Outcome Predictors of Algren et al in Pediatric Meningococcal Infection

 

Patient Population:

(1) pediatric patients with acute meningococcal infections admitted to Kosair Childrens' Hospital in Louisville, Kentucky over a 5 year period

(2) retrospective study followed by a prospective study

(3) age of patients in retrospective analysis 1 month to 16 years and in prospective analysis were 3 months to 16 years

 

Factors predicting organ failure:

(1) circulatory insufficiency

(2) low to normal WBC count (< 10,000 per µL)

(3) coagulopathy

 

where:

• circulatory insufficiency = decreased pulses, capillary refill time >= 3 seconds, low systolic blood pressure (< 70 mm Hg or < 5th percentile for age)

• coagulopathy = PT > 150% of normal, PTT > 150% of normal, or platelet count < 100,000 per µL

 

Organ failures:

(1) cardiovascular system: persistent or recurring hypotension requiring isotonic fluid boluses > 20 mL/kg and/or moderate-to-high dose inotrope or vasopressor infusion (example: dopamine > 5 µg/kg/min)

(2) respiratory system: PaO2/FIO2 ratio < 200, or mechanical ventilation required for > 24 hours

(3) central nervous system: Glasgow coma score <= 5

(4) hematologic system: WBC < 3,000 per µL, hemoglobin < 5 g/dL, or DIC (PT and PTT > 150% of normal, platelet count < 100,000 per µL, and fibrinogen degradation products >= 20 µg/mL or positive protamine sulfate test)

(5) renal system: creatinine > 2 mg/dL or BUN > 100 mg/dL

Circulatory Insufficiency	WBC count < 10,000 per µL	Coagulopathy	Probability of Organ Failure
absent	absent	absent	00.001%
absent	absent	present	00.002%
absent	present	absent	25%
absent	present	present	60%
present	absent	absent	99.99%
present	absent	present	99.99%
present	present	absent	100%
present	present	present	100%

(from Table 5, page 450)

 

Factors associated with death (Table 3):

(1) multiple organ failure present

(2) CSF WBC count < 20 per µL

(3) WBC count < 10,000 per µL

(4) stupor or coma (Glasgow Coma Score <= 8)

(5) presence of purpura

(6) metabolic acidosis (serum bicarbonate < 15 mEq/L)

(7) coagulopathy

 

The Pediatric Risk of Mortality Score (PRISM) accurately predicts the overall mortality rate.

(1) The PRISM score requires 8-24 hours of monitoring before calculation, so it may not useful in initial management decisions.

(2) No survivors were present if PRISM score indicated a mortality risk >= 50%.

(3) With PRISM mortality risks from 27-49%, there were equal numbers of survivors and nonsurvivors.

(4) Using a PRISM mortality score >= 50% as indicative of nonsurvival was 67% sensitive and 100% specific.

 

Other findings:

(1) A petechial rash present < 12 hours was not found to be clinically important

 

Functions from Stepwise Logistic Regression

 

Equations given on page 449 as predicting outcome.

 

X =

= 4.806 - (10.73 * (circulatory insufficiency)) - (0.752 * (coagulopathy)) - (5.5504 * (WBC < 10,000 per µL))

 

where:

• circulatory insufficiency = -1 if present, +1 if absent

• coagulopathy = -1 if present, +1 if absent

• WBC < 10,000 per µL = -1 if present, +1 if absent

 

probability of organ failure =

= (EXP(X)) / (1 + (EXP(X)))

 

Y =

= (- 12.73) - (6.800 * (CSF WBC count)) - (7.82 * (stupor or coma))

 

where:

• CSF WBC count < 20 per µL = -1 if present, +1 if absent

• stupor or coma = -1 if present, +1 if absent

 

probability of death =

= (EXP(Y)) / (1 + (EXP(Y)))