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Focus on SIRS and MODS
(Relates to Chapter 67, “Nursing Management: Shock and Multiple Organ Dysfunction Syndrome,” in the textbook)
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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
Insults resulting in SIRS include infection (referred to as sepsis), ischemia, infarction, and injury (see Table 67-5).
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SIRS
Triggers
Mechanical tissue trauma: burns, crush injuries, surgical procedures
Abscess formation: intraabdominal, extremities
Ischemic or necrotic tissue: pancreatitis, vascular disease, myocardial infarction
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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
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MODS
Multiple organ dysfunction syndrome (MODS) is the failure of two or more organ systems.
Homeostasis cannot be maintained without intervention.
Results from SIRS
These two syndromes represent the ends of a continuum. Transition from SIRS to MODS does not occur in a clear-cut manner.
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6. Relationship of Shock, SIRS, and MODS
Fig Relationship of shock, systemic inflammatory response syndrome, and
multiple organ ­dysfunction syndrome. CNS, Central nervous system.
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7. SIRS and MODS Pathophysiology
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
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8. SIRS and MODS Pathophysiology
Organ and metabolic dysfunction
Hypotension
Decreased perfusion
Formation of microemboli
Redistribution or shunting of blood
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9. SIRS and MODS Pathophysiology
Respiratory system
Alveolar edema
Decrease in surfactant
Increase in shunt
V/Q mismatch
End result: ARDS
The respiratory system is often the first system to show signs of dysfunction in SIRS and MODS.
Patients with ARDS require aggressive pulmonary management with mechanical ventilation.
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10. SIRS and MODS Pathophysiology
Cardiovascular system
Myocardial depression and massive vasodilation
The baroreceptor reflex causes release of inotropic (increasing force of contraction) and chronotropic (increasing heart rate) factors that enhance CO.
To compensate for hypotension, CO increases with an increase in heart rate and stroke volume.
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11. SIRS and MODS Pathophysiology
Neurologic system
Mental status changes due to hypoxemia, inflammatory mediators, or impaired perfusion
Often early sign of MODS
The patient may become confused and agitated, combative, disoriented, lethargic, or comatose.
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12. SIRS and MODS Pathophysiology
Renal system
Acute renal failure
Hypoperfusion
Release of mediators
Activation of renin-angiotensin- aldosterone system
Nephrotoxic drugs, especially antibiotics
Careful monitoring of drug levels is essential to avoid the nephrotoxic effects.
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13. 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
In the early stages of SIRS and MODS, blood is shunted away from the GI mucosa, making it highly vulnerable to ischemic injury.
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14. SIRS and MODS Pathophysiology
Hypermetabolic state
Hyperglycemia-hypoglycemia
Insulin resistance
Catabolic state
Liver dysfunction
Lactic acidosis
Glycogen stores are rapidly converted to glucose (glycogenolysis).
Once glycogen is depleted, amino acids are converted to glucose (gluconeogenesis), reducing protein stores.
Fatty acids are mobilized for fuel.
Catecholamines and glucocorticoids are released, resulting in hyperglycemia and insulin resistance.
The net result is a catabolic state, and lean body mass (muscle) is lost.
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15. SIRS and MODS Pathophysiology
Hematologic system
DIC
Electrolyte imbalances
Metabolic acidosis
DIC results in simultaneous microvascular clotting and bleeding caused by depletion of clotting factors and platelets, combined with excessive fibrinolysis.
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16. 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 are critical.
MOD mortality rates are 70% to 80% when three or more organ systems fail.
Survival improves with early, goal-directed therapy. (An example of a Sepsis Alert Protocol [eFig. 67-1] is available on the Evolve website for this chapter.)
Collaborative care for patients with MODS focuses on (1) prevention and treatment of infection, (2) maintenance of tissue oxygenation, (3) nutritional and metabolic support, and (4) appropriate support of individual failing organs.
Table summarizes management for patients with MODS.
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17. SIRS and MODS Collaborative Care
Prevention and treatment of infection
Aggressive infection control strategies to decrease risk for nosocomial infection
Once an infection is suspected, institute interventions to control the source.
Early, aggressive surgery is recommended to remove necrotic tissue (e.g., early debridement of burn tissue) that may provide a culture medium for microorganisms.
Aggressive pulmonary management, including early ambulation, can reduce the risk of infection.
