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Хирургические вмешательства и наркоз у больных
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Хирургические вмешательства и наркоз у больных

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by admin14.09.2015
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У тяжело-обожженных хирургические вмешательства и наркоз ухудшают и без того нарушенные процессы гемодинамики. Операция иссечения ожогового струпа может послужить толчком к развитию инфекции или незамеченного ранее легочного осложнения, она снижает и без того низкую сопротивляемость организма. Потери крови при этом достигают 4-5 л. При обширных ожогах ощущается недостаток в здоровой коже, годной для трансплантации, поэтому приходится прибегать к временному покрытию ран ауто-, гомо- или ксенокожей и производить повторные пластики, выжидая срок, необходимый для регенерации эпителия на донорских участках. Однако, несмотря на это, многие авторы считают первичную некрэктомию методом выбора при лечении глубоких ожогов независимо от их площади. Так, за последние 12 лет в ожоговой клинике г. Любляна данным способом лечили практически всех обожженных (2409 первичных некрэктомий).

Наибольший успех приносит первичная эксцизия у детей. С помощью этого метода увеличивается процент выживаемости и уменьшается срок госпитального лечения у детей с ожогами, занимающими до 65% и более поверхности тела. Судя по данным литературы, у взрослых больных таких успехов достичь не удалось. Большинство авторов считают наиболее целесообразным производить первичную некрэктомию в сроки от 3 до 14 дней после ожога. Иссечение должно быть выполнено тогда, когда больной выведен из состояния ожогового шока, а инфекция в ране не достигла большого развития. После завершения инфузионной терапии ожогового шока требуется еще 24-36 ч, чтобы дать оценку проведенным реанимационным мероприятиям и определить показания для первичной некрэктомий. До 4-5-го дня развитие инфекции в ожоговой ране идет не очень быстро, а начало васкуляризации в зоне клеточного поражения происходит на 3-5-й день после ожога, поэтому слишком раннее иссечение (в первые 24-48 ч) может привести к тому, что будут удалены глубжележашие ткани, в которых в эти дни еще может восстановиться кровообращение. Задержка операцией более 5 дней нежелательна в связи с тем, что в этот период бактериальная инвазия в ране может стать значительной. Иссечение тканей, в которых число грамотрицательных бактерий равно 1000 в 1 г и выше (или грамположительных кокков несколько ниже этой величины), часто приводит к сепсису и неприживлению трансплантатов.

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