POST OPERATIVE COMPLICATIONS

SIRS, SEPSIS & MODS

DR ASRAF AMIRULLAH
SIRS AND SEPSIS
 DEFINITION
. SIRS - Systemic Inflammatory Response Syndrome- disseminated inflammatory
response that arise from a number of insults including infections or trauma
 DEFINITION

. SIRS - Systemic Inflammatory Response Syndrome- disseminated inflammatory

response that arise from a number of insults including infections or trauma
. SIRS is defined by having 2 or more of the following:- pyrexia (>38oC) or
hypothermia (<36oC)- tachycardia (>90 bpm in the absence of beta blocker)-
tachypnea (>20 bpm or a requirement for mechanical ventilation)- white cell count
>12 or <4- acutely altered mental status- blood glucose of >6.6 in the absence of
diabetes
 DEFINITION
. SEPSIS = SIRS + documented source of infection (microbiologically
proven)
. SEPTIC SHOCK - refractory hypotension in addition to the above, in
the presence of invasive infection
.

SIDE NOTE: The terminology of Severe Sepsis is no longer used in the latest SSC:
International Guidelines for Management of sepsis and septic shock 2021.
 POTENTIAL CAUSES

Side note: Surgical causes often requires a surgical solution but all causes
can occur in surgical patients
 PREDISPOSING FACTORS

. Impaired barriers
. Impaired defences
 PREDISPOSING FACTORS

Impaired barriers
. Loss of gag reflex - reduced level of consciousness, drugs
. Loss of cough reflex - drugs, pain
. Ciliary function - high inspired O2, dry O2, intubation
. Gut mucosal barrier - ischaemia, change in gut flora (antibiotics)
. Urinary catheters - predispose to UTI
. IV/ arterial lines - breaching skin barriers
 PREDISPOSING FACTORS

Impaired defences
. Cell mediated immunity
. Humoural immunity
. Reticuloendothelial system
. Caused by trauma, shock, post op, sepsis, malnutrition, malignancy,
splenectomy (humoral), immunosuppressive drugs
 PATIENT ASSESSMENT

. IMMEDIATE CARE- Remember the ABCs- Major sepsis may have tachypnea
and cardiovascular changes- Give high flow oxygen and established IV access with
volume expansion by appropriate fluid bolus
 PATIENT ASSESSMEENT
. FULL PATIENT ASSESSMENTChart review- Review vital signs- CVP between
5-10 cmH2O and UOP > 30ml/H = adequate initial fluid resus.- If inadequate,
consider inotropic support.History and systematic examination- Assess patient
presenting complain to establish the likely source of infection (Eg, breathlessness
and productive cough may indicate pulmonary cause)- Systemic review: Evaluate
chronic health problems and current medication which may suggest susceptibility
to sepsis (e.g. use of steroids) or may indicate the of more intensive monitoring
(e.g. recent myocardial infarct)
 PATIENT ASSESSMENT
Review available results and arrange new investigations- TWC: abnormally high
or low in major sepsis- Urea and renal profile: look for evidence of AKI- LFT:
hyperbilirubinemia and transaminitis especially if biliary tree involved- ECG: look for
evidence of ischemia or arrhythmia- Further evaluation of possible site of sepsis
include the use of X-ray, USG, CT scanning.- Immunocompromised patient may
develop opportunistic infections. Which may require specific ix (e.g. broncho-alveolar
lavage or transbronchial biopsy for those with pneumonia)
 MANAGEMENT
The Surviving Sepsis Campaign (SSC)-It is a collaborative initiative to reduce
mortality for severe sepsis.-The SSC Hour-1 Bundle (2018) aim to begin resuscitation
and management immediately
MANAGEMENT
 MANAGEMENT
Additional critical care management- Transfusion: give packed cells if Hb<7 g/dL
- Hyperglycemia: manage with IVI Insulin- Prophylaxis: use LMWH for DVT
prophylaxis and PPI to avoid stress ulcer- Steroids: consider IV
Hydrocortisone for septic shock if hypotension responds poorly to fluids and
vasopressors.- Nutrition: use enteral nutrition unless not absorbing; consider TPN
 MANAGEMENT
Tools to measure mortality risk

