Delta SOFA Score Research Articles

Early administration of hydrocortisone, vitamin C, and thiamine in adult patients with septic shock: a randomized controlled clinical trial

BackgroundThe combination therapy of hydrocortisone, vitamin C, and thiamine has been proposed as a potential treatment in patients with sepsis and septic shock. However, subsequent trials have reported conflicting results in relation to survival outcomes. Hence, we performed this randomized controlled trial (RCT) to evaluate the efficacy and safety of early combination therapy among adult patients with septic shock.MethodsThis single-center, double-blind RCT enrolled adult patients with diagnosis of septic shock within 12 h from Northern Jiangsu People's Hospital between February 2019 and June 2021. Recruited patients were randomized 1:1 to receive intervention (hydrocortisone 200 mg daily, vitamin C 2 g every 6 h, and thiamine 200 mg every 12 h) or placebo (0.9% saline) for 5 days or until ICU discharge. The primary endpoint was 90-day mortality. The secondary endpoints included mortality at day 28, ICU discharge, and hospital discharge; shock reversal; 72-h Delta SOFA score; ICU-free days, vasopressor-free days, and ventilator support -free days up to day 28; ICU length of stay (LOS) and hospital LOS.ResultsAmong 426 patients randomized, a total of 408 patients with septic shock were included in the per-protocol (PP) analysis, of which 203 were assigned to the intervention group and 205 to the placebo group. In the PP population, the primary outcome of 90-day mortality was 39.9% (81/203) and 39.0% (80/205) in the intervention and the placebo groups, respectively, and was not significantly different (P = 0.86). There was no significant difference between two groups in 28-day mortality (36.5% vs. 36.1%, P = 0.94) or the ICU mortality (31.5% vs. 28.8%, P = 0.55) and hospital mortality (34.5% vs. 33.2%, P = 0.78). No other secondary outcomes showed significant differences between two groups, including shock reversal, vasopressor-free days, and ICU LOS. Intention-to-treat analysis included all the 426 patients and confirmed these results (all P > 0.05).ConclusionAmong adult patients with septic shock, early use of hydrocortisone, vitamin C, and thiamine combination therapy compared with placebo did not confer survival benefits.Trial registration ClinicalTrials.gov: NCT03872011, registration date: March 12, 2019.Graphic

Patient Characteristics and Outcome of Multi-organ Involvement in Dengue with Reference to SOFA Score

Background: Mortality in severe Dengue infection is attributed to development of MODS. Clinical profile, outcome and utility of SOFA score in Dengue MODS is not well studied in Indian context. Hence, this study was conducted to describe the “patient`s” characteristics and outcome in Dengue MODS with reference to SOFA score.
 Methods: We conducted an observational cross –sectional study in medicine department, Sassoon General Hospital Pune between January 2016 to January 2020. Adult dengue patients with multiorgan dysfunction based on SOFA score were included. Demographic, clinical and laboratory data were collected and analyzed. SOFA score was calculated at admission and monitor throughout admission course.
 Results: Total 69 patients were included. Male were 53.6% and mean age was 38.7±18.7 years. Most common symptoms were fever (98.6%), body ache & joint pain (69.6%), generalized weakness (62.3%), breathlessness (59.4%), headache (58%), anorexia (58%), abdominal pain & vomiting (55.1%) and bleeding manifestations (47.8%). Total 28% patients had two, 33% had three, 24.6% had four and 14.4% had ≥ 5 organs involvement. Maximum number of patients had hematological involvement (95.7%) followed by respiratory system involvement (63.8%). Mean duration of hospital stay was 9.8 days. Mortality was 43.5%. There was significant correlation of number of organs involved, pulse rate, respiratory rate, serum albumin, nervous system, respiratory system, SOFA score at admission and delta SOFA score with outcome.
 Conclusion: Dengue MODS has high mortality. Tachypnoea, tachycardia, hypoalbuminemia, respiratory failure and nervous system involvement are predictors of poor outcome. SOFA score at admission and its monitoring can serve as a useful marker to predict prognosis in dengue with multiple organ involvement.

