General purulent infection (sepsis). Endogenous intoxication at a surgical infection. Methods of detoxication and immunocorrection. Surgical aspects of AIDS and a narcotics.

 

Sepsis (infection of blood) - the acute or chronic disease described by progressing distribution in an organism of bacterial, virus or fungous flora. The sepsis can be result bacterial sowing an organism from the known center of an inflammation (suppuration), but there is enough frequently an entrance gate of an infection remain obscure. The sepsis can proceed acute, is sometimes almost lightning (when, at absence of correct treatment, the death comes within several hours or day) or chronically. Now character of current of a sepsis appreciably varies because of early antibacterial therapy.

Aetiology. Activators of a sepsis can be pathogenic, conditional - pathogenic microorganisms: cocci (staphylococci, pneumococci and meningococci), an intestinal stick, a blue purulent stick, mycobacterium tuberculosis, klebsiela, etc.; viruses of hyperform groups, etc.; mushrooms such as Candida, Aspergillums.

Pathogenesis. Generalization of an infection is caused by prevalence of the activator above bacteriostatic opportunities of an organism as a result of massive invasion (for example, having dug an abscess in blood from an infected blood clot, at attempt to squeeze out a furuncle, from infected trombocite weights, etc.), or the congenital or got decrease in immunity. The infringements of immunity before a sepsis, as a rule, remain indefinable, except for cases of blood depression. However, the sepsis arises not because of infringements of immunity in general, and owing to failure in any one of its parts, the leader to infringement of antibodies development, decrease phagocyte activity or activity of lymphocyte development etc. Therefore in most cases the sepsis is caused by one activator which duplication in norm is interfered by the immune answer, i.e. its certain part which has appeared genetically or is not damaged; change of activators during one disease represents exception, instead of a rule. The simultaneous coexistence of several activators, their change is observed at imunodepression, caused by application cytostatics, blood depression in result aplasium a bone brain or it leukemic defeats, action intensive insulations and the sunburn, roughly overwhelming the immune answer in several parts. The returnable septic bacterial infection is marked at hereditary defects complement 2, properdin and other factors of system complement. At rough defects of immunity frequently there are the so-called opportunistic infections caused by conditional - pathogenic flora, saprophytes. Approximately about 10 % of septic conditions are caused by a combination of activators. The polymicrobic sepsis meets at the infringements of immunity connected to absence of a spleen, infringements cellular (-helpers) a link of immunity at AIDS.

Adults and children without the obvious reasons of an immunodeficiency (cytostatics, steroid therapy, etc.) More often, the activator of a sepsis is staphylococci or pneumococci less often meningococci. On a background cytostatics therapy (it is especial in conditions intra hospital infected) the important role are played gram-negative with micro flora (intestinal or blue purulent stick, protey). The activator of a sepsis from an infected blood clot aneurysms of an aorta, system bottom cava veins (distal than the filter established in it), subclavia vein (at long standing in it catheter) can be both staphylococci, and blue purulent stick, and pneumococci. Lymph proliferative tumors and lymphogranulomatosis are accompanied by infringement antivirus immunity that conducts to general herpes infections (a chicken pox, surrounding deprive, a simple herpes) down to a sepsis. Infringements neytrophilopoesis because of hereditary neyropenia meet recovering staphylococcal infections sometimes development of a staphylococcal sepsis. At long reception of steroid hormones, chronic or acute bacterial septic processes and a tubercular sepsis are possible.

After removal of a spleen (at the slightest pretext) there is a predisposition to septic conditions more often meningococci or pneumococci etiology. The spleen is capable phagocyte new, the bacteria not connected to antibodies, incapsuled bacterium (in particular, meningococci and pneumococci) whereas in liver pneumococci only it is good opsonised bacterium. That the liver has undertaken function of destruction incapsuled, no opsonised bacteria after removal of a spleen, it is necessary to enter great volumes of the fresh plasma containing opsonin. The ambassador spleenectomy the maintenance in plasma such opsonin as properdin, tuftsin, developed mainly by a spleen and necessary for phagocytosis microorganisms neytrofiles, it is reduced. Properdin is also the factor "starting" an additional way of activation of system complement (from component ) - one of the important parts humeral immunity. At last, in a spleen M. Shortage antibody of all these factors, which developed in, promotes development fatal postspleenectomy syndrome.

