🫀 Interná medicína · 12

Syndróm systémovej zápalovej reakcie (SIRS), Sepsa, syndróm multiorgánovej dysfunkcie (MODS) (patofyziológia, klinická manifestácia, diagnostika, liečba)

Definícia

• SIRS je nadmerná obranná odpoveď organizmu na škodlivý podnet – infekčný aj neinfekčný (napr. trauma, operácia, ischémia, malignita) – a diagnostikuje sa pri ≥ 2 kritériách. Sepsa je podľa Sepsis-3 život ohrozujúca orgánová dysfunkcia spôsobená dysregulovanou odpoveďou hostiteľa na infekciu; MODS je progresívna dysfunkcia ≥ 2 orgánov v dôsledku život ohrozujúceho ochorenia alebo poranenia.

Etiológia a patogenéza

• Spúšťače SIRS: neinfekčné – DAMP pri poškodení alebo nekróze buniek (napr. popáleniny, akútna pankreatitída) – a infekčné – PAMP, molekuly mikrobiálneho pôvodu.
• Septický šok najčastejšie spôsobujú gramnegatívne bacily alebo grampozitívne koky; najčastejšími zdrojmi sú pľúca, brušná dutina a urogenitálny trakt.
• Rizikové faktory sepsy sú napr. ochorenie pečene, leukopénia vrátane neutropénie, invazívne pomôcky (napr. endotracheálne kanyly, cievne alebo močové katétre, drény), súčasná alebo nedávna liečba antibiotikami či glukokortikoidmi; mortalita je vyššia v extrémoch veku.
• Patofyziológia: prozápalové cytokíny (napr. TNF, IL-1) spôsobujú adhéziu neutrofilov k endotelu, aktivujú koaguláciu a tvorbu mikrotrombov; skrat krvi mimo kapiláry a mikrotromby znižujú dodávku kyslíka do tkanív.

Klinický obraz

• Kritériá SIRS (≥ 2): teplota > 38 °C alebo < 36 °C; pulz > 90/min; dychová frekvencia > 20/min alebo PaCO2 < 32 mmHg; leukocyty > 12 000/µl, < 4 000/µl alebo > 10 % nezrelých foriem.
• Sepsa bez šoku: typicky horúčka, tachykardia, potenie a tachypnoe pri normálnom TK; môžu byť prítomné prejavy vyvolávajúcej infekcie.
• Pri zhoršovaní môže byť skorým znakom (najmä u starších a veľmi mladých) zmätenosť alebo znížená bdelosť; pri poklese TK je koža paradoxne teplá, neskôr sú končatiny chladné a bledé s periférnou cyanózou a mramorovaním.
• Septický šok: sepsa s pretrvávajúcou hypotenziou vyžadujúcou vazopresory na udržanie MAP ≥ 65 mmHg a laktátom > 2 mmol/l napriek adekvátnej objemovej resuscitácii.

Diagnostika

• Orgánovú dysfunkciu pri sepse možno identifikovať ako akútny vzostup celkového SOFA skóre o ≥ 2 body v dôsledku infekcie (Sepsis-3).
• Skríning sepsy u akútne chorých hospitalizovaných (SSC 2026): NEWS, NEWS2, MEWS alebo SIRS, nie qSOFA ako jediný nástroj; sepsa je klinická diagnóza, ktorú nepotvrdzuje ani nevylučuje jediný biomarker či test.
• Pri možnej, pravdepodobnej alebo istej sepse či septickom šoku: hemokultúry čo najskôr, ideálne pred podaním antibiotík, a meranie laktátu (SSC 2026).
• Ďalšie vyšetrenia, napr. krvný obraz s diferenciálom, komplexná biochémia, moč a kultivácie z možných ložísk infekcie; zobrazovacie metódy podľa suspektného zdroja.

Liečba

• Sepsa a septický šok sú urgentné stavy (SSC 2026): pri možnom, pravdepodobnom či istom septickom šoku a pri pravdepodobnej či istej sepse bez šoku antibiotiká ihneď, ideálne do 1 hodiny od rozpoznania; pri možnej sepse bez šoku rýchle vyšetrenie a pri pretrvávajúcom podozrení antibiotiká do 3 hodín.
• Pri hypoperfúzii alebo septickom šoku sa navrhuje aspoň 30 ml/kg i.v. kryštaloidu počas prvých 3 hodín; kryštaloidy sú tekutinou 1. voľby (vyvážené pred 0,9 % NaCl, pri kraniocerebrálnom poranení 0,9 % NaCl); škroby sa nemajú používať.
• Septický šok: noradrenalín ako vazopresor 1. voľby, pri stúpajúcich dávkach pridať vazopresín; iniciálny cieľ MAP 65 mmHg, u pacientov ≥ 65 rokov sa navrhuje MAP 60–65 mmHg.
• Ak si zdroj infekcie vyžaduje intervenciu, navrhuje sa včasná kontrola zdroja, ideálne do 6 hodín od diagnózy; pri septickom šoku sa navrhujú i.v. kortikosteroidy.

