The Intensive Care Unit: Multi-Organ Failure - Essay Example

?A reflection on the care of a critically ill patient Multi-organ failure (MOF) is a common cause of death in most hospitals around the world. The Intensive Care Unit gets a lot of challenges in managing the health related complications of patients with this kind of failure. Numerous factors such as trauma and sepsis need a critical and effective management to ensure that the expected kind of care is given. Management of this kind of failures usually involves the support of organ functionality, and prevention of any side complications and iatrogenic complications. Physicians are expected to make proper clinical assessments to determine whether failures are reversible or irreversible to determine the kind of decision to make. Such assessments are useful on determining whether to withdraw treatment, the kind of therapy to apply and many others. There are a lot of controversies that surround the aspects of managing MOF. This is due to the reason that there is no known treatment cause to be taken on patients with the complication. The field lacks proper research and controlled studies that will aid in giving proper care. Instead, the current methodologies in the treatment and care of MOF patients suggest the application of different immunotherapy patients which are often full of mistakes and inapplicable in some cases. Many players in this field also rely on information from laboratories and at times, many have accepted the use of unproved interventions to control the complication. Further, the field of MOF management lacks definitive diagnostic precisions and this has been a major discouraging factor (Jevon $ Ewens 2007). All the above problems experienced in this field greatly contribute to the current lack of principled and well-defined rules to follow during patient management. This has made it difficult for physicians to realize what should happen when certain situations come up. This is one of the problems that one can identify when working with others in the area. Mostly, individuals apply what they think is right at certain times and expects families to consent to their determinations. Further, complications such as systematic inflammatory response syndrome (SIRS) and multiple organ dysfunctions (MOD) presents complications that are difficult to identify and this has further worsened the situation in ICUs dealing with critically ill patients (Jevon $ Ewens 2007). Despite the above challenges, there have been multiple developments made concerning the issue of MOF. Further research has been able to make progress in determining the physiology of SIRS; the leading cause of multiple organ failure. Major pathophysiological mechanisms that are within the inflammatory conditions of MOF have been developed with better definitions of sepsis, SIRS and MODS. Health practitioners have made progress in ensuring the prevention of organ failure by ensuring optimum circulation and faster correction of hypoxia of tissues experienced by patients in high-risks. All these developments have been important in ensuring effective care to the patient. Application of the knowledge from the pathophysiology of SIRS, sepsis and MODS helps in the determination of the best methods as regards the care of patients. This paper will reflect on the self experience of taking care of a patient with a multiple organ failure. It will define the best methodologies for application under certain situations that can complicate the process of care to the patient. My experience as regards this issue is of a 57-yr old man who was found collapsed by his wife. Examination of the man recorded some existence of SIRS, the main observation being spontaneous breathing. Initial management was immediate intubation within the ambulance fifteen minutes after the arrival. He was admitted on hospital where a follow up of examinations were done to ascertain the cause and extent of the complication. A scan of the head was done which showed normal functioning at first instances. However, extensive coronary calcification was noted on the patient after CTPA (CT pulmonary angiogram). There was also a mild impairment of the Lymphatic vessels with septal and lateral hypokineses. Given that conditions that relate to multiple organ dysfunctions are difficult to identify, multiple tests were done on the patient over the days in hospital. The final scan of the head indicated a severe damage of the brain had occurred due to anoxia. Further, there was damage of occipital lobes, caudate heads and loss of differentiation was observed in grey white matter. The patient had multiple vessel diseases that made it necessary for extensive care. Characteristics included a site that was bleeding in the groin and subclavian line. The patient also had Urticaria that resulted from the attracurium and several other characteristics. He had suffered from a total of 14 seizures and was on midazolam to enable recovery. On observation from day one, patient had been under Noradrenaline and Dobutamine. He was also under Actrapid insulin to help control his blood sugar levels. The multiple disease conditions increased the deterioration of the physical health of the patient. There was needed to make proper determinations and what was to be done in managing the health of the patient. Patient records were difficult to