SCCM Resource Library-Epidemiology and Outcomes of Multiple Organ Dysfunction Syndrome Following Pediatric Trauma

Video Transcription

My name is Elizabeth Killeen. I'm a pediatric intensivist at Seattle Children's Hospital, and I'll be presenting on the epidemiology  and outcomes of multiple organ dysfunction syndrome following pediatric trauma. While the majority of pediatric trauma mortality occurs soon after an injury, over a quarter  of pediatric trauma deaths occur after at least 24 hours of hospitalization. It's not well understood how medical sequelae  of the injury that arise during this period of critical care hospitalization may contribute to patient outcomes in addition to ongoing direct effects of the initial injury.  While organ dysfunction following trauma is well described in the adult population as a result of a severe and dysregulated systemic inflammatory response to injury,  little is known about post-traumatic organ dysfunction in children. Most studies of pediatric multiple organ dysfunction syndrome, or MODS, have included very few trauma patients.  And studies evaluating organ dysfunction in pediatric trauma populations have been limited by small sample sizes and use of adult MODS criteria  that likely underestimate organ dysfunction in children due to absence of age-based lab and vital sign thresholds. We thus aim to conduct a comprehensive evaluation  of the prevalence, risk factors, and outcomes associated with the development of organ dysfunction following severe pediatric trauma using pediatric-specific MODS criteria.  In order to compare the prevalence, mortality, and morbidity associated with MODS due to trauma versus other etiologies,  we followed the same methodology used in previously published reports examining MODS in the general PICU population. We conducted a retrospective cohort study  using the Virtual Pediatric Systems Database from 2009 to 2017. VPS is a national database of more than 1.5 million PICU admissions from over 200 participating PICUs  in the US and Canada. And trained registrars at each site input extensive clinical data from each admission. VPS includes organ dysfunction data  for the first 24 hours of the PICU admission by including the individual clinical data points that comprise three commonly used pediatric severity of illness scores.  The Pediatric Index of Mortality, the Pediatric Risk of Mortality score, and the Pediatric Logistic Organ Dysfunction score. We included patients ages one month to 17 years  admitted with an active diagnosis of a traumatic injury. We only included patients admitted following drowning or asphyxiation events if they had sustained traumatic injuries,  such as a spinal cord injury. We excluded patients whose only trauma diagnoses were superficial or soft tissue injuries or foreign bodies. We included patients admitted to the PICU  from the emergency room or the operating room. And only included patients who at least had the components of the PRISM score recorded.  Consistent with the published VPS MODS methodology, we define cardiac, respiratory, neurologic, hematologic, renal, and hepatic dysfunction present  on the first day of PICU admission by age-specific international pediatric sepsis consensus conference criteria for organ dysfunction using the raw vital sign and lab values  included in the PIM, PRISM, and PILAD scores. We assess PICU mortality and morbidity based on changes from baseline to discharge in the pediatric overall performance category  and pediatric cerebral performance category scores, which assess function and neurologic status on a scale of one to six.  We evaluated changes in POPC and PCPC by at least one and two points. And consistent with the prior literature, defined a poor neurologic or functional outcome  as a discharge POPC or PCPC of three or worse with a decline of at least one point from baseline. Finally, we also assessed a composite outcome of death or survival  with a poor functional or neurologic outcome. We evaluated how demographic, medical history, and injury factors were associated with the development of day one MODS  defined as dysfunction in two or more organ systems using generalized linear binomial regression models to conduct bivariate analyses clustered by facility  and included variables with a bivariate p-value less than 0.05 in a multivariable generalized linear Poisson regression model.  We then evaluated how the presence of MODS, the number of dysfunctional organ systems, and the type of organ system involvement were associated with each outcome  using multivariable linear Poisson regression adjusted for age, comorbid medical conditions, injury mechanism and type, and postoperative status.  A total of 31,177 patients from 150 PICUs met inclusion criteria. Half had at least one organ dysfunction on the first day of PICU admission following trauma  and 23.1% met criteria for MODS with two or more dysfunctional organ systems.  This was a higher prevalence of day one MODS than in the two prior general PICU cohorts in BPS from 2004 and 2014 that used identical methodology to define MODS.  Respiratory dysfunction was most common in all three cohorts, but the trauma cohort had relatively higher prevalence of neurologic and renal dysfunction  than the general PICU cohorts.  Several patient characteristics remain in our final multivariable model of risk factors for MODS development, including younger age, non-Hispanic black race,  and having a history of genetic or congenital differences, cardiac disease, or immunosuppression.  Patients who sustained injuries during drowning, asphyxiation, or abusive events were at highest risk for MODS development, as were patients who sustained vascular,  pelvic, chest, and brain injuries.  Finally, patients who underwent surgical intervention prior to PICU admission were also at higher risk of MODS development.  PICU mortality was 20.1% among patients with day one MODS versus 0.5% among patients without day one MODS.  And patients with MODS had significantly lower 90-day survival.  The relative risk of mortality associated with MODS  after adjustment for patient and injury factors was 32.3.  And while mortality among patients without day one MODS was similar in the trauma cohort to the two general PICU cohorts, mortality among patients with MODS following trauma  was twice that of mortality among patients with MODS in the general PICU cohorts, with substantially higher relative risk after adjustment.  Patients with MODS more commonly had declines of both one and two points in POPC between baseline and discharge, with greater risk for decline  after adjustment for confounding factors, as well as declines by at least one and two points in PCPC score, also with greater risk of decline after adjustment.  Nearly a third of MODS survivors had a poor functional or neurologic outcome at discharge compared to 8% of those without MODS. And nearly half of MODS patients  experienced the composite outcome of death or survival with poor functional or neurologic outcome, which was over four times the risk of death or survival  with a poor outcome relative to patients without MODS.  Mortality rose with each additional involved organ system to nearly 70% mortality among patients with four or more dysfunctional organ systems, with worse 90-day survival  with each additional organ system involved,  and a stepwise increase in risk of mortality after adjustment for confounding factors.  Death or survival with a poor functional or neurologic outcome also rose sequentially with each additional involved organ system to 85% among those  with four or more dysfunctional organ systems, and similarly with a stepwise increase in risk of a poor outcome after adjustment.  The mortality rate varied with the type of organ system involved, with the highest mortality among patients with hematologic dysfunction  followed by neurologic and renal dysfunction.  Survival was consistently lowest throughout the first 90 days for patients with hematologic dysfunction, and nearly two-thirds of patients  with hematologic dysfunction experienced death or survival with a poor outcome, as did half of patients with renal or hepatic dysfunction.  In evaluating what combination of organ system involvement was associated with the highest mortality, among patients with two or more dysfunctional organ systems,  the highest mortality was observed for those with hematologic dysfunction in addition to cardiac, neurologic, and renal dysfunction.  For patients with three or more dysfunctional organ systems, mortality was highest among those with combinations of neurologic, cardiac, renal, and hematologic involvement.  This study had several limitations, including that we were unable to evaluate all the components of the IPSCC criteria for organ dysfunction based on the variables included in BPS,  which may have underestimated the prevalence of organ dysfunction,  that we were limited to data for the first 24 hours after admission, and thus can't comment on patterns of organ recovery or later development of organ dysfunction.  That we don't have data on the cause of death and thus can't draw direct correlations between organ dysfunction and mortality,  and that we don't have any long-term morbidity outcomes.  Despite these limitations, we were able to identify that both the prevalence and mortality associated with MODS following pediatric trauma are higher than previously recognized  and higher than in the general PICU population, in part driven by higher prevalence of neurologic and renal dysfunction in the trauma population.  The mechanism of injury is the strongest risk factor for MODS development, suggesting that a hypoxic insult from drowning or asphyxiation may intensify the inflammatory cascade  resulting from the injury itself,  and that the burden of MODS on survivors is substantial.  Given the strong association between day one MODS and both mortality and morbidity, incorporation of early organ dysfunction following trauma may add prognostic value  to two traditional organ severity measures that are based on injury characteristics alone. Thank you very much.

