Many methods of intestinal decompression have been proposed, the requirements for which include: maximum release of the intestine from gas and liquid, prevention of infection of the abdominal cavity, unhindered removal of contents in the postoperative period, minimal traumatic manipulation.
Elimination of mechanical obstruction does not yet mean the elimination of obstruction altogether, since one or another degree of functional obstruction may remain or arise. Therefore, one of the main objectives is to prevent or quickly resolve postoperative intestinal paresis. A relationship has been established between the nature and amount of intestinal contents and the degree of intestinal motility disorders.
Intestinal decompression by puncture
A common method of intestinal decompression was to remove the contents by puncture of the intestinal wall and suction, followed by suturing the hole. The method is simple, but it does not remove at least most of the liquid. Its accumulation continues, and the risk of infection of the abdominal cavity is very high. It is more completely possible to evacuate the contents through the enterotomy opening using an electric suction, or directly through the ends of the transected intestine during its resection. In addition to these disadvantages in such cases, there is a high level of trauma.
Intestinal decompression by milking
The “milking” method - moving the contents into the underlying loops - is almost never used, since it is not possible to empty the intestines completely enough, and the injury is significant. Progressive flatulence and fluid accumulation can lead to failure of the sutured puncture or enterotomy opening. According to the literature, the mortality rate of patients with acute intestinal obstruction, complicated by opening the lumen of the digestive canal, is 3 times higher than that observed in the case of an intact intestine.
Intestinal decompression by enterostomy
At the Research Institute named after. N.V. Sklifosovsky developed a method of intestinal decompression using suspended enterostomy with the introduction of a short tube into the intestinal lumen to create an outflow, which is widely used. However, nowadays it is rarely used. This is explained by the fact that in this way it is not possible to achieve complete release of the intestinal loops. At best, the nearest loops are emptied. Recently, safer methods of intestinal decompression using nasojejunal tubes have been developed.
Considering that the main disadvantage of suspended enterostomy is incomplete bowel emptying, it was proposed to insert into the intestinal lumen not a short, but a fairly long tube (1.5-2 m) with many side holes (I. D. Zhitnyuk).
However, if the question of the feasibility of the intestine over a long distance is resolved positively, then the advantages of one or another method of drainage have not yet been definitively established. For example, some are proponents of inserting an intestinal tube through a gastrostomy, others prefer retrograde intubation of the intestine through an ileostomy, other authors recommend the use of transnasal decompression, without denying in some cases the positive effect of inserting a tube through the cecum.
Intestinal decompression with a probe
Drainage of the intestine with a long probe allows you to carefully remove the contents immediately during and create conditions in the postoperative period for its unhindered outflow. Compliance with the other two requirements - avoidance of infection and minimal trauma - depends entirely on the method of insertion and type of probe.
Despite the obvious advantages of intestinal decompression with a long probe, the method has not yet received widespread use. The main reason for this, in our opinion, is that passing a probe made from an ordinary rubber tube throughout the intestine is associated with great technical difficulties. Such a probe is very soft and constantly bends; in addition, due to the significant frictional forces that arise, it is very difficult to bring it to the appropriate place. The listed factors and the significant intestinal trauma associated with them forced many to abandon this method, replacing it with a one-time removal of intestinal contents.
An intestinal tube made from a polyvinyl chloride tube is practically free of these disadvantages. The probe is quite elastic and resilient. When immersed in the intestinal lumen, it, being wetted, slides freely along the mucous membrane, and therefore the manipulation is less traumatic and short-lived. At the distal end of the probe, 1-2 metal round balls (bearings) with a diameter of 5-5.5 mm are mounted at a distance of 15-20 mm from one another. This is necessary for better capture of the probe through the intestinal wall. In addition, the presence of metal allows, if necessary, X-ray inspection of the location of the distal end of the probe. An equally important design feature of the probes is the presence of a “blind”, that is, without side holes, proximal section 65-70 cm long in probes for intubation through the nose and 15-20 cm in probes for insertion through the cecum (or ileostomy, gastrostomy) . The presence of a “blind” end prevents the leakage of intestinal contents through the esophagus into the nasopharynx and trachea during transnasal intubation or protects the skin around the fistula from contamination during cecostomy.
Technique of intestinal intubation
The probe can be inserted through the nose, gastrostomy, ileostomy or cecostomy, rectum. Each method has its own advantages and disadvantages, which should be taken into account when choosing an intubation method in relation to your goals.
Transnasal bowel decompression
Transnasal insertion of a probe for intestinal decompression is usually carried out in conjunction with a tube, which passes a probe lubricated with petroleum jelly through the nasal passage through the esophagus into the stomach. The surgeon then grabs the probe through the wall of the stomach, passes it along the bend of the duodenum until the tip of the probe is felt by touch in the initial part of the jejunum under the ligament of Treitz. At first glance, passing a probe through the duodenum is a difficult manipulation. However, if the probe that appears in the cardiac part of the stomach is pressed against the lesser curvature so that a springy bend does not form in the stomach (and especially so that the probe does not curl up), then it moves forward quite easily with the efforts of the anesthesiologist. Further passage of the probe through the intestines is not difficult and usually takes another 5-15 minutes. It is advisable to place the probe as low as possible to the ileocecal junction, especially in case of adhesive intestinal obstruction. In such cases, the probe also ensures smooth bending of the intestine.
With any method of performing intestinal intubation for decompression, it is necessary to remove intestinal contents as the probe is passed (usually with an electric suction connected to the proximal end of the probe). However, this very important intermediate procedure may turn out to be completely ineffective if the side openings are not first closed, since air is sucked into them, rather than viscous intestinal contents. The simplest technique is to temporarily seal the holes with an adhesive plaster, which is then removed at the level of the nasal passage as the probe is immersed. The introduction of a tube of a slightly smaller diameter into the lumen of the probe in order to close the holes from the inside was not justified, since after the first turn of the probe in the intestine, it is almost impossible to remove the obstructing tube.
One of the advantages of transnasal intubation is the preservation of the cleanliness of the surgeon's hands and the surgical field, since the probe is inserted through a natural opening. This also allows the use of non-sterile probes. An equally important advantage of transnasal conduction is the thorough emptying of the upper parts of the digestive canal (stomach, duodenum), which usually cannot be achieved with retrograde intubation. The only, but very significant drawback of passing a probe through the nose is the occurrence of inflammation of the upper respiratory tract, pneumonia, because the presence of a foreign body in the nasopharynx makes breathing difficult to a certain extent, and with insufficient care for such patients, the possibility of intestinal contents reflux into the esophagus and entering the trachea. In this regard, transnasal intubation for intestinal decompression is undesirable in patients over the age of 50-60 years and is contraindicated in cases of concomitant bronchitis and pneumonia.
Prevention of these complications consists of systematic (every 2-3 hours) active aspiration of intestinal contents, taking fluids by mouth as soon as the patient becomes adequate after anesthesia. However, the main preventive measure is timely removal of the probe - no later than 3-4 days. This time, as a rule, is sufficient to resolve functional intestinal obstruction.
Transnasal intestinal intubation has been the method of choice since the use of elastic polyvinyl chloride probes.
Intestinal decompression through gastrostomy tube
This technique has found wide application, especially in pediatric surgical practice. It is devoid of the main disadvantage of transnasal intubation - the development of complications from the respiratory tract. Using a sufficiently elastic probe, it is easy to pass the bend of the duodenum. The probe can be left in the digestive canal for a long time. The disadvantages of this method of intestinal decompression are the forced deformation of the stomach and its fixation to the anterior abdominal wall, the possibility of infection of the surgeon’s hands and the surgical field. Dangerous complications include the departure of the stoma from the abdominal wall, which most often occurs in peritonitis, when the plastic properties of the peritoneum are lost. Therefore, it is advisable to perform intubation through a gastrostomy tube in case of acute intestinal obstruction and other pathology not complicated by peritonitis.
Bowel decompression through ileostomy
Ileostomy with intestinal intubation according to Zhitnyuk is currently used quite rarely. This is due to large deformation of the ileum and the possibility of infection. In addition, intubation is carried out retrogradely, that is, from bottom to top, so the end of the probe quickly goes down and the upper parts of the digestive canal are not drained, which requires transnasal insertion of a conventional gastric tube. And finally, not in all cases, after removing the probe, the stoma closes on its own, so a repeat operation is required in the future.
Intestinal decompression through cecostomy
The technique has a number of advantages.
Firstly, it is advisable to use it in elderly patients, patients with heart and lung diseases, and especially in cases where they plan to leave the tube for more than 5 days. A similar situation is most often observed when eliminating adhesive intestinal obstruction, which usually affects the ileum. The probe inserted through the cecum, thanks to its smooth bends, like a tire, straightens the loops of the intestine. Secondly, the cecum is a fairly large organ, and therefore, if necessary, a three-row purse-string suture can be applied to strengthen the probe without causing severe deformation of the intestine. A correctly applied cecostoma (with a double-row or single-row submersible purse-string suture) usually closes on its own in the next 5-14 days.
The disadvantages of intestinal decompression through the cecum, as with ileostomy, are associated with retrograde placement of the probe. It is often very difficult to pass the probe through the ileocecal valve into the ileum. In such cases, it is necessary to resort to an additional enterotomy 7-10 cm above the valve and passing a thin metal rod (for example, a button probe) through this hole and the valve into the cecum. After tying the elastic end of the probe to a metal rod, the latter is removed into the ileum along with the probe, removed, the hole in the intestine is sutured, and further intubation is performed in the usual way (Sanderson maneuver).
We must not forget about the danger of tissue infection at the time of intubation. To exclude the possibility of intestinal contents entering the abdominal cavity, it is advisable to first suture the cecum to the peritoneum, and then, having previously fenced off the wound with napkins, insert a probe.
Transanal intubation
This manipulation, as a rule, complements the already undertaken intestinal decompression by the methods mentioned. It is absolutely indicated for resection of the sigmoid colon with the imposition of a primary anastomosis, and the probe should be passed beyond the anastomosis to the splenic angle of the colon. As an independent method, transrectal decompression is usually used in pediatric practice. For adults, this technique is traumatic. Often there is a need to mobilize the splenic angle of the colon.
A prerequisite for completing any method of intubation is fixing the probe (at the nasal passage, to the abdominal wall, to the perineum), as well as the patient’s hands, since often, being in an inadequate condition, the patient can accidentally remove the probe.
Decompression of the intestine with a long intestinal tube is a therapeutic and preventive measure: in case of peritonitis, it serves as one of the main therapeutic factors, and after the elimination of mechanical intestinal obstruction, it prevents the development of functional obstruction. The presence of a probe in the intestinal lumen, in addition, reduces the likelihood of intestinal kinks and the development of adhesive obstruction.
If the basic rules for intestinal decompression and intubation techniques are followed, the postoperative period proceeds smoothly, without the usual symptoms of intestinal paresis: bloating, difficulty breathing, belching or even vomiting. Sometimes minor flatulence may be observed due to the gas present in the colon during isolated intubation of the small intestine.
In addition to regular (every 2-3 hours) removal of intestinal contents, it is advisable to rinse the intestinal lumen with small (300-500 ml) portions of warm isotonic sodium chloride solution (only 1-1.5 liters for each session). With the help of rinsing, it is possible to quickly reduce intoxication; the appearance of peristalsis is noted in some cases already by the end of the 1st day after surgery.
An important point in the management of such patients is strict recording of the daily amount of fluid released through the tube (excluding flushing). Fluid losses are replaced by administering an adequate amount parenterally. It is possible to prescribe other drugs through a targeted probe, and 2-3 days after - nutritional mixtures.
Frequent auscultation of the abdomen is required to determine the time of onset of peristalsis. Objective indicators of its recovery are also the nature and dynamics of intestinal secretions. The uniform release of fluid through the probe during inspiration indicates its passive flow and the absence of peristaltic waves. And, conversely, periodic, jerky release of intestinal contents indicates the appearance of active intestinal motility. Usually on days 3–4 and, less often, on the 5th day, intestinal motor function is completely restored, as evidenced by auscultation data, spontaneous passage of gases, and the nature of fluid release through the tube. All this serves as an indication for removing the probe. In a number of doubtful cases, to assess the state of motility, dynamic X-ray monitoring can be performed with preliminary administration of 40-60 ml of a 50-70% solution of cardiotrust (Verografin) through a probe. Radiographs or survey fluoroscopy after 5-10 minutes give a clear idea of the nature of peristalsis.
The probe is removed by pulling its end for 15-30 s. In this case, patients usually experience nausea and even the urge to vomit. During retrograde intestinal intubation, the probe is removed more slowly because it may become coiled in the terminal ileum.
Intestinal decompression has proven to be a highly effective method for the prevention and treatment of functional intestinal obstruction. It is indispensable in the surgical treatment of general peritonitis, severe forms of functional intestinal obstruction, concomitant mechanical obstruction, especially strangulation with gangrene of the intestine. Decompression is indicated and justified in order to unload the sutures in technically or clinically difficult situations, especially when the development of postoperative peritonitis is possible.
Total intubation of the small intestine is indicated to prevent intestinal paresis after long and traumatic operations on the abdominal organs and retroperitoneal space, especially with a history of motility disorders and disturbances of water-electrolyte metabolism.
Having widely and successfully used this method of intestinal decompression for peritonitis and intestinal obstruction, we consider it necessary to point out the mistakes made in the process of mastering the technique.
As already mentioned, the transnasal route of insertion of the probe is contraindicated in the presence of pneumonia or in cases where its occurrence is very likely (severe condition, old age, obesity, adynamia due to underlying or concomitant pathology). In 6 patients we observed, pneumonia was the main cause of death.
