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SOFA2.0评分的变迁
SOFA 2.0评分的变迁及其重要性
Sequential Organ Failure Assessment (SOFA)评分系统自1996年创立以来，经历了显著的发展和变化。最初，SOFA评分是为了衡量和监测重症患者的多脏器功能障碍而设计的，它提供了一种简明的方法来评估严重患者的生理状态。随着对重症医学理解的不断深入、临床实践的变化以及高级监测技术的进步，SOFA评分面临着更新和扩展的必要性，这就是SOFA 2.0评分提出的背景。
1. SOFA评分的基本结构
最初的SOFA评分系统专注于六个主要脏器系统：呼吸、凝血、肝脏、心血管、神经和肾脏。每个系统根据患者的具体情况被赋予0到4分不等的评分。总分范围是0到24分，其中分数越高表示多脏器功能障碍的程度越严重。SOFA评分通过关注患者在重症监护中的生理参数，为医生提供了一个预测病人结果的重要工具。
2. SOFA 2.0的提出
随着临床实践的演变，尤其是在重症监护和急性医疗领域的不断革新，传统的SOFA评分面临着许多局限性。例如，随着检验技术的改进和非侵入性监测手段的普及，原有的指标体系被提出了需要更新的呼声（如所述）。SOFA 2.0旨在通过纳入新的生理指标和实验室检测结果，以更好地适应目前医学实践，增强其在临床决策中的有效性。
新增变量的提议
在SOFA 2.0的构建讨论中，有多个学者提出可能纳入的新变量，例如，液体平衡、炎症标记物以及患者的个体差异（如基线健康状况和治疗反应）。这些变量可能有助于改进对重症患者的整体评估，提高对病情变化的敏感性，并最终改善患者预后。
3. SOFA评分在临床中的实用性
研究表明，SOFA评分在各种重症患者中具有预测死亡风险的能力。在一项针对类似人群的回顾性研究中，SOFA评分能够有效地预测住院死亡率。特别是SOFA评分的“Delta”变化分数（即在住院期间SOFA评分的变化）被证明在多项研究中与长期死亡风险密切相关。因此，SOFA评分不仅可用于初步评估和日常监测，而且对于临床试验中作为终点指标的有效性也日渐受到重视。
4. SOFA评分的局限性与未来方向
虽然SOFA评分作为一个重要的工具，在临床中得到了广泛的使用，但也存在一定的局限性。比如，SOFA评分可能未能精准捕捉到某些患者的个体反应，因此，SOFA 2.0的提出被视为对这一问题的回应。通过整合新的生理指标和新的技术手段，SOFA 2.0旨在提高对各类复杂临床情形的适用性，从而增强其应用价值。
5. SOFA评分的实际应用
在对感染相关脓毒症的管理中，SOFA评分被广泛用于预测预后。例如，一项研究表明，在战斗创伤患者中，SOFA评分的提高与感染发生率及后续的死亡风险显著相关。此外，修改后的心血管SOFA评分在针对脓毒症患者时具有更高的预测效能，显示出SOFA评分不断演化以适应不断变化的临床需求的可能性。
结论
SOFA 2.0评分的引入代表了一次重要的临床进步，反映了重症医学领域日益重视个体化评估和定制化治疗的趋势。随着医学技术的不断进步，SOFA评分系统的未来发展将持续围绕提高预后预测的精确性和临床决策的有效性展开。未来的研究将进一步验证SOFA 2.0在不同临床背景下的适用性，确保能够为重症患者的护理提供最有效的支持。
References
1The Sequential Organ Failure Assessment (SOFA) Score: has the time come for an update?PubMed
Rui Moreno, Andrew Rhodes, Lise Piquilloud, et al.
Crit Care. 2023 Jan 13;27(1):15. doi: 10.1186/s13054-022-04290-9.
The Sequential Organ Failure Assessment (SOFA) score was developed more than 25 years ago to provide a simple method of assessing and monitoring organ dysfunction in critically ill patients. Changes in clinical practice over the last few decades, with new interventions and a greater focus on non-invasive monitoring systems, mean it is time to update the SOFA score. As a first step in this process, we propose some possible new variables that could be included in a SOFA 2.0. By so doing, we hope to stimulate debate and discussion to move toward a new, properly validated score that will be fit for modern practice.
2Identification of a transcriptome profile associated with improvement of organ function in septic shock patients after early supportive therapy.PubMed
Matteo Barcella, Bernardo Bollen Pinto, Daniele Braga, et al.
Crit Care. 2018 Nov 21;22(1):312. doi: 10.1186/s13054-018-2242-3.
