Absolute and relative contraindications to surgery. Main contraindications to anesthesia. General anesthesia and contraindications to it


If general anesthesia is necessary, contraindications to anesthesia must be taken into account first. Every person who is about to undergo surgery should know this. Anesthesia allows surgeons to perform long-term interventions of any complexity without causing physical suffering to the patient.

However, the presence of any diseases in a person that prohibit the use of anesthesia makes its use, and therefore surgical intervention, problematic. In such cases, specialists often postpone planned surgery to a later date. late period and prescribe treatment to the patient to stabilize his condition.

In modern medical practice Several types of anesthesia are used: general, epidural, spinal and local. Each of them has its own indications and contraindications for use, which anesthesiologists always take into account before selecting anesthesia for a patient.

General anesthesia and contraindications to it

Application of anesthesia general action allows you to immerse the patient in a deep state, during which he will not feel pain from surgical manipulations performed by a specialist. This type of anesthesia is used during operations of any complexity on the abdominal organs, heart, head and spinal cord, large blood vessels, when deleting malignant neoplasms, amputation of limbs, etc. Despite wide range use, such anesthesia has a lot of contraindications.

For adults, the use of general anesthesia during surgical operations prohibited if they have:

In pediatric practice, during the surgical treatment of children under 1 year of age, there are contraindications to general anesthesia. For young patients, the use of this type of anesthesia is prohibited if:

  • hyperthermia of unknown origin;
  • viral diseases (rubella, chicken pox, mumps, measles);
  • rickets;
  • spasmophilic diathesis;
  • purulent lesions on the surface of the skin;
  • recent vaccination.

Use of general anesthesia if there are contraindications

General anesthesia can hardly be called harmless, since it has a systemic effect on the body and can provoke serious complications in a person at work. of cardio-vascular system, cause nausea, headache and other unpleasant symptoms. But there is no need to be afraid of it if the anesthesiologist, despite the presence of contraindications, allowed the patient to undergo surgery.

An experienced doctor can minimize the harm from exposure general anesthesia on the body, so the patient can and should trust it and not worry about anything. Refusal to undergo surgery can lead to more disastrous consequences than the effects of anesthesia.

The above restrictions on the use of general anesthesia do not apply to emergency cases when a person’s life depends on a timely operation. In such a situation, surgery using general anesthesia is carried out regardless of whether the patient has contraindications to it or not.

Regional types of anesthesia

In addition to general anesthesia, surgical treatment today is carried out using spinal and epidural anesthesia. Both the first and second types of pain relief refer to.

During spinal anesthesia, a specialist uses a long needle to inject the patient with an anesthetic drug into the spinal cavity filled with cerebrospinal fluid, located between the soft and arachnoid membranes of the brain and spinal cord.

With epidural anesthesia, an anesthetic is injected through a catheter into the epidural space of the spine. ensures complete relaxation of the patient’s muscles, loss of pain sensitivity and makes possible to carry out surgical intervention.

Epidural or spinal anesthesia can be used as independent method pain relief (for example, caesarean section or childbirth), and in combination with general anesthesia (during laparotomy and hysterectomy). The main advantage of pain relief methods is that severe complications after them they occur much less often than after general anesthesia. Despite this, they have many prohibitions on their use.

Absolute contraindications include:

  • severe cardiovascular diseases (complete atrioventricular block, aortic stenosis, atrial fibrillation);
  • pathologies accompanied by blood clotting disorders;
  • anticoagulant therapy during the last 12 hours;
  • arterial hypotension;
  • history of severe allergic reactions;
  • infectious process in the area of ​​​​injection of the anesthetic.

In addition to absolute prohibitions on the use of epidural and spinal anesthesia, there are relative contraindications, in which the use of these types of pain relief is allowed only in extreme cases when the patient's life is at stake.

During surgery using spinal or epidural anesthesia, the patient is conscious and aware of what is happening to him. If he is afraid of such a surgical intervention, he has the right to refuse. In this situation, the operation will be performed under general anesthesia.

When prescribing a patient, the anesthesiologist must warn him about possible consequences such an operation. The most common complications after using such a procedure are headache and the formation of hematomas at the site of injection of the anesthetic. Sometimes painkillers do not provide the patient with complete blockade nerves. This leads to the fact that during the operation the person will feel pain from surgical manipulations.

In what cases is local anesthesia prohibited?

Local anesthesia is another type of pain relief used during surgery. It consists of local injection of an anesthetic drug into the area of ​​the intended surgical intervention in order to reduce its sensitivity. The patient remains fully conscious after the administration of the anesthetic drug.

Local anesthesia rarely causes complications, so it is considered the least dangerous among all types of pain relief existing today. It is widely used for short-term and small-volume operations. Local anesthesia is also used in persons for whom any other methods of pain relief are strictly contraindicated.

