Chithandizo cha pachimake kapamba, edematous mawonekedwe

Pancreatogenic shock ndi mkhalidwe wovuta momwe ntchito za ziwalo zofunika kwambiri ndi machitidwe zimawonongeka msanga, kuthamanga kwa magazi, kutulutsa kwamtima kumatsika, mafuta a ziwalo ndi minyewa yomwe imapanga chitukuko cha ziwalo zingapo (E.S. Savelyev et al., 1983, G.A. Ryabov, 1988, Weil LH., Schubin M., 1957, Becker V. et al., 1981).

Pafupipafupi pachitukuko chadzidzidzi chimachokera ku 9.4% mpaka 22% kapena kuposa,. Nthawi zambiri, kudandaula kumachitika chifukwa cha pachimake necrotic pancreatitis.

Mankhwalawa mu pachimake necrotic pancreatitis amadziwika ndi zovuta hemodynamic kusakhazikika, limodzi ndi hypoperfusion. Mwachilengedwe, kudabwitsa kwa kapamba wam'mimba ndi endotoxin. Mankhwala a Endotoxin ndi omwe amatsogolera kwambiri chifukwa cha kufa kwa chifuwa chachikulu cha kapamba.

Kugwedeza nthawi zambiri kumapangitsa mitundu yayikulu, yowononga ya kapamba, limodzi ndi kugonjetsedwa kwa malo ofunikira a pancreatic parenchyma necrosis. Kuchuluka kwa pancreatic necrosis ndiko kutsogolera kwa zotsatsa za pathomorphological zomwe zimatsimikizira mwayi wokhala ndi endotoxin.

Focal pancreatic necrosis popanda zotsatira za kugunda kwa pancreatogenic ndi zovuta zama systemic

(maphunziro olimbitsa - pancreatitis yofatsa, Atlanta, 1992)

1. Kugonekedwa kuchipatala

2. Pakalibe mavuto, chithandizo chamankhwala sichitha

4. Nasogastric chubu

5. Ozizira pamimba

6. Ma analgesics omwe si a narcotic

8. kulowetsedwa mankhwala kuchuluka kwa 20-30 ml / kg thupi, mankhwala omwe amachepetsa katulutsidwe katemera (atropine, sandostatin, octreotide) ndipo ali ndi antiprotease athari, pakamwa pancreatic enzymes

9. Antibiotic prophylaxis ya necrosis matenda

10. Kupewa kwa zovuta za thromboembolic

11. Maantacid okhala, othandizira omwe amachepetsa katulutsidwe ka m'mimba, komanso kupewa magazi m'matumbo

Zomwe zimachitika pancreatogenic

Kudabwitsa kwa pancreatic ndi vuto la pathological lomwe limayamba chifukwa cha kuwonongeka kwambiri kwa ziwalo, zomwe zimaperekedwa ndi dontho la kukakamiza, kuchepa kwa magazi omwe akupita patsogolo, kusintha kwa hemodynamic kosinthika chifukwa cha kuwonekera kwa endotoxins, kupangika kwa DIC, komanso kuwonekera kwakanthawi kwamachitidwe osokoneza bongo.

Kukhazikitsa kwa kallikrein-kinin dongosolo, lomwe limapanga histamine, bradykinin, serotonin, ndi chifukwa chachiwiri chankhanza, limagwira ntchito yofunika kwambiri mu pathogenesis ya matenda apamba. Chifukwa chotsirizira, kuchuluka kwa mtima kumawonjezeka, kukoka kwam'mimba kwa kapamba kumasokonekera, komwe kumafalitsidwa ndi peripancreatic edema, kuchuluka kwamphamvu yotupa mu thumba la synovial, peritoneum.

Pafupipafupi mwadzidzidzi mwadzidzidzi mumakhala 9.4-22% ndi zina. Nthawi zambiri, amakumana motsutsana ndi maziko a pachimake necrotic pancreatitis.

Maziko a zipatala zapadera za pancreatitis pachimake ndi:

• mitundu ya pathologies
• Mavuto obisika komanso achilengedwe, malinga ndi kufalikira kwa kapamba,
• paripancreonecrosis ya malo okhala ndi ma cell a retroperitoneal (CHIKWANGWANI chimapezeka mkati mwa kapamba ndipo pafupi ndi pomwepo),
• gawo la yotupa.

Mu pachimake edmatous pancreatitis, mantha amadziwika ndi zovuta zosakhazikika, limodzi ndi systemic hypoperfusion. M'mayeso ake a pancreatitis oyipa kwambiri, ndi a endotoxin. Mankhwala a Endotoxin ndi omwe amatsogolera kwambiri chifukwa cha kufa kwa chifuwa chachikulu cha kapamba.

Matenda a pancreatic atha kukulira mitundu yowononga ya kapamba, yotsatana ndi kusintha kwa madera akuluakulu ndi necrosis ya minofu ya England.

Kuchepa kwa ziwalo za parenchymal kumayamba pakadutsa masiku 3-7 kuyambira nthawi yovuta kwambiri ya kapamba ndi vuto la chiwindi, mtima, impso, mapapu, komanso dongosolo lamanjenje.

Kodi zimachitika bwanji?

Zomwe zimayambitsa kukhumudwa kwa pancreatic zili pakumwa kwambiri mowa komanso kudya mopitirira muyeso.

Pancreatic necrosis amatanthauza poizoni wotupa wa England. Pancreatitis imachitika chifukwa cha mphamvu ya mkati mwa michere yake. Chifukwa chogwiritsa ntchito zinthu zambiri, kuchuluka kwa thupi kumayamba, komwe kumatanthauza kumasulidwa kwa zigawo zikuluzikulu.

