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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多脏器功能障碍综合征及监护Denomination variation1973 secondary system function failure- Tilney Summary data of 18 cases ARF patients after abdominal aortic aneurysm operation,and 17 patients died from organ failure during dialysis .19751977 MOFS，multiple organ failure syndrome-Baue，197
2、5 （Yet the treatment did not save the lives.) MOF ，multiple organ failure- Eiseman，1977 1980s MSOF，multiple system organ failure- Fry38/533 point out the relationship between MSOF and severe infection 1990s MODS,multiple organ dysfunction syndrome2020/12/242,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多脏器功,Denominati
3、on variation,1973 secondary system function failure- Tilney Summary data of 18 cases ARF patients after abdominal aortic aneurysm operation,and 17 patients died from organ failure during dialysis .19751977 MOFS，multiple organ failure syndrome-Baue，1975 （Yet the treatment did not save the lives.) MOF
4、 ，multiple organ failure- Eiseman，1977 1980s MSOF，multiple system organ failure- Fry38/533 point out the relationship between MSOF and severe infection 1990s MODS,multiple organ dysfunction syndrome,2020/12/24,2,Denomination variation1973 s,Case 1Male 26yPost-subtotal excision of colonIleocolonic st
5、oma leakageMultiple intestinal fistula,2020/12/24,3,Case 12020/12/243,Abdominal abscess,2020/12/24,4,Abdominal 2020/12/244,Long-term application of high caloria parenteral nutrition ( fat emulsion) liver tumefaction liver dysfunction SGPT 36 SGOT 144 TB 167.9 DB 102.8,2020/12/24,5,Long-term applicat
6、ion of2020/1,HR 170 RR 55PaCO2 23.8WBC 18700,Positive blood cultivation,2020/12/24,6,HR 170 Positive blood cultiv,Jan 16th septic shockJan 17th Renal function BUN 20.5 Cr 337 need inhalation of oxygen with mask continuous hemofiltration Jan 19th tracheotomy ventilator application,2020/12/24,7,Jan 16
7、th2020/12/247,Case 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 drugs ventilator application,2020/12/24,8,Case 2 male 59y2020/12/248
8、,HR 120 RR 28PaCO2 26.8WBC 12600,2020/12/24,9,HR 120 2020/12/249,Repeatedly ventricular tachycardia and fibrillation，totally 21 times electric defibrillationContinuous hyperpyrexia、high WBC、HR90、RR22Cultivation negative, antibiotics no effectivenessOrgan dysfunction came in crowdsshockRespiratory dy
9、sfunctionDeterioration of liver functionCast in urine routine test BUN、Cr oliguria、anuriaCoagulation abnormalitydeath,2020/12/24,10,Repeatedly ventricular tachyca,Acute onsetManifestatin of excessive inflammationDeteriotation of pts conditions despite active therapyMultiple organ dysfunction,Differe
10、nt pts, Same progress,Case 1: infectious,Case 2:noninfectious,2020/12/24,11,Acute onsetDifferent pts, Same,clinical behaviorAccumulativeSubstanceirreversibleMultiple organ low functioncaused by interaction between organs,Chronic disease Multiple organ low function,2020/12/24,12,clinical behaviorChro
11、nic disea,MODS followed by primary emergency disease in 24 hours,Clinical manifestationburst outSimultaneousdie quicklyprimary MODS Ischemiaischemia and reperfusionphysical and chemical injury factor,2020/12/24,13,MODS followed by primary emerg,Sequential organ dysfunction after emergency disease,MO
12、DS,Clinical behaviorDelayedSequentialReversibleMODSExcessive inflammatory mediators,2020/12/24,14,Sequential organ dysfunction a,1.Direct injury of ischemia,Oxygen & nutrient insufficiency,Integrity of cell membrane ,organelle insult,ATP,Extracellular fluid in-flow,Hydrolase activation,Natrium in-fl
13、ow,calcium in-flow,2020/12/24,15,1.Direct injury of ischemiaOxy,1.Direct injury of ischemia,Hypersensibitity in heart and brainSelective ischemiaEndothelial cell injury leads to high vascular permeability and low volume,2020/12/24,16,1.Direct injury of ischemiaHyp,permeability of cell membrane,Intra
