Pathogens can enter a wound in two ways: exogenous and endogenous.
Exogenous route (infection from the external environment):
-- air infection(out of thin air)
- contact infection(objects in contact with the wound - 0.2 seconds is enough to transmit infection!).
- droplet infection(with saliva, when coughing, etc.)
- implantation(transmitted with objects left in the tissues: suture material, endoprosthesis, tampon, drainage, etc.).
Endogenous pathway when the infection is in the body (pustular skin lesions, carious teeth, purulent otitis media, inflammation of the tonsils, purulent inflammatory diseases of the lungs, etc.).
In this case, the route of spread of infection in the body can be:
Hematogenous (through blood vessels),
Lymphogenic (via lymphatic vessels).
In surgery, a system of measures has been developed to reduce the risk of microbes entering the wound and the body as a whole. This is achieved by aseptic and antiseptic methods, which are the basis of modern prevention of nosocomial surgical infections.
All provisions for the fight against surgical infection are regulated (defined) in order No. 720 M3 of the USSR dated July 31, 1978, which is called “On improving medical care for patients with purulent surgical diseases and strengthening measures to combat intrahospital
infection."
"Antiseptic"
This is a set of measures aimed at destroying or reducing the number of microbes in the wound and in the body as a whole.
The founder of antiseptics is the English scientist J. Lister. J. Lister used carbolic acid as the first antiseptic.
The following antiseptic methods are currently used: mechanical, physical, chemical, biological and mixed.
Mechanical method- provides for the removal of microbes purely mechanically through the following measures:
Toilet the wound during all dressings and provision of primary care;
Primary surgical treatment of a wound (PSW) - excision of the edges, bottom of the wound, removal of foreign bodies, blood clots, etc.
Opening and puncture of ulcers;
Excision of dead tissue (necrectomy).
Physical method: This is the creation in the wound of unfavorable conditions for the life of microbes and the maximum reduction in the absorption of decay products and toxins from the wound. For this we use:
■ hygroscopic dressing material(gauze, cotton wool, cotton-gauze swabs, i.e. wound tamponade):
hypertonic sodium chloride solution - 10%- the high osmotic pressure of this solution promotes the flow of tissue fluids from the wound into the bandage;
■ wound drainage -differentiate between passive drainage- ordinary graduates use a thin strip of rubber glove or polyvinyl chloride tubes (often perforated:;
active (vacuum) drainage (plastic accordions, balloons or electric suction);
flow - rinsing drainage (continuous washing of the wound with antiseptic solutions - rivanol, furatsilin, antibiotics, etc.
- drying warm air wounds are an open method of treating burns and wounds;
Ultrasound;
Ural irradiation - accelerates wound regeneration: used for blood irradiation (Isolde apparatus);
Chemical method- this is the use of various antiseptics that either kill bacteria in the wound or slow down their reproduction, creating favorable conditions for the body to fight infection. These chemicals are also widely used for asepsis: treatment of hands, the surgical field, sterilization of instruments and various items needed during surgery; in addition, washing floors, walls, etc.
Biological method: involves the destruction of microorganisms using biological substances.
Three groups of biological substances are widely used in surgery. The first group of biological substances (BV) increases the protective (immunological) forces of the body: donor blood, blood components (erythrocyte, platelet, leukocyte mass, plasma) and its preparations (albumin, protein, fibrinogen, hemostatic sponge, etc.) Serums for passive immunization :
Antitetanus serum (ATS);
Anti-tetanus human immunoglobulin (ATHI);
Antigangrenous serum for the treatment and prevention of gas gangrene;
Antistaphylococcal gamma globulin and antistaphylococcal hyperimmune plasma (native plasma of donors immunized with staphylococcal toxoid) are used for surgical infections (especially for sepsis and its threat);
Antipseudomonal hyperimmune plasma Toxoids for active immunization:
Tetanus toxoid (TA) - for the prevention and treatment of tetanus; staphylococcal toxoid for surgical infection caused by staphylococcus.
The second group of biological substances:
- Enzymes with proteolytic (melting proteins) action :
A) trypsin, chymotrypsin, chymopsin (of animal origin - from the pancreas of cattle);
b) streptokinase, asperase and others - preparations of bacterial origin:
V) papain, bromelain - herbal preparations.
Enzymes lyse (melt) nonviable proteins
(necrotic) tissues. This helps to cleanse purulent wounds and trophic ulcers without resorting to necrectomy, which naturally accelerates wound healing.
– this is a complex of general and local pathological manifestations that occur during the development of infection in accidental or surgical wounds. The pathology is manifested by pain, chills, fever, enlarged regional lymph nodes and leukocytosis. The edges of the wound are swollen and hyperemic. There is a discharge of serous or purulent discharge; in some cases, areas of necrosis are formed. The diagnosis is made based on history, clinical signs and test results. Treatment is complex: autopsy, dressings, antibiotic therapy.
ICD-10
T79.3 Post-traumatic wound infection, not elsewhere classified
General information
Wound infection is a complication of the wound process caused by the development of pathogenic microflora in the wound cavity. All wounds, including operating wounds, both in purulent surgery and in traumatology, are considered primarily contaminated, since a certain amount of microbes enters the wound surface from the air, even with impeccable observance of the rules of asepsis and antisepsis. Accidental wounds are more contaminated, so in such cases the source of infection is usually primary microbial contamination. With surgical wounds, endogenous (from the internal environment of the body) or in-hospital (secondary) infection comes to the fore.
Causes
In most cases, the causative agent of infection in random wounds is staphylococcus. Rarely, Proteus, Escherichia coli and Pseudomonas aeruginosa act as the main pathogen. Anaerobic infection occurs in 0.1% of cases. After a few days in the hospital, the flora changes; gram-negative bacteria, resistant to antibacterial therapy, begin to predominate in the wound, which usually cause the development of wound infection during secondary infection of both accidental and surgical wounds.
