100. General injection technique. Preparation of instruments and a patient. Anatomical basics of choosing injection sites. Intradermal injection. Subcutaneous injections. Intramuscular injection. Indications, technique, possible complications. Catheterization of peripheral and central veins. Blood sampling from a vein. The technique of intravenous infusion and long-term infusion. Measurement of central venous pressure. Intraosseous and intra arterial infusion technique. Possible complications and their prevention.

General rules for performing injections

Injection - the introduction of a drug by injecting it under pressure into a particular environment or tissue of the body with a violation of the integrity of the skin. This is one of the most dangerous uses of medications. An incorrect injection can damage nerves, bones, tissues, blood vessels, or the body becomes infected with microflora.

There are the following types of injections: intradermal, subcutaneous, intramuscular, intravenous, intraarterial, intraarticular, intraosseous, intracardiac, subdural, subarachnoid (spinal injection), intrapleural, intraperitoneal.

To perform injections, you need sterile instruments - syringe and needle, as well as alcohol balls, injection solution (infusion system). When using each element, it is important to adhere to certain rules.

Syringes. Getting started, it is necessary to check the integrity of the syringe package, then sterile open it from the side of the piston, take the syringe by the piston and, without removing it from the package, insert it into the needle.

Needles... First of all, the integrity of the package is checked. Then it is opened sterilely from the side of the cannula, the needle is carefully removed from the cap.

Infusion systems... Manipulations are performed in the following order. The package is opened in the direction of the arrow; close the roller clamp; remove the protective cap from the vial needle and insert the needle completely into the infusion solution vial. Suspend the vial with solution and squeeze the syringe container so that it fills by "/ 2, open the roller clamp and release the air from the system. Connect to a needle or intravenous catheter, open the roller clamp and adjust the flow rate.

A set of a drug in a syringe from an ampoule.

First of all, you need to familiarize yourself with the information on the ampoule: the name of the drug, its concentration, expiration date. Make sure that the medicinal product is suitable for use: there is no sediment, the color does not differ from the standard one. Knock on the narrow part of the ampoule so that all the drug is in its wide part. Before you saw off the neck of the ampoule, you need to treat it with a cotton ball with a disinfectant solution. Cover the ampoule with a tissue to protect yourself from debris. Break off the neck of the ampoule with a firm movement. Insert a needle into it and collect the required amount of the drug. Ampoules with a wide opening should not be inverted. It is necessary to ensure that when dialing a drug, the needle is always in the solution: in this case, air will not enter the syringe.

Make sure there is no air in the syringe. If there are air bubbles on the walls, you should slightly pull back the syringe plunger, “turn” the syringe several times in a horizontal plane and squeeze out the air.

A set of a medicinal product in a syringe from a vial closed with an aluminum cap... As in the case of the ampoule, first of all, you need to read the name of the drug, concentration, expiration date on the bottle; make sure the color is the same as the standard one. Vials with solutions are checked for intact packaging and contamination. Then, with non-sterile tweezers (scissors, etc.), the part of the bottle cap covering the rubber stopper is folded back. Wipe the rubber stopper with a cotton / gauze ball moistened with an antiseptic. Insert the needle at a 90 ° angle into the vial. Draw the required amount of the drug from the vial into the syringe. Separate sterile needles and syringes are used for each withdrawal of the contents from the vial. Opened multi-dose vials are stored in the refrigerator for no more than 6 hours, if there are no contraindications according to the instructions.

Anatomical Basics of Injection Site Selection

Injections are used in the absence of a dosage form for oral administration and disorders of the absorption function of the gastrointestinal tract; if it is necessary to quickly achieve an effect in the practice of urgent and intensive therapy (intravenous I.) or the predominance of local action over the general one (intraosseous, intraarticular, intraorgan I.), as well as in the process of special diagnostic studies.

Choosing a place for subcutaneous injection depends on the thickness of the subcutaneous tissue. The most convenient areas are the outer thigh, shoulder, and subscapularis.

V / m - The injection site is chosen so that there is a sufficient muscle layer in this area and there is no accidental injury of large nerves and blood vessels. Intramuscular injections (Fig. 4) are most often performed in the gluteal region - in its upper outer part (quadrant). They use long needles (60 mm) with a large diameter (0.8-1 mm).

Injection technique. When performing injections, it is very important to follow certain rules.

Intradermal injection - the most superficial of the injections. For diagnostic purposes, 0.1 to 1 ml of liquid is injected - the mantoux reaction. The site for intradermal injection is the anterior surface of the forearm.

For intradermal injection, a 2-3 cm needle with a small lumen is required. Basically, the palmar surface of the forearm is used, and with novocaine blockages, other parts of the body.

The site of the proposed intradermal injection is treated with a cotton ball moistened with 70 ° alcohol, making smears in one direction. Stretch the skin at the site of intradermal injection and stick the needle into the skin with a cut up, then push it 3-4 mm, releasing a small amount of the drug. Bumps appear on the skin, which, with further administration of the drug, turn into a "lemon peel". The needle is removed without pressing the intradermal injection site with cotton wool.

Subcutaneous injections... With this method, the medicinal substance is injected directly under the subcutaneous tissue, preferably in an area that is well supplied with blood. Subcutaneous injections are less painful than intramuscular injections. The groin fold is the most suitable place for subcutaneous injections. Before injection, the skin is collected in a fold to determine the thickness of the subcutaneous tissue. Grasping the skin with your thumb and forefinger, an injection is made into the formed triangle. To correctly administer the medicine, it is necessary to accurately calculate the length of the fold and the thickness of the subcutaneous tissue. The needle is inserted at an angle of 45 to 90 ° to the skin surface.

Intramuscular injectionand. This method is used to introduce those medicinal substances that, when injected subcutaneously, give severe irritation (magnesium sulfate) or are slowly absorbed. The drug is injected into the posterior femoral muscle group or shoulder.

Intravenous injection... With this method, due to the mobility of patients, it is optimal to use intravenous catheters. When choosing a catheterization site, it is necessary to take into account the ease of access to the puncture site and the suitability of the vessel for catheterization. There are practically no complications if the basic rules are followed: the method should become permanent and habitual in practice. In this case, the catheter must be provided with perfect care.

Complications after injection

Violations of the rules of asepsis - infiltration, abscess, sepsis, serum hepatitis, AIDS

Wrong choice of injection site - poorly absorbable infiltrates, damage to the periosteum (periostitis), blood vessels (necrosis, embolism), nerves (paralysis, neuritis)

Incorrect injection technique - needle breakage, air or drug embolism, allergic reactions, tissue necrosis, hematoma

Infiltrate - the most common complication after subcutaneous and intramuscular injections. Most often, an infiltration occurs if: the injection is performed with a blunt needle; for intramuscular injection, a short needle is used, designed for intradermal or subcutaneous injection. Inaccurate choice of the injection site, frequent injections in the same place, violation of the rules of asepsis are also the reason for the appearance of infiltrates.

Abscess - purulent inflammation of soft tissues with the formation of a cavity filled with pus. The reasons for the formation of abscesses are the same as for infiltrates. In this case, soft tissue infection occurs as a result of violation of the rules of asepsis.

Broken needle during injection is possible when using old worn out needles, as well as with a sharp contraction of the muscles of the buttocks during intramuscular injection.

Medication embolism can occur when the oil solutions are injected subcutaneously or intramuscularly (do not inject oil solutions intravenously!) and the needle enters the vessel. Once in the artery, the oil will clog it and this will lead to a malnutrition of the surrounding tissues, their necrosis. Signs of necrosis: increasing pain in the injection area, swelling, redness or red-bluish discoloration of the skin, increased local and general temperature. If the oil is in the vein, then with the blood stream it will enter the pulmonary vessels. Symptoms of pulmonary embolism: a sudden attack of suffocation, cough, blue discoloration of the upper half of the body (cyanosis), a feeling of tightness in the chest.

Air embolism with intravenous injections is the same formidable complication as oil. The signs of embolism are the same, but they appear very quickly, within a minute.

Damage to nerve trunks can occur with intramuscular and intravenous injections, either mechanically (with the wrong choice of the injection site), or chemically, when the drug depot is near the nerve, as well as when the vessel feeding the nerve is blocked. The severity of complications can vary - from neuritis to paralysis of the limb.

Thrombophlebitis- inflammation of a vein with the formation of a thrombus in it - is observed with frequent venipuncture of the same vein, or when using blunt needles. Signs of thrombophlebitis are pain, flushing of the skin and the formation of infiltration along the vein. The temperature can be subfebrile.

Tissue necrosis can develop with unsuccessful vein puncture and mistaken introduction of a significant amount of irritant under the skin. The ingestion of drugs along the way during venipuncture is possible due to: puncturing the vein "through and through"; missed the vein initially. Most often this happens with inept intravenous administration of a 10% solution of calcium chloride. If the solution does get under the skin, you should immediately apply a tourniquet above the injection site, then inject 0.9% sodium chloride solution into and around the injection site, only 50-80 ml (will reduce the concentration of the drug).

Hematomait can also occur during an inept vein puncture: a purple spot appears under the skin, since the needle pierced both walls of the vein and the blood penetrated the tissues. In this case, the vein puncture should be stopped and pressed for a few minutes with cotton wool and alcohol. In this case, the necessary intravenous injection is made into another vein, and a local warming compress is placed on the area of \u200b\u200bthe hematoma.

Allergic reactions on the introduction of a drug by injection can occur in the form of urticaria, acute rhinitis, acute conjunctivitis, Quincke's edema, which often occur after 20-30 minutes. after drug administration. The most formidable form of allergic reaction is anaphylactic shock.

Anaphylactic shockdevelops within a few seconds or minutes from the moment the drug is administered. The faster the shock develops, the worse the prognosis. The main symptoms of anaphylactic shock: a feeling of heat in the body, a feeling of tightness in the chest, suffocation, dizziness, headache, anxiety, severe weakness, decreased blood pressure, heart rhythm disturbances. In severe cases, these signs are joined by symptoms of collapse, and death can occur a few minutes after the first symptoms of anaphylactic shock appear. Medical measures for anaphylactic shock should be carried out immediately upon revealing a sensation of heat in the body.

Long-term complications that occur two to four months after the injection are viral hepatitis B, D, C, as well as HIV infection.

Vein catheterization rules

Indications for venous catheterization. A peripheral intravenous catheter is an instrument inserted into a peripheral vein to provide access to the bloodstream.

Indications for the use of an intravenous boat:

emergency conditions in which you need quick access to the bloodstream (for example, if you need to urgently and at high speed to inject drugs);

prescribed parenteral nutrition;

overhydration or hydration of the body;

transfusion of blood products (whole blood, erythrocyte mass);

the need for rapid and accurate administration of the drug in an effective concentration (especially when the drug can change its properties when taken orally).

A well-chosen venous approach contributes greatly to the success of intravenous therapy.

Vein and catheter selection criteria. With intravenous injections, the advantage remains with the peripheral veins. Veins should be soft and elastic, without seals and knots. It is better to inject drugs into large veins, in a straight section corresponding to the length of the catheter. When choosing a catheter (Fig. 1), you must focus on the following criteria:

diameter of the vein (the diameter of the catheter should be less than the diameter of the vein);

the required rate of solution introduction (the larger the catheter size, the higher the rate of solution introduction);

potential time the catheter is in the vein (no more than 3 days).

When catheterizing veins, preference should be given to modern Teflon and polyurethane catheters. Their use significantly reduces the frequency of complications and, with high-quality care, their service life is much longer. The most common cause of failures and complications in peripheral vein catheterization is the lack of practical skills of the staff, violation of the technique of inserting and caring for a venous catheter.

Peripheral Vein Catheterization Standard Kit includes a sterile tray, sterile balls soaked in disinfectant solution, sterile "pants", adhesive plaster, peripheral intravenous catheters of several sizes, tourniquet, sterile gloves, scissors, medium bandage.

Inserting a peripheral catheter... They start by providing good illumination of the manipulation site. Then hands are thoroughly washed and dried. A standard vein catheterization kit is assembled, with several catheters of different diameters in the kit.

A tourniquet is applied 10 ... 15 cm above the proposed catheterization zone. The vein is selected by palpation.

