A 12-year prospective study of postinjury multiple organ failure - Has anything changed?
University of Colorado, Denver, Colorado, United States Archives of Surgery
(Impact Factor: 4.93).
06/2005; 140(5):432-8; discussion 438-40. DOI: 10.1001/archsurg.140.5.432
The incidence and severity of postinjury multiple organ failure (MOF) has decreased over the last decade.
A prospective 12-year inception cohort study ending December 31, 2003.
Regional academic level I trauma center.
One thousand three hundred forty-four trauma patients at risk for postinjury MOF. Inclusion criteria were aged older than 15 years, admission to the trauma intensive care unit, an Injury Severity Score higher than 15, and survival for more than 48 hours after injury. Isolated head injuries were excluded from this study. Previously identified risk factors for postinjury MOF were age, Injury Severity Score, and receiving a blood transfusion within 12 hours of injury.
Multiple organ failure was defined by a Denver MOF score of 4 or more for longer than 48 hours after injury. Multiple organ failure severity was defined by the maximum daily MOF score and the number of MOF free days within the first 28 postinjury days.
Multiple organ failure was diagnosed in 339 (25%) of 1244 patients. The mean age and Injury Severity Scores increased and the use of blood transfusion during resuscitation decreased over the 12-year study period. After adjusting for age, injury severity, and amount of blood transfused during resuscitation, there was a decreased incidence of MOF over the study period. Of the patients who developed MOF, there was a decrease in disease severity and duration as measured by the maximum daily MOF score and the MOF free days. Although the overall mortality rate remained constant, the MOF-specific mortality decreased.
The incidence, severity, and attendant mortality of postinjury MOF decreased over the last 12 years despite an increased MOF risk. Improvements in MOF outcomes can be attributed to improvements in trauma and critical care and are associated with decreased use of blood transfusion during resuscitation.
Available from: Biniam Kidane
- "Multiorgan failure was an outcome in 6 studies that attempted to adjust for other important factors, as seen in Table 3      . Three studies assessed RBC as a continuous variable    and four studies assessed RBC as a binary variable ( 6 units vs. >6 units)    . The study by Cryer et al. could not be included in the pooled analysis as neither the confidence intervals nor standard errors were available. "
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A previous meta-analysis has found an association between red blood cell (RBC) transfusions and mortality in critically ill patients, but no review has focused on the trauma population only.
To determine the association between RBC transfusion and mortality in the trauma population, with secondary outcomes of multiorgan failure (MOF) and acute respiratory distress syndrome (ARDS) or acute lung injury (ALI).
EMBASE (1947-2012) and MEDLINE (1946-2012).
Study Eligibility Criteria
Randomized controlled trials and observational studies were to be included if they assessed the association between RBC transfusion and either the primary (mortality) or secondary outcomes (MOF, ARDS/ALI).
Red Blood Cell Transfusion
A literature search was completed and reviewed in duplicate to identify eligible studies. Studies were included in the pooled analyses if an attempt was made to determine the association between RBC and the outcomes, after adjusting for important confounders. A random effects model was used for and heterogeneity was quantified using the I2 statistic. Study quality was assessed using the Newcastle-Ottawa Scale.
40 observational studies were included in the qualitative review. Including studies which adjusted for important confounders found the odds of mortality increased with each additional unit of RBC transfused (9 Studies, OR 1.07, 95%CI 1.04 – 1.10, I2 82.9%). The odds of MOF (3 studies, OR 1.08, 95%CI 1.02 – 1.14, I2 95.9%) and ARDS/ALI (2 studies, OR 1.06, 95%CI 1.03 – 1.10, I2 0%) also increased with each additional RBC unit transfused.
We have found an association between RBC transfusion and the primary and secondary outcomes, based on observational studies only. This represents the extent of the published literature. Further interventional studies are needed to clarify how limiting transfusion can affect mortality and other outcomes.
