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"It is necessary for achievement of surgical happiness... not only to perform operation skillfully, but also to prevent possible complications".
N. I. Pirogov
Traditional strategy of prevention and treatment of infectious complications in hospitals generally is based on wide use of system antibacterial therapy. Undoubtedly, implementation in clinical practice of new groups of antibacterial drugs allows doctors to expand the volume of operative measures, more safely to carry out operations at patients with a set of associated diseases. However the frequency of development of postoperative infectious complications even at planned operative measures averages 6,5% over the country.
The lethality in this group of patients reaches 12% after performance of planned operations and 27% — after the emergency interventions that in many cases is caused by decrease of the activity of traditional antibacterial drugs owing to distribution of resistant microorganisms, insufficient ability of an antibiotic to get into fabrics of a suppurative focus. It is necessary to consider as well a time factor — treatment of patients with thermal defeats, trophic ulcers, decubituses in hospitals proceeds from several weeks to several months.
Continuous threat of a reinfitsirovaniye of a wound surface of hospital microorganisms during so long period of stay of the patient in a hospital cannot be constrained only system antibacterial therapy.
The most perspective exit from current situation is visible in active implementation in each hospital of new antiseptic agents, the new dressing means allowing not only to prevent development of infectious process in a wound, but also to be a constant barrier on the way of distribution of an intrahospital infection.
Such approach allows to avoid unjustified prolonged use of antibiotics, to reduce intensity of development of resistance of microorganisms to traditional antibacterial drugs, to avoid collateral influence of antibacterial drugs on the patient, to considerably lower a total cost of treatment of the patient in a hospital and to successfully continue treatment at an out-patient stage.
The most frequent and tending to increase home and production accident are burns. This pathology meets both in peace, and in a wartime.
In the military conflicts the frequency of a burn injury made 2,5% in Afghanistan, 7% — in Tajikistan and 3,9% — in the Chechen republic. The lethality at thermal defeats in Russia reaches 2,1 — 3,3%. At deep burns the percent of a lethality is much higher. The lethality at early burn sepsis (10 — 14 days) reaches 76%.
Now deal with issues of burn pathology not only surgeons, Combustiology, but also pathophysiologists, biochemists, microbiologists, resuscitators and specialists in plastic surgery. Works on creation of new drugs for topical treatment of thermal defeats were sped up.
Burns, on degree of depth of defeat of anatomical structures, divide into 4 degrees:
• the 1st degree — an erythema and a cutaneous dropsy;
• the 2nd degree — formation of bubbles;
• FOR degree — a derma necrosis with partial preservation of sites of a rostkovy layer of epidermis, a necrosis of the epithelium covering channels of sweat, sebaceous glands and hair bulbs which become a reepitelization source;
• ZB degree — defeat of all derma;
• the 4th degree — a necrosis of skin and glubzhelezhashchy fabrics (a sinew, a muscle, a bone).
Burns of the 1st, 2nd, 3A of degree are considered rather superficial, capable to heal independently, without use of skin plastics.
Deep burns (3B — the 4th degree), as a rule, demand an operative measure.
Main objective of treatment of any burn wound — the prevention of development is purulent - septic process, creation of conditions for preservation of the remained skin elements, creation of optimal conditions for regenerator processes in a wound.
With implementation in practice of the new germicides which are specially intended for topical treatment of burn wounds doctors had an opportunity to minimize development of infectious processes, to reduce indications to surgical interventions.
Treatment of burns under a bandage is the most widespread method as in out-patient, and stationary conditions. Practically already at a stage of first-aid treatment, at a stage of transportation of the victim in a specialized hospital treatment of a burn wound under a bandage begins. The open method is applied most often at localization of burns on a face, a neck, a crotch.
Frequency of change of a bandage depends on extent of blotting of a bandage wound separated. At treatment of superficial burns without infectious process of bandaging it is possible to do 2 times a week. The good clinical effect in these cases is shown by solutions of iodophors in which iodine is immobilized on polyvinylpirrolidone:
• 1% solution of a yodopiron;
• 10% solution povidone-iodine;
• 1% solution of a yodovidon;
• 1% solution of a betadin.
