急诊医学教学课件：Multiple organ dysfunction syndrome

1、南南 京京 医医 科科 大大 学学 第第 二二 临临 床床 医医 学学 院院 The department of critical care medicineThe department of critical care medicine T h e S e c o n d A f f i l i a t e d H o s p i t a l o f N a n j i n g M e d i c a l U n i v e r s i t y T h e S e c o n d C l i n i c a l M e d i c a l S c h o o l o f N a n j i

2、n g M e d i c a l U n i v e r s i t y Multiple organ dysfunction syndrome (MODS) Im bleeding after just having my babyIm bleeding after just having my baby A 28-year-old woman at 40 weeks of gestation 8:50 spontaneous vaginal delivery a health boy 10:20 BP 90/50mmHg, bleed 500ml from vagina without

3、clot 10:30 BP 50/30mmHg, coma 10:50 Cardiac arrest ,Heart rate 0 Questions Q1.What do you want to do now? Q2.What do you want to do next? Diagnosis Cardiac arrest Amniotic fluid embolism Hemorrhagic shock Q1.What do you want to do now? Basic life support 1. Verify scene safety现场安全 2.Recognition of c

4、ardiac arrest识别骤停 3.Activation of emergency response system应急系统 4.Chest Compression胸外按压 5.Managing the Airway开放气道 6.Breathing人工呼吸 7.Defibrillation快速除颤 8.Drug therapy药物治疗 High quality CPR Case Basic life support (CPR, defibrillation) 11:00 heart rate 120 bpm Q2.What do you want to do next? Advanced l

5、ife support in ICU MODS Nervous Coma, never wake up Cardiovascular HR Blood pressure Respiratory Spo2 PaO2 Gastric and intestinal GI bleeding No bowel sound Renal Oliguria Acute renal failure Hematologic Bleeding everywhere Outline Concept Etiology Pathogenesis Clinical manifestation Diagnosis Treat

6、ment Prevent and prognosis Concept What is MODS？ Aortic aneurysm sequential systems failure Tilney in 1973 18 patients with aortic aneurysm and renal failure 17 died Tilney NL, Ballet GL, Morgan AP: Sequential systems failure after rupture of abdominal aortic aneurysms: an unsolved problem in postop

7、erative care. Ann Surg 178:117-122, 1973. How much is one plus one? Mortality of aortic aneurysm: 40-85% Mortality of acute renal failure 3% 1+1=? Why 17 died in18 patients（94.4%） ? Tilney is - Terminologies: 1973 Tilney序贯性系统衰竭 sequential system failure 1975 Baue 多发、进行性或序贯性系统或器官衰竭 （multiple，progress

8、ive or sequential system failure） 1976 Broder 多系统器官功能衰竭（multiple system organ failure，MSOF） 1977 Eiseman 多器官衰竭（multiple organ failure，MOF） 1985 Coris 全身炎症反应综合征（Systemic Inflammatory Response Syndrome, SIRS） 1991 ACCP/SCCM 多器官功能障碍综合征(multiple organ dysfunction syndrome, MODS) American College of Ches

9、t Physicians/Society of Critical Care Medicine Definition* MODS is the presence of altered organ function in a patient who is acutely ill homeostasis cannot be maintained without intervention development of progressive and potentially reversible physiological dysfunction in 2 or more organs or organ

10、 systems. Bone, R. C., R. A. Balk, F. B. Cerra, R. P. Dellinger, A. M. Fein, W. A. Knaus, R. M. Schein and W. J. Sibbald. Definitions for Sepsis and Organ Failure and Guidelines for the Use of Innovative Therapies in Sepsis. The Accp/Sccm Consensus Conference Committee. American College of Chest Phy

11、sicians/Society of Critical Care Medicine. Chest 101, no. 6 (1992): 1644-55. 1. Concept 2.Etiology 3. Pathogenesis 4. Clinical manifestation 5. Diagnosis 6. Treatment 7. Prevent and prognosis Etiology What can cause MODS? Etiology Infectious(sepsis and severe sepsis) Non-infectious: Shock Cardiac ar

12、rest Blood transfusion Burn Pancreatitis 1. Concept 2. Etiology 3.Pathogenesis 4. Clinical manifestation 5. Diagnosis 6. Treatment 7. Prevent and prognosis Pathogenesis How does MODS happen? MODS ：complex interaction of different pathogenic processes. 3.Pathogenesis 3.1.basic pathogenesis 3.1.1 infl

13、ammatory response 3.1.2 free radical 3.1.3 Gut 3.2.“two-hit” hypothesis 3.3.SIRS and CARS 3.1.1 inflammatory response Cornerstone of MODS Evidence: inflammatory mediators increase in MODS model Inject inflammatory mediators(TNF, IL-1) or endotoxin can induce MODS Inject Monoclonal antibodies against

