Postoperative wound suppuration nursing care. What signs indicate the presence of suppuration in the postoperative wound? What should you do in these cases as a ward nurse? When to carry out antibacterial prophylaxis

Like any other, purulent inflammation is the body's response to the action of any stimulus, aimed at limiting the pathological site, destroying provoking agents and restoring damage. The inflammatory response consists of three sequential phases: injury, edema, recovery. It is the nature of the edema that determines the type of inflammation.

Purulent inflammation develops with the predominance of pathogenic pyogenic bacteria in the edematous fluid (exudate). It can be Pseudomonas aeruginosa and Escherichia coli, staphylo-, gono-, streptococci, Klebsiella, Proteus. The degree of bacteria contamination of the lesion determines the likelihood and nature of the inflammatory reaction.

Pus is a liquid medium containing dead blood cells (leukocytes, phagocytes, macrophages), microbes, enzymes (proteases), destroyed and dead tissues, fats, protein fractions. It is proteases that are responsible for tissue dissolution (lysis) at the site of injury.

The following types of purulent inflammation are distinguished:

• empyema - an accumulation of pus in a cavity represented by the walls of an organ;
• abscess - a cavity resulting from tissue melting, filled with purulent exudate;
• phlegmon - spilled purulent throughout the vessels, nerves, in the fascia.

One of the most common benign tumors in the subcutaneous tissues - atheroma. It is formed in the places of greatest distribution of the sebaceous glands: head, coccyx area, face, neck. Atheroma has the appearance of a rounded formation, is a cavity enclosed in a capsule, containing fat, cholesterol, and skin cells.

It occurs as a result of the clogging of the excretory duct of the sebaceous gland. Atheroma can be single, but in most cases there is a multiple distribution of these formations of various sizes. This tumor is painless and, apart from cosmetic discomfort, does not cause any inconvenience.

There are primary (congenital) and secondary atheromas that occur with seborrhea. On palpation, they are dense, moderately painful, and have a bluish tint. Secondary tumors are localized on the face, chest, back, neck. After their opening, ulcers with undermined edges are formed.

In outpatient surgery, inflammation of atheroma is a common problem. The predisposing factors for this are the following conditions:

• lack of hygiene;
• self-squeezing of acne, especially if the rules of antiseptics are not followed;
• microtrauma (scratches and cuts);
• pustular skin diseases;
• decreased local immunity;
• hormonal disorders;
• abuse of cosmetics.

Suppurative atheroma is characterized by soreness, local redness and swelling. At large sizes, fluctuation can be noted - a feeling of fluid overflow in the elastic cavity. Sometimes the formation breaks through on its own and fatty pus is released.

Inflammation of atheroma is treated only surgically. A skin incision is performed, the contents are exfoliated with the obligatory removal of the capsule. When it is not completely removed, a relapse is possible after surgery. If atheroma has re-formed, inflammation can develop in the same area.

Suppuration of wounds

Wounds arise for numerous reasons: domestic, industrial, criminal, military, after surgery. But inflammation of the wound is not always purulent. It depends on the nature and location of damage, tissue condition, age, microbial contamination.

The factors that predispose to inflammation of the wound surface are as follows:

• wounding with a contaminated object;
• non-compliance with hygiene rules;
• the use of steroid hormones and / or cytostatics;
• excess body weight;
• malnutrition;
• vitamin deficiency;
• elderly age;
• decreased local and general immunity;
• chronic skin diseases;
• severe somatic diseases;
• hot, humid weather;
• insufficient drainage of the wound after surgery.

Usually, wound suppuration is characterized by the fact that purulent inflammatory exudate accumulates in the tissue defect. At the same time, hyperemia (redness) and "warm" edema appear around the edges due to vasodilation. In the depths of the wound, "cold" edema prevails, associated with impaired lymphatic outflow due to vascular compression.

Against the background of the listed signs, bursting, pressing pain appears, and the temperature is locally elevated in the affected area. A necrotic mass is determined under the layer of pus. Absorbed into the blood, decay products, toxins cause symptoms of intoxication: fever, weakness, headaches, decreased appetite. Therefore, if there is an inflammation of the wound, treatment should be immediate.

Suppuration of postoperative sutures

The process of inflammation of the postoperative suture occurs, as a rule, 3-6 days after surgical procedures. This is due to the ingress of pyogenic microorganisms into the place of tissue damage. Bacteria can be introduced into the wound primarily (by the subject of injury, poorly processed instruments, by the hands of medical personnel and / or the patient himself) and indirectly from the focus of chronic infection: caries, tonsillitis, sinusitis.

Factors predisposing to the development of a pathological process in the seam area:

• insufficient disinfection of medical equipment;
• non-observance of the rules of asepsis, antiseptics;
• reduced immunity;
• poor drainage of the separated wound;
• damage to the subcutaneous tissue (hematomas, necrosis);
• poor quality suture material;
• lack of hygiene by the patient;
• areas of ischemia (lack of blood supply) due to clamping of blood vessels by ligature.

If inflammation of the seam has developed, then symptoms such as redness and swelling of the skin around, soreness will be observed. First, a serous fluid mixed with blood can be separated from the seam, and then suppuration occurs.

With a pronounced process of inflammation, fever with chills, lethargy, refusal to eat appear.

A festering surgical suture should be treated only under medical supervision. Wrong independent actions can lead to the spread of infection, deepening of inflammation and the development of formidable complications up to. In this case, a rough convoluted scar is formed.

Purulent lesions of the skin and subcutaneous tissue

Pathological processes in the skin and underlying layers are very common in surgical practice. The skin and its appendages are the body's first protective barrier against various adverse effects.

The negative factors that provoke the development of skin inflammation are:

• mechanical damage (scratches, abrasions and cuts, scratches);
• exposure to high and low temperatures (burns, frostbite);
• chemical agents (household alkalis, acids, abuse of antiseptic and detergents);
• excessive sweating and sebum secretion can cause purulent inflammation of the skin;
• poor hygiene (especially in obese people);
• diseases internal organs (pathology of the endocrine, digestive systems;
• ingrown nail.

