A new prognostic scoring system for meningococcal septic shock in children. Comparison with three other scoring systems

OBJECTIVE: To develop a quick and sensitive method for identification of children with presumed meningococcal septic shock at risk of death at admission to the pediatric intensive care unit (PICU) and to compare its performance with three other prognostic systems: Glasgow Meningococcal Septicaemia Prognostic Score (GMSPS), Malley score and the Paediatric Index of Mortality (PIM). DESIGN: Multicenter retrospective cohort study. SETTING: PICUs of 14 tertiary hospitals. PATIENTS: The developmental sample included 192 children consecutively admitted to the PICUs with presumed or confirmed meningococcal septic shock from 1983 to 1995. The validation sample included 158 children consecutively admitted from 1996 to 1998. INTERVENTIONS: Clinical and laboratory data gathered during the first 2 h after admission were used to develop the new score and to compute the other scoring systems. Logistic regression was applied to identify the independent predictors of death. MEASUREMENTS AND RESULTS: Overall mortality was 31.5%. The new score included seven variables: cyanosis (2 points), Glasgow coma scale less than 8 (2 points), refractory hypotension (2 points), oliguria (1 point), leukocytes less than 4000/mm(3) (1 point), partial thromboplastin time more than 150% of control value (1 point) and base deficit more than 10 mmol/l (1 point). The new score provided the best discriminative capability, as measured by the area under the ROC curve (SEM) in the validation sample =0.88 (0.03), PIM =0.82 (0.04), Malley I =0.80 (0.04), GMSPS =0.79 (0.04) and Malley II =0.76 (0.04). CONCLUSIONS: A new prognostic score is proposed for therapeutic stratification of children with presumed meningococcal septic shock.     

The Multiple Organ Dysfunction Score (MODS) versus the Sequential Organ Failure Assessment (SOFA) score in outcome prediction

OBJECTIVE: To compare outcome prediction using the Multiple Organ Dysfunction Score (MODS) and the Sequential Organ Failure Assessment (SOFA), two of the systems most commonly used to evaluate organ dysfunction in the intensive care unit (ICU). DESIGN: Prospective, observational study. SETTING: Thirty-one-bed, university hospital ICU. PATIENTS AND PARTICIPANTS: Nine hundred forty-nine ICU patients. MEASUREMENTS AND RESULTS: The MODS and the SOFA score were calculated on admission and every 48 h until ICU discharge. The Acute Physiology and Chronic Health Evaluation (APACHE) II score was calculated on admission. Areas under receiver operating characteristic (AUROC) curves were used to compare initial, 48 h, 96 h, maximum and final scores. Of the 949 patients, 277 died (mortality rate 29.1%). Shock was observed in 329 patients (mortality rate 55.3%). There were no significant differences between the two scores in terms of mortality prediction. Outcome prediction of the APACHE II score was similar to the initial MODS and SOFA score in all patients, and slightly worse in patients with shock. Using the scores' cardiovascular components (CV), outcome prediction was better for the SOFA score at all time intervals (initial AUROC SOFA CV 0.750 vs MODS CV 0.694, p<0.01; 48 h AUROC SOFA CV 0.732 vs MODS CV 0.675, p<0.01; and final AUROC SOFA CV 0.781 vs MODS CV 0.674, p<0.01). The same tendency was observed in patients with shock. There were no significant differences in outcome prediction for the other five organ systems. CONCLUSIONS: MODS and SOFA are reliable outcome predictors. Cardiovascular dysfunction is better related to outcome with the SOFA score than with the MODS.     

脓毒症性休克伴MODS患者的预后评分估计

目的：探讨序贯器官衰竭估计（SOFA）评分和简化多系统器官衰竭（sMSOF)评分体系对脓毒症性休克伴多器官功能不全综合征（MODS）的预后预测作用。方法：回顾性分析51例脓毒症性休克伴MODS患者的资料，采用SOFA评分和sMSOF评分体系，分析这两种评分的入院评分，最大评分，△评分与预后的关系。结果：（1）51例脓毒症性休克伴MODS患者中存活7例，死亡44例，两组在性别年龄、住ICU时间、手术／非手术，入院至脓毒平性休克发生时间无差异。（2）51例患者在入ICU时或在ICU中均发生感染，感染部位以呼吸系统为多（62．8％），感染病原菌多为G^-菌感染（88．2％），合并霉菌感染26例（51．0％）。（3）入院SOFA评分两组无差异，最大SOFA评分和△SOFA评分死亡组明显高于存活组（P＜0．001），最大sMSOF评分、△sMSOF评分死亡组明显高于存活组（P＜0．05，P＜0．0001），而入院sMSOF评分存活组反而明显高于死亡组，结论：在脓毒症性休克伴MODS患者，入院时的SOFA评分及sMSOF评分不能预测预后，二种评分的最大评分和△评分对预后有很好的预测作用。     

