Predicting need for intensive care unit admission in adult emphysematous pyelonephritis patients at emergency departments: comparison of five scoring systems

Xiao-Han Yap,Chip-Jin Ng,Chen-June Seak,Zhong Ning Leonard Goh,Chen-Ken Seak,Kuang-Hung Hsu,Joanna Chen-Yeen Seak,Hsien-Yi Chen,Ming-Shun Hsieh,Chih-Huang Li,Cheng-Yu Chien,Yi-Ming Weng

doi:10.1038/s41598-019-52989-7

Abstract

This study assesses the performance of National Early Warning Score (NEWS), Quick Sepsis-related Organ Failure Assessment (qSOFA), Modified Early Warning Score (MEWS), Rapid Emergency Medicine Score (REMS), and Rapid Acute Physiology Score (RAPS) in predicting emphysematous pyelonephritis (EPN) patients’ need for intensive care unit (ICU) admission. A retrospective analysis was conducted at four training and research hospitals’ emergency departments (EDs) on all EPN adult patients from January 2007 to August 2017. Data extracted were used to calculate raw scores for five physiologic scoring systems. Mann-Whitney U tests and χ2 tests were done for numerical and categorical variables respectively to examine differences between characteristics of ICU and non-ICU patient populations. Predictability of ICU admission was evaluated with AUROC analysis. ICU patients had lower GCS scores, SpO2, platelet counts, and estimated glomerular filtration rate; and higher bands, blood urea nitrogen, creatinine, and incidences of septic shock and nephrectomy. NEWS performed best, with 73.85% accuracy at optimal cut-off of 3. In this multicentre ED EPN series, we recommend using NEWS in early identification of critical EPN patients and advance planning for ICU admission. This would reduce delays in ICU transfer and ultimately improve patient outcomes.

Highlights

This study assesses the performance of National Early Warning Score (NEWS), Quick Sepsis-related Organ Failure Assessment, Modified Early Warning Score (MEWS), Rapid Emergency Medicine Score (REMS), and Rapid Acute Physiology Score (RAPS) in predicting emphysematous pyelonephritis (EPN) patients’ need for intensive care unit (ICU) admission
It has historically been associated with high mortality rates of up to 78% in the 1970s, due to poor recognition of this rare condition leading to delayed management of septic complications; early nephrectomy was the treatment of choice, though with the advent of advanced imaging computed tomography techniques, percutaneous drainage is the favoured option with decreased mortality of 21%6–9
Compared to the group of EPN patients who did not require ICU admission, those who were admitted to the ICU had lower Glasgow Coma Scale (GCS) scores (p = 0.0070), lower SpO2 (p = 0.0036), higher incidence of septic shock (p < 0.0001), lower platelet counts (p = 0.0204), bandemia (p = 0.0058), higher blood urea nitrogen (p = 0.0123), higher creatinine (p = 0.0009), lower estimated glomerular filtration rate (p = 0.0010), higher incidence of nephrectomy (p < 0.0001) (Table 1)

Summary

Introduction

This study assesses the performance of National Early Warning Score (NEWS), Quick Sepsis-related Organ Failure Assessment (qSOFA), Modified Early Warning Score (MEWS), Rapid Emergency Medicine Score (REMS), and Rapid Acute Physiology Score (RAPS) in predicting emphysematous pyelonephritis (EPN) patients’ need for intensive care unit (ICU) admission. NEWS performed best, with 73.85% accuracy at optimal cut-off of 3 In this multicentre ED EPN series, we recommend using NEWS in early identification of critical EPN patients and advance planning for ICU admission. Emphysematous pyelonephritis (EPN) is defined as an acute, severe necrotising infection of the renal parenchyma and its surrounding tissues that results in the presence of gas in the renal parenchyma, collecting system, or perinephric tissue[1,2,3,4,5] It has historically been associated with high mortality rates of up to 78% in the 1970s, due to poor recognition of this rare condition leading to delayed management of septic complications; early nephrectomy was the treatment of choice, though with the advent of advanced imaging computed tomography techniques, percutaneous drainage is the favoured option with decreased mortality of 21%6–9. There may be differences in opinions among emergency physicians (EPs), surgeons, and intensivists on whether ICU admission is really necessary

Methods

Results

Conclusion