Early detection mods 16 พค.58

EARLY DETECTION OF MULTIPLE ORGAN

DYSFUNCTION SYNDROME

ผศ.ดร.กรองได อุณหสตู

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Multi organ dysfunction syndrome

Multi organ dysfunction syndrome (MODS) as the dysfunction of at least 2 organ systems from an inflammatory insult.

ผศ.ดร.กรองได อุณหสูต

Injury stress reaction SIRS/CARS MODS MOF

การบาดเจ็บ

เน้ือบุผวิถูกทาํลาย

ออกซเิจนไปทีเ่ซลล์น้อย

เซลล์ขาดออกซเิจน

การเผาผลาญทีไ่มใ่ชอ้อกซเิจน

ระบบภูมติา้นทาน ↑

การหล ั่งสารใหพ้ลงังานสูง

หลอดเลือดขยายตวั การใชอ้อกซเิจนผดิปกต ิ

อวยัวะทาํหน้าทีไ่มไ่ดต้ามปกต ิ

1. Temp > 38 °C or < 36 °C 2. HR > 90 /นาที 3. RR > 20 /นาที 4. WBC >12,000 or < 4000 cells mm-3


1-2 ชม. Inadequate resuscitate

Response of injury Local

response Tissue level

reaction Systemic response


Organ system Physiologic response

Cardiovascular Tachycardia

Renal Output ↓

Adrenal Cortisol release ↑

Pulmonary Minute volume ↑

CNS Altered mental state

Splanchnic Blood flow ↓

Injury

ACTH

กระตุน้การสรา้ง

cortisol

เผาผลาญ คาร์โบไฮเดรท โปรตีน ไขมนั

และโปแตสเซียม

โอกาสเกดิ การตดิเช้ือสงู

Renin

angiotensin I และangiotensin

II

หล ั่ง Aldosterone

และ vasopressin

ACTH

Catecholamine (epinephrine,

norepinephrine)

Vasopressin (ADH)

Osmo - regulation

เกดิการดูดน้ํากลบั

Vasoactive เกดิ

vasoconstriction

Metabolic เกดิ hepatic glycogeno -

lysis และ gluconeo- genesis

Insulin ไมเ่พิม่ขึน้

ลดลงสูปกตภิายใน 5 วัน

อัตรารอดชวีติ ↓

การดดูกลบัของโซเดยีม โปตัสเซยีม

สูงขึ้นทนัทใีน 24-48 ชม.

• เพิ่มการผลติกลโูคสเขาสูกระแสเลือด ลดการนาํกลโูคสเขาสูเซลล • กระตุนการเปลีย่นแปลงกรดอะมิโนเปนน้าํตาลกลโูคส สลายไขมนัเปนกรดไขมนั

กลูคากอน ยับยัง้การสราง


SIRS

Systemic Immune Response Syndrome Temp > 38 °C or < 36 °C HR > 90 /นาท ีRR > 20 /นาท ีWBC >12,000 or < 4000 cells mm-3


1 = absence 2 = mild 3 = moderate 4 = severe

Prediction of MODS

No singular standard to identify MODS No laboratory test has yet proven

diagnosis


Physiologic scoring systems determine a severity score

and predict outcome

Organ indicator none minimal mild moderate severe

Respiratory PaO2/FiO2 ratio

> 300 226-300 151-225 76-150 ≤ 75

Renal Serum creatinine (umol/L)

≤ 100 101-200 201-350 351-500 > 500

Hepatic Serum birirubin (umol/L)

≤ 20 21-60 61-120 121-240 > 240

Cardiovascular CVP/MAP < 10.0 10.1-15.0 15.1-20.0 20.1-30.0 > 30.0

Hematologic Platelet count (mm3)

> 120,000 81,000-120,000

51,000-80,000

21,000-50,000

≤ 20,000

Neurologic GCS 15 13-14 10-12 7-9 ≤ 6

Multiple Organ Dysfunction Score Marshall,J.C


Score point 1 2 3 4

Respiration PaO2FiO2 <400 <300 <200 with respiratory

support

<100 with respiratory

support

Cardiovascular Hypotension

MAP <70 Dopamine ≤5 or

dobutamine in any dose

Dopamine >5 or epinephrine

≤0.1 or norepinephrine

≤0.1

Dopamine >15 or epinephrine

>0.1 or norepinephrine

>0.1

Liver Birilubin(mg/dl)

1.2-1.9 2.0-5.9 6.0-11.9 >12.0

Renal Creatinine (mg/dl) or urine output (ml/d)

1.2-1.9 2.0-3.4 3.5-4.9 or <500 1n 24 hr

>5.0 or <200 in 24 hr

Coagulation Platelet x 103/mm3

>150 <100 <50 <25

CNS (GCS) 13-14 10-12 6-9 <6

Logistic Organ Dysfunction Score Le Gall et al


Dysfunction 0 1 2 3

Pulmonary PaO2/FiO2 >208 208-165 165-83 <83

Renal Creatinine (umol/l)

>159 160-210 211-420 >420

Hepatic Total Birilubin (umol/l)

