Systemic inflammatory response syndrome score at admission independently predicts infection in blunt trauma patients

BACKGROUND: Systemic inflammatory response syndrome (SIRS) score has been demonstrated to be an accurate predictor of outcome in critical surgical illness. To our knowledge, there is a paucity of data using SIRS score as a tool to predict posttraumatic infection. Our goal was to determine whether the severity of SIRS score at admission is an accurate predictor of infection in trauma patients. METHODS: Prospective data were collected on 4,887 blunt trauma patients admitted to a primary adult resource center designated trauma center over an 18-month period. Patients were stratified by age and Injury Severity Score (ISS). SIRS score was calculated at admission. SIRS was defined as an SIRS score > or = 2. Each patient was screened for infection by an infectious disease specialist. Those at high risk for infection were then monitored daily throughout their hospitalization. Centers for Disease Control and Prevention guidelines were used to diagnose infection. RESULTS: Of the 4,887 patients, 1,850 (38%) were admitted > 24 hours and evaluated for subsequent infection (mean ISS, 16 +/- 9; mean age, 43 +/- 19, SD). Thirty-one percent (577) of the patients acquired an infection. The mean hospital length of stay (20.2 days vs. 6.5 days) and mortality (7.8% vs. 2.7%) were significantly greater in the infected group (p < 0.001). Of the four SIRS variables (temperature, heart rate, white blood cell count, and respiratory rate), hypothermia and leukocytosis were the most significant predictors of infection (p < 0.001) when adjusted for age and ISS. SIRS scores of > or = 2 were increasingly predictive of infection when analyzed by multiple logistic regression analysis. CONCLUSION: An admission SIRS score of > or = 2 is a significant independent predictor of infection and outcome in blunt trauma. Daily SIRS scores may be a meaningful method of assessing postinjury risk of infection, and may initiate earlier diagnostic intervention for determination of infection.     

Systemic inflammatory response syndrome score at admission independently predicts mortality and length of stay in trauma patients

BACKGROUND: Recent studies have documented that the systemic inflammatory response syndrome (SIRS) score is a useful predictor of outcome in critical surgical illness. The duration and severity of SIRS are associated with posttrauma multiple organ dysfunction and mortality. We sought to determine whether the severity of SIRS at admission is an accurate predictor of mortality and length of stay (LOS) in trauma patients. METHODS: Prospective data of 4,887 trauma admissions to a Level I trauma center over a 18-month period (January 1997 to July 1998) were analyzed. Patients were stratified by age and Injury Severity Score (ISS), and a SIRS severity score (1 to 4) was calculated at admission (1 point for each component present: fever or hypothermia, tachypnea, tachycardia, and leukocytosis). The SIRS score was evaluated as an independent predictor of mortality and LOS by chi2 and multivariate logistic regression. RESULTS: Trauma patients (n = 4,887, 83% blunt injuries, 72% male) had the following characteristics: 73.1% were age 18 to 45 years, 17.5% were age 46 to 65 years, and 9.4% were age > or =66 years; 77.7% had ISS less than 15, 18.8% had ISS 16 to 29, and 3.5% had ISS greater than 29. Analysis of variance adjusting for age and ISS determined that SIRS score of 2 was a significant predictor of LOS. Furthermore, the relative risk of death increased significantly with SIRS score of 2 when age and ISS were held constant. CONCLUSION: Logistic regression analysis confirmed that a SIRS score of 2 was a significant independent predictor of increased mortality and LOS in trauma patients. These data suggest that admission SIRS scoring in trauma patients is a simple tool that may be used as a predictor of outcome and resource utilization.     

Esophageal ruptures: triage using the systemic inflammatory response syndrome score

Esophageal rupture is a rare entity. Delay in the diagnosis and treatment may threaten the patient’s life. The decision for surgical or nonsurgical treatment, however, remains controversial because advocates of both treatments have reported comparable results. To quantify the decision making, we suggest the systemic inflammatory response syndrome (SIRS) score for triage of an esophageal rupture. Using this criterion for 12 patients resulted in the survival of all of them. Therefore, we advocate use of the SIRS score for triage of an esophageal rupture.     

