SEPSIS (Greek sepsis rotting) — the general nonspecific infectious disease of acyclic type arising in the conditions of the broken reactivity of an organism at constant or periodic penetration from the local center of an infection into a circulatory bed of various microorganisms and their toxins. Pages, caused by pyogenic microflora, call also systemic purulent infection.
- 1 History
- 2 Statistics
- 3 Classification
- 4 the Aetiology
- 5 A pathogeny
- 6 Pathological anatomy
- 7 Clinical picture
- 8 Complications
- 9 The diagnosis
- 10 Treatment
- 11 The forecast
- 12 Prevention
- 13 The features of some kinds of sepsis caused by localization of primary septic center
- 14 Sepsis at children
Sepsis was known already in an extreme antiquity, to Hippocrates his emergence was connected with ratio distortion or composition of four liquids (blood, slime, bile yellow, bile black) defining according to ancient philosophers, the state of health or diseases of the person (see. Meditsina ). It is possible to find the description of symptoms of «septicaemia» (as all forms C. called long time), its differentiation from rage and a lethargy in Hippocrates's works. K. Galen understood any changes capable to cause fever as «septicaemia». Ibn-Xing, meaning «septicaemia», describes different types of fever in «A canon of medical science» and emphasizes need of the exact characteristic of a condition of an organism at this disease. Further, till Renaissance, the new ideas about essence of putrefactive processes in a human body and a private type of these processes — «septicaemia» practically did not appear. In 16 — 17 centuries of A. Paré, Paratseljs, Silvius [F. Sylvius (de le of Voye)] suggested about «septicaemia» as intoxication of an organism chemicals.
Only since the beginning of 19 century began to include only certain types of long fevers in the concept «septicaemia». The French
doctor Gaspar (M. N. V. of Gaspard) established that the pus getting to blood vessels of an animal in - small doses, can circulate in them and be neutralized, without causing death whereas even trace amounts it at repeated receipts in an organism can cause death. R. Virkhov accurately differentiated the pyemia which is characterized by purulent innidiation with a septicaemia, * for a cut metastasises are not characteristic.
The big contribution to the doctrine about sepsis' was made by N. I. Pirogov, to-ry considered that the pyemia is the miazmatichesky disease differing in a special prilipchivost, a product of the general infection of an organism in the most extensive value of this word. The infectious beginning — hypothetical miasmata (the role of microbes in development
was not known to S. yet) is formed in the fabrics of a wound which underwent extensive destruction and then, at accumulation of patients in the enclosed space of hospital, collects in the environment and begins to strike all, even not wounded. N. I. Pirogov for the first time defined value of primary center of an infection in wound S.'s pathogeny, in detail described the general and its local manifestations, classified
S. and formulated front lines for the time the principles of its treatment. He allocated two main clinical forms C. too — a septicaemia and a pyemia, but considered them as manifestations of the same pathological process, considering * that the septicaemia only then proceeds without purulent metastasises when it develops too quickly and leads to the death of the patient before their manifestation. In views on the nature and the mechanism of development of sepsis of N. I. Pirogov much more was ahead of the contemporaries, having pointed to a role and value of the general condition of an organism in emergence and development of this disease.
The second half, especially the end of 19 century, was marked by rapid development of microbiology and opening of activators of a number of infectious diseases. During this period the bacteriological concept of development of S. moves forward, according to S.'s cut arises and develops in connection with bacteremia, ability of microbes to breed in the circulating blood. However these assumptions did not come true, the possibility of reproduction of bacteria in the circulating blood did not receive confirmation. The doctrine about the septic center which is put forward by H. Schottmuller was further development of the bacteriological concept With, according to Krom the main role in a pathogeny S. was assigned to penetration of microbes from the septic center in blood; however at the same time value of reactivity of a macroorganism was not considered. At the same time numerous clinical observations and pilot studies showed that such interpretation of essence of S. cannot explain all complexity of this pathological process. It became known that even very intensive antimicrobic chemotherapy quite often does not yield positive medical takes. Therefore the attention of researchers even more often began to concentrate not only on studying of activators C., but also conditions of a macroorganism.
The Soviet scientists put forward well reasoned provision on a crucial role of a condition of a sick organism in development of sepsis, to-ry I. V. Davydovsky (1935 — 1936) defined as a problem first of all macrobiological. In the next years macrobiologists-chesky approach to S.'s studying became the main and the most recognized. Studying of a sick organism, especially its reactivity, a condition of immune system, mechanisms of circulator disturbances, intensive searches of the most effective remedies of correction of the revealed disturbances, research of means of antibacterial therapy — all this characterizes the present stage of development of the doctrine about sepsis.
Statistical data on sepsis are quite contradictory, however all of them in general characterize S. as the hardest disease with a frequent failure. According to V. I. Struchkov (1967), S. it was diagnosed on average for one of 1000 — 1500 all surgical patients. In medical institutions with the contingent preferential seriously ill data differ markedly: on materials M. And. Cousin and soavt. (1982), S.'s frequency among the patients treated in traumatologic departments in 1977 — 1981 fluctuated ranging from 0,07 to 0,1%, and after big thoracic operations with broad use of intravascular methods of a research and treatment reached 10 — 20% to number of operated.
By data I. V. Davydovsky, etc., before use of streptocides and antibiotics (see) the lethality at S. made 70 — 90%, and at cryptogenic S. it reached 100%. In the period of the Great Patriotic War of 1941 — 1945, by data I. M. Talmana, the lethality from S. in nek-ry hospitals of the deep back fluctuated from 30,8 to 67,6%. In post-war years, according to V. Ya. Shlapobersky (1952), in connection with broad use of antibiotics of firstgeneration the lethality at S. decreased to 23 — 25%, on a nek-eye to publications — to 15 — 20%. However in V. S. Savelyev's works, A. I. Tereshchinsko-go (1974), S. Popkirov (1977), B. I. Yukhtina (1979), Altemeyer (W. A. Altemeier, 1976), J. Nolte and soavt. (1977) it is noted that in 1961 — 1968 the lethality at sepsis rose again (to 40 — 45%), and at the sepsis caused by gram-positive microflora, the lethality made 20 — 29%, and gram-negative — 40 — 60%. According to B. M. Kostyuchenk and A. M. Svetukhin (1981) later data, at Institute of surgery of A. V. Vishnevsky of the USSR Academy of Medical Sciences the lethality at surgical sepsis made 30,1% (in a phase of a septicaemia of 24,3%, in a phase of a septicopyemia — 41,1%), and among patients was aged more senior than 50 years it is equal to 53,3%, and among patients of younger age there are 21,1%. In cases when treatment was begun in an early stage of a disease, lethal outcomes were not.
S.'s frequencies noted by domestic and foreign surgeons increase and a certain growth of its adverse outcomes connect with increase in number of antibiotic-resistant and antibiotiko-dependent strains of activators, a sensitization to them of the population, expansion of volume and scope of operative measures with intensive infusional care and broad use of the intravascular methods of a research which sharply expanded contact of a vascular bed with the environment.
On a clinical current distinguish S. fulminant, acute, subacute, chronic and recurrent. As special form hron. C. sepsis lenta is allocated.
In the presence of on site entrance gate of a contagium of primary septic (purulent) center causing S.'s development speak about secondary S.; in the absence of the visible septic center of S. conditionally call primary or cryptogenic.
On character of entrance gate of an infestant distinguish S. wound and arisen because of pyoinflammatory diseases of various bodies; a peculiar type of S. is burn sepsis (see. Burns ).
Depending on localization of primary center of an infection distinguish: Page oral, or stomato-gene (primary center is localized in an oral cavity); otogenic (arising as a complication of acute or chronic purulent otitis); rhinogenic (primary center is localized in a nasal cavity and adnexal bosoms); tonzillogenny (primary center in almonds, a thicket of palatal); an urosepsis (primary center in kidneys and uric ways); obstetric and gynecologic (primary center in a uterus or its appendages); umbilical (the most frequent at children of the first year of life; primary center is localized in the place of department of a stump of an umbilical cord); endocardial (the center of an infection is localized in an endocardium, hl. in the way in valves of heart); angiogenic (primary center of an infection is located in vessels; quite often arises as result of intravascular tool researches and long intravenous injections); skin (primary center forms in skin in the form of a pyoderma, a purulent pustulez, furuncles); intestinal (primary center ulcer and necrotic enteritis, colitis, a coloenteritis is). In addition to the listed above localizations, the septic center can be also in other bodies at various purulent processes, napr, is purulent - destructive damages of lungs (see), pleurae (see), purulent peritonitis, purulent thrombophlebitis (see), etc.
The special group is made by so-called surgical S., to-ry combines all cases of diseases of S. on the basis of existence of primary or metastatic suppurative focus available to an operative measure. Most often here belong wound and postoperative S. when entrance gate is the wound (see Wounds, wounds), and also S. arising against the background of or owing to purulent diseases, napr, abscess (see), an anthrax (see), osteomyelitis (cm), peritonitis (see), phlegmon (see), a furuncle (see), an empyema of a pleura (see Pleurisy), etc.
A septicaemia (S. without purulent metastasises), a pyemia (S. with metastasises) and a septicopyemia (the mixed form C.) most of modern researchers, as well as N. I. Pirogov, does not consider essentially various forms C., and considers rather as various phases of uniform septic process which are quite often passing one into another.
On a bacteriological sign distinguish staphylococcal, streptococcal, collibacillary, psevdomonozny, anaerobic, putrefactive, fungal and other types of S.
Activators C. can be any pathogenic microorganisms, hl. in the way from group of pyogenic and anaerobic bacteria (see Anaerobe bacterias, Pyogenic bacteria). Most often streptococci, colibacillus, pneumococci, meningokokk, a pyocyanic stick, a klebsiyella, proteas, a salmonella, anaerobe bacterias, sometimes — fungi meet staphylococcus (see. Actinomycetes , Aspergillosis , Candidiasis ), etc. More often microbes get from the environment, but can be transferred also from fabrics and bodies of the most sick — endogenous or autoinfection (see). Therefore data of different researchers on the frequency of separate types of activators C. are quite contradictory. In nek-ry cases the association of microbes which was available in primary center or arose during septic process can be the activator C. Such S. differs in especially heavy clinical current. According to S. Popkirov (1974), as the activator C. in modern conditions on the first place gram-negative microflora moves forward and only in 30 — 40% of cases the microbes allocated from blood of the patient belong to gram-positive. On the contrary, at S. after cardiac operations caused, apparently, vnut-rigospitalny (so-called nozokominalny) microflora (see. In nutribolnichny infections ), gram-negative activators, according to B. M. Kostyuchenk (1981), were found only in 6,6% of patients.
S.'s Emergence is usually connected with penetration of microbes and their toxins directly in a blood channel or in lymphatic ways. The invasion of the activator, as a rule, occurs through the injured skin or a mucous membrane where it is formed is purulent-infek-tsionny, so-called primary septic center. The possibility of penetration ‘the activator in blood through anatomically unimpaired skin or a mucous membrane and in the absence of local infectious and inflammatory process is admissible, apparently, only in the conditions of a critical state of an organism and falloff of its barrier functions (long deep arterial hypotension, a hypoxia, defeat by a penetrating radiation, immunodepressive and cytotoxic means, exogenous and endogenous intoxications).
From primary septic center microbes permanently or periodically come to a blood channel, causing bacteremia (see). In addition, existence of primary center is accompanied by a sensitization of an organism and change of its reactivity. Bacteremia in itself is found almost in 30% of patients with local purulent diseases and approximately at one third from them it has no clinical manifestations since the microbes which got into a blood channel perish in the bodies rich with elements of system of mononuclear phagocytes (see), and quickly disappear from the circulating blood. Thanks to immunological to a homeostasis (see) to the most frequent activators C. the person has quite high immunity fixed in phylogenesis and which is usually ripening in ontogenesis. Therefore in most cases the causative organisms which got to blood do not cause the systemic purulent infection.
I. V. Davydovsky considered that only «the break of immunity» or insufficiency of its maturing in individual life can generate the most ancient and primitive form of the general reaction what sepsis is. The break of immunity can be promoted by a number of the reasons. A certain value has massiveness of an infekt. In B. M. Kostyuchenk and A. M. Svetukhin (1981) works it was shown that in an experiment a microbic obsemenennost in 10 5 microbes on 1 g of fabric of a suppurative focus is probability of generalization of an infection critical relatively. The center with a critical level of an infekt is a powerful source of a sensitization and intoxication of an organism bacterial toxins, products of the broken metabolism and disintegration of the devitalized fabrics.
