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18UDC 616.25-002-08
CHEMICAL PLEURODESIS USING BETADINE AND GLUCOSE IN THE TREATMENT OF PATIENTS WITH TRANSUDATIVE PLEURAL EFFUSION IN CASE OF CHRONIC KIDNEY DISEASE.
A. A. Egay1'2, B. Kh. Bebezov1, A.T. Kazakbaev1, A.E. Tentimishev2, A.M. Feigin3
department of hospital surgery, KRSU named after B.N. Yeltsin, Bishkek, Kyrgyz Republic international Higher School of Medicine, Bishkek, Kyrgyzstan
3Department of thoracic surgery at the National hospital under the Ministry of Health of the Kyrgyz Republic, Bishkek, Kyrgyz Republic.
Abstract
Transudative pleural effusion (PE) is most often encountered in patients with congestive heart failure, hepatic and renal failure, and especially in their terminal stages, as an indicator of the decompensation of the patient's condition. Chemical pleurodesis (CP) has been successfully used for several decades in patients with malignant PE, both with primary lesion of the pleura, and with its secondary lesion. The choice of an agent for pleurodesis should be based on its effectiveness, safety and availability. Despite the extensive study of this issue, the search for the ideal pleurosclerosant is still underway. The question of induction of pleurodesis in transudative effusions is all the more poorly understood. CP in our country was previously used only for its malignant nature; antineoplastic agents are traditionally administered intrapleurally. The purpose of this article is to assess the efficacy and feasibility of using betadine as a CP agent for PE in patients with CKD. Material and methods: the study was conducted on 6 patients with confirmed transudative PT in CKD. Results. All six patients (100%) managed to achieve a positive effect in the form of stopping the flow of fluid through the pleural drainage. Conclusion. Pleurodesis using betadine and glucose is an effective and safe method for treating patients with recurrent transudative PE in CKD.
Key words: pleural effusion, betadine, chemical pleurodesis, chronic kidney disease.
БЕЙТАПТАРДЫН БЭЙРОКТУН OHGKOT ООРУСУНДАГЫ ТРАНССУДАТИВДИК СУЮКТУК МЕНЕН ЧЕЛДИН ТОЛУШУНДА БЕТАДИН ЖАНА ГЛЮКОЗА МЕНЕН ХИМИЯЛЫК ПЛЕВРОДЕЗИ
А.А. Егай1,2, Б.Х. Бебезов1, А.Т. Казакбаев1, А.Э. Тентимишев3, A.M. Фейгин3
'Б.Н. Ельцин атындагы КРСУ, Бишкек, Кыргыз Республикасы
2Эл аралык жогорку медицина мектеби, Бишкек шаары, Кыргыз Республикасы
3Кыргыз Республикасынын Саламаттыкты сактоо министрлигинин алдындагы Улуттук госпиталь,
Бишкек шаары, Кыргыз Республикасы
Address for Correspondence: Egay A. A. postgraduate student of the department of hospital surgery, KRSU named after B.N. Yeltsin, assistant of the department of surgical diseases, IHSM, Bishkek, Kyrgyz Republic. Email: dyusha.92(3>amail.com. Tel. +996555803050
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Аннотация
Суюктуктун толушу (СТ) - ар кандай факторлордун таасирлердин негизинде епке кабына суюктуктун топтолушужана80ден ашык оорунун симптому болуп саналат. Аныктоонун иш-чарасы катары СТны экссудат жана транссудатка белуу негизги жолу болуп саналат. Экссудативдик суюктук толуу бул чел кабыктагы сезгенуу процессинин журушу ошол эле учурда транссуцативдик СТ организмдин системалык бузулушунун кесепети болуп саналат. Транссуцативдик СТ кеп учурда топтолгон журек жетишсиздигинин, боор жана бейрек жетишсиздигинен бейтаптардын езгече алардын терминалдык стадиясында, бейтаптын абалынын декомпенсациясынын индикатору катары кеп жолугат. Торакоцентеза процедураларын жургузуу менен СТ эвакуациялоо менен энтигууну токтотуунун майнаптуу жолу болуп саналуусунда чон келемдегу суюктук дем алуунун жетишсиздигин пайда кылышы мумкун, муну менен бул категориядагы бейтаптардын оор ахыбалын ого бетер начарлатат. Химиялык плевродез (ХП) - бул процедура, облитерация кылуу максатында атайын багытталган чел кабыктын жалбыракчаларын куйгузуу. ХП бир канча он жылдардан бери залалдуу СТ менен