A wound infection develops when the number of microbes in the wound exceeds a certain critical level. With fresh traumatic injuries in a previously healthy person, this level is 100 thousand microorganisms per 1 g of tissue. With the deterioration of the general condition of the body and certain characteristics of the wound, this threshold can be significantly reduced.
Local factors that increase the likelihood of developing a wound infection include the presence of foreign bodies, blood clots and necrotic tissue in the wound. Also important is poor immobilization during transportation (causes additional trauma to soft tissues, causes deterioration of microcirculation, increase in hematomas and expansion of the necrosis zone), insufficient blood supply to damaged tissues, large depth of the wound with a small diameter of the wound channel, the presence of blind pockets and lateral passages.
The general condition of the body can provoke the development of wound infection due to severe microcirculation disorders (centralization of blood circulation during traumatic shock, hypovolemic disorders), immunity disorders due to malnutrition, nervous exhaustion, chemical and radiation injuries, as well as chronic somatic diseases. Particularly significant in such cases are malignant neoplasms, leukemia, uremia, cirrhosis, diabetes mellitus and obesity. In addition, a decrease in resistance to infection is observed during radiation therapy and when taking a number of medications, including immunosuppressants, steroids and high doses of antibiotics.
Classification
Depending on the predominance of certain clinical manifestations, purulent surgeons distinguish two general forms of wound infection (sepsis without metastases and sepsis with metastases) and several local ones. General forms are more severe than local ones, and the likelihood of death increases. The most severe form of wound infection is sepsis with metastases, which usually develops with a sharp decrease in the body's resistance and wound exhaustion due to the loss of large amounts of protein.
Local forms include:
- Wound infection. It is a localized process and develops in damaged tissues with reduced resistance. The infection zone is limited by the walls of the wound canal; there is a clear demarcation line between it and normal living tissues.
- Peri-wound abscess. Usually connected to the wound channel, surrounded by a connective tissue capsule that separates the site of infection from healthy tissue.
- Wound cellulitis. Occurs when the infection extends beyond the wound. The demarcation line disappears, the process involves adjacent healthy tissues and shows a pronounced tendency to spread.
- Purulent numbness. It develops when there is insufficient outflow of pus due to inadequate drainage or suturing the wound tightly without using drainage. In such cases, the pus cannot come out and begins to passively spread into the tissue, forming cavities in the intermuscular, interfascial and periosteal spaces, as well as in the spaces around blood vessels and nerves.
- Fistula. It is formed in the later stages of the wound process, in cases where the wound is closed with granulations on the surface, and a focus of infection remains in the depths.
- Thrombophlebitis. Develops in 1-2 months. after damage. It is a dangerous complication caused by infection of the blood clot with subsequent spread of infection along the vein wall.
- Lymphangitis And lymphadenitis. They arise as a result of other wound complications and disappear after adequate sanitation of the main purulent focus.
Symptoms of wound infection
As a rule, pathology develops 3-7 days after injury. Common signs include increased body temperature, increased heart rate, chills and signs of general intoxication (weakness, fatigue, headache, nausea). Local signs include five classic symptoms that were described back in ancient Roman times by the physician Aulus Cornelius Celsus: pain (dolor), local increase in temperature (calor), local redness (rubor), edema, swelling (tumor) and dysfunction ( function laesa).
A characteristic feature of the pain is its bursting, pulsating nature. The edges of the wound are swollen, hyperemic, and sometimes there are fibrinous-purulent clots in the wound cavity. Palpation of the affected area is painful. Otherwise, symptoms may vary depending on the form of wound infection. With a periwound abscess, the discharge from the wound is often insignificant; there is pronounced hyperemia of the wound edges, sharp tissue tension and an increase in the circumference of the limb. The formation of an abscess is accompanied by decreased appetite and hectic fever.
Prognosis and prevention
The prognosis is determined by the severity of the pathology. For small wounds the outcome is favorable, complete healing is observed. With extensive deep wounds and the development of complications, long-term treatment is required, and in some cases there is a threat to life. Prevention of wound infection includes early application of an aseptic dressing and strict adherence to the rules of asepsis and antisepsis during operations and dressings. Careful sanitation of the wound cavity with excision of non-viable tissue, adequate washing and drainage is necessary. Patients are prescribed antibiotics to combat shock, nutritional disorders and protein-electrolyte shifts.
For examining the internal and external surfaces of hollow organs and tissues located in cavities. The devices are equipped with a lighting system and special tools for collecting material for research. There are 2 types of endoscopes: rigid (metal optical tube), flexible (fiberglass tube). This method is highly informative; indirect symptoms of pathological processes can be determined.
2. Rhesus factor. Its significance in blood transfusion. Definition
Present in the blood of 85%. The r-f system is represented by 5 Ag-i: D, C, c, E, e. Based on the presence of Ag Rh 0 (D), blood is divided into Rh-positive and Rh-negative. Rhesus antigen appears in the embryo from the 5th to 8th week. Definition. 1) In clinical practice - an express method, determination with a standard universal reagent in a test tube without heating. 2) laboratory methods: A) agglutination method in a saline medium B) agglutination method in the presence of gelatin C) indirect antiglobulin test (Coombs reaction) D) reaction with anti-D-monoclonal antibodies.
3. The body’s reaction to acute purulent infection (local, general).
General - Depends on the number and virulence of the invading microbes, on the immuno-biological forces of the body. Local - redness (ruber), local heat (calor), swelling (tumor), pain (dolor), dysfunction (funcio iaesa).
4. During the transfusion, the patient showed signs of anxiety,….
Incompatibility of blood group or Rh factor - transfusion shock. Check the blood group of the donor and recipient. Treatment - Stop transfusion and connect the system with saline solution without removing the needle. Infusion therapy - blood substitutes (dextran), soda solution (sodium bicarbonate), crystalloid solutions, GCS (Prednisolone), aminophylline, furosimide. Antihistamines.
