Early Dynamic Orchestration of Immunologic Mediators Identifies Multiply Injured Patients who are Tolerant or Sensitive to Hemorrhage.

Multiply injured patients are at risk of complications including infections, acute and prolonged organ dysfunction. The immunologic response to injury has been shown to affect outcomes. Recent advances in computational capabilities have shown that early dynamic coordination of the immunologic response is associated with improved outcomes after trauma. We hypothesized that patients who were sensitive or tolerant of hemorrhage would demonstrate differences in dynamic immunologic orchestration within hours of injury. METHODS We identified two groups of multiply injured patients that demonstrated distinct clinical tolerance to hemorrhage (n = 10) or distinct clinical sensitivity to hemorrhage (n = 9) from a consecutive cohort of 100 multiply injured patients. Hemorrhage was quantified by integrating elevated shock index values for 24 hours after injury (Shock Volume). Clinical outcomes were quantified by average Marshall Organ Dysfunction Scores (MODS) from days two to five (aMODSD2-D5) after injury. Shock Sensitive (SS) patients had high cumulative organ dysfunction after lower magnitude hemorrhage. Shock Tolerant (ST) patients had low cumulative organ dysfunction after higher magnitude hemorrhage. Computational methods were used to analyze a panel of twenty immunologic mediators collected serially over the initial 72 hours after injury. RESULTS Dynamic Network Analysis demonstrated the ST patients had increased orchestration of cytokines that are reparative and protective including interleukins 9, 17E/25, 21, 22, 23 and 33 during the initial 0-8hr and 8-24hr intervals after injury. SS patients had delayed immunologic orchestration of a network of largely pro- and anti-inflammatory mediators. Elastic Net Linear Regression demonstrated that a group of five mediators could discriminate between SS and ST patients. CONCLUSIONS Preliminary evidence from this study suggest that early immunologic orchestration discriminates between patients who are notably tolerant or sensitive to hemorrhage. Early orchestration of a group of reparative/protective mediators was amplified in Shock Tolerant patients.Original Article Prospective Clinical Outcomes Study LEVEL OF EVIDENCE: III.