Sirs,Mod Amjad
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Transcript of Sirs,Mod Amjad
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SIRS, SEPSIS, AN DM O D S
Amjad Bani Hani
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Objectives
To know defnitions o SIRS, sepsis,septic shock, MODS
To become amilia with theepidemiolo!" o sepsis
To lean basic pathoph"siolo!"#in$ammation, cadio%asc&laph"siolo!"' o SIRS and sepsis
B&t frst, a eal case(
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Case presentation
)*+"ea+old male
l&+like s"mptoms o -da"
In .R Temp */01 2&lse -*3 Blood pess&e 435*3 Respiations *6 2etechial ash 7hest, 78, Abdominal
e9am nomal
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Case presentation - 2
:aboato" pH 406/, 2aO6 ;6,
2a7O6 6/
In%esti!ations pendin!
Blood, &ine c<&es Oall" int&bated and
placed on mechanical%entilation
7ental %eno&scathete inseted 7eota9ime 6 ! i%
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Case presentation - 3
In I7=(
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Case Presentation - 4
.al" !am stain on blood e%ealed!am ne!ati%e ods
2atient stated on( H"docotisone -33 m! i% >;h Recombinant acti%ated potein 7
6)!5k!5ho& o /? ho&s
.nteal n&tition %ia nasojej&nal eedin!t&be
2oph"la9is o stess &lces, deep%eno&s thomboses
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Case Presentation - Resolution
2atient !ad&all" stabili@ed and impo%ed withcomplete esol&tion o o!an d"s&nction o%e 1 da"s
inal c<&es confmed dia!nosis asmenin!ococcemia
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Infection: Part of a biggerpicture
Inection( 2esence o o!anisms in a
closed space o locationwhee not nomall" o&nd
Adapted om( Bone R7 et al0 Chest.-//6-3-(-?))+110Opal SM et al0 Crit Care Med0 63336;(S;-+60
Inection
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SIRS: System ic Inflam m atory ResponseSynrom e
SIRS( A clinicalesponse aisin! om anonspecifc ins<maniested b"
6 o the ollowin!( Tempeat&e*;7 o *?7
HR /3 beats5min
Respiations 635min CB7 co&nt-6,3335m: o),3335m: o -3Eimmat&e ne&tophils
Adapted om( Bone R7 et al0 Chest.-//6-3-(-?))+110Opal SM et al0 Crit Care Med0 63336;(S;-+60
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Sepsis: ! ore "#an $ust Inflam m ation
Sepsis( Fnown o s&spected
inection SIRS citeia
Adapted om( Bone R7 et al0 Chest.-//6-3-(-?))+110
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Severe Sepsis: %cute Organ&ysfunction
Se%ee Sepsis GSepsis with si!ns oacuteo!and"s&nction in an" o
the ollowin! s"stems( 7adio%asc&la #septicshock'
Renal Respiato"
Hepatic Hemostasis 7
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Sepsis: % Com ple' &isease
Adapted om( Bone R7 et al0 Chest.-//6-3-(-?))+110
Opal SM et al0 Crit Care Med0 63336;(S;-+60
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$argon 2((2: PIRO
InectionIn$ammation
2h"siolo!icBiochemical
SevereSepsis
Specifc O!anSe%eit"
Predisposition
Insult Response
Organ Dysfunction
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Preisposition
2e+e9istin! disease 7adiac, 2&lmona", Renal HI8
A!e #e9temes o a!e'
ende #males'
enetics T
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Response
2h"siolo!" Heat ate Respiation
e%e Blood pess&e 7adiac o&tp&t CB7
H"pe!l"cemia
Makes oIn$ammation T
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Organ &ysfunction
Lungs
Kidneys
CVS
CNS
PNS
Coagulation
GI
Liver
Endocrine
Skeletal Muscle
Adult es!iratory "istress Syndro#e
Acute $u%ular Necrosis
S&ock
Meta%olic ence!&alo!at&y
Critical Illness Polyneuro!at&y
"isse#inated Intravascular
Coagulo!at&y
Gastro!aresis and ileus
C&olestasis
