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Prevention of tromboembolic episodes - appendectomy Complications

Table of contents
Appendectomy complications
Reasons of postoperative complications 2
Reasons of postoperative complications 3
Reasons of postoperative complications 4
Indications to appendectomy
Indications to appendectomy - appendicular infiltrate
Indications to appendectomy at not changed shoot
Indications to appendectomy at an appendicism
Indications to appendectomy - postoperative supervision
Complications from a wound
Complications from a wound, the choice of methods of treatment
Complications from a wound - the general treatment
Complications from a wound - eventration
Complications from a wound - use of antibiotics for prevention of early complications
Early complications from an abdominal cavity
Peritonitis
Diffuse peritonitis
Diffuse peritonitis - a peritoneal dialysis
Diffuse peritonitis - an intestines peristaltics
Infiltrates and abscesses of an abdominal cavity
Abscesses of an abdominal cavity
Abscesses interloopy and right ileal area
Subphrenic abscesses
Phlegmons of retroperitoneal cellulose
Acute intestinal impassability
Acute postoperative pancreatitis
Complications from cardiovascular system
Thromboembolism of a pulmonary artery
Myocardial infarction, pylephlebitis
Fibrinferments and embolisms of mesenteric vessels
Prevention of tromboembolic episodes
Complications from a respiratory organs
Complications from an urinary system
Late complications from an abdominal wall
Recognition of inflammatory "tumors" of a front abdominal wall
Origins of postoperative hernias
Late complications from an abdominal wall - keloid cicatrixes
Late complications from abdominal organs
Infiltrates and abscesses of an abdominal cavity
Inflammatory "tumors" of an abdominal cavity
Intestinal fistulas
Adhesive desease
The recommended literature

The considerable difficulties arising in diagnosis and treatment of postoperative tromboembolic episodes the high lethality, their escalating quantity demand carrying out the thought-over system of preventive actions. Among the last it is necessary to reveal tromboopasny patients and to carry out nonspecific and specific prevention.
Identification of these patients has great practical value as on them among the huge mass of patients with appendicitis it is necessary to pay special attention, to concentrate forces and means for prevention of a thromboembolism. The clinical assessment of a condition of patients is of great importance. The factors contributing to thrombosis are advanced age, heart diseases, long stay in a bed, obesity. Important value has development of pyoinflammatory process and the postponed appendectomy.
Identification at sick such vascular diseases as thrombophlebitis and a phlebothrombosis, at the same time is attached to a phlebothrombosis of the lower extremities and a basin in a pathogeny of a thromboembolism of a pulmonary artery great value.
Laboratory studying of coagulant system of blood is very important. At the same time it should be noted that the coagulant system of blood represents a dynamic ratio of coagulant and anticoagulative systems, and would be wrong to think what only quantitative changes of factors of coagulation, for example, of fibrinogen, a prothrombin and others, leads to thrombosis, and decrease in their level excludes a thromboembolism (E. M. Dedkova, G. I. Lukomsky, 1969; M. S. Machabeli, 1970; A. I. Tregubenko, 1972).
In this regard dynamic supervision over coagulant and anticoagulative system of blood by studying of a koagulogramma is required from tromboopasny patients, and also research of functional relationship between them by means of B. A. Kudryashov's test (1960). It is based on comparison of the koagulogramma taken in usual conditions from the koagulogrammy blood taken in 10 — 15 minutes after an applying a tourniquet and creation of a venous hyperemia. According to B. A. Kudryashov's theory, after an applying a tourniquet processes of intravascular coagulation in this connection there is a sharp activation of anticoagulative system of blood begin, fibrinolitic activity increases and the content of heparin increases. This test reflects functionality and relationship of coagulant and anticoagulative systems and can be very useful in identification of tromboopasny patients. Increase of fibrinolitic activity for 20% and above, and heparin on 1 — 2,5 piece. in the blood taken in 10 — 15 minutes after a venous hyperemia in relation to the blood taken by a usual venipuncture it is considered the positive test testimonial of an active condition of anticoagulative system. Doubtful test at increase only of fibrinolitic activity or heparin and negative test — in the absence of their simultaneous increase. Patients with doubtful and negative test are subject to emergence of tromboembolic episodes (B. A. Kudryashov, 1964, 1965; E. M. Dedkova, G. I. Lukomsky, 1969).
The clinic quite widely applies various empirical schemes of identification of tromboopasny patients. Are the cornerstone of them clinical experience of an assessment of various indicators (age, sex) of a functional condition of coagulant system of blood. The greatest distribution was gained by the scheme of Domaniga (tab. 7).
TABLE 7. Scheme of Domaniga


Indicators

Point

Age

 

from 20 to 50 years

2

from 51 to 90 flyings

3

Floor

 

man's

1

female

2

Constitution

1

asthenic

normosthenic

2

Adipozny

3

Disease severity

 

easy

1

average

2

heavy

3

Abdominal operations

 