14、 inflammatory mediators in MODS animal can prevent animal for death( NOT work in human) Inflammation Inflammation is part of the response of vascular tissues to harmful stimuli. Inflammation infection Inflammation is not itself considered a disease but a salutary operationbut when it cannot accompli

15、sh that salutary purposeit does mischief. John Hunter, MD (17281793) Associated terminologies TermDefinition BacteremiaPresence of viable bacteria in the blood Systemic inflammatory response syndrome (SIRS) Generalized hyperinflammatory response to several impacts SepsisSIRS caused by infection Seve

16、re sepsisSepsis associated with organ dysfunction Septic shockSepsis associated with arterial hypotension ACCP/SCCM Consensus Conference Committee. Definition for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 1992;20:86474 Associated terminologi

17、es SIRS(Systemic inflammatory response syndrome) Sepsis : SIRS due to infection Severe sepsis Septic shock MODS Systemic inflammatory response syndrome(SIRS)* SIRS is an inflammatory state affecting the whole body, frequently a response of the immune system to infection, but not necessarily so. Two

18、or more of: FindingValue Temperature38 C Heart rate90/min Respiratory rate20/min or PaCO232 mmHg WBC 4x109/L (12x109/L (12,000/mm), or 10% immature (band) forms Dear SIRS, Im sorry to say that I dont like you Crit Care Med. 1997 Feb;25(2):372-4. Dear SIRS, Im sorry to say that I dont like you. Vince

19、nt JL. Sepsis 3.0 2016 Shankar-Hari, M., et al. (2016). Developing a New Definition and Assessing New Clinical Criteria for Septic Shock: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA 315(8): 775-787 Sepsis : life-threatening organ dysfunction caused

20、by a dysregulated host response to infection. organ dysfunction For clinical operationalization, organ dysfunction can be represented by an increase in the Sequential Sepsis-related Organ Failure Assessment (SOFA) score of 2 points or more, which is associated with an in-hospital mortality greater t

21、han 10%. Sequential Organ Failure Assessment (SOFA) score Glasgow coma scale quickSOFA (qSOFA) * respiratory rate of 22/min or greater, altered mentation, systolic blood pressure of 100 mm Hg or less. Septic shock* sepsis vasopressor requirement to maintain a mean arterial pressure of 65 mm Hg or gr

22、eater And serum lactate level greater than 2 mmol/L (18 mg/dL) in the absence of hypovolemia. MODS and MOF Inflammatory injury involving more than one vital organ is called multiple organ dysfunction syndrome(MODS), and the subsequent failure of more than one organ system is called multiple organ fa

23、ilure (MOF). 3.1.2 free radicals Hypoxia injure cell directly ischemia-reperfusion make free radical release White blood cells and endothelial cells interact 3.1.3 Gut Gut is the biggest bank for bacteria and toxin. Infection sources were not found in 1/3 died MODS patients with bacteremia. Intestin

24、es is sensitive to ischemia and reperfusion enteral nutrition can keep intestines mucous intact and decrease infection incidence. The population density of microorganisms in different regions of the alimentary tract. Numbers indicate colony forming units per gram or mL of luminal contents. Autointox

25、ication? total colectomies in patients with chronic constipation, to prevent “autointoxication” from toxic bowel contents Sir William Arbuthnot Lane, Bt, CB, FRCS, Legi on of Honour (4 July 1856 16 January 1943) 3.2two-hithypothesis 3.3 SIRS and CARS systemic inflammatory response syndrome (SIRS) co

26、mpensatory anti- inflammatory response syndrome (CARS):inflammatory mediators decrease Mixed antagonist response syndrome (MARS)=SIRS+CARS Taiji(太極) SIRS and CARS Jon A. Buras, Bernhard Holzmann & Michail Sitkovsky, Animal Models of sepsis: setting the stage, Nature Reviews Drug Discovery 4, 854- 86

27、5 (October 2005) 1. Concept 2. Etiology 3. Pathogenesis 4.Clinical manifestation 5. Diagnosis 6. Treatment 7. Prevent and prognosis Clinical Manifestations 4.1 Nervous 1. clinical monitor( consciousness, pupil size and reaction to light, reflection , tension) 2. bispectral analysis(BIS) 3.intra cran

28、ial pressure 4.2 Cardiovascular ECG: arrhythmia, ST-T, Blood pressure: non- invasive or invasive CVP Swan-Ganz Direct Invasive Blood Pressure Measurement Direct blood pressure measurement is performed with an intra-arterial catheter. Pulmonary Artery Catheters 4.3 Respiratory 1. signs: body position

