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| ORIGINAL ARTICLE |
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| Year : 2016 | Volume
: 4
| Issue : 1 | Page : 7-13 |
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The predictive value of systemic inflammatory response syndrome on the outcome of perforated viscus in adult
Hassan Adnan Bukhari, Mohammed Amin Mirza
Department of Surgery, Umm Al Qura University, Makkah, Saudi Arabia
| Date of Web Publication | 5-May-2016 |
Correspondence Address:
Hassan Adnan Bukhari
Department of Surgery, Umm AL Qura University, Makkah
Saudi Arabia
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/2320-3846.181809
Purpose: Perforated viscus is one of the most series conditions that need to be evaluated and studied, especially if it associated with systemic inflammatory response syndrome (SIRS). There are some studies carried out in the same subject that do not exactly clarify the predictive role of SIRS in the evaluating patients with perforated viscus, and they lack of a strong result foundation of the subject. Objective: The main purpose of this study is to evaluate the role of SIRS criteria in patients with perforated viscus and to see if SIRS have important value in predicting the surgical intervention, complications, Intensive Care Unit (ICU) admission, mortality, the outcome, and its effect on them later on. Methods: A retrospective study was carried out which included sixty patients with perforated viscus presented to Al-Noor Hospital Emergency Department in Makkah during 1435H. Certain variables including SIRS criteria were collected using a data collecting sheet. These variables are comorbidities, vital sign on presentation, the result of certain investigation), intervention which had done, presence of postoperative complication, ICU length stay, and outcome. Results: The role of SIRS criteria in patients with perforated viscus was found to be statistically significant as regards the patient's gender, the type of surgical intervention (either laparoscopic or open), and the duration of ICU admission, with P < 0.05. No statistical significance role was found between SIRS criteria and complications; mortality, status of ICU admission, and the outcome of perforated viscus patients, with P > 0.05. Conclusion: SIRS criteria in patients with Perforated visus (PV) can be used clinically to predict the need for surgical intervention and ICU admission. Keywords: Intestinal surgeries, perforated viscus, systemic inflammatory response syndrome
How to cite this article:
Bukhari HA, Mirza MA. The predictive value of systemic inflammatory response syndrome on the outcome of perforated viscus in adult. Saudi Surg J 2016;4:7-13 |
How to cite this URL:
Bukhari HA, Mirza MA. The predictive value of systemic inflammatory response syndrome on the outcome of perforated viscus in adult. Saudi Surg J [serial online] 2016 [cited 2023 Mar 31];4:7-13. Available from: https://www.saudisurgj.org/text.asp?2016/4/1/7/181809 |
| Introduction | |  |
Systemic inflammatory response syndrome (SIRS) is an inflammatory state affecting the whole body, mostly a response of the immune system to infection, but not always so. It is related to sepsis, a condition in which individuals meet criteria for SIRS and have a known infection. [1]
SIRS may be the body's response to an infectious or noninfectious insult. Although the definition of SIRS refers to it as an "inflammatory" response, it actually has pro- and anti-inflammatory components. [1]
The syndrome is a clinical response to an inflammatory, infectious, or tissue traumatic stimulus. The concept of SIRS was developed by the American College of Chest Physicians/Society of Critical Care Medicine Committee in 1992. SIRS occurs if at least two of the following criteria are present: (1) Hyperthermia >38°C or hypothermia <36°C, (2) heart rate (HR) >90/min, (3) respiratory rate (RR) >20/min or PaCO 2 < 32 mmHg, (4) white cell count (WCC) >12,000/μL or < 4000/μL, or > 10% immature white cells. With these clear definitions, clinicians can easily assess whether SIRS is present in these patients. [2]
SIRS can be incited by ischemia, inflammation, trauma, infection, or a combination of several "insults." SIRS is not always associated with infection. While not universally accepted, some have proposed the terms "severe SIRS" and "SIRS shock" to describe serious clinical syndromes that are not infectious in nature and thus cannot be labeled according to the various sepsis definitions. These terms suggest organ dysfunction or refractory hypotension not related to an infectious etiology, but rather an ischemic, traumatic, or inflammatory process. [3]
SIRS, independent of the etiology, has the same pathophysiology with minor differences in inciting cascades. Many consider the syndrome as a self-defense mechanism, which uses inflammation as the body's response to nonspecific insults that arise from chemical, traumatic, or infectious stimuli. The inflammatory cascade is complex and involves humoral and cellular responses, complement and the cytokine cascades. The relationship between these complex interactions and SIRS was best summarized by Bone as a three stage process. [4]
Stage I: Following an insult, there is local cytokine production with the goal of inciting an inflammatory response thereby promoting wound repair and recruitment of the reticular endothelial system. [4]
Stage II: Small quantities of local cytokines are released into circulation to improve the local response. This leads to growth factor stimulation and the recruitment of macrophages and platelets. This acute phase response is typically well controlled by a decrease in the pro-inflammatory mediators and by the release of endogenous antagonists. The goal is homeostasis. [4]
Stage III: If homeostasis is not restored, a significant systemic reaction occurs. The cytokine release leads to destruction rather than protection. A consequence of this is the activation of numerous humoral cascades and the activation of the reticular endothelial system and subsequent loss of circulatory integrity. This leads to end-organ dysfunction. [4]
