Common complication of bladder catheterization. Complications during catheterization of the bladder. Folk remedies for pyelonephritis
UDC 616.832-001:616.62-089.819.1-08-06
Rare case of catheterization complication Bladder in a patient with traumatic disease of the spinal cord
A.T. Khudyaev, O.G. Prudnikova, D.M. Savin
A rare case of bladder catheterization complication in a patient with traumatic spinal cord disease
A.T. Khudiaev, D.M. Savin, O.G. Prudnikova
Federal State Institution "Russian Research Center "Restorative Traumatology and Orthopedics" named after A.I. Academician G. A. Ilizarov Rosmedtekhnologii, Kurgan
(and about. CEO- Professor A.N. Dyachkov)
A rare complication that occurred during catheterization of the bladder with a permanent soft (rubber) Foley catheter for acute urinary retention in the acute period of traumatic disease of the spinal cord is presented. The complexity of clinical diagnosis is due to the violation of the conduction function of the spinal cord after its injury. Occlusion of the ureter orifice that occurred after the manipulation led to renal carbunculosis and required nephrectomy.
Key words: bladder catheterization, traumatic spinal cord disease, urinary tract infection, renal carbunculosis, nephrectomy.
The article deals with a rare complication developed during bladder catheterization with Foley permanent soft (rubber) catheter for sharp urine retention in the acute period of traumatic spinal cord disease. The difficulty of clinical diagnosis is caused by the disorder of conducting function of the spinal cord after its injury. Ureteral orifice occlusion occurred after the manipulation led to renal carbunculosis and required nephrectomy performance.
Keywords: blader catheterization, traumatic spinal cord disease, urinary tract infection, renal carbunculosis, nephrectomy.
The problem of treating bladder dysfunctions in patients with traumatic spinal cord disease has not been solved to date. The authors disagree and offer different options for emptying the bladder: permanent catheterization, suprapubic cystostomy, intermittent catheterization - describing the advantages of some and the disadvantages of others. Treatment of this category of patients is complicated by the addition of a urinary tract infection. The presented clinical case of a complication that arose against the background of a permanent bladder catheter presented difficulties in the course of diagnosis due to impaired conduction function of the spinal cord and the lack of proprioceptive reception from the internal organs involved in the pathological process.
Patient N., aged 19, was admitted to the Department of Neurosurgery of the RRC “VTO” named after A.I. acad. G.A. Ilizarov with a diagnosis of traumatic disease of the spinal cord, intermediate period. Consequences of a compression-comminuted fracture of the LI vertebra, a compression fracture of the LII vertebra with contusion and compression of the spinal cord. Condition after surgical treatment. Lower flaccid paraplegia. Dysfunction of the pelvic organs. Indwelling bladder catheter. Incorrectly spliced
a fracture of the left radius "in a typical place".
The patient was admitted for planned surgical treatment: installation of epidural electrodes for subsequent electrical stimulation of the spinal cord.
Complaints at admission to the lack of active movements and sensitivity lower extremities, dysfunction of the pelvic organs in the form of urinary retention and fecal incontinence.
Injury - fall from a height of 5 floors on the back. He was hospitalized in the neurosurgical department of the regional clinical hospital at the place of residence, where he underwent surgical treatment: laminectomy of the lixn, li vertebrae, removal of bone fragments of the body of the li vertebra, traumatic herniation of the disc "Hnxn li.II. Microsurgical decompression of the spinal cord at the level of TIxn^. Spinal fusion with preserved tibial homocostia of the Thxn-III segments Installation of a transpedicular fixator of the Thxn-III vertebrae Insertion of a permanent soft Foley catheter into the bladder Immobilization of the fracture of the left radius with a plaster splint.
Neurological status at admission: no active movements in the lower extremities. Tendon reflexes from the lower
limbs are not called. Hypotrophy of the muscles of the lower extremities. Hypesthesia of the skin from the level of the b: segment, anesthesia from the level of the bsh segment. Lower flaccid paraplegia. Dysfunction of the pelvic organs by the type of urinary retention and fecal incontinence. Indwelling Foley catheter in the bladder. Moves in a wheelchair. There is a postoperative scar up to 7 cm along the line of the spinous processes of the Th1-Ln vertebrae. The metal structure is palpated subcutaneously. On the midline of the abdomen postoperative scar after the lower median laparotomy.
The planned preoperative examination revealed failure of the posterior transpedicular fixation system. In this regard, the proposed surgical treatment plan was changed: it was planned to remount the transpedicular fixation system and install epidural electrodes.
Rice. 2. Radiographs of the left forearm. Misaligned fracture of the left radius
On the eve of surgical treatment, the patient had a sharp rise in temperature to 39.5 °C. In the general analysis of urine: protein 0.46 g/l, specific gravity 1016, leukocytes in large numbers, erythrocytes 10-12, bacteria. In the general blood test: erythrocytes 4.63 * 1012 / l, hemoglobin 137 g / l, color index 0.9, hematocrit 0.38, platelets 574 * 109 / l, leukocytes 12.1 * 109 / l, eosinophils 9% ,
rods 1%, segments 55%, lymphocytes 25%, monocytes 10%, ESR 10 mm/hour. The patient was diagnosed with a urinary tract infection, treatment was started: washing the bladder with antiseptic solutions, uroseptics were prescribed, a urine culture was taken for microflora and sensitivity to antibiotics.
However, despite the ongoing intensive treatment, the patient remained feverish, inflammatory changes in the leukocyte formula and inflammatory changes in the urine increased. In the general analysis of urine: protein 1.2 g/l, specific gravity 1011, leukocytes and erythrocytes in large numbers. In the general blood test: erythrocytes 3.15x1012 / l, hemoglobin 93 g / l, hematocrit 0.30, platelets 305 * 109 / l, leukocytes 43.4 * 109 / l, eosinophils 1%, rods 34%, segments 55%, lymphocytes 7%, monocytes 2%, ESR 62 mm/h, anisocytosis (+), vacuolization of neurophilic cytoplasm. To clarify the diagnosis, an ultrasound of the abdominal organs was performed, which revealed: the parenchyma of the right kidney is not differentiated, its structure is significantly changed, the structure of the left kidney is diffusely changed.
An urgent MRI of the abdominal cavity, retroperitoneal space and pelvic organs was performed. Found: right-sided pyelo-, ureterectasia, caused by occlusion of the mouth of the ureter with a catheter. At the same time, the end part of the urinary catheter blocked the mouth of the ureter, and the inflated cuff prevented its movement in the bladder. The catheter was immovably fixed in the mouth of the ureter.
Rice. 3. MRI results: occlusion of the orifice of the right ureter with a catheter
After consulting a urologist for emergency indications, the patient underwent surgery. An epicystostomy was performed. After opening the retroperitoneal fascia, there were signs of vitreous edema of the perirenal tissue. The kidney is swollen, cyanotic, significantly enlarged. A total lesion of the kidney with multiple carbuncles was revealed. Taking into account the total defeat of the kidney by a purulent process, a right-sided nephrectomy was performed.
Pathological examination of the drug: the size of the kidney 13*7.5*8 cm, flabby consistency. The surface is uneven with areas of bumpy bulging. The coloring is mottled. Under the capsule, finely scattered yellowish rashes. On the section, the pattern is variegated in cortical zone numerous radial yellowish stripes. In the medulla, areas of uneven blood supply, alternating with areas of light brown color. Histological examination: against the background of a sharp plethora and edema of the organ, extensive fields of leukocyte infiltration of the stroma with foci of abscess formation. Accumulations of purulent exudate in the excretory tubules. Conclusion: a picture of purulent inflammation.
In the postoperative period, blood and urine parameters improved significantly. In the general analysis of urine: protein 0.38 g/l, specific gravity 1012, leukocytes in large numbers, erythrocytes 4-6. In the general blood test: erythrocytes 3.25 * 1012 / l, hemoglobin 94 g / l, color index 0.86, hematocrit 0.26, platelets 350 * 109 / l, leukocytes 19.1 * 109 / l, eosinophils 4% , rods 12%, segments 56%, lymphocytes
21%, monocytes 3%, ESR 60 mm/hour.
With permanent catheterization, a Foley catheter connected to a urinal is used. In this method, the catheter remains inserted into the bladder, and urine is constantly excreted from it. The inflated cuff of the catheter prevents its displacement from the bladder. When using an indwelling catheter, wrinkling of the walls of the bladder very often occurs due to the constant outflow of urine and a decrease in intravesical pressure, and there is a risk of infection (bacteria enter the bladder through the inner and outer walls of the catheter). In the presented clinical case, the negative aspects of permanent catheterization fatally combined: wrinkling of the bladder led to the fact that the end part of the catheter blocked the mouth of the ureter, the inflated cuff of the catheter prevented its displacement, and the catheter was tightly fixed in the mouth of the ureter. The associated urinary tract infection caused pyelonephritis with further development of kidney carbunculosis. Violation of the innervation of internal organs (lack of pain reception from the damaged organ) did not give a clear clinical picture with obvious inflammatory changes in the blood and urine.
