High pediatric sequential organ failure assessment (pSOFA) score may predict hospital mortality in emergency department setting

1. In a large cohort study, children presenting to emergency departments with a score of 2 or higher on the pediatric sequential organ failure assessment (pSOFA) scale for septic shock had increased hospital mortality, but elevation was only 65% sensitive for mortality.

2. pSOFA elevation had a negative predictive value of 1.0 in both all ED patients and in patients with suspected infections, indicating very low mortality risk in patients with scores of 0 or 1 in this specific patient population. 

Evidence Rating Level: 2 (Good)

Study Rundown: The sequential organ failure assessment (SOFA) score is used to detect early sepsis and determine prognosis based on signs of end organ dysfunction in adults. The adapted pediatric SOFA (pSOFA) score has been validated in intensive care unit (ICU) patients, but its use for risk stratification in the emergency department (ED) setting has not yet been well studied. This multicenter study aimed to assess the utility of elevated pSOFA scores, defined as 2 or higher, in predicting hospital mortality in a broad pediatric ED population. About 4 million ED visits for patients 18 years or younger were examined, of which 4.8% had a pSOFA score of 1 and 3.2% had a score of 2 or higher. pSOFA score had a sensitivity of 65% and specificity of 97% in predicting mortality, with high negative predictive value of 1.0. Among 640,000 ED visits with suspected infection, 6.7% had a pSOFA score of 2 or higher and 0.1% had septic shock. Within the suspected infection population, pSOFA had a sensitivity of 71% and specificity of 93%. This very large cohort study suggests that pSOFA score discriminates well for mortality risk in ED patients with suspected sepsis. pSOFA had modest sensitivity, indicating that some patients who died in the hospital did not have signs of organ dysfunction in the ED. However, the negative predictive value of pSOFA elevation was very high, likely due to the pSOFA scores of 0 in the vast majority of children who present to the ED. Further study of real-world use of pSOFA would be useful in determining the future role of initial pSOFA and pSOFA trends for risk stratification in the ED.

Click to read the study in JAMA Pediatrics

Relevant Reading: Update on pediatric sepsis: A review

In-Depth [retrospective cohort]: Data from 2012 to 2020 from 6 academic children’s hospitals and 3 satellite EDs were included. Visits in which patients died in the ED were excluded. The median length of ED stay was 2.7 hours. The maximal pSOFA for each ED visit was calculated by adding respiratory, coagulation, hepatic, cardiovascular, neurologic, and kidney socres, each with a range from 0 to 4, for a total range of 0 to 24. The maximum score within the cohort was 16. Patients who died in the hospital had a significantly higher median pSOFA score of than those who survived (3 versus 0, p value < 0.001). Sepsis was defined as suspected infection with a pSOFA score of 2 or higher. Septic shock was defined as sepsis plus need for vasoactive medication and elevated serum lactate. The area under the curve (AUC) for pSOFA score in discriminating in-hospital mortality was 0.81 [95% confidence interval (CI) 0.79-0.82]. Among all patients who died in-hospital, 399 (35.8%) met criteria for sepsis or septic shock in the ED.

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