1. Paths of infection into the surgical wound.
1) exogenous: a) airborne, b) contact (instruments, linen, surgeon’s hands, dressings), c) implantation (suture and plastic material, prostheses)
2) endogenous: a) infection of the patient’s skin, b) infection of internal organs. Prevention of infections. Organizational measures related to the work of the surgical department and the hospital as a whole (rules of asepsis, antiseptics). Contact info. Everything that comes into contact with the wound must be sterile (surgical instruments, dressings, surgical linen, surgeon’s hands, patient’s skin). Implantation infection. Strict sterilization of all introduced items . endogenous infection. Prevention before planned surgery - you cannot operate if there is an inflammatory process, during the prodromal period of influenza, after an acute infectious infection. Prevention before emergency surgery - you need to know about existing foci of endogenous infection in order to prescribe additional treatment (antibiotics) before and after surgery.
2. The body's reaction to bleeding. Symptoms of acute and chronic blood loss.
Bleeding is the flow of blood from the lumen of a blood vessel due to its damage or disruption of the permeability of its wall. 3 concepts - actual bleeding, hemorrhage, hematomas. body reactions: hypovolemia develops - a decrease in the volume of circulating fluid. -> vascular changes - associated with a reflex reaction. Irritation of the valium receptors of the heart and large vessels -> activation of the hypothalamus, pituitary gland, adrenal glands -> compensatory changes in the body: 1. venospasm, 2. influx of tissue fluid, 3. tachycardia, 4. oliguria, 5. hyperventilation, 6. peripheral arteriolospasm. In the circulatory system: 1) centralization of blood circulation 2) decentralization of blood circulation 3) violation of the rheological properties of blood 4) metabolic changes 5) changes in organs. Symptoms.
3. Panaritium- acute purulent process localized in the soft tissues of the palmar surface of the fingers. classification from localization: cutaneous (purulent vesicle. Treatment - the epidermis exfoliated with pus is excised), subcutaneous (the nail phalanx is affected, throbbing pain. Treatment - the purulent focus is opened with two lateral incisions and necrectomy is performed), periungual (paronychia), subungual (detachment of the nail plate, through pus is visible through the nail plate. Treatment - the nail plate is partially resected), tendon (pus in the tendon sheath, pain in the entire finger, sausage-shaped thickening, the finger is in a forced half-bent position. Treatment - the synovial sheath is opened with two parallel incisions for through drainage), bone (club-shaped thickening of the finger, a purulent wound with a fistulous tract to the bone. Treatment is sequestration-necrectomy), articular (pain and fusiform enlargement of the joint. Treatment is contralateral incisions with through drainage), pandactelitis (all forming tissues are involved, many purulent wounds, bone destruction, tendon necrosis Treatment: the lesion is opened with two lateral incisions and necrectomy is performed).
Part I GENERAL SURGERYChapter 1 ANTISEPTICS AND ASEPSIS
Causative agents of wound infection and ways of their penetration into the wound
Throughout the centuries-old existence of medicine, right up to the second half of the 19th century, one of the most formidable dangers of operations and injuries was infection.
In the atmosphere and on all objects with which we come into contact, there is a huge number of microbes, including those that cause various purulent complications of wounds and dangerous diseases - tetanus, gas gangrene, phlegmon, etc. Microbes enter the wound as usually from outside. Until the middle of the 19th century. hospitals themselves were breeding grounds for infection. So, for example, the wounds of patients were washed with the same sponge, threads for silting or ligating blood vessels before inserting them into the eye, needles were often moistened with saliva, etc. It was the infection that was the cause of serious complications and frequent deaths of the wounded and those operated on. The mortality rate from purulent infection after amputation of limbs at that time reached 90%.
N.I. Pirogov, who was constantly faced with severe infectious complications of various wounds and operations, wrote with bitterness: “If I look back at the cemetery where those infected in hospitals are buried, then I don’t know what to be surprised at: the stoicism of the surgeons or the trust in which they continue to the government and society can still use the hospital."
Pirogov took the first step towards understanding the true cause of wound complications. Back in the middle of the 19th century, before the emergence of the doctrine of microbes, he created the doctrine of miasma (special substances or living beings that cause suppuration). And in 1867, the English surgeon J. Lister expressed a bold idea: suppuration of accidental and surgical wounds, as well as all other surgical complications, are caused by the entry of various microbes into the wound from the environment. To combat these microbes, he suggested using a 2 - 5% solution of carbolic acid. For this purpose, the surgeon’s hands and the surgical field were washed with carbolic acid,
Its vapors were sprayed into the air of the operating room, and after the operation was completed, the wound was covered with several layers of gauze soaked in the same acid. This Lister method, which consisted of destroying microbes in a wound with chemical agents, was called antiseptics (API against, 5Wed$1§ - rotting; antiseptic).
Microbes can live both in aerobic (with access to atmospheric oxygen) and anaerobic (without access to atmospheric oxygen) conditions.
Depending on the nature of the microbes, pyogenic, anaerobic and specific wound infections are distinguished.
Pyogenic infection. Penetrating into the wound, it causes inflammation and suppuration. The most common pyogenic bacteria staphylococci And streptococci. They are found on almost all objects, skin, mucous membranes, clothing, and in the air. Quite stable and cause purulent processes in the body.
Meningococci mainly affects the meninges of the brain and spinal cord, gonococci - mucous membranes of the genitourinary tract, pneumococci - lung tissue and synovial membranes of joints. Significantly complicates the course of purulent processes kicervical bacillus, which lives in the intestines and places contaminated with feces. Very delays wound healing Pseudomonas aeruginosa, the presence of which can be easily determined by the green color of the bandages.
Anaerobic infection. Caused by pathogenic anaerobes. Let's name the main ones.
Gas gangrene stick the most common causative agent of gas infection. It forms spores, produces toxins and gas. Toxins destroy red blood cells, affect the nervous system, causing intoxication of the body.