Microbes brought in from the outside and / or representatives of opportunistic flora can cause purulent inflammation of the skin and subcutaneous tissue. Suppuration of the skin is varied in the place of localization and clinical course.

Furuncle

Suppuration and sebaceous gland - boil. It can be localized to areas of the skin where there is hair. It occurs at any age. Most common in patients diabetes mellitus and / or obesity.

Clinical manifestations are expressed in typical inflammation: hyperemia, pain, increased local temperature, swelling. Sometimes this condition is accompanied by a reaction of closely located lymph nodes.

Lymphadenitis, abscess, thrombophlebitis (inflammation of the veins), phlegmon, reactive purulent arthritis, sepsis, meningitis can become complications of furunculosis.

Carbuncle

Carbuncle - acute infectious inflammation of several hair follicles with sebaceous glands. It occurs more often in persons of mature and old age. Endocrine disorders play an important role in the development of this inflammation. Typical localization is the back of the neck, back, abdomen, buttocks.

At the site of infection, a dense diffuse edema occurs, the skin becomes purple and painful. Necrotic tissue melting occurs. The carbuncle is opened in several places, creamy pus is released. The defeat with such inflammation of the skin looks like a honeycomb.

Hydradenitis

Inflammation of the sweat glands occurs mainly with untidiness, diaper rash, scratching. The first place among the provoking factors is shaving the armpits. Microtrauma to the skin occurs, and the use of a deodorant contributes to the blockage of the excretory ducts of the glands.

In the armpit, a dense painful tubercle forms, the skin becomes purple-cyanotic. As the inflammation progresses, the pain intensifies and interferes with movement. There is a fluctuation, the skin in the center becomes thinner, and thick pus breaks out.

With the spread of inflammation to other areas, due to the abundance of lymphatic tissue, a conglomerate of nodes with protruding skin papillae is formed - "bough udder". If no treatment is carried out, the process can spread - an abscess or phlegmon is formed. Sepsis is a formidable complication of hydradenitis.

Abscess

A cavity of a purulent-necrotic nature, limited by a capsule, is an abscess. More often occurs as a complication of inflammation, pustular diseases on the skin.

The cause of the development of a purulent cavity can be inflammation. stab wound or injection site when the outflow of pus is impaired.

Clinically, an abscess is manifested by edema and hyperemia of the skin in the affected area. A densely elastic painful formation is palpated deep in the tissues. The skin over the abscess is hot to the touch. Symptoms of intoxication appear.

When the abscess is opened and incomplete emptying or the presence of a foreign body in the cavity, the walls of the capsule do not fully close, and a fistula is formed. A breakthrough of pus can occur on the skin, into the surrounding tissues, into the cavity of the organs.

Phlegmon

A purulent-necrotic process of inflammation located in the cellular space, which does not have clear boundaries. The causes of phlegmon are the same as with an abscess.

In connection with the development of aesthetic medicine, the formation of phlegmon can provoke corrective procedures: liposuction, the introduction of various gels. Localization sites can be any, but more often the areas of the abdomen, back, buttocks, and neck tend to become inflamed. Not uncommon - damage to the tissues of the leg.

Gradually melting tissue, phlegmon spreads through the tissue, fascial spaces, destroying blood vessels and provoking necrosis. Often abscess, hydradenitis, furuncle are complicated by phlegmon.

Paronychium and panaritium

Panaritium is an inflammation of the soft tissues, bones and joints of the fingers of the hand, less often of the foot. The pain with panaritium can be unbearable, depriving you of sleep. At the site of inflammation - hyperemia and edema. With the development of the process, the function of the finger is disrupted.

Depending on the localization of the lesion, panaritium can be of different types:

• cutaneous - the formation of suppuration between the epidermis and the next layers of the skin with the formation of a "bubble";
• subungual - pus flowed under the nail plate;
• subcutaneous - a purulent-necrotic process of the soft tissues of the finger;
• articular - damage to the phalangeal joint;
• tendon - tendon suppuration (tendovaginitis);
• bone - the transition of a purulent process to the bone, proceeding as osteomyelitis.

Paronychium - damage to the roller near the nail. maybe after a manicure, cuticle cutting. In this condition, throbbing pain, redness, and separation of pus are noted.

Treatment

Surgery is involved in purulent inflammation of soft and other tissues of the body. When symptoms appear that indicate a purulent lesion, it is imperative to consult a doctor. Self-treatment fraught with the spread of the process and the aggravation of the situation. The main directions of treatment:

For surgical treatment the following methods are used:

• physical (laser radiation, plasma flows, vacuum treatment of the inflammation zone);
• chemical (various enzyme preparations: Trypsin, Chymotrypsin, Lysosorb);
• biological (removal of necrotic tissue by the larvae of green flies).

With conservative therapy, the following drugs are used:

• antiseptics (Povidone-iodine, Miramistin, Ethacridine, Chlorhexidine);
• water-soluble ointments (Dioxidin, Methyluracil);
• creams (Flamazin, Argosulfan);
• drainage sorbents (Collagenase);
• aerosols (Lifuzol, Nitazol).

In the period of regeneration (healing) after the operation, the following means are used:

• dressings with antibacterial ointments (Levomekol, Tetracycline, Pimafucin), stimulating substances (Vinilin, Actovegin, Solcoseryl);
• special wound dressings against inflammation and for healing (Voskopran);
• preparations based on natural polymers (Algipor, Kombutek).

Suppurative inflammation of various parts of the body is common and takes many different forms. The course of the process can be smooth or bring formidable complications leading to death. Therefore, treatment must be approached in a comprehensive manner and carry out the entire range of prescribed therapeutic measures, preventive measures to prevent the secondary occurrence of the disease.

The risk of wound complications increases with:

• performing operations against the background of blood loss and severe metabolic disorders in the patient's body;
• long-term traumatic operations on the abdominal organs;
• operations performed by unskilled surgeons;
• the use of low-quality suture materials;
• gross violations of asepsis and antiseptics.

