PIRO Concept and Clinical Failure

  • Thiago LisboaEmail author
  • Jordi Rello


In 2001, a consensus conference on sepsis definitions was convened, sponsored by several major medical societies (Levy et al. 2003). The participants at this meeting agreed that the SIRS concept was not helpful and should no longer be used per se, but rather that the systemic inflammatory response syndrome (SIRS) criteria should be incorporated into a longer list of signs of sepsis. This list includes biological signs of inflammation (e.g., increased concentrations of C-reactive protein [CRP] or procalcitonin), hemodynamic parameters [e.g., increased cardiac output, low systemic vascular resistance (SVR), low oxygen extraction ratio], signs of altered tissue perfusion (e.g., altered skin perfusion, reduced urine output), and signs of organ dysfunction (e.g., increased urea and creatinine, low platelet count or other coagulation abnormalities, and hyperbilirubinemia).


Severe Sepsis Organ Dysfunction Systemic Inflammatory Response Syndrome Sequential Organ Failure Assessment Clinical Failure 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


  1. Annane D, Sébille V, Charpentier C, Bollaert PE, François B, Korach JM et al (2002) Effect of treatment with low doses of hydrocortisone and fludrocortisone on mortality in patients with septic shock. JAMA 288(7):862–871, Erratum in: JAMA. 2008;300(14):1652. Chaumet-Riffaut, Philippe [corrected to Chaumet-Riffaud, Philippe]PubMedCrossRefGoogle Scholar
  2. Bernard GR, Vincent JL, Laterre PF, LaRosa SP, Dhainaut JF, Lopez-Rodriguez A, Steingrub JS, Garber GE, Helterbrand JD, Ely EW, Fisher CJ Jr, Recombinant human protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study group (2001) Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med 344(10):699–709PubMedCrossRefGoogle Scholar
  3. Eichacker PQ, Gerstenberger EP, Banks SM, Cui X, Natanson C (2002) Meta-analysis of acute lung injury and acute respiratory distress syndrome trials testing low tidal volumes. Am J Respir Crit Care Med 166(11):1510–1514PubMedCrossRefGoogle Scholar
  4. Ferreira FL, Bota DP, Bross A, Mélot C, Vincent JL (2001) Serial evaluation of the SOFA score to predict outcome in critically ill patients. JAMA 286(14):1754–1758PubMedCrossRefGoogle Scholar
  5. Levy MM, Fink MP, Marshall JC, Abraham E, Angus D, Cook D, Cohen J, Opal SM, Vincent JL, Ramsay G, SCCM/ESICM/ACCP/ATS/SIS (2003) 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference. Crit Care Med 31(4):1250–1256PubMedCrossRefGoogle Scholar
  6. Lisboa T, Diaz E, Sa-Borges M et al (2008a) The ventilator-associated pneumonia PIRO score: a tool for predicting ICU mortality and health-care resources use in ventilator-associated pneumonia. Chest 134(6):1208–1216PubMedCrossRefGoogle Scholar
  7. Lisboa T, Seligman R, Diaz E et al (2008b) C-reactive protein correlates with bacterial load and appropriate antibiotic therapy in suspected ventilator-associated pneumonia. Crit Care Med 36(1):166–171PubMedCrossRefGoogle Scholar
  8. Luna CM, Blancazo D, Niederman MS et al (2003) Resolution of ventilator-associated pneumonia: prospective evaluation of the clinical pulmonary infection score as an early clinical predictor of outcome. Crit Care Med 31(3):676–682PubMedCrossRefGoogle Scholar
  9. Marshall JC, Vincent JL, Fink MP, Cook DJ, Rubenfeld G, Foster D et al (2003) Measures, markers and mediators: toward a staging system for clinical sepsis. A report of the Fifth Toronto Sepsis Roundtable, Toronto, Ontario, Canada, October 25–26, 2000. Crit Care Med 31(5):1560–1567PubMedCrossRefGoogle Scholar
  10. Marshall JC, Reinhart K, International Sepsis Forum (2009) Biomarkers of sepsis. Crit Care Med 37(7):2290–2298PubMedCrossRefGoogle Scholar
  11. Martin GS, Mannino DM, Moss M (2006) The effect of age on the development and outcome of adult sepsis. Crit Care Med 34(1):15–21PubMedCrossRefGoogle Scholar
  12. Moreno RP, Diogo AC, Afonso S (2009) Risk stratification in severe sepsis: organ failure scores or PIRO? In: Rello J, Díaz E, Rodríguez A (eds) Management of sepsis: the PIRO approach. Springer, New York, pp 1–9Google Scholar
  13. Oppert M, Schindler R, Husung C, Offermann K, Gräf KJ, Boenisch O et al (2005) Low-dose hydrocortisone improves shock reversal and reduces cytokine levels in early hyperdynamic septic shock. Crit Care Med 33(11):2457–2464PubMedCrossRefGoogle Scholar
