Intensivmedizin bei älteren Patienten: Wie nützlich sind die Scoresysteme APACHE II und III?

OBJECTIVE: Scores like APACHE (Acute Physiology And Chronic Health Evaluation) were evaluated for unselected intensive care unit (ICU) admissions. Can they also be used for risk stratification and quality assurance in selected subgroups like elderly patients? METHODS: Over a 3-year period data of all admissions of a 12 bed interdisciplinary ICU were collected. APACHE II and III scores and probabilities of hospital deaths were compared with observed outcomes. The discriminatory power was evaluated by calculating the areas under the receiver operating characteristic (ROC) curves. Calibration was analyzed with standardized mortality ratios (SMR) and the Hosmer-Lemeshow goodness-of-fit statistic. RESULTS: Of 3382 admissions due to exclusion criteria, 2795 patients were analyzed, 1396 (49.9%) of these were > or = 65 years, mean age 75 (65-99) years. 62.5% were non-operative, 37.5% postoperative admissions, 35% after emergency operations. ICU mortality was 11.7%, hospital mortality 25.1%. The areas under the ROC curves were 0.77 for APACHE II and 0.79 for APACHE III (whole collective 0.83 and 0.85, respectively). The SMR was 1.17 for APACHE II and 1.23 for APACHE III compared with 1.06 and 1.22 for all patients, respectively. Calibration for elderly patients was insufficient for APACHE II (Hosmer-Lemeshow chi-square = 19, p < 0.025) as well as for APACHE III (chi-square = 41, p < 0.001), while it was good for all patients for APACHE II (chi-square = 12, p > 0.1) but not so for APACHE III (chi-square = 48, p < 0.001). CONCLUSIONS: APACHE II and III both show good discrimination for elderly patients although a little inferior than for all patients. Both scores can be used for risk stratification of elderly ICU patients. Mortality prognosis is not sufficient for geriatric patients although APACHE II calibrates well for all. Application of these scores for quality assurance in selected subgroups like elderly patients cannot be recommended based on these data.     

Negative fluid balance predicts survival in patients with septic shock: a retrospective pilot study

OBJECTIVE: We hypothesized that patients with septic shock who achieve negative fluid balance (< or =-500 mL) on any day in the first 3 days of management are more likely to survive than those who do not. DESIGN: Retrospective chart review. PATIENTS: Thirty-six patients admitted with the diagnosis of septic shock. SETTING: Twelve-bed medical ICU of a 300-bed community teaching hospital. METHODS: Medical records of 36 patients admitted to our medical ICU over a 21-month period were examined. Patients with septic shock who required dialysis prior to hospitalization were not included. A number of demographic and physiologic variables were extracted from the medical records. Admission APACHE (acute physiology and chronic health evaluation) II and daily sequential organ failure assessment (SOFA) scores were computed from the extracted data. Variables were compared between survivors and nonsurvivors and in patients who did vs those who did not achieve negative (< or = 500 mL) fluid balance in > or = 1 day of the first 3 days of management. Survival risk ratios (RRs) were used as the measure of association between negative fluid balance and survival. RRs were adjusted for age, APACHE II scores, SOFA scores on the first and third days, and the need for mechanical ventilation, by stratified analyses. RESULTS: Patients ranged in age from 16 to 85 years with a mean (+/- SE) age of 67.4 +/- 3.3 years. The mean admission APACHE II score was 25.4 +/- 1.4, and the day 1 SOFA score was 9.0 +/- 0.8. Twenty patients did not survive; nonsurvivors had higher mean APACHE II scores than survivors (29.8 vs 20.4, respectively) and higher first day SOFA scores than survivors (10.8 vs 6.9, respectively), and they were more likely to require vasopressors and mechanical ventilation compared to patients who survived. Whereas all 11 patients who achieved a negative balance of > 500 mL on > or = 1 of the first 3 days of treatment survived, only 5 of 25 patient who failed to achieve a negative fluid balance of > 500 mL by the third day of treatment survived (RR, 5.0; 95% CI, 2.3 to 10.9; p = 0.00001). At least 1 day of net negative fluid balance in the first 3 days of treatment strongly predicted survival across the strata of age, APACHE II scores, first- and third-day SOFA scores, the need for mechanical ventilation, and creatinine levels measured at admission. CONCLUSION: These results suggest that at least 1 day of negative fluid balance (< or = -500 mL) achieved by the third day of treatment may be a good independent predictor of survival in patients with septic shock. These findings suggest the hypothesis "that negative fluid balance achieved in any of the first 3 days of septic shock portends a good prognosis," for a larger prospective cohort study.     