Comparison of disease severity scoring systems in septic shock

OBJECTIVE: To compare six disease severity scoring systems as predictors of mortality in septic shock when used in the first 24 hrs of diagnosis. The six scoring systems tested were: Multiorgan Failure; the Acute Organ System Failure; the Acute Physiology and Chronic Health Evaluation (APACHE II); the Multisystem Organ Failure scoring system; the Mortality Prediction Model; and the grading of sepsis. DESIGN: Retrospective, case series, consecutive sample. SETTING: Adult ICUs of three teaching hospitals. PATIENTS: Seventy-one patients from 12 to 84 yrs, fulfilling specific criteria for the diagnosis of septic shock, who were admitted to the ICU during 15 consecutive months. MEASUREMENTS AND MAIN RESULTS: The Multiorgan Failure scoring system, Acute Physiology and Chronic Health Evaluation (APACHE II), and Acute Organ System Failure scoring system were found, with our modifications, to be statistically significant predictors of mortality. Predictive data for these three scoring systems were as follows: Multiorgan Failure scoring system p = .008, mean number of points of survivors 5.2 +/- 1.5 (SD), mean number of points of nonsurvivors 6.3 +/- 1.5; APACHE II p = .013, mean number of points of survivors 21.1 +/- 5.9, mean number of points of nonsurvivors 24.6 +/- 6.0; and Acute Organ System Failure scoring system p = .011. None of the other three scoring systems showed significant predictive ability: Multisystem Organ Failure scoring system p = .072, Mortality Prediction Model p = 0.091, and the grading of sepsis p = .27. There was a significant (p = .004) difference in the survival rate of the three hospitals. CONCLUSION: The Multiorgan Failure scoring system, APACHE II, and the Acute Organ System Failure scoring system, with minor modifications, were found to be useful prognostic tools for patients with septic shock and allowed us to compare the performance and treatment programs of different ICUs.     

Comparison of the performance of two general and three specific scoring systems for meningococcal septic shock in children

OBJECTIVE: To evaluate the performance at admission to the pediatric intensive care unit (PICU) of five severity scores, two general (the Pediatric Risk of Mortality [PRISM] II and III scores) and three specific for meningococcal septic shock (Leclerc, Glasgow Meningococcal Septicemia Prognostic Score [GMSPS], and Gedde-Dahl's MOC score) in children with this condition. DESIGN: Multicenter, retrospective, cohort study. SETTING: The PICUs from four tertiary centers. PATIENTS: Patients were 192 children ranging in age from 1 month to 14 yrs consecutively admitted to the participating PICUs during a period of 12 yrs and 6 months (January 1983 to June 1995), who were diagnosed with presumed or confirmed meningococcal septic shock. Patients with a length of stay <2 hrs were excluded from the study. INTERVENTIONS: Clinical and laboratory data gathered during the first 2 hrs after admission were used to compute the scoring systems tested. MEASUREMENTS AND MAIN RESULTS: There were 66 deaths (34%). Neisseria meningitidis was cultured from 142 (74%) children. GMSPS and PRISM II provided the best discriminative capability, as measured by the area under the receiver operating characteristic curve (SEM): 0.816 (0.036) and 0.803 (0.041), respectively. The other three scores gave lower receiver operating characteristic areas: PRISM III = 0.777 (0.043), MOC = 0.775 (0.037), and Leclerc = 0.661 (0.045). There was a statistically significant difference between the areas under the receiver operating characteristic curve of GMSPS and Leclerc (p < .01) but not between the GMSPS and the remaining three scores. All five scores presented good calibration with no significant differences between observed and predicted mortality (Hosmer-Lemeshow goodness-of-fit test). CONCLUSIONS: The specific GMSPS and the general pediatric severity system PRISM II performed better than the other three scores, being appropriate tools to assess severity of illness at admission to the PICU in children with presumed meningococcal septic shock.     

High adenosine plasma concentration as a prognostic index for outcome in patients with septic shock

