The concept of surgical sepsis. Surgical sepsis

Medvedeva Svetlana Alexandrovna,

MBDOU "Kindergarten No. 1"

KHMAO - Yugra, Nefteyugansk

Purpose of the action:

Prevent environmental pollution with plastic utensils.

Tasks:

Expand the understanding of children and adults about the harm of abandoned plastic dishes to the environment.
To develop a sense of responsibility for the purity of the nature around us by recycling plastic utensils.
Introduce various methods of making crafts and flowers from plastic dishes.
Involve parents and children in environmental and creative activities.

Expected Result:

A child who is respectful of the environment, Decorating the earth with flowers.

Participants of the action

Pupils

Teachers

Parents

Stages of the promotion:

Preparatory stage
Duration: September – October
Basic
Dates: November – March
Final
Duration: April – May

Event plan

Excursion with children to the forest.
Cleaning the forest belt and park area near the kindergarten.
Issue of the newspaper “The Earth is Crying”.
Inventing and designing posters, leaflets, “Do not litter the park area, forest belts.”
Design of the propaganda stand “The second life of plastic tableware”.
Distribution of leaflets.
Making flowers from collected plastic dishes.
Distributing flowers to passersby.
Conducting a survey “Who carried away the garbage from the forest.”
Decorating a flower bed near a kindergarten with plastic flowers made by students, parents, and teachers.
Carrying out a flower festival.
Ecological raid.

Photo report from the scene.

One day we went to the woods, we wanted to frolic!

They came, they saw. Nightmare!

We had to work hard.

Bottles, cups, plastic, stench. We removed it all. We took them with us to the city, and then moved them around.

We decided to give bottles and glasses a second life. We decided to collect a bouquet and use it to decorate the earth.

A lot of work has been done for this.

We came up with our own flowers and taught them to our mother.

They gave flowers to passers-by. So that they love the earth and take away garbage from the forest

Leaflets were distributed. We gave advice to people.

We conducted a social survey “Who took the garbage out of the forest”, passers-by responded and promised to improve.

There are holidays for mother, and there is a holiday for the earth.

And we will congratulate the flowers. We will decorate the earth.

After all, believe us, you cannot offend nature.

Let's save it. For the future. Yes?

Creative report on environmental activities.

In 2010 - 2011 When organizing the educational process, one of the areas in my work with students was designated as environmental education. All work on environmental education was aimed at developing in students a humane and value-based attitude towards nature, the main manifestations of which are:

Interest in natural objects

Kindness towards living beings

Emotional responsiveness to their condition,

The desire to actively interact with them,

The desire and ability to care for living things and create the conditions necessary for them.

During the year, the projects “Indoor Plant”, “Feed the Birds in Winter”, “Take Care of the Christmas Tree - a Green Needle”, “Let’s Decorate the Earth with Flowers” were implemented.

The most significant project was “Let’s decorate the earth with flowers.” This project was started in the fall. During a walk to the nearest forest belt in October, my pupils and I noted that the area was very polluted. Particularly highlighted was the fact that vacationers in the forest area leave behind a lot of plastic dishes and various plastic containers. The children did not remain indifferent: there was no end to their indignation. The children explained that it was impossible to do this, that nature was crying, she was hurt and offended. My students know well that nature must be taken care of, preserved and protected.

Then the children and I thought about how we could help nature. Everyone understood that it was necessary to teach people to pick up trash after themselves. But how?

To begin with, in order to attract the attention of parents of preschool children to the problem of preserving the environment, we designed a wall newspaper “Nature is Crying”, where we posted photographs of how people pollute nature, in particular the place where all city residents like to relax - in the forest park.

We conducted a survey among parents of pupils and found out that 60% of parents with children visit public gardens and parks, forests, cottages, river banks on weekends and all use disposable tableware. True, almost all parents answered that they pick up trash after themselves and leave it in specially equipped places or bury it. We were glad that it was not our parents and their children who polluted the environment.

But how can we teach and accustom those others, adults and children, who pollute it, not to do this?

At the first stage, we issued leaflets calling on vacationers not to leave trash behind, and distributed these leaflets on Fridays to the parents of those kindergarten students who planned to go out into the countryside. Later, we figured out how to get people interested in taking dishes home - we decided to tell people that disposable tableware has a second life. We have supplemented the leaflets with information that various crafts can be easily and simply made from disposable plastic tableware, and that this is an interesting, exciting, and useful activity for the whole family. We posted information on how to make a craft on the preschool educational institution’s website and on the preschool educational institution’s main stand in the central hall. Of course, among those to whom we distributed leaflets, there were also people who honestly laughed and said that they would not do crafts, but agreed that garbage should not be left in the forest.

