The Clinical Evaluation On Strategy Of MODS Bindle Therapy In The Treatment Of Patients With MODS

IntroductionMultiple organ dysfunction syndrome(MODS) means that two or more than two systems/organs dysfunction/failure present simutaniously or gradually after 24 hours for serious trauma,shock,infection,surgery operations,serious pancreatitis and so on.Nowadays,therapy for MODS is still a hot potato of critical care medicine in domestic and abroad,there has no certain therapeutic methods or guidelines for MODS.Prevention from MODS and organ supporting are the main treatment for MODS at present.Lack of early canonical,goal-directed and comprehensive therapy leads to high mortality in hospital for MODS.Objective To discuss the available treatment about MODS() by studying on the clinical evaluation of MODS bindle therapy in ICU(intensive care unit). Methods The clinical data of 84 patients with MODS are reviewed and analysed,then divided into two groups: general therapy(group A) and bundle therapy(group B) according to treatments whether bundle completed or not.Following that,the clinical evaluation of MODS bindle therapy and its effect on prognosis of MODS are discussed by observing mortality in hospital,hours for mechanical ventilation,days for ICU, infection rate in hospital as well as multiple organ injuries.Results MODS bindle therapy shows better effect on the treatment of MODS.Compared with general therapy,mortality and infection rate in hospital are reduced, meanwhile,hours for mechanical ventilation is shorter in Group B(group with bundle therapy),and index for multiple organ injuries in Group B take on steady comeback,all these are statistically significant(P<0.05).Conclusion Strategy of MODS bindle therapy is better than general therapy in clinical evaluation,and is significant for improving prognosis of patients with MODS.DiscussionTherapy for MODS is the key point in critical care medicine.Although time for patients' life may be prolonged by prevention and supporting treatment, but the state of disease would be more complicated than before,as a result,high mortality is still a problem.How to cure MODS and how to reduce mortality will be a urgent problem to be solved.1.Critical care medicine and MODS bindle therapyCritical care medicine is a subject that needs to support and cure acute pathophysiological changes endangering multiple organ function and patients' life of critical care patients.At present,treatment on critical care illnesses inclines to integration of kinds of therapy methods.And recently idea of bindle therapy has been put forward.For example, guidelines for hemodynamic monitoring and support of severe sepsis and septic shock in adult patients bring the "sepsis bundle"forward.It means a complete bindle therapy combined early antibiotics and effective hemodynamic support with other therapeutic methods that are good for prognosis such as insulin intensive treatment to regulate the glucose,using glucocorticoids,planar pressure less than 30cmH2O in mechanical ventilaition,using active protein C and so on.The massive research indicated that,the factors that affect the MODS prognosis include hemodynamic disorder,immune maladjustment(early immunity hyperfunction, later immunosuppression), hyperglycemia, organism metabolism disorder and malnutrition which are familiar in MODS and become the independent factors to affect its prognosis,except for the serious degrees of primary diseases(infection, wound, shock and so on) and multiple organs damages.All these can cause mortality, rate of infection in hospital to advance,and the time for mechanical ventilation to lengthen,as well as medical expense disbursement to increase.The MODS bindle therapy combine the factors that affect the MODS prognosis such as the early goal-directed hemodynamic support,the regular nutrition support,the insulin intensive treatment,immune regulation of Ulinastatin on the bases of general curing of primary desease and supporting of multiple organ function,according to the related guidelines(guideline for hemodynamic monitoring and support of severe sepsis and septic shock in adult patients ,guideline for clinical application of mechanical ventilation, uideline on nutrition support for critical care patients as well as its recommendation for the insulin intensive therapy).As a result ,all these therapeutic methods form a canonical, goal-directed and comprehensive treatment plan.Through the early MODS bundle therapy, the goal to improve the patients' prognosis is achieved.1.1 Early goal-directed hemodynamic supportThe early goal-directed hemodynamic support treatment is the most effective method to maintain the circulation stable for MODS patients in the early time.The goal is to guarantee enough organization irrigation and improve organization anoxia.At present,there has no the specific early-goal-directed hemodynamic support for MODS treatment.This research mainly carried on the judgment based on the guideline for severe sepsis and septic shock,and to achieve following goal in early 6 hours of ICU: 1) central venous pressure (CVP)8-12cmH2O. 2) mean arterial pressure> 65mmHg. 3) amount of urine> 0.5ml/(kg·h).In this research, all patients in the bundle therapy group can attain a designated standard in 6 hours.The result of Logistic regression analysis showed that, the early-goal-directed hemodynamic support treatment (X1) is an important influence factor for the mend of the MODS patients(P﹤0.05, OR value =2.943, 2.464).Therefore, early CVP, the mean arterial pressure, the amount of urine may take as the target of early-goal-directed hemodynamic support treatment,also may take as the goal of recurrent state appraisal for MODS patients.1.2 regular nutrition supportAccording to the guideline of nutrition support for critical care patients,the organism metabolism rate increases obviously under the serious stress condition,and organism may have a series of metabolism disorder. herefore,drops of organism nutrition condition and malnutrition is a general phenomenon in the critically ill patients,and becomes the independent factor on the prognosis of critically ill patients.So nutrition support should start as long as there has no the contraindication in the critically ill patients.On giving the nutrition support, enteral nutrition(EN) should be the nutrition support way considered first for the critically ill