Treatment of septic shock

Intensive therapy of septic shock is carried out jointly by the reanimatologist and obstetrician-gynecologist, if necessary with the involvement of a nephrologist, urologist and hematologist-coagulologist.

Carrying out of medical actions requires constant (better monitor) observation. It is necessary to perform mandatory monitoring of body temperature, skin conditions, respiration rate and pulse rate, parameters and CVP and hematocrit, ECG, hourly diuretic, acid-base and electrolyte plasma composition, proteinogram, nitrogenous slag and bilirubin content, coagulogram. It is desirable to determine BCC and the value of cardiac output: Treatment is carried out in a complex manner. It is aimed at combating shock and infection, preventing and treating complications of septic shock: acute renal and respiratory failure and bleeding due to disorders of the blood coagulation system.

Measures to combat shock should focus on restoring tissue blood flow, correcting metabolic abnormalities and maintaining adequate gas exchange.

The first two tasks are solved by performing an infusion therapy, which must be started as soon as possible and carried out for a long time. For these purposes, a permanent catheter is inserted into a large vein (usually subclavian).

Since septic shock rather early occurs hypovolemia, which is the result of a discrepancy between the capacity of the vascular bed and the volume of bcc. Then the fight against shock in the first place is to replenish the BCC.

As the infusion medium in the first stages of treatment, it is preferable to use dextran derivatives (400-800 ml of rheopolyglucin and / or polyglucin) and polyvinylpyrrolidone (hemodez, 400 ml). These drugs restore and improve the rheological properties of blood and thereby contribute to reducing viscosity, eliminating stasis and aggregation of uniform elements, improving microcirculation. In addition, these blood substitutes significantly increase the BCC due to the interstitial fluid. An important advantage of these infusion media is their ability to adsorb toxins and remove them from the body.

Find solutions in the infusion therapy of septic shock are gelatin solutions, especially decalcified gelatin, which can be administered up to 1000 ml. This drug is well tolerated by patients, can be mixed with donor blood in any proportions without causing aggregation of red blood cells, is rapidly excreted by the kidneys, contributing to detoxification.

Carrying out infusion therapy in shock patients, it is necessary to adhere to medium doses of plasma substitute, because in case of overdose undesirable side effects of these media can appear. Large-molecular dextrans are able to block the reticuloendothelial system, low-molecular-weight - to cause osmotic nephrosis. Gelatinol can promote the release of histamine and have an aggregative effect on the blood elements.

To increase the colloid osmotic pressure for the purpose of fluid transport from the interstitial space to the bloodstream, protein preparations are used: 400 ml of a 5-10% solution of albumin, 500 ml of protein. These drugs eliminate hypoproteinemia, which is always present in septic shock, and also have a pronounced detoxification effect. It is useful to transfuse dry and native plasma, which holds well the osmotic pressure and thus contributes to the recovery of bcc.

Hemotransfusions are not the main means for the elimination of hypovolemia in septic shock. Transfusion of blood, or better erythrocyte mass, is necessary if the hematocrit is less than 30. Usually, a small amount of blood or erythrocyte mass is administered not later than the 3rd day of storage (300-500 ml). Hemotransfusions are carried out in parallel with the infusion of rheologically active plasma substitutes or crystalloid solutions in the mode of hemodilution. The best effect is achieved with the use of "warm" heparinized blood. If septic shock is combined with bleeding, then blood transfusion should correspond to the degree of blood loss.

The composition of infusion therapy includes 10% or 20% glucose solution in an amount of 300-500 ml with adequate doses of insulin. The advantage of concentrated solutions of glucose is that they, while replenishing the energy costs of the organism, simultaneously possess an osmodiuretic property, which is of no small importance in the treatment of patients with septic shock.

The rate and amount of fluid infusion depend on the response of the patient to the therapy being administered. Pulse, blood pressure, CVP, minute diuresis should be evaluated after infusion of every 500 ml of fluid. The total amount of liquid in the first day, as a rule, is 3000-4500 ml, but it can reach 6000 ml. The volume of infusion media should be compared with diuresis, loss of fluid through the skin and lungs (700 ml - 400 ml for every degree of increase in body temperature), vomit, etc.

