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Sepsis

There is no universally accepted terminology and classification of sepsis. In recent years, the terms "septicemia", "bacteremia", "septic conditions", "purulent-septic disease", which often have a different meaning and mix the concepts of "infection" and "generalization of infection", have become widespread.

Sepsis, as a rule, occurs in the presence of a purulent focus and develops as a result of the depletion of anti-infective immunity.

Obstetric sepsis most often occurs due to infection in the uterus during childbirth or in the postpartum period. A certain role is played by infection of the remains of placental tissue and blood clots. The spread of infection is possible through hematogenous and lymphogenous routes. This is facilitated by the presence of chronic or acute extragenital inflammatory diseases during pregnancy and childbirth, infection during labor (prolonged labor, prolonged anhydrous period, birth injury, delayed parts of the placenta in the uterus).

The course of sepsis depends not only on the response of the macroorganism, which is mainly determined by the properties of the immune defense, but also on the nature of the pathogen. The predominance of staphylococcus has led to a more torpid course of the pathological process with a tendency to damage many internal organs, resistance to antibiotic therapy. Sepsis caused by gram-negative flora is often complicated by toxic toxic shock. Optional anaerobes and bacteroids as causative agents of postpartum sepsis often affect the hepatobiliary system, kidneys, and cause hemolysis. Adenoviral sepsis is characterized by a blockade of the woman’s immune system, which leads to a rapid course, the absence of a protective inflammatory reaction in the tissues and damage to internal organs. Mortality is difficult to establish. On average, it is about 15-30%.

The diagnosis is based on three signs: the presence of a primary purulent focus, high fever, the detection of the pathogen in the blood. The latter symptom is not necessary, while the presence of the primary purulent focus should always be taken into account when substantiating the diagnosis. The diagnosis is confirmed by the detection of signs of multiple organ failure.

Sepsis after childbirth and abortion is clinically manifested by septicemia or septicopyemia.

Septicemia is the presence of bacteria and their toxins in the bloodstream and throughout the body that periodically (wave-like) enter the general blood stream either from a wound or from disturbed microcirculation zones, where blood flow is sharply slowed.

The clinical picture and diagnosis. The clinical picture appears as a typical and atypical form. In a typical form, high body temperature (up to 40–41 ° C), repeated chills, rapidly increasing intoxication, causing impaired consciousness are observed: inhibition is first observed, then delirium intoxication. At the same time, pronounced tachycardia, tachypnea, cyanosis, arterial hypotension, oliguria, proteinuria are observed. Central venous pressure is increased, on the ECG there are signs of overload of the right heart. The hemogram is characterized by high leukocytosis and ESR, a neutrophilic shift in the blood count, and increasing anemia. Rarely, leukopenia can be observed, which usually indicates a severe course of the disease.

As a rule, in patients with septicemia, pallor of the skin with an icteric shade, cyanosis of the lips and nails are noted. Often the patient has a petechial rash on the conjunctiva of the eyes, skin of the abdomen and back, frequent loose stools, hyponatremia, hypo- and dysproteinemia, carbohydrate metabolism changes, as evidenced by moderate hypoglycemia. The response to glucose loading remains within the normal range, the shape of the glycemic curve is not changed.

In some cases (atypical form) with septicemia, a gradual increase in body temperature, single bouts of chills, significant changes in body temperature during the day are observed.

Patients with septicemia are characterized by a relatively rapid decrease in body temperature and an improvement in general condition against the background of intensive, correctly selected complex therapy. The exception is patients with fulminant sepsis, proceeding as an infectious toxic shock.

Septicopyemia most often begins on the 6th-9th day after childbirth.

The clinical picture and diagnosis. Body temperature rises to 40 ° C, repeated chills are noted. The general condition of patients is severe: adynamia, weakness, inhibited or agitated state. The skin is pale, cyanosis of visible mucous membranes, pain in the muscles and joints are observed. Patients develop heart failure, manifested by tachycardia (120-130 beats / min), tachypnea (26-30 breaths per 1 min), deaf heart tones. Blood pressure, as a rule, decreases, the hemogram is characterized by moderate leukocytosis (10-1b-109 / l). In some patients, the white blood cell count ranges from 3-109 / l to 5-109 / l, i.e. there is leukopenia. In patients with septic copy, a neutrophilic shift in the blood formula is noted, ESR is increased to 40–65 mm / h, anemia may develop. With purulent metastases, a worsening of the hemogram is noted.

