Syndrome of endogenous intoxication. Endotoxemia Syndrome of endogenous intoxication in surgical patients

Currently, one of the most difficult problems in intensive care is syndrome of endogenous intoxication(SEI), which accompanies a significant number of pathological conditions (shock, peritonitis, pancreatitis, etc.), which, as they develop, can lead to death.

Progression of endotoxicosis due to the accumulation in the blood of various origin, chemical structure and biological effects of substances called endotoxins. Endotoxins contribute to the development of acute renal and hepatic insufficiency, cardiovascular insufficiency, acute respiratory distress syndrome, ultimately leading to the appearance of an extremely serious condition - the syndrome of multiorgan dysfunction.

Endogenous intoxication - clinical syndrome, which occurs in pathological conditions of various etiology, caused by the accumulation in tissues and biological fluids of the body of products of impaired metabolism, metabolites, destructive cellular and tissue structures, destroyed protein molecules, pi accompanied by functional and morphological lesions of organs and body systems.

There are three main links that determine the severity of the condition of patients and the severity clinical symptoms: toxemia, impaired microcirculation, inhibition of the functions of the body's own detoxifying and protective systems.

The main link pathogenesis of endogenous intoxication syndrome is toxemia. Unfortunately, a clear differentiation of toxic substances of endogenous origin is practically impossible. However, in each specific case, "primary" and "secondary" endotoxins can be distinguished. So, with burns, prolonged crush syndrome, obliterating vascular diseases"primary" are products of protein degradation, "secondary" - products of natural metabolism, the accumulation of which in the body is a consequence of inhibition of the functions of natural detoxification and excretion.

Endotoxemia, violating the tone of peripheral vessels, blood rheology, kinetic and mechanical properties of blood cells, leads to tissue hypoxia, which is one of the important links in the pathogenesis of SEI, the course of which is aggravated by a decrease in the function of natural detoxification and excretion organs. Toxins block the binding sites of albumin molecules, which leads to a decrease in the effectiveness of the drug treatment, since this protein is a transport agent for many pharmacological preparations.

Clinic of endogenous intoxication syndrome.

Comparison of experimental and clinical studies revealed the following stages development of endogenous intoxication syndrome.
I stage of endogenous intoxication syndrome. Reactive-toxic occurs in response to the formation of a primary destructive focus or traumatic injury. Laboratory signs of this stage are an increase in blood levels of medium-weight molecules (MSM), products of lipid peroxidation (DC and MDA), an increase in LII.

II stage of endogenous intoxication syndrome- the stage of severe toxemia develops after a breakthrough of the gastohematological barrier, when endotoxins formed in the primary focus of intoxication enter the circulating blood, with subsequent distribution and accumulation in the body. Depending on the state of the body, its resistance and the initial level of detoxifying and immune systems, compensated and decompensated stages of severe toxemia are distinguished.

III stage of endogenous intoxication syndrome- multiorgan dysfunction (MMOD) is observed with further progression of the pathological process as a result of severe endotoxin damage to various organs and systems with the development of their functional decompensation!. Clinically, this stage is Manifested by impaired consciousness, hypoxia, severe heart failure, oliguria, paralytic ileus. In the blood, a high concentration of creatinine, urea, bilirubin is determined.

Acute intoxication is a severe pathological condition of the body, which is caused by an infectious process, poisoning with chemicals or toxins. It is important to know the stages of intoxication of the body, what this definition means, what exogenous toxins are the causes of this condition, what clinical signs and unspecified symptoms it is expressed, as well as methods of treatment.

General definition of acute poisoning

The term "intoxication of the body" is a collective and very broad definition that is used in a variety of pathological conditions and diseases. Intoxication means poisoning the body some microorganism or substance. Distinguish between exogenous and endogenous, as well as chronic and acute intoxication.

During acute poisoning the body receives at the same time a large number of poisons or toxins. This condition is expressed by the rapid deterioration of a person's condition. If the patient is in contact with the substance for a long time, for example, at the workplace, then he begins to become chronically poisoned.

Exogenous intoxication of the body

During this type of intoxication, the toxic substance enters the body from the external environment. This poisoning can be both chronic and acute. The main causes of exogenous intoxication are as follows:

Causes of endogenous poisoning

During this intoxication, toxic substances begin to be produced directly by the body. Endotoxins can be products of metabolic and inflammatory reactions, hormones and enzymes. Under certain circumstances, for example, when physical activity or acute inflammation, acute renal failure, dehydration, substances that are produced by the body itself become toxic and dangerous.

In addition, endotoxins are produced malignant neoplasms during the growth and progression of cancerous tumors. In patients who suffer from oncological diseases, all the time there is subfebrile temperature body, and the level of the inflammatory indicator in the blood test rolls over.

Signs and clinical symptoms

Symptoms and signs of intoxication will depend on the cause of the poisoning and on the way the toxin enters the body. Let us describe the main features of the clinical symptoms of intoxication, taking into account the etiology of development.

Food poisoning

On average, the first symptoms appear within the first 8 hours after eating contaminated or spoiled food. During poisoning with poisonous mushrooms, the clinical picture manifests itself after 15–20 minutes, and when infected with botulism or intoxication with canned food, after 20–24 hours.

