m.d. Shydlovscky O.V.

Actuality of sepsis as diseaseIn the USA

– annually near 750 thousand cases -from them near 200 thousands die -- treatment of one patient with a sepsis makes near 22-23 thouthant dollars.

Europe -annually near 500 thousand patients or 1:1000 hospitalized or > 21 % from hospitalized in the departments of intensive therapy

- daily dies near 1400 patients from a sepsis

Germany

- annually from a sepsis morbidity dies near 75 thousand patients Reason of death – poliorganic insufficiency grows constantly

Determination (terminology)

Sepsis – rotting

Schottmuller (1914) – About a sepsis it is possible to talk then, when in an organism there is a hearth of infection, from which constantly and periodically blood bacteria enter, as a result and there are subjective and objective symptoms of disease.

Sepsis is an infectious disease which is predefined different exciters, develops for persons with sharply mionectic protective forces of organism and characterized the presence of primary hearth, heavy making progress motion and absence of tendency, to spontaneous healing.

Determination (terminology)

Modern information:Sepsis it is not possible to consider the result of direct action

microorganisms on a macroorganism, but is investigation of substantial violations in the immune system, which in the development prokhodyat' a way from hyperactivating (phase of hyperinflammation) to imunoparalichu (phase of imunoparalichu).

Sepsis is a syndrome of system answer for inflammation (SIRS) is the heavy reaction of organism on inflammation, which is predefined an infection, heavy trauma, burns, sharp destructive pancreatitis, and second poshkodzhuyuchimi fabrics by factors.

Thru skin obstetric-gynaecological Oral (odontogenne, tonsilar) Otogenne As a result of surgical interferences and

manipulations CryptogenicMost frequent thru skin, obstetric –

gynaecological and cryptogenic

Presence of primary hearth which is constantly or periodically related to the blood or lymphatic vessel

Permanent or periodic (multiple) penetration of exciter is from a primary hearth in blood

Hematogen dissemination of infection and forming of the second septic hearths from which an exciter periodically enters blood

Acyclic motion, predefined inability of organism to localization of infection in the hearths of inflammation and effective immunoreactions

Haematological, onko-illnesses, metabolic diseases

AIS infection, tuberculosis, innate defects of the immune system

Of long duration application of cytostatics, chemical drags, immunodepressants, corticosteroids preparations

Radial therapy

Classification of sepsis

On character of microflora:A gramme positive:staphylococcuss (anreus, epidermidis)streptococci (pyogenes, pneomonic)anaerobes (bacteroids, peptococci)

A gramme is negative:collibacillus protey enterobacterklebsielamycotic

Signs of sepsis

temperature of body > 38 or < 360 graduse of Celcius

frequency of heart-throbs > 90 per min

number of respiratory motions > 20 per min, or Pa CO2 < 32 mm.

leucocytes > 12000/ml; or < 4000/ml and more than 10 % immature neytrophiles.

Classification of sepsis is on weight of clinical motion

2 signs – easy degree;

3 signs – middle weight;

4 signs – heavy;

Markers of sepsis

1. Cytocins (grow).- TNF, IL-6; 8; 10

2. С – reactive albumen (grows).

3. High temperature (for the persons of senior age is a hypothermia).

4. Bacteriemia (a fence of blood is 3 times on a day, on height of temperature)

5. Arterial LP

6. Oliguria.

7. Disorders of consciousness.

Markers of sepsis 8. Hyperleycocitosis (leycopenia). 9. Anemia. 10. Thrombocytopenia. 11. Acidosis. 12. Low BP, tachicardia. 13. Disseminate intravascular rolling up

syndrome. 14. Hypoprotein, - albuminaemia. 15. Hypertransaminaseaemia. 16. Encephalopathy. 17. State of wound and it’s process.

Quick as lightning. Runs across with development of septic shock and leads to death during 1 – 2 days

Acute sepsis. Lasts to 4 weeksSubacute. Lasts 3 – 4 monthsRecidivate. Runs across with sharpening and remission,

lasts to 6 monthsCronic sepsis. Can last to year and even anymore

Consists of symptoms :

- general intoxication

- basic disease which is a primary focus

- metastatic defeats of other organs

Beginning is acute, or from a pre-sepsis (subfebril temperature from shortly protracted gettings up of temperature)

Expressed intoxicationIntermittent type of fever (breach exciter in blood)Severe general conditionAnaemia, tachicardia, shortbreathing, is not predefined the

state of pulmonary tissue

Decline of arteriotonyExpansion of heart limitsMetastatic abscesses of lights, buds, liver, marrow,

cerebrum and his shellsHemorragic syndrome with the septic skiddings

Anaemia, speed-up BSRNeutrophilic leycocitosis, toxic grittiness of neytrophilsGrowth of levels of bilirubin, remaining nitrogen,

kreatinineHypoproteinaemia (albumin), factors of hemopexisIn urine pathological changes