Great value in S.'s development have an appearance of the activator and its biological features. So, penetration into a blood channel or lymphatic ways of causative agents of cyclic infections (e.g., mycobacteria, pale spirochetes) is not followed by S.'s emergence whereas staphylococcus, streptococci, colibacillus, proteas and a pyocyanic stick are’ the most frequent activators C. According to V. Ya. Shlapobersky (1952), the sepsis caused by staphylococcus (having ability to curtail fibrin and to settle in fabrics), often is followed by emergence of metastatic suppurative focuses; the streptococcus having fibrinolitic activity in much smaller degree causes emergence of such centers; colibacillus generally causes toxic influence. The sepsis caused by gram-positive flora is followed by emergence of metastatic suppurative focuses much more often, gives a smaller lethality, than caused by gram-negative flora, at a cut the phenomena are more expressed intoxications (see). Connect with properties of microflora also the frequency of a complication of S. toxi-infectious (septic) shock (see): by data to Bara (A. E. Vage, 1969), at gram-negative microflora septic shock arises at 20 — 25% of patients, at gram-positive — only at 5%. Nek-rym a certain pattern of innidiation is inherent to activators. E.g., hemolitic streptococci, gonokokk cause innidiation of abscesses in skin, joints more often; enterococci, the turning green streptococci — in an endocardium; pneumococci — in a meninx, joints, an endocardium; bacteroids — in lungs, a pleura, a liver, a brain.
Have value and ways of the dissemp-nation of microflora from primary center: at hematogenous distribution to a blood channel the large number of bacteria and products of their life activity gets it is (more often single-step) that is followed by tremendous oznoba and high temperature; at lymphogenous dissimination bacteremia is less expressed and more uniform as a part of microbes and products of their life activity is late in limf, nodes owing to what temperature reaction often has typhus-like character. Quite often both ways of dissimination take place; in these cases fever of tifoidny type can be followed by periodic oznoba.
The greatest value in S.'s development has an originality reactivity of an organism (see), first of all disturbance of immunity (see) and nonspecific factors of protection. The type of reaction of an organism substantially depends on character of a host defense at sepsis, edges can be normergichesky (dominance of the phenomena of an inflammation), giperergichesky (the rough, acute beginning with dominance of destruktivnodegenerativny changes) and anergic (it is characterized by a sluggish current). An immunodeficiency (see. Immunological insufficiency) can take place before emergence of primary septic center or develop owing to intoxication and bacterial aggression from this center. In the latter case early stages of an immune response are broken: a chemotaxis of leukocytes (see. Taxis ), opsonization (see Opsonins), phagocytosis (see), bactericidal activity of leukocytes (see) and blood sera. Suppression of a chemotaxis of polymorphonuclear leukocytes at development of a local purulent infection can be to Ob about fishing-leno emergence in blood of its inhibitors or defect of neutrophils. According to M. I. Kuzina and soavt. (1981), dynamics of changes of a chemotaxis is regarded as one of precursory and sensitive symptoms of a state and orientation of changes of immune system of an organism. About changes of a chemotaxis it is possible to judge, in particular, by changes of the reaction of a vezikuloobrazovaniye (fig. 1) reflecting extent of specific damage of sensibilized leukocytes, generally polinuklear, the cell-bound immune complexes which are formed of antigens of dezintegrirovanny fabrics and the preexisting antibodies (see Antigen — an antibody reaction). Its essence consists in dystrophic changes of leukocytes, preferential segmentoyaderny, and formation of emptiness — «vesicles» of various size around them, is preferential owing to «drawing apart» the erythrocytes surrounding them.
Along with suppression of a chemotaxis of leukocytes phagocytal and bactericidal activity of neutrophils, and also activation of lymphocytes, formation of specific immune antibodys, activation of monocytes and granudotsi-comrade decreases. These disturbances are expressed in decrease in bactericidal activity of blood serum, skin and mucous membranes, decrease in M, G immunoglobulins (see. Immunoglobulins ) and complement (see). Insufficiency of a complement or its components, in turn, promotes decrease in bactericidal activity of blood serum and a chemotaxis. Concerning activation of lymphocytes (see) it is known that increase in the activated T - and V-lymphocytes (see. Immunocompetent cells ), and also the lymphocytes bearing receptors for microbic antigen has positive predictive value while the surplus of T-depressors noted at the patients who died from sepsis, apparently, results in deficit of immunity.
Deficit of immunity at a local purulent infection, as a rule, goes deep from action of the aggravating factors, to-rykh first of all the infectious allergy is among (see). In process of development of allergic reaction it loses the specificity and becomes poliallergichny, arising at emergence in an organism not only the causative agent of a local infection, but also other substances, including pharmaceuticals. Quite often the allergy is shown in decrease (hypergia) or absence (anergy) of reactivity of an organism; at such states the invasion even of small amounts of microbes or their toxins causes S.'s development and leads to the death of the patient owing to free reproduction of the activator in «thermostately conditions» of an organism. This phenomenon can be regarded as the unresponsiveness to the activator (see Tolerantnost immunological) arising at systematic break of an infekt in a blood channel. So, disturbance of an early phase of an immune response at S. results in insolvency of all immune system that has crucial importance in generalization of an infection and development of septic process.
Developing of an immunodeficiency is promoted by various factors (anemia, shock, a partial or complete starvation, overfatigue, a hypovitaminosis, a repeated injury, overcooling, influence of a penetrating radiation, intoxication, disbolism and functions of closed glands); it arises at early children's and senile age quicker.
An important link in the mechanism of formation of pathological reactions at S. is intoxication of an organism the waste products of the activator and substances which are formed owing to enzymatic disintegration and the broken metabolism of fabrics. In G. A. Ivashkevich's researches (1974, 1982), etc. it was shown that at sick S. concentration of proteoli-tpchesky enzymes in plasma of the circulating blood is much higher, than in the centers of a purulent inflammation. It gave the grounds to consider that the increased formation of proteases (see Peptide hydrolysises) arises at S. not only in the center of an inflammation, but also in the circulating blood where there is a death of a large number of leukocytes, lysosomes to-rykh are rich with proteases. Increase in proteases in blood, apparently, is promoted by also increased release of enzymes leukocytes leading to activation of kinin (see) and activation of kinin nek-ry antibiotics. M. F. Kamayev (1982) considers that the major role in activation of proteolntichesky enzymes is played by microflora of the septic center, and influence of cellular lizosomalny proteases is secondary and has smaller value. Giperfermengemiya in itself causes the general intoxication of an organism, and proteolytic enzymes of high activity can besides cause a focal necrosis in various fabrics and bodies; sites of a necrosis, being planted by microbes and breaking up, turn into metastatic suppurative focuses. According to G. S. Hanes (1974), I. Hendes et al. (1975), activation of the general proteolysis at S. leads to activation coagulant and fibrinolitncheskop systems of blood with emergence of a secondary fibrinolysis (see) and the intravascular disseminated coagulation — a so-called syndrome of DVS (see. Hemorrhagic diathesis ).
The increasing activity of a thrombogenesis causing increase in activity of protivosver-ttvayushchy mechanisms promotes generalization of purulent process.
On S. Popkirov's observations (1974), P. K. Dyachenko (1980), often activators C. are as if deposited in the field of mikr about circulation (see), causing formation of the multiple microcenters of an infection and creating a new factor in S.'s pathogeny — a factor of the disturbances of microcirculation which are usually combined with deterioration in rheological properties of blood.
An essential role in S.'s pathogeny is played by a hypoproteinemia (see. Proteinemia ), caused by activation of catabolic processes and oppression of belkovoobrazovatelny function of a liver that leads to sharp disturbance of nitrogenous balance, decrease in immunological protection of an organism and oppression of reparative processes. Disturbances of energy and electrolytic balance (see. Water salt metabolism ) at S. are expressed in a hyper catabolism with the subsequent metabolic acidosis (see) therefore there are profound changes in cellular membranes and so-called sodium potassium pump: in cells the content of potassium decreases and the amount of sodium and water (hypostasis of a cell) increases, and in blood serum the content of potassium increases and the amount of sodium decreases.
Undergoes profound changes at S. carbohydrate metabolism (see): tolerance to glucose decreases and there is a resistance to insulin that is shown in relative insulinny insufficiency and a hyperglycemia (see). Resistance to insulin at S. can be caused, in particular, by defect of hormonal reception, in an origin to-rogo an essential role the raised products of the endogenous substances competing for places of binding of insulin (see) with his receptors play. In an origin of a hyperglycemia braking of secretion of insulin matters, a cut it is caused by somatotropic hormone (see), corticotropin and cortisol (see. Hydrocortisone ), products to-rykh at S. raise. The braking impact on secretion of insulin is exerted also by activation of sympathetic system, a cut prostaglandins (see) can be stimulators, products to-rykh at S. increase. In S. A. Morenkov's experiments et al. (1978, 1981) administration of inhibitors of prostaglandins, napr, indometacin, recovered a sugar content in blood to norm and provided survival of 85 — 90% of experimental animals while in control group animals perished in 100% of cases.
Development of septic process usually is followed by the disturbance of cordial activity caused by intoxication, (see) leads edges in combination with respiratory insufficiency to heavy hypoxias (see). The leading value in development of respiratory insufficiency at S. has defeat of a pulmonary parenchyma and system of surfactant (see). An essential role in in S.'s pathogeny is played also by renal failures, to-rye cease to cope with elimination of bacterial toxins, products of disintegration of fabrics and the broken metabolism; reabsorbtsionny ability of kidneys is often broken, loss of water and salts with the subsequent heavy disturbances of water and electrolytic balance and development of a renal failure (see), quite often being the premessenger of a critical phase of septic shock increases. Signs of an infectious or immune glomerulonephritis, acute intersticial are found in the vast majority of sick S. nephrite (see) up to purulent pyelonephritis (see).
Most often S. proceeds with purulent metastasises (septicopyemia). On frequency in this group the staphylococcal septicopyemia is on the first place, edges can proceed in the form of a fulminant and acute form. Existence of multiple metastatic abscesses of yellow color, to 5 — 6 cm in the diameter, quite often with a zone of a perifocal hemorrhage, localized in lungs (it is preferential under a pleura), kidneys (it is preferential under the capsule), heart, muscles, a brain and other bodies, and also septic heart attacks, purulent serosites, apostematous nephrite (see), an endocarditis (see), diffusion inflammatory processes in parenchymatous bodies is characteristic of staphylococcal S.; metastatic hypodermic abscesses (see Abscess) and phlegmons are especially characteristic of staphylococcal sepsis (see Phlegmon). At a macroscopic research parenchymatous bodies flabby, moderately plethoric or, on the contrary, pale. The spleen is usually sharply increased, flabby, gives plentiful scraping of a pulp. Limf, nodes, almonds, peyerova of a plaque which bulked up. On a mucous membrane of a stomach, a small and large intestine numerous hemorrhages, erosion and single or multiple ulcers the sizes to 1,5 szh in the diameter, with soft edges, an uneven flat bottom are frequent. Adrenal glands are a little increased in sizes, their bast layer is expanded. Mucous and serous membranes are full-blooded, with punctulate or large hemorrhages. Than more sharply sepsis flows, especially the hemorrhagic component of an inflammation is expressed. At microscopic examination in parenchymatous bodies a picture of proteinaceous or fatty dystrophy (see. Proteinaceous dystrophy, Fatty dystrophy), ochazhka of a necrobiosis and a necrosis of cells (see the Necrosis). In addition to dystrophic changes, development of diffusion serous or serous and purulent intersticial myocarditis (see), hepatitis (see), etc. is possible. In a spleen the expressed leukocytosis, plentiful accumulation of histiocytes macrophages (see Histiocytes, Macrophages) and cells of a plasmatic row (see Plasmocytes), the phenomena of an erythrophagocytosis is noted. In limf, nodes, the lymphoid device of intestines accumulation of leukocytes, proliferation of plasmocytes, accumulation of macrophages with development of a so-called reactive histiocytosis of sine, occasionally — small necrotic focuses is also observed. The bast layer of adrenal glands is hypertrophied, is preferential at the expense of cells of a puchkovy zone of bark, its cells are poor in lipoida, the content in them of RNA and an alkaline phosphatase is increased. Capillaries of a bast layer are full-blooded, with the phenomena of a staz, a part of cells of bark in a condition of a tsitpoliz (see). Thymus in a condition of involution: reduction of number of lymphoid cells, an aplasia of retiku-loepitelialny elements and their dystrophy is observed. In other endocrine organs changes, testimonial or about strengthening of their functional activity, or about decrease it depending on a phase of development of process are noted. Metastatic abscesses form pe-rivaskulyarno, usually about a small vessel or group of the capillaries containing a septic embolus (see the Embolism), are followed by the phenomena of a purulent vasculitis (see) and a perivasculitis, and also a capillaritis (fig. 2). In a zone of septic heart attacks (it is preferential in lungs, kidneys, a spleen) emboluses in arteries and accumulations of microflora in the nekrotizirovanny, melted by leukocytes fabric are clearly distinguishable. Septic emboluses in small and large arteries cause emergence of purulent or is purulent - a necrotic vasculitis, sometimes with formation of so-called acute mycotic aneurisms (see Aneurism). At a septic stage of an infectious endocarditis (see), for to-rogo preferential defeat of an endocardium of the left cameras of heart, aortal and mitral valves (especially when in lungs, kidneys, a liver and a spleen there are secondary septic centers) is characteristic, the deep ulceration of an endocardium with formation of the trombotichesky imposings supporting colonies of stafilokokk is microscopically noted.
