Early complications after surgery. Classification of postoperative complications. Measures for the treatment of chronic functional constipation in children

Early complications can arise in the first hours and days after surgery; they are associated with the inhibitory effect of narcotic substances on breathing and blood circulation, and with uncompensated water and electrolyte disturbances. Drugs that are not eliminated from the body and muscle relaxants that are not destroyed lead to respiratory depression, until it stops. This is manifested by hypoventilation (rare shallow breathing, recessed tongue), and apnea may develop.

Breathing disorders can also be caused by vomiting and regurgitation in a patient who has not completely recovered from the state of narcotic sleep. Therefore, monitoring the patient in the early postoperative period is very important. If breathing is impaired, it is necessary to immediately establish mechanical ventilation with an Ambu bag; if the tongue is retracted, use air ducts that restore the patency of the airways. In case of respiratory depression caused by the ongoing effect of narcotic substances, respiratory analeptics (nalorphine, bemegride) can be used.

Bleeding - the most serious complication of the postoperative period. It can be external (from a wound) or internal - hemorrhage in the cavity (thoracic, abdominal) tissue. Common signs of bleeding are pale skin, weak, rapid pulse, and decreased blood pressure. When bleeding from a wound, the bandage is soaked with blood, and bleeding from drains inserted into body cavities and tissue is possible. The increase in clinical and laboratory signs with slowly progressing internal bleeding allows us to clarify the diagnosis. Methods to stop bleeding are described in Chapter 5. If conservative measures are unsuccessful, wound revision and repeated surgery - relaparotomy, rethoracotomy - are indicated.

In the first days after surgery, patients may have disturbances in water-electrolyte balance, caused by an underlying disease in which there is loss of water and electrolytes (intestinal obstruction), or blood loss. Clinical signs of water-electrolyte imbalance are dry skin, increased skin temperature, decreased skin turgor, dry tongue, severe thirst, soft eyeballs, decreased central venous pressure and hematocrit, decreased diuresis, and tachycardia. It is necessary to immediately correct the deficiency of water and electrolytes by transfusion of appropriate solutions (Ringer-Locke solutions, potassium chloride, Sodium acetate + Sodium chloride, Sodium acetate + Sodium chloride + Potassium chloride). Transfusion must be carried out under the control of central venous pressure, the amount of urine released and the level of blood electrolytes. Fluid and electrolyte disorders can also occur in the late period after surgery, especially in patients with intestinal fistulas. In this case, constant correction of the electrolyte balance and transfer of the patient to parenteral nutrition are necessary.

In the early postoperative period, there may be respiratory disorders, associated with pulmonary atelectasis, pneumonia, bronchitis; These complications are especially common in elderly patients. To prevent respiratory complications, early activation of the patient, adequate pain relief after surgery, therapeutic exercises, percussion and vacuum chest massage, aerosol steam inhalations, and inflation of rubber chambers are important. All these measures contribute to the opening of collapsed alveoli and improve the drainage function of the bronchi.

Complications from the cardiovascular system often occur against the background of uncompensated blood loss, disturbed water-electrolyte balance and require adequate correction. In elderly patients with concomitant pathology of the cardiovascular system, against the background of the underlying surgical disease, anesthesia and surgery in the postoperative period, episodes of acute cardiovascular failure (tachycardia, rhythm disturbances), as well as an increase in central venous pressure, which serves as a symptom of left ventricular failure and pulmonary edema, may occur. Treatment is individual in each specific case (cardiac glycosides, antiarrhythmics, coronary dilators). For pulmonary edema, ganglion blockers, diuretics, and inhalation of oxygen moistened with alcohol are used.

During operations on the gastrointestinal tract, one of the complications may be intestinal paresis(dynamic intestinal obstruction). It usually develops in the first 2-3 days after surgery. Its main signs: bloating, absence of peristaltic bowel sounds. For the prevention and treatment of paresis, intubation of the stomach and intestines, early activation of the patient, anesthesia, epidural anesthesia, perirenal blockades, intestinal stimulants (neostigmine methyl sulfate, diadynamic currents, etc.) are used.

Urinary dysfunction in the postoperative period may be due to a change in the excretory function of the kidneys or the addition of inflammatory diseases - cystitis, urethritis, pyelonephritis. Urinary retention can also be of a reflex nature - caused by pain, spastic contraction of the abdominal muscles, pelvis, and bladder sphincters.

For seriously ill patients after long-term traumatic operations, a permanent catheter is installed in the bladder, which allows systematic monitoring of diuresis. In case of urinary retention, painkillers and antispastic agents are administered; A warm heating pad is placed on the bladder area above the pubis. If the patient's condition allows, men are allowed to stand up to try to urinate while standing. If it fails, urine is removed with a soft catheter; if this fails, with a hard (metal) catheter. As a last resort, when attempts to catheterize the bladder are unsuccessful (with benign prostatic hyperplasia), a suprapubic bladder fistula is applied.

Thromboembolic complications in the postoperative period they are rare and mainly develop in the elderly and seriously ill. The source of embolism is most often the veins of the lower extremities and pelvis. Slowing blood flow and changing the rheological properties of blood can lead to thrombosis. Prevention includes activation of patients, treatment of thrombophlebitis, bandaging of the lower extremities, correction of the blood coagulation system, which includes the use of sodium heparin, administration of agents that reduce the aggregation of blood cells (for example, dextran [average molecular weight 30,000-40,000], acetylsalicylic acid ), daily fluid transfusion to create moderate hemodilution.

Development wound infection most often occurs on the 3-10th day of the postoperative period. Pain in the wound, increased body temperature, tissue compaction, inflammatory infiltrate, hyperemia of the skin around the wound are indications for its revision, partial or complete removal of sutures. Subsequent treatment is carried out according to the principle of treating a purulent wound.

In exhausted patients who are in bed for a long time in a forced position, it is possible to develop bedsores in places of tissue compression. More often, bedsores appear in the area of ​​the sacrum, less often in the area of ​​the shoulder blades, heels, etc. In this case, the places of compression are treated with camphor alcohol, the patients are placed on special rubber circles, an anti-bedsore mattress, and a 5% solution of potassium permanganate is used. When necrosis has developed, necrectomy is resorted to, and treatment is carried out according to the principle of treating a purulent wound. To prevent bedsores, early activation of the patient, turning him in bed, treating the skin with antiseptics, using rubber circles and mattresses, and clean, dry linen are necessary.

Pain syndrome in the postoperative period. The absence of pain after surgery largely determines the normal course of the postoperative period. In addition to psycho-emotional perception, pain syndrome leads to respiratory depression, reduces the cough impulse, promotes the release of catecholamines into the blood, against this background tachycardia occurs, and blood pressure increases.

To relieve pain, you can use narcotic drugs that do not depress breathing and cardiac activity (for example, fentanyl), non-narcotic analgesics (metamizole sodium), transcutaneous electroanalgesia, long-term epidural anesthesia, acupuncture. The latter methods in combination with analgesics are especially indicated for the elderly. Pain relief allows the patient to cough up mucus well, breathe deeply, and be active, which determines a favorable course of the postoperative period and prevents the development of complications.

Postoperative period I Postoperative period

Disorders of the central mechanisms of respiratory regulation, which usually arise as a result of depression of the respiratory center under the influence of anesthetic and narcotic drugs used during surgery, can lead to acute respiratory disorders in the immediate area. The basis of intensive therapy for acute respiratory disorders of central origin is artificial pulmonary ventilation (ALV), the methods and options of which depend on the nature and severity of respiratory disorders.

