Maximum Sequential Organ Failure Assessment Research Articles

SOFA score performs worse than age for predicting mortality in patients with COVID-19.

The use of the Sequential Organ Failure Assessment (SOFA) score, originally developed to describe disease morbidity, is commonly used to predict in-hospital mortality. During the COVID-19 pandemic, many protocols for crisis standards of care used the SOFA score to select patients to be deprioritized due to a low likelihood of survival. A prior study found that age outperformed the SOFA score for mortality prediction in patients with COVID-19, but was limited to a small cohort of intensive care unit (ICU) patients and did not address whether their findings were unique to patients with COVID-19. Moreover, it is not known how well these measures perform across races. In this retrospective study, we compare the performance of age and SOFA score in predicting in-hospital mortality across two cohorts: a cohort of 2,648 consecutive adult patients diagnosed with COVID-19 who were admitted to a large academic health system in the northeastern United States over a 4-month period in 2020 and a cohort of 75,601 patients admitted to one of 335 ICUs in the eICU database between 2014 and 2015. We used age and the maximum SOFA score as predictor variables in separate univariate logistic regression models for in-hospital mortality and calculated area under the receiver operator characteristic curves (AU-ROCs) and area under precision-recall curves (AU-PRCs) for each predictor in both cohorts. Among the COVID-19 cohort, age (AU-ROC 0.795, 95% CI 0.762, 0.828) had a significantly better discrimination than SOFA score (AU-ROC 0.679, 95% CI 0.638, 0.721) for mortality prediction. Conversely, age (AU-ROC 0.628 95% CI 0.608, 0.628) underperformed compared to SOFA score (AU-ROC 0.735, 95% CI 0.726, 0.745) in non-COVID-19 ICU patients in the eICU database. There was no difference between Black and White COVID-19 patients in performance of either age or SOFA Score. Our findings bring into question the utility of SOFA score-based resource allocation in COVID-19 crisis standards of care.

876 Neuron Specific Enolase and S-100 Protein in Sepsis Associated Encephalopathy (SAE)

INTRODUCTION: Severe sepsis and septic shock represent one of medicine's oldest and most pressing problems. Sepsis-associated encephalopathy (SAE) is associated with increased mortality and decreased quality of life. By the time a patient is septic, SAE is most often already established. Currently, no standardized laboratory markers of brain injury may aid in the diagnosis. However, S-100 protein and neuron-specific enolase (NSE) may be useful biomarkers. Neuronal injury leads to the cellular release of these biomarkers into the cerebrospinal fluid and then ultimately into the bloodstream. Rapid detection will allow for early diagnosis and intervention in the clinical setting. METHODS: A systematic review evaluating patients with severe sepsis and septic shock. In 170 patients, serum S-100 and NSE were measured daily for 4 consecutive days after intensive care unit admission. Admission Glasgow Coma Scale before sedation and daily Sequential Organ Failure Assessment (SOFA) scores were recorded in all patients. Each participant was continuously observed 72 hours after withdrawing sedation. RESULTS: S-100 was elevated in 72 patients (42%) and NSE increased in 90 patients (53%). Higher maximum SOFA scores were recorded in patients with elevated biomarkers (p = 0.001). Elevation of S-100 was associated with encephalopathy (p = 0.004). CONCLUSIONS: S-100 and NSE are frequently increased in patients with severe sepsis and septic shock. The higher the biomarkers, the worse the brain failure in patients. S-100 levels can be used as predictors of early ICU mortality and better reflect the development of severe encephalopathy and brain injury than NSE levels and the GCS scores.

Prognostic impacts of repeated sepsis in intensive care unit on autoimmune disease patients: a retrospective cohort study

BackgroundAutoimmune diseases (ADs) may be complicated by sepsis when intensive care unit (ICU) admission. But repeated sepsis among AD patients has not been studied yet. The aim of this study is to investigate the impact of repeated in-ICU sepsis on the 1-year overall-cause mortality, septic shock and in-ICU death of AD patients.MethodsData of AD patients with sepsis retrieved from Medical Information Mart for Intensive Care IV (MIMIC-IV) database were divided into the single group and the repeated group according to the frequency of in-ICU sepsis. Propensity score matching was used to balance inter-group bias. Cox proportional hazard regression and sensitivity analysis were utilized to assess the variables on mortality.ResultsThe incidence of repeated in-ICU sepsis in baseline was 19.8%. The repeated in-ICU sepsis was a risk factor for 1-year overall-cause mortality among AD patients (adjusted hazard ratio [HR] = 1.50, 95% CI: 1.16–1.93, P = 0.002), with robust adjusted HRs by the adjustment for confounders in the sensitivity analysis (all P < 0.01). Maximum Sequential Organ Failure Assessment (Max SOFA), Charlson comorbidity index (CCI) and Simplified Acute Physiology Score-II (SAPS-II) were risk factors for 1-year overall-cause mortality among AD with repeated sepsis (Max SOFA: HR = 1.09, P = 0.002; CCI: HR = 1.08, P = 0.039; SAPS-II: HR = 1.03, P < 0.001).ConclusionsCompared to single hit, repeated in-ICU sepsis was independently related to a higher risk of 1-year overall-cause mortality among AD patients. Assessment tools (Higher SOFA, CCI and SAPS-II scores) were closely linked to poor prognosis of AD with repeated sepsis and helped to reflect ill physical conditions for the patients.