The main clinical criteria that testify to the elimination of hypovolemia and the restoration of bcc are normalization of the color of the skin, optimal CVP (5.0-100 mmHg), sufficient diuresis (more than 30 ml / h without diuretics, 60-100 ml / h - forcing diuresis). With appropriate capabilities, it is desirable to determine the BCC and the magnitude of cardiac output. Arterial pressure in septic shock can remain for a long time at relatively low figures - 90 mm Hg. It is not necessary to force its upswing by all means if there are signs of improvement of microcirculation (skin color, sufficient hourly diuresis).

Against the background of replenishment of bcc and improvement of rheological properties of blood for correction of hemodynamics and restoration of tissue blood flow, mandatory use of cardiac and vasoactive agents is necessary. Cardiac glycosides are administered intravenously together with 20 ml of a 40% solution of glucose in usual dosages: 0.5-1 ml of a 0.05% solution of strophanthin, or 0.5-1 ml of a 0.06% solution of Korglikona, or 1-2 ml of 0, 02% solution of Celanide (isolanide), 1-2 ml of 0.025% digoxin solution. It is advisable after the elimination of hypovolemia to use a 0.5% solution of quarantine, which, because of a possible reduction in systemic blood pressure, should be administered slowly in an amount of 2-4 ml. Curantil dilates the coronary vessels, increases the tolerance of the myocardium to hypoxia, and, in addition, inhibits the aggregation of platelets.

With success use small doses of dopamine (dopamine). This drug raises blood pressure, increases cardiac contractions and increases cardiac output. In addition, small doses of dopamine (1-5 μg / (kg-min)) decrease the resistance of renal vessels, increase renal blood flow and glomerular filtration, which increases the effectiveness of the drug in septic shock. 5 ml of a 0.5% solution of dopamine is diluted in 125 ml isotonic sodium chloride solution or 5% glucose solution and injected very slowly at 2-10 drops per minute.

After replenishing the volume of bcc with the continuing vasomotor collapse, you can use (cautiously!) The slow drop introduction of angiotensinamide. Usually, the infusion of the drug begins at a rate of 3-5 μg / min, if necessary increasing the dose to 10-20 μg / min. When the desired effect is achieved (blood pressure increase to 90-100 mm Hg), the administered dose can be reduced. To prepare a concentration of 1 μg / ml, 1 bottle (1 mg) of the drug is dissolved in 1000 ml of isotonic sodium chloride solution or 5% glucose solution, and for a concentration of 2 μg / ml in 500 ml of solvent.

In the therapy of septic shock, vasodilators such as euphyllin, papaverine, no-shpy or complamine are widely used to expand peripheral vessels. These drugs are prescribed after replenishment of the BCC with mandatory control over blood pressure figures. Dosage of medications is usual: 5-10 ml of a 2.4% solution of euphyllin, 2 ml of a 2% solution of papaverine. 2-4 ml of a 2% solution of no-shpa. Very actively expands the arterioles and venules of compliance. At the same time as the peripheral resistance decreases, the minute volume of the heart increases. 15% solution of the drug in the amount of 2 ml is administered intravenously very slowly.

Beta-adrenoblockers such as anaprilin or oxyprenolone improve blood circulation in the lungs, in the organs of the abdominal cavity, optimize coronary blood flow, facilitate the closure of arteriovenous shunts. These properties of drugs have been used to treat patients with septic shock. However, a negative foreign and chronotropic effect on the heart limits the scope of their application.

The question of the use of corticosteroids for the treatment of septic shock continues to be debated. The literature data and our own clinical experience testify in favor of these drugs. Corticosteroids not only contribute to the improvement of hemodynamics, but also have a positive effect on many pathogenetic links in septic shock. Glucocorticoids, increasing cardiac output, optimize the activity of the heart; possessing a moderate vasodilating property, improve microcirculation; reducing the flow of tissue thromboplastin and preventing the increase in platelet aggregation, reduce the severity of the DIC syndrome. In addition, these drugs weaken the action of endotoxin, stimulate the activity of enzymes involved in oxidative processes, increase the tolerance of cells to lack of oxygen, promote the stabilization of membranes, prevent the development of shock, have antihistamine properties.

