Sepsis - the general purulent infection developing owing to penetration and circulation into blood of various activators and their toxins. The clinical picture of sepsis consists of an intoksikatsionny syndrome (fever, oznob, pale earthy coloring of integuments), a trombogemorragichesky syndrome (hemorrhages in skin, mucous, a conjunctiva), metastatic defeat of fabrics and bodies (abscesses of various localizations, arthritises, osteomiyelit, etc.). As confirmation of sepsis serves allocation of the activator from culture of blood and the local centers of an infection. At sepsis performing massive dezintoksikatsionny, antibacterial therapy, an immunotherapy is shown; according to indications – surgical removal of a source of an infection.
Sepsis (blood poisoning) – the secondary infectious disease caused by hit of pathogenic flora from primary local infectious center to the blood course. Today annually in the world from 750 to 1,5 million cases of sepsis are diagnosed. Statistically, most often abdominal, pulmonary and urogenital infections therefore this problem the most urgent for the general surgery, pulmonology, urology, gynecology are complicated by sepsis. Within pediatrics the problems connected with sepsis of newborns are studied. Despite use of modern antibacterial and chemotherapeutic medicines, a lethality from sepsis remains at steadily high level – 30-50%.
Classification of sepsis
Forms of sepsis are classified depending on localization of primary infectious center. On the basis of this sign distinguish primary (cryptogene, essentsialny, idiopathic) and secondary sepsis. At primary sepsis entrance gate do not manage to be found. Secondary septic process is subdivided on:
- surgical – develops at an infection drift in blood from a postoperative wound
- obstetric and gynecologic – arises after the complicated abortions and childbirth
- – it is characterized by existence of entrance gate in departments of the urinogenital device (pyelonephritis, cystitis, prostatitis)
- skin – purulent diseases of skin and the damaged integuments (the furuncles, abscesses, burns infected wounds, etc.) are a source of an infection
- peritonealny (including biliarny, intestinal) – with localization of primary centers in an abdominal cavity
- plevro-pulmonary – develops against the background of purulent diseases of lungs (abstsediruyushchy pneumonia, a pleura empiyema, etc.)
- odontogenny – is caused by diseases of zubochelyustny system (caries, root granulomas, apikalny periodontitis, periostity, okolochelyustny phlegmons, osteomyelitis of jaws)
- tonzillogenny – arises against the background of the heavy quinsies caused by streptococci or stafilokokka
- rinogenny – develops owing to spread of an infection from a cavity of a nose and additional bosoms, usually at sinusitis
- otogenny - is connected with inflammatory diseases of an ear, more often purulent average otitis.
- umbilical – meets at an omfalita of newborns
On emergence time sepsis is subdivided on early (arises within 2 weeks from the moment of emergence of primary septic center) and late (arises after two weeks). On rates of development sepsis can be lightning (with bystry development of septic shock and approach of a lethal outcome within 1-2 days), sharp (duration 4 weeks), subsharp (3-4 months), recuring (lasting up to 6 months with alternation of attenuations and aggravations) and chronic (lasting over a year).
Sepsis passes three phases in the development: toksemiya, septitsemiya and septikopiyemiya. The phase of a toksemiya is characterized by development of the system inflammatory answer owing to the beginning of distribution of microbic ekzotoksin from primary center of an infection; in this phase bacteremia is absent. Septitsemiya is marked by a dissemination of activators, development of the multiple secondary septic centers in the form of microblood clots in the microcirculator course; persistent bacteremia is observed. Formation of the secondary metastatic purulent centers in bodies and bone system is characteristic of a phase of a septikopiyemiya.
Act as the major factors leading to failure of anti-infectious resistance and development of sepsis:
- from a macroorganism - existence of the septic center, periodically or constantly connected with the blood or lymphatic course; the broken reactivity of an organism
- from the infectious activator – qualitative and quantitative properties (massiveness, virulence, generalization by birth or a lymph)
The leading etiologichesky role in development of the majority of cases of sepsis belongs staphylococcus, to streptococci, enterokokka, meningokokka, gramotritsatelny flora (to a sinegnoyny stick, colibacillus, a protea, to the klebsiyella, an enterobakter), to a lesser extent - to fungal activators (kandida, aspergilla, actinomycetes).
Identification in blood of polymicrobic associations by 2,5 times increases the level of a lethality of patients with sepsis. Activators can get to blood from the environment or be brought from the centers of primary purulent infection.
