The article will focus on one of the most dangerous complications of the postoperative period - surgical sepsis. Purulent infection of the blood occurs due to the ingestion of harmful microorganisms into the blood. The likelihood of developing sepsis increases with a significant weakening of the body's defenses.
This disease occurs in the presence of a purulent focus of any localization. Abscesses, phlegmon, boils, mastitis and other pathologies are capable of provoking surgical sepsis. The clinical picture of blood poisoning depends on the form and stage of the disease.
The meaning of the term
Until the middle of the last century, the fight against this disease in almost 100% of cases ended in the defeat of medicine. And today, sepsis is understood to mean a severe general infectious process with a high risk of mortality. In case of acute or chronic blood infection, the bacterial, viral or fungal flora rapidly spreads in the body.
At the moment, the diagnosis of common purulent surgical infection (sepsis) is carried out in the early stages, which allows you to start treatment in a timely manner and stop the process of reproduction of opportunistic microorganisms.
Causes and causative agents of sepsis
Anything can cause this disease. Among the bacteria that most often trigger purulent-infectious processes in the body, it is worth noting:
- streptococci;
- staphylococci;
- protea;
- Pseudomonas aeruginosa;
- E. coli;
- enterobacter;
- Klebsiella;
- enterococcus;
- fusobacteria.
On the background of mycotic infection, surgical sepsis develops much less frequently. But in nine out of ten cases of fungal blood damage, the cause is the yeast-like candida fungus, which causes thrush and is mistakenly considered harmless.
As a rule, viruses are not a direct cause of surgical sepsis. Pathogens of this type are not able to form purulent foci. In this case, viruses can significantly weaken the immune system, therefore, the protective functions of the body do not work on bacterial infections.
Inflammatory mediators
Surgical sepsis alone does not occur without pathogens. At the same time, bacterial damage is not the only condition for the onset of the disease. To a greater extent, microbes do not provoke severe disorders and lead to irreversible consequences. The reason lies in the self-defense mechanisms of the body, which reacts to the pathogenic flora too clearly. As a result, the reaction is so strong that it damages its own tissues.
And since any infectious process is accompanied by inflammation, one cannot avoid the release of special biologically active substances into the blood. They are called inflammatory mediators and interfere with normal blood circulation, damage blood vessels, and cause malfunctioning of internal organs.
Therefore, the concept of the pathogenesis of surgical sepsis is not only the infection of the body. This disease is an inflammatory reaction of the body itself that occurs in response to infection by bacteria. In some people, it can be expressed to a weak degree, in others - in a stronger degree, which depends on individual characteristics. That is why, when immunity is weakened, the causative agent of surgical sepsis is not only pathogenic microbes, but also conditionally pathogenic microorganisms that normally do no harm (for example, thrush), and under the described conditions they become an infectious agent.
Types of disease
There is no single classification for surgical sepsis. In their practice, doctors use the most suitable, in their opinion, indicator to determine the type of disease. Most often, blood poisoning is distinguished by etiology, that is, by the type of pathogen that occurs:
- gram-positive or gram-negative;
- aerobic or anaerobic;
- mycobacterial or polybacterial.
Classifications of surgical sepsis provoked by representatives of staphylococcal, streptococcal, colibacillary, etc. are distinguished into separate groups.
Another reason for determining the variety of the disease is the localization of the primary focus, the infection pathways. If the cause of blood poisoning was an intervention with purulent sore throat, they talk about the tonsillogenic form of sepsis. Otogenic, odontogenic, urinogenital and other types of the disease are also distinguished. This method of classification of surgical sepsis allows us to make an assumption about the origin of the disease. If the infection pathways are unknown, sepsis is called cryptogenic.
In the course of the disease, acute, chronic and fulminant are distinguished. If with acute surgical sepsis there is about 3-4 days to save the patient, then with fulminant form - no more than a day. For the chronic form of the disease, relapses and remissions are characteristic for several months or years.
Forms and stages
Doctors distinguish several degrees of severity of the disease:
- the first is sepsis;
- the second is severe sepsis;
- the third is septic shock.
The main difference between ordinary and severe sepsis is the lack of dysfunction of the internal organs. In severe sepsis, symptoms of organ failure appear, which in the absence of treatment or its inefficiency increase, as a result of which the second degree becomes the third. Septic shock differs from severe sepsis in hypotension, which cannot be corrected, and multiple organ dysfunction against the background of severe widespread damage to blood vessels and metabolic disorders.
