Transcript MULTI ORGAN DYSFUNCTION SYNDROME

Introduction
Continued patient survival and long-term
quality of life are threatened by two clinical
syndromes-that may result in death or
profound disability
Definition
1. Sepsis - the systemic response to infection.
 SBP < 90 mmHg
 Acute mental status change
 PaO2 < 60 mmHg (PaO2 /FiO2 < 250)
 Increased lactic acid/acidosis
 Oliguria
 DIC or Platelet < 80,000 /mm3
 Liver enzymes > 2 x normal
.
Definition
2. SIRS - is a systemic inflammatory response to a
variety of insults including infection, ischemia,
infarction, and injury. It leads to disorders of
microcirculation, organ perfusion and finally to
secondary organ dysfunction.
3. MODS- the presence of altered organ function in
an acutely ill patient such that homeostasis could not
be maintained without intervention.
Homeostasis
Carvalho AC, Freeman NJ. J Crit Illness. 1994;9:51-75; Kidokoro A et al. Shock. 1996;5:223-8;
Vervloet MG et al. Semin Thromb Hemost. 1998;24:33-44.
Relationship of Shock, SIRS, and MODS
Fig. 67-1
Relationship Between Sepsis and SIRS
BACTEREMIA
INFECTION
SEPSIS
SEPSIS
TRAUMA
SIRS
BURNS
PANCREATITIS
Intra-abdominal
infection
Shock
MODS
Pancreatitis
Multiple trauma
Biliary tract
infection
Infective diseases
Burn
Non-infective diseases
Infection/Injury
Uncontrolled
inflammatory
response
SIRS
CARS
MODS
Controlled
inflammatory
response
Infection/injury
controlled
The Sepsis Continuum
SIRS
 A clinical response
arising from a
nonspecific insult,
with 2 of the
following:
 T >38oC or <36oC
 HR >90 beats/min
 RR >20/min
 WBC >12,000/mm3
or <4,000/mm3 or
>10% bands
Sepsis
Severe
Sepsis
Septic
Shock
SIRS with a Sepsis with Refractory
presumed
organ failure hypotension
or confirmed
infectious
process
.
Multiple organ dysfunction syndrome
Sl.No
System
Time from ICU admission to
onset of significant
dysfunction (days)
1.
Respiratory
1-2
2.
Hematologic
3
3.
Central nervous
4
4.
Cardiovascular
4
5.
Hepatic
5-6
6.
Renal
4-11
7.
Gastrointestinal
10-14
Risk factors of sepsis
 use of
immunosuppressive
therapies for organ
transplants
 longer lives of patients
predisposed to sepsis,
the elderly, diabetics,
cancer patients,& major
organ failure
 increased use of invasive
devices
 Underlying diseases:
neutropenia, tumors, leukemia,
cirrhosis of the liver, DM,
AIDS,& chronic conditions
 Surgery or instrumentation:
catheters.
 Prior drug therapy: Immunosuppressive drugs
 Age: males (> 40 years),
females(20-45 years)
 Miscellaneous
conditions:
childbirth, septic abortion,
trauma and burns
 indiscriminate use of
antimicrobial drugs
Classification of MODS
1. Immediate Type (Primary)
2. Delayed type (Secondary)
3. Accumulation type：
Pathogenesis of SIRS/MODS
Preoperative
Illness
Trauma or
Operation
Tissue
Injury
optimal oxygen
delivery and
support
Recovery
Inadequate
Resuscitation
SIRS/MODS
Excessive
Inflammatory
Response
Mediators involved in MODS
Humoral Mediators
 Complement
 Lipoxygenase products
 Cyclooxygenase products
 Tumor Necrosis Factor
 Interleukins (1-13)
 Growth Factors
 Platelet Activating Factor
 Procoagulants
 Fibronectin and Opsonins
 Toxic Oxygen Free Radicals
 Endogenous Opioids-
Endorphins
Cellular Inflammatory
Mediators
 Polymorphonuclear
Leukocytes
 Monocytes/Macrophages
 Platelets
 Endothelial Cells
Pathophysiology
Inflammatory response
 Release of mediators
 Direct damage to the endothelium
 Hyper metabolism
 Vasodilation leading to decreased SVR
 Increase in vascular permeability
 Activation of coagulation cascade
Initiation of Inflammatory
Response
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Inflammation
Inflammatory cells
Inflammatory cytokines
Infection
Vasodilation
Hypotension
Inflammatory
Mediators
Microvascular Plugging
Vasoconstriction
Maldistribution of Microvascular Blood Flow
Ischemia
Cell Death
Organ Dysfunction
Endothelial
Dysfunction
Edema
Pathogenesis of Severe Sepsis
Infection
Microbial Products
(exotoxin/endotoxin)
Cellular
Responses
Platelet Coagulation
Activation Activation
Oxidases
Cytokines
Kinins
Complement TNF, IL-1, IL-6
Coagulopathy/DIC
Vascular/Organ System
Injury
Multi-Organ
Failure
Death
Infection
Microbial Products
Inflammatory Cellular Responses
Platelet activation Tissue Factor Release
Cytokines Nitric Oxide Free Complement
radical Formation
Endothelial dysfunction
Capillary leak MicrovascularCell
Tissue Apoptosis Impaired Free Radical
Thrombus
AdhesionHypoxia
Vascular Damage
Tone
Multiple organ dysfunction
Hypotension ThrombocytopeniaMetabolic Poor
Altered P/F Ratio urine
<0.5ml / Tachycardia
acidosis capillary
Mental <300
refill
Status Tachypnea kg/hr
Death
Multi organ failure
Apoptosis
Gut hypoperfusion
Clinical manifestations
Respiratory system
Dyspnea
Increased RR
Alveolar edema
Decrease in surfactant
Increase in shunt
V/Q mismatch
hypoxemia
Pulmonary
hypertension
 Decrease compliance








