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INFECŢIILE ÎN CHIRURGIE
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DEFINITIE
INFECTIA Ansamblul manifestarilor locale si generale anatomo-clinice care apar în urma patrunderii si multiplicarii bacteriilor în organism.
INFECTIA CHIRURGICALA se caracterizeaza prin reactii locale însotite de fenomene clinice generale, în urma patrunderii microbilor aerobi sau anaerobi în tesuturi, printr-o poarta de intrare creata prin
diferite solutii de continuitate.
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Caracteristici ale infectiilor chirurgicale
:
- focarul infectios este de regula evidentiat la examenul clinic sau prin investigatii paraclinice ;
- focarul infectios susceptibil de a fi tratat chirurgical prin : incizie, excizie si drenaj ;
- infectia chirurgicala are un caracter invaziv prin difuziune din focarul infectios într-o anumita regiune a organismului sau în tot organismul;
- infectia chirurgicala este de obicei polimicrobiana prin asociere de mai multti microbi ;
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PATOGENIE
- factori favorizanti (diabetul, denutritia, hemoragiile, tesuturi devitalizate, intoxicatiile, vârsta, surmenajul, oboseala, subnutritia, restrictii alimentare prelungite);
- factori determinanti (prezenta bacteriilor si realizarea pragului infectios, existenta portii de intrare care poate fi accidentala sau operatorie);
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PATOGENIEContaminarea reprezinta prezenta germenilor patogeni vii la un anumit nivel:
- indirecta (prin depunerea microorganismelor din aer pe suprafata plagii ) ;- directa (prin venirea în contact a plagii cu microorganismele respective) .
Contaminarea se realizeaza cel mai adesea în urma traumatismelor care creeaza poarta de intrare pt. germeni, cât si conditiile favorabile dezvoltarii acestora .
O infectie chirurgicala acuta poate avea si o cauza endogena : însamântarea cavitatilor seroase cu germeni proveniti de la tubul digestiv.
Pentru trecerea de la contaminare la infectie sunt necesare 3 conditii : - agresivitatea crescuta germenilor contaminanti ; - conditii favorabile pt. multiplicare ;- incompetenta imunologica locala / sistemica .
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PATOGENIEIncubatia : perioada de incubatie - perioada din momentul contaminarii pâna la aparitia
primelor semne subiective si obiective sesizabile clinic.
Semnele si simptomele procesului inflamator : - locale :
- rubor ( roseata) expresia vasodilatatiei locale; - tumor (tumefactie) acumularea exudatului si în cele din urma a
puroiului; - dolor ( durere) excitatia supraliminara a terminatiilor nervoase din
tesuturi - calor ( cald) reflecta activitatea fluxului sanguin; - functio laesa ( afectarea functiei) - fluctuenta -senzatia de lichid la palparea bidigitala sau bimanuala;
- regionale : - evolutia catre fenomene inflamatorii regionale ale sistemului limfatic; - apar ca urmare a difuziunii germenilor si a toxinelor lor de la locul infectiei ( limfangita, adenita, adenoflegmon);
- generale : sunt reprezentate de ascensiunea termica; frison, tahicardie, alterarea starii generale (astenie, adinamie, inapetenta, insomnie).
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PATOGENIEA. Agentul patogen:
Orice microorganism poate determina o infectie chirurgicala.
Cel mai frecvent germeni incriminati sunt:
Aerobioza Stafilococul auriu - infectii ale plagilor
Klebsiella - cavitate peritoneala, tesuturi enterice
Echerichia Coli - asociata cu germeni anaerobi
Streptococus – aerob.
Anaerobioza Streptococus anaerob, Bacteroides, Clostridium, Pseudomonas
Fungi: Histoplasma, Candida, Actynomyces
Paraziti: Taenia Echinococus, Amoebe.
Germeni specifici: Bacilul Koch
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2.Imunitatea nespecifica:
Polimorfonucleare : depisteaza, inglobeaza, distrug germenii.
Granulocitopenia
Deficit chemotactic infectii bacteriene grave, septicemie
PATOGENIE
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PATOGENIEB. Gazda susceptibila
1.Imunitatea specifica:
•depistarea Ag,
•procesarea acestora de catre macrofage,
•activarea limfocitelor T si B,
•sinteza anticorpilor specifici.
Imunitatea specifica – mediata celular
- mediata umoral
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3.Anergia
– absenta reactiei inflamatorii cutanate (IDR).
(pacienti imunodeprimati – infectii severe)
Fenomenele imunologice antimicrobiene sunt diminuate sau absente.
