Endotoxemia

Syndrome of endogenous intoxication (endotoxemia) is the accumulation of endotoxins in the blood and tissues of the body.

Endotoxins are substances that have a toxic effect on the body. They, in turn, can be the products of the vital activity of the organism itself, or they can enter it from the outside.

Endogenous intoxication syndrome is one of the most acute problems in intensive care, as it accompanies a large number of pathological conditions, including shock, pancreatitis, peritonitis, etc. A pronounced endogenous intoxication syndrome can lead to death.

Causes of endogenous intoxication syndrome

The causes of endogenous intoxication syndrome can be very diverse. However, this process always develops when endotoxins enter the bloodstream from the sites of their formation. Through the blood, endotoxins are distributed to organs and organ systems, as well as to all tissues of the body. When the amount of aggressive components and endotoxins exceeds the natural capacity of the body in their biotransformation, endogenous intoxication syndrome occurs.

There are the following causes of endogenous intoxication syndrome:

• Diseases that occur with a purulent-inflammatory reaction in the body. These include cholecystitis, acute pneumonia, peritonitis, pancreatitis, etc.

• Severe and complex injuries: crash syndrome.

• Some chronic diseases in the acute stage, for example, diabetes mellitus, thyrotoxic goiter.

• Body poisoning.

The primary mechanisms for the occurrence of endogenous intoxication syndrome are as follows:

• resorption mechanism. When this occurs, the resorption of toxic substances (necrotic masses, inflammatory exudate) from a limited focus of infection throughout the body. This process can be started with intestinal obstruction, with abscesses, with soft tissue phlegmon, etc.

• Exchange mechanism for the development of endogenous intoxication syndrome. It is caused by excessive production of toxic substances. This mechanism of development is typical for pneumonia, acute pancreatitis, diffuse peritonitis.

• retention mechanism. According to this type, the syndrome of endogenous intoxication develops if the process of removing toxins from the body directly suffers, that is, the work of the detoxification organs is disrupted.

• reperfusion mechanism. The penetration of endotoxins into the blood occurs from tissues that have been in a state of ischemia for a long time, while the antioxidant barrier of the body has lost its consistency. This can occur in shock conditions, during surgical intervention using AIC, etc.

• The mechanism of secondary toxic aggression, in which tissues respond with a toxic reaction to the effects of endotoxins.

• An infectious mechanism in which pathogenic microorganisms from the foci of invasive infection act as endotoxins.

Classification of endotoxins

Endotoxins are those substances that lead to the formation of endotoxemia and endogenous intoxication syndrome.

The following endotoxins are distinguished, depending on the mechanism of their formation:

• Enzymes that, after activation by one or another pathological process, begin to damage tissues. These can be proteolytic and lysosomal enzymes, as well as activation products of the kallikrein-kinin system.

• The products of the natural vital activity of the body can act as endotoxins, provided they are accumulated in high concentrations. These include urea, bilirubin, etc.

• All biologically active substances that are present in the human body. These can be inflammatory mediators, cytokines, prostaglandins, etc.

• Aggressors that arise from the breakdown of foreign antigens and immune complexes.

• Toxins released by microbes or other pathological agents.

• Medium molecular substances (viruses, allergens, cholesterol, etc.).

• Products that arise during lipid peroxidation.

• Products that appear as a result of cell breakdown when their membranes are damaged by destructive processes. These can be proteins, myoglobin, lipases, phenol, etc.

• High concentrations of components of regulatory systems.

Endotoxins can have a direct and indirect effect on the body, they can affect microcirculation, the processes of synthesis and metabolism in tissues.

Symptoms of endogenous intoxication syndrome

One of the leading symptoms of endotoxemia is depression of consciousness. Its complete loss or partial reduction is possible. In parallel, the patient has severe headaches, muscle weakness appears, and myalgia is characteristic.

As the intoxication of the body progresses, nausea and vomiting join. As the patient’s body loses fluid, the mucous membranes become dry.

Tachycardia or bradycardia develops. Body temperature can rise and, conversely, fall.

Since endogenous intoxication often occurs against the background of a state of shock, the symptoms of endotoxic shock come to the fore. Certain endotoxins of a bacterial nature will definitely be present in the blood in severe human conditions, even in the absence of bacteremia. This does not depend on what provoked the syndrome of endogenous intoxication: trauma, burns, tissue ischemia, etc. Only the severity of the person’s condition is important.

Degrees of endogenous intoxication

Doctors distinguish three degrees of severity of endogenous intoxication syndrome, each of which has its own criteria:

Diagnosis of endogenous intoxication syndrome

Diagnosis of endogenous intoxication syndrome is built on the basis of an assessment of the severity of a person’s condition according to characteristic symptoms (skin tone, respiratory and heart rate, etc.). In addition, blood tests are required.

The results obtained are processed, and they will show a change in such indicators as:

• A significant increase in the number of leukocytes in venous blood.

• Exceeding the leukocyte and nuclear index of intoxication. Although sometimes these indicators can be underestimated, which indicates the failure of the hematopoietic system and detoxification of the body.

• Increase in the index of intoxication. If it exceeds 45, then this clearly indicates an imminent death.

• It is necessary to estimate the concentration of total protein in blood plasma.

• An increase in bilirubin levels.

• Increase in creatinine and urea levels.

• Increasing the concentration of lactic acid.

• An increase in the coefficient of cells of non-specific protection relative to cells of specific protection. A coefficient greater than 2,0 indicates a serious condition of the patient.

• The most sensitive sign of endotoxication is an increase in the level of the medium mass molecule.

Treatment of endogenous intoxication syndrome

Treatment of endogenous intoxication syndrome involves the removal of toxic components from the body and from the blood with an initial decrease in their concentration. Active detoxification is prescribed when 2 or 3 degrees of severity of the pathological syndrome are established.

Biological intoxication is always based on the following mechanisms:

• Biological transformation of endotoxic components in the liver. To start this mechanism, hemooxygenation, chemical oxidation of blood (indirect), its photomodification are performed. It is possible to carry out perfusion through cell suspensions or xenoorgans.

• Binding and dilution of endotoxic components. For this purpose, it is possible to perform sorption measures aimed at removing endotoxic components from the blood, from plasma, from lymph, from cerebrospinal fluid.

• Removal of endotoxic components. To implement this mechanism, the liver, kidneys, gastrointestinal tract, skin and lungs are involved. The patient undergoes intestinal dialysis, hemodialysis, enterosorption, plasmapheresis, hemo- and ultrafiltration, blood replacement, diuresis is forced.

During the period of acute intoxication, the total daily volume of water administered through a dropper should be at the level of 4-5 liters. Moreover, 2,5-3 liters should be crystalloid solutions, and the rest – colloidal and protein blood products: plasma, albumin, protein.

Forced diuresis is considered a simple and commonly used treatment for endotoxicity, which is based on the application of the body’s natural process of removing toxins from the body.

The prognosis for the syndrome of endogenous intoxication directly depends on the severity of the patient’s condition and on the root cause that led to the development of pathology.