Multiorgan Dysfunction Case File

https://medical-phd.blogspot.com/2021/05/multiorgan-dysfunction-case-file.html

Eugene C. Toy, MD, Manuel Suarez, MD, FACCP, Terrence H. Liu, MD, MPH

Case 33
A 63-year-old man underwent a surgical appendectomy and colostomy formation for a ruptured
appendicitis with abscess and devitalized cecum. At the time of the operation, he was noted to have
necrosis and perforation of the cecum with fecal  peritonitis. On postoperative day 8, the patient
remains on the ventilator with PAO2/FIO2 = 260. Over the past 48 hours, he has developed worsening
oliguria with urine output of <300 mL over the past 18 hours. The patient is becoming visibly
jaundiced.  ACT scan of the abdomen reveals no intrahepatic ductal  dilatation, moderate amount of
postoperative inflammatory changes throughout the peritoneal  cavity, and no signs of active
intrabdominal infections.

⯈What is the most likely diagnosis?

⯈What are the causes of the patient's current condition?
⯈How would you monitor and quantify the patient's organ dysfunction?
⯈What are your therapeutic strategies and goals for this patient?

ANSWER TO CASE
Multiorgan Dysfunction

Summary: This is a 63-year-man who had an operation for a ruptured appendicitis, and his course
was complicated by colonic perforation and fecal peritonitis. The patient is now developing organ
dysfunction despite adequate source control. He is showing signs of pulmonary dysfunction with
compromised oxygenation (P/F ratio = 260). In addition, h e has new-onset compromised renal and
hepatic functions a s seen by his decreased urine output and visible jaundice. There is no evidence
of continued intra-abdominal pathology. 

 Causes of the patient's current condition: The patient's initial peritonitis and subsequent
inflammatory response has resulted in organ dysfunction in multiple systems. 
 Monitoring and quantifying the organ dysfunction: Continuous monitoring of his organ
functions via standard measures (urine output, MAP, oxygen saturation, etc) is mandatory,
and the level of dysfunction is quantified using the multiple organ dysfunction scale. 
 Therapeutic strategies and goals for this patient: The therapy for multiple organ
dysfunction is mainly supportive, addressing each organ system that is injured. The
underlying cause should be treated. Mechanical support may be necessary, such as
ventilatory support for pulmonary failure and hemodialysis for renal failure.

ANALYSIS
Objectives

1. To learn to identify, quantify, and manage multiple organ dysfunctions associated with
critical illnesses.
2. To learn the factors that may contribute to the development of multiple organ dysfunction
syndrome (MODS).
3. To learn the supportive care for patients with MODS.

Considerations
This patient presented with a single identifiable cause for his illness-appendicitis, cecal perforation
with fecal peritonitis. His illness has not resolved with the removal of his diseased colon, irrigation
of the peritoneal cavity, and antibiotic administration. Instead, despite appropriate treatment of his
peritonitis, his overall status is continuing to deteriorate. His pulmonary function has declined with
a P/F ratio that is indicative of acute lung injury. Likewise, he has acute kidney injury demonstrated
by his progressive oliguria. His hepatic function has also deteriorated as evidenced by his visible
jaundice. These organs become dysfunctional days following the inciting event and continue
despite the resolution of his initial illness. These are indicative of secondary MODS.

Approach To:
Multiple Organ Dysfunction Syndrome

DEFINITIONS

MULTIPLE ORGAN DYSFUNCTION SYNDROME: The continued dysfunction of two or

more organ systems that occurs as a result of a disruption in homeostasis. The organ dysfunction
may continue despite the resolution of the initial event.

SYSTEMIC INFLAMMATORY RESPONSE SYNDROME: Occurs when 2 of the following

are present:
1 . Body temperature <36°C or > 38°C
2. Heart rate >90 beats/minute
3 . Respiratory rate >20 breaths/minute
4. White blood cell count <4000 cells/mm  or > 12,000 cells/mm  or the presence of > 10%
3 3

immature neutrophils (band forms)

ACUTE KIDNEY INJURY (AKI): AKI was formerly referred to as acute renal failure (ARF).
AKI is defined by a rapid decline in renal function (<48 hours). The decrease in renal function is
determined using urine output and/or serum creatinine levels. An absolute increase in serum
creatinine of >0.3 mg/dL or a percentage increase in serum creatinine of >50% is indicative of AKI
. Also, a reduction in urine output, defined as <0.5 mL/kg/h for more than 6 hours is also AKI .

ACUTE LUNG INJURY/ACUTE RESPIRATORY DISTRESS SYNDROME: Hypoxemic

respiratory failure, of which the most severe form is acute respiratory distress syndrome (ARDS).
Acute lung injury is defined as a P/F ratio of 200 to 300. ARDS is hypoxemic failure with a P/F
ratio of <200, bilateral fluffy infiltrates on chest x-ray, and no evidence of congestive heart failure.

P/F RATIO: (PAO2/FIO2 ) X 100. This is used to identify the degree of pulmonary failure.