Abstract
BackgroundMottling score, a tissue perfusion parameter, is correlated with outcome in septic shock patients. However, its predictive value on mortality according to prognostic covariates such as vasopressor dose and other tissue perfusion parameters remains unknown.MethodsMottling score and tissue perfusion parameters were recorded at ICU admission (H0), H-6, H 12, and H-24 and used to assess the predictive value of mottling score on 14-day mortality in a development cohort. Results were then validated in an independent cohort of septic shock patients in Brazil.ResultsOverall, 259 patients with sepsis or septic shock were included, 14-day mortality was 37%. Factors associated with death were mottling score (OR 2.26 [95% CI, 1.72–2.97]), arterial lactate level (OR 1.29 [1.11–1.5]), and urine output < 0.5 ml/Kg/h (OR 3.03 [1.37–6.69]). The C statistic for the model was 0.90 in the development cohort and 0.76 in the validation cohort. The predictive value of mottling score was not affected by vasopressor doses (p for interaction = 0.33): OR for mottling score ranged from 2.34 [1.10–3.15] in patients without vasopressor to 3.84 [1.98–7.43] in patients infused with high doses of vasopressor (> 0.8 μg/kg/min). There was no difference in the effect of mottling score on mortality according to mean arterial pressure, heart rate, cardiac index, and urine output, but we found a significant interaction between arterial lactate level and mottling score (p = 0.04). The predictive value of the mottling score remains significant when using the recent SEPSIS-3 definition of septic shock. Finally, a decrease of mottling score during resuscitation was significantly associated with better outcome after adjustment on SOFA score (p = 0.001).ConclusionsOur results support the high prognostic value of mottling score for 14-day mortality in septic patients, whatever vasopressor dosage and other perfusion parameters. Mottling score variations during resuscitation are also predictive of mortality.
Highlights
Mottling score, a tissue perfusion parameter, is correlated with outcome in septic shock patients
Sequential Organ Failure Assessment (SOFA) score was calculated within 24 h of septic shock onset
Mottling score provided a semi quantitative evaluation of mottling based on skin area extension on legs: Score 0 no mottling, score 1 small mottling area localized to the center of the knee, score 2 mottling area that does not exceed the superior edge of the knee cap, score 3 mottling area that does not exceed the middle thigh, score 4 mottling area that does not exceed the fold of the groin, and score 5 otherwise
Summary
A tissue perfusion parameter, is correlated with outcome in septic shock patients. Microcirculation blood flow impairment has been identified in septic patients [3,4,5], being more pronounced in the most severely ill patients [6]. These microvascular disorders have been associated with mortality [4] as well as their persistence despite resuscitation [7]. Brunauer et al [13] reported in septic shock patients a significant correlation between skin mottling extension and kidney perfusion (assessed by the pulsatility index), supporting the concept that mottling reflects global tissue hypoperfusion. It has been previously found that mottling score, measured 6 h after initial resuscitation in ICU, is a strong predictor of mortality in patients with septic shock at day 14 [14] and at day 28 [15]
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