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o24-72 hours: lungs begin to fail and ARDS may appear. o7-10 days: the hypermetabolic and hyperdynamic state intensifies, bacteremia with enteric organisms is common. Signs of hepatic, intestinal, and renal failure develop. o14-21 days: renal failure and liver failure become more severe. oEncephalopathy = mental status change, may occur at any time. oHematologic failure and myocardial failure are usually later manifestations. • Respiratory failure progresses early to ARDS and is characterized by tachypnea, pulmonary edema with crackles and diminished breath sounds, use of accessory muscles, and hypoxemia. • Liver failure, although early in its development, is not clinically detectable until the later stages of MODS, when jaundice, abdominal distention, liver tenderness, muscle wasting, and hepatic encephalopathy appear. oAlbumin and clotting factor synthesis decreases, protein wastes accumulate, and liver tissue macrophages (Kupffer cells) no longer function effectively.• The gastrointestinal systemoClinical manifestations of bowel involvement are hemorrhage, ileus, stress ulcers, malabsorption, diarrhea or constipation, vomiting, anorexia, abdominal pain, and pancreatitis. oIntolerance to enteral feeding may develop. oAdding to damage caused by injury to the bowel is bacterial translocation into the bloodstream resulting from the loss of the gut barrier function. • Renal failure develops at about the same time and is marked by progressive oliguria, azotemia, and edema. oIf renal shutdown is severe, anuria, hyperkalemia, and metabolic acidosis occur.• The first manifestations of cardiac failure are similar to those of septic shock: tachycardia, bounding pulse, increased cardiac output, fall in SVR, hypotension, warm skin, and supraventricular dysrhythmias. oIn the terminal stages, profound hypotension and ventricular dysrhythmias may develop.• Changes in central nervous system function may be noted. oIschemia and inflammation are responsible for the changes, which include apprehension, confusion, disorientation, restlessness, agitation, headache, decreased cognitive ability and memory, and decreased level of consciousness. oWhen ischemia is severe, seizures and coma can occur.o) Evaluation and Treatment: there is NO specific therapy for MODS, early detection/prevention is extremely importantso that supportive measures are initiated instantly. . • Initial source of inflammation must be eliminated (if possible). • Next, secondaryinsult should be avoided. • No way to determine when an organ is failing (see Table 49.1)• There are several scoring systems for severity of illnesses = APACHE II and II-Acute Physiology and Chronic Health Evaluation II and III, LODS-logistic organ dysfunction score, SOFA-sequential organ failure assessment, MODS-multiple organ dysfunction syndrome, PIRO-predisposition infection-response-organ dysfunction.