Serum IL-6 and IL-1-ra with sequential organ failure assessment scores in septic patients receiving high-volume haemofiltration and continuous venovenous haemofiltration

AIM: Sepsis is characterized by an uncontrolled release of pro-inflammatory and anti-inflammatory mediators leading to immunoparalysis, cellular and humoral dysfunction, multiorgan dysfunction and death. This study evaluated the efficacy of high-volume haemofiltration (HVHF) compared with continuous venovenous haemofiltration (CVVH) in removing these inflammatory mediators. Clinical responses were assessed with the sequential organ failure assessment (SOFA) score. METHODS: Septic patients with an end-organ dysfunction or septic shock were randomized to receive 6 h of CVVH (ultrafiltration dose of 2 L/h equivalent to about 35 mL/kg per hour or HVHF (ultrafiltration dose of 100 mL/kg per hour or 6 L/h, whichever was higher). The sequential organ failures were scored for the 24 hours preceding recruitment; at day 1, day 7, at discharge from the intensive care unit and at hospital discharge. RESULTS: Thirty-three patients were enrolled. Fifteen received HVHF and 18 received CVVH. The serum IL-6 levels (pg/mL) at baseline were similarly elevated in both groups (P = 0.745). The HVHF group showed a significant reduction after 6 h of treatment with a median interquartile range (IQR) of 20.62 (49.21) pg/mL (P = 0.025) with no similar result in the CVVH group. Non-survivors showed a higher baseline serum IL-6 compared with the survivors (median (IQR) 172.31 (261.34) vs 58.9 (104.21), P = 0.044). In the HVHF group there was a positive association between the IL-6 levels at 6 h with the SOFA scores at day 1 (r = 0.392, P = 0.001) but not at day 7. After 6 h of treatment in the HVHF group there was a direct correlation between the IL-6 levels and number of hospital days (r = 0.90, P = 0.040). The maximum SOFA scores were persistently recorded before treatment. The SOFA scores reduced in both groups from baseline to day 7 (HVHF P = 0.048; CVVH P = 0.006). The SOFA scores at day 1 is significantly higher in the non-survivors compared with the survivors (P = 0.038). CONCLUSIONS: High-volume haemofiltration at 6 L/h may seem to successfully remove some inflammatory cytokines in septic patients. The improvement in the SOFA scores at day 7 promises benefit of continuous renal replacement therapy in septic patients, but after 20 days this effect may be lost. In addition, the baseline serum IL-6 and IL-1-ra were independent predictors of a poor outcome as reflected by the higher SOFA scores at day 1.     

A modified gastrointestinal failure score for patients with severe acute pancreatitis

Purpose

No consensus has been reached to define gastrointestinal failure (GIF) associated with severe acute pancreatitis (SAP). Reintam and colleagues proposed a scoring system of GIF for critically ill patients, but its suitability for patients with SAP is questionable. The present study evaluates a modified GIF score we developed to assess the GIF of patients with SAP.

Methods

The subjects of this study were 52 patients with SAP treated between September 2010 and July 2011. We recorded the Reintam’s GIF score, our modified GIF score, the acute physiology and chronic health evaluation (APACHE) II score, the sequential organ failure assessment (SOFA) score, and other clinical values during the first 3 days after admission. The prognostic value of the modified GIF score, for evaluating the severity and outcomes of SAP, was also assessed.

Results

Compared with the Reintam’s GIF score, the modified GIF score seemed to be more valuable for predicting hospital mortality (the area under curve, AUC 0.915 vs. 0.850), multiple organ dysfunction syndrome (MODS) (AUC 0.829 vs. 0.766), and pancreatic infection (AUC 0.796 vs. 0.776). Moreover, combining the modified GIF score and the SOFA or APACHEII scores resulted in more accurate prediction of the prognosis of SAP than either score alone.

Conclusion

The modified GIF score is useful for assessing gastrointestinal system function, which may serve as an early prognostic tool to evaluate the severity and predict the outcomes of SAP.     

