Sepsis

Sepsis

Sepsis is a symptom complex caused by constant or periodic entry of microorganisms into the blood from the focus of purulent inflammation. The clinical picture is dominated by severe multiple organ disorders, while local inflammatory changes are mild. The formation of metastatic foci of purulent inflammation in various organs and tissues is characteristic. Classification.

• • epidemiological
  • Nosocomial sepsis (postnatal, postoperative, postcatheterization, postinjection, post-gynecological examinations, neonatal sepsis)
  • Community-acquired sepsis (cryptogenic, tonsillogenic, intestinal, burn).
  • Clinical classification takes into account the following features:
  • Etiology
  • Localization of the entrance gate of infection
  • Duration
  • Fulminant sepsis – 1-3 days
  • Acute sepsis – up to 6 weeks
  • Subacute or prolonged sepsis – more than 6 weeks
  • Chronic sepsis (typical for patients with immunodeficiency conditions, especially with AIDS) – more than 6 months
  • Clinical form
  • Septicemia is a form of sepsis that is not accompanied by the formation of metastatic foci of purulent infection.
  • Septicopyemia is a form of sepsis characterized by the formation of metastatic foci of purulent infection.
  • Infective endocarditis. Note. Septicemia often turns into septicopyemia, which gives reason to consider these forms as stages of one process.
  • Leading clinical and pathophysiological syndrome
  • Thrombohemorrhagic syndrome (eg, DIC)
  • Septic (infectious-toxic) shock
  • Toxic-dysgrographic state.

Etiology and epidemiology

• • Conditionally pathogenic flora – staphylococcus, streptococcus, Escherichia and Pseudomonas aeruginosa, Klebsiella, fungi of the genus Candida, less often protozoa, mixed infection
  • Patients with sepsis are not traditionally contagious
  • For some infectious diseases (salmonellosis; scarlet fever; diseases caused by opportunistic gram-negative microflora; meningococcal infection), the presence of the so-called. septic forms (symptoms of sepsis). However, the diagnosis of sepsis in these cases is not made.

since from an epidemiological point of view, the patient is dangerous to others.

Pathogenesis

• • For the development of sepsis, it will be necessary to penetrate the opportunistic pathogen through the entrance gate (often injured skin or mucous membrane) with the development of a local reaction (primary affect), reactive lymphadenitis (lymphangitis), purulent thrombophlebitis with subsequent bacteremia and toxemia. Damage to the vascular wall over a large area, phlebitis leads to the formation of infected microthrombi, causing abscesses and heart attacks of internal organs
  • The clinical picture does not depend on the etiology, there are no morphological signs indicating the specifics of the process
  • Profound metabolic disorders due to severe intoxication, the predominance of catabolism processes (hypoalbuminemia, dysproteinemia, hyperglycemia, deficiency of essential fatty acids, hypovitaminosis, metabolic acidosis). Severe dystrophic changes additionally worsen the functions of organs, which, even in the absence of clinically pronounced metastases in them, leads to systemic multiple organ failure, characteristic of the late irreversible stages of sepsis.

clinical picture. The incubation period, the cyclicity of the course, characteristic of infectious diseases, are absent. No pathognomonic signs

• • Intoxication syndrome
  • Lethargy, anorexia, changes in the psycho-emotional status to gross cerebral disorders (coma)
  • Fever (temperature curve is most often of the wrong type). Suspicion of the presence of sepsis occurs when the duration of fever is more than 5 days and the presence of unmotivated rises in body temperature to febrile values, followed by a fall to subfebrile
  • Signs of dystrophy and malnutrition with the development of malnutrition and a decrease in body weight, a decrease in skin elasticity, soft tissue turgor
  • Gastrointestinal dysfunction, nausea, vomiting (including due to intoxication)
  • Microcirculation disorders – pallor of the skin with an earthy tint, hemorrhagic rash, shortness of breath, decreased diuresis
  • Hepatolienal syndrome
  • Symptoms of damage to organs and tissues, according to the localization of metastatic foci or the entrance gate of infection.