14、cellular acidosis,Lower protein synthesis,Injury of ischemia and reperfusion,2020/12/24,17,permeability of cell membrane,Vessel permeability WBC chemotaxis,monocyte/macrophage,neutrophil,elastinase PLA2 ODFR,TNF IL8 et al IL1 IL6,liver：acutephase reaction,Remote organ injury,Tissue damage,etiologica
15、l factor,neutrophil,Adherent molecule,2.Excessive inflammation SIRS MODS,Vascular endothelial cell,SIRS,MODS,2020/12/24,18,Vessel permeability WBC chem,Clinical progress,uncontrolled stress,SIRS,Capillary leakage syndrome,MODS,MSOF,2020/12/24,19,Clinical progressuncontrolled,Important molecule in MO
16、DS,Pro-inflammatory cytokines:TNF-, IL-1、2、6 etcStimulate synthesis and release of other cytokinesActivate neutrophiles,eosinophils and monocytes;activate T and B cell;chemotaxisIncrease the expression of adherent molecule Activate complement and coagulation systemIncrease permeability of vessels,de
17、crease BPCause fever and catabolism of muscle,2020/12/24,20,Important molecule in MODS Pr,Important molecule in MODS,Anti-inflammatory cytokines: IL-4、10 etcMaintain and enhance the function of activated NK cells,monocytes,B and T cells，Inhibit proliferation of T,B cellInhibit pro-inflammatory cytok
18、ines production , receptor expression and cytotoxicity of monocytesInhibit adherent molecule expression of vascular endothelial cells(VECs)Inhibit H2O2、NO production of macrophageInhibit antigen presentation and other assistant functions of monocytes and macrophage,2020/12/24,21,Important molecule i
19、n MODS An,Important cells in MODS,Polymorphonuclear leucocyte（PMN）：Effector cell of inflammatory response. Could release several protein enzymes and ODFR to destroy VECs and stromaVECs：When activated, VECs express higher adherence to PMN and higher clotting competence;also they produce pro-inflammat
20、ory cytokines and vasodilating agent to magnify inflammatory response; finally, capillary leakage syndrome comes if VECs were destroyed.,2020/12/24,22,Important cells in MODSPolymor,Important organ in MODS,IntestinesBecause of stress, fasting and catabolism,the blood-mucosa barrier of intestines cou
21、ld be destructed, the bacteria and toxin tranlocate to blood circulation and the 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.,2020/12/24,23,Important organ in MODSIntes
22、ti,uncontrolled stress,carbohydrate metabolism dysfunction, Insulin tolerance, without Ketonemia,hyperkinetic circulatory state, Hyperpyrexia, High Stroke volume,High oxygen consumption,Protein metabolism dysfunction , high katabolism, acute phase protein,2020/12/24,24,uncontrolled stresscarbohydrat
23、,T 38or 36HR90 beat/minRR20/min or PaCO232mmHgWBC12000mm3 or 4000mm3 or premature cells 10,Sepsis,Systemic InflammatoryResponse Syndrome (SIRS),(SIR+Positive Culture),(SIR without infection),Systemic Inflammatory Response syndrome SIRS,2020/12/24,25,T 38or 36SepsisSystemic In,Chaotic internal milieu
24、 during acute phase,Disturbance of electrolytes and acid-base balanceFeverCatabolism: emaciated,anemiaAcute disseminated intravascular coagulationArrhythmiaHyperglycemia, no ketonemia,2020/12/24,26,Chaotic internal milieu during,Secondary aldosteronism -high density urine without Proteinuria, oligur
25、ia -prerenal azotemia -swollen,Plasma protein leakage -Interstitial edema -Hypoproteinemia -blood inspissasion -Hypovolemia,Capillary leakage syndrome,CLS,2020/12/24,27,Secondary aldosteronismPlasma,Diagnosis of CLS,Positive body fluid balanceBlood volume deficiencyHypoproteinemiaOrgan and total bod
