多系統(tǒng)器官衰竭英文講訴

1、Multiple Organ Dysfunction Syndrome (MODS)多器官功能障礙綜合征,Lecturer Dr. Xianmin Bu 卜獻(xiàn)民,Definition,Multiple organ dysfunction syndrome MODS: Multiple organs or systems dysfunction occur simultaneously or progressively f

2、ollowing severe infection, severe trauma and shock. The affected organs/systems may be respiratory, cardiovascular, renal, hepatic, gastrointestinal, hematological, endocrine, and central nervous system. MODS is an imp

3、ortant reason for the death of severe patient.,The Evolution of MODS,In World War I, injured soldiers died in the battlefield of profound cardiac failure. This was presumed to be caused by wound toxins, but clinical inte

4、rventions were largely undefined.In World War II and to a greater extent in the Korean War, the loss of blood volume was recognized to be the primary cause of traumatic shock. battlefield casualties were resuscitated wi

5、th blood and plasma until blood pressure returned to normal. As a result, more soldiers survived their initial insult; however, the severely injured often succumbed to oliguric renal failure.,The Evolution of MODS,1960’s

6、 - ARDS was described in Vietnam “Shock Lung”.1973 - Tilney described multiple organ failure (MOF) or Multi System Organ Failure (MSOF). They concluded that MOF syndrome was the result of a combination of preexisting

7、disease and hemorrhagic shock.1980’s - began to realize concept of sepsis. MOF was considered as a fatal expression of uncontrolled infection.1990’s – systemic hyperinflammation became the focus, now referred to as the

8、 systemic inflammation response syndrome (SIRS).,The Evolution of MODS,MODS replaces “Multi System Organ Failure” or MSOFMODS is a range of dysfunctional organs, not just failureAltered organ function in an acutely i

9、ll patient such that homeostasis cannot be maintained without intervention,MOF and MODS,Multiple organ failure (MOF):Progressive distant organ failure (initially uninvolved) following severe infectious or noninfectiou

10、s insults (severe burn, multiple trauma, shock, acute pancreatitis)MOF is the finality of MODS,mechanism,basis diseases:Severe tissue injury or blood and fluid loss due to trauma, burn and major operationSevere infec

11、tionShockresuscitation of cardiac and respiratory arrestAcute haemorrhagic necrotic pancreatitis, colic intestine obstruction, rewarming of cold injuryMisapplication of infusion, drug, or respirator.Primary diseas

12、e: coronary heart disease, liver cirrhosis, chronic nephrosis,mechanism,The mechanisms of MODS are enormously compiex and poorly understood.Systemic inflammatory response syndrome (SIRS) is the main reason of MODS.De

13、finition: pathologic inflammatory response to injury or infectionDiagnostic criteria: any two or more of the following manifestations: 1.temp > 38 or 90/min 3.respiratory rate >20/min or hyper

14、ventilation (PaCO2 12,000 cells/mm3,or 10%,mechanism,To every action there is always opposed an equal reaction: or, the mutual action of two bodies upon each other are always equal, and directed to contrary

15、parts.-Sir Isaac Newton, 1687Compensatory anti-inflammatory response syndrome (CARS)Imbalance of inflammatary response and anti-inflammatory response SIRS > CARS, MODS occurs.,mechanism,Enterogenous infecti

16、on ischemic injury ↓ Intestine mucosal barrier dysfunction ↓ Bacterial Translocation ↓ Enterogenous/ent?r infection ↓ release of inflammatory mediators ↓ MODs,Clinical featur

17、e and diagnosis,Two type: Primary: rapid, 24 hours after acute primary disease, two or more organs dysfunction. The occurrence of MODS is due to a direct injury or insult to an organ or system. As contusion of lung

18、 from trauma, coagulapathy induced by multiple blood transfusion, acute renal shut down from drugs. Secondary: tardy, after an initial organ dysfunction and a steady period, two or more organs dysfunction occurs sec

