Secondary specialized medical education. Sepsis. Treatment Sepsis Surgery

With epsis, namely surgical sepsis, is a severe general disease that usually occurs against the background of a local focus of infection and a decrease in the body's defenses.

The frequency of sepsis in acute purulent surgical diseases and injuries is quite high, and mortality ranges from 35 to 69%, depending on the form of sepsis and the type of pathogen.

Classification. There are the following types of sepsis.

1. Primary and secondary sepsis. Primary, or cryptogenic, develops in the presence of an unidentified purulent focus. Primary surgical sepsis is rare, its source often remains unclear, and the development is explained by a dormant infection. Secondary sepsis occurs against the background of a primary purulent focus (purulent peritonitis, pleural empyema, abscess and phlegmon of different localization, purulent wounds).

2. By type of pathogen: a) gram-positive sepsis - staphylococcal, streptococcal, etc.; b) Gram-negative sepsis - colibacillary, Pseudomonas aeruginosa, Proteus; c) clostridial sepsis; d) non-clostridial sepsis.

3. By phases of development: initial phase (toxemia), septicemia (sepsis without purulent metastases), septicemia (sepsis with purulent metastases).

4. According to the clinical course: fulminant, acute, septic shock, subacute, chronic.

So, sepsis should be considered as a stage in the development of a surgical infection, as a consequence of its generalization. Schematically, this process can be represented as follows:

Local purulent process - Purulent-resorptive fever - Initial phase of sepsis - Septicemia - Septicopyemia - Death

Etiology and pathogenesis. The causative agents of sepsis can be a variety of bacteria - staphylococci, streptococci, pneumococci, Escherichia (E. coli), gonococci, etc. Sepsis can also be caused by an anaerobic (gas) infection, but more often by a coccal group. In rare cases, when blood cultures of septic patients are found, two or even three types of microbes are found in various combinations. Sepsis is the most severe complication of open injuries, local inflammatory processes as well as after operations.

In some cases, the pathogenesis of sepsis is played mainly by the microbial factor, i.e., the hematogenous spread of bacteria and their deposition in various organs. In other cases, the toxic factor predominates, i.e. damage to organs and tissues by toxins and endotoxins without metastatic ulcers.

The pathogenesis of sepsis is determined by three factors.

1. Microbiological factor (type, virulence, quantity, duration of action of microbes, etc.).

2. The focus of the infection (the size, area and nature of the affected organ, the place of introduction and ways of spread, the nature of the blood circulation, etc.). Most often, sepsis is observed with open injuries of large bones and joints, with inflammatory processes on the face and in cavities. The frequency of complications of septic infection in injuries and local purulent inflammation is proportional to the severity of the injury, the extent and depth of inflammation (open injuries of the hip, knee joints, open crushed fractures of tubular bones, pelvic bones, extensive suppuration and phlegmon of soft tissues, etc.).

3. Reactivity of the body (immunobiological state of the body, the state of various organs and systems, etc.).

Pathological anatomy. Pathological changes in the organs do not have specific signs, but the sum of these changes gives a characteristic picture of sepsis. In toxic forms of non-metastasizing general purulent infection, autopsy reveals degenerative changes in various organs. Characterized by hemorrhages in the skin, mucous membranes, serous membranes and parenchymal organs. In the heart, liver, kidneys, spleen, there is usually cloudy swelling, fatty and parenchymal degeneration. Septic endocarditis, pleuropneumonia, nephritis, pyelitis, meningitis, etc. are sometimes observed.

With septicopyemia, along with the described changes, abscesses of various sizes develop in various organs. Blood cultures are often positive.

Diagnostics. The peculiarity of the disease lies in the fact that the main signs and the main picture of its clinical course are the same for various pathogens. There is not a single symptom that, in itself, could be considered specific for sepsis.

characteristic appearance a patient with sepsis. IN initial stage, especially at high temperature, the face is hyperemic, in the future, due to the development of anemia, the face becomes more and more pale, the features are sharpened. The sclera, and sometimes the skin, become icteric. Often there is a bubble rash on the lips (herpes), the smallest hemorrhages (petechiae) or a hemorrhagic rash on the skin and pustules. Very characteristic of sepsis and the early appearance of bedsores, especially in the acute course of the disease. Growing emaciation and dehydration.

One of the main constant signs of sepsis is an increase in temperature to 39 - 40 C with a tremendous chill (before the temperature rises) and pouring sweat (after the temperature drops). The temperature curve in sepsis is intermittent, laxative or constant. For sepsis without metastases, in most cases, a constant type of temperature curves is characteristic, for sepsis with metastases, a laxative temperature is characteristic with amazing daily or periodic chills due to the entry of microbes from a purulent focus into the blood.

In parallel with fever, CNS disorders are noted: headache, insomnia or drowsiness, irritability, agitation or, conversely, a depressed state, sometimes a violation of consciousness and even the psyche.

Disorders of the functions of the cardiovascular system are manifested in a decrease in blood pressure, an increase and weakening of the pulse, and the discrepancy between the pulse rate and temperature is a very bad sign. Heart sounds are muffled, sometimes murmurs are heard. Often there are foci of pneumonia.

The course of sepsis can be complicated by bacterial-toxic, or, as it is called, septic shock.

Changes in the digestive organs are indicated by deterioration or complete loss of appetite, belching, nausea, constipation and especially diarrhea, which is often profuse (“septic diarrhea”). Tongue dry, lined. The function of the liver is also impaired, which is expressed, in addition to its increase and soreness, by the icteric color of the sclera. The spleen is enlarged and painful, but due to flabbiness it is not always palpable.

Violation of kidney function is expressed in a decrease in relative density to 1010-1007 and below, the appearance of protein, cylinders, etc. The activity of other organs is also disturbed.

In addition to all these signs, sepsis with metastases is characterized by the appearance of abscesses in various organs and tissues. With purulent metastases in the lungs, pneumonia or lung abscess are observed, with bone metastases - osteomyelitis, etc.

If the source of infection was a purulent wound, then as sepsis develops, a characteristic process also occurs in it: wound healing stops and it seems to “stop” at a certain stage of healing. The granulations change from juicy and pink to dark and sluggish, sometimes pale and bleed easily. The wound is covered with a whitish-grayish or dirty coating with an abundance of necrotic tissues. Wound discharge becomes scanty and cloudy, sometimes grayish-brown, fetid.

Blood changes are characteristic of sepsis. In the initial stage, leukocytosis (up to 15 109 / l -30 109 / l), a shift of the leukocyte formula to the left and an increase in ESR are usually detected. Leukopenia is often a sign of the severity of the disease and the weak reactivity of the body. At the same time, increasing anemia develops: the number of erythrocytes decreases (up to 3 1012 / l and less). Progressive anemia (despite repeated blood transfusions) is a constant and one of the main signs of sepsis.

A valuable auxiliary method in recognizing sepsis is a regular bacteriological examination of blood. However, in the typical clinical presentation of sepsis, negative cultures do not play a decisive role in the diagnosis. Negative results of a bacteriological blood test in sepsis are especially often observed in the treatment of a patient with sulfa drugs and antibiotics, therefore, blood cultures taken before the start of treatment are of the greatest value.

So, when establishing the diagnosis of sepsis, the following clinical and laboratory data can serve as the basis.

1. Acute or subacute development of the disease in the presence of a primary focus (purulent diseases, wounds, surgery).

2. High fever, hectic or constant, with chilliness and profuse perspiration.

3. Progressive deterioration of the general condition of the patient, greater severity of general phenomena compared with local changes in the primary focus (wound, local purulent process - panaritium, carbuncle, mastitis, etc.), despite active treatment (removal of the focus of infection, opening, drainage of the abscess, etc.).

4. Cardiovascular disorders (weak pulse, tachycardia, drop in blood pressure); discrepancy between heart rate and temperature (frequent pulse with a slight increase in temperature).

5. Progressive weight loss, anemia.

6. Icteric skin, sclera; enlargement of the liver, spleen.

7. Characteristic changes in the wound (septic wound).

8. High ESR with a normal or slight increase in the number of leukocytes; neutrophilia with a shift of the leukocyte formula to the left, lymphopenia.

9. Impaired kidney function (low relative density of urine, protein, casts, formed elements).

10. Periodically occurring diarrhea.

11. Early appearance of trophic disorders (pressure sores).

12. Bacteremia.

Differential diagnosis should be carried out with typhus, miliary tuberculosis, brucellosis. If surgical sepsis is suspected, all available methods studies to identify the primary purulent focus. In the presence of an entrance gate of infection, the diagnosis of sepsis may be more justified than in sepsis without an obvious source of infection. In the latter case, tuberculosis, typhus, influenza, etc. are sometimes mistakenly diagnosed instead of sepsis. Sepsis should also be differentiated from purulent-resorptive fever, the main clinical manifestation of which is a temperature reaction.

