COMPLEX
THERAPY OF GENERAL PURULENT INFECTION WITH USE OF HBO.
Practical recommendations in surgery.
For recent ten years the actuality of problem of treating
general purulent infection (GP) steadily improves. This is because the
reduction of sensitivity of pathiogenic microbes to antibiotics; lessening of
the reactivity of sicks and long-termed period of neglecting of antiseptics
contrary to improving of application of antibiotics.
As sepsis isn't a disease itself, but one of degrees of
GP, and, besides, sepsis and septic state can't be exactly divided from each
other, the following gradation of sepsis is proposed.
1)
Purulent-resorbtive fever. Vast purulent foci; wave type development of
pathology; intermittence of fever for more than 7 days after disclosing of
focus. The inlocations are sterile.
2)
Septicemia. These are sicks with sharp purulent infection, hard general state,
strong fever, positive inlocations of blood; nevertheless metastatic purulent
foci are absent.
3)
Septicopiemia. All as for septicemia and presence of metastatic purulent foci.
4)
Chronic sepsis. Purulent foci are present; but they are not too active.
The inlocations are not sterile. Periodical sharpening of disease with
improvement of temperature.
|
|
{local
purulent process {purulent-resorbtive
fever |
|
|
recovery<---------------- |
{septicemia} |
|
|
|
{septicopiemia}-----------------> |
chronic
sepsis {death } |
The transitions of these graduations of sepsis can be
represented as in Table above (B.Kostuchenok et al.,1977).
Sepsis also can be gradated on the length of time of
process:
1)
immediate (1 - 2 days)
2)
sharp (5 - 7 days)
3)
pre-sharp (7 - 14 days)
Gradation of sepsis only by clinical forms can't be the
foundation
for development of concrete form of therapy; besides the
display of disease depends on the time, spent from the beginning of disease.
We have gradated the period of the disease at three stages. This is certainly
an abstract scheme; each concrete case has its own particularity. Nevertheless
this gradation has a practical application, for it signs the essence of
metabolical and pathophysiological processes, helping in the selection of
identification and treating.
Three periods can be signed in phase of sharp sepsis:
1)
tensed phase (1 - 3-d days);
2)
catabolic phase (4 - 9-th days);
3)
anabolic phase (10 - 30-th days).
The main systematic transgressions, attending sepsis.
1)
nervo-psychical transgressions as a sequence of toxic encephalopathia and
neirotoxicosis display themselves as apathy or excitation; diphoria; coma.
2)
cardiovascular violations - tahicardia; arterial hypotension and vascular
dystonia; rhythm violations; trophic violations and myocard ishemia,
violations of micro circulation.
3)
respiratoric transgressions - tachypnea; improvement of VPM; lowering of
coefficient of oxygen utilization; hypohemia; respiratoric alkalos;
roenthological displays of lung parenchyma violations.
4)
violation of functioning of parenchymathous organs: jaundicity of skin;
hyperbilirubinemia; hyperasothermia; isohypostenuria; pathalogy of biochemical
indexes.
5) Metabolic transgressions: coagulopathies; changes of
water-electrolytic balance; disproteinemia; sharp violations of acid-alkaline
balance.
For their determination a complex investigation is
required.
Proposed complex investigation of GP patients.
|
system under control |
the way of control |
|
central nerves system |
clinical investigation
of consciousness and psychical sphere of sick |
|
nevrologic status; |
temperature of body.
Electroencephalography; reoencephalography. |
|
respiratory organs |
clinical investigation
of frequency, rhythm and volume of breath; cyanosis of skin and phlegm;
conductivity of bronchus; ventilation of lung (percussion and
auscultation of lung; rale; friction of pleura. Roentgenoscopy;
roentgenography. |
|
hemodynamics; |
clinical investigation
of peripheral and central pulse (frequency; rhythm; tension); function
of myocard measurements of arterial and venose pressure. Investigations
of cardiac activity. Electrocardiography; central and peripheral venose
pressure; polycardiography; OCK;
reography; capillaroscopy; bulbar capillariphotography. |
|
metabolism |
outlet of liquid (volume
per day);acid-alkaline balance; biochemical shifts in urine and blood;
density of urine and blood. Coalugraphy; tromboelastography;
determination of acid-alkaline balance by micro method of Astrup; flame
photometry; containment of urea and nitrogen residues; determination of
enzyme shifts. |
|
bacteriologic control |
regular inlocations from
wounds; purulent foci; all body's liquids with determination of microbes;
especially in the moment of sharp fever. |
|
hematological control |
color of skin; presence
of petexies and hematomes; palpation and percutoral determination of
size of liver and spleen; regular control of leukocytes and erythrocytes;
myelograms. |
Clinical display and treating of sepsis in stage of
tension.
