Lung abscess incision

Lung abscess is also called lung abscess. For patients with lung abscess within three months, systemic and medical treatment should be used. Including antibiotics systemic application and positional drainage, topical drops, spray and bronchoscopy suction. Surgical treatment is considered when the above treatment is ineffective. That is, lung abscessation. Treatment of diseases: acute lung abscess lung abscess Indication Lung abscess. Contraindications 1, with systemic diseases, can not tolerate surgery. 2, local infection, not suitable for surgery. Preoperative preparation Including improving the patient's general condition, strengthening nutrition, intermittent blood transfusion, systemic antibiotics, body sputum drainage, topical spray, intratracheal drip. After 3 to 6 weeks of hospitalization, the amount of sputum is reduced to less than 50ml per day; from yellow pus thick to white sticky; appetite, body weight has increased; hemoglobin is close to normal, body temperature pulse tends to be stable, surgery can be performed. Surgical procedure The first step of general anesthesia patients should be supine until fully awake and blood pressure is stable (usually more than 6 hours after surgery) to change to a semi-sitting position. After anesthesia is awake, patients should be encouraged to take deep breathing exercises and sputum; or you can press the urgent mouth to help the patient to take a deep breath and sputum, 5 to 6 times a day, to accumulate the bronchial tuberculosis and possible accumulation of blood. Residual lung expansion and chest drainage to avoid secondary infection in the lungs. Cough must be hard, no need to force the same pain, but can not drain, but need to repeat cough, causing more pain. If the sputum is thick, it is not easy to squirt out, it can be used as a vapor inhalation, 3 times a day for 15 minutes, and oral tincture. On the first day after the operation, the patient should be lifted up and sit up for 3 to 4 times a day. Generally, 3 days after partial lung resection, after the chest drainage tube is removed (after 1 week after pneumonectomy), the patient can get out of bed. 3 to 4 days after surgery, the patient should be helped to lift the side arm to avoid adhesion of the chest wall muscles in the vicinity of the incision, affecting the movement of the arm; never wait until the incision does not hurt before starting exercise. The treatment of these aspects plays an important role in the recovery of postoperative conditions, the expansion of residual lungs and the prevention of complications, and should be given special attention. After the second step of lung resection, if the patient does not have hypoxia, it is not necessary to give oxygen. For patients with poor lung function, intermittent low flow through the nasal canal to give oxygen. When oxygen is supplied, the catheter should be inserted into the nasopharynx so that oxygen can be effectively inhaled. Sometimes the patient has a lot of sputum, and it is thick and sticky, which is not easy to get out, which seriously affects the breathing; or due to insufficient preoperative estimation, pulmonary ventilation and ventilatory insufficiency after lung surgery, resulting in hypoxia; or due to blood transfusion, excessive infusion, Over-speed, pulmonary edema and other serious conditions, the trachea should be cut in time, so that the sputum in the respiratory tract can be cleared at any time, and thus can reduce the dead space of 50% of the respiratory tract, and increase the alveolar ventilation by 25%. At the same time, the thin plastic tube can be used to inhale oxygen more effectively through the tracheal tube; however, a certain humidity and temperature should be maintained to avoid dryness of the respiratory tract and scarring of the sputum. When the sputum is viscous, the chymotrypsin can be dripped through the tracheal tube to make the sputum thin. When the breathing is weak, the anesthesia machine can be connected to the tracheal cannula for assisted breathing. When there is pulmonary edema, it should be pressurized to give oxygen, a small amount of 95% alcohol is inhaled to destroy the sticky foam, and the alveolar ventilation area is increased. At the same time, intravenous aminophylline 0.25-0.5g is slowly injected to relieve bronchospasm. In addition, should also stop infusion, switch to 50% glucose or 20% mannitol 250ml quickly into the vein, in order to diuretic, dehydration, relieve pulmonary edema, and consider the addition of digitalis drugs. After the third step of lung surgery, generally within 24 hours, the chest cavity will have 200 ~ 400ml of oozing and exudate flowing out through the drainage tube, the blood color of the drainage fluid should gradually fade. After about 24 to 72 hours, the effusion can be drained and the drainage tube can be removed. When pulling the drainage tube, the drainage tube should be disinfected near the skin and the skin around the drainage port, and the fixed line should be cut. The pad with 4 to 5 layers of Vaseline gauze pad should be placed in the drainage port and the other hand should hold the drainage tube. After the patient inhales deeply, he does not exhale and quickly pulls out the drainage tube. At the same time, the Vaseline gauze and the cotton pad are pressed against the drainage port, and the tape is pressure-wrapped to prevent the air from leaking into the chest cavity. If the drainage volume is a lot, the blood color does not change, and the