Leading complications of surgical wounds:

1. inflammatory infiltration in the walls of wounds;
2. suppuration of the surgical wound;
3. postoperative eventration;
4. ligature fistula;
5. seroma;

Inflammatory infiltrate

Inflammatory infiltration is a fairly common postoperative complication. It is based on exudative inflammation (serous, serous-fibrinous, fibrinous-purulent). The most prone to the formation of an inflammatory infiltrate are patients who have undergone surgery for destructive purulent processes in the abdominal cavity, as well as obese patients.

The main etiological factors of its occurrence, in addition to infectious, should include greater trauma to the subcutaneous tissue during surgical intervention.

To the conditions for the prevention of inflammatory infiltrate O.B. Milonov et al., (1990) include:

• mandatory stepwise delimitation of all layers of the abdominal wall with wide gauze napkins moistened with an antiseptic solution, which helps to protect tissues from excessive trauma and infectious contamination;
• replacement of instruments and repeated hand washing after the completion of the abdominal stage of the operation;
• the use of only non-reactive suture materials (nylon, lavsan, nylon, supramid, letigen-lavsan) for suturing the subcutaneous tissue and skin;
• with a pronounced thickness of subcutaneous fatty tissue - washing the wound before suturing with antiseptic solutions;
• thorough stopping of bleeding using point diathermocoagulation.

Suppuration of the operating wound

Suppuration of an operating wound is the appearance of fibrinous-purulent inflammation in response to infection of the edges of the wound. In "clean" operations, the surgical wound rarely suppurates. Therefore, an increase in the frequency of this complication in a surgical hospital should be a signal for an in-depth analysis of the causes of its development (insufficient disinfection, poor skin treatment and other violations of the rules of asepsis and antiseptics).

In most cases, suppuration of an operating wound is a consequence of hidden errors in the organization of the work of a surgical hospital or individual surgeons. In operations accompanied by the opening of hollow organs, as well as in the presence of peritonitis and other purulent-destructive processes in the peritoneal cavity, this complication is quite frequent.

Example... Patient M., 76 years old, for adenocarcinoma of the cecum underwent hemicolonectomy on the right with the imposition of an ileal-colonic anastomosis. The postoperative period is complicated by suppuration of the surgical wound. After 2 weeks. drainage of subgaleal abscess in the area of \u200b\u200bthe postoperative scar was performed. After 2 days. after that, diffuse purulent peritonitis was revealed, relaparotomy was performed. During relaparotomy, the peritoneal cavity was sanitized, peritoneal dialysis was established, and the phlegmon of the anterior abdominal wall was opened and drained. After the operation, until death, the patient is on mechanical ventilation. Despite the ongoing intensive therapy, the phenomena of peritonitis increased; increased hemodynamic disorders: blood pressure - 80/50 mm Hg. Art., heart rate - 130 beats. in 1 min, CVP - 0 cm of water. Art. Peritoneal dialysis was deficient. Subsequently, oligo-anuria, tachycardia with extrasystole, a decrease in blood pressure to 50/30 mm Hg were noted. Art., and a day after relaparotomy against the background of severe intoxication (LII - 10), cardiac arrest occurred.

Autopsy: the sheets of the peritoneum are dull, in the area of \u200b\u200bthe surgical wound on the parietal peritoneum, on the surface of the gallbladder and the lower surface of the right lobe of the liver - fibrinous-purulent overlays. The loops of the small intestine are loosely welded together by fibrinous-purulent, easily detachable adhesions. In the subhepatic space on the right and in the cavity of the lesser omentum, 50 and 150 ml of purulent exudate, respectively. In the pleural cavities - 200 ml of translucent liquid. In the heart - an aneurysm of the wall of the left ventricle in the apex with a parietal thrombus. The posterior interventricular branch of the coronary artery is obliterated in the middle third. Posthumously determined CVP index - 0th degree. The hematocrit of cadaveric blood is 0.65, which indicates a pronounced hemoconcentration. Leukocyte count of cadaveric blood increased to 3%. In the liver, there are two tumor metastatic nodes with a diameter of 2 cm.

Among the causes of infection and suppuration of the surgical wound, exogenous and endogenous factors are distinguished, which can sometimes be combined. The development of infection is always promoted by rough handling of tissues, as well as the presence of necrosis areas in the wound.

Exogenous factors include:

1. carriage of bacilli among patients and medical personnel;
2. microbial contamination of the surgeon's hands, operating field, instruments, suture and dressings, operating room air.

Endogenous infected wounds mean the penetration of microflora into the wound from the peritoneal cavity.

The overwhelming majority of wounds, even after "clean" operations lasting more than 1 hour, are colonized by microbes that get on their surface from the skin, from the air, and from other places. In the presence of favorable conditions, they multiply in necrotic tissue, blood clots and wound discharge. The volume of this nutrient substrate largely determines the rate of reproduction of microbes. At the edges of surgical wounds, necrosis of adipose tissue and especially muscles often occurs, serving as a possible springboard for the subsequent development of infection. It is also known that the less perfect the surgical technique, the more such necrosis.

In granulating wounds under the foci of reproduction of microorganisms, necrosis of the superficial layers of granulations, leukocyte infiltration and diapedetic hemorrhages occur in the absence of thrombus formation.

Example... Patient A., 69 years old, underwent cholecystectomy for chronic calculous cholecystitis. On the 7th day. after the operation, there were complaints of pain when opening the mouth. On the same day, she was examined by a neuropathologist, who revealed difficulty in opening her mouth, Horner's symptom on the right, increased mandibular reflex and increased tendon reflexes on the right. Conclusion: acute cerebrovascular accident by the type of ischemia in the vertebrobasillar basin, pseudobulbar syndrome. By the end of the same day, the patient had severe trismus with the spread of convulsive syndrome to smooth and striated muscles, which was manifested by involuntary contraction of the masticatory muscles and closing of the jaws, difficulty in swallowing, unlocalized abdominal pain. Heart rate - 110 beats. in 1 min, blood pressure - 200/120 mm Hg. Art., stomach attack (hypertonicity), respiratory arrest and cardiac arrest. Mechanical ventilation and closed heart massage were started, cardiac activity was restored. After another 6 hours, the patient had a third, last cardiac arrest. Resuscitation measures were not successful.

