Jebmh.

com Original Research Article

SOFA OR APACHE II, WHICH DESERVES MORE ATTENTION IN SEPSIS PATIENTS IN ICU?
AN EXPERIENCE FROM A TERTIARY CARE HOSPITAL IN NORTH EAST INDIA
Deepak Chaudhury1, Subhankar Paul2, Chandraprakash3, Ilias ali4

1AssistantProfessor, Department of Emergency Medicine, Gauhati Medical College and Hospital, Assam.
2Postgraduate Trainee, Department of Emergency Medicine, Gauhati Medical College and Hospital, Assam.
3Former Postgraduate Trainee, Department of Emergency Medicine, Gauhati Medical College and Hospital, Assam.
4Professor and HOD, Department of Emergency Medicine, Gauhati Medical College and Hospital, Assam.

ABSTRACT
BACKGROUND
There are several well recognised scoring systems for evaluation and prognostication of critically ill patients. While APACHE II
(Acute Physiology and Chronic Health Evaluation II) scoring system uses a point score based on physiologic parameters, age
and previous health status, the SOFA (Sequential Organ Failure Assessment) scoring system takes into account the organ
failure in critically ill patients. In the assessment of critically ill patients with suspected multiorgan dysfunction admitted in
ICU, the role of SOFA in predictive validity for in-hospital mortality is being widely discussed.

MATERIALS AND METHODS

This was a prospective study undertaken in emergency ICU of a government tertiary care hospital in North East India over a
period of one year to prognosticate the patients by using two different established scoring systems, e.g. SOFA and APACHE II.

RESULTS
The results showed that serial measurement of SOFA score during first week is a very useful tool in predicting the outcome
especially on the day 3. The APACHE II score on day of admission, though reliable, was not very effective in predicting the
mortality rate in our setup.

CONCLUSION
Serial measurement of SOFA score during first week is very useful tool in predicting the outcome of sepsis patients in ICU and
better than admission APACHE II scoring in predicting mortality.

KEYWORDS
Sepsis, MODS, SOFA, APACHE II.
HOW TO CITE THIS ARTICLE: Chaudhury D, Paul S, Chandraprakash, et al. SOFA or APACHE II, which deserves more
attention in sepsis patients in ICU? An experience from a tertiary care hospital in north east India. J. Evid. Based Med.
Healthc. 2017; 4(29), 1700-1704. DOI: 10.18410/jebmh/2017/332

BACKGROUND familiar among them are Sequential Organ Failure

Sepsis is life-threatening organ dysfunction caused by a
dysregulated host response to infection.1 Sepsis and septic
shock are major healthcare problems affecting millions of
people around the world each year is a common cause of
Intensive Care Unit (ICU) mortality and morbidity.2
Multiorgan dysfunction syndrome is well established as
the final stage of the continuum. Due to the high mortality
associated with sepsis and its complications, it is necessary
to rapidly diagnose and treat the underlying cause.3
Scoring systems for use in the Intensive Care Unit
(ICU) have been developed from the past 30 years. They
are widely used in the field of critical care medicine.4 Most
Financial or Other, Competing Interest: None.
Submission 04-03-2017, Peer Review 17-03-2017,
Acceptance 02-04-2017, Published 08-04-2017.
Corresponding Author:
Dr. Deepak Chaudhury,
House No. 3, Panjabari, Lakhimipathi,
PO: Khanapara-781037, Guwahati, Assam.
E-mail: deepak9891chaudhury@gmail.com
DOI: 10.18410/jebmh/2017/332
Assessment (SOFA) score;5 Acute Physiology and Chronic
Health Evaluation II (APACHE II);6 Simplified Acute
Physiology Score II (SAPS II);7and Multiple Organ
Dysfunction Score (MODS).8They allow a quantification of
the severity of illness and a probability of in-hospital
mortality.4 A well-performing ICU prognostic model helps to
make meaningful comparison of the hospitals current
performance with the past.9 This allows the hospital to
identify the weakness and initiate interventions aimed at
quality improvement and allow patients to choose
healthcare providers based on performance. The use of
these prognostic models help in providing meaningful
information to physicians when discussing patient
prognosis with the patients relatives.4,9 Since the results of
laboratory tests like culture and serology are available only
after 24 to 48 hours using scores like APACHE II and SOFA
may help in predicting outcome in the crucial initial hours
of management. Our study focussed on Acute Physiology
and Chronic Health Evaluation II (APACHE II) and
Sequential Organ Failure Assessment (SOFA) scoring n
critically-ill sepsis patients starting from the day of