At the initial stage of blood poisoning, which doctors call purulent-resorptive fever, extensive purulent foci and body temperature above 38 ° C are observed for seven days after opening the abscess. In this case, the results of a blood test may be within normal limits. If medical care is not provided at this stage, the disease will go to the next stage - septicotoxemia. In this case, the blood culture will show the first changes. It takes about two weeks to successfully treat septicotoxemia. Control blood tests are performed to confirm cure.
The transition of this stage to the next, to septicemia, is evidenced by a stable fever and positive results of blood sowing. Unlike septicopyemia, another form of the disease, there are no metastatic abscesses.
Separate isolated chronic sepsis, in which blood cultures can remain unsterile for a long time. The patient has a history of purulent foci. The chronic form of blood poisoning is less aggressive, periodically noted by fever, deterioration of well-being, and sometimes the appearance of new metastatic ulcers.
Sepsis as a complication of disease
Blood poisoning can occur against the background of almost any infectious and inflammatory disease. A feature of the surgical form of the disease is that it develops as a result of invasive intervention. The most common causes of surgical sepsis:
- diseases of the genitourinary system;
- wounds and purulent lesions on the skin, burns;
- osteomyelitis (bone damage);
- severe forms of angina, otitis media, sinusitis;
- infection during surgery, childbirth;
- terminal stage of cancer;
- AIDS;
- infectious and inflammatory processes of the abdominal cavity, peritonitis;
- autoimmune diseases;
- pneumonia, congestion in the lungs.
Finding the initial disease that caused the infection of the blood is a great success. Depending on the cause, one or another treatment principle for surgical sepsis is applied. The clinic of the disease also plays a role in the diagnosis of sepsis. If in the course of a laboratory study no pathogens are found in the patient’s body, the diagnosis is cryptogenic sepsis.
Is it possible to get infected from a patient
Patients with sepsis are not contagious and do not pose a danger to others, unlike people with a septic form of a severe infection (for example, salmonellosis, meningitis, scarlet fever). In this case, the risk of contracting contact with the patient is much higher. But with a septic form, doctors do not diagnose sepsis, even if the symptoms of the disease are similar to signs of blood poisoning.
In some patients, the causative agent of this disease may be their own intestinal bacteria. They inhabit the intestinal wall of every healthy person, so this kind of sepsis is not infectious. In addition, it is impossible to get infected with this type of disease from another person.
Typical symptoms
The clinic for surgical sepsis can be recognized not only by the severity of the symptoms, but also by the rate of progression of the disease. The disease can develop at lightning speed, within 1-2 days, while at the peak of the disease there may not be a high temperature at all: this is due to the variability of infectious agents or prolonged use of antibiotics. The course of surgical sepsis largely depends on the primary focus and the type of pathogen, but nevertheless it is worth noting the symptoms characteristic of any kind of blood poisoning:
- severe chills;
- a constant increase in body temperature, which has a wave-like character, which is associated with the spread of infection in the blood;
- severe sweating (the patient has to change several sets of linen during the day).
In addition to the main symptoms of sepsis, which are considered the most constant signs of the disease, the following can also occur:
- herpetiform rashes on the lips and mucous membranes;
- bleeding of superficial wounds;
- respiratory failure;
- drop in blood pressure;
- the presence of seals or pustules on the skin;
- dysuria;
- pale color of the skin and mucous membranes.
The patient feels tired even after resting. In his view, indifference, apathy, indifference to everything around him are noted. Mental disturbances can also occur when causeless euphoria unexpectedly gives way to stupor. Patients with sepsis often have hemorrhages on the skin of their limbs, resembling stripes or spots.
Sepsis in children
Most often, newborns and infants of the first year of life are sick with sepsis. According to unofficial data, for every thousand babies, 1 to 8 cases of blood poisoning are diagnosed. Over the past decade, doctors have managed to reduce child mortality, but so far they still remain high: 13-40% of babies die due to sepsis. At the slightest suspicion of this disease, it is necessary to urgently diagnose and, if confirmed, start treatment.
