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The prognostic value of the sequential organ failure assessment (SOFA) score for critically ill elderly patients with acute infective endocarditis (IE) remains unknown. From January 2015 to December 2019, 111 elderly (≥65 years) patients with acute IE were consecutively included and divided into a low SOFA (

BackgroundSequential Organ Failure Assessment (SOFA) is a practical and widely used method to describe and quantify the presence and severity of organ system dysfunctions and failures. Some proposals suggest that SOFA could be employed as an endpoint in interventional trials. To justify this, all SOFA components should have comparable weights as organ dysfunction measures. In this study we aimed to investigate whether the associations of different SOFA components with in-hospital mortality are comparable.MethodsWe performed a study based on nationwide register data on adult patients admitted to 26 Finnish intensive care units (ICUs) during 2012−2015. We determined the SOFA score as the maximum score in the first 24 hours after ICU admission. We defined organ failure as an organ-specific SOFA score of three or higher. We evaluated the association of different SOFA component scores with mortality using multivariable logistic regression analysis. ResultsOur study population comprised 63,756 ICU patients. Overall hospital mortality was 10.7%. In-hospital mortality was 22.5% for patients with respiratory failure, 34.8% for those with coagulation failure, 40.1% for those with hepatic failure, 14.9% for those with cardiovascular failure, 26.9% for those with neurologic failure and 34.6% for the patients with renal failure. The age-adjusted odds ratio for in-hospital death was 2.41 [95% confidence interval (CI) 2.27-2.56] for respiratory failure, 4.04 (95% CI 3.57-4.57) for coagulation failure, 4.24 (95% CI 3.47-5.17), for hepatic failure, 1.57 (95% CI 1.47-1.67) for cardiovascular failure, 5.00 (95% CI 4.71-5.30) for neurologic failure, and 4.93 (95% CI 4.58-5.32) for renal failure. Organ failure combinations including cardiovascular failure were associated with lower mortality than other organ failure combinations.ConclusionsAll SOFA components are associated with mortality, but their weights are not comparable. High cardiovascular SOFA scores do not imply an equally high risk as high scores of other components.

Introduction: The Surviving Sepsis Campaign published the Hour-1 Sepsis Bundle in 2018. The first-hour management of patients with sepsis in the emergency department (ED) is important, as suggested in the Hour-1 Sepsis Bundle. The objectives of the present study were to evaluate 28-day mortality and delayed septic shock with use of a complete and incomplete Hour-1 Sepsis Bundle in the ED. Methods: This prospective cohort study included adult patients with sepsis from March to July 2019. We followed the sepsis protocol used in the ED of a tertiary care hospital. Results: We enrolled 593 patients, with 55.9% in the complete Hour-1 Sepsis Bundle group. The 28-day mortality was 3.9% overall and no significant difference between the complete and incomplete Hour-1 Sepsis Bundle groups (3.6% vs. 4.2%, P = 0.707). Complete Hour-1 Sepsis Bundle treatment was not associated with 28-day mortality (adjusted OR = 2.04, 95% confidence interval [CI] = 0.72–5.74, P = 0.176) or delayed septic shock (adjusted OR = 0.74, 95% CI = 0.30–1.78, P = 0.499). Completion of each bundle did not affect outcomes of 28-day mortality and delayed septic shock. Conclusions: The complete Hour-1 Sepsis Bundle treatment in the ED was not significantly associated with 28-day mortality and delayed septic shock. Trial registration: The trial was registered in the Thai Clinical Trial Registry, TCTR 20200526013.

Background: Hyperfibrinolysis and pro/anti-inflammatory imbalance usually occur in the early stage of severe burns. Soluble urokinase-type plasminogen activator receptor (suPAR) is involved in fibrinolysis and inflammation. To date, the levels of circulating suPAR in non-survivors with severe burns remain unknown. This study aimed to investigate the early association between circulating suPAR levels and biomarkers of fibrinolysis, pro/anti-inflammatory, and prognosis. Methods: Sixty-four consecutive Chinese patients with severe burns and 26 healthy volunteers were enrolled in a prospective observational cohort. Clinical characteristics and laboratory data were collected prospectively. Blood samples were collected at 48 h post-burn, and suPAR and biomarkers of pro/anti-inflammatory and fibrinolysis were detected by enzyme-linked immunosorbent assays. Important indicators between non-survivors and survivors were compared. Linear regression analysis was performed to screen variables associated with suPAR. Logistic regression analysis and receiver operating characteristic curve (ROC) analysis were performed to evaluate the prognostic value of suPAR. Result: Compared with the control group, the circulating suPAR levels in the survivors (P

The Sequential Organ Failure Assessment (SOFA) score is commonly used in the Intensive Care Unit (ICU) to evaluate, prognosticate and assess patients. Since its validation, the SOFA score has served in various settings, including medical, trauma, surgical, cardiac, and neurological ICUs. It has been a strong mortality predictor and literature over the years has documented the ability of the SOFA score to accurately distinguish survivors from non-survivors on admission. Over the years, multiple variations have been proposed to the SOFA score, which have led to the evolution of alternate validated scoring models replacing one or more components of the SOFA scoring system. Various SOFA based models have been used to evaluate specific clinical populations, such as patients with cardiac dysfunction, hepatic failure, renal failure, different races and public health illnesses, etc. This study is aimed to conduct a review of modifications in SOFA score in the past several years. We review the literature evaluating various modifications to the SOFA score such as modified SOFA, Modified SOFA, modified Cardiovascular SOFA, Extra-renal SOFA, Chronic Liver Failure SOFA, Mexican SOFA, quick SOFA, Lactic acid quick SOFA (LqSOFA), SOFA in hematological malignancies, SOFA with Richmond Agitation-Sedation scale and Pediatric SOFA. Various organ systems, their relevant scoring and the proposed modifications in each of these systems are presented in detail. There is a need to incorporate the most recent literature into the SOFA scoring system to make it more relevant and accurate in this rapidly evolving critical care environment. For future directions, we plan to put together most if not all updates in SOFA score and probably validate it in a large database a single institution and validate it in multisite data base.

