SEPSIS. ENDOTOXICOSIS IN SURGERY. DETOXIFICATION OF ORGANISM

SEPSIS

Sepsis — normal nonspecific an infection of an organism, attributable to completely different brokers and occurring towards a background of a modified organism’s reacttivity regardless of the agent, is characterised by the identical scientific image much like endotoxicosis phenomena and poly-organ problems.

Sepsis ought to be examined because the gradual improvement of native suppurative focus, when generalization of the an infection takes place within the hematogenous and lymphogenous methods. The lethality with sepsis is excessive and in accordance with completely different authors ranges from 40 to 60%, and within the case of septic shock it reaches 85%.

Pathogenesis of sepsis is taken into account by the interplay of three elements:

The causative agent.

Main focus.

Organism reactivity.

Causative brokers of sepsis could be nearly all of the pathogenic and conditional-pathogenic microorganisms. Continuously, they’re staphylococci, streptococci, Pseudomonas aeruginosa, Proteus micro organism, anaerobic flora, bacteroids.

Usually the essential agent of sepsis is staphylococcus, the second is E.coli, particularly within the case of peritoneal and gynaecologic sepsis. The sort of agent, its organic properties (manufacturing of exo- and endotoxins), virulence, sensitivity to antibiotics, antiseptics decide the options of the scientific image of sepsis. For instance, staphylococcal, bacteroidal (anaerobic) sepsis, as a rule (95% of the circumstances), is accompanied by the event of secondary metastatic abscesses. Streptococcal, Pseudomonas aeruginosa sepsis has the course much like hematosepsis with pronounced endotoxicosis with out the formation of secondary metastatic abscesses.

With sepsis, there’s at all times an entrance gate and a main focus of an infection. The entry of an infection, or place the place the an infection happens, is broken tissue. The first focus is taken into account the positioning of irritation, occurring on the website the place the an infection appeared and is the supply of its generalization. The first focus, as a rule, coincides with the entry of an infection. Very seldom it arises at a long way from the place of an infection penetration, for instance, suppurative lymphadenitis and phlegmon, as the results of attrition of the foot pores and skin. The first foci throughout sepsis could be completely different wounds, native suppurative processes (furuncule, anthrax, phlegmon, mastitis, osteomyelitis), damaging ailments of the inner organs with the event of empyema of the pleura, peritonitis.

Within the main focus that comprises loads of useless tissue, blood clots, micro organism divide rapidely. The microbe’s exo- and endotoxins harm the partitions of the wound, new vessels, leading to thromboses, improve within the vascular wall permeability, improve in necrosis processes. All this causes infringement or full destruction of the granulation shaft of the inflammatory focus, improve within the permeability of poisons and microbes into the final blood circulation (bacteriemia).

The an infection spreads from the middle of injury hematogenously or lymphogenously or concurrently. The hematogenous method is characterised by the event of thrombophlebitis, periphlebitis, thrombembolism and continuously the formation of secondary suppurative metastatic foci. The lymphogenous method of spreading is noticed much less actually because the lymph nodes are a filtering barrier for the an infection. The first focus throughout sepsis just isn’t solely a reservoir of the an infection however renders the sensitizing motion on the affected person’s organism.

A affected person’s organism reactivity has essential significance within the improvement of sepsis. Sepsis develops as the results of exhaustion of the antiinfectious immunity beneath the affect of the first focus. On account of the motion of a big quantity of brokers and their toxins, destruction of tissue, infringement of regional blood circulation within the main focus, there’s a short-term relative deficiency of safety elements (opsonin, phagocytes). It leads to uncontrolled improve in microbes within the penetration areas (an infection entry) and the event of the suppurative course of. With inadequate mobilization of immune safety elements within the main focus there’s an exceeding within the allowable ratio of microbe-phagocytes, inflicting destruction of the phagocytes and the start of the secondary immunodeficiency improvement. With a rise within the length of this course of, the superfluous quantity of antigenes and microbic toxins go away the borders of the first focus. Thus, elements of pure resistency and particular immune response are oppressed. Thus, with sepsis there’s a deficiency of things of immune safety, which now usually are not able to limiting the damaging motion of microbes and toxins on the essential physiologic programs of an organism.

