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THE MINISTRY OF HEALTH OF THE REPUBLIC OF UZBEKISTAN THE TASHKENT MEDICAL ACADEMY Department of Surgery for General Practitioner "APPROVED" ………………………. ………………………. FEVER SYNDROME IN SURGICAL INFECTIONS (methodological manual) Tashkent-2012 THE MINISTRY OF HEALTH OF THE REPUBLIC OF UZBEKISTAN THE TASHKENT MEDICAL ACADEMY Department of Surgery of General Practitioner Authors: S.N. Navruzov- Dr.med.,Prof. Director of the Republic Scientific Centre of Oncology O.R. Teshaev- Dr.med, Prof. Head of the Department of General PractitionerSurgery A.E. Rustamov- MD, PhD, Associate professor of the Department of General Practitioner-Surgery. MD. Ph.D Yunusov I.I - Assistant Professor of Surgery for GeneralPracitioners Reviewers: Dr.med, Prof.: Ataullaev H.A. Dr.med, Prof.: Mahkamova M.N. ~1~ METHODOLOGICAL MANUAL IS INTENDED FOR THE 6-7 COURSE STUDENTS OF THE DEPARTMENT OF GENERAL PRACTITIONER-SURGERY, TASHKENT MEDICAL ACADEMY Structure • Introduction • Inter subject integration (vertical integration) - anatomical and physiological, clinical and biochemical features. • Theoretical part (Aetiopathogenesis, diagnosis, clinical features, treatment, highlights), diff. diagnosis all disease entities of this syndrome, the rare forms of disease, the tactics of GPs in various forms of course of the syndrome and its nosological forms. • Prevention (primary, secondary, tertiary). • Rehabilitation of patients after hospital treatment • Scenario POI in this syndrome • Practical skills for this syndrome (according to the list of skills-GP Surgery) – Step by step performance with the interpretation of drawings • Case studies (№ 10) for different disease entities of the syndrome • The test questions (№ 60) - 5 types of tests • References (core, additional) ~2~ Introduction The concept "surgical infection" includes diseases of infectious nature, which are treated by surgical methods, and wound infections caused by the introduction of pathogens into the wound, resulting in injury or during surgery. Fever is an important and sometimes the only symptom of surgical infection. Syndrome of fever in surgical infection has a distinctive feature and shows the characteristic temperature curve. Crucial is the role of this symptom in early detection of postoperative complications. Fever reflects the reactivity of the organism in the development of surgical infection and is the result of absorption of the decay products of the tissues. The development of surgical infection is closely associated with the course of wound healing and has the same phase - phase. In terms of pathophysiology distinguish phase alteration, exudation and proliferation (granulation). Clinical symptoms in surgical infection is determined by: the stage of wound healing, wound area, depth of lesion, the composition of the microflora involved in the development of a common source of infection and the patient (concomitant diseases). The degree of violation of general and local circulation determines the lack of delivery to the site of the introduction of cellular and chemical structures that are necessary to deal with the microflora and tissue regeneration. The essential point that determines the development of purulent process is the nature of the dose and virulence of microorganisms. A role in early detection of surgical infection belongs to the relevant knowledge of anatomy - the structure of the fascial sheaths and their importance in the spread of infection. Despite improved diagnosis and continuous improvement of antibiotic surgical infection still poses a risk to the operating surgeon as well as for GPs. According to the Republic Scientific Centre of Coloproctology (RSCC) of Uzbekistan, at 8.7% of patients after surgery for colon there are various postoperative complications, among which attention is drawn to the post-operative peritonitis, which is 67% of cases leads to death. Based on these data can be regarded as a problem of diagnosis, prevention and treatment of surgical infections is very important. Etiology. The first scientific study of pathogens of purulent infection complied R. Koch (1878), which laid the foundation for the study of the specificity of the bacteria. Performing the injection of purulent material to animals, it caused a clinically well-circumscribed infectious processes and showed that each of them is called respective views of the microorganism. Due to its proposed in 1881 by the methods of cultivation of microorganisms on solid and transparent media, he was able to identify different species of bacteria, making them carry pure cultures. This was followed by the opening stage of the various agents of purulent processes and determine their location, living conditions, the ability of resistance, etc. Gradually, the number of excited-makers purulent diseases and purulent inflammation of wounds increased by opening a specific and nonspecific bacteria: pneumococcus (1883-1884), gonorrhea (1879-1885), Escherichia coli (1885), Proteus (1885), Pseudomonas coli, pathogens anaerobic infections (1892 and later), fungi, etc. At the same XXIV Congress of the International Society of Surgeons was noted that there is already 29 aerobic and anaerobic bacteria, 9 fungi and 8 viruses. It was pointed out that since 1956, the cases of infections caused by Gram-negative bacteria. Analysis of materials of domestic and foreign literature suggests that the main causative agents of surgical infection at this stage are pathogenic plasma coagulating staphylococci MDR Gram-negative bacteria and various family Enterobacteriaceae and the genus Pseudomonos, i.e. representatives of conditionally pathogenic microflora, which normally handles the body due to the prevailing evolutionary natural protective factors that undergo marked disturbances after surgery. Noting the important role of staphylococci in the occurrence of surgical infection, it is necessary to distinguish two major factors affecting the growth of infectious complications in the hospital now. This, ~3~ above all, widespread pathogenic staphylococci and a large percentage of their carriage among healthcare workers and patients in hospitals. As well as the ability of pathogenic staphylococci to adapt quickly to chemotherapeutic drugs and, mainly, to antibiotics widely used in surgical practice. Microbial associations with the growth of microbial antibiotic resistance began to meet frequently. If, before the widespread use of antibiotics in surgical infection pathogens play a major role streptococcus, whereas in the late 40s of this century took first place staphylococcus. Of representatives of Proteus group in the festering wounds more common in Proteus mirabilis. Proteus can aggravate the severity of the purulent process burden for staph infection. Being in a symbiotic or antagonistic relationship with other infectious agents, Proteus, and Escherichia as Pseudomonas bacillus, can create conditions for the growth of some pathogens and inhibit the growth and reproduction of others. In this regard, the use of antibiotics to fight wound infection should be sure to include deliberate action on the whole association of microbes. In recent years, selected group of pathogens of purulent-inflammatory diseases - non-clostridial anaerobes, group not previously detected opportunistic pathogens. The latter can be independent agents or to be in association with aerobes. In the etiology of pyogenic infections are the most important: Bacteroides, Peptococcus, Pep-tostreptococcus, Fusobactcrium, B.fragilis. Pathogenic microorganisms of various purulent diseases isolated from wounds. Clinical groups of purulent diseases Pathogens Acute purulent diseases of soft tissue (mastitis, boils, carbuncles, festering atheroma, gidradenity, panaritiums and others) Staphylococcus spp., P. aeruginosa, Streptococcus spp. Non-clostridial anaerobic microflora Postoperative purulent wounds of soft tissues (cellulitis anterior abdominal wall after appendectomy, laparotomy, bowel surgery, after a plastic reconstructive surgery of the FIR, etc.). E. coli, Proteus spp. P. aeruginosa, Enterococcus spp. Non-clostridial anaerobic microflora. Mushrooms Post-traumatic soft tissue wounds festering limbs with damage and without damage to the bone P. aeruginosa S. aureus, S. Epidermidis Non-clostridial anaerobic microflora Postoperative or posttraumatic osteomyelitis with purulent wounds of soft tissues Staphylococcus spp. Enterobacter spp. P. aeruginosa, Klebsiella spp. Proteus spp. Non-clostridial anaerobic microflora Chronic purulent tissue wounds, sores, decubitus Non-clostridial anaerobic microflora. E. coli, S. aureus, S. Epidermidis Mushrooms, Enterococcus spp. Proteus spp. P.aeruginosa Sepsis S. aureus, S. Epidermidis Enterobacteriaceae. P. aeruginosa, Enterococcus spp. Mushrooms. "Diabetic foot", gangrene of the foot and lower leg Non-clostridial anaerobic microflora. S. aureus, S. Epidermidis E. coli, Klebsiella spp. Proteus spp. P. aeruginosa. Enterococcus spp. ~4~ Enterobacteriaceae. Mushrooms. Important role in the etiology of surgical infections are asporogenous, anaerobic bacteria. By asporogenous anaerobes include: 1. Gram-positive bacteria (Actinomyces, Arachiie, Lactobacillus); 2. Gram-negative bacteria (Bacteroides, Fusobacterium, Campilobacter); 3. Gram-positive cocci (Ruminococcus, Peptococcus, Peptostrep); 4. Gram-negative cocci (Viellonella). Table 2 presents the non-clostridial anaerobes isolated from wounds in different clinical groups of purulent diseases. At all listed diseases among asporous anaerobics are found out B. Fragilis, Peptococcus, Peptostreptococcus. When lung abscesses are distinguished as F. nucleatum, Fusobacterium spp., in postoperative septic wounds, diabetic gangrene and phlegmon, limfideme complicated by erysipelas inflammation - P. melaninogenica. The clinical group Non-clostridial anaerobes isolated from wounds with various purulent diseases Types of non-sporogenic anaerobes Lung abscesses F.nucleatum. Fusobact spp, P. melaninogen. Peptococcus. Peptostreptococ. Cholangitis B. fragilis Peptococcus. Peptostreptococ. Acute purulent diseases of soft tissues Peptococcus. Peptostreptococ. B. fragilis Post-traumatic wounds Postoperative septic wounds Peritonitis, cellulitis of the abdominal wall Diabetic phlegmon, gangrene Lymphedema complicated by erysipelas inflammation Long crush syndrome soft tissue B. fragilis, Peptococcus. Peptostreptococ. B. fragilis Peptocoecus. Peptostreptococ. P. melaninogen. B. fragilis. Peptococcus. Peptostreptococ. P. melaninogen. Peptococcus. Peptostreptococ. B. fragilis P. melaninogen. Peptostreptococ. Peptococcus B. fragilis P. melaninogen. Peptococcus. Peptostreptococ. B. fragilis Frequency of occurrence, probability of development of wound infections is directly associated with character of performed surgical intervention. 1). Pure surgical interventions (for example, hernia repair) become complicated with wound infections in 1-2 % of cases. Because of small probability of suppuration, the operative wound is closed tightly. ~5~ 2). Pure operative interventions with probable contamination (for example, cholecystectomy). Risk of development of purulent complications - 5-15 %. Operation is usually finished with primary sutures. 3). Surgical interventions with higher risk of contamination (for example, hemicolectomy, apendoctomy for a destructive appendicitis, cholecystectomy in the case of empyema or an infected cholangitis). The risk of development of purulent complications makes 10-20 %. A skin wound usually closed with drainages. 4). Surgical interventions with very high risk of contamination (for example, the opened abscess). The probability of wound infections exceeds 50 %, therefore the skin is usually single-sutured and the space between them is widely drained. Healing goes with the secondary intention. It is necessary to refer the following risk factors of occurrence of postoperative suppurations: Performance of operations in more than 12 hours after wounding; Duration of operation, so the increase in time of performance of operation over 3 hours raises the risk of infection 5 times; The rough operative technique - in 3,8 times; Presence of the exudates in the abdominal cavity - 2,7 times; Operation for malignancy - 3 times; Drainage and tampon a wound and abdominal cavity -2,3 times; Considerable tension of the wound edges; a wound location on the legs, forearms and especially in area of feet, hands. Also plays a role: Opening of hollow organs during the operation; Superfluous subincisionaneous fat Presence of accompanying diseases; Casual violation of rules of aseptic and emergency operations. Development of suppuration depends on the following basic conditions: 1) an extensive trauma of the tissues surrounding a wound and their expressed inflammatory changes, 2) presence in the wound of necrotic or bruising nonviable tissues, a hematoma or blood clots and foreign bodies that is caused by defective surgical debridement of a wound, the bad hemostasis, inadequate comparison of edges of a wound, 3) microbic pollution of the wound above critical level (10 5 microbic bodies on 1 gramme of a tissue), 4) disorder of the general condition of an organism - traumatic shock, intensive haemorrhage, the changed reactivity. Classification of surgical infection. The term "surgical infection" is accepted to include both acute and chronic suppurative disease or traumatic injuries that are associated with inflammation and at certain stages require surgical treatment. The classification of surgical infection offered by V.I.Struchkov, V.K.Gostishchev, U.V.Struchkov (1984) is most acceptable. According to clinical course and changes in tissues from all kinds of a surgical infection differ aincisione and chronic infection. 1. Aincisione surgical infection: the purulent; the putrefactive; anaerobic; specific (a tetanus, the Siberian ulcer - antrax, etc.). 2. Chronic surgical infection: the nonspecific; specific (tuberculosis, a syphilis, аctinomycosis, etc.). At some types of surgical infection may dominate local manifestations (local surgical infection), and others - common phenomenon with septic course (overall surgical infection). For purulent surgical diseases according to the principle that forms the basis of their division, several classifications have been proposed: I. By the nature of the causative agent of purulent surgical infection is classified as follows: ~6~ 1. aerobic monoinfection A gram-positive: stafilokkoki, streptokkoki, pnevmokkoki. B. Gramnegative: colibacteria, Pseudomonas aeruginosa, Proteus, meningococci, gonococci. 2. Anaerobic monoinfection: A clostridial B. non-clostridial (asporogenous) infection. 3. mixed infection A. aerobic-aerobic; B. Anaerobic-aerobic; C. Aerobic-anaerobic VA II. According to the structure of pathology: a) Surgical infectious diseases; b) Infectious complications of surgical diseases; c) postoperative infectious complications; d) Infectious complications in closed and open injuries. III. Localization: a) skin lesions, subcutaneous fat and muscle (surgical infection of soft tissues). b) The destruction covers the skull, the brain and its membranes; c) damage the neck; d) lesions of the chest wall, pleural cavity, lungs; e) the lesion of mediastinum; f) The destruction of the peritoneum and abdominal organs; g) the destruction of the pelvis; h) the destruction of bones and joints; I) heart disease and blood vessels (heart abscesses, thrombophlebitis, suppurative complications of injuries and wounds of the heart, reconstructive operations on blood vessels). IV. On the clinical course: 1. Acute purulent infection: The general; The local. 2. Chronic purulent infection: The general; The local. The pathogenesis of surgical infections and fever syndrome Pathogenesis of wound infection is determined by the interaction of pathogen with macroorganism. For the development of wound infection pathogens requires a combination of the following conditions: 1. The high number of bacteria in the wound; 2. The ability of bacteria to penetrate the protective barriers and propensity for translocation; 3. The high pathogenicity; 4. The high virulence; 5. The high toxicity; 6. Low sensitivity to drugs; 7. Ability to multiply inside the cells. The development of microbes in their penetration through the defect of skin and mucous membranes are favorable: ~7~ a) the presence in the area of trauma medium (hemorrhage, necrosis), presence of blind pockets, foreign bodies; b) the simultaneous entry of several microbes (polyinfection) that have a synergistic effect; c) the penetration of microbes increased virulence, such as pollution damage to the wound of another patient's discharge. "Critical level" bacterial infection of wounds is the number of microorganisms 105 for 1 gram of tissue, above which may be accompanied by the penetration of infection into the deeper layers of the wound with the breakthrough of the demarcation of the shaft and the development of septic complications. "Critical level" can be much less if the wound a large number of dead tissue, foreign bodies, as well as in violation of the protective reactions of humoral and cellular immunologic factors. As a result, necrotic wound process may occur in the presence of the wound 103 - 104 microorganisms per 1 gram of tissue. Reaction to the introduction of microbes is accompanied by local and general manifestations. At the present time for surgical infection treated as a variant of the cascade reaction to the focus of inflammation (systemic inflammatory response syndrome - SIRS). The term adopted by the consensus conference on sepsis in Chicago in 1991 (Bone RC et al., 1992). The center of surgical infection (the focus of inflammation) leads to the activation and entry into the blood of many and multifaceted inflammatory mediators (kinins, serotonin, prostaglandins, etc.). Effect of inflammatory mediators in peripheral vessels leads to dilation or constriction of arterioles and venules, in stasis, aggregation and microembolization, damage to the vascular endothelium. Mediators also have a direct effect on the myocardium. Further development of the systemic response to infection manifested surgical center violation tissue perfusion, decreased peripheral vascular resistance, organ dysfunction. INFLAMMATORY PROCESS STATE OF MACROORGANISM EXCITER Form State of activity Combination of agents Hyperergic Local anatomical and physiological conditions in the area of pathogen introduction Nature of the blood supply In the development of a systemic reaction to inflammation marked phasic (focus of purulent infection, sepsis, severe sepsis and septic shock). With inadequate treatment is the generalization of local infection with the formation of sepsis. Intoxication is composed of: 1) exposure to toxins and suction decay products, and 2) endotoxemy, ~8~ disorders of homeostasis due to losses through the wound surface proteins, electrolytes. The main difference between the overall reaction to suppurative process from sepsis is that all the symptoms of her sharply or disappear at the opening of a purulent focus and create good drainage; with sepsis do not. The penetration of microorganisms into the tissue causes a local reaction, which is manifested in changes in the neuro-circulatory reflex nature: first, developing arterial hyperemia, then venous stasis with formation of edema, pain, local temperature rise, violated functions. In the inflammatory exudate accumulates a large number of neutrophils. The degree of severity of local symptoms and the speed of development depends on the reactivity of the organism. The result of the local host's reaction to the penetration of the infectious agent is the development of protective barriers. First of all, formed leukocyte shaft, limiting source of infection from the body's internal environment, such as barriers are lymph vessels and nodes. In the development of tissue reaction around the purulent center and cell proliferation of the connective tissue is formed granulation shaft, which is more reliably limits the purulent focus. With long-term existence of the limited purulent process from the surrounding granulation shaft a dense pyogenic membrane, which serves as a reliable barrier that limits the process forming an abscess. In the highly virulent infections and weak response of the body protective barriers are formed slowly, which often leads to a breakthrough infection through the lymphatic pathway (vessels, nodes) in the bloodstream. In such cases, sepsis develops. Wound process - a complex set of general and local biological reactions in response to damage to organs and tissues, usually ending their healing (M.I. Kuzin.) Wound infection - the main type of surgical infection in hospitalized patients. Characteristics of the main phases of wound healing The development of surgical infection is closely associated with the course of wound healing and has the same phase - phase. It should be divided into 3 successive phases: 1. Purulent-necrotic phase of inflammation (degradation, hydration, exudation), consisting of two consecutive periods - vascular changes and wound cleansing by suppressing the microflora and the rejection of non-viable tissue. Purulent-necrotic phase of inflammation characterized by the presence of necrotic tissue, purulent discharge from the wound, infiltration of the wound edges (Fig. 1). In this phase, there is a high level of bacterial infection. In wound received fluid containing plasma proteins, blood cells, fibrin, and antibodies. Violation of metabolic processes leads to increased osmotic pressure in the tissues, resulting in acidosis develops and disturbance of microcirculation in the inflammation that leads to secondary necrosis. Directly in the depth of the wound, in the zone of secondary necrosis, rather than localized on the surface microflora, which determines the development of pathological process. 2. Phase appearance of granulation (dehydration, proliferation). In this phase is cleansed the wound of necrotic purulent secretions, there is serous discharge, significantly reduced hyperelastic tissue edema and infiltration. Neutrophilic leukocytes (macrophages) phagocytize cellular detritus, micro and small foreign matter. Productive nature of wound healing seen the emergence and development of granulation tissue, which gradually fills the wound. Recanalization occurs lymphatic vessels starts sprouting of blood vessels, forming a lot of capillaries that feed the fibroblasts. Wound healing macrophages activated fibroblasts. Fibroblasts proliferate and migrate to the site of injury by binding to fibrillar structures in fibronectin. At the same time, they actively synthesize extracellular matrix substances, including collagen. Collagen provides the closure of tissue defects and the strength of the forming scar. 3. Epithelialization phase - clinically epithelization of the wound surface and reorganization (ogrubevaniem) scar. Epithelization of the wound. ~9~ In Fig. 1. The stages of wound healing I. exudation; II. granulation; Takes place as the migration of epithelial cells from the wound edges on its surface. Migration of epithelium from the wound edges can not provide the healing of large wound areas, this may require skin grafts. The reduction of wound surface and provides the effect of closing the wound tissue contraction, to a certain extent due to the reduction of myofibroblasts. Clear boundary between the regenerative phase, and no scarring. Healing begins rapidly during the 2nd phase and then gradually fades. By this time the wound is reduced synthetic activity of fibroblasts and other cells. Amount of collagen during this phase practically does not increase, it is restructuring and formation of cross-links between collagen fibers, which grows at the expense of the strength of the scar. With increasing density of collagen formation of new blood vessels slows down, and scar tissue gradually fades. Development of the wound healing process is significantly different in wound healing as primary, secondary intention healing, or under a scab (crust). The initial tension - the healing of the wound edges with intergrowths in the absence of infection. Healing occurs within 6 - 8 days. Secondary tension - the healing of the wound in the presence of the defect, a large number of nonviable tissue, blood clots, foreign bodies, and the microbial flora above the critical level (105 for 1 gram of tissue). Under these conditions, the healing begins festering wound by replacement of the wound defect with granulation tissue and scar formation. Healing is a matter of weeks. Wound healing under a scab occurs in the presence of surface wounds, when it is covered with a crust of blood and cellular elements. Intoxication and the temperature increase in surgical infection consists of: 1. Exposure to toxins from the suction of decay products of damaged tissue. 2. Disorders of homeostasis due to losses through the wound surface proteins, electrolytes and other vital substances needed for the body. Clinic and diagnosis of inflammatory diseases Clinical symptoms Reaction to the introduction of microbes is accompanied by local and general manifestations. At the present time for surgical infection treated as a variant of the cascade reaction to the focus of inflammation (systemic inflammatory response syndrome - SIRS). Clinical manifestations of surgical infection depends on many factors: 1) the breadth and nature of injury (area of the wound, the depth of injury), 2) the stage of wound healing, and 3) the nature of the microflora, and 4) the presence of concomitant diseases. ~ 10 ~ Clinical manifestations of the general reaction is to increase body temperature, chills, excitement, or, conversely, weakness, blackout, and sometimes unconsciousness, headache, general malaise, weakness, rapid pulse, abnormal liver function, kidney disease, lowering blood pressure, stagnation in the pulmonary circulation. These symptoms may be pronounced or be inconspicuous. Fever with wound infection - the most important clinical symptom, which occurs as a result of absorption of the decay products of the tissues. When surgical infection the body temperature often reaches 40 0 C and above. In debilitated and elderly patients the temperature of the reaction can not be. There are repeated chills, painful headaches, sharply reduced hemoglobin, erythrocyte count, the number of leukocytes (up to 25-30 10 9 / L). In blood plasma globulin content increases and decreases the concentration of albumin. Characterized by a sharp acceleration of erythrocyte sedimentation rate. Appearing at the beginning of the process, it is usually observed for a long time after elimination of the infectious process. Sometimes patients with increased spleen, liver, appears icteric coloration of sclera. In patients with appetite, disturbed bowel function, there is a delay in stool, urine protein detected, and cylinders. In the dynamic studies of wound infection of the blood picture reveals the usual increase in erythrocyte sedimentation rate, increasing the number of leukocytes, leukocyte shift to the left, lymphopeny. Criteria for evaluation of wound healing in the festering wounds in the table. 