Along with general intoxication, there is a syndrome of multiple organ and polysystemic insufficiency (uterus, lungs, kidneys, liver). The apparent multiplicity of the lesion is the most characteristic manifestation of septicopyemia.

A sharp decrease in the level of protein is observed, the content of albumin decreases, the number of globulins increases. Most patients have impaired carbohydrate metabolism, which is expressed in the development of hypoglycemia. Significant changes are observed in the functional state of the adrenal cortex. Septicopyemia occurs against a background of decreased glucocorticoid function of the adrenal cortex. In the acute period of the disease, ACTH production increases 3.5 times, which is typical for a stressful state. However, despite the increase in ACTH production, the content of total and associated oxycorticosteroids is not only not increased, but, on the contrary, reduced.

The appearance of secondary purulent foci is accompanied by increased fever, intoxication. Most often, secondary purulent foci are formed in the lungs, kidneys, liver, meninges, and brain. We must not forget that the appearance of microorganisms in the patient’s blood is a temporary condition, and purulent metastases can form even when pathogens that enter the bloodstream are destroyed. The causes of purulent metastases are still unknown, but one circumstance should be borne in mind: this is a critical level of contamination. The accumulation of a certain number of microorganisms in the primary focus contributes to the development of sepsis, and their repeated accumulation in the purulent focus reduces the possibility of immune defense and becomes one of the reasons for the penetration of microorganisms into the bloodstream and the formation of purulent metastases.

Treatment. For the successful treatment of sepsis, the primary focus should be affected. In obstetric sepsis, the primary focus is primarily an inflammatory uterus (endometritis); other localization is also possible - purulent processes in the kidneys, mammary glands, perineal abscesses, post-injection abscesses.

If the primary focus of infection is in the uterus, then several treatment options are possible. If residues of the placenta or accumulation of organized blood clots in the uterine cavity are detected, which is detected by ultrasound scanning, hysteroscopy, or on the basis of clinical data, their curette removal is indicated.
In the absence of contents in the uterine cavity, it should be washed with a cooled antiseptic solution using a double-lumen catheter.

In some cases, it is necessary to decide the question of hysterectomy. It is indicated for peritonitis after cesarean section, for infectious toxic shock and sepsis with renal hepatic insufficiency in case of ineffective conservative therapy. Removal of the uterus is also indicated for necrotic endometritis.

If the primary focus is a purulent process in the mammary glands (mastitis), an abscess of the perineum, a post-injection abscess, then surgical intervention with the evacuation of pus, excision of necrotic tissue is indicated. In case of severe recurrent mastitis with intoxication, insufficient effectiveness of intensive therapy, lactation should be stopped by prescribing parlodel.

Along with exposure to the focus of infection, it is necessary to start complex antibacterial, infusion-transfusion, restorative, desensitizing, immunocorrective, symptomatic, hormonal therapy.

Particular attention and improvement requires antibiotic treatment. In this case, it is necessary to determine the sensitivity of microorganisms to them. However, in the absence of conditions for identifying the pathogen and determining its sensitivity to antibiotics (which is very common), treatment should be started as early as possible and broad-spectrum drugs should be prescribed.

Antibiotic treatment for sepsis lasts for 14-20 days, and in some cases, much longer. Their use can be completed 2-3 days after normalization of body temperature. With sepsis, more often than with other forms of postpartum purulent-septic infection, several antibiotics are justified in accordance with the characteristics of their spectrum and mechanism of action. Microbiological examination of blood, urine, uterine cavity contents, pathological material from metastatic foci and determination of sensitivity to antibiotics must be repeated to monitor the effectiveness of treatment.

At the first stage of treatment, combinations of 2-3 drugs are used. You can use cephalosporins of the third and fourth generations (fortum, longoceph, cefmetazone), which have a super-wide spectrum of antimicrobial action or combinations of semisynthetic penicillins - ampicillin, unazine, achementin or cephalosporins of the first and second generations (kefzol, cefamal and others). aminoglycosides and metronidazole for parenteral use or clindamycin.