The anti-shock effect of corticosteroids is manifested by the administration of medium and high doses of drugs. At once, 250-500 mg of hydrocortisone is administered; or 60-120 mg of prednisolone, or 8-16 mg of dexamethasone. After 2-4 hours, the preparation is repeated.

The general condition of the patient, the color and temperature of the skin, blood pressure and hourly diuresis serve as a criterion for the effectiveness of the inclusion of corticosteroids in a set of therapeutic measures.

In a day, 1000-3000 mg of hydrocortisone or equivalent amounts of prednisolone and dexamethasone are administered. These dosages are used for 1-2 days, so do not be afraid of the negative effect of exogenous corticosteroids on the functional activity of the adrenal glands and the immune properties of the body. The lack of effect on significant doses of glucocorticoids (1000 mg of hydrocortisone or the corresponding amounts of prednisolone or dexamethasone) indicates far-reaching irreversible changes in vital organs and is a poor prognostic sign. In such cases, there is no need to continue steroid therapy.

Taking into account changes in the histamine-histaminase system with septic shock, it is necessary to administer antihistamines: 1-2 ml of a 1% solution of diphenhydramine, 1-2 ml of a 2.5% solution of pipolpene, 1-2 ml of a 2% suprastin solution or 2 ml of Tavegil .

Along with the normalization of hemodynamics, infusion therapy for septic shock should have as its goal the correction of acid-base and electrolyte homeostasis.

With septic shock metabolic acidosis develops quite rapidly , which at first can be compensated by respiratory alkalosis. For correction of acidosis It is necessary to include 500 ml of lactasol, 500 ml of ricer-lactate or 150-200 ml of 4-5% sodium bicarbonate solution in the infusion therapy. The exact amount of solution is determined depending on the deficiency of bases (-BE).

To improve the oxidation-reduction processes, the use of a glucose solution with an adequate amount of insulin and vitamins is indicated: 1-2 ml of a 6% solution of vitamin B2, 1-2 ml of a 5% solution of vitamin B6, 400-500 μg of vitamin B12, 100-200 mg of cocarboxylase, 5-10 ml of 5% solution of ascorbic acid. It should be remembered that the B vitamins can not be mixed in one syringe. To improve liver function, in addition to vitamins and coenzymes, it is desirable to use choline chloride in an amount of 200 ml in the form of a 1% solution, 10-20 ml essential, 2 ml of sirepa or other hepatotropic agents.

Septic shock quickly leads to electrolyte imbalance. Already at the early stages of its development, there is a decrease in the content of K, Na, Ca, Mg ions in the plasma. In the first day of treatment, it is necessary to correct the deficiency of these ions by means of intravenous drip infusion. For this purpose, it is possible to use panangin in the amount of 10-20 ml or 4% potassium chloride solution in an amount of 10-20 ml, or 4% potassium chloride solution in an amount of 50 ml with 400-500 ml of isotonic glucose solution, do not forget about the introduction of 10 ml of a 10% solution of calcium chloride or 100 ml of a 1% solution of the same preparation. The successful use of an energy polyionic solution of the following composition is reported: 3 g of potassium chloride, 0.8 g of calcium chloride and 0.4 g of magnesium chloride are added to 1 liter of a 25% solution of glucose. Be sure to introduce adequate doses of insulin. The need for further administration of electrolyte solutions should be confirmed by laboratory data, special care should be exercised in the presence of signs of acute renal failure.

In parallel with the recovery of hemodynamic disorders and the correction of metabolic disorders, it is very important to ensure adequate oxygenation. The introduction of oxygen must begin with the first minutes of treatment, use for this all available methods up to artificial ventilation (IVL). Absolute indications for ventilation are the fall of P ₀₂ below 8-9.3 kPa (60-70 mm Hg) with 100% oxygen inhalation through the mask.

Along with anti-shock measures, the fight against infection is an integral part of the intensive therapy of septic shock .

