Prediction of survival after 48-h of intensive care following open surgical repair of ruptured abdominal aortic aneurysm.

OBJECTIVE: To identify predictive factors for 30-day mortality after 48 h of maximal treatment in intensive care unit (ICU) after repair for ruptured abdominal aortic aneurysm (RAAA). DESIGN: Retrospective study in the ICU of the university central hospital. MATERIALS AND METHODS: Between 1999 and 2003, a total of 197 patients were admitted to emergency unit due to RAAA, and 185 of them underwent open surgical repair. A total of 138 patients survived at least 48-h and were included in a study to identify factors predictive of 30-day mortality by logistic regression analysis. RESULTS: Thirty-day mortality of all RAAA patients was 46% (87/197) whereas the 30-day mortality for those alive at 48 h was 22% (31/138). Forward stepwise multivariate logistic regression analysis revealed that only organ dysfunction by SOFA score (sequential organ failure assessment) at 48-h, preoperative Glasgow Aneurysm Score, and supra-renal clamping in operation were independent predictors of death. CONCLUSIONS: Degree of organ dysfunction by SOFA score was the best predictor of 30-day mortality in RAAA patients alive at 48-h after open surgical repair.     

Results and costs of intensive care in a tertiary university hospital from 1996-2000

BACKGROUND: Costs of intensive care may be 20% of all hospital costs. Population aging likely increases the demand for intensive care services, while health care has financial limitations. Therefore data about outcome and costs of intensive care are needed. We studied changes in patient characteristics, outcome, intensity of care and costs of intensive care in a tertiary university hospital in Finland. METHODS: We analyzed retrospectively data of patients admitted to the ICU between 1 January 1996 and 31 December 2000 using the patient data management system. Postoperative and ICU patients were analyzed separately. Data included age, Apache II score, cause of intensive care admission, length and intensity of ICU care. ICU, hospital and 6-month mortality were analyzed. Intensity of care was assessed by TISS points and the annual costs of intensive care were evaluated. RESULTS: The number of ICU admissions from 1996-2000 was 11,323. The proportions of ICU and postoperative patients were 39% and 61%, respectively. The mean age of the patients did not change. The mean Apache II score increased over time both in the ICU and postoperative patients. There was no change in crude hospital mortality. Total ICU costs decreased from 8,660,000 euros (in 1997) to 7,480,000 euros (in 2000). In the ICU patients, the costs of hospital survival decreased towards the end of the study period. CONCLUSIONS: We treated more severely ill patients with unchanged outcome but at lower costs towards the end of the study period. Costs of intensive care are not necessarily increasing.     

Decrease of mortality of ruptured abdominal aortic aneurysm after centralization and in-hospital quality improvement of vascular service

Our aim was to determine whether organizational changes could improve the outcome after ruptured abdominal aortic aneurysm (RAAA). Regional centralization and quality improvement in the in-hospital chain of treatment of RAAA included strengthening of the emergency preparedness and better availability of postoperative intensive care. During the reorganization, all patients with RAAA were admitted to Helsinki University Central Hospital (HUCH) from Helsinki and Uusimaa district. RAAA patients in the hospital district of Helsinki and Uusimaa between 1996 and 2004 were identified. The study period was divided into three periods: I, control; II, change; and III, present. Of the total of 626 patients with RAAA, 352 (56%) were admitted to the HUCH, of whom 315 (90%) underwent surgery. During the study period, population-based mortality decreased from 77% to 56% (P < 0.001) and 90-day mortality, from 54% to 28% (P = 0.002). Operative 30-day mortality was 19% during the third period and lower than previously (P = 0.001). Our results seem to argue in favor of centralization of emergency vascular services with adequate manpower and operative expertise in the first line and with availability of closed-unit postoperative critical care to achieve better results as these measures were associated with a positive impact on survival.     