The use of local anesthesia during surgical interventions is prohibited if the patient has:

  • hypersensitivity to local anesthetics (Lidocaine, Bupivacaine, Benzocaine, Ultracaine, etc.);
  • mental disorders;
  • state of emotional lability;
  • respiratory dysfunction.

In the early childhood The use of local anesthesia is impossible due to the fact that Small child can not for a long time be in a motionless state. After using local anesthetics, a person may experience complications such as allergic reactions(urticaria, itching, Quincke's edema), loss of consciousness, the occurrence of an inflammatory process at the site of injection of the drug under the skin.

Before any surgical intervention, specialists conduct a thorough examination of the sick person, based on the results of which they decide on the possibility of using one or another type of anesthesia. This approach allows them to conduct successful operations with minimal risk for the patient's health.

Indications for surgery determine its urgency and can be vital, absolute and relative:

$ Vital indications for surgery – diseases or injuries in which the slightest delay threatens the patient’s life. Such operations are performed on an emergency basis, that is, after minimal examination and preparation of the patient (no more than 2–4 hours from the moment of admission). Vital indications for surgery arise in the following pathological conditions:

¾ Asphyxia;

¾ Continued bleeding: if an internal organ is damaged (liver, spleen, kidney, fallopian tube during pregnancy, etc.), heart, large vessels, with stomach ulcers and duodenum and etc.;

¾ Acute diseases of the abdominal organs inflammatory in nature(acute appendicitis, strangulated hernia, acute intestinal obstruction, perforation of a stomach or intestinal ulcer, thromboembolism, etc.), fraught with the risk of developing peritonitis or organ gangrene due to thromboembolism;

¾ Purulent-inflammatory diseases (abscess, phlegmon, purulent mastitis, acute osteomyelitis, etc.) that can lead to the development of sepsis.

$ Absolute indications for surgery – diseases in which time is needed to clarify the diagnosis and more thoroughly prepare the patient, but a long delay in surgery can lead to a condition life-threatening sick. These operations are performed urgently after a few hours or days (usually within 24–72 hours of the preoperative period. Long-term delay of surgery in such patients can lead to tumor metastases, general exhaustion, liver failure and other complications. These diseases include:

¾ Malignant tumors;

¾ Pyloric stenosis;

¾ Obstructive jaundice, etc.;

$ Relative indications for surgery – diseases that do not pose a threat to the patient’s life. These operations are performed as planned after a thorough examination and preparation at a time convenient for the patient and the surgeon:

¾ Varicose veins of the superficial veins of the lower extremities;

¾ Benign tumors and etc.

Revealing contraindications presents significant difficulties, since any operation and anesthesia represent potential danger for the patient, but clear clinical, laboratory and special criteria assessing the severity of the patient’s condition, upcoming operation and the patient's reaction to anesthesia, no.

Surgical intervention has to be postponed for some time in cases where it is more dangerous than the disease itself or there is a danger postoperative complications. Most contraindications are temporary and relative.

Absolute contraindications to surgery:

¾ Terminal condition of the patient;

Relative contraindications to surgery (any concomitant disease):

¾ Cardiac, respiratory and vascular failure;

¾ Shock;

¾ Myocardial infarction;

¾ Stroke;

¾ Thromboembolic disease;

¾ Renal - liver failure;

¾ Severe metabolic disorders (decompensation diabetes mellitus);

¾ Precomatose state; coma;

¾ Severe anemia;

¾ Severe anemia;

¾ Advanced forms of malignant tumors (stage IV), etc.

If there are vital and absolute indications, relative contraindications cannot prevent emergency or urgent surgery after appropriate preoperative preparation. It is advisable to carry out planned operations after appropriate preoperative preparation. It is advisable to carry out planned surgical interventions after all contraindications have been eliminated.

Factors that determine surgical risk include the patient’s age, the condition and function of the myocardium, liver, lungs, kidneys, pancreas, degree of obesity, etc.

The established diagnosis, indications and contraindications allow the surgeon to resolve issues of urgency and scope of surgical intervention, method of pain relief, and preoperative preparation of the patient.

Question 3: Preparing patients for planned operations.

Planned operations – when the outcome of treatment practically does not depend on the execution time. Before such interventions, the patient undergoes full examination, the operation is performed on the most favorable background in the absence of contraindications from other organs and systems, and in the presence of concomitant diseases - after reaching the stage of remission as a result of appropriate preoperative preparation. Example: radical surgery for a non-strangulated hernia, varicose veins veins, cholelithiasis, uncomplicated gastric ulcer, etc.

