SEPSIS (GENERALIZED SUPPURATIVE INFECTION)

This is a severe secondary infectious disease caused by polymicrobial strains with a peculiar response of the body and clinical picture.

Classification

1. According to the etiology:

a) staphylococcal,

b) streptococcal;

c) pneumococcal;

d) gonococcal;

e) colibacillar;

f) anaerobial;

g) mixed.

2. According to the source:

a) traumatic;

b) from internal infections (tonsillitis, pneumonia etc.);

c) postoperative;

d) cryptogenic.

3. According to the location of the primary focus:

a) gynecological;

b) urological;

c) otogenic;

d) odontogenic etc.

4. According to the clinical picture:

a) fulminant;

b) acute;

c) subacute;

d) recurrent;

e) chronic.

5. According to the time of development:

a) early (developing up to 10-14 days from the onset of disease or from the time of injury);

b) late (developing after 2 weeks).

6. According to the reaction of the patient's organism:

a) hyperergic form;

b) normal reaction (normergy);

c) hypergic form.

Sepsis is an overwhelming suppurative infection seriously aggravating the course of local suppurative inflammatory processes. Sepsis is caused by different infectious agents and their toxins presenting in the form of peculiar reactions of the organism without any specific features.

Patient complaints differ and do not always reflect the severity of the condition. In eliciting the complaints it is important to take special note of any increase in the body temperature, its pattern within 24 hrs; the presence of chills, duration and recurrence. The patient's general condition has to be assessed as well as his appetite and psychological state (euphoria or apathy).

On inspection the patient is found to be fatigued, sometimes apathetic to his surroundings. The face initially is hyperemic with glowing cheeks, but after a few days it becomes pale. Pallor of the face is more pronounced during the episodes of chills. In severe cases the face is marked by sunken cheeks and hollow eyes.

In acute sepsis, icterus (jaundice) of the sclera sets in very fast followed by the skin and visible mucus layers. The skin becomes dry and sometimes covered with sticky sweat. Profuse sweating interchanging with strong chills can be very intensive, and patients have to change their clothing several times in the day. In some cases one can find petechial hemorrhagic spots or marks on the skin of the internal surfaces of the forearm and leg.

Herpes on the lips occurs quite often as well as an increased bleeding tendency of the gums and mucus membranes in the mouth. There can be bleeding spots on the conjunctiva of the eyes, the lips as a rule are pale and in severe cases cyanotic. In critical cases there is difficulty in breathing: the nasal alae are blown out and the neck muscles are tense.

In some cases an area of infiltration appears over the skin with the skin over them hyperemic, which is an indication of the development of metastasis of the suppurative infection in septicopyemia. Pressure points on the skin (the sacral region, scapula, spinal processes of the vertebrae and the ischial tubercle) are found to be very hyperemic, pale or even necrotic, which indicates an incipient or an already developed bedsore which appears rather too early in patients with sepsis.

The increase in body temperature is a common feature of sepsis. At the beginning or during the peak of the disease the body temperature pattern is of three types: 1) remitting, in which the difference between the morning and evening temperatures is 2-3 °C, this is evidenced in septicopyemia (sepsis with metastasis); 2) constant fever, when the temperature is persistently high and the difference between the morning and evening temperatures is 0, 5 °C rarely 1 °C, it occurs in septicemia; 3) wave-like fever in septicopyemia: the period of subfebrile temperature after incision and drainage changes into a high temperature rise of up to 39-40 °C, which indicates the appearance of new suppurative metastasis. In longer lasting septic conditions and with the process moving into a chronic one the temperature pattern becomes irregular. The febrile period can continue for several days to a few months, in the terminal stages when the patient is debilitated by disease the body temperature usually becomes normal.

One of the constant symptoms of sepsis is chills. The appearance of chills corresponds to the massive entry into the blood stream of microorganisms and their toxins from the foci of infection. The recurrence of chills differ: they can occur once a day, several times a day or reappear after several days. After the episode of chills there is normally a high increase in the body temperature. Profuse sweating is quite common in sepsis.

As a result of the intoxication of cardiac muscles (toxic myocarditis) the patients are found to have a rapid pulse rather early, as the process advances, the pulse volume reduces, tachycardia worsens, reaching 120-140 beats per min. tachycardia persists long after the temperature has dropped to normal or even subfebrile. Arterial and venous blood pressure drops, especially sharply in septic shock, as a complication of the sepsis. Heart boundaries enlarge, heart sounds become dull and murmurs appear at the apex. Murmurs in the heart are transitional and disappear after the patient has recovered. If ulcerative endocarditis sets in, the heart murmurs become permanent.

