Forum on critical care issues in sepsis, adult respiratory distress syndrome, and multiorgan system failure

✍ Scribed by Plevak, D J

• Publisher: Wiley (John Wiley & Sons)
• Year: 1997
• Tongue: English
• Weight: 199 KB
• Volume: 3
• Category: Article
• ISSN: 1074-3022
• DOI: 10.1002/lt.500030110

✦ Synopsis

Edited by David J. Plevak M ultiorgan system failure monopolizes a good portion of my workday. Some time ago, I was counseling the spouse of a patient of mine regarding the usual intensive care unit issues of diagnosis, treatment, prognosis, and so on. As I proudly explained to him the number of specialists that I was employing to help care for his wife' s legion of ailments, this gentleman' s expressions acquired an inquisitive nature. Following my dissertation, he simply asked me, ''Doctor, what is your role in her management?''

After an uneasy pause and rapid self-reflection, I reassembled my composure and declared that my job was essentially to support all of her organs so that the specialists that I had just mentioned would have ample time and opportunity to drain her abscess, administer the correct combination of antibiotics, dialyze her, interpret her hepatic ultrasound scans, and evaluate the results of her liver biopsy. Later, I realized that while I was speaking, my hand gestures probably resembled that of a juggler who was attempting to keep four or five objects airborne simultaneously. Since this ''juggler revelation,'' I have learned to accept this view of my job with some degree of satisfaction. Intensivists are indeed the guardians of multiorgan system function. We take appropriate prophylactic measures (e.g., selective bowel decontamination, administration of histamine blockers, etc.) to protect organs from injury. We have devices and techniques (e.g., thromboelastograph, bronchoalveolar lavage, etc.) designed to identify organ dysfunction at an early and hopefully interventionally vulnerable stage. We now use organ support devices (e.g., inverse ratio pressure-controlled mechanical ventilation) that can sustain life beyond the time when there is any true hope of beyond hospital survival. When organ failure does occur, we quantify and obsessively compute the number and kinds of dysfunction so that we can prognosticate costs, resource requirements, and patient survival.

Multiorgan system failure results from systemically active inflammation. 1 Because the liver has a most important function in clearing inflammatory mediators, 2 those practitioners who care for patients with hepatic disease or those who have received transplant frequently have the opportunity to observe multiorgan failure in its many varied configurations and degrees of severity. We fret about tumor necrosis factor, endotoxin, platelet-activating factor, leukotrienes, thromboxane, and interleukin. These are substances that we scarcely understand, and yet we know that unimpeded access to the most intimate aspects of vital organs cannot be good for our patients. Methods concerning the direct removal of circulating mediators have been tried (e.g., customized antibodies, continuous arteriovenous hemofiltration dialysis) with variable success. However, the best remedy appears to be prevention, especially when the inciting event is sepsis.

Unfortunately, infectious organisms can find the patient with hepatic disease or liver transplantation a compliant host. Hepatic disease is associated with low complement levels, impaired neutrophil and reticuloendothelial function, and altered gut permeability. 3-4 Liver transplantation is followed by a regimen of immunosuppressive medication. To oppose this inclination toward infection, we have become particularly compulsive regarding bacterial colonization, viral serology, every temperature elevation, every new lung infiltrate, and the selection of the most appropriate antimicrobial therapy. These practices will hopefully avoid the preoccupation associated with the simultaneous motion of several individual competing concerns, as illustrated by my allusion to the image of a ''juggler.''