Currently, there are no medical procedures that do not have complications. Despite the fact that modern anesthesiology uses selective and safe drugs, and the technique of anesthesia is being improved every year, there are complications after anesthesia.

After anesthesia, there can be unpleasant consequences

When preparing for a planned operation or suddenly faced with its inevitability, each person feels anxiety not only about the surgical intervention itself, but even more because of the side effects of general anesthesia.

Undesirable phenomena of this procedure can be divided into two groups (according to the time of their occurrence):

1. Occur during the procedure.
2. Develop after a different time after the completion of the operation.

During the operation:

1. From the respiratory system: sudden cessation of breathing, bronchospasm, laryngospasm, pathological recovery of spontaneous breathing, pulmonary edema, cessation of breathing after its recovery.
2. From the side of the cardiovascular system: increased (tachycardia), slow (bradycardia) and abnormal (arrhythmia) heart rhythm. Drop in blood pressure.
3. From the nervous system: convulsions, hyperthermia (increase in body temperature), hypothermia (decrease in body temperature), vomiting, tremor (trembling), hypoxia and cerebral edema.

During the operation, the patient is constantly monitored to avoid complications.

All complications during the procedure are controlled by an anesthesiologist and have strict algorithms of medical actions aimed at their relief. The doctor has drugs on hand to treat possible complications.

Many patients describe visions during anesthesia - hallucinations. Hallucinations cause patients to worry about their own mental health. There is no need to worry, as hallucinations are caused by some narcotic drugs used for general pain relief. Hallucinations during anesthesia occur in mentally healthy people and do not recur after the end of the drug.

After completion of the operation

After general anesthesia, a number of complications develop, some of them require long-term treatment:

1. From the respiratory system.

Often manifested after anesthesia: laryngitis, pharyngitis, bronchitis. These are the consequences of the mechanical impact of the equipment used and the inhalation of concentrated gaseous drugs. Manifested by coughing, hoarseness, pain when swallowing. Usually pass within a week without consequences for the patient.

Pneumonia. A complication is possible when gastric contents enter the respiratory tract (aspiration) during vomiting. Treatment will require an additional hospital stay after surgery and the use of antibacterial drugs.

1. From the side of the nervous system.

Central hyperthermia- an increase in body temperature that is not associated with an infection. This phenomenon may be a consequence of the body's reaction to the introduction of drugs that reduce the secretion of sweat glands, which are administered to the patient before surgery. The patient's condition is normalized within one or two days after the termination of their action.

Elevated body temperature is a common consequence of anesthesia

Headache after anesthesia are a consequence of the side effects of drugs for central anesthesia, as well as complications during anesthesia (prolonged hypoxia and cerebral edema). Their duration can reach several months, pass independently.

encephalopathy(impaired cognitive function of the brain). There are two reasons for its development: it is a consequence of the toxic effect of narcotic drugs and a prolonged hypoxic state of the brain with complications of anesthesia. Despite the widespread opinion about the incidence of encephalopathy, neurologists argue that it rarely develops and only in people with risk factors (background brain diseases, old age, previous chronic exposure to alcohol and / or drugs). Encephalopathy is reversible, but requires a long recovery period.

To speed up the process of restoring brain function, doctors suggest prophylaxis before the planned procedure. In order to prevent encephalopathy, vascular drugs are prescribed. Their selection is carried out by the doctor, taking into account the characteristics of the patient and the planned operation. It is not necessary to carry out self-prophylaxis of encephalopathy, since many drugs can change blood clotting, as well as affect susceptibility to anesthetics.

Peripheral neuropathy of the extremities. It develops as a consequence of a long stay of the patient in a forced position. Manifested after anesthesia paresis of the muscles of the extremities. It takes a long time, requires physical therapy and physiotherapy.

Complications of local anesthesia

Spinal and epidural anesthesia

Spinal and epidural anesthesia replaces anesthesia. These types of anesthesia are completely devoid of the side effects of anesthesia, but their implementation has its own complications and consequences:

Often after anesthesia the patient suffers from a headache

1. Headache and dizziness. A frequent side effect, which manifests itself in the first days after surgery, ends with recovery. Rarely, headaches are persistent and continue for a long time after surgery. But as a rule, such a psychosomatic state, that is, due to the patient's suspiciousness.
2. Paresthesia(tingling, tingling sensation on the skin of the lower extremities) and loss of sensation in the skin of the legs and torso. It does not require treatment and resolves on its own within a few days.
3. Constipation. Often occur during the first three days after surgery as a consequence of anesthesia of the nerve fibers innervating the intestine. After restoring the sensitivity of the nerve, the function is restored. In the early days, mild laxatives and folk remedies help.
4. Neuralgia of the spinal nerves. The consequence of nerve injury during the puncture. A characteristic manifestation is pain in the innervated area, which persists for several months. Physiotherapy exercises and physiotherapy help to speed up the process of its recovery.
5. Hematoma (bleeding) at the puncture site. Accompanied by pain in the damaged area, headaches and dizziness. During resorption of the hematoma, there are increases in body temperature. As a rule, the condition ends with recovery.

Stem and infiltration anesthesia

1. Hematomas (hemorrhages). Occur as a result of damage to small vessels in the area of ​​anesthesia. They present with bruising and pain. They go away on their own within a week.
2. Neuritis (inflammation of the nerve). Pain along the nerve fiber, impaired sensitivity, paresthesia. You should consult with a neurologist.
3. Abscesses (suppurations). Their occurrence requires additional treatment with antibiotics, most likely in a hospital setting.

A complication of any type of anesthesia, from superficial to anesthesia, may be the development of allergic reactions. Allergies come in varying degrees of severity, from flushing and rash to the development of anaphylactic shock. These kinds of side effects can happen to any drug and food. They cannot be predicted if the patient has not previously used the drug.

When going for an operation, it is worth remembering that the qualifications of anesthesiologists will allow you to cope with any difficult and unforeseen situations. The hospital has the necessary equipment and medicines to maintain the health of the patient. Cases of death and disability from anesthesia are rare in world practice.

Laparoscopy is a surgical operation to resect the affected organ or part of it, performed through small incisions using trocars and a laparoscope. In addition, the laparoscopic method is used to diagnose diseases, as it is extremely accurate.

One of the prerogative aspects is the shortened postoperative period of laparoscopy. Rehabilitation takes place in an accelerated mode, since tissues and skin are not injured, as in abdominal surgery. For the same reason, the possibility of infection of the incisions and the formation of adhesive processes is minimized.

About the technique and types of laparoscopy

Laparoscopy is performed under anesthesia. Several incisions are made in the area of ​​the operated organs, through which surgical instruments and a laparoscope are inserted - a device equipped with a lighting component and a video camera. An enlarged image is projected onto a monitor.

For better visualization of the internal space and access to organs, carbon dioxide is supplied to the operated area. Under its influence, the folds of the abdominal cavity are straightened, which allows the surgeon to work fully. At the end of the process, the instrumentation is removed, and surgical sutures are applied to the incisions. Most often, laparoscopic surgery is performed on the organs of the digestive and genitourinary systems, less often on the chest (thoracic surgery).

The most requested operations include:

• appendectomy (appendicitis);
• colectomy (removal of the colon);
• cholecystectomy (excision of the gallbladder in the tumor process and cholelithiasis);
• hernioplasty (removal of umbilical hernia);
• cystectomy (resection of an ovarian, kidney, liver cyst)
• distal resection of the pancreas;
• gastrectomy (complete removal of the stomach).

In addition, laparoscopic excision of the spermatic vein in men with varicocele (varicose veins of the scrotum and spermatic cord), gynecological operations for endometriosis (growth of uterine cells), myoma (benign tumor) of the uterus, numerous inflammatory processes in the pelvic organs are widely practiced. Laparoscopy, according to emergency indications, is allowed to be performed during pregnancy.

