Basic Terms and Definitions 1.

Surgical infection and inflammation Infection is an process in which bacteria penetrate through the barriers (contamination), develop and divide (cell cycle), suppress the defensive mechanisms and thus disseminate; Inflammation is local, multiple stage, stereotyped process; 2. Systemic dissemination of the pathogen and mediators may result in: - Systemic inflammatory response syndrome; - or Sepsis. 3. Systemic inflammatory response syndrome (SIRS): is an inflamatory state of the whole body (the "system") without a proven source of infection. 3.1. Cause systemic dissemination of bacteria, their products and mediators; 3.2. Pathology bacteria are destroyed in circulation: - culture of blood negative! - distant infection may be the result (hematogenous); The diagnosis of SIRS is manifested by 2 or more of the following criteria: - temperature above 38C or below 36C; - Heart Rate above 90 beats/min.; - Respiratory rate above 20 breaths/min or parcial pressure of CO2 below 4.3 kPa - WBC count > 12 000/l or <4 000/ l; 4. Sepsis SIRS + infection = sepsis 4.1. Definition is the presence of SIRS resulting from vital pathogenic bacteria and their toxins in the blood and tissues; 4.2. Main types of sepsis according to its characteristics are septicemia and septicopyemia.: septicemia is a systemic disease caused by the multiplication of microorganisms in circulating blood (blood poisoning); While septicopyemia is the presence of septicemia plus formation of multiple abscesses in parenchimatous organs; bacteriaemia - transient presence of bacteria (or other microorganisms) in the blood 4.3. Main types of primary focus causing sepsis: infected wounds; local infectious processes furuncle, carbuncle, abscess, phlegmon, purulent arthritis, osteomyelitis, thrombophlebitis; other purulent infections peritonitis, pleuritis, pulmonary gangrene, urological infections, gynecological infections, etc.; cryptogenic sepsis a form of sepsis in which no primary focus of infection can be found (but this does not mean that the primary locus does not exist); 4.4. Main types of sepsis (in different medical disciplines): surgical sepsis a result of trauma, acute and chronic purulent infections, diagnostic/operative procedures; in obstetrics and gynecology: - puerperal after delivery; - gynecological purulent salpingitis, endometritis, diagnostic/operative procedures; - neonatal sepsis of the newborn; - fetal sepsis of the fetus; urological sepsis after acute purulent pyelonephritis, paranephritis, diagnostic and surgical procedures; odontological sepsis in dentistry; in ENT-diseases; others. Etiology and pathogenesis of sepsis 1.Primary focus- The primary focus of infection is needed for the development of sepsis. 2.Microorganisms/ he usually isolated Microorganisms in the case of sepsis are/ 2.1. Staphylococci in 60% of cases; 2.2. Streptococci in 25% of cases; 2.3. Proteus, pseudomonas, E.coli, others; 3.Factors in the pathogenesis of sepsis:

3.1. Microbial factor include the type, pathogenicity, virulence and number (> 100 000/gr. tissue) of bacteria that could cause sepsis; 3.2. Primary focus include a large infected wound or untreated severe purulent process. 3.3. Host defensive reactions include age and predisposing diseases of the macroorganism. 4. Main steps in the development of sepsis: 4.1. Microorganisms enter the regional blood vessels; 4.2. Some of them are destroyed, but many remain vital; 4.3. Grosser and medium sized blood vessels are not the good environment for microorganisms; 4.4. Thats why they stop and develop in microcirculation arterioles, capillaries (mainly) and venules; 4.5. In septicemia Streptococci release streptokinase stops transformation of fibrinogen into water-soluble fibrin no abscesses are formed; 4.6. In septicopyemia Staphylococci release staphylocoagu-lase coagulation is activated small coagula are formed containing fibrin, Thr and bacteria abscess formation in the lungs, liver, brain, kidneys, bones, etc.; 4.7. Bacteria and their toxins with the disturbed microcirculation cause hemorrhage, dystrophy and necrosis in tissues and organs; 4.8. The final result of 4.7. is: - MODS multiple organ dysfunction syndrome; Severe sepsis is sepsis+ multiple organ dysfunction syndrome - MODS leads MOF multiple organ failure. Septic shock is a serious condition that occurs when an overwhelming infection leads to life-threatening low blood pressure. Septic shock occurs most often in the very old and the very young. It also occurs in people who have other illnesses. Risk factors for septic shock include Diabetes AIDS Indwelling catheters Leukemia Long-term use of antibiotics Lymphoma Recent surgery or medical procedure Pathological findings in sepsis 1.Local pathological findings 2.General pathological findings: 2.1. Skin and subcutaneous adipose tissue jaundice, hematoma; 2.2. Respiratory system hemorrhagic pneumonia; 2.3. Cardiovascular system dystrophy of myocardium, vasculitis and necroses of the vascular wall; 2.4. Liver dystrophy and septic hepatitis; 2.5. Spleen and lymph nodes splenomegaly and lymphadenomegaly, necrotic changes; 2.6. Kidneys - septic nephritis and renal necroses; General symptoms: 1.1. Poor general condition, weakness, loss of appetite, headache, nausea, vomiting; 1.2. Neurological and mental disturbances to coma; Hot, dry skin with multiple petechia and hematoma; /raising/T: in septicemia up to 39 - 40C in septicopyemia up to 41C HR, RR, hepato- and splenomegaly, signs of hepatic and renal dysfunction; 2. Local signs those of the primary focus, but they become of small importance; 2.1 hypotrophic granulations ; 2.2. the Secretion from the primary focus could be decreased to absent; 2.3. Treatment is without effect, and the process of wound healing is delayed/stopped; Laboratory tests in sepsis 1. Blood culture positive; . Positive Blood culture from the blood samples that are collected before the peak of febris;

2. Signs of infection - increased WBC, Neutr., elevated sedimentation erythrocytes rate-SR; 3. Signs of: - anemia - decreased Er,lowHb,Ht,; - respiratory dysfunction - PaO2, PaCO2, pH - hepatic dysfunction - bilirubin, elevated ASAT, ALAT; - renal dysfunction -elevated urea, creatinine; - coagulation disturbances, etc. Treatment of sepsis The aim of the treatment of sepsis is to control the primary infection, the bacteria that caused the sepsis, and to support the vital finctions. 1.Surgical treatment of the primary focus -incision and surgical drainage of infected fluid collections 2. The Treatment against the causal microorganism include use of - antibiotics; - immunotherapy; 3. Support of vital functions: - correction of dehydration - infusional therapy including blood and plasma transfusions; - correction of dyselectrolitemy, acidosis, hemostasis; -also cardiotonics, hepatic protectors, diuretics, etc.