Introduction

The problem of ensuring reliable hemostasis in purulent surgery continues to be relevant even in the presence of a wide range of means for local hemostasis. This is due to the fact that a significant amount of drugs (sponges, adhesives, plates) increase the risk of infection, or simply are not recommended for use in this group of patients.
Haemoblock is a local hemostatic agent and is registered in the Russian Federation as a medical product. It contains an incomplete silver salt of polyacrylic acid, containing silver nanoparticles, which determines the bactericidal and bacteriostatic effect of Haemoblock. The substance is applied topically in cases of parenchymal and capillary hemorrhage. Sterile cotton wool or gauze tampons are soaked with the substance and applied to the bleeding, preliminarily dried up surface of the wound. In case of vast wound surfaces the substance is used in the form of spray. Haemostatic effect is achieved within 1-2 mins.
During the first stage of the medical substance action, a polyacrylic matrix structure is formed which contains albumin molecules in the cells of polyacrylic matrix. Its life cycle is not too long, since polyacrylate anion does not create strong connections with protein molecules and is sustained only due to weak bonds. But this structure is a primary organizer of a sustainable film. At the next stage silver ions are restored by albumin molecules, forming a stable complex: polyacrylate anions form a strong bond with positively charged protein molecules. Such structure is packed in several micro-
layers, creating a strong polymethacrylate film on the wound surface. That said, the reduced metal like silver in complex with proteins is a potent bactericidal factor that ensures absence of wound infection when using Haemoblock. At a later stage the surface Haemoblock-protein structure is replaced by fibrin. Whereas the polyacrylate matrix is plasmolysed within 24 hours. There is already experience in using the hemostatic agent Haemoblock in surgical practice at present. The purpose of this study was to evaluate the effectiveness of the hemostatic properties of the Haemoblock preparation for intraoperative bleeding of various origins in the clinical practice of the department of purulent surgery and proctology.

Material and methods.

The study included 250 patients. Patients were divided into 4 groups according to nosological units:
Group 1 - 100 patients with purulent diseases of the skin and soft tissues (furuncle, abscess, phlegmon, infected wounds of various kinds). The application of the drug on the wound surface on a gauze drape for 2-4 minutes was used in this group of patients with superficial wounds; tamponing of wounds for a period of 6 to 24 hours was used for deep purulent cavities, common interfascial phlegmon and tricks.
Group 2 - 50 patients with a complicated course of acute surgical pathology of the abdominal cavity and chest (acute destructive pancreatitis, peritonitis of various etiologies, liver abscesses, pleural empyema). All patients with pathology of the abdominal organs were operated on in the open way. Hemostasis was achieved by laying a drape with a Haemoblock on the bleeding tissue for 2-5 minutes. Patients with pleural empyema were operated thoracoscopically, Haemoblock solution was injected
into the pleural cavity through the thoracoport in a volume of 50-100 ml.
Group 3 - 40 patients with oncological diseases (breast cancer, melanoma, rectal cancer,
liposarcoma, cancer of the tongue). Haemoblock was applied abundantly moistened with a gauze drape on an open wound surface.
Group 4 - 60 patients of the proctological profile (suppressed epithelial coccygeal duct,
paraproctitis, patients with a functioning colostomy). Drape with Haemoblock was placed in wounds for up to 12 hours. The age of patients ranged from 21 to 76 years old. There were 172 men (68.8%) and 78 women (31.8%). Patients of working age were 81.6% (204), patients over 60 years old were 22.4% (56). The average duration of hospitalization was 12.9 days. Table 1 shows the distribution of patients according to the nature of the prior disease. Concomitant pathology that aggravated the severity of the underlying
disease was detected in 195 (78%) patients during the examination: diseases of the cardiovascular system - 78%, respiratory diseases - 47%, diseases of the gastrointestinal tract - 53%, diabetes - 46%, diseases of the genitourinary system - 39%, chronic alcohol intoxication - 54%. All patients received antibiotic therapy.

Table 1
The distribution of patients according to the nature of the prior disease

Study results
The results of observation of surgical hemostasis for various nosological profiles are given in table 2

Table 2
Results of surgical hemostasis

Clinical examples

1. Patient G., 46 years old. Diagnosis: Right-side destructive lower lobe pneumonia. Empyema pleura right. Surgery - thoracoscopic sanitation of the pleural cavity. (Figure 1.)