Enzymes imayamba kusanachitike chifukwa cha kulowetsedwa kwa ndulu mu ziwongo za kapamba, ngakhale mwa anthu athanzi, bile limapezeka mu duodenum ndipo limayanjana ndi chinsinsi.

Hemorrhagic pancreatitis, yodziwika chifukwa chakuti mothandizidwa ndi ma enzymes ake, parenchyma yokhala ndi mitsempha ya magazi imafa msanga, ndiye chindewu chachikulu cha minofu ya kapamba. Izi zimakwiyitsa chitukuko cha:

Chifukwa cha kupweteka kwamphamvu kwa kupweteka, mawonekedwe amtundu wa adrenaline adamulowetsa. Adrenaline imabweretsa kuchepetsedwa kwa mitsempha yamagazi, zolakwika zam'mimba, kupatsira kubwera kwa magazi ochulukirapo kumtima ndi ubongo. Mitsempha ina ikakhala yopapatiza, mpweya wamatenda amtundu wa m'mimba umachitika, womwe umataya magazi.

1. Ngakhale kupuma kumachitika msanga, ndi njala ya oxygen, mpweya umabwera modabwitsa chifukwa cha kusintha kwa kayendedwe ka magazi, izi zimabweretsa kupendekera pang'ono. Kuchepa kocheperako kumabweretsa imfa ngati thandizo siliperekedwa mwachangu.
2. Impso sizitenga magazi okwanira, sizipanga mkodzo, kapena zimachitika pang'ono komanso ndimdima wakuda. Vutoli limatchedwa chizindikiro cha impso.

Chithandizo cha matenda a mtima

Pancreatic shock mankhwala umalimbana ndi:

• pangani zonyowa zamadzimadzi ndikulipirira kusamutsidwa kudzera pakubweretsa mankhwala oletsa kugwedezeka,
• Kukhazikitsidwa kwa chithandizo chokwanira chododometsa ndi ma syndromes a zovuta pogwiritsa ntchito ma anti-cramping agents, blockers - Sandostatin, Octreotide, komanso ma pancreatic enzyme,
• pambuyo panjenjemera, kumenyedwa kwandala kumafunikira,
• ngalande zoyesa kuchotsa poizoni,
• probe amagwiritsidwa ntchito kuyeretsa thirakiti,
• Maantibayotiki amagwiritsidwa ntchito pofuna kupewa necrosis.

Kuchita bwino kwa mankhwalawa kumadalira nthawi yayitali yosamalidwa.

Zolemba za ntchito yasayansi pamutu wakuti "Mankhwalawa mu pachimake necrotic pancreatitis"

UDC 617.37 - 005: 616-001.36

V.E. VOLKOV, S.V. Volkov

SHOCK AT ACUTE NECROTIC PANCREATITIS

Mwa zovuta zingapo za pancreatitis pachimake, makamaka pakukhudza zotsatira za matendawa, kuwopsa kuyenera kutchulidwa. Pafupipafupi kukula kwake ndi kosiyana - kuchokera pa 9.4% mpaka 22% ndi oposa 1, 2. Nthawi zambiri, kugwedezeka kumachitika motsutsana ndi maziko a pancreatitis yacute.

Mankhwalawa mu pachimake necrotic pancreatitis amadziwika ndi zovuta hemodynamic kusakhazikika, limodzi ndi hypoperfusion. Mwachilengedwe, kudabwitsa kwa kapamba wam'mimba ndi endotoxin-buluu. Mankhwala a Endotoxin ndi omwe amatsogolera kwambiri chifukwa cha kufa kwa chifuwa chachikulu cha kapamba.

Kukula kwa mantha nthawi zambiri kumayendetsedwa ndi mitundu yayikulu, yowononga ya kapamba, yomwe imayendera limodzi nthawi zambiri ndikugonjetsedwa kwa masamba ofunikira a pancreatic parenchyma necrosis. Ndiye kuchuluka kwa pancreatic necrosis yomwe imatsogolera gawo la endomorphological lomwe limatsimikiza mwayi wopanga endotoxin ndi zovuta zina zingapo zovuta (enzymatic peritonitis, retroperitoneal cellulitis, sepsis, etc.).

Nthawi ya kukhazikitsidwa kwa mantha mu pancreatitis pachimake ndipo, makamaka, ndi pancreatic oncrosis, imatha kukhala yosiyana, zomwe zimapangitsa kuti pakhale kusiyana kwakanthawi koyamba kugwedezeka. Nthawi ya chitukuko cha mankhwalawa koyambirira nthawi zambiri imayenderana ndi enzymatic gawo la pancreatitis yovuta kwambiri ndipo nthawi zambiri imawonedwa sabata loyamba la matenda. Mankhwalawa amayambira pomwepo chifukwa cha zovuta kwambiri za toxosis komanso ziwalo zingapo. Ndizosadabwitsa kuti chiwerengero cha anthu oyamba kufa chifukwa cha mankhwalawa amafika 48%.