It was decided to refrain from further surgical treatment until the patient's condition stabilizes. The patient was discharged in a satisfactory condition under the supervision of a neurologist, urologist at the place of residence.
LITERATURE
1. Bogdanov E. I. Bladder dysfunction in organic diseases nervous system(pathophysiology, clinic, treatment) // Neurological. vestn. 1995. Vol. XXVII, no. 3-4. pp. 28-34.
2. Neurourological rehabilitation in spinal cord injuries: method. recommendations / comp. : O. G. Kogan, A. G. Shnelev. Novokuznetsk, 1978.
3. Savchenko N. E., Mokhort V. A. Neurogenic urinary disorders. Minsk: Belorus, 1970. 244 p.
4. Smallegange M., Haverkamp R. Care of patients with spinal cord injury and rehabilitation. Utrecht, 1996.
5. Epstein I. M. Urology. M., 1959. 335 p.
The manuscript was received on 20.01.09.
1. Khudyaev Alexander Timofeevich| - FGU "RSC" WTO "named after. acad. G.A. Ilizarov Rosmedtekhnologii, Deputy General Director for Scientific and Clinical Work; Head of the Laboratory of Clinical Vertebrology and Neurosurgery; MD Professor;
2. Prudnikova Oksana Germanovna acad. G.A. Ilizarov of Rosmedtekhnologii, Leading Researcher of the Laboratory of Clinical Vertebrology and Neurosurgery, Candidate of Medical Sciences;
3. Savin Dmitry Mikhailovich - Federal State Institution "RNTs "VTO" acad. G.A. Ilizarov of Rosmedtekhnologii, Neurosurgeon of the Department of Neurosurgery.
Bladder catheterization in men and women is performed in violation of the natural outflow of urine for any pathological reason. During the procedure, medical personnel use rigid metal or soft rubber catheters.
Manipulation is necessary to remove urine from the bladder or disinfect the inside of the urethra in case of infection.
Proper catheterization eliminates the occurrence of discomfort. But it is also possible to develop complications associated, as a rule, with improper care of the device or non-compliance by the patient with medical recommendations. Such consequences are easy to correct, but it is easier to prevent their occurrence.
Indications for the procedure
Bladder catheterization in women and men is a manipulation that consists in running a catheter into the urethra. It is carried out both for diagnostic and therapeutic purposes as prescribed by the urologist.
The catheter is installed in patients for a short time, for example, during surgical interventions, or when it is necessary to flush the bladder through the catheter.
But sometimes the device is inserted into the urethra for a long time during the rehabilitation period, when there are difficulties with emptying the bladder. The urethral catheter is installed in the presence of such diagnostic indications:
- Taking a urine sample for later analysis. Manipulation allows you to get urine to detect pathogenic microorganisms that seed the cavity of the bladder, as well as their species;
- Determination of the volume of separated urine, its qualitative characteristics in the process of ongoing therapy;
- Detection of any obstacles to the optimal outflow of urine through the urinary tract.
What are the therapeutic indications for bladder catheterization:
- Inability to excrete urine, usually with an acute form of pathology. This may be benign prostatic hypertrophy, blockage of the bladder neck or urethra;
- Violation of the patency of urine, provoked by hydronephrosis;
- Introduction into the bladder cavity of solutions of various pharmacological preparations for washing or treatment;
- Facilitation of urination in patients with impaired innervation of the bladder.
Catheterization is necessary for bedridden patients with severe pathologies or in the postoperative period, when a person cannot empty the bladder on his own.
What are catheters
The urethral catheter is selected individually for each patient, depending on age, gender and diagnosis. What devices can be used for staging:
Nelaton.
The device for men and women is inserted into the urethra for a short time and is easy and painless to install.
This type of catheter is intended for long-term insertion - from a week to a month. A two-way device is used to remove urine and introduce medicinal solutions into the bladder cavity. A three-way catheter allows installations.
Rubber Timan and plastic Mercier.
Before the procedure, these types of catheters are softened with hot water to acquire the elasticity of the curves characteristic of the human body.
This type of device is used when catheterization through the urethra is not possible and is inserted through a fistula specially formed by surgeons on the patient's abdominal wall. This operation is called a cystostomy.
Bladder catheterization with a soft catheter is performed by trained medical personnel, and only a doctor can insert a metal device.
Catheterization algorithm
The technique of bladder catheterization requires special skills. A metal device is most often installed when it is impossible to manipulate with a rubber or plastic device.
The patient takes a horizontal position, while under his buttocks is a small pillow or folded towel. The patient spreads his legs to the side and bends them at the knees, and the nurse treats his perineum with disinfectant solutions.
When inserting the catheter, maximum care is taken so that the integrity of the urethral mucosa is not compromised. There are some differences in the technique of bladder catheterization in men and women.
Among women
The algorithm for catheterization of the bladder in women is simpler due to the peculiarities of the anatomical structure of the urethra. How is the medical procedure performed?
- The nurse is located to the right of the woman and spreads the patient's labia for convenient treatment of the vulva with water, and then with antiseptic solutions;
- The catheter is inserted with its inner end, lubricated with glycerin or liquid paraffin, into the opening of the urethra.
If urine begins to flow after insertion of the device, the catheterization was performed correctly.
In men
The algorithm for catheterization of the bladder in men is more complex due to the greater length and smaller diameter of the urethra. Manipulation is carried out in several stages:
- After treating the glans penis with antiseptic solutions, a lubricated catheter is inserted into the urethra using tweezers;
- When installing, maximum care is taken, rotational movements are used;
- When the device reaches the site of physiological constriction, the patient takes several breaths to relax the smooth muscle;
- If spasm of smooth muscles occurs, bladder catheterization is temporarily suspended.
The fact that the procedure was carried out correctly is evidenced by the release of urine from the external opening of the catheter.
Washing the bladder
Often, urologists include in the therapeutic regimen the installation of antiseptic, anti-inflammatory or mucosal regenerating drugs.
These can be solutions of collargol, protargol, furacilin, sea buckthorn or rosehip oil. The algorithm for performing the installation consists in introducing into the cavity of the bladder medicines followed by removal of the tube.
Washing is used to remove pus, small stones, tissue decay products. Using Janet's syringe or Esmarch's mug, the nurse injects antiseptic solutions through the catheter, and then facilitates their discharge.
Manipulation is carried out until a clear liquid drains from the urinary catheter. After the procedure, the patient remains in a horizontal position for about an hour.
Catheter Care
Long-term presence of a female or male catheter requires care of the device. It is necessary to constantly maintain cleanliness at the injection site, after each urination, wash the genitals with soap.
Treatment of the urinal with soapy water is carried out daily. Care of a permanent boat should be carried out in a sterile environment with equipment that has undergone disinfection. The tube of the device must be replaced weekly.
When wearing the device for a long time, the patient can install it himself at home or resort to the help of specialists. Before carrying out a medical manipulation, it is necessary to treat with antiseptic solutions:
- Arms;
- Tool;
- Genitals.
If the placement of the catheter caused difficulty or provoked pain, it should be stopped immediately.
To remove a female or male device, cut off the tube and wait for the fluid to drain completely. After that, you can proceed to carefully remove the adapter. Then you need to use a large syringe to suck urine from the main tube, disconnected from the tank. At the final stage, a thorough disinfection of the genitals is carried out.
Possible Complications
Catheters are often placed for a long time, which can cause complications as a result of improper care. Unfortunately, errors of medical personnel during the manipulation are not excluded. What complication can occur during catheterization of the bladder:
- Infectious inflammatory process in one of the organs of the urinary system;
- Paraphimosis is a pathological process characterized by narrowing of the foreskin and infringement of the glans penis;
- Damage to the catheter of the urethra, as a result of which false channels are formed;
- Violation of the integrity of the urethra.
The most dangerous consequences for men and women include open bleeding. As a rule, medical personnel quickly detect and eliminate this complication of catheterization. To avoid the development of undesirable consequences for the bladder and urethra, proper care of the device and its installation by qualified personnel will help.
Features of the bladder catheterization procedure
Using the method of catering into a muscular organ that performs the function of accumulating and excreting urine, both therapeutic and diagnostic results can be obtained. Bladder catheterization for medical purposes is performed using a radiopaque agent to obtain responses after cystography.
If any diseases are detected, the introduction of medicinal drugs is used. Also, for therapeutic purposes, catheterization is used to remove complicated urinary outflow disorders, if independent defecation is impossible, and if it is necessary to flush through the catheter. When diagnosing, catheterization of the bladder is performed to clarify the information already received or to determine the residual volume of urine.
General presentation of the catherization procedure
Bladder catheterization in women is performed by inserting a system of tubes placed into the urinary tract to drain and collect urine from the bladder. Urinary catheters are widely used to treat incontinence or urinary retention in both women and men.
Most different kinds catheters can be used based on the existing problems of patients. Carrying out such a procedure requires special attention and qualifications of the doctor. In some cases, bladder catheterization, with knowledge of the basic information base about this procedure, can be carried out by the patient independently.