The response of an individual’s organism to the sensitization of microbic antigene throughout sepsis could be completely different:

Normergic with the prevalence of the irritation phenomena, the scientific image is characterised by the presence of secondary metastatic abscesses.

Hyperergic with the prevalence of destructive-degenerativechanges within the tissue, speedy course with the endotoxicosis phenomena, allergy and poisonous shock.

Anergic (hypergic) is characterised by languid inflammatoryreaction with a decline within the reactive forces of an organism.

One of many main elements, which determines the course of sepsis, is toxinemia (microbic toxins, merchandise of tissue disintegration) which leads to the event of the intoxication syndrome (endotoxicosis) with extreme infringements of the perform and morphology of important organs and programs (cardiovascular and respiratory programs, liver, kidneys, haemopoietic organs, and many others.).

Classification. Many classifications of sepsis are steered. The essential ones are as follows:

І. In line with the kind of the causative agent: staphylococcal, streptococcal, colibacillar, anaerobic, bacteroidic, combined, and many others.

In line with the supply: wound, postoperative, therapeutic, cryptogenic.

In line with the localization of the first cell: gynaecologic, otogenous, dontogenous, urological, umbilical and so forth.

In line with the acuteness of the scientific image: lightning,acute, subacute, relapsing, continual.

In line with the time of improvement: early (until the 14th dayfrom the second of injury) and late (after the two week from the second of injury).

In line with the character of response of an organism to thebacterial antigene: hyperergic, normergic, allergic (hypergic).

In line with the clinical-morphological attributes: hematosepsis(with out metastasises), septicopyemia (sepsis with purulent metastasises).

Scientific image. The scientific image of sepsis may be very various and relies upon upon many circumstances: etiological moments, kind of agent, organism’s response. In some circumstances, it is extremely troublesome to find out the prognosis of sepsis. The prognosis of sepsis ought to be primarily based upon the next elements: revealing the first focus, set of typical scientific options, knowledge from blood inoculation (haemoculture).

Initially, sepsis ought to be distinguished from pyo-resorptive fever. Pyo-resorptive fever is a transitive part from native suppurative course of to sepsis, noticed at any localization of suppurative foci and characterised by the final reactions of an organism (fever, chills, intoxication), occurring towards a background of absorption of tissue disintegration merchandise from the purulent cell.

In contrast to to sepsis, with pyo-resorptive fever after radical remedy of the suppurative focus (incision, drainage, eradicating the supply of an infection) the final phenomena begin to disappear, remaining for 7 days. Through the blood examination, as a rule, bacteriemia is absent.

Pyo-resorptive fever by extent of normal phenomena at all times corresponds to the severity of injury within the native focus. Ultimately, lately in clinic, the check for figuring out the bacterial stage by 1 g of tissue was efficiently utilized. With pyo-resorptive fever, the bacterial stage, as a rule, is decrease than 105 microbes/1 g of tissue.

When figuring out the prognosis of sepsis, a set of most frequently indicators are used. The character and frequency of scientific semiology are resulted within the desk.

The first focus is without doubt one of the primary signs of sepsis. With its improvement, within the main focus, various processes prevail (anemic wound, secretion is insignificant, purulent, continuously ichorous, nearly undeveloped granulation tissue).

The vast majority of surgeons consider that there’s sepsis in surgical procedure with out the an infection entry and virtually at all times is secondary, i.e. develops with the presence of a main focus of an infection (wound, purulent native course of, operative intervention, and many others.). The examination of the bacterial stage by 1 g of tissue taken by the way in which of biopsy of the first or metastatic focus helps within the prognosis of sepsis. A lot of researchers (M. I. Kuzin, V. M. Kostyuchenok, V. M. Buyanov) proved, that the seeding of 105 of cells and extra by 1 g of tissue is vital and is proof of the speedy improvement of an infection within the wound and attainable generalization. For sufferers with acute sepsis (75% of the circumstances) the vital stage (105 cells by 1 g of tissue) of main and metastatic foci gave the impression to be elevated (V. M. Kostyuchenok, A. M. Svetukhin).