Kudandaula kwakanthawi kumawonedwa pamene odwala apanga gawo la septic sequestration ya pancreatic necrosis ("kachilombo ka pancreatic necrosis" malinga ndi gulu la Atlanta-1992). Gawo ili, kumayambiriro (kuyambira pa sabata la 3 la kapamba owononga kwambiri), pakachitika zovuta zamkati zam'mimba (purulent necrotic parapancreatitis, peritonitis, kachilombo kamene kamayambitsa matenda ena, ndi zina zotere), ndipo pambuyo pake (pafupifupi mwezi umodzi atadwala matendawa), matenda opatsirana (sepsis) ) Pafupipafupi pamavuto amtundu wa purulent m'mitundu yowononga ya kapamba amasinthasintha kwambiri ndipo, malinga ndi olemba osiyanasiyana, amachokera ku 25 mpaka 73%. Kukula kwa mankhwalawa pancreatogenic nthawi zambiri amadziwika motsutsana ndi maziko oopsa a sepsis. Wodziwika bwino kwambiri wothandizira wa gram-sepsis wabwino ndi Staphylococcus aureus, gram-negative - Pseudomonas aeruginosa. Monga lamulo, sepsis ndi mantha zimawonedwa mwa odwala omwe adachitapo opaleshoni yopitilira 2-3 chifukwa cha purapy ya zovuta zowononga za pan-

creatitis, mochedwa komanso / kapena kuchepa kwaukhondo kwa retroperitoneal zowononga, pakakhala zovuta zingapo zotsatizana za gawo lomwe limayambitsa kupweteka kwa kapamba (kufooka ndi magazi a gastroduodenal, fistulas yamatumbo, ndi zina).

The pathogenesis of mantha mu pachimake necrotic pancreatitis anaphunziridwa bwino kwambiri mpaka pano. Chomwe chimatsogolera pakukula kwa vutoli ndi endotoxemia. Amakhulupirira kuti ma enzymes opakidwa pancreatic ndi omwe amachititsa matenda onsewo (toxicosis) komanso a pancreatic necrosis. Yogwiritsa ntchito mapuloteni ndi lipase, yogwira mtima pa endothelium, imayambitsa kukhathamira kwamitsempha, kukhudzika kwadzikoli, komanso kuchepa kwa madzi am'magazi, zomwe zimayambitsa magazi.

Zofunikira pakukula kwa mankhwalawa panthawi ya enzymatic endotooticosis ndi kuchepa kwa dongosolo, zomwe zimapangitsa kuti magawo azikhala osakhazikika chifukwa cha kusamveka kwamphamvu ndi kamvekedwe ka kama. Gulu la ma peptides amkati, ogwirizana pansi pa dzina loti "vasoactive kinins" (kallikrein, serotonin, bradykinin, ndi zina), amatenga nawo gawo pazindikiritso zamatenda a enzymes. Kinins ali ndi katundu wotsatira: amathandizira kukwiya, edema ndi kupweteka, kumabweretsa vasodilation, hypotension, kuchuluka kwa mtima, komanso kuchepa kwa bcc.

Tikukhulupirira kuti chimodzi mwazomwe zimapangitsa kudodometsa kwa odwala omwe ali ndi pancreatitis yayikulu ndikuchepa kwa magazi ozungulira 2, 3, 4. Pancreatitis yachilendo, kuchuluka kwa magazi ozungulira (BCC) kungachepe chifukwa cha zinthu zotsatirazi: 1) kupangika kwa edema m'malo apakati a kapamba , 2) kuphatikizidwa kwa malo a retroperitoneal space ndi hemorrhagic fluid, 3) kudzikundikira kwa hemorrhagic madzimadzi (pancreatic "ascites") pamimba pamimba (kuyambira 2-3 l kapena kuposa), 4) kuchuluka kwa madzimadzi mu malupu a matumbo omwe amapezeka TATUS paresis kapena ziwalo, 5) depositing magazi mu dongosolo zipata mtima ndi kumabungwe ena.

Pakufufuza kwa bcc mu pancreatitis ya pachimake, ndizotheka kuzindikira kwambiri hypovolemia - kuyambira 1000 mpaka 2500. Amakhulupirira kuti kutayika koyambirira kwa plasma kuchokera pabedi lamitsempha kumayendetsedwa ndi edema ya kapamba ndi ziwalo zina zamkati. M'tsogolomu, mwina chifukwa cha kuwonongeka kwa maselo ofiira amwazi ndi trypsin, kuchuluka kwapadziko lonse kumachepa.

Kuwonongeka kwakukulu kwa madzimadzi am'mimba mu pancreatitis pachimake kumabweretsa hemoconcentration, kusokonekera kwa hemodynamics chifukwa cha Hypovolemia ndi mantha. Popanga zovuta za hemodynamic ndi mantha, gawo lofunikira ndi la abale. Kukhazikitsa kwa kinin dongosolo ndi kulowa kwa magazi a kallikrein, bradykinin, kallidin, histamine ndi michere ya proteinolytic kumabweretsa kuwonjezeka kwa mtima, kutulutsa kwa plasma mu chotengera

njira yapa distalular space ndi kukula kwa hypovolemia. Zina mwa zinthu zambiri zomwe zimathandizira kukulitsa mantha: manjenje, endocrine, mtima, ndi zina zambiri.

Kugwedezeka komwe kumachitika motsutsana ndi maziko a pancreatitis pachimake nthawi zambiri kumayendetsedwa ndi kukula kwa metabolic acidosis. Komabe, chitukuko cha acidosis m'matendawa sichingafotokozedwe bwino pochepetsa kuthamanga kwa magazi ndi manjenje. Zinthu zina ziyenera kuganiziridwa. Kukhazikitsidwa kuti zinthu zina zomwe zimatulutsidwa mkati mwa kuvunda kwa kapamba zimatha kuponderezera kugwiritsidwa ntchito kwa oksijeni mu ziwalo ndi minofu, mwachitsanzo, m'chiwindi, chifukwa chake, chifukwa chosankha blockade of metabolism, kulimbikitsa kudziunjikira kwa acid metabolites.