19、ondarily. it is a consequence of the host response, which result in an inflammatory response in organ distant from the site of the initial insult.,Cardiovascular,Acute heart failuer:Tachycardia, arrhythmiaAbnormal

20、ECGShock :BP↓, coldness of extremities, oliguria microcirculation abnormal,Respiratory,acute respiratory distress syndrome (ARDS):tachypnea, wheezing, cyanose, dependence upon oxygenation support and mechanical ve

21、ntilationHyperventilation results in respiratory alkalosisSevere hypoxemia, abnormal respiratory function.,mechanical ventilation,,,,,Renal,Acute renal failure(ARF):Sudden decline of urine output (less than 400ml/24ho

22、ur) despite adequate fluidsSpecific gravity of urine ↑Na↑in urine and Cr↑in blood,,Gastrointestinal,Stress ulcer and intestinal paralysis:Haematemesis嘔血 hematochezia 便血 abdominal distention weak bowel soundsga

23、stroscope,,Hepatic,Acute hepatic failure :Jaundice Mind abnormal hepatic encephalopathyAbnormal biochemical liver function tests : bilirubin lift,Neurological,Central Nervous System failure: Conscious disturba

24、nce reactive depression of pain and sound stimulation,Disseminated intravascular coagulation (DIC),Ecchymosis 淤斑 Haematemesis 嘔血 Haemoptysis 咯血 platelet count, fibrinogen, thrombin time (PT), partial thro

25、mbin time (PTT),Early diagnosis,1.Acquaintance with the high risk factors of MODS.severe infection (sepsis), trauma, burn, acute severe pancreatitis, etcTachypnea, Tachycardia, low BP, mind abnormal, oliguria, etc.The

26、 diagnosis of infection is very important.,Early diagnosis,2. SIRS + organ dysfunction = MODSOrgan dysfunction caused by SIRS induced damage such that homeostasis cannot be maintained without supportive measures SIRS m

27、ust be identified as soon as possible in order to institute immediate treatment to try and prevent progression to MODS,Early diagnosis,3. Multiple organ dysfunction occurs progres-sively, either the initial organ or a di

28、stant organ.One organ dysfunction occurs, the others should be detected in time.DIC: ARDS, ARF, GI hemorrhage and cerebral hemorrhageIn clinic, ARDS hepatic failure, ARF and GI failure.,,Early diagnosis,4. Pay m

29、ore attention to organ dysfunction than organ failure. That SIRS evolves into MODS is a dynamic process.The dysfunction may be partial or complete, reversible or irreversible,Early diagnosis,5. Dysfunction of heart, lun

30、g, brain and kidney has a clear clinical manifestation, while until severe stage, dysfunction of liver, GI and haematological system has not a clear clinical manifestation. Some special accessory examinations are essen

31、tial.,Prophylaxis and treatment,Synthetic and Supportive TherapyHigh mortalityProphylaxis is more important.,Prophylaxis and treatment,1. Improve the quality of resuscitation, attach importance to circulation and r

32、espiratory. correct hypovolemia, restore tissue perfusion and oxygen transportation,Prophylaxis and treatment,2. Control infection is a important measure to prevent MODS.Drainage of infectious focus, clearance of

33、necrotic tissuesLocalization of infection to alleviate toxemia.Antibiotics,,,Prophylaxis and treatment,3. To manage single organ dysfunction early and block the pathologic chain reaction.More organs failure high

34、 mortality4. Improve general conditions.5. Protect intestinal mucous barrier, prevent bacterial translocation.6. Immune regulation,,acute renal failure(ARF)Defination Acute renal failure is a condition in

35、which the glomerular filtration rate is abruptly reduced, causing a sudden retention of endogenous metabolites that are normally cleared by the kidneys. Commonly, ARF is characterized by sudden reduce of urinary

