The changing pattern and implications of multiple organ failure after blunt injury with hemorrhagic shock

Abstract

Objectives: To describe the incidence of postinjury multiple organ failure and its relationship to nosocomial infection and mortality in trauma centers using evidence-based standard operating procedures.

Design: Prospective cohort study wherein standard operating procedures were developed and implemented to optimize postinjury care.

Setting: Seven U.S. level I trauma centers.

Patients: Severely injured patients (older than age 16 yrs) with a blunt mechanism, systolic hypotension (<90 mm Hg), and/or base deficit (≥6 mEq/L), need for blood transfusion within the first 12 hrs, and an abbreviated injury score ≥2 excluding brain injury were eligible for inclusion.

Measurements and main results: One thousand two patients were enrolled and 916 met inclusion criteria. Daily markers of organ dysfunction were prospectively recorded for all patients while receiving intensive care. Overall, 29% of patients had multiple organ failure develop. Development of multiple organ failure was early (median time, 2 days), short-lived, and predicted an increased incidence of nosocomial infection, whereas persistence of multiple organ failure predicted mortality. However, surprisingly, nosocomial infection did not increase subsequent multiple organ failure and there was no evidence of a "second-hit"-induced late-onset multiple organ failure.

Conclusions: Multiple organ failure remains common after severe injury. Contrary to current paradigms, the onset is only early, and not bimodal, nor is it associated with a "second-hit"-induced late onset. Multiple organ failure is associated with subsequent nosocomial infection and increased mortality. Standard operating procedure-driven interventions may be associated with a decrease in late multiple organ failure and morbidity.

Figure 1

Day of onset and frequency of multiple organ failure, nosocomial infection and death. MOF – multiple organ failure; NI – nosocomial infection.

Figure 2

Temporal relationship of nosocomial infection (NI), multiple organ dysfunction (MOF) and mortality. No MOF/No NI – patients who never experience either condition; NI/No MOF – patients who had nosocomial infection, never had MOF; MOF 1^st – patients who had MOF before a diagnosis of nosocomial infection; MOF/No NI – patients who had MOF, never had nosocomial infection; NI 1^st – patients who had nosocomial infection before a diagnosis of MOF; Concurrent – patients who had MOF and nosocomial infection diagnosed on the same day.