BACKGROUND Multiple organ dysfunction syndrome (MODS) has recently been considered as a defining syndrome of sepsis and is responsible for a high mortality rate among the patients in the intensive care units (ICUs). Prognostication of the ICU patients is an integral part of the management of the critically ill patients and many scoring systems, for that matter, have been devised and compared for their efficiency at predicting mortality. This study was conducted to evaluate and compare the validity of sequential organ failure assessment (SOFA), acute physiology and chronic health evaluation (APACHE II) and APACHE IV as mortality predictors in intensive care unit (ICU) patients suffering from MODS in sepsis. METHODS Hundred patients diagnosed with MODS in sepsis were carefully examined, followed by relevant laboratory investigations. The SOFA score was calculated daily, and the APACHE II and IV scores were calculated on the day of admission. The scores were further compared among the survivors and the non-survivors, followed by receiver operating characteristic (ROC) curve analysis of the SOFA D1, D2, and D3 and the APACHE II and IV scores to estimate their capability of mortality prediction. RESULTS The means of the APACHE II, IV and SOFA D1 were 16.57 ± 6.49, 71.91 ± 16.19 and 8.75 ± 2.20, respectively. There was a statistically significant difference in the mean APACHE II scores (14.23 ± 5.20 vs. 21.12 ± 6.38) and the mean APACHE IV scores (67.27 ± 13.21 vs. 80.91 ± 17.77) in the survivors and the nonsurvivors. A statistically significant difference was also evident in the mean ages of the survivors and the non-survivors (52.82 ± 14.67 years vs. 63.25 ± 16.98 years). The SOFA score was high among the non-survivors than the survivors right from day-1 (10.24 ± 2.08 vs. 7.98 ± 1.86) to day-20 (15.00 ± 0.00 vs. 3.14 ± 0.38). Furthermore, ROC analysis showed that the best discrimination was provided by SOFA D3 followed by the APACHE II and SOFA D1 scores, with APACHE IV score showing the least. CONCLUSIONS SOFA score on day 3 provides the best mortality prediction in patients with MODS in sepsis, as compared to APACHE II and IV scores. KEYWORDS SOFA, APACHE II, APACHE IV, Multiple Organ Dysfunction Syndrome, Sepsis

Background This study aimed to evaluate the characteristics of patients with newly diagnosed advanced lung cancer who initially presented with respiratory failure. Methods This was a retrospective study which analyzed patients in the intensive care unit (ICU) with newly diagnosed advanced lung cancer who were placed on mechanical ventilation (MV). We defined newly diagnosed lung cancer as pathological or molecular results for treatment decisions not yet determined when the patient was admitted to ICU. Results During the 14‐year inclusion period, 845 lung cancer patients requiring MV were screened. A total of 56 newly diagnosed extensive lung cancer patients were analyzed. Cancer‐related to central airway obstruction (n = 29, 51.8%) was the leading cause of respiratory failure. The significant etiologies of delay in the diagnosis of lung cancer were diagnostic error, mistaking cancer for tuberculosis, and missed hilar lesions. The six‐month survival rate was only 7.1% (n = 4). The sequential organ failure assessment (SOFA) score was significantly associated with mortality (HR = 1.142, 95% CI = 1.012–1.288, P = 0.031). The six‐month survival rate in patients receiving suitable targeted therapy and accepting chemotherapy and best supportive care was 40% (2/5), 0% (0/7), and 4.5% (2/44), respectively. Conclusions Patients with newly diagnosed advanced lung cancer with acute life‐threatening respiratory failure have poor outcomes. Cancer‐related to central airway obstruction is a leading cause of respiratory failure. Diagnostic errors such as tuberculosis and missed hilar lesions are the two main etiologies of a delay in diagnosis. The SOFA score is correlated with mortality. Targeted therapy can raise the six‐month survival rates in patients with oncogenic mutation adenocarcinoma, who survive after presentation in a critical condition., This was a retrospective study which assessed the etiologies of delayed diagnosis and characteristics of patients with newly diagnosed advanced lung cancer who initially presented with respiratory failure.

Aim:This study aimed to investigate the efficacy of C-reactive protein (CRP), lactate, procalcitonin and albumin levels and procalcitonin/ albumin ratio used as indicators of infection on mortality in critical patients admitted to the intensive care unit and their relationships with APACHE-II and SOFA scores.Materials and Methods:This study was conducted using patients’ hospital records and patient file scans. Demographic characteristics; procalcitonin, CRP, albumin and lactate levels and APACHE-II and SOFA scores were recorded. Spearman’s rank correlation was used to assess non-parametric data. ROC curve analysis was performed to determine the threshold values of blood parameters. Results: A total of 61 patients were enrolled in the present study [35 males (57.4%) and 26 females (42.6%); average age, 69.0 years]. A positive, weakly significant association was detected between APACHE-II score and procalcitonin levels. When the APACHE-II score and lactate level and procalcitonin/ albumin ratio were evaluated,Results:APACHE-II score was positively significant and weakly correlated with lactate and the procalcitonin/albumin ratio. A moderate negative correlation was found between albumin level and the APACHE-II score. The SOFA score was positively associated with both procalcitonin and lactate levels. SOFA score was positively significant and weakly correlated with the procalcitonin/albumin ratio.Conclusion:Procalcitonin, lactate and albumin levels and the procalcitonin/albumin ratio can be considered prognostic markers according to the cut-off points in terms of mortality in critically ill patients. In addition, these blood parameters were found to be useful in clinical follow-up as they are related to the APACHE-II and SOFA scoring systems used in intensive care units.