1.General activities: To general events refers to improving the patient’s condition by identifying and maximizing the elimination of dysfunctions of the main organs and systems. During the period of preoperative preparation, the functions of organs and systems are carefully studied and they are prepared for surgical intervention. The nurse must treat preoperative preparation with full responsibility and understanding. She is directly involved in examining the patient and performing treatment and preventive measures. Basic and mandatory studies before any planned surgery:

J Measurement of blood pressure and pulse;

J Measuring body temperature;

J Measurement of respiratory rate;

J Measuring the height and weight of the patient;

J Carrying out clinical analysis blood and urine; determination of blood sugar;

J Determination of blood group and Rh factor;

J Examination of stool for worm eggs;

J Statement of the Wasserman reaction (=RW);

J In elderly people - electrocardiographic study;

J According to indications – blood test for HIV; etc.

A) mental and physical preparation: creating an environment around the patient that instills confidence in the successful outcome of the operation. All medical personnel must eliminate as much as possible the moments that cause irritation and create conditions that provide complete rest for the nervous system and the patient. For the proper preparation of the patient’s psyche for surgery, it is of great importance that nursing staff follow the rules of deontology. Before the operation in the evening, the patient is given a cleansing enema, the patient takes a hygienic bath or shower and changes his underwear and bed sheets. The moral state of patients admitted for surgery differs significantly from the condition of patients who undergo only conservative treatment, since the operation is a great physical and mental trauma. Just “waiting” for surgery instills fear and anxiety and seriously undermines the patient’s strength. Starting from the emergency department and ending with the operating room, the patient looks closely and listens to everything around him, is constantly in a state of tension, turns, as a rule, to junior and mid-level medical staff, looking for support from them.

Protecting the patient's nervous system and psyche from irritating and traumatic factors largely determines the course of the postoperative period.

Pain and sleep disturbances especially injure the nervous system, the fight against which (prescribing painkillers, sleeping pills, tranquilizers, sedatives and other drugs is very important during the preoperative preparation period.

For the proper preparation of the patient’s psyche for surgery, it is of great importance that nursing staff follow the following rules of surgical deontology:

¾ Upon admission of the patient to emergency department it is necessary to provide him with the opportunity to calmly communicate with the relatives accompanying him;

¾ The diagnosis of the disease should be communicated to the patient only by the doctor, who decides in each individual case in what form and when he can do this;

¾ It is necessary to address the patient by his first name and patronymic or last name, but do not call him impersonally “sick”;

¾ Before surgery, the patient is especially sensitive to the look, gesture, mood, carelessly spoken word, and picks up all the shades of the nurse’s intonation. Conversations should be especially careful during scheduled rounds and rounds conducted for pedagogical purposes. At this moment, the patient is not only an object for research and teaching, but also a subject who catches every word of those around him and the teacher. It is very important that these words and gestures contain goodwill, sympathy, sincerity, tact, restraint, patience, and warmth. The indifferent attitude of the nurse, negotiations of the staff about personal, irrelevant things in the presence of the patient, inattention to requests and complaints give the patient a reason to doubt all further activities and put him on guard. The medical staff's conversations about the poor outcome of the operation, death, etc. have a negative effect. A nurse who carries out assignments or provides any assistance in the presence of patients in the ward must do this skillfully, calmly and confidently, so as not to cause anxiety and nervousness in them;

¾ Medical history and data diagnostic studies must be stored so that they cannot become accessible to the patient; the nurse must be the keeper of medical (medical) secrets in the broad sense of the word;

¾ In order to distract the patient from thoughts about his illness and the upcoming operation, the nurse should visit him as often as possible and, if possible, involve him in conversations that are far from medicine;

¾ Medical staff must ensure that in the hospital environment surrounding the patient there are no factors that irritate and frighten him: excessive noise, intimidating medical posters, signs, syringes with traces of blood, bloody gauze, cotton wool, sheets, tissue, tissue, organ or parts thereof, etc.;

¾ The nurse must strictly monitor strict adherence to the hospital regime (afternoon rest, sleep, bedtime, etc.);

¾ Medical staff should pay Special attention to his appearance, given that untidiness and sloppy appearance raises doubts in the patient about the accuracy and success of the operation;

¾ When talking with a patient before surgery, you should not present the operation to him as something easy, at the same time you should not frighten him with the risk and the possibility of an unfavorable outcome. It is necessary to mobilize the patient’s strength and faith in a favorable outcome of the intervention, eliminate fears associated with distorted ideas about the upcoming pain during and after surgery, report postoperative pain. When explaining, the nurse must adhere to the same interpretation given by the doctor, otherwise the patient ceases to believe the medical staff;

¾ The nurse must promptly and conscientiously carry out the doctor’s orders (taking tests, obtaining research results, medication prescriptions, preparing the patient, etc.); it is unacceptable to send the patient from the operating table to the ward due to his unpreparedness due to the fault of the medical staff; the nurse must remember that caring for the patient at night is of particular importance, since there are almost no external stimuli at night. The patient is left alone with his illness, and, naturally, all his senses are heightened. Therefore, caring for him at this time of day should be no less thorough than during the day.

