Intensive Care Medicine

, Volume 37, Issue 5, pp 801–807 | Cite as

Mottling score predicts survival in septic shock

  • H. Ait-OufellaEmail author
  • S. Lemoinne
  • P. Y. Boelle
  • A. Galbois
  • J. L. Baudel
  • J. Lemant
  • J. Joffre
  • D. Margetis
  • B. Guidet
  • E. Maury
  • G. Offenstadt



Experimental and clinical studies have identified a crucial role of microcirculation impairment in severe infections. We hypothesized that mottling, a sign of microcirculation alterations, was correlated to survival during septic shock.


We conducted a prospective observational study in a tertiary teaching hospital. All consecutive patients with septic shock were included during a 7-month period. After initial resuscitation, we recorded hemodynamic parameters and analyzed their predictive value on mortality. The mottling score (from 0 to 5), based on mottling area extension from the knees to the periphery, was very reproducible, with an excellent agreement between independent observers [kappa = 0.87, 95% CI (0.72–0.97)].


Sixty patients were included. The SOFA score was 11.5 (8.5–14.5), SAPS II was 59 (45–71) and the 14-day mortality rate 45% [95% CI (33–58)]. Six hours after inclusion, oliguria [OR 10.8 95% CI (2.9, 52.8), p = 0.001], arterial lactate level [<1.5 OR 1; between 1.5 and 3 OR 3.8 (0.7–29.5); >3 OR 9.6 (2.1–70.6), p = 0.01] and mottling score [score 0–1 OR 1; score 2–3 OR 16, 95% CI (4–81); score 4–5 OR 74, 95% CI (11–1,568), p < 0.0001] were strongly associated with 14-day mortality, whereas the mean arterial pressure, central venous pressure and cardiac index were not. The higher the mottling score was, the earlier death occurred (p < 0.0001). Patients whose mottling score decreased during the resuscitation period had a better prognosis (14-day mortality 77 vs. 12%, p = 0.0005).


The mottling score is reproducible and easy to evaluate at the bedside. The mottling score as well as its variation during resuscitation is a strong predictor of 14-day survival in patients with septic shock.


Shock Microcirculation Prognosis Mottling Intensive care medicine 


Conflict of interest

The authors had no conflict of interest.


