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INFLUENCE OF STRUCTURE AND CHARACTER OF COURSE OF MULTIPLE ORGAN DYSFUNCTION ON OUTCOME OF POLYTRAUMA
Gabdulkhakov R.M., Rakhimova R.F., Lutfarakhamanov I.I., Bulatov R.D.
Bashkir State Medical University, City Clinical Hospital No.21, Ufa, Russia
During the last decades, the rate of road
traffic injuries has shown the characteristics of epidemy, with increasing
scales of natural disasters and increasing incidence of technological disasters.
Injuries have acquired the severe and disabling pattern with simultaneous
injury to two and more anatomical regions of the body, development of shock and
multiple organ dysfunction [1-3]. The severe injury has become the main cause
of mortality in the population at the age before 40.
The strategy for timely and adequate
correction of disorders of functions of vital organs and systems, and also
subsequent efficient control of them will allow decreasing the quality of
treatment and decreasing mortality [4-8].
Objective
– to study the effect of the structure and nature of the course of
multiple organ dysfunction on the outcome of polytrauma.
MATERIALS AND METHODS
A prospective randomized controlled study
included 231 patients with polytrauma (ISS > 15). There were 60.2 % of men
at the age of 18-86 (the mean age of 43.6 ± 16.8) who were admitted to the intensive care unit
of the multi-profile City Clinical Hospital No.21, Ufa, in 2001-2016. The
exclusion criteria were pregnancy, severe decompensated concurrent diseases and
death within 48 hours after injury.
The quantitative
estimation of acute multiple organ dysfunction (MOD) was conducted with Multiple Organ Dysfunction score (MODS) [9, 10].
Logistic regression analysis and ROC-analysis
were used for estimation of influence of structure and features of MOD on
patients’ survival. ROC-analysis was interpreted with estimation of area under
curve (AUC). The predictive power of the model was high at AUC >
0.80. Odds ratio (OR) was used for estimation of a degree of influence of the
risk factors of hospital death on polytrauma outcome. AUC and OR were calculated with 95 % CI.
Med Calc and SPSS were used for statistical preparation of the
materials. Mean arithmetic (M) and standard deviation (SD) were calculated. The
analysis of variance was used for comparison of quantitative data in the
samples, χ2-test
– for analysis of categorical data. The differences were statistically significant at p < 0.05.
The examinations corresponded to WHO Helsinki Declare – Ethical
Principles for Medical Research with Human Subjects and were approved by the
ethical committee of Bashkir State Medical University (the protocol No.22, 12
December 2016).
RESULTS AND DISCUSSION
AIS was 9.74 ± 3.51, ISS –
21.4 ± 13.62 and GCS – 11.5 ± 2.45
in the study group at admission. The hospital mortality was 23.8 % (55 patients).
The intensity of multiple organ dysfunction was 4.9 ± 3.38 according to MODS. Among
MOD syndromes, CNS dysfunction (85.3 %), respiratory (66.2 %), cardiovascular
(60.6 %) and renal (52.2 %) dysfunctions were dominating. Hemostasis system and
liver dysfunctions were less frequent (33.8 % and 22.9 % correspondingly).
The table 1 shows the distribution of MOD syndromes according to their
severity, as well as mortality according to severity of organ dysfunction.
Among severe organ dysfunctions (3-4 points), the most common ones were CNS,
cardiovascular and respiratory dysfunctions. High MODS was associated with high
mortality: the mortality was 100 % in patients with hemostasis system
dysfunction of 4 points, and about 90 % for CNS, cardiovascular and respiratory
dysfunctions.
Table 1. Incidence of organ dysfunctions and mortality (n = 231)
|
System / organ |
Value |
Number of points |
||||
|
0 |
1 |
2 |
3 |
4 |
||
|
CNS |
Incidence, % |
14.7 |
36.5 |
30.7 |
13.9 |
4.3 |
|
Mortality, % |
2.9 |
4.8 |
28.2 |
64.5 |
91 |
|
|
Cardiovascular |
Incidence, % |
39.4 |
35.7 |
11.3 |
10.4 |
3.5 |
|
Mortality, % |
9.9 |
13.4 |
44.4 |
69.6 |
87.5 |
|
|
Respiratory |
Incidence, % |
33.8 |
38.5 |
17.7 |
6.1 |
3.9 |
|
Mortality, % |
2.6 |
18.0 |
46.3 |
71.4 |
88.9 |
|
|
Renal |
Incidence, % |
46.8 |
39.4 |
9.6 |
2.61 |
1.74 |
|
Mortality, % |
14.8 |
26.4 |
40.9 |
50.0 |
75.0 |
|
|
Hemostasis |
Incidence, % |
66.2 |
18.2 |
11.3 |
3.9 |
0.4 |
|
Mortality, % |
13.7 |
31.0 |
50.0 |
77.8 |
100 |
|
|
Liver |
Incidence, % |
77.1 |
20.3 |
1.74 |
0.87 |
- |
|
Mortality, % |
21.9 |
25.5 |
60 |
100 |
- |
|
Multiple organ disorders were identified in most patients. Dysfunction
of a single organ or system was diagnosed in only 6 % of patients. According to
total number of points of organ dysfunctions, all patients were distributed in
this way: the highest number (120 persons) were patients with 1-4 points
(mortality – 5 %); 5-8 points – 73 patients (mortality – 27.4 %); 9-12 points –
31 patients (mortality – 71 %); 13 and more points – 7 patients (mortality –
100 %).
Dysfunction of 2 and more organs and systems appeared in 217 (94 %)
patients. Moreover, in 78 %, MOD disappeared in 48 hours during intensive care.
