A modified gastrointestinal failure score for patients with severe acute pancreatitis

Purpose

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

Methods

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

Results

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

Conclusion

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

Extrarenal sequential organ failure assessment score as an outcome predictor of critically ill children on continuous renal replacement therapy

Background

The sequential organ failure assessment (SOFA) score is easy to calculate and has been well validated as an outcome predictor in critically ill adult patients. However, its use in children has been limited, mainly because of differences in basal reference levels of serum creatinine.

Methods

Data include 87 patients requiring continuous renal replacement therapy (CRRT) between January 2005 and July 2011. We modified the SOFA score by excluding the renal component to an extrarenal SOFA score, based on the assumption that CRRT may mitigate the renal effect on outcome and investigated the utility in predicting outcome with comparison with pediatric risk of mortality (PRISM) III, pediatric logistic organ dysfunction (PELOD), and SOFA scores.

Results

Results showed that 95.4 % (n?=?83) had multiple organ dysfunction syndrome with an overall mortality of 50.6 %. The extrarenal SOFA score at CRRT initiation and ≥20 % fluid overload were significantly associated with mortality. In comparison with the predictive power of various scoring systems, the extrarenal SOFA score showed the largest area under the receiver operating characteristic curve (extrarenal SOFA 0.774, SOFA 0.770, PRISM III 0.660, and PELOD 0.650).

Conclusions

The extrarenal SOFA score may be a useful prognostic marker in critically ill children treated with CRRT.     

Thyroid axis disturbances in adult multi-trauma patients without traumatic brain injury

Aim-Background

To evaluate thyroid axis TA hormone disturbances in adult multi-trauma patients (AMTP) without traumatic brain injury (TBI) and to correlate the results with other clinical and laboratory components of patient’s post-traumatic course.

Material

Twenty-five AMTPs without TBI were included. The selection criteria commanded previously healthy individuals with class II–III haemorrhagic shock, requiring surgical control of bleeding, with no major post-operative complications, and no deaths.

Methods

Blood was drawn for FT 3, FT 4 and TSH measurements at 24 & 72 hours post trauma, along with a full blood count, coagulation studies, and serum biochemical — hormone profile; the results were statistically assessed. Patients were also ranked with evaluation scores for disease severity and trend of clinical improvement over the following four days.

Results

Most of the TSH & FT 4 levels were within normal range at both phases. Ebb phase thyroid hormones negatively correlated with APACHE III score, ADH, CRP levels and blood volume transfused at resuscitation. FT 3 levels were marginally lower than normal in patients with class III shock.

Conclusions

Early appearance of euthyroid sick syndrome and disturbance of negative feed-back loop was observed at flow phase, with a prediction trend of FT 4 levels (flow) from ISS and SOFA score at 48 hs from ebb FT 3 levels.     

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.     

Timing the initiation of renal replacement therapy for acute kidney injury in Canadian intensive care units: a multicentre observational study

Purpose

The optimal timing for starting renal replacement therapy (RRT) in patients with acute kidney injury (AKI) is unknown. Defining current practice is necessary to design interventional trials. We describe the current Canadian practice regarding the timing of RRT initiation for AKI.

Methods

An observational study of patients undergoing RRT for AKI was undertaken at 11 intensive care units (ICUs) across Canada. Data were captured on demographics, clinical and laboratory findings, indications for RRT, and timing of RRT initiation.

Results

Among 119 consecutive patients, the most common ICU admission diagnosis was sepsis/septic shock, occurring in 54%. At the time of RRT initiation, the median and interquartile range (IQR) serum creatinine level was 322 (221-432) ??mol·L^?1. The mean (SD) values for other parameters were as follows: Sequential Organ Failure Assessment (SOFA) score 13.4 (4.1), pH 7.25 (0.15), potassium 4.6 (1.0) mmol·L^?1. Also, 64% fulfilled the serum creatinine-based criterion for Acute Kidney Injury Network (AKIN) stage 3. Severity of illness, measured using Acute Physiology and Chronic Health Evaluation (APACHE II) and SOFA scores, did not correlate with AKI severity as defined by the serum creatinine-based AKIN criteria. Median (IQR) time from hospital and ICU admission to the start of RRT was 2.0 (1.0-7.0) days and 1.0 (0-2.0) day, respectively.