determine given the multiple failures. Epithelial damage observed in the stomach can be related to inflammatory responses. It is common among patients of multiple organ dysfunctions to observe endothelium, neutrophils, coagulation and often macrophage inflammatory responses. This can result in dilation and constriction of vessels and thus blockade may occur. Further, these observations can result in tissue hypoxia, a characteristic that can lead to further damage of the tissues (Parrillo & Dellinger 2008). In taking care of the patient, multiple observations and responses had to be made to ensure that each of the organs is checked. The seizures of the patient had to be prevented as much as possible to ensure that further tissue damage did not occur. This was to be ensured through observation of ethical standards such as doing what is expected. The pressure of the patient had to be checked constantly. Bilateral air entry and auscultation of the patient was under control and enough oxygen was through intubation. The intubation composed of PRVC TV (Pressure Regulated Volume Controlled Tidal Volume)-500mls, at pH-2.86, RR-22, HCO3 and other conditions that could help ensure a stable pressure volume to lower chances of stroke and the effects of high pressure. Further, as the care-giver, constant drug administration to check on the brain damage and issuance of antibacterial medicine to curb the causative agents was a necessity. Generally, tissue hypoxia, inflammatory response of the system and damage some tissues are known to be among the causes of multiple organ failure and in patient care, these causes need to be checked to ensure high quality patient care (Wilkins et al 2010). Patient care Maintaining Oxygenation It is important to maintain adequate supply of oxygen to a critically ill patient has it has been recognized in many researches. The issue of high mortality rates has been related to insufficient oxygen supply. Critically ill patient has organ failures that might hinder the supply of oxygen to other organs and this might result to further damage. To ensure high quality care, prevention of the deficit debt was necessary in the case of the patient observed. This was ensured through extra supply of thiopental to ensure that inflammatory of tissues was corrected right on time. The administration of the drug was aimed at correcting hyper fusion of tissues especially after surgery. There was also constant observation and measurement of cardiac output to check on the adrenaline flow and urinal output. The patient was affected by sepsis and was in shock as observed on several occasions. These observations needed immediate attention given that the shock resulted in acute heart failures. To improve cardiac output, dobutamine was administered to the patient over the time of hospitalization. Dobutamine is effective in the treatment of shock and heart failure due to its ability to improve cardiac output and heart contractility. Further, the drug was very effective in this case since it has been shown clinically to have minimum probability in increasing or inducing hypertension that could lead to further shock or stroke. This had to be checked in the patient especially in cases of recorded high blood-sugar level as it was in this case (Hayes et al 2004). However, a poor prognosis was realized later on as there was no improvement realized after the treatment done to improve on cardiac output. Noradrenalin was also administered to the patient control the blood pressure of the patient. The blood pressure of the patient was observed to be low at times and this needed check. Noradrenalin works to maintain a desired blood pressure through its capability to maintain the muscle tone in the blood vessels. The patient was under actrapid to help lower his blood sugar level. This was necessary in ensuring that the blood pressure was at the expected levels. Such measures were necessary to ensure avoidance of subsequent organ failure through the decompression of tissues under the effect of the systematic inflammatory response syndrome. Infection control There was need to ensure that infections that result from carelessness in patient handling were avoided as much as possible. This was ensured through observance of hygiene. Strict attention to controlling infection was ensured through hand washing before handling the patient. Hand washing was also ensured after patient handling. This was particularly necessary when handling the bleeding groin site that was in the patient. Disinfection of tools used was ensured through the use of prophylactic antibiotics. When changing the dressing of the groin site all the above necessary measures were necessary to ensure 0% infection given that diagnosis infections, especially the ones brought about by bacteria has many problems that make it difficult. The groin site bleeding was also taken care of by the use of antibiotics to check on the causative agent. The bleeding was supposed to have been as a result of excessive acid production and to check on this, the physicians had proposed administration of pantoprazole. This medication is used to treat gastroesophageal reflux disease but it was effective in reducing excessive acid production that resulted in the bleeding. The patient was also administered with antidepressants to ensure relaxation and reduction of the brain activity