The Modified Early Warning Score (MEWS): An Instant Physiological Prognostic Indicator of Poor Outcome in Acute Pancreatitis

  • Aravind Suppiah The Pancreatic Unit, St James’s University Hospital. Leeds, West Yorkshire, UK
  • Deep Malde
  • Tameem Arab
  • Mazin Hamed
  • Victoria Allgar
  • Gareth Morris-Stiff
  • Andrew Smith
Keywords: Nomograms, Pancreatitis, Predictive Value of Tests

Abstract

Context The Modified Early Warning Score (MEWS) is a bedside scoring system that is non-invasive, simple and repeatable to reflect dynamic changes in physiological state. Objective This study aims to assess accuracy of MEWS and determine an optimal MEWS value in predicting severity in acute pancreatitis (AP). Methods A prospective database of consecutive admissions with AP to a single institution was analysed to determine value of MEWS in identifying severe acute pancreatitis (SAP) and predicting poor outcome. Receiver operator curves (ROC) were used to determine optimal accuracy. Sensitivity, specificity, negative predictive value (NPV), and positive predictive values (PPV) were calculated for the optimal MEWS values obtained. Results One-hundred and 42 patients with AP were included. The optimal highest MEWS per 24 hours period (hMEWS) and mean MEWS per 24 hour period (mMEWS) in predicting SAP as determined by ROC were 2.5 and 1.625 respectively; with hMEWS ≥3 and mMEWS >1 utilised in this cohort as MEWS scores are whole numbers. On admission, sensitivity, specificity, NPV, PPV, and accuracy of hMEWS ≥3 was 95.5%, 90.8%, 99.0%, 65.6% and 92.0%; and for mMWES >1 was 95.5%, 87.5%, 99.0%, 58.3% and 88.7%, both superior than the Imrie score: 31.5%, 92.1%, 88.9%, 40.0% and 83.5%. The accuracy of hMEWS ≥3 and mMEWS >1 increased over the subsequent 72 hours (days 0-2) from 92 to 96%, and 89% to 94%, respectively. Conclusions MEWS provides a novel, easy, instant, repeatable, reliable prognostic score that may be superior to existing scoring systems. A larger cohort is required to validate these findings.

Image: MEWS chart used in the study.

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References

Papachristou GI, Clermont G, Sharma A, Yadav D, Whitcomb DC. Risk and markers of severe acute pancreatitis. Gastroenterol Clin North Am 2007; 36: 277-296. [PMID: 17533079]

Harrison DA, D'Amico G, Singer M. Case mix, outcome, and activity for admissions to UK critical care units with severe acute pancreatitis: a secondary analysis of the ICNARC Case Mix Programme Database. Crit Care 2007; 11: S1. [PMID: 18275590]

Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med 1985; 13: 818-829. [PMID: 3928249]

Pavlidis TE, Pavlidis ET, Sakantamis AK. Advances in prognostic factors in acute pancreatitis: a mini-review. Hepatobiliary Pancreat Dis Int 2010; 9: 482-486. [PMID: 20943456]

Bhatia M. Acute pancreatitis as a model of SIRS. Front Biosci (Landmark Ed) 2009; 14: 2042-2050. [PMID: 19273184]

Blum T, Maisonneuve P, Lowenfels AB, Lankisch PG. Fatal outcome in acute pancreatitis: its occurrence and early prediction. Pancreatology 2001; 1: 237-241. [PMID: 12120201]

Halonen KI, Pettilä V, Leppäniemi AK, Kemppainen EA, Puolakkainen PA, et al. Multiple organ dysfunction associated with severe acute pancreatitis. Crit Care Med 2002; 30: 1274-1279. [PMID: 12072681]

Mofidi R, Duff MD, Wigmore SJ, Madhavan KK, Garden OJ, et al. Association between early systemic inflammatory response, severity of multiorgan dysfunction and death in acute pancreatitis. Br J Surg 2006; 93: 738-744. [PMID: 16671062]

Minne L, Abu-Hanna A, de Jonge E. Evaluation of SOFA-based models for predicting mortality in the ICU: A systematic review. Crit Care 2008; 12: R161. [PMID: 19091120]

Rees JE. Early warning scores. World Anaesth 2003; 17: 1-5

Garcea G, Gouda M, Hebbes C, Ong SL, Neal CP, et al. Predictors of severity and survival in acute pancreatitis: validation of the efficacy of early warning scores. Pancreas 2008; 37: e54-61. [PMID: 18815539]