3. TABLE 3 Comparative characteristic features of wound healing by first intention with uncomplicated wound healing process and festering wounds SPOT GENERAL Evidence 1. Normal uncomplicated healing 2. Healing, complicated by a festering wound 3. Improvement does not occur, weakness, malaise, sleep disturbed due to pain Intense, often pulsating, or moderate, but with no tendency to decrease Increase to 38-390 C or persistent low-grade fever 37.2 -37.60 C The general condition Slight deterioration after surgery, normalization to 2.3 day, sleep is not disturbed Pain Mild, aching, disappear in 2-3 days Temperature Rise after surgery to 37,5-380 C, normalization of 2-3 days Blood test ESR acceleration up to 15-20 mm / h, leukocytosis, and a small shift to the left, full normalization of the day by 6-7 Changes growing positive dynamics without (LII) on KalfCaliph <1,4 > 1,4 Lymphangitis, lymphadenitis There has been no There is often in the affected limb Hyperemia A slight, quickly resolved Puffiness A slight, quickly resolved Infiltration of tissues A slight, quickly resolved Moderate or severe, with no positive dynamics Moderate or severe, often growing Moderate, often increases are determined by deep infiltration ~ 11 ~ Discharge 1. Virtually no No growth, or (rarely) the number of bacteria flora nizhe105 per 1 g of tissue 3. The growth of microorganisms, the number of bacteria equal to or exceeding 105 per 1 g of tissue рН Early acidosis and rapid alkalization of the wound environment from 5.0 to 8.0 Persistent acidosis, the pH below 7.0 The protein concentration Rapidly decreases from 15-25 to 2.6 g / l Increases or is stable at 20-30 g / l. Cytology Cellular elements of blood neutrophils in most cases saved, the rapid emergence of poliblastov, fibrocytes, fibroblasts. Most neutrophils in varying degrees of degradation. The microflora within and extracellularly in the process distorted or incomplete phagocytosis Bacteriology wound Clinical Laboratory Serous exudate rapidly becomes purulent or profuse serous discharge impregnating fabrics 2. To determine the dynamics of wound healing and the degree of endotoxemy can be used for LII KalfCaliph. Ya Ya Kalf-Kalif empirically derived leukocyte index of intoxication - LII (cited by C. Wernicke, 1972): LII = (4M+3Y+2S+C) (Pc 1) (L+Mo) (E+1) where M - myelocytes, Y - young, S - stab; C - segmented neutrophils; Pc - plasma cells Turk; L - lymphocytes, Mo. - monocytes, E - eosinophils. By Kalf-Caliph, in healthy people LII = 1,0 0,5, by C. Wernicke (1972), 0,5 0,07. In most patients with inflammatory infiltrates LII than 1.5 (S. Wernick, 1972). At surface infiltrates LII is 1,8 0,22, in the deep - 2,6 0,26, or even higher - 5,2 1,6. Patients with higher LII 3, there are usually events purulent resorptive fever. With a smooth postoperative course LII averages 0,6 0,09. If LII exceed 1.4, then, as a rule, there are complications. Local purulent infection - morphological substrate of an infectious wound complications, when the process is localized in the wound area. Local symptoms of wound infection (redness, swelling, pain, impaired function) depends on the location and phase of the purulent process. For example, in lesions of the skin, subcutaneous tissue and muscle there are characteristic signs of inflammation, as redness, swelling, pain, increase the local temperature fluctuation appears in abscess formation. Distinguish hyperergic, ratergic, hypoergic and anergetic form of inflammatory reaction. Hyperergic reaction is characterized by rapid development of suppurative process spreads to the surrounding tissue and the vascular bundle, accompanied by the formation of thrombosis, extensive edema, and involvement in the process of lymphatic vessels, nodes and development is not only an ~ 12 ~ extensive local, but also severe general reaction. This hyperergic reaction, despite the timely and efficient treatment often leads to death. In other cases the inflammatory process is slower, less grasping tissue, with a slight swelling. The general reaction to the penetration of the microorganism is reflected in a slight increase in temperature, change in composition of blood, but it does not have a pronounced character. This ratergic response to purulent infection and local suppurative process is fairly easy to wound treated early. Anergetic form of inflammatory reaction characterized by mild local and general reactions. Inflammation limited to the localization process (abscess, etc.), swelling of surrounding tissue is almost absent; lymphangites, lymphadenitis, thrombosis not observed temperature increases are insignificant. In chronic purulent infection is characterized by signs of chronic inflammation: prolonged fever, increased erythrocyte sedimentation rate, lymphocytosis, changes in protein fractions, etc. In a long-term chronic infection can develop amyloidosis of the internal organs. Local changes in surface localization of the process are characterized by long-existing infiltrate, often - with the presence of a fistula. Temperature curves for different forms of surgical infection: Temperature sheet OPERATION (Surgical treatment of purulent foci) Temperature sheet opening burrowing pus Fever in the event of septic complications ~ 13 ~ Temperature sheet operation (surgical treatment of purulent focus, the primary joints, drainage) flushing of drainage Temperature sheet Against the background of traumatic wounds joined pneumonia Temperature sheet rashes on the skin fever in erysipelas ~ 14 ~ Diagnosis of inflammatory diseases Diagnosis of wound infection is carried out based on the following attributes: • purulent wound drainage, or; • identification of microorganisms in the inoculation of the wound; • the wound itself or diverges surgeon opened in the presence of signs of inflammation in a patient (more than 38o C temperature of the patient and there is local pain in the surgical sutures); • symptom of "fluctuations" of soft tissue in the wound area. Surgical incision infection of the surface seen in a period of 30 days after surgery (Fig. 2). Affected only the skin and subcutaneous tissue in the incision. To identify surgical infection requires one of the following three criteria: Purulent discharge from the superficial incision. Isolation of organism from culture of aseptically taken fluid or tissue surface of the cut. The presence of one of the hallmarks of inflammation: pain on palpation, local swelling, redness of the skin around the wound, fever, and the fact that the intentional opening of a surgeon cut surface, although the cut was not isolated culture of the microorganism. Surgical infection cloven appear in a period of 30 days after surgery (no implants) or a period of 1 year (with implants). It is characterized by lesions of deep soft tissue. For the diagnosis of surgical infection cloven need one of the following four criteria: Purulent discharge from a deep cut. Spontaneous disclosure cloven him intentional or open surgery when the patient has at least one of the hallmarks of inflammation: fever above 38o C, In Fig. 2. Suppuration of the wound after surgery appendectomy. Surgical infection of incision. localized pain or tenderness. The presence of painful infiltrate in the deep cut. Surgical infections organ / space infection caused in the organs or cavities by surgical intervention. For example, after surgery appendectomy formed subdiaphragmatic abscess. The latter should be recorded as intra-abdominal infection. Infection in this group appear in a period of 30 days after surgery (no implants) or a period of 1 year (with implants). For the diagnosis of surgical infection organ / space must have one of the following criteria: Purulent drainage, installed by puncture or surgery. Isolation of microorganisms from aseptically remove fluid or tissue / body cavity. The presence of an abscess or other manifestations of infection, sweeping body / cavity and detected by direct examination, during reoperation, or by histopathological radiological examination. Bacteriodiagnosis agents of wound infection should include both qualitative and quantitative analysis (Table 4). ~ 15 ~ TABLE 4 A bacteriological study of wound infection pathogens Blood, urine, swab from the wound, biopsies, sputum, punctate, extracted from drainage Qualitative research Quantitative research Aerobic Anaerobes microorganisms The content of bacteria Gram+ Gram Gram + Gram in the wound (based 1. Isolation of pure cultures of microorganisms on 1 gram of tissue or 1 ml of secretions) 2. Identification of bacteria 3. Susceptibility to antibiotics Qualitative bacteriological examination consists of three stages: • selection of pure cultures of microorganisms, • identification of microbes, • determination of their sensitivity to antibiotics. Isolation of pure culture should begin with a coloring material of the native Gram. Then produce seed in dense media and liquids. As liquid culture media using sugar or meat-peptone broth. Of solid culture media should be used 5% blood agar (for detection of bacteria, demanding to nutrients), milk-yolk-salt agar (for detection of staphylococci), Endo medium (for the detection of enterobacteria and non-fermenting Gram-negative bacteria) and, if necessary - a number of special selective media: acetimedic agar, agar brilliant green etc. Using such a broad range of culture media for planting of the material allows for one-stage selection of microorganisms and microbial inoculation to ensure the growth of which is suppressed ongoing antibiotic therapy. Produce a quantitative count of colonies in various dilutions and calculate the average number of bacteria per 1 sq. km. see the surface or at 1 g of tissue. Identification of the isolated microorganisms is carried out based on a study of their morphological and biochemical properties. Determination of microbial sensitivity to antibiotics can be done by several methods: agar diffusion method using paper disks by serial dilution in broth or agar with the E-test and the automated program. Biology of asporogenous anaerobes (in particular, the rapid death when exposed to oxygen and high nutrient requirements) determines the special methods of their selection at all stages of the bacteriological diagnosis, which are fundamentally different from traditional used when working with aerobic and facultative anaerobic microorganisms. Framework for the diagnosis of these bacteria are strict anaerobic techniques technology, as observed by a fence from the date of pathological material to identify pure cultures. As you know, nonsporogenous anaerobes are the dominant part of the normal human microflora, and therefore the chances of contamination of the pathological material, and hence obtaining false positive results. With this in mind, using well-defined species of the material: the abscess - abscess cavity contents, obtained by puncture, with purulent diseases of soft tissue - biopsies of tissues. The most important condition during transport of specimens to the laboratory is the lack of contact with atmospheric oxygen. To comply with this condition using a number of techniques. If the amount of material is less than half the amount used when taking the syringe, the material is delivered in a syringe, the needle tip closed with sterile rubber stopper. With a small sample volume, it is placed in special tubes pre-filled CO2 and sealed with rubber stoppers. Dense samples of pathological material delivered to the transport medium Carrie Blair. Blood carries oxygen-free transportation in special environments. For the cultivation of anaerobes use mikroanaerobic apparatus , which is one of the most reliable and easy-to-use devices. Anaerobic conditions are created in them, or as a result of chemical processes in gasgenerators, or by pumping air out of them and filling the oxygen-free gas mixtures. Full bakteriologic ~ 16 ~ study on isolation and identification of anaerobes nonsporogenous takes 5-7 days to 2 weeks. As a rapid diagnosis of anaerobic nonporogenous use two methods: 1) microscopy of the native material, stained by Gram stain, and 2) the study of pathological material to UV light. The treatment of purulent wounds and acute purulent surgical diseases. Basic principles of active surgical treatment of purulent wounds and acute purulent surgical diseases Treatment of extensive wounds festering, purulent surgical diseases is carried out according to the principle of active surgical treatment. The essence of this method - as soon as possible to close the wound and get good functional results. The principles of active surgical treatment of purulent wounds: 1. Surgical treatment of purulent wounds or purulent focus. 2.Drenirovanie wound perforated vinyl chloride drainage and prolonged irrigation with antiseptics in the postoperative period. Possible early closure of the wound surface with a primary, primary delayed, early secondary sutures or autodermoplasty. General and local antibiotic therapy. Increase of specific and nonspecific reactivity. The main provisions of the surgical treatment of purulent wounds are shown in Fig. 3. The first stage of treatment - incision and drainage of purulent focus, debridement with removal of all nonviable tissue within healthy. Inadequate debridement - a source of septic complications. Surgical treatment of purulent wounds involves radical removal of all nonviable tissue. However, this goal can not always be achieved due to extensive damage, the lack of clarity demarcation of nonviable tissue, complicated surgery is inexpedient in the important anatomic structures or complex contour wounds. In such cases, a phased treatment, ie necrectomy, which is produced at the border of dead tissue. Necrectomy can eliminate the bulk of nonviable tissue in the wound and make a difference during the wound healing process. Necrectomy in its purest form - non-radical surgery and involves subsequent or local medical treatment, or repeated surgery (landmark necrectomy) for a complete cleansing of the wound of nonviable tissue. The following types of surgical treatment of wounds: 1. Primary surgical treatment under the primary surgical treatment of purulent wounds should be understood first in a row in a given patient interference produced by the primary reasons. Primary surgical treatment of wounds is carried out in "fresh" (without signs of inflammation) injury in the first hours after the occurrence, based on the advance of infection, and ends with sutures. 2. Secondary surgical treatment means intervention in the conductivity of the secondary readings, ie, at the secondary changes in the wound (eg, recurrent purulent process, the development of streaks) or before closing the wound with stitches or autodermoplasty. Secondary surgical wound treatment is carried out if, after the primary surgical treatment of the wound develops an inflammatory process with the formation of purulent discharge and secondary necrosis. 3. Delayed surgical wound treatment is carried out in cases where the operation is forthcoming after a certain preparation for surgery the patient (for example, to rehabilitation wounds with antiseptics for 2 - 5 days). Often these operations are aimed at closing the wound surface. Distinguish between full and partial treatment of purulent wounds or purulent focus. Complete debridement of purulent wound excision includes it within healthy tissue. In cases where the anatomical conditions and the extent of the inflammatory process did not allow for treatment of purulent wounds in full, suggests partial surgical treatment, in which the limited disclosure of streaks, drainage, and only partial removal of necrotic tissue. ~ 17 ~ The main provisions of the surgical treatment of purulent wounds I. Surgical treatment of purulent wounds II. Additional methods of treatment of a wound • Treatment of purulent wounds pulsating stream of antiseptic; • Vacuum treatment of purulent wounds; • Treatment of purulent wounds of laser beams; • Treatment of purulent wounds with ultrasound; • Cryosurgery of purulent wounds III. Drainage of purulent wounds Suturing and systems for continuous flow irrigation I. Antibacterial therapy II. Prevention of dysbiosis III. Prevention of fungal infection IV.Detoxification therapy V. Immunocorrection Filling of the wound swabs with appropriate medication phase of wound healing Treatment in a controlled abacterial environment Reconstru ctive plastic surgery Methods of drainage of purulent wounds An important step is the surgical drainage of the wound. It allows you to quickly achieve the purification of purulent wounds, to arrest the inflammatory process, providing a flow of fluid and the continuation of effective antimicrobial therapy. Drainage - a device or a device designed to remove liquids or gases from the wounds, both natural and pathological body cavities. The probe can also be attributed to a variety of drainage, especially when it is used for the evacuation of the gastrointestinal tract. Types of drains A). Private drains - tubes that connect the body cavity with a pressurized tank. 1) Postural drainage provides a constant flow of fluid under the influence of gravity ¬ eat into the tank, located below the drained cavity. 2) Siphon drainage works on the principle of communicating vessels. The end of the drainage tube is placed in a sealed container of water drained below the cavity: thus prevent the backflow of air into the body and streamed liquid. These systems are usually used for drainage of pleural cavity (drainage Byulau). 3) Aspiration drainage. Creating a negative pressure in the receiver-(active drainage) can evacuate a larger volume of fluid from the cavity and to eliminate voids and ensure a better matching of surfaces of fabrics. B). Open drains. Their application is accompanied by a high risk area drained by the lack of integrity. This is the oldest and simplest form of drainage is still widely used in many clinics. ~ 18 ~ In). Double lumen drainages. In one channel is fed air or washing liquid, otherwise there is an active aspiration. When the air supply is used retentive micro filter. This type of drain used for the evacuation of specific environments (eg, detritus from the abscess cavity) or prolonged washing difficult pathological cavities (eg, deep abscesses of the abdominal cavity). Drainage materials must meet the following requirements: they must not have a significant mechanical irritation to the tissue to be biologically intact, as long as possible to maintain the functional (drainage) of the property. As the drainage materials used vinyl chloride, siliconized, rubber tubes. Drainage tubes may be single or Double lumen may use tubes from single systems for blood transfusion .. On the part of the drainage tube to be aligned in the cavity, causing Fig.4 Drainage of the wound with tube multiple side holes for better drainage of exudate (Fig. 4). The process of drainage may be passive, where the removal of the exudate is due to natural drainage, and active through the creation of special conditions. For the active drainage include aspiration, aspirationflushing, the flow-washable. Fig.5 Vacuum drainage of the wound Aspiration (vacuum) drainage used in suture closed wounds. For this purpose a special device in the form of an elastic reservoir-type bellows, rubber bulb or apparatus for vacuum aspiration type of OP-1 (Figure 5). Optimum conditions for a vacuum aspiration system in the range of 80 - 120 mm of water. of Art. The disadvantage of other systems, providing vacuum drainage of purulent cavity, is an uncontrolled level of dilution, since depression can have a damaging effect on the tissue, causing a vacuum flushing tissues. Aspiration-flushing drainage involves the use of two drains: one for the introduction of a purulent cavity antiseptic solutions, and another - for aspiration of the wash liquid and exudate. This type of drainage requires an airtight system, which is achieved by closing the cavity by suturing the wound. Lavage and drainage can be fractional. Flow-flushing drainage. The method is based on continuous prolonged washing purulent cavity with an antiseptic solution. For this purpose, the cavity drained by two drainage tubes, which hold the top and bottom points of the purulent cavity. Through the top of the drainage tube is constantly fed antibiotics that pass through the cavity, carrying fluid, microbial flora. Exudate was removed by drainage, which ~ 19 ~ they brought to the lower pole of the purulent cavity. For this type of drainage cavity should be closed by sutures (Fig. 6). Fig.6 Flow wash drainage For the drainage of deep-seated abscesses, such as appendicular between intestinal abscess, previously used so-called cigar drainage. It consists of a portion of a rubber surgical glove, which has cut off the fingers and palm of left it in the form of a tube, which is used as a cover for a gauze pad. In this case administered 1 to 2 gauze and the resulting drain is introduced into the cavity of the abscess, but next to the cigarette drain or through it injected into the cavity of the same vinyl chloride or rubber tube for the introduction of antibiotics. Drainage is used in cases where you need to create a wide drainage channel. Its advantage is that the rubber sheath drainage does not adhere to tissues and can be easily removed when no longer a need for drainage, and, moreover, does not remove the rubber membrane can be replaced by gauze pads as needed, ie when they lost their drainage properties. Use as a stand-alone drainage gauze impractical because quite quickly, in less than a day, gauze loses its drainage properties and turns into a traffic jam that violates the outflow of fluid. Gauze is used as haemostatics in cases where there is an increased bleeding tissue. When the swab loses its hemostatic function, it is removed. To improve the drainage of wounds (Izmailov S.G, Izmailov GA, Podushkino I. B, V.I. Loginov, 2003) used a combined drainage system consisting of two tightly interconnected hollow parts (Fig. 7). Drainage has a simple structure in the form of an elastic, soft, flexible porous cylindrical body. Corrugated is a major part of it is in the cavity of the wound and performs the basic function, which carries the drainage device. It is made of lavsan material (you can use the defective corrugated synthetic vascular prostheses). Of the modern means of drainage merit biologically active drains. They are based on material with the drainage properties, such as coal canvas algipor or tube of crosslinked hydrogel. The structure of the drainage material is introduced by immobilizing these or other drugs that increase the drainage capacity (proteolytic enzymes, antiseptics). Immobilized proteases (trypsin, kollitin, terrilitin) gradually diffuse into the wound of the drainage material and have necrolytic action, preparations and chlorhexidine dioxidine have a bactericidal effect. Products of enzymatic necrolysis and exudation of purulent wound, purulent drainage cavity is actively absorbed by the material. Such combinations of biologically active drainage materials produced by industry - daltseks trypsin band "Wave", etc. ~ 20 ~ Fig 7. Drainage: a - in a prepared form, b - corrugated portion placed in the cavity of the wound, and a smooth segment output from counteropening. Suturing a wound on purulent 1. Delayed primary suture is used for the first 5-6 days after surgical treatment, until the wound granulation. With delayed primary sutures the two surfaces of granulation tissue are reduced in direct contact. This is the safest way to treat polluted and dirty and infected traumatic wounds with large tissue defects and a high risk of sepsis. Need to free the wound of devitalized tissue, rinse with antiseptic and keep it open. Healing wounds in the open state is gradually acquiring a sufficient resistance to infection, which allows her to take in without further complications. Period of open wound is characterized by the development of capillary knots. Technically, for suturing should respect the basic principle that the wound can not be left closed cavities and pockets adaptation, and the edges of the walls of the wound should be maximum. In the festering wound is not desirable to leave ligatures of nonabsorbable material - silk, Dacron, etc. 2. Early secondary suture is placed upon the wound covered with granulation with movable edges to the development of scar tissue in it. Early secondary suture imposed within 2 weeks after surgical treatment. 3. Late secondary suture is placed upon the granulating wound, which has developed scar tissue. Wound closure is possible in these cases only after prior excision of scar tissue. Wound closure is performed 3-4 weeks after injury and later. Indications for suturing a wound or purulent on the wound after the opening of a purulent focus in the soft tissues are: 1. Complete purification of purulent wounds of necrotic and non-life-capable fabrics, achieved surgical treatment of suppurative focus or proteolytic enzymes. 2. The absence of marked inflammatory changes in skin and soft tissue around the wound. 