The management of the surgical patient with multiple system organ failure remains a formidable problem. Despite advances in critical care, the mortality of multiple organ failure remains unchanged since the syndrome was characterized almost two decades ago. At the present time there are no modalities that can actively reverse established organ failure, hence the treatment of these patients consists of metabolic and haemodynamic support until the process reverses itself or death occurs. Therefore, the best management of the surgical patient at risk for multiple organ failure is prevention of the syndrome. Strategies to avoid organ failure include early fixation of long bone fractures, prompt restoration of perfusion and oxygen delivery, the aggressive diagnosis and drainage of abdominal infection prior to organ failure, early institution of enteral nutrition and the use of specific nutritional substrates and formulas. This review will examine the current theories in the pathogenesis of multiple organ failure and detail two clinical decisions, early stabilization of fractures and prompt re-exploration for suspected abdominal sepsis, that have been associated with a reduction in the frequency of the development of organ failure.