Published on

1 Like
  • Be the first to comment

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide


  1. 1. SEPSIS Sepsis is generalized infection, which forwards by bacteremia on lowering of protective forces of organism. This problem is not only surgical, but also generally biological, because during the last years the new approaches appeared to understanding of its pathogenesis. They are in the new interpretation of general mechanisms of violation of homeostasis and inflammation. The frequency of sepsis does not fall down though the huge antibacterial therapy is used. 75000 patients die yearly in Germany. 50000 cases registered in the USA every year. Mortality consist 30-80%. Home statistics is absent to great regret.
  2. 2. TERMINOLOGY <ul><li>The researches of the last years showed that a great number of gangrenous tissues (pancreatonecrosis, polytrauma, burns) are capable to change the bacteriums in quality of starting mechanism of the generalized reaction of the organism. </li></ul><ul><li>Clinically this stage is impossible to identification from bacteremia. </li></ul><ul><li>At the coordinate conference of 1991 it was offered the term – syndrome of systematized inflammatory answer (SSIA). </li></ul><ul><li>This syndrome is caused by the microbial infection determines as sepsis. </li></ul>
  3. 3. <ul><li>The most important achievement, which changed a conception in pathogenesis of sepsis, was opening of number of powerful mediators of systematical inflammatory reaction. </li></ul><ul><li>It is informed that the starting moment in pathogenesis of sepsis is fat-polysaccharide LPS of bacterium’s membranes, in many cases, gram-negative. It is determined as endogenous toxin. That’s why reptodoglipans and teynon acid play the main role in gram-positive sepsis. They surround membrane of the gram-positive bacteriums. On the answer of the action of endogenous toxin the organism produces a great number of inflammation mediators, which bring on the system answer hitting into general blood flow. These matters – are mediators of sepsis one united under one name – cytokines. </li></ul><ul><li>Today it’s known about 40 such matters. The most significance among them has: swelling necrosis factor, interleukins 1, 6, 8. </li></ul>
  4. 4. <ul><li>The considerable role in the pathogenesis of gram-negative sepsis plays the factor of activation of thrombocytes. This phospholipid leads to the freeing of considerable amount of cytokines. </li></ul><ul><li>The last stimulate production of prostaglandin, free of radicals, oxide nitrogen, which changes in membrane and in the cell’s nucleus. </li></ul><ul><li>If unspecific immune reaction gets along with above-mentioned action, this so-called, mediate phase is bought. </li></ul><ul><li>If no, the process goes into the phase of immune-paralysis and the final phase. </li></ul><ul><li>Clinically it is displayed by syndrome of poly-organ insufficiency and septic shock. </li></ul>
  5. 5. The phases of the development of the generalized infection Local inflectional focus Purulent resorptive fever Recovery Syndrome of the systematic inflammatory answer Septicemia Lethal result Chronic sepsis Septicopyemia 1. 2. 3. 4. 5.
  6. 6. In according to coordinate conference on sepsis (Chicago, 1992) the development of sepsis is interpreted something otherwise: Local focus of infection Syndrome on the systematic inflammatory answer Sepsis Difficult (heavy) sepsis Septic shock Poly-organ insufficiency Lethal result (fatal termination)
  7. 7. CLASSIFICATION <ul><li>There is the primary and secondary sepsis. The primary or cryptogenetic is appeared under the lack of fixed primary focus. The secondary is appeared on the background of primary purulent focus. </li></ul>
  8. 8. CLASSIFICATION <ul><li>On localization of primary focus contradistinguish: </li></ul><ul><li>Surgical; </li></ul><ul><li>Obstetric-gynecological; </li></ul><ul><li>Urologic; </li></ul><ul><li>Otogenous; </li></ul><ul><li>Oral and others. </li></ul>
  9. 9. CLASSIFICATION <ul><li>For exciter appearance: </li></ul><ul><li>Gram-positive (staphylococcal, streptococcal); </li></ul><ul><li>Gram-negative (intestinal, pyocyanogenetic, proteus); </li></ul><ul><li>Anaerobic (clostridium and an clostridium). </li></ul><ul><li>For the phases of development: </li></ul><ul><li>Elementary (primary) phase (toxemia, toxicemia, toxicohemia, toxinemia); </li></ul><ul><li>Septicemia (bacterioemia without purulent metastases); </li></ul><ul><li>Septicopyemia (bacterioemia with metastases). </li></ul>
  10. 10. CLASSIFICATION <ul><li>For clinical: </li></ul><ul><li>Lightning; </li></ul><ul><li>Acute; </li></ul><ul><li>Sub-acute; </li></ul><ul><li>Chronic; </li></ul><ul><li>Septic shock. </li></ul>
