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Describe pathophysiology of SIRS. [TU 2067/2, 63/2]
What is SIRS? Outline the principles of management. [TU 2064/5,63/12,61/12]
- Temperature - >38°C (100.4°F) or < 36°C (96.8°F)
- Tachycardia - >90/min
- Tachypnea - >20/min or PaCO2 <32 mm Hg
- Total count - >12,000/µL or < 4,000/µL or >10% immature [band] forms
What is sepsis?
SIRS with documented source of infection.
What is SOFA score?
- Sepsis-related Organ Failure Assessment score, also known as Sequential Organ Failure Assessment score (SOFA score), is used to track a person's status during the stay in an intensive care unit (ICU) to determine the extent of a person's organ function or rate of failure.
- The score is based on six different scores, one each for the respiratory, cardiovascular, hepatic, coagulation, renal and neurological systems.
What is qSOFA score?
- The quick SOFA score uses three criteria,
- - Low blood pressure (SBP≤100 mmHg)
- - High respiratory rate (≥22 breaths per min)
- - Altered mentation (Glasgow coma scale<15)
The presence of 2 or more qSOFA points near the onset of infection was associated with a greater risk of death or prolonged intensive care unit stay.
Surviving Sepsis Guidelines 2017
- Definition – Sepsis is a life threatening organ dysfunction caused by a dysregulated host response to infection. Septic shock is a subset of sepsis with circulatory and cellular/metabolic dysfunction associated with a higher risk of mortality.
- Fluids – at least 30cc/kg in first 3 hours, even in patients with ESRD and CHF. Use crystalloids, consider albumin, avoid starch solutions.
- Vasopressors – Use norepinephrine (NE), avoid dopamine. Add epinephrine if NE inadequate, add vasopressin to taper NE.
- Steroid – No steroid, unless shock refractory to adequate fluids and vasopressors.
- Antibiotics – broad spectrum
- PRBC – only if Hb<7 gm/dl in absence of acutebleeding or myocardial ischemiaetc
- Source control – as soon as feasible (old guidelines – within 12 hours)
- Ventilator – TV 6cc/kg, pleateau pressure ≤30 cm H2O, BIPAP role unknown
- Goal Therapy – Target at MAP 65 mmHg. Normalize lactate. Prefer dynamic variables toassess fluid responsiveness. Deemphasize protocolized care, CVP and ScvO2
Classify shock. [TU 2057,59]
Shock is the state of cardiovascular collapse characterised by acute reduction of effective circulating volume and and inadequate perfusion of the cells and tissues.
- - Cardiogenic - Intrinsic and extrinsic
- - Hypovolemic - hemorrhage, diarrhoea
- - Distributive - Neurogenic, Septic, Anaphylactic
Describe the pathophysiology of septic shock. Enumerate the complications of septic shock. [TU 2057,59]
Pathophysiology of septic shock?
- Toxins/endotoxins from organisms like E Coli, Klebsiella, Pseudomonas, and Proteus
- Inflammation, cellular activation – of macrophages, neutrophils, monocytes
- Release of cytokines, free radicals
- Chemotaxis of cells, endothelial injury, altered coagulation cascade - SIRS
- Reversible hyperdynamic warm stage of septic shock with fever, tachycardia, tachypnoea
- Severe circulatory failure with MODS (failure of lungs, kidneys, liver, heart) with DIC
- Hypodynamic, irreversible cold stage of septic shock.
What is multiorgan dysfunction syndrome (MODS)? Discuss the principle of management of ARDS in septic shock due to severe burn. [TU 2057, 60/12]
Short note on Multisystem organ failure. [TU 2070]
Multiple organ dysfunction syndrome (MODS) refers to progressive organ dysfunction in an acutely ill patient, such that homeostasis cannot be maintained without intervention. It is at the severe end of the severity of illness spectrum of both infectious (sepsis, septic shock) and noninfectious conditions (eg, SIRS from pancreatitis).
- MODS can be classified as primary or secondary:
- ● Primary MODS - result of a well-defined insult in which organ dysfunction occurs early and can be directly attributable to the insult itself (eg, renal failure due to rhabdomyolysis).
- ● Secondary MODS - organ failure that is not in direct response to the insult itself, but is a consequence of the host's response (eg, acute respiratory distress syndrome in patients with pancreatitis).
- There are no universally accepted criteria for individual organ dysfunction in MODS. However, progressive abnormalities of the following organ-specific parameters are commonly used to diagnose MODS and are also used in scoring systems (eg, SOFA or LODS) to predict ICU mortality.