Comparison of surgical outcome and the systemic inflammatory response syndrome score between retroperitoneoscopic hand-assisted nephroureterectomy and open nephroureterectomy

The goal of this study is to compare surgical and oncological outcomes of laparoscopic nephroureterectomy and the open surgery using the concept of systemic inflammatory response syndrome (SIRS) in addition to common variables. Thirty-six and 23 patients having upper urinary tract urothelial cancer who were operated on with retroperitoneoscopic hand-assisted nephroureterectomy (RHANU) or standard open nephroureterectomy (ONU) retrospectively, were analyzed. Median operation time was 140 (range 70-200) and 60 (range 45-85) minutes, respectively in the RHANU group and the ONU group. The median days to ambulation and hospital stay of the RHANU group were significantly shorter than those of the ONU group. There was no significant difference in the incidence of SIRS and other surgical results between the two groups. In oncological outcome, no significant difference was found in the bladder recurrence rate (RHANU vs. ONU; 52% vs. 45%), local recurrence (0% vs. 0%), distant metastasis (11% vs. 13%) or survival rate (94% vs. 91%) between the RHANU group and the ONU group at 2-year follow-up. There was no port site recurrence in the RHANU group. Although the RHANU may have an advantage in terms of earlier recovery, there were no significant differences in the incidence of SIRS and oncological outcomes between the RHANU group and the ONU group.     

Persistent systemic inflammatory response syndrome is predictive of nosocomial infection in trauma

BACKGROUND: Admission systemic inflammatory response syndrome (SIRS) score has been previously reported to be an accurate predictor of infection and outcome in trauma. However, these data were limited to only one SIRS score at admission. A prior study in surgical intensive care unit (ICU) patients reported that the SIRS score on ICU day 2 declined after completion of resuscitation, and was a more accurate predictor of outcome. Our objective in this follow-up study was to prospectively evaluate the utility of daily SIRS scores in prediction of nosocomial infection and outcome in high-risk trauma patients. METHODS: Prospective data were collected on 702 consecutive trauma patients admitted over a 12-month period to the ICU. SIRS scores were calculated daily. Centers for Disease Control and Prevention guidelines were used for the diagnosis of infection. Multivariate linear regression was used for statistical analysis. RESULTS: Five hundred seventy-three (82%) patients sustained blunt injuries and 129 (18%) sustained penetrating injuries. The mean age was 43 +/- 21 years, with an overall mortality of 11.4%. Two hundred ninety (41.3%) of the study patients acquired a nosocomial infection (respiratory site most common), with an associated mortality rate of 12.4%. SIRS (defined as SIRS score >/= 2) on hospital days 3 through 7 was a significant predictor of nosocomial infection and hospital length of stay. Persistent SIRS to hospital day 7 was associated with a significant risk for increased mortality (relative risk, 4.7; 95% confidence interval, 1.41-12.87; p = 0.047). CONCLUSION: Persistent SIRS is predictive of nosocomial infection in trauma. Daily monitoring of SIRS scores is easily accomplished and should be considered in all high-risk trauma patients. Persistent SIRS in trauma should initiate early diagnostic interventions for determination of source of infection, and consideration of early empiric antimicrobial therapy.     

全身炎症反应综合征修正评分及白细胞监测鉴别脑外伤患者应激反应与早期感染的价值

目的：探讨全身炎症反应综合征修正（ASS）评分及白细胞监测鉴别应激反应和感染的应用价值。方法选择性分析2009年6月至2012年6月于本院接受治疗的脑外伤患者80例,根据是否发生早期感染分为感染组和非感染组,每组各40例。在入院7 d内对患者进行ASS评分,并于入院后前7 d以及第10、14、21 d对患者进行外周WBC监测并记录最高体温。结果感染组患者ASS平均得分（8.873±2.366）分;非感染组平均得分为（3.896±1.350）分,感染组ASS评分显著高于未感染组（t=12.347,P＜0.05）;应激反应所致体温及外周白细胞水平异常在伤后第1天最为明显,以后呈下降趋势,感染组患者下降后再次上升。结论患者伤后14～21 d的体温及白细胞走势对早期感染的诊断具有指示意义,ASS评分对早期感染有预测价值,可有助于鉴别应激反应与早期感染。     

The significance of the systemic inflammatory response syndrome (SIRS) in 1278 trauma patients