Disturbances in the peripheral mechanisms of respiratory regulation, more often associated with residual muscle relaxation or recurarization, can lead to rare gas exchange disorders and cardiac arrest. In addition, these disorders are possible in patients with myasthenia gravis, myopathies and other peripheral respiratory disorders. It consists of maintaining gas exchange by mask ventilation or repeated tracheal intubation and transfer to mechanical ventilation until muscle tone is completely restored and adequate spontaneous breathing.

Severe breathing disorders can be caused by pulmonary atelectasis, pneumonia, and pulmonary embolism. When clinical signs of atelectasis appear and the diagnosis is confirmed by X-ray, it is necessary to eliminate first of all the cause of atelectasis. With compression atelectasis, this is achieved by draining the pleural cavity to create a vacuum. For obstructive atelectasis, therapeutic bronchoscopy is performed with sanitation of the tracheobronchial tree. If necessary, the patient is transferred to mechanical ventilation. The complex of therapeutic measures includes the use of aerosol forms of bronchodilators, percussion and vibration of the chest, postural.

One of the serious problems in intensive care of patients with respiratory failure is the need for mechanical ventilation. The guidelines for solving this problem are the respiratory rate of more than 35 per 1 min, Stange test less than 15 With, pO 2 below 60 mm rt. st. despite inhalation of a 50% oxygen mixture, hemoglobin oxygen less than 70%, pCO 2 below 30 mm rt. st. . vital capacity of the lungs is less than 40-50%. The determining criterion for the use of mechanical ventilation in the treatment of respiratory failure is the increase in respiratory failure and the insufficient effectiveness of the therapy.

In early P. p. . acute hemodynamic disturbances can be caused by volemic, vascular or cardiac failure. The causes of postoperative hypovolemia are varied, but the main ones are those not replenished during surgery or ongoing internal or external ones. The most accurate assessment of the state of hemodynamics is given by comparing central venous pressure (CVP) with pulse and prevention of postoperative hypovolemia is the full compensation of blood loss and circulating blood volume (CBV), adequate pain relief during surgery, careful surgical intervention, ensuring adequate gas exchange and correction of disorders metabolism both during surgery and in early P. p. The leading place in intensive therapy for hypovolemia is occupied by therapy aimed at replenishing the volume of circulating fluid.

Vascular insufficiency develops as a result of toxic, neurogenic, toxic-septic or allergic shock. In modern conditions, cases of anaphylactic and septic shock have become more frequent in P. for anaphylactic shock (Anaphylactic shock) consists of intubation and mechanical ventilation, the use of adrenaline, glucocorticoids, calcium supplements, and antihistamines. Heart failure is a consequence of cardiac (angina, surgery) and extracardiac (toxicoseptic myocardial) causes. Its therapy is aimed at eliminating pathogenetic factors and includes the use of cardiotonic agents, coronary lytics, anticoagulants, electrical pulse cardiac stimulation, and assisted cardiopulmonary bypass. In case of cardiac arrest, cardiopulmonary resuscitation is used.

The course of P. p. to a certain extent depends on the nature of the surgical intervention, existing intraoperative complications, the presence of concomitant diseases, and the age of the patient. With a favorable course, P. p. in the first 2-3 days can be increased to 38°, and the difference between the evening and morning temperatures does not exceed 0.5-0.6°. The pain gradually subsides by the 3rd day. The pulse rate in the first 2-3 days remains within 80-90 beats per 1 min, CVP and blood pressure are at the level of preoperative values; the next day after surgery, only a slight increase in sinus rhythm is noted. After operations under endotracheal anesthesia, the next day the patient coughs up a small amount of mucous sputum, breathing remains vesicular, and single dry sounds can be heard, disappearing after coughing up the sputum. the skin and visible mucous membranes do not undergo any changes compared to their color before the operation. remains moist and may be covered with a whitish coating. corresponds to 40-50 ml/h, there are no pathological changes in the urine. After operations on the abdominal organs, the abdominal cavity remains symmetrical; bowel sounds are sluggish on days 1-3. Moderate is allowed on the 3-4th day of P. p. after stimulation, cleansing. The first postoperative revision is carried out the next day after the operation. In this case, the edges of the wound are not hyperemic, not swollen, the sutures do not cut into the skin, and the wound remains moderate during palpation. and hematocrit (if there was no bleeding during surgery) remain at the original values. On the 1st-3rd day, moderate leukocytosis with a slight shift of the formula to the left, a relative increase in ESR may be observed. In the first 1-3 days, slight hyperglycemia is observed, but sugar in the urine is not detected. A slight decrease in the level of albumin-globulin ratio is possible.

In elderly and senile people, early P. is characterized by the absence of an increase in body temperature; more pronounced and fluctuations in blood pressure, moderate (up to 20 V 1 min) and a large amount of sputum in the first postoperative days, sluggish tract. the wound heals more slowly, eventration and other complications often occur. Possible.

Due to the tendency to reduce the time a patient spends in hospital, an outpatient surgeon has to observe and treat some groups of patients already from the 3-6th day after surgery. For a general surgeon in an outpatient setting, the most important are the main complications of P. p., which can occur after operations on the abdominal and thoracic organs. There are many risk factors for the development of postoperative complications: concomitant diseases, long duration of surgery, etc. During the outpatient examination of the patient and in the preoperative period in the hospital, these factors must be taken into account and appropriate corrective therapy must be carried out.

With all the variety of postoperative complications, the following signs can be identified that should alert the doctor in assessing the course of P. p. Increased body temperature from the 3rd-4th or 6-7th day, as well as high temperature (up to 39° and above ) from the first day after the operation indicate an unfavorable course of P. p. hectic from the 7-12th day indicates a severe purulent complication. A sign of trouble is pain in the area of ​​the operation, which does not subside by the 3rd day, but begins to increase. Severe pain from the first day of P. p. should also alert the doctor. The reasons for the intensification or resumption of pain in the surgical area are varied: from superficial suppuration to intra-abdominal catastrophe.

Severe tachycardia from the first hours of P. p. or its sudden appearance on the 3-8th day indicates a developed complication. A sudden drop in blood pressure and at the same time an increase or decrease in central venous pressure are signs of a severe postoperative complication. In many complications, the ECG shows characteristic changes: signs of overload of the left or right ventricle, various arrhythmias. The causes of hemodynamic disturbances are varied: heart disease, bleeding, etc.

The appearance of shortness of breath is always alarming, especially on the 3-6th day of P. p. The causes of shortness of breath in P. p. can be pneumonia, septic shock, pleural empyema, pulmonary edema, etc. The doctor should be alerted by sudden unmotivated shortness of breath, characteristic of thromboembolism pulmonary arteries.

Cyanosis, pallor, marbled skin, purple, blue spots are signs of postoperative complications. The appearance of yellowness of the skin often indicates severe purulent complications and developing liver failure. Oligoanuria indicates a severe postoperative situation - renal failure.

A decrease in hemoglobin and hematocrit is a consequence of unreplenished surgical blood loss or postoperative bleeding. A slow decrease in hemoglobin and the number of red blood cells indicates inhibition of erythropoiesis of toxic origin. , lymphopenia or the reappearance of leukocytosis after normalization of the blood count is characteristic of complications of an inflammatory nature. A number of biochemical blood parameters may indicate surgical complications. Thus, an increase in blood and urine levels is observed with postoperative pancreatitis (but also possible with mumps, as well as high intestinal obstruction); transaminases - during exacerbation of hepatitis, myocardial infarction, liver; bilirubin in the blood - with hepatitis, obstructive jaundice, pylephlebitis; urea and creatinine in the blood - with the development of acute renal failure.

Main complications of the postoperative period. Suppuration of a surgical wound is most often caused by aerobic flora, but often the causative agent is anaerobic non-clostridial. The complication usually appears on the 5-8th day of P. p., it can occur after discharge from the hospital, but rapid development of suppuration is also possible already on the 2-3rd day. When the surgical wound suppurates, the body temperature, as a rule, rises again and is usually of a similar nature. Moderate leukocytosis is noted, with anaerobic non-clostridial flora - pronounced lymphopenia, toxic granularity of neutrophils. Diuresis, as a rule, is not impaired.

