International Journal of Surgery Open 8 (2017) 1e6

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International Journal of Surgery Open

journal homepage: www.elsevier.com/locate/ijso

Multiple organ dysfunction syndrome (MODS) prediction score in multi-trauma

patients
Leo Rendy*, Heber B. Sapan, Laurens T.B. Kalesaran
Department of Surgery, University of Sam Ratulangi, Faculty of Medicine, Manado, Indonesia

a r t i c l e i n f o a b s t r a c t

Article history: Background: Multiple organ dysfunction syndrome (MODS) in patients with major trauma remains a
Received 12 March 2017 frequent and devastating complication in emergency departments and intensive care units. Easily and
Accepted 14 May 2017 accurately identifying patients at risk for MODS post-injury, especially in multi-trauma cases, is
Available online 17 May 2017
important. The aim of this study was to develop an instrument to predict the development of MODS in
adult multi-trauma patients using clinical and laboratory data available in the first 24 h after trauma.
Keywords:
Methods: We prospectively enrolled adult multi-trauma patients with Injury Severity Score (ISS)
16,
Multi-organ dysfunction syndrome (MODS)
between 16 and 65 years old, admitted to four academic Level-I trauma centers for 1 year between
Multi-trauma
Emergency department
September 2014 and 2015. Sequential organ failure assessment score was used to determine MODS
MODS prediction score during hospitalization. A risk score was created from the final regression model consisting of significant
variables as MODS predictors.
Result: During the period of the study, 98 multi-trauma patients were included. The mean age was 35.2
years, and most were male (85.71%). The mean ISS was 23.6, mostly (76.53%) caused by blunt injury
mechanism. MODS occurred in 43 patients (43.87%). The prediction risk score consists of Revised Trauma
Score (<7.25) and lactate level
2.75 mmol/L. This study also verified several independent risk factors for
post-multi-trauma MODS such as ISS >25, presence of systemic inflammatory response syndrome, shock
grade 2 or more, and white blood cells >12,000.
Conclusion: We derived a novel simple and applicable instrument to predict MODS in adults following
multi-trauma. The use of this scoring system may allow early identification of trauma patients who are at
risk for MODS and result in more aggressive targeted resuscitation and damage control surgery.
Trial registration: ISCRTN ISRCTN16661943. 09/11/2016 retrospectively registered.
© 2017 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access
article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

1. Background physiological disarray and a hyper-inflammatory state leading to

Multi-trauma is defined as injury to at least two body regions
with total injury severity score (ISS) < 16, usually with the presence
of systemic inflammatory response syndrome (SIRS) on at least one
day during the first 72 h [1e3]. Severe trauma may promote
List of abbreviations: MODS, Multiple organ dysfunction syndrome; MOF, Mul-
tiple organ failure; SIRS, Systemic inflammation response syndrome; ATLS,
Advanced trauma life support; DSTC, Definitive surgical treatment care; ISS, Injury
severity score; RTS, revised trauma score; SOFA, Sequential organ failure assess-
ment; GCS, Glasgow coma scale; TOF, Trauma organ failure.
* Corresponding author. Department of Surgery, Medika Dramaga Hopital, Bogor,
West Java, Indonesia.
E-mail address: rendy_mercury@yahoo.com (L. Rendy).
multi-organ dysfunction syndrome (MODS) with multi-organ fail-
ure (MOF) at the end of its spectrum [4].
Incidence of post-trauma MODS-MOF is about 29% [5]. Mortality
among major trauma patients with failure of two organs is 67%, and
approaches 100% if more than three organs have failed [6]. His-
torically, a several trauma scoring system was developed to stratify
trauma patients into mortality risk groups. This paradigm proved
beneficial for triage, better resuscitation and overall patient
management.
Pathophysiology of MODS-MOF after trauma involves injury
severity with ISS
25, the presence of SIRS, and sepsis [7,8]. Pre-
vious studies found several factors correlated with the develop-
ment of MODS after trauma such as older age, high trauma scoring
(as “first hit”), the presence of shock, base deficit <8 mEq/L,
hyperlactatemia>2.5 mmol/L in the first 24 h after trauma, massive

http://dx.doi.org/10.1016/j.ijso.2017.05.003
2405-8572/© 2017 The Authors. Published by Elsevier Ltd on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://
creativecommons.org/licenses/by-nc-nd/4.0/).
2 L. Rendy et al. / International Journal of Surgery Open 8 (2017) 1e6

