Scoring system

Quite difficult and controversial question remains the choice of optimal treatment, and the first surgical approach. Principle of radical surgical treatment is based on a complete, adequate and early liquidation or delimitation of the basic, additional and potential sources (foci) of endogenous intoxication as a microbial, and dismetabolic character [2]. In the next stage of surgical treatment of peritoneal lavage performance and readjustment of the abdominal cavity provides, although not in all cases, sufficient decontamination and detoxification effect [18]. Treatment and prevention of recurrence of residual intra-abdominal infection is achieved reasonable choice of one or more ways: peritoneal lavage with antiseptics in the flow or fractional mode, programmable (staged) revision and readjustment of the abdominal cavity; laparostomy [11, 14].

In this regard, in recent years, increasing attention is paid to active methods of surgical treatment plant. Thus, programmable Improved sanitation and diagnostic brand viagra relaparotomy or laparostomy, omentobursostomii combines mandatory with different ways of decompression, detoxification and decontamination of the gastrointestinal tract (GIT) [5,6]. In modern conditions, the method remedial programmable relaparotomy or nekrsekvestrektomy, being a very effective way to eradicate widespread peritonitis and pancreatic necrosis, can prevent development of septic complications distant only when proper identification testimony. Years of experience Faculty Surgical Clinic Medical University and outcomes in patients with abdominal sepsis caused by peritonitis, can give an answer to some tactical issues. Indications for relaparotomy programmable remediation should be based on an understanding of positive and negative aspects of this method and objective assessment of the severity of the patient. Advantages and disadvantages of programmable remedial laparotomy (from the point of view, and a surgeon, and intensivista ") are presented in Table. 2.

With regard to objective estimation of the severity of the patient, our clinical experience shows the need for mandatory use of scoring system. We prefer the most simplest of them - a simplified evaluation system proposed by JRLe Gall et al. in 1983 and named the authors of SAPS [12]. According to our data, the prognostic significance of assessing the likelihood of adverse outcome when using SAPS is very high.

Indications for relaparotomy programmable remediation, omentobursostomiyam with abdominal sepsis can be formulated as follows:

1. Common putrid, fecal peritonitis, signs of anaerobic infection.

2. Unrepaired at the first operation, the source of the AU.

3. Questionable viability of the area of the intestine.

4. Postoperative peritonitis.

5. Pyo-necrotic forms of pancreatic necrosis and pancreatic peritonitis.

6. SAPS - 20-25 points.

Table 2

Programmable Improved sanitation relaparotomy

Advantages:

* A complete reorganization of the abdominal cavity;
* Timely diagnosis and correction of intra-abdominal complications;
* The possibility of active drainage of the abdominal cavity;

Disadvantages:

* Adverse systemic effects of repeated interventions (including re-development of the syndrome of "mediator storm" and the toxic shock);
* Repeated trauma of the abdominal wall and abdominal organs;
* Duration of intubation (gastrointestinal tract, trachea, urinary tract) with high risk of nosocomial pneumonia and uroinfektsii;
* Duration of mechanical ventilation;
* The need for prolonged catheterization of blood vessels at high risk of "catheter infection and angiogenic sepsis;
* A high risk of intra-abdominal bleeding and the formation of intestinal fistula;
* Duration of stay in ICU and in hospital.

Our clinical experience and literature data allow to come to the conclusion that the AU under severe multiorgan failure with damage of more than 3 systems and programmable method of readjustment and revision of the abdominal cavity loses its advantages, all while maintaining significant drawbacks [5-8].

However, it appears that the results of programmed relaparotomy in the remedial treatment of AS can be improved by strict adherence to certain principles (Table 3).

Table 3

Ways to improve the results of programmed relaparotomy remediation in AS patients with peritonitis

* Optimization of testimony based on an assessment of severity and prognosis of patients with scoring system (APACHE II, SAPS).
* The optimal choice laparostomicheskogo device and the interval between repeated bailouts.
* Dynamic objectified assessment of the abdominal cavity and peritonitis.
The combination of surgery with a rational antimicrobial therapy (systemic and selective decontamination of the digestive tract).
* Effective enteral and extracorporeal detoxification.
* Suppression tsitokinogeneza.
* Optimization of oxygen transport and metabolic support.

placebo
microadenomas
wrong interpretation
tactics
myocardial infarction