The severity of purulent-resorptive fever corresponds to the severity of the suppurative process. There is a direct relationship between them: with the elimination of the purulent focus, if irreversible changes have not occurred in the body, as, for example, during traumatic exhaustion, purulent-resorptive fever is also eliminated. In addition, in sepsis, the temperature reaction does not correspond to changes in the focus of purulent inflammation.

Treatment of sepsis is a difficult task, which must be solved individually in relation to each patient. It includes a complex of local and general therapeutic measures.

Local treatment for sepsis, aimed at eliminating the primary focus of purulent infection, is carried out according to the general rules for the treatment of purulent processes - early surgical intervention (opening an abscess, phlegmon, etc., resection of a joint and even amputation of a limb) with the creation of favorable conditions for the outflow of pus or a more radical removal of the source of infection, opening all purulent streaks, removing sequesters or foreign bodies, rest (immobilization), rare and gentle dressings, local use of antibiotics, physiotherapy procedures (ultraviolet irradiation, UHF, etc.). In some cases, local treatment in the area of \u200b\u200bthe entrance gate of the infection may not be necessary (for injections, cuts, healing boils and other subsiding foci of infection).

General treatment pursues the fight against infection and intoxication of the body, increasing the body's resistance, improving the function of various organs and systems. The main components of intensive care for sepsis are: antibiotic therapy; infusion therapy aimed at correcting homeostasis; immunotherapy; the use of anabolic steroids; measures for the prevention and treatment of complications of sepsis.

When choosing antibacterial agents, the results of the patient's blood cultures should be taken into account. Of the antibacterial agents, antibiotics are of the greatest importance - semi-synthetic penicillins, aminoglycosides, cephalosporins, as well as chemical antiseptics - dioxidin, furagin K, etc. The features of antibacterial therapy for sepsis are: 1) the use of maximum doses of the drug; 2) a combination of drugs with different spectrum of action; 3) a combination of routes of administration of antibiotics; 4) constant monitoring of the resistance of medicinal flora; 5) continuation of antibiotic therapy for at least 2 weeks after the onset of clinical recovery and receiving sin-negative blood cultures during this period.

To eliminate toxemia, toxin adsorbents (hemodez, low molecular weight polyvinyl) are introduced.

The means that increase the reactivity of the body include transfusion of blood, plasma, erythrocyte mass. With progressive anemization, blood is regularly transfused in 200-350 ml every other day. Direct blood transfusions and blood transfusions from previously immunized donors are effective.

Of the means of specific exposure, the use of anti-staphylococcal, anti-colibacillary plasma, anti-staphylococcal gamma globulin is shown, in case of suppression of cellular immunity - transfusion of leukocyte mass from immunized donors or convalescents. These remedies are indicated in acute sepsis; in chronic cases, active immunization agents (toxoids, autovaccines) are used.

It is advisable to treat acute sepsis in intensive care units using detoxification methods: plasma and hemosorption, ultrafiltration, ultraviolet blood irradiation. The most severe complications of sepsis are hepatic-renal failure and septic shock.

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On the topic: "Sepsis"

Introduction

1. Reasons

1.1 Main pathogens

2 The concept of sepsis. Classification

3 Leading clinical symptoms

3.1 Sepsis in the newborn

4 Principles of treatment

Conclusion

List of used literature

Introduction

Surgical Sepsis - Sepsis is a general purulent infection caused by various microorganisms, most often caused by foci of purulent infection, manifested by a peculiar reaction of the body with a sharp weakening of its protective properties.

Sepsis develops in the presence of a purulent focus, virulent microbial flora and a decrease in the protective properties of the body. Its source is most often acute purulent diseases of the skin and subcutaneous fat (abscesses, phlegmon, furunculosis, mastitis, etc.). Numerous symptoms of sepsis appear depending on its form and stage.

It is customary to distinguish 5 forms of the disease (B. M. Kostyuchenok et al., 1977).

1. Purulent-resorptive fever - extensive purulent foci and body temperature above 38 ° for at least 7 days after opening the abscess. Blood cultures are sterile.

2. Septicotoxemia (the initial form of sepsis) - against the background of a local purulent focus and a picture of purulent-resorptive fever, blood cultures are positive. A complex of therapeutic measures after 10 - 15 days significantly improves the patient's condition; repeated blood cultures do not give growth of microflora.

3. Septicemia - against the background of a local purulent focus and a severe general condition, high fever and positive blood cultures persist for a long time. Metastatic abscesses pet.

4. Septicopyemia - a picture of septicemia with multiple metastatic ulcers.

5. Chronic sepsis - purulent foci in history, now healed. Blood cultures are non-sterile. Periodically, there is a rise in temperature, deterioration of the general condition, and in some patients - new metastatic abscesses.

These forms pass one into another and can lead either to recovery or to death.

1. Causes of sepsis

Microorganisms that cause sepsis

Sepsis is an infection. For its development, it is necessary that pathogens enter the human body.

1.1 The main causative agents of sepsis

Bacteria: streptococci, staphylococci, proteus, Pseudomonas aeruginosa, acinetobacter, E. coli, enterobacter, citrobacter, klebsiella, enterococcus, fusobacteria, peptococci, bacteroids.

· Fungi. Basically - yeast-like fungi of the genus Candida.

· Viruses. Sepsis develops when a severe viral infection is complicated by a bacterial one. With many viral infections, general intoxication is observed, the pathogen spreads with the blood throughout the body, but the signs of such diseases differ from sepsis.

1.2 Protective reactions of the body

For the occurrence of sepsis, the penetration of pathogenic microorganisms into the human body is necessary. But for the most part, they do not cause severe disorders that accompany the disease. Protective mechanisms begin to work, which in this situation turn out to be redundant, excessive, and lead to damage to their own tissues.

Any infection is accompanied by an inflammatory process. Special cells secrete biologically active substances that cause disruption of blood flow, damage to blood vessels, disruption of the internal organs.

These biologically active substances are called inflammatory mediators.

Thus, under sepsis it is most correct to understand the pathological inflammatory reaction of the body itself, which develops in response to the introduction of infectious agents. In different people it is expressed to different degrees, depending on individual features defensive reactions.

Often the cause of sepsis is opportunistic bacteria - those that are not capable of causing harm normally, but under certain conditions can become the causative agents of infections.

1.3 What diseases are most often complicated by sepsis

sepsis protective pathogen infection

Wounds and purulent processes in the skin.

Osteomyelitis is a purulent process in the bones and red bone marrow.

Severe angina.

Purulent otitis media (inflammation of the ear).

Infection during childbirth, abortion.

Oncological diseases, especially in the later stages, blood cancer.

· HIV infection at the stage of AIDS.

Major injuries, burns.

Various infections.

Infectious and inflammatory diseases of the urinary system.

Infectious and inflammatory diseases of the abdomen, peritonitis (inflammation of the peritoneum - a thin film that lines the inside of the abdominal cavity).

Congenital disorders of the immune system.

Infectious and inflammatory complications after surgery.

Pneumonia, purulent processes in the lungs.

Nosocomial infection. Often, special microorganisms circulate in hospitals, which have become more resistant to antibiotics and various negative effects in the course of evolution.

This list can be substantially expanded. Sepsis can complicate almost any infectious disease. inflammatory disease.

Sometimes the initial disease that led to sepsis cannot be identified. During laboratory research no pathogens are found in the patient's body. Such sepsis is called cryptogenic.

Also, sepsis may not be associated with an infection - in this case, it occurs as a result of the penetration of bacteria from the intestine (which normally live in it) into the blood.

A patient with sepsis is not contagious and not dangerous to others - this is an important difference from the so-called septic forms, in which some infections can occur (for example, scarlet fever, meningitis, salmonellosis). With a septic form of infection, the patient is contagious. In such cases, the doctor will not diagnose sepsis, although the symptoms may be similar.

2. The concept of sepsis. Classification

The concept of "Sepsis" for many centuries has been associated with a severe general infectious process, ending, as a rule, with a fatal outcome. Sepsis (blood poisoning) is an acute or chronic disease characterized by the progressive spread of bacterial, viral or fungal flora in the body. Currently, there is a significant amount of fundamentally new experimental and clinical data that allows us to consider sepsis as a pathological process, which is a phase in the development of any infectious disease with different localization, caused by opportunistic microorganisms, which is based on the reaction of systemic inflammation to the infectious focus.

In 1991, in Chicago, the Conciliation Conference of the US Pulmonology and Critical Care Societies decided to use the following terms in clinical practice: systemic inflammatory response syndrome (SIRS); sepsis; infection: bacteremia; severe sepsis; septic shock.

