eMedicine Specialties > Critical Care > Medical Topics

Multisystem Organ Failure of Sepsis: Follow-up

Author: Ali H Al-Khafaji, MD, MPH, FACP, FCCP, Assistant Professor of Critical Care Medicine and Interim Director, Transplant intensive Care Unit, University of Pittsburgh Medical School
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: Jan 29, 2010

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

For excellent patient education resources, visit eMedicine's Blood and Lymphatic System Center. Also, see eMedicine's patient education article Sepsis (Blood Infection).

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
[ CLOSE WINDOW ]

References

  1. Harrois A, Huet O, Duranteau J. Alterations of mitochondrial function in sepsis and critical illness. Curr Opin Anaesthesiol. Apr 2009;22(2):143-9. [Medline].

  2. Martin CM, Priestap F, Fisher H, et al. A prospective, observational registry of patients with severe sepsis: the Canadian Sepsis Treatment and Response Registry. Crit Care Med. Jan 2009;37(1):81-8. [Medline].

  3. Blanco J, Muriel-Bombín A, Sagredo V, et al. Incidence, organ dysfunction and mortality in severe sepsis: a Spanish multicentre study. Crit Care. 2008;12(6):R158. [Medline].

  4. Shapiro NI, Trzeciak S, Hollander JE, et al. A prospective, multicenter derivation of a biomarker panel to assess risk of organ dysfunction, shock, and death in emergency department patients with suspected sepsis. Crit Care Med. Jan 2009;37(1):96-104. [Medline].

  5. Nelson DP, Lemaster TH, Plost GN, Zahner ML. Recognizing sepsis in the adult patient. Am J Nurs. Mar 2009;109(3):40-5; quiz 46. [Medline].

  6. Jaimes F, De La Rosa G, Morales C, et al. Unfractioned heparin for treatment of sepsis: A randomized clinical trial (The HETRASE Study). Crit Care Med. Apr 2009;37(4):1185-96. [Medline].

  7. Briegel J, Forst H, Haller M, et al. Stress doses of hydrocortisone reverse hyperdynamic septic shock: a prospective, randomized, double-blind, single-center study. Crit Care Med. Apr 1999;27(4):723-32. [Medline].

  8. Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Intensive Care Med. Jan 2008;34(1):17-60. [Medline].

  9. Adrie C, Alberti C, Chaix-Couturier C, Azoulay E, De Lassence A, Cohen Y. Epidemiology and economic evaluation of severe sepsis in France: age, severity, infection site, and place of acquisition (community, hospital, or intensive care unit) as determinants of workload and cost. J Crit Care. Mar 2005;20(1):46-58. [Medline].

  10. Barriere SL, Lowry SF. An overview of mortality risk prediction in sepsis. Crit Care Med. Feb 1995;23(2):376-93. [Medline].

  11. Bernard GR, Vincent JL, Laterre PF, et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med. Mar 8 2001;344(10):699-709. [Medline].

  12. Bone RC. Immunologic dissonance: a continuing evolution in our understanding of the systemic inflammatory response syndrome (SIRS) and the multiple organ dysfunction syndrome (MODS). Ann Intern Med. Oct 15 1996;125(8):680-7. [Medline].

  13. Bone RC. The pathogenesis of sepsis. Ann Intern Med. Sep 15 1991;115(6):457-69. [Medline].

  14. Bone RC, Balk RA, Fein AM, et al. A second large controlled clinical study of E5, a monoclonal antibody to endotoxin: results of a prospective, multicenter, randomized, controlled trial. The E5 Sepsis Study Group. Crit Care Med. Jun 1995;23(6):994-1006. [Medline].

  15. Bone RC, Fisher CJ Jr, Clemmer TP, Slotman GJ, Metz CA, Balk RA. A controlled clinical trial of high-dose methylprednisolone in the treatment of severe sepsis and septic shock. N Engl J Med. Sep 10 1987;317(11):653-8. [Medline].

  16. Bone RC, Fisher CJ Jr, Clemmer TP, Slotman GJ, Metz CA, Balk RA. Sepsis syndrome: a valid clinical entity. Methylprednisolone Severe Sepsis Study Group. Crit Care Med. May 1989;17(5):389-93. [Medline].

  17. Bracco D, Dubois MJ. Hemodynamic support in septic shock: is restoring a normal blood pressure the right target?. Crit Care Med. Sep 2005;33(9):2113-5. [Medline].

  18. Brun-Buisson C, Doyon F, Carlet J. Bacteremia and severe sepsis in adults: a multicenter prospective survey in ICUs and wards of 24 hospitals. French Bacteremia-Sepsis Study Group. Am J Respir Crit Care Med. Sep 1996;154(3 Pt 1):617-24. [Medline].

  19. Choi PT, Yip G, Quinonez LG, Cook DJ. Crystalloids vs. colloids in fluid resuscitation: a systematic review. Crit Care Med. Jan 1999;27(1):200-10. [Medline].

  20. Dragsted L, Jorgensen J, Jensen NH, et al. Interhospital comparisons of patient outcome from intensive care: importance of lead-time bias. Crit Care Med. May 1989;17(5):418-22. [Medline].

  21. Gando S, Iba T, Eguchi Y, et al. A multicenter, prospective validation of disseminated intravascular coagulation diagnostic criteria for critically ill patients: comparing current criteria. Crit Care Med. Mar 2006;34(3):625-31. [Medline].

  22. Higgins TL, Steingrub JS, Tereso GJ, Tidswell MA, McGee WT. Drotrecogin alfa (activated) in sepsis: initial experience with patient selection, cost, and clinical outcomes. J Intensive Care Med. Nov-Dec 2005;20(6):339-45. [Medline].

