ABSTRACT
Background and Objective:
Acute pancreatitis is a condition that presents with pain abdomen. It is an emergency condition and is associated with high mortality. The pain of acute pancreatitis is sudden on onset and starts in the epigastrium and may spread throughout the abdomen and radiate to the back. The aim of the study was to analyze the efficacy and limitations of qSOFA scoring in predicting the prognosis and thus shaping the therapeutic measures in the treatment of acute pancreatitis.
Material and Methods:
This teaching institute-based prospective and observational study was conducted on 84 patients of acute pancreatitis in the Department of General Surgery, Rajendra Institute of Medical Sciences, Ranchi from February 2021 to October 2022.
Results:
The study showed male preponderance with 65% male patients and 35% female patients. Patients were categorised from the second decade of life to the sixth, and a maximum number of cases belonged to 31-40 years of age. The average length of hospital stay was calculated to be 15.6 days. A significant association was found between qSOFA scoring and ICU admissions with the P value being 0.001. Finally, the association between qSOFA scoring and mortality was analysed to have a P value of 0.001, with the death of seven patients among the 84 included in the study.
Conclusions:
In the present study qSOFA scoring showed a sensitivity of 0.42 for a score of 1, a sensitivity of 0.36 for a score of 2, and a sensitivity of 0.03 for a score of 3. qSOFA scoring was helpful in predicting ICU admissions, as well as mortality considerably.
Keywords: Acute pancreatitis, intensive care unit (ICU) admissions, mortality, observational study, P value, quick sequential organ failure assessment (qSOFA), systemic inflammatory response syndrome (SIRS)
Introduction
Pancreatitis is a complex disease with multiple etiologies and varied presentations and outcomes.[1] An early and quick evaluation of this disease would be of great help, especially in the scenario of a developing country like India, where a delay in proper treatment, be it due to any cause, might lead to harsh and deadly outcomes. Thus, it may help both the physicians in diagnosing and treatment as well as the patients.
Acute pancreatitis is a condition that presents with abdominal pain. It can be an early phase of chronic pancreatitis. The pain of acute pancreatitis intensifies in minutes, stays constant and persists for several hours. The pain starts in the epigastrium and may spread throughout the abdomen and radiate to the back. This pain mimics almost every pain of an acute abdomen. The patients may present with profound shock as well as tachycardia, tachypnea, hypotension, confusion, disorientation and hypoxemia.
Acute pancreatitis can be an early phase of chronic pancreatitis and adult respiratory distress syndrome (ARDS). It is an emergency condition as it is associated with a high degree of mortality (20-50%).
Acute pancreatitis occurs because of premature activation of pancreatic enzymes, which is followed by auto-digestion. The inflammatory process leads to oedema and haemorrhage within the organ, which finally results in necrosis. Some of the common causes of acute pancreatitis are gallstones, alcohol abuse, or blunt trauma abdomen, to name a few. Furthermore, many sequelae might follow after acute pancreatitis, such as hemodynamic instability, bacteremia, ARDS, pleural effusion, gastrointestinal haemorrhage, renal failure and disseminated intravascular coagulation.
Acute pancreatitis is divided into two phases: early and late. The systemic inflammatory response syndrome (SIRS) characterises the early phase and lasts for about a week. Death in the early phase occurs due to multi-organ failure. The late phase can last from weeks to months and is characterised by systemic signs of inflammation and complications. Death in the late phase mostly occurs due to sepsis.
As acute pancreatitis is an emergency, an assessment of the severity of the condition carries the utmost importance. This assessment would further lead to proper diagnosis and thus effective treatment and prognosis.
Several scoring systems are used for predicting the severity and thus the mortality of the disease, such as RANSON, GLASGOW, Acute Physiologic Assessment and Chronic Health Evaluation, Simplified Acute Physiology Score, Multi-Organ Dysfunction Score, Modified Marshall Scoring System, Sequential Organ Failure Assessment (SOFA) and quick Sequential Organ Failure Assessment (qSOFA). In this study, we investigated the efficacy of quick Sequential Organ Failure Assessment (qSOFA) in predicting mortality in acute pancreatitis patients admitted to the Rajendra Institute of Medical Sciences (RIMS), Ranchi. The qSOFA system is a lesser-explored scoring system when compared to the other existing scoring systems in regard to acute pancreatitis-related mortality. As the name suggests, qSOFA is a “quick” process. It is time saving in an emergency room and can help start the therapeutic management of the disease early and thus lead to a better prognosis. The qSOFA scoring system is simpler as it considers only bedside parameters[2] which are as follows:
Altered mental sensorium − GCS < 13.