Early oral intake after arthroscopic surgery under spinal anesthesia

Purpose. We investigated the tolerability of early oral feeding (EOF) and its effects on the recovery of bowel function after spinal anesthesia. Methods. Thirty-one healthy adult patients undergoing knee arthroscopy or arthroscopic surgeries were randomly assigned to either the EOF group (n = 16) or the nil per os (NPO, n = 15) group. Spinal anesthesia was performed using hyperbaric tetracaine solution in all patients. Patients in the EOF group were allowed free access to solid and liquid food immediately after surgery before analgesia from spinal tetracaine resolved. Oral intake was prohibited for 24 h after completion of surgery in the NPO group. Results. Two patients in each group were mildly nauseated without the need for treatment. While degree of appetite determined by a visual analog scale before the first meal and time to the first gas emission showed no significant differences between groups, the median time to the first defecation in the EOF group (20.6 h) was significantly shorter than that of the NPO group (33.5 h, P = 0.005). No other complications associated with anesthesia, surgery, or EOF were noted. Conclusion. Our results suggest that the restriction of EOF after surgery not involving the gastrointestinal tract under spinal anesthesia may not be rational, and that EOF may facilitate recovery of bowel function. Received for publication on January 6, 1999; accepted on July 7, 1999     

Early massive transfusion in trauma patients: Canadian single-centre retrospective cohort study

Purpose

To determine associations between red blood cell (RBC) transfusion and early and late clinical outcomes in massively transfused adult trauma patients.

Methods

A retrospective cohort study (1992–2001) including 260 patients receiving ≥10 RBC units ≤24 hr after admission to a university-affiliated trauma centre. We extracted demographic and clinical data and used multivariable regression to determine independent effects of RBC transfusion on clinical outcomes.

Results

Patients had a high (mean [standard deviation]) injury severity score (ISS) (42.5 [15.1]), a high admission sequential organ failure assessment (SOFA) score (8.4 [3.8]), and a high hospital mortality (58.5%). They received 38 (25–64) (median [interquartile range]) blood components within 48 hr, including 19 (14–28) RBC units. For 143 patients surviving ≥48 hr, the maximum SOFA score was associated with RBC units transfused before 48 hr (linear regression beta coefficient 0.075, P < 0.0001), lower nadir hemoglobin before 48 hr (0.034, P = 0.03), age (0.032, P = 0.015), and admission SOFA (0.59, P < 0.0001). The RBC units transfused by 48 hr were not associated with either hospital mortality (n = 35) among patients surviving ≥48 hr (independent predictors, age [logistic regression odds ratio (OR) 1.06, 95% confidence interval 1.03–1.10], ISS [OR 1.07, 1.02–1.13], and maximum SOFA score [OR 1.56, 1.27–1.93]) or 48-hr mortality (n = 117) (independent predictors, admission SOFA [1.65, 1.45–1.88] and later year of hospital admission [OR 1.15, 1.02–1.29]).

Conclusions

Hospital mortality is high among massively transfused trauma patients. Among early survivors, 48-hr RBC transfusion volume is associated with increased organ dysfunction, but not hospital mortality. Also, it is not associated with 48-hr mortality. Future research should continue to explore methods to improve hemostasis and minimize the need for RBC transfusion.     

Anandamide absorption by direct hemoperfusion with polymixin B-immobilized fiber improves the prognosis and organ failure assessment score in patients with sepsis