  23. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med. Oct 1985;13(10):818-29. [Medline].

  24. Knaus WA, Sun X, Nystrom O, Wagner DP. Evaluation of definitions for sepsis. Chest. Jun 1992;101(6):1656-62. [Medline].

  25. Knaus WA, Wagner DP, Draper EA, et al. The APACHE III prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults. Chest. Dec 1991;100(6):1619-36. [Medline].

  26. Kreger BE, Craven DE, McCabe WR. Gram-negative bacteremia. IV. Re-evaluation of clinical features and treatment in 612 patients. Am J Med. Mar 1980;68(3):344-55. [Medline].

  27. Krejci V, Hiltebrand LB, Sigurdsson GH. Effects of epinephrine, norepinephrine, and phenylephrine on microcirculatory blood flow in the gastrointestinal tract in sepsis. Crit Care Med. May 2006;34(5):1456-63. [Medline].

  28. Luce JM. Pathogenesis and management of septic shock. Chest. Jun 1987;91(6):883-8. [Medline].

  29. Marsh R, Nadel ES, Brown DF. Multisystem organ failure. J Emerg Med. Oct 2005;29(3):331-4. [Medline].

  30. Marshall JC, Cook DJ, Christou NV, Bernard GR, Sprung CL, Sibbald WJ. Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome. Crit Care Med. Oct 1995;23(10):1638-52. [Medline].

  31. Nguyen HB, Corbett SW, Menes K, Cho T, Daugharthy J, Klein W. Early goal-directed therapy, corticosteroid, and recombinant human activated protein C for the treatment of severe sepsis and septic shock in the emergency department. Acad Emerg Med. Jan 2006;13(1):109-13. [Medline].

  32. Pinsky MR, Matuschak GM. Multiple systems organ failure: failure of host defense homeostasis. Crit Care Clin. Apr 1989;5(2):199-220. [Medline].

  33. Rangel-Frausto MS. Sepsis: still going strong. Arch Med Res. Nov-Dec 2005;36(6):672-81. [Medline].

  34. Revelly JP, Tappy L, Martinez A, Bollmann M, Cayeux MC, Berger MM. Lactate and glucose metabolism in severe sepsis and cardiogenic shock. Crit Care Med. Oct 2005;33(10):2235-40. [Medline].

  35. Rivers EP. Early goal-directed therapy in severe sepsis and septic shock: converting science to reality. Chest. Feb 2006;129(2):217-8. [Medline].

  36. Sands KE, Bates DW, Lanken PN, et al. Epidemiology of sepsis syndrome in 8 academic medical centers. JAMA. Jul 16 1997;278(3):234-40. [Medline].

  37. Sasse KC, Nauenberg E, Long A, Anton B, Tucker HJ, Hu TW. Long-term survival after intensive care unit admission with sepsis. Crit Care Med. Jun 1995;23(6):1040-7. [Medline].

  38. Shubin H, Weil MH. Bacterial shock. JAMA. Jan 26 1976;235(4):421-4. [Medline].

  39. Sutherland AM, Gordon AC, Russell JA. Are vasopressin levels increased or decreased in septic shock?. Crit Care Med. Feb 2006;34(2):542-3. [Medline].

  40. Tsai MH, Peng YS, Chen YC, Liu NJ, Ho YP, Fang JT. Adrenal insufficiency in patients with cirrhosis, severe sepsis and septic shock. Hepatology. Apr 2006;43(4):673-81. [Medline].

  41. Vincent JL, Bihari DJ, Suter PM, et al. The prevalence of nosocomial infection in intensive care units in Europe. Results of the European Prevalence of Infection in Intensive Care (EPIC) Study. EPIC International Advisory Committee. JAMA. Aug 23-30 1995;274(8):639-44. [Medline].

  42. Wheeler AP, Bernard GR. Treating patients with severe sepsis. N Engl J Med. Jan 21 1999;340(3):207-14. [Medline].

  43. Zeni F, Freeman B, Natanson C. Anti-inflammatory therapies to treat sepsis and septic shock: a reassessment. Crit Care Med. Jul 1997;25(7):1095-100. [Medline].

[ CLOSE WINDOW ]

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

[ CLOSE WINDOW ]

Keywords

sepsis, organ failure, multisystem organ failure of sepsis, multisystem organ failure, multiple organ failure, organ failures, multiple system organ failure, multiple organ system failure

[ CLOSE WINDOW ]

Contributor Information and Disclosures

Author

Ali H Al-Khafaji, MD, MPH, FACP, FCCP, Assistant Professor of Critical Care Medicine and Interim Director, Transplant intensive Care Unit, University of Pittsburgh Medical School
Ali H Al-Khafaji, MD, MPH, FACP, FCCP is a member of the following medical societies: American College of Chest Physicians, American College of Gastroenterology, American College of Physicians, and International Liver Transplantation Society
Disclosure: Nothing to disclose.

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: eMedicine Salary Employment

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

RELATED MEDSCAPE ARTICLES
Articles
Resource Centers
 
 
HONcode

We subscribe to the
HONcode principles of the
Health On the Net Foundation

All material on this website is protected by copyright, Copyright© 1994- by Medscape.
This website also contains material copyrighted by 3rd parties.

DISCLAIMER: The content of this Website is not influenced by sponsors. The site is designed primarily for use by qualified physicians and other medical professionals. The information contained herein should NOT be used as a substitute for the advice of an appropriately qualified and licensed physician or other health care provider. The information provided here is for educational and informational purposes only. In no way should it be considered as offering medical advice. Please check with a physician if you suspect you are ill.