1、多脏器功能障碍综合征及监护多脏器功能障碍综合征及监护Denomination variationn1973 1973 secondary system function failuresecondary system function failure-TilneyTilney Summary data of 18 cases ARF patients after abdominal aortic aneurysm operation,and 17 Summary data of 18 cases ARF patients after abdominal aortic aneurysm oper
2、ation,and 17 patients died from organ failure during dialysis.patients died from organ failure during dialysis.n1975197519771977 MOFSMOFS，multiple organ failure syndromemultiple organ failure syndrome-BaueBaue，19751975 （Yet the treatment did not save the lives.)Yet the treatment did not save the liv
3、es.)MOF MOF，multiple organ failuremultiple organ failure-EisemanEiseman，19771977n 1980s 1980s MSOFMSOF，multiple system organ failuremultiple system organ failure-Fry38/533Fry38/533 point out the relationship between MSOF and severe infectionpoint out the relationship between MSOF and severe infectio
4、nn 1990s 1990s MODS,multiple organ dysfunction syndromeMODS,multiple organ dysfunction syndrome2020/12/242Case 1Case 1Male 26yMale 26yPost-subtotal excision of colonPost-subtotal excision of colonIleocolonic stoma leakageIleocolonic stoma leakageMultiple intestinal fistulaMultiple intestinal fistula
5、2020/12/243Abdominal abscess2020/12/244Long-term application of high caloria parenteral nutrition(fat emulsion)liver tumefaction liver dysfunction SGPT 36 SGPT 36 SGOT 144 SGOT 144 TB 167.9 TB 167.9 DB 102.8DB 102.8 2020/12/245HR 170 HR 170 RR 55RR 55PaCOPaCO2 2 23.823.8WBC 18700WBC 18700Positive bl
6、ood cultivation Positive blood cultivation 2020/12/246Jan 16thJan 16th septic shockseptic shockJan 17th Jan 17th Renal functionRenal function BUN 20.5 BUN 20.5 Cr 337 Cr 337 need inhalation of oxygen need inhalation of oxygen with mask with mask continuous hemofiltration continuous hemofiltration Ja
7、n 19thJan 19th tracheotomytracheotomy ventilator application ventilator application 2020/12/247Case 2 male 59yExtensive anterior wall Myocardial infarction 20 days after onset(2002/3/6)continuous ventricular tachycardiaventricular fibrillation electric defibrillation 5 times antiarrhythmic drugs cou
8、nter shock drugs ventilator application2020/12/248HR 120 HR 120 RR 28RR 28PaCOPaCO2 2 26.826.8WBC 12600WBC 126002020/12/249nRepeatedly ventricular tachycardia and fibrillation，totally 21 times electric defibrillationnContinuous hyperpyrexia、high WBC、HR90、RR22nCultivation negative,antibiotics no effe
9、ctivenessnOrgan dysfunction came in crowdsnshocknRespiratory dysfunctionnDeterioration of liver functionnCast in urine routine test BUN、Cr oliguria、anurianCoagulation abnormalityndeath2020/12/2410Acute onsetManifestatin of excessive inflammationDeteriotation of pts conditions despite active therapyM
10、ultiple organ dysfunctionDifferent pts,Same progressCase 1:infectiousCase 2:noninfectious2020/12/2411qclinical behaviorclinical behaviorvAccumulativeAccumulativevSubstanceSubstancevirreversibleirreversibleqMultiple organ low functionMultiple organ low functionvcaused by interaction between organscau
11、sed by interaction between organsChronic disease Chronic disease Multiple organ low function Multiple organ low function 2020/12/2412MODS followed by primary emergency MODS followed by primary emergency disease in 24 hoursdisease in 24 hoursqClinical manifestationClinical manifestationvburst outburs
12、t outvSimultaneousSimultaneousvdie quicklydie quicklyqprimary MODS primary MODS vIschemiaIschemiavischemia and reperfusionischemia and reperfusionvphysical and chemical injury factorphysical and chemical injury factor2020/12/2413Sequential organ dysfunction after Sequential organ dysfunction after e
13、mergency disease,MODSemergency disease,MODSqClinical behaviorClinical behaviorvDelayedDelayedvSequentialSequentialvReversibleReversibleqMODSMODSvExcessive inflammatory mediatorsExcessive inflammatory mediators2020/12/24141.Direct injury of ischemia1.Direct injury of ischemiaOxygen&nutrient insuffici
