Multiple Organ Dysfunction Syndrome (MODS)

Definition
Dysfunction or failure of multiple organ or system happened simultaneously or sequentially
due to various etiological factors.
Etiology
Infection: Gram positive/negative bacteria fungal !irus
S"oc# "emorr"age etc$
%llergy
&urns
'rauma
Severe acute pancreatitis
(lassification of MODS
Immediate 'ype ()rimary)

Dysfunction is "appened simultaneously in t*o or

more organs due to primary disease$
Delayed type (Secondary

Dysfunction "appened in a organ ot"er organs
sequentially "appened dysfunction or failure$
%ccumulation type

Dysfunction leaded by c"ronic disease$

Mec"anism
(ommon Manifestations of MODS
Diagnosis of (riteria
Organ/ system dysfunction and failure
G+%SGO, S(O-E
'reatments of MODS
(ombined t"erapy
(orrection of isc"emia: fluid resuscitation mec"anical
ventilation
)revention of infection

drainage antibiotics
Interruption of pat"ological reaction

"emofiltration
Stabili.ation of internal environment

*ater electrolyte
acid/base imbalance
-egulation of immunity

cellular and "umor

Support of organ function
!entilator
%rtificial #idney
%rtificial liver
)rotection of enteral mucosa
Drugs of protection of "eart
%cute -enal 0ailure (%-0)
Definition
Characterized by ineffective filtration across glomeruli in short time. Such as azotemia,
imbalance of water, electrolyte and acidbase.
Etiology and classification
)rerenal
)ro1imal to #idney
Decrease in renovascular flo*
2$ 3ypovolemia severe cardiac dysfunction loss of vascular tone drugs (renal
vasoconstriction) renal artery occlusion
4$ %bdominal (ompartment Syndrome (%(S)
5$ 678 of t"e %-0
)ostrenal
Distal to #idney$
Obstruction of urinary flo*
2$ (ollecting system
4$ 9reters: tumor stone etc$
5$ &ladder outlet (strictures prostatism)
Intrinsic renal
-enal parenc"yma in:ury (glomerular filtration )
-enal tubular dysfunction
&ot"
2$ !cute glomerulonephritis
4$ !"# : renal isc"emia

"emorr"ageseptics"oc#serum anap"yla1is

;
nep"roto1ins (aminoglycosides radiocontrast dye pigments bioto1ins
polymy1in)
5$ !cute interstitial nephritis
Mec"anism
Oliguria and anuria stage

<=77ml/4=" or <277ml/4="

-enal isc"emia
2$ Decrease in glomeruli filtration

systolic blood pressure < >#pa;

decrease in endot"elia permeability after isc"emia; constriction of
renal artery$ )
4$ %'?

stasis of blood in medulla

3. Glomeruli/tubule feedbac#

isc"emia

?a@re/absorption
decrease in medullary loop and distal convoluted tubule

?a@
increase in para/macula densa

renin release

afferent %rteriole
of glomerulus spasm

-eperfusion/isc"emia in:ury: o1ygen free radicals in:ure cells

Degeneration and necrosis of tubulus endot"elium

isc"emia

%')

disorders of
transport function

accumulation of sodium and calcium loss of

potassium

degeneration of endoplasmic reticulum accumulation of matri1 protein

renal tubular necrosis

Obstruction of renal tubulus
2$ mucousa and cells
4$ filtration pressure
5$ "emoglobin and myoglobin
Infection and drugs
2$ Infection leading to decrease in renal blood flo*
4$ Drugs: amine rifampicin polymy1in
?on/oliguria acute renal failure
2$ Discrepancy of renal tubulus and glomeruli of c"ange
4$ ?ormal blood flo* in some renal unit
9rorr"agia stage

A>77ml/4="

Glomerular filtrate not concentrated

unrecovery from resorption and concentrated

function of renal tubulus reepithelia
Osmotic diuresis: large amount of $%# accumulated in body during anuria stage.
,ater diuresis

much electrolyte and water e&cess during anuria stage aggravate

uresis.
(linical manifestation
%nuria stage

2= days

t"e longest is more t"an one mont"

9rine :

hypobaric and fi&ed' albuminuria' red cells and cast

Imbalance of *ater electrolyte and acid/base$

'"ree increase

blood p"osp"orus potassium magnesium '"ree

decrease: blood calcium sodium c"loride
'*o into1ication

metabolic acidosis *ater to1ication

%ccumulation of metabolic products/uremia

a.otemia p"enol guanidine

etc$

?ausea vomiting
3eadac"e restless *ea#ness unconsciousness coma
3emorr"agic tendency

decrease in platelet function increase in capillary

fragility "epatic dysfunction DI(

Subcutaneous "emorr"age
Oral mucosa and gingiva bleeding
Gastrointestinal bleeding
,ounds bleeding
9rorr"agia stage(2= days

Mode of urine recovery

(ncrease !bruptly

usually in )

*th day

urine output increases to +),,ml/-.h abruptly.