  11. 11. <ul><li>The dimensions and disposition of the primary focus have the certain importance in the development of disease. More frequently this is on the background of purulent surgical diseases or vast wounds, ordinary with crush and necrosis of soft tissues frequently after insufficiently radical surgical treatment. </li></ul><ul><li>During the last years the cases of the beginning of sepsis are established after various invasiveness procedures: catheterization of the vessels, operations with the use of apparatus of vasomotor system, prosthetics of valves, etc. </li></ul><ul><li>These complications, which arise by reason of hospital procedures, were accorded name “nazokomial hospital sepsis” or “disease of medical progress”. </li></ul><ul><li>Some immunologists and physicians consider that sepsis is developed in those cases when the immune-deficiency states arise until the invasion of microorganisms into focus (AIDS, the drug habit, diabetes, cancer). </li></ul>
  12. 12. CLINIC <ul><li>The basic complaints are feeling of heat and fever, associated with high temperature. During sepsis with metastases is observed, more frequently high-fever heat, during the sepsis without metastases sweeps of the temperature is less than 1° C. Besides a general weakness, the loss of appetite, insomnia, sometimes - diarrhea disturb. Some patients have euphoria; some are found into state of prostration. </li></ul>
  13. 13. Objectively: <ul><li>The skin is of earthily gray color, with icterychnum hue, sometimes there is petechia break out. Tachycardia, hypotension, frequent breathing, sometimes – the wheezes are missed. Augmentation size of liver and spleen are. During the sepsis with metastases there are the second purulent focuses. The primary focus is determined by the pallor of granulations, the delay of necrosis of tissue, scantiness of secret, which is of putrefactive – hemorrhagic character. </li></ul>
  14. 14. DIAGNOSTIC <ul><li>The laboratory markers of sepsis are: </li></ul><ul><li>The progressing anemia; </li></ul><ul><li>Leukocytosis and deviation of the differential count to the left. Lymphopenia – is prognostic unfavorable sign; </li></ul><ul><li>Augmentation of intoxication indexes (differential blood index of intoxication, the level of middle molecules); </li></ul><ul><li>T-lymphocytopenia; </li></ul><ul><li>Thrombocytopenia; </li></ul><ul><li>Elevation of erythrocyte sedimentation rate; </li></ul><ul><li>The fall of the level of inorganic phosphor more than 30% brings the depression of the phagocytic bactericidal activity of granulocytes; </li></ul><ul><li>The growth of the level of tsytokines that testily about the progressing pathologies. </li></ul>
  15. 15. The PGD-syndrome includes: <ul><li>Respirator distress-syndrome. </li></ul><ul><li>Acute renal insufficiency. </li></ul><ul><li>Acute hepatic insufficiency. </li></ul><ul><li>Syndrome of disseminated intravascular coagulation (DIC). </li></ul><ul><li>Violation of the function of central nervous system. </li></ul>
  16. 16. CURE PRINCIPLES <ul><li>Timely (right) diagnosis (take into account not only clinical indexes but such criteria as acid-basic equilibrium, water-electrolyte balance, activity indexes of the inflammatory process and degree of oppression of the immune system). </li></ul><ul><li>Cure (treatment) in the department of the intensive therapy. </li></ul><ul><li>Radical surgical hearth treatment (adequate drainage, timely closing). </li></ul><ul><li>Adequate antibacterial therapy. It is necessary to take empiric antibacterial therapy before the identification of stimulus, taking into account the focus of infection, the state of kidneys, liver, the immune system. </li></ul>
  17. 17. <ul><li>5. Antitsitokinotherapy. Got and made the approbation the specific monoclonial antibodies to endotoxin LPS. </li></ul><ul><li>The antibodies to the factor of tumors of swelling are elaborated. </li></ul><ul><li>For blocking of tsitokines it is regarded the perspective the use of ibuprophenum and trental (pentoxifillin), which brake the formation of the factor of tumors of swelling and predecessors of violation of the vascular perspicacity of the lungs. It is perspective is the use of preparation interleikin-2 – roncoleikin. </li></ul>CURE PRINCIPLES
  18. 18. CURE PRINCIPLES <ul><li>Detoxication, which induces therapy in volume 3 – 6 litres for day, the amount of shown out liquid more than 1000 ml, forced diuresis (urine excretion) and the methods extra corporal detoxication, among which the priority has plazmapharez and limphosorbtion. </li></ul><ul><li>Immunocorrection depends on diagnostics displacements in the immune system. It is better to make hemotransfusion, transfusion of native and hiperimmune plasmadestination of the preparations of thymus and gamma globulins. </li></ul><ul><li>The feeding questions take an important place. Especially the early enteral feeding, which improves the bloody circulation in abdominal cavity, liver, mucous of the stomach, warns acidosis. An important role in the stimulation of the immune system of the bowels plays feeding in small intestinum. </li></ul>
  19. 19. <ul><li>9. Hormonal therapy. </li></ul><ul><li>Corticosteroids used in the threat of septic shock and also in the augmentation of amount of T-killers and T-supressors. </li></ul><ul><li>10. The correction of the system of blood coagulation. </li></ul><ul><li>Heparin or lower-molecules heparins (fraxiparin, calciparin, lavenox); desagrigents (aspirin, tiklid); proteases inhibitors (kontrikal, trasilol, gordox) are used. </li></ul>CURE PRINCIPLES