12/01/09 http://www.emedicine.com/med/topic3372.

htm#section~treatment 1
Multiple Organ Dysfunction
Syndrome (MODS)

The First Teaching Hospital Of ZZU

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 2
Case
♦ A patient,male,28-years-old,one day,fell
into a 1-meter-deep hole from the
ground.His liver was seriously injured. To
stop bleeding from liver,doctors had to put
seven bandages into his liver. During the
operation ,his Bp fell to 30/10mmHg. After
operation,he had water only 300ml/d. One
day later, he felt tachypnea. He had to use
ventilator to keep from hypoxia.

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 3
Case
♦ The bandages in his abdominal cavity was infected. His Bp fell to
80/60mmHg10 days later. We had to use dopamine to keep his Bp.
At last , bandages were taken out, then, 15 days later ,he
recovered.
♦ Question:
♦ 1.what’s the diagnosis of the patient?
♦ 2.what lead to these changes?
♦ Multiple Organ Dysfunction Syndrome

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 4
♦ Blood gas analysis :PaO2 55mmHg
♦ PaCO2 60mmHg
♦ BUN :20mmol/L
♦ Cr : 600umol/L

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 5
♦ Respiratory failure
♦ Renal failure
♦ Septic shock
♦ Hypovolemic shock

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 6
MODS--definition
♦ Presence of altered organ function in an acutely
ill patient such that homeostasis cannot be
maintained without intervention.
♦ Multiple organ failure (MOF) is the most
common cause of ICU late death following
major traumatic injury.
♦ MODS MOF

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 7
General Goal:
♦ In this lesson, we need to understand the
basic processes that cause the progression
from SIRS to septic shock, then to MODS
and describe the basic treatment plan in
caring for these patients.

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 8
 Society of Critical Care Medicine (SC

Development of MODS
Name Author Time
Sequential system failure Tilney 1973
Multiple progressive or sequential Baue 1975
systems failure
multiple organ failure Eiseman 1977
remote organ failure Polk 1977
multiple systems organ failure Fry 1980
acute organ-system failure Knaus 1985
multiple organ dysfunction syndrome ACCP/SCCM 1991
American College of Chest Physicians
12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 9
Several Concepts
♦ Systemic Inflammatory Response Syndrome
(SIRS): Patient presents with two or more of
the following criteria.
1. temperature > 38°C or < 36°C degrees Celsius
2. heart rate > 90 beats/minute
3. respiration > 20/min or PaCO2 < 32mm Hg
4. leukocyte count > 12,000/mm3, < 4,000/mm3 or
> 10% immature (band) cells

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 10
Several Concepts
♦ Infection :Microbiological event (caused by bacteria,
viruses, fungi) inducing some host response or
presence of these microorganisms in a normally sterile
tissue (CSF, peritoneum)
♦ Bacteremia (fungemia) :Presence of viable bacteria
(fungal) in the blood, as evidenced by positive blood
culture
♦ Sepsis :SIRS that has a proven or suspected microbial
etiology

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 11
Several Concepts

♦ Multiple organ dysfunction syndrome

(MODS):
Dysfunction of more than one organ, requiring
intervention to maintain homeostasis

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 12
Several Concepts
♦ Severe sepsis:Sepsis with one or more signs of
organ dysfunction, hypoperfusion, or
hypotension such as metabolic acidosis, acute
alteration in mental status, oliguria, coagulation
abnormalities or adult respiratory distress
syndrome
♦ Septic shock:Sepsis with hypotension that is
unresponsive to fluid resuscitation plus organ
dysfunction or perfusion abnormalities as listed above
for severe sepsis

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 13
♦

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 14
♦ Sepsis in United States. Incidence and
mortality of sepsis, severe sepsis, and
septic shock in United States continues
to rise. The death rates from severe
sepsis and septic shock now equal to
those caused by acute myocardial
infarction.

