The prognosis of oncologic patients in the pediatric intensive care unit

Objective To evaluate the predicted mortality rate of oncologic patients in the PICU using the PRISM score and factors that might influence short-term outcomes.Design Retrospective study.Setting: Pedriatic ICU in a university hospitalPatients and Methods The medical charts of all oncologic patients admitted to the PICU during the period from January 1983 to December 1992 were reviewed.Main Results Over a period of 10 years, 51 oncologic patients were admitted on 57 occasions to the PICU. The mortality was 32%. This is significantly higher than the overall mortality in the PICU (8%). Comparison of observed and predicted mortality, derived from the PRISM score, using chi square goodness-of-fit tests showed a significantly higher observed mortality (x ²(5)=20.1,P<0.01). Patients admitted for circulatory failure and the highest mortality (47%), followed by those with respiratory failure due to tachypnea/cyanosis (36%), central nervous system deterioration (27%), respiratory failure due to ariway obstruction (25%), and metabolic disorders (20%). Of the 31 patients who needed mechanical ventilation, 17 died (55%), and when they needed inotropic support as well, the mortality increased to 69%. The mortality rose to 100% when the patient was admitted with a septic shock, necessitating mechanical ventilation and inotropic support. The median PRISM score was 5 in the survivor group and 18.5 in the non-survivor group; this difference was found to be significant using the Wilcoxon test (P=0.01). However, some patients with high scores were found in the survivor group, as well as some with low scores in the non-survivor group.Conclusion The decision to treat opcologic patients in a PICU remains difficult and has to be considered on an individual basis. However, oncologic patients do benefit from admission to the PICU. The PRISM score is not suitable for oncologic patients in the PICU, because it underestimates the observed mortality. Other factors like neutropenia, septic shock, the need for mechanical ventilation, and inotropic support should be taken into consideration.     

Improved outcomes of children with malignancy admitted to a pediatric intensive care unit

OBJECTIVE: To assess the acute and long-term outcomes of children admitted to the intensive care unit with cancer or complications after bone marrow transplantation. DESIGN: Retrospective analysis of databases from a prospective pediatric intensive care unit (PICU) database supplemented by case notes review. SETTING: A PICU in a tertiary pediatric hospital. PATIENTS: All children with malignancy admitted to the PICU between May 1, 1987, and April 30, 1996. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: There were 206 admissions to the PICU during a 9-yr study period of 150 children with malignancies or complications after bone marrow transplantation. Forty patents died in the PICU (27% mortality rate). The most frequent indications for PICU admission were shock and respiratory disease. Of 56 children admitted with shock, there were 16 deaths (29% mortality rate). In 24 episodes of sepsis, inotropic and ventilatory support were required and 13 patients (54%) survived. Analysis of long-term survival gave estimates of 50% survival for all oncology patients admitted to the PICU and 42% for those admitted for shock. CONCLUSIONS: A high proportion of oncology patients admitted to the PICU requiring intensive intervention survive and go on to be cured of their malignancy. Our study suggests the PICU outcome for these patients has improved.     

Rheumatologic diseases in the intensive care unit: epidemiology,clinical approach,management, and outcome

Patients with systemic rheumatic diseases may be admitted to the ICU because of worsening of or development of a new manifestation of the rheumatic disease, infections caused by immunosuppression, or adverse effects of drugs used to treat rheumatic diseases. Sometimes an unrelated, acute disorder may become life threatening because of the underlying rheumatic disorder. Rheumatoid arthritis is the most common rheumatic disease seen in ICU patients, followed by systemic lupus erythematosus and scleroderma. These three conditions together account for up to 75% of rheumatic cases admitted to the ICU. The respiratory system is the organ system most commonly affected in the acute process, followed by the renal, gastrointestinal, and nervous systems. More than 50% of admissions result from infections, and 25% to 35% result from exacerbation of the underlying rheumatic condition. In about 20% of patients, the rheumatic disorder may be diagnosed for the first time in the ICU. An aggressive approach should be pursued to establish the diagnosis of either disease exacerbation or infection. Delay in instituting appropriate immunosuppressive or antimicrobial therapy may result in multiple organ system failure and a poor outcome. The mortality rate in patients with rheumatic disease exceeds that predicted by the APACHE II or SAPS II scores and is higher than that in nonrheumatologic ICU admissions. The mortality may exceed 50% in patients admitted for infection; the prognosis is comparatively better for patients with exacerbations of disease activity. Renal failure, coma, and acute abdomen are predictors of poor outcome. Early recognition of abdominal complications requiring surgical intervention may help reduce mortality.     