ооруган бейтаптарга колдонулуп келет. Ошондой эле биринчи чел кабыктын жабыркашында жана ошондой эле экинчи жолу жабыркашында да колдонулат. Плевродез учун агентти тандоодо анын майнаптуулугуна, коопсуздугуна жана мумкун болгондугуна негизделиши керек. Бул маселенин кенен изилденгенине карабай, иделдуу плевросклерозантка мурункудай эле издее журуп жатат. Транссуцативдик СТ плевродез индукциясынын суроолору анцан цагы аз изилденген. ХСТ биздин елкеде мурда залалдуу аймактарында гана колдонулуп, интраплевралдык салттуу антинеопластикалык каражаттар киргизилет. Бул макаланын максаты - енекет бейрек оорулары менен ооруган бейтаптардын СТ оорусунда ХПнын каражаты катары бетацинди колдонууцагы майнаптуулугу жана колцонуу мумкунчулугун баалоо. Материал жана усулдар: Изилдеелер транссуцативдик СТ менен жабыркаган 0БО менен ооруган 6 бейтапка жургузулген. Жыйынтыктары. Бардык 6 бейтаптын епкелерунунун чел кабыктын дренажына суюктуктун келишинин токтошу турундегу жакшы майнаптуу ийгиликке жетиштик. Жыйынтык. Бетадин жана глюкозаны колдонуу менен плевродезди ©БОдун кайталанган транссудативдик СТда оорулууларды дарылоодо майнаптуу жана коопсуз ыкмасы болуп саналат.
Ачкыч сездер: суюктук толуу (плевральный выпот), бетадин, химиялык плевродез, енекет бейрек оорулары.
ХИМИЧЕСКИЙ ПЛЕВРОДЕЗ БЕТАДИНОМИ ГЛЮКОЗОЙ У ПАЦИЕНТОВ С ТРАНССУДАТИВНЫМ ПЛЕВРАЛЬНЫМ ВЫПОТОМ ПРИ ХРОНИЧЕСКОЙ
БОЛЕЗНИ ПОЧЕК
А.А. Егай1'2, Б.Х. Бебезов1, А.Т. Казакбаев1, А.Э. Тентимишев3, A.M. Фейгин3
1КРСУ им. Б.Н. Ельцина, Бишкек, Кыргызская Республика Международная Высшая Школа Медицины, Бишкек, Кыргызская Республика Национальный госпиталь при Министерстве здравоохранения Кыргызской Республики, Бишкек, Кыргызская Республика
Аннотация
Плевральный выпот (ПВ) - это скопление жидкости в грудной полости, которое происхоцит под влиянием различных факторов и является симптомом более 80 различных заболеваний. В качестве диагностических мероприятий основополагающим является разделение ПВ на экссудат и транссудат.
и
Экссудативный плевральный выпот является проявлением воспалительного процесса в плевральной полости, в то время как транссудативный ПВ является следствием системных нарушений организма. Транссудативный ПВ наиболее часто встречается у пациентов с застойной сердечной недостаточностью, печеночной и почечной недостаточностями, а особенно в их терминальных стадиях, как индикатор декомпенсации состояния пациентов. Проводимые при этом процедуры торакоцентеза, с эвакуацией ПВ, являются эффективным способом купирования одышки, так как большой объем жидкости способен вызывать симптомы дыхательной недостаточности, усугубляющие и без того тяжелое состояние данной категории пациентов. Химический плевродез (ХП) - это процедура, направленная на преднамеренный ожог листков плевры с целью их дальнейшей облитерации. ХП уже несколько десятилетий успешно применяется у больных со злокачественным ПВ, как при первичном поражении плевры, так и при её вторичном поражении. При выборе агента для плевродеза необходимо основываться на его эффективности, безопасности и доступности. Несмотря на широкое изучение данного вопроса, по-прежнему идёт поиск идеального плевросклерозанта. Вопрос индукции плевродеза при транссуцативных выпотах тем более малоизучен. ХП в нашей стране ранее применялся только при злокачественной его природе, интраплеврально традиционно вводятся антинеопластические средства. Цель данной статьи - это оценка эффективности и возможность применения бетадина в качестве средства ХП при ПВ у пациентов с ХБП. Материал и методы: исследование проводилось на 6 пациентах с подтвержденным транссудативным ПВ при ХБП. Результаты. У всех шести пациентов удалось достичь положительного эффекта в виде прекращения поступления жидкости по плевральному дренажу. Заключение. Плевродез с использованием бетадина и глюкозы является эффективным и безопасным способом для лечения больных с рецидивирующим транссудативным ПВ при ХБП.
