Multiple Organ Dysfunction Syndrome (MODS).

The presence of altered organ function in a client who is acutely ill such that hemeostasis cannot be maintained without intervention. MODS is present when two or more organs fail .MODS results from SIRS

1. Multiple Organ Dysfunction Syndrome (MODS ).

2. SIRS is an inflammatory clinical response of the whole body without a proven source of infection. SIRS is non-specific and can be caused by ischemia, inflammation, trauma, infection, or a combination of several insults.

3. SIRS is defined as two or more of the following variables: Temperature of more than 38 degree Celsius or less than 36 degree Celsius. Heart rate of more than 90 beats per minute. Respiratory rate of more than 20 breaths per minute or a PaCO2 level of less than 32 mm of Hg. Abnormal white blood cell count (>12,000/ L or <4000 L)

4. DEFINITION OF MULTIPLE ORGAN DYSFUNCTION SYNDROME (MODS)

5. MULTIPLE ORGAN DYSFUNCTION SYNDROME (MODS)

6. CLASSIFICATION OF MULTIPLE ORGAN DYSFUNCTION SYNDROME (MODS)

7. There are two types of MODS.

8. The direct insult initially causes a localized inflammatory response that may or may not progress to SIRS. e.g. primary pulmonary injury, such as aspiration. Only a small percentage of clients develop primary MODS .

9. It is the consequence of widespread systemic inflammation, which develops after a variety of insults, and results in dysfunction of organs not involved in initial insult. The client enters a hypermetabolic state that lasts for 14-21 days. During this time the body catabolizes muscle and fat for energy, which causes profound changes in the body metabolic processes. Unless the process can be stopped, the outcome for client is death. Secondary MODS occurs with conditions such as ARDS and septic shock.

10. RISK FACTORS OF MULTIPLE ORGAN DYSFUNCTION SYNDROME (MODS)

11. ETIOLOGY OF MULTIPLE ORGAN DYSFUNCTION SYNDROME (MODS)

12. PATHOPHYSIOLOGY OF MULTIPLE ORGAN DYSFUNCTION SYNDROME (MODS)

13. RESPIRATORY-

14. CARDIOVASCULAR-

15. NERVOUS SYSTEM-

16. RENAL SYSTEM

17. MODS trigger a hypermetabolic response. Glycogen stores are rapidly converted to glucose ( glycogenolysis ). Once a glycogen is depleted, amino acids are converted to glucose (gluconeogenesis), reducing protein stores. Fatty acids are mobilized for fuel. Catecholamines and glucocortecoids are released and result in hyperglycemia and insulin resistance. The net result is a catabolic state and muscle is lost. METABOLIC DISTURBANCE

18. Failure of coagulation system manifests as Disseminated Intravascular Coagulopathy (DIC). DIC results in simultaneous micro-vascular clotting and bleeding because of the depletion of clotting factors and platelets in addition to excessive fibrinolysis. COAGULOPATHY-

19. CLINICAL MANIFESTATION OF MULTIPLE ORGAN DYSFUNCTION SYNDROME (MODS)

20. Respiratory-

21. CARDIOVASCULAR-

22. NEUROLOGIC SYSTEM-

23. GASTROINTESTINAL-

24. HEMATOLOGIC-

25. ENDOCRINE SYSTEM-

26. RENAL SYSTEM

27. DIAGNOSIS OF MULTIPLE ORGAN DYSFUNCTION SYNDROME (MODS)

28. History Underlying diseases Hypotension Oliguria or anuria Tachypnea or hyperpnea Immunocompromised patient Community or nosocomial infection Hypothermia without obvious cause

29. Physical Examination In all neutropenic patients and pelvic infection the physical examination should include rectal, pelvic, and genital examinations Perirectal, and/or perineal abscesses Pelvic inflammatory disease and/or abscesses, or prostatitis

30. Blood studies- CBC Procalcitonin (PCT) CRP Blood cultures Cardiac enzymes Urinalysis and culture Basic metabolic profile Amylase, lipase Spinal fluid and Liver profile

31. MEDICAL MANAGEMENT OF MULTIPLE ORGAN DYSFUNCTION SYNDROME (MODS)

32. Aggressive infection control strategies are essential to decrease the risk for nosocomial infections. Appropriate cultures should be sent, and broad spectrum antibiotics should be initiated. Early , aggressive surgery is recommended to remove necrotic tissue ( eg . Debridement of burn tissue) that may provide culture medium for microorganisms. Once a specific organism is identified, therapy should be modified if necessary. Aggressive pulmonary management, including early ambulation, can reduce risk of infection. Strict asepsis can reduce infections related to intra- arterial lines, endotracheal tubes, urinary catheters, IV lines and other invasive lines or procedures . Prevention and treatment of infection -

33. Controlling the mediators of inflammation is both directed at general levels of care and specific treatments targeted at the problem cells. Maintenance of positive nitrogen balance via nutrition, promotion of sleep and rest, and management of pain are important general care areas. Specific treatment includes monoclonal antibodies to control mediators such as endotoxins, interleukin-1, and tumor necrosis factors. Controlling the mediators -

34. Sedation, mechanical ventilation, analgesia, paralysis, and rest may decrease oxygen demand and should be considered. Oxygen delivery may be optimized by maintaining normal levels of hemoglobin ( eg . Transfusion of packed RBCs) and PaO2(80-100 mm Hg), using individualized tidal volumes with PEEP, increasing preload or myocardial contractility to enhance cardiac output, or reducing afterload to increase cardiac output. Maintenance of tissue perfusion -

35. The goal of nutritional support is to preserve organ function. Providing early and optimal nutrition decreases morbidity and mortality rates in patients with SIRS and MODS. The use of enteral route is preferable to parenteral nutrition, as it may enhance perfusion and decrease the bacterial load and the effects of endotoxins. Nutritional and metabolic needs -

36. The client is intubated and mechanically ventilated in order to maintain adequate oxygenation. Oxygen is given to the client until blood levels of lactate decrease towards normal. Elevated serum lactate levels indicate the use of anaerobic metabolism. Problems such as fever, seizures, and shivering increase oxygen demands. These problems should be controlled by medications and environmental changes (warming). Protecting the organs affected-

37. Used to support hemodynamic parameters. The client often becomes more and more unstable and needs more continuous monitoring N utritional support is also critical to reduce catabolism that accompanies hyper-metabolism. Dialysis is often used to reduce azotemia from renal failure. Fluids and ionotropic drugs -

38. NURSING MANAGEMENT OF MULTIPLE ORGAN DYSFUNCTION SYNDROME (MODS)