Streptococcal S. is quite often shown in the form of a fulminant form of a septicaemia (e.g., S. at an erysipelatous inflammation of wounds, tonzillogen-ny S.). It is characterized by sharp dystrophic changes of bodies, a hyperplasia of a pulp of a spleen. At piyemichesky forms in the metastatic centers the necrosis of fabrics surrounded with a zone of a serofibrinous inflammation with moderate leukocytic infiltration is noted. Development of an endocarditis is characteristic of streptococcal S., to-ry at sharply current process accepts character of ulcer. The malignant endocarditis is characterized by a combination sharply expressed to alta-rativnykh and weaker fibroplastic processes, and mitral and aortal valves are surprised more often. On an inner surface, on edge of shutters of the valve friable lurid imposings appear, at removal to-rykh ulcers are found. Further ulcers increase in sizes, gaps and separations of shutters of the valve are frequent. Distribution of ulcer process on an endocardium of an auricle or an intima of an aorta is typical. At microscopic examination among the trombotichesky and necrotic masses covering ulcer defect colonies of streptococci are visible. During the scarring of ulcers there is a wrinkling of valves and formation of defect (see the Heart diseases acquired).
Pneumococcal S. occurs seldom, preferential at children. It can develop at inflammatory processes in upper respiratory tracts and lungs. In lungs the disease is shown in the form of the typical pneumonic centers surrounded with the zone of hypostasis containing gram-positive diplococcuses (pneumococci). At pneumococcal S. development of thrombosis of sine (see Thrombosis, vessels of a brain), purulent otitis (see) and meningitis is possible (see).
Meningococcal S. is usually shown or in the form of an acute or most acute meningococcemia, or in the form of purulent meningitis (see. Meningococcal infection).
In the second half of 20 century the specific weight of S. caused by a gram-negative bacterial flora, in particular a pyocyanic stick considerably increased. Pyocyanic S. is result more often of superinfection at the weakened patients, napr, after extensive heart operations, and also at the patients receiving immunodepressive or hormonal therapy. It proceeds usually in the form of an acute or subacute septicopyemia with the processes progressing suppurative destruk-tivnymi in primary septic center. In nekrotizirovanny fabric of the center fibrin is formed, in the center and beyond its limits necrotic develop or it is purulent - necrotic vasculites, lymphadenites (see Lymphadenitis) and lim-fangiita (see Limfapgiit). The metastatic centers in bodies are usually not numerous, small, greenish, are surrounded with a reddish rim. Their education is preceded by formation of necrotic focuses owing to what at a histologic research they represent the center of a necrosis surrounded with a thin demarcation shaft and a zone of hemorrhages. In the center of the center of a necrosis accumulations of gram-negative sticks are visible. Metastatic abscesses form around vessels, in to-rykh the septic vasculitis (fig. 3) takes place. Later small abscesses can increase, having a diameter of 0,5 cm and representing pustules with a small amount of leukocytes and single microbes. Changes of internals are characterized by dystrophy, paretic gastric flatulence and intestines, poorly or moderately expressed hemorrhagic reactions. Thrombophlebitises, septic heart attacks, an endocarditis, a pericardis (see) meet seldom.
Quite often S. caused by a proteyny infection meets. Most often entrance infection atriums are intestines or wounds of skin and soft tissues, in to-rykh proteas often is the reason of suppurative processes. The wound has a characteristic appearance: it is covered with sluggish pale watery granulations (see Granulyatsionnaya fabric), separated from a wound with off-flavor. In a brain, lungs, kidneys, marrow, hypodermic cellulose the metastatic centers are possible. In the center it is quite often possible to see them sites of a necrosis.
The sepsis caused by colibacillus (kolisepsis) is observed usually at children, especially premature, or at the weakened patients with extensive injuries, wounds, burns. Kolisepsis at adults proceeds usually as a septicaemia. Paresis of intestines, hemorrhagic rash on skin, exhaustion, diffusion-pillyarostazy, proliferative in-filtrativnye processes in interstitial fabric of bodies are characteristic of it. At prolonged forms of a kolisepsis there can be purulent meningitis (see), a septic endocarditis, otitis, osteomyelitis (see) with existence in these centers of colibacillus.
Anaerobic S. is characterized by yellow skin color with a bronze shade, education in hypodermic cellulose of the metastatic centers, especially in places of pressure, pricks, bruises. The phenomena are observed hemolysis (see), myolysis, inflammatory and degenerative and necrotic changes in internals.
Among vistseromikotichesky (fungal) forms C. are most frequent Caen-didamikozny, ayepergillezny and actinomycotic sepsis is more rare. At fungal S. the septicopyemia with abscesses in lungs, a brain and other bodies is more often observed. The spleen is increased. At an aspergillosis so-called aspergillomas — the tumorous educations in lungs consisting of dense textures of a fungus can be found.
In cases of S. caused by the mixed microflora accession to staphylococcal S. of gram-negative flora most often takes place (superinfection). Exotoxin of staphylococcus in the metastatic center causes destruction of fabric then in a zone of a necrosis gram-negative flora, e.g., a pyocyanic stick actively vegetirut, strengthening processes. destructions. At pyocyanic and staphylococcal S. thrombophlebitises, malignant endocardites, septic heart attacks are more often observed. Further the pyocyanic stick suppresses reproduction of staphylococcus and the metastatic centers become monomicrobic.
Sepsis without purulent metastasises (septicaemia) is extremely difficult for morphological diagnosis as it has no specific morphological picture. The current forms C. concern to him usually most sharply (in particular, fulminant and acute). They are characterized by a combination of widespread dystrophic changes of parenchymatous bodies, microcirculator disturbances and hemorrhages. Existence of a septic spleen is typical, however so-called asplenoreaktivny forms C are quite often observed. By means of a submicroscopy (see), and electronic autoradiography (see) data on an intravital condition of leukocytes of blood can be obtained; at a septicaemia in them it is possible to find fagotsitirovanny microbes and to estimate inherent S.'s degree of incomplete phagocytosis (fig. 4). The bacteriological blood analysis and bodies of a corpse, and also studying of primary septic center is important; at secondary S. there is always an aggravation of inflammatory and destructive processes in primary center. In nek-ry cases primary septic center is not possible to find (so-called cryptogenic sepsis, sepsis without primary center).
Quite often at a septicaemia so-called septic or bacterial shock is observed (see), at Krom the sharp endotoksinemiya or (preferential gram-negative) bacteremia takes place. The combination of microcirculator disturbances, hemorrhages and the disseminated kapillyarotromboz is the cornerstone of it. In lungs against the background of hypostasis and a plethora it is noted disseminated kapil-lyarotromboz, a megakariotsitarny and fatty embolism of capillaries; in kidneys — shunting of a renal blood-groove, fibrinferments of capillaries of balls, dystrophy of an epithelium of gyrose tubules, is possible development of cortical necroses; in a liver — the centers of a lobulyarny necrosis, fibrinferments of circulatory capillaries, cholestasia (see). In a spleen, intestines, adrenal glands, a hypophysis disseminated kapillyaro-thrombosis, perivascular and peri-capillary hemorrhages, the centers of micronecroses are noted. In the thickness of a mucous membrane of a stomach and a duodenum multiple hemorrhages, small erosion and acute ulcers are found. In the thickness of skin herpetiform hemorrhages with amotio and a necrosis of epidermis, occasionally with formation of skin ulcers, and also fibrinferments of small vessels and capillaries of skin are observed.
Treats chronic forms C. hron. staphylococcal S. and sepsis lenta. Hron. staphylococcal S. proceeds usually in the form of a recurrent disease with repeated waves of innidiation. Multiple metastatic abscesses are observed in hypodermic cellulose, lungs, kidneys, is more rare in other bodies; occasionally the endocarditis, myocarditis develop. The temporary raznotipnost of suppurative focuses is characteristic: along with fresh it is purulent - the necrotic centers abscesses with the eumorphic piogenic capsule and hems on site of the former abscesses are visible.
Sepsis lenta — a chronic form of streptococcal S. — is characterized by development polipozno-yazven-nogo an endocarditis mitral and aortal, is more rare than one aortal valves. At these patients the spleen in sizes and weight is usually sharply increased (by 2 — 3 times and more). In heart, kidneys, lungs, a nervous system widespread vasculites with the phenomena of an alterativny inflammation up to a fibrinoid necrosis are observed, multiple thrombosis and an embolism, it is frequent with development of heart attacks in bodies.
Essential morphological changes are observed at S. arising in the conditions of a massive antibioticotherapia and use of other medical factors causing a therapeutic pathomorphism of sepsis. According to N. K. Permyakov, in these cases the disease often gets the wavy prolonged current, with the periods of a recurrence and remissions. Smaller extent of dystrophic changes in parenchymatous bodies, smaller quantity of purulent metastasises is observed. The type of septic vasculites changes: considerably activity of alterativny and exudative components of an inflammation in a vascular wall decreases, a cut gains lines of the chronic nonspecific productive inflammation which is rather quickly coming to an end with a sclerosis (see). Metastatic abscesses are usually small, flora in them can be not found.
S.'s Symptomatology of a polimorfn; it depends on a clinical form of a disease, existence and localization of metastasises, degree and intensity of a decompensation of functions of bodies and life support systems. At a fulminant form, edges the hl is observed. obr. at streptococcal, anaerobic and putrefactive S., the disease develops violently, sometimes within several hours; septic process quickly progresses, giving the picture inherent to clinic of infectious and toxic shock (see), comes to an end with the death of the patient in 1 — 3 days after the beginning of a disease more often.
For acute S. the most frequent symptoms characterizing disturbance of the general state and activity of a nervous system are headaches, irritability, sleeplessness, oppression of a nervous system, obscuring or a loss of consciousness. Temperature increase is constant, usually sticks to edge on high figures (39 — 40 °) at S. without metastasises and gives considerable fluctuations in the morning and in the evening in the presence of metastasises. Fever often is followed fever (see); pouring then; tachycardia (with exceeding of pulse rate concerning body temperature), edges proceeds also after normalization of temperature; arterial hypotension (see Hypotension arterial); arrhythmia of heart (see). Increase in a liver and spleen, hypostases are often observed (see. Swelled ) against the background of oligurias (see) that demonstrates severe defeat of parenchymatous bodies and the bad forecast. These changes are quite often accompanied anorexia (see), nausea (see), vomiting (see) and the exhausting septic ponosa (see). From lungs the symptoms characteristic for focal are quite often noted pneumonia (see) with multiple abscessing, sometimes extensive metastatic abscesses of gangrenous character and even total gangrene of a lung. There are dysfunctions of a brain, heart and other bodies caused by emergence in them metastatic abscesses.
Chronic S. is characterized by a sluggish current with hardly noticeable manifestations a wedge. the symptoms inherent to acute S., more than three months can also proceed. Recurrent S. is characterized by change of the periods of an aggravation with formation of metastasises by the periods of remissions and proceeds many months, sometimes years.
The clinical picture of the local septic center available to survey is usually softly expressed and often does not correspond to weight of the general phenomena. It is characterized by pallor, puffiness, slackness and dryness of granulations, scarcity wound separated, a cut has rather turbid and dirty color and quite often putrefactive character.
