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
TRAUMA
BURNS
PANCREATITIS
SEPSIS SIRS
INFECTION SEPSIS
BACTEREMIA

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

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

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

11. 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

12. 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

13. Classification of MODS
1. Immediate Type (Primary)
2. Delayed type (Secondary)
3. Accumulation type：

14. Inadequate
Resuscitation
Preoperative
Illness
Trauma or
Operation
Tissue
Injury
optimal oxygen
delivery and
support
Recovery
Excessive
Inflammatory
Response
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
 Polymorphonuclear
Leukocytes
 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
2/3/2024

18. Inflammation
Inflammatory cells
Inflammatory cytokines

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

20. 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

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
ApoptosisImpaired
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

22. Multi organ failure
Gut hypoperfusion
Apoptosis

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
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

31. Collaborative management
Goals
 Prevention and treatment of infection
 Maintenance of tissue oxygenation
 Nutritional and metabolic support, and
 Appropriate support of individual failing organs
2/3/2024

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

33. 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 al. Crit Care Med 2001, 29:1303-1310.

34. 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.

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
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

37. 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

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

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

40. THANK YOU!