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Functional computer monitoring system in the diagnosis of sepsis

An analysis of the dynamics of the criteria of a functional computer monitoring system for the systemic inflammatory response syndrome and sepsis, performed by us. showed that for sepsis, as one form of SSVR. all the characteristic features of this syndrome are inherent. First of all, this is a significant increase in the C / B ratio, corresponding to an increase in the role of anaerobic metabolic mechanisms against the background of, as a rule, a decrease in the D / A ratio. which indicates a suppression of the pumping function of the heart and an increase in dysregulation between cardiac performance and the sympathetic tone of the peripheral vascular system, which determines the total peripheral resistance. During the analysis, there were no significant differences according to the criteria of a functional computer monitoring system between observations with signs of a systemic inflammatory response syndrome (without bacteremia) and sepsis.

In 13 observations, we were able to evaluate the performance of a functional computer monitoring system at the time of proven bacteremia. Despite the absence of significant differences in the criteria of the PCM system between the systemic inflammatory response syndrome (meaning signs of SSVR without bacteremia) and sepsis, we can probably assume that the development of persistent bacteremia against SSVR is a qualitatively different stage in the development of the post-shock period. This position is confirmed, firstly, in that. that in severe mechanical trauma, bacteremia begins to be diagnosed only from the end of the first week after the damage, and the clinical signs of the systemic inflammatory response syndrome in some cases already from the first day. Secondly, bacteremia in this category of patients is always secondary, that is, the syndrome of a systemic inflammatory reaction first develops. which for one reason or another continues to progress. and already against its background bacteremia joins, which in turn increases the severity of signs of SSVR. significantly worsening the prognosis. A good example of such a development of events is the following clinical observation.

Affected M, 31 years old. and. b. No. 14277. was admitted to the clinic of military field surgery on October 17, 1990 1 hour after. how it was hit by an electric train. Prednisone - 210 mg, atropine sulfate - 0.5 ml was administered intravenously along the route. Seduxen - 40 mg. reopoliglyukina 150 ml.

Upon admission to the clinic, an extremely serious condition of the victim was diagnosed due to a severe injury to the skull and brain, an impressed fracture of the left frontal bone and the development of a subdural hematoma, compression of the brain. But emergency indications were made decompressive trepanation of the skull, the elimination of the fracture. Diagnosed with: “Open craniocerebral injury, severe brain contusion. Depressed fracture of the left frontal bone, fracture of the right parietal bone. Increasing compression of the brain by a subdural hematoma and a depressed fracture of the frontal bone. Subarachnoid hemorrhage. Multiple contusion foci in the left frontal and parietal lobes of the brain. Blood and cerebrospinal fluid aspiration into the tracheobronchal tree. ”

Severe brain contusion with multiple contusion foci, aspiration of blood and cerebrospinal fluid into the tracheobronchial tree determined the further severe course of the post-shock period. In the first two days, the main severity of the victim's condition was determined by the inefficiency of independent breathing, which required controlled mechanical ventilation. Starting from the third day, signs of a systemic inflammatory reaction syndrome appear - a rise in temperature to 38.5 ° C. tachycardia over 100 beats / min, leukocytosis with a shift of the leukocyte formula to the left. tachypnea up to 30 in I min. The ineffectiveness of spontaneous breathing and the inability to fully rehabilitate the tracheobronchial tree led to the need for a tracheostomy on the fifth day. During the sixth and seventh days after the injury in connection with the development of the clinical picture of the systemic inflammatory response syndrome, bacteriological blood tests were performed to exclude sepsis. In the same period, simultaneously with the collection of blood samples for microbiological analyzes, a study was made of indicators of a functional computer monitoring system.

During treatment in the intensive care unit, the patient received the full volume of infusion therapy, preventive antibiotic therapy was carried out (penicillin sodium salt 2 mln units intravenously six times a day and kanamycin sulfate 1 g twice daily intravenously) to prevent suppurative septic complications, which in this situation could be predicted ahead of time, based on literature data considering these complications as the leading cause of deaths in severe traumatic brain injury [4].

When studying the performance of a functional computer monitoring system, the following trajectory of the dynamics of the condition of this victim was noted on the first day after the injury and on the sixth to seventh day (Fig. 5.17).

