1. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. (Relates to Chapter 67, “Nursing Management: Shock, Systemic Inflammatory Response Syndrome, and Multiple Organ Dysfunction Syndrome,” in the textbook)

2. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 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

3. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. SIRS Triggers Mechanical tissue trauma: burns, crush injuries, surgical procedures Abscess formation: intra-abdominal, extremities Ischemic or necrotic tissue: pancreatitis, vascular disease, myocardial infarction

4. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. SIRS Triggers Microbial invasion: Bacteria, viruses, fungi Endotoxin release: Gram-negative bacteria Global perfusion deficits: Post–cardiac resuscitation, shock states Regional perfusion deficits: Distal perfusion deficits

5. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. MODS Multiple organ dysfunction syndrome (MODS) is the failure of two or more organ systems Homeostasis cannot be maintained without intervention Results from SIRS

6. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. MODS SIRS and MODS represent the ends of a continuum Transition from SIRS to MODS does not occur in a clear-cut manner

7. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. Relationship of Shock, SIRS, and MODS Fig. 67-1

8. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. SIRS and MODS Consequences of inflammatory response Release of mediators Direct damage to the endothelium Hypermetabolism Vasodilation leading to decreased SVR Increase in vascular permeability Activation of coagulation cascade

9. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. SIRS and MODS Pathophysiology Organ and metabolic dysfunction Hypotension Decreased perfusion Formation of microemboli Redistribution or shunting of blood

10. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. SIRS and MODS Pathophysiology Respiratory system Alveolar edema Decrease in surfactant Increase in shunt V/Q mismatch End result: ARDS

11. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. SIRS and MODS Pathophysiology Cardiovascular system Myocardial depression and massive vasodilation

12. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. SIRS and MODS Pathophysiology Neurologic system Mental status changes due to hypoxemia, inflammatory mediators, or impaired perfusion Often early sign of MODS

13. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. SIRS and MODS Pathophysiology Renal system Acute renal failure Hypoperfusion Release of mediators Activation of renin–angiotensin– aldosterone system Nephrotoxic drugs, especially antibiotics

14. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 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

15. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. SIRS and MODS Pathophysiology Hypermetabolic state Hyperglycemia–hypoglycemia Insulin resistance Catabolic state Liver dysfunction Lactic acidosis

16. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. SIRS and MODS Pathophysiology Hematologic system DIC Electrolyte imbalances Metabolic acidosis

17. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 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 is critical

18. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. SIRS and MODS Collaborative Care Prevention and treatment of infection Aggressive infection control strategies to decrease risk for nosocomial infections Once an infection is suspected, institute interventions to control the source

19. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. SIRS and MODS Collaborative Care Maintenance of tissue oxygenation Decrease O 2 demand Sedation Mechanical ventilation Paralysis Analgesia

20. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. SIRS and MODS Collaborative Care Maintenance of tissue oxygenation Optimize O 2 delivery Maintain normal hemoglobin level Maintain normal PaO 2 Individualize tidal volumes with PEEP

21. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. SIRS and MODS Collaborative Care Maintenance of tissue oxygenation Enhance CO Increase preload or myocardial contractility Reduce afterload

22. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 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

23. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 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

24. Copyright © 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved. 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