Delta SOFA Research Articles

SEPSIGN: early identification of sepsis signs in emergency department.

Because 20-30% of patients with sepsis deteriorate to critical illness, biomarkers that provide accurate early prognosis may identify which patients need more intensive treatment versus safe early discharge. The objective was to test the performance of sVEGFR2, suPAR and PCT, alone or combined with clinical signs and symptoms, for the prediction of clinical deterioration. This prospective observational study enrolled patients with suspected infection who met SIRS criteria without organ dysfunction (delta SOFA <2 from baseline) from 16 emergency departments. The primary endpoint was clinical deterioration (increased SOFA score ≥2 points, new or increased organ support, or death) within 72 hours of enrollment. Diagnosis and classification of infection status were adjudicated. 724 patients were enrolled, (54% men, median age 55 [38-70] y-o). Infection origin was abdominopelvic (21%), skin and soft tissues (17%), urinary (16%) and pulmonary (15%). 176 (24%) patients deteriorated, with a 28-day mortality of 1.4%. They had lower sVEGFR2 level (6.17 [5.00-7.40] vs 6.52 [5.40-7.84], p=0.024), higher circulating suPAR (5.25 [3.86-7.50] vs 4.18 [3.16-5.68], p<0.001) and higher PCT level (0.32 [0.08-1.80] vs 0.18 [0.05-0.98], p=0.004). suPAR demonstrated superior performance (AUC=0.65 [0.60-0.70]), compared to other biomarkers (PCT, AUC=0.57 [0.52-0.62] and sVEGFR2, AUC=0.58 [0.53-0.64]). Maximum accuracy was achieved from the combination of clinical information, sVEGFR2 and suPAR, yielding an AUC of 0.74 [0.69-0.78] and NPV 0.90 [0.88-0.94]. sVEGFR2 and suPAR were insufficiently accurate to rule out clinical deterioration. Panels of biomarkers will likely be needed to capture the heterogeneous mechanistic pathways involved in sepsis-related organ failure.

Impact of a multidisciplinary management team on clinical outcome in ICU patients affected by Gram-negative bloodstream infections: a pre-post quasi-experimental study

BackgroundBloodstream infections (BSIs) by Gram-negative pathogens play a major role in intensive care patients, both in terms of prevalence and severity, especially if multi-drug resistant pathogens are involved. Early appropriate antibiotic therapy is therefore a cornerstone in the management of these patients, and growing evidence shows that implementation of a multidisciplinary team may improve patients’ outcomes. Our aim was to evaluate the clinical and microbiological impact of the application of a multidisciplinary team on critically ill patients.MethodsPre-post study enrolling critically ill patients with Gram negative bloodstream infection in intensive care unit. In the pre-intervention phase (from January until December 2018) patients were managed with infectious disease consultation on demand, in the post-intervention phase (from January until December 2022) patients were managed with a daily evaluation by a multidisciplinary team composed of intensivist, infectious disease physician, clinical pharmacologist and microbiologist.ResultsOverall, 135 patients were enrolled during the study period, of them 67 (49.6%) in the pre-intervention phase and 68 (50.4%) in the post-intervention phase. Median age was 67 (58–75) years, sex male was 31.9%. Septic shock, the need for continuous renal replacement therapy and mechanical ventilation at BSI onset were similar in both groups, no difference of multidrug-resistant organisms (MDRO) prevalence was observed. In the post-phase, empirical administration of carbapenems decreased significantly (40.3% vs. 62.7%, p = 0.02) with an increase of appropriate empirical therapy (86.9% vs. 55.2%, p < 0.001) and a decrease of overall antibiotic treatment (12 vs. 16 days, p < 0.001). Despite no differences in delta SOFA and all-cause 30-day mortality, a significant decrease in microbiological failure (10.3% vs. 29.9%, p = 0.005) and a new-onset 30-day MDRO colonization (8.3% vs. 36.6%, p < 0.001) in the post-phase was reported. At multivariable analysis adjusted for main covariates, the institution of a multidisciplinary management team (MMT) was found to be protective both for new MDRO colonization [OR 0.17, 95%CI(0.05–0.67)] and microbiological failure [OR 0.37, 95%CI (0.14–0.98)].ConclusionsThe institution of a MMT allowed for an optimization of antimicrobial treatments, reflecting to a significant decrease in new MDRO colonization and microbiological failure among critically ill patients.