One of important factors procedure is the risk of infection after all manipulations. Before inserting the tube into the urethra, the opening of the urinary canal should be carefully treated with an antiseptic solution. Next, an anesthetic gel is introduced and the end of the catheter should be carefully lubricated with it. You also need to consult with your doctor about the physiological characteristics of the urethral canal. Since with the self-introduction of the catheter, it is possible to injure the channels when, out of ignorance, the catheter is inserted along the wrong paths.
Surgical catheterization of the bladder consists of suprapubic drainage of the ureter. Local anesthesia is used for the operation. These manipulations are necessary when a permanent drainage is established for the patient. After surgical operation independent urination becomes simply impossible.
Thus, doctors eliminate the obstruction of the urethra, the neck of the bladder, the impossible independent emission of urine. The operation is not performed when patients have a small bladder volume, scar formations above the pubis. After surgery, a number of complications may occur in the form of urinary streaks, bleeding, damage to the folds of the abdomen, intestines, and the formation of peritonitis.
The catheter brings invaluable help if it is necessary for the patient to wash the ureter when purulent processes have formed in the internal space of the bladder or with cystitis. Also, rinsing helps to cleanse the body of tissue decay products in tumors, small stones.
In such cases, after removing the urine, an antiseptic liquid is injected through the probing instrument. Washing the ureter through catheterization cannot be performed if fresh injuries of the organ of the urinary system or bladder, acute urethritis are found.
How is a probing medical instrument placed for women and what set is needed for manipulations? Bladder catheterization in women is faster and easier than in men.
Bladder catheterization occurs in women in the following order:
- Before proceeding with the manipulations (or you need to flush), you should purchase a complete kit, which includes the following equipment: a catheter, moisturizing gel, a pair of medical gloves, clean wipes, a syringe with water to inflate the balloon, a urinal.
- Wash your hands with an antiseptic and treat the external opening of the urethra, labia with smooth movements from top to bottom, without affecting the anus.
- Carefully put on medical gloves, avoiding touching the outer surface of the gloves with your hands.
- Lubricate the tube.
- Dilute the labia and accurately find the location of the organ of the urinary system.
- Slowly insert the tube into the opening of the organ of the urinary system.
- Gently advance the probing instrument along the canal.
- When urine appears, the probing instrument must be advanced a couple more inches. Hold the probing instrument in a fixed position while the balloon is inflated. If pain occurs, the woman should stop the process. After a short time, deflate the balloon and advance the catheter a couple more inches and try to inflate the balloon again.
- After inserting the tube, secure it and attach the urine receptacle.
Types of catheters used in practice
Types of medical tubes are usually subdivided according to shape, structure, composition, size. In medicine, soft and hard catheters are often used. A soft (rubber) catheter is an elastic tube, thirty centimeters long. The solid one consists of a handle, a rod and a beak; the inserted end has a rounded shape. This catheter is made of metal alloy.
Also, the types of probing instruments are divided into male and female. Women's pipes can be made up to a maximum of twenty-five centimeters, and men's pipes up to thirty. If it is not possible to carry out the procedure with a soft catheter, they proceed to the introduction of a hard one. All this is connected with the structure of the urethra and other individual moments of the patient's body. Depending on the patient's condition, suprapubic (permanent) and short-term (periodic) types of probing medical instruments are used.
After a long stay of the probing tube in the body, in many cases, inflammatory processes occur in the urinary canal. Any tube material can cause irritation, micro-scratches on the mucous membrane. And after removing the probing instrument, doctors recommend taking anti-inflammatory baths for several days.
Supposed negative effects after walking with urinary tubes for a long time:
- The appearance of gallstones. Edema and dropsy.
- Infectious diseases in the blood and lymph.
- Isolation of blood in the urine.
- Violation of the integrity of the skin and urethra.
- Infection of the urinary tract and kidneys.
Bladder catheterization, as practice shows, in most cases does not provide any complications to the health and general condition of the patient. The procedure, in principle, is painless, provided that all the rules and algorithm of the process are followed. You should be wary of rough manipulations that can damage the urethra and the bladder itself.
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Consequences of cystitis in women
Cystitis is a curable disease, if you follow all the necessary doctor's orders or follow the recommendations folk methods treatment. However, if the disease is not treated or the process is not brought to an end, then certain complications may arise.
What complications can occur with cystitis?
First of all, untreated or advanced cystitis can go away on its own in a few days, but at the same time it will go from an acute to a chronic form of the disease, which will eventually lead to:
- pyelonephritis (this means that the infection has passed through the urine exit routes and has risen to the kidneys),
- vesicoureteral reflux (there is a reverse movement of urine from the bladder to the kidney),
- interstitial cystitis (there is a sharp decrease in the size of the bladder),
- recurrences of cystitis, which lead to sphincter damage and urinary incontinence,
- infertility, as it affects the patient's reproductive system due to the appearance of various infections that can be sexually transmitted.
Pyelonephritis - what is it?
One of the complications of neglected or untreated cystitis is pyelonephritis - inflammation of the kidneys. It occurs as a result of the movement of infection from the bladder through the urine output to the kidneys, resulting in damage to the kidney tissue by various viruses.
The main symptoms of pyelonephritis are:
- a sharp increase in temperature (up to 40 ° C),
- fever,
- chills,
- sweating,
- the anterior wall of the peritoneum is tense,
- with light tapping lumbar the soreness of the affected kidney is determined (usually one of the kidneys suffers; bilateral pyelonephritis rarely develops).
Painful sensations in the affected kidney are observed due to stretching of its capsule (it is filled with nerve endings that perceive pain impulses); pathology in the same organ
asymptomatic. If pus accumulates in it or edema occurs when the kidney tissues are stretched, then unpleasant sensations and discomfort appear. The ongoing changes are judged by a dense infiltrate, palpable in the lumbar region 3-4 days after the onset of the disease.
With pyelonephritis, the amount of urine excreted by the patient can sharply decrease. This is due to damage to the tissues of the kidney, which loses the ability to produce fluid in sufficient volumes.
Pyelonephritis is diagnosed as follows:
- general urine analysis;
- sowing on bacteria that are in the urine (the type of microbe is determined, its sensitivity to various antibiotics is examined);
- X-ray examination of the kidneys and bladder (to monitor inflammatory process in the organs);
- Ultrasound of the urinary system.
This disease is treated only in a hospital through intensive care, which will allow the patient to recover and not become disabled, and for this it is necessary to observe:
- strict bed rest;
- mode of fluid intake;
- diet
- doctor's prescription (detoxification of the patient and the use of antibiotics to fight the disease).
If conservative methods of treatment are not successful, then a surgical operation is prescribed.
Everyone is susceptible to disease age groups: children, adults, old people. Moreover, in children and the elderly, there may be no pronounced symptoms of cystitis and manifestations of kidney damage by infection, and this greatly complicates the diagnosis of the disease.
What is vesicoureteral reflux?
Vesicoureteral reflux is a pathological process in which urine moves in the opposite direction: from the bladder to the kidney. This occurs as a result of damage to the valve system of the ureter and changes in the elasticity of the walls of the organ.
During normal operation, the valve allows fluid to pass from the kidney to the bladder, but in cystitis, it is affected and therefore remains open. This allows urine to flow into the bladder, but it can also flow back into the kidney unhindered. This complication of cystitis allows the infection to persist for a long time in the urinary system, which further contributes to the development of pyelonephritis. If the disease is not treated for a long time, then scarring occurs on the kidneys, and then they lose their functions.
The main method for diagnosing reflux is cystography: a contrast is injected into the bladder using a catheter and an x-ray is taken. If an enlargement of the urinary tract is detected, the diagnosis is confirmed.
Treatment of the disease is carried out by eliminating the causes that caused cystitis.
What is interstitial cystitis?
Interstitial cystitis is a serious complication of inflammation of the bladder, characterized by inflammation of the muscles and mucous membrane of the organ.
If this disease is not treated for a long time, then over time, the main tissues are replaced by scar tissue, which has a different structure. This causes a decrease in the elasticity of the walls of the bladder, which leads to a sharp decrease in its size.
Symptoms of this disease are the following factors:
- increased urge to urinate (at any time of the day);
- a small amount of excreted fluid;
- sudden urge to go to the toilet;
- the occurrence of sharp pain during sexual intercourse;
- possible discomfort in the pelvic area;
- blockages are possible.
In women, the symptoms of the disease may differ. This is due to the diet and the phases of the menstrual cycle.
This disease is treated with medications, and in some cases - with surgery (operation).
What is recurrent cystitis?
Chronic cystitis is dangerous for its relapses, which bring a certain discomfort with constant urge to urinate, accompanied by severe pain. In a person, this causes irritation, nervous breakdowns, or, conversely, an indifferent state.
Cystitis affects the bladder neck, eventually causing sphincter damage and this can lead to urinary incontinence. This is especially noticeable in older people.
The inflammatory process that affects the membranes of the bladder, is manifested by the presence of blood in the urine. This condition is called hemorrhagic cystitis, and the main factors in the appearance of this disease are the penetration of viruses or drug poisoning.
Treatment is carried out with the help of antibiotics and drugs that eliminate bleeding and strengthen the walls of blood vessels.
