The Sequential Organ Failure Assessment (SOFA) Score: has the time come for an update?

The Sequential Organ Failure Assessment (SOFA) score was developed more than 25 years ago to provide a simple method of assessing and monitoring organ dysfunction in critically ill patients. Changes in clinical practice over the last few decades, with new interventions and a greater focus on non-invasive monitoring systems, mean it is time to update the SOFA score. As a first step in this process, we propose some possible new variables that could be included in a SOFA 2.0. By so doing, we hope to stimulate debate and discussion to move toward a new, properly validated score that will be fit for modern practice.

Bedside assessment of left atrial pressure in critical care: a multifaceted gem.

Evaluating left atrial pressure (LAP) solely from the left ventricular preload perspective is a restrained approach. Accurate assessment of LAP is particularly relevant when pulmonary congestion and/or right heart dysfunction are present since it is the pressure most closely related to pulmonary venous pressure and thus pulmonary haemodynamic load. Amalgamation of LAP measurement into assessment of the 'transpulmonary circuit' may have a particular role in differentiating cardiac failure phenotypes in critical care. Most of the literature in this area involves cardiology patients, and gaps of knowledge in application to the bedside of the critically ill patient remain significant. Explored in this review is an overview of left atrial physiology, invasive and non-invasive methods of LAP measurement and their potential clinical application.

The PRICES statement: an ESICM expert consensus on methodology for conducting and reporting critical care echocardiography research studies.

PURPOSE: Echocardiography is a common tool for cardiac and hemodynamic assessments in critical care research. However, interpretation (and applications) of results and between-study comparisons are often difficult due to the lack of certain important details in the studies. PRICES (Preferred Reporting Items for Critical care Echocardiography Studies) is a project endorsed by the European Society of Intensive Care Medicine and conducted by the Echocardiography Working Group, aiming at producing recommendations for standardized reporting of critical care echocardiography (CCE) research studies. METHODS: The PRICE panel identified lists of clinical and echocardiographic parameters (the "items") deemed important in four main areas of CCE research: left ventricular systolic and diastolic functions, right ventricular function and fluid management. Each item was graded using a critical index (CI) that combined the relative importance of each item and the fraction of studies that did not report it, also taking experts' opinion into account. RESULTS: A list of items in each area that deemed essential for the proper interpretation and application of research results is recommended. Additional items which aid interpretation were also proposed. CONCLUSION: The PRICES recommendations reported in this document, as a checklist, represent an international consensus of experts as to which parameters and information should be included in the design of echocardiography research studies. PRICES recommendations provide guidance to scientists in the field of CCE with the objective of providing a recommended framework for reporting of CCE methodology and results.

Subcostal TAPSE: a retrospective analysis of a novel right ventricle function assessment method from the subcostal position in patients with sepsis.

BACKGROUND: Tricuspid annular plane systolic excursion (TAPSE) is frequently used as an objective measure of right-ventricular dysfunction. Abnormal TAPSE values are associated with poor prognosis in a number of disease states; however, the measure is not always easy to obtain in the critically ill. The purpose of this study is to assess the feasibility and accuracy of using a subcostal view and TAPSE measurement as a measure of right-ventricular dysfunction. A secondary aim was to perform a pilot study to assess whether right-ventricular dysfunction was associated with adverse outcomes including mortality. RESULTS: Subcostal TAPSE corresponds well with TAPSE obtained from the apical window at low and moderate TAPSE values (mean difference 1.2 mm (CI 0.04-2.36; 100% data pairs < 3-mm difference for TAPSE < 19 mm; 92% had < 3 mm difference at TAPDE < 24 mm). Subcostal TAPSE is able to accurately discriminate between abnormal and normal TAPSE results (sensitivity 97.8%, specificity 87.5%). There was no association between right-ventricular (RV) dysfunction and 90-day mortality. CONCLUSIONS: Subcostal TAPSE is a feasible and accurate alternative to conventional TAPSE from the apical view in critically ill patients. Further research is required to elucidate the relationship between RV dysfunction and outcomes in sepsis.

Feasibility of myocardial perfusion assessment with contrast echocardiography: can it improve recognition of significant coronary artery disease in the ICU?

