are not taken to remove them, inflammation will develop.
Today, drainage is considered the most effective method for creating favorable conditions for healing and restoration of the body after surgery.
Sanitation of the abdominal cavity is carried out after any surgical intervention. Most in an efficient way For this purpose drainage is considered.
Today, the attending physician has the following types of drainage:
For physiological drainage of the abdominal cavity, laxatives are used.
Prescribed medications increase intestinal motility, thereby promoting the removal of fluid from the body.
For the procedure to bring the expected result, the patient must be in a supine position.
The lower part of the body must be raised in order to evenly redistribute the fluid over the area of the peritoneum.
Experts have long known that fluid accumulation occurs in certain spaces of the abdominal cavity.
If this substance is not removed in a timely manner, it will serve as the basis for the development of inflammation. In such cases, surgical drainage is used.
The method involves the use special tubes, which are introduced into the cavity and ensure the outflow of fluid outward.
In this case, it is necessary to ensure that the patient is positioned in such a way that the fluid does not stagnate in the sinuses and pockets, but flows out of the abdominal cavity.
Most often this is a semi-sitting position, which creates excess internal pressure.
Clinical practice proves that drainage must be carried out not only after abdominal surgery, but also after laparoscopy.
In each specific case, the successful completion of the procedure is determined by the following conditions:
Each of the listed factors has a certain impact on ensuring timely and complete outflow of exudate.
IN emergency situations Temporary use of improvised means is allowed, but this should not be taken as a rule.
Currently technical means for drainage of the abdominal cavity are represented by a wide range of products.
The list includes the following elements:
An important condition for the procedure is to ensure the sterility of the instrument. Sanitation of the abdominal cavity ensures the elimination of infectious foci.
If sterility is compromised when installing tubes, the likelihood of relapse of the pathology increases sharply. The most vulnerable point in this regard is the point of contact between the tube and the skin.
According to current methods, drainage is recommended during abdominal laparoscopy.
After surgery to eliminate a certain pathology, it is very important to ensure the drainage of purulent residues.
Practice shows that rubber tubes very quickly become clogged with pus and do not perform their functions.
The tube diameter is selected from 5 to 8 mm depending on the installation location.
Today, new drainage devices have appeared that are gradually replacing the usual tubes.
In order for abdominal drainage to bring the expected results, it is very important to determine the area for installation of drainage.
The location of fluid accumulation depends on the type of pathology and anatomical features sick. Taking these circumstances into account, the appropriate area for drainage is determined by the attending physician.
Over the years, the practice has been to place tubes in front of the lower wall of the diaphragm or at the anterior wall of the stomach.
Once the installation location has been determined, a simple but responsible procedure is performed. The insertion site of the tube is thoroughly disinfected with an antiseptic solution.
After antiseptic treatment, a small incision is made in the wall of the abdominal cavity, a clamp is inserted into this incision, and a drainage tube is inserted into the cavity through the clamp.
It is very important to securely fix the clamp so that it does not fall out when the patient moves.
Drainage is installed in a similar way during laparoscopy. After this, effective drainage must be ensured.
When the tube has completed its functions, it is carefully removed. It must first be clamped to prevent infection from entering the abdominal cavity.
The abdominal drainage procedure is not medical procedure. It is performed to ensure the recovery and rehabilitation of the patient after surgical treatment.
Infectious diseases internal organs don't always give in therapeutic methods treatment.
To avoid serious complications or fatal outcome, surgical operations are performed.
The peculiarity of the surgical treatment method is that the underlying pathology is eliminated.
While restoration and rehabilitation of the body require a long period of time, and not only time, but also certain actions.
First of all, it is necessary to remove biological fluid from the abdominal cavity, the remains of which are located in different places.
Removal is performed using drainage after operations for various reasons. It could be acute appendicitis, chronic pancreatitis or cholecystitis.
Stomach ulcers are most effectively treated surgically, as well as intestinal obstruction. In each case of surgical intervention, drainage must be performed at the final stage.
The installed drainage significantly limits the patient's freedom of movement. This limitation must be put up with and endured in order for recovery to occur in accordance with the prognosis.
The abdominal cavity is considered the most vulnerable organ in human body for microbes and viruses.
When performing drainage, you must remember this and comply with all sterility requirements.
Before suturing rupture of the intra-abdominal part of the bladder it is necessary to carefully inspect the wall bladder from the inside to prevent damage to other areas. Ruptures of the extraperitoneal part of the bladder usually have a longitudinal direction, and therefore damage to the wall should be sought by pushing apart the thick folds of the contracted bladder. To do this, a finger is inserted into its cavity, which slides along the back wall and with the help of which the location and size of the defect are determined.
In case of damage only retroperitoneal part of the bladder it should be opened in the area of the anterior wall between the two previously applied holders (this incision is then used to apply an epicystostomy). It is more convenient to perform the revision from the inside, since the peri-vesical tissue on the side of the rupture is sharply infiltrated. After this, the peri-vesical tissue is widely opened in the area of the rupture, the necrotic tissue is removed and a double-row suture is applied to the defect of the bladder without suturing the mucous membrane. Tears located low (at the base of the bladder) are also more convenient to be sutured from the inside.
When suturing bladder ruptures use a double-row suture, and the inner row of sutures is applied without grasping the mucous membrane to avoid crystallization urinary stones on areas of suture material located in the lumen of the bladder.
In men, the operation is completed by applying epicystostomy. In women, you can limit yourself to installing a permanent catheter. Drainage of peri-vesical tissue in case of retroperitoneal ruptures is carried out by removing the drainage tube through the counter-aperture on the anterior abdominal wall if constant aspiration can be established. If this is not possible, the peri-vesical tissue should be drained from below through the obturator foramen (according to Buyalsky-McWhorter). If the anterior wall of the bladder is damaged, drainage of the prevesical tissue is indicated.
Having completed the intervention on damaged organs, it is necessary to quickly and atraumatically remove all clots and blood residues from the abdominal cavity, intestinal contents and urine. To do this, sequentially examine the right and left subphrenic spaces, both lateral canals, the pelvic cavity and, finally, both mesenteric sinuses (on both sides of the root of the mesentery of the small intestine). The liquid contents are removed with an electric suction, and the clots with tuffers. Fixed clots and fibrin are washed by pouring a warm isotonic sodium chloride solution or an antiseptic solution into the abdominal cavity and then removing this solution with an electric suction. The temperature of the solution should not be higher than 37-38 °C.