Summary The association between the increasing severity of systemic inflammatory response syndrome (SIRS) and the incidence of posttraumatic complications and mortality was retrospectively investigated in 1278 injured patients. Patients were divided into three groups according to their Injury Severity Score (ISS) (group A: ISS L 9 K16 points (n = 626); group B: ISS > 16 < 40 points (n = 589); group C: ISS L 40 points (n = 63)). SIRS was defined according to the criteria of the American Consensus Conference. The number of fulfilled criteria determined its severity: moderate SIRS: 2 criteria fulfilled, intermediate SIRS: 3 criteria fulfilled, severe SIRS: 4 criteria fulfilled. Additionally, acute respiratory distress syndrome (ARDS) was defined according to the Murray-Score and the multiple organ dysfunction syndrome (MODS) according to the Goris-Score. The incidence of SIRS was 42 % in group A, 70 % in group B and 100 % in group C (p < 0.05). The severity of SIRS increased with severity of trauma. Moreover, 178 of all injured patients (14 %) developed septic complications. In parallel to SIRS, the incidence of these septic complications correlated with the severity of trauma. The occurrence and severity of ARDS and MODS correlated with increased severity of SIRS and septic complications. Among patients without SIRS 15 % developed ARDS and 21 % MODS. In contrast, patients with severe SIRS and septic complications demonstrated ARDS in 99 % and MODS in 97 %. In these patients, no correlation was found between the ISS and the incidence of ARDS or MODS. There were also stepwise increases in mortality rates in the hierarchy from SIRS to septic shock. While 13 of patients with modest SIRS (5 %) and 32 of patients with intermediate SIRS (13 %) died, the mortality rate of patients with severe SIRS was 19 % (p < 0.05). In addition, a significant correlation between the incidence of septic complications and mortality was found. Injured patients with sepsis died in 13 %, those with severe sepsis in 23 %, and patients with septic shock in 33 % (p < 0.05). Thus, the increasing severity of SIRS was associated with the occurrence of posttraumatic ARDS, MODS, and mortality. Using the number of fulfilled SIRS criteria for classifying systemic inflammation, its severity may be predictive for posttraumatic complications and outcome of injured patients.      

Sepsis and the systemic inflammatory response syndrome

Sepsis and the systemic inflammatory response syndrome are common and represent a major factor in morbidity and mortality in intensive care units and the critically ill. The pathogenesis of these syndromes is becoming increasingly understood and it is hoped that this will result in improved outcome. However, novel treatments have so far failed to live up to the expectations following extensive and promising in vitro and in vivo animal studies. The aim of this review is to detail the currently used definitions of systemic inflammatory response syndrome, sepsis and septic shock and to present an overview of our current understanding of the pathophysiology which underline these conditions.     

Adrenocortical response and cortisone replacement in systemic inflammatory response syndrome

The use of steroids as an adjunct to antimicrobial therapy has been controversial for many decades. Recent reports of the use of steroids in supraphysiological rather than in "industrial" doses in patients with sustained circulatory instability has re-ignited the debate. Anecdotal reports of adrenal insufficiency in septic patients have suggested a relative cortisol deficiency in these patients with poor survival if not given supplementary steroids. The possibility that the hypothalamic pituitary adrenal axis is intimately involved in the pathogenesis of this entity has not previously been highlighted. This review looks at the relationship of sustained cytokine release and the possibility of altering the stress response with progressive loss of adrenocorticotrophic hormone release and subsequent diminution in adequate cortisol levels. The reliance on, and misinterpretation of, the short synacthen test in diagnosing the possibility of this condition is emphasized.     

Systemic inflammatory response syndrome outcome in surgical patients

Introduction

The problems of inflammation and infection as a leading cause of organ dysfunction and failure is a major problem after injury or operations. When systemic inflammatory response syndrome (SIRS) progress to multiple organ failure (MOF), the mortality reach up to 30–80% depending on the number of failed organs. Recent discoveries and improvement in patient care, a reasonable question then arises, are the incidence of MOF decreasing? The literature suggests a decrease in mortality of patients with severe organ failure and a decrease in elective surgical mortality in patients.

Methods

This is prospective study of 50 patients who underwent surgical procedure. They were followed up till date of termination with daily SIRS monitoring, development of MODS and MOF. Risk factors for MOF are addressed.

