Statistics of recent years shows that the frequency of cases of sepsis and its complications is not reduced, despite the introduction of modern methods of surgical and conservative treatment and the use of the latest antibacterial agents.

Analysis of the incidence of sepsis in large US centers showed that the frequency of the development of heavy sepsis is 3 cases per 1000 population or 2.26 cases per 100 hospitalization. 51.1% of patients were hospitalized in the separation of intensive therapy.

National Center US health statistics published a large retrospective analysis, according to which 10 million sepsis was registered in 500 non-state hospitals during the 22-year observation period. Sepsis was 1.3% of all reasons for inpatient treatment. The incidence of sepsis increased 3 times from 1979 to 2000 - from 83 to 240 cases per 100,000 population per year.

It should be noted that since the 90s of the last century there is a tendency to increase the share of gram-negative microorganisms as the most common cause of sepsis.

Earlier it was believed that sepsis is a problem of predominantly surgical hospitals. But the distribution of nosocomial infections, the use of invasive methods of research and monitoring the state of the patient, an increase in the number of patients with immunodeficiency states, widespread use of cytostatics and immunosuppressors, an increase in the number of mixtures led to an increase in the frequency of sepsis in patients of non-surgical profile branches.

Existing modern theories of the development of the septic process do not allow to reveal all the variety of nature and mechanisms for the development of this process. At the same time, they complement our understanding of this complex clinical and pathogenetic process.

The traditional approach to the problem of sepsis from the point of view of infectiology is the data presented by V.G. Bolaroshvili. Under Sepsis understand nonzologically independent infectious disease, characterized by a variety of etiological agents, manifested by bacteremia and malignant (acyclic) flow due to immunosuppression . The acyclic nature of the course of the disease is one of the determining factors, because Most of the "classic" infectious diseases (abdominal typhoids, brucellosis, leptospirosis, raped typhoids and others) proceed with bacteremia, but are not sepsis and have a cyclical flow with subsequent recovery.

According to A.V. Cinterling, sepsis are characterized by general and private characteristic clinical and clinical and anatomical signs, i.e. The presence of bacteriamia, septicemia, septicopemia, entrance gates and generatization of infection.

The central aspect in the theory of sepsis has always been the interaction of micro and macroorganism. Therefore, for sepsis, a variety of gamma microbiological factors is characterized, which in most cases are representatives of the Optional flora of open cavities of the human body. At the same time, bacteremia at sepsis is not different from that with "classical" infectious diseases. It has not been established that sepsis causative agents possess special virulent properties. Mostly they are representatives of the elective flora of the human body, therefore they do not have pronounced immunogenicity. This explains acyclicity and fatality. clinical flow sepsis.

Since 1992, sepsis began to consider in close connection with a systemic inflammatory response syndrome (CBE) - non-specific reaction of the immune system on an infectious pathogen or damage (Bone R.C., 1992). Thus, the CBO is a pathological condition due to one of the forms of surgical infection and / or damage to the tissue of non-infectious nature (injury, pancreatitis, burn, ischemia or autoimmune tissue damage, etc.). This concept is proposed by the American College of Pulmonologists and the Society of Critical Medicine Specialists (ACCP / SCCM), which led to a significant revision of the concept of pathogenesis, clinics, treatment and prevention of sepsis and its complications. CBMO is characterized by the presence of more than one of the following major clinical signs characteristic of inflammation: hyperthermia, Tachycardia, Tahipne, GEMOGRAM changes (leukocytosis / leukopenia) .

The above-mentioned clinical signs may occur during sepsis, but at the same time the presence of an infectious focus in tissues or organs is obligatory.

Thus, the modern classification of sepsis is based on the diagnostic criteria proposed at the ACCP / SCCM conciliation conference.

Local inflammation, sepsis, severe sepsis and polyorgan insufficiency - units of one chain in the body's reaction to inflammation and, as a result, generalization of microbial infection. Heavy sepsis and septic shock are a substantial part of the systemic inflammatory response syndrome on an infectious agent, and the result of the progression of systemic inflammation is the development of violation of the functions of systems and organs.

The modern concept of sepsis, based on CBSO, is not absolute and criticized by many domestic and Western scientists. Continued controversy clinical definition The CBE and its connection with the infectious process and specificity for Sepsis still raises the issue of bacteriological diagnostics, which in many cases is a decisive factor in confirming the infectious nature of the pathological process.

