Answers to questions on reports (section of surgical specialties)

Dear participants! During the reports of the section of surgical specialties, many questions have been received, for which we are very grateful! Please see answers below.

V.P. Andrushchenko

1.    Yevhen Kucher: "Good afternoon. Thanks for your informative report. My question is related to bowel intubation: complications – risk of pneumonia, intestinal trauma (intubation for peritonitis and intestinal paresis). What is your attitude to program relaparotomies? Decasan exposure in the abdominal cavity? Thank you".

Patients of older age groups with nasogastroinestinal placement of a tube are at risk of complications in the upper respiratory tract, including pneumonia. Therefore, retrograde intubation (ceco-appendicostomy) or jejunostomy (as shown in the report) is preferred in these situations. Indeed, intubation of the entire small intestine (total) is quite a traumatic procedure, so we prefer a "short tubage" (as shown in the report). Indications for relaparotomy should be strictly regulated, since it can contribute to the deterioration of the condition in insufficiently stabilized patients. Diagnostic peritoneal lavage is carried out mainly with saline solution (mechanical component) with the addition of Decasan at the final stage of the lavage, so the exposure is 10-15 minutes.

Professor O.M. Kovalenko's answers

1. Piter Pen: "What prescription pattern for gastroprotectors do you recommend?"

Gastroprotector regimen

The occurrence of bleeding and perforated ulcers is associated with severe homeostasis disruptions developing within the first hours after shockogenic thermal injury in 3.5–22% of cases. Therefore, patients with burns at the beginning of the FIRST day start to receive a complex organoprotective therapy aimed at preventing the occurrence of Curling's ulcers and gastrointestinal bleeding.

To reduce the gastrointestinal acidity, intravenous administration of histamine receptor blockers is recommended – Famotidine (Quamatel) 20 mg every 12 hours, or Omeprazole 40 mg intravenously once daily.

Local treatment includes alternating antacids (Almagel, Maalox) and enveloping (Smecta) drugs, which are administered enterally or through a nasogastric tube at commonly used dosages.

2. Piter Pen: "The volume of infusion therapy was calculated by the Parkland formula. Unfortunately, it does not take into account the depth of burns".

The Parkland formula still exists today (both in Europe and in the United States).

The first 24 hours of burn shock:

a) daily infusion volume is calculated by the Parkland formula:

V _(ml) = 4 (ml) of Ringer's lactate´ weight (kg) % of burned area,

with infusion adjustment in accordance with the rate of urine output, BP, CVP.

NB:

The infusion level is determined not by the formula, but by the rate of diuresis, BP, CVP, and HR.

The infusion rate should be adjusted every hour based on the physiological response, mainly by the volume of hourly urine output.

Urine output should be maintained at the level of:

• Adults: 0.5–1.0 ml/kg/h.
• Children: 1–1.5 ml/kg/h.

If urine output is <0.5 ml/kg/h for 1–2 consecutive hours, it is necessary to increase the infusion volume and rate by 1/3 of the current ones. If the diuresis is >1 ml/h in adults or >2 ml/kg/h in children, it is necessary to reduce the infusion volume by 1/3 of the current one.

b) infusion rate:

• infuse 50% of the calculated volume within the first 8 hours;
• 25% – within the second 8 hours;
• 25% - within the third 8 hours.

3. Artem Ivanovych Posunko: "How do you calculate nutritional support? And how early do you initiate enteral nutrition in severely burned children?"

To prevent intestinal flora translocation, early enteral nutrition is indicated in the absence of enteroparesis. To stimulate peristalsis, it is advisable to use Sorbilact in combination with Ubretid and prokinetics.

In severe patients with gastroparesis, lavage and decompression of the stomach should be performed with a nasogastric tube in the first hours after the injury, and enteral nutrition should be provided through a Nagaraj nasointestinal tube, which is edoscopically inserted into the small intestine behind the ligament of Treitz 1-2 days after the injury.

Total calorie intake is 25–50% higher than basal metabolic rate:

• children weighing up to 10 kg: 55–75 kcal/kg/day;
• children weighing more than 10 kg: 50 kcal/kg/day;
• adults: 35–40 kcal/kg/day.

Formulas:

• For children under 1 year – formulas based on high protein hydrolysis: Alfare (Switzerland), Nutrilon Pepti Gastro (the Netherlands);
• children from 1 year to 10 years – Peptamen Junior (Switzerland);
• children over 10 years of age – Peptamen (Switzerland), Peptisorb (the Netherlands);
• adults – Peptamen during the first week, followed by other formulas with greater calorie intake.

