A Simple Multiple System Organ Failure Scoring System Predicts Mortality of Patients Who Have Sepsis Syndrome*

Paul C. Hebert, M.D.;t Alanaj Drummond, Gordon R. Bernard, M.D., FC.C.P; andJames R.N.;Joel
A.

Singer, Ph.D.; Russell, M.D.

system organ failure (MSOF) score may of patients who have sepsis syndrome. Using an MSOF scoring system, we prospectively determined the presence or absence of respiratory, cardiovasculai; renal, hepatic, gastrointestinal, hematologic, and neurologic organ failure on day 1 of sepsis syndrome in 154 consecutive patients who had sepsis syndrome in the ICU of a tertiary care, teaching hospital. We used 30-day hospital mortality as the primary outcome variable. Overall 30-day mortality was 34 percent. There was a strong linear association between number of organ system failures and 30-day mortality (p<O.000l). Mortality was 20 percent in patients who had less than 3 organ system failures (n 111) and 70 percent in patients who had 3 or more organ system failures (n43). Survival was assessed using the Cox proportional hazards model and was found to be significandy different (pzz0.01) between the two groups defined by the aforementioned dichotomy after adjustment for age and sex using time to death as the primary outcome. The

A simple
predict

multiple

increase
organ interval,

mortality

odds
were

risk of death associated with 3 or more failures was 2.77 (95 percent confidence 2.74 to 2.83). Usinglogistic regression, the adjusted ratios (OR) for covariates most predictive of mortality in relative

system

hematologic

(OR
cardiovascular

6.2),

neurologic

(OR

4.4),

hepatic

and age (1.05 per year). The logistic model using the seven organ system failures and age as covariates accurately predicted outcome 75 percent of the time with a sensitivity of 51 percent and specificity of 87 percent. In conclusion, a simple scoring system tabulating the number of organ system failures present on day 1 of sepsis syndrome predicts the mortality of patients who have sepsis syndrome with reasonable
(OR=3.4), (0R2.6),
accuracy.

(Chest

1993;

104:230-35)

ARDSadult interval; ratio

respiratory MSOFmultiple

distress system

syndrome; organ

CIconfldence

failure;

ORodds

epsis

syndrome and of

is defined evidence death organ of failure

as a systemic of new organ patients organ who failure

response system (MSOF) have

to dysis a sepsis

who

have

AIDS

requiring

ICU

admission.9

In ARDS, failures, in none

infection function. major

yn

MSOF
developed of the MSOF predictor score

defined

Multisystem cause

as three in 55 percent

or more organ of nonsurvivors ill AIDS admission APACHE and

system and

survivors. In critically score on the day ofICU of mortality (an AIDS scoring than was

patients, the was a better II,2 serum Justice lactate

Multisystem critical thermore,

is a complication

of other

illness7 as well as of sepsis syndrome. FurMSOF scoring has been used to predict mortality of patients who have a variety of critical illnesses.t7 However, there are few studies that have determined whether a MSOF scoring system can be used at onset of sepsis syndrome who a MSOF have scoring to predict rigorously system mortality defined originally in a group of patients sepsis syndrome 17 We have used utility adapted

system21),

dehydrogenase mocysti$ carinii a simple prediction

level, a measure pneumonia. These

of severity of Pneuresults suggest that

MSOF score could be useful in outcome ofpatients who have sepsis syndrome. MSOF oforgan predicts an ICU asked scoring system 30-day who whether have the syndrome system, failures hospital sepsis develwas we system survivors Finally, from we the

Therefore, using a simple we asked whether the number on day

mortality

1 of sepsis of patients

syndrome in we day on

by Bihari and colleagues7 and have assessed its in outcome prediction in patients who had adult distress syndrome (ARDS)8 and in patients

syndrome. opment associated sought to failures were from asked

In addition, of MSOF with 30-day determine most of a simple

1 of sepsis

respiratory

mortality. Furthermore, which specific organ in discriminating syndrome. developed model sepsis

useful

*Fmrn

the

Division

of Critical

Care

Medicine,

St.