Surgical sepsis in children of the first year of life can develop not only as a complication of surgery. At risk are babies with local suppuration in the navel, deep phlegmon and abscesses of different localization. There is also an increased risk of disease in premature babies. Moreover, in children born before the due date, sepsis develops at lightning speed due to a completely immature immune system. You can suspect a blood poisoning in a child by the following signs:
- vomiting and diarrhea;
- lack of appetite;
- weight loss;
- dehydration;
- earthy complexion, dry skin.
Mortality among children of the first year of life is really high, but even higher is the percentage of children who, having recovered, face serious consequences of sepsis. Some of them remain disabled until the end of days, others lose their resistance to respiratory diseases, acquire dangerous pulmonary and cardiac pathologies, and lag behind their peers in physical and mental development. Whatever the complications of sepsis, it is important to remember that without timely treatment with antibiotics and immunomodulators, the child will not be able to survive.
Diagnostic measures
When examining a patient with suspected surgical sepsis, the clinical picture and the location of the pyemic foci are primarily taken into account. If external signs indicate blood poisoning, a microbiological study is carried out with the specification of qualitative and quantitative indicators. The laboratory also studies the composition of discharge from wounds, fistulas, and other biological fluids (urine, sputum, spinal substance, exudates of the pleural or abdominal cavity).
Diagnosis of surgical sepsis and further treatment of the disease should be carried out by surgeons and resuscitators in a hospital intensive care unit.
How to deal with the disease
The first step is the surgical treatment of sepsis, which involves primary or secondary treatment of a wound, purulent focus, timely amputation of affected limbs, etc. Only after measures to disinfect the wound, the doctor makes the choice of an antibacterial drug. With sepsis, doctors most often opt for third-generation cephalosporins, inhibitor-protected penicillins, and II-III generation aminoglycosides. As a rule, a course of antibiotics in cases of suspected blood poisoning is prescribed urgently, without waiting for the results of microbiological studies. When choosing a drug, the doctor should proceed from the following factors:
- the severity of the patient's condition;
- localization of the infectious and inflammatory process;
- immune system functionality;
- tendency to allergic reactions;
- kidney condition.
If positive dynamics is observed within 2-3 days, antibacterial drugs do not change. If there is no clinical effect during this time, the doctor must make adjustments to the treatment program, taking into account the results of microbiological analyzes. If it is not possible to conduct a study, then other drugs are prescribed based on the resistance of potential pathogens.
In surgical sepsis, antibiotics are administered intravenously at a maximum dose corresponding to the age and weight of the patient. The dosage regimen depends on the level of creatinine clearance. As soon as this indicator reaches normal values, the patient is transferred to intramuscular and oral antibiotics. A contraindication to the use of drugs inside is the inability to fully absorb in the gastrointestinal tract and impaired blood and lymph circulation in the muscles.
The duration of antibiotic therapy is determined by a specialist. After recovery, the doctor will give the patient basic clinical recommendations. Surgical sepsis is a complex and life-threatening disease, in which it is important to achieve a confident regression of inflammatory changes and exclude the likelihood of repeated bacteremia, new infectious-purulent foci, and block inflammatory mediators.
Even if the patient is quickly recovering, the course of therapy for blood poisoning should not be less than two weeks. Longer antibacterial treatment is required with the staphylococcal form, accompanied by bacteremia, with the localization of septic foci in the bone tissue, lungs and endocardium. Antibiotics are prescribed for patients with congenital or acquired immunodeficiency for a longer period than for patients with normal immune status. You can cancel antibiotics 5-7 days after the stabilization of the temperature and the elimination of the focus of purulent infection.
Treatment features
In old age, sepsis is especially dangerous. When choosing antibiotics, the doctor should take into account the degree of functionality of the patient's kidneys. Drugs in this group can lead to a decrease in the productivity of the excretory system, therefore, the dose of the drug is reduced.
If sepsis occurs in a pregnant woman, all medical measures should be aimed at preserving her life, therefore, in this case, all restrictions on the use of antimicrobials are removed. The patient is prescribed drugs from the same groups as the rest of the patients. In pregnant women, sepsis often becomes a complication of a urinary tract infection.
The selection of drugs for children depends on age-related contraindications and the type of blood poisoning. For example, in newborns, group B streptococci and E. coli provoke the disease. Surgical sepsis with staphylococcal infection develops with the use of invasive devices.
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