Thrombocytopenia and prognosis in intensive care

OBJECTIVE: To study the incidence and prognosis of thrombocytopenia in adult intensive care unit (ICU) patients. DESIGN: Prospective observational cohort study. SETTING: The medical ICU of a university hospital and the combined medical-surgical ICU of a regional hospital. PATIENTS: All patients consecutively admitted during a 5-month period. INTERVENTIONS: Patient surveillance and data collection. MEASUREMENTS AND MAIN RESULTS: The primary outcome measure was ICU mortality. Data of 329 patients were analyzed. Overall ICU mortality rate was 19.5%. A total of 136 patients (41.3%) had at least one platelet count <150 x 10(9)/L. These patients had higher Multiple Organ Dysfunction Score (MODS), Simplified Acute Physiology Score (SAPS) II, and Acute Physiology and Chronic Health Evaluation (APACHE) II scores at admission, longer ICU stay (8 [4-16] days vs. 5 [2-9] days) (median [interquartile range]), and higher ICU mortality (crude odds ratio [OR], 5.0; 95% confidence interval [CI], 2.7-9.1) and hospital mortality than patients with daily platelet counts >150 x 10(9)/L (p < .0005 for all comparisons). Bleeding incidence rose from 4.1% in nonthrombocytopenic patients to 21.4% in patients with minimal platelet counts between 101 x 10(9)/L and 149 x 10(9)/L (p = .0002) and to 52.6% in patients with minimal platelet counts <100 x 10(9)/L (p < .0001). In all quartiles of admission APACHE II and SAPS II scores, a nadir platelet count <150 x 10(9)/L was related with a substantially poorer vital prognosis. Similarly, a drop in platelet count to < or =50% of admission was associated with higher death rates (OR, 6.0; 95% CI, 3.0-12.0; p < .0001). In a logistic regression analysis with ICU mortality as the dependent variable, the occurrence of thrombocytopenia had more explanatory power than admission variables, including APACHE II, SAPS II, and MODS scores (adjusted OR, 4.2; 95% CI, 1.8-10.2). CONCLUSIONS: Thrombocytopenia is common in ICUs and constitutes a simple and readily available risk marker for mortality, independent of and complementary to established severity of disease indices. Both a low nadir platelet count and a large fall of platelet count predict a poor vital outcome in adult ICU patients.     

Severe pneumonia due to Legionella pneumophila: prognostic factors,impact of delayed appropriate antimicrobial therapy

OBJECTIVE: To compare the outcome of patients with severe Legionella pneumonia (LP) according to the presence or absence of prognostic factors currently reported in the literature and delays in initiating fluoroquinolones and macrolides. DESIGN: Retrospective clinical investigation. SETTING: Intensive care unit (ICU) of an university hospital. PATIENTS: Forty-three consecutive cases with no previous treatment with a macrolide or a fluoroquinolone. MEASUREMENTS AND MAIN RESULTS: The 14 (33%) patients who died of LP were compared with the 29 survivors. Thirty-eight patients (88%) received a fluoroquinolone in combination with a macrolide agent, two patients erythromycin alone and three ofloxacin alone. In univariate analysis, SAPS II more than 46 ( p=0.006) and intubation requirement ( p=0.012) were associated with a higher mortality whereas the administration of fluoroquinolones ( p=0.011) or erythromycin ( p=0.044) within 8 h of arrival on the ICU was associated with better survival. By logistic regression analysis, SAPS II score more than 46 [odds ratio (OR) 8.69; 95% confidence interval (CI) 1.15-66.7; p=0.036], duration of symptoms prior to ICU admission longer than 5 days (OR 7.46; 95% CI 1.17-47.6) were independent risk factors for death. Fluoroquinolone administration within 8 h of ICU arrival (OR 0.16; 95% CI 0.03-0.96; p=0.035) was associated with a reduced mortality. CONCLUSIONS: SAPS II score higher than 46, duration of symptoms prior to ICU admission longer than 5 days and intubation were associated with increased mortality. Initiation of fluoroquinolone therapy within 8 h of ICU admission significantly reduced mortality.     

