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. 2022 Aug 22;20(1):263.
doi: 10.1186/s12916-022-02461-7.

Modified cardiovascular SOFA score in sepsis: development and internal and external validation

Hui Jai Lee #  1 , Byuk Sung Ko #  2 , Seung Mok Ryoo #  3 , Eunah Han  4 , Gil Joon Suh  5 , Sung-Hyuk Choi  6 , Sung Phil Chung  4 , Tae Ho Lim  2 , Won Young Kim  3 , Woon Yong Kwon  5 , Sung Yeon Hwang  7 , You Hwan Jo  5 , Jonghwan Shin  1 , Tae Gun Shin  8 , Kyuseok Kim  9 ; Korean Shock Society
Collaborators, Affiliations

Modified cardiovascular SOFA score in sepsis: development and internal and external validation

Hui Jai Lee et al. BMC Med. .

Erratum in

Abstract

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.

Keywords: Mortality; Organ dysfunction scores; Sepsis; Severity of illness index.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Flow charts of the study population: suspected infection, sepsis, and septic shock cohorts. A The study population for derivation and internal validation. This cohort included patients who were suspected of having infection in a single university hospital. B An external validation cohort which included sepsis patients in three university hospital emergency departments. C Another external validation cohort which included septic shock patients in multi-center emergency departments
Fig. 2
Fig. 2
Distribution and 28-day mortality according to the original, modified, and vasopressor only cardiovascular SOFA score for each cohort. The 28-day mortality showed a linear increase with the modified cardiovascular SOFA score. Bar graphs represent the number of patients, and points with error bars indicate 28-day mortality with 95% confidence interval. Abbreviation: SOFA, sequential organ failure assessment
Fig. 3
Fig. 3
Calibration plots for 28-day mortality between the original, modified, and vasopressor only cardiovascular/total SOFA
Fig. 4
Fig. 4
Classification as sepsis and mortality rate according to the original and modified cardiovascular SOFA. The 276 patients who were classified as non-sepsis by the original SOFA score and were classified as sepsis by the modified SOFA score had a 28-day mortality of 6.5% (n = 18). Of the 11 patients classified as sepsis by the original SOFA who were classified as non-sepsis by the modified SOFA, the 28-day mortality rate was 0% (n = 0)
See this image and copyright information in PMC

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