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Lecture notes, cheat sheets
General surgery. Lecture notes: briefly, the most important
Directory / Lecture notes, cheat sheets Table of contents
LECTURE № 1. Prevention of infectious complications in surgery. Asepsis, general questions. Sterilization. Treatment of the surgeon's hands 1. Asepsis Asepsis is a set of measures aimed at preventing contamination of the surgical wound by microorganisms. The principles of asepsis are carried out using various methods: chemical, physical, biological. The principles of asepsis must be observed carefully and strictly, starting from the first contact of the patient with the doctor in the emergency department, with the emergency doctor. First contact physicians, faced with wounds and injuries, must provide first aid and deliver the patient to the hospital as soon as possible. To prevent infection from entering the wound, a sterile gauze bandage is immediately applied to it. In a surgical hospital, the principles of asepsis are ensured by the correct organization of the work of personnel, the correct layout of departments, and thorough theoretical training on this issue. The main task of asepsis in a surgical hospital is to prevent microbial agents from entering the wound. All instruments, tissues, materials, and hands of the surgeon in contact with the wound must be sterile. In addition to preventing this route of infection in the wound, it is necessary to prevent the airborne route of infection transmission. One of the main points is the organization of the work of the hospital. In each surgical hospital, various departments are distinguished in accordance with specialization. These departments include thoracic, urological, cardiac surgery, etc. There is a department of purulent surgery. This department should be isolated from other departments, medical personnel, patients themselves should not come into contact with patients from other departments. If such a department is not provided in the hospital, the department should have separate operating rooms, manipulation rooms, dressing rooms for patients with purulent-inflammatory diseases. Doctors, nurses, supplies and instruments, and wards for such patients should be separated from other patients. In addition, it is known that the content of microorganisms in the air of the operating room during the day increases significantly, therefore it is extremely important to change into sterile clothes when working in the operating room, use sterile gauze masks, caps, completely limiting any possibility of microorganisms entering the wound. It is especially important to follow these rules for students who observe the progress of the operation directly near the surgical field. 2. Sterilization This is a method aimed at eliminating living microorganisms and their spores from the surface of materials, tools and other objects that come into contact with the wound surface before, after and during surgery. Dressings, underwear, suture material, rubber gloves should be sterilized (some simple outpatient procedures, such as blood sampling for analysis, can be carried out in disposable sterile gloves), and tools. There are the following methods of sterilization. 1. Boiling (its duration depends on the type of pollution). 2. Processing with flowing steam or steam supplied under pressure in a special apparatus - an autoclave (for sterilizing contaminated dressings, linen, gowns, shoe covers). Temperature control is carried out in various ways. One of these methods is to place test tubes containing substances whose melting point corresponds to or is somewhat lower than the required temperature in the sterilization apparatus into a bix. The melting of these substances indicates that the temperature required for sterilization has been reached. 3. Bactericidal effect of ultraviolet radiation (for air disinfection in operating rooms, dressing rooms and manipulation rooms). Bactericidal lamps are turned on at the end of the working day after cleaning the premises for 3 hours, and if there is a large flow of patients during the day, it is advisable to carry out treatment with lamps during the day. 3. Treatment of the surgeon's hands according to the Spasokukotsky-Kochergin method Hand treatment is one of the most important methods of asepsis, which completely prevents the access of microorganisms to the surgical field. Wash your hands with soap and a brush before using this method. The surgeon's hands are carefully lathered with a brush in a certain direction. They begin to process the hands from the proximal phalanges of the fingers, first their palmar, and then the back surface. Carefully process each finger and interdigital spaces, observing the specified sequence. Then they wash the wrist: first from the palmar, then from the back. The forearm is processed in the same sequence. The left hand is washed first, then the right hand in the same way. This allows you to clean the skin of the hands from pollution received during the day during professional and household activities. In the future, the processing of the skin of the hands is carried out according to a special technique. The first stage includes the treatment of hands in a 0,5% solution of ammonia. The sequence of treatment of the surgeon's hands must be carefully observed. A solution of ammonia is placed in two basins, in each of which hands are treated sequentially according to the described method for 3 minutes: first in one basin, and then for the same time in the other. After that, the hands are blotted with a sterile napkin, and then wiped dry. The second stage is the treatment of hands in the same sequence with a 96% alcohol solution for 4-5 minutes. After that, the surgeon puts on sterile gloves, after which he can only touch the surgical field. Particular attention is paid to the processing of the hands of a surgeon working in the department of purulent surgery. Sterility control should be especially thorough, for which it is necessary to treat the hands not only before surgery, but also after examining a purulent wound, manipulations in it, dressings. To do this, the hands are treated according to the specified method with gauze swabs moistened with 70% ethyl alcohol for 3 minutes. LECTURE № 2. Prevention of infectious complications in surgery. Antiseptics and its types. Mechanical, chemical, physical, biological antiseptics 1. Mechanical antiseptic Antiseptics is a set of chemical, physical, biological and other measures aimed at the destruction of microorganisms in the body of a patient or in a wound. Mechanical antiseptic. This method is based on the mechanical removal of microorganisms from the wound. The main manipulation aimed at achieving this goal is the primary surgical treatment of the wound. It should be carried out for all patients and as soon as possible. This allows you to significantly clean the wound from microorganisms and prevent purulent complications of the wound. Primary surgical treatment is as follows. First, the skin around the wound is cleaned with an antiseptic, local anesthesia is performed, then all remnants of non-viable tissues, bone fragments, foreign bodies, fragments of injuring projectiles, superficially stuck bullets, chips are removed from the wound, tissue detritus is removed from the bottom and edges of the wound. The wound is dried with a sterile cotton swab and washed with an antiseptic solution. The edges of the wound are economically excised, removing all non-viable tissues. Examining the bottom of the wound, it is established whether there is damage to the vessels, nerve trunks, muscles. If there is damage, its degree is assessed and, if the vessel cannot be restored, the vessel is ligated in the wound. If the damage is not so significant, a vascular suture is performed, restoring its integrity. Similarly, the nerve trunks are restored, the primary suture of the nerve is applied, and the edges of the muscles are sutured. If the initial treatment of the wound was performed in a timely manner (no later than 24 hours after the injury) and the likelihood of complications is negligible, the suture is applied immediately after it. This is the original seam. A primary delayed suture is applied to the wound if more than 24 hours have passed since the injury before surgical treatment. In this case, sutures are applied after surgical treatment of the wound, but are tightened only after 5 days, when the likelihood of purulent complications is minimal, but before the appearance of granulations. If there are already signs in the wound that make it possible to suspect the possibility of infection (late debridement, flabby edges or a grayish-pink color of the bottom of the wound), the wound is left open and sutured only after the first granulations appear. This is a delayed suture. Physical antiseptic methods based on the use of physical methods to reduce microbial contamination of the wound. Such methods include the installation of drainage. It is known that the main condition for curing a purulent infection is the removal of purulent exudate from the focus. This significantly reduces the duration of the recovery period. The maximum part of the content is removed during surgery, but since the inflammation process cannot stop at once, a small amount of discharge accumulates in the wound for a certain time. Recovery will occur the faster, the more correctly the drainage is installed in the wound. The basic rule of purulent surgery is the creation of two incisions - an aperture and a counter-aperture. The first incision is created at the location of the fluctuation, and the other (there may be several) is created in the lower section of the wound - for the best outflow from the bottom of the wound. Drainages are rubber strips of various sizes (according to the size of the wound) that are installed in the incisions. In some cases (for example, with pleural empyema), a drainage in the form of a transparent polyethylene tube is attached to a special transparent glass vessel with measured divisions, which makes it possible to judge the amount and nature of the discharge, the severity of the inflammatory process, the quality and effectiveness of treatment. A well-known method of mechanical antiseptics, called Mikulich's tampon. The essence of this method is to create more favorable conditions for the removal of draining tampons from the wound. This improves the outflow of contents and contributes to a more accurate removal of tampons from the wound. To create a Mikulich tampon, it is necessary to sew a thread to a sterile multilayer gauze napkin. The resulting niche is filled with sterile cotton swabs, which must be removed in a timely manner in order to avoid deterioration in the efficiency of the outflow of the contents. The napkin must be replaced in a timely manner. 2. Physical antiseptic The physical method is considered to be the impact on the wound of the ultraviolet spectrum of radiation, which has a bactericidal effect on the wound area. In some cases, aseptic gauze dressings are applied to the wound to ensure the outflow of the wound contents. The effectiveness of the method is significantly increased if the gauze bandage is impregnated with a hypertonic sodium chloride solution. Along the concentration gradient, discharge from the wound (together with detritus) enters the dressing, thereby significantly improving wound drainage. 3. Chemical antiseptic Chemical antiseptic methods are represented by a variety of chemicals that have a detrimental effect on the growth and reproduction of bacteria. Such substances include, for example, sulfa drugs. The use of hydrogen peroxide as an antiseptic is widespread in purulent surgery. Its mechanism of action is mixed. So, the ingress of hydrogen peroxide into the wound and the release of oxygen in the form of abundant foam, consisting of small bubbles, on the one hand, have an adverse effect on microorganisms and cause their death, on the other hand, contribute to the mechanical removal of purulent contents and tissue detritus from the purulent wound. 4. Biological antiseptic Biological antiseptic methods are currently the most extensive effective group of antiseptic methods. These are antibiotics - chemical preparations that act bactericidal and bacteriostatically, and at present the emphasis is on the development of antibiotics with maximum efficiency and minimal side effects. Broad-spectrum antibiotics can be used in the early stages of the disease until the pathogens are verified. In addition, this group of agents includes bacteriophages, serums and toxoids. The methods of action of antiseptic drugs are quite diverse. So, ointments with the use of antiseptic drugs, sulfonamides, antibiotics are widespread. LECTURE No. 3. Features of surgical treatment 1. Stages of surgical treatment. Preoperative stage The treatment of surgical diseases is clearly divided into three stages, such as: the preoperative period, the immediate surgical intervention and the postoperative period. Preoperative period begins from the moment the patient arrives for inpatient treatment (in elective surgery, part of the activities can be carried out at the outpatient stage) and ends by the time the operation itself begins. The preoperative period itself consists of two blocks, which often (especially in emergency surgery) cannot be divided by time. This is a block of diagnostic and a block of preparatory measures. During the diagnostic stage of the preoperative period, the following goals should be achieved: it is necessary to clarify the diagnosis of the underlying disease, collect information about concomitant diseases in the most complete way, find out the functionality of the patient's organs and systems, decide on the tactics of managing the patient, if necessary, clearly formulate indications for it, decide with the necessary volume of the forthcoming surgical intervention. The preparatory block includes the following activities: conservative methods of treating the underlying disease, correction of impaired body functions aimed at preparing for surgery, direct preparation for surgery (premedication, shaving, etc.). In order to most fully fulfill all the requirements for examining a patient at the diagnostic stage, it is necessary to adhere to a certain algorithm. Swipe and pass: 1) preliminary examination (subject to a thorough analysis of complaints, the history of life and illness, which in chronic patients is traced from the onset of the disease, and in emergency patients - from the beginning of this attack); 2) a complete physical examination of the patient (palpation, percussion, auscultation according to all requirements); 3) the necessary minimum of special examination methods: biochemical analysis of blood and urine, determination of the blood group and Rh factor, blood clotting time and coagulogram, examination by a dentist, ENT doctor, consultation of a therapist, urologist - for men, gynecologist - for women, all patients over 40 years old - ECG. With planned treatment, additional studies are also possible (in order to clarify the presence of concomitant diseases). Duration of the preoperative period can vary over a very wide range - from several minutes to several months (depending on the urgency of the surgical intervention). In recent years, there has been a trend towards a reduction in preoperative intervention. Due to the high cost of the day of the patient's stay in the hospital, most of the activities of the diagnostic block during elective operations are carried out at the outpatient stage. Even a whole area of outpatient surgery is developing, but more on that below. The result of the preoperative period is the writing of a preoperative epicrisis, which should reflect the following main points: the rationale for the diagnosis, the indications for the proposed surgical intervention and its scope, the proposed anesthesia and the patient's necessarily documented consent to the operation. 2. Preparation for surgery Only the main points of preoperative preparation, which is mandatory for all planned surgical interventions, will be reflected here. To the totality of these measures, some special methods are added (such as metabolic correction during operations for thyrotoxic goiter, preparation of the large intestine during coloproctological operations). Preparation of the nervous system. The patient is a priori regarded as being in a state of neurosis. No matter how strong and strong-willed a person is, he always returns in his thoughts to the upcoming operation. He is tired of previous suffering, often there is excitement, but more often depression, depression, increased irritability, poor appetite and sleep. To level the negative aspects of this condition, you can apply medication (the use of light anxiolytics and tranquilizers), you must strictly follow all the rules and requirements of deontology, as well as properly organize the work of the planned surgical department (patients who have not yet been operated on should be placed separately from those who have already undergone surgery). ). Preparation of the cardiorespiratory system. During the normal activity of the cardiovascular system, special training is not required, but breathing correctly is a skill necessary for the patient, especially if surgical intervention on the chest is expected. This will further protect the patient from possible inflammatory complications. If there are any diseases of the respiratory tract, this must be given great attention. In the acute stage of a chronic disease or in acute diseases (bronchitis, tracheitis, pneumonia), a planned operation is contraindicated. If necessary, expectorant drugs, medicines, antibiotic therapy are prescribed. This is of great importance, since nosocomial pneumonia can sometimes nullify the work of the entire team of surgeons. If the patient has slight functional changes in the activity of the cardiovascular system, their correction is necessary (taking antispasmodics, beta-blockers, drugs that improve the metabolism of the heart muscle.). In case of severe organic pathology of the cardiovascular system, it is necessary to treat the therapist to the maximum possible compensation for impaired body functions. Then a comprehensive study is carried out, according to its results, a conclusion is made about the possibility of an operation in this case. A significant percentage is currently assigned to thromboembolic complications. Therefore, all patients need to examine the blood coagulation system, and those at risk of thromboembolism should be prevented (use heparin and its preparations, as well as aspirin). High risk groups - patients with varicose veins, obesity, oncological patients who have a violation of the blood coagulation system, forced to spend a long time in bed. Often, people who are preparing for a planned operation have anemia (hemoglobin is reduced to 60-70 g / l.). Correction of these violations is necessary, since a slowdown in regeneration may be observed. Preparation of the digestive system. Sanitation of the oral cavity to eliminate foci of a dormant infection, which can lead to stomatitis and parotitis. Sanitation of the colon before surgery on it, which includes mechanical cleaning and chemotherapeutic suppression of microflora. Immediately prior to the operation, a ban on "nothing inside" is imposed, which means depriving the patient of food and water from the very morning on the day of the operation. An enema is required 12 hours before surgery, unless special bowel preparation is performed. Laxatives try not to prescribe. To increase the body's resistance to operational stress, it is necessary to take care of the metabolic protection of the liver and increase its glycogen stores. For this, infusions of concentrated glucose solutions with vitamins (ascorbic acid, group B) are used. Methionine, ademetionine and Essentiale are also used. Preparation of the urinary system. Before the operation, a mandatory study of kidney function is carried out, since after the operation they will have to face increased requirements (massive infusion therapy, which includes the introduction of saline and colloidal solutions, glucose solutions, blood preparations and components, medicines). Preparing for emergency surgery. Emergency operations are necessary for injuries (soft tissue injuries, bone fractures) and acute surgical pathology (appendicitis, cholecystitis, complicated ulcers, strangulated hernias, intestinal obstruction, peritonitis). Preparing for an emergency operation is fundamentally different from preparing for a planned intervention. Here the surgeon is extremely limited in time. In these operations, the duration of preparation is determined by the tactical algorithm chosen by the operating surgeon. The nature of the preparation may also differ for various diseases, but still there are common points. Enemas are usually not done during emergency operations, so as not to waste time. The contents of the stomach are removed using a probe. Premedication is carried out as quickly as possible. The surgical field is prepared on the way to the operating room. Preparing for surgery in the elderly. It is carried out according to the same principles as the preparation of other categories of patients. It is only necessary to take into account the severity of concomitant pathology and correct existing disorders with the help of a general practitioner and an anesthesiologist. The volume of the forthcoming surgical intervention is selected in accordance with the general somatic condition of the patient and his ability to endure the proposed anesthesia. Preparing for surgery in pediatric patients. In this case, they try to minimize preoperative preparation. All studies that can be performed outside the hospital are carried out on an outpatient basis. It should be remembered that children have a looser bronchial mucosa, which makes them more prone to respiratory infections (bronchitis, pneumonia). 3. Postoperative period This period largely determines the patient's further quality of life, since the timing and completeness of recovery depend on its course (complicated or uncomplicated). During this period, the patient's body adapts to the new anatomical and physiological relationships that were created by the operation. This period does not always go smoothly. By time allocate: 1) early postoperative period (from the end of the operation up to 7 days); 2) late postoperative period (after 10 days). The duration of the postoperative period can vary from patient to patient, even with the same type of surgery. It's all about the individual qualities of the patient's body and the characteristics of his reaction to stress. This explains the concept of Selye, who regarded surgical trauma as the strongest stress that causes the development of the general adaptation syndrome (GAS). The first stage of OSA, or the anxiety stage (when considering the postoperative period, it is called the catabolic phase), lasts on average (depending on the severity of the surgical intervention) from 1 to 3 days. Stress causes activation of the sympathoadrenal and hypothalamic-pituitary-adrenal systems. This leads to increased secretion of glucocorticoid hormones, which cause many different effects. This is irritation of the central nervous system (hypothermia, hypotension, depression, myoplegia), increased permeability of cell membranes, activation of catabolic processes and (as a result) the development of dystrophy, negative nitrogen balance. Resistance phase, or anabolic phase, lasts up to 15 days. In this phase, anabolism processes begin to predominate. There is a normalization of blood pressure and body temperature, the energy and plastic reserves of the body increase and restore. There is an active protein synthesis, reparative processes are activated. Some authors also distinguish the phase of reverse development, i.e., the restoration of body functions disturbed during the catabolic phase. But not everyone shares this point of view. The anabolic phase smoothly passes into the convalescence phase, or, as it is also called, weight recovery phase. For a smooth course of the postoperative period, it is extremely important that the first phase is not delayed, since catabolism processes prevail in this case, regeneration is disturbed, which opens the way for complications. Laboratory diagnosis of such disorders: 1) due to the negative balance of potassium, its content in the urine increases, its concentration in the blood decreases; 2) in connection with the breakdown of protein, there is an increase in nitrogenous bases in the blood; 3) there is a decrease in diuresis. In the early postoperative period, the patient is usually concerned about pain in the area of operative intervention, general weakness, loss of appetite and often nausea, especially after interventions on the abdominal organs, thirst, bloating and flatulence (although there is more often a violation of gas and stool discharge), body temperature can rise to febrile numbers (up to 38 ° C). 4. Complications in the postoperative period. Methods of prevention and correction В early postoperative period (especially on the first day), patients need constant dynamic monitoring in order to timely recognize and treat possible complications that may occur with any type of surgical intervention. Naturally, after emergency interventions, complications develop more often, since the operation is performed in a completely unexamined patient (often in the stage of decompensation of vital functions). Among the complications it should be noted: 1) bleeding (much more often such a complication occurs in the early postoperative period, but can also be observed in the late period). This is due either to insufficient hemostasis, or to the fact that ligatures fly off the vessels. Perform a revision of the wound and ligation of the bleeding vessel; 2) complications from the respiratory system (respiratory disorders in the post-anesthetic period, atelectasis, pneumonia). Manifested by the appearance of shortness of breath, cyanosis, tachycardia; 3) acute cardiovascular failure (pulmonary edema). Manifested by lack of air, pallor, sweating, acrocyanosis, tachycardia, bloody sputum, swelling of the cervical veins. Treatment of this complication is carried out in conditions of resuscitation complication; 4) postoperative paresis of the gastrointestinal tract. Manifested by nausea, vomiting, hiccups. To prevent this complication, if indicated, the mesentery is infiltrated intraoperatively with a weak solution of novocaine, the patient is activated early after the operation. In the treatment, measures such as epidural block, perirenal blockades are used, from pharmacological methods - the introduction of prozerin; 5) development of hepatic-renal insufficiency. Manifested by the development and progression of jaundice, hypotension, tachycardia, drowsiness, lethargy, decreased diuresis, complaints of nausea and vomiting; 6) thromboembolic complications. Most often they develop in patients with a predisposition to the formation of blood clots in the veins of the lower extremities (cancer patients, patients with obesity, varicose veins, heart failure), with atrial fibrillation after operations on the vessels and the heart (in the heart and other vessels). To prevent these complications, heparin and its low molecular weight analogues are used according to special schemes. For prevention of complications The following general activities are of great importance: 1) the fight against pain. It is extremely important, because severe pain is a powerful stress factor. They can lead to lengthening of the first phase of the postoperative period; 2) improvement of the function of external respiration (breathing exercises); 3) combating hypoxia and hypovolemia (correction of water and electrolyte disorders with the help of adequate infusion therapy); 4) early activation of the patient. В late postoperative period It is extremely important to constantly monitor the patient, since complications may arise associated with insufficient adaptation of the body to new anatomical and physiological relationships or an inadequate response of the body to surgical trauma. 5. Examination of the surgical patient Examination of a surgical patient has its own characteristics. Quite often, patients need emergency treatment, when the examination is not yet fully completed, but the principle is the following: "Without a diagnosis, there is no treatment." Only from a clearly formulated diagnosis can a tactical algorithm for managing a patient be derived and clearly define the indications for surgery, its nature and scope. When examining a patient, one should not forget that the basis of diagnosis is a survey and a physical examination of the patient. Special research methods play only an auxiliary role. Naturally, one should strive to determine the specific disease that the patient has, but one should not forget that some conditions, such as an acute abdomen, shock, loss of consciousness, require emergency therapeutic measures even before their cause is clarified. An important point in the examination of a surgical patient is the assessment of operability and operational risk. Examination of the patient begins with the clarification of the patient's complaints (and they should be identified as fully as possible). Next, proceed to the collection of an anamnesis of the disease and an anamnesis of life. Particular attention should be paid to the presence of concomitant diseases. Then proceed to the physical examination (examination, palpation, percussion, auscultation). As a rule, after questioning and physical examination of the patient, it becomes possible to form an idea of a likely diagnosis. The use of special research methods is determined by what disease is suspected in a given patient. These research methods confirm or refute the initial diagnostic assumption. The patient may need, in addition to the necessary minimum laboratory tests (OAC, OAM, stool tests for worm eggs, blood for RW), and a biochemical blood test, coagulogram, blood group and Rh factor, blood and urine tests for α-amylase. Also, when examining a surgical patient (especially with purulent pathology), it is important to conduct a complex of microbiological studies, including microscopy, bacteriological examination to determine the sensitivity of the isolated microflora to antibiotics. К instrumental research methods include endoscopic, x-ray, ultrasound, as well as tomography (computer and magnetic resonance). Endoscopic research methods. 1. Laryngoscopy. 2. Bronchoscopy. 3. Mediastinoscopy. 4. Esophagogastroduodenoscopy. 5. Retrograde cholangiopancreatography (RCPG). 6. Fibrocolonoscopy. 7. Sigmoidoscopy. 8. Cystoscopy. 9. Laparoscopy. 10. Thoracoscopy X-ray research methods. 1. Minimally invasive: 1) fluoroscopy behind the screen; 2) radiography of various areas of the body; 3) tomographic research methods. 2. Invasive (require strict indications, since they give a high percentage of complications): 1) angiography; 2) percutaneous transhepatic cholangiography (PCH); 3) fistulography; 4) excretory urography; 5) intraoperative radiological research methods. Ultrasonic research methods. 1. Scanning. 2. Echolocation. 3. Dopplerography. LECTURE No. 4. Surgical operations 1. General concept Surgery is a set of measures carried out by means of physiological and mechanical effects on the organs and tissues of the body. Operations are divided into bloody and bloodless (reduction of dislocations, closed reduction of fractures, endoscopic interventions). Blood operations are surgical interventions that occur with the dissection of the skin and subcutaneous tissue. From the formed wound, the surgeon in a sharp or blunt way penetrates through the tissues to the pathological focus (altered tissues or organ). Classification of operations by purpose. 