HBO IN COMPLEX TREATING AND PROPHYLAXIS OF PURULENT-SEPTIC INFECTION OF OPERATED PATIENTS.

Practical recommendations.

The probability of purulent complications after operations (PCO) is improving and already has achieved 10-12%. Lethality is above 30%. That problem requires a solution, which can be found in complex of measurements aimed at normalization of homeostasis and actions against the biologic excitators. HBO can be included in this complex.

Persued investigations permitted to determine a high efficiency of HBO in treating of PCO. It lessens the syndromes; guarantees adequate gaseous composition; improves metabolism and reduces functional violations. It also restores immune system; accelerates the healing of wounds; suppressed microbial activity.

697 patients with wound infection were taken into account (sepsis, peritonitis, tissue infections). 328 of them received a course of HBO-therapy. 204 got HBO as a prophylaxis of PCO.

1. Characteristics of method.

The essence of HBO is the improvement of partial pressure in tissue as the result of respiration of oxygen at the improved pressure.

The procedures are held in single place curing chambers "Oka - MT" and  "BL - 3". Treating courses can be held in common curing chambers with volume more than 3000 liters with the pressure regime of 10AT, which are fooled with pressed air. That chamber can contain the stuff simultaneously with sick person. Single place chambers (OLB) with volume less than 2500 liters, the internal pressure is no more than 3AT. These chambers are fooled only with oxygen. The working pressure - is the one been supplied during the HBO. If ulcer is being cured, the working pressure usually equals 1AT of oxygen. The extra pressure - is the pressure additional to the one in normal atmosphere. Sum of extra pressure and of atmosphere's one give us an absolute pressure. Extra  and absolute ones are measured in technical atmospheres and are marked ATI and ATA correspondingly. For treating of PCO the pressure would be 0,5-2AT.

In regime 1ATI partial pressure of oxygen improves by factor 3,5-4; carbon dioxide -lessens by 2-3 mm. of mercury (with pH of blood 7,40-7,43). With 3AT the erythrocytes are not required for supply of tissue metabolism with oxygen - in ordinary conditions 2/3 of molecules of oxygen are terminated with hemoglobin; in case of HBO the major part of it is dissolved in plasma. Any kind of hypoxia can be cupped off by means of HBO.

The benefit of HBO is obvious; the problem is to select the best regimes for particular diseases and particular patients. For measurements the unit of atmosphere-hour or bar. 1bar. equates 1 hour spent at pressure of 1ATA. The doses of compression and decompression periods would also be included in sum.

To simplify the calculations of dose Table 4 can be used: there exposition is marked in vertical axis and average pressure -in horizontal one; on the cross one can receive the dose. Dose of course is a sum of ones at all procedures.

The application of doses can determine the amount of HBO in exact figure and avoid the intoxication which becomes above 20 bar. Thus, therapeutic effect lies between 8 - 20 bar.

2. Indications for treating by HBO.

Indications for application of HBO against purulent-septic infection are:

1) sepsis;

2) any peritonitis ;

3) any purulent foci of stomach;

4) tissue infections;

5) meningitis, meningoencephalitis.

Application of HBO is also desirable for prophylaxis of PCO:

1) vast and complicated operative invasions;

2) operations with additional diseases (malignant tumor; collagen diseases; cardiovascular diseases; diabetes; radiotherapy; leucopenies; hypogammaglobulinemies; after splenectomia);

3) sick and weak patients;

4) traumatic damages of stomach;

5) after preceding surgeonal treatment of dusty wound.

Probable complications and their prophylaxis.

The probable complications of HBO are:

1) Otorhinolaryngologic complications - the continuation of HBO depends on otorhinolaryngologist's conclusion;

2) barotraumata of nose; ears and lung;

3) barootitis; barosinusitis. The treating is as usual;

4) Intoxication caused by high sensitivity to oxygen.  We know hypereximia to reduce the pulse and respiratory indexes; sudden improvement of pulse index with its steady lessening from the beginning display the oxygental intoxication and demand to interrupt the procedure.

4. Investigation of patients with purulent-septic complications.

Before the course a number of investigations would be held to avoid complications and estimate the efficiency if HBO-therapy.

1. Roentgenoscopy or roentgenography of chest to avoid contraindications.

2. Otorhinolaryngologist's consultation.

3. Electroencephalogram to exclude convulsions.

4. Electrocardiogram; tetra polar reography to investigate hemodynamics.

5. Reopatography of circulation in liver.

6. Biochemical investigations: sugar in blood; protein; billyrubine. 7. Clinical blood analysis.

8. Investigation of activity of transminases.

9. Thymol and corrosive sublimate probes.

10. Diastase urine investigation.

11. Immunologic blood analysis.

12. Bacteriologic investigation by means of gaseous chromatography for determination of specter of infection.

13. Investigation of electrolyte composition of blood.

14. Investigation of acid-alkaline balance.

15. Psychical investigations.

5. Regimes and methods of HBO procedures.

Curing doctor would consult with HBO-specialist on scheme of HBO-therapy for every patient particularly: amount of procedures; their regime; exposition; medicinal therapy. Just before the procedure oil and creams would be removed from the skin; patient would be dressed in cotton (including special hat on his hair). Electrical termination with earth is necessary. The procedure would teak place no less than 30-40 min. after food reception. Ephedrine or

adrenaline are desirable for prophylaxis of otorhinolaryngoligic complications.

