Systemic inflammatory response syndrome

1. SIRS
DR ASWIN RM
11-06-2015

2. SPECTRUM
SIRS MODS INFECTION
BACTEREMIA SEPSIS SEPTIC SHOCK

3. SIRS
Dysregulation of the normal immune response
Infectious or non infectious Trigger
Massive and uncontrolled release of pro inflammatory
cytokines
Chain of events that leads to widespread tissue injury
Progresses to MODS

4. CRITERIA 2 out 4
Fever >38°C [>100.4°F]
or
Hypothermia
<36°C[<96.8°F]
(oral temperature)
Tachypnea
>24 breaths/min
Tachycardia
heart rate >90 beats/min
Leukocytosis (>12,000/μL),
Leukopenia (<4000/μL), or
>10% bands

5. SIRS ETIOLOGY

6. SIRS-NON INFECTIOUS CAUSES
Acute pancreatitis
Trauma
Post Cardiac Arrest
Burns
Surgery
Autoimmune disorders
Vasculitis
Infarctions
Thromboembolism

7. SIRS & MODS - PATHOPHYSIOLOGY
Release of mediators
Direct damage to
endothelium
Hypermetabolism
Vasodilation leading to dec
SVR
Inc in vascular permeability
Activation of coagulation
cascade

8. SIRS & MODS - PATHOPHYSIOLOGY
Organ and metabolic dysfunction due to
• Hypotension
• Decreased perfusion
• Formation of microemboli
• Redistribution or shunting of blood

9. MODS
Multi Organ Dysfunction Syndrome
At least 2 organ systems
Altered organ function in an acutely ill patient
Such that body homeo stasis cannot be maintained without intervention
PRIMARY- direct injury by the causative disease itself Ex
Rhabdomyolysis and acute kidney injury
SECONDARY - organ failure not in direct response to the insult itself but as a
consequence of a host response to the insult , Ex: ARDS in pancreatitis

10. MODS
SIRS and MODS represent ends of a continuum
Transition from SIRS to MODS DOES NOT occur in a clear-
cut manner

11. ORGAN HYPOFUNCTION
CARDIOVASCULAR
•Myocardial
depression
•Massive vasodilation
•Increased
permeability and
capillary leak
KIDNEYS
•Acute renal failure
•Hypoperfusion
•Release of mediators
•Activation of renin–
angiotensin–
aldosterone system
•Nephrotoxic drugs,
especially antibiotics
LUNGS
•Alveolar edema
•Decrease in surfactant
•Increase in shunt
•V/Q mismatch
•End result: ARDS
LIVER & GIT
•Cholestasis
•Transaminitis
•Motility decreased:
•Abdominal
distention and
paralytic ileus
•Decreased perfusion:
•Risk for ulceration
and GI bleeding
•Ischemic colitis
•Potential for bacterial
translocation
BLOOD
•Anemia
•TCP
•Coagulopathy
•DIC

12. ORGAN HYPOFUNCTION CONTD…
Metabolic
•Hyperglycemia–
hypoglycemia
• Insulin
resistance &
Catabolic state
• Lactic acidosis
CNS
• Encephalopathy
PNS
• Critical illness
neuropathy
Endocrine
• Adrenal
insufficincy
Skeletal muscle
• Rhabdomyolisis

13. SOFA SCORE
Stage1
• patient has increased volume requirements and mild respiratory
alkalosis which is accompanied by oliguria, hyperglycemia and
increased insulin requirements
Stage2
• the patient is tachypneic, hypocapnic and hypoxemic; develops
moderate liver dysfunction and possible hematologic abnormalities
Stage3
• the patient develops shock with azotemia and acid-base disturbances;
has significant coagulation abnormalities
Stage 4
• the patient is vasopressor dependent and oliguric or anuric;
subsequently develops ischemic colitis and lactic acidosis
Multiple Organ Dysfunction Score
Four clinical phases have been suggested

14. INFECTION
Entry of a new Pathogen into the body
May or may not result in bacteremia

15. BACTEREMIA
Presence of bacteria in blood,
As evidenced by positive blood cultures

16. SEPTICEMIA AND SEVERE SEPSIS
SIRS
Evidence of
bacterial
infection
SEPSIS &
SEVERE
SEPSIS
Some degree
of organ
hypofunction

17. ORGAN HYPOFUNCTION
Cardiovascular
•Systolicblood pressure
≤90 mmHg or
•Mean arterial pressure
≤70 mmHg
•That responds to
administration of IV fluid
Renal
•Urine output <0.5 mL/kg
per hour for 1 hour
•despite adequate fluid
resuscitation
Respiratory
•Pao2/Fio2 ≤250 or
•if the lung is the only
dysfunctional organ,≤200
Hematologic
•Platelet count<80,000/μL
or
•50% decrease in platelet
count from highest value
recorded over previous 3
days
Unexplained metabolic
acidosis
•A pH ≤7.30 or
•Base deficit ≥5.0 mEq/L
•Plasma lactate level >1.5
times upper limit of
normal for reporting lab

18. • Sepsis with hypotension (arterial blood pressure <90 mmHg
systolic, or 40 mmHg less than patient’s normal blood
pressure)
• for at least 1 h
• despite adequate fluid resuscitation
• or
• Need for vasopressors to maintain systolic blood pressure ≥90
mmHg or mean arterial pressure ≥70 mmHg
Severe septic
shock
• Septic shock that lasts for >1 h and
• does not respond to fluid or pressor administration
Refractory
septic shock

20. THANK YOU