28. bpm = beats per minute; MAP = mean arterial pressure; SBP = systolic blood pressure; s.d. = standard deviations; SVO 2 = venous oxygen saturation; WBC = white blood cell count. Table 6-1 Criteria for Systemic Inflammatory Response Syndrome General variables Hemodynamic variables Fever [core temp >38.3°C (100.9°F)] Arterial hypotension (SBP <90 mmHg, MAP <70, or SBP decrease >40 mmHg) Hypothermia [core temp <36°C (96.8°F)] SVO 2 >70% Heart rate >90 bpm Cardiac index >3.5 L/min per square meter Tachypnea Organ dysfunction variables Altered mental status Arterial hypoxemia Significant edema or positive fluid balance (>20 mL/kg over 24 h) Acute oliguria Hyperglycemia in the absence of diabetes Creatinine increase Inflammatory variables Coagulation abnormalities Leukocytosis (WBC >12,000) Ileus Leukopenia (WBC <4000) Thrombocytopenia Bandemia (>10% band forms) Hyperbilirubinemia Plasma C-reactive protein > 2 s.d. above normal value Tissue perfusion variables Plasma procalcitonin >2 s.d. above normal value Hyperlactatemia Decreased capillary filling
Editor's Notes
The normal endothelial tissue has tight junctions but in inflammation the vessels are dilated and become disjointed and it allows for fluid to pass that barrier easier than normal. The increased fluid to the area is what causes the swelling and pain associated with inflammation
Excessive triggering of the bodys natural defense mechanisms
Despite adequate fluid resuscitation in the absence of other causes of hypotension ex: Medications (BP, cholinergic drugs, CA-I, EtOH)
Seems to be a acronym to remember what signs to look for in sepsis P: immunocompromised states I: Bacterial introduced R: The inflammatory response couple with the coagulation response, the feed off each other, and amplify the response O: hypoperfusion, that causes (liver, kidney, GI, myocardial) dysfunction
Gram (-) Enterobacteriaceae E. Coli Klebsiella species Pseudomonas aeruginosa Gram (+) Staphylococci S. aureus Coagulase-negative staphylococcus Streptococci Strep. pyrogens Strep. pneumoniae Fungal Candida
APP: a type of protein whose plasma concentration either increases or decreases in response to inflammation , during the acute-phase response - 2 groups: (Positive and Negative) Positive associated with anti-inflammatory response: [destroy and inhibit microbes/neg feedback of inflammatory response} vs Negative associated with pro-inflammatory response
Toxic stimulus activates macrophages “recognition cells” and produce cytokines (TNF and IL-1) Neutrophils “effector cells” are then activated and adhere to epithelial cells, aggregate and formation of the microthrombus begins During this time more cytokines are formed and cause alterations to the microvascular wall Results in microvascular injury
Sepsis in different organ systems
Hepatocytes, Kupffer cells, and sinusoidal cells interactions Early: tx infection control, oxygenation, ample fluid administration and eventually transfusion and use of vasoactive drugs (like pressors and dobutamine)
The digestive tract's immune system is often referred to as gut-associated lymphoid tissue (GALT) and works to protect the body from invasion. GALT is an example of mucosa-associated lymphoid tissue
Boitano, Megan. “Hypocaloric Feeding of the Critically Ill”. December 2006, ASPEN. 2006. 21:617-622 Stress Response trauma, cardiogenic shock, sepsis, MOF and Severe acute pancreatitis
JPEN May/June 2009 Guidelines
Septic Autocannabalism Malnutrition compromised the bodys ability to mount a adequate inflammatory response to stressors
Reports of non-occlusive bowel necrosis, which suggest that early initiation of EN can be harmful Inappropriate EN into a dysfunctional gut plays a pathogenic role
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