Organ dysfunction

doi:10.1136/bmj.318.7198.1606

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Timothy W Evans,
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 …