Desk Scientific symptomatology of sepsis (in accordance with B. I. Dmytriyev, 1999)

Fever is without doubt one of the most vital attributes of the an infection generalization. Rhythmic kind of fever is usually noticed in sufferers with septicopyemia phenomena. Hectic fever with a relentless rise in temperature as much as 38.5–39°C  testifies to unfavourable progressing of the method, noticed in sufferers with septic shock, continuously with a deadly end result. Wavy fever with a low stage of elevated temperature is noticed within the subacute course of sepsis, attribute for therapeutic sepsis and sure sufferers with gynaecologic sepsis. The temperature response is absent in sufferers with hyporeactive course of sepsis.

Hemodynamic infringements are carefully linked to the depth of metabolic problems, severity of endotoxicosis, extent of hypovolemia. Haemodynamic infringements with the generalization of an infection are pronounced by a lower in ABP, coloration index, tachycardia, discount of blood quantity, infringement of the contracting perform of the myocardium.

One of the vital attribute and fixed attributes of poisonous harm of the myocardium throughout sepsis is tachycardia, which will increase with the expansion in endotoxicosis, continuously saved even with the normalization of temperature. Typically, infringements of blood circulation throughout sepsis can have a speedy course with the event of the scientific image of septic shock. Thus, acute arterial hypotension is noticed, tachycardia modifications to bradycardia with arrhythmia, impairment of consciousness (coma), extreme respiratory insufficiency, comparable to respiratory distress-syndrome, useful infringements of the liver and kidneys (oliguria, anuria) develop.

Infringements of the renal perform, comparable to poisonous nephritis, continuously worsen the scientific course of sepsis, inflicting oliguria with azotemia phenomena, change in urine (proteinuria, leukocyturia, erythrocyturia, cylindruria), improvement of peripheral hypostases. The following progressing of the method with transition into anuria and the event of acute renal insufficiency have a decisive affect on the prognosis and lethality for this group of sufferers. Infringements of the electrolytic stability and acid-base construction of the blood, which trigger hyperkalemia, hyponatremia, the incidence of metabolic acidosis or alkalosis, are carefully linked to poisonous nephritis phenomena.

Poisonous hepatitis — one of many attribute symptom-complex. It causes each the liver enlargement and its dysfunction: jaundice, hyperfermentemia transaminases, alkaline phosphatase, lactate dehydrogenase, infringement of the protein-synthetic perform (hypoproteinemia, disproteinemia). Acute hepatic insufficiency can develop typically.

Infringements of the blood coagulating system throughout sepsis present itself very brightly within the disseminated intravascular coagulation syndrome (DIC). In improvement of DIC-syndrome throughout sepsis, two phases are discovered:

Hypercoagulation with the activation of plasma fermental programs. It causes thrombophlebitises, spontaneous migrating thromboses.

Hypocoagulation with the exhaustion of coagulation mechanisms. It causes emigration or profuse bleedings, microcirculation blockade in organs (“shock lung”, acute renal and hepatic insufficiency, infringement of mind circulation).

Respiratory insufficiency throughout sepsis is the results of intoxication and direct motion of microflora on the lung parenchyma (septic pneumonia, abscesses). Poisonous harm of the pulmonary tissue causes dyspnea, phenomena of hyperhydration of the lungs, incidence of septic pneumonias, improvement of respiratory distress-syndrome.

Poisonous harm of the CNS seem the primary days after generalization of the method, comparable to encephalopathy (headache, annoyance, melancholy, apathy, sleep problems). Progressing endotoxicosis and accompanying poisonous damages of the liver and kidneys can lead to the event of deep psychological infringements (coma, intoxication delirium).

Adjustments within the peripheral blood is a vital diagnostic and prognostic criterion of sepsis. Adjustments within the purple blood seem as hypochromic anemia, anisocytosis, poikilocytosis, lower within the coloration index, improve in ESR.