The chronic form of cystitis often causes infertility. This is explained by the fact that urinary reproductive system are quite closely related, and when a disease of the urinary organs occurs, the patient's reproductive system is also damaged. Frequent relapses contribute to the emergence of various infections, including sexually transmitted diseases.
The inflammatory process that occurs in the mucous membrane of the ureter is called cystitis. This process can become acute, then the symptoms will be pronounced, and the presence of blood can be seen in the urine. In medicine, acute cystitis is called hemorrhagic. Its main features are that blood does not appear at the end of urination, but stains all urine.
Older men with adenoma are at high risk of developing acute cystitis.
Causes of the disease
There are several factors that affect the occurrence of acute cystitis:
- viruses, bacteria, fungi;
- radiation exposure to the body or the use of cytostatics;
- if a person is accustomed to endure the urge to urinate for a long time and does not go to the toilet immediately, then blood circulation in the wall of the bladder is disturbed due to overstretching of muscle fibers;
- mechanical obstruction of urine flow, for example, due to a tumor, can also cause an acute nature of the disease;
- foreign bodies that are in the lumen of the canal of the urinary system;
- neoplasms that may be in the urethra or bladder;
- low immunity;
- non-compliance with personal hygiene, when bacteria enter the bladder and cause an acute course of the disease.
In women, acute cystitis, which is characterized by blood during urination, is also caused by factors such as:
- tight underwear and clothes, which disrupts blood circulation in the pelvis;
- hypothermia.
Whatever the reasons for acute cystitis with blood, at the first sign of it, you should consult a doctor.
Signs of the disease
Acute cystitis is the most dangerous form of the disease, the main symptoms of which are manifested in the fact that blood appears in the urine (if the blood loss is large, whole clots may appear). Urine becomes dirty brown or light pink in color, acquires a very unpleasant odor.
With a long course of the disease with blood, the patient earns iron deficiency anemia, its main symptoms are shortness of breath, dizziness, weakness.
This type of cystitis begins acutely and suddenly, especially in women, and requires that treatment be started in a timely manner.
The first symptoms are severe pain during urination and fever. Also, this type of disease is characterized by the following symptoms:
- blood in the urine;
- frequent urination with blood, up to 40 times a day;
- false urge to empty the bladder;
- discomfort in the lower abdomen;
- severe pain when urinating;
- chills, weakness.
Compared with other forms of the disease, hemorrhagic cystitis in women lasts a long time, at least seven days. If treatment is not started on time, the problem can become very serious, as a complication of the disease is possible.
Note! Frequent blood loss leads to anemia.
Symptoms of the acute form of cystitis are more pronounced, in contrast to the usual form. If it is started, it will develop into a chronic one and then acute periods are replaced by remission (this remark applies to both women and men).
To prevent exacerbation and transition of cystitis into a chronic form, it is necessary the right approach in treatment and the use of effective drugs.
Treatment of the acute form of the disease
In women, acute cystitis is often caused by Escherichia coli. The drugs to which she is sensitive are:
- fluoroquinolones - levofloxacin, ofloxacin, norfloxacin;
- cephalosporins - antibacterial treatment;
- also effective drugs are ceftriaxone, augmentin, which are taken within a week.
Treatment should be started at the first signs of the disease, that is, pain and blood when urinating. You can use not only the above drugs. You should also follow these recommendations:
- diet. You can not use vegetable and dairy products, which will alkalize the urine, which will lead to irritation of the mucous membrane of the urethra, and will only contribute to the development of inflammation. All fatty, salty, pickled, spicy, canned and alcoholic beverages are also excluded;
- when treatment is necessary bed rest;
- you need to drink a lot of water, use lingonberry and cranberry fruit drinks, apple juice, weak tea, diuretic herbal teas, jelly. The daily norm of liquid is about 2.5 liters. This is necessary to cleanse and flush the bladder from pathogenic microorganisms;
- if you suffer from severe pain, then you need to take painkillers and antispasmodics - these are ibuprofen, papaverine, no-shpa, etc .;
- treatment of cystitis is also carried out with kanefron, which has an anti-inflammatory and antispasmodic effect on the body;
- you need to warm up the urea with a warm bath or heating pad;
- antibacterial vaginal or rectal suppositories are also used.
If the treatment of acute cystitis in women or men is carried out on time and effectively, then the disease is completely cured in a few days, usually it takes 3-5 days, sometimes up to a week. Already after the first intake of the necessary medication, discomfort and pain during urination disappear. Also, there is no more blood present in the urine during this process.
Complications
The main complication of cystitis is a blockage of the lumen of the bladder (tamponade). Infection can also occur, that is, microbes will enter through the blood vessels that are damaged into the blood exchange. If you do not treat cystitis for a long time, then connective tissue replaces muscle fibers, and this leads to the fact that the bladder loses its functionality.
In order to prevent such complications, it is imperative to treat acute cystitis.
Urosepsis is the most dangerous complication against the background of inflammatory processes in the organs of the genitourinary system. Generalization of urinary infection threatens the life of the patient, infectious agents from the kidneys, prostate, urethra, bladder penetrate into the bloodstream, spread throughout the body. In the absence of urgent measures, a fatal outcome occurs.
It is impossible to prevent the development of an irreversible stage of bacteremic shock: it is important to recognize the development of a serious condition in time, to prevent the spread of infection. The causes, symptoms, stages of a negative state, methods of treating urosepsis are described in the article.
general information
The pathological process develops with obstruction of the urinary tract. With purulent damage to the organs of the genitourinary system, blockage of the ducts by mineral deposits, the development of cysto- and nephrostomy, abscess and carbuncle of the kidney, renal pelvic reflux occurs, urine stagnates, intrapelvic renal pressure rises, microorganisms penetrate into the bloodstream.
The spread of infectious agents throughout the body causes acute intoxication, provokes dysfunction of the lungs, heart, and persistent hypotension. Against the background of renal, cardiac and respiratory failure, the partial pressure of oxygen decreases, toxins accumulate, the process of hematopoiesis is disrupted, hormonal failure occurs, the liver fails, and the risk of bleeding increases.
Failure of major systems and organs leads to lethal outcome. The percentage of patients who died due to bacteremic shock in infections of the genitourinary system is higher than in other diseases.
On a note:
- bacteremic shock is a dangerous condition, but the prognosis is favorable with timely detection of signs of urosepsis, seeking medical help. Important point: recognize the first signs of the spread of infection, start therapy with erased and early form until the bacteremic shock has passed into the irreversible (terminal) stage;
- with the prolonged presence of purulent, inflammatory foci in the urinary tract, it is possible to suppress the infection, but with inattention to the chronic form of pyelonephritis, purulent prostatitis, glomerulonephritis, it is impossible to completely get rid of pathogens, eliminate the zones of formation of pathological processes.
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About the rules of nutrition and diet for sand in the kidneys in women are written on this page.
Reasons for the development of pathology
In urological practice, bacteremic shock often develops after infection during endourethral and endovesical medical procedures in patients with purulent-inflammatory processes of the urogenital area. Urosepsis is one of the dangerous types of nosocomial infection. The risk of infection arises from poor treatment of the premises where urological patients are located, non-compliance with the rules of sterility during catheterization, cystoscopy, endoscopic operations on the bladder and bean-shaped organs.
Other causes of urosepsis development:
- traumatic catheterization;
- damage to the mucous membranes with retrograde ureteropyelography;
- complication of percutaneous lithotomy, transurethral resection (TUR) of the bladder;
- tissue infection during ureterocystoscopy.
Diseases complication of which is urosepsis:
- purulent prostatitis with the development of an abscess;
- acute epididymitis;
- Fournier's gangrene;
- paranephritis;
- pyonephrosis with blockage of the ducts: stones of different sizes interfere with the outflow of urine, inflammation develops against the background of stagnant processes;
- the presence of a carbuncle or abscess in the renal parenchyma;
- penetration foreign body into the bladder;
- infectious lesions of the urinary tract with blockage of the ureter;
- apostematous nephritis;
- a sharp decrease in the volume of excreted urine in infections of the genitourinary system;
- periuretal abscess against the background of compression or scar tissue of the urethra;
- development of coral-like stones with a branched structure.
Classification
Forms of bacteremic shock:
- expressed. The main task of doctors is to remove the patient from a state of shock, normalize respiratory and cardiac function, stabilize pressure, achieve urine output in a volume sufficient to prevent intoxication;
- erased. With this form, the symptoms are moderate, therapeutic measures quickly enough give a positive result.
- early;
- developed;
- irreversible.
Clinical picture
At an early stage, the manifestations of urosepsis resemble an acute form of inflammation of the prostate and kidneys. You can not bring down the temperature, take antibiotics uncontrollably.
The presence of two or more characteristic signs indicates the penetration of infection into the bloodstream from the genitourinary system:
- a temperature of 36 degrees and below, or a feverish condition with indicators of 38 degrees and above;
- tachypneous. The respiratory rate increases to 20 per minute or more. In critical situations, artificial ventilation of the lungs is required;
- increased cardiac output;
- diuresis decreases to 35 ml or less within an hour, anuria often develops - the absence of urine in the bladder;
- tachycardia, increased heart rate up to 145 or more beats per minute or more;
- systolic pressure drops sharply;
- sweating increases, the skin turns pale;
- the level of leukocytes is less than 4000 or more than 12000 mmol / m3.