pulse is fast, the blood pressure is low, and should be alert to the presence or absence of active bleeding. Therefore, in addition to the observation of breathing, pulse, blood pressure after surgery, it should also be noted whether the liquid level in the drainage tube fluctuates with the breathing and is higher than the water level inside the bottle. If the liquid level in the tube does not fluctuate, it indicates that the drainage tube has been blocked, and should be immediately checked for no bending and bending under the patient's body. If there is no abnormality, the drainage tube can be clamped and squeezed upwards by hand, and the clot that may be blocked in the tube is squeezed into the chest to release the blockage. If it is still not smooth, the possibility that the inner mouth of the drainage tube is blocked by the diaphragm, chest wall or residual lung should be considered. The drainage tube can be slightly rotated to make the nozzle exit the blockage, in order to reopen smoothly. If it still can't be smooth, it has to be removed. According to the amount of drainage in the previous stage and the condition of chest fluoroscopy, consider putting another drainage tube or changing it into thoracic puncture. In addition, it should be observed whether the hourly drainage volume is gradually reduced, and whether the drainage fluid is lightened; when active bleeding is suspected, the hemoglobin of circulating blood and drainage fluid can be repeatedly checked in addition to the hemostatic drug. If the drainage volume is large, the hemoglobin of the circulating blood gradually decreases, and the hemoglobin of the drainage fluid gradually rises or remains unchanged, that is, there may be active bleeding, and the machine should be shut off, and the chest should be opened to stop bleeding. After the partial lung resection in step 4, the residual cavity in the thoracic cavity will be filled with the remaining lungs of the over-expanded (ie, compensatory emphysema). However, if the lungs have inflammation and fibrosis, it is not easy to over-expand, so that the residual cavity can not be eliminated; and the air in the residual cavity will gradually be absorbed by the pleura, forming a high negative pressure, causing the pleural membrane to continuously seep. Conditions for the formation of bronchopleural fistula and secondary empyema are provided. This situation is especially common in tuberculosis patients. In addition, in tuberculosis patients, such as residual lung residual lesions, excessive expansion may also cause recurrence and dissemination of the lesion. Therefore, before the partial resection of the lung and during surgery, attention should be paid to the examination of the residual lung. If the surface of the remaining lung has a thickened pleura, it should be exfoliated. If it is estimated that the residual lung can not be over-expanded, or there are more residual lesions of tuberculosis in the remaining lungs, it should be added for thoracoplasty. Generally, preoperative and intraoperative estimates must be added for thoracoplasty, and the patient's physique, lung function, and intraoperative conditions may be concurrently performed with lung resection and thoracoplasty or thoracolumbar pleural stripping to remove the wall layer. The pleura covers the rest of the lungs, forming an extrapleural space to avoid the pain of two operations. If conditions are not allowed, thoracicplasty is performed within 3 to 6 weeks after the operation of the lung. Some patients do not need to be added for thoracoplasty before surgery. If the lungs cannot be expanded to the 4th posterior rib plane within 2 to 3 weeks after surgery, the effusion will continue to appear even after repeated puncture in the residual cavity. It was found that the patient was struggling with a small amount of old bloody fluid, indicating that bronchopleural fistula had occurred, and thoracoplasty should be performed in time to avoid empyema. This type of thoracoplasty can be done without cutting the first rib or leaving the posterior segment longer, without the need for tuberculosis. After the pneumonectomy, the residual cavity will be gradually filled with exudate, and the exudate will gradually become mechanized and contracted, causing the diaphragm to rise, the chest wall to collapse, the mediastinum to shift to the operation side, and the lung to compensate for emphysema. Sometimes oozing too much and too fast within 1 to 2 days after surgery, pushing the mediastinum to the healthy side, affecting the breathing and circulation, the chest tube should be slightly opened and the pleural effusion should be slowly released, and the mediastinum gradually recovers. In situ. If there is no chest drainage tube, the pumping can be puncture to reduce the pressure on the side of the operation. Pulmonary tuberculosis patients need Qin total pneumonectomy, and the contralateral lung also has more tuberculosis lesions. It is estimated that postoperative compensatory emphysema may cause recurrence and dissemination of the lesion, which can be added at the same time, or after 3 to 6 weeks. For thoracoplasty. Sometimes after the pneumonectomy, the residual fluid accumulates and shrinks, which can cause the mediastinum to shift to the surgical side, causing distortion of the trachea and large blood vessels. The patient's performance is obviously short-sighted and palpitations. For this type of patient, thoracoplasty can also be performed to correct mediastinal