The Value of the Sequential Organ Failure Assessment (SOFA) Score and Serum Lactate Level in Sepsis and Its Use in Predicting Mortality.

Background and objective Sepsis is a major health burden that leads to significant morbidity and mortality. Early diagnosis and severity prediction using various scoring systems can reduce themortality rate, particularly in developing nations. There are twoaims of this study. One is to evaluate the prognostic accuracy ofthe Sequential Organ Failure Assessment (SOFA) score and serum lactate levels in patients with sepsis to predict mortality. The other aim is to evaluate the relationship between the SOFA score and lactateso that we may be able to use lactate as a surrogate predictor of organ dysfunction and mortality in sepsis. Methods An observational prognostic accuracy study was conducted in the Department of General Surgery, Intensive Care Unit (ICU), Rajendra Institute of Medical Sciences (RIMS), Ranchi, Jharkhand, India, between 1July 2021 and 1October 2022. We selected 128 patients, calculated their SOFA and lactate levels, and divided them into survivors and non-survivors according to their outcomes after seven days of assessment. The SOFA score and serum lactate levels were assessed as predictors of mortality, and their correlation was studied. Results We observed a significant decreasing trend in the value of the mean SOFA, maximum SOFA, meanlactate, and maximum lactate among survivors, whereas an increasing trend for the same was observed in non-survivors. The receiver operating characteristic (ROC) analysis showed the best diagnostic accuracy of the mean lactate (area under the curve {AUC}=0.996, 95% confidence interval {CI}=0.964-1.00, p≤0.0001). The maximum lactate (AUC=0.987, 95% CI=0.949-0.999, p≤0.0001) and mean SOFA scores (AUC=0.986, 95% CI=0.948-0.999, p≤0.0001) were good at predicting the mortality in sepsis. A slightly lower diagnostic accuracy was found for the maximum SOFA score (AUC=0.969, 95% CI=0.923-0.992, p≤0.0001).There was a strong correlation between the mean lactate and the mean SOFA with a correlation coefficient of 0.883 and p=0.0001. A good correlation was found between maximum lactate and maximum SOFA too (correlation coefficient=0.873, p≤0.0001). Conclusion This study highlights the different predictors of mortality in the patients with sepsis. The maximum lactate was the most accurate in predicting mortality in sepsis. It also demonstrates how serum lactate, due to its strong correlation with the SOFA score, can be used in its place to predict mortality in sepsis and organ dysfunction.

The Effect of Ketamine Versus Etomidate for Rapid Sequence Intubation on Maximum Sequential Organ Failure Assessment Score: A Randomized Clinical Trial

BackgroundThe use of induction agents for rapid sequence intubation (RSI) has been associated with hypotension in critically ill patients. Choice of induction agent may be important and the most commonly used agents are etomidate and ketamine. ObjectiveThis study aimed to compare the effects of a single dose of ketamine vs. etomidate for RSI on maximum Sequential Organ Failure Assessment (SOFA) score and incidence of hypotension. MethodsThis single-center, randomized, parallel-group trial compared the use of ketamine and etomidate for RSI in critically ill adult patients in the emergency department. The study was performed under Exception from Informed Consent. The primary outcome was the maximum SOFA score within 3 days of hospitalization. ResultsA total of 143 patients were enrolled in the trial, 70 in the ketamine group and 73 in the etomidate group. Maximum median SOFA score for the ketamine group was 6.5 (interquartile range [IQR] 5–9) vs. 7 (IQR 5–9) for etomidate with no significant difference (–0.2; 95% CI –1.4 to 1.1; p = 0.79). The incidence of post-intubation hypotension was 28% in the ketamine group vs. 26% in the etomidate group (difference 2%; 95% CI –13% to 17%). There were no significant differences in intensive care unit outcomes. Thirty-day mortality rate for the ketamine group was 11% (8 deaths) and for the etomidate group was 21% (15 deaths), which was not statistically different. ConclusionsThere were no significant differences in maximum SOFA score or post-intubation hypotension between critically ill adults receiving ketamine vs. etomidate for RSI.

