Larry T. Lovelace, DO, FACEP

Board Certified Emergency Medicine

Attending; Accident Care and Treatment Center; Okla City, OK

Edmond Urgent Care; Edmond OK

What is SIRS?

The systemic inflammatory response syndrome is systemic level of acute inflammation, that may or may not be due to infection, and is generally manifested as a combination of vital sign abnormalities including fever or hypothermia, tachycardia, and tachypnea.

Definitions

Severe SIRS – SIRS in which at least 1 major organ system has failed.

Sepsis – SIRS which is secondary to infection.

Severe Sepsis – Severe SIRS which is secondary to infection.

Septic Shock – Severe sepsis resulting in hypotensive cardiovascular failure.

Criteria for SIRS

Requires 2 of the following 4 features to be present:

Temp >38.3° (100.9) or <36.0° C (96.8)

Tachypnea (RR>20)

Tachycardia (HR>90, in the absence of intrinsic heart disease)

WBC > 10,000/mm3 or <4,000/mm3 or

>10% band forms on differential

Criteria for Severe SIRS

Must meet criteria for SIRS, plus 1 of the following:

Altered mental status SBP<90mmHg or fall of >40mmHg from baseline Impaired gas exchange (PaO2/FiO2 ratio<200-250) Metabolic acidosis (pH<7.30 & lactate > 1.5 x upper

limit of normal) Oliguria (<0.5mL/kg/hr) or renal failure Hyperbilirubinemia Coagulopathy (platelets < 80,000-100,000/mm3,

INR >2.0, PTT >1.5 x control, or elevated fibrin degredation products)

Relationship Between SIRS and Sepsis

Adapted from: Marini JJ, et al. Critical Care Medicine, 2nd ed. 1997.

Risk Factors for SIRS/Sepsis

Extremes of age

Indwelling lines/catheters

Immunocompromised states

Malnutrition

Alcoholism

Malignancy

Diabetes

Cirrhosis

Male sex

Genetic predisposition?

Pathophysiology

Although inflammation is essential to host response against

infection, SIRS results from a dysregulation of the normal

response, with massive, uncontrolled release of pro-

inflammatory mediators.

Prognosis

Overall mortality from SIRS/sepsis in the U.S. is approximately 20%. Mortality is roughly linearly related to the number of organ failures, with each additional organ failure raising the mortality rate by 15%.

Prognosis

Hypothermia is one of the worst prognostic signs. Patients presenting with SIRS and hypothermia have an overall mortality of ~80%.

Treatment

Fluid Resuscitation

Vasopressors

Antibiotics

Eradication of infection

Ventilatory support, activated protein C, steroids, glycemic control, nutrition

Treatment(Fluid Resuscitation)

Rapid, large volume infusions are generally indicated in all patients with septic shock.

Some patients require up to 10L of crystalloid in the first 24 hours, with an average requirement of 4-6L.

Although resuscitation with colloid will necessitate less overall volume of fluid, there is no difference between patients treated with colloid versus crystalloid in the development of pulmonary edema, length of stay, or survival.

Treatment(Vasopressors)

These are second line agents in the treatment of septic shock (after volume resuscitation).

A goal MAP should be 60-65mmHg, although urine output, mental status, and skin perfusion are better variables to use in monitoring adequate perfusion.

Treatment(Antibiotics)

Empiric antibiotic therapy should be instituted immediately after appropriate cultures have been drawn, taking into consideration the likely source of infection,

In general, therapy should include two effective agents from different classes, for example, a beta-lactam and an aminoglycoside

Treatment(Mechanical Ventilation)

Nearly all patients with septic shock require supplemental oxygen, and approximately 80% require mechanical ventilation.

Use of mechanical ventilation not only may improve oxygenation, but the necessary sedation +/- paralysis may improve organ perfusion by diverting blood flow away from the diaphragm.

Treatment(Activated Protein C)

The PROWESS trial showed that patients who received a 96hr infusion of APC within 24 hours of presentation had a statistically lower 28-day mortality rate (25% vs. 31%).

Treatment was of greater benefit in the most acutely ill patients (APACHE II score ≥ 25).

APC has been found to not be cost effective in those patients with APACHE II scores <25 or in those with relatively low life-expectancy even in the event of survival from sespis.

Protocol for Early Goal Directed Therapy in

Septic Shock

(Adapted from NEJM 2001;

345:1368-77, in which

patients receiving this goal-

directed therapy had im-

proved in-hospital mortality

compared to those with

“standard” therapy, 31% to

47%.)

Sepsis is lucrative and becoming high profile AND

producing settlements higher than coverages

.

Textbook chapters on sepsis describe the physiologic changes and management. What the textbooks do not describe are the subtleties and nuances of early sepsis. How do patients with symptoms of early sepsis present? Why is it missed?

Sepsis Pathway

Bacteria enter the blood and trigger complex immunologic reactions

Vasodilation occurs and fluid leaks from the vessels = edema and lowered BP

Decreased blood flow = poor nutrient exchange and edema

Shock

Multisystem organ failure

DEATH

Clinically

Infection overwhelms the

body’s immune system.

Tachycardia

Tachypnea

Fever

Hypotension.

Cellular injury, tissue

damage, shock, multiorgan

failure, and death is

common.

