Multi-System Problems

Learning Objectives:
1. Describe Multi-System Problems (MSP)

2. Correlate the clinical pathway of shock, sepsis, SIRS,

and MODS on the major body systems

3. Relate the pathophysiology to the clinical

manifestations of the different types of shock

4. Schematize the identified alterations leading to MSP

 Multi-System Problems

• Every disease has the capability of following a

clinical path ending with multiple organs becoming
dysfunctional

• MSP refer to disorders that involve or affect more than

one system of bodily organs
 1. Hypovolemic 4. Distributive
• Septic
Shock 2. Cardiogenic • Anaphylactic
3. Obstructive • Neurogenic

SIRS

MODS

Organ Dysfunction

Cardiovascular Lungs GI Liver CNS Renal Skin

Relationship of Shock, SIRS, & MODS

Lewis’s Medical-Surgical Nursing, 11th Ed., 2020.

Infection SIRS Sepsis Septic Shock

MODS
Heart
Lungs Organ
Dysfunction
GI
Liver
Brain
Kidney
Skin

Relationship of Shock, SIRS, & MODS

 ASSESSMENT

1. SIRS

2. SOFA
• 2017 study – 48.9 M cases & 11 M sepsis-
2.1 related deaths worldwide
Quick (q) SOFA
• 85% occurred in low-middle-income
countries
• HCAI (health care-associated infections)
(WHO, 2021)
Comparison:
SHOCK Infection SIRS Sepsis

SIRS SEPTIC SHOCK

MODS MODS

Organ Dysfunction Organ Dysfunction

• Cardiovascular > CNS

• Cardiovascular > CNS
• Lungs > Renal
• Lungs > Renal
• GI > Skin
• GI > Skin
• Liver
• Liver
 Systemic
Inflammatory
Response Syndrome
Definition:

A systemic •infection (sepsis)

inflammatory •ischemia
response to a
variety of •infarction
insults •injury
Definition:

Morton, P.G., • Describe patients in

Fontaine, D.K. (2018).
CCN, a holistic
whom the inflammatory
approach. 11th response is fully &
edition.
systematically activated.
Definition:

• May be caused by any type of shock or by other

insults such as:

Morton, P.G.,
✓ Massive blood transfusion
Fontaine, D.K. ✓ Brain injury
(2018). ✓ Surgery
✓ Burns
CCN, a holistic ✓ Pancreatitis
approach. ✓ Infection
11th edition.
• SIRS criteria should be evaluated in any patient
with shock or any condition that might lead to
shock
 Infection SIRS Sepsis Septic Shock

• Massive BT
• Brain Injury MODS
• Surgery
• Burns Heart
• Pancreatitis Lungs Organ
Dysfunction
GI
Liver
Brain
Kidney
Skin

Relationship of Shock, SIRS, & MODS

SIRS Criteria: The first phase of the
septic process (2001)
2/4 or more
Heart Rate:
Temperature: • > 90 bpm
• > 380C
• < 360C
WBC
RR: • > 12,000 cell / mm3
➢ 20 bpm • < 4000 cell /mm3
• > 10% Band cells
➢ PaCo2 < 32mmHg
SIRS Criteria: Case Study
• A 72 y/o patient presents with;
a) fe

• Temperature of 390C

• RR of 13

• Heart Rate of 102 bpm

• WBC of 16,000 cell / mm3

• How many of the SIRS criteria does this patient meet?

a) ef
Patients with SEPSIS… (2016)

In addition to infection,

patients who have SEPSIS have

organ dysfunction

that can be identified by using the

Sequential Organ Failure Assessment (SOFA)

SOFA Calculation
1. Respiratory function Bilirubin
2. Cardiovascular function
3. Coagulation
4. Renal function Platelet
5. CNS GCS Count
6. Liver function
MAP
Vasopressors

PaO2 / FiO2 mmHg

Output & Creatinine Level
RISK Assessment:
Sequential Organ
Failure Assessment
1 2 3

GCS < 15
 Possible
Sources of
Infection
SHOCK
Shock
• An acute, widespread process of impaired tissue perfusion that
results in cellular, metabolic & hemodynamic alterations