The effect of patient transfer on outcomes after rupture of an abdominal aortic aneurysm

OBJECTIVE: Centralization of vascular surgery services has resulted in patients being transferred longer distances for treatment of life-threatening conditions. The purpose of this study was to determine whether patient transfer adversely affects the survival of people with a ruptured abdominal aortic aneurysm (RAAA). METHODS: We performed a retrospective review of all patients undergoing attempted repair of an RAAA at our centre, over a recent 3.5-year period (August 2000-December 2003). Patients were divided into those presenting directly to our centre and those transferred from another hospital. The main outcome variable was in-hospital or 30-day mortality, with secondary variables including time to surgical treatment, mortality in the first 24 hours and length of hospitalization. RESULTS: Eighty-one patients (73% men) underwent attempted open repair of an RAAA at our centre during this period. Twenty-four patients (29.6%) presented directly to our hospital, while 57 (70.4%) were transferred from another institution. The overall mortality rate was 53%. Although transferred patients took twice as long as direct patients to get to the operating room (6.3 v. 3.2 h, p=0.03), there was no difference in mortality between the 2 groups (50% v. 54%, p=ns). However, deaths of transferred patients were more likely to occur in the first 24 postoperative hours, compared with direct patients (40% v. 33%, p<0.05). Neither mean intensive care unit stay (5.8 and 8.1 d) nor total hospitalization (20.9 and 18.8 d) differed between the 2 groups. CONCLUSIONS: Although the transfer of patients with RAAA results in a treatment delay, it does not adversely affect the already high mortality rates associated with this condition. These results may be attributed to a preselection of patients who are able to tolerate such a delay.     

Outcome of stroke patients admitted to intensive care: experience from an Australian teaching hospital

The objective of this study was to determine the mortality rate and the functional outcomes of stroke patients admitted to the intensive care unit (ICU) and to identify predictors of poor outcome in this population. The records of all patients admitted to the ICU with the diagnosis of stroke between January 1994 and December 1999 were reviewed. Patients with subarachnoid haemorrhage were excluded. Data were collected on clinical and biological variables, risk factors for stroke and the presence of comorbidities. Mortality (ICU, in-hospital and three-month) and functional outcome were used as end-points. In the six-year-period, 61 patients were admitted to the ICU with either haemorrhagic or ischaemic stroke. Medical records were available for only 58 patients. There were 23 ischaemic and 35 haemorrhagic strokes. The ICU, in-hospital and three-month mortality rates were 36%, 47% and 52% respectively. There were no significant differences in the prevalence of premorbid risk factors between survivors and non-survivors. The mean Barthel score was significantly different between the independent and dependent survivors (94+/-6 vs 45+/-26, P<0.001). A substantial number of patients with good functional outcomes had lower Rankin scores (92% vs 11%, P<0.001). Only 46% of those who were alive at three months were functionally independent. Intensive care admission was associated with a high mortality rate and a high likelihood of dependent lifestyle after hospital discharge. Haemorrhagic stroke, fixed dilated pupil(s) and GCS <10 during assessment were associated with increased mortality and poor functional outcome.     

Improved survival for HIV infected patients with severe Pneumocystis jirovecii pneumonia is independent of highly active antiretroviral therapy

BACKGROUND: Despite a decline in incidence of Pneumocystis jirovecii pneumonia (PCP), severe PCP continues to be a common cause of admission to the intensive care unit (ICU) where mortality remains high. A study was undertaken to examine the outcome from intensive care for patients with PCP and to identify prognostic factors. METHODS: A retrospective cohort study was conducted of HIV infected adults admitted to a university affiliated hospital ICU between November 1990 and October 2005. Case note review collected information on demographic variables, use of prophylaxis and highly active antiretroviral therapy (HAART), and hospital course. The main outcome was 1 month mortality, either on the ICU or in hospital. RESULTS: Fifty nine patients were admitted to the ICU on 60 occasions. Thirty four patients (57%) required mechanical ventilation. Overall mortality was 53%. No patient received HAART before or during ICU admission. Multivariate analysis showed that the factors associated with mortality were the year of diagnosis (before mid 1996 (mortality 71%) compared with later (mortality 34%; p = 0.008)), age (p = 0.016), and the need for mechanical ventilation and/or development of pneumothorax (p = 0.031). Mortality was not associated with sex, ethnicity, prior receipt of sulpha prophylaxis, haemoglobin, serum albumin, CD4 count, PaO2, A-aO2 gradient, co-pathology in bronchoscopic lavage fluid, medical co-morbidity, APACHE II score, or duration of mechanical ventilation. CONCLUSIONS: Observed improved outcomes from severe PCP for patients admitted to the ICU occurred in the absence of intervention with HAART and probably reflect general improvements in ICU management of respiratory failure and ARDS rather than improvements in the management of PCP.     

