Multiple Organ Dysfunction SyndromeDefinitionMODS is characterized by the progressive functional deterioration of multiple independent organs after an acute major physiologic insult.Denomination variation1973 1973 secondary system function failuresecondary system function failure- Tilney- Tilney Summary Summary data data of of 18 18 cases cases ARF ARF patients patients after after abdominal abdominal aortic aortic aneurysm aneurysm operation,and operation,and 17 17 patients patients died died from from organ organ failure during dialysis .failure during dialysis .1975197519771977 MOFS MOFS，multiple organ failure syndrome-Bauemultiple organ failure syndrome-Baue，19751975 （Yet the treatment did not save the lives.)Yet the treatment did not save the lives.) MOF MOF ，multiple organ failure- Eisemanmultiple organ failure- Eiseman，19771977 1980s 1980s MSOF MSOF，multiple system organ failure- Fry38/533multiple system organ failure- Fry38/533 point point out out the the relationship relationship between between MSOF MSOF and and severe severe infectioninfection 1990s 1990s MODS,multiple organ dysfunction syndromeMODS,multiple organ dysfunction syndromeEtiology Sepsis syndrome Trauma Shock severe acute pancreatitis Blood transfusion After cardio-pulmonary resuscitationPathogenesisSystemic inflammatory response syndrome（SIRS）Ischemia-reperfusion injurybowel barrier dysfunctionT 38or 36HR90 beat/minRR20/min or PaCO232mmHgWBC12000/mm3 or 4000/mm3 or premature cells 10SepsisSystemic InflammatoryResponse Syndrome (SIRS)(SIR+Positive Culture)(SIR without infection)Systemic Inflammatory Response syndrome (SIRS)Vessel permeabilityVessel permeability WBC WBC chemotaxis monocyte/ /macrophage neutrophil elastinase PLA2 PLA2 ODFR TNF ILTNF IL8 et al8 et al IL IL1 1 IL IL6 6liverliver：acutephase reaction Remote organ injuryRemote organ injuryTissue damageTissue damage etiological factor neutrophilAdherent moleculeExcessive inflammation SIRS MODS Vascular endothelial cellSIRSMODS Direct injury of ischemiaHypersensibility in heart and brainSelective ischemiaEndothelial cell injury leads to high vascular permeability and low volumeClinical progressUncontrolled stressSIRSMODSType of MODSImmediate type Delayed typeInfluenced organLung-ARDSKidney-ARFLiverClinical MenifestationCardiavascular systemLungKidneyGastrointestinal tractLiverBrainBlood systemOrgans dysfunction or failureOrgan or systemdysfunctionfailurelungLiverkidneyintestineBloodHypoxemia, respirator at least 3-5daysARDS,PEEP10cmH2O,FiO20.5Bilirubin2-3mg/dL, Liver function2 normal valueBilirubin2-3mg/dL, icterusoliguriadialysisUntolerance of enteral nutrition5daysCurlingls ulcer needs blood transfusion, Acalculous cholecystitisPT or PTT elongation, platelet50-80thousand, Hypercoagulable stateDICcentral nervous systemcardiovascular systemInsanity,light orientation disorderProgressive deepen coma Ejection Fraction , capillary leakageIrresponsivity to muscle strength drugsCardiovascular failureCardiovascular failure Presence of one or more of the following:Presence of one or more of the following:Heart rate =54/minHeart rate =54/minMean arterial pressure=49mmHgMean arterial pressure=49mmHgVentricular tachycardia, ventricular Ventricular tachycardia, ventricular fibrillation,or both fibrillation,or both Serum pH=7.24 with Pco2= 40mmHgSerum pH=7.24 with Pco2= 40mmHgRespiratory failureRespiratory failure Presence of one or more of the following: Presence of one or more of the following:Respiratory rate=49/ minRespiratory rate=49/ minPaCO2=50mmHgPaCO2=50mmHgP(A-a)O2=350mmHg: P(A-a)O2=350mmHg: P(A-a)O2 P(A-a)O2 = = 713 713 (FIO2)-PaCO2-PaO2(FIO2)-PaCO2-PaO2 P Pa aOO2 2/F/Fi iOO2 2200200 Renal failureRenal failure Presence of one or more of the following:Presence of one or more of the following:Urine output=400mL/24h Urine output=100mg/dLSerum BUN =100mg/dLSerum creatinine =3.5mg/dLSerum creatinine =3.5mg/dLHepatic failureHepatic failure Serum bilirubin=6mg/dLSerum bilirubin=6mg/dLProthrombin time 4 s over control(in the Prothrombin time 4 s over control(in the absence of systemic anticoagulation)absence of systemic anticoagulation)Monitoring Organ function(risk factor) Nutritional status Immune statusTreatment Early diagnosis Supportive therapyOrgan function maintainingLung: airway; mechanical ventilationKidney: blood purificationLiver: protective therapyHeart: arrhythmic control; treat cardiac failureBrain:cerebral edema preventionBlood system: DIC preventionInternal environment maintaining Electrolyte disturbanceElectrolyte disturbance Disturbance