BACKGROUND: Septic shock is the most severe complication of sepsis and this syndrome is associated with high mortality. Treatment of septic shock remains largely supportive of hemodynamics and tissue perfusion. Early changes in organ function assessed by the Sequential Organ Function Assessment (SOFA) score are highly predictive of the outcome. However, the individual patient's response to supportive therapy is very heterogeneous, and the mechanisms underlying this variable response remain elusive. The aim of the study was to investigate the transcriptome of whole blood in septic shock patients with different responses to early supportive hemodynamic therapy assessed by changes in SOFA scores within the first 48 h from intensive care unit (ICU) admission. METHODS: We performed whole blood RNA sequencing in 31 patients: 17 classified as responders (R) and 14 as non-responders (NR). Gene expression was investigated at ICU admission (time point 1, or T1), comparing R with NR [padj < 0.01; Benjamini-Hochberg (BH)] and over time from T1 to T2 (48 h later) in R and NR independently (paired analysis, padj < 0.01; BH). Then the differences in gene expression trends over time were evaluated (Mann-Whitney, P <0.01). To identify enriched biological processes, we performed an over-representation analysis based on a right-sided hypergeometric test with Bonferroni step-down as multiple testing correction (padj < 0.05). RESULTS: At ICU admission, we did not identify differentially expressed genes (DEGs) between the two groups. In the transition from T1 to T2, the activation of genes involved in T cell-mediated immunity, granulocyte and natural killer (NK) cell functions, and pathogen lipid clearance was noted in the R group. Genes involved in acute inflammation were downregulated in both groups. CONCLUSIONS: Within the limits of a small sample size, our results could suggest that early activation of genes of the adaptive immune response is associated with an improvement in organ function.
3Changes in severity and organ failure scores as prognostic factors in onco-hematological malignancy patients admitted to the ICU.PubMed
B Lamia, M-F Hellot, C Girault, et al.
Intensive Care Med. 2006 Oct;32(10):1560-8. doi: 10.1007/s00134-006-0286-3. Epub 2006 Aug 1.
OBJECTIVE: To determine whether severity and organ failure scores over the first 3 days in an ICU predict in-hospital mortality in onco-hematological malignancy patients. DESIGN AND SETTING: Retrospective study in a 22-bed medical ICU. PATIENTS: 92 consecutive patients with onco-hematological malignancies including 20 hematopoietic stem cell transplantation (HSCT) patients (11 with allogenic HSCT). MEASUREMENTS: Simplified Acute Physiology Score (SAPS) II, Organ Dysfunction and/or Infection (ODIN) score, Logistic Organ Dysfunction System (LODS), and Sequential Organ Failure Assessment (SOFA) score were recorded on admission. The change in each score (Delta score) during the first 3 days in the ICU was calculated as follows: severity or organ failure score on day 3 minus severity or organ failure score on day 1, divided by severity or organ failure score on day 1. RESULTS: In-hospital mortality was 58%. Using multivariate analysis in-hospital mortality was predicted by all scores on day 1 and all Delta scores. Areas under the receiver operating characteristics curves were similar for SAPS II (0.78), ODIN (0.78), LODS (0.83), and SOFA (0.78) scores at day 1. They were also similar for DeltaSAPS II, DeltaODIN, DeltaLODS, and DeltaSOFA. Similar results were observed when excluding patients with allogenic HSCT. CONCLUSION: Severity and three organ failure scores on day 1 and Delta scores perform similarly in predicting in-hospital mortality in ICU onco-hematological malignancy patients but do not predict individual outcome. Decision to admit such patients to the ICU or to forgo life-sustaining therapies should not be based on these scores.
4Nonpulmonary organ dysfunction and its impact on outcome in patients with acute respiratory failure.PubMed
Ashutosh N Aggarwal, Ritesh Agarwal, Dheeraj Gupta, et al.
Chest. 2007 Sep;132(3):829-35. doi: 10.1378/chest.06-2783.
PURPOSES: This study aimed to define the prevalence, severity, and progression of nonpulmonary organ dysfunction, and its impact on outcome in patients with acute respiratory failure (ARF) at a respiratory ICU of a tertiary referral hospital in northern India. METHODS: Daily patient data were collected on 711 adult patients with ARF to calculate component and total nonpulmonary sequential organ failure assessment (SOFA) scores. Hospital survival was the main outcome measure. Multiple logistic regression modeling was conducted to assess contribution of incremental dysfunction of various nonpulmonary organ systems to mortality. Kaplan-Meier curves were drawn to assess temporal trends in survival, and group comparisons were based on log-rank test. Cox proportional hazard modeling was performed to define hazards of earlier mortality. Discrimination was evaluated using receiver operating characteristic (ROC) curves. RESULTS: Four hundred seventy-five patients (66.8%) had one or more nonpulmonary organ dysfunctions at hospital admission. The overall hospital mortality rate was 33.9%. Hospital survival rates and median survival declined steadily as the number of organs involved increased. Admission, maximum, and DeltaSOFA scores were significantly higher in nonsurvivors. Increasing baseline cardiovascular and neurologic SOFA scores, and corresponding DeltaSOFA scores, were associated with progressively higher odds of hospital mortality, as well as increasing hazard for earlier mortality after adjustment for etiology of respiratory failure. Maximum nonpulmonary SOFA score was the best discriminator in predicting mortality (area under ROC curve, 0.767). CONCLUSION: Baseline and new-onset nonpulmonary organ dysfunction significantly influences hospital survival in patients with ARF.
6Prognostic Value of Sequential Organ Failure Assessment (SOFA) Score in Critically-Ill Combat-Injured Patients.PubMed
Shannon L McCarthy, Laveta Stewart, Faraz Shaikh, et al.