Conclusion

Patients admitted to an ICU who were started on RRT generally had advanced AKI, high-grade illness severity, and multiorgan dysfunction. Also, they were started on RRT shortly after hospital presentation. We describe the current state of practice in Canada regarding the initiation of RRT for AKI in critically ill patients, which can inform the designs of future interventional trials.     

Scoring of human acute pancreatitis: state of the art

Background

Acute pancreatitis remains as one of the most difficult and challenging digestive disorder to predict in terms of clinical course and outcome. Every case has an individual course and therefore acute pancreatitis remains challenging and fascinating. Due to this variability, many different scoring systems have evolved during the last decades. Every scoring system has advantages and disadvantages. Not every scoring system is capable of assessing the clinical time course of the disease, some are only suitable for the time of initial presentation.

Aim

This paper will give an overview on the development of different widely used scoring systems and their performance in assessing severity and prognosis of acute pancreatitis.

Conclusion

Severity assessment means objective quantification of overall severity of illness. Early and reliable stratification of severity is required to decide best treatment of the individual patient, preparation for possible evolving complications or for referral to specialist centers. No single scoring system is able to cover the entire range of problems associated with treatment and assessment of acute pancreatitis. In our clinical experience, we recommend hematocrit upon admission, daily sequential organ failure assessment score and procalcitonin, C-reactive protein on day 3 and CT severity index beyond the first week. These scoring tools together with close clinical follow-up of the patient ultimately lead to an optimized treatment of this challenging disease.     

Serial lactate and admission SOFA scores in trauma: an analysis of predictive value in 724 patients with and without traumatic brain injury

Objective

Arterial lactate, base excess (BE), lactate clearance, and Sequential Organ Failure Assessment (SOFA) score have been shown to correlate with outcome in severely injured patients. The goal of the present study was to separately assess their predictive value in patients suffering from traumatic brain injury (TBI) as opposed to patients suffering from injuries not related to the brain.

Materials and methods

A total of 724 adult trauma patients with an Injury Severity Score (ISS) ≥ 16 were grouped into patients without TBI (non-TBI), patients with isolated TBI (isolated TBI), and patients with a combination of TBI and non-TBI injuries (combined injuries). The predictive value of the above parameters was then analyzed using both uni- and multivariate analyses.

Results

The mean age of the patients was 39 years (77 % males), with a mean ISS of 32 (range 16–75). Mortality ranged from 14 % (non-TBI) to 24 % (combined injuries). Admission and serial lactate/BE values were higher in non-survivors of all groups (all p < 0.01), but not in patients with isolated TBI. Admission SOFA scores were highest in non-survivors of all groups (p = 0.023); subsequently septic patients also showed elevated SOFA scores (p < 0.01), except those with isolated TBI. In this group, SOFA score was the only parameter which showed significant differences between survivors and non-survivors. Receiver operating characteristic (ROC) analysis revealed lactate to be the best overall predictor for increased mortality and further septic complications, irrespective of the leading injury.

Conclusion

Lactate showed the best performance in predicting sepsis or death in all trauma patients except those with isolated TBI, and the differences were greatest in patients with substantial bleeding. Following isolated TBI, SOFA score was the only parameter which could differentiate survivors from non-survivors on admission, although the SOFA score, too, was not an independent predictor of death following multivariate analysis.     

Microcirculatory abnormalities in patients with severe influenza A (H1N1) infection

Purpose

This study was designed to evaluate the degree of microcirculatory abnormalities in patients with severe influenza A (H1N1) infection.

Methods

We assessed the sublingual microcirculation in seven consecutive patients with acute lung injury related to influenza A (H1N1) infection. The evaluation was carried out using sidestream dark field (SDF) imaging within the first 96 hr after the patients were admitted to the intensive care unit. Thenar oxygen saturation (StO₂) was also measured with near-infrared spectroscopy (NIRS) during a vascular occlusion test. In addition, the Lung Injury Score (LIS) and the APACHE II and SOFA scores were recorded.

