多臟器功能障礙綜合征與監(jiān)護(hù)

Denominationvariation1973secondarysystemfunctionfailure---Tilney

Summarydataof18casesARFpatientsafterabdominalaorticaneurysmoperation,and17patientsdiedfromorganfailureduringdialysis.1975－1977

MOFS，multipleorganfailuresyndrome-----Baue，1975

（Yetthetreatmentdidnotsavethelives.)

MOF，multipleorganfailure-----Eiseman，1977

1980‘s

MSOF，multiplesystemorganfailure-----Fry38/533

pointouttherelationshipbetweenMSOFandsevereinfection

1990‘s※MODS,multipleorgandysfunctionsyndrome※1第一頁，共61頁。Case1Male26yPost-subtotalexcisionofcolonIleocolonicstomaleakageMultipleintestinalfistula2第二頁，共61頁。Abdominalabscess3第三頁，共61頁。Long-termapplicationofhighcaloriaparenteralnutrition(fatemulsion)

livertumefaction

liverdysfunction

SGPT36SGOT144TB167.9

DB102.8

4第四頁，共61頁。HR170RR55PaCO223.8WBC18700Positivebloodcultivation5第五頁，共61頁。Jan16th

septicshockJan17thRenalfunction

BUN20.5Cr337needinhalationofoxygenwithmask

continuoushemofiltrationJan19th

tracheotomy

ventilatorapplication6第六頁，共61頁。Case2male59yExtensiveanteriorwallMyocardialinfarction20daysafteronset(2002/3/6)

continuousventriculartachycardia→ventricularfibrillation

electricdefibrillation5times

antiarrhythmicdrugs

countershockdrugs

ventilatorapplication7第七頁，共61頁。HR120RR28PaCO226.8WBC126008第八頁，共61頁。Repeatedlyventriculartachycardiaandfibrillation，totally21timeselectricdefibrillationContinuoushyperpyrexia、highWBC、HR≥90、RR≥22Cultivationnegative,antibioticsnoeffectivenessOrgandysfunctioncameincrowdsshockRespiratorydysfunctionDeteriorationofliverfunctionCastinurineroutinetest→BUN、Cr↑

→oliguria、anuriaCoagulationabnormalitydeath9第九頁，共61頁。AcuteonsetManifestatinofexcessiveinflammationDeteriotationofpts’conditionsdespiteactivetherapyMultipleorgandysfunctionDifferentpts,SameprogressCase1:infectiousCase2:noninfectious10第十頁，共61頁。clinicalbehaviorAccumulativeSubstanceirreversibleMultipleorganlowfunctioncausedbyinteractionbetweenorgansChronicdiseaseMultipleorganlowfunction11第十一頁，共61頁。MODSfollowedbyprimaryemergencydiseasein24hoursClinicalmanifestationburstoutSimultaneousdiequicklyprimaryMODSIschemiaischemiaandreperfusionphysicalandchemicalinjuryfactor12第十二頁，共61頁。Sequentialorgandysfunctionafteremergencydisease,MODSClinicalbehaviorDelayedSequentialReversibleMODSExcessiveinflammatorymediators13第十三頁，共61頁。1.DirectinjuryofischemiaOxygen&nutrientinsufficiencyIntegrityofcellmembrane↓organelleinsult↓ATP↓

Extracellularfluidin-flowHydrolaseactivationNatriumin-flowcalciumin-flow

14第十四頁，共61頁。1.DirectinjuryofischemiaHypersensibitityinheartandbrainSelectiveischemiaEndothelialcellinjuryleadstohighvascularpermeabilityandlowvolume15第十五頁，共61頁。permeabilityofcellmembrane↑Na+Ca++H2OADPAMPIMPadenosinexanthinehypoxanthinehypoxanthineribosideUricAcidoxygen-derivedfreeradidicalsxanthineoxidasexanthineoxidaseXanthinedehydrogenaseIntracellularacidosisLowerproteinsynthesisInjuryofischemiaandreperfusion16第十六頁，共61頁。Vesselpermeability↑＋WBCchemotaxis

monocyte/macrophage

neutrophil

elastinasePLA2ODFR

TNFIL－8etal

IL－1IL－6

liver：acute

phasereactionRemoteorganinjuryTissuedamageetiologicalfactor

neutrophilAdherentmolecule2.ExcessiveinflammationSIRSMODSVascularendothelialcellSIRSMODS17第十七頁，共61頁。ClinicalprogressuncontrolledstressSIRSCapillaryleakagesyndromeMODSMSOF18第十八頁，共61頁。ImportantmoleculeinMODS

