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Multisystem Organ Failure of Sepsis: Follow-up

Coauthor(s): Sat Sharma, MD, FRCPC, Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St. Boniface General Hospital; Gregg Eschun, MD, Assistant Professor, Department of Internal Medicine, Sections of Respirology and Critical Care, St Boniface Hospital, University of Manitoba, Canada
Contributor Information and Disclosures

Updated: Apr 28, 2009

Follow-up

Further Inpatient Care

  • The major focus of resuscitation from septic shock is supporting cardiac and respiratory functions. To prevent multi-organ failure, these patients require a very close monitoring and institution of appropriate therapy for major organ function. Some of the problems encountered in these patients are the following:
  • Temperature control
    • Fever generally requires no treatment, except in patients with limited cardiovascular reserve, because of increased metabolic requirements.
    • Antipyretic drugs and physical cooling methods, such as sponging or cooling blankets, may be used to lower the temperature.
  • Metabolic support
    • Patients with septic shock develop hyperglycemia and electrolyte abnormalities.
    • Serum glucose should be kept in normal range with insulin infusion. Regular measurement and correction of electrolyte deficiency including hypokalemia, hypomagnesemia, hypocalcemia and hypophosphatemia is recommended.
  • Anemia and coagulopathy
    • Hemoglobin as low as 80 mg/dL is well tolerated and does not require transfusion unless the patient has poor cardiac reserve or demonstrates evidence of myocardial ischemia.
    • Thrombocytopenia and coagulopathy are common in sepsis and do not require replacement with platelets or fresh frozen plasma, unless the patient develops active clinical bleeding.
  • Renal dysfunction
    • Closely monitor urine output and renal function in all patients who are septic.
    • Any abnormalities of renal function should prompt attention to adequacy of circulating blood volume, cardiac output, and BP; correct these if they are inadequate.
  • Nutritional support
    • Early nutritional support is of critical importance in patients with septic shock. The enteral route is preferred unless the patient has an ileus or other abnormality.
    • Gastroparesis is observed commonly and can be treated with motility agents or placement of a small bowel feeding tube.

Transfer

  • If patients are treated initially in the wards or in the emergency department, after initial attempts at stabilization, transfer them to the ICU for invasive monitoring and support.

Deterrence/Prevention

  • Patients with impaired host defense mechanisms are at a greatly increased risk for developing sepsis and multiorgan failure. The main causes are: chemotherapeutic drugs, malignancy, severe trauma, burns, diabetes mellitus, renal or hepatic failure, old age, ventilatory support, and invasive catheters.
  • The development of severe sepsis may be prevented by avoidance of invasive catheters or removing them as soon as possible. Prophylactic antibiotics in the perioperative phase, particularly following GI surgery, may be beneficial. Use of topical antibiotics around invasive catheters and as part of a dressing for patients with burns is helpful. Maintenance of adequate nutrition, pneumococcal vaccine in patients who have had a splenectomy, and early enteral feeding are other preventive measures.
  • Prevention of sepsis and multiorgan failure with topical or systemic antibiotics in patients who are at high risk: The use of nonabsorbable antibiotics in the stomach to prevent translocation of bacteria and occurrence of bacteremia has been a controversial issue. Numerous trials have been performed over the years using either the topical antibiotics alone or a combination of topical and systemic antibiotics. A systemic review by Nathens presented no benefit in medical patients but a reduced mortality in surgical trauma patients. The beneficial effect was from a combination of systemic and topical antibiotics, predominantly by reducing lower respiratory tract infections in patients who were treated.

Prognosis

  • Several clinical trials have demonstrated a mortality ranging from 40-75% in patients with multiorgan failure of sepsis.
  • The poor prognostic factors are advanced age, infection with a resistant organism, impaired host immune status, and poor prior functional status.
  • Development of sequential organ failure, despite adequate supportive measures and antimicrobial therapy is a harbinger of a poor outcome.
  • In one study, mortality rates were 7% with SIRS, 16% with sepsis, 20% with severe sepsis, and 46% with septic shock.
  • A multicenter prospective study published in JAMA reported a mortality of 56% during ICU stay. Of all deaths, 27% occurred within 2 days of the onset of severe sepsis, and 77% of all deaths occurred within the first 14 days. The risk factors for early mortality in this study were a higher severity of illness score, presence of 2 or more acute organ failures at the time of sepsis, shock, and a low blood pH ( <7.3).

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Sepsis is the most common cause of shock leading to multiorgan failure in most ICUs and is a leading cause of death.
  • Recognition of septic shock requires features of SIRS (mental changes; hyperventilation; distributive hemodynamics; hyperthermia; hypothermia; and reduced, elevated, or left-shift on WBC) and existence of a potential source of infection.
  • Patients in septic shock require immediate cardiorespiratory stabilization with large volume of fluids intravenously, infusion of vasoactive drugs, and often, endotracheal intubation and mechanical ventilation.
  • Immediately direct intravenous empirical antibiotic therapy at all potential infectious sources.
  • Infectious processes require drainage or debridement surgically and expeditiously, even if the patient does not appear stable because the patient may not improve without emergent surgical treatment.
  • The effects of drugs used to support the hemodynamics of patients who are septic have adverse effects on splanchnic circulation. Therefore, the ideal hemodynamic therapy in these patients is not known. Following adequate fluid resuscitation, therapy with dopamine may be initiated, followed by norepinephrine when dopamine fails. The alternate approach is initiating therapy with norepinephrine and using dobutamine if inotropic support is needed.
  • Manipulation of oxygen delivery by increasing cardiac index has either shown no improvement or has worsened morbidity and mortality. Routine use of hemodynamic drugs to improve cardiac output to supranormal is not recommended.
  • Epinephrine use in septic shock as a single agent is not recommended. Epinephrine impairs splanchnic circulation and tissue perfusion.
  • Lactic acidosis of septic shock usually causes anion gas metabolic acidosis. Administration of bicarbonate therapy has a potential for worsening of intracellular acidosis. Correction of acidemia using sodium bicarbonate has not been proven to improve hemodynamics in patients who are critically ill with increased blood lactate. The above not withstanding, bicarbonate therapy has been used for pH less than 7.20 or bicarbonate less than 9 mmol/L, though no data to support this practice exist.