OBJECTIVE: Sepsis and septic shock are a common cause of mortality in critically ill patients. Many substances have been implicated in the pathophysiology of these syndromes. We postulated that adenosine may be implicated in the sepsis- or septic shock-induced blood pressure failure. Indeed, this nucleoside is a strong endogenous vasodilating agent released by endothelial cells and myocytes under circumstances of metabolic stress, such as during critical illness. DESIGN: A prospective, comparative observational study. SETTING: The adult intensive care unit of a tertiary care university hospital. PATIENTS: We measured adenosine plasma concentration (APC) in patients with severe sepsis (n = 11), in patients with septic shock (n = 14), in patients with hemorrhagic traumatic shock (n = 14), and in 12 healthy volunteers. APC was evaluated every 12 hrs over 3 days. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: At study entry, we found that APC was higher in patients with septic shock (mean +/- so = 8.4 +/-3.5 micromol/L) than in patients with hemorrhagic traumatic shock (1.1 +/- 0.6 micromol/L) and controls (0.8 +/- 0.3 micromol/L). Intermediate values (3.9 +/- 1.9 micromol/L) were found in patients with severe sepsis. APC in patients with traumatic shock did not differ from controls. In the course of the hospitalization, for both sepsis and septic shock patients, APC decreased significantly but remained higher than controls 72 hrs after entry into the study. In the septic shock group, APC was significantly higher in the nonsurvivor group (n = 6) than in the survivor group (n = 8), whatever the time of sample collection and assay. CONCLUSIONS: High adenosine plasma concentrations are found in patients with septic shock but not during traumatic shock, or in healthy volunteers. Intermediate values of circulating adenosine are found in patients with severe sepsis. APC may be a prognostic index for outcome in septic patients, with much higher values being found in nonsurvivors.     

The effects of norepinephrine infusion on oxygen consumption in a patient with septic shock

A 65-year-old man developed postsurgical septic shock, unresponsive to plasma volume expansion and administration of dopamine and dobutamine. A continuous norepinephrine infusion was then started and the dose increased to 0.62 g·kg^–1·min^–1 until the mean arterial pressure was 70 mmHg. Prior to and during the norepinephrine infusion, oxygen consumption was continuously measured with a mass spectrometer system. There was a parallel increase in mean arterial pressure and oxygen consumption (+35%). There was also an increase in cardiac index and oxygen delivery. Systemic vascular resistance was only transiently increased. In this case with septic shock, norepinephrine infusion improved hemodynamic variables with an associated increase in oxygen consumption.     

Cell-free plasma DNA as a predictor of outcome in severe sepsis and septic shock

BACKGROUND: Increased concentrations of cell-free DNA have been found in plasma of septic and critically ill patients. We investigated the value of plasma DNA for the prediction of intensive care unit (ICU) and hospital mortality and its association with the degree of organ dysfunction and disease severity in patients with severe sepsis. METHODS: We studied 255 patients with severe sepsis or septic shock. We obtained blood samples on the day of study inclusion and 72 h later and measured cell-free plasma DNA by real-time quantitative PCR assay for the beta-globin gene. RESULTS: Cell-free plasma DNA concentrations were higher at admission in ICU nonsurvivors than in survivors (median 15 904 vs 7522 genome equivalents [GE]/mL, P < 0.001) and 72 h later (median 15 176 GE/mL vs 6758 GE/mL, P = 0.004). Plasma DNA values were also higher in hospital nonsurvivors than in survivors (P = 0.008 to 0.009). By ROC analysis, plasma DNA concentrations had moderate discriminative power for ICU mortality (AUC 0.70-0.71). In multiple regression analysis, first-day plasma DNA was an independent predictor for ICU mortality (P = 0.005) but not for hospital mortality. Maximum lactate value and Sequential Organ Failure Assessment score correlated independently with the first-day plasma DNA in linear regression analysis. CONCLUSIONS: Cell-free plasma DNA concentrations were significantly higher in ICU and hospital nonsurvivors than in survivors and showed a moderate discriminative power regarding ICU mortality. Plasma DNA concentration was an independent predictor for ICU mortality, but not for hospital mortality, a finding that decreases its clinical value in severe sepsis and septic shock.     

Yersinia septic shock following an autologous transfusion in a pediatric patient.

Although the literature on infections transmitted via transfused blood focuses on viruses, Yersinia enterocolitica can also cause severe infections in patients receiving transfusions. A 13-year-old patient developed severe sepsis after an autologous blood transfusion contaminated with Y. enterocolitica. The patient was an otherwise healthy female undergoing posterior spinal fusion for congenital scoliosis. Prior to surgery, the patient donated blood for perioperative and postoperative use. A few days before the donation, she had complained of abdominal pain and was experiencing mild diarrhea. The patient received four units of packed red blood cells (PRBCs) during the surgery. Intraoperatively, the patient developed fever up to 103.6 degrees F, became hypotensive requiring epinephrine and dopamine, and developed metabolic acidosis with serum bicarbonate concentration dropping to 16 mmol/l. The surgery team believed the patient was experiencing malignant hyperthermia and attempted to cool patient during the procedure. Postoperatively, the patient was transferred to the pediatric intensive care unit and treated for severe shock of unknown etiology. The patient further developed disseminated intravascular coagulation. The patient received supportive care and was started on ampicillin/sulbactam on postoperative day (POD) one which was changed to clindamycin, ciprofloxacin and tobramycin on POD two when blood cultures grew gram-negative bacilli. On POD three, cultures were identified as Y. enterocolitica and antibiotics were changed to tobramycin and cefotaxime based on susceptibility data. Sequelae of the shock included adult respiratory distress syndrome requiring intubation and a tracheostomy and multiple intracranial hemorrhagic infarcts with subsequent seizure disorder. Due to severe lower extremity ischemia, she required a bilateral below the knee amputation. The cultures of the snippets from the bags of blood transfused to the patient also grew Y. enterocolitica. This case illustrates the importance of considering transfusion related bacterial infections in patients receiving PRBCs. All patients in shock following any type of transfusion may require aggressive antibiotic therapy, until the diagnosis and etiology are known.     

