外科-多器官障碍综合征
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ACCP/SCCM 1991
DIAGNOSIS of MODS
➢ Acutely ill patients, not chronic patients ➢ >24hrs, not patients died within 24hrs
AETIOLOGY
Primary causes
SIRS
MODS
(SIRS) (MODS)
SIRS and CARS
4. Early identification of organ function
Infection
SIRS
Sepsis
Severe Sepsis
MODS
ห้องสมุดไป่ตู้ DIAGNOSIS
1、SIRS 2、MODS
DIAGNOSIS of SIRS
Two or more of conditions below
CRITERIA of ARDS
12.. Acute in onset 2. Oxygenation: A partial pressure of arterial oxygen to fractional
inspired oxygen concentration ratio (PaO2/FiO2) < 200 mmHg regardless of PEEP . ( P/F 200-300mmHg is considered to be Acute Lung Injury, ALI )
Multiple organ dysfunction syndrome (MODS) is the presence of altered organ function in acutely ill patients. It usually involves two or more organ systems.
1.Maintain steady hemo-dynamic condition,
improve tissue perfusion---Golden hour and silver day
Human albumin Colloid
RBC Crystalline
2. Infection control
Antibiotic
Sufficient Drainage
3. Maintain intestinal mucosa
Acute respiratory distress syndrome (ARDS)
DEFINITION
ARDS refers to the syndrome of lung injury characterized by dyspnea, severe hypoxemia, decreased lung compliance, and diffuse bilateral pulmonary infiltrates
History Review
Acute respiratory failure -- primary cause of death
History Review
★ In 1973, Tilney firstly reported the sequential organ failure in surgical patients
DIAGNOSIS of MODS
ORGANS
SYMPTOM
HEART
ACUTE HEART FAILURE
PERIPHERAL CIRCULATION SHOCK
LUNG KIDNEY
ACUTE RESPIRATORY DISTRESS SYNDROME
ACUTE RENAL FAILURE
STOMACH AND INTESTINES LIVER
History of MODS
Sequential system failure Multiple progressive or sequential
system failure Multiple organ failure Remote organ failure Multiple system and organ failure
Multiple Organ Dysfunction Syndrome
Topics to be covered
➢ Multiple organ dysfunction syndrome: 20 min ➢ Acute respiratory distress syndrome : 25 min ➢ Acute renal failure : 35 min
34.. Bilateral pulmonary infiltrates on chest radiograph 4. Pulmonary artery wedge pressure (PAWP) < 18 mmHg
5.
or no clinical evidence of left atrial hypertension
Acute Renal Failure (ARF)
INCIDENCE
➢ Approximately 1% of patients on admission to the hospital
➢ 2% to 5% during the hospital stay ➢ 10%-20% patients in ICU
● Drug overdose
● Near drowning
● Pulmonary contusion
● Fat embolism
● Reperfusion pulmonary edema
post lung transplantation or
pulmonary embolectomy
Clinical manifestation
◆Time: 24~72hr after injury ◆ Tachypnea, Dyspnea , Requiring positive pressure ventilation ◆ Normal auscultatory findings in the chest ◆ Arterial blood gas: PaO2, PaO2/FiO2) < 200 mmHg
Monitoring of ARDS
◆ Arterial blood gases ◆ Respiratory parameters ◆ Haemodynamic parameters, especially
PAWP (Swan-Ganz catheter) ◆ Pulse oximetry ◆ Chest x-ray
Managements of ARDS
➢ Perform early clinical determination of respiratory difficulty ➢ Perform objective assessment with arterial blood gas and
chest radiograph, monitor saturation ➢ Provide supplemental oxygen ➢ Determine the need for intubation and mechanical ventilation ➢ Use lung-protective ventilator strategies with low tidal volume (6-8ml/kg) and low plateau pressure (<30 cmH2O) ➢ Optimize fluid status, nutrition, and treat complications
Pro-inflammatory cytokines
Anti-inflammatory cytokines
• TNF-α • IL-1、IL-6、 IL-8 • ROS • Platelet activating factor • Leukotriene, Prostaglandin
• PGE2 • IL-4、IL-10、IL-13 • TGF-β
Acute organ-system failure
Tilney
Baue
Eiseman Polk Fry Knaus
1973
1975
1977 1977 1980 1985
Multiple organ dysfunction syndrome ACCP/SCCM 1991
DEFINITION of MODS
STRESS ULCER AND ENTEROPARALYSIS
ACUTE LIVER FAILURE
BRAIN
ACUTE CENTRAL NERVE SYSTEM FAILURE
COAGULATION FUNCTION
DISSEMINATED INTRAVASCULAR COAGULATION
DIAGNOSIS of MODS
Multiple Organ Dysfunction Syndrome
(MODS)
History Review
World War II(1939-1945)
SHOCK -- primary cause of death
History Review
Acute renal failure -- primary cause of death
ARF is a potentially lethal complication ！
DEFINITION
Acute renal failure (ARF) A syndrome characterized by a rapid decrease in the ability of kidney to eliminate waste products. Clinically manifested by decreased urine output and the accumulation of the end products of the metabolism of nitrogen (urea and creatinine, Scr > 106μmol/l in male, >97μmol/l in female).
