SOFA-2: Updated SOFA score for Sepsis-3

A revised SOFA (Sequential Organ Failure Assessment) score, known as SOFA-2, was published in JAMA (Journal of the American Medical Association) on October 29, 2025. Originally developed to detect acute organ dysfunction in critically ill patients, the SOFA score is now primarily used to identify organ dysfunction in sepsis, as outlined in the Sepsis-3 guidelines.

The SOFA table had not been revised for three decades, potentially limiting its applicability to contemporary clinical practices and outcomes. This study engaged 60 experts and analyzed data from 3.34 million patients across more than 1,300 intensive care units in nine countries, including the United States, between 2014 and 2023. The resulting update introduced new definitions, additional variables, and modified thresholds for classifying the severity of organ dysfunction.  

SOFA-2 retains the six organ systems from the original SOFA (now referred to as SOFA-1), but it updates both the scoring ranges and introduces new variables to better capture organ dysfunction using a scale from 0 to 4. While researchers explored the possibility of including scores for immune and gastrointestinal systems, these were ultimately left out due to insufficient predictive evidence and data.

The SOFA-2 score is still calculated by adding up the highest scores for each of the six organ systems—within a 24-hour period. Notably, there were major updates to the respiratory, renal, and cardiovascular systems, while only slight modifications were made to the brain, liver, and coagulation systems.

Although this was published in JAMA, the final decision to formally implement the guideline rests with its sponsoring organizations: the Society for Critical Care Medicine (SCCM) and the European Society of Intensive Care Medicine (ESICM).   

Dr. Marvyn Singer, lead author of Sepsis-3 and co-author of SOFA-2, discusses SOFA-2, critiques the outdated Sepsis-2 SIRS criteria, and addresses sepsis-related payer issues in the U.S. To access the webinar replay, purchase the 2026 CDI Pocket Guide® or Unbound Edition, or purchase on-demand for $29.

Below summarizes the key organ system modifications between SOFA-2 and SOFA-1.

Respiratory

The P/F (PaO2/FIO2) ratio thresholds were updated, and the S/F (SpO2/FIO2) ratio was included to reflect the growing use of pulse oximetry rather than arterial blood gases. The S/F ratio is calculated by dividing SpO2 by FIO2. Both ratios have a cutoff of <=300 for 1 point, but thresholds differ for higher points.

“Advanced ventilatory support” is now defined as high-flow nasal oxygen, CPAP, BiPAP, non-invasive ventilation, invasive mechanical ventilation, or long-term home ventilation.

Kidney (previously Renal)

No significant changes were made to the creatinine levels > 3.5 mg/dl, although the urine output criteria were modified substantially. Four points are now assigned for receiving or meeting criteria for dialysis, including chronic use.

Cardiovascular

Vasopressor and inotrope use was clarified. Vasopressors are only scored if they are administered as a continuous intravenous infusion for at least one hour. When dopamine is the sole vasopressor used, the scoring follows these thresholds: 2 points for 20 μg/kg/min, 3 points for rates greater than 20 up to 40 μg/kg/min, and 4 points for rates over 40 μg/kg/min.

Brain (previously Central Nervous System)

GCS scores have minor updates, with additional options when the GCS score is not captured. Use of drugs to treat delirium counts as one point, even if the GCS is normal (15). If all three GCS domains can't be assessed, use the highest motor-scale score.

Liver

The most significant change is in bilirubin levels for 1 and 2 points.

Hemostasis (previously Coagulation)

Minor changes were made at the 3 and 4 point levels for platelets.