Children with human immunodeficiency virus admitted to a paediatric intensive care unit in the United Kingdom over a 10-year period

Objective There is little published experience regarding the outcome of children with human immunodeficiency virus (HIV) infection treated on a paediatric intensive care unit (PICU). We describe the outcome of children with HIV infection in our hospital over a 10-year period.Method We performed a retrospective analysis of all children with HIV infection admitted to our PICU between August 1992 and July 2002. Their ages ranged from 2 months to 11 years (median 4 months). Information collected included demographic data, clinical presentation, investigations, treatment and outcome.Results There were 42 children with HIV infection admitted to PICU during the study period, with 66 admission episodes. Sixteen (38%) children died in PICU, and 26 (62%) survived their last PICU admission. Of these, 5 died at a later date (between 1 and 32 months after discharge from PICU) and 21 survived to the time of reporting. The most frequent reason for PICU admission was respiratory failure, due either to Pneumocystis carinii pneumonia (45% of admissions) or to other respiratory pathogens (32%). Over 80% of current survivors had good outcomes in terms of growth and development; 6 children had evidence of spastic diplegia.Conclusions Although there is significant mortality among children with HIV infection admitted to PICU, many of them survive their admission, and over 80% of the survivors have good outcomes with the currently available highly active anti-retroviral therapy. This provides evidence that intensive care treatment is appropriate for this group of patients in the United Kingdom.     

Outcome of pediatric patients with multiple organ system failure

The association of multiple organ system failure (MOSF) with mortality was investigated in 831 consecutive admissions to a pediatric ICU. The incidence of MOSF (at least two organ system failures, OSF) was 27%. Of the 62 nonsurvivors, 60 (97%) had MOSF. The mortality for patients with MOSF was 54%, compared to a mortality of 0.3% for patients without MOSF. Mortality increased directly with increasing number of OSF (p less than .0001). The mortality was 1% for one OSF, 11% for two OSF, 50% for three OSF, and 75% for four OSF. Comparison of these results with data from adult ICU patients indicates that the mortality and clinical course of MOSF in children is distinct from adults. MOSF is significantly associated with mortality in pediatric patients; however, it is not sufficiently discriminating to determine continuation or withdrawal of ICU support.     

Characteristics and immediate outcome of childhood meningitis treated in the pediatric intensive care unit

Objective To describe patient characteristics, use of technology and mortality in children with meningitis admitted to the pediatric intensive care unit (PICU).Design Retrospective cohort study.Setting Fifteen US PICUs.Patients All admissions with a diagnosis of meningitis between 1995 and 2000 in the Pediatric Intensive Care Unit Evaluations (PICUEs) database.Measurements and results Of 559 patients with meningitis, 58% were male. The median age was 19 months and the median length of PICU stay was 2 days. The crude PICU mortality rate was 7%. Three hundred thirty-four (60%) patients had bacterial meningitis. Non-survivors had significantly higher Pediatric Risk of Mortality (PRISM) III scores and also constituted a larger proportion of the patients with bacterial meningitis, coma and shock upon PICU admission. The use of invasive devices was higher among non-survivors, patients with bacterial meningitis or those who were in coma or shock upon PICU admission. There was significant variation in the use of intracranial pressure (ICP) monitors by coma status and by institution. In multivariate analysis, patients had 1.26 higher odds of mortality for each unit increase in PRISM III score (odds ratio 1.26, 95% confidence interval: 1.19–1.34), while adjusting for other variables.Conclusion In a large cohort of children admitted to the PICU with meningitis, severity of illness, particularly the presence of shock or coma, was significantly associated with both the higher use of invasive medical devices and higher mortality. There was significant variation in the use of ICP monitors among the various PICUs without statistical association with survival.Presented, in part, at the 14^th Pediatric Critical Care Colloquium, San Diego, CA, USA, October 2002     

Effect of interhospital transfer on resource utilization and outcomes at a tertiary pediatric intensive care unit

Purpose

The study aimed to examine the effect of interhospital transfer on resource utilization and clinical outcomes at a tertiary pediatric intensive care unit (PICU) among patients with sepsis or respiratory failure.

