Abstract
ObjectiveWe aimed to investigate the predictive value for severe adverse outcome of plasma protein measurements on day one of life in very preterm infants and to compare total plasma protein levels with the validated illness severity scores CRIB, CRIB-II, SNAP-II and SNAPPE-II, regarding their predictive ability for severe adverse outcome.MethodsWe analyzed a cohort of infants born at 24–31 weeks gestation, admitted to the tertiary intensive care unit of a university hospital over 10.5 years. The outcome measure was “severe adverse outcome” defined as death before discharge or severe neurological injury on cranial ultrasound. The adjusted odd ratio (aOR) and 95% confidence interval (95% CI) of severe adverse outcome for hypoproteinemia (total plasma protein level <40 g/L) was calculated by univariate and multivariate analyses. Calibration (Hosmer-Lemeshow goodness-of-fit) was performed and the predictive ability for severe adverse outcome was assessed for total plasma protein and compared with CRIB, CRIB-II, SNAP-II and SNAPPE-II, by calculating receiver operating characteristic (ROC) curves and their associated area under the curve (AUC).Results761 infants were studied: 14.4% died and 4.1% survived with severe cerebral ultrasound findings. The aOR of severe adverse outcome for hypoproteinemia was 6.1 (95% CI 3.8–9.9). The rank order for variables, as assessed by AUCs and 95% CIs, in predicting outcome was: total plasma protein [0.849 (0.821–0.873)], SNAPPE-II [0.822 (0.792–0.848)], CRIB [0.821 (0.792–0.848)], SNAP-II [0.810 (0.780–0.837)] and CRIB-II [0.803 (0.772–0.830)]. Total plasma protein predicted severe adverse outcome significantly better than CRIB-II and SNAP-II (both p<0.05). Calibration for total plasma protein was very good.ConclusionsEarly hypoproteinemia has prognostic value for severe adverse outcome in very preterm, sick infants. Total plasma protein has a predictive performance comparable with CRIB and SNAPPE-II and greater than other validated severity scores.
Highlights
Advances in perinatal care have resulted in an improvement in the survival rate of very low birth weight infants (VLBWI) as well as in a decrease of the disability rate in VLBW survivors [1,2]
Amidst all the progress made over decades, neonatal outcome has been benefiting from the development and the use of illness severity scores, which have permitted quality of care evaluation, risk adjustment comparisons in benchmarking studies, management and resource implementation
The items to calculate Clinical Risk Index for Babies (CRIB), CRIB-II, Score for Neonatal Acute Physiology II (SNAP-II) and SNAPPE-II were always available, so all the remaining 761 newborns were eligible for the analysis
Summary
Advances in perinatal care have resulted in an improvement in the survival rate of very low birth weight infants (VLBWI) as well as in a decrease of the disability rate in VLBW survivors [1,2]. The Clinical Risk Index for Babies (CRIB) [3], its revised version (CRIB-II) [4], the Score for Neonatal Acute Physiology II (SNAP-II) and the SNAP Perinatal Extension II (SNAPPE-II) [5] are the most widely used scores to estimate illness severity and in-hospital mortality risk in the neonatal intensive care unit (NICU). Some authors have underlined that risk adjustment using these scores is imperfect because additional perinatal factors may significantly influence VLBWI survival [6]. Infants with similar illness severity scores may differ for their risk of death [6] and a better understanding of all the perinatal factors influencing mortality remains a meaningful challenge for neonatologists
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