多系統器官衰竭(英文)

MultipleOrganDysfunctionSyndrome(MODS)

多器官功能障礙綜合征DefinitionMultipleorgandysfunctionsyndrome（MODS）:Multipleorgansorsystemsdysfunctionoccursimultaneouslyorprogressivelyfollowingsevereinfection,severetraumaandshock.Theaffectedorgansystemsinvolvedare:respiratory,cardiovascular,renal,hepatic,gastrointestinal,hematological,endocrine,andcentralnervoussystem.MODSisanimportantreasonforthedeathofseverepatient.TheEvolutionofMODSInWorldWarI,injuredsoldiersdiedinthebattlefieldofprofoundcardiacfailure.Thiswaspresumedtobecausedbywoundtoxins,butclinicalinterventionswerelargelyundefined.InWorldWarIIandtoagreaterextentintheKoreanWar,thelossofbloodvolumewasrecognizedtobetheprimarycauseoftraumaticshock.battlefieldcasualtieswereresuscitatedwithbloodandplasmauntilbloodpressurereturnedtonormal.Asaresult,moresoldierssurvivedtheirinitialinsult;however,theseverelyinjuredoftensuccumbedtooliguricrenalfailure.TheEvolutionofMODS1960’s-ARDS

（acute

aspiratory

distress

syndrome)

wasdescribedinVietnamas

“ShockLung”.1973-Tilneydescribedmultipleorganfailure(MOF)orMultiSystemOrganFailure(MSOF).TheyconcludedthatMOFsyndromewastheresultofacombinationofpreexistingdiseaseandhemorrhagicshock.1980’s-begantorealizeconceptofsepsis.MOFwasconsideredasafatalexpressionofuncontrolledinfection.1990’s–systemichyperinflammationbecamethefocus,nowreferredtoasthesystemicinflammationresponsesyndrome(SIRS).MOFandMODSMODSreplacesMultipleOrganFailure(MOF)Multipleorganfailure(MOF):Progressivedistantorganfailure(initiallyuninvolved)followingsevereinfectiousornoninfectiousinsults(severeburn,multipletrauma,shock,acutepancreatitis)MODSisarangeofdysfunctionalorgans,notjustfailureAlteredorganfunctioninanacutelyillpatientsuchthathomeostasiscannotbemaintainedwithoutintervention.MOFisthefinalityofMODSmechanismbasisdiseases:severetissueinjuryorbloodandfluidlossduetotrauma,burnandmajoroperationsevereinfectionshockresuscitationofcardiacandrespiratoryarrestacutehaemorrhagicnecroticpancreatitis,colicintestineobstruction,rewarmingofcoldinjurymisapplicationofinfusion,drug,orrespirator.primarydisease:coronaryheartdisease,livercirrhosis,chronicnephrosismechanismThemechanismsofMODSareenormouslycomplexandpoorlyunderstood.Systemicinflammatoryresponsesyndrome(SIRS)isthemainreasonofMODS.definition:pathologicinflammatoryresponsetoinjuryorinfectiondiagnosticcriteria:anytwoormoreofthefollowingmanifestations:1.temp>38or<36°C2.heartrate>90/min3.respiratoryrate>20/minorhyperventilation(PaCO2<32mmHg)4.Whitebloodcellcount>12,000cells/mm3,or<4000cells/mm3,orimmatureneutrophils>10%

mechanismToeveryactionthereisalwaysopposedanequalreaction:or,themutualactionoftwobodiesuponeachotherarealwaysequal,anddirectedtocontraryparts.-SirIsaacNewton,1687compensatoryanti-inflammatoryresponsesyndrome(CARS)imbalanceofinflammataryresponseandanti-inflammatoryresponse

SIRS>CARS,MODSoccurs.mechanismenterogenousinfection

ischemicinjury↓intestinemucosalbarrierdysfunction↓bacterialtranslocation↓enterogenousinfection↓releaseofinflammatorymediators↓MODSclinicalfeatureanddiagnosistwotypes:primary:rapid,24hoursafteracuteprimarydisease,twoormoreorgansdysfunction.

TheoccurrenceofMODSisduetoadirectinjuryorinsulttoanorganorsystem.Ascontusionoflungfromtrauma,coagulapathyinducedbymultiplebloodtransfusion,acuterenalshutdownfromdrugs.

secondary:tardy,afteraninitialorgandysfunctionandasteadyperiod,anotherormoreorgan(s)dysfunctionoccur(s)secondarily.