Pauls

Hospital

(Drs. Hebert and Russell, and Ms. Drummond), the Department ofHealth Care and Epidemiology, University ofBritish Columbia, Vancouver, British Columbia, Canada (Dr. Singer), and Division of Pulmonary and Critical Care, Vanderbilt University, Nashville, Tenn (Dr. Bernard). tRecipient of the 1991-1992 Merck-Frosst Critical Care Medicine Research Fellowship for Western Canada. Supported in part by grant 1 R01HL43167-02 CLTR from the National Institute of Health, Bethesda, Md. Reprint requests: Dr. Russell, St. Paulr Hospital, 1081 Burrard Street, Vancouver, BC, Canada V5Z 1Y6

nonsurvivors whether predict

predetermined accurately

organ system failure mortality of individual

METHODS

criteria would patients.

Patients Patients

and

Study
in the

Design
ICU of St. Pauls Hospital, Vancouver, a tertiary

230

A Simple

MSOF

Scoring

System (Hebertetal)

Downloaded From: http://journal.publications.chestnet.org/ on 10/03/2013

Table

1-Diagnostic Sepsis

Criteria ofPatients Syndrome

Who

Had

Table

2-Multiple Ibtients
system: Hg

System Organ Failure Scoring Who Had Sepsis Syndronse

ventilator adrenergic ofhypovolemia >300 >60 fresh blood >20 one cell (PT >10 Glasgow g/L or p.mol/L mmolfL blood from the requiring more <2.0 INR, mg(L) Coma Scale CNS (GCS) injury of or alkaline from the at least the dependent shunt >20 agents with percent to maintain (PAWP >6 mm

System

of

Group 1. Core 2. 3. Heart mm Group 1.

At temperature: rate: rate >20 38.3#{176}C (101#{176}F) or 35.5#{176}C (96#{176}F) (in the breaths/mm absence ofbeta blockers) ventilation >10 LI 90 beats/mm

1. 2. 3.

Respiratory >250 mm Renal Hepatic >350 mm Cardiovascular

an A-a

gradient MAP Hg) >55

or a pulmonary system: absence creatinine bilirubin system: or fresh in 24 h system:

Respiratory Bt

or minute

Hg in the system: system:

4. system: mm adequate or urine system: If the meet bilateral must diffuse patient over output, PaO,, primary established infiltrates catheter as the two points sole significant 70 infused are 12, solution system: 333. hypotension, than 90 mm 1 h given artery Hg that wedge or a fall the filling pressure 500 1 h then and the ml of 6. in 5. BP >40 Hg for greater

phosphatase tube by

Cardiovascular systolic pressures (PAWP), saline

U/L
nasogastric accompanied 2 U of packed criteria: count, and or a melena cells white rectum

Gastrointestinal and/or a fall in hemoglobin

(pulmonary
is unresponsive 1 h) 0.5 mm diagnosis ARDS on chest failing

to at least for at least

red blood

2. 3.

Renal ratio, patient acute <19 system

rnl/kgfh

Hematologic peripheral intravascular

following platelet >2 normal,

Pulmonary

Hg (room criteria

air) or a PaOJFIo2 (PaO,fFIo2<200, PAWP for the pulmonary in mental Coma of infection. one status Scale)

blood abnormal

count >2

x 1(WL; suggesting PTF

is pneumonia, radiograph, organ Glasgow site

40 x 10#{176}/L; or
fibrmn degradation nervous in the system

coagulation

disseminated

coagulation products system: GCS

mm

Hg ifa pulmonary to he considered nervous ofat have system: least

is in place) alteration on the

7. Central
decrease *Each absent organ

<10 is present present worst

at least was

3 ifprimary determined

4.

Central
(a decrease

failure on day

to be either syndrome. The

or value

in all patients 24 h was system used failure. condition

1 ofsepsis

*patients must criteria also

must meet

a suspected

or known A criteria of sepsis and

They group B

within organ the

to determine

presence

or absence

of each

all of group the diagnosis cannot must process. ICU, Cardiopulmonary be be

at least

to fuffill

syndrome. site not be of infection. explained by The the

patients

immediately

prior

to sedation

or paralysis.

tResting conditions. jThe failing organ organ underlying care ment Sepsis system failure disease

the new

primary and

Statistical The whether organ Haenszel organ was with patients, organ as three using between effects We time goal

Analysis
of the primary mortality failures. failures
secondary

analysis increased this

in this linearly hypothesis,

study with we

was

to determine the number a Mantelnumber there and of three defined 1 and A Cox for the type of differences 2 of of

30-day system system

multidisciplinary into the clinical

were

prospectively Effects

screened of Ibuprofen

for enrollin Human 1990 for St. eligible a known vital dysfunction if they were virus. in the syndrome ICU or 154 or proven sepsis Pauls for or sign to