Malignant edema stick releases toxins that cause swelling of muscles and subcutaneous tissue. Forms spores.
Septic vibrio, releasing toxins, promotes the development of rapidly spreading edema due to serous and serous-hemorrhagic inflammation of tissues, affects blood vessels, leads to necrosis of muscles and fiber.
Tissue dissolving bacillus produces toxins that cause tissue death and melting,
Specific infection. The greatest danger in surgery is the causative agent of tetanus. Tetanus bacillus is resistant to high temperatures. It forms toxins that have a pathological effect on the nervous system and destroy red blood cells. Tetanus bacillus lives and develops only in anaerobic conditions.
Infection of a wound with microorganisms can occur from two sources: exogenous and endogenous.
Exogenous is an infection that enters the body from the external environment: from the air (airborne), from objects in contact with the wound (contact), from saliva and mucus secreted by personnel when talking and coughing (droplet), from objects left in tissues, for example, sutures and tampons (implantation).
Endogenous infection is located in the patient’s body (on the skin, in the respiratory tract, intestines) and can be introduced into the wound directly during or after surgery through the blood and lymphatic vessels.
However, an infection that enters the body does not always cause a pathological process. This is due to the action of the body's defenses. If a person is weakened by blood loss, radiation, cooling and other factors, then his protective forces are sharply reduced, which facilitates the rapid and unhindered proliferation of microbes.
Antiseptics
In modern terms antiseptic - This is a complex of therapeutic and preventive measures aimed at destroying microbes in a wound or the body as a whole.
There are mechanical, physical, chemical, biological and mixed antiseptics.
Mechanical antiseptics consists of cleansing the wound from microbes and non-viable tissues (washing purulent cavities, excision of the edges and bottom of the wound in the early stages to remove microbes that have entered it). Physical antisepsis includes physical methods by which conditions are created in the wound that prevent the life and proliferation of microbes. For example, applying an hygroscopic cotton-gauze bandage, using drying powders, hypertonic solutions, drying the wound with air, irradiating it with ultraviolet rays and a laser.
Chemical antiseptic - One of the most important methods of preventing and treating wound infections involves the use of chemicals called antiseptics. Antiseptics, in addition to having a detrimental effect on microorganisms, in most cases also have a pathological effect on tissue.
Biological antiseptics is based on the use of a large and very diverse group of drugs in terms of their mechanism of action,
affecting not only the microbial cell or its toxins, but also regulators that increase the body's defenses. Such drugs include antibiotics, bacteriophages, antitoxins, usually administered in the form of serums (antitetanus, antigangrenous), and proteolptic enzymes.
Mixed antiseptic is the most common type of antiseptic today, including the simultaneous use of several types. For example, in case of injury, primary surgical treatment of the wound (mechanical antiseptic) is performed and enter! see antitetanus serum (biological antiseptic).
Currently, a large number of different antiseptics are used.
Antiseptics.Alcohol solution of iodine(5 10 0 0 is used to disinfect the surgical field and the skin of the hands, lubricate the edges of the wound, cauterize minor abrasions and wounds.
Iodoform has a pronounced disinfectant effect. The drug dries the wound, cleans it and reduces decomposition. Prescribed in the form of powder, 10% ointment.
Lugol's solution consists of pure iodine and potassium iodide dissolved in alcohol or water. Used for washing purulent cavities.
Iodonate, iodo."ish, iodopirone are complexes of iodine with surfactant compounds. Used in 1% concentration to treat the surgical field and disinfect hands.
Chloramine B has an antiseptic effect based on the release of free chlorine. A 2% solution is used for disinfecting hands, sterilizing rubber gloves, catheters, drainage tubes, for treating infected wounds, and treating skin when affected by toxic substances of blister action.
Dgyutsid - chlorine-containing antiseptic with high bactericidal properties. Available in tablets No. 1 and >A> 2. Used in a dilution of 1: 5000 (two X° 1 tablets or one X° 2 tablet are dissolved in 5 liters of warm boiled water) for the treatment of hands, the surgical field, sterilization of rubber and plastic products, instruments, washing purulent wounds. The skin remains aseptic for at least 2 hours.
Hydrogen peroxide(3% solution) cleanses the wound well from pus and the remains of dead tissue due to the large amount of oxygen that is formed when peroxide comes into contact with tissue and blood. It has a hemostatic effect and is used for washing cancer, cavities, rinsing, and nasal tamponade.
Hydroperite - a complex compound of hydrogen peroxide and urea. Available in tablets. To obtain a 1% solution, dissolve 2 tablets of hydroperite in 100 ml of water, which is a substitute for hydrogen peroxide.
Potassium permatanate (potassium permanganate.) disinfectant and deodorant. In a 0.1 - 0.5% solution it is used to wash fetid wounds, in a 2 - 5 ° solution as a tanning agent for the treatment of burns.
Formalin(0,5 % solution) is used to disinfect instruments and rubber products.
Carbolic acid- a potent poison, used in the form of a 2 - 5% solution for disinfection of instruments, rubber gloves, catheters, living quarters, and disinfection of secretions.
Triple solution(20 g of formaldehyde, 10 g of carbolic acid, 30 g of sodium carbonate per 1000 ml of distilled water) is used for sterilization of instruments and rubber products.
Ethanol, or wine, has a disinfecting, drying and tanning effect. A 96% solution is used to treat hands, the surgical field, sterilize cutting instruments and equipment, suture material, and prepare anti-shock solutions.
Diamond green And methylene blue aniline dyes. Used as an antiseptic in the form of a 0.1 - 1% alcohol solution for burns and pustular skin lesions.
Furacilin used in a solution of 1: 5000 to treat purulent wounds and rinse cavities or as a 0.2% ointment. Has a detrimental effect on anaerobic infection.
Furagin effective in a 1:13000 solution for the treatment of wound infections and burns.
