SEPSIS

one of pressing problems of modern medicine steady tendency for growth of cases steady high mortality of 30-50%

SEPSIS
is a pathological process aggravating the course of various diseases of infectious nature; it mainly consists in uncontrolled release of endogenic mediators with a subsequent development of inflammation and organicsystemic dysfunctions at a distance from the primary focus.

The growth of sepsis incidence is associated with:

uncontrolled administration of antibiotics prolonged life span in people with severe chronic diseases a wider use of glucocorticoids, cytostatics increased invasiveness of treatment

Classifications of sepsis
Primary sepsis (cryptogenic sepsis). It is relatively uncommon. Its origin is still unclear. An association with autoinfection (chronic tonsillitis, carious teeth, dormant infection) has been suggested. Secondary sepsis develops in the presence of a pyogenic focus in the body: a suppurating wound, an acute pyogenic surgical disease, and also pyogenic complications after a surgical intervention.

Classifications of sepsis
According to the localization surgical, gynecologic,
urologic, odontogenic, otogenic sepsis.

According to the type of infecting agent:

staphylococcal, streptococcal, coli-infection, pseudomonas, anaerobic sepsis.

According to its source: wound, postoperative,

inflammatory (phlegmon, osteomyelitis, quinsy, pneumonia) sepsis.

According to the time of its development: early

(under 10-14 days from the moment of injury) and late (two weeks and more from the moment of injury).

Classifications of sepsis
According to the type of clinical course:
Fulminate clinical presentations of generalized inflammatory process becomes manifest 12-24 hours after injury. The duration is 5-7 days. Acute clinical presentations become manifest within several days; the duration is 2-4 weeks. Subacute sepsis lasts for 6-12 weeks with a favourable outcome. Chronic sepsis lasts for years with periodic exacerbations and remissions.

Classifications of sepsis
According to the nature of the bodys reaction: hyperergic, normergic, hypergic sepsis According to clinical and anatomical signs:
septicemia (without metastases) and septicopyemia

According to clinical stages: tension stage,

catabolic, anabolic, rehabilitation stage

Etiology
Sepsis can be caused by bacteria, fungi, protozoa and viruses. Bacteria account for 95% of cases. grampositive coccal flora gramnegative bacilli

Criteria for diagnostics of sepsis

A focus of infectious inflammation; Systemic Inflammation Response Syndrome (SIRS) is a pathological condition associated with surgical infection or non-infectious alteration of tissues (trauma, pancreatitis, burn, ischemia or autoimmune damage of tissues); Appearance of remote purulent foci or bacteriemia confirmed by blood culture (criteria of a generalized process).

Source of bacteriemia
genitourinary system 25% of all cases; respiratory system 20%; abscess 10% biliary system 5%; other parts 10%; unknown sources 25%.

Laboratory diagnostics of bacteriemia

Blood for investigation should be drawn from a peripheral vein. Standard manufactured vials with readymade nutrient media are preferable to laboratory vials stopped with cotton or gauze. Blood should be drawn from a peripheral vein carefully observing all rules of aseptics.

Laboratory diagnostics of bacteriemia

Blood for investigation should be drawn before administration of antibiotics. The culture should be preferably inoculated as soon as possible after the rise of temperature or onset of chills. 2 samples taken from different arms with the interval of 30 min. are the necessary minimum.

sepsis organic dysfunction

myocarditis 55.8% of all cases; pneumonia, lung abscess, pleuritis 48.4%; hepatitis 78.1%; nephritis 85.4%; meningoencephalitis 55%; gastrointestinal disorders 75.3%.

organic dysfunctions
Hemostasis dysfunction (coagulopathy of consumption); Acute respiratory distress-syndrome; Renal dysfunction; Hepatic dysfunction; CNS dysfunction.

polyorganic insufficiency
elderly or neonatal age; granulocytopenia; chronic cardiovascular or respiratory diseases; the presence of intractable infection foci; detection of bacterial flora polyresistant to antibiotics in blood.

Septic shock
Systolic pressure is below 90 mm Hg despite a quite high rate of infusion or administration of vasodepressors. Oliguria (under 30 ml/hour) despite adequate fluid provision; Circulatory and respiratory insufficiency; Pronounced metabolic acidosis.

Management of sepsis
Elimination of purulent focus
draining of the purulent focus excision of unviable infected tissues removal of foreign bodies with surgical debridement of surrounding tissues

priority methods
antibiotic therapy infusion-transfusion therapy inotropic and vascular support in shock nutritive support

additional methods
substitution immunotherapy correction of hemocoagulation disorders

Antibiotic therapy
antibiotic therapy often includes 2 or 3 drugs If there is no clinical effect within 48-72 hours the drug should be replaced duration of antibiotic therapy should be no less than 10-14 days Antibiotics can be cancelled in 4-7 days after the body temperature normalizes

 Infusion therapy (the ratio of crystalloids to colloids should be 2:1) Vascular support (dopamine or noradrenalin are drugs of choice for correction of hypotension ) Respiratory support (auxiliary oxygen inhalation to artificial lung ventilation) Nutritional support (enteral nutrition and special feeding formulas )

 Correction of immune disorders (2-5 ml/kg of intraglobin for 2-3 days ) Glucocorticoids (60-120 mg of prednisolone or 200 mg of hydrocortisone a day for 5-10 days ) Extracorporeal detoxication (hemofiltration and plasmopheresis ) Prevention of stress ulcers (H2 receptors antagonists )