Autopsy: blood was taken from the heart, pieces of the liver and spleen, the site of the surgical wound of the anterior abdominal wall for bacteriological examination. The causative agent of tetanus was identified in all organs and tissues examined .

If, under any conditions in a non-standard environment, you receive a wound, you need to properly treat it, otherwise you risk getting suppuration. A festering wound can lead to the most tragic consequences.

One of the important risk factors for suppuration is the ingress of foreign objects into the wound: earth, dirt, pieces of clothing and other other third-party inclusions. Under these conditions, there are all conditions for the development of suppuration. As practice and experience show, any untreated wound, practically always leads to the fact that it is most likely to fester.

Signs of suppuration

The development of the infection earlier, is characterized by increased pain, pulsation and distention. Puffiness and hyperemia become noticeable, after which the separation of pus begins. The scarring process can be largely inhibited with wound suppuration. In addition, this is a clear threat of the spread of infection, which is fraught with sepsis and can be fatal.

The most dangerous wounds are those with a putrid infection resulting from infection with gas gangrene, tetanus and rabies.

In addition to increased pain and swelling, a change in tissue color is also observed. Fibrinous clots become dark gray in color, and the amount of pus that is separated increases.

With the deterioration of the course of the suppuration process, the temperature can rise to 39 - 40C, while signs of general intoxication will clearly be traced.

If, in the absence of pain in patients, chills occur, the addition of a putrefactive process should be suspected.

Festering wound treatment process

Tools and materials used for dressing a purulent wound must be sterile or thoroughly disinfected.

Bandaging of purulent wounds should be carried out every day, and in the case of extensive suppurations that occur against a background of severe intoxication - twice a day.

Obligatory dressing is carried out in case of obvious getting wet. An additional indication for an extraordinary dressing is increased pain in the wound.

When dressing, the first thing to do is remove the bandage and bandage. Since the lower layers of the bandage are infected, it should not be twisted, but cut with scissors without unwinding. The skin must be supported, not allowing it to reach behind the bandage. A dressing firmly adhered to the wound should be soaked with a cotton-gauze swab moistened with hydrogen peroxide, furacilin, or saline.

If capillary bleeding begins when the dressing is removed, this place is clamped with a sterile gauze napkin, and only after the blood stops, the skin around the wound is treated.

The area around the wound is treated with iodine or alcohol, and the site of the festering wound itself is cleaned with sterile dry tampons, and after that it is thoroughly washed with an antiseptic solution, which can be chlorhexidine, hydrogen peroxide or collargol.

Necrotic areas of tissue, which begin to exfoliate, are gently grasped with tweezers and cut with sharp sterile scissors.

Suppuration of the Wound - Suppuration of an operating wound (suppuration of a postoperative wound, or suppuration of a seam) today has a number of features. First of all, the frequency of this complication increased (according to many authors, from 1 to 15% or more - A.I. Gnatyshak and L.R. Kryshtalskaya, 1967; B.V. Petrovsky, 1971; V.A.Proskurov, 1974; Altemeier , 1970; Bruun, 1970; Grun 1974; Brock, 1975, and others; 5.4% of all operations in our observations). The increase in the number of suppurations, in addition to the general reasons for the growth of hospital infections, can be explained by a number of factors:

the initial state of the patient and his unsatisfactory protective reaction;

complications that developed during the operation and in connection with errors in the operational technique;

infection of the wound during or after surgery.

Depending on the localization of suppuration, various variants of the clinical course were noted. On the chest, the purulent process is usually more severe than on the abdominal wall or extremities. A particularly severe clinical course was observed with wound suppuration after operations with artificial circulation. In this group of patients, the reactivity and immunological properties of the organism change significantly. The inflammatory reaction slows down, becomes inferior, all reparative processes are disrupted. In this regard, there was often a divergence of sutures and rapid infection of wounds, the phenomenon of hemorrhagic diathesis (in the form of multiple small hematomas along the wound). Granulation growth and healing were significantly slowed down. The lag in regenerative processes in wounds after operations with artificial circulation led to an increase in the time of their healing. Histological examination of the wound edges showed a sharp decrease in the number of leukocytes and histiocytes. Fibroblasts and fibers of fibrous tissue changed pathologically: hypertrophied fibroblasts and thickened fibers appeared. There were also observed damage to the vascular wall, areas of hemorrhage, hematomas. The wound surfaces were covered with a gray bloom, and gave off a putrid odor.

Thus, after operations with artificial circulation, the wounds have some features due to a mild inflammatory reaction and slower regeneration. A similar course of the wound process was noted during organ transplantation with the use of immunosuppressants, after severe trauma, in patients with congenital or acquired immunological insufficiency. These circumstances led them to a high frequency of wound suppuration.

According to the clinical course, patients with wound suppuration can be divided into three groups. In patients of the first group, local symptoms were expressed. The general state of health did not suffer significantly. Only a temperature reaction was noted. The outcome was generally good. In the second group, a more severe general course was noted, accompanied by severe intoxication, secondary exhaustion, and prolonged healing. In patients of the third group, wound suppuration progressed, the process spread to the surrounding tissues, often joined by peritonitis, mediastinitis, empyema pleural cavity, pneumonia, sepsis and other complications accompanied by septicemia, septic shock... They were preceded by one or another degree of unresponsiveness. The forecast has always been serious.