Laboratory signs

• • Leukocytosis or leukopenia (with the etiological role of gram-negative flora and AIDS), neutrophilia with a hyperregenerative shift to the left, progressive anemia, thrombocytopenia
  • Hypoproteinemia with dysproteinemia (decreased albumin/globulin ratio)
  • High levels of acute phase proteins
  • Changes in the coagulogram, indicating the development of DIC
  • Leukocyturia, bacteriuria, cylinduria, erythrocyturia
  • Positive results of bacteriological examination of blood (detection of blood culture), feces, urine, CSF. To obtain a positive result, three blood samples in a volume of 20-30 ml are required with an interval of 1 hour, according to probability, before the start of antibiotic therapy.
  • Hyperfermentemia, hyperbilirubinemia with damage to the relevant organs.

Diagnostic criteria for clinical forms of sepsis

• • Septicopyemia – detection of one or more foci of metastatic inflammation with identification of the pathogen
  • Septicemia
  • signs of an intoxication syndrome with severe disorders of microcirculation and central hemodynamics, an expanded clinic of thrombohemorrhagic syndrome predominate. Septic (infectious-toxic) shock is characteristic
  • Infective endocarditis (p. 999). Features of the infectious process: the entrance gate is often the mucous membrane of the pharynx, but the local focus (the source of constant entry of microorganisms into the systemic circulation) is the endocardium.

Treatment:

Tactics of conducting

• • Hospitalization
  • Etiotropic therapy. Until the results of bacteriological examination are obtained, antibiotics are selected empirically.
  • Immunostimulating therapy
  • Detoxification therapy (its adequacy ultimately determines the prognosis), incl. extracorporeal detoxification according to indications: plasmapheresis, hemosorption, blood perfusion through animal donor organs (spleen, liver)
  • Symptomatic therapy
  • The treatment is intensive care and additionally includes emergency correction of dysfunctions of vital organs (infectious-toxic shock in septicemia, decompensated heart failure in bacterial endocarditis)
  • The severity of the local inflammatory process of any localization does not correlate with the severity of sepsis. It should be borne in mind that a distant focus of purulent inflammation can be both a consequence of sepsis (metastasis) and its cause, which is important when determining treatment tactics. Drug therapy
  • Etiotropic therapy
  • Until the results of a bacteriological study are available, especially with unclear etiology, the most effective combination of gentamicin or tobramycin 3-5 mg/kg/day IV and an antibiotic from the group of cephalosporins or imipenem 500 mg IV every 6 hours
  • Antibiotics are prescribed at the maximum dosage, intravenously, for at least 2 weeks (despite the normalization of body temperature)
  • Efficiency criteria – obvious positive dynamics of the general condition and laboratory parameters.
  • Immunostimulating foods
  • Immunoglobulin for intravenous administration, intraglobin, pentaglobin
  • interferon preparations.
  • Detoxification therapy – intravenous administration of large amounts of fluid in combination with diuretics, such as furosemide (forced diuresis method)
  • The amount of fluid administered should not exceed the amount of urine excreted (in the absence of signs of dehydration in the patient)
  • It is necessary to control the indicators of central hemodynamics (BP, CVP) and the content of electrolytes in blood serum and urine
  • Vasodilators should be added.
  • Symptomatic therapy
  • With anemia and thrombocytopenia – blood transfusion, erythrocyte and platelet masses
  • Anti-inflammatory therapy: NSAIDs and glucocorticoids (the immunosuppressive effect of glucocorticoids should be taken into account)
  • Rehydration and parenteral nutrition for severe gastrointestinal dysfunction and severe eating disorders
  • Relief of heart failure and arrhythmias
  • Anti-shock measures for infectious-toxic shock (septicemia): glucocorticoids, adrenomimetic agents, plasma-substituting products, for example, polyglucin.

Surgical treatment in the presence of a focus of purulent infection accessible to surgical intervention.

Synonym. General purulent infection

ICD

• • P36 Bacterial sepsis of the newborn
  • T80.2 Infections associated with infusion, transfusion and therapeutic injection Literature
  • 336: 90—95
  • 129: 222—224