Cauze:
•Limfocite T si B defective;
•Exces de agenti antiinflamatori (corticoizi);
•Procesare defectuoasa a antigenelor;
•Populatie crescuta de limfocite T supresoare;
Conditii favorizante: malnutritia, tulburari de leucotaxie;
PATOGENIE
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4. Deficitul imunitar in afectiuni metabolice (diabet)
Modificari ale leucocitelor:
•Deficit de aderenta si migratie leucocitara prin endoteliul vascular.
•Deficit de actiune bactericida
PATOGENIE
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C. Spatiul inchis
Majoritatea infectiilor se dezvolta in spatii inchise, cu vascularizatie precara (plagi, cavitati naturale)
Conditii locale determinante:
• perfuzie tisulara diminuata
•hipoxie tisulara
•hipercapnie
•acidoza.
Corpii straini, tesuturile devitalizate si traumatismele predispun la infectii.
Fibrina constituie mediu de cultura pentru bacterii – favorizeaza formarea abceselor.
PATOGENIE
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Raspunsul acut la infectii-mediatorii inflamatiei
Reactii sistemice– febra, leucocitoza, anemie, hipergamaglobulinemie,
1) factorului de necroza tumorala,
2) interleukina 1.
Sunt sintetizate de fagocitele ce vin in contact cu tesuturile lezate,bacterii sau toxine bacteriene.
3) PGE2
Sintetizata de hipotalamusul anterior
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Infectiile chirurgicale - initial localizate.
Mecanisme de extindere:
Infectii necrozante: se raspandesc in lungul structurilor anatomice (ex fasceita necrozanta); factorul determinant este o toxina ce determina tromboza microvasculara, necroza tisulara etc.
Abcese: toxine microbiene + enzime lizozomale leucocitare = distructii tisulare si extinderea focarului infectios.
Flegmoane, celulite:
Putin puroi si mult edem tisular la nivelul tesutului adipos; extindere din aproape in aproape.
Raspunsul acut la infectii-mediatorii inflamatiei
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CLASIFICARE
Infectii chirurgicale aerobe locale:- abcesul- flegmonul- erizipelul traumatic
Infectii chirurgicale aerobe generale:- septicemia- piemia
Infectii chirurgicale anaerobe:- gangrena gazoasa- tetanos
Infectii chirurgicale specifice:- actinomicoza- actinobaciloza
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Diseminarea prin sistemul limfatic.
Streptococul si Stafilococul disemineaza prin vasele limfatice: determina limfangita vizibila sub forma de trenee congestive subcutanate.
Diseminarea prin curentul sanguin.
Erodarea vaselor sanguine: diseminare (bacteriemie, septicemie) cu metastaze septice – endocardite, abcese pulmonare, cerebrale, hepatice.
Diseminarea prin cavitati preformate
Seroasa peritoneala, pleurala, etc.
DISEMINAREA INFECTIEI CHIRURGICALE
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Fistule – deschiderea spontana a unei colectii septice si evacuare in-completa, formarea unui traiect cu supuratie si drenaj cronic.
Intarzierea cicatrizarii: secretia de interleukina 1 de catre bacterii cu activarea proteolizei (colagenaza) cu intarzierea sau oprirea procesului de cicatrizare.
Imunosupresie si suprainfectie: toxicitatea bacteriana si imunopatia de consum determina scaderea imunitatii; aparitia suprainfectiilor cu germeni oportunisti cel mai adesea rezistenti la antibiotice.
COMPLICATII
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SEPSIS, BACTEREMIE, SEPTICEMIE.
Sepsis: termen des utilizat, definind prezenta unei infectii microbiene in organism
Bacteremie: prezenta tranzitorie in circulatie a germenilor.
Descarcarile microbiene minore au rasunet clinic nesemnificativ.
Descarcarile masive sunt insotite de fenomene ca febra, frison, curbatura – necesita antibioterapie.
Ex: bacteremie de cateter venos central.
Septicemie: infectia nu mai poate fi controlata de sistemul imun.
Presupune cauze favorizante: varste mici sau inaintate, malnutritie, etilism cronic, insuficiente de organ, imunosupresie .
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30% din septicemii sunt cu etiologie plurimicrobiana.
Bacteriile Gram – elibereaza odata cu distrugerea lor endotoxina – molecula complexa ce contine polizaharide, proteine si lipidul A (componentul toxic).
Endotoxina determina initierea unui lant patologic:
1. activarea complementului seric,
2. agregarea neutrofilelor si activarea leucocitelor si plachetelor
3. eliberarea de substante vasoactive (histamine, prostaglandine, bradikinine) ce cresc permeabilitatea capilara, extravazarea masiva a plasmei, edem interstitial.
