multiple organ dysfunction syndrome
multiple
[mul´tĭ-p'l]Diagnostic procedures to confirm suspected multiple myeloma include blood analyses, quantitative immunologic assays of serum and urine, urinalysis, bone marrow aspiration and biopsy, and skeletal x-rays. Findings indicative of the disease are an increased number of plasma cells in the bone marrow (usually over 10 per cent of the total), anemia, hypercalcemia due to release of calcium from deteriorating bone tissue, and elevated blood urea nitrogen, Bence Jones protein in the urine, and osteolytic lesions that give the bone a honeycomb appearance on x-ray and lead to vertebral collapse.
Transfusions with packed red blood cells can help alleviate and minimize some of the more severe symptoms of anemia. It is important that the patient be adequately hydrated to improve viscosity of the blood and circulation, to help avoid hypercalcemia, and to maintain kidney function for excretion of the products of protein metabolism. Continued ambulation and moderate exercise help slow down the loss of minerals, especially calcium, from the bones. Other problems are related to the administration of highly toxic antineoplastic drugs.
The course of the disease is usually prolonged, with remissions and relapses over many years. Brief exacerbations, even with acute and severe symptoms, are thought to be the result of a transient inflammatory depression of neural transmission. Recovery occurs when there has been no permanent damage to the myelin sheath during the attack. Repeated attacks can, however, eventually permanently denude the axons and leave the yellow sclerotic plaques that are characteristic of the disease. Once the disease process reaches the stage of sclerosis the affected axons cannot recover and there is permanent damage.
The prevalence of MS is not certain because the disease is not one that is reported, and mild cases can be either misdiagnosed or never brought to the attention of a health care provider. It is far more common in the temperate zones of the world than in tropical and subtropical climates. The onset of symptoms most often occurs between the ages of 20 and 40 years, and the disease affects both sexes about equally.
The cause of multiple sclerosis is unknown. It is likely that an inherited immune response is somehow responsible for the production of autoantibodies that attack the myelin sheath. Some authorities believe that infection by one of the slow viruses occurs during childhood and after some years of latency the virus triggers an autoimmune response. Others believe there is an antigen or environmental trigger for the disease.
The diagnosis of multiple sclerosis is difficult because of the wide variety of possible clinical manifestations and the resemblance they bear to other neurological disorders. There is no definitive diagnostic test for the condition, but persons with objectively measured abnormalities of the central nervous system, a history of exacerbation and remission of symptoms, and demonstrable delayed blink reflex and evoked visual response are diagnosed as having either possible or probable multiple sclerosis. With time and progressive worsening of symptoms the diagnosis can become definite.
Supportive measures include a regimen of rest and exercise, a well-balanced diet, avoidance of extremes of heat and cold, avoidance of known sources of infection, and adaptation of a life style that is relatively unstressful while still being as productive as possible.
Therapeutic measures include medications to diminish muscle spasticity; measures to overcome urinary retention (such as credé's method or intermittent catheterization); speech therapy; and physical therapy to maintain muscle tone and avoid orthopedic deformities. Management of MS has been greatly enhanced by the availability of interferons beta-1a and beta-1b. Research support is strong that these medications reduce the frequency and severity of relapses.
Many multiple sclerosis patients and their families receive valuable support and encouragement from communication with others coping with the condition. A local chapter of the National Multiple Sclerosis Society is within reach of most persons in the United States. Information and assistance in all phases of the disease are available by writing to The National Multiple Sclerosis Society, 733 Third Ave., 6th floor, New York, NY 10017, or consulting their web site at http://www.nmss.org.
multiple organ dysfunction syndrome
,MODS
Patient care
Patients at risk should be closely monitored to help prevent MODS by prompt recognition and correction of perfusion problems, infection, and organ dysfunction. Patients with MODS often have pulmonary, cardiovascular, renal, and hepatic failure, often followed or accompanied by gram-negative sepsis and disseminated intravascular coagulation. Appropriate medical interventions are initiated for each failing system's problems. Nursing responsibilities include assessing for hemodynamic, acid-base and fluid and electrolyte balance, monitoring and assessing diagnostic study results, coordinating and carrying out prescribed therapies and evaluating patient responses while simultaneously assessing for adverse effects, protecting the patient from nosocomial infections and environmental stressors, and providing emotional support for the patient and family through this type of devastating illness, which has a 90% mortality rate.
