The clinical course of patients with septic abortion admitted to an intensive care unit

Objective The purpose of this study was to describe the clinical course, complications, and outcome of patients with septic abortion admitted to the intensive care unit (ICU).Design, setting, and patients In this retrospective study, the records of 63 patients with septic abortion admitted to the ICU of a university hospital in Argentina between 1985 and 1995 were reviewed.Results The mean age of the patients was 28.5 years, and 33% had had previous abortions. The mean gestational age was 10.5 weeks. The first ICU day Acute Physiology and Chronic Health Evaluation (APACHE) II mean score was 13.9. Acute renal failure developed in 73% (46 of 63) of the patients, disseminated intravascular coagulation (DIC) in 31% (15 of 49), and septic shock in 32% (20 of 63). Blood cultures were positive in 24% (15 of 62). Twelve patients died (19%). Eight of the deaths occurred during the first 48 h of the ICU admission. Compared with survivors, non-survivors had higher median number of organ failures (1.0 vs 4.0, p<0.0001), mean first ICU day SOFA scores (6.6 vs 10.0, p=0.0059), and mean APACHE II scores (12.7 vs 20.2, p=0.0003), and were more likely to have septic shock (18 vs 92%, p<0.0001), and receive dopamine (37 vs 83%, p=0.0040), mechanical ventilation (8 vs 83%, p<0.0001), and pulmonary artery catheter (8 vs 41%, p=0.0026).Conclusions Although it is an avoidable complication, septic abortion requiring admission to the ICU is associated with high morbidity and mortality.     

Is C-reactive protein a good prognostic marker in septic patients?

Rationale  Several studies have shown that C-reactive protein (CRP) is a marker of infection. The aim of this study was to evaluate CRP as marker of prognosis outcome in septic patients and to assess the correlation of CRP with severity of sepsis. Methods  During a 14-month period, we prospectively included all patients with sepsis admitted to an intensive care unit (ICU). Patients were categorized into sepsis, severe sepsis and septic shock. Acute Physiology and Chronic Health Evaluation (APACHE) II score, Simplified Acute Physiology Score (SAPS) II, Sequential Organ Failure Assessment (SOFA) score, CRP, body temperature and white cell count (WCC) of the day of sepsis diagnosis were collected. Results  One hundred and fifty-eight consecutive septic patients (mean age 59 years, 98 men, ICU mortality 34%) were studied. The area under the receiver operating characteristics curves of APACHE II, SAPS II, SOFA, CRP, body temperature and WCC as prognostic markers of sepsis were 0.75 [95% confidence interval (CI) 0.67–0.83], 0.82 (95% CI 0.75–0.89), 0.8 (95% CI 0.72–0.88), 0.55 (95% CI 0.45–0.65), 0.48 (95% CI 0.38–0.58) and 0.46 (95% CI 0.35–0.56), respectively. In the subgroup of patients with documented sepsis we obtained similar results. The ICU mortality rate of septic patients with CRP < 10, 10–20, 20–30, 30–40 and >40 mg/dL was 20, 34, 30.8, 42.3 and 39.1%, respectively (P = 0.7). No correlation was found between CRP concentrations and severity of sepsis. Conclusions  In septic patients, CRP of the day of sepsis diagnosis is not a good marker of prognosis.     

Procalcitonin (PCT) is useful in predicting the bacterial origin of an acute circulatory failure in critically ill patients

Objective To evaluate the accuracy of procalcitonin (PCT) in predicting bacterial infection in ICU medical and surgical patients. Setting A 10-bed medical surgical unit. Design PCT, C-reactive protein (CRP), interleukin 6 (IL-6) dosages were sampled in four groups of patients: septic shock patients (SS group), shock without infection (NSS group), patients with systemic inflammatory response syndrome related to a proven bacterial infection (infect. group) and ICU patients without shock and without bacterial infection (control group). Results Sixty patients were studied (SS group:n=16, NSS group,n=18, infect. group,n=16, control group,n=10). The PCT level was higher in patients with proven bacterial infection (72±153 ng/ml vs 2.9±10 ng/ml,p=0.0003). In patients with shock, PCT was higher when bacterial infection was diagnosed (89 ng/ml±154 vs 4.6 ng/ml±12,p=0.0004). Moreover, PCT was correlated with severity (SAPS:p=0.00005, appearance of shock:p=0.0006) and outcome (dead: 71.3 g/ml, alive: 24.0 g/ml,p=0.006). CRP was correlated with bacterial infection (p<10⁻⁵) but neither with SAPS nor with day 28 mortality. IL-6 was correlated with neither infection nor day 28 mortality but was correlated with SAPS. Temperature and white blood cell count were unable to distinguish shocked patients with or without infection. Finally, when CRP and PCT levels were introduced simultaneously in a stepwise logistic regression model, PCT remained the unique marker of infection in patients with shock (PCT≥5 ng/ml, OR: 6.2, 95% CI: 1.1–37,p=0.04). Conclusion The increase of PCT is related to the appearance and severity of bacterial infection in ICU patients. Thus, PCT might be an interesting parameter for the diagnosis of bacterial infections in ICU patients.     

