Usefulness of N-terminal pro-brain natriuretic peptide and C-reactive protein to predict ICU mortality in unselected medical ICU patients: a prospective, observational study

Introduction

The performance of N-terminal pro-brain natriuretic peptide (NT-proBNP) and C-reactive protein (CRP) to predict clinical outcomes in ICU patients is unimpressive. We aimed to assess the prognostic value of NT-proBNP, CRP or the combination of both in unselected medical ICU patients.

Methods

A total of 576 consecutive patients were screened for eligibility and followed up during the ICU stay. We collected each patient's baseline characteristics including the Acute Physiology and Chronic Health Evaluation II (APACHE-II) score, NT-proBNP and CRP levels. The primary outcome was ICU mortality. Potential predictors were analyzed for possible association with outcomes. We also evaluated the ability of NT-proBNP and CRP additive to APACHE-II score to predict ICU mortality by calculation of C-index, net reclassification improvement (NRI) and integrated discrimination improvement (IDI) indices.

Results

Multiple regression revealed that CRP, NT-proBNP, APACHE-II score and fasting plasma glucose independently predicted ICU mortality (all P < 0.01). The C-index with respect to prediction of ICU mortality of APACHE II score (0.82 ± 0.02; P < 0.01) was greater than that of NT-proBNP (0.71 ± 0.03; P < 0.01) or CRP (0.65 ± 0.03; P < 0.01) (all P < 0.01). As compared with APACHE-II score (0.82 ± 0.02; P < 0.01), combination of CRP (0.83 ± 0.02; P < 0.01) or NT-proBNP (0.83 ± 0.02; P < 0.01) or both (0.84 ± 0.02; P < 0.01) with APACHE-II score did not significantly increase C-index for predicting ICU mortality (all P > 0.05). However, addition of NT-proBNP to APACHE-II score gave IDI of 6.6% (P = 0.003) and NRI of 16.6% (P = 0.007), addition of CRP to APACHE-II score provided IDI of 5.6% (P = 0.026) and NRI of 12.1% (P = 0.023), and addition of both markers to APACHE-II score yielded IDI of 7.5% (P = 0.002) and NRI of 17.9% (P = 0.002). In the cardiac subgroup (N = 213), NT-proBNP but not CRP independently predicted ICU mortality and addition of NT-proBNP to APACHE-II score obviously increased predictive ability (IDI = 10.2%, P = 0.018; NRI = 18.5%, P = 0.028). In the non-cardiac group (N = 363), CRP rather than NT-proBNP was an independent predictor of ICU mortality.

Conclusions

In unselected medical ICU patients, NT-proBNP and CRP can serve as independent predictors of ICU mortality and addition of NT-proBNP or CRP or both to APACHE-II score significantly improves the ability to predict ICU mortality. NT-proBNP appears to be useful for predicting ICU outcomes in cardiac patients.     

Procalcitonin for early diagnosis and differentiation of SIRS,sepsis, severe sepsis,and septic shock

Objective To determine the value of procalcitonin (PCT) in the early diagnosis (and differentiation) of patients with SIRS, sepsis, severe sepsis, and septic shock in comparison to C-reactive protein (CRP), white blood cell and thrombocyte count, and APACHE-II score (AP-II). Design Prospective cohort study including all consecutive patients admitted to the ICU with the suspected diagnosis of infection over a 7-month period. Patients and methods A total of 185 patients were included: 17 patients with SIRS, 61 with sepsis, 68 with severe sepsis, and 39 patients with septic shock. CRP, cell counts, AP-II and PCT were evaluated on the first day after onset of inflammatory symptoms. Results PCT values were highest in patients with septic shock (12.89±4.39 ng/ml;P<0.05 vs patients with severe sepsis). Patients with severe sepsis had significantly higher PCT levels than patients with sepsis or SIRS (6.91±3.87 ng/ml vs 0.53±2.9 ng/ml;P<0.001, and 0.41±3.04 ng/ml;P<0.001, respectively). AP-II scores did not differ significantly between sepsis, severe sepsis and SIRS (19.26±1.62, 16.09±2.06, and 17.42±1.72 points, respectively), but was significantly higher in patients with septic shock (29.27±1.35,P<0.001 vs patients with severe sepsis). Neither CRP, cell counts, nor the degree of fever showed significant differences between sepsis and severe sepsis, whereas white blood cell count and platelet count differed significantly between severe sepsis and septic shock. Conclusions In contrast to AP-II, PCT appears to be a useful early marker to discriminate between sepsis and severe sepsis.     

