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An objective assessment of the severity of a patient with a systemic inflammatory response syndrome and sepsis

An objective assessment of the condition of the victim, which is necessary to draw up an adequate treatment program, as well as to evaluate the effectiveness of certain drugs or methods of therapy, is largely hampered by the complex nature of the surgical infection, the multiple aspects of the intensive care, and various surgical interventions. In this regard, many systems and scales have been developed, the assessment of which is given in the form of an integral score. All of them, as a rule, are focused on the final outcome of the process, that is, they are created on the principle of “survived - died”. Basically, such systems are more effective for predicting a fatal outcome than a favorable one [2, 22, 30, 45]. They can be used for the mass arrival of the wounded, but it is extremely doubtful their use to determine the therapeutic tactics of a particular patient at a particular time [12], which is the main tactical task in the practice of a clinician.

In 1980, DEFry et al. [17] showed that death after extensive surgical interventions or severe injuries usually occurs as a result of infectious complications and the probability of it is higher the more organs with developed insufficiency. In 1983, LE Stevens [44] proposed a technique for determining the severity of a condition by calculating individual scores for a specific organ or system. He identified seven major organs and systems for which a functional assessment was made: lungs. kidneys, liver, gastrointestinal tract, central nervous system, blood coagulation system, cardiovascular system. In each of these systems, five gradations of disorders were identified - from minimum to maximum.

So, for example, to assess liver function with an elevated level of lactate dehydrogenase and aspartate aminotransferase, but with normal bilirubin, 1 point was assigned. Five points were assigned when the patient developed precoma and the bilirubin level exceeded 8.0 mg / 100 ml.

To calculate the severity of the patient's condition, it was necessary to compare his indicators with the control values ​​available on the scale, select the three maximum values, square them and sum them up. Such a calculation algorithm was based on the assumption that the sum of the squares approximately corresponded to the exponential dependence, which also corresponded to the mortality rate.

So, a fatal outcome developing in a patient without signs of functional organ failure is noted in 3% of cases, with functional insufficiency of one organ - in 30% and 100% - with insufficiency of four organs [18]. This scale has received the name “Sepsis Severity Score”, in abbreviated abbreviation - SSS. Studies have shown a reliable relationship between the mortality rate and the severity rating on this scale, which means - the more points, the higher the likelihood of death.

In 1985, T. Skau et al. [43] conducted a study on the effectiveness of using the SSS scale and proposed a number of modifications to eliminate the existing subjectivity in the gradations of this scale. The scale they proposed was called the “Modified Septic Severity Score,” or abbreviated as MSSS. Currently, it is often used in scientific research and publications on patients with sepsis [13. fifteen].

A slightly different approach to determining the severity of sepsis was proposed by EAElebute and HBStoner] 14]. These authors divided the clinical signs of sepsis into four groups. The severity of the process in each of the groups was evaluated in a point system. These groups:

- local manifestations of wound infection;

- degree of temperature reaction;

- secondary effects of sepsis;

- laboratory data.

The patient's condition was evaluated in each of the sections and the total total score was calculated. Subsequently, this assessment method was called “Sepsis Score”, in the abbreviation - SS. Studies of its effectiveness in determining the prognosis of outcome for patients with peritonitis, pneumonia, wound infection, septicemia and mediastenitis showed quite effective prognostic value - in 84% of cases, the prognosis of the lethal outcome of the infectious process was determined correctly.

All authors who used this scale draw attention to its certain subjectivity. So, if the need for dressings is not more than once a day, then 2 points are assigned, and if more than one - 4 points. The use of this scale by various researchers showed that, on average, the correct prognosis of fatal outcome was determined in 82–87% of cases.

The presented scales were based on the position that all patients (apart from cardiological and those who died as a result of “sudden death”) die, as a rule, from sepsis. Therefore, the process of dying is the dynamics of the septic process. Thus, by evaluating the dynamics of a process from one or another position (organ or local) in any way, it is possible to predict this or that outcome with a certain degree of probability.

