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SOFA in sepsis: with or without GCS
Lu Wang1, Xudong Ma2, Guanghua Zhou3
1Department of Critical Care Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College and Chinese Academy of Medical Sciences, Peking Union Medical College Hospital, Beijing, 100730, China.
Purpose:
Sepsis is a global public health burden. The sequential organ failure assessment (SOFA) is the most commonly used scoring system for diagnosing sepsis and assessing severity. Due to the widespread use of endotracheal intubation and sedative medications in sepsis, the accuracy of the Glasgow Coma Score (GCS) is the lowest in SOFA. We designed this multicenter, cross-sectional study to investigate the predictive efficiency of SOFA with or without GCS on ICU mortality in patients with sepsis.
Methods:
First, 3048 patients with sepsis admitted to Peking Union Medical College Hospital (PUMCH) were enrolled in this survey. The data were collected from June 8, 2013 to October 12, 2022. Second, 18,108 patients with sepsis in the eICU database were enrolled. Third, 2397 septic patients with respiratory system ≥ 3 points in SOFA in the eICU database were included. We investigated the predictive efficiency of SOFA with or without GCS on ICU mortality in patients with sepsis in various ICUs of PUMCH, and then we validated the results in the eICU database.
Main Results:
In data of ICUs in PUMCH, the predictive efficiency of SOFA without GCS (AUROC [95% CI], 24 h, 0.724 [0.688, 0.760], 48 h, 0.734 [0.699, 0.769], 72 h, 0.748 [0.713, 0.783], 168 h, 0.781 [0.747, 0.815]) was higher than that of SOFA with GCS (AUROC [95% CI], 24 h, 0.708 [0.672, 0.744], 48 h, 0.721 [0.685, 0.757], 72 h, 0.735 [0.700, 0.757], 168 h, 0.770 [0.736, 0.804]) on ICU mortality in patients with sepsis, and the difference was statistically significant (P value, 24 h, 0.001, 48 h, 0.003, 72 h, 0.004, 168 h, 0.005). In septic patients with respiratory system ≥ 3 points in SOFA in the eICU database, although the difference was not statistically significant (P value, 24 h, 0.148, 48 h, 0.178, 72 h, 0.132, 168 h, 0.790), SOFA without GCS (AUROC [95% CI], 24 h, 0.601 [0.576, 0.626], 48 h, 0.625 [0.601, 0.649], 72 h, 0.639 [0.615, 0.663], 168 h, 0.653 [0.629, 0.677]) had a higher predictive efficiency on ICU mortality than SOFA with GCS (AUROC [95% CI], 24 h, 0.591 [0.566, 0.616], 48 h, 0.616 [0.592, 0.640], 72 h, 0.628 [0.604, 0.652], 168 h, 0.651 [0.627, 0.675]).
Conclusions:
In severe sepsis, it is realistic and feasible to discontinue the routine GCS for SOFA in patients with a respiratory system ≥ 3 points, and even better predict ICU mortality.
Insights
Removing the Glasgow Coma Score (GCS) from the Sequential Organ Failure Assessment (SOFA) score improves prediction of ICU mortality in sepsis patients. This modification offers a more accurate assessment for severe sepsis cases.
Area of Science:
- Critical Care Medicine
- Sepsis Pathophysiology
- Clinical Scoring Systems
Background:
- Sepsis represents a significant global health challenge, necessitating accurate severity assessment tools.
- The Sequential Organ Failure Assessment (SOFA) score is widely used for sepsis diagnosis and severity evaluation.
- The Glasgow Coma Score (GCS), a component of SOFA, has reduced accuracy in intubated and sedated sepsis patients.
Purpose of the Study:
- To evaluate the predictive performance of the SOFA score with and without the GCS for intensive care unit (ICU) mortality in sepsis patients.
- To determine if omitting GCS enhances the accuracy of SOFA in predicting sepsis-related ICU mortality.
Main Methods:
- A multicenter, cross-sectional study involving 3048 sepsis patients from Peking Union Medical College Hospital (PUMCH) and 18,108 patients from the eICU database.
- Analysis focused on ICU mortality prediction using SOFA with and without GCS.
- A subgroup of 2397 septic patients with SOFA respiratory score ≥ 3 from the eICU database was specifically analyzed for validation.
Main Results:
- In the PUMCH cohort, SOFA without GCS demonstrated significantly higher predictive efficiency for ICU mortality across multiple time points (24h to 168h) compared to SOFA with GCS (AUROC values ranged from 0.724 to 0.781 vs. 0.708 to 0.770).
- In the eICU subgroup (respiratory score ≥ 3), SOFA without GCS also showed a trend towards higher predictive efficiency for ICU mortality, although not statistically significant.
- Statistical significance (P<0.05) was observed for the superiority of SOFA without GCS in the PUMCH data.
Conclusions:
- Discontinuing the routine use of GCS in the SOFA score is feasible and realistic for severe sepsis patients, particularly those with a respiratory system score of 3 or higher.
- Omitting GCS from the SOFA score can lead to improved prediction of ICU mortality in specific sepsis populations.
- This finding supports refining sepsis assessment protocols by potentially removing GCS in certain clinical scenarios.
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