Symptoms depend on the form of urosepsis:
- acute. Signs are pronounced, the temperature quickly rises to 38-40 degrees or more, chills develop. Active accumulation of toxins, a high concentration of microorganisms can provoke a collapse. The patient often encounters two attacks, with competent and timely therapy, the attack can be suppressed, the thermometer returns to normal within a few hours. Inadequate treatment, taking inappropriate medications provokes a protracted form of the disease, intoxication of the body increases;
- subacute. The signs are less pronounced, but the infection does not disappear, the inflammatory process progresses;
- chronic. The temperature is kept at 37.5 degrees, sometimes it rises to 38 degrees, but no more. There are no signs of an acute form, intoxication persists. Against the background of the inflammatory process, the work of the bean-shaped organs is disrupted, most often the pathologies of the urinary tract are complicated by renal failure.
Diagnostics
A set of measures is required to identify the pathogen, prescribe adequate antibiotic therapy. It is important to understand how affected the urinary tract, kidneys, what is the level of leukocytes and electrolytes.
Diagnostic measures:
- urine culture;
- a blood test to clarify the indicators of leukocytes, platelets, electrolytes;
- clarification of the level of urea;
- ultrasound examination of the bladder and all organs of the genitourinary system;
- analysis of secretions from the urethra and prostate;
- radiography of the lungs;
- contrast and non-contrast urography to detect stones;
- blood culture;
- coagulogram to determine the parameters of blood clotting (prescribed before surgical treatment).
With the development of bacteremic shock after surgery, medical procedures, or against the background of renal colic, it is easier to recognize a dangerous condition. Difficulties with diagnosis arise with an erased form of urosepsis against the background of weakness of the body in chronic infections of the genitourinary system.
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General rules and methods of treatment
With the development of urosepsis, the patient is treated in a urological hospital. It is important to remember that bacteremic shock at a late stage leads to irreversible changes, urgent measures are required: intravenous infusions, bladder catheterization to control daily diuresis. In severe condition, all manipulations are carried out under the supervision of a resuscitator.
In critical situations, the patient is transferred to the intensive care unit, often requires inotropic support, the use of steroids. It is forbidden to self-medicate: urosepsis therapy at home is ineffective, the risk of death increases.
The main methods of therapy:
- antibacterial compounds: fluoroquinolones, cephalosporins, Metronidazole drug;
- hemodialysis;
- immunotherapy;
- the use of protease inhibitors;
- surgical removal of stones blocking the ducts.
Neurogenic disorders of urination significantly reduce the quality of life.
Having to get up to go to the toilet at night prevents you from getting a good night's sleep. Frequent urination during the day, inability to control the urge, leakage or incontinence against the background of a strong urge significantly limit daily activities, interfere with work and personal life. Long trips and walks, trips to the theater, concerts, etc. become impossible. All this leads to depression, worsening the course of the underlying neurological disease and exacerbating the symptoms of the lower urinary tract.
Neurogenic disorders of urination, if not properly treated, lead to severe complications from the upper urinary tract.
Least danger in terms of complications, it represents an overactive bladder without a violation of the outflow of urine. It greatly interferes with life, but does not shorten its duration.
greatest danger present (detrusor-sphincter dyssynergy). In such cases, during urination, the pressure inside the bladder becomes very high, and the urine, which cannot be expelled through the spasmodic sphincter, rises up the ureters. it vesicoureteral reflux which leads to kidney damage. Developing ureterohydronephrosis, kidney tissue becomes thinner, appears kidney failure.
The presence of residual urine in the bladder is always accompanied by urinary tract infection, manifested by cystitis (inflammation of the bladder itself) and ascending pyelonephritis (inflammation of the kidneys). Due to overactive bladder and vesicoureteral reflux, pyelonephritis in patients with neurogenic
urination disorders, as a rule, has a severe course and a high risk of developing urological sepsis.
In men, prostatitis can also be a complication of neurogenic urinary disorders.
Infected residual urine easily forms stones that require surgical treatment.
Difficulty urinating leads to protrusion of the bladder wall( diverticula), the size of which can reach the size of the bladder itself. Diverticula can also form stones and tumors.
Stages of ureterohydronephrosis.
Diverticula.
In a separate group, complications associated with the prolonged presence of a permanent urethral catheter or cystostomy in the bladder can be distinguished.
Indwelling ureral Foley catheter(with a balloon that inflates in the bladder) - a method that threatens the largest number complications.
The bacteria form a colony on the surface of the catheter called a biofilm. The special organization of this colony makes microorganisms resistant to the action of antibacterial drugs. To cope with an infection in the urinary tract is almost impossible.
A catheter balloon constantly present in the bladder injures the mucosa, which leads to the development of bladder cancer.
Urine flows continuously through the catheter, therefore, the bladder is constantly empty, which causes it to shrink over time. Cases are known when the bladder was reduced to the size of a urethral catheter balloon (20 ml). Shrinkage of the bladder makes it impossible to restore normal urination in the future.
Another option for diversion of urine is a cystostomy. This is the same Foley catheter with a balloon, only installed in the bladder through the anterior abdominal wall. This method is more secure. Since the contact area of the foreign body (catheter) with the mucosa is smaller, infections are less common. There will be no bedsores in the urethra. However the risk of bladder shrinkage and cancer is also high as if using an indwelling catheter in the urethra.
It also has its complications. There is a risk of formation urethral strictures(cicatricial narrowing) due to trauma to the urethra during catheterization. The formation of a stricture is not life threatening and is easily treated by endoscopic dissection of the scar tissue. The use of lubricants and careful insertion of the catheter will avoid such problems.
Also exists risk of infectious complications, but it is incomparably lower than when using an indwelling urethral catheter or cystostomy. When there is no permanent foreign body in the urinary tract, the infection is easier to fight. Compliance with the technique of introducing a catheter and the use of an antiseptic for the treatment of hands and genitals will allow the risk of infectious complications to be minimized.
The constant presence of a foreign body in the urethra causes inflammation of the mucosa (urethritis) and the formation of bedsores, which may require plastic surgery on the penis.
In addition, the constant presence of a catheter in the urethra or a cystostomy not only makes the problem visible to others, but is also a contraindication for undergoing some rehabilitation measures.
Today, throughout the civilized world, it is used as the main method of excreting urine. In the recommendations of international societies for the treatment of neurogenic urinary disorders, this method is called "gold standard". In Europe, the introduction of this technique in patients with spinal injury in the 70s of the XX century led to a sharp decrease in mortality from urological complications, the same as the appearance of the first antibiotic penicillin in the 40s. Urine excretion with disposable catheters 6-8 times a day mimics the natural rhythm of urination. it allows you to maintain the physiological capacity of the bladder. Absence of a permanent foreign body in the urinary tract eliminates the risk of cancer and the formation of bedsores, reduces the likelihood of biofilm formation.
Often patients who have suffered a spinal injury use various techniques (tapping on the anterior abdominal wall, irritation of the anus or other trigger zones, straining, etc.) to trigger the urination reflex. This method would be very good, if not for three points.
1. What we have already talked about above. Since the sphincter of the bladder, as a rule, is strongly clamped and does not allow urine to come out, during the process of reflex urination, the pressure in the bladder rises to abnormally high numbers. Urine travels up the ureters to the kidneys, leading to dilatation of the upper urinary tract, ascending infection, and kidney failure. Diverticula form in the bladder.
2. Reflex urination in patients with spinal cord injury above the Th6 segment can provoke - throbbing headache, anxiety, rise in blood pressure, redness of the face, sweating, bradycardia, spasticity, etc. An episode of autonomic dysreflexia due to a significant rise in blood pressure can be life threatening.
3. The bladder may not empty completely during reflex urination. We have already talked about the dangers of having residual urine.
You can not use the method of reflex emptying of the bladder without the permission of a neuro-urologist who performed a comprehensive urodynamic study (CUD) and made sure that the pressure in the bladder at the time of reflex urination remains within acceptable values, which is extremely rare.
can be triggered not only by reflex urination, but also by bladder overflow or concomitant urinary infection.
Bladder catheterization. The introduction of a catheter into the urethra (urethra) is carried out for:
evacuation of urine in violation of independent urination;
washing the bladder;
obtaining urine from the bladder for laboratory testing.
catheterization contraindicated with acute inflammation of the urethra (inevitable infection of the bladder), with damage to the urethra, with spasm of the sphincter of the bladder. For catheterization, soft (rubber or plastic) and hard (metal) catheters are used.
Catheterization is the insertion of a catheter into the bladder. Catheterization is performed to remove urine from the bladder for therapeutic and diagnostic purposes and to flush the bladder. Catheterization requires special precautions so as not to introduce infection into the bladder, since its mucous membrane has a weak resistance to infection. Therefore, catheterization should be performed only when necessary. For catheterization, soft and hard catheters are used.
The soft catheter is an elastic rubber tube 25-30 cm long and 0.33 to 10 mm in diameter (Nos. 1-30). The end of the catheter, which is inserted into the bladder, is rounded, blind, with an oval hole on the side; the outer end is cut obliquely or funnel-shaped to make it easier to insert the tip of the syringe when introducing a drug solution into the bladder.
