Validation of four prognostic scores in patients with cancer admitted to Brazilian intensive care units: results from a prospective multicenter study

Objective

The aim of the present study was to validate the Simplified Acute Physiology Score II (SAPS II) and 3 (SAPS 3), the Mortality Probability Models III (MPM₀-III), and the Cancer Mortality Model (CMM) in patients with cancer admitted to several intensive care units (ICU).

Design

Prospective multicenter cohort study.

Setting

Twenty-eight ICUs in Brazil.

Patients

Seven hundred and seventeen consecutive patients (solid tumors 93%; hematological malignancies 7%) included over a 2-month period.

Interventions

None.

Measurements and main results

Discrimination was assessed by area under receiver operating characteristic (AROC) curves and calibration by Hosmer–Lemeshow goodness-of-fit test. The main reasons for ICU admission were postoperative care (57%), sepsis (15%) and respiratory failure (10%). The ICU and hospital mortality rates were 21 and 30%, respectively. When all 717 patients were evaluated, discrimination was superior for both SAPS II (AROC = 0.84) and SAPS 3 (AROC = 0.84) scores compared to CMM (AROC = 0.79) and MPM₀-III (AROC = 0.71) scores (P < 0.05 in all comparisons). Calibration was better using CMM and the customized equation of SAPS 3 score for South American countries (CSA). MPM₀-III, SAPS II and standard SAPS 3 scores underestimated mortality (standardized mortality ratio, SMR > 1), while CMM tended to overestimation (SMR = 0.48). However, using the SAPS 3 for CSA resulted in more precise estimations of the probability of death [SMR = 1.02 (95% confidence interval = 0.87–1.19)]. Similar results were observed when scheduled surgical patients were excluded.

Conclusions

In this multicenter study, the customized equation of SAPS 3 score for CSA was found to be accurate in predicting outcomes in cancer patients requiring ICU admission.     

High-volume versus standard-volume haemofiltration for septic shock patients with acute kidney injury (IVOIRE study): a multicentre randomized controlled trial

Purpose

Septic shock is a leading cause of death among critically ill patients, in particular when complicated by acute kidney injury (AKI). Small experimental and human clinical studies have suggested that high-volume haemofiltration (HVHF) may improve haemodynamic profile and mortality. We sought to determine the impact of HVHF on 28-day mortality in critically ill patients with septic shock and AKI.

Methods

This was a prospective, randomized, open, multicentre clinical trial conducted at 18 intensive care units in France, Belgium and the Netherlands. A total of 140 critically ill patients with septic shock and AKI for less than 24 h were enrolled from October 2005 through March 2010. Patients were randomized to either HVHF at 70 mL/kg/h or standard-volume haemofiltration (SVHF) at 35 mL/kg/h, for a 96-h period.

Results

Primary endpoint was 28-day mortality. The trial was stopped prematurely after enrolment of 140 patients because of slow patient accrual and resources no longer being available. A total of 137 patients were analysed (two withdrew consent, one was excluded); 66 patients in the HVHF group and 71 in the SVHF group. Mortality at 28 days was lower than expected but not different between groups (HVHF 37.9 % vs. SVHF 40.8 %, log-rank test p = 0.94). There were no statistically significant differences in any of the secondary endpoints between treatment groups.

Conclusions

In the IVOIRE trial, there was no evidence that HVHF at 70 mL/kg/h, when compared with contemporary SVHF at 35 mL/kg/h, leads to a reduction of 28-day mortality or contributes to early improvements in haemodynamic profile or organ function. HVHF, as applied in this trial, cannot be recommended for treatment of septic shock complicated by AKI.     

Simple translational equations to compare illness severity scores in intensive care trials

Purpose

Comparison of illness severity for intensive care unit populations assessed according to different scoring systems should increase our ability to compare and meta-analyze past and future trials but is currently not possible. Accordingly, we aimed to establish a methodology to translate illness severity scores obtained from one system into another.

Materials and methods

Using the Australian and New-Zealand intensive care adult patient database, we obtained simultaneous admission Acute Physiology and Chronic Health Evaluation (APACHE) II and APACHE III scores and Simplified Acute Physiology Score (SAPS) II in 634 428 patients admitted to 153 units between 2001 and 2010. We applied linear regression analyses to create models enabling translation of one score into another. Sensitivity analyses were performed after removal of diagnostic categories excluded from the original APACHE database, after matching for similar risk of death, after splitting data according to country of origin (Australia or New Zealand) and after splitting admissions occurring before or after 2006.

