Sepsis

SEPSIS SEPSIS Sepsis is generalized infection, which forwards by Sepsis is generalized infection, which forwards by

bacteremia on lowering of protective forces of organism. bacteremia on lowering of protective forces of organism. This problem is not only surgical, but also generally This problem is not only surgical, but also generally

biological, because during the last years the new biological, because during the last years the new approaches appeared to understanding of its approaches appeared to understanding of its

pathogenesis. They are in the new interpretation of pathogenesis. They are in the new interpretation of general mechanisms of violation of homeostasis and general mechanisms of violation of homeostasis and

inflammation.inflammation.

The frequency of sepsis does not fall down though the The frequency of sepsis does not fall down though the huge antibacterial therapy is used.huge antibacterial therapy is used.

75000 patients die yearly in Germany. 50000 cases 75000 patients die yearly in Germany. 50000 cases registered in the USA every year. Mortality consist 30-registered in the USA every year. Mortality consist 30-

80%. Home statistics is absent to great regret.80%. Home statistics is absent to great regret.

TERMINOLOGYTERMINOLOGY

The researches of the last years showed that a great The researches of the last years showed that a great number of gangrenous tissues (pancreatonecrosis, number of gangrenous tissues (pancreatonecrosis, polytrauma, burns) are capable to change the polytrauma, burns) are capable to change the bacteriums in quality of starting mechanism of the bacteriums in quality of starting mechanism of the generalized reaction of the organism.generalized reaction of the organism.

Clinically this stage is impossible to identification from Clinically this stage is impossible to identification from bacteremia.bacteremia.

At the coordinate conference of 1991 it was offered the At the coordinate conference of 1991 it was offered the term – syndrome of systematized inflammatory term – syndrome of systematized inflammatory answer (SSIA).answer (SSIA).

This syndrome is caused by the microbial infection This syndrome is caused by the microbial infection determines as sepsis.determines as sepsis.

The most important achievement, which changed a The most important achievement, which changed a conception in pathogenesis of sepsis, was opening of conception in pathogenesis of sepsis, was opening of number of powerful mediators of systematical number of powerful mediators of systematical inflammatory reaction.inflammatory reaction.It is informed that the starting moment in pathogenesis It is informed that the starting moment in pathogenesis of sepsis is fat-polysaccharide LPS of bacterium’s of sepsis is fat-polysaccharide LPS of bacterium’s membranes, in many cases, gram-negative. It is membranes, in many cases, gram-negative. It is determined as endogenous toxin. That’s why determined as endogenous toxin. That’s why reptodoglipans and teynon acid play the main role in reptodoglipans and teynon acid play the main role in gram-positive sepsis. They surround membrane of the gram-positive sepsis. They surround membrane of the gram-positive bacteriums. On the answer of the action gram-positive bacteriums. On the answer of the action of endogenous toxin the organism produces a great of endogenous toxin the organism produces a great number of inflammation mediators, which bring on the number of inflammation mediators, which bring on the system answer hitting into general blood flow. These system answer hitting into general blood flow. These matters – are mediators of sepsis one united under matters – are mediators of sepsis one united under one name – cytokines.one name – cytokines.Today it’s known about 40 such matters. The most Today it’s known about 40 such matters. The most significance among them has: swelling necrosis factor, significance among them has: swelling necrosis factor, interleukins 1, 6, 8.interleukins 1, 6, 8.

The considerable role in the pathogenesis of gram-The considerable role in the pathogenesis of gram-negative sepsis plays the factor of activation of negative sepsis plays the factor of activation of thrombocytes. This phospholipid leads to the thrombocytes. This phospholipid leads to the freeing of considerable amount of cytokines.freeing of considerable amount of cytokines.The last stimulate production of prostaglandin, free The last stimulate production of prostaglandin, free of radicals, oxide nitrogen, which changes in of radicals, oxide nitrogen, which changes in membrane and in the cell’s nucleus.membrane and in the cell’s nucleus.If unspecific immune reaction gets along with If unspecific immune reaction gets along with above-mentioned action, this so-called, mediate above-mentioned action, this so-called, mediate phase is bought.phase is bought.If no, the process goes into the phase of immune-If no, the process goes into the phase of immune-paralysis and the final phase.paralysis and the final phase.Clinically it is displayed by syndrome of poly-organ Clinically it is displayed by syndrome of poly-organ insufficiency and septic shock.insufficiency and septic shock.

The phases of the development of the generalized The phases of the development of the generalized infection infection

Local inflectional focus

Purulent resorptive fever

RecoverySyndrome of the systematic inflammatory answer

Septicemia

Lethal result Chronic sepsis

Septicopyemia

1.

2.

3.

4.

5.

In according to coordinate conference on sepsis (Chicago, 1992) the In according to coordinate conference on sepsis (Chicago, 1992) the development of sepsis is interpreted something otherwise:development of sepsis is interpreted something otherwise:

Local focus of infection

Syndrome on the systematic inflammatory answer

Sepsis

Difficult (heavy) sepsis

Septic shock

Poly-organ insufficiency

Lethal result (fatal termination)

CLASSIFICATIONCLASSIFICATION

There is the There is the primaryprimary and and secondarysecondary sepsis. The primary or cryptogenetic is sepsis. The primary or cryptogenetic is appeared under the lack of fixed primary appeared under the lack of fixed primary focus. The secondary is appeared on the focus. The secondary is appeared on the background of primary purulent focus.background of primary purulent focus.


