Is skin mottling a predictor of high mortality in non-selected patients with cirrhosis admitted to intensive care unit?
Authors: Rémi Coudroy, Angéline Jamet, Arnaud W. Thille
Journal: Journal of Hepatology (2015)

Exploration of skin perfusion in cirrhotic patients with septic shockJournal of HepatologyVol. 62Issue 3PreviewSeptic shock, the most severe form of infection, is defined by a severe sepsis (acute organ dysfunction secondary to infection) associated with hypotension not reversed with fluid resuscitation [1,2]. Septic shock is a major health-care problem worldwide in the general population [2]. Full-Text PDF Reply to: “Is skin mottling a predictor of high mortality in non-selected patients with cirrhosis admitted to intensive care unit?”Journal of HepatologyVol. 63Issue 3PreviewWe would like to thank Dr Coudroy and colleagues for their letter, which gives us the opportunity to clarify some important points. Full-Text PDF Open Access In the March issue of the Journal of Hepatology, Galbois and colleagues investigated the impact of skin mottling on outcome in 42 patients with cirrhosis admitted in intensive care unit (ICU) for septic shock [[1]Galbois A. Bige N. Pichereau C. Boelle P.Y. Baudel J.L. Bourcier S. et al.Exploration of skin perfusion in cirrhotic patients with septic shock.J Hepatol. 2015; 62: 549-555Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar]. They reported that the large extent of skin mottling as well its persistence were two strong predictors of mortality. Indeed, in-ICU mortality reached 83% in cirrhosis patients with septic shock having skin mottling at admission, and none of the patients with persistent mottling for more than six hours survived [[1]Galbois A. Bige N. Pichereau C. Boelle P.Y. Baudel J.L. Bourcier S. et al.Exploration of skin perfusion in cirrhotic patients with septic shock.J Hepatol. 2015; 62: 549-555Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar]. However, the study focused exclusively on patients with septic shock, a subset of patients known to have a particularly high mortality rate. As discussed by the authors, this type of relationship between the occurrence of skin mottling and the low survival rate cannot necessarily be extrapolated to cirrhosis patients admitted in ICU for reasons other than septic shock. We recently reported the impact of skin mottling on outcome in a non-selected population of patients admitted to ICU [[2]Coudroy R. Jamet A. Frat J.P. Veinstein A. Chatellier D. Goudet V. et al.Incidence and impact of skin mottling over the knee and its duration on outcome in critically ill patients.Intensive Care Med. 2015; 41: 452-459Crossref PubMed Scopus (54) Google Scholar]. More precisely, we extracted data from our cohort in order to assess the prognosis of all cirrhosis patients with skin mottling whatever the reason for admission. Over a one-year period, 40 of the 791 patients included had cirrhosis (5.1%), which is in keeping with the usual rates reported in general ICUs [3Galbois A. Aegerter P. Martel-Samb P. Housset C. Thabut D. Offenstadt G. et al.Improved prognosis of septic shock in patients with cirrhosis: a multicenter study.Crit Care Med. 2014; 42: 1666-1675Crossref PubMed Scopus (70) Google Scholar, 4O’Brien A.J. Welch C.A. Singer M. Harrison D.A. Prevalence and outcome of cirrhosis patients admitted to UK intensive care: a comparison against dialysis-dependent chronic renal failure patients.Intensive Care Med. 2012; 38: 991-1000Crossref PubMed Scopus (71) Google Scholar]. The proportion of patients with skin mottling was significantly higher in patients with cirrhosis than in patients without cirrhosis: 45% (18 of 40 patients) vs. 28% (212 of 751 patients) (p = 0.03), which is slightly lower than the 57% rate reported by Galbois and colleagues [[1]Galbois A. Bige N. Pichereau C. Boelle P.Y. Baudel J.L. Bourcier S. et al.Exploration of skin perfusion in cirrhotic patients with septic shock.J Hepatol. 2015; 62: 549-555Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar]. However, the mortality rate of cirrhosis patients with mottling in our cohort was only 22%, a rate markedly lower than that reported in their study. Even though this was probably due to the small sample of patients studied, we did not find significant difference in mortality rate between cirrhosis patients with skin mottling and those without skin mottling (Table 1). Even in patients with persistent skin mottling for more than six hours, in-ICU mortality was only 29% (4 of 14 patients), which is not commensurate with the 100% mortality rate reported by the present study in cirrhosis patients with septic shock [[1]Galbois A. Bige N. Pichereau C. Boelle P.Y. Baudel J.L. Bourcier S. et al.Exploration of skin perfusion in cirrhotic patients with septic shock.J Hepatol. 