Distinctions between these drugs only in ways of their receiving and different molecular mass of polyvinylpirrolidone. On extent of bactericidal action these drugs are identical. Solutions of iodophors at the expense of a wide range of the antimicrobic activity including both gram-positive, and gram-negative microorganisms, and also some mushrooms warn reinfitsirova-ny a wound surface hospital microorganisms. Iodophors well dry a burn scab, do not cause allergic reaction, do not break function of eliminative organs.
Improvement of results of treatment of patients with thermal defeats 2 — the 3rd and even the 4th degree was promoted by timely active implementation in hospitals of 0,01% of solution of a miramistin (aqueous solution benzyldimethyl beta (miristoilamino)-пропил / ammonium chloride, monohydrate), a surface-active antiseptic agent. Numerous researches confirmed high activity of a miramistin concerning almost all problem hospital microorganisms, including and mushrooms.
It is revealed that are sensitive S. aureus to a miramistin — from 89 to 100% of the strains allocated from burn wounds; E. coli — from 81 to 100%, P. aeruginosa — from 42 to 76%, P. vulgaris — from 36 to 72%.
Use of this antiseptic agent allows to prevent development of infectious process on donor wounds, to quickly liquidate initial displays of suppuration in burn wounds.
The encouraging results in treatment of thermal defeats are achieved at use of an antiseptic agent of new generation — 0,1 — 0,2% of solution of Lavasept (aqueous solution of guanyl guanidine of a poligeksanid). Lavasept has bactericidal effect of a broad spectrum of activity against the bacteria and mushrooms complicating treatment of wounds, especially against stafilokokk, enterococci, a pyocyanic stick and colibacilli such as E. coli. The broad antibacterial and fungicidal effect of Lavasept remains as at albumine addition (0,2%), and in the presence of whole human blood. In these conditions the expressed bactericidal effect is observed on exposure of influence of 15 — 30 min. Thanks to a combination of two properties — high bactericidal activity and good histocompatibility of Lavasept optimizes ability of a wound to healing.
Wide range of antimicrobic activity, lack of toxicity and, the most important, its low cost give the chance of wide use of this drug in Combustiology at all stages of treatment of burned.
Dehydrating ability can consider as a lack of solutions of all above-mentioned antiseptic agents absence at them.
Therefore at emergence of excess hydration treatment of burn wounds needs to be continued under bandages with drugs with high osmotic ability and the expressed antimicrobic activity domestic multicomponent ointments on a polietilenoksidny basis.
In case of identification in wounds of aerobic microorganisms it is necessary to apply:
• Ointment hinifurit 0,5%;
• 0,5% ointment of a miramistin;
• 1% yodopironovy ointment;
• 10% ointment of a mafenid of acetate.
At identification of neklostiridalny anaerobic activators bandagings with the ointments containing or a dioxidin (5% dioxydinew ointment, Dioksi-kol), or Nitazolum (Nitatsid), or miramistin are shown (0,5% miramistinovy ointment).
For acceleration of fusion and elimination of necrotic fabrics use of enzymes is shown:
• Lavendul's ointment or bandages with the immobilized enzymes (daltseks-trypsin).
With the same purpose carrying out sorption and application therapy by means of biologically active sorbents or gel bandages with the antimicrobic, anesthetizing and proteolytic action is shown:
• diotevin (gelevin + dioxidin + terastvorilitin);
• anilodiotevin (gelevin + dioxidin + Terrilytinum + anilokain);
• kollasorb (gelevin + collagenase of a crab);
• kolladiasorb (gelevin + collagenase of a crab + dioxidin).
In the first phase of a wound process use of biologically active dressing materials on the basis of calcium alginate is justified (Sorbalgon).
For treatment moderately and few eksudiruyushchy purulent wounds in a stage of transition to the 2nd phase of a wound process use of biologically active gel bandages representing a mesh napkin on the basis of copolymer of acrylamide and acrylic acid is shown:
• Appolo PAK-AM (polymeric hydrogel + analokain + miramistin);
• Appolo PAK-AI (polymeric hydrogel + anilokain + yodovidon);
• Appolo PAA-AI (polymeric hydrogel + anilokain + yodovidon);
• Appolo PAA-AM (polymeric hydrogel + anilokain + miramistin).