Local signs of wound suppuration are swelling in the area of ​​the sutures, skin, and severe pain on palpation. However, if suppuration is localized under the aponeurosis and has not spread to the subcutaneous tissue, these signs, with the exception of pain on palpation, may not exist. In elderly and senile patients, general and local signs of suppuration are often erased, and the prevalence of the process at the same time can be large.

Treatment consists of spreading the edges of the wound, sanitation and drainage, and dressings with antiseptics. When granulations appear, ointment is prescribed and secondary sutures are applied. After careful excision of purulent-necrotic tissue, suturing with drainage and further flow-drip washing of the wound with various antiseptics with constant active aspiration are possible. For extensive wounds, surgical necrectomy (complete or partial) is supplemented with laser, X-ray or ultrasound treatment of the wound surface, followed by the use of aseptic dressings and the application of secondary sutures.

If suppuration of a postoperative wound is detected when a patient visits a surgeon in a clinic, then with superficial suppuration in the subcutaneous tissue, treatment on an outpatient basis is possible. If suppuration in deep-lying tissues is suspected, hospitalization in the purulent department is necessary, because in these cases, more complex surgery is required.

Currently, the danger of clostridial and non-clostridial infection (see Anaerobic infection), which may show signs of shock, high body temperature, hemolysis, and increasing subcutaneous crepitus, is becoming increasingly important in P. At the slightest suspicion of an anaerobic infection, urgent hospitalization is indicated. In the hospital, the wound is immediately opened wide, non-viable tissue is excised, intensive antibiotic therapy is started (penicillin - up to 40,000,000 or more per day intravenously, metronidazole - 1 G per day, clindamycin intramuscularly 300-600 mg every 6-8 h), carry out serotherapy, carry out hyperbaric oxygenation (Hyperbaric oxygenation).

Due to inadequate hemostasis during the operation or other reasons, hematomas may occur located under the skin, under the aponeurosis or intermuscularly. Deep hematomas in the retroperitoneal tissue, pelvic and other areas are also possible. In this case, the patient is bothered by pain in the area of ​​the operation, upon examination of which swelling is noted, and after 2-3 days - in the skin around the wound. Small hematomas may not be clinically apparent. When a hematoma appears, the wound is opened, its contents are evacuated, hemostasis is carried out, the wound cavity is treated with antiseptic solutions and the wound is sutured using any measures to prevent possible subsequent suppuration.

Therapy of psychosis consists of treating the underlying disease in combination with the use of antipsychotics (see Antipsychotics), antidepressants (Antidepressants) and tranquilizers (Tranquilizers). almost always favorable, but worsens in cases where states of stupefaction are replaced by intermediate syndromes.

Thrombophlebitis most often occurs in the system of superficial veins that were used during or after surgery for infusion therapy. As a rule, superficial veins of the upper extremities are not dangerous and are stopped after local treatment, including immobilization of the limb, the use of compresses, heparin ointment, etc. Superficial thrombophlebitis of the lower extremities can cause deep phlebitis with the threat of thromboembolism of the pulmonary arteries. Therefore, in the preoperative period, it is necessary to take into account coagulogram data and factors such as a history of thrombophlebitis, complicated, lipid metabolism disorders, vascular diseases, and lower extremities. In these cases, the limbs are bandaged and measures are taken to combat anemia, hypoproteinemia and hypovolemia, and normalize arterial and venous circulation. In order to prevent thrombus formation in the P. p., along with adequate restoration of homeostasis in patients with risk factors, it is advisable to prescribe direct and indirect action.

One of the possible complications of P. p. is pulmonary arteries. Pulmonary artery thromboembolism (pulmonary embolism) is more common, fatty and air embolism is less common. The volume of intensive care for pulmonary embolism depends on the nature of the complication. In the fulminant form, resuscitation measures are necessary (trachea, mechanical ventilation, closed). Under appropriate conditions, it is possible to perform emergency thromboembolectomy with mandatory massage of both lungs or catheterization embolectomy followed by anticoagulant therapy against the background of mechanical ventilation. For partial embolism of the branches of the pulmonary arteries with a gradually developing clinical picture, fibrinolytic and anticoagulant therapy is indicated.

The clinical picture of postoperative peritonitis is diverse: abdominal pain, tachycardia, gastrointestinal tract problems that cannot be controlled by conservative measures, changes in the blood count. The outcome of treatment depends entirely on timely diagnosis. Relaparotomy is performed, the source of peritonitis is eliminated, the abdominal cavity is sanitized, adequately drained, and nasointestinal intubation is performed.

Eventration, as a rule, is a consequence of other complications - paresis of the gastrointestinal tract, peritonitis, etc.

Postoperative pneumonia can occur after severe operations on the abdominal organs, especially in elderly and senile people. In order to prevent it, inhalations, cupping, breathing exercises, etc. are prescribed. Postoperative pleura can develop not only after operations on the lungs and mediastinum, but also after operations on the abdominal organs. The chest plays a leading role in diagnosis.

Outpatient management of patients after neurosurgical operations. Patients after neurosurgical operations usually require long-term outpatient observation and treatment for the purpose of psychological, social and occupational rehabilitation. After surgery for traumatic brain injury (traumatic brain injury), complete or partial impairment of cerebral functions is possible. However, in some patients with traumatic arachnoiditis and arachnoencephalitis, hydrocephalus, epilepsy, various psychoorganic and vegetative syndromes, the development of cicatricial adhesions and atrophic processes, disorders of hemo- and liquor dynamics, inflammatory reactions, and immune failure is observed.

After removal of intracranial hematomas, hygromas, areas of brain crush, etc. anticonvulsant therapy is carried out under the control of electroencephalography (Electroencephalography). In order to prevent epileptic seizures, which develop after severe traumatic brain injury in approximately 1/3 of patients, drugs containing phenobarbital (pagluferal = 1, 2, 3, gluferal, etc.) are prescribed for 1-2 years. For epileptic seizures that appear as a result of traumatic brain injury, therapy is selected individually, taking into account the nature and frequency of epileptic paroxysms, their dynamics, age and general condition of the patient. Various combinations of barbiturates, tranquilizers, nootropics, anticonvulsants and sedatives are used.

To compensate for impaired brain functions and accelerate recovery, vasoactive (Cavinton, Sermion, Stugeron, Teonicol, etc.) and nootropic (piracetam, encephabol, aminalon, etc.) drugs are used in alternating two-month courses (at intervals of 1-2 months) for 2- 3 years. It is advisable to supplement this basic therapy with agents that affect tissue metabolism: amino acids (cerebrolysin, glutamic acid, etc.), biogenic stimulants (aloe, etc.), enzymes (lidase, lecozyme, etc.).

According to indications, various cerebral syndromes are treated on an outpatient basis - intracranial hypertension (intracranial hypertension), intracranial hypotension (see Intracranial pressure), cephalgic, vestibular (see Vestibular symptom complex), asthenic (see Asthenic syndrome), hypothalamic (see Hypothalamic (Hypothalamic syndromes)), etc., as well as focal ones - pyramidal (see Paralysis), cerebellar, subcortical, etc. In case of mental disorders, observation by a psychiatrist is mandatory.

After surgical treatment of a pituitary adenoma (see Pituitary adenoma), the patient should be monitored along with a neurosurgeon, neurologist and ophthalmologist, since after surgery it often develops (hypothyroidism, insipidus, etc.), requiring hormone replacement therapy.

