Multiple organ dysfunction syndrome (MODS) occurs when altered organ function in an acutely ill patient is present to the extent that homeostasis can no longer be maintained without intervention. MODS was formerly known as multiple-system organ failure. The usual sequence of MODS depends somewhat on its cause but often begins with pulmonary failure 2 to 3 days after surgery, followed, in order, by hepatic failure, stress-induced gastrointestinal (GI) bleeding, and renal failure. Mortality rates are linearly related to the number of failed organ systems. Patients with two or more organ systems involved have a mortality rate of approximately 75%, and patients with four organ systems involved have a 100% mortality rate.
MODS was first associated with traumatic injuries in the late 1960s and has subsequently been associated with infection and decreased perfusion to any part of the body. The term MODS was adopted in 1991 at a consensus conference of the Society of Critical Care Medicine and the American College of Chest Physicians. The term MODS best describes the organ dysfunction that precedes complete failure. Primary MODS, the result of a direct injury or insult to the organ itself, is initiated by a specific precipitating event, such as a pulmonary contusion. The injury or insult causes an inflammatory response within that organ system, and dysfunction develops.
Secondary MODS develops as the result of a systemic response to infection or inflammation. Systemic inflammatory response syndrome (SIRS) is an overwhelming response of the normal
inflammatory system, producing systemic effects instead of the localized response normally seen. The inflammatory response is produced by the activation of a series of mediators and results in alterations in blood (selective vasodilation and vasoconstriction), an increase in vascular permeability, white blood cell (WBC) activation, and activation of the coagulation cascade. Mortality rates are high with MODS, and the more organ systems that fail, the higher the mortality. For example, mortality with two-organ failure is 45% to 55%, higher than 80% with three-organ failure, and approaches 100% if the failure of three or more organs persists longer than several days.
The inflammatory response can be triggered by any event, but it is most often associated with a bacterial infection. The events most often associated with the development of SIRS and MODS are shock, trauma, burns, aspiration, venomous snakebites, cardiac arrest, thromboemboli, myocardial infarction, operative procedures, vascular injury, infection, pancreatitis, and disseminated intravascular coagulation (DIC).
Nursing care plan assessment and physical examination
The patient with MODS has a history of infection, tissue injury, or a perfusion deficit to an organ or body part. Often, this injury or insult is not life-threatening but exposes the person to bacterial contamination. Question the patient (or, if the patient is too ill, the family) to identify the events in the initial insult and any history of preexisting organ dysfunction, such as chronic lung disease, congestive heart failure, and diabetes mellitus. Elicit a complete medication history and the patient’s compliance with medications, and ask if the patient has experienced recent weight loss. Determine the patient’s dietary patterns to assess the patient’s nutritional status. Take a history of the patient’s use of cigarettes, alcohol, and other drugs of abuse.
The physical examination of the patient with MODS varies, depending on the organ systems involved and the severity of their dysfunction (Table 3). Expect the patient to develop signs of pulmonary failure first and then hepatic failure and GI bleeding. Renal failure follows. Note that failures of the central nervous system (CNS) and the cardiovascular system are late signs of MODS.
The patient with MODS may be fully conscious, partially conscious, or unconscious. If the patient is oriented, she or he is likely to be very anxious and fatigued and also confused, lethargic, or comatose. Assess the patient’s ability to cope with a prolonged lifethreatening illness and the changes in roles that a severe illness brings. The patient may experience fear because of a real threat to her or his life.
Nursing care plan primary nursing diagnosis: Risk for infection related to microorganism invasion, immunosuppression, malnutrition, and presence of invasive monitoring devices.
Nursing care plan intervention and treatment plan
Management of the patient with MODS begins with the recognition of those patients who are at an increased risk for the syndrome. Care must be taken to prevent infection and maintain adequate tissue oxygenation to all body parts. Despite improvement in medical therapies, the mortality rate of MODS remains high.
