Sepsis is a kind of systemic pathogenetic reaction of the human body to the introduction of an infectious agent that develops as a result of the generalization of the infectious inflammatory process against the background of a pronounced decrease in the function of the immune apparatus.
Acute sepsis in humans makes their debut when spreading the infectious process from the primary focus, which can be a limited foci of inflammation localized in soft tissues, internal organs, joints and even bone tissue. Sepsis in an adult develops, as a rule, with a marked decrease in immunity, as well as in the untimely recognition of the primary localization and etiology of the inflammatory process, as a result of which the dispersion of toxic substances throughout the body with blood flow is observed.
Infectious sepsis should not be considered as a contagious infection, that is, this pathology is not likely to be transmitted by any of the known methods of transmission of infectious agents. Purulent sepsis is accompanied by a massive inflow of pathogenic microorganisms into the circulating blood from a festering inflammatory focus, so the course of the disease is marked by severe severity and intensity of clinical manifestations. Provided there is no timely adequate anti-inflammatory therapy, sepsis of blood in 90% of cases ends lethal.
As an etiological agent of an inflammatory reaction and the further development of a clinical symptom-complex of sepsis, virtually any pathogenic microorganism, as well as protozoa, fungi and virus particles can act. The pathogenesis of sepsis is triggered when the first portion of toxins enters the general bloodstream.
Sepsis in children occurs with a pronounced systemic inflammatory response and has a very negative effect on the patient's health.
If we look at terminology, then the diagnosis of sepsis in Greek means "rotting". Regardless of the clinical and etiopathogenetic form of sepsis, the clinical picture of the disease progresses rapidly and under no circumstances can result in spontaneous recovery. Even with the use of modern methods of treatment, sepsis of blood is characterized by a high level of mortality and has an unfavorable prognosis regarding recovery.
It should be taken into account that the development of sepsis in humans in most situations does not depend on the concentration or pathogenicity of the virus and there is a direct correlation between the activity of the septic process and the function of the human immune system. So, the same type of pathogen in a person with sufficient work of the immune system provokes the development of a short-term limited inflammatory process, and in individuals with immunodeficiency becomes the cause of sepsis development.
A special risk group for the development of sepsis is the patients in the postoperative period, as well as those who are on immunosuppressive drug therapy. In addition, as a provoker of the development of sepsis should be considered the entry of microorganisms during catheterization of the vein. Separate consideration deserves such a form of the disease as acute sepsis that occurs in the postpartum and post-abortion period, which develops as a result of getting an infectious agent into the woman's organism through the open wound surface of the uterus.
Depending on the etiopathogenesis, the source of infection, the localization of the primary infectious focus, the activity of increasing clinical symptoms, there are various forms of sepsis, each of which must necessarily be diagnosed.
Causes of sepsis
Sepsis in an adult patient or child develops as a result of massive infection with toxins and products of putrefactive destruction of pathogenic microorganisms, when applying an inadequate treatment regimen for the underlying disease, that is, specialists consider this pathology as generalization of the inflammatory process. The diagnosis of "sepsis" is an extremely dangerous condition for a person, which often ends in a fatal outcome.
Even in spite of the rapid development of the pharmaceutical industry and the introduction of new technologies in the treatment of infectious diseases, infectious sepsis is an urgent medical and social problem. In the treatment of sepsis, various highly active antibacterial drugs of the latest generation are used and, at the same time, this pathology is the leading cause of death in infectious patients.
Among the main etiopathogenetic agents of sepsis development, bacterial cocci flora, Pseudomonas aeruginosa, fungi, viruses and protozoa should be considered. The pathogenesis of sepsis develops when a combination of such links as: ingestion of an active agent of infection in the human body, a prolonged course of the inflammatory process in the primary focus of infection and increased individual reactivity of the human body.
The risk of provoking sepsis increases significantly with a high concentration of the pathogen in the primary inflammatory focus, after which a large mass of viral particles or bacterial flora enters the total blood flow. Of no small importance is the state of individual resistance of the patient's body, which can be significantly suppressed as a result of various adverse factors. As a negative factor provoking the suppression of the human immune system, severe somatic pathology, endocrine disorders, oncopathology, changes in the qualitative and quantitative composition of the blood, immunological disorders, chronic vitamin deficiency, psychoemotional stress and prolonged use of drugs of the immunosuppressive and corticosteroid groups should be considered.