Mortality and Sequential Organ Failure Assessment Score in Patients With Suspected Sepsis: The Impact of Acute and Preexisting Organ Failures and Infection Likelihood.

The main objective in this study was to assess the relative importance of chronic and acute organ failures in mortality prediction in patients with suspected sepsis at hospital admission. We also evaluated how the presence of infection influenced the ability of SOFA to predict 30-day mortality. Single-center prospective cohort study including 1,313 adult patients with suspected sepsis in rapid response teams in the emergency department. The main outcome was 30-day mortality. We measured the maximum total SOFA score during admission (SOFATotal), whereas preexisting chronic organ failure SOFA (SOFAChronic) score was assessed by chart review, allowing calculation of the corresponding acute SOFA (SOFAAcute) score. Likelihood of infection was determined post hoc as "No infection" or "Infection." SOFAAcute and SOFAChronic were both associated with 30-day mortality, adjusted for age and sex (adjusted odds ratios [AORs], 1.3; 95% CI, 1.3-14 and 1.3; 1.2-1.7), respectively. Presence of infection was associated with lower 30-day mortality (AOR, 0.4; 95% CI, 0.2-0.6), even when corrected for SOFA. In "No infection" patients, SOFAAcute was not associated with mortality (AOR, 1.1; 95% CI, 1.0-1.2), and in this subgroup, neither SOFAAcute greater than or equal to 2 (relative risk [RR], 1.1; 95% CI, 0.6-1.8) nor SOFATotal greater than or equal to 2 (RR, 3.6; 95% CI, 0.9-14.1) was associated with higher mortality. Chronic and acute organ failures were equally associated with 30-day mortality in suspected sepsis. A substantial part of the total SOFA score was due to chronic organ failure, calling for caution when using total SOFA in defining sepsis and as an outcome in intervention studies. SOFA's mortality prediction ability was highly dependent on actual presence of infection.

Addition of HbA1c to SOFA score for predicting outcomes in diabetic patients with sepsis and septic shock

Sepsis is a common cause of admissions into intensive care units (ICU’s). SOFA (sequential organ failure assessment) score has been validated as a prognostic marker in sepsis and there’s a good correlation between SOFA scoring and mortality of patients. Diabetes is a well-known predisposing factor for sepsis and we studied whether addition of HbA1c to SOFA score was helpful in predicting outcomes in diabetic patients with sepsis and septic shock. H-SOFA max score (HbA1c score added to maximum SOFA measured on any day of hospital stay) was the best predictor for in-hospital mortality. The mean H-SOFA (Max) score in the died (in-hospital mortality) group was 12.21 (±2.78), and in the discharged group was 5.49 (±2.68). Next best predictor was H-SOFA score (HbA1c score added to SOFA score at admission), followed by SOFA score. All the scores had a positive correlation with length of ICU stay. HbA1c (indicator of glycemic control) was helpful in predicting mortality when combined with the SOFA score (but not by itself). These scores may therefore be helpful to physicians and intensivists for prognostication of the patient and during counselling of the relatives, including end of life discussions.

Early Combination of Albumin With Crystalloid Administration Might Reduce Mortality in Patients With Cardiogenic Shock: An Over 10-Year Intensive Care Survey.

BackgroundIn updated international guidelines, combined albumin resuscitation is recommended for septic shock patients who receive large volumes of crystalloids, but minimal data exist on albumin use and the optimal timing in those with cardiogenic shock (CS). The objective of this study was to evaluate the relationship between resuscitation with a combination of albumin within 24 h and 30-day mortality in CS patients.MethodsWe screened patients with CS from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. Multivariable Cox proportional hazards models and propensity score matching (PSM) were employed to explore associations between combined albumin resuscitation within 24 h and 30-day mortality in CS. Models adjusted for CS considered potential confounders. E-value analysis suggested for unmeasured confounding.ResultsWe categorized 1,332 and 254 patients into crystalloid-only and early albumin combination groups, respectively. Patients who received the albumin combination had decreased 30-day and 60-day mortality (21.7 vs. 32.4% and 25.2 vs. 34.2%, respectively, P < 0.001), and the results were robust after PSM (21.3 vs. 44.7% and 24.9 vs. 47.0%, respectively, P < 0.001) and following E-value. Stratified analysis showed that only ≥ 60 years old patients benefited from administration early albumin. In the early albumin combination group, the hazard ratios (HRs) of different adjusted covariates remained significant (HRs of 0.45–0.64, P < 0.05). Subgroup analysis showed that resuscitation with combination albumin was significantly associated with reduced 30-day mortality in patients with maximum sequential organ failure assessment score≥10, with acute myocardial infarction, without an Impella or intra-aortic balloon pump, and with or without furosemide and mechanical ventilation (HRs of 0.49, 0.58, 0.65, 0.40, 0.65 and 0.48, respectively; P < 0.001).ConclusionThis study found, compared with those given crystalloid-only, resuscitation with combination albumin within 24 h is associated with lower 30-day mortality of CS patients aged≥60. The results should be conducted to further assess in randomized controlled trials.