At S. sometimes there are mental disorders, to-rye concern to group of infectious psychoses (see). In a pathogeny of mental disturbances the big role belongs to intoxication and a hypoxia of a brain. In a clinical picture of these psychoses the leading place is taken by asthenic frustration (see. Asthenic syndrome). At early stages of process the lowered mood with alarming fears for the state prevails. At heavy areactive S. there is an adynamic adynamy close to an apathetic stupor (see. Struporous states). Sometimes at the beginning of S. against the background of an adynamy there is euphoria: the patient is complacent, careless, does not understand the disease, is verbose, revaluates the opportunities. Such euphoria can be observed also in the heat of a disease against the background of a cachexia. At improvement of a somatic state these frustration are replaced by the lowered mood. Psychoses with disturbance of consciousness at sepsis are not frequent and are shown preferential in the form of delirious, deliri-ozno-oneiric and amental states. A delirium (see. The delirious syndrome) meets more often at the beginning of puerperal S., at wound S. and a septic endocarditis. At heavy S. with decrease in reactivity of an organism in the period of an aggravation the gipnagogiche-sky delirium develops more often. Development of an amentia (see. The amental syndrome) demonstrates considerable deterioration in a somatic state. At heavy S. with the phenomena of a cachexia devocalization (see) with fluctuations of clarity of consciousness (so-called oscillating consciousness) can develop. On this background there can be frustration of a body scheme (see) and oneiric frustration in the form of feeling of flight, rotation etc. (see. Oneiric syndrome). At improvement of a somatic state psychosis is reduced. Sometimes syndromes of the broken consciousness are replaced by transitional syndromes, is preferential with hallucinatory paranoid symptomatology (see. Symptomatic psychoses), to-rye in some cases it is necessary to differentiate with schizophrenia (see). At an adverse long current of S. development of the phenomena of a psychoorganic syndrome is possible (see).
S.'s Complications quite often significantly change his clinical picture and define an outcome of a disease. Such complications as acute renal and hepatonephric failure (see the Gepatorenalny syndrome, the Renal failure), respiratory insufficiency (see) and cardiovascular insufficiency (see), bleeding (see), a thromboembolism (see), decubituses (see), pneumonia, pyelonephritis, an endocarditis, are a consequence of intoxication and generalization of an infection, especially in the presence of irreplaceable loss of proteins owing to plentiful purulent separated (see. Traumatic exhaustion).
The heaviest and specific complication of S. is septic shock, to-ry can arise at any kind of S. and during any periods of its current. Clinical manifestations of septic shock of a polimorfna are also defined by a phase of development and a form of this complication. Its harbingers are change of behavior of the patient, his disorientation, disturbance of consciousness and the asthma measured by eye (see). The main sign of septic shock — quickly progressing circulatory unefficiency which is usually accompanied with tremendous oznoba and leading to deep disorders of fabric exchange. In a late stage there are disturbances of consciousness up to a coma (see), pallor of skin, a Crocq's disease (see), expressed to a tachypnea (see), an oliguria, the hyperthermia replaced by decrease in body temperature at plentiful sweating. Pulse becomes frequent to 120 — 160 beats per minute, weak filling, arrhythmic; the critical falling of the ABP which is combined with signs of reduction of venous return is quite often observed. The lethality at septic shock remains high.
S.'s Diagnosis shall be based on the comprehensive analysis and comparison of the available clinical symptoms and data of a laboratory research. At a laboratory research in sick S.' blood it is noted accruing hypochromia anemia (see), the accelerated ROE, a leukocytosis (see) with shift of a nuclear formula to the left (see. Leukocytic formula ). Bacteremia is found at S. only in 70 — 80% of cases that is explained by her inconstancy and difficulties of allocation of nek-ry types of the activator (e.g., anaerobe bacterias). At endocardial S. investigate not only a venous, but also arterial blood, from a cut microbes at this type of S. are allocated much more often. More or less surely S. can be distinguished in the presence of the following signs: discrepancy of scanty local changes in the center of an infection, heavy general reaction of an organism and the progressing deterioration in the general state in the absence of other burdening diseases and complications; emergence of the purulent metastasises which anatomically are not connected with the available center of a purulent infection; constantly or periodically found bacteremia in the presence of other signs of generalization of an infection; fever, especially from oznoba, followed by a leukocytosis with a sharp deviation to the left, the progressing decrease in a hemoglobin content and erythrocytes in blood, the progressing gi-ioproteinemiya and a pshoalbumine-miya, a lowering of arterial pressure, to-rye cannot be explained with other reasons.
Differential diagnosis is usually carried out with the diseases which are followed by fever, napr, a typhoid (see), miliary tuberculosis (see), malaria (see), a brucellosis (see), acute purulent intoxication (see. Is purulent - resorptive fever ), etc. The most difficult is differential diagnosis of S. with is purulent-rezor-btivnoy fever, despite quite accurate differential diagnostic characters formulated in I. V. Davydovsky, V. I. Struchkov, T. Ya. Aryev's works of pi other. In doubtful cases nek-ry clinical physicians follow the following rule: if after radical surgical treatment of the center of an infection and purposeful antibacterial therapy within 7 days body temperature does not decrease, keeps tachycardia, and from blood microflora is sowed, such fever is considered as an initial stage of S. and start intensive complex treatment. At it is purulent - to resorptive fever this treatment in most cases leads to decrease in temperature and to elimination of bacteremia; in the absence of positive effect the disease is finally regarded as sepsis. In difficult cases in the presence of indications for diagnosis use ultrasonic scanning, a usual and color termografiya, a laparoscopy, endoscopy and other modern methods of a research.
sick S.'s Treatment shall be carried out in a complex. Medical process is strictly individualized; at the same time it shall be based on the nek-ry general principles meeting modern expectations of an etiology, a pathogeny and the course of a disease.
First of all carry out intensive searches, operational treatment (excision, opening) and the subsequent adequate sanitation of the septic center. Radical elimination of a suppurative focus (primary or metastatic) is reasonable at all forms of sepsis as without it it is impossible to count on recovery of the patient even at the most intensive and qualified conservative therapy.
Antibacterial therapy carry out purposefully (according to data antibiotiko-grams) massive doses of antibiotics of bactericidal action (penicillin); antibiotics of bacteriostatic action (tetracyclines) in the conditions of unresponsiveness are usually inefficient. Preference shall be given to the combined antibacterial therapy by 2 — 3 drugs, napr, Oxacillinum and Methicillinum; gentamycin and lincomycin, etc. Modern semi-synthetic и# penicillin the cephalosporins possessing a wide range of antibacterial action and bystry bactericidal effect is the most effective remedies of causal treatment of sepsis. In critical situations before identification of the activator the combined use of aminoglycosides (gentamycin, sisomicin, amikacin) with penicillin (karbeni-tsillin, ampicillin) and cephalosporins is recommended (except for a tseporin). At staphylococcal S. along with semi-synthetic penicillin use of Fusidinum and rifampicin is perspective. The combined use of polusinteti-chesky penicillin and aminoglycosides gives a synergism that allows to reduce a dose of aminoglycosides and to reduce danger of their toxic influence. New perspectives for antibacterial therapy of sick S. treatment opens them in the conditions of the managed abacterial environment (see). Antibacterial therapy at S. shall be carried out before steady improvement of the general condition of the patient confirmed clinical and datas of laboratory (disappearance of fever and bacteremia, normalization of a blood count). Irrational use of antibiotics increases a lethality at sepsis.
Even at effective antibacterial therapy final elimination of the activator in an organism is possible only with the participation of its protective forces. Therefore it is necessary to try to obtain increase immunobiological (nonspecific and specific) reactivity of an organism. It is reached by hemotransfusion (see), administration of nonspecific gamma-globulin (see Immunoglobulins), protein hydrolyzates, hyperimmune anti-staphylococcal plasma, antista-phylococcal gamma-globulin, staphylococcal anatoxin (see Anatoxins), specific anti-toxic serum (see) etc.
At the combined insufficiency of T - and V-lymphocytes or deficit only of T lymphocytes enter a leucio-suspension of the healthy or immune donor; at low activation of V-lymphocytes, especially in initial phases C., apply hyperimmune plasma or gamma-globulin. According to Yu. V. Zhukov and soavt. (1977) if triple administration of anti-staphylococcal plasma at staphylococcal S. does not give nolo-zhitelny effect, then further passive immunization becomes useless. In these cases intensive searches of not recognizable suppurative focus with the subsequent elimination are necessary in its operational way. During the carrying out an immunotherapy (see) it is necessary to avoid excessive stimulation of immune systems and development of hyper-ergichesky reactions for what the constant and qualified laboratory control of blood shall be exercised.
Maintenance of a water salt metabolism (see) and acid-base equilibrium (see), volume and rheological properties of the circulating blood, the energy balance, performing disintoxication therapy (see) is carried out by means of means and methods of infusional therapy (see) and an artificial diuresis (see Poisonings). Apply also inhibitors of proteolytic enzymes — Contrykal, Trasylolum, Gordoxum; vitamin therapy (see); coenzymes — cocarboxylase, Cothiaminum; anabolic steroids — retabolil, testosterone-propionate. For decrease of the activity of coagulant system of blood (especially at a syndrome of the disseminated intravascular coagulation) use heparin.
The hypoxia and its effects are eliminated by oxygen therapy (see), including also hyperbaric oxygenation (see), edges are optimum changed by a ratio of species of microorganisms on various sites of a mucous membrane and skin, positively influences the immunological status of the patient.
At septic shock use of vasoactive drugs (steroid hormones, a kompla-mine), the artificial diuresis, means and methods improving rheological properties of blood and coronary perfusion, maintaining sokratitelny properties of a myocardium and adequate gas exchange is shown.
At mental disorders along with fortifying treatment, vitamin therapy apply nootropic means — nootropil, Encephabolum, Gammalonum and tranquilizers — meprobamate, Tazepamum, Seduxenum, Elenium; at psychoses enter intramusculary antipsychotic substances — aminazine, Stelazinum, a haloperidol, etc.
In sick S.' treatment questions of medical care for the patient (see the Nosotrophy), food, creations of the most favorable sanitary and hygienic conditions, and also use according to indications of physiotherapeutic methods and physiotherapy exercises figure prominently.
the Forecast at S. depends on virulence of microflora, a condition of immunobiological forces of an organism of the patient, timely and adequate complex therapy. When all these factors are rather favorable, the forecast can also be favorable. In other cases the forecast remains alarming, especially at patients of old age in the presence of the aggravating associated diseases (e.g., a diabetes mellitus).
S.'s Prevention consists in timely treatment of the centers of a persistent purulent infection; the qualified conservative and operational treatment of wounds, burns and local pyoinflammatory processes, a cut includes obligatory measures of increase in immunnobiologichesky properties of an organism; the most strict observance of rules asepsises (see) and antiseptic agents (see) at surgeries, infusional therapy, subcutaneous and intramuscular injections, during the carrying out an artificial respiration, intravascular researches and carrying out an intensive care; to prevention of developing of allergic diseases (see) at prescription of medicines.
The features of some kinds of sepsis caused by localization of primary septic center
Oral sepsis (synonym: stomatogenny sepsis). Are the reasons of its emergence apical periodontitis, to-rogo more than 50% of all centers of oral S., a chronic pulpitis, unextracted okolokornevy granulomas, a pathological dentogingival pocket, osteomyelitis of a jaw, antritis, etc. fall to the share. Pathogenic action of the tooth center of a chronic inflammation is connected with its sensibilizing action causing development of infek-tsionno-allergic diseases streptococcal (possibly, autoallergenny) etiologies, and also allergic reactions to the medicinal substances entered into a pulp cavity.
Subfebril-ny body temperature, discrepancy of subjective symptoms to more expressed objectively registered disturbances, sensitivity to meteofactors and inflexibility to effect of medicines, including antibiotics are characteristic of the oral S. proceeding chronically. At long existence of the center heart, kidneys, joints, etc. are surprised. The center in an oral cavity supports long, often recurrent course of rheumatism (see), with rather early damage of a myocardium and tendency to formation of heart diseases (see).
Oral S.'s diagnosis is based on his clinical picture and assessment of the indicators characterizing a sensitization of an organism. Identification of the stomatogenny center is promoted by the elektrometriya defining necrosis of a pulp, and the X-ray analysis (see Teeth, methods of a research) finding destruction of okoloverkhushechny tissues of tooth, the root channel to-rogo is not sealed up, or sealed up partially. Sometimes at a X-ray analysis the bone pathological pocket is found.
Treatment along with the general treatment of S. provides radical elimination of all revealed centers. The tooth center of a chronic inflammation is liquidated an odontectomy (see. Exodontia ) or way the endochannel of its ny treatment, the center of a medicinal sensitization — removal of medicine allergen. At a chronic septic state, visceral infectious and allergic diseases and a medicinal sensitization timely elimination of the centers is very effective. Elimination of the center does not exert noticeable impact on the course of autoallergichesky diseases.
Prevention of formation of the centers of a chronic inflammation in teeth and a parodonta is provided systematic sanitation of an oral cavity (see).
Otogenic sepsis occurs rather often (approximately at 3 — 4% of the patients operated concerning purulent diseases of an ear). Causative agents of otogenic sepsis, as a rule, are hemolitic streptococci and plazmokoaguliruyushchy staphylococcus, is frequent in combination with other microbes (pneumococci, colibacillus, Proteus, etc.); quite often anaerobe bacterias and viruses, and also mycoplasmas meet.