In case of insufficient local reaction (inflammation) other systems are included to supply the security of body. Development of hypatalamo-hypophysal system causes the tension of all supplying systems. Disproportion between reducing endogen stock and improving loading cause the decay of energetic stock and hard metabolic violations.
Septic shock with sharp hemodynamic violations and toxic
phenomena is dominating in clinical display. Flaccidity; apathy; adynamia
(something like after injection of morphine) are being developed as well as
foci (abscesses or hematomes) or diffusion (meningitis; encephalopathies;
encephalitis). Hemodynamic violations mean disbalance between abilities of
vascularity and volume of blood being supported by reduction of pressure or
its unstability are developed. Independently of the therapy taxicardia reaches
120 - 140 per min. with slight, tender pulse. Reographic index is only 50 -
60% of normal.
Cardiac violations are released through deafness of
sound, systolic noise and rhythm transgressions. Electrocardiogram can
determine hypoxic violations on myocard, blockades of conductivity, hard
metabolic transgressions. Central venous pressure improves. Violations of
micro circulation cause the change of color of face and body. Inter vascular
coagulopathia deepens cyanosis and petexial bleedings. Circulation's
violations together with hypoxemia caused by lung and oxidation-reduction
cycle, produces hard metabolic shifts. Tissue respiration is only 40% of
normal. Sharp tachypnea (40) and improvement of VPM in 2 - 2,5 times.
Hyperthermia (39 - 40 C) and hectic fever; primary and metastasic purulence
improve the violations.
Bacteriologic hemolisines, with the destruction the
erythrocytes (1,5 - 2,5 million), cause anemia, violate cerebral circulation.
Amount of leukocytes is improving; amount of lymphocytes can reduce even to
zero. Strong septic diarrhea vomity, intestine paresis and septic glossites
appear.
In treating of sepsis its complete and urgent
sanation is required. Further treating includes compensation of sharp cardiac
insufficiency; diminishing of toxemia and bacteriemia. Application of
antibacterial therapy causes limitation of size of focus; reduction of pain.
Therapy of sepsis and control of its efficiency.
|
aim |
device |
dose |
control of efficiency |
complications and
treating |
|
correction of hemo-
dynamic violations: diminishing of dis-proteinemia and supply of
calorage |
sodium chloride (0,9%); glucose (5%) |
20-50 ml/kg or by
deficit of liquid |
general dynamics; diminishing of thirst dry skin and phlegm |
hyperhydradation; sharp
widening of heart and inflation of lung |
|
protein hydrolisates plasma, 10% albumin |
1-2g of protein per 1 kg
body 250 ml/day 200 ml/day |
normalization of OCK,
hematocrytis, pressure diuresis. general conc. Of protein and in plasma |
reduce input of liquid,
moderate dehydratation improvement of art.pressure; shortage of
K,Cl,hypoglicemia; hypercoagulation; hypercortic. Therapy by short
portions; steady lessening. - vomity;bigimenia.