Sequential organ failure assessment score improves survival prediction for left ventricular assist device recipients in intensive care.

Preoperative risk scores facilitate patient selection, but postoperative risk scores may offer valuable information for predicting outcomes. We hypothesized that the postoperative Sequential Organ Failure Assessment (SOFA) score would predict mortality after left ventricular assist device (LVAD) implantation. We retrospectively reviewed data from 294 continuous-flow LVAD implantations performed at Mayo Clinic Rochester during 2007 to 2015. We calculated the EuroSCORE, HeartMate-II Risk Score, and RV Failure Risk Score from preoperative data and the APACHE III and Post Cardiac Surgery (POCAS) risk scores from postoperative data. Daily, maximum, and mean SOFA scores were calculated for the first 5 postoperative days. The area under receiver-operator characteristic curves (AUC) was calculated to compare the scoring systems' ability to predict 30-day, 90-day, and 1-year mortality. For the entire cohort, mortality was 5% at 30 days, 10% at 90 days, and 19% at 1 year. The Day 1 SOFA score had better discrimination for 30-day mortality (AUC 0.77) than the preoperative risk scores or the APACHE III and POCAS postoperative scores. The maximum SOFA score had the best discrimination for 30-day mortality (AUC 0.86), and the mean SOFA score had the best discrimination for 90-day mortality (AUC 0.82) and 1-year mortality (AUC 0.76). We observed that postoperative mean and maximum SOFA scores in LVAD recipients predict short-term and intermediate-term mortality better than preoperative risk scores do. However, because preoperative and postoperative risk scores each contribute unique information, they are best used in concert to predict outcomes after LVAD implantation.

ABO and RhD blood group are not associated with mortality and morbidity in critically ill patients; a multicentre observational study of 29 512 patients

BackgroundThe ABO and RhD blood group represent antigens on the surface of erythrocytes. The ABO blood group antigens are also present on multiple other cells. Interestingly, previous studies have demonstrated associations between the blood group and many types of disease. The present study aimed to identifying associations between the ABO blood group, the RhD blood group, and morbidity and mortality in a mixed cohort and in six pre-defined subgroups of critically ill patients.MethodsAdult patients admitted to any of the five intensive care units (ICUs) in the Scania Region, Sweden, between February 2007 and April 2021 were eligible for inclusion. The outcomes were mortality analysed at 28– and 90–days as well as at the end of observation and morbidity measured using days alive and free of (DAF) invasive ventilation (DAF ventilation) and DAF circulatory support, including vasopressors or inotropes (DAF circulation), maximum Sequential Organ Failure Assessment score (SOFAmax) the first 28 days after admission and length of stay. All outcomes were analysed in separate multivariable regression models adjusted for age and sex. In addition, in a sensitivity analysis, five subgroups of patients with the main diagnoses sepsis, septic shock, acute respiratory distress syndrome, cardiac arrest and trauma were analysed using the same separate multivariable regression models.ResultsIn total, 29,512 unique patients were included in the analyses. There were no significant differences for any of the outcomes between non-O blood groups and blood group O, or between RhD blood groups. In the sensitivity analysis of subgroups, there were no differences in mortality between non-O blood groups and blood group O or between the RhD blood groups. AB was the most common blood group in the COVID-19 cohort.ConclusionsThe ABO and RhD blood group do not influence mortality or morbidity in a general critically ill patient population.

Predictive value of serial evaluation of the Sequential Organ Failure Assessment (SOFA) score for intensive care unit mortality in critically ill patients with COVID-19: a retrospective cohort study.