BACKGROUND: Diagnosis of significant coronary artery disease (CAD) and acute coronary artery occlusion in ICU can be difficult, and an inappropriate intervention is potentially harmful. Myocardial contrast perfusion echo (MCPE) examines ultrasound contrast intensity replenishment curves in individual myocardial segments measuring peak contrast intensity and slope of return as an index of myocardial blood flow (units = intensity of ultrasound per second [dB/s]). MCPE could possibly serve as a triage tool to invasive angiography by estimating blood flow in the myocardium. We sought to assess feasibility in the critically ill and if MCPE could add incremental value to the clinical acumen in predicting significant CAD. METHODS: This is a single-centre, prospective, observational study. Inclusion criteria were as follows: adult ICU patients with troponin I > 50 ng/L and cardiology referral being made for consideration of inpatient angiography. Exclusion criteria were as follows: poor echo windows (2 patients), known ischaemic heart disease, and contrast contraindications. Seven cardiologists and 6 intensivists blinded to outcome assessed medical history, ECG, troponin, and 2D echo images to estimate likelihood of significant CAD needing intervention (clinical acumen). Clinical acumen, quantitative MCPE, and subjective (visual) MCPE were assessed to predict significant CAD. RESULTS: Forty patients underwent MCPE analysis, 6 (15%) had significant CAD, and median 11 of 16 segments (IQR 8-13) could be imaged (68.8% [IQR 50-81]). No adverse events occurred. A significant difference was found in overall MCPE blood flow estimation between those diagnosed with significant CAD and those without (3.3 vs 2.4 dB/s, p = 0.050). A MCPE value of 2.8 dB/s had 67% sensitivity and 88% specificity in detecting significant CAD. Clinical acumen showed no association in prediction of CAD (OR 0.6, p = 0.09); however, if quantitative or visual MCPE analysis was included, a significant association occurred (OR 17.1, p = 0.01; OR 23.0, p = 0.01 respectively). CONCLUSIONS: MCPE is feasible in the critically ill and shows better association with predicting significant CAD vs clinical acumen alone. MCPE adds incremental value to initial assessment of the presence of significant CAD which may help guide those who require urgent angiography.

Echocardiographic assessment of left ventricular diastolic pressure.

PURPOSE OF REVIEW: Knowledge of the left ventricular pressures throughout the cardiac cycle is of considerable assistance in managing a haemodynamically unstable patient. Invasive pressure measurement is the only accurate way to analyze ventricular diastolic pressures but this is not feasible outside the catheterization laboratory, whereas the use of a pulmonary artery catheter or Doppler echocardiography, using surrogate measurements, is available at the bedside. The ever-increasing trend toward noninvasive monitoring puts echocardiography at the forefront and considerable effort has been made to define its role in this setting. RECENT FINDINGS: Ongoing refinement of guidelines used to evaluate left ventricular diastolic function have provided a pathway for critical care physicians to better understand how to evaluate left ventricular end-diastolic pressure and/or left atrial pressures. A number of recent studies have investigated the accuracy of combined or single echocardiographic parameters in determining left ventricular diastolic pressures as compared to those obtained invasively. Specifically selected combined parameters have moderate accuracy. SUMMARY: The recent literature on the clinical application of echocardiography on the accuracy in determining left ventricular noninvasively demonstrates that although far from perfect, it can be a very useful tool.

Subjective right ventricle assessment by echo qualified intensive care specialists: assessing agreement with objective measures.

BACKGROUND: Right ventricle (RV) size and function assessment by echocardiography (echo) is a standard tool in the ICU. Frequently subjective assessment is performed, and guidelines suggest its utility in adequately trained clinicians. We aimed to compare subjective (visual) assessment of RV size and function by ICU physicians, with advanced qualifications in echocardiography, vs objective measurements. METHODS: ICU specialists with a qualification in advanced echocardiography reviewed 2D echo clips from critically ill patients on mechanical ventilation with PaO2:FiO2 < 300. Subjective assessments of RV size and function were made independently using a three-class categorical scale. Agreement (B-score) and bias (p value) were analysed using objective echo measurements. RV size assessment included RV end-diastolic area (EDA) and diameters. RV function assessment included fractional area change, S', TAPSE and RV free wall strain. Binary and ordinal analysis was performed. RESULTS: Fifty-two clinicians reviewed 2D images from 80 patients. Fair agreement was seen with objective measures vs binary assessment of RV size (RV EDA 0.26 [p < 0.001], RV dimensions 0.29 [p = 0.06]) and function (RV free wall strain 0.27 [p < 0.001], TAPSE 0.27 [p < 0.001], S' 0.29 [p < 0.001], FAC 0.31 [p = 0.16]). However, ordinal data analysis showed poor agreement with RV dimensions (0.11 [p = 0.06]) and RV free wall strain (0.14 [p = 0.16]). If one-step disagreement was allowed, agreement was good (RV dimensions 0.6 [p = 0.06], RV free wall strain 0.6 [p = 0.16]). Significant overestimation of severity of abnormalities was seen with subjective assessment vs RV EDA, TAPSE, S' and fractional area change. CONCLUSION: Subjective (visual) assessment of RV size and function, by ICU specialists trained in advanced echo, can be fairly reliable for the initial exclusion of significant RV pathology. It seems prudent to avoid subjective RV assessment in isolation.