lessening of dose or diminishing |
|
|
hormonal therapy:
cardiotrop activity anti influent. activ.; inhibition of bacter
proteases. |
prednysolon, hexametason, cortin, AKTG |
parental injection: 1day-90mg;: 2day-60mg; 3day-30mg. |
general state; normali
sation of arterial press. lessening of pain and influence |
|
|
Cardiac correction |
Glucosides Strophantin (0,05%); corglicon(0,06) lantoside; dyoxine |
0,25-1ml/day 0,15ml*6 in hard cases less than 2ml |
pulse and strike outlet normalization lessening of inflation;
injection of KCl. |
liver size; improve of
reographic index |
|
correction of water-
electrolytal balance |
CaCl 1-10%, KCl 1-2-10%, electrolytic solutions |
1-1,5g/day 4-6g/day |
general bettering; pulse
cardiogram; specter of electrolytes |
if hypercalcemia:
extrasistol., fibrillation. Rejection
of medic. if
hypercaliemia: cardiac deficiency. cardio stop in diastola |
|
correction of
acid-Alkaline balance - acidose |
sodium bicarb., 1,2-4%,lactat, TRIS-buffer |
6-8g/day 1,9%, o,2-0,3l per day |
pH-7,4;pCO2-
40mm mercury; VV-48-52;SV-24-27;BE +-0,1mecv/l |
alkaloses (especially
when shortage of external respiration |
|
hemopoes correction |
fresh cytral blood components |
0,1-0,2l 2-3 per week |
general investigation of
blood; mielogram, etc. |
|
|
deintoxical
therapy |
Hemodes;
reopoluglucin Diariesis hemodialisis |
6% solution 400ml isotonic sol manitol-1g/kg |
lessening of toxic
encephalopathy normalized diuresis |
improvement of injection
of K+ |
|
passive immunization |
Antistaphilococ plasma; immunoglobul. Polybacteriofag Stafillococc hemotransfisia inlet of leukocyte
per day |
0,2l per 2 days 3ml/day,No.3 10-20ml,No.3/ day, 7 days 200ml, No.2-3 |
lowering of temperature
intoxication;improve of thyroanibodies improvement of bacteri
cidity of plasma;H2-2,5 |
allergic reactions |
|
active immunization |
staphylococci antitoxin |
0,25 ml inject in
scapula |
development of inflam
mation,then reduction |
allergic complications |
|
improvement of
unspecific immunoreactivity |
Pirimidine, purine, mucopolisakha rides,pyrogenal, acetocan, prodigiosine |
pentoxil,metiluracil-0,2*3
per day |
improve of hemopoes,
regeneration of tissue |
|
|
inhibitors of protease |
contrical, triasilol amincapron acid |
10-20 thousand per day 5%,100ml per day |
lessening of inflation; stopping of cynines transience of capillars |
tromboses,violations of
coagulance, inactivation of sulphanil amides |
|
vitaminotherapy |
ascorbic acid, B1,B6 |
500mg/day 2ml |
improvement of
oxidation-reduction process |
allergic reactions |
|
dietotherapy |
|
|
|
|
Antibacterial
therapy. The beginning can't be delayed for 3-4 days to receive data of
analyses; active antibiotics would be used against staphylococci (oleandimysine;
eritromycine; neomycine; monomycine, ceporine); antibacterial antibiotics are
also needed. Synthetic ones are more advantageous: they are more resistant
against enzymes, less toxic and don't cause avitaminose.
The
best identification is a visual microscopic one. The schedule of medicines for
treating is represented.
Proposed
antibiotics if the cause of sepsis is unidentified.
|
|
antibiotics |
|
|
cause of sepsis |
I degree |
II degree |
|
staphylococci |
meticyline, oxycyline, ceophalosporine |
lincomicine, eritromicine |
|
streptococci |
ampiciline |
tetracyclin, levometicin |
|
enterobacteries |
ampiciline, levometicin |
tetracyclin, gentamicine |
|
|
|
|
If the excitator is determined, the following
schedule of medicines for treating is represented.
Scheme of application and doses of antibiotics if
the excitator is determined.