1. Medicinal: 1) radical (with the help of which the pathological focus is completely removed from the body); 2) palliative (as a result of this operation, the patient's life is extended, but the immediate pathological focus (tumor, etc.) remains in the body). 2. Diagnostic (diagnostic laparotomy). Operations are also divided into primary and repeated (performed on the same organ and for the same reason - reamputation, relaparotomy, resection). Classification of operations according to the nature of the intervention performed: 1) removal of the pathological focus (resective interventions); 2) restorative and reconstructive; 3) plastic. Classification of operations depending on the degree of bacterial contamination of the surgical wound: 1) clean (aseptic); 2) non-aseptic; 3) purulent operations. There is also such a thing as simultaneous operations, i.e. those in which several surgical interventions are performed on several organs simultaneously for several diseases (hernioplasty and prostatectomy). Combined surgical interventions - This is the treatment of one disease with the help of operations on various organs. For example, a hormone-dependent breast tumor is removed simultaneously with castration of a woman. Surgical intervention can be one-stage, when it is possible to achieve all the goals during the operation, as well as two-stage (for example, surgery for obstruction of the large intestine of a tumor nature) and multi-stage (reconstructive surgery for burn strictures of the esophagus). In the latter case, surgery includes several operations that are separated by time. Stages of surgical intervention: 1) operational access. Should be forgiving. In a figurative expression, "it should be as big as it needs to be, and as small as possible." Also, operational access should be anatomical and physiological; 2) operational reception. Removal of an organ (ectomy) or its (part) resection; 3) reconstruction (imposition of anastomoses, etc.); 4) suturing the wound (either through all layers, or taking into account the anatomical structure - in layers). 2. Indications for surgery. Operational risk Depending on the timing in which it is necessary to perform surgery, indications for surgery may be as follows: 1) emergency. The operation must be completed without delay. The slightest delay can lead to a worse prognosis, further quality of life, and in some cases even death. Require emergency intervention bleeding, perforation of a hollow organ, peritonitis; 2) urgent. The operation cannot be postponed for a long time due to the progression of the disease. In an emergency, the operation is not performed due to the need to prepare the patient for surgery and compensate for impaired body functions; 3) planned. A planned operation can be performed at any time. It is carried out at the moment most favorable for the patient, since the patient's condition does not cause any particular concern. Indications for a planned operation: malformations, debilitating pain syndrome, loss or decrease in working capacity, preventive surgery. Emergency surgical interventions are performed in conditions that pose a threat to life. The danger for the patient during the operation is both the surgical trauma itself and the complications associated with it (bleeding, peritonitis, etc.), and anesthesia. In connection with the presence of such a danger to the patient, vital, absolute and relative indications for surgery are distinguished. An operation is vitally indicated only in the case when the patient dies without an operation, and the operation gives him a real chance for salvation. With absolute indications, the operation is necessary and should be carried out in a short time, but a delay is possible. The operation is relatively indicated in the case when recovery (or improvement) occurs in the outcome of the operation, but the disease at this stage does not pose a real threat to the patient's life. Operative interventions according to relative indications are carried out only with an insignificant and moderate operational risk for the patient. Operational risk is divided into: 1) insignificant; 2) moderate; 3) relatively moderate; 4) high; 5) emergency (intervention only for health reasons). The following factors are important for assessing operational risk: 1) volume and duration of surgical intervention (operations of the 1st, 2nd, 3rd, 4th categories); 2) type of surgical intervention; 3) the nature of the underlying disease; 4) the presence of concomitant diseases and their severity; 5) gender (for men, all other things being equal, the risk is higher); 6) age; 7) qualifications of the anesthetist and surgical team, operating room equipment. The most important for determining the risk of concomitant diseases is cardiac pathology: coronary artery disease (including myocardial infarction), hypertension, rheumatic heart disease, cor pulmonale, cardiac arrhythmias. Regardless of the degree of a certain risk, there is such a thing as anesthetic death, i.e., the unpredictable death of a patient as a result of anesthesia, not directly related to the surgical procedure and its complications. This phenomenon is observed in 1 case per 10 thousand anesthesias. LECTURE No. 5. Pain relief. General questions of local anesthesia. infiltration anesthesia. costal nerve blocks 1. General issues of local anesthesia. Indications and contraindications for local anesthesia Anesthesia It is a turning off of any kind of sensitivity, including pain, by using a variety of medicinal substances. Anesthesia can be general (such pain relief is accompanied by a loss of consciousness) and local (anesthesia is created on a certain area of the body while maintaining consciousness). The patient under local anesthesia retains the ability to perceive what is happening, in some cases he can observe the course of the manipulation (most often with small outpatient interventions). In this regard, before the operation, it is necessary to conduct a conversation with the patient, in which to explain the approximate course of the operation and the meaning of the manipulations, to inspire the patient with optimism and confidence in the favorable outcome of the intervention. In addition, before the implementation of local anesthesia, it is necessary to use special drugs that have a calming effect on the central nervous system. The range of medical interventions performed under local anesthesia is quite wide, and, given the constantly improving technique of operations and the use of new modern drugs, their number is constantly growing. In addition, there is a group of patients who are shown the use of local anesthesia. These are elderly patients, usually with various comorbidities. The condition of such patients determines the risk of complications from general anesthesia, the severity of which exceeds the severity of the underlying disease, so this group of people is indicated for the use of local anesthesia. Contraindication for local anesthesia is children's age, since surgery, even a small one, can have a significant impact on the child's psyche. The likelihood of developing an inadequate reaction makes it necessary to refuse the use of local anesthesia in a group of people suffering from mental illness. Dermatological diseases, the presence of extensive scars soldered to the underlying tissues are contraindications to local anesthesia. Another group of contraindications is the presence of a history of allergic reactions to anesthetics. In addition, an important contraindication is the presence of internal bleeding, in which case stopping it is of paramount importance for vital indications for the patient. 2. Blockade of the costal nerve. Mechanism of action. Method of application. Main indications and contraindications Using this anesthesia is indicated for fractures of the ribs to eliminate pain impulses, prevent the development of shock, ensure adequate respiratory movements of the chest, since with fractures of one or more ribs, the pain can be so severe that it is difficult for the victim to breathe fully, i.e., there is a risk of developing respiratory insufficiency. Application This technique consists in anesthesia of the intercostal nerves corresponding to the affected area. Since the intercostal nerves depart from the spinal cord, namely, they play the main role in the realization of pain sensations, it is necessary to perform anesthesia in the region of the nerve located closer to the spine. Having determined the place of anesthesia according to it, the skin is anesthetized, and then, prescribing a solution of novocaine, the needle is advanced until it rests on the rib. Then the needle slides along the surface of the rib, first down (half the dose of anesthetic is injected), and then up (the rest of the drug is injected). Contraindication for this anesthesia, as well as for other types of local anesthesia, are the presence of skin diseases at the injection site, scars that make it difficult for the needle to enter. 3. Infiltration anesthesia. Mechanism of action. Method of application. Main contraindications At present, infiltration anesthesia, or the tight creeping infiltrate method, is widely used in various surgical interventions, since, if properly performed, it produces a very good analgesic effect and can be used in a variety of surgical interventions. An exception to its use are complex lengthy operations. Method of application Beforehand, it is necessary to make preoperative preparation according to all the rules, taking into account the general condition of the patient. Since this type of anesthesia introduces a significant amount of anesthetic solution into the body, it is necessary to first clarify whether there has been an unusual or allergic reaction to the administration of anesthetics in the anamnesis. Anesthesia is performed already on the operating table during the intervention. The shortest access is preliminarily determined and, taking it into account, an anesthetic is administered intradermally. Often this is a solution of novocaine in low concentration. Each new portion of the substance is injected into the edge of the nodule formed by the previous injection, thus an anesthetic infiltrate in the form of a lemon peel is created over the entire area of the future incision. Then, moving the needle deeper into the subcutaneous tissue, a new portion of the anesthetic solution is injected. Subcutaneous tissue is also infiltrated over the entire incision area. Only after this is the dissection of the skin and subcutaneous tissue with a scalpel. Next, layer-by-layer infiltration of muscle layers is performed, taking into account their anatomical structure. Since the muscles are in fascial cases, the distribution of the solution through the cases to the degree of tight infiltration with the drug provides sufficient anesthesia for all nerve trunks and endings. It is important to administer a sufficient amount of the drug until the desired effect is achieved. Complications with this method of anesthesia are rare and are associated with allergic reactions, non-compliance with the technique of anesthesia and the development of an overdose of the drug. Overdose explains symptoms such as dizziness, headache and weakness, lowering blood pressure (up to the development of collapse). Противопоказания to the use of this type of anesthesia are determined by hypersensitivity or the development of allergic reactions to the introduction of anesthetic substances in history. LECTURE No. 6. Pain relief. The main methods of local anesthesia. intravenous anesthesia. Blockade of perinephric tissue. Spinal anesthesia 1. The main methods of local anesthesia There are various methods of local anesthesia that allow you to anesthetize a specific area of the body, which is supposed to be operated on, while maintaining consciousness. These are various types of anesthesia, in which the anesthetic blocks the nerve endings when administered intraosseously, intravenously, on the surface of the mucous membranes, and conduction anesthesia, as well as epidural and spinal types of anesthesia - extremely effective modern methods. 2. Intravenous anesthesia. Mechanism of action. Method of application. Main indications and contraindications Most often, this type of anesthesia is used in traumatology, since it ensures that the anesthetic enters the vessels, from which it spreads to the nerve trunks, and anesthesia of the entire limb. As a rule, such anesthesia is necessary for the reposition of bone fragments in fractures, reduction of dislocations, primary and secondary surgical treatment of extensive wounds. A feature of this method is the isolation of blood circulation from the systemic blood flow to exclude the entry of an anesthetic into it and the development of undesirable systemic effects. For the implementation of anesthesia, it is necessary to raise the limb for several minutes in order to empty the vessels of the limb as much as possible. After that, a tourniquet must be applied to the limb to compress the arteries that feed the limb. An alternative to a tourniquet can be a cuff from a pressure measuring device, into which air is injected until a pressure exceeding the pressure in the arterial system is reached, and left for the duration of surgical procedures. This method should be used with caution if long-term interventions are required. As a rule, the volume of surgical intervention or manipulations on the limbs is small; therefore, intravenous anesthesia is widely used for these purposes. Another limitation is the need for careful, slow removal of the cuff or tourniquet in order for the substance to slowly enter the systemic circulation. Otherwise, undesirable effects such as dizziness, nausea, weakness and even collapse may appear. Using this method contraindicated with a history of allergic reactions to novocaine or other anesthetics. 3. Pararenal blockade. Mechanism of action. Method of application. Main indications and contraindications With this type of anesthesia, a solution of novocaine or another anesthetic is injected into the perirenal tissue, where it spreads and affects the nerve plexuses - the renal plexus, the solar plexus, and also the celiac nerves. As a result, pain sensitivity is turned off in the region of innervation of these plexuses. This is especially important and widely used in situations such as shocks, in which the exclusion of afferent pain impulses is one of the main pathogenetic measures, as well as in nephrolithiasis, an acute attack of renal colic, and also as an additional component in pain relief before surgical interventions. on the organs of the small pelvis and retroperitoneal space. Having previously determined the indications for use, they decide on the need for one- or two-sided anesthesia. Anesthesia technique. The point to be guided by when introducing a needle with a solution of novocaine or other anesthetic is the top of the angle formed on one side by the longest muscles of the back, and on the other side by the twelfth rib. On the bisector of this angle, stepping back 1 cm, find a point. At this point (on one or both sides) the skin is anesthetized. Then, pre-sending a solution of novocaine, carefully and slowly advance the needle inward at a right angle. The feeling of failure indicates that the needle has entered the perirenal tissue. In order to make sure, you need to pull the syringe plunger towards you. If at the same time blood does not appear in the syringe, then the needle is in the fiber, in this case, a novocaine solution is injected. If blood appears in the syringe, this indicates that the needle has entered the vessel. In this case, the needle is brought to the correct position and the attempt is repeated. Very formidable complications of this method, arising from gross errors and ignorance of topographic anatomy, are the entry of the needle into the intestinal cavity. In this case, the risk of infection entering the pelvic cavity and the development of peritonitis is very high. Противопоказания and precautionary measures, as in previous cases, are associated with the possibility of developing an overdose of the drug and the appearance of an allergic reaction to it. 4. Spinal anesthesia. General issues. Mechanism of action. Method of application. Main indications and contraindications This is one of the most effective methods of pain relief. Its mechanism of action is associated with the introduction of an anesthetic solution into the subarachnoid space of the spinal cord. At the same time, the posterior roots of the spinal cord are blocked and the sensory and motor fibers below the site of anesthesia are turned off. This property of subarachnoid anesthesia is associated with the impossibility of using this type of anesthesia during surgical interventions on organs whose innervation centers are located above the centers that innervate the diaphragm. In this case, turning off the motor fibers will lead to paralysis of the diaphragm and respiratory arrest. To facilitate access, the patient should sit or lie on his side, bending his back as much as possible and pressing his head to his knees. In this position, the distance between the spinous processes of the vertebrae is greatest, this provides correct access. As a rule, the injection of a needle leads to a reflex straightening of the back. In order to keep the patient in a bent back position, an assistant is needed to hold the patient in the desired position (sometimes you have to resort to the help of several people). Concentration is important, all assistants must strictly obey the instructions of the doctor conducting this type of anesthesia. Since the meaning of anesthesia lies in the penetration of the needle into the subarachnoid space, it is necessary to carefully observe the rules of asepsis and antisepsis to exclude the development of purulent-inflammatory complications. The needle injection zone is located in the middle of the distance between the spinous processes of II and III or III and IV of the lumbar vertebrae. Usually, at the same level with the spinous processes of the IV lumbar vertebra, there is a line connecting the anterior superior iliac spines. The skin at the site of the proposed injection of the needle is carefully treated with alcohol, then it is anesthetized with a solution of novocaine, after which the needle is inserted strictly along the midline of the body between the spinous processes. Produce rotational movements, the needle is injected slowly, pre-sending a solution of novocaine. The sensation of a needle failure may indicate being in the subarachnoid space. For clarification, the fluid flowing out of the needle is observed after the mandrin is removed from it. If it is a clear yellowish liquid, it is most likely cerebrospinal fluid, then the needle is inserted correctly and is in the subarachnoid space. If blood is released from the needle, it means that the puncture was performed incorrectly, and the needle is removed, after which all manipulations are repeated, inserting the needle between other spinous processes. Before anesthesia, a small amount of cerebrospinal fluid is taken into the needle, it is mixed with a solution of novocaine, and then injected into the subarachnoid space. In order to avoid the expiration of the CSF, the puncture site is hermetically sealed with a plaster. LECTURE No. 7. Narcosis 1. History of the development of anesthesia methods. Theories of anesthesia Modern surgical intervention is impossible to imagine without adequate anesthesia. The painlessness of surgical operations is currently provided by a whole branch of medical science called anesthesiology. This science deals not only with the methods of anesthesia, but also with the methods of controlling the functions of the body in a critical state, which is modern anesthesia. In the arsenal of a modern anesthesiologist who comes to the aid of a surgeon, a large number of techniques - from relatively simple (local anesthesia) to the most complex methods of controlling body functions (hypothermia, controlled hypotension, cardiopulmonary bypass). But it was not always so. For several centuries, stupefying tinctures were offered as a means of combating pain, patients were stunned or even strangled, and nerve trunks were pulled with tourniquets. Another way was to reduce the duration of surgery (for example, N. I. Pirogov removed stones from the bladder in less than 2 minutes). But before the discovery of anesthesia, abdominal operations were inaccessible to surgeons. The era of modern surgery began in 1846, when the anesthetic properties of ether vapor were discovered by chemist C. T. Jackson and dentist W. T. G. Morton and the first extraction of a tooth under general anesthesia was performed. Somewhat later, surgeon M. Warren performed the world's first operation (removal of a neck tumor) under inhalation anesthesia using ether. In Russia, the introduction of anesthesia techniques was facilitated by the work of F. I. Inozemtsev and N. I. Pirogov. The works of the latter (he made about 10 thousand anesthesias during the Crimean War) played an exceptionally large role. Since that time, the technique of anesthesia has become much more complicated and improved, opening up opportunities for the surgeon to perform unusually complex interventions. But the question of what is anesthesia sleep and what are the mechanisms of its occurrence still remains open. A large number of theories have been put forward to explain the phenomenon of anesthesia, many of which have not stood the test of time and are of purely historical interest. These are, for example: 1) Bernard's coagulation theory (according to his ideas, the drugs used for induction into anesthesia caused coagulation of the protoplasm of neurons and a change in their metabolism); 2) lipoid theory (according to her ideas, narcotics dissolve the lipid substances of the membranes of nerve cells and, penetrating inside, cause a change in their metabolism); 3) protein theory (narcotic substances bind to enzyme proteins of nerve cells and cause a violation of oxidative processes in them); 4) adsorption theory (in the light of this theory, drug molecules are adsorbed on the surface of cells and cause a change in the properties of membranes and, consequently, the physiology of the nervous tissue); 5) theory of inert gases; 6) neurophysiological theory (most fully answers all the questions of researchers, explains the development of anesthesia under the influence of certain drugs by phase changes in the activity of the reticular formation, which leads to inhibition of the central nervous system). In parallel, studies were conducted to improve the methods of local anesthesia. The founder and main promoter of this method of anesthesia was A. V. Vishnevsky, whose fundamental works on this issue are still unsurpassed. 2. Anesthesia. Its components and types Anesthetic - this is an artificially induced deep sleep with the exclusion of consciousness, analgesia, inhibition of reflexes and muscle relaxation. It becomes clear that modern anesthetic management of surgical intervention, or anesthesia, is the most complex multicomponent procedure, which includes: 1) narcotic sleep (caused by drugs for anesthesia). Includes: a) turning off consciousness - complete retrograde amnesia (events that happened to the patient during anesthesia are recorded in the memory); b) decrease in sensitivity (paresthesia, hypesthesia, anesthesia); c) proper analgesia; 2) neurovegetative blockade. It is necessary to stabilize the reactions of the autonomic nervous system to surgery, since the autonomics are not largely controlled by the central nervous system and are not regulated by anesthetic drugs. Therefore, this component of anesthesia is carried out by using peripheral effectors of the autonomic nervous system - anticholinergics, adrenoblockers, ganglionic blockers; 3) muscle relaxation. Its use is applicable only for endotracheal anesthesia with controlled breathing, but it is necessary for operations on the gastrointestinal tract and major traumatic interventions; 4) maintaining an adequate state of vital functions: gas exchange (achieved by an accurate calculation of the ratio of the gas mixture inhaled by the patient), blood circulation, normal systemic and organ blood flow. You can monitor the state of blood flow by the value of blood pressure, as well as (indirectly) by the amount of urine excreted per hour (urine debit-hour). It should not be lower than 50 ml/h. Maintaining blood flow at an adequate level is achieved by blood dilution - hemodilution - by constant intravenous infusion of saline solutions under the control of central venous pressure (normal value is 60 mm of water column); 5) maintaining metabolic processes at the proper level. It is necessary to take into account how much heat the patient loses during the operation, and to conduct adequate warming or, conversely, cooling the patient. Indications for surgical intervention under general anesthesia determined by the severity of the planned intervention and the patient's condition. The more severe the patient's condition and the more extensive the intervention, the more indications for anesthesia. Minor interventions in a relatively satisfactory condition of the patient are carried out under local anesthesia. Classification of anesthesia along the route of drug administration into the body. 1. Inhalation (narcotic substance in vapor form is supplied to the patient's respiratory system and diffuses through the alveoli into the blood): 1) mask; 2) endotracheal. 2. Intravenous. 3. Combined (as a rule, induction anesthesia with an intravenously administered drug, followed by the connection of inhalation anesthesia). 3. Stages of ether anesthesia The first stage Analgesia (hypnotic phase, round anesthesia). Clinically, this stage is manifested by a gradual depression of the patient's consciousness, which, however, does not completely disappear in this phase. The patient's speech gradually becomes incoherent. The patient's skin turns red. Pulse and respiration slightly increased. The pupils are the same size as before the operation, they react to light. The most important change in this stage concerns pain sensitivity, which practically disappears. The remaining types of sensitivity are preserved. In this stage, surgical interventions, as a rule, are not performed, but small superficial incisions and reduction of dislocations can be performed. The second stage Excitation stage. In this stage, the patient loses consciousness, but there is an increase in motor and autonomic activity. The patient is not accountable for his actions. His behavior can be compared with the behavior of a person who is in a state of extreme intoxication. The patient's face turns red, all muscles tense up, neck veins swell. On the part of the respiratory system, there is a sharp increase in breathing, there may be a short-term stop due to hyperventilation. Increased secretion of the salivary and bronchial glands. Blood pressure and pulse rate rise. Due to the increased gag reflex, vomiting may occur. Often, patients experience involuntary urination. Pupils in this stage dilate, their reaction to light is preserved. The duration of this stage during ether anesthesia can reach 12 minutes, with the most pronounced excitation in patients who have been abusing alcohol for a long time and drug addicts. These categories of patients need fixation. In children and women, this stage is practically not expressed. With the deepening of anesthesia, the patient gradually calms down, the next stage of anesthesia begins. The third stage Anesthesia sleep stage (surgical). It is at this stage that all surgical interventions are carried out. Depending on the depth of anesthesia, there are several levels of anesthesia sleep. All of them completely lack consciousness, but the systemic reactions of the body have differences. In connection with the special importance of this stage of anesthesia for surgery, it is advisable to know all its levels. Evidence first level, or stages of preserved reflexes. 1. Only superficial reflexes are absent, laryngeal and corneal reflexes are preserved. 2. Breathing is calm. 3. Pulse and blood pressure at the preanesthetic level. 4. The pupils are somewhat narrowed, the reaction to light is lively. 5. Eyeballs move smoothly. 6. Skeletal muscles are in good shape, therefore, in the absence of muscle relaxants, operations in the abdominal cavity at this level are not performed. Second level characterized by the following manifestations. 1. Weaken and then completely disappear reflexes (laryngeal-pharyngeal and corneal). 2. Breathing is calm. 3. Pulse and blood pressure at the preanesthetic level. 4. The pupils gradually dilate, in parallel with this, their reaction to light weakens. 5. There is no movement of the eyeballs, the pupils are set centrally. 6. Relaxation of skeletal muscles begins. Third level has the following clinical features. 1. There are no reflexes. 2. Breathing is carried out only due to movements of the diaphragm, therefore shallow and rapid. 3. Blood pressure decreases, pulse rate increases. 4. The pupils dilate, and their reaction to the usual light stimulus is practically absent. 5. Skeletal muscles (including intercostal) are completely relaxed. As a result of this, the jaw often droops, the retraction of the tongue and respiratory arrest can pass, so the anesthesiologist always brings the jaw forward in this period. 6. The transition of the patient to this level of anesthesia is dangerous for his life, therefore, if such a situation arises, it is necessary to adjust the dose of the anesthetic. Fourth level previously called agonal, since the state of the organism at this level is, in fact, critical. At any moment, due to paralysis of breathing or cessation of blood circulation, death can occur. The patient needs a complex of resuscitation measures. The deepening of anesthesia at this stage is an indicator of the low qualification of the anesthesiologist. 1. All reflexes are absent, there is no pupil reaction to light. 2. The pupils are maximally dilated. 3. Breathing is superficial, sharply accelerated. 4. Tachycardia, thready pulse, blood pressure is significantly reduced, may not be detected. 5. There is no muscle tone. Fourth stage Occurs after the cessation of the drug supply. The clinical manifestations of this stage correspond to the reverse development of those during immersion in anesthesia. But they, as a rule, proceed more quickly and are not so pronounced. 4. Certain types of anesthesia Mask anesthesia. In this type of anesthesia, the anesthetic in the gaseous state is supplied to the patient's respiratory tract through a mask of a special design. The patient can breathe on his own, or the gas mixture is supplied under pressure. When carrying out inhalation mask anesthesia, it is necessary to take care of the constant airway patency. For this, there are several methods. 1. Throwing the head back and setting it in the retroflexion position. 2. Removal of the lower jaw forward (prevents the retraction of the tongue). 3. Establishment of the oropharyngeal or nasopharyngeal duct. Mask anesthesia is quite difficult to tolerate by patients, so it is not used so often - for minor surgical interventions that do not require muscle relaxation. Advantages endotracheal anesthesia. This is to ensure constant stable ventilation of the lungs and the prevention of obstruction of the airways by aspirate. The disadvantage is the higher complexity of this procedure (in the presence of an experienced anesthetist, this factor does not matter much). These qualities of endotracheal anesthesia determine the scope of its application. 1. Operations with an increased risk of aspiration. 