         The important role in distribution of an infection is played with formation of a syndrome disseminated intravascular curtailing of blood (DIC). The massive infection forms a basis of fabric disintegration, an output in blood kynings and proteolytic enzymes promoting infringement of vessels permeability, stasis and formations of thrombs in system of microcirculation. Plural thromboses become environment for growth of micro flora. In development of the DIC - syndrome at a sepsis the essential role played endotoxine-lypopolisacharides from a wall of an intestinal stick, capsule polysaccharide of pneumococci, coagulates, produced by the capsule staphylococci, and with other products of a bacterial cell. One of the most investigated ways of excitation of the DIC - syndrome at a sepsis - activation of XII factor of curtailing (factor Hageman). Influencing on vascular wall, endotoxine activates XII factor, that conducts to increase of curtailing, formation callicreini and its predecessors, and together with them to activation fibrinolisis (to transformation plasmogen to plasmin), to formation cinini, activation of system complement. Accumulation of bradicinini leads to development of a shock - to falling the BP, to increase of permeability of vessels and frustration of microcirculation.

DIC-SYNDROME and shock - constant complications of the sepsis caused gram-negative by microorganisms, meningococci, the acute pneumococci and a staphylococcal sepsis. Accumulation cinins at a sepsis and the DIC-syndrome is promoted by an exhaustion of such enzymes, as cinaze, inhibitor kalikreini, healthy persons usually contained in plasma. Activated in the beginning of the DIC- syndrome fibrenolisis then it is acute reduced owing to an exhaustion of factor Hageman, kalikreini, actually plasminogeni. Oppression fibrenolisis - a characteristic attribute of the DIC- syndrome complicating a sepsis. Infected micro blood clots the DIC-syndrome inevitably leads to expressed poly organic pathology, in pathogenesis that the major role is played in the beginning with infection, and after 2-3 weeks - pathology of immune complexes. The precise border between actually septic organic pathology and immune complex syndromes after liquidation of the basic bacterial and micro thrombotic processes does not exist. Inactive, but not fag bacteria in blood clots can keep the activity and cause relapses of illness, promote its transition in chronic, is more often monoorganic process. The DIC- syndrome is practically obligatory in pathogenesis of sepsis; disappearance of its laboratory and clinical attributes testifies to successful treatment.

The thrombocytopenia and decreasing curtailing can caused not only consumption of trombocytes and factors of curtailing in blood clots. In connection with an infection, formation of antibodies, immune complexes it is activated phagocytosis (in particular, phagocytosis neutrofiles); thus from neutrofiles enzymes zlastase, chemotripsin are liberated. Surplus of these photolytic enzymes promotes damage of tissue (in particular, a vascular wall), lysis of trombocytes and some factors of curtailing that conducts, in turn, to development hemorrhagic syndrome and a acute respiratory distress-syndrome.

 

The clinical picture of a sepsis depends on the activator, a source of penetration of an infection and a condition of immunity. The beginning of disease can be rough with a tremendous fever, hyperemia, mialgia, hemorrhagic or papule rash or gradual with slowly increasing intoxication and gradual rise in temperature of a body. Too often, but to nonspecific attributes of a sepsis carry increase in a spleen and a liver, expressed disposition to sweat after a fever, acute weakness, hypodynamia, anorexia, a lock. At absence of antibacterial therapy, the sepsis, as a rule, comes to an end death from plural infringements of all bodies and systems. Thromboses (especially veins of the bottom finitenesses) in a combination with hemorrhagic syndrome are characteristic. At adequate antibacterial therapy on a background of decreasing of temperature, reduction of an intoxication through 2-4 week from the beginning of illness appear arthralgia (down to development of a polyarthritis), attributes glomerulonephritis (fiber, erythrocytes, cylinders in urine), symptoms polyserositis (noise of friction of a pleura, noise of friction of a pericardium) and myocarditis (a tachycardia, a rhythm of gallop, passing systolic noise on a top or on palm arteries, expansion of borders of relative dullness of heart, decrease or even become negative position P and displacement downwards segment ST mainly in forward chest assignments). This semiology arising on a background of improvement of the basic parameters of septic process and concerning to pathology of immune complexes, it is not necessary to confuse to attributes of actually septic, bacterial pathology. The basic displays of last fall to the first days of illness and characterized by all attributes of purulent - septic process in this or that body (purulent myocarditis, endocarditis, variants of septic defeat easy and kidneys). The main role in treatment of a sepsis played with massive antibacterial therapy and struggle by a DIC-syndrome.

