冠脉搭桥病人术后器官功能评分和预后分析

目的　采用序贯器官衰竭估计 (SOFA)评价急诊和择期冠状动脉搭桥 (CABG)术后的器官功能并对预后进行分析。方法　急诊CABG和择期CABG病人各 4 2例 ,进行回顾性分析。根据SOFA评分标准 ,确定术后在重症监护病房 (ICU)期间每天的器官功能评分 ,比较两组病人SOFA总分 (totalSOFAscore) ,分析总的最高SOFA评分 (TMS)以及各器官最差SOFA评分与预后的关系。结果　急诊组的死亡率高于择期组 (P <0 0 5 )。急诊组术后前 5d的SOFA总分均高于择期组 (P <0 0 1) ,死亡病例的TMS、除肝脏外的器官最差评分均高于存活病例 (P <0 0 5或 P <0 0 1) ,Logistic回归分析发现呼吸、心血管和中枢神经系统与死亡相关 (P <0 0 1)。急诊组存活病例的TMS高于择期组 (P <0 0 1) ,心血管支持时间和ICU停留时间较长 (P <0 0 5或P <0 0 1)。存活病例的ICU停留时间和TMS之间存在相关性 ,相关系数为 0 4 5 2 (P <0 0 1)。结论　SOFA是反映CABG病人预后的指标。急诊CABG术后器官功能评分较高 ,预后较差 ,与呼吸、心血管和中枢神经系统功能障碍有关。     

Predictive accuracy of severity scoring system: a prospective cohort study using APACHE III in a Korean intensive care unit

AIM: To evaluate the discrimination, calibration, and uniformity of fit by age group, operative status, and location before ICU admission of APACHE III in a single-center ICU population. DESIGN AND SETTING: Prospective data collection in a 25 bed mixed (surgical and medical) ICU of 850-bed teaching hospital in Pusan, South Korea. SUBJECTS AND METHODS: The worst values on APACHE III variables during 24h following ICU admission were collected from the patient's charts and clinical flow sheets of 284 consecutively admitted subjects. RESULTS: The mortality rate was 31.0%, and showed a strong positive correlation between APACHE III score (r=0.97, p<0.0001 for entire population, r=0.97, p<0.0001 for medical patients, r=0.91, p<0.0001 for surgical patients). Hospital mortality was significantly higher for medical patients than surgical patients (OR=7.23, 95% CI=3.76-13.88), and for patients located in the operating room than at ward before admitting ICU (OR=0.09, 95% CI=0.04-0.23). At the predicted risk of 0.5 (66 of APACHE III score), sensitivity was 0.72, specificity 0.91, and correct classification rate 0.85. Area under the ROC curve was 0.905 (95% CI=0.867-0.943). Correlation coefficient (r) between observed and expected mortality rate was 0.99. The value (chi-square) of Lemeshow-Hosmer (L-H) goodness-of-fit statistic was 6.54 (p=0.59). In patients stratified according to age groups, operative status, and location in the hospital before ICU admission, discrimination was generally good in all subgroups (area under the ROC curve >0.85), and the chi-squared of L-H goodness-of -fit statistic showed a good fit for all subgroup, especially for operative status. CONCLUSIONS: The predictive accuracy of the APACHE III scoring system showed better discrimination, as well as uniformity of fit. So, it was thought that could be utilized for the subject hospital.     

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     

Impact of adequate empirical antibiotic therapy on the outcome of patients admitted to the intensive care unit with sepsis

OBJECTIVES: Our primary goal was to evaluate the impact on in-hospital mortality rate of adequate empirical antibiotic therapy, after controlling for confounding variables, in a cohort of patients admitted to the intensive care unit (ICU) with sepsis. The impact of adequate empirical antibiotic therapy on early (<3 days), 28-day, and 60-day mortality rates also was assessed. We determined the risk factors for inadequate empirical antibiotic therapy.DESIGN Prospective cohort study. SETTING: ICU of a tertiary hospital. PATIENTS: All the patients meeting criteria for sepsis at admission to the ICU. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Four hundred and six patients were included. Microbiological documentation of sepsis was obtained in 67% of the patients. At ICU admission, sepsis was present in 105 patients (25.9%), severe sepsis in 116 (28.6%), and septic shock in 185 (45.6%). By multivariate analysis, predictors of in-hospital mortality were Sepsis-related Organ Failure Assessment (SOFA) score at ICU admission (odds ratio [OR], 1.29; 95% confidence interval [CI], 1.19-1.40), the increase in SOFA score over the first 3 days in the ICU (OR, 1.40; 95% CI, 1.19-1.65), respiratory failure within the first 24 hrs in the ICU (OR, 3.12; 95% CI, 1.54-6.33), and inadequate empirical antimicrobial therapy in patients with "nonsurgical sepsis" (OR, 8.14; 95% CI, 1.98-33.5), whereas adequate empirical antimicrobial therapy in "surgical sepsis" (OR, 0.37; 95% CI, 0.18-0.77) and urologic sepsis (OR, 0.14; 95% CI, 0.05-0.41) was a protective factor. Regarding early mortality (<3 days), factors associated with fatality were immunosuppression (OR, 4.57; 95% CI, 1.69-13.87), chronic cardiac failure (OR, 9.83; 95% CI, 1.98-48.69) renal failure within the first 24 hrs in the unit (OR, 8.63; 95% CI, 3.31-22.46), and respiratory failure within the first 24 hrs in the ICU (OR, 12.35; 95% CI, 4.50-33.85). Fungal infection (OR, 47.32; 95% CI, 5.56-200.97) and previous antibiotic therapy within the last month (OR, 2.23; 95% CI, 1.1-5.45) were independent variables related to administration of inadequate antibiotic therapy. CONCLUSIONS: In patients admitted to the ICU for sepsis, the adequacy of initial empirical antimicrobial treatment is crucial in terms of outcome, although early mortality rate was unaffected by the appropriateness of empirical antibiotic therapy.     