2. Operations with the use of muscle relaxants, especially thoracic ones, in which there may often be a need for separate ventilation of the lungs, which is achieved by using double-lumen endotracheal tubes. 3. Operations on the head and neck. 4. Operations with turning the body on its side or stomach (urological, etc.), in which spontaneous breathing becomes very difficult. 5. Long-term surgical interventions. In modern surgery, it is difficult to do without the use of muscle relaxants. These drugs are used for anesthesia during intubated trachea, abdominal operations, especially during surgical interventions on the lungs (tracheal intubation with a double-lumen tube allows ventilation of only one lung). They have the ability to potentiate the action of other components of anesthesia, so when they are used together, the concentration of the anesthetic can be reduced. In addition to anesthesia, they are used in the treatment of tetanus, emergency therapy for laryngospasm. For combined anesthesia, several drugs are used simultaneously. This is either several drugs for inhalation anesthesia, or a combination of intravenous and inhalation anesthesia, or the use of an anesthetic and a muscle relaxant (when reducing dislocations). In combination with anesthesia, special methods of influencing the body are also used - controlled hypotension and controlled hypothermia. With the help of controlled hypotension, a decrease in tissue perfusion is achieved, including in the area of surgical intervention, which leads to minimization of blood loss. Controlled hypothermia or lowering the temperature of either the whole body or part of it leads to a decrease in tissue oxygen demand, which allows for long-term interventions with limited or switched off blood supply. 5. Complications of anesthesia. Special forms of anesthesia Special forms of anesthesia are neuroleptanalgesia - the use of a combination of an antipsychotic (droperidol) and an anesthetic drug (fentanyl) for pain relief; - and ataralgesia - the use of a tranquilizer and an anesthetic drug for pain relief. These methods can be used for small interventions. Electroanalgesia - a special effect on the cerebral cortex with an electric current, which leads to synchronization of the electrical activity of the cortex in the α-rhythm, which is also formed during anesthesia. Anesthesia requires the presence of a specialist anesthesiologist. This is a complex procedure and a very serious interference in the functioning of the body. Properly performed anesthesia, as a rule, is not accompanied by complications, but they still happen even with experienced anesthesiologists. Quantity anesthesia complications extremely large. 1. Laryngitis, tracheobronchitis. 2. Obstruction of the respiratory tract - retraction of the tongue, entry of teeth, prostheses into the respiratory tract. 3. Lung atelectasis. 4. Pneumonia. 5. Violations in the activity of the cardiovascular system: collapse, tachycardia, other cardiac arrhythmias up to fibrillation and circulatory arrest. 6. Traumatic complications during intubation (wounds of the larynx, pharynx, trachea). 7. Violations of the motor activity of the gastrointestinal tract: nausea, vomiting, regurgitation, aspiration, intestinal paresis. 8. Urinary retention. 9. Hypothermia. 10. Edema of the brain. LECTURE No. 8. Bleeding 1. Classification Bleeding is defined as the penetration of blood outside the vascular bed, which occurs either when the walls of blood vessels are damaged or when their permeability is impaired. A number of conditions are accompanied by bleeding, which is physiological if the blood loss does not exceed certain values. These are menstrual bleeding and blood loss in the postpartum period. The causes of pathological bleeding are very diverse. A change in vascular permeability is observed in diseases and pathological conditions such as sepsis, scurvy, the last stages of chronic renal failure, and hemorrhagic vasculitis. In addition to the mechanical causes of vascular destruction due to injuries, the integrity of the vessels can be impaired due to hemodynamic factors and changes in the mechanical properties of the vascular wall itself: hypertension against the background of systemic atherosclerosis, aneurysm rupture. The destruction of the vessel wall can occur as a result of a pathological destructive process: tissue necrosis, tumor decay, purulent fusion, specific inflammatory processes (tuberculosis, etc.). There are several classifications of bleeding. Looks like a bleeding vessel. 1. Arterial. 2. Venous. 3. Arteriovenous. 4. Capillary. 5. Parenchymal. According to the clinical picture. 1. External (blood from the vessel enters the external environment). 2. Internal (blood leaking from the vessel is located in the tissues (with hemorrhages, hematomas), hollow organs or body cavities). 3. Hidden (without a clear clinical picture). For internal bleeding, there is an additional classification. 1. Leaks of blood in the tissue: 1) hemorrhages in the tissues (blood flows into the tissues in such a way that they cannot be separated morphologically. The so-called impregnation occurs); 2) subcutaneous (bruising); 3) submucosal; 4) subarachnoid; 5) subserous. 2. Hematomas (massive outflow of blood into the tissues). They can be removed with a puncture. According to the morphological picture. 1. Interstitial (blood spreads through interstitial spaces). 2. Interstitial (blood outflow occurs with tissue destruction and cavity formation). According to clinical manifestations. 1. Pulsating hematomas (in case of communication between the hematoma cavity and the arterial trunk). 2. Non-pulsating hematomas. Allocate also intracavitary bleeding. 1. Blood outflows into the natural cavities of the body: 1) abdominal (hemoperitoneum); 2) the cavity of the heart bag (hemopericardium); 3) pleural cavity (hemothorax); 4) joint cavity (hemarthrosis). 2. Blood outflows into hollow organs: gastrointestinal tract (GIT), urinary tract, etc. The rate of bleeding. 1. Acute (from large vessels, a large amount of blood is lost within minutes). 2. Acute (within an hour). 3. Subacute (during the day). 4. Chronic (within weeks, months, years). By the time of occurrence. 1. Primary. 2. Secondary. Pathological classification. 1. Bleeding resulting from mechanical destruction of the walls of blood vessels, as well as from thermal lesions. 2. Arrosive bleeding arising from the destruction of the vessel wall by a pathological process (tumor decay, bedsores, purulent fusion, etc.). 3. Diapedetic bleeding (in violation of the permeability of blood vessels). 2. Clinic of acute blood loss Blood performs a number of important functions in the body, which are mainly reduced to maintaining homeostasis. Thanks to the transport function of blood in the body, a constant exchange of gases, plastic and energy materials becomes possible, hormonal regulation, etc. is carried out. The buffer function of blood is to maintain acid-base balance, electrolyte and osmotic balance. Immune function is also aimed at maintaining homeostasis. Finally, due to the delicate balance between the coagulation and anticoagulation systems of the blood, its liquid state is maintained. bleeding clinic consists of local (due to the outflow of blood into the external environment or into tissues and organs) and general signs of blood loss. Symptoms of acute blood loss is a unifying clinical sign for all types of bleeding. The severity of these symptoms and the body's response to blood loss depend on many factors (see below). Fatal blood loss is considered to be such a volume of blood loss when a person loses half of all circulating blood. But this is not an absolute statement. The second important factor that determines the body's response to blood loss is its rate, that is, the rate at which a person loses blood. With bleeding from a large arterial trunk, death can occur even with smaller volumes of blood loss. This is due to the fact that the compensatory reactions of the body do not have time to work at the proper level, for example, with chronic blood loss in volume. General clinical manifestations of acute blood loss are the same for all bleeding. There are complaints of dizziness, weakness, thirst, flies before the eyes, drowsiness. The skin is pale, with a high rate of bleeding, cold sweat can be observed. Orthostatic collapse, development of syncope are frequent. An objective examination reveals tachycardia, a decrease in blood pressure, and a pulse of small filling. With the development of hemorrhagic shock, diuresis decreases. In the analysis of red blood, there is a decrease in hemoglobin, hematocrit and the number of red blood cells. But a change in these indicators is observed only with the development of hemodilution and in the first hours after blood loss is not very informative. The severity of clinical manifestations of blood loss depends on the rate of bleeding. There are several severity of acute blood loss. 1. With a shortage of circulating blood volume (BCC) of 5-10%. The general condition is relatively satisfactory, there is an increase in the pulse, but it is of sufficient filling. Arterial pressure (BP) is normal. When examining blood, hemoglobin is more than 80 g / l. On capillaroscopy, the state of microcirculation is satisfactory: on a pink background, fast blood flow, at least 3-4 loops. 2. With a deficit of BCC up to 15%. General condition of moderate severity. There is tachycardia up to 110 in 1 min. Systolic blood pressure drops to 80 mm Hg. Art. In the analysis of red blood, a decrease in hemoglobin from 80 to 60 g / l. Capillaroscopy reveals fast blood flow, but on a pale background. 3. With a deficit of BCC up to 30%. General serious condition of the patient. The pulse is threadlike, with a frequency of 120 beats per minute. Arterial pressure drops to 1 mm Hg. Art. With capillaroscopy, a pale background, slowing of blood flow, 60-1 loops. 4. With a BCC deficit of more than 30%. The patient is in a very serious, often agonal condition. Pulse and blood pressure on the peripheral arteries are absent. 3. Clinical picture of various types of bleeding It is possible to clearly determine from which vessel blood flows only when external bleeding. As a rule, with external bleeding, diagnosis is not difficult. When the arteries are damaged, the blood is poured into the external environment in a strong pulsating jet. Scarlet blood. This is a very dangerous condition, since arterial bleeding quickly leads to critical anemia of the patient. Venous bleeding, as a rule, is characterized by a constant outflow of blood of a dark color. But sometimes (when large venous trunks are injured), there may be diagnostic errors, since transmission pulsation of the blood is possible. Venous bleeding is dangerous with the possible development of an air embolism (with low central venous pressure (CVP)). At capillary bleeding there is a constant outflow of blood from the entire surface of the damaged tissue (like dew). Especially severe are capillary bleedings that occur when traumatizing parenchymal organs (kidneys, liver, spleen, lungs). This is due to the structural features of the capillary network in these organs. Bleeding in this case is very difficult to stop, and during surgery on these organs it becomes a serious problem. With various types internal bleeding the clinic is different and not as obvious as with external ones. Methods for determining the volume of blood loss There is a technique for tentative determination of the amount of blood loss by clinical signs (see Chapter "Clinic of acute blood loss"). Libov's method is used for surgical interventions. The amount of blood lost by patients during the intervention is defined as 57% of the mass of all gauze pads and balls used. Method for determining blood loss by specific gravity of blood (according to Van Slyke). The specific gravity of blood is determined using a set of test tubes containing a solution of copper sulphate in various dilutions. The analyzed blood is successively dripped into the solutions. The specific gravity of the dilution in which the drop does not sink and lingers for some time is considered equal to the specific gravity of blood. The volume of blood loss is determined by the formula: Vcr \u37d 1,065 x (XNUMX - x), where Vkr is the volume of blood loss, x - a certain specific gravity of blood, as well as according to the Borovsky formula, taking into account the value of hematocrit and blood viscosity. This formula is slightly different for men and women. DCCm = 1000 x V + 60 x Ht - 6700; DCCzh \u1000d 60 x V + 6060 x Ht - XNUMX, where DCKm - deficiency of circulating blood for men, DCC - deficiency of circulating blood for women, V - blood viscosity, Ht - hematocrit. The only drawback of this formula can be considered a certain inaccuracy of the values determined with its help in the early period after blood loss, when compensatory blood dilution (hemodilution) has not yet occurred. As a result, there is an underestimation of blood loss. 4. The reaction of the body in response to bleeding The body of an adult contains approximately 70-80 ml/kg of blood, and not all of it is in constant circulation. 20% of the blood is in the depot (liver, spleen). The circulating volume is blood that is not in the vessels of the depositing organs, and most of it is contained in the veins. 15% of the whole blood of the body is constantly in the arterial system, 7-9% is distributed in the capillaries, the rest is deposited in the venous system. Since blood performs homeostatic functions in the body, all physiological mechanisms are aimed at preventing violations of its functioning. The human body is quite resistant to blood loss. There are both systemic and local mechanisms to stop bleeding spontaneously. Local mechanisms include the reactions of the damaged vessel, which are due to both its mechanical properties (due to the elastic properties of the vascular wall, it contracts and closes the lumen of the vessel with intima screwing in) and vasomotor reactions (reflex spasm of the vessel in response to damage). Common mechanisms include coagulation and vascular-platelet mechanisms of hemostasis. When the vessel is damaged, the processes of platelet aggregation and the formation of fibrin clots are triggered. Due to these mechanisms, a thrombus is formed, which closes the lumen of the vessel and prevents further bleeding. All mechanisms are aimed at maintaining central hemodynamics. To this end, the body tries to maintain the volume of circulating blood by activating the following mechanisms: blood is ejected from the depot organs, blood flow slows down, and blood pressure decreases. In parallel, blood flow is maintained mainly through the main vessels (with priority blood supply to vital organs - the heart and brain). When the mechanism of centralization of blood supply is turned on, microcirculation is seriously affected, and blood flow disturbances in the microcirculatory bed begin long before clinically detectable signs of macrocirculation disorders (it should be borne in mind that blood pressure can be normal with a loss of up to 20% of BCC). Violation of capillary blood flow leads to disruption of the blood supply to the parenchyma of organs, the development of hypoxia and dystrophic processes in it. An adequate indicator of the state of microcirculation is such a clinical indicator as the debit-hour of urine. The general reaction to bleeding according to Gulyaev proceeds in four phases. These are safety (until the bleeding stops), compensatory (centralization of blood flow), reparative (hemodilution due to the movement of tissue fluid and lymph into the bloodstream) and regenerative (restoration of normal hematocrit due to regeneration of formed elements) phases. 5. Stop bleeding Temporary stopping methods. 1. Finger pressure (mainly for arterial bleeding). A method to stop bleeding immediately. Lets buy time. Unfortunately, stopping bleeding with this method is extremely short-lived. Places of digital pressure of the arteries: 1) carotid artery. The inner edge of the sternocleidomastoid muscle is at the level of the upper edge of the thyroid cartilage. The artery is pressed against the carotid tubercle on the transverse process of the VI cervical vertebra; 2) subclavian artery. Poorly amenable to finger pressure, therefore, it is possible to achieve blood flow restriction through it by moving the arm as far back as possible in the shoulder joint; 3) axillary artery. It is pressed in the armpit to the humerus. The approximate place of pressing is along the front border of hair growth; 4) brachial artery. Presses against the shoulder bone. The approximate place of pressing is the inner surface of the shoulder; 5) femoral artery. Presses against the pubic bone. The approximate place of pressing is the border between the middle and inner thirds of the inguinal ligament. 2. Maximum flexion of the limb in the joint with the roller (arterial) using: 1) pressure bandage (for venous, capillary bleeding); 2) tourniquet. It is applied proximal to the site of injury for arterial bleeding, distally for venous bleeding. Using a tourniquet for arterial bleeding, it can be applied for a maximum of 1,5 hours. If after this time the need for its use persists, it is dissolved for 15-20 minutes and then applied again, but to another place; 3) clamping on the vessel in the wound (with arterial or venous bleeding); 4) temporary arthroplasty (with arterial bleeding in the absence of an opportunity for an adequate final stop in the near future). Effective only with mandatory heparinization of the patient; 5) exposure to cold (with capillary bleeding). Final stop methods. 1. Ligation of the vessel in the wound. 2. Ligation of the vessel throughout. 3. Vascular suture. 4. Vascular transplantation. 5. Vessel embolization. 6. Vessel prosthesis (the previous methods are used for damage to large vessels that remain to stop bleeding, mainly from small arterial trunks). 7. Laser coagulation. 8. Diathermocoagulation. In the presence of massive bleeding occurring with serious disorders in the hemostasis system (DIC, consumption coagulopathy, etc.), the listed methods of stopping bleeding may not be enough, sometimes additional therapeutic measures are required to correct them. Biochemical methods effects on the hemostasis system. 1. Methods affecting the body as a whole: 1) transfusion of blood components; 2) platelet mass, fibrinogen intravenously; 3) cryoprecipitate intravenously; 4) aminocaproic acid parenterally and enterally (as one of the methods of hemostasis in gastric bleeding, especially erosive gastritis). 2. Methods of local influence. They are used in operations that involve damage to the tissue of parenchymal organs and are accompanied by capillary intractable bleeding: 1) tamponade of the wound with a muscle or omentum; 2) hemostatic sponge; 3) fibrin film. LECTURE No. 9. Transfusion of blood and its components. Features of blood transfusion therapy. blood group affiliation 1. Blood transfusion. General issues of blood transfusion Blood transfusion is one of the frequently and effectively used methods in the treatment of surgical patients. The need for blood transfusion arises in a variety of situations. The most common of these is acute blood loss, which can occur with traumatic damage to blood vessels during injuries, injuries, fractures. Bleeding can occur not only with direct damage to the vessels, but also with closed injuries, closed injuries of the abdomen are especially dangerous, in which there may be a detachment of some organs, a rupture of the spleen, accompanied by intense bleeding. Bleeding can occur with perforation of internal organs, which is a complication of many diseases, such as peptic ulcer of the stomach and intestines, ulcerative colitis, in addition, bleeding is a complication of tumor diseases. Indication for blood transfusion are some conditions that occur when bleeding. These are hemorrhagic shock, anemia, surgical interventions associated with blood loss, profuse blood loss during complicated childbirth. Often, blood can be transfused for immunological reasons, since the blood contains a large number of immune blood cells, humoral factors. In this regard, severe infectious diseases are also indications for blood transfusion. Both whole blood and its components (plasma, erythrocyte mass) and blood substitutes are subject to transfusion. Whole blood can be obtained from donors, who must be carefully screened to exclude parenteral diseases, the most important of which are currently AIDS, hepatitis C and B. Blood obtained from donors is examined for these diseases, determined and its group affiliation according to the ABO and Rhesus systems is fixed. On the package, the date of blood sampling, the name of the donor, the expiration date, and the group affiliation are recorded. Blood storage can be carried out only by preventing its clotting, for this, sodium citrate is added to the blood. The amount of sodium citrate in relation to whole blood is 1:10. Blood is stored at a strictly defined temperature in special refrigerators. Transfusion of one's own blood is carried out only in a certain situation - this is a transfusion of one's own blood to puerperas. The basic rule of blood transfusion must be observed strictly: the blood of the donor and the blood of the recipient must match the groups of the ABO system and Rh, and also have individual compatibility. 2. Blood grouping Currently, the ABO system is considered generally accepted. It is based on the allocation of individual blood groups according to the content of agglutinins and agglutinogens in them. The dependence of the formation of one or another blood type in a person is determined genetically. In persons with I (O) blood group, there are no agglutinogens in erythrocytes, but there are agglutinins in serum (α and β). Owners of II (A) blood group have agglutinogen A and agglutinin β in the blood serum. People with III (B) blood group contain agglutinogen B in erythrocytes and have agglutinins (α) in serum. And, finally, the rarest blood group - IV (AB) - contains both agglutinogens in erythrocytes, but does not have agglutinins in serum. When the agglutinins of the same name interact with agglutinogens (for example, A and α), which is possible, say, when transfusing a donor with group II blood of a recipient with group III, an agglutination (gluing) reaction of erythrocytes will occur. These blood groups are incompatible. Currently, it is believed that blood transfusion should be carried out with a complete match of blood groups according to the ABO and Rh system, as well as with the biological compatibility of the blood of the donor and recipient. 3. Method for determining the blood group according to the ABO system To conduct the study, standard hemagglutinating sera I (O), II (A), III (B), IV (AB) are required, and the first three variants of the serum should be presented in two series. The serum must be suitable for use, for this it is imperative to check its compliance with the expiration date indicated on the serum label, and visually determine its condition. Serum should not be used if it is cloudy, contains impurities, flakes, suspension, has changed color. The serum is considered suitable for use if it is transparent, the ampoule has a label indicating its main properties (series, expiration date, group affiliation, color marking according to the group affiliation), the ampoule is not damaged, not opened. A clean plate is needed, which must be divided into four parts, noting the correspondence to each specific blood group, a scarifier needle, sterile cotton swabs, a clean, dry, fat-free glass slide, and alcohol. On a plate, in accordance with the marking, apply a drop of each serum. Then the skin of the pad of the fourth finger of the left hand is treated with a sterile cotton swab with alcohol. With the help of a scarifier, the skin is pierced, removing the first drop of blood that has come out (an admixture of alcohol and tissue fluid to it can distort the results of the study). The next drop of blood is taken with a corner of a glass slide, for each drop of serum - with a clean corner of the glass. For research, a drop of blood is added to a drop of hemagglutinating serum in a ratio of 10: 1. Then, gently turning and shaking the plate, the blood is mixed. Agglutination usually comes to light in the form of loss of flakes which are well visualized. To clarify the result, an isotonic sodium chloride solution is added to the drop, after which the result is evaluated with sufficient reliability. One of the prerequisites for the study is compliance with the temperature regime. The optimum temperature is 20 - 25 °C, since already below 15 °C cold agglutination is observed, which sharply violates the specificity of this sample, and at an ambient temperature above this interval, the rate of the agglutination reaction slows down sharply. LECTURE No. 10. Transfusion of blood and its components. Evaluation of blood compatibility between donor and recipient 1. Evaluation of the results obtained in a blood test for belonging to a group according to the ABO system If hemagglutination occurs in a drop with sera I (O), III (B), but does not occur with serum II (A), and the result is similar with the sera of two sera, this means that the blood under study belongs to group III (B) according to the ABO system . If hemagglutination occurs in a drop with serums I (O), II (A), but does not occur with serum III (B), this means that the blood under study belongs to group II (A) according to the ABO system. But such a situation is also possible when hemagglutination does not occur with any of the studied sera, and both series. This means that the studied blood does not contain agglutinogens and belongs to group I (O) according to the ABO system. If agglutination occurs with all sera, and both series, this means that the test serum contains both agglutinogens (A and B) and belongs to group IV (AB) according to the ABO system. 2. Rh system. The study of blood belonging to the group according to the Rh system by the express method It is known that, in addition to the ABO system, the presence (or absence) of certain antigens in the blood makes it possible to attribute it to various groups according to other classifications. Thus, the presence of angigens of the Rh system makes it possible to classify such persons as Rh-positive, and the absence of it - as Rh-negative. Currently, when transfusing blood, they adhere to the rule of transfusing blood only of the same group according to the Rh system in order to avoid the occurrence of post-transfusion complications. Express method for determining blood grouping according to the Rh system. For the study, it is necessary to have a standard anti-Rhesus serum belonging to the IV (AB) group according to the ABO system, a Petri dish, an isotonic sodium chloride solution, a 30% solution of rheopolyglucin, a clean, dry, fat-free glass slide. First, it is necessary to dilute the standard anti-Rhesus serum with a solution of rheopolyglucin and apply a drop of it on a Petri dish. In addition, a drop of IV (AB) group serum, which does not contain antibodies, is applied to the Petri dish. Blood sampling is performed similarly to the method described when determining the ABO system. A drop of blood is taken using the angle of a glass slide, added to a drop of serum and gently mixed. A drop is taken from another angle to be added to another serum and also mixed. The preliminary result is evaluated after 4 minutes, then a drop of isotonic sodium chloride solution must be added to each drop, and the final result is evaluated after 2 minutes. If no flakes of agglutination are observed in both drops, this indicates that the test blood is Rh-negative. If agglutination occurred with both sera, the result of the study cannot be considered reliable. Finally, if agglutination occurs with anti-Rh serum, but does not occur with another, control, the blood is considered Rh-positive. 3. Conducting a biological test for the compatibility of the blood of the donor and the recipient Finally, if it is found that the donor's blood and the recipient's blood match in ABO and Rhesus systems, a biological compatibility test must be performed for transfusion. It is carried out from the very beginning of the blood transfusion. Having connected the blood transfusion system, open the clamp and inject approximately 20 ml of the donor's blood in a jet, then close the clamp and carefully observe the patient's reaction for 3 minutes. Biological incompatibility of the blood of the donor and the patient in clinical practice is rare, but can be very dangerous for the health of the recipient. We can talk about its presence if facial flushing, psychomotor agitation are observed, the patient tends to get up, inappropriate behavior, tachycardia and tachypnea, and a decrease in blood pressure may be noted. Increased breathing may be combined with a feeling of lack of air. Such a reaction is absolute contraindication for the transfusion of blood from a given donor to a given recipient. However, this does not exclude the use of other portions of donated blood from this person to other patients. If the biological test is not accompanied by the appearance of a similar reaction when repeated twice, it is considered suitable for transfusion. The transfusion is continued, however, during the entire time it is necessary to carefully monitor the recipient's condition, his blood pressure, body temperature, general condition, respiratory rate and rhythm, evaluate the frequency and quality of the pulse, pay attention to the subjective sensations of the patient: a feeling of heat, a feeling of lack of air, skin itching, pain in the lumbar region, chills, etc. Such monitoring of the patient's condition is carried out within 4 hours after blood transfusion, and if after this time there is no reaction to the transfusion, then the blood transfusion is considered successful, carried out without complications. LECTURE No. 11. Fundamentals of blood transfusion therapy. Blood substitutes, their significance and mechanism of action on the recipient's body 1. Blood substitutes. Classification. The main functions of transfusion fluids in the body In addition to blood products, transfusion of blood-substituting fluids may be necessary for adequate therapy. Different conditions require different composition and mechanism of action of transfusion media. The transfusion of transfusion media is carried out to meet a number of objectives. 1. Replenishment of the BCC. If, as a result of extensive blood loss or dehydration of another origin, such as profuse vomiting, there was a sharp decrease in the volume of circulating blood, then severe hypovolemia can lead to the development of such a formidable complication as shock. In addition, even with minor blood loss and a favorable response to blood transfusion, it is not recommended to transfuse more than 500 ml, since this significantly increases the risk of post-transfusion complications. To correct hypovolemia and microcirculation disorders, hemodynamic colloidal solutions are transfused. The most commonly used 10% solution of low molecular weight dextrans - rheopolyglucin. This substance has a variety of properties, the main of which are the replacement of BCC deficiency, an increase in rheological properties, the ability to improve microcirculation by reducing the aggregation of blood cells, and reducing its viscosity. The drug is used for shocks of various origins, severe intoxication, poisoning, with severe purulent-inflammatory diseases (peritonitis), in the treatment of burn disease. The drug is excreted by the kidneys, therefore, a contraindication for its use are severe chronic kidney diseases, especially those accompanied by the formation of renal failure, and heart failure, when it is not recommended to introduce large volumes of fluid into the body. 2. Elimination of toxins from the body. Such a task arises in various conditions, for example, acute and chronic poisoning at work (in case of non-compliance with safety regulations) and at home (often with a suicidal goal), poisoning with large doses of alcohol and its surrogates, prolonged compression syndrome, burn disease, sepsis, severe purulent - inflammatory and infectious diseases and other conditions, accompanied by the entry into the blood of a significant amount of toxic substances. In such situations, the introduced transfusion media are intended to relieve severe intoxication. Hemodez is a water-salt solution of a low molecular weight polymer compound. Due to its chemical structure, it is able to bind toxic substances, dilute the concentration and remove them through the kidneys. Similar to rheopolyglucin, the drug is not recommended for use in patients with severe chronic kidney disease, especially those accompanied by the formation of renal failure and bronchial asthma. Many specialists are now categorical about the use of gemodez in such patients, calling it a renal poison. 