Silver nitrate used as a disinfectant for washing wounds, cavities, bladder in a dilution of 1: 500 - 1: 1000; A 10% solution is used to cauterize excess granulations.
Degmin, degmicide, ritossit have antibacterial activity. Used to treat the hands of medical personnel and the surgical field.
Chlorhexidine bigluconate used for treating the hands of medical personnel and the surgical field, sterilizing instruments.
Performic acid (pervomur)- antiseptic solution, which is a mixture of hydrogen peroxide and ants
noic acid. To treat hands, sterilize gloves and instruments, prepare a working solution: pour 171 ml of a 30% hydrogen peroxide solution and 81 ml of an 85% formic acid solution into a glass flask, shake the flask and place it in a well for 1-1.5 hours. The original solution is diluted with 10 liters of boiled or distilled water.
A number of the listed antiseptics are not used in everyday practice, but in emergency situations their use will become relevant.
Sulfonamide drugs. They have a pronounced bactericidal effect on pyogenic microbes. Unlike antiseptics of the first group, they have almost no effect on the body. Poorly soluble in water.
Antibiotics. These are substances of microbial, plant or animal origin that selectively suppress the vital activity of microorganisms. Antibiotics are biological antiseptics that have bacteriostatic and bactericidal effects.
The most effective is the combined use of antibiotics with other drugs.
Asepsis-- this is the preventive destruction of microorganisms, preventing the possibility of them entering the wound, tissues and organs during surgical operations, dressings and other therapeutic and diagnostic procedures. The aseptic method consists of sterilization of material, instruments, devices and techniques for handling sterile objects, as well as strict adherence to the rules of hand treatment before surgery and dressing. Asepsis is the basis of modern surgery, and sterilization is the basis of asepsis.
There are steam, air and chemical sterilization methods.
Linen, dressings, syringes, glassware, rubber products (gloves, tubes, catheters, probes) are placed in special metal drums - bins or double thick fabric bags, which are loaded into autoclaves (special steam sterilizers). Sterilization is carried out with steam at a pressure of 2 atmospheres for 45 minutes. To control the quality of sterilization, urea and benzoic acid, which have a certain melting point, are used. An unopened container is considered sterile for 3 days.
The air method is used to sterilize surgical, gynecological, dental instruments, syringes in dry-heat ovens at a temperature of 180° - 1 hour, 160° - 2.5 hours.
An example of a chemical sterilization method is immersing cutting instruments in alcohol for 30 minutes.
In certain situations, instruments can be sterilized by boiling, immersing them in a boiler or pan with distilled or double-boiled water, 2% soda solution for 45 minutes from the moment of boiling. In emergency cases, the instruments are burned and the linen is ironed.
Currently, preference is given to underwear, syringes, and disposable instruments.
Preparing hands for surgical work. Hands are washed with soap and water, dried with a sterile cloth and treated for 2 - 3 minutes with 0.5 % solution of chlorhexindine digluconate or pervomur solution, or another antiseptic solution intended for this purpose, then put on sterile rubber gloves. If gloves are not available, then after treating the hands, the fingertips, nail beds and skin folds are lubricated with a 5% alcohol solution of iodine.
Treatment of the surgical field. It is lubricated three times with a sterile swab moistened with a 1% solution of iodonate or a 0.5% solution of chlorhexidine bigluconate. When treating the surgical field using the Filonchikov-Trossin method, the skin is lubricated with alcohol, and then twice with a 5% alcohol solution of iodine.
No matter how difficult and stressful the surgical work is, forgetting the requirements of asepsis is unacceptable.
Operating linen (surgical gowns, masks for protection against droplet infection, sheets for covering the patient, cloth napkins for covering the surgical field) are sterilized in the same way as dressings (gauze bandages, napkins, tampons, turunds, balls, cotton wool), iodine steam pressure in autoclaves (special steam sterilizers).
Chapter 2 PAIN RELIEF. RESUSCITATION
Since time immemorial, medical thought has worked tirelessly to find ways and means that could at least partially reduce pain during operations.
Attempts to reduce pain reactions during operations were made in ancient times. For example, in Ancient Assyria, for the purpose of pain relief, they caused the patient to lose consciousness by tightening a noose around the neck; in ancient China they used opium, hashish and other intoxicants; In ancient Greece, Memphis stone (a special type of marble) was used mixed with vinegar. In the Middle Ages, “miraculous” drinks made from dope, henbane, Indian hemp, poppy, opium and other poisonous drugs were often used during operations. Wine was widely used, as well as copious bloodletting to cause fainting and loss of consciousness in the person being operated on. However, such methods did not achieve their goal: they reduced pain, but were dangerous to the patient’s health.
A significant milestone in the history of surgery came in 1846, when the American student Morton discovered the analgesic properties of ether and performed the first operation (tooth extraction) under ether anesthesia. In 1847, the English scientist Simpson discovered the analgesic property of chloroform and began to use it to relieve pain in childbirth.
In the development of many theoretical and practical issues of anesthesia, priority belongs to Russian science, in particular to the physiologist A. M. Filomafitsky, surgeons F. I. Inozemtsev and N. I. Pirogov. The latter, for the first time in the history of medicine, widely used ether anesthesia in military field conditions, brilliantly proving the ability to operate without pain.
In 1880, the Russian scientist V.K. Anren discovered that a solution of cocaine has a pronounced local anesthetic property. At the same time, consciousness was not impaired at all and the sensitivity of other areas was completely preserved. This remarkable discovery marked the beginning of local anesthesia in surgery. In 1905, Einhorn discovered novocaine, which is still widely used today.
Modern surgery has two types of anesthesia, differing in the place of application of the painkillers: local anesthesia and general anesthesia (anesthesia). Doctors involved in pain management are called anesthesiologists, and nursing staff are called anesthetists.