Introduction This study was proposed to compare the ability and accuracy of modified sequential organ failure assessment (mSOFA), quick SOFA (qSOFA), and qSOFA-65 in predicting the status of nontraumatic patients referred to hospital emergency departments (EDs). Materials and methods This study was a prospective design that performed on the 746 nontraumatic patients referred to the ED. Each patient data was collected using a demographic questionnaire, mSOFA, qSOFA, and qSOFA-65 scales. Related variables of each scale were recorded based on patients' medical records. Then, the outcome of each patient in the ED was followed up and recorded. The severity and specificity of each scale were estimated by the area under receiver operating characteristic (AUROC) curve at 99% confidence interval (CI). Results The mean and standard deviation of scores were as follows: mSOFA = 4.40 ± 2.58, qSOFA = 0.50 ± 0.70, and qSOFA-65 = 0.92 ± 0.96. Patients requiring admission to the intensive care unit (ICU) were identified with AUROC curve as follows: mSOFA = 0.882 (99% CI = 0.778-0.865); qSOFA = 0.717 (99% CI = 0.662-0.773); and qSOFA-65 = 0.771 (99% CI = 0.721-0.820), which showed that mSOFA has higher sensitivity and specificity than the other two scales in identifying patients requiring admission to the ICU. Conclusion All three scales were found to be reliable for identifying nontraumatic patients at risk of death and patients requiring admission to the ICU. However, since the time and data required to complete qSOFA and qSOFA-65 are much less than those of mSOFA, it is recommended that qSOFA and especially qSOFA-65 be used in ED to identify critically ill nontraumatic patients. How to cite this article Ebrahimian A, Shahcheragh SMT, Fakhr-Movahedi A. Comparing the Ability and Accuracy of mSOFA, qSOFA, and qSOFA-65 in Predicting the Status of Nontraumatic Patients Referred to a Hospital Emergency Department: A Prospective Study. Indian J Crit Care Med 2020;24(11):1045-1050.

Objective: To investigate the incidence, clinical characteristics and outcomes of early hyperbilirubinemia in critically ill patients. Design and Setting: This is a post hoc analysis of a prospective multicenter cohort study. Patients: Patients with measured bilirubin levels within the first 2 days after ICU admission were eligible. Patients with liver cirrhosis were excluded. Endpoints: The primary endpoint was the incidence of early hyperbilirubinemia, defined as bilirubin ≥33 μmol/L within 2 days after ICU admission. Secondary endpoints included clinical characteristics of patients with versus patients without early hyperbilirubinemia, and outcomes up to day 30. Results: Of 4,836 patients, 559 (11.6%) patients had early hyperbilirubinemia. Compared to patients without early hyperbilirubinemia, patients with early hyperbilirubinemia presented with higher severity of illness scores, and higher incidences of sepsis and organ failure. After adjustment for confounding variables, early hyperbilirubinemia remained associated with mortality at day 30 (odds ratio, 1.31 [95%–confidence interval 1.06–1.60]; P = 0.018). Patients with early hyperbilirubinemia and thrombocytopenia (interaction P-value = 0.005) had a higher likelihood of death within 30 days (odds ratio, 2.61 [95%–confidence interval 2.08–3.27]; P < 0.001) than patients with early hyperbilirubinemia and a normal platelet count (odds ratio, 1.09 [95%–confidence interval 0.75–1.55]; P = 0.655). Conclusions: Early hyperbilirubinemia occurs frequently in the critically ill, and these patients present with higher disease severity and more often with sepsis and organ failures. Early hyperbilirubinemia has an association with mortality, albeit this association was only found in patients with concomitant thrombocytopenia.

Background and objective Because of the effect of vitamins on modulating the immune system function, we have evaluated the effect of supplementation with vitamins A, B, C, D, and E in ICU-admitted patients with COVID-19. Methods This study was a randomized and single-blinded clinical trial in which 60 subjects were randomly assigned to two groups. The intervention group (n=30) received vitamins, and the control group did not receive any vitamin or placebo. The intervention was included 25,000 IU daily of vitamins A, 600,000 IU once during the study of D, 300 IU twice daily of E, 500 mg four times daily of C, and one amp daily of B complex for 7 days. At baseline and after the 7-day intervention, the serum levels of inflammatory markers, vitamins, and the SOFA score were assessed. In addition, the mortality rate and duration of hospitalization were evaluated after the intervention (IRCT registration number: IRCT20200319046819N1/registration date: 2020-04-04, https://www.irct.ir/trial/46838). Results Significant changes were detected in serum levels of vitamins (p < 0.001 for all vitamins), ESR (p < 0.001), CRP (p = 0.001), IL6 (p = 0.003), TNF-a (p = 0.001), and SOFA score (p < 0.001) after intervention compared with the control group. The effect of vitamins on the mortality rate was not statistically significant (p=0.112). The prolonged hospitalization rate to more than 7 days was significantly lower in the intervention group than the control group (p=0.001). Regarding the effect size, there was a significant and inverse association between receiving the intervention and prolonged hospitalization (OR = 0.135, 95% CI 0.038–0.481; p=0.002); however, after adjusting for confounders, it was not significant (OR=0.402, 95% CI 0.086–1.883; p=0.247). Conclusion Supplementation with vitamins A, B, C, D, and E could improve the inflammatory response and decrease the severity of disease in ICU-admitted patients with COVID-19.

Introduction: The discrimination and calibration accuracy of prediction models tends to become poor over time. The performance of predictive models should be reevaluated periodically. The aim of this study was to reassess the discrimination of the six commonly used models for predicting 28-day mortality in patients with sepsis based on the Sepsis 3.0 criteria. Methods: Patient data were extracted from the fourth edition of the Medical Information Mart for Critical Care (MIMIC IV) database. The systemic inflammatory response syndrome (SIRS), Sequential Organ Failure Assessment (SOFA), Oxford Acute Severity of Illness Score (OASIS), Logistic Organ Dysfunction System (LODS), and Simplified Acute Physiology Score II (SAPS II) and III (SAPS III) scores were calculated and collected. The area under the receiver operating characteristic curve (AUROC) was used to compare the discrimination abilities of the models using non-parametric Wilcoxon statistics. The Delong method was used to perform pairwise comparisons of the AUROCs of the models. Multiple subgroup analyses for age, body mass index, and sex were performed with regard to the 28-day mortality prediction of the models. Results: A total of 12 691 patients were included. The mean age of the patients was 65.97 ± 15.77 years; 7673 patients (60.50%) were male. The mean SIRS, SOFA, OASIS, SAPS II, LODS, and SAPS III scores were higher in the non-survivor group than in the survivor group. The discrimination for 28-day mortality with the SAPS III (AUROC 0.812, 95% confidence interval (CI) 0.802–0.822) and LODS (AUROC 0.804, 95% CI 0.743–0.765) models was superior to that of the SIRS (AUROC 0.575, 95% CI 0.562–0.589), SOFA (AUROC 0.612, 95% CI 0.598–0.626), OASIS (AUROC 0.753, 95% CI 0.742–0.764), and SAPS II (AUROC 0.754, 95% CI 0.743–0.765) models. The Youden index of the SAPS III model was 0.484, which was the highest among the models. Subgroup analyses showed similar results to the overall results. Conclusions: The discrimination for 28-day mortality with the SAPS III and LODS models was superior to that of the SIRS, SOFA, OASIS, and SAPS II models. The SAPS III model showed the best discrimination capacity for 28-day mortality compared with the other models.