An optimal catheter is selected, taking into account the size of the vein, the required injection rate, and the schedule of intravenous therapy.

Re-treat hands using an antiseptic, put on gloves. The catheterization site is treated with a skin antiseptic for 30 ... 60 s and allowed to dry. Do not palpate the vein again! Having fixed the vein (it is pressed with a finger below the intended place of catheter insertion), take the catheter of the selected diameter and remove the protective cover from it. If there is an additional plug on the cover, the cover is not thrown away, but held between the fingers of the free hand.

The catheter is inserted on the needle at an angle of 15 ° to the skin, observing the indicator chamber. When blood appears in it, the angle of inclination of the stylet needle is reduced and the needle is inserted into the vein by a few millimeters. Having fixed the stylet needle, slowly move the cannula from the needle into the vein to the end (the stylet needle is not completely removed from the catheter until it is completely removed). Remove the tourniquet. Do not insert the needle into the catheter after it has been displaced from the needle into the vein! The vein is clamped to reduce bleeding and the needle is permanently removed from the catheter. The needle is disposed of in a safe manner. Remove the plug from the protective sheath and close the catheter or attach an infusion set. The catheter is fixed to the limb.

Central venous catheterization

Patients with spontaneous breathing are placed on their backs horizontally or with the head end lowered by 15В °. This helps increase neck vein filling and minimizes the risk of venous air embolism. In patients with acute heart failure, who are on artificial ventilation, a reclining position is permissible.

Central venous catheter insertion using a large-bore needle (usually N14) to enter the vein and then pass the catheter through the needle (catheter-through-needle technique) carries a high risk of damage to the vein and surrounding tissue and is rarely used today.

The method of choice for central venous catheterization is the Seldinger method, or "catheter through a guidewire". The main advantage is the limitation of trauma to the vessels and underlying structures during the catheter insertion. The sequence of manipulations is shown in Fig. 4-4. A thin needle (usually at –20) is inserted into a vein, then the syringe is removed and a thin wire guide with a flexible tip (the so-called J-guide) is inserted into the lumen of the needle. In the next step, the needle is removed from the vein, and the guidewire is used to insert the catheter into the lumen of the vessel. In fig. Figures 4-4 show a system consisting of a guide catheter that is placed on a dilator catheter. This system of catheters is inserted through the guide wire before entering the vessel lumen. Then the guidewire is removed and the catheters are retained.

The Seldinger method has the following advantages. First, the thin needle causes minimal damage to the vessel and adjacent structures; this is especially important in case of accidental puncture of an artery. Secondly, the introduction of the catheter through the guidewire ensures that the puncture hole in the vessel wall will not exceed the catheter diameter, and the possibility of bleeding from the puncture site will be minimal.

Catheter care rules

Each catheter connection is a gateway for infection. It is necessary to avoid repeatedly touching the instruments with your hands. It is recommended to change sterile plugs more often, never to use plugs, the inner surface of which could be infected.

Immediately after the administration of antibiotics, concentrated glucose solutions, blood preparations, the catheter is washed with a small amount of saline.

To prevent thrombosis and prolong the life of the catheter in the vein, it is recommended to flush the catheter with saline additionally - during the day, between infusions.

Complications after vein catheterization are divided into mechanical (5 ... 9%), thrombotic (5 ... 26%), infectious (2 ... 26%).

It is necessary to monitor the condition of the fixation bandage and change it if necessary, as well as regularly examine the puncture site in order to identify complications as soon as possible. If there is edema (Fig. 3), redness, local temperature rise, catheter obstruction, leakage, or painful sensations, the nurse removes the catheter and notifies the doctor.

When changing the adhesive bandage, do not use scissors, because you can cut off the catheter, causing it to enter the bloodstream. It is recommended to change the place of catheterization every 48 ... 72 hours. To remove the venous catheter, a tray, a ball moistened with disinfectant solution, bandage, scissors are required.

Despite the fact that catheterization of peripheral veins is a much less dangerous procedure than catheterization of central veins, if the rules are violated, it can cause a complex of complications, like any procedure that violates the integrity of the skin. Most complications can be avoided with good manipulative techniques of the staff, strict adherence to the rules of asepsis and antisepsis, and proper care of the catheter.

Technology of taking blood from a vein for laboratory research

The results of the study largely depend on the technique of taking blood, the instruments used in this case, the utensils in which the blood is stored.

When taking blood, the needle should be with a short cut and large enough so as not to injure the opposite wall of the vein and not cause damage to red blood cells with subsequent hemolysis.

Take blood with a dry, cooled syringe, drain without a needle into a dry test tube, without shaking.

Infusion / infusio / - parenteral administration of large amounts into the patient's body / from 100 ml to several liters / of various solutions, blood, blood substitutes, etc. for a long time - up to several hours a day. This method of treatment is called fluid therapy, which can be subcutaneous, intra-arterial, intravenous, intraosseous. The most preferred is intravenous infusion, which is characterized by relative ease of use, quick obtaining of a therapeutic effect, the possibility of administering the required amount of solutions of different osmosis and Ph, ease of regulating the rate of their administration and painlessness.

The main indications for intravenous infusion:

Restoration of circulating blood volume / blood loss, shock /;

Restoration of water-electrolyte balance and acid-base state / intestinal obstruction, peritonitis, intestinal fistulas /;

Elimination of the phenomena of intoxication / peritonitis and other acute diseases of the abdominal cavity /;

Maintaining adequate nutrition and metabolism / parenteral nutrition by introducing protein blood substitutes and fat emulsions /;

Impact on the rheological properties of blood and microcirculation / shock, blood loss, thrombosis /;

Fight against local and generalized infection / long-term administration of antibacterial drugs /;

Normalization of the functions of internal organs / heart, lungs, liver, kidneys, etc. /;

Cerebral edema / decrease in intracranial pressure by the administration of drugs with a dehydration effect or forced diuresis /.

Intravenous infusions are performed using a special system. To connect the system to a vein, venipuncture is performed, and with prolonged multi-day administration of large amounts of solutions, vein catheterization or, much less often, venous section / opening of the vein lumen /.

Intravenous infusion technique.

Before starting the intravenous infusion, it is necessary to check the suitability of the solution for infusion and prime the system. According to the inscription on the bottle, the nature of the injected substance, its dosage, shelf life, color and transparency are checked. The filling of the system is carried out in the treatment room, intravenous infusion - in the ward.

The patient is given a comfortable horizontal position in bed. In restless patients, the hand is fixed to the bed. With prolonged and massive infusions, a urine collection bag is placed next to the patient.

After puncture of the vein, a system is attached to the needle. With the help of a roller clamp, the rate of solution infusion is regulated (usually 50-60 drops per minute). For several minutes, it is observed whether the solution enters the skin and whether the rate of its administration can be adjusted. The flow of solution under the skin will be indicated by the appearance of soreness and swelling at the site of the needle. This can be observed if the needle is located outside the lumen of the vein or is partially in it. In cases where, in the presence of tissue infiltration, the vein is still contoured, you can try, without removing the needle, to change its direction according to the location of the vein. If you are unsure of the success of this technique, the needle should be removed and venipuncture performed elsewhere. If the injection rate cannot be adjusted, then this may be when the system is low above the bed level / higher to raise the system / or the needle rests against the vein wall. In the latter case, by carefully changing its position, you should achieve the required speed of the infusion.

Only after there is confidence that the solution is injected directly into the vein and at the required speed, the needle is fixed to the skin with an adhesive plaster and covered with a napkin. By placing a small gauze napkin or ball under the needle, it is achieved that the needle tip does not rest against the vein wall.

If it is necessary to quickly enter the bloodstream of a medicinal substance, it is injected in a stream. If the drug must be delivered slowly, then it is administered by drip. Jet infusions are performed, if necessary, to quickly replace the volume of circulating blood / massive blood loss, shock /. At the same time, no more than 500 ml of blood or blood-substituting fluids are injected, and then they switch to drip administration of solutions. Large amounts of fluid jets can overload the heart

Intravenous administration of certain hyperosmolar solutions / potassium chloride, calcium chloride / causes pain along the vein, which is eliminated by preliminary administration of lidocaine or 5-10 ml of 0.25% novocaine solution

With drip infusions, due to the slow introduction of solutions, conditions are created for good digestibility of drugs and their injections in large quantities without pronounced fluctuations in blood pressure and stress on the work of the heart.

During the IV infusion process, the nurse will repeatedly check:

The patient's condition / the presence of complaints, if necessary, checks the pulse, respiratory rate /;

Is there any tissue swelling in the area where the needle is located, which indicates that it has come out of the lumen of the vein and the solution is injected subcutaneously;

Is there no wetting of the napkin, which covers the top of the needle, which indicates that there is no tightness between the system and the cannula of the needle located in the vein;

Infusion rate;

The amount of solution in the bottle.

If the patient's condition worsens during intravenous infusion, the nurse closes the system with a roller clamp and immediately invites a doctor.

The cessation of the flow of solution into the vein can occur when the needle leaves the vein, thromboses it or the needle, displacement of the position of the needle, as a result of which its tip rests against the vein wall. To detect thrombosis, it is necessary to close the clamp and disconnect the system from the needle. When it is thrombosed, there will be no blood flow from the needle. In this case, the needle should be removed and the other vein punctured with another needle.

Central venous pressure measurement technique... CVP is measured using a Waldmann phlebotonometer connected to a blood transfusion system or blood substitutes through a glass tee. The phlebotonometer consists of a glass tube of small diameter and a special tripod with a scale. The glass tube of the apparatus is filled with isotonic sodium chloride solution and a clamp is applied to the rubber connection that goes from the phlebotonometer to the tee. Zero division of the phlebotonometer scale is set at the level of the right atrium, which corresponds to the posterior edge of the pectoralis major muscle (at the point of intersection of the third intercostal space or IV rib with the midaxillary line). In an ambulance setting, it is advisable to attach the phlebotonometer scale to a rack for blood transfusion or blood substitutes; the zero division of the apparatus is fixed by moving vertically the upper part of the rack. The cannula of the system is attached to a catheter inserted into the subclavian vein, and the transfusion of blood or blood substitute is initiated. To measure CVP, a clamp is placed below the dropper and the clamp is removed from the rubber tube that goes to the phlebotonometer. The readings of the apparatus are recorded after the liquid level in the glass tube has stabilized (on average, after 1% - 2 minutes).

The normal CVP is 30 - 100 mm of water. Art. Low CVP is markedly increased during transfusion of blood or blood substitutes and intravenous drip of osmotic diuretics (mannitol, urea) or sympathomimetic drugs (for example, with anaphylactic shock). The rise of the CVP above 150 mm of water. Art. serves as an indication for stopping or limiting the rate and volume of transfusion (with traumatic shock and massive blood loss) or for intravenous administration of digitalis drugs, ganglion blockers or α-blockers (with heart failure).

To prevent excessive introduction of fluid into the vascular bed (especially in conditions of mass accidents or disasters), it is advisable to install the bottle with the transfused solution at a level not exceeding 20 cm from the posterior edge of the pectoralis major muscle. The transfusion of blood or blood substitute will stop on its own as soon as the CVP reaches 200 mm of water. st ... Accelerated determination of CVP is performed without using a phlebotonometer by slowly lowering the bottle with the transfused solution until the transfusion stops. At this moment, the drop of the medicinal solution seems to hang in the dropper, which indicates that the CVP is equal to the pressure of the liquid column in the system. The CVP value corresponds to the vertical distance from the posterior edge of the pectoralis major muscle to the level of the liquid in the vial minus the height of the air gap in the dropper (usually 10-20 mm).

Intraosseous administration of drugsand blood testimony: Extensive burns and deformation of the extremities, collapse of the saphenous veins in shock, collapse, terminal conditions, psychomotor agitation or convulsions, impossibility of intravenous administration of drugs (primarily in pediatric practice).

contraindications: Inflammatory processes in the area targeted for intra-bone puncture.

technics:The skin is treated with tincture of iodine, then with alcohol and anesthetized by the introduction of 2-5 ml of 0.5-2% novocaine solution; patients who are in a coma or under anesthesia are not given anesthesia. The puncture is carried out with a shortened vira needle with mandrin into one of the following areas: epiphyses of tubular bones, outer surface of the calcaneus, anterior-superior spine of the ilium;in case of injuries it is not recommended to puncture near the place of damage. In the presence of psychomotor agitation or convulsive syndrome, preliminary fixation of the limb is necessary. The needle is inserted into the bone with helical movements to a depth of at least 1 cm. At the moment when the needle penetrates into the spongy substance, there is a feeling of "failure", and after removing the mandrel from the lumen of the needle, blood with drops of fat is usually released.

