SEPSIS AND MULTI SYSTEM ORGAN FAILURE

DR TAJUDDIN

FCPS FRCS

Assistant Professor of Surgery Baqai medical University Kraachi Pakistan

MULTIPLE ORGAN FAILURE

• LEADING CAUSE OF DEATH IN SURGICAL ICU

• FIRST RECOGNISED IN 1973

• SEVERE PHYSIOLOGICAL INSULT

• ORGANS BECOME HYPERMETABOLIC

• HOST RESPONSE

AETIOLOGY

• SHOCK

• INFECTION

• MASSIVE INJURY

• LARGE AMOUNT OF NECROTIC TISSUE

ORGAN FAILURE

• PULMONARY

• HEPATIC

• INTESTINAL

• RENAL

SIRS

• THERE IS A DIRECT RELATIONSHIP BETWEEN NUMBER OF ORGAN FAILING AND THE LENGTH OF TIME THE PATIENT IS IN ORGAN FAILURE WITH MORTALITY OF PATIENT.

• TO DATE IL-6 LEVEL APPEARS TO BE SINGLE BEST PREDICTOR

PATHOGENESIS

• PERSISTING FOCUS OF INFECTION

• UNCONTROLLED GENERALIZED INFECTION

• GUT MUCOSAL FAILURE

• RETICULOENDOTHELIAL SYSTEM FAILURE

• PRODUCTION OF OXYGEN FREE RADICALS

SYSTEMIC INFLAMMATORY RESPONSE SYNDROME

• IT IS MANIFESTED BY TWO OR MORE OF THE FOLLOWING CONDITIONS

• CORE TEMP OF <36 OR>38

• TACHYCARDIA >90

• TACHYPNOEA >20

• WBC >12000, <4000

SYSTEMIC INFLAMMATORY RESPONSE SYNDROME

AT LEAST ONE OF THE FOLLOWING MANIFESTATION

– ALTERED MENTAL STATE

– HYPOXAEMIA

– OLIGOURIA

WITH CLINICAL EVIDENCE OF

– INFECTION

– BACTERAEMIA

SEVERE SEPSIS

• ASSOCIATED WITH

– ORGAN DYSFUNCTION

– HYPOPERFUSION

– HYPOTENSION

• MAY INCLUDE

– LACTIC ACIDOSIS

– OLIGOURIA

– ACUTE ALTERATION IN MENTAL STATUS

INFLAMMATORY MEDIATORS

• BACTERIAL ENDOTOXINS

• TNF-á

• IL-6

• IL-1

• NITRIC OXIDE

INTESTINAL ISCHAEMIA

• IMPAIRED OXYGEN DELIVERY TO GUT

• ALTERATION IN MESENTERIC BLOOD FLOW

• REPERFUSION INJURY

• INCREASE IN INTESTINAL PERMEABILITY

• BACTERIAL TRANSLOCATION

– ENDOTOXIN

– BACTERIA

RETICULOENDOTHELIAL SYSTEM

• LIVER AND SPLEEN ARE BARRIER TO GENERALIZED SEPTIC STATE

• BACTERIA CAN BE CULTURED FROM

– LIVER

– SPLEEN

– PORTAL CIRCULATION

– INTESTINAL LYMPH NODES

• IF LIVER IS IMPAIRED

– KUPFER CELL MALFUNCTION

– ENDOTOXIN AND BACTERIA ARE RELEASED IN SYSTEMIC CIRCULATION

FREE RADICALS

• DAMAGE TO MICROVASCULAR CIRCULATION

• GENERATED DURING REPERFUSION

• WHEN OXYGEN REACTS WITH HYPOXANTHINE

• METABOLIC PRODUCTS OF ATP THAT ACCUMULATES DURING ISCHEMIA

• CONVERTED INTO SUPEROXIDE ION

• ENDOTHELIAL DAMAGE

• RELEASE OF INFLAMMATORY MEDIATORS

THE COMMON TERMINAL PATHWAY FOR ORGAN DAMAGE

• VASODILATATION

• CAPILLARY LEAK

• INTRAVASCULAR COAGULATION

• ENDOTHELIAL CELL ACTIVATION

SIRS

• MORE COMMON IN SURGICAL PATIENTS THAN DIAGNOSED

• EARLY TREATMENT OF SIRS MAY REDUCE THE RISK OF MODS

• ROLE OF THE TREATMENT IS TO ELIMINATE THE CAUSATIVE FACTOR SUPPORT THE FOLLOWING UNTIL PATIENT CAN RECOVER

– CVS SUPPORT

– RESP SYS

INFECTION SEPSIS SIRS

SYNDROME

SEPTIC

SHOCK

MORTALITY

• 7% -SIRS

• 14% - SEPSIS SYNDROME

• 40% - ESTABLISHED SEPTIC SHOCK

COMMON SURGICAL CAUSES

• ACUTE PANCREATITIS

• PERFORATED VISCUS

• PERITONITIS

• FULMINANT COLITIS

• MULTIPLE TRAUMA

• MASSIVE BLOOD TRANSFUSION

• ASPIRATION PNEUMONIA

• ISCHAEMIA REPERFUSION INJURY

• ABSCESS

TNFá

• RELEASED BY AND ACTIVATES MACROPHAGES AND NEUTROPHILS

• CYTOTOXIC TO ENDOTHELIAL CELLS AND PARENCHYMAL CELLS OF END ORGANS

• ANTI TNFá THERAPY

LIPOPOLYSACCHARIDE (LPS)

