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Serial Evaluation of the SOFA Score to Predict Outcome in Critically Ill Patients

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Serial Evaluation of the SOFA Score to Predict Outcome in Critically Ill Patients CARING FOR THE CRITICALLY ILL PATIENT Serial Evaluation of the SOFA Score to Predict Outcome in Critically Ill Patients Flavio Lopes Ferreira, MD Context Evaluation of trends in organ dysfunction in critically ill patients may help Daliana Peres Bota, MD predict outcome. Annette Bross, MD Objective To determine the usefulness of repeated measurement the Sequential Or- gan Failure Assessment (SOFA) score for prediction of mortality in intensive care unit Christian Me´lot, MD, PhD, (ICU) patients. MSciBiostat Design Prospective, observational cohort study conducted from April 1 to July 31, Jean-Louis Vincent, MD, PhD 1999. Setting A 31-bed medicosurgical ICU at a university hospital in Belgium. UTCOME PREDICTION IS IM- Patients Three hundred fifty-two consecutive patients (mean age, 59 years) admit- portant both in clinical and ted to the ICU for more than 24 hours for whom the SOFA score was calculated on administrative intensive admission and every 48 hours until discharge. care unit (ICU) manage- ⌬ Oment.1 Although outcome prediction Main Outcome Measures Initial SOFA score (0-24), -SOFA scores (differences between subsequent scores), and the highest and mean SOFA scores obtained during and measurement should not be the the ICU stay and their correlations with mortality. only measure of ICU performance, out- come prediction can be usefully ap- Results The initial, highest, and mean SOFA scores correlated well with mortality. Initial and highest scores of more than 11 or mean scores of more than 5 corre- plied to monitor the performance of an sponded to mortality of more than 80%. The predictive value of the mean score was individual ICU and possibly to com- independent of the length of ICU stay. In univariate analysis, mean and highest SOFA pare ICUs. Outcome prediction can also scores had the strongest correlation with mortality, followed by ⌬-SOFA and initial be useful in providing information on SOFA scores. The area under the receiver operating characteristic curve was largest likely patient outcomes for relatives of for highest scores (0.90; SE, 0.02; PϽ.001 vs initial score). When analyzing trends in critically ill patients and potentially for the SOFA score during the first 96 hours, regardless of the initial score, the mortality therapeutic decision making and guid- rate was at least 50% when the score increased, 27% to 35% when it remained un- ing resource allocation. Outcome pre- changed, and less than 27% when it decreased. Differences in mortality were better diction models currently available have predicted in the first 48 hours than in the subsequent 48 hours. There was no signifi- cant difference in the length of stay among these groups. Except for initial scores of not been validated for use in directing more than 11 (mortality rate Ͼ90%), a decreasing score during the first 48 hours was 2 individual patient management. associated with a mortality rate of less than 6%, while an unchanged or increasing Currently available outcome predic- score was associated with a mortality rate of 37% when the initial score was 2 to 7 tion models (such as the APACHE and 60% when the initial score was 8 to 11. [Acute Physiology and Chronic Health Conclusions Sequential assessment of organ dysfunction during the first few days 3 Evaluation], SAPS [simplified acute of ICU admission is a good indicator of prognosis. Both the mean and highest SOFA physiology score],4 and MPM [mortal- scores are particularly useful predictors of outcome. Independent of the initial score, ity probability models]5 systems) cal- an increase in SOFA score during the first 48 hours in the ICU predicts a mortality rate culate a prediction on values taken of at least 50%. within the first 24 hours of an ICU stay. JAMA. 2001;286:1754-1758 www.jama.com However these scores ignore the many 7 Author Affiliation: Department of Intensive Care, factors that can influence patient out- proportion of the ICU budget. Re- Erasme University Hospital, Free University of Brus- come during the course of an ICU stay. cently developed organ failure scores, sels, Belgium. Corresponding Author and Reprints: Jean-Louis Vin- Being able to evaluate changes in pa- such as the Sequential Organ Failure As- cent, MD, PhD, Department of Intensive Care, Erasme tient status over time thus represents sessment (SOFA) (TABLE 1)8 can help as- University Hospital, Route de Lennik, 808, B-1070 Brus- sels, Belgium (e-mail: [email protected]). an improvement on standard models. sess organ dysfunction or failure over Caring for the Critically Ill Patient Section Editor: Debo- Organ dysfunction is associated with time and are useful to