After transnasosphenoidal or transcranial removal of a prolactotropic pituitary adenoma and an increase in the concentration of prolactin in men, sexual activity decreases, hypogonadism develops, and in women, infertility and lactorrhea. 3-5 months after treatment with Parlodel, patients may recover fully and experience symptoms (during which Parlodel is not used).

When panhypopituitarism develops in P., replacement therapy is carried out continuously for many years, because stopping it can lead to a sharp deterioration in the condition of patients and even death. For hypocortisolism, ACTH is prescribed; for hypothyroidism, it is used. For diabetes insipidus, the use of adiurecrine is mandatory. Replacement therapy for hypogonadism is not always used; in this case, consultation with a neurosurgeon is necessary.

After discharge from the hospital, patients operated on for benign extracerebral tumors (meningiomas, neuromas) are prescribed therapy that helps accelerate the normalization of brain functions (vasoactive, metabolic, vitamin preparations, exercise therapy). In order to prevent possible epileptic seizures, small doses of anticonvulsants are replaced for a long time (usually). To resolve the intracranial hypertension syndrome that often remains after surgery (especially with severe congestive optic nerves), dehydrating drugs (furosemide, diacarb, etc.) are used, recommending their use 2-3 times a week for several months. With the involvement of speech therapists, psychiatrists and other specialists, targeted treatment is carried out to eliminate deficits and correct certain brain functions (speech, vision, hearing, etc.).

For intracerebral tumors, taking into account the degree of their malignancy and the extent of surgical intervention, outpatient treatment according to individual indications includes courses of radiation therapy, hormonal, immune and other drugs in various combinations.

In the outpatient management of patients who have undergone transcranial and endonasal operations for arterial, arteriovenous aneurysms and other vascular malformations of the brain, special attention is paid to the prevention and treatment of ischemic brain lesions. Prescribed drugs that normalize cerebral vessels (aminophylline, no-shpa, papaverine, etc.), microcirculation (trental, complamin, sermion, cavinton), brain (piracetam, encephabol, etc.). Similar therapy is indicated when applying extra-intracranial anastomoses. In cases of severe epileptic readiness, according to clinical data and electroencephalography results, preventive anticonvulsant therapy is administered.

Patients who have undergone stereotactic surgery for parkinsonism are often additionally prescribed long-term neurotransmitter therapy (levodopa, nacom, madopar, etc.), as well as anticholinergic drugs (cyclodol and its analogues, tropacin, etc.).

After operations on the spinal cord, long-term, often multi-year treatment is carried out, taking into account the nature, level and severity of the lesion, the radicality of the surgical intervention and the leading clinical syndromes. Prescribed to improve blood circulation, metabolism and trophism of the spinal cord. In case of gross destruction of the spinal cord substance and persistent swelling, proteolysis inhibitors (contrical, gordox, etc.) and dehydrating agents are used (). Pay attention to the prevention and treatment of trophic disorders, especially bedsores (bedsores). Considering the high incidence of chronic sepsis in severe spinal cord injuries, on an outpatient basis they may require a course of antibacterial and antiseptic therapy.

Many patients who have undergone spinal cord surgery require correction of dysfunction of the pelvic organs. Bladder catheterization or permanent catheterization, as well as tidal systems are often used for a long time. It is necessary to strictly observe measures to prevent outbreaks of urinary infection (thorough toileting of the genital organs, washing the urinary tract with a solution of furatsilin, etc.). With the development of urethritis, cystitis, pyelitis, pyelonephritis, antibiotics and antiseptics (nitrofuran and naphthyridine derivatives) are prescribed.

For spastic para- and tetraparesis and plegia, antispastic drugs (baclofen, mydocalm, etc.) are used; for flaccid paresis and paralysis, anticholinesterase drugs are used, as well as exercise therapy and massage. After operations for spinal cord injuries, general, segmental and local physiotherapy and balneotherapy are widely used. Transcutaneous electrical stimulation (including the use of implanted electrodes), which helps accelerate reparative processes and restore spinal cord conductivity, is successfully used.

After operations on the spinal and cranial nerves and plexuses (stitching, etc.) on an outpatient basis, many months or many years of rehabilitation treatment are carried out, preferably under thermal imaging control. In various combinations, drugs are used that improve (prozerin, galantamine, oxazil, dibazol, etc.) and trophism of damaged peripheral nerves (groups B, E, aloe, FiBS, vitreous, anabolic agents, etc.). For severe scar processes, lidase, etc. are used. Various options for electrical stimulation, physical and balneotherapy, exercise therapy, massage, as well as early occupational rehabilitation are widely used.

Outpatient management of patients after eye surgery should ensure continuity of treatment in accordance with the surgeon's recommendations. The patient visits an ophthalmologist for the first time in the first week after discharge from the hospital. The therapeutic tactics for patients who have undergone surgery on the eye appendages, after removing the sutures from the skin of the eyelids and conjunctiva, is to monitor the surgical wound. After abdominal operations on the eyeball, the patient is actively observed, i.e. schedules follow-up examinations and monitors the correct implementation of treatment procedures.

After antiglaucomatous operations with a fistulosing effect and a pronounced filtration cushion in early P. p., in an outpatient setting, Shallow Anterior Chamber Syndrome may develop with hypotony due to cilichoroidal detachment, diagnosed with ophthalmic lighting or ultrasound echography, if there are significant changes in the optical media of the eye or a very narrow one that cannot be dilated. In this case, cilichoroidal detachment is accompanied by sluggish iridocyclitis, which can lead to the formation of posterior synechiae, blockade of the internal operating fistula by the root of the iris or processes of the ciliary body with a secondary increase in intraocular pressure. may lead to cataract progression or swelling. In this regard, treatment tactics in an outpatient setting should be aimed at reducing subconjunctival filtration by applying a pressure bandage to the operated patient with placing a thick cotton swab on the upper eyelid and treating Iridocyclitis a. Shallow anterior chamber syndrome can develop after intracapsular cataract extraction, accompanied by an increase in intraocular pressure as a result of difficulty transferring moisture from the posterior chamber to the anterior chamber. The tactics of an outpatient ophthalmologist should be aimed, on the one hand, at reducing the production of intraocular fluid (diacarb, 50% glycerol solution), on the other hand, at eliminating the iridovitreal block by prescribing mydriatics or laser peripheral iridectomy. The lack of a positive effect in the treatment of small anterior chamber syndrome with hypotension and hypertension is an indication for hospitalization.

The management tactics for patients with aphakia after extracapsular cataract extraction and patients with intracapsular pseudophakia are identical (unlike pupillary pseudophakia). When indicated (), it is possible to achieve maximum mydriasis without the risk of dislocation and dislocation of the artificial lens from the capsular pockets. After cataract extraction, it is advisable not to remove supramidal sutures for 3 months. During this time, a smooth operating surface is formed, tissue swelling disappears, decreases or completely disappears. The continuous one is not removed; it resolves over several years. Interrupted sutures, if their ends are not tucked, are removed after 3 months. The indication for suture removal is the presence of astigmatism 2.5-3.0 diopter and more. After the stitches are removed, the patient is prescribed 20% sodium sulfacyl solution instilled into the eye 3 times a day or other medications depending on tolerance for 2-3 days. A continuous suture after penetrating keratoplasty is not removed from 3 months to 1 year. After penetrating keratoplasty, the long-term treatment prescribed by the surgeon is monitored by an outpatient ophthalmologist.

Among the complications in long-term P., a graft or infectious process may develop, most often a herpes viral infection, which is accompanied by graft edema, iridocyclitis, and neovascularization.

