Treatment of septic shock

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

Carrying out therapeutic measures requires constant (preferably monitoring) observation. It is necessary to carry out mandatory monitoring of body temperature, skin condition, respiratory rate and pulse, CVP and hematocrit indices, ECG, hourly diuresis, acid-base and electrolyte composition of plasma, proteinogram, content of nitrogenous wastes and bilirubin in the blood, coagulogram. It is desirable to determine the BCC and the value of cardiac output: Treatment is carried out in a comprehensive manner. It is aimed at combating shock and infection, preventing and treating complications of septic shock: acute renal and respiratory failure and bleeding due to disorders of the blood coagulation system.

Shock management should focus on restoring tissue blood flow, correcting metabolic disturbances, and maintaining adequate gas exchange.

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

Since hypovolemia occurs quite early in septic shock, which is a consequence of the discrepancy between the capacity of the vascular bed and the volume of the BCC, the fight against shock primarily consists of replenishing the BCC.

Dextran derivatives (400-800 ml of rheopolyglucin and/or polyglucin) and polyvinylpyrrolidone (400 ml of Hemodez) are preferable as infusion media at the first stages of treatment. These drugs restore and improve the rheological properties of blood and thereby help reduce viscosity, eliminate stasis and aggregation of formed elements, and improve microcirculation. In addition, these blood substitutes significantly increase the BCC by attracting interstitial fluid. An important advantage of these infusion media is their ability to adsorb toxins and remove them from the body.

Gelatin solutions, especially decalcified gelatinol, which can be administered up to 1000 ml, find their place in infusion therapy for septic shock. This drug is well tolerated by patients, can be mixed with donor blood in any proportions without causing erythrocyte aggregation, and is quickly excreted by the kidneys, facilitating detoxification.

When performing infusion therapy in shock patients, it is necessary to adhere to average doses of plasma substitutes, because in case of overdose, undesirable side effects of these media may appear. Large-molecular dextrans are capable of blocking the reticuloendothelial system, low-molecular ones - causing osmotic nephrosis. Gelatinol can promote the release of histamine and have an aggregating effect on blood cells.

To increase colloid-osmotic pressure for the purpose of transporting fluid from the interstitial space into the bloodstream, protein preparations are used: 400 ml of 5-10% albumin solution, 500 ml of protein. These preparations eliminate hypoproteinemia, which is always present in septic shock, and also have a pronounced detoxifying effect. Transfusion of dry and native plasma is useful, which maintains osmotic pressure well and thereby promotes the restoration of the BCC.

Blood transfusions are not the primary means for eliminating hypovolemia in septic shock. Blood transfusion, or better yet, red blood cell mass, is necessary if the hematocrit index is below 30. Usually, a small amount of blood or red blood cell mass is administered no later than the 3rd day of storage (300-500 ml). Blood transfusions are carried out in parallel with the infusion of rheologically active plasma substitutes or crystalloid solutions in the hemodilution mode. The best effect is achieved by using "warm" heparinized blood. If septic shock is combined with bleeding, then blood transfusions should correspond to the degree of blood loss.

Infusion therapy includes 10% or 20% glucose solution in the amount of 300-500 ml with adequate doses of insulin. The advantage of concentrated glucose solutions is that they, while replenishing the body's energy expenditure, simultaneously have an osmotic diuretic property, which is important in the treatment of patients with septic shock.

The rate and amount of infused fluid depend on the patient's response to the therapy. Pulse, arterial pressure, central venous pressure, and minute diuresis should be assessed after infusion of every 500 ml of fluid. The total amount of fluid during the first day is usually 3000-4500 ml, but can reach 6000 ml. The volume of infusion media should be compared with diuresis, fluid loss through the skin and lungs (700 ml - 400 ml for each degree of increase in body temperature), vomit, etc.