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     

Serial measurement of Therapeutic Intervention Scoring System-28 (TISS-28) in a surgical intensive care unit

PurposeThe aim of the study was to assess the use of the Therapeutic Intervention Scoring System-28 (TISS-28) in surgical intensive care unit (ICU) patients and the relationship of the score to the type of surgery, severity of illness, and outcome in these patients.Materials and MethodsProspectively collected data from all patients admitted to a postoperative ICU between March 1, 2004, and June 30, 2006, were analyzed retrospectively.ResultsA total of 6903 patients were admitted during the study period (63.5% male; mean age, 62.3 years) constituting 29 140 observation days. The mean Simplified Acute Physiology Score (SAPS) II, Sequential Organ Failure Assessment (SOFA), and TISS-28 scores on the day of ICU admission were 36.9 ± 18.2, 5.8 ± 3.9, and 43.2 ± 10.8, respectively. The highest admission TISS-28 was observed in patients who underwent cardiothoracic surgery (47.7 ± 10.1), the lowest in neurosurgical patients (40 ± 9.6), and both declined during the 2 weeks after ICU admission; however, in trauma patients and those admitted after gastrointestinal surgery, TISS scores increased gradually after the first 2 to 5 days in the ICU. The TISS-28 score was moderately correlated to SAPS II (R² = 0.42; P < .001) and SOFA score (R² = 0.48; P < .001) throughout the ICU stay and was consistently higher in nonsurvivors than in survivors during the first 2 weeks in the ICU.ConclusionsThere are marked variations in TISS-28 scores according to the type of surgery. Therapeutic Intervention Scoring System-28 correlates with the severity of illness and outcome in these patients.     

Usefulness of RBC distribution width and C-reactive protein to predict mortality in pediatric non-cardiac critical illness

IntroductionWe aimed to assess the performance of red blood cell distribution width (RDW), C-reactive protein (CRP) or the combination of both to predict clinical outcomes in pediatric non-cardiovascular critical illness.Materials and methodsWe analyzed 404 pediatric non-cardiovascular critically ill patients admitted to pediatric intensive care unit (PICU). Potential predictors were identified using multivariable logistic regression. We also calculated the power of RDW and CRP additive to pediatric critical illness score (PCIS) to predict mortality with calculation of C-index value, integrated discrimination improvement (IDI) and net reclassification improvement (NRI) indices.ResultsRDW and CRP independently predicted PICU mortality. The C-index value of PCIS with respect to prediction of PICU mortality was greater than that of RDW and CRP. The combination of RDW or CRP or both with PCIS did significantly increase C-index value for predicting mortality (all p < 0.01). Addition of RDW or CRP or their combination to PCIS provided IDI of 7%, 1.1% and 9.4% (p = 0.009, 0.01 and 0.003) and NRI of 15.9%, 13.1% and 19.6% (p = 0.002, 0.043 and 0.002), respectively.ConclusionsIn pediatric non-cardiovascular critically ill patients, RDW and CRP could serve as independent predictors of PICU mortality and addition of RDW or CRP or both to PCIS significantly improves the ability to predict PICU mortality.     