Attribute modifications within the white blood: elevated leukocytosis, poisonous granularity of leukocytes, left shift of neutrophilic formulation (incidence of younger, immature types of leukocytic types within the peripheral blood). Expressiveness of leukocytosis relies upon upon the character of the organism’s reactivity, sort of a pathogenic organism. Particularly excessive leukocytosis is noticed with staphylococcal sepsis, much less pronounced — with gram-negative sepsis. Pseudomonas sepsis is characterised by leukopenia extra typically, particularly with progress of the method. Leukopenia is continuously noticed within the terminal stage of endotoxicosis, throughout septic shock. Normalization of the quantity of leukocytes with the lower in endotoxicosis is a good attribute, which testifies to environment friendly remedy. Enlargement of the spleen is a frequent symptom of sepsis, which displays a poisonous motion of microflora and the event of degenerative modifications within the organ, that’s proof of a lower within the cleansing features.

Bacteriemia — one of many primary signs which verify the prognosis of sepsis. Blood inoculation throughout sepsis don’t at all times reveal bacteriemia. In line with completely different authors (V. Ya. Shlapobersky, I. G. Rufanov, M. I. Kuzin, Yu. Ya. Belokurov, A. M. Torbinsky) the per cent of revealed micro organism ranges from 22 as much as 87. With a view to enhance the outcomes of haemoculture many elements are necessary: alternative of optimum nutrient mediums, carefulness of method efficiency, quite a few inoculations, every time attainable on the top of fever assault. With a unfavourable blood inoculation with nonclaustrid types of anaerobes usually are not recognized as a rule. It requires particular circumstances of identification, costly gear, which continues to be inaccessible for sensible public well being service (A. P. Kolyesov, M. I. Kuzin, P. M. Tchuyev) usually are not recognized.

Sepsis is accompanied by pronounced endotoxicosis, the extent of which is estimated by general-toxic checks: poisonous metabolites of the blood (kreatinine, urea, residual nitrogen, and many others.), medium-molecular oligopeptides, paramecin check, leukocytic index of intoxication, hematological index of intoxication, and many others.

After the depth of infringements and the extent of attainable compensatory reactions, the situation of the cleansing organs (liver, kidneys) endotoxicosis throughout sepsis could be divided into three levels of severity (A. M. Torbinsky):

I diploma — compensation;

ІІ diploma — subcompensation;

ІІІ diploma — decompensation.

The estimation of the severity of endotoxicosis has necessary sensible worth, as a result of it permits the applying of optimum strategies of cleansing. The event of sepsis and the progress of endotoxicosis leads to radical infringements of the mobile and humoral elements of the immune system, inflicting the incidence of secondary Т-immunodeficiency, lower in phagocytosis (lower within the phagocytal exercise of leukocytes, lower within the stage of complement, accumulation of circulating immune complexes).

Therapy of sepsis ought to include the next main elements:

motion on the first cell;

correction of homeostasis infringements;

advanced cleansing remedy.

Motion on the first and metastatic foci gives lively surgical coverage: vast incision, necretomy, flowing washing with lively aspiration of the secretion (vacuum-devices), utility of ultra-violet and laser motion, remedy beneath abacterial circumstances (abacterial therapeutic device-3 (ATD-3), АТD-5, and many others.); utility of hyperbaric oxygenation (various kinds of strain wards).

Motion on brokers organisms is finished with rational antibiotic and antiseptic remedy. Antibiotic remedy is performed beneath the compulsory management of an antibioticogram and blood inoculation (each 4– 5 days). Antibiotics are utilized in maximal dozes, entered intravenously, intraarterially, endolymphatically. Extra typically semisynthetic penicillin (Ampicillin, Carbenicillin), aminoglycosides (kanamycin, gentamycin, sisomicin, amikocin), cephalosporins (cefamezin, kefzol, claphoran), imipenem (thienam) are utilized. Mix antibiotics with antiseptics (dioxydin, furagin, flagylum, metranidasole), sulfanilamide (etazole, sulfalen, biseptol). Thienam is the principally efficient.

Correction of homeostasis infringements contains actions directed upon the normalization of parameters of fidelity for the organism’s inner atmosphere: haemodynamics, protein, water-electrolyte, acid-base balances, coagulation system, immune standing, enhancing the cleansing features of programs and allocation of poisons (liver, kidneys, lungs, intestines).

