SIRS, MODS

my blood is dirty garbage WATERRRR

SIRS - abbreviation

Systemic inflammatory response syndrome

MODS - abbreviation

Multi-organ dysfunction syndrome

DIC - abbreviation

Disseminated intravascular coagulopathy

What is SIRS?

• Generalized and massive inflammatory dysfunction

  • Activation of leukocytes and endothelial cells

  • Release of infl. mediators and oxygen free radicals

Progression of SIRS

Exaggerated SIRS → Abnormalities in perfusion + hypoxia → Tissue destruction → MODS and Death

True or false:

SIRS is only caused by extracellular infections and toxins

FALSE

• There are various triggers

• Basically, anything that can result in an inflammatory response has the potential to become exaggerated

• Can have infectious or noninfectious origins!

Physiologic responses resulting in SIRS

• Vasodilation

• Increased capillary permeability

• Microvascular clotting

• Temperature alteration

Clinical presentation of SIRS

• Tachycardia

• Tachypnea and/or hypocapnia

• Leukocytosis or leukopenia

• Fever or hypothermia

Can be VARIED!

Criteria for SIRS

Requires 2 or more of the following!!!!

• Temperature

  • Greater than 100.4/38 or less than 96.8/36

• Heart rate >90 bpm

• RR > 20 bpm or PaCO2 < 32 mmHG

• WBC

  • >12000 OR <4000

  • >10% immature bands

6 parameters to monitor in the cases of SIRS

• RR

• O2 sat

• Systolic blood pressure

• Pulse rate

• LOC

• Temperature

When SIRS is the result of an infection by an invading microorganism

Sepsis

Sepsis is characterized by _________ patient response along with new ____________ related to the infection.

Sepsis is characterized by dysregulated patient response along with new organ dysfunction related to the infection.

Diagnostic criteria for sepsis

Have a lot of the same as SIRS tho

Shock is characterized by _____ tissue perfusion and _______ cellular metabolism

Shock is characterized by decreased tissue perfusion and impaired cellular metabolism

(caused by massive vasodilation)

What conditions are associated with septic shock?

• Pneumonia

• Peritonitis

• Urinary tract infection

• Invasive procedures

• Indwelling lines and catheters

What patients are at highest risk for developing septic shock?

• Older adults

• Chronic illnesses

• Immunsuppressant therapy

• Immunocompromised

• Malnourshed

• Debilitated

• Critical care patients

What is septic shock?

• Refractory hypotension despite fluid resuscitation requiring vasopressors

• Inadequate tissue perfusion → Tissue hypoxia

Criteria for Sepsis (simplified lol)

• Refractory hypotension

  • Hypotension despite fluid resuscitation

  • Sbp <90

  • MAP <70

  • SBP decreased more than 40 compared to baseline

• Vasopressor-dependent post fluid replacement (under normal circumstances, they wouldn’t need the vasopressor after fluid replacement!)

• Tissue hypoperfusion / MODS

Refractory hypotension

• Hypotension even with fluid resuscitation

• Characteristics

  • SBP <90

  • MAP <70

  • SBP decreased 40+mmHG compared to baseline

3 physiologic effects of septic shock

• Massive vasodilation

• Maldistribution of blood flow

  • Caused by increased capillary permeability

  • (think of a gardening hose with a few holes - Blood not exiting when you want it to!)

• Myocardial decompensation (heart unable to meet demands)

How does the cardiovascular system attempt to compensate for septic shock?

• SNS response → Epinephrine/Norepi

• Make the heart work harder, pump harder, pump more

• BP continues to drop

At the end, still results in narrowed pulse pressure

Early clinical presentation of septic shock

“Hot stage” - Looks like an infection

• Tachycardia

• Pulse = bounding

• Wide pulse pressure

• Warm/flushed, hyperthermia

• Hyperpnea

Not decreased LOC, but altered

Oliguria

After observing a patients ABG results, you conclude that this patient is in early septic shock.

What is this patient exhibiting?

Respiratory alkalosis + hypoxemia

Late clinical findings of septic shock?

“Cold stage” - Looks like shock

• Tachycardia

• Pulse are weak and thready

• Hypotension

  • Narrow pressure

• Cool, pale, Hypothermia

• Brady or Tachypnea

• Anuria

Decreased LOC - lethargy or coma

After observing a patients ABG results, the results support that this patient is in the late stage of septic shock.

What is this patient exhibiting?

Metabolic acidosis + hypoxemia

Hour 1 bundle for Sepsis and Septic Shock?

Upon recognition of sepsis/septic shock…

1. Measure lactate level. If elevated, remeasure

   • >2 mmol/L

2. Blood cultures (BEFORE ABX ADMIN)

3. Administer broad abx

4. Rapid admin of 30 mL/kg saline for hypotension OR lactate >4mmol/L

5. Apply vasopressors if hypotension persists to maintain MAP>65

When is it recommended to administer antibiotics in the case of sepsis/septic shock?

Within 1 hour of recognition

In the 1-hour bundle, it is recommended to apply vasopressors to maintain a MAP >___

65

What vasopressor will most likely be recommended in the 1-hour bundle?

Dopamine

True or false:

MODS can result in SIRS

FALSE

Often, MODS is a complication of SIRS!

How does SIRS result in MODS?

• Hypotension

• Decreased perfusion

• Microemboli formation

• Redistribution and shunting of blood

SIRS and MODS - Respiratory manifestations

• Bilateral fluffy infiltrates

• Decreased compliance

• Severe dyspnea

• PaO2 <200

• PAWP < 18

• Pulmonary hypertension

• Refractory hypoxemia

• Tachypnea

• V/Q mismatch

Management of respiratory failure in SIRS and MODS

• Fluids, and meds

• Whole blood

• Supplemental O2, mechanical ventilation

• Space nursing activities

• Sedation

• Analgesia

Clinical manifestations of cardiovascular failure in MODS and SIRS

• Decreased BP, MAP, SVR

• Increased HR, CO, SV

• Massive vasodilation

• Myocardial depression

• Systolic and diastolic dysfunction

Management of Neuro failure/dysfunction in SIRS/MODS

Management of renal failure/dysfunction in SIRS and MODS

Pre-renal (fluids not leaving) vs Intra-renal (fluids leaving too much)!!!