3. Possibility of an adequate comparison of the wound edges without tension over them. The condition for sutures in purulent wound is to ensure sufficient drainage of wound, which is achieved by active drainage and rational antibiotic therapy. Contraindications to the stitches on a wound purulent are: the impossibility of complete surgical treatment of purulent wounds and in her presence of necrosis, the presence of sharp inflammatory changes of the skin and surrounding soft tissues, the inability to adapt the edges and sides of the wound without excessive tension. Contraindications to the stitches on a wound purulent are: the impossibility of complete surgical treatment of purulent wounds and in her presence of necrosis, the presence of sharp inflammatory changes of the skin and surrounding soft tissues, the inability to adapt the edges and sides of the wound without excessive tension. Superimposed on the normal wound suture anchor, conducted through all layers of the wound. Good contact of the walls and edges of the wound provides a seam-Donati Parin (Fig. 8). ~ 21 ~ b a a Fig. 8 Donati suture - (a, b). In some cases, when the expected long-term retention of the wound edges by sutures, and there is danger of the eruption of stitches and wound dehiscence, Gostischevym V.K, 1972 developed a method of applying secondary-provisory joints (Fig. 10). a b c Fig. 10. Secondary provisionally seams (a, b, c). Clinical symptoms of wound cleansing and its willingness to close are: 1. The absence of inflammatory changes in the wound and surrounding tissues; 2. The absence of necrosis and nonviable tissue at the surface and deep layers of the wound; 3. A small amount of fluid (serous type); 4. The formation of fine granulations on the entire surface of the wound (not swollen, bright red). 5. Severe marginal epithelization and (or insula epithelialization). Close extensive wound surface seams are often not possible. The application allows you to close any autodermoplasts wound surface in a short time. If the granulating wound has equal edges and walls of her good contact with each other, deep in their pockets and no cavities, we can use to bring together the edges with strips of sticky plaster (Fig. 11). Extensive wound surface and can be closed by dosed tissue stretching. To close the wound in this way requires the mobilization of its edges, imposing U-shaped sutures. Gradual stretching of joints (avoid skin ischemia) leads to the gradual closure of the wound. To restore the integrity of the skin are used localplastic operations, stages in the supply of plastic flap pedicle and free skin grafts. Localplastic operation permit, using the plastic properties of the skin, move or close flaps cutted quite extensive wounds. This type of plastic is valid for defects hands, feet, neck and joint contractures. ~ 22 ~ a b Fig. 11. Convergence of the wound edges with strips of adhesive plaster (a, b). Of local plastic surgery is most commonly used normal approximation of the mobilized skin edges of the defect, with or without excision of the pre-diseased tissue. The principles of intensive therapy of purulent-septic diseases 1. Intensive therapy begins immediately on admission to hospital and the patient is carried out in full. 2. Intensive therapy should be coupled with an urgent examination of the patient, but as becoming the diagnosis of symptomatic total more directional, the pathogenesis. 3. Intensive therapy should be carried out simultaneously in three directions - the impact on the patient's body, the impact on the organism (antibiotic therapy), the impact on the source of infection. 4. Microbiological surveillance: - Collection of material (throat swabs, blood, pus, etc.), 2 times per week; - Rapid analysis, bacterioscopy screening activity of antibiotics. - Selection of pure culture, identification of microorganisms, antibiotic-otikochuvstvitelnost strains. 5. Empirical antibiotic therapy. The indications for transfusion therapy in patients with purulent-inflammatory diseases are determined by intoxication of the organism, metabolic disorders, especially protein, and electrolyte and water balance, the nature and extent volemicheskih violations, the state of immunological reactivity. Disintoxication therapy aimed at reducing the absorption of toxins from the lesion, dilution, binding and elimination of toxins from the bloodstream. The principles of detoxification therapy. 1. Reduced absorption of toxins from the site of infection: a) removal of the source or the wide opening, necrectomy, drainage, active aspiration; b) continuous irrigation with antiseptic solutions; c) hyperosmotic bandages; d) antibiotic therapy. 2. Breeding toxins: a) the introduction of substitutes detoxifying action (protein hydrolysates, polyionic, colloidal solutions in the total mass of up to 4 - 5 liters per day) 3. Elimination of toxins: a) forced diuresis after gipervolemicheskoy hemodilution (osmotic and salureticheskie agents - mannitol, etc.); b) peritoneal dialysis; c) hemodialysis; d) plasmapheresis. 4. The destruction of toxins: a) oxygen therapy, hyperbaric oxygen therapy; ~ 23 ~ b) Blood Substitutes transfusion; c) the stimulation of redox processes. 5. The adsorption of toxins: a) transfusions of plasma, protein hydrolysates, detoxification of drugs act; b) the hemo-, plasma-, and limfosorbtion; c) the B vitamins Antimicrobial chemotherapy of wound infection The most crucial point in antibiotic therapy is the choice of starting antibiotic therapy, as the first use of antibiotics has an effect on the development of all stages of the infection process, in which a dynamic change of the dominant microbiota. With antibiotic treatment can be observed two trends: inadequate or excessive dose of antibiotics. In the first case, there is persistence and the emergence of mikropatogens tertiary centers of "opportunistic" infections, the second - the development of severe dysbiosis. At the initial stage of the etiological factor is the random microbial contamination through the "gates of infection." The third - seventh day of the overwhelming dominance of endogenous and transferred to the nosocomial flora. Principles of rational antibiotic therapy The term "antimicrobial chemotherapy" means the use of chemicals designated for infectious diseases and their pathogens causing death without damaging the host tissue. The tactics of rational antibiotic therapy include: The correct choice of drug resistance in the light of identified or suspected (before the results of bacteriological examination) pathogens. Appointment of optimal doses to achieve therapeutic concentrations in the source of infection. The best way and the multiplicity of drug administration. Adequacy of duration of treatment; Changing the antibiotic and the appointment of their allowable combinations, increasing the therapeutic effect. The main factors determining the effectiveness of antibiotic wound infection are shown in (Fig. 18). Main factors determining the efficiency of wound infection Antibiotic The choice of antibiotic including : - Antibioticograms; - A dedicated agent Dosage and administration method in view: - Peculiarities of pharmacokinetics; - Course of disease The choice of antibiotic: - The most active; - The least toxic Cancel or timely change in view of the drug: - Toxicity; - The frequency of adverse reactions A timely fashion: - Repetition rate up to stable therapeutic effect; - The use of drug combinations to enhance the antibacterial effect Fig. 18. Factors determining the effectiveness of antibiotic wound infection ~ 24 ~ More than half of all currently used antibiotics in the world are betalaktams (penicillins, cephalosporins, carbapenems). Many pathogens are resistant to long-term used in the practice of antibiotics (penicillin, streptomycin, ampicillin, amoxicillin, cefazolin, etc.). The most important mechanism for the formation of beta-lactam antibiotic resistance is the production of bacteria betalaktamaz - it involves about 80% of cases of resistance as Gram-positive and gram-negative microorganisms, which is one of the main reasons for the declining effectiveness of many traditional for each hospital antibiotics. Cephalosporins. Cephalosporins - is bactericidal agents acting on Gram-positive and Gram-negative bacteria that inhibit the synthesis of bacterial cell wall. Cephalosporin antibiotics are divided into four generations. 1st generation cephalosporins (cefazolin, cephalothin) are effective for gram-positive cocci - S. aureus, S. pyogenes, S. pneumoniae (with the exception of enterococci, and coagulase coagulasepositive staphylococci resistant to methicillin). In most cases, a generation cephalosporins are active against P. mirabilis, K. pneumoniae, E. coli. 2nd generation cephalosporins (cefmetane, cefotetane, cefamandole, cefuroxime) have an increased activity against gram-negative bacteria and a broader spectrum of action compared to a generation of drugs. Preparations are stable to betalaktamazam produced by P. mirabilis, E. Coli. cefmetazole, cefotetane, cefamandole, cefuroxime have some activity against anaerobic bacteria, including B. fragilis. 3rd generation cephalosporins (cefoperazone, ceftriaxone, ceftazidime) are now considered the core group for the treatment of severe infections caused by microorganisms of the family Enterobacteriaceae, Staphylococcus and Streptococcus, Pseudomonas aeruginosa. 4th generation cephalosporins (tsefpirom, cefepime) are characterized by high activity against Gramnegative bacteria, including P. aeruginosa, Staphylococcus methicillin-sensitive and moderately active against E. faecalis. Aminoglycosides. To include aminoglycosides - kanamycin monomitsin, neomycin, gentamicin, sizomitsin, tobramycin, amikacin, netilmicin. Among the semi-synthetic aminoglycoside antibiotic amikacin the most widely used and netilmicin. New aminoglycosides are more rapid than the beta-lactam antibiotics, bactericidal action. Aminoglycosides are used: In the empirical treatment of Pseudomonas infections. In the ICU during the combination therapy of complicated forms of wound infections with semisynthetic penicillins, penicillin-protected, cephalosporins, clindamycin and metronidazole with. In the treatment of sepsis, septic endocarditis. In the treatment of skin and soft tissues. In the treatment of intra-abdominal infections. In the treatment of pneumonia. Fluoroquinolones. Fluoroquinolones occupy one of the leading antimicrobial chemotherapeutic agents combined single mechanism of antimicrobial action - inhibition of bacterial DNA gyrase. Fluoroquinolones are characterized by: High penetration of a microbial cell. High bactericidal activity associated with a higher sensitivity of the target enzymes, and high intracellular concentrations. Persistence of antimicrobial effect in subbacteriostatic concentrations. ~ 25 ~ Long post antibiotic effect when vital activity of microorganisms is not restored for some time after removal of the drug from the site of infection and suppressing induction endoenzymes, exotoxins, reduced adhesion and virulence of microorganisms. High concentration of drug in the cells of the phagocytic system (polinukleary, macrophages). Slow development of resistance. Depending on the number of fluorine atoms emit: Monofluorinated (ciprofloxacin, ofloxacin, enoksatsin, pefloxacin). Difluorinated (lomefloksatsin). ThreeFluorinated (fleur ofloxacin) connection. Of the four most widely used in the clinic of fluoroquinolones (ofloxacin, ciprofloxacin, pefloxacin, lomefloksatsin) the greatest activity against gram-negative bacteria possess ciprofloxacin and ofloxacin. The advantage is ofloksatsilline effect on staphylococci and pneumococci. 2nd generation fluoroquinolones (sparfloxacin, grepafloksatsin, trovafloksatsin, moxifloxacin, klinafloksatsin, gatifloxacin, levofloxacin, flerofloksatsin) differ from the traditional first higher activity against pneumococci, staphylococci methicillin (trovafloksatsin, moxifloxacin, klinafloksatsin), as well as some anaerobes - Clostridium spp. , Bacteroides spp. (trovafloksatsin, moxifloxacin). Glycopeptides. The group is represented by two agents glycopeptides - vancomycin and teicoplanin. Antimicrobial activity of glycopeptides applies only to Gram-positive organisms (staphylococci, including strains oxacillin-resistant). Drugs act on enterococci, including E. faecium. In the spectrum of activity of vancomycin and teicoplanin includes various streptococci, anaerobic cocci, clostridia, including C. difficille. Empiric antibiotic therapy and causal acute purulent diseases of soft tissues is presented in (Table 12). Antibacterials for the treatment of anaerobic infections. Metronidazole is characterized by a rapid bactericidal effect. The disadvantage of this drug is its narrow spectrum of activity - only anaerobic microbial groups that require additional appointment time of one, two and sometimes three drugs are active against aerobic bacteria. Metronidazole is used in combination with antibacterial drugs of different groups. Metronidazole is well compatible with cephalosporins, aminoglycosides, fluoroquinolones. Clindamycin - an antibiotic from the group of lincosamides. Clindamycin is active in the identification of gram-positive associations in the wound aerobic and anaerobic microorganisms. The effectiveness of clindamycin is increased in combination with the drug dioksidina, or with aminoglycosides 3rd generation (netilmicin, amikacin, tobramycin), due to the high activity of these agents against gramnegative microorganisms. Carbapenems. Imipenem, meropenem have a broad spectrum of antimicrobial activity, and covering aerobic and anaerobic microorganisms. A wide range of antimicrobial activity, low toxicity, low-level resistance of hospital strains can be considered drugs of choice carbapenems for empirical treatment of complicated forms of wound infection in monotherapy sepsis, severe abdominal and wound infections. Antifungal drugs. Patients with wound infection receiving prolonged antibiotic treatment by several drugs are a group of high risk of mycotic infections. T A B L E 12 ~ 26 ~ Empiric antibiotic therapy and causal patients with wound infection Funds in 1st line Disease Acute purulent diseases of soft tissue (mastitis, boils, carbuncles, festering atheroma, gidradenity, panaritiums and others). Main Alternative Cefazolin iv / or / im 1g.h 4times day Gentamicin iv/ or /im x 80 mg twice daily Doxycycline 100 mg by mouth x 1 time per day Metronidazole / 100 mg twice a day x3 Nystatin vnutr1g 3 times a day Topical: Ointment on polyethylene glycol (PEG)-based: 0.5% ointment hinifurila, levomekol, levosin, solutions: 0.01% pp miramistin Fuzidin inside h3times 0.5 g per day Clindamycin iv 600 mg 3 times a day Nizoral inside 1t, x2 times a day Topical: Ointment on the basis of PEG: 10% ointment mafenidaatsetata, dioksikol, nitatsid 1% iodine Solutions: 1% 0.1% dioxidine furagin soluble Funds in 2nd line Reserve funds Amoxicillin clavulanic acid iv to 1.2 x 3 times a day Ampicillin sulbactam iv, im 1.5 x 4 times a day Cefotaxime iv, im 2r x 4 times a day Topical: Ointment: Metildi-oksilin, streptonitol. Ciprofloxacin iv the 200 mg x 2 times a day (after blowing a transition to a tablet form). Ofloxacin iv 400 mg x 2 times per day. (after blowing a transition to a tablet form). Amikacin iv / im 500 mg 3 times a day. Netilmicin iv / im 200 mg x 2 times per day. Piperacillin tazobactam iv 4.5 g 3 times a day Ceftriaxone iv / im 1g x 2 T A B L E 13 ~ 27 ~ Empiric antibiotic therapy and causal patients with wound infection Funds in 1st line Disease Postoperative purulent wounds of soft tissues (cellulitis anterior abdominal wall after appendectomy, laparotomy, bowel surgery, after plastic reconstructive surgery, etc. Main Alternative Cefotaxime iv/im 2r x4 times a day. Amikacin iv 500 mg 3 times a day. Fuzidin 0.5gh 3raza a day inside. Carbenicillin iv x4 5g twice a day. Metronidazole iv 100mg x3 times a day. Nystatin inside 1d x3 times a day. Topical: Ointment for polyethyleneglycol (PEG) basis: levomekol, levosin, Solutions: iodophors, 0.01% Miramistin. Amoxicillin/ clavulanic acid / g to 1.2 x 3 times a day. Ampicillin/ sulbactam iv/im 1.5 x 4s per day. Ceftazidime iv / h x 1g twice daily. Clindamyc iv/im 600 mg 3 times a day. Nizoral inside of 1t * 2 times a day. Topical: Ointment on the basis of PEG: 5% dioksidinovaya, dioksikol, nitatsid, 1% yodopironovaya. Solutions: 1% dioxidine ~ 28 ~ Funds in 2nd line Reserve funds Ciprofloxacin iv the 200 mg x 2 times a day (if necessary - the transition to a tablet form) Ofloxacin iv 400 mg x 2 times a day (if necessary - the transition to a tablet form) Ceftriaxone in / 1g x 2 times a day Cefepime w / 1 g x 2 times a day Cefpirom iv 1g x 2 times a day. Vancomycin iv x in 1 g 2 times a day Teicoplanin iv 400 mg 1 time a day Netilmicin iv/im 200 mg x 2 times a day Piperacillin / tazobactam iv 4.5 g 3 times a day Imipenem / cilastatin iv 1g x 2 times a day Meropenem iv 1g 3 times a day Fluconazole iv or inside a 200 mg x 2 times a day Mortality rates for invasive mycoses caused by, for example, fungi of the genus Candida, reaches 85%. Candidiasis, as an endogenous infection can occur clinic mushrooms affection of the brain, liver, spleen, kidneys, heart, lungs, and joints. For the treatment of a doctor's arsenal has only five effective antifungal drugs: amphotericin B, fluconazole, itraconazole, and liposomal amphotericin flyutsitozin B. The choice of antibiotic should be justified not only the data of bacteriological research, and clinical manifestations of the severity of intoxication, the severity of multiple organ failure, the vastness of the purulent process. With a limited suppurative process, the absence of clinical and laboratory signs of intoxication should be preferred oral dosage forms. In complicated wound infection involving internal organs antibiotic therapy should be based only on injectable forms. In these cases, all antibiotics should be administered only through catheter into the central vein or an artery in the presence of purulent process in the lower extremities. To enhance the antimicrobial activity in the treatment of generalized forms of wound infection or identification of the association of several microorganisms, when one antibiotic does not cover the spectrum of microorganisms, shows the assignment of combination antimicrobial therapy required taking into account their synergy. As a rule, appointed by the bactericidal (penicillins, cephalosporins, aminoglycosides, rifampin, polymyxins) and bactericidal or bacteriostatic (macrolides, tetracyclines, lincosamides) with bacteriostatic agents. Combined antibiotic therapy remains the drug of choice dioxidine. Dioksidin active infections caused by Gram-negative and gram-positive bacteria (including a group of opportunistic pathogens), as well as pathogenic anaerobes. For intravenous infusion using 0.5% solution diluted in 5% glucose solution or isotonic sodium chloride solution to a concentration of 0.3%. Daily dose (600 - 700 mg) was administered in two - three steps. In severe septic states in the introduction, each using 150 ml 0.3% solution dioksidina, 1% solution dioksidina used for washing wounds. The route of administration of antibiotic. When the local nature of purulent infection in order to relieve an acute suppurative process enough to use one antibiotic with mandatory local treatment of purulent wounds with ointment under the bandage on the basis of polyethylene glycol with a broad spectrum of antimicrobial activity, or modern iodophors, dioksidina that increase the antimicrobial effects of drugs designated for general antibiotic therapy. With extensive purulent foci of sepsis is necessary to increase doses of antibiotics to the maximum. It is advisable to use a combination of 2.3 drugs. Drugs should be administered through catheters installed in the central veins, which allows the treatment of generalized forms to create and maintain long-term at the right level of concentration of the antibiotic, not only in the lesion focus, but all over the patient. With the localization of a purulent focus on the lower extremities effectively intra-arterial injection of drugs into the lower epigastric artery infusion method using clock perfuzorov. Continuous intraarterial infusion allows you to create and maintain a sufficiently high concentration of drug in the tissue while leaving the concentration of antibiotics in the general blood stream at a lower level. This enhances the effectiveness of antibiotic therapy and reduces the possibility of a general toxic effects of antibiotics. Duration of antibiotic therapy. When the local suppurative process enough antibiotics for 3 - 5 days. Longer therapy is conducted in groups of patients with acute purulent diseases of soft tissues, with the generalization of the infectious process. The criterion necessary to continue therapy or drug withdrawal should be the data of bacteriological monitoring, as well as the dynamics of clinical indicators. The main criteria for discontinuation are the disappearance of pathogenic microorganisms from suppurative focus or reducing the number of bacteria in 1 g of tissue injury, a distinct positive dynamics of clinical and laboratory parameters of wound healing, normalization of temperature, improving the overall condition of the patient. Early withdrawal of antibiotic therapy to achieve a stable clinical effect may lead to a relapse or a prolonged course of the disease and significantly complicate further treatment. ~ 29 ~ complications of antibiotic therapy 1. Allergic reactions - a pathological condition caused by sensitization of the organism with antibiotics. Their character is varied: a) The reaction of allergic-type (shock, serum sickness); b) skin reactions; c) the effect of antibiotics organotropnoe by allergization. Anaphylaxis manifested loss of consciousness, a sharp drop in blood pressure, the disappearance of the pulse. Conducted in anaphylactic shock resuscitation. Sometimes there collaptoid state. Serum disease - often manifested in the form of true allergic reactions (urticaria), as one of the symptoms. In addition, these patients expressed the common symptoms: fever, swollen lymph nodes, splenomegaly, joint pain. Skin reactions: urticaria, erythematous, bullous rash. Angioneurotic angioneurotic edema and inflammatory-necrotic lesions (Arthus phenomenon) occur less frequently. II. The toxic effect of antibiotics is manifested in several forms: 1. The neurotoxic effects (effects on the CNS, polyneuritis, neuromuscular block). 2. Toxic effects on internal organs and blood system. 