Talk:Systemic inflammatory response syndrome

high blood sugar?

I've a bit of experience with high blood sugar and I'm skeptical. Give us a reference or further explanation please. alteripse 12:39, 26 July 2005 (UTC)

The bit about hyperglycemia being a cause of SIRS seems to have been added by JFDWolff. I must say I have not seen this. Certainly, SIRS can result in profound hyperglycemia; TNFalpha, IL-1beta and IL-6 mediate insulin resistance, with secondary induction of cortisol also playing a role. →Encephalon | ζ | ∑ 08:58:21, 2005-08-07 (UTC)

I don't recall adding that. Indeed, sepsis causes insulin resistance. JFW | T@lk 14:10, 7 August 2005 (UTC)

Of course, JFW. I got that tentative impression from this [1], sorry if I've misinterpreted who changed what. In any case it was very minor, and the whole article will soon be reworked anyway. Kind regards and much thanks for your spectacular medical work here on wikipedia. →Encephalon | ζ | ∑ 14:19:35, 2005-08-07 (UTC)

Encephalon's post is absolutely correct, and indeed it's a bit shocking that you have a treatment of sepsis and SIRS that doesn't really feature a review (or even mention) of pro-inflammatory cytokines front and center. These are the big movers and shakers in inflammatory states, and they directly and immediately mediate elevation of insulin resistance (along with cortisol as Encephalon also correctly notes), so the above post expressing skepticism about elevated blood sugar is simply wrong. In fact, the definition of sepsis and SIRS both of which omit any reference to cytokines is an indication of how the field clinically is behind the research, in that although cytokine assays have been clinically available for years, they are barely used at all. Part of the problem is that concepts of inflammation taught in medical school are still oftentimes behind the times (rubor et tumor cum calore et dolore — redness and swelling with heat and pain), while more recent 'systemic' concepts of inflammation emphasize more explicitly the critical role of pro-inflammatory cytokines, and the fact that systemic inflammation is often times chronic, and often (at least initially, if not over the long term) asymptomatic. The other problem is the widespread failure (which is shocking given the evidence base) to appreciate that inflammation/immune activation is in a sense an "emergency defense mode" of the organism. It is naïve to think that other adaptive functions and priorities are not potentially sacrificed to this emergency state of organism defense - including eventual sacrifice of homeostatic balance and even autonomic function which fails in sepsis. It's only been relatively recently in our understanding of the immune system that we've come to appreciate first of all that disinhibited inflammation ('inflammaging' as it's now called) is a fundamental phenotype of aging and that all the diseases of aging have systemic inflammation as a fundamental contributing cause, as a core phenotype of aging. Indeed it's the immune system that kills you in sepsis not the bug, and pro-inflammatory cytokines mediate the sympathetic activation, fever, and elevated white count. All of this underscores the importance of regulating and perhaps even in dampening immune activation in sepsis, and perhaps in diseases of aging as well. It's interesting that no one contributing to this page seems to be aware that cytokine blockers are now being considered as a potential treatment for sepsis. It's a long overdue consideration. They are also being considered in relationship to Alzheimer's disease where the evidence is accumulating that CNS inflammation is not orthogonal to neurodegeneration, and is not benign, despite decades of largely unfounded assumption that CNS inflammation might be good if it got rid of amyloid. It's worth remembering that elevated pro-inflammatory states in any organ system leads invariably to organ failure and end-stage organ disease. In any case my point is simply that the downsides of inflammation as an emergency defense mode of the organism could be better appreciated and in fact better outlined on this page. 50.163.29.124 (talk) 17:07, 8 April 2015 (UTC) Douglas F Watt, PhD

Funny how you forget certain edits :-) JFW | T@lk 17:25, 8 August 2005 (UTC)

Actually, if you are referring to WP:MCOTW, the nomination will likely expire soon without being selected—it does not currently have sufficient votes. See Wikipedia:Medicine Collaboration of the Week/History. Nevertheless, I'll work on this at some point, probably when Psychotherapy is selected, since there is very little I can add on that topic. — Knowledge Seeker দ 05:17, August 8, 2005 (UTC)

Incidentally, assuming the other nominations didn't receive any more votes, it would need at least two more votes, I think. — Knowledge Seeker দ 05:41, August 8, 2005 (UTC)

Then let's kill it. alteripse 14:20, 7 August 2005 (UTC) Oops already dead. alteripse 14:22, 7 August 2005 (UTC)

Incorrect

The following is not part of any mediacl textbook, whatever Stedmman's may say:

SIRS with a proven source of infection is known as sepsis. The contrary, sepsis without a proven source of infection is not always SIRS (as the criteria for sepsis are slightly more broad).