Endotoxaemia in patients with severe sepsis or septic shock

Objective: To examine the incidence and the bacteriological and clinical significance of endotoxaemia in ICU patients with severe sepsis or septic shock. Design: Prospective review. Setting: A 15-bed general ICU in a university hospital. Patients: One hundred sixteen patients hospitalised in our ICU fulfilling Bone's criteria for severe sepsis or septic shock and with an available early endotoxin assay (chromogenic limulus assay). Interventions: None. Measurements and results: The clinical characteristics of the population were: age 63.6 ± 11.4 years; SAPS II: 45.4 ± 15.6; mechanical ventilation: 72.4 %; septic shock: 51.7 % (n = 60); bacteraemia: 28.4 % (n = 33); gram-negative bacteria (GNB) infection 47.4 % (n = 55); ICU mortality: 39.6 % (n = 46). Detectable endotoxin occurred in 61 patients (51.2 %; mean level: 310 ± 810 pg/ml). There was no relationship between detectable endotoxin and severity of infection at the moment of the assay. Endotoxaemia was associated with a higher incidence of bacteraemia (39.3 % vs 16.3 %; p = 0.01). There was a trend (p = 0.09) towards an association between positive endotoxin and gram-negative bacteraemia or GNB infection but this was non-significant. This relationship became significant only in the case of bacteraemia associated with GNB infection irrespective of the site of infection. Conclusion: Early detection of endotoxaemia appeared to be associated with GNB infection only in cases of bacteraemic GNB infection. Early endotoxaemia correlated neither to occurrence of organ dysfunction nor mortality in patients with severe sepsis or septic shock. This study suggests that the use of endotoxaemia as a diagnostic or a prognostic marker in daily practice remains difficult. Received: 28 September 1999 Final revision received: 31 January 2000 Accepted: 1 February 2000     

Outcome of critically ill patients treated with intermittent high-volume haemofiltration: a prospective cohort analysis

Objective: To evaluate intervention and outcome in critically ill patients treated with high-volume haemofiltration (HV-HF). Design: Prospective cohort analysis. Setting: 18-bed closed format general intensive care unit (ICU) of a teaching hospital. Patients: 30-month cohort of ICU patients treated with HV-HF. Interventions: Intermittent high-volume venovenous haemofiltration. Endpoints: Observed and predicted mortality in prospectively stratified prognostic groups. Measurements and results: Clinical and filtration data, Acute Physiology and Chronic Health Evaluation (APACHE) II, Simplified Acute Physiology Score (SAPS) II and the Madrid Acute Renal Failure (ARF) score and predicted mortality. A total of 306 patients were haemofiltrated (140 medical, 166 surgical), 52 % were oliguric. Mean APACHE II score was 31 (SD 8) and mean SAPS II score 60 (SD 16). Mean ultrafiltrate rate was 63 ml/min (SD 20). A median total of 160 litres (90 % range 49 to 453) were filtrated per patient, material costs were 565 ECU (90 % range 199 to 1514). ICU mortality was 33 %, hospital mortality 40 % [95 % confidence interval (CI) 34 to 45], predicted mortality by the ARF score 67 % (CI 66 to 69). Non-cardiac surgery mortality was 47 % (CI 39 to 54), 73 % (CI 70 to 76) predicted by APACHE II and 67 % (CI 64 to 70) by SAPS II. Observed mortality was significantly lower than predicted in all prognostic groups. The standardised mortality ratio (SMR) was no higher than the SMR in the overall ICU population. Conclusions: Mortality in HV-HF patients was lower than that predicted by illness severity scores, as was the case in all patients in our ICU. Treatment with HV-HF appears to be safe and feasible. The efficacy of HV-HF should be tested in randomised, controlled trials of suitable power. Received: 4 December 1998 Final revision received: 20 April 1999 Accepted: 17 May 1999     

The role of HIV infection and drug and alcohol dependence in hospital mortality among critically ill patients

Purpose

Critical care outcomes among HIV-infected patients have improved because of advances in HIV therapy and general improvements in intensive care unit (ICU) management. There is a high co-occurrence of drug and alcohol dependence among HIV-infected patients, and the independent role of drug and alcohol dependence among patients with and without HIV infection in outcomes of critical illness is unclear.

