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Application of SOFA score to trauma patients

Article  in  Intensive Care Medicine · April 1999

DOI: 10.1007/s001340050863

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Intensive Care Med (1999) 25: 389±394
Ó Springer-Verlag 1999 O R I GI N A L

M. Antonelli Application of SOFA score

R. Moreno
J.L. Vincent to trauma patients
C.L. Sprung
A. Mendoça
M. Passariello
L. Riccioni
J. Osborn
SOFA Group

Received: 3 March 1998

Accepted: 21 December 1998
)
M. Antonelli ( ) × M. Passariello ×
L. Riccioni × J. Osborn
Istituto di Anestesiologia e Rianimazione
and Istituto di Igiene,
Università ªLa Sapienzaº Rome, Italy
R. Moreno
Hospital de S. Antonio dos Capuchos,
ICU, Lisboa, Portugal
J.L. Vincent × A. Mendoça
Medical ICU,
Free University ªErasmeº of Brussels,
Belgium
C.L. Sprung
Hadassah Hebrew University Medical
Center, Jerusalem, Israel
Mailing address: Istituto di Anestesiologia
e Rianimazione, Università ªLa Sapienzaº,
Policlinico Umberto I, Viale del Policlinico
155, I-00 161 Rome, Italy
e-mail: max.antonelli@flashnet.it
Tel. + 39 (6) 4 46 31 01
Fax + 39(6)4 46 19 67
Abstract Objective: To assess the
ability of the SOFA score (Sequen-
tial Organ Failure Assessment) to
describe the evolution of organ dys-
function/failure in trauma patients
over time in intensive care units
(ICU).
Design: Retrospective analysis of a
prospectively collected database.
Setting: 40 ICUs in 16 countries.
Patients: All trauma patients admit-
ted to the ICU in May 1995.
Main outcome measures and results:
Incidence of dysfunction/failure of
different organs during the first
10 days of stay and the relation be-
tween the dysfunction, outcome,
and length of stay. Included in the
SOFA study were 181 trauma pa-
tients (140 males and 41 fe-
males).The non-survivors were sig-
nificantly older than the survivors
(51 years  20 vs 38  16 years,
p < 0.05) and had a higher global
SOFA score on admission (8  4 vs
4  3, p < 0.05) and throughout the
10-day stay. On admission, the non-
survivors had higher scores for re-
spiratory ( > 3 in 47 % of non-survi-
vors vs 17 % of survivors), cardio-
vascular ( > 3 in 24 % of non-survi-
vors vs 5.7 % of survivors), and neu-
rological systems ( > 4 in 41 % of
non-survivors vs 16 % of survivors);
although the trend was maintained
over the whole study period, the
differences were greater during the
first 4±5 days. After the first 4 days,
only respiratory dysfunction was
significantly related to outcome. A
higher SOFA score, admission to the
ICU from the same hospital, and the
presence of infection on admission
were the three major variables asso-
ciated with a longer length of stay in
the ICU (additive regression coeffi-
cients: 0.85 days for each SOFA
point, 4.4 for admission from the
same hospital, 7.26 for infection on
admission).
Conclusions: The SOFA score can
reliably describe organ dysfunction/
failure in trauma patients. Regular
and repeated scoring may be helpful
for identifying categories of patients
at major risk of prolonged ICU stay
or death.
Key words SOFA score × Multiple
trauma × Organ failure × Outcome

ma patients in the intensive care unit (ICU): those based

Introduction
Objective evaluation of the severity of trauma is essen-
tial for decision-making concerning prevention, patient
triage, intensive care management, outcome compari-
sons, and quality assurance. Currently, three classes of
scoring systems are available in the evaluation of trau-
on physiological parameters [Acute Physiology And
Chronic Health Evaluation (APACHE), Simplified
Acute Physiology Score, and Revised Trauma Score
(RTS)] [1±5], those based on definition of the entity
and localization of trauma [Injury Severity Score (ISS)]
[6], and those considering either anatomical lesions or
390