Impact of ventilator-associated pneumonia on outcome in patients with COPD

PURPOSES: The aim of this study was to determine the impact of ventilator-associated pneumonia (VAP) on outcome in patients with COPD. METHODS: Prospective, observational, case-control study conducted in a 30-bed ICU during a 5-year period. All COPD patients who required intubation and mechanical ventilation (MV) for > 48 h were eligible. VAP diagnosis was based on clinical, radiographic, and quantitative microbiologic criteria. Patients with unconfirmed VAP were excluded, as well as patients with ventilator-associated tracheobronchitis without subsequent VAP. Matching (1:1) criteria included MV duration before VAP occurrence, age +/- 5 years, simplified acute physiology score II on ICU admission +/- 5, and ICU admission category. Variables associated with ICU mortality were determined using univariate and multivariate analyses. RESULTS: A total of 1,241 patients were eligible; 181 patients (14%) were excluded, including 133 patients for VAT and 48 patients for unconfirmed VAP. VAP developed in 77 patients (6%), and all were successfully matched. Pseudomonas aeruginosa was the most frequently isolated bacteria (31%). ICU mortality rate (64% vs 28%), duration of MV (24 +/- 15 d vs 13 +/- 11 d [+/- SD]), and ICU stay (26 +/- 17 d vs 15 +/- 13 d) were significantly (< 0.001) higher in case patients than in control patients. VAP was the only variable independently associated with ICU mortality (odds ratio [OR], 7.7; 95% confidence interval [CI], 3.2 to 18.6; p < 0.001). In VAP patients who received corticosteroids during their ICU stay compared with those who did not receive corticosteroids, mortality rate (50% vs 82%; OR, 1.8; 95% CI, 1.2 to 2.7; p = 0.002), duration of MV (21 +/- 14 d vs 27 +/- 16 d, p = 0.043), and ICU stay (22 +/- 16 d vs 31 +/- 18 d, p = 0.006) were significantly lower. CONCLUSION: VAP is associated with increased mortality rates and longer duration of MV and ICU stay in COPD patients.     

A randomized controlled trial of an antibiotic discontinuation policy for clinically suspected ventilator-associated pneumonia

OBJECTIVE: To evaluate an antibiotic discontinuation policy for clinically suspected ventilator-associated pneumonia (VAP). DESIGN: Prospective, randomized, controlled clinical trial. SETTING: A medical ICU from a university-affiliated urban teaching hospital. PATIENTS: Between April 2002 and July 2003, 290 patients completed the clinical trial. INTERVENTIONS: Patients were assigned to have the duration of antibiotic treatment for VAP determined by an antibiotic discontinuation policy (discontinuation group) or their treating physician teams (conventional group). RESULTS: Severity of illness using APACHE (acute physiology and chronic health evaluation) II score (22.8 +/- 9.0 vs 23.2 +/- 9.4, p = 0.683) [mean +/- SD] and the clinical pulmonary infection score (7.1 +/- 0.9 vs 7.2 +/- 0.9, p = 0.222) were similar for both patient groups. The duration of antibiotic treatment for VAP was statistically shorter among patients in the discontinuation group compared to patients in the conventional antibiotic management group (6.0 +/- 4.9 days vs 8.0 +/- 5.6 days, p = 0.001). The occurrence of a secondary episode of VAP was not statistically different between these two groups (17.3% vs 19.3%, p = 0.667). Hospital mortality (32.0% vs 37.1%, p = 0.357) and ICU length of stay (6.8 +/- 6.1 days vs 7.0 +/- 7.3 days, p = 0.798) were also statistically similar. CONCLUSIONS: The application of an antibiotic discontinuation policy for clinically suspected VAP was associated with a decrease in the overall duration of antibiotic treatment. These findings suggest that shorter courses of empiric antibiotic therapy for patients treated for clinically suspected VAP can be safely achieved.     