3. nutritional function. A number of drugs are used with the main function - parenteral nutrition. It must be remembered that the effective effect of transfusion media is possible only if forced diuresis is provided, adequate to the volume of incoming fluid, carried out by introducing a solution of diuretics at the end of the system, for example, lasix (furosemide). 2. Complications of blood transfusion. Hemolytic shock, how to deal with it Complications arising from blood transfusion can be divided into three groups. 1. Hemolytic. 2. Non-hemolytic. 3. Separate syndromes arising from blood transfusion. The most severe and still occurring complications of hemotransfusion should be considered hemolytic complications (primarily hemotransfusion shock). This complication develops during transfusion of other group blood. At the same time, massive hemolysis of erythrocytes develops in the vascular bed, the released hemoglobin enters the renal tubules and clogs them, as it settles in acidic urine. Acute renal failure develops. Subjective signs of transfusion shock are severe back pain, dizziness, chills, loss of consciousness. The clinical picture is dominated by manifestations of cardiovascular insufficiency, systolic blood pressure may drop to 50 mm Hg. Art. and below. Along with this, tachycardia is observed, the pulse is so weak filling and tension that it is determined only on the central arteries. The patient's skin is pale, cold, covered with sticky cold sweat. In the lungs, auscultatory dry rales are determined (signs of interstitial pulmonary edema). The leading symptom is renal failure, which is manifested by a decrease in the debit-hour of urine, less than 10 ml. Urine cloudy, pink. In laboratory parameters - azotemia (increased creatinine, blood urea), hyperkalemia, acidosis. Treatment of transfusion shock should be two-stage. 1. At the first stage, it is necessary to stop blood transfusion at the first signs of shock, leave the needle in the vein: massive infusion therapy will be carried out through it: 1) for infusion, both crystalloid solutions (5-10% glucose solution, Ringer-Locke solution, saline) and drugs that affect the rheological properties of blood (rheopolyglucin, hydroxylated starch solutions) are used. The goal of infusion therapy is to stabilize systolic blood pressure at least at the level of 90-100 mm Hg. Art.; 2) it is also necessary to administer prednisone intravenously in the amount of 60-90 mg, which will lead to an increase in vascular tone, maintenance of blood pressure, as well as correction of immune disorders; 3) a bilateral pararenal blockade is performed with a 0,25% solution of novocaine in order to maintain intrarenal blood flow, as well as pain relief; 4) when blood pressure stabilizes, it is necessary to resort to diuretics - lasix in high doses (240-360 mg) intravenously - in order to reduce the severity of acute renal failure and prevent its progression. 2. At the second stage of helping a patient with transfusion shock, measures from the symptomatic therapy group are carried out, i.e. they are required only when individual symptoms occur. This group includes: 1) the appointment of antihistamines; 2) the use of cardiovascular drugs and analeptics; 3) the appointment of euffilin intravenously (10 ml of a 2,4% solution, slowly); 4) correction of violations of the acid-base state; 5) carrying out hemodialysis if indicated; 6) complete exchange transfusion (currently used very rarely). 3. Non-hemolytic complications of blood transfusion. Separate syndromes non-hemolytic complications. 1. Allergic reactions. They occur quite often, since blood is a foreign protein product, the body's reaction to it is inevitable. Manifestation - the appearance of eruptive elements on the skin (urticaria, maculopapular elements). 2. Pyrogenic reactions. These are chills, an increase in body temperature to febrile figures. If these reactions occur, the first measure should be the giving of desensitizing drugs, such as antihistamines (diphenhydramine, suprastin) and glucocorticoid hormones (prednisolone at a dose of 30 mg). Then it is necessary to warm the patient (wrap in a blanket, give hot tea). After 15-20 minutes, the reaction can be stopped. 3. More severe anaphylactic reactions. Associated with the development of immediate hypersensitivity. They manifest themselves as an increase in temperature (more than 39 ° C), the appearance of a profuse rash, as well as the occurrence of allergic reactions such as Quincke's edema, respiratory tract edema and lung (anaphylactic shock). With the development of pulmonary edema, symptoms of acute respiratory failure join the clinical picture, and dry or wet rales are detected in the lungs during auscultation. These conditions are already life-threatening and require emergency intensive care, including: 1) the introduction of large doses of desensitizing drugs parenterally (prednisolone 60-90 mg intravenously); 2) the introduction of a 10% solution of calcium chloride intravenously in an amount of 10 ml; 3) intravenous administration of 10 ml of a 2,4% solution of aminophylline (slowly); 4) syndromic treatment (stopping of pulmonary edema, fight against respiratory failure, etc.). 4. Infectious complications (infection of the donor with AIDS, hepatitis B and C, cytomegalovirus (CMV) and other infectious diseases), bacterial toxic shock. Individual symptomsassociated with blood transfusion. 1. Syndrome of massive blood transfusion. It develops if the body's barrier systems cannot cope with the toxic products of donated blood. 2. Hypocalcemia. Due to the fact that the blood preservative - sodium citrate - binds calcium. To prevent this complication, for every 400-500 ml of freshly citrated blood, 5 ml of a 10% solution of calcium chloride is administered intravenously to the recipient. 3. Development of DIC. 4. Acute expansion of the heart (rarely occurs with forced administration of large amounts of blood and its preparations). 5. Syndrome of homologous blood. Severe complication. It develops quite rarely with blood transfusion that matches the ABO group and the Rh factor, but is taken from a large number of different donors. This creates an immune conflict. The clinical picture is characterized by the occurrence of symptoms of hypovolemia, increased bleeding occurs, in blood tests - a decrease in hemoglobin levels, thrombocytopenia and erythrocytopenia. Treatment: restoration of the rheological properties of blood (rheopolyglucin, etc.), the use of immunosuppressants. LECTURE No. 12. Wounds 1. General concepts. Classification Wound - this is damage to tissues and organs that occurs simultaneously with a violation of the integrity of the skin and mucous membranes due to a number of reasons. The classic signs, on the basis of which it is possible to immediately establish the presence of a wound, are: 1) pain; 2) gaping; 3) bleeding. Classification of wounds. By etiology (depending on the type of traumatic agent). 1. Surgical (applied in the operating room, are aseptic). 2. Random. Depending on the type of traumatic agent. 1. Sliced. 2. Stab. 3. Chopped. 4. Bitten. 5. Bruised. 6. Crushed. 7. Torn. 8. Gunshots. 9. Burn. 10. Mixed. Depending on the presence of microflora in the wound and its quantity. 1. Aseptic. 2. Microbially contaminated. 3. Purulent. in relation to body cavities. 1. Penetrating. 2. Non-penetrating. Depending on the presence of complications. 1. Complicated. 2. Uncomplicated. Factors contributing to the occurrence of complications are the nature and degree of tissue damage, the presence of blood clots in the wound, areas of necrotic tissue, foreign bodies, microflora, its quantity and virulence. Types of wound healing: 1) by primary intention (without suppuration); 2) secondary intention (with the obligatory phase of wound suppuration and development of granulations); 3) under the scab. The type of wound healing is extremely important, since it determines the clinical course of the wound process and all medical tactics. Any wound can heal without suppuration or with it. It all depends on the fulfillment of a number of conditions. Healing conditions by primary intention. 1. Absence of high microbial contamination of the wound. 2. The absence of foreign bodies in the wound, blood clots and non-viable tissues. 3. Sufficient blood supply. 4. Precise matching of wound edges, no tension and no pockets. 5. Preservation of innervation of the edges of the wound. 6. Absence of metabolic disorders (with decompensated diabetes mellitus). Any wound should be brought into line with these conditions, since in this case the treatment will take much less time. The course of the wound process has a phase character, and surgeons have long noticed this. Various attempts have been made to classify the phases of the wound process. According to Pirogov, the wound goes through three stages - edema, wound cleansing, granulation. According to Kaliev, an early period, a degenerative-inflammatory period, and a recovery phase are distinguished. The modern classification of the phases of the wound process was proposed by M. I. Kuzin. He highlights the phases: 1) inflammation; 2) proliferation; 3) regeneration (scarring). 2. Pathophysiology of the wound process phase of inflammation. The first stage on the way to wound healing. The wound healing process begins from the moment when the bleeding stops in the wound under the action of plasma coagulation factors and platelet hemostasis. Acidosis is formed in the wound and surrounding tissues due to impaired blood supply to the damaged areas and the accumulation of organic acids. If the normal pH value of the internal environment of the body is 7,3, the pH in the wound can drop to 5 or even lower. With excessive acidification in the wound, the processes of immune defense are disrupted, but in general, acidosis in the wound is protective in nature, since it prevents the active reproduction of microorganisms. An increase in tissue acidity leads to their hydrophilicity and a parallel increase in capillary permeability. In parallel with the development of acidosis, hyperkalemia also occurs. There is an active exudation into the wound, which contributes to its cleansing. Simultaneous edema and swelling of the wound edges lead to their convergence and alignment, due to which the inflammation zone is delimited from the environment. At the same time, the edges of the wound are glued together with their exact comparison due to the loss of fibrin on the walls of the wound. In the wound, there is a change in metabolism, metabolic processes are shifted towards catabolism. At the same time, migration of inflammatory cells (macrophages, polymorphonuclear leukocytes, lymphocytes) into the wound is observed. These cells, under the action of inflammatory mediators, release enzymes and biologically active substances into the wound. Proteases promote the lysis of non-viable tissues. Oxidase prevents excessive accumulation of toxins. Superoxide dismutase leads to the accumulation of reactive oxygen species, which have a toxic effect on microorganisms. Lipase destroys the protective membranes of microbial cells and makes them available for the action of other protective factors. In parallel, an increase in serum protective factors is also observed in the wound. At the end of the inflammation phase, the wound is cleared of decay products (if any), a smooth transition to the next phase. When the wound heals by primary intention, this phase is short and takes 2-3 days, but when the wound heals by secondary intention and suppurates, this phase can last more than a week. proliferation phase. Lasts up to 14-28 days from the moment of injury. It is characterized by the predominance of granulation processes. Granulation is a young connective tissue that contains a large number of cellular elements capable of proliferation. Tissue trophism improves, new capillaries grow into newly formed tissues, microcirculation processes improve, and tissue edema decreases. Metabolic processes again shift towards anabolism. regeneration phase. Depending on how the wound healed (by primary or secondary intention), either epithelialization of the wound is observed by creeping the epithelium from the edges of the wound (healing occurs under a scab or primary intention), or a rough connective tissue scar is formed (healing occurs by secondary intention). 3. General principles of wound care In the treatment of accidental wounds, care should be taken to ensure that wound healing occurs by primary intention. This is provided by the primary surgical treatment of the wound. At the stage of first aid, it is necessary to stop bleeding, the wound is closed with an aseptic bandage. If there is damage to the bone apparatus, splinting is performed. At the stage of qualified medical care, the final stop of bleeding is carried out and surgical treatment of the wound is performed. Surgical treatment of the wound includes: 1) stop bleeding; 2) revision of the wound cavity, removal of foreign bodies and non-viable tissues; 3) excision of the edges of the wound, treatment with antiseptics; 4) comparison of the edges of the wound (suturing). Depending on the time of the surgical treatment, there are: 1) primary surgical treatment (up to 6 hours from the moment of injury); 2) delayed surgical treatment (6-24 hours from the moment of injury); 3) late surgical treatment (after 24 hours after injury). During the primary surgical treatment, the conditions are achieved under which the wound will heal by primary intention. But this is not always feasible and necessary. In some cases, it is more appropriate to leave the wound to heal by first intention. Excising the edges of the wound, one should not strive to remove as much tissue as possible. It is necessary to remove only those that are not viable in order to then adequately match the edges of the wound without strong tension (since strong tension causes ischemia of the wound edges, which makes healing difficult). The final stage of the first surgical treatment is the suturing of the wound. Depending on the time and conditions of application, the seams are distinguished: 1) primary. They are applied and tightened immediately after the primary surgical treatment. The wound is sutured tightly. The condition for applying primary sutures is that no more than 6 hours should pass from the moment of injury. When performing prophylactic antibiotic therapy, this period can be increased to 24 hours; 2) primary delayed sutures. After the primary surgical treatment of the wound, a thread is passed through all layers, but it is not tied. An aseptic dressing is applied to the wound. Subsequently, in the absence of signs of inflammation, purulent exudate, the bandage is removed and the wound is closed by tying sutures; 3) secondary early sutures. They are applied to a purulent wound after it has been cleansed and granulation has begun. The edges of the wound are reduced, which reduces its size and accelerates healing; 4) secondary late sutures. Superimposed after the formation of a scar, which is excised. The edges of the wound are compared. The treatment of a purulent wound differs from the treatment of a wound without signs of inflammation. Principles of active surgical treatment of purulent wounds and acute purulent surgical diseases. 1. Surgical treatment of a wound or purulent focus. 2. Drainage of the wound with PVC drainage and long-term washing with antiseptic solutions. 3. Early wound closure with primary delayed, early secondary sutures and skin grafting. 4. General and local antibiotic therapy. 5. Increasing the specific and nonspecific reactivity of the body. 4. Features of the course and treatment of various types of wounds incised wound (if there is no infection) normally always heals by primary intention, since all conditions are met. Chopped, bruised and especially lacerated wounds heal by secondary intention. Therefore, all these types of wounds are transferred to incised ones by conducting primary surgical treatment. Bite wounds. A feature of bite wounds inflicted by animals is that they are abundantly contaminated with saliva. The saliva of animals contains a large amount of pyogenic flora, but the purulent process differs little from the usual one. Cat bites can also be accompanied by allergy symptoms, since cat proteins are a strong allergen. With a combination of bites and scratches, a specific inflammatory disease, felinosis, can develop. Human bites, if untreated, are very difficult. Human saliva contains a large number of anaerobic microorganisms, and therefore, if inflammation develops, it is putrefactive. In addition, microorganisms isolated from humans are resistant to many antibiotics. Gunshot wounds. The severity of injury depends on the type of charge and its kinetic energy. A gunshot wound is characterized by the fact that several zones of tissue damage are distinguished in it. 1. The actual wound channel, which is formed by the projectile. Contains the projectile itself, particles of gunpowder, powder gases, fragments of clothing, blood clots. 2. Zone of primary tissue necrosis around the wound channel. It is formed due to the crushing effect of the bullet wave. 3. Zone of molecular shock. This is a zone of cell damage in which microcirculation is disturbed and necrobiotic processes develop. This condition is potentially reversible, but most often events develop in an unfavorable direction, the zone of necrosis expands. A feature of the management of a gunshot wound is a wide dissection along the entire course of the wound channel and the removal of necrotic tissue. In peacetime, primary sutures can be applied. In military conditions, primary delayed sutures are applied. Purulent wound. Treatment is carried out according to the phases of the wound process. 1. In the phase of inflammation, local treatment is carried out: dressings are made daily using the entire spectrum of mechanical, physical, and chemical antiseptic methods. When indicated (abundant exudation), more frequent dressings are performed. The damaged area is immobilized, detoxification and antibiotic therapy is carried out. Antibiotics are prescribed taking into account the sensitivity of the isolated microflora, the duration of the course is up to 3 days at normal temperature. 2. In the proliferation phase, when there is no more exudate and the wound is filled with granulations, local treatment is made more gentle. The dressings are cut down (so as not to injure the granulation tissue), the wound is not washed. Ointments are introduced into the wound that promote tissue regeneration (methyluracil, actovegin). Conduct active physiotherapy (UHF, laser and magnetotherapy). 3. In the regeneration phase, active treatment is not indicated. LECTURE No. 13. General issues of purulent infection. Etiology and pathogenesis of purulent infection in surgery. Treatment methods for purulent infection: conservative and surgical treatment 1. Etiology and pathogenesis of purulent infection in surgery Violation of the rules of asepsis and antisepsis in surgery, both during and after surgery, can lead to a purulent infection. As a rule, a purulent-inflammatory process occurs at the site of the introduction of pathogen microbes into the wound. The onset and progression of inflammation is facilitated by a decrease in the overall resistance of the body, which is almost always observed in patients of surgical hospitals of any profile. Diabetes mellitus usually leads patients to a purulent surgery hospital. Purulent-inflammatory diseases can not only occur as a complication of surgical procedures, but also be the main reason for patients to visit a surgeon. Like any other disease, purulent inflammation of any localization occurs with a combination of an etiological factor, a susceptible organism, and environmental conditions in which they interact. The etiological factor of purulent infection can be various microorganisms. These are staphylococci, Pseudomonas aeruginosa, streptococci, Escherichia coli and some others, which also cause purulent aerobic tissue inflammation. This type of infection is non-specific. Contamination of wounds with earth, deep closed wounds contribute to the occurrence of anaerobic infection, i.e. infection, a prerequisite for the occurrence of which is the almost complete impossibility of oxygen access to the wound. An example of such an infection is gas gangrene. Specific surgical infection occurs when pathogens of diphtheria, tetanus, anthrax and some others enter the wound. In addition, putrefactive infection is isolated. The entry of an etiological agent into the cellular spaces or cavities of the body leads to typical changes in cells and biologically active substances (migration of leukocytes to the area of inflammation, increased permeability of the vascular wall, etc.). Any purulent inflammation is accompanied by the appearance of general and local symptoms of infection. Local symptoms include the following five: redness, pain, fever, swelling, and impaired function. The identification of these symptoms allows you to accurately determine the inflammation of the external localization. In addition, some common symptoms of purulent intoxication are revealed. These include fever, often taking on a hectic character, weakness, lethargy, irritability, decreased performance, drowsiness, headache, lack of appetite, and some others. The inflammatory process, localized in the organs and cavities of the body, inaccessible to direct examination, can be suspected if there are general symptoms of an infectious disease. 2. The main methods of treatment of surgical infection. Conservative and surgical treatment - general concepts The general principles of treatment of purulent-inflammatory diseases include surgical and conservative methods of treatment. Surgical, as a rule, include opening a purulent focus, cleansing it, washing it with disinfectants, an antibiotic solution, and draining the wound. Conservative methods treatment at the very beginning of the disease may include the use of some physiotherapeutic methods of treatment, such as exposure to the infiltrate with high-frequency or infrared radiation, the use of anti-inflammatory ointments, the use of antibiotics orally and parenterally, the use of agents that increase the general nonspecific resistance of the organism, vitamins, parenteral detoxification therapy in case of a serious condition of the patient. LECTURE No. 14. Principles of treatment of purulent-inflammatory diseases. General and local methods of treatment. Conservative and surgical treatment 1. General principles of therapy for purulent-inflammatory diseases Depending on the stage of the disease and the general condition of the body in purulent surgery, conservative and surgical treatment is distinguished. Conservative treatment carried out at the infiltrative stage of the inflammatory process before the appearance of fluctuations, with slightly pronounced general phenomena, small purulent foci, which tend to be limited. Conservative treatment is largely represented by general measures. Usually they receive undeservedly little attention, because the doctor forgets that three essential components are involved in the inflammatory process: the microbe-causative agent, a susceptible organism with reduced immunity, and the environment in which they interact. Therefore, the impact aimed at stimulating the body's defenses is no less important than the fight against an infectious agent. Such measures include adherence to bed rest with severe general symptoms of the disease, immobilization of the limb, if the inflammatory focus is on the limbs. Among the general measures of influence, the organization of proper nutrition of the patient is singled out. This aspect is not always given due attention, although the organization of proper nutrition contributes to a faster recovery, reduces the negative effect of drugs on the patient's body, and helps to correct numerous changes in his body. General principles of nutrition at the height of the disease, with high fever: nutrition is multiple, fractional, in small portions, an increased amount of protein in all pyoinflammatory diseases, since it is lost with exudate (its severity can be determined by the level of total blood serum protein in a biochemical blood test ), restriction of carbohydrates (since they promote the growth and reproduction of bacteria), fats (in order to be gentle on the organs of the gastrointestinal tract). To reduce the effects of intoxication, especially in long-term febrile patients, with a tendency to chronicity of the disease, abundant fluid intake is indicated, especially compotes, fruit drinks from fresh fruits, rosehip broth. In order to stimulate the protective reserves of the body, biogenic stimulants are used, for example, Chinese magnolia vine, ginseng. Activation of immune capabilities is carried out with the help of transfusion of hyperimmune plasma. Sometimes, for the purpose of detoxification, intravenous infusions of hemodez, dextrans (polyglucin, reopolylyukin), glucose with ascorbic acid, and salt solutions are performed. Hemodeza is used to detoxify the body, since the high-molecular compounds that make up its composition bind all toxic substances and remove them from the body through the kidneys. Polyglucin and reopoliglyukin belong to dextrans (glucose polymers). The mechanism of their action is associated with an improvement in the rheological properties of blood, a decrease in its viscosity, normalization of blood flow, and the removal of toxic substances from the body. To stimulate the immune system, autohemotransfusion is possible. Depending on the severity of the condition, it is possible to use various symptomatic drugs, since in severe forms of purulent-inflammatory diseases, numerous changes affect many organs and organ systems. Etiological treatment includes antibiotic therapy. Before it is carried out, it is necessary to conduct a study of purulent discharge from the focus (inoculation on nutrient media) to verify the pathogen, to identify its sensitivity to antibiotics. When conducting antibiotic therapy, they are guided by the presence of allergic reactions and idiosyncrasies to the use of antibiotics in history; preference is given to intramuscular or intravenous administration, local use of drugs, for example in the form of ointments, is possible. In the absence of a sufficient effect, a change in the antibiotic is necessary, in the absence of data on the etiology of the process, broad-spectrum drugs (cephalosporins, tetracyclines, penicillins may be used) are immediately used or, based on the clinical picture, an assumption is made about the pathogen. All this is fully true in relation to nonspecific purulent infection. In case of specific surgical diseases, specific treatment is carried out - the introduction of vaccines, sera, gamma globulins, in contact with a sick person or in the presence of a contaminated wound in history, it is possible to carry out preventive vaccinations. 2. Topical treatment Local therapy includes conservative and surgical methods. Conservative treatment methods are used separately at the very beginning of the disease before the formation of an abscess, as well as in combination with surgical treatment for the purpose of faster and more effective treatment. Local treatment of the disease in the infiltrate stage includes exposure to it using physiotherapeutic techniques, such as UHF, exposure to cold or heat (compresses, heating pads). Be sure to need local application of ointments, which include antibiotics, sulfa drugs. Operative therapy is the main method of treatment of purulent-inflammatory diseases. Self-recovery from such diseases is carried out after spontaneous opening of the abscess and emptying it from purulent contents. Surgery can speed up the healing process. With small limited abscesses, panaritiums, mild general phenomena, treatment can be carried out on an outpatient basis. Diseases of moderate severity, abscesses and phlegmons of considerable size, purulent-inflammatory diseases of cavities, internal organs, boils located on the face are an indication for hospitalization and treatment in a hospital. The hospital has a special department for patients with a purulent infection, or in the conditions of the department there is a special purulent operating room and dressing room. In any case, one should strive for the maximum possible isolation of patients, premises, materials, personnel, instruments of purulent surgery. Only careful observance of the rules of asepsis and antisepsis will help prevent the further spread of infection, and ensure a speedy recovery. Depending on the size of the purulent focus, it is possible to use local or general anesthesia. There are general rules for such operations. The incision must be made at the site of the greatest fluctuation, always taking into account the location of anatomical formations: fascio-muscular sheaths, neurovascular bundles. The incisions must be made in parallel and stepping back from these formations. If there are deep streaks that do not allow cleansing the focus through the first incision, it is necessary to make another incision, determining its location along the finger located in the area of the streak. After opening the focus, it is cleansed of purulent exudate, tissue detritus, the focus is examined with a stupid finger to detect streaks. Then it is washed with an antiseptic substance, antibiotic solutions. After the end of the operation, the wound is never sutured tightly; for the best drainage, it is necessary to have an aperture and counter-opening, through which rubber drains are removed, through which the contents are drained. It is desirable to make an incision along the lowest level of the purulent focus. Dressings consist in removing the drains and replacing them with new ones, washing the wound with an antiseptic solution, filling the wound with an ointment containing an antibiotic, and applying an aseptic dressing. It is possible to use proteolytic enzymes, hypertonic sodium chloride solution - to reduce the effects of exudation and improve the outflow of pus. Sometimes such dressings have to be done repeatedly until granulations appear in the wound, which indicates recovery. 