MultipleOrganDysfunctionSyndrome(MODS)

多器官功能障礙綜合征LecturerDr.XianminBu卜獻民DefinitionMultipleorgandysfunctionsyndromeMODS:Multipleorganorsystemdysfunctionoccursimultaneouslyorprogressivelyfollowingsevereinfection,severetraumaandshock.Theaffectedorgansystemsinvolvedare:respiratory,cardiovascular,renal,hepatic,gastrointestinal,hematological,endocrine,andcentralnervoussystem.MODSisanimportantreasonforthedeathofseverepatient.TheEvolutionofMODSInWorldWarI,injuredsoldiersdiedinthebattlefieldofprofoundcardiacfailure.Thiswaspresumedtobecausedbywoundtoxins,butclinicalinterventionswerelargelyundefinedInWorldWarIIandtoagreaterextentintheKoreanWar,thelossofbloodvolumewasrecognizedtobetheprimarycauseoftraumaticshock.battlefieldcasualtieswereresuscitatedwithbloodandplasmauntilbloodpressurereturnedtonormal.Asaresult,moresoldierssurvivedtheirinitialinsult;however,theseverelyinjuredoftensuccumbedtooliguricrenalfailure.TheEvolutionofMODS1960’s-ARDSwasdescribedinVietnam“ShockLung”.1973-Tilneydescribedmultipleorganfailure(MOF)orMultiSystemOrganFailure(MSOF).TheyconcludedthatMOFsyndromewastheresultofacombinationofpreexistingdiseaseandhemorrhagicshock.1980’s-begantorealizeconceptofsepsis.MOFwasconsideredasafatalexpressionofuncontrolledinfection.1990’s–systemichyperinflammationbecamethefocus,nowreferredtoasthesystemicinflammationresponsesyndrome(SIRS).TheEvolutionofMODSMODSreplaces“MultiSystemOrganFailure”orMSOFMODSisarangeofdysfunctionalorgans,notjustfailureAlteredorganfunctioninanacutelyillpatientsuchthathomeostasiscannotbemaintainedwithoutinterventionMOFandMODSMultipleorganfailure(MOF):Progressivedistantorganfailure(initiallyuninvolved)followingsevereinfectiousornoninfectiousinsults(severeburn,multipletrauma,shock,acutepancreatitis)MOFisthefinalityofMODSmechanismbasisdiseases:Severetissueinjuryorbloodandfluidlossduetotrauma,burnandmajoroperationSevereinfectionShockresuscitationofcardiacandrespiratoryarrestAcutehaemorrhagicnecroticpancreatitis,colicintestineobstruction,rewarmingofcoldinjuryMisapplicationofinfusion,drug,orrespirator.Primarydisease:coronaryheartdisease,livercirrhosis,chronicnephrosismechanismThemechanismsofMODSareenormouslycompiexandpoorlyunderstood.Systemicinflammatoryresponsesyndrome(SIRS)isthemainreasonofMODS.Definition:pathologicinflammatoryresponsetoinjuryorinfectionDiagnosticcriteria:anytwoormoreofthefollowingmanifestations:1.temp>38or<36°C2.heartrate>90/min3.respiratoryrate>20/minorhyperventilation(PaCO2<32mmHg)4.Whitebloodcellcount>12,000cells/mm3,or<4000cells/mm3,orimmatureneutrophils>10%

mechanismToeveryactionthereisalwaysopposedanequalreaction:or,themutualactionoftwobodiesuponeachotherarealwaysequal,anddirectedtocontraryparts.-SirIsaacNewton,1687Compensatoryanti-inflammatoryresponsesyndrome(CARS)Imbalanceofinflammataryresponseandanti-inflammatoryresponse

SIRS>CARS,MODSoccurs.mechanismEnterogenousinfection

ischemicinjury↓Intestinemucosalbarrierdysfunction↓BacterialTranslocation↓Enterogenous/ent?rinfection↓releaseofinflammatorymediators↓MODsClinicalfeatureanddiagnosisTwotype:Primary:rapid,24hoursafteracuteprimarydisease,twoormoreorgansdysfunction.

TheoccurrenceofMODSisduetoadirectinjuryorinsulttoanorganorsystem.Ascontusionoflungfromtrauma,coagulapathyinducedbymultiplebloodtransfusion,acuterenalshutdownfromdrugs.

