Systemic inflammatory

response syndrome
SIRS
Mariami Berekashvili
Mariam Kakulia
Mariam Khrustali
Definition

• Systemic inflammatory response syndrome (SIRS) is an exaggerated

defense response of the body to a noxious stressor (infection, trauma,
surgery, acute inflammation, ischemia or reperfusion, or malignancy,
to name a few) to localize and then eliminate the endogenous or
exogenous source of the insult.
SIRS is defined by the satisfaction of
any 2 or more of the criteria below:
• Body temperature more than 38°C (100.4°F) or less than 36°C (96.8°F)
• Heart rate of more than 90 beats per minute
• Respiratory rate of more than 20 breaths per minute or arterial
carbon dioxide tension (PaCO2) of less than 32 mm Hg
• Abnormal white blood cell count (>12,000/µL or < 4,000/µL or >10%
immature [band] forms)
 pSIRS criteria: (2 or more)

●Abnormal core temperature (measured by rectal, bladder, oral, or central

probe) typically fever with temperature >38.5°C (101.3°F or, in young iոfaոtѕ,
>38.0°C [100.4°F]) but also including hурothermiа with temperature <36°C
(96.8°F)
●Τаϲhуϲarԁiа, defined as a mean heart rate more than two standard deviations
above normal for age, or for chilԁrеո younger than one year of age, brаԁуcаrdia
defined as a mean heart rate <10th percentile for age
●Mean respiratory rate more than two standard deviations above normal for
age or mechanical ventilation for an acute pulmonary process
●Leukocyte count elevated or depressed for age, or >10 percent immature
neutrophils
 Age group Heart rate (beats/minute) Respiratory rate Leukocyte count Systolic blood
(breaths/minute) (leukocytes × pressure (mmHg)
Tachycardia Bradycardia 103 /mm3)

Newborn (0 days >180 <100 >50 >34 <59

to 1 week)

Neonate (1 week >180 <100 >40 >19.5 or <5 <79

to 1 month)

Infant (1 month >180 <90 >34 >17.5 or <5 <75

to 1 year)

Toddler and >140 NA >22 >15.5 or <6 <74

preschool (>1 to
5 years)

School age (>5 to >130 NA >18 >13.5 or <4.5 <83

12 years)

Adolescent (>12 >110 NA >14 >11 or <4.5 <90

to <18 years)
* Pediatric systemic inflammatory response syndrome vital signs and laboratory value by age
When the source of SIRS is
an infection, it’s
called sepsis.

Almost all septic patients

have SIRS, but not all SIRS
patients are septic.
 Physiologic continuum with progressively worsening balance
between pro and anti-inflammatory responses of the body

Systemic Inflammatory Response Syndrome

(SIRS)
• ≥2 criteria SEPTIC
SEVERVE SHOCK
Evolving Sepsis SEPSIS
SEPSIS
•suspected iոfеϲtiоո+ clinical findings of altered
perfusion (not severe enough to meet sepsis criteria) EVOLVING
SEPSIS

Sepsis SIRS

Suspected iոfеϲtiоո and

Phoenix Ѕepѕiѕ Score ≥2

Septic Shock

ѕeрѕiѕ and ≥1 cardiovascular points on the Phoenix

Ѕeрsiѕ Score
Etiolo Damage Associated Molecular
Pattern (DAMP)/noninfectious
Pathogen Associated Molecular
Pattern (PAMP)/infectious
gy causes causes

• Acute mesenteric ischemia

• Bacterial sepsis
• Adrenal insufficiency
• Autoimmune disorders • Burn wound infections
• Burns • Candidiasis
• Chemical aspiration • Cellulitis
• Cirrhosis • Cholecystitis
• Cutaneous vasculitis
• Community-acquired pneumonia
• Dehydration
• Drug reaction • Diabetic foot infection
• Electrical injuries • Erysipelas
• Erythema multiforme • Infective endocarditis
• Hemorrhagic shock • Influenza
• Hematologic malignancy
• Intra-abdominal infections (eg, diverticulitis)
• Intestinal perforation
• Medication side effect (eg, from theophylline) • Gas gangrene
• Myocardial infarction • Meningitis
• Pancreatitis • Nosocomial pneumonia
• Seizure • Pseudomembranous colitis
• Substance abuse - Stimulants such as cocaine and
amphetamines • Pyelonephritis
• Surgical procedures • Septic arthritis
• Toxic epidermal necrolysis • Toxic shock syndrome
• Transfusion reactions
• Urinary tract infections (male and female)
• Upper gastrointestinal bleeding
• Total joint arthroplasty infection
• Vasculitis
 Pathophysiol
ogy The early response mediated by these
tumor
inflammatory cells involves three major
pathways
• Stage 1 is a local reaction at the site of injury rubor calor
that aims at containing the injury and limit  Activation of IL-1 and TNF alfa.
spread.  Activation of prostaglandin and
Leukotriene pathway
• Stage 2 is an early compensatory anti-  Activation of C3a – C5a complement
functio
inflammatory response syndrome (CARS) in an laesa
dolor
pathway
attempt to maintain immunological balance.
• Stage 3 is when the scale tips over towards
proinflammatory SIRS resulting in progressive
endothelial dysfunction, coagulopathy, and Their actions can broadly divide into three categories
activation of the coagulation pathway. It
 Propagation of cytokine pathway
results in end-organ micro thrombosis, and a
 Alteration of coagulation causing microcirculatory
progressive increase in capillary permeability,
eventually resulting in loss of circulatory abnormalities
 Release of stress hormones
integrity.
Infection Types of
inection:

 Bacterial
• Ιոfеϲtioո – Ιոfеctiоn is a pathologic process caused by a microorganism. It is  Viral
suspected based on physical findings, including symptoms or signs of iոfеctiоn on
examination and the presence of pediatric systemic inflammatory response syndrome
 Fungal
(pSIRS) .Definitive confirmation of infection is not required to diagnose sepsis.  Parasite

SIRS Additional symptoms:

Ø Fatigue
Ø Headache
Ø Muscle aches
Ø Loss of appetite
Ø Skin infections
Ø Respiratory infections
Ø Ear infection
Ø Urinary tract infections
Ø Gastrointestinal infections
Ø Changes in mental status: Confusion, delirium, or
disorientation
 Evolving • SIRS+ additional symptoms
sepsis

• Evolving sepsis-Clinicians should

attempt to identify children with
suspected infection and clinical
findings of altered perfusion that are
not severe enough to diagnose
sepsis or septic shock using the
Phoenix criteria, as noted below, but
who still require rapid assessment
and treatment. We define these
children as having "evolving sepsis."
 Sepsis
• Sepsis in children is defined as life-threatening organ dysfunction caused by a dysregulated host response to
infection. Unlike in adults, pediatric sepsis is diagnosed based on age-specific vital sign thresholds and clinical signs
of systemic inflammation combined with evidence of cardiovascular, respiratory, or neurological dysfunction.

Key Criteria (Based on Pediatric SIRS & Sepsis Guidelines):

• Suspected or confirmed infection

• Systemic inflammatory response syndrome (SIRS) (≥2 criteria, one of which must be abnormal temperature or
leukocyte count)
• Organ dysfunction (hypotension, altered mental status, respiratory distress, or metabolic derangements)
Septic shock
Pediatric septic shock is a severe form of sepsis characterized by circulatory failure, requiring fluid resuscitation or
vasopressor support to maintain adequate perfusion. It is defined by persistent hypotension, signs of inadequate
perfusion (cold or warm shock), or metabolic dysfunction despite adequate fluid resuscitation.

Key Features of Septic Shock in Children:

Hypotension (age-specific thresholds) OR need for vasopressors

Signs of poor perfusion:
Cold shock: prolonged capillary refill, weak pulses, low urine output
Warm shock: bounding pulses, flash capillary refill, wide pulse pressure
Altered mental status or metabolic acidosis

Early recognition and aggressive management, including fluid resuscitation, vasopressors, antibiotics, and source
control, are critical for improving outcomes.
 Phoenix sepsis score

The Phoenix Sepsis Score is a clinical tool developed to identify sepsis and septic shock in pediatric
patients. It assesses organ dysfunction across four systems:

1. Respiratory System:are used to determine the severity of respiratory failure

2. Cardiovascular System:are used to determine the severity of cardiovasculas shok
3. Coagulation:assess the potential for disseminated intravascular coagulation (DIC) or other blood
clotting issues.
4. Neurologic System:reflect the extent of central nervous system involvement.

• Sepsis: Score ≥2 in a patient with suspected infection.

• Septic Shock: ≥2 points with at least 1 point in the cardiovascular system.
Red-Flag Findings
• Presence of fever (core temperature >38.3°C [101°F] for patients three months of age
and older or >38°C [100.4°F] for infants younger than three months of age)
• Hypothermia (core temperature <36°C [96.8°F]
• Tachycardia
• Tachypnea
• Abnormal pulse (diminished, weak, or bounding)
• Abnormal capillary refill (central refill ≥3 seconds or flash refill [<1 second])
• Hypotensive
• Abnormal mental status: Irritability, Inappropriate crying, lethargic or
obtunded,Confused
• Purpura anywhere on the body or petechiae below the nipple line
• Macular erythema with mucosal changes...
Acral purpura
The essential actions consisted of:

• Recognition of children with evolving or existing sepsis

• Vascular access and rapid fluid resuscitation
• Empiric antimicrobial therapy
• Initiation of vasoactive agents to patients not responding
sufficiently to fluid resuscitation
 RAPID RECOGNITION
Institutional approach — To minimize delays in recognition of
evolving sepsis, each pediatric institution should develop a
multidisciplinary protocol/guideline to improve early identification
and treatment.

Systematic screening for identification of patients with evolving

or existing sepsis
Rapid clinical assessment for patients with sepsis, including
septic shock
Rapid initiation of resuscitation
Initial stabilization (all patients):
Key Message: Stabilization within the first minutes is critical to avoid
deterioration.
Key Steps:
• IV/IO access within 5 minutes! Two peripheral IVs (largest caliber).
• Provide supplemental oxygen to correct hypoxia.
Saturation 92-97%.
• Obtain blood culture, blood gases, lactate, and electrolytes before
antibiotics.
• Fluid Resuscitation: If no overload signs → Give 10-20 mL/kg Ringer’s
Lactate or NS over 5-10 min.
• Start broad-spectrum antibiotics immediately.
Broad-spectrum Antibiotic Regimens
References
• https://emedicine.medscape.com/article/168943-overview?_gl=1*1d6p3jy*_g
cl_au*NzAzMjIyOTM5LjE3MzkwMTAzNjc
.
• https://www.ncbi.nlm.nih.gov/books/NBK547669/
• UpTodate: Sepsis in children: Definitions, clinical manifestations, and
diagnosis
• UpTodate: “Children with sepsis in resource-abundant settings: Rapid
recognition and initial resuscitation (first hour)”
THANK YOU!