Positive Sputum Cultures in Ventilated Patients with COVID19: Utility of Antibiotic Use at a Single Academic Center

Patients with COVID-19 pneumonia on mechanical ventilation can exhibit clinical signs difficult to distinguish from ventilator-associated pneumonia (VAP). Positive sputum cultures in these patients often lead to the use of broad-spectrum antibiotics. Therefore, we aim to evaluate the clinical utility and efficacy of antimicrobial coverage for positive sputum cultures in mechanically ventilated patients with COVID-19. These subjects (n = 98) were on mechanical ventilation and had positive sputum culture after 48 h of intubation during 15 March 2020–25 May 2020 at Rush University Medical Center in Chicago, IL. Only one patient did not receive antibiotics. The primary outcome was defined as the change in Sequential Organ Failure Assessment (delta SOFA score) which was calculated by comparing the SOFA score on the day of sputum culture collection with the score at 48 h and 7 days after the initiation of treatment. There were no statistically significant delta SOFA scores after 48 h of antibiotics administration. Statistically significant changes were observed after 7 days of treatment, which could be reflective of an improvement in viral pneumonia with ICU supportive care. Physicians should consider that positive sputum cultures may not always indicate VAP and apply clinical judgement to avoid the overuse of broad-spectrum antibiotics in critically ill patients with COVID-19.

Association between fluid overload and SOFA score kinetics in septic shock patients: a retrospective multicenter study

BackgroundFluid infusion represents one of the cornerstones of resuscitation therapies in order to increase oxygen delivery during septic shock. Fluid overload as a consequence of excessive fluid administration seems to be linked to worse long-term outcome. However, its immediate effect on patient’s clinical state is poorly described. The goal of this study was to assess the impact of FO on SOFA score kinetics as a surrogate marker of organ dysfunction from day 0 to day 5.Material and methodsRetrospective, multicenter, investigator-initiated study. All adult patients (> 18 years old) admitted from January 2012 to April 2017 in one of the three ICUs for septic shock, secondary to peritonitis or pulmonary infection and mechanically ventilated, were included. Univariate analysis was performed with Student’s t and chi-square test, for continuous and categorical variables, respectively. A multivariate linear regression model evaluated the impact of FO on delta SOFA score from day 0 to day 5. Secondly, a multivariate mixed-model accounting for repeated measures analyzed the impact of FO on SOFA score kinetics.ResultsOne hundred twenty-nine patients met the inclusion criteria and were assigned into FO and no FO groups. FO occurred in 39% of the patients. The difference between SOFA score at day 0 and day 5 was more than twofold higher in the no FO group than in the FO group with a difference of 2.37 between the two groups (4.52 vs. 2.15; p = 0.001). Cumulative fluid intake at day 5 was higher in the FO group (2738 vs. 8715 ml, p < 0.001). In multivariate analysis, FO was associated with delta SOFA score: aRR = 0.15 (95% CI 0.03–0.63; p = 0.009). In mixed model, the regression coefficient for fluid overload status (r2 = 1.16; p = 0.014) indicated that the slope for SOFA score kinetic was less pronounced for patients with FO than for patients without FO.ConclusionsFO patients had a more prolonged multi-organ failure according to SOFA score kinetics during septic shock from resuscitation phase to day 5.

Epidemiology, lung mechanics and outcomes of ARDS: A comparison between pregnant and non-pregnant subjects

PurposeWe describe the epidemiology, lung mechanics and outcomes of acute respiratory distress syndrome (ARDS) complicating pregnancy. We also compare the outcomes of ARDS in pregnant and non-pregnant females. MethodsRetrospective observational study of all women admitted with ARDS. Results211 women with ARDS were admitted, which included 27 (12.8%) pregnant subjects. All were ventilated with a low tidal volume strategy. Most pregnant females presented during the third trimester. There was no difference in the lung compliance, the applied PEEP and the plateau pressures across trimesters. The pregnant females had a lower median age (25 [22-28] vs. 32 [22–42] years, p = 0.003), higher proportion of severe ARDS (40.8% vs. 10.3%, p < 0.0001), and higher driving pressure (18.2 vs. 15.5 cm H2O, p = 0.03) compared to non-pregnant females. The maternal (18.5%) and perinatal (37%) mortality was high. However, the mortality was not different between pregnant and non-pregnant subjects with ARDS. On a multivariate logistic regression analysis, the baseline APACHE II score, driving pressure and the delta SOFA score were independent predictors of mortality. ConclusionsARDS complicating pregnancy is severe and is associated with high perinatal mortality. However, the outcomes of ARDS in pregnant females were similar to non-pregnant females.

