SYSTEMIC INFLAMMATORY RESPONSE

Complications[edit]
SIRS is frequently complicated by failure of one or more organs or organ systems.[2][3][4] The
complications of SIRS include
Acute kidney injury
Shock
Multiple organ dysfunction syndrome
Causes[edit]
The causes of SIRS are broadly classified as infectious or noninfectious. Causes of SIRS include:[citation
needed]
Bacterial infections
Severe malaria
trauma
burns
pancreatitis
ischemia
hemorrhage
Other causes include:[2][3][4]
Complications of surgery
Adrenal insufficiency
Pulmonary embolism
Complicated aortic aneurysm
Cardiac tamponade
Anaphylaxis
Drug overdose
Diagnosis[edit]
Systemic inflammatory response syndrome[5]
Finding Value
Temperature <36 °C (96.8 °F) or >38 °C (100.4 °F)
Heart rate >90/min
Respiratory rate >20/min or PaCO2<32 mmHg (4.3 kPa)
WBC <4x109/L (<4000/mm³), >12x109/L (>12,000/mm³), or ≥10% bands
SIRS is a serious condition related to systemic inflammation, organ dysfunction, and organ failure. It is a
subset of cytokine storm, in which there is abnormal regulation of various cytokines.[6] SIRS is also
closely related to sepsis, in which patients satisfy criteria for SIRS and have a suspected or proven
infection.[2][3][4][7]
Many experts consider SIRS to be overly sensitive, as nearly all (>90%) of patients admitted to the ICU
meet the SIRS criteria.[8]
Adult[edit]
Manifestations of SIRS include, but are not limited to:[citation needed]
Body temperature less than 36 °C (96.8 °F) or greater than 38 °C (100.4 °F)
Heart rate greater than 90 beats per minute
Tachypnea (high respiratory rate), with greater than 20 breaths per minute; or, an arterial partial
pressure of carbon dioxide less than 4.3 kPa (32 mmHg)
White blood cell count less than 4000 cells/mm³ (4 x 109 cells/L) or greater than 12,000 cells/mm³ (12 x
109 cells/L); or the presence of greater than 10% immature neutrophils (band forms). Band forms
greater than 3% is called bandemia or a "left-shift."
When two or more of these criteria are met with or without evidence of infection, patients may be
diagnosed with "SIRS." Patients with SIRS and acute organ dysfunction may be termed "severe SIRS."[3]
[4][9] Note: Fever and an increased white blood cell count are features of the acute-phase reaction,
while an increased heart rate is often the initial sign of hemodynamic compromise. An increased rate of
breathing may be related to the increased metabolic stress due to infection and inflammation, but may
also be an ominous sign of inadequate perfusion resulting in the onset of anaerobic cellular metabolism.
[citation needed]
Children[edit]
The International Pediatric Sepsis Consensus has proposed some changes to adapt these criteria to the
pediatric population.[10]
In children, the SIRS criteria are modified in the following fashion:[11]
Heart rate is greater than 2 standard deviations above normal for age in the absence of stimuli such as
pain and drug administration, or unexplained persistent elevation for greater than 30 minutes to 4
hours. In infants, also includes heart rate less than 10th percentile for age in the absence of vagal
stimuli, beta-blockers, or congenital heart disease or unexplained persistent depression for greater than
30 minutes.
Body temperature obtained orally, rectally, from Foley catheter probe, or from central venous catheter
probe less than 36 °C or greater than 38.5 °C.
Respiratory rate greater than 2 standard deviations above normal for age or the requirement for
mechanical ventilation not related to neuromuscular disease or the administration of anesthesia.
White blood cell count elevated or depressed for age not related to chemotherapy, or greater than 10%
bands plus other immature forms.
Temperature or white blood cell count must be abnormal to qualify as SIRS in pediatric patients.[12]
Treatment[edit]
Generally, the treatment for SIRS is directed towards the underlying problem or inciting cause (i.e.
adequate fluid replacement for hypovolemia, IVF/NPO for pancreatitis,
epinephrine/steroids/diphenhydramine for anaphylaxis).[13] Selenium, glutamine, and
eicosapentaenoic acid have shown effectiveness in improving symptoms in clinical trials.[14][15] Other
antioxidants such as vitamin E may be helpful as well.[16]
Septic treatment protocol and diagnostic tools have been created due to the potentially severe outcome
septic shock. For example, the SIRS criteria were created as mentioned above to be extremely sensitive
in suggesting which patients may have sepsis. However, these rules lack specificity, i.e. not a true
diagnosis of the condition, but rather a suggestion to take necessary precautions. The SIRS criteria are
guidelines set in place to ensure septic patients receive care as early as possible.[17]
In cases caused by an implanted mesh, removal (explantation) of the polypropylene surgical mesh
implant may be indicated.[18]
History[edit]
The concept of SIRS was first conceived of and presented by Dr. William R. Nelson, of the Department of
Surgery of the University of Toronto at the Nordic Micro Circulation meeting in 1983. The presentation
followed a decade of research with colleagues including; Dr. J. Vaage of the University of Oslo, Norway,
Dr. D. Bigger, the Hospital for Sick Children, Toronto, Dr. D. Sepro of Boston University, and Dr. H. Movat
of the Department of Pathology at the University of Toronto. The laboratory experience was borne out
in the clinical setting with Canada's first trauma unit for which Nelson was a co-founder. This allowed in
the mid-1980s, the concepts of SIRS to be taught by Dr. Miles Johnson of the University of Toronto,
Department of Pathology at the undergraduate dental school, as well as to residents in the Department
of Surgery of the University of Toronto who rotated through the Regional Trauma Unit at Sunnybrook
Medical Center. SIRS was more broadly adopted in 1991 at the American College of Chest
Physicians/Society of Critical Care Medicine Consensus Conference with the goal of aiding in the early
detection of sepsis.[19]
Criteria for SIRS were established in 1992 as part of the American College of Chest Physicians/Society of
Critical Care Medicine Consensus Conference.[2] The conference concluded that the manifestations of
SIRS include, but are not limited to the first four described above under adult SIRS criteria.
In septic patients, these clinical signs can also be seen in other proinflammatory conditions, such as
trauma, burns, pancreatitis, etc. A follow-up conference, therefore, decided to define the patients with a
documented or highly suspicious infection that results in a systemic inflammatory response as having
sepsis.[20]
Note that SIRS criteria are non-specific,[20] and must be interpreted carefully within the clinical context.
These criteria exist primarily for the purpose of more objectively classifying critically ill patients so that
future clinical studies may be more rigorous and more easily reproducible