Correction of haemodynamics is carried out beneath managed haemodilution with the applying of blood substitutes, colloidal and crystalloid options (olyglucin, rheopolyglucin, lactosil, trisil, acesil, Ringer—Lock’s resolution, Darrow’s resolution), disaggregants (trental, complamin, bensohexon, rheopolyglucin). With a view to enhance rheology of the blood and correction of the DIC-syndrome together with disaggregants they apply heparin, inhibitors of proteolytic enzymes (contrical, gordox), chilled plasma, fibrinolytic lively plasma (FAP).

With a view to right hypoproteinemia and disproteinemia they apply dry native, chilled plasma, albumine, protein, albuminous hydrolysate, amino acid options.

With a view to right the water-electrolyte and acid-base stability infringements they apply electrolytic options (N1 and N2), Darrow’s options, panangin, calcium gluconate, sodium bicarbonate, in addition to inhibitors of proteolysis and anabolic hormones (nerobol, retabolil).

Correction of the immune standing throughout sepsis is performed by passive immune remedy and lively immune correction. Passive (replaceable) immune remedy is carried out by repeated transfusions of fresh-stabilized blood (fresh-citrate, heparinized), the applying of hyperimmune (antistaphylococcal, antipseudomanal) plasma or gamma globulin, interferon, bacteriophage. Energetic immune correction is carried out with preparations of the thymus (thactivin, timosin, thymalin, thymogen), bone marrow (mielopeptide, β-activin), artificial immune correctors (decaris, dauciphon) taking into consideration the diploma of growing secondary immunodeficiency.

The remedy directed on enhancing the perform of the cleansing programs is performed: the liver (nutritional vitamins of group B, C, methionine, legalon, aecenciale), the kidneys (pressured diuresis), the lungs (oxygen tent, strain ward, synthetic air flow lung (AVL) throughout septic shock), intestines (intubation, electrostimulation, enterosorption).

Correction of endotoxicosis throughout sepsis ought to be performed regarding the primary liquid mediums of an organism (blood, lymph) on the identical time, taking into consideration the extent of endotoxicosis. Detoxing remedy ought to be directed upon strengthening the perform of the essential cleansing organs (the liver, the kidneys, the lungs, the intestines) with compensated infringements of their perform, in case of subcompensation or decompensation — partial or full alternative of their features.

Throughout compensated infringements, the applying of intracorporal strategies of cleansing, haemoinfusion, endolymphatic cleansing (haemodesum, neoheamodesum, albumine towards a background of pressured diuresis), enterosorption (carbovit, enterosorf), utility sorption (activated carbon fibrous supplies), intravascular laser irradiation of the blood (ILIB), ultra-violet irradiation of the blood will likely be efficient.

With deep types of endotoxicosis (II–III stage) intracorporal strategies of cleansing are ineffective. They need to be supplemented by extracorporal cleansing taking into consideration the mechanism of motion and most pronounced cleansing impact. With acute hepatic insufficiency, haemosorption, lymphosorption, plasmosorption, plasmapheresis are utilized, which fashions to a ceratin extent the cleansing perform of the liver. Haemodialysis, haemofiltration, and haemodiafiltration (utility of “synthetic kidney” units in several working modes) are particularly indicated with acute renal insufficiency. Realization of advanced cleansing offers a chance to significantly enhance the outcomes of remedy and cut back lethality price, particularly with deep types of endotoxicosis (from 65–80% as much as 35%).

Therapy of sufferers affected by sepsis ought to be carried out in departments of intensive remedy and resuscition, outfitted with trendy diagnostic and medical gear for extracorporal cleansing.