Complications of bowel decompression
When inserting a probe transnasally, its oral segment, which does not have holes in the side walls, should be in the esophagus and outside. The last side opening, closest to the oral end, must certainly be in the stomach. If this rule is not followed, two complications may occur. If the probe is inserted too deeply, the stomach will not drain, which will manifest itself as regurgitation. If the probe is not inserted deep enough and one of the side holes ends up in the esophagus or oral cavity, reflux of intestinal contents is possible with the threat of regurgitation and aspiration pneumonia. After intubation is completed, the end of the probe protruding from the nose must be sewn to the wing of the nose with a monolithic thread No. 5-6. In one of the patients we observed, this condition was not met. Upon awakening, the patient partially removed the tube, and in the next few hours after the operation, regurgitation of stagnant contents began. It was not possible to insert the probe back into the stomach, and it was extremely undesirable to remove it completely, since the patient had general peritonitis. It is unacceptable to leave a probe through which intestinal contents are poured into the nasopharynx. Therefore, the following solution was found. A rubber tube was inserted onto the part of the probe located in the nasal cavity, pharynx, esophagus and proximal stomach (about 60 cm), which covered the existing side holes. The main probe at this time played the role of a conductor. Drainage was maintained. The patient recovered.
With retrograde intubation through an appendicocecostomy, perforation of the cecal wall by the tube is possible during passage of the ileocecal valve. We observed a patient who died from peritonitis. The probe should be inserted slowly. If this manipulation fails, you can use the Sanderson maneuver. After successfully passing the tube through the ileocecal valve, it is recommended to carefully examine the cecum in the area of the ileocecal angle so that the damage does not go unnoticed.
It can be difficult to pass from the cecum to the ileum even with the use of a special probe. If a regular rubber tube with many holes is used, then sometimes you have to use a forceps to carry it out, which creates additional difficulties and increases the likelihood of accidental damage to the intestine.
If forced to use a regular rubber tube to drain the small intestine, another complication may develop. After 5-7 days, when there is no need for drainage, the tube, when removed, may become pinched in the purse-string suture tightened around it at the base of the cecostoma. Such a ligature, descending from the tube into one of the side holes, cuts it when removing the drainage. Part of the tube remains in the intestine, being fixed in the cecostomy opening. To remove it, special surgery is required.
This complication is not observed when using polyvinyl chloride probes. If you still use a rubber tube, then in order to avoid its breakage during removal, the side holes should be made as small in diameter as possible. The purse-string sutures that screw in the intestine at the stoma site and provide a seal should not be tightened too tightly, and force should never be used when removing the probe. If disintubation is difficult, it is advisable to rotate the tube 90-180°, and if this does not help, wait several days until the ligature loosens or cuts through. Unlike nasogastric intubation, when passing the tube retrogradely through the cecum, there should be no rush to remove it.
Let's consider another complication. At the intersection of the glove tube drainage tube draining the abdominal cavity and the probe providing intestinal decompression, the wall of the latter is subjected to compression. In some cases, on the 4th-5th day, a bedsore of the intestinal wall develops with the formation. In the patients we observed, after removal of the tubular part of the graduate, the fistulas closed on their own within 7-10 days. However, a less favorable outcome is also possible.
In order to prevent this complication, it is necessary to place the abdominal cavity in such a way that they do not press on the intestine; Rigid tubes should not be used; it is possible to remove the tubular part of the tubular-glove graduate earlier.
Intestinal decompression with a long probe radically improves the results of the fight against peritonitis and paralytic ileus. The method should be widely implemented in all surgical hospitals providing emergency care.
The article was prepared and edited by: surgeonGoals: therapeutic (stimulation of bile outflow, administration of medicinal drugs), diagnostic (diseases of the gallbladder and biliary tract).
Contraindications: acute cholecystitis, exacerbation of chronic cholecystitis and cholelithiasis, gastrointestinal tumor, gastrointestinal bleeding.
To stimulate contraction of the gallbladder, one of the following stimulant substances is used::
§ magnesium sulfate (25% solution - 40-50 ml, 33% solution - 25-40 ml);
§ glucose (40% solution - 30-40 ml);
§ vegetable oil (40 ml).
3 days before the procedure, you should begin preparing the patient for duodenal intubation: give the patient a glass of warm sweet tea at night and place a heating pad on the right hypochondrium.
When preparing for the study, it is necessary to take into account concomitant pathology; sweet tea should not be given in case of diabetes mellitus; a heating pad is not indicated for diagnostic probing if giardiasis is suspected.
Required equipment:
Duodenal tube;
Stimulant substance;
Rack with numbered test tubes, Janet syringe, clamp;
Soft cushion or pillow, towel, napkin;
Rubber gloves.
The order of the procedure (Fig. 10.4):
1. Sit the patient on a chair so that the back rests tightly against the back of the aul, tilt the patient’s head slightly forward.
2. Carefully place the blind end of the probe on the root of the patient’s tongue and ask him to make swallowing movements.
3. When the probe reaches the stomach, apply a clamp to its free end.
4. Place the patient on the couch without a pillow on his right side, inviting him to bend his knees; Place a warm heating pad under your right side (on the liver area).
5.. Ask the patient to continue swallowing the probe for 20-60 minutes until the 70 cm mark.
6. Place the end of the probe into the test tube and remove the clamp; if the olive is located in the initial part of the duodenum, golden-yellow liquid begins to flow into the test tube.
7. Collect 2-3 test tubes of incoming liquid (portion A of bile), apply a clamp to the end of the probe.
If portion A of bile does not arrive, you need to slightly pull the probe back (possible twisting of the probe) or repeat probing under visual x-ray control.
Rice. 10.4. Duodenal sounding.
8. Lay the patient on his back, remove the clamp and inject a stimulant substance through the probe with a Janet syringe, apply the clamp.
9. After 10-15 minutes, ask the patient to lie on his right side again, lower the probe into the next test tube and remove the clamp: a thick, dark olive-colored liquid should flow in (portion B) - within 20-30 minutes, up to 60 ml of bile is released from the bile duct bladder (vesical bile).
If a portion of B does not enter the bile, there is probably a spasm of the sphincter of Oddi. To remove it, the patient should be injected subcutaneously with 1 ml of a 0.1% atropine solution (as prescribed by a doctor!).
10. When a transparent golden-yellow liquid begins to be released (portion C), lower the probe into the next test tube - within 20-30 minutes, 15-20 ml of bile is released from the bile ducts of the liver (hepatic bile).
11. Carefully remove the probe and immerse it in a container with a disinfectant solution.
12. Send the received portions of bile to the laboratory
Enemas
Enema (Greek) klysma- lavage) is a procedure for introducing various liquids into the rectum for therapeutic or diagnostic purposes.
The following enemas are considered therapeutic:
· Cleansing enema: it is prescribed for constipation (cleansing the lower intestine of feces and gases), according to indications - before surgery and in preparation for x-ray and ultrasound examination of the abdominal organs.
· Siphon enema: it is used in case of ineffectiveness of a cleansing enema, as well as when repeated lavage of the colon is necessary.
· Laxative enema: it is prescribed as an auxiliary cleansing agent for constipation with the formation of dense feces. Depending on the type of drug administered, hypertonic, oil and emulsion laxative enemas are distinguished.
· Medicinal enema: it is prescribed for the purpose of administering local and general medications through the rectum.
· Nutrient enema: it is used to introduce water, salt pan and glucose into the body. Other nutrients are not administered using an enema, since digestion and absorption of proteins, fats and vitamins do not occur in the rectum and sigmoid colon.
A diagnostic enema (contrast) is used to determine the capacity of the colon and introduce an X-ray contrast agent (suspension of barium sulfate) into the intestine with some methods of X-ray examination. The most informative is a contrast enema with double contrast - the introduction of a small amount of barium sulfate suspension and subsequent inflating of the intestine with air. This enema is used to diagnose diseases of the colon (cancer, polyps, diverticulosis, ulcerative colitis, etc.).
There are also the concepts of “microenema” (in which a small amount of liquid is administered - from 50 to 200 ml) and “macroenema” (in which 1.5 to 12 liters of liquid are administered).
There are two ways to introduce fluid into the rectum:
Hydraulic (for example, when administering a cleansing enema) - the liquid comes from a reservoir located above the level of the patient’s body;
Pressure (for example, when performing an oil enema) - liquid is injected into the intestines with a special rubber balloon (bulb) with a capacity of 200-250 ml, with a Janet syringe or using a complex pressure device “Colongidromat”.
Absolute contraindications for all types of enemas: gastro-
intestinal bleeding, acute inflammatory processes in the colon, acute inflammatory or ulcerative-inflammatory processes in the anus, malignant neoplasms of the rectum, acute appendicitis, peritonitis, the first days after operations on the digestive organs, bleeding from hemorrhoids, rectal prolapse.
Cleansing enema
Goals:
Cleansing - emptying the lower part of the colon by loosening feces and increasing peristalsis;
Diagnostic - as a stage of preparation for operations, childbirth and instrumental methods for examining the abdominal organs;
Therapeutic - as a stage of preparation for medicinal enemas.
Indications: constipation, poisoning, uremia, enemas before operations or childbirth, to prepare for x-ray, endoscopic or ultrasound examination of the abdominal organs, before administering a medicinal enema.
Contraindications: general.
To perform a cleansing enema, a special device is used (a device for cleansing enema), consisting of the following elements:
1. Esmarch mug (glass, rubber or metal vessel with a capacity of up to 2 liters).
2. A thick rubber tube with a clearance diameter of 1 cm and a length of 1.5 m, which is connected to the tube of Esmarch’s mug.
3. Connecting tube with tap (valve) for current regulation
liquids.
4. Glass, ebonite or rubber tip.
Necessary equipment: warm water in a volume of 1-2 liters, a device for a cleansing enema, a stand for hanging a mug, a thermometer for measuring the temperature of the liquid, an oilcloth, a diaper, a basin, a vessel, marked containers for “clean” and “dirty” intestinal tips, a spatula , Vaseline, protective clothing (mask, medical gown, apron and disposable gloves), containers with disinfectant solution.
The order of the procedure (Fig. 10.5):
Rice. 10.5. Setting up a cleansing enema (hydraulic method).
1. Prepare for the procedure: wash thoroughly
tsuki with soap and warm running water, put on a mask, apron and
Gloves.
2. Pour boiled water or liquid of the prescribed composition, volume (usually 1-1.5 l) and temperature into Esmarch’s mug.
4. Open the tap, fill the tubes (long rubber and connecting), release a few milliliters of water to displace air from the pipes and close the tap.
5. Place a basin on the floor near the couch; put on the couch
oilcloth (its free end should be lowered into the gas in case the patient cannot hold water) and a diaper on top of it.
6. Invite the patient to lie on the edge of the couch on his side (preferably on the left), bending his knees and bringing them to his stomach to relax the abdominal press (if movement is contraindicated for the patient, the enema can also be given with the patient on his back, placing a bed under him); the patient should relax as much as possible and breathe deeply, through the mouth, without straining.
7. Take a small amount of Vaseline with a spatula and lubricate the tip with it.
8. Using the thumb and forefinger of your left hand, spread the buttocks, and with your right hand, using light rotational movements, carefully insert the tip into the anus, moving it first towards the navel by 3-4 cm, then parallel to the spine to a total depth of 7-8 cm.
9. Open the tap slightly, making sure that the water does not enter the intestines too quickly, as this may cause pain.
If the patient experiences abdominal pain, it is necessary to immediately pause the procedure and wait until the pain goes away. If the pain does not subside, you should tell your doctor.
10. If the water does not flow, raise the mug higher and/or change the position of the tip, pushing it back 1-2 cm; if water still does not flow into the intestines, remove the tip and replace it (as it may be clogged with feces).
11. At the end of the procedure, close the tap and remove the tip, pressing the patient’s right buttock to the left so that liquid does not leak out of the rectum.
12. Invite the patient to squeeze the anal sphincter himself and hold the water for as long as possible (at least 5-10 minutes).
13. If after 5-10 minutes the patient feels the urge to defecate, give him a bedpan or walk him to the toilet, warning him, if possible, not to release the water immediately, but in portions.
14. Make sure that the procedure was effective; If the patient has emptied only with water and a small amount of feces, after examining the patient by a doctor, the enema must be repeated.
15. Disassemble the system and place it in a container with a disinfectant solution.
16. Remove apron, mask, gloves, wash hands.
The liquid administered through an enema has mechanical and temperature effects on the intestines, which can be regulated to a certain extent. The mechanical effect can be increased or decreased by adjusting the amount of injected liquid (on average 1-1.5 l), pressure (the higher the mug is suspended, the greater the pressure of the injected liquid) and the rate of administration (regulated by the tap of the cleansing enema device). By observing a certain temperature regime of the injected liquid, peristalsis can be enhanced: the lower the temperature of the injected liquid, the stronger the intestinal contractions. Usually, the water temperature for an enema is recommended to be 37-39 °C, but for atonic constipation, cold enemas (up to 12 °C) are used, and for spastic constipation, warm or hot ones are used to reduce spasms (37-42 °C).
Siphon enema
Siphon enema - repeated lavage of the intestines according to the principle of communicating vessels: one of these vessels is the intestine, the second is a funnel inserted into the free end of a rubber tube, the other end of which is inserted into the rectum (Fig. 10.6, a). First, a funnel filled with liquid is raised 0.5 m above the level of the patient’s body, then, as liquid enters the intestines (when the level of decreasing water reaches the narrowing of the funnel), the funnel is lowered below the level of the patient’s body and wait until it begins to flow intestinal contents (Fig. 10.6, 6). The raising and lowering of the funnel alternate, and with each rise of the funnel, liquid is added to it. Siphon lavage of the intestines is carried out until a clean floor comes out of the funnel. Usually 10-12 liters of water are administered. The amount of fluid released must be greater than the volume of fluid administered.
