How to properly perform thoracentesis in animals. Surgical treatment of chylothorax in cats

10.1. Venipuncture, venesection, catheterization of veins and arteries

Intravenous or intra-arterial administration medicinal substances It is performed, as a rule, in severe or terminal conditions of the animal.

Peripheral vein puncture is used for short-term infusion therapy (for 2-3 days) or for single or double intravenous administration of drugs in a small volume, as well as for drawing blood for testing.

Puncture of the peripheral vein is best performed on the forelimbs in the v.Cephalica, midway between the elbow and carpal joints.

Venipuncture is performed in compliance with the rules of asepsis and, as a rule, does not present any particular difficulties. The features of this manipulation are: 1) fixation of the vein with the left hand (the skin on the paw from below is folded to limit the mobility of the vein); 2) after puncturing the vein with a needle, the latter should be advanced along the lumen of the vein by 1-2 cm, for more reliable fixation of the needle in the lumen of the vessel.

More reliable and convenient is venipuncture with a special cannula of the “Vasofix” type, which is a polyethylene catheter placed on a needle. After puncture of the vein, the needle is removed, and a flexible catheter remains in the lumen of the vein, which does not injure the walls of blood vessels during unexpected movements of the animal. This catheter can be left in the vein for subsequent intravenous injections medicinal substances.

Vein catheterization can be carried out using the Seldinger method, which consists of puncturing the vein with a thick needle, through the lumen of which a conductor (metal or fishing line) is inserted into the vein, then the needle is removed along the conductor into the lumen of the vein rotational movements a catheter is inserted 4-8 cm, and the guide is removed. When the guidewire is removed, the puncture site is pressed with a sterile ball to secure the catheter. The catheter must be fixed to the skin with 2-3 stitching ligatures.

If venipuncture is impossible (paravasal hematoma, edema, need for transportation, long-term infusions, collapsed veins in terminal conditions: shock, massive blood loss, etc.), venesection is resorted to. Venesection can be performed not only on peripheral, but also on central veins (v.jugularis extema, v.femoralis, v.axillaris). Fundamentally, the venesection technique is the same for peripheral and central veins. Features are determined by the topographic-anatomical location of a particular vessel chosen for venesection.

Fig.21. Stages of venesection.

Technique (Fig. 21): in compliance with the rules of asepsis, prepare a section of skin above the selected vein (when catheterizing v.jugularis extepna, the skin is cut with a transverse incision 4-5 cm long in the middle between the corner lower jaw and the shoulder-scapular joint, or directly behind the dorsal edge of the lower jaw, which allows you to insert a catheter into v.jugularis through one of the veins - v.lingualis, v.maxillaris, v.facialis, during catheterization v. femoralis or v.axillaris - in the inguinal or axillary area, respectively. During catheterization, vcephalica is in the middle between the elbow and wrist joints). The skin is cut with a scalpel and a vein is isolated over a length of 2-3 cm, bluntly (with jaws of a clamp), under which two catgut ligatures are placed. The distal ligature is tied. By pulling the distally located ligature, they tighten and straighten the vein, and incise it with the tips of thin (ophthalmic or vascular) scissors to 1/5-1/4 of its lumen. A catheter filled with isotonic sodium chloride solution is inserted into the resulting hole at a distance of 5-20 cm, depending on the objectives being pursued and the diameter of the vessel. The ligatures are tied, fixing the catheter in the lumen of the vessel and in the wound. The skin is sutured, tying the catheter.

When catheterizing the central veins, after isolating the vessel, it is better to use the Seldinger method, or, if this is not possible, to perform catheterization central vein through any small branch flowing into the central vessel (Fig. 22). Compliance with these recommendations allows you to avoid ligation of the central vein and associated complications: bleeding, ascending thrombosis, edema of the corresponding anatomical area, etc.

Fig.22. Scheme of peripheral venous trunks used for catheterization of the central vein (v.jugulans externa). 1 — external acoustic meatus: 2 — v. temporalis superficialis. 3 - v aunculans caudalis; 4 - v.maxillans. 5 - v. Jiigulans extema. 6 - v.lmgvotacialis. 7 - v.laryngea cranialis. 8 - v.lingvahs. 9 - v.faciahs. 10 - mandibular salivary gland.

Catheterization of the central vein allows for more effective infusion therapy, keeping the catheter in the lumen of the vein longer, and catheterization of the external jugular vein makes it possible to administer medications directly to the heart, as well as measure central venous pressure, which is a necessary diagnostic test when determining the volume of infusion therapy, rate infusions.

Central venous pressure (CVP) is measured using a Waldmann apparatus, the zero mark of which is set at the level of the right atrium (Fig. 23). Venous catheter located in the external jugular vein, connect to the Waldman phlebotonometer and monitor the fluctuations of the solution in the manometer tube, which should be synchronous with the breathing phases. Upper limit vibrations of the solution corresponds to the value of the central venous pressure. In dogs, this figure normally ranges from 20 to 40 mm of water. Art.

Fig.23. Schematic representation of CVP measurement using a Waldmann apparatus.

A decrease in this indicator to 0 and below indicates a deficiency of bcc and possible development collapse. In this case, it is necessary to increase the rate and volume of infusion. The indicator is above 70 mm water column. may indicate hypervolemia, weakness of the right ventricle of the heart, the possibility of developing pulmonary edema or the development of pulmonary embolism. In this case, it is necessary to reduce the rate and volume of infusion therapy, take preventive measures and eliminate the identified cause.

In the absence of a Waldmann phlebotonometer, CVP can be measured using a conventional blood transfusion system. To do this, a small amount of liquid is first drained from the filled system so that the zero mark can be set in the lumen of the system itself (Fig. 24). Then the system is closed, connected to venous catheter, and the zero mark is set at the level of the right atrium. The system opens and the CVP indicator is taken into account according to the method described above.

Rice. 24. Schematic illustration of CVP measurement using a conventional blood transfusion system.

Measurement of central venous pressure can also be carried out in the supine position of the animal. In this case, the principles of measuring CVP do not change.

A permanent catheter requires certain care: daily toilet the puncture site or wound through which the catheter comes out, use antiseptics and change the dressing; after infusions, a so-called “heparin lock” is introduced through a plug into the lumen of the catheter - 4.5 ml of isotonic sodium chloride solution and 0.5 ml of heparin. During the period between infusions, this solution is administered through a plug every 4-6 hours. It is necessary to ensure that the catheter does not fill with blood, because this leads to its rapid thrombosis. In these cases, careful recanalization of the catheter with a guidewire is possible, followed by washing it with a heparin solution. With proper care of the catheter, it can be used for up to 2 weeks.

When catheterizing veins, complications such as thromboembolism, injury to arteries or nerves, air embolism, infectious complications(suppuration, sepsis).

Arterial catheterization is performed in four ways:

1. percutaneous puncture with a special catheter with a metal guide;
2. according to Seldinger;
3. puncture of the artery after its exposure;
4. insertion of a catheter through the arteriotomy opening (as with venesection).

We will not dwell on the technique of this manipulation in more detail, because... it is resorted to quite rarely. The most common complications are hematoma formation and arterial thrombosis.

