sepsis in the elderly
Introduction
Introduction to Septicemia in the Elderly Sepsis is a systemic infection caused by pathogenic or pathogenic bacteria that invade the bloodstream and produce toxins and other metabolites. The main clinical manifestations are chills, high fever, toxic symptoms, rash, joint pain, some migratory lesions, septic shock, etc., most of which are acute. basic knowledge Sickness ratio: 0.0001% Susceptible people: the elderly Mode of infection: non-infectious Complications: disseminated intravascular coagulation
Cause
The cause of sepsis in the elderly
Gram-negative bacilli are more common:
The cause of sepsis is mostly bacteria, even mycoplasma, etc. The abiotic bacteria are the main pathogens, and anaerobic bacteria and fungi also occupy a certain proportion. In recent years, with the broad-spectrum antibacterial drugs, the widely used immunosuppressive drugs And the development of traumatic diagnosis and treatment technology has made the pathogens of septicemia in the elderly have changed greatly. Older sepsis is more common in hospitals. Septicemia in hospital accounts for about 60% of the total number of sepsis in the elderly, which is about 3 times higher than that of young and middle-aged sepsis. The pathogenic bacteria caused by septicemia in the elderly are increased, and the pathogenic bacteria are mainly Gram-negative bacilli. About 60% or more, anaerobic bacteria increased, accounting for 15.1%. The more common pathogens are Klebsiella pneumoniae, Pseudomonas aeruginosa, Escherichia coli, Aerobacter aerogenes, Staphylococcus, Candida albicans Wait.
Multiple bacterial infections are common:
The elderly have low immune function. Older sepsis can cause mixed infections of various bacteria, which makes the disease worse and difficult to treat. The majority of cases of septicemia are 17.6%, mostly 1-3.
More resistant bacteria:
Older sepsis is more common in nosocomial infections, and conditional pathogens are common in sepsis. There are many drug-resistant strains in the pathogens of septicemia in the elderly, which are characterized by high and/or multiple drug resistance.
More common in respiratory invaders:
The path of infection of septicemia in the elderly is more severe than that of younger and younger in the respiratory tract infection. There are also many acne invaders. Other invasive pathways include urinary tract, biliary and abdominal infections, and intravascular indwelling catheters.
Prevention
Elderly sepsis prevention
Pay attention to labor protection, prevent trauma, timely disinfection and dressing if there is trauma, timely antibacterial treatment of local inflammation, prohibit extrusion, prevent bacterial spread, and perform strict disinfection and aseptic techniques in various medical treatments in hospitals. Strengthen the disinfection and isolation system in hospitals, prevent cross-infection, and rationally apply antibacterial drugs and adrenocortical hormones to avoid dysbacteriosis and reduce patient immunity.
Complication
Elderly sepsis complications Complications, disseminated intravascular coagulation
Older sepsis often leads to multiple organ failure, water, electrolyte imbalance and acid-base balance disorders, DIC and so on.
Symptom
Symptoms of sepsis in the elderly Common symptoms Low fever herpes Sanfeng fever type dysfunction tyrosinemia secondary infection coma liver failure abscess ascites
1. The onset is hidden, the symptoms are not typical
Due to the poor general condition of the elderly, the body's response is low, so that the onset of sepsis in the elderly is concealed. In the early stage, the typical symptoms are often lacking. The body temperature is not too high, mostly low-medium heat, irregular heat type, rare cold war, and even the body temperature does not rise, suggesting serious illness. Often, it only manifests as indifference, lethargy, and increased heart rate.
2. More common in septic shock
The elderly have poor immune function, and the disease often develops rapidly, which is prone to septic shock, especially when Gram-negative bacilli sepsis occurs, often with varying degrees of disturbance of consciousness.
3. Multiple organ failure (MOF) is common
The immune function of the elderly is poor, the disease develops rapidly and is not easy to control, the organs of the whole body are degraded, and the septicemia in the elderly often causes damage to important organs such as heart, lung, liver, kidney, brain, etc., eventually leading to multiple organ failure, such as acute kidney. Decline, coma, heart failure, respiratory failure, and even liver failure, water, electrolyte imbalance and acid-base balance disorders, DIC, etc.
4. May have a rash
Septic sepsis can occur in elderly sepsis.