2.Specific events: These include activities aimed at preparing those organs on which surgery is to be performed. That is, a number of studies are being carried out related to surgery on this organ. For example, during heart surgery, cardiac probing is performed, during lung surgery, bronchoscopy is performed, and during stomach surgery, analysis is performed. gastric juice and fluoroscopy, fibrogastroscopy. The stomach contents are removed the morning before. In case of congestion in the stomach (pyloric stenosis), it is washed out. A cleansing enema is given at the same time. The patient's diet on the day before surgery: regular breakfast, light lunch, sweet tea for dinner.

Before surgery biliary tract needs to be examined gallbladder, pancreas and bile ducts using special methods (ultrasound) and study laboratory indicators of the functions of these organs and the exchange of bile pigments.

At obstructive (mechanical) jaundice the flow of bile into the intestines stops, the absorption of fat-soluble substances, which includes vitamin K, is disrupted. Its deficiency leads to a deficiency of coagulation factors, which can cause severe bleeding. Therefore, before surgery, a patient with obstructive jaundice is given vitamin K ( vikasol 1% - 1 ml), calcium chloride solution, blood, its components and preparations are transfused.

Before surgery on the large intestine To prevent endogenous infection, it is very important to thoroughly cleanse the intestines, but at the same time, the patient, often exhausted and dehydrated by the underlying disease, should not starve. He gets special diet, containing high-calorie food, devoid of toxins and gas-forming substances. Since an operation is expected to open the large intestine, to prevent infection, patients begin to take antibacterial drugs during the preparation period ( colymycin, polymyxin, chloramphenicol and etc.). Fasting and the prescription of laxatives are resorted to only when indicated: constipation, flatulence, lack of normal stool. The evening before the operation and in the morning the patient is given a cleansing enema.

For surgery in the area rectum and anus(about hemorrhoids, anal fissures, paraproctitis, etc.) it is also necessary to thoroughly cleanse the intestines, since in postoperative period stool is artificially retained in the intestines for 4–7 days.

To survey departments colon resort to radiopaque (barium passage, irrigoscopy) and endoscopic (sigmoidoscopy, colonoscopy) studies.

Patients with very large, long-term hernias of the anterior abdominal wall. During the operation, the internal organs located in the hernial sac are moved into the abdominal cavity, this is accompanied by an increase in intra-abdominal pressure, displacement and high standing of the diaphragm, which complicates cardiac activity and respiratory excursions of the lungs. To prevent complications in the postoperative period, the patient is placed on a bed with the leg end raised and, after the contents of the hernial sac are reduced, a constricting bandage or sand bag is applied to the area of ​​the hernial orifice. The body is “accustomed” to the new conditions of a high position of the diaphragm, to an increased load on the heart.

Special training on a limb comes down to cleansing the skin of contamination with baths with a warm and weak antiseptic solution (0.5% ammonia solution, 2 - 4% sodium bicarbonate solution, etc.).

Other diseases and operations require appropriate special studies and preoperative preparation, often in a specialized surgical department.

¾ Preparation of the cardiovascular system:

· Upon admission – examination;

· Carrying out general analysis blood

· Biochemical blood test and, if possible, normalization of parameters

Measurement of heart rate and blood pressure

· ECG taking

Taking into account blood loss - procurement of blood and its preparations

· Instrumental and laboratory methods research (ultrasound of the heart).

¾ Preparation of the respiratory system:

· To give up smoking

· Elimination of inflammatory diseases of the upper respiratory tract.

· Conducting breath tests

· Teaching the patient proper breathing and coughing, which is important for the prevention of pneumonia in the postoperative period

· Chest fluorography or radiography.

¾ Preparing the gastrointestinal tract

· Sanitation of the oral cavity

Gastric lavage

Suction of stomach contents

· Meals on the eve of surgery

¾ Preparation of the genitourinary system:

· Normalization of kidney function;

· Conduct kidney studies: urine tests, determination of residual nitrogen (creatinine, urea, etc.), ultrasound, urography, etc. If pathology is detected in the kidneys or bladder appropriate therapy is carried out;

· For women, before surgery, a gynecological examination is required, and, if necessary, treatment. Planned operations are not performed during menstruation, as increased bleeding is observed on these days.

¾ Immunity and metabolic processes:

· Increasing the immunobiological resources of the patient’s body;

· Normalization of protein metabolism;

· Normalization of water-electrolyte and acid-base balance.

¾ Skin:

· Identification of skin diseases that can cause severe complications in the postoperative period, including sepsis (furunculosis, pyoderma, infected abrasions, scratches, etc.). Preparation of the skin requires the elimination of these diseases. On the eve of the operation, the patient takes a hygienic bath, shower, and changes his underwear;

· The surgical field is prepared immediately before the operation (1-2 hours), since over a longer period of time, cuts and scratches that may occur during shaving may become inflamed.