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 15
etiology
♦ A combination of tissue hypoxia, an
exaggerated systemic inflammatory
response, and tissue damage arising from
ischemia, necrosis, free oxygen radical and
protease attack all contribute to progressive
organ dysfunction and,ultimately, failure.

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 16
♦ Infection

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 17
♦ Non-infection
♦ 1.trauma
♦ 2.shock
♦ 3.burn
♦ 4. pancreatitis
♦ 5.ischemia/reperfusion
♦ 6.other

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 18
mechanism

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 19
Illustrates the common physiological characteristics of multiple system organ failure and the
variety of end organs/systems affected. Note that the changes induced are irrespective of the
original etiology (i.e., infectious/non infectious). Individual patients vary to the extent of MODS
12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 20
compensatory antiinflammatory response syndrome(CARS)
12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 21
Role of gut in MODS
Acute reduction in oxygen supply is
important in MODS. MODS deteriorate
hypoxia.
♦ Gut is particularly susceptible to hypoxic
injury
♦ Barrier is compromised.
♦ Bacteria translocates to blood.
♦ Endotoxin

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 22
Diagnosis
♦ 1. Basic etiology
♦ 2. Clinical signs and symptoms
♦ 3. Laboratory findings

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 23
Diagnosis
♦ Circulatory failure
∀ Criteria for diagnosis
ο Bradycardia (heart rate <50 bpm)
ο Hypotension (mean arterial pressure
<50 mmHg)
ο Ventricular tachycardia or fibrillation
ο Metabolic acidosis (pH <7.2)

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 24
Diagnosis
♦ Respiratory failure
∀ Criteria for diagnosis
ο Respiratory rate <5 or >40 breaths per
minute
ο Hypercapnia (PaCO2 > 6.7 kPa)
♦ Hypoxaemia

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 25
Diagnosis
♦ Acute renal failure
∀ Criteria for diagnosis Oliguria
Renal insufficiency with BUN > 75 mg/dl
and/or
serum creatinine > 3 mg/dl

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 26
Diagnosis
♦ Hematological failure
∀ Criteria for diagnosis
ο Leucopenia (WCC < 1000 cell / mm3)
ο Thrombocytopenia (platelet < 20,000 /
mm3)
♦ Evidence of disseminated intravascular
coagulation (DIC)

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 27
Diagnosis
♦ Hepatic failure
∀ Criteria for diagnosis
ο Serum total bilirubin > 3 mg/dl
ο Serum ALT or AST > 500 U/L

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 28
Diagnosis
♦ Gastrointestinal failure
∀ Criteria for diagnosis
ο Ileus
ο Gastroparesis
ο Hemorrhage

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 29
Diagnosis
♦ Neurological failure
∀ Criteria for diagnosis
ο Depressed level of consciousness
(Glasgow coma score <6)

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 30
Lab Studies:

♦ Laboratory tests are useful in suspected

septic shock or MODS to assess the
general hematologic and metabolic
condition of the patient. The
microbiologic studies provide results,
which may indicate occult bacterial
infection or bacteremia, and indicate the
specific microbial etiology.

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 31
Lab Studies:
An adequate hemoglobin concentration
is necessary to ensure oxygen delivery
in shock. Maintain the hemoglobin at a
level of 80 g/L or more.

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 32
Lab Studies:
♦ Platelets: Acute phase reactants,
platelets usually increase at the onset
of any serious stress. The platelet count
will fall with persistent sepsis, and DIC
may develop.

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 33
Lab Studies:
♦ WBC count: The white cell differential
and the WBC count may predict the
existence of a bacterial infection. In
adults who are febrile, a WBC count
greater than 15,000 cells/µ L or a
neutrophil band count greater than
1500 cells/µ L is associated with a high
likelihood of bacterial infection.

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 34
Lab Studies:
♦ Metabolic assessment: Perform
metabolic assessment with serum
electrolytes, including magnesium,
calcium, phosphate, and glucose, at
regular intervals.

