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

Abstract

Background: The Sepsis-3 criteria introduced the system that uses the Sequential Organ-Failure Assessment (SOFA) score to defne sepsis. The cardiovascular SOFA (CV SOFA) scoring system needs modifcation due to the change in guideline-recommended vasopressors. In this study, we aimed to develop and to validate the modifed CV SOFA score.

Methods: We developed, internally validated, and externally validated the modifed CV SOFA score using the suspected infection cohort, sepsis cohort, and septic shock cohort. The primary outcome was 28-day mortality. The modifed CV SOFA score system was constructed with consideration of the recently recommended use of the vaso‑pressor norepinephrine with or without lactate level. The predictive validity of the modifed 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 modifed CV/total SOFA score to detect mortality in patients with suspected infection, sepsis, or septic shock.

Results: We identifed 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 modifed CV/total SOFA score was well-developed and internally and externally validated in terms of discrimination and calibration. Predictive validity of the modifed CV SOFA was signifcantly 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 modifed model classifed more patients to sepsis (66.0 vs 62.5%) and identifed 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 modifed CV/total SOFA score had higher predictive validity and identifed more patients at risk of septic mortality.