The main clinical criteria indicating the elimination of hypovolemia and restoration of the circulating blood volume are normalization of skin color, optimal CVP values (5.0-100 mm H2O), sufficient diuresis (more than 30 ml/h without the use of diuretics, 60-100 ml/h - with forced diuresis). If possible, it is desirable to determine the circulating blood volume and the value of cardiac output. Blood pressure in septic shock can remain at relatively low values for a long time - 90 mm Hg. There is no need to force its increase by all means if there are signs of improved microcirculation (skin color, sufficient hourly diuresis).

Against the background of replenishment of the BCC and improvement of the rheological properties of the blood, it is necessary to use cardiac and vasoactive agents to correct hemodynamics and restore tissue blood flow. Cardiac glycosides are administered intravenously together with 20 ml of a 40% glucose solution in the usual doses: 0.5-1 ml of a 0.05% strophanthin solution, or 0.5-1 ml of a 0.06% corglycon solution, or 1-2 ml of a 0.02% celanide (isolanide) solution, 1-2 ml of a 0.025% digoxin solution. After eliminating hypovolemia, it is advisable to use a 0.5% curantil solution, which, due to a possible decrease in systemic arterial pressure, should be administered slowly in an amount of 2-4 ml. Curantil dilates the coronary vessels, increases myocardial tolerance to hypoxia and, in addition, inhibits platelet aggregation.

Small doses of dopamine (dopamine) are used successfully. This drug increases blood pressure, increases heart contractions and increases cardiac output. In addition, small doses of dopamine (1-5 mcg / (kg • min) reduce renal vascular resistance, increase renal blood flow and glomerular filtration, which increases the effectiveness of the drug in septic shock. 5 ml of 0.5% dopamine solution is diluted in 125 ml of isotonic sodium chloride solution or 5% glucose solution and administered intravenously very slowly at 2-10 drops per minute.

After replenishment of the BCC volume, with persistent vasomotor collapse, a slow drip of angiotensinamide can be used (carefully). Usually, the infusion of the drug is started at a rate of 3-5 mcg/min, increasing the dose to 10-20 mcg/min if necessary. When the desired effect is achieved (increase in blood pressure to 90-100 mm Hg), the administered dose can be reduced. To prepare a concentration of 1 mcg/ml, 1 vial (1 mg) of the drug is dissolved in 1000 ml of isotonic sodium chloride solution or 5% glucose solution, and for a concentration of 2 mcg/ml - in 500 ml of solvent.

In the treatment of septic shock, vasodilators such as euphyllin, papaverine, no-shpa or complamine are widely used to dilate peripheral vessels. These drugs are prescribed after replenishing the BCC with mandatory monitoring of arterial pressure figures. The dosage of the drugs is usual: 5-10 ml of a 2.4% solution of euphyllin, 2 ml of a 2% solution of papaverine. 2-4 ml of a 2% solution of no-shpa. Complamine very actively dilates arterioles and venules. At the same time, along with a decrease in peripheral resistance, the cardiac output increases. A 15% solution of the drug in an amount of 2 ml is administered intravenously very slowly.

Beta-blockers such as anaprilin or oxyprenolone improve blood circulation in the lungs, in the abdominal organs, optimize coronary blood flow, and facilitate the closure of arteriovenous shunts. These properties of the drugs have been tried to be used in the treatment of patients with septic shock. However, the negative inotropic and chronotropic effects on the heart limit their scope of application.

The issue of using corticosteroids for the treatment of septic shock continues to be debated. Literature data and our own clinical experience support these drugs. Corticosteroids not only improve hemodynamics, but also have a positive effect on many pathogenetic links of septic shock. Glucocorticoids, increasing cardiac output, optimize cardiac activity; having a moderate vasodilatory property, improve microcirculation; reducing the flow of tissue thromboplastin and preventing the increase in platelet aggregation, reduce the severity of DIC syndrome. In addition, these drugs weaken the effect of endotoxin, stimulate the activity of enzymes involved in oxidative processes, increase cellular tolerance to oxygen deficiency, promote membrane stabilization, prevent the development of shock lung, and have antihistamine properties.