At the second stage, everyone, parents, kindergarten staff, and students began searching for interesting information about what and how can be made from disposable plastic tableware.

Since the priority direction in the activities of our preschool educational institution is the artistic and aesthetic development of children, our pupils are accustomed to usefully organizing their leisure time and know how to do a lot with their own hands, gluing, cutting, and sculpting with pleasure. A new direction - working with plastic - has aroused interest. I myself, the students, and even entire families got involved in creative activities. I prepared and conducted a master class for parents “We use plastic dishes in creative activities.” Every day, a new craft made by my hands, the hands of my parents, appeared on the beauty shelf in the group, and later the children learned to work very well with plastic. On long winter evenings, on frosty days, when it is impossible to organize walks on the street, the children were happy to engage in creative activities. All the crafts amazed us with their beauty and originality. When it was cold winter outside, flowers made from plastic dishes delighted us with their brightness and beauty.

The group organized exhibitions of crafts made from disposable plastic tableware. Flowers made by children's hands served to decorate the interior of the group and kindergarten, and they were used to decorate the music room for the holiday. When the snow melted early in the spring and our flower beds were gray and unattractive, my students and I decided to decorate them with flowers made by ourselves. Parents and children from all over the neighborhood came to admire our flowerbeds.

During the implementation of the project, experimental activities were also organized: students buried plastic bottles in the ground in the fall. When we dug up the ground in the spring, we saw that the dishes were still lying there. I explained to them that the bottle would lie in this state in the ground for many, many years, and together we came to the conclusion that a flower would never grow in this place.

In the spring, we again began publishing leaflets with calls not to pollute nature and distributing them to residents of the neighborhood and parents who were planning to relax in nature. Preschool teachers picked up the idea of leaflets, and if one of our groups issued only 15 leaflets, then all groups issued 80 of them. The leaflets will be distributed to parents all summer. And we believe that our students and parents will not leave dishes in the forest, no matter whether because they want to keep our Earth clean or because they will engage in manual labor.

Participation in project activities provided an opportunity for students to understand the depth of the problem of nature pollution and environmental protection, to experience it personally, to independently seek a solution to this problem, to show creativity, and to evaluate the results of their activities.

When epidemiologists allow us to visit the forest belt in the fall, we will definitely go to our places and assess the state of the environment, and if it suddenly turns out that people are leaving garbage behind, then it will be necessary to try again to solve the problem of environmental pollution in some other way, but be sure to try to help nature. And even though my students have become only a year older and they are only 6 years old, it is necessary that they are also concerned about these problems and that they are already looking for ways to solve environmental problems and learn how to organize environmental protection activities.

Bibliography

Zenina T. “Environmental actions in working with preschoolers” preschool education 2002 No. 7 p. 8
Ashikov V.I. Ashikova S.G. “Semitsvetik” Program and guidance on cultural and environmental education and development of preschool children. M. 1997
Nikolaeva S.N. “How to introduce a child to nature.”
Nikolaeva S.N. “Formation of the beginnings of ecological culture” preschool education 1998 No. 2 page 13
Hofman Petra “Crafts from cocktail tubes.”
G.N. Davydov "Crafts from waste material."
Internet resources.

“Certificate of Publication” Series A No. 0000839, date of dispatch December 18, 2012, receipt No. 62502655103667

We invite preschool teachers of the Tyumen region, Yamal-Nenets Autonomous Okrug and Khanty-Mansi Autonomous Okrug-Yugra to publish their teaching material:
- Pedagogical experience, original programs, teaching aids, presentations for classes, electronic games;
- Personally developed notes and scenarios of educational activities, projects, master classes (including videos), forms of work with families and teachers.

Why is it profitable to publish with us?

The relevance of the problem of sepsis is currently determined by several reasons: the significant frequency of the disease, high mortality and, consequently, the economic damage caused by this disease in developed countries.

In our country, there are no reliable statistical data on the prevalence of sepsis, and therefore, in matters of epidemiology, we have to refer to data from other countries: in the United States, about 500 thousand cases of sepsis are registered per year. In this case, the mortality rate reaches 35-42%, and these figures have not changed over the past few decades. Among the causes of death, sepsis ranks 13th.