Soluble L-selectin levels predict survival in sepsis

OBJECTIVE: To evaluate serum soluble L-selectin as a prognostic factor for survival in patients with sepsis. DESIGN: A prospective study of mortality in patients with sepsis whose serum levels of sL-selectin were measured on admission to an intensive care unit (ICU) and 4 days later. Follow-up data on mortality were obtained from the Danish Central Office of Civil Registration. SETTING: A tertiary referral university hospital ICU in Copenhagen. PATIENTS: Sixty-three patients meeting the criteria for systemic inflammatory response syndrome (SIRS) with a suspected or verified infection in one or more major organs, and 14 control subjects. MEASUREMENTS AND RESULTS: On admission to the ICU the Simplified Acute Physiology Score (SAPS) II was calculated, and relevant microbial cultures were performed. Mortality was registered at various follow-up points: 7 days after admission, at discharge from hospital, and 3 and 12 months after admission. Serum sL-selectin levels were significantly lower in the patients than in the controls. Sepsis nonsurvivors had significantly lower levels than survivors. Efficiency analysis and receiver operation characteristics showed that the ideal cutoff point for sL-selectin as a test for sepsis survival was 470 ng/ml. The accumulated mortality in patients with subnormal sL-selectin levels on admission was significantly increased. No correlation was found between clinical or paraclinical markers, including SAPS II and sL-selectin, and no relationship to the microbial diagnosis was found. CONCLUSIONS: Serum sL-selectin is a predictor of survival in patients with sepsis. Those admitted with low sL-selectin (<470 ng/ml) are characterized by a high mortality within the subsequent 12-month period.     

Validation of severity scoring systems SAPS II and APACHE II in a single-center population

OBJECTIVE: To validate two severity scoring systems, the Simplified Acute Physiology Score (SAPS II) and Acute Physiology and Chronic Health Evaluation (APACHE II), in a single-center ICU population. DESIGN AND SETTING: Prospective data collection in a two four-bed multidisciplinary ICUs of a teaching hospital. PATIENTS AND METHODS: Data were collected in ICU over 4 years on 1,721 consecutively admitted patients (aged 18 years or older, no transferrals, ICU stay at least 24 h) regarding SAPS II, APACHE II, predicted hospital mortality, and survival upon hospital discharge. RESULTS: At the predicted risk of 0.5, sensitivity was 39.4 % for SAPS II and 31.6 % for APACHE II, specificity 95.6 % and 97.2 %, and correct classification rate 85.6 % and 85.5 %, respectively. The area under the ROC curve was higher than 0.8 for both models. The goodness-of-fit statistic showed no significant difference between observed and predicted hospital mortality (H = 7.62 for SAPS II, H = 3.87 for APACHE II; and C = 9.32 and C = 5.05, respectively). Observed hospital mortality of patients with risk of death higher than 60 % was overpredicted by SAPS II and underpredicted by APACHE II. The observed hospital mortality was significantly higher than that predicted by the models in medical patients and in those admitted from the ward. CONCLUSIONS: This study validates both SAPS II and APACHE II scores in an ICU population comprised mainly of surgical patients. The type of ICU admission and the location in the hospital before ICU admission influence the predictive ability of the models.     

Early and exclusive use of norepinephrine in septic shock

BACKGROUND: The timing and use of norepinephrine (noradrenaline) (NE) in septic shock remain a matter of controversy. AIM: To study the outcome of septic patients treated with early and exclusive NE. SETTING: Tertiary Intensive Care Unit. PATIENTS: 142 patients with septic shock. INTERVENTION: Exclusive NE infusion within 24 hours of admission to ICU. METHODS AND MAIN RESULTS: Retrospective analysis of data from a unit database identified 142 patients. Their median admission simplified acute physiology score (SAPS II) score was 46 [38, 56] with 98 (69%) receiving mechanical ventilation. Mean arterial pressure (MAP) at the start of NE infusion was 60 [58, 68]mmHg. NE infusion was started at a median of 1.3 [0.3, 5.0]h after ICU admission. Restoration and maintenance of target MAP was achieved initially in all patients and, in 61.3%, within 30 min. The median peak dose of NE was 0.28 [0.14, 0.61]microg/(kg min) and the duration of infusion was 88 [42, 175]h. SAPS II predicted mortality was 40.8%, however, only 34.5% (P = 0.27) died. Among the most severely ill patients (SAPS II score >56) actual mortality was 50.0% versus 74.7% predicted (P = 0.07). CONCLUSIONS: Early and exclusive use of NE in hyperdynamic septic shock achieved a stable MAP >75 mmHg in all patients. Survival compared favorably with that predicted by illness severity scores.     