The main signs of food poisoning:

• Vomiting and nausea are defensive reactions of the body. With the help of vomiting, the stomach removes bacteria and toxins. Mucus, bile and food debris can be seen in the masses of vomit.
• General weakness, dizziness and headache are the main symptoms of intoxication of the body.
• An increase in body temperature during food poisoning does not always appear. The manifestation of this symptom indicates a severe course of the disease and a pronounced syndrome of intoxication.
• Diarrhea. Its frequency and volume will depend on the degree of intestinal intoxication and the cause of poisoning. So, with salmonellosis, the feces are frothy and green, and with dysentery - watery.
• With the development of botulism in a patient, signs of CNS damage increase over time: vision, coordination, swallowing, speech deteriorate, paresis, paralysis and convulsions may appear.
• Tachycardia is a sign of severe intoxication, dehydration, an accelerated pulse is noted.

Drinking a lot of alcohol

Alcohol intoxication appears 2-3 hours after drinking alcohol. During methyl alcohol poisoning, symptoms may appear only after 24 hours.

Initially, the disease goes by the principle of food poisoning. The patient vomits, he develops diarrhea, his stomach hurts. But after that, convulsive seizures, hallucinations can develop, a person can fall into a coma.

Alcohol poisoning is often complicated by damage to the kidneys and liver. During a severe poisoning syndrome, breathing and heart function are disturbed.

Please note that methyl alcohol intoxication may cause visual impairment. At first, a person notices a decrease in the clarity and sharpness of what he sees. During the absence of treatment, complete blindness begins, and after a fatal outcome.

Damage by alkalis and acids

A characteristic difference of this intoxication is a burn of the mucous membrane of the esophagus and stomach, caused by substances that the patient drank. Alkalis and acids can cause a violation of the integrity of the walls of blood vessels, eat away the mucosa. Poisoning with alkalis and acids is often accompanied by bleeding in the gastrointestinal tract.

Clinical symptoms of intoxication with acids and alkalis:

• Tachycardia.
• Burning and pain in the stomach and along the esophagus.
• Hypotension (low blood pressure).
• Dyspnea.
• Violation of consciousness.
• Vomiting bloody or black contents is a sign of bleeding that has appeared.

When alkalis and acids enter the body, the pancreas, liver, and kidneys are affected.

Overdose of drugs

Any medicinal product during its improper use can cause overdose and intoxication. Signs of poisoning medical means will depend on the active substance. Most often in the next half hour after taking toxic dose medicines show the first symptoms of poisoning. They can be similar to a food toxic infection (manifested by abdominal pain, diarrhea, vomiting) or be expressed by symptoms of damage to various systems and organs.

It should be noted that in the instructions for any medication describes the symptoms that may appear with an overdose.

Infections of a bacterial or viral nature

Any infection, penetrating into the body, begins to lead to intoxication syndrome. For example, with blood intoxication, sepsis, bacteria cause an inflammatory systemic reaction, bacterial infection is noted in many systems and organs.

Intoxication syndrome in infections is expressed by an increase in body temperature to subfebrile or febrile indicators, headache, chills, dizziness and general severe weakness. Muscle pain, joint pain, diarrhea, and vomiting may occur.

Household or chad gas

The rate of increase in symptoms during gas intoxication will depend on its concentration in the air. The higher the concentration, the faster the damage to the body develops.

During the inhalation of fumes, protein and hemoglobin, which delivers oxygen to all cells, begin to turn into methemoglobin, a substance that is not able to bind oxygen. Which leads to hypoxia - a lack of oxygen, which primarily affects the kidneys, heart and brain.

Signs of gas intoxication include:

Basic diagnostic methods

Intoxication is considered a very general concept, and in order for a doctor to determine the correct etiological treatment the cause needs to be determined. The diagnosis is established by a specialist after examining the patient, examination and detailed history taking. It is important to tell your doctor the following information:

• The time of manifestation of the first signs of the disease.
• Having contact with an infectious person in recent weeks (the incubation period for certain infections can be quite long).
• Recent illnesses.
• Presence of chronic diseases (for example, hypertension, diabetes, irritable bowel syndrome, coronary disease hearts, etc.).
• What could provoke the disease (you need to tell the doctor what foods you have been eating lately and taking medications).

Do not forget that if you have an allergy to any food components or drugs, you must definitely tell your doctor about it.

To establish an accurate diagnosis, determine the pathogen and assess the person's condition, additional instrumental and laboratory examination of the patient may be required. If the person's condition is severe, then the diagnosis is made simultaneously with the first aid.

Scroll diagnostic methods, which can be necessary to establish a diagnosis during intoxication:

Intoxication is a collective concept that reflects the infection or damage to the body by microorganisms or toxins. Toxic substances can come from outside or be produced directly by the body. Treatment is prescribed by a specialist after the diagnosis is established. Why is a detailed examination of the patient, which allows you to establish the cause of the development of intoxication.

Endogenous intoxication is a disorder based on structural tissue damage, accumulation of toxic compounds with further development of the clinical picture. Equally common among adults and children. It has its own ICD code, the disease is encrypted in the X40–49 range.

Classification

The division of pathology depends on the characteristics taken as a basis. There are three types of flow:

• acute - has a sudden onset and rapid development;
• subacute - is formed gradually, the treatment takes a longer period;
• chronic - appears against the background of disorders that disturb the patient for a long time.

If you focus on the symptoms of endogenous intoxication, three stages can be distinguished:

• compensation - in the presence of a source of damage, the body copes with the violation on its own;
• subcompensation - the patient complains of a deterioration in well-being, as the natural biological mechanisms are depleted;
• decompensation - accompanied by serious functional disorders and deep structural tissue disorders that require emergency care.

The sources highlight the development of endotoxic shock, the clinic of which has its own course and degree.

Features of the pathology

The disease is based on inflammation, during which there is an irreversible change in the functioning of organs, biochemical processes. The focus is often located in abdominal cavity, cranium, covers the liver, heart, kidneys and brain.