CLINICAL VALUE OF TWO SCORING SYSTEMS, C-REACTIVE PROTEIN AND LACTATE CLEARANCE IN PATIENTS WITH SEVERE SEPSIS AT THE EMERGENCY DEPARTMENT

Introduction: More recently the grading system of sepsis was modified to include severe sepsis, septic shock, and refractory septic shock. Several indexes were found to be significantly related to short-term clinical outcome; as sequential organ failure assessment score (SOFA) and the mortality in emergency department sepsis (MEDS) score. Methods: Observational cohort study with prospective data collection. Severity of sepsis was assessed according to SOFA score, MEDS score. C-reactive protein (CRP) and 6 hours lactate clearance were measured. The outcome of patients was noticed according to the detected SOFA score, MEDS score, CRP, and lactate clearance levels in the survivors and non-survivors as well as their correlation with the severity of the disease. Results: Fifty patients with age range from 20 to 92 years. The mortality rate was 24% (12 patients). Six hours lactate clearance mean value was 21.04 ± 9.48%. Mean SOFA score at presentation was 6.56 ± 2.99 while after 72 hours, it was 5.28 ± 3.94. Mean MEDS score was 2.72. Six hours lactate clearance was significantly lower among the dead cases. MEDS score was significantly higher among the mortality cases. SOFA score whether measured at admission or after 72 hours and MEDS score were significantly higher among the dead cases. Both delta SOFA score and 6 hour lactate clearance were found to have the highest predictive characteristics with 100% sensitivity and specificity. There was statistically significant difference between area under the curve of SOFA 72 hours and 6 hours-lactate clearance when compared to CRP area under the curve. Conclusion: Both delta SOFA score and six hour lactate clearance had the highest predictive characteristics with 100% sensitivity and specificity.

Utility of sequential organ failure assessment score in prognosticating sick children in pediatric intensive care unit

Background: This study was designed to assess the utility of sequential organ failure assessment score (SOFA) score as a predictor of mortality in pediatric intensive care unit (PICU). Methods: A prospective hospital based study was carried out in PICU of Gajra Raja medical college, Gwalior, Madhya Pradesh, India. Critically ill patients admitted to PICU were recruited and followed up until they were discharged or deceased. The SOFA score was calculated for all the subjects during first 24 and 72 hours and difference between both i.e. delta SOFA was calculated . Results: The mean SOFA at 72 hours (T72) was 15.63±2.98 in non-survivors vs. 4.30±2.54 in survivors and was significantly higher (P<0.001). The negative and positive predictive values of SOFA at T 72 were comparable to pediatric logistic organ dysfunction (PELOD) score while these values were less for initial SOFA and delta SOFA score. Conclusions: Out study showed that SOFA T72 is a better predictor of mortality as compared to initial and delta SOFA score. The SOFA T 72 is comparable to PELOD score and can be used as a reliable predictor of mortality in children.

Analysis of peripheral blood lymphocyte subsets and prognosis in patients with septic shock

The purpose of the study is to study the relationship between peripheral blood lymphocyte subset proportion and prognosis in patients with septic shock. Fifty-two patients with septic shock, admitted to the intensive care unit between March 2007 and December 2010, were enrolled in this study. Peripheral blood lymphocyte subset proportions were measured using flow cytometry. The percentage of CD3⁺CD4⁺ T lymphocytes and CD19⁺ lymphocytes, CD4⁺/CD8⁺ T cell ratio were substantially lower in patients with septic shock compared to the control group (P < 0.01). The percentage of CD3⁺CD8⁺ T lymphocytes did not differ significantly between the two groups (P > 0.05). The percentage of CD16⁺CD56⁺ lymphocytes was higher in patients with septic shock than in the control group (P < 0.01). Compared with the survivor group, the percentage of CD3⁺CD4⁺ T lymphocytes and CD19⁺ lymphocytes, CD4⁺/CD8⁺ T cell ratio were clearly lower in the non-survivor group (P < 0.01). There was no difference in the percentage of CD3⁺CD8⁺ T lymphocytes between the non-survivor and survivor groups (P > 0.05). The percentage of CD16⁺CD56⁺ lymphocytes was higher in the non-survivor group than in the survivor group (P < 0.05). The total maximum SOFA score and the delta SOFA score were much higher in the non-survivor group than in the survivor group (P < 0.01). Immune imbalance occurs in patients with septic shock. Peripheral blood lymphocyte subset proportion and SOFA scores can be used to assess the treatment and prognosis of septic shock.

