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ORIGINAL ARTICLE
Year : 2018  |  Volume : 31  |  Issue : 2  |  Page : 677-680

E/A ratio and troponin I level as measures of mortality in patients with shock in pediatric intensive care units


Pediatrics Department, Faculty of Medicine, Menoufia University, Shebin Elkom, Egypt

Date of Submission06-Dec-2016
Date of Acceptance27-Feb-2017
Date of Web Publication27-Aug-2018

Correspondence Address:
Basim A Elgazzar
Pediatrics Department, Faculty of Medicine, Menoufia University, Shebin Elkom 32511
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_675_16

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  Abstract 


Objective
The aim of this study was to assess the value of E/A ratio and troponin I level as indexes of mortality in patients with shock in a pediatric intensive care unit (PICU).
Background
The E/A ratio is the ratio between the E wave and the A wave, and is used as an index of the diastolic function of the heart. Troponin I is specific of myocardial injury. Its level reflects the systolic and diastolic functions of the heart.
Patients and methods
A total of 50 children with shock in our PICU were studied. Clinical assessments, complete blood analysis, liver and renal function tests, and detection of troponin I levels were carried out. Echocardiographic assessment was carried out, including the assessment of ejection fraction% and E/A ratio.
Results
The group of dead patients had a significantly lower E/A ratio and a significantly higher troponin I level.
Conclusion
The E/A ratio and troponin I levels can be used as mortality indexes in patients with shock admitted to the PICU.

Keywords: E/A ratio, echocardiography, pediatric intensive care unit, shock, troponin I


How to cite this article:
Elgazzar BA, Hassan FM, Khattab AA, Elzayat RS. E/A ratio and troponin I level as measures of mortality in patients with shock in pediatric intensive care units. Menoufia Med J 2018;31:677-80

How to cite this URL:
Elgazzar BA, Hassan FM, Khattab AA, Elzayat RS. E/A ratio and troponin I level as measures of mortality in patients with shock in pediatric intensive care units. Menoufia Med J [serial online] 2018 [cited 2018 Nov 20];31:677-80. Available from: http://www.mmj.eg.net/text.asp?2018/31/2/677/239766




  Introduction Top


Shock is a common manifestation of many forms of critical illness. Although a patient with hypotension can have shock, shock is not necessarily defined by hypotension. That is, a patient can have a 'normal' blood pressure and have shock concurrently. Accordingly, the definition of shock is based on the concepts of oxygen delivery, circulation-related factors that govern oxygen delivery, and tissue oxygen requirements. When tissue oxygen requirements are not met by the circulatory system, because of poor myocardial function, hypovolemia, and/or hypotension, a patient is said to be in shock [1].

Assessment of ventricular function is an essential part of every echocardiographic study performed in children. Assessment of systolic function is challenging due to the confounding effect of different factors such as ventricular geometry and variable loading conditions. To understand the uses and limitations of the different echocardiographic techniques in pediatrics, you must be familiar with some physiological concepts of ventricular function [2].


  Patients and Methods Top


This study was carried out on 50 pediatric patients admitted to the pediatric intensive care unit (PICU) of Menoufia University Hospital with shock caused by sepsis or systemic inflammatory response syndrome from January 2015 to June 2015. Their ages ranged from 3 months to 12 years; 23 of them were males and 27 were females.

The Ethics Committee of the Faculty of Medicine at Menoufia University approved this study.

Inclusion criteria

All patients who presented with shock [systolic blood pressure (SBP) <10th centile for age and heart rate >90th centile for age] were included [3].

Exclusion criteria

Patients with structural heart disease were excluded.

All patients were subjected to the following:

  1. A written consent was obtained from the parents on behalf of their children
  2. Full history taking: personal history including name, age, and sex, history of present illness, past history, and family history
  3. Thorough clinical examination: general examination, including general look and vital signs assessment (heart rate, blood pressure, and respiratory rate), as well as systemic examination.