For SSVR it is characteristic: the temperature is above 38 0 or below 36 0 С; heart rate over 90 beats per minute; respiratory rate over 20 per 1 min (with mechanical ventilation p 2 CO 2 less than 32 mm Hg. St.); the number of leukocytes is more than 12×10 9 or less than 4×10 9 or the number of immature forms exceeds 10%.

Under sepsis broad sense it is proposed to understand the presence of a clearly established infectious onset that caused the onset and progression of SIRS.

Infection is a microbiological phenomenon characterized by an inflammatory response to the presence of microorganisms or their invasion of damaged host tissues.

Severe sepsis is characterized by the development of one of the forms of organo-systemic insufficiency.

Septic shock is a decrease in blood pressure due to sepsis (< 90 мм рт. ст.) в условиях адекватного восполнения ОЦК и невозможность его подъема.

There is no single classification of sepsis.

By etiology - sepsis gram (+), gram (-), aerobic, anaerobic, mycobacterial, polybacterial, staphylococcal, streptococcal, colibacillary, etc.

According to the localization of the primary foci and entrance gates of infection - tonsillogenic, otogenic, odontogenic, urinogenital, gynecological, wound sepsis, etc. Within certain limits, it suggests the etiology of sepsis. If the entrance gate is unknown, then sepsis is called cryptogenic.

Downstream - acute, or fulminant (irreversible generalization in the first 24 hours), acute (irreversible generalization in 3-4 days) and chronic sepsis.

By phases of development - 1. toxemic, manifested by symptoms of intoxication 2. septicemia (penetration of the pathogen into the blood), 3. septicopyemia (formation of purulent foci in organs and tissues).

There are stages of the disease: sepsis, severe sepsis and septic shock. The main difference between sepsis and severe sepsis is the absence of organ dysfunction. In severe sepsis, there are signs of organ dysfunction, which, with ineffective treatment, progressively increase and are accompanied by decompensation. The result of organ function decompensation is septic shock, which formally differs from severe sepsis by hypotension, but is a multiple organ failure, which is based on severe widespread capillary damage and associated severe metabolic disorders.

3. Leading clinical symptoms

With the development of sepsis, the course of symptoms can be fulminant (rapid development of manifestations within 1-2 days), acute (up to 5-7 days), subacute and chronic. Often there is atypicality or "erasing" of its symptoms (for example, at the height of the disease there may not be a high temperature), which is associated with a significant change in the pathogenic properties of pathogens as a result of the massive use of antibiotics.

The signs of sepsis largely depend on the primary focus and the type of pathogen, but the septic process is characterized by several typical clinical symptoms:

§ severe chills;

§ increase in body temperature (constant or undulating, associated with the entry into the blood of a new portion of the pathogen);

§ severe sweating with the change of several sets of linen per day.

These are the three main symptoms of sepsis, they are the most constant manifestations of the process. In addition, they may include:

§ herpes-like rashes on the lips, bleeding of mucous membranes;

§ respiratory failure, pressure drop;

§ seals or pustules on the skin;

§ decrease in the volume of urine;

§ pallor of the skin and mucous membranes, waxy complexion;

§ fatigue and indifference of the patient, changes in the psyche from euphoria to severe apathy and stupor;

§ sunken cheeks with a pronounced blush on the cheeks against the background of general pallor;

§ bleeding on the skin in the form of spots or stripes, especially on the arms and legs.

Note that in case of any suspicion of sepsis, treatment should be started as soon as possible, since the infection is extremely dangerous and can be fatal.

3.1 Sepsis in the newborn

The incidence of neonatal sepsis is 1-8 cases per 1000. Mortality is quite high (13-40%), therefore, in case of any suspicion of sepsis, treatment and diagnosis should be carried out as quickly as possible. Premature babies are at particular risk, because in their case the disease can develop at lightning speed due to weakened immunity.

With the development of sepsis in newborns (the source is a purulent process in the tissues and vessels of the umbilical cord - umbilical sepsis), the following are characteristic:

§ Vomiting, diarrhea,

§ complete refusal of the child from the breast,

§ rapid weight loss,

§ dehydration; the skin loses its elasticity, becomes dry, sometimes earthy in color;

§ often determined by local suppuration in the navel, deep phlegmon and abscesses of various localization.

Unfortunately, the mortality of newborns with sepsis remains high, sometimes reaching 40%, and even more with intrauterine infection (60-80%). Surviving and recovered children also have a hard time, because all their lives they will be accompanied by such consequences of sepsis as:

§ weak resistance to respiratory infections;

§ pulmonary pathology;

§ heart diseases;

§ anemia;

§ delay physical development;

§ damage to the central system.

Without active antibacterial treatment and immunocorrection, one can hardly count on a favorable outcome.

4. Principles of treatment

Surgical treatment of sepsis: primary and secondary surgical treatment of a wound (primary focus) in accordance with all the requirements of surgical science, timely amputation of limbs in case of gunshot wounds, etc. Choice of antimicrobials. The drugs of choice are III-generation cephalosporins, inhibitor-protected penicillins, aztreonam, and II-III generation aminoglycosides. In most cases, antibiotic therapy for sepsis is prescribed empirically, without waiting for the result of a microbiological study. When choosing drugs, the following factors should be taken into account:

the severity of the patient's condition;

place of occurrence (out-of-hospital or hospital);

The localization of the infection

the state of the immune status;

Allergy anamnesis;

function of the kidneys.

With clinical efficacy, antibiotic therapy is continued with starting drugs. In the absence of a clinical effect within 48-72 hours, they must be replaced taking into account the results of a microbiological study or, if there are none, with drugs that bridge the gaps in the activity of starter drugs, taking into account the possible resistance of pathogens. In sepsis, antibiotics should be administered only intravenously, selecting the maximum doses and dosing regimens according to the level of creatinine clearance. A limitation to the use of drugs for oral and intramuscular administration is a possible violation of absorption in the gastrointestinal tract and a violation of microcirculation and lymph flow in the muscles. The duration of antibiotic therapy is determined individually. It is necessary to achieve a steady regression of inflammatory changes in the primary infectious focus, to prove the disappearance of bacteremia and the absence of new infectious foci, to stop the systemic inflammation reaction. But even with a very rapid improvement in well-being and obtaining the necessary positive clinical and laboratory dynamics, the duration of therapy should be at least 10-14 days. As a rule, longer antibiotic therapy is required for staphylococcal sepsis with bacteremia and localization of the septic focus in the bones, endocardium, and lungs. Patients with immunodeficiency antibiotics are always used longer than patients with a normal immune status. Cancellation of antibiotics can be carried out 4-7 days after the normalization of body temperature and elimination of the focus of infection as a source of bacteremia.

4.1 Features of the treatment of sepsis in the elderly

When conducting antibacterial therapy in the elderly, it is necessary to take into account the decrease in their kidney function, which may require a change in the dose or interval of administration of b-lactams, aminoglycosides, vancomycin.

4.2 Features of the treatment of sepsis during pregnancy

When conducting antibiotic therapy for sepsis in pregnant women, it is necessary to direct all efforts to save the life of the mother. Therefore, you can use those AMPs that are contraindicated during pregnancy with non-life-threatening infections. The main source of sepsis in pregnant women is urinary tract infections. The drugs of choice are III-generation cephalosporins, inhibitor-protected penicillins, aztreonam, and II-III generation aminoglycosides.

4.3 Features of the treatment of sepsis in children

Antibacterial therapy for sepsis should be carried out taking into account the spectrum of pathogens and age restrictions for the use of certain classes of antibiotics. So, in newborns, sepsis is caused mainly by group B streptococci and enterobacteria (Klebsiella spp., E. coli, etc.). When using invasive devices, staphylococci are etiologically significant. In some cases, the causative agent may be L. monocytogenes. The drugs of choice are penicillins in combination with II-III generation aminoglycosides. Third generation cephalosporins can also be used to treat neonatal sepsis. However, given the lack of activity against listeria and enterococci, cephalosporins should be used in combination with ampicillin.

Conclusion

Mortality in sepsis was previously 100%, at present, according to clinical military hospitals - 33 - 70%.

The problem of treating a generalized infection has not lost its relevance to the present time and is in many respects far from being resolved. This is determined primarily by the fact that until now the negative trend of increasing the number of patients with purulent-septic pathology has been preserved in almost all civilized countries; there is an increase in the number of complex, traumatic and long-term surgical interventions and invasive methods of diagnosis and treatment. These factors, as well as many others (environmental problems, an increase in the number of patients with diabetes mellitus, oncology, an increase in the number of people with immunopathology), certainly contribute to both a progressive increase in the number of patients with sepsis and an increase in its severity.

Bibliography

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3. Gelfand B.R., Filimonov M.I. / Russian Medical Journal / 1999, #5/7. -6c.