Materials and methods

We analyzed a prospectively collected database of 7015 index ICU admissions at 2 teaching hospitals between January 1999 and January 2006. The ICU diagnoses were determined from prospective chart review and classified according to the dictionary of diagnoses developed by the Intensive Care National Audit and Research Council. We used logistic regression to determine the independent association of drug and alcohol dependence as well as HIV infection with in-hospital mortality. Covariates that were adjusted for included acute drug overdose, Acute Physiology and Chronic Health Evaluation II score, age, sex, hospital site, and socioeconomic variables.

Results

Of all patients, 4.4% (309 of 7015) were HIV infected; and of these, 56% (173 of 309) had a history of drug and alcohol dependence, whereas only 7.4% (502 of 6706) of the HIV-negative group had a history of drug and alcohol dependence. Drug and alcohol dependence was not independently associated with hospital mortality in either the model including all admissions (adjusted odds ratio [AOR] 0.80; 95% confidence interval [CI] 0.62-1.03) or the model including pneumonia and sepsis admissions only (AOR 0.92; 95% CI 0.59-1.41). Infection with HIV was independently associated with hospital mortality (AOR 2.16; 95% CI 1.60-2.93).

Conclusions

Although HIV infection is associated with increased hospital mortality, drug and alcohol dependence is not associated with an increased hospital mortality independent of HIV infection.     

Comparing outcomes of HIV versus non-HIV patients requiring mechanical ventilation

Background

Mechanical ventilation (MV) is a predictor of mortality in patients infected with human immunodeficiency virus (HIV) in the intensive care unit (ICU). Patients with HIV-infections are admitted to the ICU for a variety of reasons that frequently require intubation. While survival rates for HIV-infected patients continue to improve, ICU admission rates have remained consistent.

Methods

To observe the consequences of MV in HIV-infected patients, we conducted a retrospective chart review on patients with HIV (n=55) vs. matched HIV-negative patients (n=55) who required MV over a one-year period and compared the groups for differences in outcome and complications.

Results

The HIV group had twice the number of deaths (44% vs. 22%, all-cause mortality) (P=0.01). Among the HIV-positive group, 5 of 55 patients required tracheostomy and prolonged MV, compared to 15 of 55 in the control group (9% and 27%, respectively). Successful extubation was virtually identical (47% MV vs. 50% control). Ventilator-associated pneumonia (VAP) was significantly higher among HIV-positive cases (39 of 55 HIV vs. 14 of 55 non-HIV) (P=0.05). Regression analysis revealed that hypotension, hypoalbuminemia, and fever predicted a poorer outcome. Low CD4 cell counts were strongly associated with mortality.

Conclusion

HIV-infected patients requiring MV have significantly higher mortality and VAP rates than HIV-negative patients. Since VAP is associated with a poor prognosis, discovering ways to prevent it in the HIV-infected patient may improve outcome.     

The ability of the Simplified Acute Physiology Score (SAPS II) to predict outcome in coronary care patients

Objective: To evaluate the applicability of the Simplified Acute Physiology Score (SAPS II) for coronary care patients. Design: Prospective observational cohort study. Setting: Medical ICU of a community teaching hospital. Patients: 1587 consecutive patients admitted over a period of 18 months. Measurements and main results: Patients were divided in two groups according to the primary admission diagnosis: general medical intensive care (ICU) patients and intensive coronary care (CCU) patients. Score prediction was tested using criteria suitable to evaluate the discrimination and calibration properties of SAPS II. Mean SAPS II score was 31.6 (± 20.1) in ICU and 28.3 (± 15.5) in CCU patients (p = 0.06), mean risk of death 0.206 and 0.134 (p = 0.001), and observed hospital mortality 17.8 vs 10.3 %. The area under the receiver operating characteristic curve was 0.888 in ICU and 0.908 in CCU patients (p = 0.5). The correlation between predicted and observed hospital mortality was 0.62 (p = 0.001) in ICU and 0.66 (p = 0.001) in CCU patients. The calibration curves did not differ from each other. The probability of death in survivors and nonsurvivors was equally distributed in ICU and CCU patients (p = 0.5). Conclusion: We conclude that SAPS II is applicable to CCU patients in our unit. Received: 30 October 1996 Accepted: 7 August 1997     