In otogenic S.'s pathogeny essential value is ime.t by anatomotopografichesky features of an ear, especially existence of sine of a firm meninx near it. Thin bone walls of cavities of a middle and inner ear on rather big extent border on a firm meninx and on a venous sigmoid sine. In these walls there is a large number of openings and channels for circulatory and absorbent vessels, nerves, labyrinth liquid. Otogenic S.'s emergence is most often connected with thrombophlebitis of a sigmoid sine, is more rare cross, very seldom top and bottom stony and cavernous than sine, developed because of purulent otitis (see). In these cases contagiums extend from a suppurative focus on average to fish soup in the contact or vascular way to a sine, causing emergence of a periphlebitis, phlebitis, and then and thrombosis of a sine (see Thrombosis, vessels of a brain) with development of sepsis. At destruction by purulent process of back departments of a middle ear around a sigmoid sine so-called perisinuozny abscess can be formed. The sinus thrombosis and sepsis can develop also at a furuncle of acoustical pass, the person and skull, wounds and an ugly face of the same localization. Purulent innidiation at otogenic S. perhaps in a skull, in an eye-socket, paranasal sinuses, a throat, lungs, a mediastinum, heart, in bodies of a stomach, muscle, joints, hypodermic cellulose.
Fervescence to high figures (40 °) with a fever and its critical falling, tachycardia is characteristic of a clinical picture of otogenic S. in a phase of a pyemia. Gradual increase of temperature without its critical falling and oznob is sometimes observed. For an otogenic septicaemia, edge it is usually combined with a heavy sinus thrombosis, temperature of constant type without oznob, quickly occurring septic changes of internals are more characteristic high (to 40 °) (a liver, kidneys, an endocardium, intestines, etc.) and development of all symptomatology of acute S., to-ry quite often comes to an end with death.
Under the influence of antibacterial drugs the clinical picture of otogenic S. can be erased, there can occur the long remissions simulating recovery. Sometimes afebril-ny thrombosis of a sine and not purulent complications, such as limited encephalitis (see Encephalitis), an arachnoiditis (see), hydrocephaly (see) meets wet brain (see Hypostasis and swelling of a brain).
Locally, in the septic center, the picture of chronic or acute average otitis and quite often painful swelling (puffiness, infiltration) of soft tissues of the rear edge of a mastoid (Grizinger's symptom) is found. The last points to involvement in process of back cells of a mastoid and wall of a sine with formation of perisinuozny abscess. Puffiness and infiltration can extend down the course of a jugular vein that indicates a possible inflammation of its walls or fibrinferments. On the course of a jugular vein nodes are probed increased and painful limf. Emergence of pain in an ear can be caused by acute process in tympanic cavities or existence of perisinuozny abscess; pain in a neck can depend on phlebitis of a jugular vein, small and deep veins in side and back departments of a neck.
Otogenic S.'s diagnosis is established on the basis of the general and local symptoms of a disease. At suspicion on otogenic S. every 3 hour (except the period of a dream) take the body temperature of the patient; at height of rise in temperature take blood from a vein on existence of microflora. Conduct laboratory researches of functions of kidneys, a liver, a spleen, systematically investigate a leukocytic blood count. At fibrinferment of a sine there can be positive Kvekkenshtedt's test (strengthening of the expiration of cerebrospinal liquid at a lumbar puncture after a prelum of a jugular vein on the healthy party). On roentgenograms of temporal bones blackout of cellular structures of a mastoid on the party of defeat, as a rule, comes to light, and at chronic, otitis it is frequent and destruction of a bone in attiko-antral-ache areas.
Otogenic S.'s treatment provides carrying out immediate (after establishment of the diagnosis) a middle ear operation and intensive general treatment of Page. At acute average otitis make a mastoidotomy (see. Mastoiditis ), at chronic — radical (obshchepolostny) a middle ear operation; at both types of interventions are obligatory elimination of the center on average for fish soup and a wide exposure of a sigmoid sine. For the purpose of diagnosis of blood clot punktirut a sine, directing a needle up and from top to bottom: intake of blood in the syringe will testify to absence of occlusive blood clot. In the presence of blood clot open a sine and delete blood clot from an available part of a sine. Conservative treatment includes use of high doses of antibiotics and other antibacterial drugs taking into account sensitivity to them of microflora, and also other means and methods, proceeding from the general rules of treatment of S. Ezhednevno make bandagings with audit of an operational wound and its processing. If during the first days such treatment is insufficiently effective, the issue of repeated operation with the purpose of removal from hardly accessible parts of a sine of blood clot, bandaging of a jugular vein is resolved. At the same time usually there is a need of additional removal of a bone tissue over a cross sine whenever possible to edge of blood clot. Nek-ry surgeons prefer to make such radical operation at once at the first intervention, however convincing data of advantage of such tactics are not obtained.
Otogenic S.'s prevention consists in timely elimination of suppurative focuses in an ear.
Rhinogenic sepsis usually arises as a complication of the aggravated chronic antritis, an etmoidit, a frontal sinusitis, sphenoid of an it, is more rare — an acute inflammation of adnexal bosoms of a nose, furuncles and injuries of a nose. Activators (the same character as at otogenic S. — see above) can come to blood from the center of an inflammation in the contact way or on circulatory and absorbent vessels. Less often rhinogenic S.'s emergence is connected with fibrinferments. Thus is more often than others the cavernous sine, veniplexes of an eye-socket and a pterygopalatine pole, sometimes a longitudinal sine, i.e. those venous collectors are surprised, in to-rye blood from a nose and its adnexal bosoms gets.
The clinical picture of rhinogenic S. a little in what differs from otogenic. The local symptomatology depends on character and localization of the main center of an infection. Quite often there are only usual symptoms of an inflammation adnexal bosoms of a nose (see) or a furuncle of a nose (see).
At distribution of an inflammation on a cavernous bosom the so-called symptom of points — blue and pastosity around eyes can appear. At damage of veins of eye-sockets, stony sine are quite often noted an exophthalmos (see), swelled also infiltration of soft tissues of an eye-socket, disturbance of functions of these or those third cranial nerves. Patients often complain of a headache of diffuse character or pain in a nose bridge and a nape.
Rhinogenic S.'s diagnosis is based on identification of local symptoms of a disease of a nose and its adnexal bosoms and symptoms of Page.
Treatment consists in elimination in the operational way of the center of an infection and performing conservative treatment of S. by the general rules. Paranasal sinuses operation (see) is made considerably with full removal from their walls of a mucous membrane and formation of a wide anastomosis with a nasal cavity.
Prevention consists in timely treatment of diseases of a nose and its adnexal bosoms.
Tonzillogenny sepsis meets rather seldom. It arises usually as a complication acute and chronic tonsillitis (see), especially — paratonsillar abscess (see. Quinsy ). Infestants generally the same character, as at otogenic S., a clinical picture also without essential features.
The diagnosis of a disease is established on the basis of existence of symptoms of S. and inflammatory (it is especially long existing) processes in palatine tonsils; at the same time pay attention to usually available features of a current of their last inflammation.
Full removal of palatine tonsils (see) in combination with the general treatment of Page is the cornerstone of tonzillogenny S.'s treatment. Prevention consists in timely sanitation of the centers of a purulent infection in almonds.
Urosepsis — sepsis, at Krom entrance gate for contagiums are kidneys and uric ways. For the first time Velpo (A. A. L. M of Velpeau), and then Sivial (J. Civiale, 1833 — 1837) paid attention to feverish attacks at patients after catheterization and operative measures on an urethra. F. Gyuyon (1899) defined this state as uric fever. He distinguished two forms of this disease — acute and chronic and noted that at the same patient they can alternate.
Any pathogenic microflora can be the activator of an urosepsis, is more often gram-negative (colibacillus, a pyocyanic stick, proteas).
The urosepsis can be an exogenous and endogenous origin. The exogenous urosepsis arises at the fire and closed injuries of kidneys and uric ways when owing to infiltration by urine and a necrosis of the smashed fabrics uric phlegmon, peritonitis quickly develop and others is purulent - infectious complications. Quite often the urosepsis is observed in connection with endovezi-kalny and endourethral manipulations (bougieurage of an urethra, a tsistoskopiya, a retrograde piyelografiya, etc.). In these cases in a pathogeny of an urosepsis a noticeable role is played by an injury of a mucous membrane of an urethra, edge is deprived of a submucosal layer and directly contacts to venous sine of a spongy part of an urethra that promotes emergence at an injury of an uretrovenozny reflux (see) and to penetration into blood of microbes.
Tendency to an urosepsis of an endogenous origin is observed at the patients with an urinary stasis who usually have persistent infection of uric ways and reduced immunobiological properties of an organism. Besides, at them as a result of lokhanochno-cup hypertensia the lokhanochno-venous shunt is formed, through to-ry the bacterial flora and toxins can get into a blood flow. Acute obturatsionny pyelonephritis, especially often is complicated by an urosepsis when to the patient antibacterial therapy at not recovered outflow of urine from a kidney is carried out.
The clinical picture of an acute urosepsis, to-ry meets most often, is shown by remittiruyushchy fever with repeated a tremendous fever and pouring then, decrease in a diuresis, nausea, vomiting, sharp weakness, sometimes a collapse (see). During the performing adequate therapy in some cases the general condition of the patient quickly improves. Such quickly passing urosepsis often arises after bougieurage of an urethra or a tsistoskopiya (see) and is known under the name of uric or urethral fever. In other cases, despite antibacterial treatment, the suppurative metastatic focuses in a kidney with development of apostematous nephrite (see), an anthrax of a kidney appear (see Kidneys) and it is purulent - necrotic process in pararenal cellulose (see the Paranephritis). At the same time can be observed purulent cystitis (see), acute prostatitis (see), a vesiculitis (see), pelvic it is purulent - necrotic phlegmon. The syndrome of the disseminated intravascular coagulation is characteristic of an urosepsis (see. Hemorrhagic diathesis) both hemolysis with an abnormal liver function and kidneys and development of a hepatonephric syndrome (see the Gepato-renaljny syndrome). The persistent current of an acute urosepsis is usually caused by existence of unliquidated infectious process in a kidney or uric ways and often accompanies an urinary stasis.
The subacute urosepsis proceeds at an elevated temperature of a body, other septic manifestations are expressed unsharply. It is observed at patients with badly drained suppurative focus, and also at the patients weakened, suffering from a diabetes mellitus.
The chronic urosepsis is observed often in the presence of chronic purulent process in a kidney against the background of a renal failure. The acute beginning is absent. Body temperature subfebrile with rare increase to high figures. At patients bystry fatigue, weakness, exhaustion is noted, anemia accrues. Disease wavy — short-term improvement is replaced by deterioration that can be connected with badly functioning nefro-or tsistostomy, an otkhozhdeniye of a concrement, to-ry breaks outflow of urine from a kidney, etc.
The diagnosis of an urosepsis is based on existence of symptoms of S. and pyoinflammatory processes in kidneys or uric ways. Along with other data the increased content in blood of residual nitrogen, urea and creatinine, and also to a leukocyte a riya (see), a bacteriuria (see), the cylinder an uriya is especially characteristic of an urosepsis. Essential value for the diagnosis can have a bacteriological blood analysis and urine.
Treatment of an urosepsis consists in urgent removal or drainage of a suppurative focus, recovery of the broken outflow of urine and the general treatment of Page. At obturation of a pelvis of a kidney or an ureter carry out decapsulation of a kidney (see), a nephrostomy (see), open pustules and cut an anthrax of a kidney. At the complicated bladder emptying (e.g., at a tumor or abscess of a prostate, traumatic injury or a cicatricial stricture of an urethra) removal of urine through suprapubic vesical fistula is shown (see Vesicotomy). Antibacterial therapy is carried out only at the recovered outflow of urine by the general rules of treatment of Page. Not always microflora in uric ways and tissue of a kidney is identical therefore during kidney operation make its biopsy and take smears from renal fabric and a pelvis for a bacteriological research and definition of sensitivity of microflora to antibiotics. At a renal failure care in the choice of antibacterial agents and their dosages because of danger of toxic influence nek-ry of them on kidneys and a liver is necessary. Polymyxins, streptomycin, Cycloserinum are in this respect contraindicated; big care at use of tetracyclines, nitrofurans, penicillin in high doses is required; penicillin and its analogs in usual doses, levomycetinum, cephalosporin, Nevigramonum, a 5-nok are preferable. During the performing infusional therapy special attention is paid to the prevention of an oyotry renal failure and normalization of a nitrogen metabolism.