A heavy DIC- syndrome, respiratory distress-syndrome are marked plural discoid athelectasis and unstable polymorphic shadows in easy, caused interstitial hypostasis. Similar changes observed at heavy current of a sepsis irrespective of the activator and on individual roentgenograms almost different from pneumonia. However for shadows of the inflammatory nature resistance, and shadows interstitial hypostasis - is characteristic. Auscultation easy about interstitial a hypostasis can testify not sonorous rattles, crepitating.

Diagnosis. The beginning of any heavy inflammatory process accompanying with a fever, a high body temperature, at first sight, is uneasy for distinguishing from the beginning of a sepsis. However fast rise of temperature till 39-40 , a tremendous fever, the general grave condition without expressed monoorganic pathologies, high leycocytosis with young shift up to 20-30 %, clinical and laboratory attributes of the DIC- syndrome are the sufficient basis for diagnostics of a sepsis and carrying out of corresponding intensive therapy. The diagnosis of a sepsis is the extremely important for connecting with the concrete activator as bacteriostatic, antivirus or anticandidal therapy has strictly specific character. The establishment etiologic the diagnosis represents the big difficulties and it is not always possible. Crop of blood, revealing of specific bacterial antigens in 50-60 % of cases do not give the answer to a question on the nature of the activator in the first days of illness when define concrete tactics of treatment. Diagnostics of a sepsis with revealing the nature of the activator assumes daily crops of blood irrespective of negative answers in the first days of illness and the spent antibacterial therapy making an opportunity of positive results of crop all less and less probable. The important role in an establishment of the activator of a sepsis played with features of a clinical picture of illness and its first symptoms.

Staphylococcal sepsis characterized by a tremendous fever, a high fever, occurrence of a pain in muscles and bones. The muscular pain can be almost "morphinic" intensity. Usually thus on a skin it is possible to see individual papule unhemorragic the nature sometimes with formation of the smallest bubble at top papule. The general condition of patients heavy, but is not present deep general oppression, consciousness clear, patients precisely tell about the sensations. On roentgenograms easy quite often come to light plural almost identical size and density cloudlike shadows which further merge, forming non-uniform focuses and zones of disintegration. In the beginning of process, dry cough is marked and then it becomes damp with pass out plentiful yellowish color fluid. The formed abscess easy can break in pleura with development of empiema. Mialgia quite often are investigation of microabscesses in muscles. Further formation of plural phlegmons, the centers of an osteomyelitis, abscesses of a liver, kidneys and other bodies is possible.

Meningococcal sepsis differs quite often rough beginning with very heavy intoxication, entheropathy which within several hours can lead to development of a shock; the progressing congestion, quickly coming loss of consciousness are characteristic. At lines of patients on a skin appear plentiful polymorphic or monomorph papule hemorrhagic break. Ascertaining of this rash becomes the basis for the assumption about meningococcal to the nature of a sepsis and immediate purpose of the big dozes of penicillin intravenously. Hemorrhagic break testify to a heavy DIC- syndrome; it grasp not only a skin, but also hypodermic cellular tissue, therefore developing on their place necrosis can appear deep enough. Heavy microtrombotic process promotes fast formation of deep bedsore; It underlies a clinical picture glomerulonephritis (down to development anuria) and a hepatitis (moderate rise of a level of bilirubin). Heavy complication meningococcal sepsis - a hemorrhage in both adrenal glands (owing to the DIC- syndrome), causing a clinical picture of a shock. On a background of improvement of a condition of the patient and normalization of temperature meningococcal sepsis can be complicated a symmetric gangrene (dry or damp) fingers of legs, and at not enough active therapy of the DIC- syndrome - and more extensive gangrene demanding amputation of finitenesss. In hemogram, it is frequently determined leycocytosis young form shift up to 20-40 %. Clinical improvement and dynamics of a blood picture cannot coincide: leycocytosis young form shift are at times kept on a background of a normal body temperature which under influence of powerful antibacterial therapy is reduced within several days, and plural organic a pathology and deep necrosis remain for some weeks. Alongside with high leycocytosis meets and thrombocytosis (sometimes up to 1 million and more thrombocites in 1 ml of blood), in particular, due to activation colonystimulation factors of hemopoesis under influence interleukin I, produced by the macrophages processing an antigen of the activator.