Appendicitis or cholecystitis may occur during the perinatal period. Pregnancy is not a contraindication to laparoscopic surgery

Consequences of laparoscopic surgery

The laparoscopic method of resection is tolerated by patients more easily than conventional abdominal surgery. However, like any extraneous intervention in the body, surgery or diagnostics do not go unnoticed for the patient. The consequences of laparoscopy, as a rule, appear during the patient's stay in the hospital after surgery, but sometimes they can occur after discharge. The main side effects include:

• Pain syndrome . During the first twelve hours after surgery, intense pain is not considered abnormal. Damage to soft tissues, skin and internal organs causes pain, which is localized in the area of ​​the operated organ, and can also radiate (give) to the upper part of the body. To eliminate pain in the hospital, analgesics, non-steroidal and anti-inflammatory drugs are used. Less commonly used are narcotic opium alkaloids (opiates).
• Feelings of fullness in the abdomen. This symptom is provoked by the introduction of carbon dioxide during the operation. Intensive accumulation of gases in the abdominal cavity is not a postoperative pathology. If the symptom does not leave the patient on the first postoperative day, carminative drugs are prescribed.
• Heaviness in the epigastric (pit of the stomach), nausea. Occur after laparoscopy, as a result of the introduction of anesthesia. Such sensations do not need special treatment, and go away on their own.
• Headache . They can be caused by the transferred anesthesia and the excitement experienced by the patient. As a rule, they are stopped by analgesics along with pain in the area of ​​the operation. With an overly excited state of the patient, sedative medications are prescribed.
• Discomfort in the throat and esophagus. The cause of the occurrence is the use of endotracheal anesthesia (the introduction of anesthesia through the respiratory tract through a tube). These symptoms are short-lived and do not require treatment.

The intensity of postoperative symptoms depends on the individual characteristics of the patient's body and the quality of the surgery performed.

Small incisions on the body after laparoscopy heal faster than scars after abdominal resection

Possible negative manifestations

Complications after laparoscopy are rare but do occur. The occurrence of complications is due to three main reasons: an unforeseen reaction of the patient to anesthesia or the introduction of carbon dioxide, non-compliance by the patient with medical recommendations during the recovery period, poor-quality operation (medical inattention, errors).

Complications of anesthesia

Before laparoscopy, the patient undergoes an examination, which helps the anesthesiologist to choose the best anesthesia (drug and dosage) for a particular person, taking into account his individual characteristics. An inadequate reaction rarely occurs, the most extreme form of manifestation may be an acute allergic reaction - anaphylactic shock. Failure in the work of bronchopulmonary and cardiac activity can occur under the influence of carbon dioxide. The complication is rare, depending on individual characteristics (chronic heart and bronchial diseases), or abnormal gas injection.

Pathological manifestations due to the fault of the patient

Each doctor without fail gives recommendations after laparoscopy, which the patient must follow during the rehabilitation period. There are dietary restrictions, as well as prohibitions on serious physical activity after surgery to remove the affected organ or its area. If the recommendations are not followed, suppuration and infection of the sutures, bleeding, inflammatory processes in the gallbladder, uterus, urinary system and other organs of the abdominal cavity and small pelvis occur.

Complications dependent on medical staff

An illiterate operation or equipment malfunction can threaten certain negative consequences. Patients with chronic cardiac disorders, atherosclerosis, varicose veins are given blood thinners before surgery. If the doctor ignored this manipulation, there is a danger of the formation of blood clots. In case of malfunctions of the laparoscope or inadequate qualifications of the doctor, there is a risk of injury to adjacent organs and vessels. For example, removing stones from the gallbladder, an inexperienced doctor can damage its walls.

Of particular danger is the primary puncture produced by the Veress needle when the laparoscope is not yet functioning. Blind manipulation can lead to bleeding. The occurrence of adhesive process is most characteristic after resection of appendicitis. To stop standard bleeding after excision of a part of the organ, the coagulation method (cauterization with electric current) is used. Incorrect application of the method causes severe burns of internal organs. Cutting off the affected area, the doctor can burn the adjacent organ, which will lead to the development of necrosis (death) of the tissues of the organ.

Violation of sterility compliance by medical personnel is the cause of infection of the incision, and as a result, the occurrence of a purulent-inflammatory process in the suture area. Incorrect removal of an organ affected by oncology can cause cancer of the skin when it is removed from the abdominal cavity. The occurrence of postoperative hernias is due to improper suturing of the troacic openings after the removal of large fragments of organs. This complication may not manifest itself immediately after laparoscopy, but after a few weeks or months.

Mistakes during operations for resection of the gallbladder lead to a violation of the choleretic process, which can result in serious liver diseases. Pregnancy during the operation requires special attention. With the careless actions of the doctor, there is a threat of interruption (miscarriage) or the development of oxygen deficiency (hypoxia) in the fetus, as a reaction to the introduction of carbon dioxide. If unforeseen situations arise during laparoscopy, the doctor should proceed to an open laparotomy in order to avoid more serious negative consequences.

These complications can be prevented if you carefully choose the clinic for the operation. In addition, the patient must clearly follow all the doctor's advice during the rehabilitation period.

The main symptoms of complications

Immediate seeking medical help requires the appearance of the following symptoms:

• severe pain in the operated area after discharge from the hospital;
• stable hyperthermia (fever);
• discoloration of the epidermis (skin) around the scar to bright red;
• the release of purulent-blood substance in the area of ​​incisions;
• constant headache, short-term bouts of loss of consciousness.

By the end of the hospital stay, there should be no acute postoperative pain.

The patient must be hospitalized, undergo ultrasound diagnostics, and take blood tests.

The postoperative period after laparoscopy in stationary conditions lasts from 3 to 6 days, depending on the complexity of the operation. Later, the patient is sent for outpatient treatment. Rehabilitation after laparoscopic surgery, as a rule, takes place in an accelerated mode. The sutures, depending on the surgical material used, are removed on the 7-10th day or they dissolve in the body on their own.

A month later, the performance is fully restored. It is the responsibility of the patient to comply with all recommendations for adherence to the regimen and diet. During the month, the operated person should not resort to heavy physical exertion. You can not do strength exercises and lift weights. Nevertheless, rational physical activity is shown already from the second day after the operation in order to avoid the development of adhesions.

One of the most important factors is proper nutrition in the postoperative period. In the early days, the diet should consist of weak broths, oatmeal jelly. While on outpatient treatment, the patient should adhere to a light diet. The diet is based on the use of the following products:

• puree soups;
• river and sea fish containing less than 8% fat;
• turkey meat, chicken;
• protein omelette and soft-boiled eggs.
• fat-free cottage cheese, unsalted cheese;
• cereals, pasta;
• potato, fruit and berry puree.

It is necessary to eliminate from the diet:

• fat meat;
• fatty sauces based on mayonnaise;
• dishes from lentils, peas, beans;
• sweet pastry;
• spicy and smoked foods.

Compliance with the recommendations of doctors is the main condition for the prevention of complications

The consumption of alcoholic beverages is strictly prohibited. Rough food can cause difficulty and pain during its processing by the organs of the digestive tract. Obstipation (constipation) negatively affects the well-being and condition of postoperative sutures. When these symptoms occur, laxatives or an enema are recommended.

In addition to a shortened recovery period, the prerogatives of laparoscopy before abdominal surgery are: a negligible likelihood of adhesions (provided that the patient follows the doctor's recommendations), the aesthetic appearance of scars (in less than a year, the consequences of the operation cease to be noticeable). In the absence of contraindications, laparoscopic surgery is preferred.