Table 1 The SOFA scoring system (PaO2 arterial oxygen tension, FIO2 fractional inspired oxygen, MAP mean arterial pressure)
SOFA score 0 1 2 3 4
Respiration
PaO2/FIO2 (mm Hg) > 400 K 400 K 300 K 200 K 100
with respiratory support
Coagulation
Platelets ” 103/mm3 > 150 K 150 K 100 K 50 K 20
Liver
Bilirubin (mg/dl) < 1.2 1.2±1.9 2.0±5.9 6.0±11.9 > 12.0
(mmol/l) < 20 20±32 33±101 102±204 > 204
Cardiovascular
Hypotension No hypotension MAP < 70 mm Hg Dopamine K 5 Dopamine > 5 Dopamine > 15
or dobutamine or epinephrine K 0.1 or epinephrine > 0.1
(any dose)a or norepinephrine K 0.1a or norepinephrine
> 0.1a
Central nervous system
Glasgow Coma Score 15 13±14 10±12 6±9 <6
Renal
Creatinine (mg/dl) < 1.2 1.2±1.9 2.0±3.4 3.5±4.9 > 5.0
(mmol/l) < 110 110±170 171±299 300±440 > 440
or urine output or < 500 ml/day or < 200 ml/day
a
Adrenergic agents administered for at least 1 h (doses given are in mg/kg per min)

deranged physiological parameters [Trauma Injury Se-
verity Score (TRISS) and A Severity Characterization
Of Trauma (ASCOT)] [7].
Many authors have emphasized the limitations of
these scoring systems in evaluating critically ill patients,
for several reasons. First, prognostic indices were con-
ceived for comparing health care quality between differ-
ent ICUs: hospital mortality seemed to be the best out-
come measure to distinguish between ICUs with high
quality (low risk-adjusted mortality) and low quality
treatment (high risk-adjusted mortality). However,
some authors have emphasized that the prognostic val-
ue of the available scoring systems is strictly dependent
on treatment. Two patients with a similar severity of ill-
ness might have greatly differing scores based on appro-
priate or inadequate resuscitation [8]. Second, the prog-
nosis assessment based on scores is only applicable to a
study population, not to an individual patient. Third,
the components of some scores are not easily obtained.
An ideal prognostic index should be based on variables
available by standard routine examinations, applicable
to heterogeneous patient groups, readily and widely
measurable, and not related to personal judgments or
affected by treatment [9]. Fourth, current severity scor-
ing is usually based on an estimation of mortality. A
treatment that does not affect mortality may still be ef-
fective: if morbidity rather than mortality is considered
as the major outcome measure, the impact of intensive
care on quality of life, length of stay in the ICU, costs,
etc. can be evaluated [10].
Recent papers have shown a new approach to the
evaluation of organ failure, focusing on morbidity in-
stead of mortality. New scoring systems have been de-
veloped and validated, including the Multiple Organ
Dysfunction score [11], the Logistic Organ Dysfunction
System score [12], and the SOFA (Sequential Organ
Failure Assessment) score. The SOFA score was devel-
oped through a consensus process [13] and afterwards
validated in a larger population of 1449 critically ill pa-
tients [14]. SOFA is composed of scores from six organ
systems (respiratory, cardiovascular, hepatic, coagula-
tion, renal, and neurological) graded from 0 to 4 accord-
ing to the degree of dysfunction/failure (see Table 1).
The present study focused on a subgroup of trauma pa-
tients, with the aim of assessing the ability of the SOFA
score to describe the evolution of organ dysfunction/
failure over time in trauma patients in ICUs. For this
purpose, the incidence of dysfunction/failure of differ-
ent organs during the first 10 days of stay in the ICU
and the relation between the dysfunction, outcome and
length of stay was investigated.
Patients and methods
The present study was initiated as part of the activities of the work-
ing group on sepsis of the European Society of Intensive Care Med-
icine. During May 1995, all patients admitted to the ICU, except
those whose stay was less than 48 h after uncomplicated surgery,
were included in the study. A total of 1449 critically ill patients
from 40 centers in Europe, Australia, Israel, and the United States
(see appendix) were considered eligible for the study. Data were
collected on admission and daily throughout the entire ICU stay
and the worst value for each parameter was recorded as raw data.
Mortality was assessed at ICU discharge. For the evaluation of the
 391