that could result in further shock. Shock is extremely dangerous in cases of patients with brain failure and management was necessary. It is ethical to ensure cleanliness while handling patients of all kinds. It is the responsibility of all nurses to prevent further patient infection due to carelessness. In taking care of a critically ill patient, all these had to be observed while handling all infections, treatments and drug administration (Vincent 1996). Importance of Infection Control Infection is among the main causes of SIRS in the human body a condition that can develop to cause sepsis when identified. The causative bacteria is known to exist in two forms namely Gram-positive of Gram-negative. The Gram-negative bacterium is known to produce endotoxin that might trigger tissue inflammation. SIRS to infective causes and the onset of sepsis are related occurrences where there are signs of extreme and anarchic inflammatory response. Endotoxin consists of a core region on its surface and a very toxic lipid A. when these are released from the bacteria, they can easily associate with receptors in cells resulting in the activation of the cells. Further, endotoxin is known to activate endothelial and neutrophils resulting in the production of free radicals. This can lead to further inflammation of tissues and can eventually result in disseminated intravascular coagulation a factor that is known to result in the impairment of various vessels. This explains why it is important to observe cleanliness in the care of critically ill patients. Further, to curb the extent of tissue inflammation, various methodologies could be applied in this case. There was need to ensure a close regulation of the system and the use of anti-inflammatory mediators. Usually, in pro-inflammatory stimuli exhibit generic variations and this complicates things in the regulation of the system. This makes it necessary for care givers to note that both the inflammatory response of the patient and the nature or extent of the injury and damage determines the end result of the healing process. The localization of the inflammation can makes it possible for natural healing to occur at some instances. However, some instances lead to acute activation of the inflammatory system and this has been recorded to show a rise in SIRS clinical features. Although inflammation can be helpful to the patient, at some point, uncontrolled inflammation is known to result to MODS. Therefore, the anti-inflammatory mediators are very important in limiting inflammation and thereby lowering its destructive capabilities. Drugs that were administered to the patient were meant to ensure that a balance of the body in all aspects including pressure, brain activity, and production of bacteria was attained to increase the likeliness of recovery from the various organ failures (Adrie 2000). Cells Involved in Inflammatory Response Different cells play different roles as effectors of the inflammatory response. These include macrophages, neutrophils, endothelial and mast cells. Mast cells usually lay a crucial role in triggering the process of system inflammation releasing pro-inflammatory substances that are preformed such as histamine resulting in the activation of endothelial cells. When endothelial cells are activated, there is an increased activity and presence of adhesion molecules namely endothelial leukocyte adhesion (ELAM) and intercellular adhesion (ICAM) molecules. The ELAM lays the role of binding Polymorphonuclear leukocytes (PMNs) and monocytes while ICAM binds lymphocytes to PMNs. On the other hand, the leucocytes lays the role of complementary adhesion molecule production namely integrins. These leucocytes are attracted by chemokines and as a result they gradually move along the cell endothelium until they reach the site of inflammation. The named PMNs are key catalysts in tissue damage seen in SIRS. Once PMNS are activated they manufacture potent proteases and activate coagulation cascade and platelets. These productions are known to damage the endothelium and other critical tissues and also completely disrupt the microcirculation in organs and this will eventually result in organ dysfunction. High systematic levels of the cytokines are known to marginalize PMNs along endothelium cells not only in the site of production but also in other body organs (Bone 1996). Macrophages mainly lay the role of producing the toxic Reactive Oxygen Species (ROS) and also present antigen to lymphocytes. In SIRS, the macrophage cells are known to coordinate inflammatory cells through the production of secondary mediators such as prostaglandins and leucotrienes and also the production of cytokines. This activates the normal endothelial cells making it to shift to anti-fibrionolytic and pro-thrombotic from its normal anti-thrombotic activity. The activated endothelium can also change its vascular tone and even generate extra inflammatory mediators. This promotes the production of thromboxane and platelet adhesion molecules resulting in a further production of pro-coagulant and pro-inflammatory substances. The macrophage activity also limits the production of anti-thrombin III and protein C the main anti-thrombotic factors. All these activities when combined with the injury seen at the endothelium cells results blood flow impairment and development of