Purpose of studying the topic: Based on the etiology, pathogenesis, clinical picture, laboratory and instrumental examination data of the patient, be able to make and justify a detailed clinical diagnosis of the disease. Develop medical tactics and determine the scope of treatment measures.

The student should know:

1. Basics of the systemic inflammatory response of the body;

2. Causes and pathogenesis of purulent surgical diseases;

3. Clinical picture of surgical sepsis;

4. Criteria for diagnosing sepsis;

5. Surgical tactics and methods of treating sepsis;

6. Principles of antibacterial therapy;

7. Prevention of surgical sepsis.

The student must be able to:

1. Conduct an examination of a patient with this pathology;

2. Conduct a differential diagnosis of surgical sepsis with abscesses and phlegmon of various locations, peritonitis, pleural empyema, osteomyelitis.

3. Read the results of modern methods of examining a surgical patient (general blood count, general urinalysis, coagulogram, radiographs, ultrasound findings of the abdominal organs, biochemical blood test findings).

4. Based on the clinical picture data confirmed by laboratory and instrumental examination data, formulate a diagnosis and develop medical tactics.

Independent work of students:

A) Questions of basic disciplines necessary for mastering this topic:

1. Normal physiology: indicators for assessing the activity of the cardiovascular and respiratory systems.

2. Pathological physiology: local signs of inflammation, hyper- and hypodynamic types of blood circulation, pathological types of breathing during inflammatory processes, assessment of blood parameters.

3. Microbiology: types of aerobic and anaerobic pathogens, concepts of pathogenicity and virulence of microorganisms.

4. Propaedeutics of internal diseases: methods of examining patients, types of temperature curves, assessment of the results of physical, laboratory and instrumental examination of patients.

B) Tasks to check and correct the initial level of knowledge:

Topic study plan

1. Definition of the concept of septic conditions.

2. Etiology and pathogenesis.

3. Classification.

4. Clinical picture.

5. Treatment.

6. Prevention.

The term “sepsis” (Greek sepsis – literally “rotting”) was first introduced in the 4th century. BC e. Aristotle to denote the process of poisoning the body with the products of “decomposition and decay” of its own tissues.

Term “sespis” (“infection”) as an internosological concept defines a dynamic state associated with the generalization of the infectious process, and is used in various fields of clinical medicine. The variety of clinical manifestations of sepsis, combined with insufficient definition of the concept itself, has led to its broad terminological interpretation. The need to describe sepsis as a nosological form in various fields of medicine has led to the emergence of a large number of different kinds of definitions and classifications of sepsis, which are based on such signs as clinical course (fulminant, acute, subacute, chronic, recurrent), localization and presence of the pathogen at the site entrance gate (primary, secondary, cryptogenic), nature of the entrance gate (wound, purulent-inflammatory, burn, etc.), localization of the primary lesion (obstetric-gynecological, angiogenic, urosepsis, umbilical, etc.), etiological sign (gram-negative, gram-positive , staphylococcal, streptococcal, colibacillary, pseudomonas, fungal, etc.) and others.

A general purulent infection that develops as a result of the penetration and circulation of various pathogens and their toxins in the blood. The clinical picture of sepsis consists of intoxication syndrome (fever, chills, pale earthy coloration of the skin), thrombohemorrhagic syndrome (hemorrhages in the skin, mucous membranes, conjunctiva), metastatic damage to tissues and organs (abscesses of various localizations, arthritis, osteomyelitis, etc.). Sepsis is confirmed by isolating the pathogen from blood cultures and local foci of infection. In case of sepsis, massive detoxification, antibacterial therapy, and immunotherapy are indicated; according to indications – surgical removal of the source of infection.

General information

Sepsis (blood poisoning) is a secondary infectious disease caused by the entry of pathogenic flora from the primary local infectious focus into the bloodstream. Today, from 750 to 1.5 million cases of sepsis are diagnosed annually in the world. According to statistics, sepsis is most often complicated by abdominal, pulmonary and urogenital infections, so this problem is most relevant for general surgery, pulmonology, urology, and gynecology. Within the framework of pediatrics, problems associated with neonatal sepsis are studied. Despite the use of modern antibacterial and chemotherapeutic drugs, the mortality rate from sepsis remains at a consistently high level - 30-50%.

