Modern aspects of infection surgery. Textbook for students, residents, practical health workers

160 Pages·2020·3.032 MB·Russian

by  Vladimirova O. V., Korablina S. S., Lavreshin P. M., Chotchaev M. K., Brusnev L. A., Gobedzhishvili V. K., Gobedzhishvili V. V., Kudjeva F. A., Vladimirov V. I.

The Federal State Budgetary Educational Institution of Higher Education
«Stavropol State Medical University»
of the Ministry of Healthcare of the Russian Federation
Stavropol State Medical University

MODERN ASPECTS
OF INFECTION SURGERY
Textbook for students, residents,
practical health workers
Stavropol, 2020
1
УДК 616-002.3-089 (075.8)
ББК 54.561.2я73
Modern aspects of infection surgery. Textbook for students, residents, practical health
workers. Stavropol. Publishing house: StSMU-2020, 160 p.
ISBN 978-5-89822-684-8
Textbook is intended for students of the medical, dental and pediatric faculties, interns
and clinical residents for an in-depth study of the basics of surgery, as well as for doctors
of practical health care. Textbook provides an idea of surgical infection, the main acts that
regulate the rules for the prevention and treatment of nosocomial infection, the main types of
surgical infection, methods and principles of diagnosis and treatment.
Authors:
Vladimirova O.V., Candidate of Medical Sciences, Associate Professor of the General
Surgery Department, StSMU
Korablina S.S., Candidate of Medical Sciences, Assistant, General Surgery Department,
StSMU
Lavreshin P.M., Doctor of medical sciences, professor, head of general surgery
department of StSMU
Chotchaev M.K., Candidate of Medical Sciences, Assistant, General Surgery
Department, StSMU
Brusnev L.A., Candidate of Medical Sciences, Associate Professor of the General
Surgery Department, StSMU
Gobedzhishvili V.K., Candidate of Medical Sciences, Associate Professor of the
General Surgery Department, StSMU
Gobedzhishvili V.V., Candidate of Medical Sciences, Associate Professor of Surgery
Department of the Institute of Postgraduate Education of the Federal State Autonomous
Educational Institution of Higher Education I.M.Sechenov First Moscow State Medical
University
Kudjeva F.A., Candidate of Medical Sciences, Assistant, hospital surgery department,
StSMU
Vladimirov V.I., Doctor of medical sciences, professor of PSU
Reviewers:
Aidemirov A.N., Doctor of Medical Sciences, Professor, Head of the Department
of Hospital Surgery, Federal State Budget Educational Institution of Higher Education
“Stavropol State Medical University” of the Ministry of Health of the Russian Federation
(StSMU)
Topchiev M.A., Doctor of Medical Sciences, Professor, Head of the Department of
General Surgery, The Federal State Budget Educational Institution of Higher Education
“Astrakhan State Medical University” of the Ministry of Health of the Russian Federation
(ASMU)
УДК 616-002.3-089 (075.8)
ББК 54.561.2я73
Рекомендовано к печати редакционно-издательским советом СтГМУ
ISBN 978-5-89822-684-8
© Stavropol State
Medical University, 2020
2
Федеральное государственное бюджетное
образовательное учреждение высшего образования
«Ставропольский государственный медицинский университет»
Министерства здравоохранения Российской Федерации

СОВРЕМЕННЫЕ АСПЕКТЫ
ГНОЙНОЙ ХИРУРГИИ
Учебное пособие для студентов, ординаторов,
врачей практического здравоохранения
Ставрополь, 2020
3
УДК 616-002.3-089 (075.8)
ББК 54.561.2я73
С 56
Современные аспекты гнойной хирургии: учеб. пособие для студентов, ордина-
торов, врачей практического здравоохранения. Ставрополь – Изд-во СтГМУ, 2020. –
160 стр.