If a causative agent of sepsis is known, then directed, for example, anti-pseudomonas (anti-synergic), therapy. However, in the overwhelming majority of cases, due to the lack of adequate bacteriological research, an empirical treatment of sepsis is carried out, which is often successful because of the administration of drugs with the widest possible spectrum of action. Thus, the initial empirical antimicrobial therapy in patients with sepsis was effective in 91% of cases and was prolonged after the results of the bacteriological study of the blood became known.

Treatment is carried out with the maximum single and daily doses, the duration of it is 6-8 days. Treatment is continued until the body temperature normalizes for at least 3-4 days. In some cases, the replacement of the antibiotic and the continuation of the course of therapy are required.

Once again I want to emphasize that conservative treatment is effective only in the case of surgical sanitation of a purulent focus, and the preservation and the more increasing the clinical signs of intoxication and other manifestations of the infectious process against adequate antibiotic therapy may indicate a non-surgical operation or the appearance of large piemic foci, which requires their detection and sanitation.

In their clinical practice for the treatment of sepsis successfully used the following drugs or their combinations:

• monotherapy with beta-lactam antibiotics with beta-lactamase inhibitors - TIC / CK - ticarcillin / clavulonic acid (timentin) in a single dose of 3.1, daily dose of 18.6 g;
• cephalosporins III generation in combination with nitroimidazoles, for example, cefotaxime (claforan) + clion (metronidazole) or ceftazidime (fortum) + clion (metronidazole); cefotaxime (claforan) in a single dose of 2 g, daily dose of 6 g, a course dose of 48 g;
  • aminoglycosides, cephalosporins (third generation), ampicillin + sulbactam, amoxicillin + clavulanic acid, piperacillin + tazobactam, ticarcillin + clavulonic acid.
  • ceftazidime (fortum) in a single dose of 2 grams, a daily dose of 6 grams, a course dose of 48 g;
  • clione (metronidazole) in a single dose of 0.5 g, daily dose of 1.5 g, a course dose of 4.5 g;
• combinations of lincosamines and aminoglycosides, for example, lincomycin + gentamycin (netromycin) or clindamycin + gentamycin (netromycin);
  • lincomycin in a single dose of 0.9 g, daily dose of 2.7 g; clindamycin in a single dose of 0.9 g, daily dose of 2.7 g; gentamycin in a daily dose of 0, 24 g; netromycin in a daily dose of 0.4 g, a course dose of 2.0 g intravenously;
• monotherapy with meropenems, for example: meronem in a single dose of 1 g, daily dose of 3 g; hyenas in a single dose of 1 g, daily dose of 3 g.

Along with antibiotics in particularly severe cases, the use of antiseptics is recommended: dioxinine up to 1.2 g / day. -120 ml of 1% solution intravenously or furagina up to 0,3-0,5 g / day.

Infusion therapy for sepsis is aimed at maintaining the volume of circulating blood, adequate tissue perfusion, correction of homeostasis disorders and satisfaction of energy needs.

In connection with the prevalence of catabolic processes in patients with sepsis, the energy needs of the organism for parenteral nutrition are 200-300 g of glucose / day. With insulin and at least 1.5 g / kg protein.

They are replenished due to infusions of crystalloids (solutions of glucose with insulin, glucasterol, yonostearil), colloids (mainly solutions of hydroxyethyl starch-malaplasmesteril, 6 and 10% HAES sterile), solutions of fresh-frozen plasma and albumin. The volume of infusions is individual and is determined by the nature of CVP and the magnitude of diuresis. On average, 2-2.5 liters of infusion media are administered.

Antibacterial therapy for septic shock is an emergency, there is no time to identify the flora and its sensitivity to antibiotics, so treatment begins with the introduction of broad-spectrum antibiotics. Dosages usually significantly exceed the middle. Benzylpenicillin sodium salt is administered up to 40 000 000-60 000 000 units per day intravenously in 2-3 doses of benzylpenicillin, the potassium salt is intravenously administered only in laboratory-confirmed hypokalemia. It should be taken into account that 1 000 000 units of potassium salt of benzylpenicillin contains 65.7 mg of potassium, that is, 25 000 000 units of ED antibiotic can provide the minimum daily requirement of an organism in potassium.

