Multiple Organ Dysfunction Syndrome

Multiple Organ Dysfunction Syndrome

Multiple organ dysfunction syndrome (MODS) is altered organ function in an acutely ill patient that requires medical interven-tion to support continued organ function. The disorder can be further categorized as primary or secondary MODS.

Pathophysiology

Primary MODS is the result of direct tissue insult, which then leads to impaired perfusion or ischemia. Secondary MODS is most often a complication of septic shock or SIRS. However, MODS may be a complication of any form of shock because of inadequate tissue perfusion. As previously described, in shock all organ systems suffer damage from a lack of adequate perfusion that can result in organ failure. A syndrome of sequential organ failure has been further observed. The exact mechanism that trig-gers this syndrome is unknown.

Although various causes of MODS have been identified, in-cluding dead or injured tissue, infection, and perfusion deficits, it is not yet possible to predict which patients will develop MODS. This is partly because much of the organ damage occurs at the cellular level and therefore cannot be directly observed or measured. The organ failure usually begins in the lungs and is followed by failure of the liver, gastrointestinal system, and kidneys (Balk, 2000b). Advanced age, malnutrition, and coexisting diseases ap-pear to increase the risk of MODS in an acutely ill patient.

Clinical Manifestations

The clinical course of MODS follows one of two patterns. In both patterns, there is an initial event that results in low blood pressure. The cause of the drop in blood pressure is treated, and the patient appears to respond. In the first pattern of MODS (pri-mary MODS), which occurs most often when the initiating event is a pulmonary one such as lung injury, the patient experiences respiratory compromise that necessitates intubation. This usually occurs within 72 hours of the initiating event. Respiratory failure leads rapidly to MODS, resulting in a mortality rate of 30% to 75% (Fein & Calalag-Colucci, 2000).

In secondary MODS, the pattern is more insidious. It occurs most often in the patient with septic shock and progressively unfolds over about 1 month. The patient also experiences res-piratory failure and requires intubation. The patient remains hemodynamically stable for about 7 to 14 days. Despite this ap-parent stability, the patient exhibits a hypermetabolic state characterized by hyperglycemia (elevated blood glucose level), hyperlacticacidemia (excess of lactic acid in the blood), and polyuria (excessive urinary output). The metabolic rate is 1.5 to 2 times basal metabolic rate. Infection is usually present, and skin breakdown begins to occur. During this stage, there is a se-vere loss of skeletal muscle mass (autocatabolism). If the hyper-metabolic phase can be reversed, patients may survive with some damage to affected organ systems (Mizock, 2000). If the hypermetabolic process cannot be halted and cells do not re-ceive adequate oxygen and nutrients, irreversible organ failure and death occur.

If the hypermetabolic phase cannot be reversed, MODS pro-gresses and is characterized by jaundice, hyperbilirubinemia (liver failure), and oliguria progressing to anuria (renal failure), often requiring dialysis. The patient becomes less hemodynamically stable and begins to require vasoactive medications and fluid sup-port. Because of a lack of consistent definitions to describe organ failure, the exact incidence of MODS is hard to define (Balk, 2000b; Vincent & Ferreira, 2000). However, it is reasonable to say that the onset of organ dysfunction is an ominous prognostic sign; the more organs that fail, the worse the outcome.

Medical Management

Prevention remains the top priority in managing MODS. Elderly patients are at increased risk of MODS because of the lack of physiologic reserve associated with aging and the natural degen-erative process, especially immune compromise (Balk, 2000b). Early detection and documentation of initial signs of infection are essential in managing elderly patients with MODS. Subtle changes in mentation and a gradual rise in temperature are early warning signs. Other patients at risk of MODS are those with chronic illness, malnutrition, immunosuppression, and surgical or traumatic wounds.

If preventive measures fail, treatment measures to reverse MODS are aimed at (1) controlling the initiating event, (2) pro-moting adequate organ perfusion, and (3) providing nutritional support.

Nursing Management

The general plan of nursing care for the patient with MODS is the same as that for the patient in septic shock. Primary nursing interventions are aimed at supporting the patient and monitor-ing organ perfusion until primary organ insults are halted. Pro-viding information and support to family members is a critical role of the nurse in caring for patients with MODS. Addressing end-of-life decisions is an important role of the health care team to ensure that supportive therapies are congruent with the pa-tient’s wishes.

Gerontologic Considerations

The population as a whole is aging: the most rapidly growing population group consists of people over 65 years of age. The physiologic changes associated with aging, coupled with patho-logic and chronic disease states, place the older individual at in-creased risk of developing a state of shock and possibly MODS. Medications such as beta-blocking agents (metoprolol [Lopres-sor]) used to treat hypertension may mask tachycardia, a primary compensatory mechanism to increase cardiac output, during hy-povolemic states. The aging immune system may not mount a truly febrile response (temperature more than 40°C), but an in-creasing trend in body temperature should be addressed. The heart does not function well in hypoxemic states, and the aging heart may respond to decreased myocardial oxygenation with dysrhythmias that may be misinterpreted as a normal part of the aging process. Lastly, changes in mentation may be inappropri-ately misinterpreted as dementia. The older individual with a sudden change in mentation should be aggressively treated for the presence of infection and organ hypoperfusion. The elderly pa-tient can overcome shock states if signs and symptoms are treated early with aggressive and supportive therapies. Nurses play an es-sential role in assessing and interpreting subtle changes in the older patient’s response to illness.

PROMOTING COMMUNICATION

The nurse encourages frequent and open communication about treatment modalities and options to ensure that the patient’s wishes regarding medical management are met. For patients who survive MODS, communicating the goals of rehabilitation and informing the patient of progress toward those goals are essential, as the massive loss of skeletal muscle mass makes rehabilitation a long, slow process. A strong nurse–patient relationship built on effective communication will provide needed encouragement during this phase of recovery.

PROMOTING HOME AND COMMUNITY-BASED CARE

Teaching Patients Self-Care.

The patient who experiences andsurvives shock may have been unable to get out of bed for an ex-tended period of time and is likely to have a slow, prolonged re-covery. The patient and family are instructed about strategies to prevent further episodes of shock by identifying the factors im-plicated in the initial episode. In addition, the patient and fam-ily require instruction about assessments needed to identify the complications that may occur after the patient is discharged from the hospital. Depending on the type of shock and its manage-ment, the patient or family may require instruction about treat-ment modalities such as emergency administration of medications, intravenous therapy, parenteral nutrition, skin care, exercise, and ambulation. The patient and family are also in-structed about the need for gradual increases in ambulation and other activity. The need for adequate dietary intake is another crucial aspect of teaching.

Continuing Care in the Home and Community.

Because of thephysical toll associated with recovery from shock, the patient may be cared for in an extended care facility or rehabilitation setting after hospital discharge. Alternatively, a referral may be made for home care. The home care nurse assesses the patient’s physical status and monitors recovery. The nurse also assesses the ade-quacy of treatments that are continued at home and the ability of the patient and family to cope with these treatments. The patient is likely to require close medical supervision until complete re-covery occurs. The home care nurse reinforces the importance of continuing medical care and assists the patient and family to identify and mobilize community resources.