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

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

Should dialysis be offered to cancer patients with acute kidney injury?

Objectives Cancer patients are at high risk for acute kidney injury (AKI), which is associated with high mortality when renal replacement therapy is required. Because physicians might be reluctant to offer dialysis to patients with malignancies, we sought to appraise outcomes in critically ill cancer patients (mainly with hematological malignancies) who received renal replacement therapy for AKI complicating cancer management. Design Cohort study including consecutive patients who received renal replacement therapy for AKI complicating cancer management, over a 42-month period. Their mortality was compared with that of non-cancer patients who received renal replacement therapy in the same center over the same study period (control group). Setting A 12-bed medical intensive care unit in a university hospital. Results 94 critically-ill cancer patients met the inclusion criteria. Median SAPS II was 53 (IQR 40–75) and median Logistic Organ Dysfunction score was 7 (IQR 5–10). The etiology of AKI was multiple in most patients (248 identified factors in 93 patients). Hospital mortality was 51.1%. Two variables were independently associated with hospital mortality: the severity of associated organ failures at ICU admission (OR, 1.33; 95% CI, 1.11–1.59; per point) and renal function deterioration after ICU admission (OR, 5.42; 95% CI, 1.62–18.11). Characteristics of the malignancy were not associated with hospital mortality. The presence of cancer had no detectable influence on hospital mortality after adjustment for gender, age, acute severity as assessed by the SAPS II score, and chronic health status [OR 1.2, 95% CI 0.63–2.27; p = 0.57]. Conclusion ICU admission should be considered in selected critically ill cancer patients with AKI requiring renal replacement therapy.     

Early coagulation disorders after severe burn injury: impact on mortality

Objective To evaluate the time course of coagulation markers in the early postburn period and clarify the role of coagulation alterations in organ failure and in mortality prognosis. Design and setting This prospective study was conducted in the burn ICU of a tertiary hospital. Patients 45 patients with severe thermal burn injury. Measurements and results Clinical data and coagulation and fibrinolysis parameters were measured during the first postburn week. The ICU 28-day mortality rate was 33%. Significant differences in the time course of coagulation markers were observed between survivors and nonsurvivors. SOFA score distinguished between patients with overt and nonovert disseminated intravascular coagulation (DIC) during the overall investigation period. Presence of overt DIC was related to mortality (OR = 0.1). Antithrombin, protein S, plasminogen activator inhibitor 1, and SOFA score on day 3, protein C on day 5, and thrombin/antithrombin complexes on day 7 revealed a good prognostic value for ICU mortality, according to the area under ROC curves. Conclusions Severe thermal injury is associated with the early activation of coagulation cascade, presence of DIC, organ failure, and increased mortality.     

Intensive care unit acquired infection and organ failure

Objective To assess the temporal relationship between ICU-acquired infection (IAI) and the prevalence and severity of organ dysfunction or failure (OD/F). Design and setting Observational, single center study in a mixed intensive care unit of a university hospital. Patients We analyzed 1,191 patients hospitalized for more than 2 days during a 2-year observation period: 845 did not acquire IAI, 306 of whom had infection on admission (IOA); 346 did acquire IAI, 125 of whom had IOA. Measurements and results The SOFA score was calculated daily, both SOFAmax, the sum of the worst OD/F during the ICU stay, and SOFApreinf, the sum of the worst OD/F existing before the occurrence of the first IAI. The SAPS II and SOFA score of the first 24 h were significantly higher in patients with than in those without IAI. SOFApreinf of IAI patients was also higher than the SOFAmax of patients without IAI both in patients with (12.1 ± 4.6 vs. 8.9 ± 4.7) and those without IOA (9.2 ± 4.0 vs. 6.7 ± 3.5). SOFApreinf represented 85.7% of the value of SOFAmax in patients with IAI. SOFApreinf increased significantly with the occurrence of sepsis, severe sepsis, or septic shock during ICU stay. Severe sepsis and septic shock during ICU stay as well as SOFApreinf were part of the factors associated with hospital mortality. Conclusions IAI is significantly associated with hospital mortality; however, its contribution to OD/F is minor. Moreover, severity of IAI seems to be related to previous health status. This article is discussed in the editorial available at: .     