Suppuration of the wound usually proceeded with a second wave of temperature rise (on the 5th - 8th day with staphylococcus, on the 3rd - 5th - with Pseudomonas aeruginosa). Prolonged fever, starting from the first postoperative day, was more often observed. Local signs of inflammation were somewhat delayed in time and were detected on the 7th - 8th day with staphylococcus, on the 3rd - 4th day with Pseudomonas aeruginosa. Most patients, even before the appearance of local phenomena, noted a deterioration in health, pain in the wound, fever, sometimes chills, tachycardia, shortness of breath. The temperature rose to 38 ° C and higher. On examination and palpation, it was possible to detect pastiness and infiltration of the edges of the wound, in some cases areas of hyperemia and its soreness. Pus oozing between the stitches was sometimes noted. After removing the sutures, the edges easily diverged, the edematous subcutaneous fat, covered with a gray bloom, was exposed, a turbid hemorrhagic fluid or pus was released.

In cases of wound infection caused by Pseudomonas aeruginosa, the fibrinous-purulent inflammation was superficial, the pus was initially thick, viscous. On the 3rd - 4th day after dilution of the wound edges, the nature of the discharge began to change. The pus became more liquid, its color acquired a characteristic greenish-yellow tint, which is associated with the formation of a blue-green pigment - pyocyanin, which is released only under aerobic conditions. Therefore, the blue-green color of the dressings, especially their surface layers, is a very characteristic sign for local Pseudomonas aeruginosa infection. Flaccid, pale granulations bleed easily. A specific smell appeared, which was sometimes noted from the first day.

When determining the pH of purulent wounds using a universal indicator paper, it was found that Pseudomonas aeruginosa infection gives an alkaline reaction (pH 8.5 - 9.0), with staphylococcal suppuration, the reaction is weakly acidic or neutral (pH 6.8 - 7.0).

Thus, the following signs are characteristic of suppuration of a wound of Pseudomonas aeruginosa: 1) staining of the surface layers of the dressing 1 - 2 days after dressing in a blue-green color; 2) copious liquid purulent discharge of blue-green color with a specific odor; 3) flaccid, pale, easily bleeding granulations with significant swelling and swelling of the edges of the wound; 4) fluorescence in the case of irradiation with long-wave rays in a darkened room; 5) alkaline reaction of the wound (pH more than 8.5).

In a combination of several pathogens, Pseudomonas aeruginosa helps to obtain a predominance of the use of antibiotics, to which it remains most resistant.

Morphological changes in most cases of wound suppuration were of the same type. The postoperative chest wound was a gaping opening with necrotic margins soaked in pus, sometimes with exposed ribs and scapula. The spread of the process to the surrounding tissues led to rib chondritis or osteomyelitis. In some cases, the infiltration spread to the diaphragm. Often there was a communication with the pleural cavity, pleural empyema developed. With a median approach, fibrinous-purulent inflammation passed to the anterior mediastinum, penetrating in some cases into deeper tissues and giving a picture of purulent mediastinitis, pericarditis, and sometimes osteomyelitis of the sternum. Suppuration of the postoperative wound of the anterior abdominal wall, spreading beyond the aponeurosis, could lead to communication with abdominal cavity, peritonitis, eventration.

134. How is mechanical ventilation (artificial ventilation of the lungs) "mouth-to-mouth", "mouth-to-nose" performed using the "AMBU" apparatus?

Artificial ventilation of the lungs

I Artificial lung ventilation

provides gas exchange between the ambient air (or a specially selected mixture of gases) and the alveoli of the lungs.

Modern methods artificial lung ventilation (ALV) can be roughly divided into simple and hardware. Simple methods are usually used in emergency situations: in the absence of spontaneous breathing (apnea), with an acutely developed violation of the rhythm of breathing, its pathological rhythm, agonal breathing: with an increase in breathing more than 40 in 1 min, if this is not associated with hyperthermia (body temperature is higher 38.5 °) or severe unrepaired hypovolemia; with increasing hypoxemia and (or) hypercapnia, if they do not disappear after anesthesia, restoration of airway patency, oxygen therapy, elimination of life-threatening levels of hypovolemia and gross metabolic disorders. The simple methods primarily include mouth-to-mouth and mouth-to-nose expiratory ventilation (artificial respiration). In this case, the head of the patient or the victim must be in the position of maximum occipital extension (Fig. 1) to prevent tongue retraction and ensure airway patency; the root of the tongue and the epiglottis are displaced anteriorly and open the entrance to the larynx (Fig. 2). The person providing assistance stands to the side of the patient, with one hand squeezes the wings of his nose, tilting his head back, with the other hand slightly opens his mouth behind the chin. Taking a deep breath, he tightly presses his lips to the patient's mouth (Fig. 3) and makes a sharp, energetic exhalation, after which he moves his head to the side. The patient exhales passively due to the elasticity of the lungs and chest. It is desirable that the mouth of the caregiver be insulated with a gauze pad or piece of bandage, but not with a thick cloth. During mechanical ventilation, air is blown from the mouth into the nose into the patient's nasal passages (Fig. 4). At the same time, his mouth is closed, pressing lower jaw to the top and trying to pull the chin up. Air injection is usually carried out with a frequency of 20-25 per minute; with a combination of mechanical ventilation with cardiac massage (see Resuscitation) - with a frequency of 12-15 in 1 min. Simple mechanical ventilation is greatly facilitated by the introduction of oral cavity a patient with an S-shaped air duct, using a Ruben bag ("Ambu", RDA-1) or RPA-1 fur through an oronasal mask. In this case, it is necessary to ensure airway patency and tightly press the mask to the patient's face.

Hardware methods (with the help of special respirators) are used when long-term mechanical ventilation is necessary (from several hours to several months and even years). In the USSR, the most common RO-6A in its modifications (RO-6N for anesthesia and RO-6R for intensive care), as well as the simplified model RO-6-03. The "Phase-50" respirator has great capabilities. For pediatric practice, the device "Vita-1" is produced. The first domestic device for high-frequency jet ventilation is the "Spiron-601" respirator

The respirator is usually attached to the patient's airway through an endotracheal tube (see Intubation) or a tracheostomy cannula. Most often, mechanical ventilation is performed in the normal frequency mode - 12-20 cycles per minute. The practice also includes high-frequency mechanical ventilation (more than 60 cycles per minute), in which the tidal volume significantly decreases (to 150 ml or less), the positive pressure in the lungs at the end of inspiration and intrathoracic pressure decrease, and blood flow to the heart is less difficult. In addition, with mechanical ventilation in a high-frequency mode, the patient's habituation (adaptation) to the respirator is facilitated.