14、encyIntegrity of cell membrane organelle insultATP Extracellular fluid in-flowHydrolase activationNatrium in-flowcalcium in-flow 2020/12/24151.Direct injury of ischemia1.Direct injury of ischemiaqHypersensibitity in heart and brainqSelective ischemiaqEndothelial cell injury leads to high vascular pe
15、rmeability and low volume2020/12/2416permeability of cell membraneNaNa+CaCa+H H2 2O OADPADPAMPAMPIMPIMPadenosinexanthinehypoxanthinehypoxanthine ribosideUric Acidoxygen-derived free radidicalsxanthine oxidasexanthine oxidaseXanthine dehydrogenaseIntracellular acidosisIntracellular acidosisLower prot
16、ein synthesisLower protein synthesisInjury of ischemia and reperfusion2020/12/2417Vessel permeabilityVessel permeability WBC WBC chemotaxis monocyte/macrophage neutrophil elastinase PLA2 PLA2 ODFR TNF ILTNF IL8 et al8 et al ILIL1 1 IL IL6 6 liverliver：acutephase reaction Remote organ injuryRemote or
17、gan injuryTissue damage Tissue damage etiological factor neutrophilAdherent molecule2.Excessive inflammation 2.Excessive inflammation SIRS MODS SIRS MODS Vascular endothelial cellSIRSMODS2020/12/2418Clinical progressClinical progressuncontrolled stressuncontrolled stressSIRSSIRSCapillary leakage syn
18、dromeCapillary leakage syndromeMODSMODSMSOFMSOF2020/12/2419Important molecule in MODSImportant molecule in MODS Pro-inflammatory cytokines:TNF-,IL-1、2、6 etcqStimulate synthesis and release of other cytokinesqActivate neutrophiles,eosinophils and monocytes;activate T and B cell;chemotaxisqIncrease th
19、e expression of adherent molecule qActivate complement and coagulation systemqIncrease permeability of vessels,decrease BPqCause fever and catabolism of muscle2020/12/2420Important molecule in MODSImportant molecule in MODS Anti-inflammatory cytokines:IL-4、10 etcqMaintain and enhance the function of
20、 activated NK cells,monocytes,B and T cells，qInhibit proliferation of T,B cellqInhibit pro-inflammatory cytokines production,receptor expression and cytotoxicity of monocytesqInhibit adherent molecule expression of vascular endothelial cells(VECs)qInhibit H2O2、NO production of macrophageqInhibit ant
21、igen presentation and other assistant functions of monocytes and macrophage2020/12/2421Important cells in MODSImportant cells in MODSqPolymorphonuclear leucocyte（PMN）：Effector cell of inflammatory response.Could release several protein enzymes and ODFR to destroy VECs and stromaqVECs：When activated,
22、VECs express higher adherence to PMN and higher clotting competence;also they produce pro-inflammatory cytokines and vasodilating agent to magnify inflammatory response;finally,capillary leakage syndrome comes if VECs were destroyed.2020/12/2422Important organ in MODSImportant organ in MODSIntestine
23、sqBecause of stress,fasting and catabolism,the blood-mucosa barrier of intestines could be destructed,the bacteria and toxin tranlocate to blood circulation and the latter could enhance inflammatory response to form vicious cycle.So intestines are called“motor”of inflammatory response,and are source
24、s of late stage infectons of MODS pts.2020/12/2423uncontrolled stresscarbohydrate metabolism dysfunction,Insulin carbohydrate metabolism dysfunction,Insulin tolerance,without Ketonemiatolerance,without Ketonemiahyperkinetic circulatory state,Hyperpyrexia,hyperkinetic circulatory state,Hyperpyrexia,H
25、igh Stroke volume,High oxygen consumptionHigh Stroke volume,High oxygen consumptionProtein metabolism dysfunction,high Protein metabolism dysfunction,high katabolism,acute phase proteinkatabolism,acute phase protein2020/12/2424nT T 38or 38or 3636nHRHR90 beat/min90 beat/minnRRRR2020/min or PaCOmin or
