Multiple organ dysfunction syndrome pathogenesis and care: a complex systems' theory perspective

Aims and objectives:  To discuss multiple organ dysfunction syndrome (MODS) from a complex systems' theory perspective and to delineate a conceptual framework for the development and care of MODS.
Background:  MODS is an intricate and devastating manifestation of critical illness characterized by widespread aberrant molecular, cellular and systemic responses.
Design and methods:  Narrative literature review (MEDLINE, CINAHL databases) and knowledge synthesis with the theoretical assertions of chaos and complex systems' theory. Cellular and systemic response paradoxes in MODS (including cellular hypoxia, cell death and signalling) are reviewed.
Results:  The diseased person is depicted as a complex adaptive system. The relevancy of some of the principles of complex chaotic systems' theory to the proposed model is illustrated, including sensitive dependence on initial conditions, emergence, attractors, self-organization, self-organized criticality and emerging order. The transition from life-supporting to death-related organismic responses is illustrated as a critical event in MODS and care implications are drawn.
Conclusions:  Patient responses in MODS appear to conform to the principles of chaotic systems. Death is illustrated not as a consequence of homeostatic failure but as a 'deliberate' self-organized phenomenon entailing multiple dynamically evolving mechanisms.
Relevance to clinical practice:  Some of the principles of chaotic complex systems may need to be taken into account to advance care in MODS. An alternative theoretical perspective may support nurses to conceptualize both MODS and their role in a way that will help them to cope better with this devastating syndrome and develop practice.     

多脏器功能衰竭

马里兰急诊医学必知 (Maryland Emergency Medicine Pearls) 心肌梗死相关性的室性心律失常 Semhar Tewelde 急性心肌梗死治疗的进展,使室性心律失常(VA)的发生频率明显减少.室性心律失常仍然是急性心肌梗死后危及生命的并发症,所有患者在这一危险期都应严密监测.与非ST段抬高型心梗相比,ST段抬高型心梗后的室性心律失常出现更为频繁,与恶性预后相关的因素有:出现晚;持续单型室性心动过速;合并心力衰竭;心源性休克;血运重建失败或没用进行重建.     

Multiple organ dysfunction syndrome

Multiple organ dysfunction syndrome (MODS) is a clinical situation that has been described as a result of the rapid progress and advances that have been made in recent decades in the physiology, diagnosis, and therapeutic support of critically ill patients. In 1991, in view of the confusing terminology used to characterize processes coursing with systemic inflammatory response syndrome (SIRS), a consensus conference was held. A series of basic definitions were established and the term "multiple organ failure" was replace by MODS. In response to outside aggression, the organism tries to defend itself with two mechanisms: a non-specific humoral and cellular response called inflammation, and a specific antigenic response that modifies the genetic codes of cells of the defense system and constitutes an immunological response. At present it is thought that the inflammatory response is activated (SIRS) in response to an uncontrolled aggression, but an antiinflammatory response syndrome (ARS) exists as well. An exaggerated SIRS can lead to MODS. MODS usually debuts with pulmonary dysfunction. If the aggression persists, cardiovascular, renal, hepatic, coagulation, central nervous system, gastrointestinal metabolism, neuroendocrine and musculoskeletal failure follow. A series of causes often trigger this syndrome and certain factors favor it. Prevention of these causes and factors in fundamental for controlling the occurrence of MODS. At present, there is no clear treatment for MODS, although numerous studies designed to block the release of certain proinflammatory mediators or to neutralize antiinflammatory responses are being carried out.     

Multiple organ failure syndrome.