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admission into ICU as they are the most commonly used
scoring system in our setup.
The Acute Physiology and Chronic Health Evaluation
(APACHE) score is probably the best-known and most
widely used score. The original APACHE I score was first
used in 1981 and scores for three patient factors that
influence acute illness outcome (pre-existing disease,
patient reserve and severity of acute illness). These
included 34 individual variables, a chronic health evaluation
and the two combined to produce the severity score.10
Knaus et al developed the next generation of APACHE
scoring system- APACHE II. The APACHE II is measured
during the first 24 hrs. of ICU admission; the maximum
score is 71. A score of 25 predicts mortality of 50% and a
score more than 35 represents a predicted mortality of
80%.The APACHE II severity score has shown a good
calibration and discriminatory value across a range of
disease processes and remains the most commonly used
international severity scoring system worldwide.11,12
The sepsis-related organ failure assessment score was
developed to evaluate organ dysfunction in patients with
sepsis. Later, it was renamed as Sequential Organ Failure
Assessment (SOFA) score because its utility was not
restricted merely to patients with sepsis.13 The SOFA
system was created in a consensus meeting of the
European Society of Intensive Care Medicine in 1994 and
further revised in 1996. The SOFA is an organ-dysfunction
score measuring multiple organ failures daily. Each organ is
graded from 0 to 4 providing a daily score of 0 to 24
points. Serial assessment of organ dysfunction during the
initial few days of admission in ICU is a good prognostic
indicator. 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%.14,15
SOFA scoring system is better than APACHE II system
in predicting mortality in ICU surgical patients. Serial
measurements of SOFA significantly improve their
predictive accuracy.16
Vital organ dysfunctions developing after the onset of
sepsis influence outcome markedly. Studies have shown
the APACHE II score at the onset of sepsis or the SOFA
score and the number of organ dysfunctions developing
thereafter are independent prognostic factors for patients
with sepsis.15,17
The objectives of our study were to assess mortality
and morbidity of patients with sepsis in ICU and to
prognosticate the patients by using SOFA and APACHE II
scores as well as comparison between these two scoring
system in predicting mortality.
MATERIALS AND METHODS
This was a prospective observational study undertaken in
the Emergency ICU in the Department of Emergency
Medicine of Gauhati Medical College and Hospital,
Guwahati, a tertiary care Government Institution in North
East India over a period of one year from August 2014 to
July 2015 after obtaining approval from Institutional Ethical
J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 4/Issue 29/April 10, 2017
Original Research Article
Committee. In our study, sepsis was diagnosed as criteria
laid by the American College of Chest Physicians/Society of
Critical Care Medicine (ACCP/SCCM) Consensus Committee
in 1992.18
Sepsis patients above 18years of age were included in
the study. Patients primarily suffering from pancreatitis,
pulmonary embolism, cardiac tamponade, drug overdose,
anaphylaxis, adrenal insufficiency, burns, tumour-
associated lactic acidosis, patients with pregnancy and
patients on treatment with immunosuppressive agents
were excluded from the study. The detailed history, clinical
examination and all the relevant laboratory investigations
were done. All the patients of sepsis included in the study
were prognosticated on the basis of APACHE II and SOFA
scores. APACHE II was calculated on day of admission to
predict mortality and to assess the extent of multiorgan
dysfunction. SOFA scoring was done daily from day 1 to
the last day.
Statistical Methods
Descriptive and inferential statistical analysis has been
carried out in the present study. Results on continuous
measurements are presented on MeanSD (Min-Max) and
results on categorical measurements are presented in
Number (%). Significance was assessed at 5% level of
significance. Students t-test (two-tailed, independent) has
been used to find the significance of study parameters on
continuous scale between two groups on metric
parameters. Chi-square/Fisher exact test has been used to
find the significance of study parameters on categorical
scale between two or more groups. Receiver Operating
Characteristic (ROC) curves were plotted to define
discriminative value of scores as a prognosis of mortality.
An Area under ROC (AuROC) of 1 means a perfect
discrimination while 0.5 is a random chance. A model is
considered acceptable if the AuROC is 0.7 and is
considered excellent if the AuROC is 0.9. All data were
analysed with SPSS 16.0 Microsoft word 10.0 and excel
have been used to generate graphs and tables.
RESULTS AND OBSERVATIONS
After applying the inclusion and exclusion criteria, 50
patients diagnosed with sepsis were finally studied, out of
which 28 were males (56%) and 22 were females (44%).
Age of patients varied from 18 years to 90 years with mean
48.36 years (SD17.16). 18 patients (36%) died and 32
patients (64%) survived in our study (Figure 1).
For all patients, APACHE II scoring was done on day of
admission (Table 1). Mean APACHE II score was high
among non-survivors (23.289.65) than survivors
(18.757.34). However, p-value was 0.068, rendering this
difference in APACHE II scoring between survivor and non-
survivor groups statistically non-significant (Figure 2).
The SOFA score was done daily on and from day 1 of
ICU admission. It was observed that day 1 mean SOFA
score was significantly high (p=0.014) among non-
survivors (10.173.45) than survivors (7.942.64).
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However, most significant difference was observed from
day 3 onwards as shown in (Table No.2, Figure 3).
We plotted ROC curves to define discriminative value of
APACHE II and maximum SOFA scores (max SOFA) as a
prognosis of mortality (Figure 4). Area under ROC (AuROC)
of APACHE II was 0.643 while that of max SOFA score was
0.878, which demonstrated that max SOFA score had more
discriminating value than APACHE score II in predicting
mortality of sepsis patients in our study.