At histological examination the accumulation of leukocytes, damaged cells and inclusions that are not found in the norm are determined.

In the process of studying the etiology of the disorder, chronic diseases, injuries that have not been treated for a long time are determined.

Sources of internal intoxication

Poisoning is formed with the constant production of toxic substances that can destabilize the metabolism in organs, in particular, in the liver. These include:

• metabolic products in high concentrations (bilirubin, uric acid);
• compounds that appear during the development of chronic pathologies (ammonia, aldehydes);
• elements that accumulate in violation of the integrity of tissues (enzymes, protein cations);
• substances formed during the oxidation of fat-soluble compounds.

Diseases play an important role endocrine system, in which hormones are produced in unlimited quantities - biologically active substances that have a direct or indirect effect on human life.

Causes of endotoxin poisoning in the body

According to statistics, the disorder is more common in surgical practice and is treated with surgical methods, which distinguishes it from the exogenous form. The etiological factor can be:

• burns covering a considerable percentage of the body;
• injuries from prolonged tissue compression;
• acute inflammation of the pancreas with further pancreatic necrosis;
• peritonitis;
• oncology;
• benign tumors that produce hormones.

The syndrome of endogenous intoxication often occurs against the background of organ transplantation, when the immune system rejects the transplanted tissues, recognizing them as foreign.

Development mechanisms

The pathogenesis is difficult to understand and represent, it reflects microcirculation disorders, cell hypoxia and a decrease in anti-infective protection, which worsens the course of poisoning.

In medicine, there are several primary mechanisms for the development of this disease:

1. Production. Due to excessive synthesis of toxic substances in acute inflammatory pathologies (peritonitis, pancreatitis, pneumonia).
2. Resorption. It implies absorption into the general circulation of compounds that appear in limited foci of tissue decay, necrosis (phlegmon, abscess, gangrene).
3. Reperfusion. It is based on the intake of substances formed in locations that are subject to ischemia for a long time (free radicals).
4. Retentive. It is directly related to a decrease in the functional activity of the organs responsible for the elimination of toxins (liver, kidneys).
5. Infectious. It is explained by a perversion of the qualitative and quantitative ratio of the own microflora of the gastrointestinal tract, during which the bacteria synthesize toxic compounds into the organ cavity.

The severity of the flow is determined by three points: toxemia, the severity of hypoxia and the inhibition of the work of natural protective barriers.

Clinical picture

Symptoms directly depend on the stage of endogenous pathology (acute, subacute, chronic). As for the first, it is characterized by the features described in more detail in the table below.

Like any intoxication, poisoning of this type is accompanied by fever, body temperature reaches 39–40 degrees.

In the subacute stage, the clinic develops slowly, gradually, the symptoms are as follows:

• fatigue;
• dizziness;
• decrease or lack of appetite;
• weight loss
• migraine;
• sleep disturbance.

The most common is the chronic stage of endogenous poisoning, its features are:

• aching headaches, the intensity of which varies from time to time;
• gradual weight loss even with a full, high-calorie diet;
• arrhythmias;
• emotional instability.

Possible violations of the urinary system, there is urinary incontinence.

The main stages of intoxication

The clinical picture of any of the degrees of poisoning is conditionally divided into three stages. The first is referred to as reactive-toxic, a destructive focus is formed here, lipid peroxidation is observed.

At the second stage, designated as severe toxemia, natural protective barriers are violated, toxic compounds in high concentrations are carried throughout the body, to which the immune system actively responds.

If appropriate medical measures are not taken, the third stage occurs - multiorgan dysfunction. It is characterized by anuria, paralytic ileus, confusion.

Diagnostics

In surgery, a certain algorithm has been drawn up, which is followed by all doctors who examine the patient. The plan consists of items such as:

• determination of convincing signs of acute, subacute endogenous intoxication;
• put the severity of the pathological process;
• identify the source of poisoning;
• assess the saturation of internal environments with toxic elements.

Only then the doctor has the right to prescribe treatment and monitor its effectiveness.

Laboratory markers of the disease in question are as follows:

• leukocytosis, deviation from the norm of specialized indices of intoxication;
• elevated bilirubin, liver enzymes;
• decrease in total protein in blood plasma;
• an increase in the concentration of urea and creatinine;
• altered ratio of neutrophils and lymphocytes.

During the examination, the surgeon additionally writes out directions for such instrumental methods, how:

• MRI, CT;
• Ultrasound of the abdominal cavity, genitourinary system, heart;
• radiography of the body part of interest (with and without contrasting);
• electroencephalography.

These diagnostic methods allow visualizing the affected organs and identifying the degree of functional deficiency.

First aid

The patient and his relatives are required to timely call the ambulance team, which will take the victim to the emergency hospital. There are practically no specific recommendations that can alleviate a person's condition with endogenous intoxication.

In case of burns, injuries and acute inflammatory pathologies, it is not necessary to give additional medicines. The preparations will lubricate clinical picture which complicates further diagnostics.

Treatment Methods

Therapy requires a certain sequence of actions, depending on the mechanism of development and the influence of the etiological factor. Its principles are:

• source removal;
• stabilization and strengthening of the work of protective barriers;
• increase in the rate of excretion of poison;
• suppression of associated symptoms.

As for the first point, in 80-90% of cases it is required surgical intervention, implying excision, removal of decayed tissues, resection of an organ, the introduction of drains.

AT postoperative period the doctor prescribes a whole range of medications in order to correct the well-being of the victim. Consists of the following components:

• analgesics;
• antispasmodics or drugs that stimulate intestinal motility;
• saline solutions;
• diuretics;
• immunomodulators;
• colloids;
• symptomatic remedies that improve digestion, respiration, heartbeat.