Purpose Direct hemoperfusion (DHP) with polymixin B-immobilized fiber (PMX) has been reported to be effective for patients with septic shock. The aim of this study was to clarify the mechanism of PMX-DHP effect on septic shock. Methods The following parameters were measured in septic shock patients who were treated with PMX-DHP: survival rate, sepsis-related organ failure assessment (SOFA) score, acute physiology and chronic health evaluation II (APACHE-II) score, and plasma concentrations of cannabinoids [anandamide (ANA) and 2-arachidonyl glyceride (2-AG)], cytokines [interleukin (IL)-6, IL-8, IL-10], transforming growth factor β (TGF-β), and calcitonin gene-related peptide (CGRP)]. The primary end point was mortality from all causes at day 28 after intensive care unit (ICU) admission or discharge. Results The survival rate of all patients at 28 days after ICU admission was 37.5% (9/24). The survival group showed significantly lower SOFA and APACHE-II scores than the nonsurvival group after PMX-DHP treatment (P = 0.008 and 0.028, respectively). The improved SOFA score group showed a better survival rate than the nonimproved SOFA score group (71.4% versus 23.5%, P = 0.028). Plasma ANA level significantly decreased after PMX-DHP treatment both in the improved SOFA score group and in the survival group. The level of 2-AG, however, showed no significant change in either group. Conclusion ANA, an intrinsic cannabinoid that induces hypotension in septic shock, is inferred to be the main mechanism of the PMX-DHP effect. Removal of ANA by PMX-DHP could be key to successful septic shock treatment.     

The impact of organ failures and their relationship with outcome in intensive care: analysis of a prospective multicentre database of adult admissions

The database of a multicentre cohort study was analysed to determine the impact of intensive care unit (ICU) organ failures and their association with ICU mortality using sequential organ failure assessment (SOFA). A consecutive sample of 873 adult patients with a non-neurological diagnosis was identified. SOFA scores were measured every 24 h of ICU stay. The odds of ICU death within 7 days doubled (95% CI 1.3-2.9) for a 5-unit increase in total SOFA score at admission, p < 0.001. However ICU death after 7 days was not associated with total SOFA score at admission, p = 0.36. Compared to patients with a day 6 total SOFA score = 5, there was a 1-unit (95% CI 0.8-3.1) increase in the odds ratio of ICU death after 7 days with every 5-unit increase in SOFA score on day 6, p = 0.009. Continuous assessments of organ failures during an ICU admission are more useful than scores measured at admission to determine outcome and to compare ICUs.     

Scandinavian glutamine trial: a pragmatic multi-centre randomised clinical trial of intensive care unit patients

Background: Low plasma glutamine concentration is an independent prognostic factor for an unfavourable outcome in the intensive care unit (ICU). Intravenous (i.v.) supplementation with glutamine is reported to improve outcome. In a multi‐centric, double‐blinded, controlled, randomised, pragmatic clinical trial of i.v. glutamine supplementation for ICU patients, we investigated outcomes regarding sequential organ failure assessment (SOFA) scores and mortality. The hypothesis was that the change in the SOFA score would be improved by glutamine supplementation. Methods: Patients (n=413) given nutrition by an enteral and/or a parenteral route with the aim of providing full nutrition were included within 72 h after ICU admission. Glutamine was supplemented as i.v. l ‐alanyl‐l ‐glutamine, 0.283 g glutamine/kg body weight/24 h for the entire ICU stay. Placebo was saline in identical bottles. All included patients were considered as intention‐to‐treat patients. Patients given supplementation for >3 days were considered as predetermined per protocol (PP) patients. Results: There was a lower ICU mortality in the treatment arm as compared with the controls in the PP group, but not at 6 months. For change in the SOFA scores, no differences were seen, 1 (0,3) vs. 2 (0.4), P=0.792, for the glutamine group and the controls, respectively. Conclusion: In summary, a reduced ICU mortality was observed during i.v. glutamine supplementation in the PP group. The pragmatic design of the study makes the results representative for a broad range of ICU patients.     

