Application wound sorption in the complex treatment of purulent wounds

The dissertation is devoted to the study of the effectiveness of applicative wound sorption using a carbon-fibrous sorbent in the complex treatment of purulent wounds of various etiologies. Based on the clinical material of 148 patients, the features of the course of the wound process, the frequency of development of the systemic inflammatory response syndrome, the state of the antioxidant, immune, and proteolytic systems, as well as the metabolism of connective tissue, were analyzed. It has been shown that the inclusion of applicative sorption in standard therapy contributes to a decrease in the level of proinflammatory markers, a reduction in the bacterial contamination of wounds, and a shortening of the period of hospital treatment. Indications for the use of the method have been developed depending on the etiology, the area of the lesion, and the severity of inflammation.

The author has established that the degree of homeostasis disorders in purulent wounds is determined by the character of the pathogen, the prevalence of the process, and the presence of a systemic inflammatory response, while the positive effect of sorption is associated with normalization of the oxidant-antioxidant balance, a decrease in proteolytic activity, and stimulation of phagocytosis. The practical significance of the work consists in substantiating recommendations for the implementation of the method in outpatient surgery centers.

Relevance of the problem

The treatment of wounds remains one of the oldest and at the same time one of the most pressing problems in surgery. Throughout the entire period of the development of surgery, wound treatment has been continuously improved (Leshchenko I.G., Leshchenko Yu.G., 1984; Kozarov M.V. et al., 1995; Lisitsyn I.I., 2002; Kuznetsov N.A., 2004). Purulent diseases, as V.F. Voino-Yasenetsky noted, «have turned out to be the most important, the most everyday part of surgery».

At every stage of the development of surgical science, new methods of treatment were applied in accordance with the available technical capabilities (Kuzin M.I., Kostyuchenok B.M., 1990).

However, despite the large number of studies and searches, this problem cannot be considered finally resolved. To a certain extent, this is due to the complexity of the pathogenesis of the wound process and the continuing tendency toward an increase in the number of long-term and recurrent processes (Davydov Yu.A., Larichev A.B., 1999; Glukhov A.A., Minchenok A.N., 2003; Feizulin N.A., 2004).

The increase in the number of purulent diseases, postoperative purulent complications, the growing frequency of cases of generalization of infection and various toxic-allergic reactions considerably complicate the further progress of surgical science (Briskin B.S., 2000; Svetukhin A.M., Amiraslanov Yu.D., 2003; Blatun L.A., 2005).

According to data of the Ministry of Health of the Russian Federation (2000), approximately 51.8% of the bed capacity of surgical hospitals in Russia is constituted by purulent departments, and more than 40% of surgical patients are patients with purulent complications. Skin and soft tissue infections are among the most frequent complications in the clinic of surgical diseases and account for 15 to 30% of all complications (Eryukhin I.D. et al., 2003).

In the structure of nosocomial infections in surgical hospitals, the frequency of post-injection infections reaches 20%, and in outpatient polyclinic institutions – 76.5% (Afinogenov G.E. et al., 2003).

The transition of acute purulent processes into chronic ones is observed more and more often. The duration of treatment of patients with these diseases has increased significantly (Rychagov G.P. et al., 2003; Blatun L.A., 2005).

Every year in the CIS countries about 5 million patients with purulent-inflammatory diseases are registered, and in 7–50% of those who died in hospital these diseases were the main cause of death. Today the same number of suppurations is observed as before the antibacterial era (Nutov B.G. et al., 2001).

Recently, in the treatment of purulent wounds, considerable attention has been paid to methods that directly affect the wound process.

Local treatment of wounds is currently one of the main elements of the treatment of surgical infection. Many methods and means for the local treatment of wounds have been proposed, however, none of them can be called «ideal» (Lyubinetsky A.L. et al., 1988; Babaev R.F., Kuliev R.A., 1991; Grigoryan S.Kh., 1991; Adamyan A.A. et al., 2000; Svetukhin A.M., 2005; Fidarov E.Z., Zhdanovich V.V., 2004; Kuznetsov N.A., 2004; Kuzin N. et al., 1988; Swiecka-Kus J. et al., 1998; Sawada Y. et al., 1990).

One of the effective methods of local therapy of the wound process is the use of sorbing dressings. A hydrophilic sorbent absorbs from the wound surface a large amount of discharge with toxins and products of tissue disintegration dissolved in it, reduces bacterial contamination, and prevents the development of purulent-septic complications (Erskaya E.V., Sakhno L.A., 1989; Kornilov V.A. et al., 1989; Kuzin M.I., Kostyuchenok B.M., 1990; Lakhno M.L. et al., 1991; Takahashi H., 1993; Lukaszczyk K., 1995).

It must be borne in mind that the pathogenesis and course of the wound process have their own peculiarities associated, first of all, with the difference in destructive processes in the wound, the nature of the damaging agent, and the background of already existing pathological changes both in the skin and in the body as a whole. Therefore, the effectiveness of any method of wound therapy always requires separate consideration and study. The same applies to the mechanism of therapeutic action.

It should be noted that the peculiarities of the pathogenesis of the wound process are still the subject of study by various surgical schools. Some biochemical disorders present both in the wound itself and in the body as a whole have not been identified, and the metabolic factors determining the course of the wound process have been very poorly studied.