4. Ed. Eryukhina I.A ..: Surgical infections: a guide /, 2003. - 864s.

5. Zavada N.V. Surgical sepsis / 2003, -113-158 p.

6. Kolb L.I.: "Nursing in surgery". 2003, -108 p.

7. Ed. Kuzina M.I. M.: Medicine, - Wounds and wound infection. 1981, - 688s.

8. Svetukhin A. M. Clinic, diagnosis and treatment of surgical sepsis. Abstract dis. ... doc. honey. Sciences M., 1989.

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The problem of purulent infection, and with it sepsis, is of great current importance. This is primarily due to the increase in the number of patients with purulent infection, the frequency of its generalization, as well as the extremely high (up to 35-69%) mortality associated with it.

The reasons for this situation are well known and many experts associate with changes in both the reactivity of the macroorganism and the biological properties of microbes under the influence of antibiotic therapy.

According to the literature, a unity of views on the most important issues of the problem of sepsis has not yet been developed. In particular:

there is inconsistency in the terminology and classification of sepsis;

it has not been finally decided what sepsis is - a disease or complication of a purulent process;

the clinical course of sepsis is classified inconsistently.

All of the above clearly emphasizes that many aspects of the problem of sepsis require further study.

Story. The term "sepsis" was introduced into medical practice in the 4th century AD by Aristotle, who invested in the concept of sepsis the poisoning of the body with the products of decay of its own tissue. In the development of the doctrine of sepsis during the entire period of its formation, the latest achievements of medical science are reflected.

In 1865, N.I. Pirogov, even before the era of antiseptics, suggested the mandatory participation in the development of the septic process of certain active factors, the penetration of which into the body can develop septicemia.

The end of the 19th century was marked by the flourishing of bacteriology, the discovery of pyogenic and putrefactive flora. In the pathogenesis of sepsis, putrefactive poisoning (sapremia or ichoremia), caused exclusively by chemicals, entering the blood from the gangrenous focus, from putrefactive infection caused by chemicals formed in the blood itself from the bacteria that got into it and are there. These poisonings were given the name "septicemia", and if there were also purulent bacteria in the blood - "septicopyemia".

At the beginning of the twentieth century, the concept of a septic focus (Schotmuller) was put forward, considering the pathogenetic foundations of the doctrine of sepsis from this angle. However, Schotmuller reduced the whole process of development of sepsis to the formation of a primary focus and to the effect of microbes coming from it on a passively existing macroorganism.

In 1928, I.V. Davydovsky developed a macrobiological theory, according to which sepsis was presented as a general infectious disease, determined by a non-specific reaction of the body to the entry of various microorganisms and their toxins into the bloodstream.

The middle of the 20th century was marked by the development of the bacteriological theory of sepsis, which considered sepsis to be a "clinical-bacteriological" concept. This theory was supported by N.D. Strazhesko (1947). Adherents of the bacteriological concept considered bacteremia either permanent or non-permanent specific symptom of sepsis. Followers of the toxic concept, without rejecting the role of microbial invasion, the cause of severity clinical manifestations diseases were seen in the first place. In poisoning the body with toxins, it was proposed to replace the term "sepsis" with the term "toxic septicemia".

At the Republican Conference of the Georgian SSR on sepsis held in May 1984 in Tbilisi, an opinion was expressed on the need to create the science of "sepsisology". At this conference, a sharp discussion was caused by the definition of the concept of sepsis. It was proposed to define sepsis as a decompensation of the lymphoid system of the body (S.P. Gurevich), as a discrepancy between the intensity of the intake of toxins into the body and the detoxifying ability of the body (A.N. Ardamatsky). MI Lytkin gave the following definition of sepsis: sepsis is such a generalized infection in which, due to a decrease in the forces of anti-infective defense, the body loses the ability to suppress the infection outside the primary focus.

Most researchers believe that sepsis is a generalized form of an infectious disease caused by microorganisms and their toxins against the background of severe secondary immunodeficiency. The issues of antibiotic therapy for these patients are considered to be worked out to some extent, while many criteria for immunocorrection remain insufficiently clear.

In our opinion, this pathological process can be given the following definition: sepsis- a severe non-specific inflammatory disease of the whole organism that occurs when a large number of toxic elements (microbes or their toxins) enter the blood as a result of a sharp violation of its defenses.

causative agents of sepsis. Almost all existing pathogenic and opportunistic bacteria can be the causative agents of sepsis. Most often, staphylococci, streptococci, Pseudomonas aeruginosa, Proteus bacteria, anaerobic flora bacteria and bacteroids are involved in the development of sepsis. According to summary statistics, staphylococci are involved in the development of sepsis in 39-45% of all cases of sepsis. This is due to the severity of the pathogenic properties of staphylococci, which is associated with their ability to produce various toxic substances - a complex of hemolysins, leukotoxin, dermonecrotoxin, enterotoxin.

entrance gate in sepsis, the place of introduction of the microbial factor into the tissues of the body is considered. This is usually damage to the skin or mucous membranes. Once in the tissues of the body, microorganisms cause the development of an inflammatory process in the area of their introduction, which is commonly called primary septic focus. Such primary foci can be various wounds (traumatic, surgical) and local purulent processes of soft tissues (furuncles, carbuncles, abscesses). Less often, the primary focus for the development of sepsis is chronic purulent diseases (thrombophlebitis, osteomyelitis, trophic ulcers) and endogenous infection (tonsillitis, sinusitis, tooth granuloma, etc.).

Most often, the primary focus is located at the site of the introduction of the microbial factor, but sometimes it can be located far from the site of the introduction of microbes (hematogenous osteomyelitis - a focus in the bone far from the site of the introduction of the microbe).

Research has shown recent years, when a general inflammatory reaction of the body to a local pathological process occurs, especially when bacteria enter the bloodstream, various areas of necrosis appear in various tissues of the body, which become sites of sedimentation of individual microbes and microbial associations, which leads to the development secondary purulent foci, i.e. development septic metastases.

Such a development of the pathological process in sepsis - primary septic focus - the introduction of toxic substances into the blood - sepsis gave rise to the designation of sepsis, as secondary diseases, and some experts on the basis of this consider sepsis complication underlying purulent disease.

At the same time, in some patients, the septic process develops without an outwardly visible primary focus, which cannot explain the mechanism of sepsis development. This sepsis is called primary or cryptogenic. This type of sepsis is rare in clinical practice.

Since sepsis is more common in diseases that, according to their etio-pathogenetic characteristics, belong to the surgical group, the concept of surgical sepsis.

Literature data show that the etiological characteristics of sepsis are supplemented by a number of names. So, due to the fact that sepsis can develop after complications arising from surgical operations, resuscitation benefits and diagnostic procedures, it is proposed to call such sepsis nasocomial(purchased in-house) or iatrogenic.

classification of sepsis. In view of the fact that the microbial factor plays the main role in the development of sepsis, in the literature, especially foreign literature, it is customary to distinguish sepsis by the type of microbe-causative agent: staphylococcal, streptococcal, colibacillary, pseudomonas, etc. This division of sepsis is of great practical importance, because. determines the nature of the therapy of this process. However, it is not always possible to sow the pathogen from the blood of a patient with a clinical picture of sepsis, and in some cases it is possible to detect the presence of an association of several microorganisms in the patient's blood. And, finally, the clinical course of sepsis depends not only on the pathogen and its dose, but to a large extent on the nature of the reaction of the patient's body to this infection (primarily the degree of violation of its immune forces), as well as on a number of other factors - concomitant diseases, the age of the patient, the initial state of the macroorganism. All this allows us to say that it is irrational to classify sepsis only by the type of pathogen.

The classification of sepsis is based on the rate of development factor clinical signs diseases and their severity. According to the type of clinical course of the pathological process, sepsis is usually divided into: fulminant, acute, subacute and chronic.

Since two types of the course of the pathological process are possible in sepsis - sepsis without the formation of secondary purulent foci and with the formation of purulent metastases in various organs and tissues of the body, in clinical practice it is customary to take this into account to determine the severity of the course of sepsis. Therefore, sepsis without metastases is distinguished - septicemia, and sepsis with metastases - septicopyemia.

Thus, the classification structure of sepsis can be represented in the following diagram. This classification allows the doctor to present the etio-pathogenesis of the disease in each individual case of sepsis and to choose the right plan for its treatment.

Numerous experimental studies and clinical observations have shown that the following are of great importance for the development of sepsis: 1 - the state of the nervous system of the patient's body; 2 - the state of its reactivity and 3 - anatomical and physiological conditions for the spread of the pathological process.

So, it was found that in a number of conditions where there is a weakening of the neuro-regulatory processes, there is a special predisposition to the development of sepsis. In persons with profound changes in the central nervous system, sepsis develops much more often than in persons without dysfunction of the nervous system.