Respiratory rate (RR)>22/min
Systolic blood pressure < 100 mmHg
It can be done at the bedside without any invasive intervention. The qSOFA system has two distinct advantages over other scoring systems: it does not depend on laboratory results and is simple to use.[3] In the largest cohort to date, qSOFA ≥ 2 was highly specific for sepsis, sepsis-3 organ dysfunction and mortality.[4] Another study indicated that qSOFA is better than the SIRS in predicting in-hospital mortality of sepsis patients in the emergency department.[5] Segregating critically ill patients from the ones who do not need ICU admissions is vital in the emergency department, as the decision-making in such situations is done with scarce resources, based just on clinical grounds. Thus, the importance of qSOFA scoring comes into play here.
Aim: To evaluate the effectiveness and usefulness of the qSOFA scoring system in predicting mortality in acute pancreatitis.
Objective: To analyze the efficacy and limitations of the qSOFA scoring system in predicting the prognosis of acute pancreatitis and thus shaping the therapeutic measures involved in its treatment.
Materials and Methods
This institutional-based prospective and observational study had a sample size of 84 patients and was conducted from February 2021 to October 2022 in the Department of General Surgery, RIMS, Ranchi, after approval from the Institutional Ethical Committee, RIMS, Ranchi. Patients admitted as a case of acute pancreatitis in the emergency room and intensive care unit (ICU) in the Department of Surgery, RIMS, Ranchi, were included in the study. In the emergency room consecutive patients of acute pancreatitis were included. All parameters of q SOFA were collected at the time of emergency room stay by the treating doctors. The presence of lowest GCS was noted clinically, whereas higher respiratory rate and lowest systolic blood pressure were recorded by multipara monitor.
The inclusion criteria were as follows:
The patients were males and females of all age groups diagnosed as cases of acute pancreatitis.
The patients who consented to the study.
The exclusion criteria were as follows:
Patients who had mental illness or other medical conditions or did not give consent for the study.
A complete history of all patients diagnosed with acute pancreatitis was obtained. The patients were regularly monitored for vitals like pulse rate, blood pressure, respiratory rate, SpO2, random blood sugar, and urine output and were put through all required investigations such as complete blood count, serum amylase, serum lipase, serum calcium, arterial blood gas analysis, liver function tests, renal function tests and ultrasonography of the abdomen. Data were analysed and co-related with other blood investigations and contrast-enhanced computed tomography (CECT) findings. The patients were followed throughout their entire course of treatment, and inferences were made accordingly.
Statistical analysis: Data entry was conducted using Microsoft Excel, and statistical analysis was carried out using SPSS (version 24.0; SPSS Inc., Chicago, IL, USA). The summarised data presented numerical variables as mean and standard deviation and categorical variables as count and percentages. Conclusions were drawn based on the results, keeping in mind the limitations of the study.
Results
A total of 84 participants fulfilled the inclusion criteria and were included in the study. The mean demographic variables, laboratory findings and other data of the patients are shown in Table 1.
Table 1.
Variables with mean±SD and signs and symptoms
| Variables | Mean value | SD |
|---|---|---|
| Age (years) | 41.63 | ±13.54 |
| Gender (male: female) | 1.8:1 | |
| Pulse (heart beat/min.) | 98.42 | ±16.18 |
| Blood pressure (mm Hg) | 115.56 | ±19.24 |
| Respiratory rate (/min.) | 19.45 | ±2.26 |
| SpO2 (%) | 97.14 | ±2.39 |
| GCS | 14.98 | ±0.15 |
| Random blood sugar (mg/dl) | 130.01 | ±35.79 |
| Total leucocyte count (/cumm) | 9286.45 | ±3248.71 |
| Sr. calcium (mmol/L) | 1.23 | ±1.67 |
| Sr. amylase (IU/L) | 726.33 | ±398.14 |
| Sr. lipase (U/L) | 825.21 | ±463.21 |
| Hospital stay (days) | 15.69 | ±11.26 |
| ICU admission | 0.67 | |
| Pain epigastrium | 84/84 | 1.00 |
| Tenderness | 84/84 | 1.00 |
| Radiation to back | 73/84 | 0.87 |
| Nausea/vomiting | 70/84 | 0.83 |
| Abdominal distension | 49/84 | 0.58 |
| Bowel sound | 60/84 | 0.71 |
| Pleural effusion | 33/84 | 0.39 |
| Cholelithiasis | 42/84 | 0.50 |
| Alcohol/smoking | 39/84 | 0.46 |
The most common age group susceptible to developing acute pancreatitis was the 30-40-years age group, followed by patients in the age group of 50 to 60 years. The mean age of the patients in the study was 41.63 ± 13.54 years [Table 2, Figure 1].
Table 2.
Age incidence of acute pancreatitis patients
| Age group (years) | No. of cases | Percentage | Mean (SD) |
|---|---|---|---|
| <20 | 3 | 3.57 | 41.63±13.54 |
| 21−30 | 12 | 14.29 | |
| 31−40 | 30 | 35.71 | |
| 41−50 | 14 | 16.67 | |
| 51−60 | 15 | 17.86 | |
| >60 | 10 | 11.90 |
Figure 1.