3. Incisions for some purulent diseases Carbuncles should be dissected with a cruciform incision. With subarareolar mastitis, when pus is located around the nipple, it is necessary to make a paraareolar incision, that is, an incision around the nipple of the mammary gland, if there is an abscess in the thickness of the mammary gland tissue, a radial incision is made parallel to the course of the milk ducts to prevent their damage. Intramammary: the abscess is located in the fiber located between the muscles of the chest wall and the breast tissue. In this case, the incision is made along the transitional fold of the breast. With purulent parotitis, incisions are made parallel to the branches of the lower jaw. In case of purulent-inflammatory diseases of the hand, incisions are made parallel to the location of the nerve fibers (it is necessary to remember the location of the Canavela exclusion zone, in which the muscular branches of the median nerve pass, and in which the incisions are not made) in accordance with the topographic location of the palmar spaces. On the fingers, lateral incisions are made on both sides of each phalanx of the finger. LECTURE No. 15. Purulent-inflammatory diseases of the glandular organs. Mastitis. Mumps 1. Etiology and pathogenesis of acute mastitis. Classification Mastitis is a purulent-inflammatory disease of the breast tissue. The most common microorganisms (causative agents of this process) are staphylococci, streptococci, Pseudomonas aeruginosa. For the occurrence of this disease, certain conditions are necessary, which most often occur with the stagnation of milk in nursing mothers. Penetration of the infectious agent occurs through cracks in the nipple (most often) or milk ducts. The hematogenous route of infection is extremely rare. The disease in the vast majority of cases is acute and only sometimes becomes chronic. Violation of pumping, most often found in nulliparous women, leads to stagnation of milk. Invading, microorganisms receive a favorable environment for growth and reproduction, serous inflammation occurs. It is the initial stage of the process and can be reversible even with conservative treatment. Subsequently, leukocytes begin to migrate to the focus, an increase in vascular permeability leads to the release of the liquid part of the blood into the tissue - exudate. These changes indicate successive infiltrative and suppurative stages of purulent inflammation of the mammary gland. At these stages, as a rule, surgical treatment is performed. By localization, suareolar mastitis is distinguished, while the focus of inflammation is located around the areola, retromammary - inflammation is localized in the retromammary space, intramammary - the focus of inflammation is located directly in the breast tissue. 2. Clinical picture and diagnosis of acute mastitis. General clinical, laboratory and instrumental research methods used in the diagnosis of the disease The disease develops rapidly. The first symptoms are associated with galactostasis and include intense pain of a bursting nature, mainly in one mammary gland. There is a violation of the secretion of milk from this gland, it increases in size, thickens. The general health of the woman is deteriorating. There are complaints of a general nature, including the appearance of fever, chills, most often intensifying in the evening, decreased performance, appetite, and sleep disturbance. In the general blood test, an increase in the erythrocyte sedimentation rate (ESR), the appearance of leukocytosis with a shift of the leukocyte formula to the left are noted. The degree of these changes, as a rule, correlates with the severity of the inflammatory process. When examining the patient, an increase in one mammary gland in volume, local redness and hyperemia are noted. If during palpation a focus of compaction is determined without clear contours, hot to the touch, painful, then most likely the disease is at the stage of infiltration. On palpation of a group of axillary lymph nodes, it can be noted that they are enlarged, mobile, not soldered to the skin, they can be painful, but without changes in the skin above them. When a focus of suppuration appears in the mammary gland, the general condition of patients worsens significantly, fever can take on a hectic character, and general complaints are expressed. When viewed in the mammary gland, there is a focus of redness, over which softening (fluctuation) is determined. Regional lymph nodes on the side of the lesion are enlarged, not soldered to the underlying tissues and skin, painful. 3. Treatment methods for acute mastitis. General and local, conservative and surgical methods of treatment Surgical treatment includes opening and drainage of the focus. Depending on the localization of the inflammation, paraareolar, radial incisions and an incision along the transitional fold of the mammary gland are isolated. The abscess is washed, exudate is removed, all streaks are cleaned, its cavity is sanitized, drainages are installed. Common methods of treatment include a strict prohibition of feeding during illness (but milk must be expressed), the use of drugs that suppress lactation. When verifying the causative agent of the disease, antibiotic therapy is carried out, antibiotics are administered intravenously. Depending on the severity of the disease, detoxification therapy, vitamin therapy, and correction of water and electrolyte metabolism are sometimes indicated. 4. Etiology and pathogenesis of acute parotitis. Classification Parotitis - a disease accompanied by purulent inflammation of the parotid salivary glands. Microorganisms-causative agents are similar to pathogens of other forms of purulent infection. The infection can penetrate into the gland directly through the excretory duct (retrograde way), by the lymphogenous way (for example, with festering tooth cysts) or, which is much less common, by the hematogenous way. The danger of the disease lies in the possible melting of the connective tissue partitions and the spread of inflammation to the cellular spaces of the neck, and sometimes even the mediastinum. Perhaps the development of paresis of individual branches and the main trunk of the facial nerve. 5. Clinical picture and diagnosis of acute parotitis. General clinical, laboratory and instrumental research methods used in the diagnosis of the disease The onset of the disease is usually acute. The patient complains of weakness, malaise, lethargy and other manifestations of purulent intoxication. The formation of abscesses in the gland is accompanied by the appearance of puffiness, swelling and redness of the cheek, under the lower jaw. The skin becomes smooth, taut, in some places the symptom of fluctuation can be determined, here the skin is maximally thinned. On palpation, sharp pain is noted. The pain associated with the occurrence of edema and its spread to the surrounding tissues accompanies chewing, swallowing, opening the mouth, so patients prefer not to talk, consume only liquid food. With a detailed picture, it is possible to make a diagnosis already when examining a patient - the appearance of a patient with mumps is so typical. The oval of the face is deformed due to the protrusion of the cheek. When examining the oral cavity, one can note some swelling of the mucous membrane of the cheek, soft palate and pharynx from the side of inflammation. In the general analysis of blood, leukocytosis with a shift of the leukocyte formula to the left, an increase in ESR are possible. 6. Methods of treatment of acute parotitis. General and local, conservative and surgical methods of treatment Inpatient treatment is being carried out. The patient needs to ensure the rest of all muscles and formations involved in the process. To do this, it is completely forbidden to talk, chew, liquid food is allowed, preferably several times a day in small portions, preferably mechanical and chemical sparing, the food taken should not be hot or cold. Conservative treatment is possible in the early stages of the disease (UHF currents, warming compresses, etc.). Be sure to carry out antibiotic therapy, taking into account the sensitivity of the microorganism to it. Surgical treatment is indicated for the ineffectiveness of conservative therapy, the appearance of fluctuations. The incisions are made in places of determined softening, however, the topography of the facial nerve is strictly taken into account: one of the severe complications of the operation is paralysis of its branches due to their intersection. Be sure to conduct a thorough revision of the wound with the removal of all streaks, tissue detritus, purulent discharge, then washing with a solution of hydrogen peroxide and installing several drains at the incision sites. Washing the wound and replacing the drains is carried out daily. LECTURE No. 16. Purulent-inflammatory diseases of the lungs and pleura. Abscess and gangrene of the lung 1. Abscess and gangrene of the lung. Etiology and pathogenesis lung abscess is a limited focus of purulent inflammation of the lung tissue. The most common causative agent of purulent inflammation in the lung is Staphylococcus aureus. Its feature is the ability to melt lung tissue. An abscess can occur when a focus of pneumonia is suppurated, especially often abscesses occur in the lung after aspiration pneumonia that occurs when a foreign body or vomit enters its tissue, and also (somewhat less often) when an infection enters by contact, for example, with a penetrating wound of the chest. Gangrene of the lung is an unlimited inflammatory process in its tissue. Gangrene most often develops in individuals with reduced body resistance, the elderly, debilitated after serious illnesses, patients with congenital or acquired immunodeficiency, when inflammation does not tend to be limited. 2. Clinical picture of abscess and gangrene of the lung The clinical picture consists of general symptoms of a purulent infection and local manifestations of the disease, and during the course of the disease two stages can be clearly distinguished, differing in subjective and objective signs. So, the period of abscess formation is marked by the appearance of high fever (mainly in the evenings), accompanied by shaking chills. Severe purulent intoxication causes weakness, severe headache, severe malaise, sleep disturbance. There is pain in the chest associated with the involvement of the pleura in the process. The pain most often has a stabbing character, aggravated by inhalation. Patients may complain of coughing with a scant amount of mucopurulent or purulent sputum. Large abscesses cause a decrease in the respiratory surface of the lungs, which is accompanied by the appearance of shortness of breath of a mixed nature during physical exertion, and with a pronounced process even at rest. On examination, one can note an increase in the frequency of respiratory movements and the lagging of the diseased half of the chest from the healthy half in the act of breathing. Clinical research methods make it possible to identify the area of dull percussion sound and the area of increased voice trembling corresponding to it, and weakened vesicular breathing is determined by auscultation. After formation, the abscess usually opens either in the bronchus, or with a subpleural location in the pleural cavity. If the first option is regarded as a relatively favorable outcome of the process, since natural drainage allows the cavity to be almost completely emptied and the disease ends in recovery, then when an abscess breaks into the pleural cavity, the course of the disease becomes much more complicated. The accumulation of pus in the pleural cavity leads to the development of pleural empyema. It is possible to suspect a breakthrough of a lung abscess into the bronchus when there are complaints about the discharge of a large amount of purulent fetid sputum with a full mouth, after which the patient feels significant relief almost immediately. Body temperature returns to normal, chest pain and shortness of breath decrease. Clinical methods of examination make it possible to detect during this period a tympanic sound on palpation, and auscultatory - localized in accordance with the zone of the focus coarse moist rales. In the general blood test, changes typical of purulent inflammation are revealed. The diagnosis can be confirmed using the results of an x-ray examination of the chest, which reveals a limited cavity with a fluid level. Gangrene of the lung is accompanied by extremely severe intoxication of the body and in the vast majority of cases leads to the development of a lethal outcome. The general symptoms are extremely pronounced. The first glance at the patient allows us to regard the condition as extremely serious. Severe weakness, almost complete lack of appetite are noted, disturbances of consciousness are possible. The disease quickly leads to the formation of respiratory failure. Shortness of breath is significant, hypoxemia causes diffuse pale or gray cyanosis of the skin. The sputum that is coughed up is hemorrhagic in nature. Clinical examination methods allow you to determine a dull percussion sound over the entire area of \uXNUMXb\uXNUMXbthe lung tissue. Auscultation reveals moist rales over the entire lung area. 3. Methods of treatment of abscess and gangrene of the lung. General and local, conservative and surgical methods of treatment Since the prognosis of lung gangrene is always serious, examination and treatment of patients should be carried out as soon as possible. The initial task is to cleanse, and subsequently the complete elimination of the focus of purulent inflammation. To do this, depending on the location of the abscess, either it is drained (if it is located superficially), or instrumental (using a bronchoscope) drainage of the abscess and intrabronchial administration of antibiotics are used. Surgical methods of treatment gangrene of the lung involves the removal of a lobe of the lung (lobectomy) or the entire lung (pneumonectomy). Conservative treatment methods after opening the abscess through the bronchus, to improve drainage, the use of expectorants, sputum thinning agents may also be included. Currently, the main method of treatment of such diseases is antibiotic therapy. Adequately conducted antibiotic therapy can significantly limit the number of deaths from pyoinflammatory lung diseases in patients. Prior to sputum culture with verification of the pathogen, it is desirable to use broad-spectrum antibiotics or drugs that are active against the suspected pathogen. Intravenous and endobronchial routes of administration of antibiotics are preferred. In addition, patients should receive a complete fortified diet with a high protein content and carbohydrate restriction. Severe intoxication explains the need for the use of detoxifying drugs, for example, intravenous administration of gemodez, transfusion of blood plasma. According to indications, for example, in the presence of infectious-toxic shock, cardiac and respiratory analeptics can be used. LECTURE No. 17. Purulent-inflammatory diseases of the lungs and pleura. Purulent pleurisy - pleural empyema 1. Empyema of the pleura. General questions of etiology and pathogenesis. Classification of pleural empyema empyema is called the accumulation of pus in the cavities of the body. Inflammation of the pleural cavity, in which the exudate accumulating in it is purulent in nature, is called pleural empyema. The formation of empyema is usually associated with the penetration of an infectious agent into the pleural cavity in various ways. Often, empyema can develop after direct entry of microorganisms into the pleural cavity when it is injured. Inflammation often passes to the pleural cavity from inflammatory foci located in the immediate vicinity of the pleura. This happens in the presence of subpleurally located foci of pneumonia, mediastinitis, acute pancreatitis, a breakthrough of a subpleurally located lung abscess into the pleural cavity. More rare is the involvement of the pleura in the inflammatory process by the hematogenous route, from the primary foci of purulent inflammation. Empyemas are classified according to the location and extent of inflammation into limited and unlimited. Localized limited empyema are divided into apical (in the region of the apex of the lung), basal (in the region of the diaphragmatic surface of the lung), mediastinal (projected onto the medial surface of the lung facing the mediastinum), parietal (projected onto the lateral surface of the lung). Unlimited are divided into total, subtotal and small. Like other purulent-inflammatory processes, empyema can be acute and chronic. Subsequently, the resorption of purulent exudate is accompanied by the deposition of fibrin threads on the pleural sheets, which may be accompanied by their gluing and obliteration of the pleural cavity. 2. Clinical picture and diagnosis of lung empyema. General clinical, laboratory and instrumental research methods used in the diagnosis of the disease Acute empyema accompanied by the presence of general and local symptoms. The onset of the disease is acute: fever appears, the temperature rises to significant values. Unlimited empyema is accompanied by the appearance of symptoms of intoxication: weakness, headache, and drowsiness are very pronounced. Involvement in the process of the pleura leads to the appearance of pain in the chest, aggravated by a deep breath. Depending on the amount of exudate, the pain may be stabbing in nature or manifest as a feeling of constant heaviness, pressure in the chest. In addition, there are often complaints of coughing with a small amount of sputum. The accumulation of pus in the cavity of the pleura causes a decrease in the respiratory surface of the lung tissue, therefore, symptoms of respiratory failure appear, and the severity of the symptoms depends on the severity and prevalence of purulent inflammation. At first, shortness of breath occurs during physical exertion, but the less functioning lung tissue remains, the greater the severity of shortness of breath becomes, it appears even at rest. On examination, a pronounced diffuse gray cyanosis is determined, patients often take a forced position with a raised head of the bed or sitting, since breathing is greatly facilitated in this position. When examining the chest directly, asymmetry is noted during breathing of the healthy and diseased half of the chest. So, the diseased half lags behind the healthy one when inhaling, the intercostal spaces are expanded and bulge. When determining voice trembling over the area of inflammatory effusion, it is sharply reduced or not detected, percussion reveals a dull percussion sound. A tympanic percussion sound is determined above the compressed exudate of the lung. Since the mediastinal organs are often displaced by an inflammatory effusion to the healthy side, a triangular-shaped area is determined above them, on which a dull percussion sound is determined. Auscultation over the purulent discharge reveals the absence of respiratory noises, hard breathing is determined over the compressed lung. A general blood test reveals general inflammatory changes - an increase in ESR, leukocytosis with a shift of the leukocyte formula to the left, sometimes a decrease in hemoglobin level is noted. In the biochemical analysis of blood - hypoproteinemia, hypoalbuminemia, dysproteinemia. Often, an increase in the level of fibrinogen, C-reactive protein, is determined. X-ray examination has the greatest diagnostic significance, which allows not only to determine the presence and localization of purulent inflammation, but also to accurately determine the place for pleural puncture. The area of accumulation of pus is defined on the radiograph as a homogeneous blackout, a massive effusion can be suspected based on the presence of an oblique border of the shadow corresponding to the Ellis-Damuazo-Sokolov percussion line. Radiologically, a triangle of homogeneous darkening is determined from the side of a healthy lung, which is mediastinal organs displaced by an inflammatory effusion. 3. Treatment methods for lung empyema. General and local, conservative and surgical methods of treatment Treatment of the disease is divided into conservative and surgical methods. For more effective treatment, preference should be given to surgical procedures that allow the fastest and most complete removal of purulent exudate from the pleural cavity. This is a pleural puncture that provides both a diagnostic (sowing of the discharge on nutrient media to determine sensitivity to antibiotics) and a therapeutic effect (removal of exudate, introduction of antiseptics and antibiotics into the pleural cavity). In addition to the passive, there is an active method of washing the pleural cavity - pleural lavage, carried out through a system consisting of two tubes, through one of which an antiseptic solution is injected, and through the other, the solution and exudate are aspirated. An extremely important component of treatment is to ensure proper nutrition of the patient with an increase in calorie intake, the introduction of a large amount of protein to compensate for its loss with inflammatory effusion. Of great importance is the stimulation of the body's defenses, for which it is desirable to take vitamin preparations, biogenic stimulants, such as tincture of ginseng, magnolia vine. Having diagnosed pleural empyema, it is necessary to immediately begin antibiotic therapy: first, with broad-spectrum antibiotics, after clarifying the sensitivity of microorganisms, prescribe the necessary antibiotic in compliance with the principles of antibiotic therapy. Severe respiratory failure determines the need for oxygen therapy. Finally, the inefficiency of such treatment and the formation of moorings are indications for surgical treatment - dissection of the pleural cavity and removal of pleural adhesions. A thoracotomy is preliminarily performed, the pleural cavity is completely cleaned, washed with a solution of antibiotics or antiseptics, and the operation is completed by installing drains. LECTURE No. 18. Purulent-inflammatory diseases of the mediastinal organs. Purulent mediastinitis 1. Purulent mediastinitis. General questions of etiology and pathogenesis Mediastinitis - purulent inflammation of the tissue of the mediastinum. The disease occurs during the transition of the inflammatory process from the cellular spaces located in the immediate vicinity (for example, tissue of the neck, penetrating wounds of the esophagus, purulent inflammation of the pleural membrane) or direct penetration of an infectious agent in case of injuries of the mediastinal organs. Etiology. Pathogenic microbes that cause the development of inflammation of the mediastinal organs are not specific - they can cause purulent inflammation of any localization. First of all, they include staphylococci, streptococci, Escherichia coli, Proteus, Pseudomonas aeruginosa, etc. 2. Clinical picture and diagnosis of purulent mediastinitis. General clinical, laboratory and instrumental research methods used in the diagnosis of the disease In the presence of penetrating wounds, it is quite easy to suspect the occurrence of mediastinitis when typical symptoms appear. Some difficulties can be caused by the diagnosis of mediastinitis against the background of other inflammatory diseases. The classic picture of the disease is characterized by the appearance of predominantly acute, intensely dull pain in the depths of the chest, a feeling of heaviness, fullness, also spreading to the neck and (respectively, the area of pus localization) to the anterior or posterior surface of the chest. The pain is aggravated by pressure on the chest, with deep breathing. Compression of the lungs by inflammatory-enlarged organs of the mediastinum leads to the appearance of intense mixed dyspnea. Signs of a general inflammatory process are clearly manifested. They can appear against the background of complete well-being or join the existing symptoms of an inflammatory disease. Often there is a pouring sweat, chills, hectic body temperature. To confirm the diagnosis, an x-ray examination helps in many ways, which makes it possible to determine an increase in the shadow of the mediastinum in one direction or another, sometimes a compression of the lung. 3. The main methods of treatment of purulent mediastinitis. General and local, conservative and surgical methods of treatment Treatment of this disease is carried out in accordance with the basic rules of purulent surgery. So, surgical treatment includes determining the shortest access to the focus, removing detritus, tissue remnants, pus, washing the wound with an antibiotic solution, and draining. Active drainage can be performed with the injection of an antibiotic solution under low pressure and its subsequent aspiration through another drainage tube. It is necessary to inoculate the purulent discharge, determine the sensitivity of the microorganism to antibiotics and, in accordance with the information received, prescribe the necessary antibiotic (preferably parenteral administration of the drug). Until then, a broad-spectrum antibiotic may be used. If the cause of mediastinitis was a penetrating wound of the neck, esophagus, trachea, an operation is initially performed to restore the integrity of the damaged organ. If mediastinitis has developed as a transition of inflammation from the cellular spaces of the neck, it is first necessary to sanitize the primary focus of infection, carefully removing detritus and possible pus streaks. LECTURE No. 19. Acute purulent-inflammatory diseases of soft tissues. Furuncle, carbuncle 1. Furuncle, carbuncle. General questions of the etiology and pathogenesis of boils and carbuncles The disease is most common in people who neglect the rules of personal hygiene, in people with a violation of the normal microflora of the skin, suffering from diabetes mellitus (high blood sugar is an excellent breeding ground for many microorganisms), in patients with severe chronic diseases. An acute purulent process often affects the skin and its derivatives, and depending on the nature of the elements involved in the pathological process, various clinical forms are distinguished. The difference is that furuncle is an inflammation of the hair follicle, the sebaceous gland adjacent to it and the tissue around these formations. Carbuncle the same is a more extensive process involving several sebaceous glands, hair follicles, surrounding tissues, not only with skin, but also with subcutaneous fat. The most common causative agents of these diseases are strepto- or staphylococci. However, carbuncles in some cases have to be differentiated from anthrax carbuncles, which are an important symptom of an extremely severe infectious disease. 2. Clinical picture and diagnosis of carbuncle and furuncle. General clinical, laboratory and instrumental research methods used in the diagnosis of the disease The entire period of formation and reverse development of a boil, as a rule, does not take more than 5-7 days. Multiple boils are called furunculosis. In the center of the head of the boil is a hair. The furuncle itself is at first a pustule (abscess) of a bright scarlet color with a purulent white head on its top. In patients, it causes unpleasant painful sensations when touched, sometimes a slight itch. On palpation, an infiltrate is determined around the boil. The top of the abscess first dries up, and then is rejected along with pus, hair, necrotic tissues. The patient must be warned about the dangers of cutting, squeezing and other methods of removing the purulent contents of a boil or carbuncle, especially on the face, scalp, and nose. The entry of microbes into the blood can lead to serious complications, up to sepsis and purulent meningitis (inflammation of the meningeal membrane of the brain). After cleansing, the wound heals (sometimes with the formation of a small scar). The reasons leading to the occurrence of carbuncle are the same. Frequent localization of the carbuncle is the scalp, neck, back, lower back. The appearance of a carbuncle is accompanied by more pronounced general phenomena. The carbuncle has a larger size, the beginning of its formation is associated with the appearance of an infiltrate with a diameter of up to several centimeters. The skin over the infiltrate is stretched, hyperemic, shiny. On top of it there are multiple whitish heads. After some time, they are rejected, as a rule, along with necrotic tissues, hair shafts. In its place, a more significant skin defect is formed, when filled with granulation tissue and healed, a more significant scar is formed, often representing a cosmetic defect, especially on open parts of the body. The carbuncle is much more painful both at rest and on palpation. General complaints in carbuncles and boils occur, but are always less significant than in other purulent-inflammatory processes: body temperature is often subfebrile, malaise, headache, decreased appetite are slightly expressed. A complete blood count reflects nonspecific signs of purulent inflammation - an increase in ESR, leukocytosis with a shift of the leukocyte formula to the left, sometimes signs of anemia. 3. The main methods of treatment of boils and carbuncles. General and local, conservative and surgical methods of treatment Treatment can be divided into general and local, specific and nonspecific. К common methods effects on the patient's body include measures of the regimen and proper nutrition. The preferred option is bed rest, but if this is not possible, it is necessary to limit physical activity as much as possible. Nutrition should be sufficiently high in calories, but easily digestible carbohydrates should be limited, since hyperglycemia supports the vital activity of microorganisms. To increase the body's resistance to infection, it is desirable to introduce more than normal amounts of protein-rich foods. Of great importance is the introduction into the diet of foods rich in vitamin C (such as rosehip broth), as well as the use of multivitamin preparations, biogenic stimulants (such as Chinese magnolia vine, etc.). Local treatment prescribed depending on the stage of the disease. At the beginning of the disease, it is possible to use physiotherapy procedures. Immediately after the diagnosis, it is necessary to start antibiotic therapy (broad-spectrum antibiotics) using intramuscular injections, local dressings with an ointment containing an antibiotic. If conservative methods of treatment are ineffective, it is necessary to apply surgical intervention - dissection of the formation with a cruciform incision in compliance with the rules of asepsis and antisepsis. Purulent discharge and altered tissues are removed, the wound is washed with an antibiotic solution and an aseptic dressing is applied to it with a solution of an antibiotic or proteolytic enzymes. LECTURE No. 20. Acute purulent-inflammatory diseases of soft tissues. Abscess, phlegmon 1. Abscess. General questions of the etiology and pathogenesis of abscesses Abscess is a formation limited by an infiltrative capsule, inside of which there is a cavity containing purulent exudate. The abscess does not tend to spread to surrounding tissues. An abscess can occur in any part of the body. Etiology. The causative agent of the disease can be staphylococci, streptococci, E. coli, less often - other microorganisms. The formation of an abscess is associated with the penetration of microorganisms into tissues directly, for example, with injuries, wounds, injections of intact tissues or suppuration of infiltrates, hematomas and similar formations, suppuration of cysts. The conditions for the formation of abscesses in some organs are a violation of the outflow of contents from the glands and the attachment of an infection. Multiple abscesses in various organs occur with sepsis. An abscess is manifested by local and general symptoms of a purulent infection. Spontaneous breakthrough of an abscess into cellular spaces, body cavities is an unfavorable outcome. For recovery, it is necessary to cleanse the abscess from purulent contents by opening it outward. 