The impact of low-risk intensive care unit admissions on mortality probabilities by SAPS II, APACHE II and APACHE III

A large proportion of intensive care unit patients are low-risk admissions. Mortality probabilities generated by predictive systems may not accurately reflect the mortality experienced by subpopulations of critically ill patients. We prospectively assessed the impact of low-risk admissions (mortality risk < 10%) on the mortality estimates generated by three prognostic models. We studied 1497 consecutive admissions to a general intensive care unit. The performance of the three models for subgroups and the whole population was analysed. The proportions of patients designated as low risk varied with the model and differences in model performance were most pronounced for these patients. The APACHE II mortality ratios (1.32 vs. 1.19) did not differ for low- and higher risk patients, but mortality ratios generated by APACHE III (2.38 vs. 1.23) and SAPS II (2.19 vs. 1.16) were nearly two-fold greater. Calibration for higher risk patients was similar for all three models but the APACHE III system calibrated worse than the other models for low-risk patients. This may have contributed to the poorer overall calibration of the APACHE III system (Hosmer-Lemeshow C-test: APACHE III chi(2) = 329; APACHE II chi(2) = 42; SAPS II chi(2) = 62). Imperfect characterisation of the large proportion of low-risk intensive care unit admissions may contribute to the deterioration of the models' predictive accuracies for the intensive care population as a whole.     

Survival benefit in critically ill burned patients receiving selective decontamination of the digestive tract: a randomized, placebo-controlled, double-blind trial

OBJECTIVE: To evaluate whether selective digestive decontamination (SDD) reduces mortality from any cause, and the incidence of pneumonia among patients with severe burns. SUMMARY BACKGROUND DATA: SDD is a prophylactic strategy to reduce infectious morbidity and mortality in critically ill patients. Two meta-analyses and a recent randomized controlled trial demonstrated a mortality reduction varying between 20% and 40%. But this technique has never been properly evaluated in severely burned patients. METHODS: The design of this single-center trial was randomized, double blind, placebo controlled. Patients with burns > or =20% of total body surface and/or suspected inhalation injury were enrolled and assigned to receive SDD or placebo for the total duration of treatment in the burn intensive care unit (ICU). RESULTS: One hundred seventeen patients were randomized and 107 were analyzed (53 in the SDD group and 54 in the placebo group). The ICU mortality was 27.8% in the placebo group and 9.4% in the SDD group in the burn ICU. Treatment with SDD was associated with a significant reduction in mortality both in the burn ICU (risk ratio 0.25; 95% CI 0.08 to 0.76) and in the hospital (risk ratio 0.28; 95% CI 0.10 to 0.80), following adjustment for predicted mortality. The incidence of pneumonia was significantly higher in the placebo group: 30.8 and 17.0 pneumonias per 1000 ventilation days (P = 0.03) in placebo and SDD group, respectively. CONCLUSIONS: Treatment with SDD reduces mortality and pneumonia incidence in patients with severe burns.     

Analysis of the effect of conversion from open to closed surgical intensive care unit

OBJECTIVE: To compare the effect on clinical outcome of changing a surgical intensive care unit from an open to a closed unit. DESIGN: The study was carried out at a surgical intensive care unit in a large tertiary care hospital, which was changed on January 1, 1996, from an open unit, where private attending physicians contributed and controlled the care of their patients, to a closed unit, where patients' medical care was provided only by the surgical critical care team (ABS or ABA board-certified intensivists). A retrospective review was undertaken over 6 consecutive months in each system, encompassing 274 patients (125 in the open-unit period, 149 in the closed-unit period). Morbidity and mortality were compared between the two periods, along with length-of-stay (LOS) and number of consults obtained. A set of independent variables was also evaluated, including age, gender, APACHE III scores, the presence of preexisting medical conditions, the use of invasive monitoring (Swan-Ganz catheters, central and arterial lines), and the use of antibiotics, low-dose dopamine (LDD) for renal protection, vasopressors, TPN, and enteral feeding. RESULTS: Mortality (14.4% vs. 6.04%, p = 0.012) and the overall complication rate (55.84% vs. 44.14%, p = 0.002) were higher in the open-unit group versus the closed-unit group, respectively. The number of consults obtained was decreased (0.6 vs. 0.4 per patient, p = 0.036), and the rate of occurrence of renal failure was higher in the open-unit group (12.8% vs. 2.67%, p = 0.001). The mean age of the patients was similar in both groups (66.48 years vs. 66.40, p = 0.96). APACHE III scores were slightly higher in the open-unit group but did not reach statistical significance (39.02 vs. 36.16, p = 0.222). There were more men in the first group (63.2% vs. 51.3%). The use of Swan-Ganz catheters or central and arterial lines were identical, as was the use of antibiotics, TPN, and enteral feedings. The use of LDD was higher in the first group, but the LOS was identical. CONCLUSIONS: Conversion of a tertiary care surgical intensive care unit from an open to closed environment reduced dopamine usage and overall complication and mortality rates. These results support the concept that, when possible, patients in surgical intensive care units should be managed by board-certified intensivists in a closed environment.     