  1. 1.
    Vincent JL, De Backer D (2005) Microvascular dysfunction as a cause of organ dysfunction in severe sepsis. Crit Care 9(Suppl 4):S9–S12PubMedCrossRefGoogle Scholar
  2. 2.
    Ince C (2005) The microcirculation is the motor of sepsis. Crit Care 9(Suppl 4):S13–S19PubMedCrossRefGoogle Scholar
  3. 3.
    De Backer D, Creteur J, Preiser JC, Dubois MJ, Vincent JL (2002) Microvascular blood flow is altered in patients with sepsis. Am J Respir Crit Care Med 166:98–104PubMedCrossRefGoogle Scholar
  4. 4.
    De Backer D, Creteur J, Dubois MJ, Sakr Y, Vincent JL (2004) Microvascular alterations in patients with acute severe heart failure and cardiogenic shock. Am Heart J 147:91–99PubMedCrossRefGoogle Scholar
  5. 5.
    Dellinger RP, Levy MM, Carlet JM, Bion J, Parker MM, Jaeschke R, Reinhart K, Angus DC, Brun-Buisson C, Beale R, Calandra T, Dhainaut JF, Gerlach H, Harvey M, Marini JJ, Marshall J, Ranieri M, Ramsay G, Sevransky J, Thompson BT, Townsend S, Vender JS, Zimmerman JL, Vincent JL (2008) Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock: 2008. Crit Care Med 36:296–327PubMedCrossRefGoogle Scholar
  6. 6.
    Dellinger RP, Carlet JM, Masur H, Gerlach H, Calandra T, Cohen J, Gea-Banacloche J, Keh D, Marshall JC, Parker MM, Ramsay G, Zimmerman JL, Vincent JL, Levy MM (2004) Surviving Sepsis Campaign guidelines for management of severe sepsis and septic shock. Crit Care Med 32:858–873PubMedCrossRefGoogle Scholar
  7. 7.
    Ebert RV, Stead EA (1941) Circulatory failure in acute infections. J Clin Invest 20:671–679. doi: 10.1172/JCI101260 PubMedCrossRefGoogle Scholar
  8. 8.
    Altemeier WA, Cole W (1956) Septic shock. Ann Surg 143:600–607PubMedCrossRefGoogle Scholar
  9. 9.
    Kaplan LJ, McPartland K, Santora TA, Trooskin SZ (2001) Start with a subjective assessment of skin temperature to identify hypoperfusion in intensive care unit patients. J Trauma 50:620–627; discussion 627–628Google Scholar
  10. 10.
    Vic-Dupont V, Coulaud JP, Carbon C (1968) Le choc au cours des infections (signes et étiologies). Les journées de réanimation de l’Hôpital Claude Bernard, Libraries Arnette edn., ParisGoogle Scholar
  11. 11.
    Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G (2003) 2001 SCCM/ESICM/ACCP/ATS/SIS international sepsis definitions conference. Crit Care Med 31:1250–1256. doi: 10.1097/01.CCM.0000050454.01978.3B PubMedCrossRefGoogle Scholar
  12. 12.
    Moreno R, Vincent JL, Matos R, Mendonca A, Cantraine F, Thijs L, Takala J, Sprung C, Antonelli M, Bruining H, Willatts S (1999) The use of maximum SOFA score to quantify organ dysfunction/failure in intensive care. Results of a prospective, multicentre study. Working group on sepsis related problems of the ESICM. Intensive Care Med 25:686–696PubMedCrossRefGoogle Scholar
  13. 13.
    Le Gall JR, Lemeshow S, Saulnier F (1993) A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. Jama 270:2957–2963PubMedCrossRefGoogle Scholar
  14. 14.
    Koch T, Geiger S, Ragaller MJ (2001) Monitoring of organ dysfunction in sepsis/systemic inflammatory response syndrome: novel strategies. J Am Soc Nephrol 12:S53–S59PubMedGoogle Scholar
  15. 15.
    Ait-Oufella H, Maury E, Lehoux S, Guidet B, Offenstadt G (2010) The endothelium: physiological functions and role in microcirculatory failure during severe sepsis. Intensive Care Med 36:1286–1298. doi: 10.1007/s00134-010-1893-6 PubMedCrossRefGoogle Scholar
  16. 16.
    Joly HR, Weil MH (1969) Temperature of the great toe as an indication of the severity of shock. Circulation 39:131–138PubMedGoogle Scholar
  17. 17.
    Evans JA, May J, Ansong D, Antwi S, Asafo-Adjei E, Nguah SB, Osei-Kwakye K, Akoto AO, Ofori AO, Sambian D, Sylverken J, Busch W, Timmann C, Agbenyega T, Horstmann RD (2006) Capillary refill time as an independent prognostic indicator in severe and complicated malaria. J Pediatr 149:676–681. doi: 10.1016/j.jpeds.2006.07.040 PubMedCrossRefGoogle Scholar
  18. 18.
    Neveu H, Kleinknecht D, Brivet F, Loirat P, Landais P (1996) Prognostic factors in acute renal failure due to sepsis. Results of a prospective multicentre study. The French Study Group on acute renal failure. Nephrol Dial Transplant 11:293–299PubMedGoogle Scholar