At the second stage of treatment, after isolating the pathogen and determining its sensitivity to antibiotics, if necessary, antibiotic therapy is adjusted.

To increase the effectiveness of antibiotic therapy and suppress the resistance of microorganisms, especially with cross-resistance, they are combined with sulfonamide and antiseptic drugs of the nitrofuran series (furazolidone, solafur, furazolin).

In the treatment of broad-spectrum antibiotics, as a result of the development of dysbiosis, conditions are created for the occurrence of superinfection caused by a protein, Pseudomonas aeruginosa, and staphylococci. The latter is manifested by enterocolitis, intestinal toxicoinfection, pneumonia. A major role is played by superinfection caused by fungi (Candida albicans). The clinical manifestations of candidiasis are diverse - from skin candidiasis to mycotic pneumonia and candidal sepsis.

For the prevention of these complications, drugs that have both antibacterial and antifungal effects (enteroseptol, mexform, 5-NOC) should be used. They are prescribed in combination with high doses of levorin or nystatin.

Sulfanilamide preparations for the treatment of patients with sepsis do not have independent significance and can be prescribed for an allergic reaction to penicillin-type antibiotics in combination with bacteriostatic antibiotics (tetracycline, macrolides, levomycetin, fusidine).

To increase the specific and non-specific immunobiological reactivity of the body, patients from the first days of treatment are transfused with hyperimmune antistaphylococcal plasma at a dose of 100 ml after 2 days. Intramuscularly administered anti-staphylococcal gamma globulin 5 ml daily (for a course of 6 to 10 doses). For the purpose of non-specific immunotherapy, freshly frozen plasma is transfused, and biogenic stimulants (levamisole) are also prescribed.

Infusion-transfusion therapy is aimed at maintaining the volume of circulating blood, eliminating anemia, hypoproteinemia, correction of violations of the water-electrolyte and acid-base state, hemostasis. Isovolemic hemodilution is carried out under the control of colloid osmotic pressure (COD) in combination with diuresis stimulation. In the composition of hydration therapy, the ratio between colloids and crystalloids in the first 6 days is 2: 1, then for 6 days - 1: 1, in the following - 1: 1.5. In order to eliminate acute hypoproteinemia and hypoalbuminemia, solutions of plasma, protein and albumin are used. In addition, to increase the CODE use solutions of polyglucin, reopoliglukin, hemodesis and gelatin. The low COD values ​​for sepsis are explained not only by increased permeability of the vascular wall and insufficient lymphatic return of the protein to the vascular bed, but also by the imbalance between protein synthesis and breakdown and the development of so-called septic autocannibalism.

The complex treatment of patients also includes digitalization, heparin therapy (up to 20,000 units / day), antiplatelet agents (trental, xanthinol nicotinate), antipyretics, protease inhibitors (gordox), saluretics, vitamins. With pneumonia, the general principles of treating respiratory failure are observed.

Fortifying therapy consists of many elements: good care, high-grade high-calorie nutrition with a high content of vitamins, the use of anabolic steroid hormones, additional vitamin therapy, and parenteral nutrition.

With sepsis, as a rule, there is a need for treatment with corticosteroid hormones in connection with the appearance of allergic reactions. Prednisone or hydrocortisone is best used under the control of hormone levels. However, you can focus on clinical data. Most important in this regard is the level of blood pressure. With a tendency to arterial hypotension, the administration of corticosteroid hormones is especially important for the prevention of the development of toxic toxic shock.

In complex treatment, it is necessary to include desensitizing antihistamines such as suprastin, diprazine. Their purpose helps prevent the development of anaphylactic shock. The purpose of sedatives is shown: valerian, motherwort, etc. We should not forget about the conduct of symptomatic therapy (painkillers and antispasmodic drugs).

With the development of empyema of the lungs or pleura, kidney carbuncle, liver abscess, purulent meningoencephalitis, septic endocarditis, patients need specialized help. Treatment of patients with sepsis should be carried out in the department of a multidisciplinary hospital, where the opportunity for the participation of specialists from related medical disciplines is provided.

In recent years, methods of lymph and hemosorption, plasmapheresis, endolymphatic administration of antibiotics and ultrafiltration have become widespread. But they have both positive and negative sides and are used only in specialized hospitals.
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Sepsis

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