Age incidence
Males were more prone to develop acute pancreatitis at 65.48% (n = 55) of the total study sample, while females constituted only 34.52% of the study sample (n = 29). This makes males almost twice more susceptible to ICU admission after developing pancreatitis than females (M: F = 1.8:1) [Table 3].
Table 3.
Gender distribution of acute pancreatitis patients
| Sex | No. of cases | Percentage |
|---|---|---|
| Male | 55 | 65.48 |
| Female | 29 | 34.52 |
Most of the patients who developed acute pancreatitis were admitted to the hospital for a period of 10-20 days (47.62%). The severity of the disease and its ability to affect multiple systems of the body might be responsible for this long admission period [Table 4].
Table 4.
Hospital stay of acute pancreatitis patients
| Days | No. of patients | Percentage |
|---|---|---|
| >10 | 29 | 34.52 |
| 10−20 | 40 | 47.62 |
| 20−30 | 6 | 7.14 |
| 30−40 | 6 | 7.14 |
| >40 | 3 | 3.57 |
The three parameters of q SOFA score, as described earlier, were assigned a value of 1. A score of 0 was allotted to patients who did not fulfill any of the three variables. The q SOFA score of each patient was calculated, and its association with admission to the ICU was observed. A significant association was found between the q SOFA score and the requirement of ICU care (P < .05). The higher the q SOFA score, the higher the probability of a patient requiring ICU care. The q SOFA score was calculated for the patients diagnosed with acute pancreatitis, using three criteria as mentioned earlier [Table 5].
Table 5.
Association between qSOFA Score and ICU admission
| Chi-square | df | P |
|---|---|---|
| 51.28 | 3 | 0.00 |
Null hypothesis − No significant association exists between the q SOFA score and ICU admission. H0 ≠ 0.05.
In this study, a significant association exists between the q SOFA score and ICU admission, with P < .05.
We tried to find the association between the individual criteria of the q SOFA score and ICU admission. In this study, all the patients admitted with acute pancreatitis had a GCS score of 15. We tried to find an association between the systolic blood pressure of the patient and the requirement of ICU care. Among all the participants, 26% of the patients had systolic blood pressure less than 100 mm Hg and needed ICU care, while 60% of the admitted patients had systolic blood pressure more than 100 mm Hg and did not need ICU admissions. On statistical analysis, a significant association was observed between low systolic blood pressure and the need for ICU admission (P < .05) [Table 6].
Table 6.
Association between systolic BP and ICU admission
| Systolic BP (mm Hg) | ICU Admission | |
|---|---|---|
|
| ||
| Yes, n (%) | No, n (%) | |
| <100 | 22 (26) | 1 (1) |
| >100 | 11 (13) | 50 (60) |
Null hypothesis − No significant association exists between low BP and ICU admission. H0 ≠ 0.05.
In this study, even with an RR of less than 22 per min, 58% of the patients did not require ICU care. Only 34% of the patients with RR < 22 required ICU admission, while 6% of the patients with RR > 22 required ICU admission. On statistical analysis, no significant association was found between RR and the need for ICU admission (P = .07) [Table 7].
Table 7.
Association between respiratory rate and ICU admission
| RR (/min) | ICU Admission | Total | |
|---|---|---|---|
|
| |||
| Yes, n (%) | No, n (%) | ||
| <22 | 28 (34) | 49 (58) | 77 |
| >22 | 5 (6) | 2 (2) | 7 |
| Total | 33 | 51 | 84 |
Among the 84 patients, 78 recovered and were discharged from the hospital, while six expired during the treatment, making a mortality rate of 7%. The statistical analysis showed a significant association between the q SOFA score and mortality (P < .01). During the treatment, a greater risk of mortality was seen with a high q SOFA score [Table 8].
Table 8.
Outcome of the study population (n=84)
| Outcome | No. of patients | Percentage |
|---|---|---|
| Alive | 78 | 93 |
| Expired | 6 | 7 |
Null hypothesis − No significant association exists between the q SOFA score and mortality. H0 ≠ 0.01.
A significant association was found between the q SOFA score and mortality, with P < .01 [Table 9].
Table 9.