2. Clinical picture and diagnosis of abscesses. General clinical, laboratory and instrumental research methods used in the diagnosis of the disease The disease usually begins acutely. General symptoms do not differ from those of other types of purulent infection and include fever, malaise, weakness, headache, loss of appetite. Local symptoms are represented by the main signs of inflammation - redness, pain in the projection of the abscess, hyperemia, swelling and dysfunction of the organ in which the abscess is located. Usually, the presence of complaints is associated with any traumatic effects or medical manipulations carried out in violation of the rules of asepsis and antisepsis. If the abscess is located close under the skin, all signs of inflammation are well visualized. An abscess is characterized by a symptom of fluctuation: a few days after the onset of an abscess, a softening appears in its center, which is easily determined by a bellied probe. 3. The main methods of treatment of abscesses. General and local, conservative and surgical methods of treatment At the very beginning of the disease, when the abscess has not yet formed, but there are anamnestic data that suggest the possibility of its occurrence, it is permissible to use conservative methods of treatment. These include physiotherapeutic methods, exposure to UHF currents. The presence of a purulent cavity is an indication for surgical treatment. Its principles are identical for ulcers of various localizations. Sometimes, with a small abscess, a puncture is performed and the purulent exudate is removed. When sowing it on nutrient media, the pathogen microorganism and its sensitivity to antibiotics are identified. After that, it is advisable to conduct antibiotic therapy, taking into account the results of sowing. After a puncture, solutions of antibiotics or antiseptics are injected into the cavity of the abscess, most often hydrogen peroxide. Sometimes, after a puncture, an incision is made along the needle to cleanse the cavity, remove streaks and detritus, then the cavity is washed with antibiotic solutions, dried and drains are installed. The drains are changed daily and the abscess cavity is sanitized. 4. Phlegmon. General questions of etiology and pathogenesis of phlegmon Phlegmon - purulent inflammation of cellular spaces, which does not tend to limit. Phlegmon is accompanied by more pronounced general symptoms than an abscess. The causative agents of phlegmon can be the same microorganisms that cause the formation of an abscess. The causes of phlegmon are varied. To explain the mechanism of occurrence, it is necessary to know in detail the anatomical features of the cellular spaces and their relationship with various formations. So, phlegmon can occur when an abscess breaks into the cellular spaces, suppuration of extensive hematomas, injuries and direct entry of infectious agents into the cellular spaces. Having arisen in one place, pus begins to spread through the cellular spaces, fascial sheaths of the muscles, along the neurovascular bundles. This is extremely dangerous, because it leads to the appearance of foci of inflammation in other organs and cavities, and can lead to the appearance of purulent meningitis, sepsis, and arrosive bleeding. 5. Clinical picture and diagnosis of phlegmon. General clinical, laboratory and instrumental research methods used in the diagnosis of the disease The disease begins acutely, the general phenomena are very pronounced: weakness, irritability, malaise. The fever is hectic in nature, rises in the evening and is accompanied by chills. Symptoms of intoxication appear: lethargy, drowsiness, loss of appetite, tachycardia, increased respiratory movements, pallor of the skin. Local manifestations of the disease include diffuse hyperemia, swelling, soreness. The skin becomes hyperemic, hot. Above the phlegmon, there is marked pain on palpation and a symptom of fluctuation. 6. The main methods of treatment of phlegmon. General and local, conservative and surgical methods of treatment Treatment is similar to that previously described for abscesses. The difference can only be the need for immediate antibiotic therapy and surgical treatment in compliance with the imposition of aperture and counter-opening, cleansing of streaks, removal of pus and necrotic tissues. The wound must be washed with solutions of antibiotics or antiseptics, several drains should be applied to improve the outflow of the contents. If necessary, detoxification therapy is carried out using hemodez, plasma transfusion, saline solutions. LECTURE No. 21. Acute purulent-inflammatory diseases of soft tissues. Erysipelas. Acute purulent-inflammatory diseases of the bones 1. General issues of etiology and pathogenesis of erysipelas of the skin Erysipelas affects mainly the skin, sometimes mucous membranes. The causative agent of erysipelas is β-hemolytic streptococcus group A. It is known that if erysipelas once occurred and was cured, then there is a high probability of recurrence of the disease. Erysipelas is usually localized on the skin of open areas of the body: limbs, face, neck (this does not exclude the appearance of erysipelas in other parts of the body). For the occurrence of the disease, it is necessary for the pathogen to enter the damaged skin. This leads to the occurrence of serous inflammation of the skin. Erysipelas is highly contagious to others. Depending on the level of the lesion, several clinical forms of the disease are distinguished. These are erythematous (reddening of the skin), bullous (blistering), phlegmonous and necrotic forms. 2. Clinical picture and diagnosis of erysipelas. General clinical, laboratory and instrumental research methods used in the diagnosis of the disease Depending on the form of the disease, local symptoms and the severity of general symptoms may be different. Erythematous form erysipelas has such signs as very intense skin hyperemia, the contours of which are uneven and very clear, the area of hyperemia can be of any size, rises above the level of the skin. Subjectively, patients compare the sensation at the site of erysipelas with a nettle burn, in addition, they note intense pain. On palpation, swelling of the site, an increase in skin temperature and pain on palpation can be noted, but unlike pain, it is localized along the edge of the erythematous spot. Upon recovery, these changes undergo a reverse development. bullous form The disease is distinguished by the appearance of blisters filled with serous exudate against the background of the area of hyperemia, sometimes it takes on the character of serous-hemorrhagic. Phlegmonous form erysipelas is localized under the dermis in the subcutaneous fat, where the pathogen causes the development of purulent inflammation. Its localization on the extremities with mild changes in the skin makes it possible to differentiate this form from the usual phlegmon. Extremely severe variants of the disease in malnourished individuals with multiple comorbidities, reduced immunity manifest necrotic skin changes. General symptoms of the disease, characteristic of all inflammatory diseases, manifest themselves to varying degrees depending on its form. 3. The main methods of treatment of erysipelas. General and local, conservative and surgical methods of treatment The issue of hospitalization is decided depending on the general condition of the patient. With the erythematous form, treatment at home is possible. But in any case, it is necessary to take into account the high degree of contagiousness of the patient, which explains the need to place the patient in a separate room and use individual personal hygiene products. The degree of intoxication (in severe cases of the course of the disease) determines the detoxification therapy according to indications. With a significant increase in temperature, it is advisable to use antipyretic analgesics. Early antibiotic therapy allows you to interrupt the progression of the disease at the very beginning. Can be used drugs that are sensitive to streptococcus, from the group of penicillins (ampicillin, oxacillin, etc.), preferably parenteral administration of drugs. Local treatment is carried out strictly according to the doctor's prescription. Local treatment for the bullous form of the disease can be carried out using antibiotic ointments. Phlegmonous and necrotic forms of the disease require surgical intervention in accordance with the general principles of surgical treatment for pyoinflammatory diseases. 4. Osteomyelitis is an acute purulent-inflammatory disease of bone tissue. General questions of etiology and pathogenesis. Classification, clinic, treatment Osteomyelitis - an inflammatory process localized in the bone tissue. In this disease, the bone marrow is involved in the pathological process, as well as all the constituent parts of the bone tissue, the periosteum. Sometimes the inflammation spreads to the soft tissues surrounding the bone. Etiology - microbes-causative agents of the disease, common to all purulent-inflammatory diseases. They cause nonspecific osteomyelitis. Specific osteomyelitis can be caused by Mycobacterium tuberculosis, the causative agent of syphilis, and some others. The pathogen enters the bone structure in various ways. Direct penetration of microorganisms by direct contact is observed in the presence of open fractures and non-compliance with the rules of asepsis and antisepsis, when the pathogen penetrates the periosteum directly through the wound surface. Contact penetration of the pathogen is observed with a gunshot wound to the bone. Another way of penetration - through the bone marrow - is carried out by the hematogenous route. It is realized in the presence of a focus of acute or chronic purulent-inflammatory disease in the body. With the blood flow, the microbial agent can be brought into the bone, while the inflammation spreads from the inside out. Children are most often affected by osteomyelitis, because the type of blood supply to the bone predisposes them to the penetration of microbes. 5. Clinical picture and diagnosis of osteomyelitis. General clinical, laboratory and instrumental research methods used in the diagnosis of the disease The clinical manifestations of the disease depend on the body's response to the introduction of an infectious agent. So, the disease can be manifested only by local symptoms or a pronounced reaction from all organs and systems of the body. General symptoms of a purulent disease can be significantly expressed in osteomyelitis: an increase in body temperature to febrile numbers (more in the evenings and accompanied by chills), headache, drowsiness, decreased performance. According to the temperature, the number of heart contractions, the frequency of respiratory movements increase, pallor of the skin may appear. Complaints intensify during the course of the underlying disease, or these complaints appear shortly after the inflammatory disease. Then, the development of hematogenous osteomyelitis is suggested. Local symptoms of the disease may appear against the background of a gunshot wound or suppuration of a wound located on the limbs. Local symptoms are manifested by pain or a feeling of heaviness, bursting inside the bone. The affected limb swells, becomes hyperemic, the skin over the site of inflammation can be hot, the function of closely located joints is sharply disturbed. The patient spares the affected limb in every possible way, tapping along the axis of the limb is painful. The diagnosis becomes more obvious in the case of a purulent fistula that opens on the surface of the bone, from which pus is separated with pieces of necrotic bone. 6. General principles of osteomyelitis treatment. General and local, conservative and surgical methods of treatment Local treatment consists in creating an outflow for pus, cleansing the medullary canal and draining it. General treatment consists of detoxification, antibiotic therapy, adequate diet therapy, inpatient treatment with mandatory immobilization of the affected limb. LECTURE No. 22. Purulent-inflammatory diseases of the hand 1. Purulent-inflammatory diseases of the hand, the main issues of etiology and pathogenesis Purulent-inflammatory diseases of the hand are quite widespread among the population. Their danger lies in the fact that with untimely treatment, the likelihood of complications is very high, among which there may even be a partial, and in rare severe cases, a complete loss of hand function. This is very important, because in this case professional skills are lost, for people of certain professions it becomes necessary to retrain for another type of work, and sometimes it is possible to assign a disability group. Hand diseases are widespread among people engaged in physical labor, mainly workers of various profiles, etc. Predisposing factors are violations of the rules of personal hygiene, as a result of which pathogenic microorganisms constantly accumulate on the hands. Basically, these are the same microbes as the causative agents of other purulent-inflammatory diseases, among them staphylococci, streptococci, Pseudomonas aeruginosa, Escherichia coli, Proteus, etc. , to which a person does not pay due attention, does not treat with an antiseptic solution, does not apply an aseptic dressing (as always, it is necessary to treat such wounds). Especially conducive to the development of inflammation is the presence of a foreign body in the wound (for example, splinters or glass fragments). Microbes can penetrate into the soft tissues of the finger and with an accidental injection. 2. Clinical picture and diagnosis of purulent-inflammatory diseases of the hand. General clinical, laboratory and instrumental research methods used in the diagnosis of the disease As a result of the changes described above, a typical inflammatory reaction occurs with the development of general and local changes. General changes do not differ from those in other purulent-inflammatory processes, the degree of their severity depends on the extent of the inflammatory process and the general reactivity of the body. At the same time, there is a universal rule according to which the indication for surgical treatment of these diseases is the first sleepless night since the onset of the disease, associated with the severity of pain. In addition, there is an increase in body temperature (sometimes up to febrile values), symptoms of purulent intoxication - headache, weakness, deterioration in performance, apathy, adynamia, loss of appetite, drowsiness, or, conversely, sleep disturbance. Local symptoms of the disease include local signs of inflammation: this is pain at the site of inflammation, and the greatest pain occurs on palpation at the site of fluctuation, hyperemia, swelling, hot to the touch skin over the inflammation, smoothness of the contours of the furrows and lines. On examination, it is noted that the skin, hot to the touch, is thinned, tense, hyperemic, and shiny. The symptoms listed above are nonspecific and can be observed in any clinical form of purulent-inflammatory diseases of the hand. In addition, there are specific symptoms for each individual disease. Depending on the localization, it is possible to determine the involvement of certain areas in the pathological process and the likelihood of complications. 3. Clinical forms of the disease There are the following types of felons: cutaneous, subcutaneous, paronychia, articular, subungual, bone, tendon, pandactylitis. Cutaneous panaritium - the most favorable and safe form of all felons. In this case, the discharge accumulates under the epidermis, visually defined as a bubble filled with pus or hemorrhagic discharge. Its treatment consists in opening, treating with an antiseptic solution, and applying an aseptic dressing. Subcutaneous felon - Accumulation of a predominantly purulent discharge under the skin. At the same time, general symptoms of a purulent disease may be noted, but most often they are expressed slightly. The most important complaint of patients is intense shooting pain, which causes significant inconvenience to patients. When viewed on one of the phalanges of the fingers, mainly proximal, a zone of swelling, hyperemia is determined, when examining with a bellied probe, fluctuation can be determined, smoothness of the interphalangeal skin fold is noted. Paronychia - inflammation of the periungual roller. On examination, its swelling, hyperemia, swelling, pain on palpation and pain in the area of the periungual roller are noted. Subungual panaritium in some cases it develops as a complication of paronychia, in others - as an independent disease. In this case, the purulent discharge accumulates under the nail plate, which leads to its swaying, pain on palpation of the distal phalanx and nail plate, and ultimately to its discharge. Articular panaritium develops when the joint area is injured and infection occurs. At the same time, pain, swelling, swelling and hyperemia are most pronounced in the area of the affected joint, it is in a bent position, movements in the joint are impossible. Bone panaritium is a complication of other types of felons, in which the inflammatory process extends to the bone. Inflammation flows sluggishly, no improvement is noted, and after a certain time, a purulent scanty discharge with detritus, represented by necrotic pieces of bone tissue, comes out through the wound. 4. General principles of treatment of purulent diseases of the hand. General and local, conservative and surgical methods of treatment Depending on the stage at which the inflammatory process is located, preference can be given to both conservative and surgical methods of treatment. So, at the initial stage of tissue infiltration, measures are shown that contribute to the resorption of the infiltrate. These are physiotherapeutic procedures, in particular electrophoresis, UHF. At the stage of fluctuation, which is easily determined by a bellied probe during palpation of the inflammation zone, a surgical operation is performed in accordance with the basic rules of purulent surgery: an incision is made taking into account the anatomical and topographic formations of the hand (to avoid damage to the branches of the nerves), the cavity is cleaned of pus and tissue detritus, washed antiseptic solution, and drainage is installed. Antibiotic therapy is shown taking into account the sensitivity of the isolated microflora to antibiotics. With subungual felon, the nail plate is removed, with bone or articular, it is necessary to carefully remove detritus, consisting of necrotic pieces of bone. The wound is then drained. LECTURE № 23. Acute specific diseases in surgery. Tetanus 1. General issues of etiology and pathogenesis of tetanus Tetanus - a specific surgical infection, manifested by typical symptoms of tonic muscle contraction, in the most severe cases leading to the death of the patient from asphyxia. There are general and local tetanus, as well as several clinical forms in accordance with the severity of the disease. Tetanus bacillus is an anaerobic microorganism that forms spores. It can stay in the soil for a long time in an inactive state (in the form of spores), and it enters the human body when injured. Typical are injuries to the lower extremities and soil contamination. A large percentage of cases occur during the period of hostilities. Penetrating into the body, the pathogen begins to release toxins: tetanospasmin and tetanolysin. Tetanospasmin causes spasm and development of spasms of skeletal muscles, and tetanolysin - hemolysis of erythrocytes. In peacetime, the incidence of tetanus is low, and routine vaccination of children plays a significant role in this. The incubation period for tetanus is 4 to 15 days (sometimes extended to 31 days). Like other infectious diseases, tetanus can be mild, moderate, severe, or extremely severe. In addition, there are general tetanus (primarily a general form - a disease of the whole organism, when all the striated muscles of the body are involved in the process either from top to bottom or from bottom to top) and local. Local tetanus develops when the toxin acts on a limited area of the body, such as tetanus in one of the limbs. As a rule, this is the area of the body on which the contaminated wound is located. It must be remembered that often local manifestations of tetanus precede its general manifestations. In addition to acute, there are chronic and erased forms of tetanus, as well as pronounced tetanus. 2. Clinical picture and diagnosis of tetanus. General clinical, laboratory and instrumental research methods used in the diagnosis of the disease The disease begins with a prodromal period, the manifestations of which are common to many infectious diseases. This is a general malaise, weakness, headache. The main sign suggesting tetanus at this stage of the disease is muscle contractions near the contaminated wound and at a short distance from it. After a few hours (sometimes even days), the general symptoms worsen: the body temperature can reach 41 ° C, the pulse rate increases accordingly, and severe sweating appears. Among the specific symptoms of general tetanus, the appearance of convulsive twitches, and then tonic and clonic convulsions of the striated muscles of the body, is noted. Tetanus is characterized by a contraction of the mimic muscles of the face in such a way that the forehead is furrowed, the lips express a smile, and the eyes express suffering. This facial expression is called a sardonic smile. Tonic convulsions become more and more pronounced, then they acquire the character of a clonus. Their appearance is facilitated by various non-specific stimuli, such as bright light, loud sound. Spasms gradually involve in the process all the striated muscles of the body. In the most severe cases, clonic convulsions take on the character of opisthotonus, which means that the contraction of all muscles acquires a maximum character: the arms are bent at the elbow and wrist joints, the hand is clenched into a fist, the trunk and lower limbs are also extended, the body rests on the support only with the back of the head and heels. 3. The main methods of treatment of tetanus. Specific and non-specific treatments К non-specific treatments includes a number of activities. First of all, this is the hospitalization of the patient in a specialized hospital with mandatory placement in a separate ward with darkened windows and ensuring complete rest, since any non-specific effect (bright light, loud sound) can cause him to have seizures. Depending on the patient's condition, detoxification therapy, anticonvulsant therapy, including muscle relaxants, barbiturates, tranquilizers, are indicated. Detoxification therapy is carried out with transfusion blood-substituting fluids (hemodez, plasma), saline solutions are used. Electrolyte solutions - according to indications. Sometimes it becomes necessary to use artificial lung ventilation. Be sure to produce a wound toilet with the removal of all purulent-necrotic masses and washing the wound with an antiseptic solution. The operation ends with the obligatory installation of drains. К methods of specific therapy tetanus include the use of antitetanus serum and antitetanus gammaglobulin. LECTURE No. 24. Acute purulent-inflammatory diseases of serous cavities. Acute inflammation of the peritoneum - peritonitis 1. Peritonitis - general issues of etiology and anatomical and physiological features of the peritoneum Peritonitis is an inflammation of the peritoneum with exudate, often of an acute nature, accompanied by pronounced shifts in the functioning of all organs and systems, severe disturbances in water and electrolyte metabolism, in the absence of adequate treatment, often leading to death. Anatomical features of the peritoneum The peritoneum is a serous membrane. It has two sheets - visceral and parietal. The visceral sheet covers the internal organs of the abdominal cavity, and the parietal sheet from the inside is adjacent to the abdominal wall. Between the sheets there is a minimum amount of liquid that ensures the sliding of the sheets relative to each other. The serous membrane has a large number of receptors; therefore, exudate in the peritoneal cavity or fibrin filaments irritate the receptors, causing intense pain. The peritoneum provides metabolism and fluids, having the ability to both absorb fluids and substances from the abdominal cavity, and to release fluid containing exudate and fibrin filaments. This provides a protective function of the peritoneum: the loss of fibrin threads and the participation of the omentum cause a limitation of the inflammatory process in the abdominal cavity. Such peritonitis are called abdominal abscesses, such as subdiaphragmatic abscess, appendicular, etc. The nature of the exudate, as in other inflammatory processes, may be different. These are serous, purulent, serous-purulent, sometimes hemorrhagic and putrefactive contents. The limitation of inflammation in a certain area is usually carried out by soldering the sheets of the peritoneum using fibrin threads. Etiology The microbes that cause peritonitis are diverse. These include staphylococci, streptococci, Escherichia coli, Pseudomonas aeruginosa, Proteus, but mixed microflora predominates. In addition to nonspecific, specific peritonitis is also distinguished, for example, peritonitis with a tuberculosis infection of the body. For the occurrence of inflammation of the peritoneum, a change in the macroorganism is necessary - a violation of nonspecific resistance. The mechanism of penetration of microbes into the body can be different. In women, the peritoneal cavity communicates with the external environment through the openings of the fallopian tubes and the vagina. This explains the possibility of penetration of infection in inflammatory diseases of the female genital organs. In addition, the infection penetrates into the peritoneal cavity in acute inflammatory diseases of the abdominal organs - appendicitis, pancreatitis, purulent cholecystitis and gallbladder empyema, inflammatory bowel disease, liver abscesses. Usually, in this case, purulent inflammation of a hollow organ first leads to an increase in the permeability of the organ wall and the penetration of microorganisms and discharge into the abdominal cavity. With the progression of the process and the absence of adequate therapy, the likelihood of perforation of the organ and the penetration of purulent contents in large quantities into the abdominal cavity increases. Another cause of peritonitis is the penetration of infected contents during perforation of internal organs, the most common cause is perforation of a stomach ulcer, rupture of an infected appendix or gallbladder, ulcerative colitis, rupture of suppurating cysts, such as the liver and pancreas. This is extremely dangerous, because when a hollow organ is perforated, an extremely virulent microflora enters the peritoneum, causing a typical inflammation process. An infectious agent can penetrate into the peritoneal cavity directly with penetrating wounds in the abdomen, after surgical operations if aseptic and antiseptic rules are not followed or sutures are not properly applied. In women, peritonitis may be associated with gynecological pathology: a complication of non-drug abortion or ectopic (eg, tubal) pregnancy, purulent-inflammatory diseases of the female genital organs (such as salpingoophoritis, adnexitis, endometritis). Peritonitis can occur with some therapeutic diseases: systemic lupus erythematosus, rheumatic disease, some vasculitis. Often, peritonitis occurs with a tumor lesion of the peritoneum - carcinomatosis. Depending on the etiology of the process, exudate in the peritoneal cavity may have the character of serous, serous-hemorrhagic, hemorrhagic, purulent, putrefactive characters. 2. General issues of the pathogenesis of acute inflammation of the peritoneum. Clinical picture and diagnosis of peritonitis. General clinical, laboratory and instrumental research methods used in the diagnosis of the disease The onset of the disease is manifested by signs of a disease or pathological condition that led to the development of peritonitis. After microorganisms hit the wall of the peritoneum, a typical inflammatory reaction occurs, manifested by inflammatory exudation, hyperemia, edema, pain, temperature reaction. Pain in peritonitis is one of the first symptoms and is specific. Its nature lies in the irritation of the receptors of the peritoneal walls with inflammatory exudate. At the beginning of the disease, the pain is located directly above the organ, the disease of which caused the development of peritonitis. The pain is very intense, it is constant, it is not relieved by antipyretic analgesics, patients tend to take a position in which the peritoneum is minimally subjected to friction and tension. Often, patients lie on their backs with knees bent and pulled up to the stomach, trying to lie as still as possible. An objective symptom of inflammation of the peritoneum, which must be checked in the presence of any complaints of abdominal pain, is the Shchetkin-Blumberg symptom. To check it, you need to put your hand on the anterior wall of the abdominal cavity and immerse it in the abdominal cavity, then abruptly remove it. If the patient experiences pain, the symptom is positive. With limited inflammation of the peritoneum, this symptom can be positive only over the area of inflammation, for example, with inflammation of the appendix of the caecum. If the patient experiences such intense pain that it does not allow even a superficial approximate palpation, the symptom is considered sharply positive. On examination, local or extensive tension of the muscles of the anterior abdominal wall is noted, and with diffuse inflammation, scaphoid muscle retraction may be noted. The most favorable outcome of the disease, which is possible with a pronounced nonspecific defense of the body, is the limitation of inflammation in a certain area. This is due to the involvement of the omentum and the loss of fibrin strands. In the initial phase of inflammation, vomiting may occur. At first, it is reflex in nature, and then it can be associated with the paralytic need of the intestine, the paralytic effect of toxins on the stomach. This also explains the absence of noise of intestinal peristalsis during auscultation. In addition to the symptoms of the underlying disease that caused the development of peritonitis, there is a group of symptoms associated with the development of an extensive inflammatory process. This is a fever with a rise in body temperature to subfebrile numbers, tachycardia. For the diagnosis of peritonitis, tachycardia is very important, since this disease has a characteristic symptom - a discrepancy between tachycardia and body temperature. With a slight fever, tachycardia can be very significant. Frequent breathing is usually noted, and the stomach (or one of its halves) does not participate in the act of breathing. During laparoscopy at the beginning of inflammation, the peritoneum looks hyperemic, edematous, thickened, dull, sometimes rough. Usually, these changes are maximally expressed directly above the zone of the inflammatory focus. Subsequently, exudate begins to accumulate in the peritoneal cavity. The exudate contains a significant amount of protein. A blood test reveals leukocytosis, initially insignificant, with a shift of the leukocyte formula to the left, ESR slightly above normal. A biochemical blood test reveals a decrease in total blood serum protein, an increase in the level of fibrinogen, C-reactive protein, with inflammation of the internal organs, the appearance of specific markers may be noted. A day after the onset of the disease, a significant amount of toxic substances enters the bloodstream. An increase in the permeability of the vascular wall as a result of exposure to toxic substances leads to the release of a significant part of the blood plasma into the tissues. This also contributes to a decrease in the level of protein in the blood. There are significant hemodynamic disorders due to an increase in the vascular bed (vasodilation). The loss of a large volume of blood with vomiting, the exit of the liquid part of the blood from the vascular bed, exudation into the peritoneal cavity lead to hypovolemia. At this stage, paralytic ileus leads to the absence of intestinal noise during auscultation, the filling of the intestine with gases - to the appearance of a tympanic sound during percussion, significant bloating, impaired stool discharge. Inflammatory changes in the peritoneum are significantly aggravated. This leads to an increase in the severity of all symptoms. The fever becomes hectic in nature, the pulse becomes much more frequent, characterized by low filling and tension. Arterial pressure decreases. Significant intoxication leads to the appearance of a characteristic appearance that appears with peritonitis. It was described by Hippocrates and received his name. The face of such a patient is pale, the eyes are sunken, the facial features begin to sharpen, the nose and cheekbones protrude significantly on the face. Tongue coated with thick yellowish coating, dry. The condition of such a patient can be assessed as severe, the facial expression is suffering, the patient reluctantly answers questions. The next stage of the disease develops 3 days after the onset of the disease. There are severe disorders of hemodynamics, disruption of the activity of all organs and systems of the body, which in the final stage can lead to multiple organ failure and death. At this stage, the patient is pale, his skin is covered with cold sticky sweat, there may be a violation of consciousness, psychosis. The pulse is thready, blood pressure is sharply reduced. Auscultation of the heart revealed deafness of heart tones, various cardiac arrhythmias. Bowel sounds are not heard on auscultation. There is no stool, but vomiting of intestinal contents may be noted. Urination is rare, the amount of urine is reduced. 