Critical Care in the Emergency Department A Physiologic Assessment and Outcome Evaluation

OBJECTIVES: The changing landscape of health care in this country has seen an increase in the delivery of care to critically ill patients in the emergency department (ED). However, methodologies to assess care and outcomes similar to those used in the intensive care unit (ICU) are currently lacking in this setting. This study examined the impact of ED intervention on morbidity and mortality using the Acute Physiology and Chronic Health Evaluation (APACHE II), the Simplified Acute Physiology Score (SAPS II), and the Multiple Organ Dysfunction Score (MODS). METHODS: This was a prospective, observational cohort study over a three-month period. Critically ill adult patients presenting to a large urban ED and requiring ICU admission were enrolled. APACHE II, SAPS II, and MODS scores and predicted mortality were obtained at ED admission, ED discharge, and 24, 48, and 72 hours in the ICU. In-hospital mortality was recorded. RESULTS: Eighty-one patients aged 64 +/- 18 years were enrolled during the study period, with a 30.9% in-hospital mortality. The ED length of stay was 5.9 +/- 2.7 hours and the hospital length of stay was 12.2 +/- 16.6 days. Nine (11.1%) patients initially accepted for ICU admission were later admitted to the general ward after ED intervention. Septic shock was the predominant admitting diagnosis. At ED admission, there was a significantly higher APACHE II score in nonsurvivors (23.0 +/- 6.0) vs survivors (19.8 +/- 6.5, p = 0.04), while there was no significant difference in SAPS II or MODS scores. The APACHE II, SAPS II, and MODS scores were significantly lower in survivors than nonsurvivors throughout the hospital stay (p 相似文献   

Gastric mucosal pH as a prognostic index of mortality in critically ill patients.

OBJECTIVE: To determine if measurements of gastric intramucosal pH have prognostic implications regarding ICU mortality. DESIGN: Prospective comparison of outcome. SETTING: General adult ICUs in two teaching hospitals. PATIENTS: Eighty consecutive patients age 18 to 84 yrs (mean 63.4), 50 men and 30 women, 55% in the medical and 45% in the surgical services. METHODS: Gastric intramucosal pH was measured on ICU admission and again 12 hrs later. A value of greater than or equal to 7.35 was used to differentiate between normal and low gastric intramucosal pH. MEASUREMENTS AND MAIN RESULTS: Fifty-four patients had a normal gastric intramucosal pH and 26 patients had a low gastric intramucosal pH on ICU admission. The mortality rate was greater in the low gastric intramucosal pH group (65.4% vs. 43.6%; p less than .04). The frequency of sepsis and the presence of multisystem organ failure also were greater in the low gastric intramucosal pH group (p less than .01). Further stratification of patients according to gastric intramucosal pH measured 12 hrs after admission showed a greater mortality rate in patients with persistently low gastric intramucosal pH when compared with patients with normal gastric intramucosal pH during the first 12 hrs (86.7% vs. 26.8%; p less than .001). CONCLUSIONS: Measurements of gastric intramucosal pH on ICU admission, and again 12 hrs later, have a high specificity for predicting patient survival in this ICU patient population (77.8% to 80.6%). Furthermore, given its relative noninvasive nature, tonometrically measured gastric intramucosal pH may be a useful addition to patient monitoring in the ICU.     

