Mottling score is a strong predictor of 14-day mortality in septic patients whatever vasopressor doses and other tissue perfusion parameters

Guillaume Dumas, Jean-Rémi Lavillegrand, Jérémie Joffre, Naïke Bigé, Edmilson Bastos de-Moura, Jean-Luc Baudel, Sylvie Chevret, Bertrand Guidet, Eric Maury, Fabio Amorim, Hafid Ait-Oufella, Guillaume Dumas, Jean-Rémi Lavillegrand, Jérémie Joffre, Naïke Bigé, Edmilson Bastos de-Moura, Jean-Luc Baudel, Sylvie Chevret, Bertrand Guidet, Eric Maury, Fabio Amorim, Hafid Ait-Oufella

Abstract

Background: Mottling 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.

Methods: Mottling 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.

Results: Overall, 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).

Conclusions: Our 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.

Keywords: Microcirculation; Mottling; Outcome; Septic shock; Vasopressor.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
14-day mortality according to mottling score value at H-6. Error-bars represent 95% confidence interval
Fig. 2
Fig. 2
Adjusted effect of a mottling score, b arterial lactate, and c urine output at H6 on day 14 mortality (model 2). Results obtained by multivariable logistic regression with restricted cubic splines with three knots for urine output. Shaded area represents a 95% confidence interval for the trend
Fig. 3
Fig. 3
Effect of Mottling score at H6 on day 14 mortality according to different subgroups of patient. Estimates are Odds ratio with 95% confidence interval as estimated by logistic regression adjusted on SOFA score. Subset-by-Mottling score interactions on 14 day mortality were tested with the Gail and Simon test

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