Rice. 10.6. Setting up a siphon enema: a - pour water into the funnel and enter the intestines; b - after lowering the funnel, the contents of the intestines begin to be released through it.
Goals:
Cleansing - achieve effective cleansing of the intestines from feces and gases;
Medical;
Detoxification;
As a stage of preparation for surgery.
Indications: lack of effect from a cleansing enema (due to prolonged constipation), poisoning with certain poisons, preparation for intestinal surgery, sometimes if colonic obstruction is suspected (with colonic obstruction there are no gases in the rinsing waters).
Contraindications: general, serious condition of the patient.
To perform a siphon enema, a special system is used, consisting of the following elements:
Glass funnel with a capacity of 1-2 liters;
Rubber tube 1.5 m long and lumen diameter 1-1.5 cm;
Connecting glass tube (to control the passage of contents);
A thick gastric tube (or a rubber tube equipped with a tip for insertion into the intestines).
A glass tube is used to connect a rubber tube to a thick gastric tube, and a funnel is placed on the free end of the rubber tube.
Necessary equipment: a system for siphon enema, a container with 10-12 liters of clean warm (37 ° C) water, a ladle with a capacity of 1 liter, a basin for rinsing water, oilcloth, a diaper, a spatula, Vaseline, special clothing (mask, medical gown, apron, disposable gloves), containers with disinfectant solution.
Procedure to complete:
1. Prepare for the procedure: carefully you mm
wash your hands with soap and warm running water, put on a mask, apron and gloves.
2. Place a basin on the floor near the couch; put on the couch
oilcloth (the free end of which is lowered into the basin) and a diaper on top of it,
3. Ask the patient to lie on the edge of the couch, on his left side, bending his knees and bringing them to his stomach to relax the abdominal press.
4. Prepare the system, take a small amount of Vaseline with a spatula and lubricate the end of the probe with it.
5. Using the thumb and forefinger of your left hand, spread the buttocks, and with your right hand, using light rotational movements, carefully insert the probe into the anus to a depth of 30-40 cm.
6. Place the funnel in an inclined position just above the patient’s body level and fill it with 1 liter of water using a ladle.
7. Slowly raise the funnel 0.5 m above the patient’s body level.
8. As soon as the level of decreasing water reaches the mouth of the funnel, lower the funnel below the level of the patient’s body and wait until the funnel is filled with the reverse flow of liquid (water with particles of intestinal contents).
The water should not be allowed to decrease below the mouth of the funnel to prevent air from entering the tube. The entry of air into the system disrupts the implementation of the siphon principle; in this case, you should start the procedure again.
9. Drain the contents of the funnel into a basin.
In case of poisoning, it is necessary to take 10-15 ml of liquid from the first portion of rinsing water for examination.
10.Repeat washing (steps 6-9) until clean wash codes appear in the funnel.
12.Slowly remove the probe and immerse it together with the funnel in a container with a disinfectant solution.
12. Toilet the anus.
13. Remove apron, mask, gloves, wash hands.
The patient's condition should be closely monitored during the procedure, since most patients do not tolerate a siphon enema well.
Laxative enema
A laxative enema is used for persistent constipation, as well as for intestinal paresis, when administering large amounts of fluid to the patient is ineffective or contraindicated.
Hypertensive enema provides effective bowel cleansing. promote abundant transudation of water from the capillaries of the intestinal wall into the intestinal lumen and the removal of large amounts of fluid from the body. In addition, a hypertensive enema stimulates the release of copious loose stools, gently enhancing intestinal motility.
Indications: ineffectiveness of the cleansing enema, massive swelling.
Contraindications: general.
For a hypertensive enema, as a rule, one m of the following solutions is used:
10% sodium chloride solution;
20-30% solution of magnesium sulfate;
20-30% sodium sulfate solution.
To perform a hypertensive enema, the prescribed solution (50-100 ml) is heated to a temperature of 37-38 °C. It is necessary to warn the patient not to get up immediately after the enema and try to retain the solution in the intestines for 20-30 minutes.
Oil enema promotes easy passage of large stools even in cases where the introduction of water into the intestines is ineffective.
The effect of oil in the intestines is due to the following effects:
Mechanical - oil penetrates between the intestinal wall and feces, softens feces and facilitates its removal from the intestines;
Chemical - the oil is not absorbed in the intestines, but is partially saponified and broken down under the influence of enzymes, relieving spasms and restoring normal peristalsis.
Indications: ineffectiveness of a cleansing enema, spastic constipation, prolonged constipation, when tension in the muscles of the abdominal wall and perineum is undesirable; chronic inflammatory diseases of the colon.
Contraindications: general.
To perform an oil enema, as a rule, vegetable oils (sunflower, flaxseed, hemp) or petroleum jelly are used. The prescribed oil (100-200 ml) is heated to a temperature of 37-38 °C. An oil enema is usually given at night, and the patient must be warned that after the enema he should not get out of bed until the enema takes effect (usually after 10-12 hours).
Emulsion enema: it is prescribed to seriously ill patients; complete bowel movement usually occurs within 20-30 minutes. To perform an emulsion enema, use an emulsion solution consisting of 2 glasses of chamomile infusion, beaten yolks of one egg, 1 tsp. sodium bicarbonate and 2 tbsp. Vaseline oil or glycerin.
Method of performing a laxative enema. Necessary equipment: a special rubber pear-shaped balloon (pear) or a Janet syringe with a rubber tube, 50-100 ml of the prescribed substance (hypertonic solution, oil or emulsion), heated in a water bath, thermometer, gas, oilcloth with a diaper, napkin, spatula, Vaseline , mask, gloves, containers with disinfectant solutions.
Procedure to complete:
1. Prepare for the procedure: wash your hands thoroughly with soap and running water, put on a mask and gloves.
2. Draw the prepared substance into the bulb (or Janet’s syringe). Remove any remaining air from the solution container.
3. Invite the patient to lie on the edge of the bed on his left side, bending his knees and bringing them to his stomach to relax the abdominal press.
4. Place an oilcloth with a diaper under the patient.
5. Lubricate the narrow end of the pear with Vaseline using a spatula.
6. Using the thumb and forefinger of your left hand, spread the buttocks, and with your right hand, using light rotational movements, carefully insert the pear into the anus to a depth of 10-12 cm.
7. Slowly squeezing the rubber bulb, introduce its contents.
8. Holding the bulb with your left hand, squeeze it with your right hand from top to bottom, squeezing the remaining solution into the rectum.
9. Holding a napkin at the anus, carefully remove the bulb from the rectum, wipe the skin with the napkin in the direction from front to back (from the perineum to the anus).
10. Close the patient’s buttocks tightly, remove the oilcloth and diaper.
11. Place the pear-shaped balloon (Zhanet syringe) in a container with a disinfectant solution.
12. Remove the mask, gloves, wash your hands.
If a rubber tube is used to perform a laxative enema, you should lubricate it with Vaseline for 15 cm, insert it into the anus to a depth of 10-12 cm and, attaching a filled pear-shaped balloon (or a Janet syringe) to the tube, slowly inject its contents. Then it is necessary to disconnect, without unclenching, the pear-shaped balloon from the tube and. holding the tube with your left hand, squeeze it with your right hand in the “top to bottom” direction, squeezing out the remaining solution into the rectum.
Medicinal enema
A medicinal enema is prescribed in two cases:
For the purpose of direct (local) effect on the intestines: administration of the drug directly into the intestines helps reduce the phenomena of irritation, inflammation and healing of erosions in the colon, and can relieve spasm of a certain area of the intestine. For local effects, medicinal enemas are usually given with chamomile decoction, sea buckthorn or rosehip oil, and antiseptic solutions.
For the purpose of general (resorptive) effects on the body; medications are well absorbed in the rectum through the hemorrhoidal veins and enter the inferior vena cava, bypassing the liver. Most often, painkillers, sedatives, hypnotics, anticonvulsants, and nonsteroidal anti-inflammatory drugs are injected into the rectum.
Indications: local effect on the rectum, administration of drugs for the purpose of resorptive effect; convulsions, sudden agitation.
Contraindications: acute inflammatory processes in the anal area.
30 minutes before the procedure, the patient is given a cleansing enema. Basically, medicinal enemas are microenemas - the amount of substance administered does not, as a rule, exceed 50-100 m. The medicinal solution should be heated in a water bath to 39-40 ° C; otherwise, the colder temperature will cause the urge to defecate, and the medicine will not be retained in the intestines. To prevent intestinal irritation, the drug should be administered with a sodium chloride solution or an enveloping agent (starch decoction) to suppress the urge to defecate. It is necessary to warn the patient that after a medicinal enema he must lie down for an hour.
A medicinal enema is given in the same way as a laxative one.
Nutrient enema (drip enema)
The use of nutritional enemas is limited, since only water, saline, glucose solution, alcohol and, to a minimal extent, amino acids are absorbed in the lower segment. A nutritional enema is just an additional method of introducing nutrients.
Indications: impaired swallowing, esophageal obstruction, severe acute infections, intoxication and poisoning.
Contraindications: general.
If a small amount of solution is administered (up to 200 ml), a nutritional enema is given 1-2 times a day. The solution must be heated to a temperature of 39-40 °C. The procedure for performing the procedure is no different from administering a medicinal enema.
To introduce a large amount of fluid into the body, a drip enema is used as the most gentle and quite effective method. Administered drop by drop and gradually absorbed, the large volume of injected solution does not stretch the intestines and does not increase intra-abdominal pressure. In this regard, increased peristalsis and the urge to defecate do not occur.
As a rule, a drip enema is given with a 0.85% sodium chloride solution, a 15% amino acid solution or a 5% glucose solution. The medicinal solution must be heated to a temperature of 39-40 °C. 30 minutes before administering a drip nutrient enema, it is necessary to administer a cleansing enema.
To perform a nutrient drip enema, a special system is used, consisting of the following elements:
· Esmarch's mug;
· two rubber tubes connected by a dropper;
· screw clamp (it is fixed on a rubber tube above the dropper);
· thick gastric tube.
Necessary equipment: a solution of the prescribed composition and temperature, a system for drip nutrient enema, a stand for hanging a mug, a thermometer for measuring the temperature of the liquid, oilcloth, a basin, a vessel, marked containers for “clean” and “dirty” intestinal tips, a spatula, Vaseline, overalls (bowl, medical gown, apron and disposable gloves), containers with disinfectant solution.
Procedure to complete:
1. Prepare for the procedure: wash your hands thoroughly with soap and warm running water, put on a mask, apron and gloves.
2. Pour the prepared solution into Esmarch’s mug.
3. Hang the mug on a tripod at a height of 1 m above the patient’s body level.
4. Open the clamp and fill the system.
5. Close the clamp when solution appears from the probe.
6. Help the patient take a position that is comfortable for him.
7. Take a small amount of Vaseline with a spatula and lubricate the ends of the probe with it.
8. Using the thumb and forefinger of your left hand, spread the buttocks, and with your right hand, using light rotational movements, carefully insert a thick gastric tube into the anus to a depth of 20-30 cm.
9. Use the clamp to adjust the drop rate (60-80 drops per minute).
10. At the end of the procedure, close the tap and remove the probe, pressing the patient’s right buttock to the left so that fluid does not leak out of the rectum.
11. Disassemble the system and place it in a container with a disinfectant solution.
12. Remove the mask, apron, gloves, wash your hands.
The procedure lasts several hours, the patient can sleep during this time. The duty of the nurse is to constantly monitor the patient’s condition, maintain the rate of administration of drops and the temperature of the solution. To ensure a constant temperature of the injected liquid as it cools, Esmarch’s mug should be covered with heating pads.
Gas outlet pipe
A gas outlet tube is used to remove gases from the intestines during flatulence. The gas outlet tube is a rubber tube 40 cm long with an internal lumen diameter of 5-10 mm. The outer end of the tube is slightly widened, the inner end (which is inserted into the anus) is rounded. At the rounded end of the tube there are two holes on the side wall.
Indications: flatulence, intestinal atony.
Necessary equipment: sterile gas outlet tube, spatula, Vaseline, tray, vessel, oilcloth, diaper, napkins, gloves, container with disinfectant solution.
The order of the procedure (Fig. 10.7):
1, Prepare for the procedure: wash your hands thoroughly with soap and warm running water, put on a mask and gloves.
2. Ask the patient to lie on his left side closer to the edge of the bed and pull his legs towards his stomach.
3. Place an oilcloth under the patient’s buttocks, and lay a diaper on top of the oilcloth.
4. Place a vessel filled one third with water on a chair next to the patient.
5. Lubricate the rounded end of the tube with Vaseline for 20-30 cm using a spatula.
6. Bend the tube in the middle, holding the free end with the ring and little fingers of your right hand and grasping the rounded end like a writing pen.
7. Using the thumb and forefinger of your left hand, spread the buttocks, and with your right hand, using light rotational movements, carefully insert the gas outlet tube into the anus to a depth of 20-30 cm.
8. Lower the free end of the tube into the vessel and cover the patient with a blanket.
9. After an hour, carefully remove the gas outlet tube from the anus.
10.Place the gas outlet tube in a container with a disinfectant solution.
11. Toilet the anus (wipe with a damp cloth).
12.Remove gloves, mask, wash hands.
Rice. 10.7. Application of a gas outlet tube: a - type of gas outlet tube; b - insertion of a gas outlet tube; c - removal of gases using a gas outlet tube.