髓系细胞触发受体-1、降钙素原分别联合临床肺部感染评分对呼吸机相关性肺炎的诊断价值

目的探讨TREM-1、PCT分别联合CPIS在VAP中的诊断价值。方法选取2020年1月5月我院ICU收治的气管插管或气管切开接受有创机械通气治疗的住院患者156例,根据病情分为VAP组(66例)和非VAP组(90例),比较两组患者在机械通气后第1 d、3 d、7 d的血清TREM-1、PCT及CPIS间的差异。绘制ROC曲线评估血清TREM-1、PCT分别联合CPIS诊断VAP的应用价值。结果对两组患者TREM-1、PCT、CPIS进行重复测量方差分析显示:①TREM-1的时间效应、处理效应和交互效应均有统计学意义(F_时间=135.684,P<0.001;F_处理=577.117,P<0.001;F_交互=62.408,P<0.001);②PCT的时间效应、处理效应和交互效应均有统计学意义(F_时间=35.129,P<0.001;F_处理=158.284,P<0.001;F_交互=31.220,P<0.001);③CPIS的时间效应、处理效应和交互效应均有统计学意义(F_时间=14.445,P<0.001;F_处理=148.629,P<0.001;F_交互=4.968,P=0.008)。血清TREM-1、PCT和CPIS诊断VAP的AUC分别为0.977、0.907和0.922。而TREM-1+CPIS评分和PCT+CPIS评分联合诊断VAP的AUC分别为0.976和0.944,均明显高于3项指标的单独应用。结论TREM-1尤其是TREM-1+CPIS评分对机械通气患者早期诊断VAP具有优势,TREM-1+CPIS评分对评估VAP具有更高的诊断效能。     

Impact of disease severity on gastric residual volume in critical patients

AIM: To investigate whether illness severity has an impact on gastric residual volume (GRV) in medical critically ill patients. METHODS: Medical intensive care unit (ICU) patients requiring nasogastric feeding were enrolled. Sequential Organ Failure Assessment (SOFA) score was assessed immediately preceding the start of the study. Acute Physiology and Chronic Health Evaluation (APACHE) Ⅱ scores were recorded on the first, fourth, seventh, and fourteenth day of the study period. GRV was measured every 4 h du...     

外周血CD64指数对呼吸机相关性肺炎的早期诊断价值

目的： 探讨外周血CD64指数在呼吸机相关性肺炎(VAP)患者中的表达及早期诊断价值。方法：选取机械通气时间大于48 h的380例患者,根据是否发生VAP将其分为VAP组(78例)与非VAP组(302例);健康对照组为50例体检者。采用流式细胞术检测CD64,同时检测C-反应蛋白(CRP)及白细胞计数(WBC),记录临床肺部感染评分(CPIS)情况。分别比较各组患者外周血CD64指数及CRP、WBC水平的差异以及CD64指数水平与CPIS评分的相关性,评价外周血CD64指数水平对VAP患者的早期诊断价值。结果：VAP组CD64指数水平显著升高,与非VAP组和健康对照组比较,差异具有统计学意义(P<0.05);经过抗感染治疗后,VAP组患者外周血CD64指数、CRP、WBC水平及CPIS评分均较治疗前显著降低(P<0.05);相关性分析显示,外周血CD64指数与CPIS评分呈正相关(r=0.78,P<0.01)。ROC曲线分析显示,以外周血CD64指数>5.83为早期诊断VAP界限时,诊断VAP的敏感性和特异性分别为84.2%和89.8%,ROC曲线下面积(AUC)为0.865(95%CI 0.786~0.903)。结论： CD64在VAP患者中高表达,其可作为早期诊断VAP的有效指标,动态观察其水平变化对于判断感染程度及治疗效果具有重要的临床应用价值。     

