Sepsis - Causes, symptoms and treatment. MF.
Sepsis ( from Ancient Greek - decay) is the response of all organs and systems of the body to infection that occurs as a severe generalized acute or chronic infectious disease of the blood, developing against a background of deep immunodeficiency or sensitization to the pathogen antigens.
In order to diagnose "sepsis", there must be at least two criteria from the following:
• body temperature over 38 ° C or less than 36 ° C;
• Heart rate more than 90 beats per minute;
• the number of respiratory movements is more than 20 per minute or the portion pressure of carbon dioxide is less than 32 mm Hg;
• leukocytes more than 12 or less than 4, and immature neutrophils more than 10%.
Causes of sepsis
The immediate cause of sepsis is the result of excessive systemic self-destruction. These symptoms are combined in the SIRS( systemic inflammatory response syndrome - syndrome of a systemic inflammatory response), resulting in the formation of multi-organ failure( PON).There is uncontrolled autodestruction, which leads to the depletion of immune resources.
Sepsis is most commonly caused by the following pathogens: S. pyogenes, S. epidermidis, S. aureus, E. coli, Proteus spp, K. pneumonia, P. aeruginosa, S. pyogenes, S. pneymoniae, E. faecalis, Candida albicans. Often, the microflora is a combination, i.e., a mixed infection is formed.
The cause of sepsis: acute purulent diseases of soft tissues( wound sepsis, phlegmon, abscess, extensive burns, lactation mastitis) and peritonitis. The person is infected from his own endogenous flora from the respiratory tract, the gastrointestinal tract.
Causes of generalization of infection, that is, its spread throughout the body:
• incorrect surgical tactics and inadequate volume of surgical reactions;
• Wrong choice of antibiotic therapy, detoxification and symptomatic treatment;
• impaired immunoreactivity;
• presence of concomitant pathology;
• wide distribution of antibiotic-resistant strains.
Symptoms of sepsis
The most dangerous during sepsis is the multifacetedness of its symptoms, because it can occur in the form of septicemia( ie, general intestinal manifestations without visible areas of suppuration) or septicopyemia( presence of foci of infection: postoperative infected sutures,various ulcers, extensive burn or wound surfaces, abscesses, phlegmon, osteomyelitis, etc.).
To date, is the most dangerous type of staphylococcal sepsis, because it behaves quite aggressively in the body due to its adhesive, toxic and enzymatic pathogenic factor( temolysin, leucocidin, erythrogenic toxin, streptokinase, hyaluronidase, plasmocoagulase).Also, its rapidly developing antibiotic resistance is also alarming. Clinically, this form of sepsis manifests itself in the form of erysipelas and cellulite with accumulation of yellowish pus in the focus of inflammation. Streptococcus possesses antifagocytic activity, and neutrophils do not enter the inflammatory focus, so the causative agent remains untouched for some time.
Intestinal bacillus causing suppurative processes, does not have a clear limitation, and the inflammatory process spreads over the subcutaneous tissue with the formation of suppuration pockets, pus-colored pus, an unpleasant odor is weakly expressed. With the development of this sepsis, hypotension, DIC-syndrome, endotoxic shock is observed. Symptoms are very diverse, because this causative agent has a high potential for interstate genetic exchange, and for the interspecific( Salmonella, Shigella, Yersinia).The most common strains are tropic to the urinary tract and the central nervous system, they cause diarrhea and hemolytic-uremic syndrome.
Coliform bacteria .Features of sepsis caused by these pathogens are the complexity of treatment, because it is due to the presence of strains that have multiple resistance. Infection often occurs when communicating the total blood flow to the food canal.
Proteas .With the onset of sepsis of this etiology, purulent foci are more rare, but this is one of the most dangerous types of septic process, because difficulties in treatment arise not only because of antibiotic resistance( to most antibiotics!), But also because of direct suppression of antibacterial activitydrugs, as well as suppression of phagocytic activity.
To date, all gram-negative microorganisms trace the presence of "pathogenicity islands" - a complex of genes localized on chromosomes, and coding factors that suppress the protective reactions of the host. These factors suppress all types of protein synthesis.
Diagnosis of sepsis
Sepsis, as a clinical syndrome, is difficult to determine, because the syndrome of a systemic inflammatory reaction can not be considered as a "sepsis", and only when the concentration of inflammatory cytokines and other inflammatory mediators exceeds the maximum allowable concentration, the balance between pro- and anti-inflammatory mediators - the controlling function of the immune system is damaged.