Local anesthesia refers to the reversible loss of pain sensitivity in certain areas of the body under the influence of chemical, physical or mechanical means. At the heart of the month
This anesthesin suppresses the excitability of peripheral receptors and blocks the conduction of nerve impulses into the central nervous system. The patient's consciousness is preserved. Complications with local anesthesia are rare and therefore it has become widespread. The most commonly used anesthetic is novocaine.
Novocain - low toxic drug. For local anesthesia, 0.25 - 0.5 is used %, less often 1-2% solution. Anesthesia lasts about two hours, and its duration is extended by adding adrenaline (1-2 drops of a 0.1% solution per 10 ml of novocaine solution).
Dicaine also toxic, used in the form of a 0.25-2% solution in ophthalmic practice, as well as for anesthesia of the mucous membranes of the throat, nose, and ear.
Xicaine, trimecaine, ultracaine, medocaine can be used in the same cases as novocaine.
Depending on the place of impact and the place of blockade of the pain impulse, three types of local anesthesia are distinguished - superficial, infiltration and regional (regional).
Superficial anesthesia is achieved in several ways: 1) by lubricating a certain area of the mucous membrane with a solution of cocaine, dicaine, xicaine or trimecaine; 2) cooling, that is, spraying a stream of chlorethyl or other rapidly evaporating substance.
Infiltration anesthesia consists of impregnation (infiltration) of tissues with an anesthetic solution. With NN-filtration anesthesia according to Vishnevsky, the solution is pressurized with iodine into the tissue and distributed throughout the fascial spaces of the body. This achieves not only anesthesia, but also hydraulic tissue preparation. First, the skin along the incision line is anesthetized with a thin needle, then the deeper tissue is infiltrated with a longer one.
Regional anesthesia involves turning off pain sensitivity in a certain area of the body, which may be located far from the injection sites of the anesthetic solution. It is used for conduction anesthesia (an anesthetic substance is injected into the nerve, nerve plexuses and surrounding tissue); with intravascular (the anesthetic substance enters directly into a vein or artery); with intraosseous (anesthetic is injected into the cancellous bone). Intravenous and intraosseous anesthesia are possible only on the extremities. Before administering the anesthetic, a tourniquet is applied to the limb.
General anesthesia (anesthesia)
Anesthesia is “temporary functional paralysis of the central nervous system” (I.P. Pavlov), which occurs under the influence of narcotic substances and is accompanied by a loss of consciousness and pain sensitivity. The cerebral cortex is the most sensitive to drugs and the medulla oblongata is the most resistant.
Depending on the route of administration of the narcotic substance, inhalation and non-inhalation anesthesia are distinguished. With inhalation anesthesia, narcotic substances are administered in a gas mixture through the respiratory tract, with non-inhalation anesthesia - into a vein, subcutaneously, intramuscularly or into the rectum. If both routes of administration of a narcotic substance are used for pain relief, then we speak of combined anesthesia.
Preparing the patient for anesthesia. The peculiarity of this period is premedication(drug preparation), which pursues a number of goals: to calm the patient, enhance the narcotic effect of the upcoming anesthesia, suppress unwanted reflexes during induction of anesthesia and during surgery, reduce the secretion of the mucous membranes of the respiratory tract, and prevent the possibility of developing allergic reactions. To do this, the night before the operation, sleeping pills or sedatives, as well as desensitizing substances, are prescribed. On the day of the operation, it is necessary to prepare the surgical field (shave), empty the bladder, remove dentures, etc. 30 - 40 minutes before the operation, the patient is administered promedol and atropine.
During emergency operations, preparing patients for anesthesia includes gastric lavage (if the patient has eaten food in less than 2 hours) and emptying the bladder. In such cases, promedol and atropine are administered intramuscularly or intravenously.
Inhalation anesthesia. Inhaled narcotic substances are vapors of volatile liquids (ether, fluorotane, chloroform) or gases (nitrous oxide, cyclopropane). Of these, the most widespread ether. For anesthesia, specially purified ether is produced in hermetically sealed orange glass bottles.
Chloroform The analgesic effect is stronger than ether, but has a small breadth of therapeutic action and early inhibits the vasomotor center.
Ftorotan The potency of action is superior to ether and chloroform, does not irritate the mucous membranes of the respiratory tract, and quickly depresses consciousness without phenomena of excitation. However, it can lead to a drop in blood pressure and arrhythmias.
Nitrous oxide is introduced into the body mixed with oxygen (80 % nitrous oxide and 20% oxygen). Anesthesia occurs quickly, but it is not deep enough and complete relaxation of the skeletal muscles is not observed.
Cyclopropane- the most powerful inhalational anesthetic, has a wide range of therapeutic effects, and is low-toxic. Under its influence, the heart rate slows down, bronchospasm and increased bleeding are possible.
The simplest is considered to be anesthesia using a mask. In modern medicine it is almost never used, but in case of mass lesions it can be widely used.
The Esmarch mask is a wire frame covered with gauze that is placed over the patient’s nose and mouth. The main disadvantage of this mask is the inability to accurately dose the drug.
The patient's head is placed on a towel, the ends of which are covered crosswise over the eyes. To avoid burns with ether, lubricate the nose, cheeks and chin with Vaseline.
Anesthesia using masks is carried out using the drip method. First, a dry mask is applied to the face, then it is lifted and the gauze is soaked in ether. The mask is gradually brought closer to the face so that the patient gets used to the smell of the ether. After about a minute, cover your mouth and nose with the mask. If suffocation occurs, lift it and provide an influx of fresh air. After final application, ether begins to drip onto the surface of the mask until the patient falls asleep. To prevent the tongue from retracting into the mouth, an air duct is inserted to support the root of the tongue, or the lower jaw is pulled forward with hands and held in this position during anesthesia. To maintain a sufficient concentration of ether vapor, place a towel around the circumference of the mask.
