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Prognostic Validity and Reliability of the Sofa Score in Multiple Trauma Patients

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Prognostic Validity and Reliability of the Sofa Score in Multiple Trauma Patients Alexandria Journal of Anesthesia and Intensive Care 3 PROGNOSTIC VALIDITY AND RELIABILITY OF THE SOFA SCORE IN MULTIPLE TRAUMA PATIENTS Ahmed S. Okasha, M.D.*, Ayman S.H. Rofaeel, M.D.§, Said M. El-Medany, M.D.* Sameh M. Shaker, MB. BCh.# *Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, Alexandria University. §Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, Mansoura University. #Department of Critical Care, Emergency Hospital, Mansoura University. ABSTRACT Background: This study evaluated the reliability of the SOFA score in prediction of outcome in multiple traumatized patients. Methods: 44 multiple traumatized patients admitted to surgical ICU were prospectively enrolled. The SOFA score was evaluated daily throughout the first seven days of ICU stay and at ICU discharge, whereas the total maximum SOFA score was recorded as the worst of all daily recorded scores. Glasgow Outcome Scale (GOS) was used to assess outcome at time of ICU discharge. The quality of outcome was categorized as survival with either good outcome (good recovery and moderate disability) or poor outcome (severe disability and vegetative state), and non-survival. All recorded scores were analyzed in relation with both GOS and quality of outcome. Results: No significant correlation was found between SOFA score at the first and second days of ICU stay with either GOS or the quality of outcome. The correlation between SOFA score with GOS and quality of outcome exhibited the earliest significance at the third day (P <0.05), and then showed a trend of progressive improvement with subsequent daily scores till became maximum at the seventh day, at ICU discharge, and for the total maximum SOFA score. At the third day of ICU stay, survival was associated with median SOFA score of 5 for good outcome, and 7 for poor outcome, whereas, non-survival was associated with median SOFA score of 9. Conclusion: The SOFA score provides valid and reliable prognostic information in multiple trauma patients. While the best prognostic capability was achieved for the SOFA score at the seventh day of ICU stay, at ICU discharge, and for the total maximum SOFA score, SOFA score at the third day exhibited the earliest reliable outcome prediction with efficient discrimination among survivors with good outcome or poor outcome versus non-survivors. INTRODUCTION SOFA score, as an organ dysfunction/failure Multiple trauma victims are exposed to a assessment score, in prediction of outcome in potential risk for developing multiple organ multiple traumatized critically ill patients through dysfunction and/or failure, which represent major daily evaluation during ICU stay. Also, the study causes of morbidity and mortality in these aimed to evaluate the ability of SOFA score to patients(1,2). Organ dysfunction after multiple trauma discriminate among different qualitative categories is a process rather than an event, hence it should be of outcome of multiple traumatized patients; mainly seen as a continuum and should not be described the quality of survival versus non-survival. simply as present or absent. The time factor is fundamental as the development of organ failure PATIENTS AND METHODS may take some time(3). This prospective study included forty four The Sequential Organ Failure Assessment multiple injured patients, 18 to 65 years old, who (SOFA) score has been applied to improve the were admitted to the surgical intensive care unit understanding of the pathogenesis of organ (ICU) at the Emergency Hospital, Mansoura dysfunction/failure and the inter-relation between University. The study protocol was approved by the failure of various organs(4). Since mortality is institutional research and ethics committee and an directly related to the degree of organ dysfunction(5), informed consent was secured from the patient’s we hypothesized that the SOFA score could provide next of kin. Patients with preexisting systemic reliable prognostic information in multiple disease of clinical significance and those with a traumatized patients, and hence, it may aid the length of ICU stay less than 2 days were excluded. judgment of patient’s quality of outcome. Also, as Standard ICU monitoring was applied, the SOFA score is designed for sequential including continuous electrocardiogram, non- assessment of the dynamic course of organ invasive blood pressure, oxygen saturation, end tidal dysfunction, the collection of data on daily basis carbon dioxide tension, temperature, central venous may adequately reflects the progression of organ pressure, and urine output. Patients' management dysfunction/failure during a complex clinical course followed a standard protocol for management of in the intensive care unit (ICU). This study was head injury, whereas associated systemic injuries designed to test the validity and reliability of the were managed through appropriate consultation of AJAIC-Vol. (7). No. 2. September 