of acid-base balance Disturbance of acid-base balanceIntestinal mucosa barrier Intestinal mucosa barrier dysdysfunctionfunctionInternal environment maintainingLimitation of water-intakeNever get CO downInfusion volume decided by urine volume per hour when lung and brain interstitial edema happen.Raise colloid osmotic pressureUse powerful diureticUse glucocorticoidNutritional supportMetabolism supportOffer nutritional substrate but never increase organ loading.Metabolism modulationInhibition of catabolism hormonesPromote protein synthesis ,ease negative nitrogen balanceAnti-inflammation Bacteria: antibiotic Fungal infection VirusImmune modulation HemofiltrationAcute Renal Failure (ARF)DefinitionDefinition Acute Acute renal renal failure failure (ARF) (ARF) is is defined defined as as an an abrupt abrupt decline decline in in renal renal function function sufficient sufficient to to cause cause retention retention of of nitrogenous nitrogenous waste. waste. This This definition definition of of ARF ARF does does not not dependent dependent on on the the urinary urinary output output of of the the patient. patient. The The emphasis emphasis is is on on the the quality quality of of the the urine urine rather rather than than the the quantity quantity because because nonoliguric nonoliguric forms forms of of ARF ARF occur quite frequently.occur quite frequently.EtiologyPrerenal Hemorrhage, shock, fluid losing without appropriate fluid resuscitationPost renal Both side ureter or urinary flow blockedRenal Kidney ischemia (hematorrhea,sepsis, allergic reaction) Intoxication(aminoglycoside antibiotic, biotic toxin, chemical)Pathogenesis Renal ischemia Renal tubular degeneration Ischemia-reperfusion injury Mechanical obstructionClinical Manifestionoliguria stageDisturbance of electrolyte and acid-base balancewater intoxication hyponatremiahypocalcemiahypochloreamiahyperkalemiahypermagnesemiahyperphosphoremiaacidosisClinical Manifestationoliguria stage Uremia Hemorrhagic tendency InfectionClinical ManifestionDiursis stageUrine volume increase 3000ml/d14dDiscovery stageSeveral months History and physical examinationEtiologyprerenal pathogenpostrenal pathogenDiagnosis DiagnosisLaboratory Urine testUrinary catheter to record urine volumeUrine density(1.010-1.014)Urine microscopic examinationqRBC and renal tubule epithelia(renal cortex and renal medulla necrosis)qlarge Brown casts(renal failure casts)qeosinophil (interstitial nephritis)qred cell cast(glomerulonephritis)qnormal(prerenal or postrenal failure earlier period)Diagnosisrenal function examinationrenal function examinationUrine urea nitrogen ( Urine urea nitrogen ( 175mmol/24h) ( 175mmol/24h)Fractional excretion of filtrated sodium1Fractional excretion of filtrated sodium1 FEFENaNa（%）= =（U UNaNa/P/PNaNa） （P PCrCr/U/UCrCr ）100100Osmotic pressure of urineOsmotic pressure of urine *ARF- *ARF- 400 400 mOsm/LmOsm/LBUN (more than BUN (more than 3.83.89.4mmol/L per day) , 9.4mmol/L per day) , Cr Cr Urine/Plasma Cr-20Urine/Plasma Cr-1-ARF1-ARF *1-prerenal *100mg/dl in patient with ARFBUN100mg/dl in patient with ARFBUN100mg/dl in patient with ARF2.2.Need Need Need for for for enteral enteral enteral or or or hyperalimentation hyperalimentation hyperalimentation in in in patient patient patient with ARF with ARF with ARF 3.3.Need for multiple transfusions in patient with ARFNeed for multiple transfusions in patient with ARFNeed for multiple transfusions in patient with ARF4.4.Hemorrhagic complications in patient with ARFHemorrhagic complications in patient with ARFHemorrhagic complications in patient with ARF5.5.Drug intoxication with hemodialyzable substance Drug intoxication with hemodialyzable substance Drug intoxication with hemodialyzable substance Acute Respiratory Distress Acute Respiratory Distress SyndromeSyndrome(ARDS)(ARDS)DefinitionDefinition The acute respiratory distress The acute respiratory distress syndrome(ARDS) is characterized by syndrome(ARDS) is characterized by nonhydrostatic pulmonary edema and nonhydrostatic pulmonary edema and hypoxemia associated with a variety of hypoxemia associated with a variety of etiologies causing both direct and indirect etiologies causing both direct and indirect insults to the lung.insults to the lung.EtiologyDirect injury gastric content aspiration trauma drowningIndirect injury shock acute pancreatitis sepsis multiple fracturePathophysiology Ultra-inflammatory reaction Interstitial edema Diffluence increaseThe early stagePathology of lungPathology of lungqqhigh capillary