4. Serhii Sadoma: "What is the role of efferent methods in burn disease?"

Efferent methods are used in the treatment of burn disease:

• Cytapheresis: erythrocytapheresis is initiated during the burn shock.

·         Plasmapheresis: a method based on removing part of the patient's blood plasma with all toxic substances contained therein, followed by replacement with blood components, preparations and/or blood substitutes.

Plasmapheresis is indicated for almost all patients, however, it is necessary to consider the severity of the patient's condition and the failure of previous detoxification methods (hemodilution, stimulation of diuresis). Depending on the volume of plasma taken, there are three types of the procedures: low-volume – up to 20% of the volume of plasma circulation (VPC), medium-volume – 20-50% of the VPC, high-volume – 50-70% of the VPC.

·         Hemodialysis: a detoxification method based on the principle of diffusion and filtration transfer of low-molecular toxic substances and intravascular fluid from circulating extracorporeal blood to a dialysis solution through a semipermeable membrane.

Indications for hemodialysis in burn patients:

1. Acute renal failure in the stage of oligoanuria and anuria with the development of hyperhydration and azotemia in patients in the acute period of burn disease.

2. The presence of severe uremic intoxication accompanied by an acute metabolic acidosis which is not corrected by infusion therapy in patients with acute renal failure.

3. Hyperkalemia due to reduced function of the kidneys and adrenals.

4. Isotonic hyperhydration – in kidney diseases, improper plasma replacement, and in the case of ineffective drug dehydration.

·         Ultrafiltration: ultrafiltration is used to model the basic physico-chemical and structural principles of natural detoxification mechanisms. Indications: hyperhydration in acute renal failure; pulmonary edema; anasarca.

Sorption intracorporeal methods:

·         Enterosorption: allows to selectively influence the metabolism of toxic substances between the digestive juices of the gastrointestinal tract and blood, as well as to block the transfer of toxic compounds by absorbing them from the intestinal contents, eliminating them from the blood and preventing their return to the blood.

 Physio- and chemohemotherapy:

·         UBI: a method based on the effect of extracorporeal ultraviolet irradiation of the patient's blood.

·         Laser blood irradiation.

·         Application of sodium hypochlorite: inactivates large-molecular toxic compounds located on the surface of blood cells or circulating in plasma (endo- and exotoxins of microorganisms) by hydrolysis reaction; oxidizes toxins contained in cells, freely penetrating through cell membranes.

·         Ozone hemotherapy: a detoxification method that allows an intravenous infusion of ozone solutions of 0.9% sodium chloride to obtain effects comparable to those of indirect chemical oxidation (sodium hypochlorite). The use of ozone is based on oxidizing, disinfecting and bactericidal properties.

At the clinic, we use plasmapheresis and, if necessary, ultrafiltration.

5. Ergash: "What is the approach to electrical burns? Lay a patient on wet?"

1. ECG monitoring 2 times a day for three days, afterwards – according to indications.

2. Anti-shock therapy according to the burn shock treatment guidelines.

3. Myofasciotomy within the first 6 hours after injury.

6. Artem Ivanovych Posunko: "How do you use Suspur derm?"

Suspur derm is used for the treatment of 1-IIа – IIb degree burns, infected abrasions, trophic ulcers, pressure ulcers, radiation-associated ulcers, in places where split skin grafts were taken, for temporary covering of large skin defects, etc. It is able to absorb exudate, i.e. it is applied to moderately exudating wounds. Permofoum has a higher ability to absorb exudate. Each cover has its own indications. Unfortunately, it is out of production.

V.V. Sokolov

1.    Is active drainage of the pleural cavities required?

If you look at the picture, the mediastinum is drained by two drainage pipes installed side by side. They are used for continuous irrigation-aspiration. One is used to inject an antiseptic, the other is used to withdraw it. It is connected to the pleuroaspirator (suction unit with a negative pressure of minus 25 cm H2O).

2. "What do you think about the reliability of ultrasound examination of pleural cavities?"

We use ultrasound scanning to assess fluid accumulations in the pleural cavity in order to puncture and drain the fluid based on its findings. Ultrasound scanning is reliable for assessing not only fluid accumulations but also lung atelectasis and puncture biopsy of large pulmonary and pleural lesions.

3. "How is posterior mediastinitis treated?"