The intraosseous method can be used to administer the same medications as intravenous; the therapeutic effect of drugs when infused into the cancellous bone is manifested just as quickly. At the end of the injection, the needle with a mandrel, covered with a sterile napkin, can be left in the bone for subsequent infusions. Due to the strong fixation of the needle and the impossibility of its thrombosis, long-term drip infusions can be carried out.

In this regard, intraosseous administration of drugs should be preferred to intravenous drip when it is necessary to transport seriously ill patients for a long time, especially along a shaky road. During resuscitation, intraosseous blood transfusions, produced simultaneously with 2-3 syringes in different areas, can sometimes be more effective than intra-arterial blood injection.

complications: Fat embolism when too much fluid is injected too quickly, pain when the needle is very close to the cortical bone; limited osteomyelitis.

Intra-aortic and intra-arterial transfusion

Indications:

1) cardiac arrest in clinical death caused by massive unreplenished blood loss;

2) terminal condition associated with prolonged hypotension (blood pressure 60 mm Hg and below). The advantage of this method consists in the direct supply of blood to the coronary and cerebral vessels, reflex stimulation of cardiac activity. This method allows you to transfuse a sufficient amount of blood in a short time;

3) long-term administration of drug solutions into the aorta or its branches (selectively) in order to create their maximum concentration in the lesion focus in oncological diseases, purulent-destructive lesions of the abdominal and thoracic cavities, extremities, with diffuse peritonitis, destructive pancreatitis, for the purpose of thrombolysis with thrombosis, thromboembolism and obliterating diseases of the arteries.

3) sudden massive bleeding during thoracic surgery;

4) electrical injury;

5) asphyxia of various etiologies;

6) intoxication of various origins.

With intra-arterial administration, the penetration of the drug into the tissues is faster due to its high concentration in the blood. Compared with the intravenous route of administration, intra-arterial tissue filters are bypassed: lungs, liver, kidneys, in which there is a delay, destruction and excretion of drugs. This is important because the faster the substance passes from the blood to the tissues, the less it binds to plasma proteins;

Technics

In urgent cases, intra-arterial injection is performed with a syringe after percutaneous puncture or Seldinger catheterization.

When this fails, the peripheral artery is exposed with a layer-by-layer incision and puncture or arteriotomy is performed. If necessary, intra-arterial transfusion can be carried out into the great vessels of the cavities, and in case of injuries and separations of the limbs, the gaping end of the vessel can be used.

The more distal from the heart the blood is injected, the less pronounced its stimulating effect. When used for transfusion of large arteries (brachial, femoral, carotid), the effect is more pronounced due to the better and faster blood supply to the heart and brain. The risk of spasm of large vessels, thrombosis due to damage to the endothelium with the development of impaired blood supply to the extremity is forced to use peripheral arteries (radial and posterior tibial), which are easily accessible for isolation and after intra-arterial transfusion can be tied without fear of tissue ischemia due to the presence of pronounced collateral pathways ...

With the help of a Richardson balloon and a pressure gauge, a high pressure (160-200 mm Hg) is created in an ampoule with blood or a vial. Pressures below this level may be ineffective, while higher pressures may cause hemorrhage in various organs and especially in the spinal cord due to rupture of small vessels. In order to maintain a certain constant pressure in a vial of blood or blood substitutes, to prevent air embolism at the time of completion of transfusion, you can use the V.P. Sukhorukov system, which also includes an air compensator (a can from the Bobrov apparatus or a vessel of larger capacity) and a glass chamber with a floating glass float covering the system.

Reflex stimulation of the vascular tone is enhanced by intra-arterial infusion under varying pressure with a pulsating stream: strong rhythmic stretching of the arterial walls has a more powerful effect on the neuro-receptor apparatus of the vascular wall and is more physiological. To create a pulsating blood flow, the system tube is clamped with a finger or a clamp 60-80 times a minute. The effect of intra-arterial transfusion is observed with infusion at a rate of 200-250 ml in 1.5-2 minutes. under constant pressure and for 20-30 minutes. with fractional transfusion. To achieve an effect in shock, it is enough to inject 100-250 ml of blood into the artery, with clinical death and prolonged arterial hypotension up to 1000 ml. The duration of fractional transfusion is different: from several minutes to several hours - with prolonged hypotension or the development of torpid shock.

Complications of arterial puncture and catheterization

1). Arterial spasm: the pumping of blood and blood substitutes into the peripheral arteries at a pressure of over 200 mm Hg. threatens the development of a prolonged spasm. It is accompanied by pallor of the skin, muscle weakness, stiffness of finger movements, loss of sensitivity and a decrease in limb temperature. There are examples of tissue death due to prolonged spasm of the arteries, which required amputation of the limb. For the prevention of spasm, the introduction of a solution of novocaine into the fascial sheath of the neurovascular bundle (periarterial novocaine blockade) and 5-10 ml of 0.25% solution of novocaine into the lumen of the artery should be used, carefully handle the elements of the neurovascular bundle when isolating the artery, avoid introducing into the artery of cooled blood or transfusion media.

2). Arrosive bleeding, hematoma and the occurrence of false aneurysms: in order to prevent them, at the time of removing the needle, press the artery in the puncture zone for 5 minutes. Sometimes it is necessary to expose the artery and apply parietal sutures. After diagnostic and therapeutic procedures (angiography, puncture and catheterization of the great vessels), the possibility of false aneurysms is not excluded.

3). Thrombosis and obstruction of the lumen with the threat of gangrene of the limb: such a complication of the puncture of the radial artery does not threaten the viability of the hand. Before puncture, it is necessary to conduct a test for the adequacy of collateral circulation: along the projection of the vessel, the radial artery is squeezed with the fingers and the patient is asked to squeeze and unclench his fingers several times - with sufficient collateral circulation, the pale skin tone of the palm is replaced by a normal color after 10 seconds.

4). Air embolism occurs more often with direct blood pressure monitoring. Air bubbles can sometimes spread retrograde along the radial artery from the syringe used to flush arterial catheters. In addition, it may be the result of a doctor's carelessness, when there is insufficient control over the tightness of the system for intra-arterial transfusion during its installation, behind the column of the transfusion medium in the vial, with a late termination of the transfusion. The injection of blood and solutions into the artery is carried out under high pressure, which also contributes to the occurrence of air embolism.

five). Neuritis with a clinical picture of paresis or paralysis occurs when an artery is roughly exposed and adjacent nerves are injured, when blood is injected paravasally and compressed by the resulting scars.

101. Drainage and packing of wounds and body cavities. Indications for use. Types of drains and tampons. Types of tubular drainage. Passive and active drainage. Equipment and instruments for active aspiration.

Drainage is a medical method consisting in removing the contents from wounds, abscesses, contents of hollow organs, natural or pathological body cavities. Full drainage, provides a sufficient outflow of wound exudate, creates the best conditions for the early rejection of dead tissues and the transition of the healing process to the regeneration phase. There are practically no contraindications to drainage. The process of purulent surgical and antibacterial therapy revealed another advantage of drainage - the possibility of a targeted fight against wound infection.

To ensure good drainage, it has the nature of drainage, the choice is optimal for each case, the method of drainage, the position of the drainage in the wound, the use of certain medications for washing the wound (according to the sensitivity of the microflora), the maintenance of the drainage system is in good order in compliance with the rules of asepsis.

Drainage is carried out using rubber, glass or plastic tubes of various sizes and diameters, rubber (glove) graduates, specially made plastic strips, gauze tampons inserted into the wound or the drained cavity, soft probes, catheters. The introduction of rubber or plastic drains is often combined with gauze swabs, or the so-called cigar drains proposed by Spasokukotsky are used, consisting of a gauze swab placed in the finger of a rubber glove with a cut end. For better drainage of the contents, several holes are made in the rubber casing. The use for draining gauze tampons is based on the hygroscopic properties of gauze, which creates an outflow of wound contents into the bandage. For the treatment of large deep wounds and purulent cavities Mikulich proposed in 1881 a method of drainage with gauze tampons, in which a square piece of gauze is inserted into the wound or purulent cavity, stitched in the center with a long silk thread. The gauze is carefully straightened and the bottom and walls of the wound are covered with it, after which the wound is loosely packed with gauze swabs moistened with hypertonic sodium chloride solutions. Tampons are changed periodically without changing the gauze, which prevents tissue damage. If necessary, the gauze is removed by pulling the silk thread. The hygroscopic effect of a gauze swab is extremely short-lived. After 4-6 hours, the tampon must be changed. Rubber graduates have no suction properties at all. Single rubber drains are often clogged with pus and detritus, covered with mucus, causing inflammatory changes in the surrounding tissues. Therefore, drainage methods such as plugging, rubber graduation and single rubber tubing should be excluded from the treatment of purulent wounds. These methods lead to difficulty in the outflow of wound exudate, which creates conditions for the progression of wound infection.

Tubular drainages (single and multiple, double, complex, with single or multiple holes) are most adequate in the treatment of purulent wounds. When draining surgical wounds, preference is given to silicone tubes, which, in terms of their elastic-elastic characteristics, hardness and transparency, occupy an intermediate position between latex and polyvinylchloride tubes. They significantly surpass the latter in biological inertness, which makes it possible to increase the duration of the stay of drainages in wounds. They can be sterile processed by autoclaving and hot air multiple times.

The main types of drainage:

passive, active, flow-aspiration, vacuum.

With passive drainage, the outflow follows the principle of communicating vessels, so the drainage should be in the lower corner of the wound, and its second free end - below the wound. On the drain, several additional side holes are usually made.

With active drainage, negative pressure is created in the area of \u200b\u200bthe outer end of the drain. For this, a special plastic accordion, a rubber can or an electric pump is attached to the drainage.

With flow-washing no more than 2 drainages are installed into the wound by drainage ... One (or several) of them are constantly injected during the day (preferably an antiseptic solution), and otherwise it flows out. The introduction of substances into the drainage is similar to intravenous drip infusion. The method is effective and in some cases allows even infected wounds to be stitched up tightly, which subsequently speeds up the healing process (after 5-7 days of washing, the number of microorganisms in 1 ml of discharge always becomes lower than critical; after 10-12 days, more than half of the cases, the wounds become sterile)

It is important that there is no fluid retention in the wound: the amount of fluid flowing out should be equal to the amount injected. A similar method can be used to treat peritonitis. In cases where the drained cavity is hermetically sealed (a wound sewn up with sutures, an abscess cavity), they are actively used aspirating drains (vacuum)

A vacuum in the system can be created using a Genet syringe, which removes air from a sealed can with a drain connected to it, or using a water-jet suction, or a three-can system. This is the most effective method, it helps to reduce the cavity of the wound, its faster closure and elimination of inflammation.

Goal: 1. Therapeutic - the creation of an outflow of existing or expected localized accumulations of pus, blood, exudates or transudates from the wound cavity. Drainage serves to fight infection, since the conditions for the development of infection in the drained cavity are unfavorable. Drainage allows you to flush the cavity and administer drugs. 2.Preventive - in case of doubts about the consistency of the intestinal suture, to the bed of the removed gallbladder, into the subcutaneous tissue after suturing the wound. With its help, complications are diagnosed early: bleeding and anastomotic leakage. The purpose is disputed, since drainage is the entry gate of infection.

Drainage task - the earliest possible cleansing of the wound silt of the body cavity from the wound contents.

Drainage methods.

 Passive drainage discharge flows from the wound due to gravity:

Gauze swab - its work is based on the action of capillary forces, it absorbs exudate. It works no more than 6-8 hours, turning into a cork soaked in exudate, which interferes with the outflow (especially with thick pus). They are used to stop diffuse capillary bleeding (tampons with hydrogen peroxide solution) or to limit the purulent cavity. And also a gauze base for supplying drugs to wounds.

Rubber plate drainage - the action is based on the property of capillarity. When inserted into the cavity, it requires fixation, otherwise it may slip off.

