RCOG World Congress 2023

Delta SOFA Score as a Prognostic Indicator in Women admitted to an Obstetric ICU of a Tertiary Health Centre in North India

Dr Monica Agrawal (Additional Professor ) , Department of Obstetrics & Gynaecology , K G Medical University, Lucknow, UP, India

Introduction

Critically ill patients are characterized by a progressive and time-dependent organ dysfunction.

Ø Early identification of patients at risk of increasing organ damage could have an impact in terms of outcome improvement.

Ø Sequential Organ Failure Assessment (SOFA) score is useful for assessing morbidity & organ dysfunction or failure over time.

Ø Serial SOFA & Delta SOFA (Δ-SOFA) scores allow tracking and better understanding of progression of disease and response

to treatment.

Objectives

PRIMARY : Assessment of Delta SOFA (Δ SOFA) as a mortality predictor in patients admitted to an

Obstetric ICU

SECONDARY : To correlate the number and severity of organ dysfunction with maternal mortality.

To determine the critical earliest time point and critical Delta SOFA which best predicts mortality.

Delta SOFA as a predictor of length of ICU stay and intervention (ventilator and vasopressor) free days

Methodology:

Prospective observational cohort study

Obstetric ICU , Department of OBGY , KGMU, Lucknow

Duration : One year

Institutional Ethics Committee approval & informed

consent taken

125 consecutive ICU admissions fulfilling the inclusion

criteria were enrolled

SOFA score : Day 1( admission), Day 2, 3, 5, 7, 14, 21 & 28

Follow up : Daily till discharge or mortality whichever was earlier.

Treatment given , days of mechanical ventilation, vasoactive drugs &

dialysis were recorded.

Δ SOFA D1-3 & ΔSOFA D1-5 were calculated.

Group A –Survivors & Group B – Non Survivors

Chi-square test , paired student t-test & ANOVA test were used for

statistical analysis . p-value < 0.05 was regarded significant.

Discussion

To the best of our knowledge, this is the first study to evaluate the predictive performance of DELTA (Δ) SOFA scores in an Indian

obstetric ICU

Jain et al., 2016 observed maximum discriminatory power in neurological, cardiovascular & respiratory system.

Our mortality rates were lesser in comparison to study by Jain et al., 33.33%. and higher than by Kallur et al., 2014 5.88%.

Higher mortality rate , can be due to large number of referred cases with severe morbidity requiring critical care management.

Garia-Gigorro et al., 2016 reported that with increase in Δ SOFA score between 0-1 (Δ SOFA=0-1), median days of mechanical

ventilation was 3 (1-7) days and with a score Δ SOFA≥2, it was 6 (2-12) days.

Results

There were 63,324 admissions to Queen Mary’s Hospital out of which 650 (1.02%) obstetric cases were admitted to ICU.

93 were survivors (74.4%) and 32 were non-survivors (25.6%)

No significant difference in obstetric status between survivors and non-survivors

Most common indications for ICU admission were hypertensive disorders, hemorrhagic conditions and sepsis

Major etiology of maternal mortality was sepsis, followed by antepartum and postpartum eclampsia and hemorrhagic conditions (APH &PPH).

Most common co-morbid conditions : Severe anemia in 34.4% , antepartum eclampsia

29.6%, post-partum eclampsia ,, severe pre-eclampsia & thrombocytopenia in 11.2%

Cardiovascular system had the best discriminatory power followed by hepatic

system, respiratory system, hematological system and renal system.

Neurological system had the least discriminatory power

ΔSOFA D1-5 :cut-off of >(+1.5) : Maximum AUC (0.999; 95% CI 0.996-1.00, p< 0.001) 100 %

sensitivity & 98.9 % specificity , 99.9% prediction of mortality.

Mean total SOFA Score ,cut-off of > 10.4 :AUC 0.994 (95% CI 0.982- 1.000, ,p < 0.001,) 100%

sensitivity & 97.8 % specificity , 99.4% prediction of mortality.

Maximum SOFA Score : cut-off of >12.50 has 100% sensitivity ,least specificity (77.4%), 95.2 %

prediction of mortality (, 95% CI: 0.890-1.000).

92.9 % nonsurvivors on D 3 and 100% non-survivors on D 5 showed increment in ΔSOFA D1-3 & ΔSOFA D1-5 scores

Median length of mechanical ventilation of 7.5 (2-24) days & vasopressor support of 6 (0-24) days for patients with increase in ΔSOFA D1-5 was maximum & highly significant (p<0.001)

Median length of ICU Stay of patients was significantly higher with increase or no change in ΔSOFA D1-5, of 10.50 & 11 days

CONCLUSION

There is a highly significant increase in maternal mortality and decrease in ventilator and vasopressor free days with the increment in the SOFA scores as compared to admission SOFA and daily maximum SOFA scores

∆SOFA D1-5 cut off of >(+1.5) was found to be the best predictor of maternal mortality

Mean total SOFA Score with a cut off of > 10.4, was found to be the second best predictor of maternal mortality

Since cardiovascular, hepatic & respiratory systems have best discriminatory power in predicting mortality planning resource allocation for mechanical ventilation, cardiovascular monitoring, ionotropic drugs and potent antibiotics for these types of patients is important.

TAKE HOME MESSAGE

Calculation of Delta SOFA (Δ SOFA) score is relatively easy, by using variables that can be easily measured and provides an additional means of evaluating the effectiveness of treatment, should be used by all intensivists and obstetricians as a component of routine ICU care.

At primary or secondary levels, if an individual organ SOFA score ≥1 or total SOFA score ≥3, prompt referral should be done without delay

RCOG World Congress 2023

Delta SOFA Score - A prognostic indicator of maternal mortality in Obstetric ICU

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