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MODS and intensive careMODS and intensive care2Denomination 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 AR
2、F patients after abdominal aortic aneurysm operation,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 th
3、e lives.)Yet the treatment did not save the lives.)MOF MOF，multiple organ failuremultiple organ failure-EisemanEiseman，19771977n 19801980s s MSOFMSOF，multiple system organ failuremultiple system organ failure-Fry38/533Fry38/533 point out the relationship between MSOF and severe infectionpoint out th
4、e relationship between MSOF and severe infectionn 19901990s s MODS,multiple organ dysfunction syndromeMODS,multiple organ dysfunction syndrome3Case 1Case 1Male 26yMale 26yPost-subtotal excision of colonPost-subtotal excision of colonIleocolonic stoma leakageIleocolonic stoma leakageMultiple intestin
5、al fistulaMultiple intestinal fistula4Abdominal abscess5Long-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 6HR 170 HR 170 RR 55RR 55PaCOPaCO2 2 23.823.8WBC 18700WBC 18700Posi
6、tive blood cultivation Positive blood cultivation 7Jan 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 Jan 1
7、9thJan 19th tracheotomytracheotomy ventilator application ventilator application 8Case 2 male 59yExtensive anterior wall Myocardial infarction 20 days after onset(2002/3/6)continuous ventricular tachycardiaventricular fibrillation electric defibrillation 5 times antiarrhythmic drugs counter shock dr
8、ugs ventilator application9HR 120 HR 120 RR 28RR 28PaCOPaCO2 2 26.826.8WBC 12600WBC 1260010nRepeatedly ventricular tachycardia and fibrillation，totally 21 times electric defibrillationnContinuous hyperpyrexia、high WBC、HR90、RR22nCultivation negative,antibiotics no effectivenessnOrgan dysfunction came
9、 in crowdsnshocknRespiratory dysfunctionnDeterioration of liver functionnCast in urine routine test BUN、Cr oliguria、anurianCoagulation abnormalityndeath11Acute onsetManifestatin of excessive inflammationDeteriotation of pts conditions despite active therapyMultiple organ dysfunctionDifferent pts,Sam
10、e progressCase 1:infectiousCase 2:noninfectious12qclinical behaviorclinical behaviorvAccumulativeAccumulativevSubstanceSubstancevirreversibleirreversibleqMultiple organ low functionMultiple organ low functionvcaused by interaction between organscaused by interaction between organsChronic disease Chr
11、onic disease Multiple organ low function Multiple organ low function 13MODS followed by primary emergency MODS followed by primary emergency disease in 24 hoursdisease in 24 hoursqClinical manifestationClinical manifestationvburst outburst outvSimultaneousSimultaneousvdie quicklydie quicklyqprimary
12、MODS primary MODS vIschemiaIschemiavischemia and reperfusionischemia and reperfusionvphysical and chemical injury factorphysical and chemical injury factor14Sequential organ dysfunction after Sequential organ dysfunction after emergency disease,MODSemergency disease,MODSqClinical behaviorClinical be
13、haviorvDelayedDelayedvSequentialSequentialvReversibleReversibleqMODSMODSvExcessive inflammatory mediatorsExcessive inflammatory mediators151.Direct injury of ischemia1.Direct injury of ischemiaOxygen&nutrient insufficiencyIntegrity of cell membrane organelle insultATP Extracellular fluid in-flowHydr
14、olase activationNatrium in-flowcalcium in-flow 161.Direct injury of ischemia1.Direct injury of ischemiaqHypersensibitity in heart and brainqSelective ischemiaqEndothelial cell injury leads to high vascular permeability and low volume17permeability of cell membraneNaNa+CaCa+H H2 2O OADPADPAMPAMPIMPIM
15、Padenosinexanthinehypoxanthinehypoxanthine ribosideUric Acidoxygen-derived free radidicalsxanthine oxidasexanthine oxidaseXanthine dehydrogenaseIntracellular acidosisIntracellular acidosisLower protein synthesisLower protein synthesisInjury of ischemia and reperfusion18Vessel permeabilityVessel perm
16、eability 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 organ injuryTissue damage Tissue damage etiological factor neutrophilAdherent molecule2.Excessive inflammation 2.E
17、xcessive inflammation SIRS MODS SIRS MODS Vascular endothelial cellSIRSMODS19Clinical progressClinical progressuncontrolled stressuncontrolled stressSIRSSIRSCapillary leakage syndromeCapillary leakage syndromeMODSMODSMSOFMSOF20Important molecule in MODSImportant molecule in MODS Pro-inflammatory cyt
18、okines:TNF-,IL-1、2、6 etcqStimulate synthesis and release of other cytokinesqActivate neutrophiles,eosinophils and monocytes;activate T and B cell;chemotaxisqIncrease the expression of adherent molecule qActivate complement and coagulation systemqIncrease permeability of vessels,decrease BPqCause fev