Garcea G, Jackson B, Pattenden CJ, Sutton CD, Neal CP, et al. Early warning scores predict outcome in acute pancreatitis. J Gastrointest Surg 2006; 10: 1008-1015. [PMID: 16843871]

Bradley EL 3rd. A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, Ga, September 11 through 13, 1992. Arch Surg 1993; 128: 586-590. [PMID: 8489394]

Hong W, Dong L, Huang Q, Wu W, Wu J, et al. Prediction of severe acute pancreatitis using classification and regression tree analysis. Dig Dis Sci 2011. 56: 3664-3671. [PMID: 21833749]

Woo SM, Noh MH, Kim BG, Hsing CT, Han JS, et al. Comparison of serum procalcitonin with Ranson, APACHE-II, Glasgow and Balthazar CT severity index scores in predicting severity of acute pancreatitis. Korean J Gastroenterol 2011; 58: 31-37. [PMID: 21778801]

Dambrauskas Z, Gulbinas A, Pundzius J, Barauskas G. Value of the different prognostic systems and biological markers for predicting severity and progression of acute pancreatitis. Scand J Gastroenterol 2010; 45: 959-970. [PMID: 20367283]

Papachristou GI, Muddana V, Yadav D, O'Connell M, Sanders MK, et al. Comparison of BISAP, Ranson's, APACHE-II, and CTSI scores in predicting organ failure, complications, and mortality in acute pancreatitis. Am J Gastroenterol 2010; 105: 435-441. [PMID: 19861954]

Singh VK, Wu BU, Bollen TL, Repas K, Maurer R, et al. A prospective evaluation of the bedside index for severity in acute pancreatitis score in assessing mortality and intermediate markers of severity in acute pancreatitis. Am J Gastroenterol 2009; 104: 966-971. [PMID: 19293787]

Juneja D, Gopal PB, Ravula M. Scoring systems in acute pancreatitis: which one to use in intensive care units? J Crit Care 2010; 25: 358. [PMID: 20149591]

Fan JY, Huang ZW, Guo J. [Value of four scoring systems for predicting prognosis of severe acute pancreatitis]. Zhong Xi Yi Jie He Xue Bao 7: 34-40. [PMID: 19134455]

Gravante G, Garcea G, Ong SL, Metcalfe MS, Berry DP, et al. Prediction of mortality in acute pancreatitis: a systematic review of the published evidence. Pancreatology 2009; 9: 601-614. [PMID: 19657215]

Mofidi R, Duff MD, Madhavan KK, Garden OJ, Parks RW. Identification of severe acute pancreatitis using an artificial neural network. Surgery 2007; 141: 59-66. [PMID: 17188168]

Spitzer AL, Barcia AM, Schell MT, Barber A, Norman J, et al. Applying Ockham's razor to pancreatitis prognostication: a four-variable predictive model. Ann Surg 2006; 243: 380-388. [PMID: 16495704]

Wu BU, Johannes RS, Sun X, Tabak Y, Conwell DL, et al. The early prediction of mortality in acute pancreatitis: a large population-based study. Gut 2008; 57: 1698-1703. [PMID: 18519429]

Harrison DA, D'Amico G, Singer M. The Pancreatitis Outcome Prediction (POP) Score: a new prognostic index for patients with severe acute pancreatitis. Crit Care Med. 2007; 35: 1703-1708. [PMID: 17522578]

Marshall JC, Cook DJ, Christou NV, Bernard GR, Sprung CL, et al. Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome. Crit Care Med 1995; 23: 1638-1652. [PMID: 7587228]

Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA 1993; 270: 2957-2963. [PMID: 8254858]

Mason JM, Babu BI, Bagul A, Siriwardena AK. The performance of organ dysfunction scores for the early prediction and management of severity in acute pancreatitis: an exploratory phase diagnostic study. Pancreas 2010; 39: 1104-1108. [PMID: 20861697]

MEWS chart used in the study
Published
2014-11-28
How to Cite
Suppiah, A., Malde, D., Arab, T., Hamed, M., Allgar, V., Morris-Stiff, G., & Smith, A. (2014). The Modified Early Warning Score (MEWS): An Instant Physiological Prognostic Indicator of Poor Outcome in Acute Pancreatitis. JOP. Journal of the Pancreas, 15(6), 569-576. https://doi.org/10.6092/1590-8577/2829
Section
ORIGINAL ARTICLES