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
9/17/2014 2 www.drjayeshpatidar.blogspot.com
Definition
1. Sepsis - the systemic response to infection.
SBP < 90 mmHg
Acute mental status change
PaO
2
< 60 mmHg (PaO
2
/FiO2 < 250)
Increased lactic acid/acidosis
Oliguria
DIC or Platelet < 80,000 /mm
3
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
TRAUMA
BURNS
PANCREATITIS
SEPSIS SIRS
INFECTION
SEPSIS
BACTEREMIA
MODS
Biliary tract
infection
Shock
Pancreatitis
Burn
Intra-abdominal
infection
Infective diseases Non-infective diseases
Multiple trauma
SIRS CARS
MODS
Uncontrolled
inflammatory
response
Infection/Injury
Controlled
inflammatory
response
Infection/injury
controlled
The Sepsis Continuum
A clinical response
arising from a
nonspecific insult,
with 2 of the
following:
T >38
o
C or <36
o
C
HR >90 beats/min
RR >20/min
WBC >12,000/mm
3
or <4,000/mm
3
or
>10% bands
SIRS with a
presumed
or confirmed
infectious
process
.
Sepsis SIRS
Severe
Sepsis
Septic
Shock
Sepsis with
organ failure
Refractory
hypotension
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
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
Classification of MODS
1. Immediate Type (Primary)
2. Delayed type (Secondary)
3. Accumulation type
Inadequate
Resuscitation
Preoperative
Illness
Trauma or
Operation
Tissue
Injury
optimal oxygen
delivery and
support
Recovery
Excessive
Inflammatory
Response
SIRS/MODS
Pathogenesis of SIRS/MODS
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
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
Inflammation
Inflammatory cells
Inflammatory cytokines
Infection
Inflammatory
Mediators
Endothelial
Dysfunction
Vasodilation
Hypotension Vasoconstriction Edema
Maldistribution of Microvascular Blood Flow
Organ Dysfunction
Microvascular Plugging
Ischemia
Cell Death
Pathogenesis of Severe Sepsis
Infection
Microbial Products
(exotoxin/endotoxin)
Cellular
Responses
Oxidases
Platelet
Activation
Kinins
Complement
Coagulopathy/DIC
Vascular/Organ System
Injury
Multi-Organ
Failure
Death
Coagulation
Activation
Cytokines
TNF, IL-1, IL-6
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
Altered
Mental
Status
P/F Ratio
<300
Tachypnea
urine
<0.5ml /
kg/hr
Hypotension
Tachycardia
ThrombocytopeniaMetabolic
acidosis
Poor
capillary
refill
Death
Multi organ failure
Gut hypoperfusion Apoptosis
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
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
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
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
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
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
Hematologic >120 81-120 51-80 21-50 <20
Collaborative management
Goals
Prevention and treatment of infection
Maintenance of tissue oxygenation
Nutritional and metabolic support, and
Appropriate support of individual failing organs
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
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
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
Nutritional and metabolic needs
1. Monitor prealbumin and plasma transferrin level
2. Provide adequate nutrition
3. Enteral feeding
No great discovery was ever made
without a bold guess.
Isaac Newton
(1642-1727)
THANK YOU!

Multi Organ Dysfunction Syndrome

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Introduction

Continued patient survival and long-term

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