临床肺部感染评分对呼吸机相关肺炎患者预后的评价

目的探讨临床肺部感染评分(CPIS)对早期呼吸机相关肺炎(VAP)患者治疗反应及预后的评价。方法对2002年1月至2005年12月入住呼吸重症监护室且资料完整的62例VAP患者,在出现呼吸机相关肺炎前3d及患病后第1、3、5、7天的CPIS分值进行分析。结果患病后第1天(7.2±1.5)、第3天(7.3±1.3)、第5天(7.0±2.1)和第7天(5.8±3.5)与患病前3d(3.3±1.1)的评分比较明显升高;死亡组患病后第1天(7.4±1.8)、第3天(7.7±1.5)、第5天(8.5±1.4)和第7天(8.9±1.4)与患病前3d(3.6±1.1)的评分比较明显升高;存活组患病后第1天(6.9±1.0)、第3天(6.9±1.1)、第5天(5.5±1.6)与患病前3d(3.1±1.1)的评分比较升高,第7天(2.7±1.8)显著下降。患病第5天CPIS>6分时,与存活患者相比病死率增高,其敏感性和特异性分别为96.8%和74.2%;CPIS分值与机械通气时间、住呼吸重症监护室时间和住院时间呈正相关(r值分别为0.526、0.449、0.519,P=0.00)。当接受充分治疗后,患病第5天CPIS轻度下降,而在没有充分的抗菌治疗时变化不明显。结论CPIS监测可早期预测VAP患者的病情、治疗效果及预后。     

Application of the sequential organ failure assessment score to cardiac surgical patients

OBJECTIVE: To assess the applicability of the sequential organ failure assessment (SOFA) score to cardiac surgical patients. DESIGN: Observational cohort study. SETTING: Adult cardiac surgical ICU. PATIENTS: Two hundred eighteen patients requiring ICU stay > 96 h. MEASUREMENTS AND RESULTS: The SOFA score was calculated daily until ICU discharge. Derived SOFA variables-total maximum SOFA (TMS), DeltaSOFA, maximum SOFA (maxSOFA), and DeltamaxSOFA-were considered. Length of ICU stay was 8.9 +/- 6.7 days (mean +/- SD). The mortality rate was 11.0% in the ICU and 15.6% in the hospital. Nonsurvivors had higher TMS, DeltaSOFA, single-organ system, and mean total scores on day 1 (9.8 +/- 2.5 vs 7.8 +/- 2.3, p < 0.05) and thereafter until day 10. The total SOFA score on the first 10 days of ICU stay, time, survival status, and their interaction were all significant (p < 0.001), with higher SOFA scores for nonsurvivors, and lower scores for survivors that decreased as the number of days from operation increased. Cardiovascular score on day 1 carried the highest relative risk of mortality among other systems (risk ratio [RR], 2.12; 95% confidence interval [CI], 1.31 to 3.45; p < 0.01), as did maximum cardiovascular score (RR, 2.81; 95% CI, 1.62 to 4.85; p < 0.001). A growing number of failing organs was associated with mortality, from the first to the sixth postoperative day (p < 0.05). Total score on day 1, TMS, DeltaSOFA, maxSOFA, and DeltamaxSOFA were reliable predictors of mortality with area under receiver operating characteristic curve of 0.71 (SE, 0.08), 0.89 (SE, 0.05), 0.86 (SE, 0.06), 0.88 (SE, 0.05), and 0.88 (SE, 0.06), respectively. Length of hospital stay was significantly associated (p = 0.05) to TMS and DeltaSOFA and not to other SOFA scores, age, or sex. CONCLUSIONS: The SOFA score may be used to grade the severity of postoperative morbidity in cardiac surgical patients without specific adaptations. The model identifies patients at increased risk for postoperative mortality.     

Septic shock of early or late onset: does it matter?