The Sequential Organ Failure Assessment (SOFA) score has been developed to score the severity of organ dysfunction in critically ill sepsis patients and has been proven to have a high predictive value for intensive care unit (ICU) mortality in severely ill patients. Our goal was to evaluate the prognostic value of the SOFA score as well as trends in SOFA score for ICU mortality in COVID-19 patients. All consecutive patients with confirmed COVID-19 pneumonia admitted to the ICU between March 13th, 2020, and October 17th, 2020 were included in this retrospective cohort study. The worst SOFA score was evaluated daily. Multiple logistic regression models were used to evaluate the predictive value of SOFA in ICU mortality. 103 patients were included in this study. 30 patients (29%) died during their ICU stay and 73 (71%) patients were discharged alive. The ICU admission SOFA score was 5.2 ± 3.3 in ICU non-survivors vs. 4.3 ± 2.9 in ICU survivors (P = 0.15). The maximum SOFA score in ICU non-survivors was 11.7 ± 4.7 vs. 7.4 ± 4.3 in ICU survivors. SOFA scores increased the first week in both survivors and non-survivors, but the increase was less pronounced in survivors. In the multiple logistic regression models, neither admission SOFA score nor combination with delta SOFA in the first 48 hours was statistically significantly related to ICU mortality. Only the maximum SOFA score remained significant (OR = 1.23, 95% CI: 1.11-1.37, P < 0.001) in the multiple logistic models with an AUC of 0.91. Evaluation of SOFA scores in the first 48 hours after ICU admission is not a good prognostic indicator in COVID-19 patients. Only the maximum SOFA score was predictive for ICU mortality.

Predictive Value of Sequential Organ Failure Assessment Score across Patients with and without COVID-19 Infection

RationaleSequential organ failure assessment (SOFA) scores are commonly used in crisis standards of care policies to assist in resource allocation. The relative predictive value of SOFA by coronavirus disease (COVID-19) infection status and among racial and ethnic subgroups within patients infected with COVID-19 is unknown.ObjectivesTo evaluate the accuracy and calibration of SOFA in predicting hospital mortality by COVID-19 infection status and across racial and ethnic subgroups.MethodsWe performed a retrospective cohort study of adult admissions to the University of Miami Hospital and Clinics inpatient wards (July 1, 2020–April 1, 2021). We primarily considered maximum SOFA within 48 hours of hospitalization. We assessed accuracy using the area under the receiver operating characteristic curve (AUROC) and created calibration belts. Considered subgroups were defined by COVID-19 infection status (by severe acute respiratory syndrome coronavirus 2 polymerase chain reaction testing) and prevalent racial and ethnic minorities. Comparisons across subgroups were made with DeLong testing for discriminative accuracy and visualization of calibration belts.ResultsOur primary cohort consisted of 20,045 hospitalizations, of which 1,894 (9.5%) were COVID-19 positive. SOFA was similarly accurate for COVID-19–positive (AUROC, 0.835) and COVID-19–negative (AUROC, 0.810; P = 0.15) admissions but was slightly better calibrated in patients who were positive for COVID-19. For those with critical illness, maximum SOFA score accuracy at critical illness onset also did not differ by COVID-19 status (AUROC, COVID-19 positive vs. negative: intensive care unit admissions, 0.751 vs. 0.775; P = 0.46; mechanically ventilated, 0.713 vs. 0.792, P = 0.13), and calibration was again better for patients positive for COVID-19. Among patients with COVID-19, SOFA accuracy was similar between the non-Hispanic White population (AUROC, 0.894) and racial and ethnic minorities (Hispanic White population: AUROC, 0.824 [P vs. non-Hispanic White = 0.05]; non-Hispanic Black population: AUROC, 0.800 [P = 0.12]; Hispanic Black population: AUROC, 0.948 [P = 0.31]). This similar accuracy was also found for those without COVID-19 (non-Hispanic White population: AUROC, 0.829; Hispanic White population: AUROC, 0.811 [P = 0.37]; Hispanic Black population: AUROC, 0.828 [P = 0.97]; non-Hispanic Black population: AUROC, 0.867 [P = 0.46]). SOFA was well calibrated for all racial and ethnic groups with COVID-19 but estimated mortality more variably and performed less well across races and ethnicities without COVID-19.ConclusionsSOFA accuracy does not differ by COVID-19 status and is similar among racial and ethnic groups both with and without COVID-19. Calibration is better for COVID-19–infected patients and, among those without COVID-19, varies by race and ethnicity.

Discontinuation versus continuation of renin-angiotensin-system inhibitors in COVID-19 (ACEI-COVID): a prospective, parallel group, randomised, controlled, open-label trial

