The value of various severity assessment scoring systems in sepsis diagnosis and long-term prognosis prediction after cardiac surgery_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

SHEN Ruihuan ,  WANG Xu , LU Zhongyuan

Department of Pediatric Cardiac Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100037, P. R. China;

Corresponding author：

WANG Xu, Email: fwpicu@163.com

Keywords：

Sepsis; cardiac surgery; intensive care unit; survival analysis; MIMIC-Ⅲ

DOI：

10.7507/1007-4848.202007060

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Objective To evaluate the diagnostic value of various severity assessment scoring systems for sepsis after cardiac surgery and the predictive value for long-term prognosis.Methods The clinical data of patients who underwent cardiac sugeries including coronary artery bypass grafting (CABG) and (or) valve reconstruction/valve replacement were extracted from Medical Information Mark for Intensive Care-Ⅲ (MIMIC-Ⅲ). A total of 6 638 patients were enrolled in this study, including 4 558 males and 2 080 females, with an average age of 67.0±12.2 years. Discriminatory power was determined by comparing the area under the receiver operating characteristic (ROC) curve (AUC) for each scoring system individually using the method of DeLong. An X-tile analysis was used to determine the optimal cut-off point for each scoring system, and the patients were grouped by the cut-off point, and Kaplan-Meier curves and log-rank test were applied to analyze their long-term survival.Results Compared with the sequential organ failure assessment (SOFA) score, acute physiology score-Ⅲ (APS-Ⅲ, P<0.001), the simplified acute physiology score-Ⅱ (SAPS-Ⅱ, P<0.001) and logistic organ dysfunction score (LODS, P<0.001) were more accurate in distinguishing sepsis. Compared with the non-septic group, the 10-year overall survival rate of the septic group was lower (P<0.001). Except for the systemic inflammation response score (SIRS) system, the 10-year overall survival rates of patients in the high risk layers of SOFA (HR=2.50, 95%CI 2.23-2.80, P<0.001), SAPS (HR=2.93, 95%CI 2.64-3.26, P<0.001), SAPS-Ⅱ (HR=2.77, 95%CI 2.51-3.04, P<0.001), APS-Ⅲ (HR=2.90, 95%CI 2.63-3.20, P<0.001), LODS (HR=2.17, 95%CI 1.97-2.38, P<0.001), modified logistic organ dysfunction score (MLODS, HR=2.04, 95%CI 1.86-2.25, P<0.001) and the Oxford acute severity of illness score (OASIS, HR=2.37, 95%CI 2.16-2.60, P<0.001) systems were lower than those in the low risk layers.Conclusion Compared with SOFA score, APS-Ⅲ score may have higher value in the diagnosis of sepsis in patients who undergo isolated CABG, a valve procedure or a combination of both. Except for SIRS scoring system, SOFA, APS-Ⅲ, SAPS, SAPS-Ⅱ, LODS, MLODS and OASIS scoring systems can be applied to predict the long-term outcome of patients after cardiac surgery.

Citation： SHEN Ruihuan, WANG Xu, LU Zhongyuan. The value of various severity assessment scoring systems in sepsis diagnosis and long-term prognosis prediction after cardiac surgery. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2022, 29(2): 219-227. doi: 10.7507/1007-4848.202007060 Copy