19、er and catabolism of muscle21Important molecule in MODSImportant molecule in MODS Anti-inflammatory cytokines:IL-4、10 etcqMaintain and enhance the function of activated NK cells,monocytes,B and T cells，qInhibit proliferation of T,B cellqInhibit pro-inflammatory cytokines production,receptor expressi
20、on and cytotoxicity of monocytesqInhibit adherent molecule expression of vascular endothelial cells(VECs)qInhibit H2O2、NO production of macrophageqInhibit antigen presentation and other assistant functions of monocytes and macrophage22Important cells in MODSImportant cells in MODSqPolymorphonuclear
21、leucocyte（PMN）：Effector cell of inflammatory response.Could release several protein enzymes and ODFR to destroy VECs and stromaqVECs：When activated,VECs express higher adherence to PMN and higher clotting competence;also they produce pro-inflammatory cytokines and vasodilating agent to magnify infla
22、mmatory response;finally,capillary leakage syndrome comes if VECs were destroyed.23Important organ in MODSImportant organ in MODSIntestinesqBecause of stress,fasting and catabolism,the blood-mucosa barrier of intestines could be destructed,the bacteria and toxin tranlocate to blood circulation and t
23、he latter could enhance inflammatory response to form vicious cycle.So intestines are called“motor”of inflammatory response,and are sources of late stage infectons of MODS pts.24uncontrolled stresscarbohydrate metabolism dysfunction,Insulin carbohydrate metabolism dysfunction,Insulin tolerance,witho
24、ut Ketonemiatolerance,without Ketonemiahyperkinetic circulatory state,Hyperpyrexia,hyperkinetic circulatory state,Hyperpyrexia,High Stroke volume,High oxygen consumptionHigh Stroke volume,High oxygen consumptionProtein metabolism dysfunction,high Protein metabolism dysfunction,high katabolism,acute
25、phase proteinkatabolism,acute phase protein25nT T 38or 38or 3636nHRHR90 beat/min90 beat/minnRRRR2020/min or PaCOmin or PaCO2 232mmHg32mmHgnWBCWBC12000mm12000mm3 3 or or 4000mm4000mm3 3 or premature cells or premature cells 1010SepsisSepsisSystemic InflammatorySystemic InflammatoryResponse Syndrome(S
26、IRS)Response Syndrome(SIRS)(SIR+Positive Culture)SIR+Positive Culture)(SIR without infection)SIR without infection)Systemic Inflammatory Response syndromeSystemic Inflammatory Response syndrome SIRSSIRS26Chaotic internal milieu during acute phaseChaotic internal milieu during acute phaseqDisturbance
27、 of electrolytes and acid-base balanceqFeverqCatabolism:emaciated,anemiaqAcute disseminated intravascular coagulationqArrhythmiaqHyperglycemia,no ketonemia27 Secondary aldosteronism -high density urine without Proteinuria,oliguria -prerenal azotemia -swollen Plasma protein leakage -Interstitial edem
28、a -Hypoproteinemia -blood inspissasion -HypovolemiaCapillary leakage syndrome,CLS28Diagnosis of CLSqPositive body fluid balanceqBlood volume deficiencyqHypoproteinemiaqOrgan and total body Interstitial edemavlung Interstitial edemavcerebral Interstitial edema29Organs dysfunction or failureOrgan or s
29、ystemdysfunctionfailurelungLiverkidneyintestineBloodHypoxemia,respirator at list 3-5daysARDS,PEEP10cmH2O,FiO20.5Bilirubin2-3mg/dL,Liver function2 normal valueBilirubin2-3mg/dL,icterusoliguriadialysisUntolerance of enteral nutrition5daysCurlingls ulcer needs blood transfusion,Acalculous cholecystitis
30、PT or PTT elongation,platelet95%95%nKidneyKidney ARF ARF only a fewonly a few32Acute Respiratory Distress Acute Respiratory Distress Syndrome,Syndrome,ARDSARDSqPathology of lungvHigh capillary permeabilityInterstitial edemavVasoconstriction,micro thrombosis communicating branch openingvAlveolar and
31、small bronchusAtelectasisvDecreased alveolar surfactantvEdemavI type epithelial cells instead by II type cellqSymptomvTachypnea,respiratory distress can not be eased by oxygen inhalationvNo ralesvNo lung x-ray abnormality1.The early stage33qPathologyPathologyvDeteriorated lung Interstitial inflammat
32、ion,usually Deteriorated lung Interstitial inflammation,usually complicated with SEPSIScomplicated with SEPSISqSymptomSymptomvObviously dyspnoea and cyanosisObviously dyspnoea and cyanosisneeds needs ventilatorventilatorvIncreased respiratory tract secretion,ralesIncreased respiratory tract secretio
33、n,ralesvLung x-rayLung x-rayinfiltratesinfiltratesvDisturbance of consciousnessDisturbance of consciousnessvFebrile or high leucocyte Febrile or high leucocyte 2.The second stage343.Telophase qPathologyPathologyvLung parenchyma fibrosisLung parenchyma fibrosisvMicrovascular occlusionMicrovascular oc