☯ Oliguria
Urine output less than 400 ml per day
☯ Anuria
Causes of ARDS
Direct lung injury
Indirect lung injury
● Pneumonia
● Sepsis
● Aspiration of gastric
● Severe trauma
contents
● Cardiopulmonary bypass
● Inhalation injury
PREVENTION and TREATMENT
1. Maintain steady hemodynamic condition 2. Infection control 3. Maintain intestinal mucosa 4. Early identify organ function 5. Homeostasis 6. Immune-modulation
Early phase of acute respiratory distress syndrome showing interstitial changes and patchy infiltrates
Late stage of acute respiratory distress syndrome showing bilateral and diffuse alveolar and reticular opacification
Development of MODS
➢ SIRS and CARS ➢ Gut hypothesis ➢ Endotoxin macrophage theory ➢ Tissue hypoxia-micro-vascular hypothesis
--- Systemic inflammatory response syndrome (SIRS) --- Compensatory Anti-inflammatory Response Syndrome (CARS)
DIAGNOSIS of MODS
➢ Acutely ill patients, not chronic patients ➢ >24hrs, not patients died within 24hrs
AETIOLOGY
Primary causes
SIRS
MODS
(SIRS) (MODS)
SIRS and CARS
4. Early identification of organ function
Infection
SIRS
Sepsis
Severe Sepsis
MODS
ห้องสมุดไป่ตู้ DIAGNOSIS
1、SIRS 2、MODS
DIAGNOSIS of SIRS
Two or more of conditions below
CRITERIA of ARDS
12.. Acute in onset 2. Oxygenation: A partial pressure of arterial oxygen to fractional
inspired oxygen concentration ratio (PaO2/FiO2) < 200 mmHg regardless of PEEP . ( P/F 200-300mmHg is considered to be Acute Lung Injury, ALI )
Multiple organ dysfunction syndrome (MODS) is the presence of altered organ function in acutely ill patients. It usually involves two or more organ systems.
1.Maintain steady hemo-dynamic condition,
improve tissue perfusion---Golden hour and silver day
Human albumin Colloid
RBC Crystalline
2. Infection control
Antibiotic
Sufficient Drainage
3. Maintain intestinal mucosa
Acute respiratory distress syndrome (ARDS)
DEFINITION
ARDS refers to the syndrome of lung injury characterized by dyspnea, severe hypoxemia, decreased lung compliance, and diffuse bilateral pulmonary infiltrates
History Review
Acute respiratory failure -- primary cause of death
History Review
★ In 1973, Tilney firstly reported the sequential organ failure in surgical patients
DIAGNOSIS of MODS
ORGANS
SYMPTOM
HEART
ACUTE HEART FAILURE
PERIPHERAL CIRCULATION SHOCK
LUNG KIDNEY
ACUTE RESPIRATORY DISTRESS SYNDROME
ACUTE RENAL FAILURE
STOMACH AND INTESTINES LIVER
History of MODS
Sequential system failure Multiple progressive or sequential
system failure Multiple organ failure Remote organ failure Multiple system and organ failure
Multiple Organ Dysfunction Syndrome
Topics to be covered
➢ Multiple organ dysfunction syndrome: 20 min ➢ Acute respiratory distress syndrome : 25 min ➢ Acute renal failure : 35 min
34.. Bilateral pulmonary infiltrates on chest radiograph 4. Pulmonary artery wedge pressure (PAWP) < 18 mmHg
5.
