MULTIPLE ORGAN DYSFUNCTION SYNDROME

MODS#medical-surgical nursing

1. SEMINAR ON MULTIPLE ORGAN DYSFUNCTION SYNDROME Presented by, Ms. Gautami .S. Tirpude S.Y.MSc Nursing B.V.C.O.N,Pune

2. AIM: At the end of the seminar students will be able to gain indepth knowledge regarding multiple organ dysfunction syndrome.

3. Define MODS List down etiological factors of MODS. Understand the classification of MODS. Describe the pathoysiology of MODS. Enlist Clinical manifestations and diagnostic tests are to be performed for MODS. List down complications of MODS. Explain collaborative management including nursing management. GENERAL OBJECTIVES: At the end of the seminar students will be able to:

4. Multiple organ dysfunction syndrome (MODS), also known as multiple organ failure (MOF), total organ failure (TOF) or multisystem organ failure ( MSOF). It is altered organ function in acutely ill patients that requires medical intervention to support continued organ function. INTRODUCTION

5. It is another phase in the progression of shock states. MODS contributes to about 50% of ICU deaths Dysfunction of one organ system is associated with 20% mortality, and if more than four organs fail, the mortality is at least 60% ( Rossaint & Zarbock , 2015) CONTD….

6. Systemic Inflammatory Response Syndrome is a generalized systemic inflammatory response to a variety of insults, including infection, ischemia, infarction, and injury. MODS results from SIRS and is the failure of several interdependent organ systems. MODS is the major cause of death of patients in the critical care units. CONTD….

7. MODS is the failure of two or more organ systems in an acutely ill patient such that homeostasis cannot be maintained without intervention. 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 secondary organ dysfunction. DEFINITION

8. SR.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

9. Patients with infection Shock episode associated with a rupture aneurysm, acute pancreatitis, sepsis, burns or surgical operation. Patients >65 years of age because of there decreased organ reserve and presence of co- morbidities. Severe trauma, multiple injury, massive blood loss, hypovolemic shock and infection. RISK FACTORS

10. Sepsis Major trauma Burns Pancreatitis Aspiration syndromes Extracorporeal circulation (e.g. cardiac bypass) Multiple blood transfusion Ischaemia – reperfusion injury Autoimmune disease Heat-induced illness Eclampsia Poisoning/toxicity ETIOLOGY

11. Immediate type(primary): Dysfunction/Failure occurring simultaneously in two or more organs due to primary disease. Delayed type(secondary): Dysfunction occurred in one organ other organs sequentially fail. Accumulation type: Dysfunction is cause by chronic disease. It is irreversible CLASSIFICATION OF MODS

12. PATHOPHYSIOLOGY INFECTION INFLAMMATORY MEDIATORS ENDOTHELIAL DYSFUNCTION VASODILATION HYPOTENSION MICROVASCULAR PLUGGING VASOCONSTRICTION EDEMA MALDISTRIBUTION OF MICROVASCULAR BLOOD FLOW ISCHEMIA CELL DEATH ORGAN DYSFUNCTION

13. Respiratory system Dyspnea Increased RR Alveolar edema Decrease in surfactant 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 CLINICAL MANIFESTATION

14. 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 CLINICAL MANIFESTATION

15. History community or nosocomial infection immunocompromised patient underlying diseases Some clues to a septic event include Fever or unexplained signs with malignancy Hypotension Oliguria or anuria Tachypnea or hyperpnea Hypothermia without obvious cause Bleeding DIAGNOSIS

16. 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 Contd..

17. CBC basic metabolic profile procalcitonin (PCT) CRP Blood cultures Urinalysis and culture Cardiac enzymes Amylase, lipase Spinal fluid and Liver profiles Blood lactate Contd …

18. Prevention and treatment of infection Maintenance of tissue oxygenation Nutritional and metabolic support Appropriate support of individual failing organs  Collaborative management

19. 1.PREVENTION & TREATMENT OF INFECTION Aggressive infection control strategies Cultures Broad-spectrum antibiotic therapy Necessary therapy should be initiated once a specific organism is identified. Aggressive pulmonary management, including early ambulation. Strict asepsis

20. 2. MAINTENANCE OF TISSUE OXYGENATION Decrease oxygen demand & increase oxygen delivery are essential. Sedation, mechanical ventilation, analgesia, and rest decrease oxygen demand. Oxygen delivery may be optimized by maintaining normal levels of haemoglobin , using individualized tidal volumes with PEEP.

21. 3. NUTRITIONAL & METABOLIC NEEDS The goal of nutritional support is to preserve organ function. Hypermetabolism in MODS can result in profound weight loss, cachexia & further organ failure. Early & optimal nutrition Using enteral route. Parenteral nutrition should be intitiated . Glycemic control (<150mg/dl), using insulin infusions.

