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 |
|