3. The main methods of treatment of peritonitis. General and local, conservative and surgical methods of treatment Emergency hospitalization in a surgical hospital and a surgical method of treatment are absolutely indicated. If the examination at admission suggests the presence of peritonitis, it is necessary to identify its cause. Diseases preceding the development of peritonitis, complaints and some features of the examination in certain diseases can reveal the etiology. At the initial stage of the disease, access should be able to eliminate the original cause of the disease. If the patient was admitted with signs of diffuse peritonitis, a median laparotomy is performed, providing the necessary access to all organs of the abdominal cavity. The initial goal of treatment is to eliminate the immediate cause of the development of peritonitis. This is the removal of a purulently modified appendix, gallbladder, festering ovarian cyst, suturing of a perforation of a stomach or intestinal ulcer, and other surgical interventions. Then it is necessary to remove the exudate and sanitize the peritoneal cavity. Finish the operation with the installation of drains. In addition, it is necessary before, during and after the operation to correct violations of water-salt and electrolyte metabolism. For this, intravenous infusions of saline solutions, Hemodez solution for detoxification, rheopolyglucin solution to improve microcirculatory disorders, plasma infusion are carried out. A solution of antibiotics is injected into the peritoneal cavity (antibiotics are administered intravenously according to generally accepted schemes). In some cases, peritoneal dialysis, hemodialysis are indicated. LECTURE No. 25. Thermal lesions of the skin. burns 1. General issues of burn skin lesions. Burn classification. Features of skin lesions depending on the influencing factor Burns - this is damage to the skin as a result of exposure to high temperatures, concentrated acids or alkalis, and other chemically active substances. Skin lesions in the form of burns are often found in young children as a result of insufficient attention from adults, in this case, burns are most often observed when overturning dishes with hot (sometimes even boiling) water, food. Often, burns of a similar nature occur in adults with inattentive behavior in everyday life. Occupational burns occur as a result of non-compliance with safety regulations when working with chemically active and explosive substances. Burns as a result of exposure to various types of weapons are found among fighters in the battle zone. Sometimes burns occur during suicidal attempts (burns of the esophagus). Burns can be caused when intruders try to disfigure a person's appearance. Extensive burns can be observed in persons caught in a burning room during a fire. Here are the main groups of patients in burn centers. Thus, according to the etiological basis, the following groups of burns can be distinguished: from exposure to high air temperature, high-temperature liquids or solids, acids, alkalis and other chemically active substances. According to the nature of the skin lesion, coagulative necrosis and colic necrosis are distinguished. Coagulation, or dry, necrosis occurs when the surface of the skin is exposed to acids, high temperatures (more than 60 ° C). The damage in this case is superficial, a hard dark crust forms on the skin - a scab - with clearly defined contours. The contours and shape of the burn correspond to the stain of acid that has fallen on it. Coliquation, or wet, necrosis occurs when the skin is exposed to alkalis, temperatures, relatively low - less than 60 ° C. In this case, the damage is deeper and spreads over a much larger area than the initially acting alkali. On examination, colic necrosis looks different (depending on the depth of tissue damage), but always has blurry, fuzzy contours. 2. Determining the degree of depth of skin lesions According to the depth of the lesion, deep and superficial burns are distinguished. There is a classification according to which the depth of tissue damage during burns is divided into several degrees. I degree - superficial burns, only the upper layer of the epidermis is affected, only hyperemia of the skin is visually determined. Subjectively, there is a feeling of heat, burning of the skin. Such burns often occur in people with a fair skin type when exposed to sunlight. They require only conservative symptomatic treatment and pass on their own, without leaving behind persistent skin changes. II degree - superficial burns, however, in addition to hyperemia, at the site of exposure to the factor, blisters with serous contents appear, resulting from the peeling of the surface layers of the epidermis from the underlying ones. Subjectively, more pronounced symptoms are noted: burning sensation, heat, pain, palpation of the damaged area - soreness. Such burns are most often observed in everyday life, sometimes sunburns of this severity are noted. Treatment is conservative, it is forbidden to open blisters. IIIA degree - superficial burns, however, necrosis of the superficial layers of the skin is noted. These burns are much more severe both in terms of the reaction from the whole organism, and in terms of the duration of recovery from them. Nevertheless, with this degree, the possibility of self-restoration of the upper layers of the skin remains. IIIB degree - deep burns, the death of the entire dermis is noted with the involvement of hair follicles, sweat and sebaceous glands. When examining a burn, sensitivity to painful stimuli in the area of damage is determined. Deep burns are accompanied by loss of pain sensitivity. Urgent hospitalization in a burn hospital is required for adequate local (surgical) and general treatment. IV degree - deep burns, in which not only all layers of the skin can be damaged, but also the underlying subcutaneous fat, muscle tissue and even bone. 3. Area of burn skin lesions. The method of "palm" and the rule of "nines" in determining the area of the burn In order to determine the area of the burn, several methods are used. The simplest, not requiring additional tools and fairly accurate method is the "palm" method. After some research, it was reliably revealed that the size of the human palm corresponds to 1% of the skin of the human body. Thus, by comparing the area of the burn with the size of the palm, the exact area of the burn can be determined. Another rule for determining the area of a burn is also quite simple - this is the rule of "nines". It is known that the area of various areas of the body is 9% of the total surface of the skin, with the exception of the perineum, the area of which is 1%. 9% of the total area correspond to the upper limb, thigh, lower leg with foot, as well as the head and neck. 18% of the total area are the anterior and posterior surfaces of the body. 4. Pathogenetic bases of damage to the body with burn lesions of the skin At present, due to the unfavorable situation regarding terrorist activities, the need for the ability to diagnose and treat burn disease is of great importance. Burn disease is a complex of pathophysiological changes in the body, the most important of which are hemodynamic disorders, severe intoxication of the body. Burn disease has several stages in its development. The first of these is burn shock. The leading pathogenetic aspect of its occurrence is severe dehydration of the body. it hypovolemic shock. As a result of dehydration, there is a decrease in the volume of circulating blood. There is a discrepancy between the volume of the vascular bed and the amount of circulating blood. In addition, an increase in blood viscosity, resulting from the release of the liquid part of the blood into the tissues, causes a violation of microcirculation, blood slugging. Compensatory centralization of blood circulation occurs. Clinically, burn shock can be suspected in a patient if, during dynamic observation, a drop in blood pressure is noted (in older people who had hypertension before the disease with a constant level of pressure at high numbers, shock can develop even at blood pressure values of 120/80 mm Hg. Art. ), increased heart rate, tachypnea, lethargy, drowsiness. It is necessary to make dynamic monitoring of kidney function, since a decrease in the amount of urine discharge, observed in dynamics, makes it possible to suspect the development of acute renal failure. Patients note thirst, during examination, dryness of the skin, mucous membranes, and tongue is noted. If the burn shock was successfully stopped, the next stage of the course of the burn disease begins - acute burn toxemia. It is accompanied by the entry into the blood of a significant amount of toxic substances formed as a result of tissue breakdown. Toxico-resorptive syndrome is accompanied by the appearance of fever, its degree depends on the extent of the lesion. In addition, a significant amount of toxins affects all organs and systems, significantly disrupting their activities. So, the heart muscle reacts to intoxication by increasing the heart rate, with auscultation, deafness of tones is noted. Dynamic monitoring of laboratory parameters is necessary for the timely diagnosis of organ failure. The next period of septicotoxemia is accompanied by the development of purulent complications against the background of a sharply reduced general resistance of the organism. burn wound is a gateway for the penetration of infectious agents into the body, and the purulent process can take on any character, up to sepsis. 5. Principles of treatment and correction of disorders in the body with burn lesions of the skin Treatment depends on the degree, stage, extent of damage. It is generally accepted that treatment is divided into conservative and surgical, as well as local and general. Before treatment, it is necessary to make a primary toilet of the burn wound, treating its circumference with sterile cotton swabs dipped in warm soapy water. Foreign bodies, scraps of clothing, exfoliated epidermis are removed, blisters are opened with sterile instruments. There is an open way to treat burns. To do this, it is necessary to maintain a constant temperature in the room (to prevent the development of pneumonia and other complications, since the patient must lie without clothes) and optimal humidity. In order to prevent the development of purulent complications, the patient should be in an individual ward. Care for such patients should be extremely thorough, it is necessary to constantly straighten the sheet carefully to avoid the formation of bedsores. The surface of the burn wound is usually treated with antiseptic ointments. Depending on the degree of the burn, it is necessary to carry out adequate anesthesia, in severe cases even using narcotic analgesics, this will help alleviate the course of burn shock. Surgical treatment is performed under adequate anesthesia. It is indicated for deep burns. In the early stages, it consists in removing necrotic tissue. Deep burns are an indication for transplantation of the superficial layers of the skin. From an immunological point of view, in order to avoid the development of rejection, it is necessary to use your own surface layers of the skin as a donor, which are taken with a special tool. The skin flap is incised in a certain way, which allows it to stretch, and applied to the affected areas. Of great importance in the prevention and treatment of burn shock is adequate fluid transfusion. Hypovolemia, intoxication and thickening of the blood are indications for transfusion of hemodez, rheopolyglucin, saline solutions, plasma, albumin. Often indicated the appointment of antihistamines. 6. First aid for burn skin lesions If the burn occurred due to contact with the skin of chemicals, it is necessary to immediately begin washing the burn site under cool running water for 15-20 minutes. Usually this time is sufficient for complete removal of the substance from the surface of the skin. The same first aid for thermal burns. After that, it is necessary to apply a dry, clean bandage and consult a doctor. It is forbidden to treat the surface of the burn yourself, pierce or cut the bubbles. LECTURE No. 26. Thermal lesions of the skin. Skin lesions from exposure to low temperatures. Frostbite 1. Frostbite. Etiology. General issues of the pathogenesis of frostbite, changes in the body that occur under the influence of low temperatures. Classification of the degree of damage to the skin frostbite is a skin lesion resulting from disorders of microcirculation in the vessels associated with exposure to low temperatures on the skin. Exposure of the skin to cold leads to vasospasm. This is a reversible phenomenon, therefore, if after a few hours a person enters a warm room where he is given first aid, vasospasm is gradually replaced by their expansion, blood circulation is restored, and the effects of frostbite are fully restored after a week. However, prolonged frostbite, which results in deep skin damage, proceeds somewhat differently. The classification of frostbite by depth echoes the previously presented classification of burns. Common to them is the possibility of regeneration of the skin after damage. I degree - superficial frostbite, in which, as described above, morphological changes in the skin do not occur, all the changes that have occurred are reversible. It is manifested by blanching of the skin, sometimes paresthesia in the form of tingling, however, pain sensitivity is completely preserved, since necrotic changes in the skin are not observed. When warming, the restoration of blood circulation is accompanied by the appearance of pain or burning at the site of frostbite, sometimes itching. Visually, blanching and cyanosis are gradually replaced by hyperemia and slight swelling. When warmed, all functions of an organ or limb are completely restored. First aid for frostbite is to warm the limb by any means, for example, using a bath with a gradual increase in temperature, starting from 16 ° C. Gently, taking into account the reduced sensitivity and vulnerability of the skin, rub the affected area. Such a bath is continued until the limb is warm, usually 40-50 minutes, and then the surface of the skin is treated with an alcohol solution and insulated, previously covered with a sterile bandage. It is advisable to give the victim hot meat broth or tea, and then carefully cover with a woolen blanket to avoid heat loss. II degree - superficial frostbite, in which the surface layer of the epidermis is damaged. Despite this, the full restoration of the skin also occurs, but somewhat longer (up to 10 days). On examination, the area of frostbite does not differ from that in frostbite I degree, however, when warming, subjective sensations are expressed much more intensely, pain, burning and itching can cause significant inconvenience, swelling and hyperemia of tissues persist for several days. An important distinguishing feature of this degree of frostbite is the appearance of blisters filled with serous contents at the site of the lesion. Bubbles can open on their own, but it is strictly forbidden to open them at home, since there is a high risk of developing purulent complications. After opening the bladder, the skin looks thin, hyperemic, shiny, easily injured and very painful on palpation. The treatment of such frostbite is conservative; immediately after opening, an aseptic bandage is applied to them. You can apply a bandage with ointments containing an antiseptic or antibiotic. Depending on violations of the general condition, such patients can be hospitalized in a hospital for the correction of homeostasis disorders. III degree - these frostbites are considered deep. Morphological changes that distinguish this form of lesion are accompanied by necrotic changes in the surface layer of the skin, dermis, up to the subcutaneous fat. The sequence of changes is as follows: first, there is a long-term effect of low temperatures on the skin. This is accompanied by vasospasm, then microcirculation disorders and changes in the vascular wall. When warmed, necrosis of the skin develops, regeneration does not occur, granulation tissue is formed, and subsequently a connective tissue scar is formed. When viewed after warming, the frostbite area looks extremely edematous, the skin is sharply hyperemic, cyanosis is noted in some places, blisters can sometimes form, but unlike the previous degree, their contents include an admixture of blood. Since the entire skin undergoes necrosis, the pain sensations are completely lost: if, after opening the blisters, irritation of the skin is produced, no reaction is noted. Such patients are treated in a hospital. In addition to local treatment, the general principles of which are described above, it is necessary to treat microcirculation disorders. To reduce blood viscosity, improve its rheological properties, intravenous infusions of rheopolyglucin, polyglucin are performed, antibiotic solutions are administered to prevent the development of purulent-inflammatory complications, and heparin and trental are used to reduce the likelihood of blood clots. IV degree - deep frostbite - the highest degree of depth of damage when exposed to low temperatures. The intensity of the damaging factor is so great that necrotic changes develop not only in the skin, but also in the underlying tissues. Reverse regeneration is not possible. Reaction to any kind of stimuli is lost. The limb looks cyanotic, the skin is cold to the touch, active and passive, movements in the joints are impossible. After warming the limb, its color changes to dark cyanotic, significant edema develops not only above the affected area, but also for a considerable distance from the site of the initial injury. The skin may exfoliate in the form of blisters containing dark hemorrhagic contents. Tissue damage reaches its maximum intensity, gangrene of the limb develops. 2. General principles for the treatment of skin lesions when exposed to low temperatures General treatment is carried out according to the principles outlined above, taking into account the individual condition of the patient. Local conservative treatment can be carried out only as a preparation for surgical treatment, which is carried out in accordance with the timing of the development of changes in the area of damage. So, surgical manipulations begin to be carried out a week after frostbite. Necrotomy is performed first. This operation is symptomatic, since it eliminates only the symptoms of the disease (tissue swelling). After the formation of necrosis, necrotic tissues are removed, and after the formation of a demarcation line that separates healthy tissues from dead ones, the limb is amputated. LECTURE No. 27. Fundamentals of traumatology. Soft tissue injuries 1. Classification of traumatic injuries of soft tissues. Compression, bruise, sprain, rupture. General issues of transport immobilization Distinguish open (with damage to the integrity of the skin) and closed (without violating the integrity of the skin) damage to soft tissues. This section focuses on closed soft tissue injuries. Among them, there are compression, bruise, sprain and rupture. The mechanism of obtaining this group of injuries is the impact of a mechanical factor. Injury. The main morphological and clinical disorders at the site of exposure to the damaging factor. Diagnosis and general principles of treatment of bruises. Injury - this is a closed soft tissue injury, resulting from the impact of a mechanical factor of varying intensity. Speaking about a bruise, it is more correct to mean the morphological nature of the damage, and not the mechanism of injury. Contusion does not rule out other types of injury, such as fractures, since the mechanism of these injuries usually involves combined injuries. The main objective sign of a bruise is a hemorrhage, and by its shape it is possible to determine which object caused the injury. The description of the hemorrhage should take into account its localization, size in length and width in centimeters, distance from any anatomical formations, contours, shape, surface. By the color of the hemorrhage, one can determine the duration of the injury: this is due to the destruction of red blood cells and the successive transformations of the bilirubin pigment. A bruise is accompanied by such a subjective symptom as pain at the site of injury. With small injuries, pain is not very significant, only when an extensive hematoma is formed, the pain can be intense. With extensive hematomas, a complication is possible as an infection. The bruise is accompanied by edema and swelling in the area of injury. Treatment of bruises is mainly symptomatic and consists in the local application of cold and various absorbable lotions. Large hematomas are punctured. 2. Sprains and ruptures of soft tissues are the main morphological and clinical disorders at the site of exposure to a damaging factor. Diagnosis and general principles of treatment of sprains and tears Stretching and tearing. These injuries are also associated with the impact of a mechanical factor. This type of injury is typical for muscles and tendons. Most often they occur in athletes, but they also occur in untrained people when exposed to a significant load. Both sprains and ruptures of muscles and tendons are accompanied by symptoms such as pain, swelling, swelling, dysfunction. Their difference lies in the fact that the rupture is accompanied by a greater severity of subjective sensations, the pain at the time of the rupture is extremely intense, edema and swelling are expressed directly above the injury zone, the function of the muscle or tendon is completely lost. A dip can be determined above the damage zone. When sprained, the pain is dull and much less intense, the function of the limb is preserved. Treatment for incomplete damage (stretching) is conservative, similar to treatment for bruises (applying cold - locally, physiotherapy methods - to speed up recovery), treatment for ruptures is surgical and consists in suturing the muscle or tendon in the most sparing position of the limb (most often - flexion) . Subsequently, the limb is immobilized in a functionally advantageous position until the integrity is fully restored. For a more complete recovery, it is recommended to use physiotherapy methods, massage and physiotherapy exercises. 3. Main issues of transport immobilization. Definition, rules for conducting, fixed assets and methods used in carrying out transport immobilization Transport immobilization is a set of measures aimed at creating immobility of the body during transportation to the hospital. Transport immobilization is widely used for fractures, bleeding from the vessels of the extremities, damage to the nerve trunks of the extremities, and prolonged compression of the extremities. Immobilization can be carried out with standard tires or with the help of improvised means. Standard splints are represented by Cramer's ladder splint, the frame of which is effectively modeled for immobilization of the upper or lower extremities. If it is necessary to immobilize for hip fractures, three Kramer splints are used. The Dieterikhs tire is used for immobilization of the lower extremities. It consists of wooden plates moving relative to each other, a plywood sole, fixed with special fasteners. For immobilization in case of damage to the cervical spine, a Shants collar is used, which with its ends should rest against bone formations - the chest and mastoid processes of the temporal bone. This contributes to effective immobilization while sparing the upper respiratory tract. Pneumatic tires are very easy to use, the principle of operation of which is based on the creation of immobilization due to forced air. They are hermetically sealed cases. Among the available tools, boards, sticks, even branches from trees, ski fragments are used. Fixation is carried out with the help of scarves, scarves, pieces of durable matter. When carrying out transport immobilization, certain rules must be observed. Two adjacent joints must be fixed. So, in case of a fracture of one or more bones of the forearm, two adjacent joints must be fixed for immobilization. Since fixation is made to a solid base, it is necessary to protect soft tissues from damage. To do this, between the tire and the limb, you need to lay some kind of fabric, clothing. In case of an injury accompanied by bleeding, it is necessary to temporarily stop bleeding before immobilization. It must be remembered that with open fractures, the risk of damage to the neurovascular bundle of the limb is extremely high; therefore, during immobilization, it is strictly forbidden to reduce the fracture, the distal part of the limb is carefully fixed in its original position. LECTURE No. 28. Fundamentals of traumatology. bone fractures 1. Classification of bone fractures according to the mechanism, the nature of the relative position of the fragments, the degree of damage to the skin Fracture is a damage to the bone resulting from mechanical action, leading to a violation of its integrity. Fractures are classified according to the violation of the integrity of the skin into open, in which bone fragments damage the skin from the inside and can be seen in the depth of the wound on examination, and closed, when the skin is not damaged, and a fracture can only be judged by the presence of certain signs of a fracture. According to the nature of the damage, fractures are divided into transverse, helical, comminuted, oblique. This is judged by the nature of the relative position of the fragments of the distal and proximal ends of the bone, according to X-ray examination. However, the nature of the fracture can be assumed by the mechanism of injury, for example, a direct mechanism, when the impact of a traumatic agent is perpendicular to the length of the bone, often causes transverse fractures, and twisting (for example, a fracture of the lower leg according to this principle occurs when the foot is fixed and the body rotates) leads to oblique fractures . A heavy object falling from a height onto a bone, such as a radius, will result in a comminuted fracture. According to the principle of displacement of fragments, fractures with displacement and without it are distinguished. The displacement of fragments occurs with a large force acting on the bone. The displacement of fragments can be rotational, and can occur along the length, width, axis. To determine the displacement, it is necessary to draw imaginary lines on the x-ray image corresponding to the axes of the distal and proximal fragments. So, if these lines intersect at a certain angle, then this is an offset along the axis (with an angle open outward, inward, backward or anteriorly), if the fragments go behind each other, then this is a displacement along the length, if to the sides of each other, displacement in width. 2. Fractures. General clinical, laboratory and instrumental research methods used in the diagnosis of the disease Closed fractures can be suspected in the presence of the following signs: from the anamnesis, the presence of any injury with a typical mechanism is revealed, after which the patient felt pain, swelling, hyperemia appeared, and sometimes dysfunction. These are the main signs of a fracture. The pain that arose at the time of the fracture is very intense, constant, aching in nature. It is localized directly at the location of the fracture, and if tapping along the axis of the limb, the pain intensifies at the site of the fracture. Swelling immediately forms at the fracture site as a result of swelling of the surrounding tissues. On palpation and an attempt to displace the distal and proximal fragments, it is possible to determine the crunch of rubbing limbs (crepitus) and this is a pathognomonic sign of a fracture. The fracture causes pathological movement of the limb at the fracture site, however, in order to avoid damage to soft tissues and neurovascular bundles, this symptom should be determined as carefully as possible. Sometimes, as a result of a fracture, a change in the shape, configuration of the limb occurs, which is determined visually. Sometimes there is a significant impairment of function, active movement can be completely lost. Displacement of fragments can be dangerous because the neurovascular bundles that run along the inside of the limb can be damaged. To clarify the nature of the fracture, it is necessary to determine the sensitivity and motor function of the limb. Related to this is the need for transport immobilization of the limb in the position in which it was at the time of first aid. A fracture of the limb can be suspected when comparing the length of the limbs, sometimes the displacement of fragments along the length causes an elongation of the damaged limb by several centimeters. Sometimes fractures are not accompanied by severe pain and may even remain unnoticed by patients, which is often associated with osteoporosis that occurs in women during menopause, a complication of glucocorticoid therapy, and pathology of the parathyroid glands. There are pathological fractures that occur at the site of a bone tumor with thinning of the bone tissue. Open fractures are accompanied by the appearance of all the above symptoms, the presence of bone fragments in the wound is a reliable sign of a fracture. These fractures are accompanied by a significantly greater number of complications than closed ones. These include damage to the nerve trunks and vascular bundles, infectious complications, damage to internal organs, malunion, etc. Infectious complications occur most often with open fractures with soil contamination of the wound, and the most unfavorable complication is the development of anaerobic tetanus infection and gas gangrene. A presumptive diagnosis is established at the scene by an ambulance team, in the emergency department of the hospital, and in the emergency room. To confirm the presumptive diagnosis, it is necessary to produce x-rays, at least in two projections. The frontal (or frontal), lateral (or sagittal) and 3/4 views are usually required. X-ray images make it possible to reliably diagnose the fact of a fracture, to clarify its nature, which is extremely important for further treatment tactics. 