Performance of the PIRO score for predicting mortality in patients with ventilator-associated pneumonia

The ventilator-associated pneumonia (VAP) PIRO score is a new scoring system based on the PIRO concept. The aim of this study was to validate the PIRO score against the Acute Physiology and Chronic Health Evaluation (APACHE) II and VAP APACHE II in an independent group of VAP patients. Areas under the receiver operating characteristic curves were compared to determine the tests' abilities to predict intensive care unit and 28-day mortality. Variables associated with intensive care unit mortality were evaluated. One hundred and forty-eight intensive care unit patients who met radiographic and clinical criteria for VAP were included. The area under the receiver operating characteristic curves for predicting intensive care unit mortality with the PIRO, APACHE II and VAP APACHE II scores were 0.605 (P=0.03), 0.631 (P=0.01) and 0.724 (P <0.0001), respectively. Areas under the receiver operating characteristic curve for predicting 28-day mortality were 0.614 (P=0.01) for PIRO, 0.633 (P=0.01) for APACHE II and 0.697 (P=0.002) for VAP APACHE II. No differences in area under the receiver operating characteristic curve between scores were found at either endpoint. Variables independently associated with intensive care unit mortality were bacteraemia (adjusted odds ratio 7.16, 95% confidence interval 1.19 to 42.98, P=0.03) and APACHE II (1.06, 1.01 to 1.11, P=0.006). VAP PIRO score was not a good predictor of intensive care unit and 28-day mortality. The low sensitivity and specificity of VAP PIRO score preclude its use clinically.     

Predictors of mortality in ARDS patients referred to a tertiary care centre: a pilot study

BACKGROUND AND OBJECTIVE: In order to identify parameters predicting intensive care unit mortality in patients transferred to a specialized tertiary centre because of progressive acute respiratory distress syndrome, an observational pilot study was carried out involving 94 patients. METHODS AND RESULTS: Forty-one patients (43.6%) died. Survival was defined as intensive care unit discharge. Survivors were younger (32.0 +/- 11.8 vs. 39.1 +/- 12.4 yr, P = 0.008), at admission they had a lower acute physiology and chronic health evaluation (APACHE) II score (21.7 +/- 5.4 vs. 25.4 +/- 5.2, P = 0.0009), higher PaO2/FiO2 (122 +/- 79 vs. 79 +/- 42 mmHg, P = 0.002), lower positive end-expiratory pressure (10.6 +/- 3.1 vs. 12.5 +/- 3.7 cmH2O, P = 0.02) and a lower Murray score (2.8 +/- 0.63 vs. 3.0 +/- 0.62, P = 0.04). No differences were observed for tidal volumes and peak inspiratory pressures. Days of hospitalization and mechanical ventilation prior to transferral were not related to survival. Multivariate analysis of variables assessed on admission detected only differences for age (P = 0.014) and APACHE II (P = 0.005). Odds ratio was 1.06 (95% confidence interval (CI): 1.013-1.119) for age and 1.21 (CI: 1.059-1.381) for APACHE II. Multivariate analysis of changes in respiratory parameters, APACHE II and Murray score during the first 3 days after transferral revealed a significant difference only for positive end-expiratory pressure (P < 0.008). Corresponding odds ratio was 2.40 (CI: 1.25-4.58) for an increase of 1 cmH2O/24 h. CONCLUSION: Age-related mortality in this small, but highly selected group of patients with established ARDS increased early in life even in a population with an overall mean age of 35.1 yr. APACHE II was the only clinical predictor for mortality on admission. The need for a substantial increase in positive end-expiratory pressure after transferral markedly reduced the chance to survive.     