HBO would be begun in presence of curing doctor to indicate immediately claustrophobia, improved sensitivity to oxygen and compression. An instruction would take place before it. Patient wouldn't smoke for three hours after the procedure - otherwise the effect can be brief and slight. Arterial pressure and pulse would be controlled. Before the procedure arterial pressure, pulse index, integral reogram and reopatogram would be investigated; cardiogram and encephalogram would be done in the process of HBO. Reception of sedative and spasmolitic medicines of compulsory in advance.

Application of HBO for treating of PCO and purulent sepsis in general includes some particular details. In treating of PCO the purulent focus would be prepared to drain as soon as possible.

The regime of HBO is individual for every patient; it depends on degree of disease and hardness of infectious intoxication.

To determine that the following figures are of primary importance:

1) Pathogenetic investigations. That is persued by means of chromatograph "Tsvet (color)-06" (bacteriologic express-diagnosis; density of pollution with microbes; identification of infection dangerous microbes). Gaseous chromatography for determination of character of infection (the analysis takes only 45 min.): aerobe or anaerobe one  is especially important. That chromatogram can determine the efficiency of therapy, and change it, if needed. It also can detect the efficiency of antimicrobal therapy.

2) Immunologic investigations for determination of resistance of body - that is a complex of immunologic indexes. Especially important are the tests of helper and depressor activity of T and B lymphocytes. The improvement of possession of immunoglobulines permits to make the conclusion of the positive effect of treating.

3) Investigations of maximal dose, that yet permits to avoid oxygental intoxication - can determine the displays of intoxication from the very beginning and transform the regime in time. For this the investigations of central and peripheral hemodynamics (integral reography), hemodynamics of liver by means of reopathography.

Improvement of reduced stroke volume and stroke index, VPM and cardioindex, lowering of peripheral vascular resistance, improvement of liver circulation, normalization of cardiogram are good phenomena and permit to improve the dose. The peripheral resistance is above 2000 din/sec.*sm.5; lowering of stroke volume by 15%; stroke index by 10%; VPM by 15-20% or cardiac index by 12-16% as well as reduction of circulation in liver display the negative influence of HBO. Vasadilatoral therapy, stabilization of circulation (nitroglycerin) and medicines for improvement of circulation (trental, heparin) would be applied. If the success is nevertheless absent, the dose would be lessened. The new regime would correspond to the maximal value of pO2.

Electroencephalogram can determine the moment of beginning of intoxication (that is when foci of epileptiforal activity in cerebrum arrive) and lessen the dose or interrupt the procedure.

HBO diminishes the complex hypoxia: restores the activity of intestine, supplies the viability of intestinal margin of peritonital sicks, normalizes the activity of parenchymatous organs, improves the immunity and antibacterial therapy.

In treating of PCO the dose can be 12-20 bar.; pressure - 1,5-2,5ATA with exposition of 60-90 min. The first 1 - 2 days 2 - 3 procedures would be done in a day; later - 1; with unimprovment of limit of 20 bar.

For prophylaxis of PCO the values for course would be: 4,5 - 8 bar.; pressure - 1,5ATA; exposition - 50-60 min. is also desirable immediately after the operation with no exceding of limit of 20 bar.

The selection of dose would depend generally on the values, represented in 3 group of investigations.

6. Clinical recommendations.

1) HBO for PCO would be completed with specific therapy; operation. HBO only lessens the inflammation; the period of treating and lethality.

2) The figures for HBO depend on individual state of patient; his sensitivity to oxygen and efficiency of treating.

3) If the infection is too developed and strong, HBO would be applied very tenderly, with compulsory correction of all violations.

4) If the anaerobes are too sensitive to oxygen, the application of HBO can cause their simultaneous immediate death with later pollution and intoxication of body. Thus hemodilution and stimulation of diuresis are desirable.

5) Clinic control (gaseous chromatography; reopatography; cardiogram; immunocontrol) is compulsory; the subjective feelings of patient can't be real display of state.

6) For immediate determination of oxygental intoxication permanent cardiographic and encephalographic control are needed.

7) Application of vasodilators, coronalitics, medicines for improvement of circulation can improve the transport of oxygen to the tissue.

8) The violations of conductivity at cardiogram can't be the contraindication for the application of HBO.

9) HBO for prophylaxis of infection in wound is desirable in prophylaxis complex of other diseases (diabetes, cardiovascular diseases, diseases of liver) combined with malignant tumor; radiotherapy; hypogammaglobulinemia; acatalasemia; splenectonomy; for sick and weak patients.

The principle effect of HBO - is normalization of general circulation of blood - plasmatic and globular volumes; potassium and sodium balance; coagulative and anticoagulative systems. Normalization of tissue metabolism; reduction of energy application; improvement of activity if antibiotics all of these improves the general therapeutic effect.

We believe, our recommendations would improve the application of HBO in treating of PCO and avoiding the complications.

Normogram for determination of dose in bar.