Association between the qSOFA Score and mortality
| Chi-Square | df | P |
|---|---|---|
| 25.23 | 3 | 0.00 |
Discussion
Of all the patients diagnosed with acute pancreatitis and admitted to RIMS, Ranchi, 84 were included in this study, out of whom, 65% were male and 35% female. A study by Hallac et al.[6] (2019) had 51.5% male and 48.5% female patients. Another study on acute pancreatitis by Rasch et al. (2022),[7] compared the q SOFA score and the Emergency Room Assessment of Acute Pancreatitis (ERAP) score, which had a male-to-female ratio of 1.3:1. In their 2019 study, Liu et al.[8] had 56.95% male and 43.05% female patients. So, we can conclude that our study had a percentage of males and females more or less comparable to other studies. With alcohol being the most common cause of acute pancreatitis, a gender-based variation can be seen in the dose-response relationship between alcohol and acute pancreatitis, as women experience higher risks even with lower levels of alcohol intake, comparatively.[9]
Acute pancreatitis mainly affects the adult population, and chronic pancreatitis has an incidence and a prevalence of 4-14/100,000 and 13-52/100,000 per year, respectively.[10,11] It also affects children, with an incidence of 10-15/1,00,000 per year.[12] The incidence increases with age.[13] The incidence of alcohol-induced acute pancreatitis precedes chronic alcohol-related pancreatitis by a decade.[14] The most common cause of acute pancreatitis continues to be gallstones.[15] A retrospective study found that patients admitted for acute pancreatitis were 5 years older than patients with recurrent chronic pancreatitis.[16] In the present study, 35.71% of the patients were 31-40 years of age, followed by those 21-30 years of age with 14.29%.
Ramírez-Maldonado et al.[17] categorised the patients of acute pancreatitis into two groups among whom the mean length of stay of immediate oral and conventional oral refeeding was 3.4 (SD ± 1.7) and 8.8 (SD ± 7.9) days, respectively (P < .001).
Shahein et al. (2020)[18] in their study on children with acute pancreatitis reported that the mean age was 12 years (range, 7.6-17.4 years), 55% were females and the median length of hospital stay was 3 days. In 2018, Maisam Abu-El-Haija conducted a study and concluded that adolescents of age > 14 years had a median of 2.87 days of length of stay with an interquartile range of 1.61-4.81; P < .001).[19] Another study by Fagenholz et al.[20] concluded that the mean length of stay in cases of acute pancreatitis was 6.9 days. These studies state that the cases of acute pancreatitis had a stay of 4-8 days in the hospital, which is contradictory to the length of stay of 15.69 days in the current study. The increased length of stay in the current study might be due to many reasons such as late presentation to the hospital and scarcity of resources.
In our study on acute pancreatitis, taking into account the q SOFA scoring system resulted in 14 out of 17 patients getting admitted to the ICU among those who scored 1 and 12 out of 12 patients admitted to the ICU among those who scored 2; one patient who had a q SOFA score of 1 also got an ICU admission, while the rest had a score of 0. Concluding this, our study had a q SOFA score 1 sensitivity of 0.42, q SOFA score 2 had a sensitivity of 0.36 and q SOFA score 3 had a sensitivity of 0.03.
In a study by Rasch et al.,[7] the q SOFA score was found to have the potential to predict ICU admission (AUC = 0.730, P = .002). Wagner et al.,[21] in their retrospective cohort review of 161 patients, demonstrated that a qSOFA score of 2 or higher 48 hours after admission was correlated to the severity of pancreatitis and need for ICU admission with a specificity of 94% and sensitivity of 33%. Hallac et al.[6] reported that a qSOFA score of 2 or greater suggests a diagnosis of significant acute pancreatitis with a sensitivity of 4% and a specificity of 99%.
According to a study by Li et al.[22] on the prediction of mortality in the emergency room on non-trauma patients, the non-survival group (P < .001) had a statistical qSOFA score. Goktekin[23] mentioned in his study on 98 patients qSOFA score of 1 and above in 17 and 0 in 81 patients had a P value of 0.004. Under the qSOFA criteria with cut-off > 0, the AUC was 0.641, sensitivity 39.58%, specificity 86%, CI% 0.538-0.735 and P = 0.001. In the current study, the P value drawn for the analysis of the association between qSOFA and mortality was 0.001, showing it to be significant.
Conclusions
The q SOFA system, devised as a scoring system to assess the severity of sepsis, is now taking into account the prediction of mortality in acute pancreatitis. The q SOFA scoring system proves helpful in this context as the scoring system does not include any laboratory investigations or imaging techniques and is done at the bedside. This scoring system is considerably helpful in predicting ICU admissions, as well as mortality. An early triage of patients and a quick start of treatment accordingly will be of great help in shaping better management of acute pancreatitis.
Limitations of the study
The prognostic potential of the q-SOFA score was analysed and established with prospective patient data, but the sample size recruited was low at a single centre, which was liable for referral bias.
The confirmation of the results in a larger multicentric study would be better.
Combining the q-SOFA criteria with Laboratory parameters like BUN and CRP results in the emergency room assessment of acute pancreatitis ERAP score, which is a more sensitive prognostic score for the prediction of MODS and mortality in Acute Pancreatitis.[7]
Conflicts of interest
There are no conflicts of interest.
Funding Statement
Nil.
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