Penrose "cigar" drain - tube filled with gauze, or a combination of latex tube with glove rubber.

Tubular drains - material: latex, rubber, silicone, polyvinyl chloride, polyethylene, fluoroplastic. The best drains made of biologically inert material with an anticoagulant coating. Drainage diameter - 2-5 mm - small wounds of the hand, forearm. 10 -20 mm - extensive damage and an abundance of exudate

Multichannel drains - allow you to combine the outflow of exudate and the introduction of drugs

 Active suction drainage - removal of fluid by creating negative pressure outside the wound against the background of positive pressure in the wound, leading to the removal of exudate.

Closed drainage systems are usually used.

. Purpose of plugging - elimination of the cavity. Then the cavity cannot be sutured or tamponized with tissue. The end of a long gauze swab is inserted into the deepest point of the wound, and then it is loosely laid layer by layer, it can be soaked in ointment, antiseptic or antibiotic. For the fastest elimination of the cavity, it is necessary to avoid its tight tampon and systematically remove part of the tampon.

Indication - the need for hemostasis. Tamponade is used both to stop parenchymal or capillary bleeding and to stop bleeding from larger vessels, especially veins. Bleeding can be stopped only with a tight tamponade, with preliminary impregnation with a hemostatic. Typically, the tampon should be removed after 24 hours. Only in case of danger of recurrence of massive bleeding, the tampon is left up to 7-8 days. Before removing the tampon, it is necessary to carry out hemostatic therapy, lower blood pressure and high pressure, and also prepare for a surgical stop of bleeding.

The gauze swab has a weak and short-term drainage property.

The main purpose of its application is to delimit the area of \u200b\u200boperation or the place of disaster from the rest of the cavity.

The delivered tampon is a foreign body for the body, causes an inflammatory reaction, manifested by the deposition of fibrin on the surfaces of organs in contact with the tampon, and then the formation of connective tissue on its basis. Understanding this process allows the surgeon to clearly navigate the timing of the removal of the tampon.

Already starting from 2 days after the operation, the fallen out fibrin quite firmly fixes the tampon to the organs. Therefore, removing the tampon for 2-6 days is a serious mistake, since it not only leads to the destruction of adhesions that delimit the free abdominal cavity, but

and can cause destruction of these organs with the development of complications.

In the following days, the body's reaction to a foreign body will be aimed at its expulsion: on the 6-7th day, lysis of fibrin begins, which fixes the tampon to the tissues (licking the tampon).

Removing the tampon:

On days 7-8, it can be easily removed in two stages: on the 7th day, a tampon

pull up, take out on the 8th. Its extraction should not be forced! If a significant effort is applied, then its extraction should be postponed for 1-3 days. Before removing the patient, anesthetize is necessary.

Some features of drainage:

1. Combination of tamponing with drainage. This is necessary to combine the delimitation of the wound and create a good outflow - the drainage tubes are brought to the desired area, and the tampons are inserted on the sides outward from them. Silicone rubber tubing should be used for drainage.

2. Suction tube. To avoid this, a U-shaped cut is made from the side of the inner end.

3. Drainage holes The number and location of side holes depends on the purpose of the drainage. When draining the gastrointestinal tract, many side holes are cut, but too large and frequent holes will cause the tube to bend. If the tube is perforated for a considerable length, then this leads to infection of the entire canal. The presence of holes at the level of the subcutaneous tissue is the cause of its phlegmon. If a similar situation occurs when draining the pleural cavity, then subcutaneous emphysema or pneumothorax will develop. In cases where the drainage passes through a free cavity and some of the holes in it are located above the level of exudate, it may not function because will either suck in air, or liquid entering the drain through the bottom hole will pour out through the top hole. If there is not a large amount of drainage to be separated, a rubber strip is used.

4. The degree of the required level of negative pressure in the drainage system. With a slight negative pressure - the best outflow, because drainage does not adhere to tissues (abdominal cavity - gravity drainage). When it is necessary to drain a leaky cavity, a powerful suction system is connected to the drain. But the strong vacuum interferes with wound healing.

5. Several drains. In cases where a significant amount of discharge is expected, several drains are installed. However, it must be remembered that drainage of a foreign body - causes bedsores of internal organs.

6. Washing of infected cavities and wounds. It is not always recommended to flush through the drainage, because: - in the absence of sealing, the liquid flows past the tube, and in the presence of sealing, the pressure in the cavity (prevents collapse, contributes to the penetration of the infected contents into the bloodstream). All this can be avoided by using a flow-drainage system (2-lumen drainage). In some cases, through drains are placed through the entire wound or cavity. As a rule, they are placed in order to form anastomoses on them and prevent stenosis.

7. Tampons and drains are taken out, usually through a separate skin incision. Around the drainage placed in the pleural cavity, there should be a situational suture, which is tightened after the drainage is removed. In some cases, when it is important that the inner end of the drainage is exactly in a certain place or would not come out of the lumen of the organ cavity, it should be fixed there with a catgut suture.

102. Principles and techniques of wound drainage. Methods of flow-aspiration drainage of wounds. Vacuum wound drainage. Principles and techniques of chest cavity drainage.

Drainage - the method is based on the principles of capillarity and communicating vessels. An extremely important element of physical antiseptics. It is used in the treatment of all types of wounds, after most operations on the chest and abdominal cavity.

Drainage requirement:

1. The requirement of careful adherence to the rules of asepsis (removal or change of drainage is indicated when inflammatory changes appear around it, much less often such changes develop in cases where drainages are removed from the wound through healthy tissues). The possibility of infection penetration into the depth of the wound along the drainage lumen is prevented by two-fold replacement with sterile ones within 24 hours of the entire peripheral part of the drainage system, including the graduated vessels for collecting secretions. An antiseptic solution (furacilin solution, diocide, rivanol) is usually poured onto their bottom.

2. Drainage should ensure the outflow of fluid throughout the entire period of treatment of a cavity, wound, etc. Loss of drains can be a serious complication that aggravates the outcome of surgery. Prevention of this is achieved by carefully fixing the drainage with an outer cover, bandage, leukoplast or silk suture, best of all for a rubber sleeve put on the drainage tube near the skin.

3. The drainage system should not be squeezed or kinked both in the depth of the wound and outside it. The location of the drains should be optimal, i.e. the outflow of fluid should not be due to the need to give the patient a forced position in bed.

4. Drainage should not cause any complications (pain, tissue damage and large vessels).

Drainage technique.

With any of its methods, the tubes should be placed exactly at the bottom of the purulent cavity, taking it through the lowest section of the purulent focus (in the supine position), which ensures the outflow of pus from the wound according to the principle of gravity. With any other option, the pus on the drainage will not go away. The drainage gauge is selected depending on the size of the wound cavity. For small wounds, small-diameter tubes (1-5 mm) are convenient. With deep extensive wounds, the use of large-caliber drainages (10-20mm) is indicated.

For purulent wounds of small size, without leaks and pockets, use one continuous PVC drainage or two tubes (Fig. 1).

With deep wounds, all layers of the wound should be drained separately and tubes should be installed in the subcutaneous tissue, the intermuscular space. With a complex wound configuration, the presence of purulent leaks and pockets, each purulent cavity must be drained separately (Fig. 2).

Drainage installation rules.

 Drainage should be soft, smooth, made of durable, preferably radiopaque material, and should not bend or twist in or out of the wound. Solid drains injure, squeeze the surrounding tissue and lead to necrosis and pressure ulcers of the internal organs.

 Drainage material must not collapse in the wound.

 Drainages are impractical to install if they need to be constantly changed.

 Drainage is always the entrance gate of infection.

 An inert anticoagulant coating does not cause inflammation and should have minimal deposition of fibrin or exudate.

 Drains are not led out through the wound as this increases the risk of infection and prevents the wound from healing. Counter-openings are used to remove drainage.

 Drains must be securely sewn to the skin, otherwise the drain may fall out or fall into the drainage cavity.

 Drainage should go through the lowest point of the wound or purulent cavity.

 Drainages are not passed through the bursae and tendon sheaths because reactive fibrosis leads to dysfunction.

 An intestinal anastomotic drain should not be placed close to the suture line, as this increases the risk of pressure ulcers and anastomotic leakage.

 Drainage of the abdominal cavity is advisable for abscesses and ineffective for diffuse peritonitis. Abdominal drains are often the cause of paralytic bowel obstruction and pile formation, which can cause mechanical obstruction.

 Aspiration drains cannot be used in the treatment of growing hematoma, and in the abdominal cavity only two-channel drains do not suck the intestines.

Do not drain the pleural cavity only after pulmonectomy.

Drainage of the pleural cavity should always be active due to the presence of physiological depression in the pleural cavity. For the same reason, the drainage of the pleural cavity must be tight, since the ingress of atmospheric air into the pleural cavity leads to total pneumothorax and collapse of the lung. In the case of an uncomplicated postoperative period, drains from the pleural cavity are removed after 2 days. 30 minutes before removing the drainage, the patient is injected with an anesthetic. Then, having treated the skin around the drainage with an antiseptic solution, anesthesia is performed with a 0.5% solution of novocaine of the chest wall at the outlet of the drainage tube.

The drainage is squeezed with a Kocher clamp and a silk U-shaped suture is applied around the skin through the skin, the threads of which are not tightened in the left hand. Having cut off the old fixing suture with scissors, the drainage tube is quickly removed with the right hand, while simultaneously tightening the U-shaped suture, thereby preventing air from entering the pleural cavity.

The simplest way of drainage is passive, when the evacuation of the contents of the cavity or wound discharge occurs as a result of the pressure difference in the cavities and (or) under the influence of gravity, capillary forces. Gravity is determined by the height of the fluid column in the drain below the level of the drainage area. The pressure difference between atmospheric and inside the cavity is usually present. But, if the pressure in the abdominal cavity is always 10 - 15 mm Hg. higher than atmospheric, then in the pleural cavity it is positive only on exhalation. When inhaling, a vacuum is created, therefore, a water lock is used to prevent the return of wound discharge and, above all, air. This feature was taken into account when draining the pleural cavity with the Bulau system (Fig. 1). The anachronism of the design does not detract from the reliability and simplicity of the system, which allows, thanks to the absolute tightness of the water lock, to straighten the lung and eliminate the residual pleural cavity. Of course, the Bulau system is also possible in a more modern design. It is used in thoracic surgery to expand the lung, mainly when active drainage systems are undesirable. Namely, after pneumonectomy, when there is a danger of excessive displacement of the mediastinum, and with bronchopleural fistulas, when active aspiration will lead to an increase in air discharge through the fistula.

Active drainage is a more complex method, requiring the use of aspiration devices or systems (Fig. 7). It can be conditionally closed when the system needs to be depressurized for emptying, and closed when there are non-return valves and drain valves in the structure.

Most of the stationary systems belong to conditionally closed aspiration systems. At the present time, apparently, the use of a water jet suction (Fig. 8), operating on the principle of a spray gun, should be considered history.

Stationary aspiration systems include the well-known Lavrenovich aspirator (Fig. 9), well-known throughout the territory of the former USSR and well-proven, invented within the walls of our hospital (former Central Clinical Hospital No. 1 of the Ministry of Railways). Unfortunately, now it is almost impossible to get it. There are other models of stationary aspirators, but they are less reliable and need periodic shutdown. Centralized vacuum aspiration systems are increasingly being used. The great advantage of stationary systems is the ability to adjust the degree of vacuum, unlimited service life and the ability to evacuate not only liquid separated, but also an unlimited amount of air. Therefore, they are used mainly in thoracic and cardiac surgery, when the pleural cavity is opened. In addition, according to special indications, these systems can be used in other areas of surgery.

The common disadvantages of stationary aspiration systems are their dependence on power supply, high cost and, what is most important for the clinician, the impossibility of full activation of the patient connected to the device.

The simplest conditionally closed active aspiration systems operate on the basis of the shape memory principle. Their main component is rubber and plastic pears, accordions, so they are all autonomous and do not restrict the patient's movement. The simplicity, accessibility and convenience of these systems for the patient do not compensate for the need for depressurization of the system, the possibility of back-throwing the contents of the container and the lack of control over the degree of vacuum. Domestic systems of this type are supplied without drains and extension pipes, in addition, the design of the adapter between the drain and the accordion is such that there is always a narrowing in this place.