Prevention and treatment of thrombophlebitis. In animals that are in a serious condition in conditions of limited mobility, complications such as thrombophlebitis of peripheral veins quite often occur with the possible subsequent development of thromboembolism of the pulmonary artery, small pulmonary arteries or cerebral arteries with the corresponding clinic (up to sudden death). The development of these complications is associated with limited mobility, dehydration, impaired blood viscosity, and coagulopathy. Prevention is intravenous infusion of isotonic solutions (try to avoid hypertonic solutions, as well as drugs that enhance blood coagulation (!)); the use of alcohol compresses on the limbs at the sites of intravenous solutions; early physical activity, massage of the limbs; use of heparin ointment locally and subcutaneous administration of heparin at a rate of 100 U/kg twice a day for 3-4 days, followed by oral administration of aspirin 0.01 g/kg with food 2-3 times a day.

10.2. Puncture of the pericardium and pleural cavity

Pericardial puncture is performed in cases of cardiac tamponade, traumatic hemopericarditis, and massive exudative pericarditis.

Pericardial puncture is performed with the animal in the supine position, preferably after sedation. The puncture site is located in the angle between the costal arch and the xiphoid process. After anesthetizing the injection site with a 0.5% novocaine solution, a thick puncture needle is directed slightly medially in the sagittal plane and at an angle of 45° in the frontal plane to a depth of 2 to 5 cm, allowing the novocaine needle to be inserted until slight resistance of the pericardium is felt; when the latter is pierced, the contents of the heart sac are obtained (Fig. 25). In severe cases of purulent pericarditis, pericardial catheterization is possible using a technique similar to Seldinger catheterization. In addition, pericardial puncture can be performed in the 4th intercostal space at the junction of the bony part of the rib into the cartilaginous part.

Fig.25. Schematic representation of pericardial puncture. a — top view; 6 - side view.

During puncture of the pericardium, injuries to the heart are possible (blood is released in spurts through the needle); damage to the coronary arteries, which can lead to cardiac arrest or subsequent heart attack; pneumothorax, injury to the abdominal organs during diaphragmatic hernia.

Pleural puncture is performed for traumatic hemo- or pneumothorax, exudative tense pleurisy, accompanied by pulmonary insufficiency.

Pleural puncture is performed in the 7-8th intercostal space along the line of the glenohumeral joint. During puncture, the skin is shifted by 1-2 cm; with a needle placed on a syringe, the skin and muscles are pierced along the anterior edge of the underlying rib (to avoid injury to the intercostal artery) and the needle is inserted 3-4 cm. In the presence of pneumothorax, when pulling the syringe plunger, the piston does not return to its original position. There may be traces of blood or pus in the syringe. If it is necessary to evacuate air from the pleural cavity, a rubber tube is put on a thick needle and sealed at the junction. After pleural puncture its contents are evacuated actively (Fig. 26) using a Janet syringe (while periodically clamping the tube with a clamp) or passively using the Bulau method (Fig. 27).

Fig.26. Puncture of the pleural cavity. 1 - lungs; 2 - air.

Fig.27. Drainage no Bülau. 1 - tube; 2 — rubber fingertip; 3 — spacer (match); 4 - incision in the fingertip; 5 - valve; b - air.

Bulau drainage is carried out using a long tube with a needle at one end and a valve at the other. The valve is made of a rubber fingertip, the hole of which is tied to the tube, and the end is cut to 1.5-2 cm. In the area of ​​the cut, you can install a spacer (match) for better work valve The valve is lowered into a vessel with furatsilin. When inhaling, excess air from the pleural cavity is released through the valve.

If long-term drainage of the pleural cavity is necessary, especially when closed damage chest, lung rupture resort to thoracentesis. Thoracentesis is carried out using a trocar, the lumen of which must be wide enough to pass a drainage tube through. After anesthetizing the intercostal space, the chest wall is pierced with a trocar, the stylet is removed, and a perforated drainage tube is inserted into the pleural cavity to a depth of 10-15 cm, which is then hermetically sutured to the skin. chest wall.

In the absence of a trocar, thoracentesis is carried out as follows: cut the skin in the area of ​​the chest wall at a distance of 2-3 cm;

the skin with the wound opening is shifted by 2-2.5 cm so that the wound is above the anterior edge of the underlying rib (to prevent injury to the intercostal artery). After additional anesthesia of the intercostal space, a Billroth clamp with a drainage tube clamped in it is inserted into the pleural cavity with a sharp stabbing movement. The tube is inserted 10-15 cm into the pleural cavity, and the clamp is removed. The wound is sealed with sutures, the tube is sutured to the skin with two silk ligatures (Fig. 28). The contents of the pleural cavity are actively evacuated using a Janet syringe, and then transferred to drainage according to Bulau.

Fig.28. Performing thoracentesis using a Billroth forceps.

10.3. Toilet trachea and bronchi

The need to toilet the tracheobronchial tree arises in case of aspiration various liquids into the bronchi (especially gastric contents) and the development of aspiration syndrome, with severe pneumonia, lung abscess.

If aspiration syndrome develops, after sedating the animal, the trachea is intubated, and a polyvinyl chloride drainage with an end and one side hole is inserted through the endotracheal tube. An isotonic sodium chloride solution, antibiotics, and glucocorticoids are installed through the drainage, which thins the mucus and stimulates coughing; after this, the contents of the trachea are evacuated using an electric suction. The drainage is periodically washed with furatsilin to maintain its patency. Active aspiration is carried out until the flow of sputum, pus or other aggressive liquids stops. With this manipulation, it is possible to injure the tracheal mucosa (during rough manipulations) with the occurrence of bleeding and the development of laryngospasm.

In severe chronic processes in the lungs, it is necessary to moisturize the airways by introducing fluids orally (per os) or parenterally in combination with oxygen inhalation.

To stimulate coughing and lavage of the tracheobronchial tree, percutaneous puncture or microtracheotomy can be used. The trachea is punctured below the cricoid cartilage through the interannular ligament along the midline with the animal in the dorsal position. When a needle is inserted into the trachea, a “failure” is felt, after which air appears in the syringe when the piston is pulled. Antibiotics and mucolytics are injected into the trachea. After their administration, as a rule, a strong cough reflex occurs, therefore, after administering the drugs, the needle must be immediately removed from the trachea. Punctures are used if it is necessary to use this manipulation once or twice. If this is not enough, then a catheter is inserted into the trachea through a thick needle (after preliminary anesthesia) to a depth of 3-7 cm. The needle is removed and the catheter is sutured to the skin. The catheter is removed after the amount of sputum has decreased. Catheter care is carried out according to general rules. The administration of drugs is carried out depending on the severity of the pathological process and can reach 6-8 times a day.

10.4. Tracheal intubation

Tracheal intubation is used during endotracheal anesthesia or when artificial ventilation lungs.

Tracheal intubation in animals can be carried out without the help of a laryngoscope as follows: after sedating the animal according to the method described above, the mouth is opened wide with ribbons, the tongue is fixed and pulled out with a tongue holder, the root of the tongue is pressed with a long spatula or forceps at the base of the epiglottis, and the entrance to the trachea is opened. . An endotracheal tube of the appropriate diameter is inserted between the vocal cords into the trachea without effort, so as not to injure the mucous membranes of the larynx and trachea (Fig. 29).

Fig.29. View of the entrance to the trachea from the oral cavity during intubation. 1 - tongue; 2 - forceps, 3 - epiglottis: 4 - vocal cords; 5 - entrance to the trachea (glottis); 6 - tonsils; 7 - sky.

