Multiple organ failure in the elderly
Introduction
Introduction to multiple organ failure in the elderly Multiple OrganFailure (MOF) refers to the simultaneous or sequential occurrence of two or more organ failures in a short period of time under severe stress, infection, poisoning, and major stress. Multi-organic failure (MOFE) is based on the decline of multiple organ function in the elderly. It is guided by chronic diseases of multiple organs in the elderly. Under certain incentives, multiple organ functions are induced by single organ dysfunction. Depletion. basic knowledge The proportion of illness: 0.006% Susceptible people: the elderly Mode of infection: non-infectious Complications: shock, coma
Cause
Causes of multiple organ failure in the elderly
(1) Causes of the disease
The organ function of the elderly declines with age. On this basis, chronic diseases of multiple organs cause the organ function to further decline and are in a critical state of failure. At this time, some stresses that are not serious can affect the function of an organ. And lead to a chain reaction, similar to the domino phenomenon, multiple organ failure, some scholars have analyzed 122 cases of MOFE, the average suffering from more than 3 kinds of chronic diseases, up to 9 kinds, chronic heart and lung disease more common, MOFE incentives, lung infections top , accounting for 72.73%, sepsis accounted for 7.28%, surgery or trauma only accounted for 1.82%, and others reported that cerebrovascular accident, gastrointestinal bleeding, heavy drinking, nephrotoxic antibiotic application can become the cause of MOFE, this point with young and middle-aged Human induced MOF is very different due to trauma, major surgery, burns and sepsis.
(two) pathogenesis
D-galactose was used to establish a senile Wistar rat model. More than 10 aging biochemical indicators, hereditary indexes and functional indicators were consistent with the aging animals. Classical anti-aging drugs can block the aging effect of D-galactose. The reliability of the aging model was confirmed. On the basis of this, the animal models of MOFE and MOF were established by low perfusion method and endotoxin method. The results showed that the pathophysiological characteristics of MOFE were as follows.
1. Significant organ pathological change integral
MOFE was significantly higher than MOF, low perfusion for 4h, the total score was 14 times in MOF group, and the score of cardio-renal lesion was 22 times in MOF group. The score of pathological changes in each organ was 2-6 times of MOF group, respectively. Lung injury is particularly serious, the most severe organs are damaged, MOFE group is lung, MOF group is kidney; organ damage severity order, MOFE group is lung, liver, heart, kidney, gastrointestinal; MOF group is kidney, liver, heart , lung, gastrointestinal.
2. Survival time
The MOFE group was longer than the MOF group. The 4h survival rate was 66.7% in the MOFE group and 42.1% in the MOF group. The 8h survival rate was 44.4% in the MOFE group and 25.0% in the MOF group.
3.24h sudden death measurement
The MOFE group is lower than the MOF group.
The important device functional load and liver mitochondrial oxidation-reduction potential MOFE group were higher than MOF group. Table 2 suggested that the energy metabolism of important organs in MOFE group was lighter.
5. Increase in total plasma amino acid (TAA)
The MOFE group was lower than the MOF group. The experiment confirmed that the increase of TAA was positively correlated with the low perfusion time. At the same time, the increase of plasma branched-chain amino acids and aromatic amino acids in the MOFE group was lower than that in the MOF group, suggesting that the amino acid metabolism of the MOFE group was mild.
6. Changes in blood ammonia/arginine ratio
This value can reflect liver ammonia metabolism, low perfusion for 2h, MOF group increased by 3.1 times, MOFE group increased by 0.88 times; low perfusion for 8h, MOF group increased by about 30 times, MOFE group only increased by 20 times (Table 3 ), suggesting that the ammonia metabolism disorder of the liver is lower in the MOFE group than in the MOF group.
7. Blood ketone body ratio (acetoacetic acid / -hydroxybutyric acid ratio)
After liver failure in rats, the blood ketone level increased, the ketone body ratio decreased (0.33±0.11), and the normal control group (0.72±0.26). This ratio was parallel to the hepatocyte mitochondrial free MAD/NADH ratio, representing hepatocyte mitochondrial oxidation. The reduction potential reflects the energy metabolism of hepatocytes, and this decrease indicates liver energy metabolism disorder during liver failure.
The above experimental results are consistent with the clinical findings. The autopsy confirmed that the pathological changes of various organs of MOFE were serious, but the clinical response was mild and the survival time was longer, but the final mortality rate was higher, suggesting that the response should not be flattened during the diagnosis and treatment. Confused and delayed diagnosis, losing the opportunity to rescue.