Semisynthetic penicillins are widely used. Methicillin sodium salt is administered 1-2 g every 4 hours intramuscularly or intravenously. For intravenous drip infusion, each gram of the drug is diluted in 100 ml of isotonic sodium chloride solution. The maximum daily dose is 12 g. Oxacillin and dicloxacillia sodium salt are applied 1 g every 4 hours intramuscularly or intravenously (for intravenous drip the drug is diluted in 100 ml of isotonic sodium chloride solution), the maximum daily dose is 6 g. Ampicillin sodium salt (pentrexyl ) is used 1,5-2 g every 4 hours intramuscularly or intravenously with 20 ml of isotonic sodium chloride solution; the maximum daily dose is 12 g. Carbenicillin disodium salt (pyopen) is administered 2 g after 4 hours intramuscularly or intravenously into 40 ml of isotonic sodium chloride solution; daily dose - 12 g.

When choosing a drug, it should be remembered that ampicillin and carbenicillin have the widest spectrum of action. Methicillin, dicloxacillin and oxacillin are resistant to penicillinase, so they have a pronounced effect on the microorganisms producing penicillinase. Carbenicillin has a bactericidal effect on the Pseudomonas aeruginosa, resistant to other antibiotics of the penicillin series.

The preparations of the group cephalosporins are successfully used. Cephaloridine (cephrine), cefazolin (cephazole), cephalexin are prescribed for 1 g every 4 hours or 2 g every 6 hours intramuscularly or intravenously; the maximum dose is 8 g.

A wide spectrum of antimicrobial action is possessed by antibiotics of the aminoglycoside group. The maximum daily dose: kanamycin sulfate - 2 g (injected 0.5 g every 6 hours); gentamycin sulfate 240 mg (the drug is administered at 80 mg every 8 hours); in the same dosages tobramycin sulfate is used; Amikacin (semisynthetic kanamycin sulfate) - 2 g (injected 0.5 g every 6 hours). Aminoglycosides are usually administered intramuscularly, but in cases of severe sepsis within 2-3 days, intravenous drip administration is possible. A single dose of the drug is diluted in 200 ml of isotonic sodium chloride solution or 5% glucose solution; the rate of administration is 60-80 drops per minute.

Sodium succinate (chloramphenicol), which can be used intravenously or intramuscularly for 1 g every 6-8 hours, has not lost its importance in antibacterial therapy of septic shock of levomycetin; the maximum daily dose is 4 g. In addition to these approved drugs, it is possible to use the newest generations of broad-spectrum antibiotics.

Dosages of drugs are largely determined by the excretory function of the kidneys. At normal, and the more so high diuresis the maximum amounts of antibiotics are used.

To enhance the antimicrobial effect and expand the spectrum of antibiotics can be combined with each other. When choosing a combination of drugs, it is necessary to take into account the nature of their interactions (indifferent, additive, sykergidic or antagonistic), the likely summation of their side effects and the possibility of intravenous administration of at least one of them. The most common combinations of antibiotics are: ampicillin with oxacillin, natural and semisynthetic penicillins with aminoglycosides, cephalosporins with aminoglycosides, levomycetin with gentamycin or lincomycin.

Considering the wide prevalence of anaerobic infection, preparations of metronidaleol (100 ml of 0.5% solution 2-3 times a day) should be included in the complex of antibacterial agents.

As is known, the fight against infection involves the elimination of the focus of infection. In surgical practice, the issue of early and complete removal of the septic focus is undoubted. It is not so easy to solve the issue of eliminating the source of infection in gynecological practice, if this source is the uterus. Therefore, many very authoritative authors in case of shock caused by septic abortion are recommended to perform careful instrumental emptying of the uterus simultaneously with massive anti-shock and antibacterial therapy. Other authors believe that manipulations in the uterine cavity adversely affect the course of septic shock and worsen the prognosis. Our experience confirms the dangers of such interventions. Of course, it captivates the view that the constant supply of microorganisms or their toxins to the bloodstream of a patient is much more dangerous than a one-stage breakthrough in the process of instrumental emptying of the uterus. However, clinical practice shows: with septic shock, especially developed in the foyer of community-acquired abortion, infection is infrequently limited to the outside of the fetal egg. Much more often in the process involve the myomas, the uterine veins or the infection goes beyond the uterus. In such cases, instrumental removal of the fetal egg does not lead to the desired effect.