Classification of sepsis

Forms of sepsis are classified depending on the location of the primary infectious focus. Based on this symptom, primary (cryptogenic, essential, idiopathic) and secondary sepsis are distinguished. In primary sepsis, the entrance gate cannot be detected. The secondary septic process is divided into:

surgical– develops when infection enters the blood from a postoperative wound
obstetrics and gynecology– occurs after complicated abortions and childbirth
urosepsis– characterized by the presence of entrance gates in parts of the genitourinary apparatus (pyelonephritis, cystitis, prostatitis)
cutaneous– the source of infection is purulent skin diseases and damaged skin (boils, abscesses, burns, infected wounds, etc.)
peritoneal(including biliary, intestinal) – with localization of primary foci in the abdominal cavity
pleuropulmonary– develops against the background of purulent lung diseases (abscess pneumonia, pleural empyema, etc.)
odontogenic– caused by diseases of the dental system (caries, root granulomas, apical periodontitis, periostitis, peri-maxillary phlegmon, osteomyelitis of the jaws)
tonsillogenic– occurs against the background of severe sore throats caused by streptococci or staphylococci
rhinogenic– develops due to the spread of infection from the nasal cavity and paranasal sinuses, usually with sinusitis
otogenic- associated with inflammatory diseases of the ear, most often purulent otitis media.
umbilical– occurs with omphalitis of newborns

Based on the time of occurrence, sepsis is divided into early (occurs within 2 weeks from the appearance of the primary septic focus) and late (occurs later than two weeks). According to the rate of development, sepsis can be fulminant (with rapid development of septic shock and death within 1-2 days), acute (lasting 4 weeks), subacute (3-4 months), recurrent (lasting up to 6 months with alternating attenuation and exacerbations) and chronic (lasting more than a year).

Sepsis in its development goes through three phases: toxemia, septicemia and septicopyemia. The toxemia phase is characterized by the development of a systemic inflammatory response due to the onset of the spread of microbial exotoxins from the primary site of infection; in this phase there is no bacteremia. Septicemia is marked by the dissemination of pathogens, the development of multiple secondary septic foci in the form of microthrombi in the microvasculature; persistent bacteremia is observed. The septicopyemia phase is characterized by the formation of secondary metastatic purulent foci in the organs and skeletal system.

Causes of sepsis

The most important factors leading to the breakdown of anti-infective resistance and the development of sepsis are:

on the part of the macroorganism - the presence of a septic focus, periodically or constantly associated with the blood or lymphatic bed; impaired body reactivity
on the part of the infectious pathogen - qualitative and quantitative properties (massiveness, virulence, generalization in the blood or lymph)

The leading etiological role in the development of most cases of sepsis belongs to staphylococci, streptococci, enterococci, meningococci, gram-negative flora (Pseudomonas aeruginosa, Escherichia coli, Proteus, Klebsiella, Enterobacter), and to a lesser extent - fungal pathogens (Candida, Aspergillus, Actinomycetes).

Detection of polymicrobial associations in the blood increases the mortality rate of patients with sepsis by 2.5 times. Pathogens can enter the bloodstream from the environment or be introduced from foci of primary purulent infection.

The mechanism of sepsis development is multi-stage and very complex. From the primary infectious focus, pathogens and their toxins penetrate the blood or lymph, causing the development of bacteremia. This causes activation of the immune system, which responds by releasing endogenous substances (interleukins, tumor necrosis factor, prostaglandins, platelet activating factor, endothelins, etc.), causing damage to the endothelium of the vascular wall. In turn, under the influence of inflammatory mediators, the coagulation cascade is activated, which ultimately leads to the occurrence of DIC syndrome. In addition, under the influence of released toxic oxygen-containing products (nitric oxide, hydrogen peroxide, superoxides), perfusion, as well as oxygen utilization by organs, decreases. The natural outcome of sepsis is tissue hypoxia and organ failure.

Symptoms of sepsis

The symptoms of sepsis are extremely polymorphic and depend on the etiological form and course of the disease. The main manifestations are due to general intoxication, multiple organ disorders and localization of metastases.

In most cases, the onset of sepsis is acute, but a quarter of patients experience so-called presepsis, characterized by feverish waves alternating with periods of apyrexia. The state of pre-sepsis may not develop into a full picture of the disease if the body manages to cope with the infection. In other cases, the fever takes an intermittent form with severe chills, followed by fever and sweating. Sometimes permanent hyperthermia develops.