It is important to remember that the bend of the tube with the convex side should be directed towards upper jaw(Fig.30). The correct position of the tube is controlled visually (when air is pumped into the tube, the chest expands) and auscultation (breathing sounds are heard over the entire surface chest). If the endotracheal tube is not positioned correctly, abdominal distension in the epigastric region is visually determined, and gurgling conduction noises are heard on auscultation above the lungs and in the epigastric region. In this case, it is necessary to immediately remove the tube from the esophagus and repeat intubation more carefully. If the endotracheal tube is in the trachea, then it is necessary to inflate the cuff with a syringe, or, if the latter is absent, pack the larynx with a bandage moistened with an antiseptic solution (furacilin 1: 5000, chlorhexidine 1: 400). This measure will prevent air from escaping from the trachea and will allow effective ventilation. After tracheal intubation, the tube must be connected to a ventilator and inhalation of an oxygen-air or gas-narcotic mixture must begin.

Fig.30. Tracheal intubation diagram. 1 — endotracheal tube; 2 — inflatable cuff.

If non-inhalation anesthesia is performed while maintaining spontaneous breathing, it is necessary to humidify the air entering the lungs, for which a 2-3-layer gauze cloth moistened with water is placed on the outer opening of the inhalation tube.

10.5. Tracheostomy

One of the most effective ways ensuring cross-country ability respiratory tract in cases where long-term artificial ventilation (ALV) is necessary, if tracheal intubation is impossible as a result of tracheal injury or laryngeal edema (for example, with Quincke's edema), as well as in the presence of a foreign body. In addition, in some emergency situations accompanied by acute respiratory failure and severe hypoxia, the presence of an endotracheal tube in the trachea increases the length of the so-called “dead space” in which gas exchange products accumulate, which significantly worsens the situation (Fig. 31).

Fig.31. Dead space diagram

In these cases, tracheostomy is also indicated, which allows you to sharply reduce the path of oxygen to the lungs, as well as thoroughly sanitize the bronchial tree, removing blood, mucus, sputum, etc. from it.

Technically, tracheostomy is performed in compliance with all rules of asepsis and antiseptics. As a rule, the condition of the animal in cases where tracheostomy is necessary does not allow anesthesia, so this operation is performed using local anesthesia. With the animal in the supine position, a longitudinal midline incision above the trachea is used to cut through the skin and underlying tissue down to the trachea. Then, with a sharp scalpel, the trachea is pierced so as to simultaneously pierce, and not push away its mucous membrane, then, in one movement, the II and III rings of the trachea are cut, and a tracheostomy tube of the appropriate diameter is inserted into the resulting hole. It is best to use special double plastic tubes; in the absence of the latter, any tube of suitable diameter can be used. The wound is sutured and drained with a glove strip. The tube is fixed to the skin with separate stitching ligatures. The tube is additionally fixed with a gauze bandage, and to humidify the air, an isotonic sodium chloride solution is periodically injected into the trachea, or a moistened gauze cloth is tied to the outer end of the tracheostomy tube. It should be remembered that a tracheostomy requires careful care, like any surgical wound. It is advisable to remove a tracheostomy gradually, replacing a larger diameter tube with a smaller one.

10.6. Long-term bladder catheterization

Quite a responsible manipulation, the need for which arises in acute renal failure, pelvic fractures, polytrauma accompanied by rupture Bladder; during long-term surgical interventions, when control over the excretory function of the kidneys is necessary; for diseases accompanied by dysfunction of the pelvic organs; in severe conditions of animals associated with diseases of any etiology, in which animals may be in a comatose or close to this state for several days. Long-term catheterization of the bladder allows not only constant monitoring of the excretory function of the kidneys, but also facilitates hygiene care for the animal during this period. Catheterization of the bladder is carried out in compliance with the rules of asepsis (a sterile catheter is used, before insertion of which a thorough toilet of the external genitalia and urethral area must be performed). It is best to use soft Pezzer or Foley catheters for these purposes. In the absence of the latter, ordinary rubber catheters can be used. After inserting the catheter into the bladder, it is fixed with separate stitching ligatures, which in males are passed through the foreskin, and in females - through the labia. The catheter is washed twice a day with antiseptic solutions (furacilin 1: 5000, chlorhexidine 1: 400, etc.) in an amount corresponding to the volume of the bladder. During operations on the bladder, this volume should not exceed 1/4-1/5 of the volume of the filled bladder. In order to prevent cystitis, therapy is carried out, including 5-NOK, furagin, diuretic herbs. Catheterization can last 5-7 days, depending on the pathological process. If necessary, catheterization can be repeated 2-3 days after removal of the catheter.

10.7. Decompression, drainage and lavage of the stomach and intestines

The need for emergency decompression of the stomach arises when the latter is torsion, when it is impossible to insert a tube into the stomach. In this situation, only urgent gastric decompression can significantly reduce the manifestation of cardiopulmonary failure, slow down or even stop the development of painful shock, and ultimately save the animal. With this pathology, there is a sharp bloating of the abdomen with percussion tympanitis over its entire surface. The simplest manipulation in these cases is puncture decompression of the stomach. To carry it out, it is necessary to pierce the midline in the middle between the navel and the xiphoid process with a thick Dufault needle. abdominal wall and stomach, releasing the air. The disadvantage of this method is that if immediate surgical intervention is not possible, after some time the stomach is filled with gases again, which requires repeated puncture. At the same time, during surgery it is not always possible to detect the site of punctures in the stomach wall. A more reliable method of decompression for this disease is trocar decompression with the introduction of a tube into the gastric cavity through the lumen of the trocar. Thanks to this, it is possible to lavage the stomach, long-term decompression, perform infusion correction of homeostasis disorders before surgery, as well as accurately detect the puncture site of the stomach wall during surgery.

Drainage and gastric lavage are carried out before surgery (to prevent aspiration syndrome), in case of acute poisoning, when it is necessary to thoroughly wash the stomach from toxic agents, in postoperative period(especially during gastric operations), for the purpose of enteral nutrition. Before surgery and in case of poisoning, gastric lavage is carried out using the “siphon” method. To do this, a thick vaseline-smeared gastric tube, gradually pushing it forward at the moment of swallowing movements of the animal (Fig. 32). The approximate length of the probe is determined by the distance from the incisors to the navel, for which the probe is placed along the outer surface lower jaw, chest and abdomen; a mark is then placed on the tube to serve as a guide when inserting the tube into the stomach.

Fig.32. Inserting a probe into the animal's stomach.

Gastric lavage using the “siphon” type is carried out as follows: a glass funnel is attached to the outer end of the probe, which is raised up above the animal and filled with water. Then the funnel is lowered down, achieving evacuation of the stomach contents. At the same time, they try to ensure that the funnel is constantly filled with water and no air gets into the stomach. Carrying out pendulum-like movements up and down 4-5 times, they achieve good washing of the folds of the gastric mucosa. Then the rinsing waters are drained and the procedure is repeated from the beginning until they become clean.