Tissue injury, whether from infection, blood or volume loss, trauma, or inflammation such as pancreatitis, induces local and systemic responses. The systemic responses include shock, reperfusion, systemic inflammation (hypermetabolism) with primary organ dysfunction, and secondary organ dysfunction that either becomes progressive and leads to death or from which the patient recovers and enters into a period of prolonged rehabilitation. Each of these responses has its pathogenesis and treatments that are appropriate and effective. The research indicates that the responses may contribute to the development of cell and organ injury and to progressive multiple organ failure syndrome and death, particularly in the case of the systemic inflammatory response. Current therapy is designed to rapidly remove the cause of injury, resuscitate the microcirculation, and institute nutrition therapy to prevent single and generalized nutrient deficiencies and promote repair and healing. Newer therapies are designed to modulate the inflammatory response itself to minimize its injury potential and promote tissue repair and recovery of the patient. Genetic regulation of metabolism is also a pathogenetic mechanism. Its role in these responses is just starting to be understood--new therapies will need to await this understanding. Once the patient begins to recover, rehabilitation tends to be long and problematic. Nonetheless, significant survival rates are now occurring, with continued improvements expected in response to the newer therapeutic approaches. Planned rehabilitation thus becomes an important component of effective recovery. Professionals trained in critical care and well versed in cellular and molecular biology provide the milieu within which continued improvements in prevention, therapy, and outcome will continue to occur.     

老年人肺部感染诱发多器官功能不全35例分析

目的探讨老年人肺部感染诱发多器官功能不全（MODSE）的临床特点、诊断及治疗措施。方法回顾性分析35例肺部感染诱发MODSE老年患者的临床资料。结果本组治愈好转20例,死亡15例：80岁以上死亡8例;衰竭器官越多,死亡率越高。结论老年人肺部感染容易诱发MODSE,认识其临床特点,及时诊断,及早采取综合治疗是降低死亡率的关键。     

SARS: clinical presentation, transmission, pathogenesis and treatment options

SARS (severe acute respiratory syndrome) appeared as the first emerging infectious disease of this century. It is fortunate that the culprit virus can be grown without much difficulty from a commonly used cell line, allowing an unlimited supply of isolates for further molecular studies and leading to the development of sensitive diagnostic assays. How the virus has successfully jumped the species barrier is still a mystery. The superspreading events that occurred within hospital, hotel and high-density housing estate opens a new chapter in the mechanisms and routes of virus transmission. The old practice of quarantine proved to be still useful in controlling the global outbreak. Despite all the available sophisticated tests, alertness with early recognition by healthcare workers and prompt isolation of suspected cases is still the most important step for containing the spread of the infection. Although the rapidly evolving outbreak did not allow the conducting of systematic clinical trails to evaluate treatment options, the accumulated experience on managing SARS patients will improve the clinical outcome should SARS return. Although SARS led to more than 700 deaths worldwide, the lessons learnt have prepared healthcare systems worldwide to face future emerging and re-emerging infections.     

关于SARS医院感染的控制指南--2003年4月24日修订版

1 门诊病人/分诊处置 卫生保健机构的分诊护士应该迅速对那些需要做出SARS评价的病人转移到隔离就诊区,以尽量减少传染给其他待诊病人的可能性。 病人应该带面罩,最好是过滤呼气的面罩。 医护人员在在分诊过程中须带口罩和眼罩,并在接触任何病人前后、进行可能导致污染的活动后和脱去手套后洗手。 无论在什么情况下,调查中的SARS疑似病例应该与临床诊断病例分开。     

Multiple systems organ failure: epidemiology and prognosis

This article reviews the basic epidemiologic and prognostic data for the syndrome of MSOF. When MSOF is defined as severe physiologic abnormalities, it occurs following a wide variety of diseases. The distinguishing feature of MSOF appears not to be the underlying etiology, but the uniform and frequently fatal outcome once it develops. This suggests that MSOF may represent a final common pathway to death rather than a clinical syndrome with a single underlying etiology. Regardless of cause, evaluating the incremental impact of new therapy on MSOF will be assisted by the adoption of uniform definitions as well as by the explicit measurement of severity of disease and calculation of individual probabilities of death.     

Bone disease in organ transplant patients: pathogenesis and management

Bone disease is common in recipients of kidney, heart, lung, liver, and bone marrow transplants, and causes debilitating complications, such as osteoporosis, osteonecrosis, bone pain, and fractures. The frequency of fractures ranges from 6% to 45% for kidney transplant recipients to 22% to 42% for heart, lung, and liver transplant recipients. Bone disease in transplant patients is the sum of complex mechanisms that involve both preexisting bone disease before transplant and post-transplant bone loss due to the effects of immunosuppressive medications. Evaluation of bone disease should preferably start before the transplant or in the early post-transplant period and include assessment of bone mineral density and other metabolic factors that influence bone health. This requires close coordination between the primary care physician and transplant team. Patients should be stratified based on their fracture risk. Prevention and treatment include risk factor reduction, antiresorptive medications, such as bisphosphonates and calcitonin, calcitriol, and/or gonadal hormone replacement. A steroid-avoidance protocol may be considered.     