Adrenal insu''iciency
&a%do#yolysis
Specifc therapyexists
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! agnitue of t#e Problem
.stimated 6-1,333 deaths om =S-//1 data
Hi!h cost o mana!ement #I7= cae,dia!nostic testin!, d&!s' .stimated 63 da" :OS 66,333 cost
Repesents /0*E o all deaths
.>&als deaths ate ac&te m"ocadialinaction
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"#e Incience of Sepsis in t#e
)nite States
The incidence o sepsis has
inceased /-0* pecent o%e thelast ten "eas0
This "ea, se%ee sepsis will likel"
take 6-1,333 li%es0
Sepsis is the leadin! ca&se odeath in the non+coona" I7=0
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Se%ee sepsis takes moe li%esthan beast, colon5ectal,panceatic, and postate cance
combined0
One o e%e" thee patients who
de%elop se%ee sepsiswill die within a month0
So&ce( Societ" o 7itical 7ae
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Severe Sepsis is deadly
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Severe Sepsis is Com m on
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Severe Sepsis is increasing
in incidence
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Sepsis: &efining a &isease Continuum
A clinical esponseaisin!om a nonspecifcins<, incl&din! 6 othe ollowin!( Tempeat&e J*;o7 o
K*?o7 HR J/3 beats5min Respiations J635min CB7 co&nt
J-6,3335mm*oK),3335mm*o-3E immat&e
ne&tophils
SIRS G s"stemic in$ammato" esponses"ndome0
Bone et al0 Chest.-//6-3-(-?))0
SIRS with a pes&med oconfmed inectio&spocess
SepsisSIRSInection5Ta&ma SevereSepsis
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Sepsis: &efining a &isease Continuum
Bone et al0 Chest.-//6-3-(-?)) Cheele and Benad0 N Engl J Med0 -///*)3(6340
SepsisSIRSInection5Ta&ma SevereSepsis
Sepsis with J- si!n o o!anail&e 7adio%asc&la #eacto"
h"potension' Renal Respiato" Hepatic Hematolo!ic 7
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*piem iology of Sepsis"#e International Co#ort Stuy
SepsisInection
SevereSepsis
SepticShock
-; 6; 6) *3
*1E motalit"
8353 patients with LOS > 24h
4277 infections (2696 on admission)
Percent of cases within each cateor!
Albeti, Int 7ae Med 6336
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Causes of Sepsis
Bacteial inections aethe most common ca&seo sepsis, b&t sepsis canalso be ca&sed b" &n!al,paasitic, o %ialinections0
The inection can
oi!inate om an"wheein the bod"0
So&ce:www.clevelandclinic.org
http://www.clevelandclinic.org/http://www.clevelandclinic.org/ -
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Sources of Sepsis"#e International Co#ort Stuy
SevereSepsis
SepticShock
Respiato" ?? 1*Abdomen / 63
Bacteemia -) -?
=ina" -- --
M<iple + +
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! icrobiology of Sepsis"#e International Co#ort Stuy
SevereSepsis
SepticShock
am+positi%e )) )3
am+ne!ati%e )4 )4
&n!al / -*
2ol"micobial + +
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Inade>&ate
Res&scitation
Pat#ogenesis of SIRS+! O&S
2eopeati%e Illness
Ta&ma oOpeation
Tiss&e Inj&"
optimal o9"!endeli%e" and
s&ppot
Reco%e"
ExcessiveInammatory
Response
SIRS5MODS
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Initiation of Inflam m atory Response
om Cheele L Benad,
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M ediators of Septic
Response
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Pro-inflam m atory
M ediatorsBacterial EndotoxinTNF-Interlekin-!Interlekin-"Interlekin-#$latelet %ctivatin& Factor '$%F(
Inter)eron-*amma$rosta&landins+ekotrienes
Nitric ,xide
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Anti-inflam m atory
M ediators Interlekin-!$*E.
$rotein /Interlekin-"Interlekin-0Interlekin-!.