Stunning, or rausch anesthesia, used for minor operations (incision, opening of abscesses, etc.). In addition to ether, chloroethyl and chloroform are used for short-term stunning. Any mask for drip anesthesia or, in extreme cases, a piece of gauze folded several times, soaked in an anesthetic, is placed on the patient’s nose and mouth lubricated with Vaseline. The patient is asked to take a deep breath several times, and a rapid loss of consciousness occurs. The mask is removed. Loss of sensation lasts 3 to 4 minutes.
Anesthesia machine more secure. The domestic industry produces anesthesia machines of a wide variety of models: from light portable to stationary. Anesthesia using devices ensures high accuracy and stability in maintaining the concentration of the narcotic substance.
For traumatic and lengthy operations it is preferable pubertal anesthesia. An endotracheal (special rubber) tube is inserted into the trachea using a laryngoscope and connected to the anesthesia machine instead of a rubber mask, which improves the supply of the respiratory mixture and avoids the complications observed with mask anesthesia. Muscle relaxants are used during intubation anesthesia. - drugs that relax skeletal muscles. With the help of muscle relaxants, the supply of strong narcotic drugs is significantly reduced, and therefore the intoxication of the body is reduced.
Clinical course of ether anesthesia. The ether anesthesia clinic is considered a classic one. Other narcotic substances may cause some deviations during anesthesia. The following stages of anesthesia are distinguished.
/ stage (analgesia) lasts 3 - 4 minutes. The patient's consciousness becomes clouded, pain sensitivity decreases, and then disappears. The patient is confused in his answers and answers incoherently.
// stage (excitement) resembles a state of alcoholic intoxication. The patient screams, sings, swears, and tries to “leave” the table. The pupils are dilated and reactive to light (contract when exposed to light). Breathing is uneven, deep, noisy, sometimes delayed. Blood pressure rises, pulse quickens.
/// stage - surgical. The patient should be kept at this stage throughout the entire operation, but this must be done very skillfully and carefully. A lack of a narcotic substance leads to awakening, and when a large amount of the drug is given (overdose), poisoning and death of the patient occurs. The surgical stage is divided into four levels.
The first level is characterized by the appearance of even deep breathing. The patient's eyelids stop responding to lifting them with the fingers, the corneal reflex is preserved, the pupils narrow to their original sizes, and swimming movements of the eyeballs are observed. The gag reflex disappears. Muscle tone decreases. Blood pressure and pulse return to baseline.
The second level is surgical anesthesia. Swimming movements of the eyeballs disappear, the pupils are narrow and reactive to light, the corneal reflex is negative. Muscle tone decreases. Pulse and blood pressure are kept within the limits of what they were before anesthesia.
The third level (deep anesthesia) is acceptable only for a short time. The pulse quickens, blood pressure drops, breathing is shallow. The reaction to light disappears, but the pupils remain narrow.
The fourth level is dangerous for the patient. Breathing is shallow, pulse is fast, blood pressure is low. The pupils dilate, the cornea becomes dry, and the palpebral fissure opens. This is a consequence of an overdose of ether. Taxi! level is unacceptable.
IVstage - tonal. There is a disappearance of all reflexes, complete relaxation of the muscles, which leads to respiratory arrest and cardiac paralysis.
Awakening occurs in the reverse order --- third, second, first stage.
Non-inhalational anesthesia. Used for short-term (no more than 30 - 40 minutes) operations when relaxation of skeletal muscles is not required. Intravenous administration of non-volatile narcotic substances is mainly used: hexenal, sodium thiopental, predione (viadrnla), sodium hydroxybutrate, propanidide (sombrevin). Anesthesia occurs quickly (in 2-3 minutes) without the stage of excitation. There is loss of consciousness, eye movements and reaction to light are preserved. This state corresponds to the first level of the third stage.
Combined anesthesia. Currently, combined multicomponent anesthesia is widely used. It includes complex premedication, the use of various combinations of substances for introductory and main anesthesia.
Complications during anesthesia. When carrying out anesthesia, especially with a mask, it is possible asphyxia -- a state of increasing suffocation associated with a sharp lack of oxygen in the body. In the initial stages of anesthesia, asphyxia may be associated with laryngeal spasm. Therefore, narcotic substances should be administered in doses. In the second stage of anesthesia, vomit may enter the respiratory tract. When vomiting occurs, turn the patient's head to the side, clean the oral cavity with gauze and deepen the anesthesia. In later stages, asphyxia may occur due to tongue retraction or drug overdose. Blueness of the lips, darkening of the blood in the wound, increased heart rate, dilated pupils (do not respond to light), wheezing breathing signal impending asphyxia. In such cases, it is necessary to remove the mask from the patient, restore the airway (remove foreign bodies, fluid, insert an air duct if the tongue is retracted or extend the lower jaw) and apply artificial ventilation.
The endotracheal tube is removed 30 minutes after the end of anesthesia, but you should always remember about the possibility of the patient biting off the tube due to convulsive contraction of the masticatory muscles upon awakening.
The most severe complications of anesthesia are respiratory and cardiac arrest. This is usually caused by an overdose of drugs.
Caring for patients after anesthesia includes continuous observation until they regain consciousness, since * during this period various complications are possible (vomiting, respiratory or cardiac problems, shock, etc.).
Reanimation
After complete cessation of blood circulation and cessation of breathing, the body's cells continue to live for some time. The most sensitive to oxygen starvation are the cells of the cerebral cortex, which remain viable after cardiac arrest for 5 to 7 minutes. The period of time when life can be restored is called the period of “clinical death”. It begins from the moment the heart stops. Signs of cardiac arrest are the absence of pulsation in the carotid and femoral arteries, sharp dilation of the pupils and absence of reflexes. At a later date, clinical death turns into biological, or true death of the body.
Measures aimed at restoring the most important vital functions of the body in order to revive the patient are called resuscitation. The modern comprehensive method of revitalization includes cardiac massage, artificial respiration, intravenous or intra-arterial blood transfusions and polyglucoses.