Certain names and details have been

altered to protect identities

CASES

Actual Cases

Actual transcripts of notes

Actual Ad

As the ability to diagnose and treat cancer continues to improve, a doctor's failure to diagnose cancer becomes more significant. A patient's chances of survival are directly linked to the stage of the cancer when it is discovered, and a failure to diagnose cancer in an early stage can mean that the patient may undergo more rigorous and painful medical treatment than would otherwise be necessary.

Failure to diagnose cancer can occur because of a number of medical mistakes or medical , and the risk of failure to diagnose cancer is in some part dependent upon the type of cancer involved. Different types of cancer have different growth patterns and different prognostic implications at various times.

Cervical Cancer A type of cancer easily detectable by smear tests. The survival rates are quite high if detected in early stages, but errors in screening

and misinterpretation of results can cause a failure to diagnose cancer that may lead to infertility or death. Breast Cancer Responds well to early treatment, but can remain undetected for lengthy amounts of time. A failure to diagnose cancer of the breast

tissue can result in serious delays in starting treatment, sometimes causing the loss of one or both breasts, or the death of the patient. Prostate Cancer Like breast cancer, prostate cancer usually has an excellent recovery rate for early treatment. Failure to diagnose cancer of the prostate

has declined a bit as the methods used for screening continue to improve. Esophageal Cancer The distinct symptoms and contributing risk factors should prevent competent doctors from a failure to diagnose cancer of the

esophagus, as patients have difficulty swallowing, a chronic cough, and generally experience severe weight loss. Colon Cancer A failure to diagnose cancer of the colon usually relates to the failure to properly evaluate and respond to complaints of rectal bleeding.

Colon cancer is the second leading cause of death in cancer patients. Early treatments of all of these cancers are far less painful and strenuous than the later courses of action that may be required as a

result of failure to diagnose cancer. A doctor's failure to diagnose cancer can result in unnecessary pain and suffering and financial hardship. If you or someone you love has suffered as the result of a doctor's failure to diagnose cancer, you may be entitled tocompensation for medical treatment and hospital costs, lost wages, cost of home care or hospice care, funeral expenses, and other costs associated with the misdiagnosis, such as pain and suffering. The medical malpractice attorneys at Greenberg & Bederman have experience representing victims of failure to diagnose cancer and can help you determine your legal rights and plan for the future.

If you or a loved one has suffered due to a failure to diagnose cancer, call a Maryland Medical Malpractice Lawyer at Greenberg & Bederman in MD at (301) 589-2200 or in DC or VA toll free (888) 926-8583, Baltimore, MD at (443) 573-1111 or submit an online failure to diagnose cancer questionnaire.

As the ability to diagnose and treat cancer continues to improve, a doctor's failure to diagnose cancer becomes more significant. A patient's chances of survival are directly linked to the stage of the cancer when it is discovered, and a failure to diagnose cancer in an early stage can mean that the patient may undergo more rigorous and painful medical treatment than would otherwise be necessary.

Failure to diagnose cancer can occur because of a number of medical mistakes or medical , and the risk of failure to diagnose cancer is in some part dependent upon the type of cancer involved. Different types of cancer have different growth patterns and different prognostic implications at various times.

Cervical Cancer A type of cancer easily detectable by smear tests. The survival rates are quite high if detected in early stages, but errors in screening

and misinterpretation of results can cause a failure to diagnose cancer that may lead to infertility or death. Breast Cancer Responds well to early treatment, but can remain undetected for lengthy amounts of time. A failure to diagnose cancer of the breast

tissue can result in serious delays in starting treatment, sometimes causing the loss of one or both breasts, or the death of the patient. Prostate Cancer Like breast cancer, prostate cancer usually has an excellent recovery rate for early treatment. Failure to diagnose cancer of the prostate

has declined a bit as the methods used for screening continue to improve. Esophageal Cancer The distinct symptoms and contributing risk factors should prevent competent doctors from a failure to diagnose cancer of the

esophagus, as patients have difficulty swallowing, a chronic cough, and generally experience severe weight loss. Colon Cancer A failure to diagnose cancer of the colon usually relates to the failure to properly evaluate and respond to complaints of rectal bleeding.

Colon cancer is the second leading cause of death in cancer patients. Early treatments of all of these cancers are far less painful and strenuous than the later courses of action that may be required as a

result of failure to diagnose cancer. A doctor's failure to diagnose cancer can result in unnecessary pain and suffering and financial hardship. If you or someone you love has suffered as the result of a doctor's failure to diagnose cancer, you may be entitled to compensation for medical treatment and hospital costs, lost wages, cost of home care or hospice care, funeral expenses, and other costs associated with the misdiagnosis, such as pain and suffering. The medical malpractice attorneys at Greenberg & Bederman have experience representing victims of failure to diagnose cancer and can help you determine your legal rights and plan for the future.

If you or a loved one has suffered due to a failure to diagnose cancer, call a Maryland Medical Malpractice Lawyer at Greenberg & Bederman in MD at (301) 589-2200 or in DC or VA toll free (888) 926-8583, Baltimore, MD at (443) 573-1111 or submit an online failure to diagnose cancer questionnaire.

In many “failure to diagnose” cases, or “delay in diagnosis” cases, the patient presented with a virulent and aggressive bacterial sepsis and unfortunately no treatment can save the patient. However, the failure or delay in diagnosis often results in years of litigation. Obvious problems with meeting standards of care are apparent, and the cases are tragic. Defense attorneys are reluctant to litigate these cases.

P U L S E

60-90 beats per minute is considered the textbook normal