5. Migration damage
The migration of septicemia in the elderly is more common. It is caused by the spread of bacterial emboli to other parts of the body. It is more common in septicemia caused by pyogenic bacteria (especially Staphylococcus aureus) and anaerobic bacteria. Commonly, there are lung abscesses. Subcutaneous abscess, etc., easily complicated by endocarditis.
6. The increase in white blood cell count is not obvious
The elderly have poor reactivity, and the white blood cells are not obvious, which can be normal or low. The left shift of the nucleus is not obvious, and the platelet count is obviously decreased.
7. There are many serious underlying diseases
Patients have serious underlying diseases before the occurrence of sepsis, such as malignant tumors, blood diseases, diabetes, uremia, chronic bronchitis and emphysema, cirrhosis and peritonitis, etc., with clinical manifestations of primary disease, often clinical The symptoms are intricate.
The clinical manifestations of senile sepsis are not typical. The elderly patients have poor response, and the total number of white blood cells is not obvious. The symptoms of primary infection often mask the symptoms of sepsis, which makes the rate of missed diagnosis and misdiagnosis of elderly septicemia high. Some patients do not get a positive result until blood culture. Being diagnosed has affected early diagnosis.
All elderly patients with acute fever, total white blood cells and neutrophils increased, normal or low, and not limited to a system of acute infection, should consider the possibility of sepsis, medical history and detailed physical examination to assist diagnosis and It is speculated that the disease has a certain meaning, and there are newly infected respiratory tracts, urinary tracts, biliary tracts, etc.; or there are hemorrhoids, traumatic injuries; or intravascular indwelling catheters; or various focal infections are treated with effective antibiotics, but the body temperature is still not Those who can control should be highly suspected of the possibility of sepsis, such as rash and migratory abscess in the course of the disease, the clinical diagnosis of sepsis can be basically established, detailed physical examination can often find the primary lesion or invasion pathway, and according to this Infer the type of pathogen.
Examine
Examination of sepsis in the elderly
Blood picture
Leukocytes often increase significantly, the percentage of neutrophils increases, the left nucleus shifts, poisoning particles may appear, eosinophils decrease or disappear, and the total number of white blood cells in severe patients and a few Gram-negative bacilli patients can be normal or reduced, but The percentage of neutrophils is often still increased.
2. Pathogen examination
Blood culture is the most important. It is advisable to collect blood before antibiotic application and during chills and high fever. It should be sent several times. The blood volume should be at least 1/10 of the medium (about 5-10 ml), and the positive rate of bone marrow culture is higher. If necessary, it should be used for anaerobic culture at the same time. After the bacteria are separated, the drug sensitivity test should be used to guide the treatment. The coincidence rate between the in vitro test results and the clinical efficacy is about 80%. In recent years, it has been reported that blood is being made. At the same time of culture, the anti-coagulated whole blood was centrifuged and precipitated with leukocyte smear for acridine orange staining. Among the 62 blood culture-positive persons, 47 (76%) were positive, stained with Gram, and 32 (52%) were positive. It is considered that early diagnosis is possible. Due to the slow growth of fungi and low positive rate, gas chromatography can be used to detect its metabolites for rapid diagnosis.
The sputum test can detect serum endotoxin, which is helpful for Gram-negative bacilli sepsis. For migratory lesions, ultrasound, radionuclide, X-ray and other related examinations can be used.
Diagnosis
Diagnosis and diagnosis of sepsis in the elderly
Diagnostic criteria
Blood culture and (or) bone marrow culture positive is the basis for the diagnosis of senile sepsis. Blood culture is the most commonly used. In order to obtain a higher positive rate, it is advisable to collect blood before application of antibacterial drugs and during chills and high fever. Each time the amount of blood is not less than 5ml, if antibacterial drugs have been applied, membrane filtration, collection method, blood clot culture method, or magnesium sulfate, -lactamase, p-aminobenzoic acid, etc. may be added to the culture medium. In order to destroy some commonly used antibacterial drugs, attention should also be paid to the cultivation of anaerobic bacteria, fungi and L-type bacteria. The positive rate of bone marrow culture is higher than that of blood culture, and smears such as pus, cerebrospinal fluid, chest and ascites, and sputum are examined or Culture, there are also opportunities to detect pathogens, after the isolation of pathogenic bacteria should be carried out antibacterial sensitivity test and combined drug sensitivity test to determine the minimum inhibitory concentration (MIC) for reference when selecting or adjusting antibacterial drugs, if necessary, the minimum sterilization Concentration (MBC), serum bactericidal test also has important reference significance.