A common disadvantage of all “shape memory” drainage systems is the relatively small volume of contents evacuated without recharging the system. They are designed to evacuate only liquid discharge, therefore, for their normal operation, complete wound tightness is required. Otherwise, the system very quickly becomes inoperative, filling with air. For this reason, these systems are not used in thoracic surgery, where large air volume aspiration is required. It is inappropriate to use them in abdominal surgery, where passive drainage is sufficient to evacuate the wound discharge. The area of \u200b\u200bapplication of autonomous aspiration systems (based on the principle of "shape memory") are wounds after operations on soft tissues that are not subjected to external pressure sufficient for a spontaneous adequate outflow of contents. First of all, these are breast surgery and traumatology. In addition, minor operations on the abdominal wall, especially in obese patients, when a narrow and deep wound cannot be adequately drained by passive drainage.

Suction drainage from the pleural cavity

Suction drainage is a fundamental intervention in the chest cavity. If this intervention is carried out carefully, then the possibility of postoperative complications is reduced to a minimum, and many serious, life-threatening diseases will be healed. If the drainage is used improperly, recovery will not occur, and septic complications may develop. The drainage and suction apparatus consists of a drainage tube, which is inserted into the pleural cavity, and a suction system connected to the drainage. The number of suction systems used is very large. Various rubber and synthetic tubes are used for the suction drainage of the pleural cavity.

For the most commonly used drainage, a rubber tube about 40 cm long with several lateral holes at the end is used. This tube is placed along the lung (base to apex) and passed over the diaphragm from the pleural cavity outward. The drain is attached to the skin with a knotty U-shaped suture. When the suction drain is removed, the threads are tied again and the opening in the chest is hermetically sealed. A triple-barreled suction catheter (Viereck) is advantageous, allowing free passage by an inserted tube.

Introducing a suction drain

In the chest between the two pleural sheets, intrapleural pressure is below atmospheric. If air or liquid gets between the pleural sheets, then the normal physiological state can only be restored by prolonged suction drainage. A closed drainage system is used to suck pleural fluid in recurrent pneumothorax and to treat empyema. This drain is now usually inserted into the intercostal space through a trocar. The thickness of the drainage tube is determined in accordance with the consistency of the suctioned substance (air, as well as aqueous humor or serous, fibrinous, bloody, purulent fluid).

On the drainage, paint or thread mark the place to which it will be introduced. The size of the trocar must match the size of the drain. It is advisable to have at least three trocars of different sizes with suitable tubes of 5, 8 and 12 mm in diameter. Before inserting the trocar, make sure that the selected drainage tube can easily pass through it.

The skin incision site is filtered with novocaine to the pleura. A trial puncture in the designated place makes sure that there really is the desired air or liquid. The assistant gives the patient the necessary position: the patient must sit and rest on a high-raised operating table so that the puncture area protrudes as much as possible, and the selected intercostal space is, if possible, expanded. The scalpel is used to cut the skin over the length of the trocar Then the trocar is inserted with a strong movement along the upper edge of the rib into the pleural cavity. After removal of the trocar, not hindered fluid release or free entry and exit of air indicates its correct introduction. Drain and remove the trocar tube. If you are not convinced that the drainage is in the correct place, in order to prevent the puncture of the lung, heart or large vessel with a trocar, it should be punctured again with all measures for its localization under X-ray control.

Before closing each thoracotomy hole, a drainage is introduced into the pleural cavity, which is brought out above the diaphragm through a separate hole in the intercostal space. A forceps is passed through a hole about 1-2 cm in size into the pleural cavity under the control of the eyes and under the protection of the left hand to ensure the correct position of the drainage from the inside. The drainage is pulled with a forceps through the chest wall from the inside out. Pay attention to the fact that the drainage section free from the holes is in the chest cavity at least 5 cm. If the fixation of the drainage to the skin is broken, then it slips out, and the first lateral hole appears outside the pleural cavity above the skin. In this case, a closed system turns into an open one, suction becomes ineffective, and pneumothorax often occurs.

Suction systems

There are so-called. individual ("bed side") and centralized suction systems. The suction action due to the hydrostatic effect can be obtained by a tube lowered under water, a water or gas pumping device (in this case, the action is based on a valve effect) or an electric pump. For both individual and central systems, individual regulation must be ensured. If the release of air from the lung is insignificant, then due to its simplicity, the Biilau drainage system is still successfully used today, which can be sufficient for expanding the lung. The glass tube submerged under water (disinfectant solution) is equipped with a valve made of a finger cut from a rubber glove, which prevents suction back. The Biilau system uses the physical law of communicating vessels to move the bottles under the bed to create a suction effect.

The Fricar air pump is best suited to modern requirements. This device can work continuously for many days without getting hot. The strength of the suction effect can be precisely adjusted.

Central suction units are triggered by an oxygen can system or a powerful suction pump. A system of outgoing pipes, if necessary, provides hospital departments located on different floors. The required number of hospital beds can be connected as required. An oxygen-powered system has the advantage that the same tubing system provides the suction and delivery of oxygen to the individual hospital beds. The suction action is provided by a valve tube mounted in the direction of the oxygen flow. In this case, however, the effect is not achieved, which is produced by the central suction pump.

Individual adjustments can be made with a dosimeter tap connected to a well-functioning pressure gauge, or through the so-called. system of three bottles. The latter can be easily prepared by yourself. This system also has the advantage that it can easily and reliably create a very low suction effect (from 10 to 20 cmH2O). It is rarely possible to achieve such low pressures with factory gauges.

Indications for suction drainage: Spontaneous and traumatic pneumothorax, hemothorax

BULAU PLEURAL CAVITY DRAINING

Indications:

Removal of liquid content from the pleural cavity / inflammatory exudate, pus, blood /;

Removal of air from the pleural cavity.

It is used after operations on the lungs and mediastinal organs to prevent compression of the lungs with air and remove wound exudate, spontaneous or traumatic pneumothorax, hydro and hemothorax, purulent pleurisy.

The method is based on long-term drainage according to the siphon principle.

To remove air, drainage is installed at the highest point of the pleural cavity - in the 2nd intercostal space along the mid-clavicle line, with total pleural empyema - at the lowest point / 5-7 intercostal space along the mid-axillary line /. For drainage of limited cavities, drainage is introduced in its projection. Two drains can be installed at the same time - one for removing air, the other for liquid content. Or, through one drainage, the flushing liquid is introduced, and through the other it flows out.

Drainage of the pleural cavity should be preceded by its puncture, which makes it possible to ascertain the presence of pleural contents and its nature.

The patient sits on the dressing table, dangling his legs and placing them on a support. On the side opposite to the puncture, an emphasis is placed on the body / lifting the head end of the table panel, or a stool covered with a pillow with a sheet is placed, or the patient is supported /. The arm from the side of the chest to be drained is thrown onto the healthy shoulder girdle. A doctor wearing sterile gloves and a mask treats the drainage site as an operation. The skin, subcutaneous tissue and intercostal muscles are anesthetized. Changing the needle, the same syringe punctured the pleural cavity slightly above the upper edge of the selected rib so as not to injure the intercostal artery. Entry into the pleural cavity is determined by the feeling of failure. By pulling the plunger of the syringe towards oneself, make sure that there is content in the pleural cavity. After that, the needle is removed and a skin incision up to 1 cm long is made in this place.

Further introduction of the drainage tube into the pleural cavity can be carried out through a trocar or using a clamp.

If a trocar is used, it is inserted into the pleural cavity through a previously made incision with rotational movements (until a feeling of failure appears). Then the stylet is removed and a drainage tube squeezed with a clamp is inserted through the trocar sleeve into the pleural cavity.

This is done quickly so that as little air as possible gets into the pleural cavity, which leads to the collapse of the lung. The drain is prepared in advance. The end of the drain, intended for introduction into the pleural cavity, is cut obliquely. 2-3 cm away from it, 2-3 side holes are made. 4-10 cm above the upper lateral opening, which depends on the thickness of the chest and is determined by pleural puncture, a ligature is tightly tied around the drainage. This is done to control the position of the drain so that the last hole is in the pleural cavity and the drain does not bend. After removing the sleeve, the tube is carefully pulled out of the pleural cavity until a control ligature appears.

A U-shaped suture is applied around the tube, sealing the pleural cavity. The seam is tied with a bow on balls. The tube is fixed to the skin with 1-2 sutures. Pay attention to the tightness of the seams around the tube - it should be tightly covered by soft tissues, not allowing air to pass through when coughing and straining.

The insertion of the drain tube with a clamp can be done in several ways.

One of the methods involves finger control of penetration into the pleural cavity. To do this, under local anesthesia in the intercostal space / one rib below the intended site of the drainage / make a skin incision up to 2 cm long. Long forceps with closed branches above the overlying rib penetrate into the pleural cavity. The jaws of the clamp are carefully opened and the subcutaneous canal is expanded. Then the clamp is removed and a finger in a sterile glove is inserted into the canal. The existing adhesions between the lung and the pleura are severed, if there are blood clots, they are removed. Penetration into the pleural cavity is ascertained by the sensation of a lung swelling when inhaling. A drainage tube is inserted into the pleural cavity. The pleural cavity is sealed, as when draining it with a trocar. This method is less dangerous than drainage of the pleural cavity using a trocar.

In another method, the drainage is inserted into the pleural cavity blindly. However, the likelihood of damage to the lung is unlikely, since the drainage is installed in a cavity in which there is no lung tissue / lung is compressed /. In this method, a drainage tube is inserted through an incision in the skin and subcutaneous tissue into the pleural cavity by rotational movements, clamped by the tip of a clamp with sharp branches. After feeling a sense of failure, the clamp is opened slightly and the drainage is pushed with the other hand to the required depth / control mark /. The clamp is then closed and carefully removed while holding the tube at the desired level.

After the introduction and sealing of the drainage through it, the pleural exudate is pumped out with a syringe. At the outer end of the drainage tube, a safety valve is fixed - a finger from a rubber glove with a 1.5-2 cm incision.

This glove valve is completely immersed in a jar - a collection of antiseptic solution / furacilin, rivanol /. The tube is fixed to the jar so that the valve does not float and is always in solution. The valve protects against the ingress of air and the contents of the collection can into the pleural cavity. During inspiration, due to the negative pressure in the pleural cavity, the falling edges of the valve will prevent the solution from being sucked into it. When you exhale, the contents of the pleural cavity will flow freely through the valve into the container for collecting secretions.

The outer part of the drainage system should be of sufficient length so that when the patient's body position changes, the drainage is not removed from the antiseptic bottle. Drainage works effectively if the collection jar is located 50 cm below the patient's body surface.

Before removing the drainage tube, the U-shaped suture is untied, the patient is asked to hold his breath, the tube is removed at this time and the U-shaped suture is tied again, but finally by 3 knots and without a ball.

When caring for the pleural drainage according to Bulai, it is necessary to ensure that its tightness does not occur. The reasons for the depressurization of the pleural cavity can be: partial loss of the drainage tube before one of the side holes appears above the skin, violation of the integrity of the tube, tightening of the glove valve with its location above the level of the antiseptic solution in the bottle, failure of the U-shaped suture.

With pneumothorax, the pleural cavity is drained into the 2nd intercostal space along the mid-clavicular line. This is done with a thick needle, through the lumen of which a drainage tube with a diameter of 2-3 mm is inserted. With constantly accumulating air, a tube up to 5 mm in diameter is inserted through the trocar.

Passive drainage can be combined with periodic / fractional / flushing of the pleural cavity. It is most effective to do this in the presence of two drainages: through a thinner, flushing liquid is introduced, through another, wider diameter - it flows out. Rinsing can be done with a syringe or with an intravenous system connection. The amount of a solution injected once depends on the volume of the cavity.

"

Definition of wound drainage

Wound drainage is a therapeutic and prophylactic surgical method aimed at creating conditions that are unfavorable for the development of infection in the wound by maintaining a long-term evacuation of wound discharge and ensuring control over the course of the local pathological process.