ISBN 978-5-89822-684-8
Учебное пособие предназначено для студентов лечебного, стоматологического и пе-
диатрического факультетов, ординаторов для углубленного изучения основ хирургии, а
также для врачей практического здравоохранения. В пособии дано представление о хи-
рургической инфекции, основных актах, регулирующих правила профилактики и лече-
ния внутрибольничной инфекции, основных видах хирургической инфекции, методах и
принципах диагностики и лечения.
Авторы:
Владимирова О.В., к.м.н., доцент кафедры общей хирургии СтГМУ
Лаврешин П.М., д.м.н., профессор, зав. кафедрой общей хирургии СтГМУ
Кораблина С.С., к.м.н., ассистент кафедры общей хирургии СтГМУ
Гобеджишвили В.К., к.м.н., доцент кафедры общей хирургии СтГМУ
Байчоров Х.М., к.м.н., ассистент кафедры общей хирургии СтГМУ
Чотчаев М.К., ассистент кафедры общей хирургии СтГМУ
Бруснев Л.А., к.м.н., доцент кафедры общей хирургии СтГМУ
Гобеджишвили В.В., к.м.н., доцент кафедры хирургии ФГАОУ ВО «Первый Москов-
ский государственный медицинский университет имени И. М. Сеченова» Миниздрава
РФ, институт последипломного образования
Куджева Ф.А., к.м.н., ассистент кафедры госпитальной хирургии СтГМУ
Владимиров В.И.. д.м.н., профессор ПГУ
Рецензенты:
Айдемиров А.Н., д.м.н., профессор, заведующий кафедрой госпитальной хирургии
Федерального государственного бюджетного образовательного учреждения высшего об-
разования «Ставропольский государственный медицинский университет» Министерства
здравоохранения Российской Федерации
Топчиев М.А., д.м.н., профессор, заведующий кафедрой общей хирургии Феде-
рального государственного бюджетного образовательного учреждения высшего образо-
вания «Астраханский государственный медицинский университет» Министерства здра-
воохранения Российской Федерации
УДК 616-002.3-089 (075.8)
ББК 54.561.2я73
С 56
Рекомендовано к печати редакционно-издательским советом СтГМУ
ISBN 978-5-89822-684-8
© Ставропольский государственный
медицинский университет, 2020
4
CONTENT
Chapter 1. SURGICAL INFECTION ..............................................................6
Classification ..................................................................................6
Forms of inflammation ...................................................................8
Common signs of a surgical infection ............................................8
Local signs of surgical infection ..................................................10
Diagnostic methods for surgical infection ....................................11
Chapter 2. ACUTE PURULENT NON-SPECIFIC INFECTION .................13
Chapter 3. SPECIFIC SURGICAL INFECTION ........................................116
TEST PROBLEMS ....................................................................142
CASES .......................................................................................152

5
CHAPTER 1. SURGICAL INFECTION
Surgical infection is the introduction and reproduction of
pathogenic microorganisms in the body, followed by tissue damage and
the formation of an inflammation focus as a result of direct exposure
(including the release of toxins by the microorganism) or by immune
reactions. For this, as a rule, two conditions are necessary: first –
overcoming the protective forces of the macroorganism, second – the
presence of a certain sensitivity of the organism to the pathogenic agent.
A surgical infection is an infection that develops as a result of
surgery or requires surgery.
Classification of the Surgical infection:
• depending on the type of pathogen,
• depending on the number of pathogens,
• according to the clinical course,
• by prevalence (general, local),
• by localization.
The following microorganisms are among the most common
pathogens of surgical infection:
– aerobic and optional grams (+) of cocci: Staphylococcus,
Streptococcus, Enterococcus;
– optional anaerobic gram (-) sticks: bacteria of the Enterobactericeae
family of Escherichia, Klebsiella, Proteus, Enterobacter, Citrobacter;
– aerobic non-fermenting gram (-) sticks and coccobacilli:
Pseudomonas, Acinetobacter;
– aerobic and optional anaerobic grams (+) sticks: Lactobacillus;
– anaerobic gram (-) bacteria: Bacteroides, Fusobacterium,
Veillonella;
– anaerobic gram (+) cocci: Peptostreptococcus, Peptococcus;
– Anaerobic gram (+) bacteria: Clostridium.