Results

All patients received invasive mechanical ventilation and at least one of the following adjuvant therapies: inhaled nitric oxide (n = 4), extracorporeal membrane oxygenation (n = 1), prone position (n = 4), recruitment maneuver (n = 3), and hydrocortisone 50 mg·hr^?6 (n = 6). The median time from admission to microcirculatory assessment was 21 hr. Three patients had bacterial superinfection. The median LIS and PaO₂/F _i O₂ were 2.5 (2.25-3.25) and 178 (158-212), respectively. Three subjects were treated with norepinephrine. During a vascular occlusion test, the microcirculation was moderately to severely compromised with a NIRS ascending slope of 2.39%·sec^?1 (1.75-2.67%·sec^?1), 66% (60-86%) of perfused small vessels in the sublingual microcirculation, and a microvascular flow index of 1.9 (1.3-2.6). The degree of microcirculatory abnormalities detected by the NIRS and SDF imaging techniques was correlated with the severity of the disease, as reflected by the SOFA and APACHE II scores.

Conclusions

The microcirculation as assessed by SDF imaging and NIRS techniques was compromised in patients with acute respiratory distress syndrome (ARDS) and influenza A (H1N1) infection.     

Analysis of the efficacy of direct hemoperfusion with polymyxin B-immobilized fiber (PMX-DHP) according to the prognostic factors in patients with colorectal perforation

Purpose

Direct hemoperfusion with polymyxin B-immobilized fiber (PMX-DHP) has been reported to improve the outcomes in patients with colorectal perforation. We retrospectively identified prognostic factors in patients with colorectal perforation and considered the efficacy of PMX-DHP based on these prognostic factors.

Methods

One hundred and fifty-six patients who underwent surgery for colorectal perforation in our department between November 1995 and March 2011 were enrolled in this study. The clinicopathological factors were compared between the survivor and non-survivor groups.

Results

There were 28 patients (17.9 %) who died within 28 days after surgery. According to the multivariate analysis, an Acute Physiology and Chronic Health Evaluation II (APACHE II) score of 17 or more was a significant independent prognostic factor (P = 0.002, odds ratio = 5.39). There was a significant difference in the survival rates between the patients with APACHE II scores of 16 or less and those with scores of 17 or more who had received the PMX-DHP (+) (P < 0.0001).

Conclusion

The APACHE II score is useful as a prognostic factor in patients with colorectal perforation, and the survival rate was 50 % or lower among the patients with APACHE II scores of 17 or higher. Therefore, PMX-DHP appears to have limited efficacy in serious cases.     

Value of the SOFA score as a predictive model for short-term survival in high-risk liver transplant recipients with a pre-transplant labMELD score ≥30

Introduction

The Sequential Organ Failure Assessment (SOFA) score has been applied for the prediction of survival in critically ill patients. We analysed the value of the SOFA score for the prediction of short-term survival after liver transplantation in high-risk liver transplant recipients with a labMELD score ≥30.

Patients and methods

We conducted a retrospective single-centre analysis including 88 consecutive liver transplants in adults between January 1, 2007 and December 31, 2010 with a pre-transplant labMELD score ≥30. The SOFA score was assessed preoperatively, directly after transplantation and on post-operative days (PODs) 1–10. Combined and living-related liver transplants were excluded. Receiver operating characteristic (ROC) curve analysis with the Hosmer–Lemeshow test and application of the Brier score were used to calculate sensitivity, specificity, overall model correctness and calibration. Cutoff values were selected with the best Youden index.

Results

ROC curve analysis showed areas under the curve (AUROCs) >0.8 for the SOFA score on PODs 1–10 for the prediction of hospital mortality, 30-day mortality and 3-month mortality with Hosmer–Lemeshow test results that confirmed good model calibration (p?>?0.05). The Brier score demonstrated an accuracy of prediction (<0.25) of hospital mortality, 30-day mortality and 3-month mortality for the SOFA scores on PODs 4–9 indicating superior accuracy on PODs 7 and 8 with cutoff values for the SOFA score between 16.5 and 18.5. The pre-transplant SOFA score failed to reach AUROCs >0.7 (0.603–0.663) for the prediction of short-term survival.