Drainage indications

The need to ensure the outflow of the discharge into the external environment in the presence of a local purulent-inflammatory focus or conditions conducive to the development of a purulent-inflammatory process in the wound, as well as the need to evacuate localized accumulations of blood, bile, lymph, transudate, etc., and control over the course of the wound process, including with a high risk of postoperative bleeding.

Drainage types

Drainages can be latex rubber strips, rubber, glass, PVC, silicone, Teflon, fluoroplastic tubes. The previously used wound drainage with gauze drains is currently not recommended due to the very rapid cessation of their functioning (4-6 hours). The disadvantage of rubber drains is the rapid separation of fibrin and adhesions from the cavity in which they are installed. Currently, complex drains are often used: multi-lumen, T-shaped, fan, rubber-gauze ("cigar") drains with cuffs, etc. General requirements - drainage should be soft, smooth, durable, preferably transparent and made of radiopaque material ...

Types and methods of wound drainage

Drainage types: passive, active, flow-washing. For passive drainage, it is currently recommended to use PVC perforated tubular drains or "cigar" drains (thin tube filled with gauze). The location of the drain should be such that the outflow is from top to bottom, under the influence of gravity.

For active drainage of a sealed wound cavity, vacuum aspiration (using a rubber bulb, suction) is used, which helps to eliminate dead spaces, adhere the edges of wounds, reduce the possibility of microflora penetration from the outside. The location of the drain should ensure the flow of the discharge from the bottom up, against the force of gravity. It should be remembered that active drainage cannot be used to evacuate growing hematomas.
Flow-flush drainage is carried out by the aspiration-flush method with the installation of counter perforated drains, through one of which the drug is injected, and the other is the outflow. The introduction can be inkjet and drip, fractional or continuous. The outflow can be done in a passive and active way. This method protects wounds from secondary seeding, promotes more complete removal of the discharge, creates conditions for a controlled abacterial environment and favorable conditions for wound healing.

Features of drainage of postoperative wounds: a high risk of suppuration of postoperative wounds, as a rule, is associated with wound contamination during the operation, expressed by subcutaneous tissue, the impossibility of eliminating "dead spaces", etc. In this case, drainage of the wound with the installation of counter perforated drainages through counteropening and postoperative dialysis. Most often, such drainage is required for radical mastectomy, for giant ventral hernias, amputation of a limb, for radical surgical treatment of purulent foci of soft tissues. When opening purulent foci, passive drainage is usually carried out through the wound, which is always less preferable.
The drainage technique is studied during classes in wards, dressing rooms and operating rooms when analyzing the treatment of patients with primary and secondary purulent wounds.

Drainage complications

Complications of drainage are obstruction and loss of drainage, leakage of the drained wound cavity, compression and damage to organs and tissues, microbial contamination through drainage tubes.

DRAINAGE- a method aimed at ensuring the outflow of discharge from wounds, creating conditions unfavorable for the development of m / s, as well as ensuring control over the course of the local process

Drainage after surgery is the event that ends with most surgical operations. Although some doctors believe that drainage slows down the patient's recovery and even increases the risk of complications. Who is right, and in what cases it is impossible to do without drainage?

What is drainage in medicine

The term "drainage" is translated as "dehumidification" and is used in a wide variety of areas, implying about the same thing. In medicine, drainage refers to the installation of a hollow tube into a postoperative wound, the other end of which is brought out. The purpose of such a design is to ensure the evacuation (removal) of pathological contents outside to accelerate the healing of internal wounds and prevent the development of repeated

Also, through the tube, you can wash the wound cavity with antiseptics, which is also important after complex operations associated with the opening of abscesses. The exudate cannot be completely removed: some of it continues to form for several hours after surgery. Postoperative drainage allows you to inject disinfecting solutions into the cavity.

Curious! The first mentions of surgical wound drainage are found in the treatises of Hippocrates. And this is the 4th century BC.

Doctors who call to refuse drainage are guided by the fact that open communication of the postoperative wound with the external environment can easily lead to infection. Also, long-term foreign bodies in the human body in the form of tubes contribute to the formation of fistulas - channels formed by tissues and connecting internal organs with the surface environment. But these two problems can be prevented if you follow the basic requirements:

• choosing the right type of drainage;
• adherence to the technique of its installation (surgical drainage must perform its function regardless of the position of the patient's body);
• careful fixation;
• competent care of drainages (maintaining cleanliness, antiseptic treatment);
• timely removal of drainage (immediately after its function is performed).

Types of modern drainages

The surgeon will determine the type of drainage that will be installed for a particular patient. His choice depends on several factors: the surgical site, the nature of the intervention, the amount and intensity of pathological fluids after the operation.

Passive

This type of drainage involves laying thin tubes filled with sterile gauze into the wound cavity. Passive drainage is installed so that the outflow of the contents goes from the inside to the outside due to gravity. It will no longer be possible to treat the wound cavity with an antiseptic. Passive drainage is used for shallow, simple wounds.

Due to the small thickness of the tubes (and in some cases these are just flat corrugated strips), removal of passive drainage does not create additional scars. The wound from it heals quickly and without traces.

Active

Suitable for deep and difficult wounds. It involves the installation of a whole system of interconnected flexible tubes connected to a vacuum system. It can be a plastic accordion or an electric pump. With their help, not only purulent masses are evacuated, but also dead cells and particles of separating flesh.

By the way! The outside of the tube also connects to the container or bag. This allows you to assess the amount and quality of the released pathological contents and determine when it is time to remove the drainage (less than 30-40 ml per day).

The active type of wound drainage also includes flushing and flowing surgical drainage. This is already a system of two parallel tubes, one of which removes the contents, and the second serves to introduce antiseptics and saline solutions into the wound cavity for washing.

Indoor and outdoor

This is another classification of postoperative drains. Closed drainage is a type of drainage in which the outer end of the tube is tied or pinched. This just allows you to avoid infection of the wound cavity from the outside. A syringe is used to evacuate the contents or inject medicinal solutions.

Open drainage is not pinched from the outside. The end of the tube is placed in a sterile vessel to collect pathological contents. If you monitor the state of the air in the ward (regularly carry out quartzing and wet cleaning), as well as change the container in time and monitor its sterility, then there will be no problems with infection.

After what operations are drainage placed

Drainage is necessary on the enzyme-forming organs (stomach, pancreas, intestines, etc.), because the first few hours or days after surgery, in addition to the natural secretion, pathological contents will also form in them.

Also, drainage in surgery must be installed when opening abscesses on any part of the body, even if it is a superficial operation under local anesthesia. In this case, passive drainage under the dressing is suitable, which is removed after a day.

Sometimes wounds resulting from plastic surgery are drained. The drainage system in such cases allows you to monitor the absence of the development of internal bleeding. Many doctors drain the mammary glands after breast augmentation surgery, because the installed implants take root faster and better in a dry cavity.

Drainage tube care, algorithm

Since the drain is installed in a patient who has just had surgery, the entire responsibility for caring for the system falls on the shoulders of the medical staff. The patient is only required to monitor the position of the body so that the tubes do not bend or pinch.

Important! Neither the drainage tube nor the wound should be touched with your hands! Doing so may cause infection, bleeding, or improper installation. If you need to fix the drainage, you should call the nurse.

The change of the vessel or bag in which the contents is collected is carried out as it is filled. Before emptying and draining the container, the nurse shows it to the doctor to assess the quality of the drainage system and the need to extend it. While the container is being changed, the lower end of the tube is pinched to prevent infection from entering the wound cavity. The clamp can only be removed after an empty sterile vessel has been installed.

Removal of the drainage system is carried out in the operating room or dressing room. If it is passive drainage, it is limited to treating the abdominal wound with an antiseptic and applying a bandage. Active drains require suturing and suturing of the holes where the tubes were threaded.

If you neglect wound drainage due to fear of the risk of complications in the form of fistulas and infection, you can get even more serious consequences. Suppuration and a constant increase in the amount of exudate can lead to the fact that pus is poured into free cavities and lead to inflammation of nearby organs. And this is an acute intoxication with fever, which can lead to the death of a person weakened by a recent operation.

Wounds. Primary surgical treatment. Drainage of wounds.

Wounds. Classification of wounds.

Wound

The main signs of a wound

Bleeding;

Functional impairment.

Elements of any woundare:

The bottom of the wound.

Wounds are classified on various grounds.

Puncture wounds

Puncture wounds are dangerous because, due to the small number of symptoms, damage to deep-lying tissues and organs can be seen, therefore, a particularly careful examination of the patient's wounds is also necessary by the fact that microorganisms are introduced into the depths of the tissues with a wounding weapon, and the wound discharge, without finding a way out , serves as a good breeding ground for them, which creates especially favorable conditions for the development of purulent complications.

Cut wounds

Chopped wounds

Scalped wounds patchwork.

Bitten wounds

Poisoned wounds

Gunshot wounds -

- wound channel area

- bruised area

Secondary necrosis zone;

3. By infection

The course of the wound process

During the healing of wounds, the resorption of dead cells, blood, lymph occurs, and due to the inflammatory reaction, the process of cleansing the wound is carried out. The wound walls close to each other are glued together (primary gluing). Along with these processes in the wound, connective tissue cells multiply, which undergo a number of transformations and turn into fibrous connective tissue - a scar. On both sides of the wound, there are opposite processes of neoplasm of blood vessels that grow into a fibrin clot that sticks together the walls of the wound. Simultaneously with the formation of a scar and blood vessels, the epithelium multiplies, the cells of which grow on both sides of the wound and gradually cover the scar with a thin layer of the epidermis; in the future, the entire layer of the epithelium is completely restored.

Signs of wound suppuration correspond to the classic signs of inflammation, as a biological response of the body to a foreign agent: dolor (pain);

calor (temperature);

tumor (swelling, edema);

rubor (redness);

functio lesae (dysfunction);

INFLAMMATION

The stage is characterized by the presence of all signs of a purulent wound process. In a purulent wound, there are remnants of non-viable and dead tissue of its own, foreign objects, dirt, accumulation of pus in cavities and folds. Viable tissues are edematous. There is an active absorption of all this and microbial toxins from the wound, which causes the phenomena of general intoxication: an increase in body temperature, weakness, headache, lack of appetite, etc.

Stage treatment objectives: drainage of the wound to remove pus, necrotic tissue and toxins; fighting infection. Wound drainage can be active (using devices for aspiration) and passive (drainage tubes, rubber strips, gauze wipes and turundas moistened with water-salt solutions of antiseptics. Therapeutic (medicinal) agents for treatment:

Hypertonic solutions:

The most commonly used by surgeons is a 10% sodium chloride solution (the so-called hypertonic solution). In addition to him, there are other hypertonic solutions: 3-5% boric acid solution, 20% sugar solution, 30% urea solution, etc. Hypertonic solutions are designed to ensure the outflow of wound discharge. However, it was found that their osmotic activity lasts no more than 4-8 hours, after which they are diluted with wound secretion, and the outflow stops. Therefore, recently, surgeons refuse to use a hypertonic solution.

In surgery, various ointments are used on a fatty and petrolatum base; Vishnevsky ointment, synthomycin emulsion, ointments with a / b - tetracycline, neomycin, etc. But such ointments are hydrophobic, that is, they do not absorb moisture. As a result, tampons with these ointments do not provide an outflow of wound secretions, they become only a cork. At the same time, the antibiotics present in the ointments are not released from the ointment compositions and do not have a sufficient antimicrobial effect.

Pathogenetically justified the use of new hydrophilic water-soluble ointments - Levosin, Levomikol, mafenide-acetate, oflokain. Such ointments contain antibiotics that easily pass from the composition of the ointments into the wound. The osmotic activity of these ointments exceeds the effect of a hypertonic solution by 10-15 times, and lasts for 20-24 hours, therefore, one dressing per day is enough for an effective effect on the wound.

Enzyme therapy (enzyme therapy):

For the speedy removal of dead tissue, necrolytic drugs are used. Proteolytic enzymes are widely used - trypsin, chymopsin, chymotrypsin, terrilitin. These drugs cause lysis of necrotic tissue and accelerate wound healing. However, these enzymes also have disadvantages: in the wound, enzymes retain their activity for no more than 4-6 hours. Therefore, for effective treatment of purulent wounds, the dressings must be changed 4-5 times a day, which is almost impossible. It is possible to eliminate such a lack of enzymes by including them in ointments. So, Iruksol ointment (Yugoslavia) contains the enzyme pentidase and the antiseptic chloramphenicol. The duration of enzyme action can be increased by immobilizing them in dressings. So, trypsin immobilized on napkins acts for 24-48 hours. Therefore, one dressing per day fully provides a therapeutic effect.

