IV. Table of contents of teaching
PROTOCOL OF DIAGNOSTICS AND PRIMARY THERAPY OF SEPSIS
Presently most widespread in world practice is classification accepted in 1991 in the USA at Conciliatory Conference of societies of Pulmonologist and Critical care medicine (АРСР/SCCM). In accordance with the decisions of this Conference it is suggested to utillize the followings concepts:
An infection is the clinical-microbiological phenomenon, characterized a local inflammatory reaction in reply to the presence of microorganisms or on a damage microorganisms earlier healthy fabrics;
Bacteriemia is being of living microorganisms in blood;
A system inflammatory reaction is an universal reaction, showing (developing) up in reply to different extreme influences: trauma, especially polytrauma, heavy diseases, pancreatitis, peritonitis and etc The clinical symptoms of this reaction followings:
temperature of body >38 or < 36°С;
amount of leucocytes > 12×109 /l or < 4×109 /l or amount of immature forms > 10%;
frequency of pulse > 90 in 1 min;
breathing frequency > 20 in 1 min;
A sepsis is a system answer for an infection, characterized the symptoms of system inflammatory reaction, on a background an obvious local infectious process.
A heavy sepsis (sepsis-syndrome) is development of signs of insolvency (to insufficiency) on a background the clinical signs of system inflammatory reaction and infectious process.
Septic shock is an extreme form of display of generalization of inflammatory reaction, showing up in instability of hemodynamics, in spite of the conducted intensive therapy.
Pathogeny of sepsis
|
Violations are in the immune system |
|
H |
|
State of allergy |
earth
of purulent inflammation
|
M |
assive
troop
landing
of
mediators
of
inflammation
(cytocins,
kinins,
proteases
and
other)
|
Extraordinary inflammatory reaction (systemic inflammatory response syndrome – SIRS) |
|
Decline of general reactivity (anaemia, shock, diabetes, avitaminosises, obesity, supercooling and other) |
|
SIRS, compensated system of defence |
|
S |
IRS,
decompensated system of defence (sepsis)
|
Survival |
|
Septic shock |
Multiorgan insufficiency |
Second hearths of infection |
DIAGNOSTICS
Systemic inflammatory response syndrome diagnosed on the basis of the signs listed above. This diagnosis not can sound independently, but only together with one or another nosology form (pneumonia of SIRS-III – that means the presence of pneumonia, accompanied three from four signs of SIRS). SIRS is an important sign, testifying to possibility of transition of process in more heavy forms and requiring acceptance of adequate measures on treatment.
Sepsis diagnosed in accordance with the criteria indicated higher. For him a presence is needed at least three signs of system inflammatory reaction on a background an obvious local infectious process or verify bacteriemia (fungemia, virusemia), saved on an extent at least of three days, in spite of the conducted therapy.
The diagnosis of sepsis-syndrome is formulated at presence of the symptoms of system inflammatory reaction, demonstrating on a background the verify source of infection and laboratory information, testifying to development of insolvency of one or another organ (appendix 1) in default of other obvious reasons, explaining it is the state, indicated higher (extreme stages of chronic diseases and etc).
Septic shock is a decline of arterial pressure below 90 mm of mercury on a background a septic process, in spite of adequate infusion therapy and conducted treatment.
Laboratory diagnostics:
- Obligatory:
Three-hour temperature
A blood test is general (thrombocytes)
Analysis of urine
Every hour diuresis
Biochemistry: К+, Na+, bilirubin, AST, ALT, kreatine, urea, general albumen and proteinogramma, plasmozyme, fibrinogen, fibrinolysis
Bacterioscopy of stroke from a wound
Microbiological research of blood (2 tests) on sterility, wet, separated from a wound, at mechanical ventilation of lungs are sowing of the bronchial separated, removed catheter and drainage.
Research of intestinal flora on dysbacteriosis.
- Expediently:
Immune status;
Procalcitonin;
C-reactive albumen (quantitative method).
An examination, establishment of diagnosis of disease, foresee determination of gravity of the patient condition. In that behalf a ball estimation is most objective. So, the scale of Glasgow (table 1) allows to estimate the functional state of central nervous system at the different variants of violation of consciousness at the trauma of head, endogenous intoxication, poisonings. Patients with an index higher more chances have 9 marks on convalescence. The indexes of scale of Glasgow are entered as an element of estimation of the general state of patient and prognosis of disease in the system of SAPS (simplified acute physiology score). This system is based on the balls estimation of rejections each of parameters from normal sizes – aside both increases and diminishing. Take into account 14 indexes, including marks of scale of Glasgow (table 2).
On the sum of marks of the system of SAPS estimate the prognosis of disease, determining weight of the state of patient the same (table 3).
PRIMARY MEDICAL TACTIC
An examination and treatment of patient with surgical sepsis-syndrome and septic shock must be conducted in the conditions of intensive therapy department jointly by a surgeon and reanimator. Operative interference (as a rule the second surgical treatment) at presence of testimonies is executed in an urgent order. Interference can be set aside only at the unstable indexes of hemodynamics, to implementation of measures, resulting in its stabilizing.
The volume of operative interference must plug in itself: maximally complete necrectomy, adequate draining of hearth, mainly by double-opening tubes. Setting of intravascular catheters is expedient for regional therapy.
ANTIBACTERIAL THERAPY
The way of introduction, mainly, is intravenous. The choice of antibiotics is determined, at first, by localization of hearth, stipulating development of generalization process, and, secondly, weight of the state of patient, SAPS appraised on a scale.
To beginning of antibiotic therapy it is necessary to get the results of the no less 2th sowing.
Principle of antibiotic therapy – deescalative.
The first stage of deescalative antibiotic therapy is the maximally early (empiric) beginning of treatment the most effective antibiotic or their combination. The use of such preparations is expedient, as carbapenems, cephalosporins of the IV generation, fluoroquinolons.
The second stage is the first correction of therapy. Carried out after 18-36 hours on the basis of etiotropic of information of baclaboratory (presence of type of exciter).
The third stage is the repeated correction – on 3-4 days, after the receipt of information about the sensitiveness of microflora to the antibiotics.
Іntravenous antibiotic therapy must begin in the flow of the first hour from the moment of recognition of heavy sepsis after the receipt of the proper cultures.
It is necessary to over-estimate the antibacterial mode in 48-72 hours.
Microorganisms can be not sharp enough. But on their side time and amount!
There are not good antibiotics. There are sensible microorganisms!
IMMUNOTHERAPY
Amount of preparations, able to affect immune system great enough. Some of them are settled to the use and utillized in clinical practice.
Presently method of substitute (passive) immunization at development of sepsis, heavy sepsis and septic shock with the purpose of correction of immune status considered confessedly. Among plenty enough of preparations of immunoglobulins, from positions of evidential medicine survived multicentral blind randomized researches only preparation of «Pentaglobin».
Preparation is used at development of sepsis, heavy sepsis, septic shock (both Gram-negative and Gram-positive) in a dose 3-5 ml/kg of weight during 3 days.