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Multiple Organ Dysfunction in the Pediatric Intensive Care Unit
Objectives
This chapter will:
- 1.
Describe the clinical manifestation of pediatric multiple organ dysfunction syndrome (MODS), including pathogenetic pathways and specific pediatric MODS causes.
- 2.
Detail theoretic mechanisms of organ damage and current literature available in this field.
- 3.
Present available therapeutic strategies for pediatric MODS management.
Multiple organ dysfunction syndrome (MODS), initially described as multiple systems organ failure in adult patients in 1960, represents a critical state characterized by several clinical aspects (bleeding, sepsis, respiratory, hepatic, cardiac, and renal failure) that, if not controlled, can lead to a patient's death. In 1992 it was classified finally as a distinct syndrome by the American College of Chest Physicians/Society of Critical Care Medicine consensus conference.
MODS is represented by a wide spectrum of organ dysfunction (two or more organ systems involved) with the inability to maintain the patient's metabolic need without any intervention. This syndrome currently is considered in adult and pediatric patients as the major cause of death in the intensive care unit. In 2005 the International Pediatric Sepsis Consensus Conference delineated organ-specific diagnostic criteria for this dysfunction when triggered by a septic state.
A dysregulated immune response, or immune paralysis, in which the homeostasis between the proinflammatory and antiinflammatory reaction is lost is thought to be key in the development of MODS. Lungs are usually the first organ involved in either adult or pediatric patients. Myocardial involvement follows closely, with neurologic involvement as the third most common system involved.
MODS has been classified as early or primary, which occurs in the first 7 days of illness, or late/secondary, which occurs after 7 days.
Epidemiology and Scoring Systems for Pediatric Multiple-Organ Dysfunction Syndrome
MODS is more common in adults than in children and it is associated primarily with sepsis and trauma. This probably is because the functional organ reserve of the adult patient is reduced compared with children. In pediatric patients with sepsis, however, the incidence of MODS may reach up to 30% to 73% of cases, whereas in patients admitted to the pediatric intensive care unit (PICU) with nonseptic diagnosis it shows a lower incidence ranging from 11% to 54%.
Wilkinson et al. showed that one fourth of children with MODS have chronic diseases in their pre-PICU clinical history. Most recently, a comorbid condition was noted among 64% of children admitted to the PICU. Compared with previously healthy children, those with chronic health issues show a twofold increased risk of unscheduled admission to the PICU.
The incidence of MODS, as defined by the International Pediatric Sepsis Consensus Conference also independently increased the risk of death by 60% when controlling for the number of dysfunctional organs.
Such a wide range of clinical presentations reflects a broad variation in epidemiology, access to the healthcare system, and the differences in the definitions of MODS. The incidence rate of MODS is significantly higher in neonates compared with older children (14.6% vs. 5.5%) probably because of differences in organ response to injury between neonates and children. Neurologic, cardiovascular, and hepatic dysfunctions are specific and independent predictors of death among neonates and deserve specific scoring systems.
Other important risk factors for the development of the pediatric MODS in PICU are hematopoietic stem cell transplantation, hypoxic-ischemic encephalopathy, hemophagocytic lymphohistiocytosis (HLH), and thrombocytopenia-associated multiple organ failure.
The two most widely used scoring system in pediatrics to describe and quantify the severity of MODS are the pediatric logistic organ dysfunction (PELOD) score and the pediatric multiple organ dysfunction score (P-MODS). Both of these two scoring systems have been extrapolated by scoring systems used in the adults. However, only the PELOD score, which includes cardiovascular, neurologic, liver function, coagulation, respiratory, and renal variables, has been validated clinically. In the neonatal period (first 28 days of life) the neonatal multiple organ dysfunction (NEOMOD) score is the only score that provides information on organ dysfunction in this selected population of patients.
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