The PIRO Concept: O is for organ dysfunction

[Jean-Louis Vincent] Thank you very much indeed, and let's move to the fourth letter – 'O'. The concepts have evolved over time, and I would like to start by asking the panel whether they agree that we need to stratify organ dysfunction, perhaps with several other levels of organ dysfunction, or if they prefer to stick to respiratory failure versus no respiratory failure, renal failure versus no renal failure, and that kind of dichotomous separation.My next question of course will go to the various organs, and we may ask, for example, whether we can improve the ways to diagnose neurological status, with the Glasgow Coma Score, and liver dysfunction, with bilirubin. Perhaps we also need to ask whether we could better evaluate gut function or metabolic function – should we speak about tolerance to feeding, insulin requirements and that sort of thing?But let's start with the first general question – again, do you agree that there is a need for stratification or would you be happy with the more dichotomous separation? I think this question is particularly relevant when it refers to renal dysfunction because I've spoken recently to a number of intensivists with a special interest in renal function and they say that, as you have acute lung injury and ARDS [acute respiratory distress syndrome] in respiratory dysfunction, maybe we need to have a common definition of renal failure. So do we agree with this proposal?[John C Marshall] Intuitively, I've always liked the idea of describing organ dysfunction as an intervention – in other words, ventilation or what you have to do to treat renal failure – having a sense that things are basically OK or things have completely failed or you're somewhere in the middle. So to me, the acute lung injury model is a nice reflection of that. So I think there's probably merits to having several levels. At this stage I think our understanding is that the more refinement we have in describing something, the more potential you have to get out of