For the purpose of intraoperative decompression of the stomach and prevention of aspiration syndrome, the probe after this manipulation is left until the end of the operation. If postoperative long-term drainage of the stomach is necessary (for decompression, lavage, enteral nutrition, etc.), during anesthesia, a thin tube of the appropriate diameter is passed through the nasal passage into the oral cavity, from where it is inserted with a forceps into the esophagus and passed into the stomach. This manipulation is not complicated and does not require any special skills. The end of the probe is fixed with a ligature to the nose.

Unfortunately, in some animals with an easily excitable psyche in the postoperative period, the probe can cause a sharply negative reaction with an attempt to remove it. In such situations, it is recommended to instill the nasal passage with Dicaine or other local anesthetics, as well as install anesthetics into the oral cavity. As a rule, after 24-48 hours the animals get used to the unpleasant sensations and do not attempt to remove the probe. This method of inserting a probe provides long-term decompression of the stomach and makes it possible to provide enteral nutrition to the animal for 5-7 days.

Intestinal intubation is carried out during surgery for diffuse fibrinous-purulent peritonitis, in acute intestinal obstruction, when there is a sharp bloating of the intestines and overstretching of its walls with gases and intestinal contents. The need for this manipulation increases when the surgeon is uncertain about the viability of the tissues of the intestinal wall, and the possibility of developing suture failure after enterotomy (when removing foreign bodies), or in the area of ​​the anastomosis (during intestinal resection). As our experience shows, it is most advisable to perform intestinal intubation using a closed type - transanal method. Intestinal intubation should be preceded by the introduction of a 0.25% solution of novocaine in an amount of 1-2 ml/kg into the root of the mesentery. After this, the assistant inserts a thick curved tube transanally into the rectum (a large-diameter endotracheal tube can be used for these purposes) and passes a perforated PVC tube through it into the colon. The surgeon grabs it through the wall of the colon and, using “stringing” movements with both hands, gradually moves the endotracheal tube through the intestinal lumen to the required location (50-60 cm beyond the enterotomy site). As a rule, this manipulation is carried out quite quickly and easily. The greatest difficulties arise when passing a tube from the large intestine to the small intestine, which is associated with anatomical structure transition of the small intestine to the large intestine.

The presence in this area of ​​the so-called “Bauginian valve”, which is a kind of protective barrier for the penetration of colonic contents with the corresponding microflora into the lumen of the small intestine, does not allow the probe to be immediately inserted into the lumen of the small intestine, however, with some skills this manipulation is carried out quite quickly. Further advancement of the probe is easy. The diagram of transanal intestinal intubation is shown in Fig. 33.

The presence of a probe in the small intestine makes it possible to decompress the intestine, avoid failure of the anastomotic sutures, prevent postoperative paresis,, if necessary, wash the intestines to reduce intoxication, and provide enteral nutrition. The outer end of the probe is sutured to the perianal fold, after which a plastic bag is put on it to collect intestinal fluid. content. In the postoperative period, the probe is washed with mineral water without gas 2-3 times during the day. Colon lavage is continued for two to three days until normal peristalsis is restored and normal intestinal contents appear from the tube. The probe is removed by carefully slowly pulling on its end.

Fig.33. Scheme of transanal intestinal intubation. 1 - small intestine (terminal department); 2 — intestinal intubation tube; 3 — line of anastomosis, 4 — “Bauginian valve”; 5 - cecum; 6 - large intestine; 7 - anus

10.8. Nasal tamponade

In anesthesiological practice, damage to the nasal passages is often encountered (injury to the mucous membrane during rough manipulations, head injury, various diseases), accompanied heavy bleeding.

If it is impossible to stop the bleeding with medications or anterior tamponade, they resort to posterior tamponade of the nasal passages. To do this, the animal is put under anesthesia, intubated (to avoid obstruction of the trachea with blood and clots), and a thin catheter, 3 times the length of the nasal passages, is passed through the nasal passages to the epiglottis. Here he is grabbed with a forceps and taken outside. A strip of gauze (tampon) of appropriate thickness, moistened with a 3% solution of hydrogen peroxide, is firmly fixed to the end of the catheter. Pulling up the second end of the catheter, a gauze swab is gradually introduced into the nasal passages, its other end is fixed from the outside. If necessary, posterior tamponade is supplemented with anterior tamponade. Usually 1-2 hours are enough to stop the bleeding, but if necessary, tampons can be left in the nasal passages for up to 24 hours.

(plerocentesis) - a procedure in which the pleura is punctured through the intercostal space for the purpose of diversion and aspiration of pathological contents (or), normalization respiratory function, as well as for diagnosing content.

Transudate effusions arise from decreased plasma and result from decreased plasma oncotic pressure and increased hydrostatic pressure. The most common causes are metastasis in the chest cavity, kidney and liver pathologies.

Exudate effusions are formed under the influence of local pathological or surgical processes, causing an increase in capillary patency and subsequent exudation of intravascular components. There are many reasons for this: neoplasms, pulmonary embolism, dry pleurisy, etc.

The nature and volume of pleural effusions and the amount of air are determined by a doctor using an x-ray of the chest cavity and directly during thoracentesis in a dog or cat.

Indications

The main indications for thoracentesis are the presence of air, large pleural effusions, or pleural effusions of any size in the pleural space that cause difficulty breathing.

Contraindications and complications

A contraindication to thoracentesis in animals is increased bleeding, but if there is a sufficiently large amount of blood in the pleural space, respiratory failure may occur. Then the doctor weighs the risks and decides whether this procedure is necessary now. If the case is not an emergency, then there is time to adjust blood clotting.

Owners must be warned about possible complications procedures – lung injury.

Technique

The technique for performing thoracentesis in dogs and cats is as follows. The procedure is most often carried out without sedation or local sedation, it is not painful and is well tolerated by animals. At the same time, oxygen is supplied. However, with aggressive or very restless patients, it is sometimes necessary to resort to sedatives.

Thoracentesis requires sterile needles of 18–22 diameters, 20 ml syringes, an infusion system, a three-way tap or hemostatic clamp, and a vessel for collecting fluid.

Thoracentesis is usually performed in the 7th–8th intercostal space with right side(this is the safest area for needle insertion) or in the area of ​​maximum fluid accumulation. The position of the animal depends on the type of pathology. Thus, if there is air in the chest cavity, the animal is placed on its side and the puncture is made dorsally, and in the presence of fluid - in a standing, sitting or chest position, and the puncture is made ventrally. The injection site is carefully trimmed and treated with an antiseptic solution.

The puncture is carried out along the cranial edge of the rib, since there are intercostal vessels and nerves on the caudal edge.

The needle is inserted into the pleural space with a cut towards the lungs and parallel to the chest wall to avoid injury to the lung tissue. Aspiration of the contents is carried out while it is possible to remove fluid through the system, and is carried out with slight negative pressure to prevent the lung tissue from being sucked into the needle. It is usually not possible to completely remove content.

Thoracentesis is performed 1–3 times; if fluid collects again, it is recommended to apply

One of the problems in veterinary medicine in cats and dogs is diseases of the chest cavity, in which free fluid accumulates, resulting in respiratory failure and hemodynamic disturbances.

One of these diseases is chylothorax– pathological accumulation of lymph in the chest cavity.

Chylothorax has clinical, radiological and pathomorphological features of the manifestation of pathology similar to other types of diseases in which effusion occurs in the pleural cavity, a displacement of the mediastinum is created and an obstacle to the normal expansion of the lungs.