The main link in the pathogenesis of the development of sepsis is the spread of infectious agents from the primary inflammatory foci through the blood and lymphatic reservoirs with the subsequent formation of secondary septic metastases, which also increase the inflammation process. The pathomorphological substrate of sepsis is the formation of a variety of ulcers of different localization.
The development of generalization of the infectious process in the course of sepsis is caused by the prevalence of the toxic effect of the pathogen on the organism over the bacteriostatic properties of the immune defense factors. The development of sepsis is possible not only with massive disruption of immunity, but even with the disruption of the work of any link in the work of the human immune system, which is accompanied by a violation of antibody production, a decrease in phagocytic activity of macrophages, and suppression of lymphocyte activity.
Classification of sepsis
In most situations of sepsis development, the primary focus of the inflammatory process is known, except for wound sepsis, which is also quite common. All etiopathogenetic variants of sepsis develop against the backdrop of reduced work of the human immune apparatus, due to which favorable conditions are created for the dissemination of the pathogen.
Separation of sepsis into various forms is made by specialists on the basis of available anamnestic data. Thus, depending on the origin of the primary inflammatory focus of infection, a variety of forms of sepsis are distinguished. In surgical sepsis, the primary infectious focus is a suppuration wound or limited abscesses. Obstetrical and gynecological sepsis develops when technology and sanitary norms are violated during delivery or medical abortion, so that the wound surface of the uterus is a favorable surface for the propagation of infectious agents. Urologic purulent sepsis occurs in patients with chronic urinary retention, accompanied by the development of changes in the inflammatory nature. To rare etiopathogenetic forms of sepsis are rhinogenous, otogenous and tonsilogenous, in which the gate of infection is located in the ENT organs.
Depending on the pathogenetic mechanisms of the development of sepsis, a septicemic form of the disease is distinguished, in which metastatic foci of purulent infection are not formed, and septicopyemic, characterized by the generalization of the pathological process by the deep spread of infection.
Considering the intensity of the increase in clinical and laboratory markers of sepsis, this pathology can occur in a lightning (several days), acute (up to one week), subacute (less than 6 weeks) and chronic (more than 6 weeks) form. Chronic sepsis belongs to the category of rare infectious pathologies prone to frequent recurrence.
Symptoms and signs of sepsis
The course of sepsis may be accompanied by the development of polymorphic clinical symptoms, the manifestations of which often simulate the clinical picture of other diseases and pathological conditions. The erased clinical picture of sepsis in most situations is due to the use of intensive antibiotic therapy, which, unfortunately, is not accompanied by a total death of the pathogen. Atypical clinical picture of sepsis in this situation is the development of pathogenesis of the disease with an unexpressed pyretic reaction. The main pathognomonic clinical marker of sepsis is hectic fever, accompanied by excessive sweating, spasmodic pulse and arterial pressure, chills and headache, general weakness, vomiting and diarrhea, loss of appetite, dehydration and rapid weight loss.
In an objective examination of a patient suffering from sepsis, attention is drawn to the earthy coloring of the skin with a decrease in its elasticity and turgor, as well as the presence of common subcutaneous phlegmon and abscesses.
Sepsis in children at early stages of development provokes disturbances of the psychoemotional state, up to the formation of crude neurologic symptoms and profound disturbance of consciousness. Chronic sepsis provokes the development of slow-progressive multiorgan failure with the appearance of characteristic pathomorphological changes in various internal organs.
Clinical criteria for the onset of DIC syndrome, as the most common variant of the complicated course of sepsis, is the appearance of a profuse rash of hemorrhagic nature, nonspecific disseminated myalgia, respiratory disorders, as an indirect sign of interstitial pulmonary edema .
Clinical criterion for the change of the pathogen in sepsis is a sharp deterioration of the condition, manifested by a rapid rise in body temperature, chills, increasing leukocytosis. Often, such changes accompany the septicopyemic cavity.
Diagnosis of sepsis
The diagnosis of "sepsis" at the pre-laboratory stage becomes possible provided that the patient's clinical symptomatology is adequately assessed, provided that it is typical. In addition, one should take into account the anamnestic data that preceded the development of the clinical picture of sepsis (postoperative period, injury and severe forms of the infectious disease).