重症急性胰腺炎早期脏器功能不全持续时间与治疗对策

目的探讨重症急性胰腺炎（severe acute pancreatitis,SAP）影响脏器功能不全持续时间的因素及其对患者转归的作用以及相应的治疗策略。方法2000年1月至2005年6月连续收治74例Ⅱ型SAP患者,按脏器功能不全持续时间分为两组：脏器功能不全持续时间≤3d,为暂时性脏器功能不全组（20例）;脏器功能不全持续时间〉3d,为持续性脏器功能不全组（54例）。比较两组患者在SAP并发症和病死率方面的差异。结果74例SAPⅡ型患者中,心血管系统功能不全发生率80％、肺脏47％、肝脏37％、肾脏20％;暂时性脏器功能不全组多脏器功能不全所占比例明显低于持续性脏器功能不全组（P〈0．01）。暂时陛脏器功能不全组并发症发生率和病死率明显低于持续性脏器功能不全组（P值分别为0．038和0．054）。结论脏器功能不全持续存在3d以上是预示SAP患者死亡的危险因素,避免脏器功能不全发生或缩短脏器功能不全的持续时间是改善SAP患者预后的关键。     

重症急性胰腺炎早期液体治疗策略的探讨

目的探讨重症急性胰腺炎(SAP)早期两种不同液体治疗策略对患者预后的影响。方法回顾性分析我院2000年1月至2011年11月期间收治的符合入选标准且达到液体治疗目标的97例SAP患者,2000年1月至2004年12月期间收治的患者采用传统的液体治疗方法(简称传统治疗组,n=34),2005年1月至2011年11月期间收治的患者采取的早期目标指导的液体治疗策略(简称早期目标治疗组,n=63),比较2组间急性生理与慢性健康状况Ⅱ评分(APACHEⅡ)、器官功能不全评分(Marshall)、多器官功能障碍综合征(MODS)发生率、胰腺感染率和住院病死率的差异。结果与传统治疗组相比,早期目标治疗组患者液体治疗后第3天时的APACHEⅡ和Marshall评分较传统治疗组明显降低(APACHEⅡ评分:7.38±4.01比11.35±4.27,P=0.011;Marshall评分:4.13±2.06比6.82±3.15,P=0.016)。另外,早期目标治疗组患者入院后7 d内MODS发生率、胰腺感染率和住院病死率也较传统治疗组有所降低(MODS:46.0%比61.8%,P=0.139;胰腺感染率:31.7%比44.1%,P=0.226;住院病死率:15.8%比23.5%,P=0.355),但其差异均无统计学意义。结论本研究有限的病例结果提示,早期目标指导的液体治疗可在一定程度上缓解SAP病情,但能否改善SAP患者预后有待临床进行前瞻性随机对照研究。     

Sequential organ failure assessment score in predicting outcome in patients with acute pancreatitis

Aims/Objectives

To evaluate the sequential organ failure assessment (SOFA) score pertaining to the severity and outcome in acute pancreatitis, and compare its outcome with the APACHE II score in terms of accuracy and ease of operation with a view to establishing whether the SOFA scoring system can replace APACHE II in predicting severity and outcome of acute pancreatitis.

Methods

Fifty cases of acute pancreatitis were evaluated in this prospective study. These patients were treated as per standard protocols and followed up daily. Both SOFA and APACHE II scores were calculated at admission and thereafter at 48-hour intervals till discharge or death. Subsequently, the data were analysed, and receiver operating characteristic curves were made for SOFA, APACHE II and other biochemical parameters; a p-value < 0.05 was taken as significant.

Results

The SOFA score showed a significant association in predicting the severity of the disease, especially during the first week. Moreover, it decreased the predicted severity of APACHE II by 18% and mortality by 4.5%.

Conclusion

On the day of admission, SOFA scores were comparable with APACHE II in predicting the outcome with a higher area under the ROC curve, and displayed better predicting capability as compared to APACHE II.     

Progression of Organ Failure in Patients Approaching Brain Stem Death

We performed a retrospective cohort study to document the progression of organ dysfunction in 182 critically ill adult patients who subsequently met criteria for brain stem death (BSD). Patients were admitted to intensive care units (ICUs) of Mayo Medical Center, Rochester, MN, between January 1996 and December 2006. Daily sequential organ failure assessment (SOFA) scores were used to assess the degree of organ dysfunction. Serial SOFA scores were analyzed using analysis of variance (ANOVA). Mean (standard deviation, SD) SOFA score on the first ICU day was 8.9 (3.2). SOFA scores did not significantly change over the course of ICU stay. 67.6% of patients donated one or more organs after BSD was declared. The median time from ICU admission to declaration of BSD was 18.8 h (interquartile range 10.3–45.0), and in those who donated organs, the time from declaration of BSD to organ retrieval was 11.8 h (9.5–17.6). The fact that mean SOFA scores did not change significantly over time, even after BSD occurred, has implications for the timing of retrieval of organs for transplantation.     

