Multi organ dysfunction syndrome

Introduction
Continuedpatientsurvivalandlong-termqualityoflifearethreatenedbytwoclinicalsyndromes-thatmayresultindeathorprofounddisability
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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
.
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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.
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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.
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Relationship of Shock, SIRS, and MODS
Fig. 67-1
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Relationship Between Sepsis and SIRS
TRAUMA
BURNS
PANCREATITIS
SEPSIS
SIRS
INFECTION
SEPSIS
BACTEREMIA
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MODS
Biliary tract infection
Shock
Pancreatitis
Burn
Intra-abdominal infection
Infective diseases
Non-infective diseases
Multiple trauma
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SIRS
CARS
MODS
Uncontrolled inflammatory response
Infection/Injury
Controlled inflammatory response
Infection/injury controlled
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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
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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
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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
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Classification of MODS
1.Immediate Type (Primary)
2.Delayed type (Secondary)
3.Accumulation type
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Inadequate Resuscitation
Preoperative Illness
Trauma or Operation
Tissue Injury
optimal oxygen delivery and support
Recovery
Excessive Inflammatory Response
SIRS/MODS
Pathogenesis of SIRS/MODS
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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
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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
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Initiation of Inflammatory Response
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Inflammation
Inflammatory cells Inflammatory cytokines
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Infection
Inflammatory
Mediators
Endothelial
Dysfunction
Vasodilation
Hypotension
Vasoconstriction
Edema
Maldistributionof MicrovascularBlood Flow
Organ Dysfunction
Microvascular Plugging
Ischemia
Cell Death
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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
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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
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Multi organ failure
Gut hypoperfusion
Apoptosis
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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
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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
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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.
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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.
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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
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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
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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
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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
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Collaborative management
Goals
Prevention and treatment of infection
Maintenance of tissue oxygenation
Nutritional and metabolic support, and
Appropriate support of individual failing organs
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Early Goal-Directed Therapy
NEJM2001;345:1368-77.
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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
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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.
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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.
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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
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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
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Nutritional and metabolic needs
1.Monitor prealbuminand plasma transferrinlevel
2.Provide adequate nutrition
3.Enteralfeeding
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“No great discovery was ever made without a bold guess.”
Isaac Newton
(1642-1727)
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THANK YOU!
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Multi organ dysfunction syndrome

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Multi organ dysfunction syndrome