O que todo intensivista deve saber sobre sistemas de pontuação de prognóstico e mortalidade ajustada ao risco

In the practice of medicine, multiple scores and prognostic systems have been developed to quantify disease severity, assess prognosis, and guide therapeutic interventions. The Glasgow Coma Scale, the Model for End Stage Liver Disease (MELD), and the American Society of Anesthesiologists Physical Status Classification are but a few examples. Heterogeneity in the practice of intensive care medicine, the high cost of care, the very real chance of death in intensive care units (ICUs), and the desire to make comparisons between ICUs have prompted the development and refinement of ICU-specific prognostic systems.

Scoring systems may be generic or disease-specific, may be used for cohort analysis or individual patient assessment, can be based on physiologic derangement or resource allocation, and may be simple or complex. In critical care practice, two major categories of scoring systems exist. Organ failure scores (e.g., the Sequential Organ Failure Assessment, SOFA) describe a patient’s physiologic derangements by organ system to provide an objective assessment of the extent and severity of organ dysfunction. The other major category is the severity-of-illness prognostic model, a discussion of which will occupy the majority of this commentary. These systems (e.g., the Acute Physiology and Chronic Health Evaluation, APACHE) use physiologic data, pre-morbid conditions and information regarding the nature of the current illness to predict the likelihood of mortality.

Sequential Organ Failure Assessment: an organ dysfunction score Multiple organ dysfunction syndrome is a major cause of ICU morbidity and mortality. The extent and severity of organ dysfunction may be quantified in a number of organ dysfunction scores, the most prominent of which is the SOFA.(8) Originally designed to be used in patients with sepsis, the SOFA is
now used in all patient groups. Daily scores can be calculated and used to track the degree of organ dysfunction throughout a patient’s ICU stay – in contrast to generic prognostic systems, which are designed to give a prediction based on the first ICU day alone. Scores between 0 and 4 are assigned to each of the cardiovascular, respiratory, hepatic, hematologic, neurologic and renal systems, depending on the degree of derangement, and are summed to yield a total SOFA score. Such scores were not originally designed to predict mortality, but high absolute scores and an increase in a score within the first 96 hours of ICU care are associated with increased risk of death.(9)


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