STUDY OBJECTIVES: To determine possible differences in morbidity and mortality between early and late onset of septic shock in ICU patients. DESIGN: Systematic data collection. SETTING: Thirty-one-bed, mixed, medicosurgical ICU in a university hospital. PATIENTS: All 65 patients who acquired septic shock after admission to the ICU between February 1999 and April 2000. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Forty-one of the 65 patients presented with septic shock within 24 h of admission to the ICU (early septic shock [ESS]); the other 21 patients acquired septic shock > 24 h after ICU admission (late septic shock [LSS]). Eleven patients had a second episode (7 patients in the ESS group, and 4 patients in the LSS group), and 1 patient in the LSS group had a third episode of septic shock. Patients with ESS had higher APACHE (acute physiology and chronic health evaluation) II (mean +/- SD, 26 +/- 6 vs 20 +/- 6; p = 0.002) and sequential organ failure assessment (SOFA) scores (11 +/- 3 vs 7 +/- 3, p < 0.001) on ICU admission, and a higher blood lactate concentration at the onset of shock (median 3.70 mEq/L; interquartile range, 2.6 to 6.6 mEq/L; vs median, 2.50 mEq/L [interquartile range, 1.8 to 4.0 mEq/L], p = 0.03) than patients with LSS. However, the duration of septic shock (median, 42 h [interquartile range, 21 to 97 h] vs median, 93 h [interquartile range, 32 to 241 h], p = 0.058) and the length of ICU stay after the onset of septic shock (median, 75 h; [interquartile range, 38 to 203 h] vs median, 321 h [interquartile range, 96 to 438 h], p = 0.018), was shorter in patients with ESS than patients with LSS. The ICU mortality rate was 63% (26 patients) in the ESS group, and 88% (21 patients) in the LSS group (p = 0.071). At the onset of the first episode of shock, patients with ESS had higher SOFA scores (11 +/- 3 vs 9 +/- 3, p = 0.045), lower pH (7.24 +/- 0.15 vs 7.33 +/- 0.12, p = 0.01), and were treated with higher doses of dopamine (median, 20 microg/kg/min [interquartile range, 14 to 20 microg/kg/min] vs median, 12 microg/kg/min [interquartile range, 8 to 20 microg/kg/min], p = 0.028) than patients with LSS. CONCLUSIONS: Septic shock is more severe when of early onset, as reflected by more severe organ dysfunction, greater lactic acidosis, and higher vasopressor requirements, yet the outcome is better, as reflected by a shorter duration of the shock episode, shorter ICU stay, and slightly lower mortality rates. These differences may influence clinical trials of therapeutic agents for sepsis, and should be taken into account when analyzing the results.     

Clinical importance of delays in the initiation of appropriate antibiotic treatment for ventilator-associated pneumonia

STUDY OBJECTIVES: To determine the influence of initially delayed appropriate antibiotic treatment (IDAAT) on the outcomes of patients with ventilator-associated pneumonia (VAP). SETTING: Medical ICU of Barnes-Jewish Hospital, St. Louis, a university-affiliated urban teaching hospital. PATIENTS: One hundred seven consecutive patients receiving mechanical ventilation and antibiotic treatment for VAP. INTERVENTIONS: Prospective patient surveillance and data collection. MEASUREMENTS AND RESULTS: All 107 patients eventually received treatment with an antibiotic regimen that was shown in vitro to be active against the bacterial pathogens isolated from their respiratory secretions. Thirty-three patients (30.8%) received antibiotic treatment that was delayed for >or= 24 h after initially meeting diagnostic criteria for VAP. These patients were classified as receiving IDAAT. The most common reason for the administration of IDAAT was a delay in writing the antibiotic orders (n = 25; 75.8%). The mean time (+/- SD) interval from initially meeting the diagnostic criteria for VAP until the administration of antibiotic treatment was 28.6 +/- 5.8 h among patients classified as receiving IDAAT, compared to 12.5 +/- 4.2 h for all other patients (p < 0.001). Forty-four patients (41.1%) with VAP died during their hospitalization. Increasing APACHE (acute physiology and chronic health evaluation) II scores (adjusted odds ratio, 1.13; 95% confidence interval, 1.09 to 1.18; p < 0.001), presence of malignancy (adjusted odds ratio, 3.20; 95% confidence interval, 1.79 to 5.71; p = 0.044), and the administration of IDAAT (adjusted odds ratio, 7.68; 95% confidence interval, 4.50 to 13.09; p < 0.001) were identified as risk factors independently associated with hospital mortality by logistic regression analysis. CONCLUSION: These data suggest that patients classified as receiving IDAAT are at greater risk for hospital mortality. Clinicians should avoid delaying the administration of appropriate antibiotic treatment to patients with VAP in order to minimize their risk of mortality.     

Application of the Sequential Organ Failure Assessment (SOFA) Score to Bacteremic ICU Patients