26、 PaCO2 232mmHg32mmHgnWBCWBC12000mm12000mm3 3 or or 4000mm4000mm3 3 or premature cells or premature cells 1010SepsisSepsisSystemic InflammatorySystemic InflammatoryResponse Syndrome(SIRS)Response Syndrome(SIRS)(SIR+Positive Culture)SIR+Positive Culture)(SIR without infection)SIR without infection)Sys
27、temic Inflammatory Response syndromeSystemic Inflammatory Response syndrome SIRSSIRS2020/12/2425Chaotic internal milieu during acute phaseChaotic internal milieu during acute phaseqDisturbance of electrolytes and acid-base balanceqFeverqCatabolism:emaciated,anemiaqAcute disseminated intravascular co
28、agulationqArrhythmiaqHyperglycemia,no ketonemia2020/12/2426 Secondary aldosteronism -high density urine without Proteinuria,oliguria -prerenal azotemia -swollen Plasma protein leakage -Interstitial edema -Hypoproteinemia -blood inspissasion -HypovolemiaCapillary leakage syndrome,CLS2020/12/2427Diagn
29、osis of CLSqPositive body fluid balanceqBlood volume deficiencyqHypoproteinemiaqOrgan and total body Interstitial edemavlung Interstitial edemavcerebral Interstitial edema2020/12/2428Organs dysfunction or failureOrgan or systemdysfunctionfailurelungLiverkidneyintestineBloodHypoxemia,respirator at li
30、st 3-5daysARDS,PEEP10cmH2O,FiO20.5Bilirubin2-3mg/dL,Liver function2 normal valueBilirubin2-3mg/dL,icterusoliguriadialysisUntolerance of enteral nutrition5daysCurlingls ulcer needs blood transfusion,Acalculous cholecystitisPT or PTT elongation,platelet95%95%nKidney ARFKidney ARF only a fewonly a few2
31、020/12/2431Acute Respiratory Distress Acute Respiratory Distress Syndrome,Syndrome,ARDSARDSqPathology of lungvHigh capillary permeabilityInterstitial edemavVasoconstriction,micro thrombosis communicating branch openingvAlveolar and small bronchusAtelectasisvDecreased alveolar surfactantvEdemavI type
32、 epithelial cells instead by II type cellqSymptomvTachypnea,respiratory distress can not be eased by oxygen inhalationvNo ralesvNo lung x-ray abnormality1.The early stage2020/12/2432qPathologyPathologyvDeteriorated lung Interstitial inflammation,usually Deteriorated lung Interstitial inflammation,us
33、ually complicated with SEPSIScomplicated with SEPSISqSymptomSymptomvObviously Obviously dyspnoeadyspnoea and cyanosisneeds and cyanosisneeds ventilatorventilatorvIncreased respiratory tract secretion,Increased respiratory tract secretion,ralesralesvLung x-rayinfiltratesLung x-rayinfiltratesvDisturba
34、nce of consciousnessDisturbance of consciousnessvFebrile or high Febrile or high leucocyteleucocyte 2.The second stage2020/12/24333.Telophase qPathologyPathologyvLung parenchyma fibrosisLung parenchyma fibrosisvMicrovascularMicrovascular occlusion occlusionvIncreased preload,hypoxiaIncreased preload
35、,hypoxiaqSymptomSymptomvDeep comaDeep comavArrhythmiaArrhythmiabradycardiabradycardiacardiac arrestcardiac arrest2020/12/2434Diagnosis2020/12/2435Acute Renal Failure,ARFAcute Renal Failure,ARFqEtiology vPrerenal3Hemorrhage,shock,fluid losing without appropriate fluid resuscitationvpost renal3both si
36、de ureter or urinary flow blockedvrenal3kidney ischemia(hematorrhea,sepsis,allergic reaction)3intoxication(aminoglycoside antibiotic,biotic toxin,chemical)2020/12/24361.History and physical examinationvEtiologyvprerenal pathogenvpostrenal pathogenDiagnosis of ARF 2020/12/2437 Oligouria phase Hypovol
37、emia Fluid test*Urine no increase Urine increase Urine specific gravity 1.010 1.020 Urine sediment Renal tubule epithelium and cast Negative Urine sodium concentration（mmol/L）40 20 Urine/plasma urea 10：1 Urine/plasma creatinine 30：1 Plasma potasium heighten quickly Heighten slowly hemocrit，plasma pr
38、otein discend rise*5GNS250500ml injected IV in 30-60min,then observe urine output 2.Differentiation Diagnosis with prerenal ARF2020/12/24383.Differentiation Diagnosis with Postrenal ARFqB type ultrasound(renal enlargement,ureter)qAbdominal x-rays(calcification,calculus or Obstruction)2020/12/24394.4