Materials and methods

Data on 2146 consecutive admissions with respiratory failure or sepsis to the PICU were analyzed. Data included demographics, admission source, and outcomes. Admission source was classified as interhospital transfer from the emergency departments (ED), wards, or PICUs of referring hospitals; or from the study hospital ED (direct).

Results

Compared with direct admissions, inter-PICU transfers had higher crude mortality (odds ratio, 1.93; 95% confidence interval, 1.31-2.84) but not significant mortality difference (odds ratio, 1.16; 95% confidence interval, 0.71-1.86) after adjusting for illness severity, age, and sex. Conversely, ED transfers had lower PICU mortality than direct ED admissions. Children with transfer admissions stayed significantly longer and used more intensive care technology in the study PICU than children directly admitted (P < .01). In comparisons within quartiles of mortality risk, inter-PICU transfers had longer hospitalization and higher mortality in all but the highest quartile.

Conclusions

Interhospital transfer, particularly inter-PICU transfer, was associated with significant hospital resource consumption that often correlated with admission illness severity. Future prospective studies should identify determinants of pretransfer illness severity and investigate decision making underlying interhospital transfer.     

Epidemiology of acute renal failure and outcome of haemodiafiltration in intensive care

Objective: To examine the epidemiology of acute renal failure (ARF) and to identify predictors of mortality in patients treated by continuous venovenous haemodiafiltration (CVVHDF). Design: Uncontrolled observational study. Setting: One intensive care unit (ICU) at a surgical and trauma centre. Patients: A consecutive sample of 3591 ICU treatments. Measurements and results: Demographic data, indications for ICU admission, severity scores and organ system failure at the beginning of CVVHDF were set against the occurrence of ARF and ICU mortality. 154 (4.3 % of ICU patients and 0.6 % of the hospital population) developed ARF and were treated with CVVHDF. Higher American Society of Anesthesiologists (ASA) status and higher Apache II score were associated with ICU incidence of ARF. However, these criteria were not able to predict outcome in ARF. A simplified predictive model was derived using multivariate logistic regression modelling. The mortality rates were 12 % with one failing organ system (OSF), 38 % with two OSF, 72 % with three OSF, 90 % with four OSF and 100 % with five OSF. The adjusted odds ratio (OR) of death was 7.7 for cardiovascular failure, 6.3 for hepatic failure, 3.6 for respiratory failure, 3.0 for neurologic failure, 5.3 for massive transfusion and 3.7 for age of 60 years or more. Conclusion: General measures of severity are not useful in predicting the outcome of ARF. Only the nature and number of dysfunctioning organ systems and massive transfusion at the beginning of CVVHDF and the age of the patients gave a reliable prognosis in this group of patients. Received: 8 July 1996 Accepted: 21 August 1997     

The burden of viral infections in pediatric intensive care unit between endemic and pandemic coronavirus infections: A tertiary care center experience

ObjectivesTo measure the prevalence of viral infections, length of stay (LOS), and outcome in children admitted to the pediatric intensive care unit (PICU) during the period preceding the COVID-19 pandemic in a MERS-CoV endemic country.MethodsA retrospective chart review of children 0–14 years old admitted to PICU with a viral infection.ResultsOf 1736 patients, 164 patients (9.45%) had a positive viral infection. The annual prevalence trended downward over a three-year period, from 11.7% to 7.3%. The median PICU LOS was 11.6 days. Viral infections were responsible for 1904.4 (21.94%) PICU patient-days. Mechanical ventilation was used in 91.5% of patients, including noninvasive and invasive modes. Comorbidities were significantly associated with intubation (P-value = 0.025). Patients infected with multiple viruses had median pediatric index of mortality 2 (PIM 2) scores of 4, as compared to 1 for patients with single virus infections (p < 0.001), and a median PICU LOS of 12 days, compared to 4 in the single-virus group (p < 0.001). Overall, mortality associated with viral infections in PICU was 7 (4.3%). Patients with viral infections having multiple organ failure were significantly more likely to die in the PICU (p = 0.001).ConclusionViral infections are responsible for one-fifth of PICU patient-days, with a high demand for mechanical ventilation. Patients with multiple viral infections had longer LOS, and higher PIM 2 scores. The downward trend in the yearly rate of PICU admissions for viral infections between the end of the MERS-CoV outbreak and the start of the COVID-19 pandemic may suggest viral interference that warrants further investigations.     