For more effective sanitation one assistant lifts the edges of the laparotomy wound, the second pours 1.5-2 liters of solution into the abdominal cavity at once, and the surgeon “rinses” the intestinal loops and the greater omentum in this solution for 1-2 minutes. The procedure is repeated until the washing liquid becomes clear.
Application for draining the abdominal cavity using only gauze pads and napkins is a gross mistake, since this causes injury to the peritoneum, which leads to the development adhesive process, damage and infection of the peritoneum.
When draining the abdominal cavity one should take into account the characteristics of the spread of infected fluid and its possible accumulation, and be guided by the anatomical topography of the peritoneum. Thus, in case of trauma to the abdominal organs, not complicated by peritonitis, one drain is brought to the area of the sutured injury or the resection zone, the second is inserted into the corresponding lateral canal or into the small pelvis.
In case of peritonitis, drain pelvic cavity, lateral canals and subphrenic space on the right and/or left.
Abdominal drains must be removed only through separate punctures abdominal wall. They do it as follows. Based on the expected position of the drainage (make sure that the drainage does not bend sharply when passing through the abdominal wall), the surgeon pierces the skin with a pointed scalpel, and then, replacing the scalpel with a hemostatic clamp, pierces the entire thickness of the abdominal wall with a clamp from the outside inward and obliquely in the direction of the drainage. At the same time, another with a hand inserted into the abdominal cavity to the puncture site, the surgeon protects the intestinal loops from damage by the clamp. The obliquely cut outer end of the drainage is grabbed with a clamp from the side of the abdominal cavity and removed along the required length, controlling the position of the drainage and its side holes with the hand in the abdominal cavity. Each drainage tube must be securely fixed with a strong ligature to the anterior abdominal wall, since accidental and premature loss of drainage can cause serious problems in the further treatment of the victim.
Drainage, excreted from the abdominal cavity, cannot be left open if its length does not allow the outer end of the tube to be immediately lowered below body level. If the drainage tube is short, then with each respiratory movement, a column of liquid located in the lumen of the drainage moves from the abdominal cavity and into the abdominal cavity, creating all the conditions for its infection. Therefore, the lumen of short drainages is temporarily blocked with clamps or ligatures; such drainages are extended as soon as possible.
To create effective system drainage the outer end of the drainage should be 30-40 cm below the level of the lowest point of the abdominal cavity.
Novocaine blockade of reflexogenic zones.
Optimal access to all parts of the abdominal cavity is provided by a median laparotomy, since depending on the location of the lesion, the abdominal wall wound can be expanded upward or downward. If widespread peritonitis is detected during an operation performed from a different incision, then you should switch to a median laparotomy.
Up to 100.0 ml of 0.5% novocaine solution is injected into the area of the celiac trunk, the root of the transverse mesentery, thin and sigmoid colon, which ensures a reduction in the need for narcotic analgesics, eliminates reflex vascular spasm, thereby creating conditions for an earlier restoration of peristalsis.
3. Elimination or reliable isolation of the source of peritonitis
In the reactive phase it is possible to carry out radical operations(gastric resection, hemicolectomy) since the likelihood of anastomotic failure is insignificant.
In toxic and terminal cases, the scope of the operation should be minimal - appendectomy, suturing the perforation, resection of the necrotic area of the gastrointestinal tract with the application of entero- or colostomy, or delimitation of the lesion from the free abdominal cavity. All reconstructive operations are transferred to the second stage and performed in more favorable conditions for the patient.
Washing reduces the content of microorganisms in the exudate below a critical level (10 5 microbial bodies in 1 ml), thereby creating favorable conditions for eliminating the infection. Tightly fixed fibrin deposits are not removed due to the risk of deserosis. Removing exudate by wiping with gauze wipes is unacceptable due to trauma to the serous membrane.
The washing liquid must be isotonic. The use of antibiotics does not make sense, since short-term contact with the peritoneum cannot have the desired effect on the peritoneal flora.
Most antiseptics have a cytotoxic effect, which limits their use. The electrochemically activated sodium chloride solution (0.05% sodium hypochlorite) does not have this drawback; it contains activated chlorine and oxygen, therefore it is especially indicated in the presence of anaerobic flora. Some clinics use ozonated solutions.
In toxic and terminal stages peritonitis, when intestinal paresis becomes independent clinical significance carry out nasogastrointestinal intubation of the small intestine with a vinyl chloride probe.
The length of intubation is 70-90 cm distal to the ligament of Treitz. If necessary, the colon is drained through the anus.
In rare cases, a gastro-, jejuno-, or appendicostomy is applied to insert the probe.
IN postoperative period probe correction of the enteral environment is carried out, including decompression, intestinal lavage, enterosorption and early enteral nutrition. This reduces the permeability of the intestinal barrier to microflora and toxins, leading to early restoration of the functional activity of the gastrointestinal tract.
6. Drainage of the abdominal cavity is carried out using vinyl chloride or rubber tubes, which are brought to the purulent focus and brought out through the shortest route.
In Fig. Option for drainage of the abdominal cavity in case of destructive appendicitis, non-limited local peritovitis. Options for drainage of the abdominal cavity for widespread and general peritonitis [from. V.K. Gostishchev “Operative purulent surgery”, M. Medicine, 1996], for lavage.
7. The laparotomy wound is sutured leaving drainage in the subcutaneous fatty tissue.
Treatment of residual infection depends on the technique used to complete the operation. These are different ways of dealing with residual (residual) infection, related to methods of drainage of the abdominal cavity, or, more precisely, methods of removing exudate and other infected and toxic contents from the abdominal cavity.
1. Suturing the wound tightly without drainage, hoping that the peritoneum itself will cope with the remaining infection. can be used only for local non-limited serous peritonitis with a non-critical level of bacterial contamination, in the absence of the risk of the formation of abscesses and infiltrates. Under these conditions, the body can suppress the infection itself or with the help of antibiotic therapy.
2. suturing the wound with passive drainage. Drains are also used for local administration of antibiotics.
3. suturing with drainage for lavage (flow-through and fractional). The method is practically not used due to the complexity of correcting protein and electrolyte disturbances and a decrease in effectiveness after 12-24 hours of use.
4. bringing the edges of the wound closer together (semi-closed method) with the installation of drainage back wall br.pol., for dorsoventral lavage with aspiration of flowing fluid through the median wound.