Atrial fibrillation in a tertiary care multidisciplinary intensive care unit--incidence and risk factors

Atrial fibrillation is a common arrhythmia in an intensive care unit. We performed a prospective observational study over a period of three months, to study the incidence, risk factors and outcome of patients who develop atrial fibrillation in a multidisciplinary intensive care unit. All patients above the age of 50 years were eligible. Exclusion criteria were: cardiac or oesophageal surgery during current hospitalisation, atrial fibrillation at admission, implanted pacemaker and expected intensive care unit stay of less than 24 hours. Sixty-one patients were included in the study. Eighteen patients (29.5%, confidence interval 18-40) developed atrial fibrillation. Incidence of atrial fibrillation was 4.02 episodes per 100 patient days. Patients who developed atrial fibrillation had higher age (71.3 years vs. 63.2 years, P=0.001), severity of illness (APACHE II 25.4 vs. 20.0, P=0.005) and sepsis at admission (9/18 vs. 9/43, P=0.01). They also had higher in-hospital mortality (Risk ratio 2.7, 95% confidence interval 1.3-5.4). Standardised mortality ratio was higher in patients who developed atrial fibrillation (1.08 vs. 0.63). Patients who developed atrial fibrillation required a longer period of mechanical ventilation and inotropic support. Multivariate logistic regression analysis showed age >75 years, APACHE II score >20 and sepsis at admission were independent predictors for development of atrial fibrillation in critically ill patients. Although atrial fibrillation by itself is unlikely to be the cause of higher mortality, it is likely to be a marker for increased mortality and resource utilisation in the intensive care unit.     

The effect of lead time bias on severity of illness scoring, mortality prediction and standardised mortality ratio in intensive care--a pilot study

The effect of lead time bias on severity of illness scoring, mortality prediction and standardised mortality ratios was examined in a pilot study of 76 intensive care (ICU) patients using APACHE II, APACHE III and SAPS II scoring systems. The inclusion of data collected in the period prior to ICU admission increased severity of illness scores and estimated risk of hospital mortality significantly for all three scoring systems (p < 0.01) by up to 14 points and 42.7% (APACHE II), 50 points and 26.3% (APACHE III) and 23 points and 33.4% (SAPS II), respectively. Standardised mortality ratios fell from 0.99 to 0.79 (APACHE II), 0.96 to 0.84 (APACHE III) and 0.75 to 0.64 (SAPS II), but these changes failed to reach statistical significance. Lead time bias had most effect in medical patients and on emergency admissions, and least effect in patients admitted from the operating theatre. These trends suggest that mortality ratios may not necessarily reflect intensive care unit performance and indicate that a larger study of the effect of lead time bias, case mix, pre-ICU care or post-ICU management on standardised mortality ratios is indicated.     

Survival after stentless and stented xenograft aortic valve replacement: a concurrent,controlled trial

BACKGROUND: To define the impact of stentless versus stented valve design on survival late after xenograft aortic valve replacement, a retrospective analysis of all consecutive patients operated on between January 1992 and April 2000 was undertaken. METHODS: Two hundred ninety-two patients had stented (group 1) and 376 stentless (group 2) xenograft aortic valve replacements. Age was older in group 1 (75 +/- 4 vs 70 +/- 7 years, p = 0.01), whereas male gender and aortic stenosis were equally prevalent. Advanced New York Heart Association class III-IV (85% vs 78%, p = 0.03) and associated procedures (53% vs 41%, p = 0.01) were more common in group 1. Aortic cross-clamp (80 +/- 28 vs 96 +/- 23 minutes, p = 0.01) and bypass (91 +/- 56 vs 129 +/- 34 minutes, p = 0.01) times were shorter in group 1. Logistic regression and Cox proportional hazard methods were used to define the role of demographic and operative variables on hospital and late survival, freedom from valve-related mortality, and reintervention. RESULTS: Early mortality was higher in group 1 (6.2% vs 2.6%, p = 0.02). Smaller aortic anulus (p = 0.008), aortic cross-clamp (p = 0.03), and coronary disease requiring bypass (p = 0.03) were associated with hospital mortality. During follow-up (37 +/- 30 vs 43 +/- 35 months, p = NS), 66 late deaths were recorded (12% vs 9%, p = NS). At 8 years, survival (70 +/- 5% vs 81 +/- 3%, p = 0.01), freedom from cardiac- (85 +/- 1% vs 92 +/- 3%, p = 0.02), and valve-related death (79 +/- 5% vs 95 +/- 2%, p = 0.004) were higher in group 2. Freedom from structural deterioration was similar (92 +/- 5% vs 93 +/- 3%, p = NS), but freedom from reoperation was lower in group 2 (99 +/- 1% vs 90 +/- 4%, p = 0.009). Multivariate analysis showed female gender (p = 0.02), age (p = 0.03), and smaller valve size (p = 0.05) to be associated with late mortality; age (p = 0.06) and diagnosis of aortic stenosis (p = 0.008) with cardiac mortality; longer intensive care unit stay (p = 0.001) and stented xenografts (p = 0.05) with valve-related mortality; and younger age (p = 0.01) and stentless xenograft (p = 0.05) with reoperation. CONCLUSIONS: Use of stentless xenografts correlates with better survival and freedom from cardiac- and valve-related mortality than stented valves. However, bias favoring stented valves in older and sicker patients exists. Selective survival advantage of stentless xenograft is confined to valve-related mortality. Stentless valves are more likely to be replaced for dysfunction.     