To increase of a level, interleukin I (as endogenic pyrogen) connected a fever, neytrofilosis, proliferations of T-helpers, development of antibodies.

Pneumococcal sepsis characterized by the usual beginning for a sepsis: a tremendous fever, rise of a body temperature until 39-40 . However, in these cases there is an expressed intoxication with adynamia, but without loss of consciousness and a shock. Patients tersely answer questions, are quickly exhausted. Break on a skin, mialgia, phlegmons and other displays septikopyemia pneumococci to a sepsis are not peculiar. Absence expressed organic pathologies on a background of the heaviest general condition is indicative. Distinctive feature of disease is quite often preservation of small percent young form of leukocytes in blood whereas to other kinds of a bacterial sepsis it is peculiar uneosinophilia. Leycocytosis at pneumococcal sepsis moderate, but young form of leukocytes shift may be expressed. Hemorrhagic the syndrome usually is absent. Current pneumococci a sepsis not so rough, as meningococcal (exceptions can be!), But improvement of a condition under influence of antibacterial therapy also comes not so quickly, as at meningococcal a sepsis.

First attributes of adequacy of treatment appear reduction of weakness, disappearance shivering and occurrence of appetite though the body temperature during several days can remain increased, only finding out the tendency to decrease. Underestimation of a subjective parameter of improvement is rather dangerous, as absence of laboratory attributes of improvement on a background kept febrile temperatures can create erroneous representation about an inefficiency of antibacterial therapy while penicillin (instead of antibiotics of a wide spectrum of action) is shown at pneumococci sepsis during all disease proceeding of many weeks, and sometimes and months (for example, at an infected blood clot in a large vessel). Relapse of a fever, deterioration of the general condition, renewal of a fever testify to untimeliness of a cancellation of penicillin. All this demands not change of an antibiotic, and returning to treatment by penicillin in the big dozes (usual at pneumococci and meningococcal sepsis of a dozen of penicillin for adults, 20000000-24000000 D/day, it is not necessary to increase components essentially as at dozes 30000000-40000000 D/day can develop heavy hemorrhagic syndrome caused by desegregations of thrombocites). Feature of pneumococci a sepsis is small expressiveness or full absence bright organic displays of illness though this kind of a sepsis, as well as others, can become complicated immunocomplex by a syndrome of this or that character.

Sepsis, caused by gram-negative microorganisms (an intestinal stick, protey, blue purulent stick), meets or at presence of a large entrance gate (postoperative abscesses in a belly cavity, abscesses in a small basin after the gynecologic interventions, an infected blood clot in aneurism to the expanded aorta), or at acute suppression of immunity (cytostatics therapy, lymphoproliferative tumors of system of blood, acute leucosis). In diagnostics of these forms of sepsis, the major role are played with bacteriological analysis - crop of blood, urine, fluid, bacteryoscopy of exudates from wounds and prints surfaces. One of displays blue purulent  sepsis (sometimes staphylococcal) becomes necrotic a hemorrhage: break (at times individual) the sated dark red, almost black color, surrounded with dark red shaft and rising above a skin surface. These sometimes painful (it is especial in the beginning) formations gradually grow. The body temperature remains febrile there are affiliated eliminations on other sites of a skin and in internal bodies (found out at pathoanatomical research). Necrotic hemorrhages practically do not give in to usual kinds of antibacterial therapy because of surrounding them dense thrombotic a shaft, but inside these formations there is an active pathogenic flora. The mechanism of formation necrotic hemorrhages, apparently, is close pathogenesis gangrenes at which the main role are played with the center necrosis, surrounded with gradually extending zone of a thrombosis: the infection provokes formations of thrombs, blood clots make a nutrient medium for growth of microorganisms and block receipt of antibiotics in necrotic center. Process appears self-taken owing to an exhaustion of system fibrynolisis. The basic means of break of this vicious circle is local application dimetilsulphus with an antibiotic on a background of usual antibacterial therapy and increase fibrynolitic activity of blood with the help of massive transfusions of chilled plasma.