The following investigations were carried out:

  1. Laboratory investigations: blood samples were collected within 12 h of admission, and the following investigations were carried out. Complete blood count measured by a Coulter apparatus (Beckman 750 Int L.S.A.; Beckman, Taipei, Taiwan, ROC) (parameters were considered according to WHO criteria) [4], serum creatinine level (normally 0.4–1.3 mg/dl), blood urea nitrogen (normally 5–21 mg/dl), alanine aminotransferase (normally 10–40 U/l), aspartate aminotransferase (normally 7–56 U/l), and troponin I by semiluminescence (normally <0.02 ng/ml)
  2. Transthoracic echocardiography imaging: using Philips HD 11 device (Philips), the following measures were obtained within 12 h after admission and daily during the 7-day observation period:


    1. Ejection fraction = left ventricular end-diastolic volume − left ventricular end-systolic volume/left ventricular end-diastolic volume × 100 using the parasternal long-axis view (normally >55%) [5].
    2. E/A ratio by placing the pulsed Doppler above the mitral ring [5].


Patients were followed-up for 7 days or until discharge from the PICU.

Mortality was defined as 28-day all-cause mortality (death within 28 days due to any cause) [6].

The data collected were tabulated and statistically analyzed using SPSS statistical package (V17; SPSS Inc, Chicago, Illinois, USA) on an IBM-compatible computer. In the following sections, continuous variables are expressed as means and SD after checking for normality of distribution.

Differences between patients who died and those who survived were analyzed by the paired sample t-test. A P value less than 0.05 was considered statistically significant.


  Results Top


Mechanical ventilation was significantly higher in dead patients compared with survivors, and no significant differences between dead patients and survivors with regard to age, sex, cause of admission, heart rate, and SBP were found, as shown in [Table 1].
Table 1: Demographic and clinical data of the studied patients at day 1

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Thrombocytopenia, troponin I level, blood urea nitrogen, and creatinine level were significantly higher in dead patients compared with survivors, and no significant differences between dead patients and survivors were found with regard to hemoglobin, white blood cell count, and liver function as shown in [Table 2].
Table 2: Laboratory data of the studied patients at day 1

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The E/A ratio was significantly lower in dead patients compared with survivors, and no significant difference between dead patients and survivors with regards to ejection fraction% was found as shown in [Table 3].
Table 3: Echocardiographic data of the studied patients at day 1

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  Discussion Top


In our study, there was a significant relationship between mechanical ventilation and mortality. Rady et al. [7]also found that mechanical ventilation was a risk factor for mortality; in their study, they found that patients who were intubated had a higher risk of mortality and that arterial blood gases derangement increased the risk of mortality, especially partial arterial oxygen pressure. Mortality was 100% in patients with PaO2 less than 42 mmHg.

Moreover, ina study by Panico et al. [8], conducted on children aged between 1 month and 15 years, pressure control/assist control was the initial mode of mechanical ventilation in 86% of cases, and the median durations of mechanical ventilation and PICU stay were 15 days. They found that peak inspiratory pressure, airway pressure gradient on day 1, and the mean airway pressure gradient over the first 7 days of mechanical ventilation were significantly associated with mortality, which is consistent with our results.

We found that there was no significant relationship between heart rate and SBP on the one hand and mortality on the other hand, and this is not in agreement with Rady et al. [7], who found that risk of mortality was almost doubled in infants with SBP less than 44 mmHg or in children with SBP less than 57 mmHg and adolescents with SBP less than 66 mmHg, and that the risk of mortality was doubled in infants with heart rate less than 50 beat/min or in children with heart rate less than 40 beat/min.

Our study proved a significant relationship between thrombocytopenia and mortality, which is in agreement with Krishnan et al. [9]who found that thrombocytopenia and falling platelet counts were associated with increased risk of mortality and length of stay in the PICU.

A significant relationship was found between acute renal failure and mortality. Krishnamurthy et al. [10] also found that acute renal failure was associated with adverse outcomes, including high mortality.

