Section Paediatrics Original Article

Paediatric Risk of Mortality III Score to Predict

Outcome in Patients Admitted to PICU with
Dengue Fever
1Clinical fellow, Birmingham children’s
hospital, Birmingham, UK.
2Assistant Professor (Pediatric intensive

care), Pediatric Cardiac Evaluation and

Cardiac Surgery unit, J N Medical College,
AMU, Aligarh.
3Clinical Fellow, Noah;s Ark Children

Hospital, University hospital of Wales,

Akanksha Jain1, Shahzad Alam2*, Akunuri Shalini3, Rufaida Cardiff, Wales, UK.
4Fellow Pediatric Nephrology, Sir Gangaram
Mazahir4 hospital, New Delhi.

ABSTRACT

DOI:10.21276/iabcr.2018.4.2.24
Background: The objective of the current study was to evaluate the ability of PRISM III score
calculated within 24 hours of PICU admission to predict outcome in patients with dengue fever.
Materials & Methods: The prospective cohort study included children admitted to PICU with
diagnosis of ‘Dengue with warning sign’ and ‘Severe Dengue’. Outcome included PICU mortality, Received: 23.04.18
Accepted: 15.05.18
length of PICU stay (LOS), need for mechanical ventilation and renal replacement therapy (RRT).
PRISM III score was calculated and compared with outcome groups. Calibration of the score was
measured using Hosmer-Lemeshow modification of chi square test and discrimination using Area
*Corresponding Author
under the curve of Receiver Operating Characteristic curves.
Results: This study included 151 patients with 54.3% Dengue with warning signs and 45.7% severe
Dengue. Median PRISM III-24 score of patients who died (p-0.001), required RRT (p-0.006), Dr. Shahzad Alam,
Assistant Professor, PCE-CS unit, J N
mechanical ventilation (p-0.032) and those with prolonged LOS (p-0.003) were significantly higher. Medical College, AMU, Aligarh, UP, India.
Hosmer-Lemeshow modification of chi square test to assess calibration showed good fit of PRISM Email: aaalishahzad@gmail.com
III-24 model to predict mortality (χ2-2.022; p-0.846), need for RRT (χ2-3.564; p-0.614), prolonged
LOS (χ2-4.360; p-0.499) and need for mechanical ventilation (χ2-7.497; p-0.186). ROC curve for the
Copyright: © the author(s) and publisher.
PRISM III-24 model to predict the discriminating power yield an AUC of 0.923 (95% CI: 0.829-1.000) IABCR is an official publication of Ibn Sina
for mortality, 0.953 (95% CI: 0.896-1.000) for need for RRT, 0.682 (95% CI: 0.494-0.870) for need for Academy of Medieval Medicine & Sciences,
registered in 2001 under Indian Trusts Act, 1882.
mechanical ventilation and 0.663 (95% CI: 0.563-0.764) for prolonged LOS.
Conclusion: PRISM III is an effective tool to predict mortality and need for RRT in patient with dengue This is an open access article
distributed in accordance with the Creative
fever. Commons Attribution Non Commercial (CC BY-
NC 4.0) license, which permits others to
distribute, remix, adapt, build upon this work
Key words: Pediatric Risk of Mortality III score, Mortality, Dengue fever, Pediatric Intensive care unit non-commercially, and license their derivative
works on different terms, provided the original
work is properly cited and the use is non-
commercial.

INTRODUCTION_____________________
Assessment of illness severity is crucial in ICU for quality
assessment, characterizing the severity of illness at
admission and assessing the prognosis. [1-3] This can be done
with the mortality prognostic scores that objectively
determine the severity of the patient and estimate the
probability of death.[4] Ever since the introduction of mortality
scores in the ICU, they have become an important tool for
quality control and research.[5] The Pediatric Risk of Mortality
(PRISM) score is one of the mortality prognostic scores used
in the pediatric intensive care unit.[1] PRISM score was
developed from Physiological Stability Index (PSI) to reduce
the number of physiological variables (from 34 to 14 and the
number of range from 75 to 23) required for pediatric ICU
mortality risk assessment and obtain an objective weighting
for remaining variables.[1] PRISM III is an updated version of
the scoring system published in 1996, has several
improvements over the original PRISM.[6]
Dengue fever has become an important public health
problem in world especially in tropical countries affecting 390
million people annually with 96 million manifesting