On the eve of surgery the patient is examined by an anesthesiologist, who determines the composition and timing of premedication; the latter is carried out, as a rule, 30–40 minutes before surgery, after the patient has urinated, removed dentures (if any), as well as other personal belongings.

The patient, covered with a sheet, is taken on a gurney head first to the operating unit, in the vestibule of which he is transferred to the operating gurney. In the preoperative room, a clean cap is put on the patient’s head and clean shoe covers are put on his feet. Before bringing the patient to the operating room, the nurse must check whether the bloody linen, dressings, and instruments from the previous operation have been removed.

Disease history, x-rays the patient is delivered at the same time as the patient.

The established diagnosis of esophageal cancer is absolute indication to surgery - everyone admits this and, according to various surgeons, varies widely - from 19.5% to 84.4%. Average operability figures according to domestic literature are 47.3%. Consequently, approximately half of the patients are scheduled for surgery, and the second are not subject to surgical treatment. What are the reasons for refusing surgery for such a large number patients with esophageal cancer?

First of all, this is the refusal of the patients themselves from the proposed surgical treatment. It was reported above that the percentage of patients who refused surgery for various surgeons reaches 30 or more.

The second reason is the presence of contraindications to surgical intervention, depending on the state of the already middle-aged organism. Esophageal resection surgery for cancer is contraindicated in patients with organic and functional heart diseases, complicated by circulatory disorders and lung diseases; unilateral pulmonary tuberculosis is not a contraindication, as well as pleural adhesions, although they undoubtedly aggravate and complicate the operation. Diseases of the kidneys and liver - nephronephritis with persistent hematuria, albuminuria or oliguria, Botkin's disease, cirrhosis - are also considered a contraindication to surgical treatment esophageal cancer.

The operation of esophageal resection is also contraindicated in weakened patients who have difficulty walking and are severely exhausted until they are brought out of this condition.

The presence of at least one of the listed diseases or conditions in a patient with esophageal cancer will inevitably lead to his death either during the operation of esophageal resection or in the postoperative period. Therefore, in front of them radical operations contraindicated.

There are different opinions regarding the age of patients scheduled for surgery. G. A. Gomzyakov demonstrated a 68-year-old patient who was operated on for cancer of the lower thoracic esophagus. She underwent transpleural resection of the esophagus with simultaneous esophagogastric anastomosis in chest cavity. After the demonstration by F. G. Uglov, S. V. Geynats, V. N. Sheinis and I. M. Talman, the opinion was expressed that old age in itself is not a contraindication to surgery. Garlock, Klein, M. S. Grigoriev, B. N. Aksenov, A. B. Rise and others share the same opinion.

A number of authors believe that age over 65-70 years is a contraindication to resection of the esophagus, especially through the transpleural route. We believe that elderly patients with esophageal cancer should be scheduled for surgery with caution. It is necessary to take into account all age-related changes and the general condition of the patient, take into account the scale of the proposed operation depending on the location of the tumor, its prevalence and the method of surgical approach. Without a doubt, esophageal resection for small carcinoma lower section esophagus using the Savinykh method can be successfully performed in a 65-year-old patient with moderately severe cardiosclerosis and pulmonary emphysema, while resection of the esophagus with a transpleural approach in the same patient can end unfavorably.

MILITARY-MEDICAL ACADEMY

Department of Military Traumatology and Orthopedics

"APPROVED"

Head of the Department

Military traumatology and orthopedics

professor major general medical service

V. SHAPOVALOV

"___" ____________ 2003

Senior Lecturer at the Department of Military Traumatology and Orthopedics
candidate medical sciences
Colonel of the Medical Service N. LESKOV

LECTURE No.

in military traumatology and orthopedics

On the topic: “Plasty of bone cavities and tissue defects

For osteomyelitis"

for clinical residents, students of faculties I and VI

Discussed and approved at a department meeting

"_____" ____________ 2003

Protocol No._____


LITERATURE

a) Used in preparing the text of the lecture:

1. Akzhigitov G.N., Galeev M.A. and others. Osteomyelitis. M, 1986.

2. Aryev T.Ya., Nikitin G.D. Muscle plasticity of bone cavities. M, 1955.

3. Bryusov P.G., Shapovalov V.M., Artemyev A.A., Dulaev A.K., Gololobov V.G. Combat injuries to limbs. M, 1996, p. 89-100.

4. Vovchenko V.I. Treatment of wounded with gunshot fractures of the femur and tibia, complicated by defects. dis. Ph.D. honey. Sciences, St. Petersburg, 1995, 246 p.