Treatment of the patient with MODS can be divided into four main areas: anti-infectives, maintenance of tissue perfusion and oxygenation, nutritional support, and immunomodulation. Anti-infective therapy is guided by culture and sensitivity reports. Any potential source of infection should be investigated and eliminated. Antifungal and antiviral agents are used primarily with immunocompromised patients, who are especially susceptible to fungal and viral infections.
Maintaining and monitoring tissue perfusion and oxygenation are crucial to the survival of the patient with MODS. Measurement of oxygen delivery and consumption is necessary to guide fluid replacement therapy and inotropic support of cardiac function. To maximize all components of oxygen delivery (in particular, cardiac index, hemoglobin, and oxygen saturation), the physician maintains the hematocrit within the normal range or even at a supranormal level with blood transfusions. Mechanical ventilation with positive end-expiratory pressure and modes such as pressure control ventilation and inverse ratio inspiration expiration are used to maintain adequate oxygenation and oxygen delivery. The success of maintaining oxygen delivery is evaluated by following the trend of oxygen consumption. Metabolic demands dramatically increase in MODS. When oxygen delivery cannot meet the body’s metabolic demands, these demands may be decreased with sedation, pharmacologic paralysis, and temperature control. The goal in the future is to develop medications that allow for immunomodulation therapy to alter the detrimental effects of the systemic immune-inflammatory response. Tumor necrosis factor and IL-1 are two cytokines that exert a broad effect on the endothelium, leukocytes, and fibroblasts. Experts hope that modulation of both of these cytokines can decrease many of the body’s responses to inflammation. The presence of endotoxin, a substance that is released with the destruction of gram-negative bacteria, stimulates the inflammatory response. Modulation of endotoxin would also decrease many of the body’s responses to inflammation.
Any potential source of infection should be eliminated if possible. Change the dressing on all invasive line sites and surgical wounds according to protocol to keep the area free of infection and to monitor for early signs of infection. Maintain aseptic technique with all dressing changes and manipulation of intravenous lines. Institute the measures that are necessary to prevent aspiration when patients are placed on enteral feedings. Keep the head of the bed elevated, and check for residual volume and tube placement every 4 hours.
To limit the patient’s oxygen expenditure, provide frequent rest periods and create a quiet environment whenever possible. Schedule procedures and nursing care interventions so that the patient has periods of uninterrupted rest. Manage situations of increased metabolic demand— such as fever, agitation, alcohol withdrawal, and pain—promptly so that the patient conserves energy and limits oxygen consumption. Monitor the patient’s environment for sensory overload. Provide purposeful, planned stimuli and keep extraneous, constant noises to a minimum. Provide for planned, uninterrupted rest periods to avoid sleep deprivation. Monitor bony prominences and areas of high risk for skin breakdown. Note that MODS is one of the most critical illnesses that a patient can develop. Although the patient might be well sedated and unresponsive, the family or significant others are generally very anxious, upset, and frightened that the patient might not survive.
These fears are realistic, particularly if multiple organs are involved. Provide the significant others with accurate information about the patient’s course and his or her prospects for recovery. Encourage the legal representative to participate in decisions about extraordinary measures to keep the patient alive if the patient cannot speak for himself or herself. Determine if the patient has a living will or has discussed his or her desire to be kept alive by technology during a potentially terminal illness. If the decision is to terminate life support, work with the significant others to provide a dignified death for the patient in an environment that allows the family to participate and grieve appropriately. Provide referrals to the chaplain, clinical nurse specialist, or grief counselor as needed.
Nursing care plan discharge and home health care guidelines
Although no specific adaptive structural changes need to be made, near the time of discharge assess the patient’s individual needs. Because organ dysfunction or failure is individualized, home care preparation should be based on meeting the individual’s needs. Be sure the patient understands all medications prescribed, including dosage, route, action, and side effects.
Describe the importance of avoiding fatigue and taking frequent rests. Teach the patient to eat small, frequent meals to maintain adequate nutrition. Teach the patient any needed postoperative care: incision care, signs and symptoms of infection, pain management, activity restrictions. Also teach the patient the signs and symptoms of infection and when to report them to the primary healthcare provider.