SOC SEPTIC !!!
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DIAGNOSTICUL INFECTIILOR CHIRURGICALE
EXAMEN CLINIC REPETAT:
Infectie localizata: Durere, tumefactie, congestie, caldura locala, impotenta functionala.
Infectie generalizata: febra, frison, stare generala alterata, hipotensiune, tahicardie, oligurie.
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DIAGNOSTICUL INFECTIILOR CHIRURGICALE
Investigatii de laborator:
•Date generale: Leucocitoza sau leucopenie
Acidoza
•Hemoculturi: 2 hemoculturi la interval de 15 min (sange venos sau sange arterial in suspiciune de endocardita).
Explorari imagistice:
Ex radiologice (torace, abdomen, schelet
CT – pentru localizari oculte, profunde.
Scintigrafia Ga67 si In111
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TRATAMENTUL INFECTIILOR CHIRURGICALE
Incizie si dreanaj - pentru localizari superficiale sau profunde, viscerale – metode clasice sau minim invazive.
Excizie- apendicita acuta, gangrena gazoasa.
Antibioterapie – necesara infectiilor severe sau a celor minore survenite la pacienti tarati – monoterapie sau asocieri de antibiotice.
Antibioterapie cu spectru larg la inceput sau dupa criterii empirice, ulterior conform rezultatului antibiogramei.
Suport circulator – revascularizare prin lambou muscular, plastie omentala, medicatie vasodilatatoare.
Suport nutritional: terapie nutritionala agresiva, parenterala sau enterala.
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Prognostic
Mortalitate 10% la pacientii cu sepsis (febra, frison, stare toxica).
Mortalitate 60% la pacientii cu soc sepic si M.S.O.F.
Riscul de recadere este de 20 % la pacientii care sunt afebrili dupa tratament.
Cand se sisteaza antibioterapia?
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GANGRENA GAZOASA
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Diagnosticul bacteriologic
1.Examinare MACROSCOPICA - dupa aspect
2.Examinare pe FROTIURI
3.Insamintare pe medii de cultura
4.Identificarea culturilor : criterii
5.Cercetarea sensibilitatii la antibiotice
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GANGRENA GAZOASA
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GANGRENA GAZOASA
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GANGRENA GAZOASA
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FASCEITA NECROZANTA
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FASCEITA NECROZANTA
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Fasceita necrozanta - cicatrizare
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Fasceita necrozanta - cicatrizare
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Fasceita necrozanta - cicatrizare
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FLEGMON ISCHIORECTAL BILATERAL
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ABCESE HEPATICE MULTIPLE
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ABCESE HEPATICE MULTIPLE
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ABCES IN PATUL VEZICULEI BILIARE
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Gangrena infectata
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GANGRENA INFECTATA
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INFECTII CU CLOSTRIDII
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TENOSINOVITA EXTENSOR POLICE
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BURSITA OLECRANIANA
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Foliculita
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Celulita
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FLEBITA SI CELULITA LA PLICA COTULUI
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PANARITII, TENOSINOVITE
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Abces rece subscapular
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Abces hepatic
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Abces hepatic amoebian
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Chist hidatic hepatic
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Infectii nosocomiale
Echipa chirurgicala ca sursa de infectii:
Comportament in sala de operatie, imbracaminte, igiena personalului.
Antisepsie si asepsie, detergenti, antiseptice utilizate.
Sala de operatii ca sursa de infectii:
Incapere, cai de acces, aerisire, izolatie, filtru salii de operatie.
Pacientul ca sursa de infectii:
Infectii preexistente, pregatire defectuoasa a tubului digestiv in chirurgia abdominala.
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Proceduri de izolare
Pacientii cu infectii severe se izoleaza in incaperi speciale;Sala de operatii sepice;Casolete si material de folosinta exclusiva;Compartiment cu circuit separat.
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Infectia plagii postoperatoriiProfilaxie:Tehnica chirurgicala adecvataAntibioprofilaxie la cazurile cu risc (diabet, copii, varstnici, diverse tare
organofunctionale);Monitorizarea zilnica a plagii;Drenaj subcutan profilactic, aspirativ;
Tratament:Suprimarea firelor de sutura cutanata – plaga larg deschisaLavaj cu antiseptice, pansamente zilnice sau oricand este necesarExcizii tesut necrotic, debridare, mesaj.