Bacteremia is one of the important, but not mandatory manifestations of sepsis, since frequency is possible in its manifestation, especially in cases of long-term course of the disease. The absence of confirmed bacteremia should not affect the diagnosis in the presence of the above-mentioned clinical criteria of sepsis, which is important for the attending physician when making a decision on the amount of therapy conducted. Even with the most scrupulous observance of blood intake techniques and the use of modern microbiological technologies for diagnosis in patients with the most severe approach of sepsis, the frequency of positive results, as a rule, does not exceed 40-45%.

The detection of microorganisms in the bloodstream without clinical and laboratory confirmations of CSMO should be regarded as transient bacteremia, which may occur during salmonellosis, yersiniosis and a number of others intestinal infections. High and long-lasting bacteremia, signs of generatization of the infectious process have a weighty clinical significance when making a diagnosis of Sepsis.

The detection of the pathogen is an important argument in favor of the diagnosis of sepsis due to:

- evidence of the mechanism for the development of sepsis (for example, catheter-associated infection, UROSPSIS, gynecological sepsis);

- confirmation of the diagnosis and determination of the etiology of the infectious process;

- Justification of the choice of antibiotic therapy scheme;

- Evaluation of the effectiveness of therapy.

A positive result of sowing blood for sterility is the diagnostically most informative research method. Blood seeds should be carried out at least 2 times a day (within 3-5 days), as early as possible after the start of the temperature rise or 1 hour before the introduction of antibiotics. To increase the probability of excitation of the pathogen, it is possible to produce 2-4 sowing with an interval of 20 minutes. Antibacterial therapy Sharply reduces the possibility of seducing the pathogen, but does not exclude a positive result of sowing blood for sterility.

The role of the polymerase chain reaction in the diagnosis of bacteremia and the interpretation of the results obtained remains unclear for practical application.

The negative results of blood crops do not serve as the basis for eliminating sepsis. In such cases, it is necessary to carry out the material for the microbiological research from the alleged focus of infection (the spinal fluid, urine, sowing the sputum separated from the wound, etc.). When searching for an infection, it is necessary to remember the possible translocation of the conditionally pathogenic microflora from the intestine against the background of a decrease in local resistance in the intestinal wall - blood supply disorders, chronic inflammation in combination with a general immunosuppression.

When making the diagnosis of Sepsis, it is necessary to take into account the following signs indicating the generalization of infection:

- detection of leukocytes in liquid media of the body, which are normally sterile (pleural, spinal fluid, etc.);

- perforation of the hollow organ;

- radiographic signs of pneumonia, the presence of purulent sputum;

- clinical syndromes, in which the likelihood of the infectious process is high;

- fever with a manifestation of severe intoxication, possibly bacterial nature;

- hepatosplegaly;

- the presence of regional lymphadenitis at the place of possible entrance gates of infection;

- lesion polyorganity (pneumonia, meningitis, pyelonephritis);

- rash on the skin (polymorphic rash, frequent combination of inflammatory and hemorrhagic elements);

- Signs of DVS syndrome, etc.

Sepsis therapy It is aimed at eliminating the focus of infection, maintain hemodynamics and respiration, correction of homoseostasis disorders. The treatment of sepsis is a complex problem requiring a multidisciplinary approach, which includes a surgical sanitation of the focus of infection, the purpose of adequate etiology antibacterial treatment and the use of intensive therapy methods and prevention of complications.

Given the fact that the beginning of the development of sepsis is associated with the reproduction and circulation of microorganisms, and its etiological confirmation requires a certain time, a question of choosing an adequate antibacterial drug (ABP) emerges for empirical therapy and criteria for evaluating therapy effectiveness.

According to retrospective studies, the early appointment of effective antibacterial therapy correlated with a decrease in mortality in the treatment of uncomplicated sepsis. Therefore, an important point in the choice of ABP for empirical therapy of sepsis is:

- alleged ethiology of the process;

- spectrum of the drug;

- method and characteristics of dosing;

- Security profile.

It is possible to assume the nature of the microflora, which caused CBE, on the basis of the localization of the primary focus of infection (Table 2).

Thus, even before obtaining the results of bacteriological sowing, focusing on the estimated focus of a bacterial infection, you can choose an effective scheme of empirical antibiotic therapy. It is recommended to carry out microbiological monitoring of the sized microflora in each clinic, which allows you to create a "hospital microbiological passport". This must be taken into account when appointing an ABP.

Local epidemiological data on the structure of pathogens and their sensitivity to ABP should be taken into account, which may be the basis for creating local protocols of empirical antibiotic therapy.