Patterns and early evolution of organ failure in the intensive care unit and their relation to outcome

Introduction

Recognition of patterns of organ failure may be useful in characterizing the clinical course of critically ill patients. We investigated the patterns of early changes in organ dysfunction/failure in intensive care unit (ICU) patients and their relation to outcome.

Methods

Using the database from a large prospective European study, we studied 2,933 patients who had stayed more than 48 hours in the ICU and described patterns of organ failure and their relation to outcome. Patients were divided into three groups: patients without sepsis, patients in whom sepsis was diagnosed within the first 48 hours after ICU admission, and patients in whom sepsis developed more than 48 hours after admission. Organ dysfunction was assessed by using the sequential organ failure assessment (SOFA) score.

Results

A total of 2,110 patients (72% of the study population) had organ failure at some point during their ICU stay. Patients who exhibited an improvement in organ function in the first 24 hours after admission to the ICU had lower ICU and hospital mortality rates compared with those who had unchanged or increased SOFA scores (12.4 and 18.4% versus 19.6 and 24.5%, P < 0.05, pairwise). As expected, organ failure was more common in sepsis than in nonsepsis patients. In patients with single-organ failure, in-hospital mortality was greater in sepsis than in nonsepsis patients. However, in patients with multiorgan failure, mortality rates were similar regardless of the presence of sepsis. Irrespective of the presence of sepsis, delta SOFA scores over the first 4 days in the ICU were higher in nonsurvivors than in survivors and decreased significantly over time in survivors.

Conclusions

Early changes in organ function are strongly related to outcome. In patients with single-organ failure, in-hospital mortality was higher in sepsis than in nonsepsis patients. However, in multiorgan failure, mortality rates were not influenced by the presence of sepsis.     

Prognostication of critically ill patients with acute-on-chronic liver failure using the Chronic Liver Failure–Sequential Organ Failure Assessment: A Canadian retrospective study

PurposeWe evaluated the Chronic Liver Failure–Sequential Organ Failure Assessment (CLIF-SOFA) score to predict survival in a Canadian critically ill cohort with acute-on-chronic liver failure.MethodsWe retrospectively examined 274 acute-on-chronic liver failure patients admitted to a quaternary level intensive care unit (ICU) between April 1, 2000, and April 30, 2011. We evaluated severity of illness scores, including the Acute Physiology and Chronic Health Evaluation (APACHE) II, model for end-stage liver disease (MELD), Child-Turcotte-Pugh (CTP), SOFA, and CLIF-SOFA.ResultsOn ICU admission, patients had the following median (interquartile range): APACHE II, 23 (19-28); MELD, 26 (19-35); CTP, 12 (10-13); SOFA, 15 (11-18); and CLIF-SOFA, 17 (13-21). In-hospital survival was 40%. There were no significant differences in survival for cirrhosis etiology, reason, or year of admission. The CLIF-SOFA score had the greatest area under receiver operating curve of 0.865 (95% confidence interval, 0.820-0.909) and outperformed the CTP, MELD, SOFA, and APACHE II scores. Sequential Organ Failure Assessment score performance improved on the third day of ICU admission (area under receiver operating curve, 0.935; 95% confidence interval, 0.895-0.975).ConclusionsThe CLIF-SOFA and SOFA scores during the first 3 days of ICU admission appear to be highly predictive of in-hospital mortality.     

Incidence, organ dysfunction and mortality in severe sepsis: a Spanish multicentre study

Introduction

Sepsis is a leading cause of admission to non-cardiological intensive care units (ICUs) and the second leading cause of death among ICU patients. We present the first extensive dataset on the epidemiology of severe sepsis treated in ICUs in Spain.

Methods

We conducted a prospective, observational, multicentre cohort study, carried out over two 3-month periods in 2002. Our aims were to determine the incidence of severe sepsis among adults in ICUs in a specific area in Spain, to determine the early (48 h) ICU and hospital mortality rates, as well as factors associated with the risk of death.