This endorsed a multi-hit theory behind the progression of SIRS to organ dysfunction and possibly multiple organ dysfunction syndrome. In this theory, the event that initiates the SIRS cascade "primes the pump." With each additional event, an altered or exaggerated response occurs, leading to progressive illness. The key to preventing the multiple hits is adequate identification of the cause of SIRS and appropriate resuscitation and therapy. Depending on the inciting factors, many SIRS states resolve without specific intervention. [5]
Trauma, inflammation or infections lead to the activation of the inflammatory cascade. When SIRS is mediated by an infectious insult, the inflammatory cascade is often initiated by endotoxin or exotoxin. Tissue macrophages, monocytes, mast cells, platelets, and endothelial cells are able to produce a multitude of cytokines. Cytokines tissue necrosis factor-α (TNF) and interleukin 1 (IL-1) are first released and initiate several cascades. The release of IL-1 and TNF (or the presence of endotoxin or exotoxin) leads to cleavage of the nuclear factor kappa B (NF-kB) inhibitor. Once the inhibitor is removed, NF-kB is able to initiate the production of mRNA that will induce the production other pro-inflammatory cytokines. IL-6 and IL-8 and interferon-gamma are the primary pro-inflammatory mediators induced by NF-kB. TNF and IL-1 have been shown to be released in large quantities within 1 h of an insult and have both local and systemic effects. [6]
They are responsible for fever and the release of stress hormones (norepinephrine, vasopressin and activation of the renin-angiotensin-aldosterone system). Other cytokines, especially IL-6, stimulate the release of acute phase reactants such as C-reactive protein. Infection has been shown to induce a greater release of TNF than does trauma, which therefore leads to a greater release of IL-6 and IL-8. This is suggested to be why there is higher fever associated with infection than trauma. [7]
The cumulative effect of this inflammatory cascade is an unbalanced state with inflammation and coagulation dominating. To counteract the acute inflammatory response, the body is equipped to reverse this process via counter inflammatory response syndrome (CARS). IL-4 and IL-10 are cytokines responsible for decreasing the production of TNF, IL-1, IL-6, and IL-8. The acute phase response also produces antagonists to TNF and IL-1 receptors. [5]
These antagonists either bind the cytokine and thereby inactivate it or block the receptors. The balance of SIRS and CARS is a critical factor in determining a patient's outcome. [5]
A careful review of initial vital signs is an integral component to making the diagnosis. Repeating of vital signs periodically during the initial evaluation period is necessary as multiple other factors (stress, anxiety, exertion of walking to the examination room, etc.) may lead to a false diagnosis of SIRS. A focused physical examination based on a patient's complaints is adequate in most situations. [8]
Evaluation for evidence of hypoperfusion (skin mottling, mental status changes, delayed capillary refill, and decreased urinary output) should be performed in all patients. Those that are unable to provide any history should also undergo a complete physical examination including a rectal examination to rule out a perirectal abscess or gastrointestinal bleeding. [9]
To completely assess SIRS, a minimum of a complete blood cell count with differential to evaluate for leukocytosis or leucopenia in required. Routine laboratory tests will often include a basic metabolic profile while other laboratory tests should be individualized based on history and physical examination findings. Patients being seen in an outpatient physician's office or emergency room will require a different evaluation than a currently hospitalized patient with new onset SIRS. The selection of imaging studies depends on the differential diagnosis that is being entertained. [10],[11]
Sedimentation rates and C-reactive proteins are not sensitive in distinguishing between causes of SIRS but may be helpful in certain circumstances. The lack of specificity significantly diminishes the clinical role of acute phase reactants in narrowing the differential diagnosis, but when elevated, may have a role in monitoring response to treatment. Pro-calcitonin levels have shown variable clinical utility in differentiating infectious from noninfectious causes and their lack of routine availability in most hospitals limits their usefulness. [12]
Although mortality and morbidity of perforated viscus are significant and can lead to intra-abdominal abscess, wound dehiscence, SIRS, septic shock and multi-organ failure, the use of SIRS as a predictive value of on the outcome of perforated viscus is still underestimated. [13]
Perforated viscus may often carry severe morbidity or mortality when a differential diagnosis from simple small bowel obstruction was made in the past. [14]
Early diagnosis of perforated viscus is very important for surgeons because delayed diagnosis often leads to severe complications. [8]
Compared with planned elective surgery, emergency surgery carries a higher risk of morbidity and mortality. When a patient requires an emergency operation, it is important to identify which subgroups of patients are at high risk of developing complications. The American Society of Anesthesiologists (ASA) physical status is routinely used to provide a patient's overall preoperative health status. Anesthesiologists worldwide use ASA physical status to predict operative risk. However, it has been criticized because of the inconsistent rating of the status by different anesthesiologists. That is why the appearing of SIRS as a predictive value of on the outcome of perforated viscus may be lifesaving or even a factor decreasing the complications for the patient later on. [15]
In this study, we had spot the light on the role of SIRS in predicting the surgical intervention, complications, Intensive Care Unit (ICU) admission and the outcome in patients with perforated viscus. This may help us to see the real role of SIRS with these patients and also preventing further complications; improve the management and the outcome of their condition.