In case of empirical sepsis therapy, the combination of two ABP is most often used. The arguments in favor of the appointment of combination therapy are:

- the inability to differentiate gram-positive or gram-negative etiology of infection in a clinical picture;

- high probability of sepsis polyimicrobial etiology;

- Risk of resistance to one of antibiotics.

With continued clinical efficacy, antibacterial therapy continues to be carried out by starting drugs assigned empirically. In the absence of a clinical effect for 48-72 hours, the ABP must be replaced with regard to the results of a microbiological study or, if there are no suchness, overlapping gaps in the activity of starting antibiotics, taking into account the possible resistance of pathogens.

When sepsis, the ABP must be administered only intravenously, selecting maximum doses and dosing modes in terms of creatinine clearance. The restrictions on the use of drugs for intake and intramuscular administration is a possible disturbance of absorption in the gastrointestinal tract and a disruption of microcirculation and lymphotok in the muscles. The duration of antibacterial therapy is determined individually.

Before therapy, the ABP is the following tasks:

- to achieve a sustainable regression of inflammatory changes in the primary infectious focus;

- prove the disappearance of bacteremia and the absence of new infectious foci;

- Keep the reaction of systemic inflammation.

But even with a very rapid improvement in the well-being and obtaining the necessary positive clinical and laboratory dynamics (at least 3-5 days normal temperature) The standard duration of therapy should be at least 10-14 days when taking into account the restoration of laboratory indicators. Long-term antibacterial therapy is required during staphylococcal sepsis with bacteremia (especially caused by MRSA strains) and localization of a septic focus in the bones, endocardium and lungs.

The use of generation cephalosporins III combined with beta-lactamase inhibitors is reasonable in the treatment of sepsis.

Highly efficient is the combination of cefopezone and sulbactam - cefosulbin. Cefoperazone is active in relation to aerobic and anaerobic gram-positive and gram-negative microorganisms (Table 3). Sulbactam is an irreversible beta-lactamase inhibitor, which are allocated by microorganisms, resistant to beta-lactam antibiotics. He warns the destruction of penicillins and cephalosporins beta lactamases. In addition, sulbactams binds to penicillin-binding proteins, exhibits synergism while simultaneously use with penicillins and cephalosporins.

Thus, the combination of sulbactam and cefoperazone allows to achieve synergide antimicrobial effects in relation to the microorganisms sensitive to the cefoperazone, which reduces the minimum overwhelming concentration of 4 times for data of bacteria and increases the effectiveness of therapy.

These series of studies show that 80-90% of the strains of microorganisms isolated from patients with sepsis have a sensitivity to cefoperazone / sulbactam (cefosulbin), including strains A.. baumannii. and P.. aeruginosa. . The use of cefoperazone / sulbactam (cefosulbinal) for clinical efficacy is not inferior to carbapenes and may be an alternative to the frequency generation and aminoglycosides of the frequency combination of cephalosporins.

High clinical and microbiological efficacy was shown in the treatment of sepsis (up to 95%), due to multi-resistant strains of gram-negative and gram-positive microorganisms.

Thus, the range of antibacterial activity of cefoperazone / sulbactam (cefosulbin) against anaerobic pathogens allows us to recommend this drug In the treatment of abdominal, surgical and gynecological sepsis.

Clinical efficacy in the treatment of infectious complications using cefoperazone / sulbactam (cefosulbin) is shown on a group of patients with burns and oncological pathology.

Early appointment of effective etiotropic therapy is an important factor in the treatment of sepsis and often solves the fate of the patient. In many cases, the attending physician does not have a time reserve for the selection of ABP, which is due to the severity of the clinical course of sepsis, therefore it is necessary to make the most effective antibacterial agent with the widest possible spectrum of antibacterial action. Given the wide range of antimicrobial action, the possibility of intravenous use, good pharmacokinetics and pharmacodynamics of cefoperasone / sulbactam (cefosulbin), this combined antibacterial drug can be recommended as the first line of empirical therapy for the treatment of sepsis.

Thus, taking into account the high clinical efficacy shown in a number clinical studies, good pharmacistic, cefopoperazone / sulbactam (cefosulbin) can be a drug selection when treating sepsis until bacteriological confirmation is obtained.

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The treatment of sepsis is carried out in the separation of intensive therapy. It includes surgical treatment, antibacterial therapy, detoxification therapy and immunotherapy, elimination of water and electrolyte and protein disorders, restoring disturbed functions of organs and systems, balanced high calorie nutrition, symptomatic treatment.

