Sepsis - Diagnosis

It is proposed to establish the diagnosis of "sepsis" in the presence of two or more symptoms of a systemic inflammatory reaction with a proven infectious process (this also includes verified bacteremia).

The diagnosis of "severe sepsis" is proposed to be established in the presence of organ failure in a patient with sepsis.

Sepsis is diagnosed based on agreed criteria that form the basis of the SOFA (Sepsis oriented failure assessment) scale - Table 23-3.

Septic shock is generally understood to mean a decrease in blood pressure below 90 mm Hg in a patient with clinical signs of sepsis, despite adequate replenishment of the volume of circulating blood and plasma. The decisions of the Consensus Conference recommended not to use terms that do not have a specific semantic load, such as "septicemia", "sepsis syndrome", "refractory septic shock".

In some cases, when there is no certainty about the presence of an infectious focus (pancreatic necrosis, intra-abdominal abscess, necrotizing soft tissue infections, etc.), the procalcitonin test can be of significant help in diagnosing sepsis. According to a number of studies, today it is characterized by the highest sensitivity and specificity, significantly exceeding such a widespread indicator as C-reactive protein in the latter parameter. The use of a semi-quantitative method for determining the level of procalcitonin should, according to a number of specialists, become a routine study in clinical practice in cases where there are doubts about the presence of an infectious focus.

The quality of the examination plays a decisive role in choosing the adequate scope of surgical intervention and the outcome of the disease.

The main clinical symptoms of sepsis in gynecological patients are the presence of a purulent focus in combination with the following symptoms: hyperthermia, chills, changes in skin color, rashes and trophic changes, severe weakness, changes in the functions of the nervous system, dysfunction of the gastrointestinal tract, the presence of multiple organ failure (respiratory, cardiovascular, renal and hepatic).

There are no laboratory criteria specific to sepsis. Laboratory diagnostics of sepsis is based on data that reflect the fact of severe inflammation and the degree of multiple organ failure.

Red blood cell production is reduced in sepsis. Anemia in sepsis is observed in all cases, with 45% of patients having hemoglobin levels below 80 g/l.

Sepsis is characterized by neutrophilic leukocytosis with a left shift, in some cases a leukemoid reaction with a leukocyte count of up to 50-100 thousand and higher may be observed. Morphological changes in neutrophils in sepsis include toxic granularity, the appearance of Dohle bodies and vacuolization. Thrombocytopenia in sepsis occurs in 56% of cases, lymphopenia - in 81.2%.

The degree of intoxication is reflected by the leukocyte intoxication index (LII), which is calculated using the formula:

LII = (S+2P+ZYu+4Mi)(Pl-1) / (Mo+Li) (E+1)

Where S is segmented neutrophils, P is band neutrophils, Y is young leukocytes, Mi is meloocytes, Pl is plasma cells, Mo is monocytes, Li is lymphocytes, E is eosinophils.

The LII is normally equal to approximately 1. An increase in the index to 2-3 indicates a limitation of the inflammatory process, an increase to 4-9 indicates a significant bacterial component of endogenous intoxication.

Leukopenia with high LII is a poor prognostic sign for patients with septic shock.

Determination of acid-base balance (ABB) parameters, and especially lactate level, allows to determine the stage and severity of septic shock. It is believed that patients in the early stages of septic shock are characterized by compensated or subcompensated metabolic acidosis against the background of hypocapnia and high lactate level (1.5-2 mmol/l and higher). In the late stages of shock, metabolic acidosis becomes uncompensated and can exceed 10 mmol/l in terms of base deficit. The level of lactacidemia reaches critical limits (3-4 mmol/l) and is a criterion for the reversibility of septic shock. The severity of acidosis largely correlates with the prognosis.

Although the violation of the blood aggregation properties to one degree or another develops in all patients with sepsis, the frequency of disseminated intravascular coagulation syndrome is only 11%. Hemostasis parameters in patients with septic shock indicate the presence of, as a rule, a chronic, subacute or acute form of DIC syndrome. Subacute and acute forms in patients with septic shock are characterized by severe thrombocytopenia (less than 50-10 ⁹ g / l), hypofibrinogenemia (less than 1.5 t / l), increased consumption of antithrombin and plasminogen, a sharp increase in the content of fibrin and fibrinogen derivatives, an increase in the chronometric indicator of thromboelastogram, blood clotting time, a decrease in the structural indicator of thromboelastogram.

In chronic DIC syndrome, moderate thrombocytopenia (less than 150-10 ⁹ g/l), hyperfibrinogenemia, increased consumption of antithrombin III, and hyperactivity of the hemostasis system (decrease in the chronometric indicator and increase in the structural indicator on the thromboelastogram) are noted.

Determination of serum electrolyte concentrations, protein levels, urea, creatinine, and liver function tests helps to determine the function of the most important parenchymal organs - the liver and kidneys.

Patients with sepsis are characterized by pronounced hypoproteinemia. Thus, hypoproteinemia less than 60 g/l is observed in 81.2-85% of patients).

Although the absence of positive blood culture data does not eliminate the diagnosis in patients with a clinical picture of sepsis, patients with sepsis need to undergo microbiological testing. Blood, urine, discharge from the cervical canal, discharge from wounds or fistulas, as well as material obtained intraoperatively directly from the purulent focus are subject to testing. Not only the identification of the detected microorganisms (virulence), but also their quantitative assessment (degree of contamination) is of significant importance, although the results of such studies, due to the duration of their implementation, are often assessed retrospectively.

Bacteriological confirmation of bacteremia is complex and requires compliance with certain conditions. To detect bacteremia, blood culture is preferably performed either as soon as possible after the onset of fever or chills, or 1 hour before the expected temperature rise, preferably before the start of antibiotic therapy. It is advisable to perform 2 to 4 blood collections at intervals of at least 20 minutes, since an increase in the frequency of cultures increases the likelihood of isolating the pathogen. Blood is collected from a peripheral vein (not from a subclavian catheter). As a rule, it is recommended to take 10-20 ml of blood in 2 vials for aerobic and anaerobic incubation for 7 days at each collection, in children under 12 years - 1-5 ml.

Instrumental diagnostics of sepsis (ultrasound, radiological, including CT; MRI) are aimed at clarifying the severity and spread of purulent lesions in the primary focus, as well as identifying possible secondary purulent (metastatic) foci.

Currently, the APACHE II scale is used for an objective assessment of the severity of patients' condition in sepsis, the adequacy of the therapy, and the prognosis. Studies conducted in patients with abdominal surgical sepsis have shown an almost direct dependence of mortality on the severity of the condition (the sum of points on the APACHE II scale). Thus, with a sum of less than 10 points on this scale, there were no fatal outcomes. With a sum of points from 11 to 15, the mortality rate was 25%, with a sum of 16 to 20 points, the mortality rate was 34%; in patients with a sum of points from 21 to 25, the mortality rate was 41%, with a sum of points from 26 to 33, the mortality rate reached 58.9%; with a sum of points over 30, it was the highest - 82.25%.

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