The development of sepsis is facilitated by a number of factors that reduce the reactivity of the patient's body. These factors include:

a state of shock that has developed as a result of an injury and is accompanied by a violation of the function of the central nervous system;

significant blood loss accompanying the injury;

various infectious diseases that precede the development of the inflammatory process in the patient's body or injury;

malnutrition, vitamin deficiency;

endocrine and metabolic diseases;

the age of the patient (children, elderly people are more easily affected by the septic process and tolerate it worse).

Speaking about the anatomical and physiological conditions that play a role in the development of sepsis, the following factors should be pointed out:

1 - the value of the primary focus (the larger the primary focus, the more likely the development of intoxication of the body, the introduction of infection into the blood stream, as well as the impact on the central nervous system);

2 - localization of the primary focus (the location of the focus in close proximity to large venous highways contributes to the development of sepsis - soft tissues of the head and neck);

3 - the nature of the blood supply to the zone of the location of the primary focus (the worse the blood supply to the tissues where the primary focus is located, the more likely it is that sepsis develops);

4 - the development of the reticuloendothelial system in the organs (organs with a developed RES are faster freed from the infectious onset, they rarely develop a purulent infection).

The presence of these factors in a patient with a purulent disease should alert the doctor to the possibility of developing sepsis in this patient. According to the general opinion, a violation of the body's reactivity is the background against which a local purulent infection can easily turn into its generalized form - sepsis.

In order to effectively treat a patient with sepsis, it is necessary to know well the changes that occur in his body during this pathological process (diagram).

The main changes in sepsis are associated with:

hemodynamic disturbances;

respiratory disorders;

impaired liver and kidney function;

the development of physico-chemical changes in the internal environment of the body;

disturbances in peripheral blood;

changes in the body's immune system.

hemodynamic disturbances. Hemodynamic disorders in sepsis occupy one of the central places. The first clinical signs of sepsis are associated with impaired activity of the cardiovascular system. The severity and severity of these disorders are determined by bacterial intoxication, the depth of disturbance of metabolic processes, the degree of hypovolemia, and compensatory-adaptive reactions of the body.

The mechanisms of bacterial intoxication in sepsis are combined into the concept of "syndrome of low output", which is characterized by a rapid decrease in cardiac output and volumetric blood flow in the patient's body, frequent small pulse, pallor and marbling of the skin, and a decrease in blood pressure. The reason for this is a decrease in the contractile function of the myocardium, a decrease in the volume of circulating blood (BCC) and a decrease in vascular tone. Circulatory disorders with general purulent intoxication of the body can develop so quickly that it is clinically expressed by a kind of shock reaction - “toxic-infectious shock”.

The appearance of vascular unresponsiveness is also facilitated by the loss of neurohumoral control associated with the influence of microbes and microbial decay products on the central nervous system and peripheral regulatory mechanisms.

Hemodynamic disorders ( low cardiac output, stasis in the microcirculation system) against the background of cellular hypoxia and metabolic disorders, leads to an increase in blood viscosity, primary thrombosis, which in turn causes the development of microcirculatory disorders - DIC syndrome, which are most pronounced in the lungs and kidneys. The picture of "shock lung" and "shock kidney" develops.

Respiratory failure. Progressive respiratory failure, up to the development of a "shock lung", is characteristic of all clinical forms of sepsis. The most pronounced signs of respiratory failure are shortness of breath with rapid breathing and cyanosis of the skin. They are caused primarily by disorders of the respiratory mechanism.

Most often, the development of respiratory failure in sepsis leads to pneumonia, which occurs in 96% of patients, as well as the development of diffuse intravascular coagulation with platelet aggregation and the formation of blood clots in the pulmonary capillaries (DIC syndrome). More rarely, the cause of respiratory failure is the development of pulmonary edema due to a significant decrease in oncotic pressure in the bloodstream with severe hypoproteinemia.

To this it should be added that respiratory failure may develop due to the formation of secondary abscesses in the lungs in cases where sepsis occurs in the form of septicopyemia.

Violation of external respiration causes changes in the gas composition of the blood during sepsis - arterial hypoxia develops and pCO 2 decreases.

Changes in the liver and kidneys with sepsis, they are pronounced and are classified as toxic-infectious hepatitis and nephritis.

Toxic-infectious hepatitis occurs in 50-60% of cases of sepsis and is clinically manifested by the development of jaundice. Mortality in sepsis complicated by the development of jaundice reaches 47.6%. Liver damage in sepsis is explained by the action of toxins on the hepatic parenchyma, as well as impaired liver perfusion.

great value for the pathogenesis and clinical manifestations of sepsis has impaired renal function. Toxic nephritis occurs in 72% of patients with sepsis. In addition to the inflammatory process that develops in the kidney tissue during sepsis, the DIC syndrome that develops in them, as well as vasodilation in the juxtomedular zone, which reduces the rate of urine output in the renal glomerulus, leads to impaired renal function.

Impaired function vital organs and systems of the patient's body with sepsis and the resulting violations of metabolic processes in it lead to the appearance physical and chemical shifts in the patient's internal environment.

This takes place:

a) Change in the acid-base state (AKS) towards both acidosis and alkalosis.

b) The development of severe hypoproteinemia, leading to impaired function of the plasma buffer capacity.

c) Developing liver failure exacerbates the development of hypoproteinemia, causes hyperbilirubinemia, a disorder of carbohydrate metabolism, manifested in hyperglycemia. Hypoproteinemia causes a decrease in the level of prothrombin and fibrinogen, which is manifested by the development of coagulopathy syndrome (DIC syndrome).

d) Impaired kidney function contributes to the violation of acid-base balance and affects the water-electrolyte metabolism. Potassium-sodium metabolism is especially affected.

Peripheral blood disorders considered an objective diagnostic criterion for sepsis. In this case, characteristic changes are found in the formula, both red and white blood.

Patients with sepsis have severe anemia. The reason for the decrease in the number of erythrocytes in the blood of patients with sepsis is both the direct breakdown (hemolysis) of erythrocytes under the action of toxins, and the inhibition of erythropoiesis as a result of exposure to toxins on the hematopoietic organs (bone marrow).

Characteristic changes in sepsis are noted in the formula of the white blood of patients. These include: leukocytosis with a neutrophilic shift, a sharp "rejuvenation" of the leukocyte formula and toxic granularity of leukocytes. It is known that the higher the leukocytosis, the more pronounced the activity of the body's response to infection. Pronounced changes in the leukocyte formula also have a certain prognostic value - the less leukocytosis, the more likely an unfavorable outcome in sepsis.

Considering changes in peripheral blood in sepsis, it is necessary to dwell on the syndrome of disseminated intravascular coagulation (DIC). It is based on intravascular blood coagulation, leading to blockade of microcirculation in the vessels of the organ, thrombotic processes and hemorrhages, tissue hypoxia and acidosis.

The trigger mechanism for the development of DIC in sepsis are exogenous (bacterial toxins) and endogenous (tissue thromboblasts, tissue decay products, etc.) factors. An important role is also assigned to the activation of tissue and plasma enzyme systems.

In the development of the DIC syndrome, two phases are distinguished, each of which has its own clinical and laboratory picture.

First phase characterized by intravascular coagulation and aggregation of its formed elements (hypercoagulation, activation of plasma enzyme systems and blockade of the microvasculature). In the study of blood, a shortening of the clotting time is noted, plasma tolerance to heparin and the prothrombin index increase, and the concentration of fibrinogen increases.

In second phase coagulation mechanisms are depleted. The blood during this period contains a large amount of fibrinolysis activators, but not due to the appearance of anticoagulants in the blood, but due to the depletion of anticoagulant mechanisms. Clinically, this is manifested by a distinct hypocoagulation, up to complete blood incoagulability, a decrease in the amount of fibrinogen and the value of the prothrombin index. Destruction of platelets and erythrocytes is noted.

immune shifts. Considering sepsis as the result of a complex relationship between macro- and microorganism, it must be emphasized that the state of the body's defenses plays a leading role in the genesis and generalization of infection. Of the various defense mechanisms of the body against infection, the immune system plays an important role.

As numerous studies show, an acute septic process develops against the background of significant quantitative and qualitative changes in various parts of the immune system. This fact requires targeted immunotherapy in the treatment of sepsis.

In the publications of recent years, information has appeared about fluctuations in the level of nonspecific resistance and selective susceptibility to certain infectious diseases in persons with certain blood groups according to the ABO system. According to the literature, sepsis most often develops in people with blood types A (II) and AB (IV) and less often in people with blood types O (1) and B (III). It is noted that people with blood groups A (II) and AB (IV) have a low bactericidal activity of blood serum.

