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Ann Thorac Surg 2006;82:2072-2078
© 2006 The Society of Thoracic Surgeons

Original Articles: Cardiovascular

Relation of the Sequential Organ Failure Assessment Score to Morbidity and Mortality After Cardiac Surgery

Tommi Pätilä, MDa,*, Sinikka Kukkonen, MD, PhDb, Antti Vento, MD, PhDa, Ville Pettilä, MD, PhDb, Raili Suojaranta-Ylinen, MD, PhDb

a Department of Cardiothoracic Surgery, Helsinki University Meilahti Hospital, Helsinki, Finland
b Department of Anesthesiology and Intensive Care Medicine, Helsinki University Meilahti Hospital, Helsinki, Finland

Accepted for publication June 2, 2006.

* Address correspondence to Dr Pätilä, Department of Cardiothoracic Surgery, University of Helsinki Meilahti Hospital, PO Box 340, FIN-00029 HUS, Helsinki, Finland. (Email: tommi.patila{at}hus.fi).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
BACKGROUND: Organ dysfunction evaluation using Sequential Organ Failure Assessment (SOFA) has been shown to predict mortality and morbidity in adult cardiac surgical patients with prolonged recovery. The purpose of this study was to evaluate the utility of SOFA in prediction of mortality and morbidity in a cohort of heterogeneous consecutive adult cardiac surgical patients.

METHODS: A prospective study of 857 consecutive patients entering in a single cardiac postoperative intensive care unit was assigned during the year 2004. The European System for Cardiac Operative Risk Evaluation (EuroSCORE) of each patient was assessed preoperatively. SOFA was calculated daily until intensive care unit discharge or for a maximum of 7 days. SOFA change between the first and the third postoperative day, maximum SOFA during the first 3 days, and maximal SOFA were calculated. Length of intensive care unit stay and 30-day mortality were assessed.

RESULTS: Maximum SOFA during the first 3 days and maximal SOFA-predicted 30-day mortality (area under the curve, 0.763 and 0.779, respectively) also correlated with the length of intensive care unit stay (p < 0.001 and p < 0.001, respectively). The EuroSCORE predicted both mortality and intensive care unit stay (p < 0.0001 and p < 0.0001). The correlation coefficient between the EuroSCORE and maximum SOFA during the first 3 days or maximal SOFA was low (r = 0.34 and 0.33, respectively, p < 0.0001 and p = 0.0001).

CONCLUSIONS: The SOFA score is an independent predictor of mortality and length of stay in cardiac surgical patients. The SOFA score is associated with mortality and morbidity even when assessed in the early postoperative period after adult cardiac surgery.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 
Postoperative scoring of cardiac surgical patients in the intensive care unit (ICU) is necessary for the measurement of morbidity. The measurement of morbidity is more sensitive than mortality in the evaluation of new treatment modalities, cost/benefit, or the quality and management of the ICU. It also holds possibilities for the comparison of results of institutions or surgeons. Risk-adjusted morbidity differences between surgeons’ performances might differ much more than mortality rates and also have economic aspects.

When preoperative risk algorithms are widely used and accepted in the practice of cardiac surgery, postoperative scoring would give another time point for patient evaluation, if assessed as an aid for clinical decision-making. After the operation, certain factors affecting the patient might be downgraded and new issues raised. The question to be asked at this time might be whether to continue ICU care. Many of the available ICU outcome prediction models ignore changes in patient status [1–3], which is the strength of the Sequential Organ Failure Assessment (SOFA) scoring system.

The SOFA system was created in a consensus meeting of the European Society of Intensive Care Medicine in 1994 and further revised in 1996. The SOFA is a six-organ dysfunction/failure score measuring multiple organ failure daily. Each organ is graded from 0 (normal) to 4 (the most abnormal), providing a daily score of 0 to 24 points (Table 1). The objective in the development of the SOFA was to create a simple, reliable, and continuous score easily obtained in every institution [4].