|
|
Antibiotics |
|
|
cause of sepsis |
I degree |
II degree |
|
staphilococc penicillinonegative |
Bezilpenicyline, each 3 hours,0,5-1 mln units |
lincomicine(2g), eritromicine (12g),ceporine(1-4g) - all No.4 a
day.- |
|
staphylococci penicillinomaking |
oxcaceline, ampiox100-200mg/kg a day,each 6 hours |
lincomicine, eritromicine,ceporine tetracycline, 0,5-0,8g |
|
streptococci |
ampiciline |
erythromycin, levometicin |
|
colon bacillus |
ampiciline, ceophalosporine |
tetracycline, levometicin |
|
blue pus bacillus |
polymixin(100mg*3 per day); gentamicine(1,2-1,8 mg/kg) |
streptomicine levometicin; tetracycline |
Usually
the applied therapy isn't enough to treat sepsis. Combination is desirable:
a)
inhibitors of cellar membrane (penicillines, cephalosorines);
b)
detergents (polymixines, antifungous medicines);
c)
synthesis suppressers (levomecitine, tetracycline, streptomycin,
macrolides:
oleandimicine, erythromycine);
d)
managing of the nucleic acid synthesis (actinomicine, rubomicine,
lincomicine).
To
improve the concentration of antibiotic in purulent foci the intervascular
injections are preferable.
The
application of antibiotics by no means reject application of antiseptics: local
(furaciline, rocal, dioxydine, etc.) and general ones (1% blue metilen,
chlorophillipt solution).
The sulphanilamines, especially prolonged ones, are also
of use. They strengthen the activity of antibiotics and lessen their toxicity;
they are of peroral utilization: sulphodemisine -4-6g on four receptions per
day; sulphodemitoxine -1g a day; sulphacamphocain -10% solution 2ml, 4-6 times a
day, injections. The displays of efficiency of therapy are reductions of
inflammations; intoxication; fever; the purulent focus would compulsory become
opened.
2. Specifications of catabolic phase of sepsis and
their treating.
The peculiarity of that phase is improvement of protein,
lard and carbohydrate catabolism, utilization of enzymes, reduction of
functional abilities of organs and systems. De compensation of water-electrolyte
and acid-alkaline balances as well as inactivation of enzymes take place. The
zone of inflammation and destruction enlarges. Secondary infections are usual.
Purulent activity improves reduction of proteins. Purulent activity is supported
by endogen toxins (appearing as the result of catabolic processes and decay of
necrotic tissue). All these determines the specification of therapy: treating of
focus first of all by means of local antibioticotherapy and streaming aspiration
method. As the control lessening of fever and local inflammations can be taken.
Local application of proteolitic enzymes (tripsin or
chymopsin,10-20 mg per 30-50 ml of solution lessens the resistance of microbes
and inflammation. But on the other hand it can improve sepsis. A severe control
of proteolytic activity of blood is needed. The application of
antibioticotherapy would be based on antibioticogram: the mistakes in selection
of medicine can cause antibioticoresistance, toxic activity and disbacteriosis;
allergic and toxic reactions.
|
Accessory reactions at antibiotic therapy
(I.Cassirsky). |
||
|
mechanism of reaction |
dangerous for life |
undangerous |
|
ALLERGIC REACTIONS |
||
|
response
on antibiotic; degree depends on doze Usually
appears at repetitive application of medicine but sometimes can appear
from the beginning of
therapy. |
anaphylactic shock inflation of larynx, asthma, rinit, glossit |
anginonevro skin pruritus,urticaria conjunctivitis |
|
TOXIC REACTIONS |
||
|
caused by organotropic pharmocodynamic activity of
antibiotics, degree depends on dose and period of application |
intoxication of blood agranulocytose and plastic
anemia |
violation of vestibular apparatus, kidney, peripheral
nevrites Vomity glossites,hypermia diarrhea, |
|
DISBACTERIOSES AND OTHER PHENOMENA CAUSED BY
CHEMIOTHERAPEUTIC |
general candidosepsis enthercolites, secondary |
local candidoses-trush, etc. |
|
ACTIVITY OF ANTIBIOTICS |
pneumonies. |
|
Besides
controlling of these complications the sensitivity analysis
to
an exact antibiotic is required. Deintoxication therapy besides the resorbtion
in wound (drainage, aspiration) deletes toxins from vessels (diariesis;
hemodialysis, peritoneal dialysis).