From different positions approached in 1981, WA Knaus et al. [23], when they began to determine the severity of the condition of the patient who was in the intensive care unit from the first days of his stay. They selected 34 physiological indicators, which were ranked from 0 to 4 points depending on how far they were from the average physiological values. The final score was determined by summing all deviations. Subsequently, methods were applied to this scale, with the help of which the same scoring was made for the effect of chronic concomitant diseases and the patient's age. As a result, a technique for assessing the severity of the condition, called “Acute Physiology and Chronic Health Evaluation”, was created. The abbreviation from the first letters is widely used in the form of "ARASNE". The first studies on the new system showed its effectiveness in predicting the likelihood of deaths.

It should be emphasized that the described system was developed on the basis of the contingent of patients who were admitted to the intensive care and intensive care unit with acute pathology - trauma, acute surgical diseases, postoperative period, etc., so that the severity of the infection process was minimal in some cases although patients with a generalized inflammatory process probably still met [24-26).

It is all the more interesting to compare the effectiveness of this scale with the scales developed on the contingent of patients with sepsis and designed to evaluate this particular category of patients. In the work of JLMeakins et al. [28] in 1984, a study was conducted of the effectiveness of using this technique in patients with intra-abdominal purulent diseases (limited and widespread peritonitis, single and multiple abdominal abscesses). As a result of the studies, the authors conclude that the introduction of additional information about the nature of the purulent-inflammatory process in the abdominal cavity and its anatomical localization to the data of the ARACNE system did not lead to any significant changes in the prognosis efficiency.

Comparison of the effectiveness of evaluating the prognostic value in patients with generalized signs of infection by comparing two scales - SSS and APACNE showed that there is a close direct positive correlation between them (r = 0.81. P <0.001). Thus, the equally high prognostic value of both methods, their close correlation, despite a different approach to the formation of the initial array, are important evidence of the non-specificity of the generalized inflammatory reaction.

Subsequently, given the bulkiness of the system, the authors based on it created a new system - ARACNE II. in which 12 routine indicators were used, constantly monitored in patients in the intensive care unit. In the proposed system, the assessment of the patient's condition can vary from O to 71 points, but, as a rule, above 40 points is extremely rare. When the severity of the condition is 30 points, mortality is estimated at least 70%,

In domestic literature, the problem of an objective assessment of the severity of the condition of the victims is also given quite a lot of attention. An example is the development of Yu.N. Tsibin et al. [4] the so-called T-criterion, on the basis of which the duration of the shock period was estimated and, accordingly, the probability of a fatal outcome was predicted.

This method can only be attributed to some extent to assessing the severity of the condition, since it is based on the morphological “scoring of shock injury” and functional criteria - blood pressure, pulse, etc.

There are literature data on attempts to qualimetry a surgical infection [I], [3].
The system developed by A.V. Stolbov, as presented in the publication [3 |, is based on the widespread (mentioned above) scales SSS, MSSS, SS.

In our samples of systems for assessing the severity of the condition of the victims, three, from our point of view, important properties can be noted.

Firstly, these systems are intended for use in the mass admission of the wounded and sick. They can also be used with success for a comparative assessment of the effectiveness of new drugs and treatments. However, they are not intended to develop tactical programs in the treatment of specific patients requiring intensive care and, accordingly, to assess their effectiveness.

Secondly, no differences were found, but, on the contrary, a highly reliable correlation was noted between assessment systems created on the basis of a study of patients with local and generalized purulent-inflammatory processes, and between systems created without taking into account the specificity of patients, but only based on the severity of the pathological process, developing organ disorders and the need for intensive care.

Thirdly, the development of a dynamic assessment of the severity of the condition of a sick body should always be focused on specific tasks. Only then does it gain completeness and objectivity.

From the foregoing, it seems obvious that the task of creating a system for the dynamic assessment of the patient’s condition with generalized inflammatory processes and with the determination of its main vital characteristics at a particular point in time, as well as with the possibility of developing a tactical treatment plan based on it, followed by a phased assessment of its effectiveness, remains to the present time relevant.

In this regard, a completely new approach to solving this problem was proposed by a group of scientists from Buffalo, USA. The system they developed was based on several points.

First, the literature that appeared at that time (the beginning of the 70s) about existing patterns in the development of pathological processes in sepsis. This refers to the growing imbalance between the delivery and consumption of oxygen by tissues and the mismatch between increased cardiac output and disproportionately reduced peripheral resistance (9, 46-48).

Secondly, the extremely dynamic nature of extreme conditions, requiring appropriate timely monitoring and correction, which is impossible without the use of modern computer technology.

