Clinical Review ABC of intensive care

Organ dysfunction

BMJ 1999; 318 doi: http://dx.doi.org/10.1136/bmj.318.7198.1606 (Published 12 June 1999) Cite this as: BMJ 1999;318:1606
  1. Timothy W Evans,
  2. Mark Smithies

    Most illness and death in patients in intensive care is caused by the consequences of sepsis and systemic inflammation. These conditions are responsible for an estimated 100 000 deaths a year in the United States alone. The systemic inflammatory response syndrome (SIRS) produces a clinical reaction that is indistinguishable from sepsis in the absence of an infecting organism

    Understanding the pathogenesis of multiple organ failure is the key to reducing the unacceptably high mortality associated with sepsis

    Definitions of systemic inflammatory response syndrome (SIRS), sepsis, septic shock, and multiple organ dysfunction syndrome (American College of Chest Physicians, 1992)

    Systemic inflammatory response syndrome

    Two or more of the following clinical signs of systemic response to endothelial inflammation:

    • Temperature >38°C or <36°C

    • Heart rate >90 beats/min

    • Tachypnoea (respiratory rate >20 breaths/min or hyperventilation (PaCO2<4.25 kPa))

    • White blood cell count >12×109/l or <4×109/l or the presence of more than 10% immature neutrophils

    In the setting (or strong suspicion) of a known cause of endothelial inflammation such as:

    • Infection (bacteria, viruses, fungi, parasites, yeasts, or other organisms)

    • Pancreatitis

    • Ischaemia

    • Multiple trauma and tissue injury

    • Haemorrhagic shock

    • Immune mediated organ injury

    • Absence of any other known cause for such clinical abnormalities

    Sepsis

    Systemic response to infection manifested by two or more of the following:

    • Temperature >38°C or <36°C

    • Raised heart rate >90/min

    • Tachypnoea (respiratory rate >20 breaths/min or hyperventilation (PaCO2<4.25 kPa))

    • White blood cell count >12×109/l or <4×109/l or the presence of more than 10% immature neutrophils

    Septic shock

    Sepsis induced hypotension (systolic blood pressure <90 mm Hg or a reduction of 40 mm Hg from baseline) despite adequate fluid resuscitation

    Multiple organ dysfunction syndrome

    Presence of altered organ function in an acutely ill patient such that homoeostasis cannot be maintained without intervention

    Pathogenesis

    Systemic sepsis may complicate an obvious primary infection such as community acquired pneumonia or a ruptured abdominal viscus. Frequently, however, an infective source cannot be identified and the type of organism cultured …

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