Multisystem Organ Failure of Sepsis Follow-up

  • Author: Ali H Al-Khafaji, MD, MPH; Chief Editor: Michael R Pinsky, MD, CM, FCCP, FCCM   more...
 
Updated: Oct 26, 2011
 

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.
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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.

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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.
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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).
  • Lobo et al determined that multiple organ failure is the primary cause of death in high-risk patients following surgery; the risk factors of death due to multiorgan failure should be considered in determining risk stratification.[9]
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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).

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Contributor Information and Disclosures
Author

Ali H Al-Khafaji, MD, MPH  Associate Professor of Critical Care Medicine, Director, Transplant Intensive Care Unit, University of Pittsburgh School of Medicine

Ali H Al-Khafaji, MD, MPH 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.

Specialty Editor Board

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.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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: Nothing to disclose.

Timothy D Rice, MD  Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, St 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 of Academic Affairs, Department of Critical Care Medicine, 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, European Society of Intensive Care Medicine, 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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Stages of sepsis based on American College of Chest Physicians/Society of Critical Care Medicine Consensus Panel guidelines.
Pathogenesis of sepsis and multiorgan failure.
Venn diagram showing overlap of infection, bacteremia, sepsis, systemic inflammatory response syndrome (SIRS), and multiorgan dysfunction.
Acute respiratory distress syndrome (ARDS) present in this chest x-ray (CXR) film is a common organ system affected in multiorgan failure of sepsis.
Acute respiratory distress syndrome (ARDS) shown in this chest x-ray (CXR) film is a common complication of septic shock. Note bilateral airspace infiltration, absence of cardiomegaly, vascular redistribution, and Kerley B lines.
Organizing phase of diffuse alveolar damage (ARDS) secondary to septic shock shows diffuse alveolar injury and infiltration with inflammatory cells.
Organizing diffuse alveolar damage in a different location showing disorganization of pulmonary architecture.
A high-power view of organizing diffuse alveolar damage (ARDS) shows hyperplasia of type II pneumocytes and hyaline membrane deposits.
Table 1
Organ SystemMild CriteriaSevere Criteria
PulmonaryHypoxia/hypercarbia requiring assisted ventilation for 3-5 daysARDS requiring PEEP* >10 cm H2 O and FiO2† < 0.5
HepaticBilirubin 2-3 mg/dL or other liver function tests more than twice normal, PT elevated to twice normalJaundice with bilirubin 8-10 mg/dL
RenalOliguria (< 500 mL/d or increasing creatinine) 2-3 mg/dLDialysis
GastrointestinalIntolerance of gastric feeding for more than 5 daysStress ulceration with need for transfusion, acalculous cholecystitis
HematologicaPTT >125% of normal, platelets < 50-80,000Disseminated intravascular coagulation
CardiovascularDecreased ejection fraction with persistent capillary leakHyperdynamic state not responsive to pressors
CNSConfusionComa
Peripheral nervous systemMild sensory neuropathyCombined motor and sensory deficit
*Positive end-expiratory pressure



†Fraction of inspired oxygen



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