An integrated approach to the treatment of sepsis implies not only a combination of means and methods, but also parallel, simultaneous use. Multifactor changes in the body during sepsis, features of the primary focus of infection, the initial state of the body, concomitant diseases determine the individual approach to the treatment of a patient with sepsis.

Surgery

Pathogenetic and ethiotropic sepsis therapy provides for the elimination of an infection source and the use of antibacterial drugs.

Surgical intervention is performed in an emergency or urgent order. After stabilization of the basic functions of the body, primarily hemodynamics. Intensive therapy in these cases should be short-term and efficient, and the operation is performed whenever possible with adequate anesthesia.

Operational intervention can be primary when it is performed in the threat of generating infection or under sepsis, complicated by the flow of purulent diseases. Repeated operational interventions are performed when sepsis develops in the postoperative period or the primary operation did not lead to an improvement in the state of the patient with sepsis.

In operational intervention, the source of the infection is removed, if the state of the focus is allowed with a limited purulent process (the abscess of the breast, post-adjusting abscess), or an organ with an abscess (pyosalpinx, purulent endometritis, spleen abscess, kidney carbuncoon). More often operational treatment It is to open the abscess, phlegmon, the removal of non-viable tissues, the opening of purulent chambers, pockets, drainage.

With purulent peritonitis, the task of surgical treatment is the elimination of the cause, adequate sanitation abdominal cavity (according to re-sanations); With osteomyelitis - opening of intraosseous uluses and drainage.

Repeated operational interventions are performed not only in the development of complications in the postoperative period, the appearance of purulent metastases, the suppuration of the Russian Academy of Sciences. Operations include opening and drainage of purulent chambers, pockets, shift drainage, transformation of purulent foci, cavity, repeated necrectomy, secondary surgical treatment of jointed wounds, opening and drainage of metastatic purulent foci.

The rehabilitation of purulent foci by closed methods (puncture, drainage) is performed with the formed glands. These are intra-abdominal and intrahepatic abscesses, ventilated pancreatic cysts, unfavorable lung abscesses, empty pleura, purulent arthritis.

Infected implants, foreign bodies that led to the generation of infection are to be removed (metal structures during osteosynthesis, vascular and articular dentures, heart valves, mesh implants with a plastic of abdominal, chest wall defects). Infected venous catheters also need to be deleted.

Antibacterial therapy

The importance of ethiotropic therapy of sepsis is undoubted, it is starting as early as possible. The fight against microflora is carried out as a focus of infection - local antibacterial therapy - adequate drainage, ethane necrectomy, flow-washing drainage, the use of antiseptics: sodium hypochlorite, chlorhexidine, dioxidine, ultrasound cavitation, etc.

The basis of general antibacterial therapy is antibiotics. Antibiotic therapy can be in two versions - primary selection of drugs or change of antibiotic treatment regimen. Most often, during sepsis, antibacterial therapy is empirical: drugs are chosen taking into account the intended pathogen and, depending on the primary source. For example, the wound septice most often has a staphylococcal nature, abdominal - mixed, mostly gram-negative, including anaerobic.

The high risk of severe complications and fatal outcome when items with effective antibacterial therapy even for a day is fraught with unpredictable consequences, forces treatment with combination therapy, and with severe sepsis - with reserve antibiotics.

Cefalosporins of the third-fourth generation are used to choose from the third-fourth-fourth generation, fluoroquinolones in combination with clindomycin or dioxide or method liphog, for monotherapy - carbopenmes.

In modern conditions, the role of nosocomial infection in the once-pitting sepsis is extremely high, and with the development of polyorgan deficiency (PON), the choice of an antibiotic for empirical therapy is important, if not defining. In such conditions, carbopenmes (impediment, meropenem) play a primary role.

The advantage of these drugs is a wide range of action on aerobic and anaerobic flora (the drug is used in a monovariant). Microflora is highly sensitive to antibiotics of this group. The preparations are characterized by high trail to different tissues, and the tropiness to the peritoneum is higher than that of all other antibiotics.

In the choice of an antibiotic for empirical therapy, it is important to establish not only the estimated pathogen of infection, but also the primary source (leather and subcutaneous fiber, bone and joints, pancreas, peritonitis during colon perforations or under appendicitis). Selection of antibiotics, taking into account their organotroposis, is one of the most important components of rational antibacterial therapy. The organotoxicity of drugs is also taken into account, especially in the conditions of Pon.