“ASSESSMENT OF SOFA VS QSOFA VS DELTA SOFA IN ICU PATIENTS”

Objective: Ÿ To study the demographic prole of patients with sepsis and multiple organ dysfunction syndrome in patients with intensive care units. Ÿ To evaluate the use of SOFA Score for predicting the mortality in patients with severe sepsis. Ÿ To evaluate the use of MAX SOFA and DELTA SOFA for assessing the outcome of patients with severe sepsis. Materials and Methods: A sample of 100 patients who were admitted to intensive care units and fullled the inclusion criteria were selected for this study from the tertiary care hospital, between September 2021- September 2022 with suspected/conrmed sepsis. It was a prospective observational study. Results: SOFA Score at 48 hours, 96 hours, max SOFA, Δ SOFA showed mortality with a P-value of &lt;0.001 which is statistically signicant. Hence, use of SOFA score, Δ SOFA score, and MAX SOFA score are good predictors of outcomes in patients with sepsis. Conclusion: Sequential assessment of organ dysfunction during the rst few days of ICU admission is a good indicator of prognosis. SOFA score at 48 hours and MAX SOFA score, as well as Δ SOFA score, are useful predictors of the outcome as compared to SOFA score at admission

Accuracy of the persistent AKI risk index in predicting acute kidney injury in patients admitted to the intensive care unit for acute respiratory failure.

To evaluate the accuracy of the persistent AKI risk index (PARI) in predicting acute kidney injury within 72 hours after admission to the intensive care unit, persistent acute kidney injury, renal replacement therapy, and death within 7 days in patients hospitalized due to acute respiratory failure. This study was done in a cohort of diagnoses of consecutive adult patients admitted to the intensive care unit of eight hospitals in Curitiba, Brazil, between March and September 2020 due to acute respiratory failure secondary to suspected COVID-19. The COVID-19 diagnosis was confirmed or refuted by RT-PCR for the detection of SARS-CoV-2. The ability of PARI to predict acute kidney injury at 72 hours, persistent acute kidney injury, renal replacement therapy, and death within 7 days was analyzed by ROC curves in comparison to delta creatinine, SOFA, and APACHE II. Of the 1,001 patients in the cohort, 538 were included in the analysis. The mean age was 62 ± 17 years, 54.8% were men, and the median APACHE II score was 12. At admission, the median SOFA score was 3, and 83.3% had no renal dysfunction. After admission to the intensive care unit, 17.1% had acute kidney injury within 72 hours, and through 7 days, 19.5% had persistent acute kidney injury, 5% underwent renal replacement therapy, and 17.1% died. The PARI had an area under the ROC curve of 0.75 (0.696 - 0.807) for the prediction of acute kidney injury at 72 hours, 0.71 (0.613 - 0.807) for renal replacement therapy, and 0.64 (0.565 - 0.710) for death. The PARI has acceptable accuracy in predicting acute kidney injury within 72 hours and renal replacement therapy within 7 days of admission to the intensive care unit, but it is not significantly better than the other scores.

Development and deployment of interpretable machine-learning model for predicting in-hospital mortality in elderly patients with acute kidney disease

Background Acute kidney injury (AKI) is more likely to develop in the elderly admitted to the intensive care unit (ICU). Acute kidney disease (AKD) affects ∼45% of patients with AKI and increases short-term mortality. However, there are no studies on the prognosis of AKD in the elderly. Methods Data from 2666 elderly patients with AKD in the Medical Information Mart for Intensive Care IV were used for model development and 535 in the eICU Collaborative Research Database for external validation. Based on 5 machine learning algorithms, 33 noninvasive parameters were extracted as features for modeling. Results In-hospital mortality of AKD in the elderly was 29.6% and 31.8% in development and validation cohorts, respectively. The comprehensive best-performing algorithm was the support vector machine (SVM), and a simplified online application included only 10 features employing SVM (AUC: 0.810 and 0.776 in the training and external validation cohorts, respectively) was deployed. Model interpretation by SHapley Additive exPlanation (SHAP) values revealed that the difference (AKD day – ICU day) in sequential organ failure assessment (delta SOFA), Glasgow coma scale (GCS), delta GCS, delta peripheral oxygen saturation (SpO2), and SOFA were the top five features associated with prognosis. The optimal target was determined by SHAP values from partial dependence plots. Conclusions A web-based tool was externally validated and deployed to predict the early prognosis of AKD in the elderly based on readily available noninvasive parameters, assisting clinicians in intervening with precision and purpose to save lives to the greatest extent.