Examinations of patients after operations for retinal detachment are carried out on an outpatient basis after 2 weeks, 3 months, 6 months, 1 year and when complaints of photopsia or visual impairment appear. If retinal detachment recurs, the patient is referred to. The same tactics of patient management are followed after vitreectomy for hemophthalmos. Patients who have undergone surgery for retinal detachment and vitreectomy should be warned about following a special regime that excludes low head tilts and heavy lifting; Colds accompanied by coughing and acute shortness of breath, for example, should be avoided.

After operations on the eyeball, all patients must follow a diet that excludes spicy, fried, salty foods and alcoholic beverages.

Outpatient management of patients after abdominal surgery. After operations on the abdominal organs, P. p. may be complicated by the formation of fistulas of the gastrointestinal tract. for patients with artificially formed or naturally occurring fistulas is an integral part of their treatment. Fistulas of the stomach and esophagus are characterized by the release of food masses, saliva and gastric juice; for fistulas of the small intestine - liquid or pasty intestinal chyme, depending on the level of location of the fistula (high or low small intestinal). Discharge from colonic fistulas - . From rectal fistulas, mucopurulent is released, from fistulas of the gallbladder or bile ducts - bile, from pancreatic fistulas - light transparent pancreatic. The amount of discharge from fistulas varies depending on the nature of food, time of day and other reasons, reaching 1.5 l and more. With long-existing external fistulas, their discharge macerates the skin.

Observation of patients with gastrointestinal tract fistulas includes assessment of their general condition (adequacy of behavior, etc.). It is necessary to monitor the color of the skin, the appearance of hemorrhages on it and the mucous membranes (in case of liver failure), determine the size of the abdomen (in case of intestinal obstruction), liver, spleen, and the protective reaction of the muscles of the anterior abdominal wall (in case of peritonitis). At each dressing, the skin around the fistula is cleaned with a soft gauze cloth, washed with warm water and soap, rinsed thoroughly and gently blotted dry with a soft towel. Then it is treated with sterile Vaseline, Lassar paste or syntomycin emulsion.

To isolate the skin in the fistula area, elastic adhesive cellulose-based films, soft pads, patches and activated carbon filters are used. These devices prevent skin and uncontrolled release of gases from the fistula. An important condition for care is the discharge from the fistula in order to avoid contact of the discharge with the skin, underwear and bed linen. For this purpose, a number of devices are used to drain the fistula with discharge of discharge from it (bile, pancreatic juice, urine into a bottle, feces into a colostomy bag). From artificial external biliary fistulas, more than 0.5 l bile, which is filtered through several layers of gauze, diluted with any liquid and given to the patient during meals. Otherwise, severe disturbances of homeostasis are possible. Drains inserted into the bile ducts must be washed daily (with saline or furatsilin) ​​so that they are not encrusted with bile salts. After 3-6 months, these drains must be replaced with x-ray monitoring of their location in the ducts.

When caring for artificial intestinal fistulas (ileo- and colostomies) formed for therapeutic purposes, self-adhesive colostomy bags or colostomy bags attached to a special belt are used. The selection of colostomy bags is made individually, taking into account a number of factors (location of the ileo- or colostomy, its diameter, the condition of the surrounding tissues).

Enteral (tube) administration is important in order to satisfy the patient’s body’s needs for plastic and energy substances. It is considered as one of the types of additional artificial nutrition (along with parenteral), which is used in combination with other types of therapeutic nutrition (see Tube nutrition, Parenteral nutrition).

Due to the exclusion of some parts of the digestive tract from the digestive processes, it is necessary to create a balanced diet, which assumes an average consumption of 80-100 for an adult G squirrel, 80-100 G fat, 400-500 G carbohydrates and the appropriate amount of vitamins, macro- and microelements. Specially developed enteral mixtures (enpits), canned meat and vegetable diets are used.

Enteral nutrition is provided through a nasogastric tube, or a tube inserted through a gastrostomy or jejunostomy. For these purposes, use soft plastic, rubber or silicone tubes with an outer diameter of up to 3-5 mm. The probes have an olive at the end, which facilitates their passage and installation in the initial part of the jejunum. Enteral nutrition can also be provided through a tube that is temporarily inserted into the lumen of an organ (stomach, small intestine) and removed after feeding. Tube feeding can be carried out using the fractional method or drip. The intensity of intake of food mixtures should be determined taking into account the patient’s condition and stool frequency. When performing enteral nutrition through a fistula, in order to avoid regurgitation of the food mass, the probe is inserted into the intestinal lumen at least 40-50 cm using an obturator.

Outpatient management of patients after orthopedic and traumatological operations should be carried out taking into account the postoperative management of patients in the hospital and depends on the nature of the disease or musculoskeletal system for which it was undertaken, on the method and characteristics of the operation performed on a particular patient. The success of outpatient management of patients depends entirely on the continuity of the treatment process begun in a hospital setting.

After orthopedic and traumatological operations, patients can be discharged from the hospital without external immobilization, in various types of plaster casts (see Plaster technique), distraction-compression devices can be applied to the limbs (Distraction-compression devices), patients can use various orthopedic products after surgery (tire-sleeve devices, insoles, arch supports, etc.). In many cases, after operations for diseases and injuries of the lower extremities or pelvis, patients use crutches.

On an outpatient basis, the attending physician should continue to monitor the condition of the postoperative scar so as not to miss superficial or deep suppuration. It may be caused by the formation of late hematomas due to unstable fixation of fragments with metal structures (see Osteosynthesis), loosening of parts of the endoprosthesis when it is not firmly fixed in it (see Endoprosthetics). The causes of late suppuration in the area of ​​the postoperative scar can also be rejection of the allograft due to immunological incompatibility (see Bone grafting), endogenous with damage to the surgical area by hematogenous or lymphogenous route, ligature fistulas. Late suppuration may be accompanied by arterial or venous bleeding caused by purulent melting (arrosion) of the blood vessel, as well as pressure ulcers of the vessel wall under the pressure of a part of a metal structure protruding from the bone during immersion osteosynthesis or a knitting needle of a compression-distraction apparatus. With late suppuration and bleeding, patients require emergency hospitalization.

On an outpatient basis, rehabilitation treatment started in the hospital continues, which consists of therapeutic physical education for joints free from immobilization (see Therapeutic physical education), gypsum and ideomotor gymnastics. The latter consists of contraction and relaxation of the muscles of the limb, immobilized in a plaster cast, as well as imaginary movements in joints fixed by external immobilization (extension) in order to prevent muscle atrophy, improve blood circulation and bone tissue regeneration processes in the area of ​​surgery. Physiotherapeutic treatment continues, aimed at stimulating muscles, improving microcirculation in the surgical area, preventing neurodystrophic syndromes, stimulating the formation of callus, and preventing stiffness in the joints. The complex of rehabilitative treatment in an outpatient setting also includes activities aimed at restoring movements in the limbs necessary for servicing oneself in everyday life (climbing stairs, using public transport), as well as general and professional ability to work. in P., p. is not usually used, with the exception of hydrokinesitherapy, which is especially effective in restoring movements after operations on the joints.

After spinal surgery (without damage to the spinal cord), patients often use semi-rigid or rigid removable corsets. Therefore, in an outpatient setting, it is necessary to monitor the correct use of them and the integrity of the corsets. During sleep and rest, patients should use a hard bed. On an outpatient basis, physical therapy classes aimed at strengthening the back muscles, manual and underwater massage, continue. Patients must strictly adhere to the orthopedic regimen prescribed in the hospital, which consists of unloading the spine.

After surgery on the bones of the limbs and pelvis, the doctor on an outpatient basis systematically monitors the condition of the patients and the timeliness of removing the plaster cast, if an external one was used after the operation, carries out the areas of surgery after removing the plaster, and promptly prescribes the development of joints freed from immobilization. It is also necessary to monitor the condition of metal structures during immersion osteosynthesis, especially with intramedullary or transosseous insertion of a pin or screw, in order to timely detect possible migration, which is detected by X-ray examination. When metal structures migrate with the threat of skin perforation, patients require hospitalization.