The effect of intensive insulin therapy on infection rate, vasospasm, neurologic outcome, and mortality in neurointensive care unit after intracranial aneurysm clipping in patients with acute subarachnoid hemorrhage: a randomized prospective pilot trial

It is unclear if avoiding hyperglycemia during intensive care after acute brain injury improves morbidity, mortality, and neurologic outcome. This prospective randomized trial tested whether intensive insulin therapy affected infection rates, vasospasm, mortality, or long-term neurologic outcome in subarachnoid hemorrhage patients during their intensive care unit (ICU) stay. Comparison was made against conventional insulin therapy using a randomized trial design. The primary outcome measure was infection rate until the fourteenth postoperative day in the ICU or until patient discharge. Secondary end points were the incidence of vasospasm until the fourteenth postoperative day in the ICU or until patient discharge, and neurologic outcome and mortality at 6 months follow-up. A total of 78 patients were prospectively enrolled and randomly assigned either to conventional insulin therapy or to intensive insulin therapy (38 and 40 patients, respectively). The infection rate during the study was significantly higher in patients who received conventional insulin therapy than in patients who received intensive insulin therapy (42% vs. 27%; P<0.001). The incidence of vasospasm during the study was also similar in conventional and intensive therapy groups (31.5% vs. 27.6% in the conventional and intensive insulin therapy groups; P=0.9). Overall mortality rates at 6 months were similar in the 2 groups (18% vs.15%; P=0.9), as was the neurologic outcome at 6 months [modified Rankin score >3 in 22/38 patients (57.8%) in the conventional therapy group vs. 21/40 patients (52.5%) in the intensive insulin therapy group; P=0.7]. Intensive insulin therapy in patients with acute subarachnoid hemorrhage admitted to a postoperative neurosurgical ICU after surgical clipping of intracranial aneurysms decreases infection rates. The benefit of strict glycemic control on postoperative vasospasm, neurologic outcome, and mortality rates does not seem to be affected by intensive insulin therapy.     

Outcome in patients requiring renal replacement therapy after surgery for ruptured and non-ruptured aneurysm of the abdominal aorta.

OBJECTIVES: to study the course of postoperative acute renal failure requiring renal replacement therapy (RRT) in patients with ruptured (RAAA) and non-ruptured (EAAA) aneurysm of the abdominal aorta (AAA) and to investigate the predictive value regarding outcome of parameters collected during the illness. DESIGN: retrospective study in a university hospital. MATERIALS AND METHODS: the records of 42 patients, 21 with RAAA and 21 with EAAA, were reviewed. RESULTS: overall mortality was 69%, 71% for RAAA patients and 66% for EAAA patients. RRT was started 9 (2-28) days - median (range) - postoperatively and continued during 9 (2-50) days. Renal function recovered in nine of the 13 survivors after 18 (2-50) days. Length of ICU stay was 50 (2-132) days for survivors vs. 19 (6-56) days for non-survivors. The systemic inflammatory response syndrome (SIRS) or need for vasoactive support was associated with poor outcome and the ability to wean from vasoactive or ventilatory support with improved outcome. CONCLUSIONS: RAAA and EAAA patients requiring postoperative RRT both had a high mortality. The ICU stay of non-survivors was shorter than that of survivors, who had a 75% chance of regaining renal function. The ability to wean from ventilatory and inotropic support may be of help in the clinical management of patients requiring RRT after AAA surgery.     

In-hospital outcome of patients discharged from the ICU with tracheostomies.

OBJECTIVE: To document the outcome of patients discharged from the intensive care unit (ICU) with tracheostomies. DESIGN AND SETTING: This was a retrospective study conducted in the ICU of Dr George Mukhari Hospital, Pretoria. PATIENTS: All patients discharged from the ICU with tracheostomies over a period of 1 year from 1 January to 31 December 2003. INTERVENTIONS: None. MEASUREMENTS: The main variables studied were post-ICU mortality and length of hospital stay, the Glasgow Coma Scale (GCS) at discharge from ICU and the multiple organ dysfunction score on the day of discharge from the ICU. MAIN RESULTS: Forty-seven patients were discharged with tracheostomies during the study period. The post-ICU mortality was 57%. The mortality of patients discharged with a GCS below 8 was statistically higher than that of patients discharged with a GCS above 8 (79% v. 22%, p = 0.0002). Survivors had significantly longer duration of hospitalisation (26.95 +/- 21.47 days v. 13.48 +/- 14.24 days, p = 0.021) than non-survivors. The mortality rate was higher if the tracheostomy was performed for a low GCS than when it was performed for reasons other than a low GCS (p = 0.0001). The 20 surviving patients were decannulated before discharge from hospital. CONCLUSION: The outcome of patients discharged from the ICU with tracheostomies is, on the whole, unfavourable compared with predicted mortality. A GCS of less than 8 is a good predictor of poor outcome.     