In septicopyemia, suppurative metastases occur in the lungs leading to a quick development of lung abscess or gangrene of the lung. This is most often associated with diffuse bronchitis and hypostatic pneumonia (as a result of the inadequate lung ventilation). Examination of the patient reveals a rapid breathing rate (sometimes up to 30-50 per min), cough with scanty amounts of mucus or mucopurulent sputum, and in the case of an abscess complicating pneumonia, the cough is productive of massive purulent sputum. Percussion note is dull over the lung and on auscultation - breath sounds are reduced, crepitations and moist bubbly rales are heard in accordance with the existing pneumonia.

Patients with sepsis suffer insomnia, and often underestimate their critical state and seem not to be much concerned about their condition, in some instances, however, there is euphoria. In cases of very high body temperatures and serious chills patients look anxious and delirious. Sometimes they are confused and can develop acute psychosis.

Examination of the GIT reveals loss of appetite, nausea, belching and sometimes diarrhea, which results from the development of stomach acidity (achillia), reduced pancreatic function, the depression of enteritis or colitis. There can be sometimes gastric or intestinal bleedings in the form of bloody vomitus or melaena (tarry) stools.

The oral cavity inspection reveals dry tongue covered with brown or grey fur or crimson in colour, often with hemorrhagic gums. In long - lasting cases there are cracks on the tongue edges.

Jaundice of the skin and the eye in sepsis is not a common occurrence (affecting every fourth patient), but increased serum bilirubin is common. Palpation reveals an enlarged liver with the edges below the costal margin, tender firm in hepatitis and soft flaccid in fat dystrophy. In long - standing sepsis the patient can develop cirrhosis of the liver.

Abdominal palpation of the patient with sepsis reveals an enlarged tender spleen that is initially soft but turns to firm as the disease progresses.

In the case of traumatic sepsis an initially red bright and healthy granulation tissue becomes pale, friable, watery and bleeds easily on touch. Wound epithelization stops. Wound discharge is scanty, seropurulent and sometimes dirty brown with offensive odour. Oedema of the surrounding tissues worsens: wound edges get puffy with palebluish colouration. This condition is usually accompanied by lymphangitis, lymphadenitis and thrombophlebitis.

Changes in the blood picture are a constant feature. The patient quickly becomes anemic: within a few days after the onset of disease hemoglobin level falls to 70-80 g/l, at the same time the amount of erythrocytes drops to 3x10¹²/l and below, there is anisocytosis and poikylocytosis. There is a change in the composition of leucocytes: neutrophilosis is often in the range of 8-15x10⁹/l, sometimes up to 20x10⁹/l. Lymphocytes and eosinophyles decrease up to aneosinophylia. The appearance of immature elements and myelocytes in the leukocyte formula with a simultaneous increase in toxic granules of neutrohiles and aneosinophylia are an unfavourable prognostic sign. ESR increases to 60-80 mm/hr with minimal or average leucocytosis.

Hypoproteinemia proceeds at a fast rate: protein content is less than 70g/l and in severe cases as low as 60-50 g/l and below, albumin reduces to 30-40%, globulin levels increase mainly through the α ₁ and α ₂ fractions.

Respiratory insufficiency and the metabolic disorders in the organism lead to the imbalance in the acid-base state of blood and the development of acidosis. Changes occur in the clotting and anticoagulation properties of blood: prothrombin and fibrinogen levels decrease while the fibrinolytic activity of blood plasma as well as that of heparin increase. The blood changes that are found on laboratory investigations are actually not specific to sepsis alone, but when these results are used in complex with the presenting clinical picture, they facilitate the establishment of the correct diagnosis and help to assess the severity of the condition.

Bacteremia is not a constant feature of sepsis but it occurs very often (in about 90% of cases). Blood specimens for culture have to be taken several times and at different times of the day at the height of fever. Urine, sputum, wound secretions or contents of serous cavities also have to be sent for bacteriological investigations. The isolation of microorganisms from blood is an important diagnostic feature of sepsis. However, a negative blood culture result does not rule out the diagnosis of sepsis.

Urine investigation shows a low specific gravity, the presence of proteins, cylinders, leucocytes and bacteria, which increase as the disease progresses.

The transition of a local suppurative process into septic is not always easy to establish. The beginning of sepsis can take different forms: the incubation period can be very short or take several days. Fulminant sepsis starts suddenly often with severe chills. Acute sepsis is often preceded by general body weakness (fatigue), headache, pains in the muscles and joints that can persist for 2-3 days. The rise in body temperature can either be of a constant nature or sudden and associated with chills.