5. bringing the edges of the wound closer together using various devices with repeated revisions and sanitation. We use the term planned laparoscopic debridement. The indication for use is the presence of a pronounced adhesive process in severe forms of purulent-fibrinous peritonitis with sub- and decompensation of vital functions important organs. The number of revisions is from 2-3 to 7-8. Interval from 12 to 48 hours.
6. open method (laparostomy according to N.S. Makokha or Steinberg-Mikulich) for the purpose of drainage of exudate through the wound covered with tampons with ointment. When changing tampons, it is possible to monitor the condition of the intestinal loops adjacent to the wound. It should be used in the presence of multiple unformed intestinal fistulas, extensive wound suppuration or phlegmon of the abdominal wall.
GENERAL TREATMENT.
Antibacterial therapy
The most adequate regimen of empirical antibacterial therapy (before microbiological verification of the pathogen and determination of its sensitivity to antibiotics) is a combination of synthetic penicillins (ampicillin) or cephalosporins with an aminoglycoside (gentamicin or vancocin) and metronidazole. This combination acts on almost the entire spectrum of possible pathogens of peritonitis.
Upon receipt of a bacteriological analysis, the appropriate combination of antibiotics is prescribed
Routes of administration:
1) local (intra-abdominal) - through irrigators, drainages (dual-purpose drainage).
a) Intravenous
b) Intra-arterial (intra-aortic, c celiac trunk, into the mesenteric or omental arteries)
c) Intramuscular (only after restoration of microcirculation)
d) Intraportal - through recanalized umbilical vein in the round ligament of the liver.
d) Endolymphatic. Anterograde - through a microsurgically catheterized peripheral lymphatic vessel on the dorsum of the foot or a pulpless inguinal lymph node. Retrograde - through the thoracic lymphatic duct. Lymphotropic interstitial - through the lymphatic network of the lower leg, retroperitoneal space.
Immune therapy.
Among the drugs that improve the immunoreactive properties of the body, immunoglobulin, antistaphylococcal g-globulin, leukocyte mass, antistaphylococcal plasma, leukinferon - a complex of human interferons and cytokines are used.
The use of pyrogenal, decaris (levamisole), prodigiosan, thymalin and other “drugs that stimulate weakened immunity” in malnourished patients, according to many authors, is contraindicated.
Corrective therapy in the postoperative period
Adequate pain relief.
Along with traditional ways treatment of pain using narcotic analgesics, prolonged epidural analgesia is used local anesthetics, acupuncture, electroanalgesia.
Balanced infusion therapy.
Total quantity the fluid administered to the patient during the day consists of physiological daily needs (1500 ml/m2), water deficiency at the time of calculation and unusual losses due to vomiting, drainage, increased sweating and hyperventilation.
Prevention and treatment of multiple organ failure syndrome
The pathogenetic basis for the development of MOF syndrome is hypoxia and cell hypotrophy due to impaired respiration, macro- and microhemodynamics.
Measures for the prevention and treatment of MODS are:
· Elimination of infectious-toxic source.
· Removal of toxins using efferent surgery methods.
· Ensuring adequate pulmonary ventilation and gas exchange (often long-term mechanical ventilation).
· Stabilization of blood circulation with restoration of blood volume, improvement and maintenance of heart function. Normalization of microcirculation in organs and tissues.
· Correction of protein, electrolyte, acid-base composition of blood.
· Parenteral nutrition.
Restoration of gastrointestinal function
The most effective way to restore gastrointestinal motility is intestinal decompression with a transnasal probe followed by rinsing it.
Normalization nervous regulation and restoration of intestinal muscle tone is achieved by replenishing protein and electrolyte imbalances. After which it is possible to use anticholinesterase drugs (prozerin, ubretide), ganglion blockers (dimecoline, benzohexonium).
For MOF, the use of forced diuresis, hemodialysis, plasmapheresis, hemofiltration through pig organs (liver, spleen, lungs), mechanical ventilation, and HBO is indicated.
HBOT is capable of stopping all types of hypoxia that develop during peritonitis, helps to accelerate the reduction of bacterial contamination of the peritoneum, and enhances the motor-evacuation function of the intestine.
Hemosorption, lymphosorption, plasmapheresis and other detoxification methods cannot be considered as independent methods of treating peritonitis that provide significant advantages.
It is necessary to place emphasis on the prevention of endotoxemia using methods to combat residual infection ( surgical methods and antibacterial therapy).
Most low indicators mortality is achieved with the use of planned laparosanations (20%).
According to inst. Them. Vishnevsky in the treatment of a homogeneous group of patients with peritonitis of appendicular origin with closed drainage years = 24%, with staged lavage 12%. The frequency of abscesses during dialysis and drainage = 27 and 26.6%, with staged washing - 4%. The frequency of sepsis with staged lavage is 12.2%, with drainage and lavage the same - 31%.
In case of widespread purulent peritonitis, a median laparotomy, evacuation of exudate, and elimination of the source of peritonitis are sequentially performed. Exudate, bile, pus, urine, gastric and intestinal contents are removed using an electric suction, the source of infection is isolated with large napkins and eliminated.
The affected organ (vermiform appendix, gallbladder) is removed, the hole in the intestine, stomach is sutured, necrectomy is performed for pancreatic necrosis, obstructive resection of the colon, etc. The desire for radical intervention (gastric resection, gastrectomy, colon resection, etc.) in conditions of widespread peritonitis is contraindicated and is strictly commensurate with the severity of the condition patient and the severity of the purulent-destructive process in the abdominal cavity.
The abdominal cavity is washed with solutions of antiseptics - sodium hypochlorite, potassium furagin, dioxidine, as well as isotonic solution sodium chloride with ultrasonic cavitation and subsequent aspiration of liquid with an electric suction until " clean water" For sanitation of the abdominal cavity, only solutions that can be administered intravenously are acceptable, as this avoids intoxication caused by the absorption of drugs into the blood.
The procedure is repeated several times, consuming from 2 to 7 liters of liquid. The cavity is filled to the edges of the wound with a solution at body temperature, the intestinal loops and omentum are moved into the cavity with light movements, and then the contents are aspirated with an electric suction, also removing it from under the diaphragm, from the lateral canals, the small pelvis, and the omental bursa.
Drainage of the stomach and intestines is an integral component of the treatment of patients. A nasogastric tube must be inserted. The issue of total intubation of the small intestine is decided individually. With severe paresis jejunum with inflated fibrin-coated loops, nasointestinal intubation is performed, passing the probe beyond the Treitz ligament to a distance of 60-80 cm.
