Which Cardiovascular Change Occurs In A Patient With Systemic Inflammatory Response Syndrome (Sirs)?

• Periodical List
• Scand J Trauma Resusc Emerg Med
• 5.17; 2009
• PMC2806258

Scand J Trauma Resusc Emerg Med. 2009; 17: 67.

The Systemic Inflammatory Response Syndrome (SIRS) in acutely hospitalised medical patients: a accomplice report

Pål Comstedt

¹Department of Infectious Diseases, Odense University Hospital, Odense, Denmark

Merete Storgaard

²Section of Infectious Diseases, Århus University Infirmary, Skejby, Denmark

Annmarie T Lassen

¹Department of Infectious Diseases, Odense University Hospital, Odense, Denmark

³Institute of Clinical Enquiry, Academy of Southern Denmark, Odense, Denmark

Received 2009 Sep 3; Accustomed 2009 Dec 27.

Abstract

Background

Sepsis is an infection which has evoked a systemic inflammatory response. Clinically, the Systemic Inflammatory Response Syndrome (SIRS) is identified by two or more symptoms including fever or hypothermia, tachycardia, tachypnoea and modify in blood leucocyte count. The human relationship between SIRS symptoms and morbidity and mortality in medical emergency ward patients is unknown.

Methods

We conducted a prospective cohort study of the frequency of SIRS and its relationship to sepsis and death amid acutely hospitalised medical patients. In 437 consecutive patients, SIRS condition, blood pressure, infection and comorbidity on access was registered together with 28-day mortality.

Results

A hundred and 50-four patients (35%) had SIRS on admission, 211 patients (48%) had no SIRS, and 72 patients (16%) had insufficient data to evaluate their SIRS status. SIRS patients were 2.2 times more frequently infected, with 66/154 SIRS patients versus 41/211 not-SIRS patients: p < 0.001, relative take a chance (RR) two.2 (95% conviction interval (CI) 1.6-three.i), and they had a vi.ix times higher 28-day mortality than non-SIRS patients with 15/154 SIRS patients versus three/211 non-SIRS patients: p = 0.001, RR 6.9 (95% CI 2.0-23.iii). Well-nigh of the deaths amongst patients with SIRS occurred amongst patients with malignant conditions. Septic shock developed in four/154 (iii%) of the patients with SIRS, whereas this occurred in only one of the 211 patients (0.v%) without SIRS on arrival: p = 0.08, RR five.v (95% CI 0.6-48.vi).

Conclusion

Nosotros found SIRS condition on admission to be moderately associated with infection and strongly related to 28-day mortality.

Background

Sepsis is a systemic inflammatory response to a confirmed or suspected infection. Clinically, the Systemic Inflammatory Response Syndrome (SIRS) is the occurrence of at least ii of the following criteria: fever >38.0°C or hypothermia <36.0°C, tachycardia >90 beats/minute, tachypnea >20 breaths/minute, leucocytosis >12*10⁹/l or leucopoenia <four*10^nine/l [one,2].

The development from sepsis to septic shock represents a continuum with increasing bloodshed. The in-hospital/28-24-hour interval mortality in severe sepsis is 10%-twoscore% and in septic shock it is xxx%-60% [three-xi]. Early treatment with antibiotic and fluid resuscitation has been found to be strongly related to increased survival, which makes severe sepsis a condition which is important to identify and treat as early as possible [2,12,13].

Although a few studies have evaluated the progress of SIRS amongst emergency ward patients with suspected infection, nigh studies of SIRS have focused on patients in intensive care units (ICUs) [viii-eleven,fourteen,fifteen]. The occurrence and usefulness of registered SIRS status amid all acute medical patients in an emergency ward is unknown.

The aim of the present study was to describe the relevance of SIRS in predicting morbidity and bloodshed amidst patients in a medical emergency ward.