ENDOTOXICOSIS DURING PURULENT SURGICAL PATHOLOGY

Ideas and Strategies of Correcting Endotoxicosis

Endogenous intoxication syndrome is the principal reason behind demise in sufferers affected by purulent an infection. Endotoxicosis throughout a purulent surgical pathology has a posh aetio-pathogenesis, which incorporates impairment of nearly all of organs and programs of an organism. Shows of endotoxicosis throughout purulent an infection can come up towards a background of great damages of tissue (burns, frost chew, syndrome of lengthy compression, intensive traumas with necrosis of the gentle tissue), damaging purulent ailments of the inner organs (pancreatitis, cholecystitis, appendicitis, and many others.), in addition to towards a background of infringement of the pure cleansing programs (renal, hepatic insufficiency).

In line with trendy views, aetio-pathogenesis of the intoxication syndrome throughout purulent an infection consists of the next primary central elements:

Metabolic infringements within the main focus of an infection beneath the motion of microbic toxins and enzymes.

Infringements to the barrier features of tissues and organs asa results of primary modifications in haemodynamics and microcirculation, leading to toxemia.

Infringement of the system of binding and transporting toxicsubstances from tissue to the excretory organs.

Infringement to the cleansing programs of an organism.

Infringement to the system of poisons allocation from an organism.

The issue of the first focus is decided by the motion of microflora on account of the tissue hypoxia improvement with infringement to metabolism towards a background of traumatic or inflammatory destruction of tissue. Pathogenic properties of the brokers of purulent an infection are predetermined by proteolytic, necrotic, plasmocoagulation motion of bacterial exo- and endotoxins, bacterial enzymes. It leads to infringement of endocellular homeostasis, improvement of infringements of mobile metabolism, change within the permeability of mobile membranes and, consequently, allocation of poisonous merchandise into the interstitial area and liquid mediums (blood, lymph).

Within the main focus of an infection, pronounced infringements of metabolism processes are marked. On account of the infringement of digestion of fat and carbohydrates, protein-dependant energetic change arises when the essential power supply for cells are amino acids. It leads to sharp activation of proteolysis in tissue and blood, disintegration of protein constructions of the very important organs. Hypoproteinemia develops, which results in problems of synthesis of proteins needed for regeneration, haemostasis, and immune safety.

In blood and tissues, medium molecular oligopeptides, so-called meddle-size molecules (MSM), that are the intermediate merchandise of proteolysis, accumulate. The construction of gear which enter the pool of MSM may be very various: glycopeptides, nucleopeptides, oligocarbohydrats, and many others. Medium -size molecules have a complete spectrum of unfavourable motion on an organism: oppression of erythrogenesis with the incidence of anemia, oppression of  gluconeogenesis and DNA synthesis, infringement of processes of tissue respiration with suppression of mitochondria features. The MM has cytotoxic and immunodepressive motion (oppression of phagocytar exercise of leukocytes, delay in formation precipitate of lymphocytes).

The definition of MSM is a particularly informative check of endotoxicosis throughout completely different ailments, that are accompanied by elevated proteolysis towards a background of generalization of an infection (peritonitis, pancreatitis, sepsis, intensive traumas, burns). It offers a chance to authentically decide the depth of endotoxicosis, estimate the prognosis and effectivity of the utilized remedy. An important position within the pathogenesis of endotoxicosis is infringements of the lipid metabolism, particularly peroxide oxidation of lipids (POL). Throughout pathology, the antioxidant system continuously suffers, ensuing within the accumulation within the organism of extremely poisonous merchandise of POL (aldehydes, ketone, fatty acids, oxidations), i.e. lipid peroxidation syndrome develops. Injury to the membrane lipids, lipoprotein, swelling and destruction of mitochondria and lysosomes, inactivation of enzymes, infringement of mobile division and phagocytosis are noticed. The marked metabolic infringements (proteolysis, peroxidation of lipids) promote the coming into of a big quantity of vasoactive substances (catecholamin, kinin, histamine, serotonin, and many others.) into the circulating blood, leading to vital modifications within the blood circulation, microcirculation. Vasoactive substances promote dilatation of the peripheral vessels, improve in permeability of the vascular wall, suppress tissue respiration and oxidizing phosphorylation. It worsens endotoxicosis. Infringements of tissue microcirculation amplify on account of aggregation of erythrocytes, improve in blood viscosity, delay of blood circulation and deposition of blood in tissues. These infringements can result in the event of disseminated intravascular coagulation syndrome (DIC-syndrome). The DIC-syndrome causes acute useful insufficiency of important organs (lungs, kidneys, liver, mind), which may trigger deadly penalties.