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.&#x0D; 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.&#x0D; 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 &amp; joint pain (69.6%), generalized weakness (62.3%), breathlessness (59.4%), headache (58%), anorexia (58%), abdominal pain &amp; 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.&#x0D; 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.

Impact of Admission SOFA Score and 48-Hour Delta SOFA on Clinical Outcomes of Critically Ill Patients

Impact of Admission SOFA Score and 48-Hour Delta SOFA on Clinical Outcomes of Critically Ill Patients

Outcome of allogeneic hematopoietic stem cell transplant recipients admitted to the intensive care unit with a focus on haploidentical graft and sequential conditioning regimen: results of a retrospective study

Haploidentical transplantation has extended the availability of allogeneic hematopoietic stem cell transplant (alloHCT) to almost all patients. Sequential conditioning regimens have been proposed for the treatment of hematological active disease. Whether these new transplantation procedures affect the prognosis of critically ill alloHCT recipients remains unknown. We evaluated this question in a retrospective study including consecutive alloHCT patients admitted to the intensive care unit of a tertiary academic center from 2010 to 2017. During the study period, 412 alloHCTs were performed and 110 (27%) patients-median age 55 (36-64) years-were admitted to ICU in a median time of 58.5 (14-245) days after alloHCT. Twenty-nine (26%) patients had received a haploidentical graft and 34 (31%) a sequential conditioning. Median SOFA score was 9 (6-11). Invasive mechanical ventilation (MV) was required in 61 (55%) patients. Fifty-six (51%) patients died in the hospital. Independent factors associated with in-hospital mortality were as follows: MV (OR=8.44 [95% CI 3.30-23.19], p<0.001), delta SOFA between day 3 and day 1 (OR=1.60 [95% CI 1.31-2.05], p<0.0001), and sequential conditioning (OR=3.7 [95% CI 1.14-12.92], p=0.033). Sequential conditioning was also independently associated with decreased overall survival (HR=1.86 [95% CI 1.05-3.31], p=0.03). Other independent factors associated with reduced overall survival were HCT-specific comorbidity index ≥2 (HR=1.76 [95% CI 1.10-2.84], p=0.02), acute GVHD grade ≥2 (HR=1.88 [95% CI 1.14-3.10], p=0.01), MV (HR=2.37 [95% CI 1.38-4.07, p=0.002), and vasopressors (HR=2.21 [95% CI 1.38-3.54], p=0.001). Haploidentical transplantation did not affect outcome. Larger multicenter studies are warranted to confirm these results.

Clinical impact of lung ultrasound monitoring for diagnosis of ventilator associated pneumonia: A diagnostic randomized controlled trial.

Studies have shown that lung-ultrasound may be superior to chest x-ray (CXR) in diagnosing ventilator-associated pneumonia (VAP). This study investigated whether the use of lung-ultrasound monitoring could detect VAP earlier and improve patient outcome. This was a single-center diagnostic randomized controlled trial. In the control group, VAP was diagnosed using a combination of CXR and clinical findings. In the intervention group, VAP was diagnosed using a combination of lung-ultrasound and clinical findings. The primary outcome measured was ventilator free days (VFD). Secondary outcomes were ICU mortality, length of stay in ICU, change in Sequential Organ Failure Score at day 4 compared to day 0 (delta SOFA), antibiotic duration and ventilator days. We randomized intubated patients until 44 VAP diagnosis was made in each group. VFD was higher in the intervention group than in the control group (7.80+/- 9.7days versus 3.7+/- 6.4days, p=.044). There were no differences between the groups in terms of ICU mortality (p=.104), ICU length of stay, (p=.058), ventilator days, (p=.081), delta SOFA (p=.10) and antibiotic duration (p=.70). The use of lung-ultrasound monitoring for diagnosis of VAP improves patient outcome when compared to the standard diagnostic strategy that relies on CXR.

Intraoperative Hemorrhagic Shock in Cancer Surgical Patients: Short and Long-Term Mortality and Associated Factors.