Perilipin 2 (PLIN2) is a lipid droplet protein with various metabolic functions. However, studies investigating PLIN2 in the context of inflammation, especially in systemic and acute inflammation, are lacking. Hence, we assessed the relevance of serum PLIN2 in critically ill patients. We measured serum PLIN2 serum in 259 critically ill patients (166 with sepsis) upon admission to a medical intensive care unit (ICU) compared to 12 healthy controls. A subset of 36 patients underwent computed tomography to quantify body composition. Compared to controls, serum PLIN2 concentrations were elevated in critically ill patients at ICU admission. Interestingly, PLIN2 independently indicated multiple organ dysfunction (MOD), defined as a SOFA score &gt, 9 points, at ICU admission, and was also able to independently predict MOD after 48 h. Moreover, serum PLIN2 levels were associated with severe respiratory failure potentially reflecting a moribund state. However, PLIN2 was neither a predictor of ICU mortality nor did it reflect metabolic dysregulation. Conclusively, the first study assessing serum PLIN2 in critical illness proved that it may assist in risk stratification because it is capable of independently indicating MOD at admission and predicting MOD 48 h after PLIN2 measurement. Further evaluation regarding the underlying mechanisms is warranted.

Infectious biomarkers such as procalcitonin (PCT) can help overcome the lack of sensitivity of the quick Sequential Organ Failure Assessment (qSOFA) score for early identification of sepsis in emergency departments (EDs) and thus might be beneficial as point-of-care biomarkers in EDs. Our primary aim was to investigate the diagnostic performance of PCT for the early identification of septic patients and patients likely to develop sepsis within 96 h of admission to an ED among a prospectively selected patient population with elevated qSOFA score. In a large multi-centre prospective cohort study, we included all adult patients (n = 742) with a qSOFA score of at least 1 who presented to the ED. PCT levels were measured upon admission. Of the study population 27.3% (n = 202) were diagnosed with sepsis within the first 96 h. The area under the curve for PCT for the identification of septic patients in EDs was 0.86 (95% confidence interval (CI): 0.83–0.89). The resultant sensitivity for PCT at a cut-off of 0.5 µg/L was 63.4% (95% CI: 56.3–70.0). Furthermore, specificity was 89.2% (95% CI: 86.3–91.7), the positive predictive value was 68.8% (95% CI: 62.9–74.2), and the negative predictive value was 86.7% (95% CI: 84.4–88.7). The early measurement of PCT in a patient population with elevated qSOFA score served as an effective tool for the early identification of sepsis in ED patients.

SM Osama Bin Abdullah,1 Rune Husås Sørensen,1 Finn Erland Nielsen2,3 1Department of Emergency Medicine, Slagelse Hospital, Slagelse, Denmark; 2Department of Emergency Medicine, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Slagelse, Denmark; 3Copenhagen Center for Translational Research, Copenhagen University Hospital, Bispebjerg and Frederiksberg, Slagelse, DenmarkCorrespondence: SM Osama Bin AbdullahDepartment of Emergency Medicine, Slagelse Hospital, Ingemannsvej 50, Slagelse, DK-4200, DenmarkTel +45 31 61 81 84Email sabdu@regionsjaelland.dkObjective: This study aimed to determine the prognostic accuracy of SOFA in comparison to quick-SOFA (qSOFA) and systemic inflammatory response syndrome (SIRS) in predicting 28-day mortality in the emergency department (ED) patients with infections.Methods: A secondary analysis of data from a prospective study of adult patients with documented or suspected infections admitted to an ED in Denmark from Oct-2017 to Mar-2018. The SOFA scores were calculated after adjustment for chronic diseases. The prognostic accuracy was assessed by analysis of sensitivity, specificity, predictive values, likelihood ratios, and area under the receiver operating characteristic curve (AUROC) with 95% confidence intervals (CI).Results: A total of 2045 patients with a median age of 73.2 (IQR: 60.9– 82.1) years were included. The overall 28-day mortality was 7.7%. In patients meeting a SOFA score ≥ 2, qSOFA score ≥ 2, and SIRS criteria ≥ 2 the 28-day mortality was 13.6% (11.2– 16.3), 17.8% (12.4– 24.3) and 8.3% (6.7– 10.2), respectively. SOFA ≥ 2 had a sensitivity of 61.4% (53.3– 69.0) and specificity of 67.3% (65.1– 69.4), qSOFA ≥ 2 had a sensitivity of 19.6% (13.7– 26.7) and specificity of 92.4% (91.1– 93.6), and SIRS ≥ 2 had a sensitivity of 52.5% (44.4– 60.5) and specificity of 51.5% (49.2– 53.7). The AUROC for SOFA compared to SIRS was: 0.68 vs 0.52; p< 0.001 and compared to qSOFA: 0.68 vs 0.63; p=0.018.Conclusion: A SOFA score of at least two had better prognostic accuracy for 28-day mortality than SIRS and qSOFA. However, the overall accuracy of SOFA was poor for the prediction of 28-day mortality.Keywords: emergency department, infectious disease, SOFA, SIRS, qSOFA, sepsis, mortality, prognostic accuracy

The alarmingly aggravating incidents of sepsis and septic shock, and associated mortality, morbidity, and annual treatment costs among ICU admissions are an increasing concern SepINav is a medical informatics endeavor that helps ICU practitioners and researchers to monitor and intervene on the existing sepsis patients more efficiently and interactively and conduct retrospective studies to seek rationales to different sepsis scenarios in the ICU Moreover, Bayesian Online Changepoint Detection will help the practitioners understand the structural changes in patients’ vital sign regimes that may harbinger prior to septic shock Besides, several additional features are added to this data-driven software tool to promise efficient monitoring and intervention and address confounding medical interventions in the ICU © 2021 The Author(s)