Prognostic factors for cancer patients in the postanesthetic recovery unit

OBJECTIVE: To assess the prognosis of cancer patients in an intensive care unit (ICU), to compare the capabilities of severity scoring systems to predict hospital death, and to improve prediction by adding new variables. PATIENTS AND METHODS: Cohort study in a medical-surgical ICU of a university hospital. Demographic and oncologic characteristics were collected along with death records for all nonsurgical cancer patients admitted between January 1995 and June 2000. Severity scores and risk of death were calculated. RESULTS: In the cohort of 250 patients studied, the hospital mortality rate was 58% and the ICU mortality rate was 38.8%. The best predictions were made with the third version of the Acute Physiology and Chronic Health Evaluation (APACHE III), the total maximum Sequential Organ Failure Assessment (SOFA) score, and the total maximum Multiple Organ Dysfunction Score (MODS). The APACHE II and the Simplified Acute Physiology Score (SAPS), version II, were good predictors, whereas the systems of the International Council on Mining and Metals overestimated hospital mortality and the Modality Prediction Model at 0 and 24 hours (MPM0 and MPM24) and the Logistic Organ Dysfunction System underestimated it. The total maximum SOFA and MODS scores had the greatest discriminating capability and the SOFA0, the MODS0, MPM0, and MPM24 had the poorest. All assessment systems except the APACHE III improved when we added new mortality-associated variables: prior functional status, diabetes, radiographic lung infiltrates, mechanical ventilation, and vasoactive support. CONCLUSIONS: Medical oncology patients should not all be denied intensive care. None of the systems assessed offer clinically relevant advantages for predicting hospital mortality in nonsurgical oncology patients in the ICU, although we recommend the SAPS II because it includes oncologic variables, is easy to score, and has good prognostic capability.     

Preoperative risk analysis—a reliable predictor of postoperative outcome after transthoracic esophagectomy?

Background and aims In patients with esophageal carcinoma, transthoracic esophagectomy is associated with high postoperative morbidity and mortality rates. The question of this study was whether an individualized preoperative risk analysis is able to predict postoperative outcome.Materials and methods Based on prospectively accumulated data of 126 patients with a malignant esophageal tumor, a preoperative composite risk score using objective parameters was evaluated. All patients underwent a transthoracic en bloc esophagectomy with two-field lymphadenectomy. The risk score was correlated to the postoperative course which was classified according to the days of intensive care unit (ICU) treatment, hours of mechanical ventilation, and reoperation and readmission to the ICU. A multivariate analysis was performed to identify single risk factors.Results The overall morbidity rate was 55%, while the mortality rate was 5.6%. According to the composite risk score, 22.8% of the patients had a “low” risk, 53.2% had a “moderate” risk, and in 19% the preoperative risk was classified as “high”. There was a significant correlation of the preoperative risk and the postoperative course (p<0.001). Multivariate analysis identified age, general status, and preoperative pulmonary function as independent risk factors of the postoperative outcome.Conclusion Preoperative risk analysis in particular pulmonary function and general status helps to select patients for transthoracic esophagectomy to reduce postoperative morbidity.     

Endovascular repair of ruptured abdominal aortic aneurysms: experience in a community hospital

The endovascular technique has been recently used as an alternative procedure for selected patients with ruptured abdominal aortic aneurysm (RAAA) as a result of the potential for decreasing morbidity, mortality, and recovery time. We examined our institution's results with endovascular repair of RAAA. Between July 2005 and April 2006, four patients underwent endovascular repair of infrarenal RAAA. We performed a retrospective analysis of our comorbidities, operation time, length of intensive care unit and hospital stay, morbidity and mortality, blood transfusions, and secondary interventions on these patients at our institution. The median age was 73.2 years (range, 66-82 years); 75 per cent were male and 25 per cent were female. Mean operating time was 90 minutes. We had no operative or postoperative mortalities. Five complications occurred in three patients. These included acute renal failure, common femoral artery intimal dissection, graft thrombosis of the iliac limb, ischemic colitis, and chronic obstructive pulmonary disease exacerbation. Endovascular repair of RAAA by an endovascular team is feasible in the community hospital setting. Our limited number of patients in this study does not allow us to compare it directly with results from the standard open procedure. A larger, multicenter study may eventually show this method to be helpful in patients who require repair of RAAA.     