Results

The translational models were APACHE III = 3.08 × APACHE II + 5.75; APACHE III = 1.47 × SAPS II + 8.6; and APACHE II = 0.36 × SAPS II + 4.4. The area under the receiver operating curve for mortality prediction was 0.853 (95% confidence interval, 0.851-0.855) for the “APACHE II derived APACHE III” score and 0.854 (0.852-0.855) for the “SAPS II derived APACHE III” vs 0.854 (0.852-0.855) for the original APACHE III score. Similarly, it was 0.841 (0.839-0.843) for the “SAPS II derived APACHE II score” vs 0.842 (0.840-0.843) for the original APACHE II score. Correlation coefficients as well as intercepts remained very similar in all subgroups analyses.

Conclusions

Simple and robust translational formulas can be developed to allow clinicians to compare illness severity between studies involving critically ill patients. Further studies in other countries and health care systems are needed to confirm the generalizability of these results.     

Comparison between SAPS II and SAPS 3 in predicting hospital mortality in a cohort of 103 Italian ICUs. Is new always better?

Purpose

More recent severity scores should be more reliable than older ones because they account for the improvement in medical care over time. To provide more insight into this issue, we compared the predictive ability of the Simplified Acute Physiology Score (SAPS) II and SAPS 3 (originally developed from data collected in 1991–1992 and 2002, respectively) on a sample of critically ill patients.

Methods

This was a prospective observational study on 3,661 patients from 103 Italian intensive care units. Standardized mortality ratios (SMRs) were calculated. Assessment of calibration across risk classes was performed using the GiViTI calibration belt. Discrimination was evaluated by means of the area under the receiver operating characteristic analysis.

Results

Both scores were shown to discriminate fairly. SAPS 3 largely overpredicted mortality, more than SAPS II (SMR 0.63, 95?% CI 0.60–0.66 vs. 0.87, 95?% CI 0.83–0.91). This result was consistent and statistically significant across all risk classes for SAPS 3. SAPS II did not show relevant deviations from ideal calibration in the first two deciles of risk, whereas in higher-risk classes it overpredicted mortality.

Conclusions

Both scores provided unreliable predictions, but unexpectedly the newer SAPS 3 turned out to overpredict mortality more than the older SAPS II.     

Usefulness of open lung biopsy in mechanically ventilated patients with undiagnosed diffuse pulmonary infiltrates: influence of comorbidities and organ dysfunction

Background

The purpose of this study was to evaluate the clinical usefulness of open lung biopsy (OLB) in patients undergoing mechanical ventilation for diffuse pulmonary infiltrates of unknown etiology.

Methods

This was a 10-year retrospective study in a 10-bed medical intensive care unit. The medical records of 36 ventilator-dependent patients who underwent OLB for the diagnosis of unknown pulmonary infiltrates from 1994 to 2004 were reviewed retrospectively. Data analyzed included demographic data, Charlson age–comorbidity score, number of organ dysfunctions, Acute Physiology and Chronic Health Evaluation (APACHE) II, Simplified Acute Physiology Score (SAPS) II, Sequential Organ Failure Assessment (SOFA) score, ventilation variables, and radiological patterns. Diagnostic yield, effect on subsequent treatment changes, and complications of OLB were also assessed.

Results

A specific clinico-pathologic diagnosis was obtained for 31 patients (86%). The most common diagnoses were interstitial pneumonia (n = 17, including 8 acute interstitial pneumonia) and viral pneumonia (n = 4). Therapeutic modifications were made in 64% of patients. Patients who received OLB less than 1 week after initiation of mechanical ventilation were more likely to survive (63% versus 11%; P = 0.018). There were no major complications associated with the procedure. Factors independently associated with survival were the Charlson age-comorbidity score, number of organ dysfunction and the PaO₂/FiO₂ ratio on the day of the OLB.

Conclusion

OLB can provide a specific diagnosis in many ventilator-dependent patients with undiagnosed pulmonary infiltrate. Early OLB seems to be useful in critically ill patients with isolated respiratory failure.     