The condition of a patient with sepsis quickly worsens. The skin acquires a pale gray (sometimes jaundiced) color, and facial features become sharper. Herpetic rashes on the lips, pustules or hemorrhagic rashes on the skin, hemorrhages in the conjunctiva and mucous membranes may occur. In the acute course of sepsis, patients quickly develop bedsores, dehydration and exhaustion increase.

Under conditions of intoxication and tissue hypoxia during sepsis, multiple organ changes of varying severity develop. Against the background of fever, signs of dysfunction of the central nervous system are clearly expressed, characterized by lethargy or agitation, drowsiness or insomnia, headaches, infectious psychoses and coma. Cardiovascular disorders are represented by arterial hypotension, weakening of the pulse, tachycardia, and deafness of heart sounds. At this stage, sepsis can be complicated by toxic myocarditis, cardiomyopathy, and acute cardiovascular failure.

The respiratory system reacts to pathological processes occurring in the body with the development of tachypnea, pulmonary infarction, respiratory distress syndrome, and respiratory failure. On the part of the gastrointestinal tract, anorexia, the occurrence of “septic diarrhea” alternating with constipation, hepatomegaly, and toxic hepatitis are noted. Dysfunction of the urinary system during sepsis is expressed in the development of oliguria, azotemia, toxic nephritis, and acute renal failure.

Characteristic changes also occur at the primary site of infection during sepsis. Wound healing slows down; granulations become sluggish, pale, bleeding. The bottom of the wound is covered with a dirty grayish coating and areas of necrosis. The discharge becomes cloudy in color and has a foul odor.

Metastatic foci in sepsis can be detected in various organs and tissues, which causes the layering of additional symptoms characteristic of the purulent-septic process of this localization. The consequence of infection in the lungs is the development of pneumonia, purulent pleurisy, abscesses and gangrene of the lung. With metastases to the kidneys, pyelitis and paranephritis occur. The appearance of secondary purulent foci in the musculoskeletal system is accompanied by the phenomena of osteomyelitis and arthritis. When the brain is damaged, cerebral abscesses and purulent meningitis occur. There may be metastases of a purulent infection in the heart (pericarditis, endocarditis), muscles or subcutaneous fat (soft tissue abscesses), abdominal organs (liver abscesses, etc.).

Complications of sepsis

The main complications of sepsis are associated with multiple organ failure (renal, adrenal, respiratory, cardiovascular) and DIC syndrome (bleeding, thromboembolism).

The most severe specific form of sepsis is septic (infectious-toxic, endotoxic) shock. It often develops with sepsis caused by staphylococcus and gram-negative flora. Harbingers of septic shock are the patient's disorientation, visible shortness of breath and impaired consciousness. Disorders of blood circulation and tissue metabolism are rapidly increasing. Characteristic symptoms include acrocyanosis against the background of pale skin, tachypnea, hyperthermia, a critical drop in blood pressure, oliguria, increased heart rate to 120-160 beats. per minute, arrhythmia. Mortality in the development of septic shock reaches 90%.

Diagnosis of sepsis

Recognition of sepsis is based on clinical criteria (infectious-toxic symptoms, the presence of a known primary focus and secondary purulent metastases), as well as laboratory indicators (blood culture for sterility).

At the same time, it should be taken into account that short-term bacteremia is also possible in other infectious diseases, and blood cultures in sepsis (especially against the background of antibiotic therapy) are negative in 20-30% of cases. Therefore, blood culture for aerobic and anaerobic bacteria must be carried out at least three times and preferably at the height of a febrile attack. A bacterial culture of the contents of the purulent lesion is also carried out. PCR is used as a rapid method for isolating the DNA of the causative agent of sepsis. In the peripheral blood, there is an increase in hypochromic anemia, acceleration of ESR, leukocytosis with a shift to the left, opening of purulent pockets and intraosseous ulcers, sanitation of cavities (with soft tissue abscess, phlegmon, osteomyelitis, peritonitis, etc.). In some cases, resection or removal of the organ along with the abscess may be required (for example, with an abscess of the lung or spleen, kidney carbuncle, pyosalpinx, purulent endometritis, etc.).

