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Comparative Study
. 2020 Feb 21;15(2):e0229199.
doi: 10.1371/journal.pone.0229199. eCollection 2020.

Comparison of a modified Sequential Organ Failure Assessment Score using RASS and FOUR

Gabriel Piñeiro Telles  1 , Isabella Bonifácio Brige Ferreira  2 , Rodrigo Carvalho de Menezes  3 , Thomas Azevedo do Carmo  4 , Paula Lins David Pugas  1 , Lara Freitas Marback  1 , Maria B Arriaga  5   6 , Kiyoshi F Fukutani  5 , Licurgo Pamplona Neto  7 , Sydney Agareno  7 , Kevan M Akrami  6   8 , Nivaldo Menezes Filgueiras Filho  2   4   7   9 , Bruno B Andrade  1   3   5   6
Affiliations
Comparative Study

Comparison of a modified Sequential Organ Failure Assessment Score using RASS and FOUR

Gabriel Piñeiro Telles et al. PLoS One. .

Abstract

Objective: ICU severity scores such as the Sequential Organ Failure Assessment (SOFA) determine neurologic dysfunction based on the Glasgow Coma Scale, a tool that may be limited in a critically ill population. It remains unknown whether alternative methods to assess for neurologic dysfunction, such as FOUR and RASS, are superior. This study aimed to determine the predictive performance of a modified SOFA tool in a large Brazilian ICU cohort.

Design: Prospective cohort single center study.

Setting: Mixed surgical and medical ICU in Salvador, Bahia, Brazil between August 2015 and December 2018.

Patients: All acutely ill ICU admissions, other than postoperative patients or those with insufficient data, were eligible for study inclusion.

Measurements and main results: 2147 patients were admitted to the ICU, of which 999 meeting inclusion criteria were included in the final analysis with a median age of 72 years (IQR 58-83) and a female predominance 545 (54%). The SOFA score using GCS, RASS and FOUR for the neurologic component performed marginally in the ability to predict general ICU mortality (SOFAGCS AUC 0.74 vs SOFARASS AUC 0.71 and SOFAFOUR AUC 0.67), with SOFAFOUR performing significantly lower compared to either SOFARASS and SOFAGCS (p<0.04, p<0.004 respectively). All three scores demonstrated decreased discriminate function in the mechanically ventilated population (SOFAGCS AUC 0.70 vs SOFARASS AUC 0.70 and SOFAFOUR AUC 0.55), though SOFAFOUR remained significantly worse when compared to SOFAGCS or SOFARASS (p = 0.034, p = 0.014, respectively).. Furthermore, performance was poor in a subset of patients with sepsis (n = 145) at time of admission (SOFAGCS AUC 0.66 vs SOFARASS AUC 0.55 and SOFAFOUR AUC 0.56).

Conclusion: Modification of the neurologic component in the SOFA score does not appear to improve mortality prediction in the ICU.

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Conflict of interest statement

The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. Flowchart of study participants.
Fig 2
Fig 2
Comparison of receiver operating characteristic (ROC) curves for prediction of ICU mortality by Sequential Organ Failure Assessment (SOFA) using Glasgow Coma Scale (GCS), Richmond Agitation and Sedation Scale (RASS) and Full Outline of UnResponsiveness (FOUR) neurologic assessment substitutions in the total cohort (A), subset undergoing mechanical ventilation (B) and septic subset (C). Comparisons between the absolute and differences of AUC were considered significant for p<0.05. AUC = area under the curve.
Fig 3
Fig 3. Adjusted and unadjusted Cox regression model for ICU mortality.
The effects of traditional and modified SOFA upon survival are constant over time and did not vary when each one was adjusted for age, gender and BMI (body mass index).
See this image and copyright information in PMC

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