醫(yī)學教學課件：Multiple Organ Dysfunction Syndrome (MODS)

MultipleOrganDysfunctionSyndrome

(MODS)DefinitionDysfunctionorfailureofmultipleorganorsystemhappenedsimultaneouslyorsequentiallyduetovariousetiologicalfactors.EtiologyInfection:Grampositive/negativebacteria,fungal,Virus

Shock:hemorrhage,etc.AllergyBurnsTraumaSevereacutepancreatitisClassificationofMODSImmediateType(Primary)：Dysfunctionarehappenedsimultaneouslyintwoormoreorgansduetoprimarydisease.Delayedtype(Secondary）：Dysfunctionhappenedinaorgan,otherorganssequentiallyhappeneddysfunctionorfailure.Accumulationtype：Dysfunctionleadedbychronicdisease.AttentionImmediateTypeNotrelatedtoSIRSCoupinjurywithchemicalorphysicalfactorsNotimeintervalfromdiseaseARDS+ARForARDS+ARF+DIC+LFDelayedtypeNotthedirectoutcomefrominjuryRelatingtoSIRS（systemicinflammatoryresponsesyndrome）TimeintervalexistedfromprimarydiseaseAccumulationtypeAccumulationIrreversibleARDS:acuterespiratorydistresssyndromeARF:acuterenalfailureLF:liverfailureMechanism

InflammatorymediatorsprimingSIRSleadingtoMODSVascularpermeability↑＋PMN

chemotaxisMono/Macrophage

PMN

elastase

PLA2oxygenfreeradicalsTNFIL－8IL－1IL－6

Liver：acutephaseRemoteorganinjuryTissueinjury

EndotheliumInjuryfactors

PMNPAFAdhensivemoleculesDICpolymorphonucleocytePAF,plateletactivatingfactorCommonManifestationsofMODS

OrganSymptomsHeartAcuteheartfailurePeripheralcirculationShockLungALI/ARDSKidneyARFGastro-intestineStressulcer/enteroparalysisLiverAcutehepaticfailureBrainCNSfailureCoagulationDICDiagnosisofCriteriaOrgan/systemdysfunctionandfailureGLASGOWSCORETreatmentsofMODSCombinedtherapyCorrectionofischemia:fluidresuscitation,mechanicalventilationPreventionofinfection：drainage,antibiotics

Interruptionofpathologicalreaction：hemofiltrationStabilizationofinternalenvironment：water,electrolyte,acid-baseimbalance

Regulationofimmunity：cellularandhumor

SupportoforganfunctionVentilatorArtificialkidneyArtificialliverProtectionofenteralmucosaDrugsofprotectionofheartThanks!AcuteRenalFailure(ARF)Definition

Characterizedbyineffectivefiltrationacrossglomeruliinshorttime.Suchasazotemia,imbalanceofwater,electrolyteandacid-base.EtiologyandclassificationPrerenalProximaltokidneyDecreaseinrenovascularflowHypovolemia,severecardiacdysfunction,lossofvasculartone,drugs(renalvasoconstriction),renalarteryocclusionAbdominalCompartmentSyndrome(ACS)50%oftheARFPostrenalDistaltokidney.ObstructionofurinaryflowCollectingsystemUreters:tumor,stone,etc.Bladderoutlet(strictures,prostatism)IntrinsicrenalRenalparenchymainjury(glomerularfiltration)RenaltubulardysfunctionBoth

Acuteglomerulonephritis

ATN:renalischemia（hemorrhage,septic,shock,serumanaphylaxis）;nephrotoxins(aminoglycosides,radiocontrastdye,pigments,biotoxins,polymyxin)

AcuteinterstitialnephritisMechanismOliguriaandanuriastage（<400ml/24hor<100ml/24h）RenalischemiaDecreaseinglomerulifiltration（systolicbloodpressure<8kpa;decreaseinendotheliapermeabilityafterischemia;constrictionofrenalartery.)ATN（stasisofbloodinmedulla）3.Glomeruli-tubulefeedback（ischemia→Na+re-absorptiondecreaseinmedullaryloopanddistalconvolutedtubule→Na+increaseinpara-maculadensa→reninrelease→afferentArterioleofglomerulus

spasm）Reperfusion-ischemiainjury:oxygenfreeradicalsinjure cellsDegenerationandnecrosisoftubulusendothelium：ischemia→ATP→disordersoftransportfunction→accumulationofsodiumandcalcium,lossofpotassium→degenerationofendoplasmicreticulum,accumulationofmatrixprotein→renaltubularnecrosisObstructionofrenaltubulusmucousaandcellsfiltrationpressurehemoglobinandmyoglobinInfectionanddrugsInfectionleadingtodecreaseinrenalbloodflowDrugs:amine,rifampicin,polymyxinNon-oliguriaacuterenalfailureDiscrepancyofrenaltubulusandglomeruliofchangeNormalbloodflowinsomerenalunit

Urorrhagiastage（>800ml/24h

）Glomerularfiltratenotconcentrated：un-recoveryfromresorptionandconcentratedfunctionofrenaltubulusre-epitheliaOsmoticdiuresis:largeamountofBUNaccumulatedinbodyduringanuriastage.Waterdiuresis：muchelectrolyteandwaterexcessduringanuriastageaggravateuresis.ClinicalManifestationAnuriastage：（7－14days，thelongestismore thanonemonth）Urine:（hypobaricandfixed;albuminuria;redcellsandcast）Imbalanceofwater,electrolyteandacid-base.Threeincrease：bloodphosphorus,potassium,magnesium Threedecrease:bloodcalcium,sodium,chlorideTwointoxication：metabolicacidosis,watertoxicationAccumulationofmetabolicproducts-uremia（azotemia,phenol,guanidine,etc.）：Nausea,vomitingHeadache,restless,weakness,unconsciousness,comaHemorrhagictendency（decreaseinplateletfunction,increaseincapillaryfragility,hepaticdysfunction,DIC