Value of an intrahospital infection is big: its growth is promoted by broad application of invasive diagnostic procedures, immunosupressivny medicines (glucocorticoids, tsitostatik). In the conditions of an immunodeficiency, against the background of a trauma, an operational stress or sharp blood loss the infection from the chronic centers freely extends on an organism, causing sepsis. Premature children, patients are more subject to development of sepsis, it is long being on IVL, a hemodialysis; oncological, hematologic patients; patients with diabetes, HIV infection, primary and secondary immunodeficiencies.
Mechanism of development of sepsis multistage and very difficult. From primary infectious center pathogens and their toxins get into blood or a lymph, causing development of bacteremia. It causes activation of immune system which reacts emission of the endogenous substances (interleykin, a factor of a necrosis of tumors, prostaglandins, a factor of activation of platelets, endotelin, etc.) causing damage an endoteliya of a vascular wall. In turn, under the influence of mediators of an inflammation the coagulation cascade becomes more active that finally leads to emergence of the DVS-syndrome. Besides, under the influence of the released toxic oxygen-containing products (nitrogen oxide, peroxide of hydrogen, superoxides) perfusion, and also oxygen utilization by bodies decreases. A natural result at sepsis is the fabric hypoxia and organ insufficiency.
The sepsis symptomatology extremely of a polimorfn, depends on an etiologichesky form and the course of a disease. The main manifestations are caused by the general intoxication, polyorgan violations and localization of metastasises.
In most cases the beginning of sepsis sharp, however at a quarter of patients is observed the so-called presepsis which is characterized by the feverish waves alternating with the apireksiya periods. The condition of presepsis can not pass into the developed disease picture in case the organism manages to cope with an infection. In other cases fever takes the intermittiruyushchy form with the expressed oznoba which are replaced by heat and perspiration. Sometimes the hyperthermia of constant type develops.
The condition of the patient with sepsis is quickly made heavier. Integuments get pale-gray (sometimes icteric) color, features are pointed. There can be herpetic rashes on lips, gnoynichka or hemorrhagic rashes on skin, hemorrhages in a conjunctiva and mucous membranes. At the sharp course of sepsis patients quickly have decubituses, dehydration and exhaustion accrues.
In the conditions of intoxication and a fabric hypoxia at sepsis polyorgan changes of varying severity develop. Against the background of fever the signs of violation of the TsNS functions which are characterized by block or excitement, drowsiness or sleeplessness, headaches, infectious psychoses and a coma are distinctly expressed. Cardiovascular violations are presented by arterial hypotonia, weakening of pulse, tachycardia, dullness of warm tones. At this stage sepsis can be complicated by toxic myocarditis, a cardiomyopathy, sharp cardiovascular insufficiency.
The respiratory system reacts to the pathological processes happening in an organism development , a heart attack of a lung, respiratory a distress syndrome, respiratory insufficiency. From bodies of a GIT anorexia, emergence of the "septic ponos" alternating with locks, gepatomegaliya, toxic hepatitis is noted. Dysfunction of an urinary system at sepsis is expressed in development of an oliguriya, azotemiya, toxic nephrite, OPN.
In primary center of an infection at sepsis there are also characteristic changes. Healing of wounds is slowed down; granulations become sluggish, pale, bleeding. The bottom of a wound becomes covered by a dirty-grayish raid and sites of necroses. Separated gains muddy color and a fetid smell.
The metastatic centers at sepsis can come to light in various bodies and fabrics that causes stratification of the additional symptomatology peculiar is purulent - septic to process of this localization. As the investigation of a drift of an infection in lungs serves development of pneumonia, purulent pleurisy, abscesses and gangrene of a lung. At metastasises in kidneys there are piyelita, paranephrites. Emergence of the secondary purulent centers in musculoskeletal system is followed by the phenomena of osteomyelitis and arthritis. At damage of a brain developing of cerebral abscesses and purulent meningitis is noted. Existence of metastasises of a purulent infection in heart is possible (perikardit, an endocarditis), muscles or hypodermic fatty cellulose (abscesses of soft fabrics), abdominal organs (liver abscesses, etc.).
The main complications of sepsis are connected with polyorgan insufficiency (kidney, nadpochechnikovy, respiratory, cardiovascular) and the DVS-syndrome (bleedings, a thrombembolia).