Komplikácie a prognóza

• MODS môže nasledovať po akomkoľvek type šoku, najčastejšie pri sepse; hypoperfúzia spôsobuje dysfunkciu až zlyhanie orgánov, napr. obličiek, pľúc, pečene, mozgu a srdca.
• Napr. ARDS, akútne poškodenie obličiek (zvyčajne akútna tubulárna nekróza) a akútna encefalopatia (delírium, porucha vedomia).
• Koagulopatia z intravaskulárnej koagulácie so spotrebou koagulačných faktorov, z nadmernej fibrinolýzy alebo najčastejšie z kombinácie oboch; diseminovaná intravaskulárna koagulácia (DIC).
• Septický šok je podskupinou sepsy s výrazne vyššou mortalitou v dôsledku závažných obehových a bunkových/metabolických abnormalít.

Kľúčové pojmy

syndróm systémovej zápalovej odpovede
sepsa	sepsis
septický šok
syndróm multiorgánovej dysfunkcie
orgánová dysfunkcia
laktát
hemokultúra
vazopresor
noradrenalín	noradrenalinum
diseminovaná intravaskulárna koagulácia	coagulatio intravasalis disseminata

📎 Zdroje:

Systemic Inflammatory Response Syndrome - StatPearls - NCBI Bookshelf (definícia)Systemic inflammatory response syndrome (SIRS) is an exaggerated defense response of the body to a noxious stressor, which can include infection, trauma, surgery, acute inflammation, ischemia or reperfusion, or malignancy
Systemic Inflammatory Response Syndrome - StatPearls - NCBI Bookshelf (definícia)SIRS is diagnosed when ≥2 specific criteria—alterations in temperature, heart rate, respiratory rate, or white blood cell count—are present.
The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), JAMA 2016 - PMC (definícia)Sepsis is defined as life-threatening organ dysfunction caused by a dysregulated host response to infection.
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (definícia)Multiple organ dysfunction syndrome is the progressive dysfunction of ≥ 2 organs due to life-threatening illness or injury.
Systemic Inflammatory Response Syndrome - StatPearls - NCBI Bookshelf (etiology[0])Common DAMP triggers, eg, cellular injury or necrosis, releasing intracellular content into the extracellular space, including:
Systemic Inflammatory Response Syndrome - StatPearls - NCBI Bookshelf (etiology[0])Burns
Systemic Inflammatory Response Syndrome - StatPearls - NCBI Bookshelf (etiology[0])Acute pancreatitis
Systemic Inflammatory Response Syndrome - StatPearls - NCBI Bookshelf (etiology[0])PAMPs are microbial-derived molecules that trigger immune responses via pathogen-recognition receptors
Sepsis and Septic Shock - MSD Manual Professional Edition (Full Review Mar 2026) (etiology[1])Most cases of septic shock are caused by gram-negative bacilli or gram-positive cocci, and the most common sources are pulmonary, intra-abdominal, or genitourinary sites
Sepsis and Septic Shock - MSD Manual Professional Edition (Full Review Mar 2026) (etiology[2])Liver disease, including cirrhosis and metabolic dysfunction–associated liver disease
Sepsis and Septic Shock - MSD Manual Professional Edition (Full Review Mar 2026) (etiology[2])Leukopenia, including neutropenia (especially associated with cancer or cytotoxic medications)
Sepsis and Septic Shock - MSD Manual Professional Edition (Full Review Mar 2026) (etiology[2])Invasive devices, including endotracheal tubes, vascular or urinary catheters, drainage tubes, and other foreign materials
Sepsis and Septic Shock - MSD Manual Professional Edition (Full Review Mar 2026) (etiology[2])Current or recent treatment with antibiotics or glucocorticoids
Sepsis and Septic Shock - MSD Manual Professional Edition (Full Review Mar 2026) (etiology[2])Sepsis-related mortality is higher at the extremes of age
Sepsis and Septic Shock - MSD Manual Professional Edition (Full Review Mar 2026) (etiology[3])An inflammatory stimulus (eg, a bacterial toxin) triggers production of pro-inflammatory mediators, including tumor necrosis factor (TNF) and interleukin (IL)-1
Sepsis and Septic Shock - MSD Manual Professional Edition (Full Review Mar 2026) (etiology[3])These cytokines cause neutrophil–endothelial cell adhesion, activate the coagulation cascade, and generate microthrombi.
