Describing organ dysfunction in the intensive care unit: a cohort study of 20,000 patients

Andrea Soo, Danny J Zuege, Gordon H Fick, Daniel J Niven, Luc R Berthiaume, Henry T Stelfox, Christopher J Doig, Andrea Soo, Danny J Zuege, Gordon H Fick, Daniel J Niven, Luc R Berthiaume, Henry T Stelfox, Christopher J Doig

Abstract

Background: Multiple organ dysfunction is a common cause of morbidity and mortality in intensive care units (ICUs). Original development of the Sequential Organ Failure Assessment (SOFA) score was not to predict outcome, but to describe temporal changes in organ dysfunction in critically ill patients. Organ dysfunction scoring may be a reasonable surrogate outcome in clinical trials but further exploration of the impact of case mix on the temporal sequence of organ dysfunction is required. Our aim was to compare temporal changes in SOFA scores between hospital survivors and non-survivors.

Methods: We performed a population-based observational retrospective cohort study of critically ill patients admitted from January 1, 2004, to December 31, 2013, to 4 multisystem adult intensive care units (ICUs) in Calgary, Canada. The primary outcome was temporal changes in daily SOFA scores during the first 14 days of ICU admission. SOFA scores were modeled between hospital survivors and non-survivors using generalized estimating equations (GEE) and were also stratified by admission SOFA (≤ 11 versus > 11).

Results: The cohort consisted of 20,007 patients with at least one SOFA score and was mostly male (58.2%) with a median age of 59 (interquartile range [IQR] 44-72). Median ICU length of stay was 3.5 (IQR 1.7-7.5) days. ICU and hospital mortality were 18.5% and 25.5%, respectively. Temporal change in SOFA scores varied by survival and admission SOFA score in a complicated relationship. Area under the receiver operating characteristic (ROC) curve using admission SOFA as a predictor of hospital mortality was 0.77. The hospital mortality rate was 5.6% for patients with an admission SOFA of 0-2 and 94.4% with an admission SOFA of 20-24. There was an approximately linear increase in hospital mortality for SOFA scores of 3-19 (range 8.7-84.7%).

Conclusions: Examining the clinical course of organ dysfunction in a large non-selective cohort of patients provides insight into the utility of SOFA. We have demonstrated that hospital outcome is associated with both admission SOFA and the temporal rate of change in SOFA after admission. It is necessary to further explore the impact of additional clinical factors on the clinical course of SOFA with large datasets.

Keywords: Cohort studies; Critical illness; Intensive care units; Multiple organ failure; Natural history; Organ dysfunction scores.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Hospital mortality by a admission, b maximum, and c highest SOFA scores. SOFA, Sequential Organ Failure Assessment
Fig. 2
Fig. 2
Hospital mortality by a admission, b maximum, and c highest SOFA scores excluding CNS component. CNS, central nervous system; SOFA, Sequential Organ Failure Assessment
Fig. 3
Fig. 3
a–d SOFA scores by hospital mortality overall and by subgroups (admission SOFA, period, and LOS). SOFA, Sequential Organ Failure Assessment; LOS, length of stay
Fig. 4
Fig. 4
a–c SOFA scores by hospital mortality overall using a nonlinear, b spline, and c categorical GEE models. The points represent results from the piecewise linear GEE model. SOFA, Sequential Organ Failure Assessment
Fig. 5
Fig. 5
a–d SOFA scores by ICU mortality overall and by subgroups (admission SOFA, period, and LOS). SOFA, Sequential Organ Failure Assessment; LOS, length of stay
Fig. 6
Fig. 6
Hospital mortality by early change in daily SOFA scores. SOFA, Sequential Organ Failure Assessment
Fig. 7
Fig. 7
ICU mortality by early change in daily SOFA scores. SOFA, Sequential Organ Failure Assessment
Fig. 8
Fig. 8
ROC and PR curves for predictors of hospital and ICU mortality. ROC, receiver operating characteristic; PR, precision-recall

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