If a device for external transosseous osteosynthesis is applied, the task of the outpatient doctor is to monitor the condition of the skin in the area where the pins are inserted, regularly and in a timely manner, and to monitor the stable fastening of the device structures. If necessary, additional fastening is performed, individual units of the device are tightened, and if the inflammatory process begins in the area of ​​the spokes, soft tissues are injected with antibiotic solutions. With deep suppuration of soft tissues, patients need to be sent to a hospital to remove the pin in the area of ​​suppuration and insert a new pin into the unaffected area, and, if necessary, reinstall the device. When the bone fragments are completely consolidated after a fracture or orthopedic surgery, the device is removed on an outpatient basis.

After orthopedic and traumatological operations on joints, physical therapy, hydrokinesitherapy, and physiotherapeutic treatment aimed at restoring mobility are carried out on an outpatient basis. When using transarticular osteosynthesis to fix fragments in cases of intra-articular fractures, the fixing pin (or pins), the ends of which are usually located above the skin, are removed. This manipulation is carried out within a time frame determined by the nature of the damage to the joint. After operations on the knee joint, synovitis is often observed (see Synovial bursae), and therefore it may be necessary to jointly evacuate the synovial fluid and administer medications according to indications, incl. corticosteroids. When postoperative joint contractures develop, along with local treatment, general therapy is prescribed aimed at preventing scarring, para-articular ossification, normalizing the intra-articular environment, regenerating hyaline cartilage (injections of the vitreous, aloe, FiBS, lidase, rumalon, ingestion of non-steroidal anti-inflammatory drugs - indomethacin, brufen, voltaren, etc.). After removal of plaster immobilization, persistent swelling of the operated limb is often observed as a consequence of post-traumatic or postoperative lymphovenous insufficiency. In order to eliminate edema, they recommend manual massage or using pneumatic massagers of various designs, compression of the limb with an elastic bandage or stocking, and physiotherapeutic treatment aimed at improving venous outflow and lymph circulation.

Outpatient management of patients after urological operations is determined by the functional characteristics of the organs of the genitourinary system, the nature of the disease and the type of surgery undergone. for many urological diseases it is an integral part of complex treatment aimed at preventing relapse of the disease and rehabilitation. At the same time, continuity of inpatient and outpatient treatment is important.

To prevent exacerbations of the inflammatory process in the genitourinary system (pyelonephritis, cystitis, prostatitis, epididymo-orchitis, urethritis), continuous sequential use of antibacterial and anti-inflammatory drugs is indicated in accordance with the sensitivity of the microflora to them. The effectiveness of treatment is monitored by regular testing of blood, urine, prostate secretions, and ejaculate culture. If the infection is resistant to antibacterial drugs, multivitamins and nonspecific immunostimulants are used to increase the body's reactivity.

In case of urolithiasis caused by impaired salt metabolism or a chronic inflammatory process, after removal of stones and restoration of urine passage, correction of metabolic disorders is necessary.

After reconstructive operations on the urinary tract (plasty of the ureteropelvic segment, ureter, bladder and urethra), the main task of the immediate and long-term postoperative period is to create favorable conditions for the formation of anastomosis. For this purpose, in addition to antibacterial and anti-inflammatory drugs, agents that promote softening and resorption of scar tissue (lidase) and physiotherapy are used. The appearance of clinical signs of impaired urine outflow after reconstructive surgery may indicate the development of a stricture in the anastomotic area. For its timely detection, regular follow-up examinations, including X-ray radiological and ultrasound methods, are necessary. With a slight degree of narrowing of the urethra, the urethra can be performed and the above set of therapeutic measures can be prescribed. If a patient has chronic renal failure (renal failure) in late renal failure, it is necessary to monitor its course and treatment results through regular examination of biochemical blood parameters, drug correction of hyperazotemia and water and electrolyte disturbances.

After palliative surgery and ensuring the outflow of urine through drainages (nephrostomy, pyelostomy, ureterostomy, cystostomy, urethral catheter), it is necessary to carefully monitor their function. Regular change of drains and washing of the drained organ with antiseptic solutions are important factors in the prevention of inflammatory complications in the genitourinary system.

Outpatient management of patients after gynecological and obstetric operations is determined by the nature of the gynecological pathology, the volume of the operation performed, the characteristics of the course of P. p. and its complications, and concomitant extragenital diseases. A set of rehabilitation measures is carried out, the duration of which depends on the speed of restoration of functions (menstrual, reproductive), complete stabilization of the general condition and gynecological status. Along with general restorative treatment (etc.), physiotherapy is carried out, which takes into account the nature of the gynecological disease. After surgery for tubal pregnancy, medicinal hydrotubation is performed (penicillin 300,000 - 500,000 units, hydrocortisone hemisuccinate 0.025 G, lidase 64 UE in 50 ml 0.25% novocaine solution) in combination with ultrasound therapy, vibration massage, zinc, and then resort treatment is prescribed. To prevent adhesions after operations for inflammatory formations, zinc electrophoresis is indicated in low frequency mode (50 Hz). To prevent relapse of endometriosis, electrophoresis of zinc and iodine is performed, sinusoidal modulating currents, and pulsed ultrasound are prescribed. Procedures are prescribed after 1-2 days. After operations on the uterine appendages for inflammatory formations, ectopic pregnancy, benign ovarian formations, after organ-preserving operations on the uterus and supravaginal amputation of the uterus due to fibroids, patients remain disabled for an average of 30-40 days, after hysterectomy - 40-60 days. Then they carry out an examination of their ability to work and give recommendations, if necessary, to exclude contact with occupational hazards (vibration, exposure to chemicals, etc.). Patients remain on dispensary registration for 1-2 years or more.

Outpatient treatment after obstetric surgery depends on the nature of the obstetric pathology that caused surgical delivery. After vaginal and abdominal operations (fertility operations, manual examination of the uterine cavity), postpartum women receive a period of 70 days. An examination in the antenatal clinic is carried out immediately after discharge from the hospital; in the future, the frequency of examinations depends on the particular course of the postoperative (postpartum) period. Before being removed from the dispensary registration for pregnancy (i.e. by the 70th day), the following is carried out. If the reason for operative delivery is extragenital, an examination by a therapist, and, if indicated, by other specialists, and a clinical and laboratory examination are required. A complex of rehabilitation measures is carried out, which includes general strengthening procedures, physiotherapy, taking into account the nature of somatic, obstetric pathology, and the peculiarities of the course of P. p. For purulent-inflammatory complications, zinc electrophoresis is prescribed with diadynamic low-frequency currents, in a pulsed mode; for postpartum women who have had concomitant kidney pathology, pulsed ultrasound is indicated for the area of ​​the kidneys, the collar zone according to Shcherbak. Since even during lactation it is possible 2-3 months after birth, contraception is mandatory. Wounds and wound infection, ed. M.I. Kuzina and B.M. Kostyuchenok, M., 1981; Guide to eye surgery, ed. L.M. Krasnova, M., 1976; Guide to neurotraumatology, ed. A.I. Arutyunova, parts 1-2, M., 1978-1979; Sokov L.P. Course of traumatology and orthopedics, p. 18, M., 1985; Strugatsky V.M. Physical factors in obstetrics and gynecology, p. 190, M., 1981; Tkachenko S.S. , With. 17, L., 1987; Hartig V. Modern infusion therapy, trans. from English, M., 1982; Shmeleva V.V. , M., 1981; Yumashev G.S. , With. 127, M., 1983.

II Postoperative period

the period of treatment of the patient from the end of the surgical operation until its fully determined outcome.