Short-term and long-term mortality in very elderly patients admitted to an intensive care unit

Objective To report short-term and long-term mortality of very elderly ICU patients and to determine independent risk factors for short-term and long-term mortalityDesign and setting Retrospective cohort study in the medical/surgical ICU of a tertiary university teaching hospital.Patients 578 consecutive ICU patients aged 80 years or older.Results Demographic, physiological, and laboratory values derived from the first 24 h after ICU admission. ICU mortality of unplanned surgical (34.0%) and medical patients (37.7%) was higher than that of planned surgical patients (10.6%), as was post-ICU hospital mortality (26.5% and 29.7% vs. 4.4%). Mortality 12 months after hospital discharge, including ICU and hospital mortality, was 62.1% in unplanned surgical and 69.2% in medical patients vs. 21.6% in planned patients. Only median survival of planned surgical patients did not differ from survival in the age- and gender-matched general population. Independent risk factors for ICU mortality were lower Glasgow Coma Scale score, higher SAPS II score, the lowest urine output over 8 h, abnormal body temperature, low plasma bicarbonate levels, and higher oxygen fraction of inspired air. High urea concentrations and admission type were risk factors for hospital mortality, and high creatinine concentration was an independent risk factor for 12-month mortality.Conclusion Mortality in very elderly patients after unplanned surgical or medical ICU admission is higher than after planned admission. The most important factors independently associated with ICU mortality were related to the severity of illness at admission. Long-term mortality was associated with renal function.This article is discussed in the editorial available at:     

Mechanical ventilation in critically ill cancer patients: outcome and utilisation of resources

Intensive care is increasingly being used in the management of cancer patients. It is important that a disproportionate share of special care resources is not expended on futile care of terminally ill patients. A requirement for mechanical ventilation has been stated to affect survival in cancer patients. The objectives of this study were to determine our hospital utilisation of ICU facilities and the prospects of a successful outcome in cancer patients with a need for ventilatory support. The Norwegian Radium Hospital is a 400-bed cancer hospital with a 12-bed combined postoperative and intensive care unit (PO/ICU). For each patient admitted to the PO/ICU, patient data including diagnosis, therapeutic interventions, use of resources and outcome are entered in a computerised database. We reviewed all 10,051 patients admitted during a 5-year period, focusing on the patients receiving ventilatory support. There were 347 patients who were treated with mechanical ventilation, 228 patients only for a short period postoperatively after extensive surgery. A further 119 patients (mean age 68 years, mean SAPS 33.5) were treated with mechanical ventilation for more than 24 h or died during treatment in the ICU; 65 patients (55%) were admitted after elective surgery, 24 (20%) after surgical emergencies and 30 (25%) after medical emergencies. Metastatic disease was present in 59% of them. These 119 patients comprised 1.18% of all patients admitted to the PO/ICU, but utilised 28% of all resources. They included 34 patients (29%) who died during the ICU stay, while 69 patients (58%) were still alive after 6 months. The ICU mortality in different groups was: surgical patients 24%, gynaecological patients 9%, oncological patients 63%. The mortality in the age group >70 years was 15%. The role of ICU facilities, including mechanical ventilation, is important for optimal supportive care in cancer patients. Our results indicate that this treatment modality should not generally be restricted in critically ill cancer patients. The quality of life of the patients who survived should be of interest to those involved in further medical and ethical decisions concerning the level of care in the ICU. Electronic publication: 12 January 1999     

Influence of age on outcome of mechanically ventilated patients in an intensive care unit.

OBJECTIVE: To assess the influence of age on the outcome of patients receiving prolonged mechanical ventilation. DESIGN: Retrospective study. SETTING: Intensive care unit. PATIENTS: A total of 1,141 patients in our ICU during a 32-month period. A total of 536 patients required mechanical ventilation. After exclusion of 171 patients ventilated for less than 24 hrs after surgery, 365 patients were investigated. MEASUREMENTS AND MAIN RESULTS: Two hundred sixty-six (73%) patients were aged less than 70 yrs; 99 (27%) patients were greater than or equal to 70 yrs. There was no significant difference in mortality rate between the younger and the older age groups. There was no significant influence of other important factors, such as severity of illness, duration of mechanical ventilation, or length of ICU stay. The only factor showing a significant influence on patient outcome was the reason for mechanical ventilation. There were more survivors in the group being ventilated because of ventilatory insufficiency than in the group with oxygenation impairment (57.8% vs. 23.9%, p less than .001). CONCLUSION: An influence of age on the outcome of mechanically ventilated patients in the ICU could not be ascertained in this study.     

The prognostic value of nutritional and inflammatory indices in critically ill patients with acute respiratory failure.