The respiratory therapist assists the physician in determining when to intubate the patient and initiate mechanical ventilation. Mechanical ventilation ensures adequate oxygenation and carbon dioxide retention, protects the patient against aspiration, and serves to rest the muscles of breathing and reduce oxygen consumption. The health care provider frequently measures arterial blood gases and pulse oximetry, continually monitors cardiac rhythms, assesses electrolyte and renal function, ensures patient and family comfort and understanding, and protects the patient against complications, including deep venous thrombosis, pressure ulcers, malnutrition, and hospital-acquired infections.
Multiple Organ Dysfunction Syndrome
| DRG Category: | 205 |
| Mean LOS: | 5.3 days |
| Description: | MEDICAL: Other Respiratory System Diagnoses With Major CC (If the patient develops this syndrome during the hospital stay, the reason for admission will determine the DRG assigned) |
Multiple organ dysfunction syndrome (MODS) occurs when altered organ function in an acutely ill patient is present to the extent that homeostasis can no longer be maintained without intervention. MODS was formerly known as multiple system organ failure. The usual sequence of MODS depends somewhat on its cause but often begins with pulmonary failure 2 to 3 days after surgery, followed, in order, by hepatic failure, stress-induced gastrointestinal (GI) bleeding, and renal failure. Mortality rates are linearly related to the number of failed organ systems. Patients with two or more organ systems involved have a mortality rate of approximately 75%, and patients with four organ systems involved have a 100% mortality rate.
MODS was first associated with traumatic injuries in the late 1960s and has subsequently been associated with infection and decreased perfusion to any part of the body. The term multiple organ dysfunction syndrome was adopted in 1991 at a consensus conference of the Society of Critical Care Medicine and the American College of Chest Physicians as it best describes the organ dysfunction that precedes complete failure. Primary MODS, the result of a direct injury or insult to the organ itself, is initiated by a specific precipitating event, such as a pulmonary contusion. The injury or insult causes an inflammatory response within that organ system, and dysfunction develops.
Secondary MODS develops as the result of a systemic response to infection or inflammation. Systemic inflammatory response syndrome (SIRS) is an overwhelming response of the normal inflammatory system, producing systemic effects instead of the localized response normally seen. The inflammatory response is produced by the activation of a series of mediators and results in alterations in blood (selective vasodilation and vasoconstriction), an increase in vascular permeability, white blood cell (WBC) activation, and activation of the coagulation cascade. Mortality rates are high with MODS, and the more organ systems that fail, the higher the mortality. For example, mortality with two-organ failure is 45% to 55%, higher than 80% with three-organ failure, and approaches 100% if the failure of three or more organs persists longer than several days.
Causes
The inflammatory response can be triggered by any event, but it is most often associated with a bacterial infection. The events most often associated with the development of SIRS and MODS are shock, trauma, burns, aspiration, venomous snakebites, cardiac arrest, thromboemboli, myocardial infarction, operative procedures, vascular injury, infection, pancreatitis, and disseminated intravascular coagulation.
Genetic considerations
Heritable defects in the production of cytokines such as interleukin-6 have been suggested in the etiology of MODS. Animal studies have identified an inherited form of complement deficiency, but clear genetic contributions to MODS have not been elucidated.
Gender, ethnic/racial, and life span considerations
Young adults, males twice as often as females, are at particular risk for MODS because they are the primary trauma population. Increased risk in the trauma patient is related to more prolonged hypotension, extensive amounts of tissue damage, and higher infection and sepsis rates. Patients over age 65 who experience MODS have higher rates of mortality. The normal aging process causes dysfunction of organ systems and, in some patients, immunosuppression. With a significant injury or insult, therefore, it is much easier for organ systems in the elderly to fail. Teenagers, young adults, and adults of all ages who abuse alcohol and who are malnourished are also at risk because of the role of alcohol in immunosuppression. There are no known racial or ethnic considerations with MODS.
