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Mottling score, StO₂ predict mortality in cirrhosis, septic shock

High mottling score and knee tissue oxygen saturation accurately predicted mortality rates in patients with cirrhosis and septic shock, according to study data published in the Journal of Hepatology.

“Severe infections represent one of the most dreadful complications of liver cirrhosis,” the researchers wrote. “Cirrhosis has been identified as an independent risk factor of mortality in patients with septic shock. Despite improved outcome of patients with cirrhosis and septic shock during the last years, their mortality remains around 65%.”

Researchers conducted a prospective observational study in the ICU at a tertiary teaching hospital in France and included patients with cirrhosis who were admitted to the department due to septic shock. Forty-two patients were included in the final analysis and matched with 75 patients with septic shock without cirrhosis to assess whether the mottling score and tissue oxygen saturation (StO₂) were predictors of death in this patient population.

Every 6 hours for 24 hours, patients with cirrhosis underwent various tests that provided data on macrocirculation and organ perfusion.

Overall, 71% of patients died by 14 days, 78% died by 28 days, 76% of patients were in the ICU and 82% of patients were in the hospital.

At 6 hours of observation, parameters reflecting macrocirculation were not associated with mortality, whereas higher arterial lactate and mottling score were associated with mortality, according to the research. All patients with a mottling score greater than 1 died, leading researchers to conclude that mottling score was the highest predictor of mortality among the cohort (OR = 42.4; 95% CI, 2.3-785.9). Patients with a mottling score between 0 and 1 had a higher probability of survival (log-rank test < .001). Five patients experienced a decrease in mottling score, of which four patients survived (P = .004).

Also at 6 hours, researchers observed a decrease in knee StO₂ in nonsurviving patients and predicted mortality; sensitivity was 0.45 and specificity was 1.

Unlike the control patients, mottling kinetic was different in patients with cirrhosis in which a delayed mottling appearance was evident in nonsurvivors and earlier mottling disappearance was observed in survivors.

Analysis using laser-Doppler showed a higher rate of StO₂ and skin perfusion found in the patients with cirrhosis.  

“For the first time, we investigated skin perfusion in cirrhotic patients with septic shock,” the researchers concluded. “We have shown that the mottling score and knee StO₂, measured as early as 6 hours after the vasopressors were started, are very specific predictors of 14-day mortality. … We found that the mottling score and knee StO₂ had lower sensitivity in predicting in cirrhotic patients due to delayed mottling appearance and higher knee StO₂ related to higher skin perfusion in this population.”

The researchers further stated: “Clinicians should be aware of these results, to be concerned about septic shock in cirrhotic patients and to rapidly refer them to ICU, even in the absence of mottling.” – by Melinda Stevens 

Disclosure: The researchers report no relevant financial disclosures.