Multi organ dysfunction syndrome


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Multi organ dysfunction syndrome

  1. 1. Introduction Continuedpatientsurvivalandlong-termqualityoflifearethreatenedbytwoclinicalsyndromes-thatmayresultindeathorprofounddisability 9/17/2014 2
  2. 2. 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 . 9/17/2014 3
  3. 3. 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. 9/17/2014 4
  4. 4. 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. 9/17/2014 5
  5. 5. Relationship of Shock, SIRS, and MODS Fig. 67-1 9/17/2014 6
  7. 7. MODS Biliary tract infection Shock Pancreatitis Burn Intra-abdominal infection Infective diseases Non-infective diseases Multiple trauma 9/17/2014 8
  8. 8. SIRS CARS MODS Uncontrolled inflammatory response Infection/Injury Controlled inflammatory response Infection/injury controlled 9/17/2014 9
  9. 9. 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/mm3or >10% bands SIRS with a presumed or confirmed infectious process . Sepsis SIRS Severe Sepsis Septic Shock Sepsis with organ failure Refractory hypotension 9/17/2014 10
  10. 10. Multiple organ dysfunction syndrome Sl.No System Time from ICUadmission 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 9/17/2014 11
  11. 11. Risk factors of sepsis use of immunosuppressive therapies for organ transplants longer lives of patients predisposed to sepsis, theelderly, diabetics, cancer patients&major organfailure increased use of invasive devices indiscriminate use of antimicrobial drugs Underlying diseasesneutropenia, tumors, leukemia, cirrhosis of the liver, DM, AIDS,&chronic conditions Surgery or instrumentation: catheters Prior drug therapyImmuno- suppressive drugs Agemales (> 40 years), females(20-45 years) Miscellaneous conditions childbirth, septic abortion, trauma and burns 9/17/2014 12
  12. 12. Classification of MODS 1.Immediate Type (Primary) 2.Delayed type (Secondary) 3.Accumulation type 9/17/2014 13
  13. 13. Inadequate Resuscitation Preoperative Illness Trauma or Operation Tissue Injury optimal oxygen delivery and support Recovery Excessive Inflammatory Response SIRS/MODS Pathogenesis of SIRS/MODS 9/17/2014 14
  14. 14. Mediators involved in MODS HumoralMediators Cellular Inflammatory Mediators Complement Lipoxygenaseproducts Cyclooxygenaseproducts Tumor Necrosis Factor Interleukins (1-13) Growth Factors Platelet Activating Factor Procoagulants Fibronectinand Opsonins Toxic Oxygen Free Radicals Endogenous Opioids- Endorphins PolymorphonuclearLeukocytes Monocytes/Macrophages Platelets Endothelial Cells 9/17/2014 15
  15. 15. Pathophysiology Inflammatory response Release of mediators Direct damage to the endothelium Hyper metabolism Vasodilationleading to decreased SVR Increase in vascular permeability Activation of coagulation cascade 9/17/2014 16
  16. 16. Initiation of Inflammatory Response 9/17/2014 17
  17. 17. Inflammation Inflammatory cells Inflammatory cytokines 9/17/2014 18
  18. 18. Infection Inflammatory Mediators Endothelial Dysfunction Vasodilation Hypotension Vasoconstriction Edema Maldistributionof MicrovascularBlood Flow Organ Dysfunction Microvascular Plugging Ischemia Cell Death 9/17/2014 19
  19. 19. 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 CoagulationActivation Cytokines TNF, IL-1, IL-6 9/17/2014 20
  20. 20. 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 Thrombocytopenia Metabolic acidosis Poor capillary refill Death 9/17/2014 21
  21. 21. Multi organ failure Gut hypoperfusion Apoptosis 9/17/2014 22
  22. 22. 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 9/17/2014 23
  23. 23. 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 9/17/2014 24
  24. 24. 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 alCrit Care Med 2001, 29:1303-1310. 9/17/2014 25
  25. 25. 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. 9/17/2014 26
  26. 26. 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 alCrit Care Med 2001, 29:1303-1310. 9/17/2014 27
  27. 27. 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 alCrit Care Med 2001, 29:1303-1310. 9/17/2014 28
  28. 28. 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 9/17/2014 29
  29. 29. 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 9/17/2014 30
  30. 30. Collaborative management Goals Prevention and treatment of infection Maintenance of tissue oxygenation Nutritional and metabolic support, and Appropriate support of individual failing organs 9/17/2014 31
  31. 31. Early Goal-Directed Therapy NEJM2001;345:1368-77. 9/17/2014 32
  32. 32. 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 Angus DC, et alCrit Care Med 2001, 29:1303-1310. 9/17/2014 33
  33. 33. 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. 9/17/2014 34
  34. 34. 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. 9/17/2014 35
  35. 35. 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 9/17/2014 36
  36. 36. Nursing intervention 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 9/17/2014 37
  37. 37. Nursing intervention Nutritional and metabolic needs 1.Monitor prealbuminand plasma transferrinlevel 2.Provide adequate nutrition 3.Enteralfeeding 9/17/2014 38
  38. 38. “No great discovery was ever made without a bold guess.” Isaac Newton (1642-1727) 9/17/2014 39
  39. 39. THANK YOU! 9/17/2014 40