- ●Respiratory – Partial pressure of arterial oxygen (PaO2)/fraction of inspired oxygen (FiO2) ratio
- ●Hematology – Platelet count
- ●Liver – Serum bilirubin
- ●Renal – Serum creatinine (or urine output)
- ●Brain – Glasgow coma score
- ●Cardiovascular – Hypotension and vasopressor requirement
In general, the greater the number of organ failures, the higher the mortality, with the greatest risk being associated with respiratory failure requiring mechanical ventilation.
Classification of surgical wounds?
American College of Surgeons wound classification -
• Clean wounds - an uninfected surgical wound in which no inflammation is encountered and the respiratory, alimentary, genital, or uninfected urinary tracts are not entered. In addition, clean wounds are primarily closed and, if necessary, drained with closed drainage. Surgical wound incisions that are made after nonpenetrating (ie, blunt) trauma should be included in this category if they meet the criteria.
• Clean contaminated wound - surgical wound in which the respiratory, alimentary, genital, or urinary tracts are entered under controlled conditions and without unusual contamination. Specifically, surgical procedures involving the biliary tract, appendix, vagina, and oropharynx are included in this category, provided no evidence of infection is encountered and no major break in technique occurs.
• Contaminated wounds - open, fresh, accidental wounds. In addition, surgical procedures in which a major break in sterile technique occurs (eg, open cardiac massage) or there is gross spillage from the gastrointestinal tract and incisions in which acute, nonpurulent inflammation is encountered are included in this category.
• Dirty or infected wounds - old traumatic wounds with retained or devitalized tissue and those that involve existing clinical infection or perforated viscera. This definition suggests that the organisms causing postoperative infection were present in the wound before the surgical procedure.
What is surperficial surgical site infection?
Infection occurs within 30 days after the operation and infection involves only skin and subcutaneous tissue of the incision and at least one of the following:
- 1. Purulent drainage with or without laboratory confirmation, from the superficial incision
- 2. Organisms isolated from an aseptically obtained culture of fluid or tissue from the superficial incision
- 3. At least one of the following signs or symptoms of infection: pain or tenderness, localised swelling, redness, or heat and superficial incision is deliberately opened by surgeon, unless incision is culture-negative
- 4. Diagnosis of superficial incisional SSI made by a surgeon or attending physician
What is deep surgical site infection?
- Infection occurs within 30 days after the operation if no implant is left in place or within 90 days if implant is in place and the infection appears to be related to the operation and infection involves deep soft tissue (e.g. fascia, muscle) of the incision and at least one of the following:
- 1. Purulent drainage from the deep incision but not from the organ/space component of the surgical site
- 2. A deep incision spontaneously dehisces or is deliberately opened by a surgeon when the patient has at least one of the following signs or symptoms: fever >38°C), localised pain or tenderness, unless incision is culture-negative
- 3. An abscess or other evidence of infection involving the deep incision is found on direct examination, during reoperation, or by histopathologic or radiologic examination
- 4. Diagnosis of deep incisional SSI made by a surgeon or attending physician
What is organ space surgical site infection?
Infection occurs within 30 days after the operation if no implant is left in place or within 90 days if implant is in place and the infection appears to be related to the operation and infection involves any part of the anatomy (e.g., organs and spaces) other than the incision which was opened or manipulated during an operation and at least one of the following:
- 1. Purulent drainage from a drain that is placed through a stab wound into the organ/space
- 2. Organisms isolated from an aseptically obtained culture of fluid or tissue in the organ/space
- 3. An abscess or other evidence of infection involving the organ/space that is found on direct examination, during reoperation, or by histopathologic or radiologic examination
- 4. Diagnosis of organ/space SSI made by a surgeon or attending physician.
Claviene Dindo classiﬁcation of postoperative surgical complications
I Any deviation from the normal postoperative course without the need of pharmacologic treatment or surgical, endoscopic,and radiologic interventions. Allowed therapeutic regimens are drugs as antiemetic, antipyretics, analgesics, diuretics,electrolytes, and physiotherapy. This grade also includes the wound infections opened at the bedside
II Requiring pharmacologic treatment with drugs other than such allowed for grade I complications: blood transfusions and parenteral nutrition are also included
III Requiring surgical, endoscopic, and radiologic interventions: a. Intervention not under general anesthesia b. Intervention under general anesthesia
IV Life-threatening complication (including CNS complications) requiring IC-ICU management: a. Single organ dysfunction (including dialysis) b. Multiorgan dysfunction
V Death of the patient