The anti-shock effect of corticosteroids is manifested when medium and high doses of drugs are administered. 250-500 mg of hydrocortisone is administered at one time; or 60-120 mg of prednisolone, or 8-16 mg of dexamethasone. After 2-4 hours, the administration of the drug is repeated.

The criteria for the effectiveness of including corticosteroids in a complex of therapeutic measures are the general condition of the patient, the color and temperature of the skin, blood pressure and hourly diuresis.

1000-3000 mg of hydrocortisone or equivalent amounts of prednisolone and dexamethasone are administered daily. Such dosages are used for 1-2 days, so there is no need to fear a negative effect of exogenous corticosteroids on the functional activity of the adrenal glands and the immune properties of the body. The lack of effect on significant doses of glucocorticoids (1000 mg of hydrocortisone or corresponding amounts of prednisolone or dexamethasone) indicates advanced irreversible changes in vital organs and is a poor prognostic sign. In such cases, there is no need to continue steroid therapy.

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

Along with normalization of hemodynamics, infusion therapy for septic shock should aim to correct acid-base and electrolyte homeostasis.

In septic shock, metabolic acidosis develops quite quickly, which at first can be compensated by respiratory alkalosis. To correct acidosis, it is necessary to include 500 ml of lactasol, 500 ml of Ringer's lactate or 150-200 ml of 4-5% sodium bicarbonate solution in the infusion therapy. The exact amount of solution is determined depending on the base deficit (-BE).

To improve oxidation-reduction processes, it is recommended to use a glucose solution with an adequate amount of insulin and vitamins: 1-2 ml of 6% vitamin B2 solution, 1-2 ml of 5% vitamin B6 solution, 400-500 mcg of vitamin B12, 100-200 mg of cocarboxylase, 5-10 ml of 5% ascorbic acid solution. It should be remembered that B vitamins cannot be mixed in the same syringe. To improve liver function, in addition to vitamins and coenzymes, it is advisable to use choline chloride in the amount of 200 ml as a 1% solution, 10-20 ml of Essentiale, 2 ml of Sirepar or other hepatotropic agents.

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

In parallel with the restoration of hemodynamic disorders and correction of metabolic disorders, it is of great importance to ensure adequate oxygenation. Oxygen administration should begin from the first minutes of treatment, using all available methods for this, including artificial lung ventilation (ALV). An absolute indication for ALV is a drop in P ₀₂ below 8-9.3 kPa (60-70 mm Hg) during inhalation of 100% oxygen through a mask.

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

If the causative agent of sepsis is known, then targeted therapy, such as antipseudomonal (antipseudomonal) therapy, is carried out. However, in the vast majority of cases, due to the lack of adequate bacteriological testing, empirical treatment of sepsis is carried out, which, due to the prescription of drugs with the broadest possible spectrum of action, is often successful. Thus, initial empirical antimicrobial therapy in patients with sepsis was effective in 91% of cases and was extended after the results of bacteriological blood testing became known.

Treatment is carried out with maximum single and daily doses, its duration is 6-8 days. Treatment is continued until body temperature is normalized for at least 3-4 days. In some cases, it is necessary to change the antibiotic and continue the course of therapy.

Once again, I would like to emphasize that conservative treatment is effective only in the case of surgical sanitation of the purulent focus, and the persistence and, especially, the increase in clinical signs of intoxication and other manifestations of the infectious process against the background of adequate antibacterial therapy may indicate the non-radical nature of the operation or the appearance of large pyemic foci, which requires their identification and sanitation.