Neurologic system
 Mental status changes



Seizures
Confusion
Hepatic encephalopathy
GIT
 Mucosal ischemia
 Hypo perfusion
 GI bleeding
 Gut leakiness
Clinical manifestations
CVS
Myocardial depression
Increased HR/CO/SVR
Decreased stroke
volume/MAP/EF
Hypotension
Vasodilation
Hematologic
Increased bleeding time &
fibrin split products
Decreased platelet &
clotting factor
Endocrine
Hyperglycemia
Increased ADH production
and ACTH
Clinical manifestations
Nonspecific symptoms of sepsis :
 fever
 chills
 fatigue, malaise
 anxiety or confusion
 absent symptoms in serious infections,
especially in elderly individuals
Angus DC, et al. Crit Care Med 2001, 29:1303-1310.
Clinical staging
stage 1- volume requirements are a little
higher than expected
Stage 2 - occult dysfunction in each organ
stage 3 - each organ has an overt dysfunction
and requires support
stage 4- patient dies from sequential organ
failure.
Diagnosis
History
 community or nosocomial infection
 immunocompromised patient
 underlying diseases
 Some clues to a septic event include
 Fever or unexplained signs with malignancy or
instrumentation
 Hypotension
 Oliguria or anuria
 Tachypnea or hyperpnea
 Hypothermia without obvious cause
Angus DC, et al. Crit Care Med 2001, 29:1303-1310.
 Bleeding
Diagnosis
Physical Examination
 In all neutropenic patients and pelvic infection
the physical exam should include rectal,
pelvic, and genital examinations
 perirectal, and/or perineal abscesses

pelvic inflammatory disease and/or
abscesses, or prostatitis
Angus DC, et al. Crit Care Med 2001, 29:1303-1310.
Diagnosis
 CBC
 Blood cultures
 basic metabolic profile
 Urinalysis and culture
 procalcitonin (PCT)
 Cardiac enzymes
 CRP
 Amylase, lipase
 IL-6 (>300 pg/mL)
 Spinal fluid and
 Liver profiles
 Blood lactate
MODS scoring system
ORGAN
SYSTEM
0
1
2
3
4
Cardio
vascular
<120
120-140
>140
inotropes
Lactate>5
Respiratory
>300
226-300
151-225
76-150
<75
Renal
<100
101-200
201-350
351-500
>500
Central
nervous
system
15
13-14
10-12
7-9
<6
Hepatic
<20
21-60
61-120
121-240
>240
81-120
51-80
21-50
<20
Hematologic >120
Collaborative management
Goals
 Prevention and treatment of infection
 Maintenance of tissue oxygenation
 Nutritional and metabolic support, and
 Appropriate support of individual failing organs
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Early Goal-Directed
Therapy
NEJM 2001;345:1368-77.
Complications
1. Adult respiratory distress syndrome (ARDS)
2. Disseminated Intravascular Coagulation (DIC)
3. Acute Renal failure (ARF)
4. Intestinal bleeding
5. Liver failure
6. Central Nervous System dysfunction
7. Heart failure
8. Death
Angus DC, et al. Crit Care Med 2001, 29:1303-1310.
List of Nursing Diagnoses
1. Ineffective airway clearance related to excessive
secretion, presence of an artificial airway, neuromuscular
dysfunction.
2. Impaired gas exchange related to VQ mismatch,
intrapulmonary shunting, alveolar hypoventilation.
3. Decreased cardiac output related to alterations to
preload, afterload and contractility.
4. Imbalanced nutrition less than body requirements related
to less intake of exogenous nutrients and increased
metabolic demand.
List of Nursing Diagnoses
5. Ineffective tissue perfusion (cardiopulmonary, renal) related
to decreased myocardial oxygen supply than demand.
6. Acute confusion related to sensory overload, sensory
deprivation and sleep pattern disturbance.
Nursing intervention
Prevention and treatment of infection
1. Aggressive infection control strategies
2. Appropriate cultures
3. Initiate broad spectrum antibiotic therapy
4. Early aggressive surgery to remove necrotic tissue
5. Aggressive pulmonary management
6. Strict asepsis
Nursing intervention
Maintenance of tissue oxygenation
1. Sedation
2. Mechanical ventilation
3. Analgesia
4. Paralysis and
5. Rest
6. Maintaining normal levels of hemoglobin
7. Use PEEP
8. Increase preload and reduce afterload
Nursing intervention
Nutritional and metabolic needs
1. Monitor prealbumin and plasma transferrin level
2. Provide adequate nutrition
3. Enteral feeding
Isaac Newton
(1642-1727)
“No great discovery was ever made
without a bold guess.”
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