Infringements of the system of bending and transport of poisons to websites of allocation from the organism (the kidneys, the gasterointestinal tract (GIT), the lungs, the pores and skin) have nice worth within the improvement of endotoxicosis. This method consists of transport (gastrointestinal tract) and the binding perform of erythrocytes, protein, plasma (albumen, antibodies), buffer blood programs. Erythrocytes are able to adsorbing endotoxins, organic amines, medium molecules on the floor. Oppression of erythrogenesis and destruction of erythrocytes beneath the motion of bacterial toxins, incidence of anemia significantly cut back the erythrocytes’ transport perform of poisons.

The cleansing impact of albumin is predetermined by the formation of simply dissociated bonds with molecules of many natural and inorganic compounds, thus, the poisonous properties of the transported toxins lower. Moreover, albumin causes pure haemodilution and improves tissue microcirculation. Infringements of albuminous change throughout purulent an infection (hypoproteinemia, hypoalbuminemia) significantly cut back the transport and cleansing perform of plasma, promote the rise of endotoxicosis. A big position in cleansing is performed by the buffer blood system supposed for the preservation of acid-base stability between the blood and interstitial liquid. The buildup of great quantities of un-oxidized merchandise of metabolism within the blood and tissue in the course of the generalization of an infection promotes the incidence of infringements of buffer programs (metabolic acidosis, alkalosis).

The central organ of cleansing is the liver, which carries out the transformation of poisonous substances into nontoxical metabolites because of processes of oxidation, hydrolysis, renewal, conjugation which happen in hepatocytes. Kupffer’s cells present clearing of the blood from micro organism, toxins, immune complexes, merchandise of disintegration. Through the generalization of infections beneath the motion of microflora, poisonous and damaging damages of the hepatic parenchima, which causes hepatic insufficiency and a lower within the cleansing features, are noticed. It has essential significance for the liquidation of endotoxicosis and the prognosis of the illness.

Purposeful hepatic insufficiency comparable to poisonous hepatopathy is noticed roughly in 80% of the sufferers with sepsis. It seems as intrahepatic cholestasia with jaundice phenomena, infringements of hydrocarbonic change and fermental perform (hyperglycemia, hyperfermentemia transaminase, lactadehydrogenase, alkaline phosphatase), infringements of protein-synthetic perform of the liver (hypoproteinemia, hypoalbuminemia, prothrombinopenia). Infringements of the coagulation system and the event of the DICsyndrome are carefully linked with harm to the liver.

For the correction of endotoxicosis, regular functioning of the programs eradicating the toxins from the organism (kidneys, lungs, GIT) has nice worth. The kidneys take the central place within the system eradicating toxins from the organism. Infringements of renal perform sharply worsen endotoxicosis in the course of the generalization of an infection not solely on account of the buildup of poisonous merchandise, but in addition by the problems of homeostasis regulation (ionic blood construction, acid-base stability). With sepsis, two sorts of acute renal insufficiency (ARI) can develop: prerenal and renal. Prerenal ARI is predetermined by infringements of haemodynamics (vasodilation, discount of filtration effectivity on account of renal ischemia), it has a reverse nature and renews with the normalization of haemodynamics. Renal ARI develops on the idea of poisonous harm or direct microbic motion on the renal parenchyma (glomerulonephritis, pyelonephritis) with the event of nephropathy. Clinically it seems as infringement of diuresis (oliguria with conversion into anuria), change of urine construction (proteinuria, cylindruria, bacteriuria). Lower in osmotic clearance, clearance of free water and sodium are noticed on this background (azotemia, hypercreatinemia, improve within the contents of medium molecules within the blood and urine).

Progressing oliguria, improvement of anuria outcome within the incidence of respiratory distress-syndrome (RDS), or “shock lungs”, characterised by hyperhydration of pulmonary tissue (hypostasis lung), acute respiratory insufficiency and hypercapnia. Thus, arterial anoxemia and normal anoxemia of organs and tissues develop.

