Surgical treatment of sepsis

Given the severity and multi-organ damage in patients with sepsis and especially septic shock, including decompensation of the cardiovascular and respiratory systems, treatment of such patients should be carried out in specialized departments that have all the methods of diagnosis, monitoring and treatment, including extracorporeal detoxification methods . If patients can not be transferred to such units, treatment should be carried out in a ward or intensive care unit. A prerequisite is the availability of the operating unit.

Treatment for sepsis should be conservative-surgical, necessarily including both components. Even to this day, doctors continue to err in regard to the appropriateness and scope of surgical intervention for sepsis and especially septic shock. This is mainly due to the refusal of the operation or the restriction of the scope of surgical intervention due to the severe condition of the patients and the fear that patients "will not undergo surgery." In the best case, palliative interventions are carried out with this approach, in others - the treatment is reduced to vigorous conservative therapy, and first of all - antibacterial.

However, the issue of radical removal or sanation of the primary purulent focus in patients with sepsis (as well as pyemic foci, if any) is no longer discussed throughout the world. Thus, from the thoroughness and radicalization of the surgical component of the treatment of gynecological sepsis (extirpation of the uterus in the hysterogenic form of sepsis, the removal of tubo-ovarian abscesses, the emptying of extragenital abscesses, the removal of purulent-necrotic tissues of the small pelvic tissue with parametrization, adequate excision of the edges of the purulent wound with the opening of all pockets and swollen with wound infection), and also from adequate drainage, often the outcome of the disease depends, i.e. Life is sick.

Surgical tactics

It is now generally accepted that surgical tactics for sepsis and even septic shock should be active, and an adequate sanitizing surgical component of treatment serves as a guarantee for the survival of such patients. It must be remembered that palliative interventions in patients with generalized infection not only do not save the situation, but also often aggravate it.

Attempts for curettage of the uterine cavity in patients with hysterogenic sepsis are categorically contraindicated, since in practice they take away insignificant chances for life from patients. Removal of placental tissue, fetal egg and purulent-necrotic endometrium in patients with generalized infection (sepsis) does not make any sense and can dramatically worsen the patient's condition due to the development of septic shock, especially if entry into the uterus is carried out at low arterial pressure or at the time of curettage "prevention" of septic shock is carried out by intravenous administration of antibacterial agents that promote massive lysis of microorganisms.

Timely hysterectomy - removal of the active primary focus, toxins and infected emboli from which enter the blood in large quantities - is vitally shown, and even the patient's serious condition (except for atonal) is not an obstacle, as this is the only, though not guaranteed chance to avoid a lethal outcome.

In lightning and acute forms of hysterogenic sepsis (direct connection with labor, abortion), all patients are shown hysterectomy after preoperative preparation and removal from shock.

With surgery, one should not pull, better results (survival) are obtained in patients operated in the first 12 hours after admission. An adequate volume of surgical intervention is the extirpation of the uterus with the tubes, sanitation and drainage of the abdominal cavity. Prognostically favorable is the removal of the primary focus of infection by the "block", when the uterus is removed along with the infected fetus, placenta or remnants of the placental tissue (in the event that miscarriage or labor has already occurred earlier).

From the technical performance of the operation, in particular the nature of blood loss, the reliability of hemostasis and the adequacy of drainage, the course of the postoperative period, and often also the survival rate, depends. The gain in time can be provided only by the presence of a well-coordinated highly skilled operating team, and not by haste, which is accompanied by careless hemostasis and other surgical defects.

Features of surgical intervention in such patients:

