MODS

The presence of altered organ function in an acutely ill patient such that homeostasis cannot be maintained without intervention. Otherwise known as: Multiple System Organ Failure (MSOF) Progressive Systems Failure Multisystem Failure (MSF)

Epidemiology Develops during 15% of all ICU admissions Occurs in 20-47% of patients after multiple trauma Infection Early, inadequate resuscitation accounts for 50% of MODS

SEQUENCE OF ORGAN FAILURE a. Usually begins with low grade fever, tachycardia and dyspnea b. Dyspnea in the 1st week worsens that ET and Mechanical Ventilation is required c. Day 7-10  bilirubin and serum creatinine level increases  positive culture results  impaired wound healing  Fluid resuscitation + inotropic agents are required d. During days 14-21  compensatory mechanisms fail  patient becomes hemodynamically unstable  Renal dysfunction worsens  Dialysis is required. e. Death often occurs within day 21-28 Theories of Pathogenesis . 1. Infection and host septic response MODS that stem from sepsis, severe sepsis and septic shock +massive tissue injury = first hit =>early MODS 2. Two hit hypothesis Initial assault and resuscitation followed by secondary but altered SIRS reaction Complications: increased organ failure, secondary infection or repeated surgery 3. Complexity theory Sustained hit: initial insult+successful resuscitation ff by sustained alterations=late and sustained SIRS =>MODS 4. Macrophage-Cytokine Hypothesis Excessive and prolonged stimulation of macrophages and neutrophils= prod n of cytokines and inflammatory mediators, 30% of pts who die of MODS have no infection

5. Microcirculatory hypothesis Failure of o2 delivery to keep up with o2 consumption => tissue ischemia and organ dysfunction Ischemia=damage of vascular endothelium, endothelial cell surf adhesion cytokines= tissue injury = decreased ability of RBC to deform themselves 2 perioxidation of lipids=inability to move (RBC) 6. Gastrointestinal dyshomeostasis hypothesis Gut acts as reservoir for bacteria and endotoxin = perpetuates the development of MODS Definitions for Organ Failure     Pulmonary ARDS Unexplained hypoxemia w/ suspected sepsis Bilateral pulmonary infiltrates Deterioration of ABG Progressive deterioration of two or more organs over a brief period of time

Hepatobiliary     Elevated Liver enzymes Bilirubin levels above 2mg/dl Decreased albumin levels Elevated prothrombin time

Gastrointestinal  Paralytic ileus  Intolerance to feeding  GI bleeding Renal  Oliguria  Increased Serum creatinine above normal levels (0.6-1.5mg/dl)

CNS  Declining GCS  Acute change in mental status Coagulation  Dec PC by 25%  Inc PTT  Obvious bleeding Cardiovascular  Tachycardia  hypotension Etiologic/ Precipitating factors  Chronic Diseases

       

Immunosuppressive Therapy Extremes of Age Malnutrition (alcoholism) Cancer Severe Trauma Sepsis SIRS Cellular events leading to MODS: inflammation: pancreatitis and retained necrotic tissue, hypoperfusion: shock and trauma, Infection: endotoxemia

 Interventions are specific to the underlying cause of the organ dysfunction Hemodynamic monitoring Use of monitoring devices to measure CV function PRINCIPLE: Blood flows from a region of higher pressure to one of lower pressure

Left Ventricular Systole = 110-130 mmHg Resting Aortic pressure= 80 mmHg End of diastole= 4-12mmHg Right ventricular systole = 15- 25mmHG, Pulmonary artery diastolic pressure = 8-15mmHG End of Diastole = 0-8mmHg Equipment  CVP, PA, Arterial catheter  Flush system  Stopcocks, IV solution, tubing, flush device  Pressure Bag  transducer Amplifier or monitor Central Venous Pressure Monitoring  Intermittent measurement of the CVP is possible through a water Manometer  Pressure in the Vena Cava or right atrium = used to assess RV function & venous return (R Chambers)

    

An indirect way of assessing right ventricular filling (preload) Preferred site of insertion RJV RJV- straight line to the SVC, Subclavian vein preferred site if without risk for bleeding or pneumothorax Decreased CVP:Reduced right ventricular preload, Distributive shock Increased CVP:Hypervolemia, HF, Cardiac tamponade, Pleural effusion Nursing Interventions - Cleanse and shave the area of insertion -keep the dressing intact and dry - Monitor for s/s of infection - Locate the phlebostatic level Pulmonary artery pressure monitoring

Fluoroscopy may be used during insertion to visualize progression of the catheter through the heart chambers to the pulmonary artery.