Mortality discrimination in acute myocardial infarction: comparison between APACHE III and SAPS II prognosis systems

Objective: To compare the Acute Physiology, Age and Chronic Health Evaluation (APACHE) III with the Simplified Acute Physiology Score (SAPS II) in discriminating in-hospital mortality for intensive care unit (ICU) patients with acute myocardial infarction (AMI). Design: Prospective, observational, multicenter study. Setting: 70 Spanish ICUs. Patients and participants: 1711 patients with AMI and representative of Spanish ICUs. Measurements and results: APACHE III score, APACHE III system probability of death (APACHE III probability), SAPS II score and in-hospital mortality were noted for each patient. Two hundred and twenty three (13.0 %) patients died in the hospital. The sensitivity (± SE), specificity (± SE), and accuracy (± SE) for the APACHE III score were, respectively, 75.8 ± 2.9, 75.9 ± 1.1, and 75.9 ± 1.0. The corresponding figures for APACHE III probability were 75.3 ± 2.9, 79.2 ± 1.1, and 78.7 ± 1.0, and for SAPS II 72.2 ± 3.0, 75.9 ± 1.1, and 75.4 ± 1.0. Conclusions: The results indicate good discrimination by the three tests. APACHE III probability shows a statistically significant improvement in accuracy and specificity when compared with the two scores. Received: 4 July 1996 Accepted: 27 November 1996     

Relationship between the timing of administration of IgM and IgA enriched immunoglobulins in patients with severe sepsis and septic shock and the outcome: a retrospective analysis

Purpose

Because the use of IgM and IgA enriched polyclonal intravenous immunoglobulins (eIg) is a standard of care in critically ill patients admitted to our intensive care unit (ICU) with the diagnosis of severe sepsis or septic shock, we investigated if the delay from the onset of severe sepsis and septic shock and their administration could influence the outcome.

Materials and Methods

The medical records of all patients with severe sepsis or septic shock admitted to our ICU from July 2004 through October 2009 and treated with eIg (Pentaglobin®; Biotest, Dreieich, Germany) were retrospectively examined.

Results

A total of 129 adult patients with severe sepsis or septic shock were considered eligible. Thirty-two percent of patients died during the ICU stay. Survivors were given eIg significantly earlier than nonsurvivors (23 vs 63 hours, P < .05). The delay in the administration of eIg and the Simplified Acute Physiology Score II were the only variables that entered stepwise a propensity score-adjusted logistic model. The delay in the administration of eIg was a significant predictor of the odds of dying during the ICU stay (odds ratio for 1 hour of delay, 1.007; P < .01; 99% confidence interval from 1.001 to 1.010) and proved to be independent from the Simplified Acute Physiology Score II and other variables.

Conclusions

The efficacy of eIg, being maximal in early phases of severe sepsis and/or septic shock, is probably time dependent.     

The Multiple Organ Dysfunction Score as a descriptor of patient outcome in septic shock compared with two other scoring systems.

OBJECTIVE: To demonstrate if daily Multiple Organ Dysfunction scoring could describe outcome groups in septic shock better than daily Acute Physiology and Chronic Health Evaluation (APACHE) II and Organ Failure scores. DESIGN: A prospective cohort study. SETTING: A medical and surgical adult intensive care unit (ICU) at a tertiary referral center. MEASUREMENTS AND MAIN RESULTS: Daily data collection over a 14-month period was performed on 368 ICU patients, 39 of whom developed septic shock while in the ICU. These data were entered into a computer programmed to calculate APACHE II, Organ Failure, and Multiple Organ Dysfunction scores. The admission Multiple Organ Dysfunction scores for nonsurvivors and survivors of septic shock in the ICU was 6.5 +/- 2.7 and 6.6 +/- 2.8 (SD), respectively. These patients deteriorated due to the development of septic shock during their ICU stay resulting in a maximum Multiple Organ Dysfunction score of 12.2 +/- 3.7 in nonsurvivors and 9.4 +/- 2.7 in survivors (p < .05). The difference between the maximum and initial Multiple Organ Dysfunction scores (delta score) was also significantly greater in nonsurvivors than in survivors (5.6 +/- 4.7 vs. 2.8 +/- 3.0) (p < .05). There were no significant differences between the maximum and delta scores in the outcome groups using the APACHE II and Organ Failure scoring systems. These results were mirrored by 2.3 +/- 0.7 and 1.7 +/- 0.5 organ failures in nonsurvivors and survivors, respectively (p < .01). For all 368 patients, the initial and maximum Multiple Organ Dysfunction scores were 3.5 +/- 2.5 and 10.5 +/- 3.6, respectively. CONCLUSION: Maximum and delta Multiple Organ Dysfunction scores mirrored organ dysfunction and could accurately describe the outcome groups, whereas daily APACHE II and Organ Failure scores could not.     