A prospective study of fever in the intensive care unit

Objective: To determine the epidemiology of fever on the intensive care unit (ICU). Design: Prospective, observational study. Setting: Nine-bed general ICU in a 500-bed tertiary care inner city institution. Patients: 100 consecutive admissions of 93 patients over a 4-month period between July and October 1996. Interventions: All patients were seen and examined by one investigator within 24 h of ICU admission. Patients were followed up on a daily basis throughout their ICU stay, and all clinical and laboratory data were recorded during the admission. Measurements and results: Fever (core temperature ≥ 38.4 °C) was present in 70 % of admissions, and it was caused by infective and non-infective processes in approximately equal number. Most fevers occurred early in the course of the admission, within the first 1–2 days, and most lasted less than 5 days. The median Acute Physiology and Chronic Health Evaluation (APACHE) II score was 15 ( ± 0.6). The 70 episodes associated with fever at any time were associated with a significantly higher APACHE II score on admission than the afebrile episodes (15.8 ± 6.1 vs 12.1 ± 6.7, p = 0.04). The most common cause of non-infective fever was in the group designated post-operative fever (n = 34). All the patients in the post-operative fever group were febrile on day 0 or day 1; their mean admission APACHE score was 12.4 ( ± 4.4) compared to 15.9 ( ± 7.1) for the remaining patients (p = 0.01). Fever alone was not associated with a higher mortality: 26/70 (37 %) of febrile patients died, compared to 8/30 (27 %) of afebrile patients, (χ ² = 1.23, p = 0.38). Prolonged fever ( > 5 days) occurred in 16 patients. In 13 cases, fever was due to infection, and in the remaining 3 both infective and non-infective processes occurred concurrently. The mortality in the group with prolonged fever was 62.5 % (10/16) compared to 29.6 % (16/54) in patients with fever of less than 5 days' duration, a highly significant difference (p < 0.0001). Conclusions: Fever is a common event on the intensive care unit. It usually occurs early in the course, is frequently non-infective and is often benign. Prolonged fever is associated with a poor outcome. Post-operative fever is a well-recognised but poorly defined syndrome which requires further study. Received: 29 December 1998 Final revision received: 16 March 1999 Accepted: 14 April 1999     

Procalcitonin (PCT) is useful in predicting the bacterial origin of an acute circulatory failure in critically ill patients

Objective To evaluate the accuracy of procalcitonin (PCT) in predicting bacterial infection in ICU medical and surgical patients. Setting A 10-bed medical surgical unit. Design PCT, C-reactive protein (CRP), interleukin 6 (IL-6) dosages were sampled in four groups of patients: septic shock patients (SS group), shock without infection (NSS group), patients with systemic inflammatory response syndrome related to a proven bacterial infection (infect. group) and ICU patients without shock and without bacterial infection (control group). Results Sixty patients were studied (SS group:n=16, NSS group,n=18, infect. group,n=16, control group,n=10). The PCT level was higher in patients with proven bacterial infection (72±153 ng/ml vs 2.9±10 ng/ml,p=0.0003). In patients with shock, PCT was higher when bacterial infection was diagnosed (89 ng/ml±154 vs 4.6 ng/ml±12,p=0.0004). Moreover, PCT was correlated with severity (SAPS:p=0.00005, appearance of shock:p=0.0006) and outcome (dead: 71.3 g/ml, alive: 24.0 g/ml,p=0.006). CRP was correlated with bacterial infection (p<10⁻⁵) but neither with SAPS nor with day 28 mortality. IL-6 was correlated with neither infection nor day 28 mortality but was correlated with SAPS. Temperature and white blood cell count were unable to distinguish shocked patients with or without infection. Finally, when CRP and PCT levels were introduced simultaneously in a stepwise logistic regression model, PCT remained the unique marker of infection in patients with shock (PCT≥5 ng/ml, OR: 6.2, 95% CI: 1.1–37,p=0.04). Conclusion The increase of PCT is related to the appearance and severity of bacterial infection in ICU patients. Thus, PCT might be an interesting parameter for the diagnosis of bacterial infections in ICU patients.     

The impact of delirium on the prediction of in-hospital mortality in intensive care patients

Introduction  

Predictive models, such as acute physiology and chronic health evaluation II (APACHE-II), are widely used in intensive care units (ICUs) to estimate mortality. Although the presence of delirium is associated with a higher mortality in ICU patients, delirium is not part of the APACHE-II model. The aim of the current study was to evaluate whether delirium, present within 24 hours after ICU admission, improves the predictive value of the APACHE-II score.     

Relationship between thyroid function and ICU mortality: a prospective observation study

Introduction

Although nonthyroidal illness syndrome is considered to be associated with adverse outcome in ICU patients, the performance of thyroid hormone levels in predicting clinical outcome in ICU patients is unimpressive. This study was conducted to assess the prognostic value of the complete thyroid indicators (free triiodothyronine (FT3), total triiodothyronine; free thyroxine, total thyroxine, thyroid-stimulating hormone and reverse triiodothyronine) in unselected ICU patients.