Predicting six-month mortality of patients with traumatic brain injury: usefulness of common intensive care severity scores

Introduction

The aim of this study was to evaluate the usefulness of the APACHE II (Acute Physiology and Chronic Health Evaluation II), SAPS II (Simplified Acute Physiology Score II) and SOFA (Sequential Organ Failure Assessment) scores compared to simpler models based on age and Glasgow Coma Scale (GCS) in predicting long-term outcome of patients with moderate-to-severe traumatic brain injury (TBI) treated in the intensive care unit (ICU).

Methods

A national ICU database was screened for eligible TBI patients (age over 15 years, GCS 3–13) admitted in 2003–2012. Logistic regression was used for customization of APACHE II, SAPS II and SOFA score-based models for six-month mortality prediction. These models were compared to an adjusted SOFA-based model (including age) and a reference model (age and GCS). Internal validation was performed by a randomized split-sample technique. Prognostic performance was determined by assessing discrimination, calibration and precision.

Results

In total, 1,625 patients were included. The overall six-month mortality was 33%. The APACHE II and SAPS II-based models showed good discrimination (area under the curve (AUC) 0.79, 95% confidence interval (CI) 0.75 to 0.82; and 0.80, 95% CI 0.77 to 0.83, respectively), calibration (P > 0.05) and precision (Brier score 0.166 to 0.167). The SOFA-based model showed poor discrimination (AUC 0.68, 95% CI 0.64 to 0.72) and precision (Brier score 0.201) but good calibration (P > 0.05). The AUC of the SOFA-based model was significantly improved after the insertion of age and GCS (∆AUC +0.11, P < 0.001). The performance of the reference model was comparable to the APACHE II and SAPS II in terms of discrimination (AUC 0.77; compared to APACHE II, ΔAUC −0.02, P = 0.425; compared to SAPS II, ΔAUC −0.03, P = 0.218), calibration (P > 0.05) and precision (Brier score 0.181).

Conclusions

A simple prognostic model, based only on age and GCS, displayed a fairly good prognostic performance in predicting six-month mortality of ICU-treated patients with TBI. The use of the more complex scoring systems APACHE II, SAPS II and SOFA added little to the prognostic performance.     

Platelet mitochondrial membrane depolarization reflects disease severity in patients with sepsis and correlates with clinical outcome

Introduction

Sepsis is still a leading cause of morbidity and mortality, even in modern times, and thrombocytopenia has been closely associated with unfavorable disease outcome. Decreases in mitochondrial membrane potential (depolarization) were found in different tissues during sepsis. Previous work suggests that mitochondrial dysfunction of platelets correlates with clinical disease activity in sepsis. However, platelet mitochondrial membrane potential (Mmp) has not been investigated in a clinical follow-up design and not with regard to disease outcome.

Methods

In this study, platelet mitochondrial membrane depolarization was assessed by means of a fluorescent Mmp-Index with flow cytometry in 26 patients with sepsis compared with control patients. Platelet Mmp-Index on admission was correlated with the clinical disease scores Acute Physiology and Chronic Health Evaluation Score II (APACHE II), Sequential Organ Failure Score (SOFA), and Simplified Acute Physiology Score II (SAPS II). Finally, platelet Mmp-Index on admission and follow-up were compared in the group of sepsis survivors and nonsurvivors. Expression of the prosurvival protein Bcl-xL in platelets was quantified by immunoblotting.

Results

Platelet mitochondrial membrane depolarization correlated significantly with the simultaneously assessed clinical disease severity by APACHE II (r = -0.867; P < 0.0001), SOFA (r = -0.857; P <0.0001), and SAPS II score (r = -0.839; P < 0.0001). Patients with severe sepsis showed a significant reduction in platelet Mmp-Index compared with sepsis without organ failure (0.18 (0.12 to 0.25) versus 0.79 (0.49 to 0.85), P < 0.0006) or with the control group (0.18 (0.12 to 0.25) versus 0.89 (0.68 to 1.00), P < 0.0001). Platelet Mmp-Index remained persistently low in sepsis nonsurvivors (0.269 (0.230 to 0.305)), whereas we observed recovery of platelet Mmp-Index in the survivor group (0.9 (0.713 to 1.017)). Furthermore, the level of prosurvival protein Bcl-xL decreased in platelets during severe sepsis.