In critically ill patients suffering from acute respiratory failure, weaning from ventilatory assistance is a key survival factor in intensive care units (ICU). The aim of this study was to provide deeper insight into laboratory methods allowing improved monitoring of that critical period. Eighty-three ICU patients (mean age 63.9 years), classified according to the Second Acute Physiology and Chronic Health Evaluation criteria, were submitted to mechanical ventilation, antibiotherapy and nutritional support. Weaning attempts required degressive pressure support ventilation. The biological status of the patients was assessed by the serial measurement of inflammatory (C-reactive protein and alpha1-acid glycoprotein) and of nutritional (albumin and transthyretin) indicators whose aggregation yields a prognostic inflammatory and nutritional index (PINI). Statistical analyses compared ventilatory and biological data recorded on admission and at the time of extubation. Results showed that vital capacity and plasma concentrations of albumin and transthyretin rose, whereas rapid shallow breathing index, C-reactive protein and PINI values declined during the tested period. Persistent low transthyretin concentrations were predictive of lethality while increased values were associated with improved ventilatory performances. The PINI scoring formula worked as an independent predictor of the weaning trial outcome. The study underlined the value of the PINI system for the successful management of the weaning procedure.     

Efficacy of adequate early antibiotic therapy in ventilator-associated pneumonia: influence of disease severity

OBJECTIVE: To test the hypothesis that the outcome of patients with ventilator-associated pneumonia (VAP) depends on both their baseline severity at VAP onset and the adequacy of empirical antibiotic therapy. DESIGN AND SETTING: Prospective clinical study in six intensive care units in Paris, France. PATIENTS. One hundred and forty-two patients with VAP after >/= 48 h of mechanical ventilation. MEASUREMENTS AND RESULTS: Patients were compared according to whether adequate antibiotics were started when VAP was first suspected (D0). At day 0, the rate of adequate antibiotic therapy was 44.4% and rose to 92% at day 2. Outcomes were recorded at the ICU and hospital discharge. Overall, no significant mortality difference was found with and without adequate early antibiotics. When patients were also classified based on the initial Logistic Organ Dysfunction score (LOD), mortality was significantly higher with inadequate early antibiotic therapy in the groups with LOD 相似文献   

Evaluation of the SOFA score: a single-center experience of a medical intensive care unit in 303 consecutive patients with predominantly cardiovascular disorders

Objective: To evaluate the use of the Sequential Organ Failure Assessment (SOFA) score, the total maximum SOFA (TMS) score, and a derived variable, the ΔSOFA (TMS score minus total SOFA score on day 1) in medical, cardiovascular patients as a means for describing the incidence and severity of organ dysfunction and the prognostic value regarding outcome. Design: Prospective, clinical study. Setting: Medical intensive care unit in a university hospital. Patients: A total of 303 consecutive patients were included (216 men, 87 women; mean age 62 ± 12.6 years; SAPS II 26.2 ± 12.7). They were evaluated 24 h after admission and thereafter every 24 h until ICU discharge or death between November 1997 and March 1998. Readmissions and patients with an ICU stay shorter than 12 h were excluded. Main outcome measure: Survival status at hospital discharge, incidence of organ dysfunction/failure. Interventions: Collection of clinical and demographic data and raw data for the computation of the SOFA score every 24 h until ICU discharge. Measurements and main results: Length of ICU stay was 3.7 ± 4.7 days. ICU mortality was 8.3 % and hospital mortality 14.5 %. Nonsurvivors had a higher total SOFA score on day 1 (5.9 ± 3.7 vs. 1.9 ± 2.3, p < 0.001) and thereafter until day 8. High SOFA scores for any organ system and increasing number of organ failures (SOFA score ≥ 3) were associated with increased mortality. Cardiovascular and neurological systems (day 1) were related to outcome and cardiovascular and respiratory systems, and admission from another ICU to length of ICU stay. TMS score was higher in nonsurvivors (1.76 ± 2.55 vs. 0.58 ± 1.39, p < 0.01), and ΔSOFA/total SOFA on day 1 was independently related to outcome. The area under the receiver-operating characteristic curve was 0.86 for TMS, 0.82 for SOFA on day 1, and 0.77 for SAPS II. Conclusions: The SOFA, TMS, and ΔSOFA scores provide the clinician with important information on degree and progression of organ dysfunction in medical, cardiovascular patients. On day 1 both SOFA score and TMS score had a better prognostic value than SAPS II score. The model is closely related to outcome and identifies patients who are at increased risk for prolonged ICU stay. Received: 6 August 1999 Final revision received: 3 January 2000 Accepted: 28 March 2000     

Is tracheostomy associated with better outcomes for patients requiring long-term mechanical ventilation?