Prevention
Prevention of multiple organ failure in the elderly
1. Strengthen the training of medical staff and grassroots health care personnel in geriatrics, improve the awareness and vigilance of MOFE, and should have high risk factors for MOFE during physical examination and follow-up (such as single and multiple organ dysfunction, chronic bronchitis accompanied by Pulmonary infection, poor nutritional status, especially those with obvious weight loss in the near future, long-term unreasonable application of antibiotics, etc., screening, establishing follow-up files, closely tracking the functional status of various organs, actively treating their chronic diseases, preventing The function of each organ is further degraded.
2. Strengthen health education for high-risk groups, enhance self-care awareness, enable active prevention of chronic diseases in various systems, prevent recurrent episodes, master early clinical manifestations of organ failure, facilitate early detection, early treatment, and low immune function, accompanied by Patients with chronic lung disease should take some measures to improve their immune function.
3. Elderly people who are malnourished due to illness should actively give nutrition therapy. The goal of nutritional support therapy for critically ill patients is to provide enough calories and protein to ensure the energy necessary for normal metabolism of organs.
4. Because the elderly absorb, excrete, metabolize, distribute and play a significant role in young people, and the elderly often have multiple diseases at the same time. There are many kinds of drugs, which are prone to contradictions and adverse reactions, sometimes making the disease Sharpening down and strengthening the rational use of drugs for the elderly, especially those at risk, is an important measure to reduce the incidence of MOFE.
5. Pulmonary infection is the killer of the elderly. In particular, it should be prevented. The most important point is to strengthen the physical fitness, so that "the righteousness is in the air, the evil can't be done", but also the "virtual evil spirits, avoiding the timely" Always pay attention to changes in the external climate, especially the changes in cautious solar terms. For patients with very weak or critically ill conditions, the solar terms and the changes in the day and night are the problems of their lives. Therefore, before and after the solar terms, the elderly should pay more attention to them. Nurse, maintain emotional stability, avoid excessive fatigue, pay attention to moderate diet, smooth stools, etc. This kind of nursed back can often play a role in prevention and protection.
Complication
Complications of multiple organ failure in the elderly Complications, shock, coma
Common major complications include hemorrhage, shock, coma, electrolyte imbalance and so on.
Symptom
Symptoms of multiple organ failure in the elderly Common symptoms Respiratory failure, coma, dyspnea, anti-infective ability, hypercoagulable state, oliguria, thrombocytopenia, hematuria, no urinary intravascular coagulation
As the elderly age, the organ reserve function of each organ is continuously reduced, which is significantly different from that of the average adult.
The main clinical features of MOFE compared to MOF:
1 The condition is prolonged and repeated;
2 The sequence of organ failure is obviously related to the underlying disease, and it has certain predictability; the general order of occurrence is heart, lung, kidney and brain;
3 various infections, especially lung infections, are the primary cause of MOFE (about 2/3); followed by acute exacerbations of various chronic diseases;
4 chronic basic diseases, some as many as 10 kinds, heart, lung disease is the most common;
5 Increasing the mortality rate with the number of organ failure, the prognosis is worse in patients with renal failure;
6 more than 4 organ failures may still be successful;
7 clinically divided into 3 types, one more polyphase than MOF;
8 Due to the large number of underlying diseases, the previous medications are complicated and there are many contradictions in treatment.
1.MOFE classification
Type I (singly-phase, rapid pattern): under the inducement of infection (mainly lung infection) and acute exacerbation of heart, brain, kidney and other chronic diseases, first single organ failure (mainly respiratory failure) Or heart failure), followed by 2 or more organs in a short period of time, and 49.4% of them recovered or died in a short period of time.
Type II (two-phase, delayed pattern): Based on the single-phase type, it recovers in a short period of time. There is a short interval. In this period, the condition is relatively stable, and 2 cases will occur again in a short time. Or more than 2 organ failure, after treatment recovery or death, accounting for about 32.4%.
Type III (multi-phase, recurrent pattern): MOF is repeated multiple times on the basis of biphasic type, and later recovered or died, accounting for 18.2%. Type III is a unique clinical type of MOFE. Type III is mainly related to the following factors:
Most patients with type 1III have more organs in the first two cases of multiple organ failure or only involve the heart and lung organs, which is easier to treat.
2 does not involve the kidney, blood and other poor prognosis system, although the prognosis is related to the number of organs invaded, but if the invasion of the kidney, even if the invasion of organs is not much, its prognosis is poor, the blood system appears later in multiple organ failure, Once it happens, other organs are already exhausted, so it is not easy to treat.