Materials and methods

Patient population

All acutely hospitalised medical patients admitted to the medical emergency ward as well equally medical patients admitted directly to ICU, Odense University Hospital in a half-dozen-week period (3 September to 14 Oct 2007) were included. Patients transferred from other wards or hospitals were excluded. If patients had more than one access to the department during the inclusion catamenia, they were included at the first admission and non at the following admissions.

Odense University Infirmary serves as a chief infirmary for 185,000 people. The medical emergency ward admits adult patients (> age xv years) with acute medical weather condition, with the exception of patients with a suspected astute centre disease or verified diabetes, chronic gastroenterological, haematological or nephrological disease.

There were no interventions related to the report, and all patients received standard intendance following the ward'due south guidelines.

Information collection and categorisation of patients

SIRS was defined as fulfilling at least two of the following four criteria: fever >38.0°C or hypothermia <36.0°C, tachycardia >xc beats/infinitesimal, tachypnea >xx breaths/minute, leucocytosis >12*10⁹/fifty or leucopoenia <4*10⁹/50.

The body temperature, heartbeat frequency and respiratory frequency of all patients were registered on inflow past the nurses. The information were nerveless a few minutes after the patient arrived in the ward. The nurses were aware of the study and were repeatedly reminded to obtain a total set of observations for all patients. Documentation of infection was based on the clinical evaluation within the offset ii days subsequently inflow, including clinical examinations also as radiological evaluation, and where infection was suspected past the clinical doc or indicated past claret, urine and other cultures. Leucocyte count on arrival and information on previous hospitalisation were obtained from the electronic Patient Administrative System of Funen County, and comorbidity was defined as the main discharge diagnoses (if any) during the last six months.

Follow upward was performed on solar day 28 past recording the occurrence of documented infection, handling in ICU, start of antibiotic treatment, development of sepsis, severe sepsis or septic stupor, length of hospital stay, diagnosis on belch, 28 day mortality and, if possible, the course of bloodshed. The follow-up registration was made by chart review past ane of the authors (PC), with evaluation by a specialist in infectious diseases (MS or AL) if there were any doubts well-nigh interpretation or classification. SIRS status was evaluated in a separate setting, simply parameters registered on patient inflow were not blinded in the nautical chart review.

Just infection, sepsis, severe sepsis and septic shock occurring within the starting time two days of the hospital stay were registered in guild to exclude conditions acquired in the hospital.

Infection was defined as identification of a relevant pathogen past microscopy/culture/polymerase concatenation reaction, positive serology, pneumonia verified past chest X-ray, infection documented with other imaging techniques, positive urine dip test combined with symptoms of urine tract infection, or as typical clinical symptoms such as erysipelas.

Sepsis was defined as SIRS plus a documented infection

Severe sepsis was defined equally sepsis plus at least 1 of the post-obit (without other comorbidity/therapeutic explanation): Glasgow coma calibration ≤ 14; PaO₂ ≤ nine.75 kPa; oxygen saturation ≤ 92%, PaO₂/FiO₂ ≤ 250;, pH ≤ 7.3; lactate ≥ two.5 mmol/l; creatinine ≥ 177 μmol/50; 100% increase of creatinine in patients with known kidney illness; oliguria ≤ thirty ml/h in ≥ three h or ≤ 0.7 50/24 h, prothrombin fourth dimension ≤ 0.6; platelets ≤ 100*10^ix/l; bilirubin ≥ 43 μmol/l; paralytic ileus; systolic claret pressure ≤ xc mm Hg or systolic blood force per unit area fall ≥ forty mm Hg from baseline.

Septic shock was defined as sepsis plus a systolic claret pressure level of ≤ 90 mmHg or systolic blood pressure fall ≥ xl mmHg from the baseline despite acceptable fluid resuscitation or the employ of vasopressor agents.

Analyses

Based on symptoms on arrival, the patients were categorised with SIRS, not-SIRS, and if essential information was missing, as unknown SIRS condition. The categorisation was conducted without a noesis of the event of any result variables.

Patients were compared using a chi-squared test for dichotomous variables and a Mann-Whitney test for continuous variables. P values < 0.05 were considered statistically pregnant. Relative adventure was calculated comparing patients with and without SIRS on arrival, with 95% conviction intervals calculated on the basis of the distribution of the counting information.