On localization of primary focus On localization of primary focus contradistinguish:contradistinguish:

Surgical;Surgical;

Obstetric-gynecological;Obstetric-gynecological;

Urologic;Urologic;

Otogenous;Otogenous;

Oral and others.Oral and others.


For exciter appearance:For exciter appearance:Gram-positive (staphylococcal, streptococcal);Gram-positive (staphylococcal, streptococcal);Gram-negative (intestinal, pyocyanogenetic, Gram-negative (intestinal, pyocyanogenetic, proteus);proteus);Anaerobic (clostridium and an clostridium).Anaerobic (clostridium and an clostridium).

For the phases of development:For the phases of development:Elementary (primary) phase (toxemia, toxicemia, Elementary (primary) phase (toxemia, toxicemia, toxicohemia, toxinemia);toxicohemia, toxinemia);Septicemia (bacterioemia without purulent Septicemia (bacterioemia without purulent metastases);metastases);Septicopyemia (bacterioemia with metastases).Septicopyemia (bacterioemia with metastases).


For clinical:For clinical:

Lightning;Lightning;

Acute;Acute;

Sub-acute;Sub-acute;

Chronic;Chronic;

Septic shock.Septic shock.

The dimensions and disposition of the primary focus The dimensions and disposition of the primary focus have the certain importance in the development of have the certain importance in the development of disease. More frequently this is on the background of disease. More frequently this is on the background of purulent surgical diseases or vast wounds, ordinary purulent surgical diseases or vast wounds, ordinary with crush and necrosis of soft tissues frequently after with crush and necrosis of soft tissues frequently after insufficiently radical surgical treatment.insufficiently radical surgical treatment.During the last years the cases of the beginning of During the last years the cases of the beginning of sepsis are established after various invasiveness sepsis are established after various invasiveness procedures: catheterization of the vessels, operations procedures: catheterization of the vessels, operations with the use of apparatus of vasomotor system, with the use of apparatus of vasomotor system, prosthetics of valves, etc.prosthetics of valves, etc.These complications, which arise by reason of hospital These complications, which arise by reason of hospital procedures, were accorded name “nazokomial procedures, were accorded name “nazokomial hospital sepsis” or “disease of medical progress”.hospital sepsis” or “disease of medical progress”.Some immunologists and physicians consider that Some immunologists and physicians consider that sepsis is developed in those cases when the immune-sepsis is developed in those cases when the immune-deficiency states arise until the invasion of deficiency states arise until the invasion of microorganisms into focus (AIDS, the drug habit, microorganisms into focus (AIDS, the drug habit, diabetes, cancer).diabetes, cancer).

CLINICCLINIC

The basic complaints are feeling of heat The basic complaints are feeling of heat and fever, associated with high and fever, associated with high temperature. During sepsis with metastases temperature. During sepsis with metastases is observed, more frequently high-fever is observed, more frequently high-fever heat, during the sepsis without metastases heat, during the sepsis without metastases sweeps of the temperature is less than 1° sweeps of the temperature is less than 1° C. Besides a general weakness, the loss of C. Besides a general weakness, the loss of appetite, insomnia, sometimes - diarrhea appetite, insomnia, sometimes - diarrhea disturb. Some patients have euphoria; some disturb. Some patients have euphoria; some are found into state of prostration.are found into state of prostration.

Objectively:Objectively:

The skin is of earthily gray color, with The skin is of earthily gray color, with icterychnum hue, sometimes there is petechia icterychnum hue, sometimes there is petechia break out. Tachycardia, hypotension, frequent break out. Tachycardia, hypotension, frequent breathing, sometimes – the wheezes are missed. breathing, sometimes – the wheezes are missed. Augmentation size of liver and spleen are. During Augmentation size of liver and spleen are. During the sepsis with metastases there are the second the sepsis with metastases there are the second purulent focuses. The primary focus is determined purulent focuses. The primary focus is determined by the pallor of granulations, the delay of necrosis by the pallor of granulations, the delay of necrosis of tissue, scantiness of secret, which is of of tissue, scantiness of secret, which is of putrefactive – hemorrhagic character.putrefactive – hemorrhagic character.

DIAGNOSTICDIAGNOSTICThe laboratory markers of sepsis are:The laboratory markers of sepsis are:

The progressing anemia;The progressing anemia;Leukocytosis and deviation of the differential count to Leukocytosis and deviation of the differential count to the left. Lymphopenia – is prognostic unfavorable sign;the left. Lymphopenia – is prognostic unfavorable sign;Augmentation of intoxication indexes (differential Augmentation of intoxication indexes (differential blood index of intoxication, the level of middle blood index of intoxication, the level of middle molecules);molecules);T-lymphocytopenia;T-lymphocytopenia;Thrombocytopenia;Thrombocytopenia;Elevation of erythrocyte sedimentation rate;Elevation of erythrocyte sedimentation rate;The fall of the level of inorganic phosphor more than The fall of the level of inorganic phosphor more than 30% brings the depression of the phagocytic 30% brings the depression of the phagocytic bactericidal activity of granulocytes;bactericidal activity of granulocytes;The growth of the level of tsytokines that testily about The growth of the level of tsytokines that testily about the progressing pathologies.the progressing pathologies.

