Beyond the first target-range blood pressure: persistent multidomain physiologic abnormalities and mortality in trauma-associated shock

Abstract Conventional blood-pressure targets may be reached during trauma resuscitation while metabolic, thermal, and coagulation abnormalities persist. We examined whether this residual burden was associated with mortality. MIMIC-IV v3.1 was primary; eICU provided a common-variable cross-database analysis. The index was the first ICU hour with mean arterial pressure ≥ 65 mmHg or systolic blood pressure ≥ 90 mmHg; prior hypotension was not required. Mean burden across three hourly domains (0–3) was summarized through a fixed 6-h landmark among patients alive, still in the ICU, and evaluable at that time. Of 640 eligible MIMIC-IV stays, 428 were evaluable at 6 h; 108 subsequently died. Each one-domain increase was associated with hospital mortality (adjusted odds ratio 2.26, 95% confidence interval 1.64–3.10). Cause-specific hazard ratios were 3.19 (1.86–5.48) during 0–24 h, 2.66 (1.58–4.49) during 24–72 h, and 1.36 (1.00-1.85) thereafter. The association was present in both MIMIC-IV hemorrhage-phenotype strata (interaction P = 0.790). In eICU, the adjusted odds ratio was 2.46 (2.22–2.74). Residual multidomain burden was associated with higher mortality, especially within 72 h, supporting continued reassessment of unresolved shock physiology after a target-range pressure is first observed.