In severe cases of endogenous poisoning, they resort to mechanical blood purification: hemodialysis, plasmapheresis. If a secondary infection is suspected, the doctor prescribes broad-spectrum antibiotics.

Possible consequences

Complications develop if the patient delayed treatment, asked for help late, or the doctor prescribed inadequate therapy. The prognosis is unfavorable with the development of:

• renal, hepatic insufficiency;
• infectious-toxic or hypovolemic shock;
• sepsis;
• coma;
• nosocomial pneumonia.

The most terrible consequence is considered to be a lethal outcome, the onset of death depends on the speed of diagnosis and therapy.

Prevention

In order to avoid the formation of endogenous poisoning, it is only necessary to treat pathologies in a timely manner and observe healthy lifestyle life. There are no special specific measures, everything depends on the consciousness and interest of the person himself. The patient must understand that without his desire, no one will solve the formed problem.

Expert opinion

The outcome of the pathology depends on a combination of factors, the main of which are the adequacy of therapy, the quality of the operation, the competence of the doctor and the mood of the patient. Often complications are formed not because of the mediocrity of the doctor, but ignoring medical recommendations. It must be remembered that a burn that affected a high percentage skin, a large abscess, gangrene will not resolve themselves, and methods traditional medicine The maximum that they will do is to remove the clinical manifestations for a short period of time.

Harm to a person is caused not only by poisons coming from environment. Endogenous toxicity is pathological condition, in which dangerous compounds are formed directly in the body. Various factors provoke the release of toxins into the bloodstream, but the main cause is acute and chronic forms diseases. After medication or surgical treatment negative symptoms disappear, all vital systems begin to function actively.

Distinctive features of pathology

Endogenous intoxication of the body, or endotoxicosis, develops as a result of the accumulation of excess amounts of endo- and exotoxins in tissues and cells. The disease proceeds against the background of the inflammatory process, causes numerous irreversible disorders in the absence of therapy. Endogenous toxins decompose neighboring tissues, provoke poisoning and its rapid distribution throughout the body. As a rule, the pathological focus is formed in the abdominal cavity, and then covers the structural renal elements, hepatocytes, cardiovascular and nervous systems.

Often, diagnosis reveals inflammation at the stage of toxic-dystrophic tissue decomposition, which requires the use of all the principles of its correction. Poisoning proceeds in several stages, but the main source of the disease is always the organ that was initially affected. This is based on the greater concentration of toxins in his tissues.

If a person has high resistance to pathogenic microorganisms, the risk of developing endogenous intoxication is reduced. People whose immune status leaves much to be desired are subjected to poisoning.

The following systems are involved in the process of intoxication:

• barriers of biological origin, which should prevent the release of toxic compounds from the inflammatory focus;
• neutralizing substances that destroy or neutralize endotoxins.

The trigger is rarely a single substance, several compounds poisoning the body are involved in the mechanism of endogenous intoxication penetrating into the bloodstream and plasma. This condition occurs when poisons enter the bloodstream, they spread through the vessels of the affected organ. But there is another way - tissue fluid and (or) lymph.

Main stages of endotoxin poisoning

Endogenous (endogenous) intoxication includes three stages. At the initial stage, it is difficult to identify pathology, but biochemical analyzes may show a slight increase in the concentration of leukocytes and protein breakdown products. Poisoning with toxins of internal origin at this stage can occur under the influence of traumatic injuries or in the presence of an inflammatory focus caused by pathogenic microorganisms.

The second stage, or the stage of severe toxemia, develops after the release of endogenous toxins from their bloodstream, overcoming the hematological barrier. Their concentration reaches the maximum level, toxic compounds spread throughout the body through the flow of biological fluid, penetrate into cells and tissues. The progression of this stage of poisoning is directly dependent on the person's resistance:

1. compressed phase. Under the influence of toxins, malfunctions occur internal organs, degeneration of tissues, decrease or increase in blood supply. This is necessary for the ability of vital systems to fully carry out their functions.
2. decompensated phase. Pathological changes, attempts by the body to adapt to them do not bring tangible results. Organs can not cope with the increased load, stop working or function only partially.

With endogenous intoxication, an organism with strong immunity launches compensation mechanisms. The volume and speed of blood flow increases, T-lymphocytes (killer cells) are activated to destroy poisonous foreign proteins.

Lack of treatment leads to the development of severe disorders in the third stage of endotoxin poisoning.. Multiorgan dysfunction is accompanied by damage to all body systems in the presence of functional decompensation. A huge amount of toxins and metabolic products is found in the blood. The kidneys are unable to filter harmful compounds and excrete them in the urine.

By binding to erythrocytes, endogenous toxins do not allow them to react with molecular oxygen and deliver it to the brain. The regulation of all vital systems ceases - as a result, cardiac and respiratory arrest occurs. At this stage, even carrying out urgent resuscitation measures will not be able to save a person's life.

Sources of internal intoxication

Regular use of pharmacological drugs by people with chronic diseases is a necessity. Pathologies occur against the background of constant production of endotoxins by damaged tissues., which destroy neighboring organs, especially the liver. These toxic compounds include:

• high concentrations of metabolic products (bilirubin, uric acid and its salts);
• substances that accumulate during improper metabolism (free ammonia, aldehydes);
• compounds formed during the breakdown of cells in violation of the integrity of tissues (protein cations, indoles, lipase);
• substances involved in the regulation of all vital systems in excess concentration (activated enzymes);
• oxidation products of fat-soluble compounds;

Some poisons that enter the human body from the outside can be classified as endotoxins. They become a source of the formation of an inflammatory focus, poison neighboring areas of the internal organs with the products of their metabolism.

