Sepsis

Description:

Sepsis is a special kliniko-pathogenetic form of any infectious disease, ever in connection with a heavy premorbidal background (a diabetes mellitus decompensation, rickets, a drug disease, an immunodeficiency, various injuries), or because of high virulence or (and) a large number of receipt of a microbe activator or an unusual way of receipt to bodies and fabrics of a macroorganism, there is a failure of resistance of an organism therefore meta former localization of pathogenic flora become the centers of their rough reproduction and sources of repeated generalizations of the activator.
It is system inflammatory response of an organism which leads to development of septic shock and a syndrome of multiorgan insufficiency.

It is more difficult to revaluate relevance of a problem of sepsis. Spread of this pathology it is connected with difficulty of diagnosis at early stages, the atypical erased current and tendency to a hronifikation.

Classification of sepsis by the place of penetration of the activator:
- chrezkozhny
- obstetric and gynecologic
- urosepsis
- otogenic
- oral
- surgical
- angiogenic
- cryptogenic

Sepsis reasons:

Incidence of sepsis is connected to distribution of antibiotics of a broad spectrum of activity, their uncontrolled appointment, including at self-treatment. It is established that to uslovnopatogenny microorganisms the person has no specific immune response.
On an origin allocate the following forms of sepsis:
- streptococcal
- staphylococcal
- esherikhiozny
- klebsiyellezny
- psevdomonadny
- meningococcal
- HYP infection (influenza stick)

Pathogeny:

The pathogeny of development of sepsis is characterized by staging.
1. Implementation of the activator and formation of primary center.
2. Break of a microorganism in blood (bacteremia).
3. Owing to release of toxins bacteria observe a toksinemiya.
4. Activator dissimination in internals, formation of the secondary centers in a spleen, a myocardium, kidneys, adrenal glands, skin.
5. Activation of immune system, but with its incomplete functions. It leads to release of antiinflammatory mediators, but this process does not come to the end completely, and accumulation of cytokines results.
6. Damage of cells of fabrics, with perfusion disturbance. These changes conduct to shock.
7. Development of septic shock. Septic shock is sepsis with disturbance of a hemodynamics and development of a syndrome of multiorgan insufficiency.

Sepsis symptoms:

Sepsis is divided by a current on fulminant, acute, subacute and chronic (хрониосепсис).
Classification of sepsis by pathogenetic forms:
1. A septicaemia (there are no centers, but reproduction of the activator happens in macrophages).
2. A septicopyemia (the secondary multiple centers in various bodies. In a large number bodies of reticuloendothelial system are surprised).
3. Septic endocarditis.

Harbingers of sepsis is long temperature reaction, temperature "candles" within 2-3 hours, wavy fever with the apireksiya periods, a fever and chilling.
Any fervescence, any unreasonable feverish wave it should not be disregarded the doctor, especially pernicious pattern "calming" diagnoses as flu or a SARS.
Skin – a sepsis mirror. Its pallor, dryness is characteristic, in the beginning there can be a hyperemia. On skin secondary pustulous elements appear. These are small bubbles of the size of a pin head with absolutely transparent contents. Development of a dieback – infectious and allergic dermatitis (a small tortoiseshell, a nodal erythema) is possible. Damage of joints in the form of polyarthritis is characteristic. Pulmonary fabric is surprised depending on an etiology, at staphylococcal sepsis lung abscesses form, the staphylococcal distress syndrome, parenchymatous respiratory insufficiency develops). The sizes of a spleen and liver increase.
Dissociation of a temperature curve – decrease in temperature against the background of increase in leukocytes is possible.
As it was already mentioned above, sepsis can be caused by various microorganisms – gram-negative and gram-positive. Depending on it sepsis has some features in a clinical picture.
At a gram-positive etiology of sepsis acute explosive temperature reaction against the background of absence of a headache is observed. Sharply heart failure with tachycardia, short wind develops. Changes of integuments are reminded by rash at a meningokoktsemiya – extensive sites of a necrosis of skin and secondary small-bubbling rashes. Signs of respiratory insufficiency with formation of abscesses in lungs accumulate. The typical distress syndrome and signs of shock develops.
Sepsis can be caused also by gram-negative flora, is more often – enterobakteriya. The beginning of a disease is followed by the expressed intoxication symptoms – a headache, nausea and vomiting. Acute vascular insufficiency and infectious and toxic shock develops, hemodynamics indicators fall, the ABP decreases, the heart rate, change of an index of Algover increases (the pulse relation to systolic pressure, normal equals 0,5-0,6). Integuments are covered with the spots reminding cadaveric.