The prognostic value of the subjective assessment of peripheral perfusion in critically ill patients

The physical examination of peripheral perfusion based on touching the skin or measuring capillary refill time has been related to the prognosis of patients with circulatory shock. It is unclear, however, whether monitoring peripheral perfusion after initial resuscitation still provides information on morbidity in critically ill patients. Therefore, we investigated whether subjective assessment of peripheral perfusion could help identify critically ill patients with a more severe organ or metabolic dysfunction using the Sequential Organ Failure Assessment (SOFA) score and lactate levels. : Prospective observational study. Multidisciplinary intensive care unit in a university hospital. Fifty consecutive adult patients admitted to the intensive care unit. None. Patients were considered to have abnormal peripheral perfusion if the examined extremity had an increase in capillary refill time (>4.5 seconds) or it was cool to the examiner hands. To address reliability of subjective inspection and palpation of peripheral perfusion, we also measured forearm-to-fingertip skin-temperature gradient (Tskin-diff), central-to-toe temperature difference (Tc-toe), and peripheral flow index. The measurements were taken within 24 hours of admission to the intensive care after hemodynamic stability was obtained (mean arterial pressure >65 mm Hg). Changes in SOFA score during the first 48 hours were analyzed (delta-SOFA). Individual SOFA score was significantly higher in patients with abnormal peripheral perfusion than in those with normal peripheral perfusion (9 +/- 3 vs. 7 +/- 2, p < 0.05). Tskin-diff, Tc-toe, and peripheral flow index were congruent with the subjective assessment of peripheral perfusion. The proportion of patients with delta-SOFA score >0 was significantly higher in patients with abnormal peripheral perfusion (77% vs. 23%, p < 0.05). The logistic regression analysis showed that the odds of unfavorable evolution are 7.4 (95% confidence interval 2-19; p < 0.05) times higher for a patient with abnormal peripheral perfusion. The proportion of hyperlactatemia was significantly different between patients with abnormal and normal peripheral perfusion (67% vs. 33%, p < 0.05). The odds of hyperlactatemia by logistic regression analysis are 4.6 (95% confidence interval 1.4-15; p < 0.05) times higher for a patient with abnormal peripheral perfusion. Subjective assessment of peripheral perfusion with physical examination following initial hemodynamic resuscitation in the first 24 hours of admission could identify hemodynamically stable patients with a more severe organ dysfunction and higher lactate levels. Patients with abnormal peripheral perfusion had significantly higher odds of worsening organ failure than did patients with normal peripheral perfusion following initial resuscitation.

The sequential organ failure assessment score as a useful predictor for estimating the prognosis of systemic inflammatory response syndrome patients being treated with extracorporeal blood purification.

Systemic inflammatory response syndrome (SIRS) is a major cause of morbidity and mortality in critically ill patients. Extracorporeal blood purification procedures are becoming important for treating these patients. However, the cost of these procedures is high. Therefore, a prognostic marker would be helpful. To establish the reliability of the Sequential Organ Failure Assessment (SOFA) score as a prognostic indicator, we evaluated daily changes in the SOFA score of 40 SIRS patients who needed blood purification procedures such as continuous renal replacement therapy (CRRT), endotoxin adsorption, bilirubin adsorption, and/or plasma exchange. Twenty patients survived and 20 died. Although the baseline scores of the two groups (survivors and non-survivors) did not differ, both the maximum value of the SOFA score and the DeltaSOFA score (the difference between the maximum SOFA and baseline SOFA scores) were significantly higher in the non-survivor group. The mortality rate among patients with a maximum SOFA score greater than or equal to 18 or a DeltaSOFA score greater than or equal to 3 was higher than for the rest of the patients. The changes in the SOFA score correlated well with the outcomes of the SIRS patients. The maximum SOFA score and the DeltaSOFA score are therefore likely to be useful prognostic markers.