2015; 62: 549-555Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar]. The strikingly low mortality rate in our cohort is probably explained by lower severity. Indeed, the simplified acute physiology score (SAPS) II and the sequential organ failure assessment (SOFA) score were only 41 [31–58] and 6.5 [3.3–11.8] in our study versus 69 [52–86] and 14.0 [12.0–18.0] in the study by Galbois and colleagues. It has been shown that the SAPS II score was a strong predictor of mortality, even in septic patients with cirrhosis [[3]Galbois A. Aegerter P. Martel-Samb P. Housset C. Thabut D. Offenstadt G. et al.Improved prognosis of septic shock in patients with cirrhosis: a multicenter study.Crit Care Med. 2014; 42: 1666-1675Crossref PubMed Scopus (70) Google Scholar]. The SOFA score, which assesses the number of organ dysfunctions induced during septic shock [[5]Vincent J.L. Moreno R. Takala J. Willatts S. De Mendonca A. Bruining H. et al.The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine.Intensive Care Med. 1996; 22: 707-710Crossref PubMed Scopus (7777) Google Scholar], is also a relevant predictor of mortality in cirrhosis patients [[6]Levesque E. Hoti E. Azoulay D. Ichai P. Habouchi H. Castaing D. et al.Prospective evaluation of the prognostic scores for cirrhotic patients admitted to an intensive care unit.J Hepatol. 2012; 56: 95-102Abstract Full Text Full Text PDF PubMed Scopus (157) Google Scholar]. Despite a trend over recent years favouring better outcome, admission to ICU for septic shock remains associated with high mortality, especially in cirrhosis patients who are at high risk for multiple organ failure [[3]Galbois A. Aegerter P. Martel-Samb P. Housset C. Thabut D. Offenstadt G. et al.Improved prognosis of septic shock in patients with cirrhosis: a multicenter study.Crit Care Med. 2014; 42: 1666-1675Crossref PubMed Scopus (70) Google Scholar]. Although skin mottling could indicate suboptimal hemodynamic resuscitation, the extremely high mortality rate reported by Galbois and colleagues may be due to the specific population of patients studied, i.e. the patients with cirrhosis admitted to ICU for septic shock and multiple organ dysfunctions. It has been found that skin mottling was a risk factor of mortality not only in patients with septic shock [[7]Ait-Oufella H. Lemoinne S. Boelle P.Y. Galbois A. Baudel J.L. Lemant J. et al.Mottling score predicts survival in septic shock.Intensive Care Med. 2011; 37: 801-807Crossref PubMed Scopus (208) Google Scholar] but also in non-selected patients admitted in ICU for another reason [[2]Coudroy R. Jamet A. Frat J.P. Veinstein A. Chatellier D. Goudet V. et al.Incidence and impact of skin mottling over the knee and its duration on outcome in critically ill patients.Intensive Care Med. 2015; 41: 452-459Crossref PubMed Scopus (54) Google Scholar]. From our observations, the impact of skin mottling on outcome of cirrhotic patients nonetheless seems to be markedly lower when they are admitted to ICU for a reason other than septic shock.Table 1Baseline characteristics of the 40 cirrhosis patients admitted to our ICU over a one-year period.Data are expressed in median (interquartile) according to their distribution using the Kolmogorov–Smirnov test. Continuous variables are compared using the Mann–Whitney test, and categorical variables using the Fisher exact test. Open table in a new tab Data are expressed in median (interquartile) according to their distribution using the Kolmogorov–Smirnov test. Continuous variables are compared using the Mann–Whitney test, and categorical variables using the Fisher exact test. Therefore, skin mottling could be an early severity sign associated with worse outcomes. This easy-to-assess clinical sign could help to promptly discriminate high-risk patients requiring ICU admission or treatment intensification to relieve this sign of poor peripheral perfusion. The authors who have taken part in this study declared that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript. We wish to thank Jeffrey Arsham, an American medical translator, who has reread and reviewed our English-language text.