3. Teratogenic effects of antibiotics. III. Adverse reactions caused by the direct pharmacodynamic action of antibiotics: 1. Toxic shock 2. Dysbacterioses 3. Superinfection. For errors of antibiotics include: 1) widely used without evidence, and 2) the use of low or unjustifiably high doses without evidence, and 3) use of antibiotics without the sensitivity of the microflora, and 4) failure to comply with the rules of sound combination; 5) lack of knowledge of contraindications, and 6) use of antibiotics without prior trial on the body's sensitivity to a particular antibiotic. THE SPECIFIC ISSUE OF SURGICAL INFECTION. Surgical infection of soft tissue Surgical infections are the leading soft-tissue pathology in the primary structure of the uptake of surgical patients in the outpatient management, and in the hospital - post-operative nosocomial infections of soft tissues accounted for 40% of all nosocomial infections. However, the classification of infections in surgery not fully edited. Its division into purulent, putrid, anaerobic (clostridial and non-clostridial) and specific does not meet modern requirements (S.A. Shlyapnikov, 2003). It is therefore advisable to introduce students and young surgeons to the classification proposed by D. N. Ahzenholz in 1991, which is widely used by foreign experts. We are talking about levels cheryreh soft tissue surgical infections. Level I - the affection of the own skin. Level II - the affection of the subcutaneous tissue. Level III - damage to the superficial fascia. Level IV - the affection of the muscles and deep fascial structures. The affection of the skin Many of the special concept that refers to infection of the skin - impetigo, ecthyma, and others are discussed in the national medical literature in the course of dermatology. In this regard, we consider the following diseases at the I level, boil and erysipelas. ~ 30 ~ Furuncle (Fig. 19) - an acute purulent necrotic inflammation of the follicle and surrounding tissues. Called the golden bowl (Staphylococcus aureus), rarely white (Staphylococcus pyogenes albus) staphylococci. Contamination of the skin, micro predispose to disease. Significant role in the occurrence of boils and boils the development has weakened body defenses caused by debilitating chronic disease, vitamin deficiency, diabetes, etc. Boils do not develop on the skin, hairless (palms and palmar surface of fingers, soles). Most often they are observed in skin areas exposed to pollution (forearm, wrist rear) and friction (back of the neck, lower back, gluteal femoral region). Infection is introduced into the body through broken skin (cracks, scratches), and therefore of particular importance in the prevention of disease assumes compliance with hygiene standards at home and at work. The clinical picture. Around the hair is formed by a small pustule with a slight inflammatory infiltrate in the form of nodules. During this period the patient feels a slight itching and tingling. By the end of the 1-2 days produced inflammatory infiltrate, which acts conically above the skin. The skin over the infiltration of red and becomes painful when touched. At the top of the infiltrate has been a slight accumulation of pus with a black dot (necrosis) in the center. Later pustule dries and breaks often, and the 3-7th day of purulent infiltration and necrotic tissue is melted in the form of a rod with the remains of hair stand out from the pus. The resulting purulent wound is cleaned, filled with granulation tissue and healing. At the site of inflammation is a small whitish, somewhat sunken scar. Multiple lesions boils called furunculosis. The appearance of many boils in a limited area of the body is called the local furunculosis. Sometimes the occurrence of boils in the form of multiple eruptions continued with little remission for several years. This process is called chronic, recurrent furunculosis. Furuncle usually does not cause significant changes in the general condition of the patient, but in some locales ulcer patient's condition may be severe. Severe clinical course observed in boils face (upper lip, nasolabial fold, nose and suborbital region). Significant development of venous and lymphatic network on the face contributes to the rapid spread of infection. Progressive vein thrombophlebitis can move on to the venous sinuses anastomoses of the dura mater, which leads to their thrombosis, threatening severe complications - a purulent basal meningitis. Quickly there is swelling of the face, tight painful palpable veins, rapidly deteriorating general condition of the patient's body temperature reaches a high level (40 - 41 ° C), there are severe neck stiffness, impaired vision. Progressive venous thrombosis and sepsis with boils were often result from attempts to ~ 31 ~ squeeze out the contents of the boil, remove (cut) it while shaving, massage. The prognosis of these complications are very serious. Lethality varies, according to different authors, from 9 to 65%. Furuncle may be complicated by lymphangitis, regional lymphadenitis. Especially dangerous is progressing acute thrombophlebitis and sepsis. Acute thrombophlebitis develops in boils, which erythematous haemorrhagic form are located near the large saphenous vein, and sepsis is more common in boils, which are located in the facial area. Abscess may also develop the surrounding tissue. If such an abscess appears near the joint (articular abscess), the infection can pass to him and give rise to purulent arthritis. Forecast. In uncomplicated furunculosis prognosis is quite favorable. Boils and abrasions should be differentiated from gidradenitom, anthrax, pseudofurunculosis infants and some infectious granulomas (tuberculosis, actinomycosis, syphilis). Treatment. When boils and abrasions use local and general treatment. Local treatment: 1) careful toilet of skin inflammation around the hearth - 70% rubbing alcohol, 2% salicylic alcohol; 2) lubrication of 1-3% alcoholic solution of methylene blue, brilliant green, and others; 3) on the scalp and neck hairs around infiltrate carefully cut off; 4) early in the process has a positive effect sometimes boil tincture of iodine lubrication; 5) which revealed the presence and empty boil ointment applied to various antiseptics; 6) In the presence of necrotic mass necessary to create conditions that are aimed at accelerating a discharge of purulent-necrotic core. Used for this treatment ointment to soften the skin over the necrotic core. In the protracted process of applying nadsechenie skin in the area of the rod with a sharp scalpel, removing the necrotic core. It is recommended to provide peace of the affected extremity furuncles. It is strictly forbidden squeezing the contents boil and massage in the inflammatory focus. For pain relief apply dry heat (heating pad, solux), as well as UHF. With the localization of boils on body, neck and limbs must be applied labels, protecting the skin in the area of inflammation from mechanical impact. The indications for hospitalization is the localization process in the face of the risk of complications. gangrenous necrotizing form Necessary as soon as possible to begin vigorous treatment with antibiotics. If a patient with boils, abrasions or heat, it is prescribed strict bed rest and antibiotics in combination with sulfanilamides, detoxication therapy. Surgery is rarely used, only the development of suppurative complications (eg, cellulitis). In chronic furunculosis effective subcutaneous staphylococcal vaccine, immunization with staphylococcal toxoid y-globulin. ~ 32 ~ Erysipelas. Erysipelas inflammation is an infectious disease characterized by acute serous, rapidly spreading inflammation of the skin, at least - the mucous membrane in which the zone of inflammation sharply demarcated from the surrounding tissue unaltered. Classification form of erysipelas. • erythematosus. • erythematous-bullous. • erythematous-hemorrhagic. • haemorrhagic bullosa. • bullosa necrotic. • abscess. • gangrenosum. Erysipelas contagious and can lead to nosocomial diseases. More often localized erysipelas of the face, head and lower extremities. Very rarely it affects the mucous membranes of the lips, mouth, pharynx. Erysipelas is caused by different types of strep, L-forms of bacteria. In the development of the disease plays an important role local and general predisposition of the body, an allergic condition. Pathogenic streptococci from exogenous sources (usually) falls into the skin at microtraumas or other damage. When the endogenous source of streptococcus enters the skin lymphogenous or hematogenous route. Pathologic anatomy. The disease onset is characterized by the appearance of sharply hyperemic, clearly demarcated lesions in the form of plaques. There is serous inflammation localized in the reticular layer and along the lymphatic vessels of the subcutaneous tissue. There is a plethora of blood vessels and lymph vessels overflow lymph containing large amounts of streptococci. In the affected area marked desquamation and parakeratosis of the epidermis. Inflammatory exudate detach the epidermis, forming bubbles of various sizes that contain clear, yellowish fluid, which is typical for bullous form of erysipelas. In the exudate of bubbles may accumulate a large number of neutrophils and content becomes purulent character. In rare cases, the exudate becomes hemorrhagic in nature (hemorrhagic erysipelas). When suppuration of fluid in the subcutaneous tissue abscess develops, typical forms of phlegmonous erysipelas. In debilitated patients exudate and toxins streptococcus blood circulation, tissue trophism of the skin, which leads to extensive necrosis and the development of necrotic (gangrenous) faces. Pathogenesis. In the development of erysipelas note the following sequence: acute or latent infection, endo-or exogenous factor permitting, allergic reactions, skin disorder trophism. Primary erysipelas develops in contact with streptococci in the skin of the exo - or endogenous sources. Streptococcus introduced through scratches, wounds, scrapes, scratches, scrapes, diaper rash of the skin. Secondary erysipelas develops as a complication of local purulent process (furuncle, carbuncle, infected wound, etc.). Secondary erysipelas affects the skin, directly adjacent to the purulent focus and is subjected to infection. The clinical picture. The disease manifests marked general and local manifestations. Violations of the general state precede the development of local symptoms. There may be a prodromal period of malaise, weakness, headache. Then there are terrific chills, severe headache, nausea, vomiting, tachycardia, breathing quickens, the temperature quickly rises to 40 - 41 ° C. There is severe intoxication, which may be accompanied by delirium. Appetite disappears, there insomnia, constipation, decreased amount of urine, which defines the content of protein, erythrocytes, leukocytes, hyaline and granular cylinders. In the blood - moderate normochromic anemia, leukocytosis and neutrophilia pronounced, decrease in eosinophils. The liver and spleen in most patients is increasing. To form erythematous erysipelas characterized by local symptoms: swelling, burning pain, heat sensation in the affected area, hyperesthesia of the skin, the appearance of a bright red with sharp edges, serrated edges. As the outlines of the affected area is similar to a map. ~ 33 ~ In the bullous form as a result of detachment of the epidermis exudate formed of different size bubbles. The contents of the bubbles, which are contagious streptococcus, may facilitate the transport of faces by contact. Exudate is serous blisters, haemorrhagic and purulent (Fig. 20). Bullous disease of erysipelas usually lasts 1-2 weeks. In the phlegmonous erysipelas changes on the skin surface can be Just noticeable, but in the subcutaneous tissue is noted seropurulent soaking tissue accumulation of pus. The In Fig. 20. Erythematous-bullous form of general condition of the patient more difficult. erysipelas In the phlegmonous erysipelas inflammation of the inflammatory process begins with skin lesions. Symptoms of subcutaneous phlegmon and intramuscular fat are the same as symptoms of an ordinary phlegmon. In malnourished, debilitated and elderly patients, as well as the presence of hypovitaminosis and heavy neutron crystallographic disorders bullous form of erysipelas and abscess may become necrotic. Form of erysipelas (erythematous, bullous, abscess, etc.), correct to consider the phases of the process. Erythematous erysipelas may form under the influence of adequate treatment in this phase to end in recovery, and the weakness of the immune-forces or late begun and inferior treatment may develop the following phases of the disease (bullous, abscess, necrotic). Mug on the trunk is often wandering, migrating. When migrating inflammation may occur again in the previously affected areas. Erysipelas is a creeping, if it is gradually spreading over the surface of the skin. If the process consistently affects various parts of the body, the face is called migrating. Relapse of erysipelas leads to sclerosis of tissues, lymphatic disorder, and therefore there are swelling, sharply breaking form and function of the organ. Complications of erysipelas of the process: The spread of infection from the skin of the surrounding tissue. Metastasis of streptococcal infection, adherence of secondary infection and the development of severe toxemia. Purulent lesions joint capsules, tendon sheaths, joints, muscles in their tendinous part, the affection of the veins (thrombophlebitis). Infectious psychoses, etc. Differential diagnosis. Differentiate from erythema should face, dermatitis, phlegmon, lymphangites, pseudoerysipelas, cutaneous anthrax. When lymphangites marked red bands or reddening of the skin in a grid according to the location of lymph vessels. If you suspect a bullous erysipelas and gangrenous forms, especially when in contact with sick animals, to conduct a differential diagnosis of cutaneous anthrax, which is characterized by the presence of lesions in the center section of necrotic tissue with associated vesicles at the periphery, and extensive soft tissue edema (anthrax carbuncle) , an increase in regional lymph nodes. Treatment. In the erythematous form of erysipelas patients admitted to a hospital infection. Patients with other forms of erysipelas hospitalized in the surgical hospital. In the hospital provide immobilization of the affected limb. It is desirable to isolate the patient in a private room. Necessary to conduct a comprehensive therapy with sulfa drugs, antibiotics and ultraviolet radiation. Of antibiotics prescribed penicillin, semisynthetic penicillins. When ultraviolet light is used erythemic or sub erythemic dose. At first, usually determine an individual biodose , ie , the minimal dose of ultraviolet rays, which is obtained when a weak erythema reaction in the ~ 34 ~ skin region located symmetrically affected. After this affection, erythema or bullous erysipelas irradiated area: limbs - 4-5 biodoses, the person - 3 biodoses In the phlegmonous erysipelas irradiation should be performed with caution as it may lead to increased swelling and thrombosis of small vessels in the skin. When gangrenous erysipelas irradiation is contraindicated. Wet dressings and baths are contraindicated. In the erythematous form of erysipelas the affected area is treated with alcohol and iodine. In the bullous form of blisters after treatment with alcohol and reveal the bandage with chlorhexidine, cintomitsine emulsion, suspension or streptotsidis tetracycline ointment, etc. In the phlegmonous and gangrenous forms additionally produce an autopsy collection of pus, drainage, removal of necrotic tissue. Prophylaxis. Activities aimed at preventing disease and infection from a patient with erysipelas, are reduced to fighting with contact infection. The first group includes measures to prevent and timely processing of micro traumas, abrasions received in the workplace, at home, strict personal hygiene. Prevention of infection around the contact is determined by the strict isolation of patients and aseptic conditions in their care. The affection of the subcutaneous tissue The second level of destruction are anthrax, hydradenitis, cellulitis, abscess. Carbuncle - acute suppurative inflammation of multiple necrotic hair follicles and sebaceous glands in the transition of the inflammatory process in subcutaneous tissue, causing her death, which applies to the superficial fascia. Pathogens - Staphylococcus aureus infection or staphylostrepcoccusis , rarely streptococcus. Emerald, tends to be single. Its causes are the same and boil. It is more common in diabetic patients. Pathologic anatomy. In the thick skin and subcutaneous tissue inflammatory infiltrate formed large size, a few exciting hair follicles. Because of circulatory disorders form necrotic areas, merging in the future in a common focus. Around the necrotic area develops pus, necrotic tissue undergo partial melting and gradual rejection. Pus through multiple holes in the skin stands out on its surface. After sloughing wound granulation tissue and runs rough massive scar is formed. Necrotic decay and may be subject to the fascia covering the muscles in the area of inflammatory infiltrate relatively ¬. The clinical picture. Most often the carbuncle develops on the back of the neck, shoulder and in the interscapular region, lower back, buttocks, at least - on the limbs. Initially, there is little inflammatory infiltrate with superficial pustules, which are rapidly increasing. There is tension fabric, sharp pain on palpation, arching, tearing pain. The skin in the area of the infiltrate becomes purple hue, tense, swollen (Fig. 21).. Thinned epidermis over the fire breaks necrosis in several places, formed a few holes, of which stands a thick greenish-gray pus. In the future some holes merge, forming a large defect in the skin, through which flows a lot of pus and necrotic tissue are rejected. The body temperature rises to 40 ° C, there is severe toxicity (nausea and vomiting, appetite loss, severe headache, insomnia, possible delirium. Complications: lymphangitis, lymphadenitis, progressive thrombosis, sepsis, purulent meningitis. The differential diagnosis should be performed between conventional and anthrax carbuncle. In Fig. 21 Carbuncle back of the Treatment. The patient should be hospitalized in a surgical ward. At the beginning of carbuncle (stage inflammatory neck ~ 35 ~ infiltrate) used intramuscular injections of antibiotics and sulfa drugs into the longer-acting, UHF-therapy. Carbuncle on the surface imposes a dry bandage or aseptic bandage with cintomitsine, streptomitsine emulsion. General activities of the patient is prescribed rest (bed rest, immobilization of limbs, and carbuncle prohibit a person to talk to, give liquid food). Showing painkillers, drinking plenty of fluids. Dissection of the infiltrate, failure of conservative treatment for 2 - 3 days, an increase of intoxication are the indications for surgical intervention. The operation In Fig. 22. Carbuncle dissection and usually performed under general anesthesia. In the excision of necrotic tissue presence of carbuncle operation lies in its dissection and excision of necrotic tissue. (Fig. 22). Two mutually perpendicular section begins with healthy skin. Cross-cut cut through the skin and necrotic glubokole-containing tissue (adipose tissue, and sometimes fascia). The resulting patches with necrotic tissue separated from the fascia or muscle within healthy tissue. Then each of the flaps alternately seized with forceps and surgical scissors with pointed excised non-viable skin, subcutaneous fat. Wound copiously washed with 3% hydrogen peroxide and antiseptic solutions, drain its surface. In a wound swab is introduced with the hypertonic solution of sodium chloride, an antiseptic, a solution of proteolytic enzymes. Tampons are changed daily. When a person carbuncle appoint conservative treatment, using all of the funds, and under the inflammatory infiltrate and locally applied antibiotics UHF therapy. If anthrax is small, you can use it within the excision of healthy tissue, followed by drainage of the wound and applying primary suture. In the postoperative period were active aspiration and administration of proteolytic enzymes (better - terrilitina), antiseptics and antibiotics. Forecast. With timely treatment of carbuncle favorable prognosis, but malnourished, debilitated patients with severe diabetes, as well as the carbuncle shall not exclude the possibility of a bad outcome. Hydradenitis (Fig. 23) - an acute purulent inflammation of apocrine sweat glands. Called staphylococcus, golden chalice (Staphylococcus aureus). Located in the armpit, much less - in the inguinal and perianal areas, and women - in the nipple. Predisposing to the development of its causes dermatitis (eczema, diaper rash), excessive sweating, uncleanliness. Infection enters through the ducts of glands on the lymphatic system or through a small skin injury (bruises, scratches). In sweat glands occurs inflammatory infiltrate with subsequent purulent Fig.23 Hydradenitis fusion of the surrounding tissue. Suppurative process often takes on the character of subacute, often relapses. The clinical picture. In the depth of subcutaneous tissue appears dense painful knot. At first, he covered the skin intact, and then its surface becomes purplish-red, bumpy. When abscess formation infiltrate appears fluctuation, which is formed through a small hole is allocated creamy pus. Duration of infiltration - 10 -15 days. Hydradenitis differentiate from tuberculosis of axillary nodes, Hodgkin's disease and lymphosarcoma. Treatment. General treatment - antibiotic therapy, sulfonamides. With recurrent forms - specific immunotherapy (stafiloanatoksin, stafilovaccine , autovaccine) bracing means. ~ 36 ~ Local treatment - treatment of skin lesions in ethanol, 2% boron and 10% camphor spirit, dry heat, UHF-therapy. Surgical treatment. When suppuration inflammatory infiltrate produce autopsy an abscess incision along the skin folds. With recurrent, persistent current hydrodenitis when the inflammatory process involved in fatty subcutaneous tissue armpit, make excision of purulent foci, together with all the subcutaneous fat that area with the imposition of primary suture and drainage of purulent wounds. Displaying ultraviolet irradiation of the skin, UVIS. An abscess. Abscess is a limited collection of pus in the tissues and organs. Localization and size of abscesses are the most diverse. The form of the cavity is different - from simple to complex curved with multiple pockets and blind passages. The cause of the abscess is the penetration of germs into the tissues through abrasions, punctures, wounds, as well as therapeutic manipulations (injection, subcutaneous injection) produced without complying with the rules of asepsis. An abscess may develop abrasions, lymphadenitis, suppuration of the hematoma, with a total of purulent infection (metastatic abscesses). Metastatic abscesses are located away from the primary site of infection Feature of the abscess as a purulent process is limited the presence of pyogenic membrane - the inner wall of the abscess, lined with granulation tissue. Pyogenic membrane separates the necrotic process and produces exudate. Abscesses caused by staphylococci, streptococci, at least - Pseudomonas and E. coli, etc. By the nature of the flow abscess may be acute or chronic. If the abscess becomes chronic, a pyogenic membrane formed two layers: the inner, facing into the cavity, and composed of granulations, and the outer formed by mature connective tissue. In some diseases the pus can spread interstitial crevices and settle in places remote from the primary localization of the abscess. An example is the socalled cold abscesses (wandering abscess), characteristic of tuberculosis, which can be emptied through the fistulous passages. The clinical picture. With significant accumulation of pus is usually expressed in the general reaction: fever, weakness, loss of appetite, insomnia, changes in the blood, morning and evening temperature fluctuations. Over the abscess is noted swelling and redness of the skin. Only with deep-seated abscess, these symptoms In Fig. 24. Symptom fluctuation. are absent. An important feature of an abscess in the presence of other signs of acute inflammation is a symptom fluctuation, or fluctuation (Fig. 24). It is due to the presence of fluid (pus), enclosed in a cavity with elastic walls, which transmits the impulse in the form of waves from one wall in all directions. This symptom is absent when the wall is very thick, and a small abscess cavity and in depth. In this case it is necessary to carry out diagnostic puncture of abscess or ultrasound of soft tissue (Fig. 25) ~ 37 ~ Represents a significant threat to break the abscess into any cavity (joint, pleural cavity). In chronic abscess signs of acute inflammation may be almost entirely absent. In these cases, swelling, a small pain, symptom fluctuations and puncture data allow a diagnosis. For the diagnosis of abscesses is necessary to use ultrasound. Ultrasound imaging of abscess depends on the stage of its development. Formed an abscess has clear irregular contours, heterogeneous liquid structure with the presence of fine sediment that settles at rest on the walls of the abscess, or moves with a change in body position. It can be observed amplification of the posterior wall of Education. In Fig. 25. Ultrasound picture of soft tissue Abscess formed around most of the rim is abscess. visualized with various degrees of increased echogenicity, with an irregular inner contour (pyogenic capsule). Ultrasonic signs of an abscess formed appear 8-12 days after its formation. Sign of an abscess is hypoechoic unformed education, often irregularly shaped, with fairly uniform content, the lack of rim (capsule) increased echogenicity. Around education can be identified hypoechoic area of varying severity (zone of edema). Differential diagnosis. Necessary to differentiate normal from cold abscess, ie, migrating abscess tuberculous origin, characterized by the presence of the main focus of tuberculosis, slow development, lack of acute inflammation. Abscess should also be differentiated from a hematoma, aneurysm and vascular tumors. Treatment. The diagnosis of abscess is an indication for surgical intervention, whose goal regardless of the localization of the abscess is opening, emptying and draining the cavity. Puncture aspiration of abscess with pus and subsequent introduction into the cavity of the abscess antibiotics, enzyme preparations can be used only on strict indications, in some locales abscess. Operation - opening superficial abscess - is performed under local infiltration anesthesia of 0.25% or 0.5% solution of novocaine or short-term intravenous anesthesia. (Sombrevin, ketamine, etc.). For opening the abscess choose the shortest line access, taking into account the anatomical and topographical features of the body above the point of greatest fluctuation. Often reveal an abscess on the needle: the original puncture the abscess, followed by needle-dissected tissue. At the opening of an abscess on the possibility of coming to its lower pole, to create good conditions for drainage. In order to reduce exposure of surgical field isolate gauze area in the center of which is expected to open the abscess, and making a small hole in the wall of an abscess, the pus is removed electric pumps. Aspirated pus, the incision extends remaining pus and necrotic tissue is removed. If the abscess cavity is extensive, her finger examined, dividing the bridge, removing tissue sequesters. Abscess cavity was washed with an antiseptic solution (Fig. 26). Abscess cavity drained by one or more rubber or In Fig. 26. Abscess of the left tibia. Washing the plastic tube and injected into her gauze sponges wound with antiseptics after opening the soaked in a solution of proteolytic enzymes, abscess puncture needle ~ 38 ~ antiseptics and antibiotics. When emptying failure in the main incision is made counteropening. In chronic abscess excised with its capsule within healthy tissue, sutured the wound and drain for active aspiration to prevent recurrence of infection. General treatment includes antibiotics, taking into account the sensitivity of the microflora, the use of specific treatment (staphylococcal toxoid immunization, the use of specific y-globulin). Cellulitis (abscess) - an acute purulent inflammation of the subcutaneous fat and cellular spaces (subcutaneous). The agents of cellulitis are usually staphylococci and streptococci, which penetrate into the fiber through the damaged skin, mucous membranes or hematogenous route. Phlegmon is a distinct disease, but may be a complication of various suppurative processes (carbuncle, abscess, etc.). The inflammatory exudate fat spreads, moving from one fascial sheath to another through the holes to neurovascular bundles. Pushing back the cloth, squeezing and destroying the vessels, pus leads to necrosis of tissue. When phlegmon distinguish two phases of inflammation - serous and purulent infiltration of melting. By the nature of the exudate distinguish purulent, purulent, hemorrhagic, and putrefactive forms of cellulitis. Depending on the location of isolated epi-and subfascial (intermuscular) forms of diffuse purulent inflammation of the tissue. In certain locales abscess is a special name. Perinephric tissue inflammation called paranefritom, perienteric - paracolitis, rectal - paraproctitis. The clinical picture. The clinical picture of cellulitis characterized by the rapid emergence and spread of painful swelling, redness poured over it, high temperature (40 ° C and above), pain, dysfunction of the affected body part. Swelling is a dense infiltration, which then softens. The disease often begins abruptly, with chills, headache, general malaise, accompanied by severe intoxication, increase in body temperature to 40 ° C. There is a high leukocytosis and neutrophilia pronounced. Subcutaneous abscess, developing primary, can lead to several complications (lymphadenitis, lymphangitis, erysipelas, thrombosis, sepsis, etc.). In the propagation of cellulitis in the surrounding tissue can occur secondary septic arthritis, and other tendovaginitis purulent lesions. Subcutaneous abscess may develop secondarily in diseases such as osteomyelitis, suppurative arthritis, suppurative pleurisy. Subcutaneous abscess person may be complicated by progressive thrombophlebitis of the veins of face and purulent meningitis. Treatment of patients spend in hospital. In the stage of serous infiltration of cellulitis acceptable conservative treatment. Assign bed rest, antibiotics, create peace. Locally around phlegmon used UHF- ~ 39 ~ therapy. In the delimitation process and the formation of ulcers (limited cellulitis) are conducting an autopsy and drainage of cellulitis. With progressive phlegmon postponement of surgery is not allowed. Under general anesthesia produce operation. Phlegmon reveal one or several parallel slits. The direction of the cuts is determined by the localization of cellulitis: the extremities of their conduct on limb, in the gluteal areas - along the lower gluteal folds on the abdomen - in the course of the muscles of the chest - in the course of the pectoralis major muscle fibers on the lateral surface of the chest - a hike of edges on the back - along the spine. The wounds were washed with antiseptic, drain drainage pipes. In specialist hospitals can apply active debridement, which consists in excision of all nonviable tissue, evacuation of pus from cellulitis, draining several drainage tubes and the imposition of a primary suture. After a drainage tube in the postoperative period produces an active aspiration. Putrid infection. Usually putrid abscess combined with anaerobic staphylococcal infection. More often is caused by Proteus vulgaris, Escherichia coli. predisposing factors 1. Traumatic wounds with a lot of crushed, devitalized tissue, bite, gunshot wounds. 