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30ASSESSMENT OF THE EFFICIENCY OF TREATMENT OF THE DISTRIBUTED APPENELICULAR PERITONITIS IN CHILDREN Abbasov Kh.Kh.1, Abdurakhimova A.F.2, Gafforova S.Sh.3, Mukhammedova F.F.4, Yusupova Sh.Sh.5
1Abbasov Khojimuhammad Khabibullayevich - Student; Abdurakhimova Amira Farrukhovna - Student;
Gafforova Sadoqat Shokirovna - Student; 4Mukhammedova Fariza Farkhodovna - Student;
5Yusupova Shahlo Shavkatovna - Student, DEPARTMENT OF PEDIATRIC SURGERY, SAMARKAND STATE MEDICAL INSTITUTE, SAMARKAND, REPUBLIC OF UZBEKISTAN
Abstract: analysis and comparison of the validity of prognostic scales (SOFA, APACHE II, SAPS, MODS, PRISM) was conducted on data from 166 patients. In the main group of patients, the undertaken preoperative preparation tactics allows to stabilize the general condition of the patients already on the first day after the operation. At the same time, mortality in the main group varied in the range of 1,8-2,9% (APACHE II - SOFA), and in the comparison group 12,5% - 16,7% (APACHE II, MODS - SOFA). The study of the dynamics of indicators on prognostic scales against the background of DAP allows us to identify the most complex groups of patients who need a more serious resource of intensive therapy. When using any of the scales, a linear relationship is found between the number of points and the level of mortality (for example, for SAPS, each ten-point increase corresponds to an increase in mortality of about 10%).
Keywords: children, appendicular peritonitis, treatment, integral prognostic scales.
Introduction. According to world statistics the general incidence of appendicitis is from 3 to 6 on 1000 children with the peak of incidence at the age of 9-12. Peritonitis against the background of destructive forms of appendicitis at children develops in 8 times more often than at adults, and its
generalized forms meet by 2.5 times more often than local [1, 3, 7, 8, 11, 15. 17]. Despite achievements in diagnostics of an acute appendicitis, the frequency of development of its destructive forms fluctuates from 20 to 74% [5, 6, 9, 19]. Achievements of modern medicine gave to surgeons a number of the effective methods allowing to save life the patient with peritonitis. However, the number of postoperative complications remains at the level of 10-15% in the last decade and does not tend to decrease [6]. And, development of these complications remains low-predicted, so, and insufficiently operated process [7]. In this regard further improvement of surgical tactics at children with destructive forms of appendicitis remains a priority task [8].
Today in universal surgical practice, assessment of a condition of the patient on shipping of an operative measure is the most basic moment and is included in all standards and protocols of preparation and treatment of patients in hospitals of a surgical profile [3, 9]. Various integrated scales of assessment of a state which on the one hand allow to define degree of dysfunction of organ systems are for this purpose used and judgments of the forecast can form a basis, with another - prove tactics of the carried-out treatment, its efficiency and also that is not unimportant, define economic costs of treatment [2, 4].
Research objective: to carry out the analysis of use of the most often used predictive scales in urgentny surgery at patients in two groups of comparison, on weight of a current estimated as patients with multiorgan insufficiency (MOI) against the background of the distributed appendicular peritonitis (DAP).
Materials and methods: the analysis and comparison of validity of predictive scales is carried out on these 166 patients. The scale of SOFA was counted on 63 patients (45 - the main group and 18 - group of comparison), APACHE II - on 116 patients (81 - the main group and 35 - group of comparison), SAPS II - on 157 patients (113 - the main group and 44 - group of comparison), MODS - on 78 patients (50 - the main group and 28 - group of comparison), PRISM - on 120 patients (94 - the main group and 26 - group of comparison). On all scales the
probability of a lethal outcome within the first day of hospitalization decided on use of necessary parameters. The main group was made by patients to whom in the presurgical period the complex of an intensive care directed to correction of a hypovolemia and the metabolic acidosis which developed against the background of DAP is included. The group of comparison was made by patients, the protocol of an intensive care at whom was fulfilled at once after the emergency surgical intervention.