Conclusions

Our results confirm the usefulness of the SOFA score in high-risk liver recipients during the early post-operative course, especially on PODs 7–8 for the prediction of hospital mortality, 30-day mortality and 3-month mortality and may be useful to predict futile early acute retransplantation.     

The predictive value of the Oxford Acute Severity of Illness Score for clinical outcomes in patients with acute kidney injury

ObjectiveTo compare the performance of the Oxford Acute Severity of Illness Score (OASIS), the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, the Simplified Acute Physiology Score II (SAPS II), and the Sequential Organ Failure Assessment (SOFA) score in predicting 28-day mortality in acute kidney injury (AKI) patients.MethodsData were extracted from the Beijing Acute Kidney Injury Trial (BAKIT). A total of 2954 patients with complete clinical data were included in this study. Receiver operating characteristic (ROC) curves were used to analyze and evaluate the predictive effects of the four scoring systems on the 28-day mortality risk of AKI patients and each subgroup. The best cutoff value was identified by the highest combined sensitivity and specificity using Youden’s index.ResultsAmong the four scoring systems, the area under the curve (AUC) of OASIS was the highest. The comparison of AUC values of different scoring systems showed that there were no significant differences among OASIS, APACHE II, and SAPS II, which were better than SOFA. Moreover, logistic analysis revealed that OASIS was an independent risk factor for 28-day mortality in AKI patients. OASIS also had good predictive ability for the 28-day mortality of each subgroup of AKI patients.ConclusionOASIS, APACHE II, and SAPS II all presented good discrimination and calibration in predicting the 28-day mortality risk of AKI patients. OASIS, APACHE II, and SAPS II had better predictive accuracy than SOFA, but due to the complexity of APACHE II and SAPS II calculations, OASIS is a good substitute.Trial RegistrationThis study was registered at www.chictr.org.cn (registration number Chi CTR-ONC-11001875). Registered on 14 December 2011.     

Frey’s Pancreaticojejunostomy in Tropical Pancreatitis: Assessment of Quality of Life. A Prospective Study

Introduction

Tropical pancreatitis is a form of chronic pancreatitis originally described in the tropics. Prospective studies in Western countries have shown improved quality of life (QOL) following surgery in alcoholic chronic pancreatitis. In studies on Frey’s pancreaticojejunostomy for tropical pancreatitis, improvement in pain was considered the endpoint, and there is a paucity of data in the literature with regard to QOL with tropical pancreatitis following surgery.

Objective

Our objective was to prospectively analyze the outcome of Frey’s pancreaticojejunostomy in tropical pancreatitis and health-related QOL following surgery by administering the Short Form 36-item health survey (SF-36).

Materials and methods

A total of 25 patients underwent Frey’s pancreaticojejunostomy between 2010 and 2012 and were included in the study; data were collected prospectively. The visual analog scale (VAS) for pain and the SF-36 form were used to record health-related QOL preoperatively, and at 3 and 12 months post-surgery, comparing the same with the general population.

Results

Patients with tropical pancreatitis experience poor QOL (26.71 ± 15.95) compared with the general population (84.54 ± 12.42). Post-operative QOL scores (78.54 ± 15.84) were better than the pre-operative scores (26.71 ± 15.95) at 12-month post-surgery follow-up. The VAS score for pain improved at 12 months post-surgery (1.58 ± 1.41 vs. 8.21 ± 1.64). Two of the three patients (12.5 %) who had diabetes were free from anti-diabetes medication at 12 months post-surgery. Steatorrhea was seen in five patients (20.8 %) before surgery and increased to eight (33.3 %) at 12 months post-surgery. Mean body weight increased from 45.75 kg pre-operatively to 49.25 kg at 12 months post-operatively.

Conclusions

Frey’s pancreaticojejunostomy effectively reduces pain in tropical pancreatitis, with significant improvement in health-related QOL, which is comparable with the general population in most aspects.     