Pro-inflammatorycytokines:TNF-αβ,IL-1、2、6etcStimulatesynthesisandreleaseofothercytokinesActivateneutrophiles,eosinophilsandmonocytes;activateTandBcell;chemotaxisIncreasetheexpressionofadherentmoleculeActivatecomplementandcoagulationsystemIncreasepermeabilityofvessels,decreaseBPCausefeverandcatabolismofmuscle19第十九頁，共61頁。ImportantmoleculeinMODS

Anti-inflammatorycytokines:IL-4、10

etcMaintainandenhancethefunctionofactivatedNKcells,monocytes,BandTcells，InhibitproliferationofT,BcellInhibitpro-inflammatorycytokinesproduction,receptorexpressionandcytotoxicityofmonocytesInhibitadherentmoleculeexpressionofvascularendothelialcells(VECs)InhibitH2O2、NOproductionofmacrophageInhibitantigenpresentationandotherassistantfunctionsofmonocytesandmacrophage20第二十頁，共61頁。ImportantcellsinMODSPolymorphonuclearleucocyte（PMN）：Effectorcellofinflammatoryresponse.CouldreleaseseveralproteinenzymesandODFRtodestroyVECsandstromaVECs：Whenactivated,VECsexpresshigheradherencetoPMNandhigherclottingcompetence;alsotheyproducepro-inflammatorycytokinesandvasodilatingagenttomagnifyinflammatoryresponse;finally,capillaryleakagesyndromecomesifVECsweredestroyed.21第二十一頁，共61頁。ImportantorganinMODSIntestinesBecauseofstress,fastingandcatabolism,theblood-mucosabarrierofintestinescouldbedestructed,thebacteriaandtoxintranlocatetobloodcirculationandthelattercouldenhanceinflammatoryresponsetoformviciouscycle.Sointestinesarecalled“motor”ofinflammatoryresponse,andaresourcesoflatestageinfectonsofMODSpts.22第二十二頁，共61頁。uncontrolledstresscarbohydratemetabolismdysfunction,Insulintolerance,withoutKetonemiahyperkineticcirculatorystate,Hyperpyrexia,HighStrokevolume,HighoxygenconsumptionProteinmetabolismdysfunction,highkatabolism,acutephaseprotein23第二十三頁，共61頁。T＞38℃or＜36℃HR＞90beat/minRR＞20/minorPaCO2＜32mmHgWBC＞12000mm3or＜4000mm3orprematurecells＞10％SepsisSystemicInflammatoryResponseSyndrome(SIRS)(SIR+PositiveCulture)(SIRwithoutinfection)SystemicInflammatoryResponsesyndrome

SIRS24第二十四頁，共61頁。ChaoticinternalmilieuduringacutephaseDisturbanceofelectrolytesandacid-basebalanceFeverCatabolism:emaciated,anemiaAcutedisseminatedintravascularcoagulationArrhythmiaHyperglycemia,noketonemia25第二十五頁，共61頁。Secondaryaldosteronism---highdensityurinewithoutProteinuria,oliguria

---prerenalazotemia---swollenPlasmaproteinleakage---Interstitialedema

---Hypoproteinemia

---bloodinspissasion---HypovolemiaCapillaryleakagesyndrome,CLS26第二十六頁，共61頁。DiagnosisofCLSPositivebodyfluidbalanceBloodvolumedeficiencyHypoproteinemiaOrganandtotalbodyInterstitialedemalungInterstitialedemacerebralInterstitialedema27第二十七頁，共61頁。OrgansdysfunctionorfailureOrganorsystemdysfunctionfailurelungLiverkidneyintestineBloodHypoxemia,respiratoratlist3-5daysARDS,PEEP>10cmH2O,FiO2>0.5Bilirubin>2-3mg/dL,Liverfunction>2normalvalueBilirubin>2-3mg/dL,icterusoliguriadialysisUntoleranceofenteralnutrition>5daysCurlingl'sulcerneedsbloodtransfusion,AcalculouscholecystitisPTorPTTelongation,platelet<50-80thousand,HypercoagulablestateDICcentralnervoussystemcardiovascularsystemInsanity,lightorientationdisorderProgressivedeepencoma

