Scoring systems (pediatrics)

Kinds of scoring systems
A number of schemes and models have been developed for scoring patients in intensive care. They all strive to meet the following criteria in order to be used for:
 * standardized classification of the severity of the condition;
 * standardized assessment of prognosis;
 * assessment of the course of the disease;
 * evaluation of treatment costs and its effectiveness;
 * decision support for individual patients;
 * assessment of new therapeutic procedures by patient stratification;
 * quality control.

In the basic division, we can distinguish two groups that differ in their approach to assessing the severity of the patient's condition:

Physiological approach

It is independent of therapy, monitors deviation and its size from physiological norms for individual parameters and correlates this dysfunction with mortality. An example is the PRISM score (Pediatric Risk of Mortality Score).

It is treatment-dependent, based on the principle that the amount and intensity of treatment is proportional to the patient's instability, and thus to the risk of death. An example is the TISS (Therapeutic Intervention Scoring System).
 * Therapeutic approach

The basic breakdown of scoring schemes is as follows:
 * Two properties are essential for all scoring systems: discrimination of the scoring system, i.e. the ability to determine patient survival/non-survival, and calibration of the scoring system, i.e. the degree of agreement between predicted and actual mortality (sensitivity).
 * The essence of model prediction of disease development and treatment outcome is a procedure in which the scoring system assigns a certain point value to the deviation of a laboratory and/or physical quantity from the normal value (physiological approach) or the need to use therapeutic procedures (therapeutic approach). The point value is then multiplied by the coefficients that were obtained by regression analysis according to the importance of the parameter in large groups of patients and directly determines, for example, the probability of the patient's death.
 * It is essential to realize that a high probability of death does not mean that the patient will actually die. E.g. with a 50% probability of death, it can only be said that half of the patients with this risk will die, and therefore it is not possible to use the evaluation according to the scoring schemes for ethical decisions. Prediction of death, however, allows an objective assessment of the patient's condition.
 * Scoring systems can be used for disease prognosis, in this case it almost predicts the mortality of a group of patients. They are unsuitable for predicting individual mortality and do not say anything about the clinical course of the disease. The second possibility is their use as continuous scoring schemes for the daily objectification of the clinical status of an individual patient.
 * disease-specific scoring systems (eg sepsis, trauma, meningococcal infection, pulmonary involvement, state of consciousness);
 * universally applicable scores.

Silverman score – to determine the degree of RDS in newborns
Evaluation: Score > 3–4 b. indicates severe respiratory distress.

Downes score – for obstruction of upper RT
Evaluation': .
 * score ≤ 2 points: possible outpatient procedure;
 * score < 5 points: care on a standard bed is sufficient;
 * score 5–7 points: ICU care + i.v. line;
 * score > 7 points: probability of tracheal intubation, usually 20 min. therapeutic trial and if the condition does not improve intubation.

Modified Downes score for lower RT obstruction
Evaluation':
 * score 1–3 points: inhalation/nebulization β2-mimetics and parasympatholytics;
 * score 3–4 points: continuous inhalation/nebulization β2-mimetic + humidified heated O2 + steroids, consider i.v. aminophylline;
 * score 4–5 points: dtto + β2-mimetic infusion + ev. UPV;
 * score > 5 UPV points.

Benes score
The GCS evaluation is most often used to 'evaluate the quantitative state of consciousness. A simplified variant of Czech origin – the so-called Beneš score is far less used, it is not routinely recognized, but it is sometimes sufficient for simple interpretation.

Glasgow coma scale
The Glasgow Coma Scale (GCS) assesses the state of consciousness, objectifying a quantitative disturbance of consciousness regardless of the underlying cause. It is a commonly used scheme and has completely replaced the subjective assessment of the state of consciousness and the terms somnolence, sopor, stupor, coma. It rates three quantities: 'verbal response, eye opening and motor response. The minimum value is 3 points, the maximum is 15 points. GCS exists in two modifications - for infants and children'. GCS evaluation: GCS is presented by one number from the interval 3-15, which is formed by summing the points according to the following table. The maximum number is 15 points, the minimum number is 3 points.

Multiorgan Failure Score
The risk of death is evidently dependent on the number of organs that fail or have failed. In adult medicine, this fact is known as the "rule of 3". Mortality when one organ system fails is 30%, with two 60%, three 90% and four or more 100%. In children, the prediction of mortality according to organ failure is more optimistic.

It is clear that the risk of death is not just the sum of the predicted mortality of individual organs, and therefore better expresses the situation with the simultaneous failure of several organs. Example: the risk of mortality with 3 organ failures is 50%, which is significantly higher than the simple sum of the risk of death with one organ failure (1%) and the other two organ failures (10%). The Multiorgan Failure Score (MOFS) can be used to assess organ status on a daily basis and very well reflects the success of therapy.

Failure of the relevant organ system is defined as the presence of at least one of the above parameters!

Pediatric Risk of Mortality Score
The PRISM score is used for critically ill newborns, infants, children and adolescents, it is not used for the group of immature newborns and adults. It was revised in 1996 (PRISM III). The values included in the PRISM III score are collected within the first 12 hours (PRISM III – 12) or within the first 24 hours (PRISM III – 24). The most pathological values are recorded. 14 measured values + another 23variable parameters are included in PRISM.

The basic 14 values include:
 * systolic BP;
 * diastolic BP;
 * heart rate;
 * respiratory rate;
 * FiO2;
 * pO2;
 * pCO2;
 * Quick;
 * aPTT;
 * S-calcium;
 * S-potassium;
 * glycemia;
 * bilirubin;
 * bicarbonate.

Among other variable parameters we include TT, type of disease, pupil reaction, GCS value, child's age, value of leukocytes, platelets, urea, creatinine, SaO2, pH, Operational Performance…

Examples of other scoring systems include the so-called PIM 2 (Pediatric Index of Mortality), PELOD Score (Pediatric Logistic Organ Dysfunction) or Rotterdam Score Meningococcal septic shock in children, which predicts death in meningococcemia according to parameters of potassium, base excess, platelets and CRP value.

From a mathematical point of view, the calculations are complex, as logarithmic values of some parameters are also often applied. Therefore, for all these scoring schemes there are online calculators, where after entering the appropriate values, the program will calculate the score itself.

Related Articles

 * Apgar score

Source

 * HAVRÁNEK, Jiří: Monitoring v intenzivní péči