  19. 19.
    Oppert M, Engel C, Brunkhorst FM, Bogatsch H, Reinhart K, Frei U, Eckardt KU, Loeffler M, John S (2008) Acute renal failure in patients with severe sepsis and septic shock–a significant independent risk factor for mortality: results from the German prevalence study. Nephrol Dial Transplant 23:904–909. doi: 10.1093/ndt/gfm610 PubMedCrossRefGoogle Scholar
  20. 20.
    Mikkelsen ME, Miltiades AN, Gaieski DF, Goyal M, Fuchs BD, Shah CV, Bellamy SL, Christie JD (2009) Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock. Crit Care Med 37:1670–1677. doi: 10.1097/CCM.0b013e31819fcf68 PubMedCrossRefGoogle Scholar
  21. 21.
    Jansen TC, van Bommel J, Woodward R, Mulder PG, Bakker J (2009) Association between blood lactate levels, sequential organ failure assessment subscores, and 28-day mortality during early and late intensive care unit stay: a retrospective observational study. Crit Care Med 37:2369–2374. doi: 10.1097/CCM.0b013e3181a0f919 PubMedCrossRefGoogle Scholar
  22. 22.
    Jansen TC, van Bommel J, Schoonderbeek FJ, Sleeswijk Visser SJ, van der Klooster JM, Lima AP, Willemsen SP, Bakker J (2010) Early lactate-guided therapy in intensive care unit patients: a multicenter, open-label, randomized controlled trial. Am J Respir Crit Care Med 182(6):752–761. doi: 10.1164/rccm.200912-1918OC PubMedCrossRefGoogle Scholar
  23. 23.
    Dubin A, Edul VS, Pozo MO, Murias G, Canullan CM, Martins EF, Ferrara G, Canales HS, Laporte M, Estenssoro E, Ince C (2008) Persistent villi hypoperfusion explains intramucosal acidosis in sheep endotoxemia. Crit Care Med 36:535–542. doi: 10.1097/01.CCM.0000300083.74726.43 PubMedCrossRefGoogle Scholar
  24. 24.
    Dubin A, Pozo MO, Casabella CA, Palizas F Jr, Murias G, Moseinco MC, Kanoore Edul VS, Palizas F, Estenssoro E, Ince C (2009) Increasing arterial blood pressure with norepinephrine does not improve microcirculatory blood flow: a prospective study. Crit Care R13:R92. doi: 10.1186/cc7922 CrossRefGoogle Scholar
  25. 25.
    Sakr Y, Dubois MJ, De Backer D, Creteur J, Vincent JL (2004) Persistent microcirculatory alterations are associated with organ failure and death in patients with septic shock. Crit Care Med 32:1825–1831PubMedCrossRefGoogle Scholar
  26. 26.
    Lima A, Jansen TC, van Bommel J, Ince C, Bakker J (2009) The prognostic value of the subjective assessment of peripheral perfusion in critically ill patients. Crit Care Med 37:934–938. doi: 10.1097/CCM.0b013e31819869db PubMedCrossRefGoogle Scholar
  27. 27.
    Trzeciak S, McCoy JV, Phillip Dellinger R, Arnold RC, Rizzuto M, Abate NL, Shapiro NI, Parrillo JE, Hollenberg SM (2008) Early increases in microcirculatory perfusion during protocol-directed resuscitation are associated with reduced multi-organ failure at 24 h in patients with sepsis. Intensive Care Med 34:2210–2217. doi: 10.1007/s00134-008-1193-6 PubMedCrossRefGoogle Scholar
  28. 28.
    De Backer D, Creteur J, Dubois MJ, Sakr Y, Koch M, Verdant C, Vincent JL (2006) The effects of dobutamine on microcirculatory alterations in patients with septic shock are independent of its systemic effects. Crit Care Med 34:403–408. doi: 00003246-200602000-00018 PubMedCrossRefGoogle Scholar

Copyright information

© Copyright jointly held by Springer and ESICM 2011

Authors and Affiliations

  • H. Ait-Oufella
    • 1
    • 2
    Email author
  • S. Lemoinne
    • 1
  • P. Y. Boelle
    • 3
    • 4
    • 5
  • A. Galbois
    • 1
  • J. L. Baudel
    • 1
  • J. Lemant
    • 1
  • J. Joffre
    • 1
  • D. Margetis
    • 1
  • B. Guidet
    • 1
    • 4
    • 5
  • E. Maury
    • 1
    • 4
    • 5
  • G. Offenstadt
    • 1
    • 4
    • 5
  1. 1.Service de Réanimation MédicaleAP-HP, Hôpital Saint-AntoineParis Cedex 12France
  2. 2.Inserm U970, Paris Research Cardiovascular CenterParisFrance
  3. 3.Service de santé publiqueAP-HP, Hôpital Saint-AntoineParisFrance
  4. 4.Université Pierre et Marie Curie-Paris 6, UMR S707ParisFrance
  5. 5.Inserm U707ParisFrance

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