Table 1 performed. Laboratory data obtained were routine blood cell count
Demographics and characteristics of the study sample. and lactate at admission followed by renal function test, liver
Data Result function test, blood gas analysis, and others as indicated by each
Total, n 98
patient's clinical course.
Age 35.2a The main outcome of MODS-MOF was assessed using the
Sex; male:female 84 (85.71%): 14(14.28%) Sequential Organ Failure Assessment (SOFA) Score [11]. SOFA
Cause 72 (73.47%) identifies organ dysfunction or failure across six organ systems, and
 Traffic accident 12 (12.24%)
consists of measures of PaO2/FIO2 ratio (respiratory system),
 Criminal violence 7 (8.11%)
 Fall from height 2 (1.35%) platelet count (hematology), Glasgow Coma Scale (central nervous
 Animal attack 2 (1.35%) system), mean arterial pressure and inotropics (cardiovascular
 Thermal/electric system), urine output and creatinine level (renal system), and total
Mechanism 74 (75.51%)
bilirubin (liver-digestive system). The occurrence of MODS is
 Blunt 12 (12.24%)
 Penetrating 12 (12.24%)
defined as a SOFA score of
1 in >1 system, and MOF as a SOFA
 Combination score of
3 in
2 organ systems. Other outcomes collected
Pre-hospital duration (hours) 6.33a included intensive care unit and hospital length of stay, and in-
 Referral from other hospital 54 (55.10%) hospital mortality.
 Direct to our trauma center 44 (44.90%)
a
Mean. 3. Results

During the 1-year study period 98 multi-trauma patients met

blood transfusion (>6 bag of packed red blood cells), elevated IL-6
level, and emergency definitive airway in the pre-hospital setting
or resuscitation at the emergency department [9,10]. Rapid and
earlier recognition of risk for MODS would be beneficial for
improving trauma center referral systems, meaning aggressive
resuscitation could begun much earlier before the lethal post-
trauma systemic cascade had evolved into its endpoint (MOF)
with associated high mortality rate and higher health cost. This
study attempted to validate these risk factors and develop a scoring
instrument to predict MODS after injury using variables in the pre-
hospital and emergency department settings.
2. Methods
This 1-year prospective cohort study was held at four academic
level-1 trauma centers in Indonesia:Kandou Hospital, Manado;
Kariadi Hospital, Semarang; Sanglah General Hospital, Bali; and
Universitas Hasanudin Hospital, Makassar. The inclusion criteria
were as follows: multi-trauma patients with ISS
16, age between
16 and 65 years, no chronic co-morbid illnesses, and no previous
major trauma with or without surgery. The study had ethical
clearance approved by ethics review board of each hospital
involved.
Demographic data collected included age and sex, pre-hospital
transport time, vital signs on arrival, definitive airway (performed
during pre-hospital transfer or at the emergency department
before surgery), Abbreviated Injury Scale for each body region to
generate the ISS, final diagnosis, and major intervention or surgery
the criteria for inclusion, and comprised the study population. The
average age was 35.2 years, most patients were male (85.71%, 84 vs
14), most had trauma caused by traffic accidents (73.47%), and most
had blunt trauma (75.51%) (see Table 1). Age and sex were insig-
nificant predictors for MODS so were excluded from the prediction
model.
Of all multi-trauma samples, 43 developed MODS (43.87%). Of
patients who developed MODS, 12 progressed to MOF (12.24%). In-
hospital death occurred in 13 (11 MOF, 2 MODS) (13.26%). Table 2
shows study outcomes and Fig. 1 shows MODS distribution.
Average hospital length of stay for all samples was 11.06 days.
The mean of trauma severity as measured by ISS was 23.59 and
by RTS was 7.345. Most samples showed SIRS (88.89%), had high
white blood cell count (mean 19,455 cells/mL), high lactate level
(mean 3.14 mmol/L), normal average platelet count (229,000 cells/
mL), and 12 patients had emergency definitive airway (12.2%). Of 98
samples, 43 were from patients in varying degrees of shock (mean
grade 2.05). There were five significant variables predictive of
MODS from the univariate analysis (see Table 3) and these were
included in the predictor model.
3.1. Post-multi-trauma MODS prediction score model
After univariate analysis for each independent factor, all vari-
ables were further analyzed using logistic regression analysis.
When the model consisted of all nine variables, statistic analysis
showed no significance. The next step was to construct a prediction
model that included independent variables one by one without

Table 2
Outcomes for the study sample.

