Local treatment and care of the thoracotomy wound is carried out according to the general rules adopted in surgery. Skin sutures, in the absence of complications and wound healing by primary intention, are removed on the 10th day. After removal of the epidural or subpleural catheter, in the presence of pain in the wound area, anesthesia is performed by conducting intercostal or paravertebral blockade.
One of the most dangerous complications of the postoperative period is intrapleural bleeding. According to some authors, its frequency after resection of the lungs reaches 4—% (Isaev DS, 1981). The danger of this complication is directly dependent on the morbidity of surgical intervention, its duration, the state of coagulation and anticoagulation systems of blood and .
The immediate cause of intrapleural bleeding is a consequence of a defect in hemostasis: surgical and biochemical . With insufficient surgical hemostasis, a large vessel usually bleeds. The basis of biochemical bleeding are violations of the processes of coagulation and / or increased fibrinolytic activity of the blood.
The division is somewhat arbitrary, as there is often a combination of various causes of bleeding. None of the postoperative complications of interventions on the lungs causes so much doubt and frustration from unreasonable, and at the same time unjustified decisions, like intrapleural bleeding. Expectant tactics can be just as dangerous as a vain retoracotomy. It is not possible to determine the source of bleeding during retoracotomy in all cases. Thus, according to data from 66 operated patients, the sources of bleeding were determined in 51 (77%), and only in 7 (10.6%) large vessels were found. However, a direct indication for emergency retoracotomy is considered to be intensive, more than 250 ml per hour, blood flow through the drains against the background of deterioration of the patient’s general condition.
In other cases, the question of the presence of continuing intrapleural bleeding should be resolved no later than 10 hours after the operation. If, against the background of taking all measures of conservative therapy, the total amount of excreted blood (or exudate with a hematocrit close to blood hematocrit) is 900 ml, set the indications for performing a second surgical intervention.
In the case of stopped intrapleural bleeding and the formation of coagulated hemothorax, the question of further treatment of the patient can be solved in two ways.
On the one hand, after operations on the lungs, coagulated hemothorax in 50% of cases is complicated by recurrent bleeding and may contribute to the development of pleural empyema . On the other hand, repeated intervention in patients who have undergone severe traumatic surgery, aggravated by additional blood loss, can significantly worsen their condition and lead to unpredictable consequences, as well as, in turn, be a factor contributing to the development of postoperative empyema of the levorus . The question apparently must be solved individually.
Considerable experience gained in the clinic and in other institutions allows to realize the position that a rothorotomy with slow protracted intrapleural hemorrhages with the formation of a limited coagulated hemothorax should become a valid exception . The undoubted indication for surgical debridement of the pleural cavity is the suspicion of a relapse of intrapleural bleeding. Perform retoracotomy
appropriate for massive coagulated hemothorax in young and middle-aged patients with preserved functional reserves of the body. The operation should be carried out in the early stages, usually in the first three days after the preoperative preparation, aimed at stabilizing the patient’s condition.
Conservative treatment of coagulated hemothorax, effective prophylaxis and treatment of postoperative pleural empyema became possible with the widespread introduction into clinical practice of modern proteolytic enzymes.
Experimental and clinical studies conducted in the clinic proved the high efficacy of the domestic drug terrylitin in coagulated hemothorax and pleural empyema. Territorial and streptokinase are the drugs of choice for local fibrinolytic therapy. They possess much more activity than fibrinolysin, trypsin, ribonuclease. The clinic’s experience in applying local proteolytic therapy has shown that targeted use of proteolytic enzymes and fibrinolysis activators allows achieving a good clinical effect in 96% of patients with coagulated postoperative hemothorax and early fibrinothorax and hemofibrinothorax. Studies have shown that intrapleural administration of enzymes is accompanied by an increase in fibrinolysis by a factor of 2 to 2 compared with circulating blood.An increase in blood proteolytic activity is not observed. The number of leukocytes of pleural exudate after lysis of clots increases sharply and their phagocytic activity increases. When postoperative coagulated hemothorax is the optimal time to start fibrinolytic therapy for the 4-10th day after the operation.
The use of proteolytic enzymes significantly increased the efficiency of cavity sanation during the development of pleural empyema and expanded the possibilities of its conservative therapy.
In the last decade, new generations of enzyme preparations — immobilized and modified proteases — have been used in clinical practice. The VSankt-Petersburg Research Institute of Antibiotics and Enzymes has developed a technology for producing modified Termilitin — terridecases, a high-purity drug for protein that contains almost no ballast substances. It has a high degree of proteolytic activity and retains it, unlike the native drug, for a long time. Terridekaza is compatible with all antibiotics, except for polypeptides, does not have a local irritant effect, which allows you to enter it parenterally in large doses.
Studies conducted nnye clinic have shown that terrikaza can be successfully and effectively used in the treatment of coagulated hemothorax, with early fibrinothorax and treatment of pleural empyema. It was convincingly shown that the use of terrikease in the early postoperative period does not lead to the development of intrapleural bleeding, does not adversely affect the healing of the bronchus stump after pneumonectomy. Experimental and clinical studies have convincingly proved the validity of early (2– days after surgery) use of proteolytic enzymes for the treatment of coagulated hemothorax and prevention of early fibrinothorax. Local fibrinolytic therapy in the early postoperative period is indicated both for the treatment of advanced complications and for prophylactic purposes in patients with a high risk of developing pleural empyema,to facilitate the management of the pleural cavity in the selected mode.