By the number of pathogens of surgical infection:
– monoinfection (staphylococcal, streptococcal, proteus, gonococ-
cal, etc.)
– polyinfection (staphylococcal and colibacillary, staphylococcal
and streptococcal, etc.).
According to the clinical course (body reaction):
– acute surgical infection
– chronic surgical infection.
Acute surgical infection:
6
– acute nonspecific infection.
– acute specific infection (tetanus, anthrax, wound diphtheria,
actinomycosis, tuberculosis and wound syphilis, etc., acute clostridial
infection).
Chronic surgical infection:
– non-specific infection (as the outcome of acute non-specific
infection);
– specific infection (tuberculosis, syphilis, actinomycosis, etc.).
By prevalence:
– local (abscess, carbuncle, etc.)
– general surgical infection (sepsis).
Localization distinguishes a surgical infection:
• integument of the skull and its contents;
• neck;
• bones and joints;
• skin, subcutaneous tissue of the limbs and trunk;
• chest wall, pleura and lungs;
• mediastinum;
• peritoneum and abdominal organs;
• the pelvis and its organs.
Factors determining the pathogenesis and clinical course of a
surgical infection.
1. Etiological factors.
– Type of microbe, its pathogenicity, virulence, drug resistance.
– The number of microorganisms that penetrated the tissue
(a critical level of 10 microbes per 1 g of tissue).
– Mono – or polymicrobial flora.
2. Local factors:
– Routes of penetration of microorganisms (tissue, lymph, blood).
– Ways of the spread of microbes in the body (in contact – continuum;
in extent – continuum, lymphogenous, hematogenous).
– Disorder of blood and lymph flow.
– The presence of necrosis and hemorrhage (hematomas).
– The state of local tissue immunity.
3. The immune-biological state of the body.
– Reactivity: normergic, hyperergic, hypoergic, anergic.
– Resistance (stability, resistance) of the body (normal, increased,
decreased).
– Specific resistance – immunity.
7
– Nonspecific resistance – the level of lysozyme, complement,
cationic proteins, phagocytosis activity, etc.
Forms of inflammation:
– alternative,
– exudative
– promorative.
The nature of exudative inflammation:
– serous,
– serous fibrinous,
– serous-purulent,
– purulent, etc.
The main pathophysiological and pathological changes in the
focus of inflammation:
1. The accumulation of metabolites, vasoactive substances, a change
in pH leads to the development of reactive hyperemia.
2. Increased vascular permeability in the focus of inflammation
leads to exudation, swelling, throbbing pain.
3. Reactive hyperemia is subsequently replaced by congestive
hyperemia, stasis, thrombosis, necrosis (cells, tissue sites) occur.
4. Migration of macrophage leukocytes – phagocytosis; the
breakdown of leukocytes, tissues, the release of lysosomal enzymes –
proteolysis.
5. Rejection (sequestration) of dead tissue sites – the beginning of
abscess formation.
6. The development of granulation tissue (pyogenic capsule) around
the inflammatory focus, fragmentation of necrotic tissues, accumulation
of pus – the formation of an abscess.
7. Progression of the process or reverse development.
Signs of surgical infection:
– general
– local
For acute surgical infection is most characteristic the hectic type of
fever, for chronic – a constant, remitting or intermittent fever.
Causes of endotoxemia (toxemia) during surgical infection.
1. Vital products of microbes, their toxins – microbial toxemia;
2. Tissue toxemia (peptides, polypeptides, proteinases, colla-
genases);
3. Biologically active substances (histamine, serotonin, bradykinin);
4. Toxemia of a metabolic nature due to:
8
– metabolic disorganization – the accumulation of end products of
metabolism;
– metabolic toxemia – the accumulation of intermediate exchange
products;
– metabolic depletion – a violation of the synthesis of ATP or its use.