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Infectia plagii postoperatorii
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TRATAMENTControlul infectiei - pregatirea locala preoperatorie - profilaxia - controlul propriu-
zis al infectiei nosocomiale.
Pregatirea preoperatorie: • se vor trata preoperator infectiile preexistente;• bacteriile comensale de pe pielea pacientului sunt o cauză comună de infectie -
dusul preoperator cu sapun antiseptic scade cu 50% rata infectiilor.• decontaminarea colonului si curatirea mecanica a intestinului se practica de
rutina inaintea unei operatii colo-rectale.
Profilaxia cu antibiotice:• Se vor folosi antibiotice cu spectru adecvat bacteriilor din flora respectiva, o
cura cat mai scurta (de preferat o singura doza), eventual un antibiotic de linia a doua (o cefalosporina) care nu este utilizat in tratarea infectiilor grave.
• Este esential sa avem niveluri serice adecvate la momentul chirurgical, cand este posibila contaminarea.
• Antibioticul trebuie administrat intramuscular sau intravenos pentru a avea, cu certitudine, niveluri serice adecvate.
• In interventii prelungite, se poate administra o noua doza de antibiotic postoperator.
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TRATAMENTTratamentul chirurgical• incizia si debridarea tuturor tesuturilor necrozate;• drenajul abcesului• indepartarea corpilor straini
Principii ce trebuie aplicate pentru evitarea complicatiilor de plaga: hemostaza atenta imbunatatirea aportului sanguin la nevoie se va evita crearea de spatii moarte evitarea suturilor tensionate interventia va fi rapida fara a prelungi inutil timpul operator inainte de inchidere se vor efectua irigatii abundente cu solutie sterila
de Ringer lactat
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TRATAMENTTerapia de sustinere- repaus la pat, - imobilizarea regiunii infectate, - ridicarea segmentului de corp in proclivitate pentru a favoriza drenajul sanguin si limfatic.
Terapia cu oxigen hiperbar- utila in mionecrozele clostridiene. Poate reduce toxemia si scade masa de tesut excizat.
Antibioterapia curativa• In cazul in care identitatea germenului este necunoscuta, se vor administra antibiotice bactericide cu
spectru cat mai larg (de preferinta Cefalosporine de generatie superioara 3-4).• Antibioticoterapia se efectuează de regula cu asocieri de antibiotice. Sunt indicate asocierile dintre
betalactamine (Penicilinele, Meticiclina, Oxacilina, Ampicilina şi Cefalosporinele), oligozaharide (Streptomicina, Kanamicina, Gentamicina, Neomicina) si polimixine (Polimixina B, Colistin).
• Se vor administra in doze mari, la nivelul maxim admis/ kg corp.• Administrarea antibioticelor se face:
- oral, in cazul în care bolnavul are o buna toleranta digestiva si un tranzit intestinal regulat - intramuscular la intervale fixe (6,8,12 ore) - intravenos la intervale fixe (6,8,12, 24 ore) - intravenos continuu – diluand antibioticul in solutia de perfuzat, cu administrare controlata
• Antibioterapia se continua pana la obtinerea rezultatelor dorite.
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TRATAMENT
PROFILAXIA INFECTIILOR NOSOCOMIALE• respectarea asepsiei alaturi de antibioterapia profilactica preoperatorie si a
masurilor de profilaxie specifice fiecarei infectii nosocomiale• urmarirea celor mai frecvente infectii nosocomiale (urinare, pulmonare, de
plaga operatorie) si informarea periodica a clinicienilor (din 6 in 6 luni)• perfectionarea continua a personalului medical. La 250 paturi de spital este
utila prezenta unei asistente si a unui medic epidemiologist care sa asigure activitatea de supraveghere si formare a personalului medical.
• asigurarea resurselor materiale pentru derularea programului (spitale corespunzatoare, conditii de munca satisfacatoare etc);
• studiul bacteriologic periodic al spitalului sau clinicii (odata la 5 ani).
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PROFILAXIA INFECTIILOR INTRASPITALICESTI
MASURI DE ASEPSIE SI ANTISEPSIE:
Conditii de comportament in sala de operatie
Spalarea miinilor
Manusile de cauciuc
Campul operator
Pregatirea bolnavului
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PROFILAXIA INFECTIILOR INTRASPITALICESTI
Scurtarea spitalizarii.
Reducerea florei microbiene din tubul digestiv.
Antibioprofilaxia.
Tehnica chirurgicala corect dimensionata ca amploare si dificultate in conformitate cu statusul biologic al pacientului si stadiul evolutiv al afectiunii chirurgicale.