• RELEASED FORM GRAM NEGATIVE

• ACTIVATES MACROPHAGES

• ACTIVATION OF CD14

• ANTI LPS ANTIBODY TREATMENT

INTERLEUKINS

• IL-6 AND IL-1á CAUSE ENDOTHELIAL CELL ACTIVATION AND DAMAGE

• PROMOTE COMPLEMENT AND CHEMOKINES RELEASE

• INTRAVENOUS STEROIDS TREATMENT

PLATELET ACTIVATING FACTOR (PAF)

• IMPLICATED PARTICULARLY IN ACUTE PANCREATITIS

• ANTI-PAF ANTIBODY TREATMENT

INDUCIABLE NITRIC OXIDE SYNTHETASE (iNOS)

• SYNTHESIZED BY ACTIVATED ENDOTHELIAL CELLS

• ACTIVATES ENDOTHELIAL CELLS AND LEUCOCYTES

• POTENT NEGATIVE INOTROPE

THE PATIENT

• HISTORY

• EXAMINATION

– COLLAPSED

– PYREXIA

– TACHYCARDIA

– HYPOTENSION

– EXTREMITIES

• INITIALLY WARM DUE TO VASODILATATION

• LATER COLD DUE TO HYPO PERFUSION

– RIGORS

LOOK FOR THE CAUSE

• INSPECT THE URINE

– CLOUDY

– THICK

• EXAMINE CHEST

• EXAMINE ABDOMEN

• IS THERE CVP LINE

– THAT MAY BE INFECTED

DIAGNOSIS

• BLOOD CULTURE

• OTHER MICROBIOLOGY SAMPLES

• TIP OF CVP

• PERFORM WHITE CELL COUNT

MANAGEMENT

• INTRAVENOUS ANTIBIOTICS

• INTRAVENOUS SUPPORT OF CIRCULATION

– IN SEVERE CASES CVP LINE IS USED TO MONITOR THIS

• DISCUSS WITH MICROBIOLOGIST

• TREAT THE CAUSE AS REQUIRED

ICU CHART

INSPECT THE CHART IN TERMS OF SYSTEMS

• CIRCULATION

– PULSES

– BP

– CVP

– RESPONSE TO THERAPY IN LAST 24 HOURS

ICU CHART

• RESPIRATION- IF THE PATIENT IS ON VENTILATOR

– TIDAL VOLUME

– MINUTE VOLUME

– RESPIRATORY RATE

– VENTILATOR PRESSURE

– CHECK BLOOD GASES

INTENSIVE CARE
INTAKE OUTPUT CHART

• FLUID BALANCE

– THE TOTAL INPUT VERSUS THE TOTAL OUTPUT IN LAST 24 HOURS

– REPLACEMENT OF EXCESSIVE LOSS

– IS URINE OUTPUT ADEQUATE

• INTRAVENOUS REGIMEN

– WRITTEN UP FOR NEXT 24 HOURS

– DOES IT NEED ADJUSTMENT ACCORDING TO FLUID BALANCE

CRITICAL CARE- INVESTIGATIONS

• CHECK THE DAYS RESULTS

– UREA AND ELECTROLYTES

– HAEMOGLOBIN

– CHEST XRAY

• IV CHARTS ADJUSTED ACCORDING TO ELECTROLYTES

• SERUM ALBUMIN

– LOW VALUES CAUSES FALL IN ONCOTIC PRESSURE PREDISPOSE TO PULMONARY OEDEMA

CRITICAL CARE – DRUG TREATMENT

• REVIEW THE ANALGESIA

• CHECK THE EFFECT OF ANALGESIA ON

– PULSE RATE

– BP

• ANTIBIOTICS

– STARTED

– STOPPED

– CONTINUED

– CHANGED

• TEMPERATURE

CRITICAL CARE – THE PATIENT

• PULSE

• EVIDENCE OF PERIPHERAL OEDEMA

• STATE OF HYDRATION

• BOWEL SOUNDS

• EXAMINATION OF WOUNDS

• LOCALIZED TENDERNESS IN CALF MUSCLES

• NEUROLOGICAL DETERIORATION

• CO-RELATE CHART WITH EXAMINATION

SURGICAL MANAGEMENT

• WOUND DRESSINGS

• WOUND DEHISCENCE

• DRAINS

– ABDOMINAL

– WOUND

• STITCHES

• STATE OF POST OPERATIVE ILEUS

• BED SORES

• INFECTED IV DRIP SITE

SURGICAL NUTRITION

• ENTRAL

• PARENTRAL

• TOTAL PARENTRAL NUTRITION (TPN)

• PEG

• DIET

THERAPEUTIC GOALS

• TISSUE OXYGENATION PREVENTING HYPOXAEMIA

• CARDIOVASCULAR STABILITY

• NORMOTHERMIA

• ADEQUATE ANALGESIA

• END ORGAN FUNCTION

• MAY ALSO INCLUDE

• ANTIBIOTIC COVER

• STEROID COVER

• TIGHT CONTROL OF BLOOD SUGAR

SHOEMAKER'S GOALS

– CARDIAC INDEX (CI) > 4.5L MIN

– OXYGEN DELIVERY(DO2)>600ML MIN

– OXYGEN CONSUMPTION (VO2)>170 ML MIM

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