Itisaconsequenceofthehostresponse,whichresultinaninflammatoryresponseinorgandistantfromthesiteoftheinitialinsult.cardiovascularsystemacuteheartfailure:tachycardia,arrhythmiaabnormalECGshock:BP↓,coldnessofextremities,oliguriamicrocirculationabnormalrespiratorysystemacuterespiratorydistresssyndrome(ARDS):tachypnea,wheezing,cyanoseseverehypoxemia,abnormalrespiratoryfunctionhyperventilationresultsinrespiratoryalkalosisdependenceuponoxygenationsupportandmechanicalventilationurinarysystemacuterenalfailure(ARF):suddendeclineofurineoutput(lessthan400ml/24hour)despiteadequatefluidsspecificgravityofurine↑natrium↑inurineandcreatinine↑inbloodgastrointestinestressulcerandintestinalparalysis:hematemesis嘔血hematochezia便血abdominaldistentionweakbowelsoundsgastroscopeliveracutehepaticfailure:jaundicemindabnormalhepaticencephalopathyabnormalbiochemicalliverfunctiontests:bilirubin↑,transaminase↑

neurologicalsystemcentralnervoussystemfailure:consciousdisturbancereactivedepressionofpainandsoundstimulationdisseminatedintravascularcoagulation(DIC)ecchymosis淤斑

hematemesis嘔血

hemoptysis咯血

plateletcount↓,fibrinogen↓,thrombintime(PT)↑,partialthrombintime(PTT)↑earlydiagnosis1.acquaintancewiththehighriskfactorsofMODS.earlydiagnosis2.SIRS+organsdysfunction=MODSorgansdysfunctioncausedbySIRSinduceddamagesuchthathomeostasiscannotbemaintainedwithoutsupportivemeasuresSIRSmustbeidentifiedassoonaspossibleinordertoinstituteimmediatetreatmenttopreventprogressiontoMODSearlydiagnosis3.Multipleorgansdysfunctionoccurprogres-sively,eithertheinitialorganoradistantorgan.Oneorgandysfunctionoccurs,theothersshouldbedetectedintime.earlydiagnosis4.Paymoreattentiontoorgandysfunctionthanorganfailure.ThatSIRSevolvesintoMODSisadynamicprocess.Thedysfunctionmaybepartialorcomplete,reversibleorirreversibleEarlydiagnosis5.Dysfunctionofheart,lung,brainandkidneyhasaclearclinicalmanifestation,whileuntilseverestage,dysfunctionofliver,GIandhaematologicalsystemhasnotaclearclinicalmanifestation.Somespecialaccessoryexaminationsareessential.ProphylaxisandtreatmentSyntheticandSupportiveTherapyHighmortalityProphylaxisismoreimportant.Prophylaxisandtreatment1.Improvethequalityofresuscitation,attachimportancetocirculationandrespiratory.correcthypovolemia,restoretissueperfusionandoxygentransportationprophylaxisandtreatment2.ControlinfectionisaimportantmeasuretopreventMODS.Drainageofinfectiousfocus,clearanceofnecrotictissuesLocalizationofinfectiontoalleviatetoxemia.Antibioticsprophylaxisandtreatment3.Tomanagesingleorgandysfunctionearlyandblockthepathologicchainreaction.Themoredysfunctionalorgans,thehighermortality.4.Improvegeneralconditions.CorrectdisorderofwaterandelectrocytesCorrectdisturbanceofacid-basebalanceCorrecthypoalbuminemiaCorrectmalnutritionProphylaxisandtreatment5.Protectintestinalmucousbarrier,preventbacterialtranslocation.useofglutamine,somatropin(growthhormone)6.immuneregulationuseofthymopeptidesandhumanimmunoglobulins

acuterenalfailure(ARF)definition

Acuterenalfailureisaconditioninwhichtheglomerularfiltrationrateisabruptlyreduced,causingasuddenretentionofendogenousmetabolitesthatarenormallyclearedbythekidneys.

Commonly,ARFischaracterizedbysuddenreduceofurinaryoutput.oliguriaurinevolume<400ml/dayauriaurinevolume<100ml/daynonoliguricacuterenalfailure

Theurinevolumeperdayismorethan800ml,thebloodureanitrogen(BUN)andserumcreatinineriseprogressively.etiologyandclassificationPrerenalARFinadequaterenalperfusionPostrenalARFobstructiontotheurineoutflowofbilateraluretersofkidneysIntrarenalARFacutetubularnecrosisandacutecorticalnecrosiscausedbytherenalischemiaandrenaltoxicosis.EtiologyandclassificationPrerenalARF

inadequaterenalperfusion

Hypovolemia

Hemorrhage

Gastrointestinalfluidloss

(nasogastricsuction,high-outputfistula,diarrhea,etc.)

Renalloss

(excessivediureticuse,diabetesinsipidus,diabetesmellitus)

Surgery

Burns

EtiologyandclassificationPrerenalARF

inadequaterenalperfusionDecreasedeffectivevascularvolume

Sepsis

Hepaticfailure

Anaphylacticshock

Neurogenicshock

Vasodilators

Impairedcardiacfunction

Myocardialinfarction

Pulmonaryembolus

Cardiactamponade

Congestiveheartfailure

MechanicalventilationEtiologyandclassificationPostrenalARF

obstructiontotheurineoutflowureteralobstruction

Stone

Infection(pyelo