Modern combined intubation anesthesia. The sequence of its implementation and its advantages. Complications of anesthesia and the immediate post-anesthetic period, their prevention and treatment.

Method of examination of a surgical patient. General clinical examination (examination, thermometry, palpation, percussion, auscultation), laboratory research methods.

Preoperative period. The concept of indications and contraindications for surgery. Preparation for emergency, urgent and planned operations.

Surgical operations. Types of operations. Stages of surgical operations. Legal basis for the operation.

postoperative period. The reaction of the patient's body to surgical trauma.

The general reaction of the body to surgical trauma.

Postoperative complications. Prevention and treatment of postoperative complications.

Bleeding and blood loss. Mechanisms of bleeding. Local and general symptoms of bleeding. Diagnostics. Assessment of the severity of blood loss. The body's response to blood loss.

Temporary and permanent methods of stopping bleeding.

History of the doctrine of blood transfusion. Immunological bases of blood transfusion.

Group systems of erythrocytes. Group system av0 and group system Rhesus. Methods for determining blood groups according to the systems av0 and rhesus.

The meaning and methods for determining individual compatibility (av0) and Rh compatibility. biological compatibility. Responsibilities of a Blood Transfusion Physician.

Classification of adverse effects of blood transfusions

Water-electrolyte disorders in surgical patients and principles of infusion therapy. Indications, dangers and complications. Solutions for infusion therapy. Treatment of complications of infusion therapy.

Trauma, injury. Classification. General principles of diagnostics. stages of assistance.

Closed soft tissue injuries. Bruises, sprains, tears. Clinic, diagnosis, treatment.

Traumatic toxicosis. Pathogenesis, clinical picture. Modern methods of treatment.

Critical disorders of vital activity in surgical patients. Fainting. Collapse. Shock.

Terminal states: pre-agony, agony, clinical death. Signs of biological death. resuscitation activities. Efficiency criteria.

Skull injuries. Concussion, bruise, compression. First aid, transportation. Principles of treatment.

Chest injury. Classification. Pneumothorax, its types. Principles of first aid. Hemothorax. Clinic. Diagnostics. First aid. Transportation of victims with chest trauma.

Abdominal trauma. Damage to the abdominal cavity and retroperitoneal space. clinical picture. Modern methods of diagnostics and treatment. Features of combined trauma.

Dislocations. Clinical picture, classification, diagnosis. First aid, treatment of dislocations.

Fractures. Classification, clinical picture. Fracture diagnosis. First aid for fractures.

Conservative treatment of fractures.

Wounds. Classification of wounds. clinical picture. General and local reaction of the body. Diagnosis of wounds.

Wound classification

Types of wound healing. The course of the wound process. Morphological and biochemical changes in the wound. Principles of treatment of "fresh" wounds. Types of seams (primary, primary - delayed, secondary).

Infectious complications of wounds. Purulent wounds. Clinical picture of purulent wounds. Microflora. General and local reaction of the body. Principles of general and local treatment of purulent wounds.

Endoscopy. History of development. Areas of use. Videoendoscopic methods of diagnosis and treatment. Indications, contraindications, possible complications.

Thermal, chemical and radiation burns. Pathogenesis. Classification and clinical picture. Forecast. Burn disease. First aid for burns. Principles of local and general treatment.

Electrical injury. Pathogenesis, clinic, general and local treatment.

Frostbite. Etiology. Pathogenesis. clinical picture. Principles of general and local treatment.

Acute purulent diseases of the skin and subcutaneous tissue: furuncle, furunculosis, carbuncle, lymphangitis, lymphadenitis, hydroadenitis.

Acute purulent diseases of the skin and subcutaneous tissue: erysopeloid, erysipelas, phlegmon, abscesses. Etiology, pathogenesis, clinic, general and local treatment.

Acute purulent diseases of cellular spaces. Phlegmon of the neck. Axillary and subpectoral phlegmon. Subfascial and intermuscular phlegmon of the extremities.

Purulent mediastinitis. Purulent paranephritis. Acute paraproctitis, fistulas of the rectum.

Acute purulent diseases of the glandular organs. Mastitis, purulent parotitis.

Purulent diseases of the hand. Panaritiums. Phlegmon brush.

Purulent diseases of serous cavities (pleurisy, peritonitis). Etiology, pathogenesis, clinic, treatment.

surgical sepsis. Classification. Etiology and pathogenesis. The idea of ​​the entrance gate, the role of macro- and microorganisms in the development of sepsis. Clinical picture, diagnosis, treatment.

Acute purulent diseases of bones and joints. Acute hematogenous osteomyelitis. Acute purulent arthritis. Etiology, pathogenesis. clinical picture. Medical tactics.

Chronic hematogenous osteomyelitis. Traumatic osteomyelitis. Etiology, pathogenesis. clinical picture. Medical tactics.

Chronic surgical infection. Tuberculosis of bones and joints. Tuberculous spondylitis, coxitis, drives. Principles of general and local treatment. Syphilis of bones and joints. Actinomycosis.

anaerobic infection. Gas phlegmon, gas gangrene. Etiology, clinic, diagnosis, treatment. Prevention.

Tetanus. Etiology, pathogenesis, treatment. Prevention.

Tumors. Definition. Epidemiology. Etiology of tumors. Classification.

1. Differences between benign and malignant tumors

Local differences between malignant and benign tumors

Fundamentals of surgery for disorders of regional circulation. Arterial blood flow disorders (acute and chronic). Clinic, diagnosis, treatment.

Necrosis. Dry and wet gangrene. Ulcers, fistulas, bedsores. Causes of occurrence. Classification. Prevention. Methods of local and general treatment.

Malformations of the skull, musculoskeletal system, digestive and genitourinary systems. Congenital heart defects. Clinical picture, diagnosis, treatment.

Parasitic surgical diseases. Etiology, clinical picture, diagnosis, treatment.

General issues of plastic surgery. Skin, bone, vascular plastics. Filatov stem. Free transplantation of tissues and organs. Tissue incompatibility and methods of its overcoming.

Postoperative complications. Prevention and treatment of postoperative complications.

Causes of complications:

tactical mistakes.

Technical errors.

Reassessment of the body's ability to undergo surgery.

The presence of comorbidities.

Non-compliance of patients with hospital regimen.

Complications that appeared directly during the operation.

Bleeding (small blood loss, large blood loss).

Damage to organs and tissues.

thromboembolic complications.

Complications of anesthesia.

Complications in organs and systems on which surgery was performed.

Secondary bleeding (causes: slipping of the ligature from the blood vessel; the development of a purulent process is erosive).

The development of purulent processes in the area of ​​surgical intervention.

Divergence of seams.

Violation of the functions of organs after interventions on them (impaired patency of the gastrointestinal tract, biliary tract).

In a significant number of cases, these complications require repeated surgical interventions, often under adverse conditions.

Complications that appeared in the postoperative period.

(Complications in organs that were not directly affected by surgery).

Complications from the cardiovascular system.

Primary - when there is a development of heart failure due to a disease of the heart itself;

Secondary - heart failure develops against the background of a severe pathological process (purulent intoxication, blood loss, etc.);

Acute cardiovascular failure;

myocardial infarction; arrhythmias, etc.;

Collapse /toxic, allergic, anaphylactic, cardio- and neurogenic/;

Thrombosis and embolism / mainly slowing of blood flow in the vessels of the veins of the lower extremities with varicose veins, thrombophlebitis, etc., elderly and senile age, oncological pathology; obesity, activation of the coagulation system, unstable hemodynamics, damage to the walls of the vessel, etc./.

Complications from the respiratory system.

Acute respiratory failure;

Postoperative pneumonia;

• Atelectasis;

  Pulmonary edema.

Prevention principles.