Prevention of bacterial infection and sepsis in acute severe pancreatitis.

Between 1984 and 1986 six patients with acute respiratory failure (requiring ventilation for at least 3 days) complicating acute pancreatitis were managed on the intensive care unit (median ventilation period 6 days; range 3-41 days). Between 1987 and 1989 nine similar patients were managed (median ventilation period 35 days, range 4-69 days), and a regimen of enteral tobramycin, polymyxin and amphotericin to selectively decontaminate the digestive tract (SDD) was introduced. Five of six patients treated before 1987 had serious infections (three Gram-negative, one fungal), compared with only one of nine patients treated with SDD (P < 0.05). Clinical signs of sepsis were evident for 62% of the pre-SDD period, compared with 39% of the period during SDD therapy (P < 0.001). Systemic antibiotic prescribing was reduced in the SDD group; however, mortality remained unaffected with only two patients surviving pre-SDD and three during SDD treatment. SDD reduces infection rates and sepsis in patients with acute pancreatitis and may help to improve the prognosis of this life-threatening condition.     

Admission hyperglycemia as a prognostic indicator in trauma

OBJECTIVE: The purpose of this study was to assess the utility of two levels of hyperglycemia as predictors for mortality and infectious morbidity in traumatically injured patients. METHODS: All patients >or= 17 years old presenting to a Level I trauma center as a "trauma alert" or a "trauma code" from January 1, 2000, through December 31, 2000, were reviewed. Hypoglycemic patients (glucose concentration < 70 mg/dL) were excluded (n = 4). Patients were considered hyperglycemic with an admission glucose concentration > 200 mg/dL (moderate hyperglycemia) or an admission glucose concentration in the upper quartile for the group (mild hyperglycemia [glucose concentration > 135 mg/dL]). RESULTS: Seven hundred thirty-eight patients were included in the study. Hyperglycemia was associated with increased mortality among both patients with moderate hyperglycemia (34.1% vs. 3.7%, p < 0.01) and those with mild hyperglycemia (15.5% vs. 2%, p < 0.01) compared with corresponding normoglycemic groups. Hyperglycemia proved to be an independent predictor of mortality and of hospital and intensive care unit length of stay after multiple logistic regression while controlling for age, Injury Severity Score, Revised Trauma Score, and gender. Infectious complications, including pneumonia (9.4% vs. 2%, p = 0.001), urinary tract infections (6.6% vs. 1.4%, p = 0.001), wound infections (4.9% vs. 0.6%, p = 0.039), and bacteremia (5% vs. 1.1%, p = 0.004), were significantly increased in patients with elevated glucose concentrations. Hyperglycemia is an independent predictor of increased infectious morbidity controlling for age, gender, and Injury Severity Score in multiple logistic regression models. CONCLUSION: Hyperglycemia independently predicts increased intensive care unit and hospital length of stay and mortality in the trauma population. It is associated with increased infectious morbidity. These associations hold true for mild hyperglycemia (glucose concentration > 135 mg/dL) and moderate hyperglycemia (glucose concentration > 200 mg/dL).     