Methods

A total of 480 consecutive patients without known thyroid diseases were screened for eligibility and followed up during their ICU stay. We collected each patient''s baseline characteristics, including the Acute Physiology and Chronic Health Evaluation II (APACHE II) score and thyroid hormone, N-terminal pro-brain natriuretic peptide (NT-proBNP) and C-reactive protein (CRP) levels. The primary outcome was ICU mortality. Potential predictors were analyzed for possible association with outcomes. We also evaluated the ability of thyroid hormones together with APACHE II score to predict ICU mortality by calculation of net reclassification improvement (NRI) and integrated discrimination improvement (IDI) indices.

Results

Among the thyroid hormone indicators, FT3 had the greatest power to predict ICU mortality, as suggested by the largest area under the curve (AUC) of 0.762 ± 0.028. The AUC for FT3 level was less than that for APACHE II score (0.829 ± 0.022) but greater than that for NT-proBNP level (0.724 ± 0.030) or CRP level (0.689 ± 0.030). Multiple regression analysis revealed that FT3 level (standardized β = -0.600, P = 0.001), APACHE II score (standardized β = 0.912, P < 0.001), NT-proBNP level (standardized β = 0.459, P = 0.017) and CRP level (standardized β = 0.367, P = 0.030) could independently predict primary outcome. The addition of FT3 level to APACHE II score gave an NRI of 54.29% (P < 0.001) and an IDI of 36.54% (P < 0.001). The level of FT3 was significantly correlated with NT-proBNP levels (r = -0.344, P < 0.001) and CRP levels (r = -0.408, P < 0.001).

Conclusion

In unselected ICU patients, FT3 was the most powerful and only independent predictor of ICU mortality among the complete indicators. The addition of FT3 level to the APACHE II score could significantly improve the ability to predict ICU mortality.     

Impact of obesity in mechanically ventilated patients: a prospective study

Objective  To analyze the influence of severe obesity on mortality and morbidity in mechanically ventilated intensive care unit (ICU) patients. Design  Prospective, multi-center exposed/unexposed matched epidemiologic study. Setting  Hospital setting. Patients  Severely obese patients (body mass index (BMI) ≥ 35 kg/m²), mechanically ventilated for at least 2 days were matched with unexposed nonobese patients (BMI < 30 kg/m²) for center, gender, age (±5 years), and the simplified acute physiology (SAPS) II score (±5 points). We recorded tracheal intubation, catheter placement, nosocomial infections, development of pressure ulcers, ICU and hospital outcome. Results  Eighty-two severely obese patients (mean BMI, 42 ± 6 kg/m²) were compared to 124 nonobese patients (mean BMI, 24 ± 4 kg/m²). The ICU course was similar in both the groups, except for the difficulties during tracheal intubation (15 vs. 6%) and post-extubation stridor (15% vs. 3%), which were significantly more frequent in obese patients (P < 0.05). The ICU mortality rate did not differ between obese and nonobese patients (24 and 25%, respectively); nor did the risk-adjusted hospital mortality rate (0.76, 95% confidence interval 0.41–1.16 in obese patients versus 0.82, 95% confidence interval 0.54–1.13 in nonobese patients). Conditional logistic regression confirmed that mortality was not associated with obesity. Conclusion  The only difference in morbidity of obese patients who were mechanically ventilated was increased difficulty with tracheal intubation and a higher frequency of post-extubation stridor. Obesity was not associated either with increased ICU mortality or with hospital mortality. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users. This article is discussed in the editorial available at doi: . The authors have no financial interest in any aspect of this report.     

C-reactive protein as a prognostic factor in intensive care admissions for sepsis: A Swedish multicenter study

PurposeC-reactive protein (CRP) is not included in the major intensive care unit (ICU) prognostic tools such as the Simplified Acute Physiology Score (SAPS). We assessed CRP on ICU admission as a SAPS-3 independent risk marker for short-term mortality and length of stay (LOS) in ICU patients with sepsis.Materials and methodsAdult ICU admissions satisfying the Sepsis-3 criteria to four southern Swedish hospitals were retrospectively identified and divided into a low CRP group (<100 mg/L) and a high CRP group (>100 mg/L) based on the admission CRP level. The standardized mortality ratio (SMR) was calculated.ResultsA total of 851 admissions were included. The SMR was higher in the high CRP group (0.85 vs. 0.67, P = .001 in the whole sepsis group and 0.85 vs. 0.59, P = .003 in the culture-positive subgroup). The CRP levels also correlated with ICU and hospital LOS in survivors (P < .001 and P = .002), again independent of SAPS-3.ConclusionAn admission CRP level >100 mg/L is associated with an increased risk of ICU and 30-day mortality as well as prolonged LOS in survivors, irrespective of morbidity measured with SAPS-3. Thus, CRP may be a simple, early marker for prognosis in ICU admissions for sepsis.     

