Mods

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Multiple Organ Dysfunction Syndrome (MODS)

The First Teaching Hospital Of ZZU

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Case ♦ A patient,male,28-years-old,one day,fell

into a 1-meter-deep hole from the ground.His liver was seriously injured. To stop bleeding from liver,doctors had to put seven bandages into his liver. During the operation ,his Bp fell to 30/10mmHg. After operation,he had water only 300ml/d. One day later, he felt tachypnea. He had to use ventilator to keep from hypoxia. 12/01/09

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Case ♦ The bandages in his abdominal cavity was infected. His Bp fell to

80/60mmHg10 days later. We had to use dopamine to keep his Bp. At last , bandages were taken out, then, 15 days later ,he recovered. ♦ Question: ♦ 1.what’s the diagnosis of the patient? ♦ 2.what lead to these changes? ♦ Multiple Organ Dysfunction Syndrome

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♦ Blood gas analysis :PaO2 55mmHg ♦

PaCO2 60mmHg

♦ BUN :20mmol/L ♦ Cr : 600umol/L

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♦ Respiratory failure ♦ Renal failure ♦ Septic shock ♦ Hypovolemic shock

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MODS--definition ♦ Presence of altered organ function in an acutely

ill patient such that homeostasis cannot be maintained without intervention. ♦ Multiple organ failure (MOF) is the most common cause of ICU late death following major traumatic injury. ♦ MODS MOF

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General Goal: ♦ In this lesson, we need to understand the

basic processes that cause the progression from SIRS to septic shock, then to MODS and describe the basic treatment plan in caring for these patients.

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Society of Critical Care Medicine (SC

Development of MODS Name

Author

Time

Sequential system failure

Tilney

1973

Multiple progressive or sequential systems failure

Baue

1975

multiple organ failure

Eiseman

1977

remote organ failure

Polk

1977

multiple systems organ failure

Fry

1980

acute organ-system failure

Knaus

1985

multiple organ dysfunction syndrome ACCP/SCCM

1991

American College of Chest Physicians 12/01/09

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Several Concepts ♦

1. 2. 3. 4.

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Systemic Inflammatory Response Syndrome (SIRS): Patient presents with two or more of the following criteria. temperature > 38°C or < 36°C degrees Celsius heart rate > 90 beats/minute respiration > 20/min or PaCO2 < 32mm Hg leukocyte count > 12,000/mm3, < 4,000/mm3 or > 10% immature (band) cells

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Several Concepts ♦ Infection :Microbiological event (caused by bacteria, viruses, fungi) inducing some host response or presence of these microorganisms in a normally sterile tissue (CSF, peritoneum) ♦ Bacteremia (fungemia) :Presence of viable bacteria (fungal) in the blood, as evidenced by positive blood culture ♦ Sepsis :SIRS that has a proven or suspected microbial etiology

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Several Concepts

♦ Multiple organ dysfunction syndrome

(MODS): Dysfunction of more than one organ, requiring intervention to maintain homeostasis

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Several Concepts ♦ Severe sepsis:Sepsis with one or more signs of organ dysfunction, hypoperfusion, or hypotension such as metabolic acidosis, acute alteration in mental status, oliguria, coagulation abnormalities or adult respiratory distress syndrome ♦ Septic shock:Sepsis with hypotension that is unresponsive to fluid resuscitation plus organ dysfunction or perfusion abnormalities as listed above for severe sepsis

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♦

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♦ Sepsis in United States. Incidence and

mortality of sepsis, severe sepsis, and septic shock in United States continues to rise. The death rates from severe sepsis and septic shock now equal to those caused by acute myocardial infarction.

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etiology ♦ A combination of tissue hypoxia, an

exaggerated systemic inflammatory response, and tissue damage arising from ischemia, necrosis, free oxygen radical and protease attack all contribute to progressive organ dysfunction and,ultimately, failure.

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♦ Infection

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♦ Non-infection ♦ 1.trauma ♦ 2.shock ♦ 3.burn ♦ 4. pancreatitis ♦ 5.ischemia/reperfusion ♦ 6.other

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mechanism

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Illustrates the common physiological characteristics of multiple system organ failure and the variety of end organs/systems affected. Note that the changes induced are irrespective of the original etiology (i.e., infectious/non infectious). Individual patients vary to the extent of MODS 12/01/09

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compensatory antiinflammatory response syndrome(CARS) 12/01/09

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Role of gut in MODS Acute reduction in oxygen supply is important in MODS. MODS deteriorate hypoxia. ♦ Gut is particularly susceptible to hypoxic injury ♦ Barrier is compromised. ♦ Bacteria translocates to blood. ♦ Endotoxin 12/01/09

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Diagnosis ♦ 1. Basic etiology ♦ 2. Clinical signs and symptoms ♦ 3. Laboratory findings