If the entire small intestine is sharply distended, its diameter exceeds 5 cm, overflowing with liquid contents with toxic products of putrefaction and fermentation throughout, the serous membrane is covered with massive deposits of fibrin, with hemorrhages, or the operation was performed for peritonitis with mechanical intestinal obstruction, or was accompanied by dissection extensive adhesions, decompression of the small intestine is indicated by total intubation using a Miller-Abbott probe.
With any type of intubation of the small intestine, a separate probe is inserted into the stomach, since with a gaping pyloric canal, due to the intestinal probe passing through it, intestinal contents flow into the stomach and can cause vomiting, regurgitation, and aspiration.
The residence time of the probe is determined by the presence of discharge through it and the appearance of peristaltic bowel sounds. Usually this is 3-4 days after surgery. During total splinting of the small intestine during operations for peritonitis and intestinal obstruction, the probe is left in place for up to 7 days, if necessary.
If it is impossible to perform nasointestinal intubation of the small intestine, retrograde intubation through an ileostomy is used. On ileum A purse-string suture is placed 20-80 cm from the ileocecal angle and a Miller-Abbott type drainage tube is inserted through the puncture and passed in a retrograde direction to the Treitz ligament. The purse-string suture is tightened and the intestine at the site of drainage is fixed to the abdominal wall. It is possible to carry out drainage into the colon through a gastrostomy tube in the same way technical method. In all cases, a nasogastric tube is inserted.
Complete sanitation of the abdominal cavity during surgery is not always possible due to technical difficulties caused by destructive process in the abdominal cavity and disruption of organ relationships. This requires withdrawal pathogenic microflora, toxic products inflammation, fibrin, pus from the abdominal cavity and in the postoperative period, especially since the inflammatory process in the peritoneum continues after elimination or isolation of the source of infection.
Count on protective forces peritoneum with a blind suture of the abdominal cavity, with advanced forms of peritonitis is not necessary due to the development of purulent complications and further progression of peritonitis.
Even with a favorable course inflammatory process Toxic exudate accumulates in the abdominal cavity after surgery. Absorbed into the blood, it helps maintain toxicosis.
Indications for drainage of the abdominal cavity during peritonitis are determined primarily by inflammation of the peritoneum (form, extent, stage of the process). Drainage tubes with peritonitis quickly become delimited, their lumen closes, and they cease to function. The use of gauze swabs as drainage is not only ineffective in conditions of widespread peritonitis, but also harmful. Adhesions quickly form around the tampons, and a significant inflammatory reaction develops.
Communication with the free abdominal cavity stops, tampons become a kind of “plugs” that clog the holes in the abdominal wall and contribute to the accumulation of exudate. The use of glove, glove-gauze and tubular-glove drainages is possible for local peritonitis.
Sanitation of the abdominal cavity after surgery is determined by its drainage. There are three types of drainage systems: fixed drainage systems— passive drainage with spontaneous discharge of exudate; fixed drainage systems using multiple drainage tubes and active influence on the source of inflammation in the abdominal cavity (washing, active aspiration); staged sanitation using laparostomy.
With passive drainage, upper and lower drainages are installed to evacuate exudate, and rubber-gauze drainage is installed to expand the drainage channel area.
To actively influence the source of inflammation, two upper drains are placed in the upper floor of the abdominal cavity - under the liver on the right and under the diaphragm on the left, the other two are installed in the side canals of the abdominal cavity and a drainage for evacuating exudate from the pelvis. If necessary, drains can be installed in various departments abdominal cavity depending on the prevalence of peritonitis.
Options for drainage of the abdominal cavity with widespread peritonitis (a, b, c)
Drainage of the abdominal cavity in case of widespread peritonitis for peritoneal lavage (a, b, c). Use drainage tubes and cigarette drains
a - effective lavage; b, c - decrease in efficiency
Indications for laparostomy:
. widespread peritonitis III—IVА, IVB stages with severe endogenous intoxication, multiple organ failure;
. widespread or limited peritonitis with necrosis of the abdominal organs or retroperitoneal tissue;
. anaerobic peritonitis;
. delayed relaparotomy for postoperative peritonitis, both with a tendency to delineate multiple foci of inflammation in various parts of the abdomen, and with a widespread process;
. eventration with widespread peritonitis through purulent wound, and also when high risk eventration (suppuration of the surgical wound with necrosis of the skin, muscles, aponeurosis).
There is a simple and affordable method using a zipper (zipper-laporostomy). This option of laparostomy allows you to control inflammation in the abdominal cavity and perform staged sanitation and necrectomy.
After wide laparotomy (relaparotomy) and elimination of the source of peritonitis and sanitation of the abdominal cavity, the subhepatic and subphrenic spaces and the small pelvis are drained. To temporarily close the abdominal cavity, industrial zippers with a length of at least 30 cm and a width of each half of 2-2.5 cm are used. Vinyl chloride tubes are sewn to the edges of the zipper, washed thoroughly, rinsed and stored until use. alcohol solution chlorhexidine.
Before fixing to the skin, the zipper is separated and alternately sutured behind a fixed tube to the edges of the surgical wound. The detachable parts are fixed using U-shaped skin sutures, 2-2.5 cm away from the edges of the wound. After commit individual parts When zippers are applied to the skin, an omentum is placed on the intestinal loops, and a napkin moistened with an antiseptic is placed between the walls of the wound to prevent damage to the adjacent intestinal loops by the zipper.
The program for postoperative management of patients with widespread peritonitis during laparostomy includes: choosing a rational method of pain relief; multiple dressings with revision of the abdominal cavity, anastomotic area, former source of infection and rinsing with an antiseptic solution; necrectomy, prevention and localization of complications in the abdominal cavity; suturing a laparotomy wound.
For planned sanitation during laparostomy, local anesthesia is used - epidural anesthesia (extended); intravenous, inhalation (mask and intubation anesthesia). Indications for intubation anesthesia include the possibility of breathing problems during routine sanitation of the abdominal cavity; refusal of repeated use of mask and intubation anesthesia has a positive moral impact on the patient and his relatives.
The first sanitation with revision of the abdominal cavity is carried out in the operating room, 15-20 hours after the intervention. Open the zipper, remove the gauze pad, inspect the edges of the wound, separate the loose adhesions between the edges of the dissected aponeurosis and the adjacent loops of intestine or omentum. The abdominal cavity is inspected and up to 2-3 liters of antiseptic solution are injected into it.