+ipoxins*1-/SF
T*F
I+-!R%
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Pat#op#ysiology of Sepsis
Sepsis can lead to widespeadin$ammation and blood clottin!0
Blood clottin! d&in! sepsis ca&sesed&ced blood $ow to limbs and
%ital o!ans, and can lead to o!anail&e o tiss&e dama!e0So&ce( 7itical 7ae
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Pat#op#ysiology of Sepsis
In simple temssepsiscan be %iewedas an imbalance o
in$ammation,coa!&lation, andfbinol"sis.
In nomal patientshomeostasis ismaintained whenthese ae balanced.
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Pat#op#ysiology of Sepsis
D&in! a nomal esponse to bacteia inthe blood the imm&ne s"stem eleasesin$ammato" mediatos to pomoteeco%e" o the tiss&e0
These mediatos ae known as( T&mo
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Pat#op#ysiology of Sepsis
The elease o the in$ammato"mediatos stats the 7oa!&lation 7ascadeleadin! to the de%elopment o a clot0
To maintain this clot, inhibitos aeeleased
to s&ppess fbinol"sis o beakdown0This is necessa" to ha%e time o the
bod" to desto" the bacteia beoe theclot is !one0
So&ce( 7itical 7ae
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Pat#op#ysiology of Sepsis
Once the bacteia oanti!en is isolated,the po+in$ammato"mediatos attactne&tophils o CB7swhich attack theanti!en and t" to
en!&l it.
aphics( Deloes Nittel, 633?
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Pat#op#ysiology of Sepsis
To pe%ent the esponse omdama!in! nomal tiss&e, anti+in$ammato"mediatos ae eleased
incl&din! tansomin! !owth actosand intele&kins #I:+)'0 This balance oin$ammato" and anti+in$ammato"mediatos esticts the in$ammation
esponse to the local site o inection.
So&ce( 7itical 7ae
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Pat#op#ysiology of Sepsis
Chen the bod" is &nable to maintainthe appopiate balance, the imm&neesponse is no lon!e local b&tbecomes s"stemic0
In$ammation and alteed clottin!>&ickl" spead tho&!h the bod"0
So&ce( 7itical 7ae
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Pat#op#ysiology of Sepsis
The peson withthe inection
which was oncelocali@ed co&ldbecome citicall"ill i this pocess is
not coected.
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,om eostasis Is )nbalance inSevere Sepsis
7a%alho A7, eeman
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Coagulation an ibrinolysis
"ernard# $%& '* 2++,-344-,+.699/7+9
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.et/s .oo0 a .ittle &eeper
Thee ae * inte!ated esponses to sepsis
Acti%ation o In$ammation
Acti%ation o 7oa!&lation
Impaiment o ibinol"sis
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%ctivation of Inflam m ation
In$ammation is the bod"Ps esponse toinection.
Chen this occ&s white blood cells #CB7s'!eneate and elease c"tokines omediatos o in$ammation.
In$ammato" mediatos incl&de( T&monecosis acto+a, Intele&kin+-#I:+-',Intele&kin+? #I:+?' and 2latelet acti%atin!acto.
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%ctivation of Inflam m ation
Altho&!h these c"tokines #T
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%ctivation of Inflam m ation
Thee is basicall" a t&!o wa !oin! on betweenthe po+in$ammato"and anti+ in$ammato"components o the bod"0
In sepsis, contin&edelease o po+
in$ammato" c"tokineso%ewhelms the anti+in$ammato" c"tokines0
2o+in$ammato" #I:+-,I:+?,T
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%ctivation of Coagulation
In$ammation and coa!&lation aeclosel" linked0 The c"tokines omin$ammation stim&late coa!&lationpathwa"s0 This es<s in the omin! othe en@"me thombin0
This pod&ces clottin! in the bod"0
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%ctivation of Coagulation
The enhancedclottin! contin&esmakin! tin" clots o
micothombi inthe %asc&la s"stemwhich impais blood$ow and o!an
pe&sion.