Childhood respiratory infection in the pathogenesis of COPD

A respiratory infection in childhood has been implicated in one of the risk factors for COPD. The hypothesis that latent adenoviral infection is involved in the pathogenesis of COPD have been studied for 15 years. A DNA virus, adenovirus(Ad), early gene 1A (ElA gene) was identified in lung tissue of COPD. The E1A gene expression enhances the soluble intercellular adhesion molecule (ICAM) 1 expression and the recruitment of inflammatory cells into airways of COPD lungs. In vitro experiments, E1A gene transfected cells exhibited the enhanced inflammatory response to tobacco smoke. The excess production of ICAM-1, IL-8, and TGF- beta by lung epithelial cells transfected with the Ad E1A gene. Respiratory infections in childhood including Ad infection may be an important risk factor for the pathogenesis of COPD.     

SARS患者并发多器官功能障碍的临床分析

目的　对严重急性呼吸综合征 (SARS)患者的相关器官功能障碍进行分析 ,探讨 SARS患者并发多器官功能障碍综合征 (MODS)的因素。方法　回顾性分析 135例 SARS和 13例并发 MODS的 SARS住院患者的临床资料。结果　 SARS可导致器官功能障碍 ,主要有急性呼吸窘迫综合征 (ARDS)、免疫系统损伤、心脏损害、肝功能损害、MODS等 ,发生率越高 ,病情越重 ,病死率越高。 SARS引起 MODS时 ,病死率高达92 .3% ,主要表现为 ARDS(76 .9% )、免疫系统损伤 (92 .3% )、心血管功能障碍 (30 .8% )、凝血功能障碍(6 1.5 % )、肝功能损伤 (38.5 % )和肾功能障碍 (5 3.8% )等。结论　 SARS相关器官功能障碍与病情发展及预后密切相关。 SARS并发 MODS可能与 SARS病毒所致免疫损伤、全身炎症反应综合征等有关。     

收治SARS病区院内感染的预防

严重急性呼吸综合征(SARS)因其病原学及其生物学特性未明,临床消毒隔离工作缺乏理论指导和实践经验,致使院内感染特别是医务人员感染率高.本着"从严从全从速"的指导思想,严格进行消毒隔离工作,在70日内共收治了85例SARS病人,无1例发生院内感染.从病区的准备,病人的安置,戴口罩,医务人员、陪人、探视的管理及护理人员的调配等方面,以飞沫隔离和接触隔离为重点,介绍了收治SARS病区的隔离工作;从空气消毒、口罩消毒、病人呼吸道分泌物的处理、病区随时消毒、污物的处理及呼吸机的消毒等方面介绍了收治SARS病区的消毒工作.     

Multiple organ failure following lamp oil aspiration

CASE REPORT: A 26-month-old previously healthy boy of 15 kg was admitted to our hospital due to cyanosis following the aspiration of lamp oil. Aspiration resulted from the patient's father inducing emesis by digital stimulation of the boy's throat after the patient had ingested an unknown amount of lamp oil. Endotracheal intubation was done on the second hospital day in the Pediatric Intensive Care Unit (PICU) due to respiratory failure manifested by hypercapnia and hypoxemia. Mechanical ventilation, including high frequency oscillatory ventilation (HFOV) with iNO at 20 ppm, was started. However, he developed a spiked fever and developed an acute respiratory distress syndrome, a pneumothorax, and diffuse subcutaneous emphysema. His course was further complicated by anuric renal failure, rhabdomyolysis, severe hepatitis, pancytopenia, elevation of cardiac enzymes, and disseminated intravascular coagulation over the following days. He died on the ninth day of hospitalization because of multiorgan failure.