Large vein

Vena cava

Right atrium

Right ventricle

Tricuspid valve

Balloon is inflated

Pulmonic valve

Branch of the pulmonary artery

After the catheter reaches a small pulmonary artery the balloon is deflated and the catheter is secured by sutures Pressures measured through the pulmonary artery catheter: CVP Pulmonary artery systolic and diastolic pressure Mean pulmonary artery pressure Pulmonary artery wedge pressure

Significance: PAdiastolic and Wedge pressure: > left ventricular diastolic pressure (preload) >Pulmonary artery pressure = 25/9 mmHg >Mean pressure = 15 mmHg

Nursing Interventions  Catheter care  Locate the phlebostatic axis

Complications:       infection Pulmonary artery rupture Thromboembolism Catheter kinking Dysrrhythmias air embolism

Intra-arterial Blood pressure Monitoring  Used to obtain direct and continuous BP measurements  Useful in ABG measurements and procurement of blood samples 1. Selection of an arterial site (radial, brachial, femoral or dorsalis 2. Checking of contralateral circulation is done

Nursing Interventions  Site preparation  Care of the catheter Complications  Local obstruction with distal ischemia  External hemorrhage  Air embolism, blood loss  Pain, arterio spasm, infection **PCWP: normal= 4.5-13mmHg, critically ill patients = should be maintained at 18mmHg Circulatory Assistive Devices Devices that are temporarily used to improve the heart s ability to pump I. Intra-aortic balloon pump > Provides a means of increasing aortic diastolic pressure and enhances coronary and peripheral blood flow > Uses internal counterpulsation to augment the pumping action of the heart Diastolic inflation Increases coronary perfusion (due to inc pressure wave in the ascending aorta) Less intense pressure wave in the lower aorta = ENHANCED ORGAN PERFUSION

Balloon deflation

Decreases ejection resistance= INCREASED CARDIAC PUMPING EFFICIENCY, DECREASED MYOCARDIAL O2 CONSUMPTION

Goals: Increased stroke volume improved coronary artery perfusion decreased cardiac workload decreased myocardial demand

Maintaining Intra-aortic balloon counterpulsation The nurse should make timing adjustments to maximize its effectiveness by synchronizing it with the cardiac cycle. The nurse should make frequent neurovascular assessment of the lower extremities. The patient has a great risk for circulatory compromise to the leg where the balloon is inserted. II. Ventricular Assist Devices These devices are electrical pumps or pumps driven by air. They assist or replace the ventricular pumping action of the heart. Is a pump bypassing the affected ventricle and allowing the heart to rest and recover More complex devices that perform some or all of the pumping function for the heart VADs can circulate as much blood per minute as the patient s heart, if not more. Each VAD is used to support one ventricle can be combined with an oxygenator (ECMO)

Indications for VAD: Cardiogenic shock Postcardiotomy ventricular failure Patients waiting for transplantation Inability to be weaned from CP bypass after surgery LAVD RVAD RA -> pump -> patient via cannulation of the pulmonary artery LA -> pump - > patient via cannulation of the ascending aorta

TYPES OF VAD Centrifugal - External, non-pulsatile, cone-shaped devices with internal mechanisms that spin rapidly (tornado-like action) pulls blood from a large vein into the pump pushes it back into a large artery Pneumatic External/ implanted pulsatile devices With flexible reservoir housed in a rigid exterior The reservoir fills blood from the Atrium or Ventricle + pressurized air = compression of the reservoir blood goes back to the circulation Electric: External/ implanted pulsatile devices Total Artificial Hearts Designed to replace both ventricles. Are experimental With flexible reservoir housed in a rigid exterior Same with pneumatic

Contraindications for VAD: Prolonged cardiac arrest with severe neurologic damage Irreversible extensive myocardial damage

Complications of VAD & AH Bleeding disorders Hemorrhage Thrombus Emboli Infection Renal failure Right heart failure Multi-system failure Mechanical failure

Nursing Care with VAD Cardiac perfusionists Frequent assessment of vs, hd, i&o Monitor for and treat arrhythmias promptly

ARTIFICIAL AIRWAYS I. Endotracheal tubes/intubation -involves passing an et through the mouth or nose into the trachea.