When conducting antibiotic therapy, it is necessary to take into account the possibility of massive release of bacterial endotoxins in the bactericidal effects of drugs. When the shell of gram-negative bacteria is destroyed, polysaccharide (endotoxin), gram-positive bacteria - Teichoic acid with the development of Yaryshe-Hersheimer's syndrome. The toxic effect of these substances on the cardiovascular system is particularly pronounced.

After the selection of the pathogen from the hearth and blood is corrected by antibiotic therapy.

With staphylococcal sepsis caused by methicyl lifeline staphylococcus, oxacillin is used, with intraosseous foci of infection - in combination with gentamicin.

If sepsis is caused by methicillin-resistant stamps of staphylococcus, vancomycin or rifampicin is shown. The latter is quickly developed by the stability of microflora, which determines the need to combine it with ciprofloxacin.

With streptococcal sepsis antibiotics of choice, taking into account the sensitivity of the microbial flora are ampicillin, cefotoxin, vancomycin, imipenem, meropenem.

Pneumococcal sepsis determines the use of cephalosporins of the third-fourth generation, carbopenmes, vancomycin.

Among the gram-negative flora are dominated by enterubacteria, poly-resistant to antibiotics: E. coli, P. Mirabien, P. vulgaris, Klebs.spp., CitrobacterFreundis. The main antibiotics in the treatment of diseases caused by these microorganisms are carbopenmes. When you select Pseudomonas SPP., Acinetobacter SPP., Different, as a rule, multiple drug resistance, selection antibiotics are carboopenmes or ceftazidine in combination with amikacin.

Abdominal sepsis caused by anaerobic pathogens (bacteroids) or wound clodridial sepsis determine the need for combined therapy (cephalosporins, fluoroquinolones in combination with clindamycin, dioxide, metronidazole), and with abdominal sepsis - carbopenmes.

With fungal (candidal) sepsis, antibacterial therapy includes caspophungin, amphotericin B, fluconazole.

The basic principles of sepsis antibiotic therapy are as follows.

Empirical therapy begins with the use of the maximum therapeutic doses of cephalosporins of the third-fourth generation, semi-synthetic aminoglycosides, with ineffectiveness quickly go to fluoroquinolones or carbopenmes. The correction of antibiotic therapy is carried out according to the results of bacteriological studies of the contents of purulent focus, blood. If the drugs are effective, treatment is continuing.

If necessary, use a combination of two antibiotics with different spectrum of action or antibiotic with one of the chemical antiseptics (nitrofurans, dioxidine, metronidazole).

Antibacterial drugs are injected with different ways. Antiseptics are used locally (intracable, endotragically, intraosnially into the hollow of the joint, etc. depending on the localization of the focus), and the antibiotics are injected intramuscularly, intravenously, intraarterially.

The duration of the antibiotic treatment course is individual and depends on the state of the patient (the treatment continues to eliminate the signs of the SCRD: normalization of body temperature or decrease to subfebrile numbers, normalizing the number of leukocytes or moderate leukocytosis with a normal blood formula).

With osteomyelitis, the remaining cavity in the liver, lightly after the balance of the abscess, residual pleural cavity In emphasis, during sepsis caused by S. aureus, antibiotic therapy continues for 1-2 weeks after clinical recovery and two negative blood crops.

The answer to adequate antibacterial therapy is manifested in 4-6 days. The lack of effect determines the search for complications - the formation of metastatic foci, purulent chambers, the appearance of necroca foci.

Hypovolemia with shock, especially infectious toxic, is always available and it is determined not only by losing fluid, but also by the redistribution of it in the body (intravascular, interstitial, intracellular). Violations of the BCC are due to both developed sepsis and the initial levels of changes in the water-electrolytic balance associated with the main disease (abscess, phlegmon, emphasis, ventilated wound, burns, peritonitis, osteomyelitis, etc.).

The desire for the restoration of the BCC to normophemia is due to the need to stabilize hemodynamics, microcirculation, oncotic and osmotic blood pressure, the normalization of all three water basins.

Restoration of the water and electrolyte balance is the question of paramount importance, and is provided by colloid and crystalloid solutions. From colloidal solutions, preference is given to dextranum and hydroxyethylined starch. To restore the oncotic properties of blood, the correction of hypoalbumine (hypoproteinemia) in the acute situation, albumin remains ideal means in concentrated solutions, native, freshly frozen donor plasma.

