Development and Validation of a Rapid and Efficient Prognostic Scoring System for Sepsis Based on Oxygenation Index, Lactate and Glasgow Coma Scale

Figures & data

Figure 1 Flow chart of the study.

Abbreviations: AUROC, area under the receiver operating characteristic; ROC, receiver operating characteristic curve; GCS, Glasgow Coma Scale; APACHE II, Acute Physiology and Chronic Health Evaluation II; SOFA, sequential organ failure assessment.

Table 1 Comparison of Base Information of Derivation and Validation Groups

Variable	Derivation Group (608)	Validation Group (213)	P-value
Age, years	58 ± 17	57± 19	0.348
Male, n (%)	390(64.1%)	138(64.8%)	0.866
Temperature, °C	37.3± 1.3	37.1± 1.0	0.865
Heart rate, beats/min	108± 20	111± 20	0.390
Breathing rate, beats/min	24± 5	24± 6	0.315
SBP, mmHg	121± 26	117± 23	0.083
DBP, mmHg	74± 17	72± 17	0.207
GCS (IQR)	15(15,15)	15(15,15)	0.514
Death, n (%)	131(21.5%)	42(19.7%)	0.574
SOFA (IQR)	5(3,7)	5(2,8)	0.648
APACHE II (IQR)	15(12,20)	15(10,20)	0.422

Abbreviations: APACHE II, Acute Physiology and Chronic Health Evaluation II; SOFA, sequential organ failure assessment; GCS, Glasgow coma scale; SBP, systolic blood pressure; DBP, diastolic blood pressure.

Table 2 Weight and Score of Scoring Items in the New Scoring System (GOL)

Variables	Value of Variables	Score of Variables
Oxygenation Index	>271	0
	≤271	1
Lac (mmol/L)	<2.3	0
	≥2.3	1
GCS	15	0
	<15	1

Notes: The new scoring system, named GOL, consists of three indicators, namely Oxygenation Index, Lac, and GCS, each contributing 0 or 1 to the GOL, with a maximum and minimum GOL score of 3 and 0, respectively.

Abbreviations: Lac, lactic acid; GCS, Glasgow coma scale.

Table 3 Relationship Between Clinical Characteristics and GOL Scores of Patients with Sepsis in the Derivation Group

Variable	GOL 0(192)	GOL 1(260)	GOL 2(123)	GOL 3(33)	P-value
Age, years	56 ± 17	59± 18	57± 16	59± 17	0.361
Male, n (%)	121(63.0%)	175(67.3%)	76(61.8%)	18(54.5%)	0.416
Temperature, °C	37.2± 1.0	37.2± 1.7	37.2± 1.0	37.2± 1.4	0.998
Heart rate, beats/min	105± 17	110± 21	109± 22	120± 25	0.001
Breathing rate, beats/min	22± 3	24± 5	25± 6	25± 5	<0.001
SBP, mmHg	120± 20	126± 26	119± 29	103± 28	<0.001
DBP, mmHg	73± 13	76± 16	72± 20	64± 19	<0.001
SPO2, %	96± 4	93± 7	94± 7	89± 12	<0.001
PH	7.44± 0.06	7.44± 0.07	7.41± 0.08	7.33± 0.12	<0.001
PO2, mmHg	84± 23	83± 34	80± 27	78± 29	0.523
PCO2, mmHg	33± 7	34± 11	34± 14	35± 14	0.633
LAC, mmol/L	1.42± 0.37	1.75± 1.21	2.79± 2.24	4.9± 2.8	<0.001
Oxygenation index	346± 47	239± 68	204± 44	204± 32	<0.001
WBC, 109/L	13± 8	13± 9	14± 10	17± 13	0.069
PLT, 109/L (IQR)	157(96,248)	164(95,244)	153(65,245)	97(46,202)	0.233
Hemoglobin, g/L	109± 26	113± 30	113± 33	112± 31	0.528
HCT	0.33± 0.07	0.34± 0.09	0.34± 0.09	0.34± 0.09	0.314
Albumin, g/L	37± 7	33± 6	32± 6	30± 8	0.002
Urea nitrogen, mmol/L (IQR)	5.61(4.12, 8.38)	6.49(4.49,10.33)	6.89(4.99,12.81)	10.83(7.16,16.90)	<0.001
Creatinine, μmol/L	75(60,95)	80(60,116)	83(59,146)	146(60,218)	0.243
Cys-C, mg/L (IQR)	1.09(0.86,1.34)	1.12(0.92,1.54)	1.18(0.91,1.85)	1.61(0.99,2.08)	0.441
Fibrinogen, g/L	4.43± 1.57	4.42± 1.59	4.24± 1.91	3.33± 1.89	0.003
D-dimer (IQR)	2.54(1.21,6.52)	3.16(1.49,8.38)	3.65(1.27,8.30)	7.76(4.22,15.09)	<0.001
Total bilirubin, μmol/L (IQR)	13.9(8.7,23.6)	11.8(8.0,19.6)	13.6(8.7,22.7)	14.0(7.9,33)	0.817
ALT, IU/L (IQR)	30(17,62)	23(14,47)	26(15,58)	29(8,33)	0.110
AST, IU/L (IQR)	33(20,64)	31(22,62)	42(25,72)	52(28,210)	<0.001
PCT(IQR)	1.16(0.31,4.3)	0.91(0.23,3.62)	1.32(0.27,12.42)	6.2(2.2,20)	0.004
GCS(IQR)	15(15,15)	15(15,15)	13(10,15)	8(6,10)	<0.001
Infection sites, n (%)					<0.001
Lung (pneumonia)	81(42.2)	170(65.4)	75(61)	19(57.6)
Intra-abdominal site	67(34.9)	47(18.1)	26(21.1)	7(21.2)
Others	44(22.9)	43(16.5)	22(17.9)	7(21.2)