Conclusion

In this study, we demonstrated that mitochondrial membrane depolarization in platelets correlates with clinical disease severity in patients with sepsis during the disease course and may be a valuable adjunct parameter to aid in the assessment of disease severity, risk stratification, and clinical outcome.     

Pharmacokinetics of prolonged infusion of high-dose dexmedetomidine in critically ill patients

Introduction

Only limited information exists on the pharmacokinetics of prolonged (> 24 hours) and high-dose dexmedetomidine infusions in critically ill patients. The aim of this study was to characterize the pharmacokinetics of long dexmedetomidine infusions and to assess the dose linearity of high doses. Additionally, we wanted to quantify for the first time in humans the concentrations of H-3, a practically inactive metabolite of dexmedetomidine.

Methods

Thirteen intensive care patients with mean age of 57 years and Simplified Acute Physiology Score (SAPS) II score of 45 were included in the study. Dexmedetomidine infusion was commenced by using a constant infusion rate for the first 12 hours. After the first 12 hours, the infusion rate of dexmedetomidine was titrated between 0.1 and 2.5 μg/kg/h by using predefined dose levels to maintain sedation in the range of 0 to -3 on the Richmond Agitation-Sedation Scale. Dexmedetomidine was continued as long as required to a maximum of 14 days. Plasma dexmedetomidine and H-3 metabolite concentrations were measured, and pharmacokinetic variables were calculated with standard noncompartmental methods. Safety and tolerability were assessed by adverse events, cardiovascular signs, and laboratory tests.

Results

The following geometric mean values (coefficient of variation) were calculated: length of infusion, 92 hours (117%); dexmedetomidine clearance, 39.7 L/h (41%); elimination half-life, 3.7 hours (38%); and volume of distribution during the elimination phase, 223 L (35%). Altogether, 116 steady-state concentrations were found in 12 subjects. The geometric mean value for clearance at steady state was 53.1 L/h (55%). A statistically significant linear relation (r ² = 0.95; P < 0.001) was found between the areas under the dexmedetomidine plasma concentration-time curves and cumulative doses of dexmedetomidine. The elimination half-life of H-3 was 9.1 hours (37%). The ratio of AUC_0-∞ of H-3 metabolite to that of dexmedetomidine was 1.47 (105%), ranging from 0.29 to 4.4. The ratio was not statistically significantly related to the total dose of dexmedetomidine or the duration of the infusion.

Conclusions

The results suggest linear pharmacokinetics of dexmedetomidine up to the dose of 2.5 μg/kg/h. Despite the high dose and prolonged infusions, safety findings were as expected for dexmedetomidine and the patient population.

Trial Registration

ClinicalTrials.gov: NCT00747721     

Impact of de-escalation therapy on clinical outcomes for intensive care unit-acquired pneumonia

Introduction

De-escalation therapy is a strategy currently used for the management of nosocomial pneumonia. In this study, we evaluated clinical outcomes and risk factors related to de-escalation therapy in patients with intensive care unit (ICU)-acquired pneumonia.

Methods

This was a retrospective observational cohort study of ICU patients who developed pneumonia more than 48 hours after admission to the ICU at Samsung Medical Center from September 2004 to December 2007.

Results

The 137 patients comprised 44 (32.1%) who received de-escalation therapy and 93 in the non-de-escalation group. The de-escalation group showed a lower pneumonia-related mortality rate than the non-de-escalation group by day 14 (2.3% vs. 10.8%, respectively; P = 0.08) and by day 30 (2.3% vs. 14%, respectively; P = 0.03) after the diagnosis of pneumonia. The variables independently associated with ICU-acquired pneumonia-related mortality included the Acute Physiology and Chronic Health Evaluation II (APACHE II) score and the modified Clinical Pulmonary Infection Score (CPIS) after 5 days with pneumonia. The non-de-escalation group had significantly higher APACHE II score and modified CPIS after 5 days with ICU-acquired pneumonia compared to the de-escalation group. Among all patients, 20.4% (28 of 137) had negative cultures for pathogens, and 42.9% (12 of 28) received de-escalation therapy. The latter 12 patients received de-escalation therapy and survived 30 days after the diagnosis of pneumonia.