Accuracy of Quick Sequential Organ Failure Assessment Score to Predict Sepsis Mortality in 121 Studies Including 1,716,017 Individuals: A Systematic Review and Meta-Analysis.

We performed a meta-analysis to assess whether the newly introduced quick Sequential Organ Failure Assessment score could predict sepsis outcomes and compared its performance to systematic inflammatory response syndrome, the previously widely used screening criteria for sepsis. DATA SOURCES: We searched multiple electronic databases including MEDLINE, the Cochrane Library, Embase, Web of Science, and Google Scholar (up to March 1, 2019) that evaluated quick Sequential Organ Failure Assessment score, systemic inflammatory response syndrome, or both (International Prospective Register of Systematic Reviews [PROSPERO]: CRD42018103327). STUDY SELECTION: Studies were included if the outcome was mortality, organ dysfunction, admission to ICU, ventilatory support, or prolonged ICU stay and if prediction performance was reported as either area under the curve, odds ratio, sensitivity, or specificity. DATA EXTRACTION: The criterion validity of the quick Sequential Organ Failure Assessment score and systemic inflammatory response syndrome criteria were assessed by measuring its predictive validity for primary (mortality) and secondary outcomes in pooled metrics as mentioned. The data were analyzed using random effects model, and heterogeneity was explored using prespecified subgroups analyses. DATA SYNTHESIS: We screened 1,340 studies, of which 121 studies (including data for 1,716,017 individuals) were analyzed. For mortality prediction, the pooled area under the curve was higher for quick Sequential Organ Failure Assessment score (0.702; 95% CI, 0.685-0.718; I 2 = 99.41%; p < 0.001) than for systemic inflammatory response syndrome (0.607; 95% CI, 0.589-0.624; I 2 = 96.49%; p < 0.001). Quick Sequential Organ Failure Assessment score consistently outperformed systemic inflammatory response syndrome across all subgroup analyses (area under the curve of quick Sequential Organ Failure Assessment vs. area under the curve of systemic inflammatory response syndrome p < 0.001), including patient populations (emergency department vs ICU), study design (retrospective vs prospective), and countries (developed vs resource-limited). Quick Sequential Organ Failure Assessment score was more specific (specificity, 74.58%; 95% CI, 73.55-75.61%) than systemic inflammatory response syndrome (specificity, 35.24%; 95% CI, 22.80-47.69%) but less sensitive (56.39%; 95% CI, 50.52-62.27%) than systemic inflammatory response syndrome (78.84%; 95% CI, 74.48-83.19%). CONCLUSIONS: Overall, quick Sequential Organ Failure Assessment score outperforms systemic inflammatory response syndrome in predicting sepsis outcome, but quick Sequential Organ Failure Assessment score has relative strengths/weaknesses (more specific but less sensitive) compared with systemic inflammatory response syndrome.

A cumulative decision model for three-alternative choice in concurrent chains.

Traditional models for choice in the concurrent-chains procedure have assumed that terminal-link stimuli acquire value as conditioned reinforcers, and that 2-alternative choice provides a measure of relative value according to the matching law. By contrast, the cumulative decision model (CDM; Christensen & Grace, 2010) explains choice as the aggregate effect of comparing delays to a criterion on initial-link responding, not conditioned reinforcement. Here we test whether the CDM can account for choice in 3-alternative concurrent-chains (3ACC) and compare it with the hyperbolic value-added model (HVA; Mazur, 2001), which assumes that choice depends on the increase in conditioned reinforcement value signaled by terminal-link stimuli and has been successful in previous 3ACC research (Mazur, 2000). In Experiment 1, 4 pigeons responded in 3ACC in which the terminal links were fixed-interval schedules, and parameter estimates from fits of CDM and HVA were used to calculate predictions for conditions with variable-interval terminal links. The predictions of CDM were more accurate than those of HVA. In Experiment 2, 7 pigeons responded in 3ACC in which the terminal links were fixed-interval schedules. Although both models described the data well, residuals from HVA fits showed a systematic pattern predicted by CDM, characterized by a third-order polynomial with a negative cubic coefficient. Finally, we conducted a residual meta-analysis (Sutton, Grace, McLean, & Baum, 2008) of data from prior 3ACC studies. HVA residuals showed the same negative cubic pattern as in Experiment 2, whereas no systematic pattern was found in the CDM residuals. Overall, results support the CDM and suggest that the same principles which describe binary choice in concurrent chains generalize without modification to 3-alternative choice. (PsycINFO Database Record