Available from: PubMed Central
- "Infectious complications included bacteremia, urinary tract infection, wound infection, fungemia, sepsis, abscess, infected decubitus ulcer, infected hardware, meningitis, and osteomyelitis. The Multiple Organ Failure (MOF) Score was calculated as described by Ciesla et al . The ordinal MOF score was converted to a binary outcome variable with MOF score ≥4 designated as Multiple Organ Failure. "
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ABSTRACT: Advances in technology have made extensive monitoring of patient physiology the standard of care in intensive care units (ICUs). While many systems exist to compile these data, there has been no systematic multivariate analysis and categorization across patient physiological data. The sheer volume and complexity of these data make pattern recognition or identification of patient state difficult. Hierarchical cluster analysis allows visualization of high dimensional data and enables pattern recognition and identification of physiologic patient states. We hypothesized that processing of multivariate data using hierarchical clustering techniques would allow identification of otherwise hidden patient physiologic patterns that would be predictive of outcome.
Multivariate physiologic and ventilator data were collected continuously using a multimodal bioinformatics system in the surgical ICU at San Francisco General Hospital. These data were incorporated with non-continuous data and stored on a server in the ICU. A hierarchical clustering algorithm grouped each minute of data into 1 of 10 clusters. Clusters were correlated with outcome measures including incidence of infection, multiple organ failure (MOF), and mortality.
We identified 10 clusters, which we defined as distinct patient states. While patients transitioned between states, they spent significant amounts of time in each. Clusters were enriched for our outcome measures: 2 of the 10 states were enriched for infection, 6 of 10 were enriched for MOF, and 3 of 10 were enriched for death. Further analysis of correlations between pairs of variables within each cluster reveals significant differences in physiology between clusters.
Here we show for the first time the feasibility of clustering physiological measurements to identify clinically relevant patient states after trauma. These results demonstrate that hierarchical clustering techniques can be useful for visualizing complex multivariate data and may provide new insights for the care of critically injured patients.
Available from: uni-ulm.de
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ABSTRACT: In dieser Arbeit werden die Inzidenz, der Verlauf und das Outcome des posttraumatischen Organ- und Multiorganversagens im Jahr 2005 an der Universität Ulm beschrieben. Es handelt sich hierbei um eine retrospektive Studie mit 55 intensivmedizinisch behandelten Polytraumata. Vorraussetzung war die Aufnahme der Patienten über den Schockraum der Universität Ulm in dem vom 01.01.2005 bis zum 31.12.2005 festgesetzten Studienintervall sowie eine intensivmedizinische Behandlungsdauer von mindestens 48 Stunden. Schwerverletzte unter 18 Jahren oder mit einem Injury Severity Score unter 16 Punkten wurden ausgeschlossen. Die Klassifikation des singulären oder multiplen Organversagens erfolgte unter Anwendung des SOFA-Scores. Insgesamt fiel ein hoher Anteil an über 60-jährigen Polytraumatisierten auf. Die meisten von uns dokumentierten Unfälle entstanden im Straßenverkehr. Insgesamt wurde ein durchschnittlicher Injury Severity Score von 29,1 ± 8,98 Punkten erreicht. Polytraumata mit Sepsis, schwerer Sepsis oder septischem Schock zeigten in 100 % ein Organversagen. Bei einer schweren Sepsis trat ein Multiorganversagen in 67 % und bei einem septischen Schock in 100 % auf. Insgesamt 84 % der Schwerverletzten erlitten ein singuläres (38 %) oder multiples (46 %) Organversagen. Am häufigsten trat ein Herz-Kreislaufversagen (75 %) auf. Ein Lungenversagen zeigten 42 %, ein Nierenversagen 35 %, ein Leberversagen 16 % und ein Gerinnungsversagen 9 % der Verunfallten. Der größte Anteil des Multiorganversagens lag bei Polytraumata mit Leberversagen (100 %). Insgesamt lag die Traumaletalität bei 9 %. In der Gruppe mit Multiorganversagen verstarben 12 %, in der Gruppe mit singulärem Organversagen 10 % der Schwerverletzten. Aufgrund von Unterschieden in den einzelnen Studiendesigns, -populationen, -intervallen und durch eine differente Datenauswertung war der Vergleich der hier beschriebenen Daten mit der aktuell verfügbaren Literatur teilweise eingeschränkt.
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