| Methods | | |
Study design
Retrospective cohort study.
Population sample
The sample included 60 patients (40 males and 20 females) with age ranged from (34-80 years) with perforated viscus presented to Al-Noor Hospital Emergency Department in Makkah during 1435H from a total of 1500 ER patients admitted the hospital.
Variables
Certain variables including SIRS criteria will be collected using a data collecting sheet. These variables are co-morbidities, vital signs on presentation, the result of certain investigation (White blood cell count, arterial blood gases, plain X-ray, ultrasound, computed tomography abdomen), intervention which was done to each patient, presence of postoperative complication, ICU length stay and outcome.
Approvals for this study were obtained through the Al-Noor Hospital authorities before any data collection. All the patients with perforated viscus were identified at our institution within the medical charting system. The patients that were significantly unstable preoperatively or were being operated on for frank perforated viscus were excluded. A retrospective review was then conducted identifying patients that exhibited a severe SIRS or shock (septic or septic shock-like syndrome). [4]
Statistical significance was defined on an alpha value of 0.05. A secondary logistic analysis was also performed on key risk factors, to exclude confounding covariates. These latter results are reported as the beta coefficient and P value.
| Results | | |
The role of SIRS criteria in patients with perforated viscus was found to be statistically significant as regards the patient's gender, the type of surgical intervention (either laparoscopic or open), and the duration of ICU admission, with P value of 0.04, 0.007, and 0.05, respectively [Table 1] and [Figure 1]. On the other hand, no statistical significance role was found between SIRS criteria and complications; mortality, status of ICU admission and the outcome of perforated viscus patients, with P value more than 0.05 [Table 2] and [Figure 2].
| Discussion | | |
Emergency perforated viscus admissions comprise a significant part of the inpatient workload, especially in recent years when the total numbers referrals have progressively increased. [14] However, not all the patients admitted to acute surgical wards require immediate surgery or other interventional treatments.
The immediate identification of this subset of patients would facilitate earlier discharge, thus reducing the workload burden. Different methods have been investigated so far for the prediction of the outcomes and hospital stay. [16]
SIRS represents a useful indicator during acute surgical admissions such as perforated viscus. It may be a significant independent predictor of outcome and ICU use. [17]
In this study, general demographic details (sex, age, and race), the presence or absence of SIRS at admission, necessity for surgery or other interventions, the need for critical care support, i.e., (ICU), the total length of the ICU stay and patients mortality were recorded. SIRS were defined according to the standard criteria if patients had two or more positive criteria. The set of vital signs used to determine whether the patient was SIRS positive or negative were the first set of observations and WCCs count taken at the point of admission to the surgical unit.
Patients were divided into two groups: Those who had SIRS at admission (SIRS positive) and those who did not (SIRS negative). The primary outcome measure was to find whether the presence or absence of SIRS on emergency perforated viscus cases is related to the subsequent immediate surgical intervention, clinical outcome, complications, morbidity, and mortality among the patients.
Since SIRS was conceived could lead as the initial stage of generalized inflammation that if not controlled, could lead eventually to the development of sepsis and multi-organ dysfunction, the majority of the studies of SIRS have focused on trauma patients due to their relatively high incidence of these complications, SIRS at admission has been shown to be an independent predictor of both mortality and length of hospital stay and predictive of the development of septic complications in the patient group. [18]
There are a few studies of SIRS in perforated viscus patients, but some of them interpret general surgical patients regarding SIRS status on admission. In patients admitted with general medical conditions, SIRS has been shown to be poor at distinguishing those with infective etiologies from those without. [19]
This study results showed that SIRS criteria in patients with PV can be used clinically to predict the need for surgical intervention and ICU admission.