3

The score equal 11 or above, indicates a tromboopasnost. The provided scheme, as well as other empirical schemes (Ruppert, Ventsel), is not exact and gives only relative orientation in a tromboopasnost of patients.
Such patients revealed on clinical and to datas of laboratory need carrying out specific and nonspecific prevention.
Nonspecific prevention of tromboembolic episodes is directed to stimulation of anticoagulative system and maintenance of its activity up to standard in the postoperative period. Some surgeons consider it the main in prevention of thromboembolisms (Stalport, 1955; Vosschulte, 1964). Considering a huge number of the made appendectomies, this prevention should pay close attention.
Modern researches of coagulant and anticoagulative systems of blood revealed influence on it of an operative measure and such factors leading to hypercoagulation as an operational injury and activation of fabric pro-coagulants (I. G. Turovets, 1970), a pain syndrome (V. P. Baluda, 1960; O. Ya. Kovsh, 1959; Rehn, 1955), suppuration of an operational wound (E. M. Dedkova, G. I. Lukomsky, 1969), long stay in a bed and delay of a blood flow (N. I. Bgantsev, 1962; Schlag, 1963; Ochsner et al., 1970), frequent intravenous infusions (M. I. Kolomiychenko, V. A. Akimov, 1959), etc.
Nonspecific prevention of tromboembolic episodes is carried out at all stages of treatment of patients acute and an appendicism. The preoperative period has to be used for normalization of function of cardiovascular and respiratory system, the maximum decrease in psychological impact of the forthcoming operation and a hospital situation where the patient often arrives for the first time. It is necessary to apply widely tranquilizers in before - and in the postoperative period.
Big requirements are imposed on the operation period. Intervention should be made without serious consequences at rather broad access to a worm-shaped shoot. It creates necessary conditions for reduction of technical difficulties and a tightening of intervention. Careful attitude to fabrics, a careful hemostasis with the minimum volume of the alloyed fabrics promotes reduction of hit in blood of fabric pro-coagulants.
In the postoperative period early activation of the patient is necessary. Already next day after appendectomy in the absence of diffuse peritonitis and other heavy complications we lifted patients. As the active propagandist of an early rising M. A. Kimbarovsky specified, at the same time not sitting in a bed, and walking matters. Further this situation found confirmation in works of Wright, Osborne which indicated increase several times blood-groove speeds when walking, and muscular tension promotes strengthening of a spontaneous fibrinolysis of Cioffi, Imbimbo (1961).
When there is no possibility of early activation of the patient, it is necessary to take measures to strengthening of a blood-groove in the lower extremities by giving of sublime situation and bandaging to them. Remedial gymnastics which especially persistently should be carried out at the patients who are in a serious condition with various complications is of great importance.
The massage of shins and hips recommended to E. M. Dedkova, G. I. Lukomsky (1969), Lorhan (1955) is applied not by all surgeons in connection with danger of a separation of blood clot at an asymptomatic current of a phlebothrombosis.
At repeated thromboembolisms of a pulmonary artery, unsuccessful anticoagulating therapy of vein thromboses of extremities and a basin, and sometimes and as primary preventive measure apply bandaging of the lower vena cava now. Operation is for the first time described by T. Kokher, and applied by Trendelenburg in 1911. But only in recent years it is eurysynusic, especially in the USA. The age of the patient is considered contraindication 80 years and existence of malignant new growths are more senior (Knothe, 1970). Bandaging is carried out ekstraperitonealno between bifurcation and hepatic veins. E. M. Dedkova and G. I. Lukomsky (1969) point to a possibility of plication of a vein by the device UKB-25. Miles (1966) imposes the special teflon clip which is keeping a blood stream, but not passing blood clots. Development of hypotension, renal failure, vein thromboses of an iliofemoral segment, developing of trophic ulcers is possible. After operation impose elastic bandage from finger-tips to an inguinal fold.
According to Oshcner with coauthors (1970), from 315 supervision bandaging of a vena cava yielded at 73% of patients excellent result, at 22% — good and at 5% — satisfactory. Constant hypostasis arose at 3,9%, varicose ulcers — at 9,7% of patients.
So far in literature there is no consensus about expediency of prevention of thromboses and embolisms purpose of anticoagulants. Danger of hemorrhagic complications, a possibility of a separation of blood clot induced Linton (1946), Stalport (1955), Vosschulte (1964) to refuse use of anticoagulants and to carry out only nonspecific prevention (Deutsch, Leeb, 1957). D. P. Pavlovsky (1967) propagandizes broad use of antikogulyant after the most various interventions. We do not justify it at the patients who transferred appendectomy completely sharing I. G. opinion of Turovets (1964), de Bakey (1954) and others that similar practice is dangerous and is not justified. At the same time considered specific prevention absolutely shown at identification of tromboopasny patients.
We applied anticoagulants of indirect action since 2 — 3 days after appendectomy. In necessary cases these terms can be reduced. At impossibility of enteral reception of anticoagulants and need of receiving immediate effect applied heparin. Control of effect of anticoagulants is exercised by research of a koagulogramma. At a favorable current of the postoperative period it is necessary to reduce gradually doses of anticoagulants with 10 — the 12th day of their appointment. Heparin is applied by the first 2 — 3 days of specific prevention, further replacing it with anticoagulants of indirect action.



 
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