Comparison of two simplified severity scores (SAPS and APACHE II) for patients with acute myocardial infarction

The Simplified Acute Physiology Score (SAPS), the Acute Physiology and Chronic Health Evaluation II (APACHE II), the Acute Physiology Score (APS), and the Coronary Prognostic Index (CPI), calculated within the first 24 h of ICU admission, were compared in 76 patients with acute myocardial infarction (AMI). Sixteen (21%) patients subsequently died in the ICU. The nonsurvivors had significantly higher SAPS, APACHE II, and CPI scores than the survivors. ROC curves drawn for each severity index were in a discriminating position. There were no significant differences either between the areas under the ROC curves drawn for SAPS, APACHE II, and CPI, or between the overall accuracies of these indices. APS provided less homogeneous information. We conclude that SAPS and APACHE II, two severity indices which are easy to use, assess accurately the short-term prognosis, i.e., the ICU outcome, of patients with AMI.     

Procalcitonin (PCT) is useful in predicting the bacterial origin of an acute circulatory failure in critically ill patients

Objective: To evaluate the accuracy of procalcitonin (PCT) in predicting bacterial infection in ICU medical and surgical patients.¶Setting: A 10-bed medical surgical unit.¶Design: PCT, C-reactive protein (CRP), interleukin 6 (IL-6) dosages were sampled in four groups of patients: septic shock patients (SS group), shock without infection (NSS group), patients with systemic inflammatory response syndrome related to a proven bacterial infection (infect. group) and ICU patients without shock and without bacterial infection (control group).¶Results: Sixty patients were studied (SS group: n = 16, NSS group, n = 18, infect. group, n = 16, control group, n = 10). The PCT level was higher in patients with proven bacterial infection (72 - 153 ng/ml vs 2.9 - 10 ng/ml, p = 0.0003). In patients with shock, PCT was higher when bacterial infection was diagnosed (89 ng/ml - 154 vs 4.6 ng/ml - 12, p = 0.0004). Moreover, PCT was correlated with severity (SAPS: p = 0.00005, appearance of shock: p = 0.0006) and outcome (dead: 71.3 g/ml, alive: 24.0 g/ml, p = 0.006). CRP was correlated with bacterial infection (p < 10^-5) but neither with SAPS nor with day 28 mortality. IL-6 was correlated with neither infection nor day 28 mortality but was correlated with SAPS. Temperature and white blood cell count were unable to distinguish shocked patients with or without infection. Finally, when CRP and PCT levels were introduced simultaneously in a stepwise logistic regression model, PCT remained the unique marker of infection in patients with shock (PCT S 5 ng/ml, OR: 6.2, 95 %CI: 1.1-37, p = 0.04).¶Conclusion: The increase of PCT is related to the appearance and severity of bacterial infection in ICU patients. Thus, PCT might be an interesting parameter for the diagnosis of bacterial infections in ICU patients.     

