European Journal of Cardiovascular Medicine

Sepsis with multiple organ dysfunction syndrome (MODS) is one of the most common causes of mortality and morbidity in intensive care units worldwide. While early sepsis is potentially reversible with timely resuscitation and source control, progression to severe sepsis and septic shock is associated with a substantial rise in mortality. MODS represents the terminal stage of this continuum, characterised by progressive and often sequential failure of two or more organ systems.

Given the high mortality associated with sepsis-MODS, early and objective risk stratification is essential to guide clinical decision-making, resource allocation, and communication with patients and families regarding prognosis. Over the past three decades, several scoring systems have been developed for use in the intensive care unit to quantify severity of illness and estimate the probability of in-hospital mortality. Two of the most widely validated and used systems are the Acute Physiology and Chronic Health Evaluation II (APACHE II) score [2] and the Sequential Organ Failure Assessment (SOFA) score [3].

APACHE II incorporates acute physiological derangement, age, and chronic health status measured within the first 24 hours of admission, while the SOFA score evaluates the degree of dysfunction across six organ systems and can be calculated serially to track trends in organ dysfunction over the course of illness. A well-performing prognostic model allows comparison of a unit's performance against benchmarks, identification of areas for quality improvement, and more informed prognostic discussions with patients and relatives.

This study was undertaken to evaluate the clinical and demographic profile of patients presenting with sepsis-associated MODS at a Department of general medicine. Narayana medical college, Nellore, and to assess the ability of APACHE II and serial SOFA scores, along with individual clinical and laboratory parameters, to predict 30-day mortality in this population.

Aims and Objectives

To evaluate patients with sepsis and multiple organ dysfunction syndrome using the SOFA score and the APACHE II score, and to assess the correlation of these scores — along with associated clinical and laboratory parameters — with 30-day mortality.

Study Design and Setting

This was a prospective and retrospective observational study conducted in the Department of General Medicine, Narayana Medical College and General Hospital, Nellore, Andhra Pradesh, India, over a period of one year.

Sample Size

One hundred and twenty (n = 120) adult patients admitted with sepsis and clinical/laboratory evidence of multiple organ dysfunction syndrome were enrolled during the study period.

Inclusion and Exclusion Criteria

Patients above 18 years of age with evidence of sepsis and MODS at the time of admission were included. Patients on immunosuppressant medications, those with retroviral infection, and antenatal patients were excluded from the study.

Data Collection and Procedures

After obtaining informed consent from patients and attending relatives, all patients underwent detailed history taking, clinical examination, and relevant laboratory investigations, including complete hemogram, renal function tests, serum electrolytes, liver function tests, and arterial blood gas analysis. Blood and urine cultures, Widal test, malaria smear, dengue serology, chest radiography, and abdominal ultrasonography were performed where clinically indicated to establish the diagnosis of sepsis-MODS as per American College of Chest Physicians/Society of Critical Care Medicine (ACCP/SCCM) consensus criteria [1].

The APACHE II score was calculated within the first 24 hours of admission. The SOFA score was calculated on day 1 (SOFA I) and day 3 (SOFA III) of admission, and the mean of the two values was derived (mean SOFA score) for patients in whom both values were available. Use of vasopressors/inotropes, mechanical ventilatory support, and dialytic intervention were recorded, as these variables contribute to SOFA scoring. Patients were followed up for the primary outcome — survival or death — at 30 days from admission.

Statistical Analysis

Data were entered and analysed using SPSS and Epi Info software. Continuous variables are expressed as mean ± standard deviation and were compared between survivors and non-survivors using the independent samples t-test. A two-tailed p-value < 0.05 was considered statistically significant.

Overall 30-Day Outcome

Of the 120 patients enrolled, 76 (63.3%) survived and 44 (36.6%) died within 30 days of admission (Table 1, Figure 1). This mortality rate is consistent with previously reported national and international estimates for sepsis-MODS, which range from approximately 30% to 80%.

Table 1. Thirty-day outcome in patients with sepsis-MODS (N = 120).

Age and Sex Distribution

Patient age ranged from 18 to 90 years (mean 40 years). The majority of deaths occurred in patients above 40 years of age (Table 2, Figure 2).

Table 2. Age-wise distribution of survivors and non-survivors.

There were 62 males and 58 females in the study. Mortality was 29.0% (18/62) among males and 44.8% (26/58) among females, suggesting a numerically higher mortality among female patients (Table 3, Figure 3).

Table 3. Sex-wise distribution of survivors and non-survivors.

Age itself was not a statistically significant predictor of mortality: mean age was 53.02 ± 14.54 years in survivors versus 51.72 ± 17.53 years in non-survivors (t = 0.30, p = 0.38).

APACHE II Score and Mortality

Table 4. APACHE II score in survivors versus non-survivors (Figure 4).

The APACHE II score, calculated within the first 24 hours of admission, was significantly higher in non-survivors (25.63 ± 5.78) compared with survivors (16.81 ± 4.52; p < 0.05), confirming its value as an early predictor of 30-day mortality in sepsis-MODS.