Results

A total of 4,317 patients were admitted and 2,619 patients were eligible for the study; 311 (11.9%) of these presented at least 1 episode of severe sepsis, and 324 (12.4%) episodes of severe sepsis were recorded. The estimated accumulated incidence for the population was 25 cases of severe sepsis attended in ICUs per 100,000 inhabitants per year. The mean logistic organ dysfunction system (LODS) upon admission was 6.3; the mean sepsis-related organ failure assessment (SOFA) score on the first day was 9.6. Two or more organ failures were present at diagnosis in 78.1% of the patients. A microbiological diagnosis of the infection was reached in 209 episodes of sepsis (64.5%) and the most common clinical diagnosis was pneumonia (42.8%). A total of 169 patients (54.3%) died in hospital, 150 (48.2%) of these in the ICU. The mortality in the first 48 h was 14.8%. Factors associated with early death were haematological failure and liver failure at diagnosis, acquisition of the infection prior to ICU admission, and total LODS score on admission. Factors associated with death in the hospital were age, chronic alcohol abuse, increased McCabe score, higher LODS on admission, ΔSOFA 3-1 (defined as the difference in the total SOFA scores on day 3 and on day 1), and the difference of the area under the curve of the SOFA score throughout the first 15 days.

Conclusions

We found a high incidence of severe sepsis attended in the ICU and high ICU and hospital mortality rates. The high prevalence of multiple organ failure at diagnosis and the high mortality in the first 48 h suggests delays in diagnosis, in initial resuscitation, and/or in initiating appropriate antibiotic treatment.     

Association of cell-free plasma DNA with hospital mortality and organ dysfunction in intensive care unit patients

Objective To investigate the concentration of cell-free plasma DNA and its association with organ dysfunction and hospital mortality in intensive care unit patients. Design and setting Prospective cohort study in a medical and two medical-surgical intensive care units in a university hospital. Patients 228 critically ill patients admitted to the ICUs between January 2004 and July 2005. Measurements and results Blood samples were collected as soon as possible after ICU admission, the following morning, and 48 h after the second sample. The cell-free plasma DNA was measured by real-time quantitative PCR assay for the β-globin gene. Physiological and mortality data were collected to the clinical database. Hospital mortality rate and SOFA scores were primary outcome measures. The maximum plasma DNA concentrations were correlated significantly with APACHE II points and with maximum SOFA scores. Cell-free plasma DNA concentrations were higher in hospital non-survivors than in survivors (median 9,366 vs. 6,506 GE/ml). Using logistic regression analysis, the maximum plasma DNA was an independent predictor of hospital mortality. Conclusions The maximum plasma DNA concentration measured during the first 96 h of intensive care is associated with the degree of organ dysfunction and disease severity. Moreover, the maximum DNA concentration is independently associated with hospital mortality. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Mortality after discharge from intensive care: the impact of organ system failure and nursing workload use at discharge

OBJECTIVES: Mortality after ICU discharge accounts for approx. 20-30% of deaths. We examined whether post-ICU discharge mortality is associated with the presence and severity of organ dysfunction/failure just before ICU discharge. PATIENTS AND METHODS: The study used the database of the EURICUS-II study, with a total of 4,621 patients, including 2,958 discharged alive to the general wards (post-ICU mortality 8.6%). Over a 4-month period we collected clinical and demographic characteristics, including the Simplified Acute Physiology Score (SAPS II), Nine Equivalents of Nursing Manpower Use Score, and Sequential Organ Failure Assessment (SOFA) score. RESULTS: Those who died in the hospital after ICU discharge had a higher SAPS II score, were more frequently nonoperative, admitted from the ward, and had stayed longer in the ICU. Their degree of organ dysfunction/failure was higher (admission, maximum, and delta SOFA scores). They required more nursing workload resources while in the ICU. Both the amount of organ dysfunction/failure (especially cardiovascular, neurological, renal, and respiratory) and the amount of nursing workload that they required on the day before discharge were higher. The presence of residual CNS and renal dysfunction/failure were especially prognostic factors at ICU discharge. Multivariate analysis showed only predischarge organ dysfunction/failure to be important; thus the increased use of nursing workload resources before discharge probably reflects only the underlying organ dysfunction/failure. CONCLUSIONS: It is better to delay the discharge of a patient with organ dysfunction/failure from the ICU, unless adequate monitoring and therapeutic resources are available in the ward.     

