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Download MBBS General Surgery PPT 13 Systemic Inflammatory Response Syndrome Lecture Notes

Download MBBS (Bachelor of Medicine, Bachelor of Surgery) General Surgery PPT 13 Systemic Inflammatory Response Syndrome Lecture Notes

This post was last modified on 07 April 2022


Systemic Inflammatory Response

Syndrome,MODS,Sepsis

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Infection

Presence of organisms in a closed space or

location

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where not normally found

Infection


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SIRS: Systemic Inflammatory Response Syndrome

A 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 Inflammation

Sepsis:

? 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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Infection

Physiologic

Inflammation

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Biochemical

Severe

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Sepsis

Specific 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 arising

SIRS 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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or

4,000/mm3 or >10%

immature neutrophils

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Sepsis: Defining a Disease Continuum

Infection/

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Trauma

SIRS 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 delivery

Inadequate

Excessive

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and support

Resuscitation

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Inflammatory

Response

Recovery

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SIRS/MODS

Initiation of Inflammatory Response

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From Wheeler & Bernard, NEJM 1999


Homeostasis 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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Operation

Tissue Injury

optimal oxygen

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Inadequate

Excessive

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delivery and support

Resuscitation

Inflammatory

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Response

Recovery

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SIRS/MODS

Regulation of oxygen delivery

Normal

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Abnormal

Cardiac

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output

BP=CO * SVR

Cardiac

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Output

regional distribution

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regional distribution

Intra Organ Distribution

Intra Organ Distribution

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Microcirculation

Microcirculation

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QO2 = Flow * O2 content
Oxygen 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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Q

III

IV

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NADH + H+

H+

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1/2 O2 + H+ H2O

NAD+

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