When the endocrine system is disrupted, excessive production of biologically active substances occurs. A high concentration of hormones contributes to the occurrence of violations of the functional activity of other systems, provokes tissue damage, reduces the body's resistance. Often this condition is accompanied by the formation of one or more inflammatory foci.

Causes of endotoxin poisoning in the body

The syndrome of endogenous intoxication is more typical for surgery, since diseases that cause tissue decomposition are most often treated with surgery. Self-poisoning occurs with the following pathologies:

1. Extensive burns.
2. Injuries from prolonged pressure or bruising.
3. Pancreatitis in the acute stage.
4. Inflammation of the sheets of the peritoneum.
5. Malignant or benign neoplasms.

Poisoning of the body with endotoxins can occur directly during an open surgical operation. The intervention is usually carried out against the background of respiratory problems, significant blood loss, and anesthetic manipulations.

Endogenous intoxication sometimes occurs during an organ transplant operation. The transplant is rejected by the human body as a foreign body. An inflammatory process develops, accompanied by destructive changes in the donor organ.

Detoxification of cells and tissues will not be complete if it penetrates into the human body along the ascending path or from the outside coli. Favorable factors for its active reproduction with the release of toxins include burn disease or grass with an open wound surface. With radiation damage, a violation of lipid metabolism occurs. The resulting products have a strong toxic effect on the cells and tissues of internal organs.

Mechanisms of the pathological process

When diagnosing using modern instrumental techniques and conducting studies of biological fluids, the mechanisms of action of endotoxins were identified. Usually, intoxication occurs when they are combined or when one action is changed to another. The following mechanisms of poisoning by endogenous toxins formed in the human body are described in the developments of domestic specialists:

1. production toxemia. A significant change in the composition of biological fluids provokes changes in metabolism. Usually this condition occurs when the endocrine system fails, lack of vitamins and minerals, oxygen starvation tissues, their dystrophy and decomposition.
2. retention toxinemia. It develops as a result of a violation of the excretion of metabolic products from the body. For example, if pulmonary gas exchange decreases, then the concentration of carbon dioxide in the bloodstream increases, causing endogenous intoxication.
3. Resorption toxinemia. During the decomposition of tissues, the products of protein breakdown enter the internal cavities. This mechanism is characterized by rapid progression with deformation of bones, skin surfaces, mucous membranes, and soft tissues.

To determine endogenous intoxication, it is important not only to determine the provoking factor and species, but also the ability of harmful compounds to accumulate in the affected areas.

Some types of poisoning provoke necrotic tissue damage. which will not recover even with timely medical care. But most toxins shift the balance in the body at the cellular level, which further causes disturbances in the functional activity of one of the systems. Such changes are reversible after urgent therapy.

The clinical picture of poisoning the body with endotoxins

Despite the large number of diseases that occur with the production of endotoxins, in surgery there is a commonality of signs of intoxication. The severity of symptoms depends on the stage of poisoning:

1. Acute.
2. Subacute.
3. Chronic.

At the acute stage of endogenous intoxication, an increased concentration of harmful compounds inside the bloodstream is diagnosed. They are associated with most of the red blood cells, molecular oxygen circulates freely, its deficiency occurs in the brain tissues. This stage is characterized by the following symptoms:

• severe disorders of the gastrointestinal tract: nausea, vomiting, bloating, diarrhea or constipation;
• increased sweating, cold perspiration, chills;
• hyperthermia, complicated by a feverish state;
• painful spasms localized in different parts of the body;
• tremor of the upper and lower extremities;
• arterial hypertension, which is replaced by a sharp drop in pressure to the lower levels.

Increased toxicity of endogenous toxins causes convulsions, paralysis, severe joint and muscle pain. There is a high probability of loss of consciousness, coma, pulmonary and cerebral edema.

The subacute stage occurs with a slight increase in the concentration of toxic compounds. All vital systems are actively functioning, negative changes are just beginning to gain momentum. When examining patients, doctors identify the following signs of intoxication:

1. The temperature is raised to subfebrile indicators.
2. There is nausea, indigestion, lack of appetite, weight loss.
3. A person feels fatigue, dizziness, drowsiness, apathy.
4. During the day, the pressure rises sharply, and then decreases.
5. The victim is worried about headaches, which can be replaced by migraines.

chronic stage endogenous intoxication is the most common. It develops against the background of untreated poisoning of various etiologies, disruption of the urinary system, and a decrease in the functional activity of the liver to cleanse the blood of toxins. Patients experience the following symptoms:

• indigestion, duodenum, small and large intestines;
• emotional instability: depression, mood swings, weakness, fatigue, lethargy;
• headache, taking a chronic course;
• pallor, dry skin;
• weight loss;
• arrhythmias, arterial hypotension or hypertension.

Chronic endogenous intoxication negatively affects the appearance of a person. Eruptions appear on the skin, hair falls out profusely, nails exfoliate. Improper metabolism provokes increased secretion of the sebaceous glands.

The characteristic features of this stage of poisoning include a significant decrease in the body's resistance to bacterial or viral infections. Manifestation is activated allergic reactions with the development of autoimmune diseases. Urination disorders often occur: incontinence, urine leakage.

Diagnosis and treatment of pathology

Diagnosis is based on the examination of the patient, the study of the results laboratory tests blood and urine. A huge number of diseases that have caused endogenous intoxication require individual approach to the survey. But in the vast majority of cases, doctors use the following instrumental methods:

1. Magnetic resonance imaging.
2. Ultrasound procedure.
3. X-ray.

At the first stage of treatment, detoxification therapy is carried out using solutions of salts and glucose. If necessary, patients are prescribed procedures to cleanse the blood of endotoxins: hemosorption, hemodialysis. If the poison accumulates in the gastrointestinal tract, then washing with a probe, taking adsorbents or enterosorbents is required. In chronic intoxication, the use of vaseline oil enemas is recommended.