In other cases, with successful first sanitation, they are repeated according to the state of the inflammatory process, general condition sick. The disappearance of purulent exudate, subsidence of inflammatory phenomena, restoration of intestinal motility are indications for removing the laparostomy and suturing the abdominal wall wound. The wound is sutured through all layers using Donati sutures. Carry out 2-4, in extremely severe cases - 8-10 stage sanitation.
An increase in intra-abdominal pressure with widespread peritonitis is caused by intestinal paresis, its overdistension with gases, liquid contents, and accumulation of fluid in the abdominal cavity. High intra-abdominal pressure causes serious dysfunction of organs and systems; this is called abdominal compartment syndrome.
These changes are expressed in a disorder of cardiovascular activity (displacement of the heart as a result of movement of the diaphragm, a decrease in cardiac output, a decrease in visceral blood flow, including renal, an increase in pressure in the inferior vena cava and hepatic veins, an increase in central venous pressure). The gas exchange function of the lungs is disrupted due to increased intrathoracic pressure, disruption of respiratory excursions of the lungs, decreased tidal volume, etc.
To reduce intra-abdominal pressure in widespread peritonitis, it is advisable to complete the operation by suturing the skin without suturing the aponeurosis, and during laparostomy using a zipper, fix the zipper to the hemmed vinyl chloride tube with intradermal sutures.
A comprehensive treatment program for patients with purulent peritonitis is carried out taking into account the stage of toxicosis.
For grade I endotoxemia, traditional infusion-transfusion therapy aimed at correcting homeostasis, as well as conventional intracorporeal detoxification using detoxifying blood substitutes and forced diuresis, are sufficient. With concomitant hepatic-renal failure, ultraviolet blood irradiation and hemosorption are indicated as efferent methods.
For stage II endotoxemia, in addition to traditional corrective therapy and intracorporeal detoxification, plasmapheresis, hemofiltration, and their combination are advisable.
For grade III endotoxicosis, programmed sanitation of the abdominal cavity, infusion-transfusion corrective therapy, and decompression are indicated gastrointestinal tract, programmed sessions of efferent detoxification and hemocorrection: programmed UVOC, plasmapheresis, hemofiltration.
Hemofiltration for peritonitis removes toxins from plasma, interstitial fluid and cells. In this case, there is no trauma to cellular elements, minimal loss of protein and immunity to immune factors occurs. Sessions of efferent detoxification methods are carried out under the dynamic control of homeostasis indicators and general toxicity tests.
Undoubtedly, all these are emergency methods, but the urgent start of extra-organ elimination of toxic products from the body’s environments should not be followed by a quick end to this type of treatment. It should be taken into account that in case of widespread peritonitis, the source of intoxication is first the focus purulent inflammation, organ destruction. After its elimination, the main source of intoxication remains the inflamed parietal and visceral peritoneum.
Even with a favorable course of peritonitis, considerable time is required to eliminate inflammation of the peritoneum and resolve visceritis. Against the background of a deep disturbance of microcirculation and impaired absorption, conditions are created for toxic products to enter the internal environment of the body in significant quantities. The inclusion of the mechanism of artificial purification of blood and lymph during this period provides a certain time for maintaining and restoring the function of the organs of the body’s natural detoxification system.
An important principle of detoxification is a combination of abdominal sanitation, intestinal intubation and efferent detoxification methods.
IN modern conditions gram-positive microflora - staphylococcus and streptococcus - in monoculture are highly sensitive to a wide range of antibiotics.
At the same time, to suppress staphylococcal infection, it is more rational to use semi-synthetic drugs: methicillin, ampicillin, carbenicillin, ampiox and aminoglycosides - gentamicin, kanamycin, tobromycin, amikacin. The sensitivity of the isolated staphylococcal microflora to these antibiotics is 62.5-100%.
To suppress streptococcal infection in general, the range of antibiotics used can be expanded by introducing penicillin, oleandomycin, lincomycin, etc. Significantly less sensitivity is observed when isolating fecal streptococcus, but even in these cases, more hope can be placed on gentamicin, carbenicillin, tobromycin, amikacin. sensitivity to which significantly exceeds 80%.
The spectrum of antibiotic-sensitive gram-negative microflora is significantly narrowed. Escherichia coli sensitive in 60-95.2% to carbenicillin, gentamicin, amikacin. Proteus and Pseudomonas aeruginosa remain sensitive to gentamicin, tobromycin, amikacin and, less commonly, carbenicillin. For microbial associations, the combined use of antibiotics is more effective.
When selecting antibiotics, their distribution in the body is taken into account, as well as the possibility of interaction, since the synergistic, antagonistic and indifferent effects of antibiotics are known. The best option is a combination of drugs with a synergistic effect. In this case, drugs with different mechanisms of action should be selected (but the sensitivity of the microflora should remain high to all selected antibiotics), and contraindications to certain antibiotics should be taken into account.
In modern conditions, for purulent peritonitis, aminoglycosides (gentamicin, amikacin, tobromycin), third-fourth generation cephalosporins, carbopenems, metronidazole, dioxidine are most often used.
Various options for the course of the inflammatory process in the abdominal cavity, depending on the nature of the pathogen and the degree of endotoxemia, make it possible to establish the basic clinical and microbiological parameters for the selection of antibacterial drugs even before identifying the microflora and determining sensitivity to antibiotics.
In extremely severe patients, MIP > 20, SAPS > 8 points, empirical antibiotic therapy begins with reserve antibiotics that have wide range action and minimal toxicity. These are fourth generation cephalosporins, carbopenems. Carbopenems are ideal drugs for empirical monotherapy: they cover the entire spectrum of pyogenic flora (aerobes + anaerobes), and the sensitivity of microbial flora to them is high. If this therapy turns out to be effective, then it should not be corrected based on the results of a microbiological study.
Main performance criteria various options antibacterial therapy: body temperature, leukocytosis, dynamics of bacterial contamination of the abdominal cavity, frequency of reinfection or lack of microflora growth.
Among the complications of antibiotic therapy for peritonitis, the Jarisch-Herxheimer reaction occurs. Clinically, this reaction is manifested by high (up to 39.5 ° C), often hectic fever, pale skin, dry mucous membranes, tongue, high leukocytosis, shift of the blood count to the left and toxemia. Often such a reaction against the background of improvement in the patient’s condition has no logical explanation. They change the antibiotic, increase its dose, and prescribe new combinations of drugs. However, the essence of such an exacerbation reaction lies in the development of a new wave of endogenous toxicosis, up to toxic shock as a result of the bactericidal action of antibiotics.
