surgical sepsis. Surgical sepsis reaction of systemic inflammation in the macroorganism to the infectious focus Sepsis in surgery clinic diagnostics treatment

On average, sepsis develops in 1-13 per 1000 hospitalized patients. In intensive care units, it can reach from 3-5.5 to 17%.

Definition of pathological conditions associated with sepsis.

Bacteremia is the presence of viable bacteria in the blood (a microbiological phenomenon).

Systemic inflammatory response syndrome - a systemic inflammatory response to various severe tissue damage, manifested by two or more of the following signs:

Temperature more than 38.5 o C or less than 36.5 o C;

Tachycardia more than 90 per minute.

The respiratory rate is more than 20 per minute. or PaCO 2 less than 32 mm Hg.

The number of leukocytes is more than 12000 in 1 mm 3, less than 4000. Or more than 10% of stab neutrophils.

Sepsis is a systemic inflammatory response to an infection (SIRS syndrome in the presence of a focus of infection).

Severe sepsis is sepsis associated with organ dysfunction, hypoperfusion, or hypotension. Perfusion disorders may include lactic acidosis, oliguria, acute impairment of consciousness, etc.

Hypotension is a systolic blood pressure less than 90 or a decrease of more than 40 from the usual level in the absence of other causes of hypotension.

Septic shock is sepsis with hypotension that persists despite adequate correction of hypovolemia + perfusion disorders (lactic acidosis, oliguria or acute impairment of consciousness), requiring the use of catecholamines.

Syndrome of multiple organ dysfunction - a violation of the function of organs in a patient in serious condition (on their own, without treatment, maintaining homeostasis is impossible).

Primary sepsis (cryptogenic)

Secondary sepsis develops against the background of a purulent focus)

By localization primary focus: surgical (acute and chronic surgical diseases, injuries, diagnostic procedures, complications of surgical interventions), gynecological, urological, otogenic, odontogenic, nosocomial (heart valves, prostheses of vessels, joints, catheters in vessels, etc.)

By type of pathogen: staphylococcal, streptococcal, colibacillary, anaerobic. Gram positive, Gram negative.

The entrance gate is the site of infection (usually it is damaged tissue).

The primary focus is a site of inflammation that has arisen at the site of infection and subsequently serves as a source of sepsis. In some cases, the primary focus may not coincide with the entrance gate due to lymphadenitis.

Secondary foci - the spread of infection beyond the primary focus with the formation of pyemic foci in organs and tissues. Formerly - Cruvelier's embolic theory. Now - hyperfermentemia - impaired capillary circulation - migration of leukocytes with the release of toxic proteins - necrosis - infection.

pathogens

Earlier in the 30-50 years - mainly streptococcus, then staphylococcus and gram-negative microflora. More often, sepsis is caused by a monoculture (about 90%), while an association of microbes can be sown in the primary focus.

According to the microflora of the primary focus, it is not always possible to judge the nature of the causative agent of sepsis (for example, gram-negative flora in the primary focus, gram-positive in the blood).

The clinical picture is largely determined by the properties of the pathogen.

Staphylococcus has the ability to coagulate fibrin and settle in tissues - in 95% of cases it quickly leads to the formation of pyemic foci.

Streptococcus has pronounced fibrinolytic properties - rarely causes piemi (35%).

Escherichia coli - mainly toxic.

A stick of blue-green pus - metastatic foci are few, small, more often localized under the epicardium, pleura, kidney capsule, while in staphylococcal sepsis the foci are large and localized in soft tissues, lungs, kidneys, bone marrow.

Due to the pronounced intoxication effect, gram-negative flora leads to the development of septic shock in 2/3 of cases.

In most cases, blood is not a breeding ground for microbes.

In addition to the characteristics of microbes, the course of sepsis is greatly influenced by the number of microbial bodies themselves - more than 10 in 5.

Symptoms of surgical sepsis.

Primary focus - 100%

Intoxication - 100%

Positive repeated blood cultures - 80%

Temperature above 38 - 90% - three types: continuous, remitting, undulating

Tachycardia - 80%

Toxic myocarditis, toxic hepatitis, nephritis, chills, peripheral edema.

Diagnostics.

The basis of diagnosis is the clinical picture.

Search for pyemic foci.

Important is the microbiological (qualitative and quantitative) study of blood discharged from wounds or fistulas, tissue of a purulent focus, and also (depending on the possible localization of foci of inflammation) urine, cerebrospinal fluid, sputum, exudate of the pleural cavity, abdominal cavity, etc.

An objective assessment of the severity of the condition of patients upon admission and during intensive care should be carried out on the basis of the integrated systems SAPS, APACHE, SOFA.

Examination and treatment of a patient with surgical sepsis should be carried out in an intensive care unit jointly by a surgeon and a resuscitator.

Surgery.

Surgical treatment of primary and secondary purulent foci.

