Transcript GETTING TO KNOW SIRS

DR. AKINWUNMI AKINWUNTAN
M.B;BS(Ib), MHSc (Ib), FMCOG, FWACS
BACKGROUND
• Localized inflammation is a physiological
protective response which is generally
tightly controlled by the body at the site
of injury
• Loss of this local control or an overly
activated response results in an
exaggerated systemic response which is
clinically identified as Systemic
Inflammatory Response Syndrome (SIRS)
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DEFINITION
• Is an inflammatory state affecting the whole
body, frequently a response of the immune
system to infection, but not necessarily so
ICD-10
• The active pathways leading to such
pathophysiology may include fibrin deposition,
platelet aggregation, coagulopathies and
leukocyte liposomal release
• First described in 1983 – Dr. William Nelson
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CAUSES OF SIRS
• INFECTIONS
• NON – INFECTIONS
Trauma, Burns, Pancreatitis, Ischemia, and Hemorrhage
– Other causes include:
– Complications of surgery
– Adrenal insufficiency
– Pulmonary embolism
– Complicated aortic aneurysm
– Cardiac tamponade
– Anaphylaxis
– Drug overdose
– Polypropylene Mesh Surgical Implant
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CAUSES OF SIRS
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PATHOPHYSIOLOGY
• SIRS defines a clinical response to a nonspecific
insult of either infectious or noninfectious origin
• Thus SIRS is not always related to infection
• At a local site of injury or infection and during the
initial appearance of pro- and anti-inflammatory
mediators in the circulation, the beneficial effects of
these mediators outweigh their harmful effects
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PATHOPHYSIOLOGY…..
• Only when the balance between these two forces is
lost do these mediators become harmful
• Sequelae of an unbalanced systemic proinflammatory
reaction include shock, transudation into organs, and
defects in coagulation
• An unbalanced systemic compensatory antiinflammatory response can result in anergy and
immunosuppression
• The proinflammatory and anti-inflammatory forces
may ultimately reinforce each other, creating a state
of increasingly destructive immunologic dissonance
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CRITERIA FOR SIRS (ADULTS)
FINDINGS
TEMP
HEART RATE
RESP RATE
WHITE CELL
COUNT
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VALUE
<36 °C (96.8 °F) or >38 °C (100.4 °F)
>90/min
>20/min or PaCO2<32 mmHg (4.3 kPa)
<4x109/L (<4000/mm³), >12x109/L (>12,000/mm³), or >10% bands
1992 ACCP & SCCM SIRS = 2 OR MORE
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CRITERIA FOR SIRS IN CHILDREN
FINDING
VALUE
TEMP
Obtained orally, rectally, Foley’s catheter probe or Central venous
catheter probe <36 °C or > 38.5 °C
HEART RATE
> 2 S.D. above normal for age in the absence of stimuli such as pain
and drug administration, or unexplained persistent elevation for
greater than 30 minutes to 4 hours
In infants, also includes Heart rate < 10th percentile for age in the
absence of vagal stimuli, beta-blockers or congenital heart disease
or unexplained persistent depression for greater than 30 minutes
RESP RATE
> 2 S.D. above normal for age or the requirement for mechanical
ventilation not related to neuromuscular disease or the
administration of anesthesia
WBC
Elevated or depressed for age not related to chemotherapy, or >10%
bands plus other immature forms
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International Paediatric Sepsis Consensus
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• Note that SIRS criteria are non-specific and must be
interpreted carefully within the clinical context
• These criteria exist primarily for the purpose of more
objectively classifying critically ill patients so that future
clinical studies may be more rigorous and more easily
reproducible
• As an alternative, when two or more of the systemic
inflammatory response syndrome criteria are met without
evidence of infection, patients may be diagnosed simply with
"SIRS.“
•
Patients with SIRS and acute organ dysfunction may be
termed "severe SIRS"
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COMPLICATION
• SIRS
SEPSIS
SEVERE SEPSIS
SEPTIC SHOCK
MULTIPLE ORGAN DYSFUNCTION
SYNDROME (MODS)
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•
•
•
•
•
•
Acute lung injury
Acute kidney injury
Shock
Anaemia
GI Bleeding
DIC
Multiple Organ Dysfunction Syndrome
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TREATMENT
TREAT UNDERLYING PROBLEM OR INCITING
CAUSE
– Adequate Fluid Replacement for Hypovolemia
– Epinephrine/Steroids/Diphenhydramine for
anaphylaxis
– Selenium, Glutamine, Eicosapentaenoic acid
have worked in clinical trials
– Vitamin E (Antioxidant)– May be helpful
– Removal of implanted mesh(Explantation)
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TREATMENT…..
• Long-term antibiotics, when clinically indicated,
should be as narrow spectrum as possible to limit
the potential for superinfection
– This is suggested by a new fever, a change in the white
blood cell [WBC] count, or clinical deterioration
• Unnecessary vascular catheters and Foley catheters
should be removed as soon as possible
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CONCLUSION
“It is not uncommon in the NICU to be presented with the
scenarios of two infants of same gestational age, with similar
prenatal and delivery histories, who both have blood cultures
positive for group B streptococcus. One infant is active, alert
and tolerating feedings. The other is on the ventilator,
hypotensive and receiving volume and vasopressor support –
and is the sickest child in the nursery. Why, if both infants
have the same infection, does the clinical presentation differ?
It is believed that, in infants who develop sepsis, the host
develops a systemic reaction to the bacteria. This reaction
induces the release of substances known as inflammatory
mediators, which contribute to the signs and symptoms and
to the pathophysiologic sequelae of sepsis”
(Carol Botwinski, Neonatal Network vol.20. No.5, Aug 2001)
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