Management of hemorrhagic shock is well codified by international guidelines. These guidelines are predominantly based on trauma patients. We aimed to evaluate factors associated with 30-day mortality and long-term survival after intraoperative hemorrhagic shock during major oncological surgery. This retrospective study was conducted in a cancer referral center from January 2013 to February 2018. All adult cancer patients admitted in the operative room for scheduled or emergency oncological surgery associated with an intraoperative hemorrhagic shock were included. Eighty-four patients were included in this study. The 30-day mortality rate was 26% (n = 22), the mean follow-up from the time of ICU admission was 20 months (95% CI, 15-25 months), 39 (46%) patients died during this period. Using logistic regression for multivariate analysis, factors independently associated with 30-day mortality were SAPS II score (odds ratio (OR) =1.056, 95% confident interval (CI) =1.010-1.1041), delta SOFA (SOFA score at day 3 - SOFA score at day 1) (OR= 1.780, 95% CI 1.184-2.677) and ISTH-DIC score (OR = 2.705, 95% CI 1.108-6.606). Using Cox multivariate analysis, factors associated with long-term mortality were delta SOFA (hazard ratio (HR) =1.558, 95% CI 1.298-1.870), ISTH-DIC score (HR = 1.381, 95% CI 1.049-1.817), hepatic dysfunction (HR = 7.653, 95% CI 2.031-28.842), and Charlson comorbidity index (HR = 1.330, 95% CI 1.041-1.699). The worsening of organ dysfunctions during the first 3 days of ICU admission as well as intraoperative coagulation disturbances (increased ISTH-DIC score) are independently associated with short and long-term mortality. Comorbidities (Charlson comorbidity index) and postoperative hepatic dysfunction were independently associated with long-term mortality. Early perioperative bundle strategies should be evaluated in order to improve patient's survival in this specific situation.

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.

Echocardiogram-guided resuscitation versus early goal-directed therapy in the treatment of septic shock: a randomized, controlled, feasibility trial

ObjectiveEchocardiography is often used to guide septic shock resuscitation, but without evidence for efficacy. We conducted an intensive care unit (ICU)-based randomized controlled feasibility trial comparing echocardiography-guided septic shock resuscitation (ECHO) with early goal-directed therapy (EGDT).MethodsWe conducted a single center, randomized controlled feasibility trial at a 468-bed academic tertiary care center in Utah, USA. Adult patients with early septic shock were assessed and treated at defined intervals over 6 h using an echocardiogram-guided resuscitation protocol or a slightly modified EGDT protocol. Feasibility outcomes were fluid balance, dobutamine administration, and time to lactate clearance. The primary clinical outcome was changed in sequential organ failure assessment score at 48 h (delta SOFA). Secondary outcomes included inpatient mortality, ICU-free days, and ventilator-free days at 28 days.ResultsThirty participants, 15 per group, were randomized and completed the study. Baseline characteristics were similar between groups. Patients were randomized within a median of 3.5 h of meeting inclusion criteria but had received a median of 3 L crystalloid by then. Fluid administration during the study protocol was similar in both groups (median ECHO 0 vs EGDT 1 L, p = 0.61). Eleven (73%) subjects in each arm received ≤ 1 L fluid. Dobutamine administration was also similar (20% vs 13%, p > 0.99). Twenty-one patients (70%) had lactate clearance prior to the first study assessment. No difference was observed in delta SOFA (median − 4 for ECHO vs − 6 for EGDT, p = 0.10) nor mortality (33% ECHO vs 20% EGDT, p = 0.68).ConclusionsNo experimental separation was observed in this randomized, controlled feasibility trial. Early lactate clearance, coupled with substantial fluid administration before randomization, suggests that patients were already resuscitated before arrival in the ICU. Future trials of echocardiogram-guided sepsis resuscitation will likely need to enroll in the emergency department.Trial registrationThis study was retrospectively registered at clinicaltrials.gov (identifier NCT02354742, title Echo vs EGDT in severe sepsis and septic shock) on February 3, 2015. Registration was completed before review or analysis of any data.

Acute respiratory failure due to diffuse parenchymal lung diseases in a respiratory intensive care unit of North India.

Background: Acute respiratory failure (ARF) due to diffuse parenchymal lung diseases (DPLDs) is associated with high mortality. Whether ARF due to acute interstitial pneumonia (AIP), idiopathic pulmonary fibrosis (IPF) and non-IPF DPLDs behaves differently remains unclear. Methods: A retrospective analysis of consecutive DPLD subjects with ARF admitted to respiratory intensive care unit (RICU). The baseline clinical, demographic characteristics, cause of ARF and mortality were compared between the groups. Results: 145 (5.8% of RICU admission) subjects (mean [SD] age, 51.6 [14.7] years, 406% males) with DPLD-related ARF (17 AIP; 32 IPF; 96 non-IPF DPLD) were admitted. Common causes of ARF were acute exacerbation of the underlying DPLD (n=59, 40.4%) followed by infections (n=48, 37.5%). There was no difference in the peak, plateau and driving pressures across groups. The mortality rate was 45.5% (66/145) and was highest in AIP (82%) followed by IPF (59%) and non-IPF DPLD (34%). On multivariate logistic regression analysis, baseline APACHE II score, PaO2:FiO2 ratio, delta SOFA, and the use of invasive mechanical ventilation were independent predictors of mortality. The type of underlying DPLD however, did not affect survival. Conclusions: DPLD-related ARF is an uncommon cause of admission even in a RICU, and is associated with a high mortality. (Sarcoidosis Vasc Diffuse Lung Dis 2018; 35: 363-370)