3 patients are relatively young.
4 The accumulation of treatment experience and the improvement of treatment conditions are expected. With the improvement of comprehensive first aid technology and the accumulation of MOFE treatment experience, the proportion of type III patients may increase.
2. MOFE staging MOFE clinical general is divided into 3 phases:
(1) Phase 1 (pre-failure period): Organs and functions have changed based on aging and chronic diseases, and the corresponding indicators are between normal and abnormal.
(2) Phase 2 (depletion compensation period): The relevant organs have been unable to maintain normal function, but they still have compensatory ability and respond well to treatment.
(3) Phase 3 (depletion decompensation period): The relevant organs are obviously depleted, have poor response to treatment measures, and are easy to enter the irreversible stage.
The clinical treatment practice confirms that clearing the clinical stage of MOFE is conducive to mastering the progress of the disease and timely prevention and treatment. This is the key to improving the effectiveness of treatment. For example, in the early stage of failure, on the one hand, the relevant indicators should be closely observed to grasp the progress of the disease; on the other hand, it should be active. Treat all relevant organ-based diseases, and predictively protect the functions of various organs and systems to prevent entry into the decompensation period; if they have entered the decompensation period, they should not lose the opportunity to perform organ function support therapy to prevent entry into decompensation .
The aging of the organs of the elderly, low function, combined with a variety of chronic diseases, and organ function is very poor or in a critical state of failure, easy to be confused with the early symptoms of MOFE, thus improving the pathogenesis of MOFE, clinical passage, disease The incentives, pathophysiology, clinical manifestations, various examination parameters and diagnostic criteria are the key to diagnosis, but the diagnostic criteria of MOF are not uniform, the theoretical characteristics are the same, and the selection of indicators depends on the conditions. The following criteria were proposed in conjunction with clinical practice.
Examine
Examination of multiple organ failure in the elderly
Plasma C5a level
The immune function of the elderly is low, and the proportion of lung infection in MOFE is a large proportion. This is mainly because immunity plays an important role in the pathogenesis of MOFE. Complement components and their degradation products C5a, C3a, etc. are related to organ failure. The release of mediators from mast cells causes pathological changes such as increased vascular permeability. It is reported that the upper limit of C5a activity in healthy elderly people (60 years old) is 13.92 U/ml, and the activity of C5a in MOFE patients is significantly increased, which is 28±0.7 U/ml. Dynamic observation also showed that the C5a activity in the blood of MOFE patients changed with the condition. C5a increased when the condition was severe, and C5a decreased when the condition was relieved. It was also proved in laboratory studies that in low perfusion, the infection caused MOFE animal model, C5a also As the development of MOFE increases significantly, C5a in plasma can be used as an auxiliary diagnostic indicator for MOFE.
2. Changes in the cytokine network
Cytokine networks include all interleukins (ILs), hematopoietic cell cloning stimulators, interferons, tumor necrosis factor (TNF), etc. These cytokines can be expressed by different cells and have complex interactions, among which interleukins -1 (IL-1), interleukin-6 (IL-6), a key component of the network, which has a close interaction between each other, participates in immune regulation, initiates the host's non-specific immune defense system, and Mediated inflammatory response, plasma levels of IL-1, IL-6, and TNF in patients with MOFE were significantly increased. Plasma levels of IL-1, IL-6, and TNF were significantly higher in patients with MOFE, and were significantly higher than survival. In the group of patients, dynamic observation found that the patient's condition was worse or worse, and the levels of plasma IL-1, IL-6, and TNF changed accordingly. When the condition worsened, the above three cytokine levels gradually increased and remained high. Level, in which TNF rises fastest, IL-6 rises slowly, and the condition continues to deteriorate until dying. IL-1, TNF suddenly drops to a very low level, while IL-6 remains at a high level, with The condition gradually improved, and the three factors gradually returned. , Suggesting that blood IL-1, IL-6, TNF monitor changes in the level of MOFE progression of the disease, the prognosis are meaningful.
3. Blood molecular weight substances
Molecular weight of blood (MMS) may be a toxic source of uremia. The renal function of the elderly is reduced. The MMS level in the blood is significantly higher than that of the young and middle-aged. The MMS level of healthy elderly (60 years old) is 4485.8 U/L. Renal failure is 11215.5 U / L, and renal failure can be as high as 20638.6 U / L. Clinical results show that MMS content of more than 20,000 U / L, the prognosis is very poor, no renal failure, MMS is still significantly increased, The MMS function of renal clearance in MOFE patients has been significantly inhibited. The content of MMS in blood can be used as an auxiliary diagnostic index of MOFE, and it has certain reference significance for prognosis.