If you were to look in a medical Texbook (i.e. Intensive Care Medicine by Irwin and Rippe,The ICU Book by Marino,Cecil Textbook of Medicine,The Oxford Textbook of Medicine,Harrison's Principles of Internal Medicine), in stead of a dictionary, you would find that that quote is incorrect.

Reading Intensive Care Medicine[2] and The ICU book[3] I found this

1 SIRS was coined to describe the systemic response to a wide variety of insults that is characterized by two or more of the following:

• Body temperature greater than 38° C or less than 36° C
• Heart rate greater than 90 bpm
• Tachypnea greater than 20/min
• White bloodcell count greater than 12,0000 cells per mm3, or less than 4,000 cells per mm3, or the presence of greater than 10% immature neutrophils.

2 When SIRS is the result of a confirmed infectious process it is termed sepsis. (In other words: SIRS + infection = sepsis. This is not the same as "the criteria for sepsis are slightly more broad.")

I will correct the page since I think Textbooks are more reliable than dictionaries. Nomen Nescio 00:04, 18 March 2006 (UTC)

I think there is some dispute in the literature-- if you read the review paper and the emedicine article (sepsis) they differ from you wrote above.

The review article I cited says:

Infection is defined as the pathological process caused by the invasion of normally sterile tissue or fluid or body cavity by pathogenic or potentially pathogenic microorganisms. [4]

As for source of infection -- I think that is really an awful definition and I find it hard to believe it is a formal definition. Being a live-- you have sources of infection all around... the air you breathe. Technically, it is true that a positive blood culture is not a source of infection-- that said, if there is a positive blood culture there was a source of infection-- 'cause the culture wouldn't be positive otherwise (ignoring contamination). A source of infection is a theoretical thing. If what you write is true, I find it hard to believe that practically some proof of infection is not required to make a diagnosis.

As for the differences between SIRS and sepsis:

The sepsis definition has in it:

White blood cell count < 4000 cells/mm³ or > 12000 cells/mm³ (< 4 x 109 or > 12 x 109 cells/L), or greater than 10% band forms (immature white blood cells).

Note the bit greater than 10% band forms -- this is not in the SIRS definition.

I think we need to find a something in the primary literature that nails the definition-- some sort of concensus definition. Oxford's and Harrison's may have an outdated definition-- and personally I find them somewhat unsatisfatory.

Nephron 00:46, 18 March 2006 (UTC)

I've looked in the most recent edition of the Textbooks I mentioned above, and they all offer the same definition of SIRS. But, more to the point, this is a condition that IMHO would fall under intensive care medicine. Since I quoted a major textbook (Irwin and Ripe, but also Marino should not be underestimated) on intensive care medicine (and the most recent edition) my suggestion would be to accept that as the best possible source as to what SIRS is. If this textbook does not provide a correct definition we could just as well stop using textbooks (on haematology, oncology, pulmonology, cardiology, endocrinology, et cetera) alltogether.