The heaviest specific form of sepsis is septic (infectious and toxic, endotoxic) shock. It develops at the sepsis caused by staphylococcus and gramotritsatelny flora more often. As harbingers of septic shock serve the patient's disorientation, visible short wind and violation of consciousness. Quickly disorders of blood circulation and fabric exchange accrue. The hyperthermia, critical falling HELL, an oliguriya, increase of pulse to 120-160 are characteristic against the background of pale integuments, . in a minute, arrhythmia. The lethality at development of septic shock reaches 90%.
Diagnosis of sepsis
Recognition of sepsis is based on clinical criteria (infectious and toxic symptomatology, existence of the known primary center and secondary purulent metastasises), and also laboratory indicators (crops of blood on sterility).
At the same time, it is necessary to consider that short-term bacteremia is possible also at other infectious diseases, and crops of blood at sepsis (especially against the background of the carried-out antibiotic treatment) in 20-30% of cases happen negative. Therefore crops of blood on aerobic and anaerobic bacteria it is necessary to carry out a minimum it is triple and it is desirable at height of a feverish attack. Also it is made contents of the purulent center. As an express method of release of DNA of the causative agent of sepsis PTsR is used. In peripheral blood increase of gipokhromny anemia, acceleration of SOE, with shift is noted to the left.
Treatment of sepsis
Patients with sepsis are hospitalized in intensive care unit. The complex of medical actions includes antibacterial, dezintoksikatsionny, symptomatic therapy, an immunotherapy, elimination of proteinaceous and water and electrolytic violations, restoration of functions of bodies.
For the purpose of elimination of the source of an infection supporting the course of sepsis surgical treatment is carried out. It can consist in opening and drainage of the purulent center, performance of a nekrektomiya, opening of purulent pockets and intra bone abscesses, sanitation of cavities (at abscess of soft fabrics, phlegmon, osteomyelitis, peritonitis, etc.). In certain cases the resection or removal of body together with an abscess (for example can be required, at abscess of a lung or spleen, a kidney anthrax, a piosalpinksa, a purulent endometritis, etc.).
Fight against microbic flora assumes purpose of an intensive course of antibiotic treatment, flowing washing of drainages, local introduction of anti-septic tanks and antibiotics. Before receiving crops with an antibiotikochuvstvitelnost therapy is begun empirically; after verification of the activator if necessary change of antimicrobic medicine is made. At sepsis for performing empirical therapy tsefalosporina, ftorkhinolona, karbapenema, various combinations of medicines are usually used. At a kandidosepsisa etiotropny treatment is carried out amfoteritsiny In, flukonazoly, kaspofunginy. Antibiotic treatment continues within 1-2 weeks after normalization of temperature and two negative bakposev of blood.
Dezintoksikatsionny therapy at sepsis is carried out by the general principles with use of salt and polyionic solutions, the forced diuresis. For the purpose of correction of BRAIDS electrolytic infusion solutions are used; for restoration of proteinaceous balance amino-acid mixes, albumine, donor plasma are entered. For fight against bacteremia at sepsis procedures of an extracorporal detoxication are widely used: plasma exchange, haemo sorption, haemo filtration. At development of a renal failure the hemodialysis is applied.
The immunotherapy assumes use of anti-staphylococcal plasma and gamma globulin, transfusion of leykotsitarny weight, purpose of immunostimulators. As symptomatic means cardiovascular medicines, analgetics, anticoagulants, etc. are used. Intensive medicamentous therapy at sepsis is carried out before permanent improvement of a condition of the patient and normalization of indicators of a homeostasis.
Forecast and prevention of sepsis
The outcome of sepsis is defined by virulence of microflora, the general condition of an organism, timeliness and adequacy to the carried-out therapy. Patients of advanced age, with the accompanying general diseases, immunodeficiencies are predisposed to development of complications and the adverse forecast. At different types of sepsis the lethality makes 15-50%. At development of septic shock the probability of a lethal outcome is extremely high.
Preventive measures concerning sepsis consist in elimination of the centers of a purulent infection; correct maintaining burns, wounds, local infectious and inflammatory processes; observance of an asepsis and antiseptics when performing medical and diagnostic manipulations and operations; prevention of a hospital infection; performing vaccination (against a pnevmokokkovy, meningococcal infection, etc.).