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Sepsis is known as systemic inflammatory response syndrome, which is a common disease in intensive care unit (ICU). Sepsis has the characteristics of high incidence rate, serious illness, rapid disease development, and high mortality all over the world. At present, the pathogenesis of sepsis is not completely clear, but most studies believe that the pathogenesis of sepsis is closely related to the changes of immune function and cell/organ function and the imbalance of inflammation-anti-inflammatory system.
Sequential Organ Failure Assessment is known as SOFA score, was developed to assess the acute morbidity of critical illness at a population level and has been widely validated as a tool for this purpose across a range of healthcare.
In recent years, the SOFA score has become widely used in healthcare. The SOFA score is an increasingly important tool in defining both the clinical condition of the individual patient and the response to therapies in the context of clinical trials and especially in ICU patients. Standardization between different assessors is key to detecting response to treatment if the SOFA score is to be used as an outcome in sepsis patients.
Standard approach for Calculation of the SOFA score
SOFA score may traditionally be calculated on admission to ICU. There are six biomarkers that reflecting the function of an organ system (respiratory, cardiovascular, renal, neurological, hepatic, and hematological) and allocates a score of 0–4 as described below: -
Terminology of SOFA score
There are variations of terminology used for SOFA score, in the range of applications. Several terms are commonly used and are associated with:
· Admission SOFA:
The admission SOFA score is calculated based on the severe value for admission to ICU.
· Daily Maximum SOFA score:
The daily maximum SOFA score is equivalent to the daily SOFA score as when calculated for each 24 h assessment; the most severe value of each sub-score for that time should be calculated in the assessment of the SOFA score.
· Maximum SOFA score:
The maximum SOFA score describes the highest daily SOFA score over the course of the study period.
· Delta SOFA score:
The delta SOFA is calculated as the change in total SOFA score (or that of an individual sub-score) between a defined time point and the baseline value. The baseline value may be the admission SOFA.
· Mean SOFA:
The mean SOFA score is calculated for an individual patient over the course of a defined study period based on the total SOFA score for each study day.
Biomarkers related to SOFA score
1. Respiratory system
The network of organs and tissues that help you breathe includes airways, lungs, and blood vessels. The muscles that power your lungs are also part of the respiratory system. These parts work together to move oxygen throughout the body and clean out waste gases like carbon dioxide.
Fi02 is fraction of inspired oxygen. It is the volumetric fraction of oxygen in the inhaled gas. Patients who have trouble in breathing are provided with oxygen-enriched air, which means a higher-than-atmospheric FiO2.Natural air includes 21% oxygen, which is equivalent to FIO2 of 0.21. Oxygen-enriched air has a higher FIO2 than 0.21; up to 1.00 which means 100% oxygen. FIO2 is typically maintained below 0.5 even with mechanical ventilation, to avoid oxygen toxicity. Severe sepsis is characterized by an increase in oxygen demand and therefore oxygen enriched air is given to some patients depending on their oxygen levels.
PaO2 means measured the partial pressure of carbon dioxide in arterial blood. PaO2 means Partial pressure of carbon dioxide. (PaO2): These measures how well carbon dioxide can move out of your body. Normal range of Pa02 is 38 to 42 millimeter of mercury mm Hg(5.1 to 5.6 kPa) . In sepsis patients, multiple organ compromise, including renal dysfunction and tissue hypo perfusion.
For SOFA score, calculation we take the Pa02/ Fi02 ratio.
Here we take hospital data for analysis. Make a calculated field for checking SOFA score according to the respiratory biomarker with respect to gender and age group. Age group is made by taking bin size 20.
Used, tableau visualization and create a Tree map.
This Tree map concludes, that for the age group of 40-80 male patients have more SOFA score. The SOFA score is only 1 but the number of patients is more as compared to Female.
2. Nervous System
The nervous system includes the brain, spinal cord, and a complex network of nerves. This system sends messages back and forth between the brain and the body. The brain is what controls all the body's functions. The spinal cord runs from the brain down through the back.
The Glasgow Coma Scale (GCS) is used to objectively describe the extent of impaired consciousness in all types of acute medical, sepsis and trauma patients. The scale assesses patients according to three aspects of responsiveness: eye-opening, motor, and verbal responses.
Eye response
1. No eye opening
2. Eye opening to pain
3. Eye opening to sound
4. Eyes open spontaneously
Motor response
1. No motor response.
2. Abnormal extension to pain
3. Abnormal flexion to pain
4. Withdrawal from pain
5. Localizing pain
6. Obeys commands
Verbal response
1. No verbal response
2. Incomprehensible sounds
3. Inappropriate words
4. Confused
5. Orientated
The responses are scored between 1 and 5 with a combined total score of 3 to 15, with 15 being normal.
3. cardiovascular system:
The blood circulatory system (cardiovascular system) delivers nutrients and oxygen to all cells in the body. It consists of the heart and the blood vessels running through the entire body. The arteries carry blood away from the heart, the veins carry it back to the heart.
Mean arterial pressure (MAP) is the average arterial pressure throughout one cardiac cycle, systole, and diastole. MAP is influenced by cardiac output and systemic vascular resistance, each of which is influenced by several variables. Consider anything between 70- and 100-mm Hg (millimeters of mercury) to be normal. Sepsis is a common pathway to Actuate Kidney Injury. The Surviving Sepsis recommends a mean arterial pressure (MAP) of 65 mmHg or higher to minimize the risk of death and end-organ failure.