The use of intensive care information systems alters outcome prediction

Objective: To study the effect of using an Intensive Care Information System (ICIS) on severity scores and prognostic indices: Acute Physiology and Chronic Health Evaluation II (APACHE II), Simplified Acute Physiology Score II (SAPS II), and Mortality Probability Models II (MPM II). Design: Prospective pilot study. Setting: A 20-bed medical-surgical intensive care unit (ICU) in a teaching hospital. Patients: 50 consecutive adult patients admitted to the ICU on a bed equipped with an ICIS. Interventions: None. Measurements and results: In each patient all the physiologic variables, as required by the severity scores, were both manually charted and recorded by ICIS. ICIS registration resulted in the extraction of more abnormal values for all physiologic variables (except temperature): p < 0.05. Higher severity scores and mortality prediction were achieved by using ICIS charting: predicted mortality increased by 15 % for APACHE II compared to manual charting, 25 % for SAPS II, and 24 % for MPM₀. ICIS charting resulted in higher severity scores and mortality prediction for 29 of the 50 patients using APACHE II with a mean increase in mortality prediction in this subgroup of 27 %. In the case of SAPS II, ICIS charting resulted in higher scores in 23 of the 50 patients and in the case of MPM₀ in 13 patients, the mean increase in mortality in these subgroups being 64 and 148 %, respectively. Conclusions: The use of ICIS charting to acquire the most abnormal physiologic values for severity scores and the derived prognostic indices results in a higher mortality prediction. Comparison of groups of patients and/or ICUs based on severity scores is impossible without standardization of data collection. The mortality prediction models have to be revalidated for the use of ICIS charting. While awaiting this, we suggest that every patient record in local regional, national, or international ICU databases should be marked as being recorded by manual or by ICIS charting. Received: 16 December 1997 Accepted: 11 June 1998     

Outcome prediction in intensive care: results of a prospective, multicentre, Portuguese study

Objective: To compare the performance of the New Simplified Acute Physiology Score (SAPS II) and Acute Physiology and Chronic Health Evaluation (APACHE) II in an independent database, using formal statistical assessment. Design: Analysis of the database of a multicentre, prospective study. Setting: 19 intensive care units (ICUs) in Portugal. Patients: Data for 1094 patients consecutively admitted to the ICUs were collected over a period of 4 months. Following the original SAPS II and APACHE II criteria, the analysis excluded patients younger than 18 years of age, readmissions, acute myocardial infarction, burns, patients in the post-operative period after coronary artery bypass surgery, and patients with a length of stay in the ICU of less than 24 h. The group analysed comprised 982 patients. Interventions: Collection of the first 24 h admission data necessary for the calculation of SAPS II, APACHE II, Therapeutic Intervention Scoring System (TISS), Simplified TISS, organ system failure and basic demographic statistics. Vital status at discharge from the hospital was registered. Measurements and results: In this cohort, discrimination was better for SAPS II than for APACHE II (SAPS II: area under the receiver operating characteristic curve 0.817, standard error 0.015; APACHE II: 0.787, 0.015; p < 0.001); however, both models presented a poor calibration, with significant differences between observed and predicted mortality (Hosmer-Lemeshow goodness-of-fit tests H and C, p < 0.001). In a stratified analysis, this study was unable to demonstrate any definite pattern of association between the poor performance of the models and specific subgroups of patients except for the most severely ill patients, where both models overestimated mortality. Conclusions: SAPS II performed better than APACHE II in this independent database, but the results do not allow its use, at least without being customised, to analyse quality of care or performance among ICUs in the target population. Received: 2 April 1996 Accepted: 24 October 1996     

Comparison of three severity scores for critically ill cancer patients

Objective To compare three scoring systems, the Acute Physiology and Chronic Health Evaluation (APACHE) II, the Simplified Acute Physiology Score (SAPS) II and a modified Mortality Probability Model II (ICU cancer mortality model, ICMM) for their prognostic value for mortality during hospital stay in a group of cancer patients admitted to a medical ICU.Design Prospective cohort study.Setting Medical ICU of a tertiary care hospital.Patients Two hundred forty-two consecutive cancer patients admitted to the ICU.Measurements and results Variables included in APACHE II, SAPS II and the ICMM scores as well as demographic data were assessed during the first 24 h of stay in the ICU. Hospital mortality was measured; it was 44%. Calibration for all three scoring systems was acceptable, SAPS II yielded a significantly superior discrimination between survivors and non-survivors. The areas under the receiver operating characteristic curves were 0.776 for APACHE II, 0.825 for SAPS II and 0.698 for the ICMM.Conclusion The SAPS II was superior to APACHE II and ICMM. The newly developed ICMM does not improve mortality prediction in critically ill cancer patients.     