Bayesian approach to predict hospital mortality of intensive care readmissions during the same hospitalisation

No specific prognostic model has been developed for patients readmitted to the intensive care unit (ICU) during the same hospitalisation. This study assesses the performance of the Acute Physiology and Chronic Health Evaluation (APACHE) II predicted mortality measured at the time of ICU readmission and whether incorporating information prior to the readmission will improve its performance to predict hospital mortality of patients readmitted to ICU during the same hospitalisation. A total of 602 readmissions during the same hospitalisation between 1987 and 2002 were identified. The first admission APACHE II predicted mortality was significantly associated with the hospital mortality only in the subgroup of patients readmitted within seven days of ICU discharge (odds ratio 1.16, 95% confidence interval 1.01 to 1.34; P = 0.035). In the subgroups of patients readmitted within seven days of discharge, the readmission APACHE II predicted mortality was also significantly better than the first admission APACHE II predicted mortality in discriminating between survivors and non-survivors (area under the receiver operating characteristic curve: 0.785 vs. 0.676, z statistic = 2.93; P = 0.003). Incorporating the first admission APACHE II predicted mortality to the readmission APACHE II predicted mortality, either by multilevel likelihood ratios or logistic regression, did not significantly improve its discrimination (area under the receiver operating characteristic curve: 0.792 vs. 0.785, z statistic = 0.52; P = 0.603). Our results suggested that information on prior ICU admission during the same hospitalisation is not as important as the severity of illness measured at the time of readmission in determining the mortality of intensive care readmissions during the same hospitalisation.     

Elective intrahospital admissions versus acute interhospital transfers to a surgical intensive care unit: cost and outcome prediction

After a decade of intense fiscal scrutiny, appropriate utilization of intensive care resources remains controversial. In particular, the financial impact of patients transferred to a tertiary surgical intensive care unit (SICU) from a community hospital (interhospital) is unknown, especially when compared with elective (intrahospital) SICU admissions admitted from the tertiary center itself. We prospectively studied outcome and costs in 82 consecutive tertiary SICU admissions. Half were transferred acutely from community hospitals and half were transferred from within the hospital or postoperatively. Severity of illness (APACHE II) was scored on day 1, at the same time of the day (9:00-10:00 AM) and by one attending surgeon (BCB). Acute transfer patients had a significantly elevated mortality (36%) when compared with elective admissions (12%) (p less than 0.05). When stratified by APACHE II score, acute transfers had twice the mortality for equivalent APACHE II scores (p less than 0.05). Acute transfer patients with APACHE II scores greater than 19 had an 89% mortality; those nonsurvivors cost $128,652 each. From these results we conclude the following: (1) Acute transfer patients have a significantly elevated mortality when compared with elective intrahospital admissions with equivalent APACHE II day-1 scores; (2) patients transferred acutely to tertiary SICUs are significantly more costly, irrespective of outcome; (3) admission source (elective vs. acute transfer) should be seriously considered when evaluating patient outcome and cost in a SICU.     

Continuous venovenous hemodiafiltration versus hemodialysis as renal replacement therapy in patients with acute renal failure in the intensive care unit

OBJECTIVE: Hemodialysis (HD) and continuous venovenous hemodiafiltration (CVVHDF) have been adopted as forms of renal replacement therapy (RRT) in patients with acute renal failure (ARF). Although CVVHDF has many advantages, previous studies reported no definite improvement in survival rate compared to HD. MATERIAL AND METHODS: In this retrospective study, 148 intensive care unit patients underwent HD (70 males, 25 females; mean age 45 +/- 17 years) or CVVHDF (42 males, 11 females; mean age 52 +/- 18 years). The severity of illness was estimated at the initiation of RRT and on the third day of RRT and presented using the APACHE III scoring system. The number of organ failures was checked at the initiation of RRT. RESULTS: The survival rate was 46% in the HD group and 21% in the CVVHDF group (p = 0.002). CVVHDF was applied to the more severely ill patients, who had longer periods using a ventilator (p = 0.002) and/or vasopressor (p < 0.001), higher numbers of organ failures (p < 0.001) and higher initial APACHE III scores (p < 0.001). Among patients with APACHE III scores > 103, the survival rate was 13% in the CVVHDF group and 0% in the HD group. In patients with kidney failure and failure of two other organs, the survival rate was 9% in the HD group and 36% in the CVVHDF group (p = 0.035). CONCLUSION: The mortality rate in the CVVHDF group was higher than that in the HD group, which may have been because CVVHDF was applied to the more severely ill patients. In contrast, CVVHDF may give a chance of survival to patients with APACHE III scores > 103 and may be more useful than HD in patients with failure of three or more organs.     