• A severe mismatch between the supply & demand of oxygen is

the common features of ALL types of shock

• Ineffective tissue perfusion occurs when an imbalance develops

between cellular oxygen supply & oxygen cellular demand

• This imbalance can occur for a variety of reasons & eventually results in
cellular dysfunction and death
• A complex pathophysiologic process that often results in MODS &
death
 Types Affected System Etiology Treatment
• Fluid replacement
• Blood & fluids • Due to intravascular
1. Hypovolemic with balanced
compartment volume loss
crystalloid
• State of relative
hypovolemia resulting
• Combination of
from pathological
2. Distributive • Vascular system vasoconstrictors &
redistribution of the
fluid replacement
absolute intravascular
volume
• Depends on the
situation
• Primary cardiac • Inadequate function of
3. Cardiogenic • Drugs, surgery, or
dysfunction the heart
other interventional
procedures
• Blockage of the • Hypoperfusion due to • Immediate life–
4. Obstructive
circulation elevated resistance saving intervention
 SHOCK
• A complex pathophysiologic process
• Involve ineffective tissue perfusion & acute circulatory failure
• Categorized in 4 stages:
1) Initial
2) Compensatory Progression through each stage varies
3) Progressive with the:
4) Refractory • Patient’s prior condition
• Duration of initiating event
• Response to therapy
• Correction of the underlying
cause
 Types & Causes of SHOCK
Types & Causes Associated Conditions
1. Cardiogenic
• Diastolic dysfunction • Cardiac tamponade
• Dysrhythmias • Bradydysrhythmias , Tachydysrhythmias
• Valvular stenosis or regurgitation,
• Structural factors ventricular septal rupture, tension
pneumothorax

• MI, cardiomyopathy, blunt cardiac injury,

• Systolic dysfunction (inability severe systemic or pulmonary
of the heart to pump blood hypertension, myocardial depression from
forward) metabolic problems
Types & Causes of SHOCK
Types & Causes Associated Conditions

2. Hypovolemic
Hemorrhagic (Absolute) Hypovolemia
• External loss of whole blood • Hemorrhage from trauma, surgery, GI bleed
• Vomiting, diarrhea, excessive diuresis,
• Loss of body fluids diabetes insipidus, diabetes

Non-Hemorrhagic (Relative) Hypovolemia

• Fluid shifts • Burn injuries, ascites
• Fracture of long bones, ruptured spleen,
• Internal bleeding hemothorax, severe pancreatitis

• Massive vasodilation • Sepsis

• Pooling of bloods or fluids • Bowel obstruction
Types & Causes of SHOCK
Types & Causes Associated Conditions
3. Distributive
Anaphylactic Shock
• Contrast media, blood or blood products,
drugs, insect bites, anesthetic agents, food
• Hypersensitivity (allergic) or food additives, vaccines, latex,
environmental agents

Neurogenic Shock
• Hemodynamic consequence of
spinal injury/or disease at or
above T5 • Severe pain, drugs, hypoglycemia, injury
• Spinal anesthesia
• Vasomotor center depression
Types & Causes of SHOCK
Types & Causes Associated Conditions

3. Distributive
Septic Shock
• Pneumonia, peritonitis, UTI, invasive
• Infection procedures, indwelling lines & catheters

• Older adults, patients with chronic diseases

(diabetes, CKD, HF)
• At-risk patients • Patients receiving immunosuppressive
therapy or who are malnourished or
debilitated
Types & Causes of SHOCK
Types & Causes Associated Conditions

4. Obstructive

• Cardiac tamponade, tension

• Physical obstruction impeding
pneumothorax, superior vena cava
the filling or outflow of blood
syndrome, abdominal compartment
resulting in reduced CO
syndrome, pulmonary embolism
 Compensatory Mechanisms Used to Maintain
Circulatory Function, & Blood Volume

CARDIOVASCULAR FUNCTION BLOOD VOLUME

Hypothalamus – stimulation of thirst Liver – constriction of veins

Posterior Pituitary – stimulate ADH release & sinusoids with
Kidney – salt & water retention & the mobilization of stored blood
release of aldosterone
• ↑ HR & cardiac contractility
• Vasoconstriction of vessels in
skin & non-vital organs Adrenal Cortex - RAAS

↓ Urine Output
Goal of Treatment:

ALL Shock States:

Reverse the tissue

hypoperfusion & hypoxia
SHOCK Pathophysiology
Initial Compensatory Progressive Refractory

↓ CO SNS • Failure of CM to • Unresponsive

• Neural meet tissue to treatment
• Hormonal metabolic
Threatened • Chemical needs MODS
Tissue responses • Perpetration of
Perfusion shock DEATH

