PREVENTION OF SEPSIS AND MULTIPLE ORGAN FAILURE IN CRITICALLY ILL PATIENTS

Today, sepsis, ARDS and the multiple organ failure syndrome (MOF) are the leading causes of death in intensive care units. The most importan t precipitating factors for the development of MOF include sepsis, cir culatory shock, and severe tissue injury. Circulatory and respiratory failure (ARDS) are usually the first signs of organ dysfunction, frequ ently followed by hepatic, gastrointestinal, renal, neurological, haem atological and coagulation failure (DIC). Finally death occurs after 1 -6 weeks in many cases. Since the morbidity and mortality of establish ed MOF is still high (mortality 50-90%), early identification of risk patients is essential to allow timely therapeutic intervention. Based on the currently available clinical and experimental data the followin g procedures are recommended: (1) Use intensive monitoring including g astric pH and pulmonary artery catheters. (2) Optimise oxygen transpor t by maintaining high cardiac index (> 4.5 ml kg(-1) min(-1)), using i ntravenous colloids, administration of dopexamine and if necessary oth er inotropic drugs. (3) Indications for assisted/controlled ventilatio n should be liberal during the initial phase of the illness/trauma and the haemoglobin value should not be allowed to drop too low (10 - 12 g dL(-1)) in order to guarantee high blood oxygen content. (4) Start e nteral nutrition with special immune-nutrition formula without delay, but avoid over feeding (optimal ca 30 Kcal kg(-1) day(-1)). (5) Place the patients in semi-sitting rather than in supine position to prevent aspiration of gastric contents, to improve respiration and to facilit ate bowel movement. (6) Provide effective pain relief preferably by co ntinuous epidural analgesia when applicable (in acute pancreatitis, af ter surgery and trauma etc.) rather than giving high doses of opioids that prolong paralytic ileus and may delay weaning from mechanical ven tilation. (7) Show restraint in the use of broad spectrum antibiotics unless there are clear indications to use them. (8) Install continuous haemofiltration/dialysis at an early stage of renal failure for dialy sis, optimal fluid therapy, and to allow unrestricted amount of nutrit ion. (9) In selected patients, therapy which may improve the microcirc ulation after shock and reperfusion can be attempted. (10) In patients with trauma, early surgical intervention for control of haemorrhage, decompression, efficient debridement of wounds and early stabilization of all major fractures are also important preventive measures. Finall y, the clinical course of the patient should be followed very closely; respiratory and haemodynamic therapy may have to be adjusted to the p atients response quite frequently; infections focus has to be sought a nd antibiotic and/or surgical treatment instituted when necessary. Wit h this and similar treatment protocols the outcome of critically ill p atients has improved markedly in recent years. Substantial progress ha s also been made in understanding the nature and development of the pr imary triggering illnesses and remote organ failure. With improved awa reness of early diagnosis and therapeutic intervention, new diagnostic and monitoring techniques as well as with the help of modern molecula r and cellular biology, further improvement in outcome of critically i ll patients is to be expected in the near future.