Abstract Background: Patients admitted to intensive care units (ICUs) are at a high risk of acquiring blood stream infections. We examined whether SOFA score on ICU admission and on the day of bacteremia can predict the occurrence of bacteremia and the outcome of bacteremic ICU patients. Patients and Methods: All patients admitted to a multidisciplinary ICU for more than 48 h from January 1, 2002 to December 31, 2004, were prospectively studied. Demographic, clinical and laboratory data were recorded on admission for all patients and additionally, on the day of the first bacteremic episode for those patients who developed bacteremia. Accordingly, APACHE II and SOFA scores were calculated on the same day. Results: A total of 185 patients developed one or more episodes of bacteremia, giving an incidence of 9.6 per 1,000 ICU days. The ICU mortality rate was 43.9% for bacteremic and 25.8% for the remaining patients (p < 0.001). Admission SOFA score was independently associated with the occurrence of bacteremia (OR = 1.20, 95% CI: 1.11–1.26, p < 0.001). Among bacteremic patients, SOFA score on the day of bacteremia was the only independent prognostic factor for outcome (OR = 1.44, 95% CI: 1.21–1.71, p < 0.001). When all patients were included in the multivariate analysis, admission SOFA (OR = 1.3, CI: 1.16–1.38, p < 0.001), APACHE II (OR = 1.1, CI: 1.02–1.11, p = 0.003) score and the presence of bacteremia (OR = 1.8, CI: 1.1–2.9, p = 0.023) were independently associated with the outcome. Conclusion: Admission SOFA score is independently associated with the occurrence of ICU-acquired bacteremia, whereas it is not sufficient to predict the outcome of patients who subsequently will develop this complication. However, SOFA score on the first day of bacteremia is an independent prognostic factor for outcome in these patients.     

PSI、APACHEⅡ和SOFA三种评分对医院获得性肺炎预后的评估价值

目的探讨PSI、APACHEⅡ和SOFA评分对医院获得性肺炎患者预后的判断价值以及年龄对SOFA评分效能的影响。 方法回顾性分析我院2016年1月至2017年12月收治的80例医院获得性肺炎患者的资料,其中未手术组医院获得性肺炎患者40例,围手术组医院获得性肺炎患者40例,用诊断为医院获得性肺炎的24 h内各项实验检查结果和生理参数最差值分别进行PSI、APACHEⅡ和SOFA评分。以30 d后是否存活作为预后指标,绘制受试者工作特征曲线(receiver operating characteristic curve, ROC),比较三种评分的差别。对SOFA评分在借鉴APACHⅡ年龄评分的基础上再次评分,比较SOFA评分在加权年龄前后评分效能的变化。 结果ROC曲线分析表明,三种评分均可预测医院获得性肺炎30 d病死率。40例未手术组医院获得性肺炎PSI、APACHEⅡ、SOFA曲线下面积分别为0.75、0.69、0.66。40例围手术组医院获得性肺炎PSI、APACHEⅡ、SOFA曲线下面积分别为0.87、0.64、0.70。80例医院获得性肺炎PSI、APACHEⅡ、SOFA曲线下面积分别为0.80、0.73、0.66。对SOFA评分进行年龄加权后,其40例未手术组医院获得性肺炎曲线下面积为0.75;40例围手术组医院获得性肺炎曲线下面积为0.75;80例医院获得性肺炎曲线下面积为0.72。 结论PSI评分能较好的评价医院获得性肺炎患者的预后,年龄对医院获得性肺炎的预后评价不容忽视。     

Effect on ICU mortality of a full-time critical care specialist

APACHE II scoring was obtained retrospectively on patients admitted to the ICU of a university hospital for two consecutive years. During the first year the patients were treated by their attending physician (group 1); during the second year, by a trained critical care specialist in cooperation with the attending physician (group 2). There were 223 patients in group 1 and 216 in group 2. The mean APACHE II scores were equivalent (group 1, 19.0 +/- 9.1 vs group 2, 18.3 +/- 8.2, p = NS). ICU mortality was reduced by 52 percent (group 1, 27.8 percent mortality vs group 2, 13.4 percent mortality p less than 0.01) and overall hospital mortality was reduced 31.0 percent (group 1, 35.5 percent vs group 2, 24.5 percent, p less than 0.01). No increased significance in ICU or hospital mortality reduction could be shown between subgroups of patients with APACHE II scores of 0 to 14, 15 to 24, and greater than 25. This retrospective analysis suggests that a full-time, trained critical care specialist may have made a significant impact on the management of critically ill patients at our institution.     

Morbid obesity in the medical ICU.