不同时点序贯器官衰竭评估评分对重症医学科患者院内死亡的预测价值比较

目的比较不同时点序贯器官衰竭评估（SOFA）评分对重症医学科（ICU）患者院内死亡的预测价值,以期为实际临床工作中合理选用SOFA评分指标提供一定的研究证据。 方法从美国重症监护数据库中选择住院时间>72 h的成年ICU患者,提取其基本信息与相关检验指标并计算不同时点SOFA评分,以院内死亡为结局指标,采用多因素Logistic回归分析不同时点SOFA评分与院内死亡的关联,绘制受试者工作特征（ROC）曲线并计算曲线下面积（AUC）以评价各指标的预后预测价值。 结果共有11 968例患者纳入最终分析,其中男性患者占56.15%,平均年龄为（64.75±16.63）岁,院内病死率为10.41%（1246/11 968）。多因素Logistic回归分析显示不同时点SOFA评分均与院内死亡密切相关（P均<0.0001）,ROC曲线分析显示不同时点SOFA评分预测院内死亡的能力存在差异,以T₇₂最高（AUC=0.7246,95%CI：0.7101~0.7391）。 结论对于住院时间>72 h的成年ICU患者,入院后72 h的SOFA评分可能具有更好的预后预测价值。     

Analysis of physiologic alterations in intensive care unit patients and their relationship with mortality

PURPOSE: To analyze patient physiologic alterations (events) and multiple organ failure during intensive care unit (ICU) stay and examine their relationship with ICU mortality. MATERIAL AND METHODS: A total of 17598 consecutive patients were studied for 10 months (1997-1998) in 55 European ICUs (EURICUS-II). Hourly data were collected on critical and noncritical systolic blood pressure, heart rate, oxygen saturation, and urinary events throughout ICU stay. Sepsis-related Organ Failure Assessment (SOFA) score was collected daily (6409 patients). RESULTS: SAPS-II was 31.2 +/- 18.4 and ICU mortality 13.9%. There were 3.4 +/- 9.2 noncritical (duration, 3.9 +/- 11.4 hours) and 2 +/- 7.5 critical (3.8 +/- 13.1 hours) systolic blood pressure events per patient. Heart rate, oxygen saturation, and urinary events had similar values. Nonsurvivors had significantly more and longer physiologic alterations vs survivors. Mortality was significantly related to mean daily duration of events and mean and maximum daily SOFA. Discrimination capacity to predict ICU mortality was measured using various models: with SAPS II, area under the receiver operating characteristic curve was 0.80; with APACHE III-classified diagnosis added, 0.84; with mean duration of events/ICU day, 0.91; and with mean and maximum SOFA scores, 0.95. CONCLUSION: Routinely gathered ICU data on physiologic variables and multiple organ failure can offer considerable complementary information not provided by usual mortality prediction systems; and their weight in daily care policy decisions may need to be revisited.     

Association between trends in clinical variables and outcome in intensive care patients with faecal peritonitis: analysis of the GenOSept cohort

