multiorgan dysfunction syndrome MOD.pptx

Multi organ dysfunction syndrome

1. 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 PaO 2 < 60 mmHg ( PaO 2 /FiO2 < 250) Increased lactic acid/acidosis Oliguria DIC or Platelet < 80,000 /mm 3 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 >38 o C or <36 o C HR >90 beats/min RR >20/min WBC >12,000/mm 3 or <4,000/ mm 3 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 Immediate Type (Primary) Delayed type (Secondary) 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 6/22/2012

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 Endothelial damage Endothelial damage 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 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

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 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 6/22/2012

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

33. Complications Adult respiratory distress syndrome ( ARDS ) Disseminated Intravascular Coagulation ( DIC ) Acute Renal failure ( ARF ) Intestinal bleeding Liver failure Central Nervous System dysfunction Heart failure Death Angus DC, et al . Crit Care Med 2001, 29:1303-1310.

34. List of Nursing Diagnoses Ineffective airway clearance related to excessive secretion, presence of an artificial airway, neuromuscular dysfunction. Impaired gas exchange related to VQ mismatch, intrapulmonary shunting, alveolar hypoventilation. Decreased cardiac output related to alterations to preload, afterload and contractility. 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 Aggressive infection control strategies Appropriate cultures Initiate broad spectrum antibiotic therapy Early aggressive surgery to remove necrotic tissue Aggressive pulmonary management Strict asepsis

37. Nursing intervention Maintenance of tissue oxygenation Sedation Mechanical ventilation Analgesia Paralysis and Rest Maintaining normal levels of hemoglobin Use PEEP Increase preload and reduce afterload

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

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

40. THANK YOU!