Assessment

Justification of the choice of surgical tactics in practice and true sign of inefficiency of conservative treatment in theoretical medicine is very difficult. Most studies have ascertained the trends in these or other indicators, but say about 100% of the diagnostic value of simple and affordable for certain symptoms or syndrome is difficult. To solve this problem it is expedient to change some tactical approach to the formulation of schemes. It is advisable to assume that the treatment of any patient can be carried out semi-closed method. The question of choosing a method of treatment occurs intraoperatively. The main selection criteria are: the nature of exudates (including bacteriological data, bacterial contamination), the time of peritonitis, the degree of dysfunction of major organ systems. With a high degree of professional discipline and clinical laboratory equipment, all these signs, except the nature of the microflora can be determined in the first hours of admission and intraoperatively. The transition to the half-open method of surgical treatment is appropriate at a purulent RP (bacterial contamination above 5KOE / g), with signs of anaerobic peritonitis [18]. In the analysis of flow in the first stage RP study evaluated the results of treatment, timing of development (progression) of Poland. It is obvious that the time before surgery, as a reflection of the human factor is important for all patients (Table 2). Prognostic and momentary assessment of the severity of patients with APACHE II scales and MIP [12,16,21] has clinical and scientific value and is recommended by the Conciliation Conference Societies pulmonologists and intensive care specialists, as well as [6,10,16], during work of the Plenum of concern commissions "Emergency Surgery" and "Purulent surgery" (Rostov on Don, 1999) [16.21].

Subjective factors that contribute to the development (progression) of postoperative peritonitis can be considered: an erroneous assessment of peritonitis, an erroneous assessment of the sanitation of the abdominal cavity, erroneous intraoperative diagnosis, erroneous assessment of the consistency of the walls of the hollow body, an erroneous method of drainage, physical or biological leaks seam of the hollow body, poor hemostasis , traumatic manipulation in the abdomen, the underestimation of activity (virulence, bacterial contamination) microflora, inadequate prevention of infection. Objective factor is the imperfection of local and general immune responses, which occurs in 27-61% of cases of abdominal sepsis [2,7] and the discrepancy between body reserves the influence of intoxication in all its pathophysiologic clinical manifestations. A more detailed discussion of the results of treatment of patients with RP requires a prior explanation.

Firstly, for a better evaluation of treatment can be applied to the concept of abdominal sepsis [4,13,20], whereby the presence of two or more symptoms of these (body temperature higher than 38 ° C or below 36 ° C; tachycardia of more than 90 beats per minute; tachypnea over 20 breaths per minute (with IVL-pCO2 less than 32 mm Hg), white blood cell count over 12,000 cells in the MCL or less than 4000 cells ml or the number of immature (stab) forms of neutrophils, myelocytes, juvenile than 10%) is defined as a syndrome of systemic reaction to inflammation - SSRV (Systemic inflammation response syndrom - SIRS), which if proven focus of infection is defined as sepsis (in our case, abdominal sepsis). In the literature there are data that indicate that "sepsis, in essence, reflects a certain degree of severity of the patient" [13]. Developing such criteria as the result of years of research based on the detection of the generalization of inflammation in the form of dominance "of the destructive effects of cytokines" and "endothelial dysfunction of capillaries [9]. According to the same author, a diagnosis of "sepsis" is lawful if SSRV, signs of organ-system dysfunction (or the appearance of piemicheskih centers) in the presence of an infectious inflammation focus.

Secondly, the rationale for preoperative presence of multiple organ dysfunction syndrome (PAYG) will require brand viagra substantial effort. In addition, there are differences in the assessment criteria for PAYG [15,17] and in the terminology of [6]. Syndrome of multiorgan dysfunction is dysfunction of organs from terminally ill, whose homeostasis can not be maintained without intervention [12]. Most readily available for emergency determination SPO-deficiency symptoms are: heart rate <55/min, mean arterial pressure <50 mm Hg or systolic BP <60 mm Hg, respiratory rate> 49/min, the need for mechanical ventilation, leukocyte count <1000 ml-1, hematocrit < 21% of the sum score of Glasgow <7 [15]. More difficult, but not less informative is the definition of the level of total bilirubin, creatinine, blood pH, partial pressure of blood gases. Interest is the development of informative laboratory tests [3].

Analysis was performed in all groups on the basis of the scale of APACHE II, IIP. To determine the multiple organ dysfunction syndrome elected the following symptoms: heart rate (sinus rhythm)> 110 per minute, respiratory rate> 24 per minute, mean arterial pressure <71 mm Hg, the level of hematocrit <20%, the Glasgow Coma Scale <11. The presence of one of the symptoms characterized "monoorgannuyu dysfunction, the presence of two or more symptoms defines" multiple organ dysfunction. A feature of this concept is the distinction in the concept of "dysfunction" and "failure". Signs of multiorgan dysfunction, taken arbitrarily determined before surgery, so were not taken into account the level of creatinine, the state of blood gases, blood pH, urine output.

Case fatality rate 10.4% defines a set of the first group of patients whose treatment may have should be different. The main reasons for the negative results of treatment are underestimating the early signs of organ dysfunction, existing prior to the operation and development of thromboembolic complications. The most informative symptoms correlated with the nature of the exudate were mean arterial pressure, the rate of Glasgow coma scale and frequency of respiratory movements. The bulk of deaths observed in the purulent exudate (19%). With a score of APACHE II> 20 mortality was more than two-thirds (by APACHE II> 30 - 100%), resulting in these cases need to justify the refusal of the landmark renovation of the abdominal cavity, or their conduct. The effectiveness of total nasogastrointestinal intubation without landmark renovation at a purulent exudate can be estimated at 8-10% of deaths. Application of this technique in other types of abdominal exudate useful only to prevent insolvency mezhkishechnogo anastomosis or other processes leading to the destruction of the intestinal wall (Table 3).

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