BackgroundSARS-CoV-2 entry in human cells depends on angiotensin-converting enzyme 2, which can be upregulated by inhibitors of the renin–angiotensin system (RAS). We aimed to test our hypothesis that discontinuation of chronic treatment with ACE-inhibitors (ACEIs) or angiotensin II receptor blockers (ARBs) mitigates the course o\\f recent-onset COVID-19.MethodsACEI-COVID was a parallel group, randomised, controlled, open-label trial done at 35 centres in Austria and Germany. Patients aged 18 years and older were enrolled if they presented with recent symptomatic SARS-CoV-2 infection and were chronically treated with ACEIs or ARBs. Patients were randomly assigned 1:1 to discontinuation or continuation of RAS inhibition for 30 days. Primary outcome was the maximum sequential organ failure assessment (SOFA) score within 30 days, where death was scored with the maximum achievable SOFA score. Secondary endpoints were area under the death-adjusted SOFA score (AUCSOFA), mean SOFA score, admission to the intensive care unit, mechanical ventilation, and death. Analyses were done on a modified intention-to-treat basis. This trial is registered with ClinicalTrials.gov, NCT04353596.FindingsBetween April 20, 2020, and Jan 20, 2021, 204 patients (median age 75 years [IQR 66–80], 37% females) were randomly assigned to discontinue (n=104) or continue (n=100) RAS inhibition. Within 30 days, eight (8%) of 104 died in the discontinuation group and 12 (12%) of 100 patients died in the continuation group (p=0·42). There was no significant difference in the primary endpoint between the discontinuation and continuation group (median [IQR] maximum SOFA score 0·00 (0·00–2·00) vs 1·00 (0·00–3·00); p=0·12). Discontinuation was associated with a significantly lower AUCSOFA (0·00 [0·00–9·25] vs 3·50 [0·00–23·50]; p=0·040), mean SOFA score (0·00 [0·00–0·31] vs 0·12 [0·00–0·78]; p=0·040), and 30-day SOFA score (0·00 [10–90th percentile, 0·00–1·20] vs 0·00 [0·00–24·00]; p=0·023). At 30 days, 11 (11%) in the discontinuation group and 23 (23%) in the continuation group had signs of organ dysfunction (SOFA score ≥1) or were dead (p=0·017). There were no significant differences for mechanical ventilation (10 (10%) vs 8 (8%), p=0·87) and admission to intensive care unit (20 [19%] vs 18 [18%], p=0·96) between the discontinuation and continuation group.InterpretationDiscontinuation of RAS-inhibition in COVID-19 had no significant effect on the maximum severity of COVID-19 but may lead to a faster and better recovery. The decision to continue or discontinue should be made on an individual basis, considering the risk profile, the indication for RAS inhibition, and the availability of alternative therapies and outpatient monitoring options.FundingAustrian Science Fund and German Center for Cardiovascular Research.

Edema in critically ill patients leads to overestimation of skeletal muscle mass measurements using computed tomography scans

ObjectivesChanges in muscle mass and quality are important targets for nutritional intervention in critical illness. Effects of such interventions may be assessed using sequential computed tomography (CT) scans. However, fluid and lipid infiltration potentially affects muscle area measurements. The aim of this study was to evaluate changes in muscle mass and quality in critical illness with special emphasis on the influence of edema on this assessment. MethodsChanges in skeletal muscle area index (SMI) and radiation attenuation (RA) at the level of vertebra L3 were analyzed using sequential CT scans of 77 patients with abdominal sepsis. Additionally, the relation between these changes and disease severity using the maximum Sequential Organ Failure Assessment (SOFA) score and change in edema were studied. ResultsSMI declined on average 0.35%/d (±1.22%; P = 0.013). However, SMI increased in 41.6% of the study population. Increasing edema formation was significantly associated with increased SMI and with a higher SOFA score. Muscle RA decreased during critical illness, but was not significantly associated with changes in SMI or changes in edema. ConclusionIn critically ill patients, edema affects skeletal muscle area measurements, which leads to an overestimation of skeletal muscle area. A higher SOFA score was associated with edema formation. Because both edema and fat infiltration may affect muscle RA, the separate effects of these on muscle quality are difficult to distinguish. When using abdominal CT scans to changes in muscle mass and quality in critically ill patients, researchers must be aware and careful with the interpretation of the results.

Sequential organ failure assessment score for predicting outcome of severely ill obstetric patients admitted to intensive care unit

Background and Aim: Severe maternal illness is a life-threatening condition for pregnant women and often requires admission into the ICU. The aim was to evaluate the performance of maximum sequential organ failure assessment (SOFA) score to predict the outcome of patients admitted to ICU. Material and Methods: This prospective study was done on 121 consecutive women with severe obstetric illness admitted to the ICU during one year. Basic demographic, obstetrical data, indication of admission to ICU and interventions done were noted. SOFA score was evaluated according to the worst score for each of its six components every 24 hr till discharge or death in ICU. The receiver-operator characteristic (ROC) curve was constructed to predict the outcome of ICU. For analysis, patients were categorized as survivors and non-survivors. Results: Out of 121 patients admitted, 65 survived and 56 died with mortality rate of 45.9%. There were no differences among survivor and non-survivor patients regarding demographic data, obstetrical data and interventions done, but anaemia and inadequate ante natal care was more common in non survivors. ICU utilisation rate of obstetric patients was 1.9%. Most patients were admitted due to obstetric causes (87.6%), mainly for hypertensive disorders (46%) and were post caesarean (84.29%). Total maximum SOFA scores were higher in non-survivors than in survivors (14.09 ± 5.53 vs 7.47 ± 4.58, P