After the symptoms of poisoning are eliminated, the treatment of the underlying pathology begins. Usually, all inflammatory processes complicated by the addition of a secondary bacterial infection Therefore, patients are treated with antibiotics. To prevent complications, patients are prescribed vitamins, microminerals, probiotics, immunostimulants.

A class of medium molecular substances of various nature;

peroxide products;

Non-homogeneous ingredients of non-viable tissues;

Aggressive complement components;

Bacterial toxins (exo- and endotoxins).

Endotoxins cause destruction of proteins and cell lines, block synthetic and oxidative processes. Particular attention should be paid to the biological active substances(BAS) and medium molecules (SM).

There are clear correlations between the concentration in the blood and tissues of the products of the kallikrein-kinin cascade, biogenic amines, and the degree of structural damage in many acute processes. In all cases, an increase in the activity of inflammatory mediators is combined with an increase in the severity of lesions of organs and systems (S. A. Simbir-

tsev, N. A. Belyakov, 1994).

Endotoxins have direct and indirect impact onstructure of cells, cells themselves, systems and organs (distant actionaction).

By action at the level of cellular structures endotoxins can be classified as follows (S. A. Simbirtsev, N. A. Belyakov
having a cytolytic effect;

Lysosomal enzyme activators;

Mitochondrial energy blockers;

Initiators of free radical processes;

Ribosomal synthesis inhibitors;

1 capable of influencing various cellular formations.

The distant action of endotoxins is expressed by damage to the systemmicrocirculation topics, which is observed both in the form of isolated extra- and intravascular disorders, and combined changes. to extravascular changes. include dysregulation of peripheral vascular tone, among intravascular fromchanges the main place is given to violations of the rheological state of the blood, violations of transcapillary and transmembrane metabolism.

At the level of interorgan and intersystem influences (dnstaitnoedamage) the action of endotoxins is refracted as follows; Yum (S. A. Simbirtsev, N. A. Belyakov (1994):

"complement and white blood cell activators;

1 activators of the kallikrein-kinin system;

"activators of coagulation and fibrinolysis;

"substances that change the tone of smooth muscles;

Aggregation inductors;

affecting the permeability of the vascular wall.

Conclusion. The development of the process of intoxication can be represented

2. Tissue hypoxia

Tissue hypoxia is caused by endotoxins that disrupt the processes of oxygen uptake at the tissue level. Integral-| Another indicator for assessing the severity of hypoxia is the definition partial pressure oxygen in the arterial blood (p O) (see also chapter 6. ACUTE RESPIRATORY FAILURE-1 ACCURACY).

3. Inhibition of the function of the body's own detoxifying and protective systems

R A necessary link that promotes development and transformation;

SEI in multiple organ failure is (V. A. Ostapenko, 1994):

1. Inhibition (decrease) of the function of organs and systems of natural children.

sycations. These include:

Development of inadequate detoxification, excretory and synergistic
tetic functions of the liver; ;

Excretory function of the kidneys;

Non-respiratory functions of the lungs.

2. Inhibition (decrease) of the body's defense systems. These include:

Secondary immunological deficiency;

Inhibition of natural resistance systems;

Inhibition of antioxidant protection.

Consideration of the pathogenesis of SEI in the light of the interconnectedness and conditionality of various links is of great practical importance in substantiating treatment methods.

Clinic

The characteristic manifestations of SEI are symptoms of a decrease (oppression) of the level of consciousness in their entire range from clear to complete shutdown (see section 23.2. QUANTITATIVE SYNDROMES OF CONSCIOUSNESS DISTURBANCE and chapter 5. Fainting, COLLAPSE, COMA). The existing disorders of consciousness are accompanied by weakness, muscle and headaches, nausea, vomiting, dry mucous membranes, tachycardia, tachy- or bradypnea, hypo- or hyperthermia. At the initial stages of the development of SEI, clinical manifestations do not fully reflect the degree of EI, but subsequently a clear correlation appears between clinical manifestations and laboratory data (see tables 1.13., 1.14.).

Clinical manifestations of SEI are also violations of capillary perfusion, rheological properties of blood, water and electrolyte balance in tissues; violations of vascular tone and deficiency of BCC (with advanced SEI - severe hypotension); blood clotting disorders (thrombosis, DIC); card iodine depression; respiratory distress syndrome; tissue hypoxia, tissue destruction and, as an outcome of the cooperative action of adverse conditions, organ (for example, acute renal) or multiple organ failure,

The clinical manifestations of SEI have much in common with shock states(see Chapter 8. SHOCK CONDITIONS) and in severe cases determine the picture of endotoxic shock. Almost all severe intoxications associated with trauma, ischemia, burns, etc., have a distinct endotoxemic component, i.e., they are accompanied by the appearance of bacterial endotoxins in the blood, even in the absence of diagnosable bacteremia (V.V. Banin, 1994).

Criteria and diagnosis of endogenous intoxications

SEI severity assessment is based on clinical and laboratory data. The latter include the following groups of studies (N. A. Belyakov, M. Ya. Malakhova, 1994). !. Hematological:

NST-test (reflects the activation of peroxidase systems of neutrophils);

Lysosomal-cationic test (determination of cationic proteins of granules of cells);

Degenerative changes in leukocytes (toxigenic granularity, inclusions of Knyazkov-Dele, Amato grains, hypersegmentation of nuclei, etc.);

The ability to transport substances of low and medium molecular weight (VLMW).