permeabilityhigh capillary permeabilityInterstitial edemaInterstitial edemaqqvasoconstrictionvasoconstriction, microthrombosis communicating branch opening, microthrombosis communicating branch openingqqalveolar and small alveolar and small bronchusAtelectasisbronchusAtelectasisqqdecreased decreased alveolar surfactantalveolar surfactantqqedemaedemaqqtype I epithelial cells instead by type II cellstype I epithelial cells instead by type II cellsSymptomSymptomqqtachypnea, respiratory distress tachypnea, respiratory distress can not be eased by oxygen inhalationcan not be eased by oxygen inhalationqqno ralesno ralesqqno lung x-ray abnormalityno lung x-ray abnormalityPathologyPathologyqqdeteriorated lung interstitial deteriorated lung interstitial inflammation,usually complicated with sepsisinflammation,usually complicated with sepsisSymptomSymptomqqobviously dyspnea and cyanosisneed obviously dyspnea and cyanosisneed ventilatorventilatorqqincreased respiratory tract secretion, ralesincreased respiratory tract secretion, ralesqqlung x-rayinfiltrateslung x-rayinfiltratesqqdisturbance of consciousnessdisturbance of consciousnessqqfebrile or high leucocytefebrile or high leucocyte The second stage Telophase PathologyPathologyqqlung parenchyma fibrosislung parenchyma fibrosisqqmicrovascular occlusionmicrovascular occlusionqqincreased preload, hypoxiaincreased preload, hypoxiaSymptomSymptomqqdeep comadeep comaqqarrhythmiabradycardiacardiac arrestarrhythmiabradycardiacardiac arrestDiagnosisDiagnosis Essential diagnostic tests and procdures Essential diagnostic tests and procdures History and physical examination History and physical examination Chest radiographChest radiographArterial blood gas measurementsArterial blood gas measurementsFurther Further diagnostic diagnostic tests, tests, based based on on the the clinical circumstances clinical circumstances Diagnosis RR28/min or/and respiratory distress PaO28 KPa or PaO2/FiO2200 Chest radiograph (+)Strategy of ameliorating oxygen metabolism:Strategy of ameliorating oxygen metabolism: improve oxygen delivery improve oxygen deliveryqqrespiratory support-to improve arterial blood respiratory support-to improve arterial blood oxygen contentoxygen content44higher inhalated oxygen concentration,ventilatorhigher inhalated oxygen concentration,ventilatorqqincrease cardiac output increase cardiac output 44Heart rate, cardiac rhythm, cardiac contractility, Heart rate, cardiac rhythm, cardiac contractility, preload/afterloadpreload/afterloadqqBlood systemBlood system44raise hemoglobin concentrationraise hemoglobin concentrationTreatmentTreatmentStrategy of ameliorating oxygen metabolism: increase oxygen extraction ratioqqameliorate interstitial edemaqqreduce blood capillary permeabilityqqameliorate oxygen extraction of cellsTreatment Correct hypoxemia quicklyqquse ventilator as soon as possibleqqappropriate PEEP（ regain alveolar function and functional residual capacity)TreatmentMaintain circulation and ameliorate lung interstitial edemaqproper crystal-colloid rateqdiureticqnegative water balance (according to CVP/PAWP , urine output and lung auscultation)Treatment Prevent and treat infection Block SIRSqcorticoid in the initial stageqmediators inhibitor (Ibuprofen, Dentoxifylline,TNF antibody)Stress ulcer and intestinal dysfunction DefinitionStress ulcer is characterized by the acute inflammation and ulcer of the upper alimentary tract and dysfunction of the gastrointestinal motility and barrier,mainly located in stomach. It occurs secondary to severe insults such as trauma, shock, etc.DefinitionIntestinal dysfunction includes the disorder of digestion, absorption and intestinal mucosal barrier.Etiology and pathogenesisCushing ulcerCurling ulcerClinical Manifestation Hematemesis Melena Perforation of alimentary tractNon-operative therapy Intravenous hemeostatic drug Anti-excretion of digestive juice Decrease vessel pressure Local hemostatic drugOperation Failure of non-operative therapy PerforationAcute Hepatic FailureDefinitionCharacterized by the diffuse lesion and reduction of the hepatic ability of synthesis, transportation,storage and detoxification.Etiology Virus hepatitisChemical poisonesisSevere traumaShockSepsisClinical Manifestation Conscious disturbance Jaundice Hepatic odor Hemorrhage Other organ failureTreatment Anti-infection Hyperammonemia correction Nutrition amelioration liver transplantationQuestionsWhat is the therapeutic principle for MODS?Which electrolyte disorders may occur in ARF?What is the most important treatment for ARDS?