In clinical practice, the following drugs or their combinations are successfully used to treat sepsis:

• monotherapy with beta-lactam antibiotics with beta-lactamase inhibitors - TIC/CC - ticarcillin/clavulanic acid (timentin) in a single dose of 3.1, daily dose of 18.6 g;
• third generation cephalosporins in combination with nitroimidazoles, for example, cefotaxime (claforan) + clion (metronidazole) or ceftazidime (fortum) + clion (metronidazole); cefotaxime (claforan) in a single dose of 2 g, a daily dose of 6 g, a course dose of 48 g;
  • aminoglycosides, cephalosporins (III generation), ampicillin + sulbactam, amoxicillin + clavulanic acid, piperacillin + tazobactam, ticarcillin + clavulanic acid.
  • ceftazidime (Fortum) in a single dose of 2 g, daily dose of 6 g, course dose of 48 g;
  • clion (metronidazole) in a single dose of 0.5 g, daily dose of 1.5 g, course dose of 4.5 g;
• combinations of lincosamines and aminoglycosides, for example, lincomycin + gentamicin (netromycin) or clindamycin + gentamicin (netromycin);
  • lincomycin in a single dose of 0.9 g, daily dose of 2.7 g; clindamycin in a single dose of 0.9 g, daily dose of 2.7 g; gentamicin in a daily dose of 0.24 g; netromycin in a daily dose of 0.4 g, course dose of 2.0 g intravenously;
• monotherapy with meropenems, for example: meronem in a single dose of 1 g, daily dose of 3 g; gienam in a single dose of 1 g, daily dose of 3 g.

Along with antibiotics, in particularly severe cases, the use of antiseptics is recommended: dioxidine up to 1.2 g/day - 120 ml of 1% solution intravenously or furagin up to 0.3-0.5 g/day.

Infusion therapy for sepsis is aimed at maintaining circulating blood volume, adequate tissue perfusion, correcting homeostasis disorders and meeting energy needs.

Due to the prevalence of catabolic processes in patients with sepsis, the body's energy needs during parenteral nutrition are 200-300 g of glucose/day with insulin and at least 1.5 g/kg of protein.

They are replenished by infusions of crystalloids (glucose solutions with insulin, glucasteryl, ionosteryl), colloids (mainly solutions of oxyethyl starch-plasmasteryl, 6 and 10% HAES-steryl), solutions of fresh frozen plasma and albumin. The volume of infusions is individual and is determined by the nature of the central venous pressure and the amount of diuresis. On average, 2-2.5 liters of infusion media are administered.

Antibacterial therapy for septic shock is urgent, there is no time to identify the flora and determine its sensitivity to antibiotics, so treatment begins with the introduction of broad-spectrum antibiotics. Dosages are usually significantly higher than the average. Benzylpenicillin sodium salt is administered up to 40,000,000-60,000,000 IU per day intravenously in 2-3 doses. Benzylpenicillin potassium salt is administered intravenously only with laboratory-confirmed hypokalemia. It should be taken into account that 1,000,000 IU of benzylpenicillin potassium salt contains 65.7 mg of potassium, i.e. 25,000,000 IU of the antibiotic can provide the body's minimum daily requirement for potassium.

Semisynthetic penicillins are widely used. Methicillin sodium salt is administered at 1-2 g every 4 hours intramuscularly or intravenously. For intravenous drip infusion, each gram of the drug is diluted in 100 ml of isotonic sodium chloride solution. The maximum daily dose is 12 g. Oxacillin and dicloxacillin sodium salt are used at 1 g every 4 hours intramuscularly or intravenously (for intravenous drip administration, the drug is diluted in 100 ml of isotonic sodium chloride solution), the maximum daily dose is 6 g. Ampicillin sodium salt (pentrexil) is used at 1.5-2 g every 4 hours intramuscularly or intravenously with 20 ml of isotonic sodium chloride solution; The maximum daily dose is 12 g. Carbenicillin disodium salt (pyopen) is administered at 2 g every 4 hours intramuscularly or intravenously in 40 ml of isotonic sodium chloride solution; the daily dose is 12 g.

When choosing a drug, it should be remembered that ampicillin and carbenicillin have the broadest spectrum of action. Methicillin, dicloxacillin and oxacillin are characterized by resistance to penicillinase, therefore they have a pronounced effect on microorganisms that produce penicillinase. Carbenicillin has a bactericidal effect on Pseudomonas aeruginosa, which is resistant to other antibiotics of the penicillin series.