EjectionFraction

↓,capillaryleakageIrresponsivitytomusclestrengthdrugs28第二十八頁，共61頁。GlasgowScore29第二十九頁，共61頁。InfluencedorganLung——ARDS>95%Kidney——ARF

onlyafew30第三十頁，共61頁。AcuteRespiratoryDistressSyndrome,ARDSPathologyoflungHighcapillarypermeability——InterstitialedemaVasoconstriction,microthrombosis——communicatingbranchopeningAlveolarandsmallbronchus——AtelectasisDecreasedalveolarsurfactantEdemaItypeepithelialcellsinsteadbyIItypecellSymptomTachypnea,respiratorydistresscannotbeeasedbyoxygeninhalationNoralesNolungx-rayabnormality1.Theearlystage31第三十一頁，共61頁。PathologyDeterioratedlungInterstitialinflammation,usuallycomplicatedwithSEPSISSymptomObviouslydyspnoeaandcyanosis——needsventilatorIncreasedrespiratorytractsecretion,ralesLungx-ray——infiltratesDisturbanceofconsciousnessFebrileorhighleucocyte↑.Thesecondstage32第三十二頁，共61頁。3.Telophase

PathologyLungparenchymafibrosisMicrovascularocclusionIncreasedpreload,hypoxiaSymptomDeepcomaArrhythmia—bradycardia—cardiacarrest33第三十三頁，共61頁。Diagnosis34第三十四頁，共61頁。AcuteRenalFailure,ARFEtiologyPrerenalHemorrhage,shock,fluidlosingwithoutappropriatefluidresuscitationpostrenalbothsideureterorurinaryflowblockedrenalkidney

ischemia(hematorrhea,sepsis,allergicreaction)intoxication(aminoglycosideantibiotic,biotictoxin,chemical)35第三十五頁，共61頁。1.HistoryandphysicalexaminationEtiologyprerenalpathogenpostrenalpathogenDiagnosisofARF36第三十六頁，共61頁。2.DifferentiationDiagnosiswithprerenalARF37第三十七頁，共61頁。3.DifferentiationDiagnosiswithPostrenalARFBtypeultrasound(renalenlargement,ureter)Abdominalx-rays(calcification,calculusorObstruction)38第三十八頁，共61頁。4.LaboratoryUrinetestUrinarycathetertorecordurinevolumeUrineacidity/density(1.010-1.014)UrinemicroscopicexaminationRBCandrenaltubuleepithelia(renalcortexandrenalmedullanecrosis)LargeBrowncasts(renalfailurecasts)Eosinophil↑(interstitialnephritis)Redcellcast(glomerulonephritis)Normal(prerenalorpostrenalfailureearlierperiod)39第三十九頁，共61頁。5.renalfunctionexaminationUrineureanitrogen↓

(<180mmol/24)UrineNa↑(>175mmol/24h)Fractionalexcretionoffiltratedsodium>1

FENa（%）=（UNa/PNa）×（PCr/UCr）×100osmoticpressureofurine

*ARF------<400mOsm/L

*prerenalARForglomerulonephritis------>400mOsm/LBUN(morethan

3.8－9.4mmol/Lperday),Cr↑Urine/PlasmaCr------<20renalfailureindex,RFIRFI＝Una×（PCr/UCr）

