Efficacy of Prognostic Scoring Systems and Neutrophil-to- Lymphocyte Ratio (NLR) Among Critically Ill Elder Sepsis Patients

Abstract

Objectives: Several scoring models and biomarkers are available to predict survival among critically ill patients. However, their accuracy among older adults with sepsis has been questioned. In this study, we aimed to evaluate the currently used prognostic scoring scales and neutrophil-tolymphocyte ratio (NLR) in the prediction of survival among older adults with sepsis. Materials and Methods: The study prospectively included older adults who were admitted to the intensive care unit (ICU) with sepsis. On admission, Acute Physiology And Chronic Health Evaluation (APACHE)-II, Sequential (sepsis-related) Organ Failure Assessment (SOFA), Glasgow coma scale (GCS) score, and NLR were calculated. By the end of a 28-day follow-up period, survivors and non-survivors were compared for the study parameters. Results: Overall, the data of 36 patients were analyzed (mean age: 80.00±6.37 years, female: 58.3%). The rate of mortality was 47.3% (n=17). The mean SOFA score and the median NLR on admission were significantly lower in survivors [SOFA: 10.37±2.91, and NLR: 9.64 (11.25)] vs non-survivors [SOFA: 12.82±3.21 and NLR: 14.95 (35.53)] (p<0.05) but the mean APACHE-II and the median GCS score were comparable. Using ROC curve analysis, we determined that only the SOFA score and NLR could predict mortality. Conclusion: The present study showed that, among older adults with sepsis admitted to the ICU, baseline SOFA score and NLR but not APACHE-II or GCS score could successfully predict mortality. Further studies are required to evaluate the utility of existing prognosis scales in older people.

Keywords

• Organ Dysfunction Scores
• Sepsis
• APACHE
• Survival
• Intensive Care Units
• Aged

Yaşlı Sepsis Hastalarında Prognostik Puanlama Sistemlerinin ve Nötrofil-Lenfosit Oranının (NLO) Etkinliği

Abstract

Amaç: Yoğun bakım hastalarında mortaliteyi tahmin eden birçok puanlama sistemi ve biyobelirteç mevcuttur. Ancak yaşlı sepsis hastalarında kullanılabilirlikleri konusunda netlik bulunmamaktadır. Bu çalışmada, yaşlı sepsis hastalarında sağkalımı öngörmede şu anda kullanılan prognostik skorlama ölçeklerini ve nötrofil lenfosit oranını (NLO) değerlendirmeyi amaçladık. Gereç ve Yöntem: Çalışmaya yoğun bakım ünitesine sepsis tanısı ile yatırılan yaşlı hastalar prospektif olarak dahil edildi. Başvuru anında Akut Fizyoloji ve Kronik Sağlık Değerlendirmesi-II (APACHE), Sıralı (sepsisle ilişkili) Organ Yetmezliği Değerlendirmesi (SOFA) ve Glasgow koma skoru (GKS) puanı ve NLO hesaplandı. 28 günlük bir takip süresinin sonunda, hastalar “hayatta kalanlar” ve “hayatta kalmayanlar” olarak iki gruba ayrıldı ve çalışma parametreleri yönünden karşılaştırıldı. Bulgular: Otuz altı hastanın verileri analiz edildi (ortalama yaş: 80,00±6,37 yıl, kadın: %58,3). Ölüm oranı %47,3 (n=17) idi. Başvuru anındaki ortalama SOFA skoru ve medyan NLO, hayatta kalanlarda [SOFA: 10,37±2,91 ve NLR: 9,64 (11,25)], hayatta kalmayanlara [SOFA: 12,82±3,21 ve NLR: 14,95 (35,53)] (p<0,05) göre anlamlı olarak daha düşüktü, ancak ortalama APACHE-II ve medyan GKS skoru benzerdi. ROC eğrisi analizini kullanarak, sadece SOFA skorunun ve NLO’nun mortaliteyi tahmin edebileceğini belirledik Sonuç: Bu çalışma, yoğun bakım ünitesine kabul edilen sepsisli yaşlı hastalar arasında, APACHE-II veya GKS skorunun değil, başlangıç SOFA skorunun ve NLO’nun mortaliteyi başarıyla tahmin edebileceğini gösterdi. Yaşlılarda mevcut prognoz ölçeklerinin faydasını değerlendirmek için daha ileri çalışmalara ihtiyaç vardır.

