Actuality of sepsis as disease

In 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

Definition of term (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 suppurative focus , 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 run from a way from hyperactivating (phase of hyperinflammation) into immunoparesis (phase of immunoparesis). 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 damaging tissues secondary factors.

 Thru skin

obstetric-gynaecological
Oral (odontogenic, tonsilar) Otogenous

As a result of surgical interferences and

manipulations Cryptogenic Most frequent thru skin, obstetric gynaecological and cryptogenic

 Presence of primary focus which is constantly or

periodically related to the blood or lymphatic vessel Permanent or periodic (multiple) penetration of causative agent is from a primary focus in blood Hematogenic dissemination of infection and forming of the second septic focuses from which an causative agent periodically enters to blood Acyclic motion, failure of organism to localization of nidus of infection in the focuses of inflammation and effective immune response

 Hematological, oncological, metabolic

diseases AIDS infection, tuberculosis, birth defects of the immune system Long-term administration of cytostatic drugs, chemical drags, immunodepressants, corticosteroids preparations Radiation 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 enterobacter klebsiela mycotic

Signs of sepsis
temperature of body > 38 or < 360 degrees of

centigrade
frequency of cardiac beats > 90 per min respiratory rate > 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 severity of clinical run

2 signs easy degree; 3 signs middle; 4 signs heavy;

Markers of sepsis
1. Cytocins (grow).- TNF, IL-6; 8; 10 2. reactive albumen (grows). 3. High temperature (for the persons of senior age is a hypothermia). 4. Bacteriemia (a blood drawing 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. Syndrome intravascular disseminate clotting. 14. Hypoproteinemia, Hypoalbuminaemia. 15. Hypertransaminaseaemia. 16. Encephalopathy. 17. State of wound and its process.

 Quick as lightning. Runs across with

development of septic shock and leads to death during 1 2 days Acute sepsis. Lasts to 4 weeks Subacute. Lasts 3 4 months Relapse. Is advanced with periods of recrudescence and remission, lasts to 6 months Cronic 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 intoxication Intermittent type of fever (breach exciter in blood) Severe general condition Anaemia, tachicardia, shortbreathing, is not predefined the state of pulmonary tissue

 Decline of arteriotony Distention of cardiac borders

Metastatic abscesses of lungs, kidneys,

liver, marrow, cerebrum and his shells Hemorragic syndrome with the septic skiddings

 Anaemia, speed-up BSR

Neutrophilic leycocitosis, toxic granulosity of

neutrophils Growth of levels of bilirubin, rest nitrogen, kreatinine Hypoproteinaemia (albumin), factors of hemopexis In 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.

tachycardia

hyperthermia

Stage surplus stress answer

diminishing of arterio-venouse difference is on oxygen increase of lactat concentration the satiation of arterial blood goes down by oxygen increase of bilirubin level stress ulcers and erosions of stomach develop the 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 extrass a heavy lactat is acidosis an arterio-venouse difference diminishes polyorganic insufficiency develops

Stage D pre-terminal stage of SIRS

decline of arteriotony and cardiac extrass cardiac insufficiency is expressed the consumption of oxygen is sharply mionectic lactoacidosis heavy 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 focus

early and radical sanation of festerings focusses
wide access necretomy

draining of festering focus

application of sorbents ointments are on vatersolubable basis running draining immobilization of area Secondary guy-sutures on a wound in 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 patient

1. 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 patient

7.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 (2-blocators).