The experience of gynecological practice shows that the approach to the elimination of the focus of infection in septic shock should be strictly individual. In the case of an infected early miscarriage in the absence of signs of an inflammatory process in the myometrium and outside the uterus, emptying the uterine cavity is permissible by careful scraping; scraping is certainly indicated for bleeding that is not a consequence of the DIC syndrome. At the beginning of a late miscarriage, the elimination of an infected fetal egg is performed by performing rhodostimulating therapy with a dropwise intravenous injection of oxytocin or prostaglandins; The delayed reentry is removed by instrumental means.

The most radical way to fight a foci of infection is to remove the uterus. This operation should be resorted to with failure of intensive therapy of shock, conducted during 4-6 hours. The main difference between septic shock and other types of shock is the rate of development of deep and irreversible changes in vital organs, so the time factor in the treatment of such patients becomes crucial. The delay in the radical removal of the septic focus, connected both with the overcoming of the moral barrier of inevitability of removal of the uterus in young women, and with the need for surgical intervention in patients in extremely serious condition, can cost the life of the patient. The operation of choice is extirpation of the uterus with removal of the fallopian tubes, drainage of the parameter and abdominal cavity. In some cases, patients who are in a very serious condition, in the absence of macroscopically expressed changes in the uterine tissue, it is permissible to manufacture a supra-vaginal amputation of the uterus. Removal of the fallopian tubes and drainage of the abdominal cavity are also mandatory in these cases.

The development of septic shock against a background of limited or diffuse peritonitis certainly requires surgical intervention, removal of the focus of infection (uterus, appendages) with a wide drainage of the abdominal cavity.

Correction of immune disorders in patients with sepsis

Immunotherapy for sepsis is extremely complex and can be effectively targeted only if there are appropriate immunological studies, preferably by an immunologist, since any link of immunity or many of its links can be disrupted.

In the case of deficiency of cellular factors (T-system), it is advisable to administer leukemia (3-4 doses of 300 ml), human leukocyte interferon at a dose of 10 000-20 000 ME. If the factors of humoral immunity are insufficient (B-system), the use of specific hyperimmune plasma is effective 5-7 ml / kg to 10 doses per course. For the treatment of combined immunodeficiency, the use of leukemia, thymus preparations - T-acacin, thymalin is recommended. With a combined deficit of subpopulations of T and B lymphocytes or an increase in circulating immune complexes in the plasma, hemosorption, which has an immunomodulating effect, is suitable in the authors' opinion.

If the pathogen is known, it is effective to use the appropriate specific immunized sera (antistaphylococcal, anti-synergic).

Recently in the literature there have been reports about the effectiveness of pathogenetic methods of treatment, which, of course, is a very encouraging fact. This is the use of polyclonal immunoglobulins (pentaglobin) with a high concentration of endotoxin in plasma in patients with Gram-negative septic toxic diseases.

Numerous studies have reported the successful use of monoclonal antibodies to endotoxin and individual cytokines capable of binding TNF, IL-1 and INF-gamma in the treatment of sepsis and its complications.

Symptomatic therapy is used in all patients with sepsis. It is individual and includes the use of analgesic, antihistamine, antispasmodic, sedative drugs, vitamins, coenzymes, agents that improve the processes of tissue vascularization and repair, and by indications of cardiac, hepatotropic, neurotropic drugs.

Elimination of hemocoagulation disorders is achieved by the appointment of blood protease inhibitors: gordoksa at a dose of 300 000-500 000 units, kontrikala at a dose of 800 000-1 500 000 units or tracerol at a dose of 125 000-200 000 units per day.

The appointment of heparin is advisable only under the control of a coagulogram or aggregogram in the presence of chronic DVS-syndrome and an increase in the aggregation properties of blood. The average dose of heparin is 10 thousand units per day (2.5 thousand units x 4 times subcutaneously).