5. Gaidukov V.M. Modern methods treatment of false joints. Author's abstract. doc. dis. L, 1988, 30 p.

6. Grinev M.V. Osteomyelitis. L., 1977, 152 p.

7. Diagnosis and treatment of wounds. Ed. SOUTH. Shaposhnikova, M., 1984.

8. Kaplan A.V., Makhson N.E., Melnikova V.M. Purulent traumatology of bones and joints, M., 1985.

9. Kurbangaleev S.M. Purulent infection in surgery. M.: Medicine. M., 1985.

10. Treatment of open bone fractures and their consequences. Mater. conf. dedicated to the 100th birthday of N.N. Pirogov. M., 1985.

11. Melnikova V.M. Chemotherapy of wound infections in traumatology and orthopedics. M., 1975.

12. Moussa M. Plastic surgery of osteomyelitic cavities with some biological and synthetic materials. dis. Ph.D. honey. Sci. L, 1977.

13. Nikitin G.D. Chronic osteomyelitis. L., 1982.

14. Nikitin G.D., Rak A.V., Linnik S.A. and others. Surgical treatment of osteomyelitis. St. Petersburg, 2000.

15. Nikitin G.D., Rak A.V., Linnik S.A. and others. Bone and musculoskeletal plastic surgery in the treatment of chronic osteomyelitis and purulent false joints. St. Petersburg, 2002.

16. Popkirov S. Purulent-septic surgery. Sofia, 1977.

17. Experience of Soviet medicine in the Great Patriotic War 1941-1954 M., 1951, vol. 2, pp. 276-488.

18. Wounds and wound infection. Ed. M.I.Kuzin and B.M.Kostyuchenko. M.. 1990.

19. Struchkov V.I., Gostishchev V.K., Struchkov Yu.V. Guide to purulent surgery. M.: Medicine, 1984.

20. Tkachenko S.S. Military traumatology and orthopedics. Textbook. M., 1977.

21. Tkachenko S.S. Transosseous osteosynthesis. Uch. allowance. L.: VMedA im. S.M.Kirova, 1983.

22. Chronic osteomyelitis. Sat. scientific works Len. sanitary and hygienic honey Institute. Ed. prof. G.D.Nikitina. L., 1982, t. 143.

2, 3, 4, 6, 13, 14, 15, 20.

VISUAL AIDS

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Introduction

The problem of osteomyelitis cannot currently be considered completely resolved. The reasons for this are largely determined by the special properties of bone tissue - its rigidity, tendency to necrosis when exposed, poor circulation and infection (formation of bone sequestration), cellular structure (formation of closed purulent foci, which themselves are a source of infection), condition unstable equilibrium in the “macroorganism-microbe” system, changes in the immunoreactivity of the body.

The long course (years and tens of years) of all forms of chronic osteomyelitis, the occurrence of exacerbations after periods of calm, severe complications (amyloidosis, kidney stone disease, allergization of the body, deformities, contractures and ankylosis of joints in a vicious position of the limb) - all this gave rise to the near In the past, osteomyelitis was considered an incurable disease. The development by domestic authors of the pathology and treatment system for acute and chronic osteomyelitis made it possible to refute this statement. The successful use of antibiotics in the post-war period and the introduction of radical plastic surgery into practice made it possible to obtain a lasting recovery in 80-90% of operated patients.

Currently, due to the evolution of purulent infection and changes in resistance human body in relation to it, there is an increase in the number of unsuccessful treatment outcomes for osteomyelitis, an increase in the number of late relapses of the disease, and the manifestation of generalization of infection. Osteomyelitis, like other purulent diseases and complications, becomes a social and sanitary-hygienic problem.

Over the past decades, open fractures and their adverse consequences have attracted increasing attention from surgeons, traumatologists, immunologists, microbiologists and doctors of other specialties. This is explained primarily by the worsening nature of injuries due to an increase in the number of multiple and combined injuries, as well as high percentage suppurative processes in patients with open bone fractures. Despite the noticeable progress of medicine, the frequency of suppuration in open fractures reaches 45%, and osteomyelitis - from 12 to 33% (Goryachev A.N., 1985).

A significant increase in surgical activity in the treatment of injuries, their consequences and orthopedic diseases, expansion of indications for internal osteosynthesis, an increase in the proportion of elderly patients among those operated on, and the presence of immunodeficiency of various origins in patients lead to an increase in the number of suppurations and osteomyelitis.

This lecture will discuss the issues of surgical treatment of osteomyelitis depending on the phase wound process and the size of the resulting surgical treatment secondary bone defect: direct and crossed muscle, free and non-free bone grafting.

Many domestic and foreign scientists have been involved in the diagnosis and treatment of purulent osteomyelitis. Of particular importance were the works of the Finnish surgeon M. Schulten, who first used muscle plastics in 1897 to treat bone cavities in chronic purulent osteomyelitis, and the Bulgarian surgeon S. Popkirov, who in 1958 showed the effectiveness of surgical treatment of bone cavities in osteomyelitis using the method of bone autoplasty.