Frequency of colonization and pneumonia and development of resistance in long-term ventilated intensive-care patients subjected to selective decontamination of the digestive tract

Colonization of the oropharynx with potentially pathogenic microorganisms (PPM) is a highly significant factor in the pathogenesis of bacterial pneumonia in intensive care patients. Via colonization of the oropharynx, bacteria pass into the tracheobronchial tree, where they can give rise to pneumonia after overcoming pulmonary resistance mechanisms. By a new, prophylactic antibiotic treatment schedule consisting in selective decontamination of the digestive tract (SDD) with locally applied nonabsorbable antibiotics, Stoutenbeek achieved drastic lowering of the colonization and infection rate in trauma patients. In the present study, we wanted to check whether this new prophylactic antibiotic schedule can be applied on a surgical intensive care ward in all patients with long-term ventilation, irrespective of the diagnosis, and whether it affords advantages over a conventional antibiotic schedule. MATERIALS AND METHODS. All patients on a surgical intensive care ward in whom it was expected that mechanical ventilation would be necessary for more than 4 days were included in the study. During the first 6 months 83 patients were investigated, in whom antibiotics were only administered when the presence of infection had been confirmed, in accordance with generally accepted guidelines (control group). In the second 6-month period, 82 patients were selectively decontaminated with 4 x 100 mg polymyxin E, 4 x 80 mg tobramycin and 4 x 500 mg amphotericin B, administered through the gastric tube and in an antimicrobial paste in the oropharynx (SDD group). The SDD schedule entailed systemic administration of cefotaxime in the first 3-4 days. RESULTS. In the control group, enterobacteria/Pseudomonas spp. were isolated significantly more frequently than in the SDD group (P less than 0.001): in the pharyngeal smear in up to 53%, in the tracheal secretion up to 36%, and in the rectal smear in up to 93% of the patients In the SDD group in the 1 week the frequency of gram-negative aerobic bacteria in the pharynx decreased from 33% to 5%, in the tracheal secretion from 23% to 14% and in the rectum from 86% to 52% (24% in the second week). However, the decrease in gram-negative microorganisms was accompanied by significant increase in the frequency of Staphylococcus epidermidis and enterococci. The SDD schedule proved to be effective with regard to the rate of infection. In the control group, 35 patients developed pneumonia (42%) as against 5 patients receiving SDD prophylaxis (6%). The duration of mechanical ventilation in the patients with pneumonia was 5 days longer than in patients without pneumonia.(ABSTRACT TRUNCATED AT 400 WORDS)     

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.     

Nosocomial infections adversely affect the outcomes of patients with serious intraabdominal infections

BACKGROUND: Patients with serious intraabdominal infections (IAI) who subsequently acquire nosocomial infections (NI) have been shown to have adverse outcomes. We evaluated factors that put patients at risk for developing NI and examined the effect of the NI on outcomes. METHODS: This study was a retrospective review of NI among 168 patients diagnosed with IAI over a seven-year period. RESULTS: Sixty-six patients (39.3%) developed 98 NI (23 urinary tract, 20 surgical site, 19 pneumonia, 14 bloodstream, 12 recurrent peritonitis, seven intravascular catheter-related, and three enteric). There were 35 males and 31 females. Patients with NI were older (56.0 +/- 18.3 vs. 47.0 +/- 15.6 years, p = 0.001), had a higher admission APACHE II score (10.7 +/- 6.1 vs. 7.5 +/- 5.1 points, p = 0.001), and more often had concomitant medical diagnoses (27.3% vs. 12.7%, OR = 2.57, 95% CI: 1.159-5.69, p = 0.018) than those who did not develop infection. Antimicrobial resistance among the IAI was higher in the NI group (19.7 vs. 5.9%, OR = 3.93, 95% CI: 1.41-10.93, p = 0.006). Patients who developed NI had an increased mortality rate (27.0% vs. 4.0%, OR = 8.87, 95% CI: 2.82-27.86, p < or = 0.0001), longer hospital stay (24.7 +/- 19.5 vs. 11.7 +/- 8.1 days, p < or = 0.0001), required more days of intravenous antibiotics (11.5 +/- 8.0 vs. 7.6 +/- 4.4 days, p < or = 0.0001), and were more likely to be admitted to an intensive care unit (54.5% vs. 25.5%, OR = 3.51, 95% CI: 1.82-6.77, p < or = 0.0001). Multivariate analysis demonstrated that antimicrobial resistance and an APACHE II score of > or = 10 independently predicted the development of a nosocomial infection. Age >/= 50 years, APACHE II score > or = 10, or the presence of a NI independently predicted death. CONCLUSIONS: The development of NI following treatment of an IAI significantly affects mortality, hospital length of stay, and treatment. Early recognition and treatment of these infections, combined with strategies to prevent NI, may be important to improve outcomes in this patient population.     