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How to cite this article: Jain A, Alam S, Shalini A, Mazahir R. Paediatric Risk
Website: Quick Response code
of Mortality III Score to Predict Outcome in Patients Admitted to PICU with
www.iabcr.org Dengue Fever: A Comparative Study. Int Arch BioMed Clin Res. 2018;4(2):80-
83.
DOI: 10.21276/iabcr.2018.4.2.24
Source of Support: Nil, Conflict of Interest: None

International Archives of BioMedical and Clinical Research [80] April – June 2018 | Vol 4| Issue 2
www.iabcr.org Jain A, et al: Pediatric risk of mortality III score in Dengue patients.

clinically.[7,8] Recently WHO has reported an increase in antibody. Twenty-two (14.6%) patients were found positive
number of Dengue cases from 2.2 million in 2010 to 3.2 for both NS1 antigen and IgM antibodies. Median PRISM III-
million in 2015.[8] Since no specific treatment exists except 24 score of patients with ‘Dengue with warning signs’ was 5
symptomatic management; early detection and correct (0-13) and those with ‘Severe Dengue’ was 8 (0-24).
prognostication of the disease is important to avoid Baseline characteristics of the patients are depicted in table
complications.[9,10] The objective of the current study was to 1. Prolonged LOS was considered as PICU LOS of more
evaluate the ability of PRISM III score calculated in the first than 4 days.
24 hours (PRISM III-24) of PICU admission to accurately Median PRISM III-24 score of patients who died was 18
predict the outcome in patients with dengue fever. (range 8-23) compared to 5 (range 0-24) for those who
survived; difference being statistical significant (p-0.001).
METHODS__________________________ Median PRISM III-24 score of patients who required RRT,
This prospective cohort study was conducted in a tertiary mechanical ventilation and those with prolonged LOS was
care hospital which included children ≤18 years old admitted also significantly higher than those who did not required RRT
in PICU from April 2015 to March 2016. Patients with (p-0.006), mechanical ventilation (p-0.032) and those without
diagnosis of ‘Dengue with warning sign’ and ‘Severe Dengue’ prolonged LOS (p-0.003) (table 2). Hosmer-Lemeshow
according to WHO classification were included. Dengue modification of chi square test to assess calibration showed
fever was diagnosed based on clinical signs and symptoms good fit of PRISM III-24 model to predict mortality (χ2-2.022;
and confirmed with serological testing by ELISA method p-0.846), need for RRT (χ2-3.564; p-0.614), prolonged LOS
detecting NS1 antigen and IgM antibody. Patients were (χ2-4.360; p-0.499) and need for mechanical ventilation (χ2-
managed as per WHO guidelines. Data related to patient 7.497; p-0.186).
demography were collected. Relevant investigations were ROC curve (table 3) for the PRISM III-24 model to predict the
sent and PRISM III score was calculated in the first 24 hours discriminating power yield an AUC of 0.923 (95% CI: 0.829-
based on clinical findings and investigations of the patients 1.000) for mortality (figure 1), 0.953 (95% CI: 0.896-1.000)
using online calculators. for need for RRT (figure 2), 0.682 (95% CI: 0.494-0.870) for
The primary outcome of interest was PICU mortality. Other need for mechanical ventilation and 0.663 (95% CI: 0.563-
outcome studied were length of PICU stay (LOS), need for 0.764) for prolonged LOS. The best cut-off chosen from the
mechanical ventilation and renal replacement therapy (RRT). ROC of PRISM III-24 score for predicting mortality was 12.5
For further analysis, LOS was dichotomized as upper (worst) with a sensitivity of 80.0% and specificity of 91.1% and for
25th percentile versus lower (best) 75th percentile. need for RRT was 11.5 with sensitivity of 100% and
Considering the mortality due to dengue fever as 5% based specificity of 88.5%. The cut-off with the sensitivity and
on the unpublished data from our center with 95% confidence specificity of the outcome indicators are shown in table 4.
interval and margin of error 5%, required sample size for the
study was approximately 72. Table 1: Baseline characteristic of the patients Dengue fever
Statistical analysis was performed using SPSS software. in the study. (n-151)
Continuous data were expressed as median with range and Dengue With Severe
Variables
Warning Sign (n-82) Dengue (n-69)
categorical data as absolute number with percentage.
PRISM III score in the outcome groups were expressed as Age (Years) ± SD* 8.5 (0.5 – 17.0) 7.0 (0.3 – 17.0)
median and compared using Mann-Whitney U test. P value Median Day of Illness at
5 (2 – 10) 5 (1 – 9)
<0.05 was considered as significant. The analysis was done Admission (Range)*
for overall performance of the score including the extent to Sex
which the PRISM III score accurately predicts the dependent Male 51 30
variable, which indicates the goodness of fit (calibration) and Female 31 39
ability to separate subjects who experienced the outcome
Signs And Symptoms
event, from the others (discrimination). Calibration was
Fever 75 58
measured using Hosmer-Lemeshow modification of chi
Abdominal Pain 76 50
square test. The calibration test yield of p value > 0.05
Vomiting 48 40
indicates a good fit (the higher the p value, the better the fit
Headache 2 7
of the model). Discriminative power of scoring systems was
Mucosal Bleed 0 8
assessed using area under the curve (AUC) of receiver
Altered Sensorium 0 3
operating characteristic curves (ROC). Cut-off of the PRISM
Seizures 0 7
III score for outcomes along with sensitivity and specificity
Hepatomegaly 46 32
were also calculated.
Hypotension 0 49
Respiratory Distress 0 10
RESULTS___________________________ Oliguria 0 8
This study included 151 patients with dengue fever admitted
Pleural Effusion 27 39
to PICU with a median age of 7 years (range 3 months – 17
years) including 53.6% males and 46.4% females. Eighty- PRISM III-24 score * 5 (0 - 13) 8 (0 - 24)
two (54.3%) patients were classified as Dengue with warning *- median (range)
signs and 69 (45.7%) as severe Dengue according to WHO
classification. Median day of illness at presentation was 5th DISCUSSION________________________
day of fever (range 3rd – 8th day). Commonest presenting With the technological advances in pediatric intensive care
symptoms was fever (98%) followed by vomiting (68.9%) and units there is a need for strict quality control and identify the
abdominal pain (63.6%). Sixty-nine (45.7%) patients had patients at risk for death. The mortality rates and the
NS1 antigen positive and 60 (39.7%) were positive for IgM prognosis of the disease conditions could be explained by
International Archives of BioMedical and Clinical Research [81] April – June 2018 | Vol 4| Issue 2
www.iabcr.org Jain A, et al: Pediatric risk of mortality III score in Dengue patients.