There are three methods of high-frequency ventilation (volumetric, oscillatory and jet). Volumetric is usually carried out with a respiration rate of 80-100 per 1 min, oscillatory - 600-3600 per 1 min, providing vibration of a continuous or intermittent (in normal frequency mode) gas flow. The most widespread is high-frequency jet mechanical ventilation with a breathing rate of 100-300 per minute, in which a stream of oxygen or a gas mixture under a pressure of 2-4 atm is blown into the airways through a needle or catheter with a diameter of 1-2 mm. Jet ventilation can be performed through an endotracheal tube or tracheostomy (in this case, injection occurs - suction of atmospheric air into the respiratory tract) and through a catheter inserted into the trachea through the nasal passage or percutaneously (puncture). The latter is especially important in cases where there are no conditions for tracheal intubation or the medical staff does not have the skill to carry out this procedure.

Artificial ventilation of the lungs can be carried out in an automatic mode, when the patient's spontaneous breathing is completely suppressed by pharmacological drugs or specially selected ventilation parameters. It is also possible to carry out auxiliary mechanical ventilation, in which the patient's spontaneous breathing is preserved. Gas is supplied after a weak attempt by the patient to inhale (trigger mode of auxiliary ventilation), or the patient adapts to an individually selected mode of operation of the apparatus.

There is also an intermittent mandatory ventilation (IPV) mode, commonly used during the gradual transition from mechanical ventilation to spontaneous breathing. In this case, the patient breathes on his own, but a continuous flow of heated and humidified gas mixture is supplied to the respiratory tract, which creates a positive pressure in the lungs throughout the entire respiratory cycle. Against this background, at a given frequency (usually from 10 to 1 time in 1 min), the respirator produces an artificial breath, which coincides (synchronized PPVL) or does not coincide (unsynchronized LLVL) with the patient's next spontaneous inhalation. The gradual delivery of artificial breaths prepares the patient for spontaneous breathing.

The mode of mechanical ventilation with positive end-expiratory pressure (PEEP) from 5 to 15 cm of water has become widespread. Art. and more (for special indications!), in which the intrapulmonary pressure during the entire respiratory cycle remains positive with respect to atmospheric. This mode contributes to the best distribution of air in the lungs, a decrease in blood shunting in them and a decrease in the alveolar-arterial oxygen difference. With artificial ventilation of the lungs with PEEP, atelectasis is straightened, pulmonary edema is eliminated or reduced, which helps to improve oxygenation of arterial blood with the same oxygen content in the inhaled air. However, with positive pressure ventilation at the end of inspiration, the intrathoracic pressure increases significantly, which can lead to difficulty in blood flow to the heart.

The relatively rarely used method of mechanical ventilation - electrostimulation of the diaphragm - has not lost its significance. By periodically irritating either the phrenic nerves or directly the diaphragm through the external or needle electrodes, it is possible to achieve its rhythmic contraction, which ensures inhalation. Electrical stimulation of the diaphragm is often used as an auxiliary mechanical ventilation method in postoperative period, as well as in the preparation of patients for surgery.

With modern anesthesia (see. General anesthesia), mechanical ventilation is performed primarily in connection with the need to provide muscle relaxation with curariform drugs. Against the background of mechanical ventilation, it is possible to use a number of analgesics in doses sufficient for full anesthesia, the introduction of which under conditions of spontaneous breathing would be accompanied by arterial hypoxemia. By maintaining good blood oxygenation, mechanical ventilation helps the body to cope with surgical trauma. In a number of surgical interventions on the organs of the chest (lungs, esophagus), separate intubation of the bronchi is used, which makes it possible to turn off one lung from ventilation during the operation to facilitate the work of the surgeon. Such intubation also prevents leakage of contents from the operated lung into the healthy lung. In surgical interventions on the larynx and airways, transcatheter high-frequency jet ventilation is successfully used, which facilitates the examination of the operating field and allows maintaining adequate gas exchange when the trachea and bronchi are opened. Considering that under conditions of general anesthesia and muscle relaxation, the patient cannot respond to hypoxia and hypoventilation, it is of particular importance to control the content of blood gases, in particular, constant monitoring of the partial pressure of oxygen (pO2) and partial pressure of carbon dioxide (pCO2) percutaneously with using special sensors. When performing general anesthesia in emaciated, debilitated patients, especially in the presence of respiratory failure before surgery, with severe hypovolemia, the development of any complications during general anesthesia that contribute to the occurrence of hypoxia (lowering blood pressure, cardiac arrest, etc.), the continuation of mechanical ventilation in within a few hours after the end of the surgery. In the event of clinical death or agony, mechanical ventilation is a mandatory component of the resuscitation benefit. It can be stopped only after complete restoration of consciousness and full-fledged independent breathing.

In the complex of intensive therapy (Intensive therapy), mechanical ventilation is the most powerful means of combating acute respiratory failure. It is usually passed through a tube that is inserted into the trachea through the lower nasal passage or tracheostomy. Careful care of the airways and their complete drainage are of particular importance. With pulmonary edema (Pulmonary edema), pneumonia (Pneumonia), respiratory distress syndrome in adults (Respiratory distress syndrome in adults), artificial ventilation with PEEP is sometimes indicated up to 15 cm of water. Art. and more. If hypoxemia persists even with a high PEEP, the combined use of traditional and high-frequency jet mechanical ventilation is indicated.

Auxiliary mechanical ventilation is used in sessions up to 30-40 minutes in the treatment of patients with chronic respiratory failure. It can be used in outpatient clinics and even at home after appropriate training of the patient.