1.	van Diepen S, Graham MM, Nagendran J, et al. Predicting cardiovascular intensive care unit readmission after cardiac surgery: derivation and validation of the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) cardiovascular intensive care unit clinical prediction model from a registry cohort of 10, 799 surgical cases. Crit Care, 2014, 18(6): 651.
2.	Vincent JL, Sakr Y, Sprung CL, et al. Sepsis in European intensive care units: Results of the SOAP study. Crit Care Med, 2006, 34(2): 344-353.
3.	Nee PA. Critical care in the emergency department: Severe sepsis and septic shock. Emerg Med J, 2006, 23(9): 713-717.
4.	Reinhart K, Daniels R, Kissoon N, et al. Recognizing sepsis as a global health priority—A WHO resolution. N Engl J Med, 2017, 377(5): 414-417.
5.	Fleischmann C, Scherag A, Adhikari NK, et al. Assessment of global incidence and mortality of hospital-treated sepsis: Current estimates and limitations. Am J Respir Crit Care Med, 2016, 193(3): 259-272.
6.	Gotts JE, Matthay MA. Sepsis: Pathophysiology and clinical management. BMJ, 2016, 353: 1585-1604.
7.	Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA, 2016, 315(8): 801-810.
8.	Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med, 1996, 22(7): 707-710.
9.	Vincent JL, de Mendonça A, Cantraine F, et al. Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: Results of a multicenter, prospective study. Working Group on "Sepsis-related Problems" of the European Society of Intensive Care Medicine. Crit Care Med, 1998, 26(11): 1793-1800.
10.	Khwannimit B. A comparison of three organ dysfunction scores: MODS, SOFA and LOD for predicting ICU mortality in critically ill patients. J Med Assoc Thai, 2007, 90(6): 1074-1081.
11.	Minne L, Abu-Hanna A, de Jonge E. Evaluation of SOFA-based models for predicting mortality in the ICU: A systematic review. Crit Care, 2008, 12(6): 161-173.
12.	Granholm A, Møller MH, Krag M, et al. Predictive performance of the Simplified Acute Physiology Score (SAPS) Ⅱ and the initial Sequential Organ Failure Assessment (SOFA) score in acutely ill intensive care patients: Post-hoc analyses of the SUP-ICU inception cohort study. PLoS One, 2016, 11(12): e0168948.
13.	Safari S, Shojaee M, Rahmati F, et al. Accuracy of SOFA score in prediction of 30-day outcome of critically ill patients. Turk J Emerg Med, 2016, 16(4): 146-150.
14.	ffrench-O'Carroll R, Frohlich S, Murphy N, et al. Predictors of outcome in decompensated liver disease: Validation of the SOFA-L score. Ir Med J, 2015, 108(4): 114-116.
15.	Pan HC, Jenq CC, Tsai MH, et al. Scoring systems for 6-month mortality in critically ill cirrhotic patients: A prospective analysis of chronic liver failure - sequential organ failure assessment score (CLIF-SOFA). Aliment Pharmacol Ther, 2014, 40(9): 1056-1065.
16.	Le Gall JR, Loirat P, Alperovitch A, et al. A simplified acute physiology score for ICU patients. Crit Care Med, 1984, 12(11): 975-977.
17.	Moemen ME. Prognostic categorization of intensive care septic patients. World J Crit Care Med, 2012, 1(3): 67-79.
18.	Wang H, Ye L, Yu L, et al. Performance of sequential organ failure assessment, logistic organ dysfunction and multiple organ dysfunction score in severe sepsis within Chinese intensive care units. Anaesth Intensive Care, 2011, 39(1): 55-60.
19.	Chen Q, Zhang L, Ge S, et al. Prognosis predictive value of the Oxford Acute Severity of Illness Score for sepsis: A retrospective cohort study. PeerJ, 2019, 7: e7083-e7096.
20.	Kaukonen KM, Bailey M, Pilcher D, et al. Systemic inflammatory response syndrome criteria in defining severe sepsis. N Engl J Med, 2015, 372(17): 1629-1638.
21.	Johnson AE, Pollard TJ, Shen L, et al. MIMIC-Ⅲ, a freely accessible critical care database. Sci Data, 2016, 24(3): 1-9.
22.	Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS international sepsis definitions conference. Intensive Care Med, 2003, 29(4): 530-538.
23.	Camp RL, Dolled-Filhart M, Rimm DL. X-tile: A new bio-informatics tool for biomarker assessment and outcome-based cut-point optimization. Clin Cancer Res, 2004, 10(21): 7252-7259.
24.	Johnson AE, Stone DJ, Celi LA, et al. The MIMIC Code Repository: Enabling reproducibility in critical care research. J Am Med Inform Assoc, 2018, 25(1): 32-39.
25.	Zhang Z. Accessing critical care big data: A step by step approach. J Thorac Dis, 2015, 7(3): 238-242.
26.	DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: A nonparametric approach. Biometrics, 1988, 44(3): 837-845.
27.	Boumendil A, Somme D, Garrouste-Orgeas M, et al. Should elderly patients be admitted to the intensive care unit? Intensive Care Med, 2007, 33(7): 1252-1262.
28.	Hennessy D, Juzwishin K, Yergens D, et al. Outcomes of elderly survivors of intensive care: A review of the literature. Chest, 2005, 127(5): 1764-1774.
29.	Nathanson BH, Higgins TL, Brennan MJ, et al. Do elderly patients fare well in the ICU? Chest, 2011, 139(4): 825-831.
30.	Sacanella E, Pérez-Castejón JM, Nicolás JM, et al. Mortality in healthy elderly patients after ICU admission. Intensive Care Med, 2009, 35(3): 550-555.
31.	de Jonge E, Bosman RJ, van der Voort PH, et al. Intensive care medicine in the Netherlands, 1997-2001. Ⅰ. Patient population and treatment outcome. Ned Tijdschr Geneeskd, 2003, 147(21): 1013-1017.
32.	Li Y, Yan C, Gan Z, et al. Prognostic values of SOFA score, qSOFA score, and LODS score for patients with sepsis. Ann Palliat Med, 2020, 9(3): 1037-1044.
33.	Johnson AE, Kramer AA, Clifford GD. A new severity of illness scale using a subset of acute physiology and chronic health evaluation data elements shows comparable predictive accuracy. Crit Care Med, 2013, 41(7): 1711-1718.
34.	Liao MM, Lezotte D, Lowenstein SR, et al. Sensitivity of systemic inflammatory response syndrome for critical illness among ED patients. Am J Emerg Med, 2014, 32(11): 1319-1325.
35.	Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM consensus conference committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest, 1992, 101(6): 1644-1655.
36.	Churpek MM, Zadravecz FJ, Winslow C, et al. Incidence and prognostic value of the systemic inflammatory response syndrome and organ dysfunctions in ward patients. Am J Respir Crit Care Med, 2015, 192(8): 958-964.
37.	Knaus WA, Wagner DP, Draper EA, et al. The APACHE Ⅲ prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults. Chest, 1991, 100(6): 1619-1636.