the severity of patients.[11] This makes the use of prognostic Overall mortality due to Dengue fever in the current study
indicators an essential quality criterion in patient care which which includes children admitted to PICU was 3.3% which is
in turn helps in early recognition of the severity and in better slightly higher than the WHO case fatality rate 2.5% among
utilization of the resources. This is especially true for Dengue those hospitalized for Dengue. [8] The current rate is an
fever where inability to act promptly can lead to state of overestimate of the mortality rate as it includes only patient
irreversible shock and death. admitted in PICU and rate would decrease to around 2%
considering the total admission for Dengue fever during the
Table 2: Comparison of PRISM III-24 score with the outcome study period. In the current study median PRISM III-24 score
PRISM III-24 was significantly higher in patients who died (18) compared
VARIABLE N p value
score
Hospital mortality
to those who survived (5) which is consistent with earlier
Died 5 18 (8,23) reports. Bilan et al reported a significantly higher mean
0.001
Survived 146 5 (0,24) PRISM III-24 score in patients who died (28.85 vs 12.76;
Need for dialysis p<0.001) in PICU. [13] Similarly Mehta et al found average
Yes 3 18 (12,23) PRISM III-24 score to be higher in non-survived (14.6)
0.006
No 148 5 (0,24)
compared to those who survived (4.1). [14] Although PRISM
Need for mechanical ventilation
Yes 12 10 (3,23) III score is primarily for predicting mortality the current study
0.032
No 139 5 (0,24) found a significant higher PRISM III-24 score in patients who
Length of stay required RRT, mechanical ventilation and those with
< 4 days 117 5 (0,23) prolonged LOS.
0.003
≥ 4 days 34 7.5 (4,24)