2. Urinary phlegmon in fractures of the pelvis. 3. Phlegmon of the anterior abdominal wall after injury to the colon (fecal cellulitis), putrid peritonitis. Clinical manifestations. According to clinical manifestations of infection are often reminiscent of putrid gas gangrene, but differs from it on several grounds. 1. The general condition. Picture of intoxication, high body temperature, restlessness, delirium, dry tongue. 2. Local manifestations. Inflammatory changes, flushing wounds, fever, necrosis of wound edges, pain in the wound. In the context of discovering the healthy blood supply muscles. 3. The character of discharge. Limited accumulation of gas in the fatty tissue of the wound. Putrid or fetid purulent fusion of tissues, only a limited area of the wound. On the radiograph is determined by a significant accumulation of gas in the wound Treatment. In the putrid infection, as in the anaerobic treatment should be started immediately, be complex and involve primarily the radical excision of nonviable tissue, eliminating pockets, streaks, followed by adequate draining and prolonged washing with an antiseptic solution. The principles of antimicrobial therapy, as well as correction of metabolic and circulatory disorders do not differ from those used in gas gangrene. Forecast. The favorable outcome of the disease is possible only in a timely initiated therapy. Surgical infections brush (panaritiums and phlegmon) Classification. I. Purulent diseases of the fingers (panaritiums). 1. Skin felon. 2. Subcutaneous felon. 3. Tendinous whitlow (thecal abscess). 4. Articular whitlow. 5. Bone felon. 6. Osteo-articular felon. 7. Paronychia. 8. Subungual felon. 9. Pandaktilit. 10. Furuncle (carbuncle) rear toes. Superficial forms of felon - cutaneous, subcutaneous, paronychia, hyponychial. Deep forms of felon - bone (acute and chronic), tendon, bone and joint, pandaktilit. II. Purulent diseases of the brush 1. Thenar abscess intra-musculature. 2. Intra-musculature of hypo-thenar abscess. 3. Commissural abscess (helotic abscess). 4. Median palmar space abscess (over-and under-tendinous above and subgaleal). 5. The cross (U-shaped) abscess. 6. Subcutaneous abscess back of the hand. 7. Subgaleal abscess back of the hand. 8. Furuncle (carbuncle) back of the hand. All acute purulent diseases of fingers called felon, paronychia except when the Suppurative process is located above the nail plate at its base. ~ 40 ~ In order to select a rational therapy appropriate to allocate stage process: initial (sero-infiltrative) and purulent (pus-necrotic). The reasons are various felon finger injuries: cuts, punctures, bites, burrs, abrasions through which penetrates pyogenic microflora. Occurrence of acute purulent processes in the fingers and hands most often caused by Staphylococcus aureus, which dominates in 69-90% of cases, at least - in a monoculture, often - in associations. For the bite of infected wounds as one of the causes of whitlow and phlegmon, especially characteristic of anaerobic microflora. The clinical picture. The predominant symptom is pain - from gnawing at ways to pulsating sinus and abscess formation in unbearable. In most cases, patients reported fever and deterioration of general condition. Pretty soon edema of the affected phalanx or just your finger. The intensity of the flare depends on the depth of purulent process, and its absence in no way does not indicate the absence of purulent process. Impaired function of the finger is almost always observed. Point palpation bellied probe reveals the zone of maximum pain, lesions typical of a joint or tendon. Skin felon. The most common cause is a felon mikrotrauma manufacturing, consumer injury. In skin exudate felon is under the epidermis and detach it in a bubble, the content of which is serous, purulent or hemorrhagic in nature (Fig. 30). There have been moderate pain. Sometimes the disease is accompanied by significant increases in body temperature, severe regional lymphadenitis and lymphangitis. In Fig. 30. skin felon Subcutaneous felon. This disease belongs to the most common type of suppurative inflammation of the brush. Subcutaneous panaritiums pains are gradually increasing, jerking, pulsating character. Pain patients are deprived of rest and sleep. On examination, the finger of tension fabric, sometimes flattening interphalangeal flexion furrow. Flushing of the skin expressed mild. In Fig. 31. Subcutaneous felon. With a significant swelling of the a - subcutaneous felon; phalanges is determined by the pallor b - in the form of subcutaneous whitlow "cufflinks" of the skin, which arose due to compression of vascular interstitial fluid. Subcutaneous panaritiums pus tends to spread in depth, since the connective bridge, going perpendicular to the thumb, limit the spread of the periphery, are natural barriers, channels, guide the transition of infection to tendons, joints and bone phalanx (Fig. 31). Paronychia. When the superficial paronychia occurs painful swelling around the nail shaft, hyperemia of the surrounding tissues, the overhang of the affected nail roll around on the nail plate. ~ 41 ~ In some cases the pus penetrates deep paronychia under the nail plate, left it. In this purulent exudate appears through the detached edge of the nail. "Saped" pus-edge nail plate loses contact with the nail bed. There is a nail peeling all over, ie, a felon hyponychial (Fig. 32). In Fig. 32. a) felon b) hyponychial felon Subungual felon. Inflammatory purulent exudate accumulates under the nail plate, detaches from the last nail bed and a few lifts it. On palpation marked fluctuation nail plate. Commit it to the box disappears, but remains a strong attachment to the proximal nail in the matrix. Swelling and redness of the skin with subungual felon is not expressed. The main symptom is a throbbing, arching pain in the ungual phalanx. Complete "sequestration," or removal of the nail plate surgically create the necessary prerequisites to recovery. Articular panaritium. The disease occurs after injury to the interphalangeal or metacarpophalangeal finger domains with their dorsal surface, where the joints are covered with a thin layer of soft tissue. Infection of wound channels can easily penetrate into the joint gap (Fig. 33). Inflamed joint becomes spindle-shaped, dorsal interphalangeal furrows are smoothed. Flexor-extensor movements a finger leads to a sharp increase in pain in In Fig.33. Articular panaritium the affected joint. With involvement in the inflammatory process ligament, cartilage and bone apparatus of the finger there is abnormal mobility, a sense of crepitations, "laxity" of the articular surfaces. Radiographically at 12-14 day determined joint space narrowing. Bone felon. Bone felon developing in the transition of the pathological process of soft tissue finger to the bone, ie, this process is secondary. In general, developing bone felon from running or non-radical cured subcutaneous whitlow (Fig. 34). Pains are dull, constant. From the wound through the fistula scant purulent discharge, sometimes with small bone sequestration. Phalanx clavate thickened. Function of the brush is considerably reduced. In Fig. 34. Bone felon (sequestration of the diaphysis of the middle phalanx). Be aware that the X-ray only after 10-14 days can be found destruction of bone tissue that is not a ground for postponing the operation. Surgical treatment is indicated in severe clinical picture of the felon, the patient complained of persistent pain or reported on a sleepless night because of pain in the finger. ~ 42 ~ Tendinous panaritium(thecal abscess). Subcutaneous whitlow is sometimes the cause tendovaginitis. The infection spreads to the tendon sheath and the flexor tendon of fingers (Fig. 35). Deterioration of general condition, appearance jerking, throbbing pain around the finger, even with the swelling of the tissues In Fig. 35 Tendon felon. Accumulation interphalangeal smoothed the furrows - the symptoms of of pus in the tendon sheath tendon felon. Finger becomes hot dogs and is in a state of light bending. Extension finger leads to a sharp increase in pain while bending significantly reduces its severity. This symptom is one of the main tendon in panaritiums. Pandaktilit - it - suppurative inflammation of tissues of the finger. Pandaktilit - usually the result of improper treatment of purulent process or running a finger (Fig. 36). Pandaktilit accompanied by severe intoxication (headache, fever), regional lymphangitis, and axillary lymphadenitis cubital. In the blood, expressed as changes characteristic of acute suppurative inflammation. The clinical picture consists of a set of pandaktilita all purulent lesions thumb The disease develops gradually. The reason it is a virulent infection, incorporating finger as a result of In Fig.36 Pandaktilit tissue injury. You may experience pandaktilita and simple forms of felon. When pandaktilite pain gradually intensified and become an intense, painful, arching nature, swollen finger is blue-purple. The inflammatory process is developing according to the type of wet or dry necrosis. Of fistulas or postoperative wounds scant secretions. Granulation gray, lifeless. Forecast. When the function hand pandaktilite much suffering. Usually develop contracture finger. Often, especially when pandaktilite II - V finger, to prevent the generalization of infection, and rapid elimination of the purulent process in the failure of other therapies operation of choice is complete amputation thumb. Phlegmon of the brush are the name, depending on the localization of infection (see classification). The clinic is manifested by edema, hyperemia and tissue soreness in the affected area cells space. Function suffers from purulent foci adjacent to the fingers. The intensity of pain during passive movements in them to a large extent depends on the involvement in the process of tendon sheaths. Practically all the brush phlegmon develops swelling of the tissues back surface. General health is suffering, it is possible fever, the development limfangoitis of body temperature can rise to 40 0C. The principles of treatment. The primary method of treatment - surgery. Treatment of inflammatory diseases of the fingers and wrist involves several steps, neglecting any of them inevitably complicates the course of the inflammatory process. Before the operation, the brush should be washed several times with running water and soap and, if necessary, shaved. The most common surgery performed under anesthesia wires outside the focus of inflammation 1-2% solution of novocaine, or 1.5% sodium trimekaina, including the localization process in the nail or middle phalanx of a finger - on-Lukashevich Oberst. In the propagation process proximal to - carry out the blockade of the nerves in the lower third of the forearm or anesthesia on Usoltsev. In the space phlegmon Pirogov - Paron regional anesthesia is advisable to make the top third of the forearm or in the armpit. With known contraindications to local anesthesia operation carried out under general anesthesia. Incision, while ensuring optimal choice of the direction of an adequate volume of transactions should be spared as "workers" of the hand, respectively, the scheme Metzgeg J.T. (1955). Scalpel should cut only the skin, and all further manipulations in the tissues is carried out by their "moving apart" under the control eyes. ~ 43 ~ The next step is a careful necrectomy operations, where abscess should focus on the type of excised primary surgical treatment. Necrectomy for bone and joint structures involves removing only the sequestered sites. Immobilization of the thumb in a functionally advantageous position in the postoperative period is mandatory regardless of the form of the disease. The duration of immobilization determine the terms of relief of acute inflammation. Early development of the active movements of the fingers and hands (after removal of drains and sutures) contributes to a full recovery ¬ NIJ hand function. Treatment of certain forms of felon. The incision is carried out with paronychia on the back surface, parallel to the edges of the nail bed towards the base of a finger phalanx with exposed roots nail. Hyponychial reveal felon from the same incision and remove the nail plate, after dissecting it into two halves to the ground. Remove necrotic tissue, and further treatment is carried out with a water-soluble ointment on the basis of. Ointment is placed on the tissue flap, formed after the cut. Subcutaneous whitlow terminal phalanx of the oval reveal or semi-oval section, conducted at the lateral and anterior surface of the terminal phalanx. If the suppurative process is not in the terminal phalanx, produce lateral incisions with preservation of the skin in the joint. Surgery for bone felon involves removing the affected area of bone within the healthy tissue (removal of produce sharp spoon). If the disease is fairly long and has formed fistula, the inflammation in the skin and subcutaneous tissue, usually not pronounced. In this situation, carry out a radical necrosequestrectomy, remove the abnormal granulation in the soft tissues and the wound closed by primary suture with the imposition of drainage and flushing of the system. Bone tissue is gently scrape acute bone spoon. In the case of sequestration of the phalanx is removed only sequesters freely behind keeping the main body of the bone. Surgical intervention for tendon panaritiums determined by the state adjacent to the tendon sheath subcutaneous tissue. In the intact tissue (in the case of tenosynovitis after injection directly into the vagina) limit the operational manual dissection of the distal tendon sheath (on the middle phalanx) and proximal (in the projection of the corresponding head of the metacarpal bone) departments. After the evacuation of fluid and vaginal lavage with an antiseptic solution to the cavity to drain the entire length of perforated with microirrigator whose ends we derive through the slits, and the skin sutures. When the subcutaneous tissue is also involved in pyo-destructive process, perform longitudinal incision on the lateral surface of the finger with the palm arched extension in the projection of the "blind sac" tendon sheath. Dermal-subcutaneous flap separate from the vagina, which tends to be partially or completely necrotic, be sure to retain the palmar neurovascular bundle and perform a thorough necrectomy subcutaneous tissue excised sections of nonviable necrotic tendon sheath and tendon fibers. Completely excised tendon only with explicit its necrosis, when it presented a structureless mass. When the articular or osteoarticular panaritiums usually perform Z-shaped incision on the dorsum of the finger in the projection of the corresponding joint. Arthrotomy is carried out audit of the joint cavity and remove the purulent exudate. In the absence of lesions in bone destruction reorganize the joint cavity with an antiseptic solution and a perforated drainage with microirrigator (Figure 37). In identifying bone destruction scrape the affected area of periosteum and bone of acute bone spoon, and drain the joint cavity. An extremely important point is further decompression of the joint, otherwise perhaps the progression of degradation. Decompression reduces joint intraarticular pressure is achieved diastasis between the In Fig. 37. Drainage at the articular joint ends, which contributes to inflammation and panaritiums. cupping prevents the formation of intra-articular adhesions. The imposition of compression-distraction ~ 44 ~ device or traction metalloplaster design using a modified needle Kirchner is possible only when there is no inflammation in the soft tissues of articulated phalanges. Often when a finger believe pandaktilite preservation hopeless and amputated his or affected phalanx. However, with proper surgical treatment may preserve the finger. Even the flexor-extensor lost motion, the finger remains a very important function of the confrontation and capture, without which greatly reduced the practical activity of man. Perform incision on the lateral surface of the finger with an arched extension to the palmar surface of the brush head in the projection of the corresponding metacarpal bone. Palmar skin and subcutaneous flap separate of the flexor tendons with preservation of neurovascular bundles in the same way separate rear flap. Both flaps are deploying, which provides good access to all structures of the finger. Under conditions of acute inflammation of the wound with gauze strips filled with the ointment on the basis of water-soluble and is left open. Later, during the dressings, if necessary, perform the landmark event necrectomy. Complete surgical drainage and guide the imposition of the wash system and primary sutures only with full confidence in adequately performed necrectomy. As the inflammation subsided and wound cleansing skin defects can be closed by secondary sutures. Рис. In 38.Fig.Дренирование 38. Drainage of флегмоны тенара и cellulitis thenar and гипотенара hypothenar Treatment phlegmon brush At various locations on the hand of a purulent focus, there are some on-line access, which should be the most short and gentle. It should be noted that the implementation of large longitudinal cuts is unacceptable. Creating access is possible by modifying the incision on the type of S-shaped, arched or broken, mindful of the fact that the scar tissue contracts in length. Phlegmon of thenar reveal arcuate incision parallel to the fold of skin thenar and outwards away from her with a cut on contraperturnym back of the hand in the first interdigital area of the gap. The incision in phlegmon of hypothenar spend on the inner edge elevation with hypothenar muscles counteropening on back of the hand on the outer edge of V metacarpal bone (Fig. 38). For opening phlegmon median palmar space is advisable to make the cut on the distal palm crease of skin from IV to II interdigital gap with its further continuation in the skin fold of thenar (fig. 39). In Fig. 39. The incisions used for opening the phlegmon median palmar space. ~ 45 ~ Drainage ways in phlegmon of the median palmar space are presented in Figure 40. In Fig. 40. Drainage of phlegmon in the median palmar space. a - subgaleal (over tendinous) abscess b-ongaleal abscess, c- under the tendinous Phlegmon back of the hand of the arcuate sections operate performed taking into account the lines of Langer. For the opening of the U-shaped cellulitis perform lateral cuts on the middle phalanx of the thumb and V main phalanx of finger I, of which reveal the corresponding tendon sheath. Lateral longitudinal incisions on the forearm reveal space Pirogov - Paron (Fig. 41). In Fig. 41. Flow-flushing drainage at the U-shaped brush with phlegmon breakthrough in space Pirogov - Paron. a - the cut, b-synovial drainage sheaths of fingers I and V and the space Pirogov - Paron. Upon completion of the operation should be preferred drainage and leaching systems with primary suture, which reduces the duration of the postoperative period and early rehabilitation of patients. ~ 46 ~ Diabetes mellitus and purulent infection. During the surgical diseases, developing or occurring with diabetes mellitus, is one of the important issues of modern surgery. Background to a large extent due to the fact that the incidence of diabetes progressively increases and reaches 2-3%, while in older age groups increased to 5-9%. Accordingly, increases the number of surgical patients with diabetes mellitus. Surgery for acute purulent diseases in diabetic patients ranged from 6 to 25% of the total number of surgical operations. Suppurative processes (abscess, abscess, furuncle, carbuncle) develops in 10-25% of patients with diabetes. Mortality in diabetic patients when combined with its purulent surgical diseases reaches 20% of cases. Surgical infection and diabetes, runs at the same time, different number of features. On the one hand, any, even minor, purulent focus is a violation of all metabolic processes, leading to insulin deficiency, progression of diabetes and its decompensation. On the other hand, metabolic disorders, slowing regeneration and repair of tissues complicate and worsen during the inflammatory process, contribute to its spread and generalization. Every third patient was a diabetic coma triggered by various infectious toxic diseases. The emergence of infectious disease depends not only on the amount and properties of the pathogen, but also on the initial state of the microorganism, the endocrine glands, and physiological characteristics associated diseases and other factors. It is known that disturbances of carbohydrate, protein, fat metabolism, changes in electrolyte and acid-base balance water exchange, the suppression of regenerative - reparative ability of the organism - the inevitable companions of diabetes. They are the backdrop for the adverse flow of purulent-necrotic processes. Diabetic Foot The term "diabetic foot" syndrome indicate the anatomical and functional changes of the foot in various combinations, associated with diabetic neuropathy, micro-and macroangiopathy, osteoarthropathy, against which there are severe purulent-necrotic lesions. According to the World Health Organization, worldwide there are over 120 million patients with diabetes mellitus (DM). Experts predict by 2010 the number of patients will increase to 239.4 million. Changes in the vascular, nervous and skeletal systems in diabetes, the most pronounced in the peripheral regions of the lower limbs, frequently contribute to the development of necrotic processes in the foot. The main factors contributing to the affection of the lower extremities, are peripheral neuropathy, and atherosclerotic changes in arteries of the lower extremities. Purulent infection of the lower extremities is a leading cause of hospitalization in the surgical separation of patients with diabetes mellitus. Various purulent and purulent necrotic lesions feet (phlegmon, gangrene of fingers and feet, ulcers, osteomyelitis, etc.) have been reported in 64.8% of patients with diabetes mellitus (Mokhov E.M, et al., 2005). Classification of diabetic foot At the present time have identified a number of classifications of diabetic foot syndrome: etiological and pathogenetic on the principle of clinical and morphological principle of clinical and diagnostic principle and combined classification. A.P. Kalinin, D.S.Rafibekov et al. (2000) on the etiological and pathogenetic principle there are three main types of diabetic foot: Type I- diabetic foot with the predominant development of diabetic neuropathy: a) complicated and b) uncomplicated. Type II - diabetic foot with a primary ischemic syndrome due to severe micro-and macroangiopathy: ~ 47 ~ a) complicated and b) uncomplicated. Type III - diabetic foot with associated symptoms of neuropathy and arterial hypoxemia at the same time: a) complicated and b) uncomplicated. Wagner F. classifies the lesion stop diabetes, depending on the depth of tissue destruction: Classification of diabetic ulcers on feet (Wagner F., 1981): 0-th stage - skin intact, can be bone deformation. At this stage the group is at high risk (dry skin, flat feet, deformation). Stage 1 - superficial, noninfected ulcers. Stage 2 - infected ulcer penetrates through all layers of the skin and it is located on the bottom of the tendon, bone and joint; Stage 3 - a deep ulcer that penetrates to the muscles, with a massive bacterial contamination, the development of the abscess and the possible accession of osteomyelitis; Stage 4- gangrene of the foot or a single finger (local gangrene); Stage 5 - spread gangrene, requiring a "large" amputations. 