Table 2 Demographic characteristics of the 18 patients and SOFA

scores (total and for each organ) (mean ± SD) calculated on admis-
sion in survivors and non-survivors
No. (%) of patients
Females 41 (23)
Males 140 (77)
Infection on admission [No. (%)]
Present 21 (12)
Absent 156 (88)

Survivors Non-survivors
Age (years) (mean ± SD)* 38 ± 16 51 ± 20
ICU outcome [No. = (%)] 147 (81) 34 (19)
Hospital outcome [No. = (%)] 143 (80) 36 (20)
Patients still in ICU after 10 days 79 (53) 9 (26)
[No. = (%)]**
Total SOFA score*** 4±3 8±4 Fig. 1 Total SOFA score of survivors and non-survivors over time.
Respiratory system*** 1.6 ± 1.2 2.5 ± 1 The scores of non survivors were always significantly (* p < 0.05)
Coagulation 0.4 ± 0.7 1±1 higher during the first week. On days 8, 9, and 10 non-survivors
showed a similar trend, but this was not statistically significant at
Liver 0.4 ± 0.8 0.7 ± 1 the 0.05 level. Sixty-eight patients were discharged from the ICU
Cardiovascular system 0.4 ± 0.9 1.2 ± 1.6 alive and 25 subjects died within the first 10 days. Two patients
Neurological system 1.3 ± 1.5 1.8 ± 1.5 died and 5 were discharged during the first 24 h. On day 2, 6 pati-
ents died and 12 were discharged; on day 3, 2 patients died and 11
Renal system 0.3 ± 0.9 0.7 ± 1.2 were discharged; on day 4, another 2 patients died and 15 were dis-
2
* p < 0.001; ** c test: p < 0.01; *** t-test: p < 0.05 charged; on day 5, 3 patients died and 5 were discharged; on day 6,
5 died and 4 were discharged; on day 7, 2 died and 4 were dis-
charged; on day 8, 3 died and six were discharged; on days 9 and
presence or the absence of infection at admission and during the 10, no patient died and 6 were discharged. All the other survivors
ICU stay, the attending physicians were generically recommended and non-survivors were discharged or died after the first 10 days
to follow the Centers for Disease Control and Prevention guidelines of their ICU stay
for the diagnosis of nosocomial infections. Details concerning data
collection, terminology, and definitions are reported elsewhere
[14]. This study analyzed the data collection in the subpopulation admission to the ICU. ICU mortality was 19 % (34 pa-
of 181 trauma patients. The data were evaluated over a period of tients). The 34 non-survivors were significantly older
10 days, comparing the scores of survivors and non survivors, their
length of stay (LOS) in the ICU, and the incidence of infection.
than the 147 survivors (51  20 years vs 38  16 years,
After all the data had been collected, data were analyzed at the p < 0.001) and also had a higher total SOFA score (8  4
Institute of Hygiene of the University La Sapienza, Rome and in vs 4  3, p < 0.05) (Table 2). Over the 10-day period the
the Department of Biostatistics of the Free University of Brussels SOFA score remained higher in non survivors than in
using the Nanostat program (Adelso, Italy) and the SPSS/PC pro- survivors (Fig. 1). After 10 days, only 9 (26 %) of the 34
gram (version 5.0, SPSS, Chicago, Ill., USA). For a single missing non-survivors were still in the ICU, 25 (71 %) having
value a replacement was calculated using the mean of the preced-
ing and subsequent score. If more than one consecutive result was
died before. Seventy-nine (53 %) patients who survived
missing, it was considered as a missing value in the analysis. Means were discharged after the first 10 days (Table 2).
of continuous data were compared by a two-tailed t-test in sub- On admission, non-survivors had a higher respirato-
groups with normal data distribution. In cases of non-normality ry score than survivors (2.5  1 vs 1.6  1.2, p < 0.05),
(large positive skewness), a nonparametric rank test was used but the scores of the other variables were not signifi-
(Kruskal-Wallis test). Categorical data were evaluated using the cantly different. Stratification by the severity of the
chi-square statistics with Yates' correction and the chi-square test
for trend [15] or Fisher's test, when appropriate. Multiple regres-
scores for each variable on admission showed that non
sion analysis was used to evaluate the impact of each variable on survivors had more severe scores for respiratory, coagu-
the length of ICU stay and Cox's proportional hazards method for lation, cardiovascular, and neurological systems (47 %
the analysis of survival. Results are means ± SD. of the non-survivors and 17 % of the survivors had a
score of 3 or 4 for the respiratory system; 24 % of the
non-survivors had a cardiovascular score of 3 or 4, but
only 5.7 % of the survivors; 41 % of the non-survivors
Results
vs 16 % of survivors had a neurological score of 4)(Ta-
The principal characteristics of the 181 trauma patients ble 3). Although the trend was maintained over the
(141 males and 41 females) are reported in Table 2. study period, the differences were greater during the
Twenty-one patients (12 %) had a focus of infection on first 4±5 days. After the first 4 days, only the presence
392