Early activation of patients;

Breathing exercises;

Adequate position in bed;

Adequate anesthesia;

Antibiotic prophylaxis;

Sanitation of the tracheobronchial tree (expectorants, sanitation through an endotracheal tube; sanitation bronchoscopy);

Control of the pleural cavity (pneumo-, hemothorax, pleurisy, etc.);

Massage, physiotherapy.

Complications from the digestive organs are more often functional in nature.

Paralytic obstruction (leads to increased intra-abdominal pressure, enteral intoxication).

Ways to prevent paralytic ileus.

during the operation - careful attitude to tissues, hemostasis, blockade of the root of the mesentery of the intestine, minimal infection of the abdominal cavity;

early activation of patients;

adequate diet;

decompressive measures;

correction of electrolyte disorders;

epidural anesthesia;

novocaine blockade;

intestinal stimulation;

physiotherapy activities.

Postoperative diarrhea (diarrhea) - exhausts the body, leads to dehydration, reduces immunobiological resistance;

acholytic diarrhea (extensive resection of the stomach);

shortening of the length of the small intestine;

neuro-reflex;

infectious origin (enteritis, exacerbation of chronic bowel disease);

septic diarrhea on the background of severe intoxication.

Complications from the liver.

Liver failure /jaundice, intoxication/.

Complications from the urinary system.

acute renal failure /oliguria, anuria/;

acute urinary retention / reflex / ischuria;

exacerbation of existing pathology /pyelonephritis/;

inflammatory diseases /pyelonephritis, cystitis, urethritis/.

Complications from the nervous system and mental sphere.

sleep disturbance;

p / o psychosis;

paresthesia;

paralysis.

bedsores- aseptic necrosis of the skin and underlying tissues due to compression disturbance of microcirculation.

Most often occur on the sacrum, in the area of ​​​​the shoulder blades, on the back of the head, on the back of the elbow joints, and on the heels. Initially, the tissues become pale, their sensitivity is disturbed; then puffiness, hyperemia, development of areas of necrosis of black or brown color joins; purulent discharge appears, the presenting tissues are involved up to the bones.

Prevention.

early activation;

unloading of the corresponding areas of the body;

smooth bed surface

• treatment with antiseptics;

  physiotherapy;

  anti-decubitus massage;

Stage of ischemia - treatment of the skin with camphor alcohol.

Stage of superficial necrosis - treatment with 5% potassium permanganate solution or 1% brilliant green alcohol solution to form a scab.

Stage of purulent inflammation - according to the principles of treatment of a purulent wound.

Complications from the surgical wound.

Bleeding (causes: slipping of the ligature from the blood vessel; development of a purulent process - erosive; initially insufficient hemostasis);

Formation of hematomas;

Formation of inflammatory infiltrates;

Suppuration with the formation of abscesses or phlegmon (violation of asepsis rules, primary infected operation);

Divergence of the edges of the wound with prolapse of internal organs (eventration) - due to the development of the inflammatory process, a decrease in regenerative processes (oncopathology, beriberi, anemia, etc.);

Prevention of wound complications:

Compliance with asepsis;

Careful attitude to fabrics;

Prevention of the development of the inflammatory process in the area of ​​surgical intervention (adequate antiseptic).

Blood coagulation disorders in surgical patients and principles of their correction. hemostasis system. Research methods. Diseases with violation of the coagulation system. Influence of surgical operations and drugs on the hemostasis system. Prevention and treatment of thromboembolic complications, hemorrhagic syndrome. DIC is a syndrome.

There are two types of spontaneous hemostasis:

1. Vascular-platelet - ensuring the stop of bleeding in case of damage to the vessels of the microvasculature,

2. Enzymatic - playing the most prominent role in damage to vessels of a larger caliber.

Both types of hemostasis in each specific situation work almost simultaneously and in concert, and the division into types is caused by didactic considerations.

Spontaneous hemostasis is provided due to the coordinated action of three mechanisms: blood vessels, blood cells (primarily platelets) and plasma.

Vascular-platelet hemostasis is provided by spasm of damaged vessels, adhesion, platelet aggregation and their viscous metamorphosis, resulting in the formation of a blood clot obturating the damaged vessel and preventing bleeding.

Enzymatic hemostasis is a complex multicomponent process, which is usually divided into 2 phases:

A multi-stage and multi-component stage, as a result of which prothrombin is activated with its transformation into thrombin.

The final stage in which fibrinogen under the influence of thrombin is converted into fibrin monomers, which then polymerize and stabilize.

Sometimes in the first phase, 2 subphases are distinguished: the formation of prothrombinase (thromboplastin) activity and the formation of thrombin activity. In addition, in the literature, the post-coagulation phase following the polymerization of fibrin is sometimes distinguished - stabilization and retraction of the clot.

In addition to the coagulation system, the human body has an anti-coagulant system - a system of inhibitors of the blood coagulation process, among which antithrombin-3, heparin and proteins C and S are of the greatest importance. The system of inhibitors prevents excessive thrombus formation.

Finally, the resulting thrombi can undergo lysis due to the activity of the fibrinolytic system, the main representative of which is plasminogen, or profibrinolysin.

The liquid state of the blood is provided by the coordinated interaction of the coagulation, anticoagulation systems and fibrinolysis. Under conditions of pathology, especially when vessels are damaged, this complete and perfect balance of antagonistic pairs of activators and inhibitors of the blood coagulation process can be disturbed. Back in the 19th century, Claude Bernard established the fact of post-aggressive stimulation of blood clotting. This applies to any aggression, including surgical. The activity of the blood coagulation system begins to increase already during the operation and remains at a high level for 5-6 days of the postoperative period. This reaction has a protective value, aimed at reducing blood loss and creating conditions for the repair of tissue and vascular damage, if it is adequate to the strength and duration of aggression. If it turns out to be insufficient (less often) or excessive (more often), the deployment of adaptive-compensatory mechanisms in the patient's body is disrupted and prerequisites for the occurrence of complications are created.

By itself, post-aggressive hypercoagulation is not a pathogenic factor, but in combination with vascular damage during surgery and imminent postoperative hypodynamia with slowing blood flow in some vascular areas, it can lead to pathological thrombosis. This combination of conditions for pathological thrombus formation was described by R. Virchow and is known as the "Virchow triad".

Methods for studying hemostasis. There are classic laboratory tests that characterize the general ability of blood to clot, and differential. The study of classical tests is mandatory in each patient before performing an urgent or planned surgical intervention. The study of individual components of the coagulation system using differential tests is carried out according to special indications in case of detection of defects in the functioning of the coagulation system and its inhibitors.

Classic tests:

Blood clotting.

The duration of bleeding, or bleeding time.

The number of platelets per unit volume of peripheral blood.

Thrombotest.

Blood clotting. There are several ways to determine blood clotting, the most popular of which is the Lee-White method. All methods are based on determining the time of fibrin formation in blood or plasma. Normal blood coagulability values ​​when determined according to Lee-White are 5-10 minutes (according to some sources, from 4 to 8 minutes)

The duration of bleeding, or bleeding time, is also determined in various ways, among which the Duke method is the most widely used. After dosed damage to small vessels of the palmar surface of the distal phalanx of the finger or earlobe, the time from the moment of damage to the stop of bleeding is determined. Normal values ​​for Duke are 2.5 - 4 minutes.

The number of platelets per unit volume of peripheral blood is counted in stained blood smears using special cameras or devices - celloscopes. The normal content of platelets is 200-300 x 10 / l (according to other sources, - 250 - 400 x 10 / l)

Thrombotest is a method that allows you to quickly assess the tendency of enzymatic hemostasis to hyper- or hypocoagulation. The principle of the method is based on the fact that blood plasma mixed with a weak solution of calcium chloride in a test tube gives a different character of a fibrin clot. The results are evaluated in conventional units - in degrees:

6-7 degrees - characterized by the formation of a dense fibrin sac of a homogeneous structure, - are noted with a tendency to hypercoagulation;

4, 5 degrees - a mesh bag of fibrin is formed in the test tube, - are characteristic of normocoagulation;

1, 2, 3 degrees - are characterized by the formation of separate threads, flakes or grains of fibrin, - are noted during hypocoagulation.

