Multiple systems failure and circulatory support.

Abstract

As our knowledge of and capabilities in surgery improve, the problems that we encounter change. We have learned to better support the circulation and the heart, the kidneys, the lungs and other organs in patients after trauma or after operation and failure of any one of these organs alone has been less of a problem. In the early 1970's, there was a simultaneous or sequential development of problems or failure of several organs. We called this syndrome multiple, progressive or sequential systems or organ failure (MOF). It is truly a syndrome related to surgical progress. By defining the problem and developing an understanding of it, we can better prevent its occurrence and increase the survival and well-being of those under our care. Common factors in patients who develop this syndrome include some or all of following: A) A multiple systems injury or extensive soft tissue injury and/or a major or extensive operation. These can lead to MOF, even in a previously normal patient. In patients with limited systems such as with prior vascular disease or emphysema, the problem is intensified. B) A period of shock accompanying the injury or operation and/or later circulatory instability with a marginal cardiac output. C) Requirement for multiple and perhaps continuous blood transfusions. D) Renal injury or an alteration in renal blood flow that may not be evident initially. E) Marginal ventilatory function with atelectasis, aspiration, fat embolism or other problems. F) Early problems such as continued or recurrent bleeding requiring reoperation, large hematomas, tissue necrosis, peritoneal contamination, pulmonary injury or head injury. G) Catabolism with all of its attendant problems. H) Failure of rapid return of gastrointestinal function and discontinuation of intravenous infusions to enable oral intake and spontaneous adequate ventilation for extubation. I) There are often clinical or technical errors or problems such as a leaking anastomosis or wound separation. J) Depressed host resistance leading to invasive sepsis or abscesses. As this occurs, ventilatory failure ensues or there is a worsening of previously abnormal ventilation, right heart failure secondary to increased pulmonary vascular resistance or myocardial depression with increased venous pressure, progressive evidence of hepatic failure with a rising bilirubin, renal failure and problems with an altered sensorium, coagulation and stress ulceration. The key factor in most reports on this problem has been infection. Attention to the problems of cell injury and a better definition of changes in host resistance, the relationship fsepsisto to pulmonary, renal and hepatic failure and other organ relationships should help to prevent this problem. The injured or surgically-treated patient who has experienced a severe metabolic insult may have multiple systems or organ failure. Careful evaluation, a well-planned operative procedure, and excellent supportive postoperative care with elimination of clinical or technical errors and prevention of sepsis should result in survival of most of these patients.