Among exudative pleurisy in cats and dogs, chylothorax ranges from 0.7 to 3%, and neoplastic and viral manifestations range from 12 to 64%.

There are several etiological and pathogenetic factors leading to the development of the disease.

Trauma is a rare cause chylothorax in cats and dogs, the thoracic duct is quickly restored, and effusions resolve without treatment within 10-15 days.

Chylothorax may occur due to diffuse lymphatic abnormalities, including intestinal lymphangiectasia or generalized lymphangiectasia with subcutaneous lymphatic leakage.

Dilatation of lymphatic vessels (thoracic lymphangiectasia) with exudation of lymph into the chest cavity may be a reaction to increased lymph formation in the liver or lymphatic pressure due to increased venous pressure.

Sometimes a combination of two factors is noted: an increase in lymph volume and a decrease in drainage into the venous collectors.

Possible causes of chylothorax are neoplasms in the cranial part of the mediastinum (lymphosarcoma, thymoma), fungal granulomas, venous thrombosis and congenital anomalies of the thoracic lymphatic duct.

In most animals, despite careful examination, the underlying cause of chylothorax remains unclear (idiopathic chylothorax).

Diagnosis and choice of treatment methods for sick animals with chylothorax remains a pressing and difficult task to this day.

In the domestic literature there is very little material devoted to the clinic, diagnosis (morphology), conservative and surgical treatment of chylothorax in dogs and cats.

Late diagnosis of the disease, and existing tactics exclusively conservative approach to treatment of chylothorax with pronounced clinical manifestations, it leads to prolongation of the pathological process, the result of which will be the development of irreversible changes in the pleura of the lung (fibrosing pleurisy).

Standard methods of conservative (thoracentesis, anti-inflammatory therapy) and surgical (thoracoabdominal, thoracovenous drainage, pleurodesis, thoracic duct ligation) are currently promising methods for treating this pathology, but success (relapse-free course) is 40–60%.

The purpose of the work is the evaluation of the result surgical methods treatment of chylothorax using various methods.

Materials and methods. The material consisted of 60 animals (cats) diagnosed with chylothorax, and which were subjected to surgical treatment in the period from 2002 to 2010. Surgical treatment included: ligation of the thoracic lymphatic duct n-13, pleuroperitoneal shunting n-9, ligation + pleurodesis n-25.

In 13 animals, diagnostic thoracoscopy revealed fibrosing pleurisy and surgical treatment was refused.

All animals were subjected to clinical and additional diagnostic methods.

The clinical method of the study involved the collection of anamnestic data on the timing and duration of manifestations of breathing disorders.

Particular attention was paid to visual assessment external manifestation violations breathing movements chest, degree and type of shortness of breath.

Clinical manifestations of the disease at almost all stages were characterized by: difficulty breathing and shortness of breath - the main symptom of effusion into the pleural cavity. Dry non-productive cough.

As additional research methods, we used thoracentesis, radiography, morphological examination of the material obtained from the chest cavity, clinical and biochemical tests blood, ECG, ECHO KG, thoracoscopy.

X-ray examination of animals

X-ray examination of the chest cavity was performed using two mutually perpendicular projections, lateral and direct (dorso-ventral).

Typically, the X-ray picture was characterized by total darkening with characteristic features the presence of fluid in the chest cavity and caudo-dorsal displacement of the caudal lobes of the lungs. The shadow of the heart silhouette is partially or completely erased, the usual sharp angles of the costophrenic junction are absent (Fig. 1a, b).

Thoracentesis and differential morphological examination

Thoracentesis (pleural puncture) was performed for diagnostic and therapeutic purposes.

Pleural puncture was performed in the 7-8th intercostal space along the line of the osteochondral junction on the left and right, focusing on the cranial edge of the next rib.

After pleural puncture, the pathological contents of the pleural cavity were evacuated and subjected to subsequent examination.

In case of chylothorax, milk transudate was determined white or mixed with a small amount of blood. During centrifugation, the exudate generally did not form a sediment (the sediment is represented by blood elements); a biochemical study indicated a large amount of triglycerides characteristic of chylothorax.

Separately differentiated from pseudochylous effusions (rarely found in animals) by the content of cholesterol and triglycerides.

All punctures from the pleural cavity were subjected to microscopic cytological examination, where purulent and neoplastic processes were excluded.

Thoracoscopy was performed under conditions general anesthesia for detailed visualization of the condition of the lungs and neoplasms in the cranial mediastinum (Fig. 2).
Surgery

Surgical treatment of chylothorax involved surgical intervention under conditions of general anesthesia and artificial ventilation, both open and endoscopic (thoracoscopy).

Pleuroperitoneal (passive) shunting Operation stages:

3. Using a linear approach from the middle of the chest in the caudal direction to the umbilical region, the skin, subcutaneous tissue, and muscles were dissected. An entrance to the thoracic region was provided through the angle of the diaphragm in the area of ​​the xiphoid process. The perihepatic space was freed from adipose tissue and omentum. Silicone drainage was implanted to the communication between the chest and abdominal cavities, followed by fixation of the drainage in the tissues of the diaphragm. The surgical wound was sutured in layers (Fig. 3 a, b).

The purpose of this technique is to create a message and the possibility of outflow of chylous exudate into the abdominal cavity, where it is subsequently absorbed and lymph is recirculated in the body.

Pleurodesis

Operation stages:

1. Fixing the animal on its back.

2. Processing surgical field according to generally accepted methods.

3. A mini-access in the area of ​​the xiphoid process is used to access the chest cavity; depending on the stage of the pathological process, partial pleurectomy or targeted treatment with chemicals is carried out under endoscopic control.

The purpose of this surgical intervention is to create adhesive inflammation of the lungs in an expanded state.

Open ligation of the thoracic lymphatic duct

Operation stages:

1. Fixation of the animal in a lateral position.

2. Treatment of the surgical field using generally accepted methods.

3. Access was made to the chest cavity on the left or right in the area of ​​the 8-10 intercostal space with layer-by-layer dissection of tissue (skin, subcutaneous tissue, muscles). After access to the chest cavity, surgical access to the abdominal cavity was carried out nearby, a part of the mesentery and intestine was isolated for the purpose of lymphography using a visceral lymphatic collector.

4. Lymphography was performed with a 1% solution of methylene blue with a volume of no more than 0.5 ml injected into the lymphatic vessel. The contrast agent entered the lumbar cistern and stained the thoracic lymphatic duct (Fig. 4a, b).

Under visual control, a non-absorbable ligature was applied to the visible thoracic lymphatic duct through access to the chest cavity. suture material Prolene 4-0, 5-0. The surgical wound was sutured in layers.

The purpose of this technique was to stop the flow of lymph through the thoracic lymphatic duct into the chest cavity.

Closed ligation of the thoracic lymphatic duct

Unlike open ligation, closed method involves ligation of the thoracic lymphatic duct endoscopic method(thoracoscopy) without wide access to the chest cavity (Fig. 5a, b, c).

Thoracic duct ligation and pleurodesis

This type of surgical intervention involves the use of two methods described above simultaneously - ligation and pleurodesis.

The purpose of this technique is to combine two methods: stopping the flow of lymph through the thoracic lymphatic duct into the chest cavity and creating an adhesive inflammation of the lung and parietal pleura. After which the lung assumes a straightened position in the chest cavity, and in cases of recurrent chylothorax, the possibility of its collapse is reduced. The risk of respiratory failure is sharply reduced.