Sepsis and Septic Shock - MSD Manual Professional Edition (Full Review Mar 2026) (etiology[3])Poor capillary flow resulting from this shunting, along with capillary obstruction by microthrombi, decreases delivery of oxygen and impairs removal of carbon dioxide and waste products.
Systemic Inflammatory Response Syndrome - StatPearls - NCBI Bookshelf (clinical[0])Body temperature >100.4 °F (38 °C) or <96.8 °F (36 °C) Heart rate >90 bpm Respiratory rate >20 breaths/minute or PaCO2 <32 mm Hg (4.3 kPa) Leukocyte count >12,000/μL, <4,000/μL, or >10% immature forms (bands)
Sepsis and Septic Shock - MSD Manual Professional Edition (Full Review Mar 2026) (clinical[1])With sepsis (without septic shock), patients typically have fever, tachycardia, diaphoresis, and tachypnea; blood pressure remains normal. Other signs of the causative infection (eg, cough and fever for a patient with pneumonia) may be present.
Sepsis and Septic Shock - MSD Manual Professional Edition (Full Review Mar 2026) (clinical[2])As sepsis worsens or septic shock develops, an early sign, particularly in older adults or the very young, may be confusion or decreased alertness.
Sepsis and Septic Shock - MSD Manual Professional Edition (Full Review Mar 2026) (clinical[2])Blood pressure decreases, yet the skin is paradoxically warm. Later, extremities become cool and pale, with peripheral cyanosis and mottling.
Sepsis and Septic Shock - MSD Manual Professional Edition (Full Review Mar 2026) (clinical[3])Septic shock is defined as sepsis with persistent hypotension requiring vasopressors to maintain mean arterial pressure ≥ 65 mm Hg and having a serum lactate > 2 mmol/L, despite adequate volume resuscitation.
The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3), JAMA 2016 - PMC (diagnostics[0])Organ dysfunction can be identified as an acute change in total SOFA score ≥2 points consequent to the infection.
Surviving Sepsis Campaign Adult Guidelines 2026 | SCCM (diagnostics[1])For acutely ill patients in hospital, we “recommend” using NEWS, NEW2, MEWS, or SIRS over qSOFA as a single tool to screen for sepsis.
Surviving Sepsis Campaign Adult Guidelines 2026 | SCCM (diagnostics[1])Sepsis is a clinical diagnosis and should not be ruled in or ruled out using a single biomarker or diagnostic test.
Surviving Sepsis Campaign Adult Guidelines 2026 | SCCM (diagnostics[2])For adults with possible, probable, or definite sepsis or septic shock, we “recommend” collecting blood cultures as soon as possible and ideally before the administration of antimicrobial therapy.
Surviving Sepsis Campaign Adult Guidelines 2026 | SCCM (diagnostics[2])For adults with possible, probable, or definite sepsis or septic shock, we “suggest” measuring blood lactate.
Sepsis and Septic Shock - MSD Manual Professional Edition (Full Review Mar 2026) (diagnostics[3])Tests include CBC with differential, comprehensive metabolic panel, lactate, blood cultures, urinalysis and urine culture, and cultures of other body fluids from potential sites of infection
Sepsis and Septic Shock - MSD Manual Professional Edition (Full Review Mar 2026) (diagnostics[3])chest or other radiographs, CT, or MRI may be required, depending on the suspected source.
Surviving Sepsis Campaign Adult Guidelines 2026 | SCCM (treatment[0])Sepsis and septic shock are medical emergencies; treatment and resuscitation should begin immediately.
Surviving Sepsis Campaign Adult Guidelines 2026 | SCCM (treatment[0])For adults with possible, probable, or definite septic shock, we “recommend” administering antimicrobial therapy immediately, ideally within 1 hr of recognition.
Surviving Sepsis Campaign Adult Guidelines 2026 | SCCM (treatment[0])For adults with probable or definite sepsis without shock, we “recommend” administering antimicrobial therapy immediately, ideally within 1 hr of recognition.
Surviving Sepsis Campaign Adult Guidelines 2026 | SCCM (treatment[0])For adults with possible sepsis without shock, we “suggest” a time-limited course of rapid investigation and if concern for infection persists, the administration of antimicrobial therapy within 3 hours from the time when sepsis was first suspected.