When evaluating the results of the hemogram of a patient suffering from sepsis, a pronounced leukocytosis with an explicit stab-shift shift of the formula to the left against the background of absolute thrombocytopenia attracts attention. To identify the causative agent of sepsis, a bacteriological study of its blood culture should be applied, which should be performed three times at intervals of one hour before the use of antibacterial drugs.
Assessing the severity of the condition of a patient suffering from any etiopathogenetic form of sepsis, one should first take into account his individual "systemic inflammatory response", which is a systemic reaction of the body to the effect of an active infectious agent. A distinctive feature of sepsis in this situation is the generalization of the pathological inflammatory process with a tendency to develop multiple restricted inflammatory foci.
As instrumental additional methods of visualization of sepsis, various methods of radiation diagnosis in the form of radiography, ultrasound and computed tomography should be used. So, when septic manifestations are localized in the bone tissue, the patient develops x-ray signs of osteomyelitis in the form of development of limited or extended areas of bone destruction. In the case of multiple organ inflammation, the inflammatory and infectious process sepsis is diagnosed fairly quickly on ultrasound and tomographic scans in the form of skin signs of intra-abdominal and intrathoracic abscesses, unlimited infiltrates.
In severe sepsis, the patient has signs of cardiovascular failure in the form of hypotension and hypoperfusion. Biochemical laboratory disorders occur, as a rule, in the terminal stage of sepsis and are a reflection of multiple organ failure.
Treatment of sepsis
Determination of the volume and specificity of therapy for sepsis should be made on the basis of features of the pathogenesis of the development of the disease. The main link in the therapy of sepsis is the use of various techniques that stop the manifestation of DIC syndrome and prevent the further spread of infectious and inflammatory agents throughout the body. All patients in whom the course of the clinical picture of the underlying disease is complicated by the development of sepsis, are subject to immediate hospitalization in the intensive care ward of the intensive care unit, as the course of this pathology is extremely aggressive and prone to lightning-fast development of the lethal outcome. When untimely use of drugs of pathogenetic significance, sepsis can be complicated by hemorrhage to the adrenal glands, gangrene of the extremities, irreversible changes in the internal organs.
After the rapid method of determining the sensitivity of the pathogen of infection, it is necessary to begin immediately massive antibacterial therapy in the maximum admissible doses of the drug. With the existing clinical and laboratory signs of DIC syndrome, it is justified to conduct active plasmapheresis, for which the patient is withdrawn 1.5 l of plasma and intravenously injected about 1 l of fresh frozen plasma. Severe sepsis is the basis for increasing the volume of fresh frozen frozen plasma, but not more than two liters. The conduct of plasmapheresis must be combined with heparin therapy (the daily dose for an adult is 40,000 units). The preferred way to administer Heparin in this situation is parenteral.
When developing a patient suffering from sepsis, hypotension should use drugs of the sympathomimetic group, however, with pronounced hypotension, the first-line drug is Prednisolone once. Prolonged reception of corticosteroid therapy is extremely unfavorable for sepsis, with the exception of the existing hemorrhage in the adrenal glands. The presence in the patient of signs of arterial hypotension is not a contraindication for carrying out plasmapheresis, however, the volume of fresh frozen frozen plasma should be reduced to 500 ml.
In most situations it is not possible to carry out an emergency analysis of flora sensitivity to different groups of antibacterial drugs, therefore, it is necessary to conduct so-called empirical antibacterial therapy consisting of a combination of Gentamycin in a daily dose of 160 mg and Cephaloridine in a daily dose of 4 g with a preferred parenteral route of administration. Objective criteria that testify to the effectiveness of antibiotic therapy are improvement of the subjective state of the patient, stabilization of hemodynamic disorders, a decrease in body temperature, the disappearance of chills, a decrease in the intensity of the rash. The laboratory criteria for the positive efficacy of antibacterial treatment is the reduction in the concentration of stab elements and, in general, the elimination of inflammatory parameters.
In a situation where the causative agent of sepsis is anaerobic flora, the drug of choice is Metronidazole 500 mg per day, and with fungal infection - Fluconazole at a daily dose of 200 mg. In order to improve the performance of the patient's immune apparatus, it is advisable to use Immunoglobulin with the preferred intravenous administration.