Before use, the catheters are poured with boiling water and boiled for 10-15 minutes, after use, thoroughly washed with warm water and soap and wiped with a soft cloth. Store rubber catheters in long enamel and glass boxes with a lid, filled with a 2% solution of boric or carbolic acid. If this is not done, they dry out, lose their elasticity and become brittle. Hospitals have special sterilizers for storing rubber catheters. Formalin tablets are placed at the bottom of the sterilizers, the vapors of which ensure the sterility of the catheters.
A solid catheter (metal) consists of a handle, a shaft and a beak. The urethral end is blind, rounded with two lateral oval openings. The length of the male catheter is 30 cm, female - 12-15 cm with a small bent beak.
The introduction of a solid catheter is carried out by a doctor or nurse. The soft catheter is inserted by a nurse or (at home) a caring relative specially trained in this technique.
Insertion of a catheter in a woman. Before the procedure, the person caring for the patient should wash their hands with soap and warm water, and wipe the nail phalanges with alcohol and tincture of iodine. Women are pre-washed or douched if there is vaginal discharge. The caregiver stands to the right of the patient, who lies on her back with knees bent and legs apart. With the left hand, the labia are parted, and with the right hand, from top to bottom (toward the anus), the external genital organs and the opening of the urethra are carefully wiped with a disinfectant solution (mercuric chloride solution 1: 1000, furacilin or a solution of mercury oxycyanide). Then, with tweezers, they take a catheter doused with sterile vaseline oil, and carefully insert it into the opening of the urethra. The appearance of urine from the external opening of the catheter indicates that it is in the bladder.
When the urine stops coming out on its own, you can lightly press through the abdominal wall on the bladder area to remove residual urine from it. The urethra of women is short (4-6 cm), so catheterization is not very difficult. If you need to take urine for culture, the edges of a sterile tube are passed over the flame and, after filling, are closed with a sterile cotton plug.To prevent ascending infection, the caregiver must strictly follow the rules.
The introduction of a catheter in men is much more difficult, since their urethra has a length of 22-25 cm and forms two physiological constrictions that create obstacles for the passage of the catheter. During catheterization, the patient lies on his back with slightly bent knees and legs apart, a urinal, a tray or a mug is placed between the feet, where urine flows down the catheter. The person performing the manipulation takes the penis in his left hand and carefully wipes its head, foreskin and urethral opening with cotton wool moistened with a solution of boric acid. Then, with his left hand, he spreads the sponges of the external opening of the urethra, and with his right hand, with tweezers or a sterile gauze napkin, inserts a soft catheter, previously poured with sterile vegetable or vaseline oil, with little effort. As soon as the catheter enters the bladder, urine appears. If it is not possible to pass an elastic catheter, a metal catheter is used. A solid catheter for men is inserted only by a doctor.
The catheter should not be removed after the urine comes out, but a little earlier so that the urine stream flushes the urethra after the catheter is removed.
To long-term drainage of the urinary bubbles are resorted to with persistent urination disorders in order to avoid multiple catheterizations. To do this, use a soft Nelaton catheter, which is fixed with strips of adhesive plaster to the head of the penis or thigh. More preferable is a soft catheter with an inflatable balloon at the end (Pomerantsev-Foley balloon catheter), which allows the catheter to be securely fixed in the bladder. The catheter must be inserted with a securely connected plastic sterile tube, lowered into a closed, also sterile container. In the course of the catheter, an infection can easily penetrate into the urinary tract, so the external opening of the urethra should be protected with a bandage moistened with an antiseptic solution.
URINARY CATHETER CARE
The presence of a permanent catheter in a patient to remove urine from the bladder provides for careful hygienic care and compliance with the optimal drinking regimen for patients. The patient needs to drink fluids more often, reducing the concentration of urine and thus reducing the likelihood of developing a urinary tract infection. Hygiene measures should include care for the perineum and the catheter itself.
In doing so, the following precautions must be observed:
Wash the perineum from front to back;
Ensure that the catheter tube is securely attached to the inner surface of the thigh with a patch;
Attach the drainage bag to the bed so that it is below the patient's bladder, but does not touch the floor;
Ensure that the catheter tube is not kinked or looped.
107. Drainage of hollow organs using endoscopic equipment. Drainage through operatively applied external fistulas (gastrostomy, jejunostomy, colostomy, epicystostomy, etc.), care for them. Mistakes, complications and their prevention.
Drainage of the genital organs using endoscopic equipment. With tumor and cicatricial narrowing of the esophagus, the pyloric part of the stomach, there is a violation of the passage of food and starvation. To combat starvation, long-term, over many days and even weeks, tube enteral nutrition is required. To conduct a probe (usually a thin plastic catheter), modern esophagogastroscopes on fiber optics are successfully used. The endoscopist finds the place of narrowing and, under the control of vision, pushes the catheter through it, previously passed into the instrumental channel of the endoscope. The endoscope is removed. A rubber probe is passed through the nose into the oral cavity, the outer ring of the plastic catheter is tied to it and, thus, the latter is passed through the lower nasal passage and attached to the cheek with strips of adhesive tape. This position of the catheter does not disturb the patient, is easily tolerated and allows the introduction of a sufficient amount of liquid, well-digestible food (broth, milk, fruit and vegetable juices, mineral water, sweet tea and special nutritional mixtures, tailored to the body's needs for energy, proteins, vitamins, salts, trace elements). The taste of food does not matter.
With tumors of the rectum, complicated by mechanical intestinal obstruction, it is sometimes possible during rectoscopy to hold a gas outlet tube above the tumor. This allows you to divert gases and make a siphon enema. Thus, it is possible to partially resolve the phenomena of obstruction, alleviate the patient's condition and conduct a full preparation for the operation.
Fistulas In the local treatment of a fistula, preference is given to an open method of treatment using an aspiration-flow system by introducing a silicone double-lumen tube into the purulent cavity. This method of treatment of an unformed fistula contributes to rapid sanitation and reduction of the cavity due to granulations, followed by the formation of a fistula.
Gastrostomy care
If your patient had an operation for an obstruction of the esophagus and a gastrostomy was placed on him (a hole formed in the wall of the stomach and anterior abdominal wall into which a rubber tube is inserted), his feeding is associated with some peculiarities.
In order to prevent the contents of the stomach from flowing out, the tube is bent and bandaged or clamped with a clamp. Before feeding, the tube is released and a funnel is put on its end, into which the nutrient mixture is poured.
To care for the skin around the gastrostomy, you should:
if there is hair around the gastrostomy, shave the skin smoothly;
after each feeding, rinse the skin with warm boiled water or a solution of furacilin (1 tablet of furacilin per glass of warm boiled water). You can use a weak pale pink solution of potassium permanganate (a few crystals per glass of warm boiled water);
on the skin around the gastrostomy after washing, apply the ointments recommended by the doctor ("Stomagezin") or pastes (zinc, Lassara, dermatol) and sprinkle with talc (tannin or kaolin powder can also be used). The use of ointments, pastes, powders promotes the formation of a crust around the gastrostomy and protects the skin from irritation by gastric juice;
when the ointment or paste is absorbed, remove its remnants with a napkin;
wash the rubber tube used for feeding through the gastrostomy with a small amount of warm boiled water after feeding.
colostomy care
A colostomy is an artificially formed fistula of the large intestine that emerges on the surface of the abdominal wall with the formation of a new outlet for the body's waste products (feces). At home, the patient cares for the colostomy on his own or with the help of an assistant caring for him. Immediately after the rectum has been brought to the abdominal wall, care for a colostomy is the same as for a dirty wound. After cleaning from feces, the stoma is treated with antiseptic solutions (furatsilin) and an aseptic dressing is applied. At proper care the bandage should be changed immediately after contamination, and the skin around it should be treated with antiseptics and zinc ointment. The skin must not be irritated.
To treat a colostomy, you should:
remove excreted liquid or formed feces;
treat the skin around the colostomy with warm boiled water and dry it with napkins;
apply Lassar paste (dermatol or zinc paste) or Stomagezive ointment to the skin;
remove excess paste or ointment after soaking with napkins;
put on the protruding mucous membrane ("rose") a napkin lubricated with petroleum jelly;
close the fistula with gauze;
put cotton on the bandage;
strengthen the bandage with a bandage or bandage.
After the formation of a fistula (colostomy), colostomy can be used.
To change the colostomy bag, you should:
prepare a clean colostomy bag (with scissors, enlarge the central hole of the plate so that it neatly accommodates the colostomy);
carefully separate the used pouch, starting from the top. Try not to pull the skin;
throw away the used colostomy bag by placing it in a paper or plastic bag or wrapping it in newspaper;
wipe the skin around the stoma using dry gauze or paper towels;
rinse the stoma with warm boiled water;
wash the skin around the stoma with warm boiled water;
blot the skin dry with napkins (you can not use cotton wool, as it leaves villi);
Lubricate the skin around the colostomy with Stomagesive cream or Lassar paste;
remove excess cream with a gauze cloth;
using a measure, re-measure the size of the colostomy;
Glue a clean colostomy bag onto your stoma following the manufacturer's instructions.