The revealed correlative dependence suggests a clinical dependence of the determination of the blood type of people in order to predict their predisposition to the development of infection and the severity of its course.

Clinic and diagnosis of sepsis. The diagnosis of surgical sepsis should be based on the presence of a septic lesion, clinical presentation, and blood cultures.

As a rule, sepsis without a primary focus is extremely rare. Therefore, the presence of any inflammatory process in the body with a certain clinical picture should make the doctor assume the possibility of developing sepsis in the patient.

The following clinical manifestations are characteristic of acute sepsis: high body temperature (up to 40-41 0 C) with slight fluctuations; increased heart rate and respiration; severe chills preceding an increase in body temperature; an increase in the size of the liver, spleen; often the appearance of icteric coloration of the skin and sclera and anemia. Initially occurring leukocytosis may later be replaced by a decrease in the number of leukocytes in the blood. Bacterial cells are found in blood cultures.

The detection of metastatic pyemic foci in a patient clearly indicates the transition of the septicemia phase to the septicopyemia phase.

One of the most common symptoms of sepsis is heat the body of the patient, which is of three types: undulating, remitting and continuously high. The temperature curve usually displays the type of sepsis. The absence of a pronounced temperature reaction in sepsis is extremely rare.

Continuous high temperature characteristic of a severe course of the septic process, occurs with its progression, with fulminant sepsis, septic shock, or extremely severe acute sepsis.

remitting type the temperature curve is observed in sepsis with purulent metastases. The patient's body temperature decreases at the time of suppression of the infection and the elimination of the purulent focus and rises when it is formed.

wave type the temperature curve occurs in the subacute course of sepsis, when it is not possible to control the infectious process and radically remove purulent foci.

Speaking of such a symptom of sepsis as high fever, it should be borne in mind that this symptom is also characteristic of general purulent intoxication, which accompanies any local inflammatory process that is quite active with a weak protective reaction of the patient's body. This was discussed in detail in the previous lecture.

In this lecture, it is necessary to dwell on the following question: when in a patient with a purulent inflammatory process, accompanied by a general reaction of the body, does the state of intoxication turn into a septic state?

Understanding this issue allows the concept of I.V. Davydovsky (1944,1956) about purulent-resorptive fever as a normal general reaction of a "normal organism" to the focus of a local purulent infection, while in sepsis this reaction is due to a change in the patient's reactivity to a purulent infection.

Purulent-resorptive fever is understood as a syndrome resulting from resorption from a purulent focus (purulent wound, purulent inflammatory focus) of tissue breakdown products, resulting in general phenomena (temperature above 38 0 C, chills, signs of general intoxication, etc.). At the same time, purulent-resorptive fever is characterized by a complete correspondence of the general phenomena to the severity of pathological changes in the local focus. The more pronounced the latter, the more active the manifestation of general signs of inflammation. Purulent-resorptive fever usually proceeds without deterioration in the general condition, if there is no increase in the inflammatory process in the area of the local focus. In the next few days after radical surgical treatment of the focus of local infection (usually up to 7 days), if foci of necrosis are removed, streaks and pockets with pus are opened, the general symptoms of inflammation are sharply reduced or completely disappear.

In those cases when, after radical surgery and antibiotic therapy, the phenomena of purulent-resorptive fever do not disappear within the specified period, tachycardia persists, one must think about the initial phase of sepsis. Blood culture will confirm this assumption.

If, despite intensive general and local therapy of a purulent inflammatory process, high fever, tachycardia, the general serious condition of the patient and the effects of intoxication persist for more than 15-20 days, one should think about the transition of the initial phase of sepsis to the stage of the active process - septicemia.

Thus, purulent-resorptive fever is an intermediate process between a local purulent infection with a general reaction of the patient's body to it and sepsis.

Describing the symptoms of sepsis, one should dwell in more detail on symptom of the appearance of secondary, metastatic purulent foci, which finally confirm the diagnosis of sepsis, even if it is not possible to detect bacteria in the patient's blood.

The nature of purulent metastases and their localization largely affect the clinical picture of the disease. At the same time, the localization of purulent metastases in the patient's body, to a certain extent, depends on the type of pathogen. So, if Staphylococcus aureus can metastasize from the primary focus to the skin, brain, kidneys, endocardium, bones, liver, testicles, then enterococci and viridescent streptococci - only to the endocardium.

Metastatic ulcers are diagnosed on the basis of the clinical picture of the disease, laboratory data and the results of special research methods. Purulent foci in soft tissues are relatively easy to recognize. To detect ulcers in the lungs, in abdominal cavity X-ray and ultrasound methods are widely used.

Blood cultures. Sowing the causative agent of purulent infection from the patient's blood is the most important moment in the verification of sepsis. The percentage of microbes inoculated from the blood, according to various authors, ranges from 22.5% to 87.5%.

Complications of sepsis. Surgical sepsis is extremely diverse and the pathological process in it affects almost all organs and systems of the patient's body. Damage to the heart, lungs, liver, kidneys and other organs is so common that it is considered a sepsis syndrome. The development of respiratory, hepatic and renal insufficiency is rather the logical end of a serious illness than a complication. However, there may be complications with sepsis, which most experts include septic shock, toxic cachexia, erosive bleeding, and bleeding that occurs against the background of the development of the second phase of the DIC syndrome.

Septic shock- the most severe and formidable complication of sepsis, mortality in which reaches 60-80% of cases. It can develop in any phase of sepsis and its occurrence depends on: a) strengthening of the purulent inflammatory process in the primary focus; b) accession of another flora of microorganisms to the primary infection; c) the occurrence in the patient's body of another inflammatory process (exacerbation of a chronic one).

The clinical picture of septic shock is quite bright. It is characterized by the sudden onset of clinical signs and their extreme severity. Summarizing the literature data, we can distinguish the following symptoms that allow us to suspect the development of septic shock in a patient: 1 - a sudden sharp deterioration in the general condition of the patient; 2 - decrease in blood pressure below 80 mm Hg; 3 - the appearance of severe shortness of breath, hyperventilation, respiratory alkalosis and hypoxia; 4 - a sharp decrease in diuresis (below 500 ml of urine per day); 5 - the appearance of a patient with neuropsychiatric disorders - apathy, adynamia, agitation or mental disorders; 6 - the occurrence of allergic reactions - erythematous rash, petechiae, peeling of the skin; 7 - the development of dyspeptic disorders - nausea, vomiting, diarrhea.

Another severe complication of sepsis is "wound exhaustion”, described by N.I. Pirogov as “traumatic exhaustion”. This complication is based on a long-term purulent-necrotic process during sepsis, from which the absorption of tissue decay products and microbial toxins continues. In this case, as a result of tissue breakdown and suppuration, there is a loss of protein by tissues.

Erosive bleeding occurs, as a rule, in a septic focus, in which the vessel wall is destroyed.

The appearance of one or another complication in sepsis indicates either inadequate therapy of the pathological process, or a sharp violation of the body's defenses with a high virulence of the microbial factor and suggests an unfavorable outcome of the disease.

Treatment of surgical sepsis - represents one of the difficult tasks of surgery, and its results so far have not satisfied surgeons. Mortality in sepsis is 35-69%.

Given the complexity and diversity of pathophysiological disorders occurring in the patient's body with sepsis, the treatment of this pathological process should be carried out in a complex manner, taking into account the etiology and pathogenesis of the disease. This set of activities must necessarily consist of two points: local treatment primary focus, based mainly on surgical treatment, and general treatment aimed at normalizing the function of vital organs and systems of the body, fighting infection, restoring homeostasis systems, increasing immune processes in the body (table).

General principles for the treatment of sepsis

TREATMENT S EPS I S A
local	o b e
1. Immediate opening of the abscess with a wide incision; maximum excision of necrotic tissues of a purulent wound.	1. Purposeful use of modern antibiotics and chemotherapy drugs.
2. Active drainage of the abscess cavity.	2. Passive and active immunotherapy.
3.Early closure of the defect fabrics: suturing, skin plastic surgery.	3. Long-term infusion therapy
4. Carrying out treatment in a controlled abacterial environment.	4. Hormone therapy
	5.Extracorporeal detoxification: hemosorption, plasmasorption, lymphosorption.
	6. Application of hyperbaric oxygen therapy (HBO)

Surgical treatment of purulent foci (primary and secondary) is as follows:

all purulent foci and purulent wounds, regardless of the period of their occurrence, should be surgically treated (excision of necrotic tissues or opening of the abscess cavity with a wide dissection of the tissues above it). With multiple foci, all primary foci are subjected to surgical intervention.

after surgical intervention it is necessary to ensure active drainage of the wound, using an active flushing drainage system; active washing of the wound must be carried out for at least 7-12 days for 6-12-24 hours;

if possible, it is better to finish the surgical treatment of the wound with suturing the wound. If this is not indicated, in the postoperative period it is necessary to prepare the wound as soon as possible for the application of secondary sutures or skin grafting.