39、.Laboratory Urine testLaboratory Urine testqUrinary catheter to record urine volumeUrinary catheter to record urine volumeqUrine acidity/density(1.010-1.014)Urine acidity/density(1.010-1.014)qUrine microscopic examinationUrine microscopic examinationvRBC and renal tubule epithelia(renal cortex and R
40、BC and renal tubule epithelia(renal cortex and renal medulla necrosis)renal medulla necrosis)vLarge Brown casts(renal failure casts)Large Brown casts(renal failure casts)vEosinophilEosinophil(interstitial nephritis)(interstitial nephritis)vRed cell cast(Red cell cast(glomerulonephritisglomerulonephr
41、itis)vNormal(Normal(prerenalprerenal or or postrenalpostrenal failure earlier period)failure earlier period)2020/12/24405.5.renal function examinationrenal function examinationnUrine urea nitrogen(175mmol/24h)nFractional excretion of filtrated sodium1 FENa（%）=（UNa/PNa）（）（PCr/UCr）100nosmotic pressure
42、 of urine *ARF-400 mOsm/LnBUN (more than 3.89.4mmol/L per day),Cr nUrine/Plasma Cr-1-ARF *1-prerenal2020/12/2441Intensive careqOrgan and system function Monitoring and supportvObject1.ameliorate oxygen metabolism2.ameliorate nutrien stateqTherapy aimed at stress and inflammatory MediatorsqTreatment
43、of capillary leakageqTreatment of primary disease2020/12/2442Oxygen metabolism MonitoringqCritical DO2qAssay of plasma lactic acid/pyruvic acid2020/12/2443Oxygen associated indexqDODO2 2 Oxygen Delivery-Oxygen Delivery-Oxygen offered to the body in a certain period by circulatory system DO DO2 2COCO
44、（1.381.38SaOSaO2 2+0.003+0.003PaOPaO2 2）qVOVO2 2 Oxygen Consumption-Oxygen Consumption-Oxygen consumpted by all cells in a certain period.VO VO2 2Ca-vDOCa-vDO2 2COCO10102020/12/2444Critical DOCritical DO2 2VOVO2 2DODO2 2SepsisARDSMODSNormalCritical delivery oxygenCritical delivery oxygen2020/12/2445
45、Lactic Acid and cells hypoxiaqLactic Acid-latent cells hypoxia lactic acidosis-tissue perfusion deficiency and cells hypoxia Lactic Acid normal value-0.5-1.5 0.5-1.5 mmolmmol/L/L 4-5 mmol/LSB and PH lactic acidosis qL/P rate -cells hypoxia L/P rate normal value-10:12020/12/2446Strategy of ameliorate
46、 oxygen metabolismStrategy of ameliorate oxygen metabolism qImprovement of oxygen deliveryvrespiratory support-to improve arterial blood oxygen contentphigher inhalated oxygen concentration,ventilatorvincrease cardiac output pHeart rate,cardiac rhythm,cardiac contractility,preload/after loadvBlood s
47、ystemprise hemoglobin concentration2020/12/2447Strategy of ameliorate oxygen metabolismStrategy of ameliorate oxygen metabolismqIncrease oxygen extraction ratiovAmeliorate interstitial edemavReduce blood capilary permeabilityvAmeliorate oxygen extraction of cells2020/12/2448Treatmen of CLSTreatmen o
48、f CLSqLimitation of water-intakeLimitation of water-intakevpremise:never get CO downpremise:never get CO downvInfusion volume decided by urine volume per hour Infusion volume decided by urine volume per hour when lung and brain interstitial edema happen.when lung and brain interstitial edema happen.
49、qRise colloid osmotic pressureRise colloid osmotic pressureqUse powerful diureticUse powerful diureticqUse Use glucocorticoidglucocorticoid2020/12/2449Nutritional supportNutritional supportqMetabolism supportMetabolism supportvOffer nutritional substrate but never Offer nutritional substrate but nev
50、er increase organ loading.increase organ loading.qMetabolism modulationMetabolism modulationvInhibition of catabolism hormonesInhibition of catabolism hormonesvPromote protein synthesis,ease negative Promote protein synthesis,ease negative nitrogen balancenitrogen balance2020/12/2450Nutritional supp