Clinical symptoms of endotoxemia in surgical infection:
 Disorder of higher nervous activity: agitation, bad sleep,
nightmares, psychosis, depression of consciousness, coma.
 Growing weakness, weakness.
 Decrease in intellectual activity, limitation of interest in others.
 Disability.
 Pain in joints, muscles, lower back, headaches.
 Increased metabolism, increased heat production, increased body
temperature, increased sweating.
 Thermoregulation disorder – the development of fever.
 The extreme degree of thermoregulation disorder is hyperthermic
shock (pale hyperthermia, Ombredan syndrome).
Ombredan syndrome is characterized by a progressive increase in
temperature, inhibition of consciousness or agitation, pale color of the
skin, their dryness, shortness of breath, cardiovascular insufficiency
(Ps– 120-140 per 1 minute, weak filling and tension; blood pressure –
90-70 mm Hg . and below). Hyperthermic shock may result in the death
of the patient. For his early diagnosis, hourly thermometry is needed.
Disorder of the cardiovascular system: tachycardia, arterial
hypotension, decreased central output pressure.
Disorders of the gastrointestinal tract: loss of appetite, nausea,
vomiting, diarrhea, stool retention.
Renal dysfunction: oliguria, in the urine – protein, cylinders, red
blood cells; may develop acute renal failure (ARF) – anuria, azotemia.
Changes in the blood: leukocytosis, left shift, toxic granularity
of neutrophils, high ESR, anemia, dysproteinemia, hypoproteinemia,
bilirubinemia. Enlarged regional and distant lymph nodes, possibly
enlarged spleen.
In severe cases, disorders of the blood coagulation system develop,
often there is a syndrome of disseminated intravascular coagulation
(DIC – syndrome).
There are three degrees of toxicosis severity:
1. Mild toxicosis: general condition satisfactory, subjectively
moderate discomfort, low-grade fever, leukocytosis 8 – 10x109 / l,
ESR – 15 – 20 mm / hour.
9
2. Toxicosis of moderate severity: general state of moderate sever-
ity, subjectively expressed discomfort, high temperature, intermittent,
tachycardia up to 100 beats per minute, leukocytosis 11-16x109 / l, shift
of the white blood formula to the left, toxic granularity of neutrophils +,
++; ESR – 21 – 40 mm / hour.
3. Severe toxicosis: general condition is severe or extremely severe,
severe discomfort, high temperature, hectic fever with chills, severe
tachycardia, pulse 100 – 130 beats per min., Leukocytosis 17 – 30x109 /
l, pronounced shift of the blood count to the left, aneosinophilia, toxic
neutrophil granularity ++, +++, ESR 40 mm / h, dysproteinemia, hypo-
proteinemia, anemia, bilirubinemia.
LOCAL SIGNS OF SURGICAL INFECTION
Local symptoms:
– local hyperemia of the skin – redness (rubor)
– edema – a tumor of tissues (tumor)
– palpation determined soreness and fluctuation – pain (dolor),
– impaired function of the affected area – (functio laesa).
– local temperature increase – heat (calor)
All delimited foci of inflammation are characterized by a pronounced
reaction of the blood:
– acceleration of ESR;
– leukocytosis with a shift to the left and moderate toxic changes in
neutrophils.
The foci of absorption are: purulent streaks, the presence of necrotic
tissues, crushed tendons, fascia, muscles, bone sequestration, foreign
bodies. Under these conditions, the resorption process is most pro-
nounced, because significant spread and accumulation of pus in tissue
spaces does not have time to be limited to a granulation shaft, which can
interfere with absorption. Resorption occurs by the lymphogenous and
hematogenous pathways.
The development of fever in this case is due to the absorption of
protein decay products and bacteria. The severity of the condition of
surgical patients is exacerbated by the fact that, simultaneously with
the absorption of toxic products, there is a big loss with pus proteins,
enzymes, electrolytes, impaired bowel function.
The severity of the fever corresponds to the severity of the
suppuration process.
10