Table 3 Severity stratification of SOFA scores for each organ on

admission obtained by the chisquare test with continuity correc-
tion
Non- Survivors p
survivors
Number of patients 34 147
Respiratory system [No. = (%)],
p < 0.0001*, 3 df
0 10 (29) 84 (57) 0.006*, 1 df
2 8 (23) 39 (26)
3 11 (32) 22 (15) 0.034*, 1 df
4 5 (15) 2 (2) 0.003 ²
Coagulation [No. = (%)],
p = 0.015*, 3 df
0 17 (50) 113 (77) 0.003*, 1 df
1 8 (23) 16 (11) Fig. 2 Survival rate of trauma patients with a SOFA score for the
2 6 (17) 14 (19) respiratory system above and below 3. All patients with a respira-
3 3 (9) 4 (3) tory score less than 3 closed squares had a significantly higher sur-
vival rate over time
Liver [No. = (%)], p = 0.79*
0 29 (85) 124 (84)
1 2 (6) 12 (8)
2 3 (9) 9 (6) over 65 years was 4.9 times that of those under 65
Cardiovascular system (p < 0.001), and patients with a total SOFA score equal
[No. = (%)], p = 0.012*, 3 df to or greater than 5 had a death rate 2.7 times that of pa-
0 23 (68) 130 (88) 0.006*, 1 df
1 3 (9) 8 (5) tients with a SOFA score of less than 5 (p < 0.05).
3 4 (12) 5 (3)
4 4 (12) 4 (2.7) 0.041 ²
Neurological system Discussion
[No. = (%)], p = 0.012*, 3 df
0 15 (44) 95 (65) 0.044*, 1 df The currently available trauma scoring systems includ-
2 3 (9) 11 (7) ing the RTS, ISS, TRISS, and ASCOT [1±7] all have
3 2 (6) 17 (12) their limitations. TRISS has become the most widely
4 14 (41) 24 (16) 0.003*, 1 df
used and reliable scoring system for trauma outcome as-
Renal system [No. = (%)], sessment and quality assurance [16]. The APACHE II
p = 0.915*
0 26 (76) 109 (74) system has been validated in outcome prediction and
1 5 (15) 25 (17) quality assurance in critically ill patients [17±19]. Unfor-
3 1 (3) 7 (5) tunately, the ISS does not describe physiologic variables
4 2 (6) 6 (4) and APACHE II does not have a component for ana-
Comparison between non-survivors and survivors: * chisquared tomical injury in trauma patients. Moreover, some au-
test with continuity correction; ² Fisher's exact test; df = degrees thors [20, 21] dispute the ability of the APACHE II
of freedom score to predict outcome in ICU trauma patients.
None of these scores, including SOFA provide suffi-
cient confidence for a prediction of outcome for individ-
of respiratory dysfunction had a significant prognostic ual patients [22]. All these scores [4, 17] have been
value (Fig. 2). designed to predict mortality but do not describe or-
Multiple regression analysis showed that a higher gan failure or its evolution. Recent scoring systems,
SOFA score, admission to the ICU from the same hospi- like SOFA, have tried to focus on morbidity as well [12,
tal, and the presence of infection on admission were the 23].
three major variables associated with a longer ICU LOS Recently, LeGall et al. [12] proposed a Logistic Or-
(additive regression coefficient: 0.85 days per SOFA gan Dysfunction System (LODS) score based on a com-
point, 4.14 days for admission from the same hospital, plicated calculation to assess organ failure in the ICU.
and 7.26 days for infection on admission) (Table 4). Even though both that score and the SOFA score de-
When Cox analysis was applied to mortality, those scribe organ dysfunction, LODS is basically different as
patients older than 65 years and with a SOFA score it is calculated and validated only on the day of admis-
greater than 5 had a significantly higher probability of sion. Moreover, SOFA analyzes organ failure as a dy-
death. Using these two predictors of survival, Cox re- namic process, and the simplicity of the score and of
gression showed that the death rate of patients aged the values used allows easy, repeated measures.