Conclusions

Patients in the de-escalation group showed a significantly lower mortality rate compared to patients in the non-de-escalation group. De-escalation therapy can be safely provided to patients with ICU-acquired pneumonia if they are clinically stable by day 5, even in those whose respiratory specimen cultures yield no specific pathogens.     

间歇性高容量血液滤过对严重脓毒症炎症介质的影响

目的:探讨间歇性高容量血液滤过(PHVHF)对严重脓毒症血清中肿瘤坏死因子-α(TNF-α)、白介素-6(IL-6)和白介素10(IL-10)等炎症介质的影响,评价其治疗严重脓毒症的临床疗效。方法:2009年3月至2011年3月收住到温州医学附属第六医院的40例严重脓毒症患者纳入本研究,并随机分成对照组(常规治疗)和PHVHF组,PHVHF组患者入选后除接受常规治疗外,还接受72h的PHVHF治疗。在治疗前和治疗72h后收集血标本,检测血清中TNF-α、IL-6和IL-10炎症介质水平变化。同时进行急性生理和慢性健康状况评分(APACHEⅡ)、简化的急性生理评分(SAPSⅡ)和序贯器官功能衰竭评分(SOFA)。结果:经PHVHF治疗后,患者的病情和血流动力学指标明显改善。TNF-α、IL-6、IL-10浓度较治疗前明显下降(P<0.05)。相反,对照组上述指标却无明显变化(P>0.05)。结论:PHVHF治疗可以改善脓毒症患者的临床病情和血流动力学,有效地清除血浆炎症介质。因此,PHVHF是一种治疗严重脓毒症患者可行的辅助治疗模式。     

External validation of Acute Physiology and Chronic Health Evaluation IV in Dutch intensive care units and comparison with Acute Physiology and Chronic Health Evaluation II and Simplified Acute Physiology Score II

Purpose

The aim of this study was to validate and compare the performance of the Acute Physiology and Chronic Health Evaluation (APACHE) IV in the Dutch intensive care unit (ICU) population to the APACHE II and Simplified Acute Physiology Score (SAPS) II.

Materials and Methods

This is a prospective study based on data from a national quality registry between 2006 and 2009 from 59 Dutch ICUs. The validation set consisted of 62?737 patients; the 3 models were compared using 44?112 patients. Measures of discrimination, accuracy, and calibration (area under the receiver operating characteristic curve (AUC), Brier score, R², and ?-statistic) were calculated using bootstrapping. In addition, the standardized mortality ratios were calculated.

Results

The original APACHE IV showed good discrimination and accuracy (AUC = 0.87, Brier score = 0.10, R² = 0.29) but poor calibration (?-statistic = 822.67). Customization significantly improved the performance of the APACHE IV.The overall discrimination and accuracy of the customized APACHE IV were statistically better, and the overall ?-statistic was inferior to those of the customized APACHE II and SAPS II, but these differences were small in perspective of clinical use.

Conclusions

The 3 models have comparable capabilities for benchmarking purposes after customization. Main advantage of APACHE IV is the large number of diagnoses that enable subgroup analysis. The APACHE IV coronary artery bypass grafting (CABG) model has a good performance in the Dutch ICU population and can be used to complement the 3 models.     

Usefulness of a clinical diagnosis of ICU-acquired paresis to predict outcome in patients with SIRS and acute respiratory failure

Purpose

Neuromuscular abnormalities are common in ICU patients. We aimed to assess the incidence of clinically diagnosed ICU-acquired paresis (ICUAP) and its impact on outcome.

Methods

Forty-two patients with systemic inflammatory response syndrome on mechanical ventilation for ≥48 h were prospectively studied. Diagnosis of ICUAP was defined as symmetric limb muscle weakness in at least two muscle groups at ICU discharge without other explanation. The threshold Medical Research Council (MRC) Score was set at 35 (of 50) points. Activities in daily living were scored using the Barthel Index 28 and 180 days after ICU discharge.

Results

Three patients died before sedation was stopped. ICUAP was diagnosed in 13 of the 39 patients (33%). Multivariate regression analysis yielded five ICUAP-predicting variables (P < 0.05): SAPS II at ICU admission, treatment with steroids, muscle relaxants or norepinephrine, and days with sepsis. Patients with ICUAP had lower admission SAPS II scores [37 ± 13 vs. 49 ± 15 (P = 0.018)], lower Barthel Index at 28 days and lower survival at 180 days after ICU discharge (38 vs. 77%, P = 0.033) than patients without ICUAP. Daily TISS-28 scores were similar but cumulative TISS-28 scores were higher in patients with ICUAP (664 ± 275) than in patients without ICUAP (417 ± 236; P = 0.008). The only independent risk factor for death before day 180 was the presence of ICUAP.