26、y Interstitial edemalung Interstitial edemacerebral Interstitial edema,2020/12/24,28,Diagnosis of CLSPositive body,Organs dysfunction or failure,Organ or system,dysfunction,failure,lung,Liver,kidney,intestine,Blood,Hypoxemia, respirator at list 3-5days,ARDS,PEEP10cmH2O,FiO20.5,Bilirubin2-3mg/dL, Liv
27、er function2 normal value,Bilirubin2-3mg/dL, icterus,oliguria,dialysis,Untolerance of enteral nutrition5days,Curlingls ulcer needs blood transfusion, Acalculous cholecystitis,PT or PTT elongation, platelet50-80thousand, Hypercoagulable state,DIC,central nervous system,cardiovascular system,Insanity,
28、light orientation disorder,Progressive deepen coma,Ejection Fraction , capillary leakage,Irresponsivity to muscle strength drugs,2020/12/24,29,Organs dysfunction or failureO,Glasgow Score,2020/12/24,30,Glasgow Score2020/12/2430,Influenced organ,Lung ARDS 95%Kidney ARF only a few,2020/12/24,31,Influe
29、nced organLung ARDS202,Acute Respiratory Distress Syndrome, ARDS,Pathology of lungHigh capillary permeabilityInterstitial edemaVasoconstriction,micro thrombosis communicating branch openingAlveolar and small bronchusAtelectasisDecreased alveolar surfactantEdemaI type epithelial cells instead by II t
30、ype cellSymptomTachypnea, respiratory distress can not be eased by oxygen inhalationNo ralesNo lung x-ray abnormality,1.The early stage,2020/12/24,32,Acute Respiratory Distress Syn,PathologyDeteriorated lung Interstitial inflammation,usually complicated with SEPSISSymptomObviously dyspnoea and cyano
31、sisneeds ventilatorIncreased respiratory tract secretion, ralesLung x-rayinfiltratesDisturbance of consciousnessFebrile or high leucocyte,.The second stage,2020/12/24,33,Pathology.The second stage2020,3. Telophase,PathologyLung parenchyma fibrosisMicrovascular occlusionIncreased preload, hypoxiaSymp
32、tomDeep comaArrhythmiabradycardiacardiac arrest,2020/12/24,34,3. Telophase Pathology2020/12/,Diagnosis,2020/12/24,35,Diagnosis2020/12/2435,Acute Renal Failure, ARF,Etiology PrerenalHemorrhage, shock, fluid losing without appropriate fluid resuscitationpost renalboth side ureter or urinary flow block
33、edrenalkidney ischemia (hematorrhea,sepsis, allergic reaction)intoxication(aminoglycoside antibiotic, biotic toxin, chemical),2020/12/24,36,Acute Renal Failure, ARFEtiolo,1.History and physical examinationEtiologyprerenal pathogenpostrenal pathogen,Diagnosis of ARF,2020/12/24,37,1.History and physic
34、al examina,2.Differentiation Diagnosis with prerenal ARF,2020/12/24,38,2.Differentiation Diagnosis wi,3.Differentiation Diagnosis with Postrenal ARF,B type ultrasound(renal enlargement, ureter)Abdominal x-rays(calcification, calculus or Obstruction),2020/12/24,39,3.Differentiation Diagnosis wi,4. La
35、boratory Urine test,Urinary catheter to record urine volumeUrine acidity/density(1.010-1.014)Urine microscopic examinationRBC and renal tubule epithelia(renal cortex and renal medulla necrosis)Large Brown casts(renal failure casts)Eosinophil (interstitial nephritis)Red cell cast(glomerulonephritis)N
36、ormal(prerenal or postrenal failure earlier period),2020/12/24,40,4. Laboratory Urine testUrinar,5. renal function examination,Urine urea nitrogen ( 175mmol/24h)Fractional excretion of filtrated sodium1 FENa（%）=（UNa/PNa）（PCr/UCr ）100osmotic pressure of urine *ARF- 400 mOsm/LBUN (more than 3.89.4mmol
37、/L per day) ,Cr Urine/Plasma Cr-1-ARF *1-prerenal,2020/12/24,41,5. renal function examinationU,Intensive care,Organ and system function Monitoring and supportObjectameliorate oxygen metabolismameliorate nutrien stateTherapy aimed at stress and inflammatory MediatorsTreatment of capillary leakageTrea
38、tment of primary disease,2020/12/24,42,Intensive careOrgan and system,Oxygen metabolism Monitoring,Critical DO2Assay of plasma lactic acid/pyruvic acid,2020/12/24,43,Oxygen metabolism MonitoringCr,Oxygen associated index,DO2 Oxygen Delivery-Oxygen offered to the body in a certain period by circulato