To correct the disorders of the acid-alkaline state, 1% solution of potassium chloride during alkalosis or 5% sodium bicarbonate solution with acidosis is used. Amino acid mixtures (aminon, amino acid, alvezin), protein, albumin, dry and native plasma of donor blood are introduced to restore the protein balance. To combat anemia, regular transfusions of freshly consisted blood, erythrocytic mass are shown. The minimum hemoglobin concentration under sepsis 80-90 g / l.

Disinfecting therapy

Disinfecting therapy is carried out according to general principles, it includes the use of infusion media, saline solutions, as well as forced diuresis. The amount of fluid injected (polyionic solutions, 5% solution of glucose, polyglyukin) is 50-60 ml (kg / day) with adding 400 ml of hemodesa. About 3 liters of urine should be allocated per day. Lazix, mannitol, mannitol use to strengthen the urinations. In polyorgan deficiency with the predominance of renal failure, methods of extracorporeal detoxification are used: plasmapheresis, gemofiltration, hemosorption.

In acute and chronic renal failure, hemodialysis is used, which allows removed only excess fluid and toxic substances with a small molecular weight. Gemofiltration expands the spectrum of removed toxic substances - products of impaired metabolism, inflammation, decay of tissues, bacterial toxins. Plasmapheresis is effective for removing toxic substances dissolved in plasma, microorganisms, toxins. Remote plasma is replenished with donor freshly frozen plasma, albumin in combination with colloid and crystalloid solutions.

With severe sepsis, the level of IGY, IgM, IgA is particularly reduced, a pronounced decrease in T- and B lymphocytes reflects the progressive insufficiency of immunity when the infectious process is not allowed. The indicators of the violation (perversion) of the body's immune response are manifested in the blood level of the CEC. The high level of the CEC also testifies to the violation of phagocytosis.

Of the means of specific impact, the use of antistaphococcal and anticolibacilla plasma, antistaphococcal gamma globulin, polyglobulin, Gabriglobin, Sandobulin, Pentaglobin is shown. In the oppression of cellular immunity (decrease in the absolute content of T-lymphocytes), the violation of the phagocytic reaction shows the transfusion of leukocytic mass, including from immunized donors, freshly prepared blood, the purpose of the drugs of the fork gland - thimaline, and the storage factories.

Passive immunization (substitution therapy) is carried out during the period of development, at the height of the disease, during the period of recovery, the means of active immunization - anatoxins, outovaccines are shown. Nonspecific immunotherapy includes lysozyme, Prodigiosan, Timalin. Taking into account the role of cytokines in the development of sepsis, interleukin-2 is used (Roncolekin) with a sharp decrease in the level of T-lymphocytes.

Corticosteroids are shown as substitution therapy after determining the hormonal background. Only with the complication of sepsis by bacterial-toxic shock are prescribed prednigasal (in 1 day to 500-800 mg, then 150-250 mg / day) for a short period (2-3 days). Corticosteroids in conventional therapeutic doses (100-200 mg / day) are used in allergic reactions.

Due to the high level of kininogenov, during sepsis and the role of kinines in a microcirculation violation into complex therapy of sepsis include proteolysis inhibitors (Galds of 200,000 - 300,000 units / day or contrikal of 40,000 - 60,000 units / day).

Symptomatic treatment provides for the use of cardiac, vascular tools, analgesics, anticoagulants, means that reduce vascular permeability, etc.

Intensive sepsis therapy is carried out for a long time, to a persistent improvement in the condition of the patient and restoring homeostasis.

The nutrition of the patients with sepsis should be diverse and balanced, high-calorie, with sufficient protein content and vitamins. Necessarily inclusion in the daily diet fresh vegetables and fruit. With normal activity gastrointestinal tract Preference should be given to enteral nutrition, otherwise it is necessary to complete or additional parenteral nutrition.

The high degree of catabolic processes under sepsis is determined by the PON and is accompanied by the flow rate of tissue as a result of the destruction of its own cellular structures.

The specific energy value of the daily diet should be 30-40 kcal / kg, the consumption of protein 1.3-2.0-1 kg or 0.25-0.35 g of nitrogen / kg, fat - 0.5-1 g / kg. Vitamins, trace elements and electrolytes - in the amount of daily needs.

Balanced nutrition begins as early as possible, without waiting for catabolic changes in the body.

With enteral nutrition, conventional foods are used, with probe diet, they give a balanced nutrient mixtures with the addition of certain ingredients. Parenteral nutrition provide solutions of glucose, amino acids, fat emulsions, electrolyte solutions. You can combine probe and parenteral nutrition, enteral and parenteral nutrition.