We used open and endoscopic ligation of the thoracic lymphatic duct.

Postoperative treatment included monitoring the possible consequences of thoracic surgery. Conducting a course of antibiotic and anti-inflammatory therapy. The course of antibiotic therapy was five days, the sutures were removed on the tenth day, after endoscopic manipulation on the third.

Result and discussion

In assessing the results of treatment, great importance was given to data from subsequent clinical observation of operated animals over a period of ten days to one and a half years. (see table).

Results and methods of surgical treatment. Table

The criteria were not only the clinical condition, but also radiographic methods (Fig. 6a, b.).

The prognosis for chylothorax, according to many authors, is extremely restrained. When choosing treatment methods, they study the cause of the disease and begin treatment with methods conservative therapy, Without positive results move on to surgery. We have not achieved long-term positive drug treatment in any animal.

In our opinion, the beginning of surgical treatment is rather arbitrary, and the timing of the development of fibrosing pleurisy is unpredictable. In some cases, we noted the development of fibrosing pleurisy two to three weeks after the onset of clinical signs and did not see them after five months of the disease (video, Fig. 7).

According to our observations, the isolated method of ligation of the thoracic lymphatic duct recurred in six cases; in two animals, repeated surgical intervention was performed to the extent of ligation and pleurodesis (Fig. 8a, b).

The surgical method of bypassing the chest and abdominal cavity was usually complicated by catheter occlusion after surgery. Another disadvantage is the reverse flow of contents when using valveless catheters.

The most effective method was a combination of ligation and pleurodesis. The rehabilitation period was slightly reduced in animals that underwent endoscopic ligation using thoracoscopic techniques when applying a ligature to the thoracic lymphatic duct.

conclusions. According to our observations, true chylothorax in cats does not respond to conservative therapy. The presented results of surgical methods for treating chylothorax in cats allow us to draw conclusions about the need for surgical treatment. The use of combined surgical methods makes it possible to achieve complete or long-term remission of the disease.

Literature.

1. Vorontsov A.A., Shchurov I.V., Larina I.M. Some features and results of operations on the thoracic organs in cats and dogs. Vet clinic. 2005 №11(42), 15-17.

2. Birchard S.J., Fossum T.W. Chylothorax in the dog and cat. Vet clin NorthAm Small Anim Pract. 1987 17, 271-283

3. Birchard S.J., Ware W.A. Chylothorax associated with congestive cardiomyopathy in cat. JAT Vet MedAssoc. 1986 189, 1462 - 1464.

4. Birchard S.J., Smeak D.D., McLoughlin M.A. Treatment of idiopathic chylothorax in dogs and cats. J AT Vet Med I 1998 212, 652-657.

5. Breznock EM: Management of chylothorax: Aggressive medical and surgical approach. Vet Med Report 1:380.

6. Forrester S.D., Fossum T.W., Rogers K.S. Diagnosis and treatment of chylothorax associated with lymphoblastic lymphosarcoma in four cats. J AT Vet MedAssoc. 1991 198, 291-294.

7. Sturgess K. Diagnosis and management of chylothorax in dogs and cats. in Pract. 2001 23, 506-513.

8. Thompson M.S., Cohn L.A., Jordan R.C. Use of routine for medical management of idiopathic

Drainage of the pleural cavity (thoracentesis) is the process of inserting a special drainage tube through a small surgical incision. It is prescribed to remove excess fluid and air from the pleural cavity.

Indications for pleural drainage

The main indication for drainage is damage thoracic, due to which pus, blood or exudate begins to accumulate in the pleural cavity. Most often this occurs after surgery. In this case, the drainage tube is kept in the sternum until the fluid disappears completely.

Insertion of a drainage tube may also be required if the following factors are present:

• accumulation of air between the petals of the pleura;
• empyema (accumulation of pus);
• pleural effusions of a malignant nature;
• benign pleural effusions (copious or repeated);
• pneumothorax and hydrothorax.

Puncture collection technique

To collect a puncture, the doctor sits the patient on a dressing table. The patient places his feet on a special stand and rests his torso on a chair. The hand on the manipulation side is thrown onto the opposite forearm.

Throughout the entire procedure, the doctor wears sterile gloves and a mask. First of all, it anesthetizes the puncture site, as with normal operation. The patient is first tested for an anesthetic drug to rule out an allergic reaction. It is important to note that not only the skin is anesthetized, but also the subcutaneous tissue and intercostal muscles.

Next, it is produced using a syringe. It is performed on an area that is located just above the upper edge of the rib. The needle is inserted very carefully until it completely passes through the intercostal tissue. When the specialist stops feeling resistance from the needle under pressure, it means it has reached the intended location.

The position of the puncture must be observed exactly, otherwise there is a risk of damage to the artery. After this, the doctor slowly withdraws the plunger of the syringe to check for the presence of fluid in the cavity.

The next step is to check the pleural cavity for the presence of air. The puncture procedure is repeated using a sterile needle. A special device for determining pressure - a pressure gauge - is attached to the nozzle. If the scale shows values ​​lower atmospheric pressure, which means there are no deviations from the norm. Otherwise, the patient is prepared for drainage.

If there is liquid in the syringe during puncture, then drainage is performed. At the injection site, the doctor makes a small incision with a scalpel, the width of which does not exceed 1 cm. Then, with rotational movements, the specialist inserts the trocar, after which he removes its stylet and inserts a drainage tube into the sleeve. To prevent air from entering, back side it is experienced with a special clamp.

The cut end of the tube is launched through a tube, just above which there are two asymmetrical side holes. This must be done very carefully to prevent the upper puncture from entering the pleural cavity.

All of the above manipulations are carried out very quickly to prevent air from entering the pleural chamber. Instruments must be sterilized and prepared in advance; during thoracentesis, all of them are at hand by a specialist. When the drainage tube is inserted to the required depth, the surrounding tissue is sealed with a special suture, which ensures the tightness of the insertion area.

With very careful movements, the specialist removes the tube, while holding the tube so that it does not lose its position. The liquid that appears in the catheter indicates the correctness of this procedure.

Connecting the suction unit

Further actions are aimed at connecting the aspiration unit, which is used as:

• Subbotin-Perthes system;
• electric suction with water supply.

The adhesive ensures the tightness of all elements. Carrying out drainage using this method helps reduce pressure in the pleural cavity. After the effect of the anesthetic drug wears off, the anesthetic is reintroduced.

To remove the drainage, you need to loosen the seams a little. The patient holds his breath during this manipulation. The affected area is tightened with a loose suture, after which a special bandage is fixed to it.

Pleural drainage for pneumothorax

Pneumothorax occurs as a result of rupture of the alveoli, which occurs in the upper lobes of the lungs. Most often, this condition occurs among the young population. Develops as a result of trauma to the thoracic region.

Emphysema of the pleural cavity or oxygen deprivation is extremely alarming symptoms, at their first manifestations, drainage is performed. It is important to note that manifestations of emphysema and accumulation of exudate are key indications for pleural drainage. Drainage allows you to maintain low pressure and pump out exudate from the pleural cavity after surgery. If the lungs are not affected, one drainage tube is inserted, otherwise two.