Treatment of severe acute respiratory distress syndrome: role of extracorporeal gas exchange

Objective To evaluate the effect of extracorporeal gas exchange (ECMO) on mortality of patients referred with severe acute respiratory distress syndrome (ARDS).Design and setting Prospective observational study in a university hospital ICU.Patients 150 patients with severe ARDS.Interventions Multimodal treatment with and without ECMO.Measurements and main results We treated 118 patients (78.7%) conservatively and 32 patients with ECMO. Patients in the ECMO group presented with significantly more severe disease (lung injury score 3.8 ± 0.3 vs. 3.3 ± 0.4; SOFA score 52 ± 14 vs. 43 ± 12; and SAPS score 14 ± 3.3 vs. 10 ± 3.5). Mortality in ECMO-treated patients tended to be higher than that with conservative treatment (46.9% vs. 28.8%, p = 0.059). Multivariate logistic regression analyses with backward selection excluded ECMO as predictor of mortality (p = 0.79). Independent predictors of mortality were age (odds ratio 1.044, 95% confidence interval 1.014–1.075, p = 0.004), mean pulmonary artery pressure (1.082, 1.026–1.141, p = 0.036), sequential organ failure assessment score (1.148, 1.018–1.294, p = 0.024), and days of mechanical ventilation prior to referral (1.064, 1.008–1.123, p = 0.025).Conclusion ECMO treatment does not predict mortality in patients with most severe ARDS.     

Risk factors of early redialysis after weaning from postoperative acute renal replacement therapy

Objective The aim of this study was to identify risk factors for redialysis in postoperative patients with acute renal failure (ARF) who had previously been weaned from acute dialysis. Although recovery of renal function is anticipated in patients with ARF, no data have been reported on successful weaning from acute dialysis. Design and setting Retrospective observational case-control study in a 64-bed surgical ICU. Patients and methods Success in discontinuing dialysis was defined as cessation from dialysis for at least 30 days. A total of 304 postoperative patients who underwent acute renal replacement therapy in a surgical ICU between July 2002 and April 2005 were included. SOFA score biochemical data and renal function parameters were assessed on the day after the last session of renal replacement therapy, designated as day 0 (D0). Results We could wean 94 patients (30.9%) from acute dialysis for more than 5 days, and 64 of these (21.1%) were successfully weaned for at least 30 days. The independent predictors for resuming dialysis within 30 days were: (a) longer duration of dialysis (OR 1.06), (b) higher SOFA score on D0 (OR 1.44), (c) oliguria (urine output < 100cc/8 h; OR 4.17) on D1, and (d) age over 65 years (OR 6.35). The area under the ROC curve was 0.880. Two-way analysis of variance with repeated measurements over time showed a larger decline in SOFA score and an increase in urine output in patients with successful cessation of dialysis. Kaplan–Meier analysis showed a significant difference in early resumption of dialysis between patients with or without oliguria at D0. Conclusions More than two-thirds of patients weaned from postoperative acute dialysis for more than 5 days were free of dialysis for at least 30 days. Less urine output, longer duration of dialysis, age over 65 years, and higher disease severity score are predictive of a patient's redialysis after initial weaning from acute dialysis. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users. The complete list of NSARF members is provided in the Acknowledgements. This study was financially supported by the Improving Dialysis Quality Research Funds, the Ta-Tung Kidney Foundation and Taiwan National Science Council (grant: NSC 95-2314-B-002-166). There are no conflicts of interest.     

The Multiple Organ Dysfunction Score (MODS) versus the Sequential Organ Failure Assessment (SOFA) score in outcome prediction

OBJECTIVE: To compare outcome prediction using the Multiple Organ Dysfunction Score (MODS) and the Sequential Organ Failure Assessment (SOFA), two of the systems most commonly used to evaluate organ dysfunction in the intensive care unit (ICU). DESIGN: Prospective, observational study. SETTING: Thirty-one-bed, university hospital ICU. PATIENTS AND PARTICIPANTS: Nine hundred forty-nine ICU patients. MEASUREMENTS AND RESULTS: The MODS and the SOFA score were calculated on admission and every 48 h until ICU discharge. The Acute Physiology and Chronic Health Evaluation (APACHE) II score was calculated on admission. Areas under receiver operating characteristic (AUROC) curves were used to compare initial, 48 h, 96 h, maximum and final scores. Of the 949 patients, 277 died (mortality rate 29.1%). Shock was observed in 329 patients (mortality rate 55.3%). There were no significant differences between the two scores in terms of mortality prediction. Outcome prediction of the APACHE II score was similar to the initial MODS and SOFA score in all patients, and slightly worse in patients with shock. Using the scores' cardiovascular components (CV), outcome prediction was better for the SOFA score at all time intervals (initial AUROC SOFA CV 0.750 vs MODS CV 0.694, p<0.01; 48 h AUROC SOFA CV 0.732 vs MODS CV 0.675, p<0.01; and final AUROC SOFA CV 0.781 vs MODS CV 0.674, p<0.01). The same tendency was observed in patients with shock. There were no significant differences in outcome prediction for the other five organ systems. CONCLUSIONS: MODS and SOFA are reliable outcome predictors. Cardiovascular dysfunction is better related to outcome with the SOFA score than with the MODS.     