The Sequential Organ Failure Assessment or SOFA score was developed to assess the acute morbidity of critical illness at a population level and has been widely validated as a tool for this purpose across a range of healthcare settings and environments.In recent years, the SOFA score has become extensively used in a range of other applications. A change in the SOFA score of 2 or more is now a defining characteristic of the sepsis syndrome, and the European Medicines Agency has accepted that a change in the SOFA score is an acceptable surrogate marker of efficacy in exploratory trials of novel therapeutic agents in sepsis. The requirement to detect modest serial changes in a patients’ SOFA score therefore means that increased clarity on how the score should be assessed in different circumstances is required.This review explores the development of the SOFA score, its applications and the challenges associated with measurement. In addition, it proposes guidance designed to facilitate the consistent and valid assessment of the score in multicentre sepsis trials involving novel therapeutic agents or interventions.ConclusionThe SOFA score is an increasingly important tool in defining both the clinical condition of the individual patient and the response to therapies in the context of clinical trials. Standardisation between different assessors in widespread centres is key to detecting response to treatment if the SOFA score is to be used as an outcome in sepsis clinical trials.

The purpose of the study is to identify the components of immunity, which might predict the development of multiple organ failure in patients after heart surgery.Material and methods. The study included 40 patients who were operated in cardiac surgery Department. The inclusion criteria were the presence of indications for cardiac surgery. The exclusion criteria were the presence of infective endocarditis in patients. Before the operation and after 24 hours we studied the blood level of leukocytes and lymphocytes. We analyzed the phenotype of immune cells using monoclonal antibodies, serum levels of procalcitonin and C3 and C4 complement components. All patients were evaluated for multiple organ disfunction (MOD) using the SOFA scale.The results showed that cardiac surgery leads to the development of MOD, statistically significant multidirectional changes in both quantitative and qualitative composition of all cells of the immune system, significant changes in the level of C3 and C4 components of the cascade of complement and plasma level of pro-calcitonin. ROC analysis was revealed that the relative content of monocytes is less than 7.1% of the number of leukocytes as well as the absolute content of monocytes with the CD14 + HLA-DR + phenotype less than 0.32_109/l in the preoperative period, and the C3 level of the complement component less than 0.52 g/l, as well as the maximum SOFA score in the postoperative period, were the best predictors of MOD after the procedures.Conclusion. The components of innate immunity make it possible to predict the complication of the cardiac surgery, earlier than the SOFA scale.

Purpose of the study: to investigate the epidemiology of sepsis in patients with different locations of the infection focus, who were admitted to the intensive care unit (ICU) of a multi-specialty hospital in 2014 and 2016.Material and methods. A retrospective analysis of examination and treatment of 860 patients admitted to ICU of a multi-specialty hospital with the diagnosis ‘sepsis’ in 2014 and 2016 was carried out. Sepsis was diagnosed pursuant to the Sepsis-2 Guidelines and verified by blood procalcitonin test. The gender, age, main diagnosis, patient’s severity at the time of admission to ICU, duration in ICU, and peculiarities of intensive care and outcomes were studied.Results. Sepsis was diagnosed at admission in 2014 in 361 (8.6%) patients out of 4175 patients, in 2016 — in 499 (10.5%) out of 4726 patients who were admitted to ICU and had infection foci of different location. Abdominal sepsis was diagnosed in 72.3% of patients, pulmonary — in 19.7%; in 8% of patients, sepsis complicated the terminal stage of various, mostly oncological, diseases. In 2016, sepsis detectability at admission to ICU increased by 22.1% vs. the 2014 level assumed as 100% (χ2=9.281; P=0.003). In case of the abdominal sepsis, mortality amounted to 50.3% and was not different from mortality in pulmonary sepsis — 52.1% (χ2=0,163; P=0.687). The ICU in-patient duration in case of pulmonary sepsis was considerably longer than in case of abdominal. The age was a predictor of mortality in case of abdominal sepsis (the age older than 65 years predicted the risk of lethal outcome with sensitivity equal to 58.8% and specificity equal to 59.9%), which was not true for pulmonary sepsis. The mortality prognosis during abdominal sepsis was improved by combined analysis of the SOFA score and patient’s age at admission: AUROC of the combined index was equal to 0.816 (95%-confidence interval: 0.783–0.846). Depending on the infection focus location, specificity of influence rendered on mortality by different clinical indices and management methods was determined.Conclusion. Patients admitted to ICU with sepsis represent a group of a high mortality risk amounting to 50% approximately. During chronological analysis, sepsis detectability increases but mortality does not change. Patients with pulmonary sepsis at admission to ICU are characterized by a greater severity of condition due to multiple organ failure than in case of abdominal sepsis; in such patients it is impossible to predict the risk of mortality based on APACHE II and SOFA score. Taking into account heterogeneity of the sepsis patient population, deepening of the knowledge about peculiarities of pathogenesis and clinical pattern of abdominal and pulmonary sepsis is the basic requirement for improvement of the results of treatment of this complication.

The aim of the study was to determine the effect of chronic alcohol abuse on the course and outcome of bacterial meningitis (BM). We analyzed records of patients with BM who were hospitalized between January 2010 and December 2017 in the largest neuroinfection center in Poland. Out of 340 analyzed patients, 45 (13.2%) were alcoholics. Compared with non-alcoholics, alcoholics were more likely to present with seizures (p