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 35
Lab Studies:
♦ Renal and hepatic function: Assess
renal and hepatic function with serum
creatinine, BUN, bilirubin, alkaline
phosphate, and alanine
aminotransferase (ALT).

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 36
Lab Studies:
♦ Prothrombin time (PT) and activated
partial thromboplastin time (aPTT):
Assess coagulation status with
prothrombin time (PT) and activated
partial thromboplastin time (aPTT).
Patients with clinical evidence of
coagulopathy require additional tests to
detect the presence of DIC.

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 37
♦ PT
♦ fibrinogen
♦ platelet
♦ DIC

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 38
Blood cultures
♦ Blood culture is the primary modality for aiding in the
diagnosis for intravascular infections (eg, endocarditis)
and infections of indwelling intravascular devices.
♦ Patients at risk for bacteremia include adults who are
febrile with an elevated WBC or neutrophil band
counts, elderly patients who are febrile, and patients
who are febrile and neutropenic. These populations
have a 20-30% incidence of bacteremia.
♦ The incidence of bacteremia is at least 50% in patients
with sepsis and evidence of end-organ dysfunction.

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 39
Urinalysis and urine culture:
♦ Order a urinalysis and urine culture for
every patient who is MODS. Urinary
infection is a common source for sepsis,
especially in elderly individuals. Adults
who are febrile without localizing
symptoms or signs have a 10-15%
incidence of occult urinary tract infection
(UTI).

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 40
Imaging Studies:

♦ A variety of imaging modalities are

employed to diagnose clinically
suspected focal infection, detect the
presence of a clinically occult focal
infection, and detect complications of
sepsis and septic shock.

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 41
Imaging Studies:
♦ Obtain a chest radiograph in patients
with severe sepsis because the clinical
examination is unreliable for
pneumonia. Clinically occult infiltrates
have been detected by routine use of
chest radiography in adults who are
febrile without localizing symptoms or
signs and in patients who are febrile
and neutropenic without pulmonary
symptoms.

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 42
12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 43
12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 44
Imaging Studies:

♦ Ultrasound is the imaging modality of

choice when a biliary tract source is
suspected to be the source of sepsis.
♦ CT scan is the imaging modality of
choice for excluding intraabdominal
abscess or a retroperitoneal source of
infection.

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 45
Imaging Studies:
♦ When there is clinical evidence of a
deep, soft tissue infection, such as,
crepitus, bullae, hemorrhage, or foul
smelling exudates, obtain a plain
radiograph. The presence of soft tissue
gas and the spread of infection beyond
clinically detectable disease may require
surgical exploration.

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 46
prognosis
♦ Mortality/Morbidity: Mortality from
multiorgan dysfunction syndrome
remains high. Mortality rates from
ARDS alone is 40-50%. Once additional
organ system dysfunction occurs, the
mortality rate increases as much as
90%.
♦ Four organs failure, 100%

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 47
Medical Care:
General supportive care

♦ Initial treatment includes support of respiratory

and circulatory function, supplemental oxygen,
mechanical ventilation, and volume infusion.
Treatment beyond these supportive measures
includes a combination of several parenteral
antibiotics, removal or drainage of infected foci,
treatment of complications, and pharmacologic
interventions to prevent further harmful host
responses.

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 48
ICU
♦ Patient should be admitted to ICU(intensive
care unit)
♦ Mechanical ventilator
♦ Monitor
♦ CRRT
♦ Special doctor and nurse

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 49
12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 50
12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 51
12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 52
12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 53
Ventilation
♦ Essential
♦ strategy that uses lower tidal volumes and
inspiratory pressures than were used in the past.
tidal-volume goal of 6 ml per kilogram of predicted
body weight
♦ positive end-expiratory pressure (PEEP)
♦ High levels of positive end-expiratory pressure
(PEEP) are not better than low levels of PEEP for
acute respiratory distress syndrome (ARDS),
according to the results of a randomized trial

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 54
12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 55
♦ Administer supplemental oxygen to any
patient who is MODS with hypoxia or
respiratory distress. If the patient's
airway is not secure or respirations are
inadequate, perform endotracheal
intubation and mechanical ventilation.