Sepsis at newborns:

Sepsis during the early period of a neonatality is most urgent for the premature, weakened babies. On emergence time at newborns allocate early and late sepsis. Early neonatal sepsis is a development of sepsis in children in the first 3 days of life. Early sepsis develops as a result of pre-natal or early post-natal infection. As primary center of an infection pre-natal pneumonia often acts. The infection source in that case is the opportunistic flora inhabiting patrimonial ways of mother, however is not excluded also a transplacental way infection.
Late neonatal sepsis is diagnosed in case of the manifesto of a disease aged is more senior than 3 days of life, at the same time infection occurs postnatalno. Primary center of an infection is found. Sepsis proceeds with formation of one or several septicopyemic, metastatic, pyoinflammatory centers, the septicopyemia is quite often diagnosed. The typical metastatic center is purulent meningitis.

Diagnosis:

For a bacterial research the hemoculture for the purpose of identification of the activator undertakes. Crops of blood on sugar broth, on MPA and MPB are made.
During the first two days it is necessary to carry out not less than 5 crops a day. Blood is taken away on 10 ml, crops is made separately on 2 flasks. On each 5 ml of blood use 50 ml of sugar broth.
Also an urokultura, cultures from available suppurative focuses are used.
In the analysis of peripheral blood: hyperleukocytosis or leukopenia, development of anemia.
The analysis of urine finds signs piyelo-and a glomerulonephritis.

Treatment of Sepsis:

For treatment of sepsis the complex early therapy including antibacterial therapy, anti-coagulative, anti-fermental drugs, passive and active immunization, immunostimulation, extracorporal methods of clarification of blood is shown (hemosorption, immunosorption, a plasmapheresis, a limfosorbtion, laser radiation of blood, filtering through a ksenoselezenka).
The combined prescription of antibiotics is shown (not less than 2, depending on sensitivity): benzylpenicillin sodium salt of 300 - 500 000 PIECES on kg + gentamycin 4-6 гр in days. The maximum dose of penicillin – to 40 mln units; aminoglycosides (amikacin) in a combination with cephalosporin 3-4 generations. In addition – anti-anaerobic drugs - metronidazole of 100 ml intravenously, clindamycin; aminoglycosides + amoxicillin + anti-anaerobe bacterias; aminoglycosides + ciprofloxacin + anti-anaerobe bacterias. The chosen tactics of treatment needs to be conducted within 10 days after normalization of temperature.
Carry infusionally out desintoxication. 5% albumine to 400 ml, реополюглюкин, реамберин are entered, the forsorovanny diuresis is carried out.
For prevention of the IDCS 1000 PIECES of heparin (a daily dose of 24 000 PIECES) are hourly entered. At development of hypercoagulation the heparin combination to proteolysis inhibitors is shown, at a gipokoaglyation it is not necessary to stop administration of heparin, only to reduce its dosage.
Anti-staphylococcal immunoglobulin is entered in a dose of 5 ml on 1 kg of a body. A course – 5 injections.
Correction of acid-base balance, electrolytes, kislorodterapiya is in parallel carried out.
At the expressed septic shock – to 1000 mg of glucocorticoids, at ITSh – to 800 mg/days.
An important role is played by immunostimulation: the lysozyme of 100-200 mg intramusculary within 10 days, reception of Prodigiosanum raises a leukopoiesis, phagocytal activity, it is entered intramusculary 1 time in 3 days in a dose of 50 mg, the course consists of 5-6 injections.
From antiseptic agents intravenous administration of a hlorfillipt in the form of 0,2% of spirit solution is used (2 ml of a hlorfillipt + 38 ml of a fiz.rastvor).