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Multiple Organ Dysfunction Syndrome

Prepared ByDr. Hanan Said Ali

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Learning Outcomes: Define multiple organ dysfunction

syndrome. Idenyify systematic dysfunction associated

with MODS: CNS Respiratory Cardiovascular Gastrointestinal Liver Renal Haematological

Learning Outcomes Cont.:

Describe how to assess the patient systematically.

Explain the priorities and principles of management for these patients.

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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.

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.

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CNS dysfunction associated with MODS

1Neuroendocrine exhaustionAltered release of hypothalamic products

(e.g. growth hormone- releasing hormone).Glucose intolerance.Failure to mount a febrile response.Neurological pulmonary oedema.

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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.

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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. 8

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. 9

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.

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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.

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Gastrointestinal involvement in MODS

Stomach : ulceration, stress ulcer bleeding, decreased gastric motility.

Pancreas : pancreatitis.

Gallbladder : Acalculous cholecystitis ( inflammation unrelated to gallstone).

Colon : Colitis.

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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.

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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.

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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.

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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

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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.

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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.

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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. 19

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.

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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.

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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.

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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 %.23

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

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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.

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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.

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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.

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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.28

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

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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. 30

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. 31

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