Topic 11-12 D

Q-1

MODS usually is characterized by more than two organ dysfunctions that occur simultaneously resulting from an underlying etiology (Asim, Amin, & El-Menyar, 2020); (Ladhe, House-Kokan, & Gillespie, 2019). An example we have all been seeing up close and personal is Covid-19 infections, and those who have severe infections usually end up with MODS (Robba, Battaglini, Pelosi, & Rocco, 2020). The organs that are most likely affected are those that have ACE-2 receptors on them, as that is how COVID enters the cells, are the Lungs, Heart, and Kidney (Robba, Battaglini, Pelosi, & Rocco, 2020). With a severe enough infection, you will see an additional failure of the heart and the kidney organs (Robba, Battaglini, Pelosi, & Rocco, 2020).

From a MODS perspective, the underlying etiology is the current infection, and the characteristics that indicate organ failure in the heart and kidneys individually are the same characteristics that we measure for MODS with the exception that they are both occurring at the same time (Asim, Amin, & El-Menyar, 2020); (Ladhe, House-Kokan, & Gillespie, 2019). So for the heart, dysfunction of the organ within COVID is that it is symptomatic spontaneous bradycardia which is a result of disruption of the electrical conduction system of the heart due to the COVID infection (Asim, Amin, & El-Menyar, 2020); (Ladhe, House-Kokan, & Gillespie, 2019);(Robba, Battaglini, Pelosi, & Rocco, 2020). For the kidneys, there are the same tell-tale signs as singular renal failure such as elevated Creatinine above 50% of baseline, elevated potassium, phosphorus, magnesium, and reduced or absent renal output (Asim, Amin, & El-Menyar, 2020); (Ladhe, House-Kokan, & Gillespie, 2019).

Differentials for Cardiac organ dysfunction would include electrolyte disturbance, hypoxia, beta-blocker overdose, cardiac ischemia, and more (Asim, Amin, & El-Menyar, 2020); (Ladhe, House-Kokan, & Gillespie, 2019). Differentials for renal failure would include hypotension, sepsis, acute tubular necrosis, glomerulonephritis, post-renal obstruction, and many more (Asim, Amin, & El-Menyar, 2020); (Ladhe, House-Kokan, & Gillespie, 2019).

Treatment in MODS regardless of etiology is supportive care of the organ, or organs involved, itself until the underlying etiology can be treated (Asim, Amin, & El-Menyar, 2020); (Ladhe, House-Kokan, & Gillespie, 2019). In the COVID case with MODS, supportive care would include an external pacemaker until an internal pacemaker can be implanted, and fluids, possible diuretic, and diuretic challenges, and even possible dialysis (Robba, Battaglini, Pelosi, & Rocco, 2020).

Unfortunately, there is no gold standard for the treatment of MODS as it can affect any combination of organs in multiple ways, however, the censuses still stand that supportive care until the etiology is resolved is the appropriate treatment (Asim, Amin, & El-Menyar, 2020); (Ladhe, House-Kokan, & Gillespie, 2019).

References: Asim, M., Amin, F., & El-Menyar, A. (2020). Multiple organ dysfunction syndrome: Contemporary insights on the clinicopathological spectrum. Qatar medical journal, 2020(1), 22. https://doi.org/10.5339/qmj.2020.22 LADHA, E., HOUSE-KOKAN, M., & GILLESPIE, M. (2019). The ABCCs of sepsis: A framework for understanding the pathophysiology of sepsis. Canadian Journal of Critical Care Nursing, 30(4), 12–21. Robba, C., Battaglini, D., Pelosi, P., & Rocco, P. (2020). Multiple organ dysfunction in SARS-CoV-2: MODS-CoV-2. Expert review of respiratory medicine, 14(9), 865–868. https://doi.org/10.1080/17476348.2020.1778470

Q-2

There are some therapies that have been known to induce ARDS, some of which include Transfusion-associated acute lung injury (TRALI), drug overdose, pancreatitis from propofol induction, burns, reperfusion injury, graft dysfunction, and acute organ rejection (Matthay et al, 2019). TRALIs and other immune reactions can occur from mismatched blood typing and the body's overresponse to it which leads to ARDS due to increased amounts of neutrophils and subsequent increase in permeability (Matthay et al, 2019). Another example would be pancreatitis which causes the body to release cytokines, which then again cause an increase in permeability of neutrophils to the lung, causing an increase in edema and subsequent ARDS (Matthay et al, 2019).

Radiological findings are consistent with the Berlin criteria in ARDS patients with surrounding pulmonary edema or pneumonia (Matthay et al, 2019). The chest x-ray in ARDS are hard to distinguish against others like pulmonary edema, or pneumonia, however, the only difference that helps is the timeframe (Matthay et al, 2019). The difference is that if a patient has a relatively mild film within 12-24 hours prior, and the new film shows severe diffuse bilateral pulmonary edema, then with that criteria the diagnosis and classification of ARDS can be made (Matthay et al, 2019). The berlin criteria cover this idea as it includes timing, risk factors, severity, and the film (Matthay et al, 2019).