or no clinical evidence of left atrial hypertension
Acute Renal Failure (ARF)
INCIDENCE
➢ Approximately 1% of patients on admission to the hospital
➢ 2% to 5% during the hospital stay ➢ 10%-20% patients in ICU
● Drug overdose
● Near drowning
● Pulmonary contusion
● Fat embolism
● Reperfusion pulmonary edema
post lung transplantation or
pulmonary embolectomy
Clinical manifestation
◆Time: 24~72hr after injury ◆ Tachypnea, Dyspnea , Requiring positive pressure ventilation ◆ Normal auscultatory findings in the chest ◆ Arterial blood gas: PaO2, PaO2/FiO2) < 200 mmHg
Monitoring of ARDS
◆ Arterial blood gases ◆ Respiratory parameters ◆ Haemodynamic parameters, especially
PAWP (Swan-Ganz catheter) ◆ Pulse oximetry ◆ Chest x-ray
Managements of ARDS
➢ Perform early clinical determination of respiratory difficulty ➢ Perform objective assessment with arterial blood gas and
chest radiograph, monitor saturation ➢ Provide supplemental oxygen ➢ Determine the need for intubation and mechanical ventilation ➢ Use lung-protective ventilator strategies with low tidal volume (6-8ml/kg) and low plateau pressure (<30 cmH2O) ➢ Optimize fluid status, nutrition, and treat complications
Pro-inflammatory cytokines
Anti-inflammatory cytokines
• TNF-α • IL-1、IL-6、 IL-8 • ROS • Platelet activating factor • Leukotriene, Prostaglandin
• PGE2 • IL-4、IL-10、IL-13 • TGF-β
Acute organ-system failure
Tilney
Baue
Eiseman Polk Fry Knaus
1973
1975
1977 1977 1980 1985
Multiple organ dysfunction syndrome ACCP/SCCM 1991
DEFINITION of MODS
STRESS ULCER AND ENTEROPARALYSIS
ACUTE LIVER FAILURE
BRAIN
ACUTE CENTRAL NERVE SYSTEM FAILURE
COAGULATION FUNCTION
DISSEMINATED INTRAVASCULAR COAGULATION
DIAGNOSIS of MODS
Multiple Organ Dysfunction Syndrome
(MODS)
History Review
World War II(1939-1945)
SHOCK -- primary cause of death
History Review
Acute renal failure -- primary cause of death
ARF is a potentially lethal complication ！
DEFINITION
Acute renal failure (ARF) A syndrome characterized by a rapid decrease in the ability of kidney to eliminate waste products. Clinically manifested by decreased urine output and the accumulation of the end products of the metabolism of nitrogen (urea and creatinine, Scr > 106μmol/l in male, >97μmol/l in female).
☯ Oliguria
Urine output less than 400 ml per day
☯ Anuria
Causes of ARDS
Direct lung injury
Indirect lung injury
● Pneumonia
● Sepsis
● Aspiration of gastric
● Severe trauma
contents
● Cardiopulmonary bypass
● Inhalation injury
PREVENTION and TREATMENT
1. Maintain steady hemodynamic condition 2. Infection control 3. Maintain intestinal mucosa 4. Early identify organ function 5. Homeostasis 6. Immune-modulation
Early phase of acute respiratory distress syndrome showing interstitial changes and patchy infiltrates
Late stage of acute respiratory distress syndrome showing bilateral and diffuse alveolar and reticular opacification
Development of MODS
➢ SIRS and CARS ➢ Gut hypothesis ➢ Endotoxin macrophage theory ➢ Tissue hypoxia-micro-vascular hypothesis
--- Systemic inflammatory response syndrome (SIRS) --- Compensatory Anti-inflammatory Response Syndrome (CARS)