To test for per linear patient

used the

x#{176} statistic

trends with was

comparing 30-day to determine

April
syndrome Hospital inclusion suspected

1992,
study in

trial. During the period from December 250 patients with at least group A criteria
1) were screening the current of infection in group B (Fable expected or were as the present later identified log. Patients study at least accompanied A plus one were 6 h), had 1). Patients to survive positive criteria MSOF and entered were if there by all new into was organ the considered of the

mortality. whether

An important a difference MSOF. system or

analysis mortality this (group

(Table

in 30-day To answer failures more

between
we patients comparison as the 1 and patients failures

patients
defined having having less

without
two MSOF groups than

question, 1) and

respectively, organ

as follows: system for model the was 30 days of groups risk of death

site listed (not in group death,

alterations listed moribund brain Day ICU could could of the study. The deaths more, syndrome citing time who 1 was have have 250

(group primary to 2 after

2).

Kaplan-Meier

excluded suspected immunodeficiency

curves#{176}#{176} were proportional ofage

constructed within curves sex. the hazards

of groups outcome. test adjusting with each

to death survival and

for human

calculated

defined been developed consecutive

day of onset
in Table time the met at the during

of sepsis 1. That ICU of admission course. eligibility

syndrome is, sepsis to the criteria hospital 30 days. therapies outcome calculated nurse system 2. The to failures difficulty Coma Scale (A.

as defined

by the

determined 100

associated

As a result,

patients

the

for this 80 mortality. most

>1

primary related many use a similar to death scoring

outcome this of the to sepsis

in this study syndrome trials mortality 30 days

was 30-day occur within new primary were

We considered

end-point

to be clinically evaluating as the as the curves

relevant

because

Furtherin sepsis variable, using

60

clinical

30-day within

rationale. was done ofthe systems was

Survival by a critical purpose classified

40

primary
care ofthe study.

outcome. research Organ in Table compiled each patient. system

Patient was of seven of sepsis number MSOF laboratory coded

J.

D.) 1 a

20

not aware organ syndrome of organ score, values on

failure on day total assign Missing were in in was using Scale 0 0 1 2 3 4 5 6

as present listed were for organ of the

or absent

according systems a scale for scoring system the failure from

to criteria that failed 0 to 7, absent. or heavily for the

Number

of Organ

Failures

individual

as organ arose who by from were

A foreseeable Glasgow This Coma sedated. Glasgow

coding
patients addressed

determination values

Ficua 1. Mortality per number oforgan system failures of patients who had sepsis syndrome. There was a significant linear increase in mortality (percent) with each additional organ system failure
MH,I<0.#{176}#{176}#{176}1). Mortality

paralyzed

difficulty

assigning

system

failures

to 100 percent

ranged from 10 percent for five or six organ

with system

zero organ failures.

CHEST

I 104 I 1 I JULY,

1993

231

Downloaded From: http://journal.publications.chestnet.org/ on 10/03/2013

Table

3-Clinical
Nonsurvivora

Characteristics ofSepsis

in Survivors Syndrome
Survivors

and

RESULTS

Nonsurvivors (n)

The clinical characteristics nonsurvivors of sepsis syndrome 3. Cardiac disease (medical and

of

the survivors and are shown in Table pneu-

Clinical
Age, <20 yr

Characteristics

(n)

postoperative),

5 21

1 4 18 30 35/18 6 2 4 1 4 8 2 6 4 2 7 6 1

20-39 40-59
60 Sex, M/F underlying failure diagnosis

33
42 70/31 12 6 13 8 (excluding disease disease disease pneumonia) 3 12 9 3 6 4 patients 14 7 4

monia, and trauma were the most common primary underlying diagnoses. The overall 30-day mortality of our patients who had sepsis syndrome was 34 percent. Using the Mantel-Haenszel x2 we found a strong linear association (p(O.OOOl) between the number oforgan system ranged system failures and 30-day mortality from 10 percent for patients failure to 100 percent organ system Kaplan-Meier patients failures. survival 1 and (Fig 1). Mortality who had no organ who were had

