Evaluation of Dynamic Variation in Red Cell Distribution Width as a Septic Marker in Comparison with Procalcitonin Levels and Clinical Scores in Patients with Sepsis or Septic Shock: A Prospective Observational Study

BACKGROUND: Sepsis is a dysregulated host response to infection resulting in potentially life-threatening organ dysfunction. Elevation in red cell distribution width (RDW), a simple routinely done investigation, could be a prognostic marker in these patients. AIM: We performed this prospective observational study to assess role of dynamic variation of RDW in predicting 30-day mortality in patients with sepsis or septic shock presenting and getting admitted in intensive care unit (ICU) in Fayoum, Egypt. METHODS: Between January 2019 and January 2021, 150 patients with sepsis or septic shock at admission were prospectively evaluated for association between RDW value on admission, on day 4, on day 7, and 30-day mortality. To find out factors associated independently with 30-day mortality, we applied multivariate logistic regression analysis and used the analysis to develop nanogram for prediction of mortality on admission. RESULTS: Among 150 patients, 89 (59.3%) were male. Mean age of the patients was 59.6 ± 12.28 years. Regarding RDW on admission (RDW-0), the mean was 14.1 ± 1.9 while on day 4 (RDW-4), the mean was 14.5 ± 1.97, and on day 7 (RDW-7), the mean was 14.4 ± 2.03. Seventy-four (49.3%) patients died during the period of 30 days follow-up. Multiple logistic regression models for the parameters associated with the mortality outcome at admission were done, for age, higher age was associated with higher probability of mortality, OR = 1.07 (95% CI: 1.02, 1.13). Male sex was associated with lower probability of mortality as compared to females, OR = 0.02 (95% CI: 0.06, 0.80). Higher acute physiologic assessment and chronic health evaluation (APACHE) II score, RDW value, and procalcitonin level, all were associated with higher mortality probability. For APACHE II score, higher level was associated with higher odds of mortality, OR = 1.16. For RDW value on admission, higher value was associated with higher odds of mortality, OR = 1.66. For procalcitonin level at admission, higher level was associated with higher odds of mortality, OR = 1.54. Odds for mortality for those who showed any increase in RDW in day 4 as compared to day 0 are higher as compared to those who showed a decrease or no change in RDW, OR = 2.8, p-value = 0.007. CONCLUSIONS: We found that an increase in RDW value on admission and on day 4 is significantly associated with mortality. And that, an increase in RDW value from day 0 to day 4 is also significantly associated with mortality Therefore, a combination of baseline RDW value and an  increase in serial RDW values can be a promising independent prognostic marker in patients with sepsis or septic shock.

[1]  J. Vincent,et al.  The early change of SOFA score as a prognostic marker of 28-day sepsis mortality: analysis through a derivation and a validation cohort , 2019, Critical Care.

[2]  Dr S.R. Ramakrishnan.  Comparison of Mortality Prediction, of APACHE II, SAPS II and SOFA ICU Scoring Systems in Patients with Severe Sepsis and Septic Shock in ICU of A Tertiary Care Hospital , 2019 .

[3]  Eun Jin Kim,et al.  A Simple Scoring System Using the Red Blood Cell Distribution Width, Delta Neutrophil Index, and Platelet Count to Predict Mortality in Patients With Severe Sepsis and Septic Shock , 2018, Journal of intensive care medicine.

[4]  Kimberly Fowler,et al.  Predicting Mortality of Patients With Sepsis: A Comparison of APACHE II and APACHE III Scoring Systems , 2017, Journal of clinical medicine research.

[5]  M. Singer,et al.  Beta-blockers in sepsis: time to reconsider current constraints? , 2017, British journal of anaesthesia.

[6]  D. D. de Lange,et al.  The impact of frailty on ICU and 30-day mortality and the level of care in very elderly patients (≥ 80 years) , 2017, Intensive Care Medicine.

[7]  E. Papathanassoglou,et al.  Systematic review of gender‐ dependent outcomes in sepsis , 2017, Nursing in critical care.

[8]  A. Bhalla,et al.  Elevated Red Cell Distribution Width as a Prognostic Marker in Severe Sepsis: A Prospective Observational Study , 2017, Indian journal of critical care medicine : peer-reviewed, official publication of Indian Society of Critical Care Medicine.

[9]  Asmita A. Mehta,et al.  Predictors of mortality of severe sepsis among adult patients in the medical Intensive Care Unit , 2017, Lung India : official organ of Indian Chest Society.

[10]  R. Bellomo,et al.  The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). , 2016, JAMA.

[11]  T. Rea,et al.  Assessment of Clinical Criteria for Sepsis: For the Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). , 2016, JAMA.

[12]  Adil Rafiq Rather,et al.  The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3) , 2015 .

[13]  J. Mathew,et al.  Broadening of the red blood cell distribution width is associated with increased severity of illness in patients with sepsis , 2014, International journal of critical illness and injury science.

[14]  P. Abreu-González,et al.  Red Blood Cell Distribution Width during the First Week Is Associated with Severity and Mortality in Septic Patients , 2014, PloS one.

[15]  A. C. Tanrıkulu,et al.  Is a complete blood cell count useful in determining the prognosis of pulmonary embolism? , 2014, Wiener klinische Wochenschrift.

[16]  T. Yoo,et al.  An increase in red blood cell distribution width from baseline predicts mortality in patients with severe sepsis or septic shock , 2013, Critical Care.

[17]  B. Horne,et al.  Red cell distribution width is predictive of mortality in trauma patients , 2013, The journal of trauma and acute care surgery.

[18]  Jae Hyuk Lee,et al.  Red cell distribution width is a prognostic factor in severe sepsis and septic shock. , 2013, The American journal of emergency medicine.

[19]  Y. Jang,et al.  Red blood cell distribution width predicts early mortality in patients with acute dyspnea. , 2012, Clinica chimica acta; international journal of clinical chemistry.

[20]  G. Martin.  Sepsis, severe sepsis and septic shock: changes in incidence, pathogens and outcomes , 2012, Expert review of anti-infective therapy.

[21]  Bertrand Guidet,et al.  Variability of Intensive Care Admission Decisions for the Very Elderly , 2012, PloS one.

[22]  J. Kline,et al.  The Sequential Organ Failure Assessment score for predicting outcome in patients with severe sepsis and evidence of hypoperfusion at the time of emergency department presentation* , 2009, Critical care medicine.

[23]  G. Luckemeyer,et al.  Sepsis in the intensive care unit: etiologies, prognostic factors and mortality. , 2008, Revista Brasileira de terapia intensiva.

[24]  M. Pfeffer,et al.  Red cell distribution width as a novel prognostic marker in heart failure: data from the CHARM Program and the Duke Databank. , 2007, Journal of the American College of Cardiology.

[25]  R. Nap,et al.  Analysis of physiologic alterations in intensive care unit patients and their relationship with mortality. , 2007, Journal of critical care.

[26]  E. Ruokonen,et al.  Incidence, treatment, and outcome of severe sepsis in ICU-treated adults in Finland: the Finnsepsis study , 2007, Intensive Care Medicine.

[27]  Marc Moss,et al.  The effect of age on the development and outcome of adult sepsis* , 2006, Critical care medicine.

[28]  J. Vincent,et al.  Hypoalbuminemia in Acute Illness: Is There a Rationale for Intervention?: A Meta-Analysis of Cohort Studies and Controlled Trials , 2003, Annals of surgery.

[29]  J. Vincent,et al.  Serial evaluation of the SOFA score to predict outcome in critically ill patients. , 2001, JAMA.