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

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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;24:33-44.9/17/2014 5www.drjayeshpatidar.blogspot.com

Relationship of Shock, SIRS, and MODS

Fig. 67-1

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Relationship Between Sepsis and SIRS

TRAUMA

BURNS

PANCREATITIS

SEPSIS SIRSINFECTION 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/minWBC >12,000/mm3

or <4,000/mm3 or >10% bands

SIRS with a

presumed

or confirmed

infectious

process

.

SepsisSIRS

Severe

Sepsis

Septic

Shock

Sepsis with

organ failure

Refractory

hypotension

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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

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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

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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

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

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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

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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

DysfunctionVasodilation

Hypotension Vasoconstriction Edema

Maldistribution of Microvascular Blood Flow

Organ Dysfunction

Microvascular Plugging

Ischemia

Cell Death

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Pathogenesis of Severe SepsisInfection

Microbial Products(exotoxin/endotoxin)

Cellular

Responses

OxidasesPlatelet

ActivationKinins

Complement

Coagulopathy/DICVascular/Organ System

Injury

Multi-Organ Failure

Death

CoagulationActivation

CytokinesTNF, 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

ThrombocytopeniaMetabolic

acidosis

Poor

capillary

refill

Death

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Multi organ failure

Gut hypoperfusionApoptosis

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Clinical manifestationsRespiratory 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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Clinical manifestationsCVS

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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Clinical manifestationsNonspecific 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, 29:1303-1310.9/17/2014 25www.drjayeshpatidar.blogspot.com

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 Angus DC, et al Crit Care Med 2001, 29:1303-1310.9/17/2014 27www.drjayeshpatidar.blogspot.com

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, 29:1303-1310.9/17/2014 28www.drjayeshpatidar.blogspot.com

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

NEJM 2001;345:1368-77.9/17/2014 32www.drjayeshpatidar.blogspot.com

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 interventionPrevention 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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Nursing interventionMaintenance 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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Nursing interventionNutritional and metabolic needs

1. Monitor prealbumin and plasma transferrin level

2. Provide adequate nutrition

3. Enteral feeding

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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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