）：SubcutaneoushemorrhageOralmucosaandgingivableedingGastrointestinalbleedingWoundsbleeding

Urorrhagiastage(14days）：ModeofurinerecoveryIncreaseAbruptly：

usuallyin5－7thday，urineoutputincreasesto1500ml/24habruptly.Increasegradually：Usuallyin7－14thday，urineoutputincreasesto200－500ml/24hIncreasetardily：Whenurineoutputincreasesto500－700ml/24h，stoppingincreasing.Prognosisispoor.

Imbalanceofwater,electrolyte;andazotemiastillexist.ComplicatingwithinfectioneasilyStageofrecovery（severalmonths）：anemiaweaknessWastingDiagnosisHistoryandphysicalexaminationEtiologyWhetherprerenalfactorsexistWhetherpostrenalfactorsexistExaminationofurineRecordurineoutputperhourAcidurine,specificgravitystabilizesattherangeof1.010-1.014MicroscopicexaminationMoreredcellsandrenaltubulusepithelia（cortexandmedullanecrosis)Lenitybrowncast（renalfailurecast）Acidophiliccellincrease（interstitialnephritis）Redcellcast（glomerularnephritis）Nonapparentabnormality（earlystagewithprerenalorpostrenalfailure）ExaminationofrenalfunctionUrineBUNdecrease,lessthan180mmol/24husually.Urinesodiumincrease,morethan175mmol/24h.Fractionalexcretionoffiltratedsodiumismorethan１.5

FENa（%）=（UNa/PNa）×（PCr/UCr）×100UrineosmolalityLessthan350mOsm/LinARFMorethan500mOsm/LinprerenalfailureorglomerularnephritisSerumBUN,Cr：elevatingfor3.8－9.4mmol/L/dPlasma/urineCr>20Renalfailureindex(RFI)

RFI＝UNa×（PCr/UCr

）

RFI＞１.5:ARFRFI＜１:PrerenaloliguriaRenalandprerenaloliguriaRenalandpostrenalRenalultrasound（nephrauxe,ureterexpansion）PlainabdominalX-ray（calcification,stoneorobstruction）intravenouslypyelography(IVP)RetrogradepyelographyTreatmentOliguriaoranuriastageControlfluidinput:bodyweightisdecreased0.5kgdaily.Outputisinput,lessinputisbetterthanthemoreFluidamountdaily＝dominanceloss＋non-dominanceloss －endogenywaterNutritionLessprotein,highcalorie,highvitamindietProteinsynthesishormone:GH,testosterone

Corectionofelectrolyteimbalance(hyperkalemia,hyponatremia,hypocalcemia,acidosis）

Antibiotics:harmfultokidneyBloodpurificationhemodialysis：artificialkidney.Highclearancerateforsmallmolecules;hemodynamicsunstableperitonealdialysis：smallmolecularsubstances;infection;lowclearanceratehemofiltration：highclearancerateformiddlemolecules;hemodynamicsstable

Urorrhagiastage

Infuseoptimalfluid，avoidinglossofextracellularfluidFluidinfusionis1/3~1/2fluidoutputequivalently.CorrectionofelectrolyteInfusesodiumandpotassiumaccordingtodeterminationofelectrolytedaily.Increaseamountprotein.TreatinfectionactivelyProphylaxisTodiagnosevolumedeficienttimelyPerformfluidtestfirstwhenoliguriaexistedTotreataccordingtofluiddeficientTocorrectwaterandelectrolyteimbalanceinpatientswithtraumaandpre-operationManagementofxenotypebloodinfusionTorisepHvaluesinurineforalkaliMannitolfordiuresisRestrictinotropicagentsNorepinephrinepressoragentTreatmentsofDICHeparinAcuteRespiratoryDistressSyndrome(ARDS)Definition

Acutepulmonarydysfunctionoriginatingfromdiffuseinfiltrateandpulmonarycompliancedecreasedleadingtoseverehypoxia.ARDSisaninflammatoryprocessNotaaccumulationofedemafluidBothlungsPredisposingconditionsInjuryLunginjury：lungcontusion,smoke,aspirationofgastriccontents,toxicgas,drowning,oxygenExtra-lunginjury:fractures,trauma,burns,massivetransfusion,amnioticfluidthrombosis,transplantationOperation:cardiopulmonarybypass,majoroperationInfection:sepsis/septicshockShockandDICMechanismInitialstagePulmonarycapillarypermeabilitylungparenchymaedema.ErythrocytesexudatesLeukocytesinfiltratedeteriorationofcellulardamagesPulmonaryvasoconstriction,thrombosis,A-Vshunt.AlveoliEdemaDPLHyalineandbloodyfluidHyalineandbloodyfluidinbronchia→flakeatelectasisAdvancedstagePulmonaryparenchymainflammationaggravatedComplicatingwithinfectionFinalstagePulmonaryfibrosisCapillaryvesselsocclusionAfterloadrise,hypoxiaClinicalManifestation1.InitialstageTachypnea,refractorytosupplementaloxygenProgressivehypoxemiaNoralesUnrevealinginchestX-ray2.AdvancedstageProminentdyspneaandcyanosisNeedmechanicalventilationRales;bronchisecretionrise