Global health considerations
Although no data are available on global prevalence, according to the World Health Organization, motor vehicle injury is the ninth leading cause of death in the world, leading to 1.3 million deaths in 2011. Traffic injury is an important cause of sepsis and MODS.
Assessment
History
The patient with MODS has a history of infection, tissue injury, or a perfusion deficit to an organ or body part. Often, this injury or insult is not life-threatening but exposes the person to bacterial contamination. Question the patient (or, if the patient is too ill, the family) to identify the events in the initial insult and any history of preexisting organ dysfunction, such as chronic lung disease, congestive heart failure, and diabetes mellitus. Elicit a complete medication history and the patient’s compliance with medications and ask if the patient has experienced recent weight loss. Determine the patient’s dietary patterns to assess the patient’s nutritional status. Take a history of the patient’s use of cigarettes, alcohol, and other drugs of abuse.
Physical examination
The physical examination of the patient with MODS varies depending on the organ systems involved and the severity of their dysfunction (Table 1). Symptoms vary widely but may include fever, chills, fatigue, muscle weakness, shortness of breath, and mental status changes. The patient will likely appear acutely ill. Expect the patient to develop signs of pulmonary failure first and then hepatic failure and GI bleeding. Renal failure follows. Note that failures of the central nervous system and the cardiovascular system are late signs of MODS.
| ORGAN SYSTEM | SYMPTOMS OF DYSFUNCTION |
|---|---|
| Central nervous system | Decreased level of consciousness, confusion, lethargy |
| Cardiovascular system |
|
| Pulmonary system |
|
| GI system | Diminished or absent bowel sounds, abdominal distention, intolerance of tube feedings, upper or lower gastrointestinal bleeding, diarrhea |
| Hepatic system | Jaundice, petechiae, increased bruising |
| Renal system | Polyuria, oliguria, or anuria |
| Coagulation system | Oozing or bleeding from intravenous sites or invasive line sites; bruising and petechiae; bleeding into body parts or cavities; cool, pale to mottled extremities; necrotic digits |
| General appearance | Weight loss and muscle wasting; temperature < 98.8°F or > 104.4°F |
Psychosocial
The patient with MODS may be fully conscious, partially conscious, or unconscious. If the patient is oriented, she or he is likely to be very anxious and fatigued and also confused, lethargic, or comatose. Assess the patient’s ability to cope with a prolonged life-threatening illness and the changes in roles that a severe illness brings. The patient may experience fear because of a real threat to her or his life.
Diagnostic highlights
General Comments: Diagnostic data are collected to establish the dysfunction of each of the body’s systems (Table 2).
| Test | Normal Result | Abnormality With Condition | Explanation |
|---|---|---|---|
| Complete blood count | Red blood cells (RBCs): 4–5.5 million/μL; WBCs: 4,500–11,000/μL; hemoglobin (Hgb): 12–18 g/dL; hematocrit (Hct): 37%–54%; reticulocyte count: 0.5%–2.5% of total RBCs; platelets: 150,000–400,000/μL | Varies with condition: > 12,000 mm3 or < 4,000 mm3 or > 10% band cells (immature cells); RBCs, Hgb, Hct, blood cells, decreased | Underlying disorder may cause alterations in blood cell counts; SIRS leads to production of inflammatory mediators and alterations in WBC counts; hematological failure may lead to suppression of cell production |
| Partial thromboplastin time (activated; APPT) | Varies by laboratory; generally 21–35 sec | Prolonged; may be prolonged > 80 sec | May be prolonged if liver failure and hematological failure occurs |
| Prothrombin time (PT) | Varies by laboratory; generally 11–13 sec | Prolonged > 15 sec | May be prolonged if liver failure occurs |
Other Tests: Electrocardiogram, multiple cultures and sensitivities (blood, wound, urine, sputum, catheters), arterial blood gases, pulmonary artery pressure monitoring, cardiac output and index, derived oxygen variables (oxygen delivery, oxygen consumption), electrolytes, glucose
| ORGAN | DEFINITION OF FAILURE | DIAGNOSTIC FINDINGS |
|---|---|---|
| Lungs | Need for ventilator-assisted breathing to treat hypoxemia for 5 days in the postoperative period or until death |
|
| Kidneys | Serum creatinine concentration > 2 mg/dL; for patients with preexisting renal disease, doubling of admission serum creatinine level |
|
| Liver | Serum bilirubin concentration > 2 mg/dL with elevation of either serum aspartate aminotransferase concentration or lactic dehydrogenase concentration above twice normal | See definition |