Video Summary

In this presentation, Dr. Elizabeth Killeen discusses the epidemiology and outcomes of multiple organ dysfunction syndrome (MODS) following pediatric trauma. The study aims to understand how medical complications after pediatric trauma contribute to patient outcomes. The study used the Virtual Pediatric Systems Database to evaluate the prevalence, risk factors, and outcomes associated with MODS in children. The study found that half of the patients had at least one organ dysfunction, and 23.1% met criteria for MODS. Patients with MODS had higher mortality rates and poorer functional and neurologic outcomes. The study highlights the need to incorporate early organ dysfunction assessment to improve prognosis in pediatric trauma patients.

Asset Subtitle

Shock Non Sepsis, Worldwide Data, Pediatrics, 2022

Asset Caption

INTRODUCTION: While multiple organ dysfunction syndrome (MODS) is common among general PICU populations, existing studies have found a low incidence of MODS in pediatric trauma patients, typically by applying adult criteria to single-center pediatric cohorts. We used pediatric criteria to determine the incidence and outcomes of MODS among critically injured children in a national PICU database.
METHODS: We conducted a retrospective cohort study of PICU patients < 18 years with traumatic injury in the Virtual Pediatric Systems (VPS) database from 2009-2017. We used International Pediatric Sepsis Consensus Conference criteria to identify MODS on Day 1 of PICU admission and estimated the risk of mortality and poor functional outcome (Pediatric Overall/Cerebral Performance Category [POPC/PCPC] ≥3 with ≥1 point worsening from baseline) for MODS and for each type of organ dysfunction using generalized linear Poisson regression adjusted for age, comorbidities, injury region and mechanism, and post-operative status.
RESULTS: MODS was present on Day 1 of PICU admission in 23.1% of 37,332 trauma patients (n=8,621). PICU mortality was 20.0% among patients with MODS vs. 0.5% among patients without MODS (adjusted RR 32.3, 95% CI 24.1-43.4). Mortality ranged from 1.5% for one dysfunctional organ system to 69.0% for ≥4 organ systems, and was highest among patients with hematologic dysfunction (43.1%) and renal dysfunction (29.6%). Death or poor functional outcome occurred in 46.7% of MODS patients vs. 8.3% of patients without MODS (aRR 4.4, 95% CI 3.4-5.3). Among survivors, MODS was associated with an adjusted mean 5.3 additional PICU days (95% CI 5.2-5.5),.and 40.4% of MODS survivors experienced a decline in POPC/PCPC from baseline vs 9.7% of survivors without MODS (aRR 3.3, 95% CI 2.6-4.3).
CONCLUSIONS: MODS occurs more frequently following pediatric trauma than previously reported and is associated with high risk of morbidity and mortality. Based on existing literature using identical methodology that identified Day 1 MODS in 18.6% of general PICU patients in VPS with 10.3% mortality, both the incidence and mortality associated with MODS are higher among trauma patients than the general PICU population, suggesting the need for particular attention to MODS prevention and treatment strategies among critically injured children.

Meta Tag

Content Type Presentation

Knowledge Area Shock Non Sepsis

Knowledge Area Pediatrics

Knowledge Area Worldwide Data

Knowledge Level Advanced

Membership Level Select

Tag Multiple Organ Dysfunction

Tag Epidemiology Outcomes

Tag Pediatrics

Year 2022

Keywords

epidemiology

outcomes

multiple organ dysfunction syndrome

pediatric trauma

medical complications

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