Diagnostics consists only in monitoring the reserve capacities of organs and systems, which under various clinical cases are under great impact. Under control are: respiratory system, cardiovascular system, acid-base composition of blood to prevent a change in pH towards alkalosis or acidosis, kidney function.
So for example, on the side of the heart and blood vessels often observed:
- arrhythmias;
- "cardiac" edema or ascites;
- acrocyanosis;
- on ECG - focal changes of the myocardium, ie in certain leads( I, II, III, V₁, etc.), deviations from the norm variants will be tracked;
- drop in pulse and pressure despite cardiac support;
- signs of impaired peripheral microcirculation( a symptom of white spots, petechiae, hemorrhages).
When evaluating the respiratory system, pay attention to:
BHD( respiratory rate);
The gas composition of blood( partial pressure of oxygen and carbon dioxide in the peripheral blood) helps to control the dynamics of changes in acid-base balance. Evaluation of liver function:
- liver size;
- The level of bilirubin, with predominant dominance of any fraction( indirect or direct bilirubin);
- Concentration of AlT( alanine aminotransferase), AsT( aspartate aminotransferase), alkaline phosphatase( alkaline phosphatase);
- Against a background of liver failure, in addition to jaundice, bleeding often occurs due to hepato-associated pathology of hemostasis.
Evaluation of kidney function determines the parameters of minute / hourly / diuresis, electrolytes, urea, creatinine, glomerular filtration, tubular reabsorption.
On the part of the pancreas, ultrasound signs, the concentration of amylase in the blood and urine are used as diagnostic criteria.
When evaluating the function of the digestive tract: diarrhea and vomiting.
Adrenal glands look at systolic pressure, which drops below 90 mm Hg and allergic reactions, which can result in anaphylactic shock.
The evaluation of the immunocompetent system is assessed by the leukocyte intoxication index( LII), which is the only available way to assess the condition and reactivity of the immune system. This index is calculated by the formula of Kalf-Kalifa and, the normal index is 0.3-1.5 conditional units. An increase in this indicator may be due to the disappearance of eosinophils, the relative number of segment-nucleated, rod-shaped, young neutrophilic granulocytes, or a decrease in lymphocytes and monocytes. The advantage of LII is the translation of hemograms into numerical indicators reflecting intoxication and insufficiency of immunity.
Treatment of sepsis
Because of the occurrence of multiple organ dysfunction, as well as the absence of clear diagnostic criteria, the co-authors specializing in this topic have created a table of "clinical and laboratory stages of organ damage"( DN Sizov et al 1998), facilitatingselection of medical measures.
Treatment consists in elimination of the arising complications, which in the majority are resuscitative. For example, when acute renal failure occurs, hemofiltration, hepatoprotectors and hemodialysis are used, in case of hemodynamic disorders, vascular permeability and circulating blood volume are restored, cardiostimulating and vasotropic drugs are cardiovascular, pulmonary insufficiency is used, ventricular H2 blockers / blockers are used for stress bleedingpumps / sucralfate. As for antibiotic therapy, antibiotics should be given according to the results of bacterial studies or against the most likely pathogens. For the latter case, a table has also been created:
| Localization of the primary focus | The most likely causative agents of the |
| The lungs( nosocomial pneumonia developed outside the ICU) | Streptococcus pneumonia, Enterobacteriaceae( E. coli), Staphylococcus aureus |
| The lungs( nosocomial pneumonia developed in the ICU) | Pseudomonias aeruginosa, Acinetobacter spp, as well as the above-listed pathogens |
| Abdominal cavity | Bacteroides spp, Enterococcus spp, Streptococcus spp, Pseudomonias aeruginosa, Staphylococcus aureus |
| Skin and soft tissues | Streptococcus spp, Staphylococcus aureus, Enterobacteriaceae |
| Kidneys | Enterobacteriaceae, Enterococcus spp |
| stomatopharynx | Staphylococcus spp, Streptococcus spp, anaerobes |
| after splenectomy | Streptococcus pneumonia, Haemophilis influenzae |
| intravenous catheter | Staphylococcus epidermididis, Staphylococcus aureus, Enterococci and Candida |
Complications sepsis
DIC, arrhythmias, gastrointestinal based bleedingstress factors, intestinal reperfusion, etc. The outcome for complications in most cases is unfavorable and results in a fatal outcome.
Therapist doctor Shabanova I.Е.