Sepsis caused by blue purulent stick, on a background imunodepression (of cytostatics therapies, tumors of system of blood) differs extreme weight and quickly developing shock. The same sepsis, which has arisen at normal parameters of blood because of break of an infection from the infected blood clot, can proceed acutely; the condition of patients worsens gradually; antibacterial therapy renders some positive, but unstable effect. In general, the sepsis caused by gram-negative micro flora, without an entrance gate, at normal structure of leukocytes and without reception immunodepresants is rather improbable. For a sepsis caused by an intestinal stick, are characteristic absence organic pathologies and septycopyemia, fast development of a shock (sometimes it is literally within 2-3 hours from the moment of occurrence febrile temperatures).

Diagnostics of the sepsis caused by gram-negative micro flora, in hematological and oncological hospitals quite often take the doctor on duty which nevertheless prior to the beginning of antibacterial therapy (simultaneously with the first introduction of an antibiotic) should take blood on crop in any sterile closed utensils and to put in thermostat at 37. In diagnostics of a sepsis, is not necessary to neglect any attribute, allowing estimating character of pathogenic flora. So, if a source of a sepsis became any symptoms of puss on a cavity (pleuras empyema, an intestinal abscess, etc.) character of micro flora try to define to a certain extent on a smell.

As clinical attribute of change of the activator on a background of the current septic process, change of a clinical picture of illness serves: on a background of progressing improvement of a condition the body temperature suddenly rises, there is a fever, accrues leycocytosis and again is found out expressed young form of it shift. Similar changes are possible and owing to formation septycopyemia cavities. Therefore simultaneously with searches of the new activator it is necessary all accessible means to exclude presence of an abscess of internal bodies (an intrahepatic abscess, kidneys carbuncle, etc.).

Sepsis caused by viruses of herpes, meets almost exclusively on a background heavy imunodepression of lymphoprolipherative diseases (including acute lymphoblust -cellular leucosis), lymphogranulomatosis. Diagnostics of generalization of a virus surrounding depriving does not represent work when process begins with small characteristic segmentary break. Then break distributed on all skin and arise on a mucous membrane of an oral cavity, a trachea, bronchial tubes, a gullet, vocal chords. Exact also can proceed and a sepsis caused by a virus of a chicken pox, less often - a virus of simple herpes. In the developed picture, all three processes are practically indiscernible. Damage of a surface break, removal of crusts (it to do impossible!) it can be accompanied secondary infected elements of a rash and development of usually staphylococcal sepsis.

Treatment of a sepsis should be first pathogenesis. As the main role in development of a sepsis (as against any other infection) is played with massiveness of an infection, presence of microorganisms at blood and at all tissue at a combination with expressed dissemination intravascular curtailing of blood also therapy is directed against two components of process - infections and the DIC-syndrome. Patients with a sepsis should be hospitalized immediately at suspicion on it in branch of intensive therapy or reanimation. Hemorrhages in adrenal glands, a gangrene of finitenesss and irreversible changes of internal bodies are consequence of overdue pathogenesis therapy of a sepsis patient.

After an establishment of the diagnosis from a vein take blood on crop, for biochemical researches (bilirubin, prothrombin, transaminase, creatinin, albuminous fractions) and for the analysis of system of curtailing (fybrinolitic activity, protaminsulphus and ethanol tests, products of degradation fibrinogen). At research of blood calculation trombocytes, and then and reticulocites is obligatory. Right after captures of blood on various researches through the same needle enter in a vein an antibiotic according to character of a prospective infection, but in the greatest possible dozes. At presence of the expressed attributes of the DIC- syndrome (in particular, a plentiful rash, it is especial hemorrhagic character), mialgia and morbidities of muscles at palpations, polymorphic shadows interstitial hypostasis easy or more or less same shadows hematogenic dissemination infections on the roentgenogram of bodies of a chest cavity should be immediately started plasmapheresis. Delete near 1,5 l of plasmas, replacing it approximately on 2/3 corresponding volume of chilled plasma. At heavy current of a sepsis, the volume of poured chilled plasma can exceed volume of out plasmas; to enter thus it is necessary not less than 2 l chilled plasma.