EpiData version 3.1 was used for information registration and STATA version 8 (STATA Corporation^®, Texas, USA) for statistical analysis.

Ethics

In accordance with Danish regulations, the written report was approved by the Danish Information Protection Agency.

Results

During the enrolment catamenia, a total of 643 patients were admitted to the medical ward or directly to the ICU every bit medical patients. Of these, 206 were transferred from other wards or had previously participated in the study. The remaining 437 consecutive acute medical patients were enrolled in the study.

A hundred and fifty-four of the 437 patients (35%) had SIRS on arrival, 211 patients (48%) did not accept SIRS, and 72 (xvi%) had unknown SIRS status. Patients with unknown SIRS condition were younger than patients with known SIRS status (Table ​ ane). Among patients with known SIRS status, patients without SIRS were younger than patients with SIRS on arrival, and fewer had comorbidity (Table ​ 2).

Tabular array i

Basic characteristics - all patients

	Patients with known SIRS status (N = 365)	Unknown SIRS (N = 72)	P-value
Characteristic	North (%) or median (range)	Due north (%) or median (range)
Male person sex	173 (47%)	40 (56%)	0.21
Age (years)	lx (xv-96)	50 (15-88)	0.004
Comorbidity	135 (37%)	26 (36%)	0.89
Malignancy	26 (7%)	five (vii%)	0.96
Cardiovascular	18 (5%)	ane (i%)	0.18
Pulmonary affliction	28 (8%)	3 (four%)	0.29

Basic characteristics among acute medical patients with and without known systemic inflammatory (SIRS) status.

Table 2

SIRS or no SIRS on inflow

Variable	Non SIRS (N = 211)	SIRS (N = 154)	P-value
	N (%) or median (range)	N (%) or median (range)
Male sex activity	96 (46%)	77 (50%)	0.40
Age (years)	56 (xv-92)	62 (xv-96)	0.008
Comorbidity	69 (33%)	66 (43%)	0.047
Malignancy	eleven (5%)	15 (ten%)	0.x
Cardiovascular	10 (5%)	8 (5%)	0.84
Pulmonary disease	ix (4%)	xix (12%)	0.004
Documented community-acquired infection	41 (19%)	66 (43%)	<0.001
Positive blood cultures	three (1%)	eight (5%)	0.06
Mortality on day 28	3 (ane%)	xv (10)	<0.001

Basic characteristics and issue among acute medical patients according to systemic inflammatory response (SIRS) on arrival

Infection and severity of disease

Infection was documented in 66/154 (43%) of the patients with SIRS and in 41/211 (19%) of the not-SIRS patients (p < 0.001) (Figure ​ 1). This corresponds to a 2.2 (95% CI 1.6-iii.ane) times higher proportion of patients with infection among SIRS patients. Among all 365 patients with known SIRS status, 107 patients had an infection and 66 (62%) presented with SIRS, while 41 (38%) did not.

Acute medical patients co-ordinate to systemic inflammatory response (SIRS) on arrival, customs-acquired infection, sepsis, severe sepsis and septic stupor (Northward = 437).

Septic shock occurred among 4/154 (3%) of the patients with SIRS, while this was only found among 1 of the 211 patients (0.5%) without SIRS on arrival (p = 0.08). This corresponds to a 5.five (95% CI 0.vi-48.6) times college proportion of septic shock amid patients who accept SIRS on arrival compared to patients without SIRS.

Eleven patients had bacteraemia with eight/154 SIRS-positive patients compared to 3/211 patients who did non present with SIRS: p = 0.06, RR 3.7 (95% CI 0.99-13.five).

All patients with SIRS and bacteraemia developed severe sepsis (n = 7) or septic daze (n = 1).

