EMILIO AGUINALDO COLLEGE

Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4339/41 www.eac.edu.ph

SCHOOL OF NURSING

Definition
● In a 1975 editorial by Baue, the concept of “multiple, progressive or sequential systems failure”
was formulated as the basis of a new clinical syndrome. Several different terms were proposed
thereafter (eg, multiple organ failure, multiple system organ failure, and multiple organ system
failure) to describe this evolving clinical syndrome of otherwise unexplained progressive
physiologic failure of several interdependent organ systems. Eventually, the term MODS was
proposed as a more appropriate description.
● Multiple organ dysfunction syndrome (MODS) refers to the critical illness characterized by by the
development of progressive and potentially reversible physiologic dysfunction in 2 or more organs
or organ systems leading to longer stays in the intensive care unit (ICU) and, in severe conditions,
results in higher mortality (27%–100%).
● Multiple organ dysfunction syndrome (MODS) is altered organ function in acutely ill patients that
requires medical intervention to support continued organ function.
● Dysfunction of one organ system is associated with 20% mortality, and if more than four organs
fail, the mortality is at least 60%

Assessment/Characteristic description
Although MODS cannot be predicted, clinical severity evaluation techniques can be utilized to
foretell a patient's risk for organ failure and mortality. These clinical evaluation instruments consist of:
● APACHE (Acute Physiology and Chronic Health Evaluation)
● SAPS (Simplified Acute Physiology Score)
● PIRO (Predisposing factors, the Infection, the host Response, and Organ
● dysfunction)
● SOFA (Sequential Organ Failure Assessment) score

1. APACHE (Acute Physiology and Chronic Health Evaluation) - used for initial evaluation
● APACHE II score is a general measure of disease severity based on current physiologic
measurements, age & previous health conditions. The score can help in the assessment of
patients to determine the level & degree of diagnostic & therapeutic intervention.

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 EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4339/41 www.eac.edu.ph

SCHOOL OF NURSING

2. PIRO (Predisposing factors, the Infection, the host Response, and Organ dysfunction)

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 EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4339/41 www.eac.edu.ph

SCHOOL OF NURSING

3. SOFA (Sequential Organ Failure Assessment) score

Respiratory (Lungs):
- Difficulty breathing/Shortness of breath (dyspnea)
- Requiring intubation and mechanical ventilation
Cardiovascular (Heart):
- Low blood pressure
- Edema
- Tiredness
Renal (Kidneys):
- Decreased urine output
- Confusion
- Darkened urine
- Itchy skin
Hepatic (Liver):
- Jaundice
- Diarrhea
- Nausea
- Vomiting blood
Hematologic (Blood):
- Internal or External Bleeding
- Clotting
Neurologic (Brain)
- Lost of consciousness or Confusion

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 EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4339/41 www.eac.edu.ph

SCHOOL OF NURSING

Diagnostics
Diagnosis of MODS involves laboratory tests to identify sepsis in order to assess the general hematologic
and metabolic condition of the patient.

● A CBC with differential is necessary to evaluate oxygen delivery in shock, and with persistent
sepsis, the platelet count will fall. The White Blood Cell count and differential can predict the
existence of a bacterial infection.
● A complete metabolic panel (CMP) will assess serum electrolytes, as well as renal and hepatic
function.
● Serum lactate assesses tissue hypoperfusion – elevated levels indicate that significant tissue
hypoperfusion exists, signaling a worse degree of shock and higher mortality.
● PT and aPTT will assess coagulation status and evidence of coagulopathy would require
additional tests to detect disseminated intravascular coagulation (DIC).
● Blood cultures can be used to diagnose intravascular infections and infections of indwelling
intravascular devices.
● A urinalysis and urine culture should be done since urinary infection is a common source of
sepsis, especially in the elderly.
● Secretions or tissue of Gram stain and culture should be obtained from sites of potential infection.

Various imaging methods are also used to diagnose focal infections and evaluate complications of sepsis
and septic shock.

