Sequential Organ Failure Assessment Score As a Predictor of Outcome in Sepsis in Pediatric Intensive Care Unit

Abstract

Sequential organ failure assessment (SOFA) score is used as a predictor of outcome of sepsis in the pediatric intensive care unit. The aim of the study is to determine the application of SOFA scores as a predictor of outcome in children admitted to the pediatric intensive care unit with a diagnosis of sepsis. The design involved is prospective observational study. The study took place at the multidisciplinary pediatric intensive care unit (PICU), tertiary care hospital, South India. The patients included are children, aged 1 month to 18 years admitted with a diagnosis of sepsis (suspected/proven) to a single center PICU in India from November 2017 to November 2019. Data collected included the demographic, clinical, laboratory, and outcome-related variables. Severity of illness scores was calculated to include SOFA score day 1 (SF1) and day 3 (SF3) using a pediatric version (pediatric SOFA score or pSOFA) with age-adjusted cutoff variables for organ dysfunction, pediatric risk of mortality III (PRISM III; within 24 hours of admission), and pediatric logistic organ dysfunction-2 or PELOD-2 (days 1, 3, and 5). A total of 240 patients were admitted to the PICU with septic shock during the study period. The overall mortality rate was 42 of 240 patients (17.5%). The majority (59%) required mechanical ventilation, while only 19% required renal replacement therapy. The PRISM III, PELOD-2, and pSOFA scores correlated well with mortality. All three severity of illness scores were higher among nonsurvivors as compared with survivors (p < 0.001). pSOFA scores on both day 1 (area under the curve or AUC 0.84) and day 3 (AUC 0.87) demonstrated significantly higher discriminative power for in-hospital mortality as compared with PRISM III (AUC, 0.7), and PELOD-2 (day 1, [AUC, 0.73]), and PELOD-2 (day 3, [AUC, 0.81]). Utilizing a cutoff SOFA score of >8, the relative risk of prolonged duration of mechanical ventilation, requirement for vasoactive infusions (vasoactive infusion score), and PICU length of stay were all significantly increased (p < 0.05), on both days 1 and 3. On multiple logistic regression, adjusted odds ratio of mortality was elevated at 8.65 (95% CI: 3.48–21.52) on day 1 and 16.77 (95% confidence interval or CI: 4.7–59.89) on day 3 (p < 0.001) utilizing the same SOFA score cutoff of 8. A positive association was found between the delta SOFA ([Δ] SOFA) from day 1 to day 3 (SF1–SF3) and in-hospital mortality (chi-square for linear trend, p < 0.001). Subjects with a ΔSOFA of ≥2 points had an exponential mortality rate to 50%. Similar association was—observed between ΔSOFA of ≥2 and—longer duration of inotropic support (p = 0.0006) with correlation co-efficient 0.2 (95% CI: 0.15–0.35; p = 0.01). Among children admitted to the PICU with septic shock, SOFA scores on both days 1 and 3, have a greater discriminative power for predicting in-hospital mortality than either PRISM III score (within 24 hours of admission) or PELOD-2 score (days 1 and 3). An increase in ΔSOFA of >2 adds additional prognostic accuracy in determining not only mortality risk but also duration of inotropic support as well.