Prevention of an urosepsis is bystry recovery of outflow of urine at obturatsionny acute pyelonephritis or an acute ischuria, drainage of suppurative focuses in a kidney and uric zatek with the subsequent antibacterial therapy, use of the means raising an immune responsiveness of an organism.
Obstetric and gynecologic sepsis arises against the background of primary inflammatory process in female generative organs. It can develop after the delivery (puerperal S.) or after abortion (postabortion S.); in these cases the physiological and anatomic changes in an organism of the woman occurring during pregnancy, childbirth and in a puerperal period cause nek-ry features of a clinical current of S. V the same cases when S. arises as a complication of purulent gynecologic diseases (e.g., a pyosalpinx) or after gynecologic operations, it practically does not differ from surgical Page.
The postnatal sepsis (which was called earlier a maternity fever) up to the middle of 19 century claimed many human lives. According to Ledger (W. J. Ledger), in the fifties 19 century every third woman in childbirth died of puerperal S. in nek-ry obstetric hospitals. In 1843 Holmes (O. of W. Holmes) suggested about contageousness of puerperal fever, and in 1847. And. Zemmeljveys proved correctness of it the assumption practically, having considerably lowered a lethality from puerperal infectious diseases by implementation in obstetric practice of processing of obstetrical hands in antiseptic solution before each vaginal examonation of women in labor. Scientific development of questions of the prevention puerperal (as well as other types) infections began after L. Pasteur (1863) and J. Lister's researches (1867).
Maternal mortality from obstetric and gynecologic S. sharply decreased (by 10 — 20 times) after implementation in practice of sulfanamide drugs and antibiotics. In our country it became an unusual occurrence in clinical practice in connection with the purposeful scheduled maintenance which is carried out by clinics for women, wide network of obstetric hospitals, improvement of medical care to pregnant women, women in labor and women in childbirth.
Obstetric and gynecologic S. almost always a secondary disease, a cut bears in itself a certain print of primary center (an endometritis, mastitis, the suppurated hematoma of a vagina or a parametrium, etc.). Its activators are causative agents of puerperal diseases (see), for to-rykh is characteristic on-limikrobnost. In an etiology of puerperal diseases an escalating role is played by gram-negative opportunistic pathogenic bacteriums. Golden staphylococcus is the dominating causative agent of a lactational mastitis, aerobic gram-negative microorganisms — an endometritis, pyelonephritis, septic shock; peritonitis (after Cesarean section) can be caused by both gram-negative, and gram-positive microorganisms, and also their associations; anaerobic microorganisms come to light at the most severe forms of puerperal is purulent - a septic infection (septic shock, peritonitis).
Obstetric and gynecologic S. can develop during the entering of microorganisms from the environment (generally hospital strains) or owing to activation of own pathogenic and opportunistic microflora of a macroorganism. Postnatal and postabortion S. — preferential raiyevy. Primary septic center at puerperal and postabortion S. is in most cases localized in a uterus, inside the cut after the delivery and abortion is formed an extensive wound surface; it is especially favorable for an invasion of mikroorgenizm placental platform (see), supplied with numerous circulatory and absorbent vessels. At Cesarean section (see) the center of an infection can develop also in the place of a section of a uterus and a front abdominal wall. The septic center can be created owing to infection of ruptures of a crotch, a vagina, a neck of uterus, especially if they remain not distinguished and not sewn up. Obstetric and gynecologic S. of an endogenous origin can arise at adnexitis (see), a parametritis (see), etc., to-rye, in turn, can develop at hit of microflora from the vnege-nitalny centers (at purulent otitis, pharyngitis, appendicitis, etc.).
Obstetric and gynecologic S.'s development during pregnancy is promoted by a colpitis, a negenital-ny bacterial infection, late toxicoses of pregnant women, bleeding from generative organs, a diabetes mellitus, obesity, and also carrying out intravascular methods of a research of a functional condition of a fruit, surgical correction of istmiko-cervical insufficiency; at the time of delivery — premature izlity amniotic waters with a long anhydrous interval, the continuing childbirth, repeated vaginal examonations, a birth trauma, obstetric operations, bleedings from generative organs, carrying out intravascular methods of a research of a functional condition of a fruit and sokratitelny activity of a uterus is long; in a puerperal period — subinvolution of a uterus, a delay of parts of a placenta, existence of the extragenital centers of a purulent infection, anemia, endocrine diseases, etc. In the presence of the listed factors of women carry to group of high risk of developing of puerperal diseases with possible development of S. and hold the relevant preventive and medical activities. At the same time consider that even at healthy women during pregnancy and in early terms of a puerperal period the partial tranzitorny immunodeficiency is observed, and at puerperal diseases — oppression of immune system.
Obstetric and gynecologic S. can proceed in the form of fulminant, acute, subacute and chronic S., in a phase of a septicaemia or a septicopyemia. Postnatal sepsis as a septicaemia is characterized preferential early (on 2 — the 3rd days after the delivery) by the beginning, high temperature of a body (to 40 — 41 °), a repeated fever, quickly accruing intoxication, the tachycardia, an oliguria and other symptoms inherent to acute Page. Local changes in area of primary center of an infection (is more often in a uterus) can vary from weak signs of an inflammation to a heavy endometritis (see the Metroendometritis). Due to the broad use of antibiotics cases of sepsis with gradual fervescence and its considerable razmakha within a day, single attacks of a fever, with other unsharply expressed clinical manifestations are observed. Sometimes the latent current of a septicaemia after the delivery meets. As a result of adequate complex therapy at women in childbirth with a septicaemia the positive effect is usually quickly reached. The exception is made by patients with fulminant sepsis.
The septicopyemia begins on 10 more often — the 17th day after the delivery and is characterized by emergence (against the background of a septicaemia) the secondary septic centers in various bodies. In vessels of a uterus and a parametrium the infected blood clots are formed, at fusion to-rykh microorganisms come to a blood stream and are brought in the remote bodies where there are purulent metastasises; the clinical picture of sepsis in many respects depending on purulent defeat of these or those bodies develops.
The postabortion sepsis arising usually after extra sick-lists (so-called criminal) abortions, proceeds, as a rule, more hard, than puerperal, and differs in less favorable outcomes. Septic shock in obstetric practice most often develops at extra hospital abortions. Extremely seldom after extra hospital abortions anaerobic S. meets, the activator to-rogo is preferential Clostridium perfringens. Gangrene of a wall of a uterus, the heavy general rezorb-tivno-toxic process caused by a resorption from a uterus of exotoxins, decomposition products of the parts of fetal egg and tissues of the uterus which were late in it develops. Bystry development of a disease, a triad of signs — jaundice with a bronze shade, a haemoglobinaemia and a haemoglobinuria are characteristic. The oliguria is noted, up to an anury (see), color of urine — dark and chocolate or brown. The concern, an asthma increase, cyanosis is noted. In a clinical picture manifestations of septic shock (see above), and then — an acute renal failure dominate (see).
Obstetric and gynecologic S.'s diagnosis is established on the basis of the general symptoms of S. and clinical manifestations of the septic center in generative organs. At suspicion on S. conduct a careful two-handled research (vaginas - but - belly stenochnoye, is more rare direct entero belly stenochnoye), survey of a vagina and neck of uterus in mirrors (see. Gynecologic research). Make necessary laboratory analyses. Clinical trial of urine allows to reveal or exclude to pyelonephritis quite often complicating a current of a puerperal period that is important for differential diagnosis. Prior to antibacterial therapy, in the course of treatment and before an extract make the bacteriological analysis of the corresponding material — blood, lokhiya, wound separated, exudate, to a moloka of urine.
At emergence of difficulties in obstetric and gynecologic S.'s diagnosis along with traditional apply modern equipment rooms and tool methods of a research. For the purpose of improvement of diagnosis and forecasting of puerperal diseases attempts to use of mathematical methods of page are made by use of the COMPUTER.
The differential diagnosis of obstetric and gynecologic S. should be carried out with mastitis, pyelonephritis, and also with sepsis of other origin (urosepsisg sepsis at infectious diseases, etc.). However clinical practice shows that the majority * cases of high fever at women in childbirth is caused by puerperal: infection.
Obstetric and gynecologic S.'s treatment, as well as other kinds of S., shall be etiotropnymg complex, systematic and active; it is begun as it is possible - earlier and carry out by the general rules of treatment of Page. The septic center is liquidated in the operational way; apply antibacterial means, hl. obr. antibiotics. Operational methods vary depending on character and localization of primary and secondary centers of an infection. In the presence of pus its evacuations by cuts, drainage, disclosure of a postoperative wound promote. At obstetric peritonitis (e.g., after Cesarean section), perforation of a wall; a uterus (e.g., after criminal abortion) it is shown hysterectomy (see), in the presence of a pyosalpinx (see. Adnexitis ) — removal patholologically the changed appendages (see. Uterine tubes ; Ovaries, operations ).
As allocation and identification of activators, definition of their sensitivity to antibiotics take the known time, begin an antibioticotherapia proceeding from the available data on preferential activators at various forms C. taking into account character of primary center of an infection. Approximate idea of the microorganisms which are contained in the center can be received by means of a bacterioscopy with coloring across Gram (see. Bacteriological techniques, frame method). Results of the microbiological analysis use for correction of an antibioticotherapia. Usually apply modern antibiotics of a broad spectrum of activity to obstetric and gynecologic S.'s treatment — polusintetiche-sky penicillin, aminoglycosides, cephalosporins. They are appointed in combination with antifungal antibiotics (nystatin). Combinations antr1biotikov are highly effective: a gene-tamipin with benzylpenicillin or iolusintetichesky penicillin, to tents and Qing with lincomycin, ampicillin with Oxacillinum. At the sepsis caused by asporous anaerobe bacterias, in particular bacteroids use lincomycin, left and big fellows, the erythromycin, rifampicin or drug used for treatment of a trichomoniasis — metronidazole.
Obstetric and gynecologic S.'s prevention comes down to the prevention of puerperal diseases and abortions (especially extra pain-nichnykh). The clinic for women reveals the pregnant women belonging to group of high risk of development of tnoyno-infectious processes or already sick and hold preventive and medical events.
Postabortion S.'s prevention provides carrying out fight against extra hospital abortions (see Abortion artificial, criminal) by sanitary and explanatory work, promotion of modern methods of contraception (see Contraceptives), and also perhaps early hospitalization and treatment of women after such abortions.
Sepsis at infectious diseases. At a number of infectious diseases the usual cyclic current owing to the changed immune condition of a macroorganism can pass in septic, acyclic. Such S.'s activators are causative agents of the basic infectious disease, it develops under the general laws of development of S., beginning with formation of the local septic center, to-ry causes expansion of a clinical picture C. S.'s emergence at infectious diseases happens at high virulence of the activator and sharply broken (perverted) condition of humoral and cellular immunity and nonspecific factors of protection of an organism. Therefore the disease is observed more often at newborns, small children, old men, pregnant women and women in labor, persons with immune and endocrine diseases. So, septic forms of the dysentery (see) caused by Grigoriev's shigellas — Shigi (see the Shigella), are observed usually at exhausted, often suffering from a nutritional dystrophy (see), inhabitants of Asia and Africa, especially at children. In especially hard cases local clinical displays of an infectious disease (and consequently, and the septic center) cannot be found and the disease proceeds in the form of so-called primary S., or they pale in a clinical picture into insignificance.
Septic forms can be observed at many infectious diseases — intestinal infections, a typhoid (see), an ugly face (see), scarlet fever (see), plague (see), a malignant anthrax (see), a brucellosis (see), a meningococcal infection (see), etc. However in modern clinical practice they are observed extremely seldom. The sepsis caused by causative agents of intestinal infectious diseases, as a rule, begins with the expressed symptoms of an acute gastroenteritis (see) or gast-r about en rubbed an eye of litas (see). Then there are gektichesky fever, oznoba; is defined gepato-liyenal-ny a syndrome (see), damages of kidneys, a liver, a meninx, heart, adrenal glands, etc. are possible. The current can be long. Sepsis at an uncomplicated ugly face happens seldom, usually intermediate link are the hypodermic abscesses, phlegmons complicating an ugly face. Sepsis at scarlet fever in most cases arises in connection with developing of thrombophlebitis of veins of a neck and sine of a firm meninx. The septic form of plague develops after a bubonic form, but meets as well in the absence of buboes. Anthracic S. arises at damage of upper airways, bronchial tubes, a gullet and is rare at a skin form of a malignant anthrax. Sepsis with formation of metastatic abscesses and the centers of purulent fusion in muscles and internals is typical for a sap (see) and melioidosis (see). The isolated cases of S. caused by a mycoplasma, gonokokka, etc.