Procedure

Drainage begins with the preparation of two drainage tubes with holes, which have special cuts at the end. The doctor sits the patient down, tilts his body slightly forward, and fixes the position with a chair or any other object. The puncture is taken from the 4th intercostal space. Its consistency determines the type of catheter that will be used during manipulation:

• in the presence of air, use small tubes;
• mucus is removed with a middle catheter;
• Large tubes are used to draw out blood clots and pus.

If the daily withdrawal does not exceed 100 ml, the outer end of the tube is lowered into a container with water. The patient then takes a deep breath and exhales slowly, while the specialist pulls out the tube. Gauze soaked in oil is applied to the insertion site.

The use of active drainage promotes more efficient removal of pathological contents. Its action is based on reducing the pressure at the end of the outlet system. Complete release of exudate is ensured by forced pumping. 1 or 2 catheters (made of polyvinyl chloride or silicone) with stenotic openings are inserted into the pleural cavity. In this case, there must be complete sealing at the junction with the fabrics. The other end of the tube is connected to a closed chamber where pressure is released. The functions of the camera can be performed by both manual and automated devices, for example, a water jet.

What drainage methods are there?

Experts from different countries have been improving pleural drainage for a long time, developing new methods for its implementation. Modern approaches not only simplified the task of doctors, but also significantly reduced the time of the manipulation itself:

• Closed vacuum method.
• Subbotin's method.
• Active aspiration.

Boiled water is taken into a medical container and tightly closed with a rubber lid. The process of cooling the liquid is accompanied by vacuum. When connected to an excretion catheter, up to 180 ml of exudate can be withdrawn.

Closed vacuum method

The idea is to pump out air from a sealed container using a Janet syringe, after which a tube is connected to it. An important condition this method is the complete tightness of the vessel.

Subbotin method

For this method, you will need 2 sealed containers, which will be fixed one above the other using a tube. From the top, water will flow to the bottom, thus increasing the free space. The resulting vacuum causes air to be drawn into the upper container, which helps normalize the pressure. At the time of pumping air into lower vessel the pressure temporarily decreases. The drainage tube is passed to one of the containers, due to which its stimulation is ensured until the end of the water transfusion.

Active aspiration

This is the most effective method, which, in addition to pumping out exudate, promotes faster healing technological wound. Active aspiration involves connecting a glass tube to a flexible pipe. The latter leads to the water jet pump. Pumping is carried out by a pump, while a pressure gauge controls the pressure. The vacuum is determined by the water jet.

What monitoring is needed for patients with a chest tube?

In patients with a chest tube or continuous drainage system, it is important to monitor for air bubbles in the water sealed container. Their absence indicates that the air has been completely removed, and the area of ​​the expanded lung blocks the holes of the thoracic catheter.

If, during the patient’s inhalation, periodic appearance of bubbles is observed, this indicates the correct operation of the drainage system and the presence of pneumothorax, which still persists. The gurgling of air, which is noted during inhalation and exhalation, indicates that air has entered the system. This can be checked:

When draining the pleural cavity, it is worth monitoring the air gurgling

• squeezing the outlet tube - if air then stops flowing, most likely a leak occurs in it;
• the clamp must be moved along the tube in the direction of drainage, constantly monitoring for the presence of bubbles;
• the area where air flow stops indicates a catheter defect. In this case, it is immediately replaced;
• if air continues to flow even after clamping the tube, there is a defect in the drainage system that needs to be replaced.

During drainage, it is important to constantly monitor the patient. If subcutaneous emphysema develops, it is necessary to change the catheter insertion site.

What complications can there be after drainage?

Difficulties may arise when the pleura thickens during insertion of the tube. Sometimes specialists observe an accumulation of blood in the pleural cavity. If the latter contains jelly-like inclusions, this is fraught with kinking or blockage of the tube. Bleeding wounds after drainage can also be dangerous.

Some patients note painful sensations upon completion of drainage. In medicine, cases of infection have been described when sterility and the rules for pleural drainage are not observed. Particular care must be taken if the patient has poor blood clotting. Important complications that may occur after drainage are:

• subcutaneous emphysema;
• incorrect tube installation;
• incision hemorrhage;
• pain;
• third party infection.

Swelling of the expanded lung may occur as a result of fluid entering it from the capillaries. It is worth noting that the drainage procedure is serious and requires maximum skill and attention from medical personnel. To carry it out, you need a special set of sterile instruments.

The pressure in the pleural cavity is lower than atmospheric pressure, so specialists check the presence of air in it using a pressure gauge. Before pumping out the fluid, if the case requires it, a puncture must be performed. Pleural drainage should only be performed by a qualified specialist, otherwise serious consequences may occur.

4356 0

A gentle technique for draining pathological cavities in the lungs by introducing drainage through a trocar has been used for a long time. Subsequently, this method was used mainly to treat patients with pulmonary tuberculosis, and then acute suppuration of the lungs, mainly abscesses. In the treatment of pulmonary gangrene, drainage through thoracentesis was rarely used. Thus, Gross (cited by A. Brunner, 1942) successfully treated 3 patients with pulmonary gangrene in this way, 3 of whom recovered, and in 1 a residual pulmonary cavity was formed. A. Brunner (1942) used drainage by thoracentesis in 2 patients with pulmonary gangrene to prepare for subsequent pneumotomy.

In the USSR, the method of drainage through thoracentesis in patients with abscesses and gangrene of the lungs was first used in hospital at the suggestion of I. S. Kolesnikov surgical clinic VMA named after. S. M. Kirov in 1968. Preliminary results of this treatment were presented in 1969 by L. S. Lesnitsky, and then summarized by him in his Ph.D. thesis (1970). Subsequently, numerous reports appeared on the use of this method in patients with pulmonary abscesses and only a few reports on the treatment of patients with pulmonary gangrene with thoracentesis and drainage. Thus, V. Vainrub et al. (1978), having achieved recovery in all 3 patients they observed with a limited form of pulmonary gangrene, propose drainage by thoracentesis in these cases as an alternative to lobectomy.

E. Cameron, J. Whitton (1977) used drainage through thoracentesis instead of lobectomy in 7 patients with limited and widespread forms of pulmonary gangrene caused by Friedlander's bacillus. A thick rubber drain was inserted into the decay cavity in the lung through the bed of the previously removed rib fragment. All patients recovered. P. M. Kuzyukovich (1978), who proposes drainage through thoracentesis as an independent method in such cases, also objects to lung resections in patients with a limited form of pulmonary gangrene. Of the 33 patients he observed, 14 recovered, in 6 the process progressed to chronic form. 13 patients died.

The results obtained cannot be considered satisfactory, especially since the transition of the process to a chronic form cannot be called success either. The advisability of using thoracentesis and drainage of lung cavities in patients with gangrene in order to prepare for resection was indicated by E. A. Wagner et al. (1980).

In the group of patients we observed, treatment of 23 patients with pulmonary gangrene began with drainage through thoracentesis. In 16 of them it was ineffective, and these patients subsequently underwent lung resection or pneumotomy. In 7 cases, drainage through thoracentesis was the only treatment method (Table 1).

