Neonatal Sequential Organ Failure Assessment (nSOFA) Score within 72 Hours after Birth Reliably Predicts Mortality and Serious Morbidity in Very Preterm Infants

A Global Assessment of Coagulation Profile and a Novel Insight into Adamts-13 Implication in Neonatal Sepsis

Neonatal sepsis is a life-threatening condition associated with significant morbidity and mortality. Sepsis-induced coagulopathy is a well-recognized entity, signifying the strong cross-talk between inflammation and coagulation. The aim of the present study was to compare the coagulation profile between the acute phase of sepsis and recovery in term and preterm neonates. Additional comparisons to healthy neonates were undertaken. Levels of clotting, anti-clotting factors and ADAMTS-13 (A disintegrin and metalloprotease with thrombospondin type-1 motives), the cleaving protein of von Willebrand factor (VWF), were measured in 16 term and preterm neonates in the acute phase of infection and following recovery, as well as in 18 healthy neonates. Clotting times were prolonged, while levels of particular clotting factors were lower in the acute phase of infection compared to controls and recovery. On the other hand, levels of fibrinogen, factor VIII (FVIII) and VWF were significantly higher in the acute phase in comparison to controls and recovery, while they remained persistently higher in the infection group compared to controls. In regard to the anticlotting mechanism, a clear suppression was observed in septic neonates. ADAMTS-13 levels were significantly lower in the acute phase of infection in comparison to controls and recovery (p = 0.015 and 0.004, respectively), while a trend toward superimposed normalization was demonstrated post infection, as higher ADAMTS-13 levels were measured in recovered neonates compared to controls (p = 0.002). The coagulation profile is considerably deranged in neonatal sepsis. ADAMTS-13 deficiency in septic neonates is a novel finding with promising future implications, as ADAMTS-13 substitution may serve as a useful therapeutic option in neonatal sepsis, prompting further investigation in future studies.

Early Prediction of Mortality after Birth Asphyxia with the nSOFA

(1) Birth asphyxia is a major cause of delivery room resuscitation. Subsequent organ failure and hypoxic-ischemic encephalopathy (HIE) account for 25% of all early postnatal deaths. The neonatal sequential organ failure assessment (nSOFA) considers platelet count and respiratory and cardiovascular dysfunction in neonates with sepsis. To evaluate whether nSOFA is also a useful predictor for in-hospital mortality in neonates (≥36 + 0 weeks of gestation (GA)) following asphyxia with HIE and therapeutic hypothermia (TH), (2) nSOFA was documented at ≤6 h of life. (3) A total of 65 infants fulfilled inclusion criteria for TH. All but one infant received cardiopulmonary resuscitation and/or respiratory support at birth. nSOFA was lower in survivors (median 0 [IQR 0-2]; n = 56, median GA 39 + 3, female n = 28 (50%)) than in non-survivors (median 10 [4-12], p < 0.001; n = 9, median GA 38 + 6, n = 4 (44.4%)). This was also observed for the respiratory (p < 0.001), cardiovascular (p < 0.001), and hematologic sub-scores (p = 0.003). The odds ratio for mortality was 1.6 [95% CI = 1.2-2.1] per one-point increase in nSOFA. The optimal cut-off value of nSOFA to predict mortality was 3.5 (sensitivity 100.0%, specificity 83.9%). (4) Since early accurate prognosis following asphyxia with HIE and TH is essential to guide decision making, nSOFA (≤6 h of life) offers the possibility of identifying infants at risk of mortality.

Use of an electronic medical record to optimize a neonatal sepsis score for mortality prediction

OBJECTIVE

Late-onset sepsis (LOS) is a significant cause of mortality in preterm infants. The neonatal sequential organ failure assessment (nSOFA) provides an objective assessment of sepsis risk but requires manual calculation. We developed an EMR pipeline to automate nSOFA calculation for more granular analysis of score performance and to identify optimal alerting thresholds.

METHODS

Infants born <33 weeks of gestation with LOS were included. A SQL-based pipeline calculated hourly nSOFA scores 48 h before/after sepsis evaluation. Sensitivity analysis identified the optimal timing and threshold of nSOFA for LOS mortality.

RESULTS

Eighty episodes of LOS were identified (67 survivors, 13 non-survivor). Non-survivors had persistently elevated nSOFA scores, markedly increasing 12 h prior to culture. At sepsis evaluation, the AUC for nSOFA >2 was 0.744 (p = 0.0047); thresholds of >3 and >4 produced lower AUCs.

CONCLUSIONS

nSOFA is persistently elevated for infants with LOS mortality compared to survivors with an optimal alert threshold >2.

Sequential organ failure assessment scores to predict outcomes: from adults to neonates

PURPOSE OF REVIEW

Organ dysfunction severity scores (sequential organ failure assessment or SOFA) are commonly used in the adult and pediatric populations when assessing risk of mortality and adverse outcomes from sepsis. In contrast to sepsis definition in adults and children, clinical and laboratory criteria for defining neonatal sepsis have been inconclusive. More recently, studies have attempted to better understand the clinical progression of neonatal sepsis and associated mortality. This data has guided the development of a neonatal SOFA (nSOFA) score, based on common patterns of organ dysfunction observed in this population.

RECENT FINDINGS

Although SOFA scores in the adult and pediatric populations have their limitations with moderate sensitivities and specificities depending on the clinical setting, the nSOFA score has been validated in predicting sepsis attributable mortality in very low birth weight (VLBW) infants across several patient cohorts. Furthermore, the nSOFA score has been adapted for use in neonatal disease states, other than sepsis, with similar prognostic utility.

SUMMARY

Utilizing an nSOFA scoring system for prediction of sepsis attributable mortality in preterm infants allows for targeted interventions based on risk stratification, as well as better delineation of neonatal sepsis with subsequent improvements in research and patient safety outcomes.