Keywords

SOFA score - PELOD-2 - PRISM III - outcome prediction - septic shock

Publication History

Received: 18 February 2020

Accepted: 06 June 2020

Article published online:
30 July 2020

• References

• 1 Fisher JD, Nelson DG, Beyersdorf H, Satkowiak LJ. Clinical spectrum of shock in the pediatric emergency department. Pediatr Emerg Care 2010; 26 (09) 622-625
• 2 Shanley TP, Hallstrom C, Wong HR. Pediatric Critical Care—4th Edition. Accessed November 3, 2019 at: https://www.elsevier.com/books/pediatric-critical-care/Fuhrman/978-0-323-07307-3
• 3 Carcillo JA, Fields AI. American College of Critical Care Medicine Task Force Committee Members. Clinical practice parameters for hemodynamic support of pediatric and neonatal patients in septic shock. Crit Care Med 2002; 30 (06) 1365-1378
• 4 Sarthi M, Lodha R, Vivekanandhan S, Arora NK. Adrenal status in children with septic shock using low-dose stimulation test. Pediatr Crit Care Med 2007; 8 (01) 23-28
• 5 Beal AL, Cerra FB. Multiple organ failure syndrome in the 1990s. Systemic inflammatory response and organ dysfunction. JAMA 1994; 271 (03) 226-233
• 6 Vincent JL, Bihari D. Sepsis, severe sepsis or sepsis syndrome: need for clarification. Intensive Care Med 1992; 18 (05) 255-257
• 7 Leteurtre S, Duhamel A, Grandbastien B. et al. Daily estimation of the severity of multiple organ dysfunction syndrome in critically ill children. CMAJ 2010; 182 (11) 1181-1187
• 8 Goddard JM. Pediatric risk of mortality scoring overestimates severity of illness in infants. Crit Care Med 1992; 20 (12) 1662-1665
• 9 Ferreira FL, Bota DP, Bross A, Mélot C, Vincent JL. Serial evaluation of the SOFA score to predict outcome in critically ill patients. JAMA 2001; 286 (14) 1754-1758
• 10 Matics TJ, Sanchez-Pinto LN. Adaptation and validation of a pediatric sequential organ failure assessment score and evaluation of the sepsis-3 definitions in critically ill children. JAMA Pediatr 2017; 171 (10) e172352-e172352
• 11 Ha EJ, Kim S, Jin HS. et al. Early changes in SOFA score as a prognostic factor in pediatric oncology patients requiring mechanical ventilatory support. J Pediatr Hematol Oncol 2010; 32 (08) e308-e313
• 12 Goldstein B, Giroir B, Randolph A. ; International Consensus Conference on Pediatric Sepsis. International pediatric sepsis consensus conference: definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 2005; 6 (01) 2-8
• 13 Rhodes A, Evans LE, Alhazzani W. et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. Intensive Care Med 2017; 43 (03) 304-377
• 14 Pollack MM, Patel KM, Ruttimann UE. PRISM III: an updated pediatric risk of mortality score. Crit Care Med 1996; 24 (05) 743-752
• 15 Leteurtre S, Duhamel A, Deken V, Lacroix J, Leclerc F. Groupe Francophone de Réanimation et Urgences Pédiatriques. Daily estimation of the severity of organ dysfunctions in critically ill children by using the PELOD-2 score. Crit Care 2015; 19 (01) 324
• 16 Schlapbach LJ, Straney L, Bellomo R, MacLaren G, Pilcher D. Prognostic accuracy of age-adapted SOFA, SIRS, PELOD-2, and qSOFA for in-hospital mortality among children with suspected infection admitted to the intensive care unit. Intensive Care Med 2018; 44 (02) 179-188
• 17 Arikan AA, Citak A. Pediatric shock—Signa Vitae. Accessed October 23, 2019 at: http://www.signavitae.com/2008/04/pediatric-shock/
• 18 Sinniah D. Shock in children. Accessed October 23, 2019 at: webcache.googleusercontent.com/search?q=cache:Jw9pJugqsKkJ:https://pdfs.semanticscholar.org/8485/636ffb90f8816b31f2061538a1481484770e.pdf+&cd=1&hl=en&ct=clnk&gl=in
• 19 Singh D. (PDF) Mortality rates in pediatric septic shock. Accessed October 23, 2019 at: https://www.researchgate.net/publication/312632469_Mortality_rates_in_pediatric_septic_shock
• 20 Taori RN, Lahiri KR, Tullu MS. Performance of PRISM (Pediatric Risk of Mortality) score and PIM (pediatric index of mortality) score in a tertiary care pediatric ICU. Indian J Pediatr 2010; 77 (03) 267-271
• 21 Khajeh A, Noori NM, Reisi M, Fayyazi A, Mohammadi M, Miri-Aliabad G. Mortality risk prediction by application of pediatric risk of mortality scoring system in pediatric intensive care unit. Iran J Pediatr 2013; 23 (05) 546-550
• 22 Moreno R, Vincent JL, Matos R. et al. The use of maximum SOFA score to quantify organ dysfunction/failure in intensive care. Results of a prospective, multicentre study. Working Group on Sepsis related Problems of the ESICM. Intensive Care Med 1999; 25 (07) 686-696
• 23 Jones AE, Trzeciak S, Kline JA. The Sequential Organ Failure Assessment score for predicting outcome in patients with severe sepsis and evidence of hypoperfusion at the time of emergency department presentation. Crit Care Med 2009; 37 (05) 1649-1654
• 24 Raith EP, Udy AA, Bailey M. et al; Australian and New Zealand Intensive Care Society (ANZICS) Centre for Outcomes and Resource Evaluation (CORE). Prognostic accuracy of the SOFA score, SIRS criteria, and qSOFA score for in-hospital mortality among adults with suspected infection admitted to the intensive care unit. JAMA 2017; 317 (03) 290-300