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

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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