• It is advisable to use only lower-median laparotomy.
• During the operation, a careful audit of not only the pelvic organs and abdominal cavity but also the retroperitoneal space is necessary, especially if the intraoperative findings in terms of volume and severity are incomparable with the clinical picture and do not agree with the preliminary preoperative conclusion. In such cases, it is logical to pay attention to the search for a true source, which may be, for example, destructive pancreatitis.
• Errors that undoubtedly worsen the patient's condition are: incision of the uterus and removal of the fetus and the afterbirth during the operation, as well as the fixation of the uterus with sharp instruments penetrating the cavity (corkscrews, Muso-type clips). These manipulations facilitate the technical operation due to the decrease in the size of the uterus, but in this case, especially in the first case, a large number of thromboplastins and purulent emboli additionally enter the blood, which can cause a sharp deterioration of the condition until septic shock and death of the patient.
• It is advisable to use the technique of removal of the uterus "block", for which at large sizes of the uterus it is necessary to prolong the incision of the anterior abdominal wall.
• Fixation of the uterus before the beginning of all manipulations is carried out by two long clamps of Kocher, superimposed on the ribs of the uterus. Clamps prevent the entry of toxins into the blood, perform haemostatic function, they can additionally be linked together and used as a "holder."
• Clamps on the ligaments should be applied in such a way that their ends are in the avascular zones, this is especially important in the presence of large venous, sometimes varicose-extended plexuses; blood loss in this case is minimal.
• Much attention should be given to the thoroughness of hemostasis. Operations performed in the phase of hypocoagulation DIC syndrome, accompanied by increased bleeding and the formation of hematomas, they are often time-consuming because of the need for additional hemostasis. If there is bleeding in the parameter, if the bleeding vessel is not visible, temporary hemostasis should be performed by pressing or applying soft clamps. After palpation, and in some cases of visual revision of the ureter, a vessel is ligated. The ligation of the uterine vessels and individual vessels in the parameter is usually sufficient.
• In some cases with continued bleeding it is more expedient and safer to make a ligation of the internal iliac artery from the appropriate side. To do this, it is necessary to expand the parameters widely to orientate oneself in the special features of the topography of the retroperitoneal space. It should be remembered that the ligation of the internal iliac artery is a responsible exercise and it is necessary to resort to it only in case of emergency, as in this zone there are vital structures such as the main vessels of the pelvis - the common, external and internal iliac arteries and corresponding veins, of which the greatest danger to manipulation is the internal iliac vein, the lateral wall adjoining the posterior and lateral walls of the internal iliac artery, and the posterior one - all intimately Knitted with pelvic periosteum (so the wound dressing her veins attempts are always unsuccessful). To preserve the trophism of tissues (primarily the bladder and gluteal region), the ligation of the internal iliac artery is preferable to produce as low as possible from the place of its departure from the main trunk; Below the site of the upper vestibular artery from it. If this is impossible for any reason, the dressing is performed immediately after the internal iliac artery is separated from the common one. It is necessary palpatory and visually once again to make sure that the internal iliac artery is bandaged, and not external and not general (such cases are described in practice). In doubtful situations, as well as in the absence of experience in carrying out such manipulation, a specialist in vascular surgery should be invited to take a job. It is advisable to dissect the fascial sheet (case) covering the vessel, tangentially insert the corresponding Deshampa needle under the vessel and double-tie it with a strong non-absorbable ligature, without crossing it. It is important to remember that the ureter is also located in the surgical zone, fixed, as a rule, to the posterior leaf of the broad ligament, but sometimes (hematomas, manipulations in the parameter) lie freely in the parameter. To prevent injury to the ureter, a strict rule for the ligation of the internal iliac artery should be not only palpation, but also visual control, since large veins may be "clicks" when squeezed, similar to what the ureter gives during palpation.
• Very rarely, only bilateral ligation of the internal iliac arteries is effective, which undoubtedly worsens the conditions of reparation, but is the only means of saving the patient.
• The absence of capillary bleeding during surgery is an unfavorable sign (spasm and thrombosis of peripheral vessels). After a virtually bloodless operation in this case, then bleeding may occur, often requiring relaparotomy, additional hemostasis and drainage. The surgeon should remember that even with the most technical operation performed in septic patients, it is possible later to experience anemigraine bleeding and bleeding from a wound associated with the progression of DIC syndrome and the development of hypocoagulation. To control possible intraabdominal bleeding in such patients, always keep the dome of the vagina open, even with minimal blood loss, and avoid overlapping of frequent deaf sutures on the skin and aponeurosis, which will allow us to recognize in time the extensive sub-panurotic hematomas. The operation is completed by sanation and drainage of the abdominal cavity. In the postoperative period within 1-3 days, an ADP is performed, which allows to reduce intoxication and to remove the exudate from the abdominal cavity. With late admission of patients (subacute current of hysterogenic sepsis, chroniosepsis), when the role of the primary focus is reduced, surgical treatment is indicated in the following cases:
  • presence of a purulent process in the appendages or cellulose of the small pelvis;
  • the detection of pus or blood from the abdominal cavity;
  • suspected old uterine perforation;
  • the presence of progressive arthritis, which does not stop during treatment;
  • active purulent process in the primary focus;
  • the appearance of signs of irritation of the peritoneum.

Manifestations of sepsis or septic shock in patients with purulent inflammatory formations of pelvic organs of any severity or any localization serve as vital indications for surgical treatment.

As a rule, the development of sepsis in patients with purulent inflammatory diseases of the pelvic organs results in extremely prolonged (for months and sometimes several years) conservative treatment, often with repeated palliative interventions.

With surgical treatment after diagnosis of sepsis should not be delayed, since with the persistent purulent focus in the body, the course of the disease at any time can complicate septic shock, possibly a sudden progression of the multi-organ failure in sepsis, and the appearance of thromboembolic complications. Any of these complications of sepsis is fraught with a fatal outcome.

Patients with sepsis showed a rapid examination, aimed primarily at clarifying the degree and form of multiple organ failure, revealing extragenital and pyemic purulent foci, as well as complex treatment, which is also a preoperative preparation. As a rule, with the onset of intensive treatment, the patient's condition improves. This time is expedient for using for operative treatment.

With the development of septic shock operative treatment is initiated after a short but intensive preoperative preparation, including all the pathogenetic moments of impact on the shock and removal of the patient from shock.

Conservative treatment of patients with sepsis consists in intensive therapy, pathogenetically affecting the main damaging factors.

[1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11], [12]