Complete excision of non-viable tissues;

Full flow drainage;

Washing the foci with antiseptics;

It is possible to close the wound earlier with sutures or with the help of skin grafting - 1500 ml of water evaporates from a wound with an area of 10% per day.

Intensive therapy.

Intensive care methods can be divided into two groups

Priority methods, the effectiveness of which has been proven (significant reduction in mortality) in clinical practice or in prospective controlled randomized trials:

Antimicrobial therapy;

Infusion-transfusion therapy;

Artificial nutritional support (enteral and parenteral nutrition). You need 4000 kcal/day.

Respiratory support.

Additional methods, the use of which seems to be pathogenetically reasonable, but is not generally recognized.

Replacement immunotherapy with intravenous immunoglobulins (Ig G, IgM + IgG);

Extracorporeal detoxification (hemo-, plasma filtration);

Monitoring of the septic process.

Dynamic monitoring of the patient during intensive care should be carried out in three directions:

Monitoring the state of the main focus of infection and the emergence of new ones.

Evaluation of the course of the systemic inflammatory response syndrome (scoring of the severity of the patient's condition).

Analysis of the functional usefulness of individual organs and systems.

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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: Streptococcus, Staphylococcus, Proteus, Pseudomonas aeruginosa, Acinetobacter, Escherichia coli, Enterobacter, Citrobacter, Klebsiella, Enterococcus, Fusobacterium, Peptococcus, 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 varying degrees, depending on the individual characteristics of protective 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 and inflammatory disease.

Sometimes the initial disease that led to sepsis cannot be identified. During laboratory tests, 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%.

In a broad sense, sepsis is proposed to be understood as 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;

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

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

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General information

Sepsis (blood poisoning) is a secondary infectious disease caused by the ingress of pathogenic flora from the primary local infectious focus into the bloodstream. Today, from 750 to 1.5 million cases of sepsis are diagnosed annually in the world. According to statistics, abdominal, pulmonary and urogenital infections are most often complicated by sepsis, therefore this problem is most relevant for general surgery, pulmonology, urology, gynecology. Within pediatrics, the problems associated with neonatal sepsis are studied. Despite the use of modern antibacterial and chemotherapeutic drugs, mortality from sepsis remains at a consistently high level of 30-50%.

Sepsis classification

Forms of sepsis are classified depending on the localization of the primary infectious focus. Based on this feature, primary (cryptogenic, essential, idiopathic) and secondary sepsis are distinguished. In primary sepsis, the entrance gate cannot be found. The secondary septic process is divided into:

surgical- develops when infection enters the blood from a postoperative wound
obstetric and gynecological- occurs after complicated abortions and childbirth
urosepsis- characterized by the presence of an entrance gate in the departments of the genitourinary apparatus (pyelonephritis, cystitis, prostatitis)
cutaneous- the source of infection is purulent skin diseases and damaged skin (boils, abscesses, burns, infected wounds, etc.)
peritoneal(including biliary, intestinal) - with localization of primary foci in the abdominal cavity
pleuropulmonary- develops against the background of purulent lung diseases (abscessing pneumonia, pleural empyema, etc.)
odontogenic- due to diseases of the dentoalveolar system (caries, root granulomas, apical periodontitis, periostitis, maxillary phlegmon, osteomyelitis of the jaws)
tonsillogenic- occurs against the background of severe sore throatscaused by streptococci or staphylococci
rhinogenic- develops due to the spread of infection from the nasal cavity and paranasal sinuses, usually with sinusitis
otogenic- associated with inflammatory diseases of the ear, more often purulent otitis media.
umbilical- occurs with omphalitis of newborns

According to the time of occurrence, sepsis is divided into early (occurs within 2 weeks from the moment the primary septic focus appears) and late (occurs later than two weeks). According to the rate of development, sepsis can be fulminant (with the rapid development of septic shock and the onset of death within 1-2 days), acute (lasting 4 weeks), subacute (3-4 months), recurrent (lasting up to 6 months with alternating attenuation and exacerbations) and chronic (lasting more than a year).

Sepsis in its development goes through three phases: toxemia, septicemia and septicopyemia. The toxemia phase is characterized by the development of a systemic inflammatory response due to the onset of the spread of microbial exotoxins from the primary focus of infection; in this phase, bacteremia is absent. Septicemia is marked by dissemination of pathogens, the development of multiple secondary septic foci in the form of microthrombi in the microvasculature; there is persistent bacteremia. The septicopyemia phase is characterized by the formation of secondary metastatic purulent foci in the organs and the skeletal system.

Causes of sepsis

The most important factors leading to the breakdown of anti-infective resistance and the development of sepsis are:

on the part of the macroorganism - the presence of a septic focus, periodically or constantly associated with the blood or lymphatic channel; impaired reactivity of the body
on the part of the infectious agent - qualitative and quantitative properties (massiveness, virulence, generalization by blood or lymph)

The leading etiological role in the development of most cases of sepsis belongs to staphylococci, streptococci, enterococci, meningococci, gram-negative flora (Pseudomonas aeruginosa, Escherichia coli, Proteus, Klebsiella, Enterobacter), to a lesser extent - fungal pathogens (candida, aspergillus, actinomycetes).