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%ctivation of ibrinolysis
ibinol"sis, o the beakdown o clots, isthe bod"Ps esponse to the inceasedclottin! and in$ammation0
In sepsis this beakdown is inhibited oslowed beca&se o mediatos0 Thesemediatos ae called(
2lasmino!en Acti%ato Inhibito+- #2AI+-'
Thombin Acti%atable ibinol"sisInhibito #TAI'
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%ctivation of ibrinolysis
The incease le%els o these twoinhibitos,
2lasmino!en Acti%ato Inhibito+-#2AI+-' and Thombin Acti%atableibinol"sis Inhibito #TAI', s&ppessfbinol"sis e%en moe ceatin! astate o coa!&lopath"0
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aphics( Deloes Nittel, 633?
The In$ammato", 7oa!&lation,and ibol"tic Response to
Inection
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! a0ing ! atters 1 orse"#e Role of *not#elium in
Sepsis
aphic( Deloes Nittel, 633?
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! a0ing ! atters 1 orse"#e Role of *not#elium in
Sepsis
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! a0ing ! atters 1 orse
In sepsis the endotheli&m becomesdama!ed which makes thein$ammato" pocess wose b"
eleasin! moe c"tokines #T
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&am age *not#elium
aphics( Deloes Nittel,633?
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Putting it all "oget#er
The imbalance
o In$ammation,7oa!&lation, and
ibinol"sis and theeQects on endotheli&mcan lead to o!anail&e e%en death ilet &ndetected o&nteated0
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Inade2ate
Resscitation
Pat#ogenesis of SIRS+! O&S
2eopeati%e Illness
Ta&ma oOpeation
Tiss&e Inj&"
optimal o9"!endeli%e" and
s&ppot
Reco%e"
.9cessi%eIn$ammato"
Response
SIRS5MODS
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UO6 G low V O6
content
B2G7O V S8R
Intra ,r&an 3istri4tion
re&ional distri4tion
1icrocirclation
/ardiac,tpt
Intra ,r&an 3istri4tion
re&ional distri4tion
1icrocirclation
Regulation of o'ygen elivery
/ardiacotpt
'orma0 1norma0
O'ygen &elivery
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O'ygen &elivery
Deli%e"(Demand mismatch
DiQ&sion limitation #edema'
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O'ygen Consum ption
NADH+H+
NAD+ADP + P
i
1/2 O2+H+
ATP
H+ Cytc
H2O
H+
H+
H+ H+
Q
2"&%ate Deh"do!enase #2DH' acti%it" deceased
Deceased deli%e" o Acet"l 7oA to T7A c"cle
Mitochondial d"s&nction
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!estion" # $y do SepticPatients D ie?
%ns5er6 ,r&anFailre
i
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O rgan %ail!re andM ortality
7nas8 et al9 '!:#"(6
3irect correlation 4et5een nm4er o) or&ansystems )ailed and mortality9
1ortality 3ata6
1 22% 31% 34% 35% 40% 42% 41%2 52% 67% 66% 62% 56% 64% 68%
3 80% 95% 93% 96% 100%
100%
100%
;,SF 3! 3. 3< 30 3= 3" 3>
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Evidence-&ased Sepsis
' !idelines/omponents6 Early Reco&nition
Early *oal-3irected Therapy
1onitorin& Resscitation
$ressor ? Inotropic Spport
Steroid Replacement
Recom4inant %ctivated $rotein /
Sorce /ontrol *lycemic /ontrol
Ntritional Spport
%d@ncts6 Stress Alcer $rophylaxis8 3T$rophylaxis8 Trans)sion8 Sedation8
%nal&esia8 ,r&an Replacement
Evidence-&ased Sepsis
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Evidence &ased Sepsis' !idelines
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Severe Sepsis:"#e inal Com m on Pat# ay
Endothelial Dysunction andMicrovascular Thrombosis
Hypoperusion/Ischemia
Acute Organ Dysunction
!evere !epsis"
Death
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Severe Sepsis:! anagem ent of Our Case
Endothelial Dysunction andMicrovascular Thrombosis
Hypoperusion/Ischemia
Acute Organ Dysunction
!evere !epsis"
Death
rhA#$$orticosteroids
%luids&asopressors
$&&H%
Enteralnutrition
!urvival