KPC-producing Klebsiella pneumoniae enteric colonization acquired during intensive care unit stay: the significance of risk factors for its development and its impact on mortality

A prospective observational study of 226 intensive care unit (ICU) patients was conducted during a 25-month period. Rectal samples were taken at day 1, 4, and 7 and, afterwards, once weekly. Klebsiella pneumoniae was identified using standard techniques, whereas the presence of bla_KPC gene was confirmed by PCR. During ICU stay, 72.6% of the patients were colonized with Klebsiella pneumoniae carbapenemases (KPC)–producing K. pneumoniae (KPC-Kp). Male gender, prior bed occupants, and patients in nearby beds colonized with KPC-Kp, tracheotomy, number of invasive catheters inserted, and number of antibiotics administered were the major risk factors for KPC-Kp colonization. ICU mortality (35.4%) was significantly related to Simplified Acute Physiology II score and respiratory insufficiency upon admission, cortisone administration, aminoglycoside administration, confirmed KPC-Kp infection, and severe sepsis or septic shock. The high prevalence of KPC-Kp enteric carriage in ICU patients and the significant mortality associated with KPC-Kp infection dictate the importance of early identification and isolation of such carriers.     

Impact of standard procedures and clinical standards on cost-effectiveness and intensive care unit performance in adult patients after cardiac surgery

Objective: To investigate the impact of organizational procedures on intensive care unit (ICU) performance and cost-effectiveness after cardiac surgery. Design: Prospective study. Setting: Cardiothoracic ICU at a university hospital. Patients: Thousand five hundred twenty-six consecutive patients over a period of 18 months. Interventions: The first 6 months were used as the control period. Afterwards selected organizational changes were introduced, such as written standard procedures, time schedules and discharge reports. Measurements: Demographic data, surgical procedures, length of ICU and hospital stay and hospital outcome were recorded. Severity of illness was assessed daily using Acute Physiology and Chronic Health Evaluation (APACHE II), Simplified Acute Physiology Score (SAPS II) and Organ Failure Score (OFS). Intensity of treatment and nursing care was monitored by the Therapeutic Intervention Scoring System (TISS). RIYADH ICU Program (RIP 5.0) was used to determine the relationship of observed to predicted mortality (standardized mortality ratio SMR) and the effective costs per survivor. Main results: SMR decreased continuously after the establishment of new management procedures while all other factors all other factors remained unchanged. Comparing outcome according to APACHE II on ICU admission demonstrated a significantly increased ICU performance in high risk patients with an APACHE II of 20–30 points (p < 0.05) while effective costs per survivor decreased significantly from DM 29,988 to DM 13,568 DM (p < 0.05). Conclusions: Organizational changes can improve ICU performance and cost-effectiveness after cardiac surgery. The RIP may be used to monitor the clinical and economical effects of change. Received: 16 December 1998 Accepted: 28 July 1999     

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.     

Plasma-induced endothelial oxidative stress is related to the severity of septic shock

OBJECTIVE: To estimate the capacity of plasma from septic shock patients to induce in vitro reactive oxygen species (ROS) production by endothelial cells and to analyze whether ROS production is related to the severity of the septic shock. DESIGN: Prospective, observational study. SETTING: Medical intensive care unit in a university hospital. PATIENTS: Twenty-one patients with septic shock. INTERVENTIONS: The in vitro capacity of plasma from septic shock patients to induce ROS production by naive human umbilical vein endothelial cells (HUVEC) was quantified by using a fluorescent probe (2',7'-dichlorodihydrofluorescein diacetate). MEASUREMENTS AND MAIN RESULTS: Blood samples were collected on day 1, day 3, and day 5 from 21 consecutive septic shock adult patients and from ten healthy volunteers. Patients mean age was 58 yrs old, mean Sequential Organ Failure Assessment (SOFA) score at admission was 12, mean severity illness assessed by Simplified Acute Physiology Score (SAPS) II was 53, and the mortality rate was 47%. In addition to assessment of in vitro ROS generation by HUVEC, oxidative stress in blood was evaluated by measuring lipid peroxidation products and enzymatic and nonenzymatic antioxidants. Septic shock was associated with oxidative stress and an imbalance in antioxidant status. As compared with controls, plasma-induced ROS production by naive HUVEC was significantly higher in septic shock. Moreover ROS production was significantly correlated with SAPS II (p = .028) and SOFA values (p = .0012) and was higher in nonsurvivors than in survivors. In contrast, no correlation was found between the severity of the septic shock and any of the levels of lipid peroxidation products or enzymatic and nonenzymatic antioxidants. CONCLUSION: Plasma from septic shock patients induces ROS formation by naive HUVEC, and the extent of ROS formation correlates with mortality and with criteria of the severity of septic shock as SOFA score and SAPS II.