Acute septic shock during thrombolysis in a patient with acute pulmonary thromboembolism

A 65-year-old man developed severe septic shock during thrombolytic treatment with urokinase for pulmonary thromboembolism associated with deep venous thrombosis of the right lower limb. Blood cultures were positive forKlebsiella pneumoniae and treatment was successful only when the antibiotics were infused via the same route as the urokinase.     

高容量血液滤过对多器官功能障碍综合征患者炎症介质的影响

目的:观察高容量血液滤过(HVHF)对多器官功能障碍综合征(MODS)患者炎症介质的清除效果,探讨HVHF对MODS患者的治疗作用.方法:19例MODS患者随机分为HVHF组10例和连续性静脉-静脉血液滤过(CVVH)组9例;用酶联免疫吸附法(ELISA)测定HVHF和CVVH治疗前及治疗后6、12、24 h时患者血清中肿瘤坏死因子-α(TNFα)、白细胞介素-6(IL-6)、白细胞介素-8(IL-8)水平,并观察两组患者的死亡率、ICU住院时间和血浆尿素氮(BUN)、肌酐(Scr)值的变化.结果:HVHF和CVVH治疗后两组患者血清TNFα、IL-6、IL-8水平均有下降;HVHF治疗组患者各时间点血清中TNFα、IL-6、IL-8下降更为明显(P＜0.05).结论:HVHF治疗能明显增加MODS患者血清中TNFα、IL-6、IL-8的清除能力,改善MODS患者的预后.     

成人重症监护病房患者多器官功能障碍综合征预后因素分析

目的：分析多器官功能障碍综合征（MODS）患者病因构成、病死率、预后等情况。方法：收集上海市徐汇区中心医院和上海交通大学附属新华医院成人重症监护病房（ICU）2008年9月—2009年9月,84例MODS病史资料,进行流行病学分析。结果：（1）成人ICU MODS年发病率为12.28%,总住院病死率46.43%。（2）原发病包括感染、手术后、休克、心肺复苏后,其中感染占33.33%、手术后占17.86%、胰腺炎占19.05%、休克占9.52%、心肺复苏后占4.76%、其他（包括中毒、药物过敏、挤压综合征、肠系膜血栓、肺栓塞、自免性疾病等）占15.48%。（3）70岁以上与70岁以下患者病死率有显著差异（P=0.025）（4）各器官功能障碍发生率分别为肺89.29%、循环系统61.9%、凝血系统55.95%、肾51.19%、脑23.81%、肝22.62%、胃肠8.33%。（5）患者病死率随着发生功能障碍器官数目的增加而显著升高,3个以上器官障碍与2个器官障碍的病死率有显著差异（P=0.0005）。结论：肺是最常受累的器官,年龄、受累器官的数目是MODS预后的重要指标;综合性治疗使患者的生存时间延长,但不能降低病死率。     

多器官功能障碍综合征患者胃肠功能损伤流行病学调查

目的：调查国内多器官功能障碍综合征（multiple organ dysfunction syndrome,MODS）患者胃肠功能损伤的流行病学情况。方法：采用多中心、前瞻性调查方法,分析2002年3月—2005年1月全国11省市的37家三级医院1087例MODS患者的病历资料。结果：1087例患者中,胃肠功能损伤的发生率、病死率分别为78.8%、61.7%。其中入住重症监护室（ICU）患者其28d病死率为58.9%。MODS患者胃肠功能损伤发生及死亡的高危因素分别为存在腹水、未应用或未适当应用肠内营养,用用肾上腺素等。结论：MODS患者胃肠功能损伤发生率高,其发生高危因素及死亡高危因素与腹水、肠内营养的应用等相关。患有胃肠功能损伤的MODS患者其入住ICU28d病死率较非胃肠功能损伤患者显著升高。     

1例重症鹦鹉热衣原体肺炎并发脓毒性休克患者的护理

总结1例重症鹦鹉热衣原体肺炎并发脓毒性休克患者的护理经验。 护理要点：预防和控制院内感染,社区获得性肺炎转重症肺炎的预警护理,机械通气的护理要点,脓毒性休克的护理,不全性肠梗阻后的营养支持及胃肠道功能恢复的护理,健康宣教。经过积极治疗和精心护理,17天后患者好转出院。随访1个月恢复良好,体重增加。