Is C-reactive protein a good prognostic marker in septic patients?

Rationale  Several studies have shown that C-reactive protein (CRP) is a marker of infection. The aim of this study was to evaluate CRP as marker of prognosis outcome in septic patients and to assess the correlation of CRP with severity of sepsis. Methods  During a 14-month period, we prospectively included all patients with sepsis admitted to an intensive care unit (ICU). Patients were categorized into sepsis, severe sepsis and septic shock. Acute Physiology and Chronic Health Evaluation (APACHE) II score, Simplified Acute Physiology Score (SAPS) II, Sequential Organ Failure Assessment (SOFA) score, CRP, body temperature and white cell count (WCC) of the day of sepsis diagnosis were collected. Results  One hundred and fifty-eight consecutive septic patients (mean age 59 years, 98 men, ICU mortality 34%) were studied. The area under the receiver operating characteristics curves of APACHE II, SAPS II, SOFA, CRP, body temperature and WCC as prognostic markers of sepsis were 0.75 [95% confidence interval (CI) 0.67–0.83], 0.82 (95% CI 0.75–0.89), 0.8 (95% CI 0.72–0.88), 0.55 (95% CI 0.45–0.65), 0.48 (95% CI 0.38–0.58) and 0.46 (95% CI 0.35–0.56), respectively. In the subgroup of patients with documented sepsis we obtained similar results. The ICU mortality rate of septic patients with CRP < 10, 10–20, 20–30, 30–40 and >40 mg/dL was 20, 34, 30.8, 42.3 and 39.1%, respectively (P = 0.7). No correlation was found between CRP concentrations and severity of sepsis. Conclusions  In septic patients, CRP of the day of sepsis diagnosis is not a good marker of prognosis.     

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 ICU. Patients Eighty-five consecutive septic patients: 59 men and 26 women. Measurements and results Urinary 8-OHdG was analyzed using isotope-dilution liquid chromatography with tandem mass spectrometry (LC/MS/MS). ICU mortality in these 85 septic patients was 25.9% (n = 22) and hospital mortality 38.8% (n = 33). APACHE II scores of survivors on day 1, on day 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. The excretion of the urinary 8-OHdG, as measured using isotope-dilution LC/MS/MS, as the APACHE II score, were correlated with the outcome of critically septic patients in medical ICU. An erratum to this article can be found at     

Do Patients With COVID-19 Benefit from Rehabilitation? Functional Outcomes of the First 100 Patients in a COVID-19 Rehabilitation Unit

ObjectiveTo determine the benefits associated with brief inpatient rehabilitation for coronavirus 2019 (COVID-19) patients.DesignRetrospective chart review.SettingA newly created specialized rehabilitation unit in a tertiary care medical center.ParticipantsConsecutive sample of patients (N=100) with COVID-19 infection admitted to rehabilitation.InterventionInpatient rehabilitation for postacute care COVID-19 patients.Main Outcome MeasuresMeasurements at admission and discharge comprised a Barthel Activities of Daily Living Index (including baseline value before COVID-19 infection), time to perform 10 sit-to-stands with associated cardiorespiratory changes, and grip strength (dynamometry). Correlations between these outcomes and the time spent in the intensive care unit (ICU) were explored.ResultsUpon admission to rehabilitation, 66% of the patients were men, the age was 66±22 years, mean delay from symptom onset was 20.4±10.0 days, body mass index was 26.0±5.4 kg/m², 49% had hypertension, 29% had diabetes, and 26% had more than 50% pulmonary damage on computed tomographic scans. The mean length of rehabilitation stay was 9.8±5.6 days. From admission to discharge, the Barthel index increased from 77.3±26.7 to 88.8±24.5 (P<.001), without recovering baseline values (94.5±16.2; P<.001). There was a 37% improvement in sit-to-stand frequency (0.27±0.16 to 0.37±0.16 Hz; P<.001), a 13% decrease in post-test respiratory rate (30.7±12.6 to 26.6±6.1; P=.03), and a 15% increase in grip strength (18.1±9.2 to 20.9±8.9 kg; P<.001). At both admission and discharge, Barthel score correlated with grip strength (ρ=0.39-0.66; P<.01), which negatively correlated with time spent in the ICU (ρ=–0.57 to –0.49; P<.05).ConclusionsInpatient rehabilitation for COVID-19 patients was associated with substantial motor, respiratory, and functional improvement, especially in severe cases, although there remained mild persistent autonomy loss upon discharge. After acute stages, COVID-19, primarily a respiratory disease, might convert into a motor impairment correlated with the time spent in intensive care.     

