ACDIS insight: Reviewing SOFA-2

by Laurie L. Prescott RN, MSN, CCDS, CCDS-O, CDIP, CRC

In October, JAMA Network Open published the consensus statement Rational and Methodological Approach Underlying the Development of the Sequential Organ Failure Assessment (SOFA)-2 Score. The original SOFA score presented in 1996 was developed to identify organ dysfunction in patients with sepsis and was subsequently expanded to include all critically ill patients. With the introduction of the Sepsis-3 criteria by the Third International Consensus Definitions for Sepsis and Septic Shock in 2016, SOFA scoring became an integral tool for determining organ dysfunction in the context of infection, thereby facilitating the identification and confirmation of sepsis. 

Sepsis-3 defines sepsis as an infection that leads to an increase of at least two points in a patient's SOFA score compared to their baseline. Although there are competing criteria for diagnosing sepsis, many organizations now use Sepsis-3 criteria as their clinical standard. The recent release by JAMA describes the methodological approach and rationale applied in the development of a revised SOFA scoring system, SOFA-2, recognizing that practices have changed since the inception of SOFA in 1996. The report states,

SOFA-2 incorporates both commonly measured and readily collectable physiological and laboratory variables as well as the degree of organ support required to maintain the physio-biochemical variables at normal, or acceptably abnormal, levels. Organ support has been expanded to include present-day management practices, such as invasive ventilation modalities, renal replacement therapy, and cardioactive drugs, devices, use of which was far more limited when the SOFA-1 score was published in 1996.

Like SOFA-1, the SOFA-2 score assesses six separate organ systems. Below is a summary of the changes to these assessments and corresponding scoring.

Brain

• The name of the organ system changed from central nervous system to brain
• The diagnosis of delirium requiring medication treatment has been incorporated into the criteria
• Glasgow Coma Scale (GCS) scoring values have been adjusted

Respiratory

• Noninvasive respiratory support and extracorporeal membrane oxygenation (ECMO) have been incorporated
• PaO₂/Fi0₂ (PF) ratio (mm Hg) scoring values have been adjusted

Note: Advanced ventilatory support includes high-flow nasal cannula, continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), noninvasive ventilation, invasive mechanical ventilation, or long-term home ventilation.

Cardiovascular

• Summation of doses of catecholamines
• Incorporation of other vasopressor and inotrope agents
• Incorporation of mechanical support devices

Note: Vasopressor medication is only used in scoring when given by continuous infusion for at least one hour. Mechanical support includes venoarterial ECMO, intra-aortic balloon pump, left ventricular assist device, and microaxial flow pump.

Liver

• The name of the organ system changed from hepatic to liver
• Bilirubin level scoring values have been adjusted

Kidney

• Creatinine and urine output scoring values have been adjusted
• Renal replacement therapy has been adjusted

Hemostasis

• The name of the organ system changed from coagulation/hematological to hemostasis
• Platelet count scoring values have been adjusted

Other revisions include:

• Definitions of dysfunction for each organ system
• Alternatives for variables that are not available or not indicated
• Rules for scoring related to special circumstances, such as sedation and  chronic organ dysfunction
• Rules for scoring when information is missing on or after day 1

What do these changes mean to CDI practice?

Organizations that utilize Sepsis-3 criteria and SOFA scoring to identify and clinically validate the presence of sepsis should review the consensus statement and apply it to existing practices.

This statement offers both definitions and guidance for identifying organ dysfunction related to the central nervous, respiratory, liver, , cardiovascular, renal, gastrointestinal, and immune systems as well as hemostasis This information and guidance can be used to develop clinical and diagnostic parameters beyond simply identifying a systemic infection.

For a full explanation of the updated revisions, refer to the consensus statement in its entirety, as not all definitions and scoring factors are included in the above summary. 

References

• Moreno, R. Rhodes, A., Ranzani, O., Salluh, J. I. F., Berger-Estilita, J., Coopersmith, C. M., Juffermans, N. P., Laffey, J., Reinikainen, M., Neto, A. S., Tavares, M., Timsit, J.-F., Lopez, M. D. P. A., De Waele, J., Dos Santos, C. C., … Singer, M. (2025, October 29). Rationale and methodological approach underlying the development of the Sequential Organ Failure Assessment (SOFA)–2 score: A consensus statement. JAMA Network Open, 8(10), e2545040. https://doi.org/10.1001/jamanetworkopen.2025.45040
• Singer, M., Deutschman, C. S., Seymour, C. W., Shankar-Hari, M., Annane, D., Bauer, M., Bellomo, R., Bernard, G. R., Chiche, J.-D., Coopersmith, C. M., Hotchkiss, R. S., Levy, M. M., Marshall, J. C., Martin, G. S., Opal, S. M., Rubenfeld, G. D., van der Poll, T., Vincent, J.-L., & Angus, D. C. (2016, February 23). The third international consensus definitions for sepsis and septic shock (sepsis-3). JAMA, 315(8), 801–810. https://doi.org/10.1001/jama.2016.028

Editor’s note: Prescott is the former interim ACDIS director and CDI education director for HCPro, as well as the author of the ACDIS Pocket Guide and ACDIS Outpatient Pocket Guide. For questions about this article, please contact the ACDIS team at info@acdis.org.