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Objectives: Organ failure worsens outcome in sepsis. The relationship between SOFA (change in SOFA from T0 to T72)
Sequential Organ Failure Assessment (SOFA) score numerically was examined for linearity.
quanties the number and severity of failed organs. We examined Results: A total of 248 subjects aged 57 16 years, 48% men,
the utility of the SOFA score for assessing outcome of patients were enrolled over 2 years. All patients were treated with a
with severe sepsis with evidence of hypoperfusion at the time of standardized quantitative resuscitation protocol; the in-hospital
emergency department (ED) presentation. mortality rate was 21%. The mean SOFA score at T0 was 7.1 3.6
Design: Prospective observational study. points and at T72 was 7.4 4.9 points. The area under the
Setting: Urban, tertiary ED with an annual census of >110,000. receiver operating characteristic curve of SOFA for predicting
Patients: ED patients with severe sepsis with evidence of in-hospital mortality at T0 was 0.75 (95% condence interval
hypoperfusion. Inclusion criteria: suspected infection, two or 0.68 0.83) and at T72 was 0.84 (95% condence interval 0.77
more criteria of systemic inammation, and either systolic blood 0.90). The SOFA was found to have a positive relationship with
pressure <90 mm Hg after a uid bolus or lactate >4 mmol/L. in-hospital mortality.
Exclusion criteria: age <18 years or need for immediate surgery. Conclusions: The SOFA score provides potentially valuable
Interventions: SOFA scores were calculated at ED recognition prognostic information on in-hospital survival when applied to
(T0) and 72 hours after intensive care unit admission (T72). The patients with severe sepsis with evidence of hypoperfusion at the
primary outcome was in-hospital mortality. The area under the time of ED presentation. (Crit Care Med 2009; 37:1649 1654)
receiver operating characteristic curve was used to evaluate KEY WORDS: sepsis; severe sepsis; scoring system; Sequential
the predictive ability of SOFA scores at each time point. The Organ Failure Assessment; mortality
R ecent estimates indicate that hospitalizations originate in the emer- with suspected infection (13). Although
the rate of severe sepsis hos- gency department (ED), underscoring the Mortality in Emergency Department
pitalizations doubled during the importance of developing and evalu- Sepsis rule has performed reasonably well
the past decade, and the age- ating accurate and reliable methods for in the general population of ED patients
adjusted population-based mortality is in- assessing illness severity and prognosis to with suspected infection (14), it has been
creasing, resulting in at least 215,000 allow for proper allocation of limited hos- reported to be less accurate in patients
deaths in the United States yearly (1, 2). pital resources (35) and inclusion in who are more severely ill, where predic-
It is estimated that one half of sepsis early interventions (6, 7). tion is perhaps more important (15). Ac-
There are several outcome prediction cordingly, the validation of a simple scor-
models that are currently available for ing system that would remain accurate
*See also p. 1807. use in clinical practice. Among them are when applied to patients with severe sep-
From the Department of Emergency Medicine
(AEJ, JAK), Carolinas Medical Center, Charlotte, NC; the Acute Physiology and Chronic Health sis at the time of ED presentation is of
Division of Critical Care Medicine (ST), Department of Evaluation IV Score (8), the Simplied high priority for both bedside clinical
Emergency Medicine, UMDNJ-Robert Wood Johnson Acute Physiology Score III (9), the Logis- care and clinical research trials.
Medical School at Camden, Cooper University Hospital, tic Organ Dysfunction Score (10), and the Previous investigators have identied
Camden, NJ.
Supported, in part, by grant K23GM076652-01A1, Mortality Probability Model III (11), a link between the number of dysfunc-
from the National Institute of General Medical Scienc- which were derived and validated on large tional organs and both short-term and
es/National Institutes of Health to Dr. Jones and groups of intensive care unit (ICU) pa- long-term mortality among ED patients
K23GM083211 to Dr. Trzeciak. Dr. Jones has received tients and require historical data or data with infection (16). The Sequential Organ
a grant from Critical Biologics Corporation. Dr. Kline
has stock ownership in CP Diagnostics. Dr. Kline has after ICU admission for calculation. Pre- Failure Assessment (SOFA) score is a
received patents from US Patent # 7,083,574. Dr. vious investigations have shown that simple and objective score that allows for
Trzeciak has received grant support from Novo Nor- most of these scores possess inadequate calculation of both the number and the
disk, Eli Lilly, Biosite. predictive abilities when adapted to ED severity of organ dysfunction in six organ
For information regarding this article, E-mail:
alan.jones@carolinas.org populations (12). The one ED-based scor- systems (respiratory, coagulatory, liver,
Copyright 2009 by the Society of Critical Care ing system, the Mortality in Emergency cardiovascular, renal, and neurologic)
Medicine and Lippincott Williams & Wilkins Department Sepsis score, was derived and (Table 1), and the score can measure in-
DOI: 10.1097/CCM.0b013e31819def97 validated on large groups of ED patients dividual or aggregate organ dysfunction
7/31; 23%
positive relationship to in-hospital mor-
25 tality. These data suggest that use of the
SOFA score is an acceptable method for
11/57; 19% risk stratication and prognosis of ED
20
patients with severe sepsis with evidence
of hypoperfusion and that the SOFA
15 score may be a useful measurement to
6/53; 11%
5/54; 9%
follow in clinical and research settings.
10
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0
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Delta SOFA
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Figure 3. The relationship between delta Sequential Organ Failure Assessment ( SOFA) score and al: Epidemiology of severe sepsis in the
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come, and associated costs of care. Crit Care
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This report has several limitations to plied prospectively, they might have per-
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be considered. First, we made an adapta- formed with different accuracy because of Critical care in the emergency department: A
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