Siphon enema (performed by two people) Condition - the procedure is performed in the presence of a doctor
| STEPS | JUSTIFICATION |
| 1. Preparation for the procedure 1. Explain to the patient the essence and course of the upcoming procedure and obtain his consent to perform the procedure | Patient motivation to cooperate. Respect for patient rights to information |
| 2. Prepare equipment | Necessary condition for the procedure |
| 3. Wear gloves and apron | |
| 4. Lay an oilcloth on the sheet covering the couch so that it hangs into the basin, and lay a diaper on top of it. Ask or help the patient to lie on the couch on his left side. His legs should be bent at the knees and slightly brought towards his stomach | If the rectum does not retain water, water will drain into the pelvis. Anatomical feature of the location of the lower part of the large intestine. Facilitation of insertion of probe and water |
| 5. Lubricate the rounded end of the probe with Vaseline for 30-40 cm | Facilitating the insertion of a probe into the intestine, preventing the patient from experiencing unpleasant sensations |
| II. Performing the procedure 6. Spread the buttocks with fingers I and II of the left hand, insert the rounded end of the probe into the intestine with the right hand and move it to a depth of 30 - 40 cm | Provides the ability to effectively carry out the procedure |
| 7. Attach a funnel to the free end of the probe. Hold the funnel slightly inclined, at the level of the patient’s buttocks, and pour 1 liter of water into it from a jug. | Preventing air from entering the intestines |
| 8. Slowly raise the funnel to a height of 1 m. Invite the patient to breathe deeply. As soon as the water reaches the mouth of the funnel, lower it below the level of the buttocks, without pouring water out of it until the funnel is completely filled | Provides control over the flow of water into the intestines and its removal back |
| 9. Drain the water into the prepared container | |
| STEPS | JUSTIFICATION |
| 10. Repeat points 7-9, using 10 liters of water | Ensuring the effectiveness of the procedure |
| GP. Completion of the procedure 11. At the end of the procedure, disconnect the funnel and slowly progressively remove the probe from the intestine, wiping it with toilet paper | Patient safety is ensured The probe is mechanically cleaned |
| "12. Immerse used items in a container with disinfectant. Pour rinsing water down the drain | Ensuring infection safety |
| 13. Wipe the skin in the anal area with toilet paper from front to back (in women) if the patient is helpless. Wash the perineum | Prevention of urinary tract infection and perineal skin maceration |
| 14. Remove gloves and apron. Wash and dry your hands | Ensuring infection safety |
| 15. Help the patient get off the couch (or move him for transport) | Ensuring Patient Safety |
| 16. Make a record of the procedure and the patient’s reaction | Ensuring continuity of nursing care |
Hypertonic enema
Bowel intubation(lat. in, inside + tuba pipe; syn. intestinal probing) - insertion of a tube into the intestinal lumen for diagnostic and therapeutic purposes.
A tube may be inserted into the small intestine through the mouth or nose, through a gastrostomy tube or ileostomy tube; into the colon - transanally or through a colostomy.
Diagnostic intestinal intubation is used to obtain material for histological, cytological and other studies. In 1967, Y. A. Fox proposed a method of blind probing of the colon to obtain the contents and biopsy of the colon mucosa.
In 1955, D. H. Blankenhorn et al. proposed a method of intestinal intubation, the essence of the cut is that a long (8-10 m) thin (1-1.5 mm) polyvinyl chloride probe with a mercury weighting agent is inserted through the nose. The probe passes through the entire digestive tract. In this way, the length of the intestine was measured, sensors were passed through the probe to determine pH, electrical activity, and the contents were obtained through the probe for biochemical research.
This probe was also used to insert the endoscope into the colon and terminal ileum. The method is dangerous because complications such as intestinal perforation, injury to the intestinal wall with a probe or the end of an endoscope are possible. These diagnostic methods have been completely replaced by endoscopic methods based on the use of fiber optics (see Intestinoscopy, Colonoscopy).
In 1910, Westerman pioneered the use of insertion of a tube through the nose into the stomach and duodenum in the treatment of peritonitis. Mat as (R. Matas, 1924), Wangesteen (O. H. Wangesteen, 1955) successfully used constant aspiration of the contents of the small intestine for mechanical and dynamic intestinal obstruction.
For more efficient suction of the contents of the small intestine, various modifications of thin single- and double-channel intestinal probes have been developed that can move throughout the intestine.
Therapeutic intestinal intubation is used for intestinal paresis and paralysis, for acute inflammatory diseases, after major and traumatic operations on the abdominal organs, for the prevention and treatment of intestinal obstruction; for feeding patients in the early postoperative period, for fixing the intestines in a certain position after reconstructive operations such as Noble's operation (see Noble's operation).
During therapeutic intestinal intubation, the contents are evacuated from the small intestine, which is overfilled and distended with liquid and gases, since overflow with contents leads to disruption of blood flow in the vessels of the intestinal wall, their thrombosis, necrosis and perforation of the intestinal wall. For this purpose, it is most advisable to use the Abbott-Miller probe.
Small bowel intubation through the mouth or nose can be used preoperatively, intraoperatively, and postoperatively.
Methodology
In order to prepare for surgery or when trying to conservatively treat patients with intestinal obstruction, intubation of the small intestine is performed with the patient sitting or reclining.
After anesthesia, e.g. Dicaine solution, the mucous membrane of the pharynx, through the lower nasal passage, the probe is passed into the esophagus, and then into the Stomach. Turn the patient on the right side and advance the probe to the second mark (pyloric level), inflate the cuff of the probe, and at the same time aspirate the contents using a vacuum apparatus. After emptying the stomach, the probe is slowly advanced to the third mark, and subsequently the cuff along with the probe slowly moves during intestinal peristalsis (15 - 20 cm per hour) to a level of 2-3 m. X-ray control is required, especially during the passage of the probe through the pylorus and through the small intestine (up to 3-4 times depending on the advancement of the probe).
When performing intubation on the operating table, the probe is first inserted into the stomach, and further along the intestine the probe is directed by the surgeon from the side of the opened abdominal cavity. After passing the probe, the head end of the table is raised. The duration of the probe is 3-7 days, depending on the restoration of intestinal motility and the patency of the probe.
Intubation of the intestine through the mouth and nose gives a good therapeutic effect, but inserting a probe (even a Cantor probe with a weight at the end) is difficult in case of intestinal paresis. Prolonged presence of a probe in the intestine can lead to the development of various complications: sinusitis, otitis, pneumonia, esophagitis, stenosis of the esophagus and pharynx, rupture of varicose veins of the esophagus, perforation of the esophagus, stomach, and intestines.
Intubation of the small intestine through a gastrostomy (Fig. 1) or ileostomy is also used, which can be done due to the impossibility of passing a probe through the mouth or nose. To intubate the small intestine, a thin long rubber tube with multiple holes is inserted through the ileostomy, which empties significant sections of the intestine (I. D. Zhitnyuk, 1965).
Intubation of the lower segments of the colon is sometimes used for the conservative treatment of sigmoid volvulus. In these cases, a thick gastric tube is inserted into the sigmoid colon through a sigmoidoscope.
In order to protect the anastomotic sutures on the colon, a number of surgeons use transanal intubation of the colon. Use specially designed single- or double-channel probes or a thick gastric tube. The probe is inserted during surgery above the anastomosis (Fig. 2) for 3-5 days and removed after restoration of intestinal function.
Bibliography: Berezov Yu. E. Surgery of stomach cancer, M., 1976, bibliogr.; Galperin Yu. M. Paresis, paralysis and functional intestinal obstruction, M., 1975, bibliogr.; Dederer Yu. M. Pathogenesis and treatment of acute intestinal obstruction, M., 1971, bibliogr.; Zhitnyuk I. D. Treatment of dynamic obstruction in peritonitis, Vestn, hir., t. 95, No. 12, p. 8, 1965; Rozanov I. B. and Stonogin V. D. On the prevention of insufficiency of the duodenal stump after gastrectomy, Surgery, No. 6, p. 31, 1965, bibliogr.; Simonyan K. S. Adhesive disease, M., 1966, bibliogr.; Surgery of the digestive organs, ed. I. M. Matyashina et al., vol. 3, p. 9 and others, Kyiv, 1974; Shalkov Yu. L., Nechitailo P. E. and Grishina T. A. Method of intestinal decompression in the treatment of functional intestinal obstruction, Vestn, hir., t. 118, no. 2, p. 34, 1977.,
V. P. Strekalovsky.
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In acute NK, surgical and conservative treatment is carried out, taking into account both local changes in the intestine and abdominal cavity, and general pathophysiological changes in the body.
Conservative treatment is used according to strict indications: with dynamic NK, in the initial stages of some forms of mechanical NK, namely: a) with adhesive NK; b) in the initial stages of intussusception and volvulus of the sigmoid OC; c) in advanced cases of low obstructive obstruction OK [AA. Shalimov, V.F. Saenko, 1987], as well as in certain forms of obstructive (coprostasis, helminthic glomeruli, gallstones) obstruction.
In case of early hospitalization and the absence of obvious signs of mechanical NK, siphon enemas are performed, decompression of the upper gastrointestinal tract is performed, and if appropriate probes are available, the gastric contents are pumped out and the intestines are intubated. The so-called Smith, Edlich and Leonard steerable probes are especially effective for this purpose. A fibrogastroscope can be used to pass unguided probes through the pylorus. Hemodynamic disturbances in patients in this group are usually not pronounced, and to compensate for the loss of fluid and electrolytes, it is enough to administer 1.5-2 liters of saline solutions, and in case of frequent vomiting, in addition, 300-500 ml of plasma or its substitutes.
In patients with severe symptoms of intoxication (peritonitis with severe strangulation and obstructive NK), conservative treatment is contraindicated.
When carrying out conservative treatment, constant aspiration of gastric and intestinal contents, a siphon enema, and lumbar novocaine blockade according to A.V. are performed. Vishnevsky, ganglion blockers, symlatolytic and antispasmodic agents are used. These measures allow a number of patients to restore the motor function of the stomach and intestines when they are atony. Suction of gastric, especially intestinal contents is indicated for paralytic and partial obstructive NK, the presence of an inflammatory process in the abdominal cavity, adhesive NK, which is especially easy to decompress. For possible perforation of the intestine when the probe is in place for a long time and quickly removed, a very slow (50-60 cm/h) removal of the probe is recommended (V.I. Chernov et al, 1999).
Emptying the distal parts of the intestine is achieved using cleansing and siphon enemas. In order to stimulate intestinal motor function, bilateral lumbar (perinephric) novocaine blockade according to A.B. is widely used. Vishnevsky, which to a certain extent is a therapeutic and diagnostic tool that allows, in some cases, to differentiate mechanical NK from dynamic. An indicator of the effectiveness of conservative treatment is usually the restoration of intestinal patency and an improvement in the general condition of the patient. Restoration of intestinal patency is usually indicated by copious stools with the passage of large amounts of gas, a decrease in flatulence and pain.
When evacuating the contents of the stomach, duodenum and colon, good results are often obtained by a thin double-lumen probe with an inflatable rubber balloon mounted at its end (Miller-Abbott probe), a siphon enema, which allows, in case of obstructive tumor NK, to remove gases and intestinal contents beyond the narrowed area. Intravenous administration of polyionic and plasma-replacing solutions makes it possible to restore the bcc and eliminate hydroionic disorders. The introduction of only polyionic solutions and 5-10% glucose solutions leads to increased sequestration of fluid in the “third” space (due to high osmotic pressure in the intestinal lumen). Therefore, they must be used in combination with plasma and plasma replacement solutions.
It should be noted that in some cases, the passage of a small amount of gases and feces after an enema cannot have any particular diagnostic significance, since they can depart from the distal parts of the obstructed intestine, but the NC as such remains. If it is impossible to perform an enema, it can be assumed that the mechanical obstacle is located in the lower parts of the OC. It is possible to eliminate NK with conservative measures in 40-50% of patients with dynamic NK, adhesive disease, in whom the clinical picture is caused not by a mechanical obstacle, but mainly by a violation of intestinal motor function, in patients with coprostasis, intestinal obstruction with rough, indigestible food, etc.
Conservative treatment (gastric lavage, aspiration of duodenal and intestinal contents, siphon enemas, antispasmodics or anticholinesterase drugs) in the absence of a pronounced effect should be carried out for no more than 3-4 hours. If during this time conservative measures do not produce an effect, then NC is mechanical in nature and emergency surgery is indicated. Prolongation of this period is dangerous due to the possibility of developing irreversible changes in the intestines, abdominal cavity and vital organs. The effectiveness of conservative treatment can be determined by control RI of the abdominal organs; preservation of small intestinal levels usually indicates the lack of result of conservative therapy.
Absolute contraindications to the conservative method of treatment as the main one in the treatment of NK are signs of increasing intoxication and peritonitis.
The tactics should be different for patients delivered early, but in serious condition with obvious strangulation NK (rapid deterioration of hemodynamics, the presence of free fluid in the abdominal cavity, increasing leukocytosis, increased proteolytic activity of the blood).
In case of acute NK, even before surgery, a special correction of the water-electrolyte balance (WEB) is required, i.e. preoperative preparation is necessary. This issue is of particular importance in elderly and senile patients.
Preoperative preparation of these patients should be intensive and take minimal time. Imbalance of EBV disturbances (especially potassium) before surgery can be the cause of a number of complications that develop after surgical trauma (persistent intestinal paresis, acute dilatation of the stomach, atony of the bladder, general muscle adynamia, acidosis, alkalosis, pulmonary complications, decline in cardiovascular activity) [I.D. Ustinovskaya, 1971].
Unliquidated hydroelectrolyte disturbances in the preoperative period increase the risk. During the period of dynamic observation and diagnostic research, the patient should simultaneously be prepared for possible surgery. Preoperative preparation is carried out with intensive infusion therapy. Blood is taken for general analysis, determination of hematocrit, total protein, sodium, potassium and chloride content. If possible, the CBS indicators are examined. Preoperative preparation should not exceed 3-4 hours from the moment the patient is admitted to the hospital. The purpose of this preparation is to replenish the deficit of blood volume, remove the patient from a state of shock and correct pathophysiological disorders occurring in the internal environment of the patient’s body, and impaired functions of vital organs and systems.
