MULTIPLE ORGAN DYSFUNCTION SYNDROME

PREVIOUSLY KNOWN AS MULTIPLE ORGAN FAILURE (MOF) OR MULTISYSTEM

ORGAN FAILURE (MSOF),
IS A CONDITION THAT OCCURS WHEN TWO OR MORE ORGANS OR ORGAN
SYSTEMS ARE UNABLE TO FUNCTION IN THEIR ROLE OF MAINTAINING
HOMEOSTASIS.
MODS ISNT AN ILLNESS ITSELF; RATHER, ITS A MANIFESTATION OF ANOTHER
PROGRESSIVE UNDERLYING CONDITION.
THE USE OF "MULTIPLE ORGAN FAILURE" OR "MULTISYSTEM ORGAN FAILURE"
SHOULD BE AVOIDED SINCE THAT PHRASE WAS BASED UPON PHYSIOLOGICAL
PARAMETERS TO DETERMINE WHETHER OR NOT A PARTICULAR ORGAN WAS
FAILING.

CAUSES

SIRS (SYSTEMIC INFLAMMATORY RESPONSE SYNDROME)
SEPSIS- MOST COMMON CAUSE IN OPERATIVE AND NON-OPERATIVE
PATIENTS
INJURY (ACCIDENT, SURGERY)
HYPOPERFUSION
HYPERMETABOLISM

CURRENTLY, INVESTIGATORS ARE LOOKING INTO GENETIC TARGETS FOR
POSSIBLE GENE THERAPY TO PREVENT THE PROGRESSION TO MULTIPLE
ORGAN DYSFUNCTION SYNDROME.

SOME AUTHORS HAVE CONJECTURED THAT THE INACTIVATION OF THE
TRANSCRIPTION FACTORS NF-B AND AP-1 WOULD BE APPROPRIATE
TARGETS IN PREVENTING SEPSIS AND SIRS.

PATHOPHYSIOLOGY

o RESPIRATORY FAILURE IS COMMON IN THE FIRST 72 HOURS AFTER THE
ORIGINAL INSULT.
o HEPATIC FAILURE (57 DAYS)
o GASTROINTESTINAL BLEEDING(1015 DAYS)
o RENAL FAILURE (1117 DAYS)

GUT HYPOTHESIS
THE MOST POPULAR HYPOTHESIS BY DEITCH TO EXPLAIN MODS IN CRITICALLY ILL.

Due to splanchnic hypoperfusion and the subsequent mucosal
ischaemia there are structural changes and alterations in
cellular function.
This results in increased gut permeability, changed immune
function of the gut and increased translocation of bacteria.
Hepatic dysfunction leads to toxins escaping into the
systemic circulation and activating an immune response.

This results in tissue injury and organ dysfunction.
ENDOTOXIN MACROPHAGE HYPOTHESIS

GRAM-NEGATIVE INFECTIONS IN MODS PATIENTS ARE RELATIVELY COMMON,
ENDOTOXINS HAVE BEEN ADVANCED AS PRINCIPAL MEDIATOR IN THIS
DISORDER
IT IS THOUGHT THAT FOLLOWING THE INITIAL EVENT CYTOKINES ARE
PRODUCED AND RELEASED. THE PRO-INFLAMMATORY MEDIATORS
ARE: TUMOR NECROSIS FACTOR-ALPHA (TNF-), INTERLEUKIN-1,
INTERLEUKIN-6, THROMBOXANE A2, PROSTACYCLIN, PLATELET ACTIVATING
FACTOR, AND NITRIC OXIDE.

TISSUE HYPOXIA-MICROVASCULAR HYPOTHESIS

AS A RESULT OF MACRO- AND MICROVASCULAR CHANGES INSUFFICIENT
SUPPLY OF OXYGEN OCCURS. HYPOXEMIA CAUSES CELL DEATH AND ORGAN
DYSFUNCTION.

INTEGRATED HYPOTHESIS

SINCE IN MOST CASES NO PRIMARY CAUSE IS FOUND, THE CONDITION COULD
BE PART OF A COMPROMISED HOMEOSTASIS INVOLVING THE PREVIOUS
MECHANISMS.

DIAGNOSIS

THE EUROPEAN SOCIETY OF INTENSIVE CARE ORGANIZED A CONSENSUS
MEETING IN 1994 TO CREATE THE "SEPSIS-RELATED ORGAN FAILURE
ASSESSMENT (SOFA)" SCORE TO DESCRIBE AND QUANTITATE THE DEGREE OF
ORGAN DYSFUNCTION IN SIX ORGAN SYSTEMS. USING SIMILAR PHYSIOLOGIC
VARIABLES THE MULTIPLE ORGAN DYSFUNCTION SCORE WAS DEVELOPED.

FOUR CLINICAL PHASES HAVE BEEN SUGGESTED:

Stage 1 the patient has increased volume requirements and mild
respiratory alkalosis which is accompanied by oliguria, hyperglycemia and
increased insulin requirements.
Stage 2 the patient is tachypneic, hypocapnic and hypoxemic; develops
moderate liver dysfunction and possible hematologic abnormalities.
Stage 4 the patient is vasopressor dependent and oliguric or anuric;
subsequently develops ischemic colitis and lactic acidosis
Stage 3 the patient develops shock with azotemia and acid-
base disturbances; has significant coagulation abnormalities.
CLINICAL MANIFESTATIONS

EARLY FINDINGS MAY INCLUDE:
FEVER- USUALLY GREATER THAN 101F (38.3 C)
TACHYCARDIA
NARROWED PULSE PRESSURE
TACHYPNEA
DECREASED PULMONARY ART ERY PRESSURE (PAP, PAWP, AND CVP)
INCREASED CARDIAC OUTPUT

AS SIRS PROGRESSES, FINDINGS REFLECT IMPAIRED PERFUSION OF THE
TISSUES AND ORGANS SUCH AS:

DECREASED LOC
RESPIRATORY DEPRESSION
DIMINISHED BOWEL SOUNDS
JAUNDICE
OLIGURIA OR ANURIA
INCREASED PAP AND PAWP
DECREASED CARDIAC OUTPUT


DIAGNOSTIC TESTS

ABG ANALYSIS
CBC
XRAYS
MRI
CT-SCAN
ANGIOGRAPHY


TREATMENT

MEHANICAL VENTILATION AND SUPPLEMENTAL OXYGEN
HEMODYNAMIC MONITORING
FLUID INFUSION (CRYTALLOIDS AND COLLOIDS)
VASOPRESSORS
SERIAL LABORATORY VALUES
DIALYSIS
ANTIMICROBIAL AGENTS


NURSING CARE AND MANAGEMENT

MAINTAIN THE PATIENTS AIRWAY AND BREATHING WITH THE USE OF MECHANICAL
VENTILATION AND SUPPLEMENTAL OXYGEN
MONITOR VITAL SIGNS, OXYGEN SATURATION, HEMODYNAMIC PARAMETERS AND CARDIAC
RHYTHM FOR ARRHYTHMIAS.
ADMINISTER IV FLUIDS AS ORDERED.
MONITOR LABORATORY VALUES.
MONITOR INTAKE AND OUTPUT.
ADMINISTER APPROPRIATE MEDICATIONS AS ORDERED.
PROVIDE EMOTIONAL SUPPORT TO THE PATIENT AND FAMILY.