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Current concept of pathophysiology of sepsis

Current concept of pathophysiology of sepsis. Manutham Manavathongchai MD. ACCP/SCCM Consensus definitions. Systemic inflammatory response syndrome ( SIRS) Tachycardia, HR >2 SD, <1yr bradycardia Mean RR >2 SD WBC elevate or depressed for age Core temp >38.5 ° C or <36 ° C

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Current concept of pathophysiology of sepsis

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  1. Current concept of pathophysiology of sepsis Manutham Manavathongchai MD

  2. ACCP/SCCM Consensus definitions • Systemic inflammatory responsesyndrome ( SIRS) • Tachycardia, HR >2 SD, <1yr bradycardia • Mean RR >2 SD • WBC elevate or depressed for age • Core temp >38.5 °C or <36 °C one of two have to be abn Temp or WBC

  3. ACCP/SCCM Consensus definitions • Infection • Inflammatory response to microorganisms, or • Invasion of normally sterile tissues

  4. ACCP/SCCM Consensus definitions • Sepsis • Infection plus • SIRS criteria

  5. ACCP/SCCM Consensus definitions • Severe Sepsis • Sepsis plus • Cardiovascular dysfunction or • Acute respiratory distress syndrome (ARDS) or • Other 2 organs dysfunction

  6. Organ dysfunction • Cardiovacular • pulmonologic • Neurologic • Hematologic • Renal • Hepatic

  7. ACCP/SCCM Consensus definitions • Septic shock • Sepsis plus • Hypotension despite fluid resuscitation or • Need vasoactive drugs or • 2 organs dysfunction

  8. Sepsis Adapted from: Bone RC et al. Chest. 1992;101:1644-55. Opal SM et al. Crit Care Med. 2000;28:S81-2.

  9. ACCP/SCCM Consensus definitions • Multiple Organ Dysfunction Syndrome (MODS) • Altered organ function in an acutely ill patient • Homeostasis cannot be maintained without intervention

  10. Early sepsis • Innate system (non specific) • Adaptive system (specific)

  11. Innate system (non specific) • Cell adhesion molecules • Procoagulants and anticoagulants • Nitric oxide synthase

  12. Russel JA. N Engl J Med 2006;355:1699-713

  13. Russel JA. N Engl J Med 2006;355:1699-713

  14. Ann Emerg Med. 2006;48:28-54

  15. SYSTEMIC ACTIVATION OF COAGULATION Intravascular deposition of fibrin Depletion of platelets and coagulation factors Bleeding Thrombosis of small and midsize vessels Organ failure DEATH

  16. Septic shockRole of NO • Infection induce NOS expression • High level Help eradicate infection butAlso cause vasodilation/ Massive hypotension Samjot S et al Chest 2005;128:1706

  17. Activated protein c in Pediatric septic shock P<0.01, n=30 60 50 40 Activated protein C activity 30 20 10 Survivors Non-Survivors Samransamruajkit et al ATS 2005

  18. Adaptive system (specific) • Cell-mediated response (T-cells) • Humoral response (B-cells)

  19. Organ dysfunction • Circulatory dysfunction: redistribution of bl flow : vascular resistance : myocardial contraction • Acute lung injury : microvascular permeability • Liver, kidney , CNS dysfunction

  20. Septic shock stage/Course Early resuscitation Aggressive Rx Paliative Rx “Early Warm Shock” “Reversible Phase” “Irreversible Phase”

  21. Septic shockGeneral principle summary Early Recognition Immediate Resuscitation **Prevention Stabilization Prevention Prophylactic AbxP IatrogenicVaccine Early RecognitionWarm ShockReversiblesigns of hypo Perfusion Wide PP UO Immediate Resuscitation1 st HR ResuscitationABCVolumeInotropeSteroids StabilizationHemodynamic supportAppropriateInotrope use Close monitoringNutrition

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