Keywords

• Organ İşlev Bozukluğu Puanları
• Sepsis
• APACHE
• Hayatta Kalma
• Yoğun Bakım Üniteleri
• Yaşlı

Ethical Statement

Ethics Committee Approval: The Health Sciences University Non-Invasive Research Ethics Committee approved the study protocol (code: 46418926-18/55). Informed Consent: Written informed consent was obtained for each participant. Peer-reviewed: Externally peer-reviewed.

References

1. 1. Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017;43:304-377.
2. 2. Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med. 2001;29:1303-1310.
3. 3. Rudd KE, Johnson SC, Agesa KM, et al. Global, regional, and national sepsis incidence and mortality, 1990-2017: analysis for the Global Burden of Disease Study. Lancet. 2020;395:200-211.
4. 4. Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med. 1996;22:707-710.
5. 5. Knaus WA, Draper EA, Wagner DP, et al. APACHE II: a severity of disease classification system. Crit Care Med. 1985;13:818-829.
6. 6. Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2:81-84.
7. 7. Godinjak A, Iglica A, Rama A, et al. Predictive value of SAPS II and APACHE II scoring systems for patient outcome in a medical intensive care unit. Acta Med Acad. 2016;45:97-103.
8. 8. Nik A, Sheikh Andalibi MS, Ehsaei MR, et al. The Efficacy of Glasgow Coma- Scale (GCS) Score and Acute Physiology and Chronic Health Evaluation (APACHE) II for Predicting Hospital Mortality of ICU Patients with Acute Traumatic Brain Injury. Bull Emerg Trauma. 2018;6:141-145.