Antiburn hydrogel bandages in 15 min. cause anesthesia. The soothing effect proceeds after drawing a bandage within 90 min.
In recent years with success the new atraumatic bandages of Vosko-pran created on the basis of beeswax are applied. Salve dressings Voskopran represent an otkrytoyacheisty basis (a polyester grid) with an atraumatic wax layer thanks to what granulations and a young epithelium are not injured and painlessness of bandaging is provided. Beeswax of which the grid, adjacent to a wound, is made has a promoting effect on reparative processes in a wound.
Bandages included various ointments:
• 5% dioxydinew ointment;
• Synthomycin linimentum of 10%;
• 10% methyluracil ointment. Voskopran (without ointment covering) depending on a clinical situation is used with putting any medicine.
For treatment of burns of the 2nd degree, and also stimulation of process of a reepiteli-zation in places of capture of the split skin transplants use of the absorbing hydrocolloid bandage Gidrokoll and Branolind N. is shown.
In 1966, Charles Fox synthesis of silver sulfadiazine cream began an era of successful treatment of burn wounds with the ointments which are successfully combining bactericidal action of ions of silver and streptocide. They influence gram + and on gram-flora. Gradual release of ions of silver suppresses their growth throughout the long period of finding of a bandage on a wound that is important at high risk of reinfection hospital strains. They are effective and at fungal superinfection, slowly dissociating in a wound. The bandages containing silver ions are painless when imposing on a wound surface, do not dry on a wound, easily being removed from a surface. Their merit is penetration into fabric depth. Local and their system toxicity is rare.
In the Russian Federation drugs with silver ions in a complex with streptocides are registered under names Argosulfan, Dermasinum, Silvederm, Sulfargin, Flamazinum.
and bigger percent of silver
The aerosol form provides contactless effect
The greatest experience of use in Russia
Enters the List of WHO of "The main medicines of 2003"
Their feature is that they do not form a coagulate — a scab, well get into nekrotizirovanny fabric and exudate. Fabric the detritis impregnated with drug forms protective "pillow" under which there is a forced formation of granulations. It is important also because system antibiotics do not reach microorganisms in a necrosis zone where microcirculation (effect of pharmacological unavailability) is broken.
At the infected burns 1 — the 2nd degree the new generation of the dressing means providing on a wound is implemented into practice of their treatment:
• creation of a wet microenvironment;
• removal of excesses of exudate and necrotic fabrics;
• support of constant temperature;
• protection against external infections;
• the minimum damage of a wound surface at repeated bandagings.
The following new dressing materials conform to all above-mentioned requirements:
• algipor, algimaf;
• hydrogel bandages of Akvaflo, Kura gel, Kurafil, Kurafil-gel;
• alginate hydrocolloid dressing material Altek PRO;
• calcium-alginate dressing material of Kurasorb and Kurasorb of ZN.
For treatment of burns 1 — the 2nd degree, burn wounds at an epithelization stage, for the prevention and treatment of inflammatory process in the field of donor wounds with high clinical success new foam-forming aerosols — Dioksizol, Nitazolum, Sulyodovizol, Gipozol-AN are used. Unlike earlier implemented foam-forming drug of Olazol (with sea-buckthorn oil) the structure of modern apenny aerosols included the germicides (a dioxidin, yodovidon, Ciminalum, Nitazolum) operating on aerobic and anaerobic microflora including neklostridialny (bacteroids, peptokokk, peptostreptokokk).
New foam drugs in aerosol package create a barrier to infection of wounds. They do not possess "greenhouse effect". Applications of foam are atraumatic. It is possible to cover with a small amount of the drug transferred to foam wound surfaces, big on the area, and to fill volume and narrow wound channels ("pockets"). Advantage of an aerosol form is speed of processing of a wound surface and duration of medical effect that is important at mass arrival of victims when the delayed processing of a wound at stages of evacuation of wounded from the defeat center is necessary.