Results

There are total 31 patients who develop SIRS, of whom 7 patients develop severe sepsis and 4 went into MOF.

Conclusion

Early detection of SIRS helps us to prevent multiple organ dysfunction syndrome (MODS)/MOF, leading to lesser hospital stay and better outcome.     

Assessment of surgical invasiveness of augmentation ileocystoplasty applying the systemic inflammatory response syndrome score in patients with spina bifida

PURPOSE: Applying the systemic inflammatory response syndrome (SIRS), we investigated the surgical invasiveness of augmentation ileocystoplasty in patients with spina bifida. MATERIALS AND METHODS: A total of 23 patients with spina bifida underwent augmentation ileocystoplasty. We diagnosed the cases as SIRS when they fulfilled at least 2 of the 4 SIRS criteria. We developed SIRS score, the sum of the number of positive items for the duration of SIRS, as a parameter of surgical invasiveness. We investigated the relationships between SIRS score and various factors and compared SIRS scores of augmentation with those of other urological operations as a control, which consisted of radical prostatectomy (25 patients) and radical nephrectomy (20 patients). RESULTS: We found a positive relationship between SIRS score and the operation time of augmentation. SIRS scores were significantly higher in the patients who underwent operations diverting ventriculoperitoneal shunt to ventriculoatrial shunt concurrently with augmentation. However, the operation times were not significantly different between the cases with and without shunt operations. SIRS scores in cases of augmentation were significantly higher than those of the major urological operations compared. CONCLUSION: When evaluated by the SIRS score, the factors related to the surgical invasiveness of augmentation ileocystoplasty were a longer operating time and concurrent shunt diversion. The higher invasiveness of this operation compared with major urological operations was also revealed. These facts should be considered carefully when the indications for augmentation ileocystoplasty are determined.     

The effects of surgical fracture fixation on the systemic inflammatory response to major trauma

Early stabilization of major long bone fractures is beneficial in reducing the incidence of acute respiratory distress syndrome and multiple organ failure, both of which are caused by activation of the systemic inflammatory response. This activation results in tissue recruitment of and injury by circulating polymorphonuclear leukocytes. The reasons for clinical benefits of early fracture stabilization in major trauma are unknown. Published studies indicate that fracture surgery increases the posttraumatic inflammatory response. Major surgery to stabilize fractures carries a higher complication rate when performed on patients whose hypovolemic shock is not fully corrected. Thus, fracture care should be tailored to the patient, not dictated by the injured bone. Understanding the impact of fracture surgery on the systemic inflammatory response to major trauma is necessary to refine treatment and to apply it optimally to all patients.     

Systemic inflammatory response syndrome and nosocomial infection in trauma

BACKGROUND: Admission systemic inflammatory response syndrome (SIRS) score has been previously reported to be an accurate predictor of infection and outcome in trauma. However, the data were limited to the first 7 days of admission. Our objective in this follow-up study was to prospectively evaluate the utility of daily SIRS scores in the second and third week of admission as compared with the first week in prediction of nosocomial infection and outcome in high-risk trauma patients. METHODS: Prospective data were collected on 1,277 consecutive trauma patients admitted during a 28-month period to the intensive care unit. SIRS scores were calculated daily for the first week and every other day for the following 2 weeks. Patients were categorized into SIRS occurring "early" (week 1), "middle" (week 2), and "late" (week 3). Centers for Disease Control and Prevention guidelines were used for the diagnosis of infection. Multivariate linear and logistic regression analyses were utilized for statistical analyses, controlling for the covariates of age, Injury Severity Score, and admission Glasgow Coma Scale score. RESULTS: The trauma cohort included patients with blunt injuries (84%) and penetrating injuries (16%). The mean age was 43 +/- 21 years with an overall mortality of 14.7%. Nosocomial infection developed in 580 (45.4%) of the study patients (respiratory site most common) with a total of 1,001 infections (some patients with multiple infections). SIRS (defined as SIRS score >/=2) was common, with 92.4% of patients manifesting SIRS at admission. SIRS was most prevalent during the first week postinjury (91% of patients manifesting SIRS), decreasing to 69% and 50% during postinjury weeks 2 and 3. SIRS was more common in patients who acquired nosocomial infections compared with noninfected patients. Logistic regression analysis confirmed that patients with "middle" SIRS during week 2 (odds ratio [OR] 17.62, confidence interval [CI] 12.95-23.97, p < 0.0001, receiver operating characteristic [ROC] 0.83) and "late" SIRS during week 3 (OR18.12, CI 12.71-25.84, p < 0.0001, ROC 0.81) had significantly greater risk for nosocomial infection compared with patients with "early" SIRS during week 1 (OR 4.55, CI 2.57-8.06, p < 0.0001, ROC 0.65) postinjury. CONCLUSION: SIRS is predictive of nosocomial infection in trauma through postinjury day 21. Nosocomial infection should be considered as a treatable cause of SIRS in trauma patients, and early diagnostic interventions should be initiated to evaluate for potential causes.     