J Intensive Care Med. 2022 Nov;37(11):1426-1434. doi: 10.1177/08850666221078196. Epub 2022 Feb 16.
Infection is a frequent and serious complication after combat-related trauma. The Sequential Organ Failure Assessment (SOFA) score has been shown to have predictive value for outcomes, including sepsis and mortality, among various populations. We evaluated the prognostic ability of SOFA score in a combat-related trauma population. Combat casualties (2009-2014) admitted to Landstuhl Regional Medical Center (LRMC; Germany) intensive care unit (ICU) within 4 days post-injury followed by transition to ICUs in military hospitals in the United States were included. Multivariate logistic regression was used to determine predictive effect of selected variables and receiver operating characteristic (ROC) curve analysis was used to evaluate overall accuracy of SOFA score for infection prediction. Of the 748 patients who met inclusion criteria, 436 (58%) were diagnosed with an infection (32% bloodstream, 63% skin and soft tissue, and 40% pulmonary) and were predominantly young (median 24 years) males. Penetrating trauma accounted for 95% and 86% of injuries among those with and without infections, respectively (p < 0.001). Median LRMC admission SOFA score was 7 (interquartile range [IQR]: 4-9) in patients with infections versus 4 (IQR: 2-6) in patients without infections (p < 0.001). Thirty-day mortality was 2% in both groups. On multivariate regression, LRMC SOFA score was independently associated with infection development (odds ratio: 1.2; 95% confidence interval: 1.1-1.3). The ROC curve analysis revealed an area under the curve of 0.69 for infection prediction, and 0.80 for mortality prediction. The SOFA scores obtained up to 4 days post-injury predict late onset infection occurrence. This study revealed that for every 1 point increase in LRMC SOFA score, the odds of having an infection increases by a factor of 1.2, controlling for other predictors. The use of SOFA score in admission assessments may assist clinicians with identifying those at higher risk of infection following combat-related trauma.
7Modified cardiovascular SOFA score in sepsis: development and internal and external validation.PubMed
Hui Jai Lee, Byuk Sung Ko, Seung Mok Ryoo, et al.
BMC Med. 2022 Aug 22;20(1):263. doi: 10.1186/s12916-022-02461-7.
BACKGROUND: The Sepsis-3 criteria introduced the system that uses the Sequential Organ-Failure Assessment (SOFA) score to define sepsis. The cardiovascular SOFA (CV SOFA) scoring system needs modification due to the change in guideline-recommended vasopressors. In this study, we aimed to develop and to validate the modified CV SOFA score. METHODS: We developed, internally validated, and externally validated the modified CV SOFA score using the suspected infection cohort, sepsis cohort, and septic shock cohort. The primary outcome was 28-day mortality. The modified CV SOFA score system was constructed with consideration of the recently recommended use of the vasopressor norepinephrine with or without lactate level. The predictive validity of the modified SOFA score was evaluated by the discrimination for the primary outcome. Discrimination was assessed using the area under the receiver operating characteristics curve (AUC). Calibration was assessed using the calibration curve. We compared the prognostic performance of the original CV/total SOFA score and the modified CV/total SOFA score to detect mortality in patients with suspected infection, sepsis, or septic shock. RESULTS: We identified 7,393 patients in the suspected cohort, 4038 patients in the sepsis cohort, and 3,107 patients in the septic shock cohort in seven Korean emergency departments (EDs). The 28-day mortality rates were 7.9%, 21.4%, and 20.5%, respectively, in the suspected infection, sepsis, and septic shock cohorts. The model performance is higher when vasopressor and lactate were used in combination than the vasopressor only used model. The modified CV/total SOFA score was well-developed and internally and externally validated in terms of discrimination and calibration. Predictive validity of the modified CV SOFA was significantly higher than that of the original CV SOFA in the development set (0.682 vs 0.624, p < 0.001), test set (0.716 vs 0.638), and all other cohorts (0.648 vs 0.557, 0.674 vs 0.589). Calibration was modest. In the suspected infection cohort, the modified model classified more patients to sepsis (66.0 vs 62.5%) and identified more patients at risk of septic mortality than the SOFA score (92.6 vs 89.5%). CONCLUSIONS: Among ED patients with suspected infection, sepsis, and septic shock, the newly-developed modified CV/total SOFA score had higher predictive validity and identified more patients at risk of septic mortality.
8SOFA and mortality endpoints in randomized controlled trials: a systematic review and meta-regression analysis.PubMed
Harm-Jan de Grooth, Irma L Geenen, Armand R Girbes, et al.
Crit Care. 2017 Feb 24;21(1):38. doi: 10.1186/s13054-017-1609-1.
BACKGROUND: The 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. METHODS: The 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 I ). RESULTS: Of 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, I = 5%); the overall mortality effect explained by SOFA score (R ) 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, I = 12%) and explained 3% of the overall mortality effect (R ). Delta SOFA was significantly associated with mortality (slope = 0.70 (95% CI 0.26; 1.14), p = 0.004, I = 0%) and explained 32% of the overall mortality effect (R ). CONCLUSIONS: Treatment 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.