Therefore, it seems appropriate to compare clinical observation data with changes in biochemical, microbiological, and immunological indicators characterizing the severity of destructive processes in the wound. Such a study will broaden the understanding of the pathogenesis of the wound process and elucidate the mechanisms of the therapeutic effect in the local application of the method of applicative wound sorption. The foregoing considerations formed the basis for the present study.

Aim of the study

Improvement of the results of treatment of patients with purulent wounds through the use of a carbon-fibrous sorbent in the complex treatment of this category of patients.

Research objectives

1. To study the features of the clinical course and the severity of homeostasis disorders in purulent wounds.

2. To study the influence of applicative wound sorption on the clinical course of purulent wounds.

3. To determine the possible mechanisms of effectiveness of applicative wound sorption in purulent wounds of various origins.

Scientific novelty

1. The frequency of the systemic inflammatory response syndrome in purulent wounds has been established depending on their etiology, size, and microbial contamination. It was found that the appearance of the systemic inflammatory response is accompanied by an increase in the plasma of collagen metabolism products and a disturbance of the antioxidant and immune systems.

2. It was revealed that the use of applicative wound sorption creates favorable conditions for wound healing and shortens the period of hospital treatment. The degree of effectiveness of the method is determined by the activity of the inflammatory process, the area of the wound surface, and the presence of the systemic inflammatory response syndrome.

3. It was determined that the positive effect of applicative wound sorption in purulent wounds is accompanied by a stable tendency toward normalization of the antioxidant system, metabolism of connective tissue biopolymers, proteolytic activity of blood, and stimulation of phagocytosis.

Practical significance

As a result of the conducted studies, the existing ideas about homeostasis disorders in purulent wounds of various origins have been expanded. The obtained results can serve as baseline criteria for the introduction of more advanced methods of their correction into the complex treatment of this category of patients.

Based on a comprehensive assessment of the course of the wound process after the use of applicative wound sorption, indications for its use have been developed depending on the etiology of the purulent wound, its size, and the severity of inflammation.

The mechanisms of the positive influence of applicative wound sorption and the degree of its effectiveness have been established on the basis of the use of socio-economic factors in predicting the course of the wound process. This made it possible to recommend this method for implementation in outpatient surgery centers.

Main provisions submitted for defense:

1. The number of patients with purulent wounds in a general surgical hospital increases in the spring-summer period. In purulent wounds, the systemic inflammatory response syndrome develops in more than half of the cases. The specific character of the wound microflora does not exert a significant influence on its frequency.

2. The degree of homeostasis disorders in purulent wounds is determined by their etiology, prevalence, severity of the inflammatory process, the nature of the pathogen, and the frequency of the systemic inflammatory response.

3. The use of applicative wound sorption in purulent wounds significantly reduces the manifestations of the systemic inflammatory reaction, accelerates wound healing, and shortens the period of hospital stay.

4. The mechanisms of the positive effect of applicative wound sorption in purulent wounds are associated with a decrease in plasma proteolytic activity, the level of diene conjugates, protein-bound oxyproline, C-reactive protein, and von Willebrand factor, against the background of an increase in spontaneous and stimulated chemiluminescence of neutrophils.

Implementation

The main provisions of the dissertation have been implemented in the work of the surgical departments of the Municipal Healthcare Institution Clinical Hospital No. 9 of Yaroslavl.

The results of the research are used in the educational process at the Department of Hospital Surgery of the Yaroslavl State Medical Academy with students of the 5th and 6th years of the medical faculty, interns, and clinical residents.

Approval of the dissertation

The main provisions of the dissertation were reported at: the third annual seminar within the framework of the Interregional Conference «Treatment of Wounds and Wound Infection» (Yaroslavl, 2003); the XXV Scientific and Practical Conference of Surgeons of the Republic of Karelia (Petrozavodsk, 2003); the III Russian Conference of General Surgeons with International Participation (Rostov-on-Don – Anapa, 2005).

The III Conference of Surgeons of Russia (Tver, 2003); school

On the topic of the dissertation, 9 works have been published, of which 6 are in central press, including 2 in journals included in the list of the Higher Attestation Commission (VAK).

The dissertation is presented on 150 pages of typewritten text, consisting of a table of contents, introduction, literature review, clinical characteristics of patients and research methods, three chapters of original research, conclusion, findings, practical recommendations, and a list of references comprising 272 sources, of which 167 are domestic and 105 foreign. The presented material is illustrated with 51 tables and 12 figures.

The work was carried out at the State Educational Institution of Higher Professional Education «Yaroslavl State Medical Academy of the Federal Agency for Healthcare and Social Development» (Rector – Academician of RAMS, Professor Yu.V. Novikov) at the Department of Hospital Surgery (Head of the Department – Doctor of Medical Sciences, Professor V.V. Rybachkov). The clinical material consisted of data from the examination and treatment of patients with purulent wounds who were treated at the II Surgical Department of the Municipal Healthcare Institution Clinical Hospital No. 9 of the city of Yaroslavl (Chief Physician – Doctor of Medical Sciences, Professor M.I. Maiorov). The study of immunological parameters was carried out at the Laboratory of Clinical Immunology of MUZ MSCh YaNPZ (Head of the Laboratory – Doctor of Medical Sciences, Professor A.A. Baranov). Microbiological studies were conducted at the Department of Microbiology with the course of Immunology of YaSMA (Doctor of Medical Sciences, Professor E.B. Shvireva).