(ncrease gradually

%sually in *

+.th day

urine output increases to -,,

),,ml/-.h
(ncrease tardily

/hen urine output increases to ),,

*,,ml/-.h

stopping increasing.
0rognosis is poor.
Imbalance of *ater electrolyte; and a.otemia still e1ist$
(omplicating *it" infection easily
Stage of recovery

several mont"s

anemia
*ea#ness
,asting
Diagnosis
3istory and p"ysical e1amination
Etiology
,"et"er prerenal factors e1ist
,"et"er postrenal factors e1ist
E1amination of urine
-ecord urine output per "our
%cid urine specific gravity stabili.es at t"e range of 2$727/2$72=
Microscopic e1amination
1ore red cells and renal tubulus epithelia

corte& and medulla

necrosis2
3enity brown cast

renal failure cast

!cidophilic cell increase

interstitial nephritis

4ed cell cast

glomerular nephritis

#on apparent abnormality

early stage with prerenal or postrenal

failure

E1amination of renal function

9rine &9? decrease less than +5,mmol/-.h usually.
9rine sodium increase more than +*)mmol/-.h$
0ractional e1cretion of filtrated sodium is more t"an

$6
67 #a

% #a/0 #a

0 Cr /% Cr

:+,,
9rine osmolality
3ess than ;), mOsm/3 in !46
1ore than ),,mOsm/3 in prerenal failure or glomerular nephritis
Serum &9? (r

elevating for ;.5

<.. mmol/3/d
)lasma/urine (rA47
-enal failure inde1 (-0I)
46(

% #a:

0 Cr / % Cr

-0I

$6: %-0
-0I

: )rerenal oliguria
-enal and prerenal oliguria
-enal and postrenal
2$ -enal ultrasound

nep"rau1e ureter e1pansion

4$ )lain abdominal C/ray

calcification stone or obstruction

5$ intravenously pyelograp"y ( I!))

=$ -etrograde pyelograp"y
'reatment
Oliguria or anuria stage
(ontrol fluid input: body *eig"t is decreased 7$6#g daily$
Output is input, less input is better than the more
0luid amount daily

dominance loss

non/dominance loss

endogeny
*ater
?utrition
3ess protein, high calorie, high vitamin diet
0rotein synthesis hormone= >?, testosterone
(orection of electrolyte imbalance
@hyperAalemia, hyponatremia, hypocalcemia, acidosis

%ntibiotics:"armful to #idney
&lood purification
1. hemodialysis

artificial kidney. High clearance rate for small molecules;

hemodynamics unstable
1. peritonealdialysis

small molecular substances; infection; low clearance rate

1. hemofiltration

high clearance rate for middle molecules; hemodynamics stable

9rorr"agia stage
Infuse optimal fluid

avoiding loss of e1tra cellular fluid

6luid infusion is +/;B+/- fluid output equivalently.
(orrection of electrolyte
(nfuse sodium and potassium according to determination of electrolyte daily.
Increase amount protein$
'reat infection actively
)rop"yla1is
'o diagnose volume deficient timely
)erform fluid test first *"en oliguria e1isted
'o treat according to fluid deficient
'o correct *ater and electrolyte imbalance in patients *it" trauma and pre/
operation
Management of 1enotype blood infusion
'o rise p3 values in urine for al#ali
Mannitol for diuresis
-estrict inotropic agents
?orepinep"rine
pressor agent
'reatments of DI(
3eparin
%cute -espiratory Distress Syndrome (%-DS)
Definition
!cute pulmonary dysfunction originating from diffuse infiltration and pulmonary compliance
decreased leading to severe hypo&ia.
%-DS is an inflammatory process
?ot a accumulation of edema fluid
&ot" lungs
)redisposing conditions
In:ury
+ung in:ury

lung contusion smo#e aspiration of gastric contents

to1ic gas dro*ning o1ygen
E1tra/lung in:ury: fractures trauma burns massive transfusion
amniotic fluid t"rombosis transplantation
Operation: cardiopulmonary bypass ma:or operation
Infection: sepsis/septic s"oc#
S"oc# and DI(
Mec"anism
Initial stage
)ulmonary capillary permeability lung parenc"yma edema$
Eryt"rocytes e1udates
+eu#ocytes infiltrate to deterioration of cellular damages
)ulmonary vasoconstriction t"rombosis %/! s"unt$
%lveoli
Edema
D)+
3yaline and bloody fluid
3yaline and bloody fluid in bronc"ia

fla#e atelectasis
%dvanced stage
)ulmonary parenc"yma inflammation aggravated
(omplicating *it" infection
0inal stage
)ulmonary fibrosis
(apillary vessels occlusion
%fterload rise "ypo1ia
(linical manifestations
Initial stage
'ac"ypnea refractory to supplemental o1ygen
)rogressive "ypo1emia
?o rales
9nrevealing in c"est C/ray
4$ %dvanced stage
)rominent dyspnea and cyanosis
?eed mec"anical ventilation
-ales; bronc"i secretion rise
("est C/ray: bilateral infiltrates
(onscious disturbance
'emperature and leu#ocytes rise
5$ 0inal stage
%rr"yt"mia

bradycardia

cardiac arrest
Deep coma
Diagnosis
)redisposing conditions
%cute in:ury
Systemic infection
--A57
Dyspnea
'ransplantation
E1clude ot"er conditions
Diagnostic (riteria
'"erapy D 'reatment
(orrection of "ypo1emia Euic#ly
Mec"anical ventilation earlier
Optimal )EE) recovery of alveolar function and functional residual
capacity
Open lung
-ecovery of circulation and prevention of pulmonary interstitial edema
Optimal colloid and crystal fluid ratio
Optimal diuretics
Optimal negative fluid balance

'o evaluate by (!)/)%,) urine and rales

'reatment of infection:
/sputum drainage; antibiotics
&loc# SI-S
Glucocorticosteroid earlier
Inflammatory mediators in"ibitor

(buprofen, o&pentifylline, "#6 !b.

3eparin
3emofiltration
Mec"anical ventilation
!entilatory mode: positive ventilation
)EE): t"e optimal
)revention of "ypovolemia: prevention of imbalance of !/F
&arotrauma: )I)

67cm34O