Prediction of outcome in perforation peritonitis: Sequential organ function assessment score and inflammatory mediators

Madam, Limited health resources of a developing country remain a logistic concern for patient care. Mortality prediction of patients may aid in optimal allocation of limited resources. Perforation peritonitis is the commonest surgical emergency in Indian subcontinent and still carries considerable morbidity and mortality.[1] We explored the utility of a clinical scoring system versus laboratory inflammatory markers for mortality prediction in patients of perforation peritonitis following emergency abdominal laparotomy. The investigated mortality predictors included sequential organ function assessment (SOFA) score, serum interleukin (IL)-10, and procalcitonin. This is a secondary analysis of 120 patients of perforation peritonitis included for effect of anesthetic interventions on their clinical outcome. The original research was undertaken only after clearance from Institutional Ethical Committee. The SOFA score (n = 120) and systemic inflammatory mediators (n = 60) were assessed preoperatively and on specified postoperative days [Table 1]. The association between various indicators and mortality was evaluated using receiver operating characteristics (ROC) analysis, exhibiting an area under the curve (AUC) for strength of the association, if any. The ROC curve analysis showed lack of any significant relationship between 28-day mortality and preoperative IL-10 and procalcitonin (P = 0.928 and 0.351, respectively) as well as postoperative IL-10 (P = 0.569). It was significant for preoperative and postoperative SOFA score (P = 0.002 and 0.000, respectively) and postoperative procalcitonin on both second and fourth day (P = 0.025 and 0.039, respectively).Table 1: Comparison of mortality predictors between survivors and nonsurvivorsThe AUC for preoperative and postoperative SOFA score was 0.77 (95% confidence interval (CI): 0.64–0.89) and 0.91 (95% CI: 0.83–0.99), and it was 0.78 (95% CI: 0.52–1.04) and 0.76 (95% CI: 0.53–1.00) for procalcitonin on second and fourth postoperative day, respectively. The mean values of each of these mortality predictors were significantly worse among nonsurvivors (n = 12) as compared to survivors (n = 108) (P < 0.05) [Table 1]. Based on our observations, it appears that SOFA score correlates better than any of the inflammatory mediators (IL as well as procalcitonin) with mortality in these patients. Although there are studies noting utility of clinical scores including SOFA for predicting mortality in patients with perforation peritonitis, there is no comparison with inflammatory mediators.[2] Interestingly, we noted that postoperative SOFA score is a more accurate predictor than preoperative score similar to that observed in one other study.[3] This is perhaps a result of patients response to the surgery by this time, being manifested in the first day postoperative score. The inability of procalcitonin in predicting mortality of septic patients as compared to SOFA is evidenced earlier also, as is the failure of interleukins.[45] Thus, we conclude that clinical score may still be better than laboratory markers for outcome prediction in perforation peritonitis, the commonest surgical emergency of our settings. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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