Cephalosporin group drugs are used successfully. Cephaloridine (ceporin), cefazolin (kefzol), cephalexin are prescribed at 1 g every 4 hours or 2 g every 6 hours intramuscularly or intravenously; the maximum dose is 8 g.

Aminoglycoside antibiotics have a broad spectrum of antimicrobial action. The maximum daily dose is: kanamycin sulfate - 2 g (0.5 g administered every 6 hours); gentamicin sulfate - 240 mg (the drug is administered 80 mg every 8 hours); tobramycin sulfate is used in the same doses; amikacin (semi-synthetic kanamycin sulfate) - 2 g (0.5 g administered every 6 hours). Aminoglycosides are usually administered intramuscularly, but in cases of severe sepsis, intravenous drip administration is possible for 2-3 days. A single dose of the drug is diluted in 200 ml of isotonic sodium chloride solution or 5% glucose solution; the rate of administration is 60-80 drops per minute.

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

The dosage of the drugs is largely determined by the excretory function of the kidneys. With normal, and especially high diuresis, the maximum quantities of antibiotics are used.

To enhance the antimicrobial effect and expand the spectrum of action, antibiotics can be combined with each other. When choosing a combination of drugs, it is necessary to take into account the nature of their interaction (indifferent, additive, serotonin or antagonistic), the probable summation of their side effects and the possibility of intravenous administration of at least one of them. The most commonly used combinations of antibiotics are: ampicillin with oxacillin, natural and semi-synthetic penicillins with aminoglycosides, cephalosporins with aminoglycosides, chloramphenicol with gentamicin or lincomycin.

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

As is known, the fight against infection includes the elimination of the source of infection. In surgical practice, the issue of early and complete removal of the septic focus is beyond doubt. It is not so easy to resolve the issue of eliminating the source of infection in gynecological practice if this source is the uterus. Therefore, many highly authoritative authors in shock caused by septic abortion recommend simultaneously with massive anti-shock and antibacterial therapy to perform careful instrumental emptying of the uterus. Other authors believe that manipulations in the uterine cavity adversely affect the course of septic shock and worsen the prognosis. Our experience confirms the danger of such interventions. Of course, the opinion that the constant flow of microorganisms or their toxins into the patient's bloodstream is much more dangerous than their one-time breakthrough during instrumental emptying of the uterus is enticing. However, clinical practice shows that in septic shock, especially developing in the foyer of an out-of-hospital abortion, the infection is rarely limited to the fetal egg. Much more often, myomstriae, uterine veins are involved in the process, or the infection goes beyond the uterus. In such cases, instrumental removal of the ovum does not lead to the desired effect.

Experience in gynecological practice shows that the approach to eliminating the source of infection in septic shock should be strictly individual. In the case of an infected early miscarriage, in the absence of signs of an inflammatory process in the myometrium and outside the uterus, emptying the uterine cavity by gentle curettage is acceptable; curettage is certainly indicated for bleeding that is not a consequence of DIC syndrome. In the case of a late miscarriage, the infected ovum is eliminated by conducting labor-stimulating therapy with intravenous drip administration of oxytocin or prostaglandins; the retained placenta is removed instrumentally.

The most radical way to combat the source of infection is to remove the uterus. This operation should be resorted to when intensive therapy for shock, carried out for 4-6 hours, is unsuccessful. The main difference between septic shock and other types of shock is the rate of development of deep and irreversible changes in vital organs, so the time factor is of crucial importance when treating such patients. Delay in radical removal of the septic focus, associated with both overcoming the moral barrier of the inevitability of uterine removal in young women and the need for surgical intervention in patients in an extremely serious condition, can cost the patient's life. The operation of choice is extirpation of the uterus with removal of the fallopian tubes, drainage of the parametrium and abdominal cavity. In some cases, in patients in an extremely serious condition, in the absence of macroscopically expressed changes in the uterine tissue, supravaginal amputation of the uterus is permissible. Removal of the fallopian tubes and drainage of the abdominal cavity are also mandatory in these cases.