Surviving Sepsis Campaign Adult Guidelines 2026 | SCCM (treatment[1])For adults with sepsis-induced hypoperfusion or septic shock, we “suggest” administering at least 30 mL/kg of IV crystalloid in the first 3 hr.
Surviving Sepsis Campaign Adult Guidelines 2026 | SCCM (treatment[1])For adults with sepsis or septic shock, we “recommend” using crystalloids as first-line fluid for resuscitation.
Surviving Sepsis Campaign Adult Guidelines 2026 | SCCM (treatment[1])For adults with sepsis or septic shock undergoing initial resuscitation, we “suggest” using balanced crystalloids over 0.9% saline.
Surviving Sepsis Campaign Adult Guidelines 2026 | SCCM (treatment[1])For patients with sepsis and traumatic brain injury, we suggest using 0.9% saline.
Surviving Sepsis Campaign Adult Guidelines 2026 | SCCM (treatment[1])For adults with sepsis or septic shock, we “recommend against” using starches for resuscitation.
Surviving Sepsis Campaign Adult Guidelines 2026 | SCCM (treatment[2])For adults with septic shock, we “recommend” using norepinephrine as the first-line agent over dopamine, epinephrine, or selepressin.
Surviving Sepsis Campaign Adult Guidelines 2026 | SCCM (treatment[2])For adults with septic shock on escalating doses of norepinephrine, we “suggest” adding vasopressin.
Surviving Sepsis Campaign Adult Guidelines 2026 | SCCM (treatment[2])For adults with septic shock, we “recommend” an initial MAP target of 65 mm Hg over higher MAP targets.
Surviving Sepsis Campaign Adult Guidelines 2026 | SCCM (treatment[2])For adults with septic shock 65 years old or older, we “suggest” an initial MAP range of 60-65 mm Hg over higher ranges.
Surviving Sepsis Campaign Adult Guidelines 2026 | SCCM (treatment[3])For adults with sepsis or septic shock and a specific anatomical diagnosis or source of infection that requires source control, we “suggest” early source control over late source control, ideally within 6 hr of diagnosis of sepsis or septic shock requiring source control.
Surviving Sepsis Campaign Adult Guidelines 2026 | SCCM (treatment[3])For adults with septic shock, we “suggest” using IV corticosteroids.
Shock - MSD Manual Professional Edition (Full Review Jun 2026) (complications[0])MODS can follow any type of shock but is most common when sepsis is the cause.
Sepsis and Septic Shock - MSD Manual Professional Edition (Full Review Mar 2026) (complications[0])Decreased perfusion causes dysfunction and sometimes failure of one or more organs, including the kidneys, lungs, liver, brain, and heart.
Systemic Inflammatory Response Syndrome - StatPearls - NCBI Bookshelf (complications[1])Respiratory system: Acute respiratory distress syndrome (ARDS) due to inflammatory alveolar damage
Systemic Inflammatory Response Syndrome - StatPearls - NCBI Bookshelf (complications[1])Renal system: Acute kidney injury, typically due to acute tubular necrosis
Systemic Inflammatory Response Syndrome - StatPearls - NCBI Bookshelf (complications[1])Central nervous system: Acute encephalopathy, often presenting as delirium or altered mental status
Sepsis and Septic Shock - MSD Manual Professional Edition (Full Review Mar 2026) (complications[2])Coagulopathy may develop because of intravascular coagulation with consumption of major clotting factors, excessive fibrinolysis in reaction thereto, and more often a combination of both.
Systemic Inflammatory Response Syndrome - StatPearls - NCBI Bookshelf (complications[2])disseminated intravascular coagulation (DIC)
Sepsis and Septic Shock - MSD Manual Professional Edition (Full Review Mar 2026) (complications[3])Septic shock is a subset of sepsis with significantly increased mortality due to severe circulatory and cellular/metabolic abnormalities

Precvičiť tému (6)

Kartičky

Vymenujte kritériá SIRS (historická definícia z roku 1991). Koľko ich musí byť splnených?

Najprv si odpoveď povedz nahlas alebo v duchu – až potom ju odkry.

Ako je podľa Sepsis-3 definovaná sepsa a septický šok a čo tvorí qSOFA?

Najprv si odpoveď povedz nahlas alebo v duchu – až potom ju odkry.

Vymenujte hlavné kroky iniciálnej liečby septického šoku u dospelých podľa Surviving Sepsis Campaign 2026.

Najprv si odpoveď povedz nahlas alebo v duchu – až potom ju odkry.