Temporal trends of postinjury multiple-organ failure: still resource intensive, morbid, and lethal

Abstract

Background: While the incidence of postinjury multiple-organ failure (MOF) has declined during the past decade, temporal trends of its morbidity, mortality, presentation patterns, and health care resources use have been inconsistent. The purpose of this study was to describe the evolving epidemiology of postinjury MOF from 2003 to 2010 in multiple trauma centers sharing standard treatment protocols.

Methods: "Inflammation and Host Response to Injury Collaborative Program" institutions that enrolled more than 20 eligible patients per biennial during the 2003 to 2010 study period were included. The patients were aged 16 years to 90 years, sustained blunt torso trauma with hemorrhagic shock (systolic blood pressure < 90 mm Hg, base deficit ≥ 6 mEq/L, blood transfusion within the first 12 hours), but without severe head injury (motor Glasgow Coma Scale [GCS] score < 4). MOF temporal trends (Denver MOF score > 3) were adjusted for admission risk factors (age, sex, body max index, Injury Severity Score [ISS], systolic blood pressure, and base deficit) using survival analysis.

Results: A total of 1,643 patients from four institutions were evaluated. MOF incidence decreased over time (from 17% in 2003-2004 to 9.8% in 2009-2010). MOF-related death rate (33% in 2003-2004 to 36% in 2009-2010), intensive care unit stay, and mechanical ventilation duration did not change over the study period. Adjustment for admission risk factors confirmed the crude trends. MOF patients required much longer ventilation and intensive care unit stay, compared with non-MOF patients. Most of the MOF-related deaths occurred within 2 days of the MOF diagnosis. Lung and cardiac dysfunctions became less frequent (57.6% to 50.8%, 20.9% to 12.5%, respectively), but kidney and liver failure rates did not change (10.1% to 12.5%, 15.2% to 14.1%).

Conclusion: Postinjury MOF remains a resource-intensive, morbid, and lethal condition. Lung injury is an enduring challenge and should be a research priority. The lack of outcome improvements suggests that reversing MOF is difficult and prevention is still the best strategy.

Level of evidence: Epidemiologic study, level III.

Figure 1

Kaplan-Meier curves for MOF incidence and outcomes across biennial periods from 2003 to 2010. A, MOF incidence. B, Mortality in MOF patients. C, ICU stay in MOF patients. D, Ventilation days in MOF patients.

Figure 2

Kaplan-Meier curves for the incidence of individual organ failures across biennial periods from 2003 to 2010. A, Lung failure incidence. B, Cardiac failure incidence. (log-rank p = 0.0042, Wilcoxon p = 0.0012) (log-rank p = 0.0117, Wilcoxon p = 0.0111). C, Renal failure incidence. D, Liver failure incidence (log-rank p = 0.9158, Wilcoxon p = 0.8927) (log-rank p = 0.3978, Wilcoxon p = 0.4082). Stratum 2004, 2003 to 2004; Stratum 2006, 2005 to 2006; Stratum 2008, 2007 to 2008; Stratum 2010, 2009 to 2010.

Figure 3

MOF onset by biennial period. A, Onset of MOF by postinjury day. B, Percentage of all MOF cases (and respective mortality) that started 3 days or less, 4 days to 7 days, more than 7 days.

Figure 4

MOF-related mortality. A, Timing of death among MOF patients relative to MOF onset. B, Mortality of MOF by onset of MOF (e.g., in the biennial 2009 to 2010, 50% of the patients diagnosed with MOF within 3 days after injury died during this hospitalization).

Figure 5

Resource use by MOF and survival status. A, Median days and IQR in the ICU and on MV. B, Proportion of total ICU days (left chart) and MV days (right chart) by MOF and survivor status. C, Proportion of patients by MOF and survival status.