Multiple organ dysfunction syndrome
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Multiple Organ Dysfunction Syndrome. Prepared By Dr. Hanan Said Ali. Learning Outcomes:. Define multiple organ dysfunction syndrome. Idenyify systematic dysfunction associated with MODS: CNS Respiratory Cardiovascular Gastrointestinal Liver Renal Haematological.

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Multiple Organ Dysfunction Syndrome

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Multiple Organ Dysfunction Syndrome

Prepared By

Dr. Hanan Said Ali


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.


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.


CNS dysfunction associated with MODS

1Neuroendocrine exhaustion

  • Altered release of hypothalamic products

    (e.g. growth hormone- releasing hormone).

  • Glucose intolerance.

  • Failure to mount a febrile response.

  • Neurological pulmonary oedema.


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.


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.


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.


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.


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.


Gastrointestinal involvement in MODS

  • Stomach : ulceration, stress ulcer bleeding,

    decreased gastric motility.

  • Pancreas : pancreatitis.

  • Gallbladder : Acalculous cholecystitis

    ( inflammation unrelated to gallstone).

  • Colon : Colitis.


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.


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.


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.


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


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.


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.


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.


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.


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.


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.


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 %.


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 required


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.


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.


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.


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.


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


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.


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.


THANK YOU


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