Systemic warming as an adjunct to resuscitation in peritonitis: a pilot, randomized controlled trial

BACKGROUND: Bacterial peritonitis is accompanied by a high risk of sepsis and endotoxin production resulting in physiological derangements and a high mortality rate. Localized and systemic warming improves tissue perfusion, oxygen tension, and outcomes after surgery. The purpose of this study was to examine the effectiveness of systemic warming as an adjunct to standard antibiotic and fluid resuscitation in patients with peritonitis. METHODS: In this pilot randomized controlled trial, patients presenting with an acute abdomen were randomized into control and warmed groups using sequential envelopes. Local Ethics Committee approval was obtained. Systemic warming was delivered using the Inditherm warming mattress set at 40 degrees C. Standard oxygen, fluid resuscitation, and antibiotics were delivered simultaneously. Acute Physiology and Chronic Health Evaluation (APACHE) II scores were recorded on admission and 24 h later or just prior to surgery, whichever was earlier. RESULTS: Thirty-three patients were recruited. The APACHE II scores on admission were comparable (median 9.0 [range 2-23] and 9.0 [0-20], respectively, for the control and warmed groups (p = 0.70; Mann-Whitney U test)). No patient showed any adverse effects of warming. There were statistically significant improvements in APACHE II scores (p = 0.028; Wilcoxon signed ranks test) and the magnitude of its change (p = 0.048; Mann-Whitney U test) in the warmed group compared with the control group. CONCLUSIONS: Systemic warming may reduce physiological derangements and improve the prognosis in patients with intra-abdominal crisis. The technique may be used safely as an adjunct to standard resuscitation in peritonitis.     

Selective digestive decontamination: the light as changed from red to green

OBJECTIVES: To study the efficacy of selective digestive decontamination (SDD) for the prevention of nosocomial infections, particularly pneumonia, as well as its impact on the emergence of multiresistant bacteria. DATA SOURCES: Data collected from the Pubmed: original articles, review articles and editorial published on SDD. The keywords were: selective digestive decontamination, pneumonia, intensive care unit, infection. DATA SELECTION: Ten randomized clinical trials performed since 1995 in mechanically ventilated adult patients hospitalized in intensive care unit. RESULTS: The rationale for the use of SDD consists on the parenteral administration of a short course of antibiotic associated with the topical use of non-absorbable antibiotics directed against Gram negative bacteria. Five randomized studies described a reduction in the incidence of pneumonia associated with SDD. Only one study has showed a decrease in mortality rate. The other five studies, which present some methodological limitations, concluded the lack of efficacy of SDD. Regarding the emergence of multiresistant bacteria, the literature underlines the role of environment. The use of SDD seems to trigger the resistance in endemic areas, while these are softened in the units with a good control of their ecology. CONCLUSION: The data from the literature provide arguments to use SDD in targeted patient populations like multiple traumas in intensive care units, which have a low rate of multiresistant bacteria.     

APACHE II, data accuracy and outcome prediction

From review of 122 intensive care charts, Acute Physiology and Chronic Health Evaluation (APACHE) II points were determined for eight physiological values. Using a strict interpretation of APACHE II criteria, an average of 20.6% of these points were higher and 6.7% lower than the points entered originally into an intensive care database. The resulting 1.73 points mean increase in APACHE II score increased predicted mortality from 24.8% to 27.8% and decreased the mortality ratio (observed hospital deaths ÷ predicted deaths) from 1.52 (95% confidence interval: 1.11–2.03) to 1.35 (95% confidence interval: 0.99–1.81). There were few errors entering the data recorded on the audit form into the intensive care unit database with an optical mark reader and keyboard. Inaccuracy and inconsistency in data collection must be excluded before differences in mortality ratios are ascribed to intensive care unit performance.     

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.