L ONG-TERM A IR M EDICAL S ERVICES S YSTEM P ERFORMANCE U SING APACHE-II AND M ORTALITY B ENCHMARKING

Objective. Air medical transport programs have been in existence for two decades. During this time, no outcome measures have been developed for these services. The authors examined severity scoring and mortality data from their air medical service to characterize its performance and to identify trends in acuity and mortality over a 15-year period. Methods. APACHE-II scores derived at the time of transport and hospital mortality data have been concurrently recorded in the flight database for adult transports since 1986. The authors analyzed these data and examined the correlation between APACHE-II score at the time of transport and hospital mortality for the 15-year period 1986-2001. Results. 13,808 adult transports were identified. APACHE data were available for 8,204 patients (59%) and mortality for 10,845 (79%), respectively. The number of transports increased from 935 to 1,231 per year. Mean APACHE-II for all patients was 11.6 ± 8.4. Overall mortality was 22%. Both patient acuity and mortality were trending upward over time. The correlation between APACHE-II and mortality was close and linear (mortality = 0.018 ? APACHE-II - 0.0243, R² = 0.97). Conclusions. Both severity of illness and mortality of air-transported patients appear to be increasing slowly over time in response to changes in the health care system. The strong correlation between APACHE-II performed at the time of transport and mortality validates this technique for benchmarking. The slope of this correlation is an outcome-based characteristic of system performance that may allow monitoring of a system over time and comparisons between systems.     

Septic shock in patients with the acquired immunodeficiency syndrome

Objective: To evaluate the prognosis of patients with septic shock admitted to an intensive care unit (ICU), according to their HIV serostatus. Design: Retrospective study. Setting: Medical ICU of a university hospital. Patients: 76 patients with septic shock admitted to the same ICU, of whom 28 were HIV positive and 48 were HIV negative. Measurements and results: Severity scores, number and type of organ failures, and survival rates were assessed in the two groups of patients. Glasgow Coma Scale and general severity scores [Acute Physiology and Chronic Health Evaluation II and Simplified Acute Physiology Score (SAPS)] were significantly worse in HIV-infected patients. The total number of organ failures was also higher in the HIV-positive group: 3.7 ± 0.2 vs 3.1 ± 0.2 in the HIV-negative group (p < 0.001). On day 28, 21 (46 %) HIV-negative patients were dead compared to 26 (93 %) patients in the HIV-positive group (p < 0.001). In the multivariate analysis, HIV infection was an independent risk factor for mortality, as were the SAPS score, use of mechanical ventilation, and the McCabe score. Conclusions: This study reports a considerable excess mortality in HIV-infected patients with septic shock. Although severity of illness was clearly much more pronounced in HIV-positive patients, retroviral infection was independently associated with death. Improving survival in HIV-positive patients with septic shock may require earlier diagnosis and treatment of the causative infection. Received: 30 September 1996 Accepted: 8 July 1997     

Markers of inflammation as determinants of mortality in intensive care unit patients

In this study, the investigators explored the relationship between mortality rate and serum levels of C-reactive protein (CRP), erythrocyte sedimentation ratio (ESR), albumin, and hemoglobin, leukocyte, and platelet counts of patients at the time of first admission to the intensive care unit (ICU). A total of 123 patients were admitted to 2 different ICUs. In the emergency departments, serum levels of CRP, ESR, and albumin and hematologic parameters of 81 patients who died and 42 patients who survived were compared. A Studentt test and the χ² test were used for statistical analyses. Mean CRP and ESR levels and leukocyte counts were higher in nonsurvivor than in survivor groups (P<.001 for all). Additionally, serum CRP and ESR elevations and leukocyte counts were determined to be individually related to mortality (P<.001, P<.05, and P<.05, respectively). The investigators concluded that initial serum levels of CRP and ESR and leukocyte counts can be used as determinants of mortality in ICU patients.     

