Systemic Inflammatory Response Syndrome (SIRS) AND Sepsis

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Systemic Inflammatory Response Syndrome
(SIRS)ANDSepsis

• Kaitlyn Smith
• Scott Edgecomb

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What is SIRS ??

• Defines a clinical response to a non-specific
  insult of either infectious or noninfectious
  origin.
• Can be caused by
• Ischemia
• Inflammation
• Trauma
• Infection
• OR
• Several Combined Insults
• It is NOT always related to INFECTION!

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Criteria for Systemic Inflammatory Response
Syndrome

• Clinical Response SIRS
• Includes two or more of the following
• Temperature gt 38 C orlt 36 C
• Heart rate gt 90 / min
• Respiratory rate gt 20/min or PaO2 lt 32 mmHg
• White blood count gt 12,000 cells/mm3 or lt 4000
  cells/mm3

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Many things may lead to SIRS

• Non-Infectious SIRS

• Infectious SIRS

• Bacterial
• UTIs
• Pneumonia
• Colitis
• Influenza
• Pyelonephritis
• Wound/Burn Infections
• Cellulitis
• Cholecystitis
• Infective Endocarditis
• Meningitis
• Septic Arthritis
• Toxic Shock Syndrome
• Others

• Myocardial Infarction
• Substance Abuse
• Seizure
• Dehydration
• Chemical Aspiration
• Intestinal Perforation
• Transfusion Reaction
• Pancreatitis
• Cirrhosis
• Autoimmune Disorders
• Adrenal Insufficiency
• Burns
• Hemorrhagic Shock
• Drug Reaction / Side Effects (Theophylline)
• Others

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Laboratory Studies

• Complete Blood Count
• Basic Metabolic Panel
• Cardiac Enzymes
• Lactic Acid
• Blood Cultures (Draw prior to antibiotic
  administration)!!!
• Urinalysis with culture

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Treatment of SIRS

• Volume resuscitation
• DVT Stress Ulcer Prophylaxis
• Give blood components to treat coagulopathies
• Provide oxygen therapy to prevent tissue
  hypoperfusion
• Antimicrobial therapies (Vancomycin, Zosyn,
  Cefepime, Levaquin, Fluconazole).

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Potential Complications of SIRS

• 26 develop sepsis, 18 develop severe sepsis and
  4 develop septic shock.
• Respiratory failure, Acute Respiratory Distress
  Syndrome (ARDS), and nosocomial pneumonia
• Renal Failure
• GI Bleeding stress gastritis
• Anemia
• Deep Vein Thrombosis (DVT)
• IV Catheter related bacteremia
• Electrolyte abnormalities
• Hyperglycemia
• Disseminated Intravascular Coagulation (DIC)
• .

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M.C. - A Case Review

• M.C. is a 74 year old female admitted through the
  ED from a long term care facility on April 22nd.
• PMH Dementia, CVA (with right hemiparesis),
  Bipolar, Chronic hypernatremia, NIDDM, diabetic
  neuropathy, CAD, PVD, HTN, GERD, chronic kidney
  disease, e.coli UTI, Chronic lower extremity
  cellulitis.
• DNR/DNI
• Presented to ED with worsening left lower
  extremity swelling and redness.
• VS Temp 36.9 oral
• HR Sinus rhythm 78
• RR 18
• BP 115/65
• SpO2 93 on room air
• Administered Vancomycin and Rocephin IV in ED.
• Admitted to 5B

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M.C. - A Case Review

• 04/28/12 (6 Days Later)
• Pt remained on 5B since admission r/t nephrogenic
  diabetes insipidus (r/t longstanding lithium use
  in past) treatment (D5W infusion, trending
  sodiums, DDAVP inj). Pts sodium level had been
  150-157. Baseline sodium was 145-148.
• Pt noted to be increasingly lethargic (pt
  currently on a Fentanyl patch 25 mcg/hr q3d and
  chronic bipolar meds including Cymbalta 60 mg po
  daily). Pts baseline mental status being alert,
  demented but able to answer simple questions.
• Temp 38.2 rectally
• Pt had been off antibiotics for several days r/t
  apparent resolving cellulitis infection.

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M.C. - A Case Review

• Same dayevening hours 1800-0000)
• Temp 39.5 rectally. HR sinus tachycardia 120s.
• What interventions should be considered?
• What about her lethargy?
• Blood cultures x 2 ordered. Only one set drawn.
  2nd set cancelled as pt administered Cefepime
  prior to 2nd set being drawn.
• Fentanyl patch and cymbalta dcd.
• Spo2 noted to be 87-91 and pt remained on room
  air.
• Any thoughts????