Study objective: To describe the clinical course, complications, and prognostic factors of morbidly obese patients admitted to the ICU compared to a control group of nonobese patients. DESIGN: A retrospective study. SETTING: Two university-affiliated hospitals. METHODS: We reviewed the medical records of 117 morbidly obese patients (body mass index >/= 40 kg/m(2)) admitted to the medical ICU between January 1994 and June 2000. Data collected included demographic information, comorbid condition, APACHE (acute physiology and chronic health evaluation) II score, invasive procedures, organ failure, and in-hospital mortality. RESULTS: Obstructive airway disease, pneumonia, and sepsis were the main reasons for admission to the ICU in the morbidly obese group. Sixty-one percent of the morbidly obese patients and 46% of the nonobese group required mechanical ventilation (p = 0.02). The mean lengths of mechanical ventilation and ICU stay were significantly longer for the morbidly obese group (7.7 +/- 9.6 days and 9.3 +/- 10.5 days vs 4.6 +/- 7.1 days and 5.8 +/- 8.2 days, respectively; p < 0.001). APACHE II scores were not significantly different in the two groups (19.1 +/- 7.6 and 20.6 +/- 12.2; p = 0.6). Overall mortality was 30% for the morbidly obese patients and 17% for the nonobese group (p = 0.019). By multivariate analysis, multiorgan failure (odds ratio [OR], 4.6; 95% confidence interval [CI], 2.1 to 16.6), PaO(2)/fraction of inspired oxygen < 200 for > 48 h (OR, 2.3; 95% CI, 1.2 to 7.8), and depressed left ventricular ejection fraction < 40% (OR, 1.4; 95% CI, 1.03 to 13.8) were independently associated with ICU mortality in the morbidly obese group. CONCLUSION: We conclude that critically ill morbidly obese patients are at increased risk of morbidity and mortality compared to the nonobese patients.     

Prognosis and outcome of 26 patients with systemic necrotizing vasculitis admitted to the intensive care unit

OBJECTIVES: To investigate presenting features, prognostic factors and outcomes of patients with systemic necrotizing vasculitis (SNV) admitted to the intensive care unit (ICU). METHODS: We retrospectively reviewed the medical records of all 210 SNV patients followed in our university hospital and admitted to the ICU between 1982 and 2001, with respect to clinical features, ICU disease severity scores (APACHE II and SAPS II), the Birmingham vasculitis activity score (BVAS), the five-factors score (FFS) and outcomes. RESULTS: Twenty-six patients (16 men, 10 women) with a mean age of 46.3+/-16.5 yr were included. The reasons for ICU admission were: active SNV, 20 (77%); infection, 3 (12%); others, 3 (12%). SNV was diagnosed in 11 (42%) patients in the ICU. The mean APACHE II and SAPS II scores were significantly higher for patients who died in the ICU (P = 0.01 and P = 0.01 respectively). After a mean follow-up of 31.4+/-29.2 months, the overall mortality rate was 39% (10 patients). Among patients admitted to the ICU with active SNV, BVAS calculated at ICU admission was significantly higher for non-survivors at the end of follow-up (26.9+/-13.0 vs 14.7+/-4.6, P = 0.02). CONCLUSION: The main reason for admitting SNV patients to the ICU was active vasculitis, which was often the first manifestation of SNV and led to its diagnosis. ICU disease severity scores at admission were associated with mortality in the ICU but did not predict long-term outcome, unlike BVAS, which accurately predicted long-term outcome but not ICU prognosis for patients admitted to the ICU with active SNV.     

Prognostic role of clinical and laboratory criteria to identify early ventilator-associated pneumonia in brain injury

BACKGROUND: We investigated the role of the clinical pulmonary infection score (CPIS), serum levels of procalcitonin (PCT), C-reactive protein (CRP), and serum amyloid A (SAA) in the detection of patients with early ventilator-associated pneumonia (VAP). METHODS: Observational study in a university hospital. In 58 patients with severe brain injury receiving mechanical ventilation, CPIS, PCT, CRP and SAA were evaluated at ICU entry and at days 3 to 4 of hospital stay for VAP diagnosis (confirmed by endotracheal aspirate or BAL cultures). RESULTS: We found the following: (1) PCT at entry was increased in patients who later had early VAP develop (25 patients) compared to no VAP (median, 1.4 ng/mL; 25-75 percentiles, 0.14-0.78; vs median, 0.2 ng/mL; 25-75 percentiles, 0.76-2.4, p<0.001; sensitivity, 76%; and specificity, 75%); (2) CPIS increased at the day of VAP diagnosis, compared to entry (median, 6.6+/-1.1 vs 1.5+/-1.1, p<0.001; sensitivity, 97%; specificity, 100%), while other serum inflammatory markers did not change; and (3) deterioration in oxygenation and changes in tracheal secretions were the main determinants of CPIS changes. CONCLUSIONS: PCT may be a useful marker to predict which patients subsequently have early VAP. The CPIS could help as an early way to detect the patients with early VAP and who need further diagnostic testing.     