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 56
12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 57
12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 58
12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 59
12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 60
12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 61
12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 62
Intravascular volume resuscitation

♦ All patients with MODS require supplemental

fluids. Assessment of the patient's volume
and cardiovascular status guides the amount
and rate of infusion. For adult patients who
are hypotensive, administer an isotonic
crystalloid solution (sodium chloride 0.9% or
Ringer lactate) in boluses of 500 mL (10
mL/kg in children), with repeat clinical
assessments after each bolus.

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 63
♦ Administer repeat boluses until signs of adequate
perfusion are restored. A total of 4-6 L may be
required. Monitor patients for signs of volume
overload, such as dyspnea, pulmonary crackles,
and pulmonary edema, on chest radiograph.
Improvement, stabilization, and normalization of
the patient's mental status, heart rate, BP,
capillary refill, and urine output indicate adequate
volume resuscitation

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 64
♦ A centrol venous pressure of 10-15 mm Hg, a
PAOP greater than 18 mm Hg, or a rise in the
PAOP by 5 mm Hg or more following fluid bolus
indicates adequate volume resuscitation. Such
patients are susceptible to volume overload;
therefore, administer further fluid carefully. Colloid
resuscitation (with albumin or pentastarch) has no
proven benefit over isotonic crystalloid resuscitation
(normal saline or Ringer lactate).
♦ pulmonary artery occlusion pressure (PAOP)

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 65
Vasopressor supportive therapy
When proper fluid resuscitation fails to restore
hemodynamic stability and tissue perfusion,
initiate therapy with vasopressor agents. These
agents are dopamine, norepinephrine,
epinephrine, and phenylephrine. These
vasoconstricting drugs maintain adequate BP
during life-threatening hypotension and preserve
perfusion pressure for optimizing flow in various
organs. Maintain the mean BP required for
adequate splanchnic and renal perfusion (mean
arterial pressure [MAP] of 60 or 65 mm Hg)
based on clinical indices for organ perfusion.

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 66
Renal-dose dopamine
♦ Low-dose dopamine does not protect
the patient from developing acute renal
failure, and there is no data stating that
it preserves mesenteric profusion; the
routine use of this practice is not
recommended.

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 67
Empirical antimicrobial therapy
♦ Administer initial antibiotics. Selection of
particular agents is empirical and is based on an
assessment of the patient's underlying host
defenses, the potential sources of infection, and
the most likely responsible organisms.
Antibiotics must be broad spectrum and cover
gram-positive, gram-negative, and anaerobic
bacteria because all classes of these organisms
produce identical clinical pictures. Administer
antibiotics parenterally in doses adequate to
achieve bactericidal serum levels.

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 68
♦ Many studies have found that clinical
improvement correlates with the
achievement of serum bactericidal
levels rather than the number of
antibiotics administered.

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 69
♦ Patients who are immunocompetent usually
can be treated with a single drug with broad-
spectrum coverage, such as a third-
generation cephalosporin. Patients who are
immunocompromised usually require dual
antibiotic coverage with broad-spectrum
antibiotics with overlapping coverage. Within
these general guidelines, no single
combination of antibiotics is clearly superior
to others

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 70
large doses of corticosteroids
No date exists in the medical literature
supporting the routine use of high
doses of corticosteroids in patients with
sepsis or septic shock and MODS.

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 71
♦ Surgical Care: Take patients with
infected foci to surgery after initial
resuscitation and administration of
antibiotics for definitive surgical
treatment. Little is gained by spending
hours stabilizing the patient when an
infected focus persists.

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 72
CRRT
♦ Continuous renal replacement treatment
♦ Cytokines lead to SIRS
♦ Useful in Pancreatitis

12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 73
12/01/09 http://www.emedicine.com/med/topic3372.htm#section~treatment 74