Currently, it is more effective to assign prolonged low molecular weight heparin analogues - fractiparin 0.4 ml once a day or kleksana at a dose of 20 mg (0.2 ml) once a day, they are injected subcutaneously into the anterior or posterolateral area of the abdominal wall at the level belt. With the introduction of drugs must comply with a number of conditions: with the injection of the needle should be located vertically and pass the entire thickness of the skin, squeezed into the fold; The injection site can not be ground. For obese patients who weigh more than 100 kg, doses of heparin and its analogues are doubled.

All patients showed the use of disaggregants (antiaggregants). In the composition of infusion therapy include rheopolyglucin, apply also kurantil (trental). The latter is included in the infusion medium on an average of 100-200 mg / day, and if necessary (the inability to apply direct anticoagulants) the dose can be increased to 500 mg / day. With a gradual introduction of the drug.

The use of freshly frozen plasma also contributes to the elimination of coagulation disorders, while fresh-frozen plasma is a universal drug that eliminates both hypo- and hypercoagulation, and is indicated to all patients with sepsis.

[1], [2]

Extracorporeal methods of detoxification

Indications for the use of extracorporeal methods of detoxification in patients with sepsis are:

• progression of acute hepatic-renal insufficiency;
• toxic manifestations from the side of the central nervous system (intoxication delirium, coma);
• inefficiency of conservative therapy.

Extracorporeal methods of detoxification are used in patients with severe multi-organ failure. The choice of method of detoxification depends on those tasks that need to be solved, proceeding, as a rule, from the severity of the patient's condition (severe or very serious), and most importantly, from the technical capabilities of this hospital. If the method of ultraviolet irradiation of blood (UFO) is available and should be widely used to treat purulent patients in almost all hospitals, then for treatment by other methods it is necessary to use the appropriate departments of multi-profile hospitals.

Thus, sepsis is the most severe complication of a purulent process, the treatment of which is difficult and not always effective. Therefore, it is extremely important to carry out all preventive measures of this terrible complication in a timely manner, the main ones being the detection and sanitation of a purulent focus.

As indicated above, a set of therapeutic measures for septic shock should include funds that prevent the development of acute renal failure or contribute to its elimination. Prophylaxis of acute renal failure is the rapid and sufficient replacement of bcc with the inclusion of rheologically active liquids and agents (reopolyglucin, polyglucin, hemodez, trental) in the infusion medium, followed by intravenous injection of 10 ml of a 2.4% solution of euphyllin, 2-3 ml of a 2% solution but-spines and 40 mg of Lasix.

With the development of acute kidney failure, the first aid is provided by the gynecologist in conjunction with the reanimatologist. The course of further treatment is adjusted by the nephrologist, or the patient is transferred to the appropriate department. Treatment of acute renal failure begins with replenishment of BCC, for which use solutions that improve microcirculation: rheopolyglucin, polyglucin, gemodez. Then, the funds that remove the vascular spasm are prescribed: every 5 hours, 5-10 ml of a 2.4% solution of euphyllin and 2-4 ml of a 2% solution of no-shpa are administered. You can use a glucose-novocaine mixture (250 ml of 20% glucose solution, 250 ml of 0.25% solution of novocaine and 12 units of insulin). In parallel with vasoactive substances, diuretics are used. Saluretic Lasix is administered on 80-120 mg every 3-4 hours. Rapid action osmodiretic mannitol is administered as a 15% solution in an amount of 200 ml. With a positive diuretic effect, the infusion therapy is continued in accordance with the amount of urine output. If there is no effect on the administration of mannitol, the rate of infusion of the fluid should be slowed down and, to avoid intercellular edema of the parenchymal organs, do not use osmodiuretics again. Persistent anuria with a replenished volume of circulating blood dictates the mandatory restriction of the infusion liquid to 700-1000 ml / day.