Primary

Pneumonia Respiratory Trauma Overdose Sepsis Cardiac Neurologic Gastrointestinal

in patients curves

five or more for with

constructed in patients

in groups

2. Mortality

Malignancies
Renal disease Postoperative Cardiac Noncardiac Other

less than three organ system percent (n = 111) compared in patients failures,
comparing

failures (group with 70 percent or more organ

1) was 20 (n = 43) system

with

MSOF

(three

group 2). The Cox proportional the survival curves of

hazards model groups 1 and 2

organ using

system 30-day

failure. mortality

A logistic as the model, intervals was also based Model individual the

regression outcome organ adjusted and failures

model number odds

was

constructed system and system of likely with was used 95 parameters. (OR) organ

oforgan

failures, age, and From the logistic percent confidence

failure The outcomes were logistic were basis outcomes values, with model

as model ratios CI) for each outcome outcome were sensitivities, All statistical version

adjusted for the effects of age and sex was highly significant (p 0.00502, Fig 2). The increase in relative risk of death associated with three or more organ system failures was 2.77 (95 percent CI, 2.74 to 2.83). The logistic regression model confirmed the prediction based on the Mantel-Haenszel organ system failures predicted also enabled a quantification
mortality

(95 percent used sepsis

x2 that
30-day of the system

calculated. to test syndrome. predictions calculated A two-tailed (PC-SAS predictions

number of mortality and risk of 30-day failures. A

individual on the
observed predictive to establish were version done 2.2

patients
of the

who had
model. and one

Predicted was more compared

survival

with

individual

organ

established

on which

and we then accuracies. of two computer).

specificities, analyses 6 or SAS

significant increase in the risk of death (l#{224}ble 4) was noted in patients who had hematologic (OR = 6.3 with 95 percent

a of 0.05

significance on a Sun

for all comparisons. programs

with 95 percent with 95 percent

cular organ

100 80

CI from 1.3 to 29.8), neurologic (OR=4.4 CI from 1.9 to 10.3), hepatic (OR = 3.4 CI from 1.06 to 10.7), and cardiovas(OR = 2.6 with 95 percent CI from 1.2 to 5.8) system failure. Age was also used as a model for The probability each additional age of the of death increased by year of life (p<0.001) sample of patients who had 5

parameter. percent above sepsis Group 2 (n-53) Table

and Age

60 40

the mean syndrome.

Cl)

20
0 0 6 12 18 24 30

4-Adjusted (Covariates) Ibtients

Odds Ratios ofOrgan System Failures Associated With 30-Day Mortality of Who Had Sepsia Syndrome
Odds Confidence Intervals 0.69-4.00 1.18-5.77 0.76-9.81 1.06-10.70 0.22-5.41 1.29-29.77 1.86-10.32 1.02-1.08 logistic regression. p Values 0.2581 0.0179 0.1240 0.0394 0.9129 0.0228 0.0007

Covariates Respiratory

Ratios5 1.66 2.61 2.73 3.37 1.09 6.20 4.39 1.05 calculated using

Days
FIGURE 2. Group survival over 30 days of patients who had sepsis syndrome. Patients were divided into two groups. Group 1 (n = 111) had less than three organ systems that failed and group 2 (n =43) had three or more organ systems that failed. Kaplan-Meier curves for each group were computed using time to death as the outcome. Using a Cox proportional hazards model adjusted for age and sex, the group 1 survival curve was signfficantly different from the group 2 survival curve (p<0.00502).

Cardiovascular

Renal
Hepatic Gastrointestinal Hematologic Neurologic

Age
#{216}Jds ratios

0.0010

232

A Simple

MSOF

Scoring

System

(Hebert

et a!)

Downloaded From: http://journal.publications.chestnet.org/ on 10/03/2013

Table

5-Logistic
Observed
Dead

Model*

3). The

respiratory

(n

74),

neurologic

(n =

65),

and

Alive

cardiovascular common organ sepsis syndrome.

(n = 63) organ systems were the most systems to fail in patients who had Hepatic (n = 23), renal (n = 17), he12) organ in our paindividual
77

Predicted
Dead 27 26 (17.5%) (16.8%) 53 *Sensitjvity cent; predictive 13 88 (8.4%) (57.1%) 101 percent; value specificity 40 114 154 88/101 percent;

matologic (n = 13), and gastrointestinal (n system failures were much less frequent tients.
organ

Alive

The system

30-day

mortality was 65 percent; cardiovascular, and

associated as follows:

with

failures

hematologic,

=
positive

27/53

= 50.9 =
88/114

=
67.5

= =

87.1

per-

predictive value

27/40 percent;

negative 115/154

percent; hepatic, renal, 53 percent; intestinal,

neurologic, 53 percent; 52 percent; gastro46 percent.