The victim needs urgent delivery to a medical facility, since only there can the entire range of revival measures be carried out. Cardiac massage and artificial respiration are carried out continuously even during transportation. If resuscitation measures are performed by one person, cardiac massage and artificial respiration should be alternated: for 15 heartbeats, two strong breaths in a row to the victim, since it has been established that the leading cause of death of brain cells is not a decrease in oxygen in the blood, but a loss of vascular tone. In medical institutions, artificial respiration is performed using devices in combination with intubation, cardiac massage, heart stimulation with devices and medications.
Resuscitation measures are carried out until
good independent activity of the heart and breathing will be restored or until signs of biological death appear (cadaveric spots, corneal opacity, rigor mortis).
Heart massage. Indicated for palpitations and cardiac arrest. It can be performed using the open (direct) or closed (indirect) method.
Direct massage heart surgery is performed during an operation with the chest or abdominal cavity open, and the chest is also specially opened, often even without anesthesia and observing the rules of asepsis. After exposing the heart, it is carefully and gently squeezed with your hands at a rhythm of 60-70 times per minute. Direct cardiac massage is advisable in an operating room.
Indirect massage heart (Fig. 1) is much simpler and more accessible in any conditions. It is done without opening the chest simultaneously with artificial respiration. By pressing on the sternum, you can move it 3-6 cm towards the spine, compress the heart and force blood out of its cavities into the vessels. When the pressure on the sternum ceases, the cavities of the heart straighten, and blood from the veins is sucked into them. Indirect cardiac massage can maintain pressure in the systemic circulation at a level of 60 - 80 mmHg.
Rice. 1. Indirect cardiac massage
The technique of indirect cardiac massage is as follows: the person providing assistance places the palm of one hand on the lower third of the sternum, and the second hand on the back surface of the previously applied one to increase pressure. 50-60 pressures are applied to the sternum per minute in the form of quick thrusts. After each pressure, the hands are quickly removed from the chest. Period
pressure should be shorter than the period of chest expansion.
When performing a heart massage in children, the position of the hands is the same as during a massage in adults. For older children, massage is performed with one hand, and for newborns and under the age of one year - with the tips of 1-2 fingers.
The effectiveness of cardiac massage is assessed by the appearance of pulsation in the carotid, femoral and radial arteries, and an increase in blood pressure to 60 - 80 mm Hg. Art., constriction of the pupils, the appearance of their reaction to light, restoration of breathing.
Artificial respiration. To carry out the necessary gas exchange during artificial respiration, 1000-1500 ml of air must enter the lungs of an adult with each breath. Known methods of manual artificial respiration do not create sufficient ventilation in the lungs and are therefore ineffective. In addition, their production is difficult with simultaneous cardiac massage. Breathing from mouth to mouth or mouth to nose is more effective.
Breath "mouth to mouth"(Fig. 2) is performed as follows: the victim’s head is tilted back. The person providing assistance covers the victim’s mouth with a handkerchief or gauze, pinches his nose and, taking a deep breath, exhales air into the victim’s mouth. If there is a special air duct, then it is inserted into the mouth and air is blown in. The air duct is inserted so that it presses the tongue to the floor of the mouth. The victim exhales independently due to the confluence of the chest.
Air blowing "isomouth to nose": The victim’s head is thrown back, the lower jaw is raised with the hand and the mouth is closed. The person providing assistance takes a deep breath, tightly covers the victim’s nose with his lips and blows the air out of his lungs.
Rice. 2. Artificial respiration "mouth to mouth"
When performing resuscitation on young children, it is necessary to cover the child's mouth and nose with your lips and blow air into these airways at the same time.
The skin and mucous membranes isolate the internal environment from the external and reliably protect the body from the penetration of microbes. Any violation of their integrity is an entry point for infection. Therefore, all accidental wounds are obviously infected and require mandatory surgical treatment. Infection can occur from the outside (exogenous) by airborne droplets (when coughing, talking), by contact (when touching the wound with clothing, hands) or from the inside (endogenous). Sources of endogenous infection are chronic inflammatory diseases of the skin, teeth, tonsils, and the route of infection spread is the blood or lymph flow.
As a rule, wounds become infected with pyogenic microbes (streptococci, staphylococci), but infection can also occur with other microbes. Infection of a wound with tetanus bacilli, tuberculosis, and gas gangrene is very dangerous. Prevention of infectious complications in surgery is based on strict adherence to the rules of asepsis and antisepsis. Both methods represent a single whole in the prevention of surgical infection.
Antiseptics - a set of measures aimed at destroying microbes in the wound. There are mechanical, physical, biological and chemical methods of destruction.
Mechanical antiseptics includes carrying out primary surgical treatment of the wound and its toilet, i.e., removal of blood clots, foreign objects, excision of non-viable tissue, washing of the wound cavity.
Physical method is based on the use of ultraviolet irradiation, which has a bactericidal effect, and the application of gauze dressings, which absorb wound fluid well, dry the wound and thereby contribute to the death of microbes. The same method involves the use of a concentrated saline solution (the law of osmosis).
Biological method based on the use of serums, vaccines, antibiotics and sulfonamides (in the form of solutions, ointments, powders). Chemical method The fight against microbes is aimed at the use of various chemicals called antiseptics.
Drugs used against pathogens of surgical infections can be divided into 3 groups: disinfectants, antiseptics and chemotherapy. Disinfectants substances are intended primarily to destroy infectious agents in the external environment (chloramine, sublimate, triple solution, formaldehyde, carbolic acid). Antiseptic products are used to destroy microbes on the surface of the body or in serous cavities. These drugs should not be absorbed in significant quantities into the blood, as they can have a toxic effect on the patient’s body (iodine, furatsilin, rivanol, hydrogen peroxide, potassium permanganate, brilliant green, methylene blue).
Chemotherapy the drugs are well absorbed into the blood through various methods of administration and destroy microbes in the patient’s body. This group includes antibiotics and sulfonamides.