2. Biochemical and biophysical:

Substances of medium molecular weight (SMMW) in biological fluids and oligopeptic fractions (OP);

Components of lipid peroxidation (LPO) and antio! sidant system (AOS);

Chemiluminescence of biological fluids and homogenates;|

Electron paramagnetic resonance (EPR); nuclear magnetic resonance (NMR);

Limit hydrocarbons in exhaled air;

Components of inflammatory mediators (biogenic amines, likrein-kinin system, some classes of prostaglandins. new (PG), etc.;

Metabolites characterizing the types of metabolism and functions of vital organs.

3. Microbiological and immunological:

Bacterial toxins (limulus test - determination of bacterial lipopolysaccharides (LPS), immunological detection of bacterial antigens);

Dynamics of microflora oral cavity, pharynx and skin;

Determination of complement components;

Integral assessment of the severity of immunosuppression;

4. Design criteria:

Leukocyte index of intoxication (LII);

Clinical and laboratory indices (Marchuk, Shugaev, Garielyan, Malakhova, Grinev, etc.).

5. Biological testing

During recent years generally recognized biochemical mar! rum of the presence and assessment of the severity of SEI is the definition of c(

them molecules (N. I. Gabrielyan et al., 1981, 1983; V. K. Gostishchev | et al., 1992). At present, the concept of a biological "substrate" has been formed as a measure of the body's metabolic response to an aggressive factor. These are low and medium molecule substances;masses (VNSMM) and oligopeptides (OP)(M. I. Malakhova, 1994, 195

Note. 1. VNSMM are non-protein things of any nature: urea, creatinine, uric acid, glucose, M
The terms used for VLMMM are: medium molecules, substances of medium molecular weight, substances of low and medium molecular weight.

2. OP are peptides with a molecular weight of not more than 10 kD. OPs consist of at least two pools: regulatory (RP) and non-regulatory (NP) peptides. RP - tissue hormones that play an important role in the process of life, the concentration of which in the blood is strictly controlled. NPs have several variants of formation, the main of which are processes of extracellular (in the blood) inorganic unregulated level and unpredictable properties (M, Ya. Malakhova, 1994).

The values ​​of some clinical and biochemical parameters most commonly used to assess the degree of endogenous intoxication are presented in Table. 28 and 29.

The general principles of detoxification are based on the relief of the main links in the pathogenesis of SEI. The leading value belongs to efferent (aimed at excretion) methods of correction. The principles of active detoxification are based on the stimulation and/or modeling of the physiological processes of detoxification. Biological detoxification is based on three main mechanisms (K. Ya. Gurevich, A. L. Kostyuchenko, 1994):

The first of these is the biological transformation of toxicsome substances in the liver. The main role in its implementation is played by the mono-amine oxidase system of the liver, and its functioning is based on the processes of oxidation and the action of BAB enzymes. This mechanism is modeled by such operations as blood oxygenation, blood photomodification, perfusion through xenoorgans, organ sections, and cell suspensions.

The second biological mechanism of detoxification isdeposition and binding of toxic substances. This is realized by the processes of autohemodilution and the functioning of the immune system, which recognizes and binds foreign substances with the help of sorption mechanisms. This mechanism is modeled by a complex of sorption techniques: hemo- and plasma-sorption, lymph-, liquor-sorption, etc.

Elimination is the third important mechanism of detoxification.(removal) of toxic substances. It is provided by the functioning of the kidneys, liver, lungs, gastrointestinal tract, skin. This mechanism is modeled during plasma and cytopheresis, hemodialysis, hemo- and ultrafiltration, etc.

The classification of intra- and extracorporeal methods of efferent therapy, depending on their modeling of biological processes of detoxification, is as follows.

1. Biotransformation of toxic substances:

Indirect electrochemical oxidation of blood;*

Hemoxigenation;

Perfusion through xenoorgans and cell suspensions;

Photo modification of blood.*

2. Dilution and binding (immobilization) of toxic substances:

infusion hemodilution; *

hemosorption;

Stasmosorption;

Lymphosorption;

Gotazmolymphosorption;

Liquorosorption.

3. Elimination (removal) of toxic substances:

Forced diuresis;*

peritoneal dialysis; *

Enterosorption;*

Intestinal dialysis;*

Hemodialysis;

Blood replacement;

Plasmapheresis;

Hemofiltration;

Ultrafiltration.

Note.*Intracorporeal methods of treatment are marked.
(see chapter 5. Syncope, collapse, coma). To determine the reduction (oppression) of the level of consciousness, you can use the scale Ch(see Table 1.5).

Other hallmark SEI is short for "

The appearance of yellowness of the skin and sclera is a gnostic unfavorable sign, since this is evidence; no about the development of acute liver failure and a decrease in the body's detoxification capabilities (see Chapter 12 ACUTE LIVER AND LIVER FAILURE).

With “clean” wounds, despite severe symptoms and toxicity, body temperature may be normal or even slightly reduced. Purulent-inflammatory diseases are characterized by a genetic body temperature with a rise in the evening to 38-40 ° C and a sharp decrease almost to the norm by morning.

Hemodynamic changes in SEI, as well as all others, are not specific. The cause of increased heart rate, with | There may be shock, a reaction to pain, blood loss, and previous heart failure. It should be remembered that lowering, pressure below 90 mm Hg. Art. characteristic of shock AND degree (see the chapter SHOCK CONDITIONS).

The main biochemical parameters of SEI against the background of peritoneum are presented in Table. 2.13.