Mortality

Total mortality at day 28 was 21/437 (five%). Among the 154 patients who presented with SIRS, 15 (ten%) died within 28 days compared to 3/211 (ane%) not-SIRS patients and 3/72 patients (iv%) with unknown SIRS status. This corresponds to a 6.ix (95% CI 2.0-23.3) times higher bloodshed amid SIRS patients than amidst patients without SIRS (p < 0.001) (Table ​ 2). Among the 15 patients who presented with SIRS and died within 28 days, 13 had no documented infection on arrival, one had sepsis and ane had astringent sepsis. None of the v patients who presented with septic stupor died within 28 days.

Discussion

Nosotros establish a loftier prevalence of SIRS (35%) among acutely hospitalised medical patients, a moderate relation between SIRS and infection (RR 2.2), and a high (x%) 28-day mortality among SIRS patients.

The strength of our study is the sequent inclusion of all patients from the acute medical emergency ward, the prospective design with identification of symptoms and infection on arrival, and the possibility of following upward on all patients with the aid of the unique personal identification numbers used by all Danish citizens in all contact with the hospital system [16]. As all deaths amidst Danish citizens are registered nether their unique personal registration numbers irrespective of whether expiry occurs in infirmary or at home, and as all patients were followed upwards until death or day 28, whichever came starting time, nosotros are confident that nosotros have identified all deaths.

The weakness of the report is the fact that not all acute medical patients were admitted to the ward, as patients suspected of suffering acute heart disease or with verified diabetes, chronic gastroenterological, haematological or nephrological disease were admitted directly to other wards. Equally in other non-blinded observational studies, there is a risk of biased registration which we take tried to avert by registration of SIRS symptoms and documented infection in two dissimilar settings without any cognition of conclusions from the opposite setting. It is important to remember that the results reflect the standard of intendance in the actual ward, which is non necessarily generalisable to other wards.

Equally in other studies [8,fifteen], nosotros found that a high proportion of the acute patients (35%) had SIRS on admission. Other studies have constitute SIRS to exist a predictor of infections, severity of disease, organ failure and outcome in ICU patients[9,11], and we accordingly found a 2.2 times higher proportion of infection, a 5.5 times higher take a chance of septic shock, a 3.7 times higher proportion of bacteraemia and a six.9 times college 28-day mortality among SIRS patients than among not-SIRS patients.

We institute SIRS status to be highly correlated with 28-day mortality, which is in contrast to a previous study of patients from an emergency ward with suspected infection [viii]. Interestingly, nosotros found that the high 28-day mortality amidst SIRS patients was largely attributable to patients without documented infection on arrival (xiii/xv deaths), which means that SIRS among patients without infection is a bad prognostic factor, reflecting the fact that SIRS is a general expression of the caste of acute physiological disturbance which the patient is suffering [17]. In the nowadays study, most of the deaths amid patients with SIRS but no infection occurred among patients with malignant conditions, which highlights the prognostic importance of pre-existing conditions. Similarly, a previous report constitute that SIRS patients without infection had more comorbidity and a higher mortality than patients without SIRS [9].

The 28-mean solar day bloodshed was i/42 (2%) amongst septic patients, 1/20 (5%) among patients with astringent sepsis, and 0/5 (0%) among patients with septic shock. Given the depression numbers, the results must be interpreted with caution, but the observed mortality is lower than in almost other studies of patients with sepsis and septic shock [three-7,9,10]. A likely explanation is a difference in patient selection and inclusion criteria. For instance, nosotros included patients with infection documented according to predefined rules. A different definition of documented or suspected infections would modify the reported mortality. In the present written report we had a systematic selection of patients with suspected heart disease, confirmed diabetes and other chronic disorders who were systematically admitted to other wards, and we may have included patients with less comorbidity than in other studies. Our patients were identified by symptoms on inflow and signs of community-caused infection, whereas well-nigh other studies include patients from intensive intendance units or they identified patients past discharge diagnosis. These studies include patients with community-acquired likewise as nosocomial infections. As in the present study, ii studies of emergency ward patients with suspected infection showed an in-hospital mortality of 1% for simple sepsis and 4-9% for severe sepsis [8,xv].