The main clinical and laboratory signs of sepsis.

1. Acute or subacute development of the disease in the presence of a primary focus (suppurative disease, wound, surgery).

2. High body temperature, hectic or constant, with chills and profuse sweating.

3. Progressive worsening of the patient's general condition, pronounced general clinical presentations compared to minimal local features in the primary focus (wound, mastitis etc.), despite the vigorous therapeutic measures (liquidation of the focus of infection, incision and drainage etc.).

4. Cardiovascular disorders (weak pulse, tachycardia, low blood pressure); divergence between the pulse rate and body temperature (rapid pulse with minimal rise in body temperature).

5. Progressive weight loss and anemia.

6. Yellowish colouration (icterus) of the skin and sclera; enlarged liver and spleen.

7. Characteristic changes in the wound (septic wound).

8. High ESR with normal or minimal increase in the leucocytes and neutrophils and a shift of the leukocyte formula to the left, lymphopaenia.

9. Kidney dysfunction (low specific gravity, protein cylinders and blood cells in urine).

10. Periodic watery stools or diarrhea.

11. Early development of trophic disorders (bed sores).

12. Bacteremia.

In fulminant sepsis symptoms develop and progress very fast. The primary foci in these cases are often furuncles and carbuncles of the face, the patient quickly develops oedema of the face, and the eyes are closed as a result of oedema of the fatty layers on the side of the suppurative focus. Patients develop severe chills; temperature increases to 39-40 °C, leucocytosis with a shift to the left. Patients are found to be agitated but soon become lethargic, on the 2^nd-3^rd day they lose consciousness; there is extreme tachycardia (pulse rate up to 120-140 beats per min).

Acute sepsis that presents as septicemia is characterized by sudden onset in the presence of a primary focus, as in fulminant sepsis. The patient's body temperature increases, chills develop, anemia worsens at a fast rate, there is leucocytosis, the liver and spleen enlarge. Blood culture shows the presence of microorganisms.

When secondary (metastatic) suppurative foci appear (on the skin, or subcutaneous layers, rarely in the lungs) at the beginning of acute sepsis or septicemia in the presence of a primary suppurative focus, then this should be taken as evidence of septicopyemia.

The presence of a primary focus is an indispensable condition for the diagnosis of sepsis. In the presence of corresponding clinical features but the absence of any primary focus, in order to establish the diagnosis of sepsis, acute infectious diseases have to be excluded (typhoid, paratyphoid, tuberculosis, brucellosis, tularemia) or other systemic diseases (collagen diseases), diseases of the blood, lymphogranulomatosis etc.

The constant symptoms of sepsis are: the increase in body temperature, leucocytosis with a shift to the left, progressing anemia, tachycardia, decrease in blood pressure, chills, profuse sweating.

Clinical features of diseases with similar presentations as sepsis in the presence of a primary suppurative focus (acute suppurative diseases of the soft tissues, purulent diseases of serous cavities - pleurisy, peritonitis, infected burns, infected wounds) may be evident in purulent absorption fever.

Purulent absorption fever - This is caused by suppuration and the absorption from the purulent foci of products of purulo-ichorous tissue disintegration and accompanies all types of suppurative inflammations. Absorption enhances the formation of suppurative accumulations and pockets leaving in the focus nonresolvable necrotic tissues, crushed tendons, fascia, muscles, bone sequestra and foreign bodies - bullets, missile fragments, pieces of clothing etc. In such conditions granulation boundary that normally prevents absorption fails to develop around the spread and accumulation of pus in the tissue spaces.

Unlike sepsis the intensity of suppurative absorption fever corresponds to the severity of the suppurative infectious process, there is a direct relationship between them: the fever subsides when the purulent focus is liquidated. The main clinical features of suppurative (purulent) absorption fever are the temperature reaction, the character and nature of which are not constant and nonspecific.

The prevention of suppurative absorption fever consists largely in the early surgical treatment of pyogenic infections - elimination of focus of infection, incision and drainage, adequate primary surgical wound debridement and the correct timing of drainage of pockets of pus etc.