We found that serum troponin I was significantly related to mortality, which coincides with Lipshultz et al. [11]who found that elevation of blood cTnT in children is related to the severity of myocardial damage and predicts subsequent subclinical and clinical cardiac morbidity and mortality.

We used the E/A ratio as a measure of diastolic function; we found that diastolic dysfunction was significantly related to mortality. Similar results were obtained by Sankar et al. [12] who found that left ventricular dysfunction is a common finding in septic shock, and that grade 1 diastolic dysfunction is associated with a significant increase in mortality.


  Conclusion Top


Mechanical ventilation, thrombocytopenia, renal failure, E/A ratio, and troponin I level are significantly related to mortality in patients with shock admitted to the PICU.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Abraham E, Reinhart K, Opal S, Demeyer I, Doig C, Rodriguez AL, et al. Efficacy and safety of tifacogin (recombinant tissue factor pathway inhibitor) in severe sepsis: a randomized controlled trial. JAMA 2003; 290 :238–247.  Back to cited text no. 1
    
2.
Sutherland GR, di Salvo G, Claus P, D'hooge J, Bijnens B. Strain and strain rate imaging: a new clinical approach to quantifying regional myocardial function. J Am Soc Echocardiogr 2004; 17:788–802.  Back to cited text no. 2
    
3.
Hotchkiss RS, Tinsley KW, Karl IE. Role of apoptotic cell death in sepsis. Scand J Infect Dis 2003; 35:585–592.  Back to cited text no. 3
    
4.
World Health Organization. Iron deficiency anaemia: assessment, prevention and control, a guide for programme managers. Geneva: World Health Organization; 2001.  Back to cited text no. 4
    
5.
Weidemann F, Eyskens B, Jamal F. Quantification of regional left and right ventricular radial and longitudinal function in healthy children using ultrasound-based strain rate and strain imaging. J Am Soc Echocardiogr 2002; 15:20–28.  Back to cited text no. 5
    
6.
Bergenzaun L, Öhlin H, Gudmundsson P, Willenheimer R, Chew MS. Mitral annular plane systolic excursion (MAPSE) in shock: a valuable echocardiographic parameter in intensive care patients. Cardiovasc Ultrasound 2013; 11:16.  Back to cited text no. 6
    
7.
Rady HI, Mohamed SA, Mohssen NA, ElBaz M. Application of different scoring systems and their value in pediatric intensive care unit Department of Pediatrics. Gaz Egypt Paediatr Assoc 2014; 62:3–4.  Back to cited text no. 7
    
8.
Panico FF, Troster EJ, Oliveira CS, Faria A, Lucena M, João PR, et al. Risk factors for mortality and outcomes in pediatric acute lung injury/acute respiratory distress syndrome. Pediatr Crit Care Med 2015; 16:194–200.  Back to cited text no. 8
    
9.
Krishnan J, Morrison W, Simone S, Ackerman A. Implications of thrombocytopenia and platelet course on pediatric intensive care unit outcomes. Pediatr Crit Care Med 2008; 9:502–505.  Back to cited text no. 9
    
10.
Krishnamurthy S, Narayanan P, Prabha S, Mondal N, Mahadevan S, Biswal N, Srinivasan S. Clinical profile of acute kidney injury in a pediatric intensive care unit from Southern India: a prospective observational study. Indian J Crit Care Med 2013; 17:207–213.  Back to cited text no. 10
    
11.
Lipshultz SE, Rifai N, Sallan SE, Lipsitz SR, Dalton V, Sacks DB, et al. Predictive value of cardiac troponin t in pediatric patients at risk for myocardial injury. Circulation 1997; 96:2641–2648.  Back to cited text no. 11
    
12.
Sankar J, Das RR, Jain A, Dewangan S, Khilnani P, Yadav D, et al. Prevalence and outcome of diastolic dysfunction in children with fluid refractory septic shock – a prospective observational study. Pediatr Crit Care Med 2014; 15:370–378.  Back to cited text no. 12
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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Introduction
Patients and Methods
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