Shayan Rakhit1,2,3, Li Wang1,4, Christopher J Lindsell4, Morgan A Hosay1,3,5, James W Stewart3,6, Gary D Owen7, Fernando Frutos-Vivar8,9, Oscar Pen Uelas8,9, Andre S Esteban8,9, Antonio R Anzueto10,11, Konstantinos Raymondos12, Fernando Rios13, Arnaud W Thille14, Marco Gonza Lez15, Bin Du16, Salvatore M Maggiore17, Dimitrios Matamis18, Fekri Abroug19, Pravin Amin20, Amine A Zeggwagh20, E Wesley Ely1,2,21,22,23, Eduard E Vasilevskis1,2,22,23,24,25, Mayur B Patel1,2,3,23,26,27. 1. Critical Illness, Brain Dysfunction, and Survivorship (CIBS) Center, Nashville, TN. 2. Vanderbilt University School of Medicine, Nashville, TN. 3. Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, TN. 4. Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN. 5. Baylor University, Waco, TX. 6. Meharry Medical College, Nashville, TN. 7. Department of Pharmacy, Vanderbilt University Medical Center, Nashville, TN. 8. University Hospital of Getafe, Getafe, Community of Madrid, Spain. 9. Centro de Investigación Biomédica en red de Enfermedades Respiratorias, Getafe, Comunidad of Madrid, Madrid, Spain. 10. Department of Pulmonary Diseases and Critical Care Medicine, University of Texas Health Science Center, San Antonio, TX. 11. Pulmonary Section, Audie L Murphy VA Hospital, South Texas Veterans Healthcare System, US Department of Veterans Affairs, San Antonio, TX. 12. Hannover Medical School, Hannover, Germany. 13. Alejandro Posadas National Hospital, El Palomar, Buenos Aires, Argentina. 14. Poitiers University Hospital Center, Poitiers, France. 15. Medellin Clinic and Pontifical Bolivaran University, Medellin, Colombia. 16. Peking Union Medical College Hospital, Beijing, China. 17. G. d'Annunzio University of Chieti and Pescara, Chieti, Italy. 18. Papageorgiou General Hospital, Pavlos Melas, Thessaloniki, Greece. 19. Fattouma Bourguiba University Hospital, Monastir, Tunisia. 20. Bombay Hospital Institute of Medical Sciences, Mumbai, India. 21. Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN. 22. Geriatric Research, Education, and Clinical Center (GRECC) Service, Nashville VA Medical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs, Nashville, TN. 23. Center for Health Services Research, Vanderbilt University Medical Center, Nashville, TN. 24. Section of Hospital Medicine, Division of General Internal Medicine and Public Health, Department of Medicine, Vanderbilt University Medical Center, Nashville, TN. 25. Ibn Sina University Hospital Center & Mohammed V University of Rabat, Rabat, Morocco. 26. Surgical Service, Nashville VA Medical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs Nashville, TN. 27. Departments of Neurosurgery and Hearing and Speech Sciences, Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, TN.
Abstract
OBJECTIVE: In a multicenter, international cohort, we aimed to validate a modified Sequential Organ Failure Assessment (mSOFA) using the Richmond Agitation-Sedation Scale, hypothesized as comparable to the Glasgow Coma Scale (GCS)-based Sequential Organ Failure Assessment (SOFA). SUMMARY BACKGROUND DATA: The SOFA score, whose neurologic component is based on the GCS, can predict intensive care unit (ICU) mortality. But, GCS is often missing in lieu of other assessments, such as the also reliable and validated Richmond Agitation Sedation Scale (RASS). Single-center data suggested an RASS-based SOFA (mSOFA) predicted ICU mortality. METHODS: Our nested cohort within the prospective 2016 Fourth International Study of Mechanical Ventilation contains 4120 ventilated patients with daily RASS and GCS assessments (20,023 patient-days, 32 countries). We estimated GCS from RASS via a proportional odds model without adjustment. ICU mortality logistic regression models and c-statistics were constructed using SOFA (measured GCS) and mSOFA (measured RASS-estimated GCS), adjusted for age, sex, body-mass index, region (Europe, USA-Canada, Latin America, Africa, Asia, Australia-New Zealand), and postoperative status (medical/surgical). RESULTS: Cohort-wide, the mean SOFA=9.4+/-2.8 and mean mSOFA = 10.0+/-2.3, with ICU mortality = 31%. Mean SOFA and mSOFA similarly predicted ICU mortality (SOFA: AUC = 0.784, 95% CI = 0.769-0.799; mSOFA: AUC = 0.778, 95% CI = 0.763-0.793, P = 0.139). Across models, other predictors of mortality included higher age, female sex, medical patient, and African region (all P < 0.001). CONCLUSIONS: We present the first SOFA modification with RASS in a "real-world" international cohort. Estimating GCS from RASS preserves predictive validity of SOFA to predict ICU mortality. Alternative neurologic measurements like RASS can be viably integrated into severity of illness scoring systems like SOFA.
OBJECTIVE: In a multicenter, international cohort, we aimed to validate a modified Sequential Organ Failure Assessment (mSOFA) using the Richmond Agitation-Sedation Scale, hypothesized as comparable to the Glasgow Coma Scale (GCS)-based Sequential Organ Failure Assessment (SOFA). SUMMARY BACKGROUND DATA: The SOFA score, whose neurologic component is based on the GCS, can predict intensive care unit (ICU) mortality. But, GCS is often missing in lieu of other assessments, such as the also reliable and validated Richmond Agitation Sedation Scale (RASS). Single-center data suggested an RASS-based SOFA (mSOFA) predicted ICU mortality. METHODS: Our nested cohort within the prospective 2016 Fourth International Study of Mechanical Ventilation contains 4120 ventilated patients with daily RASS and GCS assessments (20,023 patient-days, 32 countries). We estimated GCS from RASS via a proportional odds model without adjustment. ICU mortality logistic regression models and c-statistics were constructed using SOFA (measured GCS) and mSOFA (measured RASS-estimated GCS), adjusted for age, sex, body-mass index, region (Europe, USA-Canada, Latin America, Africa, Asia, Australia-New Zealand), and postoperative status (medical/surgical). RESULTS: Cohort-wide, the mean SOFA=9.4+/-2.8 and mean mSOFA = 10.0+/-2.3, with ICU mortality = 31%. Mean SOFA and mSOFA similarly predicted ICU mortality (SOFA: AUC = 0.784, 95% CI = 0.769-0.799; mSOFA: AUC = 0.778, 95% CI = 0.763-0.793, P = 0.139). Across models, other predictors of mortality included higher age, female sex, medical patient, and African region (all P < 0.001). CONCLUSIONS: We present the first SOFA modification with RASS in a "real-world" international cohort. Estimating GCS from RASS preserves predictive validity of SOFA to predict ICU mortality. Alternative neurologic measurements like RASS can be viably integrated into severity of illness scoring systems like SOFA.