Chapter 74. Evaluation of the Patient with Multiple Organ Dysfunction Syndrome

1. Multiple organ dysfunction syndrome (MODS) is common in critically ill patients and associated with a high mortality rate.

2. There are many underlying etiologies of MODS. In the overall intensive care unit (ICU) population, sepsis is the most common cause of MODS.

3. MODS is characterized by dysfunction of 2 or more organs or systems.

4. Inflammation and microvascular abnormalities are involved in the development of MODS.

5. Therapies for MODS should target the underlying cause, supporting the patient and correcting the physiologic and metabolic derangements caused by dysfunction of the organs and systems.

6. Patients with MODS often require surgery and other invasive procedures.

7. Whenever possible, optimize MODS patients preoperatively.

8. Methods of optimization are dictated by the affected organs and the severity of physiologic and metabolic derangements.

Progress in life support therapies has led to the recognition of pathophysiologic states that are unique to critically ill patients. Diverse disease states can cause progressive dysfunction and ultimately complete failure of various organs and systems. This condition is commonly referred to as the multiple organ dysfunction syndrome (MODS). High-grade organ failure that necessitates life-sustaining therapies is often referred to as multiorgan system failure. The development of MODS portends a poor outcome. In fact, MODS is one of the leading causes of death for ICU patients.1,2 This chapter reviews basic aspects of MODS, surgical and nonsurgical procedures that are commonly performed in patients with MODS, and the preoperative preparation and optimization of MODS patients for surgery.

The development of organ dysfunction as a separate disease process from the initial injury was first appreciated during World War II. Wounded soldiers were rapidly and aggressively resuscitated with blood products to normalize blood pressure, and they were more promptly evacuated to medical facilities than in previous wars. Although initial survival was improved, many soldiers who survived the initial trauma subsequently died of renal failure.3,4 This led to changes in fluid resuscitation practices in subsequent wars, including the rapid infusion of crystalloids and more aggressive resuscitation. During the Vietnam War, many soldiers who survived their initial trauma developed "shock lung" (acute respiratory failure). At the same time, acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) were increasingly being described in civilian ICUs.5 During the 1970s, advances in critical care medicine led to improved initial survival from many injuries. However, many patients who survived initial resuscitation went on to develop progressive failure of various organs and systems.6,7

Various terms have been used to describe the spectrum of dysfunction of different organs and systems (reviewed in Bone et al8), including multiple organ failure,9 multiple-organ-failure-syndrome,1 multiple system organ failure,10 progressive or sequential organ failure,6 or MODS.8,11 The term MODS is most widely used and encompasses the spectrum from mild organ dysfunction to complete organ failure. In addition, scoring systems have been devised to assess patients and to predict outcome.4,12-16 In this chapter the ...