microthrombi. Endothelial cells then move away from each other and this increases the permeability of the vascular structure. This permeability is further triggered through the production of leucotrienes (Bone1996). Many of the substances that trigger multi-organ failure are actually produced by activated endothelium cells and the above named pro-inflammatory cells. The activity explained above gradually results in the familiar characteristics of the critically ill patient namely deep vasodilatation that may or may not exhibit large fluid requirements and hypotension. In the activated nature, endothelial cells are seen to increase the production of endothelins; a vasoconstrictor substance. From various analyzed researches, the role of this substance is not clear as far as SIRS is concerned but in several occasions, it has shown capabilities of reducing blood flow to organs such as the brain, gut and kidneys and also plays an important role in pulmonary hypertension. Cytokines All the cells explained above namely, endothelial, PMNs, macrophages and monocytes are known to produce cytokines. These are substances that play the role of transmitting inflammation. They act as hormones during SIRS, MODS and even sepsis. Naturally, there are cytokines that are known tom promote inflammation such as Tumor necrosis factors (TNF) and Interleukin-1 (IL-1) and those that inhibit inflammation namely IL-4 and IL-10. When TNF gets into subjects, they are known to trigger signs of SIRS and in most cases; their level of serum corresponds to the development of SIRS and finally MODS. TNF also facilitates the activation of endothelial cells, macrophages, and PMNs as well as that of the coagulation and complement systems. This results in the manufacture of more cytokines in the system and inflammatory mediators. It also increases the recruitment of cells that effect inflammatory. IL-1 is released alongside or in response to the secretion of TNF. They are usually produced by the macrophages and also perform almost the same activities that are triggered by TNF. They are usually responsible for the acute phase liver response through the induction process (DE PABLO 2011). The anti-inflammatory cytokines are usually synthesized by lymphocytes and monocytes and perform their functions by inhibiting the production and secretion of pro-inflammatory mediators. They play an important role in regulating the process of inflammatory response. However, on the critically ill patient, they are known to result to immunosuppressant due to their inhibitory nature and this creates and inability within tissues to produce appropriate response thus resulting in further infection. The main cause for SIRS and the resultant complications namely sepsis and MODS is the invasive infection at any site of the human body. As explained, the infection of any site triggers the occurrence of many other processes that finally result to damage of cells. This will eventually lead to the damage of different organs and if the condition remains unchecked for longer periods, it ends up as multi-organ dysfunction. However, there is second process where the actual products of the bacteria that was present and its resultant products were recorded to cause SIRS. This is related to the nature of the gut and the entire system (DE PABLO 2011). The structure of the process and characteristics of micro-circulation that takes place within the mucosal villi and the equal high but critical requirement of oxygen makes the gut vulnerable to hypoxia and hypoperfusion. The lumen of the intestine contains a very large number of organisms. Further, the presence of large amounts of mucus and mucosal ischemia is also known to make the walls of the gut more permeable to bacteria and other harmful toxins. This has been a common characteristic or symptom that has been found and r4esearched in critically ill patients. The bacteria may result in dysfunction of normal defense hosts such as the liver and lymphoid tissue. Further, most of the critically ill patients are malnutrition and this has been seen to impair the protective function of the gut. A combination of all these factors enables endotoxin, bacteria and cytokines from the gut system to enter the circulation where they induce or amplify the process of inflammation. This is also the characteristic that was recorded in the critically ill patient who had a continuous bleeding site in his groin (Bolton 1996). Management of SIRS Infection Diagnosis Diagnosing bacterial infection has shown major problems in many cases. Differentiating the different types of bacteria is vexatious and signs of supposed infection do not depict any signs of bacterial growth. In other cases, they can even show that there was no any previous antibiotic therapy even if it was given. This leads t the need to use the CT scan to diagnose any form of infection. The safety of the critically ill patient who goes through the CT scan is usually determined by the availability f transfer facilities. Although many risks are involved in the procedure of patient transportation and surgery, the benefits of being able to diagnose the infection lead to administration of treatment and this outweighs the risks. Antibiotic Therapy The administration of antibiotics come has an easy task to carry but it needs care and constant monitoring to ensure that the process is beneficial