34、clusionvIncreased preload,hypoxiaIncreased preload,hypoxiaqSymptomSymptomvDeep comaDeep comavArrhythmiaArrhythmiabradycardiabradycardiacardiac arrestcardiac arrest35Diagnosis36Acute Renal Failure,ARFAcute Renal Failure,ARFqEtiology vPrerenal3Hemorrhage,shock,fluid losing without appropriate fluid re
35、suscitationvpost renal3both side ureter or urinary flow blockedvrenal3kidney ischemia(hematorrhea,sepsis,allergic reaction)3intoxication(aminoglycoside antibiotic,biotic toxin,chemical)371.History and physical examinationvEtiologyvprerenal pathogenvpostrenal pathogenDiagnosis of ARF 38 Oligouria pha
36、se Hypovolemia 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
37、，plasma protein discend rise*5GNS250500ml injected IV in 30-60min,then observe urine output 2.Differentiation Diagnosis with prerenal ARF393.Differentiation Diagnosis with Postrenal ARFqB type ultrasound(renal enlargement,ureter)qAbdominal x-rays(calcification,calculus or Obstruction)404.4.Laborator
38、y 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 RBC and ren
39、al tubule epithelia(renal cortex and renal medulla necrosis)renal medulla necrosis)vLarge Brown casts(renal failure casts)Large Brown casts(renal failure casts)vEosinophil(interstitial nephritis)Eosinophil(interstitial nephritis)vRed cell cast(glomerulonephritis)Red cell cast(glomerulonephritis)vNor
40、mal(prerenal or postrenal failure earlier period)Normal(prerenal or postrenal failure earlier period)415.5.renal function examinationrenal function examinationnUrine urea nitrogen(175mmol/24h)nFractional excretion of filtrated sodium1 FENa（%）=（UNa/PNa）（）（PCr/UCr）100nosmotic pressure of urine *ARF-40
41、0 mOsm/LnBUN (more than 3.89.4mmol/L per day),Cr nUrine/Plasma Cr-1-ARF *1-prerenal42Intensive careqOrgan and system function Monitoring and supportvObject1.ameliorate oxygen metabolism2.ameliorate nutrien stateqTherapy aimed at stress and inflammatory MediatorsqTreatment of capillary leakageqTreatm
42、ent of primary disease43Oxygen metabolism MonitoringqCritical DO2qAssay of plasma lactic acid/pyruvic acid44Oxygen associated indexqDODO2 2 Oxygen Delivery-Oxygen Delivery-Oxygen offered to the body in a certain period by circulatory system DO DO2 2COCO（1.381.38SaOSaO2 2+0.003+0.003PaOPaO2 2）qVOVO2
43、2 Oxygen Consumption-Oxygen Consumption-Oxygen consumpted by all cells in a certain period.VO VO2 2Ca-vDOCa-vDO2 2COCO101045Critical DOCritical DO2 2VOVO2 2DODO2 2SepsisARDSMODSNormalCritical delivery oxygenCritical delivery oxygen46Lactic Acid and cells hypoxiaqLactic Acid-latent cells hypoxia lact
44、ic acidosis-tissue perfusion deficiency and cells hypoxia Lactic Acid normal value-0.5-1.5 mmol/L0.5-1.5 mmol/L 4-5 mmol/LSB and PH lactic acidosis qL/P rate -cells hypoxia L/P rate normal value-10:147Strategy of ameliorate oxygen metabolismStrategy of ameliorate oxygen metabolism qImprovement of ox
45、ygen deliveryvrespiratory support-to improve arterial blood oxygen contentphigher inhalated oxygen concentration,ventilatorvincrease cardiac output pHeart rate,cardiac rhythm,cardiac contractility,preload/after loadvBlood systemprise hemoglobin concentration48Strategy of ameliorate oxygen metabolism
46、Strategy of ameliorate oxygen metabolismqIncrease oxygen extraction ratiovAmeliorate interstitial edemavReduce blood capilary permeabilityvAmeliorate oxygen extraction of cells49Treatmen of CLSTreatmen of CLSqLimitation of water-intakeLimitation of water-intakevpremise:never get CO downpremise:never
47、 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.qRise colloid osmotic pressureRise colloid osmotic pressureqUse powerful diureticUse powerful diu
48、reticqUse glucocorticoidUse glucocorticoid50Nutritional supportNutritional supportqMetabolism supportMetabolism supportvOffer nutritional substrate but never Offer nutritional substrate but never increase organ loading.increase organ loading.qMetabolism modulationMetabolism modulationvInhibition of
49、catabolism hormonesInhibition of catabolism hormonesvPromote protein synthesis,ease negative Promote protein synthesis,ease negative nitrogen balancenitrogen balance51Nutritional supportNutritional supportqAdd accessoriesAdd accessoriesvPromote protein synthesis and cell growthPromote protein synthe
50、sis and cell growthvModulate immunologic responseModulate immunologic response qEnteral nutritionEnteral nutritionvProtect bowel blood-mucosa barrier(prevent Protect bowel blood-mucosa barrier(prevent from infection from infection)52Discussion of therapy for stress and Discussion of therapy for stre