As the report shows, posterior mediastinitis is treated in the same way as any other mediastinitis. The mediastinal pleura is opened thoracoscopically, with emptying of the purulent cavities and gentle removal of the necrotized mediastinal cellular tissue. It is drained and washed with in- and outflow continuously after surgery.

V.V. Smyshchuk

1. Valentyn Hrepachevskyi: "Will the use of siphon enemas result in possible perforation of the incarcerated intestine? Thank you".

Siphon enemas were used not in all cases. When used, it was always supervised by a surgeon, who determined the feasibility of further use.

2. Valentyn Komar: "What are the clear signs of non-viability of the intestine?"

No peristalsis, no vascular pulsation, the black-green color of the intestine, no reaction to warm saline solution (peristalsis is not restored, vascular pulsation does not appear).

3. Savoliuk Sergii: "What are the tactics for intestinal resections?"

Depending on the situation, either anastomosis or stoma. Regarding alloplasty, in cases of a phlegmon of the hernial sac, alloplasty was not performed.

4. Savoliuk Sergii: "without conversion?"

In cases where herniotomy surgery was started, most of them were performed with conversion.

5. Savoliuk Sergii: "How are intraoperative tactics determined, if resection is performed in favor of intestinal ostomy?"

Stoma exteriorization and alloplasty in the absence of purulent-septic changes in the hernial sac and patient's compensated general condition.

6. "Alloplasty for all incarcerated hernias?"

Alloplasty was performed in the absence of purulent-septic changes in the hernial sac and patient's compensated general condition.

Y. P. Feleshtynskyi

1. Ihor Nosenko: "Do you have experience of treating ventral hernias after treating gastroschisis?"

In our practice, there have been no cases of treatment of ventral hernias after gastroschisis.

2. Savoliuk Sergii: "Dear Yaroslav Petrovych! How often do you use local anesthesia at the stages of hernioplasty? Ventral? Inguinal? For open and laparoscopic interventions? What medications? Dosage? Purpose and place of administration?"

We use local anesthesia for inguinal, femoral, umbilical hernias and small-sized epigastrocele. Drug: Longocaine 0.25% 50-150 ml, local infiltration anesthesia. In open and laparoscopic interventions for ventral hernias, general anesthesia is more common, in some cases – spinal anesthesia.

3. Savoliuk Sergii: "And the 2nd question: what is the number of patients operated by using multimodal anesthesia? Spinal anesthesia? Under the rapid recovery surgery protocol?"

There were about 10% of such patients. These were patients with small and medium-sized hernias.

4. Savoliuk Sergii: "And how do you see the prospects for applying the protocol of rapid recovery in laparoscopic surgery of ventral hernias?"

The prospect of applying the rapid recovery protocol to laparoscopic ventral hernia surgery will be more commonly used for small and medium-sized hernias.

5. Taras Volodymyrovych Vitiuk: "How is intra-abdominal pressure controlled?"

Intra-abdominal pressure is monitored indirectly by using a Foley catheter and Abdopressure device before surgery, during surgery, and in the postoperative period. The elevation limit is 12 mm Hg.

6. Savoliuk Sergii: "Dear Yaroslav Petrovych! How often do you use Decasan alone without antibiotic prophylaxis? Since the European headline does not always recommend antibiotic prophylaxis, what are your conclusions about the headline's recommendations?"

Antiseptic Decasan alone, without antibiotic prophylaxis, was used in case of "clean" wounds (primary inguinal, femoral, umbilical hernias). In the case of "conditionally clean" wounds (recurrent hernias, postoperative hernias), antibiotic prophylaxis was used, and in some cases, antibacterial therapy was used.

7. Serhii: "What is the percentage of purulent-septic complications in the p/o period?"

When using antiseptic Decasan alone, without antibiotic prophylaxis, for "clean" wounds, the percentage of purulent-septic complications is less than 1%.

8. Ivan Krashevskyi: "Have you used negative pressure in the treatment of complications after AGP?"

Answer: Yes, we have used VAC therapy for infected seromas after allogernioplasty of postoperative ventral hernias. It is an effective technique.

9. "Good afternoon. What mesh do you use?"

We use classic lightweight polypropylene mesh implants, composite mesh implants, and mesh implants with anti-adhesive collagen coating.

10.  Silvester Ferenz: "Why Clexane?"

In our practice, Clexane was used to most of the patients. Its application showed good results.

11. "I thank the distinguished speakers for their informative reports. I'm already listening to the third report mentioning Decasan. Why only it?"

In our practice, the use of Decasan has good outcomes.