Impact of gender on treatment and outcome of ICU patients

BACKGROUND: Gender modifies immunologic responses caused by severe trauma or critical illness. The aim of this study was to investigate the impact of gender on hospital mortality, length of intensive care unit (ICU) stay, and intensity of care of patients treated in ICUs. METHODS: Data on 24,341 ICU patients were collected from a national database. We measured severity of illness with Acute Physiology and Chronic Health Evaluation II (APACHE II) scores and intensity of care with Therapeutic Intervention Scoring System (TISS) scores. We used logistic regression analysis to test the independent effect of gender on hospital mortality. We compared the lengths of ICU stay and the intensity of care of men and women. RESULTS: Male gender was associated with increased hospital mortality among postoperative ICU patients [adjusted odds ratio 1.33 (95% confidence interval 1.12-1.58, P = 0.001)] but not among medical patients [adjusted odds ratio 1.02 (95% confidence interval 0.92-1.13, P = 0.74)]. Male gender was associated with an increased risk of death particularly in the oldest age group (75 years or older) and among the patients with relatively low APACHE II scores (<16). Mean length of ICU stay was 3.2 days for men and 2.6 days for women (P < 0.001). Male patients comprised 61.7% of the study population but consumed 66.0% of days in intensive care. CONCLUSION: Male gender contributes to poor outcome in postoperative ICU patients. Approximately two-thirds of ICU resources are consumed by male patients.     

Obesity and coronary artery surgery.

OBJECTIVE: To assess whether obesity is a risk factor for morbidity and mortality in patients undergoing elective coronary artery revascularization. DESIGN: Prospective, clinical study. SETTING: University hospital. PARTICIPANTS: Three hundred forty-five consecutive patients who underwent elective coronary revascularization with cardiopulmonary bypass and without associated procedures. INTERVENTIONS: Patients were assigned to the obese group if their body mass index was greater than 30 for men and 28.6 for women, according to the World Health Organization indications. MEASUREMENTS AND MAIN RESULTS: Preoperative and intraoperative variables were collected and checked for homogeneity of the groups. Postoperative outcome was assessed on the basis of intubation time, intensive care unit (ICU) and postoperative hospital stay, mortality rate, and incidence of transfusions, reoperations, low-output syndrome, minor and major neurologic dysfunction, minor and major lung dysfunctions, renal dysfunction, and superficial and deep infections. The effect of obesity on postoperative outcome was tested with a multivariate logistic regression analysis. Obese and control patients had the same intubation time and ICU and postoperative hospital stay. Mortality and all major complications occurred with the same incidence in the two groups. Obese patients had a significantly (p < 0.05) greater rate of superficial infections and more (24.1% v 7.4%; p < 0.001) minor lung complications. Conversely, they had a significantly lower transfusion rate (27.5% v42.7%; p < 0.01). CONCLUSION: Obese patients had only minor complications after coronary artery surgery. The large body surface area because of obesity protects them against the hemodilution-related transfusion risk.     

Abdominal aortic aneurysm surgery in a district general hospital: a 15-years experience

