So systemic inflammatory response syndrome is
a relatively new
diagnosis, although it's been around for a
long time and it's often but not
always associated with sepsis, it's part of
a syndrome that may lead
to septic shock and death, but not always.
It's associated with a general breakdown of
the body's immune system with the
development of generalized tissue
And we really don't understand this process.
It's not always related to infection.
But in a nonspecific response to ischemia,
loss of oxygen,
trauma, inflammatory processes or infection.
It's part of a continuum, and it's often
seen as the presenting
condition of this problem.
So the diagnostic criteria for the SIRS
SIRS, sepsis and septic shock, follow this
For SIRS criteria, you need two criteria,
temperature greater than 38 °C, a heart rate
greater than 90,
a respiratory rate greater than 20 or
PaCO2 of less than 32. In other words, the
patient's really working at breathing and a
white blood count that's greater than
So you need two of those to make the
diagnosis of SIRS. To take the next step and
make the diagnosis of sepsis,
updated guidelines now take into account the
Sequential Organ Failure Assessment, or SOFA.
This assessment scores each organ system,
based on a corresponding indicator.
For example, the respiratory system is
assessed by P/F ratios, coagulability is
assessed by plate account, liver function is
assessed by bilirubin,
cardiovascular by blood pressure, brain by
the Glasgow coma score and renal
function by creatinine levels.
In order to meet the criteria for sepsis,
patients must now have an increase of two or
more points in their SOFA score.
Septic shock is the next step in this very
bad condition, this is sepsis with
hypotension despite adequate fluid
So in a situation where you're sure you have
fluid resuscitated adequately
and you still have hypotension, you've got
severe shock criteria.
And then the final stage of this is, prior to
death, in many
cases, unfortunately, is multiple organ
So everything above, plus the evidence of
more than two organs
failing. So cardiac, respiratory, renal, any
two organs, often liver
failure, at this point. Treatment is very
starts with early antibiotic therapy.
Every delay in administering antibiotics
mortality by eight percent.
That's an amazing statistic.
A one-hour delay in starting antibiotics
increases the likelihood the patient's going
to die by eight percent.
Effective hemodynamic support is essential
but difficult, the current drug of
choice is norepinephrine or noradrenaline is
the other name for it,
and it's given intravenously, obviously,
but in very high doses in some of these
patients. The third step is effective volume
This is also important to use the best fluid
substance and this is very controversial.
So artificial colloid, albumin, normal
saline, balanced salt,
high concentration saline, 3% or 5% saline,
are the right agents to use, or hypotonic
It's all extremely controversial, and it has
been for 40 or 50 years.
I've read documentation from after the
Second World War showing that the
right fluid at the right time has been a
challenge for medical people for a very
long period of time. The best fluid is not
known, but maintenance
of normal or slightly high central venous
pressure appears to be the best
path, irrespective of the fluid used.