Results: use of one of the considered integrated scales for assessment of weight of a state and the forecast is informative and can be used at children with DAP. At the same time it should be noted that indicators of a clinical current and lethality in the main group on the long-term forecast considerably exceed the same indicators in group of comparison. More visually this picture is reflected by summary assessment of efficiency of the undertaken tactics of treatment of children with DAP which is reflected by us in the form of the graphic cryptogram in figure 1.
Basic group Group of comparison
Note: T-criterion - between indicators in groups of comparison
Fig. 1. Summary data on dynamics of the status of children with DAP on predictive scales of assessment of the general state
Apparently from the chart, in the main group indicators in all rating scales considerably decrease in the first day after operation: for MODS and SOFA almost twice, and for APACHE II, SAPS, PRISM, more than by 1.5 times.
In group of comparison these indicators considerably differed. So, in the first day after operation on indicators of MODS and PRISM, in this group of patients reliable positive shifts are noted, and at assessment on scales of SOFA, APACHE II, SAPS these shifts made 1.2-1.3%.
Summary frequency of lethality among children with DAP on predictive scales is presented on figure 2.
□ SOFA DAPACHE II DSAPS □ MODS □ PRISM
Group of
Diffuse peritonitis Spilled peritonitis In total
□ SOFA DAPACHE II DSAPS □ MODS □ PRISM
Fig. 2. Lethality frequency among children with DAP on
predictive scales
Apparently from figure 2, for all predictive scales almost identical lethality, in the main group which varied within 1.8% on a scale of APACHE II, 2.3% on scales of SAPS and MODS,
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2.5% on a scale of PRISM and 2.9% on SOFA scale is noted. In group of comparison this indicator corresponded: 12.5% on scales of APACHE II and MODS, 13.3% on SAPS, 13.5% on PRISM and 16.7 on SOFA scale. Thus, assessment of a condition of children with DAP at receipt with use of one of the integrated predictive scales (SOFA, APACHE II, SAPS, MODS, PRISM) which are often used in world practice, allows to define not only degree of dysfunction of organ systems and forms a basis of the forecast of survival, but also proves tactics of the carried-out treatment, its efficiency and also defines economic costs of treatment. In the comparative analysis of results of treatment of children with DAP with use of integrated assessment of degree of dysfunction of organ systems on indicators of predictive scales (SOFA, APACHE II, SAPS, MODS, PRISM), it is noted that in the main group of patients the undertaken tactics of preoperative preparation allows for the first day after operation to achieve stabilization of the general condition of patients. At the same time, lethality in the main group varied within 1.8-2.9% (APACHE II - SOFA), and in group of comparison of 12.5% -16.7% (APACHE II, MODS - SOFA).
Studying of dynamics of indicators on predictive scales against the background of DAP allows to reveal the most complex groups of patients for whom more serious resource of an intensive care is necessary. When using any of scales the linear dependence between the number of points and level of lethality comes to light (for example, for SAPS - to each ten-mark increase there corresponds increase in lethality about 10%).
Conclusions. Assessment of a condition of children with DAP at receipt with use of one of the integrated predictive scales (SOFA, APACHE II, SAPS, MODS, PRISM) which are often used in world practice allows to define not only degree of dysfunction of organ systems and forms a basis of the forecast of survival, but also proves tactics of the carried-out treatment, its efficiency and also defines economic costs of treatment. In the comparative analysis of results of treatment of children with DAP with use of integrated assessment of degree of dysfunction of organ systems on indicators of predictive scales (SOFA,
APACHE II, SAPS II, MODS, PRISM) it is noted that in the main group of patients the undertaken tactics of preoperative preparation allows in the first day after operation to achieve stabilization of the general condition of patients. At the same time, the probability of a lethal outcome in the main group was reduced by 5.7 times.
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