May 19, 2022, 6:12 PM
Multiple organ dysfunction syndromes (MODS) or multiorgan system failure, commonly associated with critical illness, is defined by the coexisting presence of physiologic dysfunction and/or failure of two or more organs (Kress & Hall, 2018). Based on the authors, this syndrome emerges in the setting of severe sepsis, in any type of shock, severe inflammatory disorders such as pancreatitis, and trauma.
Recently at work, we cared for an 83y/o male patient who presented in the ED with GI bleed due to a perforated gastric ulcer. Patient has a history of DVT on Eliquis, HTN, and ETOH abuse. Patient had laparotomy and Graham Omental Patch, and extensive abdominal lavage. The patient remained intubated after the surgery and extubated after several days. After a few days, patient spiked a fever, and further lab findings include elevated Lactic acid, leukocytosis, and elevated Procalcitonin. CT Chest and abdomen/pelvis were ordered. Reports came back with pneumonia and a gastric leak. Patient was treated with IV antibiotics, and the surgeon performed another laparotomy and a repair of the omentum. Patient came back to ICU extubated from surgery. In the early morning after surgery, the patient became obtunded, hypotensive, tachycardic, developed acidemia, was eventually intubated, and was started on pressors and sodium bicarb drip. Also, the patient was found to be in acute kidney failure; a nephrology consult was called and recommended dialysis. Unfortunately, the patient did not survive because of MODS caused by septic shock.
The differential diagnoses for this patient’s case fall in low-output shock states, including hypovolemic shock, cardiogenic shock, and obstructive shock. Based on Neviere (2022), as the severity of shock worsens (e.g., cool skin and cyanosis), organ dysfunction develops (e.g., oliguria, acute kidney injury, altered mental status). Notably, the presentation is nonspecific, such that many other conditions (e.g., acute respiratory distress syndrome) may present similarly. Thus, according to Felner & Smith (2017), the management of severe sepsis and septic shock requires a structured process that ensures proper diagnostic evaluation and the implementation of evidence-based interventions expediently to improve outcomes. This approach requires (1) empiric antibiotic coverage of an infectious source while cultures are pending, (2) optimal fluid resuscitation, (3) pressor and/or inotrope treatment for specific patients, and (4) review of additional treatments such as drainage of abscesses, removal of lines, moderate (but not intensive) control of hyperglycemia (as required), and (5) consideration of steroids in specific patient subsets when indicated.
In general, the greater the number of organ failures, the higher the mortality, with the most significant risk being associated with respiratory failure requiring mechanical ventilation (Neviere, 2022).
Felner, K. & Smith, R.L. (2017). Sepsis and shock. In McKean, S.C., Ross, J.J. Dressler, D.D. & Scheurer, D.B. (Eds.). Principles and Practice of Hospital Medicine (2nd ed., Chap. 141, pp. 1121-1122). McGraw-Hill Education.
Kress, J.P. & Hall, J.B. (2018). Approach to the patient with critical illness. In Jameson, J.L., Kasper, D.L., Longo, D.L., Fauci, A.S., Hauser, S.L. & Loscalzo, J. (Eds). Harrison’s Principles of Internal Medicine (20th Ed, Vol.2, Part 2, Chap. 293, p. 2027). McGraw-Hill Education.
Neviere, R. (March 07, 2022). Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis. UpToDate. https://www.uptodate.com/contents/sepsis-syndromes-in-adults-epidemiology-definitions-clinical-presentation-diagnosis-and-prognosis?search=multiorgan%20dysfunction%20syndrome&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H10
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