Conclusions

A clinical diagnosis of ICUAP was frequently established in this patient group. Despite lower SAPS II scores, these patients needed more resources and had high mortality and prolonged recovery periods after ICU discharge.     

Training in data definitions improves quality of intensive care data

Background  

Our aim was to assess the contribution of training in data definitions and data extraction guidelines to improving quality of data for use in intensive care scoring systems such as the Acute Physiology and Chronic Health Evaluation (APACHE) II and Simplified Acute Physiology Score (SAPS) II in the Dutch National Intensive Care Evaluation (NICE) registry.     

Case mix,outcomes and comparison of risk prediction models for admissions to adult,general and specialist critical care units for head injury: a secondary analysis of the ICNARC Case Mix Programme Database

Introduction

This report describes the case mix and outcome (mortality, intensive care unit (ICU) and hospital length of stay) for admissions to ICU for head injury and evaluates the predictive ability of five risk adjustment models.

Methods

A secondary analysis was conducted of data from the Intensive Care National Audit and Research Centre (ICNARC) Case Mix Programme, a high quality clinical database, of 374,594 admissions to 171 adult critical care units across England, Wales and Northern Ireland from 1995 to 2005. The discrimination and calibration of five risk prediction models, SAPS II, MPM II, APACHE II and III and the ICNARC model plus raw Glasgow Coma Score (GCS) were compared.

Results

There were 11,021 admissions following traumatic brain injury identified (3% of all database admissions). Mortality in ICU was 23.5% and in-hospital was 33.5%. Median ICU and hospital lengths of stay were 3.2 and 24 days, respectively, for survivors and 1.6 and 3 days, respectively, for non-survivors. The ICNARC model, SAPS II and MPM II discriminated best between survivors and non-survivors and were better calibrated than raw GCS, APACHE II and III in 5,393 patients eligible for all models.

Conclusion

Traumatic brain injury requiring intensive care has a high mortality rate. Non-survivors have a short length of ICU and hospital stay. APACHE II and III have poorer calibration and discrimination than SAPS II, MPM II and the ICNARC model in traumatic brain injury; however, no model had perfect calibration.

     

Acute kidney injury in critically ill patients with 2009 influenza A (H1N1) viral pneumonia: an observational study

Objective

To describe the incidence, risk factors, and impact on mortality of acute kidney injury (AKI) in patients with 2009 influenza?A (H1N1) viral pneumonia requiring mechanical ventilation.

Design

Observational cohort study.

Patients and methods

AKI was defined as risk, injury or failure, according to the RIFLE classification. Early and late AKI were defined as AKI occurring on intensive care unit (ICU) day?2 or before, or after ICU day?2, respectively. Demographic data and information on organ dysfunction were collected daily.

Results

Of 84 patients, AKI developed in 43 patients (51%). Twenty (24%) needed renal replacement therapy. Early and late AKI were found in 28 (33%) and 15 (18%) patients, respectively. Patients with AKI, as compared with patients without AKI, had higher Acute Physiology and Chronic Health Evaluation (APACHE)?II score and ICU mortality (72% versus 39%, p?<?0.01) and presented on admission more marked cardiovascular, respiratory, and hematological dysfunction. Patients with early but not late AKI presented on admission higher APACHE?II score and more marked organ dysfunction, as compared with patients without AKI. ICU mortality was higher in late versus early AKI (93% versus 61%, p?<?0.001). On multivariate analysis, only APACHE?II score and late but not early AKI [odds ratio (OR) 1.1 (95% confidence interval 1.0?C1.1) and 15.1 (1.8?C130.7), respectively] were associated with mortality.

Conclusions

AKI is a frequent complication of 2009 influenza?A (H1N1) viral pneumonia. AKI developing after 2?days in ICU appears to be associated with different risk factors than early AKI, and is related to a higher mortality rate.     