Throughout sepsis, there could be poisonous harm to the GIT (stress ulcers of the abdomen and intestines, intestinal bleeding, paralytic impassability), leading to a lower within the allocation of poisons by the intestines, and endotoxicosis can worsen.

The marked infringements of the cleansing programs and programs eradicating toxins in the course of the generalization of an infection continuously incorporate with one another, i. e. polyorgan insufficiency syndrome (POIS) happens, giving excessive lethality price. It’s fairly apparent that remedy of endotoxicosis with purulent an infection ought to be carried out in a posh taking into consideration the troublesome aetio-pathogenesis with simultaneous motion on the essential elements of this course of. Solely advanced cleansing with correction of homeostasis can change the vicious circle of endotoxicosis formation and cut back lethality price. For profitable correction of endotoxicosis with purulent an infection it’s essential to observe the primary rules:

Detoxing ought to be carried out regarding the primary mediums of an organism (blood, lymph).

Detoxing remedy ought to be the directed upon strengthening the perform of primary organs of cleansing and excretion (the liver, the kidneys, the intestines, the pores and skin) with compensated infringements of perform, partial or full alternative of their features in case of subcompensated and decompensated infringements. With compensated infringements, the applying of intracorporal strategies of cleansing (hemoinfusion cleansing, endolymphatic remedy, enterosorption, utility sorption, laser remedy) is efficient sufficient. Detoxing of the blood and lymph in the course of the gentle diploma of endotoxicosis is performed successfully by the introduction of cleansing substances into the blood or lymphatic system (haemodesum, neohaemodesum, albuminum, polydesum). Detoxing is feasible to hold out towards a background of managed haemodilution — pressured diuresis with the applying of saluretics and osmodiuretics — lasixum, manitol). Software of enterosorption offers a chance to strengthen the cleansing impact by the sorption of poisons which excrete by the intestinal tract. For enterosorption activated coal (granulated sorbents, comparable to carbovitum, and many others.), preparations of polyvinylpyrolidone (enterodesum, enterosorpt) are used.

Software sorption is especially utilized with the presence of volumetric wounds, burns (coal sorbents comparable to carbovitum or carbon fibrous supplies). It promotes the sorption of poisons and microorganisms on the wound floor, reduces the diploma of micro organism within the wounds, promotes its quick clearing from necrotic mass and improvement of granulations. On the identical time final years laser remedy (intravascular laser blood irradiation, irradiation of wounds with unfocused helium-neon laser) is used.

With deep types of endotoxicosis (subcompensation or decompensation of cleansing programs) intracorporal strategies are ineffective. It’s essential to complement them with extracorporal cleansing with taking into consideration the mechanism of motion and therapeutic impact. With this objective, the strategies of clearance of the blood (hemosorption), plasma (plasmosorption), lymph (lymphosorption) by passing it by columns with coal sorbents are extensively utilized. Plasmapheresis is efficient sufficient — division of blood into uniform components and plasma with the next injection of uniform components and donor plasma as an alternative of eliminated poisonous ones. With acute hepatic insufficiency, haemosorption, lymphosorption, plasmosorption, plasmapheresis are indicated, which mannequin to a sure extent the cleansing perform of the liver. With renal insufficiency, haemodialysis with the applying of “synthetic kidneys” is utilized. Thus, the blood is cleared from low-molecular compounds with the assistance of selective diffusion by membranes fabricated from cellophane, cellulose, and different supplies. Azotemia is diminished, infringements of acid-base stability is corrected. The haemodiafiltration methodology is much more efficient, throughout which two processes unite — dialysis with the removing of low-molecular compounds (urea, kreatinine) and haemofiltration with the removing of medium molecular compounds. Haemofiltration is a method of clearance by semipermeable membranes by convection because of excessive transmembrane strain.

The given strategies of cleansing with the applying of photodynamic remedy (ultra-violet blood irradiation, intravascular laser irradiation of blood) are supplemented. Strategies of tissue hypoxia correction with hyperbaric oxygenation (HBO) in strain wards obtained vast utility.