evaluate morbid- rah J. Cook, MD, Consulting Editor, JAMA. Advisory Board: David Bihari, MD; Christian Brun- high rates of ICU morbidity and mortal- ity. Although these scoring systems were Buisson, MD; Timothy Evans, MD; John Heffner, MD; 6,7 ity, and, as such, accounts for a high developed to describe and quantify or- Norman Paradis, MD. 1754 JAMA, October 10, 2001—Vol 286, No. 14 (Reprinted) ©2001 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/25/2021 SOFA SCORE TO PREDICT OUTCOME Table 1. The Sequential Organ Failure Assessment (SOFA) Score* SOFA Score Variables 012 3 4 Respiratory Pao2/FIO2,mmHg Ͼ400 Յ400 Յ300 Յ200† Յ100† Coagulation Platelets ϫ103/µL‡ Ͼ150 Յ150 Յ100 Յ50 Յ20 Liver Bilirubin, mg/dL‡ Ͻ1.2 1.2-1.9 2.0-5.9 6.0-11.9 Ͼ12.0 Cardiovascular Hypotension No hypotension Mean arterial Dop Յ5ordob Dop Ͼ5, epi Յ0.1, Dop Ͼ15, epi Ͼ0.1, pressure (any dose)§ or norepi Յ0.1§ or norepi Ͼ0.1§ Ͻ70 mm Hg Central nervous system Glasgow Coma Score Scale 15 13-14 10-12 6-9 Ͻ6 Renal Creatinine, mg/dL Ͻ1.2 1.2-1.9 2.0-3.4 3.5-4.9 or Ͻ500 Ͼ5.0 or Ͻ200 or urine output, mL/d࿣ *Norepi indicates norepinephrine; Dob, dobutamine; Dop, dopamine; Epi, epinephrine; and FIO2, fraction of inspired oxygen. †Values are with respiratory support. ‡To convert bilirubin from mg/dL to µmol/L, multiply by 17.1. §Adrenergic agents administered for at least 1 hour (doses given are in µg/kg per minute). ࿣To convert creatinine from mg/dL to µmol/L, multiply by 88.4. gan function and not to predict out- dated patients, the assumed Glasgow Table 2. Demographics of Study come, the obvious relationship be- Coma Score Scale was used to evalu- Population* tween organ dysfunction and mortality ate the neurological status. Characteristics Values has been demonstrated in several stud- The total SOFA was calculated as the No. of patients 352 ies.9-12 We were interested in evaluating sum of all daily SOFA scores during the Age, mean (SD) [range], y 59 (17) [18-95] Sex whether repeated measurement of the ICU stay for each patient. The mean score Men 230 SOFA score, by including alterations over was defined as the ratio of total score to Women 122 time, could help refine outcome predic- the length of stay (LOS) in the ICU. The Type of admission, No. (%) Medical 195 (55.4) tion. highest score recorded during the ICU Surgical 157 (44.6) stay was also noted. The ⌬-SOFA score Length of ICU stay, d METHODS Mean 6.5 was defined as the difference between 2 Median 4.0 Following approval by the the ethical subsequent scores; for example, the Range 1-56 review board of Erasme University Hos- ⌬-SOFA score 48-0 was the difference be- No. (%) of deaths 81 (23) pital, Free University of Brussels, Bel- tween the 48-hour SOFA score and the *ICU indicates intensive care unit. gium, which waived informed con- admission score. sent on the basis that this was an Odds ratios with 95% confidence in- RESULTS epidemiological study without inter- tervals were computed using a univari- The study included 352 patients with a vention, all patients (Ͼ18 years) ad- ate logistic regression model with ICU mean (SD) age of 59 (17) years mitted to the 31-bed medicosurgical de- outcome as the dependent variable. A (TABLE 2). From the expected 13620 partment of intensive care for more than ␹2 statistics test (with Yates correction variables, 267 were missing (215 bili- 24 hours during a 4-month period when applicable) was used to evaluate rubin levels, 21 creatinine concentra- (April 1-July 31, 1999) were included the statistical significance of categori- tions, 15 PaO2/FIO2 [fraction of inspired in the study. cal variables. The results are pre- oxygen] ratios, and 16 platelet counts). Demographic, laboratory, and clini- sented as mean (SD). Comparisons of As expected, the initial SOFA score was cal data were collected, and the SOFA the areas under the receiver operating significantly related to vital status. An score (0-24, Table 1) was calculated, on characteristic (ROC) curves were also initial SOFA score up to 9 predicted a admission and every 48 hours until dis- performed with a test based on the dif- mortality of less than 33% while an charge. In the calculation of the score, ference between the 2 areas and the SE initial SOFA score of greater than 11 the worst values for each parameter in of the difference.13 Using Statview (SAS predicted a mortality rate of 95% the 24-hour period were used. For a Institute, Cary, NC) and Medcal (Med- (FIGURE 1A). The highest SOFA score single missing value, a replacement was cal Software, Mariakerke, Belgium), was also correlated with mortality: high- calculated from the mean of the sum of all statistical tests were 2-tailed and a est scores of 10 correlated with a mor- the results immediately preceding and P value Ͻ.05 was considered signi- tality rate of 40% while those higher than following the missing value.
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