Ключевые слова: плевральный выпот, бетадин, химический плевродез, хроническая болезнь почек.
Introduction
Pleural effusion (PE) is an abnormal accumulation of fluid between the layers of the pleura, which occurs as a result of an imbalance between its formation and absorption. In chronic kidney disease (CKD), according to studies by Bintcliffe O.J. et al. (2016), PE is a very common phenomenon, especially in patients at the last stages of this disease and in patients receiving hemodialysis [2]. According to Kinasewitz G.T. (1997), two main mechanisms of PE formation in CKD should be distinguished: 1. Development of nephrotic syndrome and, as a consequence, a decrease in plasma oncotic pressure due to proteinuria; 2. Hypervolemia, which develops as a result of impaired excretion of fluid and leads to an increase in hydrostatic pressure in the vessels [12]. According to the observations of M.V. Shestakova. et al. (2011), diabetes mellitus is the main cause of CKD worldwide [14]. According to research by DeBiasi E.M. (2015) and Walker S.P. (2017), in patients with CKD, when PE appears, mortality increases statistically significantly [3,16].
PE in CKD is by its nature a transudate, but in rare cases of end-stage renal disease, uremic pleurisy
may occur, in which effusion is exudative [10]. The pathogenesis and treatment of uremic pleurisy is still a question not fully resolved, the latest study by Seo H.M. (2019) showed the successful use of high doses of prednisolone in the treatment of a patient with bilateral uremic pleurisy [13]. Drug treatment of transudative PE in CKD consists in reducing the consumption of sodium chloride and liquid, using various groups of diuretics, and transfusing an albumin solution.
Surgical care for patients with PE in CKD makes sense only in patients who are resistant to drug treatment and hemodialysis sessions. The presence of dyspnea and X-ray confirmed PE is the reason for periodic thoracentesis, which, according to Nathan J. et al. (2011), is associated with the development of complications such as pneumothorax and pleural empyema [8]. Traditionally, it is believed that the management of patients with PE in CKD is reduced to the treatment of the underlying disease and periodic evacuation of the effusion by pleural puncture, chest tube insertion is an unwanted procedure that will lead to uncontrolled loss of fluid and, along with it, protein fractions [11]. One of the treatment options is the chemical pleurodesis procedure, which is widely used for malignant PE
and spontaneous pneumothorax [6,11].
Chemical pleurodesis (CP) is a procedure aimed to create aseptic inflammation of the pleural layers with their subsequent obliteration by introducing various chemical agents into the pleural cavity. In recent decades, this issue has been actively studied and several effective substances are already known for the successful implementation of this procedure. According to the work of A.P. Kolesnik. et al. (2016), the most common agents are talcum powder, tetracycline derivatives, Bleomycin [5, 17]. The main criteria for choosing a substance for CP are safety, availability and efficacy. Undoubtedly, the above substances meet all the criteria, but for our country, the problem is the financial availability of these drugs. The most accessible, but no less effective from this point of view are substances such as povidone iodine (betadine) and silver nitrate [9, 15]. The question of the use CP in PE of a transudative nature is also poorly understood. Akopov A.L. et al. (2017) shared the experience of using bleomycin as an agent for CP in patients with transudative PE in hepatic failure, the effectiveness of this technique was 86% with minimal side effects [!]■
Material and methods
Participants and settings. In the department of thoracic surgery of the National Hospital under the Ministry of Health of the Kyrgyz Republic, from December 2019 to September 2020, there were 6 patients with drug-resistant PE that complicated the course of CKD. Of these six patients, four are women and two are men, aged 47 to 82. All six patients had long-term diabetes mellitus, which was further complicated by CKD, and in two patients diabetes mellitus was combined with congestive heart failure. Given the long history of the underlying disease, these patients received conservative treatment in endocrinology departments. Despite this, the course of diabetes mellitus was complicated by the development of CKD. Bilateral PE was diagnosed in three patients (50%), right-sided fluid accumulation in two (33.3) and left-sided in one (16.7%). This patient underwent multiple punctures of the pleural cavity with fluid evacuation from 600 ml to 3 liters, for 3 months to 2 years, the interval between thoracocentesis ranged from 2 weeks to 2 months. Despite the ongoing drug therapy aimed at restoring the oncotic pressure of blood plasma and improving
the excretory function of the kidneys, hydrothorax was recurrent.