= was

77.2

accuracy

50 percent;

respiratory,

74.7 percent.

A logistic

model

also

used

to

calculate

the The major finding

DIscussIoN

probability of death threshold probability our model, patients nonsurvivors outcome specificity to identify ity = 50.9 101 patients (Table enabled of the only percent) who The

for individual of 50 percent were classified 5). Comparisons

patients. Using a determined from as survivors or with the observed and able

of this

study

was

a strong

linear

association between a simple MSOF ber of organ system failures on syndrome, patients finding three or and 30-day hospital syndrome who had failures)
.

score, the numday 1 of sepsis mortality Another MSOF in ICU as synimportant (defined of sepsis

a calculation logistic model. 27 of 53 but was eventually model

of the sensitivity The model was

who had sepsis was that patients more organ

nonsurvivors able to identify survived correctly classified (accuracy

(sensitiv88 of the
=

at onset

(specificity alive
=

drome had a significantly greater day period than did patients who The overall mortality in the while mortality was 70 percent compared with 20 percent for have MSOF. The Kaplan-Meier both groups clearly illustrate

mortality over a 30did not have MSOF. 34 percent with MSOF not of

87. 1 percent). dead outcome percent) who We also as a function

or
74.7

in 115 of 154 patients had sepsis syndrome. the sum type of the of organ

study was in patients

tabulated

of organ system

system failures

failure (Fig

patients who did survival curves that prognosis

is much

30

Survivors
(I) C

*i
20
:;

Nonsurvivors

I-

0
w

10

z
0

I I iiL1
i1
iti
1 2

#{149}

I:
5 6

Total
Distribution syndrome. Survivors are pattern. There are seven organ. From left to right, bar 3, neurologic failure hematologic failure (n = proportion of nonsurvivors
FIGURE

Number

of organ

failures

3.

of patients and represented by bars per total bar 1 represents (n =45); bar 4, 1 1) and bar 7, increases with

individual organ system failures in patients who had sepsis the solid black portion of the bar and nonsurvivors by the cross number of organ system failures each representing a different respiratory failure (n = 57); bar 2, cardiovascular failure (n 49); hepatic failure (n = 13); bar 5, renal failure (n = 13); and bar 6, gastrointestinal failure (n 12). The plot demonstrates that the the number of organ failures.

CHEST

I 104

I 1 I JULY,

1993

233

Downloaded From: http://journal.publications.chestnet.org/ on 10/03/2013

worse syndrome logistic increased

in

patients

with

MSOF

at

onset

of

sepsis

than in patients without MSOF. Using regression, we were able to determine the risk of3O-day mortality associated with each failure. associated hepatic with an A signfficant increase in the risk with neurologic, hematologic, failure. Age was also signfficantly increased risk of death in our

The system reasons.

criteria failure First,

used for definition of individual in this study were chosen there are no standard accepted organ we have definitions who had system found

organ for two defini-

organ system ofdeath was cardiac, associated and

tions for individual be used. Secondly, score

mortality

failures that could that a simple MSOF was associated and with of patients

using had AIDS threshold

these

of patients

ARDS8

who

patients who had sepsis syndrome. We believe that our sample of patients who had sepsis syndrome is similar to other studies of patients who have sepsis syndrome because we used a very similar definition Bone and prospectively and of sepsis syndrome, modified from because we identified patients

The
absence review

and who were admitted to our ICU. values establishing the presence or failure were determined and by clinical judgment; that hematologic and with hepatic significantly the criteria (OR
=

of organ system of the literature it must be

=

by are

however,

emphasized 4.39), 2.61),

otherwise arbitrary. Neurologic (OR cardiovascular

6.20), in-

calculated

the

MSOF

score

at onset

(OR= were

failure

of sepsis syndrome, and because we observed a 30day mortality in our patients (34 percent) that was similar to the 30 percent mortality reported by Bone and colleagues.4 We believe used that this simple to predict that MSOF mortality Several the other number score early has not

