Level Up RN - SIRS, SEPSIS, MODS

What is SIRS?

Systemic Inflammatory Response Syndrome
- SIRS is a nonspecific inflammatory response to body insult
  - Gives us information that something is going on in the body, and it is trying to defend against
- An exaggerated immune response
  - With SIRS the body is attempting to defend itself from the given threat by localizing and eliminating the source of the problem
    - The problem is… it is going above and beyond from normal/healthy immune response that we expect.
      - EX of NORMAL response: a cut on the finger = vasodilation in the affected area. Allow WBC and other things to come and protect against bacteria. Localized edema, pain, redness, tenderness… WHICH IS NORMAL
- SIRS IS A FINDING!
  - It is what you are observing in this patient, that then should help us to get to the point of being able to diagnose the primary cause of this condition!
- Potentially lethal
  - Though this exaggerated response is meant to be defensive, it can lead to an end-organ Dysfunction, and eventually death, due to the regulated cytokines storm (inflammatory cascade that goes out of control).
- Red flag for healthcare providers
  - By becoming familiar with serves criteria, healthcare professionals, have the chance to intervene before irreversible harm is done to the patient!

What SIRS isn’t:

When there is SEPSIS there might be SIRS. HOWEVER not all SIRS are SEPSIS. Not ALL SIRS is infection.
Specific or diagnostic
- SIRS is a collection of assessment findings for patients, that lets us know that something in their body has their immune system overworked.
- Not specific to infection, trauma, to anything else. We can’t say for sure when a patient who has SIRS is septic, has an infection, or has a tissue insult.
- ITS NOT DIAGNOSTIC! You are not diagnosing a patient with SIRS.

SIRS CRITERIA

Any two or more of the following:
- Core body temperature:
  - > 38°C (100.4°F) or < 36°C (96.8°F)
- Heart rate:
  - >90 bpm
    - Notice that the cutoff is 90, which is not above 100 (which is where we are used to defining tachycardia)
      - Important: if you are working with patients who are tachycardia,who are over 100 bpm, then you will miss the patients just in that beginning. Where they’re starting to have that systemic response.
- Respirations:
  - > 20 bpm or PaCo2 < 32 mmHg
    - If I am breathing 19 breaths per minute, and my PaCo2 is at 30, that is still a positive SIRS criteria.
    - IF BOTH ARE TRUE, IT ONLY COUNTS FOR 1 out of the criteria.
- WBC count:
  - >12,000/mm3 or 4,000/mm3
    - Does not indicate infection, it means badness of some sort!

Is it infection?

Possible causes of SIRS:
- COULD be infection
- COULD be tissue insult
  - Surgery
  - Trauma
- COULD be ischemia
- COULD be malignant; cancer
- COULD be reperfusion

So… what do we do about it?

NOTIFY the PROVIDER of any patients meeting SIRS CRITERIA (REMEMBER IT IS 2 OR MORE OF THE CRITERIA!)
Identify and treat the underlying cause
- Thoroughly assessed patients for potential source of infection
  - Identification of sepsis
  - SIRS criteria
- Draw labs, including CBC, lactate, blood cultures
- Obtain an EKG for tachycardia
- If indicated, obtain an ABG for respiratory dysfunction
Supportive treatment
- IV Fluid resuscitations as indicated
- Antipyretics for fever of indicated
Assess for potential end-organ dysfunction
- Patient using the sequential organ failure assessment (SOFA)

What is sepsis?

Life-threatening organ function caused by a regulated response to infection
- Sepsis is a life-threatening medical emergency. It exists when a persons body injures its own tissues while trying to defend against and affection.
  - Organ dysfunction
    - Organ dysfunction can be evaluated with a substantial organ failure assessment (SOFA) score

What is SOFA?

This assessment tool can be used to identify the function and performance of several body systems.
Increase mortality is directly Proportional with SOFA score scores. As a patient score increases, so does the risk of death.
- SOFA score is not an individual predictor of mortality.
This is not a perfect tool for for instance, accurate assessments are difficult in patient receiving paralytics or sedation.
- Q-SOFA
  - Used for triage or rapid assessment situations
  - Q-SOFA Score of two or more near the onset of infection is associated with a greater risk of death or prolonged ICU stay
    - Altered mental status
      - A patient would alter mentation should receive one point, GCS <15
      - Tachypnea
        A patient with an elevated respiratory rate should receive one point, >22
      - Systolic Hypotension
        A patient with systolic hypotension should receive one point, < 100 mmHg
Assumed baseline SOFA. Score for patients without preexisting organ dysfunction is ZERO!
Acute points change in patients consequent to infections that constitutes organ dysfunction is TWO!

Findings associated with Sepsis

SIRS criteria
- Remember to be on the lookout for SIRS criteria, as some of all these findings will be present and patient with sepsis
Organ Dysfunction
- An acute SOFA score of 2+ points In the face of infection constitutes organ dysfunction. Specific findings will vary based on which body system is affected.
Infection specific findings
- Findings of sepsis related to urinary tract infections may be different than those associate with pneumonia or a cutaneous infection.

The workup and treatment

when caring for a patient, you suspect to be experienced sepsis, what should you do??
- Notify the provider immediately, especially with regards to findings of organ dysfunction
- Draw lab; CBC, BMP, lactate, CRP, etc.
- Assess other findings; EKG for tachycardia, ABG for tachypnea, Need for intubation for decrease GCS, etc.
- Attempt to identify the source of infection; Urine/blood/wound cultures, thorough head to toe assessment, etc.
- Advocate for early administration of broad-spectrum antibiotics, aggressive, fluid, resuscitation, and additional support care as indicated.
Blood pressure needs to be up
- IV fluid bolus for patients in sepsis - 30 mL/kg

What is septic shock?

A subset of sepsis
- Septic shock is a classification of substance marked by hemodynamic instability, despite appropriate intravascular volume repetition (Fluid resuscitation)
- Not all patients with sepsis have septic shock but all patients in septic shock have sepsis
Lethal
- Hospital mortality and patient experiencing septic shock is greater than 40%. This means that two of every five patient experience septic shock will die in the hospital..

Criteria

The patient who have received adequate volume citation, septic shock, may be identified by the presence of both of the following criteria:
- >65 mmHg
  - Persistent hypotension requiring vasopressors to maintain a mean arterial pressure (MAP); >65
- 2 mmol/L
  - Lactic acid, which is Found in patient with a serum lactate; >2 mmol/L

Hypotension, tachycardia, and warm and flushed skin

Treatment of Septic Shock

Primary source treatment
- As with SIRS and sepsis, every effort should be made to identify and appropriately treat the exact cause of the patient septic shock
Fluid resuscitation
- Patient and septic shock will require ongoing vascular volume support with the use of IV fluids
Vasopressin’s
- Vasopressor such as norepinephrine, epinephrine, dopamine, etc. should be initiated with a titration goal of maintaining a MAP greater than 65 mmHg. MAP Targeting is preferable to SBP for accurate evaluation of end-organ perfusion
  - REMEMBER: MAP = (2 x DBP + SBP)/3
Monitoring
- Continue monitoring for patients SOFA Scores, serum, lactate levels, and need for ongoing vasopressor support. May you give meaningful information about the progress of a given patient

What is MODS?

Multiple organ dysfunction

Shocks

insufficient blood flow, lack of profusion
- Circulatory failure
Hypovolemic shock
- Blood loss, trauma, or surgery, GI loss (excess vomitiing, diarrhea), fluid loss ‘(diarresis)

Inflammatory process