Enforced
diariesis begins from 2-3hours of water loading by isotonic solutions of
electrolytes and glucose, controlled by hemocritis and OCK with following by
injection of mannitol (1g/kg). Water loading goes on with solution of 2,5-4g
KCl, 6g NaCl and 10g of glucose per 10l of solution. The speed of injection
would be equal to speed of diuresis and can be estimated from:
speed of injection (drop/min.) = volume for
injection (ml)/time of treating (hours)
This
cycle can be repeated, if required. The contraindications are: collapse after
cardiovascular deficiency and transgressions of kidney activity (with
azotemia,oliguria). During that procedure the level of electrolytes would be as
represented in Table 6.
|
Indexes of blood electrolytes, optimal for the
enforced diuresis. |
||
|
electrolytes |
mekv/liter |
mg,% |
|
K of plasma |
4,1-5,2 |
16-20 |
|
K of erythrocytes |
90-115 |
352-450 |
|
Ca of plasma |
4,5-5,5 |
9-11 |
|
Na of
plasma |
120-150 |
274-343 |
|
Na of erythrocytes |
17-20 |
39-46 |
|
Mg of plasma |
1,5-3,5 |
1,8-4,2 |
Correction
of hemodynamic violations is done simultaneously with detoxification.
Improvement of protein losses cause the requirement of improvement of dose of
injecting protein. Anabolics are also desirable here: retabolil injections in
tissue (1ml once a week); nerobol (0,05 twice a day). Reception of adjuvants
would be interrupted. Injection of antistaphylococci plasma would be held on the
14-th day after the beginning of disease. Anatoxin is injected under skin,
0,5ml. Injection of vaccine done from dead micro flora is permitted - first
injection - 0,05ml; later - dose would be doubled each time; 10-12 injections on
the whole. Microbial polysaccharides, purines and pyridines.
3.
Clinical pathology and treating of sepsis in anabolic stage.
Recreation
includes a special period when anabolic processes are dominating and the
structural proteins are restored. It usually goes moderately; but sometimes has
a sharp character - so called "vagal cryse", lasts for several hours
with following healing. During anabolic period endocrine-vegetative mechanisms
are developed with stimulation of protein and carbohydrate synthesis
(hypertension of parasympatical vegetative system and hyper secretion of
anabolics). Steady graduate recreation takes place. Estimates, based on
utilization of nitrogen in body, represent the development of 120g of tissue
every day. The task is to supply that process with energy and plastic materials.
Good diet, proteins, vitamins are required. The antibiotic therapy would be
interrupted if the recreation goes on; otherwise the schedule of used
antibiotics would be changed according to antibioticogram and therapy would go
on.
4.
HBO in case of GP.
Difficulties
in treating of GP force to develop new methods of doing that. The task is:
supplying with conditions of the best recreation of organs and systems of body;
activation of reserves and compensatory systems in new conditions of aggression;
stimulation of regeneration and reduction of treating period. As far as
oxygental shortages are usually developed at the end of sepsis, in Yaroslavl
Medical Institute HBO was proposed to be included in recreation therapy.
4.1.
Indications for the application of HBO.
a)
hard metabolic transgressions, caused by toxic-inflammation process and
hyperpirexia;
b)
respiratory violations of various degrees;
c)
cardiovascular deficiency resulting from septic activity (myocardit; endocardit;
pancardit; etc.);
d)
hemolysis and violation of blood recreation system by microbes and toxins;
e)
sharp violations of parenchimatous organs.
4.2.
Patophysiological proposals for application of HBO in treating sepsis.
Excitators
of purulent infection acting on blood and cells, can combine high active
symptomatic compounds. Hyper production of catecholamines cause hemodynamic
violations. Activity of toxins in tissue results in gystamino- and seratino-like
complexes which cause vasodilation and stasis, sharpening circulatory
violations. Transgressions in micro circulatory cause supply of tissue with
oxygen. Ishemiac anoxia together with damaging cardiac muscle cause congestion.
Adding coagulopatic violations deepen the violation of oxygental supply.
As
the result the syndrome of "shock lung" is formed with sharp
respiratory deficiency. Compensatory tachypnea, improvement of VPM, taxicardia
cannot compensate the shortage of oxygental supply of arterial blood.
Violations
at the first step of oxygental circulation cause the improvement of anaerobe
phase of metabolism with improvement of synthesis of organic acids. Acidation of
pH embarrasses the termination of oxygen to hemoglobin. Anemia and
hemoglobinopatia cause hemic hypoxia.