Some concerns that arise with treating ARDS are pronation concerns, ventilator concerns within PEEP settings, and the use of neuromuscular blockers (Matthay et al, 2019). With prone positioning, as it can help greatly by changing the location of gas exchange to different lung fields, actually getting the patient prone comes with its own inherent risks such as tube or line loss from repositioning (Wiart et al., 2021). With ventilation changes and higher PEEP, there is an increased risk of barotrauma or pneumothorax which will only worsen the condition (Matthay et al, 2019). Finally, neuromuscular blockers such as vecuronium have to be used in caution with patients who have myasthenia gravis as the mechanism of action of vecuronium is similar to myasthenia gravis, and we can actually send a patient into a myasthenia crisis accidentally (Dontukurthy, 2020). References: Dontukurthy, S., Wisler, C., Raman, V., & Tobias, J. D. (2020). Myasthenia gravis and sugammadex: A case report and review of the literature. Saudi journal of anaesthesia, 14(2), 244–248. https://doi.org/10.4103/sja.SJA_721_19 Matthay, M.A., Zemans, R.L., Zimmerman, G.A., Arabi, M. Y., Beitler, J.R., Mercat, A., Herridge, M., Randolph, A.G., Calfee, C., S. (2019). Acute Respiratory Distress Syndrome. Public Health Emergency Collection Nat Rev Dis Primers. 5(1), 18. https://10.1038/s41572-019-0069-0 Wiart, A., Castanares-Zapatero, D., Wittebole, X., Maerckx, G., David, G., Laterre, P.-F., & Gerard, L. (2021). Prone Positioning in Spontaneously Breathing Subjects With Moderate or Severe ARDS During Invasive Ventilation. Respiratory Care, 66(5), 724–732. https://doi-org.lopes.idm.oclc.org/10.4187/respcare.08461

Q-3

The patient arrived from a local nursing home for altered mental status. He is 72-year-old male who was admitted to a skilled nursing facility for rehabilitation following a total hip replacement. Staff states he became altered this afternoon and was unable to ambulate this evening. Right hip note swollen and red surgical incision site He was admitted to the facility last night, and very little information is known.

History: hypertension, atrial-fibrillation, and type 2 diabetes

Allergies: none

Medications: metformin, Lisinopril, amiodarone and warfarin

Patient weight/height: 220 pounds and 5ft 9in

Vitals: HR is 150, BP is 84/50, RR is 22/min, O2 is 96 percent, glucose 280 mg/dl, temp 94.8 F, ETCO2 20 mm Hg with a normal waveform, and lung sounds are clear.

Differential diagnosis: Infected right hip surgical site, right hip cellulitis, left hip osteomyelitis, UTI, septicemia, bacteriuria

Treatment: High volumes of normal saline, norepinephrine low dose started, pan cultured, sepsis alert protocol and IV Vancomycin 1g initiated, patient is admitted.

The next morning his LOC continues to worsen, BUN/ creatinine are 50/1.9, with less than 10ml of urine per hour over night and he is intubated in the ICU. Lactic Acid level is 12

In response to the systemic invasion of microorganisms, the body triggers the production of inflammatory mediators and characteristic signs and symptoms, such as fever or hypothermia, tachycardia, tachypnea, and an increase or decrease in peripheral white blood cell counts develop, all of which are essential components of the SIRS criteria. It was at this stage that the diagnosis of sepsis, which often predisposed the failure of vital organs, currently referred to as multiple organ dysfunction syndromes (MODS). MODS is defined as a progressive physiologic failure of two or more organ systems in acutely ill patients (Gourd & Nikitas, 2020). This patient has renal dysfunction, cardiac, and altered mental status unable to maintain airway.

Establishing vascular access and initiating aggressive fluid resuscitation should be the initial priority when managing patients with severe sepsis or septic shock. Treatment plan at this point includes, treating underline infectious process per culture results, supportive therapy, which may include ventilator support, vasopressors, and hemodialysis and maintaining nutritional status. The goals of initial resuscitation involved the use of crystalloids or colloids to maintain central venous pressure of 8–12mmHg and a mean arterial pressure (MAP) of at least 65mmHg with fluid and norepinephrine or dopamine as the initial vasopressor of choice (Murray & Coursin, 2018).

 

Gourd, N. M., & Nikitas, N. (2020). Multiple Organ Dysfunction Syndrome. Journal of intensive care medicine, 35(12), 1564–1575. https://doi.org/10.1177/0885066619871452

Murray, M. J., & Coursin, D. B. (2018). Multiple organ dysfunction syndrome treatment. The Yale Journal of Biology and Medicine, 66(5), 501–510. Retrieved from: https://pubmed.ncbi.nlm.nih.gov/78235425351/