<34 34-68 69-137 >137

Cardiac Inotropes

No inotropes Only one inotrope at a small dose

Any inotrope at moderate dose

or >1 agent, all at small

dose

Any inotrope at large dose

or >2 agents, at moderate

dose

Denver Post injury Multiple organ Failure Score (Moore)

• ISS >15, survived longer 48 hr, ≥ 16 years of age


SOFA score 0 1 2 3 4

Respiration PaO2FiO2 or SaO2/FiO2 mmHg

>400 <400 221-301

<300 142-220

<200 67-141

<100 <67

Coagulation >150 <150 <100 <50 <20


<1.2 1.2-1.9 2.0-5.9 6.0-11.9 >12.0


No hypotension

MAP <70 Dopamine ≤5 or any

Dopamine >5 or

notepinephrine ≤0.1

Dopamine >15 or

norepinephrine >0.1

CNS (GCS) 15 13-14 10-12 6-9 <6


<1.2 1.2-1.9 2.0-3.4 3.5-4.9 or <5.00

>5.0 or <200

SOFA Score The European Society of Intensive Care Medicine


SOFA score 0 1 2 3 4

Respiration PaO2FiO2 or SaO2/FiO2 mmHg

>400 <400 221-301

<300 142-220

<200 67-141

<100 <67

Coagulation >150 <150 <100 <50 <20


<1.2 1.2-1.9 2.0-5.9 6.0-11.9 >12.0


No hypotension

MAP <70 Dopamine ≤5 or any

Dopamine >5 or

notepinephrine ≤0.1

Dopamine >15 or

norepinephrine >0.1

CNS (GCS) 15 13-14 10-12 6-9 <6


<1.2 1.2-1.9 2.0-3.4 3.5-4.9 or <5.00

>5.0 or <200

SOFA Score The European Society of Intensive Care Medicine

Mortality SOFA score

<10% 0-6

15-20% 7-9

40-50% 10-12

50-60% 13-14

>80% 15

>90% 15-24

Mortality Score trend (First 48 hrs)

>50% Increasing

27-35% Unchanged

<27% Decreasing


Problems lead to MODS

Decrease cerebral blood flow Metabolic acidosis Decrease bowel sounds Oliguria Hyperdynamic hypotension Fever False hypovolemia Pulmonary edema


Hypoperfusion or hypotension variables;

Tissue perfusion variables; Hyperlactatemia (>2 mmol/L) Hemodynamic variables: Arterial hypotension (SBP <90 mm Hg,

MAP <70, or SBP decrease >40 mm Hg)


Classification of MODS

Immediate Type (1° type) Dysfunction is happened simultaneously

in 2 or more organs due to primary disease. Delayed type (2° type) Dysfunction happened in a organ, other

organs sequentially happened dysfunction or failure.

Accumulation type： Dysfunction leaded by chronic disease.



Stage of Sepsis SIRS

• pyrexia or hypothermia

• tachycardia in the absence of b-blocker • tachypnea or requirement for

mechanical ventilation) • WBC > 12 or < 4 x 10

Severe SIRS • SIRS with altered organ perfusion

or dysfunction not due to infection

Sepsis • SIRS with a documented source

of infection

Severe sepsis • sepsis associated with

organ dysfunction, hypoperfusion, or hypotension

Septic shock • sepsis with hypotension

despite adequate fluid resuscitation with the presence of perfusion abnormalities


Respiratory failure is common in the first 72 hrs after the original insult

Hepatic failure (5-7days)

Gastrointestinal bleeding (10-15 days)

Renal failure (11-17 days)

2-3 days: SIRS develops 7-10 days: hypermetabolic state develops 14-21 days: unstable stage


If MODS is not reversed by day 21, the client will die

Death occurs between day 21-28, after injury

Patient Care

Temperature control Metabolic support Anemia & coagulopathy Renal dysfunction Nutritional support


The early warning score Norfolk & Norwich University

3 2 1 0 1 2 3

HR <40 41-50 51-100 101-110

111-130

>130

SBP <70 71-80 81-100 101-199 >200

RR <8 9-14 15-20 21-29 >30

Temp <35.0 35.1-36.5

36.6-37.4

37.5

LOC A V P U

Score Activity

≥3 Repeat scoring within 15 min

MEWS 3 2 1 0 1 2 3

RR <8 9-14 15-20 21-29 >30

HR <40 40-50 51-100 101-110

111-129

>129

SBP <70 71-80 81-100 101-199 >200

LOC U P V A Confuse

Temp (°C) <35.0 35.1-36

36.1-38 38.1-38.5

>38.6

Hourly Urine for 2 hours

>10 cc/hr

>30 cc/hr

>45 cc/hr

Score Activity

1-2 Observe q 2 hr

3 Observe q 1 hr

>4 Observe q 30 mins

“Early treatment with antibiotic and fluid resuscitation has been found

to be strongly related to increased survival, which makes severe sepsis a condition which is important to identify and treat

as early as possible.”


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Early detection mods 16 พค.58