0, 1, 2, 3 stages - neuropathic, and 4, 5 stages - neuro-ischemic. Malum perforans on stage (Arlt Bernhard., 2005) Degree 1. Skin necrosis Degree 2. Ulcer without the involvement of bones and joints Degree 3. Ulcer involving bone and joint Degree 4. The spread of infection from Malum perforans (lack of clear boundaries). M.I. Ahunbaev, A.P. Kalinin, D.S. Rafibekov (1997) proposed clinical diagnostic classification of lesions of the lower extremities in diabetes mellitus: I. Diabetic hyperkeratosis of the lower extremities. II. Diabetic neuropathy of the lower extremities. III. Diabetic osteoarthropathy of the lower extremities. IV. Diabetic angiopathy of lower extremities. V. Diabetic ulcers: 1) finger, and 2) feet, and 3) leg. VI. Diabetic abscess: 1) finger, and 2) feet, and 3) leg, and 4) femur. VII. Diabetic phlegmon 1) the fingers, and 2) feet, and 3) leg, and 4) femur. VIII. Dry diabetic gangrene: 1) finger, and 2) feet, and 3) leg; 4) the lower extremity. IX. Diabetic gangrene moist: 1) finger, and 2) feet, and 3) leg; 4) the lower extremity. On clinical and morphological principle B.M. Newspapers and A.P. Kalinin (1991) identify six major clinical variants of necrotic lesions of the foot in diabetes: 1. Specific damage to the skin and nails of the foot in diabetes. 2. Local gangrenous changes in the foot: a) gangrene of the fingers; b) the local gangrene of the skin on the foot. 3. Gangrene in combination with advanced infection. a) progressive atherosclerotic gangrene b) local gangrene of the foot with a good blood supply. 4. Ulcers: a) ulcer on the plantar surface of the foot; b) ulcers on the toes. 5. Nonspecific suppurative-necrotic processes cells spaces of the foot in diabetes: a) the central plantar space abscess; b) the lateral plantar phlegmon space; c) the medial plantar phlegmon space; ~ 48 ~ g) dorsal foot abscess. 6. Anaerobic surgical infection of the foot in diabetes: a) clostridial gangrene; b) non-clostridial gangrene. The pathogenesis of diabetic angiopathy of lower extremities The pathogenesis of lesions of the lower extremities in diabetes mellitus includes typical changes: microangiopathy, macroangiopathy, polyneuropathy, osteoarthropathy caused by disturbances in the immune system, hormonal status, metabolic changes (disorders of protein, fat and carbohydrate metabolism), genetic shifts, hemorheological disorders. The major pathogenetic processes that lead to the development of diabetic angiopathy of lower extremities include: 1 - a violation of glucose metabolism in nervous tissue, and 2 - Damage to microvessels feeding the nerves of 3 - glycation of neural structures, 4 accelerated aging. Nervous tissue contains the enzymes aldose reductase and polioldegidrogenazis that provide polyol path of glucose utilization. A characteristic of diabetes excessive activation of this pathway is accompanied by accumulation of sorbitol in the nerve tissue and other polyols, which leads to swelling of the nerve structures and a lack of mioinozitolis - an intermediate product of glucose utilization, which is a necessary intracellular substance. Disturbed metabolism of phospholipids, decreases the activity of K-Na-ATPase, the sodium content increases with a simultaneous decrease in the concentration of calcium and cAMP. The result is a destruction of nerve cells, demyelination and axonal degeneration of nerves, degeneration of Schwann cells, perineural and endosclerosis neural vessels. Microangiopathy is characterized by lesions only small vascular network. In the basal membrane of capillaries accumulated PAS-positive substances, including mucopolysaccharides, glycoproteins, and lipids. Membrane thickening of capillaries in 2-5, sometimes 8-10 times, it gradually split into layers, between which the collagen fibers. These changes of the membrane and the endothelium violate election filtration of biological fluids and exchange diffusion, which makes it difficult or impossible to remove metabolic products, providing nutrients and oxygen. Hypoxia causes destruction of the tissues, contribute to the development of necrotic gangrenous process. Macrovascular atherosclerotic lesions of arteries shows medium and small-caliber arterioles. Most often these changes are detected in the popliteal, tibial arteries and the arteries of the foot. Lipid peroxidation, one of the mechanisms of atherogenesis, plays an important role in the development of diabetic foot. Lipid peroxides have toxicity and membranotropic violate the permeability of cell membranes and lysosomal contribute to their degradation, release of lysosomal enzymes and autolysis of cells. In the damaged epithelium, blood vessels deposited protein-lipid complexes, and peroxides of polyunsaturated fatty acids may be the reason for the accelerated development of thrombogenesis and hyperagulatisis syndrome. Somatic and autonomic neuropathy contribute to the development of foot ulcer. Sensory neuropathy in diabetic patients manifested reduced pain, tactile, temperature, vibration and proprioceptive sensitivity. In the foot, deprived of an adequate response to mechanical, thermal or chemical injury, often develop necrotic process. Osteoarthropathy in diabetes are caused by neuropathy and calcium therapy . In patients with diabetes decreases the activity of cellular and humoral immunity, increases the viscosity of blood with a tendency to thrombosis, and thrombosis with obliteration of the vessels of the foot and a violation of collateral circulation, slows down the process of tissue regeneration and increase the healing time of wounds. ~ 49 ~ Diabetic Clinic of the lower extremities. Diabetic neuropathy Neuropathy can lead to the following types of lesions stop: 1. Neyropaticheskoi ulcer, 2. Osteoarthropathy (with the subsequent development of Charcot joints) 3. Neuropathic edema. Neuropathic ulcers - a sore spot in high blood pressure or mechanical irritation occurring against a background of peripheral neuropathy, manifested distal, symmetric sensory, autonomic neuropathic disorders. By manifestations of diabetic neuropathy include paresthesias, disturbances of various kinds of sensitivity. For diabetic neuropathy is characterized by changes in pain and tactile sensitivity of the type "ragged socks," with "holes" indicate areas with relatively fewer violations. Pain in the feet during the night, disappearing when walking indicate deep frustration and vibration sensitivity. Violation of motor innervation is characterized by atrophy of the muscles of the foot. Interphalangeal joints quickly fixed in a bent position (prominent claw toes). Damage to the autonomic innervation of the foot is characterized by impaired thermoregulation its "auto sympathectomy 'and degeneration of the sweat glands. Foot Skin becomes thin, dry and thin-skinned. As a result, often formed blisters and cracks, which are the portal of entry. Ulcers on the foot are the typical manifestations of neuropathy in diabetic patients (Fig. 50). Pain syndrome is not expressed. Typical location of the ulcers are areas protruding metatarsal heads, medial surface of the I toe, heel, cushions 'clawed' toes. Sizes are small ulcers. Their diameter is 1-2 cm, but they are deep down they are the tendon, or bone joint area. Neuropathic edema as a manifestation of diabetic In Fig. .50. Neuropathic form of diabetic neuropathy is associated with the violation of foot (plantar surface of the trophic ulcer vasomotor functions, such as arteriovenous shunting. of the foot). At the same foot and lower leg cold to the touch, painless. On palpation of tissue swelling in the area of dense and remain under pressure "pit." Patients with neuropathy do not feel the spatial arrangement of "anesthetized" stop and therefore often receive mechanical, chemical or thermal injury, not noting that. Injuries to the skin may be in contact with foreign objects footwear, wearing footwear improperly selected, the processing of nails, corns. Repetitive mechanical stress at first leads to an inflammatory autolysis and subepidermal hematoma, which opened to the skin surface, forming an ulcer. Diabetic osteoarthropathy Diabetic osteoarthropathy - a combined lesion of bone and articular organs, ligaments and tendons due to diabetic micro-and macroangiopathy neuropathy. Changes in the bones and joints of the foot in diabetes manifested by three main processes: 1) lesions of bones and joints with diabetic neuropathy; 2) Infectious arthropathies, and 3) bone and articular changes caused by endocrine and metabolic disorders. ~ 50 ~ Diabetic neuro-osteoarthropathy - a syndromecomplex of aseptic destruction of bones and joints of the foot in diabetes (Charcot foot). Diabetic osteoarthropathy is characterized by destructive and lytic changes in the bones and joints mainly on foot. The most pronounced changes in bony structures and ligaments of the foot are called joint or Charcot foot. It is this form at the clinic is called "diabetic foot". Clinical symptoms of undifferentiated osteoarthropathy in the early stages of (Arlt Bernhard, 2005): 1. Swelling. 2. The absence of pain. 3. Redness. 4. An increase in temperature. 5. Good pulsation according to sonography. 6. Increased scintigraphic activity Charcot foot is characterized for: increasing the transverse size of the foot, transverse and longitudinal arches, an increase of strain and ankle joint, the coracoid and hammer toes deformity, acting head of metatarsal bones of the foot. Stage of diabetic osteoarthropathy (Charcot foot). Stage 1 - the presence of edema of the foot, hyperthermia and congestion; Stage 2 - the formation of foot deformities, radiographically determined bone changes in the form of osteoporosis, bone destruction, fragmentation of bone structures; Stage 3 - severe foot deformity, pathological fractures and dislocations; Stage 4 - the formation of ulcers, infection with which it is possible the rapid development of gangrene. S. Forgacs (1987) distinguishes three stages in the bones of radiographic abnormalities in diabetes mellitus: Stage I (initial manifestation) - limited osteoporosis, subluxation, cortical bone defect; Stage II (progression) - osteolysis, fragmentation, fracture and periosteal reaction; Stage III (healing) - filling in the cortical defect, spikes, ankylosis, arthrosis. Changes in bones and joints in diabetes identified in the metatarsal and tarsal bones in the ankle joints and the joints of the big toe. Patients significantly reduced footprint, which is why the most prominent areas of the foot have high blood pressure and are the source for the formation of deep ulcers and necrosis. Develop a variety of bending and deformation, resulting in a broken joint mobility and gait changes. In cases of infectious complications in diabetic arthropathy appearance of ulcers, sores and fistulas, in which leave the bone sequester. Diabetic angiopathy In patients with diabetes affects the blood vessels - Diabetic angiopathy. It is divided into microangiopathy and macroangiopathy. Microangiopathy may occur before clinical signs of diabetes. The frequency of these lesions in patients with diabetes is 97% or more. In the genesis of angiopathy major role for lipid metabolism disorders, and systemic arterial hypertension. Atherosclerosis in diabetes is different early-onset, rapid development, more severe. Atherosclerosis has a distal direction and character multisegmentarny affection. The process develops in about 10 years earlier compared with a similar group of people without diabetes. A characteristic feature of diabetes, arteriosclerosis is Menkeberga - calcification of tunica media of arteries of different diameters in the absence of lesions inside and outside of the envelope. B.M.Gazetov and A.P. Kalinin (1991) distinguish three types of angiopathies: 1. Microangiopathy is one manifestation of neuropathy and is characterized by lesions of the arterioles and capillaries; 2. Macroangiopathy - atherosclerosis of large arteries and less leg femoral and iliac arteries, where blood flow is greatly disturbed the feet; ~ 51 ~ 3. The combination of microangiopathy and atherosclerosis of arteries of lower extremities. Clinical manifestations of diabetic micro - or macroangiopathy are: fatigue when walking, unusual sensitivity to cold (coldness, paresthesias, and sensations as burning, creeping, "chills", numbness of various parts of the foot), leg pain during walking or rest, intermittent claudication. Complaints of the patient on intermittent claudication is a characteristic feature of macroangiopathy. One manifestation of ischemic gangrene of the foot is finger and development of necrosis (Fig. 51). When microangiopathy may occur a paradoxical phenomenon: the presence of deep venous disorders, up to the necrotizing process, while maintaining ripple a.dorsalis pedis et a. tibialis posterior and the absence of any significant pain. In Fig. 51. Ischemic form of diabetic foot (disarticulation I finger the development of secondary necrosis in the surgical wound). Features of necrotic lesions in diabetes The clinical picture of purulent-necrotic complications of diabetic angiopathy is characterized by atypical course. Wound healing of any type of diabetes dramatically impaired. Feature of the disease is a significant backlog of local changes of the general symptoms. The spread of purulent-necrotic process goes on tendon sheath, ligament, aponeurosis at a relatively well-preserved skin. The disease can be protracted relapsing character with the extension phase of exudation, and destruction, and an extremely slow onset phase of proliferation. The features of wound healing in diabetes are: 1) violation of the chemotaxis of phagocytes and functional decline in their activity, and 2) slowing down of collagen synthesis, and 3) lethargy granulations and delay their appearance in the wound, and 4) the timing delay of epithelialization. In diabetes, immunologic changes abruptly reaction. Damage to phagocytosis against violations of humoral immunity leading to increased susceptibility to various infections. In 90% of patients with portal of entry are localized in the ungual phalanx or the interdigital spaces. Frequently observed in skin lesions haircut nails, minor mechanical damage. Paronychia develops first, then the infectious process extends to the foot. Other sources of pyo-necrotic lesions of the foot are the wounds and diabetic ulcers of fingers, feet and legs with the development of phlegmon of the central, medial and lateral cells spaces of the foot. Skin lesions and paronychia of foot - the most common cause local gangrene in the foot. Gangrene of one or more fingers may be dry, with a clear line of demarcation, and moist. Typical of diabetes is the development of gangrene in the foot with a well-developed blood supply. Due to the fact that such an option arises because of gangrene, severe neuropathy, pain is virtually absent, sick late to seek medical care, despite the fact that the necrotic process spread over a considerable part of the foot. The infection is often putrid character, dominated by the processes of necrosis, with a scanty accumulation of pus. Patients with diabetes are more likely than in the main population, there are different clinical variants of anaerobic infections. Non-clostridial gas gangrene occurs almost exclusively in diabetes mellitus. The ~ 52 ~ anaerobic process is accompanied by severe diabetes necrolysis with blistering with serous-hemorrhagic content. Treatment Current combined treatment of purulent-necrotic lesions of the lower limbs is in the recovery of diabetes, reducing vascular trophic disorders, intoxication, withdrawal and inflammation sparing surgery. The first determining factor in successful treatment is adequate correction of blood glucose. Are optimal normoglycemia or blood glucose levels within 7.2 m mol / l fasting and no more than 10 m mol / l in 1.5 2 hours after meals. Principles of complex surgical treatment of neuropathic diabetic foot infected form: • Compensation for diabetes • Unloading of the affected limb • Targeted Antibiotic • Anticoagulation, antiplatelet therapy • Treatment of Neuropathy • Surgical treatment of purulent focus • Local medical treatment injuries • Additional methods of treatment of a wound • The plastic closure of the wound defect The main condition for ulcer healing is the elimination of high pressure on this area, which is achieved by imposing a special plaster cast for 3 - 4 weeks or wearing orthopedic shoes. The use of antibiotics is shown in the presence of necrotic lesions, given the nature of the pathogen and its sensitivity, the severity of the process and speed healing. Antibiotic therapy based on the type of sequential therapy. When antibiotic therapy until the sensitivity of microflora to Assign broad-spectrum antibiotics and antibacterials (metrogil) taking into account the possible presence in the focus of anaerobic microorganisms. The duration of parenteral antibiotic therapy in patients with deep necrosis or gangrene in the background of an adequate surgical treatment should be an average of 4 weeks, and in combination with enteral administration through - up to 10 weeks with high doses of the drug. Drugs of choice in antibiotic clindamycin are, amoksiklaf, imipinem, ciprofloxacin. In addition to the intramuscular, intravenous antibiotics should use the techniques of regional infusion - intra-arterial, intraosseous route of administration. At the Department of General Surgery VPO "Mordovia State University of Mordovia" was first developed and applied the method of intraosseous injection of drugs in the synthesis of Ph.D. thesis Rygina E.A (2000). This method combines the advantages of not only regional but also tissue therapy, which significantly increases the therapeutic efficacy of drugs administered. Of great importance in ensuring the regional blood flow is given antiplatelet, angioprotectors, antihypoxants and other means. For drugs with antiplatelet effects, include aspirin, chimes, trental, tiklid. Anticoagulant effect is heparin, flogilin. Rheological properties improve blood reopolyglukine, reoglyuman, polidez. To vasoactive drugs include nicotinic acid, derivatives of pentoxifylline (trental, agapurin) Sermion. For the treatment of patients with ischemic diabetic foot used intravenous prostaglandin E1 (vazaprostan). The drug is injected at a dose of 60 mg / day to 250 ml of saline solution for 10-14 days. Pathogenetically justified is the use of drugs with antioxidant effect: mexidol, dimefosfon, aevit, α-tocopherol, retinol acetate. In the pathogenetic therapy of neuropathy used drugs of alpha lipoic acid (tiotaktsid). Tiotaktsid 600 T assigned 1 per day for 3 weeks. The drug is introduced into the I / O, slow, pre-diluted in 200 ml 0.9% saline solution of sodium chloride. Then designate maintenance oral therapy 600 mg tiotaktsidous 1 per day. Used vitamins containing benfotiamine (milgama). Sugar Plum "milgama-100" (Germany) 100 mg and 100 mg of benfotiamine pyridoxine hydrochloride. The drug injection "milgama - N» 2 ml administered ~ 53 ~ daily i/v. In the future do for 2-3 injections per week, then go to the reception "milgamap -100» 1 tablet daily. To normalize the exchange of all kinds, neurovascular regulation of blood coagulation properties, suppressing overproduction of hormones important to use countresular angioprotectors, anabolic hormones (nerabol, retabolil, silabolin), cholesterol-lowering drugs (miskleron, diosporin, tribusponin, lipostabil), preparations of nicotinic acid (teonikol, Nikoshpan , komplamin), vitamins (askorutin, B1 and B6). Treatment of diabetic neuro-osteoarthropathy include: 1. immobilization for 5-6 months 2. antibiotic therapy; 3. use of orthopedic footwear, 4. surgical techniques. Principles of complex neuro-surgical treatment of ischemic diabetic foot form: • Compensation for diabetes • Unloading of the affected limb • Targeted Antibiotic • Anticoagulation, antiplatelet therapy • Correction of ischemia • Surgical treatment of purulent focus • Local medical treatment injuries • Additional methods of treatment of a wound • Symptomatic treatment The basis of surgical treatment of purulent-necrotic complications of diabetic foot put savings principle (Fig. 52). Diabetic Foot Type A Type B Type C (combination of A and B) Successful therapy of arterial circulatory disorders Treatment of diabetic foot by Bernhard Arlt Type A - diabetic foot with a primary arterial blood supply to the violation, Type B diabetic foot with associated symptoms of neuropathy and arterial hypoxemia By Arlt Bernhard only in patients with diabetic foot type B successful local (local) surgery. In patients with diabetic foot type C primarily needed therapy aimed at restoring blood flow to meet local surgical treatment. ~ 54 ~ Treatment of neuropathic ulcers carried a medical podiatrists. Treatment includes special handling for ulcers - removal edges, necrotic tissue, areas of hyperkeratosis, scabs, interfering marginal epithelization. During the intervention is carried out by inoculation pus breeding ground for verification of the causative agent and determine its sensitivity to antibiotics. If there is a painless superficial ulcers and no signs of cellulite are shown dressing in an outpatient setting, oral antibiotics. Surgical treatment should be gentle and wear, possibly delayed in nature, aimed at conducting local operations that preserve the limb or its supporting function. Elective surgery in patients with diabetes should be carried out in the morning and possibly early in the week, which makes it possible to provide better monitoring of patients in the postoperative period. Local surgery (necrectomy, amputation finger) is used in the absence of edema, a normal skin condition and stored in the femoral artery pulsation, good efficacy of antibiotic therapy, a good blood supply of the foot (according to the Doppler ultrasound). Surgical treatment of purulent necrotic phlegmon cellulitis is in the showdown, the evacuation of pus as possible necrectomy, drainage. For the opening of the foot plantar phlegmon used depending on the location of the abscess medially or laterally-foot-foot sections of Delorme. Initially, perform an audit of necrotic suppurative focus, identify and reveal pus formed streaks and pockets of the fracture of bones and joints. Then excised obviously nonviable tissue and tissue imbibirovannye pus, remove all the tendons are located in the purulent focus. Leaving only viable tissue. The spread of necrotic suppurative focus without clear boundaries can not achieve radical surgical treatment during the same operation, so is suitable necrectomy, landmark necrectomy that allow distinguish clearly necrosis. The ongoing necrotic process dramatically worsens diabetes, leading to decompensation of carbohydrate metabolism, ketoacidosis, and in some cases and hyperglycemic coma. Should not rush to conduct an amputation. All available means and methods directed to transfer wet gangrene dry. Indications for surgical interventions in the necrotic lesions of the foot, depending on the urgency of the operation are presented in Table 3. Local treatment of wounds is the daily dressings, excision of necrotic tissue. Before the appearance of granulation after treatment of a wound antiseptic bandage with ointment in a water-soluble base. Active removal of toxins from the body is achieved by using hemosorption, plasmaeritrosorbtis, plasmapheresis, and ultraviolet laser irradiation of blood. Bactericidal effect of sodium hypochlorite solutions possess and ozonized solutions that can be used intravenously as well as locally in the necrotic focus. In the treatment using hyperbaric oxygen therapy. The indications for amputation of toes are: - Dry or moist gangrene or phalanges of fingers - Dry necrosis of the surfaces of the fingers, - Suppurative destructive osteoarthropathy and osteomyelitis of bones, - The development of gangrene of large ulcers. Performed amputation wedge 2-3-4 toes, amputation 5.1 angulate fingertips. In all cases, the resection is performed distal metatarsal head. In patients with coronary and neuro-ischemic CP after failure of medical therapy, or progression of ischemic preservation, the presence of stenotic atherosclerosis (by angiography) were recommended reconstructive surgery thrombusarterectum Y, angioplasty, distal bypass surgery. Diabetes is not a contraindication to bypass surgery, stents and distal tibial and peroneal to the vessels needed to restore blood flow to the diabetic foot. If through the arterial reconstruction was able to improve blood circulation, on the ischemic foot amputation may be performed by the finger. Absolute contraindications for reconstructive surgery for chronic lower limb ischemia are: chronic heart failure III A of Art., Acute myocardial infarction, acute cerebrovascular accident; total calcification of the aorta and vessels of the lower limbs, absence of blood flow in the distal vein. In diabetic gangrene of the foot for limb salvage using amputation of the foot. ~ 55 ~ Trans metatarsal amputation of the foot is shown: - In patients with good blood supply of the foot against the background of neuropathy, and infection with a lesion of the distal part of the foot; - In patients with ischemic diabetic foot shape with limited gangrene of fingers or most of the gangrene of the distal part of the foot. In the treatment of diabetic gangrene is necessary to achieve distinguishing necrotic foci, and the transition to dry wet gangrene. Indications for high amputation after prolonged conservative treatment, not brought the desired results are: - Extensive ischemic necrosis of the anterior and middle part of the foot and heel; - Wet gangrene of the foot with the spread of proximal extremities, with progressive intoxication; - Long-existing extensive necrosis of the plantar surface in combination with severe destructive forms of osteomyelitis of the foot bones; - Critical limb ischemia with severe pain that can not be a conservative therapy, surgical vascular impossibility of correction. - Suppurative destructive arthritis of the foot. With extensive necrotic lesions of the most favorable position in terms of amputation rehabilitation are amputated at the lower third of the leg. Amputation of leg at the level of choice and is indicated for widespread gangrene or in connection with the loss of the support function (most of plantar necrosis of the skin, including the heel area, extensive non-healing sores of the foot). Amputation at the thigh level shows at popular gangrene, the progression of necrotic suppurative process in the lower leg, which developed as a result of severe ischemia, sepsis. Operation of choice is a skinfascial-muscular method of amputation. Acute specific surgical infection Tetanus Tetanus - a specific acute infectious disease caused by spore-forming anaerobic bacillus