Nek-ry infectious diseases are described (a sapropyra, cholera, a visceral leushmaniosis, etc.) owing to decrease or a perversion of immunobiological reactivity of the patient can be complicated by the sepsis caused by the microorganisms which are not activators of a basic disease. At patients with a typhoid sepsis of such genesis develops owing to generalization of microflora from suppurated mezenterialny limf, nodes, at other patients secondary microflora arrives from the septic centers in lungs (e.g., at pneumonia), urinary tract (e.g., at a pyelocystitis), skin (e.g., at a pyoderma), etc. In these cases the disease proceeds more often as heavy septicopyemic process.
S.'s diagnosis at infectious diseases is based on existence of the septic phenomena which developed against the background of an infectious disease. It is necessary to differentiate the bacteremia which is an indispensable link of a pathogeny of many infectious diseases from sepsis (e.g., a typhoid, a brucellosis, a meningococcal infection, etc.).
Treatment is carried out according to the standard principles of therapy of S.
Sepsis at children
the Main feature of S. at children the high frequency and weight of this infectious process connected preferential with tranzi-even immaturity of the immune system which is especially expressed in the first half of the year of life is. Any pre-natal bacterial or fungal flora (see. The pre-natal infection) can lead to pre-natal S.'s development; at newborn, premature and children of the first three months of life of S. meets more often than at children of other age period.
As well as at adults, S. at children can be caused by various microorganisms; also gate for contagiums (skin, an oral cavity, ears, a navel, lungs, intestines) are in the same way very various. At newborns serve more rare at babies entrance vorotakhm the umbilical or operational wound, and also kateterizirovanny main veins can (in this case microflora is especially virulent and steady against the majority of antibiotics). More often activators C. at children are staphylococcus, to the Crimea immunity is not developed; besides, they promote a sensitization of an organism and differ in resistance to antibiotics. The organism of the child has the raised susceptibility to effect of staphylococcal toxin. S.'s cases at children caused by other microorganisms became frequent: colibacillus, pneumococcus, meningokokky, pyocyanic stick, klebsiyelly, Proteus, salmonella, foxes-teriyami p fungi.
Increase of a staphylococcal infection at newborns substantially is explained by increase in number of healthy carriers of pathogenic staphylococcus, especially among personnel of maternity homes there is a N of hospitals. The main tank of a carriage is the mucous membrane of a nasopharynx. Persons from service personnel, or mother and the children sick with staphylococcal diseases can also be a source of a contagium. Quite often infection occurs through objects of leaving, a diaper, air dust, etc.
Anti-and intranatal infection matters (see. Antenatal pathology). Antenatal infection of a fruit can arise when the woman during pregnancy transferred a pyoderma, staphylococcal quinsy, a serious septic illness with disturbance of permeability of a placenta for coccal flora or has the infectious centers (caries of teeth, chronic otitises) which are followed by tranzitorny bacteremia. In these cases pre-natal death of a fruit or the birth of the child with a pyoderma or a serious septic illness is possible. Intranatal infection of a fruit is observed more often than antenatal; it happens at pathological childbirth, especially long, to a long anhydrous interval, at to-rykh operational grants, and also in the presence at the woman in labor of an endometritis, a colpitis, a pyelocystitis, etc. were applied. Conditions for the ascending infection of amniotic waters, placentae, a fruit, its covers, an umbilical cord therefore, by data I. A. Stern, G. I are at the time of delivery created. Mitrofanova, in these cases to 40 — 80% of children will be born the infected stafilokokka.
In a puerperal period (see) already during the first hours and days of life of the child his skin, a nose, a pharynx and intestines become populated by stafilokokka: by the end of the first days from 40 to 70% of newborns become carriers of pathogenic strains of staphylococcus. At 60 — 80% of these children after an extract from a maternity home the carriage of pathogenic stafilokokk proceeds. However in most cases action of this microflora is not shown or limited only to focal lesions of skin (vezikulopustulez, a pseuofurunculosis, etc.), an umbilical wound (omphalitis), conjunctivas since character and weight of infectious process depend hl. obr. from a condition of an organism of the child; during the easing it also the septic centers can form.
promotes Emergence and S.'s development in children a number of anatomo-physiological features of their organism: immaturity of many bodies and systems, in particular c. N of page, weakness of immunobiological and enzymatic reactions. Immaturity of the gipofi-zarno-adrenal system which is taking part in adaptatsionnoobmenny processes is of great importance. The hyperpermeability of various physiological barriers — epithelial, endothelial and connective tissue is characteristic that provides tendency to generalization of pathological processes. Weight of a current of S. is promoted by immaturity of the secretory device (kidneys, lungs, intestines), and also reduced ability of a liver to a detoxication.
The big role in increase in a susceptibility to an infection in general, and staphylococcal in particular, at children of the first weeks of life is played by immunological insufficiency in the period of a neonatality what lower testifies at them to, than at adults, quantity of mature T lymphocytes, low ability of V-lymphocytes within the first two weeks of life to be transformed to the cells producing antibodies, decrease in humoral factors of immunity. At newborns (see Newborn) and children of chest age (see. Baby ) also functional insolvency of system of phagocytosis (incompleteness), low hemotaksichesky activity of neutrophils, low level of content of antitoxin in blood serum is noted. Aged from 2 up to 6 months at children the phase of a so-called physiological immunodeficiency caused by disappearance of maternal antibodies and insufficient synthesis own is noted. Immunological insufficiency at newborns is aggravated also at the inborn or acquired hypotrophy (see. Dystrophy ) and artificial feeding of children (see).
The pathological anatomy
At premature, newborns and babies of S. proceeds in a phase of a septicaemia, for a cut, except existence of the septic center more often, the myeloid metaplasia and a hyperplasia of a spleen, marrow, limf, nodes, a thymus gland are characteristic. In an interstitium of a liver, kidneys, a myocardium, lungs myeloid infiltration, in vessels — leykostaza is found. In a mik-rotsirkulyatorny bed — productive and productive and necrotic vasculites, to-rye are sources of hemorrhages along with such complications of S. as the disseminated intravascular coagulation. At the same time there is hemorrhagic rash on skin, hemorrhages in mucous and serous membranes, in tissue of internals, in a gastric cavity, intestines. Hypostasis, a plethora of lungs, a brain and its covers is noted. In parenchymatous bodies the expressed dystrophic changes up to a necrosis of separate cells are observed, in mucous membranes of respiratory tracts and went. - kish. a path — the phenomena of Qatar connected with accession of consecutive infection. Rather often, especially at prolonged treatment by antibiotics, the ulcerative enterites and coloenterites caused autoflory in the conditions of dysbacteriosis (see) meet. Icteric coloring of skin as a result of toxic hemolysis of erythrocytes and septic hepatitis is sometimes observed. Crucial importance for the pathoanatomical diagnosis has detection of the septic center, especially if this center in itself did not play a noticeable role in a clinical picture of a disease.
Development of preferential hematogenous metastatic necroses or abscesses is characteristic of a septicopyemia at children, in the center to-rykh bacterial emboluses are found. Often there are purulent metastasises in serous covers with development of purulent metastatic meningitis (see), arthritis (see), pleurisy (see), pericardis (see), peritonitis (see). As a rule, are observed bronchial pneumonia (see Pneumonia), in these conditions the abscessing character, and also catarral or purulent otitis can accept edges. The septic (infectious) polipozno-malignant endocarditis of valves of an aorta is observed preferential at children after 3 years; at babies it is casuistry. The hyperplasia of a spleen, diffusion productive intracapillary are characteristic of it glomerulonephritis (see), heart attacks in a spleen, kidneys, a brain. The polipozno-malignant endocarditis of the three-leaved valve as a result of thrombophlebitis of a subclavial vein after its catheterization occurs at newborns and children of chest age. At the same time thromboembolisms of branches of a pulmonary artery and necrotic or purulent metastasises in lungs are observed.
Pre-natal S. is characterized by existence of the septic center in fabrics of an afterbirth (in an umbilical cord, fetal membranes, a placenta) in the form of abscesses or diffusion leukocytic infiltration. At a hematogenous way of infection thrombophlebitis of an umbilical vein with distribution of process on vessels of system of a portal vein is observed (see. Pylephlebitis ). At newborn or mortinatus, died from pre-natal S., jaundice is observed (see), the expressed hemorrhagic diathesis, gepato-and a splenomegaly, at a septicopyemia — multiple purulent or it is purulent - necrotic metastasises in bodies. In metastasises the activator is found, as a rule, in a large number. For the pre-natal S. caused by listeriya (see Listeriosis), formation of granulomas is typical, necrotic encephalitis and multiple necroses in bodies are characteristic of mycotic S.
On localization of primary center at children umbilical, intestinal, pulmonary and skin sepsis is more often observed. Umbilical S. — the most frequent form C. at newborns and children of early chest age. Entrance gate for contagiums are not disappeared stump of an umbilical cord (see), umbilical arteries, an umbilical vein (in cases of carrying out on it intravascular manipulations) or short the epiteli-zovanny granulating surface of a bottom of an umbilical pole formed after falling away of a stump of an umbilical cord. The septic center can be located in day of an umbilical pole, in umbilical arteries or a vein. The combination of simultaneous defeat of a bottom of an umbilical pole and umbilical vessels is possible. At localization of the septic center in day of an umbilical pole it is observed ulcer or ulcer and necrotic omphalitis (see) up to development of phlegmon of a front abdominal wall (see); occasionally the productive omphalitis meets formation of colossal cells of foreign bodys, it is preferential as the response to infection with fungi. In umbilical arteries the septic center is shown in the form of purulent or is purulent - a productive trombarteriit, and the distal piece of an artery is surprised more often. In an umbilical vein (fig. 5) preferential productive is observed or it is purulent - productive phlebitis (see), localized at portal fissures (at the place of standing of the end of a catheter at intravenous manipulations). In view of the small volume of the septic center with umbilical vessels its recognition is helped by the histologic research and smears taken from a gleam of vessels. Metastatic abscesses at umbilical S. meet in a liver, lungs, is more rare — in kidneys, adrenal glands. More often than abscesses, metastatic purulent meningitis is observed, and at mycotic umbilical S. — necrotic encephalitis.
Intestinal and pulmonary S. in a phase of a septicaemia occur at newborns and at early chest age: intestinal — in the presence of yazvennonekrotichesky enteritis or a coloenteritis, pulmonary — at the abscessing pneumonia (fig. 6). More often activators are salmonellas, iyersiniya, pathogenic strains of colibacillus. Intestinal S. can proceed as in a phase of a septicaemia, and a seitiko-pyemia.
Skin S. develops at purulent processes in skin and hypodermic cellulose.
The clinical picture
S. at children (a septicaemia or a septicopyemia) consists of the general symptoms of a disease and existence of the piogenic centers. S.'s manifestations depend on age of the child, virulence of a microorganism, character of the piogenic center. However among various manifestations of S. is such, to-rye are in a varying degree characteristic of all kinds of a disease.
Pre-natal sepsis results from transplacental infection of a fruit. Distinguish pre-natal S. at the birth of the child, the septic phenomena with existence of jaundice, the expressed hemorrhagic diathesis, increase in a liver and spleen are found in it; at a septicopyemia quite often diagnose focal pneumonia, meningitis, an ulcer coloenteritis, peritonitis, multiple purulent and necrotic metastasises in bodies. In more mild cases at the child with transplacental infection during the first hours and days of life arise purulent damages of skin of a staphylococcal etiology (vezikulo-pustulez, a pemphigus, abscesses, paronychias), otitis, a nasopharyngitis, purulent conjunctivitis, a dacryocystitis, infectious process in an umbilical wound, to-rye can lead to development S. Vnutriutrobny S. quite often leads to death of a fruit.