Detection of polymicrobial associations in the blood increases the mortality rate in patients with sepsis by 2.5 times. Pathogens can enter the bloodstream from the environment or be introduced from foci of primary purulent infection.

The mechanism of development of sepsis is multistage and very complex. From the primary infectious focus, pathogens and their toxins penetrate the blood or lymph, causing the development of bacteremia. This causes activation of the immune system, which reacts with the release of endogenous substances (interleukins, tumor necrosis factor, prostaglandins, platelet activating factor, endothelins, etc.) that cause damage to the endothelium of the vascular wall. In turn, under the influence of inflammatory mediators, the coagulation cascade is activated, which ultimately leads to the occurrence of DIC. In addition, under the influence of released toxic oxygen-containing products (nitric oxide, hydrogen peroxide, superoxides), perfusion decreases, as well as oxygen utilization by organs. A logical outcome in sepsis is tissue hypoxia and organ failure.

Symptoms of sepsis

The symptomatology of sepsis is extremely polymorphic, depending on the etiological form and course of the disease. The main manifestations are due to general intoxication, multiple organ disorders and localization of metastases.

In most cases, the onset of sepsis is acute, however, in a quarter of patients, the so-called presepsis is observed, characterized by febrile waves alternating with periods of apyrexia. The state of presepsis may not turn into a detailed picture of the disease if the body manages to cope with the infection. In other cases, the fever takes an intermittent form with severe chills, followed by heat and sweating. Sometimes hyperthermia of a permanent type develops.

The condition of the patient with sepsis is rapidly aggravated. The skin becomes pale gray (sometimes icteric) color, facial features are sharpened. There may be herpetic rashes on the lips, pustules or hemorrhagic rashes on the skin, hemorrhages in the conjunctiva and mucous membranes. In the acute course of sepsis, bedsores quickly develop in patients, dehydration and exhaustion increase.

Under conditions of intoxication and tissue hypoxia, sepsis develops multiple organ changes of varying severity. Against the background of fever, signs of CNS dysfunction are clearly expressed, characterized by lethargy or agitation, drowsiness or insomnia, headaches, infectious psychoses and coma. Cardiovascular disorders are represented by arterial hypotension, weakening of the pulse, tachycardia, deafness of heart tones. At this stage, sepsis can be complicated by toxic myocarditis, cardiomyopathy, and acute cardiovascular failure.

The respiratory system reacts to the pathological processes occurring in the body with the development of tachypnea, pulmonary infarction, respiratory distress syndrome, respiratory failure. On the part of the digestive tract, anorexia is noted, the occurrence of "septic diarrhea" alternating with constipation, hepatomegaly, toxic hepatitis. Violation of the function of the urinary system in sepsis is expressed in the development of oliguria, azotemia, toxic nephritis, acute renal failure.

In the primary focus of infection in sepsis, characteristic changes also occur. Wound healing slows down; granulations become lethargic, pale, bleeding. The bottom of the wound is covered with a dirty grayish coating and areas of necrosis. The discharge acquires a cloudy color and a fetid odor.

Metastatic foci in sepsis can be detected in various organs and tissues, which causes the layering of additional symptoms characteristic of the purulent-septic process of this localization. The consequence of the introduction of infection into the lungs is the development of pneumonia, purulent pleurisy, abscesses and gangrene of the lung. With metastases to the kidneys, pyelitis, paranephritis occur. The appearance of secondary purulent foci in the musculoskeletal system is accompanied by the phenomena of osteomyelitis and arthritis. With brain damage, the occurrence of cerebral abscesses and purulent meningitis is noted. There may be metastases of a purulent infection in the heart (pericarditis, endocarditis), muscles or subcutaneous adipose tissue (soft tissue abscesses), abdominal organs (liver abscesses, etc.).

Complications of sepsis

The main complications of sepsis are associated with multiple organ failure (renal, adrenal, respiratory, cardiovascular) and DIC (bleeding, thromboembolism).

The most severe specific form of sepsis is septic (infectious-toxic, endotoxic) shock. It often develops with sepsis caused by staphylococcus aureus and gram-negative flora. The harbingers of septic shock are the disorientation of the patient, visible shortness of breath and impaired consciousness. Disorders of blood circulation and tissue metabolism are rapidly growing. Characterized by acrocyanosis against the background of pale skin, tachypnea, hyperthermia, a critical drop in blood pressure, oliguria, increased heart rate up to 120-160 beats. per minute, arrhythmia. Mortality in the development of septic shock reaches 90%.