4. Other
The liver is the only organ that produces acetoacetate and beta-hydroxybutyrate. It detects acetoacetate and beta-hydroxybutyrate in arterial blood, and the ratio of ketone bodies (acetoacetate/-hydroxybutyrate) as an indicator of liver function. State, the experiment shows that the proportion of ketone body is closely related to liver failure. The proportion of ketone body in blood of MOFE patients with liver failure also has obvious changes. In addition, the content of plasma fibronectin (Fn) in patients with MOFE decreases, and pathological changes and classification Have a certain relationship.
In patients with pulmonary infection, X-rays can show abnormalities.
Diagnosis
Diagnosis and diagnosis of multiple organ failure in the elderly
Diagnostic criteria
Basic condition
Anyone with 60 years of age who has chronic diseases of more than 2 organs and/or more than 2 types of organ dysfunction, and who have the following 2 or more organ failures.
2. Lung
Hypoxemia occurs after infection, trauma or surgery, and adult respiratory distress syndrome (ARDS) characterized by dyspnea is further developed. Respiratory rate is >28 beats/min, PaO2 progressively decreases, and patient occurs when PaO2<8.00 kPa Hypercapnia; patients with PaCO2>6.67kPa need oxygen (FiO2>50%), A-aDO2>46.6kPa, according to the specific conditions of the elderly, there is respiratory distress, and the use of a ventilator, the diagnosis can be established.
3. Heart
The heart of the elderly has degenerative changes, myocardial fiber compliance declines, stress is reduced, myocardial systolic and diastolic function and blood output are significantly reduced, cardiac index (CI) is reduced, the older the CI, the lower the CI, the assessment of cardiac function, we It is recommended to use the New York Heart Association (NYHA) Level 4 classification method. Older people often suffer from chronic pulmonary heart disease, chronic heart failure, infection, trauma and cardiogenic shock, etc., which can trigger heart failure, if present. Chronic hypoxia, metabolic acidosis, shock and CI below 2.1L/m2 can confirm the diagnosis.
4. Kidney
In the low blood flow perfusion, the earliest affected organs are the kidneys. Because the elderly are most likely to have renal arteriosclerosis and tubular atrophy, when the renal blood flow is reduced to a certain extent, the micro-enzymes in the kidney microcirculation Formation, renal tubular epithelial necrosis, renal failure, clinical manifestations of oliguria or anuria, urea nitrogen (BUN)> 35.7mmol / L (100mg / dl), creatinine (Cr) 176mol / L (2mg / dl).
5. Liver
Liver damage caused by metabolic disorders and toxic substance spillage is an important factor in promoting the failure of other organs. Its clinical features are jaundice, serum bilirubin >51.3mol/L (3mg/dl), ALT, AST and LDH>normal values. 2 times, low protein and prothrombin caused by non-liver disease.
6. gastrointestinal tract
Gastrointestinal ischemia, gastrin and adrenal glucocorticoid secretion increased, intestinal mucosal permeability increased, barrier function decreased and toxin absorption caused by gastrointestinal mucosal necrosis, therefore, as long as it is determined to be stress ulcer bleeding or endoscopic Mirror examination, surgery confirmed gastrointestinal mucosal bleeding, erosion or ulcer can diagnose the disease.
7. Central nervous system
Brain Failure Determination The Glasgow-Pittburgh Coma Score (GCs) method is recommended here. The score is divided into 7 major items, 35 grades, GCS35 is divided into normal, 27-16 is divided into early failure, and 15 to 8 is divided into brain failure. However, the cause of cerebrovascular disease and the influence of drugs should be excluded, and those with conditions can be combined with electrophysiological and imaging examinations for comprehensive judgment.
8. Blood system
In the early stage of MOFE, in addition to the left shift of naive cells and leukocyte nuclei, platelets increased significantly due to hypercoagulable state of the blood. In the late stage of MOFE, diffuse intravascular coagulation (DIC) consumed a large number of platelets, coagulation factors and secondary Fibrinolysis, manifested as thrombocytopenia, clotting mechanism disorders, platelets <20 × 109 / L (20,000 / mm3), fibrinogen <2.0g / L (0.2g / dl), prothrombin time > 15min.