If your patient uses adhesive (adhesive) bags, position the center of the hole over the stoma (use a mirror to check the correct position) and press it evenly against the skin, making sure that the plate is smooth and without wrinkles.
Check that the drain hole of the bag is correctly positioned (hole down) and that the latch is in the closed position. The used colostomy bag should be emptied by opening the lower part of the closed colostomy bag with scissors, and the contents should be flushed down the toilet. Rinse the bag thoroughly under running water, wrap it in newspaper and throw it in the trash.
cystostomy care
put an oilcloth and a diaper under the buttocks of the patient, and then the vessel;
change gloves and toilet the penis;
put on sterile gloves, take Janet's syringe and draw 50-100 ml of antiseptic solution into it;
slowly inject the solution into the bladder through the catheter;
disconnect the syringe from the catheter, while the solution should independently flow into the substituted tray;
wash the bladder several times until "clean wash water";
if the patient moves independently, then place the end of the catheter in a polyethylene urinal, which must be fixed under clothing on the abdomen or thigh;
as urine accumulates, empty the urinal through the lower opening equipped with a valve;
treat the urinal daily with a solution of disinfectants, usually a 3% solution of chloramine;
before discharge from the clinic, teach the patient how to use a permanent urinal and treat it with disinfectants.
Such patients are under the supervision of nursing staff for a long time. The catheter is changed by the doctor at least once a month.
The patient needs regular, at least 2 times a week, bladder lavage. This procedure should be carried out while the patient is in the hospital or at home.
108. Enemas: indications, contraindications, equipment, patient preparation and enema technique. Types of enemas: emptying, laxative, washing (siphon), medicinal. Features of their implementation. Gas removal from the colon.
Enemas. This is a therapeutic or diagnostic effect, which consists in the retrograde introduction of a liquid substance into the colon.
Therapeutic enema is given:
to stimulate intestinal motility (laxative effect);
for washing and medicinal effects on the intestine;
for the introduction of drugs or nutrients into the body.
For diagnostic purposes, enemas are most often used to determine topographic relationships in the abdominal cavity, to identify pathological processes in the large intestine by X-ray contrast studies.
Contraindications any enemas are acute inflammatory and ulcerative processes in the rectum, acute appendicitis, peritonitis, intestinal bleeding, bleeding hemorrhoids, decaying colon cancer, anal fissure, rectal prolapse, sharp pains in the abdomen during the procedure.
Devices for setting enemas
Usually, Esmarch's mug is used to set enemas (in everyday life it is also simply called an "enema" or "heater"), a combined heating pad (a heating pad with an attached special plug, hose and tip, also commonly called an "enema" or "heater"), a douche (commonly called "pear"). The use of douches for cleansing enemas in adolescence and adulthood is ineffective and inconvenient. Before use, the tip should be inspected and removed for burrs and sharp edges, if any.
Enema technique.
To set up a cleansing enema, you should:
fill Esmarch's mug 2/3 of the volume with water at room temperature;
close the valve on the rubber tube;
check the integrity of the edges of the tip, insert it into the tube and lubricate with petroleum jelly;
open the screw on the tube and release some water to fill the system;
close the valve on the tube;
hang Esmarch's mug on a tripod;
lay the patient on a trestle bed or bed closer to the edge on the left side with legs bent and pulled up to the stomach;
put an oilcloth under the buttocks, lower its free edge into a bucket;
spread your buttocks and rotational movement gently insert the tip into the rectum;
open the tap on the rubber tube;
gradually introduce water into the rectum;
monitor the patient's condition: if there is pain in the abdomen or urge to stool, lower Esmarch's mug to remove air from the intestines;
when the pain subsides, again raise the mug above the bed until almost all the liquid comes out;
leave a little liquid so as not to introduce air from the mug into the intestines;
carefully remove the tip with a rotational movement with the tap closed;
leave the patient in the supine position for 10 minutes;
send a walking patient to the toilet room for bowel movements;
put a vessel on a patient who is on bed rest;
after emptying the intestines, wash the patient;
cover the bedpan with oilcloth and take it to the toilet room;
the patient is comfortable to lay down and cover with a blanket;
Rinse Esmarch's mug and tip well and disinfect with a 3% solution of chloramine;
store the tips in clean jars with cotton wool at the bottom, boil the tips before use.
Cleansing enemas put with a delay in stool due to atony, reflex spasm of the intestine, the presence of a mechanical obstacle to the advancement of feces (tumors, adhesions, compression of the intestine from the outside), in violation of the contractile function of the intestine of neurogenic origin. In addition, a cleansing enema is placed according to special indications (before operations, childbirth, some x-ray studies, etc.).
Isotonic and hypotonic saline solutions (0.9% and 0.5% sodium chloride solutions) irritate the intestinal wall least of all. They are used for colitis. The temperature of the injected liquid should be in the range of 20-40 °C. Colder enemas are irritating and are used for intestinal atony.
Laxative enemas cause an increase in the flow of fluid into the lumen of the intestine from the vessels of the intestinal wall, the revival of peristalsis and, as a result, give a laxative effect. For this, hypertonic salt solutions, vegetable oil, vaseline oil are used.
Salts (table salt, sea salt, Karlovy Vary salt) are administered in the form of 10-15% thermal solutions (40 ° C) in an amount of 100-200 ml using a rubber balloon or a syringe through a soft rubber catheter. The patient is given complete rest and offered to hold the injected liquid for 20-30 minutes, after which there is abundant, often repeated loose stools, gases pass well.
The oil acts gently, laxatively, softens fecal masses, eliminates intestinal spasm, normalizes peristalsis and lubricates the intestinal wall without causing irritation.
For laxative microclysters, glycerol is used in an amount of 10 ml, which is injected through a catheter. Glycerin irritates the intestinal mucosa, after which light stools appear. The laxative effect of microclysters is possible with the introduction of 2-3 ml of a 10% solution of antipyrine or 5 ml of a 1% solution of pilocarpine in 20 ml of water.
Siphon enemas set for the purpose of complete emptying of the colon and, therefore, for the most complete removal from the lumen of the colon of decay products, putrefaction, toxins in toxic and ulcerative colitis, allergic lesions of the colon mucosa, poisoning. Siphon enemas also make it possible to dilute stool at the site of narrowing of the colon (for example, with tumors) and can eliminate obstructive colonic obstruction.
For siphon enemas, weak solutions of potassium permanganate (1:1000), sodium bicarbonate and sodium chloride (3 g per 1000 ml) heated to 40-42 ° C are used.
During a siphon enema, unlike a cleansing enema, the rubber tube is not removed from the rectum and the liquid is removed through it when the funnel is lowered. Bowel emptying is facilitated, the liquid does not linger in the intestinal lumen, does not irritate the mucous membrane and does not cause a prolonged increase in intra-intestinal and intra-abdominal pressure.
Medicinal enemas used to reduce inflammation in the rectum and meninge of the sigmoid colon, stimulate the healing of ulcers and erosions, and treat inflammatory processes in surrounding organs and tissues. To obtain a therapeutic effect, enemas must be kept in the intestines for a long time, therefore) their volume is small (from 50 to 200 ml). After the introduction of the fluid, bed rest is prescribed for 1.5-2 hours with a pillow placed under the buttocks.
Gas removal from the intestines. With atony, incision of the intestine, a large amount of gases accumulate in its lumen, which are formed as a result of the ongoing processes of decay and fermentation. Most often this occurs with peritonitis and after abdominal surgery. Excessive accumulation of gases causes pain, makes breathing difficult, and makes you feel worse. Under normal conditions, gases exit under the action of peristalsis through the anus. After operations, a spasm of sphincters occurs and intestinal motility is disturbed, preventing the passage of gases. When a rubber tube is inserted into the anus, gases come out due to increased intra-intestinal pressure, even in the absence of peristalsis. A gas tube is usually placed after a laxative enema or microclyster with glycerin.
The patient is placed on a rubber circle covered with a diaper so that the leaking intestinal contents do not stain the bed. A rubber probe with a rounded end and side holes is inserted into the anus, lubricated with petroleum jelly, and gently rotated to a depth of 10-15 cm. The outer end of the tube is lowered into a pad placed between the patient's legs. The tube is left for several hours, during which the patient lies on his back. After removing the gas outlet tube, the anus area is washed with warm water and a piece of cotton wool is placed between the buttocks.
109. Examination of surgical patients. Purposeful clarification of the patient's complaints and the history of the development of the disease. Concomitant diseases and operations. Tolerance of drugs.
The subjective part of the medical history begins with the clarification of complaints - what worries the patient at the time of admission. During the collection of complaints, the student is required to pay attention and sensitivity to the patient. To find out all the necessary features of the disease, you need to have a certain skill: to know what questions to ask, what to pay special attention to, and what to skip, etc. It is always necessary to direct the conversation in the right direction, not allowing the patient to go away from the topic of conversation, remaining with this is extremely attentive and tactful to the patient, which will achieve maximum frankness of the patient. All this concerns not only the collection of complaints, but also the entire subjective part of the medical history.