Table 1

Drainage of lung cavities through thoracentesis in patients with pulmonary gangrene

The essence of the method is to insert a drainage tube into the destructive cavity through a trocar after preliminary puncture of the abscess and thoracentesis of the chest wall. The technique for draining pulmonary abscesses through thoracentesis was developed in our clinic by L. S. Lesnitsky. It is described in detail in the monograph by I. S. Kolesnikov and V. S. Vikhrnev “Lung Abscesses” (1973).

To ensure a constant flow of pus through the drainage, the latter can be left open under a thick cotton-gauze bandage that absorbs pus, or connected to another drainage tube lowered under water according to Bulau-Petrov. You can also use vacuum drainage with a slight vacuum not exceeding 1.96-2.94 kPa (20-30 cm of water column). It must be emphasized that the large vacuum created in the destructive cavity can provoke arrosive bleeding.

The most important element of drainage of purulent cavities by thoracentesis is their systematic sanitation through a drainage tube antiseptic solutions. After administering the first portion of the solution, the patient’s reaction can be used to judge the condition of the bronchi draining the abscess. If the bronchi are patent, a cough immediately appears and the patient coughs up purulent sputum and the injected solution. If the cough does not appear, then the bronchi are obstructed. In this case, the syringe is disconnected from the drainage, the patient is asked to cough, after which the injected solution along with pus flows out through the drainage. About 200 ml of solution is used in fractional portions during one wash. Rinsing the cavity should continue until the last portions of the solution flowing through the drainage become transparent and do not contain pus. The patient's condition should be monitored and if he becomes tired or dizzy, he should stop rinsing the cavity.

The effectiveness of the treatment can be judged both by changes in the patient’s well-being and condition, and by data from laboratory and radiological studies. Often in the first days after surgery, the amount of sputum released when coughing increases, which indicates restoration of the patency of the draining bronchi. If within 5-7 days the amount of purulent discharge through the drainage decreases and its character changes, the amount and character of the sputum decreases (often initially smelly and thick, it gradually becomes more liquid, mucopurulent, and then odorless mucous), the temperature decreases body and the general condition of the patient improves, then drainage by thoracentesis can be considered effective and it is advisable to continue it.

No improvement general condition, persistent fever, copious department purulent sputum, ongoing pathological changes in leukocytes, and a radiologically determined level of fluid in the cavity where the drainage is located determine the need for more extensive drainage - pneumotomy or resection. It is dangerous to persist in treating patients with pulmonary gangrene by drainage using thoracentesis, since the process in the lung may begin to progress and the most favorable moment for performing the operation will be missed.

If the course of the process is favorable, the drainage can be removed as soon as the body temperature and the composition of leukocytes normalize, the separation of purulent sputum and pus through the drainage stops, and x-ray examination the disappearance of inflammatory infiltration in the circumference of the cavity will be established, its size will decrease and there will be no horizontal level of liquid in it, as can be seen in the above observation.

Patient Z., 61 years old, was admitted to the clinic on August 13, 1968 with complaints of weakness, pain in the right half of the chest, cough with purulent sputum up to 150 ml per day. She became acutely ill 1 month ago after hypothermia. After 1 week, she was hospitalized with a diagnosis of influenza. therapeutic department, where right-sided upper lobe lobar pneumonia was initially diagnosed. The patient was treated with morphocycline, but the condition did not improve, a foul odor appeared when breathing, and then purulent-putrefactive sputum.

Upon admission to the clinic, the condition was serious. High fever (up to 38.5 C). Severe pallor of the skin and exhaustion of the patient were noted. Pulse 120 per minute, rhythmic, satisfactory filling. Blood pressure 18/12 kPa (135/90 mm Hg). A shortening of the percussion sound was noted over the right lung, and during auscultation, weakened breathing with an amphoric tinge and numerous moist rales were heard. Blood test: Hb 90 g/l, er. 3.1.10 to 12 degrees/l, l. 8.4 10 to the 9th power/l, p. 19%, p. 58%, lymph. 15%, e. 1%, mine. 7%. Total protein 50 g/l. A/G 0.4.

X-ray 08/14/68 - a huge destructive cavity with a wide level of fluid, occupying almost the entire upper lobe right lung. On August 15, 1968, the cavity was drained by thoracentesis from the subclavian fossa (Fig. 1), during which about 300 ml of thick pus was simultaneously removed. After washing the cavity in the lung through the drainage during the 1st night, the patient coughed up another 300 ml of thick pus mixed with blood. The bandages and bedding were soaked with pus. During sanitation, small sequestration of lung tissue emerged through the drainage over several days. During the first 5 days after drainage, the daily amount of sputum decreased and amounted to 200, 150, 100, 50 and 30 ml, respectively. On the 6th day, the patient’s condition improved: she had an appetite and “it became easier to breathe.” Body temperature returned to normal after a week. The radiograph after 9 days (Fig. 2) shows a decrease in the cavity’s size, the absence of fluid in it, and the drainage is located at the base of the cavity. The drainage was removed after 2 weeks. The patient was discharged with a dry residual cavity. For 1½ years she felt well, the dry residual lung cavity was preserved.

Rice. 1. Gangrene of the upper lobe of the right lung in the stage of a giant abscess, the cavity of which was drained by thoracentesis

Rice. 2. A large dry cavity in the upper lobe of the right lung, remaining after evacuation of pus and necrotic areas of the lung through a drainage tube.

There were few complications after drainage by thoraconcentesis in the analyzed group of patients. Mild subcutaneous emphysema in the area of ​​the drainage tube was observed in all patients. In only one case, drainage was complicated by phlegmon of the soft tissues of the chest wall.

As can be seen from table. 1, drainage of the lung cavity through thoracentesis in 16 patients was not effective enough; they were subjected to repeated operations. In only 2 patients, after sanitation, the condition improved, in 4, the effect of drainage was questionable, and in 10, drainage by thoracentesis had no effect. The reasons for this were the progression of lung gangrene, the presence of multiple cavities of destruction and large sequestration of lung tissue.

Drainage through thoracentesis was the only method of treatment in 2 patients with widespread and in 5 patients with limited forms of pulmonary gangrene. 6 people were discharged from the clinic. In 5 patients, huge lung cavities with fluid levels formed after purulent-putrefactive decay of necrotic areas of lung tissue (lung gangrene in the stage of a giant abscess) were drained. Sanitation of cavities through drainage was effective, and patients were discharged with dry residual lung cavities. One patient died with bilateral pulmonary gangrene, which developed against the background of agranulocytosis and bronchial asthma. Her condition was extremely serious, and she could not have endured any other surgical intervention.

Analysis of the results of treatment of pulmonary gangrene by drainage by thoracentesis led to the conclusion that as an independent method it can be used only in patients with large destructive cavities containing pus or small sequestra that have not yet been rejected. In the latter cases, it seems advisable to administer proteolytic enzymes through the drainage to accelerate the lysis of dead areas of lung tissue.

Drainage by thoracentesis can also be used for the purposes of detoxification and accelerating the emptying of pus through the bronchi in those patients where resection and even pneumotomy pose a great risk to the patient’s life. The use of drainage of lung cavities through thoracentesis to prepare for resection is unjustified due to the risk of complications and the formation of a thoracic fistula, the elimination of which usually requires a small, but undesirable surgical intervention in conditions of acute purulent infection.

Kolesnikov I.S., Lytkin M.I., Lesnitsky L.S.

Lung gangrene and pyopneumothorax