Zomwe zimachitika mwa gawo la enzymatic mu pachimake necrotic pancreatitis ndi kugwedezeka zimaphatikizanso ma cytokines-peptides omwe ali ndi vuto la chitetezo cha mthupi, makamaka kutupa kwamphamvu. Izi zimaphatikizapo ma interleukins, ma interferon, zotupa necrosis, ndi zina zambiri. Kukula kwa enzymatic gawo lovuta kwambiri lecotic pancreatitis ndikuwopseza ndikuwonjezereka kwa kuchuluka kwa pro-kutupa cytokines (TOTA, IL-6, IL-18, etc.). Kuopsa kwa matenda atha kuweruzidwa ndi mulingo wama cytokines wamagazi mu pancreatic necrosis yayikulu komanso kupweteka kwa pancreatogenic. cytokinemia ikhoza kukhala chizindikiro cha matenda.

Kusiyanitsa kwakukulu kwa kapangidwe kake, ntchito zake ndi kagayidwe kake ka zikondamoyo za pancreatitis pachimake kumabweretsa kutsegulira ndikumasulidwa kwa ambiri a ma cytokines. Mphamvu zawo zimakhala ndi mbali imodzi, pakulowetsa matenda obwera chifukwa cha zochita zina, komanso, kuwonongeka kambiri ziwalo (makamaka mapapu, chiwindi, impso ndi myocardium). Kulephera kwa ziwalo zingapo komwe kumachitika nthawi imodzi ndichimodzi mwazinthu zazikulu zoyambitsa kudandaula koyambirira, komwe kumakulitsa, kuwonongeka kwa ziwalo zofunika kwambiri ndi machitidwe. Kugwedeza mochedwa, komwe kumawonekera ndi zovuta za purseat pancreatitis ya pachimake ndi sepsis, kumayamba chifukwa cha cytokinemia yoyambitsidwa ndi bakiteriya liposaccharides motsutsana ndi cytokine kusalinganika komanso oxidative kupsinjika kwa chikhalidwe cha sepsis.

Kuyambira tsiku loyamba la chitukuko cha pancreatitis pachimake yowopsa chifukwa chododometsa, njira zingapo komanso zodalirana zimayang'aniridwa: kutsekeka kwa chitetezo cha chitetezo (chitetezo choyambirira), kusalinganika kwa ma cytokines motsogozedwa ndi dimbidwe lakuthwa la pro-yotupa, kuyambitsa zingapo za endotoxemia, ziwalo zingapo, kulephera kapena kusokoneza kwa matenda. ndi ena

Kukula kwa kugwidwa koyambirira kwa pancreatitis yodziwika bwino nthawi zambiri kumachitika tsiku lachitatu la matenda. Kugwedezeka kumachitika motsutsana ndi maziko a enzyme ndi pro-kutupa cytokinemia (nkhope kutupa, nkhawa, kufupika, oliguria, peritonitis) ndikuwonetsedwa ndi magulu atatu a zizindikiro:

- tachycardia (kugunda kwa mtima> 120) kapena bradycardia (kugunda kwa mtima sindingapeze zomwe mukufuna? Yesani ntchito yosankha mabuku.

- kupuma kwapadera> 20 mphindi kapena pCO2 10%.

Zizindikiro ziwiri kapena zingapo za SIRS kuphatikiza kupezeka kwa kutsimikizika kwa matenda obwerekera, malinga ndi njira ya Chicago Protocol, wodwalayo amapezeka ndi sepsis. Sepsis ndi kukhalapo kwa ziwalo zingapo (kulephera kwa ziwalo ziwiri kapena kupitilira apo ndi machitidwe) imatchedwa "sepsis" yayikulu, ndipo sepsis yoopsa yokhala ndi hemodynamics yosakhazikika imatchedwa "septic shock".

Zomwe zimalepheretsa mantha oyamba ndikugwiritsa ntchito chipinda chothandizira kwambiri, chomwe nthawi zambiri chimagwiritsidwa ntchito pancreatitis yacute. Muzochitika izi, kutsindika sikuyenera kukhala pa antisecretory, koma pa mankhwala a anticytokine. Njira zothandiza kwambiri zochotsekera kwa ma cytokines okhala ndi chiwopsezo cha pancreatogenic ndi hemosorption, hemofiltration yotalikirapo komanso achire plasmapheresis. Ndi nkhawa yomwe yayamba kale, zomwe zimakonda komanso zosautsa kwambiri kwa wodwala ndizovuta

kukweza kwakukulu hemofiltration ndi njira yothandiza, Mosiyana ndi plasmapheresis, yomwe imapangidwa makamaka mu mawonekedwe a centrifuge. Tiyenera kukumbukira kuti njira ya plasmapheresis imangothandiza osati kutulutsa kosavuta kwa thupi ku plasma yoopsa. Kuphatikiza pa mphamvu yogwiritsira ntchito, njira ya plasmapheresis ili ndi katundu wokhudzana ndi gwero la toxosis, makamaka kapamba ndi kachigawo kakang'ono ka zakumwa za poizoni (exudates). Pankhani imeneyi, plasmapheresis, makamaka makomedwe, ayenera kuonedwa ngati njira imodzi yothandiza yothetsera endotoxemia mwa odwala omwe ali ndi pancreatitis yovuta kwambiri komanso kuwopsa.