Thirdly, a certain set of physiological signs that allow to characterize the patient from the point of view of a “temporary cut”, which can serve as the basis for identifying typical pathophysiological patterns.

Fourth, the development of statistical multivariate analysis methods for solving applied problems in the field of medicine and. in particular, the allocation of pathophysiological images in patients requiring dynamic monitoring and treatment in intensive care units.

Based on these theoretical assumptions, an algorithm was developed by a community of physicians (Department of Surgery, State University of New York at the Buffalo General Hospital) and mathematicians (Thomas J. Watson Research Center and Systems Research Center IBM) [16. 32, 33. 35] and created a computer program implemented in the whole system. - “CARE-system”, an abbreviation for “Clinical Assessment Research and Education system” [37].

The basis for the development of this system was the results of the analysis of the clinical course in 157 patients. The main feature in the collection of material was the simultaneous study of the basic physiological and biochemical parameters. After careful visualization of the material, 695 data blocks were selected for statistical processing. In the course of mathematical analysis, four typical pathological clusters were identified. According to the classification of JHSiegel et al. [34] clusters are designated as follows:

- a cluster of “stress response”;

- a cluster of “metabolic imbalance”,

- a cluster of "respiratory failure";

- a cluster of “heart failure”.

Based on the determination of the Euclidean distance to each of them and the calculation of the smallest, it was determined to which particular cluster the patient being examined belongs to at a given time. Using the developed mathematical apparatus made it possible to accurately assess the qualitative side of the changes (that is, towards which cluster the patient became closer compared to the previous study) and make an appropriate quantitative assessment.

Many years of experience in operating this system in a 750-bed clinical hospital in Buffalo, USA, revealed both positive and negative aspects of the system. Firstly, it is characterized by high lability and allows a fairly reliable assessment of the effectiveness of the therapy. Secondly, the use of this system has significantly reduced mortality in surgical patients, not counting those who underwent cardiac surgery, from 18.8 to 10.5%.

At the same time, there were a number of drawbacks in the system itself, which were laid down even during its formation, which adversely affected its further functioning. Firstly, the lack of clear (meaning objective) criteria for the severity of the septic process did not allow the use of randomized sampling when developing the system. In repeated publications, the authors emphasized that the clinical observations of patients with septic and traumatic shock (without specifically defining these concepts), as well as myocardial infarction, are the basis of this system.

Secondly, during the selection of signs for creating this system, the authors proceeded only from pathophysiological expediency. At the same time, features with a high degree of mutual correlation were not excluded and statistical analysis criteria, including the so-called “principal component method”, were not used, which significantly contributed to the distortion of the resulting information space.

Thus, during the formation of the eleven-dimensional information space, distortion was allowed, which was subsequently revealed when studying the functional features of this system at “nodal” or “transitional” points using the mathematical apparatus of the theory of “catastrophes” [6]. In the course of mathematical analysis, it was shown that at “transitional" points, situations are possible where, with the same data, the patient’s pathophysiological profile can be correlated not with one but with two typical profiles, which is incorrect and indicates a fundamental error of the theory.

Unfortunately, after a cascade of publications on the effectiveness developed by JHSiegel et al. computer monitoring systems [31–38, 40–42], the publication of the results of the analysis of this system using the theory of “disasters” probably led. to the complete cessation of work in this direction. At the same time, the algorithm they developed was perfectly used by G. Anvanzolini et al. [7] to create a system of functional computer monitoring in patients with a cardiac surgical profile. It should be noted that these authors used precisely the “principal components” method to highlight significant features in the process of mathematical analysis, describing in detail its algorithm as an applied method.

Thus, on the basis of the already widespread understanding of the key links in the pathogenesis of sepsis, an attempt was made to create a promising system of functional monitoring. It turned out to be quite effective from different points of view and, first of all, showed the feasibility of an approach based on the concept of a “clinical image”. It seems to us that the use of the algorithm proposed by these authors on the basis of a randomized sample of victims, taking into account the necessary additional methods of statistical processing, should lead to the creation of a qualitatively new system of functional computer monitoring that retains all the positive properties of the “CARE-system”, but without its drawbacks.
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An objective assessment of the severity of a patient with a systemic inflammatory response syndrome and sepsis

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