Strict asepsis can decrease infections related to intraarterial lines, endotracheal tubes, urinary catheters, IV lines, and other invasive devices or procedures.
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18. SIRS and MODS Collaborative Care
Maintenance of tissue oxygenation
Decreased O2 demand
Sedation
Mechanical ventilation
Paralysis
Analgesia
These patients have greater oxygen needs and decreased oxygen supply to the tissues.
Oxygen delivery may be optimized by maintaining normal levels of hemoglobin (e.g., transfusion of packed RBCs) and PaO2 (80 to 100 mm Hg), using individualized tidal volumes with positive end-expiratory pressure, increasing preload (e.g., fluids) or myocardial contractility to enhance CO, or reducing afterload to increase CO.
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19. 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.
Protein-calorie malnutrition is one of the primary manifestations of hypermetabolism and MODS.
Because of their relatively short half-life, the nurse should monitor plasma transferrin and prealbumin levels to assess hepatic protein synthesis.
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20. 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.
The goal of nutritional support is to preserve organ function.
Providing early and optimal nutrition decreases morbidity and mortality rates in patients with SIRS and MODS.
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21. SIRS and MODS Collaborative Care
Support of failing organs
ARDS: aggressive O2 therapy and mechanical ventilation
DIC: appropriate blood products
Renal failure: continuous renal replacement therapy or dialysis
Continuous renal replacement therapy is better tolerated than hemodialysis, especially in a patient with hemodynamic instability.
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Audience Response Question
A patient admitted to the hospital from a long-term care facility appears to be in the late stage of shock with systemic inflammatory response syndrome (SIRS). Which of the following orders implemented by the nurse has the highest priority?
1. Insert an indwelling urinary catheter.
2. Insert two large-bore intravenous catheters.
3. Administer 0.9% normal saline at 100 mL/hr.
4. Administer 100% oxygen by non-rebreather mask.
Answer: 4
Rationale: A patient in the irreversible stage of shock (late stage) will demonstrate profound hypotension and hypoxemia. If the condition progresses to systemic inflammatory response syndrome, the patient may experience profound hypoxemia. Oxygenation is a priority and should be initiated first with a 100% oxygen delivery method such as a non-rebreather mask.
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Audience Response Question
A patient with a history of alcoholism is admitted to the intensive care unit (ICU) with hemorrhage from esophageal varices. Admission vital signs are blood pressure 84/58 mm Hg, pulse 105 beats/min, and respiratory rate 32 breaths/min. The nurse recognizes the onset of systemic inflammatory response syndrome (SIRS) upon finding:
1. Pulmonary edema.
2. Cardiac dysrhythmias.
3. Absent bowel sounds.
4. Decreasing blood pressure.
Answer: 1
Rationale: The respiratory system is often the first system to show signs of dysfunction in systemic inflammatory response syndrome. Increases in capillary permeability facilitate movement of fluid from the pulmonary vasculature into pulmonary interstitial spaces. The fluid then moves to the alveoli, causing alveolar edema and pulmonary edema.
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Case Study
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Case Study
28-year-old woman is brought to the ED by her mother with confusion, fever, and “flu for past week.”
She has been vomiting for the past 2 days and has noted generalized edema.
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Case Study
The patient did not seek medical care before today.
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Case Study
Vital signs
Blood pressure 88/54
Heart rate 112
Temperature 103.5°F
Respiratory rate 24
Chest x-ray shows bilateral infiltrates.
WBC and lactic acid elevated
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Case Study
She is admitted to the ICU with a possible diagnosis of sepsis.
Urine output is amber and only 15 mL/2 hr.
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Discussion Questions
Nurse notes petechiae and jaundiced skin. What do these signs indicate?
What are some treatments that you would anticipate being done for her?
Jaundice indicates an increased bilirubin level that is related to impaired liver function. The petechiae could indicate disseminated intravascular clotting (DIC).
A priority is aggressive treatment of the infection. Maintenance of oxygenation—intubation and use of mechanical ventilator. Assessment of all body systems and support as needed.
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Discussion Questions
How should she receive nutritional support? How would blood glucose be affected?
What can you do to prevent further infection?
3. Enteral nutrition is the preferred option. If this is not possible, she will need parenteral nutrition (PN). With PN, because of the increased glucose, she will need glucose monitoring and supplemental insulin.
4. Infection control strategies need to be implemented in the ICU, so she does not develop any hospital-acquired infections (HAIs).
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