Table 4 Multiple regression analysis of the three major variables
associated with a longer ICU LOS (higher SOFA score, admission
from the same hospital, and the presence of infection on admis-
sion). Data refer to the first 5 days of ICU stay, as this period was
the most significant for prognosis. Cox analysis was used to verify
the impact of each variable on the length of ICU stay instead of
multiple regression. Cox regression is the only suitable method to
analyze the simultaneous effect of the prognostic factors on the
length of ICU stay
Day Additive regression coefficient (days)
SOFA Hosp. Infect No. of Mean
point patients LOS (days)
0 0.85 4.13 7.26 181 9.33 (9)
1 0.74 3.58 7.18 172 8.82 (8.99)
2 0.82 3.04 5.78 152 8.99 (8.94)
3 0.69 2.94 6.04 137 8.97 (8.88)
4 0.66 3.5 4.2 118 9.42 (8.25)
The SOFA score should be considered a tool which
describes organ dysfunction and the severity of dysfunc-
tion of each organ, and not simply a global number giv-
ing no information on individual organ status. Even
though the primary aim of the SOFA score is not to pre-
dict mortality, a relationship exists between organ fail-
ure and death, and thus between morbidity and mortali-
ty [14].
In a retrospective analysis, the relationship between
the SOFA score and outcome has been evaluated [14].
In the present study, scores for ICU survivors and non-
survivors with trauma have been collected prospectively
for evaluation and then compared. The study popula-
tion consisted of 181 ICU trauma patients, with a gender
distribution (77 % male) characteristic of trauma [24,
25]. The 81 % survival rate was close to that reported
by Wong et al. [22], who compared the APACHE II
score to the TRISS score in a larger population of 470
trauma patients.
The present study shows that the SOFA score can
also describe organ failure in trauma patients and may
be useful for assessing the evolution of organ failure
over time. Non-survivors had a higher total SOFA score
and the majority of them died within the first 10 days.
When analyzed each day for 10 consecutive days, the
SOFA score also showed a persistent trend with values
always higher in non survivors than in survivors. Inter-
estingly, the respiratory score seemed to distinguish be-
tween the survivors and the non-survivors better than
the other components. Non-survivors also had more se-
vere scores for cardiovascular and neurological systems.
As for the general ICU population, we expected that
a prolonged ICU stay could have been predicted on ad-
mission on the basis of the failure of those organs gener-
ally requiring longer intensive care support ± that is, car-
diovascular, neurological, and respiratory systems. Mul-
tiple regression analysis showed that only a higher
393
SOFA score, admission from the same hospital, and the
presence of infection on admission were the variables
associated with a longer stay in the ICU. Each unit of
SOFA measured on admission was associated with an
increase in the length of stay in the ICU of 0.85 days; pa-
tients admitted from the same hospital stayed 4.13 days
longer, and infection on admission increased the length
of stay by 1 week.
When a Cox analysis was applied to mortality, the si-
multaneous presence of a SOFA score above 5 on ad-
mission and age over 65 years was associated with an in-
creased death rate. The latter finding is in accordance
with those of other authors [22]. A strong association
between age and the onset of infectious complications,
such as nosocomial pneumonia, has been previously de-
scribed [26], but we are not able to identify any specific
pattern of organ dysfunction in the infected trauma pa-
tients in the present study. As it is difficult to identify
the exact time of onset of infection during the ICU
stay, attention was focused on the presence or absence
of infections on admission.
The main limitation of the present study was the lack
of an ISS, as it was not recorded in the multicenter study.
However, the comparison of a trauma score with SOFA
to predict outcome or LOS in the ICU was beyond the
scope of the present study, and the possibility of inte-
grating the two scores for the evaluation of trauma pa-
tients requires further study. A further limitation is that
being a multicenter study, there may be systematic dif-
ferences between centers. This could confound the ef-
fects of the variables included in the study, although in
practice this is unlikely to be important as all multicen-
ter trials present the same problem. Another point of
criticism is certainly linked to evaluation of the presence
or absence of infection on ICU admission. This is not a
part of the SOFA score, but it is indeed true that this as-
pect was evaluated solely based on the opinion of the at-
tending physician, who generically followed the recom-
mendations of the Centers for Disease Control and Pre-
vention. It is difficult to judge the correctness of this
evaluation. In practice, these difficulties arise for all di-
agnoses of nosocomial infection and not only for the di-
agnosis of infection on ICU admission. Moreover, the
fact that the presence of infection on admission was
one of the variables associated with a longer ICU stay
is compatible with, but does not constitute proof of, a
correct diagnosis by the attending physician.
When applied, the SOFA score only provides a use-
ful tool to describe, and not predict, the evolution of in-
dividual patients' conditions. It is worth stressing that,
conceptually, its use gives information that is not differ-
ent from that used to describe, for example, the severity
of the acute respiratory distress syndrome.
Even though the SOFA score was conceived as a de-
scriptive score for organ failure, it may be helpful for
identifying multiple trauma patients with a poor prog-
 394