The principles of treatment of osteomyelitis were developed back in 1925 by T.P. Krasnobaev. They include: influence on the body to reduce intoxication, normalize homeostasis; medicinal effect on pathogens; surgical treatment of the disease focus.

Surgical treatment of osteomyelitis is of critical importance; all methods of general and local influence on the body, aimed at optimizing the wound process, have only additional meaning, all of them are not effective enough without rational surgical tactics.

In case of exacerbation of the osteomyelitic process, opening and drainage of the purulent focus is indicated, necrosis - sequestrectomy. Reconstructive and plastic surgeries are performed after acute inflammatory phenomena have subsided. During surgery, a radical sequestrectomy is performed, resulting in the formation of a secondary bone cavity or bone defect along the length.

Elimination of the defect and stabilization of the bone are necessary conditions for the treatment of osteomyelitis.

Operative methods Treatments for bone defects in chronic osteomyelitis can be divided into two main groups: conservative and radical in relation to the resulting secondary cavity.

Conservative methods include isolated local treatment with antibiotics for all forms of osteomyelitis, the use of trephination and bone treatment (flattening of lesions, the use of fillings, most of which are only of historical significance).

If the cavity is small (up to 3 cm), it can be treated under a blood clot (Schede technique), cavities large sizes require replacement. For this purpose, in some cases, fillings are used.

In medicine, fillings mean organic and inorganic substances, introduced into cavities with hard walls to cure caries and chronic osteomyelitis. A distinctive feature of all types of fillings is the absence of biological connections with the body, primarily vascular and nervous. That is why it is incorrect to call plastic surgery for chronic osteomyelitis “biological filling.”

There are three types of fillings: those designed to be rejected or removed in the future; designed for resorption and biopolymer materials.

There are more than 50 types of fillings. The most serious research on the use of fillings was carried out by M. Mussa (1977), who used biopolymer compositions containing antibiotics in the treatment of chronic osteomyelitis. Currently, the drug “Kollapan” is used to replace bone cavities.

Regardless of the material, all fillings, all compositions are allogeneic biological tissues, which, when introduced into the bone cavity, become foreign bodies. This violates the basic principles of surgical treatment of wounds - removal, and not the introduction of foreign bodies into it (Grinev M.V., 1977). Therefore the percentage positive results treatment in general among various authors who used fillings does not exceed 70-75%.

Modern research speak about the fundamental unacceptability of most types of fillings when used in surgical practice.

The most acceptable currently is to replace the cavity with blood-supplied muscle or bone tissue.

The initially existing bone defect, which is expanded through necrosequestrectomy and radical clearance, remains the main treatment problem. It cannot be accomplished on its own; it exists for many months and years, turning into a bed of chronic purulent process, supporting fistulas and additionally damaging and destroying bone tissue. Such a wound is not capable of self-healing (Ivanov V.A., 1963). The task becomes even more difficult when a bone defect causes instability or when its continuity is disrupted.

Indications and contraindications for surgical treatment

The existence of a fistula supported by a bone cavity is, in the vast majority of cases, an absolute indication for surgical treatment. Fistulaless forms of osteomyelitis, including Brody's abscess, which are usually almost asymptomatic, as well as more superficial defects of soft tissue and bone, called osteomyelitic ulcers, are also subject to surgery. In most cases, it is very difficult to establish what is the main reason preventing the healing of an ulcer or fistula - sequesters, granulations, scars, foreign bodies or a cavity, therefore, the most correct and mandatory is the removal of all pathological tissues that form a purulent focus in the form of a cavity or surface defect fabrics. Patients who underwent repeated surgical interventions did not receive healing only because the final stage of the operation was not carried out - the elimination of the resulting secondary cavity or bone defect. In 46.7% of cases, the cavity itself is the main cause of a non-healing fistula or ulcer; in 2% of cases, independently or after surgery on the site of osteomyelitis, the fistula is supported by detached bone sequestra (Nikitin G.D. et al., 2000).

Thus, the indications for surgical treatment of osteomyelitis are:

1. The presence of non-healing fistulas or ulcers that correspond to the X-ray picture of osteomyelitis;

2. A form of osteomyelitis that occurs with periodic exacerbations;

3. Fistulaless forms of osteomyelitis, confirmed x-ray;

4. Rare forms of chronic osteomyelitis, complicated by tuberculosis, syphilis, tumors of the skeletal system.

Contraindications to surgical treatment are identical to those before any other operation. The most serious obstacle to plastic surgery is acute inflammation in or near the site of osteomyelitis. In these cases, opening and drainage of the abscess, expansion of the fistulous tract, sometimes trephination of the bone, removal of sequesters and antibacterial therapy. Temporary contraindications may arise in case of extensive bone lesions in relatively fresh cases of hematogenous osteomyelitis, where topical diagnosis of osteomyelitis is difficult, since the boundaries of the lesion have not been determined, or a pathological fracture is possible due to weakening of the bone. In these cases, it is advisable to postpone the operation for 2-3 months, so that during this period the acute inflammatory process, the bone became stronger and the focus began to demarcate.