Table 3: Showing AUC of ROC curve of PRISM III-24 score with

outcome
95% Confidence
Outcome AUC
Interval
Hospital Mortality 0.923 0.829-1.000
Need for dialysis 0.953 0.896-1.000
Need for mechanical ventilation 0.682 0.494-0.870
Prolonged LOS 0.663 0.563-0.764

Table 4: Showing the cut-off of the PRISM III-24 score with

sensitivity and specificity for the outcome derived from the
ROC curve.
Outcome Cut-off Sensitivity Specificity

7.5 100% 64.4%

Hospital Mortality 12.5 80% 91.1%
17.5 60% 97.9%

7.5 100% 63.5%

Fig 1: Receiver operating curve showing PRISM III-24 score
Need for dialysis 11.5 100% 88.5%
17.5 66.7% 97.3%
and mortality in Dengue patients.

Need for 7.5 66.7% 64.7%

mechanical 9.5 58.3% 86.3%
ventilation 12.5 33.3% 90.6%

4.5 97.1% 22.2%

Prolonged LOS 5.5 61.8% 64.3%
6.5 58.8% 59.8%

In the current study PRISM III-24 score was used to predict

the outcome of patients with Dengue fever admitted in PICU.
First developed and validated by Pollack et al in the year
1997 with data from 32 PICU PRISM III has been used for a
variety of purposes, including PICU care trait mortality risk
based on first 12 hours or 24 hours of PICU stay, estimating
risk-adjusted length of PICU stay and quantifying severity of
illness for other purposes.[6,12] In the current study median
PRISM III-24 score was higher in patients with severe
Dengue compared to those with Dengue with warning sign
which signifies that the patients with severe dengue were
sicker at admission or during first 24 hours of PICU stay than Fig 2: Receiver operating curve showing PRISM III-24 score
those diagnosed as Dengue with warning sign. and need for RRT in Dengue patients.

International Archives of BioMedical and Clinical Research [82] April – June 2018 | Vol 4| Issue 2
www.iabcr.org
The Hosmer-Lemeshow modification of chi square test
showed satisfactory goodness of fit of PRISM III-24 score for
predicting mortality in Dengue fever. Pollack et al also found
adequate goodness of fit of PRISM score for predicting
mortality in their study while validating PRISM score using
Hosmer-Lemeshow modification of chi square test. [1] They
also validated the same in subgroup of patients of each PICU
separately, surgical and non-surgical patients, patients with
cardiovascular, neurological and respiratory diseases. [1] The
calibration of PRISM score to predict mortality was also
validated by Costa et al in their PICU.[15] PRISM III score
model was also evaluated for calibration and found to have
adequate goodness of fit for predicting mortality by Pollack
et al. [12] The current study also found satisfying goodness of
fit of PRISM III score for predicting need for RRT, mechanical
ventilation and prolonged LOS.
The AUC for ROC curve for PRISM III to predict mortality in
the current study was 0.923 which is comparable to earlier
studies. Pollack et al found an excellent discrimination of
PRISM III score to discriminate between survivors and death
with AUC of 0.950 among training sample and 0.902 among
validation sample.[12] Mehta et al found the AUC of 0.96
whereas Costa et al found that AUC of 0.76 for PRISM III in
their PICU to predict mortality.[14,15] The current study also
found a satisfactory discriminatory performance of PRISM III
score in discriminating patient who need RRT however the
performance to discriminate patients who need mechanical
ventilation and those who required prolonged LOS was poor.
The best cut-off of PRISM III to discriminate mortality was
12.5 that for need for RRT was 11.5 with good sensitivity and
specificity. However, no satisfactory cut-off could be
determined for patients who require mechanical ventilation
and had prolonged LOS. The cut-off of 9 for PRISM III score
was found to be best to predict mortality in studies by Mehta
et al and Prashanth et al. [14,16]
CONCLUSION_______________________
PRISM III score has proved to be an effective tool to predict
mortality among patient with dengue fever admitted in PICU.
International Archives of BioMedical and Clinical Research
Jain A, et al: Pediatric risk of mortality III score in Dengue patients.
In addition to mortality its ability to predict need for RRT was
also found adequate however was unsatisfactory to predict
need mechanical ventilation and prolonged LOS.
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