Irrational antibacterial therapy, unfounded long-term use antibiotics in patients with peritonitis disrupt the natural balance of microflora. The influence of antibiotic-resistant flora is increasing. The spectrum of action of the drugs should be taken into account. Otherwise, superinfection occurs, i.e. as a result of therapy occurs new disease with special clinical manifestations.
The causative agents of the infection can be natural inhabitants of the body, fungi, hospital flora. A similar condition is regarded as “tertiary peritonitis”. Essentially it is a dysbacteriosis, often caused by methicillin-resistant Staphylococcus aureus. Vancomycin and teicoplakin are indicated. For superinfection caused by a stick of blue-green pus, carbopenems (namely, meropenem) are effective.
System fungal infection occupies a significant place as a manifestation of dysbacteriosis. It causes fungal infection of organs, the development of candidiasis up to candidasepsis. The main symptom of this complication is dyspeptic disorders. A reliable diagnosis can be established only by microbiological examination and determination of the ratio of natural intestinal microflora.
Treatment and prevention of the described complications of antibacterial therapy takes important place with severe peritonitis, abdominal sepsis. Differential diagnosis Jarisch-Herxheimer reactions with developing purulent complications presents known difficulties. If the course of inflammation is favorable and body temperature is normalized, and then significant fluctuations suddenly appear, antibiotics should be discontinued for 2-3 days.
If this cannot be done due to the severity of the patient’s condition and intractable inflammation, the combination of antibiotics is changed, reducing their use to a minimum, and sulfonamides and nitrofuran drugs are used. Of the quinoxaline derivatives, dioxidin is effective.
After 9-10 days of massive antibacterial therapy for peritonitis, more attention should be paid to the prevention of these complications, without waiting for the development of candidiasis or other dysbacteriosis. Complex therapy provides for full protein nutrition, vitamins C, group B, multivitamins. As a means specific protection antifungal drugs are used antibacterial drugs: nystatin, levorin, fluconazole.
An important role in the treatment of dysbiosis is played by the restoration of the natural intestinal microflora. For these purposes, colibacterin, bifidumbacterin or bificol are prescribed. There are certain indications for the use of each drug, which are clarified after microbiological research feces
In case of widespread purulent peritonitis, a median laparotomy, evacuation of exudate, and elimination of the source of peritonitis are sequentially performed. Exudate, bile, pus, urine, gastric and intestinal contents are removed using an electric suction, the source of infection is isolated with large napkins and eliminated.
The affected organ (appendix, gallbladder) is removed, the hole in the intestine, stomach is sutured, necrectomy for pancreatic necrosis, obstructive resection of the colon, etc. are performed. The desire for radical intervention (gastric resection, gastrectomy, resection of the colon, etc.) in conditions of widespread peritonitis is contraindicated and is strictly commensurate with the severity of the patient’s condition and the severity of the purulent-destructive process in the abdominal cavity.
The abdominal cavity is washed with solutions of antiseptics - sodium hypochlorite, potassium furagin, dioxidine, as well as an isotonic solution of sodium chloride with ultrasonic cavitation and subsequent aspiration of the liquid with an electric suction to “clean water”. For sanitation of the abdominal cavity, only solutions that can be administered intravenously are acceptable, as this avoids intoxication caused by the absorption of drugs into the blood.
The procedure is repeated several times, consuming from 2 to 7 liters of liquid. The cavity is filled to the edges of the wound with a solution at body temperature, the intestinal loops and omentum are moved into the cavity with light movements, and then the contents are aspirated with an electric suction, also removing it from under the diaphragm, from the lateral canals, the small pelvis, and the omental bursa.
Drainage of the stomach and intestines is an integral component of the treatment of patients. A nasogastric tube must be inserted. The issue of total intubation of the small intestine is decided individually. In case of severe paresis of the jejunum with swollen loops coated with fibrin, nasointestinal intubation is performed, passing the probe beyond the Treitz ligament to a distance of 60-80 cm.
If the entire small intestine is sharply distended, its diameter exceeds 5 cm, overflowing with liquid contents with toxic products of putrefaction and fermentation throughout, the serous membrane is covered with massive deposits of fibrin, with hemorrhages, or the operation was performed for peritonitis with mechanical intestinal obstruction, or was accompanied by dissection extensive adhesions, decompression of the small intestine is indicated by total intubation using a Miller-Abbott probe.
With any type of intubation of the small intestine, a separate probe is inserted into the stomach, since with a gaping pyloric canal, due to the intestinal probe passing through it, intestinal contents flow into the stomach and can cause vomiting, regurgitation, and aspiration.
The residence time of the probe is determined by the presence of discharge through it and the appearance of peristaltic bowel sounds. Usually this is 3-4 days after surgery. During total splinting of the small intestine during operations for peritonitis and intestinal obstruction, the probe is left in place for up to 7 days, if necessary.
If it is impossible to perform nasointestinal intubation of the small intestine, retrograde intubation through an ileostomy is used. A purse-string suture is placed on the ileum 20-80 cm from the ileocecal angle and a Miller-Abbott type drainage tube is inserted through the puncture and passed in a retrograde direction to the Treitz ligament. The purse string suture is tightened and the intestine at the site of drainage is fixed to the abdominal wall. It is possible to carry out drainage into the colon through a gastrostomy tube using a similar technique. In all cases, a nasogastric tube is inserted.
Complete sanitation of the abdominal cavity during surgery is not always possible due to technical difficulties caused by the destructive process in the abdominal cavity and disruption of organ relationships. This requires the removal of pathogenic microflora, toxic products of inflammation, fibrin, pus from the abdominal cavity and in the postoperative period, especially since the inflammatory process in the peritoneum continues after elimination or isolation of the source of infection.
There is no need to rely on the protective forces of the peritoneum in case of a closed suture of the abdominal cavity or in advanced forms of peritonitis due to the development of purulent complications and further progression of peritonitis.
Even with a favorable course of the inflammatory process, toxic exudate accumulates in the abdominal cavity after surgery. Absorbed into the blood, it helps maintain toxicosis.
Indications for drainage of the abdominal cavity during peritonitis are determined primarily by inflammation of the peritoneum (form, extent, stage of the process). Drainage tubes with peritonitis quickly become delimited, their lumen closes, and they cease to function. The use of gauze swabs as drainage is not only ineffective in conditions of widespread peritonitis, but also harmful. Adhesions quickly form around the tampons, and a significant inflammatory reaction develops.