Diagnosis of sepsis

Recognition of sepsis is based on clinical criteria (infectious-toxic symptoms, the presence of a known primary focus and secondary purulent metastases), as well as laboratory parameters (blood culture for sterility).

At the same time, it should be borne in mind that short-term bacteremia is also possible with other infectious diseases, and blood cultures with sepsis (especially against the background of ongoing antibiotic therapy) are negative in 20-30% of cases. Therefore, blood cultures for aerobic and anaerobic bacteria must be carried out at least three times and preferably at the height of a febrile attack. Bacteriological culture of the contents of the purulent focus is also performed. PCR is used as an express method for isolating the DNA of the causative agent of sepsis. In the peripheral blood, there is an increase in hypochromic anemia, an acceleration of ESR, leukocytosis with a shift to the left, opening of purulent pockets and intraosseous abscesses, sanitation of cavities (with soft tissue abscess, phlegmon, osteomyelitis, peritonitis, etc.). In some cases, it may be necessary to resect or remove an organ along with an abscess (for example, with an abscess of the lung or spleen, carbuncle of the kidney, pyosalpinx, purulent endometritis, etc.).

The fight against microbial flora involves the appointment of an intensive course of antibiotic therapy, flow-through washing of drains, local administration of antiseptics and antibiotics. Prior to culture with antibiotic susceptibility, therapy is started empirically; after verification of the pathogen, if necessary, the antimicrobial drug is changed. In sepsis, cephalosporins, fluoroquinolones, carbapenems, and various combinations of drugs are usually used for empirical therapy. With candidosepsis, etiotropic treatment is carried out with amphotericin B, fluconazole, caspofungin. Antibiotic therapy continues for 1-2 weeks after normalization of temperature and two negative blood cultures.

Detoxification therapy for sepsis is carried out according to general principles using saline and polyionic solutions, forced diuresis. In order to correct the CBS, electrolyte infusion solutions are used; amino acid mixtures, albumin, donor plasma are introduced to restore the protein balance. To combat bacteremia in sepsis, extracorporeal detoxification procedures are widely used: hemosorption, hemofiltration. With the development of renal failure, hemodialysis is used.

Immunotherapy involves the use of antistaphylococcal plasma and gamma globulin, transfusion of leukocyte mass, the appointment of immunostimulants. As symptomatic agents, cardiovascular drugs, analgesics, anticoagulants, etc. are used. Intensive drug therapy for sepsis is carried out until a stable improvement in the patient's condition and normalization of homeostasis.

Forecast and prevention of sepsis

The outcome of sepsis is determined by the virulence of the microflora, the general condition of the body, the timeliness and adequacy of the therapy. Elderly patients with concomitant general diseases, immunodeficiencies are predisposed to the development of complications and an unfavorable prognosis. With various types of sepsis, the mortality rate is 15-50%. With the development of septic shock, the probability of death is extremely high.

Preventive measures against sepsis consist in the elimination of foci of purulent infection; proper management of burns, wounds, local infectious and inflammatory processes; observance of asepsis and antiseptics when performing medical and diagnostic manipulations and operations; prevention of nosocomial infection; carrying out

The frequency of sepsis in the United States is currently thousands of cases per year, and mortality reaches a thousand (Angus D. C, 2001). According to some reports, among patients who have undergone sepsis, 82% die after 8 years, and the predicted life expectancy is 5 years (Quartin A. A.).

Sepsis is not so much the presence of live bacteria in the patient's blood ("bacteremia"), but the result of a "cascade" of humoral and cellular reactions associated with the release of cytokines from host cells (macrophages, neutrophils) stimulated by bacterial toxins

The release of pro-inflammatory tumor necrosis factor cytokines, interleukins and other agents (complement activation products, vasoconstrictors and dilators, endorphins) causes a damaging effect on the vascular endothelium, which is the central link in the spread of systemic inflammation beyond the boundaries of the vascular bed and its adverse effects on target organs.

Toxic bacterial products, entering the circulation, activate systemic defense mechanisms. Subsequently, macrophages begin to secrete anti-inflammatory cytokines IL 10, IL 4, IL 13, soluble TNF receptors, and others aimed at suppressing a generalized infection.

Sepsis is a pathological process that is a phase (stage) of the development of any infectious disease with different primary localization of the focus, which is based on the formation of a systemic generalized inflammation reaction. Conference of Clinical Chemotherapists and Microbiologists (2001)

Surgical sepsis is a severe general infectious-toxic disease that occurs as a result of a sharp violation of the relationship between infectious agents and immune defense factors in the primary focus, which leads to the failure of the latter, secondary immunodeficiency and homeostasis disorders. (Conference on the standards of diagnosis and treatment in purulent surgery (2001)

ACCP/SCCM classification and terminology of the society of thoracic surgeons and intensive care physicians (R. Bone et al. 1992) Bacteremia the presence of viable bacteria in the blood (Comment: bacteremia is an optional feature, it should be considered not as a criterion for sepsis, but as a laboratory phenomenon. Detection of bacteremia should serve as a reason for persistent search for the source of infection in patients with suspected sepsis.It should be borne in mind that instead of bacteremia there may be toxinemia or a mediator).