Methods. We used the method of pleurodesis with a 10% solution of betadine produced by Pharmaceutical Plant Egis under a license from Mundipharma (Switzerland) in combination with a 40% glucose solution. All patients underwent drainage of the pleural cavity on the side of the PE; with bilateral hydrothorax, the placement of pleural drainage was carried out on the side of the greater accumulation of fluid. The main requirement for the induction of pleurodesis was the complete expansion of the lung, which was confirmed by X-ray examination. Before CP, for the purpose of anesthesia, 50 ml of a 1% solution of Lidocaine was injected intrapleurally. In our opinion, this volume and concentration will not cause symptoms in patients associated with the reabsorption of lidocaine. After that, the drainage was blocked, and the patient was recommended to change the position of the body, the exposure was 20 minutes, followed by the removal of the anesthetic. Next, a 10% solution of Betadine in a volume of 20 ml and a 40% solution of glucose in a volume of 80 ml were injected intrapleurally, the drainage was blocked for 2 hours, while the patient was advised to change the position every 30 minutes. When 100 ml or less was discharged, the drain tube was removed.
Control radiography was performed after 1, 3 and 6 months. In addition to induction of pleurodesis, all patients received drug therapy under the supervision of an endocrinologist and nephrologist. The efficacy of pleurodesis was assessed both radiographically and clinically.
Results
Two patients (33.3%) had subtotal hydrothorax before draining the pleural cavity, radiographically the shading reached the anterior segment of ribs II and III, in three patients (50%) the fluid level reached IV and V ribs, and in one patient (16.7 %), the PE level was below the V rib. All patients had varying degrees of dyspnea, dry cough and heaviness in the chest, all symptoms were reduced after draining the pleural cavity.
The daily separation of fluid, before the CP procedure, ranged from 300 ml to 950 ml. At the time of administration of the chemical agent, pain syndrome was not observed in 4 patients (66.7%), two patients (33.3%) noted pain in one half of the
chest, the assessment was carried out using a visual analogue scale (VAS) and was 6 and 8 points, respectively. Pain syndrome were relieved by a single injection of non-steroidal anti-inflammatory drugs. In the next 72 hours, one patient experienced a single increase in body temperature up to 39 ° C without any further consequences.
The average duration of the stay of the drainage tube in the pleural cavity was 3.17 days, after which the discharge decreased to 100 or 50 ml per day and the drainage was safely removed.
At the moment, not all six patients have passed three follow-up examinations, but the effect in the form of the absence of PE accumulation on the CP side was achieved in all six patients, which amounted to 100%. No late complications after CP were observed inpatients.
Discussion
The management of patients with end-stage CKD, complicated by the appearance of PE, is a complex issue and still not fully resolved. It is known that the appearance of fluid in the pleural cavity in patients with CKD significantly increases mortality [3,16].
Puncture of the pleural cavity, followed by PE evacuation, is a palliative type of care that effectively eliminates shortness of breath, but does not solve the problem of the underlying disease. Also, with each portion of the fluid removed, protein fractions are eliminated from the body, which leads to the development of a vicious circle [7]. Drainage of the pleural cavity is also not a way out of this situation, as it leads to constant loss of fluid and carries additional complications in the form of possible development of pleural empyema [12].
CP is a very effective way to deal with recurrent malignant PE and as the final stages of surgery in bullous lung disease [6, 11]. Despite the wide coverage of this issue, in our country there is no experience of using this type of treatment in relation to transudative PE. Traditional treatment of patients with transudative PE is the treatment of their underlying disease, but this does not always give a significant effect, and the condition of patients with each thoracentesis can worsen.
This article presents the results of treatment of 6 patients with transudative PE, which developed in the presence of CKD. Betadine was chosen as a pleurosclerosant, which, when it enters the pleural
cavity, causes a burn of its leaves and their further adhesion to each other. The main advantages of Betadine are its availability and safety. In terms of its effectiveness, according to research, it is inferior to agents such as talc, tetracycline derivatives and silver nitrate.
There is a limited amount of information in the literature on the use of betadine and glucose as agents for CP, and effect using it due to transudative PE is unknown. In our study, cessation of PE accumulation was achieved in all six cases (100%). Most of the patients did not experience pain during this, and the temperature reaction was observed only in 1 case.
Conclusion
Conclusions. 1. Introduction of 50 ml of 1% lidocaine solution, before the induction of pleurodesis, is an effective method of analgesia and does not have effects associated with its absorption; 2. A solution of betadine and glucose can be successfully used in patients with transudative pleural effusion in CKD. This technique meets all the criteria for pleurosclerosants: efficacy, availability and safely.
Conflict of interest. Authors declare no conflict of interest.
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