2004 Alexandria Journal of Anesthesia and Intensive Care 4 the corresponding surgical specialties. Hemo- disability (MD), severe disability (SD), persistent dynamicaly unstable patients were managed with vegetative state (PVS), and death] were categorized increasing the rate of intravenous fluid into three qualitative outcome categories. Outcome administration, followed by continuous infusion of was classified as survival and non-survival (death). vasoactive drugs (dopamine, dobutamine, or The quality of survival was further categorized into epinephrine) according to a pre-adjusted infusion either good outcome (GR and MD) or poor outcome rate. (SD and PVS). All daily recorded SOFA scores Evaluation of organ dysfunction was performed were analyzed in relation to GOS and the quality of according to the set of clinical (respiratory support, outcome. mean arterial blood pressure, Glasgow Coma Scale and urine output) and laboratory (arterial blood gas STATISTICAL ANALYSIS analysis, platelets count, bilirubin concentration, Data were analyzed with Statistical Package for serum creatinine) parameters of the SOFA score. Social Sciences program (SPSS, version 10), and The most abnormal value for each parameter in were presented as median (SD), or as indicated every 24 hours period was recorded, and the total elsewhere. Spearman Rank Correlation Analysis score was interpreted as shown in table 1(4,6). The was used to test the relationship between daily SOFA score was recorded at ICU admission (first SOFA scores with GOS, and with the quality of day), then daily throughout the first seven days of outcome. For the purpose of analysis, GOS was ICU stay, and at time of ICU discharge. The total ranked as 5 to 1 for GR to death, respectively. maximum SOFA score was recorded as the worst Pearson Chi-square test was used to test the degree score of all daily recorded SOFA scores throughout of conditional distribution/response of qualitative the whole period of the study. For every organ variables; the distribution of values of the quality of system, organ dysfunction was defined as SOFA outcome (as the dependent variable) across different score of 1-2, meanwhile organ failure was defined values of all recorded SOFA scores (as the as SOFA score of 3-4. independent variable). A probability (P) value was Glasgow Outcome Scale (GOS) was used considered to be statistically significant if < 0.05, to assess outcome at time of ICU discharge. For the and highly significant if < 0.01. purpose of assessing the quality of outcome, the five components of GOS [good recovery (GR), moderate Table (1): The Sequential Organ Failure Assessment (SOFA) score(4,6). SOFA score 0 1 2 3 4 ≤ 200 ≤ 100 Respiration > 400 ≤ 400 ≤ 300 with respiratory with respiratory PaO /FiO (mmHg) 2 2 support support Coagulation Platelets (×103/mm3) > 150 ≤ 150 ≤ 100 ≤ 50 ≤ 20 Liver Bilirubin (mg/dl) < 1.2 1.2 – 1.9 2.0 – 5.9 6.0 – 11.9 > 12.0 (µmol/l) (< 20) (20-32) (33-101) (102-204) (>204) Dopamine > 5 or Dopamine > 15 or Dopamine ≤ 5 Cardiovascular No MAP < 70 epinephrine ≤ 0.1 epinephrine > 0.1 or or dobutamine Hypotension hypotension mmHg or norepinephrine norepinephrine > (any dose)* ≤ 0.1* 0.1* Central nervous system 15 13 – 14 10 – 12 6 – 9 < 6 Glasgow Coma Score Renal Creatinine (mg/dl) < 1.2 1.2 – 1.9 2.0 – 3.4 3.5 – 4.9 > 5 (µmol/l) (< 110) (110-170) (171-299) (300-440) (> 440) or urine output or < 500 ml/day or < 200 ml/day *Adrenergic agents administered for at least 1 hour (doses given are in µg/kg/min). MAP; mean arterial pressure. AJAIC-Vol. (7). No. 2. September 2004 Alexandria Journal of Anesthesia and Intensive Care 5 RESULTS <0.05; table 4). Survival was associated with Patients' characteristics and the duration of ICU median SOFA score of 5 for good outcome, and 7 stay are displayed in table 2. All patients sustained for poor outcome, whereas, non-survival was trauma to the head plus one or more of other associated with median SOFA score of 9 (figure 1). anatomical sites/systems (chest, abdomen or The best correlation with outcome was orthopedic trauma). Patients were distributed achieved with SOFA score at the seventh day of according to their outcome at ICU discharge (GOS ICU stay, at discharge, and with the total maximum and quality of outcome; table 3). No significant SOFA score (P <0.01; table 4). For both the SOFA correlation was found between SOFA score score at the seventh day and at discharge, good evaluation over the first and second days of ICU outcome was associated with a median value of 2, stay, with either GOS or the quality of outcome poor outcome was associated with median value of (table 4). The correlations between SOFA scores at 7 and 5 respectively, whereas, non-survival was subsequent days of follow up with GOS and the associated with a median value of 11 and 12 quality of outcome were significant (P <0.05; table respectively (figure 1). For the total maximum 4), and showed a trend of progressive improvement SOFA score, survival was associated with median starting from the third day through SOFA score at SOFA score of 7 for good outcome, and 11 for poor discharge.
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