Abbreviations: SBP, systolic blood pressure; DBP, diastolic blood pressure; SPO₂, oxygen saturation; PH, hydrogen ion concentration; PO₂, arterial oxygen partial pressure; PCO₂, arterial carbon dioxide partial pressure; LAC, lactate; WBC, white blood cell; PLT, platelet; HCT, hematocrit; Cys-C, cystatin-C; ALT, aspartate aminotransferase; AST, alanine aminotransferase; PCT, procalcitonin; IQR, interquartile range; GCS, Glasgow coma scale; GOL, the new scoring system developed in this study; APACHE II, Acute Physiology and Chronic Health Evaluation II; SOFA, sequential organ failure assessment.

Table 4 Univariate Analysis and Multivariate Logistic Regression Analysis Between Survival and Death Groups in the Derivation Group

Variable	Univariate Analysis			Multivariate Logistic Regression Analysis
	Survival (477)	Death (133)	P-value	B	OR (95% CI)	P-value
Age, years	57 ± 17	60± 17	0.062	-	-	-
Male, n (%)	308(64.6%)	82(62.6%)	0.676	-	-	-
Temperature, °C	37.3± 1.1	37.2± 2.1	0.297	-	-	-
Heart rate, beats/min	107± 20	112± 20	0.020	−0.006	0.994(0.982,1.006)	0.341
Breathing rate, beats/min	23± 5	25± 6	0.001	0.025	1.025(0.981,1.071)	0.260
SBP, mmHg	122± 25	119± 28	0.291	-	-	-
DBP, mmHg	74± 16	72± 9	0.121	-	-	-
SPO2, %	95± 6	92± 9	0.003	−0.022	0.977(0.945,1.009)	0.194
PH	7.43± 0.07	7.40± 0.11	0.001	−0.538	0.584(0.024,4.034)	0.740
PO2, mmHg	82± 26	82± 39	0.918	-	-	-
PCO2, mmHg	34± 10	32± 12	0.147	-	-	-
LAC, mmol/L	1.79± 1.23	2.91± 2.56	<0.001	0.151	1.163(1.001,1.352)	0.035
Oxygenation index	274± 81	226± 66	<0.001	0.001	1.001(0.997,1.006)	0.573
WBC, 109/L	13± 9	13± 10	0.620	-	-	-
PLT, 109/L (IQR)	160(95,248)	144(65,226)	0.027	0.001	1.001(0.999,1.003)	0.319
Hemoglobin, g/L	113± 30	106± 29	0.011	0.001	1.001(0.969,1.033)	0.975
HCT	0.34± 0.08	0.32± 0.08	0.013	−0.850	0.427(0.010,9.321)	0.830
Albumin, g/L	34± 7	29± 6	<0.001	−0.080	0.923(0.885,0.963)	<0.001
Urea nitrogen, mmol/L (IQR)	6.11(4.29,9.59)	8.10(5.63,13.30)	<0.001	−0.003	0.997(0.954,1.035)	0.754
Creatinine, μmol/L	77(60,106)	97(61,153)	0.004	−0.003	0.997(0.993,1.000)	0.649
Cys-C, mg/L (IQR)	1.09(0.88,1.49)	1.37(1.01,1.93)	<0.001	0.249	1.283(0.834,1.972)	0.257
Fibrinogen, g/L	4.42± 1.60	4.01± 1.92	0.025	−0.017	0.983(0.851,1.136)	0.814
D-dimer (IQR)	2.99(2.16,7.16)	4.16(1.78,11.47)	0.001	−0.020	0.980(0.948,1.014)	0.256
Total bilirubin, μmol/L (IQR)	12.6(8.3,21.6)	13.2(8.3,23.2)	0.662	-	-	-
ALT, IU/L (IQR)	27(15,57)	25(16,47)	0.829	-	-	-
AST, IU/L (IQR)	33(21,64)	40(25,69)	0.027	0.000	1.000(1.000,1.000)	0.572
PCT(IQR)	0.98(0.22,4.84)	2.31(0.80,8.82)	<0.001	−0.006	0.994(0.983,1.005)	0.304
GCS(IQR)	15(15,15)	15(10,15)	<0.001	0.152	1.164(1.024,1.325)	0.020
GOL (IQR)	1(0,1)	2(1,2)	<0.001	0.680	1.973(1.200,3.244)	0.011
SOFA (IQR)	4(2,6)	8(5,11)	<0.001	0.189	1.208(1.101,1.326)	<0.001
APACHE II (IQR)	15(11,19)	19(15,24)	<0.001	0.053	1.054(1.001,1.110)	0.048