As to the blood culture thingy, in the current version it is evident blood is not be the source but it is a means of establishing the presence or absence of infection. Nomen Nescio 16:57, 18 March 2006 (UTC)

While I realize this debate was going on almost a year ago, current literature, most specifically the Surviving Sepsis Campaign, regards sepsis as 2 SIRS criteria and a suspected source of infection. Even suspecting bacteremia is sufficient to define someone as septic. In up to 20% of cases of sepsis, no source is ever found. While I'm trying to find further primary literature supporting 10% bands as a SIRS criteria, this was one of the criteria used for inclusion into the Early Goal Directed Therapy paper and a simple google search for SIRS turns up the same information bandemia. Bdolcourt 21:08, 27 January 2007 (UTC)

Although medical journals present more recent theories, we should not forget that they are still under peer review. AFAIK it is when these suggestions have been accepted they are incorporated in Textbooks. Making IMHO the latter still better as reference. What do you think?Nomen Nescio^{Gnothi seauton} 15:15, 5 February 2007 (UTC)

Texts often lag 10 years or more when it comes to actual practice. Relying on textbooks to keep up with cutting edge practice is not recommended. When a paper is published, especially in a reliable journal, it has passed the first peer review process. These same papers are what is used as the source for the texts. Bdolcourt 03:36, 6 February 2007 (UTC)

I think a couple of papers is the minimum-- if the one paper isn't a consensus statement by a large cross-section the mainstream medical community. Take a look at postperfusion syndrome (aka pumphead)-- which came to media attention 'cause of a NEJM article... and was the basis for entertainment in The National Enquirer. Nephron  T|C 04:12, 7 February 2007 (UTC)

Of course, if we can find a new consensus by e.g.the Intensive Care Society (that is organisations related to intensive care) I have no problem introducing a new definition. However, as Nephron suggests, one article in any journal does not a consensus among intensivists make.Nomen Nescio^{Gnothi seauton} 00:44, 8 February 2007 (UTC)

The SIRS criteria, not including 10% band forms are from the American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference. Definitions for sepsis and organ failures and guidelines for the use of innovative therapies in sepsis. Crit Care Med. 1992;20:864-874.

They were republished in the "Consensus conference definitions for sepsis, septic shock, acute lung injury, and acute respiratory distress syndrome: time for a reevaluation." Crit Care Med. 2000 Jan;28(1):232-5. Here, 10% immature forms was used as one of the criteria. User:Bdolcourt|Bdolcourt]] 04:47, 9 February 2007 (UTC)

In all fairness, I do not see why those references from 1992 and 2000 should be used instead of the current reference to Irwin and Rippe, which is from 2003(????). Again, if you have references to consensus after 2003 your suggestion is more than reasonable. Lacking that I think we should keep Irwin and Rippe as the most authorative reference.Nomen Nescio^{Gnothi seauton} 19:58, 10 February 2007 (UTC)

Are you arguing that 10% bands is included or is not included? In the version of Irwin and Rappe I looked at, it includes 10% bands as a SIRS criteria. This seems consistant with the medical literature I'm familiar with. Interestingly, the reference they use is the 1992 Concensus statement which does not include bands.

But as an aside, using a consensus statement from multiple societies would be preferable to using a textbook with a later publication date, unless that textbook cites more recent literature.

I should add, that this is one more reason why I think SIRS should merged into Sepsis. SIRS and Spesis are intimately linked. SIRS exists as clinical criteria to define sepsis. I have never actually seen someone diagnosed with "SIRS." Technically, I'm not sure that the definition of SIRS has been updated by concensus statement. The 2000 Consensus statement actually only redefines sepsis and doesn't specifically redefine SIRS, even though it does. I won't even get into the 2001 Consensus Statement attempts to broaden the definition of sepsis even more and tries to bypass the concept of SIRS criteria.Bdolcourt 00:16, 11 February 2007 (UTC)

The current definition of sepsis is incorrect. The infection does not need to be documented i.e. verified by a blood culture for sirs to be sepsis. To quote Harrison's..."If infection is suspected or proven, a patient with SIRS is said to have sepsis." Jbarne06 18:00, 8 August 2007 (UTC)

Cytokines & Cells Online Pathfinder Encyclopaedia

Although a very interesting site, this is not a medical reference. Please provide a medical journal or textbook. Second, you fail to understand that severe infection also causes a "cytokine storm." Since SIRS is defined as absence of infection how do you differentiate between infection and non-infection related "cytokine storm?" In short, the assertion is incorrect. Nomen Nescio^{Gnothi seauton} 09:39, 30 May 2006 (UTC)