Sepsis at newborns results more often from infection in time and after the delivery, less often — in the pre-natal period. Distinguish harbingers, early symptoms and the developed picture C. Harbingers are a delay of increase of weight, overdue (after 10 days) falling away of an umbilical cord and the complicated course of healing of an umbilical wound. Treat early symptoms: slackness, lack of appetite, vomiting, discoloration of skin (pallor or pale-gray color, Crocq's disease, cyanosis of a nasolabial triangle). Sharp toxicosis is characteristic of the developed picture of a septicaemia (see. Toxic syndrome), acute (sometimes fulminant) current. The child quickly loses flesh, features are pointed, skin becomes wax-like, yellowish, jaundice is quite often noted. Slackness and an adynamia increase, to-rye in some cases are replaced by concern and spasms. There are vomiting, a diarrhea. Body temperature usually does not reach high figures, more often happens subfebrile, and in the most hard cases even normal. The liver is often increased; the splenomegaly (see), so characteristic of S. of adults, is noted at children in later period of Page. Initial pastosity of fabrics quickly is replaced by the general hypostasis (see). Sometimes the sclerema develops (see the Sclerema of newborns). In hard cases develop a syndrome of the disseminated intravascular coagulation with dot hemorrhages and bleeding, cardiovascular and respiratory insufficiency. In 7 — 14 days signs of a septicopyemia — metastatic abscesses in bones, joints, lungs, a middle ear, kidneys, a liver, intestines, etc., leading quite often to a lethal outcome can already appear. Quickly progressing critical condition, gray or marble coloring of skin, an asthma, disturbance of blood circulation, a hypouresis, hemorrhages on skin and mucous membranes, bleeding is characteristic of septic shock. Koagulogramma (see) more than at sepsis, it is typical for a syndrome of the disseminated intravascular coagulation, in particular sharply decreases number of thrombocytes. Quite often signs of a so-called shock lung are found (see Lungs).
Umbilical S. arises usually at the end of the first — the beginning of the third week of life. At the same time falling away of the funic rest and the slowed-down epithelization of an umbilical wound because of the phenomena of an omphalitis are noted later (in 10 days and more) (see). The catarral omphalitis (the so-called becoming wet navel), pyorrhea, ulcer of a navel, repeated openings of a wound are often observed; sometimes long the bloody crust in the center of a navel, testimonial of existence of the dozing infection in umbilical vessels does not disappear. Abdominal distention, puffiness of an abdominal wall, an expanded (congestive) vein and arteries in a circle of a navel is noted, to-rye are palpated in the form of reinforced and intense cords (Krasnobayev's symptom), increased inguinal limf. nodes.
Due to the increase of diseases of children ulcer and necrotic, sometimes perforative, enteritis, colitis, a coloenteritis, to-rye are caused by antibiotic-resistant stafilokokka, cases intestinal S. Osobenno severe damages of intestines became frequent cause staphylococcus in association with viruses and fungal flora, and also at stratification (e.g., pneumonia, dysentery and DR-) -
Defeat went on other infection. - kish. a path of a staphylococcal etiology at newborn children is secondary after such diseases as a staphyloderma, an omphalitis, purulent otitis, pneumonia, etc. At intestinal S. a condition of the child heavy, the phenomena of toxicosis are expressed, body temperature increases, vomiting is noted, the chair, excrements enteritichesky (liquid, watery, yellow color) or ente-rokolitichesky (liquid, with impurity of greens, sometimes blood) character becomes frequent. At peritonitis vomiting becomes frequent, in emetic masses impurity of intestinal contents appears. The stomach is blown sharply up, intense, skin on it shines, is edematous; the peristaltics of intestines is not listened.
Sepsis at is premature - N y x is, as a rule, connected with the complicated course of pregnancy and childbirth, is frequent with transplacental infection of a fruit. S.'s manifestations at premature children (cm. Premature children ) are less expressed, than at children of other age, disease more long. Body temperature is often normal. Of these cases of S. it can be suspected on the basis of so-called microsymptoms — inexplicable decrease in body weight (to 18 — 22%), existence of the piogenic centers, slackness, a grayish shade of skin, vomiting by bile, a chair of dispeptic character, etc. Increase in a liver and spleen is sometimes observed. The Pivkhmichesky centers appear more often on the first — the second month of life. Are more often noted damage of kidneys with the expressed hamaturia (see), purulent meningitis, paraproctitis (see), ulcer nekro-tichesky coloenteritis, osteomyelitis, etc.
Sepsis udety chest age meets less than at newborn and premature. It is shown more brightly, than at premature — high temperature, the toxic phenomena, a high leukocytosis, a neutrocytosis. The heaviest current is observed at bacterial destruction of lungs, acute hematogenous osteomyelitis.
Sepsis udety advanced age meets rather seldom; on clinical manifestations it differs from sepsis at adults a little.
Diagnosis The page at children, as well as at adults, is based on the analysis and comparison of the available displays of a disease (see above) and use of modern laboratory, hardware and tool methods of a research. Pre-natal S.'s diagnosis can be promoted by the data obtained at a research of the pregnant women and women in labor who are previously selected in risk group on possible infection of a fruit, and also a histologic research of a placenta. At sick children make careful searches of the piogenic centers by means of x-ray methods of a research, sometimes punctures with a cytologic and bacteriological research of punctate.
Differential diagnosis carry out with a pre-natal hypoxia and birth trauma (see), pre-natal pneumonia, pre-natal infections — a cytomegaly (see), a toxoplasmosis (see), listeriosis (see) etc. In particular, excretion, high at sepsis, with urine of dezoksi-ribonucleosides can be an early differential diagnostic character in these cases. Careful assessment of clinical features of a disease, data of clinical trial of blood, biochemical and bacteriological researches allows to make the correct diagnosis in most cases.
S.'s Treatment at children, as well as at adults, shall be directed to elimination of the septic centers, performing antibacterial and disintoxication therapy and increase in immunological forces of the sick child. At surgical S. elimination of the septic centers is carried out by operational methods. The piogenic centers demanding an operative measure are localized most often in lungs and a pleura, a peritoneum, a fatty tissue (hypodermic, mediastinums, pararenal), bones and joints, wounds and burn surfaces. Operative measure is carried out right after identification of the center since no intensive care without sanitation of an abscess will bring treatment. Surgical tactics depends on age of the child and the nature of purulent process.
At newborns are limited to the minimum volume of intervention. At peritonitis it is more reasonable to make a laparotomy only at detection of perforation. At phlegmon, edges has necrotic character at this age, carry out small cuts of skin (see. Phlegmon, newborns ). At otitis are rather effective a paracentesis (see) and an antropunktion (see). Sparing shall be also the draining acute hematogenous osteomyelitis operations (see). At the bacterial destruction of lungs observed by hl. obr. children of the first months have lives, apply drainage of a pleural cavity (see. Aspiration drainage) and temporary occlusion of a bronchial tube (bronkho-blokation) of the struck share. The good effect can be gained at an uncomprehensive thoracotomy (see), at a cut make release of a lung from commissures and a pnevmoabstses-sotomiya.
At children of more advanced age for sanitation of suppurative focuses resort to more extensive interventions. Diffuse peritonitis operation shall be radical, to-ruyu, as a rule, end washing of an abdominal cavity antiseptic solutions (see. Peritoneal dialysis). Sanitation of suppurative focuses in soft tissues, bones and serous cavities by methods of single or long washing by antiseptic solutions is effective. Treat long flowing washing from trepanation openings of the centers of hematogenous osteomyelitis, joint cavities at purulent arthritis such methods, deep piogenic zatek in soft tissues, postoperative wounds.
In postoperative period (see) control a condition of a wound, look for and sanify possible new suppurative focuses.
Children shall have a multidimensional general treatment of S. Antibacterial therapy is carried out taking into account data of a microbiological blood analysis, punctate, pus from the center opened during an operative measure, etc. The rational combination and timely replacement with one others shall be philosophy of prescription of antibiotics. Duration of each course shall not exceed 10 — 14 days. The best combinations are erythromycin with Monomycinum, erythromycin with streptomycin, Oleandomycinum with tetracycline, Oletetrinum with Sigmamycinum. Penicillin in usual therapeutic dosages without combination to other antibiotics shall not be applied at a staphylococcal infection as nearly 80% of stafilokokk are steady against it, however there is a positive experience of use of high doses of penicillin (200 000 PIECES on 1 kg of weight a day in 3 — 4 injections, a course 5 — 7 days) at severe forms staphylococcal S. Effektivna semi-synthetic penicillin (Methicillinum, Oxacillinum, orbenin, tselbenin), to-rye are not inactivated by a penicillinase of staphylococcus. For the purpose of prevention of a fungal infection at a long antibioticotherapia (over 2 — 3 weeks) appoint nystatin.
Need of long infusional therapy forces to catheterize the central veins (see Catheterization blow puncture). It allows to recover vodnoelektrolitny balance, to provide parenteral food, to enter pharmaceuticals, etc.
For the purpose of a detoxication enter low-molecular solutions (reopo-liglyukin, Haemodesum), carry out an artificial diuresis; the good medical effect is gained at hemosorptions (see). Appoint drink of 5% of solution and daily intravenous administration of 20% of solution of glucose, every other day pour in plasma, Ringer's solution, etc. during the entire period of toxicosis. In an initial stage of toxicosis carry out hormonal therapy (Prednisolonum on 1 mg on 1 kg of weight a day, within 5 — 6 days, etc.). At sharply expressed toxicosis use neuroleptics (aminazine, etc.).
For increase in immunobiological forces of an organism appoint hemotransfusion, injection of plasma, gamma-globulin; carry out a hematotherapy; appoint B12 vitamins, V of B2, B6, C, nukleinovokisly sodium, pentoxyl, etc. As specific immunotherapies (see) use (depending on an etiological factor) staphylococcal gamma-globulin, staphylococcal plasma, plasma, antibody-containing against a pyocyanic stick, a colibacillus, native staphylococcal anatoxin (children after 3 weeks have lives), etc. For the purpose of desensitization of an organism appoint Dimedrol or Pipolphenum.
For prevention and treatment of a syndrome of the disseminated intravascular coagulation enter heparin to provide increase in a blood clotting time twice in comparison with time of coagulation at the healthy child.
From the first days of treatment appoint cardiacs: at the expressed tachycardia — strophanthin with glucose intravenously, no more than 2 times a day, Cordiaminum subcutaneously 2 — 3 times a day (in the presence of indications it is possible for a thicket), at slackness of the child — caffeine inside or subcutaneously 2 — 3 times a day.
In fight against respiratory insufficiency the leading place is taken air-cure (see) and oxygen therapy (see). At newborn and premature at sharp respiratory insufficiency begin with an oxygenotherapy (giving the moistened oxygen via Bobrov's device, use of an oxygen tent, etc.), and then pass to an air-cure.
The air-cure to winter time is carried out in the conditions of the warmed verandahs or walking rooms; time of stay in them is gradually increased (from 15 — 25 min. till 1 — 2 o'clock, 2 — 3 times a day).
At staphylodermas (vezikulo-pustulez, abscesses of skin) physiotherapeutic methods use (UF-radiation, UVCh, medical bathtubs, etc.). Physiotherapeutic hmetoda apply also at a tendency of pneumonia to a long current, to acceleration of a rassasyvaniye of plevrokostalny imposings, at diseases of an umbilical wound (the becoming wet navel, an omphalitis), etc.
The correct feeding and care of children (see the Baby) are of great importance as these factors are one of leaders in increase in body resistance of the child. At sharply expressed respiratory insufficiency feeding should be carried out by the decanted breast milk from a spoon. Restriction of amount of food is made only at dispeptic frustration.
The forecast, Prevention
the Forecast at S. at children depends on virulence of activators, a condition of immunobiological forces and age of the child, timeliness of N of adequacy of treatment. At modern diagnostic methods and S.'s treatments the forecast improves, however remains still serious, especially at newborns and even more at premature.
S.'s prevention at children begins in clinic for women during overseeing by the pregnant woman (see Patronage). Recommend to the pregnant woman good nutrition, vitamins, observance of the mode and sufficient stay in the fresh air that promotes maintenance of immunity; reveal purulent diseases and timely appoint complex treatment.
In a maternity home include strict observance of the sanitary and hygienic and anti-epidemic mode in measures of prevention. Newborns and their mothers are provided with individual sets of linen and blankets. The employees who got sick with acute respiratory, pyoinflammatory and other diseases are discharged of work; women in childbirth and newborns with these diseases are isolated. Personnel and patients for the prevention of dispersion of microbes at cough, sneezing and a conversation use polymeric masks. Carry out fight against a carriage of polygenic strains of staphylococcus at medical personnel. For creation of rather intense active anti-toxic immunity against staphylococcus to pregnant women of risk group (from 32nd week of pregnancy) enter staphylococcal anatoksinony
After an extract from maternity at home preventive actions the district doctor and the patronage sister spend, to-rye watch the organization and the correct carrying out feeding and observance of the sanitary and hygienic mode, and also early detection and treatment gnoynyd the centers of local localization.
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M. I. Lytkin; G. D. Ovrutsky (ostomies.), B. L. Gurtova (gin.), I. I. Zolotarev (Ur.), T.E. Ivanovskaya (stalemate. An. sepsis at children), R. I. Kai, D. S. Sarkisov (a stalemate. An.), O. S. Misharev (it is put. hir.), V. T. Palchun (ENT SPECIALIST), V. I. Pokrovsky (inf.), V. A. Tabolin (sepsis at children), M. A. Tsivilko (psikhiat.).