multiple Organ Dysfunction

1. Multiple Organ
Dysfunction Syndrome (MODS)

2. • Introduction
• Components of Multiple Organ Dysfunction
• Organ-specific manifestations of dysfunction & respective management strategies
• Summary
Flow of Talk
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3. Introduction
Section 1
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4. John C. Marshall et al. The Multiple Organ Dysfunction Syndrome: Syndrome, Metaphor, and Unsolved Clinical Challenge. Society of Critical Care Medicine and Wolters Kluwer Health.
September 2021: Vol: 49;9: 1402-13
What is
Multiple Organ Dysfunction Syndrome (MODS)?
• The development of potentially
reversible physiologic derangement
involving two or more organ
systems not involved in the disorder
that resulted in ICU admission, and
arising in the wake of a potentially
life-threatening physiologic insult.

5. Scott L. et al. Pediatrics January 2022; 149 (Supplement_1): S13–S22. 10.1542/peds.2021-052888C
Clinical Scenarios
Involving >1 Organ System Dysfunction

6. John C. Marshall et al. The Multiple Organ Dysfunction Syndrome: Syndrome, Metaphor, and Unsolved Clinical Challenge. Society of Critical Care Medicine and Wolters Kluwer Health.
September 2021: Vol: 49;9: 1402-13
History of MODS
• The first ICUs appeared during the
decade of the 1950s;
• Contemporary intensive care has its
origins in the 1952 polio epidemic in
Denmark, with the recognition by Ibsen
that lethal respiratory failure could be
supported by external positive pressure
ventilation, performed not by machines,
but by medical students.

7. Geoffrey P. Dobson et al. Front Med (Lausanne). 2022; 9: 968453.
Impact of MODS
• The incidence of MODS depends on the
criterion used for MOF as there is no
consensus on a single definition as the gold
standard.
• The reported incidence of MODS among
critically ill trauma patients varies widely from
28% to 88%
MODS in Trauma

8. John C. Marshall et al. The Multiple Organ Dysfunction Syndrome: Syndrome, Metaphor, and Unsolved Clinical Challenge. Society of Critical Care Medicine and Wolters Kluwer Health.
September 2021: Vol: 49;9: 1402-13
Organ Dysfunction - A Dynamic & Iterative Process
• Initiated by a severe insult to normal
homeostasis (e.g. multiple trauma,
infection, or shock)
• Further modified by preexisting
limitations on functional reserve.
• This disruption activates systemic
changes in immune, metabolic,
endocrine, and vascular function that
evolved to preserve vital function.
• It can further aggravate injury to support
failing physiology, for example.
ventilator-induced lung injury (VILI).

9. Assessment of MODS Severity (Scoring Systems)
• Scoring Systems & the
Organ-Specific Parameters Measured
• These clinical scoring systems, although
useful for an initial assessment of MODS
severity in daily practice.
Nicholas M Gourd et al. J Intensive Care Med . 2020 Dec;35(12):1564-1575. doi: 10.1177/0885066619871452.
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10. Triggers for MODS Development
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• Infectious shown in red (sepsis)
• Noninfectious in purple.
John C. Marshall et al. The Multiple Organ Dysfunction Syndrome: Syndrome, Metaphor, and Unsolved Clinical Challenge. Society of Critical Care Medicine and Wolters Kluwer Health.
September 2021: Vol: 49;9: 1402-13

11. Components of
Multiple Organ Dysfunction
Section 2
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12. 12
MODS and Cardiac Dysfunction
Happens when tissue O2 supply is
unable to meet the cardiac oxygen
demand (e.g., acute myocardial
infarction, circulatory arrest,
hypovolemic shock)
Myocardial Ischemia Reperfusion Injury
Asim M, Amin F, El-Menyar A., Qatar Medical Journal 2020:1 http://dx.doi.org/10.5339/qmj.2020.22

13. 13
MODS and Cardiac Dysfunction
• Recurrent among ICU patients.
• Distinguished by increased
oxidative stress and deregulated
inflammatory response
Systemic Inflammation Response Syndrome
Asim M, Amin F, El-Menyar A., Qatar Medical Journal 2020:1 http://dx.doi.org/10.5339/qmj.2020.22

14. 14
MODS and Cardiac Dysfunction
• Stress reaction to critical illness is
distinguished by increased
catecholamine levels in plasma,
autonomic dysfunction, and
increased sympathetic initiation
Catecholamine Induced Cardiac Dysfunction
Asim M, Amin F, El-Menyar A., Qatar Medical Journal 2020:1 http://dx.doi.org/10.5339/qmj.2020.22