As SIRS symptoms on arrival are related to infection besides as 28-day bloodshed, it might be useful to brand a systematic registration of this among acute medical patients. However, 38% of the infected patients did not accept SIRS on inflow, and they would be missed if SIRS were used every bit the merely way to place infected patients. If the main purpose was to place patients with a high risk of mortality, the question is whether a systematic SIRS registration of acute medical patients offers more data and gives better guidance to the clinician than he or she had in advance.

From a clinical epidemiological point of view, a systematic registration of SIRS status in a patient arriving at a medical emergency ward may provide improved information for decision making in management of the patient. The symptoms provide information to the clinical doctor on the caste to which he or she can await infection in a patient presenting with SIRS, but also provides data of an expected high 28-day mortality. SIRS symptoms provide information on a patient with a highly activated immune response due either to infections or to other conditions, and a systematic registration of the symptoms might serve to further sharpen attention among the staff in medical emergency wards. SIRS patients in a medical emergency ward are a very diverse group. Nosotros believe a better understanding of the unlike patient subcategories can do good time to come selection of patients for specific therapies. Whether or not a systematic registration of SIRS status improves decision making and treatment in the medical emergency ward is yet unknown, but it would be possible to test this with, for example, a randomised blueprint.

In conclusion

In acutely hospitalised medical patients, the prevalence of SIRS is loftier (35%). SIRS is only moderately related to infection on inflow, but is highly related to 28-twenty-four hours mortality.

Competing interests

The authors declare that they have no competing interests.

Authors' contributions

PC contributed to the blueprint of the study, obtained data, fabricated the analysis, interpreted the data and wrote the outset typhoon. MS and AL contributed to the design of the study and the interpretation of the data and fabricated a critical revision of the manuscript. All authors have read and approved the final manuscript.