*>1------ARF*<1------prerenal40第四十頁，共61頁。IntensivecareOrganandsystemfunctionMonitoringandsupportObjectameliorateoxygenmetabolismamelioratenutrienstateTherapyaimedatstressandinflammatoryMediatorsTreatmentofcapillaryleakageTreatmentofprimarydisease41第四十一頁，共61頁。OxygenmetabolismMonitoringCriticalDO2Assayofplasmalacticacid/pyruvicacid42第四十二頁，共61頁。OxygenassociatedindexDO2OxygenDelivery---OxygenofferedtothebodyinacertainperiodbycirculatorysystemDO2＝CO×（1.38×SaO2+0.003×PaO2）VO2OxygenConsumption---Oxygenconsumptedbyallcellsinacertainperiod.VO2＝Ca-vDO2×CO×1043第四十三頁，共61頁。CriticalDO2VO2DO2SepsisARDSMODSNormalCriticaldeliveryoxygen44第四十四頁，共61頁。LacticAcidandcellshypoxiaLacticAcid↑--latentcellshypoxia

lacticacidosis--tissueperfusiondeficiencyandcellshypoxia

LacticAcidnormalvalue---0.5-1.5mmol/L

＞4-5mmol/L→SBandPH↓→lacticacidosisL/Prate↑--cellshypoxia

L/Prate

normalvalue---10:145第四十五頁，共61頁。Strategyofameliorateoxygenmetabolism

Improvementofoxygendeliveryrespiratorysupport---toimprovearterialbloodoxygencontenthigherinhalatedoxygenconcentration,ventilatorincreasecardiacoutput

Heartrate,cardiacrhythm,cardiaccontractility,preload/afterloadBloodsystemrisehemoglobinconcentration46第四十六頁，共61頁。StrategyofameliorateoxygenmetabolismIncrease

oxygenextractionratioAmeliorateinterstitialedemaReducebloodcapilarypermeabilityAmeliorateoxygenextractionofcells47第四十七頁，共61頁。TreatmenofCLSLimitationofwater-intakepremise:nevergetCOdownInfusionvolumedecidedbyurinevolumeperhourwhenlungandbraininterstitialedemahappen.RisecolloidosmoticpressureUsepowerfuldiureticUseglucocorticoid48第四十八頁，共61頁。NutritionalsupportMetabolismsupportOffernutritionalsubstratebutneverincreaseorganloading.MetabolismmodulationInhibitionofcatabolismhormonesPromoteproteinsynthesis,easenegativenitrogenbalance49第四十九頁，共61頁。NutritionalsupportAddaccessoriesPromoteproteinsynthesisandcellgrowthModulateimmunologicresponse

EnteralnutritionProtectbowelblood-mucosabarrier(preventfrominfection)50第五十頁，共61頁。DiscussionoftherapyforstressandinflammatorymediatorsAntagonismandclearanceAimatexcessivecytokines---post-translationlevelsReductionofsynthesis

keepthebalancebetweenpro-andanti-cytokines---intranscriptionlevels

---intranslationlevel51第五十一頁，共61頁。CytokinesmodulationIntranscriptionlevelAnti-mRNAexpression

(NF-κBisinchargeofmanykindsofcytokineexpression.)TranslationlevelReducecytokinessynthesisPosttranslationlevelAnti-cytokines(antibodyorsolublereceptor)BlockreceptorofcytokinesClearanceofcytokines(plasmapheresis)52第五十二頁，共61頁。TreatmenofARDSCorrecthypoxemiaquicklyuseventilatorassoonaspossibleappropriatePEEP（regainalveolarfunctionandfunctionalresidualcapacity)53第五十三頁，共61頁。TreatmenofARDSMaintainCirculationandlunginterstitialedemaPropercrystal/colloidrateDiureticNegativewaterbalance(accordingtoCVP/PAWP,urineoutputandlungauscultation)54第五十四頁，共61頁。TreatmenofARDSPreventandtreatinfectionBlockSIRScorticoidintheinitialstagemediatorsinhibitor(Ibuprofen,Dentoxifylline,TNFantibody)55第五十五頁，共61頁。TreatmentofARFOliguriaoranuriastage

(7-10days,average5-6andmax.morethan1month)confinewaterintakeEqualwaterintakeandoutputfluidintakeperday=(dominantwaterlosing)+(nondominantwaterlosing)-(endogeneouswater)or0.5kgnutrientLowprotein,highcalorie,highVitaminproteinsynthesishormones56第五十六頁，共61頁。TreatmentofARFcorrectelectrolytesimbalaHyperkalemiaHyponatremia