15. 15
MODS and Respiratory Dysfunction
• The lung is "primed" by the initial
insult, such as pneumonia, acid
aspiration, or contusion, followed by
the "second hit“ by mechanical
ventilation, which leads to an immense
pulmonary inflammatory response.
Acute Respiratory Distress Syndrome
Asim M, Amin F, El-Menyar A., Qatar Medical Journal 2020:1 http://dx.doi.org/10.5339/qmj.2020.22

16. 16
MODS and Renal Dysfunction
• Dysregulated immune responses and
systemic inflammation
• Hemodynamic changes including
alterations of renal blood flow,
macrocirculation & microcirculation
• Dysfunction of renal microvascular
endothelial cells
• The injury of renal tubular epithelial
cells
Sepsis-induced Acute Kidney Injury
He F-F, Wang Y-M, Chen Y-Y, Huang W, Li Z-Q and Zhang C (2022), Front. Pharmacol. 13:981578. doi: 10.3389/fphar.2022.981578

17. 17
MODS and Brain Injury
• Extracranial organ dysfunction is
common after severe TBI and
significantly impacts clinical care and
outcomes following injury.
Relevant Mechanisms and Clinical Consequences of
Multiorgan Dysfunction After Severe Traumatic Brain Injury (TBI)
He F-F, Wang Y-M, Chen Y-Y, Huang W, Li Z-Q and Zhang C (2022), Front. Pharmacol. 13:981578. doi: 10.3389/fphar.2022.981578

18. 18
• The inciting infection varies in its site, severity,
and microbiology, as well as in the duration of
time that has elapsed since onset and the start of
treatment.
• MODS in sepsis reflects a complex interplay of
factors originating in the
 Initial inciting insult
 Innate immune and metabolic response of the
host
 Beneficial and harmful consequences of
intensive care unit (ICU) supportive care
MODS and Sepsis
Rachel Pool, Hernando Gomez, John A. Kellum, Volume 34, Issue 1, 2018, Pages 63-80, ISSN 0749-0704, ISBN 9780323566339, https://doi.org/10.1016/j.ccc.2017.08.003.

19. Organ-specific Manifestations of
Dysfunction & Respective Management
Strategies
Section 3
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20. First Step - Updation in SOFA Scoring
Moving from SOFA 1.0 to SOFA 2.0
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Rui Moreno et al. Crit Care. 2023 Jan 13;27(1):15. doi: 10.1186/s13054-022-04290-9.
Some variables that may be considered for inclusion in
a Sequential Organ Failure Assessment (SOFA) score version 2.0

21. Organ-specific Manifestations of Dysfunction and
Respective Management Strategies
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John C. Marshall et al. The Multiple Organ Dysfunction Syndrome: Syndrome, Metaphor, and Unsolved Clinical Challenge. Society of Critical Care Medicine and Wolters Kluwer Health.
September 2021: Vol: 49;9: 1402-13

22. Dmytriiev D. et al. Anaesth. pain & intensive care 2019;23(1):84-91
Pain Management in Combined Organ Failures – Step 1
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23. Dmytriiev D. et al. Anaesth. pain & intensive care 2019;23(1):84-91
Pain Management in Combined Organ Failures – Step 2
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24. Dmytriiev D. et al. Anaesth. pain & intensive care 2019;23(1):84-91
Pain Management in Combined Organ Failures – Step 3
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25. Bidirectional Relationship Between
The Kidneys And Other Organs
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Asim M, Amin F, El-Menyar A., Qatar Medical Journal 2020:1 http://dx.doi.org/10.5339/qmj.2020.22

26. Current Extracorporeal Organ Support (ECOS)
Techniques for MODS
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Asim M, Amin F, El-Menyar A., Qatar Medical Journal 2020:1 http://dx.doi.org/10.5339/qmj.2020.22

27. Heat Stroke-induced Liver Injury
Etiology and Therapeutic Strategies
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Wang et al. Critical Care (2022) 26:391

28. Anish Kumar, Narinder Pal Singh. Indian Journal of Critical Care Medicine February 2015 Vol 19 Issue 2:99-108
Clinical Scenarios Altering
Antimicrobial Pharmacokinetics in MODS
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29. Summary
• MODS remains a leading cause of morbidity and mortality in ICU settings with an
enormous burden on healthcare resources.
• Identification of potential preventable predisposing factors of MODS could assist
in better prognosis.
• Given the lack of effective treatment for MODS, its early recognition, the early
intensive care unit admission, and the initiation of invasive organ support remain
the most effective strategies of preventing its progression and improving
outcomes.
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30. Thank You