Specific species of sepsis

Sepsis can develop in the blood of some specific pathogens, for example, with actinomycosis, tuberculosis, etc.

Aktinomicotic sepsis complicates visceral actinomycosis. Distribution during the actinomyosis can lead to an isolated damage to metastasis of one of the organ or to the development of metastases simultaneously in several organs.

Clinically actinomicotic peymain is accompanied by a significant exacerbation of the actinomycotic process, an increase in temperature to 38-39 ° C, the formation of new actinomycotic infiltrates, purulent foci in different areas bodies and organs, strong pain, depletion and severe common state of the patient.

For the treatment of actinomycotic sepsis, in addition to means and methods used in bacterial sepsis, have a special large dose of antibiotics, actinolizats and blood transfusion.
Anaerobic sepsis can develop with anaerobic gangrene caused by clostridia. Sepsis can also be caused by other anaerobic microorganisms, although it happens much less often.

Anaerobic sepsis usually develops with severe injuries, in weakened, telescreen wounded. There is a rapid development of anaerobic gangrene with a high body temperature (40-40.5 ° C), frequent and small pulse, extremely difficult state, confusion or loss of consciousness (sometimes it is preserved, but excitement, euphoria). In peaceful time, anaerobic sepsis is almost never found.

To the above method of treating sepsis during anaerobic form, add intramuscular and intravenous drip administration of large doses of antichangrenous serum (10-20 prophylactic doses per day), intravenous drip and intramuscular administration of the mixture of antigangreas phages.

The sepsis of the newborns is more often associated with the introduction of infection (mainly staphylococcus) through the umbilical wound, abrasion, etc. Growing temperatures, lethargy, skin rash, jaundice, diarrhea and vomiting, hemorrhage into the skin and mucous membranes are constituted clinical picture Sepsis in children. Chills rarely, the spleen increases early.

Pneumonic foci, purulent pleurisy, lung abscesses and pericarditis, which are found during sepsis and are accepted for the main disease, are brought to the diagnostic errors. Sometimes sepsis occurs under the guise of food intoxication.

VC. Hotels

Antimicrobial agents are an essential component of comprehensive sepsis therapy. In recent years, convincing evidence has been obtained that early, adequate empirical antibacterial therapy of sepsis leads to a decrease in mortality and frequency of complications (the category of evidence C). A series of retrospective studies also makes it possible to conclude that adequate antibacterial therapy reduces mortality during sepsis caused by gram-negative microorganisms (proven category C), gram-positive microorganisms (evidence category D) and mushrooms (evidence category C). Given the data on improving the outcomes of the disease in early adequate antibacterial therapy, antibiotics during sepsis should be appointed urgently after clarifying the nosological diagnosis and until the results of bacteriological research (empirical therapy) are obtained. After receiving the results of a bacteriological study, the antibacterial therapy mode can be changed taking into account the isolated microflora and its antibiotic sensitivity.

Etheological diagnostics of sepsis

The microbiological diagnosis of sepsis is determining in the choice of adequate antibacterial therapy modes. Antibacterial therapy aimed at a well-known pathogen provides a significantly best clinical effect than empirical, aimed at a wide range of probable pathogens. That is why the microbiological diagnosis of sepsis should be given no less attention than the choice of therapy mode.

The microbiological diagnosis of sepsis involves the study of a probable focus (s) of infection and peripheral blood. In that case, if the alleged focus of infection and peripheral blood distinguishes the same microorganism its etiological role in the development of sepsis should be considered proven.

When highlighting various pathogens from the focus of infection and peripheral blood, it is necessary to evaluate the etiological significance of each of them. For example, in the case of sepsis, developing

shelly against the backdrop of late nosocomial pneumonia, when highlighting the respiratory tract P.. aeruginosa. In a high titer, and from peripheral blood - coagulategative staphylococcus, the latter, most likely, should be regarded as a contaminating microorganism.

The effectiveness of microbiological diagnostics is completely dependent on the correctness of the fence and transportation of pathological material. The basic requirements are: the maximum approximation to the infection hearth, preventing the contamination of the material of the extraneous microflora and the proliferation of microorganisms during transportation and storage before the start of the microbiological research. The listed requirements are able to comply with the greatest extent when using specially designed industrial production devices (special needles or blood intake systems, compatible with transport media, containers, etc.).

The use of nutroculture prepared in the laboratory for hemoculture, cotton tampons for the fence of the material, as well as various kinds of primary means (utensils from food) should be excluded. Concrete protocols for the fence and transportation of pathological material must be agreed with the microbiological service of the institution and strictly implemented.