The PGD-syndrome includes:The PGD-syndrome includes:

Respirator distress-syndrome.Respirator distress-syndrome.

Acute renal insufficiency.Acute renal insufficiency.

Acute hepatic insufficiency.Acute hepatic insufficiency.

Syndrome of disseminated intravascular Syndrome of disseminated intravascular coagulation (DIC).coagulation (DIC).

Violation of the function of central nervous Violation of the function of central nervous system.system.

CURE PRINCIPLESCURE PRINCIPLES1.1. Timely (right) diagnosis (take into account not Timely (right) diagnosis (take into account not

only clinical indexes but such criteria as acid-only clinical indexes but such criteria as acid-basic equilibrium, water-electrolyte balance, basic equilibrium, water-electrolyte balance, activity indexes of the inflammatory process activity indexes of the inflammatory process and degree of oppression of the immune and degree of oppression of the immune system).system).

2.2. Cure (treatment) in the department of the Cure (treatment) in the department of the intensive therapy.intensive therapy.

3.3. Radical surgical hearth treatment (adequate Radical surgical hearth treatment (adequate drainage, timely closing).drainage, timely closing).

4.4. Adequate antibacterial therapy. It is necessary Adequate antibacterial therapy. It is necessary to take empiric antibacterial therapy before the to take empiric antibacterial therapy before the identification of stimulus, taking into account identification of stimulus, taking into account the focus of infection, the state of kidneys, the focus of infection, the state of kidneys, liver, the immune system.liver, the immune system.

5. Antitsitokinotherapy. Got and made the approbation 5. Antitsitokinotherapy. Got and made the approbation the specific monoclonial antibodies to endotoxin LPS.the specific monoclonial antibodies to endotoxin LPS.

The antibodies to the factor of tumors of swelling are The antibodies to the factor of tumors of swelling are elaborated.elaborated.

For blocking of tsitokines it is regarded the perspective the For blocking of tsitokines it is regarded the perspective the use of ibuprophenum and trental (pentoxifillin), which use of ibuprophenum and trental (pentoxifillin), which brake the formation of the factor of tumors of swelling brake the formation of the factor of tumors of swelling and predecessors of violation of the vascular and predecessors of violation of the vascular perspicacity of the lungs. It is perspective is the use of perspicacity of the lungs. It is perspective is the use of preparation interleikin-2 – roncoleikin.preparation interleikin-2 – roncoleikin.

CURE PRINCIPLES

CURE PRINCIPLESCURE PRINCIPLES6.6. Detoxication, which induces therapy in volume 3 – 6 litres Detoxication, which induces therapy in volume 3 – 6 litres

for day, the amount of shown out liquid more than 1000 ml, for day, the amount of shown out liquid more than 1000 ml, forced diuresis (urine excretion) and the methods extra forced diuresis (urine excretion) and the methods extra corporal detoxication, among which the priority has corporal detoxication, among which the priority has plazmapharez and limphosorbtion.plazmapharez and limphosorbtion.

7.7. Immunocorrection depends on diagnostics displacements Immunocorrection depends on diagnostics displacements in the immune system. It is better to make in the immune system. It is better to make hemotransfusion, transfusion of native and hiperimmune hemotransfusion, transfusion of native and hiperimmune plasmadestination of the preparations of thymus and plasmadestination of the preparations of thymus and gamma globulins.gamma globulins.

8.8. The feeding questions take an important place. Especially The feeding questions take an important place. Especially the early enteral feeding, which improves the bloody the early enteral feeding, which improves the bloody circulation in abdominal cavity, liver, mucous of the circulation in abdominal cavity, liver, mucous of the stomach, warns acidosis. An important role in the stomach, warns acidosis. An important role in the stimulation of the immune system of the bowels plays stimulation of the immune system of the bowels plays feeding in small intestinum.feeding in small intestinum.

9. Hormonal therapy.9. Hormonal therapy.Corticosteroids used in the threat of Corticosteroids used in the threat of septic shock and also in the septic shock and also in the augmentation of amount of T-killers and augmentation of amount of T-killers and T-supressors.T-supressors.

10. The correction of the system of blood 10. The correction of the system of blood coagulation.coagulation.Heparin or lower-molecules heparins Heparin or lower-molecules heparins (fraxiparin, calciparin, lavenox); (fraxiparin, calciparin, lavenox); desagrigents (aspirin, tiklid); proteases desagrigents (aspirin, tiklid); proteases inhibitors (kontrikal, trasilol, gordox) are inhibitors (kontrikal, trasilol, gordox) are used.used.

CURE PRINCIPLESCURE PRINCIPLES

Education

Sepsis