2. Systemic inflammatory response syndrome (SIRS, SIRS Systemic Inflammatory Response Syndrome). This is a pathological condition that is one of the forms of surgical infection or tissue damage of a non-infectious nature (trauma, burn, ischemia, etc.) and is clinically characterized by the presence of at least two (three for CS) of the following signs:

38.5 °C or 90 bpm 3. Respiratory rate > 20 per minute or PaCO2 38.5 °C or 90 bpm. 3. Respiratory rate > 20 per minute or PaCO2 11 1. Body temperature> 38.5 ° C or 90 bpm. 3. Respiratory rate > 20 per minute or PaCO2 38.5 °C or 90 bpm. 3. Respiratory rate > 20 per minute or PaCO2 38.5 °C or 90 bpm. 3. Respiratory rate > 20 per minute or PaCO2 38.5 °C or 90 bpm. 3. Respiratory rate > 20 per minute or PaCO2 38.5 °C or 90 bpm. 3. Respiration rate > 20 per minute or PaCO2 title="(!LANG:1. Body temperature > 38.5 °C or 90 bpm 3. Respiration rate > 20 per minute or PaCO2

4. Severe sepsis sepsis associated with organ dysfunction, hypoperfusion, or hypotension. Perfusion disorders may include: lactic acidosis, oliguria, acute impairment of consciousness. Hypotension systolic blood pressure less than 90 mm Hg. Art. or its decrease by more than 40 mm Hg. Art. from normal levels in the absence of other causes of hypotension.

Clinical and laboratory signs of organ dysfunction (one of the following is sufficient): dysfunction in the homeostasis system (consumption coagulopathy): fibrinogen degradation products> 1/40; dimers > 2; prothrombin index 0.176 µmol/l; sodium in urine 34 µmol/l; an increase in the levels of ASAT, ALAT or alkaline phosphatase 2 times or more from the upper limit of the norm; CNS dysfunction: 1/40; dimers > 2; prothrombin index 1/40; dimers > 2; prothrombin index 0.176 µmol/l; sodium in urine 34 µmol/l; an increase in the levels of ASAT, ALAT or alkaline phosphatase 2 times or more from the upper limit of the norm; CNS dysfunction: 1/40; dimers > 2; prothrombin index 1/40; dimers > 2; prothrombin index uk-badge="" uk-margin-small-right="">

The first is a complication of the inflammatory process, interconnected with the state of the primary focus. This variant of sepsis is more considered as a complication and is set at the end of the diagnosis. For example: an open fracture of the bones of the lower leg, extensive anaerobic phlegmon of the lower leg and thigh, sepsis.

The second clinical variant of sepsis, septicopyemia is a rare disease or complication, when the defining criterion is the occurrence of metastatic foci. When formulating the diagnosis, the word "sepsis" in such cases is brought forward, then the localization of the foci is indicated.

Severity scoring systems such as SAPS and APACHE are recommended to standardize sepsis scores and obtain comparable study results. Diagnosis of organ dysfunction and assessment of its severity should be carried out using the MODS and SOFA score scales, which have great informational value with a minimum of clinical and laboratory parameters.

85%); - violation of the functions of the central nervous system (80%); - leukocytosis (> 85%) and shift of the blood formula to the left (up to 90%); - anemia (80-100%); - hypoproteinemia (in 80%); - toxic myocarditis" title="(!LANG: Symptoms of sepsis are polymorphic. It manifests itself: 90%); - anemia (80-100%); - hypoproteinemia (in 80%); - toxic myocarditis" class="link_thumb"> 28 !} The symptomatology of sepsis is characterized by polymorphism. It manifests itself: - fever (> 85%); - violation of the functions of the central nervous system (80%); - leukocytosis (> 85%) and shift of the blood formula to the left (up to 90%); - anemia (80-100%); - hypoproteinemia (in 80%); - toxic myocarditis (up to 80%); -increased ESR (> 85%); The primary focus is found in 100% of patients. - Respiratory distress syndrome is detected in 40% of patients, - DIC in 11% 85%); - violation of the functions of the central nervous system (80%); - leukocytosis (> 85%) and shift of the blood formula to the left (up to 90%); - anemia (80-100%); - hypoproteinemia (in 80%); - toxic myocarditis "> 85%); - dysfunction of the central nervous system (80%); - leukocytosis (> 85%) and a shift in the blood formula to the left (up to 90%); - anemia (80-100%); - hypoproteinemia (in 80 %); - toxic myocarditis (up to 80%); - increased ESR (> 85%); - the primary focus is found in 100% of patients. - Respiratory distress syndrome is detected in 40% of patients, - DIC in 11% "> 85%); - violation of the functions of the central nervous system (80%); - leukocytosis (> 85%) and shift of the blood formula to the left (up to 90%); - anemia (80-100%); - hypoproteinemia (in 80%); - toxic myocarditis" title="(!LANG: Symptoms of sepsis are polymorphic. It manifests itself: 90%); - anemia (80-100%); - hypoproteinemia (in 80%); - toxic myocarditis"> title="The symptomatology of sepsis is characterized by polymorphism. It manifests itself: - fever (> 85%); - violation of the functions of the central nervous system (80%); - leukocytosis (> 85%) and shift of the blood formula to the left (up to 90%); - anemia (80-100%); - hypoproteinemia (in 80%); - toxic myocarditis"> !}