B. tetani. Secreted exotoxin consists of a stick and tetanospazmina tetanogemolizina. Tetanospazmin, acting on the nervous system, causes the development of tonic and clonic convulsions of striated muscle, and destroys red blood cells tetanogemolizin. Manifestations of the disease are determined by the action of exotoxin in the body. B. tetani is found as a saprophyte in the intestines of many domestic animals (horse, cow, etc.), as well as humans. Excreted in the feces, the pathogen enters the soil. If any accident contaminated wound is an immediate risk of the disease tetanus. The highest incidence observed during the wars, as gunshot wounds are almost always contaminated. The incubation period of tetanus ranges from 4 to 14 days, but the disease can develop at a later date. The shorter the incubation period, the heavier the clinical course of tetanus and higher mortality. Incubation period is determined by: 1) type (rods, spores), the dose and virulence of microorganisms, 2) the localization, nature and extent of tissue destruction; 3) the state of immune-body forces. The man is very sensitive to tetanus toxin and has almost no natural immunity to it. Classification I. Depending on where the introduction of the pathogen distinguish The following types of tetanus: the wound, after infection , post-burn, post-operative, after frostbite, after electric shock. Allocate as neonatal tetanus and post-natal tetanus, which develops when the penetration of the pathogen through the lining of the uterus or birth canal. Tetanus can also occur after a miscarriage. II. The prevalence of isolated: ~ 56 ~ a) The general (common) Tetanus: I) primary common form; 2) the descending form, 3) rising form in which seizures begin with a plot wound up and distributed to remote areas with the development of lockjaw. b) local (limited) Tetanus: 1) limbs, 2) head (tetanus cephalicus), developed under the influence of toxin on the cranial nerves. With the affection of the facial nerve paresis or convulsions observed facial muscles, with the affection of IX-XI pairs of nerves - a violation of taste. In severe cases, seizures occur pharyngeal muscle spasm of the glottis - this form resembles the picture of rage and, therefore, called tetanus hydrophobicus; 3) the body (including viscera tetanus), 4) a combination of limited locations (arm, torso, etc.). Local tetanus limited lesion of different muscles in the wound, the disease more easily than with general tetanus. It is believed that local tetanus is caused by the uneven distribution of tetanotoksine with maximum concentration and the effect on the corresponding segments of the spinal cord, which explains the local symptoms. Local tetanus is the first phase of general tetanus, but often fails to recognize. III. On the clinical course are four forms of tetanus: 1) acute, characterized by the rapid flow, 2) chronic, and 3) a pronounced tetanus, and 4) worn form. Distinguished: the shape of a very severe, moderate, light. The more severe form of the disease, the shorter the incubation period. The clinical picture. In the prodromal period are determined by the initial, Just noticeable symptoms of tetanus - headache, fatigue, irritability, weakness, profuse sweating, pain, stress and a twitching of the muscles around the wound area. The most characteristic symptom - the emergence of tonic and clonic spasms of skeletal muscles. The disease begins acutely. Appears fatigue of masticatory muscles during eating, developed tonic spasms - lockjaw, which makes opening the mouth. These seizures are sometimes replaced by clonic. In some patients, there is also muscle cramps in the wound area. Facial muscles spasmodically contract and give the face a typical expression, known as "sardonic smile" and characterized the expression of scornful laughter. With the development of the disease quickly spread to the convulsions muscles of the neck, back, abdomen, extremities and accompanied by excruciating pain in the muscles. Tonic and clonic convulsions occur at least, even a slight stimulation (touch, light, etc.). Spastic contraction of the muscles of back, neck and extremities accompanied by a sharp reextent trunk and extremities. This situation is called opisthotonos (Fig. 53). Seizures lasted several minutes. Severe twitching of muscles can cause ruptures of muscles or broken bones. At the beginning of the disease increases the temperature of the patient's body. Sometimes the temperature reaches 42 ° C or more, there is increased heart rate to 120 beats per minute, heart sounds - loud and clear. Perspiration. During the general convulsions, death can occur as a result of asphyxiation caused by a In Fig. 53. Opisthotonos of tetanus. strong reduction of the intercostal muscles, larynx, and diaphragm. Death from tetanus may occur in 1 - 2 days (fulminant form), the acute form - for 4 - 5 days. Subacute form of tetanus is characterized by slow attack symptoms, moderate their expression, in this form the majority of patients recover within 20 - 30 days. In chronic tetanus muscle tension develops slowly, clonic convulsions is not marked, temperature is normal or low-grade: the disease lasts several weeks or months and ends in recovery the patient. ~ 57 ~ Complications of tetanus can be divided into early, associated with tetanus and wound complications, and late. Of early complications occur pneumonia. Pneumonias in tetanus – atelektatitis , aspiration, hypostatic. Asphyxia, together with pneumonia is a major cause of death due to tetanus. During the tetanus may develop anaerobic or purulent-septic wound complications, which are revealed to the development of tetanus or during treatment. Diagnosis of tetanus. Early symptoms of tetanus are: 1) dragging pain in the wound, muscle twitching this area, 2) excessive sweating, not corresponding to the height of rise of temperature, 3) sometimes back pain. Bacteriological study has practical implications for early diagnosis. In the early stages of the disease and obscure, obliterated the clinical picture of tetanus must be differentiated from the following diseases: strychnine poisoning, encephalitis, meningitis, basal skull fracture, tetany, rage, hysteria, myositis, etc. Prophylaxis. All preventive measures are divided into two groups. 1.Specific, active-passive antitoxic prevention, aimed at enhancing immunity to tetanus toxin. It is the active immunization of antitetanus toxoid (1 ml, after 3 weeks. 1.5 ml and after 3 weeks. Another 1.5 ml of toxoid under the skin) and a mandatory intramuscular 1500-3000 ME tetanus toxoid after every accidental injury. Preferred prophylactic agents during emergency specific prevention of tetanus is presented in Appendix 1. Previously intradermally into the anterior surface of the lower third of the forearm is introduced from a specially enclosed vial 0.1 ml of serum diluted 1:100. If after 20 minutes of induration at the injection site serum does not exceed 0.9 cm, redness around the small, injected subcutaneously with 0.1 ml of undiluted serum and in 50 - 70 minutes with no response - the entire dose. With the introduction of a positive reaction test doses of serum should be repeated only with extensive injuries. Administered subcutaneously at intervals of 20 min - 0.5, 2.5, 5 ml of serum diluted 1:100, and in the absence of reaction - the rest of the dose. If there is no sample vials of serum, the serum is usually introduced subcutaneously at a dose of 0.1 ml and 30 min - 0.2 ml, and in the absence of reaction in 1 - 1 1 / 2 hours - the rest of the dose. 2.Nonspecific prevention consists of measures aimed at removing bacteria from the wound and the wound in the creation of conditions unfavorable to their development. These activities are reduced to an early and complete debridement, which mechanically release it from hitting ¬ Shih bacteria and dead tissue, blood clots, which are a breeding ground for microorganisms. Emergency prophylaxis of tetanus includes primary debridement with removal of foreign bodies and necrotic tissue and specific prevention of tetanus. Indications for emergency specific prevention of tetanus. a) Injury to the violation of the integrity of the skin and mucous membranes. b) frostbite and burns II-IV degree. c) unsafe abortion. d) Delivery outside of hospitals. e) Gangrene or necrosis of any type, abscesses. f) Transactions related to the opening of the lumen of the gastrointestinal tract. g) The animal bites. h) Penetrating wounds of the abdomen. The main objectives of a comprehensive treatment of tetanus: 1. Reduced income and neutralization again coming from a wound in the body of tetanus toxin. 2. Decrease and total cessation of tonic and clonic convulsions. 3. Improve the overall normalization of cardiac activity, relief of pulmonary ventilation. 4. Prevention and control of secondary complications (pneumonia, sepsis, etc.). ~ 58 ~ Treatment of tetanus is carried out in complex: 1. Produce a broad revision, wound treatment under general anesthesia. 2. Tetanus toxoid is administered by the method of A. Bezredko, intramuscularly, immediately after the diagnosis of disease. The dose for adults is 100000 - 150000 ME; for newborns 10000 - 20000 ME, for the older children - 20000 - 80000 ME. Before the introduction of the serum is heated to 36-37 ° C. The introduction of serum repeated within 2 - 3 days in a row, reducing the dose every time 50 000 ME. These doses provide adequate protective levels (0,1 ME in 1 ml of serum from patients) needed to neutralize free circulating toxin in a long time. Overall course dose of serum is usually 200 000 - 350000 ME. Serum recommend intramuscular injection, and only in extreme cases, along with intramuscular use on the first day by slow intravenous administration of 50 000 ME tetanus serum diluted with isotonic sodium chloride solution 5 times. 3. Used drugs, neuroplegic therapies and muscle relaxants to reduce or even stop seizures. a) Of the anticonvulsants with mild to moderate severity of seizures by intravenous diazepam is used in combination with hexenal, thiopental sodium and chlorpromazine-(50 mg every 6 hours). In severe persistent cramps and muscle relaxants are used. b) From neuroplegic therapies increasingly using chlorpromazine. The drug is used in 2.5% solution of 4 ml intramuscular injection of 4-5 times per day. Applied also neuroplegic mixture: 1 - 2 ml of 2.5% solution of chlorpromazine, 3 ml of 1% solution of diphenhydramine on 5 - 6 times a day. c) Of the curariform resources used hondelfin, diplatsin. In severe tetanus, involvement of respiratory muscle cramps and threatened asphyxia injected depolarizing muscle relaxants anti action (tubocurarine) the transfer of the patient on mechanical ventilation (ALV). 4. In order to improve cardiac used kordiamin, korglikon. To improve breathing produce oxygen inhalation. 5. For the prevention of wound infection, pneumonia prescribe antibiotics. Tetanus patient must be in an isolated, dark, remote from the noise chamber. Observation and care is carried out individually. As a result of suffering a tetanus immunity is not created. Rabies Rabies - an acute viral illness that occurs after exposure to damaged skin saliva of infected animals. Characterized by development of a kind of fatal encephalitis. The etiology and pathogenesis. The causative agent belongs to the rhabdovirus. Pathogenic for many warm-blooded animals that are beginning to shed virus in saliva 7 - 8 days prior to the onset of clinical symptoms. Following the introduction of the virus through broken skin on the nerve trunks reaches the brain, causing in him swelling, hemorrhage, degeneration of nerve cells. The virus enters also in the salivary glands and saliva released into the environment. Symptoms within. The incubation period lasts from 7 days to one year (usually 1 - 3 months). Allocate the stage warning, excitement and paralysis. Stage lasts for precursors 1 - 3 days. Under the precursors the patient has discomfort in the area of the bite or spit (burning, pulling sensation, itching), although the wound healed already, unexplained anxiety, depression, and insomnia. Excitation stage is characterized by hydrophobia (rabies), aerophobia, subfebrile temperature, increased salivation, the emergence of hallucinations. I sometimes see rampage attacks from aggressive actions. After 2 - 3 days excitement turns to paralysis of the muscles of limbs, tongue, or face. After the onset of clinical symptoms of patients unable to save. Death occurs in 12 - 20 hours after onset of paralysis. Treatment. Rabies is help from the local treatment of wounds, scratches and abrasions, the introduction of rabies vaccine , or simultaneous use of rabies immune globulin and rabies vaccine . ~ 59 ~ Rabies The culture concentrated purified inactivated dry is a vaccine strain of rabies virus Vnukovo-32. Local treatment of injuries Local treatment of wounds, scratches and abrasions are extremely important and should be performed immediately or as soon as possible after the bite or injury: wound surface copiously washed with water and soap (or detergent), and the wound was treated with 70% alcohol or 5% tincture of iodine. If there are indications for the use of rabies immunoglobulin, it is used just before suturing. If possible, avoid suturing the wound. Suturing is shown only in the following cases: - With extensive wounds - more suggestive of skin sutures after preliminary treatment of the wound; - For cosmetic reasons (the imposition of skin sutures to the wound a person); - Suturing of bleeding vessels in order to stop external bleeding. After the local treatment of injuries immediately begin treatment and preventive immunization. Therapeutic and prophylactic immunization Indications: contact and bites people mad, suspicious for rabies or unknown animals. Contraindications. Not available. The scheme of therapeutic and preventive immunization. Detailed scheme of therapeutic and prophylactic immunization and notes to the scheme presented in Appendix 2. Rabies immune globulin (RIG) to designate as soon as possible after contact with the disposable, suspicious for rabies or unknown animals (see Figure therapeutic and prophylactic immunization in Appendix 2), but no later than 3 days after exposure. RIG does not apply after the administration of rabies vaccine. The dose of rabies immune globulin (RIG). Heterologous (horse) rabies immunoglobulin is assigned to a dose of 40 ME per 1 kg body weight of adult or child. Homologous (human) rabies immunoglobulin is assigned to a dose of 20 ME per 1 kg of body weight. Example: The victim's body weight 60 kg, the activity of the immunoglobulin (indicated on the labels and capsules pack), for example, 200 ME per 1 ml. In order to determine the required dose for administration of immunoglobulin to the weight of the victim (60 kg) multiplied by 40 ME and divide that number by the activity of the drug (200 ME), that is: 60 × 40 = 12 ml 200 How can the majority of the calculated dose should be infiltrated with AIG in the tissue around the wound and deep wounds. If the anatomical location of injury (finger-tips, etc.) can not enter the entire dose in the tissue around the AIG wounds, the rest of AIG injected intramuscularly (muscle buttocks, upper thigh, shoulder). Localization of immunoglobulin should be different from the place of vaccination. Anaerobic surgical infection (gas gangrene) Anaerobic infection - is one form of wound infection, in which the decisive role played by various types of anaerobic microorganisms. Anaerobic bacteria are the basis of the normal human microflora. For an infection to an additional condition: trauma, dysbiosis, the operation - that is, the circumstances under which the representatives of normal microflora of the fall in unusual circumstances and are beginning to show its pathogenic properties. If you violate the integrity of organs and various anaerobic microbes injuries are almost always present. Therefore, any surgery or trauma may be complicated by an anaerobic infection. Anaerobic non-clostridial infection, especially self-infection is caused by saprophytic (conditionally pathogenic microflora). Clostridial (spore) microbes should be seen as an invasion from outside. In the wound healing process, usually involving anaerobes and aerobes in different proportions. Anaerobic wound infection (gas gangrene). This type of wound infections among the most formidable, life-threatening complications of wounds of any origin. The most commonly causes gas gangrene ~ 60 ~ Clostridium perfringens. Second place belongs to chactote Cl. novyi (Cl. Oedematiens), Cl. septicum, Cl. histolyticum. Predisposing factors. 1. Extensive crushing of tissues. Gunshot wounds and comminuted with extensive injuries, contaminated land and scraps of clothing. 2. Local or general circulatory disorders: tight bandage, bandaging, or thrombosis, severe blood loss. 3. Primary surgical treatment of heavily contaminated wounds, performed within 6 hours after injury. 4. Inadequately performed initial debridement. 5. The reduced reactivity of the organism, fatigue, exhaustion, prolonged starvation, hypothermia, treatment with glucocorticoids. Classification. 1. On pathoanatomical classification are the following forms of anaerobic gangrene: emphysematous, edematous (toxic), mixed, necrotic (putrefactive), abscess and tissue melted. Emphysematous (classical) form is characterized by predominance tissue gas over the swelling. The primary agent of her most is Clostridium perfringens. Edema (toxic) form differs by a sharp toxicity, prevalence of edema on gas production. Pathogen Cl. Oedematiens. The mixed form is reminiscent of toxic gas-and anaerobes. Necrotizing form characterized by the disintegration of tissues. Most often it is the causative agent of Cl. Sporogenes. Abscess form. Emphysema and edema are less pronounced. Occurs in combination with suppuration. Tissue melted form, occurs only hard and vigorously. 2. Clinical classification identified two forms: acute and lightning. 3. By anatomical classification there are three most common forms of anaerobic infections. 1. The primary lesion of the muscles (myositis clostridial class-classical form). 2. The primary lesion of subcutaneous fat and connective tissue (clostridial cellulitis or edema-toxic form). 3. The mixed form, where the pathological process involving all types of soft tissue. The clinical picture. The incubation period of 3 - 6 hours to 1 - 2 days. Lightning forms can lead to death within the first two days. The main complaint: the increasingly intolerable pressing pain in the affected area. If the patient received narcotic analgesics, pain may be absent. Condition of the affected patient progressively deteriorated, as manifested severe weakness, pale skin, sweating, feeling of anxiety. The pulse rate increases rapidly. Blood pressure drops, the body temperature remains constant or increases sometimes, confused consciousness, delirium. At external examination, attention is drawn to the growing soft tissue swelling, pale skin, often with no other expressed classical signs of inflammation. On palpation of the subcutaneous tissue revealed a dense infiltrate. Characterized by a gradual increase in swelling of extremities (symptom strings pressing or dressing). In diagnosis wounds sharply painful injury, with no redness, and suppuration, typical of other infectious processes. On the surface of the wound is gray powder, discharge from the wound yellow-brown color with an unpleasant sweet, putrid odor. On palpation of the wound is determined by a crackling sound. Marked decrease in hematocrit, an increase of bilirubin due to hemolysis of red blood cells, leukocytosis with a relative and absolute lymphopenia. In the smear of the wound determined by large Gram-positive rods. Classic manifestation of anaerobic infections are cellulitis, fasciitis, myositis. Differential diagnosis of wound infection aerogenous forms presented in (Table 18). ~ 61 ~ T A B L E 18 Differential diagnosis of wound infection forms aerogenous Symptoms Clostridial cellulitis Clostridial necrotizing myositis Streptococcal myositis Wet gangrene of vascular origin Incubation period Beginning Pain Edema More than 3 days Acute Strong Is expressed 3-4 days Subacute Expressed Is expressed More than 5 days Gradual Nonpermanent Explicit Color of the skin less than 3 days Gradual No As a rule, there is no Not changed Marked pallor Exudates No Earthy black with bubbles No The presence of gas The smell of wound The change of muscle The presence of toxic Profluvium Marked, painted in pink As a rule, there is no Little sweet Pale with a copper tint Pronounced seroseptic A light separation minor Sour-tart Minor Pronounced necrosis Easy Septic No Easy Massive necrotic changes Extremely difficult Gradually increasing to severe Profluvium Septic On a radiograph of lesions observed accumulation of gas, the p characteristic caused by the divergence of the soft tissues (muscles, fat) under the action of gases. Classic fasciitis is the most common variant of anaerobic non-clostridial cellulitis of the soft tissues. When fasciitis is usually no loss of skin and muscle. The fascia has a dull color, thick. In later stages, there is purulent fusion fascia. If inflammation has spread to the muscle bundles - developing myositis, in which the foreground are the effects of severe intoxication. A distinctive feature of clostridial cellulitis is marked flatulence. Isolation of anaerobic bacteria in the laboratory. Diagnostics. One of the common symptoms of anaerobic infection is the absence of microflora in the crops with the standard methods of their selection (without the use of anaerobic culture apparatus). For rapid diagnosis of native produce smears or fingerprints, followed by Gram stain. By microscopy can be assumed that in the inflammatory process leading role played by anaerobic microorganisms. Response obtained after 30 - 40 min. The final bacteriological response with full identification of the microbe can be obtained after 5 - 7 days. The most appropriate method in the clinic now - it's cultivation of anaerobes in the anaerobic culture apparatus. Necessary compliance requirements of 2: 1. Prevent accidental contamination, 2. Prevent loss of agent from the time of the material. Easier to protect from the action of anaerobic bacteria in oxygen transport of the material in disposable syringes, but better - in special seamed bottles, such as penicillin. The material in the bottle is placed in a ~ 62 ~ puncture. Vial - transport medium with or without her, but obligatory filling an oxygen-free mixture consisting of 80% nitrogen, 10% hydrogen and 10% of carbon dioxide, nitrogen use one. Gas-liquid chromatography (GLC) allows to obtain reliable information on the involvement of anaerobes in the inflammatory process as quickly as in the microscopic rapid diagnosis in 30 - 40 min. Volatile fatty acids (acetic, propionic, butyric, isobutyric, valeric, isovaleric, caproic, phenol and its derivatives) are specific metabolites of anaerobic microbial activity. Volatile fatty acids are toxic metabolites and their level can be judged on the severity of intoxication. According to GLC and MS (mass spectrometry) can be identified not only asporogenous anaerobes, but clostridial microflora (pathogens gas gangrene), which is characteristic for the presence of 10-hydroxy acids. In the process of diagnosis of anaerobic infections to clarify the local pathological changes apply all kinds of instrumental examination, including x-rays, ultrasound, since according to the clinical examination of patients to judge the prevalence of the pathological process may be difficult. Treatment. The main condition for successful prevention of gas gangrene - removal of all nonviable tissue and timely initial debridement. Surgical treatment consists of a wide incision wounds in combination with excision of necrotic tissue. At the same time beginning to enter large amounts of semi-synthetic penicillin, tetracycline. The most common surgical option - the use of broad " trouser stripe" cuts involving dissection of the skin, fascia and muscle to the bone with a thorough washing of wounds hydrogen peroxide, potassium permanganate. Excision of the muscles that have, gray color, not bleeding when cut, is mandatory. Loose bone fragments and splinters of bone viability is questionable, to be removed. Cut through all the muscle fascial sheaths, as increasing swelling of the muscles leads to compression in their own bed. The wounds are left open for good aeration, use tampons with hydrogen peroxide and potassium permanganate. A characteristic feature of non-radical surgery is performed after the operation preserves the fever. So the question of re-treatment wound (necrectomy) should not be put off, thinking that fever - a reaction to the surgery.In the most severe cases (with the affection of gas gangrene limb) amputation or disarticulation perform limb. Amputations performed without tourniquet with finger pressing the vessel by the guillotine method. Surgical wound is left open. Apply a bandage with anti-gangrenous bacteriophage, be sure to mobilize the limb. In the presence of fracture immobilization spend skeletal traction or plaster Longuet. Using a circular plaster cast is not valid.When choosing antimicrobials used drugs that specifically act on anaerobes (clindamycin meropinem, thienyl, dioxidine, drugs metronidazole).It is shown that hyperbaric oxygen (HO). The reason for its use are two factors: an antibacterial effect of hyperoxia and hypoxia, the presence of (circulatory, fabric, mixed) in clinical illness (especially in a state of shock). Serotherapy. For the prevention of anaerobic gangrene serum is used anti-gangrenous. Polyvalent serum contains one ampoule toxoids against three types of agents of gas gangrene (as against 10,000 IU: against Cl. Perfringens, Cl. Oedematiens, Cl.Septicum). Monovalent serum contains toxoids of only one type of (50,000 IU each). Before the introduction of the main dose conducting intracutaneous test serum diluted 1:100 in order to identify the sensitivity to the protein. Specific treatment consists of applying a mixture of anti-gangrenous sera. One therapeutic dose is 150 000 IU (50,000 IU of