The fight against microbial flora involves prescribing an intensive course of antibiotic therapy, flow-through rinsing of drains, local administration of antiseptics and antibiotics. Before antibiotic-susceptible cultures are obtained, therapy is started empirically; After verification of the pathogen, the antimicrobial drug is changed if necessary. In case of sepsis, cephalosporins, fluoroquinolones, carbapenems, and various combinations of drugs are usually used for empirical therapy. For candidosepsis, etiotropic treatment is carried out with amphotericin B, fluconazole, caspofungin. Antibiotic therapy continues for 1-2 weeks after normalization of temperature and two negative blood cultures.

Detoxification therapy for sepsis is carried out according to general principles using saline and polyionic solutions, forced diuresis. To correct CBS, electrolyte infusion solutions are used; To restore protein balance, amino acid mixtures, albumin, and donor plasma are introduced. To combat bacteremia in sepsis, extracorporeal detoxification procedures are widely used: hemosorption, hemofiltration. When kidney failure develops, hemodialysis is used.

Immunotherapy involves the use of antistaphylococcal plasma and gamma globulin, transfusion of leukocytes, and the administration of immunostimulants. Cardiovascular drugs, analgesics, anticoagulants, etc. are used as symptomatic drugs. Intensive drug therapy for sepsis is carried out until the patient’s condition improves permanently and homeostasis indicators normalize.

Forecast and prevention of sepsis

The outcome of sepsis is determined by the virulence of the microflora, the general condition of the body, the timeliness and adequacy of the therapy. Elderly patients with concomitant general diseases and immunodeficiencies are predisposed to the development of complications and an unfavorable prognosis. For various types of sepsis, mortality is 15-50%. With the development of septic shock, the likelihood of death is extremely high.

Preventive measures against sepsis consist of eliminating foci of purulent infection; proper management of burns, wounds, local infectious and inflammatory processes; compliance with asepsis and antisepsis when performing therapeutic and diagnostic procedures and operations; prevention of hospital infection; carrying out

Sepsis represents a very serious problem for all medical science and surgery in particular. This condition is a generalization of infection, which occurs due to the breakthrough of the infectious principle into the systemic bloodstream. Sepsis is one of the natural outcomes of a surgical infection if the patient does not receive proper treatment and his body cannot cope with a highly virulent pathogen and, on the contrary, if the peculiarity of his immune reactions predisposes to such a development of events. In the presence of a purulent focus and increasing signs of intoxication, therapeutic measures to remove the local infection should be started as quickly as possible, since purulent-resorptive fever turns into full-blown sepsis after 7-10 days. This complication must be avoided at all costs, since the mortality rate for this condition reaches 70%.

Terms such as presepsis and purulent-septic condition have been excluded from the nomenclature and are now inappropriate.

The entrance gate is the site of infection. As a rule, this is an area of damaged tissue.

There are primary and secondary foci of infection.

1. Primary – an area of inflammation at the site of penetration. Usually coincides with the entrance gate, but not always (for example, phlegmon of the lymph nodes of the groin area due to panaritium of the toes).

2. Secondary, so-called metastatic or pyemic foci.

Classification of sepsis

According to the location of the entrance gate.

1. Surgical:

1) spicy;

2) chronic.

2. Iatrogenic (as a result of diagnostic and therapeutic procedures, such as catheter infection).

3. Obstetrics and gynecology, umbilical, neonatal sepsis.

4. Urological.

5. Odontogenic and otorhinolaryngological.

In any case, when the portal of entry is known, sepsis is secondary. Sepsis is called primary if it is not possible to identify the primary focus (entry gate). In this case, the source of sepsis is assumed to be a focus of dormant autoinfection.

According to the speed of development of the clinical picture.

1. Fulminant (leads to death within a few days).

2. Acute (from 1 to 2 months).

3. Subacute (lasts up to six months).

4. Chroniosepsis (long-term wave-like course with periodic febrile reactions during exacerbations).

By gravity.

1. Moderate severity.

2. Heavy.

3. Extremely heavy.

There is no mild form of sepsis.

According to etiology (type of pathogen).

1. Sepsis caused by gram-negative flora: colibacillary, proteus, pseudomonas, etc.

2. Sepsis caused by gram-positive flora: streptococcal and staphylococcal.

3. Extremely severe sepsis caused by anaerobic microorganisms, in particular bacteroides.

Phases of sepsis.