All complaints can be conditionally divided into two groups:
Main complaints;
Survey on systems and organs.
Main complaints
After a question about complaints, the patient expresses his feelings directly at the time of examination or sensations that are characteristic of his present condition.
The main complaints are those that are associated with the development of the underlying disease. The main complaints are divided into three groups:
Complaints of pain;
Complaints of a general nature;
Complaints related to dysfunction of organs.
Pain complaints. When complaints of pain are specified:
Localization of pain;
Irradiation (place of reflection of pain);
Time of appearance (day, night);
Duration (permanent, periodic, paroxysmal);
Intensity (strong, weak, interferes or does not interfere with sleep, work);
Character (aching, stabbing, cutting, dull, sharp, pulsating, etc.);
The reason that causes pain (a certain position of the body, movement, breathing, eating, nervous state, etc.);
Concomitant pain phenomena (palpitations, nausea, vomiting, feeling of lack of air, etc.);
Change in pain general condition(weakness, loss of sleep, change in appetite, irritability, etc.).
All of the above parameters are extremely important, because. allow to differentiate the pain syndrome in different diseases. Clarification of the nature of pain, its irradiation makes it possible to distinguish biliary colic from renal, gastric ulcer from duodenal ulcer.
General complaints may be : weakness; malaise; increased fatigue; poor appetite; bad sleep; weight loss headache; decrease in performance.
Clarification of complaints of a general nature not only allows you to clarify the nature of the disease, but also contributes to the assessment of the general condition of the patient.
Complaints related to dysfunction of organs. Complaints associated with a violation of the functions of the main affected system of the patient have certain features due to the difference in the functioning of the affected organ or system itself (the cardiovascular system is characterized by weakness, palpitations, pain in the left side of the chest, etc.; for the respiratory system - shortness of breath , cough, etc.; for the digestive system - belching, nausea, vomiting, etc.).
Survey by organ systems
This section is of particular importance in therapy, when it is especially important to take into account the condition of all organs and systems of the patient during treatment. When examining a surgical patient, this section is not distinguished, and the nature of concomitant diseases is reflected only in the life history.
With the help of additional questions, it is necessary to conduct a detailed survey on all other body systems. In this case, only pathological deviations are fixed. The following are possible complaints due to the predominant lesion of certain organs and systems:
1) in diseases accompanied by lesions of the skin and mucous membranes: itching, pain, rashes, ulcerations, bleeding, etc.;
2) in diseases accompanied by damage to the lymph nodes: an increase in their size, localization of the lesion, pain, suppuration, etc.;
3) in diseases accompanied by muscle damage: pain (their localization and connection with movements), movement disorders, etc.;
4) with damage to the bones (spine, ribs, sternum, tubular bones): pain (their localization, nature and time of occurrence);
5) when the joints are affected: pain (at rest or during movement, day or night), dysfunction, localization of the lesion, lameness, shortening of the limb, etc.;
6) in diseases of the respiratory system: nasal breathing (free, difficult), the nature and amount of discharge from the nose (mucus, pus, blood). Pain in the region of the paranasal sinuses. Pain when talking and swallowing. Voice changes. Pain in the chest: localization, nature, connection with breathing and coughing. Shortness of breath, its nature and conditions of occurrence. Suffocation, time of its occurrence, duration, concomitant phenomena. Cough (dry, wet, painful), time of onset and duration. Sputum, its discharge, quantity, properties (color, impurities, layering). Hemoptysis, the conditions for its appearance;
7) in diseases of the cardiovascular system: pain behind the sternum and in the region of the heart (exact localization, nature, duration, irradiation, what is accompanied by, causes and conditions of occurrence, calming influences), shortness of breath (severity, character), palpitations, interruptions in work of the heart, headaches, dizziness, flying "flies" before the eyes, swelling, changes in diuresis;
8) in diseases of the digestive system: appetite, taste, mouth odor, salivation, thirst, chewing, swallowing, heartburn, belching, nausea, vomiting (nature of vomit), the time of their occurrence and dependence on the quantity and quality of food taken, pain (localization , character, strength, duration, dependence on the time of eating, on movement and physical exertion, irradiation, methods of pain relief), bloating, heaviness, rumbling, transfusion, bowel activity (stool), number of bowel movements, tenesmus (false urges), itching in the anus, hemorrhoids, rectal prolapse, gas discharge, stool properties (amount, consistency, mucus, blood), weight loss;
9) in diseases of the urination system: pain in the lumbar region and bladder (their nature and irradiation), frequent and painful urination, quantity and color of urine, edema;
10) in diseases of the hematopoietic and endocrine systems: pain in the bones of the throat, fever, general weakness, bleeding, swollen lymph nodes, heaviness in the hypochondria, thirst, dry mouth increased appetite (bulimia), frequent urination, itching in the vagina, palpitations, weight loss or obesity, drowsiness or insomnia, weakness in the limbs, sweating or dry skin;
I) in diseases of the nervous system: headache, dizziness, memory, mood and its change, behavioral characteristics, decreased performance, irritability, sleep patterns (does it fall asleep and wake up easily, sleep depth, does he use sleeping pills or drugs, insomnia).
HISTORY OF THE DEVELOPMENT OF THE DISEASE (ANAMNESIS MORBI)
This section describes all the details of the manifestation of the underlying disease, i.e. the disease that determines the severity of the patient's condition and his main complaints, in connection with which he was admitted to the hospital.
In surgical patients, the main disease is considered to be the disease for which surgical intervention is performed. If the patient has competing diseases, two anamnesis of the disease is written.
When describing anamnesis morbi, it is necessary to consistently state the following provisions.
The beginning of the disease. When and how the disease began (gradually, suddenly). Its first manifestations, the alleged cause of development (overwork of the patient, errors in the diet, the influence of professional, domestic, climatic factors, etc.).
The course of the disease: the sequence of development of individual symptoms, periods of exacerbation and remission.
The results of previous studies: laboratory, instrumental.
Previously used methods of treatment: medical, surgical, physiotherapeutic, etc., evaluation of their effectiveness.
Immediate reasons" for this hospitalization: worsening of the condition, failure of the previous treatment, clarification of the diagnosis, planned therapy admission on an emergency basis.
The change in the patient's well-being during his stay in the hospital There is a simpler scheme of the history of the disease, expressed in just seven questions.
1 When (date and hour) the disease began.
2 What factors contributed to the onset of the disease? How did the disease begin (first manifestations).
4 How did the symptoms of the disease develop in the future?
5 How was the patient examined, how was he treated? Was the treatment effective? Were there any surgeries for the underlying disease?
6 How has the work capacity changed.
7 What prompted the patient to see a doctor at the present time. It should be noted that when collecting an anamnesis (the subjective part of the medical history, one must not only listen to the patient's answers, but also use medical certificates and documents (outpatient card, extracts from the medical history, expert opinions, etc.).
LIFE HISTORY (ANAMNESIS VITAE) The patient is examined for all the features of life that have at least some significance for the diagnosis and treatment of the patient. Schematically, the main sections of anamnesis vitae can be represented as follows.
a common partBrief biographical information is given:
Place of birth with a description of the change in climatic factors during physical and mental development.
The professional history is specified:
At what age does he work?
Main profession and its changes;
Characteristics of the working premises (lighting, air features);
Working hours;
The presence of adverse professional factors (physical, chemical, forced position during work, excessive mental or physical stress).
Household history:
Living conditions (housing conditions, hygienic regimen, features of rest);
Diet.
Bad habits:
The nature of the abuse (tobacco, alcohol, drugs);
At what age and how often?
Past illnesses and injuries:
Transferred surgical interventions indicating the date (year) of their implementation and the characteristics of the course of the postoperative period;
Serious injuries, including neuropsychiatric;
Transferred serious diseases (myocardial infarction, cerebrovascular accident, pneumonia, etc.);
Concomitant chronic diseases (ischemic heart disease, hypertension, diabetes mellitus, etc.), features of their course, the nature of the therapy used.
Epidemiological history (epidanamnesis):
The presence or absence of the following infectious diseases in the past is clearly indicated: hepatitis, tuberculosis, malaria, sexually transmitted diseases, HIV infection;
Blood transfusions, injections, invasive treatments, travel outside the permanent place of residence and contact with infectious patients in the last 6 months.
Gynecological history (for women):
The beginning of menstruation, their nature, the date of the beginning of the last menstruation (to select the time for performing a planned surgical intervention, which is undesirable against the background of menstruation due to violations of the coagulation system during this period);
Number of pregnancies, childbirth, abortions;
In the presence of menopause - its manifestations.
Allergic history:
Intolerance to drugs;
Household and food allergies;
The nature of the course of allergic reactions (rash, fever, bronchospasm, anaphylactic shock, etc.).
Heredity:
Health of direct relatives (parents, children, brothers, sisters);
Cause of death of direct relatives;
If there is a hereditary predisposition for the underlying disease, indicate whether direct relatives suffer from it.
Insurance history:
The duration of the last sick leave;
The total duration of sick leave for this disease for the calendar year;
The presence of a disability group, the period of re-examination.
Availability of an insurance policy and its data.
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