22. 4. SUPPORT OF FAILING ORGANS Support of any failing organ is primary goal of therapy. Patient with ARDS - aggressive oxygen therapy & mechanical ventilation. Renal failure – Dialysis Hemodynamic instability – continous renal replacement therapy.

23. Adult respiratory distress syndrome (ARDS) Disseminated Intravascular Coagulation (DIC) Acute Renal failure (ARF) Intestinal bleeding Liver failure Central Nervous System dysfunction Heart failure Death COMPLICATIONS

24. 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. LIST OF NURSING DIAGNOSIS

25. 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. CONTD..

26. Aim : Supporting the patient and monitoring organ perfusion until primary organ insults are halted. 1. Promoting Communication Encourage frequent and open communication about treatment modalities. Information regarding goals of rehabilitation and expectations for progress. NURSING MANAGEMENT

27. Effective communication provides needed encouragement during this phase of recovery. 2. Promoting Home, Community-Based, and Transitional Care: Educating Patients About Self-Care Continuing and Transitional Care Contd..

28. Year  : 2017  |   Volume  : 146  |   Issue  : 3  |   Page  : 346-353 An observational study of incidence, risk factors & outcome of systemic inflammatory response & organ dysfunction following major trauma Author Name: Satish Balkrishna Dharap ,  Sanket Vishnu Ekhande Department of Surgery, Lokmanya Tilak Municipal Medical College & General Hospital, Mumbai, India Publication Date: 08/01/2018 RESEARCH ARTICLES:

29. Background & objectives:  Trauma is known to lead to systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS), which is often a cause of late deaths after injury. SIRS and MODS have been objectively measured using scoring systems. This prospective observational study was carried out in a tertiary care hospital in India to evaluate SIRS and MODS following trauma in terms of their incidence, the associated risk factors and the effect on the outcome. Methods:  All adult patients with major life- and limb-threatening trauma were included. Patients who died within 24 h, those with severe head injury, known comorbidity , immunocompromised state, on immunosuppressants or pregnancy were excluded. SIRS and MODS scores were recorded after initial management (baseline score), on days 3 and 6 of admission. SIRS was defined as SIRS score of ≥2 and MODS was defined as MODS score of ≥1.

30. Results:  Two hundred patients were enrolled. SIRS was noted in 156 patients (78%). MODS was noted in 145 (72.5%) patients. Overall mortality was 39 (19.5%). Both SIRS and MODS scores were significantly associated with age >60 yr, blunt injury, (lower) revised trauma score hypotension on admission and (higher) injury severity score, but not with gender, pre-hospital time or operative treatment. Interpretation & conclusions:  Both SIRS and MODS scores were associated with longer Intensive Care Unit (ICU) stay, more ICU interventions and higher mortality. Incidence of MODS was significantly higher in patients with SIRS. Both scores showed rising trend with time in non-survivors and a decreasing trend in survivors. The serial assessment of scores can help prognosticate outcome and also allocate appropriate critical care resources to patients with rising scores.

31. We have covered the following points in today’s seminar: Introduction Definition of MODS & SEPSIS Risk and Etiological factors Classification & Pathophysiology of MODS Clinical Manifestations Diagnostic Evaluation Management Complications Nursing Management & Research article SUMMARY

32. Multiple organ failure is the commonest cause of death in the intensive care unit setting. There are numerous precipitating factors including sepsis, trauma and pancreatitis. The resulting tissue hypoxia, exaggerated inflammatory response and generation of free oxygen radicals leads to tissue damage and organ dysfunction. CONCLUSION

33. No definitive treatment for MODS. Management still revolves around support of organ function and prevention of iatrogenic complications until recovery occurs. An increasing emphasis is being placed on prevention of organ dysfunction, including maintenance of tissue oxygenation, nutrition and infection control. Contd..

34. BOOKS Medical surgical nursing, Brunner and suddarths published by Wolters Kluwer (India) PVT LTD 2010 fifth edition, pg. no.273-275. Medical surgical nursing clinical management for positive outcome jayce M. Black Jane Hokanson Hawks, published by Elsevier, a division of reed Elsevier India Privet Limited 2007, 7 th edition, pg. no.1744-1749 Medical surgical nursing, BT Basavanthappa , jaypee brother’s medical publishers (P) New Delhi 2003, first edition, pg. no. 225-228 BIBLIOGRAPHY

35. Medical surgical nursing, BT Basavanthappa , jaypee brother medical publisher (P) new Delhi 2009 2 nd edition, pg. no. 628-631 JOURNAL International Journal Of Surgery Open. Indian Journal Of Medical Research. SITES: https://en.wikipedia.org/wiki/Multiple_organ_dysfunction_syndrome https://www.slideshare.net/drjayeshpatidar/multi-organ-dysfunction-syndrome https://www.slideshare.net/AkinbiOlubayodeo/multiple-organ-dysfunction-syndrome-65476967