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Systemic Inflammatory Response Syndrome – Special Devices (ICU and Brain Death Determination)

by Brian Warriner, MD
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    00:00 So it takes highly skilled people to use this thing. 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 inflammation. And we really don't understand this process. It's not always related to infection, but a nonspecific response to ischemia, loss of oxygen, trauma, inflammatory processes or infection. It's part of a continuum and is often seen as the presenting condition of this problem. So the diagnostic criteria for the SIRS Continuum are SIRS, Sepsis and Septic Shock, follow this pattern. For SIRS criteria you need two criteria, either a temperature greater than 38ºC, 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 12,000.

    01:20 So you need two of those to make the diagnosis of SIRS. To take the next step and make the diagnosis of Sepsis, you need to have SIRS plus a source of infection.

    01:32 So you either have to have a suspected source or be able to prove that you've got a source of infection.

    01:38 The next step is Severe Sepsis. And this is when organ dysfunction begins to intervene, low blood pressure and decrease profusion of organs. And this is characterized by Lactic Acidosis, which is measured in the blood, systolic blood pressure of less than 90, or a great drop in systolic pressure. So those things in combination define Severe Sepsis Criteria. Septic shock is the next step in this very bad condition. This is severe Sepsis with Hypotension despite adequate fluid resuscitation. So, in a situation where you're sure you've fluid resuscitated adequately and you still have hypotension, you've got Severe Shock Criteria.

    02:26 And then the final stage of this, prior to death in many cases unfortunately, is Multiple Organ Dysfunction Syndrome. 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 aggressive and starts with early antibiotics therapy. Every delay in administering antibiotics increases mortality by 8%. That's an amazing statistic.

    03:02 A one hour delay in starting antibiotics increases the likelihood the patient's going to die by 8%. Effective Hemodynamic Support is essential, but difficult.

    03:14 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.

    03:26 The third step is Effective Volume Management. This is also important to use the best fluid replacement substance and this is very controversial. So, artificial colloid, albumin, normal saline, balanced salt, high concentration saline, 3% or 5% saline, which are the right agents to use, or hypotonic solutions.

    03:50 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. So we're now going to step away from


    About the Lecture

    The lecture Systemic Inflammatory Response Syndrome – Special Devices (ICU and Brain Death Determination) by Brian Warriner, MD is from the course The ICU.


    Author of lecture Systemic Inflammatory Response Syndrome – Special Devices (ICU and Brain Death Determination)

     Brian Warriner, MD

    Brian Warriner, MD


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