We can suppose that almost 1/3 of the patients had MOD which developed as
response to a severe injury and showed the transitory pattern. Other 2/3 of the
patients had MOD, which disappeared later, with its manifestation worsening the
prognosis [11, 12].
During 3 days, we performed a comparative study of intensity of MOD in deceased
patients and survivals. Within the first 24 hours, severity of MOD in deceased
patients was 2.1 times higher than in survived ones (p < 0.001): 3.79 ± 2.63 points (n = 176) in survived, 7.96
± 2.89 points (n = 55) in deceased patients. By the third day, a response to
intensive care, the decrease in MOD severity was only 14.7 % in deceased
patients (p = 0.033), whereas survived patients demonstrated 4-folf decrease (p
< 0.001) as compared to the first day.
Therefore, the activity of MOD at admission,
and the subsequent intensity of its manifestations are the important predictors
of poor outcome [13-15].
With logistic regression and ROC-analyses, we
estimated the predictive significance of the dynamic examination of MOD
intensity (the table 2). The conducted studies showed that sensitivity and AUC
of MODS had increased significantly during estimation of prognosis on the
second day and especially on the third day (p < 0.01). Manifestation of MOD
caused 1.49-fold increase in probability of hospital death on the second day (p
< 0.01), 2.75 increase on the third day (p < 0.001) as compared to the
first day.
Table 2. ROC areas and probability of lethal outcome in dynamic examination of number of points (n = 231)
|
Value |
Time of examination, days |
||
|
1 |
2 |
3 |
|
|
AUROC (95% CI) |
0.85 |
0.94*** |
0.97*** |
|
Cut point |
> 4 |
> 3 |
> 3 |
|
Sensitivity |
44.4 |
62.9* |
88.9** |
|
Specificity |
95.6 |
95.5 |
95.5 |
|
Accuracy |
83.5 |
87.8 |
93.9 |
|
Regression ratio (bk) |
0.48 ± 0.07 |
0.88 ± 0.12 |
1.49 ± 0.25 |
|
OR (95% CI) |
1.62 (1.41-1.85) |
2.41** (1.91-3.06) |
4.45*** (2.75-7.21) |
Note: * – p < 0.05; ** – p < 0.01; *** – p < 0.001 in comparison with the first 24 hours; OR – odds ratio.
Therefore, realization of dynamic estimation
of MOD severity as a response to adequate intensive care is more important
during estimation of prognosis.
A degree of influence on an outcome of some
syndromes of organ dysfunctions is important from scientific and practical
perspectives. The logistical regression analysis showed that along with a
number of affected organs and systems, the main factors of the outcome were
dysfunctions of CNS, cardiovascular, respiratory and hemostatic systems (p <
0.01) (the table 3). However renal and hepatic dysfunctions were not associated
with lethal outcome (p > 0.05).
Table 3. Relationship between organ dysfunction and hospital mortality
|
System/organ |
Regression ratio (bk)* |
р |
OR (95% CI) |
|
Respiratory (n = 152) |
0.67 ± 0.24 |
0.0053 |
1.95 (1.22-3.12) |
|
Cardiovascular (n = 140) |
1.20 ± 0.22 |
0.0001 |
3.31(2.16-5.07) |
|
CNS (n = 196) |
1.82 ± 0.28 |
0.0001 |
6.17 (3.60-10.59) |
|
Renal (n = 120) |
0.32 ± 0.24 |
0.178 |
1.38 (0.86-2.21) |
|
Hemostasis (n = 76) |
1.03 ± 0.38 |
0.006 |
2.81(1.34-5.90) |
|
Liver (n = 54) |
0.649 ± 0.623 |
0.297 |
1.91(0.56-6.49) |
|
Number of organs (n = 172) |
1.21 ± 0.19 |
0.0001 |
3.36 (2.30-4.91) |
Note: * standard error.
At the next stage, we tried to estimate the
influence of organ dysfunctions on survival after 7 days. The patients who died
within the first 7 days were excluded. Respiratory (n = 124; р = 0.001; OR = 2.64 (95 % CI = 1.48-4.73) and
hepatic (n = 44; р = 0.032; OR
= 4.73 (95 % CI = 1.14-19.5) dysfunctions demonstrated higher influence on the
outcome after 1 week. The influence of CNS and cardiovascular dysfunctions was
still high, but to a lesser degree as compared to the first day (p < 0.01).
Renal and
hemostasis dysfunctions lost their actuality (p > 0.05).
Therefore, in patients with polytrauma,
dysfunctions of CNS, respiratory, cardiovascular and hemostasis systems, as
well as a number of organ dysfunctions, showed the highest influence on
hospital mortality. After one week, the influence of respiratory and hepatic
dysfunctions increases. The influence of other organs and systems show a trend
to decrease.
CONCLUSION
1. In patients with polytrauma and ISS >
15, the main MOD syndromes are CNS (85.3 %), respiratory (66.2 %) and
cardiovascular (60.6 %) dysfunctions.
2. Dysfunctions of two and more systems and organs are noted in 94 % of
patients. Moreover, 1/3 (35.9 %) had MOD which disappears within 48 hours, i.e.
it has the transitory pattern.
3. The predictive value of MODS increases in the process of its dynamic
examination.
4. Dysfunctions of CNS, cardiovascular, respiratory and hemostasis
systems, as well as a number of organ dysfunctions, make the highest influence
on polytrauma outcome. After one week, the increase in influence of respiratory
and hepatic dysfunctions appears, whereas the influence of dysfunctions of
other organs and systems shows a trend to decrease.
Information on financing and conflicts of interests
The study was conducted without sponsorship. The authors declare the absence of any clear or potential conflicts of interests relating to publication of this article.
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