Objective: to determine the feasibility of using C-reactive protein (CRP) and cholesterol levels as biochemical screening markers for multiple organ dysfunction syndrome (MODS) in patients after abdominal surgery.Materials and methods. A prospective case-control study was performed in 192 patients who receivedtreatment at the Intensive Care Unit (ICU) after abdominal surgery. Patients were classified into two groups: Group 1 (n=95) of patients without MODS and Group 2 (n=97) of patients with MODS. The signs of MODS were identified based on 2001 SCCM/ACCP consensus conference criteria. During the first three post-operative days, total cholesterol and CRP levels were measured, and severity was assessed using prognostic scoring systems (SOFA and Apache III). Logistic regression analysis was used to evaluate five MODS prediction models based on total cholesterol levels, CRP levels, a combination of cholesterol and CRP levels as well as SOFA and Apache III scores.Results. Cholesterol levels in Group 2 were found to be significantly lower than those in Group 1 (3.13 (2.6–3.74) mmol/l vs 4.09 (3.26–5.01) mmol/l; P0.05). Significantly increased CRP levels in Group 2 compared to Group 1 were found (168.7 (90.2–247.2) mg/l vs 85.9 (35.6–172.6) mg/l; P0.05). AUC, sensitivity, and specificity values were determined for the study models and scales based on total cholesterol levels (AUC 0.679; 95% confidence interval (CI) 0.625–0.732), CRP levels (AUC 0.67; 95% CI 0.6–0.74), a combination of cholesterol and CRP levels (AUC 0.819; 95% CI 0.721–0.917), SOFA score (AUC 0.786; 95% CI 0.744–0.829), and Apache III score (AUC 0.631; 95% CI 0.582–0.68). The optimal threshold was 3.4 mmol/l and 96.5 mg/l for cholesterol and CRP levels, respectively.Conclusion. Total cholesterol and CRP monitoring revealed them as screening biomarkers informative for predicting MODS within the first three days after abdominal surgery. Using all these models, the probability of MODS development in a patient can be calculated as a function of the numerical value of the biomarker.

Resource allocation in our overcrowded hospitals would require classification of inpatients according to the severity of illness, the evolving risk and the clinical complexity. Reverse triage (RT) is a method used in disasters to identify inpatients according to their use of hospital resources. The aim of this observational prospective study is to evaluate the use of RT in medical inpatients of an Italian Hospital and to compare the RT score with National Early Warning Score, Sequential Organ Failure Assessment and Charlson Comorbidity Index. Cluster sampling was performed on high dependency unit (HDU), geriatrics (Ger) and internal medicine (IM) wards. We calculate RT, NEWS, SOFA and CCI from inpatient charts. Length of stay (LOS), transfer to a higher level of care, death and discharge date were collected after 30 days. We obtained demographics, comorbidities, severity and clinical complexity of 260 inpatients. We highlighted differences in NEWS, SOFA and CCI in the three divisions. On the contrary RT score was uniformly high (median 7), with 85% of patients with RT = 8. NEWS, SOFA and CCI were higher in patients with higher RT score. We used the sum of the interventions listed by RT (RT sum) as a proxy of the level of care needed. RT-sum showed moderate correlation with NEWS (r = 0.52 Spearman, p

Background India is one of the seven identified countries in South-East Asia region regularly reporting dengue fever (DF)/dengue hemorrhagic fever (DHF) outbreaks. Even though the dengue prodrome and evolution of illness are most often similar in many patients, progress and outcome may differ significantly depending on the severity of illness as well as treatment instituted. We studied the clinical manifestations, outcome and factors predicting mortality of serology confirmed dengue fever cases admitted in Multidisciplinary Intensive Care Unit (MICU) of a high acuity healthcare facility in India. Methodology All patients with serology proven dengue fever admitted to MICU between 1st July 2015 and1st December 2015 were included in the study. Clinical presentation, laboratory findings, severity of illness scores and outcome were recorded. Results Majority of the patients (58.4%) belonged to 21–40 year age group. Hepatic (96.8%) followed by hematological (79.2%) involvement were the most common findings. CNS involvement observed among 27%. Survival to hospital discharge was 78.9%. Respiratory and gastrointestinal system involvement was associated with increased mortality. Acute respiratory distress syndrome (ARDS), acute kidney injury (AKI) and shock were the clinical syndromes associated with mortality. Serum lactate, aspartate transaminase (AST) and alanine transaminase (ALT) were significantly elevated among non survivors. Significant difference in sequential organ failure assessment (SOFA) and acute physiology and chronic health evaluation (APACHE) scores was also observed among survivors and non survivors. Conclusion Organ system involvement and higher disease severity scores are strong predictors of mortality. High index of suspicion for atypical manifestations of dengue is warranted. How to cite this article Padyana M, Karanth S, Vaidya S, Gopaldas JA. Clinical Profile and Outcome of Dengue Fever in Multidisciplinary Intensive Care Unit of a Tertiary Level Hospital in India. Indian J Crit Care Med 2019;23(6):270–273.

BACKGROUND Disease's severity classification systems are applied to measure the risk of death and to choose the best therapy for patients admitted to intensive care unit (ICU). The aim of the study was to verify risk of death calculated with APACHE II (Acute Physiology and Chronic Health Evaluation II), SAPS II (Simplified Acute Physiology Score II), SOFA (Sequential Organ Failure Assessment) and evaluate correlation between these scores. The usefulness of SOFA score as a sole scale also was assessed. METHODS This was a retrospective study conducted in 30-beds ICU in Krakow, Poland. Every male and female patient over 18 years old who was admitted to the ICU between 18.04.2016 and 12.08.2016 was included in the analysis. Patients who were transferred from another ICU were excluded from the research. APACHE II, SAPS II, SOFA were calculated after admission using laboratory results and clinical examination. Discrimination and calibration were used to validate these scoring system. RESULTS Analysis included 86 patients. The outcomes were compared within survivors and non-survivors groups. The prediction of death was statistically significant only for APACHE II and SAPS II. The best AUROC was for APACHE II 0.737 and SAPS II 0.737; discrimination for SOFA was not statistically significant. There was high correlation only between SAPS II and APACHE II results (r ≥ 0.7, P < 0.01). The calibration was excellent for SAPS II, P = 0.991, and slightly worse for APACHE II, P = 0.685, and SOFA, P = 0.540. Patients who survived spent more days on ICU (P < 0.01), mean Length of Stay (LOS) in this group was 38.25 ± 16.80 days. CONCLUSIONS APACHE II and SAPS II scales have better discrimination, calibration and power to predict deaths on ICU than SOFA. Among these scales SOFA did not achieve expected results.

Introduction. It is estimated that every year 31 million people suffer from sepsis and even 6 million cases of illness end up in the patient’s death. In 2016 the current definition of sepsis was established as a life-threatening multiorgan failure resulting from an abnormal immune response caused by patient infection. The pathobiological approach rejects the current method of diagnosing sepsis based on the occurrence of SIRS, because many other non-infectious diseases may also cause its occurrence. There was proposed a scale of progressive organ failure called SOFA and qSOFA. In May 2017, WHO released a resolution that obliges European Union countries to raise awareness about sepsis prevention, diagnosis, treatment and management. Results. A nurse is the person who spends the most time with a patient, thus becoming the best observer of changes in his/her vital functions and well-being. Nurses working in basic health care, hospital emergency ward and all departments not involved in intensive medical care, have an important role in prevention of infections, as over 70% of sepsis cases begins in a non-hospital environment, and the current level of public knowledge reaches only 14%.