Orthotopic liver transplantation in critically ill cirrhotic patients with multi-organ failure: a single-center experience

Due to the lack of donor organs for orthotopic liver transplantation (OLT) in Germany, a larger proportion of patients advance to multi-organ failure (MOF) before OLT. Twenty-three patients on the waiting list for OLT were admitted to our intensive care unit (ICU) from January 2007 until September 2009. They consisted of 16 men and 7 women of median (25th–75th percentile) age of 60 years (54–65). Acute Physiology and Chronic Health Evaluation (APACHE II) score upon ICU admission was 26 (19–34); Model of End-Stage Liver Disease (MELD) score was 29 (22–41); Sequential Organ Failure Assessment (SOFA) score was 12 (8–16). The 90-day mortality rate was 39%. A decrease in MELD score during the first 48 hours (−2 [−5–0] vs 2 [−1–4]; P = .019) was associated with survival. Thirteen patients underwent transplantation from the ICU. By the time of the OLT, the MELD scores had deteriorated to 38 (33–39) and SOFA scores to 19 (18–19). All patients were mechanically ventilated and received hemodynamic support with catecholamines. Ten of 13 patients (77%) received renal replacement therapy and/or single pass albumin dialysis. Eight of 13 patients (62%) had a SOFA score of 3 or 4 (organ failure) in each of the respective subscores for the cardiovascular, renal, and respiratory systems at the time of OLT. The 90-day mortality rate after OLT was 38% and the 1-year-mortality rate was 54%. Patients who did not survive 90 days post OLT showed lower MELD scores on admission (33 [18–35] vs 44 [32–46]; P = .045), an increased MELD during the first 48 hours (3 [1–4] vs −2 [−8–1]; P = .002), and a longer ICU stay before OLT (32 [18–37] vs 8 [2–15]; P = .006). In conclusion, OLT may be successful treatment for cirrhotic patients with MOF. Outcomes of MOF in cirrhotic patients may improve after OLT but are generally worse than acceptable. A shorter ICU waiting time seemed to be beneficial.     

Early intervention with phosphodiesterase‐5 inhibitors after prostate brachytherapy improves subsequent erectile function

Study Type – Therapy (case series)
Level of Evidence 4

OBJECTIVE

To examine the early use of phosphodiesterase‐5 inhibitor (PDE‐5i; sildenafil citrate) in preventing subsequent erectile dysfunction (ED) after (monotherapy) prostate brachytherapy (PB, an accepted option for Gleason 6 or low‐volume Gleason 7 prostate cancer), as PB is currently being offered more frequently in younger patients, and ED can be a side‐effect often within the first 12 months after treatment.

PATIENTS AND METHODS

We examined a single‐surgeon series of 69 patients who had been treated with PB from 2002 to 2005. All patients had a follow‐up of ≥1 year; prospectively, and patients had baseline, 6‐ and 12‐month assessments using the Sexual Health Inventory for Men (SHIM) and International Index of Erectile Function (IIEF)‐6 scores. The 69 patients were divided into early treatment with PDE‐5i (31) and not treated with PDE‐5i (38), and their SHIM and IIEF‐6 scores were compared at baseline, 6 and 12 months. Daily sildenafil (25–50 mg) was given immediately after PB for 12 months. Overall, for the entire group, the mean prostate‐specific antigen (PSA) level was 6.8 ng/mL; 78% had Gleason 6 cancer and 20% had Gleason 7 (3 + 4) cancer. The mean age in the early PDE‐5i group was 64.8 years, and was 66.0 years in the no‐PDE‐5i group. The mean radiation dose in the early PDE‐5i group was 50.2 Gy, and 43.9 Gy in the other group (P= 0.08).