shift. After the fifth step of the lower lobe resection, especially after the left lower lobe resection, if the patient is too high, the remaining lungs will occasionally fall and cause bronchial distortion, causing atelectasis in the upper lobe. At this time, the patient has symptoms such as shortness of breath, sweating, hypoxia, repeated sputum sputum, tracheal movement to the side of the operation, and disappearance of the surgical side (or tuberculosis). The diagnosis can be confirmed by chest fluoroscopy. In the event of atelectasis, the semi-sitting position should be lowered immediately, even lying down or on the side of the healthy side, encouraging the patient to use force to pull the tongue, if necessary, pull out the tip of the tongue, insert a catheter through the nostril during deep inhalation. The trachea is irritating. After the bronchus is restored to the original position and the sputum accumulated in the bronchus is squirmed out, the patient's urgency is gradually improved, and the surgical side is restored to the alveolar breath sound. If the patient is weak and unable to squat; or the atelectasis has been around for a long time, the alveolar memory has been absorbed, and when the coughing action is impossible to discharge the secretion, the bronchoscopy should be performed in time (if necessary) Performed multiple times). The reason for the occurrence of empyema in the sixth step is mostly due to the division of the lesion during the operation, or the secretion overflows when the bronchus is cut, which is caused by contamination of the chest. Postoperative bronchial pleural fistula due to poor healing of the bronchial stump; or pleural effusion did not discharge in time, providing favorable conditions for bacterial reproduction, is also a common cause of empyema. Therefore, each time for thoracic puncture, in addition to strict aseptic operation, after the pumping, blue and streptomycin should be injected into the thoracic cavity to prevent infection. Once the turbid fluid or obvious pus is withdrawn, the closed thoracic drainage should be re-examined after the diagnosis of empyema, and the thoracoplasty should be performed in time after the symptoms of poisoning are improved. There are two reasons for the occurrence of bronchopleural palsy in the seventh step: the first one is the cause of the bronchial stump itself: 1 the bronchial stump site has inflammation before surgery and is not found; 2 the postoperative stump is too long, and the secretions are accumulated. Can not be discharged, causing infection; 3 improper operation, uneven spacing of the suture, uneven tension, or the needle is too shallow to cause the suture to fall off; 4 the suture is too thick, the endocrine secretion of the bronchus flows along the suture pinhole to the stump Infection caused outside; 5 stump separation is too thorough, bronchial artery ligation is too high, so that stump infection does not heal, resulting in bronchopleural fistula. Early patients can have old bloody pleural effusions, and pus will emerge after the late empyema has formed. Once found, chest drainage should be performed immediately, and thoracic angioplasty should be performed to eliminate the dead space. If necessary, it can be added as a suture. In the eighth step, if the incision is contaminated during the operation, the wound infection is prone to occur. Especially in the supine position, the upper end of the incision is pressed on the inner edge of the scapula, which is more prone to redness, suppuration, and sometimes even under the scapula. Once an infection is discovered, in addition to the application of antibiotics, the drainage should be removed. Such as the formation of a abscess under the scapula, long-term unhealed, the lower part of the scapula can be removed to facilitate drainage complication Blood chest Before the chest is closed, the chest wall, diaphragm and intercostal space should be carefully examined. Especially for the wound with adhesion, it should be carefully coagulated and burned. Check for loosening of the vascular ligation line. After careful observation and record the color and quantity of the thoracic drainage fluid, under normal circumstances, it should be gradually reduced, the color becomes lighter. If it continues to ooze or decrease, it will suddenly increase. The blood of the drainage fluid will become thicker and should be alert to active bleeding in the chest. Can first give hemostatic drugs, static fibrinogen, after conservative treatment for 4 ~ 6h, if the chest drainage is still a thicker bloody exudate, more than 100ml per hour, and blood pressure drops, pulse increases, chest radiograph When there is a moderate amount of fluid or large clots in the chest, you should consider reopening the chest to stop bleeding and remove the blood clots in the chest. 2. Bronchial pleural fistula Because of the inflammatory changes and infection of the bronchi of the lung abscess, the bronchial mucosa has poor healing ability. If the bronchial stump is not properly treated, it may cause bronchopleural palsy in the postoperative period. 3. Thoracic infection or empyema Intraoperative abscess rupture contaminated the thoracic cavity, the thoracic cavity was not completely flushed, the lesion was not completely removed, the lung wound was leaked, the chest drainage tube was removed prematurely, or the pleural effusion was not treated in time. These factors can cause postoperative operation. Thoracic infection or empyema.