Treatment of the wound process is best done in an abacterial environment, as suggested by the Institute of Surgery. A.V. Vishnevsky RAMS.

General treatment in sepsis should be carried out in an intensive care unit and include the following points:

targeted use of various modern antibiotics and chemotherapy drugs;

active and passive immunotherapy (use of vaccines and sera);

long-term infusion-transfusion therapy aimed at correcting impaired functions of vital organs and systems of the patient's body. This therapy should provide correction of homeostasis - normalization of electrolyte balance and acid-base balance; correction of hypoproteinemia and anemia, restoration of BCC. In addition, the task of infusion therapy is to normalize the activity of the cardiovascular and respiratory systems, liver and kidney function, as well as detoxify the body using forced diuresis. Great importance in infusion therapy is given to maintaining the energy supply of body tissues - parenteral nutrition.

Antibiotic and chemotherapy much attention is paid to sepsis. Currently, the opinion of clinicians is unanimous that the choice of antibiotic should be based on data from antibiograms. At the same time, the need to immediately begin antibiotic treatment at the first suspicion of the development of sepsis is strongly emphasized, without waiting for a response from a laboratory test. How to be?

The way out of this situation is to prescribe several (two or three) broad-spectrum drugs at once. Usually, for this purpose, it is recommended to prescribe semi-synthetic penicillins, cephalosporins, aminoglycosides and dioxidine. When the data of bacteriological studies on the sensitivity of microflora to antibiotics are known, the necessary correction is made in their appointment.

In the treatment of sepsis with antibiotics, the dose of the drug and the route of its introduction into the body are of great importance. The dose of the drug should be close to the maximum, ensuring the creation in the patient's blood of such a concentration of the drug, which will reliably suppress the vital activity of the microflora. Clinical practice has shown that a good effect can be obtained if the antibiotic is administered intravenously in combination with dioxidine. The sensitivity of microflora to dioxidine ranges from 76.1 to 83%. With the location of the focus of infection in the lower extremities, antibiotics can be administered intra-arterially. If the lungs are affected, the endotracheal route of administration of the drug should be used. In some cases, antibiotics are added to the novocaine solution when performing novocaine blockades.

For antibiotic therapy, antibiotics with bactericidal properties should be used, because. antibiotics with bacteriostatic properties do not provide a good therapeutic effect. The duration of treatment with antibacterial drugs is 10-12 days (until the temperature is completely normalized).

Immunotherapy is of great importance in the treatment of sepsis. It is customary to use drugs that have both non-specific and specific effects.

Non-specific immunotherapy - replenishment of cellular elements of blood and proteins, stimulation of their reproduction by the body of the patient himself. It includes the transfusion of freshly citrated blood and its components - leuko-platelet mass, protein preparations - amino acids, albumin, protein, as well as the introduction of biogenic stimulants - pentoxyl, methyluracil into the patient's body.

Specific immunotherapy - the introduction into the patient's body of various sera and toxoid (anti-staphylococcal plasma, anti-staphylococcal gamma globulin, bacteriophage, staphylococcal toxoid). The introduction of plasma provides passive immunization of the patient's body, toxoid - active. The means of active immunization also include autovaccine - an immunopreparation against the pathogen that causes this infectious process. With a low level of T-lymphocytes and their insufficient activity, the introduction of lymphocytes (leukemia) of an immune donor or stimulation of the T-lymphocyte system with drugs such as decaris (levamisone) is indicated.

Corticosteroids in the treatment of sepsis. Based on the anti-inflammatory and positive hemodynamic effects of corticosteroids, they are recommended for use in severe forms of sepsis and especially in septic shock. In the treatment of patients with sepsis, prednisolone and hydrocortisone are prescribed. In addition, the appointment of anabolic hormones is shown - nerabol, nerabolil, retabolil, which enhance protein anabolism, retain nitrogenous substances in the body, and are also necessary for the synthesis of protein, potassium, sulfur and phosphorus in the body. To achieve the desired therapeutic effect during hormone therapy, it is necessary to infuse protein preparations, fats, carbohydrates.

Methods of extracorporeal detoxification of the body . To activate detoxification therapy for sepsis in Lately methods of extracorporeal detoxification of the patient's body began to be widely used: hemosorption, plasmapheresis, lymphosorption.

Hemosorption- removal of toxic products from the patient's blood using carbon adsorbents and ion-exchange resins, developed by Yu.M. Lopukhin et al. (1973). With this method, a system consisting of a roller pump that drives blood through a column with adsorbents is included in the arteriovenous shunt between the radial artery and the vein of the forearm.

Plasma sorption- removal of toxic products from the blood plasma of a patient with sepsis using sorbents. The method was also proposed by Yu.M. Lopukhin et al. (1977, 1978, 1979). The essence of the method lies in the fact that with the help of a special apparatus, the blood flowing in the arterial knee of the arteriovenous shunt is separated into formed elements and plasma. Given that all toxic substances are in the blood plasma, it is passed through a special sorbent column, where it is cleansed of toxins. Then the purified plasma, together with blood cells, is injected back into the patient's body. In contrast to hemosorption during plasmasorption, blood cells are not injured.

Lymphosorption- a method of detoxification of the body, based on the removal of lymph from the patient's body, its detoxification and return back to the patient's body.

The prerequisite for the method was the recent use of external drainage of the lymphatic duct for detoxification of the body and the removal of lymph, which contains twice as many toxins as blood plasma. However, the removal of a large amount of lymph from the patient's body led him to the loss of a large amount of protein, fats, electrolytes, enzymes, cellular elements, which required their replenishment after the procedure.

In 1976, R.T. Panchenkov et al. developed a method in which the outward lymph is passed through a special column containing activated carbon and ion-exchange resins, and then reinfused intravenously to the patient.

Intravascular laser irradiation of blood. Recently, intravascular laser blood irradiation has been used to treat patients with sepsis. For this, a helium-neon laser is used. With the help of a special nozzle, radiation is delivered through a glass guide into a vein. Glass guide is inserted into a catheterized subclavian, femoral or large peripheral vein of the upper limb. The duration of the session is 60 minutes, the course of treatment is 5 procedures. The interval between courses is two days.

Intravascular laser irradiation of blood makes it possible to reduce endogenous intoxication and correct the immune response.

Hyperbaric oxygen therapy (HBO). In the literature of recent years, there are reports of the successful use of HBO in the complex treatment of patients with severe forms of sepsis. The rationale for the use of HBO in sepsis was the development of severe polyetiological hypoxia of the body: impaired tissue respiration, impaired redox processes and blood flow, development of cardiovascular and respiratory failure.

The use of HBO leads to a significant improvement in external respiration, improved gas exchange, which leads to a decrease in shortness of breath, a decrease in heart rate and a decrease in temperature.

True, the procedure for conducting HBO is quite complicated, it requires special equipment and trained personnel. This equally applies to the methods of extracorporeal detoxification of the body.

Lecture 12

According to the literature, a unity of views on the most important issues of the problem of sepsis has not yet been developed. In particular:

There is inconsistency in the terminology and classification of sepsis;

It has not been finally decided what sepsis is - a disease or complication of a purulent process;

The clinical course of sepsis is classified inconsistently.

All of the above clearly emphasizes that many aspects of the problem of sepsis require further study.

The end of the 19th century was marked by the flourishing of bacteriology, the discovery of pyogenic and putrefactive flora. In the pathogenesis of sepsis, putrefactive poisoning (sapremia or ichoremia) began to be isolated, caused exclusively by chemicals entering the blood from a gangrenous focus, from putrefactive infection caused by chemicals formed in the blood itself from bacteria that got into it and are there. These poisonings were given the name "septicemia", and if there were also purulent bacteria in the blood - "septicopyemia".

The middle of the 20th century was marked by the development of the bacteriological theory of sepsis, which considered sepsis to be a "clinical-bacteriological" concept. This theory was supported by N.D. Strazhesko (1947). Adherents of the bacteriological concept considered bacteremia either permanent or non-permanent specific symptom of sepsis. The followers of the toxic concept, without rejecting the role of microbial invasion, saw the cause of the severity of the clinical manifestations of the disease, first of all. In poisoning the body with toxins, it was proposed to replace the term "sepsis" with the term "toxic septicemia".

As studies of recent years have shown, when a general inflammatory reaction of the body to a local pathological process occurs, especially when bacteria enter the bloodstream, various areas of necrosis appear in various tissues of the body, which become sites of sedimentation of individual microbes and microbial associations, which leads to the development secondary purulent foci, i.e. development septic metastases.

