Addition of new criteria to Sequential Organ Failure Assessment for patients with subarachnoid hemorrhage

Abstract

Introduction: Subarachnoid hemorrhage (SAH) is defined by an acute bleeding in the cisterns of the brain. It occurs in 15.7% of 100,000 inhabitants per year and generally is due to sacular aneurysm rupture. Approximately 30% of the patients die because of the first bleeding episode and 45% by the end of the first month; whereas 48% of these patients show severe neurological disorder. Generally the early occlusion of the aneurysm is recommended to prevent recurrent bleeding and to create conditions for the treatment of vasospasm. The purpose of the treatment is to prevent or reverse ischemic disabilities through the hemodynamic therapy (hypervolemia, hypertension, hemodilution and hyperdynamism-4 H therapy). The Sequential Organ Failure Assessment (SOFA) was originally created for sepsis, but its quality is now used in other medical conditions. Therefore, we add some criteria to the index to assess patients with SAH. Objective: Besides the SOFA score, to evaluate serum glucose, arterial lactate, magnesium, calcium, sodium, hourly diuresis and axillary temperature as prognostic factors in patients with SAH. Study design A prospective observational study carried out between March 2007 and December 2008 in the neurovascular ICU at São José do Avaí Hospital, Itaperuna, RJ, Brazil. Study patients were those diagnosed with SAH by computerized tomography (CT) of the skull. Methods: Informed consent was obtained for each patient/family; APACHE II (criteria for admission) and SOFA weekly, serum (table presented) glucose, lactate, calcium, sodium and magnesium; and measurement of the axillary temperature and hourly diuresis were the additional prognostic factors. The study enrolled 91 patients diagnosed with SAH, confirmed by CT of the skull in the neurovascular ICU at São José do Avaí Hospital. The conduct in relation to the approach of these new criteria was the same in all patients evaluated. The patients were divided into two groups according to their development in the ICU: Group I-patients who had good evolution (out of ICU); and Group II-patients who progressed to death in the ICU (Table 1). Results: Among 91 patients, 68 (74.72%) were female and 23 (25.27%) were male. The APACHE II for admission varied from 2 to 34, with an average of 15.5. The maximum spent time in the ICU was 49 days (two patients). Group I had 55 patients (60.4%) and the 36 remaining patients (39.6%) were classified as Group II. Table 2 presents the results of the criteria examined in the study obtained in both groups. Conclusions: We can conclude that the group of patients with SAH has a female predominance (68:23). The APACHE II score in Group I was 11.9, while in Group II it was 17.9. Regarding the criteria used to assess patients with SAH, it was observed that the only criterion that showed statistical significance in the prediction of death was the serum sodium (P = 0.002). The other criteria evaluated did not have statistical significance in predicting the prognosis of patients. A new complementary study is necessary to standardize these additional criteria to SOFA as an assessing method of prognosis of patients with SAH, but we can conclude that the change in values of serum sodium has fundamental importance on the development of this group of patients.