Besides the listed above attributes of the DIC- syndrome, it is necessary to take into account and a symptom of thrombosis formation needles at punction of veins, and also fast thrombosis formation after a puncture of a finger for the analysis of blood. On a background of a sepsis of these attributes, it is enough for a reliable establishment of the diagnosis of the DIC- syndrome. After plasmapheresis, and if necessary and during its carrying out apply heparin in a dozen 20000-24000 D/day to adults. Heparin enters me/v dropsy or it is continuous, or hourly. To increase intervals between introductions of dozes heparin, at least in the first day of treatment, does not follow. Presence of hemorrhagic syndrome is not contra-indication, and the indication for treatment by heparin. If plasmapheresis is impracticable, introduction of chilled plasma in the same volume is necessary, as well as at plasmapheresis. In the first days of treatment, hypodermic and intramuscular injections are undesirable.

At an arterial hypotension apply sympathomymetics, at proof decrease in arterial pressure intravenously enter hydrocortisone or prednizolony in a doze, sufficient for stabilization of a condition of the patient then steroid hormones cancel this very day, and at their long application (if there is no hemorrhage in adrenal glands long therapy by glucocorticoids is extremely undesirable) - within 2-3 days. In itself the arterial hypotension does not serve as contra-indication to plasmapheresis which should be begun in this case with introduction i/v 500-1000 ml of chilled plasma and to carry out in small volume (500-800 ml pass out plasmas).

           Traditional, but effective enough methods efferent therapies of a sepsis are haemosorbtion, plasmosorbtion and plasmapheresis. At presence of the modern equipment, modern sorbents and the prepared personnel, these technologies do not lose the value and now, actively influencing on the major factors pathogenesis a syndrome endogenous intoxication, hyperbylirubinaemia, expressed hepatoprotective action, etc.

However quite often there is a need of increase of efficiency of methods efferent therapies especially when other methods of treatment (conservative, operative) it is not possible to achieve improvement or even stabilization of this or that clinical situation. The basic ways of optimization efferent therapies in conditions of clinic are a combination in one contour of several methods detoxication:

- plasmapheresis and plasmosorbtion. Procedure is carried out on the device of Russian manufacture "Hemopheniks" with use of plasma filter "PPhM-01-." at the first stage a session: it is carried out(is spent) in a mode continuous membrane plasmapheresis, thus out 25-30 % of volume of circulating plasma (VoCP). Then the plasma piece of a highway joins to sorbent to a column and is connected to a returnable department of a contour. The second stage of procedure consists in transition with plasmapheresis in plasmosorbtion. For 3-3,5 hours of a session it is possible to achieve volume plasmoperfusion 80-100 % VoCP.

Plasmosorbtion+ plasmosorbtion. Into structure of a contour enter 2 sorbent columns: the first - in the beginning of a contour; the second - at a stage of return of plasma. First, the given model extracorporeal detoxication allows to carry out double clearing of blood of toxins. Second, use in one contour of different types sorbent columns essentially expands a spectrum sorbent toxins and, thus, influences on pathogenesis of diseases more fundamentally. Recently preference we give combinations biospecific sorbents ("Ovosorb") with carbon sorbents ("GCGD").

For carrying out of long and numerous intravenous infusions usually there is a necessity in catheterization one of peripheral or less often than the central veins. It is necessary to remember thus, that the deferred rises of a body temperature (after several days of its proof decrease) can be investigation of veins thrombosis near catheter, and also infected of blood clot or adjoining hypodermic cellular tissue; the skin in this place appears hyperemia. In such cases catheter either take absolutely, or enter in other vein.

Antibacterial therapy of a sepsis is defined by a kind of the prospective or established activator. If neither clinical, nor laboratory attributes do not allow to establish with any reliability etiology the factor appoint a rate of so-called empirical antibacterial therapy: gentamycin (160-240 mg / ml) in a combination with cephalorydyn (cephoryni) or cephasolini (kephzol) in a doze 4 g/day i/v. To estimate efficiency of antibacterial therapy on a background of other medical actions it is necessary on improvement of a subjective condition of the patient, stabilization the BP, to decrease in a body temperature, disappearance of a fever, reduction of number old or to absence new break on a skin. Reduction of percent concerns to laboratory attributes of effectiveness of antibiotics young form elements in the blood count. Distinct weighting of a condition on all listed parameters during 24-48 h and deterioration of state of health of patients the next day after the beginning of antibacterial therapy testify to an inefficiency of the chosen antibiotics and necessity of their replacement.