3. First aid for suspected fracture If the victim has a closed fracture, it is strictly forbidden to perform reduction at the scene. It is necessary to perform anesthesia, transport immobilization with standard or improvised means, close the wound with an aseptic dressing, if necessary, stop the bleeding and take the patient to a specialized hospital. If the fracture is closed, after transport immobilization, the patient is taken to the hospital. 4. Principles of treatment of fractures. General principles of treatment - adequate anesthesia, reposition and fixation of fragments in the correct position Treatment of fractures in the hospital consists of various methods of repositioning and fixing fragments in the required position. General principles of treatment include proper nutrition (eating foods rich in calcium, such as milk, cottage cheese, sour cream) and the use of drugs that accelerate the formation of bone regenerate. For adequate anesthesia, it is enough to introduce 20-50 ml into the fracture area (depending on the massiveness of the damage, fractures of large bones require a larger amount of anesthetic). For anesthesia, the needle is injected directly into the hematoma, then the syringe plunger is pulled towards itself and, if blood appears in the syringe, the contents of the syringe are injected into the hematoma area. After anesthesia, repositioning is possible. Distinguish between open and closed reduction. Open reposition is carried out directly in the wound if the fracture is open. In addition, indications for open reposition is the interposition of soft tissues or bone fragments between fragments. Closed reposition is carried out by means of traction along the axis of the limb and control of its distal fragment. For repositioning, an assistant is needed to hold the proximal bone fragment. In accordance with the nature of the fracture, established by x-ray, reposition of fragments is performed. So, displacement along the axis is eliminated by traction along the axis of the limb, displacement along the width - by traction of the distal fragment in the opposite direction to the displacement. Rotational displacement is eliminated by traction along the axis of the limb with simultaneous rotation of its distal fragment in the direction opposite to the displacement, while simultaneously holding the proximal one. The effectiveness of manual reposition is controlled by the results of the X-ray image. If manual repositioning did not completely restore the axis, it is necessary to resort to hardware repositioning methods. Fixation of fragments in the correct position can be carried out by applying a plaster bandage that holds the fragments in the correct position. There are methods of hardware reposition and fixation that allow not only to eliminate the displacement, but also to keep the fragments in the correct position until the bone regenerate is formed. These methods include skeletal traction, in which special spokes are passed through various bone protrusions, to which a load is attached. During reposition, the correct axis of the limb is determined by the proximal fragment. The largest load is used for fractures of the femur. Displacements are eliminated by creating a thrust opposite to the displacement of fragments. Fixation methods include closed and open osteosynthesis. Special tires CITO, the Ilizarov apparatus are widely used. A favorable outcome of a fracture may be a complete restoration of the integrity of the bone with preservation of its function, less favorable - a fused fracture with partial dysfunction, the formation of a false joint, improperly fused fractures with preservation of function and its partial loss. Unfavorable outcomes can be associated with both incorrect treatment tactics and individual characteristics of the body (such as vitamin deficiency, malnutrition, diabetes mellitus, severe chronic diseases), in which the formation of bone regenerate is slowed down. LECTURE No. 29. Sepsis 1. General provisions Sepsis represents a very serious problem for all medical science and surgery in particular. This condition is a generalization of infection that occurs due to a breakthrough of the infectious onset into the systemic circulation. Sepsis is one of the natural outcomes of a surgical infection if the patient does not receive proper treatment, and his body cannot cope with a highly virulent pathogen and, on the contrary, if the peculiarity of his immune reactions predisposes to such a development of events. In the presence of a purulent focus and an increase in signs of intoxication, therapeutic measures to remove a local infection should be started as soon as possible, since purulent-resorptive fever turns into full-blown sepsis in 7-10 days. This complication must be avoided at all costs, as mortality in this condition reaches 70%. Terms such as presepsis, purulent-septic condition are excluded from the nomenclature and are now invalid. The entrance gate is the site of infection. As a rule, this is an area of damaged tissue. Distinguish between primary and secondary foci of infection. 1. Primary - an area of inflammation at the site of implementation. Usually coincides with the entrance gate, but not always (for example, phlegmon of the lymph nodes of the inguinal region due to panaritium of the toes). 2. Secondary, so-called metastatic or pyemic foci. Sepsis classification According to the location of the entrance gate. 1. Surgical: 1) sharp; 2) chronic. 2. Iatrogenic (as a result of diagnostic and therapeutic procedures, such as catheter infection). 3. Obstetric-gynecological, umbilical, neonatal sepsis. 4. Urological. 5. Odontogenic and otorhinolaryngological. In any case, when the entrance gate is known, sepsis is secondary. Sepsis is called primary if it is not possible to identify the primary focus (entrance gate). In this case, the focus of dormant autoinfection is assumed to be the source of sepsis. By the rate of development of the clinical picture. 1. Lightning (leads to death within a few days). 2. Acute (from 1 to 2 months). 3. Subacute (lasts up to six months). 4. Chroniosepsis (long-term undulating course with periodic febrile reactions during exacerbations). By gravity. 1. Moderate severity. 2. Heavy. 3. Extremely heavy. There is no mild course of sepsis. By etiology (type of pathogen). 1. Sepsis caused by gram-negative flora: colibacillary, proteic, pseudomonas, etc. 2. Sepsis caused by gram-positive flora: streptococcal and staphylococcal. 3. Extremely severe sepsis caused by anaerobic microorganisms, in particular bacteroids. phases of sepsis. 1. Toxemic (IV Davydovsky called it purulent-resorptive fever). 2. Septicemia (without the formation of metastatic purulent foci). 3. Septicopyemia (with the development of pyemic foci). It should be noted that over time, the species composition of microorganisms that are the predominant causative agents of sepsis changes. If in the 1940s the most common pathogen was streptococcus, which gave way to staphylococcus, now the era of gram-negative microorganisms has come. One of the important criteria for sepsis is the species uniformity of microorganisms sown from primary and secondary foci of infection and blood. 2. Pathogenesis of sepsis Microorganisms are still considered the main cause of sepsis, which determines its course, and the virulence of the pathogen, its dose are of decisive importance (the titer of microorganisms should be at least 10: 5 per gram of tissue). The state of the patient's body should also be recognized as extremely important factors influencing the development of sepsis, and factors such as the state of the primary and secondary foci of infection, the severity and duration of intoxication, and the state of the body's immune system are of decisive importance. Generalization of infection occurs against the background of allergic reactions to a microbial agent. With an unsatisfactory state of the immune system, the microorganism enters the systemic circulation from the primary focus. The intoxication that precedes and is maintained by the primary focus changes the general reactivity of the organism and forms a state of sensitization. The immune system deficiency is compensated by increased reactivity of nonspecific defense factors (macrophage-neutrophilic inflammation), which, coupled with the body's allergic predisposition, leads to the development of an uncontrolled inflammatory reaction - the so-called systemic inflammatory response syndrome. In this condition, there is an excessive release of inflammatory mediators both locally in the tissue and into the systemic circulation, which causes massive tissue damage and increases toxemia. Sources of toxins are damaged tissues, enzymes, biologically active substances of inflammatory cells and waste products of microorganisms. primary focus is not only a constant source of microbial agent, but also continuously maintains a state of sensitization and hyperreactivity. Sepsis can be limited only to the development of a state of intoxication and a systemic inflammatory reaction, the so-called septicemia, but much more often pathological changes progress, septicopyemia develops (a condition characterized by the formation of secondary purulent foci). Secondary purulent pyemic foci occur during metastasis of microflora, which is possible with a simultaneous decrease in both the antibacterial activity of the blood and the violation of local protective factors. Microbial microinfarcts and microembolism are not the cause of the pyemic focus. The basis is a violation of the activity of local enzyme systems, but, on the other hand, the resulting pyemic foci cause activation of lymphocytes and neutrophils, excessive release of their enzymes and tissue damage, but microorganisms settle on the damaged tissue and cause the development of purulent inflammation. When it occurs, the secondary purulent focus begins to perform the same functions as the primary one, that is, it forms and maintains a state of intoxication and hyperreactivity. Thus, a vicious circle is formed: pyemic foci support intoxication, and toxemia, in turn, determines the possibility of developing foci of secondary infection. For adequate treatment it is necessary to break this vicious circle. 3. Surgical sepsis Surgical sepsis is an extremely severe general infectious disease, the main etiological moment of which is a violation of the functioning of the immune system (immunodeficiency), which leads to generalization of the infection. By the nature of the entrance gate, surgical sepsis can be classified into: 1) wound; 2) burn; 3) angiogenic; 4) abdominal; 5) peritoneal; 6) pancreatogenic; 7) cholangiogenic; 8) intestinal. Traditionally, the clinical manifestations of sepsis are considered to be such signs as: 1) the presence of a primary purulent focus. In most patients, it is characterized by significant size; 2) the presence of symptoms of severe intoxication, such as tachycardia, hypotension, general disorders, signs of dehydration; 3) positive repeated blood cultures (at least 3 times); 4) the presence of the so-called septic fever (large difference between morning and evening body temperatures, chills and heavy sweat); 5) the appearance of secondary infectious foci; 6) pronounced inflammatory changes in the hemogram. A less common symptom of sepsis is the formation of respiratory failure, toxic reactive inflammation of organs (most often the spleen and liver, which causes the development of hepatosplenomegaly), and peripheral edema. Often myocarditis develops. Violations in the hemostasis system are frequent, which is manifested by thrombocytopenia and increased bleeding. For the timely and correct diagnosis of sepsis, it is necessary to have a solid understanding of the signs of the so-called septic wound. It is characterized by: 1) flaccid pale granulations that bleed when touched; 2) the presence of fibrin films; 3) poor, serous-hemorrhagic or brown-brown discharge from the wound with an unpleasant putrefactive odor; 4) cessation of the dynamics of the process (the wound does not epithelize, ceases to be cleaned). One of the most important signs of sepsis should be recognized as bacteremia, but the presence of microbes in the blood according to crops is not always determined. In 15% of cases, crops do not grow, despite the presence of clear signs of sepsis. At the same time, a healthy person may experience a short-term violation of blood sterility, the so-called transient bacteremia (after tooth extraction, for example, bacteria can be in the systemic circulation for up to 20 minutes). To diagnose sepsis, blood cultures should be repeated despite negative results, and blood should be taken at different times of the day. It should be remembered: in order to make a diagnosis of septicopyemia, it is necessary to establish the fact that the patient has bacteremia. According to modern recommendations, the mandatory diagnostic criteria, on the basis of which a diagnosis of surgical sepsis can be made, are: 1) the presence of a focus of infection; 2) previous surgical intervention; 3) the presence of at least three of the four signs of systemic inflammatory response syndrome. The systemic inflammatory response syndrome can be suspected if the patient has a complex of the following clinical and laboratory data: 1) axillary temperature more than 38 °C or less than 36 °C; 2) increased heart rate more than 90 in 1 min; 3) insufficiency of the function of external respiration, which is manifested by an increase in the frequency of respiratory movements (RR) of more than 20 per minute or an increase in pCO2 of more than 32 mm Hg. Art.; 4) leukocytosis beyond 4-12 x 109, or the content of immature forms in the leukocyte formula is more than 10%. 4. Septic complications. Sepsis treatment The main complications of sepsis, from which patients die, should be considered: 1) infectious-toxic shock; 2) multiple organ failure. Infectious-toxic shock has a complex pathogenesis: on the one hand, bacterial toxins cause a decrease in the tone of arterioles and a violation in the microcirculation system, on the other hand, a violation of systemic hemodynamics is observed due to toxic myocarditis. In infectious-toxic shock, acute cardiovascular failure becomes the leading clinical manifestation. Tachycardia is observed - 120 beats per minute and above, heart sounds are muffled, the pulse is weak filling, systolic blood pressure decreases (90-70 mm Hg and below). The skin is pale, the extremities are cold, sweating is not uncommon. There is a decrease in urination. As a rule, a harbinger of shock is a sharp increase in temperature with chills (up to 40-41 ° C), then the body temperature drops to normal numbers, a complete picture of shock unfolds. Treatment of shock is carried out according to the general rules. The main links of treatment. 1. Elimination of intoxication. 2. Sanitation of purulent-inflammatory foci and suppression of infection. 3. Correction of immune disorders. In many ways, the same measures are used to achieve these goals (as detoxification therapy) 1. Massive infusion therapy. Up to 4-5 liters per day of plasma-substituting solutions (neocompensan, gemodez, rheopolyglucin, hydroxylated starch). When carrying out infusion therapy, special attention should be paid to the correction of electrolyte disturbances, changes in the acid-base state (elimination of acidosis). 2. Forced diuresis. 3. Plasmapheresis. 4. Lymph and hemosorption. 5. Hyperbaric oxygenation. 6. Removal of pus. For the sanitation of foci of infection - local treatment: 1) removal of pus, necrotic tissues, wide drainage of the wound and its treatment according to the general principles of the treatment of a purulent wound; 2) the use of topical antibacterial agents (levomecol, etc.). Systemic treatment: 1) massive antibiotic therapy with the use of at least two broad-spectrum or targeted drugs, taking into account the sensitivity of the isolated pathogen. Antibiotics only parenterally (muscle, vein, regional artery or endolymphatic). 2) antibiotic therapy is carried out for a long time (for months) until a negative result of blood culture or clinical recovery, if the initial culture did not give growth. Various methods can be used to correct immune disorders: the introduction of a leukocyte suspension, the use of interferon, hyperimmune antistaphylococcal plasma, in severe cases, the use of glucocorticosteroids. Correction of immune disorders should be carried out with the obligatory consultation of an immunologist. An important place in the treatment of patients is occupied by providing them with an adequate amount of energy and plastic substrates. The energy value of the daily diet should not be lower than 5000 kcal. Vitamin therapy is indicated. In special cases, debilitated patients may be transfused with fresh citrate blood, but the use of fresh frozen plasma, albumin solution is much preferable. With the development of organ failure, treatment is carried out according to the standards. LECTURE No. 30. Fundamentals of surgical oncology 1. General provisions Oncology is a science that studies the problems of carcinogenesis (causes and mechanisms of development), diagnosis and treatment, and prevention of tumor diseases. Oncology pays close attention to malignant neoplasms due to their great social and medical significance. Oncological diseases are the second leading cause of death (immediately after diseases of the cardiovascular system). Every year, about 10 million people fall ill with oncological diseases, half as many die from these diseases every year. At the present stage, lung cancer occupies the first place in terms of morbidity and mortality, which has overtaken stomach cancer in men, and breast cancer in women. In third place is colon cancer. Of all malignant neoplasms, the vast majority are epithelial tumors. Benign tumors, as the name implies, are not as dangerous as malignant ones. There is no atypia in the tumor tissue. The development of a benign tumor is based on the processes of simple hyperplasia of cellular and tissue elements. The growth of such a tumor is slow, the mass of the tumor does not grow into the surrounding tissues, but only pushes them back. In this case, a pseudocapsule is often formed. A benign tumor never metastasizes, there are no decay processes in it, therefore, with this pathology, intoxication does not develop. In connection with all the above features, a benign tumor (with rare exceptions) does not lead to death. There is such a thing as a relatively benign tumor. This is a neoplasm that grows in the volume of a limited cavity, such as the cranial cavity. Naturally, tumor growth leads to an increase in intracranial pressure, compression of vital structures and, accordingly, death. malignant neoplasm characterized by the following features: 1) cellular and tissue atypia. Tumor cells lose their former properties and acquire new ones; 2) the ability to autonomous, i.e., uncontrolled by organismal processes of regulation, growth; 3) rapid infiltrating growth, i.e. germination of surrounding tissues by a tumor; 4) the ability to metastasize. There are also a number of diseases that are precursors and harbingers of tumor diseases. These are the so-called obligate (a tumor necessarily develops in the outcome of the disease) and facultative (a tumor develops in a large percentage of cases, but not necessarily) precancers. These are chronic inflammatory diseases (chronic atrophic gastritis, sinusitis, fistulas, osteomyelitis), conditions accompanied by tissue proliferation (mastopathy, polyps, papillomas, nevi), cervical erosion, as well as a number of specific diseases. 2. Classification of tumors Classification by tissue - the source of tumor growth. Epithelial. 1. Benign: 1) papillomas; 2) polyps; 3) adenomas. 2. Malignant (cancer): 1) squamous; 2) small cell; 3) mucous membranes; 4) skirr. Connective tissue. 1. Benign: 1) fibromas; 2) lipomas; 3) chondromas; 4) osteomas. 2. Malignant (sarcomas): 1) fibrosarcomas; 2) liposarcomas; 3) chondrosarcomas; 4) osteosarcomas. Muscle. 1. Benign (fibroids): 1) leiomyomas (from smooth muscle tissue); 2) rhabdomyomas (from striated muscles). 2. Malignant (myosarcomas). Vascular. 1. Benign (hemangiomas): 1) capillary; 2) cavernous; 3) branched; 4) lymphangiomas. 2. Malignant (angioblastomas). nervous tissue. 1. Benign: 1) neuromas; 2) gliomas; 3) ganglioneuromas. 2. Malignant: 1) medulloblastoma; 2) ganglioblastomas; 3) neuroblastoma. Blood cells. 1. Leukemias: 1) acute and chronic; 2) myeloid and lymphoblastic. 2. Lymphomas. 3. Lymphosarcomas. 4. Lymphogranulomatosis. mixed tumors. 1. Benign: 1) teratoma; 2) dermoid cysts; 3) hamartomas. 2. Malignant (teratoblastomas). Tumors from pigment cells. 1. Benign (pigmented nevi). 2. Malignant (melanoma). International Clinical Classification for TNM Letter T (tumor) denotes in this classification the size and extent of the primary lesion. For each localization of the tumor, its own criteria have been developed, but in any case Tue (from lat. Tumor in situ - "cancer in place") - not germinating the basement membrane, T1 - the smallest size of the tumor, T4 - a tumor of considerable size with the germination of surrounding tissues and decay. Letter N (nodulus) reflects the state of the lymphatic apparatus. Nx - the state of regional lymph nodes is unknown, there are no distant metastases. N0 - verified the absence of metastases in the lymph nodes. N1 - single metastases in regional lymph nodes. N2 - multiple lesions of regional lymph nodes. N3 - metastases to distant lymph nodes. Letter M (metastasis) reflects the presence of distant metastases. Index 0 - no distant metastases. Index 1 indicates the presence of metastases. There are also special letter designations that are placed after a histopathological examination (it is impossible to set them clinically). Letter R (penetration) reflects the depth of tumor penetration into the wall of a hollow organ. Letter G (generation) in this classification reflects the degree of differentiation of tumor cells. The higher the index, the less differentiated the tumor and the worse the prognosis. Clinical staging of cancer according to Trapeznikov I stage. Tumor within the organ, no metastases to regional lymph nodes. II stage. The tumor does not grow into surrounding tissues, but there are single metastases to regional lymph nodes. III stage. The tumor grows into the surrounding tissues, there are metastases in the lymph nodes. The resectability of the tumor at this stage is already questionable. It is not possible to completely remove tumor cells surgically. IV stage. There are distant metastases of the tumor. Although it is believed that only symptomatic treatment is possible at this stage, resection of the primary focus of tumor growth and solitary metastases can be performed. 3. Etiology, pathogenesis of tumors. Diagnosis of a tumor disease A large number of theories (chemical and viral carcinogenesis, disembryogenesis) have been put forward to explain the etiology of tumors. According to modern concepts, a malignant neoplasm occurs as a result of the action of numerous factors, both external and internal environment of the body. The most important of the environmental factors are chemicals - carcinogens that enter the human body with food, air and water. In any case, the carcinogen causes damage to the genetic apparatus of the cell and its mutation. The cell becomes potentially immortal. With the failure of the immune defense of the body, further reproduction of the damaged cell and a change in its properties occur (with each new generation, the cells become more and more malignant and autonomous). Violation of cytotoxic immune responses plays a very important role in the development of a tumor disease. Every day, about 10 thousand potentially tumor cells appear in the body, which are destroyed by killer lymphocytes. After about 800 divisions of the original cell, the tumor acquires a clinically detectable size (about 1 cm in diameter). The entire period of the preclinical course of a tumor disease takes 10-15 years. 1,5-2 years remain from the moment when a tumor can be detected to death (without treatment). Atypical cells are characterized not only by morphological but also by metabolic atypia. Due to the perversion of metabolic processes, the tumor tissue becomes a trap for the energy and plastic substrates of the body, releases a large amount of under-oxidized metabolic products and quickly leads to exhaustion of the patient and the development of intoxication. In the tissue of a malignant tumor, due to its rapid growth, an adequate microcirculatory bed does not have time to form (the vessels do not have time to grow behind the tumor), as a result, the processes of metabolism and tissue respiration are disturbed, necrobiotic processes develop, which leads to the appearance of foci of tumor decay, which form and maintain state of intoxication. In order to detect an oncological disease in time, the doctor must have oncological alertness, that is, it is necessary to suspect the presence of a tumor during the examination, based only on small signs. Establishing a diagnosis based on obvious clinical signs (bleeding, sharp pains, tumor disintegration, perforation into the abdominal cavity, etc.) is already belated, since the tumor manifests itself clinically at stages II-III. For the patient, it is important that the neoplasm be detected as early as possible, at stage I, then the probability that the patient will live after the treatment for 5 years is 80-90%. In this regard, screening examinations, which can be carried out during preventive examinations, acquire an important role. In our conditions, the available screening techniques are fluorographic examination and visual detection of cancer of external localizations (skin, oral cavity, rectum, breast, external genitalia). Examination of an oncological patient must be completed with a histopathological examination of a suspicious formation. The diagnosis of a malignant neoplasm is untenable without morphological confirmation. This must always be remembered. 4. Cancer treatment Treatment should be comprehensive and include both conservative measures and surgical treatment. The decision on the scope of the forthcoming treatment of an oncological patient is made by a council, which includes an oncologist, a surgeon, a chemotherapist, a radiologist, and an immunologist. Surgical treatment may precede conservative measures, follow them, but a complete cure for a malignant neoplasm without removal of the primary focus is doubtful (excluding blood tumors that are treated conservatively). Surgery for cancer can be: 1) radical; 2) symptomatic; 3) palliative. radical operations imply the complete removal of the pathological focus from the body. This is possible due to the implementation of the following principles: 1) ablastics. During the operation, it is necessary to strictly observe ablastics, as well as asepsis. The ablasticity of the operation is a prevention of the spread of tumor cells in healthy tissues. For this purpose, the tumor is resected within healthy tissues, without affecting the tumor. In order to check the ablasticity after resection, an emergency cytological examination of the imprint smear from the surface remaining after resection is performed. If tumor cells are found, the resection volume is increased; 2) zoning. This is the removal of nearby tissue and regional lymph nodes. The volume of lymph node dissection is determined depending on the prevalence of the process, but it must always be remembered that the radical removal of lymph nodes leads to the occurrence of lymphostasis after surgery; 3) antiblasts. This is the destruction of locally advanced tumor cells, which in any case dissipate during surgery. This is achieved by chipping the circumference of the pathological focus with antitumor drugs, regional perfusion with them. Palliative surgery carried out in the event that it is impossible to carry out a radical operation in full. In this case, a part of the tumor tissue array is removed. Symptomatic operations are carried out to correct emerging disorders in the activity of organs and systems associated with the presence of a tumor node, for example, the imposition of an enterostomy or a bypass anastomosis in a tumor obturating the outlet section of the stomach. Palliative and symptomatic operations cannot save the patient. Surgical treatment of tumors is usually combined with other methods of treatment, such as radiation therapy, chemotherapy, hormonal and immunotherapy. But these types of treatment can also be used independently (in hematology, radiation treatment of skin cancer). Radiation therapy and chemotherapy can be applied in the preoperative period in order to reduce tumor volume, remove perifocal inflammation and infiltration of surrounding tissues. As a rule, the course of preoperative treatment is not long, since these methods have many side effects and can lead to complications in the postoperative period. The bulk of these therapeutic measures is carried out in the postoperative period. If the patient has stages II-III of the process, surgical treatment must necessarily be supplemented with a systemic effect on the body (chemotherapy) in order to suppress possible micrometastases. Special schemes have been developed to achieve the maximum possible removal of tumor cells from the body, without exerting a toxic effect on the body. Hormone therapy is used for some tumors of the reproductive sphere. List of used literature 1. Avanesyants E. M., Tsepunov B. V., Frantsuzov M. M. Handbook of surgery. M.: ANMI, 2002. 2. Arapov D. A. Anaerobic gas infection. M.: Medicine, 1977. 3. Bychenko D. Yu. Stolbnyak. M.: Medicine, 1982. 4. Gostishchev VK Purulent-septic surgery. M.: Medicine, 1982. 5. Gostishchev VK Guide to practical exercises in general surgery. M.: Medicine, 1987. 6. Korzh A. A., Mezhenina E. P. Handbook of traumatology and orthopedics. Kyiv: Health, 1980. 7. Kuzin M. I., Harsan S. Sh. Local anesthesia. M.: Medicine, 1982. 8. Kurbangaliev S. M. Purulent infection in surgery. M.: Medicine, 1985. 9. Mazurin M. F., Demyanuk D. G. Ambulatory surgery. Kyiv: Health, 1988. 10. Mazurin M. F., Demyanuk D. G. Acute purulent diseases of the hand. Kyiv: Health, 1981. 11. Malyarchuk V. I. Course of lectures on general surgery. M.: RUDN, 1999. 12. Myshkin K. I., Franfurkt L. A. The course of faculty surgery in tables and diagrams. Saratov, 1991. 13. Saveliev V.S. 50 lectures on surgery. M.: Triada X, 2004. 14. Handbook of surgery. / Ed. Schwartz S., Shiers J., Spencer F. St. Petersburg: Peter, 2000. 15. Pods V. I. Handbook of clinical surgery. M.: Medicine, 1994. 16. Pods V. I., Pods Yu. V. General surgery. M.: Medicine, 1988. 17. Timofeev N. S., Timofeev N. N. Aseptic and antiseptic. Leningrad: Medicine, 1980. 18. Usov DV Selected lectures on general surgery. Tyumen. 1995. 19. Textbook on general surgery. / Ed. Chernova V.N.M.: Book, 2003. 20. Khoronko Yu. V., Savchenko S. V. Handbook of emergency surgery. Rostov-on-Don: Phoenix, 1999. Authors: Mishinkin P.N., Neganova A.Yu.
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