The incidence of patients presenting with both ruptured abdominal aortic aneurysm (RAAA) and elective abdominal aortic aneurysm (EAAA) increases with age. The aim of our study was to find out the incidence of RAAA, age and sex groups of patients at risk, and 30-day all-cause perioperative mortality associated with RAAA as well as EAAA repair in a busy district general hospital over a 15-year time period. All patients operated for AAA during 1989-2003, both elective and ruptured, were included in the study. Patients who died in the community from RAAA were also included. The data were collected from the hospital information system, theater logbooks, intensive therapy unit records, postmortem register, and patients' medical notes. We divided the data for RAAA into two groups of 7.5 years each to see if there was any improvement over time in 30-day postoperative mortality. There were 816 cases of AAA, which included 468 RAAAs (57%) and 348 EAAAs (43%). Out of 468 RAAAs, 243 patients had emergency repair, of whom 213 were males. There were 201 patients who had RAAA postmortem (43%). Median age (range) was 73 (54-94) years in males and 77 (52-99) years in females, with a male-to-female ratio of 7:1. The peak incidence of RAAA was over 60 years of age in males and 70 years in females. Incidence of RAAA was 7.3/100,000/year in males and 5/100,000/year in females. For RAAA, 30-day perioperative mortality was 43% (105/243) while overall mortality was 70% (330/468), which includes deaths in the community. There was no improvement in 30-day mortality over time after comparing data for the first 7.5 years (50/115, 43.5%) with those for the second set of 7.5 years (55/128, 43%). There were 348 patients who had EAAA repair over the same period, comprising 282 males, with a male:female ratio of 4.3:1. The 30-day mortality in the elective group was 7.75%. Incidence and mortality of RAAA remain high. A high proportion of patients with AAA remain undiagnosed and die in the community. More lives may be saved if a screening program is started for AAA.     

Critical care management of the obstetric patient

Purpose

To review a series of critically ill obstetric patients admitted to a general intensive care unit in a Canadian centre, to assess the spectrum of diseases, interventions required and outcome.

Methods

A retrospective chart review was performed of obstetric patients admitted to the intensive care unit of an academic hospital with a high-risk obstetric service, dunng a five-year penod. Data obtained included the admission diagnosis. ICU course and outcome. Daily APACHE II and TISS scores were recorded.

Results

Sixty-five obstetric patients, representing 0.26% of deliveries in this hospital, were admitted to the ICU during the study period. All had received prenatal care. Admission diagnoses included obstetric (71%) and nonobstetric (29%) complications. The mean APACHE II score was 6.8 ± 4.2 and mean TISS score was 24 ± 8.1. Twenty-seven patients (42%) required mechanical ventilation. No maternal mortality occurred and the perinatal mortality rate was 11 %.

Conclusions

A small proportion of obstetric patients develop complications requiring ICU admission. The out-come in this study was excellent, in contrast to that reported in other published studies with similar ICU admission rates. The universal availability of prenatal care may be an important factor in the outcome of this group of patients. The lack of a specific severity of illness scoring system for the pregnant patient makes comparison of case series difficult.     

Preoperative and ICU Scoring Models for Predicting the In-Hospital Mortality of Patients With Ruptured Abdominal Aortic Aneurysms

ObjectivesThis study’s objective was to compare several preoperative and intensive care unit (ICU) prognostic scoring systems for predicting the in-hospital mortality of ruptured abdominal aortic aneurysms (RAAAs).DesignRetrospective cohort study.SettingSingle tertiary university center.ParticipantsThe study comprised 157 patients.InterventionsNone.Measurements and Main ResultsA total of 157 patients (82% male) presented with RAAA at Charité University Hospital from January 2011 to December 2020. The mean age was 74 years (standard deviation ten years). In-hospital mortality was 29% (n = 45), of whom nine patients (6%) died en route to the operating room, 13 (8%) on the operating table, and 23 (15%) in the ICU. A total of 135 patients (86%) were admitted to the ICU. All six models demonstrated good discriminating performance between survivors and nonsurvivors. Overall, the area under the curve (AUC) for RAAA preoperative scores was greater than those for ICU scores. The largest AUC was achieved with the Vascular Study Group of New England (VSGNE) RAAA risk score (AUC = 0.87 for all patients, AUC = 0.84 for patients admitted to the ICU), followed by Hardman Index (AUC = 0.83 for all patients, AUC = 0.81 for patients admitted to the ICU), and Glasgow Aneurysm Score (AUC = 0.74 for all patients, AUC = 0.83 for patients admitted to the ICU). The largest AUC for ICU scores (only patients admitted to the ICU) was achieved with Simplified Acute Physiology Score II (0.75), followed by Sepsis-related Organ Failure Assessment (0.73), and Acute Physiology and Chronic Health Evaluation II (0.71).ConclusionsPreoperative and ICU scores can predict the mortality of patients presenting with RAAA. In addition, the discriminatory ability of preoperative scores between survivors and nonsurvivors was larger than that for ICU scores.     