1. Small medical encyclopedia. - M.: Medical encyclopedia. 1991-96 2. First aid. - M.: Great Russian Encyclopedia. 1994 3. Encyclopedic Dictionary of Medical Terms. - M.: Soviet Encyclopedia. - 1982-1984.

The period of treatment of a patient from the end of the surgical operation to its fully determined outcome... Large medical dictionary

Occurring after surgery; this term is applied to the patient's condition or to his treatment carried out during this period.

The most common and dangerous complications in the early postoperative period are complications from the wound, cardiovascular, respiratory, digestive and urinary systems, as well as the development of bedsores.

Rice. 9-7.Complications of the early postoperative period (by organs and systems)

Complications from the wound

In the early postoperative period, the following complications are possible from the wound:

Bleeding;

Development of infection;

Seams coming apart.

In addition, the presence of a wound is associated with pain, which manifests itself in the first hours and days after surgery.

Bleeding

Bleeding is the most serious complication, sometimes threatening the patient’s life and requiring repeated surgery. Prevention of bleeding is mainly carried out during surgery. In the postoperative period, to prevent bleeding, place an ice pack or a load of sand on the wound. For timely diagnosis, monitor pulse, blood pressure, and red blood counts. Bleeding after surgery can be of three types:

External (bleeding occurs into the surgical wound, which causes the bandage to become wet);

Bleeding through the drainage (blood begins to flow through the drainage left in the wound or some kind of cavity);

Internal bleeding (blood pours into the internal cavities of the body without entering the external environment), the diagnosis of internal bleeding is especially difficult and is based on special symptoms and signs.

Development of infection

The foundations for preventing wound infections are laid on the operating table. After the operation, you should monitor the normal functioning of the drainages, since the accumulation of unevacuated fluid can become a good breeding ground for microorganisms and cause a suppurative process. In addition, it is necessary to prevent secondary infection. To do this, patients must be bandaged the next day after surgery in order to remove the dressing material, which is always wet with sanguineous wound discharge, treat the edges of the wound with an antiseptic and apply a protective aseptic bandage. After this, the bandage is changed every 3-4 days or more often if indicated (the bandage is wet, has come off, etc.).

Seam divergence

Suture dehiscence is especially dangerous after abdominal surgery. This state is called eventration. It may be associated with technical errors when suturing the wound, as well as with a significant increase in intra-abdominal pressure (with intestinal paresis, peritonitis, pneumonia with severe cough syndrome) or the development of infection in the wound. To prevent suture dehiscence during repeated operations and a high risk of developing this complication, suturing the wound of the anterior abdominal wall with buttons or tubes is used (Fig. 9-8).

Rice. 9-8. Suturing a wound of the anterior abdominal wall on tubes

Complications from the cardiovascular system

In the postoperative period, myocardial infarction, arrhythmia, and acute cardiovascular failure may occur. The development of these complications is usually associated with concomitant diseases, so their prevention largely depends on the treatment of concomitant pathology.

The issue of preventing thromboembolic complications is important, the most common of which is pulmonary embolism - a serious complication, one of the common causes of death in the early postoperative period.

The development of thrombosis after surgery is caused by a slowdown in blood flow (especially in the veins of the lower extremities and pelvis), increased blood viscosity, impaired water and electrolyte balance, unstable hemodynamics and activation of the coagulation system due to intraoperative tissue damage. The risk of pulmonary embolism is especially high in elderly obese patients with concomitant pathology of the cardiovascular system, the presence of varicose veins of the lower extremities and a history of thrombophlebitis.

Principles for the prevention of thromboembolic complications:

Early activation of patients;

Impact on a possible source (for example, treatment of thrombophlebitis);

Ensuring stable hemodynamics;

Correction of water and electrolyte balance with a tendency to hemodilution;

The use of disaggregants and other agents that improve the rheological properties of blood;

The use of anticoagulants (for example, heparin sodium, nadroparin calcium, enoxaparin sodium) in patients with an increased risk of thromboembolic complications.

Complications from the respiratory system

In addition to the development of a severe complication - acute respiratory failure, associated primarily with the consequences of anesthesia, great attention should be paid to the prevention of postoperative pneumonia - one of the most common causes of death in patients in the postoperative period.

Principles of prevention:

Early activation of patients;

Antibiotic prophylaxis;

Adequate position in bed;

Breathing exercises, postural drainage;

Thinning sputum and using expectorants;

Sanitation of the tracheobronchial tree in seriously ill patients (through an endotracheal tube during prolonged mechanical ventilation or through a specially applied microtracheostomy during spontaneous breathing);

Mustard plasters, jars;

Massage, physiotherapy.

Digestive complications

The development of anastomotic suture leakage and peritonitis after surgery is usually associated with the technical features of the operation and the condition of the stomach or intestines due to the underlying disease; this is a subject for consideration in private surgery.

After operations on the abdominal organs, to varying degrees, the development of paralytic obstruction (intestinal paresis) is possible. Intestinal paresis significantly disrupts the digestive processes. An increase in intra-abdominal pressure leads to a high standing of the diaphragm, impaired ventilation of the lungs and heart activity. In addition, there is a redistribution of fluid in the body and the absorption of toxic substances from the intestinal lumen.

The foundations for the prevention of intestinal paresis are laid during surgery (careful treatment of tissues, minimal infection of the abdominal cavity, careful hemostasis, novocaine blockade of the mesenteric root at the end of the intervention).

Principles of prevention and control of intestinal paresis after surgery:

Early activation of patients;

Rational diet;

Gastric drainage;

Peridural blockade (or perinephric novocaine blockade);

Insertion of a gas outlet tube;

Hypertensive enema;

Administration of motor stimulation agents (eg, hypertonic solution, neostigmine methyl sulfate);

Physiotherapeutic procedures (diadynamic therapy).

Complications from the urinary system

In the postoperative period, the development of acute renal failure, impaired renal function due to inadequate systemic hemodynamics, and the occurrence of inflammatory diseases (pyelonephritis, cystitis, urethritis, etc.) are possible. After surgery, it is necessary to carefully monitor diuresis, not only during the day, but also hourly diuresis.

The development of inflammatory and some other complications is facilitated by urinary retention, often observed after surgery. Impaired urination, which sometimes leads to acute urinary retention, is of a reflex nature and occurs as a result of a reaction to pain in the wound, reflex tension of the abdominal muscles, and the effects of anesthesia.

If urination is impaired, simple measures are first taken: the patient is allowed to stand up, he can be taken to the toilet to restore the usual environment for urination, analgesics and antispasmodics are administered, a warm heating pad is placed on the suprapubic area. If these measures are ineffective, it is necessary to perform catheterization of the bladder.

If the patient cannot urinate, it is necessary to release urine with a catheter at least once every 12 hours. During catheterization, it is necessary to carefully observe the rules of asepsis. In cases where the patient's condition is severe and constant monitoring of diuresis is necessary, the catheter is left in the bladder for the entire early postoperative period. In this case, the bladder is washed twice a day with an antiseptic (nitrofural) to prevent ascending infection.

Prevention and treatment of bedsores

Bedsores are aseptic necrosis of the skin and deeper tissues due to impaired microcirculation due to prolonged compression.

After surgery, bedsores usually form in seriously elderly patients who have been in a forced position (lying on their back) for a long time.

Most often, bedsores occur on the sacrum, in the area of ​​the shoulder blades, on the back of the head, the back of the elbow joint, and the heels. It is in these areas that the bone tissue is located quite close and there is pronounced compression of the skin and subcutaneous tissue.

Prevention

Prevention of bedsores involves the following measures:

Early activation (if possible, stand, seat patients, or at least turn from side to side);

Clean dry linen;

Rubber circles (placed in the areas of the most common locations of bedsores to change the nature of pressure on the tissue);

Anti-decubitus mattress (mattress with constantly changing pressure in separate sections);

Treatment of skin with antiseptics.