1. van Diepen S, Graham MM, Nagendran J, et al. Predicting cardiovascular intensive care unit readmission after cardiac surgery: derivation and validation of the Alberta Provincial Project for Outcomes Assessment in Coronary Heart Disease (APPROACH) cardiovascular intensive care unit clinical prediction model from a registry cohort of 10, 799 surgical cases. Crit Care, 2014, 18(6): 651.
2. Vincent JL, Sakr Y, Sprung CL, et al. Sepsis in European intensive care units: Results of the SOAP study. Crit Care Med, 2006, 34(2): 344-353.
3. Nee PA. Critical care in the emergency department: Severe sepsis and septic shock. Emerg Med J, 2006, 23(9): 713-717.
4. Reinhart K, Daniels R, Kissoon N, et al. Recognizing sepsis as a global health priority—A WHO resolution. N Engl J Med, 2017, 377(5): 414-417.
5. Fleischmann C, Scherag A, Adhikari NK, et al. Assessment of global incidence and mortality of hospital-treated sepsis: Current estimates and limitations. Am J Respir Crit Care Med, 2016, 193(3): 259-272.
6. Gotts JE, Matthay MA. Sepsis: Pathophysiology and clinical management. BMJ, 2016, 353: 1585-1604.
7. Singer M, Deutschman CS, Seymour CW, et al. The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA, 2016, 315(8): 801-810.
8. Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine. Intensive Care Med, 1996, 22(7): 707-710.
9. Vincent JL, de Mendonça A, Cantraine F, et al. Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: Results of a multicenter, prospective study. Working Group on "Sepsis-related Problems" of the European Society of Intensive Care Medicine. Crit Care Med, 1998, 26(11): 1793-1800.
10. Khwannimit B. A comparison of three organ dysfunction scores: MODS, SOFA and LOD for predicting ICU mortality in critically ill patients. J Med Assoc Thai, 2007, 90(6): 1074-1081.
11. Minne L, Abu-Hanna A, de Jonge E. Evaluation of SOFA-based models for predicting mortality in the ICU: A systematic review. Crit Care, 2008, 12(6): 161-173.
12. Granholm A, Møller MH, Krag M, et al. Predictive performance of the Simplified Acute Physiology Score (SAPS) Ⅱ and the initial Sequential Organ Failure Assessment (SOFA) score in acutely ill intensive care patients: Post-hoc analyses of the SUP-ICU inception cohort study. PLoS One, 2016, 11(12): e0168948.
13. Safari S, Shojaee M, Rahmati F, et al. Accuracy of SOFA score in prediction of 30-day outcome of critically ill patients. Turk J Emerg Med, 2016, 16(4): 146-150.
14. ffrench-O'Carroll R, Frohlich S, Murphy N, et al. Predictors of outcome in decompensated liver disease: Validation of the SOFA-L score. Ir Med J, 2015, 108(4): 114-116.
15. Pan HC, Jenq CC, Tsai MH, et al. Scoring systems for 6-month mortality in critically ill cirrhotic patients: A prospective analysis of chronic liver failure - sequential organ failure assessment score (CLIF-SOFA). Aliment Pharmacol Ther, 2014, 40(9): 1056-1065.
16. Le Gall JR, Loirat P, Alperovitch A, et al. A simplified acute physiology score for ICU patients. Crit Care Med, 1984, 12(11): 975-977.
17. Moemen ME. Prognostic categorization of intensive care septic patients. World J Crit Care Med, 2012, 1(3): 67-79.
18. Wang H, Ye L, Yu L, et al. Performance of sequential organ failure assessment, logistic organ dysfunction and multiple organ dysfunction score in severe sepsis within Chinese intensive care units. Anaesth Intensive Care, 2011, 39(1): 55-60.
