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MultipleOrganDysfunctionSyndrome MODS 多器官功能障碍综合征 LecturerDr XianminBu卜献民 Definition MultipleorgandysfunctionsyndromeMODS Multipleorgansorsystemsdysfunctionoccursimultaneouslyorprogressivelyfollowingsevereinfection severetraumaandshock Theaffectedorgans systemsmayberespiratory cardiovascular renal hepatic gastrointestinal hematological endocrine andcentralnervoussystem MODSisanimportantreasonforthedeathofseverepatient TheEvolutionofMODS InWorldWarI injuredsoldiersdiedinthebattlefieldofprofoundcardiacfailure Thiswaspresumedtobecausedbywoundtoxins butclinicalinterventionswerelargelyundefined InWorldWarIIandtoagreaterextentintheKoreanWar thelossofbloodvolumewasrecognizedtobetheprimarycauseoftraumaticshock battlefieldcasualtieswereresuscitatedwithbloodandplasmauntilbloodpressurereturnedtonormal Asaresult moresoldierssurvivedtheirinitialinsult however theseverelyinjuredoftensuccumbedtooliguricrenalfailure TheEvolutionofMODS 1960 s ARDSwasdescribedinVietnam ShockLung 1973 Tilneydescribedmultipleorganfailure MOF orMultiSystemOrganFailure MSOF TheyconcludedthatMOFsyndromewastheresultofacombinationofpreexistingdiseaseandhemorrhagicshock 1980 s begantorealizeconceptofsepsis MOFwasconsideredasafatalexpressionofuncontrolledinfection 1990 s systemichyperinflammationbecamethefocus nowreferredtoasthesystemicinflammationresponsesyndrome SIRS TheEvolutionofMODS MODSreplaces MultiSystemOrganFailure orMSOFMODSisarangeofdysfunctionalorgans notjustfailureAlteredorganfunctioninanacutelyillpatientsuchthathomeostasiscannotbemaintainedwithoutintervention MOFandMODS Multipleorganfailure MOF Progressivedistantorganfailure initiallyuninvolved followingsevereinfectiousornoninfectiousinsults severeburn multipletrauma shock acutepancreatitis MOFisthefinalityofMODS mechanism basisdiseases Severetissueinjuryorbloodandfluidlossduetotrauma burnandmajoroperationSevereinfectionShockresuscitationofcardiacandrespiratoryarrestAcutehaemorrhagicnecroticpancreatitis colicintestineobstruction rewarmingofcoldinjuryMisapplicationofinfusion drug orrespirator Primarydisease coronaryheartdisease livercirrhosis chronicnephrosis mechanism ThemechanismsofMODSareenormouslycompiexandpoorlyunderstood Systemicinflammatoryresponsesyndrome SIRS isthemainreasonofMODS Definition pathologicinflammatoryresponsetoinjuryorinfectionDiagnosticcriteria anytwoormoreofthefollowingmanifestations 1 temp 38or90 min3 respiratoryrate 20 minorhyperventilation PaCO212 000cells mm3 or10 mechanism Toeveryactionthereisalwaysopposedanequalreaction or themutualactionoftwobodiesuponeachotherarealwaysequal anddirectedtocontraryparts SirIsaacNewton 1687Compensatoryanti inflammatoryresponsesyndrome CARS Imbalanceofinflammataryresponseandanti inflammatoryresponseSIRS CARS MODSoccurs mechanism Enterogenousinfectionischemicinjury Intestinemucosalbarrierdysfunction BacterialTranslocation Enterogenous ent rinfection releaseofinflammatorymediators MODs Clinicalfeatureanddiagnosis Twotype Primary rapid 24hoursafteracuteprimarydisease twoormoreorgansdysfunction TheoccurrenceofMODSisduetoadirectinjuryorinsulttoanorganorsystem Ascontusionoflungfromtrauma coagulapathyinducedbymultiplebloodtransfusion acuterenalshutdownfromdrugs Secondary tardy afteraninitialorgandysfunctionandasteadyperiod twoormoreorgansdysfunctionoccurssecondarily itisaconsequenceofthehostresponse whichresultinaninflammatoryresponseinorgandistantfromthesiteoftheinitialinsult Cardiovascular Acuteheartfailuer Tachycardia arrhythmiaAbnormalECGShock BP coldnessofextremities oliguriamicrocirculationabnormal Respiratory acuterespiratorydistresssyndrome ARDS tachypnea wheezing cyanose dependenceuponoxygenationsupportandmechanicalventilationHyperventilationresultsinrespiratoryalkalosisSeverehypoxemia abnormalrespiratoryfunction mechanicalventilation Renal Acuterenalfailure ARF Suddendeclineofurineoutput lessthan400ml 24hour despiteadequatefluidsSpecificgravityofurine Na inurineandCr inblood Gastrointestinal Stressulcerandintestinalparalysis Haematemesis呕血hematochezia便血abdominaldistentionweakbowelsoundsgastroscope Hepatic Acutehepaticfailure JaundiceMindabnormalhepaticencephalopathyAbnormalbiochemicalliverfunctiontests bilirubinlift Neurological CentralNervousSystemfailure