Of particular importance in the diagnosis of sepsis has a study of peripheral blood. The best results are possible to obtain when using industrial production environments (bottles) in combination with automatic bacterial growth analyzers. However, it is necessary to keep in mind that bacteremia  The presence of a microorganism in systemic blood flow is not a pathognomonic sign of sepsis. The detection of microorganisms even in the presence of risk factors, but without clinical and laboratory confirmations of a systemic inflammatory response syndrome, should not be regarded as sepsis, but as transient bacteremia. Its occurrence is described after therapeutic and diagnostic manipulations, such as broncho- and fibrogastroscopy, colonoscopy.

Under the observance of strict requirements for the correct fee of the material and the use of modern microbiological techniques, positive hemoculture under sepsis is observed in more than 50% of cases. When highlighting typical pathogens, such as Staphylococcus. aureus., Klebsiella pneumoniae., Pseudomonas. aeruginosa.Mushrooms, for diagnosis, as a rule, just one positive result. However, when selecting microorganisms that are skin sapries and capable samples capable of contaminating ( Staphylococcus. epidermidis., other coagulategable staphylococci, difteroids), two positive hemocultures are required to confirm true bacteremia. Modern automatic methods for studying the hemoculture allow you to fix the growth of microorganisms for 6-8 hours of incubation (up to 24 hours), which allows you to obtain accurate identification of the pathogen after 24-48 hours.

For adequate microbiological blood test, the following rules should be strictly followed.

1. Blood for research must be taken before the appointment of antibiotics. If the patient already receives antibacterial therapy, the blood should be taken immediately before the next administration of the drug. A number of commercial media for blood tests are in their composition sorbents of antibacterial drugs, which increases their sensitivity.

2. The standard of blood test for sterility is the fence of a material of two peripheral veins with an interval of up to 30 minutes, while from each vein blood must be selected in two bottles (with media for the allocation of aerobes and anaerobes). However, recently, the feasibility of studying on the anaerobes is questioned due to unsatisfactory ratio cost-effectiveness. With a high cost of consumables for study, the frequency of the extraction of anaerobes is extremely low. In practice, with limited financial opportunities, it is enough to limit the blood fence into one bottle for the study of aerubs. If there are suspicion of fungal etiology, it is necessary to use special environments to highlight mushrooms.

It is shown that a larger samples have no advantage in terms of the frequency of detection of pathogens. Blood fence at the height of the fever does not increase the sensitivity of the method ( cATEGORY OF PROTECTION S.). There are recommendations for the collection of blood two hours before the peak of fever achieve, but this is fulfilled only in those patients whose temperature rise has stable frequency.

3. Blood for research must be taken from peripheral veins. Not shown advantage of blood collection from the artery ( cATEGORY OF PROTECTION S.).

No blood fence from the catheter is not allowed!The exceptions are cases of suspicion of catheter-associated sepsis. In this case, the purpose of the study is to assess the degree of contamination of the microbes of the inner surface of the catheter and the blood pressure from the catheter is an adequate goal of the study. To do this, simultaneous quantitative bacteriological examination of the blood obtained from intact peripheral veins and from a suspicious catheter should be carried out. If one and the same microorganism is distinguished from both samples, and the quantitative ratio of the samples of the catheter and veins is equal to or more than 5, then the catheter is likely to be a source of sepsis. The sensitivity of this method of diagnosis is more than 80%, and specificity reaches 100%.

4. Blood fence from peripheral veins should be carried out with careful observance of asepsis. The skin at the venipunction site is twice with a solution of iodine or povidone-iodine with concentream movements from the center to the periphery for at least 1 minute. Immediately before the fence, the skin is treated with 70% alcohol. When conducting venopunction, the operator uses sterile gloves and a sterile dry syringe. Each sample (about 10 ml of blood or in the amount recommended by the instructions of the bottle manufacturer) is taken into a separate syringe. The cover of each bottle with the medium before piercing the needle for the inoculation of blood from the syringe is treated with alcohol. In some systems for sowing blood, special highways are used, allowing blood collection from veins without the help of a syringe - gravity, under the suction action of a vacuum in a bottle with a nutrient medium. These systems have an advantage, because Eliminates one of the steps of manipulation, the potentially increasing probability of contamination is the use of a syringe.

Careful skin treatment, bottle cover and the use of commercial systems for blood intake with an adapter allow to reduce the degree of contamination of samples up to 3% or less)