Влияние цитофлавина на эффективность интенсивной терапии новорожденных с некротизирующим энтероколитом

Postoperative treatment of necrotizing enterocolitis (NEC) in newborns is a challenging problem in pediatric surgery due to high mortality rate among these patients. It is extremely important to search for novel treatments that will not only reduce the death rate, but also improve patients' quality of life. Objective. To improve the outcomes of newborns with NEC in the early postoperative period using cytoflavin, a metabolic antihypoxant/antioxidant. Patients and methods. This study included 77 newborns with NEC operated on in the Department of Neonatal Surgery between 2018 and 2021. All study participants were divided into two groups according to their treatment in the postoperative period. Group 1 (experimental) included 41 NEC patients (53.2%), whereas group 2 (control) included 36 NEC patients (46.8%). The sequential organ failure assessment (SOFA) scale adjusted for neonates was used to evaluate patients' condition. Results. Participants from the experimental group stayed in the intensive care unit for 7.46 ± 1.8 days on average. The maximum SOFA score was 12 and lasted for 3 days in 14 infants (34.1%). Twenty-eight patients had lung ventilation for a mean time of 36.3 ± 4.9 h. Newborns from the control group stayed in the intensive care unit for 10.7 ± 1.2 days on average. Seventeen patients (47.2%) had the maximum SOFA score of 12 for 3 days. The mean duration of lung ventilation was 58.7 ± 4.8 h. Recovery of intestinal transit by 72 h postoperatively was observed in 8 patients from Group 1 and 2 patients from Group 2 (the difference was significant p &lt; 0.05). Conclusion. Hypoxic intestinal damage plays a significant role in NEC development; therefore, metabolic therapy in newborns with NEC ensures a rapid positive effect and faster improvement. Early administration of metabolic therapy with cytoflavin in newborns with NEC reduces the incidence and severity of complications and prevents the progression of multiple organ failure. Key words: necrotizing enterocolitis, postoperative period, cytoflavin

Early intra-aortic balloon pump in acute decompensated heart failure complicated by cardiogenic shock: Rationale and design of the randomized Altshock-2 trial

Cardiogenic shock (CS) is a systemic disorder associated with dismal short-term prognosis. Given its time-dependent nature, mechanical circulatory support may improve survival. Intra-aortic balloon pump (IABP) had gained widespread use because of the easiness to implant and the low rate of complications; however, a randomized trial failed to demonstrate benefit on mortality in the setting of acute myocardial infarction. Acute decompensated heart failure with cardiogenic shock (ADHF-CS) represents a growing resource-intensive scenario with scant data and indications on the best management. However, a few data suggest a potential benefit of IABP in this setting. We present the design of a study aimed at addressing this research gap. The Altshock-2 trial is a prospective, randomized, multicenter, open-label study with blinded adjudicated evaluation of outcomes. Patients with ADHF-CS will be randomized to early IABP implantation or to vasoactive treatments. The primary end point will be 60 days patients' survival or successful bridge to heart replacement therapy. The key secondary end point will be 60-day overall survival; 60-day need for renal replacement therapy; in-hospital maximum inotropic score, maximum duration of inotropic/vasopressor therapy, and maximum sequential organ failure assessment score. Safety end points will be in-hospital occurrence of bleeding events (Bleeding Academic Research Consortium >3), vascular access complications and systemic (noncerebral) embolism. The sample size for the study is 200 patients. The Altshock-2 trial will provide evidence on whether IABP should be implanted early in ADHF-CS patients to improve their clinical outcomes.

Abstract 331: Trajectories of Sequential Organ Failure Assessment (sofa) Scores After Cardiac Arrest