Diagnostic role of soluble triggering receptor expressed on myeloid cell-1 in patients with sepsis

BACKGROUND:

Biomarkers may be helpful in risk stratification and prediction of mortality in septic patients. This study aimed to investigate the diagnostic role of soluble triggering receptor expressed on myeloid cell-1(sTREM-1), procalcitonin (PCT), C-reactive protein (CRP) and other inflammatory markers in patients with sepsis.

METHODS:

A total of 56 patients with systemic inflammation response syndrome (SIRS) who had been admitted to the ICU department of the Second Hospital of Tianjin Medical University between May 2009 and July 2010 were enrolled. They were divided into a sepsis group (n=32) and a SIRS group (n=24). Twenty-five non-SIRS patients served as controls. The sepsis group was sub-divided into a survival group and a death group according to 28-day prognosis. The values of sTREM-1, PCT, CRP, white blood cell (WBC), and neutrophil count percentage (N) were measured. Acute physiology and chronic health evaluation II (APACHE II) score were determined within 24 hours. The correlation between sTREM-1 and APACHE II score was analyzed. Quantitative data were analyzed by the F test or the Kruskal-Wallis test.

RESULTS:

The plasma level of sTREM-1 in the sepsis group was significantly higher than that in the SIRS group and control group. The plasma level of sTREM-1 in the non-survival group was significantly higher than that in the survival group. In the sepsis group, the plasma sTREM-1 level was positively correlated with APACHE II score (r=0.426, P= 0.032). The area under the ROC curve of sTREM-1 was 0.935, larger than that of PCT and CRP.

CONCLUSION:

Plasma sTREM-1 is useful in the diagnosis of sepsis at early stage. The increased level of sTREM-1 during the first 24 hours may be correlated with poor outcome of patients with sepsis.KEY WORDS: Sepsis, sTREM-1, Acute physiology and chronic health evaluation II score, Enzyme-linked immunosorbent assay, Procalcitonin, C-reactive protein     

Diagnostic value and prognostic evaluation of Presepsin for sepsis in an emergency department

Introduction

Presepsin levels are known to be increased in sepsis. The aim of this study was to evaluate the early diagnostic and prognostic value of Presepsin compared with procalcitonin (PCT), Mortality in Emergency Department Sepsis (MEDS) score and Acute Physiology and Chronic Health Evaluation II (APACHE II) score in septic patients in an emergency department (ED) and to investigate Presepsin as a new biomarker of sepsis.

Methods

This study enrolled 859 consecutive patients with at least two diagnostic criteria for systemic inflammatory response syndrome (SIRS) who were admitted to Beijing Chao-yang Hospital ED from December 2011 to October 2012, and 100 age-matched healthy controls. Patients were stratified into four groups: SIRS, sepsis, severe sepsis, and septic shock. Plasma Presepsin and serum PCT were measured, and MEDS score and APACHE II score were calculated at enrollment. Comparisons were analyzed using the Kruskal-Wallis and Mann–Whitney U tests.

Results

On admission, the median levels of plasma Presepsin increased with sepsis severity. The areas under the receiver operating characteristic (AUC) curves of Presepsin were greater than those of PCT in diagnosing sepsis, and predicting severe sepsis and septic shock. The AUC of Presepsin for predicting 28-day mortality in septic patients was slightly lower than that of PCT, MEDS score and APACHE II score. The AUC of a combination of Presepsin and MEDS score or APACHE II score was significantly higher than that of MEDS score or APACHE II score alone in predicting severe sepsis, and was markedly higher than that of Presepsin alone in predicting septic shock and 28-day mortality in septic patients, respectively. Plasma Presepsin levels in septic patients were significantly higher in non-survivors than in survivors at 28 days’ follow-up. Presepsin, MEDS score and APACHE II score were found to be independent predictors of severe sepsis, septic shock and 28-day mortality in septic patients. The levels of plasma Presepsin were positively correlated with PCT, MEDS score and APACHE II score in every septic group.

Conclusion

Presepsin is a valuable biomarker for early diagnosis of sepsis, risk stratification, and evaluation of prognosis in septic patients in the ED.     

Effect of corticosteroids on arginine vasopressin–containing vasopressor therapy for septic shock: a case control study

Purpose

Studies showing corticosteroids decrease time to shock reversal in septic shock did not include arginine vasopressin, which also may reduce the duration of catecholamine therapy. Thus, the effect of corticosteroids on vasopressin-containing vasopressor regimens is unknown. We designed this study to evaluate the effect of corticosteroids on time to vasopressin-containing vasopressor withdrawal and the proportion of patients alive without vasopressors at day 7.