Outcome after assisted ventilation in children with acquired immunodeficiency syndrome

Twenty-two pediatric patients with AIDS required assisted ventilation during 27 pediatric ICU (PICU) admissions. Patients were retrospectively divided on the basis of whether they required assisted ventilation for acute respiratory failure (ARF) or for another reason. Sixteen (59%) courses of assisted ventilation were for ARF. The PICU mortality rate was 81% for the ARF group. Eleven (41%) courses of assisted ventilation were for reasons not involving ARF. The PICU mortality rate for the group without ARF was 9%, significantly lower (p less than .01) than for the ARF group. Pneumocystis carinii pneumonia (PCP) was documented during 48% of admissions. Occurrence of PCP did not affect mortality, nor was it more likely in those with than without ARF. Two patients with ARF survived to discharge from the hospital. Both died within 1 yr of ARF. Thus, the short-term prognosis for pediatric AIDS patients requiring assisted ventilation for ARF is extremely poor.     

Short-term outcome among patients with leukemia and lymphoma admitted to a medical intensive care unit

We report here the short-term outcome of medical intensive care unit (MICU) admissions of patients with leukemia or lymphoma. We reviewed the charts of 29 such patients. Of 21 patients with acute leukemia admitted to the MICU, seven survived to leave the hospital; of eight patients with lymphoma, two survived to leave the hospital. The acute physiologic score (APS) (a system in which 0 to 4 points are given for the degree of deviation from normal for several organ systems) was used to score each patient on day 1 of their MICU stay. The APS for all patients with leukemia and lymphoma admitted to MICU was 28 +/- 11. The mortality was 69%, which is not significantly different from the predicted mortality of 56% for patients with the same APS but no underlying malignant disease. Among the survivors, young age and early stage of disease were predictors of favorable outcome.     

Methicillin-resistant Staphylococcus aureus colonization is not associated with higher rate of admission to pediatric intensive care unit

Purposes

Methicillin-resistant Staphylococcus aureus (MRSA) colonization is consistently rising. The question whether the MRSA colonization places the patients at higher risk, requiring higher levels of care when being admitted, has never been studied. We conducted this study to determine the impact of MRSA colonization status on the required level of care upon admission to hospital.

Basic procedures

We conducted a retrospective chart review in 1000 plus–bed tertiary care academic institute. Our study population composed of all the patients who were admitted from January 2011 to March 2011. We found 7413 pediatric admissions that were identified as the study subjects. We assessed and divided study subjects into 2 groups, MRSA colonized and MRSA noncolonized. Methicillin-resistant Staphylococcus aureus–colonized patients were further grouped into those admitted to either pediatric intensive care unit (PICU) or ward, and these 2 groups were analyzed using P value, Fisher exact test, relative risks, and odds ratios.

Main findings

We found a total of 7413 admissions, 753 were admitted in PICU (average pediatric risk of mortality score 18), and 6660 were admitted in pediatric wards (average pediatric risk of mortality score, 5). We found that MRSA colonization was 20 (2.66%) of 753 in PICU admissions and 155 (2.33%) of 6660 in ward admissions. We found that rate of admissions difference between MRSA colonized and MRSA noncolonized groups was clinically insignificant (P > .05).

Principal conclusions

We conclude that MRSA colonization does not increase the need of care in PICU upon admission to hospital from emergency department. However, these preliminary results need to be confirmed through larger, multicenter, and multicountry data analysis.     