Recently, gas chromatography (especially gas liquid chromatography, GLC), ion chromatography (IC) and other rapid diagnostic techniques can also be used to diagnose senile sepsis, and lysate test (LLT) can detect serum and other specimens in Gram. The endotoxin of the negative bacilli is helpful for the diagnosis of Gram-negative bacteria sepsis.
Differential diagnosis
According to the main characteristics of sepsis, it must be differentiated from the relevant diseases.
1. High fever with cold war
Should be identified with the following diseases:
1 Malaria: P. vivax is a regular daily episode, showing a violent violent war, high fever followed by sweating and obvious intermittent remission, falciparum malaria fever, chills and irregularities, but the total number of white blood cells and neutrophils are not high The symptoms of systemic poisoning are mild, and the diagnosis depends on the blood film or bone marrow smear to see the malaria parasite;
2 acute pyelonephritis: may have high fever and chills, but often have low back pain and kidney pain, white blood cells and pus cells can be found in the urine, urine culture has pathogen growth, blood culture is negative;
3 suppurative cholangitis: may have high fever, chills, but there is a history of biliary colic, jaundice, serum bilirubin increased, bile duct area has obvious tenderness and pain, blood culture is negative;
4 Streptococcus pneumoniae pneumonia: rushing high fever, there may be chills, but there are cough, chest pain, rust color sputum, lungs can have physical signs, X-ray films show lung inflammation, sputum culture can have Streptococcus pneumoniae growth The blood culture is negative, and the latter three diseases, such as the growth of pathogenic bacteria in the blood culture, indicate that sepsis has been complicated.
2. High fever with significant increase in white blood cells should be identified with the following diseases:
1 meningococcal meningitis: acute high fever, head pain, vomiting, neck rigidity, Kernig's sign positive, skin may have sputum and ecchymosis, cerebrospinal fluid is purulent, smear staining microscopic examination shows Gram-negative double Cocci, blood culture may also have this bacteria growth, often popular in winter and spring.
2 epidemic encephalitis: acute high fever, disturbance of consciousness, mild meningeal irritation, cerebrospinal fluid is non-purulent, mild white blood cells increased, the popular season is summer and autumn.
3 leptospirosis: acute high fever, inguinal lymphadenopathy, tenderness, gastrocnemius pain and tenderness, a certain regional and seasonal and epidemic water contact history, penicillin early treatment is effective.
4 epidemic hemorrhagic fever: regional, seasonal, first fever, not too high, fever after a few days, but then the condition is worse, the hypotension shock period, followed by oliguria, or even no urine Renal failure, such as the improvement of the condition can also appear polyuria, early drunkenness, skin mucosal bleeding, conjunctival edema, proteinuria, white blood cells and neutrophils significantly increased, up to (10 ~ 30) × 109 / L Above, even a leukemia-like reaction, blood culture is negative.
5 adult adult's disease (adult Still's disease): its clinical manifestations of fever and increased white blood cells, very similar to sepsis, fever can last for several months, systemic poisoning symptoms are mild, a few transient rashes can occur repeatedly, blood culture repeated Negative, antibiotic treatment is ineffective, indomethacin has a certain antipyretic effect, and adrenocortical hormone is effective.
3. Hyperthermia and leukopenia
Should be identified with the following diseases:
1 Typhoid and paratyphoid: the onset is slower, the fever is more trapezoidal, and it is persistently high fever after 1 week. It may have rose rash, hearing loss, significant reduction of white blood cells, and paratyphoid fever may have migratory inflammation. Blood culture or bone marrow culture may have typhoid or paratyphoid Salmonella growth.
2 Acute miliary tuberculosis: slow onset, persistent high fever, no obvious cough, negative blood culture, X-ray chest X-ray can show miliary tuberculosis after 2 weeks of onset.
3 malignant histiocytosis: persistent fever, mostly relaxation heat or irregular heat, long-term non-return, often anemia, weight loss, white blood cell reduction, blood culture multiple negative, antibiotic treatment is invalid, blood smear, bone marrow smear Malignant tissue cells can be diagnosed with lymph node biopsy.