Methods

This retrospective, case-control study included patients admitted to the intensive care units of an academic medical center who received vasopressin-containing vasopressor regimens for septic shock with or without concomitant corticosteroids. Twenty-one corticosteroid-treated patients were matched to those without corticosteroids.

Results

Both groups had similar Acute Physiology And Chronic Health Evaluation (APACHE) II, Simplified Acute Physiology Score (SAPS) II, and Sequential Organ Failure Assessment (SOFA) scores. There was no significant difference in median time to vasopressor withdrawal (65 hours vs 20 hours, P = .09) whether corticosteroids were given or withheld. Patients who received corticosteroids, however, were significantly more likely alive without vasopressors at day 7 than patients who received a vasopressin-containing vasopressor regimen alone (80.9% vs 47.6%, P = .02).

Conclusions

Although corticosteroids did not improve the time to withdrawal of vasopressin-containing vasopressor therapy they significantly increased the proportion of patients alive without vasopressors at day 7.     

Quality of life of survivors from severe sepsis and septic shock may be similar to that of others who survive critical illness

Introduction

The objective of the present study was to compare the health-related quality of life (HR-QoL) of survivors from severe sepsis and septic shock with HR-QoL in others who survived critical illness not involving sepsis.

Methods

From March 1997 to March 2001, adult patients in an eight-bed medical/surgical intensive care unit (ICU) of a tertiary care hospital admitted with severe sepsis or septic shock (sepsis group; n = 305) were enrolled and compared with patients admitted without sepsis (control group; n = 392). Patients younger than 18 years (n = 48) and those whose ICU stay was 1 day or less (n = 453) were excluded. In addition, patients exhibiting nonsevere sepsis on admission were excluded (n = 87). Finally, patients who developed nonsevere sepsis or severe sepsis/septic shock after admission were also excluded (n = 88).

Results

In-hospital mortality rates were 34% in the sepsis group and 26% in the control group. There were no differences in sex, age, main activity (work status), and previous health state between groups. Survivors in the sepsis group had a significantly higher Acute Physiology and Chronic Health Evaluation II score on admission (17 versus 12) and stayed significantly longer in the ICU. A follow-up appointment was held 6 months after ICU discharge, and an EQ-5D (EuroQol five-dimension) questionnaire was administered. A total of 104 sepsis survivors and 133 survivors in the control group answered the EQ-5D questionnaire. Sepsis survivors reported significantly fewer problems only in the anxiety/depression dimension. Although there were no significant differences in the other dimensions of the EQ-5D, there was a trend towards fewer problems being reported by sepsis survivors.

Conclusion

Evaluation using the EQ-5D at 6 months after ICU discharge indicated that survivors from severe sepsis and septic shock have a similar HR-QoL to that of survivors from critical illness admitted without sepsis.     

Heparin clearance during continuous veno-venous haemofiltration

Objective

To determine whether premature clotting of haemofiltration circuits could be related to heparin removal across the filter membrane into the ultrafiltrate.

Design

Randomised study using either unfractionated (n=8) or low molecular weight (n=7) heparin for anticoagulation of the haemofiltration circuit at 1000 and 600U/h respectively. Samples were drawn at 1 and 2 h from arterial and venous limbs of the haemofilter circuit for measurement of plasma heparin (as anti-Factor Xa activity), antithrombin III and haematocrit. Ultrafiltrate samples were collected at the same time for measurement of anti-Xa activity.

Setting

Intensive care unit.

Patients

Patients in acute renal failure requiring haemofiltration.

Results

Both unfractionated and low molecular weight heparin plasma levels were within the range required for therapeutic anticoaguation in all but one patient at 2 h. Ultrafiltrate anti-Xa levels were insignificant. Antithrombin III levels in these critically ill patients were subnormal in 11 of the 15 studies.

Conclusions

Despite their small sizes, neither unfractionated nor low molecular weight heparins cross the haemofilter membrane into the ultrafiltrate in any measurable quantity. Both heparins were present in plasma at a level suitable for therapeutic anticoagulation. Subnormal levels of antithrombin III may be an important factor in determining filter longevity.