The following circuit of empirical antibacterial therapy assumes, that the sepsis is caused not staphylococcal, not by an intestinal stick and not meningococcal (meningococcal sepsis at an inefficiency of antibacterial treatment usually proves hemorrhagic rash). The least defeat of internal bodies is marked usually at pneumococcal a sepsis. In this connection, it is expedient to replace cephalosporin with the big dozes of penicillin (20000000-24000000 D/day i/v for 8 introductions or i/v it is continuous dropping), simultaneously continuing treatment by gentamycin.

If results of the carried out research allow counting, that the sepsis is caused gramm-negative microorganisms, to the patient appoint carbenicillini (20-30 g/day i/v dropping or steam for 6-8 introductions) and still continuing application of gentamycin. As carbenicillini concerns to desegregate preparations (i.e. interferes with aggregation thrombocites), displays not heavy hemorrhagic syndrome - more, than usually, the expressed hemorrhages are possible in the field of injections, mechanical traumas. If these antibiotics are effective, in it hemorrhagic syndrome cannot be examined as the indication to their cancellation; only strict exception of complex therapy of others desegregate means (first of all not steroid anti-inflammatory preparations) is necessary.

Treatment established or prospective pneumococcal or meningococcal sepsis includes i/v introduction of penicillin in the mentioned above dozes. Practically in all cases of inefficiency, penicillin therapy at these patients the question is about incorrectly made etiological diagnosis. In an estimation of efficiency of antibacterial therapy of these two kinds of a sepsis it is important to pay attention to subjective improvement of state of health on stabilization of process, absence of deterioration of a condition during several days, and not just on a body temperature. All these attributes speak well efficiency of spent therapy; form the sufficient basis for preservation of spent treatment constant, without any vanity and unreasonable change of antibiotics. As occurrence steady against penicillin shtam among pneumococci and meningococci practically is not observed, there are no bases for a cancellation of this antibiotic during all course of treatment (not less than 3 weeks) under condition of their efficiency.

Antibacterial therapy of the sepsis, which has arisen on a background previous imunodepression, is especially difficult. In these cases of antibiotics using quite often render temporary effect - the body temperature is reduced, the state of health improves (in these cases organics displays of a sepsis are frequently insignificant), but then suddenly the fever, a fever, etc. again begin. In the anamnesis at such patients quite often-big spectrum of the used antibiotics rendering a temporary positive effect. In these cases therapy by preparations the scale - globulins, entered intravenously (in particular, endubulin in a dozen 1-2 g on 10 kg of weight of a body of 1 times in 7-10 days is shown, and at heavy current of a sepsis 2 times a week; endubulin it is undesirable to use before plasmapheresis and those days when were carried out transfusion of plasmas, erythrocyte weights, albumin and other albuminous preparations).

Staphylococcal sepsis therapy is expedient for beginning with application of an antibiotic from group cephalosporines with gentamycin (see above). If the effect is insufficient, gentamycin it is possible to replace amikacin (500 mg 2-3 times day). Even at insignificant kidney insufficiency cephalosporins can appear acutely kidney toxic (they are deduced by kidneys). Kidney toxic and used in this circuit amynoglycosides (gentamycin, etc.). Therefore, therapy by the specified antibiotics should be accompanied to constants (2 times a week) by the control of a level creatinin in blood, analyses of urine and definition diurhesis.

Deterioration of function of the kidneys, demanding or cancellations of antibiotics of the given lines, or reduction of their doze counted on creatinin clearance, is shown by reduction diurhesis (down to anuria when it is necessary massive immediate plasmapheresis) and increase of a level creatinin for limits of its top border of norm. Duration of antibacterial therapy at a sepsis is determined by existence of the basic displays of illness (including immune complex); usually negative results of crops of blood have no value as criterion of a cancellation of antibiotics.

Antibacterial therapy should be continued not less than 2-3 weeks at the most favorable current of illness. At the delayed process, occurrence of attributes septic endocarditis, septycopyemic centers and an osteomyelitis antibacterial therapy is continued with many months.

Thus, the long directed antibacterial therapy, heparin, chilled plasma, plasmapheresis- the basic ways of treatment of the sepsis, directed on destruction of the activator, activation fagocitosis in a spleen and factors humoral immunity, suppression cinini, introduction antyagregantion factor of plasma and plasminogeni, necessary for activation fybrinolisis. Plasmapheresis strengthens removing the destroyed cells, bacteria, activates phagocyte function of a spleen which at a sepsis, as a rule, appears blocked.