Ngati mankhwalawa adayamba kudwala osaphunzitsidwa (mwachitsanzo, atavomera mochedwa patancreatic necrosis), chithandizo chachikulu chiyenera kukhala kulowetsedwa-kuthandizira mankhwala pogwiritsa ntchito colloidal ndi crystalloid kukonzekera kuti athetse dongosolo la hypoperfusion, kubwezerera kwa kutayika kwa protein-electrolyte ndi Kusintha kwazowonetsa zamatsenga. Ndikofunika kuthandizira pulogalamu yolowetsayi ndikutulutsa kwa kugunda kwa hydrocortisone mu 250-500 mg tsiku lililonse, zomwe zimapangitsa kusokonezeka kwa hemodynamic chifukwa cha mantha. Kuti muchepetse endotoxemia yomwe ikukula pang'onopang'ono kwa odwala omwe ali ndi pancreatic necrosis, ndikofunikira kugwiritsa ntchito kukakamiza diuresis.

Ngati mankhwalawa akayamba kudwala wodwala "wodwala", ndiye kuti kuphatikiza kwamatenda koopsa kumayenera kuzindikirika ngati kovuta kwambiri, matendawo akupita patsogolo, ndipo chithandizo chomwe chikugwiritsidwa kale ntchito sichokwanira. Muzochitika izi, kupuma ndi corticosteroid thandizo limafunikira limodzi ndi kulowetsedwa kwa plasma, reopoliglukin, Refortan, etc. Pambuyo pa hemodynamics okhazikika mwa odwala omwe adakumana ndi vuto loyambirira la pancreatogenic, ndikofunikira kuyambitsa funso la extracorporeal detoxization. Njira yosankhira pano ndi plasmapheresis. Pokhapokha ngati pali kupuma kwambiri pamatenda ophatikizika ndi aimpso kulephera komanso kuzungulira kwa magazi, njira ya hemofiltration ndiyotheka. Malinga ndi A.D. Tolstoy et al. , zofunikira za boma la plasmapheresis pansi paopseza kuwopseza ziyenera kukhala zovuta kwambiri:

- mawonekedwe a membrane

- Mlingo wawung'ono (8-10 ml / kg kulemera kwa thupi) pamtundu wa plasma,

- "zofewa" zotuluka (200-300 ml / h),

- kubwezeretsa kutaya kwa plasma "dontho ndi dontho",

- kufanana kulowetsedwa kwatsopano kwa makulidwe antiferment kukonzekera ndi antioxidant zotsatira ndi zina zothandiza achire zotsatira (gabexate mesylate, nafamostat, etc.).

Zochizira septic mantha chifukwa cha pancreatic necrosis ndi zovuta zake, mwadzidzidzi venoarterial hemosorption osakanikirana ndi kuphatikizika kwa ultraviolet Photomodization akufuna. Popeza mankhwalawa achitropic mankhwala omwe amagwiritsidwa ntchito mu endotoxin akudwala kwambiri am'mabokosi ambiri a kaboni,

kuchuluka kwa kuyambitsa kumayambiriro kwa kununkhira kuyenera kuwonjezereka ndi kuchepa kwake pang'onopang'ono mpaka kumapeto kwa njira yochotsera ndikusintha kwa kulowetsedwa kwa kukonza ("aimpso") Mlingo wa vasopressors. Njira yamakonzedwe opangira detoxification ikuphatikizidwa (kuchotsa + oxidation ya poizoni), chifukwa chake, pakutha kwa kuzungulira kwa hemocorrection, ndikofunikira kuwonjezera ntchito yoyendetsa magazi ndi kulowetsedwa kwa albumin.

Kunja, pochiza matenda ochita septic, amagwiritsa ntchito kuphatikiza kwa nthawi yayitali komanso kukhathamiritsa kwa mpweya wambiri. Kugwiritsa ntchito chiwembu chotere kwa odwala omwe akuchita opaleshoni ya sepsis amachepetsa kufa kwa septic mantha ndi 28%.

Pazaka khumi zapitazi, kusintha kwa magazi pogwiritsa ntchito intravenous immunoglobulins ndi njira ina yosiyana ndi njira zamankhwala zamankhwala zomwe zimafotokozedwa kale. Kukonzekera kwa immunoglobulin kwa makonzedwe amkati kumakhala ndi ma antibodies osiyanasiyana motsutsana ndi bacteria ndi ma virus. Immunoglobulins, makamaka yomwe imakhala ndi IgG, imayambitsa kuyambitsa mapangidwe a antigen / antibody, kenako ndikumangiriza kwawo kwa Fc zidutswa za Ig receptors pa membrane wa phagocyte, zomwe zimawonjezera mphamvu ya kuphatikiza kwa anti- komanso intracellular antigen. Ma IgM okhala ndi ma immunoglobulins amalimbikitsa endotoxins yama bakiteriya komanso amathandizira ntchito ya opsonizing yogwirizira, phagocytosis ndi bacteri losis. Kuphatikiza apo, ma immunoglobulins amasinthira mawonekedwe ndi zochitika za ma cytokine receptors, kuchepetsa kuchepa kwa cytokine cascade, ndipo potero amawonetsa zotsatira zotsutsana ndi kutupa. Pomaliza, ma immunoglobulins amatha kukhala ndi bactericidal zotsatira za maantibayotiki 1, 9. Kuchuluka kwakukulu komanso kotsimikizika kwa ma immunoglobulins kunadziwika kwambiri mu septic shock, yomwe imalola kuti igwiritsidwe ntchito, limodzi ndi ma anticytokines (interleukin-2, roncoleukin), ngati mankhwala osokoneza bongo a immuno.