Escala APACHE II para pacientes críticos con cáncer sólido. Estudio de reclasificación

Objective

To improve the accuracy of the Acute Physiology and Chronic Health Evaluation (APACHE) II model for predicting hospital mortality in critically ill cancer patients.

Which score system can best predict recipient outcomes after living donor liver transplantation?

Introduction

Many scoring systems have been suggested to predict the outcomes of deceased donor liver transplantations. The aims of this study were to compare the Model for End-Stage Liver Disease (MELD) score with respect to other scores among patients who underwent living donor liver transplantation (LDLT) seeking to evaluate the best system to correlate with postoperative outcomes after LDLT.

Methods

We analyzed retrospectively data from 202 adult patients who underwent LDLT from January 2008 to July 2010. We calculated preoperative MELD, MELD-sodium, MELD to serum sodium ratio (MESO), integrated MELD, United Kingdom MELD, Child-Turcotte-Pugh, Acute Physiology and Chronic Health evaluation II (APACHE II), and Sequential Organ Failure Assessment (SOFA) scores in all patients. We analyzed the correlation of each score with postoperative laboratory results, as well as survival at 1, 3, 6 and 12 months after LDLT.

Results

There was significant positive correlation between all scores and peak total bilirubin during the first 7 days after LDLT. The MELD score showed the greatest correlation with peak total bilirubin (r = 0.745). APACHE II and SOFA scores at 6 months and 1 year after LDLT and MESO score at 1 year after LDLT showed acceptable discrimination performance {area under the receiver operating characteristic curves (AUC) >0.7, while other scoring systems showed poor discrimination. However, the AUCs of each score were not significantly different from the MELD score AUC.

Conclusion

The MELD score most correlated with total bilirubin after LDLT, while the APACHE II and SOFA scores seemed to correlate with mortality after LDLT.     

Combining sequential organ failure assessment (SOFA) score with acute physiology and chronic health evaluation (APACHE) II score to predict hospital mortality of critically ill patients

The ability to accurately adjust for the severity of illness in outcome studies of critically ill patients is essential. Previous studies have showed that Sequential Organ Failure Assessment (SOFA) score and Acute Physiology and Chronic Health Evaluation (APACHE) II score can predict hospital mortality of critically ill patients. The effects of combining these two scores to predict hospital mortality of critically ill patients has not been evaluated. This cohort study evaluated the performance of combining the APACHE II score with SOFA score in predicting hospital mortality of critically ill patients. A total of 1311 consecutive adult patients admitted to a tertiary 22-bed multidisciplinary intensive care unit (ICU) in Western Australia were considered. The APACHE II, Admission SOFA, Delta SOFA and maximum SOFA score were all related to hospital survival in the univariate analyses. Combining Max SOFA (area under receiver operating characteristic curve 0.875 vs. 0.858, P = 0.014; Nagelkerke R2: 0.411 vs. 0.371; Brier Score: 0.086 vs. 0.090) or Delta SOFA score (area under receiver operating characteristic curve 0.874 vs. 0.858, P = 0.003; Nagelkerke R2: 0.412 vs. 0.371; Brier Score: 0.086 vs. 0.090) with the APACHE II score improved the discrimination and overall performance of the predictions when compared with using the APACHE II score alone, especially in the emergency ICU admissions. Combining Max SOFA or Delta SOFA score with the APACHE II score may improve the accuracy of risk adjustment in outcome studies of critically ill patients.     

Graft Vessel Disease Following Heart Transplantation: A Systematic Review of the Role of Statin Therapy

Background

Graft vessel disease (GVD) is a significant cause of morbidity and mortality in cardiac allograft recipients. Hyperlipidemia is a risk factor for GVD, and the majority of patients will display abnormal lipid profiles in the years following transplant.

Objective

This systematic review aims to establish the clinical impact of statins in cardiac allograft recipients, critically appraising the literature on this subject.

Methods

A literature search for randomized studies assessing statin use in cardiac allograft recipients was undertaken. The Cochrane Central Registry of Controlled Trials, MEDLINE, EMBASE, clinicaltrials.gov, and the Transplant Library from the Centre for Evidence in Transplantation were searched. The primary outcome was presence of GVD. Secondary outcomes included graft and patient survival, acute rejection, and adverse events. Meta-analysis was precluded by heterogeneity in outcome reporting and therefore narrative synthesis was undertaken.