19. Chen Q, Zhang L, Ge S, et al. Prognosis predictive value of the Oxford Acute Severity of Illness Score for sepsis: A retrospective cohort study. PeerJ, 2019, 7: e7083-e7096.
20. Kaukonen KM, Bailey M, Pilcher D, et al. Systemic inflammatory response syndrome criteria in defining severe sepsis. N Engl J Med, 2015, 372(17): 1629-1638.
21. Johnson AE, Pollard TJ, Shen L, et al. MIMIC-Ⅲ, a freely accessible critical care database. Sci Data, 2016, 24(3): 1-9.
22. Levy MM, Fink MP, Marshall JC, et al. 2001 SCCM/ESICM/ACCP/ATS/SIS international sepsis definitions conference. Intensive Care Med, 2003, 29(4): 530-538.
23. Camp RL, Dolled-Filhart M, Rimm DL. X-tile: A new bio-informatics tool for biomarker assessment and outcome-based cut-point optimization. Clin Cancer Res, 2004, 10(21): 7252-7259.
24. Johnson AE, Stone DJ, Celi LA, et al. The MIMIC Code Repository: Enabling reproducibility in critical care research. J Am Med Inform Assoc, 2018, 25(1): 32-39.
25. Zhang Z. Accessing critical care big data: A step by step approach. J Thorac Dis, 2015, 7(3): 238-242.
26. DeLong ER, DeLong DM, Clarke-Pearson DL. Comparing the areas under two or more correlated receiver operating characteristic curves: A nonparametric approach. Biometrics, 1988, 44(3): 837-845.
27. Boumendil A, Somme D, Garrouste-Orgeas M, et al. Should elderly patients be admitted to the intensive care unit? Intensive Care Med, 2007, 33(7): 1252-1262.
28. Hennessy D, Juzwishin K, Yergens D, et al. Outcomes of elderly survivors of intensive care: A review of the literature. Chest, 2005, 127(5): 1764-1774.
29. Nathanson BH, Higgins TL, Brennan MJ, et al. Do elderly patients fare well in the ICU? Chest, 2011, 139(4): 825-831.
30. Sacanella E, Pérez-Castejón JM, Nicolás JM, et al. Mortality in healthy elderly patients after ICU admission. Intensive Care Med, 2009, 35(3): 550-555.
31. de Jonge E, Bosman RJ, van der Voort PH, et al. Intensive care medicine in the Netherlands, 1997-2001. Ⅰ. Patient population and treatment outcome. Ned Tijdschr Geneeskd, 2003, 147(21): 1013-1017.
32. Li Y, Yan C, Gan Z, et al. Prognostic values of SOFA score, qSOFA score, and LODS score for patients with sepsis. Ann Palliat Med, 2020, 9(3): 1037-1044.
33. Johnson AE, Kramer AA, Clifford GD. A new severity of illness scale using a subset of acute physiology and chronic health evaluation data elements shows comparable predictive accuracy. Crit Care Med, 2013, 41(7): 1711-1718.
34. Liao MM, Lezotte D, Lowenstein SR, et al. Sensitivity of systemic inflammatory response syndrome for critical illness among ED patients. Am J Emerg Med, 2014, 32(11): 1319-1325.
35. Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. The ACCP/SCCM consensus conference committee. American College of Chest Physicians/Society of Critical Care Medicine. Chest, 1992, 101(6): 1644-1655.
36. Churpek MM, Zadravecz FJ, Winslow C, et al. Incidence and prognostic value of the systemic inflammatory response syndrome and organ dysfunctions in ward patients. Am J Respir Crit Care Med, 2015, 192(8): 958-964.
37. Knaus WA, Wagner DP, Draper EA, et al. The APACHE Ⅲ prognostic system. Risk prediction of hospital mortality for critically ill hospitalized adults. Chest, 1991, 100(6): 1619-1636.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

The value of various severity assessment scoring systems in sepsis diagnosis and long-term prognosis prediction after cardiac surgery

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