There are integrated tests that allow characterizing both individual types of spontaneous hemostasis and individual phases of enzymatic hemostasis.

The general state of vascular-platelet hemostasis is characterized by bleeding time, or the duration of bleeding. For a general assessment of enzymatic hemostasis, thrombotest and blood clotting are used. An assessment of the state of the first phase of enzymatic hemostasis can be carried out on the basis of a study of the prothrombin index according to Quick (PTI), which is normally 80-105%. The second phase can be characterized by the concentration of fibrinogen in venous blood (normal - 2-4 g / l)

Under conditions of pathology, fibrinogen degradation products may appear in the peripheral blood due to an increase in the activity of the fibrinolytic system, as well as a large number of fibrin monomers, which, when interacting with each other, form complex compounds that reduce the efficiency of enzymatic hemostasis, and sometimes block it. These compounds are detected using paracoagulation tests (ethanol, protamine sulfate and beta-naphthol). Positive paracoagulation tests indicate the development of a general DIC or massive local intravascular coagulation in the patient's body.

Thrombotic and thromboembolic diseases in surgical patients.

Deep vein thrombosis of the leg and pelvis (DVT)

DVT is a common complication of the postoperative period, in most cases it is asymptomatic. In a relatively small proportion of patients with DVT, poor clinical manifestations are noted in the form of aching pain in the calf muscles, aggravated by dorsal flexion of the foot, swelling in the ankles, and moderate or mild cyanosis of the skin of the rear of the foot.

Diagnosis is carried out on the basis of clinical, instrumental and coagulation studies. Of the instrumental studies, ultrasonic angioscanning and radiopaque phlebography are the most informative. In coagulological studies, a decrease in the content of platelets, a decrease in the concentration of fibrinogen, and positive paracoagulation tests are noted.

Treatment has 2 tasks:

1. prevention of further progression of thrombosis,

2. prevention of pulmonary embolism.

To solve the first problem, direct anticoagulants are used - heparin and its low molecular weight fractions under the control of blood clotting and activated partial thromboplastin time (APTT) for 5-7 days, followed by a transition to long-term use of indirect anticoagulants under the control of IPT.

Preventive measures to prevent pulmonary embolism (PE) in diagnosed DVT:

Strict bed rest for the entire period of heparin therapy.

Thrombectomy - with segmental thrombosis of large veins.

Implantation of cava filters for floating thrombi in the femoral or iliac vein.

Pulmonary embolism (PE)

PE is closely pathogenetically associated with DVT and develops as a result of a thrombus detachment from the vascular wall and its migration into the pulmonary vessels.

Depending on which part of the pulmonary vessels is turned off from the blood circulation, the following forms of PE are distinguished:

supermassive (with the exclusion of 75-100% of the pulmonary vessels);

massive (with the exclusion of 45-75% of the vessels of the small circle);

non-massive, shared (15-45%);

small (up to 15%),

the smallest, or microvascular PE.

Accordingly, the following clinical forms are distinguished:

lightning fast and fast (heavy);

delayed (moderate);

erased, latent (light)

In the clinic, severe forms of PE are more common, accounting for about 5-8% of the causes of postoperative mortality.

Clinic. Clinical manifestations of pulmonary embolism are extremely variable and are determined primarily by the volume of pulmonary vessels excluded from the circulation.

In severe PE, manifestations of circulatory-respiratory failure play a leading role in the clinic. There are: an acute onset with pain behind the sternum or in the chest, shortness of breath (tachypnea), cyanotic coloration of the skin of the neck, chest, face, upper body, swelling of the cervical veins, tachycardia, lowering blood pressure. In cases of supermassive PE, death occurs within minutes.

With mild and moderate PE, there are no serious hemodynamic and respiratory disorders. Sometimes there is an “unmotivated increase in body temperature” against the background of a completely satisfactory general condition and unexpressed shortness of breath. In the early stages, radiographs do not find significant changes, and in the later stages, signs of infarction pneumonia can be detected.

Diagnosis is based on clinical, radiological, electrocardiographic and coagulation studies. On non-contrast chest radiographs, there is an increase in the transparency of the lung fields, along with an increase in the pattern of the roots of the lungs. An ECG study reveals signs of overload of the right heart.

The most highly informative diagnostic method is angiopulmography - x-ray contrast study of leukocytes.

In coagulological studies, as in patients with DVT, a decrease in the concentration of fibrinogen, a decrease in the content of platelets and the appearance of fibrinogen degradation products and fibrin-monomeric complexes in the peripheral blood are noted.

PE treatment.

Shock elimination.

Reducing hypertension in the pulmonary circulation.

Oxygen therapy.

Administration of cardiac glycosides.

Carrying out fibrinolytic therapy by intravenous administration of streptokinase, fibrinolysin and heparin preparations.

In specialized angiosurgical hospitals, it is possible to perform an operation - embolectomy.

Prevention of thrombotic and thromboembolic complications.

All patients who underwent surgery need preventive measures aimed at preventing the development of DVT and PE, but the nature of the measures taken varies depending on the risk of thrombotic and thromboembolic complications.

At low risk, non-specific preventive measures are taken, which include:

Early activation of patients,

Physiotherapy,

pain relief,

Normalization of bowel function,

Maintenance of normal water and electrolyte balance and acid-base state of the blood, directed regulation of blood viscosity.

Non-specific measures are carried out in all patients who have undergone any surgical intervention.

In "thrombotic patients", in addition to these measures, it is necessary to carry out specific prophylaxis, since their risk of developing thrombotic and thromboembolic complications is incomparably higher than that of the "average patient".

Thrombo-prone patients include the following:

Patients with a preoperative marked increase in the content of fibrinogen in the blood and a decrease in fibrinolytic activity.

Patients with chronic disorders of venous circulation (with varicose veins of the lower extremities, post-thrombophlebitic disease)

Patients with widespread atherosclerosis, coronary artery disease with severe hemodynamic disorders.

Patients suffering from diabetes and obesity.

Patients with severe purulent infection, sepsis.

Cancer patients, especially those with advanced forms of metastatic cancer.

Specific methods for preventing DVT and PE include:

Tight bandaging of the lower extremities in violation of venous circulation.

Preoperative and postoperative administration of heparin or its low molecular weight fractions.

Postoperative appointment of antiplatelet agents and the introduction of low molecular weight dextrans.

Intermittent pneumatic compression of the legs.

DIC - syndrome (disseminated intravascular coagulation syndrome)

DIC is not a disease, but an acquired symptom complex that complicates many pathological processes and is characterized by a complete imbalance in the hemostasis system. According to the prevalence, DIC can be local, organ and general (generalized), and according to the clinical course - acute, subacute and chronic.

In surgical practice, one often encounters acute generalized DIC. The reasons for it may be:

Severe long-term operations, especially in patients with common malignant diseases;

Traumatic and hemorrhagic shock;

Massive transfusions of donor blood;

Transfusion of incompatible blood;

Severe purulent infection, sepsis.

In its development, DIC has 2 phases:

Hypercoagulation, intravascular platelet aggregation and activation of the kallikrein-kinin system and the complement system,

Hypocoagulation with increasing consumption coagulopathy, overactivation and subsequent depletion of the fibrinolytic system.

Diagnosis is based on a comparison of clinical and coagulological data.

The first phase is usually brief and asymptomatic.

