Primary Nursing Diagnosis

Risk for infection related to microorganism invasion, immunosuppression, malnutrition, and presence of invasive monitoring devices

OUTCOMES. Immune status; Knowledge: Infection control; Risk control; Risk detection; Nutrition status; Treatment behavior: Illness or injury; Hydration

INTERVENTIONS. Infection control; Infection protection; Surveillance; Fluid/electrolyte management; Medication management: Temperature regulation

^ PLANNING AND IMPLEMENTATION Collaborative

Management of the patient with MODS begins with the recognition of those patients who are at an increased risk for the syndrome. Care must be taken to prevent infection and maintain adequate tissue oxygenation to all body parts. Despite improvement in medical therapies, the mortality rate of MODS remains high.

Treatment of the patient with MODS can be divided into four main areas: anti-infectives, maintenance of tissue perfusion and oxygenation, nutritional support, and immunomodulation. Anti-infective therapy is guided by culture and sensitivity reports. Any potential source of infection should be investigated and eliminated. Antifungal and antiviral agents are used primarily with immunocompromised patients, who are especially susceptible to fungal and viral infections.

Maintaining and monitoring tissue perfusion and oxygenation are crucial to the survival of the patient with MODS. Measurement of oxygen delivery and consumption is necessary to guide fluid replacement therapy and inotropic support of cardiac function. To maximize all components of oxygen delivery (in particular, cardiac index, hemoglobin, and oxygen saturation), the physician maintains the hematocrit within the normal range or even at a supranormal level with blood transfusions. Mechanical ventilation with positive end-expiratory pressure and modes such as pressure control ventilation and inverse ratio inspiration expiration are used to maintain adequate oxygenation and oxygen delivery. The success of maintaining oxygen delivery is evaluated by following the trend of oxygen consumption. Metabolic demands dramatically increase in MODS. When oxygen delivery cannot meet the body's metabolic demands, these demands may be decreased with sedation, pharmacologic paralysis, and temperature control. The goal in the future is to develop medications that allow for immunomodulation therapy to alter the detrimental effects of the systemic immune-inflammatory response. Tumor necrosis factor and IL-1 are two cytokines that exert a broad effect on the endothelium, leukocytes, and fibroblasts. Experts hope that modulation of both of these cytokines can decrease many of the body's responses to inflammation. The presence of endo-toxin, a substance that is released with the destruction of gram-negative bacteria, stimulates the inflammatory response. Modulation of endotoxin would also decrease many of the body's responses to inflammation.

Pharmacologic Highlights

Medication or Drug Class

Dosage

Description

Rationale

Anti-infective

Varies with drug

Therapy focuses on

Prevent and control infection

therapy; anti

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