OBJECTIVE: To evaluate the effect of tracheostomy on intensive care unit (ICU) and in-hospital mortality for patients requiring prolonged (> 3 days) mechanical ventilation (MV). DESIGN, SETTING, AND PATIENTS: We retrospectively reviewed the charts of all consecutive patients admitted to our 18-bed tertiary care ICU over 3 yrs (2002-2004) and who received prolonged MV. Outcomes of tracheostomized and nontracheostomized patients were evaluated using univariable and multivariable logistic-regression analyses and by constructing a case-control cohort using a propensity score for performing tracheostomy. MV duration for controls was at least equal to the time from MV onset to tracheostomy for the matched case. MEASUREMENTS AND MAIN RESULTS: Of the 506 patients requiring prolonged MV, 166 were tracheostomized after a median of 12 days of MV. Nontracheostomized patients had higher ICU (42% vs. 33%, p = .06) and in-hospital (48% vs. 37%, p = .03) mortality rates and shorter MV durations and ICU lengths of stay. Performing a tracheostomy (odds ratio, 0.58; 95% CI, 0.37-0.90) was independently associated with a lower probability of ICU death, even after adjusting for other important prognostic factors. No significant differences were detected between the 120 cases and their matched controls regarding ICU admission and day-3 clinical characteristics. After conditional logistic-regression analysis, tracheostomy was associated with lower risk of ICU (odds ratio, 0.47; 95% CI, 0.24-0.89) and in-hospital (odds ratio, 0.48; 95% CI, 0.25-0.90) death. CONCLUSIONS: Tracheostomy performed in our ICU for long-term MV patients was associated with lower ICU and in-hospital mortality rates, even after carefully controlling for ICU admission and day-3 clinical and physiologic differences between groups. Whether these results reflect that physicians were able to adequately select for tracheostomy patients who, despite having similar physiologic and demographic variables, had the highest probabilities of survival or that the procedure itself really affected the outcomes of these patients will remain speculative.     

Validation of the SAPS 3 admission prognostic model in patients with cancer in need of intensive care

Objectives To validate the SAPS 3 admission prognostic model in patients with cancer admitted to the intensive care unit (ICU).Design Cohort study.Setting Ten-bed medical–surgical oncologic ICU.Patients and participants Nine hundred and fifty-two consecutive patients admitted over a 3-year period.Interventions None.Measurements and results Data were prospectively collected at admission of ICU. SAPS II and SAPS 3 scores with respective estimated mortality rates were calculated. Discrimination was assessed by area under receiver operating characteristic (AUROC) curves and calibration by Hosmer–Lemeshow goodness-of-fit test. The mean age was 58.3 ± 23.1 years; there were 471 (49%) scheduled surgical, 348 (37%) medical and 133 (14%) emergency surgical patients. ICU and hospital mortality rates were 24.6% and 33.5%, respectively. The mean SAPS 3 and SAPS II scores were 52.3 ± 18.5 points and 35.3 ± 20.7 points, respectively. All prognostic models showed excellent discrimination (AUROC ≥ 0.8). The calibration of SAPS II was poor (p < 0.001). However, the calibration of standard SAPS 3 and its customized equation for Central and South American (CSA) countries were appropriate (p > 0.05). SAPS II and standard SAPS 3 prognostic models tended somewhat to underestimate the observed mortality (SMR > 1). However, when the customized equation was used, the estimated mortality was closer to the observed mortality [SMR = 0.95 (95% CI = 0.84–1.07)]. Similar results were observed when scheduled surgical patients were excluded.Conclusions The SAPS 3 admission prognostic model at ICU admission, in particular its customized equation for CSA, was accurate in our cohort of critically ill patients with cancer.This work was performed at the Intensive Care Unit, Instituto Nacional de Cancer, Rio de Janeiro, Brazil. Financial support: institutional departmental funds. Conflicts of interest: none.     

