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Multiple Organ Dysfunction Syndrome

Multiple Organ Dysfunction Syndrome. Prepared By Dr. Hanan Said Ali. Learning Outcomes:. Define multiple organ dysfunction syndrome. Idenyify systematic dysfunction associated with MODS: CNS Respiratory Cardiovascular Gastrointestinal Liver Renal Haematological.

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Multiple Organ Dysfunction Syndrome

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  1. Multiple Organ Dysfunction Syndrome Prepared By Dr. Hanan Said Ali

  2. Learning Outcomes: • Define multiple organ dysfunction syndrome. • Idenyify systematic dysfunction associated with MODS: • CNS • Respiratory • Cardiovascular • Gastrointestinal • Liver • Renal • Haematological

  3. Learning Outcomes Cont.: • Describe how to assess the patient systematically. • Explain the priorities and principles of management for these patients.

  4. Multiple Organ Dysfunction Syndrome Definition • Is a consequence of the inability to maintain end- organ perfusion and oxygenation, resulting in injury and organ failure. • E.g. The inability of the pulmonary system to oxygenate the blood adequately through ventilation and gas exchange is considered pulmonary failure.

  5. CNS dysfunction associated with MODS 1. Septic encephalopathy • Neurological alteration ranging from altered concentration and intermittent confusion to seizures and coma. 2. Critical illness polyneuropathy • It presents clinically as limb and chest wall weakness, although sensory deficits can occur alone or in combination.

  6. CNS dysfunction associated with MODS 1Neuroendocrine exhaustion • Altered release of hypothalamic products (e.g. growth hormone- releasing hormone). • Glucose intolerance. • Failure to mount a febrile response. • Neurological pulmonary oedema.

  7. CNS dysfunction associated with MODS Patient assessment • Conscious level ( Glasgow coma scores) • Mental agitation and confusion. • Profound weakness and muscle wasting. • EEGs may exhibit evidence of changes consistent with metabolic or anoxic encephalopathy.

  8. Respiratory system involvement in MODS • It occupies range of dysfunction from acute lung injury to acute respiratory distress syndrome. Patient assessment • General appearance. • Lung fields ...... Wheeze. • Chest – x ray .....Interstitial oedema. • Pulse oximetry .......Sa O2< 90%. • Pulmonary secretions ....Early loose white ... Later thicker & more profuse.

  9. Respiratory system involvement in MODS Patient assessment • ABGs.....Early PaO2 low & PaCO2 low.... Alkalosis Later.... PaO2 rise with in PH....acidosis. • Heart rate...... Tachycardia, low blood pressure. Cardiovascular involvement in MODS • Loss of peripheral autoregulation leads to: Inappropriate vasodilatation . • Maldistribution of flow. • Decreased oxygen extraction.

  10. Cardiovascular involvement in MODS Patient assessment • Heart rate and rhythm..... Tachycardia, hypotension, ventricular arrhythmias. • Mean arterial pressure...... 60 mmHg is usually necessary to maintain perfusion of organ. • Urine output..... Maintain a urine output of >0.5 ml/ kg/hour.

  11. Cardiovascular involvement in MODS Patient assessment Cont. • Arterial base deficit...... Blood gas analysis is highly suggestive of tissue ischemia or infarction. • Lactate ..... Blood lactate levels may be good indication of global ischemia ( levels > 2 mmoI/I reflect tissue hypoxia) . • Temperature ...... May increased or decreased.

  12. Gastrointestinal involvement in MODS • Stomach : ulceration, stress ulcer bleeding, decreased gastric motility. • Pancreas : pancreatitis. • Gallbladder : Acalculous cholecystitis ( inflammation unrelated to gallstone). • Colon : Colitis.

  13. Gastrointestinal involvement in MODS Patient assessment • Abdomen ..... Assess distension, discomfort and pain, and the presence of bowel sounds. • Faces ..... Presence of diarrhea, color, consistency, frequency, and presence of blood. • Gastric intolerance...... Nausea, vomiting, large aspirates > (200 ml) from the NGT. • Ultrasound ....... Acalculous cholecystitis, fluid collection within the abdomen.

  14. Liver involvement in MODS • The serum bilirubin exceeds 20 – 30 umI/I ( jaundice). • Elevation in liver function enzymes to more than twice normal levels. • Abnormal prothrombin time. • Hepatic encephalopathy.

  15. Liver involvement in MODS Patient assessment • Conscious level and neurological status. • Skin, mucous membranes, and invasive line sites. • Inspected daily for evidence of coagulation abnormalities .............. Bleeding from gums, purpura, bleeding from line sites.