Redirecting and merging articles into Sepsis

I'd propose (however I don't know how to properly tag them) that the article SIRS redirect to Sepsis. SIRS is not up to date with current literature and is essentially fully encompassed by the article on Sepsis. Secondarily, I tend to think that Septic Shock and Multiple organ dysfunction syndrome should be merged into Sepsis. Both Septic Shock and MODS are spectrums of Sepsis. All three articles cover much of the same material and it would stengthen the Sepsis article to include a bit more on the full spectrum of the disease process without making it significantly longer and would eliminate redundacy. Especially as Sepsis is a very hot topic in critical care right now, it will certainly be easier and more complete to keep 1 article current than to keep 3 (or 4) articles up to date. Bdolcourt 18:02, 26 January 2007 (UTC)

The above text was copy-pasted from Wikipedia talk:WikiProject Clinical medicine#Redirecting and merging articles into Sepsis. Please post replies here. Dlodge 18:37, 27 January 2007 (UTC)

• OPPOSE. The fact that SIRS, sepsis and septic shock are on a spectrum doesn't matter IMHO. Asperger's and Autism are also on a spectrum and they have separate articles and an article explaining the spectrum (pervasive developmental disorders). The prognosis of SIRS, sepsis, septic shock and MODS are quite different-- for that reason alone I think they should be separate. Also, the audience (which is the general public) I don't think cares about the spectrum... they care about prognosis and treatment and that differs for different places on the spectrum. Nephron  T|C 01:05, 30 January 2007 (UTC)
• Oppose, per Nephron. A spectrum does not mean they are identical. Case in point, how do SIRS and MODS resulting from a non-infectious cause relate to sepsis?Nomen Nescio^{Gnothi seauton} 17:20, 4 February 2007 (UTC)

• Oppose, as above. Axl 14:17, 20 February 2007 (UTC)

• It could go under the stages off Stress. SIRS beeing the reaction of the body to the stress, followed by Sepsis, Severe Sepsis and finaly Septic Shock. It can maybe include the SIRS+CARS=MARS, endothelial cells and its secretions. Fremoki 21:07, 22 April 2007 (UTC)

SIRS not necessarily a serious medical condition

I would dispute that sirs is necessarily a serious medical condition. Running for a bus can ensure that you fulfil the criteria (HR > 90 and RR > 20) Less friviously flu ( HR >90 and Temp >38) likewise. Tonywolff 15:30, 18 February 2007 (UTC)

Cute, TW, but the defining criteria presume abnormal vital signs at rest. The ill do not literally run to receive treatment. RuralPAmd 16:24, 4 April 2007 (UTC)

In all seriousness, I think we should delete the "medical emergency" phrase from the introduction here because many patients who meet SIRS criteria can be safely managed at home (eg. flu, gastroenteritis).Empyema (talk) 11:48, 27 November 2008 (UTC)

Sirs is the red flag that indicates the stage is set for sepsis. Mortality in septic patients is directly related to how quickly antiboiotic and other medications are started. The sooner you pick up on sirs the sooner you can pick up on sepsis. On the other hand, not every single patient fits the algorithm for the above protocol. That is where the rest of the symptoms such as altered mental status can help the physician make the call. So yes the flu or running for the bus can throw up a flag, but the physician then can make the further call. The flag however will bring medication sooner to a patient in need, improving prognosis. Patients die quickly from sepsis, within hours, and that is an emergency in anyones book! —Preceding unsigned comment added by 162.135.0.6 (talk) 19:25, 24 April 2009 (UTC)

Peter Attia M.D. (now Ketosis deitician) suggest that excercise can induce a temporary SIRS like inflamed/fluid-retentive state in the comments here below but I don't think anyone has any peer-reviewed sources. http://eatingacademy.com/sports-and-nutrition/ketones-carbohydrates-can-co-exist — Preceding unsigned comment added by 122.251.218.31 (talk) 23:38, 2 March 2014 (UTC)

An extra potential defining characteristic?

According to Cecil's 7th ed., PaCO2 less than 32mmHg can also be used as one of the 2 symptoms that define SIRS. Peetiemd (talk) 15:12, 9 April 2008 (UTC)