Figure 1

Surgical Procedure Torakoports 10 mm and 10 mm introduced into the pleural cavity on the right under endotracheal anesthesia. Up to 200.0 ml of sanioserous-fibrocystic discharge in the pleural cavity. During the revision, massive loose adhesions between the middle and lower lobes of the lung and the parietal pleura. Fibrin is mechanically removed, the remaining fragments are removed by suction. No defect of the lung tissue was detected. The pleural cavity is washed physiologic saline, Haemoblock 50 ml is
introduced with an exposure of 5 minutes (Figure 2).

Figure 2

2 drainage for flow-aspiration system are installed. Hemostasis - dry. There are no foreign bodies. Stitches for wounds. Aseptic bandage.
2. Patient G., 28 years old. Diagnosis: Abscess of the right lower leg. Polydrug, HIV. Surgery - opening of abscess / phlegmon of soft tissues Surgical Procedure 10 cm incision is made above the infiltrate in the posterior surface of the right tibia under
intravenous anesthesia. Up to 50 ml of creamy pus and atheromatous purulent masses were released. Seeding. When revision the purulent cavity is limited, it is located subcutaneously, measuring 6 * 5 * 5 cm, there is no purulent leakage. The wound is washed with chlorhexidine solution, drained by drape with a Haemoblock. Aseptic bandage.
3. Patient R., 37 years old. Diagnosis: Acute destructive pancreatitis. Mixed pancreatic necrosis. Enzymatic peritonitis, omentobursitis, retroperitoneal phlegmon on the left. Abdominal sepsis. Syndrome of multiple organ failure, endogenous intoxication. Bilateral pneumonia. Surgical interventions: 15.08.17 - laparoscopy, 24.08.17 - lumbotomy, sanitation of the retroperitoneal space, 07.09.17, 11.09.17, 13.09.17, 15.09.17, 17.09.17, 27.09.17, 05.10.17 - revision of the saclesser omental sac and retroperitoneal space.
Surgical Procedure Sanitation of the retroperitoneal space (Figure 3.).

Figure 3

Oblique lumbotomic access to the retroperitoneal space on the left is made under endotracheal anesthesia. Retroperitoneal fiber is edematous. Purulent discharge from the retroperitoneal space is obtained. The tail of the pancreas is determined by palpation. Abundant contact bleeding is noted. Gauze pad with Haemoblock and silicone drainage are installed. The latter is fixed to the skin through a separate counterpuncture. Aseptic bandage. 3 recurrent bleeding was observed during the observation: 2 arrosive of omental sac and 1 of soft tissue lumbotomy access.
4. Patient N., 58 years old with mixed pancreatic necrosis and abdominal sepsis. Abundant
arrosive bleeding was noted during ligation, the wound was tightly tamped by drapes withHaemoblock for 24 hours. A relapse of bleeding from the omental sac was noted after 3 days against the background of the existing hypoproteinemia (total protein 47 g / l, albumin 12 g / l). 50 ml of Haemoblock was injected, the wound was re-tightly tamponed for 24 hours.
5. Patient V., 42 years old with acute purulent pelviorectal paraproctitis and congenital
immunodeficiency Ig E. Meter tampons with Haemoblock installed after opening of paraproctitis, abundant leakage of blood from wounds was noted after 12 hours. Taken in the operating room, the wounds are washed, re-tamponed. A small leakage of blood was noted in the postoperative period, which was stopped by spraying with Haemoblock.
6. Patient C., 78 years old. Diagnosis: melanoma of the back with multiple metastases, bleedingfrom the tumor (Figure 4). Gauze cloth with Haemoblock is applied for 1 day. Recurrent bleeding on the ligation. The tumor is excised, bleeding is stopped with Haemoblock solution.

Conclusions

The Haemoblock drug showed reliable hemostatic properties. The level of secondary bleeding in a sample of 250 patients was 1.2%. Additional advantages of the drug include:
- convenient liquid form,
- maximum delivery to the place of application,
- no contraindications when working in purulent cavities,
- good interaction with dressings,
- good visualization of the wound through the drug.
The disadvantage of Haemoblock is the reduction of hemostatic properties in severe
hypoalbuminemia (albumin levels below 12 g / l). Additional spraying of the wound surface (increased consumption of the drug) is required in this case.