Surgery. With active intervention at an early stage, days of EY, it is enough to eliminate the cause in order to interrupt the further development of endotoxicosis. In advanced forms, the products of intermediate metabolism accumulate in the vascular bed and parenchymal organs, causing multiple organ failure; therefore, the chemical elimination of the focus of inflammation and its sanitation contribute to the elimination of only individual components of EI.

Conservative treatment patients with EI should be built with a degree of endotoxicosis (VK Gostishchev et al., 1994). Common methods of influencing EI include infusion therapy, various methods of extracorporeal detoxification (see above), and hyperbaric oxygenation.

intoxication varying degrees, M±m

(V.K. Gostishchev et al., 1992).

(lf + mo) x (e-i)

mi - mcelocytes;

c - segmented leukocytes;

then - metamyelocytes;

p - stab leukocytes; pl - plasma cells; lf - lymphocytes; mo - monocytes;

e - eosinophils; 2-3 - stabilization;

4-9 - significant bacterial concentration; Yu and above - bacterial shock. Note. Growth LII and a fall in leukocytosis are a poor prognosis.

The patient must be provided with full parenteral

The total volume of fluid administered during acute intoxication is 4-5 l / day. Of this amount, 2.5-3 liters should be accounted for by crystalloid solutions, the rest - colloids and protein! blood products (plasma, albumin, protein). The choice of infusion-1 transfusion media, their combination are determined by the nature of volemic disorders, deficiency of protein and electrolyte composition of the blood. Correction of the water-electrolyte composition is carried out using saline solutions Ringer-Lock type. Cotion of dysproteinemias is carried out with the help of protein hydrolysates! plasma and proteins.

A simple and widely used treatment for EY is forced diuresis based on natural use! the process of removing toxic substances from the body. Preliminary, moderate hemodilution is carried out, for which solutions of crystals * are used, low molecular weight dextrans, and in case of hypovolemia - 1000 ml of saline, 200 ml 4% sodium bikau bonate solution and 400 ml of rheopolyglucin, then mannitol from calculation 1 - 1.5 g / kg or 40-80 mg of lasix; after that, the infusion of a glucose solution, protein preparations (blood plasma, alb-min solution, protein hydrolyzate) is continued in a volume of 1000-1500 ml. In addition, the composition of transfusion media includes solutions of porridge chloride (40-60 ml of a 10% solution or 100-120 ml of a 4% solution fractionally), sodium chloride (50 ml of a 10% solution), calcium chloride (30-10% solution) to correct the inevitable carrying out the technique of forced diuresis, loss of electrolytes. Treatment is under the control of hourly diuresis and CVP, electr

Antibacterial therapy is carried out with drugs widely! spectrum of action in a combination of three drugs of different groups. P] this takes into account the type of microorganism and its sensitivity to the drug.

As immunocorrective therapy, immune modulators are used: Taktivin (synonym: T-activin) 1 ml 0.01 % dissolve ra i/k(daily, course of 10-12 injections), thymalin, adults 5-20 mg daily (30-100 mg per course), levamisole (usually 50 m * 3 times a day for 4-5 days, repeat the course after 7 days; il! 150 mg 1 time / day, course 5-7 days), diucifon 0.1 g 3-4 times a day or injected intramuscularly 4 ml 5% solution (0.2 g) 1 time per day.

LITERATURE

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2. Belyakov N. A., Malakhova M. Ya. Criteria and diagnosis of endogenous intoxications. In: Endogenous intoxications. Abstracts of the international symposium June 14-16, 1994. - St. Petersburg, 1994. - S. 60-62.

3. N. I. Gabrielyan, E. R. Levitsky, O. I. Shcherbakov, et al. Hypothesis of medium molecules in the practice of clinical nephrology. // Ter. arch., 1983, No. 6. - S. 76-78.

4. Gostishchev V.K., Sazhin V.P., Avdovenko A.L. Peritonitis. - M.: Medicine, 1992. - 224 p.: ill.

5. Gurevich K. Ya., Kostyuchenko A. L. Modern concept application of methods of efferent therapy for endogenous intoxication. In: Endogenous intoxications. Abstracts of the international symposium June 14-16, 1994 - St. Petersburg, 1994. - P. 89-94.

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7. Luzhnikov E. A., Goldfarb Yu. S. Pathogenesis of endotoxicosis in acute exogenous poisoning and methods for its correction. In: Endogenous intoxications. Abstracts of the International Symposium June 14-16, 1994 - St. Petersburg, 1994. - S. 37.

8. Malakhova M. Ya. Formation of the biochemical concept “substrate of endogenous intoxication*. In: Endogenous intoxications. Abstracts of the international symposium June 14-16, 1994 - St. Petersburg, 1994. - P. 38.

9. Malakhova M. Ya. Methods of biochemical registration of endogenous intoxication. // Efferent therapy, 1995., Volume 1, No. 1. - S. 61-64.

10. Malakhova M. Ya., Belyakov N. A., Simbirtsev S. A., Ershov A. L. Quantitative assessment of the severity of the critical state and phases of development of endogenous intoxication. In: Endogenous intoxications; Abstracts of the International Symposium June 14-16, 1994 - St. Petersburg, 1994. - P. 77.

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12. A guide for emergency physicians./Ed. V. A. Mikhailovich, A. G. Miroshnichenko. - 3rd ed., revised. and additional - St. Petersburg: "Nevsky dialect", 2001. - 704 p.: ill.

I. Simbirtsev SA, Belyakov NA Pathophysiological aspects of endogenous intoxications. In: Endogenous intoxications. Abstracts of the International Symposium June 14-16, 1994 - St. Petersburg, 1994.-S. 5-9.