Vasopressin or norepinephrine in early hyperdynamic septic shock: a randomized clinical trial

Objective To compare the effects of arginine-vasopressin (AVP) and norepinephrine (NE) on hemodynamic variables, organ dysfunction, and adverse events in early hyperdynamic septic shock.Design and setting Randomized, controlled, open-label trial.Patients and participants Twenty-three patients with early (12 h) hyperdynamic septic shock in two teaching hospitals.Interventions AVP (0.04–0.20 U min^–1, n = 13) as a single agent or NE (0.1–2.8 μg kg^–1 min^–1, n = 10) infusion for 48 h to achieve mean arterial pressure at or above 70 mmHg.Measurements and results Hemodynamic parameters and Sequential Organ Failure Assessment (SOFA) score were measured. AVP and NE equally increased mean arterial pressure over 48 h, but NE was required in 36% of AVP patients at 48 h. Compared to baseline, AVP increased systemic vascular resistance, decreased exposure to NE, decreased cardiac output by decreasing heart rate, increased creatinine clearance, and improved SOFA score. The PrCO₂ – PaCO₂ difference remained stable throughout the study. One AVP patient developed acute coronary syndrome with dose-dependent ECG changes. Three patients in both groups died during their ICU stay.Conclusion In early hyperdynamic septic shock, the administration of high-dose AVP as a single agent fails to increase mean arterial pressure in the first hour but maintains it above 70 mmHg in two-thirds of patients at 48 h. AVP decreases NE exposure, has no effect on the PrCO₂ – PaCO₂ difference, and improves renal function and SOFA score.This work was supported by the Cardiovascular Critical Care research Network FRSQ and departmental funding.     

Outcome of patients with end-stage renal disease admitted to the intensive care unit

OBJECTIVES: To describe the clinical course of patients with end-stage renal disease (ESRD) admitted to the intensive care unit (ICU) and to compare the performance of Acute Physiology and Chronic Health Evaluation (APACHE) III and Sequential Organ Failure Assessment (SOFA) in predicting their outcome. PATIENTS AND METHODS: This retrospective cohort study consisted of patients with ESRD admitted to 3 ICUs between January 1, 1997, and November 30, 2002. Data on demographics, APACHE III score, SOFA score, development of sepsis and organ failure, use of mechanical ventilation, and mortality were collected. RESULTS: Of the 476 patients with ESRD who underwent dialysis during the study period, 93 (20%) required admission to the ICU. The most common ICU admission diagnosis was gastrointestinal bleeding. The first day median (Interquartile range) APACHE III score, SOFA score, and APACHE III predicted hospital mortality rate were 64 (47-79), 6 (5-8), and 12.9% (4.2%-30.8%), respectively. The observed ICU, hospital, and 30-day mortality rates were 9%, 16%, and 22%, respectively. Nonrenal organ failure developed in 48 patients (52%) and sepsis in 15 patients (16%). Mechanical ventilation was required In 26 patients (28%). The area under the receiver operating characteristic curve for the first-day APACHE III probability of hospital death in predicting 30-day mortality was 0.78 (95% confidence interval, 0.68-0.86) compared with 0.66 (95% confidence interval, 0.55-0.76) for the SOFA score (P = .16). CONCLUSIONS: The observed hospital mortality of patients with ESRD admitted to the ICU is relatively low. There is no statistically significant difference in the performance of APACHE III and SOFA prognostic models in discriminating between 30-day survivors and nonsurvivors.     