Since sepsis is more common in diseases that, according to their etio-pathogenetic characteristics, belong to the surgical group, the concept of surgical sepsis.

The classification of sepsis is based on the rate of development of clinical signs of the disease and the severity of their manifestation. According to the type of clinical course of the pathological process, sepsis is usually divided into: fulminant, acute, subacute and chronic.

The development of sepsis is facilitated by a number of factors that reduce the reactivity of the patient's body. These factors include:

A state of shock that has developed as a result of an injury and is accompanied by a violation of the function of the central nervous system;

Significant blood loss accompanying the injury;

Various infectious diseases that precede the development of the inflammatory process in the patient's body or injury;

Malnutrition, beriberi;

Endocrine and metabolic diseases;

The age of the patient (children, elderly people are more easily affected by the septic process and tolerate it worse).

Speaking about the anatomical and physiological conditions that play a role in the development of sepsis, the following factors should be pointed out:

2 - localization of the primary focus (the location of the focus in close proximity to large venous highways contributes to the development of sepsis - soft tissues of the head and neck);

4 - the development of the reticuloendothelial system in the organs (organs with a developed RES are faster freed from the infectious onset, they rarely develop a purulent infection).

In order to effectively treat a patient with sepsis, it is necessary to know well the changes that occur in his body during this pathological process (diagram).

The main changes in sepsis are associated with:

1- hemodynamic disorders;

2- respiratory disorders;

3- violations of the function of the liver and kidneys;

4- the development of physico-chemical changes in the internal environment of the body;

5- disturbances in peripheral blood;

6- shifts in the body's immunological system.

To this it should be added that respiratory failure may develop due to the formation of secondary abscesses in the lungs in cases where sepsis occurs in the form of septicopyemia.

Violation of external respiration causes changes gas composition blood in sepsis - arterial hypoxia develops and pCO 2 decreases.

Changes in the liver and kidneys with sepsis, they are pronounced and are classified as toxic-infectious hepatitis and nephritis.

Of great importance for the pathogenesis and clinical manifestations of sepsis is impaired renal function. Toxic nephritis occurs in 72% of patients with sepsis. In addition to the inflammatory process that develops in the kidney tissue during sepsis, the DIC syndrome that develops in them, as well as vasodilation in the juxtomedular zone, which reduces the rate of urine output in the renal glomerulus, leads to impaired renal function.

Impaired function vital organs and systems of the patient's body with sepsis and the resulting disorders metabolic processes it leads to the appearance physical and chemical shifts in the patient's internal environment.

This takes place:

a) Change in the acid-base state (AKS) towards both acidosis and alkalosis.

b) The development of severe hypoproteinemia, leading to impaired function of the plasma buffer capacity.

d) Impaired kidney function contributes to the violation of acid-base balance and affects the water-electrolyte metabolism. Potassium-sodium metabolism is especially affected.

Peripheral blood disorders considered an objective diagnostic criterion for sepsis. In this case, characteristic changes are found in the formula, both red and white blood.

In the development of the DIC syndrome, two phases are distinguished, each of which has its own clinical and laboratory picture.

As shown by numerous studies, an acute septic process develops against the background of significant quantitative and qualitative changes in various parts of the immune system. This fact requires targeted immunotherapy in the treatment of sepsis.

In the publications of recent years, information has appeared about fluctuations in the level of nonspecific resistance and selective susceptibility to certain infectious diseases of persons with certain groups blood according to the ABO system. According to the literature, sepsis most often develops in people with blood types A (II) and AB (IV) and less often in people with blood types O (1) and B (III). It is noted that people with blood groups A (II) and AB (IV) have a low bactericidal activity of blood serum.

Clinic and diagnosis of sepsis. The diagnosis of surgical sepsis should be based on the presence of a septic lesion, clinical presentation, and blood cultures.

The detection of metastatic pyemic foci in a patient clearly indicates the transition of the septicemia phase to the septicopyemia phase.

One of the most common symptoms of sepsis is heat the body of the patient, which is of three types: undulating, remitting and continuously high. The temperature curve usually displays the type of sepsis. The absence of a pronounced temperature reaction in sepsis is extremely rare.

Continuous high temperature characteristic of a severe course of the septic process, occurs with its progression, with fulminant sepsis, septic shock, or extremely severe acute sepsis.

wave type the temperature curve occurs in the subacute course of sepsis, when it is not possible to control the infectious process and radically remove purulent foci.

Thus, purulent-resorptive fever is an intermediate process between a local purulent infection with a general reaction of the patient's body to it and sepsis.

Metastatic ulcers are diagnosed on the basis of the clinical picture of the disease, laboratory data and the results of special research methods. Purulent foci in soft tissues are relatively easy to recognize. To detect abscesses in the lungs, in the abdominal cavity, X-ray and ultrasound methods are widely used.

Blood cultures. Sowing the causative agent of a purulent infection from the patient's blood is the most important moment sepsis verification. The percentage of microbes inoculated from the blood, according to various authors, ranges from 22.5% to 87.5%.

Erosive bleeding occurs, as a rule, in a septic focus, in which the vessel wall is destroyed.

Treatment of surgical sepsis - represents one of the difficult tasks of surgery, and its results so far have not satisfied surgeons. Mortality in sepsis is 35-69%.

The urgency of the problem of sepsis is currently determined by several reasons: a significant incidence of the disease, high mortality and, consequently, the economic damage caused by this disease in developed countries.

In our country, there are no reliable statistics on the prevalence of sepsis, and therefore, in the issue of epidemiology, one has to refer to data from other countries, for example, about 500,000 cases of sepsis per year are recorded in the United States. At the same time, lethality reaches 35-42%, and these figures have not changed over the past few decades. Among the causes of death, sepsis ranks 13th.

The purpose of studying the topic: Based on the etiology, pathogenesis, clinical picture, data of laboratory and instrumental examination of the patient, be able to make and substantiate a detailed clinical diagnosis of the disease. Develop medical tactics and determine the scope of therapeutic measures.

The student must know:

1. Fundamentals of the systemic inflammatory response of the body;

2. Causes and pathogenesis of purulent surgical diseases;

3. Clinical picture of surgical sepsis;

4. Criteria for the diagnosis of sepsis;

5. Surgical tactics and methods of treatment of sepsis;

6. Principles of antibiotic therapy;

7. Prevention of surgical sepsis.

The student must be able to:

1. Conduct an examination of a patient with this pathology;

2. Conduct a differential diagnosis of surgical sepsis with abscesses and phlegmon of various localization, peritonitis, pleural empyema, osteomyelitis.

3. Read results modern methods examination of a surgical patient general analysis blood, urinalysis, coagulogram, radiographs, findings of ultrasound of the abdominal organs, the conclusion of a biochemical blood test).

4. Based on the data of the clinical picture confirmed by the data of laboratory and instrumental examination, formulate a diagnosis and develop medical tactics.

Independent work of students:

A) Questions of basic disciplines necessary for the assimilation of this topic:

1. Normal physiology: indicators for assessing the activity of the cardiovascular and respiratory systems.

2. Pathological physiology: local signs of inflammation, hyper- and hypodynamic type of blood circulation, pathological types of breathing in inflammatory processes, evaluation of blood parameters.

3. Microbiology: types of aerobic and anaerobic pathogens, concepts of pathogenicity and virulence of microorganisms.

4. Propaedeutics of internal diseases: methods of examination of patients, types of temperature curves, evaluation of the results of physical, laboratory and instrumental examination of patients.

B) Tasks for checking and correcting the initial level of knowledge:

Topic study plan

1. Definition of the concept of septic conditions.

2. Etiology and pathogenesis.

3. Classification.

4. Clinical picture.

5. Treatment.

6. Prevention.

For the first time, the term "sepsis" (Greek sepsis - literally "decay") was introduced in the 4th century. BC e. Aristotle to refer to the process of poisoning the body with the products of "decomposition and putrefaction" of its own tissues.

Term “sespis” (“infection”) as an internosological concept defines the dynamic state associated with the generalization of the infectious process and is used in various fields of clinical medicine. The variety of clinical manifestations of sepsis, combined with the lack of definition of the concept itself, has led to its broad terminological interpretation. The need to describe sepsis as a nosological form in various fields of medicine has led to the emergence of a large number of different kinds of definitions and classifications of sepsis, which are based on such signs as the clinical course (fulminant, acute, subacute, chronic, recurrent), localization and presence of the pathogen at the site of the entrance gate (primary, secondary, cryptogenic), the nature of the entrance gate (wound, purulent-inflammatory, burn, etc.), localization of the primary focus ( obstetric-gynecological, angiogenic, urosepsis, umbilical, etc.), etiological sign (gram-negative, gram-positive, staphylococcal, streptococcal, colibacillary, pseudomonas, fungal, etc.) and others.