Transcript Sepsis

m.d. Shydlovscky O.V.
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
Determination (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 primary hearth, 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
prokhodyat' a way from hyperactivating (phase of hyperinflammation)
to imunoparalichu (phase of imunoparalichu).
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
second poshkodzhuyuchimi fabrics by factors.
 Thru skin
 obstetric-gynaecological
 Oral (odontogenne, tonsilar)
 Otogenne
 As a result of surgical interferences and
manipulations
 Cryptogenic
Most frequent thru skin, obstetric – gynaecological
and cryptogenic
 Presence of primary hearth which is constantly or
periodically related to the blood or lymphatic vessel
 Permanent or periodic (multiple) penetration of
exciter is from a primary hearth in blood
 Hematogen dissemination of infection and forming of
the second septic hearths from which an exciter
periodically enters blood
 Acyclic motion, predefined inability of organism to
localization of infection in the hearths of
inflammation and effective immunoreactions
 Haematological, onko-illnesses, metabolic diseases
 AIS infection, tuberculosis, innate defects of the
immune system
 Of long duration application of cytostatics, chemical
drags, immunodepressants, corticosteroids
preparations
 Radial 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 graduse of Celcius
 frequency of heart-throbs > 90 per min
 number of respiratory motions > 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
weight of clinical motion
 2 signs – easy degree;
 3 signs – middle weight;
 4 signs – heavy;
Markers of sepsis
1. Cytocins (grow).- TNF, IL-6; 8; 10
2. С – reactive albumen (grows).
3. High temperature (for the persons of senior age is a
hypothermia).
4. Bacteriemia (a fence of blood 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. Disseminate intravascular rolling up syndrome.
14. Hypoprotein, - albuminaemia.
15. Hypertransaminaseaemia.
16. Encephalopathy.
17. State of wound and it’s process.
 Quick as lightning. Runs across with development of
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septic shock and leads to death during 1 – 2 days
Acute sepsis. Lasts to 4 weeks
Subacute. Lasts 3 – 4 months
Recidivate. Runs across with sharpening 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
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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
 Expansion of heart limits
 Metastatic abscesses of lights, buds, liver, marrow,
cerebrum and his shells
 Hemorragic syndrome with the septic skiddings
 Anaemia, speed-up BSR
 Neutrophilic leycocitosis, toxic grittiness of neytrophils
 Growth of levels of bilirubin, remaining 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 В – surplus stress answer
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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)
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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
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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 (Н2-blocators).