Background We assessed the ability of baseline and serial measurements of mid-regional proadrenomedullin (MR-proADM) and mid-regional proatrial natriuretic peptide (MR-proANP) to predict 28-day mortality in critically ill patients with pneumonia compared with Acute Physiological and Chronic Health Evaluation IV (APACHE IV) model and Sequential Organ Failure Assessment (SOFA) score. Methodology Biomarkers were collected for the first five days in this retrospective observational cohort study. Biomarker clearance (as a percentage) was presented as biomarker decline in five days. We investigated the relationship between biomarkers and mortality in a multivariable Cox regression model. APACHE IV and SOFA were calculated after 24 hours from intensive care unit admission. Results In 153 critically ill patients with pneumonia, 28-day mortality was 26.8%. Values of baseline MR-proADM, MR-proANP, and APACHE IV were significantly higher in 28-day nonsurvivors, but not significantly different for SOFA score. Baseline MR-proADM and MR-proANP, APACHE IV, and SOFA had a low area under the curve in receiver operating characteristics (ROC) curves. No optimal cut-off points could be calculated. Biomarkers and severity scores were divided into tertiles. The highest tertiles baseline MR-proADM and MR-proANP were not significant predictors for 28-day mortality in a multivariable model with age and APACHE IV. SOFA was not a significant predictor in univariable analysis. Clearances of MR-proADM and MR-proANP were significantly higher in 28-day survivors. MR-proADM and MR-proANP clearances had similar low accuracy to identify nonsurvivors in ROC curves and were divided into tertiles. Low clearances of MR-proADM and MR-proANP (first tertiles) were significant predictors for 28-day mortality (hazard ratio [HR]: 2.38; 95% confidence interval [CI]: 1.21-4.70; p = 0.013 and HR: 2.27; 95% CI: 1.16-4.46; p = 0.017) in a model with age and APACHE IV. Conclusions MR-proADM and MR-proANP clearance performed better in predicting 28-day mortality in a model with age and APACHE IV compared with single baseline measurements in a mixed population of critically ill with pneumonia.

Background: Exertional heat stroke (EHS) is a life-threatening injury that can lead to acute kidney injury (AKI). The clinical characteristics of and risk factors for EHS complicated with AKI have been poorly documented.Methods: A retrospective study with EHS admitted to the intensive care unit (ICU) from January 2008 to June 2019 was performed. Data including baseline clinical information at admission, main organ dysfunction, 90-day mortality and total cost of hospitalization were collected.Results: A total of 187 patients were finally included, of which 82 (43.9%) had AKI. AKI patients had more severe organ injury and higher total hospitalization costs than non-AKI patients. Multivariate logistic analysis showed that lymphocyte, neutrophil, D-dimer and myoglobin (MB) ≥ 1,000 ng/ml were independent risk factors for AKI caused by EHS. In addition, SOFA score [hazard ratio (HR) 4.1, 95% confidence interval (95% CI) 1.6–10.8, P = 0.004] and GCS score (HR 3.2, 95% CI 1.2–8.4 P = 0.017) were the risk factor for 90-day mortality in patients with EHS complicated with AKI, with an area under the curve (AUC) of 0.920 (95% CI 0.842–0.998, P < 0.001) and 0.851 (95% CI 0.739–0.962, P < 0.001), respectively. Survival analysis showed that the 90-day mortality in AKI patients was significantly high (P < 0.0001) and the mortality rate of patients with AKI stage 2 was the highest than other stages.Conclusions: EHS complicated with AKI is associated with higher hospitalization costs and poorly clinical outcomes. MB ≥1,000 ng/ml, Inflammation, coagulation were associated with the occurrence and development of AKI. Early treatment strategies based reducing the SOFA and GCS score may be pivotal for improving the prognosis of EHS.

Several immune mechanisms activate in COVID-19 pathogenesis. Usually, coronavirus infection is characterized by dysregulated host immune responses, interleukine-6 increase, hyper-activation of cytotoxic CD8 T lymphocytes. Interestingly, Vitamin D deficiency has been often associated with altered immune responses and infections. In the present study, we evaluated Vitamin D plasma levels in patients affected with different lung involvement during COVID-19 infection.Lymphocyte phenotypes were assessed by flow cytometry. Thoracic CT scan involvement was obtained by an image analysis program.Vitamin D levels were deficient in (80%) of patients, insufficient in (6.5%) and normal in (13.5%). Patients with very low Vitamin D plasma levels had more elevated D-Dimer values, a more elevated B lymphocyte cell count, a reduction of CD8 + T lymphocytes with a low CD4/CD8 ratio, more compromised clinical findings (measured by LIPI and SOFA scores) and thoracic CT scan involvement.Vitamin D deficiency is associated with compromised inflammatory responses and higher pulmonary involvement in COVID-19 affected patients. Vitamin D assessment, during COVID-19 infection, could be a useful analysis for possible therapeutic interventions.'retrospectively registered'.

This study aimed to evaluate the accuracy and prognostic value of the sequential organ failure assessment (SOFA) score combined with C-reactive protein (CRP) in patients with complicated infective endocarditis (IE). A total of 246 consecutive patients with complicated IE were included in the multicentric prospective observational study. These patients were divided into four groups depending on the SOFA score and CRP optimal cutoff values (≥5 points and ≥17.6 mg/L, respectively), which were determined using the receiver operating characteristic analysis: low SOFA and low CRP (n = 83), low SOFA and high CRP (n = 87), high SOFA and low CRP (n = 25), and high SOFA and high CRP (n = 51). The primary endpoint was in-hospital death, and the secondary endpoint was long-time mortality, defined as subsequent readmission and 3-years mortality in the follow-up period. High SOFA score and high CRP were associated with approximately 29.410% (15/51) of higher incidence of in-hospital death with an area under the curve of 0.872. Multivariate analyses showed that age [odds ratio (OR) = 2.242, 1.142–4.401], neurological failure (Glasgow Coma Scale ≤ 12) (OR = 2.513, 1.041–4.224), Staphylococcus aureus (OR = 2.151, 1.252–4.513), SOFA ≥ 5 (OR = 9.320, 3.621–16.847), and surgical treatment (OR = 0.121, 0.031–0.342) were clinical predictors for in-hospital death. On following up for 12–36 months, SOFA ≥ 5 (p = 0.000) showed higher mortality. A high SOFA score combined with increased CRP levels is associated with in-hospital mortality. Also, SOFA score, but not CRP, predicts long-term mortality in complicated IE.