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

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

eccSOFA: SOFA illness severity score adapted to predict in-hospital mortality in emergency critical care patients

BackgroundBoarding of ICU patients in the ED is increasing. Illness severity scores may help emergency physicians stratify risk to guide earlier transfer to the ICU and assess pre-ICU interventions by adjusting for baseline mortality risk. Most existing illness severity scores are based on data that is not available at the time of the hospital admission decision or cannot be extracted from the electronic health record (EHR). We adapted the SOFA score to create a new illness severity score (eccSOFA) that can be calculated at the time of ICU admission order entry in the ED using EHR data. We evaluated this score in a cohort of emergency critical care (ECC) patients at a single academic center over a period of 3 years.MethodsThis was a retrospective cohort study using EHR data to assess predictive accuracy of eccSOFA for estimating in-hospital mortality risk. The patient population included all adult patients who had a critical care admission order entered while in the ED of an academic medical center between 10/24/2013 and 9/30/2016. eccSOFA's discriminatory ability for in-hospital mortality was assessed using ROC curves.ResultsOf the 3912 patients whose in-hospital mortality risk was estimated, 2260 (57.8%) were in the low-risk group (scores 0–3), 1203 (30.8%) in the intermediate-risk group (scores 4–7), and 449 (11.5%) in the high-risk group (scores 8+). In-hospital mortality for the low-, intermediate, and high-risk groups was 4.2% (95%CI: 3.4–5.1), 15.5% (95% CI 13.5–17.6), and 37.9% (95% CI 33.4–42.3) respectively. The AUROC was 0.78 (95%CI: 0.75–0.80) for the integer score and 0.75 (95% CI: 0.72–0.77) for the categorical eccSOFA.ConclusionsAs a predictor of in-hospital mortality, eccSOFA can be calculated based on variables that are commonly available at the time of critical care admission order entry in the ED and has discriminatory ability that is comparable to other commonly used illness severity scores. Future studies should assess the calibration of our absolute risk predictions.     

A prospective study on adrenal cortex responses and outcome prediction in acute critical illness: results from a large cohort of 203 mixed ICU patients

Objective To assess whether adrenal cortex hormones predict ICU mortality in acute, mixed, critically ill patients. Design and setting Prospective study in consecutive intensive care patients in the general ICU of a teaching hospital. Patients 203 severely ill patients with multiple trauma (n = 93), medical (n = 57), or surgical (n = 53) critical states. Measurements and results Within 24 h of admission in the ICU a morning blood sample was obtained to measure baseline cortisol, corticotropin (ACTH), and dehydropiandrosterone sulfate (DHEAS). Subsequently a low-dose (1 μg) ACTH test was performed to determine stimulated cortisol. The incremental rise in cortisol was defined as stimulated minus baseline cortisol. Overall, 149 patients survived and 54 died. Nonsurvivors were older and in a more severe critical state, as reflected by higher SOFA and APACHE II scores. Nonsurvivors had a lower incremental rise in cortisol (5.0 vs. 8.3 μg/dl and lower DHEAS (1065 vs. 1642 ng/ml) than survivors. The two groups had similar baseline and stimulated cortisol. Multivariate logistic regression analysis revealed that age (odds ratio 1.02), SOFA score (1.36), and the incremental rise in cortisol (0.88) were independent predictors for poor outcome. Conclusions In general ICU patients a blunted cortisol response to ACTH within 24 h of admission is an independent predictor for poor outcome. In contrast, baseline cortisol or adrenal androgens are not of prognostic significance.     

Outcomes in critically ill patients with hematologic malignancies who received renal replacement therapy for acute kidney injury in an intensive care unit

Introduction

In critically ill patients with hematologic malignancies, acute kidney injury (AKI) usually occurs in the context of multiple organ failure due to various etiologies and is associated with poor prognosis. The objective of the present study was to identify the prognostic factors associated with intensive care unit (ICU) mortality in patients with hematologic malignancies and AKI requiring renal replacement therapy (RRT).

Methods

We retrospectively evaluated 94 patients with hematologic malignancies and AKI who received RRT in the ICU of Samsung Medical Center, Seoul, Korea, between January 2004 and December 2007.