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Review of Progress Notes
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M.C. A Case Review

• 04/29/12 Transfer to Intermediate Care at 0200.
• VS HR 156 Sinus tachycardia (IV Lopressor 5 mg
  administered)
• Temp 40 degrees celsius rectally.
• Lung sounds coarse, cxray obtained, 2 L/min o2
  placed on pt and spo2 up to 95. Lasix 20 mg IV
  given.
• Cxray resulted no infiltrate, negative for
  pulmonary edema.
• What do we think of this treatment????
• D5W reordered at 100 ml/hr for hypernatremia
  (Na150) as pt not in CHF. IVF indicated for
  presumed infection, BP stable at this point so
  heavy resuscitation not required.
• Lower extremities noted to be cool and slightly
  mottled.
• Urine and stool studies sent.
• Sputum culture sent.
• K3.0 20 meq KCL given
• Vanco and Zosyn added and given IV.

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Review of IO
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M.C. A Case Review

• 04/29/12 0800
• VS Temp 37.4 rectally
• HR 103 Sinus Tachycardia
• RR 22
• SpO2 100 on 3 l/min o2 via nasal cannula
• BP 123/60
• D5W continues to infuse at 100 ml/hr
• Vancomycin, Zosyn and Cefepime administered as
  ordered.
• Head CT negative for acute process.
• Troponin noted to be 0.5 on am labs.

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M.C. A Case Review

• 04/29/12 1400
• VS 38.3 rectally
• HR 132 Sinus Tachycardia
• RR 20
• Spo2 100 on 3 l/min o2 via nasal cannula
• BP 147/48
• No additional lab studies ordered. No change in
  treatment plan.

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M.C. A Case Review

• 04/30/12 0900
• VS Temp 37.1 rectally
• HR 111 Sinus Tachycardia
• RR 18
• SpO2 99 on room air
• BP 128/65
• D5W infusion continues for hypernatremia.
  Antibiotic coverage unchanged.
• Troponin down to 0.16 (cardiac strain due to
  acute illness per Cardiology).

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M.C. A Case Review

• 05/01/12 -
• Induced sputum positive for MRSA.
• Vancomycin IV continued.
• Pt transferred back to 5B.

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What is Sepsis?

• Sepsis is defined as systemic inflammatory
  response syndrome with presumed or confirmed
  infection.
• Sepsis is derived from the Greek word sepien
  meaning to make rotten.
• Sepsis differs greatly from just plainInfection.
• Severe sepsis is one of the most significant
  challenges in critical care units

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Bacteria causing Sepsis

• Gram negative bacteria account for 70 of all
  cases of sepsis.
• E. coli
• Klebsiella
• Enterobacter
• Pseudomonas
• Serratia Marcescens

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Patients at risk of developing severe sepsis

• All critically ill patients
• Severe community-acquired pneumonia
• Intra-abdominal surgery
• Meningitis
• Chronic diseases (including diabetes, heart
  failure, chronic renal failure, and COPD)
• Compromised immune status (HIV/AIDS, use of
  cytotoxic and immunosuppressive agents, malignant
  neoplasms, and alcoholism)
• Cellulitis
• Urinary tract infection

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Defining the progression of Sepsis

• Sepsis
• SIRS with presumed or confirmed infection

As time goes by
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Defining progression of Sepsis

• Severe Sepsis
• 37 of severe sepsis patients present in the
  emergency department.
• Severe sepsis is associated with organ
  dysfunction, perfusion abnormalities or
  hypoperfusion.

Clinical Signs
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Defining progression of Sepsis

• Clinical Signs of Severe Sepsis
• Mottled skin
• Oliguria
• Mental status changes
• Decreased platelet count
• Respiratory Distress
• Abnormal heart function

As time goes by
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Defining progression of Sepsis

• Septic Shock
• Sepsis with perfusion abnormalities and
  hypotension despite adequate fluid resuscitation

Patient Symptoms
Warm Stage- Hyperperfusion
Confusion Increased
cardiac output Increased blood pressure Increased
respiratory rate Increased urine output Very
good ABG Low grade temperature
Cold Stage- Hypoperfusion Decreased cardiac
output Decreased Urine output Poor ABG
(metabolic acidosis) Severe hypotension ARDS,
ATN, MSOF and DIC
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Treatment of Sepsis

• Administer antimicrobial agents
• Volume resuscitation
• Vasopressor therapy to maintain adequate blood
  pressure
• Give blood components to treat coagulopathies
• Administer inotropic therapy to maintain cardiac
  contractility
• Provide oxygen therapy to prevent tissue
  hypoperfusion

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Multiple Organ Dysfunction Syndrome

• A manifestation of another underlying condition.
  Secondary MODS involves organ or organ system
  failure thats due to sepsis (two or more organs
  lasting greater than 24hrs).
• ARDS (Adult respiratory distress syndrome)
• ATN ( Acute tubular necrosis)
• DIC ( Disseminated intravascular coagulation)

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Sepsis Mortality

• Sepsis is the leading cause of death in ICUs
  with a mortality rate between 40-60.
• Sepsis affects more than 700,000 patients in the
  United States each year.
• The estimated annual cost of treating sepsis is
  approximately 17 billion.
•