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systemic inflammatory response syndrome

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  1. 1. Systemic Inflammatory Response Syndrome Dr. Vinayak
  2. 2. <ul><li>Shock associated with sepsis syndrome is common cause of death in surgical intensive care units. </li></ul><ul><li>Patient in shock from sepsis are at risk for subsequent multiple organ failure. </li></ul><ul><li>Multiple organ failure can be caused by an exaggerated endogenous inflammatory response to invasive infection. </li></ul><ul><li>Ultimate survival of infected patient in shock may depend on therapies that ameliorate the immune response while the patient retains the capacity to kill invading microorganisms. </li></ul>
  3. 3. <ul><li>Bone and colleagues defined four categories of clinical disease that represented successive levels of escalating severity of inflammatory response </li></ul><ul><li>Consensus conference described the response to infection as beginning with a systemic inflammatory response syndrome (SIRS). </li></ul><ul><li>SIRS is not exclusively a reaction to infection but can also be observed in response to the sterile insult of pancretitis, aspiration pneumonitis , burns, trauma and post-surgery. </li></ul>
  4. 4. Criteria for four categories of systemic inflammatory response syndrome <ul><li>Systemic inflammatory response syndrome (SIRS)‏ </li></ul><ul><li>Two or more of the following, </li></ul><ul><li>due to either an infectious or a noninfectious </li></ul><ul><li>etiology: </li></ul><ul><li>• Temperature 38C or 36C </li></ul><ul><li>• Respiratory rate 24 breaths/ min </li></ul><ul><li>• Heart rate 90 beats/ min </li></ul><ul><li>• WBC count 12,000/L or 4000/L, or 10% </li></ul><ul><li>immature (bands) cells in peripheral </li></ul><ul><li>blood smear </li></ul>
  5. 5. <ul><li>Sepsis— </li></ul><ul><li>same criteria as SIRS with clearly </li></ul><ul><li>established focus of infection </li></ul>
  6. 6. <ul><li>Severe sepsis— </li></ul><ul><li>Sepsis associated with organ dysfunction and </li></ul><ul><li>hypoperfusion </li></ul><ul><li>Indicators of hypoperfusion : </li></ul><ul><li>Systolic blood pressure <90 mmhg </li></ul><ul><li>>40 mmhg fall from normal systolic blood pressure </li></ul><ul><li>Lacticacidemia </li></ul><ul><li>Oliguria </li></ul><ul><li>Acute mental status changes </li></ul>
  7. 7. <ul><li>Septic shock — </li></ul><ul><li>Patient with sever sepsis who: </li></ul><ul><li>Are not responsive to intravenous fluid </li></ul><ul><li>infusion for resuscitation </li></ul><ul><li>Require inotropic or vasopressor agents to </li></ul><ul><li>maintain systolic blood pressure </li></ul>
  8. 8. <ul><li>Majority of SIRS patient have clinically suspected or culture-positive site of infection. </li></ul><ul><li>Four most common sites of infection: </li></ul><ul><li>pulmonary </li></ul><ul><li>bloodstream </li></ul><ul><li>genitourinary tract </li></ul><ul><li>intra-abdominal infections </li></ul>
  9. 9. <ul><li>Bacterias responsible for septic shock: </li></ul><ul><li>Gram positive sepsis 44% </li></ul><ul><li>Gram negative sepsis 44% </li></ul><ul><li>Fungamia 3% </li></ul><ul><li>Mixed infections in remaining cases </li></ul>
  10. 10. <ul><li>Top three gr +ve bacterias </li></ul><ul><li>Staphylococcus aureus </li></ul><ul><li>Enterococcus species </li></ul><ul><li>Coagulase negative staphylococcus species </li></ul><ul><li>Top three gr -ve bacterias </li></ul><ul><li>Escherichia coli </li></ul><ul><li>Klebsiella species </li></ul><ul><li>Pseudomonas aeruginosa </li></ul>
  11. 11. <ul><li>It indicates that with new diagnosis of SIRS blood culture should be obtain as well as culture from suspected sites before instituting empirical therapy with antibiotics </li></ul><ul><li>Broad spectrum antibiotics may prevent progression to septic shock </li></ul><ul><li>Emperical antifungal therapy should not be routinely given unless patient is immunocompromised </li></ul><ul><li>Toxins released by bacteria killed by antibiotics are capable of provoking the inflammatory response </li></ul>
  12. 12. SIRS as an Exaggerated Inflammatory Response <ul><li>Systemic inflammatory response syndrome (SIRS)‏ </li></ul><ul><li>Definition </li></ul><ul><li>Delocalized and dysregulated inflammation process of high intensity. It leads to disorders of microcirculation, organ perfusion and finally to secondary organ dysfunction. </li></ul>
  13. 13. <ul><li>This secondary dysfunction is not due to primary insult, but due to autoaggressive systemic inflammatory response of the organism to the primary insult. </li></ul><ul><li>This systemic inflammatory response syndrome (SIRS), leads without therapeutic intervention to multiple organ dysfunction syndrome (MODS) and death. </li></ul>
