Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
. 2020 Mar;107(4):402-412.
doi: 10.1002/bjs.11361. Epub 2019 Nov 6.

Multiple organ dysfunction after trauma

E Cole  1 , S Gillespie  1 , P Vulliamy  1 , K Brohi  1 ; Organ Dysfunction in Trauma (ORDIT) study collaborators
Collaborators, Affiliations

Multiple organ dysfunction after trauma

E Cole et al. Br J Surg. 2020 Mar.

Abstract
in English, Spanish

Background: The nature of multiple organ dysfunction syndrome (MODS) after traumatic injury is evolving as resuscitation practices advance and more patients survive their injuries to reach critical care. The aim of this study was to characterize contemporary MODS subtypes in trauma critical care at a population level.

Methods: Adult patients admitted to major trauma centre critical care units were enrolled in this 4-week point-prevalence study. MODS was defined by a daily total Sequential Organ Failure Assessment (SOFA) score of more than 5. Hierarchical clustering of SOFA scores over time was used to identify MODS subtypes.

Results: Some 440 patients were enrolled, of whom 245 (55·7 per cent) developed MODS. MODS carried a high mortality rate (22·0 per cent versus 0·5 per cent in those without MODS; P < 0·001) and 24·0 per cent of deaths occurred within the first 48 h after injury. Three patterns of MODS were identified, all present on admission. Cluster 1 MODS resolved early with a median time to recovery of 4 days and a mortality rate of 14·4 per cent. Cluster 2 had a delayed recovery (median 13 days) and a mortality rate of 35 per cent. Cluster 3 had a prolonged recovery (median 25 days) and high associated mortality rate of 46 per cent. Multivariable analysis revealed distinct clinical associations for each form of MODS; 24-hour crystalloid administration was associated strongly with cluster 1 (P = 0·009), traumatic brain injury with cluster 2 (P = 0·002) and admission shock severity with cluster 3 (P = 0·003).

Conclusion: Contemporary MODS has at least three distinct types based on patterns of severity and recovery. Further characterization of MODS subtypes and their underlying pathophysiology may lead to future opportunities for early stratification and targeted interventions.

Antecedentes: La naturaleza del síndrome de disfunción orgánica múltiple (Multiple Organ Dysfunction Syndrome, MODS) resultante de un traumatismo está evolucionando a medida que avanzan las prácticas de reanimación y más pacientes sobrevive a las lesiones y pueden recibir cuidados críticos. El objetivo de este estudio fue caracterizar los subtipos actuales MODS en atención crítica de trauma a nivel poblacional. MÉTODOS: Los pacientes adultos ingresados en unidades de cuidados intensivos de trauma se incluyeron en este estudio de prevalencia puntual de 4 semanas. MODS se definió como una puntuación total diaria de la escala de Evaluación de Fallo Orgánico Secuencial (Sequential Organ Failure Assessment, SOFA) > 5. Se utilizó el agrupamiento jerárquico de las puntuaciones SOFA a lo largo del tiempo para determinar los subtipos MODS.

Resultados: Se incluyeron 440 pacientes, de los cuales 245 (56%) presentaron MODS. MODS conllevó una alta mortalidad (22% versus 1%, P < 0,001) y 24% de las muertes fueron precoces, durante las primeras 48 horas tras el traumatismo. Se identificaron tres patrones de MODS, estando todos presentes al ingreso. En el tipo 1, MODS se resolvió de forma temprana, con una mediana de tiempo de recuperación de 4 días y una mortalidad del 14%. El tipo 2 presentaba un tiempo de recuperación retardado (mediana 13 días) y una mortalidad del 35%. El tipo 3 presentaba un tiempo de recuperación prolongado (mediana 25 días) y una mortalidad asociada alta del 46%. El análisis multivariable reveló asociaciones clínicas diferentes para cada tipo de MODS, con la administración de cristaloides durante 24 horas fuertemente asociada al tipo 1 (P < 0,001); el traumatismo craneal al tipo 2 (P < 0,01); y la gravedad del shock al ingreso al tipo 3 (P < 0,01). CONCLUSIÓN: Los MODS actuales presentan al menos tres tipos distintos basados en patrones de gravedad y recuperación. La caracterización de los subtipos de MODS y su fisiopatología subyacente puede contribuir a futuras oportunidades de estratificación temprana e intervenciones dirigidas.