Apache II Non-Survived Survived

<10 2(11.1%) 4(12.5%) Figure 3. Showing Comparison of Serial SOFA Scores
10-20 5(27.8%) 16(50.0%) in Survivors vs. Non-Survivor Sepsis Patients
20-30 8(44.4%) 10(31.3%)
>30 3(16.7%) 2(6.3%)
Total 18(100.0%) 32(100.0%)
MeanSD 23.28 9.65 18.75 7.34
Table 1. Comparison of APACHE II Score
in Survivors and Non-Survivors

SOFA Score Non-Survived Survived p value

Day 1 10.17 3.45 7.94 2.64 0.014*
Day 2 11.63 4.33 8.28 2.62 0.002**
Day 3 13.42 4.06 6.84 2.96 <0.001**
Day 4 10.78 3.77 5.94 3.41 0.001**
Day 5 12.25 4.8 4.55 3.27 <0.001**
Day 6 12.29 6.1 3.39 2.77 <0.001**
Day 7 14.2 3.9 2.82 2.61 <0.001**
Day 8 13 3.39 2.45 2.5 <0.001**
Day 9 13.8 4.09 1.81 1.72 <0.001**
Day 10/last day 13.5 5.69 1.33 1.23 <0.001**
Table 2. Comparison of Serial SOFA
Scores in Survivors and Non-Survivors

Figure 4. ROC Curve of APACHE II and Max

Sofa Score for Predicting Mortality in Sepsis
Patients with their Respective AuROC

Figure 1. Pie Diagram Showing Frequency
Distribution of Survivors and Non-Survivors
Figure 2. Showing Comparison of APACHE II Scores
in Survivors vs. Non-Survivor Sepsis Patients
DISCUSSION
Sepsis is the main cause of mortality from infection,
especially if not recognised early and treated aggressively.
Its recognition thereby mandates urgent attention. The
mortality recorded in our study was 36%. In large clinical
trials, the mortality associated with severe sepsis and
septic shock ranges between 13% and 50%.19There is lack
of statistical data concerning incidence of sepsis in India.
The incidence and mortality rates are considered higher
than in the West. In a multicentre, prospective,
observational study conducted in four Intensive Therapy
Units (ITUs) in India from June 2006 to June 2009 where a
total of 5,478 ITU admissions were studied. Systemic
Inflammatory Response Syndrome (SIRS) with organ
dysfunction was found in 25% of patients of which 52.77%
were due to sepsis. The incidence of severe sepsis was
16.45% of all admissions. ITU mortality of all admissions
was 12.08% and that of severe sepsis was 59.26%.20