SOFA Scores and Mortality

Table 5. Day-1 SOFA score in survivors versus non-survivors (Figure 5).

The mean SOFA I score was approximately 5 in survivors versus 10 in non-survivors, a highly significant difference (p < 0.05), indicating that a higher day-1 SOFA score is associated with increased mortality risk.

Table 6. Day-3 SOFA score in survivors versus non-survivors (Figure 6). SOFA III was calculable in 110 of 120 patients, as 5

non-survivors died within the first two days.

able 7. Mean SOFA score (average of day 1 and day 3) in survivors versus non-survivors figure 7

The p-value was significant across all three SOFA parameters (SOFA I, SOFA III, and mean SOFA), reinforcing that a higher and/or rising SOFA score over the course of admission is associated with a greater probability of death.

Clinical and Laboratory Parameters

Table 8 summarises the remaining clinical and laboratory parameters assessed for their correlation with 30-day mortality.

Table 8. Clinical and laboratory parameters in survivors versus non-survivors (Figures 8–10).

Heart rate, respiratory rate, Glasgow Coma Scale, serum sodium, serum creatinine, and serum bilirubin all showed statistically significant correlation with mortality (p < 0.05). In contrast, rectal temperature, PaO₂, pH, serum potassium, hematocrit, total leukocyte count, and platelet count did not reach statistical significance.

In this prospective and retrospective observational study of 120 patients with sepsis-associated MODS managed in the medical wards and intensive care unit of a tertiary care teaching hospital, both APACHE II and SOFA scoring systems demonstrated strong and statistically significant correlation with 30-day mortality, consistent with their established role as prognostic tools in critical care.

The overall mortality of 36.6% observed in this cohort falls within the wide range (30–80%) reported across national and international studies of sepsis-MODS [1,7,9], reflecting the heterogeneity of case-mix, severity at presentation, and available critical care resources across settings. Most deaths occurred in patients above 40 years of age, and although non-survivors were numerically younger on average than survivors in this cohort, the difference in age between groups was not statistically significant, suggesting that age alone is an unreliable standalone predictor of outcome in this population. A numerically higher mortality was observed among females (44.8%) compared with males (29.0%); this descriptive finding warrants cautious interpretation given the modest sample size and merits confirmation in larger cohorts.

The APACHE II score, calculated within the first 24 hours of admission, was significantly higher among non-survivors, supporting its established utility as an early risk-stratification tool. The SOFA score, assessed serially on day 1 and day 3, showed an even more pronounced separation between survivors and non-survivors, with the day-3 (SOFA III) and mean SOFA scores yielding the largest t-statistics in this cohort. This is consistent with the premise that serial monitoring of organ dysfunction — rather than a single admission-day snapshot — provides incremental prognostic information, as a rising SOFA trajectory over the first days of admission likely reflects failure to reverse the underlying septic process, a pattern previously reported by Vosylius et al. and Ferreira et al. [5,6]. This concords with reports that serial SOFA tracking outperforms a single APACHE II value in some settings [10,11,13], although other authors have found APACHE II to remain the stronger predictor [12].

Among individual clinical and laboratory parameters, heart rate, respiratory rate, Glasgow Coma Scale, serum sodium, serum creatinine, and serum bilirubin each showed independent significant association with mortality — findings that are biologically coherent, as tachycardia, tachypnoea, altered sensorium, hypernatremia, renal dysfunction, and hyperbilirubinemia are all recognised markers of physiological decompensation and organ injury in sepsis; the prognostic value of the Glasgow Coma Scale at admission, in particular, has been independently confirmed elsewhere [4]. In contrast, rectal temperature, PaO₂, arterial pH, serum potassium, hematocrit, total leukocyte count, and platelet count did not reach statistical significance in this cohort, which may reflect the relatively modest sample size, the compensatory nature of some of these parameters in early sepsis, or population-specific variation.

These findings are broadly concordant with existing literature demonstrating that combining a validated admission severity score (APACHE II) with a dynamic, serially trended organ-dysfunction score (SOFA) offers complementary prognostic value [8,14,15] — the former capturing baseline severity and comorbidity burden, and the latter capturing trajectory of organ dysfunction under treatment.

Both the APACHE II score and serial SOFA scores (SOFA I, SOFA III, and mean SOFA) showed a statistically significant correlation with 30-day mortality in patients with sepsis-associated multiple organ dysfunction syndrome in this cohort. Higher values of APACHE II, SOFA I, and SOFA III were associated with greater mortality, and serial monitoring of SOFA scores across admission days appeared to offer better prognostic discrimination than a single time-point measurement, with a rising SOFA trend signalling higher mortality risk.

Heart rate, respiratory rate, serum sodium, serum creatinine, Glasgow Coma Scale, and serum bilirubin were independently associated with mortality and may serve as accessible bedside adjuncts to formal scoring systems. Given its comparable or marginally better predictive performance and simpler bedside calculation relative to APACHE II, the SOFA score — particularly when trended serially — is a practical and advisable tool for prognosticating patients with sepsis-MODS in medical intensive care settings.

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