RESULTS

In the no‐PDE‐5i group, the mean baseline SHIM score of 17.1 decreased rapidly to 9.1 at 6 months (P= 0.01) and stayed at 9.3 at 12 months (P= 0.01). In the early PDE‐5i group, the mean baseline SHIM score of 21.8 decreased slightly to 17.6 at 6 months (P= 0.2), and was maintained at 17.9 at 12 months (P= 0.2). Using the Wilcoxon rank‐sum test, the 6‐ and 12‐month SHIM scores in the two groups (P < 0.001). The IIEF‐6 questionnaire confirmed the SHIM analysis.

CONCLUSIONS

After PB patients had a significant decline in SHIM/IIEF‐6 scores at 6 and 12 months. Our results indicate a 50% decrease in the quality of their erections. This provides an opportunity to initiate early intervention with PDE‐5i or perhaps vacuum constriction devices or intraurethral alprostadil. In this study, the early use of PDE‐5i after PB maintained erectile function at both 6 and 12 months.     

急性胰腺炎继发胰周感染的危险因素分析

目的:探讨急性胰腺炎(AP)早期继发胰周感染的危险因素。方法:回顾性分析2010年1月—2016年10月间中南大学湘雅医院连续收治的、起病72 h内入院的826例AP患者资料,比较其中住院期间出现胰周感染与未出现胰周感染患者之间临床特点及入院24 h血化验结果,分析胰周感染的危险因素,并单独分析急性重症胰腺炎(SAP)继发胰周感染的危险因素。结果:826例AP患者中,发生胰周感染患者30例(3.6%)。单因素与多因素Logistic回归分析结果显示,持续器官功能衰竭(48 h)(OR=21.143,P0.001)、男性(OR=11.659,P=0.003)以及入院24 h内白蛋白降低(OR=0.872,P=0.006)是预测AP患者发生早期胰周感染的独立危险因素。住院期间,59例SAP患者发生胰周感染21例(35.6%),单因素与多因素Logistic回归分析结果显示,持续性器官功能衰竭(1周)(OR=7.47,P=0.007)是SAP继发胰周感染的独立危险因素。结论:起病早期出现持续性器官功能衰竭,男性以及入院24 h内白蛋白减少是AP患者继发胰周感染的危险因素,且器官功能衰竭持续时间越长,发生胰周感染的风险越高。     

Reduction of Postoperative Complication Rate with the Use of Early Oral Feeding in Gynecologic Oncologic Patients Undergoing a Major Surgery: A Randomized Controlled Trial

Background

A randomized controlled trial was performed to assess the outcome of early oral postoperative feeding (EOF) compared with traditional oral feeding (TOF) in gynecologic oncology patients undergoing a complex laparotomy, including upper abdominal surgery.

Methods

Patients aged 18–75 years, undergoing an elective laparotomy and with a preoperative suspicion of gynecologic malignancy, were eligible. Exclusion criteria included infectious conditions, intestinal obstruction, severe malnutrition, American Society of Anesthesiologists score ≥4, intestinal resection, and postoperative stay in the intensive care unit lasting >24 h. Patients allocated to EOF received liquid diet in the first postoperative day and then regular diet. Patients received traditional feeding scheme until resolution of postoperative ileus to start liquid diet. The primary end-point of the trial was length of hospital stay.

Results

Between January 1, 2007, and November 17, 2007, a total of 143 patients were randomized to receive either EOF or TOF. Hospital stay for patients who received EOF (n = 71) was 4.7 vs. 5.8 days for the TOF group (n = 72) (P = 0.006). The mean level of postoperative satisfaction was significantly higher in the EOF group (82.8 vs. 71.7 mm, P ≤ 0.001). Patients who received the TOF scheme had significantly higher overall postoperative complications (39 vs. 17% in EOF group, P = 0.003) and infective complications (14% in TOF group vs. 3% in EOF group, P = 0.017). Variables such as nausea and vomiting, analgesic and antiemetic requirement as well as level of pain and quality of life were not different between groups.