Ma immunoglobulin odziwika bwino amaphatikiza mankhwala monga intraglobin (okhala ndi makamaka IgG), pentaglobin (IgM), venogen-lobulin (France), ndi sandoglobulin (Switzerland). Ma immunoglobulins apakompyuta opangidwa ndi makampani angapo (IMBIO ndi ena) ali ndi 5% IgG, amayeretsedwa kuchokera ku prekallikrein activator ndi ma molekyulu othandizira. Mlingo wa immunoglobulin ndi 25 ml. Mankhwalawa amamuwonjezera pa dilution ya 1: 1 - 1: 4 ndi njira ya shuga ya 5% kapena njira ya saline yothandizira pamlingo wosaposa 8 ml / min. Mlingo wa ma immunoglobulins mwa odwala a purulent-septic zimatengera kuuma kwa matendawa ndipo nthawi zambiri amachokera ku 25 ml mpaka 100 ml ya pro dosi. Mukuwopsezedwa kwa septic, tsiku lililonse mankhwala a immunoglobulins amafika 2 ml / kg pa kulemera kwa thupi.

Mphamvu yamatenda a immunoglobulins imawonetsedwa pakukhazikika kwa hemodynamics, kuchepa kwa kufunika kwa mankhwala a vasopressor, kusintha kwamphamvu kwa mapangidwe a ziwalo zingapo, kulephera kwa tizilombo toyambitsa matenda. Khalidwe labu zasintha pambuyo kukhazikitsa immunoglo-

a bulins akutumizira: kumaliza kwa phagocytosis, kuchuluka kwa hemolytic ntchito yothandizira ndi plasma ndende ya Ig. Pamodzi ndi immunoglobulins mu septic pancreatogenic shock, hyperimmune plasma ingagwiritsidwenso ntchito ndi bwino.

Pakachitika mantha a endotoxin, ndikofunikira kusiya zoyambitsa maantibayotiki m'malo mwa njira imodzi ya hemocorrection (hemosorption kapena immunotherapy yokhala ndi ma immunoglobulins a intravenous management, kapena plasma yachilendo). Izi ndichifukwa chowopsa chakutukuka kwa matenda a Jarisch-Herxheimer's (kufa kwa ma grorgan-negative tizilombo tating'onoting'ono ndikumasulidwa kwa misa yayikulu ya endotoxins). Mbali yothandizira mankhwalawa polimbana ndi endotoxin yomwe yayamba, yomwe ikufuna kuthana ndi tizilombo toyambitsa matenda, iyenera kuphatikizapo:

- ultraviolet Photomodization wamagazi,

- makina ophatikizira amagetsi osakanizira (kulowetsedwa kwa 0,05-0.1% sodium hypochlorite solution),

- kulowetsedwa kwa ma antiseptics (dioxidine, chlorophyllipt, ndi zina).

Zomwe zili pamwambapa zikuwonetsa kugwedezeka kwamphamvu

Pancreatitis, yomwe imatanthauzidwa ngati kusokonezeka kwakukulu kwa hemodynamic ndi systemic hypoperfusion, kwenikweni ndi chifukwa cha endotoxemia wambiri. Endotoxin yoyambirira komanso mochedwa imagwirizana ndi aseptic ndi septic magawo a pachimake necrotic pancreatitis. Mitundu iyi yododometsa imasiyana onse munjira ya chitukuko komanso njira zowakonzera. Nthawi yomweyo, malingaliro onse omwe amagwiritsidwa ntchito pochiza mankhwalawa amayenera kusungidwa: kuchotsedwa kwa hypoperfusion (makonzedwe a colloid ndi kukonzekera kwa Crystalloid), kupuma komanso chithandizo cha vasopressor, kuyang'anira mahomoni a corticosteroid, mankhwala a mtima, ndi zina zambiri. njira zoyenera zothetsera nkhawa, poganizira momwe wodwalayo alili.

1. Tolstoy A.D., Panov V.P., Zakharova E.V., Bekbausov S.A. Manjenjemera ndi kapamba owopsa. SPb.: Nyumba ya Skif Publishing, 2004. 64 p.

2. Volkov V.E. Pachimake kapamba. Cheboksary: ​​Nyumba yofalitsa ya Chuvash. University, 1993.140 s.

3. Nesterenko Yu.A., Shapovalyants S.G., Laptev V.V. Pancreatic necrosis (chipatala, matenda, chithandizo). M., 1994.264 s.

4. Ermolov A.S., Turko A.P., Zhdanovsky V.A. Kuwunika kwaimala mu odwala osagwiritsidwa ntchito omwe ali ndi pancreatitis pachimake // Gulu, kufufuza, zovuta zamankhwala zadzidzidzi. M., Omsk, 2000.S. 172-176.

5. Savelyev V.S., Buyanov V.M., Ognev Yu.V. Pachimake kapamba. M: Mankhwala, 1983. 239 p.

6. Weil M.G., Shubin G. Kuzindikira komanso kuchiza matenda. M: Mankhwala, 1971.328 s.

7. Chalenko V.V., Redko A.A. Kuchotsa. St. Petersburg, 2002.581 s.

8. Schmidt J., Haus S., Mohr V.D. Plasmapheresis wophatikizidwa ndi ma kontena owonetsa kukokoloka kwa odwala omwe akuchita opaleshoni ya sepsis // Care Med., 2000. No. 2 (5). R. 532-537.