In
these conditions cellar membranes can't protect from external aggression and
tissue hypoxia is developed. All kinds of hypoxia in mix combine complex
hypoxia.
Described
mechanism of development of hypoxia in conditions of GP is the first reason for
application of HBO.
Generalized
surgeonal infection is caused by microbes; the improved pressure of oxygen
directly influences on them with inhibition. This is the second reason for
application of HBO in complex treating of sepsis.
GP
significantly weakens the protective system; normalization of oxygental balance
on contrary improves immune system and its response on aggression. This is the
third reason for application of HBO in complex treating of sepsis.
4.3.
General recommendations on application of HBO.
Permanent
control of state of patient is compulsory during the procedure.
For
prophylaxis of otorhinolaryngologic transgressions dropping of 3% solution of
ephedrine or 1% solution of adrenaline are used.
All
kinds of oil and would be removed from the skin before the procedure.
Maximal
aeration of wound is required - it accelerates the necrosis and releasing of
wound with later recreation.
The
first procedure is additionally important for it permits to discover individual
sensitivity to oxygen. Selection of time, working pressure of oxygen, amount of
procedures depends on the age, additional diseases, hardness of sepsis
transgressions and other individual specifications.
Scheme
of application of HBO dependently of hardness of process (table of amount of
procedures per day during HBO therapy.
day since the beginning
|
state of sick |
1 |
2 |
3 |
4 |
5 |
6 |
7 |
8 |
9 |
10 |
11 |
12 |
sum per course |
|
hard (tension phase) |
3 |
2 |
2 |
1 |
- |
- |
- |
- |
1 |
1 |
1 |
1 |
11-12 |
|
medium (catabolic) |
2 |
1 |
1 |
1 |
1 |
- |
- |
- |
1 |
1 |
1 |
- |
8-10 |
|
maximal pressure (AT) |
3 |
3 |
3 |
3 |
2 |
- |
- |
- |
2 |
2 |
2 |
2 |
|
|
isopression period (hour) |
1-1,5 |
1-1,5 |
1-1,5 |
1 |
1 |
- |
- |
- |
1 |
1 |
1 |
1 |
|
If the maximal pressure of chamber is less than 3AT, the
isopression period would be prolonged to preserve the multiplication of tine and
pressure of procedure unchanged.
4.4. Specifications and results of application of
HBO at different stages of GP.
In tension phase HBO prevents from hypoxic damaging of
tissue. The pressure is 3AT; saturation (isopression period) - 60 - 80 min.;
break between the procedures - 4-6 hours. As usual already after 3-4 procedures
the toxic-infectional displays are lessening; temperature falls; arterial
pressure, respiration and pulse are normalized; improves auresis; lessens
azotemia; betters acid-alkaline balance. Oxygenation of arterial blood comes
also to normalized. Purulent processes, inflation and hypermia around the wound
are lessening. >From 6 to 8 procedures would be held in that period.
In catabolic phase HBO improves reparation. One procedure
a day is proposed in that period with 2AT pressure and saturation for 40 min.
That regime excludes oxygental intoxication with prolongation of influence of
HBO.
Indications for finishing of HBO are: recreation of
patient; diminishing of violations to be healed; active reparation in wound.
Following the recommendations of application of HBO
maximally lessens the risk of complications; nevertheless permanent control of
patient is necessary to prevent barotraumata or oxygental intoxication.
4.5. Complications and risk of HBO.
The displays of oxygental intoxication are: paleness;
trembling of mouth; sweatiness; dizziness; vomity. Pulse is improving.
Interruption of injection of oxygen and extra decompression are required.
Repetitive procedures can be tried only with reduced pressure (less 2AT) and
saturation time.
Conditional contraindications for HBO are:
a) epilepsy;
b) caverns in lung;
c) violations of respiratoric conductivity;
d) claustrophobia;
e) improved sensitivity to oxygen.
Complex therapy including HBO of 140 patients with GP pathology in
Yaroslavl Medical Institute permitted to reduce
the lethality to 27%.