Mechanical ventilation is used in patients in a coma (trauma, brain surgery), as well as with peripheral lesions of the respiratory muscles (polyradiculoneuritis, spinal cord injury, amyotrophic lateral sclerosis). In the latter case, mechanical ventilation has to be carried out for a very long time - months or even years, which requires particularly careful patient care. Mechanical ventilation is widely used in the treatment of patients with chest trauma, postpartum eclampsia, various poisonings, cerebrovascular accidents, tetanus, and botulism.

Monitoring the adequacy of mechanical ventilation. When carrying out emergency mechanical ventilation using simple methods, it is sufficient to observe the color of the skin and movements of the patient's chest. The chest wall should rise with each inhalation and collapse with each exhalation. If, instead, the epigastric region rises, then the blown air does not enter the respiratory tract, but into the esophagus and stomach. The cause is most often the wrong position of the patient's head.

When carrying out long-term mechanical ventilation, its adequacy is judged by a number of signs. If the patient's spontaneous breathing is not suppressed pharmacologically, one of the main signs is a good adaptation of the patient to the respirator. With a clear consciousness, the patient should not have a feeling of lack of air, discomfort. Breathing sounds in the lungs should be the same on both sides, the skin is of the usual color, dry. Signs of inadequacy of mechanical ventilation are increasing tachycardia, a tendency to arterial hypertension, and when using artificial ventilation with PEEP - to hypotension, which is a sign of a decrease in blood flow to the heart. It is extremely important to control pO2, pCO2 and the acid-base state of the blood; pO2 during mechanical ventilation should be maintained at least 80 mm Hg. Art. In severe hemodynamic disturbances (massive blood loss, traumatic or cardiogenic shock), an increase in pO2 up to 150 mm Hg is desirable. Art. and higher. pCO2 should be maintained by changing the minute volume and respiration rate at the maximum level at which the patient fully adapts to the respirator (usually 32-36 mm Hg). During prolonged mechanical ventilation, metabolic acidosis or metabolic alkalosis should not occur. The first one most often indicates violations of peripheral blood circulation and microcirculation, the second - about hypokalemia and cellular hypohydration.

Complications. With prolonged mechanical ventilation, tracheobronchitis, pneumonia often occur; pneumothorax is a dangerous complication, because under mechanical ventilation, air rapidly accumulates in the pleural cavity, squeezing the lung, and then displacing the mediastinum. During mechanical ventilation, it is possible for the endotracheal tube to slip into one of the bronchi (more often to the right). This often happens during transportation and movement of the patient.

During ventilation, a bulge may form in the inflatable cuff of the endotracheal tube, which covers the opening of the tube and prevents ventilation.

Features of artificial ventilation in pediatrics. In children, especially early age, laryngitis, laryngeal edema and other complications associated with intubation easily occur. Therefore, they are advised to perform tracheal intubation with a tube without an inflatable cuff. Tidal volume and respiratory rate are selected according to age and body weight. In newborns, a respiratory rate of 30-40 or more is set in 1 min. With asphyxiation of newborns, aspiration of meconium and respiratory disorders caused by infantile cerebral palsy, along with traditional simple and hardware methods of mechanical ventilation, oscillatory high-frequency mechanical ventilation with a frequency of 600 or more per 1 min is successfully used.

Features of artificial lung ventilation in military field conditions. In military field conditions, as well as when providing assistance to victims of peacetime disasters (fires, earthquakes, accidents in mines, railway accidents, plane crashes), mechanical ventilation can be complicated by the presence in the atmosphere of various kinds of harmful impurities (toxic gases and combustion products, radioactive substances, biological agents, etc.). A person providing assistance, being in a gas mask, oxygen mask or protective suit, cannot resort to mechanical ventilation using the mouth-to-mouth or mouth-to-nose method. Even after removing the victim from the affected area, it is dangerous to use these methods, because toxic or biological agents may already be in his lungs and enter the respiratory tract of the rescuer. Therefore, hand-held ventilators - self-expanding bags and furs - are of particular importance. All of them, as well as automatic respirators, must be equipped with special filters-deactivators to prevent harmful impurities from entering the patient's respiratory tract. An exception is drugs for high-frequency jet ventilation, if they have an autonomous source of compressed gas and are used transcatheterically (without injection of ambient air).

Bibliography: Burlakov R.I., Galperin Yu.Sh. and Yurevich V.M. Artificial lung ventilation: Principles, methods, equipment, M., 1986, bibliogr .; Zilber L.P. Artificial ventilation of the lungs with acute respiratory failure, M., 1978, bibliogr .; Cara M. and Poyavere M. First health care for breathing disorders caused by road trauma, poisoning and acute diseases, per. with French., M., 1979; Kassil V.L. Artificial ventilation of the lungs in intensive care, M., 1987, bibliogr .; Popova L.M. Neuroreanimatology, p. 104, M., 1983; Smetnev A.S. and Yurevich V.M. Respiratory therapy in the clinic of internal diseases, M., 1984.

An artificial lung ventilation apparatus (ventilator) is a medical equipment that is designed for forced supply of a gas mixture (oxygen + compressed dried air) into the lungs in order to saturate the blood with oxygen and remove carbon dioxide from the lungs.

The ventilator can be used both for invasive (through an endotracheal tube inserted into the patient's airways or through a tracheostomy) and for non-invasive mechanical ventilation through a mask.

The ventilator can be either manual (AMBU bag) or mechanical. Compressed air for the operation of a mechanical apparatus can be supplied from both central system gas supply medical institution or a compressed air cylinder (during transportation), and from an individual mini-compressor (reality in the countries of the ex-USSR).

Modern ventilators are extremely high-tech medical equipment. They provide respiratory support to the patient in both volume and pressure. There are a variety of ventilation modes, including AUTOMODE, which allows the patient to switch from controlled breathing to spontaneous breathing.