  16. Liver involvement in MODS Patient assessment Cont. • Conjunctiva and skin color ...... Jaundice. • Urine analysis ....... Bilirubin level. • Liver function tests ...... Carried out at least every 2 – 3 days in the acute phase. • Clotting test ........ On daily basis

  17. Renal involvement in MODS • Renal dysfunction which has four stages: • Onset It may correspond with pre- renal failure. It may last hours to days depending on the cause. • Oliuric – anuric phase. Lasts 1 – 6 weeks. The GF reduced & body fluid overload, blood urea & creatinine, uraemia.

  18. Renal involvement in MODS • Diuretic phase ........ Increase urine output & in renal function. • Recovery phase ........ GF returns to at least 70 – 80 of normal within 1 – 2 years.

  19. Renal involvement in MODS Patient assessment • Oedema ......... (Peripheral and pulmonary) nausea, vomiting, pruritis. • Urine output ..... ( the aim is > ml/kg/hour). • Urine ........ Specific gravity, glucose, protein. • Blood urea & creatinine, potassium, PH. • Intravascular fluid volume status.

  20. Haematological involvement in MODS • Bleeding from line sites and wounds. • Bleeding into skin, ranging from petechiae, to gross echymosis & mucosa and gum. • Stress ulcer, peptic ulcer, GIT bleeding.

  21. Haematological involvement in MODS Patient assessment • Assess skin ........ Petechiae, purpura, bruising • Gums & mucous membranes ....... Bleeding. • Sclera and conjunctiva ........ Hg. • IV cannula site, arterial cannula sites, chest drain, wounds, tracheostomy site ..... bleeding • Sputum during endotracheal suction.

  22. Haematological involvement in MODS Patient assessment • Urine analysis for evidence of haematuria. • Stool for evidence of melaena. • Nasogastric aspirate ...... Gastric bleeding. • Measurement of haemoglobin, platelet count, prothrombin time, PTT.

  23. Priorities and principles of management Initial resuscitation includes: • Airway • A patent airway. • Intubation should be considered. • Breathing • Oxygen therapy or ventilatory support to maintain O2 saturation of 90 – 95 %.

  24. Priorities and principles of management Initial resuscitation includes: • Circulation • The aim is the rapid restoration of organ perfusion and perfusion pressure . • Administration of colloid challenges ( aliquots of 200 ml) • Measure CVP. • If unsuccessful ....... Vasoactive drugs are required

  25. Priorities and principles of management Early Interventions • Once the patient stabilize, any injuries should be treated (removal of necrotic tissue, deriding burn, stabilize fracture. • Drainage of any collection or abscesses. • Blood, urine, and other cultures, should done to identify source of sepsis. • Appropriate antibiotics should be prescribed.

  26. Priorities and principles of management Further Interventions Metabolic • Body temperature should be maintained within the normothermic range 36.0 37.5 C. • Strict control of blood glucose. Infection • Abscesses should be located and drained. • Prevention of secondary infection. • Care of IV cannula.

  27. Priorities and principles of management Further Interventions Cont. Renal • Furosemide or dopamine have no effect on improving renal function but they convert oliguria to more normal urine output. • Haemofiltration can be used. • Nephrotoxic and hepatotoxic drugs should be avoided.

  28. Priorities and principles of management Further Interventions Cont. Gastrointestinal tract • Prophylaxis against GI bleeding. • Provision of appropriate nutrition . • Monitoring and maintenance of electrolyte. Haematological. • Haemoglobin levels of 7 – 9 g/dl should be. • Blood transfusion if Hg less than 7g/dl. • Any clotting abnormalities should be corrected.

  29. Priorities and principles of management Further Interventions Cont. Musculoskeletal • Pressure area should be protected from damage. • Early passive movement and mobilization. • Frequent change position. • Circulation

  30. Priorities and principles of management Further Interventions Cont. Supporting the circulation • Fluids administration. If fluids does not improve stroke volume further but the main arterial pressure (MAP) • Vasopressors ( e.g. Norepinephrine are used in high – output). • Inotropes ( e.g. Dobutamine in low-output) • Epinephrine can be used for either effect.

  31. Priorities and principles of management Further Interventions Cont. Supporting the respiration The aim is to: • Maintain saturations ( usually) > 90%. These through: • Use of lower tidal volumes ( 6-8 ml/kg) • Higher levels of PEEP ( up to 20 cmH2O) • Prone positioning. • Inhaled nitric oxide or prostacyclin.

  32. THANK YOU

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