Secondary:tardy,afteraninitialorgandysfunctionandasteadyperiod,twoormoreorgansdysfunctionoccurssecondarily.

itisaconsequenceofthehostresponse,whichresultinaninflammatoryresponseinorgandistantfromthesiteoftheinitialinsultCardiovascularAcuteheartfailuer:Tachycardia,arrhythmiaAbnormalECGShock:BP↓,coldnessofextremities,oliguriamicrocirculationabnormalRespiratoryacuterespiratorydistresssyndrome(ARDS):tachypnea,wheezing,cyanose,dependenceuponoxygenationsupportandmechanicalventilationHyperventilationresultsinrespiratoryalkalosisSeverehypoxemia,abnormalrespiratoryfunction.RenalAcuterenalfailure(ARF):Suddendeclineofurineoutput(lessthan400ml/24hour)despiteadequatefluidsSpecificgravityofurine↑Na↑inurineandCr↑inbloodGastrointestinalStressulcerandintestinalparalysis:Haematemesis嘔血hematochezia便血abdominaldistentionweakbowelsoundsgastroscopeHepaticAcutehepaticfailure:JaundiceMindabnormalhepaticencephalopathyAbnormalbiochemicalliverfunctiontests:bilirubinliftNeurologicalCentralNervousSystemfailure:ConsciousdisturbancereactivedepressionofpainandsoundstimulationDisseminatedintravascularcoagulation(DIC)Ecchymosis淤斑Haematemesis嘔血Haemoptysis咯血plateletcount,fibrinogen,thrombintime(PT),partialthrombintime(PTT)Earlydiagnosis1.AcquaintancewiththehighriskfactorsofMODS.severeinfection(sepsis),trauma,burn,acuteseverepancreatitis,etcTachypnea,Tachycardia,lowBP,mindabnormal,oliguria,etc.Thediagnosisofinfectionisveryimportant.Earlydiagnosis2.SIRS+organdysfunction=MODSOrgandysfunctioncausedbySIRSinduceddamagesuchthathomeostasiscannotbemaintainedwithoutsupportivemeasuresSIRSmustbeidentifiedassoonaspossibleinordertoinstituteimmediatetreatmenttotryandpreventprogressiontoMODSEarlydiagnosis3.Multipleorgandysfunctionoccursprogres-sively,eithertheinitialorganoradistantorgan.Oneorgandysfunctionoccurs,theothersshouldbedetectedintime.DIC:ARDS,ARF,GIhemorrhageandcerebralhemorrhageInclinic,ARDShepaticfailure,ARFandGIfailure.Earlydiagnosis4.Paymoreattentiontoorgandysfunctionthanorganfailure.ThatSIRSevolvesintoMODSisadynamicprocess.Thedysfunctionmaybepartialorcomplete,reversibleorirreversibleEarlydiagnosis5.Dysfunctionofheart,lung,brainandkidneyhasaclearclinicalmanifestation,whileuntilseverestage,dysfunctionofliver,GIandhaematologicalsystemhasnotaclearclinicalmanifestation.Somespecialaccessoryexaminationsareessential.ProphylaxisandtreatmentSyntheticandSupportiveTherapyHighmortalityProphylaxisismoreimportant.Prophylaxisandtreatment1.Improvethequalityofresuscitation,attachimportancetocirculationandrespiratory.correcthypovolemia,restoretissueperfusionandoxygentransportationProphylaxisandtreatment2.ControlinfectionisaimportantmeasuretopreventMODS.Drainageofinfectiousfocus,clearanceofnecrotictissuesLocalizationofinfectiontoalleviatetoxemia.AntibioticsProphylaxisandtreatment3.Tomanagesingleorgandysfunctionearlyandblockthepathologicchainreaction.Moreorgansfailurehighmortality4.Improvegeneralconditions.5.Protectintestinalmucousbarrier,preventbacterialtranslocation.6.Immuneregulation

acuterenalfailure(ARF)Defination

Acuterenalfailureisaconditioninwhichtheglomerularfiltrationrateisabruptlyreduced,causingasuddenretentionofendogenousmetabolitesthatarenormallyclearedbythekidneys.

Commonly,ARFischaracterizedbysuddenreduceofurinaryoutput.oliguriaurinevolume<400ml/dayauriaurinevolume<100ml/daynonoliguricacuterenalfailure

Theurinevolumeperdayismorethan800ml,thebloodureanitrogen(BUN)andserumcreatinineriseprogressively.EtiologyandclassificationPrerenalARFinadequaterenalperfusionPostrenalARFobstructiontotheurineoutflowofbilateraluretersofkidneysIntrarenalARFacutetubularnecrosisandacutecorticalnecrosiscausedbytherenalischemiaandrenaltoxicosis.EtiologyandclassificationPrere