Infusion therapy is carried out by administering albumin, plasma and colloidal plasma replacement fluids, macromolecular dextrans, isotonic sodium chloride solution mixed with an equal amount of 1.9% sodium lactate solution, glucose solution, electrolytes, vitamins, protein substitutes in a stream, preferably into two veins at once . To correct acidosis, use a 4% solution of sodium bicarbonate (250-300 ml), Trisbuffer. Its use is indicated for heart patients, as it contains little sodium. However, it should be noted that in case of an overdose, alkalosis, hyperkalemia, and hypotension occur.
In case of microcirculatory disorders, approximately half of the administered polyglucin is replaced with hemodez or rheopolyglucin. If a patient with nodulation or extensive volvulus of the tuberculosis is admitted 8-10 hours after the onset of the disease or later with the threat of bacterial shock, 200-300 mg of prednisolone is added to the administered fluids, bringing its total dose to 800-1000 mg/day.
At the same time, cardiac glycosides, ATP, cocarboxylase, and ascorbic acid are administered. It is recommended to administer the fluid under the control of central venous pressure (CVP), for which purpose a catheter is inserted into the subclavian vein immediately after admission.
In patients admitted in serious condition, but at a later stage (3-4 days and later), preoperative preparation should be much longer, since homeostasis disturbances in them depend not only on the severity of the process, but also on the greater extent of its duration . The time for preoperative preparation of such patients can reach up to 3-4 hours. In this case, a simple rule is used: each day of illness requires at least 1 hour of preoperative preparation [Yu.M. Pantsyrev, 1988]. This is an approximate rule; the preparation time is adjusted depending on the clinical picture, hemodynamic parameters, electrolyte composition of the blood plasma, etc. If there is a threat of intestinal necrosis, the preoperative preparation time is sharply reduced.
In patients delivered late, when the entire gastrointestinal tract located above the obstruction is significantly overstretched with liquid and gases, intestinal decompression is of great importance in preoperative preparation: first, the gastric contents are pumped out, then a probe for intestinal intubation is inserted through the nose, gradually moving it into distally and at the same time sucking out the intestinal contents.
It should be taken into account that the fluid deficit in the body on the 3-4th day of the disease can reach 6-8 liters or more, therefore the main therapeutic measure is the administration of large quantities of isotonic (Ringer's solution) or weakly hypertonic (1-1.5% - j) saline solutions and 5% glucose solution. After diuresis is restored, 150-200 ml of a 1% potassium chloride solution is added to the administered fluids. At low blood pressure, a polyglucin solution, plasma or albumin is added to saline solutions. Albumin is recommended to be administered at the end of preoperative preparation, since it easily diffuses into the lumen of the obstructed intestinal loop and, increasing the osmotic pressure there, promotes the transudation of fluid into its lumen. Thiamine or, better yet, cocarboxylase, ATP in large doses (up to 2 g), and cardiac glycosides are administered. After administering 1.5-2 liters of saline solutions, 300-500 ml of hemodez or rheopolyglucin are added to them. If renal function is not restored, it is advisable to administer the same amount of mannitol.
To judge the severity of dehydration and evaluate preoperative preparation, the time during which the patient did not take food or water is determined, and the amount of vomit and urine excreted over the last 24 hours is estimated. “Unnoticeable losses” should also be calculated based on the fact that they amount to 1-1.5 l/day for a person with an average body weight.
You should pay attention first of all to dry skin and CO, tissue turgor disorders. Important information is provided by the determination of hematocrit and, if possible, bcc. The loss of electrolytes is judged by the content of sodium, potassium and chlorides in the blood plasma, however, the administration of saline solutions should be started immediately after the patient’s admission, without waiting for test results, which are of great importance for further correction of infusion therapy, the effectiveness of which is also judged by the amount of secreted urine using an indwelling catheter inserted into the bladder. It should be 40-50 ml/h with full compensation of losses. Another sign of sufficiency of fluid administration is a decrease in the relative density of urine below 1020 and normalization of hematocrit values. With strangulation NK, the operation is performed against the background of infusion therapy, without waiting for complete compensation of the disturbed homeostasis. Delaying surgery for impending intestinal necrosis is a mistake.
A rough estimate of the amount of plasma lost can be given by changes in the amount of fluid evacuated from the abdominal cavity and strangulation loop of the intestine. With a light and light pink color of the liquid, the volume of lost plasma is approximately 1/3 of the volume of the evacuated liquid, with a dark red or brown color - from 1/2 to 1/3 of its volume. If plasma losses are small, they can be compensated by the introduction of plasma substitutes. In case of very large plasma losses (during strangulation of a significant part of the TC), plasma replacement fluids and plasma are administered in approximately equal volumes, with preference given to low molecular weight plasma substitutes (hemodee, rsopolyglucin, neocomlensan), especially in cases of severe microcirculation disorders. Compensation for cellular protein loss is not such an urgent task, and it is carried out in the postoperative period.
The approximate volume of red blood cells excluded from the circulating blood can be determined by the hemoglobin content in the abdominal cavity and the lumen of the intestinal strangulation loop. The resected intestinal loop also contains blood, the amount of which averages 40-60% of its mass. If calculations carried out in this way show that no more than 20% of the total mass of red blood cells is excluded from circulation (which contributes to the loss of 1 liter of blood for a person with average body weight), there is no need for blood transfusion and one can limit oneself to the introduction of plasma and its substitutes. In case of more massive loss of red blood cells, freshly citrated or canned blood of short-term storage is transfused (shelf life up to 3-4 days). The amount of blood transfused should be 1.5-2 times less than the volume of lost blood, and the amount of plasma and plasma substitutes should be correspondingly greater than the volume of plasma loss in order to create moderate hemodilution. This helps improve microcirculation.
Elimination of the source of shockogenic influences, metabolic and hemodynamic disorders, as well as the causes that give rise to them, serves as a reliable guarantee of a successful impact on protective reactions and improved treatment results. Depending on the nature of the homeostasis disturbance, various solutions are used. If the patient, along with symptoms of extracellular dehydration (nausea, vomiting, dry tongue and dry mouth without thirst, hypotension, frequent weak pulse, dizziness, headache, etc.), also has an increase in indicators indicating hemoconcentration, as well as a decrease in electrolytes, It is recommended to use a polyionic composition: glucose 15 g, sodium chloride 4.5 g, potassium chloride 3.7 g, calcium chloride 0.2 g and distilled water up to 500 ml in an amount of 1000-2000 ml. With normal or elevated sodium levels, but with a deficiency of only potassium, a mixture is used (which is a 5% glucose solution, 1 liter of which contains 7.4 g of potassium chloride, i.e. decinormal concentration), 1 ml of which contains 0.1 meq each of potassium and chlorine.
When replacing lost water and electrolytes before surgery, consideration should be given to administering fluids during and after surgery. If disturbances in water and electrolyte metabolism are combined with the development of metabolic acidosis, a 4.2% sodium bicarbonate solution is used; in case of respiratory acidosis, oxygen therapy is used. When using corrective mixtures, vitamins C and group B are additionally introduced, as well as insulin 1 unit per 3-4 g of glucose.
Potassium deficiency is eliminated by slow intravenous administration of Le Quesne solution in the AA modification. Krokhalev (3.0 potassium chloride, 2.0 sodium chloride per 1 liter of 3% glucose solution) in the amount of 1 liter. For better utilization of potassium by cells, a 40% glucose solution with insulin is administered.
To correct impaired protein metabolism, mixtures of free amino acids are used in ratios corresponding to those in the blood of a healthy person.
To replenish energy reserves, add 100 ml of a 40% glucose solution with insulin to both solutions.
At all costs, one should not strive to fully compensate for all the fluid and electrolytes lost by the body before surgery, as this may be associated with an unreasonably long delay in surgical intervention, and too rapid administration of large quantities of solutions can lead to dangerous overload of the heart, especially in persons elderly and senile age.
With ongoing preoperative preparation, 2-3 hours is enough to administer 1-1.5 liters. The remaining amount required for full compensation must be administered during and after surgery.
When replenishing fluid losses in cardiac patients, as well as in any case when intravenously administering large amounts of fluid (over 200 ml/h), the patient should be auscultated every 30 minutes in order to promptly recognize congestive wheezing in the lungs and reduce the rate of administration.
To determine the required rate of introduction of solutions, you can use the following approximate formula:
(Number of milliliters of liquid)/(4 x number of hours before surgery)=Number of drops per minute
The effectiveness of the measures taken can be judged by the level and improvement of pulse filling, an increase in blood pressure, an increase in the amount of urine excreted (40-50 ml/h with a specific gravity below 1020), and a decrease in hematocrit. It is recommended to administer saline solutions under the supervision of a urine test until the amount of chlorine in the urine becomes normal. This will indicate sufficient compensation for sodium losses, although the latter do not exactly coincide with chlorine losses, but generally correspond to them.
There is a more accurate way to determine chlorine deficiency: chlorine, as an extracellular ion, is distributed in the extracellular fluid, which makes up about 20% of all body fluids. The chlorine content in extracellular fluid is on average 10 3 meq/l. Thus, the total amount of chlorine is 10 3 x 20% of body weight. Based on these data, chlorine deficiency can be calculated using the formula (Alder, 1960):
Chlorine deficiency = (Body weight (kg) x 10 3 mEq/l)/5
To this number should also be added chlorides, corresponding to the extracellular part of the water, which is introduced to cover the deficiency. Extracellular water makes up about 1/3 of the total body water. Thus, a more accurate formula can be represented as follows:
Amount of chlorine required for replacement (meq) = (Body weight (kg) x 10 3 meq/l)/5 + (Estimated water deficit (l))/3
If there are no signs of hypokalemia (electrocardiogram (ECG)), the amount contained in the administered Ringer's solution before surgery is sufficient. In addition, effective compensation for potassium deficiency can be carried out only if the kidneys have good function and the amount of urine excreted is normal, since potassium is absorbed relatively slowly by cells, and the accumulation of its excess amount in the blood plasma can lead to deterioration in activity and even cardiac arrest.
At very late stages of admission of patients (4-5 days and later), in whom, as a result of “imperceptible” losses, relatively more fluid is lost than electrolytes, the concentration of the latter in body fluids, despite the losses, may increase, and, therefore, dehydration will become hypertonic (cellular). In such cases, pronounced metabolic acidosis is always observed. Treatment should begin with the administration of isotonic solutions of glucose and bicarbonate or sodium lactate, followed by an infusion of plasma, and only later, when diuresis begins to recover, isotonic saline solutions are administered.
With strangulation NK, fluid losses are very significant and can occur in a short time. Plasma losses are also much greater than with obstructive NK, and unlike the latter, a significant volume of red blood cells are often excluded from circulation due to their deposition in the wall and lumen of the strangulated intestinal loop and sweating into the abdominal cavity (which gives the transudate a hemorrhagic character).
During preoperative preparation, oxygen therapy is carried out, cardiac and painkillers (promedol, fentanyl) are administered.
The operation is performed under combined endotracheal surface anesthesia with nitrous oxide with the use of depolarizing muscle relaxants. To avoid possible regurgitation, it is necessary to empty the stomach before surgery. The increased sensitivity of patients with NK to barbiturates and muscle relaxants should also be taken into account. This type of anesthesia provides a sufficient depth of anesthesia and good relaxation of the abdominal wall muscles.
The surgical approach for NK should create the most favorable conditions for revision of the abdominal cavity not only manually, but also visually, determining the level of the obstacle and performing the necessary intervention. More often, a wide mid-median laparotomy is used, in which the incision can be extended upward or downward, depending on the nature of the detected pathology. This incision allows you to perform a full revision with the least trauma and more quickly and perform the entire required volume of the operation.
When a patient is admitted in the early stages of the disease, when there is still no sharp intestinal bloating, it is not difficult to establish the location and nature of NK and it can be eliminated quite easily without resorting to intestinal eventration. The intestinal loops adjacent to the wound are removed into the wound and 100-150 ml of 0.25% novocaine are injected at the root of its mesentery. The same is done with the transverse mesentery and in the solar plexus area. Such a blockade allows you to remove afferent impulses, which do not stop under the influence of anesthesia. It prevents the development of shock during surgery. After the novocaine blockade, the effusion present in the abdominal cavity is removed and an inspection of the intestine begins. The location of the NK is usually determined by the state of the strangulated intestinal loops: above the obstacle they are swollen, below - collapsed. It is best to begin the inspection of the intestine from the ileocecal angle. Often, such a revision and identification of NK sites are difficult due to severe intestinal bloating. When the obstruction is localized in the colon, the colon is usually sharply swollen. This sign is very characteristic, and having discovered it, you should immediately begin to audit the OK. If there is pathology in the OC itself or in the final section of the ileum, the cause of obstruction is detected immediately. At the same time, measures are taken to prevent cooling and drying of the intestinal loops.
Moving from the ileocecal angle up along the TC, they reach the site of the obstacle. In case of sudden bloating and overflow of contents, the intestines should be emptied first. This significantly reduces the trauma of the operation and makes it easier to perform. In addition, removal of the contents of the distended intestine (decompression) contributes to the early restoration of the tone of the intestinal wall, its blood supply, reduction of intraintestinal pressure, early restoration of peristalsis and resolution of the phenomena of postoperative paralytic NK.
