Systemic Inflammatory Response
Syndrome,MODS,Sepsis
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InfectionPresence of organisms in a closed space or
location
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where not normally foundInfection
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SIRS: Systemic Inflammatory Response SyndromeA clinical response arising from a
nonspecific insult manifested by 2 of the
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fol owing:
? Temperature: 38?C or 36?C
? HR: 90 beats/min
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? Respirations: 20/min? WBC count: 12,000/mL or 4,000/mL
or >10% immature neutrophils
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Sepsis: More Than Just InflammationSepsis:
? Known or suspected infection
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? SIRS criteria
Severe Sepsis: Acute Organ Dysfunction
? Severe Sepsis =
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Sepsis with signs of acute organ
dysfunction in any of the fol owing
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systems:? Cardiovascular (septic shock)
? Renal
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? Respiratory
? Hepatic
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? Hemostasis? CNS
? Unexplained metabolic acidosis
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Sepsis: A Complex Disease
Septic Shock:
Sepsis induced with hypotension despite adequate resuscitation along with
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the presence of perfusion abnormalities which may include, but are not limited
to lactic acidosis, oliguria, or an acute alteration in mental status
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Multiple Organ Dysfunction Syndrome (MODS):Presence of altered organ function in an acutely il patient such
that homeostasis cannot be maintained without intervention
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InfectionPhysiologic
Inflammation
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Biochemical
Severe
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SepsisSpecific Organ
Severity
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Predisposition
? Pre-existing disease
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? Cardiac, Pulmonary, Renal? HIV
? Age (extremes of age)
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? Gender (males)? Genetics
? TNF polymorphisms (TNF promoter high secretor genotype)
Response
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Physiology
Markers of Inflammation
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? Heart rate? TNF
? Respiration
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? IL-1
? Fever
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? IL-6? Blood pressure
? Procalcitonin
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? Cardiac output
? PAF
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? WBC? Hyperglycemia
Organ Dysfunction
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? Lungs
? Adult Respiratory Distress Syndrome
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? Kidneys? Acute Tubular Necrosis
? CVS
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? Shock
? CNS
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? Metabolic encephalopathy? PNS
? Critical Il ness Polyneuropathy
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? Coagulation
? Disseminated Intravascular Coagulopathy
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? GI? Gastroparesis and ileus
? Liver
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? Cholestasis
? Endocrine
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? Adrenal insufficiency? Skeletal Muscle
? Rhabdomyolysis
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Sepsis: Defining a Disease Continuum
Infection/
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Trauma
SIRS Sepsis Severe Sepsis
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A clinical response arisingSIRS with a presumed or
from a nonspecific insult,
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confirmed infectious
including 2 of the following:
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process? Temperature 38oC or
36oC
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? HR 90 beats/min
? Respirations 20/min
? WBC count 12,000/mm3
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or4,000/mm3 or >10%
immature neutrophils
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Sepsis: Defining a Disease Continuum
Infection/
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TraumaSIRS Sepsis Severe Sepsis
? Sepsis with 1 sign of organ failure
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? Cardiovascular (refractory
hypotension)
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? Renal? Respiratory
? Hepatic
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Shock
? Hematologic
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? CNS? Unexplained metabolic
acidosis
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Pathogenesis of SIRS/MODS
Preoperative Il ness
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Trauma or Operation
Tissue Injury
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optimal oxygen deliveryInadequate
Excessive
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and support
Resuscitation
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InflammatoryResponse
Recovery
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SIRS/MODS
Initiation of Inflammatory Response
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From Wheeler & Bernard, NEJM 1999Homeostasis is unbalanced in Severe Sepsis
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Carvalho AC, Freeman NJ. J Crit Il ness. 1994;9:51-75; Kidokoro A et al. Shock. 1996;5:223-8;Vervloet MG et al. Semin Thromb Hemost. 1998;24:33-44.
Coagulation and Fibrinolysis
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Bernard, GR. NEJM 2001;344;10:699-709
Pathogenesis of SIRS/MODS
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Preoperative Illness
Trauma or
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OperationTissue Injury
optimal oxygen
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Inadequate
Excessive
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delivery and supportResuscitation
Inflammatory
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Response
Recovery
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SIRS/MODSRegulation of oxygen delivery
Normal
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Abnormal
Cardiac
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outputBP=CO * SVR
Cardiac
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Output
regional distribution
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regional distributionIntra Organ Distribution
Intra Organ Distribution
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Microcirculation
Microcirculation
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QO2 = Flow * O2 contentOxygen Delivery
? Delivery: Demand mismatch
? Diffusion limitation (edema)
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Oxygen Consumption
H+
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H+Cytc
H+
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H+
I
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QIII
IV
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NADH + H+
H+
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1/2 O2 + H+ H2ONAD+
ADP + Pi
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ATP
?Pyruvate Dehydrogenase (PDH) activity decreased
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?Decreased delivery of Acetyl CoA to TCA cycle?Mitochondrial dysfunction
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Severe Sepsis:The Final Common Pathway
Endothelial Dysfunction and Microvascular
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Thrombosis
Hypoperfusion/Ischemia
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Acute Organ Dysfunction(Severe Sepsis)
Death
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Components:? Early Recognition
? Early Goal-Directed Therapy
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? Monitoring
? Resuscitation
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? Pressor / Inotropic Support? Steroid Replacement
? Recombinant Activated Protein C
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? Source Control
? Glycemic Control
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? Nutritional Support? Adjuncts:
? Stress Ulcer Prophylaxis, DVT Prophylaxis, Transfusion, Sedation, Analgesia,
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Organ Replacement