STUDY OF METABOLIC DISORDERS AND THE CLINICAL EFFECTIVENESS OF THEIR CORRECTION IN THE POSTOPERATIVE PERIOD AS A MEASURE OF PREVENTION OF THE DEVELOPMENT OF FAILURE OF SMALL INTESTINAL ANASTOMOSES IN PATIENTS WITH A BACKGROUND OF INT RAABDOMINAL INFECTION
Authors: Boyko V. , Tymchenko M. , Ivanova Yu. , Kryvorotko I. , Lazyrskyi V. , Minukhin D. , Lavrinenko A. 
Published: October 2024

Summary. Purpose: to study the clinical effectiveness of correction of metabolic disorders in the postoperative period as a means of preventing the development of small intestinal failure. anastomoses against the background of intra-abdominal infection.
Material and methods. The data were based on the studied results of the correction of metabolic disorders in the postoperative period during the surgical treatment of 283 places, which had been treated at the State Institution «Zaitsev V.T. Institute of General and Urgent Surgery of the National Academy of Medical Sciences of Ukraine», which had been the clinical base of the Surgery Department №1 of the Kharkiv National Medical University; divided into two: the first - comparison (142 patients), the second — the main group (141 patients); patients had been homogeneous, representative and comparable in terms of gender, age, concomitant diseases, terms of return to the hospital from the moment of illness. All patients had undergone surgical interventions in the abdominal cavity with resection of the small intestine (imposing surgical sutures on the wall of the small intestine) in conditions of intra-abdominal infection. The diagnostic research program had included general clinical laboratory, instrumental, as well as immunological, immunoenzymatic, bacteriological and morphological studies. In this array, the received information had been entered into an electronic database and analyzed using the Excel statistical program package for Mac and STATISTICA.
Results. For all patients, in the postoperative period, infusion-detoxification therapy had been used, which had been based on hemodilution, identification and inactivation of groups of toxic products in the vascular bed, influence on the functions of natural detoxification organs, improvement of rheological properties of blood and microcirculation. For hemodilution, polyionic solutions had been used taking into account osmolality and electrolyte balance in combination with 10% glucose solution; the daily amount of infusion media had ranged from 30 to 100 ml/kg of the patient’s weight with sufficient diuresis. In addition, colloidal solutions had been used (low molecular weight dextran, hydroxyethyl starch derivatives and modified gelatin preparations); the daily amount of colloids had been up to 20 ml/kg of weight at an average rate of administration of 15 ml/min. Among the methods of extracorporeal detoxification, plasmapheresis had been used, hepatoprotectors had been prescribed (preparations of ademethionine, L-ornithine-L-aspartate, lipoic acid), and thiazotic acid preparations. The therapy complex had also included antioxidants (ascorbic acid 10%), agents that had neutralized the cellular effects of circulating toxic substances (nonspecific - heparin, specific - glutamic acid), antihypoxants of plastic action, regulators of energy metabolism (cytochrome C). For adequate correction of venous return and level of preload, crystalloids had been administered in combination with a three-time administration of specific anti-edema/anti-inflammatory agents (aescinic salt of 2,6-diaminohexanoic acid). Of the colloidal solutions, preference had been given to hydroxyethyl starch, modified gelatins, and derivatives of polyatomic alcohols. Transfusion of fresh frozen plasma had been performed in the presence of signs of consumption coagulopathy and reduced coagulation potential. In the case of low perfusion pressure, drugs of dopamine or dobutamine and/or noradrenaline and epinephrine had been used. Preference had been given to dobutamine, which provided an increase in splanchnic and nerve blood flow in small doses (2–5 μg/kg/min) and did not lead to an increase in total peripheral vascular resistance but effectively increased the perfusion of internal organs. In order to suppress oxidative stress and improve the functions of mitochondria, an agonist of purinergic (P2Y1) receptors nicotinimidadenine dinucleotide (10 mg intravenous) had been used. Initial antibiotic therapy (ABT) in case of need subgrouping of the comparison and the main group had been based on the polymicrobial nature of the inflammatory process. Aerobic microflora had been most often detected in the studied subjects – In 73 (86.4%) cases, of which associations with other aerobes or anaerobes had been determined in 29 (34.6%) patients. The basis of antibacterial therapy had been a two-stage de-escalation approach: at the first stage, the empirical prescription of drugs with a change in their regimen (if necessary) after receiving the results of the sensitivity of the identified microflora.
Conclusions. 1. The key to successful treatment of intra-abdominal infection had been first of all adequate sanitation or maximum delimitation of the primary focus. It had been considered mandatory to perform intestinal intubation as one of the initial measures to combat intoxication, with subsequent intra- and postoperative use of the capabilities of the intubation probe for intestinal conduction lavage, enterosorption, selective decontamination of intestines, enteral tube feeding, as well as sufficient sanitation and drainage of the abdominal cavity. 2. An important part of the treatment program at all stages, starting with preoperative preparation, had been detoxification therapy with the removal of toxic metabolites through natural visual pathways, as well as maintenance or restoration of the detoxification function of the main organ. In the most severe cases, it had been necessary to use efferent methods of detoxification (plasmapheresis). 3. Early enteral tube feeding had been the main point of detoxification. It had stimulated the main functions of the intestines, improved splanchnic microcirculation, reduced the risk of developing stress ulcers, and had played an important role in maintaining homeostasis. 4. In the system of treatment of severe intra-abdominal infection, it had been advisable to include antioxidants in a complex with the introduction of antibiotics and vasoactive drugs, as well as to use biological therapy (bacteriophages).