Multiple Organ Failure

SEPSIS/MULTIPLE ORGAN
FAILURE
DR SULEIMAN OTARU S.
ANAESTHESIA DEPT
UATH, GWAGWALADA
INTRODUCTION
 Sepsis describes the host response syndrome to an infectious insult. It is characterised by a pro-
inflammatory, pro-coagulant state and is frequently accompanied by organ dysfunction resulting
from organ hypoxia.
 Sepsis is one of the most frequent causes of death worldwide, but there are challenges in
collecting reliable data at the population level
 From data published in 2020, there were 48.9 million cases and 11 million sepsis-related deaths
worldwide, representing 20% of all global deaths
 Almost half (20 million) of all estimated sepsis cases worldwide occurred in children under 5 years
of age.
 For every 1000 hospitalized patients, an estimated 15 patients will develop sepsis as a
complication of receiving health care.
 While sepsis can affect any individual worldwide, significant regional disparities in incidence and
mortality exist with the highest rates in lower-middle-income countries
 Sepsis is costly; the average hospital-wide cost of sepsis was estimated to be more than
US$ 32 000 per patient in high-income countries
PATHOPHYSIOLOGY
Pathogenesis of sepsis
An overview
Anti-inflammatory
Host mediators
Pathogen Infection e.g. IL-10, IL-1ra receptor
responses
antagonists
Pro-inflammatory
mediators
Leucocyte activation e.g. Tumour necrosis factor,
IL-1, IL-6, IL-8,
nitric oxide
Mitochondrial Inflammation
dysfunction
Microvascular Endothelial
flow dysfunction
redistribution Tissue factor expression
Organ Tissue injury
dysfunction
Inhibition of Activation of
Microvascular
fibrinolysis coagulation
coagulation/
Death thrombosis
The role of the endothelium
• Release of mediators of vasodilatation and/or
vasoconstriction
• Release of cytokines and inflammatory mediators
• Allows leucocytes to access infection sites
• Plays an important role in the coagulation cascade,
maintaining the physiological equilibrium between
coagulation and fibrinolysis
Tissue injury Formation of fibrin clot

• In sepsis, the regulatory function of the endothelium fails,
leading to:
• Excessive vasodilation and relative hypovolaemia
• Leaking capillaries and generalised tissue damage
• Tissue factor (TF) release initiates procoagulant state
• Micro-thrombus formation compromising blood supply and leading to
tissue necrosis
• Inactivation of Protein C and suppression of fibrinolysis
Tissue injury Formation of fibrin clot

WHO IS AT RISK
 older persons
 pregnant or recently pregnant women
 neonates
 hospitalized patients
 patients in intensive care units
 people with weakened immune systems (for example HIV, cancer)
 people with chronic medical conditions (for example kidney disease,
cirrhosis).
SYMPTOMS AND SIGNS
 fever or low temperature and shivering

 confusion
 difficulty breathing
 clammy and sweaty skin
 extreme body pain or discomfort
 high heart rate, weak pulse or low blood pressure
 low urine output.
Symptoms in children include:
•fast breathing
•convulsions
•pale skin
•lethargy
•difficulty waking up
•feeling cold to the touch.
In children under 5 years old, it can cause difficulty feeding, frequent
vomiting or lack of urination.
The disease continuum
Infection SIRS Sepsis Severe Sepsis MOF Death
 In 1991 The American College of Chest Physicians and the Society of Critical Care
Medicine (ACCP/SCCM) at a Consensus Conference developed clear clinical
definitions for the disease continuum.
 These groups developed three terms for the progression of clinical symptoms: SIRS,
sepsis, severe sepsis and septic shock.
 It is important to realise that these stages do not necessarily imply an increasing
severity of infection, but rather an increasingly severe systemic response to infection.
Systemic inflammatory response
syndrome (SIRS)
• SIRS (systemic inflammatory response syndrome) represents

the clinical presentation of the widespread inflammation that
results from a variety of insults and can also be caused by trauma,
burns, pancreatitis and other insults…
• The conference defined an initial SIRS, that requires evaluation of:
• temperature,
• heart rate,
• respiratory rate and
• white blood cell count.
Systemic Inflammatory Response Syndrome
Diagnosis comprises 2 or more of the following:
• Tachycardia >90 bpm

• Core temperature <36°C or >38°C
• Tachypnoea >20 bpm or PaCO2 <4.2 kPa
• WCC >12,000 or <4,000 or
>10% immature neutrophils
Clinical Progression
Sepsis :
1) - two or more of SIRS, plus
2) - documented or suspected infection
(presence of commonly recognised signs of infection
without an identifiable pathogen being isolated)
Possible sites of a new infection
 Pneumonia or empyema
 Urinary tract infection
 Acute abdominal infection
 Meningitis
 Skin / soft tissue inflammation
 Bone / joint infection
 Catheter or device infection
 Endocarditis
 Wound infection
Severe sepsis: sepsis + one organ dysfunction
• Circulatory failure
• Respiratory failure
• Renal failure
• Haematological failure
• Hepatic failure
• “Brain failure”
Severe sepsis – organ failures
 Circulatory Systolic BP <90mmHg or MAP <65mmHg or

reduction in SBP 40 mmHg from baseline
 Respiratory O2 saturation <90% on air or oxygen or
PaO2:FiO2 <40 kPa
 Renal Urine output <0.5 ml/kg/hr for >2 hrs or
Creatinine >176 µmol/l acutely
 Haematological Platelets <100x109 or INR >1.5 or APTT >60s
 Hepatic Plasma lactate >4 mmol/l or

Bilirubin >34 µmol/l
 Mental Acute alteration in mental status
Septic Shock
Septic shock: Acute circulatory failure unexplained by other causes.
Circulatory failure is defined as:
persistent arterial hypotension (SBP < 90 mmHg, MAP< 65, or a

reduction in SBP 40 mmHg from baseline) despite adequate volume
resuscitation.
Septic Shock
Initially is suggested by evidence of end organ hypoperfusion:
• haemodynamic instability
• mottled skin
• decreased urine output
• altered level of consciousness
• lactic and metabolic acidosis
Later - circulatory failure leading to multi-organ failure:

• reduced SVR, leaking capillaries
• slightly increased, followed by decreased Cardiac Output
• coagulopathy with thrombocytopenia
• ARDS, ARF, liver failure, hypoglycaemia
Although most patients in shock will be hypotensive, some patients

will have preserved systolic pressure early in shock as a result of
excessive catecholamine release.
MANAGEMENT
 Initially resuscitate the patient by assessment of the airway, breathing and

circulation (ABC).
SEPSIS CAMPAIGN BUNDLE
 Oxygen
 Antibiotics
 Culture
 Fluid
 Urine output
 Lactate measurements

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SEPSIS/MULTIPLE ORGAN

Tissue injury Formation of fibrin clot

Tissue injury Formation of fibrin clot

 fever or low temperature and shivering

• SIRS (systemic inflammatory response syndrome) represents

Diagnosis comprises 2 or more of the following:

• Tachycardia >90 bpm

Infection SIRS Sepsis Severe Sepsis MOF Death

Severe sepsis: sepsis + one organ dysfunction

 Circulatory Systolic BP <90mmHg or MAP <65mmHg or

 Hepatic Plasma lactate >4 mmol/l or

Septic shock: Acute circulatory failure unexplained by other causes.

Circulatory failure is defined as:

persistent arterial hypotension (SBP < 90 mmHg, MAP< 65, or a

Later - circulatory failure leading to multi-organ failure:

Although most patients in shock will be hypotensive, some patients

 Initially resuscitate the patient by assessment of the airway, breathing and

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