1. Toxemic (I.V. Davydovsky called it purulent-resorptive fever).

2. Septicemia (without the formation of metastatic purulent foci).

3. Septicopyemia (with the development of pyemic foci).

It should be noted that over time, the species composition of microorganisms that are the predominant causative agents of sepsis changes. If in the 1940s. the most common pathogen was streptococcus, which gave way to staphylococcus, now the era of gram-negative microorganisms has arrived.

One of the important criteria for sepsis is the species uniformity of microorganisms cultured from primary and secondary foci of infection and blood.

2. Pathogenesis of sepsis

Microorganisms are still considered the main cause of sepsis, determining its course, and the virulence of the pathogen and its dose are decisive (the titer of microorganisms must be at least 10: 5 per gram of tissue). The condition of the patient’s body should also be recognized as extremely important factors influencing the development of sepsis, and factors such as the condition of the primary and secondary foci of infection, the severity and duration of intoxication, and the state of the body’s immune system are of decisive importance. Generalization of infection occurs against the background of allergic reactions to a microbial agent. When the immune system is unsatisfactory, the microorganism enters the systemic bloodstream from the primary focus. Intoxication preceding and maintained by the primary focus changes the overall reactivity of the body and forms a state of sensitization. The deficiency of the immune system is compensated by an increased reactivity of nonspecific protective factors (macrophage-neutrophilic inflammation), which, coupled with the allergic predisposition of the body, leads to the development of an uncontrollable inflammatory reaction - the so-called systemic inflammatory response syndrome. In this condition, there is an excessive release of inflammatory mediators both locally into the tissue and into the systemic circulation, which causes massive tissue damage and increases toxemia. Sources of toxins are damaged tissues, enzymes, biologically active substances of inflammatory cells and waste products of microorganisms.

Primary focus is not only a constant source of microbial agents, but also continuously maintains a state of sensitization and hyperreactivity. Sepsis can be limited only to the development of a state of intoxication and a systemic inflammatory reaction, the so-called septicemia, but much more often pathological changes progress, and septicopyemia develops (a condition characterized by the formation of secondary purulent foci).

Secondary purulent pyemic foci occur when microflora metastasize, which is possible with a simultaneous decrease in both the antibacterial activity of the blood and a violation of local protective factors. Microbial microinfarctions and microembolisms are not the cause of the occurrence of a pyaemic focus. The basis is a disruption of the activity of local enzyme systems, but, on the other hand, the resulting pyaemic foci cause activation of lymphocytes and neutrophils, excessive release of their enzymes and tissue damage, but microorganisms settle on the damaged tissue and cause the development of purulent inflammation. When a secondary purulent focus occurs, it begins to perform the same functions as the primary one, that is, it forms and maintains a state of intoxication and hyperreactivity. Thus, a vicious circle is formed: pyaemic foci support intoxication, and toxemia, in turn, makes it possible to develop foci of secondary infection. For adequate treatment it is necessary to break this vicious circle.

3. Surgical sepsis

Surgical sepsis is an extremely severe general infectious disease, the main etiological point of which is a dysfunction of the immune system (immunodeficiency), which leads to generalization of the infection.

According to the nature of the entrance gate, surgical sepsis can be classified into:

1) wound;

2) burn;

3) angiogenic;

4) abdominal;

5) peritoneal;

6) pancreatogenic;

7) cholangiogenic;

8) intestinogenic.

Traditionally, clinical manifestations of sepsis include the following:

1) the presence of a primary purulent focus. In most patients it is characterized by significant size;

2) the presence of symptoms of severe intoxication, such as tachycardia, hypotension, general condition disorders, signs of dehydration;

3) positive repeated blood cultures (at least 3 times);

4) the presence of so-called septic fever (a large difference in morning and evening body temperatures, chills and heavy sweating);

5) the appearance of secondary infectious foci;

6) pronounced inflammatory changes in the hemogram.

A less common symptom of sepsis is the formation of respiratory failure, toxic reactive inflammation of organs (most often the spleen and liver, which causes the development of hepatosplenomegaly), and peripheral edema. Myocarditis often develops. There are frequent disturbances in the hemostatic system, which is manifested by thrombocytopenia and increased bleeding.