● A chest x-ray can diagnose pneumonia infiltrates. X-ray can also help identify a deep soft tissue
infection.
● Ultrasound is used when a biliary tract infection is suspected as the source of sepsis.
● Computed tomography (CT) is utilized when assessing for an intra-abdominal abscess or a
retroperitoneal source of infection.

Etiology
Multiple organ dysfunction syndrome (MODS) can be caused by any serious illness, injury, or
infection. Although the precise causes of MODS are not fully understood, healthcare professionals
believe that wide inflammation and reduced blood flow when combined, were responsible for organ
damage.
MODS is caused by an overwhelming, uncontrolled systemic inflammatory response that is
activated by a number of hostile stimuli including:
- Sepsis - infection in the blood that may lead to widespread inflammation; could ultimately
progress to MODS.
- Hypoperfusion - described as “reduced amount of blood flow”
- Hypovolemic shock - severe blood or fluid loss that causes heart to unable to pump enough blood
to the body
- Severe trauma like vehicular accident (physical trauma), resulting in massive tissue injury.

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 EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4339/41 www.eac.edu.ph

SCHOOL OF NURSING

Pathophysiology

Pharmacotherapy
● The agents used are norepinephrine, epinephrine, vasopressin, and dopamine.. These drugs
maintain adequate blood pressure during life-threatening hypotension and preserve perfusion
pressure for optimizing flow in various organs.

Drug Classification Mechanism of Indication Contraindication Adverse Effects Nursing

Action Responsibilities

Vasopressin Antidiuretic increases water indicated to ● Hypersensiti ● Nausea ● use caution

Hormone permeability of increase vity ● hypersensiti with HF and
the kidney blood ● vascular vity reaction CV disease
collecting duct pressure in disease ● contraindicate
and distal adults in especially d in renal
convoluted coronary failure and
vasodilatory
tubule leading artery disease hypersensitivit
to water shock y to pork
retention, also refractory to ● monitor BP,
increases the HR, and EKG
peripheral application during therapy
vascular of fluids and ● monitor urine
resistance catecholami specific
leading to nes. gravity and
increased BP osmolality
● weigh patient
and assess for
edema
● monitor

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 EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4339/41 www.eac.edu.ph

SCHOOL OF NURSING

electrolyte
panel

norepinephrin vasopressor increase blood treatment of ● should be ● chest pain or ● monitor BP

e pressure and severe avoided in discomfort. continuously if
cardiac output hypotension patients with ● headache. possible or
by stimulating and shock mesenteric or ● lightheadednes every couple of
alpha-adrenergi peripheral s, dizziness, or minutes
c receptors in vascular fainting. ● may result in
the blood thrombosis as ● nervousness. rebound
vessels, the ● slow, fast, or hypotension
demonstrates subsequent irregular due to tissue
minor beta vasoconstrict heartbeat. ischemia when
activity ion will discontinue
increase the ● monitor EKG
area of and CVP
ischemia and ● if patient is
infarction. awake instruct
them to report
headaches,
dizziness, or
chest pain

epinephrine Antiasthmatic, Affecting both Asthma and ● hypersensitiv ● tachycardia ● Assess lung
bronchodilator, beta1 and beta2 COPD ity to ● headache sounds, pulse,
vasopressor also has alpha exacerbations, sympathomi ● palpitation BP, and other
agonist allergic metic drugs, ● nausea, hemodynamic
properties reactions, closed-angle vomiting, parameters
resulting in cardiac arrest, glaucoma, ● weakness, ● Monitor for
bronchodilation anesthesia anesthesia and tremors. chest pain
and increases in adjunct with ● Instruct
HR and BP. halothane patient to use
Inhibits as directed
hypersensitivity ● Patient should
reactions. insure
adequate fluid
intake to
liquefy
secretions