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  		Table 1. The Sequential Organ Failure Assessment (SOFA) Score
 
Although SOFA was developed primarily to describe and quantify organ function, it has been demonstrated in several studies to predict mortality and morbidity of critically ill patients [5–9]. Reports on the SOFA scoring system in cardiac surgical patient population have been sparse. The study by Ceriani and colleagues [10] included patients with an ICU stay of 4 days or more. SOFA scores of adult cardiac surgical population with uneventful recovery have not been published [10–12].

A lack of well validated, widely accepted postoperative ICU outcome prediction score for cardiac surgical patients is evident. Our aim was to examine the utility of the SOFA scoring system in the postoperative evaluation of cardiac surgical patients. We calculated associated European System for Cardiac Operative Risk Evaluation (EuroSCORE) values in the same population to enable comparison with the SOFA scores. The EuroSCORE has been well documented to predict morbidity and mortality after cardiac surgery in Europe and in North America [13–17]. We also evaluated the association of postoperative SOFA with preoperative EuroSCORE and sought to determine whether this later assessment would have impact in the prediction of morbidity and mortality.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
Study Population
Between January 1, 2004 and December 31, 2004, 902 patients underwent cardiac surgery or surgery of the great intrathoracic vessels in the University of Helsinki Meilahti Hospital. The study included all of the 855 cardiac surgical patients admitted in the 14-bed postcardiac surgery ICU. Excluded were transplantation patients and patients transferred into other ICUs after operation. From the postcardiac surgery ICU, patients were transferred directly to the surgical ward; no intermediate care unit was available. Approval for the study was given by the local ethics committee, which waived the need for informed consent.

Data Collection and Measurements
EuroSCORE data of each patient were collected preoperatively. Risk factors included in the EuroSCORE model were age, female gender, chronic pulmonary disease, extracardiac arteriopathy, neurologic dysfunction, previous cardiac surgery, increased serum creatinine level, active endocarditis, critical preoperative state, unstable angina, decreased left ventricular function, recent myocardial infarction, pulmonary hypertension, emergent surgery, cardiac operation other than isolated coronary artery bypass grafting, surgery on the thoracic aorta, and postinfarct septal rupture [13]. Patients’ demographic, laboratory, and clinical data were collected in the ICU.

The SOFA score (Table 1) was calculated every 24 hours until discharge or for a maximum of 7 days. In the calculation of the score, the worst values for a given day for each variable were included. The assumed Glasgow Coma Score values were used in sedated patients until proven otherwise. A value of 3 was used for the renal score in patients with continuous venovenous hemofiltration started in an indication of relatively low urine output and massive fluid load.

The maximum SOFA (maxSOFA) score was determined as the highest SOFA value during the ICU stay, {Delta}-SOFA31 was calculated by subtracting lowest SOFA value from highest SOFA value during the first 3 days. Patients discharged from the ICU before day 3 were included in the {Delta}-SOFA31 calculations. MaxSOFA3d was measured as the highest SOFA score during the first 3 days.

The Central Statistical office of Finland provided the 30- and 60-day mortality. Accuracy of the Central Statistical office of Finland concerning mortality is excellent. All individuals permanently living in Finland at the time of death are compiled in these statistics.

The SOFA and EuroSCORE were separately calculated for risk of death and compared. EuroSCORE was assessed from a larger group of patients: 5 patients died in the operating room.

Statistical Methods
Data were analyzed with SPSS 12.0 (SPSS Inc, Chicago, IL). Predictive power regarding 30-day and 60-day mortality was assessed by receiver operating characteristic (ROC) curve analysis. SOFA scores and EuroSCOREs during ICU stay were evaluated using nonparametric Kruskal-Wallis test with several groups and the Mann-Whitney U test between two groups. ICU mortalities among different groups according to ICU stay were compared using the Fisher test. Correlation between SOFA scores and the EuroSCORE values was assessed by the Spearman nonparametric test.


   Results
Top
 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
During the study period, complete data from the consecutive 855 patients entering the postcardiac surgery ICU were gathered for the evaluated variables. Surgical procedures are presented in Table 2. Of these patients, 444 stayed 2 days or longer and 84 stayed 7 days or longer in the ICU. All patients needed respiratory support when they arrived at the ICU, and the infusions given were adrenalin in 73%, noradrenalin in 80%, dopamine in 2%, and dobutamine in 0.6%. Prevalence of intraaortic balloon pump use was 2.8%.