To empty the intestines of stagnant contents, closed methods (transnasal) of TB intubation with a probe with multiple holes are often used, while simultaneous suction of stagnant contents (Figure 4) already on the operating table. Similar decompression is continued in the postoperative period. In the absence of a long special probe, you can use a regular probe inserted into the stomach or into the initial part of the colon.
Figure 4. Transnasal intubation of TB
In some cases, if it is impossible to use a closed method, there is a danger of intestinal rupture, they resort to entrostomy or bowel evacuation through a gestrostomy. Bowel emptying by enterotomy is performed through the collapsed intestine, i.e. below the obstacle. When the intestine is necrotically changed, its distal segment is taken out of the surgical field and the proximal segment is crossed through it within healthy tissues and the part of the intestine to be resected is removed.
Decompression of the stomach and upper intestines is recommended to be performed both during surgery and in the postoperative period, also with the help of a special probe inserted through a gastrostomy (Y.M. Dederer, 1971), to empty the intestinal loops, as with cecostomy (D.A. Arapov and V.V. Umansky, 1971).
The main objective of surgical intervention is to eliminate a mechanical obstruction or create a bypass for intestinal contents. The nature of the measures taken depends on the causes of obstruction, the condition of the intestines and the patient. In case of small intestinal obstruction, one should strive for complete elimination of the cause, up to intestinal resection with the imposition of an interintestinal anastomosis (dissection of adhesions, intestinal resection for a tumor, intestinal dissection with removal of gallstones, etc.). This rule does not apply to colonic obstruction, in the treatment of which the simultaneous application of an interintestinal anastomosis leads to insufficient sutures and the development of peritonitis. Only if the tumor is located on the right side, obstructing the OC, in young patients with unadvanced NC, right-sided hemicolectomy with ileotransverse anastomosis is considered acceptable (Figure 5). In other cases, two-stage and three-stage operations are considered more appropriate. A two-stage operation - resection of the intestine bearing the tumor, with the imposition of an unnatural anus (AP) on the adducting loop, the second stage is an anastomosis between the adducting and efferent loops.
Figure 5. Right hemicolectomy (scheme): a - boundaries of intestinal resection (shaded); b — ileotranseverzoanastomosis is applied
Three-stage operation - unloading cecostoma or unnatural ZP proximal to the site of obstruction; resection of the OC area with the tumor with interintestinal anastomosis; closed cecostomas.
If there is a constriction of the intestine with adhesions or cords, it is eliminated by dissecting it. When the intestine is constricted by a soldered appendix (40), an ileal diverticulum, or a fallopian tube, the adhesions are cut at the apex of these organs so as not to open their lumen. During volvulus, the intestine and its mesentery are devalued (turned) in the direction opposite to the direction of volvulus. In some cases (volvulus of the sigmoid colon, cecum), detorsion is supplemented with fixation surgery. In case of volvulus of the sigmoid OK and gross changes in its walls, it is recommended to perform a two-stage resection of the intestine. In the first stage, the corresponding section of the intestine is removed and the unnatural gastrointestinal tract is ground up; in the second stage, it is eliminated.
For PC caused by gallstones, an enterotomy is performed, the stone is removed and the intestinal incision is sutured.
After eliminating the obstacle, the state of viability of the affected intestinal loop is assessed, but if it is clearly non-viable, its resection is carried out even before the obstacle is eliminated. In this case, first of all, it is necessary to bandage or at least immediately clamp the vessels of the mesentery. This should be done in order to avoid the entry of toxic substances flowing from the strangulation loop of the intestine.
If the viability of the intestine is impaired and its obvious necrosis, intestinal resection is performed (Figure 6). It should be remembered that intestinal necrosis begins with CO and its signs in the serous membrane may be absent. To determine the viability of the intestine, a number of techniques are used. When warmed, the intestine that has changed its appearance, if viable, usually turns pink, peristalsis and a distinct pulsation of blood vessels appear. The peritoneum of a viable intestine is usually shiny. To more quickly identify the latter, 0.2-0.3 ml of a 0.01% solution of acetylcholine 1:10 can be injected into the mesentery of a questionable area of the intestine.
Figure 6. TB resection:
a — intersection of the mesentery, its wedge-shaped resection; b — intersection of the intestine between the clamps; c — formation of an end-to-end anastomosis; d — final view of the small intestinal anastomosis
A viable intestine reacts with the rapid appearance of vigorous peristalsis [V.V. Ivanov, 1966]. For this purpose, transillumination is used - luminescent research (M.Z. Seagal, 1973). Intestinal viability is determined using local intestinal thermometry by the difference in temperature between healthy and altered intestines. A temperature difference of more than 2 o C indicates deep damage to the intestinal wall (K.Ya. Chuprakova and L.A. Kozmina, 1973).
To determine the viability of the intestinal wall, the “wet paper” symptom is used: if, after the formation of a fold from the intestinal wall, it does not straighten out, then it is considered that the intestinal loop is not viable.
In all cases, if there is suspicion of intestinal wall nonviability, it is recommended to perform its resection.
When a knot is formed between the thin and sigmoid OC, the knot is untied after the sigmoid OC is emptied using a puncture. If it is not possible to untie the knot between the loops of the colon, then there is a need to dissect the intestinal loop that formed the knot and release the strangulated intestinal loop, and then restore the integrity of the dissected intestine.
If intussusception is present, disinvagination is performed (Figure 7). After this, it may be necessary to fix the intestinal wall to the anterolateral abdominal wall with interrupted sutures. If it is impossible to perform disinvagination or the inserted intestine is necrotic, intestinal resection is performed.
Figure 7. Disinvagination: a - conventional method; b - according to Hutchinson; c - according to Feldman
With obstructive NC, an obstacle obstructing the intestinal lumen is eliminated (dissection of adhesions that caused obstruction). During resection, it is necessary to dissect the intestine proximally from the obstacle at a distance of 20-30 cm. A large amount of liquid content accumulated in the intestinal lumen must be emptied. The significance of the latter is significantly great in terms of reducing intoxication, eliminating pressure on the intestinal wall and restoring its tone. For this purpose, a purse-string suture is placed on the opposite edge of the mesenteric attachment or the intestinal lumen is opened in its center. A glass tube with a diameter of 10-12 mm and a length of about 15 cm is inserted into the lumen of the latter. A rubber tube is attached to the glass tube. The purse string suture is tightened around the tube, but not tied. The assistant helps to empty the intestinal contents without putting unnecessary pressure on it.
After emptying the intestinal contents, the tube is removed from the lumen, the purse-string suture is tied and several interrupted sutures are placed on top. A number of authors recommend that in particularly severe cases, enterostomy be performed in one or more places.
Bowel resection should be performed within healthy tissue. In this case, the adductor knee is resected over a long distance - up to 50 cm from the area of necrosis, the abductor - up to 20 cm. In case of extensive intestinal necrosis, Trasylol is administered during surgery for 1-2 days of the postoperative period.
Anastomosis after intestinal resection is best done end-to-end (A.A. Shalimov, V.F. Saenko, 1987). When resection of necrotic intestine, the necrotic mesentery should also be removed, since leaving it can cause peritonitis and death. Peritonitis and the patient's serious condition are not a contraindication to resection of non-viable intestine. In cases of NK caused by inflammatory infiltrates and a powerful adhesive process, bypass anastomoses are performed. After completion of the operation, the abdominal cavity is drained, irrigated with an antibiotic solution (intraoperative sanitation) and tightly sutured. If indicated, the abdominal cavity is drained to drain exudate and administer antibiotics in the postoperative period. Intraoperative unloading of the dilated section of the intestine helps restore microcirculation in the intestinal wall, its tone and peristalsis. Unloading of the dilated segment can be achieved by transnasally introducing perforated probes into the TC during surgery or introducing similar probes through a gastro- or cecostomy (Figure 8, 9).
Figure 8. Intubation of TB through a gastrostomy tube
Figure 9. Intubation of TB through a cecostomy
In the postoperative period, a set of therapeutic measures is carried out aimed at preventing and removing the patient from a state of shock, correcting disorders of water-salt and protein metabolism, preventing and treating complications. Active infusion therapy is carried out until stable improvement in the patient's condition. In the first days, the stomach and upper intestines are emptied with a nasointestinal tube. In case of severe TB paresis, an enterostomy was traditionally placed in one or several places. In recent years, our observations show that intraoperative nasointestinal intubation makes it possible, even on the operating table, to quickly empty the intestines of putrefactive contents and gases, restore the tone of the intestinal wall, improve its blood circulation and motor function. Our experience shows that intraoperative nasointestinal intubation is a fairly effective means of eliminating intoxication of the body and restoring intestinal motility.
In the postoperative period, the patient is constantly monitored, hemodynamic parameters are determined, and daily fluid loss is measured (the amount of fluid released from the stomach and intestines through an endotracheal tube, with vomiting, etc.).
The main objectives of treating patients with NK after surgery are:
1) restoration of changes in the internal environment of the body and maintenance of its normal composition;
2) accurate compensation and maintenance of the normal volume of intracellular, extracellular fluid and circulating blood in general by calculating external losses (vomiting) and internal movements (transudation into the abdominal cavity and intestinal lumen), as well as “imperceptible” losses under the control of diuresis;
3) restoration of the body’s electrolyte balance;
4) compensation of protein losses by transfusion of plasma and protein preparations;
5) elimination of violations of the WWTP;
6) improving the function of vital organs;
7) restoration of bcc;
8) elimination of hemomicrocirculation disorders and improvement of the rheological properties of blood;
9) combating pain shock (drugs, analgesics);
10) prevention of hypoxia, anoxia and cerebral edema - oxygen therapy and plasma transfusion;
11) maintaining liver function by infusion of glucose solutions with insulin, administration of vitamins, glutamic acid, proteins in an easily digestible form;
12) restoration of the amount of fluid in the body and oncotic pressure of the blood;
13) improvement of blood supply to the kidneys, precise control of diuresis;
14) combating intoxication (detoxification) by introducing broad-spectrum antibiotics into the abdominal cavity, intestinal lumen and parenterally, carefully removing transudate from the abdominal cavity, treating intestinal loops;
15) combating overdistension of intestinal loops and restoration of intestinal motility by evacuation of intestinal contents during surgery, intestinal decompression in the postoperative period by constant suction of gastric contents, stimulation of its motor function;
16) parenteral nutrition;
17) decrease in blood proteolytic activity;
18) stimulation of the body’s immunoactive forces.
All these therapeutic measures must be individualized in accordance with the characteristics of the course of the disease in a given form and in a given patient.
Very diverse processes occur in the body of one and the same patient, and accordingly, treatment should be comprehensive. To fulfill both requirements - an individual approach and complexity, it is necessary to know the nature of the processes occurring in the body of a given patient and be able to evaluate them quantitatively.
It is necessary in each specific case to know and be able to calculate how much of a particular solution should be administered, what is preferable to transfuse in this case - plasma, glucose or salt solutions, isotonic or hypertonic solutions, etc. The variety of disorders that occur in the patient’s body as a result of NK can be divided into the following main groups:
1) loss of the most important components of the human body - water, electrolytes, plasma, cellular protein, red blood cells, leading to disruption of homeostasis;
2) discoordination of regulatory mechanisms - nervous endocrine system, enzymatic processes;
3) dystrophic processes in the cells of vital organs, developing as a result of intoxication and disruption of the composition of the internal environment of the body.
Advances in the treatment of NK, achieved in recent years, are largely associated with the restoration of homeostasis, replenishment of losses of fluid, proteins and electrolytes. Recently, in connection with the development of our knowledge regarding the nature of disorders of the internal environment of the body, intensive therapy measures aimed at correcting regulatory mechanisms are becoming increasingly important. Modern methods of studying the nature of changes in the internal environment of the body help to accurately assess the nature of the pathological processes occurring in the patient’s body. However, most of these methods require a certain period of time, complex equipment and therefore are of little use in emergency surgery, especially in regional conditions. Based on this, you can use simple methods for quantitative assessment of disturbances in the volume of water, salts, proteins, changes in blood volume, etc., which can help the surgeon develop the correct treatment plan.
For example, knowledge of the clinic, the symptomatology of dyshydria and blood and urine tests are sufficient to determine the form of dehydration. The significance of this is very great, since intensive care measures that are life-saving in one form of dehydration can be harmful or even disastrous in another. In the late stage of the disease, compensation for impairment of CBS becomes of certain importance. Here it is necessary to know exactly the nature of the changes occurring, since therapeutic measures for acidosis (observed in most cases in the later stages of the disease) and alkalosis are diametrically opposed. In the late stages of acute NK, metabolic acidosis is observed in the vast majority of cases. When compensating for losses of water and electrolytes, the use of adrenal cortex preparations involved in the regulation of water-salt metabolism may be important.
These drugs can be administered in the postoperative period only according to strict indications, when there is indeed convincing evidence of depletion of the function of the adrenal cortex. On the other hand, glucocorticoids improve hemodynamic parameters during shock, as they contribute to the compaction of walls, capillaries and a decrease in their permeability, enhance the response of smooth muscle elements of blood vessels to pressor impulses and norepinephrine, and normalize the electrolyte exchange of the myocardium and the vascular wall (Yu.M. Dederer, 1971) .
Protein losses must be urgently compensated, for which it is recommended to transfuse liquids containing plasma proteins or solutions of large-molecular plasma substitutes. Compensation for their losses, which is not as urgent as compensation for losses of intracellular proteins, consists of parenteral administration of solutions of amino acids, protein hydrolysates and oral administration of proteins with food. Due to the fact that extracellular proteins are lost mainly as a result of transudation into the abdominal cavity, lumen and wall of the obstructed loop, these losses can be approximately estimated by measuring the volume of transudate in the abdominal cavity, the contents of the obstructive (or strangulation) loop and determining the percentage of protein in them. You can use an approximate calculation based on the average protein content in the transudate: light or pink transudate contains 2-3% protein; with dark hemorrhagic coloring, the protein content in it increases to 4-5%. The loss of cellular protein should be compensated based on the fact that a person’s daily protein requirement is on average 100-120 g.