antiperfringens, antiseptikum, antiedematiens. When installed pathogen is introduced only serum of the same name). Delayed treatment of gas gangrene (late diagnosis, watchful waiting) with disastrous consequences. Forecast. With appropriate treatment promptly initiated a favorable prognosis. ~ 63 ~ Primary prevention of surgical infection Primary prevention of surgical infection includes prevention of diseases provoking secondary immunity weakness first and foremost – diabetes mellitus. This kind of prevention implies regular blood sugar tests, especially in patients with high risk. The following point is the appropriate personal hygiene and sanitation. Especially high attention must be given to a working facilities and hygiene, preventing thus microfissures and lesions on the hand. For the types of the surgical infection which seems to be the complication of an inappropriate surgical treatment, some manipulations for example – postinjection abscesses, septic complications of the inadequate wound debridement after major wounds. To this point are the next situations also to be considered – insufficient opening of the purulent focus also leads to a complicated postoperative course with the elevated body temperature. Secondary prevention Secondary prophylaxis implies mainly the prevention of the life-threatening complication of the disease through the appropriate treatment, wound debridement and openings. For example the face furuncle can lead to the sinus thrombosis with the intracranial spread of the infection, which is associated with high mortality and morbidity. For many entities is therefore the prevention of sepsis crucial. Tertiary prevention This type of prophylaxis implies mainly the post curative rehabilitation of the patient, aiming first of all to treat the background disease. Sanatorium-and-spa treatment becomes for this purpose the mainstay of the follow-up such patients. Many patients with the common suppurative diseases need no prophylaxis. The diabetic patients on the other hand require appropriate diet and tertiary prophylaxis. The rehabilitation of the patients with the amputated lower extremities is the most challenging in this setting. Rehabilitation of patients after hospital treatment Most patients require outpatient monitoring after hospital treatment. At the same time every day make shift bandage on the wound, if necessary, measurement of body temperature, blood test for leukocytosis, etc. Specific rehabilitation measures generally are not required. Good nutrition, antibiotic therapy significantly accelerated wound healing and patient return to normal work. Some patients who underwent limb immobilization in the future need for some complex rehabilitation - physical exercise, etc. Require special attention, patients with concomitant diabetes mellitus. Required are constant monitoring and correction of blood glucose. Practical skills Practical skills needed to be obtained by the students generally include the thorough examination technique which shortly can be described as following: - Problems of the patients - patient complaints - The detailed history of the patient - Live history, habits, diseases, the problems of the relatives - The present status – constitutional features, body mass index, obesity or weight lost - Body temperature - The respiratory system – with the skills of palpation, percussion and auscultation, breathing behavior - Cardiovascular – pulse, heart auscultation, blood pressure measurement, edema - Digestive – complaints, thirst in diabetic patients, appetite - Urinary tracts – polyuria - Endocrinology features - Neural – sensitivity disturbance - Local examination: with comparison of the lesion with the normal extremity Fluctuation symptom Function disorder The 5 classic inflammation symptoms need to be evaluated by the students. ~ 64 ~ Case studies (10) 1. In a patient with multiple gunshot wounds to the thigh after surgical treatment of the wound sutured tightly. Longuet superimposed plaster. After a day diagnosed with clostridium infection. Due to the ineffectiveness of surgery performed under tourniquet amputation stump with the formation of made flaps. Stump sutured to the abandonment of the glove 2 drainages. In what condition worsened, signs of clostridial infections detected in the stump with the transition to the abdominal wall. a) What mistakes were made in the treatment of a patient? b) How to continue the treatment? 2. At the time of work during the excavation was injured with damage to the integument. After 3 days, despite debridement, surgical suture appeared around edema, cyanosis, marked crepitus on palpation. The doctor diagnosed "gas gangrene" and sent the material in the bacteriological laboratory. Assignment: a. What material was taken for investigation, collection and transport of feature? b. Call the methods of laboratory diagnosis of gas gangrene: basic, accelerated, rapid methods. List the main steps of the method. c. What are agents of gas gangrene, specify their taxonomic position (family, genus, species), especially the morphological and tinktorial properties. d. List the factors that contribute to the development of gas gangrene. e. Explain the pathogenesis of gas gangrene. f. Gas gangrene is usually a mixed infection. Explain, in association with which the bacteria are clostridia in the foci of infection and why? g. How biologics conducted specific treatment? Its structure and principle of its receipt. 3. In the rural medical post (RMP) at the reception to GPs came the patient C. 59 years old. The patient with the words of the patient is treated at home during the last week about CHD, hypertension. I took injections of papaverine with dibazol. For 15 years, suffering from diabetes mellitus (type II), are not regularly treated. 3 days ago in a patient in the left gluteal painful swollen seal zone of hyperemia. Later joined by fever and chills notes in the evening. House itself has not taken drugs, about the increasing pain, worsening of the patient being asked to GPs RMP. Objective: The patient suffers from morbid obesity, weight is 120 kg with height 160 cm overall condition of the patient at the time of the inspection of medium gravity, there is a forced situation, the body temperature at the time of examination 37.0 C at night raises to 38,5-39 S. blood pressure 150/90 mmHg, pulse 88 b in minute. Locally: the left buttock - especially the skin of the upper outer quadrant of the edematous, hyperemic, sealed, and hot touch. Symptom fluctuation can not be mentioned because of the subcutaneous adipose tissue is highly developed. However, in the center of the hyperemic zone is characterized by blanching of the skin pattern. Complete Hb - 127 g / l; blood Red blood cells - 4.5 x 10 x 12 / l; count White blood cell - 14.0 x 10 * 9 / L - Stab - 12%; - Segmented -44%; - Eosinophils - 1% - basophils - (-)-monocytes - 4%; ESR - 15 mm / hour. 4. Patient C. for about 3 weeks ago was the injury of metal shavings in the projection of the proximal interphalangeal joint of the 3-finger palmar surface of the left. Chips removed in the medical unit at work, the wound was treated with 5% alcoholic solution of iodine. Gradually increase the pain in the joint, the ~ 65 ~ finger became spindle-shaped, motion in the joints become painful sharply, and then with abnormal mobility in it, one day before the treatment the patient noted increased body temperature to 38 C, almost no sleep because of the intense pain of pulsating character. The skin over the joint, hyperemic, edematous tissue strongly, finger spindle-shaped, sharp movements are painful. There is a slight swelling of the dorsum of the left hand. Your diagnosis? Stage of the process? Kind of a special survey, which helped establish the diagnosis? View the online help? Postoperative patient follow-up? Complete blood count Hb - 121 g / l; Red blood cells - 4.2 x 10 x 12 / l; White blood cell - 10.1 x 10 * 9 / L - Stab - 8%; - Segmented -48%; - Eosinophils - 1% - basophils - (-)-monocytes - 4%; ESR - 12 mm / hour. 5. In the RMP at the reception for invited GPs H. patient for 19 years. Patient notes sickly seal the left breast, fever to 38.5 C, and headaches. The patient has recently (last week) had her first child and breastfeeding, while noting moderate pain during feeding (about which she had stopped to feed this chest). Home alone to attach ointment bandage with alcohol. After that marks a sharp deterioration in pumping pyorrhea. The patient grew and developed normally, no bad habits. Birth proceeded without complications, gave birth to a term vaginal delivery. Objective: general condition of the patient at the time of the inspection of medium gravity, there is a slight hyperemia of face, body temperature is 37.5 C at night raises blood pressure to 110/70 S. 38,5-39 mm Hg, pulse 96 b per minute . Locally: Left breast increased slightly compared to the right, mostly in the upper gland seal and marked hyperemia. Symptom fluctuation is positive. With light pressure and pumping marked pyorrhea from the nipple. Axillary lymph nodes increased somewhat, moderately painful. The right breast and lymph nodes in the opposite side intact. These surveys, conducted by general clinic Complete blood Hb - 119 g / l; count Red blood cells - 4.2 x 10 x 12 / l; White blood cell - 13.1 x 10 * 9 / L - Stab - 8%; - Segmented -48%; - Eosinophils - 1% - basophils - (-)-monocytes - 4%; ESR - 12 mm / hour. 6. In a patient with localized on face furunculosis person within the last day the temperature increases, and headache. Increased body temperature to 38 C. What are the possible complications boil faces? What is the tactic of GPs in this situation? 7. Patient F, 42 years old, one day before treatment to GPs to receive said increase in temperature to 39 C with chills and headache. An objective examination revealed a clear-cut and bright zone of hyperemia in the right leg, with single bubbles in the center of the flare. From the words of 2 years ago noted this symptomatology. Combined therapy did not receive. ~ 66 ~ Your diagnosis? Spend the differential diagnosis with other diseases with similar events taking place? The tactics of GPs in this pathology? Types of prevention of this disease? 8. Patients after 6 months ago hysterectomy with appendages, followed by repeated treatments of radiation and chemotherapy, there is a vast area of redness and fluctuations in the right buttock, without clear boundaries, which appeared after intramuscular injection in an outpatient setting. The temperature increase at the same time moderate. Revealed an abscess cavity, the patient's condition improved somewhat, but after 3 days and observed similar phenomena on the left. Your diagnosis? Your opinion about this case - what is that? Specify the methods of research? 9. Patient E., aged 17, complaints of pain and redness of the skin on the anterior surface of the forearm, pain in right armpit during movements of the shoulder joint. The body temperature of the previous night had risen to 38.5S. 2 days ago when the patient chores injured thumb of his right hand. Your assumptions at the expense of the underlying disease? What causes this specific symptoms? Treatment strategy? 10. In 46 years the tractor on the back of the neck indicated a tight painful infiltrate with extensive congestion zone. Infiltrate slightly raised above the skin and spontaneously was discovered a few holes. The general condition of the patient of moderate severity. There is an increase in body temperature to 39 C. Any movement is extremely painful neck. List the diseases with similar symptoms? Your final diagnosis? Tactics of the GP-surgeon? Explain to the patient primary prevention? ~ 67 ~ CONTROL TEST QUESTIONS (60) Syndrome of fever in surgical infection Topic: Characteristics of fever and other clinical manifestations of local surgical infection. Types of fever. Methods of diagnosis and treatment. The tactics of the general practitioner. Rehabilitation and prevention. Tests with one correct answer. 1. What factors other than microorganisms, often contribute to the development of anaerobic infections? a) large, deep wounds contaminated with muscle injury b) Loss of circulation c) reducing the body's immune resistance d) anemia e) All answers are correct 2. Classification of sepsis in clinical course (specify the wrong answer): a) fulminant b) acute c) subacute d) chronic e) a chronic relapsing 3. Choose the acute specific infection: a) lymphadenitis, parotitis, bursitis b) whitlow, abscesses, cellulitis c) diphtheria of wounds, tetanus, anthrax, rabies d) ulcers, fistulas, gangrene e) abtsess, carbuncle 4. What types of fever do you know a) low-grade b) febrile c) piretic d) hyperperetic e) all answers are correct 5. What type of fever occurs in peri appendiceal abscess a) low-grade b) febrile c) normal d) hectic e) hypo febrile 6. What type of fever observed in appendicular infiltrate in a patient a) normal b) febrile c) low-grade d) hectic e) hypo febrile ~ 68 ~ 7. In-hospital infection - this is basically a) Gram-negative microflora b) gram-positive microflora c) both of above mentioned d) gonorrheal e) a specific 8. Healing clinic is most pronounced when applied to the purulent wound after surgical treatment a) The primary joints b) secondary sutures c) the significant difference is not determined d) Tertiary seams e) without seams 9. Treatment of wound healing in the first phase includes a) anti-inflammatory therapy b) stimulating the growth of granulation c) To promote the process of cleansing the wound, creating a wound rest d) adaptation of the wound edges e) the right a) and c) 10. Active drainage of purulent wound - this is a) the outflow of pus on drainage tube by gravity b) the outflow of pus on drainage capillary c) washing the wound extended through the drainage tube d) long-term drainage of the wound with a constant vacuum aspiration e) right c) and d) 11. Nosocomial infections in recent years a) is not observed b) is rarely observed c) there is often d) tends to be more frequent e) right c) and d) 12. Adverse effects of prolonged use of antibiotics can be explained a) the weakening of the body b) the creation of antibiotic-resistant flora c) and then both d) flu e) acute respiratory viral infection 13. Characteristic for pyosepticemia a) general weakness, exhaustion b) purulent foci of metastasis in various organs and tissues c) a sharp pain and inflammation of the stormy surface of purulent metastases d) hectic temperature e) the relative subsided by the end of the process of metastasis formation of pyogenic 14. Fever is considered "acute" it lasts a) no more than 2 weeks ~ 69 ~ b.) no more than 70 days c) Not more than 1 week d)more than a year e)2 days 15 Increased body temperature from 37 to 38 C is: a) subfebrile fever (from Lat. Sub under, below + febris fever).. b) febrile fever. c) b) piretic (from the Greek. Pyretos fever) fever. d) c)is hyperpiretic fever. e) d)normal temperature 16. Usually, with an increase in body temperature by 1 degree heart rate increases at least a)8-12 beats a minute. b) 30 beats per 1 minute. c)40 beats a minute. d) 50-54 beats per 1 minute. e) does not increase Tests with the issue containing an element of denial. 1. Nosocomial infection include everything except: a) infection, acquired in a hospital setting b) infection, hematogenous and lymphogenous spreading paths c) infection, ranked in the survey d) infection that hit during the operation e) All answers 2. Complications of sepsis include all of the above, except a) The septic bleeding b) thromboembolism arteries and organs c) ascites, anasarca d) a septic endocarditis e) pneumonia 3. Clinical classification of sepsis includes all of the following forms, except a) The post-operative b) recurrent a) chronic d) acute e) fulminant 4. By the actions recommended in sepsis, are all listed, but a) The opening of a purulent focus b) the limited administration of the liquid c) intramuscular injection of antibiotics d) blood transfusion e) the introduction of vitamin 5. The conditions favoring the development of the microflora of purulent in its penetration into the body, are all listed, but ~ 70 ~ a) the availability or integrity of the epidermis of the skin epithelium of the mucous b) the penetration of several microbial species synergist c) defects of the skin or mucous d) the presence in the area of tissue injury e) microbial penetration increased virulence 6. Purulent infiltration of the microflora causes a tissue reaction, expressed all the above, except a) arterial hyperemia b) venous stasis c) the occurrence of pain d) the local temperature rise e) loss of sensitivity 7. Specify the major symptoms of anaerobic infection (wrong answer): a) pain in the wound b) bloating of the extremities c) a feeling of tightness dressing d) a twitch in the wound e) swelling Tests with a clinical situation, and several blocks of questions 1. At the reception the doctor asked a man aged 37, he a doctor, who recently returned from Yamana. Concerned about the increase in body temperature every 48 hours - occurs with a regular increase and decrease to normal. The minimum temperature below 37 C day. Your first diagnosis: a) three day malaria b) Diabetes c) 4 days malaria d) Avian influenza e)fluctuation . 2. What kind of examination is needed: a) EGDFS b) Blood sugar c) Blood on the sterility d) colonfiberscopy e) ultrasound 3. Where to send the patient: a) surgeon b) GP doctor c) hospital of infectious diseases d) therapist e) urologist Multiple-choice tests. 1. Signs of inflammation: a) local temperature rise b) Diabetes c) hyperemia ~ 71 ~ d swelling, impaired function e)fluctuation . f) obesity g) pain 2. Fever Pale - fever accompanied with pale skin. It is characteristic of (2 answers) a) sepsis. b) peritonitis (end stage) c)Hepatitis d) influenza e) mastitis 3. About unclear fever say when (3 answers) a) fever lasts more than 3 weeks; b) the temperature is higher 380S; c) after a week cause surveys temperatures remains unclear. d) All of fever clear e) after a year. 5. Associate convulsions with fever may be, if (3 answers) a) the child's age does not exceed 5 years; b) there are no diseases that could be the cause of seizures (eg, meningitis); c) seizures were not observed in the absence of fever. d) Age of child no more than 2 years e) There is no convulsions with fever f) No answers Subject: fever in patients with furuncles, carbuncles, hydradenitis, subcutaneous and corn abscess, phlegmon, and lymphadenitis. Differential diagnosis of phlegmon lymphangites and erysipelas. Boil on the face of danger. The role of diabetes and other metabolic diseases in the development of the carbuncle and boils. Felon. Features of the flow depending on the surgical anatomy of the wrist. Cutaneous, subcutaneous, tendon, joint and bone forms felon. Pandaktilitis. Paronychia and ingrown nails. The clinic, diagnostic techniques, differential diagnosis, complications and treatment. The tactics of the SPM. Rehabilitation and prevention. Pain and space-occupying lesions in the breast. Classification. Clinical picture, diagnosis, differential diagnosis. Methods of investigation and treatment. The tactics of the SGs. Rehabilitation and prevention. Tests with one correct answer. 1. Burning pain, feeling of heat in the area of reddened, bright redness with sharp edges, high temperatures typical for a disease? a)erysipelas b) phlegmon c) abscess d) anthrax e) gangrene 2. A strong, painful, throbbing, sleep deprivation pain in the finger phalanx and sharply increasing when lowering arms says: a) subcutaneous panaritium b)in erysipelas ~ 72 ~ c) in Raynaud's disease d) cutaneous whitlow e) Raynaud's syndrome 3. The patient on the back of the neck there is inflammation of formation purple red in color with a lot of pus in the form of points screens. In the analysis: sugar 12mmol / l, Lake. 11.0 thousand, ESR 20 mm / h. What disease in a patient? a) carbuncle b) Anthrax c) abscess d) boil e) abscess. 4. Deterioration of the general condition, appearance jerking, throbbing pain around the finger, even swelling of the tissues with a smoothed interphalangeal furrows characteristic: a) subcutaneous whitlow b) Bone felon c) tendinous panaritium d)Articular felon e) No answer 5. A sharp pain and swelling in the thenar region and the radial edge of the brush, smoothing of the palmar creases and sharp pain on palpation characterized for: a)subgaleal phlegmon brush b)Interdigital phlegmon . c) phlegmon of thenar d) phlegmon of hypothenar e) hydradenitis 6. Why to make radial and semilunar incisions with mastitis? (Indicate the wrong answer) a)not to damage the milk ducts b) not to damage the blood vessels c) to create good drainage of pus d) not to damage the nerves 7. The main sign of an abscess: a)reddening of the skin b) pain in affection c) fever d) dysfunction. e) fluctuation 8.Furuncle, usually caused by a) Streptococcus b) Staphylococcus c) the gonococcus d) Pseudomonas aeruginosa e) Proteus 9. Causative agent of hydradenitis is often a) Streptococcus ~ 73 ~ b) against c) Staphylococcus aureus d) Pseudomonas aeruginosa e) E. coli 10. Abscess of infiltrate characterized by the presence a) pain b) hyperthermia c) the fluctuations d) flushing of the skin e) leukocytosis with a shift to the left leukocyte 11. Patients with diabetes mellitus receiving insulin in the treatment of purulent wounds a) indicated is the use of proteolytic enzymes (trypsin, chymotrypsin) b) does not show the application of enzymes c) use of the enzyme solved individually d) all of the above e) no answers Tests with the issue containing an element of denial. 1. In the initial stage of acute serous mastitis is not applied: a) cutting b) preventing stagnation of milk a) antibiotic therapy d) ultrasound therapy e) a retromammarial penicillin novocaine blockade 2. Distinguish between all these types of panaritium, except a) Skin b) subcutaneous c) tendon d) bone e) palmar 3. Complication of subcutaneous felon third finger left hand may be all of the following, except a) tendon felon b) The bone-felon c) articular whitlow g) phlegmon brush d) forearm phlegmon 4. Danger of hypodermic felon 2nd phalanx of little finger may be all of the above, except a) the development of tenosynovitis b) necrosis of the finger flexor tendon c) the development of cellulitis of forearm d) development of a phlegmon of the shoulder g) fat pulmonary embolism ~ 74 ~ 5. In the treatment of furuncle in the first phase of inflammation all of the following is applied, except a) folding boil antibiotic solution dissolved in novocaine b) the physiotherapy currents UHF c) opening the focus of inflammation d) high-calorie food e) immunocorrecting therapy 6. Treatment of furuncle includes all of the following, except a) rubbing the surrounding skin with alcohol 70 ° b) in the presence of necrosis - squeezing and dressing with a hypertonic salt solution c) folding of penicillin with novocaine around the inflammatory infiltrate g) sulfa drugs inside d) UV irradiation 7. Indicated for the neck carbuncle all, except a) hot compress with ointment Vishnevsky b) by intramuscular injection of antibiotics c) sulfanilamide drugs inside d) vitamin d) UV irradiation Tests with a clinical situation, and several blocks of questions 1. At the reception, the doctor turned 59 years old man with complaints: a painful bulge in the occipital region with a common temperature and a severe general weakness. In this connection became more liquid to make a little thinner. I. What is a provisional diagnosis can be assumed: a)carbuncle b) tumor c) hydradenitis d) lipoma e) atheroma II. What laboratory tests necessary for this patient, except: a) sugar in the urine b) of anal blood c) blood sugar d) of anal urine e) TORCH infection III. This patient's blood sugar 5.11 mmol / liter. Sugar in the urine of 4% What type of diabetes, given the age: a) diabetes -1 type b) Type -2 diabetes c) diabetes - comb type d) Family diabetes e) No diabetes ~ 75 ~ Multiple-choice tests. 1. What are affected tissues in pandaktilitis: a) skin b) cartilage c) tendon d) joints, bone e) mucous 2. What action will be recommended for the patient with mastitis: a) Early operation with cuts b) Timely operation c) anti-inflammatory therapy d) struggle with milk production e) struggle with stagnation of milk 3. What are the cuts made during the opening of mastitis: a) D-Volkovich b) trouser stripe c) Cross of Pirogov d) radial e) semilunar incision under the breast (according to Bardengeir) 4. What are the associated pathologies predisposing to the formation of furuncle: a) peritonitis unclear etiology b) vitamin deficiency c) immunodeficiency d) hypertension e) Diabetes 5. On which areas of the body is often localized hydradenitis: a) axillary region b) navel c) hands d) face e) in the crotch 6. The causative agent of erysipelas: a) gonococcus b) streptococcus c) diplococcus d) enterococcus 7. In the pathogenesis of felon plays a major role: a) abrasions b) pricks c) Cracks d) obesity e) cachexia 8. Erysipelas is more often localized: a) on the lower extremities b) in the upper extremities c) On the scalp d) in small joints e) in all areas of the body ~ 76 ~ References (core) 1. Sepsis at the beginning of the XXI century. Savelev V.S et all. Practice Manual, Moscow, Littera 2006 2. Essays of purulent surgery, V.F.Voyno-Yasenetskiy, 1946, Medgiz 3. Electronic manual on surgical infection, V.D Fedorov 4. General surgery V.K Gostischev, GEOTAR-MED, 2004 5. Infections in surgery, a guide for doctors, V.K Gostischev., 2007 6. Operational purulent surgery, V.K Gostischev, Medicine, 1996 7. Wounds and wound infection, M.I Kuzin, 1990 Medicine References(additional) 1. Infection control in surgical practice. Vivian G.Loo et all. ACS SURGERY. Principles and practice, 2008 2. Acute wound care. 2007 Stephen R.Sullivan et all. ACS Surgery Principles and practice 3. Prevention of postoperative infection. 2008 Jonatan Meakins. ACS Surgery Principles and practice 4. Soft tissue infection. 2007 Mark A.Malangoni et all. ACS Surgery Principles and practice 5. Nosocomial infection E.Patchen Dellinger 2003, ACS Surgery Principles and practice 6. Lee J.Skandalakis et all. Surgical anatomy and technique, 2009 pocket manual. Springer ~ 77 ~