Serial evaluation of the SOFA score to predict outcome in critically ill patients.

Evaluation of trends in organ dysfunction in critically ill patients may help predict outcome. To determine the usefulness of repeated measurement the Sequential Organ Failure Assessment (SOFA) score for prediction of mortality in intensive care unit (ICU) patients. Prospective, observational cohort study conducted from April 1 to July 31, 1999. A 31-bed medicosurgical ICU at a university hospital in Belgium. Three hundred fifty-two consecutive patients (mean age, 59 years) admitted to the ICU for more than 24 hours for whom the SOFA score was calculated on admission and every 48 hours until discharge. Initial SOFA score (0-24), Delta-SOFA scores (differences between subsequent scores), and the highest and mean SOFA scores obtained during the ICU stay and their correlations with mortality. 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 corresponded to mortality of more than 80%. The predictive value of the mean score was independent of the length of ICU stay. In univariate analysis, mean and highest SOFA scores had the strongest correlation with mortality, followed by Delta-SOFA and initial SOFA scores. The area under the receiver operating characteristic curve was largest for highest scores (0.90; SE, 0.02; P<.001 vs initial score). When analyzing trends in the SOFA score during the first 96 hours, regardless of the initial score, the mortality rate was at least 50% when the score increased, 27% to 35% when it remained unchanged, and less than 27% when it decreased. Differences in mortality were better predicted in the first 48 hours than in the subsequent 48 hours. There was no significant difference in the length of stay among these groups. Except for initial scores of more than 11 (mortality rate >90%), a decreasing score during the first 48 hours was associated with a mortality rate of less than 6%, while an unchanged or increasing score was associated with a mortality rate of 37% when the initial score was 2 to 7 and 60% when the initial score was 8 to 11. Sequential assessment of organ dysfunction during the first few days of ICU admission is a good indicator of prognosis. Both the mean and highest SOFA scores are particularly useful predictors of outcome. Independent of the initial score, an increase in SOFA score during the first 48 hours in the ICU predicts a mortality rate of at least 50%.

Evaluation of the SOFA score: a single-center experience of a medical intensive care unit in 303 consecutive patients with predominantly cardiovascular disorders. Sequential Organ Failure Assessment.

To evaluate the use of the Sequential Organ Failure Assessment (SOFA) score, the total maximum SOFA (TMS) score, and a derived variable, the deltaSOFA (TMS score minus total SOFA score on day 1) in medical, cardiovascular patients as a means for describing the incidence and severity of organ dysfunction and the prognostic value regarding outcome. Prospective, clinical study. Medical intensive care unit in a university hospital. A total of 303 consecutive patients were included (216 men, 87 women; mean age 62 +/- 12.6 years; SAPS II 26.2 +/- 12.7). They were evaluated 24 h after admission and thereafter every 24 h until ICU discharge or death between November 1997 and March 1998. Readmissions and patients with an ICU stay shorter than 12 h were excluded. Survival status at hospital discharge, incidence of organ dysfunction/failure. Collection of clinical and demographic data and raw data for the computation of the SOFA score every 24 h until ICU discharge. Length of ICU stay was 3.7 +/- 4.7 days. ICU mortality was 8.3% and hospital mortality 14.5%. Nonsurvivors had a higher total SOFA score on day 1 (5.9 +/- 3.7 vs. 1.9 +/- 2.3, p < 0.001) and thereafter until day 8. High SOFA scores for any organ system and increasing number of organ failures (SOFA score > or = 3) were associated with increased mortality. Cardiovascular and neurological systems (day 1) were related to outcome and cardiovascular and respiratory systems, and admission from another ICU to length of ICU stay. TMS score was higher in nonsurvivors (1.76 +/- 2.55 vs. 0.58 +/- 1.39, p < 0.01), and deltaSOFA/total SOFA on day 1 was independently related to outcome. The area under the receiver-operating characteristic curve was 0.86 for TMS, 0.82 for SOFA on day 1, and 0.77 for SAPS II. The SOFA, TMS, and deltaSOFA scores provide the clinician with important information on degree and progression of organ dysfunction in medical, cardiovascular patients. On day 1 both SOFA score and TMS score had a better prognostic value than SAPS II score. The model is closely related to outcome and identifies patients who are at increased risk for prolonged ICU stay.