Consciousdisturbancereactivedepressionofpainandsoundstimulation Disseminatedintravascularcoagulation DIC Ecchymosis淤斑Haematemesis呕血Haemoptysis咯血plateletcount fibrinogen thrombintime PT partialthrombintime PTT Earlydiagnosis 1 AcquaintancewiththehighriskfactorsofMODS severeinfection sepsis trauma burn acuteseverepancreatitis etcTachypnea Tachycardia lowBP mindabnormal oliguria etc Thediagnosisofinfectionisveryimportant Earlydiagnosis 2 SIRS organdysfunction MODSOrgandysfunctioncausedbySIRSinduceddamagesuchthathomeostasiscannotbemaintainedwithoutsupportivemeasuresSIRSmustbeidentifiedassoonaspossibleinordertoinstituteimmediatetreatmenttotryandpreventprogressiontoMODS Earlydiagnosis 3 Multipleorgandysfunctionoccursprogres sively eithertheinitialorganoradistantorgan Oneorgandysfunctionoccurs theothersshouldbedetectedintime DIC ARDS ARF GIhemorrhageandcerebralhemorrhageInclinic ARDShepaticfailure ARFandGIfailure Earlydiagnosis 4 Paymoreattentiontoorgandysfunctionthanorganfailure ThatSIRSevolvesintoMODSisadynamicprocess Thedysfunctionmaybepartialorcomplete reversibleorirreversible Earlydiagnosis 5 Dysfunctionofheart lung brainandkidneyhasaclearclinicalmanifestation whileuntilseverestage dysfunctionofliver GIandhaematologicalsystemhasnotaclearclinicalmanifestation Somespecialaccessoryexaminationsareessential Prophylaxisandtreatment SyntheticandSupportiveTherapyHighmortalityProphylaxisismoreimportant Prophylaxisandtreatment 1 Improvethequalityofresuscitation attachimportancetocirculationandrespiratory correcthypovolemia restoretissueperfusionandoxygentransportation Prophylaxisandtreatment 2 ControlinfectionisaimportantmeasuretopreventMODS Drainageofinfectiousfocus clearanceofnecrotictissuesLocalizationofinfectiontoalleviatetoxemia Antibiotics Prophylaxisandtreatment 3 Tomanagesingleorgandysfunctionearlyandblockthepathologicchainreaction Moreorgansfailurehighmortality4 Improvegeneralconditions 5 Protectintestinalmucousbarrier preventbacterialtranslocation 6 Immuneregulation acuterenalfailure ARF DefinationAcuterenalfailureisaconditioninwhichtheglomerularfiltrationrateisabruptlyreduced causingasuddenretentionofendogenousmetabolitesthatarenormallyclearedbythekidneys Commonly ARFischaracterizedbysuddenreduceofurinaryoutput oliguriaurinevolume 400ml dayauriaurinevolume 100ml daynonoliguricacuterenalfailureTheurinevolumeperdayismorethan800ml thebloodureanitrogen BUN andserumcreatinineriseprogressively Etiologyandclassification PrerenalARFinadequaterenalperfusionPostrenalARFobstructiontotheurineoutflowofbilateraluretersofkidneysIntrarenalARFacutetubularnecrosisandacutecorticalnecrosiscausedbytherenalischemiaandrenaltoxicosis Etiologyandclassification PrerenalARFinadequaterenalperfusionHypovolemiaHemorrhageGastrointestinalfluidloss nasogastricsuction high outputfistula diarrhea etc Renalloss excessivediureticuse diabetesinsipidus diabetesmellitus SurgeryBurns Etiologyandclassification PrerenalARFinadequaterenalperfusionDecreasedeffectivevascularvolumeSepsisHepaticfailureAnaphylacticshockNeurogenicshockVasodilatorsImpairedcardiacfunctionMyocardialinfarctionPulmonaryembolusCardiactamponadeCongestiveheartfailureMechanicalventilation Etiologyandclassification PostrenalARFobstructiontotheurineoutflowUreteralobstructionStoneInfection pyelonephritis TraumaticdisruptionTumorUrethralobstructionObstructionofFoleycatheterMucusBloodclots Etiologyandclassification IntrarenalARFacutetubularnecrosisandacutecorticalnecrosiscausedbytherenalischemiaandrenaltoxicosis GlomerulonephritisPoststreptococcalglomerulonephritisSystemiclupuserythematosusandotherconnectivetissuedisordersSclerodermaMalignanthypertensionEclampsia preeclampsiaOthers Etiologyandclassification IntrarenalARFVasculitisInterstitialnephritisDrugs methicillin InfectionNeoplasm lymphoma leukemia orsarcoidosis AcutetubularnecrosisIschemia prerenalevents Antibiotics amphotericin aminoglycosides RadiocontrastagentsPigmentload e g myoglobin肌红蛋白asinrhabdomyolysis横纹肌溶解 Heavymetals mercury Solvents carbontetrachloride ethyleneglycol Clinicalfindingsinoliguriaorauriaperiodlastfor7 14daysThelongeroliguriaperiod theworseprognosis Clinicalfindingsinoliguriaorauriaperiod 1 Waterandelectrolytedisorderandacid baseimbalancewaterintoxicationhyperka

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