Results

Seven randomized controlled trials (RCTs) were identified. The majority of RCTs demonstrated some risk of bias, and methods of outcome measurement were variable. Studies reporting incidence or severity of GVD suggest that statins do confer benefit. Survival benefit from statin use is modest. There is a low incidence of adverse events attributable to statins. There was no difference in the overall number of episodes of rejection.

Conclusion

Whilst the methodological quality of evidence describing the use of statins in cardiac allograft recipients is limited, the available evidence suggests benefit from their use. This is compatible with the effects of statins in non-transplant patients with cardiovascular disease. Furthermore, the rate of adverse events in the trials is low.     

The effect of underlying liver disease on short-term outcomes following bariatric surgery

Background

Morbid obesity is strongly associated with nonalcoholic fatty liver disease. However, the effect of underlying liver disease on clinical outcomes following bariatric surgery has not been well studied. This study aims to determine the effect of underlying liver disease on short-term outcomes in bariatric patients using the model of end-stage liver disease (MELD) scoring system as a practical measure of hepatic dysfunction.

Methods

A retrospective cohort analysis was performed using data from the American College of Surgeons’ National surgery quality improvement program participant use files. The study population consisted of patients that underwent elective laparoscopic-stapled bariatric surgery for morbid obesity between 2005 and 2012. Patients were excluded if they had a bleeding disorder or renal failure requiring dialysis. The optimal MELD cut-off score to predict 30-day adverse events was determined and used to stratify patients into two groups. The primary outcome was 30-day adverse events, defined as a postoperative complication or reoperation. The secondary outcome was 30-day mortality. A multiple logistic regression was performed to adjust the odds ratio (OR) estimate for 30-day adverse events based on the MELD cut-off score.

Results

38,875 patients were included in the study population. A MELD score of 7.9 was determined to be the optimal cut-off to predict 30-day adverse events based on the maximized linear combination of specificity and sensitivity. After adjusting for confounding, the OR estimates for 30-day adverse events and mortality using the cut-off score as the key predictor were 1.22 [95 % CI 1.06–1.41] and 2.33 [95 % CI 1.19–4.56], respectively.

Conclusions

Using this large national surgical registry, bariatric patients with MELD scores ≥7.9 had a significant but marginal risk of 30-day adverse events and mortality. This suggests that severity of liver disease may affect bariatric surgery outcomes and should be considered during preoperative evaluations.     

Validierung des Acute Physiology and Chronic Health Evaluation (APACHE) III Scoringsystems und Vergleich mit APACHE II auf einer deutschen Intensivstation

Objectives: The aim of the study was to systematically validate the APACHE III scoring system concerning severity of illness classification and prediction of hospital mortality. Such data have not yet been determined in a large population of critically ill patients in germany. Methods: 531 patients (ICU stay >4?hours) were prospectively and consecutively investigated. The day-1-scores and risk-of-death predictions of APACHE III and APACHE II were determined. A comparison was performed between both scoring systems, and the correlation with the observed hospital mortality was examined. Results: For both main validation criteria, as were discrimination (areas under the ROC-curves: APACHE III 0.873; APACHE II 0.859) and calibration (goodness-of-fit testings; p>0.05), both scoring systems provided satisfying results concerning hospital mortality, no system showing a significantly superior performance. Compared to the observed hospital mortality (13.4%), the prediction of APACHE III (13.2%) was extremely accurate, whereas the prediction of APACHE II was higher (16.8%). The standard (mortality index not significantly <or>1.0) provided by APACHE III was fulfilled, while the standard given by APACHE II was surpassed. The mean scores and the mean risk-of-death predictions for non-survivors were significantly higher compared to survivors (p<0.001). The individual score values of both systems were found to have a strong correlation (r=0.922). Conclusions: APACHE III (like APACHE II) provides a sufficient severity of disease classification and accurately predicts overall hospital mortality in a representatively large german population of a medical ICU. Therefore APACHE III can be regarded as validated for the use in comparable german ICUs. For use as a standard the more recently introduced APACHE III seems to be superior to the established but older APACHE II. However, each user will – depending on the particular questions to be addressed – carefully have to evaluate, if the improvement of prognostic accuracy really justifies the increased amount of workload necessary for calculating APACHE III score and risk prediction.     