The second phase is characterized by an outbreak of hemorrhagic manifestations on the part of the skin, gastrointestinal tract, urinary system, genitals, and wounds. Profuse bleeding, in turn, can lead to massive blood loss, hypovolemic shock and multiple organ failure with its clinical manifestations.

In coagulological studies, in the first phase, a decrease in blood clotting time is noted, in the second - an increase. In all phases of DIC, a decrease in the number of platelets, a decrease in the concentration of fibrinogen, the appearance and a progressive increase in the content of soluble fibrin-monomeric complexes and fibrinogen degradation products in the peripheral blood are noted.

Treatment of DIC:

Intensive care of the underlying suffering that triggered DIC;

Intravenous infusions of low molecular weight dextrans in the hypercoagulable phase;

Transfusions of fresh frozen plasma at all stages of the evolution of DIC;

Transfusions of erythromass, erythrosuspension and platelet concentrates in the hypocoagulation phase, accompanied by massive bleeding;

In the later stages of the development of the disease - intravenous administration of antiprotease drugs;

Intravenous administration of corticosteroid hormones.

Diseases accompanied by a decrease in blood clotting.

Diseases accompanied by a decrease in blood clotting can be congenital and acquired.

Among hereditary coagulopathies, about 90-95% are hemophilia and hemophiloid conditions.

The term "hemophilia" means 2 diseases:

hemophilia A due to deficiency of plasma factor 8,

hemophilia B (Christmas disease) associated with a deficiency of plasma coagulation factor 9 (the plasma component of thromboplastin, antihemophilic globulin B).

All other hemorrhagic diatheses caused by congenital deficiency of various coagulation factors are hemophiloid conditions (hemophilia C, hypoproconvertinemia, hypoprothrombinemia, hypo- and aphyrinogenemia)

Hemophilia affects only men. Hemophiloid conditions occur in both men and women.

Diagnosis of hemophilia is based on clinical and coagulological data.

Characteristic manifestations of hemophilia are repeated bleeding provoked by various, often minor mechanical damage. Early and specific clinical manifestations of hemophilia are hemarthroses.

Laboratory both types of hemophilia are characterized by prolongation of blood clotting time and APTT with normal bleeding time, fibrinogen concentration and normal platelet count.

Depending on the content of deficient factors in the blood, 4 clinical forms of hemophilia are distinguished:

severe - with the content of a deficient factor from 0 to 3%;

moderate - with the content of a deficient factor from 3.1 to 5%;

light - from 5.1 to 10%;

latent - from 10.1 to 25%.

Tactics of the surgeon in hemophilia. Against the background of hemophilia, only emergency and urgent surgical interventions are performed. Operations are performed under the cover of transfusion of large doses of freshly stabilized blood, native and fresh frozen plasma, antihemophilic plasma and cryoprecipitate under the control of blood clotting and APTT.

For preoperative preparation, if it is necessary to perform urgent surgical interventions, you can use recombinant preparations obtained by genetic engineering methods - immunate, cogenate, recombinant.

Doses and frequency of administration of antihemophilic drugs are determined by the severity of the intervention and the initial state of hemostasis. In the postoperative period, the introduction of hemostasis correction agents (in the catabolic phase) is continued. Methods for monitoring the effectiveness of ongoing therapy are the determination of blood clotting and activated partial thromboplastin time (APTT)

In addition, in the catabolic phase of the postoperative period, intravenous transfusions of a 5% solution of aminocaproic acid are performed (the drug prolongs the action of coagulation factors contained in plasma and cryoprecipitate) and parenterally administered corticosteroid hormones (suppress the reaction of post-traumatic inflammation, prevent isosensitization).

Acquired coagulopathy.

Of the acquired coagulopathies, manifested by a decrease in blood clotting, cholemia and acholia are of the greatest interest for surgery.

Cholemic bleeding occurs during operations performed for obstructive jaundice. The causes of cholemic bleeding are:

deficiency of calcium ions due to their binding in the blood by bile acids;

deficiency of prothrombin complex factors - due to malabsorption of vitamin K in the digestive canal.

In laboratory studies, patients with obstructive jaundice show an increase in blood clotting time and a decrease in PTI.

To prevent cholemic bleeding in patients with obstructive jaundice, Vikasol is administered parenterally before surgery and plasma containing deficient coagulation factors is transfused intravenously.

Acholic bleeding occurs during operations in patients with external or low internal bile duct fistulas. The cause of these bleedings is a deficiency of prothrombin complex factors, which develops as a result of malabsorption of vitamin K in the digestive tract. Prevention does not differ from that in patients with obstructive jaundice.

- Early - as a rule, develop in the first 7 days after surgery;

- Late - develop through various periods after discharge from the hospital

From the side of the wound:

1. Bleeding from a wound

2. Suppuration of the wound

3. Eventration

4. Postoperative hernia

5. Ligature fistulas

From the side of the operated organ (anatomical area):

- Failure of the anastomosis sutures (stomach, intestine, bronchus, etc.).

- Bleeding.

– Formation of strictures, cysts, fistulas (internal or external).

- Paresis and paralysis.

- Purulent complications (abscesses, phlegmon, peritonitis, pleural empyema, etc.).

From other organs and systems:

- From the CCC - acute coronary insufficiency, myocardial infarction, thrombosis and thrombophlebitis, pulmonary embolism;

- From the side of the central nervous system - acute cerebrovascular accident (stroke), paresis and paralysis;

- Acute renal and hepatic failure.

- Pneumonia.

Postoperative complications can be represented as a diagram

Care begins immediately after the end of the operation. If the operation was performed under anesthesia, the anesthesiologist gives permission for transportation. With local anesthesia - the patient is moved to a stretcher after the operation, either independently or with the help of staff, after which he is transported to the postoperative ward or to the ward in the surgical department.

sick bed should be prepared by the time he arrives from the operating room: covered with fresh linen, heated with heating pads, there should be no wrinkles on the sheets. The nurse should know in what position the patient should be after the operation. Patients usually lie on their backs. Sometimes, after surgery on the organs of the abdominal and thoracic cavities, patients lie in the Fowler position (semi-sitting position on the back with limbs bent at the knee joints).

Patients operated on under anesthesia are transported to the intensive care unit (intensive care) on the bed of the same unit. Transferring from the operating table to the functional bed is carried out under the supervision of an anesthesiologist. The unconscious patient is carefully lifted from the operating table and transferred to the bed, while avoiding sharp flexion of the spine (dislocation of the vertebrae is possible) and hanging of the limbs (dislocations are possible). It is also necessary to ensure that the bandage from the postoperative wound is not torn off and the drainage tubes are not removed. At the time of transferring the patient to the bed and transportation, there may be signs of impaired breathing and cardiac activity, therefore, the escort of the anesthesiologist and the anesthetist nurse Necessarily . Until the patient regains consciousness, he is laid horizontally, his head is turned to the side (prevention of aspiration of gastric contents into the bronchi - the nurse must be able to use an electric suction to help the patient with vomiting). Covered with a warm blanket.

To better provide the body with oxygen, humidified oxygen is supplied through a special device. To reduce bleeding of the operated tissues, an ice pack is placed on the wound area for 2 hours or a load (usually a sealed oilcloth bag with sand). Drainage tubes are attached to the system to collect the contents of the wound or cavity.

In the first 2 hours, the patient is in a horizontal position on his back or with a lowered head end, since in this position the blood supply to the brain is better provided.

During operations under spinal anesthesia, the horizontal position is maintained for 4-6 hours due to the risk of developing orthostatic hypotension.

After the patient regains consciousness, a pillow is placed under his head, and the hips and knees are raised to reduce blood stasis in the calf muscles (prevention of thrombosis).