 

         Surgical aspects AIDS and narcotisms

         Acquired Immune Deficiency Syndrome (AIDS) is the most dangerous infectious disease conducting by a lethal outcome on the average later 10-11 years after infection by a human immunodeficiency virus (HIV). According to the United Nations, published in the beginning of 2000, pandemia HIV / AIDS already has carried away lives more than 18 million person and today in the world there lives 34,3 million. HIV - infected.

         In Russia for April, 2001 it has been registered by 103 thousand. HIV - infected, and only in 2000 the new case has been revealed 56471.

         Now it is proved three ways of transfer of the HIV - infection: sexual; by means of parenteral introductions of a virus with preparations of blood or through infected tools.

          Taking into account features of current of the HIV - infection, it is impossible to deny with confidence its absence at this or that patient. For the medical personnel each patient should be considered as the possible carrier of a virus infection. In all cases of possible contact to biological liquids of the patient (blood, wound separated, separated from drainages, etc.) it is necessary to use a secret of a glove to wash and disinfect hands is more often, to use a mask, goggles or a transparent screen for eyes. To not accept participation in work, with patients at presence of grazes on a skin, of hands or superficial defects of a skin.

        Special safety measures should be observed at operations. The medical personnel, which has defeats on a skin (cuts, skin diseases), should be released from direct treatment of patients with the HIV - infection and uses of the equipment contacting to them. As protection during operation by surgeons, anesthesiologists and operational nurses plastic aprons, over sleeves, disposable dressing gowns from a nonwoven material should be used.

         For protection of a mucous membrane of eyes it is necessary to use glasses, for protection of a nose and a mouth - double masks, two pairs are put gloves on hands, or use special gloves (fig.3, 4)

                                          

Fig. 1 Special protective gloves for protection of the personnel during operation at HIV - infected and AIDS patients.

Fig 2. Goggles and masks for work with HIV - infected patients and patients AIDS

 At operations HIV - infected and patients with AIDS the tools used only for the given category of patients and having marks "AIDS" are used. Sharp and cutting tools during operation are not recommended to be handed. The surgeon should take itself tools from a table of the operational sister.

         Bandaging of patients in the postoperative period and also the manipulations, which are not demanding anesthesiology, the manual, are carried out in specially intended for the given category of patients dressing. The surgeon and the dressing nurses put on the same as and on operation. Tools are marked with an inscription "HIV" and used at bandaging only HIV /AIDS-patients. Processing of the used material, tools and study is carried out the same as and in operational.

It is possible to relate features of local process: massive defeat of tissue, presence extensive purulent cavities, languid current, propensity to distribution to depth, to formation extensive phlegmons, the big area purulent - destructive defeats, with the expressed intoxication and heavy current is purulent - necrotic.          

Especial attention deserves post injections abscesses which characterized the big zone of defeat, languid current and ability for cause a sepsis. In them pathogens main role has there is a progressing decrease in immunity and activations of conditionally pathogenic flora. Therefore intramuscular injections of the medicines, capable to cause aseptic necrosis of soft tissue, at a HIV infected persons may to apply only in unusual cases.

           Unfortunately, medical workers ignore this rule of introduction of medicines. Investigation of it is proof high frequency post injections abscess owls at a HIV infected. The category high risk of such abscesses is children age till 5 years (fig. 3). Such phenomenon natural, since it is caused both a hereditary immunodeficiency and the compelled injections during this period of a life of the child - inoculations, treatment of children's inflammatory diseases, complexity of other ways of introduction of medical products.

         

                       5       10     15    20     25     30     35    40   45      50     55 (age)

   Fig. 3. Frequency post injections abscesses at a HIV - infected.

At virus carriers, the postoperative period proceeds without complications and changes of blood. Wrote out patients in the same terms, as not infected HIV of surgical patients. In the postoperative period at patients with AIDS, it is especially in a combination to other infections, long time the high temperature was kept. Healing of an operational wound at all patients occurs primary tension, but seams removed on 10 - 30 day. At studying the immune status increased) parity -suppressors/-helpers is marked. Amplification fybrinolytic activity, not accompanied by increase bleeding tissue is marked also.