Use of antiseptic solutions.

Solutions of furacillin, hydrogen peroxide, boric acid, etc. are widely used. It has been established that these antiseptics do not have sufficient antibacterial activity against the most frequent causative agents of surgical infection.

Among the new antiseptics, one should single out: iodopyrone, a preparation containing iodine, is used to treat the hands of surgeons (0.1%) and treat wounds (0.5-1%); dioxidine 0.1-1%, sodium hypochlorite solution.

Physical treatments.

In the first phase of the wound process, quartzing of wounds, ultrasonic cavitation of purulent cavities, UHF, hyperbaric oxygenation are used.

Laser application.

In the phase of inflammation of the wound process, high-energy or surgical laser is used. With a moderately defocused beam of a surgical laser, pus and necrotic tissues are evaporated, thus complete sterility of wounds can be achieved, which in some cases allows a primary suture to be applied to the wound.

GRANULATION

The stage is characterized by complete cleansing of the wound and the execution of the wound cavity with granulations (tissue of bright pink color with a granular structure). It first performs the bottom of the wound, and then fills the entire wound cavity. At this stage, its growth should be stopped.

Stage objectives: anti-inflammatory treatment, protection of granulations from damage, stimulation of regeneration

These tasks are answered by:

a) ointments: methyluracilic, troxevasinic - to stimulate regeneration; fat-based ointments - to protect granulations from damage; water-soluble ointments - anti-inflammatory effect and protection of wounds from secondary infection.

b) herbal preparations - aloe juice, sea buckthorn and rosehip oil, Kalanchoe.

c) use of a laser - in this phase of the wound process, low-energy (therapeutic) lasers with a stimulating effect are used.

EPITHELIZATION

The stage occurs after the completion of the bottom of the wound and its cavity with granulation tissue. Stage objectives: to speed up the process of epithelialization and scarring of wounds. For this purpose, sea buckthorn and rosehip oil, aerosols, troxevasin-jelly, low-energy laser irradiation are used. At this stage, the use of ointments that stimulate the growth of granulations is not recommended. On the contrary, it is recommended to switch back to water-salt antiseptics. It is helpful to allow the dressing to dry to the wound surface. In the future, it should not be torn off, but only cut along the edges, as it detaches due to epithelialization of the wound. It is recommended to moisten such a bandage from above with iodonate or other antiseptic. In this way, a small wound under the scab is healed with a very good cosmetic effect. In this case, a scar is not formed.

With extensive skin defects, long-term non-healing wounds and ulcers in the 2nd and 3rd phases of the wound process, i.e. after cleansing the wounds from pus and the appearance of granulations, dermoplasty can be performed:

a) artificial leather

b) a split displaced flap

c) walking stem according to Filatov

d) autodermoplasty with a full-thickness flap

e) free autodermoplasty with a thin-layer flap according to Thirsh

At all stages of the treatment of purulent wounds, one should remember about the state of immunity and the need to stimulate it in patients of this category.

The first and main stage in the treatment of wounds in a medical institution is the primary surgical treatment.

Primary surgical treatment of wounds (PCO). The main thing in the treatment of wounds is their primary surgical treatment. Its purpose is to remove non-viable tissue, the microflora in them and thereby prevent the development of wound infection.

Primary surgical treatment of wounds:

It is usually performed under local anesthesia. Stages:

1. Inspection of the wound, toilet of the skin edges, their treatment with aetiseptic (tincture of iodine 5%, do not get into the wound);

2. Revision of the wound, excision of all nonviable tissues, removal of foreign bodies, small fragments of bones, dissection of the wound, if necessary, to eliminate pockets;

3. The final stop of bleeding;

3. Drainage of the wound, if indicated;

4. Primary wound suture (according to indications);

Distinguish between early primary surgical treatment, carried out in the first day after injury, delayed - during the second day and late - 48 hours after injury. The earlier the primary surgical treatment is performed, the more likely it is to prevent the development of infectious complications in the wound.

During the Great Patriotic War, 30% of wounds were not surgically treated: small superficial wounds, through wounds with small inlet and outlet openings without signs of damage to vital organs, blood vessels, multiple blind wounds.

Primary surgical treatment must be instantaneous and radical, that is, it must be performed in one stage and in the process, non-viable tissues must be completely removed. First of all, they operate on the wounded with an imposed hemostatic tourniquet and extensive shrapnel wounds, with soil contamination of the wounds, in which there is a significant risk of anaerobic infection.

Primary surgical debridement consists in excision of the edges, walls and bottom of it within healthy tissues with the restoration of anatomical relationships.

Initial surgical treatment begins with incision of the wound. With a bordering incision 0.5 - 1 cm wide, the skin and subcutaneous tissue around the wound are excised and the skin incision is extended along the axis of the limb along the neurovascular bundle for a length sufficient to inspect all the blind pockets of the wound and excise non-viable tissues. Further along the skin incision, the fascia and aponeurosis are dissected. This provides a good examination of the wound and reduces muscle compression due to their swelling, which is especially important for gunshot wounds.

After cutting the wound, scraps of clothing, blood clots, free-lying foreign bodies are removed and the excision of crushed and contaminated tissues is started.

Muscles are excised within healthy tissues. Muscles that are not viable are dark red, dull, do not bleed when cut and do not contract when touched with forceps.

Intact large vessels, nerves, tendons should be preserved during wound treatment, and contaminated tissues should be carefully removed from their surface. (Small bone fragments freely lying in the wound are removed, sharp, devoid of periosteum, the ends of the bone fragments protruding into the wound are bite off with nippers. If damage to vessels, nerves, tendons is found, their integrity is restored. non-viable tissues and foreign bodies are completely removed, the wound is sutured (primary suture).

Late surgical treatment performed according to the same rules as the early one, but with signs of purulent inflammation, it boils down to removing foreign bodies, cleaning the wound from dirt, removing necrotic tissue, opening leaks, pockets, hematomas, abscesses in order to provide good conditions for the outflow of wound discharge.

Tissue excision, as a rule, is not performed due to the danger of generalization of the infection.

The final stage of the primary surgical treatment of wounds is the primary suture, restoring the anatomical continuity of tissues. Its purpose is to prevent secondary wound infection and to create conditions for wound healing by primary intention.

The primary suture is applied to the wound within 24 hours after injury. The primary suture, as a rule, also ends with surgical interventions during aseptic operations. Under certain conditions, purulent wounds are closed with a primary suture after opening subcutaneous abscesses, phlegmon and excision of necrotic tissues, providing in the postoperative period good conditions for drainage and long-term washing of wounds with solutions of antiseptics and proteolytic enzymes.

The primary delayed suture is applied within 5 - 7 days after the primary surgical treatment of wounds before the appearance of granulations, provided that no wound suppuration occurs. Delayed sutures can be applied in the form of provisional sutures: the operation is completed by stitching the edges of the wound and tightening them after a few days, if the wound has not suppurated.

In wounds sutured with a primary suture, the inflammatory process is poorly expressed and healing occurs by primary intention.

During the Great Patriotic War, the primary surgical treatment of wounds due to the risk of infection was not performed in full - without the imposition of a primary suture; used primary delayed provisional seams. When acute inflammation subsided and granulations appeared, a secondary suture was applied. The widespread use of the primary suture in peacetime, even when treating wounds at a later date (12-24 hours), is possible thanks to targeted antibacterial therapy and systematic observation of the patient. At the first signs of infection in the wound, it is necessary to partially or completely remove the stitches. The experience of the Second World War and subsequent local wars showed the inexpediency of using the primary suture for gunshot wounds, not only due to the characteristics of the latter, but also due to the lack of the possibility of systematic observation of the wounded in military field conditions and at the stages of medical evacuation.

The final stage of the primary surgical treatment of wounds, delayed for some time, is the secondary suture. It is applied to a granulating wound in conditions when the danger of wound suppuration has passed. Terms of application of the secondary suture from several days to several months. It is used to accelerate wound healing.

An early secondary suture is applied to granulating wounds within 8 to 15 days. The edges of the wound are usually mobile, they are not excised.

A late secondary suture is applied at a later time (after 2 weeks), when cicatricial changes have occurred in the edges and walls of the wound. The convergence of the edges, walls and bottom of the wound in such cases is impossible, therefore, the edges are mobilized and the scar tissue is excised. In cases where there is a large skin defect, a skin transplant is performed.

Indications for the use of a secondary suture are: normalization of body temperature, blood composition, a satisfactory general condition of the patient, and from the side of the wound, the disappearance of edema and hyperemia of the skin around it, complete cleansing of pus and necrotic tissues, the presence of healthy, bright, juicy granulations.

Various types of sutures are used, but regardless of the type of suture, the basic principles must be observed: there should not be any closed cavities or pockets in the wound, the adaptation of the edges and walls of the wound should be maximized. The sutures should be removable, and ligatures should not remain in the sutured wound, not only from non-absorbable material, but also from absorbable material, since the presence of foreign bodies in the future can create conditions for wound suppuration. With early secondary sutures, the granulation tissue must be preserved, which simplifies the surgical technique and preserves the barrier function of the granulation tissue, which prevents the spread of infection to the surrounding tissues.

Healing of wounds sutured with a secondary suture and healed without suppuration is usually called healing by the type of primary tension, in contrast to true primary tension, since, although the wound heals with a linear scar, the processes of scar tissue formation occur in it through the maturation of granulations.

Drainage of wounds

Wound drainage plays an important role in creating favorable conditions for the course of the wound process. It is not always carried out, and the surgeon determines the indications for this procedure. According to modern concepts, wound drainage, depending on its type, should provide:

Removal of excess blood (wound contents) from the wound and thereby the prevention of wound infection (any training pitchfork);

Tight contact of the wound surfaces, which helps to stop bleeding from small vessels (vacuum drainage of the spaces located under the flaps);

Active cleansing of the wound (during its drainage with constant postoperative irrigation).

There are two main type of drainage: active and passive (Fig. 1).

Types of wound drainage and their characteristics

Figure: left. Types of wound drainage and their characteristics

Passive drainage

It involves the removal of wound contents directly through the line of skin sutures and is able to ensure drainage of only the superficial sections of the wound. This provides for the imposition, above all, of an interrupted skin suture with relatively wide and leaky inter-suture gaps. It is through them that drainages are installed, which can be used as parts of drainage pipes and other available material. By moving the edges of the wound apart, drainages improve the outflow of wound contents. It is quite understandable that such drainage is most effective when installing drains taking into account the action of gravity.

In general, passive wound drainage is simple, the downside of which is its low efficiency. Drainage with a piece of glove rubber in the photo on the left. Obviously, passive drains are not able to provide drainage of wounds with a complex shape, and therefore can be used, first of all, for superficial wounds located in those areas where the requirements for the quality of the skin suture can be reduced.

Active drainage

It is the main type of drainage of wounds of complex shape and involves, on the one hand, the sealing of a skin wound, and on the other, the presence of special drainage devices and instruments for carrying out drainage tubes (Fig. 2).

Standard devices for active drainage of wounds with a set of wires for passing drainage tubes through tissues.

Fig 2. Standard devices for active drainage of wounds with a set of guides for passing drainage tubes through tissues.

An important feature of the active wound drainage method is its high efficiency, as well as the possibility of floor drainage of the wound. In this case, the surgeon can use the most precise skin suture, the quality of which is fully preserved when removing the drainage tubes away from the wound. It is advisable to choose the outlet of the drainage tubes in the "hidden" areas, where additional punctate scars do not worsen the aesthetic characteristics (scalp, axillary cavity, pubic area, etc.).

Active drains are usually removed 1-2 days after the operation, when the volume of daily wound discharge (through a separate tube) does not exceed 30-40 ml.

The greatest drainage effect is obtained from tubes made of a non-wettable material (for example, silicone rubber). The lumen of the PVC tubing can quickly become blocked by clotting. The reliability of such a tube can be increased by its preliminary (before installation in the wound) washing with a solution containing heparin.