A day after the victim arrives at the clinic, the phase of the hyperdynamic stress reaction is recorded, which was the result of a timely operation and a balanced, quite adequate, intensive care. As noted above. in connection with the restoration of spontaneous breathing, the patient was initially transferred to independent breathing, symptomatic therapy was carried out. In connection with the increase from the third day of the symptoms of the syndrome of a systemic inflammatory reaction, the doses of antibiotics were increased - the sodium salt of penicillin to 72 million units. per day intravenously.
Claforan was administered intralumbally and intracarotidally in a dose of 2 g. Given the X-ray picture in the lungs: “. in both lungs there are shallow focal areas of blackout that are most characteristic of aspiration”. the tracheostomy was made to the victim. daily sanitation bronchoscopy was performed. During this period, the development of the inflammatory process in the lungs was accompanied by a rather pronounced increase in anemia (a decrease in hemoglobin to 84 g / l, hematocrit to 0.23 l / l), which was noted during the study in the functional computer monitoring system 22.10. Microbiological studies performed on 22.10 did not reveal microflora growth. The performed blood transfusion performed on October 22 made it possible to eliminate the signs of anemia, and the manifestations of CVD came in first place. Microbiological studies performed on 23.10 showed the growth of St.epidermidis in three parallel samples. In fig. 5.18 shows the pathophysiological profile of this victim on October 22.

Fig. 5.17.

The trajectory of the dynamics of the state of the injured M. in the system of functional computer monitoring



.

It can be seen that the minimum distance in this period is determined to the cluster of “hypovolemic disorders”, which is manifested primarily in a sharp increase in oxygen extraction by tissues, an increase in the arteriovenous gradient, and an increase in oxygen consumption up to 200 ml / m2. In this way, compensation for a reduced level of the transport agent hemoglobin is achieved. It must be emphasized that during this period the victim expressed signs of a systemic inflammatory reaction syndrome due to the development of pneumonia, and microbiological blood tests for sterility of microflora growth were not revealed. In fig. 5.18 presents the pathophysiological profile of this victim the day after the replenishment of blood loss. The indicators necessary for its calculation were obtained during repeated microbiological studies. As follows from the graph, the distance to the profile of “metabolic disorders” becomes minimal, and the C / B ratio reaches 5.8. In the same period, positive results of microbiological blood tests were obtained - St. was found in the crops epidermidis.

Distance R = 8.0; A = 6.5; B = 4.8; C = 5.1; D = 2.6; C / B; 1.07; D / A = 0.4

Fig. 5.18.

The pathophysiological profile of the injured M. 10/22/90, 10 hours.

Distances to typical clusters are indicated. Legend, as in fig. 4.13.



The data presented indicate that for sepsis, as one of the forms (albeit the most severe) of the systemic inflammatory response syndrome, all its signs are inherent in TON! including those characteristic of a functional computer monitoring system — the prevalence of a typical pathophysiological profile of “metabolic disorders”. This suggests the dominance of the processes of anaerobic metabolism over processes requiring the presence of oxygen. Inhibition of the pumping function of the heart is noted, which manifests itself in a decrease in the specific single myocardial productivity against the background of the possible, due to tachycardia, compensation of minute productivity, pathological relationships between heart performance and total peripheral resistance are established.



Distance R = 3.6; A = 8.6; B = 1.6; C = 9.2; D = 5.3 $ С / В = 5.В; D / A = 0.6

Fig. 5.19.

The pathophysiological profile of the injured M. 10/23/90. 9 hours

Distances to typical clusters are indicated. Legend, as in fig. 4.13.



Thus, studies in the system of functional computer monitoring of the dynamics of the course of the post-shock period in a patient with a diagnosed development of sepsis did not reveal any signs specific to this pathology.

The analysis of various types of clinical course of the post-traumatic period, made in this chapter based on the dynamics of the criteria of a functional computer monitoring system in comparison with clinical and laboratory data. allows you to reliably distinguish three different types: uncomplicated. “Transitional” - “threatening the development of a systemic inflammatory response syndrome” and complicated by the development of a “systemic inflammatory response syndrome and sepsis”.

In the last, third, group, the use of the criteria of a functional computer monitoring system did not allow to reliably determine the characteristic differential signs of sepsis and SSVR. occurring without bacteremia.

At the same time, the clinical feasibility of such a division seems obvious. Firstly, the development of sepsis (that is, the appearance of bacteremia against the background of a systemic inflammatory response syndrome) is a qualitatively different, more difficult stage during the post-traumatic period. Violations of the protective mechanisms are so pronounced that not only the waste products of microorganisms enter the systemic circulation. but also the microorganisms themselves begin to multiply actively in the vascular bed. Secondly, the identification of a specific pathogen makes it possible to narrow the range of antimicrobial agents used, which is not indifferent from different points of view.

Of particular practical importance, as we believe, is the second group - “threatening the development of the USSR”. Early detection of this type of traumatic disease course should allow for more effective preventive and prophylactic therapy of the systemic inflammatory response syndrome, which will undoubtedly have a favorable effect on the prognosis.
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Functional computer monitoring system in the diagnosis of sepsis

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