Mods

多器官功能障碍综合征 Multiple organ dysfunction Syndrome Emergency Department The First Affiliated Hospital Zhengzhou University Liu Baochi

MODS 的概念 (Concept of MODS) • Multiple organ dysfunction syndrome (MODS)

means sequential dysfunction or failure of two or more than two organs after 24 hours of severe injury or inflammation.

• MODS is different from some advanced

stage of chronic disease with multiple organ failure.

概

述

Introduction

Multiple-organ failure(MOF) emerged as a new syndrome 30 years ago as a result of our ability to keep patients alive with advanced technology. it remains the leading cause of death in the intensive care unite(ICU).

MODS 是危重病患者的主要致死

原因  high incidence  great expense  high mortality

对器官衰竭认识的回顾 Review the Recognition of Organ Failure World War 1, injured soldiers died in the battlefield of profound cardiac failure.

Review the Recognition of Organ Failure World War 2,injured soldiers were rapidly transported for definitive care provided in field units, resuscitated with blood and plasma,more soldiers survived their initial traumatic insult,however the severely injured often succumbed to be renal failure.

Review the Recognition of Organ Failure Vietnam War,Balanced salt solutions were used for traumatic shock, crystalloid infusion was added to blood replacement,renal failure occurred less, mortality decreased. A new entity termed shock lung became the primary cause of late deaths. The term adult respiratory distress syndrome (ARDS) was coined to describe this

Recognition of Organ Failure In the mid-1970s,widespread application of advanced organ support (mechanical ventilation, total parenteral nutrition, hemodialysis) increased the capacity to sustain critically injured patients. No longer were patients dying of isolated pulmonary failure. A new syndrome of multiple organ failure emerged as the leading cause of late postinjury death.

多器官功能障碍综合征 Multiple Organ Dysfunction Syndrome (MODS) • The continuum of illness severity that encompasses MODS spans a wide range of clinical presentations.

• MODS improves our ability to describe organ dysfunction at an early point on the continuum.

病 因 Causes • Severe trauma • Severe infection • Shock, especially traumatic or infectious ones. • Mistreatment . • Patients with chronic disease vulnerable to develop MODS.

发 病 机 制 Pathogenesis 1. 单相速发型 (rapid single-phase type) 2. 双相迟发型 (delayed two-phases type)

primary insult insult primary MODS MODS

+

MODS MODS

sepsis sepsis recovery recovery death death

rapid singlephase type

delayed twophases type

二次打击学说 (Theory of Double-Hit) first first hit hit 炎症细胞激活 炎症细胞激活

SIR SIR

e

g xa

g

te a er

d

second hit hit second MODS MODS

mi ld

recovery recovery SIR: systemic inflammatory response

缺血及缺血－再灌注损伤 Ischemia and Ischemia-reperfusion Injury

• hemorrhagic shock, low tissue perfuse directly leads to cells necrosis.

• Reperfusion injury : After resuscitation of

hypovolemia shock , ischemia tissue gets reperfusion and extensive tissue injury occurs.

Ischemia-reperfusion Ischemia-reperfusion injury injury 2+ OFR,Ca OFR,Ca2+ overload overload

Organ Organ dysfunction dysfunction or or failure failure

Inflammatory Inflammatory mediators mediators

Neutrophils Neutrophils

No-reflow No-reflow

Endothelial cells cells Endothelial

Systemic Systemic inflammatory inflammatory response response Distal Distal organ organ dysfunction dysfunction or or failure failure

OFR: Oxygen Free Radical

ATP ATP↓↓

肠屏障功能损伤及肠道细菌移 Damage of Intestinal Barrier & Bacterial Translocation 位

肠粘膜供血不足 肠粘膜屏障破坏 通透性增加

创伤 、 休克 、 感 染 体循 环 SIRS

MODS

细胞因 子炎症 介质

细菌、内毒素

动物实验：肺损伤后增加感染易感性 VILI Increases Susceptibility to Infection•Rats ventilated for 1 hour

•Instillation of bacteria; animals followed for 48 hours

Lin, Zhang, Chen, Slutsky (Critical Care Medicine)

炎症介质水平增高 Cytokine Levels Control Minimal stress

4

10

BAL TNF-α ( pg/ml)

104

Serum IL-6 ( pg/ml)

#

1 0 00

1000 100 Entry

24 h

36 h

100

entry

24 h

36 h

Ranieri et al JAMA 1999;282:54-61

inflammation response

全身炎症反应综合征 systemic inflammatory response syndrome (SIRS) • Temperature above 380C or below 360 C; • Heart rate greater than 90beats/min; • Respiratory rate greater than 20breaths/min • WBC>12000 cells/mm or less than 4000 cells/mm or greater than 10% immature (bands) forms.

炎症反应和抗炎反应失 衡 SIRS/CARS balance • Systemic

Inflammation Response Syndrome

• Compensatory Antiinflammation Response Syndrome

Development of inflammation promote

inhibit

SIRS

CARS

MODS

临床表现

Clinical

feature • Patient in shock associated with sepsis or

SIRS frequently have have a characteristic clinical picture consisting of fever,techycardia, hypotension, and altered mental status. • In the early stages may be a hyperdynamic profile. Manifested by elevated cardiac index and a decreased systemic vascular resistance.