Drainage of panaritium: a) drainage tube; b) the introduction of the tube into the wound; c) washing; d) removing the tube.

Failure to drain or its lack of efficiency can lead to the accumulation of a significant amount of wound contents in the wound. The further course of the wound process depends on many factors and can lead to the development of suppuration. However, even without the development of purulent complications, the wound process in the presence of a hematoma changes significantly: all phases of scar formation are lengthened due to a longer process of organizing an intra-wound hematoma. A very unfavorable circumstance is a prolonged (several weeks or even months) increase in the volume of tissues in the area of \u200b\u200bthe hematoma. The scale of tissue scarring increases, and the quality of the skin scar may deteriorate.

Factors contributing to wound healing:

General condition of the body;

The nutritional status of the body;

Age;

Hormonal background;

Development of wound infection;

Oxygen supply condition;

Dehydration;

Immune status.

Types of wound healing:

Healing primary intention- fusion of the edges of the wound without visible scar changes;

Healing secondary tension - healing through suppuration;

- healing under the scab -under the formed crust, which should not be removed prematurely, further traumatizing the wound.

Wound dressing steps:

1. Removing the old bandage;

2. Inspection of the wound and surrounding area;

3. Toilet of the skin surrounding the wound;

4. Toilet of the wound;

5. Manipulation of the wound and preparing it for the imposition of a new bandage;

6. Applying a new bandage;

7. Fixation of the bandage (see section Desmurgy)

Wounds. Classification of wounds.

Wound (vulnus) - mechanical damage to tissues or organs, accompanied by a violation of the integrity of their integuments or mucous membranes. It is the violation of the integrity of the integumentary tissues (skin, mucous membrane) that distinguishes wounds from other types of damage (contusion, rupture, stretching). For example, a rupture of the lung tissue caused by blunt trauma to the chest is considered a rupture, and in the case of damage with a knife - a lung wound, because there is a violation of the integrity of the skin.

It is necessary to distinguish between the concept of "wound" and "injury". In essence, a wound is the end result of tissue damage. The concept of injury (vulneratio) is understood as the process of damage itself, the entire complex and multifaceted set of pathological changes that inevitably occur during the interaction of tissues and a wounding projectile both in the area of \u200b\u200bdamage and throughout the body. However, in everyday practice, the terms wound and wound are often used interchangeably and are often used interchangeably.

The main signs of a wound

The main classic signs of wounds are:

Bleeding;

Violation of tissue integrity;

Functional impairment.

The severity of each sign is determined by the nature of the injury, the volume of damaged tissues, the peculiarities of the innervation and blood supply of the wound channel zone, the possibility of injury to vital organs.

Elements of any woundare:

Wound cavity (wound channel);

The bottom of the wound.

A wound cavity (cavum vulnerale) is a space bounded by the walls and bottom of the wound. If the depth of the wound cavity significantly exceeds its transverse dimensions, then it is called a wound channel (canalis vulneralis).

Wounds are classified on various grounds.

1. By the nature of tissue damage:

Puncture wounds applied with a piercing weapon (bayonet, needle, etc.). Their anatomical feature is their considerable depth with little damage to the integument. With these wounds, there is always a danger of damage to vital structures located deep in the tissues, in the cavities (vessels, nerves, hollow and parenchymal organs). Appearance and presentation of puncture wounds Does not always provide sufficient data for a diagnosis. So, with a puncture wound of the abdomen, it is possible to injure the intestine or the Liver, but the discharge of intestinal contents or blood from the wound usually cannot be detected. With a puncture wound, in an area with a large array of muscles, a large artery may be damaged, but external bleeding may also be absent due to muscle contraction and displacement of the wound channel. An interstitial hematoma is formed with the subsequent development of a false aneurysm.

Puncture wounds are dangerous because, due to the small number of symptoms, damage to deep-seated tissues and organs can be seen, therefore, a particularly careful examination of patients is necessary e wounds also by the fact that with a wounding weapon microorganisms are introduced into the depths of the tissues, and the wound discharge, not finding a way out, serves as a good breeding ground for them, which creates especially favorable conditions for the development of purulent complications.

Cut wounds applied with a sharp object. They are characterized by a small number of destroyed cells; the surrounding letters are not damaged. The gaping of the wound allows you to inspect the damaged tissue and creates good conditions for the outflow of the discharge. With a cut wound, there are the most favorable conditions for healing, therefore, when treating any fresh wounds, they tend to turn them into cut wounds.

Chopped wounds applied with a heavy sharp object (checker, ax, etc.). Such wounds are characterized by deep tissue damage, wide gaping, bruising and concussion of the surrounding tissues, which reduces their resistance and regenerative abilities.

Bruised and lacerated wounds (crushed) are the result of exposure to a blunt object. They are characterized by a large number of crushed, bruised, blood-soaked tissues with impaired vitality. Bruised blood vessels often rhombus. In bruised wounds, favorable conditions are created for the development of infection.

Scalped woundstangent to the surface of the body of the wound inflicted with a sharp cutting object. If the flap remains on the leg, then such a wound is called patchwork.

Bitten wounds are characterized not so much by extensive and deep damage as by severe infection with the virulent flora of the human or animal mouth. The course of these wounds is more often than others complicated by the development of an acute infection. Bite wounds can be infected with the rabies virus.

Poisoned wounds - these are wounds into which poison gets into (with a bite of a snake, scorpion, penetration of toxic substances), etc.

Gunshot wounds - special among the wounds. They differ from all others in the nature of the wounding weapon (bullet, splinter); the complexity of the anatomical characteristics; a feature of tissue damage with areas of complete destruction, necrosis and molecular shock; a high degree of infection; a variety of characteristics (through, blind, tangent, etc.).

I distinguish the following elements of a gunshot wound:

- wound channel area - the area of \u200b\u200bdirect impact of the traumatic projectile;

- bruised area - area of \u200b\u200bprimary traumatic necrosis;

- molecular shock zone- area of \u200b\u200bsecondary necrosis;

A special approach in the treatment of such wounds, and, moreover, very different in peacetime and in wartime, at the stages of medical evacuation.

2. Due to wound damage divided into operational (intentional) and accidental.

3. By infectionsecrete wounds aseptic, freshly infected and purulent.

Purulent wound (burn) with areas of necrosis

4. In relation to body cavities (cranial cavity, chest, abdomen, joints, etc.) distinguish between penetrating and non-penetrating wounds. Penetrating wounds pose a great danger due to the possibility of damage or involvement in the inflammatory process of the membranes, cavities and organs located in them.

5. Allocate simple and complicated wounds, in which there is any additional tissue damage (poisoning, burns) or a combination of soft tissue injuries with damage to bone, hollow organs, etc.

The course of the wound process

The development of changes in the wound is determined by the processes occurring in it and the general reaction of the body. In any wound, there are dying tissues, hemorrhage and lymphatic effusion. In addition, a certain amount of microbes gets into wounds, even if they are clean, operating rooms.

GOU VPO "Perm State Medical Academy of the Ministry of Health of the Russian Federation"

Department of General Surgery

Drainage of wounds and body cavities

Lecturer: Associate Professor Dyachenko M.I.

Performed by A.I. Kravchenko, O. Yu. Savinykh.

DRAINING AND TAMPONING OF WOUNDS AND BODY CAVITIES

Drainage (fr. Drainer - drainage) is a medical method, which consists in removing the contents from wounds, abscesses, contents of hollow organs, natural or pathological cavities of the body. Full drainage, provides a sufficient outflow of wound exudate, creates the best conditions for the early rejection of dead tissues and the transition of the healing process to the regeneration phase. There are practically no contraindications to drainage. The process of purulent surgical and antibacterial therapy revealed another advantage of drainage - the possibility of a targeted fight against wound infection.

To ensure good drainage, it has the nature of drainage, the choice is optimal for each case, the method of drainage, the position of the drainage in the wound, the use of certain medications for washing the wound (according to the sensitivity of the microflora), the maintenance of the drainage system is in good order in compliance with the rules of asepsis.

Drainage is carried out using rubber, glass or plastic tubes of various sizes and diameters, rubber (glove) graduates, specially made plastic strips, gauze tampons inserted into the wound or the drained cavity, soft probes, catheters. The introduction of rubber or plastic drains is often combined with gauze swabs, or the so-called cigar drains proposed by Spasokukotsky are used, consisting of a gauze swab placed in the finger of a rubber glove with a cut end. For better drainage of the contents, several holes are made in the rubber casing. The use for draining gauze tampons is based on the hygroscopic properties of gauze, which creates an outflow of wound contents into the bandage. For the treatment of large deep wounds and purulent cavities Mikulich proposed in 1881 a method of drainage with gauze tampons, in which a square piece of gauze is inserted into the wound or purulent cavity, stitched in the center with a long silk thread. The gauze is carefully straightened and the bottom and walls of the wound are covered with it, after which the wound is loosely packed with gauze swabs moistened with hypertonic sodium chloride solutions. Tampons are changed periodically without changing the gauze, which prevents tissue damage. If necessary, the gauze is removed by pulling the silk thread. The hygroscopic effect of a gauze swab is extremely short-lived. After 4-6 hours, the tampon must be changed. Rubber graduates have no suction properties at all. Single rubber drains are often clogged with pus and detritus, covered with mucus, causing inflammatory changes in the surrounding tissues. Therefore, drainage methods such as plugging, rubber graduation and single rubber tubing should be excluded from the treatment of purulent wounds. These methods lead to difficulty in the outflow of wound exudate, which creates conditions for the progression of wound infection.

Tubular drainages (single and multiple, double, complex, with single or multiple holes) are most adequate in the treatment of purulent wounds. When draining surgical wounds, preference is given to silicone tubes, which, in terms of their elastic-elastic characteristics, hardness and transparency, occupy an intermediate position between latex and polyvinylchloride tubes. They significantly surpass the latter in biological inertness, which makes it possible to increase the duration of the stay of drainages in wounds. They can be sterile processed by autoclaving and hot air multiple times.

Drainage requirement:

1. The requirement of careful adherence to the rules of asepsis (removal or change of drainage is indicated when inflammatory changes appear around it, much less often such changes develop in cases where drainages are removed from the wound through healthy tissues). The possibility of infection penetration into the depth of the wound along the drainage lumen is prevented by two-fold replacement with sterile ones within 24 hours of the entire peripheral part of the drainage system, including the graduated vessels for collecting secretions. An antiseptic solution (furacilin solution, diocide, rivanol) is usually poured onto their bottom.

2. Drainage should ensure the outflow of fluid throughout the entire period of treatment of a cavity, wound, etc. Loss of drains can be a serious complication that aggravates the outcome of surgery. Prevention of this is achieved by carefully fixing the drainage with an outer cover, bandage, leukoplast or silk suture, best of all for a rubber sleeve put on the drainage tube near the skin.

3. The drainage system should not be squeezed or kinked both in the depth of the wound and outside it. The location of the drains should be optimal, i.e. the outflow of fluid should not be due to the need to give the patient a forced position in bed.

Only in the presence of poorly treated extensive festering wounds, gunshot fractures of the limb bones, the treatment of which occurs without immobilization. Toxic-resorptive fever, sepsis Purulent infection of wounds is always accompanied by a general reaction of the body, the severity of which is proportional to the prevalence and nature of the process. The degree of the body's general reaction to suppuration depends ...

Softens the scab, thus making it easier to remove the suture. Such stitches should also be removed before the 8th postoperative day due to possible scarring at the sites of skin puncture with a needle. After removing the suture, the edges of the wound are fixed with a sterile microporous adhesive plaster. 2. Prevention of tetanus In the United States, 2/3 of new cases of tetanus are the result of lacerations and ...

Environment (secondary microbial contamination). Secondary microbial contamination can occur if a protective aseptic dressing is not applied to the wound in time, is strained, or is soaked in blood and wound discharge. Microbes, once in a favorable environment, begin to multiply. Prevention and control of wound infection are among the most pressing problems of surgery. The course of the wound ...

It is dangerous because the rapid death of microorganisms in this case will lead to a massive release of endotoxins and endotoxic shock. Surgery on damaged organs The nature of surgery for abdominal trauma depends on its type and the damaged organ. Liver. For small linear wounds, U-shaped sutures are used to perform hemostasis, which should be applied in the transverse ...