Euthyroid sick syndrome in trauma patients with severe inflammatory response syndrome

Objective： To investigate the alternations of thyroid hormone in traumatic patients with severe inflammatory response syndrome （SIRS）. Methods： Fifty traumatic patients with severe SIRS were enrolled and divided into two groups according to whether they presented multiorgan dysfunction syndrome （MODS）. Thyroid hormone measurements were taken, including total triiodothyronine （ TT3 ）, total thyroxine （TT4）, free triiodothyronine （FT3）, free thyroxine （ FT4 ） and thyroid stimulating hormone （TSH）. The acute physiology and chronic health evaluation II （ APACHE II ） score was calculated according to clinical data. The outcomes of recovery or deterioration were recorded, as well as the length of time from the onset of SIRS to the time thyroid hormones were measured. Results： Euthyroid sick syndrome （ESS） was presented in 45 cases. TT3 level was negatively correlated with APACHE II score （r = -0.330, P 〈0. 05）, and TT3/TI＇4 value was negatively correlated with the duration of SIRS（ r = -0.316, P〈0.05）. TT3, TT4 and levels in MODS patients were significantly lower than those without MODS （ P 〈 0.05 ）. MODS patients got low TT4 or FT4 level more frequently than those without MODS （ P 〈 0.05 ）. Compared with the patients in normal TSH group, the patients with decreased TSH had lower T3, T4, recovery rate and higher APACHE II scores, MODS incidence, but there was no difference between two groups （P〉0.05）. Conclusions： Trauma patients with severe SIRS have high possibility to get ESS, which occurs more frequently and severely in MODS patients. It shows the influences of SIRS on the thyroid axes. With the persistence and aggravation of SIRS, there is a progressive reduction of thyroid hormone.     

Predicting outcome after traumatic brain injury: development and validation of a prognostic score based on admission characteristics

The early prediction of outcome after traumatic brain injury (TBI) is important for several purposes, but no prognostic models have yet been developed with proven generalizability across different settings. The objective of this study was to develop and validate prognostic models that use information available at admission to estimate 6-month outcome after severe or moderate TBI. To this end, this study evaluated mortality and unfavorable outcome, that is, death, and vegetative or severe disability on the Glasgow Outcome Scale (GOS), at 6 months post-injury. Prospectively collected data on 2269 patients from two multi-center clinical trials were used to develop prognostic models for each outcome with logistic regression analysis. We included seven predictive characteristics-age, motor score, pupillary reactivity, hypoxia, hypotension, computed tomography classification, and traumatic subarachnoid hemorrhage. The models were validated internally with bootstrapping techniques. External validity was determined in prospectively collected data from two relatively unselected surveys in Europe (n = 796) and in North America (n = 746). We evaluated the discriminative ability, that is, the ability to distinguish patients with different outcomes, with the area under the receiver operating characteristic curve (AUC). Further, we determined calibration, that is, agreement between predicted and observed outcome, with the Hosmer-Lemeshow goodness-of-fit test. The models discriminated well in the development population (AUC 0.78-0.80). External validity was even better (AUC 0.83-0.89). Calibration was less satisfactory, with poor external validity in the North American survey (p < 0.001). Especially, observed risks were higher than predicted for poor prognosis patients. A score chart was derived from the regression models to facilitate clinical application. Relatively simple prognostic models using baseline characteristics can accurately predict 6-month outcome in patients with severe or moderate TBI. The high discriminative ability indicates the potential of this model for classifying patients according to prognostic risk.