Contraindications to surgery may also arise in cases where there are technical difficulties for its implementation: a significant size of the bone cavity with a corresponding lack of soft tissue in the affected area and the impossibility of obtaining them on the other limb. This forces one to resort to transplantation of free musculocutaneous flaps using microvascular techniques.

Indications for surgery. A distinction should be made between indications that are general in nature, for example emergency care, and special ones, depending on the characteristics of each disease.

The need for surgical intervention is dictated by the disease itself, its nature and course. As in adults, there are three groups of diseases.

1. Diseases requiring emergency or urgent surgery, such as strangulated hernia, congenital atresia of the gastrointestinal tract, perforated appendicitis, penetrating injury, etc.

2. Diseases that require surgery, but not urgently or urgently, for example, non-strangulated hernia, hydrocephalus, multifingered, hemangioma.

3. Diseases for which it is advisable to postpone surgical interventions until the child reaches a certain degree of development, for example, cleft palate, abnormalities of the genitourinary organs, malformations of the heart and great vessels.

Contraindications for surgery. Absolute contraindication is a preagonal or atonal state, also a state of shock or collapse. First, it is necessary to remove the child from them, and then to understand the feasibility and possibility of surgical intervention.

Unpromising operations are contraindicated, for example in non-viable newborns, complex recovery operations in children with severe mental development disorders.

Along with contraindications depending on general condition body and local changes, children have a number of relative contraindications. These include:
1) nutritional disorders (dystrophy), insufficient general development, weight loss;
2) anemia;
3) digestive disorders, diarrhea;
4) diseases respiratory organs, their catarrhal states;
5) unsatisfactory condition of the skin: pyoderma, fresh phenomena of exudative diathesis;
6) active rickets;
7) infectious diseases V acute period, during incubation and for the first time after transfer, their so-called goitrous-lymphatic state.

In addition to those mentioned, other unfavorable conditions for the operation may occur. However, in case of a threat to life, for example, intussusception, acute appendicitis, strangulated hernia, all of them cannot be an obstacle to the necessary surgical intervention.

Parental consent. Surgical interventions in children should be performed after obtaining written permission from parents or responsible caregivers. Deviations from this rule are permissible in the absence of them in cases of emergency or urgent surgery. If it is impossible to obtain their written consent, it is recommended to urgently convene a council of at least two doctors and notify the head of the department and the chief physician of the hospital.

Timing of the operation. The duration of the operation depends on the nature of the disease and the indications for the operation. Surgery can be performed on a child at any age, even a newborn.

It is urgent and urgent to operate on children in life-threatening situations. They depend on the nature of the disease, the development and general health of the child, as well as on the capabilities of the surgical technique and the state of anesthesiology.

Research before surgery. In most cases, a general clinical examination is sufficient. However, in some cases, in case of anomalies, injuries or diseases accompanied by significant impairment of the functions of the relevant organ systems (circulation, respiration, excretion, etc.), special studies are necessary.

For some diseases Hematological and biochemical blood tests are of great importance: blood sugar and proteins, colloid resistance; determination of chlorides, potassium, sodium, calcium, inorganic phosphorus, alkaline phosphatase, acid-base balance, blood enzymes, etc. Monograms and osmograms are also of great importance in the practice of pediatric surgical clinics. For some diseases, methods are indicated functional diagnostics liver, kidneys, endocrine glands, methods of cytological, chemical, microbiological studies.

In the indicated cases, X-ray examination methods are used: fluoroscopy, radiography, the use of contrast agents, tomography, ascending and descending urography, bronchography, angiography, angiocardiography, etc. Of particular importance in children is x-ray examination for the presence of an enlarged thymus gland.

Endoscopic research methods: sigmoidoscopy, cystoscopy, esophagoscopy, tracheo- and bronchoscopy found wide application. Special smaller tools are used. During production, sufficient experience of a doctor is required.

Preparing for surgery depends on the nature of the intervention itself, the disease, age and general condition of the child. Before major operations, a detailed check of the child’s health using functional diagnostic methods is necessary.

For urgent surgical interventions about acute appendicitis, intussusception, strangulated hernia, etc. it is necessary to restore impaired water-salt metabolism by administering Ringer-Locke solution or isotonic sodium chloride solution and blood transfusion.

Responsibility for proper preparation for surgery, for its correct implementation, and for the correct post-operative care are borne equally by both the attending surgeon and the anesthesiologist.

As soon as the child begins to navigate the environment, it is necessary to take into account his emotional state. In mental preparation, the assistance of parents and educators is very important. Children should be prepared both for hospitalization and for the upcoming operation.

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