  14. Parnham MJ (2005) Immunomodulatory effects of antimicrobials in the therapy of respiratory tract infections. Curr Opin Infect Dis 18(2):125–131PubMedCrossRefGoogle Scholar
  15. Póvoa P (2008) Serum markers in community-acquired pneumonia and ventilator-associated pneumonia. Curr Opin Infect Dis 21(2):157–162PubMedCrossRefGoogle Scholar
  16. Rabello L, Rosolem M, Leal J et al (2009) Understanding the PIRO concept: from theory to clinical practice. Rev Bras Ter Intensiva 22(1):64–68Google Scholar
  17. Rello J (2008) Demographics, guidelines and clinical experience in severe community-acquired pneumonia. Crit Care 12(Suppl 6):S2PubMedCrossRefGoogle Scholar
  18. Rello J, Lisboa T, Lujan T, Gallego M, Kee C, Kay I, Lopez D, Waterer GW, DNA-Neumococo Study Group (2009) Severity of pneumococcal pneumonia associated with genomic bacterial load. Chest 136(3):832–840PubMedCrossRefGoogle Scholar
  19. Rodriguez A, Lisboa T, Blot S, Martin-Loeches I, Solé-Violan J, De Mendoza D, Rello J, Community-Acquired Pneumonia Intensive Care Units (CAPUCI) Study Investigators (2009) Mortality in ICU patients with bacterial community-acquired pneumonia: when antibiotics are not enough. Intensive Care Med 35(3):430–438PubMedCrossRefGoogle Scholar
  20. Romo H, Amaral AC, Vincent JL (2004) Effect of patient sex on intensive care unit survival. Arch Intern Med 164(1):61–65PubMedCrossRefGoogle Scholar
  21. Rosolem M, Rabello L, Leal J et al (2010) Understanding the PIRO concept: from theory to clinical practice – Part 2. Rev Bras Ter Intensiva 21(4):425–431Google Scholar
  22. Veesenmeyer JL, Hauser AR, Lisboa T, Rello J (2009) Pseudomonas aeruginosa virulence and therapy: evolving translational strategies. Crit Care Med 37(5):1777–1786PubMedCrossRefGoogle Scholar
  23. Vidaur L, Gualis B, Rodriguez A et al (2005) Clinical resolution in patients with suspicion of ventilator-associated pneumonia: a cohort study comparing patients with and without acute respiratory distress syndrome. Crit Care Med 33(6):1248–1253PubMedCrossRefGoogle Scholar
  24. Vidaur L, Planas K, Sierra R et al (2008) Ventilator-associated pneumonia: impact of organisms on clinical resolution and medical resources utilization. Chest 133(3):625–632, Epub 2008 Jan 15PubMedCrossRefGoogle Scholar
  25. Vincent JL (2009) PIRO: the key of success? In: Rello J, Diaz E, Rodríguez A (eds) Management of sepsis: the PIRO approach. Springer, New York, pp 1–9CrossRefGoogle Scholar
  26. Vincent JL, de Mendonça A, Cantraine F, Moreno R, Takala J, Suter PM et al (1998) Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: results of a multicenter, prospective study. Working group on “sepsis-related problems” of the European Society of Intensive Care Medicine. Crit Care Med 26(11):1793–1800PubMedCrossRefGoogle Scholar
  27. Vincent JL, Opal S, Torres A, Bonten M, Cohen J, Wunderink R (2003a) The PIRO concept: I is for infection. Crit Care 7(3):252–255PubMedCrossRefGoogle Scholar
  28. Vincent JL, Wendon J, Groeneveld J, Marshall JC, Streat S, Carlet J (2003b) The PIRO concept: O is for organ dysfunction. Crit Care 7(3):260–264PubMedCrossRefGoogle Scholar
  29. Vincent JL, Sakr Y, Sprung CL, Ranieri VM, Reinhart K, Gerlach H, Moreno R, Carlet J, Le Gall JR, Payen D, Sepsis Occurrence in Acutely Ill Patients Investigators (2006) Sepsis in European intensive care units: results of the SOAP study. Crit Care Med 34(2):344–353PubMedCrossRefGoogle Scholar
  30. Wichmann MW, Inthorn D, Andress HJ, Schildberg FW (2000) Incidence and mortality of severe sepsis in surgical intensive care patients: the influence of patient gender on disease process and outcome. Intensive Care Med 26(2):167–172PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2012

Authors and Affiliations

  1. 1.Critical Care Department and Infection Control CommitteeHospital de Clinicas de Porto AlegrePorto AlegreBrazil
  2. 2.Intensive Care Unit, Hospital Santa RitaRede Institucional de Pesquisa e Inovação em Medicina Intensiva (RIPIMI)Porto AlegreBrazil
  3. 3.Critical Care DepartmentVall d’Hebron University HospitalBarcelonaSpain

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