When plasma proteins are lost, the most urgent task is to eliminate hemodynamic disorders, primarily by normalizing oncotic pressure and, consequently, restoring volume.
For this purpose, only colloidal solutions of large molecular compounds that can provide sufficient CODE can be used. In addition to plasma and blood serum, solutions of large-molecular plasma substitutes of a non-protein nature (polyglucin, dextran) can also be used. These substances perform the function of maintaining oncotic pressure. Losses of extracellular protein (plasma) must be urgently compensated even before surgery, since a decrease in blood volume predisposes to shock.
Compensation for intracellular protein losses is carried out by parenteral administration of solutions of amino acids, protein hydrolysates and oral administration of proteins.
To cover the loss of extracellular protein, it is necessary to transfuse plasma or serum in an amount of at least half the volume of fluid evacuated from the intestinal lumen and abdominal cavity.
To cover the body's minimum need for protein consumed as a result of metabolic processes, the introduction of 300-400 ml of plasma per day is sufficient.
Replacement of extracellular protein is especially important in the preoperative period and during surgery, when it is necessary to quickly eliminate hemodynamic disturbances, restore bcc and retain fluid in the vascular bed by increasing oncotic pressure [Yu.M. Dederer, 1971]. In the postoperative period, the loss of proteins due to transudation processes is practically not observed; proteins are lost during natural metabolic processes, and therefore their parenteral administration can be stopped when intestinal function is restored and it becomes possible to administer them with food.
When deciding on the amount of plasma to be transfused to a patient with NK, it is necessary to take into account both the duration of the disease and the general condition of the patient. The above rules are useful as a guide for determining the loss of extracellular protein when circumstances do not allow resorting to more complex research methods.
With strantulation forms of NK, a significant decrease in blood volume is also observed, which leads to severe hemodynamic disturbances. It has been established (Yu.M. Dederer, 1971) that BCC in strangulation forms can decrease by 30% or more.
Losses of water and electrolytes during NK must be quickly and adequately compensated. At the same time, it is important to know the nature of dehydration developing during acute NK, since therapeutic measures for different types of the latter are not the same.
It is necessary to solve two main questions: 1) how much fluid the patient has lost and 2) what solutions and in what ratios need to be administered.
In elderly and senile patients, the introduction of fluid into the bloodstream causes additional stress on the heart if a large volume is administered quickly, without taking into account the individual characteristics of the state of the cardiovascular system. In each specific observation, the question of choosing an infusion medium or optimal combinations of several media, the volume of liquid, its distribution in time and the sequence of administration is decided individually. The rate of administration of solutions in patients with severe impairment of cardiac contractile function should not exceed 60 drops/min.
With the initial hypohemodynamic type of circulatory disorder, it is considered advisable to administer drugs in the following sequence: glucose solutions, protein drugs, saline solutions. In case of pronounced hyperdynamic blood circulation, infusion therapy begins with saline solutions, then glucose solutions and protein preparations are introduced.
To normalize hemomicrocirculation and improve metabolic acidosis, it is advisable to achieve moderate hemodilution (hematocrit 35) and warm the injected solutions to body temperature.
Colloidal solutions and protein preparations (plasma, albumin, protein) in combination with crystalloids are effective in eliminating hypovolemia. When the phenomena of extracellular hypohydration predominate, sodium chloride solutions with a limited infusion of glucose are used, which is administered only after compensation of the osmotic deficiency in the extracellular fluid. If the phenomena of cellular hypohydration predominate, infusion therapy should begin with the introduction of iso- or hypotonic glucose solutions to replenish water losses.
Correction of hydroionic disorders must meet the following requirements: 1) replenishment of the loss of intracellular fluid; 2) restoration of the total amount of water, primarily in the intracellular space; E) combined replenishment of fluid loss in the extracellular space and electrolyte deficiency.
For replacement therapy, the following is necessary: a) a basal solution to replace water losses (glucose, fructose solution); b) the main solution to compensate for the loss of water and electrolytes, Rinter-Lactate solution; c) three solutions to compensate for the loss of electrolytes: sodium chloride, sodium lactate, potassium chloride.
When the electrolyte composition is normalized using a solution of potassium chloride, the CBS stops.
Compensation for the disturbed sodium balance is carried out in accordance with the level of sodium in the plasma.
While diuresis remains negative in the postoperative period, potassium administration should be abstained, but if diuresis is sufficient, on the contrary, potassium administration should be given importance.
To cover the body's energy costs, 600-1000 ml of 10%, 20% glucose solutions are administered with the addition of the required amount of insulin (1 unit of insulin per 4 g of glucose). To maintain myocardial metabolism, cocarboxylase, adenosine triphosphoric acid, vitamin preparations, and cardiac glycosides are used.
The amount of glucose is limited to 1 liter based on the following considerations: the body loses fluid without loss of electrolytes through evaporation through the skin and during respiration. These losses amount to about 1 liter, the remaining losses (with urine, sweat, food juices) occur with the simultaneous loss of electrolytes and therefore must be replaced with saline solutions or other liquids containing electrolytes.
The amount of protein-containing fluids, as a rule, is about 20-25% of the total volume of fluid administered (until the patient begins to take protein-containing substances orally).
The remaining amount of fluid is administered in the form of polyelectrolyte isotonic saline solutions, the volume of which was 1.5-2 l/day in the first days after surgery. When the patient begins to drink, the amount of saline solution administered decreases. When suctioning the contents of the gastrointestinal tract by intubation, the amount of saline solutions increases according to the amount of evacuated contents.
For a more or less correct calculation of fluid and electrolyte losses, it is necessary to know the clinical signs of a particular condition. Signs of water intoxication are salivation, lacrimation, vomiting, diarrhea, skin swelling and signs of increased intracranial pressure (headache, disorientation, muscle twitching, bradycardia, hypertension). Signs of salt intoxication include anorexia, nausea, vomiting, hoarseness, subcutaneous edema, pulmonary edema, ascites, hydrothorax. General symptoms of salt deficiency: weakness, motor restlessness, “silence in the stomach,” and later peripheral vascular collapse. Since the above symptoms are partly nonspecific, it is highly desirable to determine the hematocrit, chloride and sodium content in the blood.
Adequate compensation for the loss of potassium ions is very important in the postoperative period. Its amount in digestive juices and sweat is 2-3 times greater than in plasma, so excessive loss of digestive juices through vomiting can lead to a significant deficiency of potassium in the body. This is also facilitated by sweating, which in some patients is quite profuse. In the postoperative period, when diuresis is normalized, potassium chloride is administered (2.5 g in 1 liter of isotonic glucose solution).
If the preoperative potassium deficiency was small and the postoperative period proceeds smoothly, this amount is sufficient to cover the minimum daily requirement. In cases where the patient is admitted late, as well as in the postoperative period, a significant amount of potassium is lost, which means that the amount of potassium chloride solution increases. Considering that digestive juices contain an average of 10 meq/l of potassium, 0.75 g of potassium chloride (250 ml of 0.3% solution) should be administered for each liter of evacuated contents.
Additionally, the amount of potassium that the patient is expected to have lost before surgery is administered. An average of 70-100 meq (2.7-4 g) of potassium is released from the body per day (Yu.M. Dederer, 1971); if the duration of the disease is 3 days and during this period the patient did not eat food and was not given potassium supplements, then the loss of potassium is at least 210 mEq (8.1 g), which corresponds to 15 g of potassium chloride. Given the presence of potassium reserves in the body and the danger of rapidly introducing too large quantities, these losses should be compensated gradually.
When administering potassium solutions, it is necessary to follow some rules: 1) diuresis is absolutely necessary - 40-50 mg eq/hour; 2) solutions should not contain more than 30-40 meq of potassium per liter; 3) maximum daily dose - 3 mEq per 1 kg of weight; 4) the maximum rate of administration is 20 mEq/h. Overdose can lead to cardiac arrest at serum levels of 7-14 mEq/L. Potassium overdose is best recognized by changes in the ECG (Yu.M. Dederer, 1971).
In the first days of the postoperative period, the most characteristic change in CBS is metabolic acidosis. In the future, especially with prolonged suction of intestinal contents, hypokalemic alkalosis may develop, which is explained by the loss of potassium in digestive juices and urine. In addition, increased secretion of the antidiuretic hormone aldosterone by the adrenal glands during a stressful situation also increases potassium excretion. Aldosterone sharply reduces sodium excretion and causes increased water resorption in the kidneys and contributes to a decrease in COD in the extracellular space (A.S. Sons and I.F. Lvov, 1966). The authors showed that with the introduction of mineralocorticoids, the amount of sodium in the blood serum increases significantly, which is the result of the mobilization of inactive sodium that does not participate in metabolism due to insufficient secretion of mineralocorticoids by the adrenal cortex (depletion of the adrenal cortex). In this regard, mineralocorticoids are also used in the complex of therapeutic measures for NK.
Glucose-electrolyte mixtures are also used to correct potassium levels. Up to 200-600 mmol of potassium is administered per day in the form of panangin and potassium chloride solutions.
Energy costs are replenished by using various combinations of glucose solutions and amino acids (2500-3000 cal).
In order to enhance the absorption of nitrogen from administered drugs, they should be combined with the administration of anabolic steroids, insulin, and a complex of vitamins.
Detoxification is carried out using antitoxic drugs and the method of forced diuresis. Normalization of CBS is carried out taking into account electrolyte shifts. Metabolic acidosis is corrected by the use of sodium bicarbonate, lactasol, trisamine; in case of metabolic alkalosis, potassium deficiency is compensated by introducing large doses of ascorbic acid, enzyme inhibitors (trasylol 300 thousand units/day or its analogues). To combat infection, along with the rational use of antibiotics, taking into account the sensitivity of the microflora, passive and active immunization is used. It is advisable to administer parenterally or orally solutions of potassium chloride in an amount adequate to the daily loss for 3-5 days after normalization of its content in plasma.
If there are signs of shock, colloidal solutions (about 15-20 ml/kg body weight) are administered to replace fluids, followed by electrolyte infusion solutions. If there are no signs of shock, therapy with electrolyte infusion solutions is started immediately.
It should be borne in mind that an excess amount of injected fluid, if it is not too large, does not pose any particular danger with normal kidney function, but it is undesirable in the presence of pathological changes in the kidneys or heart.
To calculate the total amount of fluid administered, add up the volume of vomit, urine (excreted from the onset of the disease), transudate, intestinal contents and “imperceptible” losses.
In cases where it is difficult to take into account fluid losses from the onset of the disease based on calculations, it is necessary to make a rough estimate based on the duration of the disease, the form of NK, clinical signs, and the severity of dehydration (dry skin and CO, blood pressure).
A simple, although not particularly accurate, calculation of fluid loss can be made based on the hematocrit, using the Vandall formula:
where G is the hematocrit indicator.
Control of the amount of urine excreted is very important, especially in the postoperative period. The production of a normal amount of urine per day (1400 ml) is a fairly reliable indicator of the adequacy of the amount of fluid administered. To do this, a catheter is inserted into the bladder and the amount of urine is measured every hour (normally 50-60 ml are released per hour).
It is necessary to accurately take into account the amount of fluid introduced and removed from the body. A patient weighing 70 kg should receive 3.5 liters of fluid per day plus the amount that he loses through drainage or vomiting.
Treatment of general dehydration consists of a combination of administration of basic solutions and glucose solutions. The administration of hypertonic solutions is strictly contraindicated, since even a temporary increase in osmotic pressure in the extracellular space will increase cellular dehydration and worsen the patient’s condition for some time [Yu.N. Dederer, 1971].
Adequate dosage of administered fluid and electrolytes can be carried out if their losses are known using modern methods for studying EBV. However, in patients with NK, in most cases, a significant part of laboratory tests cannot be carried out, since they take too much time, and in the 1-2 hours that the surgeon has at his disposal, he must not only assess the degree of loss of EBV solutions, but also have time to prepare the patient. In addition, these patients are often admitted at night when the laboratory is closed, and in most hospitals, especially in rural ones, EBV testing is usually not performed.
Thus, if for research work these studies are of undoubted value, then in practical work the surgeon has to rely on clinical data and some simple laboratory tests that can be performed in most medical institutions. In such cases, you should pay attention to the following points:
1) the patient’s complaints and medical history (thirst, nausea, frequency of vomiting, duration of the disease, amount of vomit, amount of urine);
2) examination data (skin turgor, CO dryness, pulse, blood pressure, NS disorders);
3) the amount of fluid taken in and excreted (urine, vomit, aspirated contents of the stomach and intestines);
4) hematocrit indicator;
5) the amount of protein in the blood plasma;
6) determination of the content of electrolytes in blood plasma;
7) determination of the content of electrolytes in urine and evacuated contents of the stomach and intestines.
To combat intoxication during NK, the following measures are proposed:
1) suppression of the vital activity of microflora located in the intestinal lumen and beyond, through local and general use of antibiotics and other antibacterial agents;
2) removal of toxic substances from the body by evacuation of transudate from the abdominal cavity and intestinal contents by abdominal dialysis, as well as treatment of the abdominal organs with surfactants;
3) the introduction of specific antitoxic serums, which, however, has not yet left the experimental stage;
4) nonspecific increase in the patient’s body’s resistance to toxic substances through the administration of adrenal hormones.
Due to the fact that toxic products are mainly exo- and endotoxins of microorganisms, suppressing the viability of the latter can help reduce intoxication. For this purpose, it is recommended to administer broad-spectrum antibiotics into the intestinal lumen through a tube. At the same time, intestinal decompression carried out with this technique helps prevent the development of microbes and necrobiotic processes in it.
