THE STATE OF ENDOGENOUS INTOXICATION IN PATIENTS WITH WIDESPREAD PERITONITIS
M.Y. NASIROV, S.V. SUSHKOV 1, N.J. HAJIYEV
Azerbaijan Medical University, Baku, AZERBAIJAN,
General and Emergency Surgery of AMS of the Ukraine, Kharkov, UKRAINE 1
As is known, the basic pathogenetic part of widespread peritonitis (WP) is an endogenous intoxication (EI). The outcome of the treatment of WP mainly depends on the intensity of EI, conditioned by the action of inflammatory mediators of microbial toxins and decay products of tissues. For the objectification of the assessment of the severity of EI we carried out preoperative determination of the level of medium-molecular peptides (MMP), indicators of activity of lipid peroxidation (ALP) - diene conjugates (DC), malonic dialdehyde (MDA), catalase activity (CAT) in the blood plasma of 60 patients with RP. LP-AOD indicators (antioxidant protection) were studied also in peritoneal exudate and urine. The severity of peritonitis was assessed by MIP index: 17 patients had MIP-I, 23 - MIP-II and 20-MIP-III. In 15 healthy individuals these figures were taken as a norm. In patients with MIP-I concentration DK in plasma was 89.8%, MDA- 66.5%, MMP - 48.0%, and the activity of CAT 13.1% above the norm. In the same patients the content of MDA in urine was 2.1 times (đ<0,001), and MMP - by 52.7% (đ<0,001) above the norm. In peritoneal exudate taken during during the operation the level of MDA constituted an average of 2,45±0,07 nmol/ml, and MMP - 0,81 0,81±0,05 gr/l. During MIP-II CAT activity decreases by 31.7% against the background of 2.4 times increase of DC and 2.6 times increase of MDA. Before the operation MDA and SMP content in the urine of the patients was higher than in healthy persons, significant to 300.0% and 59.7%, respectively. The level of MDA and MMP in peritoneal exudate of the patients was higher than in MIP-I. Preoperative CAT activity in plasma in patients with MIP-III was reduced to 44,8% (đ<<0,001), and on the contrary, the contents of DC and MDA was increased 3.5 times (đ<0,001) as compared to norm. In these patients, the level MMP in the plasma increased 2.1 times (đ<0,001). The level of MDA in urine was 6.6 times, and MMP - by 69.2% significantly higher than in healthy people. The content of MDA in peritoneal exudate was 3,80±0,12 nmol/ml, and of MMP – 1,3±0,09 qr/l. Thus, in WP, there occurs an imbalance in the LP-AOP system . The increased intensity of lipid peroxidation leads to general decrease of AOP, which is accompanied by excessive accumulation of LP and MMP products. The depth of the severity of EI in patients with WP corresponds to the level of oxidative stress and severity of peritonitis.
THE ALGORITHM OF THE MANAGEMENT OF ABDOMINAL COMPARTMENT SYNDROME IN OBESE PATIENTS AFTER EXTENSIVE ALLOHERNIOPLASTICS
Republican Specialized Centre of Surgery named after acad. V. Vakhidov, Tashkent,
Despite the improvement and introduction of new technological methods for the correction of giant abdominal hernias, in the early postoperative period cases of the development of intra-abdominal hypertension syndrome (IAHS), often with fatal consequences are frequent. Indicators of fatality, according to Russian authors reach 15%-17%, according to the data of foreign authors - 17% - 19%.
The aim of the study: To compare the dynamics of intra-abdominal pressure (IAP) for in various methods of management of patients after extensive alogernioplasty and determine the optimum tactics of management of this category of patients.
Materials and methods: The analysis of 48 patients treated in intensive care unit of RSCS named after academician Vladimir Vahidov over the period of 2007-2009, with IAHS in the postoperative period. In all patients, indicators of IAP in all patients corresponded to II-III degree of IAHS, and body weight index (BWI) constituted 25.4 - 27.6 ± 3.2. Patients were divided into 3 groups with 16 patients in each. Patients of the 1 group were managed by traditional postoperative methods: artificial pulmonary ventilation (APV) was conducted in the “Volume control” modes with a square inspiratory flow. In the 2nd and 3rd group of patients APV was conducted in the modes of “Pressure control” by descending inspiratory flow. For the improvement of the excursion of the chest there was performed elevation (45° - 50°) of the head end of the bed a pad placed under the lumbar region. To reduce the IAP in 1st and 2nd group of patients there was carried out early drug stimulation of the intestines, and in the 3rd group, for the reduction of IAP there was carried out epidural anesthesia. All patients underwent an adequate infusion and antibiotic therapy, based on common principles. Indicators of acid-base status (ABS), reduction of IAP to the level I, and improvement of the general clinical status of patients in all groups constituted the basis for the transfer of patients to independent breathing.
Results and their discussions: In the result of the study it was revealed that in the first 3 days high IAP (15-20 mm of mercury) maintained in all three groups, which is associated with developing postoperative intestinal paresis, and in some cases, tension of the anterior abdominal wall due to postoperative pain. It was noted that in the next 3-5 days all patients had increased level of IAP up to 23 mm of mer. Optimization of a conditions of the patient of the 2nd group, - led to a decrease in the participation of auxiliary muscles in the breathing act and stabilization of IAP within 11-13 mm of mercury. In the third group – studies of improvements of the conditions of the patient in combination with epidural anesthesia, resulting in stabilization of IAP on 11 – 16th days up to 9-11mm. of mercury, lack of the participation of auxiliary muscles and the formation of peristalsis, anesthesia and decrease of tension in the anterior abdominal wall.
Conclusion: APV in “Pressure control” mode with a descending inspiratory flow and optimization of the conditions of a patient in combination with epidural anesthesia makes it possible to achieve an optimal reduction of IAP on 11 – 16th days, lack of the participation of auxiliary muscles, leads to the formation of peristalsis, against the background of adequate anesthesia and decrease of tension in the anterior abdominal wall.