SOFA and mortality endpoints in randomized controlled trials: a systematic review and meta-regression analysis

BackgroundThe sequential organ failure assessment score (SOFA) is increasingly used as an endpoint in intensive care randomized controlled trials (RCTs). Although serially measured SOFA is independently associated with mortality in observational cohorts, the association between treatment effects on SOFA vs. effects on mortality has not yet been quantified in RCTs. The aim of this study was to quantify the relationship between SOFA and mortality in RCTs and to identify which SOFA derivative best reflects between-group mortality differences.MethodsThe review protocol was prospectively registered (Prospero CRD42016034014). We performed a literature search (up to May 1, 2016) for RCTs reporting both SOFA and mortality, and analyzed between-group differences in these outcomes. Treatment effects on SOFA and mortality were calculated as the between-group SOFA standardized difference and log odds ratio (OR), respectively. We used random-effects meta-regression to (1) quantify the linear relationship between RCT treatment effects on mortality (logOR) and SOFA (i.e. responsiveness) and (2) quantify residual heterogeneity (i.e. consistency, expressed as I2).ResultsOf 110 eligible RCTs, 87 qualified for analysis. Using all RCTs, SOFA was significantly associated with mortality (slope = 0.49 (95% CI 0.17; 0.82), p = 0.006, I2 = 5%); the overall mortality effect explained by SOFA score (R2) was 9%. Fifty-eight RCTs used Fixed-day SOFA as an endpoint (i.e. the score on a fixed day after randomization), 25 studies used Delta SOFA as an endpoint (i.e. the trajectory from baseline score) and 15 studies used other SOFA derivatives as an endpoint. Fixed-day SOFA was not significantly associated with mortality (slope = 0.35 (95% CI −0.04; 0.75), p = 0.08, I2 = 12%) and explained 3% of the overall mortality effect (R2). Delta SOFA was significantly associated with mortality (slope = 0.70 (95% CI 0.26; 1.14), p = 0.004, I2 = 0%) and explained 32% of the overall mortality effect (R2).ConclusionsTreatment effects on Delta SOFA appear to be reliably and consistently associated with mortality in RCTs. Fixed-day SOFA was the most frequently reported outcome among the reviewed RCTs, but was not significantly associated with mortality. Based on this study, we recommend using Delta SOFA rather than Fixed-day SOFA as an endpoint in future RCTs.

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.

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.

Endotoxin Elimination in Patients with Septic Shock: An Observation Study.

To evaluate the effectiveness of endotoxin elimination with an adsorption column in patients with septic shock and endotoxemia. The elimination therapy was guided by a new bedside method of measuring endotoxin activity (EA). Intensive care unit (ICU) patients with septic shock and suspected Gram-negative infection were consecutively added to the study group within the first 24 h. Endotoxin elimination was performed using hemoperfusion with the Alteco LPS Adsorber. The primary endpoint was improvement in organ function within the first 24 h of treatment. A secondary objective was to assess the usefulness of a new method of measuring EA to help guide endotoxin elimination therapy. Out of 64 patients 18 had a high baseline EA [0.70 EA units (0.66–0.77)]. Those patients had endotoxin elimination treatment in addition to conventional medical therapy. At 24 h after endotoxin elimination, the EA had decreased to 0.56 EA units (0.43–0.77), (p = 0.005); MAP increased from 69 (62–80) to 80 mm Hg (68–88), (p = 0.002), and noradrenaline use decreased from 0.28 (0.15–0.80) to 0.1 μg/kg/min (0.00–0.70) at the same time (p = 0.04). The SOFA score had decreased from 11 (9–15) to 9 (7–14) points 24 h after endotoxin elimination (p = 0.01) with a median delta SOFA –2 points. Endotoxin elimination did not have a significant effect on the ICU length of stay or ICU mortality. Effective endotoxin elimination resulted in a significant improvement in hemodynamic parameters and of organ function. The application of the EA assay was useful for the bedside monitoring of endotoxemia in critically ill ICU patients.