Communication with the free abdominal cavity stops, tampons become a kind of “plugs” that clog the holes in the abdominal wall and contribute to the accumulation of exudate. The use of glove, glove-gauze and tubular-glove drainages is possible for local peritonitis.
Sanitation of the abdominal cavity after surgery is determined by its drainage. There are three types of drainage systems: fixed drainage systems - passive drainage with spontaneous discharge of exudate; fixed drainage systems using multiple drainage tubes and active influence on the source of inflammation in the abdominal cavity (washing, active aspiration); staged sanitation using laparostomy.
With passive drainage, upper and lower drainages are installed to evacuate exudate, and rubber-gauze drainage is installed to expand the drainage channel area.
To actively influence the source of inflammation, two upper drains are placed in the upper floor of the abdominal cavity - under the liver on the right and under the diaphragm on the left, the other two are installed in the side canals of the abdominal cavity and a drainage for evacuating exudate from the pelvis. If necessary, drainages can be installed in different parts of the abdominal cavity, depending on the extent of peritonitis.
Options for drainage of the abdominal cavity with widespread peritonitis (a, b, c)
Drainage of the abdominal cavity in case of widespread peritonitis for peritoneal lavage (a, b, c). Use drainage tubes and cigarette drains
a - effective lavage; b, c - decrease in efficiency
Indications for laparostomy:
. widespread peritonitis of stages III—IVA, IVB with severe endogenous intoxication, multiple organ failure;
. widespread or limited peritonitis with necrosis of the abdominal organs or retroperitoneal tissue;
. anaerobic peritonitis;
. delayed relaparotomy for postoperative peritonitis, both with a tendency to delineate multiple foci of inflammation in various parts of the abdomen, and with a widespread process;
. eventration with widespread peritonitis through a purulent wound, as well as with a high risk of eventration (suppuration of the surgical wound with necrosis of the skin, muscles, aponeurosis).
There is a simple and affordable method using a zipper (zipper-laporostomy). This option of laparostomy allows you to control inflammation in the abdominal cavity and perform staged sanitation and necrectomy.
After wide laparotomy (relaparotomy) and elimination of the source of peritonitis and sanitation of the abdominal cavity, the subhepatic and subphrenic spaces and the small pelvis are drained. To temporarily close the abdominal cavity, industrial zippers with a length of at least 30 cm and a width of each half of 2-2.5 cm are used. Vinyl chloride tubes are sewn to the edges of the zipper, washed thoroughly, rinsed and stored in an alcohol solution of chlorhexidine until use.
Before fixing to the skin, the zipper is separated and alternately sutured behind a fixed tube to the edges of the surgical wound. The detachable parts are fixed using U-shaped skin sutures, 2-2.5 cm away from the edges of the wound. After fixing the individual parts of the zipper to the skin, an omentum is placed on the intestinal loops, and a napkin moistened with an antiseptic is placed between the walls of the wound to prevent damage to the adjacent intestinal loops by the zipper.
The program for postoperative management of patients with widespread peritonitis during laparostomy includes: choosing a rational method of pain relief; multiple dressings with revision of the abdominal cavity, anastomotic area, former source of infection and rinsing with an antiseptic solution; necrectomy, prevention and localization of complications in the abdominal cavity; suturing a laparotomy wound.
For planned sanitation during laparostomy, local anesthesia is used - epidural anesthesia (extended); intravenous, inhalation (mask and intubation anesthesia). Indications for intubation anesthesia include the possibility of breathing problems during routine sanitation of the abdominal cavity; refusal of repeated use of mask and intubation anesthesia has a positive moral impact on the patient and his relatives.
The first sanitation with revision of the abdominal cavity is carried out in the operating room, 15-20 hours after the intervention. Open the zipper, remove the gauze pad, inspect the edges of the wound, separate the loose adhesions between the edges of the dissected aponeurosis and the adjacent loops of intestine or omentum. The abdominal cavity is inspected and up to 2-3 liters of antiseptic solution are injected into it.
In other cases, with successful first sanitation, they are repeated according to the state of the inflammatory process and the general condition of the patient. The disappearance of purulent exudate, subsidence of inflammatory phenomena, restoration of intestinal motility are indications for removing the laparostomy and suturing the abdominal wall wound. The wound is sutured through all layers using Donati sutures. Carry out 2-4, in extremely severe cases - 8-10 stage sanitation.
An increase in intra-abdominal pressure with widespread peritonitis is caused by intestinal paresis, its overdistension with gases, liquid contents, and accumulation of fluid in the abdominal cavity. High intra-abdominal pressure causes serious dysfunction of organs and systems; this is called abdominal compartment syndrome.
These changes are expressed in a disorder of cardiovascular activity (displacement of the heart as a result of movement of the diaphragm, a decrease in cardiac output, a decrease in visceral blood flow, including renal, an increase in pressure in the inferior vena cava and hepatic veins, an increase in central venous pressure). The gas exchange function of the lungs is disrupted due to increased intrathoracic pressure, disruption of respiratory excursions of the lungs, decreased tidal volume, etc.
To reduce intra-abdominal pressure in widespread peritonitis, it is advisable to complete the operation by suturing the skin without suturing the aponeurosis, and during laparostomy using a zipper, fix the zipper to the hemmed vinyl chloride tube with intradermal sutures.
A comprehensive treatment program for patients with purulent peritonitis is carried out taking into account the stage of toxicosis.
For grade I endotoxemia, traditional infusion-transfusion therapy aimed at correcting homeostasis, as well as conventional intracorporeal detoxification using detoxifying blood substitutes and forced diuresis, are sufficient. With concomitant hepatic-renal failure, ultraviolet blood irradiation and hemosorption are indicated as efferent methods.
For stage II endotoxemia, in addition to traditional corrective therapy and intracorporeal detoxification, plasmapheresis, hemofiltration, and their combination are advisable.
For stage III endotoxicosis, programmed sanitation of the abdominal cavity, infusion-transfusion corrective therapy, decompression of the gastrointestinal tract, programmed sessions of efferent detoxification and hemocorrection are indicated: programmed UVOC, plasmapheresis, hemofiltration.
Hemofiltration for peritonitis removes toxins from plasma, interstitial fluid and cells. In this case, there is no trauma to cellular elements, minimal loss of protein and immunity to immune factors occurs. Sessions of efferent detoxification methods are carried out under the dynamic control of homeostasis indicators and general toxicity tests.