Dopamine inotropic, immediate used to ● should not be ● Shortness of ● Monitor

catecholamine improve blood used in breath. hemodynamic
vasopressor precursor of pressure, patients with ● Numbness. s closely: BP,
noradrenaline cardiac pheochromoc ● Feeling HR, EKG,
that directly output, and ytoma, in cold. CVP, and
stimulates urine output patients with ● Fast, slow, PAOP if
alpha, beta and uncorrected or pounding available
peripheral tachyarrhyth heartbeat. ● Obtain
dopaminergic mias or ● Chest pain. parameters for
receptors in a ventricular ● Lightheaded hemodynamic
dose-dependent fibrillation. ness values

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 EMILIO AGUINALDO COLLEGE
Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4339/41 www.eac.edu.ph

SCHOOL OF NURSING

manner, as well ● Irritation may

as acting occur at IV
indirectly by site
releasing
endogenous
noradrenaline
from storage
sites in
sympathetic
nerve endings.

Care of Management
a. Medical
● Prevention remains the top priority in managing MODS. Older adult patients are at increased risk
for MODS because of the lack of physiologic reserve and the natural degenerative process,
especially immune compromise (Kress & Hall, 2018). Early detection and documentation of initial
signs of infection are essential in managing MODS in older adult patients. Subtle changes in
mentation and a gradual rise in temperature are early warning signs. Other patients at greater
risk for MODS are those with chronic illness, malnutrition, immunosuppression, or surgical or
traumatic wounds.
● If preventive measures fail, treatment measures to reverse MODS are aimed at (1) controlling the
initiating event, (2) promoting adequate organ perfusion, (3) providing nutritional support, and (4)
maximizing patient comfort.

b. Nursing
● The general plan of nursing care for patients with MODS is the same as that for patients with
shock. Primary nursing interventions are aimed at supporting the patient and monitoring organ
perfusion until primary organ insults are halted. Providing information and support to family
members is a critical role of the nurse. The health care team must address end-of-life decisions
to ensure that supportive therapies are congruent with the patient’s wishes.
1. Support of the respiratory system with supplemental oxygen and/or mechanical ventilation
to provide optimal oxygenation
2. Fluid replacement to restore intravascular volume
● also known as fluid resuscitation.
● fluids are given to improve cardiac and tissue oxygenation, which in part depends on flow. The
fluids given may include crystalloids (electrolyte solutions that move freely between
intravascular compartment and interstitial spaces), colloids (large-molecule IV solutions), and
blood components (packed red blood cells, fresh-frozen plasma, and platelets).
● Crystalloid and Colloid Solutions
○ Isotonic crystalloid solutions are often selected because they contain the same
concentration of electrolytes as the extracellular fluid and, therefore, can be given
without altering the concentrations of electrolytes in the plasma. IV crystalloids
commonly used for resuscitation in hypovolemic shock include 0.9% sodium chloride
solution (normal saline) and lactated Ringer’s solution. Lactated Ringer’s solution more

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Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4339/41 www.eac.edu.ph

SCHOOL OF NURSING

closely resembles plasma and is considered a more appropriate first choice solution
over 0.9% normal saline.
○ While normal saline is an isotonic solution, large infusions may cause hypernatremia,
hypokalemia, and hyperchloremic metabolic acidosis.
○ A disadvantage of using isotonic crystalloid solutions is that some of the volume given is
lost to the interstitial compartment and some remains in the intravascular compartment.
This occurs as a consequence of cellular permeability that occurs during shock.
Diffusion of crystalloids into the interstitial space means that more fluid may need to be
given than the amount lost to support tissue perfusion.
○ Care must be taken when rapidly administering isotonic crystalloids to avoid both
underresuscitating and overresuscitating the patient in shock. Insufficient fluid
replacement is associated with a higher incidence of morbidity and mortality from lack of
tissue perfusion, whereas excessive fluid administration can cause systemic and
pulmonary edema that progresses to ALI, intra-abdominal hypertension (IAH) and
abdominal compartment syndrome (ACS), and MODS.
○ IV colloidal solutions are similar to plasma proteins, in that they contain molecules that
are too large to pass through capillary membranes. Colloids expand intravascular
volume by exerting oncotic pressure, thereby pulling fluid into the intravascular space,
increasing intravascular volume.
○ In addition, colloids have a longer duration of action than crystalloids, because the
molecules remain within the intravascular compartment longer. Typically, if colloids are
used to treat tissue hypoperfusion, albumin is the agent prescribed.
○ With all colloidal solutions, side effects include the rare occurrence of anaphylactic
reactions. Nurses must monitor patients closely.
○ When administering large volumes of crystalloid solutions, the nurse must monitor the
lungs for adventitious sounds, signs and symptoms of interstitial edema, work of
breathing (i.e., increasing effort required for the patient to breathe, depth of breathing,
respiratory rate), and changes in oxygen saturation.