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The SOFA or APACHE scores are not intended to be
used as a tool for patient management, but as means to
clinically characterise a septic patient and prognosticate
early. Because, even patients presenting with modest
dysfunction can deteriorate further very rapidly
emphasising the seriousness of this condition and the need
for prompt and appropriate intervention, if not already
being instituted. Several components of SOFA assessing
systemic dysfunction require laboratory testing and thus
may not be promptly available. Other elements, such as
the cardiovascular score, can be affected by iatrogenic
interventions. APACHE II score also has the disadvantage
of complicated evaluations.9 However, APACHE II and
SOFA scorings have widespread popularity within the
critical care community and have a well-validated
relationship with mortality in critically ill patients in various
studies.4,9,14,21
Many studies have shown that high APACHE II score at
the time of admission was associated with high mortality.4,6
Merwe et al22 has validated the use of the APACHE II
model to accurately describe the risk of ICU death of the
patient population in a tertiary ICU in a developing country.
Arabiet al23 also had shown significantly high APACHE II
scores in non-survivors. In our study, though it was
statistically not-significant (p=0.068), mean APACHE II
score on day 1 definitely high among non-survivors than
survivors (23.28 v/s 18.75).
SOFA score has been validated extensively for
prognostification in critically ill patients. Results of daily
SOFA scoring in our study are in accordance with other
similar studies around the world. Vosylius et al24 in their
study on 117 ICU patients with sepsis showed that the
changes in the severity of organ dysfunction were closely
related to the outcome of the patients admitted to ICU,
where SOFA score on day 1 and day 3 was significantly
higher in non-survivors than those in survivors. They have
also showed that the trend of the mean SOFA score for the
first seven days of ICU stay showed a progressive decrease
in the total number of patients and the significant
difference of SOFA scores between survivors and non-
survivors in each day over the first week in the ICU, which
was also evident in our study. Vincent et al25 in their
multicentric study spreading over 16 countries showed that
the total SOFA score increased in 44% of the non-
survivors, but in only 20% of the survivors who stayed in
ICU for at least 1week.Fereria et al found initial SOFA score
up to 9 predicted mortality of less than 33% while an initial
SOFA score of greater than 11 predicted a mortality rate of
95%. However, in a recent study by Georgescu et al26 had
shown that for the APACHE II and SOFA scores the
differences when deceased and survivors were compared
were not statistically significant (APACHE II- 26.766.742
vs. 23.188.175 respectively for SOFA- 8.0293.099 vs.
7.1363.342).
Furthermore, in our study, we plotted ROC curves to
define discriminative value of scores as a prognosis of
mortality. Value of AuROC more than 0.7 shows good
discriminating value.
J. Evid. Based Med. Healthc., pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 4/Issue 29/April 10, 2017
Original Research Article
Ferreira et al observed that AuROC was largest for
Highest SOFA scores (0.90; SE, 0.02) than other SOFA
derived variables including mean SOFA score (0.88, SE
0.03) and was significantly larger than initial SOFA scores
(P<0.001). Hence, in our study, we plotted ROC curves for
APACHE II against maximum SOFA score (max SOFA) for
predicting outcome.
AuROC of APACHE II was 0.643 while that of max SOFA
score was 0.878, which demonstrated that max SOFA score
had more discriminating value than APACHE score II in
predicting mortality of sepsis patients.
The areas under ROC were found to be 0.622 and
0s.705 for APACHE II and SOFA respectively for predicting
mortality in patients with septic shock in a prospective
study by Georgescu et al,26 which is quite similar with our
results.
However, contrary to our findings, a study by Ho KM et
al for determining hospital mortality, APACHE II score
27
showed a better calibration and discrimination (AuROC
0.858) than max SOFA (AuROC 0.829) and admission SOFA
(AuROC 0.791). Another study by Hwang et al28 among
ICU patients showed that the area under the curve for the
SOFA score was not different from APACHE II scoring
system in predicting the outcomes. However, it is
acknowledged that method for calculating SOFA scores is
easier and simpler than APACHE II.
CONCLUSION
Serial measurement of SOFA score during first week is very
useful tool in predicting the outcome of sepsis patients in
ICU. However, the APACHE II score on day of admission,
was not very effective in predicting the mortality rate in our
study, though it was found reliable in various other studies.
The trend of SOFA score was progressively declining in
survivors while non-survivors had stable higher score
during the first week and thereafter. The SOFA score on
day 3 was better compared with SOFA score on day 1 as
the tool for outcome prediction.
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