Introduction: Acute elevations of biomarkers reflecting myocardial injury, thrombosis, systemic inflammation, and heart dysfunction are associated with poor prognosis among hospitalized patients with COVID-19.1-3 In this study, we aimed to determine levels of these biomarkers in patients that were hospitalized with COVID-19 pneumonia at our institution during the first pandemic wave. Secondly, we aimed to determine if these biomarkers correlate with risk assessment tools such as MEWS (Modified Early Warning Score) and SOFA (Sequential Organ Failure Assessment) scores that reflect disease severity and clinical deterioration of patients. Patients and Methods: Data of 40 consecutive hospitalized patients with PCR-confirmed SARS- CoV-2 infection and pneumonia verified by imaging methods were considered for the analysis. Results: The mean age was 80.5 ± 9.9 years and 25 (78.1%) were women. Of these patients, 9 (22.5%) had a significant renal insufficiency (eGFR 14 pg/mL) while 10 patients (32.3%) satisfied acute heart failure rule-in criteria according to natriuretic peptide cut-off values adjusted for age. The mean hs-cTnT value was 28.9 ± 42.7 pg/mL while mean NT-proBNP value was 2481 ± 4662 pg/mL. One-third of patients (32.3%) had C-reactive protein values >41.1 mg/L (mean 33.7 ± 39.1 mg/L), highly predictive of severe disease. Nearly two-thirds of patients (N=19, 61.3%) had D-dimer levels >2.1 mg/L that was highly predictive of in-hospital death in previous studies (Figure 1). The mean MEWS and SOFA scores were 2.5 ± 1.6 and 3.1 ± 2.3 points, respectively. In decreasing order of relationship, CRP, D-dimer, and NT-proBNP values significantly correlated with both MEWS and SOFA scores as shown in Table 1. Troponin values had a borderline association with both risk scores. Conclusions: Our data show that a significant number of patients hospitalized due to COVID-19 were elderly and with a high risk of thrombotic events and cardiac insufficiency. Likewise, a high inflammatory burden was observed in one-third of patients. CRP correlated the most with MEWS and SOFA score, followed by D-dimer levels and NT- proBNP while no significant interaction was observed with cardiac troponin values.

Background Sepsis is a life-threatening clinical condition that happens when the patient’s body has an excessive reaction to an infection, and should be treated in one hour. Due to the urgency of sepsis, doctors and physicians often do not have enough time to perform laboratory tests and analyses to help them forecast the consequences of the sepsis episode. In this context, machine learning can provide a fast computational prediction of sepsis severity, patient survival, and sequential organ failure by just analyzing the electronic health records of the patients. Also, machine learning can be employed to understand which features in the medical records are more predictive of sepsis severity, of patient survival, and of sequential organ failure in a fast and non-invasive way. Dataset and methods In this study, we analyzed a dataset of electronic health records of 364 patients collected between 2014 and 2016. The medical record of each patient has 29 clinical features, and includes a binary value for survival, a binary value for septic shock, and a numerical value for the sequential organ failure assessment (SOFA) score. We disjointly utilized each of these three factors as an independent target, and employed several machine learning methods to predict it (binary classifiers for survival and septic shock, and regression analysis for the SOFA score). Afterwards, we used a data mining approach to identify the most important dataset features in relation to each of the three targets separately, and compared these results with the results achieved through a standard biostatistics approach. Results and conclusions Our results showed that machine learning can be employed efficiently to predict septic shock, SOFA score, and survival of patients diagnoses with sepsis, from their electronic health records data. And regarding clinical feature ranking, our results showed that Random Forests feature selection identified several unexpected symptoms and clinical components as relevant for septic shock, SOFA score, and survival. These discoveries can help doctors and physicians in understanding and predicting septic shock. We made the analyzed dataset and our developed software code publicly available online.

Background The diagnostic and prognostic utility of various sepsis scores varied among different cohorts and settings. Methods A prospective cohort study in adult patients with sepsis at Siriraj Hospital (Bangkok, Thailand) was conducted during January to July 2019. The performance of sepsis assessments, including systemic inflammatory response syndrome (SIRS) score, sequential organ failure assessment (SOFA) score, quick sepsis-related organ failure assessment (qSOFA) score, modified early warning score (MEWS), and national early warning score (NEWS), for sepsis detection and mortality prediction were compared with agreement between 2 infectious disease (ID) specialists to determine their sepsis and septic shock status as the reference standard. Results Among the 470 subjects included in this study, 206 patients (43.8%) were determined by 2 ID specialists to have sepsis. Systemic inflammatory response syndrome ≥2, qSOFA ≥2, and NEWS ≥5 yielded the highest sensitivity (93.2%), specificity (81.3%), and accuracy (72.6%), respectively, for detecting sepsis. The SIRS ≥2 had the highest sensitivity (97.8%), whereas qSOFA ≥2 had the highest specificity (61%) and accuracy (69.7%) for predicting mortality among sepsis patients. Receiver operating characteristic (ROC) curve showed MEWS to have the highest discriminatory power for sepsis detection (area under the ROC curve [AUROC], 0.79; 95% confidence interval [CI], 0.74–0.83), whereas SOFA had the highest discriminatory power for predicting hospital mortality (AUROC, 0.76; 95% CI, 0.69–0.79). Conclusions The NEWS ≥5 and qSOFA ≥2 were the most accurate scoring systems for sepsis detection and mortality prediction, respectively. Each scoring system is useful for different specific purposes relative to early detection and mortality prediction in sepsis patients., NEWS ≥5 and qSOFA ≥2 were the most accurate scoring systems for sepsis detection and mortality prediction, respectively. Each scoring system is useful for different specific purposes relative to early detection and mortality prediction in sepsis.