3. Vasoactive medications to restore vasomotor tone and improve cardiac function

● Vasoactive medications are given in all forms of shock to improve the patient’s hemodynamic
stability when fluid therapy alone cannot maintain adequate MAP.
● These medications help increase the strength of myocardial contractility, regulate the heart rate,
reduce myocardial resistance, and initiate vasoconstriction.
● Vasoactive medications are selected for their action on receptors of the sympathetic nervous
system. These receptors are known as alpha-adrenergic and beta-adrenergic receptors.
Beta-adrenergic receptors are further classified as beta-1 and beta-2 adrenergic receptors.
● When alpha-adrenergic receptors are stimulated, blood vessels constrict in the cardiorespiratory
and GI systems, skin, and kidneys. When beta-1 adrenergic receptors are stimulated, heart rate
and myocardial contraction increase. When beta-2 adrenergic receptors are stimulated,
vasodilation occurs in the heart and skeletal muscles, and the bronchioles relax.
● The medications used in treating shock consist of various combinations of vasoactive
medications to maximize tissue perfusion by stimulating or blocking the alpha- and
beta-adrenergic receptors.

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Gov. D. Mangubat Ave., Brgy. Burol Main, City of Dasmariñas, Cavite 4114, Philippines
Tel. Nos. (046) 416-4339/41 www.eac.edu.ph

SCHOOL OF NURSING

● Vasoactive medications should never be stopped abruptly, because this could cause
severe hemodynamic instability, perpetuating the shock state.
○ When vasoactive medications are given, vital signs must be monitored frequently (at least
every 15 minutes until stable, or more often if indicated).
○ Vasoactive medications should be given through a central venous line, because
infiltration and extravasation of some vasoactive medications can cause tissue necrosis
and sloughing
○ Individual medication dosages are usually titrated by the nurse, who adjusts drip rates on
the basis of the prescribed dose and target outcome parameter (e.g., BP, heart rate) and
the patient’s response. Dosages are changed to maintain the MAP at a physiologic level
that ensures adequate tissue perfusion (usually greater than 65 mm Hg).

4. Nutritional support to address the metabolic requirements that are often dramatically
increased in shock
● Nutritional support is an important aspect of care for critically ill patients. Increased metabolic
rates during shock increase energy requirements and therefore caloric requirements. Patients in
shock may require more than 3000 calories daily. The release of catecholamines early in the
shock continuum causes rapid depletion of glycogen stores. Nutritional energy requirements are
then met by breaking down lean body mass. In this catabolic process, skeletal muscle mass is
broken down even when the patient has large stores of fat or adipose tissue. Loss of skeletal
muscle greatly prolongs the patient’s recovery time.
● Parenteral or enteral nutritional support should be initiated as soon as possible. Enteral nutrition
is preferred, promoting GI function through direct exposure to nutrients and limiting infectious
complications associated with parenteral feeding.
● Implementing early enteral nutrition has been found to promote gut-mediated immunity, reduce
metabolic response to stress, and improve overall patient morbidity and mortality.

5. Monitor Urine Output

6. Promoting Communication
○ Nurses should encourage frequent and open communication about treatment modalities
and options to ensure that the patient’s wishes regarding medical management are met.
Patients who survive MODS must be informed about the goals of rehabilitation and
expectations for progress toward these goals, because massive loss of skeletal muscle
mass makes rehabilitation a long, slow process. A strong nurse–patient relationship built
on effective communication provides needed encouragement during this phase of
recovery.

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