Independent variable Mean Significance Cut off point Sensitivity Specificity

ISS 23.59 <0.0001* 25.8 51.2% 80%

Emergency definitive airway 0.99 e e e
RTS 7.354 <0.001* 7.25 65.1% 78.2%
SIRS 88 (88.89%) 0.02*
Shock 2.05 <0.001* 1.86 74.4% 70.9%
Hemoglobin 12.29 0.078 e e
White blood cells count (cells/mL) 19,455 0.048* 11,980 90.7% 25.5%
Platelet count (cells/mL) 229,000 0.128 e e e
Lactate level (mmol/L) 3.14 <0.001* 3.44 48.8% 85.5%

* ¼ p<0.05.
 L. Rendy et al. / International Journal of Surgery Open 8 (2017) 1e6 3

Fig. 1. Distribution of system organ involved in MODS-MOF patients.

losing significance. The most accurate final structure of the model such as ISS. Anatomical damage after multi-trauma is represented
consisted of RTS and lactate level with p ¼ 0.002. The formula/ by ISS. This anatomical injury severity alone has predictive power
equation for this prediction is as follows: for occurrence of MODS [12]. This study included multi-trauma
patients with ISS
16, representing major trauma, as this has a
1 higher likelihood than minor trauma of progressing to MODS-MOF.
P¼ 
1 þ e½10:33þ0:52ðlactate levelÞ1:65ðRTSÞ Anatomical (tissue) damage will induce physiological de-
rangements such as elevated heart and respiratory rates, altered
level of consciousness, and shock, and will stimulate alternative
metabolism pathways (resulting in hyperlactatemia), production of
P ¼ prediction by chance for post-multi-trauma MODS, 0  P  1 inflammation mediators, and development of SIRS with the likeli-
e ¼ 2.71; 10.33 is constant for the best regression model; 0.52 is hood of MODS developing, and ultimately MOF [13,14].
regression coefficient for lactate; 1.65 is regression coefficient Physiological parameters that correlate significantly with MODS
for RTS are RTS, shock, and SIRS. Low RTS, higher degree of shock, and the
presence of SIRS during admission or the pre-hospital setting show
For example, a multi-trauma patient who has head concussion, heavy physiological derangement caused by trauma and inade-
torso blunt trauma, tension pneumothorax, and zygomatic fracture quate resuscitation. In cases of inadequate resuscitation, the
admitted to the emergency department with systolic blood pres- cascade of hyper-inflammation of SIRS-MODS-MOF may occur, and
sure of 80 mmHg, respiratory rate 30 times per minute, and GCS 14 this must be addressed by Advanced Trauma Life Support (ATLS)
has an RTS of 6.817 (see Additional File 1 for RTS calculation) and and Definitive Surgical Trauma Care (DSTC) principles. Other pa-
lactate meter of 4.5 mmol/L. rameters of significance that represent worsening body function
Prediction score for post-multi-trauma MODS ¼ are high lactate level (>2.75 mmol/L) and leukocytosis
1þe
1
ð10:3þ0:52:4:51:65:6:817Þ ¼ 0:92ð92%Þ, meaning this patient has a 92% (>11,980e12,000/mL). The number of leukocytesin the systemic
likelihood of eventually developing MODS. circulation increases when the systemic inflammation response
triggered by trauma becomes excessive. Hyperlactatemia occurs in
response to activation of anaerobic metabolic pathways when the
4. Discussion aerobic metabolism is compromised such as in hypovolemic shock,
ischemia, and hypoxia, particularly in patients in need of emer-
Regardless of the type of trauma whether it is blunt trauma, gency airway support.
penetrating or combination of both, any trauma mechanism will All these variables interact in a variety of ways. For example, the
create damaged to tissue which is represented by trauma score definitions of SIRS and shock overlap in terms of vital signs. Patients
with severe hypovolemic shock will have lower RTS because they
Table 3 have lower blood pressure, consciousness level, and respiration
Independent variables as MODS predictors and their significance. rate. Leukocytosis is a definition component in SIRS. Trauma pa-
tients with hypovolemic shock caused by massive bleeding may
Data n Percentage
have thrombocytopenia, anemia, lower blood pressure and reduced
MODS 43 43.87%a consciousness (lower RTS). Patients with severe injury in several
 2 organ systems  20  46.51%b
 3 organ systems  16  37.21%b
body regions (high ISS) may have shock with ongoing bleeding