9. Pancreas
In the past, people rarely included pancreas in MOF. It may be due to the general situation of MOF disease, which obscures its main performance. It should pay attention to the monitoring of blood urease amylase and blood sugar, but pay attention to the liver and kidney function damage, due to liver Hypoglycemia occurs as a result of decreased insulin inactivation and decreased renal clearance of insulin.
Differential diagnosis
Since MOFE is the common destination of many different kinds of diseases, and many diseases can also appear in the development process without multi-organ damage in the definition of MOFE, the correct understanding of the MOFE concept is very important in differential diagnosis, although MOFE can It is simply defined as "two or more organs or systemic dysfunctions or failures that occur simultaneously or sequentially", but in practice, this definition has the following drawbacks:
1 can not distinguish between MOFE and other types of organ failure, because only in the case of organ failure, many pathological conditions can occur, as early as before MOFE and MOF, there are already such as "hepatic and renal syndrome", "hepatic encephalopathy" "Pulmonary encephalopathy", "cardiac pulmonary edema" and other diseases involving multiple organ failures. In addition, if multiple traumatic violence directly affects multiple organs, the patient is dying before or after long-term chronic disease organ function loss. At the time of repayment, multiple organ failures can occur, but none of them belong to the category of MOFE.
2 Over-emphasis on the end point of organ failure does not reflect the development of MOFE, because if organ failure is emphasized as a diagnostic criterion, then when the diagnosis is established, the patient has almost no hope of survival, and this late diagnosis is difficult to guide early clinical prevention. Not conducive to the study of pathogenesis.
3 can not fully reflect the clinical features of MOFE, because organ dysfunction is only one of the clinical features of MOFE, in addition, in the pathogenesis of MOFE also showed uncontrolled systemic inflammation, immune dysfunction, high dynamic circulation and persistence Characteristics of systemic inflammatory response syndrome or compensatory anti-inflammatory syndrome such as high metabolism. According to the latest understanding in the 1990s, MOFE is a common complication of SIRS, and its pathogenesis is still not very clear, but it is likely Susceptible to traumatic, shock, infection and inflammation, leading to acute multi-system or organ dysfunction caused by uncontrolled systemic inflammation. MOFE dysfunction means that an organ cannot maintain its own function, thereby affecting the systemic environment. Stable.
MOFE can be divided into primary and secondary:
1 Primary MOFE is the result of a direct action of a certain physiological damage. Organ dysfunction is caused by the damage itself, so it occurs early. For example, the immediate consequences of trauma can cause lung contusion, while skeletal muscle is destroyed and a large number of muscles are produced. Red protein causes acute renal failure, multiple blood transfusions cause coagulopathy, and the result is primary MOFE. However, during the development of primary MOFE, the systemic inflammatory response is not as significant as secondary MOFE;
2 secondary MOFE is different, it is not directly caused by the original damage itself, but the result of abnormal body reaction, the original damage causes SIRS, and excessive systemic inflammatory reaction can cause multiple organ dysfunction at a distance, so There is a pause between secondary MOFE and the original injury. Secondary MOFE is easy to be complicated. At this time, systemic inflammatory response and immune dysfunction are the basis. Systemic infection is the follow-up process of SIRS or CARS. Sexual MOFE is one of the most serious consequences of the continued development of this SIRS or Sepsis.
The differential diagnosis points of multiple organ dysfunction syndrome are:
1 Most of the organs function well before the onset of the disease;
2 has serious causes of trauma, infection and shock;
3 has a manifestation of systemic inflammatory response syndrome;
4 From the initial attack to the occurrence of distant organ dysfunction often with a few days or weeks interval, the organ of failure is often not the organ directly damaged by the primary factor;
5 course of disease, unless the development of the end stage, organ dysfunction and pathological changes can be reversed, and once cured, clinically will not relapse or transfer to a chronic course, some of the chronic diseases that are common in internal medicine, end-stage multiple organ failure, Senile multiple organ failure and multiple organ failures that are not related in etiology are not within the scope of multiple organ dysfunction syndrome.
Deitch has done this description:
1 depleted organs usually do not directly come from the primary injury;
2 There is a large gap in time from primary injury to organ failure;
3 not all patients have bacteriological evidence;
More than 430% of patients had no lesions found in clinical and autopsy;
5 Identifying and treating infections may not improve the survival rate of patients. These manifestations reflect the characteristics of organ damage caused by uncontrolled systemic inflammatory response and can identify organ failure in some non-MOFE concepts.
