Page 596 - ACCCN's Critical Care Nursing

Multiple Organ Dysfunction Syndrome 573

Case study, Continued
bronchospasm) and regular steroids ordered (exacerbation COPD/ via infusions. He was coagulopathic, his lactate level had risen and
asthma). The adrenaline infusion continued (MAP 70 mmHg) and his abdomen was still distended.
maintenance fluids commenced (CVP 14 mmHg). A noradrenaline
infusion was added after 2 hours of admission to maintain MAP > For days 4 and 5 in ICU, Mr Wyland continued to be in septic shock
65 mmHg and weaned within 4 hours of commencement. He was and intravenous vasopressin was added. A CAT scan was per-
actively cooled to 33.5°C for 24 hours (to improve outcome post formed to exclude hypoxic brain injury. Some right ventricular dila-
arrest). tion was noted on TOE, however his left ventricular function had
normalised. While clinical concern was raised about the possibility
New infiltrates were noted on chest X-rays (possible pulmonary of an ischaemic gut (offensive stools), he was not considered an
oedema, aspiration or left ventricular dysfunction). Intravenous operative candidate. His antibiotics were changed on day 5
frusemide was administered and a transoesophageal echo (TOE) (meropenem and vancomycin) to cover secondary infection.
revealed an ejection fraction of 25–30%. A bronchoscopy was
performed to exclude obstruction. Nasogastric feeding was On day 6 in ICU Mr Wyland showed some signs of improvement.
commenced. His bronchospasm was resolving. Inotrope requirements were
decreasing and vasopressin and noradrenaline infusions were
On the evening of day 1 in ICU Mr Wyland’s blood glucose levels weaned. Candida was isolated on endotracheal aspirates on day 7
(BGLs) were unstable and an insulin infusion was commenced to of ICU stay (nystatin commenced) and Mr Wyland remained intoler-
maintain glycaemia at 4–10 mmol/L. His abdomen was distended, ant to enteral feeding. A further prokinetic (erythromycin) was
bowel sounds were quiet and enteral feeding was ceased due to added. He remained fully ventilated with improving oxygenation,
high aspirates. Intravenous metoclopramide was commenced CRRT continued and his lactate levels were decreasing.
(prokinetic).
By day 8 in ICU Mr Wyland’s lung mechanics were improving and
By day 2 in ICU Mr Wyland developed renal dysfunction (creatinine
141 µmol/L). By the evening he was anuric and CRRT was com- IV salbutamol, ketamine and sedation were weaned. His ICU stay
menced (CVVHDF). His BP was increasingly labile and a noradrena- was further complicated by intermittent bowel obstructions and
line infusion was recommenced. He was now febrile despite being lower GI bleeding (requiring massive transfusion) secondary to
on CRRT. Enteral feeding was recommenced and feeds were being ischaemia during his initial cardiac arrest. This was managed con-
absorbed. servatively and nutrition maintained via a combination of TPN and
enteral feeding when tolerated. He had a tracheostomy tube
Microbiology results available on day 3 revealed a pneumococcal inserted on day 11 and commenced T-piece trials by day 16. He
lung infection and human metapneumovirus on nasopharyngeal also suffered from critical illness polymyoneuropathy which was
aspirate, therefore oseltamivir was ceased and antibiotics changed diagnosed on the basis of continued weakness post-cessation of
according to sensitivities. Mr Wyland was becoming increasingly sedation. He had established good urine output by day 25 in ICU
unstable haemodynamically (septic shock, LV dysfunction) requir- and was discharged from ICU on day 40 for further pulmonary and
ing 12 mcg/min of adrenaline and 15 mcg/min of noradrenaline physical rehabilitation.

Research vignette

Schmidt H, Hoyer D, Rauchhaus M, Prondzinsky R, Hennen R, Schlitt Methods
A et al. ACE-inhibitor therapy and survival among patients with 178 score-defined consecutive patients were enrolled. Inclusion
multiorgan dysfunction syndrome (MODS) of cardiac and non- criteria was an APACHE II score ≥20 at admission to the ICU.
cardiac origin. International Journal of Cardiology 2010; 140(3): Patients were evaluated for ACEI therapy and followed for 28, 180
296–303. and 365 days. HRV was calculated according to international
standards.
Abstract Results
Background 68 patients received an ACEI during their ICU stay whereas 110 did
The multiple organ dysfunction syndrome (MODS) is the sequen- not. The 28-day mortality was 55% (no ACEI treatment) vs 22%
tial failure of organ systems after a trigger event (e.g. cardiogenic (ACEI treatment, p < 0.0001) and the 1-year mortality accounted for
shock) with a high mortality. ACE-inhibitors (ACEI) are known to 75% (no ACEI) vs 50% (ACEI), p < 0.0001. There was no significant
ameliorate depressed autonomic dysfunction (heart rate variability survival difference between early and later application of ACEI
– HRV) to improve endothelial function and to decrease blood (after day 4), both application modes were characterised by an
pressure. Modifications of these targets reduce major adverse improved survival. MODS patients with ACEI treatment at admis-
cardiovascular events (patients with arterial hypertension, coro- sion had a better preserved HRV.
nary artery disease and chronic heart failure). Our study aimed Conclusions
to characterise potential benefits of ACEI therapy in MODS Our results may suggest that MODS patients with ACEI treatment
patients. may have lower short-and longer-term mortality. HRV was less