Cardiac arrest (CA) often results in multi-system organ failure (MSOF). The Sequential Organ Failure Assessment (SOFA) Score is a tool based on the assessment of 6 physiological systems and can quantify severity of MSOF. Understanding the epidemiology, temporal dynamics and anticipated course of MSOF after CA is critical to both clinical care and prognostication. We included patients treated at a single center after CA from 2010-2019, regardless of arrest location or etiology. We electronically extracted all medication, laboratory, ventilator, intake and output data. We calculated SOFA scores daily for up to five days (or until death or discharge). We used group-based trajectory modeling (GBTM, also known as growth curve mixture modeling) to identify groups of patients with distinct trajectories of SOFA over time. We started by fitting trajectories with third order polynomials then sequentially eliminated higher order terms with non-significant coefficients. We used AIC and BIC to determine the number of groups. We included 2,740 patients, of whom most (1,633; 59%) were male, with mean (SD) age of 59 (16) years. Most arrests (2,106; 76%) occurred out-of-hospital and 837 (30%) had a shockable initial rhythm. Overall survival to discharge was 38%. Bilirubin was infrequently checked in this cohort, so we excluded the liver subscale of SOFA from total SOFA calculation making maximum SOFA 20. Mean presenting SOFA was 6 (3), and mean SOFA on day 2 was 6 (4). We identified 5 groups of patients with unique trajectories of SOFA over time. Baseline demographics and survival differed across trajectory groups. Despite showing delayed MOSF onset with rapidly rising SOFA from baseline to day 2, 26% of Group 4 still survived to discharge, while Group 3, which had an initially severe but rapidly improving MSOF had a 32% survival rate. Unique patterns of MSOF after CA can be identified using GBTM. Delayed onset of severe MSOF is less prognostically ominous than commonly believed by clinicians.

Anion Gap Was Associated with Inhospital Mortality and Adverse Clinical Outcomes of Coronary Care Unit Patients.

Background Anion gap (AG) has been proved to be associated with prognosis of many cardiovascular diseases. This study is aimed at exploring the association of AG with inhospital all-cause mortality and adverse clinical outcomes in coronary care unit (CCU) patients. Method All data of this study was extracted from Medical Information Mart for Intensive Care III (MIMIC-III, version 1.4) database. All patients were divided into four groups according to AG quartiles. Primary outcome was inhospital all-cause mortality. Lowess smoothing curve was drawn to describe the overall trend of inhospital mortality. Binary logistic regression analysis was performed to determine the independent effect of AG on inhospital mortality. Result A total of 3593 patients were enrolled in this study. In unadjusted model, as AG quartiles increased, inhospital mortality increased significantly, OR increased stepwise from quartile 2 (OR, 95% CI: 1.01, 0.74-1.38, P = 0.958) to quartile 4 (OR, 95% CI: 2.72, 2.08-3.55, P < 0.001). After adjusting for possible confounding variables, this association was attenuated, but still remained statistically significant (quartile 1 vs. quartile 4: OR, 95% CI: 1.02, 0.72-1.45 vs. 1.49, 1.07-2.09, P = 0.019). Moreover, CCU mortality (P < 0.001) and rate of acute kidney injury (P < 0.001) were proved to be higher in the highest AG quartiles. Length of CCU (P < 0.001) and hospital stay (P < 0.001) prolonged significantly in higher AG quartiles. Maximum sequential organ failure assessment score (SOFA) (P < 0.001) and simplified acute physiology score II (SAPSII) (P < 0.001) increased significantly as AG quartiles increased. Moderate predictive ability of AG on inhospital (AUC: 0.6291), CCU mortality (AUC: 0.6355), and acute kidney injury (AUC: 0.6096) was confirmed. The interactions were proved to be significant in hypercholesterolemia, congestive heart failure, chronic lung disease, respiratory failure, oral anticoagulants, Beta-blocks, angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB), and vasopressin treatment subgroups. Conclusion AG was an independent risk factor of inhospital all-cause mortality and was associated with adverse clinical outcomes in CCU patients.

Predictive value of the sequential organ failure assessment (SOFA) score for prognosis in patients with severe acute ischemic stroke: a retrospective study.

ObjectiveTo identify the risk factors for early death and determine the predictive value of the sequential organ failure assessment (SOFA) score for prognosis of severe acute ischemic stroke (AIS).MethodsA total of 110 patients with severe AIS were enrolled and divided into the non-survivor (n = 34) and survivor groups (n = 76). Logistic regression analysis was conducted to identify risk factors for early death, while the receiver operator characteristic (ROC) curve was used to determine the predictive effect of the SOFA score on prognosis.ResultsLogistic regression analysis showed that urinary tract infection (odds ratio [OR] = 17.364, 95% confidence interval [CI]: 1.903–158.427), mechanical ventilation (OR = 1.754, 95% CI: 1.648–2.219), and osmotic therapy (OR = 2.835, 95% CI: 1.871–5.102) were significantly correlated with early death of severe AIS. ROC curve analysis of the area under the curve after hospitalization showed that the maximum SOFA and ΔSOFA scores exceeded 0.7.ConclusionOur study shows that urinary tract infection, mechanical ventilation, and osmotic therapy are risk factors for early death of severe AIS. The SOFA score has good predictive value for prognosis of severe AIS. These findings may provide a guideline for improving clinical outcome.