Currently, the most advanced technology for synchronizing a ventilator with a patient is neuro-controlled ventilation of the lungs (NAVA technology; developed by Maquet), when the signal coming from the respiratory center of the medulla oblongata along the phrenic nerve to the diaphragm is recorded by special highly sensitive sensors located in the transition area esophagus into the stomach (cardia area).

Surgical wound infections (HRI) develop within 30 days after surgery, except for those cases when the wound remains foreign body... In case of implantation of foreign material, the risk of wound infection persists for a year.

Depending on the depth of tissue damage, wound infections are divided into three clinically significant categories:
a) Surface HRI.
b) Deep HRI (involving fascia and muscles).
c) Cavity SRI (spread of infection to any anatomical formations affected by surgical manipulations).

2. What are the classic signs of superficial, deep and cavitary surgical wound infection (SRI)?

Superficial and deep surgical wound infections (SRI):
Calor (heat)
Tumor (swelling)
Rubor (redness)
Dolor (pain)

Cavity surgical wound infection (CSI) is indicated general symptoms: fever, intestinal obstruction and / or shock. Additional studies may be required to clarify the diagnosis.

3. Is it possible to predict the further development of SRI based on the type of wound?

Yes. Based on the degree of contamination, wounds can be classified into one of four categories: clean, clean-contaminated, contaminated, and dirty infected. Clean wounds - atraumatic wounds without signs of inflammation, with full adherence to the rules of asepsis and without opening the hollow organs. Clean-contaminated wounds are identical to the previous ones, except that the hollow organ was opened.

Contaminated wounds are caused by a clean object, with minimal contact with infected material. Dirty, infected wounds develop as a result of trauma from a contaminated object or significant ingestion of infected material into the incision. According to the literature, the frequency of suppuration for each category of wounds is 2.1%; 3.3%; 6.4% and 7.1% respectively.

4. What other factors, besides the type of wound, allow predicting the development of wound infection?

Physical condition (but the classification of the American Society of Anesthesiologists), the results of intraoperative bacterial cultures and length of hospital stay before surgery are important predictors of postoperative CRI. Adequate regional blood supply is also important, as evidenced by the low frequency of wound suppuration in the facial area.

5. What factors can the surgeon control to reduce the incidence of SSI?

Reducing the incidence of postoperative infection is helped by shortening the duration of surgery, obliterating the dead space, careful hemostasis, minimizing the presence of foreign materials (including excess sutures) and gentle tissue handling. The use of electrocoagulation for hemostasis does not increase the incidence of wound infections.

6. Does prophylactic systemic antibiotics reduce the likelihood of infection?

The use of antibiotics for contaminated and dirty infected wounds is absolutely indicated and is more of a cure than a prevention. For any clean, contaminated wounds, antibiotic prophylaxis is recommended. Initially, prophylactic antibiotic treatment for clean wounds was carried out only in the case of implantation of synthetic material. The general consensus was that any benefit of prophylactic antibiotics in pure surgery outweighs the potential risk of side effects from misuse.

However, strictly speaking, after any operation, a certain amount of foreign material (for example, sutures) remains in the wound, and even a single suture can lead to suppuration due to bacteria introduced into the brine, which in themselves will not cause infection. In addition, a large, prospective, randomized trial of prophylactic antibiotic use in pure surgery has shown the obvious value of prophylaxis in reducing the incidence of SSI.

7. When should antibacterial prophylaxis be carried out?

The maximum positive result is achieved when there is a therapeutic concentration of antibiotics in the tissues at the time of contamination. Consequently, the effectiveness of prophylaxis is increased if antibiotics are given immediately before the surgical incision; later prophylactic administration of antibiotics is pointless. Multiple dose antibiotic regimens have no advantage over single dose regimens. Random choice of antibiotics (not in line with hospital recommendations) can even increase the incidence of SSI.

8. Is it necessary to carry out pulse-hydropressive wound treatment in the operating room?

Yes. A comprehensive study of the results of pulse-hydropressive wound treatment in soft tissue contamination was carried out. It has also been shown to be seven times more effective in reducing bacterial contamination than blowing with a rubber bulb. The elastic properties of soft tissues facilitate the removal of microparticles in the intervals between fluid supply. The optimum pressure and pulse frequency should be 4-5 kg \u200b\u200bper cm2 and 800 pulses per minute, respectively.

9. Do antibiotics and hydropressive treatment allow for more closure of dirty or contaminated wounds by primary intention?

Despite these effective therapies, the decision on primary wound closure remains challenging for the surgeon, requiring experience and medical intuition. Primary closure of the brine is always preferable, as it shortens the incidence of disease and improves the cosmetic result. However, when the infection develops, the consequences are quite serious, and the brine must be reopened. The decision on the primary closure of the brine is made taking into account the degree of contamination, the amount of necrotic tissue or the size of the dead space left, the adequacy of the blood supply, the effectiveness of drainage, the time elapsed since damage and implantation of foreign material.

In general, it is safer to leave the questionable wound open and allow it to heal by secondary intention or to perform delayed closure of the brine after 3-5 days. Delayed sutures are the trade-off that often distinguishes the experienced surgeon from the enthusiastic layman.

10. The usual frequency of suppuration in typical operations.

Cholecystectomy 3%
Inguinal hernia repair 2%
5%
Thoracotomy 6%
Colectomy 12%

11. What microorganisms are most often the causative agents of wound infections?

Since staphylococcus aureus is one of the most common organisms on the skin, it is also the most common cause of CSI. However, SRIs in a number of areas are associated with other microorganisms. If the intestine has been opened, the causative agents of the infection are usually representatives of the Enterobacteriaceae family and anaerobes; at dissection biliary tract and the esophagus, in addition to the named microbes, enterococci become infectious agents. Other areas, such as the urinary tract or vagina, contain microorganisms such as group D streptococci, Pseudomonas, and Proteus.

12. How is wound infection related to timing surgery?

In typical cases, a wound infection develops 5-7 days after surgery; however, a lightning-fast form may develop. Clostridial infections develop when there is a large amount of nonviable tissue in an enclosed space and are a classic example of the fulminant form of CVI.