29、, frequency, movement 2.spo2 3.Lung funtion 4. imaging (X ray ,CT ) 5.ABG(arterial blood gas) 1 pH 6.810 7.3507.450 2 PCO2 53.0 35.045.0 mmHg 3 PO2 75.0 80.0110.0 mmHg 4 BE -24.4 -2.03.0 mmol/L 5 TCO2 9.9 22.029.0 mmol/L 6 HCO3 7.2 22.024.0 mmol/L 7 spo2 89% 90-100% FIO2=90% PO2/FIO2=75/90%=83100 AR

30、DS 4.4 Gastric and intestines 1. clinical monitor(bowel sound, occult blood) 2.PH of the gastric juice 3. PH of the gastric mucous(pHi) pHi7.35 ischemia 4.5 Renal urinary volume Blood creatinine and blood Urea Nitrogen creatinine clearance rate Urine : 5ml/hour anuria ( 100ml/day)* Oliguria (400ml/d

31、ay)* BUN(blood Urea Nitrogen) 3.71 2.507.50 mmol/L CRE(Blood creatinine) 34.3 45.084.0 mol/L Acute renal failure 4.6 Hepatic Transaminase(alanine aminotransferase ALT and aspartate transaminase AST) Total bilirubin and direct bilirubin lactate dehydrogenase(LDH) AdmissionDay 0Day1Normal ALT815610660

32、40 IU/L AST142162564040 IU/L TBIL9.49143.210.0020.05 mol/L DBIL5.4650.620.006.80 mol/L LDH6404998 80240 IU/L Acute Hepatic failure 4.7 Hematologic 1. blood routine test(RBC,WBC,PLT) 2. blood coagulation test(PT, APTT,D-dimmer, fibrinogen degradation product) Admissionday0day1normal WBC15.8 20.17.54.

33、010.0 109/L RBC4.37 2.374.103.505.50 1012/L HGB107.0 67.0124110.0 150.0 g/L PLT195 9735100300 109/L Day0 Blood transfusion: RBC: 30U Plasma: 2000ml cryoprecipitate: 30U PLT: 40U Admissionday0day0day1 PT11.9long35.913.69.0 13.0 s APTT31.4long long58.420.0 40.0 s FIB4.08 no0.542.04 FDP20.80 279.1 0 34

34、5. 00 150.3 0 0.00 5.00 g/ml D- dimmer 9.58No 40.0 0 84.600.59mg /L Day0 Blood transfusion: RBC: 30U Plasma: 2000ml cryoprecipitate: 30U PLT: 40U 4.8 Infection The source Culture Features of MODS 1.remote organ injury 2.interval of time between primary injury and organ dysfunction. 3.hyper-dynamic c

35、irculation(high output low resistance) 4.high oxygen supply and usage dysfunction 5. hypermetabolism and energy use dysfunction Course of MODS Stage 1(shock) is characterized by an acute event that is associated by a variable period of hypotension. Stage 2(resuscitation) is the period of active resu

36、scitation that lasts up to 24 hours. Stage 3(hypermetabolism) is the phase of stable hypermetabolism (eg, increased oxygen consumption) that may persist for 7-10 days. During this time the patient appears to be stable and doing well by the usual clinical criteria. Stage 4(failure) usually occurs bet

37、ween day 14 and 21. Death usually occurs 21-28 days after the initial event. 1. Concept 2. Etiology 3. Pathogenesis 4. Clinical manifestation 5.Diagnosis 6. Treatment 7. Prevent and prognosis organ dysfunction For clinical operationalization, organ dysfunction can be represented by an increase in th

38、e Sequential Sepsis-related Organ Failure Assessment (SOFA) score of 2 points or more, which is associated with an in-hospital mortality greater than 10%. Sequential Organ Failure Assessment (SOFA) score 1. Concept 2. Etiology 3. Pathogenesis 4. Clinical manifestation 5. Diagnosis 6.Treatment 7. Pre

39、vent and prognosis 6.Treatment 0.Organ replacement therapy 1.treat the primary disease. 2.inprove the oxygen metabolism, treat tissue hypoxia. 3.metabolism support 4.Immune support 6.0 Organ Replacement therapy 6.1Treat the primary disease Drain Antibiotics Operation for trauma If the gut work, use

40、it Resuscitation for shock 6.2Oxygen metabolism 1. increase Oxygen Delivery (DO2) DO2=Q*CaO2*10 DO2=Q*1.34*HB*SaO2*10 the O2 content in arterial blood (Cao2) in mL/L and the cardiac output (Q) in L/min 2.decrease Oxygen consume Cool( 1 7% O2 demand 25% O2 consumption） Sedation Mechanical ventilation 3.organ perfusion Fluid norepinephrine dobutamine 6.3 Metabolism support Autocannibalism (cannibalism is the act or practice of humans eating the flesh of other human beings) Hyperglycemia Hyperlactatemia protein catabol