The influence of the key provisions of International Guidelines for Management of Severe Sepsis and Septic Shock: 2012 with additional enteroprotection on the course of septic process and severity of encephalopathy in the structure of multiple organ failu

L.А. Maltseva, N.F. Mosentsev, V.N. Lisnichaya, L.A. Yutkina

Abstract


Research purposes: to explore the influence of the key aspects of International Guidelines for Management of Severe Sepsis and Septic Shock: 2012 with additional enteroprotection on the course of sepsis and severity of encephalopathy in the structure of multiple organ failure. Materials and met­hods. In order to build a medical form of the basic sepsis therapy, which is based on the medical principles of evidence, it is necessary to use the components, which have already confirmed their importance: early diagnosis of the generalization of infectious process; surgical sanitation of septic areas; rational antimicrobial chemotherapy, modern and timely support or prosthesis of diseased organs and systems, and nutritional support. High sorption activity, modeling of the structure of chymus, which is significant for the prosthetics of the barrier function of the gastrointestinal tract, positive dynamics of the enterocyte metabolism, stimulation of motor function, as a preparatory stage before the initiation of early enteral nutrition, are the pathophysiological factors for the use of the natural pectin sorbents with the purpose of enterosorption. Twenty five patients were involved into the research for the analysis. CI-DO2-VO2 parameters were studied, as well as indicators of septic severity, multiple organ failure, systemic inflammatory response syndrome, dynamics of cytokine concentration: tumor necrosis factor α, interleukin 1 (IL-1); IL-4; interferon α; immunoglobulins (Ig): IgA, IgM, IgG. The research was conducted on days 1, 3, 5, 7 and 28. Statistical analysis results are based on parametric T-test by Student and non-parametric T-test by Wilcoxon. Results. Clinical observation of the patients’ condition till day 28 of the disease revealed that the gastrointestinal tract plays an important role in the development of the multiple organ failure. Restoration of the nutritional function in 17 patients resulted in a rapid regression of the multiple organ disorders and a subsequent recovery. Pectin sorbent enteroprotection prevented a massive inflow of endotoxin and repeated injury of the vascular endothelium of target organs; therefore, multiple organ failure in this group was of sanogenetic nature. Presence in pectin sorbents of antioxidant micronutrients increased the resistance of vessel walls to the action of the oxidants and contributed to the regeneration of the enterocytes, but this effect was non-significant, so, the use of sorbents was not effective in patients with acute erosions and ulcers of the gastrointestinal tract, as well as for prevention of gastrointestinal bleeding, even in the combination with proton pump inhibitors. Bacteriological efficiency of the treatment was evalu­ated as eradication of pathogen in 9 patients, relapse — in 6, and re-infection in 5 patients. Conclusions. Summing up the results of the research, we can confirm that despite the recovery of overall oxygenation in the conditions of supranormal DO2-VО2 values, on days 3–5 four criteria of the systemic inflammatory response were detected, which was considered by us as the probability of the risk of delayed regression of systemic syndrome, and of the inflammatory response, subsequently. It was confirmed clinically on the 7th day by two criteria (leukocytes — 15.18 · 109/l; juvenile forms — 11.88 %). Points of AРACHE II and SOFA having decreased compared to background values on the 5th day, “froze” on day 7. On the 7th day, neurological symptoms were considered as semi-coma — 10.88 points. Highest concentration of pro-inflammatory cytokines on day 5–7 of the study can be explained by their reperfusion origin after the resumption of splanchnic circulation. The anti-inflammatory IL-4 on the 7th day remained below the level of 29.27 %, however, it was still higher than its normal level on the 5th day by 77.42 %, which could be indicated as a positive dynamics. On day 7 of the study, the concentrations of IgA and IgM increased, while IgG was reducing, and reached its minimum content for the entire study period — 11.30 g/l. The intensive care treatment, based on the key aspects of International Guidelines for Management of Severe Sepsis and Septic Shock: 2012 with additional enteroprotection, has a positive impact on the course of sepsis and severity of encephalopathy in the structure of multiple organ failure: on the 28th day from the beginning of the disease, 11 patients have died, predicted mortality rate was 51 %, true mortality rate is 35.5 %. So, we achieved reduction in the predicted mortality rate by 15.5 %.

Keywords


septic process; encephalopathy; multiple organ failure; enterosorbent

References


Dellinger K.P., Levy M.M., Carlet J.M., Bion J. et al. Surviving Sepsis Campaign: International guidelines for management of sever sepsis and septic shock: 2012 // Crit. Care Med. — 2013. — 41(2). — Р. 580-637.




DOI: https://doi.org/10.22141/2224-0586.3.82.2017.102320

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