For timely and correct diagnosis of sepsis, it is necessary to have a firm understanding of the signs of the so-called septic wound. It is characterized by:

1) flaccid pale granulations that bleed when touched;

2) the presence of fibrin films;

3) scanty, serous-hemorrhagic or brown-brown discharge from the wound with an unpleasant putrefactive odor;

4) cessation of the dynamics of the process (the wound does not epithelialize and ceases to be cleansed).

Bacteremia should be recognized as one of the most important signs of sepsis, but the presence of microbes in the blood is not always determined by culture data. In 15% of cases, cultures do not grow, despite the presence of clear signs of sepsis. At the same time, a healthy person may experience a short-term violation of blood sterility, the so-called transient bacteremia (after tooth extraction, for example, bacteria can remain in the systemic bloodstream for up to 20 minutes). To diagnose sepsis, blood cultures must be repeated, despite negative results, and blood must be taken at different times of the day. It should be remembered: in order to make a diagnosis of septicopyemia, it is necessary to establish the fact that the patient has bacteremia.

1) presence of a focus of infection;

2) previous surgical intervention;

3) the presence of at least three out of four signs of systemic inflammatory response syndrome.

Systemic inflammatory response syndrome can be suspected if the patient has the following clinical and laboratory data:

1) axillary temperature more than 38 °C or less than 36 °C;

2) increased heart rate more than 90 per minute;

3) insufficiency of external respiration function, which is manifested by an increase in respiratory rate (RR) of more than 20 per minute or an increase in pCO2 of more than 32 mm Hg. Art.;

4) leukocytosis beyond 4-12 x 109, or the content of immature forms in the leukocyte formula is more than 10%.

4. Septic complications. Treatment of sepsis

The main complications of sepsis, from which patients die, should be considered:

1) infectious-toxic shock;

2) multiple organ failure.

Infectious-toxic shock has a complex pathogenesis: on the one hand, bacterial toxins cause a decrease in arteriolar tone and disruption in the microcirculation system, on the other hand, there is a disturbance in systemic hemodynamics due to toxic myocarditis. In infectious-toxic shock, the leading clinical manifestation is acute cardiovascular failure. Tachycardia is observed - 120 beats per minute and above, heart sounds are muffled, the pulse is weakly filled, systolic blood pressure decreases (90-70 mm Hg and below). The skin is pale, the extremities are cold, and sweating is common. There is a decrease in urine output. As a rule, a harbinger of shock is a sharp increase in temperature with chills (up to 40-41 ° C), then the body temperature drops to normal values, and the full picture of shock unfolds.

Treatment of shock is carried out according to general rules.

The main links of treatment.

1. Elimination of intoxication.

2. Sanitation of purulent-inflammatory foci and suppression of infection.

3. Correction of immune disorders.

In many ways, the same measures are used to achieve these goals (as detoxification therapy)

1. Massive infusion therapy. Up to 4-5 liters per day of plasma-substituting solutions (neocompensan, hemodez, rheopolyglucin, hydroxylated starch). When carrying out infusion therapy, special attention should be paid to the correction of electrolyte disturbances and shifts in the acid-base state (elimination of acidosis).

2. Forced diuresis.

3. Plasmapheresis.

4. Lympho- and hemosorption.

5. Hyperbaric oxygenation.

6. Removal of pus.

To sanitize foci of infection - local treatment:

1) removal of pus, necrotic tissue, wide drainage of the wound and its treatment according to the general principles of treating a purulent wound;

2) use of topical antibacterial agents (levomekol, etc.).

Systemic treatment:

1) massive antibacterial therapy using at least two broad-spectrum or targeted drugs, taking into account the sensitivity of the isolated pathogen. Antibiotics only parenterally (into a muscle, vein, regional artery or endolymphatic).

2) antibacterial therapy is carried out for a long time (for months) until a negative blood culture result or clinical recovery, if the culture initially did not give growth. Various methods can be used to correct immune disorders: administration of a leukocyte suspension, the use of interferon, hyperimmune antistaphylococcal plasma, and in severe cases, the use of glucocorticosteroids. Correction of immune disorders should be carried out with the obligatory consultation of an immunologist.

An important place in the treatment of patients is occupied by providing them with an adequate amount of energy and plastic substrates. The energy value of the daily diet should not be lower than 5000 kcal. Vitamin therapy is indicated. In special cases, debilitated patients can be given a transfusion of freshly citrated blood, but the use of fresh frozen plasma and albumin solution is much preferable.

If organ failure develops, treatment is carried out according to standards.