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  		Table 2. Surgical Procedures
 
The EuroSCORE (mean ± SD) of these patients was 5.3 ± 3.5, and the mean logistic EuroSCORE was 8.0 ± 11.1%. Five patients died in the operating room, 12 patients died during their ICU stay, and 13 patients died after ICU discharge and within 60 days postoperatively. The 30-day mortality of all the operated on patients was 2.4%. Readmission rate to ICU was 2.6%. Table 3 summarizes the EuroSCORE and SOFA scores according to the length of stay in the ICU.


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  		Table 3. Patients Divided in Groups According to Length of Intensive Care Unit Stay
 
The predictive power of SOFA variables in mortality, namely maxSOFA3d (area under the curve [AUC], 0.76; 95% confidence interval [CI], 0.62 to 0.91) and maxSOFA (AUC, 0.78; 95% CI, 0.64 to 0.92), was reasonably good by ROC analysis (Fig 1) and comparable with the EuroSCORE (AUC, 0.87; 95% CI, 0.79 to 0.94) and the logistic EuroSCORE (AUC, 0.84; 95% CI, 0.76 to 0.92, Fig 1). The correlation of {Delta}-SOFA31 with 30-day mortality was only fair (AUC, 0.66; 95% CI, 055 to 0.77; p = 0.006). Lengths of ICU stay according to different maxSOFA scores are presented in Figure 2. Mortality increased with increasing SOFA scores, higher SOFA scores were associated with EuroSCORE, and there was also significant association with higher EuroSCORE and higher logistic EuroSCORE, respectively (Fig 3). Correlations between EuroSCORE and maxSOFA and maxSOFA3d were low (p < 0.0001; r = 0.33; 95% CI, 0.27 to 0.39; and p < 0.0001; r = 0.34; 95% CI, 0.27 to 0.40) respectively, Spearman correlation test). A similarly low correlation was observed between logistic EuroSCORE and maxSOFA and maxSOFA3d (p < 0.0001, r = 0.34, 95% CI, 0.2 to 0.40 and p < 0.0001, r = 0.35, 95% CI, 0.29 to 0.41, respectively, Spearman correlation test).


Figure 1
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  		Fig 1. The maximum Sequential Organ Failure Assessment score during first 3 days of intensive care unit (MaxSOFA3d) stay correlated with mortality along with the highest SOFA during first week of intensive care unit stay (maxSOFA). Logistic European System for Cardiac Operative Risk Evaluation (EuroSCORE) and EuroSCORE also correlated with mortality. (CI = confidence interval.)

 

Figure 2
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  		Fig 2. (A) Intensive care unit stay (continuous line) was longer in patients with a higher maximum Sequential Organ Failure Assessment score during first 3 days (maxSOFA3d) and (B) higher SOFA scores during first week (maxSOFA). Higher European System for Cardiac Operative Risk Evaluation (EuroSCORE) values (dotted line) were obtained from the patients who stayed longer in the ICU.

 

Figure 3
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  		Fig 3. (A) The continuous line describes the 30-day mortality (left scale) of the patients divided in groups according to maximum Sequential Organ Failure Assessment scores during first 3 days in the intensive care unit (ICU) (maxSOFA3d). The number of patients in each group can be seen in the upper row. The dotted line shows the Higher European System for Cardiac Operative Risk Evaluation (EuroSCORE) values of the patients in the same groups (right scale). (B) Similar parallel curves can be seen when patient groups were divided according to maximum SOFA score during the first week (MaxSOFA).

 

   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
In this study we demonstrate a significant correlation of the SOFA score in the mortality of the cardiac surgery patients in postoperative period. The highest SOFA score during the first 3 postoperative days and a greater increase in SOFA score during first 3 postoperative days had a significant correlation in the 30-day mortality.

