title: The utility of scoring systems in critically ill cirrhotic patients admitted to a general intensive care unit.
abstract: OBJECTIVE
  This study aimed to establish which prognostic scoring tool provides the greatest discriminative ability when assessing critically ill cirrhotic patients in a general intensive care unit (ICU) setting.
  
  
  METHODS
  This was a 12-month, single-centered prospective cohort study performed in a general, nontransplant ICU. Forty clinical and demographic variables were collected on admission to calculate 8 prospective scoring tools. Patients were followed up to obtain ICU and inhospital mortality. Receiver operating characteristic curve analysis was used to determine the discriminative ability of the scores. Univariate and multivariate analyses were used to identify any independent predictors of mortality in these patients. The incorporation of any significant variables into the scoring tools was assessed.
  
  
  RESULTS
  Fifty-nine cirrhotic patients were admitted over the study period, with an ICU mortality of 31%. All scores other than the renal-specific Acute Kidney Injury Network score had similar discriminative abilities, producing area under the curves of between 0.70 and 0.76. None reached the clinically applicable level of 0.8. The Sequential Organ Failure Assessment score was the best performing score. Lactate and ascites were individual predictors of ICU mortality with statistically significant odds ratios of 1.69 and 5.91, respectively. When lactate was incorporated into the Child-Pugh score, its prognostic accuracy increased to a clinically applicable level (area under the curve, 0.86).
  
  
  CONCLUSIONS
  This investigation suggests that established prognostic scoring systems should be used with caution when applied to the general, nontransplant ICU as compared to specialist centers. Our data suggest that serum arterial lactate may improve the prognostic ability of these scores.
authors.affiliation: Academic Unit of Anaesthesia, Pain and Critical Care Medicine, University of Glasgow, School of Medicine, Royal Infirmary, Glasgow, UK. Electronic address: 0900192e@student.gla.ac.uk.
authors.forename: Philip
authors.initials: P
authors.lastname: Emerson
authors.affiliation: University of Glasgow Medical School, Glasgow, G12 8QQ, UK; Academic Unit of Anaesthesia, Pain and Critical Care Medicine, University of Glasgow, School of Medicine, Royal Infirmary, Glasgow, UK; Glasgow Royal Infirmary, Castle Street, Glasgow, G4 0SF, UK. Electronic address: joanne.mcpeake@glasgow.ac.uk.
authors.forename: Joanne
authors.initials: J
authors.lastname: McPeake
authors.affiliation: Nursing and Healthcare School, School of Medicine, University of Glasgow, Glasgow, G12 8LL, UK. Electronic address: Anna.O'Neill@glasgow.ac.uk.
authors.forename: Anna
authors.initials: A
authors.lastname: O'Neill
authors.affiliation: Medical Statistics, School of Mathematics and Statistics, College of Science and Engineering, University of Glasgow, Glasgow, G12 8QW, UK. Electronic address: Harper.Gilmour@glasgow.ac.uk.
authors.forename: Harper
authors.initials: H
authors.lastname: Gilmour
authors.affiliation: Glasgow Royal Infirmary, Castle Street, Glasgow, G4 0SF, UK. Electronic address: Ewan.Forrest@glasgow.ac.uk.
authors.forename: Ewan
authors.initials: E
authors.lastname: Forrest
authors.affiliation: Glasgow Royal Infirmary, Castle Street, Glasgow, G4 0SF, UK. Electronic address: apuxty@doctors.org.uk.
authors.forename: Alex
authors.initials: A
authors.lastname: Puxty
authors.affiliation: Academic Unit of Anaesthesia, Pain and Critical Care Medicine, University of Glasgow, School of Medicine, Royal Infirmary, Glasgow, UK; Glasgow Royal Infirmary, Castle Street, Glasgow, G4 0SF, UK. Electronic address: John.Kinsella@glasgow.ac.uk.
authors.forename: John
authors.initials: J
authors.lastname: Kinsella
authors.affiliation: Department of Clinical Physics, University of Glasgow, Glasgow, UK. Electronic address: martin.shaw@nhs.net.
authors.forename: Martin
authors.initials: M
authors.lastname: Shaw
mesh_terms: D058186:Acute Kidney Injury; D000328:Adult; D000368:Aged; D000704:Analysis of Variance; D019540:Area Under Curve; D016638:Critical Illness / Q000401:mortality; D005260:Female; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units; D019344:Lactic Acid / Q000097:blood; D008103:Liver Cirrhosis / Q000097:blood / Q000401:mortality*; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D063305:Organ Dysfunction Scores; D011379:Prognosis; D011446:Prospective Studies; D012372:ROC Curve
chemical_list: D019344:Lactic Acid
keywords: Cirrhosis; Critical care; ICU outcomes; Scoring tools