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Diagnosis ♦ Circulatory failure ∀ Criteria for diagnosis ο Bradycardia (heart rate <50 bpm) ο Hypotension (mean arterial pressure

<50 mmHg) ο Ventricular tachycardia or fibrillation ο Metabolic acidosis (pH <7.2)

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Diagnosis ♦ Respiratory failure ∀ Criteria for diagnosis ο Respiratory rate <5 or >40 breaths per

minute ο Hypercapnia (PaCO2 > 6.7 kPa) ♦ Hypoxaemia

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Diagnosis ♦ Acute renal failure ∀ Criteria for diagnosis Oliguria

Renal insufficiency with BUN > 75 mg/dl and/or serum creatinine > 3 mg/dl

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Diagnosis ♦ Hematological failure ∀ Criteria for diagnosis ο Leucopenia (WCC < 1000 cell / mm3) ο Thrombocytopenia (platelet < 20,000 /

mm3) ♦ Evidence of disseminated intravascular coagulation (DIC)

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Diagnosis ♦ Hepatic failure ∀ Criteria for diagnosis ο Serum total bilirubin > 3 mg/dl ο Serum ALT or AST > 500 U/L

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Diagnosis ♦ Gastrointestinal failure ∀ Criteria for diagnosis ο Ileus ο Gastroparesis ο Hemorrhage

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Diagnosis ♦ Neurological failure ∀ Criteria for diagnosis ο Depressed level of consciousness

(Glasgow coma score <6)

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Lab Studies: ♦ Laboratory tests are useful in suspected

septic shock or MODS to assess the general hematologic and metabolic condition of the patient. The microbiologic studies provide results, which may indicate occult bacterial infection or bacteremia, and indicate the specific microbial etiology.

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Lab Studies: An adequate hemoglobin concentration is necessary to ensure oxygen delivery in shock. Maintain the hemoglobin at a level of 80 g/L or more.

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Lab Studies: ♦ Platelets: Acute phase reactants,

platelets usually increase at the onset of any serious stress. The platelet count will fall with persistent sepsis, and DIC may develop.

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Lab Studies: ♦ WBC count: The white cell differential

and the WBC count may predict the existence of a bacterial infection. In adults who are febrile, a WBC count greater than 15,000 cells/µ L or a neutrophil band count greater than 1500 cells/µ L is associated with a high likelihood of bacterial infection.

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Lab Studies: ♦ Metabolic assessment: Perform

metabolic assessment with serum electrolytes, including magnesium, calcium, phosphate, and glucose, at regular intervals.

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Lab Studies: ♦ Renal and hepatic function: Assess

renal and hepatic function with serum creatinine, BUN, bilirubin, alkaline phosphate, and alanine aminotransferase (ALT).

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Lab Studies: ♦ Prothrombin time (PT) and activated

partial thromboplastin time (aPTT): Assess coagulation status with prothrombin time (PT) and activated partial thromboplastin time (aPTT). Patients with clinical evidence of coagulopathy require additional tests to detect the presence of DIC.

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♦ PT ♦ fibrinogen ♦ platelet ♦ DIC

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Blood cultures ♦ Blood culture is the primary modality for aiding in the

diagnosis for intravascular infections (eg, endocarditis) and infections of indwelling intravascular devices. ♦ Patients at risk for bacteremia include adults who are febrile with an elevated WBC or neutrophil band counts, elderly patients who are febrile, and patients who are febrile and neutropenic. These populations have a 20-30% incidence of bacteremia. ♦ The incidence of bacteremia is at least 50% in patients with sepsis and evidence of end-organ dysfunction.

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Urinalysis and urine culture: ♦ Order a urinalysis and urine culture for

every patient who is MODS. Urinary infection is a common source for sepsis, especially in elderly individuals. Adults who are febrile without localizing symptoms or signs have a 10-15% incidence of occult urinary tract infection (UTI).

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Imaging Studies: ♦ A variety of imaging modalities are

employed to diagnose clinically suspected focal infection, detect the presence of a clinically occult focal infection, and detect complications of sepsis and septic shock.

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Imaging Studies: ♦ Obtain a chest radiograph in patients

with severe sepsis because the clinical examination is unreliable for pneumonia. Clinically occult infiltrates have been detected by routine use of chest radiography in adults who are febrile without localizing symptoms or signs and in patients who are febrile and neutropenic without pulmonary symptoms.

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Imaging Studies: ♦ Ultrasound is the imaging modality of

choice when a biliary tract source is suspected to be the source of sepsis. ♦ CT scan is the imaging modality of choice for excluding intraabdominal abscess or a retroperitoneal source of infection.

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Imaging Studies: ♦ When there is clinical evidence of a

deep, soft tissue infection, such as, crepitus, bullae, hemorrhage, or foul smelling exudates, obtain a plain radiograph. The presence of soft tissue gas and the spread of infection beyond clinically detectable disease may require surgical exploration.