Bacterial - toxic shock - this is sometimes referred to as septic shock. It can occur as a complication of sepsis at any of its stages of development. Bacterial - toxic shock is an altered reaction of the organism to the entry into the bloodstream of pyogenic microorganisms or their toxins. Initial signs of bacterial - toxic shock are high body temperature (up to 40-41 °C), terrific chills, which interchange with profuse sweating and a reduction of the temperature to normal or subfebrile. Changes in the psychological status of the patient (restlessness, motor agitation and sometimes psychosis) appear early in the disease process and are accompanied by the decrease in blood pressure and oliguria or even preceding them. Pulse is fast (up to 120-150 beats per min) and weak, arrhythmia is often found with a low blood pressure. The skin is pale, with acrocyanosis; breathing is fast (up to 30-50 per min). Changes in the urine output set in very fast as evidenced by progressing oliguria.

Treatment. Treatment of sepsis must be based on underlying etiologic and pathologic factors.

Primary suppurative focus (the entry point) plays not only the initial but also supportive role. Surgical treatment of suppurative foci (abscess, phlegmon, infected wounds) involves the surgical debridement: a thorough excision of dead tissues, incision and drainage.

Antibiotic therapy in sepsis has the following peculiarities.

1. The use of maximal dosage of the preparations. Antibiotics of the second group (cephalosporins, semisynthetic aminoglycosides) are prescribed and if they are found ineffective, a quick switch is made to the tienam.

2. Combination of two antibiotics with different spectra of action or an antibiotic with one of the chemical antiseptics (nitrofuran, dioxidin, metronidazol);

3. Giving antibiotics according to the sensitivity of the isolated microorganisms to the intended drug and making corrections when necessary;

4. Combination of topical (intrapleural, endotracheal, intraosseous etc. depending on the location of the infection) and general (intramuscularly, intravenous, intraarterial) routes of administration of the antibiotics and antiseptics;

5. The duration of antibiotic therapy depends on the patient's condition (treatment is continued for two more weeks after the clinical recovery of the patient and after two negative blood cultures).

Detoxication therapy includes the use of haemodes and saline solutions. Efficient detoxicating is achieved by the method of forced diuresis. The amount of fluid infused (polyion solutions, 5% solution of glucose, polyglucin) constitutes 50-60 ml/kg a day in addition to 400 ml of haemodes. The amount of diuresis per day should be around 3l. To improve diuresis, lasix and mannitol are given. The absorption methods of detoxication are also used - hemoand lymph adsorption.

Transfusion therapy is achieved by using solutions that correct the imbalances in acid-base composition and electrolyte imbalance (1% solution of potassium chloride in alkalosis or 5% solution of sodium bicarbonate in acidosis), as well as protein preparations: amino acid solutions (aminon, aminozol, alvesin), protein, albumin, dry and native blood plasma. Anemia is treated by the transfusion of fresh frozen blood.

Nutrition of the septic patient should be balanced, containing different varieties of food and of high caloric value (4000-5000 kcal/day), with adequate protein content (1-1, 5 g/kg per day) and vitamins. The patient's daily diet should contain a variety of fruits and fresh vegetables in adequate amounts. The patient with normal GIT functions should be fed enterally as much as the condition allows. In cases where it is impossible to feed enterally the patient should be placed on either full or partial parenteral feeding.

Specific acting preparations that are often used include antistaphylococcal and anticolibacillar plasma, antistaphylococcal gamma globulins, and pentaglobin. In case of cellular immune deficiency (a decrease in the absolute values of T lymphocytes) leukocyte mass from immunized donors is indicated. Passive immunization is indicated in acute sepsis. In chronic sepsis or during recovery from an acute sepsis, preparations for active immunization are indicated - anatoxin, autovaccine. Nonspecific immune therapeutic substances - lysocim, prodigiosan and thymalinum are also used.

Taking into account the role cytokines play in sepsis, interleukin - 2 (roncoleikin) is prescribed. Indications for its use are extremely low levels of T-lymphocytes.

Corticosteroids are used for substitution therapy after the hormone status has been assessed. It is only when sepsis has been complicated by the development of bacterial - toxic shock that corticosteroids are given in the first days; prednizolon - up to 500-800 mg stat, and then 150-50 mg a day for a short period (2-3 days). Corticosteroids in the usual therapeutic dosage (100-200 mg a day) are prescribed when there is some allergic reaction in the septic patient.

Considering the high concentrations of kininogens in sepsis and the role of kinin in microcirculatory disorders, inhibitors of proteolysis (gordox - 200, 000-300, 000 units a day or contrycal - 40, 000-60, 000 units a day) are included in the complex therapeutic measures.

Supportive measures include cardiac drugs, vascular drugs, analgesics, anticoagulants, substances that increase vascular permeability etc.

Intensive therapy of sepsis should be continued for a long time until the patient becomes very stable and hemostasis is restored.

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