patients.Patient that can not afford the enteral nutrition (EN) or have the contraindication of EN should choose total parenteral nutrition (TPN).when the gastro-intestinal tract of patient may be used safely,nutrition support should gradually turn to EN or the oral administration.The clinical research indicated,the nutrition support retarded would cause the malnutrition rapidly, and will be corrected difficultly.In addition,the insufficiency of nutrition and the negative balance of protein energy have correlation with the malnutrition and the hematogenous infection,and have direct effect on the prognosis of patients in intensive care unit(ICU).Patients in bindle therapy Group were given the nutrition support early according to the guideline in the research, and finally the Logistic regression analysis confirmed that regular nutrition support is the influencing factor of the mend of the MODS patients statistically(P﹤0.05, OR=3.647,3.690).1.3 insulin intensive treatment and control of hyperglycemiaHyperglycemia for irritability is a question which the ICU patient exists generally.The insulin intensive treatment in critically ill patients has obtained the explicit effect, that can reduce patient's mortality ,cripple rate and infection rate.Yao Yongming thought the insulin intensive treatment refers final goal is to control glucose in the normal value scope (3.89-6.12mmol/l) but simultaneously need not to scruple about the insulin amount.According to Van Den Berghe, to control glucose in the 4.0-6.1mmol/l scope is appropriate.In order to reduce the risk of hypoglycemia, the control goal of glucose is relaxed frequently to 8.3 mmol/L, and many clinical findings thought the strict control of glucose level (6.1-8.3mmol/l) may improve the prognosis of critically ill patients obviously, meanwhile,it can drop the mechanical ventilation time, the ICU treatment time, the rate of MODS obviously.But in the guideline of nutrition support for critical care patients A level recommendation like this: Nutrition support of Any form should be coordinated with the insulin intensive treatment, and control the blood glucose level strictly≤7.5mmol/l, and should avoid the hypoglycemia occurring.This study takes the blood glucose≤7.5mmol/l as a goal, and the monitors glucose strictly to avoid the hypoglycemia occurring.The results demonstrated that the MODS patient had metabolism to be unusual, the blood glucose increase in varied degree. After the bindle therapy, the glucose drop steadily , the Logistic regression analysis result demonstrated that the insulin intensive treatment affects the mend of MODS patients, has the significance to its change for the better (P﹤0.05, OR=1.419,1.203).1.4 immune regulation of UlinastatinModern research indicated that, MODS is the result of wild organism inflammation response,namely the serious result of unbalance between systemic inflammatory reaction syndrome(SIRS) and Compensatory anti- inflammatory response syndrome(CARS).The unbalance of SIRS/CARS can lead to the inflammation reactive diffusion and out of control,and turn its protection function into self-destructive function,then damage various cells of organ to cause its dysfunction.Ulinastatin is one kind of trypsin inhibitor separated and purified from the human urine,which may suppress activities of many kinds of enzyme in the blood,suppress the excessive release of inflammation mediumsuch as cytokines, and reduce the organ damage from each kind of proteinase and the inflammation medium.As a result,it has important efffect on the treatment of acute pancreatitis, shock, improvement surgery prognosis, especially on reducing the external circulation complications,and it can improve immunity function after the surgery of stomach and intestines cancer .At present,Ulinastatin are used in the critical care patients to play its immune regulation role.The findings of this study showed that, immune regulation treatment of Ulinastatin have statistics significance in improving the prognosis of MODS patients(P﹤0.05, OR=1.885,1.820).2. MODS bindle therapyBoth general therapy group and bindle therapy group patients were given following treatment: 1) treats the primary diseases positively.2) support treatment for organs function.On the basis of above treatments,bundle therapy combined such treatments:①T he early goal-directed hemodynamic support treatment, in 6 hours achieving the anabiosis goal: CVP achieves 8~12cmH2O,MAP>65mmHg, Amount of urine> 0.5ml·kg-1·h-1. Regular nutrition support.The insulin intensive treatment, to control blood glucose≤7.5mmol/l, and avoid the hypoglycemia occurring.Using Ulinastatin to carry on the immune regulation treatment.The findings showed that,compared with general therapy group,mortality,infection rate in hospital,hours of mechanical ventilation were shorter in the bindle therapy group,simultaneously the organs function targets such as index (PaO2/FiO2), CREA, TBIL, shock index, Glasgow grading and so on internal organs function targets restored more quick and obvious in bundle therapy group, the differences had statistics significance (P< 0.05).In summary, Strategy of MODS bindle therapy is better than general therapy in clinical evaluation,and is significant for improving prognosis of patients with MODS.It provides the scientific basis for clinical practice of MODS bindle therapy,and provides the new idea for treatments and cures of MODS.In addition, MODS bindle therapy emphasize the cognition and the compliance of guidelines on critical care medicine for clinician to cause the standardized treatment of MODS.Therefore, the MODS bindle therapy is worth further studying and promotion clinically, and will give the unceasing consummation and supplement in future work.ConclusionStrategy of MODS bindle therapy may reduce the mortality ,infection rate in hospital,hours for mechanical ventilation of MODS patients,thus reduces the medical expense disbursement.Meanwhile,it favors the the restoration of damaged organ function.The blood glucose level drop steadily.The early goal-directed hemodynamic support treatment, the regular nutrition support, the insulin intensive treatment,immune regulation treatment of Ulinastatin were advantageous for improving the prognosis. The study provides the scientific basis for clinical practice of MODS bindle therapy,and provides the new idea for treatments and cures of MODS.