Timing of intensive care unit admission in relation to ICU outcome

This study assessed the relationship between admission time (from hospital admission to ICU admission) and mortality predicted by the Mortality Prediction Model (MPM), actual mortality, and resource use. All admissions, except elective surgery patients, to the general medical/surgical ICU of a tertiary care hospital during a 24-month period were studied (n = 1,889). Patients admitted to the ICU within 1 day of hospital admission had lower predicted and actual mortality, and used fewer resources than patients admitted later. Predicted mortality was higher than actual mortality for patients admitted to the ICU early and was lower than actual mortality for later ICU admissions. Transfers had higher predicted and actual mortality, and used more resources than nontransfer patients. Time from hospital admission to ICU admission can be a potentially useful variable in models of ICU outcome.     

Prognostic factors in obstetric patients admitted to an Indian intensive care unit

OBJECTIVES: Obstetric patients form a significant proportion of intensive care unit admissions in countries like India, where maternal mortality is high (440 per 100,000 deliveries). We studied the diseases requiring intensive care and prognostic factors in obstetric patients. DESIGN: Retrospective chart review. Acute Physiology and Chronic Health Evaluation (APACHE) II data were prospectively collected. SETTING: Multidisciplinary intensive care unit of a public hospital in Mumbai, India. PATIENTS: Women admitted during pregnancy or 6 wks post-partum during a 5-yr study period (1997-2001). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Four hundred fifty-three obstetric patients (age 25.5 +/- 4.6 yrs [mean +/- SD], mean gestational age 31 wks) were admitted (548 intensive care unit admissions per 100,000 deliveries), 138 with single organ failure and 152 with multiple organ failure. Ninety-eight women died (mortality rate 21.6%). Mortality was comparable in antepartum (n = 216) and postpartum (n = 247) admissions but increased with increasing number of organs affected. There were 236 fetal deaths (52%), of which 104 occurred before hospital admission. Median APACHE II score was 16 (interquartile range, 10-24), and standardized mortality ratio (observed deaths/predicted deaths) was 0.78. Compared with pregnant patients admitted with obstetric disorders (n = 313), those with medical diseases (n = 140) had significantly lower APACHE II scores (median 14 vs. 17) but higher observed mortality rate (28.6% vs. 18.5%; odds ratio, 1.76; 95% confidence interval, 1.08-2.87) and standardized mortality ratio (1.09 vs. 0.66). On multivariate analysis, increased mortality rate was associated with acute cardiovascular (odds ratio, 5.8), nervous system (odds ratio, 4.73) and respiratory (odds ratio, 12.9) failure, disseminated intravascular coagulation (odds ratio, 2.4), viral hepatitis (odds ratio, 5.8), intracranial hemorrhage (odds ratio, 5.4), absence of prenatal care (odds ratio, 1.94), and >24 hrs interval between onset of acute symptoms and intensive care unit admission (odds ratio, 2.3). CONCLUSIONS: Multiple organ failure is common in obstetric patients; mortality rate increases with increasing organ failure. APACHE II scores overpredict mortality rate. Standardized mortality ratio is lower in obstetric disorders than in medical disorders. Lack of prenatal care and delay in intensive care unit referral adversely affect outcome and are easily preventable.     

Stratification of prognosis in granulocytopenic patients with hematologic malignancies using the APACHE-II severity of illness score

The APACHE-II (acute physiology and chronic health evaluation) severity of disease classification system was used to stratify prognosis of granulocytopenic patients with hematologic malignancies. A total of 146 admissions were retrospectively reviewed. In 26 ICU admissions, mortality was 69.2%; in 120 admissions to the ward, mortality was 15.8%. The APACHE-II score successfully stratified prognosis in both ward and ICU settings. Respiratory failure and the presence of pneumonia on chest x-ray were identified as poor prognostic factors. ICU patients admitted for monitoring or postoperative care had a better prognosis than those admitted for severe cardiopulmonary compromise. We suggest that the APACHE-II system is useful for stratifying prognosis for clinical research in this group of patients, although it remains to be shown whether it will be useful in predicting the prognosis of individual patients.     