(OR

3.37)

associated

creased risks of death of patients who had sepsis syndrome. There was overlap between the definitions of cardiovascular and neurologic criteria of sepsis syndrome (Table 1) and of organ failure (Table 2). In contrast, there was no overlap of hematologic or hepatic failure because they were not part ofthe sepsis syndrome definition. Thus, to have either hematologic or hepatic
organ

been course scales system

previously

in the

of sepsis syndrome. have established failures is proportional

predictive of organ of critically different MSOF. system organ Each

to mortality

failure,

the

patient

had

to have

additional of This the

ill adultse,1a,l3,ll7m, despite using quite definitions for individual organ failures and A major advantage of this MSOF scoring its simplicity. systems were individual Organ classified system system failures on a dichotomous failure was

is

dysfunction as defined by sepsis syndrome. might have contributed to the seriousness presence of hematologic and hepatic failure. Our study suggests that may be useful in predicting patients who have not documented sensitive is certainly treatment trials. We accurate in sepsis the ability individual found a prime groups that the MSOF outcomes

of seven scale.

scoring system of groups of we have system is outcome, it

organ

scored

as present available criteria nurse each study. multi-

or absent using simple criteria on day 1 of sepsis syndrome. that we minimized used and the masking potential observer potential patients Therefore, score

that are readily The objective

sepsis syndrome. that the MSOF known candidate at baseline the MSOF

Although scoring to affect

to interventions

of the research bias in scoring of this care,

to compare placebo and in randomized control scoring system patient model, was not

patient. There are two First, we studied disciplinary whether this ICU.

limitations in one tertiary

it

is

not 30-day

established mortality

in prediction syndrome.

of individual Using a logistic score had

outcome we tested of The

MSOF

predicts

of patients who have and in other settings ment and patient number of patients failures; therefore,

sepsis syndrome in other ICUs such as the Emergency DepartSecondly, there were had five and six organ regarding a small system in

of the MSOF patients who

to predict mortality sepsis syndrome.

wards. who

model developed in this study including age and the presence system failure were accurate correctly cent of (specificity) negative percent, There

used eight parameters, or absence of organ Predictions The model

conclusions

patients

in seven organ systems. in 75 percent of patients.

these groups may not be generalizable even though a statistically significant linear trend was observed. The small number of patients in these groups may be explained partly by the screening process and by the entry criteria of the Cardiopulmonary Effects of Ibuprofen in Sepsis clinical trial. We excluded patients who were moribund, patients with suspected or proven brain immunodeficiency be more syndrome study.
234

predicted mortality (sensitivity) in 51 perpatients and correctly predicted survival in 87 percent ofpatients. The positive and predictive values were 68 percent and 77 respectively. are several reasons why predictive models limitations in individual First, predictive scales patient outcome are derived from

death, and patients positive for human virus. These excluded patients may to have MSOF on the patients included day 1 of sepsis in this MSOF

have serious prediction.tm

likely than

groups of patients groups may have patients. Secondly, tions render such

and therefore trends observed in little or no meaning for individual wide CIs around individual predicpredictions essentially meaningless.
A

Simple MSOF Scoring

System

(Hebertet&)

Downloaded From: http://journal.publications.chestnet.org/ on 10/03/2013

Thirdly,

predictive may not of patients.

scales be valid

derived when

from applied

one

sample to another

of

9 Frye organ 10 Carrico

DE, failure:

Pearlstein the role Meakins failure Does failure? AE,

L, Fulton ofuncontmlled JL, drainage Am Dittmer patients. RH. JE. 260:530-34

RL,

Polk

HC.

Multiple Arch DE, 1986; Surg

system 1980; RV.

patients sample

infection. JC, Arch Surg Fry

115:136-40 CJ, organ LW. organ E, Baue MM, JAMA PM, 1990; Marshall of Maier 121:196-208 pus Multiple 23:775-87 multisystem failure. Clin organ Chest S. reverse organ Multiple 11 12 13 14 Norton multiple Faist failure Descamp syndrome.

In conclusion, predicted 30-day syndrome. This have groups

example,

a simple MSOF scoring system mortality of patients who had sepsis simple MSOF scoring system may in have predicting sepsis mortality syndrome. of For to of concould who

intra-abdominal 1985; Heberer 1983; 149:347-50 G.

J Surg
H,

several

applications

in polytrauma Demling 1988; Gadek

of patients this MSOF equivalence and clinical treatment trials.

