Does Treating Systemic Inflammatory Response Syndrome Lead to Better Outcomes in Surgical Patients?
A 40-year-old obese woman presents for a laparoscopic cholecystectomy for acute cholecystitis and cholelithiasis. The gallbladder was found to be inflamed, and the case was converted to open. The most common systemic complications of open cholecystectomy
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Nader Soliman
Case A 40-year-old obese woman presents for a laparoscopic cholecystectomy for acute cholecystitis and cholelithiasis. The gallbladder was found to be inflamed, and the case was converted to open. The most common systemic complications of open cholecystectomy are pulmonary in nature; however, surgical procedure-related complications are also possible such as surgical site or intra-abdominal infections, a bile leak, or bleeding, all of which may produce an inflammatory response. The inflammatory response is initiated by cytokines, which are polypeptide signaling molecules that adhere to specific receptors with an autocrine, paracrine, and/or endocrine mechanism in response to an instigating stimulus. This process is kept in check with anti-inflammatory cytokines. At times, the pro-inflammatory cytokines overwhelm the anti-inflammatory cytokines, which may lead to a systemic inflammatory response rather than a localized one. The major influential pro-inflammatory cytokines are as follows: interleukin-1 (IL-1), tumor necrosis factor-alpha (TNF-α[alpha]), interleukin-6 (IL-6), interleukin-8 (IL-8), and macrophage inflammatory protein-1α(alpha) (MIP-1alpha). The major anti-inflammatory cytokines are interleukin-10 (IL-10) and interleukin-13 (IL-13). Systemic inflammatory response syndrome (SIRS) is defined as a systemic response to a nonspecific infectious or noninfectious insult. Examples are burns, pancreatitis, an autoimmune disorder, ischemia, or trauma. The presence of two or more of the following clinical criteria helps establish the diagnosis of SIRS: (1) body temperature >38°C (100.4°F) or 90 beats per minute, (3) respiratory rate more than 20 breaths per minute or N. Soliman Department of Anesthesiology, New York University, New York, NY 10016, USA N. Soliman (&) 3844 Wasatch Ave Apt 4, Los Angeles, CA 90066, USA e-mail: [email protected]
hyperventilation with an arterial carbon dioxide tension (PaCO2) ≤32 mm Hg, and (4) abnormal white blood cell count (>12,000/mcL or 10 % immature [band] forms) [1–3]. This unchecked destructive response may lead to organ dysfunction and failure.
Questions Does treating SIRS lead to better outcomes in surgical patients? If so, which treatment options are most promising? PRO: I believe that recognition and early treatment of SIRS are important to influence its natural course and decrease morbidity and mortality. Did you know that the Italian SEPSIS study showed an inverse correlation between the identification of SIRS and the development of sepsis [1]? This is why there are several different treatment strategies for SIRS including physiological, pharmacological, and/or cytokine adsorption therapy [1]. These strategies target supposed triggers, early mediators, and physiological responses to inflammation. CON: You might be right, but what are these strategies and how do they work exactly in the treatment for SIRS and multi-organ dysfunction syndrome? PRO: Great question Early goal-directed therapy works by optimizing cardiac pre-load, after-load, and contract
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