Systemic Inflammatory Response Syndrome SIRS and Multiple Organ

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Systemic Inflammatory Response Syndrome (SIRS) and Multiple Organ Dysfunction Syndrome (MODS) Chapter 67 Copyright

Systemic Inflammatory Response Syndrome (SIRS) and Multiple Organ Dysfunction Syndrome (MODS) Chapter 67 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

SIRS • Systemic inflammatory response syndrome (SIRS) is a systemic inflammatory response to a

SIRS • Systemic inflammatory response syndrome (SIRS) is a systemic inflammatory response to a variety of insults • Generalized inflammation in organs remote from the initial insult Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

SIRS • Triggers • Mechanical tissue trauma: burns, crush injuries, surgical procedures • Abscess

SIRS • Triggers • Mechanical tissue trauma: burns, crush injuries, surgical procedures • Abscess formation: intraabdominal, extremities • Ischemic or necrotic tissue: pancreatitis, vascular disease, MI Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

SIRS • Triggers • Microbial invasion: bacteria, viruses, fungi • Endotoxin release: gram-negative bacteria

SIRS • Triggers • Microbial invasion: bacteria, viruses, fungi • Endotoxin release: gram-negative bacteria • Global perfusion deficits: postcardiac resuscitation, shock states • Regional perfusion deficits: distal perfusion deficits Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

MODS • Multiple organ dysfunction syndrome (MODS) is the failure of two or more

MODS • Multiple organ dysfunction syndrome (MODS) is the failure of two or more organ systems • Homeostasis cannot be maintained without intervention • Results from SIRS Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Relationship of Shock, SIRS, and MODS Copyright © 2014 by Mosby, an imprint of

Relationship of Shock, SIRS, and MODS Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study SIRS Wavebreak Media/Thinkstock • K. R. , a 28 -year-old woman, is

Case Study SIRS Wavebreak Media/Thinkstock • K. R. , a 28 -year-old woman, is brought to the ED by her mother with confusion, fever, and “flu for past week. ” • She has been vomiting for the past 2 days and has noted generalized edema. • Vital signs: T 103. 5° F , HR 112, R 24, BP 88/54 Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

SIRS and MODS Pathophysiology • Consequences of inflammatory response • Release of mediators •

SIRS and MODS Pathophysiology • Consequences of inflammatory response • Release of mediators • Direct damage to the endothelium • Hypermetabolism • Increase in vascular permeability • Activation of coagulation cascade Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

SIRS and MODS Pathophysiology • Organ and metabolic dysfunction • Hypotension • Decreased perfusion

SIRS and MODS Pathophysiology • Organ and metabolic dysfunction • Hypotension • Decreased perfusion • Formation of microemboli • Redistribution or shunting of blood Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

SIRS and MODS Pathophysiology • Respiratory system • Alveolar edema • Decrease in surfactant

SIRS and MODS Pathophysiology • Respiratory system • Alveolar edema • Decrease in surfactant • Increase in shunt • V/Q mismatch • End result: ARDS Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

SIRS and MODS Pathophysiology • Cardiovascular system • Myocardial depression and massive vasodilation •

SIRS and MODS Pathophysiology • Cardiovascular system • Myocardial depression and massive vasodilation • Results in SVR and BP • Baroreceptors respond to enhance CO • Albumin and fluid move out of blood vessels Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

SIRS and MODS Pathophysiology • Neurologic system • Mental status changes due to hypoxemia,

SIRS and MODS Pathophysiology • Neurologic system • Mental status changes due to hypoxemia, inflammatory mediators, or impaired perfusion • Often early sign of MODS Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

SIRS and MODS Pathophysiology • Renal system • Acute kidney injury (AKI) • Hypoperfusion

SIRS and MODS Pathophysiology • Renal system • Acute kidney injury (AKI) • Hypoperfusion • Release of mediators • Activation of renin-angiotensin-aldosterone system • Nephrotoxic drugs, especially antibiotics Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

SIRS and MODS Pathophysiology • GI system • Motility decreased: abdominal distention and paralytic

SIRS and MODS Pathophysiology • GI system • Motility decreased: abdominal distention and paralytic ileus • Decreased perfusion: risk for ulceration and GI bleeding • Potential for bacterial translocation Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

SIRS and MODS Pathophysiology • Hypermetabolic state • Hyperglycemia-hypoglycemia • Insulin resistance • Catabolic

SIRS and MODS Pathophysiology • Hypermetabolic state • Hyperglycemia-hypoglycemia • Insulin resistance • Catabolic state • Liver dysfunction • Lactic acidosis Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