39、ry system DO2CO（1.38SaO2 + 0.003PaO2）VO2 Oxygen Consumption- Oxygen consumpted by all cells in a certain period. VO2Ca-vDO2CO10,2020/12/24,44,Oxygen associated indexDO2 Oxy,Critical DO2,VO2,DO2,SepsisARDSMODS,Normal,Critical delivery oxygen,2020/12/24,45,Critical DO2VO2DO2SepsisNorma,Lactic Acid and
40、 cells hypoxia,Lactic Acid-latent cells hypoxia lactic acidosis -tissue perfusion deficiency and cells hypoxia Lactic Acid normal value- 0.5-1.5 mmol/L 4-5 mmol/LSB and PH lactic acidosis L/P rate - cells hypoxia L/P rate normal value- 10:1,2020/12/24,46,Lactic Acid and cells hypoxiaL,Strategy of am
41、eliorate oxygen metabolism,Improvement of oxygen deliveryrespiratory support-to improve arterial blood oxygen contenthigher inhalated oxygen concentration,ventilatorincrease cardiac output Heart rate, cardiac rhythm, cardiac contractility, preload/after loadBlood systemrise hemoglobin concentration,
42、2020/12/24,47,Strategy of ameliorate oxygen,Strategy of ameliorate oxygen metabolism,Increase oxygen extraction ratioAmeliorate interstitial edemaReduce blood capilary permeabilityAmeliorate oxygen extraction of cells,2020/12/24,48,Strategy of ameliorate oxygen,Treatmen of CLS,Limitation of water-in
43、takepremise: never get CO downInfusion volume decided by urine volume per hour when lung and brain interstitial edema happen.Rise colloid osmotic pressureUse powerful diureticUse glucocorticoid,2020/12/24,49,Treatmen of CLSLimitation of w,Nutritional support,Metabolism supportOffer nutritional subst
44、rate but never increase organ loading.Metabolism modulationInhibition of catabolism hormonesPromote protein synthesis ,ease negative nitrogen balance,2020/12/24,50,Nutritional supportMetabolism,Nutritional support,Add accessoriesPromote protein synthesis and cell growthModulate immunologic response
45、Enteral nutritionProtect bowel blood-mucosa barrier (prevent from infection ),2020/12/24,51,Nutritional supportAdd accesso,Discussion of therapy for stress and inflammatory mediators,Antagonism and clearanceAim at excessive cytokines - post-translation levelsReduction of synthesis keep the balance b
46、etween pro- and anti- cytokines - in transcription levels - in translation level,2020/12/24,52,Discussion of therapy for str,Cytokines modulation,In transcription levelAnti-mRNA expression (NF-B is in charge of many kinds of cytokine expression.)Translation levelReduce cytokines synthesisPost transl
47、ation level Anti-cytokines(antibody or soluble receptor)Block receptor of cytokinesClearance of cytokines(plasmapheresis),2020/12/24,53,Cytokines modulationIn transcr,Treatmen of ARDS,Correct hypoxemia quicklyuse ventilator as soon as possibleappropriate PEEP（regain alveolar function and functional
48、residual capacity),2020/12/24,54,Treatmen of ARDSCorrect hypoxe,Treatmen of ARDS,Maintain Circulation and lung interstitial edemaProper crystal/colloid rateDiureticNegative water balance (according to CVP/PAWP , urine output and lung auscultation),2020/12/24,55,Treatmen of ARDSMaintain Circu,Treatme
49、n of ARDS,Prevent and treat infectionBlock SIRScorticoid in the initial stagemediators inhibitor (Ibuprofen, Dentoxifylline,TNF antibody),2020/12/24,56,Treatmen of ARDSPrevent and tr,Treatment of ARF,Oliguria or anuria stage (7-10days,average 5-6 and max. more than 1 month)confine water intakeEqual
50、water intake and output fluid intake per day=(dominant water losing )+ (non dominant water losing) - (endogeneous water)or 0.5kgnutrient Low protein, high calorie,high Vitaminprotein synthesis hormones,2020/12/24,57,Treatment of ARFOliguria or an,Treatment of ARF,correct electrolytes imbalaHyperkale