Staphylococcus sepsis : - frequent quick as lightning forms, run across exceptionally

hardness, without a septicopyemia, death to 90% during 1 – 2 days

- sharp forms : a skin and oral gate of infection, prevail, pustule pouring out

- frequent metastatic festerings hearths are in buds, bones, endocardium

- recidivate duration with acutening - large probability of chronic motion (during years)

Blue puss sepsis

- the clinic of the expressed general intoxication predominates

- without metastatic defeats

- a liquid pus is in a far with a strong putrid smell

- bandage dark blue - green color

Anaerobic sepsis

- acute beginning, heavy motion

- high temperature, gectic temperature curve

- frequent development of septic shock

- a septicopyemia is with the defeat of brain, liver, lights

The stages of system answer syndrome for inflammation

Stage A - the physiology reaction of organism on inflammation, operating trauma.

tachycardiahyperthermia

Stage В – surplus stress answerdiminishing of arterio-venouse difference is on oxygenincrease of lactat concentrationthe satiation of arterial blood goes down by oxygenincrease of bilirubin levelstress ulcers and erosions of stomach developthe level of kreatinine grows

The stages of system answer syndrome for inflammation

Stage C – decompensate answer for stress (state of shock)

decline of arteriotony and cardiac extrassa heavy lactat is acidosisan arterio-venouse difference diminishespolyorganic insufficiency develops

Stage D – pre-terminal stage of SIRSdecline of arteriotony and cardiac extrasscardiac insufficiency is expressedthe consumption of oxygen is sharply mionecticlactoacidosisheavy system disfunction of all organs and systems

Treatment of sepsis

Place of treatment - reanimation

Success of treatment is determined:timely diagnostics;

adequate (in obedience to an exciter) antibacterial therapy;

scalene supporting therapy;

removal of contributory infringement moments

Directions of treatment

- influence on the organism of patient (nutritive support, passive imunotherapy, extracorporal detoxication)

- influence on microorganism (adequate, timely, of long duration, by courses, antibacterial therapy)

- treatment of infection focus (sanation of festering hearth, opening of metastatic abscesses)

Surgery of festering focusearly and radical sanation of festerings focusseswide accessnecretomydraining of festering focusapplication of sorbentsointments are on vatersolubable basisrunning drainingimmobilization of areaSecondary guy-sutures on a woundin relation to an abdominal region are programmable

laparotomia (laparopertion)

Influence on microorganism(antibacterial therapy of sepsis)

Empiric antibacterial therapy

Appoint at an infectious process without the exact results of bacteriologic examinations, antibiotics of wide spectrum of action taking into account localization of festering focus.

Purposeful antibacterial therapy

Appointed after authentication of exciter

Algorithm of antibacterial therapy setting 1. Clinical grounds: hyperthermia, heating, suspicion on the focus of

inflammation.

2. Choice of antibiotic:

- on toxicness and pharmakokinetics of preparation

- sensitiveness of exciter

- possibility of combination

3. Advantage preparations of bactericidal action (penicilini, cefalosporini, phtorchinolones, aminoglycosides, carbopenems).

Algorithm of antibacterial therapy setting

4. Advantage of not combination of antibacterial preparations, but monotherapy.

5. Optimum dose – maximally possible for age of patient.

6. Ways of antibiotics introduction:

into the cavities, intravenous, intramuscular

7. Correction of antibiotics

- at unefficiency of treatment

- at the low sensitiveness of microflora

Duration of antibacterial therapy

1. Conducted to achievement of proof positive dynamics 2. Criteria of sepsis antibacterial therapy sufficientness - proof normalization of temperature - positive dynamics of infectious process - absence of system inflammatory answer signs - normalization of gastro-enteric tract function - normalization of white blood indexes - subzero hemoculture

Influence on the organism of patient1. Primary reanimation - providing of BCV

- normalization of arteriotony

- proceeding in a diuresis

- providing of saturation of oxygen in venous blood scope not less than 70 %.

2. Infusion therapy (crystalloids, synthetic colloids, squirrel of blood, vitamins, hormones)

Volume of liquid: 50 ml/kg/day + loss on drainages + 500 ml on a 1 degree of temperature higher norms

Influence on the organism of patient

3. Vasopresors : at arterial LP which is irresponsive on infusion therapy.

4. Isotropic therapy: (cardiac preparations) – for the increase of cardiac extrass is Dobutaminum; vasopressors is adrenalin, dophamin.

5. Steroids – for support BP - hydrocortizon is from 200 mg to 1 gr on days.

6. Preparations of blood: - washed erythrocites - hyperimmune plasma - freeze plasma - leucothromboconcentrate

Influence on the organism of patient7.Treatment of pulmonary distress syndrome

(artificial ventilation of lights is for liquidation of hypoxia).

8. Analgesia and neuro-muscle blockade (ALV+analgetics) on a background miorelaxants.

9. Stimulation and substituting for the function of kidneys(venous hemophiltration, intermitant hemodialisis).

10. Correction water-electrolyte balance and PH of blood.

11. Prophylaxis of venous thromboses (deep veins of lower extremities).

12. Prophylaxis of stress ulcers (Н2-blocators).