Combined cardiac surgical procedures in octogenarians: operative outcome

Introduction The number of patients with an indication for cardiac surgery in their ninth decade of life is increasing. This study analyses the single-center results with combined and redo cardiac surgical procedures in octogenarians retrospectively. Patients and methods Three groups were evaluated: (I) Two hundred and thirty six patients with combined cardiac surgical procedures, mean age 83.1 ± 2.5 years, 107 male (129 female). Combined aortic valve replacement (AVR) and aorto coronary bypass (ACB) was done in 215, double valve replacement (DVR) in 21. (II) AVR + ACB-group: 215 patients out of group I. (III) Control group consisting of 124 patients with a mean age of 74.1 ± 2.8 years (range 70–79.9 years) who received combined AVR and ACB. Risk stratification was done using the additive and logistic Euro-score; values are given as mean ± standard deviation and were compared using either the t-test or the Chi-square test. Results The observed mortality in group I was 9.3%. Re-intubation was observed in 10.2% and was one major risk factor for in-hospital mortality. As second risk factor, DVR could be identified. 14.8% required hemodialysis postoperatively, but this affected only the length of stay on intensive care unit (ICU) but not mortality. When comparing group II with group III, mortality was higher (10% vs. 4%), the need for hemodialysis was more frequent (16.3% vs. 4.9%), and the incidence of postoperative psycho-syndromes was also higher (26% vs. 8.1%, all: P < 0.05). The duration of ventilation (2.7 ± 7.7 vs. 1.6 ± 4.3 days) and the length of stay on ICU (8.2 ± 8.8 vs. 5.7 ± 6.4) were longer without reaching statistical significance (P > 0.05). The Euro-score overestimated the real mortality in all groups. Conclusions Octogenarians requiring combined cardiac surgical procedures required more resources and had a higher in-hospital mortality compared to younger patients. The observed in-hospital mortality was much lower than the predicted justifying the indication for surgical therapy in these patients. Patient selection, however, seems to be important but the Euro-score alone was rather ineffective in predicting poor outcome.     

Application of SOFA score to trauma patients

Objective: To assess the ability of the SOFA score (Sequential Organ Failure Assessment) to describe the evolution of organ dysfunction/failure in trauma patients over time in intensive care units (ICU). Design: Retrospective analysis of a prospectively collected database. Setting: 40 ICUs in 16 countries. Patients: All trauma patients admitted to the ICU in May 1995. Main outcome measures and results: Incidence of dysfunction/failure of different organs during the first 10 days of stay and the relation between the dysfunction, outcome, and length of stay. Included in the SOFA study were 181 trauma patients (140 males and 41 females).The non-survivors were significantly older than the survivors (51 years ± 20 vs 38 ± 16 years, p < 0.05) and had a higher global SOFA score on admission (8 ± 4 vs 4 ± 3, p < 0.05) and throughout the 10-day stay. On admission, the non-survivors had higher scores for respiratory ( > 3 in 47 % of non-survivors vs 17 % of survivors), cardiovascular ( > 3 in 24 % of non-survivors vs 5.7 % of survivors), and neurological systems ( > 4 in 41 % of non-survivors vs 16 % of survivors); although the trend was maintained over the whole study period, the differences were greater during the first 4–5 days. After the first 4 days, only respiratory dysfunction was significantly related to outcome. A higher SOFA score, admission to the ICU from the same hospital, and the presence of infection on admission were the three major variables associated with a longer length of stay in the ICU (additive regression coefficients: 0.85 days for each SOFA point, 4.4 for admission from the same hospital, 7.26 for infection on admission). Conclusions: The SOFA score can reliably describe organ dysfunction/failure in trauma patients. Regular and repeated scoring may be helpful for identifying categories of patients at major risk of prolonged ICU stay or death. Received: 3 March 1998 Accepted: 21 December 1998