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MULTI ORGAN DYSFUNCTION SYNDROME

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

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MULTI ORGAN DYSFUNCTION SYNDROME

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  1. MULTI ORGAN DYSFUNCTION SYNDROME

  2. Introduction Continued patient survival and long-term quality of life are threatened by two clinical syndromes-that may result in death or profound disability

  3. 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 .

  4. 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.

  5. 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.

  6. Relationship of Shock, SIRS, and MODS Fig. 67-1

  7. Relationship Between Sepsis and SIRS BACTEREMIA SEPSIS TRAUMA BURNS INFECTION SEPSIS SIRS PANCREATITIS

  8. Intra-abdominal infection Shock Pancreatitis Multiple trauma Biliary tract infection Burn MODS Infective diseases Non-infective diseases

  9. Infection/Injury Uncontrolled inflammatory response Controlled inflammatory response SIRS CARS Infection/injury controlled MODS

  10. Severe Sepsis Septic Shock SIRS Sepsis The Sepsis Continuum • 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/mm3or <4,000/mm3 or >10% bands SIRS with a presumed or confirmed infectious process Sepsis with organ failure Refractory hypotension .

  11. Multiple organ dysfunction syndrome

  12. Risk factors of sepsis • use of immunosuppressive therapies for organ transplants • longer lives of patients predisposed to sepsis, theelderly, diabetics, cancer patients,& major organ failure • increased use of invasive devices • indiscriminate use of antimicrobial drugs • Underlying diseases: neutropenia, tumors, leukemia, cirrhosis of the liver, DM, AIDS,& chronic conditions • Surgery or instrumentation: catheters. • Prior drug therapy: Immuno-suppressive drugs • Age: males (> 40 years), females(20-45 years) • Miscellaneous conditions: childbirth, septic abortion, trauma and burns

  13. Classification of MODS • Immediate Type (Primary) • Delayed type (Secondary) • Accumulation type：

  14. Preoperative Illness Trauma or Operation Tissue Injury optimal oxygen delivery and support Excessive Inflammatory Response Inadequate Resuscitation Recovery SIRS/MODS Pathogenesis of SIRS/MODS

  15. Mediators involved in MODS Humoral Mediators Cellular Inflammatory 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 • PolymorphonuclearLeukocytes • Monocytes/Macrophages • Platelets • Endothelial Cells

  16. 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

  17. Initiation of Inflammatory Response

  18. Inflammation Inflammatory cells Inflammatory cytokines

  19. Infection Endothelial Dysfunction Vasodilation Inflammatory Mediators Hypotension Microvascular Plugging Vasoconstriction Edema Maldistribution of Microvascular Blood Flow Ischemia Cell Death Organ Dysfunction

  20. Pathogenesis of Severe Sepsis Infection Microbial Products (exotoxin/endotoxin) Cellular Responses Platelet Activation Cytokines TNF, IL-1, IL-6 CoagulationActivation Kinins Complement Oxidases Coagulopathy/DIC Vascular/Organ System Injury Endothelial damage Endothelialdamage Multi-Organ Failure Death

  21. Infection Microbial Products Inflammatory Cellular Responses Platelet activation Tissue Factor Release Cytokines Nitric Oxide Free radical Formation Complement Endothelial dysfunction Capillary leak Microvascular Thrombus Cell Adhesion Tissue Hypoxia Apoptosis Impaired Vascular Tone Free Radical Damage Multiple organ dysfunction Poor capillary refill P/F Ratio <300 Tachypnea urine <0.5ml / kg/hr Hypotension Tachycardia Thrombocytopenia Metabolic acidosis Altered Mental Status Death

  22. Multi organ failure Apoptosis Gut hypoperfusion

  23. 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

  24. 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

  25. 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.

  26. 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.

  27. 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 • Bleeding Angus DC, et al. Crit Care Med 2001, 29:1303-1310.

  28. 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.

  29. Diagnosis • CBC • basic metabolic profile • procalcitonin (PCT) • CRP • IL-6 (>300 pg/mL) • Blood cultures • Urinalysis and culture • Cardiac enzymes • Amylase, lipase • Spinal fluid and • Liver profiles • Blood lactate

  30. MODS scoring system

  31. Collaborative management Goals • Prevention and treatment of infection • Maintenance of tissue oxygenation • Nutritional and metabolic support, and • Appropriate support of individual failing organs

  32. Early Goal-Directed Therapy NEJM 2001;345:1368-77.

  33. Complications • Adult respiratory distress syndrome (ARDS) • Disseminated Intravascular Coagulation (DIC) • Acute Renal failure (ARF) • Intestinal bleeding • Liver failure • Central Nervous System dysfunction • Heart failure • Death Angus DC, et al. Crit Care Med 2001, 29:1303-1310.

  34. List of Nursing Diagnoses • Ineffective airway clearance related to excessive secretion, presence of an artificial airway, neuromuscular dysfunction. • Impaired gas exchange related to VQ mismatch, intrapulmonary shunting, alveolar hypoventilation. • Decreased cardiac output related to alterations to preload, afterload and contractility. • Imbalanced nutrition less than body requirements related to less intake of exogenous nutrients and increased metabolic demand.

  35. 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.

  36. Nursing intervention Prevention and treatment of infection • Aggressive infection control strategies • Appropriate cultures • Initiate broad spectrum antibiotic therapy • Early aggressive surgery to remove necrotic tissue • Aggressive pulmonary management • Strict asepsis

  37. Nursing intervention Maintenance of tissue oxygenation • Sedation • Mechanical ventilation • Analgesia • Paralysis and • Rest • Maintaining normal levels of hemoglobin • Use PEEP • Increase preload and reduce afterload

  38. Nursing intervention Nutritional and metabolic needs • Monitor prealbumin and plasma transferrin level • Provide adequate nutrition • Enteral feeding

  39. “No great discovery was ever made without a bold guess.” Isaac Newton (1642-1727)

  40. THANK YOU!

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