Journal: Can J Surg 51(2):97-102, 2008.
Reprint: Center for Emergency Surgery, Clinical Center of Serbia, 2 Paster St. Belgrade 11000, Serbia and Montenegro (Z Lausevic, MD, PhD)
Faculty Disclosure: Abstracted by R. Klotz, who has nothing to disclose.
Multiple organ failure (MOF) is the leading cause of late death after trauma. There is no gold standard for quantification of the degree of organ damage. Several scores are used, the most well-known of which are the Multiple Organ Dysfunction (MOD) score and the Denver postinjury MOF score. There has been no improvement in outcomes of MOF after injury. Injury severity, late or inadequate resuscitation, inadequate surgical intervention, persistent inflammatory focus, previous organ damage, chronic disease and age over 65 years may affect the presentation and outcome of MOF.
Mediators play a role in the development of MOF and may be used as predictors of posttraumatic development and mortality. A dysfunctional systemic inflammatory response syndrome (SIRS) is the central event in MOF pathogenesis. Criteria for SIRS include a body temperature >38ºC or <36ºC, heart rate >90 beats/min, tachypnea (>20 breaths/min at room temperature or a PaCO2 <32 mmHg), white blood cell count >12,000 or <4,000 mm-3 or >10% bands. It is still not possible to identify the risk group in time to undertake efficient intervention.
The aim of this study was to assess the kinetics of C-reactive protein (CRP), interleukin-6 (IL-6), interleukin-10 (IL-10), and phospholipase A2 group II (PLA2-II) as predictors of MOF. The authors also sought to assess criteria for SIRS and Simplified Acute Physiology Score (SAPS II) values and to create predictive models of MOF development.
This prospective study included 75 patients treated for severe injuries at surgical ICUs. Ten patients were excluded due to development of MOF in the first 24 hours after injury and to lethal outcome in the first 48 hours. The remaining 65 patients were followed for 10 days. These patients were separated into two groups: the first group (n=29) were patients with severe injury without organ insufficiency, while the second group (n=36) were patients with severe injury and organ insufficiency. Markers and mediators of inflammation were determined in all patients within the first 24 hours and then on the second, third, seventh and tenth day of hospitalization. Patients with primary injury to the CNS were excluded.
The number of SIRS variables was significantly different between the patient groups with and without MOF on day 5 of hospitalization. Further, a significant correlation was found between SIRS determinants and the appearance and progression of MOF in the first 5 of 7 observed days.
Experience suggests that MOF appears in two forms: early and late. Most studies consider the period within 72 hours of admission to be the upper limits for diagnosis of early MOF. MOF appearing after 72 hours is diagnosed as late. In this study, out of 36 patients with MOF, 55.6% had the early form.
Respiratory insufficiency is almost always the first to appear, followed by cardiovascular decompensation. Hepatic failure is usually a late manifestation of MOF. The mortality rate follows the increase in the number of affected organs. It varies from 11% in patients with single organ failure to 62% in patients with failure of 2 systems. Insufficiency of 3 or more organs almost always results in a lethal outcome, even with the best conditions for treatment.
Patients with MOF had higher CRP levels compared to patients without MOF, indicating CRP levels are a good early marker of morbidity. Increased secretory PLA2-II activity is associated with the development of postinjury MOF. The IL-6 level may be a marker of cytokine cascade and may reflect a complex inflammatory host response and the severity of disease or injury.
IL-6 kinetics in the first days of hospitalization may suggest the development of MOF, even before clear clinical symptoms develop. Average IL-10 after the injury, even in the first 24 hours, indicates the development of MOF. Average daily concentrations of PLA2-II can determine with significant confidence which patients will develop MOF. This study showed that the most important parameters are serum IL-6 concentrations on day 1 and the number of SIRS criteria on day 4. |