  14. 14. Pathogenesis <ul><li>Proinflammatory cytokines: </li></ul><ul><ul><li>TNF – alpha </li></ul></ul><ul><ul><li>IL - 1, IL – 6, IL – 8, IL – 12 </li></ul></ul><ul><ul><li>Interferon – gamma </li></ul></ul><ul><li>Anti-inflammatory cytokines </li></ul><ul><ul><li>IL – 4, IL – 10, IL – 13 </li></ul></ul><ul><ul><li>Transforming growth factor (TGF) - beta </li></ul></ul>
  15. 15. Systems responsible for inflammatory response
  16. 16. Pathogenesis <ul><li>Proinflammatory cytokines activate: </li></ul><ul><ul><li>Biochemical systems </li></ul></ul><ul><ul><ul><li>Complement, coagulation, kinin, etc. </li></ul></ul></ul><ul><ul><li>Endothelial cells </li></ul></ul><ul><ul><li>PMN's/platelets </li></ul></ul><ul><ul><li>Release of secondary mediators </li></ul></ul><ul><ul><ul><li>NO, prostaglandins, vasoactive agents, endorphins, free-O 2 radicals, etc. </li></ul></ul></ul>
  17. 17. The complex interactions involved in SIRS with both beneficial and deleterious effects
  18. 19. Pathways for recovery from SIRS or progression to MODS
  19. 20. Sepsis Mechanisms of Injury <ul><li>Ischemia </li></ul><ul><li>Cytopathic injury </li></ul><ul><ul><li>Massive proinflammatory response </li></ul></ul>
  20. 21. Septic Shock Pathophysiology: Cardiovascular <ul><li>Systemic circulation </li></ul><ul><ul><li>Arterial & venous dilation </li></ul></ul><ul><ul><li>Biventricular depression of the ejection fraction with ventricular dilatation. </li></ul></ul>
  21. 22. Septic Shock Pathophysiology: Vascular <ul><li>Regional circulation </li></ul><ul><ul><li>Altered blood flow </li></ul></ul><ul><li>Microcirculation </li></ul><ul><ul><li>Development of microthrombi </li></ul></ul><ul><ul><ul><li>Decreased functional capillaries </li></ul></ul></ul><ul><ul><li>Abnormal O 2 utilization </li></ul></ul><ul><ul><li>Increased microvascular permeability </li></ul></ul>
  22. 23. Sepsis Specific Organ Responses <ul><li>Lung: </li></ul><ul><ul><li>V/Q mismatch </li></ul></ul><ul><ul><ul><li>Hypoxemia </li></ul></ul></ul><ul><ul><li>Increased microvascular permeability </li></ul></ul><ul><ul><ul><li>Interstitial/alveolar edema </li></ul></ul></ul><ul><ul><li>ARDS </li></ul></ul>
  23. 24. Sepsis Specific Organ Responses <ul><li>Gastrointestinal: </li></ul><ul><ul><li>Impaired GI motility </li></ul></ul><ul><ul><ul><li>Bacterial translocation >> MODS </li></ul></ul></ul><ul><ul><li>Stress-ulcer GI bleeding </li></ul></ul><ul><ul><li>Hepatic dysfunction </li></ul></ul>
  24. 25. Sepsis Specific Organ Responses <ul><li>Kidney: </li></ul><ul><ul><li>Altered renal function </li></ul></ul><ul><ul><li>ATN/ acute renal failure </li></ul></ul><ul><ul><ul><li>Increases mortality rate </li></ul></ul></ul><ul><li>Neurologic: </li></ul><ul><ul><li>Encephalopathy </li></ul></ul><ul><ul><li>Peripheral polyneuropathy </li></ul></ul><ul><ul><ul><li>68% - 100% </li></ul></ul></ul>
  25. 26. Sepsis Specific Organ Responses <ul><li>Hematologic: </li></ul><ul><ul><li>Leukocytosis/leukopenia </li></ul></ul><ul><ul><li>Thrombocytopenia </li></ul></ul><ul><ul><li>Coagulopathy </li></ul></ul><ul><ul><li>DIC </li></ul></ul><ul><ul><ul><li>~ 15% - 20% </li></ul></ul></ul>
  26. 27. Management The key of management is early recognition of the condition <ul><li>The priorities in the management are ABCs . </li></ul><ul><li>First priority is to secure adequate airway and oxygenation. </li></ul><ul><li>Suplemental oxygen to be given to all patients. </li></ul><ul><li>Adequate amount of fluids to restore the perfusion of the vital organs . </li></ul>
  27. 28. Cardiovascular support <ul><li>preload - MAP </li></ul><ul><li>Contractility – Sr. Ca, Sr.Mg,hypoxemia, beta blockers </li></ul><ul><li>Inotropic agents </li></ul><ul><li>afterload </li></ul>
  28. 29. Hematologic support <ul><li>Transfusion of platelets </li></ul><ul><li>Transfusion of FFP </li></ul>
  29. 30. Monitoring <ul><li>Respiratory monitoring </li></ul><ul><li>Cardiovascular monitoring </li></ul>
  30. 31. Indications for ICU admission <ul><li>Intubation for airway support </li></ul><ul><li>Respiratory failure requiring higher FIO2. or reqiring mechanical ventilation </li></ul><ul><li>Requiring advanced cardiovascular / inotropic support </li></ul><ul><li>Renal replacement therapy </li></ul>
  31. 32. Summary <ul><li>SIRS is systemic inflammatory response to variety of stimuli </li></ul><ul><li>Infection is present in only 50% of cases </li></ul><ul><li>Once systemic response has been initiated it continues despite being self harming </li></ul><ul><li>Prompt diagnosis and effective resuscitations are essential </li></ul><ul><li>Progression to MODS carries high mortality rate </li></ul>