| Gastrointestinal tract | Requirement of two units of blood replacement within 24 hr for presumed stress bleeding or endoscopic confirmation of upper GI bleeding from acute GI ulcers |
|
Primary nursing diagnosis
Diagnosis
Risk for infection related to microorganism invasion, immunosuppression, malnutrition, and presence of invasive monitoring devicesOutcomes
Immune status; Knowledge: Infection control; Risk control; Risk detection; Nutrition status; Treatment behavior: Illness or injury; HydrationInterventions
Infection control; Infection protection; Surveillance; Fluid/electrolyte management; Medication management: Temperature regulationPlanning and implementation
Collaborative
Management of the patient with MODS begins with the recognition of those patients who are at an increased risk for the syndrome. Care must be taken to prevent infection and maintain adequate tissue oxygenation to all body parts. Despite improvement in medical therapies, the mortality rate of MODS remains high.
Treatment of the patient with MODS can be divided into four main areas: anti-infectives, maintenance of tissue perfusion and oxygenation, nutritional support, and immunomodulation. Anti-infective therapy is guided by culture and sensitivity reports. Any potential source of infection should be investigated and eliminated. Antifungal and antiviral agents are used primarily with immunocompromised patients, who are especially susceptible to fungal and viral infections.
Maintaining and monitoring tissue perfusion and oxygenation are crucial to the survival of the patient with MODS. Measurement of oxygen delivery and consumption is necessary to guide fluid replacement therapy and inotropic support of cardiac function. To maximize all components of oxygen delivery (particularly cardiac index, Hgb, and oxygen saturation), the physician maintains the Hct within the normal range or even at a supranormal level with blood transfusions. Mechanical ventilation with positive end expiratory pressure and modes such as pressure-control ventilation and inverse I:E ratio (inspiration:expiration) ventilation are used to maintain adequate oxygenation and oxygen delivery. The success of maintaining oxygen delivery is evaluated by following the trend of oxygen consumption. Metabolic demands dramatically increase in MODS. When oxygen delivery cannot meet the body’s metabolic demands, these demands may be decreased with sedation, pharmacologic paralysis, and temperature control. The goal in the future is to develop medications that allow for immunomodulation therapy to alter the detrimental effects of the systemic immune-inflammatory response. Tumor necrosis factor and interleukin-1 are two cytokines that exert a broad effect on the endothelium, leukocytes, and fibroblasts. Experts hope that modulation of both of these cytokines can decrease many of the body’s responses to inflammation. The presence of endotoxin, a substance that is released with the destruction of gram-negative bacteria, stimulates the inflammatory response. Modulation of endotoxin would also decrease many of the body’s responses to inflammation.
Pharmacologic highlights
| Medication or Drug Class | Dosage | Description | Rationale |
|---|---|---|---|
| Vasopressor therapy | Varies with drug | Dopamine, epinephrine, norepinephrine, phenylephrine, vasopressin | Maintains circulation and tissue perfusion after volume resuscitation has been accomplished |
| Anti-infective therapy; antifungal agents; antiviral agents | Varies with drug | Therapy focuses on dysfunctional system and culture results; cefotaxime, ceftriaxone, cefuroxime, ticarcillin-clavulanate, piperacillin-tazobactam, imipenem-cilastatin, clindamycin, metronidazole | Prevents and controls infection |
| H2 receptor antagonist | Varies with drug | Ranitidine (Zantac), cimetidine (Tagamet), famotidine (Pepcid), nizatidine (Axid) | Blocks gastric secretion and maintains the pH of gastric contents above 4 |
Other Drugs: Recombinant human-activated protein C was withdrawn from the market in 2011 for use in sepsis and MODS; corticosteroids (controversial)
Independent
Any potential source of infection should be eliminated if possible. Change the dressing on all invasive line sites and surgical wounds according to protocol to keep the area free of infection and to monitor for early signs of infection. Maintain aseptic technique with all dressing changes and manipulation of intravenous lines. Institute measures to prevent aspiration when patients are placed on enteral feedings. Keep the head of the bed elevated and check for residual volume and tube placement every 4 hours.