Almost all pathogenic and conditionally pathogenic bacteria can be the causative agents of sepsis. The most common causative agent of sepsis is the genus Staphylococcus aureus. Basically, S.aureus (15.1%), E.coli (14.5%), S.epidermidis (10.8%), other coagulase-negative staphylococci (7.0%), S. pneumoniae are sown from the blood with bacteremia (5.9%), P. aeruginosa (5.3%), K. pneumoniae (5.3%). Low-virulence microorganisms are significant as pathogens when isolated from two or more material samples. In recent years, there have been certain changes in the etiology of cholesterol in the direction of increasing the role of saprophytic staphylococci, enterococci and fungi.

Septic shock is the result of decompensated multiple organ failure that develops before the onset of hemodynamic disturbances as a result of complex metabolic and immunological reactions leading to impaired transcapillary metabolism.

The most important aspect of sepsis therapy is the sanitation of primary and secondary purulent foci according to the principles of active surgical treatment with the removal of all nonviable tissues, the implementation of adequate drainage, and the early closure of wound surfaces with sutures or various types of plastic surgery.

1. Methods whose effectiveness has been confirmed by extensive clinical practice - adequate antibiotic therapy; - respiratory support. (IVL or oxygen support for spontaneous breathing). -Infusion-transfusion and detoxification therapy. - nutritional support. Hemodialysis in acute renal failure.

3. Methods and drugs, the use of which is pathogenetically justified, but the effectiveness of which has not been confirmed from the standpoint of evidence-based medicine: heparin therapy antioxidants protease inhibitors karyoplasm pentoxifylline prolonged hemofiltration corticosteroids monoclonal antibody therapy recombinant antithrombin III albumin

4. Methods widely used in practice, but without substantiated evidence of their effectiveness either experimentally or in the clinic: hemosorption, lymphosorption, indirect electrochemical oxidation of blood with sodium hypochlorite, UVR, HLFL of blood, lymph, plasma, infusion of ozonized solutions of crystals, endolymphatic antibiotic therapy, infusion of xenoperfusate.

SESSION PLAN #32

date according to the calendar-thematic plan

Groups: Medicine

Discipline: Surgery with the basics of traumatology

Number of hours: 2

Topic of the lesson: Surgical sepsis

Lesson type: lesson learning new educational material

Type of training session: lecture

The goals of training, development and education: formation of knowledge about the causes, clinical picture, diagnostic methods, differential diagnosis and principles of treatment of surgical sepsis. .

Education: on the specified topic.

Development: independent thinking, imagination, memory, attention,students' speech (enrichment of vocabulary words and professional terms)

Upbringing: responsibility for the life and health of a sick person in the process of professional activity.

As a result of mastering the educational material, students should: know the causes, clinical picture, methods of diagnosis, differential diagnosis and principles of treatment of surgical sepsis.

Logistics support of the training session: presentation, situational tasks, tests

STUDY PROCESS

Organizational and educational moment: checking attendance at classes, appearance, availability of protective equipment, clothing, familiarization with the lesson plan;

Student survey

Familiarization with the topic, setting learning goals and objectives

Presentation of new material,v polls(sequence and methods of presentation):

1. Concept, classification of sepsis. Causes of occurrence. clinical picture.

2. Laboratory and instrumental diagnostic methods. Differential diagnosis. Principles of treatment.

3. Features of the course of the wound process in sepsis.

Fixing the material : solution of situational problems, test control

Reflection: self-assessment of the work of students in the classroom;

Homework: pp. 164-168; pp. 324-320;

Literature:

1. Kolb L.I., Leonovich S.I., Yaromich I.V. General surgery. - Minsk: Vysh.shk., 2008.

2. Gritsuk I.R. Surgery. - Minsk: New Knowledge LLC, 2004

3. Dmitrieva Z.V., Koshelev A.A., Teplova A.I. Surgery with the basics of resuscitation. - St. Petersburg: Parity, 2002

4. L.I.Kolb, S.I.Leonovich, E.L.Kolb Nursing in Surgery, Minsk, Higher School, 2007

5. Order of the Ministry of Health of the Republic of Belarus No. 109 "Hygienic requirements for the arrangement, equipment and maintenance of healthcare organizations and for the implementation of sanitary-hygienic and anti-epidemic measures to prevent infectious diseases in healthcare organizations.