The optimal position in bed after surgery may vary, depending on the nature and area of ​​surgery. For example, patients who have undergone operations on the abdominal organs, after they regain consciousness, are laid in bed with their heads slightly raised and legs slightly bent at the knees and hip joints.

Prolonged stay of the patient in bed is not desirable, due to the high risk of complications caused by physical inactivity. Therefore, all factors that deprive him of mobility (drainages, long-term intravenous infusions) must be taken into account in time. This is especially true for elderly and senile patients.

There are no clear criteria that determine the timing of the patient's getting out of bed. Most patients are allowed to get up 2-3 days after surgery, but the introduction of modern technologies in medical practice changes a lot. After laparoscopic cholecystectomy, it is allowed to get up in the evening, and many patients are discharged for outpatient treatment the very next day. Getting up early increases confidence in a favorable outcome of the operation, reduces the frequency and severity of postoperative complications, especially respiratory and deep vein thrombosis.

Even before the operation, it is necessary to teach the patient the rules of getting out of bed. In the evening or the next morning, the patient should already sit on the edge of the bed, clear his throat, move his legs, while in bed he should change his position as often as possible, make active movements with his legs. At the beginning, the patient is turned on his side, to the side of the wound, with bent hips and knees, while the knees are on the edge of the bed; the doctor or nurse helps the patient to sit up. Then, after taking a few deep breaths and exhalations, the patient clears his throat, stands on the floor, takes 10-12 steps around the bed, and goes back to bed. If the patient's condition does not worsen, then the patient should be activated in accordance with his own feelings and the doctor's instructions.

Sitting in bed or chair is not recommended because of the risk of slowing down venous blood flow and the occurrence of thrombosis in the deep veins of the lower extremities, which in turn can cause sudden death due to thrombus separation and pulmonary embolism.

For the timely detection of this complication, it is necessary to measure the circumference of the limb daily, palpate the calf muscles in the projection of the neurovascular bundle. The appearance of signs of deep vein thrombosis (edema, cyanosis of the skin, an increase in the volume of the limb) is an indication for special diagnostic methods (ultrasound dopplerography, phlebography). Especially often, deep vein thrombosis occurs after traumatological and orthopedic operations, as well as in patients with obesity, oncological diseases, and diabetes mellitus. Reducing the risk of thrombosis in the postoperative period is facilitated by the restoration of disturbed water-electrolyte metabolism, the prophylactic use of direct-acting anticoagulants (heparin and its derivatives), early activation of the patient, bandaging the lower extremities with elastic bandages before surgery and in the first 10-12 days after it.

After major operations, a serious condition usually develops as a response to severe, prolonged trauma. This reaction is considered as natural and adequate. However, in the presence of excessive irritation and the addition of additional pathogenetic factors, unforeseen conditions that aggravate the postoperative period (for example, bleeding, infection, suture failure, vascular thrombosis, etc.) may occur. Prevention of complications in the postoperative period is associated with rational preoperative preparation of the patient (see. Preoperative period), the correct choice of anesthesia and its full implementation, strict adherence to the rules of asepsis and antisepsis, careful handling of tissues by the surgeon during the operation, the choice of the desired method of operation, good technique implementation and timely implementation of medical measures to eliminate various deviations in the normal course of the postoperative period.

Some time after a major operation, under the influence of pain impulses emanating from an extensive surgical wound, shock and collapse may develop, which is facilitated by blood loss. After a period of anxiety, blanching of the skin, cyanosis of the lips, blood pressure drops, the pulse becomes small and frequent (140-160 beats per minute). In the prevention of postoperative shock, the removal of painful irritations is important. After extensive traumatic interventions, which inevitably cause prolonged and intense pain, they resort to the systematic administration of drugs not only at night, but several (2-3, even 5) times a day for the first two, and sometimes three days. In the future, the pain decreases, which allows you to limit the use of drugs (only at night, 1-2 days). If repeated use is necessary, it is better to use promedol rather than morphine. Some authors recommend to use superficial anesthesia with nitrous oxide to relieve pain in the postoperative period. At the same time, measures are needed to replenish blood loss and the appointment of antihistamines (diphenhydramine).

With the development of postoperative shock, the patient is warmed in bed, the foot end of the bed is raised and complex anti-shock therapy is carried out (see Shock). Upon removal of shock phenomena, further measures are carried out according to individual indications.

Bleeding in the postoperative period may occur due to slipping of ligatures from the gastric arteries, the stump of the auricle of the heart, the stumps of the vessels of the root of the lung, the arteries of the limb stump, from the intercostal, internal thoracic, inferior epigastric and other arteries. Bleeding can also start from small vessels that did not bleed during the operation due to a drop in blood pressure and therefore remained untied. In later periods, massive bleeding can occur due to vessel erosion during the development of a purulent process (the so-called late secondary bleeding). Characteristic signs of acute bleeding are: severe pallor, frequent small pulse, low blood pressure, patient anxiety, weakness, profuse sweat, bloody vomiting, wetting of the bandage with blood; with intra-abdominal bleeding percussion in sloping areas of the abdomen with percussion, dullness is determined.

Treatment is aimed at stopping bleeding with simultaneous intravenous or intra-arterial blood transfusion. The source of bleeding is determined after opening the wound. Bleeding vessels are ligated during relaparotomy, rethoracotomy, etc. In hematemesis after gastric resection, conservative measures are initially carried out: careful gastric lavage, local cold, gastric hypothermia. If they are unsuccessful, a second operation with revision and elimination of the source of bleeding is indicated.

Postoperative pneumonia occur more often after operations on the organs of the abdominal and thoracic cavity. This is due to the common innervation of these organs (vagus nerve) and the limitation of respiratory excursions that occurs after such operations, difficulty in coughing up sputum and poor ventilation of the lungs. Stagnation in the pulmonary circulation, due to the lack of respiratory excursions and, in addition, the weakening of cardiac activity and the immobile position of the patient on his back, are also important.

Respiratory disorders with the subsequent development of pneumonia can also occur after a major operation in the cranial cavity. The source of pneumonia may be a postoperative pulmonary infarction. These pneumonias usually develop at the end of the first or beginning of the second week after surgery, characterized by severe chest pain and hemoptysis.

In the prevention of postoperative pneumonia, an important place is occupied by the introduction of painkillers; pain relief promotes deeper and more rhythmic breathing, facilitates coughing. However, morphine and other opiates should not be prescribed in large doses (especially with pneumonia that has already begun), so as not to cause oppression of the respiratory center. Cardiac agents are very important - injections of camphor, cordiamine, etc., as well as proper preparation of the respiratory tract and lungs of the patient in the preoperative period. After the operation, the upper half of the body is raised in bed, the patient is turned more often, they are allowed to sit down, get up earlier, and therapeutic exercises are prescribed. Bandages applied to the chest and abdomen should not restrict breathing. As therapeutic measures for pneumonia, oxygen therapy, banks, heart, expectorants, sulfanilamide and penicillin therapy are used.

At pulmonary edema there is a sharp shortness of breath with bubbling breathing, sometimes with hemoptysis. The patient is cyanotic, in the lungs there are many different moist rales. Treatment depends on the cause of the swelling. Apply heart, painkillers, bloodletting, oxygen therapy; fluid is aspirated from the tracheobronchial tree by intubation. If necessary, systematic, repeated aspiration, a tracheotomy is performed and the contents of the respiratory tract are periodically aspirated through a catheter inserted into the tracheotomy opening. The tracheotomy tube must always be passable; if necessary, it is changed or well cleaned. Liquefaction of the secretion of the respiratory tract is carried out using aerosols or washing. At the same time, oxygen therapy and other therapeutic measures are carried out. Patients are placed in separate rooms served by specially trained personnel. With a sharp violation of breathing, they resort to controlled artificial respiration with the help of a breathing apparatus.

