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Surgical sepsis. Actual trends in ethiopathogenesis and modalities of improvement of the treatment results


Author: Ion Balica
Degree:doctor habilitat of medicine
Speciality: 14.00.27 - Surgery
Year:2008
Scientific consultant: Vladimir Hotineanu
doctor habilitat, professor, State University of Medicine and Pharmacy "Nicolae Testemitanu"
Institution:
Scientific council:

Status

The thesis was presented on the 23 April, 2008
Approved by NCAA on the 19 June, 2008

Abstract

Adobe PDF document1.49 Mb / in romanian

Thesis

CZU 617-089-06: 616.94-091-08

Adobe PDF document 16.00 Mb / in romanian
258 pages


Keywords

severe surgical sepsis, acute phase reaction, proinflammatory cytokines, pleuro-pulmonary sepsis, abdominal sepsis, tegumentary sepsis, septic pulmonary injury.

Summary

The study was performed in the basis of analysis of 2003 patients with severe surgical infections treated in department of thoracic surgery, septic abdominal surgery and septic ICU of Clinical Republican Hospital, Chishinau, Moldova from 1995 to 2005. Case histories were analyzed using definitions adapted at the International Consensus Conferences in 1991 and 2001. Main objective of this work was study of clinical, diagnostic and treatment peculiarities of surgical sepsis with different primary sources in order to improve clinical outcomes. Anatomic stratification of patients produced 3 basic groups: acute pleuro-pulmonary infections - 1389 cases (69,3%), postoperative peritonitis and infected pancreatic necrosis – 486 (24,3%) and skin and soft tissue infections – 128 cases (6,4%). In the total group sepsis was identified in 1330 cases (66,4%), among these patients 968 (72,8% from 1330) had severe sepsis (793 – with organ dysfunction and 175 with septic shock).

Diagnostic complex included clinical examination, repeated chest films and blood biochemical assays, immunological tests of TNFalfa and IL-6, acute phase reactants (protein C, haptoglobin, properdine B, ceruloplasmin, cathepsin G, alfa1-antitrypsin, molecules of middle molecular weight, necrotic substances) in broncho-alveolar lavage fluid and in serum of the patients with pulmonary inflammations and destructions, postoperative peritonitis, infected pancreatic necrosis, skin and soft tissue infections. Dynamic bacteriologic assays from primary and secondary focuses were performed. In cases of lethal outcome morphological examination of organs containing primary and metastatic focuses was performed.

In the general study group males prevailed over females (73%) with average age of 42,4±2,5 years. More then 1/3 of the patients with severe sepsis had serious associated pathologies (according to Charlson score≥6). These conditions included chronic alcoholism, diabetes mellitus, hepatic cirrhosis. Gravity of sepsis was determined using Calf-Calif index (>13), APACHE II score (>20), SAPS II (>38). Organ dysfunction was attested by MOFS score >3 and SOFA score >7. In total study group gram-negative monocultures were predominantly obtained from primary focuses, followed by gram-positives. Positive hemocultures were registered in 15,4% of patients. The most frequently affected organ were lungs(66,7% in the general group), both in patients with insufficiency of a single organ( 64%), and in patients with multiple organ dysfunction(71%). In descending order after lungs follow renal insufficiency, hepatic, gastro-intestinal and brain affect. Septic shock was attested in 9% of patients, more frequently in patients with acute pulmonary destructions.

The study demonstrated differences in clinical presentation, evolution and management of severe sepsis with diverse localization of primary focuses. Thus, the group of pleuro-pulmonary sepsis consisted of patients with acute pneumonias with severe evolution (62), patients with acute gangrenous pulmonary destructions (1029) and with acute pleural empyema in 298 cases. More then 77% of patients form this group were males, with average age of 46,3±1,2 years. From them 28% presented signs of chronic alcoholism. Bacteriologic analysis of the pus from gangrenous abscesses revealed presence of nonclostridial anaerobes in 44% of patients with gangrenous abscesses of lung. Study of the broncho-alveolar lavage fluid in patients with pneumonia and pulmonary abscesses demonstrated presence of neutrophilic alveolitis, more intensive in patients with destructions. Analysis of broncho-alveolar lavage fluid also detected presence of TNF-alfa and propedine B in pulmonary parenchyma comparment. Increased serum levels of reactive protein C, haptoglobin, ceruloplasmin, cathepsin G, alfa1-antitrypsin, IL-6, TNF-alfa in patients with pulmonary destructions confirm presence of acute phase reaction in these conditions. All patients with acute pulmonary destructions (APDs) showed increased concentrations of immunoglobulins A, M, G and CH50, whereas in the group of deceased patients serum levels of immunoglubulins and CH50 were decreased. Levels of circulant immune complexes raised in patients with APDs and remained increased in deceased patients. Statistic seminification had decrease of Ttotal and Blimf in patients with APDs versus controls. The measure of systemic response to pulmonary sepsis is characterized by values of ILI>14, APACHE II score >20, SAPS II score >37, MOSF, SOFA. The extrapulmonary affect was registered in kidneys, liver, brain and hematopoietic system.

The second group – abdominal sepsis – was consisted of patients with postoperative peritonitis and infected pancreatic necrosis. Among them 24% had sepsis, 68%- severe sepsis and 8% - septic shock. Pulmonary affect is characteristic for patients from this group. It was diagnosed in 54% of patients with postoperative peritonitis and in 87% with infected pancreatic necrosis. In these patients pleuro-pulmonary lesions appeared in the interval of 2-50 days after the onset of disease and presented diagnostic and prognostic value in abdominal sepsis. In this group males prevailed over females, with average age of 45 years and mean number of laparotomies was 3-4 for each patient. Patients with hepatic cirrhosis (Charlson score >6) showed predisposition for septic evolution of peritonitis. Severity criteria of physiological derangement were following: ILI >11, APACHE II >23, SAPS II>37, MOSF >4, SOFA >8.

Patients with infections of skin and soft tissues had septic evolution in 37,5% of cases, among these cases severe sepsis developed 62,5% of patients (inclusively 20,3% as septic shock). Presence of staphylococcal bacteremia was characteristic for this group (in 95,6% of survivors and in 36% of deceased). In 1/3 of these patients septic embolism from primary and secondary foci was demonstrated (regional purulent thrombophlebitis, acute bacterial endocarditis). Severity of sepsis in this group was attested using following values of clinical scores: APACHE II >17, SAPS II >32, MOSF >3, SOFA >6.

Analysis of the risk factors for lethality in septic patients permits to clarify modalities of imporvement of treatment results in actual clinical environment. Among these modalities we mention: monitorization of SIRS criteria in all patients with inflammatory/purulent surgical diseases, immediate transfer of patients with documented sepsis in ICU, early sanation of primary and secondary focuses, adequate antibiotic therapy, maximal avoidance of reinterventions and mechanical respiration, adherence to recommendations of International Consensus guide of management of severe sepsis and septic shock, rapid discharge of patients from intensive care departments.