Detoxification of the body is achieved by restoring normal diuresis. This requires adequate replacement of fluid losses. A good detoxification effect is provided by stimulation, forcing diuresis by administering Lasix (30-40 mg) with moderate hemodilution. Good adsorbents of toxins that promote their elimination by the kidneys are synthetic plasma expanders (reopolyglucin, neocomlensan, hemodez, neodez).
Hyperbaric oxygen therapy (HBO) and the administration of vitamins and glucose may be of some importance for normalizing the function of internal organs. The latter is especially necessary when infusions of cardiac muscle tonics are used as an energy resource.
The use of HBOT promotes earlier normalization of homeostasis parameters and restoration of intestinal function.
Oxygen therapy is carried out during the first 2-3 days after surgery. It brings significant benefits, reduces hypoxia, improves the absorption of gases in the intestines, and therefore reduces bloating. Oxygen therapy is delivered in a humidified form through a catheter. Oxygen barotherapy is very effective.
For patients in serious condition, in whom depletion of adrenal cortex function can be expected, 100-125 mg of hydrocortisone is added to the administered fluids within 2-4 days after surgery, reducing the dosage to 50 mg by the 3-4th day.
Cardiac medications are prescribed depending on the state of the heart and blood pressure. It is recommended to avoid the use of potent vasoconstrictors to avoid subsequent vascular collapse. If there are signs of decline in cardiac activity, intravenous infusions of strophanthin (injected as part of administered glucose solutions in small doses) and cordiamine (2 ml 3-4 times a day) are prescribed. To improve metabolic processes, vitamins B and C are administered parenterally (until intestinal function is normalized and, therefore, the patient can receive adequate nutrition).
If anuria develops, a lumbar novocaine blockade should be performed according to Vishnevsky, and mannitol should be administered (500-1000 ml of a 10% solution).
More than 1/4 of all complications developing in the postoperative period in patients undergoing surgery for acute NK are associated with infection. The most serious infectious complication of acute NK, often occurring even before surgery, is peritonitis, the prevention and treatment of which is one of the main tasks of the postoperative period. In this regard, it is necessary to carry out antibacterial therapy using the most powerful agents, such as antibiotics. In this case, permanent monitoring of the sensitivity of microbial flora to antibiotics should be considered an indispensable condition for the effectiveness of antibiotic therapy. Broad-spectrum antibiotics are usually used: aminoglycosides (monomycin, kanamycin, gentamicin) and semisynthetic penicillins (oxacillin, ampicillin, etc.), as well as cephalosporins (ceporin), which are administered intramuscularly, intravenously, endolymphatically, intraperitoneally.
To prevent thromboembolic complications, a set of measures is carried out: elastic compression of the veins of the lower extremities, active regimen, prescription of antiplatelet agents, direct and indirect anticoagulants.
To prevent the occasional thrombosis of small veins of the intestinal wall, heparinization is started (20-30 thousand units/day).
One of the features of the postoperative period in acute NK is the presence of intestinal paresis, therefore measures aimed at emptying the intestine, restoring its peristalsis and activating its motor function are important. Combating paresis and paralytic NK and stimulating intestinal motor function are an important task of the postoperative period.
Evacuation of contents from intestinal loops that are sharply overfilled with liquid and gases is an important stage of the operation. If the afferent loop is slightly swollen, then evacuation should not be carried out, and the contents of the strangulated intestinal loop are removed with the resected loop. Outdated techniques (for example, removal of one of the loops followed by enterotomy and evacuation of intestinal contents by “milking”), associated with violations of asepsis with traumatization of the intestinal loops, should not be used.
Intestinal decompression for the purpose of preventing and treating paresis is carried out using various methods. The most effective of them are those that ensure the evacuation, first of all, of intestinal contents from the upper intestines.
In order to restore the tone and motor function of the stomach and intestines in the postoperative period, continuous aspiration of gastrointestinal contents is performed.
Emptying the gastrointestinal tract is achieved by periodic gastric lavage using a thin nasogastric tube inserted into the stomach through the nose, or, which is much more effective, by constant aspiration with a thin probe using suction devices. Cleansing enemas help to empty the intestines and restore its tone. However, their use requires taking into account the nature of the operation. Inserting a gas tube may be effective.
A good drainage effect is observed when the sphincter is stretched at the end of the operation. In patients who are not undergoing resection of the OC, a siphon enema can be used.
Emptying the bowel with an endotracheal tube (nasointestinal intubation during surgery) is very effective.
Constant removal of stagnant intestinal contents with a probe reduces the effects of intoxication and improves its tone. In addition, constant intestinal decompression creates the most favorable conditions for restoring intestinal motility. When intestinal motility is restored and bowel noise appears, suction is stopped and the probe is removed.
The essence of intestinal intubation with a probe inserted transnasally or (if indicated) through a gastrostomy tube is that a rubber or plastic probe equipped with holes is passed through the nose or gastrostomy tube into the stomach, duodenum and colon. Passing the probe may present some difficulties. After the probe is passed into the area of the duodenum - the small intestinal flexure, its end may rest against the intestinal wall and it must be given the correct direction in this place. If a significant part or almost all of the TC is involved in the pathological process, the probe can be passed to the end of the TC. The last hole in the wall of the tube should be located in the antrum of the stomach. The insertion site of the probe into the stomach is sealed with several purse-string sutures or as with Witzel gastrostomy.
In cases where only the lower parts of the TC are overfilled with liquid and gases, it is considered advisable to pass the endotracheal tube through the cecostomy into the TC in the oral direction (see Figure 9).
If intestinal resection or enterotomy has been performed, or if there are signs of peritonitis, microirrigators are inserted into the abdominal cavity to administer antibiotics. The abdominal cavity is usually sutured tightly. After the operation is completed, the anal sphincter is stretched.
Of particular importance in the immediate postoperative period is parenteral nutrition, which is associated with limited oral intake of nutrients, increased breakdown of tissue protein and significant losses of nitrogen. Consequently, parenteral nutrition in the immediate postoperative period should be aimed, along with the correction of energy and water-salt metabolism, and at restoring a positive nitrogen balance (N.H. Malinovsky et al, 1974; A.B. Sudzhyan, 1991).
To ensure regular peristalsis, it is first necessary to correct the water and electrolyte balance.
Elimination of postoperative paresis or intestinal atony is also achieved by improving mesenteric circulation using hyperosmolar-hyperoncotic solutions at a rate of 8 ml/kg of body weight. In some cases, especially with established intestinal atony, it is considered necessary to repeat the infusion. This takes into account contraindications (heart failure, organic kidney damage, dehydration) and the risk of hyperosmolar coma. It should be remembered that all degrees of hypoproteinemia can lead to a decrease in gastrointestinal motility up to the development of paralytic NK.
In order to stimulate intestinal motility, ganglion-blocking agents are used - α and β-adrenergic blockers (dimecoline, etc.), which inhibit inhibitory efferent impulses in the ganglia and simultaneously stimulate the motility of the intestinal muscles [N.M. Baklykova, 1965; A.E. Norenberg-Charkviani, 1969].
Stimulation of peristalsis (and at the same time replenishment of chloride deficiency) is facilitated by the intravenous administration of 20-40 ml of 10% sodium chloride solution. A.P. Chepky et al. (1980) against the background of balanced transfusion therapy, the next day after surgery, 400-800 ml of a 15% sorbitol solution and 2-3 ml of 20% calcium pantothenate are prescribed. If there is no effect, aminazine is additionally administered a day later (0.2-0.3 ml of a 2.5% solution 3-4 times a day), followed by a cleansing enema.
This therapy continues for 3-4 days. The use of cholinesterase inhibitors to enhance parasympathetic innervation (1-2 ml of 0.05% proserin solution) and m-cholinergic drugs (aceclidine - 1-2 ml) with repeated cleansing and hypertonic enemas is indicated.
For early restoration of intestinal motor function, guanitidine, isobarine and ornid are used. Ornid is administered intravenously at 0.5-1 ml of a 5% solution.
Aminazine has great activity [Yu.L. Shalkov et al., 1980], which is used in 1 ml of 2.5% solution 2 times a day.
Leridural anesthesia has a good effect.
In cases of severe postoperative intestinal paresis, lumbar novocaine blockade according to Vishnevsky often gives a good therapeutic effect. Electrical stimulation is also used in the complex of therapeutic measures aimed at restoring the motor-evacuation function of the gastrointestinal tract. In the absence of mechanical causes and an increase in peritonitis, a positive effect is achieved after 4-5 sessions of electrical stimulation.
When signs of restoration of the motor, digestive and absorption functions of the intestine appear, enteral tube feeding is advisable, which reduces the number of complications associated with the need for long-term parenteral nutrition (complications during catheterization of large veins, allergic reactions, risk of infection). A nasojejunal probe can be used for this purpose.
In addition to the means used to stimulate intestinal motility, a necessary condition for restoring peristalsis is the normalization of metabolism, compensation for the deficiency of proteins, fluids and electrolytes, increasing the dose of administered vitamins, and the introduction of vikasol, against the background of which the effectiveness of other means increases [Yu.N.Dederer, 1971].
For the same purpose, adrenolytic drugs are prescribed (they are contraindicated when blood pressure decreases) or novocaine blockade, after which a 10% hypertonic solution of sodium chloride is infused intravenously (0.5 ml of a 10% solution per 1 kg of patient weight). The infusion can be repeated 2-3 times a day. After intravenous administration of sodium chloride, a siphon enema is performed 30 minutes later.
Stimulation of intestinal motility with drugs for severe paresis should be combined with constant suction of gastric contents or, which is much more effective, with intestinal intubation.
Nutrition of patients begins as soon as the evacuation function of the stomach and intestines is restored. In case of obstruction with significant distension of the intestinal loops, restoration of peristalsis occurs no earlier than after 3-4 days. In case of colonic obstructive obstruction, ileocecal intussusception, the motor function of the stomach and colon is usually not impaired. These patients are allowed to take liquid food the very next day after surgery.
After resection of the colon, if the remaining part of the intestine is functionally complete, it is allowed to drink the next day. In cases where a thin tube is inserted into the patient's intestines through the nose, drinking is allowed the next day after surgery. Another day, soft-boiled eggs, jelly, liquid semolina porridge, a small piece of butter, and broth are allowed. In the following days, it is necessary to provide a sufficient amount of protein in the diet of patients.
In acute NK, despite the progress achieved, mortality remains high and averages 13-18% (M.I. Kuzin, 1988).
The main reason for the high mortality rate is late hospitalization of patients and profound disorders of salt, water and protein metabolism, as well as intoxication, which develops as a result of the breakdown of intestinal contents and the formation of a large number of toxic substances. In this disease, the mortality rate is equal to the time (number of hours) that elapsed from the onset of the disease to surgery.
Timely hospitalization and early surgical intervention are the main guarantee for a favorable treatment outcome. According to statistics, mortality among patients with acute NK who were operated on in the first 6 hours is 3.5%, and among those operated on after 24 hours - 24.7% or more.
An ultrasound rectal probe consists of two concentric tubes - external and internal. The inner tube moves freely inside the outer (fixed) one. A sensor operating at a frequency of 3.5 MHz is mounted at the inner end of the movable tube. The depth of insertion of the probe into the rectum and the angle of inclination are adjusted mechanically in accordance with the study conditions. When the inner tube moves longitudinally, it is possible to record echo signals from the bladder at any level. Transverse echographic scans of the pelvic organs surrounding the rectum (prostate and seminal vesicles) can be obtained by radial scanning with automatic 360° rotation of the oscillatory disk located inside the transducer. The tip of the probe, pre-lubricated with petroleum jelly, is slowly inserted into the rectum to a depth of 8 - 9 cm. The tightness of the probe's fit to the rectal mucosa is achieved by filling a small rubber balloon at its top with water. This also serves to protect the rectal mucosa from unwanted ultrasound effects. The depth of the probe inserted into the rectum is adjusted by scanning at intervals of 0.5 cm from the base of the bladder and seminal vesicles to the apex. The ultrasound rectal probe is connected to a gray scale scanning attachment, which allows for rapid recording of echo signals and improved image quality on the display screen. Carrying out transrectal echography using a hand-held probe expands the information content of the method due to the possibility of its introduction into the rectum to a greater depth, above the base of the prostate gland, which makes it possible to obtain an echographic image of the bottom of the bladder and seminal vesicles. At the same time, the height of ultrasound scanning on an Aloka chair is limited to 10 cm. The advantage of performing echography with a rectal probe mounted in the chair is the preservation of stable research conditions, which is important for assessing the results of repeated echography during the monitoring of patients or their treatment. This is explained by the fact that a change in the angle of insertion of the rectal probe in relation to the longitudinal axis of the prostate gland during repeated studies inevitably affects the echographic picture and affects the final result of determining the volume of the gland. When performing a perineal biopsy of the prostate gland due to suspected prostate cancer under ultrasound control, it is preferable to use a manual rectal probe to determine the “zone of interest” in the gland. Its administration in some cases may be accompanied by pain, especially with anal fissures or rectal diverticula. Difficulties when inserting a rectal probe arise when the prostate adenoma is large in size with its predominant growth towards the rectum or when prostate cancer spreads to the walls of the rectum. In such cases, before the examination, local anesthesia of the rectal mucosa is performed with lidocaine. It should be borne in mind that the introduction of a rectal probe can cause vegetative-vascular crises, and the rapid entry of lidocaine into the blood in some cases contributes to a decrease in blood pressure and the development of collapse. To prevent these complications, before transrectal echography, it is necessary to examine the patient’s cardiovascular system and identify pathological changes in the rectum.