Conclusions

On the basis of these findings, the policy of EOF should be used after a complex gynecologic oncologic laparotomy.     

Histological Damage of Colonic Epithelium is Associated with Clinical Severity and Outcome in Colectomized Critically Ill Patients

Background

Severe intestinal mucosal damage and organ failure has been associated in experimental models. Our purpose was to determine whether there is any association between histopathological findings and postoperative mortality among ICU patients undergoing emergency colectomies for various illnesses.

Methods

In a retrospective case control study, total colectomy specimens from 50 patients in a mixed ICU were analysed: 18 had sepsis, 11 vascular operations, and 21 Clostridium difficile colitis. Overall thickness, the width of epithelial defects, and presence of cryptal damage were assessed. Extent of necrosis and amount of neutrophils were separately evaluated in the layers of the colonic wall. Clinical features, including sequential organ failure assessment (SOFA) scores and survival, were registered.

Results

The histopathological findings for the three clinical entities were similar, except for the abundance of characteristic pseudomembranes in the Clostridium group. Mucosal height (maximum) showed a negative correlation with SOFA score on admission (ρ = ?0.296, P = 0.037), and with preoperative blood lactate level (ρ = ?0.316; P = 0.027). The nonsurvivors had wider enterocyte defects (60 vs. 40.8, P = 0.002) and more severe crypt damage (61 vs. 27 %; P = 0.024) than the survivors.

Conclusions

The histopathological damage involves all layers of the colon wall among ICU patients being largely similar in sepsis, C. difficile infection, and ischemia after vascular operations. Mucosal epithelial damage is associated with clinical severity of the illness and mortality.     

Early Enteral Nutrition Prevents Intra-abdominal Hypertension and Reduces the Severity of Severe Acute Pancreatitis Compared with Delayed Enteral Nutrition: A Prospective Pilot Study

Background

To investigate the effects of early enteral nutrition (EEN) on intra-abdominal pressure (IAP) and disease severity in patients with severe acute pancreatitis (SAP).

Methods

Enteral nutrition (EN) was started within 48 h after admission in the EEN group and from the 8th day in the delayed enteral nutrition (DEN) group. The IAP and intra-abdominal hypertension (IAH) incidence were recorded for 2 weeks. The caloric intake and feeding intolerance (FI) incidence were recorded daily after EN was started. The severity markers and clinical outcome variables were also recorded.

Results

Sixty patients were enrolled to this study. No difference about IAP was found. The IAH incidence of the EEN group was significantly lower than that of the DEN group from the 9th day (8/30 versus 18/30; P = 0.009) after admission. The FI incidence of the EEN group was higher than that of the DEN group during the initial 3 days of feeding (25/30 versus 12/30; P = 0.001; 22/30 versus 9/30; P = 0.001; 15/30 versus 4/30; P = 0.002). Patients with an IAP <15 mmHg had lower FI incidence than those with an IAP ≥15 mmHg on the 1st day (20/22 versus 17/38; P < 0.001), the 3rd day (11/13 versus 8/47; P < 0.001), and the 7th day (3/5 versus 3/55; P = 0.005) of feeding. The severity markers and clinical outcome variables of the EEN group were significantly improved.

Conclusions

Early enteral nutrition did not increase IAP. In contrast, it might prevent the development of IAH. In addition, EEN might be not appropriate during the initial 3–4 days of SAP onset. Moreover, EN might be of benefit to patients with an IAP <15 mmHg. Early enteral nutrition could improve disease severity and clinical outcome, but did not decrease mortality of SAP.     