6. Order of the Ministry of Health of the Republic of Belarus No. 165 "On disinfection, sterilization by healthcare institutions

Teacher: L.G. Lagodich

TEXT OF THE LECTURE

Lecture topic: Surgical sepsis

Questions:

1. Concept, classification of sepsis. Causes of occurrence. clinical picture.

Etiology.Sepsis (sepsis, Greek - putrefaction) is a condition that is characterized by the generalization of a bacterial infection, popularly - "blood poisoning". Any purulent-inflammatory focus in the body is normally limited by immune mechanisms. In the event of their breakdown, the infection is generalized through the blood to all tissues and organs. Less commonly, fungal sepsis is recorded, in particular, caused by candida. Viralinfections can have a severe generalized course, however, by themselves, in the absence of secondary bacterial flora, to the developmentsepsis is not given.

The role of various bacteria in the etiology of sepsis is ambiguous. Distinguish between pathogenic and opportunistic bacteria. The cause of sepsis is pathogenicbacteria can appear only in exceptional cases, mainly when infected with ultra-high infectious doses. In this case, protectivemechanisms of the body are insufficient to neutralize the generalized infectious process. For example, meningococcal sepsisfulminant meningococcemia.

Almost the only cause of sepsis is opportunistic bacteria. These include gram (+) coccal flora, primarily aureusstaphylococcus, as well as streptococci, pneumococci, enterococci and gram-negative rod-shaped flora - Escherichia and Pseudomonas aeruginosa,Klebsiella, Enterobacter, Proteus, etc.

The development of sepsis may be associated with the generalization of not one, but two or three pathogens, which mainly occurs with surgical sepsis, in patientswith bedsores, osteomyelitis.

At the present stage, sepsis is increasingly being recorded as a nosocomial infection. It occurs most often in surgical hospitals,especially the departments of purulent surgery.

Classification.

1. Primary sepsis (entrance gate not installed).

2. Secondary (developed from a specific purulent focus).

By clinical course:

1. Lightning (the clinical picture develops rapidly within 1-3 days from the moment the infection is introduced).

2. Acute (within 1-2 months from the onset of the disease).

3. Subacute (after 2-3 months from the onset of the disease).

4. Chronic (after 5-6 months from the onset of the disease).

Phases of the course of sepsis:

1. Initial phase. When blood cultures, microflora is sown, the duration of the initial phase of sepsis is 15-20 days (this phase is preceded by purulent-resorptive fever, which is a normal general reaction of the body to a purulent infection for about 7 days).

2. Septicemia(the duration of the septic state is more than 15-20 days, there are no metastatic pyemic foci, but blood cultures are positive).

3. Septicopyemia(the appearance of purulent metastatic foci in soft tissues, lungs, liver, etc.).

Complications:

Bleeding (arrosive and due to disseminated intravascular coagulation).

Septic shock.

Early exhaustion.

Pathogenesis.

The development of bacteremia, the circulation of pathogens in the vascular bed, in themselves, do not yet indicate the development or even an obligate threat of development.sepsis. The key link in pathogenesis is the disruption of the protective mechanisms of the response, which determines the stabilization of bacteremia, the developmentirreversible generalized infectious process of acyclic course.

First of all, these are non-specific defense mechanisms. The role of reducing the immune response is much smaller, immunity is not intended forsuppression of opportunistic flora, otherwise symbiosis would be impossible. At the same time, the mechanisms of nonspecific and specific protection are largely are interconnected.

The most important mechanism for the development and progression of sepsis is the rapid,virtually unrestricted hematogenous spread of the pathogen with the formation of secondary metastatic foci of infection in soft tissues and internal organs. Macro- and microphages contribute to the penetrationpathogens in different tissues (the phenomenon of incomplete phagocytosis).

As a result of damage to the vascular endothelium, their permeability increases, and the processes of intravascular hypocoagulation intensify. Ultimately thisleads to damage to the vascular wall, the development of widespread septic vasculitis, the formation of multiple microthromboses.

The central link in the pathogenesis of sepsis is the progressiveaccumulation of endotoxins ,

Installed acceleration of apoptosis processes , which determines the premature involution of cells of different organs. This is considered as one of the importantmechanisms of rapidly progressing insufficiency of the cardiovascular system, respiration, kidneys, etc., developing in severe sepsis.

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

Clinic.

Unlike all other infectious diseases, sepsis is characterized by an acyclic course with progressive hematogenous spread of the pathogen, notcontrolled by defense mechanisms.

The clinical manifestations of sepsis vary widely from inconspicuous initial microsymptoms to extremely severecondition requiring urgent intensive care.