to the patient. Appropriate antibiotics should be given to the patient at an early stage to prevent the spread of infection. However, this dosage should be discontinued when the expected results of clearing the infection have been achieved or when analysis shows that there is no sign of change in the patient. When the clinical conditions of the patient allow, withdrawal of antibiotic administration may be very effective or may increase the chances of obtaining a positive result. The length of time taken in administration of antibiotic for treatment, the choice of antibiotic to use and the need for combination therapy versus monotherapy makes the processes contentious (Rudis & Rowland 2005). The antibiotics are administered within short durations of usually 3-5 days for specific conditions such as pneumonia, tuberculosis and, meningitis. The administration of such antibiotics is usually discontinued when there is need to do so to prevent damage. Conditions that persist for more than 5 days usually require that all antibiotic therapy is ceased and a new search for the causative agent of such pyrexia is started. Other causative agents of the infection such as adverse effects of drugs, and inflammatory conditions are considered in the search for the causative agent. Short courses of antibiotic therapy are emphasized on because they reduce the probability of the body to develop resistance of antibiotics. To complicate everything in this case, as a nurse one should also ensure to be careful in antibiotic administration given that some researches also argue that incomplete administration of the antibiotic may also lead to the development of antibiotic resistance. Further, short courses of intensive therapy of antimicrobial are also administered to the patient to prevent the onset of secondary fungal infection (Balk 2000). Ethical Issues It is important to observe some principles when it comes to the care of a critically ill patient for his life to be prolonged or to increase chances of survival. In the case of the patient, when the treatment and forms of therapy indicate no changes in the health situation, withdrawal is necessary to avoid giving wrong descriptions. The family of the patient had to be informed on withdrawal and the reasons for doing it to avoid any legal confrontations as well as inform them on the situation of the patient. As the care givers, we also had to ensure that decisions that regard to “Do not Attempt Resuscitation” (DNAR) were recorded effectively and explanations that could communicate the situation of the patient were appropriately provided. The DNAR was necessary to communicate decisions to all healthcare workers that could be involved with the patient. The DNAR was only provided to the care givers, recognized family members and health representatives of the patient to ensure confidentiality. Physiological support Through having enough experience through the care of a critically ill patient, one will eventually learn several things that might be ignored in ensuring the survival of the patient. While caring for such patients, small mistakes can result in further damage and it is necessary for caregivers to learn to prevent the preventable. Avoidable complications include malnutrition, biochemical abnormalities and application of poor aseptic techniques. Conditions such as hypotension should be avoided in all instances of serving the patient. This is the reason as to why the patient was under drugs that could cause relaxation and at times induce sleep to avoid any complications that can occur (Rello 2012). In the care of a critically ill patient, early diagnosis and immediate treatment of all possible causes or sources of infection and organ hypoperfusion is expected. Quality nursing care and regular physiotherapy to the patient has been shown through various researches to be effective in increasing the chances of patient survival. Nurses should ensure to protect and take care of pressure areas and all affected regions devotedly. All administrations that still remain questionable such as the use of antacids and H2-antagonists that work to protect gastric should not be applied when better methods are available. Nutrition There has been increased awareness of the detrimental effects that malnutrition can have on critically ill patients. Critically ill patients require adequate and immediate nutrition given the positive effects of nutrition. Nutrition plays an important role in the synthesis of proteins, gut protection and also enhancement of the body immunology. Enteral nutrition is instituted early especially within the first 24 hrs to ensure that the optimum requirements are obtained. However, exceptions as it is known are given to instances of specific management of surgery and the attainment of a desired body balance. Sedation Although still used, sedation was seen to be well controlled and administered in minimum quantities due to concerns of side effects that might result. Sedation is done under sophisticated mechanical ventilators to permit the comfort of the patient as well as increase their awareness, and also enhance coughing. Sedation drugs that were administered to the patient include midazolam and Fentanyl. The dosage was constantly reduced over time to minimize side effects from affecting the patient further (Rello 2012). Conclusion It is recognized