Prognostic value of Sequential Organ Failure Assessment and Simplified Acute Physiology II score compared with trauma scores in the outcome of multiple-trauma patients

Background

Prospective data regarding the prognostic value of the Sequential Organ Failure Assessment (SOFA) score in comparison with the Simplified Acute Physiology Score (SAPS II) and trauma scores on the outcome of multiple-trauma patients are lacking.

Methods

Single-center evaluation (n = 237, Injury Severity Score [ISS] >16; mean ISS = 29). Uni- and multivariate analysis of SAPS II, SOFA, revised trauma, polytrauma, and trauma and ISS scores (TRISS) was performed.

Results

The 30-day mortality was 22.8% (n = 54). SOFA day 1 was significantly higher in nonsurvivors compared with survivors (P < .001) and correlated well with the length of intensive care unit stay (r = .50, P < .001). Logistic regression revealed SAPS II to have the best predictive value of 30-day mortality (area under the receiver operating characteristic = .86 ± .03). The SOFA score significantly added prognostic information with regard to mortality to both SAPS II and TRISS.

Conclusions

The combination of critically ill and trauma scores may increase the accuracy of mortality prediction in multiple-trauma patients.     

Initial and delayed onset of acute respiratory failure: factors associated with development and outcome

In a prospective observational study of 1038 adult admissions to a 31-bed medical/surgical intensive care unit (ICU), acute respiratory failure (ARF, defined as a Pao(2)/Fio(2) ratio 48 h after ICU admission) in 49 (16%). On admission, the cardiovascular sequential organ failure assessment (SOFA) score was higher in initial than in delayed onset ARF (1.1 +/- 1.5 vs 0.6 +/- 1.2, P < 0.05). High admission serum C-reactive protein concentrations (OR 1.08, 95% CI 1.04-1.12, P = 0.0001) and SOFA scores (OR 1.20, 95% CI 1.08-1.33, P = 0.0007) were the factors independently associated with initial ARF, and a low Glasgow coma scale (GCS) score (OR 1.13, 95% CI 1.04-1.21, P = 0.0018) was associated with delayed onset ARF. In initial ARF, a high SOFA score (OR 1.24, 95% CI 1.12-1.38, P = 0.0001) and a low GCS score (OR 0.89, 95% CI 0.83-0.96, P = 0.0013) on admission, and in delayed onset ARF, a low GCS score at 48 h (OR 0.67, 95% CI 0.54-0.84, P = 0.0011) were independently associated with death. The mortality rate was similar for initial and delayed onset ARF.     

Therapeutic options in patients with early T stage and advanced N stage of tonsillar squamous cell carcinomas

Objective

To compare the therapeutic role of surgery followed by radiotherapy (OPRT) and concurrent chemoradiotherapy (CCRT) in patients with early T (T1/T2) and advanced N (N2/N3) stage tonsillar squamous cell carcinoma.

Study Design

Historical cohort study.

Setting

A tertiary hospital.

Subjects and Methods

The medical records of 42 patients who met the eligible criteria (24 patients were treated by OPRT, 18 patients by CCRT) were reviewed.

Results

Mean overall survival (OS) and disease-free survival (DFS) were 49.0 months and 43.0 months in OPRT group, respectively, and 39.6 months and 35.0 months in CCRT group, respectively (P = 0.18 for OS, P = 0.29 for DFS between the two groups). There was also no significant difference in survival estimates between OPRT and CCRT group in terms of two-year OS (P = 0.18) and two-year DFS (P = 0.45). In the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30, the scores for global health status and symptom scales did not differ between the two groups. However, the OPRT group reported better functional scales and significantly higher scores for cognitive (P = 0.008) and social function (P = 0.03). Among single items, a significantly lower score for insomnia (P = 0.007) was noted in the OPRT group. In EORTC QLQ-H&N35 modules, there were no significantly different scales between the two groups except scores for nutritional supplements, in which the OPRT group presented lower symptom scores (P = 0.02).

Conclusion

OPRT could be still a viable option for managing selected cases of advanced oropharyngeal cancer because one can expect comparable therapeutic outcome as well as quality of life.