Nozoe et al. agreed with our study results when they demonstrated that patients with perforated viscus that needs immediate surgical intervention had higher SIRS scores than those without. [20]
Stephenson et al. also agreed with our results and add another interesting finding when they found that the number of positive SIRS criteria had important prognostic differences in patients affected by SIRS, those with four positive criteria were more prone to receive surgical operation, intensive treatments and a fatal outcome. [14]
Even more interestingly the analysis in their study of the SIRS positive patients of the risks conferred by the different criteria showed that the group of patients positive RR was the one associated with high mortality and in which surgical interventions were more beneficial, followed by the group of WCC and finally the one with positive HR/temperature. [14]
These results also confirmed by what Tsumura et al. stated in their study when they found a very significant relationship between number of SIRS factors and the presence of SIRS as well as the urgency for intervention; although, these factors were evaluated for correlated predictive values in the univariate analysis, not using Chi-square as we used in the current study. [1]
Based on this data, we believe that the initial mere discrimination of patients according to the SIRS status shall now be paralleled by the concomitant analysis, in the SIRS positive patients of the number and type of positive criteria. Theses may provide the clinician with the additional useful prognostic data that could help in the decision-making process, especially when considering surgical intervention.
Furthermore, the results of this study showed no significant relation between SIRS criteria and complications or comorbidities among patients such as intraoperative abscess or wound infection.
Regarding surgery, this study showed a significant relationship between SIRS criteria among patients and whether they were operated or not and even open or laparoscopic intervention but not with the type of operation done.
Studies on surgical patients with perforated viscus have been limited to the postoperative period but have shown that the persistence of SIRS overtime is associated with a poor outcome, and the actual resolution of existing SIRS is associated with a good outcome. [21] These findings also have been demonstrated in patients after gastrointestinal surgery and in trauma victims. [22]
After the operation, this study showed no relation between SIRS criteria and complications found among patients or even their fate or mortality rate.
Although in this study, SIRS criteria were found to be not related to the status of ICU admission among patients, however, the duration of the stay of the patients in the ICU showed a significant relationship to the SIRS criteria.
In correlation with Tsumura et al. who concluded in their study results that the SIRS predictive factors were considered to be useful to predict surgical intervention in perforated viscus, and to contribute to the improvement of outcomes like ICU admission as well as hospital stay. [1]
Furthermore, Stephenson et al. confirmed this when they found in their study that one-third of patients admitted as acute surgical admission already have systemic inflammation using the definition of SIRS, and this leads to longer ICU stay in comparison to other patients as well as more interventions adopted during the in-hospital stay. Furthermore, SIRS positive patients were more likely in their study to require surgery, admission to a critical care unit; longer hospital stays. [14]
On the other hand, their study disagreed with our results when they found that SIRS could predict not only mortality but also comorbidity among patients, and they may experience a fatal outcome compared with those without SIRS at admission. [14]
A potential application of these findings is that in the emergency unit where this study was performed there is currently no system for the triage of the patients. The priority at which the patient is seen by the admitting doctor often is determined by the subjective judgment of the stuff nurse who initially evaluates the patient. Although the WCC will not be ready immediately at admission, all the other criteria for the diagnosis of SIRS are easily determined and therefore could be used as a simple and objective marker of the patient's clinical condition.
The main limitation of this study is in its retrospective nature where the patient's presents with different types of perforated viscus, as well as the diagnostic procedures were a mix of invasive procedures and less invasive ones.
Another potential limitation of this study is that in the presence of the underlying chronic condition on admission it could not possible to distinguish whether the acute or chronic disease was co-responsible for the SIRS and to which degree.
In addition, because of the rarity of the research topic, some of the limitations that we faced were that we could not use a large number of patients, and we took all PV patients from one hospital only. Future researches should include a larger number of PV patients and from many hospitals across the country. One thing also to be put into consideration and it might show a more accurate results in future studies, is the measurement of the duration from the beginning of illness to the arrival to the hospital, because the presence of SIRS may vary depend on the time of arrival of patients to the hospital.
We recommend to obviate all these biases by evaluating results presented in a prospective study and evaluation using the SIRS status. The hypothesis is to determine if prioritizing patients according to their SIRS status at admission may change the clinical outcomes regarding mortality, morbidity, early interventions and days in the ICU unit.
| Conclusion | | |
We can conclude from the results of this study that SIRS criteria in patients with PV clinically can be used to predict the need for surgical intervention and ICU admission. However if we want SIRS to be effective predictor tool for complications, mortality, comorbidity, outcome, surgical intervention, ICU length of stay in the hospital for PV patients we still need further and stronger researches with larger samples of PV patients.
Acknowledgment
Alzahrani, Hassan Ahmed M Abdullaziz Mahmood Dwaib ALHUSSEIN ALI ALMEADI Duaa besheit Almatrafi Hawthan Ali Alzahrani, Dina Abdullah Sharbini Hanan Jamhour Alossiami.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]
[Table 1], [Table 2]
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