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

Correction of immune disorders in patients with sepsis

Immunotherapy for sepsis is extremely complex and can be effectively and purposefully carried out only with the appropriate immunological studies, preferably by an immunologist, since any link in the immune system or many of its links can be impaired.

In case of deficiency of cellular factors (T-system), it is advisable to administer leukocyte suspension (3-4 doses of 300 ml), human leukocyte interferon at a dose of 10,000-20,000 IU. In case of deficiency of humoral immunity factors (B-system), it is effective to use specific hyperimmune plasma 5-7 ml/kg up to 10 doses per course. For the treatment of combined immunodeficiency, it is recommended to use leukocyte suspension, thymus preparations - T-acgavin, thymalin. In case of combined deficiency of T- and B-lymphocyte subpopulations or an increase in circulating immune complexes in plasma, according to the authors, hemosorption is advisable, which has an immunomodulatory effect.

If the pathogen is known, the use of appropriate specific immunized serums (antistaphylococcal, antipseudomonal) is effective.

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

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

Symptomatic therapy is used in all patients with sepsis. It is individual and includes the use of analgesics, antihistamines, antispasmodics, sedatives, vitamins, coenzymes, agents that improve tissue vascularization and reparation processes, and, if indicated, cardiac, hepatotropic, neurotropic agents.

Elimination of hemocoagulation disorders is achieved by prescribing blood protease inhibitors: gordox at a dose of 300,000-500,000 U, contrical at a dose of 800,000-1,500,000 U, or trasylol at a dose of 125,000-200,000 U per day.

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

Currently, it is more effective to prescribe prolonged low-molecular analogues of heparin - fraxiparin at 0.4 ml once a day or clexane at a dose of 20 mg (0.2 ml) once a day, they are administered subcutaneously in the anterior or posterolateral region of the abdominal wall at waist level. When administering drugs, a number of conditions must be observed: when injecting, the needle must be positioned vertically and pass through the entire thickness of the skin, clamped in a fold; the injection site must not be rubbed. For obese patients weighing more than 100 kg, the doses of heparin and its analogues are doubled.

All patients are prescribed antiplatelet agents. Rheopolyglucin is included in the infusion therapy, and curantil (trental) is also used. The latter is included in the infusion media at an average of 100-200 mg/day, and if necessary (impossibility of using direct anticoagulants), the dose can be increased to 500 mg/day with gradual introduction of the drug.

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

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Extracorporeal methods of detoxification

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

• progression of acute hepatorenal failure;
• toxic manifestations from the central nervous system (intoxication delirium, comatose state);
• ineffectiveness of conservative therapy.

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

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

As stated above, the complex of therapeutic measures for septic shock should include agents that prevent the development of acute renal failure or facilitate its elimination. Prevention of acute renal failure is achieved by rapid and sufficient replenishment of the BCC with the inclusion of rheologically active fluids and agents (rheopolyglucin, polyglucinn, hemodez, trental) in the infusion media, followed by intravenous administration of 10 ml of a 2.4% solution of euphyllin, 2-3 ml of a 2% solution of no-shpa and 40 mg of lasix.