Risk Assessment in Patients with Ruptured Abdominal Aortic Aneurysms

Objectives: Surgery of ruptured abdominal aortic aneurysms is associated with a high mortality rate, mostly related to multi-organ-failure after a prolonged intensive care therapy. In a retrospective study attempts are made to identify individual organ-dysfunction risk profiles influencing the outcome.

Methods: Fifty seven patients (53 men, 4 women, mean age 71.8 ±8.8 years) with ruptured abdominal aortic aneurysms underwent graft replacement in a three year period. Fourty eight preoperative, 13 intraoperative and 34 postoperative variables were analyzed. A multi-organ dysfunction (MOD) score was used.

Results: The perioperative mortality rate was 31%. Significance of pre-existing risk factors at admission was identified only for cardiovascular diseases. Multiple linear regression analysis indicated that hemoglobin < 90g/l, systolic blood pressure < 80 mmHg and ECG signs of ischemia at admission are highly significant risk factors. Patients, who died later than 48 hours postoperatively, deceased mainly from MOD (93%) and required intensive care significantly longer than surviving patients (p < 0.0005). All patients with a MOD score > 4 died (n = 7). These patients required 26% of all ICU-days and 72% of the ICU-days of the nonsurvivors.

Conclusion: Patients with ruptured aortic aneurysms should not be excluded from treatment. However, a physiological scoring system after 48 h appears justifiable in order to decide on the appropriateness of continued ICU support.     

Outcome predictors and new score of critically ill cirrhotic patients with acute renal failure.

BACKGROUND: End-stage liver disease is often complicated by renal function disturbances. Cirrhotic patients with acute renal failure admitted to intensive care units (ICUs) have high mortality rates. This work seeks to identify specific predictors of hospital mortality in critically ill cirrhotic patients with acute renal failure. METHODS: A total of 111 patients with cirrhosis and acute renal failure were admitted to ICU from March 2003 to February 2005. Twenty-six demographic, clinical and laboratory variables were prospectively gathered as predictors of survival on the first day of ICU admission. RESULTS: The overall hospital mortality rate was 81.1%. The univariate analysis identified 11 of the 32 variables as prognostically valuable. The multiple logistic regression analysis (excluding five scoring systems) indicates that the mean arterial pressure (MAP), serum bilirubin, respiratory failure and sepsis on the first day in ICU are significantly related to prognosis. The best Youden index (sensitivity + specificity - 1) yields cutoff points of 80 MAP (in mmHg) and 80 serum bilirubin (in micromol/L) (or 4.7 mg/dL) and indicates acute respiratory failure and sepsis. A simple model for mortality is developed on the basis of these four readily available parameters on Day 1 of ICU admission. The new score (MBRS score: MAP + bilirubin + respiratory failure + sepsis) displays an excellent area under the receiver operating characteristic curve (0.898 +/- 0.031, P < 0.001). The mortality rate exceeds 90% when the MBRS (MAP + bilirubin + respiratory failure + sepsis) score is 2 or higher. CONCLUSION: The MBRS score is a straightforward, reproducible and easily adopted evaluative tool with good prognostic abilities, which generates objective data for patient families and physicians and supplements a clinical judgment of prognosis.     

Community mortality after ruptured abdominal aortic aneurysm is unrelated to the distance from the surgical centre

BACKGROUND: Ruptured abdominal aortic aneurysm (RAAA) carries a high community mortality. Raigmore Hospital, Inverness serves Highland Region, an area the size of Wales with a population of 204,000. The aim of this retrospective review was to determine the community mortality and hospital mortality rates from RAAA in Highland Region and to assess whether distance travelled had any significant impact on survival. METHODS: Data were retrieved from hospital records, the Registrar General for Scotland and the Information and Statistics Division of the National Health Service in Scotland about patients diagnosed with RAAA between 1992 and 1999. RESULTS: Of 198 patients with RAAA, 131 (66 per cent) were transferred to Raigmore Hospital while the other 67 (34 per cent) died in a community hospital or at home. Of those reaching Raigmore 109 (83 per cent) had surgery, of whom 65 (60 per cent) survived. The overall community mortality rate was 67 per cent while the hospital mortality rate was 50 per cent. The hospital and community mortality rates for patients living within 50 miles of Raigmore Hospital were 60 and 67 per cent respectively, compared with 26 and 68 per cent for those living more than 50 miles away. CONCLUSION: Distance from Raigmore Hospital had no significant impact on community mortality from RAAA.