Multiple System Organ Failure Score

Patient's body weight

Does the patient have a known site of infection?

Does the patient have a suspected site of infection? (Y or N)

Core body temperature

Heart rate in the absence of beta blockers

Respiratory rate

Minute ventilation

Systolic blood pressure

Maximum drop in systolic blood pressure maintained for at least 1 hour

Was the pulmonary artery wedge pressure > 12 mm Hg during this fall?

Did the blood pressure fail to improve after infusing at least 500 mL of normal saline in 1 hour?

Minimum urine output

PaO2

FIO2 (enter as a fraction 0.21 to 1.00)

Is the primary diagnosis pneumonia?

Are there diffuse bilateral infiltrates on chest X-ray?

Glasgow Coma score prior to onset of sepsis syndrome

Worst Glasgow Coma score the 1st 24 hours after onset of sepsis syndrome

Is the patient ventilator dependent?

A-a gradient

Pulmonary shunt in percent (enter from 0 to 100)

Are adrenergic agents required to keep mean arterial pressure > 55 mm Hg?

Pulmonary artery wedge pressure

Creatinine

Bilirubin

Alkaline phosphatase

Is fresh blood seen in nasogastric tube drainage?

Is melena present?

Is fresh blood being passed per rectum?

Hemoglobin prior to onset of sepsis

Lowest hemoglobin during 1st 24 hours of sepsis syndrome

Number of red cell units transfused during past 24 hours

White blood cell count

Platelet count

International Normalized Ratio (INR) for prothrombin time (PT)

Is the patient receiving heparin?

Patient's PTT

Upper limit of normal for PTT

Fibrin degradation products

Is a primary CNS injury present?