Endoscopic endoluminal vacuum therapy is superior to other regimens in managing anastomotic leakage after esophagectomy: a comparative retrospective study

Background

Anastomotic leakage after esophagectomy is a life-threatening complication. No comparative outcome analyses for the different treatment regimens are yet available.

Methods

In a single-center study, data from all esophagectomy patients from January 1995 to January 2012, including tumor characteristics, surgical procedure, postoperative anastomotic leakage, leakage therapy regimens, APACHE II scores, and mortality, were collected, and predictors of patient survival after anastomotic leakage were analyzed.

Results

Among 366 resected patients, 62 patients (16 %) developed an anastomotic leak, 16 (26 %) of whom died. Therapy regimens included surgical revision (n = 18), endoscopic endoluminal vacuum therapy (n = 17), endoscopic stent application (n = 12), and conservative management (n = 15). APACHE II score at the initiation of treatment for leakage was the strongest predictor of in-hospital mortality (p < 0.0017). Conservatively managed patients showed mild systemic illness (mean APACHE II score 5) and no mortality. In systemically ill patients matched for APACHE II scores (mean, 14.4), endoscopic endoluminal vacuum therapy patients had lower mortality (12 %) compared to surgically treated (50 %, p = 0.01) cases and patients managed by stent placement (83 %, p = 00014, log rank test). No other clinical or laboratory parameters significantly influenced patient survival.

Conclusions

Endoscopic endoluminal vacuum therapy was the best treatment of anastomotic leakage in systemically ill patients after esophagectomy in this retrospective analysis. It should therefore be considered an important instrument in the management of this disorder.     

Predictive ability of the ISS, NISS, and APACHE II score for SIRS and sepsis in polytrauma patients

Purpose

Systemic inflammatory response syndrome (SIRS) and sepsis as causes of multiple organ dysfunction syndrome (MODS) remain challenging to treat in polytrauma patients. In this study, the focus was set on widely used scoring systems to assess their diagnostic quality.

Methods

A total of 512 patients (mean age: 39.2?±?16.2, range: 16?C88?years) who had an Injury Severity Score (ISS) ??17 were included in this retrospective study. The patients were subdivided into four groups: no SIRS, slight SIRS, severe SIRS, and sepsis. The ISS, New Injury Severity Score (NISS), Acute Physiology and Chronic Health Evaluation II (APACHE II) scores, and prothrombin time were collected at admission. The Kruskal?CWallis test and ??²-test, multinomial regression analysis, and kernel density estimates were performed. Receiver operating characteristic (ROC) analysis is reported as the area under the curve (AUC). Data were considered as significant if p?<?0.05.

Results

All variables were significantly different in all groups (p?<?0.001). The odds ratio increased with increasing SIRS severity for NISS (slight vs. no SIRS, 1.06, p?=?0.07; severe vs. no SIRS, 1.07, p?=?0.04; and sepsis vs. no SIRS, 1.11, p?=?0.0028) and APACHE II score (slight vs. no SIRS, 0.97, p?=?0.44; severe vs. no SIRS, 1.08, p?=?0.02; and sepsis vs. no SIRS, 1.12, p?=?0.0028). ROC analysis revealed that the NISS (slight vs. no SIRS, AUC 0.61; severe vs. no SIRS, AUC 0.67; and sepsis vs. no SIRS, AUC 0.77) and APACHE II score (slight vs. no SIRS, AUC 0.60; severe vs. no SIRS, AUC 0.74; and sepsis vs. no SIRS, AUC 0.82) had the best predictive ability for SIRS and sepsis.

Conclusion

Quick assessment with the NISS or APACHE II score could preselect possible candidates for sepsis following polytrauma and provide guidance in trauma surgeons?? decision-making.