两种评价急性肾衰竭患者预后及肾脏转归积分模型的比较

目的　比较急性生理和平素健康评估Ⅱ (APACHEⅡ )与急性肾小管坏死 个体严重程度指数 (ATN ISI)两种积分模型对急性肾衰竭 (ARF)患者的预后和肾脏转归的预示效果。方法　回顾性分析了近 1 0年的 42 2例ARF患者资料 ,比较两种积分模型对患者病死率及肾脏转归的预测效果 ,并采用两种积分评定方式对ARF发生 30、45、60d后的肾脏转归进行了判别分析。结果　随着两种模型积分值的增加 ,患者的病死率升高 ,当ATN ISI积分≥ 0 85、APACHEⅡ积分≥ 35时病死率为 1 0 0 % ;APACHEⅡ和ATN ISI模型的ROC曲线下的面积分别为 0 81 7± 0 0 2 1和 0 880± 0 0 1 8,表明两种模型对ARF患者病死率的判别均有意义。对肾脏转归的判别 ,ATN ISI在各评定时间的判别符合率均高于APACHEⅡ ;ATN ISI积分≥ 0 75时 ,均需依赖透析治疗 ;<0 75但≥ 0 58时 ,肾功能未恢复正常 ;肾功能完全恢复者积分值均在 0 58以内。APACHEⅡ积分≥ 2 6时 ,均需依赖透析治疗 ;<2 6时 ,肾功能完全恢复和肾功能不全病人之间无明显积分界限 ;但≤ 2 2时 ,上述二者所占比例分别为 80 4%和1 9 6 %。结论　两种积分模型对ARF患者的病死率及肾脏转归均有较好的预示效果 ,但ATN ISI积分模型对肾脏转归的预示价值更优于APACHEⅡ。     

ICU患者呼吸机相关肺部念珠菌感染的物种分布、药敏及患者死亡危险因素的分析

目的 呼吸机相关肺部念珠菌感染(VAPCI)是ICU患者死亡的重要因素之一,但目前数据有限。我们旨在通过研究了解梅州地区ICU VAPCI患者的流行病学,抗真菌治疗和患者死亡危险因素。方法 选择该地区3家三级医院2010年1月至2017年12月ICU中发生VAPCI的319例患者为研究对象,进行呼吸道标本培养,测定分离念珠菌菌株的抗菌敏感性,运用Logistic多元回归分析ICU VAPCI患者死亡的危险因素。结果 8年间ICU VAPCI的发生率为2.19%(319/14 597),病死率为53.29% (171/319); 319例患者分离共获得念珠菌菌株343株,其中白色念珠菌所占比例最高,达46.36%(159/343),其它依次为热带念珠菌、光滑念珠菌、近平滑念珠菌、克柔念珠菌和季也蒙念珠菌等非白念珠菌,合计占53.64%(184/343);药敏结果显示,6种念珠菌对5种常用抗真菌药物的敏感率除了光滑念珠菌对3种唑类药物敏感率略低于80%外,其他敏感率都高于80%,其中白色念珠菌的敏感率都高于90%;Logistic多元回归分析显示,年龄、恶性肿瘤、血清白蛋白、APACHEII评分、合并基础疾病≥ 3、导管留置时间和住ICU时间是VAPCI的独立的死亡危险因素;ROC分析显示,APACHEII评分大于19分和血清白蛋白低于或等于25 g/L是这两项独立危险因素的最佳预测值。结论 ICU VAPCI致病菌株以白色念珠菌为主,死亡率高,临床应重视对具备上述危险因素患者加强监测和真菌药敏监测,降低患者死亡率。     

Development and validation of a multivariate prediction model for patients with acute pancreatitis in Intensive Care Medicine

Background/objectives

Development and validation of a multivariate prediction model for patients with acute pancreatitis (AP) admitted in Intensive Care Units (ICU).