References

• Os RC, Balk RA, Cerra FB, Dellinger RP, Fein AM, Knaus WA, Schein RM, Sibbald WJ. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM Consensus Briefing Committee. American College of Breast Physicians/Society of Critical Care Medicine. Chest. 1992;17:1644–1655. doi: ten.1378/breast.101.6.1644. [PubMed] [CrossRef] [Google Scholar]
• Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart Thou, Angus DC, Brun-Buisson C, Beale R, Calandra T, Dhainaut JF, Gerlach H, Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson BT, Townsend S, Vender JS, Zimmerman JL, Vincent JL. Surviving Sepsis Campaign: international guidelines for management of astringent sepsis and septic shock: 2008. Crit Care Med. 2008;17:296–327. doi: 10.1097/01.CCM.0000298158.12101.41. [PubMed] [CrossRef] [Google Scholar]
• Martin GS, Mannino DM, Eaton S, Moss Thousand. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med. 2003;17:1546–1554. doi: 10.1056/NEJMoa022139. [PubMed] [CrossRef] [Google Scholar]
• Angus DC, Linde-Zwirble WT, Lidicker J, Clermont Chiliad, Carcillo J, Pinsky MR. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001;17:1303–1310. doi: ten.1097/00003246-200107000-00002. [PubMed] [CrossRef] [Google Scholar]
• Padkin A, Goldfrad C, Brady AR, Young D, Black N, Rowan Grand. Epidemiology of severe sepsis occurring in the starting time 24 hrs in intensive care units in England, Wales, and Northern Ireland. Crit Intendance Med. 2003;17:2332–2338. doi: 10.1097/01.CCM.0000085141.75513.2B. [PubMed] [CrossRef] [Google Scholar]
• Finfer S, Bellomo R, Lipman J, French C, Dobb G, Myburgh J. Adult-population incidence of astringent sepsis in Australian and New Zealand intensive care units. Intensive Care Med. 2004;17:589–596. doi: ten.1007/s00134-004-2157-0. [PubMed] [CrossRef] [Google Scholar]
• Brun-Buisson C, Meshaka P, Pinton P, Vallet B. EPISEPSIS: a reappraisal of the epidemiology and outcome of severe sepsis in French intensive intendance units. Intensive Intendance Med. 2004;17:580–588. doi: 10.1007/s00134-003-2121-4. [PubMed] [CrossRef] [Google Scholar]
• Shapiro Northward, Howell Medico, Bates DW, Angus DC, Ngo Fifty, Talmor D. The clan of sepsis syndrome and organ dysfunction with mortality in emergency section patients with suspected infection. Ann Emerg Med. 2006;17:583–90. doi: 10.1016/j.annemergmed.2006.07.007. [PubMed] [CrossRef] [Google Scholar]
• Rangel-Frausto MS, Pittet D, Costigan M, Hwang T, Davis CS, Wenzel RP. The natural history of the systemic inflammatory response syndrome (SIRS). A prospective study. JAMA. 1995;17:117–123. doi: 10.1001/jama.273.2.117. [PubMed] [CrossRef] [Google Scholar]
• Brun-Buisson C, Doyon F, Carlet J, Dellamonica P, Gouin F, Lepoutre A, Mercier JC, Offenstadt G, Régnier B. Incidence, risk factors, and result of severe sepsis and septic shock in adults. A multicenter prospective study in intensive intendance units. French ICU Grouping for Severe Sepsis. JAMA. 1995;17:968–974. doi: 10.1001/jama.274.12.968. [PubMed] [CrossRef] [Google Scholar]
• Sprung CL, Sakr Y, Vincent JL, Le Gall JR, Reinhart K, Ranieri VM, Gerlach H, Fielden J, Groba CB, Payen D. An evaluation of systemic inflammatory response syndrome signs in the Sepsis Occurrence In Acutely Ill Patients (SOAP) written report. Intensive Intendance Med. 2006;17:421–427. doi: 10.1007/s00134-005-0039-8. [PubMed] [CrossRef] [Google Scholar]
• Rivers E, Nguyen B, Havstad S, Ressler J, Muzzin A, Knoblich B, Peterson E, Tomlanovich Chiliad. Early goal-directed therapy in the treatment of severe sepsis and septic shock. N Engl J Med. 2001;17:1368–1377. doi: 10.1056/NEJMoa010307. [PubMed] [CrossRef] [Google Scholar]
• Kumar A, Roberts D, Wood KE, Lite B, Parrillo JE, Sharma S, Suppes R, Feinstein D, Zanotti Due south, Taiberg L, Gurka D, Kumar A, Cheang M. Elapsing of hypotension earlier initiation of effective antimicrobial therapy is the critical determinant of survival in human septic stupor. Crit Care Med. 2006;17:1589–1596. doi: 10.1097/01.CCM.0000217961.75225.E9. [PubMed] [CrossRef] [Google Scholar]
• Dremsizov T, Clermont Thou, Kellum JA, Kalassian KG, Fine MJ, Angus DC. Severe sepsis in community-caused pneumonia: when does it happen, and do systemic inflammatory response syndrome criteria help predict course? Chest. 2006;17:968–978. doi: 10.1378/breast.129.iv.968. [PubMed] [CrossRef] [Google Scholar]
• Smith SW, Pheley A, Collier R, Rahmatullah A, Johnson L, Peterson PK. Astringent sepsis in the emergency department and its clan with a complicated clinical form. Acad Emerg Med. 1998;17:1169–1176. doi: 10.1111/j.1553-2712.1998.tb02691.x. [PubMed] [CrossRef] [Google Scholar]
• Frank L. Epidemiology. When an entire country is a cohort. Science. 2000;17:2398–2399. doi: 10.1126/science.287.5462.2398. [PubMed] [CrossRef] [Google Scholar]
• Brun-Buisson C. The epidemiology of the systemic inflammatory response. Intensive Care Med. 2000;17(Suppl i):S64–S74. doi: 10.1007/s001340051121. [PMC free article] [PubMed] [CrossRef] [Google Scholar]

---

Articles from Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine are provided hither courtesy of BioMed Central

---

Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2806258/

Posted by: smithdecorichiggy.blogspot.com

Share this post