In adult cardiac surgical patients with ICU stay of more than 4 days, Ceriani and colleagues [10] demonstrated that the SOFA score identified patients at increased risk for postoperative mortality. They also postulated, that SOFA could be used without any specific adaptations to grade postoperative morbidity. Our study also included patients with uneventful recovery and minimum postoperative ICU stay. We especially assessed SOFA variables of the first postoperative days to gauge the patients with straightforward recovery without incidents. We demonstrated an association of SOFA score in the mortality and morbidity during the first 3 days of postoperative ICU stay, even when uncomplicated patients were included. Thus, our study further supports the applicability of SOFA in adult cardiac surgical patients. However, despite the SOFA calculations providing information of peroperative and postoperative variables, the predictive power of the EuroSCORE for mortality was better.

Numerous preoperative risk-assessment scoring systems have been published. Preoperative evaluation gives information about the patient, mainly demographics, comorbidities, and heart disease. We used the EuroSCORE because it is widely accepted in Europe and has been selected as an official preoperative scoring system in our institution. It has also been validated in North America and Japan [16]. The EuroSCORE has been evaluated in the prediction of morbidity in many studies. Also in our study, the EuroSCORE was associated with a long postoperative stay.

Preoperative risk stratifications ignore the individual anatomic aspects of the patient’s heart disease and also the performance of the operating surgeon, whereas postoperative patient scoring gives information of the situation after the operation. In addition to the preoperative patient status assessment, postoperative organ function scoring support the existing data with another point of view.

The rather low correlation coefficient between SOFA and the EuroSCORE is because they both predict mortality and morbidity well, but reveal different high-risk patients. A patient with a low preoperative risk according to the EuroSCORE might have a stormy postoperative course that can be assessed by SOFA. This supports the potential of a look at the evolution of patient risk during the treatment process. Furthermore, additive assessment of these scores might be advantageous. The low incidence of index events in our material prevented further calculations.

The EuroSCORE has been proven to predict morbidity and mortality, and our study supports this observation compared with morbidity assessed by SOFA and also by length of ICU stay. The combination of preoperative cardiac lesions, perioperative cardiac events, complications, comorbidities, and the use of cardiopulmonary bypass (CPB) may predispose cardiac surgical patients to postoperative organ dysfunction resembling that of a general ICU population. The compatibility of the SOFA scoring system has been evaluated in both prospective and retrospective studies [4–9].

When organ function after cardiac surgery is examined, the cardiovascular evaluation is of great interest. Assessment of perfusion and imaging of ventricular wall thickening and movement with controlled end-diastolic pressure would give the most information about heart function [18], but the routine performance of these kinds of measurements would be laborious, expensive, and unnecessary in most cases.

In the SOFA scoring system, cardiovascular measurement is performed on treatment criteria, and the inotropic agents and vasopressors needed for appropriate cardiac output and blood pressure are gauged. Extensive and liberal use of inotropic agents and vasopressors because of myocardial stunning and the inflammatory response caused by CPB might lead to high scores in this particular organ system in all the patients in the first hours after ICU admission. It has been demonstrated that if ejection fraction decreased to below 0.46 in cardiosurgical patients, the need for inotropic agents was 71% to 100%. Even patients with a proper ejection fraction may need inotropic support because of local wall motion abnormalities and an increase in left ventricular end-diastolic pressure. Transient myocardial ischemia secondary to cardiac surgery and cardioplegic arrest may be associated with myocardial stunning and the need for inotropic and mechanical support [19–21].

Cardiovascular scoring simply by medication is thus less sensitive in detecting the differences among patients on the first postoperative day, nevertheless sensitivity increases over time. On the other hand, institutional preferences in the use of inotropic and vasoactive drugs affect the scoring. In our institution, we use mostly epinephrine and less dopamine and dobutamine, which give higher scoring in SOFA. However, patient-related changes in vasoactive treatment reflected by change in SOFA score during the first ICU days may be highly predictive for later death because extended need for vasoactive treatment is associated with unfavorable outcome after cardiac surgery [11].