Regardless of the etiologic factors, death occurs from the

Ineffective Cellular Consumption of Oxygen
from either a perfusion deficit or an inability of the cell to
downregulate oxygen into useable energy
 PHASES of SHOCK: Signs/Symptoms

Signs & PHASES

Symptoms IRREVERSIBLE/
COMPENSATING PROGRESSIVE
REFRACTORY
1. Heart Rate Tachycardia Tachycardia Slowing
2. Pulse Bounding Weak, Thready Absent
< 90 mmHg
SBP Normal • In hypertensive, 25% < 60 mmHg
3. Blood
below baseline
Pressure
DBP Normal Decreased Decreasing to 0
4. Respiration Tachypnea Tachypnea Slowing
• Depth Deep Shallow Irregular, shallow
 PHASES of SHOCK: Signs/Symptoms

Signs & PHASES

Symptoms IRREVERSIBLE/
COMPENSATING PROGRESSIVE
REFRACTORY
5. Temperature Varies Decreased Decreasing
Anxious, restless, irritable,
6. LOC Confused, lethargic Unconscious, Comatose
alert, oriented
7. Skin / Mucous Cyanotic, mottled, cold,
Cool, pale Cold, moist, clammy, pale clammy
Membranes
15 ml/hour decreasing to
8. Urine output Normal Decreasing to <20 ml/hr anuria
9. Bowel sounds Normal Decreasing Absent
Signs & Symptoms:
6 • LOC
1 • Heart Rate

7 • Skin / MM
2 • Pulse

3 • Blood 8 • UO
Pressure

4 • Respiration
9 • Bowel Sound

5 • Temperature
Definition

• Failure of two or more organ systems in an acutely

ill patient

• Altered organ function in an acutely ill patient

• Another phase in the progression of shock state

Definition

• Compromise tissue perfusion

• One organ system is associated with 20% mortality

• 70% mortality if organ failure >4

Pathophysiology:

• Complication of any form of shock caused by

inadequate tissue perfusion

• Frequently occurs toward the end of the continuum

when tissue perfusion cannot be effectively restored
 Shock

SIRS • Advanced age

• Malnutrition
MODS • Comorbidities

Organ Dysfunction

Cardiovascular Lungs GI Liver CNS Renal Skin

Pathophysiology

Lewis’s Medical-Surgical Nursing, 11th Ed., 2020.

Clinical Manifestations:

Sequence of organ dysfunction

depends on the patient’s

primary illness & comorbidities

prior to experiencing shock

Clinical Manifestations

Lungs • Progressive dyspnea • Intubation

• Respiratory failure • Mechanical ventilation

• Hypoperfusion • ↑ amounts of IVF

Circulation • ↓ BP, PR, RR • Vasoactive agents to support BP & CO
• Cold, sweaty skin

Hypermetabolic State • Hyperglycemia

• Hyperlactic acidemia
• ↑ BUN
• Metabolic rate = 1.5 to 2X the BMR
• Severe loss of skeletal muscle mass to meet the
energy demands of the body (autocatabolism)
Clinical Manifestations

Liver • Hepatic dysfunction 7-10 • ↑ bilirubin & liver function

days test

Kidneys
• ↑ creatinine
• Anuria

• Dysfunctional (↓ tissue perfusion, anaerobic metabolism)

Hematologic • Worsening immunocompromise
System
• ↑ risk of bleeding

Cardiovascular • Unstable
System • Unresponsive to vasoactive agents
• May progress to coma

• Impaired function
Brain
• LOC
• Confusion
SHOCK 1 Impaired Tissue Perfusion

2 ↓ CO

3 ORGAN Dysfunction

Lungs Liver 10 Endocrine System

4 7 • ↑ bilirubin, liver
• respiratory failure • Hypothalamus
function test
• Shock liver • Pituitary gland
• Adrenal glands
Heart
5 Kidneys • Catecholamines
• ↓ BP, RR 8
• Tachycardia • Anuria • RAAS
• ↑ creatinine • Chemoreceptors &
Baroreceptors
6 Brain
• ↓ LOC 9 GI
• Confusion • hypermetabolic rate 11 Skin
• Hyperglycemia • Cold, clammy, pale
• Bleeding
1. Described Multi-System Problems (MSP)

2. Correlated the clinical pathway of shock,

sepsis, SIRS, and MODS on the major
body systems

3. Related the pathophysiology to the clinical

manifestations of the different types of
shock

4. Schematized the identified alterations

leading to MSP