4 organ systems  7  16.28%b followed by lower hemoglobin level, tachycardia and more rapid
MOF 12 of 43 MODS developed to MOF 12.24%a and 27.91%b breathing during SIRS. Trauma patients who need emergency
In-hospital death 13 (11 from MOF, 2 from MODS) 13.26%a and 30.23%b airway support are in a hypoxic state, and if hemorrhagic shock
Hospital LOS (days) 11.06a and 12.28b
occurs this will activate anaerobic metabolic pathways resulting in
ICU treatment (days) 1.59a and 2.95b
hyperlactatemia. Logistic regression analysis helps us to calculate
a
Of all multi-trauma samples. relationships among these predictive factors and their outcomes
b
Of all MODS samples.
4 L. Rendy et al. / International Journal of Surgery Open 8 (2017) 1e6

[15]. The results of our multivariate logistic regression analysis 4.4. Further works
identified two significant variables predictive of MODS after multi-
trauma: lactate level and RTS. Further large-scale studies are needed to prospectively validate
this predictive tool in other heterogeneous trauma populations at
multi-trauma centers.
4.1. Outcome measure
Funding
MODS occurred in 43.87% of multi-trauma samples of whom
one-third eventually developed MOF in
3 organ systems with a
None.
mortality rate of 91.67%. Organ systems involved in MODS after
multi-trauma in our study are shown in Additional File 2. MODS is
the last step before MOF. MODS and MOF have high mortality rates Availability of data and material
and management of MODS at the intensive care unit is associated
with a high health care cost. Rather than trying to cure MODS, early The datasets during and/or analysed during the current
detection and prevention strategies are more valuable [16]. study available from the corresponding author on reasonable
Directed resuscitation and damage control strategy as early as request.
possible will hopefully reduce the morbidity and mortality caused
by MODS-MOF after multi-trauma, and this may be achieved by Authors' contributions
detecting patients at highrisk for MODS as early as possible using a
predictive tool. LR-study design, collection of data, interpretation of data, sta-
tistical analysis, drafted manuscript. HBS- study design, interpre-
tation of data, critically reviewed manuscript. LK- study design,
4.2. Post-multi-trauma MODS prediction score (PMPS) interpretation of data, critically reviewed manuscript. All authors
read and approved the final version of the article.
This prediction score is an instrument for use during the acute
phase of trauma to stratify patients at risk for MODS after multi-
trauma. According to this instrument, patients with a PMPS Competing interests
score >0.5 (50% chance of getting MODS) will be transferred to
level-I/Major Trauma Center, with 24-h stand-by of trauma sur- The authors declare that they have no competing interests.
geons and surgical intensive care unit, with the objective of early
directed intervention in the SIRS-MODS-MOF-death cascade as Consent for publication
early as possible. Patients predicted as being less likely to develop
MODS (PMPS score <0.5) will be transferred to level II-III Trauma Not applicable.
Center/Trauma Unit. See Additional File 3 for a list of trauma
centers.
Ethics approval and consent to participate
A similar study on organ failure after trauma describes the
Denver Emergency Department Trauma Organ Failure (TOF)
The study was approved after review of the protocol by local
score [17]. In that study, a single center study of 4000 adult
institutional review board of all hospital involved in this study.
trauma participants, Vogel et al. developed a score for predicting
multi-organ failure after trauma using a logistic regression model
and SOFA score to define MOF. The TOF score consists of several Acknowledgments
variables such as age
65 years, emergency intubation, hemat-
ocrit level, systolic blood pressure, blood urea nitrogen
30 mg/ The authors wish to thank Professor J.H Lolombulan for the
dL, and leukocytes
20,000/mL. There are several differences computer program used to solve the equations of post-multi-
between that study and ours. First, the Denver TOF study is trauma MODS prediction score.
retrospective while ours is a prospective cohort. Its inclusion
criteria collected all trauma patients including minor trauma, Appendix 1. RTS calculation
while our study only include major trauma, which has a higher
likelihood of progressing to MODS then MOF. It may be prefer-
able to create a tool to predict a worse state of disease (MODS)
before this reaches its severest form (MOF) by which time it is
more difficult to manage.
Respiratory rate (breaths/min) 0 1e5 6e9 >30 10e29
Score 0 1 2 3 4
4.3. Conclusion Score x 0.2908 ¼ a
Systolic blood pressure (mm Hg) 0 1e49 50e75 76e89 >90
Score 0 1 2 3 4
We derived a novel simple and applicable instrument to predict
Score x 0.7326 ¼ b
MODS in adults following multi-trauma. The use of this scoring Glasgow Coma Score 3 4e5 6e8 9e12 13e15
system may allow early identification of trauma patients in the first Score 0 1 2 3 4
24 h after multi-trauma. The “alarm” sign may stratify patients who Score x 0.9368 ¼ g
are at risk for MODS and result in more aggressive targeted RTS ¼ a þ b þ g (score range 0e7.8408)