VOLKOV VLADIMIR EGOROVICH adabadwa mu 1935. Amaliza maphunziro awo ku Kazan Medical Institute. Doctor of Medical Sayansi, Pulofesa, Mtsogoleri wa Dipatimenti Yachipatala ya Opaleshoni ya Chuvash State University, Wolemekezeka wa Sayansi ya Chechen Republic ndi Russian Federation, Membala wa Science Science for Opaleshoni ndi Membala waovuta Commission "Infection in Surgery" RAMS. Wolemba zofalitsa zopitilira sayansi zopitilira 600.

VOLKOV SERGEY VLADIMIROVICH. Onani p. 42__________________________

Kodi kugwedezeka kwamapazi kumatanthauza chiyani?

Kugwedezeka kwa kapamba ndi vuto lalikulu la thupi lomwe limayamba chifukwa cha zovuta zapakhansa, ndipo nthawi zambiri limayenderana ndi maziko a necrosis ya minofu yayikulu yapancreatic, ndipo imayendera limodzi ndi kuchepa kwa kuthamanga kwa magazi, kutsika kwa magazi, komanso kugwira ntchito kwa ziwalo zofunika.

Vutoli limadziwika ndi kuperewera kwamphamvu kwa magazi kwa ziwalo zonse.

Njira yowopsa kwambiri pakugwedezeka kwa pancreatic ndi kulowetsa kwa zinthu zakupha m'magazi, zomwe zimatengedwa m'thupi lonse ndi magazi ndikuwatsogolera pakupanga endotoxin.

Ndili zovuta izi zomwe zimawerengedwa kuti ndizomwe zimayambitsa kufa pancreatic shock.

Mankhwalawa pachimake pancreatitis nthawi zambiri amakula motsutsana ndi maziko oopsa, owonongeka a matendawa, omwe amaphatikizidwa ndi kuwonongeka kwa necrotic kwambiri. Kuchuluka kwa necrosis kumawerengedwa ngati njira yayikulu pakuwerengera chiopsezo chokhala ndi pancreatic shock.

Mankhwala, mitundu yoyambirira komanso mochedwa ya nkhawa imasiyanitsidwa.

Chithunzithunzi

Pachimake necrotic pancreatic mantha amatsogolera pakupanga njira zowonongeka mthupi lonse. Komabe, imawonetsedwa molakwika pakubwera kwa magazi. Zizindikiro zazikuluzikulu za mantha a pancreatic ndi:

1. Kuchulukitsa (kupitirira 120 kumenyedwa / mphindi) kapena kutsitsidwa (mpaka 70 kumenyedwa / mphindi) kugunda kwamtima.
2. Kutsika kwapang'onopang'ono kwa kukakamiza, osati kugwiritsidwa ntchito ndi chithandizo chamankhwala.
3. Centralization ndi decentralization kayendedwe ka magazi, kuchepa kwakukulu kwa kuchuluka kwa magazi, magazi osagwirizana.
4. Manja ndi mapazi ozizira, khungu la khungu.
5. Kupweteka kwambiri pamimba ndi hypochondrium.
6. Kuchepetsa mseru
7. Kupumira komwe sikupereka mpumulo.
8. Thupi.
9. Kuthetsa madzi m'thupi.
10. Phula lokhazikika.
11. Kutupa m'mimba.

Pakuchepa kwa pancreatic, kutentha kwambiri (kupitirira 38) kapena kutsika (pansi pa 36), kutentha kwadzaoneni kumatha kuonedwa. Mlingo wa kupuma umaposa 20 mpweya pamphindi, kugunda kwa mtima koposa 90 pamphindi. Ululu umatchulidwa kwambiri, wodwalayo amatha kusochera.

Pankhani ya zizindikiro za kukhudzidwa kwa pancreatic, muyenera kuyimbira ambulansi nthawi yomweyo, chifukwa izi ndizowopsa pamoyo wa munthu.

Limagwirira a chitukuko cha matenda

Kugwedezeka kwa pancreatitis pachimake kumachitika makamaka chifukwa cha kuwonongeka kwa necrotic ya pancreatic parenchyma minofu, zotsatira zoyipa m'thupi la ma enzymes ndi ma bacteria obwera chifukwa chake. Amanenanso kuti:

1. Ndi OP, chifukwa cha kutupa, kuphipha kwa kapamba, kufinya ndi ndulu, ma enzymes am'mimba sangalowe m'matumbo, motero amamuyika gland ndikuyamba kuiwononga. Popita nthawi, maselo othandizira a pancreatic amafa, amawola, ndikupangitsa kukula kwa njira zopatsirana, sepsis (poyizoni wamagazi).
2. Kuperewera kwa kapamba, enzymatic toxosis komanso sepsis zimayambitsa kusintha kwakukuru m'magazi ndi ntchito ya ziwalo zamtima zamagetsi, zomwe zimatsogolera pakupanga kufinya kwa pancreatic.
3. Kugwedezeka kwapweteka, komwe kumayamba chifukwa cha kupweteka kwambiri, kumabweretsa vasoconstriction. Chifukwa chake, magazi amayamba kuyenda kwambiri mpaka mtima ndi ubongo. Chifukwa cha kuchepa kwa mitsempha yamagazi, ziwalo ndi minyewa zimasowa mpweya, ndipo kugwira ntchito kwa mapapu ndi kwamikodzo kumasokonekera.
4. Impso sizitha kutulutsa mkodzo, zomwe zimabweretsa kutupa kwa ziwalo zonse zamkati.