In septic shock of acute renal failure in the stage of oligoanuria characterized by the rapid development of azotemia and hyperkalemia, therefore in the infusion therapy should include at least 500 ml of 20% glucose solution with insulin. Glucose inhibits protein catabolism, and also helps reduce hyperkalemia. As a potassium antidote, 10% calcium gluconate or chloride solution and 4-5% sodium hydrogen carbonate solution are used. To improve the excretion of nitrogenous slags, along with measures that normalize kidney function, one should not forget about such simple methods as gastric lavage with sodium bicarbonate solution followed by the introduction of algal and siphon enemas with sodium bicarbonate solution.

Conservative treatment of acute renal failure can be applied only at a slow rate of growth of azotemia and dyslexia. Common indications for the transfer of a patient for hemodialysis in the department of an artificial kidney are: increased serum potassium levels up to 7 mmol / l and more. The level of urea - up to 49,8 mmol / l and more, the level of creatinine - up to 1,7 mmol / l and more, pH less than 7.28, - BE - 12 mmol / l, hyperhydration with the phenomena of pulmonary edema and brain.

The following measures are necessary for the prevention and treatment of acute respiratory failure:

• strict correction of water balance, which is. On the one hand, in timely replenishment of the bcc and, on the other hand, in preventing or eliminating hyperhydration;
• maintenance of the necessary level of oncotic blood pressure due to the introduction of protein preparations;
• timely use of corticosteroid therapy;
• mandatory cardiac therapy and the use of vasodilators;
• adequate oxygenation, with the increase of hypoxia - a timely transition to mechanical ventilation.

Thus, all major measures aimed at eliminating septic shock, serve to eliminate the phenomena of acute respiratory failure.

Syndrome DVS blood is an important link in the pathogenesis of septic shock, so the prevention of related bleeding, including uterine, in fact, is the timely and adequate treatment of shock, aimed at optimizing tissue perfusion. Inclusion in the complex of ongoing therapy with heparin, as a specific anticoagulant, is not indisputable. Despite all the positive properties of heparin, including its ability to increase the body's resistance to tissue hypoxia and the action of bacterial toxins, the use of this anticoagulant should be carried out exclusively individually. Usually, the treatment is performed by a hematologist under the control of the coagulogram, taking into account the ICD stage and the individual sensitivity of the patient to heparin.

Anticoagulant and antithrombotic effects of heparin are associated with the content of antithrombin III, the level of which decreases with septic shock, therefore, heparin therapy must be combined with transfusion of fresh donor blood in an amount of 200-300 ml.

Treatment of the late stage of septic shock with the advent of hemorrhagic syndrome, including uterine bleeding, also requires a differentiated approach. With sepsis, the patient's body, even after the sanation of the foci of infection, experiences a severe double breakdown of hemostasis: ubiquitous intravascular coagulation of blood with microcirculation in the organs and subsequent depletion of haemostasis mechanisms with uncontrolled bleeding.

Depending on the parameters of the coagulogram, substitution therapy ("warm" donor blood, lyophilized plasma, dry, native and fresh-frozen plasma, fibrinogen) and / or antifibrinolytic drugs (countercracker, gordox) is administered.

Criteria for the effectiveness of the complex therapy of septic shock are improvement of patient's consciousness, disappearance of cyanosis, warming and puffiness of the skin, reduction of tachycardia and dyspnea, normalization of CVP and arterial pressure, increased rate of urination, elimination of thrombocytopenia. Depending on the severity of the septic shock associated with the characteristics of the microflora and the reactivity of the microorganism, the timeliness of the onset and adequacy of the therapy, the normalization of the above indices occurs within a few hours or several days. However, the removal of a patient from a state of shock should not serve as a signal to end the intensive therapy of a purulent-septic disease, which was the cause of the development of shock. Purposeful antibacterial, detoxification and gemostimulating therapy, replenishment of energy resources and increase of body's own defenses, normalization of CBS and electrolyte homeostasis should continue until the complete elimination of the infectious process.

After discharge from the hospital, the patient needs a follow-up medical examination for 5 years with the purpose of timely detection and treatment of possible long-term consequences of septic shock: chronic renal failure, Shihan syndrome, diencephalic syndrome according to the type of Iscenko-Cushing's disease, diabetes, Waterhouse-Frideriksen syndrome.

[3], [4], [5], [6], [7], [8], [9]