Question

A fully functional, independent woman who is 96 years old lives with her 2 daughters. Patient develops abdominal pain increasing over 5 days; constipation for 1 day. Has history of: high blood pressure CAD congestive heart failure cataracts hearing impairments knee osteoarthritis Her medications: lisinopril, furosemide, ASA, and metoprolol. Examination She is acutely ill, appeared uncomfortable and volume depleted. On exam, she has abdominal distention, hypoactive bowel sound and no mass is found. Cardiac exam revealed S1, S2, no S3. Laboratory findings: WBC..................13290 HCT...................42 Na.....................128 K.......................2.6 Bun/creatinine......normal (14/0.8) Click Here to view the CT: Click herePreview the document A left hemicolectomy was performed on day 2 and patient lost a lot of blood and return to the SICU in shock, intubated and on pressure support. On day 5 she is presumed to be in MOF. 1. What is the pathophysiology for MOF in this case? What different management could have minimized or prevented patient going into MOF? 2. Summarize the type of assessment and management based on evidence and guidelines? 3. What severity of illness scoring tool would you use? (SOFA, CURB-65, etc)

Answer 1

MOF means multiple organ failure. It is often caused by an overwhelming, uncontrolled systemic inflammatory response that is activated by a number of hostile stimuli including sepsis, hypovolemic shock, and severe trauma resulting in massive tissue injury. It is a severe, life-threatening condition that usually occurs as a result of major trauma, burns, or fulminant infections. Whatever the initiating event, once established, MOF has a high mortality.

* A definite explanation has not been found. Local and systemic responses are initiated by tissue damage.
In this patient, the reason could be sepsis and shock.

In this patient, MOF could be due to splanchnic hypoperfusion and the subsequent mucosal ischaemia there are structural changes and alterations in cellular function. This results in increased gut permeability, changed immune function of the gut and increased translocation of bacteria. Liver dysfunction leads to toxins escaping into the systemic circulation and activating an immune response. This results in tissue injury and organ dysfunction.

and As a result of macro- and microvascular changes insufficient supply of oxygen occurs. Hypoxemia causes cell death and organ dysfunction.

* Patient could be saved from MOF by proper management like control over loss of blood during surgery. By controlling infection and by controlling over complications of surgery. Patient could be checked for respiratory distress and post surgical complications.

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Treatment of patients with septic shock has the following three major goals:

- To resuscitate the patient from septic shock, using supportive measures to correct hypoxia, hypotension, and impaired tissue oxygenation

- To identify the source of infection and treat it with antimicrobial therapy, surgery, or both

- To maintain adequate organ system function, guided by cardiovascular monitoring, and to interrupt the pathogenesis of multiple organ dysfunction syndrome (MODS).

There is no drug or device that can reverse organ failure that has been judged by the health care team to be medically and/or surgically irreversible (organ function can recover, at least to a degree, in patients whose organs are very dysfunctional, where the patient has not died, and some organs, like the liver or the skin, can regenerate better than others),- with the possible exception of single or multiple organ transplants or the use of artificial organs or organ parts, in certain candidates in specific situations. Therapy, therefore, is usually mostly limited to supportive care, i.e. safeguarding hemodynamics, and respiration. Maintaining adequate tissue oxygenation is a principal target. Starting enteral nutrition within 36 hours of admission to an intensive care unithas reduced infectious complications.

*** Severity of illness is defined as the extent of organ system derangement or physiologic decompensation for a patient. It gives a medical classification into minor, moderate, major, and extreme. The SOI class is meant to provide a basis for evaluating hospital resource use or to establish patient care guidelines.

SOFA system - This score was developed to quantify the severity of patients illness, based on the degree of organ dysfunction data on six organ failures and are scored on a scale of 0-4.