Abbreviations: SBP, systolic blood pressure; DBP, diastolic blood pressure; SPO₂, oxygen saturation; PH, hydrogen ion concentration; PO₂, arterial oxygen partial pressure; PCO₂, arterial carbon dioxide partial pressure; LAC, lactate; WBC, white blood cell; PLT, platelet; HCT, hematocrit; Cys-C, cystatin-C; ALT, aspartate aminotransferase; AST, alanine aminotransferase; PCT, procalcitonin; IQR, interquartile range; GCS, Glasgow coma scale; GOL, the new scoring system developed in this study; APACHE II, Acute Physiology and Chronic Health Evaluation II; SOFA, sequential organ failure assessment.

Figure 2 ROC curves of GOL, SOFA and APACHE II in the derivative group.

Abbreviations: ROC, receiver operating characteristic curve; GOL, the new scoring system developed in this study; APACHE II, Acute Physiology and Chronic Health Evaluation II; SOFA, sequential organ failure assessment.

Figure 3 SOFA (A) and APACHE II (B) levels in different OLG scores.

Abbreviations: GOL, the new scoring system developed in this study; APACHE II, Acute Physiology and Chronic Health Evaluation II; SOFA, sequential organ failure assessment.

Figure 4 The 28-day mortality (A), MV (B), and AICU (C) with different OLG scores.

Abbreviations: MV, mechanical ventilation; AICU, admission to intensive care unit; GOL, the new scoring system developed in this study.

Table 5 Logistic Regression Analysis Regarding Correlations Between Clinical Outcomes and GOL

Variables	GOL 1 vs 0 OR (95% CI)	p-value	GOL 2 vs 0 OR (95% CI)	p-value	GOL 3 vs 0 OR (95% CI)	p-value
28-day mortality
Unadjusted	2.040(1.124–3.701)	0.019	6.366(3.436–11.794)	<0.001	27.451(11.009–68.448)	<0.001
Adjusted*	1.760(0.910–3.405)	0.093	5.723(2.839–11.537)	<0.001	20.378(6.257–66.369)	<0.001
MV
Unadjusted	4.553(2.830–7.323)	<0.001	12.681(7.281–22.086)	<0.001	34.222(12.158–96.331)	<0.001
Adjusted*	3.949(2.315–6.734)	<0.001	12.191(6.547–22.699)	<0.001	20.276(6.074–67.685)	<0.001
AICU
Unadjusted	3.717(2.343–5.896)	<0.001	11.205(6.515–19.272)	<0.001	24.300(9.243–63.883)	<0.001
Adjusted*	3.261(1.953–5.445)	<0.001	8.549(4.701–15.545)	<0.001	5.455(1.792–16.606)	0.003

Notes: *Risk factors adjustment included age, gender, temperature, heart rate, breathing rate, SBP, DBP, SPO2, PH, PO2, PCO2, white blood cell count, platelet count, hemoglobin, HCT, albumin, urea nitrogen, creatinine, cystatin-C, fibrinogen, D-dimer, total bilirubin, alanine aminotransferase, aspartate aminotransferase, PCT, Infection sites.

Abbreviations: MV, mechanical ventilation; AICU, admission to intensive care unit; OR, odds ratio; IC, confidence interval; GOL, the new scoring system developed in this study.

Figure 5 Decision curve analysis for the outcome of 28-day mortality. For clinically relevant threshold probabilities (above 18% and 43%), OLG was superior to APACHE II and SOFA, respectively.

Abbreviations: GOL, the new scoring system developed in this study; APACHE II, Acute Physiology and Chronic Health Evaluation II; SOFA, sequential organ failure assessment.

Table 6 AUC Comparison of Adverse Outcome Prediction Based on GOL, APACHE II, and SOFA in Validation Cohort

Endpoint	Scores	AUC (95% CI)	SE	P- value	P for Comparison
28-day death	GOL	0.785(0.724,0.838)	0.0372	<0.001	Ref
	APACH II	0.790(0.729,0.843)	0.0389	<0.001	0.902
	SOFA	0.798(0.738,0.850)	0.0417	<0.001	0.735
AICU	GOL	0.766(0.703,0.821)	0.0303	<0.001	Ref
	APACH II	0.676(0.608,0.738)	0.0368	<0.001	0.030
	SOFA	0.789(0.728,0.842)	0.0335	<0.001	0.498
MV	GOL	0.774(0.712,0.828)	0.0289	<0.001	Ref
	APACH II	0.667(0.599,0.730)	0.0368	<0.001	0.008
	SOFA	0.855(0.801,0.900)	0.0257	<0.001	0.011

Abbreviations: GOL, the new scoring system developed in this study; APACHE II, Acute Physiology and Chronic Health Evaluation II; SOFA, sequential organ failure assessment; MV, mechanical ventilation; AICU, admission to intensive care unit; AUC, the area under the curve.