J Trauma
Posttraumatic

assess placebo trolled

scoring at onset patients

system may be useful of sepsis syndrome in randomized scoring system

failure.
Dorinsky Med 15 Villar Multiple

Multiple

organ

11:581-91 Manzano syndrome 1991; Coalson 1983; E,

This MSOF

J,
Care RC,

JJ,
6:75-80

Blazquez failure JD,

MA,

Qumntana

J,

Lubillo failure. system

organ

in acute et al.

respiratory organ syndrome. Septic 19:1146-51 A, Kiess ventricular ofadult 141:659-65 M,

also be used for continuous quality improvement to compare groups ofpatients who have sepsis syndrome and who were admitted at different periods to an ICU. However, predictive mortality ther
larger

J Crit
16 Bell

JJ,
Jiskala failure.

Smith

Multiple distress E. 1991; and

failure
Intern 17 18 Ruokonen multiple Russell

and infection Med organ

in adult 99:293-97

respiratory A, D, Alhava Med Belzberg

Ann and Dodek preload

this MSOF scoring scales are of limited of individual patients.

system and other use in predicting We recommend fursystem syndrome in

J,
and Am

Kari

shock

Crit Care
Lockhat than Rev PM, with Chest EA, consumption Respir

JA, Ronco delivery

JJ,

studies other

to validate this MSOF scoring samples of patients who have sepsis settings and from other centers.

P. Oxygen are 19 greater distress Montaner Lawson ICU-admitted

in survivors JSG, LM, Hawley patients PCP Draper of disease Feinstein

in nonsurvivors Dis 1990; Bonco system acute 1992;

respiratory

from

syndrome.

JJ,
failure

Russell predicts

JA, Quieffen mortality failure JE. Cnt staging

J,
of

REFERENCES 1 Bone and 2 Bone Care 3 Bone clinical ofsevere 58 4 Bone drome: 5 Young 3rd ed. RC, Fisher clinical eds. Draper system M, prostacyclmn NV, Smithies ill patients. CJ, Clemmer Sepsis Crit sepsis. entity. Principles EA, Wagner failure. Gimson on N Engl organ failure. Ann oxygen TP, Care Slotman Group. GL, Med GJ, and Sepsis Douglas diseases. JE. 202:685-93 effects and JL. 1988; The of vasodiuptake microbiin Prognosis 25 The synRG 23 24 Methylprednisolone a valid LS. New WA, D, organ Gram-negative York: Churchill Severe Study In: Mandell 1990; Zimmerman 1985; delivery 1987; R, Arch Surg Meakins RC. RC. Med RC, trial Gram-negative Chest agree CJ, Lets sepsis; on terminology: Clemmer Sepsis shock. iT, background, definition Slotaman Group. clinical features 20 of sepsis. GJ, in the and Crit The

et al. Multiple

respiratory
102:1823-28 DP, Zimmerman system. prognostic syndrome.

secondary
APACHE Care system Med for

to AIDS-related Knaus 1985; 21 Justice 320:1388-93 22 Freidman Fundamental Book, libshirani model. Knaus M, 1991; Schafer prediction do they 1111-16 et hospital Clin WA, al. 1985; LM, WA, II: a severity 13:818-29 AC,

intervention.

1991; 100802-08

Wagner

classification AR. A new

1991;
Fisher

19:973-76
Severe Study N Engl A controlled treatment 317:6531987;

Methylprednisolone sepsis and

the acquired

immunodeficiency Furberg of clinical 191-211 R. A plain Invest Wagner APACHE Med DP, III for mans 5:63-8 Draper prognostic critically CD, trials.

N EngI Survival St. Louis:

Med

1989;
In:

of high-dose septic

methylprednisolone

Med

DeMets 2nd guide ed

DL.

analysis. Mosby-Year hazards JE, Bergner

to the EA, ill

proportional

1989; 17:389-93

Zimmerman system; hospitalized risk

Jr, BennettJE, 6 Knaus in acute 7 Bthari lation critically 8 Marshall ology

and practice Livingstone, DP, Surg

ofinfectious 611-36

prediction adults. Chest Outcome care 1990;

of

mortality 100:1619-36 JH, Maurer models predict

A, Jochimsen on admission outcome?

F, Emde in a medical Crit

C, Care

et al Med

A, et al. The Med

with

intensive

unit: 18:

individual

317:397-403 123:309-15

JC, Christou
ofmultiple

Horn

CHEST

I 104

I 1 1 JULY.

1993

235

Downloaded From: http://journal.publications.chestnet.org/ on 10/03/2013