Complications from the cardiovascular system. In the postoperative period, some patients develop relative heart failure, blood pressure drops to 100/60 mm Hg. Art., shortness of breath, cyanosis appear. On the ECG - an increase in heart rate, an increase in the systolic rate. A decline in cardiac activity in a previously altered cardiovascular system is associated with a load caused by an operating injury, anoxia, narcotic substances, neuroreflex impulses from the intervention area. Therapy consists in the use of cardiac drugs (camphor, caffeine, cordiamine), painkillers (omnopon, promedol), intravenous administration of 20-40 ml of a 40% glucose solution with 1 ml of ephedrine or corglicon.

In the first three days after surgery, especially after severe traumatic operations on the organs of the chest and abdominal cavity, acute cardiovascular failure may occur. An effective measure in the fight against it is intra-arterial blood transfusion in fractional portions of 50-70-100 ml with norepinephrine (1 ml per 250 ml of blood). Favorable results are also given by the introduction into the vein of a 5% solution of glucose with norepinephrine. Along with this, cardiac agents are administered, the patient is warmed, and oxygen therapy is used.

Terrible complication of the postoperative period are thrombosis and embolism of the pulmonary artery (see Pulmonary trunk). The occurrence of thrombosis is associated with disorders of the blood coagulation system, and primary thrombi usually form in the deep veins of the leg. Prolonged stasis, weakening of cardiac activity, age-related changes, and inflammatory processes predispose to the formation of blood clots. Prevention of thromboembolic complications consists in allowing the patient to move early after surgery and monitoring the state of the blood coagulation system, especially in elderly patients. With increased blood clotting (according to the coagulogram), anticoagulants are prescribed under the control of a systematic determination of the prothrombin index.

After abdominal surgery, it may occur dehiscence of the abdominal wound, accompanied by eventration (falling out) of the viscera. This complication is observed between the 6th and 12th day after the operation, mainly in malnourished patients with flatulence or severe cough that developed in the postoperative period. With eventration, an immediate operation is necessary - the reduction of the prolapsed organs and the suturing of the wound with thick silk. Interrupted sutures are carried out through all layers of the abdominal wall (except for the peritoneum) at a distance of at least 1.5-2 cm from the edges of the wound.

Complications from the gastrointestinal tract. With hiccups, the stomach is emptied with a thin tube, a 0.25% solution of novocaine is given to drink, and atropine is injected under the skin. Persistent, excruciating hiccups can force the use of a bilateral novocaine blockade of the phrenic nerve in the neck, which usually gives a good effect. However, persistent hiccups may be the only sign of localized peritonitis with subdiaphragmatic effusion. With regurgitation and vomiting, the cause that causes these phenomena is first identified. In the presence of peritonitis, it is necessary first of all to take measures to combat its source. Vomiting can be supported by stagnation of the contents in the stomach and the presence of flatulence in the patient due to dynamic obstruction (postoperative paresis) of the intestine. Flatulence usually occurs by the end of the second day after surgery on the abdominal organs: patients complain of abdominal pain, a feeling of fullness, difficulty in deep breathing. During the study, abdominal distention, high standing of the diaphragm are noted. To remove gases from the intestines, suppositories with belladonna are prescribed, a gas outlet tube is inserted into the rectum for a while to a depth of 15-20 cm, in the absence of effect, a hypertonic or siphon enema. The most effective means of dealing with postoperative dynamic obstruction of the gastrointestinal tract is long-term suction of the contents of the stomach (see Suction for a long time).

A rare but severe complication in the postoperative period is an acute expansion of the stomach, which also requires constant drainage with a thin probe and at the same time general strengthening measures (see Stomach). Another serious disease, sometimes occurring in the postoperative period and proceeding with the clinical picture of paralytic obstruction, is acute staphylococcal enteritis. Weakened, dehydrated patients in the coming days after surgery may develop parotitis (see). If parotitis becomes purulent, an incision is made in the gland, taking into account the location of the branches of the facial nerve.

In patients with pathological changes in the liver in the postoperative period, liver failure may develop, which is expressed in a decrease in the antitoxic function of the liver and the accumulation of nitrogenous slags in the blood. One of the initial signs of latent liver failure is an increase in the level of bilirubin in the blood. With obvious insufficiency, icterus of the sclera, adynamia, and enlargement of the liver occur. A relative violation of the antitoxic function of the liver is observed in the coming days in most patients who have undergone major interventions. With signs of liver failure, a carbohydrate diet is prescribed with the exclusion of fat, 20 ml of a 40% glucose solution is administered intravenously daily with simultaneous subcutaneous injections of 10-20 units of insulin. Mineral waters are prescribed inside (, No. 17). They give atropine, calcium, bromine, cardiac drugs.

Violations are varied metabolic processes in the postoperative period. With persistent vomiting and diarrhea, intestinal fistulas, dehydration occurs due to the loss of large amounts of fluid, intestinal contents, bile, etc. Together with the liquid contents, electrolytes are also lost. Violation of the normal water-salt metabolism, especially after major operations, leads to heart and liver failure, a decrease in the filtration function of the renal glomeruli and a decrease in diuresis. When acute renal failure occurs, urine output decreases and stops, blood pressure drops to 40-50 mm Hg. Art.

In case of violations of water-salt metabolism, drip administration of liquids, electrolytes (Na and K), oxygen therapy is used; to improve kidney function, a pararenal blockade is performed. An indicator of improvement in kidney function is a daily urine output of up to 1500 ml with a specific gravity of about 1015.

With exhaustion, suppuration, intoxication after operations on the gastrointestinal tract, a violation of the protein balance may occur - hypoproteinemia. In combination with clinical data, the determination of proteins (total protein, albumins, globulins) is of great practical importance, being also one of the functional methods for assessing the state of the liver, where albumins and some globulins are synthesized. To normalize disturbed protein metabolism (to increase the amount of albumin by reducing globulins), parenteral administration of protein hydrolysates, serum, dry plasma is used, blood is transfused, and liver function is stimulated with medications.

Postoperative acidosis It is characterized mainly by a decrease in the alkaline reserve of the blood and, to a lesser extent, by an increase in ammonia in the urine, the accumulation of acetone bodies in the urine, and an increase in the concentration of hydrogen ions in the blood and urine. The severity of postoperative acidosis depends on the violation of carbohydrate metabolism after surgery - hyperglycemia. The complication often develops in women. The main cause of postoperative hyperglycemia is considered to be the weakening of the oxidative abilities of tissues, liver dysfunction plays a lesser role. Moderate postoperative acidosis does not give visible clinical manifestations. With severe acidosis, weakness, headache, loss of appetite, nausea, vomiting, and water-salt imbalance are noted. In the most severe cases, drowsiness, respiratory disorders ("big breath" Kussmaul), coma with a fatal outcome appear. Cases of this kind are very rare. With uncompensated postoperative moderate and severe acidosis, insulin therapy with glucose is successfully used.

After extensive interventions, especially after complex operations on the organs of the chest and abdominal cavity, a condition often develops. hypoxia(oxygen starvation of tissues). Clinically, hypoxia is characterized by cyanosis of the mucous membranes, fingertips, impaired cardiac activity, deterioration in general well-being. To combat hypoxia, oxygen therapy is used in combination with glucose-insulin therapy.

A severe postoperative complication is hyperthermic syndrome, which develops in the next few hours after the operation as a result of disproportion in heat generation and heat transfer. Patients develop cyanosis, shortness of breath, convulsions, blood pressure drops, the temperature rises to 40 ° and even 41-42 °. The etiology of this condition is associated with the upcoming cerebral edema. As therapeutic measures, intravenous administration of significant amounts of hypertonic glucose solution, moderate hypothermia are used.