9. 9. Raith EP, Udy AA, Bailey M, et al. Prognostic Accuracy of the SOFA Score, SIRS Criteria, and qSOFA Score for In-Hospital Mortality Among Adults With Suspected Infection Admitted to the Intensive Care Unit. JAMA. 2017;317:290-300.
10. 10. Naqvi IH, Mahmood K, Ziaullaha S, et al. Better prognostic marker in ICU - APACHE II, SOFA or SAP II! Pak J Med Sci. 2016;32:1146-1151.
11. 11. Desai S, Lakhani JD. Utility of SOFA and APACHE II score in sepsis in rural set up MICU. J Assoc Physicians India. 2013;61:608-611.
12. 12. Trancă S, Petrișor C, Hagău N, et al. Can APACHE II, SOFA, ISS, and RTS Severity Scores be used to Predict Septic Complications in Multiple Trauma Patients? J Crit Care Med (Targu Mures). 2016;2:124-130.
13. 13. Knox DB, Lanspa MJ, Pratt CM, et al. Glasgow Coma Scale score dominates the association between admission Sequential Organ Failure Assessment score and 30-day mortality in a mixed intensive care unit population. J Crit Care. 2014;29:780-785.
14. 14. Salciccioli JD, Marshall DC, Pimentel MA, et al. The association between the neutrophil-to-lymphocyte ratio and mortality in critical illness: an observational cohort study. Crit Care. 2015;19:13.
15. 15. Riché F, Gayat E, Barthélémy R, et al. Reversal of neutrophil-to-lymphocyte count ratio in early versus late death from septic shock. Crit Care. 2015;19:439.
16. 16. Chelluri L, Pinsky MR, Donahoe MP, et al. Long-term outcome of critically ill elderly patients requiring intensive care. JAMA. 1993;269:3119-3123.
17. 17. Martin-Loeches I, Guia MC, Vallecoccia MS, et al. Risk factors for mortality in elderly and very elderly critically ill patients with sepsis: a prospective, observational, multicenter cohort study. Ann Intensive Care. 2019;9:26.
18. 18. Minne L, Ludikhuize J, de Jonge E, et al. Prognostic models for predicting mortality in elderly ICU patients: a systematic review. Intensive Care Med. 2011;37:1258-1268.
19. 19. Singer M, Deutschman CS, Seymour CW, et al. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). JAMA. 2016;315:801-810.
20. 20. Huang Z, Fu Z, Huang W, et al. Prognostic value of neutrophil-to-lymphocyte ratio in sepsis: A meta-analysis. Am J Emerg Med. 2020;38:641-647.
21. 21. Vincent JL, de Mendonça A, Cantraine F, et al. Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Working group on “sepsisrelated problems” of the European Society of Intensive Care Medicine. Crit Care Med. 1998;26:1793-1800.
22. 22. Ferreira FL, Bota DP, Bross A, et al. Serial evaluation of the SOFA score to predict outcome in critically ill patients. JAMA. 2001;286:1754-1758.
23. 23. Martin GS, Mannino DM, Moss M. The effect of age on the development and outcome of adult sepsis. Crit Care Med. 2006;34:15-21.
24. 24. Gupta V, Karnik ND, Agrawal D. SOFA Score and Critically Ill Elderly Patients. J Assoc Physicians India. 2017;65:47-50.
25. 25. Andersen FH, Flaatten H, Klepstad P, et al. Long-term survival and quality of life after intensive care for patients 80 years of age or older. Ann Intensive Care. 2015;5:53
26. 26. Kumarasamy C, Sabarimurugan S, Madurantakam RM, et al. Prognostic significance of blood inflammatory biomarkers NLR, PLR, and LMR in cancer-A protocol for systematic review and meta-analysis. Medicine (Baltimore). 2019;98:e14834.
27. 27. Menges T, Engel J, Welters I, et al. Changes in blood lymphocyte populations after multiple trauma: association with posttraumatic complications. Crit Care Med. 1999;27:733-740.
28. 28. Forget P, Khalifa C, Defour JP, et al. What is the normal value of the neutrophil-to-lymphocyte ratio? BMC Res Notes. 2017;10:12.
29. 29. Lee JS, Kim NY, Na SH, et al. Reference values of neutrophil-lymphocyte ratio, lymphocyte-monocyte ratio, platelet-lymphocyte ratio, and mean platelet volume in healthy adults in South Korea. Medicine (Baltimore). 2018;97:e11138.
30. 30. Zhou M, Li L, Wang X, et al. Neutrophil-to-Lymphocyte Ratio and Platelet Count Predict Long-Term Outcome of Stage IIIC Epithelial Ovarian Cancer. Cell Physiol Biochem. 2018;46:178-186.
31. 31. Afari ME, Bhat T. Neutrophil to lymphocyte ratio (NLR) and cardiovascular diseases: an update. Expert Rev Cardiovasc Ther. 2016;14:573-577.
32. 32. Peng Y, Li Y, He Y, et al. The role of neutrophil to lymphocyte ratio for the assessment of liver fibrosis and cirrhosis: a systematic review. Expert Rev Gastroenterol Hepatol. 2018;12:503-513.
33. 33. Badrinath K, Shekhar M, Sreelakshmi M, et al. Comparison of Various Severity Assessment Scoring Systems in Patients with Sepsis in a Tertiary Care Teaching Hospital. Indian J Crit Care Med. 2018;22:842-845.
34. 34. Headley J, Theriault R, Smith TL. Independent validation of APACHE II severity of illness score for predicting mortality in patients with breast cancer admitted to the intensive care unit. Cancer. 1992;70:497-503.
35. 35. Capuzzo M, Valpondi V, Sgarbi A, et al. Validation of severity scoring systems SAPS II and APACHE II in a single-center population. Intensive CareMed. 2000;26:1779-1785.
36. 36. Alalawi MSM, Aljabran HAM, Alkhamri AM, et al. Glasgow Coma Scale in Anticipation of Sepsis and Septic Shock: Review Article. Egypt J Hosp Med. 2017;69:2663-2666.
37. 37. Mohammad RJ. Comparison of Glasgow Coma Scale and GCS-Age Prognosis Score in Older Adult Patients. 2019;10:35-40.
38. 38. Rau CS, Wu SC, Chen YC, et al. Effect of Age on Glasgow Coma Scale in Patients with Moderate and Severe Traumatic Brain Injury: An Approach with Propensity Score-Matched Population. Int J Environ Res Public Health. 2017;14:1378.
39. 39. Bledsoe BE, Casey MJ, Feldman J, et al. Glasgow Coma Scale Scoring is Often Inaccurate. Prehosp Disaster Med. 2015;30:46-53.
40. 40. Kehoe A, Rennie S, Smith JE. Glasgow Coma Scale is unreliable for the prediction of severe head injury in elderly trauma patients. Emerg Med J. 2015;32:613 LP -615.