Undoubtedly, all these are emergency methods, but the urgent start of extra-organ elimination of toxic products from the body’s environments should not be followed by a quick end to this type of treatment. It should be borne in mind that in case of widespread peritonitis, the source of intoxication is first the focus of purulent inflammation, the destruction of the organ. After its elimination, the main source of intoxication remains the inflamed parietal and visceral peritoneum.
Even with a favorable course of peritonitis, considerable time is required to eliminate inflammation of the peritoneum and resolve visceritis. Against the background of a deep disturbance of microcirculation and impaired absorption, conditions are created for toxic products to enter the internal environment of the body in significant quantities. The inclusion of the mechanism of artificial purification of blood and lymph during this period provides a certain time for maintaining and restoring the function of the organs of the body’s natural detoxification system.
An important principle of detoxification is a combination of abdominal sanitation, intestinal intubation and efferent detoxification methods.
In modern conditions, gram-positive microflora - staphylococcus and streptococcus - in monoculture are highly sensitive to a wide range of antibiotics.
At the same time, to suppress staphylococcal infection, it is more rational to use semi-synthetic drugs: methicillin, ampicillin, carbenicillin, ampiox and aminoglycosides - gentamicin, kanamycin, tobromycin, amikacin. The sensitivity of the isolated staphylococcal microflora to these antibiotics is 62.5-100%.
To suppress streptococcal infection in general, the range of antibiotics used can be expanded by introducing penicillin, oleandomycin, lincomycin, etc. Significantly less sensitivity is observed when isolating fecal streptococcus, but even in these cases, more hope can be placed on gentamicin, carbenicillin, tobromycin, amikacin. sensitivity to which significantly exceeds 80%.
The spectrum of antibiotic-sensitive gram-negative microflora is significantly narrowed. Escherichia coli is sensitive in 60-95.2% to carbenicillin, gentamicin, amikacin. Proteus and Pseudomonas aeruginosa remain sensitive to gentamicin, tobromycin, amikacin and, less commonly, carbenicillin. For microbial associations, the combined use of antibiotics is more effective.
When selecting antibiotics, their distribution in the body is taken into account, as well as the possibility of interaction, since the synergistic, antagonistic and indifferent effects of antibiotics are known. The best option is a combination of drugs with a synergistic effect. In this case, drugs with different mechanisms of action should be selected (but the sensitivity of the microflora should remain high to all selected antibiotics), and contraindications to certain antibiotics should be taken into account.
In modern conditions, for purulent peritonitis, aminoglycosides (gentamicin, amikacin, tobromycin), third-fourth generation cephalosporins, carbopenems, metronidazole, dioxidine are most often used.
Various options for the course of the inflammatory process in the abdominal cavity, depending on the nature of the pathogen and the degree of endotoxemia, make it possible to establish the basic clinical and microbiological parameters for the selection of antibacterial drugs even before identifying the microflora and determining sensitivity to antibiotics.
In extremely severe patients with MIP > 20 and SAPS > 8 points, empirical antibiotic therapy begins with reserve antibiotics that have a broad spectrum of action and minimal toxicity. These are fourth generation cephalosporins, carbopenems. Carbopenems are ideal drugs for empirical monotherapy: they cover the entire spectrum of pyogenic flora (aerobes + anaerobes), and the sensitivity of microbial flora to them is high. If this therapy turns out to be effective, then it should not be corrected based on the results of a microbiological study.
The main criteria for the effectiveness of various options for antibacterial therapy: body temperature, leukocytosis, dynamics of bacterial contamination of the abdominal cavity, frequency of reinfection or lack of microflora growth.
Among the complications of antibiotic therapy for peritonitis, the Jarisch-Herxheimer reaction occurs. Clinically, this reaction is manifested by high (up to 39.5 ° C), often hectic fever, pale skin, dry mucous membranes, tongue, high leukocytosis, shift of the blood count to the left and toxemia. Often such a reaction against the background of improvement in the patient’s condition has no logical explanation. They change the antibiotic, increase its dose, and prescribe new combinations of drugs. However, the essence of such an exacerbation reaction is the development of a new wave of endogenous toxicosis, up to toxic shock as a result of the bactericidal effect of antibiotics.
Irrational antibacterial therapy and unreasonably long-term use of antibiotics in patients with peritonitis disrupt the natural balance of microflora. The influence of antibiotic-resistant flora is increasing. The spectrum of action of the drugs should be taken into account. Otherwise, superinfection occurs, i.e. As a result of therapy, a new disease with special clinical manifestations arises.
The causative agents of the infection can be natural inhabitants of the body, fungi, hospital flora. A similar condition is regarded as “tertiary peritonitis”. It is essentially a dysbiosis, often caused by methicillin-resistant Staphylococcus aureus. Vancomycin and teicoplakin are indicated. For superinfection caused by a stick of blue-green pus, carbopenems (namely, meropenem) are effective.
Systemic fungal infection as a manifestation of dysbiosis occupies a significant place. It causes fungal infection of organs, the development of candidiasis up to candidasepsis. The main symptom of this complication is dyspeptic disorders. A reliable diagnosis can be established only by microbiological examination and determination of the ratio of natural intestinal microflora.
Treatment and prevention of the described complications of antibacterial therapy plays an important role in severe peritonitis and abdominal sepsis. Differential diagnosis of the Jarisch-Herxheimer reaction with developing purulent complications presents certain difficulties. If the course of inflammation is favorable and body temperature is normalized, and then significant fluctuations suddenly appear, antibiotics should be discontinued for 2-3 days.
If this cannot be done due to the severity of the patient’s condition and intractable inflammation, the combination of antibiotics is changed, reducing their use to a minimum, and sulfonamides and nitrofuran drugs are used. Of the quinoxaline derivatives, dioxidin is effective.
After 9-10 days of massive antibacterial therapy for peritonitis, more attention should be paid to the prevention of these complications, without waiting for the development of candidiasis or other dysbacteriosis. Complex therapy includes complete protein nutrition, vitamins C, group B, and multivitamins. Antifungal antibacterial drugs are used as specific means of protection: nystatin, levorin, fluconazole.
An important role in the treatment of dysbiosis is played by the restoration of the natural intestinal microflora. For these purposes, colibacterin, bifidumbacterin or bificol are prescribed. There are certain indications for the use of each drug, which are clarified after microbiological studies of stool.