Pediatric cancer type predicts infection rate,need for critical care intervention,and mortality in the pediatric intensive care unit

Purpose

Up to 38 % of children with cancer require pediatric intensive care unit (PICU) admission within 3 years of diagnosis, with reported PICU mortality of 13–27 % far exceeding that of the general PICU population. PICU outcomes data for individual cancer types are lacking and may help identify patients at risk for poor clinical outcomes.

Methods

We performed a retrospective multicenter analysis of 10,365 PICU admissions of cancer patients no greater than 21 years old among 112 PICUs between 1 January 2009 and 30 June 2012. We evaluated the effect of cancer type, age, gender, genetic syndrome, stem cell transplantation, PRISM3 score, infections, and critical care interventions on PICU mortality.

Results

After excluding scheduled perioperative admissions, cancer patients represented 4.2 % of all PICU admissions (10,365/246,346), had overall mortality of 6.8 % (708/10,365) vs. 2.4 % (5,485/230,548) in the general PICU population (RR = 2.9, 95 % CI 2.7–3.1, p < 0.001), and accounted for 11.4 % of all PICU deaths (708/6,215). Hematologic cancer patients had greater median PRISM3 score (8 vs 2, p < 0.001), rates of sepsis (27 vs 9 %, RR = 2.9, 95 % CI 2.6–3.1, p < 0.001), and mortality (9.6 vs 4.5 %, RR = 2.1, 95 % CI 1.8–2.5, p < 0.001) compared to solid cancer patients. Among hematologic cancer patients, stem cell transplantation, diagnosis of acute myeloid leukemia, PRISM3 score, and infection were all independently associated with PICU mortality.

Conclusions

Children with cancer account for 4.2 % of PICU admissions and 11.4 % of PICU deaths. Hematologic cancer patients have significantly higher admission illness severity, rates of infections, and PICU mortality than solid cancer patients. These data may be useful in risk stratification for closer monitoring and patient counseling.     

Early worsening heart failure in patients admitted with acute heart failure – a new outcome measure associated with long‐term prognosis?

A major limitation in acute heart failure (AHF) research has been the lack of an outcome measure paralleling re-infarction in acute coronary syndromes. The aim of the present study was to assess the time course, prognostic factors and outcome of early worsening heart failure (WHF) in patients admitted for AHF to a community hospital. All AHF admissions between December 2003 and March 2004 in a regional medical center were recorded. Patients were followed through admission and for 6 months after discharge. Early WHF was defined as WHF occurring during the initial 7 days from admission. Study endpoints were cardiovascular mortality and WHF (defined as worsening or persistent signs or symptoms of AHF requiring rescue therapy or hospital readmission). Early WHF rate was 29% and was associated with markers of AHF severity on presentation (higher troponin I, lower oxygen saturation, need for mechanical ventilation, intravascular diuretics and inotropes). Early WHF was a powerful predictor of death during 6 months of follow up, with an age-adjusted hazard ratio of 3.3 (95% confidence interval 1.7–6.3). Early WHF is a common adverse event in patients admitted with AHF, and is associated with AHF severity and excessive 6-month mortality. WHF should be considered as a clinically important endpoint in AHF studies.     

Effect of acute renal failure requiring renal replacement therapy on outcome in critically ill patients

OBJECTIVES: Acute renal failure is a complication in critically ill patients that has been associated with an excess risk of hospital mortality. Whether this reflects the severity of the disease or whether acute renal failure is an independent risk factor is unknown. The aim of this study was to analyze severity of illness and mortality in a group of critically ill patients with acute renal failure requiring renal replacement therapy in a number of Austrian intensive care units. DESIGN: Prospective, multicenter cohort study. PATIENTS AND SETTING: A total of 17,126 patients admitted consecutively to 30 medical, surgical, and mixed intensive care units in Austria over a period of 2 yrs. MEASUREMENTS AND MAIN RESULTS: Analyzed data included admission data, Simplified Acute Physiology Score, Logistic Organ Dysfunction system, Simplified Therapeutic Intervention Scoring System, length of intensive care unit stay, intensive care unit mortality, and hospital mortality. Of the admitted patients, 4.9% (n = 839) underwent renal replacement therapy because of acute renal failure (renal replacement therapy patients). These patients had a significantly higher hospital mortality (62.8% vs. 15.6%, p<.001), which remained significantly higher even when renal replacement therapy patients were matched with control subjects for age, severity of illness, and treatment center. Since univariate analysis demonstrated further intensity of treatment to be an additional predictor for outcome, a multivariate model including therapeutic interventions was developed. Five interventions were associated with nonsurvival (mechanical ventilation, single vasoactive medication, multiple vasoactive medication, cardiopulmonary resuscitation, and treatment of complicated metabolic acidosis/alkalosis). In contrast, the use of enteral nutrition predicted a favorable outcome. CONCLUSIONS: The results of our study suggest that acute renal failure in patients undergoing renal replacement therapy presents an excess risk of in-hospital death. This increased risk cannot be explained solely by a more pronounced severity of illness. Our results provide strong evidence that acute renal failure presents a specific and independent risk factor for poor prognosis.     