Adult Sepsis Guideline 2021 - recommend against the qSOFA score compared to
SIRS, NEWS and MEWS

National Early Warning Score (NEWS) - NEWS is a tool developed by the Royal
College of Physicians which improves the detection and response to clinical
deterioration in adult patients and is a key element of patient safety and improving
patient outcomes. Guide in frequency of monitoring. (e.g: 0-4 (4-6 hrly), 3 in any
parameter (hrly review), >7 (continuous))

Modified Early Warning Score (MEWS) - simple, physiological score that aims to
prevent delay in intervention or transfer of critically ill patients.- it predicts chance of
ICU admission or death within 60 days.
MODS
MULTI SYSTEM FAILURES

MODS also referred as MOF- it is an important cause of death- it refers to the process
whereby more than one organ system has deranged functions and require support
Outcome of MOF- Established MOF has extremely poor prognosis- In two-organ
failure, mortality rate is in the region of 50% and increase to 66% on day 4- In three-
organ failure, mortality rate is around 80% on the first day, increasing to 96% if it
does not resolve- In four-organ failure, survival is unlikely
MULTI SYSTEM FAILURES

Definition of individual organ system failureCVS (one or more of the following)- HR

<54bpm or symptomatic bradycardia- MAP<49 mmHg or (>70mmHg requiring inotropic
support)- Occurrence of ventricular fibrillation or tachycardia (VT or VF)- Serum
pH<7.24 with normal pCO2Respiratory failure- RR <5 or >49bpm- pCO2 >6.65 kPa
(49mmHg)- alveolar-arterial gradient >46.55- ventilator-dependent on day 4 in ICU
MULTI SYSTEM FAILURES

Definition of individual organ system failure

Renal failure- UOP <479 ml in 24Hrs or <159 in 8Hrs- Urea >36 mmol/L- Creatinine
>310- Dependent on haemofiltrationHaematological failure- TWC <1- Platelet <20-
Haematocrit <0.2%- DIC
MULTI SYSTEM FAILURES

Definition of individual organ system failureNeurological failure- GCS<6 in the absence of

sedationGI failure- Ileum >3 days- Diarrhea >4days- GI bleeding- Inability to tolerate enteral
feed in absence of primary gut pathologySkin failure - decubitus ulcerEndocrine failure -
hypoadrenalism or abnormal TFT
MULTI SYSTEM FAILURES

Treatment and prevention of MOF- Emphasis must be on identifying at-risk

patients early, and intervening quickly to prevent MOF.- To optimise the chance of
recovery, the initial insult must be treated.- Early nutritional support, via the gut, is
increasing recognised as important in improving outcome.
 SUMMARY

. Sepsis is a mediator disease

. Prevention of sepsis is better than cure
. Clinical signs may be obvious, but are often covert
. Treatment is much easier at early stage
. The Sepsis Surviving Campaign guidelines, particularly the ‘SSC Hour-1
Bundle’, are a useful as starting point in the management of the patient with
severe sepsis.
 QUIZ

1) On day 4 post Op, this patient has decubitus ulcer, ileus> 3days and new
occurrence of ventricular tachycardia in ward. What is the predicted mortality rate
for this patient?

2) Despite fluid therapy and vasopressors, this patient with liver abcess still unable
to maintain his MAP>65 and remain hypotensive. What is the other option that u may
consider?3) Loss of cough reflex is NOT the predisposing factor for impaired
barriers. (True or False)
 SOURCE
> Surviving Sepsis Campaign: International Guidelines
for Management of Sepsis and Septic Shock 2021>
The Inflammatory Response pg 25-27
- Sabiston Textbook of Surgery> Sepsis and multiple
organ failure (pg 165-181) - Care of the Critically Ill
Surgical Patient (Third Edition)> Postoperative
complication (pg 266-272) - MRCS Part A: Essential
Notes Book 1
THANK YOU