Chifukwa cha kuwonongeka kwakukulu kwa maselo a pancreatic, madzi omwe amapezeka amapita ziwalo zapafupi, ma enzyme amayamba kuwononga mitsempha yamagazi:

• Lipase ndi proteinase, yomwe imagwira makoma amitsempha yamagazi, imawonjezera kuchuluka kwawo, kutayika kwa plasma, kukula kwa magazi, kutupa.
• Ma testpsins amawononga maselo ofiira amwazi.

Thupi limataya madzimadzi, mitsempha yamagazi imatsekeka, mafupa amkati mwa iwo. Kuchulukitsa kwa magazi kumayambitsa kutsika kwa magazi, kuchepa kwa magazi, komanso kuthamanga kwa mtima.

Cholinga chakukhazikitsidwa kwa kugwedezeka kwa pancreatic, koopsa kwambiri, ndi sepsis. Kuwonongeka kwa minofu ya pancreatic yakufa kumabweretsa kukula kwa matenda opatsirana. Pamene tizilombo tating'onoting'ono tomwe timayambitsa matenda oopsa ofunikira tikulowa m'magazi athupi, sepsis imayamba, yomwe imapangitsa chidakwa chonse. Zotsatira zake, kuchedwa kwa petoreatic pancreatic.

Thandizo loyamba lothandizira

Wopweteketsa mtima akapeza wodwalayo kunyumba, ayenera kuonetsetsa kuti kuli mtendere. Munthuyo azikhala pansi ndipo ayimbire ambulansi. Madokotala asanafike, ndikofunikira kutsatira malamulo awa:

• Wovutitsidwayo sayenera kupatsidwa chakumwa chilichonse, chakudya, mankhwala a ululu kapena mankhwala ena onse.
• Pamimba, mutha kuyika chopukutira kapena botolo lamadzi ozizira, wokutidwa ndi nsalu ya ayezi. Izi zimachepetsa pang'ono kuwawa.
• Ndikofunika kuthandiza wodwalayo kudekha komanso kumasuka, momwe mavuto am'mimba am'mimba, zochitika zamanjenje zimakulitsa ululu ndikupangitsa kufalikira kwa magazi, mtima kugwira ntchito.

Kuchipatala komanso kupumula kwa vuto

Wodwala wodwala matenda a pancreatic amatha kugonekedwa kuchipatala. M'dipatimenti yodzidzimutsa, chithandizo cha vutoli chimangokhala:

1. Kuyeretsa thupi ndi magazi a poizoni.
2. Kubwezeretsa kuchepa kwamadzi.
3. Kubwezeretsa moyenera acid-base.
4. Matenda a mamasukidwe akayendedwe, acidity, mankhwala zikuchokera magazi.
5. Anachepetsa ululu ndi kupsinjika.
6. Kupewa kwa chitukuko cha matenda.

Pofuna kuchotsa pang'onopang'ono zinthu zapoizoni m'thupi, amayamba kukhazikitsa ngalande. Ngati mukufuna kutulutsa m'mimba, kumveka kumachitika. Zikuchitikanso kutiyeretsa magazi a poizoni wogwiritsa ntchito ma ufesi.

Ngati ndi kotheka, zitha kupangidwa:

• hemofiltrate (kufalitsa magazi kudzera mu hemofilter ndi kulowetsedwa kwa kulowetsedwa kwa njira yothetsera),
• plasmapheresis (zitsanzo zamagazi, kuyeretsa kwake ndikubwerera).

Njirazi zimathandizanso kuyeretsa magazi a poizoni. Dziwani kuti ma sorbents amagwiritsidwa ntchito makamaka pancreatic necrosis, ndipo akakhala ndi mantha, hemofiltration kapena plasmapheresis amachitidwa. Kuphatikiza kwa njirazi kumachepetsa chiopsezo chaimfa pafupifupi 28%.

Kusintha matendawa madzi, acid-base usawa, kapangidwe ka magazi, wodwalayo amapaka jakisoni wa kulowetsedwa kwa mankhwala:

• Kutayika kwa mapuloteni-electrolyte kumabwezeredwa ndi njira za colloidal ndi crystalloid. Zimathandizanso kuti magazi azisintha.
• Pofuna kuchepetsa kupweteka kwambiri, amapaka jakisoni wa ma pinkiller, antispasmodics.
• Pofuna kupewa kukula kapena kufalikira kwa matenda, matenda opatsirana opatsirana ndi mankhwala amapatsidwa mankhwala.
• Ngati ndi kotheka, owonda magazi ndi magazi amawundikiranso.

Chaposachedwa, kusinthika kwa thupi ndi makina ofanana a immunoglobulins (mwachitsanzo, Pentaglobin, Intraglobin, Lobulin) ndi njira yabwino kwambiri yothandizira mankhwalawa. Ma immunoglobulins amachepetsa ntchito yofunika ya matenda ndi mabakiteriya, omwe amathandizira kuti matendawo atuluke komanso ayambe kugwira ntchito.

M'masiku oyambirira a chithandizo, wodwalayo amawonetsedwa ndi njala yayikulu. Muzovuta kwambiri, zitha kusamutsidwa ku zakudya zopanda ntchito.

Kuneneratu

Mkhalidwe wamatumbo umakula mu 9-22% ya odwala.

Kafukufuku awonetsanso kuti njira za necrotic mu kapamba zimayambitsa kuchepa msanga kwa chitetezo chathupi. Chiwerengero cha anthu omwe amafa chifukwa chadzidzidzi choyambirira cha pancreatogenic chikufika pa 48%, ndipo chifukwa chakumapeto kwa mawonekedwe a mankhwalawa, kuchuluka kwa zovuta ndizodziwika bwino - kuchokera pa 24 mpaka 72%.

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