resuscitation and better management.

 L. Rendy et al. / International Journal of Surgery Open 8 (2017) 1e6 5

Appendix 2. Distribution of multiple organ dysfunction

syndrome after multi-trauma and the organ system involved

MODS Respiration Cardiovascular Renal Hematology Neurology Liver Total

2 organ systems 8 6 7 4 6 0 31 (25.6%)

3 organ systems 13 14 7 11 11 1 57 (47.1%)

4 organ systems 7 5 7 6 6 2 33 (27.3%)
Total 28 (23.1%) 25 (20.6%) 21 (17.4%) 21 (17.4%) 23 (19%) 3 (2.5%) 121 (100%)

Appendix 3. Levels of trauma center

Type of trauma center Level of care Element of care Additional function

RCS ACS

Major Trauma Level-I Tertiary care facility central to the trauma 24 h in house coverage  Medical rehabilitation
Center (MTC) system  General surgeons, anesthesiology, all surgical  Referral resource for
Total care traumatology from prevention to subspecialists communities in nearby regions
rehabilitation  Emergency medicine  Provides leadership in
 Radiology prevention, public education to
 Internal medicine surrounding communities
 Pediatrics  Education of the trauma team
 Critical care members, organized teaching,
 Hemodialysis research efforts, new innovations
in trauma care
 Meets minimum requirement for
annual volume of severely
injured patients
Trauma Unit Level-II Able to initiate definitive care for all injured 24-h immediate coverage by general surgeons, as well Provides trauma prevention and
(TU) patients as specialists in orthopedic surgery, neurosurgery, continuing education program for
anesthesiology, emergency medicine, radiology, and staff
critical care.
Tertiary care needs such as cardiac surgery,
hemodialysis, and microvascular surgery may be
referred to Level I
Level-III Able to provide prompt assessment, 24-h immediate coverage by emergency medicine  Has developed agreements for
resuscitation, surgery, intensive care and Prompt availability of general surgeons and patients requiring more
stabilization of injured patients and anesthesiologists comprehensive care than Level I
emergency operations or II Trauma Center
 Provides back-up care for rural
and community hospitals
 Offers continuing education for
the nursing and allied health
personnel or the trauma team
 Involved with the prevention
efforts and must have an active
outreach program for its referring
communities
Local Level-IV Able to provide ATLS prior to transfer of Basic emergency department facilities to implement Has developed transfer agreements
Emergency patients to a higher level trauma center ATLS for patients requiring more
Hospital Provides evaluation, stabilization, and 24-h laboratory coverage. comprehensive care at Level I or II
(LEH) diagnostic capabilities for injured patients Available trauma nurse and physicians upon patients' Trauma center
arrival
May provide surgery and critical care if available
Level V Provide initial stabilization and diagnostic Basic emergency department facilities to implement Has developed transfer agreements
capabilities and prepares patients for ATLS for patients requiring more
transfer to higher level of care Available trauma nurse and physician available upon comprehensive care at Level I to III
patient arrival. trauma center
After hour activation protocol if facility is not open
24 h a day
May provide surgery and critical care services if
available

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