Noninvasive vs. conventional mechanical ventilation in patients with chronic obstructive pulmonary disease after failure of medical treatment in the ward: a randomized trial

OBJECTIVE: We conducted a randomized prospective study comparing noninvasive positive pressure ventilation (NPPV) with conventional mechanical ventilation via endotracheal intubation (ETI) in a group of patients with chronic obstructive pulmonary disease who failed standard medical treatment in the emergency ward after initial improvement and met predetermined criteria for ventilatory support. DESIGN AND SETTING: Prospective randomized study in a university hospital 13-bed general ICU. PATIENTS: Forty-nine patients were randomly assigned to receive NPPV (n=23) or conventional ventilation (n=26). RESULTS: both NPPV and conventional ventilation significantly improved gas exchanges. The two groups had similar length of ICU stay, number of days on mechanical ventilation, overall complications, ICU mortality, and hospital mortality. In the NPPV group 11 (48%) patients avoided intubation, survived, and had a shorter duration of ICU stay than intubated patients. One year following hospital discharge the NPPV group had fewer patients readmitted to the hospital (65% vs. 100%) or requiring de novo permanent oxygen supplementation (0% vs. 36%). CONCLUSIONS: The use of NPPV in patients with chronic obstructive pulmonary disease and acute respiratory failure requiring ventilatory support after failure of medical treatment avoided ETI in 48% of the patients, had the same ICU mortality as conventional treatment and, at 1-year follow-up was associated with fewer patients readmitted to the hospital or requiring for long-term oxygen supplementation. An editorial regarding this article can be found in the same issue (http://dx.doi.org/10.1007/s00134-002-1503-3).     

Impact of early ICU admission for critically ill cancer patients: Post-hoc analysis of a prospective multicenter multinational dataset.

ObjectivesEarly intensive care unit (ICU) admission, in Critically Ill Cancer Patients (CICP), is believed to have contributed to the prognostic improvement of critically ill cancer patients. The primary objective of this study was to assess the association between early ICU admission and hospital mortality in CICP.DesignRetrospective analysis of a prospective multicenter dataset. Early admission was defined as admission in the ICU < 24 h of hospital admission. We assessed the association between early ICU admission and hospital mortality in CICP via survival analysis and propensity score matching.ResultsOf the 1011patients in our cohort, 1005 had data available regarding ICU admission timing and were included. Overall, early ICU admission occurred in 455 patients (45.3%). Crude hospital mortality in patients with early and delayed ICU admission was 33.6% (n = 153) vs. 43.1% (n = 237), respectively (P = 0.02). After adjustment for confounders, early compared to late ICU admission was not associated with hospital mortality (HR 0.92; 95%CI 0.76–1.11). After propensity score matching, hospital mortality did not differ between patients with early (35.2%) and late (40.6%) ICU admission (P = 0.13). In the matched cohort, early ICU admission was not associated with mortality after adjustment on SOFA score (HR 0.89; 95%CI 0.71–1.12). Similar results were obtained after adjustment for center effect.ConclusionIn this cohort, early ICU admission was not associated with a better outcome after adjustment for confounder and center effect. The uncertainty with regard to the beneficial effect of early ICU on hospital mortality suggests the need for an interventional study.     

Outcome and prognostic factors in critically ill cancer patients admitted to the intensive care unit