SIRS and MODS Pathophysiology • Hematologic system • DIC • Electrolyte imbalances • Metabolic

SIRS and MODS Pathophysiology • Hematologic system • DIC • Electrolyte imbalances • Metabolic acidosis Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study SIRS Wavebreak Media/Thinkstock • K. R. is admitted to ICU with a

Case Study SIRS Wavebreak Media/Thinkstock • K. R. is admitted to ICU with a possible diagnosis of sepsis. • Her urine output is amber and only 15 m. L/2 hr. • Chest x-ray shows bilateral infiltrates. • WBC count and lactic acid are elevated. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

SIRS and MODS Collaborative Care • Prognosis for MODS is poor • Goal: prevent

SIRS and MODS Collaborative Care • Prognosis for MODS is poor • Goal: prevent the progression of SIRS to MODS • Vigilant assessment and ongoing monitoring to detect early signs of deterioration or organ dysfunction are critical Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

SIRS and MODS Collaborative Care • Collaborative care for patients with MODS focuses on

SIRS and MODS Collaborative Care • Collaborative care for patients with MODS focuses on • Prevention and treatment of infection • Maintenance of tissue oxygenation • Nutritional and metabolic support • Appropriate support of individual failing organs Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study SIRS Wavebreak Media/Thinkstock • K. R. has a urinary catheter inserted as

Case Study SIRS Wavebreak Media/Thinkstock • K. R. has a urinary catheter inserted as well as a central venous catheter. • Her doctor talks with her mother about the possibility of mechanical ventilation. • K. R. ’s mother asks why she is so sick and what can be done for her. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

SIRS and MODS Collaborative Care • Prevention and treatment of infection • Aggressive infection

SIRS and MODS Collaborative Care • Prevention and treatment of infection • Aggressive infection control strategies to decrease risk for nosocomial infection • Strict asepsis • Assess need for invasive lines • Once an infection is suspected, institute interventions to control the source Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

SIRS and MODS Collaborative Care • Maintenance of tissue oxygenation • Decrease O 2

SIRS and MODS Collaborative Care • Maintenance of tissue oxygenation • Decrease O 2 demand increase O 2 delivery • Sedation • Mechanical ventilation • Analgesia • Rest Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

SIRS and MODS Collaborative Care • Nutritional and metabolic needs • Goal of nutritional

SIRS and MODS Collaborative Care • Nutritional and metabolic needs • Goal of nutritional support: preserve organ function • Total energy expenditure is often increased 1. 5 to 2. 0 times Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

SIRS and MODS Collaborative Care • Nutritional and metabolic needs • Use of the

SIRS and MODS Collaborative Care • Nutritional and metabolic needs • Use of the enteral route is preferred to parenteral nutrition • Monitor plasma transferrin and prealbumin levels to assess hepatic protein synthesis Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Case Study SIRS Wavebreak Media/Thinkstock • The nurse notes that K. R. has developed

Case Study SIRS Wavebreak Media/Thinkstock • The nurse notes that K. R. has developed petechiae and jaundiced skin. • What do they indicate? • What are some treatments that you would anticipate being done for her? Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

SIRS and MODS Collaborative Care • Support of failing organs • ARDS: aggressive O

SIRS and MODS Collaborative Care • Support of failing organs • ARDS: aggressive O 2 therapy and mechanical ventilation • DIC: appropriate blood products • Renal failure: continuous renal replacement therapy or dialysis Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Audience Response Question A patient with a history of alcoholism is admitted to the

Audience Response Question A patient with a history of alcoholism is admitted to the ICU with hemorrhage from esophageal varices. Admission VS are BP 84/58 mm Hg, HR 105, and RR 32 breaths/min. The nurse recognizes the onset of systemic inflammatory response syndrome (SIRS) upon finding: a. pulmonary edema. b. cardiac dysrhythmias. c. absent bowel sounds. d. decreasing blood pressure. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

Audience Response Question A patient admitted to the hospital from a long-term care facility

Audience Response Question A patient admitted to the hospital from a long-term care facility appears to be in the late stage of shock with systemic inflammatory response syndrome (SIRS). Which order implemented by the nurse has the highest priority? a. Insert an indwelling urinary catheter. b. Insert two large-bore intravenous catheters. c. Administer 0. 9% normal saline at 100 ml/hr. d. Administer 100% oxygen by non-rebreather mask. Copyright © 2014 by Mosby, an imprint of Elsevier Inc.

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