To limit the patient’s oxygen expenditure, provide frequent rest periods and create a quiet environment whenever possible. Schedule procedures and nursing care interventions so that the patient has periods of uninterrupted rest. Manage situations of increased metabolic demand—such as fever, agitation, alcohol withdrawal, and pain—promptly so that the patient conserves energy and limits oxygen consumption.
Monitor the patient’s environment for sensory overload. Provide purposeful, planned stimuli and keep extraneous, constant noises to a minimum. Provide for planned, uninterrupted rest periods to avoid sleep deprivation. Monitor bony prominences and areas of high risk for skin breakdown. Note that MODS is one of the most critical illnesses that a patient can develop. Although the patient might be well sedated and unresponsive, the family or significant others are generally very anxious, upset, and frightened that the patient might not survive.
These fears are realistic, particularly if multiple organs are involved. Provide the significant others with accurate information about the patient’s course and his or her prospects for recovery. Encourage the legal representative to participate in decisions about extraordinary measures to keep the patient alive if the patient cannot speak for himself or herself. Determine if the patient has a living will or has discussed his or her desire to be kept alive by technology during a potentially terminal illness. If the decision is to terminate life support, work with the significant others to provide a dignified death for the patient in an environment that allows the family to participate and grieve appropriately. Provide referrals to the chaplain, clinical nurse specialist, or grief counselor as needed.
Evidence-Based Practice and Health Policy
Kyle, U.G., Coss Bu, J.A., Kennedy, C.E., & Jefferson, L.S. (2010). Organ dysfunction is associated with hyperglycemia in critically ill children. Intensive Care Medicine, 36(2), 312–320.
- Investigators conducted a retrospective cohort study among 110 patients being treated in a pediatric intensive care unit and found that patients with dysfunction of three or more organs were 6.1 times more likely to experience intermittent hyperglycemia (95% CI, 1.8 to 21.2; p = 0.004), even when being treated with an insulin drip. Fifty-five percent of patients had dysfunction of three or more organs.
- Severe hyperglycemia was experienced by a significantly greater proportion of patients with dysfunction of three or more organs (17.2%) compared to patients with dysfunction of less than three organs (2.2%) (p = 0.01). However, hyperglycemia had no significant effect on survival, which was 70% overall at hospital discharge.
Documentation guidelines
- Physical assessment findings:
- Neurological: Mental status response to stimuli; if pharmacologically paralyzed, then peripheral nerve stimulation testing
- Pulmonary: Respiratory rate, auscultation findings, amount of ventilatory support, oxygen saturation by pulse oximetry
- Hemodynamics: Cardiac output/index, right and left ventricular measures of preload and afterload; oxygen delivery; oxygen consumption
- Renal function: Fluid intake and urine output
- Hepatic function: Color of skin and sclera, presence of petechiae, bruising, oozing, or frank bleeding
- Response to acute, life-threatening illness: Anxiety level, coping
Discharge and home healthcare guidelines
Although no specific adaptive structural changes need to be made, assess the patient’s individual needs near the time of discharge. Because organ dysfunction or failure is individualized, home-care preparation should be based on meeting the individual’s needs. Be sure the patient understands all medications prescribed, including dosage, route, action, and side effects.
Describe the importance of avoiding fatigue and of taking frequent rests. Teach the patient to eat small, frequent meals to maintain adequate nutrition. Teach the patient any needed postoperative care: incision care, signs and symptoms of infection, pain management, activity restrictions. Also teach the patient when to report signs and symptoms of infection to the primary healthcare provider.