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prognosis ♦ Mortality/Morbidity: Mortality from

multiorgan dysfunction syndrome remains high. Mortality rates from ARDS alone is 40-50%. Once additional organ system dysfunction occurs, the mortality rate increases as much as 90%. ♦ Four organs failure, 100% 12/01/09

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Medical Care: General supportive care

♦ Initial treatment includes support of respiratory

and circulatory function, supplemental oxygen, mechanical ventilation, and volume infusion. Treatment beyond these supportive measures includes a combination of several parenteral antibiotics, removal or drainage of infected foci, treatment of complications, and pharmacologic interventions to prevent further harmful host responses.

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ICU ♦ Patient should be admitted to ICU(intensive

care unit) ♦ Mechanical ventilator ♦ Monitor ♦ CRRT ♦ Special doctor and nurse

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Ventilation ♦ Essential ♦ strategy that uses lower tidal volumes and

inspiratory pressures than were used in the past. tidal-volume goal of 6 ml per kilogram of predicted body weight ♦ positive end-expiratory pressure (PEEP) ♦ High levels of positive end-expiratory pressure (PEEP) are not better than low levels of PEEP for acute respiratory distress syndrome (ARDS), according to the results of a randomized trial

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♦ Administer supplemental oxygen to any

patient who is MODS with hypoxia or respiratory distress. If the patient's airway is not secure or respirations are inadequate, perform endotracheal intubation and mechanical ventilation.

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Intravascular volume resuscitation ♦ All patients with MODS require supplemental

fluids. Assessment of the patient's volume and cardiovascular status guides the amount and rate of infusion. For adult patients who are hypotensive, administer an isotonic crystalloid solution (sodium chloride 0.9% or Ringer lactate) in boluses of 500 mL (10 mL/kg in children), with repeat clinical assessments after each bolus.

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♦ Administer repeat boluses until signs of adequate

perfusion are restored. A total of 4-6 L may be required. Monitor patients for signs of volume overload, such as dyspnea, pulmonary crackles, and pulmonary edema, on chest radiograph. Improvement, stabilization, and normalization of the patient's mental status, heart rate, BP, capillary refill, and urine output indicate adequate volume resuscitation

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♦ A centrol venous pressure of 10-15 mm Hg, a

PAOP greater than 18 mm Hg, or a rise in the PAOP by 5 mm Hg or more following fluid bolus indicates adequate volume resuscitation. Such patients are susceptible to volume overload; therefore, administer further fluid carefully. Colloid resuscitation (with albumin or pentastarch) has no proven benefit over isotonic crystalloid resuscitation (normal saline or Ringer lactate). ♦ pulmonary artery occlusion pressure (PAOP)

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Vasopressor supportive therapy When proper fluid resuscitation fails to restore hemodynamic stability and tissue perfusion, initiate therapy with vasopressor agents. These agents are dopamine, norepinephrine, epinephrine, and phenylephrine. These vasoconstricting drugs maintain adequate BP during life-threatening hypotension and preserve perfusion pressure for optimizing flow in various organs. Maintain the mean BP required for adequate splanchnic and renal perfusion (mean arterial pressure [MAP] of 60 or 65 mm Hg) based on clinical indices for organ perfusion. 12/01/09

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Renal-dose dopamine ♦ Low-dose dopamine does not protect

the patient from developing acute renal failure, and there is no data stating that it preserves mesenteric profusion; the routine use of this practice is not recommended.

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Empirical antimicrobial therapy ♦ Administer initial antibiotics. Selection of

particular agents is empirical and is based on an assessment of the patient's underlying host defenses, the potential sources of infection, and the most likely responsible organisms. Antibiotics must be broad spectrum and cover gram-positive, gram-negative, and anaerobic bacteria because all classes of these organisms produce identical clinical pictures. Administer antibiotics parenterally in doses adequate to achieve bactericidal serum levels.

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♦ Many studies have found that clinical

improvement correlates with the achievement of serum bactericidal levels rather than the number of antibiotics administered.

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♦ Patients who are immunocompetent usually

can be treated with a single drug with broadspectrum coverage, such as a thirdgeneration cephalosporin. Patients who are immunocompromised usually require dual antibiotic coverage with broad-spectrum antibiotics with overlapping coverage. Within these general guidelines, no single combination of antibiotics is clearly superior to others 12/01/09

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large doses of corticosteroids No date exists in the medical literature supporting the routine use of high doses of corticosteroids in patients with sepsis or septic shock and MODS.

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♦ Surgical Care: Take patients with

infected foci to surgery after initial resuscitation and administration of antibiotics for definitive surgical treatment. Little is gained by spending hours stabilizing the patient when an infected focus persists.

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CRRT ♦ Continuous renal replacement treatment ♦ Cytokines lead to SIRS ♦ Useful in Pancreatitis

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