PubMed Disclaimer

Figures

Figure 1
Figure 1
Unsupervised hierarchical clustering of sequential organ failure assessment scores from admission to day 28 Shades of red within the heatmap indicate patients with multiple organ dysfunction (MODS), defined by a Sequential Organ Failure Assessment (SOFA) score of 6 or higher. Patients discharged from critical care were assigned a score of 0 (blue). Patients who died within 28 days had missing scores after the date of death (black). Dashed line indicates the level of dendrogram transection used for analysis.
Figure 2
Figure 2
Multiple organ dysfunction syndrome development, recovery and associations Mean Sequential Organ Failure Assessment (SOFA) score in relation to time after admission to hospital by a multiple organ dysfunction syndrome (MODS) clusters and b presence of MODs and traumatic brain injury (TBI); error bars represent 95 per cent confidence intervals and the dotted line indicates the threshold for diagnosing MODS. c Time to resolution of MODS in survivors, defined as time after admission to first reaching a SOFA score of less than 6; the dotted line represents day 8 (discrimination between MODS status in cluster 1 and that in clusters 2 and 3). d Crystalloid administration over 24 h. e Percentage of patients with TBI (head Abbreviated Injury Score of at least 3). f Admission base deficit per cluster. Median values (bold line), i.q.r. (box) and error bars (range) are shown in c,d and f. *P < 0·010 (c,d,f Kruskal–Wallis test with multiple comparisons of selected cluster groups using Bonferroni correction; e χ2 test).
Figure 3
Figure 3
Multiple organ dysfunction syndrome by site and crystalloid use a Percentage of patients who developed multiple organ dysfunction syndrome (MODS) by Organ Dysfunction in Trauma (ORDIT) site in rank order. b Scatter plot showing percentage of patients per site with MODS in clusters 1, 2 and 3 in relation to median crystalloid use per site (cluster 1 MODS: r s = 0·65, P < 0·001; cluster 2 MODS: r s = 0·15, P = 0·424; cluster 3 MODS: r s = 0·56, P = 0·001; all MODS: r s = 0·66, P < 0·001). c Percentage of patients remaining in MODS on each day after admission in quartiles of initial 24‐h crystalloid administration.
See this image and copyright information in PMC

References

    1. Fröhlich M, Lefering R, Probst C, Paffrath T, Schneider MM, Maegele M et al; Committee on Emergency Medicine, Intensive Care and Trauma Management of the German Trauma Society Sektion NIS . Epidemiology and risk factors of multiple‐organ failure after multiple trauma: an analysis of 31 154 patients from the TraumaRegister DGU. J Trauma Acute Care Surg 2014; 76: 921–928. - PubMed
    1. Sauaia A, Moore EE, Johnson JL, Chin TL, Banerjee A, Sperry JL et al Temporal trends of postinjury multiple‐organ failure: still resource intensive, morbid, and lethal. J Trauma Acute Care Surg 2014; 76: 582–592. - PMC - PubMed
    1. Cannon JW, Khan MA, Raja AS, Cohen MJ, Como JJ, Cotton BA et al Damage control resuscitation in patients with severe traumatic hemorrhage: a practice management guideline from the Eastern Association for the Surgery of Trauma. J Trauma Acute Care Surg 2017; 82: 605–617. - PubMed
    1. Shepherd JM, Cole E, Brohi K. Contemporary patterns of multiple organ dysfunction in trauma. Shock 2017; 47: 429–435. - PMC - PubMed
    1. Rosenthal MD, Moore FA. Persistent inflammatory, immunosuppressed, catabolic syndrome (PICS): a new phenotype of multiple organ failure. J Adv Nutr Hum Metab 2015; 1: pii: e784. - PMC - PubMed

Substances