nosis and with a higher probability of a prolonged ICU
stay. The usefulness of this score as regards prospective
decision making for individual patients remains to be
evaluated.
Appendix
Participating centers in the SOFA study
Erasme University Hospital (Brussels, Belgium); Universitµ La
Sapienza (Rome, Italy); Hosp. S. M. delle Grazie (Naples, Italy);
Universitätsklinik für Chirurgie (Vienna, Austria); Klinikum der
F. S.U Jena (Jena, Germany); Charing Cross Hospital (London,
United Kingdom); Hosp. Geral de St. Antônio (Porto, Portugal);
C. H. U. Vaudois (Lausanne, Switzerland); Univ. Cat. del Sacro
Cuore (Rome, Italy); University Hospital (Ghent, Belgium); Uni-
versity Hospital (Milan, Italy); H. G. U. Vall d'Hebron (Barcelona,
Spain); Hôpital St. Joseph (Paris, France); Kuopio University Hos-
pital (Kuopio, Finland); Ospedale Maggiore di Milano (Milan, Ita-
ly); Hadassah Hebrew Univ. Med. Cent. (Jerusalem, Israel); Free
University Hospital (Amsterdam, The Netherlands); Cattinara
Hospital (Trieste, Italy); Hospital Senhora da Oliveira (Gui-
marˆes, Portugal); Academisch Ziekenhuis (Nijmegen, The Neth-
erlands); Academic Hospital Dijkzigt (Rotterdam, The Nether-
lands); Comp. Hosp. Sta. Casa (Porto Alegre, Brazil); Hôpital
Boucicaut (Paris, France); Western General Hospital (Edinburgh,
United Kingdom); Hosp. Geral de St. Antonio dos Capuchos (Lis-
boa, Portugal); Bristol Royal Infirmary (Bristol, United King-
dom); KAT General Hospital (Athens, Greece); C. H. U. de Nan-
tes (Nantes, France); C. S. Santa Marcelina (Sˆo Paulo, Brazil);
Guy's Hospital (London, United Kingdom); St. Elizabeth Zie-
kenhuis Tilburg (Tilburg, The Netherlands); University Hospital
(Manchester, United Kingdom); Royal Prince Alfred Hospital
(Sydney, Australia); C. H. U. de Li›ge (Li›ge, Belgium);
C. H. R. U. de Marseille (Marseille, France); Hosp. Israelita Albert
Einstein (Sˆo Paulo, Brazil); The Toronto Hospital (Toronto, Ca-
nada); Hospital General de Castello (Castellon, Spain); C. H. U.
Cochin Port Royal (Paris, France).

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