In order to restore adequate perfusion, normalize the cellular metabolism, correct homeostasis disorders, reduce the concentration of inflammatory mediators and toxic metabolites, it is necessary to begin infusion therapy involving the use of crystalloid and colloidal solutions from the first hours of the patient's stay in the hospital. Correction of a pronounced circulating blood volume deficit is achieved by the use of dextrans, hydroxyethyl starch.
Complications and consequences of sepsis
In generalized sepsis, the patient develops primarily hemodynamic and respiratory complications due to a sharp fall in PaO2 and an increase in the permeability of the air-blood barrier. The result of the above changes is the sweating of the liquid component into the alveoli, provoking a violation of the gas exchange function of the lungs. X-ray signs of development of shock lung is a progressive infiltration of pulmonary fields of bilateral localization, which is observed in almost 20% of patients with sepsis. Clinical symptoms of shock lung in sepsis are similar to those that develop with pneumonia of viral or pneumocystic nature.
With a sharp fall in the OPSS and a decrease in the volume of circulating blood, the pathogenesis of septic shock develops. Among the provocators of its development, mention should be made of the increased permeability of the vascular wall of the capillaries and the subsequent release of the liquid component from the vascular bed. Progression of septic shock, as a variant of complication of sepsis, is observed during dehydration, which is typical for most background infections. In the onset of septic shock, the patient does not have cardiac output impairment or there is a compensatory increase, which allows differential diagnosis with cardiogenic, obstructive and hypovolemic shock .
Hemodynamic disorders in septic shock debut after one day and consist in the development of an increase in the end-diastolic and end-systolic volume with a decrease in the ejection fraction. The development of the lethal outcome of septic shock is more likely not from hemodynamic disorders, but from multiple organ failure.
The negative effect of sepsis is also on the kidneys, which is manifested laboratoryally by oliguria, azotemia, proteinuria and cylindruria. Development of renal failure in sepsis occurs as a result of damage to the renal capillaries and tubular necrosis. In some patients, against the background of sepsis, development of glomerulonephritis, interstitial nephritis, cortical necrosis of the kidneys is noted.
In 50% of cases of sepsis, there is a development of various blood clotting disorders caused by thrombocytopenia, which is the main provocative factor in the development of DIC syndrome.
Chronic sepsis is complicated, as a rule, by polyneuropathy, the establishment of which becomes possible only after the application of electrophysiological methods of investigation. The appearance of the symptomatology of polyneuropathy in a patient with sepsis requires differentiation with Guillain-Barre syndrome , metabolic disorders and toxic damage to the nervous system.
Prevention of sepsis
The basic link in preventing the development of sepsis is the timely diagnosis of infectious and inflammatory processes in the human body and the appointment of an adequate therapy. Selection of therapy should be based primarily on the etiologic factor of infection, which becomes possible with the analysis of the sensitivity of the flora. The treating specialists must necessarily conduct explanatory work on the dangers of self-treatment and the need for timely detection of infectious and other inflammatory processes occurring in the body.
When managing a patient who suffers from even a limited purulent inflammatory process ( panaritium , furuncle ), it should be borne in mind that he is a potential patient for the development of sepsis. In this regard, surgical treatment of the patient should be supported by the appointment of medicamental anti-inflammatory and antimicrobial therapy. At the initial examination of the patient, who was admitted to the reception due to the existing wound surface on the skin, the treating physician should pay special attention to the issues of primary surgical treatment with observance of all sanitary and hygienic standards of aseptic and antiseptic.
In view of the increased incidence of postpartum and postabortion sepsis in the morbidity structure of this pathology, increased attention of gynecologists should be paid to the issues of compliance with sanitary standards in the operating room. In addition, it is necessary to exclude the possibility of conducting medical abortion outside the medical institution.
As a prophylaxis for the development of otogenic and tonsilogenic sepsis, it is necessary to conduct regular sanation of the oral cavity and the auricles. Patients who have impaired the function of the immune apparatus, it is necessary to take prophylactic courses for immunostimulants of plant origin, since these persons are classified as a risk for the development of sepsis.
? Sepsis - which doctor will help ? If there is or suspected development of sepsis, you should immediately seek advice from such doctors as an infectious disease specialist, a surgeon, a hematologist.