Bedside myocardial perfusion assessment with contrast echocardiography.

This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency medicine 2016. Other selected articles can be found online at http://www.biomedcentral.com/collections/annualupdate2016. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.

Do we need a critical care ultrasound certification program? Implications from an Australian medical-legal perspective.

Medical practitioners have a duty to maintain a certain standard of care in providing their services. With critical care ultrasound gaining popularity in the ICU, it is envisaged that more intensivists will use the tool in managing their patients. Ultrasound, especially echocardiography, can be an 'easy to learn, difficult to manage' skill, and the competency in performing the procedure varies greatly. In view of this, several recommendations for competency statements have been published in recent years to advocate the need for a unified approach to training and certification. In this paper, we take a slightly different perspective, from an Australian medical-legal viewpoint, to argue for the need to implement a critical care ultrasound certification program. We examine various issues that can potentially lead to a breach of the standard of care, hence exposing the practitioners and/or the healthcare institutions to lawsuits in professional negligence or breach of contract. These issues, among others, include the failure to use ultrasound in appropriate situations, the failure of hospitals to ensure practitioners are properly trained in the skills, the failure of practitioners to perform an ultrasound study that is of a reasonable standard, and the failure of practitioners to keep themselves abreast of the latest developments in treatment and management. The implications of these issues and the importance of having a certification process are discussed.

Rapid acquisition in concurrent chains: evidence for a decision model.

Pigeons' choice in concurrent chains can adapt to rapidly changing contingencies. Grace, Bragason, and McLean (2003) found that relative initial-link response rate was sensitive to the immediacy ratio in the current session when one of the terminal-link fixed-interval schedules was changed daily according to a pseudorandom binary sequence (e.g., Schofield & Davison, 1997). The present experiment tested whether the degree of variation in delays across sessions had any effect on acquisition rate in Grace et al.'s (2003) rapid-acquisition procedure. In one condition ("minimal variation"), the left terminal link was always fixed-interval 8 s and the right terminal link was either fixed-interval 4 s or fixed-interval 16 s. In the other condition ("maximal variation"), a unique pair of fixed-interval values was used in each session. Responding was sensitive to the current-session immediacy ratio in both conditions, but across subjects there was no systematic difference in sensitivity. These results challenge the view that initial-link responding in the rapid-acquisition procedure is determined by changes in the learned value of the terminal-link stimuli, and suggests instead that a process resembling categorical discrimination may control performance. A decision model based on the assumption that delays are categorized as short or long relative to the history of delays provided a good account of the data and shows promise in being able to explain other choice phenomena.

Integrated versus segregated accounting and the magnitude effect in temporal discounting.

Temporal discounting rates in humans generally decrease as the amount of reward increases, a phenomenon known as the magnitude effect. In the present study, we examined whether temporal discounting and the magnitude effect are related to segregation of choices in terms of gains or losses for waiting for or expediting receipt of a reward. Subjects (N = 24) responded to a series of hypothetical choices about amounts of money available either immediately or after a delay. The immediate and delayed amounts either were presented as integrated amounts in the baseline condition or were segregated as differential gains or losses for choosing delayed or expedited consumption (delay and speedup conditions, respectively). Temporal discounting rates decreased in the segregated conditions, in accord with the standard discounted utility model but contrary to the hypothesis that the subjects were choosing on the basis of reward differentials in the baseline condition. The size of the magnitude effect was comparable in the baseline and the delay conditions but decreased in the speed-up condition. These results challenge explanations of the magnitude effect in terms of an increasing proportional sensitivity property of the utility function (Loewenstein & Prelec, 1992) and the hypothesis that subjects choose on the basis of differentials even when the rewards are presented as integrated amounts.