OBJECTIVE: To assess survival in cancer patients admitted to an intensive care unit (ICU) with respect to the nature of malignancy, cause of ICU admittance, and course during ICU stay as well as to evaluate the prognostic value of the Acute Physiology and Chronic Health Evaluation (APACHE) III score. DESIGN: Retrospective cohort study. SETTING: ICU at a university cancer referral center. PATIENTS: A total of 414 cancer patients admitted to the ICU during a period of 66 months. INTERVENTIONS: None. MEASUREMENTS: Charts of the patients were analyzed with respect to underlying disease, cause of admission, APACHE III score, need and duration of mechanical ventilation, neutropenia and development of septic shock, as well as ICU survival and survival after discharge. Mortality data were compared with two control groups: 1362 patients admitted to our ICU suffering from diseases other than cancer and 2,776 cancer patients not admitted to the ICU. MAIN RESULTS: ICU survival was 53%, and 1-yr survival was 23%. The 1-yr mortality rate was significantly lower in both control groups. Patients admitted after bone marrow transplantation had the highest mortality. In a multivariate analysis, prognosis was negatively influenced by respiratory insufficiency, the need of mechanical ventilation, and development of septic shock during the ICU stay. Admission after cardiopulmonary resuscitation yielded high ICU mortality but a relatively good long-term prognosis. Admission after surgery and as a result of acute hemorrhage was associated with a good prognosis. Age, neutropenia, and underlying disease did not influence outcome significantly. Admission APACHE III scores were significantly higher in nonsurvivors but failed to predict individual outcome satisfactorily. All patients with APACHE III scores of >80 died at the ICU. CONCLUSION: A combination of factors must be taken into account to estimate a critically ill cancer patient's prognosis in the ICU. The APACHE III scoring system alone should not be used to make decisions about therapy prolongation. Admission to the ICU worsens the prognosis of a cancer patient substantially; however, as ICU mortality is 47%, comparable with severely ill noncancer patients, general reluctance to admit cancer patients to an ICU does not seem to be justified.     

心源性休克患者院内死亡危险因素分析

目的:探讨影响重症监护室心源性休克（cardiogenic shock, CS）患者死亡的危险因素。方法:采用回顾性队列研究，收集eICU合作研究数据库v2.0（The eICU Collaborative Research Database V2.0, eICU-CRD v2.0）截止2018年5月发布的来自美国多家医院组成的重症患者临床数据。选择诊断为CS的患者，根据院内死亡情况分为生存组与死亡组，收集入选患者年龄、性别、体质量质量指数（body mass index, BMI），急性生理学与慢性健康状况评分Ⅳ（acute physiology and chronic health status score Ⅳ, APACH-Ⅳ）、首次简化急性生理学评分Ⅱ（simplified acute physiology score Ⅱ, SAPS-Ⅱ）、种族、重症监护室（intensive care unit, ICU）类型、临床合并症、入院诊断、血流动力学参数、重要治疗、临床结局等。对两组年龄、性别、BMI，APACH-Ⅳ、SAPS-Ⅱ进行倾向性匹配，对匹配结果采用多因素Logistic回归分析死亡的危险因素。受试者特征工作（receiver operator characteristic, ROC）曲线评估其临床效用。结果:最终纳入33 998例患者，其中院内生存组27 596例，死亡6 402例（占18,83%），倾向性匹配6 301对；匹配后两组在急性肾衰竭发生率(29.33% vs. 31.82%)、机械通气时间[(6.05±5.77) d vs. (4.97±5.11) d]、ICU时间[(101.35±154.59) h vs. (110.15±175.58) h]、总住院时间[(12.73±10.53) d vs. (9.53±10.35) d]上差异具有统计学意义（ P<0.01）；多变量Logistic回归分析显示：年龄、BMI、APACH-Ⅳ、SAPS-Ⅱ、部分合并症（除外起搏器植入术后）、入院诊断（心搏骤停、急性心梗、心力衰竭、呼吸系统疾病及消化道出血）及部分治疗措施[无创机械通气、血液净化、冠状动脉旁路移植（coronary artery bypass grafting，CABG）手术、血管活性药物应用]是CS患者院内死亡的危险因素（ P<0.05）；心脏辅助装置（ventricular assist device, VAD）植入是CS患者院内死亡的保护性治疗措施（ HR[95% CI]: 0.49[0.24~0.98], P=0.045）；多变量ROC曲线分析结果显示：模型可较好的预测ICU病死率[AUC=0.80(95% CI: 0.784~0.816), P<0.01]及在院病死率[AUC=0.779(95% CI: 0.765-0.793), P<0.01]。 结论:在ICU的CS患者中，年龄、BMI、APACH-Ⅳ、SAPS-Ⅱ、部分合并症（除外起搏器植入术后）、入院诊断（心搏骤停、急性心梗、心力衰竭、呼吸系统疾病及消化道出血）及部分治疗措施（无创机械通气、血液净化、CABG手术、血管活性药物应用）是CS患者院内死亡的独立危险因素，VAD植入可能改善CS患者院内病死率。相关因素的ROC曲线显示模式可以较好的预测临床结局。