Results

The study sample included 65 men and 29 women with a median age of 49 years (interquartile range [IQR], 36-61 years). The median Simplified Acute Physiology Score II and Sequential Organ Failure Assessment (SOFA) scores at ICU admission were 64 (IQR, 46-79) and 13 (IQR, 9-16), respectively. The RRT for AKI was initiated at a median time of 1 day (IQR, 0-4 day) after ICU admission. Seventy-two (77%) patients died in the ICU after a median time of 4 days (IQR, 2-20 days) after the initiation of RRT. Among the 22 patients who survived, 5 (23%) required RRT after ICU discharge. Intensive care unit mortality was associated with an etiology of AKI, Simplified Acute Physiology Score II score, and SOFA score. Modified SOFA (mSOFA) score (defined as the sum of the 5 nonrenal components of the SOFA score) at the initiation of RRT was lower in survivors than in nonsurvivors. In a multiple logistic regression analysis, ICU mortality was independently associated with mSOFA score (odds ratio, 1.83 per mSOFA score increase; 95% confidence interval, 1.38-2.42) at the initiation of RRT. The estimated area under the curve for mSOFA score was 0.902 (95% confidence interval, 0.831-0.972).

Conclusion

The severity of organ failure, excluding renal failure, at initiation of RRT was independently associated with ICU mortality in patients with hematologic malignancies and AKI requiring RRT.     

Urinary biomarker of oxidative stress correlating with outcome in critically septic patients

Objective To determine whether urinary 8-hydroxy-2′-deoxyguanosine (8-OHdG), an in vivo parameter of oxidative stress, is correlated with the outcome of critically septic patients. Design and setting Clinical outcome study in an adult medical intensive care unit (ICU). Patients 85 consecutive septic patients (59 men, 26 women). Measurements and results Patient characteristics and the clinical course were examined. Urinary 8-OHdG was analyzed using isotope-dilution liquid chromatography with tandem mass spectrometry (LC/MS/MS). ICU mortality was 25.9% (22/85) and hospital mortality 38.8% (33/85). Survivors' APACHE II scores on days 1 and 3 and the difference between them differed significantly from those of nonsurvivors (day 1, 21.0 ± 7.1 vs. 25.9 ± 8.0; day 3, 15.0 ± 5.8 vs. 23.2 ± 8.3; difference, 6.0 ± 5.5 vs. 1.7 ± 6.6). Urinary 8-OHdG was significantly lower in survivors than in nonsurvivors on day 1 (1.8 ± 2.4 vs. 3.0 ± 2.4). The area under receiver operating characteristic curve analysis for the association between day 1 urinary 8-OHdG and ICU mortality was 0.71. The comparison performed upon discharge from hospital revealed similar results. Conclusions This is a preliminary study. Excretion of urinary 8-OHdG, as measured using isotope-dilution LC/MS/MS, and the APACHE II score were correlated with the outcome of critically septic patients in medical ICU.     

Daily evaluation of organ function during renal replacement therapy in intensive care unit patients with acute renal failure

PurposeThe aim of this study was to assess changes in organ function in acute renal failure patients during renal replacement therapy and relate them to outcome.Materials and MethodsMedical and nursing charts from 111 patients with acute renal failure who underwent renal replacement therapy (hemodialysis or hemofiltration) from July 2000 until July 2002 on a 31-bed medicosurgical intensive care unit (ICU) at a university hospital in Belgium and in whom the Sequential Organ Failure Assessment (SOFA) score was calculated daily before the start of therapy until the seventh day, or the end of therapy, were analyzed. Changes in SOFA score over time (Δ SOFA) were calculated.ResultsOf 111 patients, 63 (57%) died in the ICU. Nonsurvivors were older (68 [52-76] vs 59 [48-70] years, P = .017) and had initially higher respiratory, cardiovascular, and total SOFA scores compared with survivors. A greater Δ renal SOFA at 24 hours was associated univariantly with a higher risk of ICU mortality (odds ratio, 1.7; 95% confidence interval, 1.2-2.6; P = .013). In a multivariate analysis with ICU outcome as the dependent variable, only age, cardiovascular SOFA score on admission, and the change in total SOFA score over the first 24 hours were independently associated with a greater risk of death.ConclusionsAssessment of these factors in the first 24 hours of renal replacement therapy could help identify patients at higher risk of mortality early during their ICU admission.