world over that the mortality rate of critically ill patients has been in increase recently. This can be attributed to the poor techniques for prognosis of multiple organ failure. Many variables in this field are constantly changing given the many flaws that exist and this has made it difficult to access the level of improvement made over the recent years. The persistence of organ failure with increased mortality dictates that new improvements in prognosis, prevention and treatment techniques for MOF are needed. All the participating parties must access the new suggested methodologies such immunotherapy to check their effectiveness given that the old methods have failed to give the kind of results that are expected. More research should especially be directed towards establishing the exact role of various substances in MOF and good and effective methodologies developed to inhibit any process that might lead to SIRS that will also result in MOF. References Adrie C. 2000. The inflammatory balance in human sepsis. Intensive Care Med 26: 364–75. Amato MBP, Barbas CSV, Medeiros DM et al. 1998. Effect of a protective ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med 338: 347–54. Balk RA. 2000. Severe sepsis and septic shock definitions, epidemiology, and clinical manifestations. Crit Care Clin 16: 179–91. BAUE, A., BERLOT, G., & GULLO, A. (2008). Sepsis and organ dysfunction: epidemiology and scoring systems : pathophysiology and therapy. Milano, Springer. Bolton CF. 1996. Sepsis and the systemic inflammatory response syndrome: neuromuscular manifestations. Crit Care Med 24: 1408–16. Bone RC, Grodzin CJ, Balk RA. 1997. Sepsis: a new hypothesis for pathogenesis of the disease process. Chest 112: 235–43. Bone RC. 1996. Immunological dissonance: a continuing evolution in our understanding of the systemic inflammatory response syndrome (SIRS) and the multiple organ dysfunction syndrome (MODS). Ann Intern Med 125: 680–87. BRUNKHORST, F. (2007). Time course and relationship between plasma selenium concentrations, systemic inflammatory response, sepsis, and multiorgan failure. British Journal of Anaesthesia. 98, 775-784. CHATBURN, R. L., & MIRELES-CABODEVILA, E. (2011). Handbook of respiratory care. Sudbury, MA, Jones & Bartlett Learning. CLAYTON, J., & STARR, J. (2008). Novel Approaches to the Treatment of Sepsis Syndrome. Cook, D. J. et al (1996). Stress ulcer prophylaxis in critically ill patients. Resolving discordant meta-analyses. Journal of the American Medical Association 275, 308–14.Journal of Pharmacy Practice. 21, 371-379. DE PABLO, R., MONSERRAT, J., REYES, E., DIAZ-MARTIN, D., RODRIGUEZ ZAPATA, M., CARBALLO, F., DE LA HERA, A., PRIETO, A., & ALVAREZ-MON, M. (2011). Mortality in Patients With Septic Shock Correlates With Anti-Inflammatory But not Proinflammatory Immunomodulatory Molecules. Journal of Intensive Care Medicine. 26, 125-132. GERLACH, A., & MURPHY, C. (2011). An Update on Nutrition Support in the Critically Ill. Journal of Pharmacy Practice. 24, 70-77. Griffiths, R. D., Palmer, T. E. A. & Jones, C. (1996). Outcome of intensive care patients given glutamine supplemented parenteral nutrition. Clinical Intensive Care 7, 168. HARVEY, C. J., HARVEY, M. G., & WIECZOREK, R. R. (2007). Hemodynamic monitoring of the critically ill obstetric patient. [White Plains, N.Y.], Education & Health Promotion, March of Dimes. Hayes, M. A et al (2004). Elevation of systemic oxygen delivery in the treatment of critically ill patients. New England Journal of Medicine 330, 1717–22. HEDENSTIERNA, G., MANCEBO, J., BROCHARD, L., & PINSKY, M. R. (2009). Applied Physiology in Intensive Care Medicine. Berlin, Heidelberg, Springer-Verlag Berlin Heidelberg. Heller A, Koch T, Schmeck J et al. 1998. Lipid mediators in inflammatory disorders. Drugs 55: 487–96. JEVON, P., & EWENS, B. (2007). Monitoring the critically ill patient. Oxford, Blackwell Pub. Kim PK, Deutschman CS. 2000. Inflammatory responses and mediators. Surg Clin North Am 80: 885–94. KOTB, M., & CALANDRA, T. (2003). Cytokines and Chemokines in Infectious Diseases Handbook. Infectious Disease. Springer. PARRILLO, J. E., & DELLINGER, R. P. (2008). Critical care medicine: principles of diagnosis and management in the adult. Philadelphia, PA, Mosby Elsevier. Reynolds JV, O’Farrelly C, Feighery C et al. 1996. Impaired gut barrier function in malnourished patients. Br J Surg 83: 1288–91. RUDIS, M., & ROWLAND, K. (2005). Current Concepts in Severe Sepsis and Septic Shock. Journal of Pharmacy Practice. 18, 351-362. SAKR, Y., REINHART, K., BLOOS, F., MARX, G., RUSSWURM, S., BAUER, M., & RELLO, J., LIPMAN, J., & LISBOA, T. (2012). Sepsis management PIRO and MODS. Heidelberg, Springer-Verlag Berlin Heidelberg. http://public.eblib.com/EBLPublic/PublicView.do?ptiID=884757. Vincent J.-L. et al. (1996). The SOFA (sepsisrelated organ failure assessment) score to describe organ dysfunction/ failure. Intensive Care Medicine 22, 707–10. WILKINS, R. L., DEXTER, J. R., & HEUER, A. J. (2010). Clinical assessment in respiratory care. St. Louis, Mo, Mosby. YOUNG, L. (2001). Sepsis old problem, new treatments. Thesis (M.S.N.)--Gonzaga University, 2001. Grootendorst, A. F. (1994). The potential role of hemofiltration in the treatment of patients with septic shock and multiple organ dysfunction syndrome. Advances in Renal Replacement Therapy 1, 176–84. Read More