Unifying Concepts

Knaus Criteria for Multiple System Organ Failure (MSOF)

Multiple systems organ failure is said present when more than one of the system dysfunctions detected by test values exceeding the threshold values.

Acute Organ System Dysfunction

Respiratory failure (presence of one or more):

  • Respiratory frequency <5, >49 (>two years of age)

  • Alveolar-arterial difference in O2 >350 mmHg or PaO2/ Fi02 <200 (without congenital cardiac lesion)

  • Requires mechanical ventilatory support >24 h

  • PaCO2, >50 mmHg and pHa <7.25

Circulatory failure (presence of one or more):

  • Heart rate <50/mm or episode of ventricular tachycardia/fibrillation

  • Mean systemic arterial pressure <50 mmHg and (or) systolic systemic arterial pressure <60 mmHg

  • Cardiac Index <2 L/min per sq. meter of body surface (acute onset) and (or) pHa <7.25, PaCO2, <35 without respiratory failure

Renal failure (presence of one or more):

  • Urine volume 9.3 mL/kg body weight per hour for 8 h

  • Serum creatinine >266 umol/L

  • Urea nitrogen >1.00 g/L or urea >0.60 g/L

Hepatic failure (presence of both):

  • Bilirubin >60 mg/L or a twofold increase in alkaline phosphatase in serum and

  • Prothrombin time >4 s over upper limit of normal range or a twofold increase in aspartate aminotransferase in serum

Hematologic failure (presence of one or more):

  • Leukocytes <1500/mL or >40000/mL

  • Platelets <20000/mL or evidence of ongoing disseminated intravascular coagulation

Neurologic failure

  • Glasgow Coma Scale <6 (without sedation)

Uncontrolled sepsis (presence of one or more):

  • Positive blood culture despite antibiotic therapy

  • Fever >39.5 °C (rectal temp) for >24 h or spikes on three successive days



  1. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. Prognosis in acute organ-system failure. Ann Surg. 1985 Dec;202(6):685-93. [Medline]
  2. Marsh HM. Metabolic integrity of specific organ systems. Clin Chem. 1990 Aug;36(8 Pt 2):1547-51. [Medline]
Created: Jan 30, 2007
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