Special Concerns

  • A continuum of severity from sepsis to septic shock and multiorgan failure exists. The clinical spectrum usually begins with infection that potentially leads to sepsis and organ dysfunction. In one study with 2527 patients evaluated, 26% developed sepsis, 18% developed severe sepsis, and 4% developed septic shock. The incidence of positive blood cultures was 17% in patients with sepsis and 69% in patients with septic shock.
  • The pathogenesis of septic shock and multiorgan failure occurs from mediators produced because of the immune response of the host. Despite encouraging data from animal studies, immunosuppressive agents, such as high-dose corticosteroids, have not shown any benefit in humans.
  • Recent research has focused on modifying the host response to sepsis by infusion of antibodies against gram-negative endotoxin, gamma globulins, monoclonal antibodies against tumor necrosis factor, blockade of eicosanoid production, blockade IL-1 activity, and inhibition of nitric oxide synthase. These approaches have demonstrated modest success in animal experimentation but cannot be recommended for general use at this time.
 


More on Multisystem Organ Failure of Sepsis

Overview: Multisystem Organ Failure of Sepsis
Differential Diagnoses & Workup: Multisystem Organ Failure of Sepsis
Treatment & Medication: Multisystem Organ Failure of Sepsis
Follow-up: Multisystem Organ Failure of Sepsis
Multimedia: Multisystem Organ Failure of Sepsis
References
Further Reading
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References

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Further Reading

Clinical guidelines
Drotrecogin alfa (activated) for severe sepsis.
National Institute for Health and Clinical Excellence (NICE) - National Government Agency [Non-U.S.].  2004 Sep.  31 pages.  NGC:004523

Practice parameters for hemodynamic support of sepsis in adult patients: 2004 update.
Society of Critical Care Medicine - Professional Association.  2004 Sep.  21 pages.  NGC:004181

Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2008.
Society of Critical Care Medicine - Professional Association.  2004 (revised 2008 Jan).  44 pages.  NGC:006316

Clinical trials
Regulation of Endocrine, Metabolic, Immune and Bioenergetic Responses in Sepsis

Uremic Toxins in the Intensive Care Unit (ICU): Patients With Sepsis

Effects of Voluven on Hemodynamics and Tolerability of Enteral Nutrition in Patients With Severe Sepsis


Related eMedicine topics

Acute Renal Failure

Acute Respiratory Distress Syndrome

Cardiogenic Shock

Sepsis, Bacterial

Septic Shock






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Keywords

multisystem organ failure of sepsis, sepsis, organ failure, multiple organ failure, organ failures, multiple system organ failure, multiple organ system failure, multiple organ dysfunction syndrome, MODS

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Contributor Information and Disclosures

Coauthor(s)

Sat Sharma, MD, FRCPC, Professor and Head, Division of Pulmonary Medicine, Department of Internal Medicine, University of Manitoba; Site Director, Respiratory Medicine, St. Boniface General Hospital
Sat Sharma, MD, FRCPC is a member of the following medical societies: American Academy of Sleep Medicine, American College of Chest Physicians, American College of Physicians-American Society of Internal Medicine, American Thoracic Society, Canadian Medical Association, Royal College of Physicians and Surgeons of Canada, Royal Society of Medicine, Society of Critical Care Medicine, and World Medical Association
Disclosure: Nothing to disclose.

Gregg Eschun, MD, Assistant Professor, Department of Internal Medicine, Sections of Respirology and Critical Care, St Boniface Hospital, University of Manitoba, Canada
Gregg Eschun, MD is a member of the following medical societies: American College of Chest Physicians, American Thoracic Society, Canadian Medical Association, and College of Physicians and Surgeons of Manitoba
Disclosure: Nothing to disclose.

Medical Editor

Cory Franklin, MD, Professor, Department of Medicine, Rosalind Franklin University of Medicine and Science; Director, Division of Critical Care Medicine, Cook County Hospital
Cory Franklin, MD is a member of the following medical societies: New York Academy of Sciences and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Daniel R Ouellette, MD, FCCP, Associate Professor of Medicine, Wayne State University School of Medicine; Consulting Staff, Pulmonary Disease and Critical Care Medicine Service, Henry Ford Health System
Daniel R Ouellette, MD, FCCP is a member of the following medical societies: American College of Chest Physicians and American Thoracic Society
Disclosure: Boehringer Ingleheim Honoraria Speaking and teaching; Pfizer Honoraria Speaking and teaching

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michael R Pinsky, MD, CM, FCCP, FCCM, Professor of Critical Care Medicine, Bioengineering, Cardiovascular Disease and Anesthesiology, Vice-Chair, Academic Affairs, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center
Michael R Pinsky, MD, CM, FCCP, FCCM is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American Heart Association, American Thoracic Society, Association of University Anesthetists, Shock Society, and Society of Critical Care Medicine
Disclosure: LiDCO Ltd Honoraria Consulting; iNTELOMED Intellectual property rights Board membership; Edwards Lifesciences Honoraria Consulting; Applied Physiology, Ltd Honoraria Consulting; Cheetah Medical Consulting fee Consulting

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