In case of acute renal failure, first aid is provided by a gynecologist together with a resuscitator. The course of further treatment is adjusted by a nephrologist, or the patient is transferred to the appropriate department. Treatment of acute renal failure begins with replenishment of the BCC, for which solutions that improve microcirculation are used: rheopolyglucin, polyglucin, hemodez. Then, agents that relieve vascular spasm are prescribed: 5-10 ml of a 2.4% solution of euphyllin and 2-4 ml of a 2% solution of no-shpa are administered every 4 hours. A glucose-novocaine mixture can be used (250 ml of a 20% glucose solution, 250 ml of a 0.25% solution of novocaine and 12 U of insulin). Diuretics are used in parallel with vasoactive agents. The saluretic lasix is administered at 80-120 mg every 3-4 hours. The fast-acting osmotic diuretic mannitol is administered as a 15% solution in an amount of 200 ml. With a positive diuretic effect, infusion therapy is continued in accordance with the amount of urine excreted. If there is no effect on the administration of mannitol, the rate of fluid infusion must be slowed down and, in order to avoid intercellular edema of parenchymatous organs, osmotic diuretics should not be used again. Persistent anuria with a replenished circulating blood volume dictates a mandatory limitation of the infused fluid to 700-1000 ml/day.

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

Conservative treatment of acute renal failure can be used only with a slow rate of increase in azotemia and dyselectremia. Generally accepted indications for transferring a patient for hemodialysis to the artificial kidney department are: an increase in the serum potassium level to 7 mmol / l or more, urea level - up to 49.8 mmol / l or more, creatinine level - up to 1.7 mmol / l or more, pH less than 7.28, - BE - 12 mmol / l, hyperhydration with pulmonary and cerebral edema.

For the prevention and treatment of acute respiratory failure, the following measures are necessary:

• strict correction of water balance, which consists, on the one hand, in timely replenishment of BCC and, on the other hand, in the prevention or elimination of hyperhydration;
• maintaining the required level of blood oncotic pressure through the administration of protein preparations;
• timely use of corticosteroid therapy;
• mandatory cardiac therapy and the use of vasodilators;
• adequate oxygenation, and if hypoxia increases, timely transition to mechanical ventilation.

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

The DIC syndrome is an important link in the pathogenesis of septic shock, therefore, prevention of bleeding associated with it, including uterine bleeding, essentially consists of timely and adequate treatment of shock aimed at optimizing tissue perfusion. The inclusion of heparin as a specific anticoagulant in the complex of the therapy is not indisputable. Despite all the positive properties of heparin, including its ability to increase the body's resistance to tissue hypoxia and the action of bacterial toxins, the use of this anticoagulant should be strictly individual. Usually, treatment is carried out by a hematologist under the control of a coagulogram, taking into account the stage of DIC and the individual sensitivity of the patient to heparin.

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

Treatment of the late stage of septic shock with the appearance of hemorrhagic syndrome, including uterine bleeding, also requires a differentiated approach. In sepsis, the patient's body, even after the sanitation of the source of infection, experiences a severe double breakdown of hemostasis: widespread intravascular blood coagulation with impaired microcirculation in the organs and subsequent depletion of hemostasis mechanisms with uncontrolled bleeding.

Depending on the coagulogram results, replacement therapy is carried out (“warm” donor blood, lyophilized plasma, dry, native and fresh frozen plasma, fibrinogen) and/or antifibrinolytic drugs are administered (contrycal, gordox).

The criteria for the effectiveness of complex therapy for septic shock are improved patient consciousness, disappearance of cyanosis, warming and pinking of the skin, decreased tachycardia and dyspnea, normalization of central venous pressure and arterial pressure, increased urination rate, and elimination of thrombocytopenia. Depending on the severity of septic shock associated with the characteristics of the microflora and the reactivity of the microorganism, the timeliness of the start and adequacy of the therapy, the normalization of the above indicators occurs within a few hours or several days. However, bringing the patient out of shock should not serve as a signal for the end of intensive therapy for the purulent-septic disease that caused the development of shock. Targeted antibacterial, detoxifying and hemostimulating therapy, replenishment of energy resources and an increase in the body's own defenses, normalization of acid-base balance and electrolyte homeostasis should continue until the infectious process is completely eliminated.

After discharge from the hospital, the patient requires dispensary observation for 5 years in order to promptly identify and treat possible long-term consequences of septic shock: chronic renal failure, Sheehan's syndrome, diencephalic syndrome such as Itsenko-Cushing's disease, diabetes, Waterhouse-Friderichsen syndrome.

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