- provides a patent airway when the patient is having respiratory distress that cannot be treated with simpler methods. -method of choice in emergency care - for patients who can t maintain an adequate airway on their own -for mechanical ventilation -for suctioning secretions from the pulmonary tree -once inserted, a cuff around the tube is inflated to prevent air from leaking around the outer part of the tube, to minimize the possibility of subsequent aspiration and to prevent movement of the tube. -cuff pressures should be checked every 8-12 hours to maintain cuff pressure between 20-25mm Hg -high pressures can cause: tracheal bleeding, ischemia and pressure necrosis while low cuff pressure can increase the risk of aspiration pneumonia. -routine deflation of the cuff is not recommended due to the increased risk of aspiration and hypoxia. -the cuff is deflated prior to the removal of the tube. - warmed, humidified O2 should always be introduced through the tube, whether the patient is breathing spontaneously or receiving ventilatory support. -may be used for no more than 3 weeks, after which, a tracheostomy is considered to decrease trauma and irritation to the tachael lining, to reduce incidence of vocal cord paralysis and to decrease the work of breathing. Disadvantages:  Causes discomfort  Depressed cough and swallowing reflexes  Secretions tend to be thicker  Mechanical trauma  Risk for aspiration  Ulceration, stricture of the larynx or trachea  Inability of the patient to talk Interventions:  Instruct patient and family members about the et tube  Provide comfort measures  Suction PRN  Restrain patient if needed to prevent untintentional removal of the tube  Provide alternative modes of communication II. MECHANICAL VENTILATORS -provide an appropriate level of mechanical ventilator support when necessary OBJECTIVES:  Physiologic objectives y To support otherwise manipulate pulmonary gas exchange y To increase lung volume y To reduce or otherwise manipulate the work of breathing  Clinical objectives y To reverse hypoxemia y To reverse acute respiratory acidosis y To relieve respiratory distress y To prevent or reverse atelectasis y To reverse ventilator muscle fatigue y To permit sedation and or/ neuromuscular blockade y To decrease systemic myocardial O2 consumption y To reduce intracranial pressure

To stabilize the chest wall

INDICATIONS: 1. 2. 3. 4. 5. 6. 7. 8. Patients with a continuous decrease in oxygenation (PaO2) An increase in arterial CO2 levels (PaCO2) Persistent acidosis (decreased pH) PaO2 <50mmHg with FiO2 >0.60 PaO2>50mmHg with pH <7.25 Vital capacity < 2 times tidal volume Negative inspiratory force<25cmH2O Respiratory rate > 35/min

MAJOR TYPES OF MECHANICAL VENTILATORS A. Negative external pressure ventilators: - Attempt to duplicate spontaneous breathing. - Decreases intrathoracic pressure during inspiration allowing air to flow into the lung, filling its volume. - used mainly in: > chronic respiratory failure associated with neuromuscular conditions: - poliomyelitis - muscular dystrophy -amyotrophic lateral sclerosis - myasthenia gravis - inappropriate for unstable patients or complex patient who requires frequent ventilatory changes - are simple to use and do not require intubation of the airway, consequently they are especially adaptable for home use Types 1. IRON LUNG (drinker respirator tank) - is a negative pressure chamber used for ventilation. - currently used by polio survivors 2. BODY WRAP (Pneumowrap) and Chest Cuirass (Tortoise Shell) - are portable devices that require a rigid cage or shell to create a negative pressure chamber around the thorax and abdomen. DISADVANTAGES: a. Inability to provide adequate support to patients with lung disease b. Available only in controlled mode c. Problems with proper fit and system leaks **Regardless of the type of negative pressure ventilator, failure to maintain a proper seal around the chest may result in inadequate alveolar ventilation B. Positive Pressure Ventilators - inflate the lungs by exerting positive pressure on the airway, similar to a bellows mechanism, forcing the alveoli to expand during inspiration. - Expiration occurs positively. - requires endotracheal intubation or tracheostomy Types:

Classified according to the method of ending the inspiratory phase of respiration: 1. Pressure Cycled ventilators - Ends inspiration when a preset pressure has been reached. - The ventilator cycles on, delivers a flow of air until it reaches a predetermined pressure, then cycles off. - LIMITATION: Tidal volume delivered may be inconsistent because the delivery of the volume of air varies according to the patient s airway resistance or compliance. - Are intended for short-term use. - Time-cycled ventilators - Terminate or control inspiration after a preset time. - The volume of air is regulated by the length of inspiration and the flow rate of the air. - Pure time-cycling is rarely used for adults. - Mostly used in newborns and infants - Volume-cycled ventilators - Most commonly used - The volume of air to be delivered with each respiration is preset - Once the preset volume is delivered to the patient, the ventilator cycles off and exhalation occurs passively. - The volume of air delivered is relatively constant, ensuring consistent, adequate breaths despite varying airway pressures - Non-invasive Positive Pressure Ventilation - Can be given via facemasks that cover the nose and mouth, nasal masks or other nasal devices. - Decreases the risk for nosocomial infections - The ventilator can be set with a minimum back up rate for patients with periods of apnea ADJUSTING THE VENTILATOR: - The ventilator is adjusted so that the patient is comfortable and breathes in sync with the machine. - If the volume ventilator is adjusted appropriately, the patient s arterial blood gas values will be satisfactory and there will be little or no cardiovascular compromise. - The ventilator needs to be assessed to make sure that it is functioning properly and that the settings are appropriate. Things to be assessed: y Type of ventilator y Controlling mode (controlled ventilation, assist-controlled ventilation, synchronized intermittent mandatory ventilation) y Tidal volume (usually 10-15ml/kg), and rate settings (usually 12-16/ min) y FiO2 (fraction of inspired oxygen) setting y Inspiratory pressure reached and pressure limit (normal=15-20cm H2O, this increases if there is increased airway resistance or decreased compliance) y Sensitivity ( a 2-cm H2O inspiratory force should trigger the ventilator) y Inspiratory-to-expiratory ration (usually 1:3, 1 inspiration to 3 seconds of expiration or 1:2) y Minute volume (tidal volume x RR, usually 6-8L/min) y Sigh settings (1.5 times the tidal volume and ranging from 1-3 per hour), if applicable y Water in the tubing, disconnection or kinking of the tubing y Humidification (humidifier filled with water) and temperature y Alarms (turned on and functioning properly) y PEEP and/or pressure support level, if applicable. (usually 5-15 cm H2O) TROUBLE SHOOTING VENTILATOR PROBLEMS

PROBLEM A. ventilator Increase in peak airway pressure

CAUSE -Coughing or plugged airway tube -patient bucking ventilator -decreasing lung compliance

SOLUTION -suction airway, empty condensation fluid from circuit -adjust sensitivity -manually ventilate patient. -assess for hypoxia or bronchospasm -check arterial blood gas values -sedate only if necessary -check tubing, reposition patient, insert an oral airway if necessary -manually ventilate the patient, notify the MD -clear secretions -none -check entire ventilator circuit for patency -correct leak

-tubing kinked -pneumothorax -atelectasis or bronchospasm -Increase in compliance -leak in ventilator or tubing cuff on tube/ humidifier is not tight

Decrease in pressure or loss of volume

B. Patient Cardiovascular compromise

Barotrauma/ pneumothorax

Pulmonary infection

-decrease in venous return due to -Assess for adequate volume status by application of positive pressure to lungs measuring heart rate, blood pressure, CVP, PCWP, and urine output -notify MD if values are Abnormal -application of positive pressure to -notify MD lungs; high mean airway pressures lead -prepare patient for CT insertion to alveolar rupture -avoid high pressure settings for patients with COPD, ARDS or history of pneumothorax -bypass of normal defense -use meticulous aseptic technique mechanisms, frequent beaks in -provide frequent mouth care ventilator circuit; decreased mobility, -Optimize nutritional status impaired cough reflex