Postoperative cardiac surgical patients have certain peculiarities in other organ systems that may modify SOFA scoring, especially in the early postoperative period. CPB and general anesthesia causes ventilation/perfusion mismatch and intrapulmonary shunting, compromising oxygenation. The underlying causes include atelectasis, hemodilution, and noncardiogenic pulmonary edema from the endothelial dysfunction [22].

Hepatic dysfunction is fairly common after open heart surgery, and transient hyperbilirubinemia will develop in about one third of the patients. Most of the increase of total bilirubin caused by CPB occurs on the first postoperative day. This comes from an increase in unconjugated bilirubin by increased hemolysis peroperatively [23]. In the case of hepatic failure, it takes a few days for hyperbilirubinemia to develop.

In critically ill patients, discontinuation of sedatives for neurologic evaluation was not practiced until adequate hemodynamic stability was reached. Thus, patients with stroke might receive too low SOFA scores in the first few days. However, critically ill patients with an unstable postoperative course after cardiac surgery are almost without exception in severe fluid excess when it is uncommon to reach normal mental status according to the Glasgow Coma Scale even with intact brain [24].

CPB has been shown to lower platelet count in the early postoperative period, thus affecting the SOFA score by itself. Depression of hematopoietic system shows lowering of the platelet count during days, when the imbalance between normal depletion and the formation of new platelets becomes evident [25].

Continuous hemofiltration as a renal support for fluid removal is indicated in some cardiac surgical patients despite normal renal function measured by SOFA. These treatments are initiated individually by evaluating the whole status of the patient not by following rigid criteria. In these cases, the treatment might change the renal SOFA score without alterations in the organ function.

In a recent study, Hekmat and colleagues [26] developed a specific postoperative score for cardiac surgical patients, the Cardiac Surgery Score (CASUS). It has similarities with the SOFA score. Same measured variables include arterial partial pressure of oxygen/fraction of inspired oxygen ratio, serum creatinine level, serum bilirubin level, platelet count, and neurologic state, although point limits differ and neurologic score is simplified from Glasgow Coma Scale. CASUS also measures the cardiovascular score, although according to the multiple organ dysfunction score [27]. Additional variables in CASUS compared with the SOFA are blood lactate level, intraaortic balloon pump usage, ventricular assist device existence, and continuous venovenous hemofiltration or dialysis. In the CASUS model inotropic agents were excluded based on different therapy protocols between ICUs and variation in patient volume status. This kind of minor modification of SOFA scoring might be advantageous, although not proven. For a clinical use, the organ function score system should be as simple as possible. Multicenter studies would be needed for a scoring system to identify the most important postoperative parameters for cardiac surgical patients.

Our purpose was to analyze a cohort of major cardiac surgery patients. Because of the rather small cohort and low mortality, no restrictions according to type of surgery were made. Different surgical procedures are associated with different pathophysiologic heart diseases, different perfusion times, and different amount of surgical trauma. These factors lead to variability in the morbidity and mortality of the population. Restriction of analysis in one type of surgery might have given more detailed information of the function of SOFA. The rather small sample size of 855 patients is a significant limitation in our study. The single institution assessment also limits the usefulness of our results.

Our study shows the feasibility of SOFA scoring in the assessment of a cardiac surgical patient population. SOFA correlates well in the morbidity and mortality, despite being rather simple. This kind of daily scoring might be advantageous for clinical use for evaluating the ICU population at certain time for optimizing the consumption of ICU resources and to characterize severity of the patient material as an outcome measure instead of mortality in clinical trials. Moreover, the description of organ dysfunction is simple enough to be repeatedly and reliably measured in every institution. Values based on laboratory, oxygenation, and vasoactive treatment can be easily gathered automatically if a patient data management system is available. The SOFA score would be too gross for individual decision-making, but SOFA score sequences might be helpful in identifying certain organ dysfunction development for a patient recovering after cardiac surgery.

There are evident problems associated with the SOFA score in the assessment of postoperative cardiac surgical patients. The SOFA score system has a very good association to the mortality and morbidity in our study. Concomitant evaluation of the EuroSCORE further proves the usefulness of postoperative scoring system in the evaluation of cardiac surgical patients. For optimal scoring system, multicenter studies should be executed. [28].


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

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