36、output.,,oliguria urine volume<400ml/dayauria urine volume<100ml/daynonoliguric acute renal failure The urine volume per day is more than 800ml, the blood urea nitrogen(BUN) and serum creatinine ri

37、se progressively.,Etiology and classification,Prerenal ARF inadequate renal perfusionPostrenal ARF obstruction to the urine outflow of bilateral ureters of kidneysIntrarenal ARF acute tubular necrosis and acut

38、e cortical necrosis caused by the renal ischemia and renal toxicosis.,Etiology and classification,Prerenal ARF inadequate renal perfusion Hypovolemia   Hemorrhage    Gastro

39、intestinal fluid loss (nasogastric suction, high- output fistula, diarrhea, etc.)   Renal loss (excessive diuretic use, diabetes insipidus, diabetes mellitus)   

40、;Surgery    Burns,Etiology and classification,Prerenal ARF inadequate renal perfusionDecreased effective vascular volume   Sepsis   Hepatic failure 

41、0; Anaphylactic shock   Neurogenic shock   VasodilatorsImpaired cardiac function   Myocardial infarction Pulmonary embolus    Cardiac tamponade&#

42、160;  Congestive heart failure   Mechanical ventilation,Etiology and classification,Postrenal ARF obstruction to the urine outflowUreteral obstruction   Stone  &#

43、160;Infection (pyelonephritis)   Traumatic disruption TumorUrethral obstruction   Obstruction of Foley catheter   Mucus   Blood clots,Etiology and clas

44、sification,Intrarenal ARF acute tubular necrosis and acute cortical necrosis caused by the renal ischemia and renal toxicosis. Glomerulonephritis   Poststreptococcal glomerulonephritis  

45、; Systemic lupus erythematosus and other connective tissue disorders   Scleroderma   Malignant hypertension   Eclampsia/preeclampsia   Others,Etiol

46、ogy and classification,Intrarenal ARF Vasculitis Interstitial nephritis   Drugs (methicillin)   Infection   Neoplasm (lymphoma, leukemia, or sarcoidosis)Acute tubu

47、lar necrosis   Ischemia (prerenal events)   Antibiotics (amphotericin, aminoglycosides)   Radiocontrast agents   Pigment load (e.g., myoglobin 肌紅蛋白as in rha

48、bdomyolysis橫紋肌溶解)   Heavy metals (mercury)   Solvents (carbon tetrachloride, ethylene glycol),Clinical findings in oliguria or auria period last for 7~14 days The longer oliguri

49、a period, the worse prognosis.,Clinical findings in oliguria or auria period,1.Water and electrolyte disorder and acid-base imbalance water intoxication hyperkalemia hypochloremia hyponatremia hypermagnese

50、mia hypocalcemia and hyperphosphatemia metabolic acidosis2.azotemia and uremia3.hemorrhagic tendency,In high output periodUrine volume>400mlLast for 14 daysHypokalemia and secondary infection,DiagnosisMo

51、nitor urine volume and examine urine Blood examination progressive rise in serum creatinine(Cr) and blood urea nitrogen(BUN)Fluid replacement test and diuretic test,Treatment in oliguria period Use of diuritics

52、Restriction of water and electrolyte intakeSupply nutritionProphylaxis and treatment of hyperkalemiaCorrection of acidosisPrevent and control infectionHemopurification Hemodialysis and peritoneal dialysis,I

53、ndications for hemopurificationCr in blood>442umol/L[K+]>6.5mmol/LSevere metabolic acidosisExaggerated uremiaSymptoms and signs of water intoxication,hemodialysis,in high output periodKeep balance of water a

54、nd electrolytePrevent and control infectionNutritional supportPrevent the occurrence of complications,Thanks for your cooperation,,人有了知識，就會具備各種分析能力，明辨是非的能力。所以我們要勤懇讀書，廣泛閱讀，古人說“書中自有黃金屋?！蓖ㄟ^閱讀科技書籍，我們能豐富知識，培養(yǎng)邏輯思維能力；通