For SOFA score calculation we take the Map biomarker.
Here we take hospital data for analysis. Make a calculated field taking MAP for check SOFA score according to the cardiovascular system with respect to gender and age group. Age group is made by taking bin size 20.
Used tableau visualization and created a packed bubble Chart.
This packed bubble chart concludes, that for the age group of 40-80 male patients have more having SOFA score 0. The SOFA score of female patients is more as compared to male Patients, according to our data analysis.
4. Liver:
Liver is the largest solid organ in the body, It removes toxins from the body's blood supply, maintains healthy blood sugar levels, regulates blood clotting, and performs hundreds of other vital functions. It is located beneath the rib cage in the right upper abdomen.
Bilirubin is an orange-yellow pigment formed in the liver by the breakdown of hemoglobin and excreted in bile. Bilirubin-direct. Biomarker: Some bilirubin is bound to a certain protein (albumin) in the blood. This type of bilirubin is called unconjugated, or indirect, bilirubin. In the liver, bilirubin is changed into a form that your body can get rid of. This is called conjugated bilirubin or direct bilirubin. Bilirubin-Direct: Normal range: 0.1-0.3 mg/dL or 1.7-5.1 μmol/L (SI units) Normal results: are generally 0.3 mg/dL Not sure what unit. Dataset has recorded: As col(W) Min = 0.01, Max = 37.5.
Bilirubin-Total. Biomarker: Total bilirubin is a combination of direct and indirect bilirubin. Bilirubin-Total: Normal range: 0.3-1.0 mg/dL or 5.1-17 μmol/L (SI units) Normal results: are 1.2 milligrams per deciliter (mg/dL) for adults and usually 1 mg/dL for those under 18 Not sure what unit. Dataset has recorded: There seem to be 2 columns and col 1(AC) : Min = 0.1, Max = 49.2, col 2(AD) : Min = 1.1, Max = 50.2.
Impact of Bilirubin in sepsis:
Total Bilirubin: Sepsis can cause a variety of symptoms, including jaundice. Sepsis, amongst other reactions, causes cytokine release during the body's attempt to fight infection. These cytokines, also the reason for inflammation during sepsis, disrupt our body's ability to regulate bilirubin. Our bodies therefore cannot process bilirubin normally, leading to a buildup of bilirubin in the bloodstream, which turns the skin and eyes a yellow color, also known as jaundice.
Higher Bilirubin: Elevated levels may indicate liver damage or disease. Higher than normal levels of direct bilirubin in your blood may indicate your liver isn't clearing bilirubin properly. Commonly during sepsis, increased bilirubin levels are a late event during multiorgan dysfunction. In a large cohort of ICU patients, 11% had an 'early' hepatic dysfunction defined as a bilirubin concentration of greater than 2 mg/dL (> 34 μmol/L) within 48 hours of admission.
Lower Bilirubin: Lower than normal direct bilirubin levels are usually not a concern.
5. Coagulation:
Blood coagulation is a process that changes circulating substances within the blood into an insoluble gel. The gel plugs leaks in blood vessels and stops the loss of blood. The process requires coagulation factors, calcium and phospholipids. The coagulation factors (proteins) are manufactured by the liver.
Platelets are the primary function of the platelet is thought to be hemostasis, thrombosis, and wound healing through a complex activation process leading to integrin activation and formation of a “core” and “shell” at the site of injury, other physiological roles for the platelet exist including immunity and communication. 150 to 400 × 109/L is the normal Platelets count.
Multiple mechanisms likely contribute to severe thrombocytopenia, which occurs late in the clinical progression of sepsis. Decreased platelet production, increased platelet activation and consumption in thrombi, or increased destruction may remove platelets from the circulation.
For SOFA score calculation we take the Platelets biomarker.
Here we take hospital data for analysis. Make a calculated field taking Platelets for check SOFA score according to the cardiovascular system with respect to gender and age group. Age group is made by taking bin size 20.
Used, tableau visualization and create a Stacked Bar Chart.
This Stacked Bar chart concludes, that for the age group of 60-80 male patients have more having SOFA score 1 as compared to female patients having SOFA score 0, according to our data analysis.
6. Kidney:
Kidneys are two reddish-brown bean-shaped organs. They are located on the left and right in the retroperitoneal space, and in adult humans are about 12 centimeters (4+1⁄2 inches) in length. They receive blood from the paired renal arteries, blood exits into the paired renal veins. Each kidney is attached to a ureter, a tube that carries excreted urine to the bladder.
Creatine is synthesized primarily in the liver and then transported through blood to the other organs, muscle, and brain. Normal ranges are 0.7 to 1.3 mg/dL (61.9 to 114.9 µmol/L) for men 0.6 to 1.1 mg/dL (53 to 97.2 µmol/L) for women. Sepsis reduces production of creatinine, which blunts the increase in serum creatinine after sepsis, potentially limiting the early detection of acute kidney injury.
Summery:
In this blog, we only cover the biomarker that associated with the SOFA Score. For analysis, we choose hospital data and find out some SOFA score. Next blog we will discuss more about SOFA Score.
If the SOFA Score >= 2 + suspected infection = sepsis.
References:
5. https://www.epainassist.com/infections/systemic-inflammatory-response-syndrome.