肺功能障碍 Pulmonary Dysfunction • The acute lung injury in MODS reflects the pathophysiologic pulmonary manifestation of a systemic inflammatory process. • ARDS is characterized by ventilationperfusion abnormalitis, noncardiogenic pulmonary edema, decreased functional residual capacity, refractory hypoxemia, diffuse infiltrates on chest X-rays, and decreased lung compliance.

胃肠道功能障碍 Gastrointestinal dysfunction • Including gastritis or ulcerations, pancreatitis, acalculous cholecystitis, malabsorption, and mucosal atrophy breakdown of the gut mucosal barrier predisposes to the translocation of bacteria or toxins that can perpetuate the inflammatory process.

肝功能障碍 Liver dysfunction • The liver appears to play a pivotal role in

the progression and outcome of MODS. The vital metabolic functions of the liver, as well as the host defense functions of the Kuffer cell, are key processes. • With progressive hepatic dysfunction, the synthetic and metabolic roles of the liver deteriorate,causing substantial increases in the plasma levels of glucose, triglycerides, amino acids, bilirubin, urea and lactate.

肾功能障碍 Renal dysfunction • Renal dysfunction in MODS may

arise due to kidney hypoperfusion or direct tissue damage by activated inflammatory cells and their mediators. • Shock associated with sepsis or SIRS, redistribution of blood flow or inadequate perfusion pressure may contribute to renal dysfunction.

心功能障碍 Cardiac dysfunction • Depressed coronary blood flow,

direct endotoxin toxicity, and the presence of a circulating myocardial depressant factor have all been proposed as possible mechanisms.

中枢神经系统功能障碍 Central nervous system manifestation • Because compensatory mechanisms in

shock are aimed at preserving blood flow to the brain and the heart, central nervous system manifestation may appear late. • Mental status is frequently measured objectively using Glasgow Coma Scale, Which takes into account, on a graded scale, the patient’s best eye opening, verbal, and motor responses.

诊断 Diagnosis • Two basic conditions: severe stroke and advanced medical treatment.

• There is no special pathology change. mainly extensively inflammation.

MODS scores (Marshall 1995) 0 1 2 3

4 <75

PaO2/FI>300 O2

226-300

151-225

76-150

Cr <100 umol/L

101-200

201-350

351-500

>500

Bi <20 umol/L

21--60 61-120

121-140

>240

PAR

<10.0 10.5— 15.1— 20.1— >30.0 15.0 20.0 30.9

Plat

>120

80-120 51-80 21-51 <20

MODS 治疗 Treatment 3 RING CONSIST OF LIFE CHAIN

PRE-HOSPITAL

Emergency department

E ICU

1. 控制出血与体液复苏

Bleeding control and fluid esuscitation Emergency operation control bleeding. Fluid and blood transfusion. Resuscitation of hypovolemia shock.

2. 迅速祛除病因 abscess

drainage

第三腰椎骨折并脱位 Fracture and dislocation of lumber 3

十二指肠破裂修补 Repair ruptured duodenum

3. 呼吸支持

Breath support entilation after emergency operatio

4. 肾功能保护和血液净化治疗 Protecte renal function and hemodailysis

5. 抗生素应用

Utility of antibiotic

• Use antibiotic to control infection.

• Combine and substitute use. • Downstairs use.

6. DIC 的预防与治疗 Prevention and treatment of DIC (1)Early diagnosis and early treatment. (2)Different methods at different stage.

7. 免疫调节治疗

Immunotherapeutic intervention

Ability to measure the activation state of host defenses accurately. A clear comprehension of the interactions among the various components of the immune system during health and disease. A much more rapid and precise identification of pathogens and microbial toxins.

8. 营养支持 Nutrition support Early nutritional support has been demonstrated to reduce the frequency of infectious complications. Overfeeding patient or administering excess carbohydrates will lead to excess production of CO2. normally, 25 to 28 nonprotein calories/kg/day.

Advantages of PN Ease of delivery, Ordered=delivered Functional gut not required Ability to maintain body weight and fat Ability to replenish vitamin and minerals

Disadvantages of PN Gut atrophy (GALT, Mucosa) Metabolic (hyperglycenia, stress response) Immunosuppressive Imbalanced (AA, lipids) Venous thrombosis

9. 中西医结合治疗

Treatment with traditional Chinese medicine

western medicine combining with traditional Chinese medicine can reduce the mortality of MODS 。

症急性胰腺炎

Severe acute pancreati

康复出院 recovery

Above certain attitude, there is no rain and no cloud. If your life is sheltered by cloud, that is your heart not yet fly that high. Most of us commit mistakes by resisting problems, as they try hard to vanish the cloud. The Correct way is to find the path to the peak above the cloud. There the sky is always blue.

在某个高度之上，就没有风雨云层。如果你生命中的云层遮蔽了阳光，那是因为你 的心灵飞得还不够高。大多数人所犯的错误是去抗拒问题，他们努力试图消灭云层。 正确的做法是发现使你上升到云层之上的途径，那里的天空永远是碧蓝的。