Prognostic factors,clinical course,and hospital outcome of patients with chronic obstructive pulmonary disease admitted to an intensive care unit for acute respiratory failure

OBJECTIVE: To describe prognostic factors, clinical course, and hospital outcome of patients with chronic obstructive pulmonary disease admitted to an intensive care unit for acute respiratory failure. DESIGN: Analysis of prospectively collected data. SETTING: A multidisciplinary intensive care unit of an inner-city university hospital. PATIENTS: Patients with chronic obstructive pulmonary disease admitted to an intensive care unit for acute respiratory failure from August 1995 through July 1998. MEASUREMENTS AND MAIN RESULTS: Data were obtained concerning demographics, arterial blood gas, Acute Physiology and Chronic Health Evaluation (APACHE) II score, sepsis, mechanical ventilation, organ failure, complications, and hospital mortality rate. Fifty-nine percent of patients were male, 63% white, and 36% African-American; the mean age was 63.1 +/- 8.9 yrs. Noninvasive mechanical ventilation was tried in 40% of patients and was successful in 54% of them. Invasive mechanical ventilation was required in 61% of the 250 admissions. Sepsis developed in 31% of patients, nonpulmonary organ failure in 20%, pneumothorax in 3%, and acute respiratory distress syndrome in 2%. Multiple organ failure developed in 31% of patients with sepsis compared with 3% without sepsis (p <.0001). Predicted and observed hospital mortality rates were 30% and 15%, respectively. Differences in age and arterial carbon dioxide and oxygen tensions between survivors and nonsurvivors were not significant. Arterial pH was lower in nonsurvivors than in survivors (7.21 vs. 7.25, p =.0408). The APACHE II-predicted mortality rate (p =.0001; odds ratio, 1.046; 95% confidence interval, 1.022-1.070) and number of organ failures (p <.0001; odds ratio, 5.524; 95% confidence interval, 3.041-10.031) were independent predictors of hospital outcome; invasive mechanical ventilation was not an independent predictor. CONCLUSIONS: Physiologic abnormalities at admission to an intensive care unit and development of nonrespiratory organ failure are important predictors of hospital outcome for critically ill patients with chronic obstructive pulmonary disease who have acute respiratory failure. Improved outcome would require prevention and appropriate treatment of sepsis and multiple organ failure.     

Emergency medical readmission: long-term trends and impact on mortality

There is increasing emphasis on prevention of emergency medical readmissions. The broad pattern of acute medical readmissions was studied over a seven-year period and the impact of any readmission on 30-day mortality was recorded. Significant predictors of outcome, including co-morbidity and illness severity score, were entered into a multivariate regression model, adjusting the univariate estimates of the readmission status on mortality. In total, 23,114 consecutive acute medical patients were admitted between 2002-8; the overall readmission rate was 27%. Readmission independently predicted an increased 30-day mortality; the odds ratio, was 1.12 (95% confidence interval (CI) 1.09 to 1.14). This fell to 1.05 (95% CI 1.02 to 1.08) when adjusted for outcome predictors including acute illness severity. The trend for readmissions was to progressively increase over time; the median times between consecutive admissions formed an exponential time series. Efforts to reduce or avoid readmissions may depend on an ability to modify the underlying chronic disease.