The most characteristic clinical manifestations of sepsis:

Fever .Already at a very early stage, the temperature rises above 38 about C , can reach a hyperpyrectic level (above 40 ° C).The fever is not constant, with large diurnal fluctuations, higher temperature in the evening and its decrease in the morning. Periodsmaximum fever lasts several hours. Despite the high fever, patients experience a feeling of cold, muscle tremors appear,"goose pimples". The drop in temperature can occur critically or lytically.

Critical decline is accompanied by heavy sweats.

With septicopyemia occurring with multiple pyemic foci, daily temperature fluctuations reach 3-4°C. With the development of sepsis in individualsin the elderly, the temperature reaction is smoothed out, the maximum fever may be limited to a subfebrile level (below 38 ° C).

Intoxication . In sepsis, bacteremia is always accompanied by accumulation inblood endotoxins, which determines the development of intoxication. Intoxication is characterized by severe headaches, dizziness, feeling of weaknessup to a state of complete prostration, nausea, sometimes with vomiting, which does not even bring temporary relief to the patient. There is no appetite. Insomnia. Sometimesdisorders of consciousness - delirium, precoma. Sometimes meningism.

Splenomegaly - a sharp increase in the spleen. Hemogram: leukocytosis, often hyperleukocytosis. Neutrophilia with a shift to the left. The development of neutrophilia - an increase in the number of macrophages - corresponds toa sharp increase in phagocytic activity of the blood and characterizes an adequate response of the body to infection. When the body's response is exhaustedleukocytosis may be replaced by leukopenia. In this case, neutropenia may develop, significantly limiting the possibilities of treating patients. ESRincreases. Progressive thrombocytopenia characterizes the threat of microthrombosis, the development of DIC.

Hemorrhagic rashes They are detected in about 1/3 of patients with sepsis. Very variable - from point ecchymosis to largehemorrhagic-necrotic elements with stellate borders. Mostly localized on the anterior surface of the chest, abdomen,hands. Rashes are not itchy, are detected in the first days of the disease.

primary foci. These are purulent-inflammatory foci of different localization. Sepsis can be their complication. They can match the entrance gateinfections, but often they are not.

Secondary foci. They indicate a progressive hematogenous spread of the pathogen. They are characterized by the appearance of metastaticpyemic foci of different localization (abscesses, phlegmon, furunculosis, osteomyelitis, etc.), lesions of internal organs (endocarditis, destructivepneumonia), the spread of a purulent-inflammatory process to the meninges (purulent meningitis).

Syndrome of multiple organ failure . The development of systemic vasculitis in sepsis, with damage to the vascular endothelium, ultimately leads tothe formation of DIC-syndrome and multiple organ failure. This indicates the terminal stage, the threat of death. Clinically, the syndrome is diverse, developscardiovascular, respiratory and renal failure.

2. Laboratory and instrumental diagnostic methods. Differential diagnosis. Principles of treatment.

The main laboratory research methods are bacteriological studies + clinic of the disease.

Bacteriological research blood is very important for diagnosis and subsequent treatment, although a special approach is required for sowing the pathogen. This is due to the characteristics of the pathogen (usually anaerobe).

Requirements for a blood test for sterility:

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. AtThe choice of drugs should take into account the following factors:

The severity of the patient's condition;

Place of occurrence (out-of-hospital conditions or hospital);

Localization of the infection;

The state of the immune status;

Allergy history;

Kidney function.

With clinical efficacy, antibiotic therapy is continued with starting drugs. In the absence of a clinical effect within 48-72 hours, theyshould be replaced based on the results of microbiological testing or, if not available, with drugs that cover gaps in activitystarting preparations, 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. Restriction for usedrugs for oral and / m administration are 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 stable regression of inflammatory changes in the primaryinfectious focus, to prove the disappearance of bacteremia and the absence of new infectious foci, to stop the reaction of systemic inflammation. But even whena very rapid improvement in well-being and obtaining the necessary positive clinical and laboratory dynamics, the duration of therapy should be at least10-14 days. As a rule, longer antibiotic therapy is required for staphylococcal sepsis with bacteremia and localization of the septic focus inbones, 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 afternormalization of body temperature and arrange nen I focus of infection as a source of bacteremia.

3. Features of the course of the wound process in sepsis.

Difficulties in the early diagnosis of sepsis are often associated with a biased or belated assessment of changes in the wound - the primary focus of infection. There are such changes in sepsis. One of the typical prerequisites for the possible development of sepsis is the extent of traumatic injury and also the degree of tissue destruction in the wound. The most characteristic sign of destabilization of the wound process can be considered:

Increased tissue edema;

Increased pain, at first glance causeless;

Increased tissue infiltration along the periphery of the wound;

Progressive spread of peripheral necrosis;

The nature of the wound exudate usually indicates the specificity of the microflora, and its increase is a poor prognostic sign.

A characteristic sign of the generalization of the infectious process is the melting of granulations in the wound.