Stages of development

There are three stages in the development of bedsores:

Ischemia stage: tissues become pale, sensitivity is impaired.

Stage of superficial necrosis: swelling and hyperemia appear, and areas of black or brown necrosis form in the center.

Stage of purulent melting: an infection occurs, inflammatory changes progress, purulent discharge appears, the process spreads deeper, even to damage the muscles and bones.

Treatment

When treating bedsores, it is necessary to comply with all measures related to prevention, since they are, to one degree or another, aimed at eliminating the etiological factor.

Local treatment of pressure ulcers depends on the stage of the process.

Ischemia stage - the skin is treated with camphor alcohol, which causes vasodilation and improved blood flow in the skin.

Stage of superficial necrosis - the affected area is treated with a 5% solution of potassium permanganate or a 1% alcohol solution of brilliant green. These substances have a tanning effect and create a scab that prevents infection.

Stage of purulent melting - Treatment is carried out according to the principle of treating a purulent wound. It should be noted that it is much easier to prevent bedsores than to treat them.

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The early postoperative period can be uncomplicated or complicated.
During an uncomplicated postoperative period, a number of changes occur in the body in the functioning of the main organs and systems. This is due to the influence of factors such as psychological stress, anesthesia and post-anesthesia state, pain in the area of ​​the surgical wound, the presence of necrosis and injured tissue in the operation area, forced position of the patient, hypothermia, nutritional disturbances and some others.

In a normal, uncomplicated course of the postoperative period, the reactive changes that occur in the body are usually moderate and last for 2-3 days. In this case, a fever of up to 37.0-37.5 °C is noted. CNS inhibition is observed. The composition of peripheral blood changes (moderate leukocytosis, anemia and thrombocytopenia), blood viscosity increases.
The main tasks during an uncomplicated postoperative period are correction of changes in the body, monitoring the functional state of the main organs and systems, and carrying out measures aimed at preventing possible complications.
Intensive therapy for an uncomplicated postoperative period is as follows:

• fighting pain,
• restoration of the function of the cardiovascular system and microcirculation,
• prevention and treatment of respiratory failure,
• correction of water and electrolyte balance,
• detoxification therapy,
• balanced diet,
• control of the function of the excretory system.

Let's take a closer look at ways to combat pain. To reduce pain, both very simple and quite complex measures are used:
Getting the correct position in bed
It is necessary to relax the muscles in the area of ​​the surgical wound as much as possible. After operations on the abdominal and thoracic organs, the Fowler position is used for this: the head end is raised (half-sitting position), the lower limbs are bent at the hip and knee joints at an angle of approximately 120°.
Wearing a bandage
The measure significantly reduces pain when moving and coughing.
Use of narcotic analgesics
It is necessary in the first 2-3 days after extensive abdominal operations. They use promedol, omnopon, morphine.
Use of non-narcotic analgesics
It is necessary in the first 2-3 days after minor operations and starting from 3 days after traumatic interventions. Injections of analgin and baralgin are used. It is also possible to use tablet preparations.
Use of sedatives
Allows you to increase the threshold of pain sensitivity. They use seduxen and relanium.

Epidural anesthesia
It is an important method of pain relief in the early postoperative period during operations on the abdominal organs, as it is a powerful means of preventing and treating postoperative intestinal paresis.
In the postoperative period, changes occur in the patient's body, which are usually divided into three phases: catabolic, reverse development phase and anabolic phase.
a) Catabolic phase
The catabolic phase usually lasts 5-7 days. Its severity depends on the severity of the patient’s preoperative condition and the traumatic nature of the intervention performed. During this period, changes occur in the body, the purpose of which is the rapid delivery of the necessary energy and plastic materials. At the same time, activation of the sympatho-adrenal system is noted, the flow of catecholamines, glucocorticoids, and aldesterone into the blood increases.
Neurohumoral processes lead to changes in vascular tone, which ultimately causes disturbances in microcirculation and redox processes in tissues. Tissue acidosis develops, and due to hypoxia, a predominance of anaerobic glycolysis is noted.
The catabolic phase is characterized by increased protein breakdown, which reduces not only the protein content in muscles and connective tissue, but also enzymatic proteins. Protein loss is very significant and during major operations amounts to up to 30-40 g per day.
The course of the catabolic phase is significantly aggravated by the addition of early postoperative complications (bleeding, inflammation, pneumonia, etc.).
b) Reverse development phase
This phase is the transition from catabolic to anabolic. Its duration is 3-5 days. The activity of the sympathoadrenal system decreases. Protein metabolism is normalized, which is manifested by a positive nitrogen balance. At the same time, the breakdown of proteins continues, but an increase in their synthesis is also noted. The synthesis of glycogen and fats increases.
Gradually, anabolic processes begin to prevail over catabolic ones, which means a transition to the anabolic phase.
c) Anabolic phase
The anabolic phase is characterized by the active restoration of those changes that were observed in the catabolic phase. The parasympathetic nervous system is activated, the activity of growth hormone and androgens increases, and protein synthesis sharply increases
and fats, glycogen reserves are restored. Thanks to the listed mechanisms, reparative processes, growth and development of connective tissue are ensured. The completion of the anabolic phase corresponds to the complete recovery of the body after surgery. This usually happens after about 3-4 weeks.

1. COMPLICATED POSTOPERATIVE PERIOD

Complications that can occur in the early postoperative period are divided according to the organs and systems in which they occur. Often complications are caused by the presence of concomitant pathology in the patient. The diagram shows the most common complications of the early postoperative period (Fig. 9.7),
Three main factors contribute to the development of complications:

• the presence of a postoperative wound,
• forced situation
• influence of surgical trauma and anesthesia.

G

Surgical shock, pain, sleep disturbance
Hepatic
renal
failure
Uroinfection,
violation
urination

h.
Rice. 9.7
Complications of the early postoperative period (by organs and systems)

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Currently, there is an increase in certain nosological forms of infectious diseases, primarily viral infections. One of the directions for improving treatment methods is the use of interferons, as important nonspecific factors of antiviral resistance. These include cycloferon, a low molecular weight synthetic inducer of endogenous interferon.

Dysbacteriosis in children

The number of microbial cells present on the skin and mucous membranes of a macroorganism in contact with the external environment exceeds the number of cells of all its organs and tissues combined. The weight of the microflora of the human body is on average 2.5-3 kg. The importance of microbial flora for a healthy person was first noticed in 1914 by I.I. Mechnikov, who suggested that the cause of many diseases are various metabolites and toxins produced by various microorganisms that inhabit the organs and systems of the human body. The problem of dysbacteriosis in recent years has caused a lot of discussions with an extreme range of opinions.

Diagnosis and treatment of infections of the female genital organs

In recent years, throughout the world and in our country, there has been an increase in the incidence of sexually transmitted infections among the adult population and, which is of particular concern, among children and adolescents. The incidence of chlamydia and trichomoniasis is increasing. According to WHO, trichomoniasis ranks first in frequency among sexually transmitted infections. Every year, 170 million people worldwide become ill with trichomoniasis.

Intestinal dysbiosis in children

Intestinal dysbiosis and secondary immunodeficiency are increasingly encountered in the clinical practice of doctors of all specialties. This is due to changing living conditions and the harmful effects of the preformed environment on the human body.

Viral hepatitis in children

The lecture “Viral hepatitis in children” presents data on viral hepatitis A, B, C, D, E, F, G in children. All clinical forms of viral hepatitis, differential diagnosis, treatment and prevention that currently exist are presented. The material is presented from a modern perspective and is intended for senior students of all faculties of medical universities, interns, pediatricians, infectious disease specialists and doctors of other specialties who are interested in this infection.