IntroductionPatients admitted to intensive care following surgery for faecal peritonitis present particular challenges in terms of clinical management and risk assessment. Collaborating surgical and intensive care teams need shared perspectives on prognosis. We aimed to determine the relationship between dynamic assessment of trends in selected variables and outcomes.MethodsWe analysed trends in physiological and laboratory variables during the first week of intensive care unit (ICU) stay in 977 patients at 102 centres across 16 European countries. The primary outcome was 6-month mortality. Secondary endpoints were ICU, hospital and 28-day mortality. For each trend, Cox proportional hazards (PH) regression analyses, adjusted for age and sex, were performed for each endpoint.ResultsTrends over the first 7 days of the ICU stay independently associated with 6-month mortality were worsening thrombocytopaenia (mortality: hazard ratio (HR) = 1.02; 95% confidence interval (CI), 1.01 to 1.03; P <0.001) and renal function (total daily urine output: HR =1.02; 95% CI, 1.01 to 1.03; P <0.001; Sequential Organ Failure Assessment (SOFA) renal subscore: HR = 0.87; 95% CI, 0.75 to 0.99; P = 0.047), maximum bilirubin level (HR = 0.99; 95% CI, 0.99 to 0.99; P = 0.02) and Glasgow Coma Scale (GCS) SOFA subscore (HR = 0.81; 95% CI, 0.68 to 0.98; P = 0.028). Changes in renal function (total daily urine output and renal component of the SOFA score), GCS component of the SOFA score, total SOFA score and worsening thrombocytopaenia were also independently associated with secondary outcomes (ICU, hospital and 28-day mortality). We detected the same pattern when we analysed trends on days 2, 3 and 5. Dynamic trends in all other measured laboratory and physiological variables, and in radiological findings, changes inrespiratory support, renal replacement therapy and inotrope and/or vasopressor requirements failed to be retained as independently associated with outcome in multivariate analysis.ConclusionsOnly deterioration in renal function, thrombocytopaenia and SOFA score over the first 2, 3, 5 and 7 days of the ICU stay were consistently associated with mortality at all endpoints. These findings may help to inform clinical decision making in patients with this common cause of critical illness.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-015-0931-8) contains supplementary material, which is available to authorized users.     

Comparison of Sepsis-related Organ Failure Assessment (SOFA) score and CIS (cellular injury score) for scoring of severity for patients with multiple organ dysfunction syndrome (MODS)

OBJECTIVE: To evaluate the usefulness of cellular injury score (CIS) and Sepsis-related Organ Failure Assessment (SOFA) score for determination of the severity of multiple organ dysfunction syndrome (MODS). DESIGN: A prospective observational study. SETTING: A medical and surgical intensive care unit (ICU) of a teaching hospital. Patients: Forty-seven consecutive MODS patients. MEASUREMENTS AND RESULTS: SOFA score and CIS were measured every day for 12 months for 47 MODS patients. Comparison was made of the SOFA score and CIS for usefulness in the scoring of severity of MODS in 26 survivors and 21 non-survivors. In addition, receiver operating characteristics (ROC) analysis was used to determine the usefulness of these two indexes as predictors of prognosis. No significant differences were found on admission between the survivors and non-survivors, but significant differences between the two subgroups (p < 0.001) were found in maximum value within 1 week after admission and maximum value during the course of treatment for both indexes. Analysis of changes after admission indicated that significant differences between survivors and non-survivors began to appear on day 3 of admission for both indexes; at that time SOFA score began to deteriorate in the non-survivors while CIS began to improve in the survivors. ROC analysis demonstrated that the area under the ROC curve was 0.769 for SOFA scores and 0.760 for CIS. CONCLUSIONS: Both SOFA score and CIS sequentially reflected the severity of MODS. Furthermore, they were comparable in diagnostic value as predictors of prognosis. These findings may indicate the possibility that MODS is a summation of effects of cellular injury. In addition, sequential evaluation of both SOFA score and CIS would provide a more accurate prediction of prognosis than conventional methods.     

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

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

Non-neurological organ dysfunction in neurocritical care

PURPOSE: To determine the incidence of non-neurological organ dysfunction in patients with severe neurological injury. MATERIALS AND METHODS: Modified daily SOFA (mSOFA) scores were retrospectively calculated for 55 consecutive patients with severe head injury or subarachnoid hemorrhage. mSOFA was defined as the sum of the 5 non-neurological component SOFA scores, maximum mSOFA as the sum of the most abnormal non-neurological SOFA component scores and delta mSOFA as the difference between maximum mSOFA and admission mSOFA. Organ failure was defined as a SOFA component score > or =3. RESULTS: Median (IQR) admission, maximum and delta mSOFA scores were 4 (3-6), 8 (6-9), and 2 (1-5), respectively. Respiratory and cardiac failure developed in 80% and 82% of patients, respectively. No patient developed renal or hepatic failure. Three patients developed hematological failure. There was no difference between survivors and nonsurvivors with respect to admission mSOFA (P =.45), maximum mSOFA (P =.54), or delta mSOFA (P =.19). There was no difference between those patients with favorable or unfavorable neurological outcome with respect to admission mSOFA (P =.24), maximum mSOFA (P =.84), or delta mSOFA (P =.20). CONCLUSIONS: Cardiopulmonary failure, as defined by SOFA, is common in intensive care unit patients with severe head injury and subarachnoid hemorrhage. In contrast to other intensive care unit patient populations, the mortality of patients with closed head injury or subarachnoid hemorrhage was not related to the severity of organ dysfunction on admission or its development during the intensive care unit stay.     

不同评分系统对ICU中肺部感染患者预后评估的意义

目的 不同评分工具对ICU中肺部感染患者预后评估的意义.方法 本研究收集了2018-01-01-06-30于天津市第四中心医院综合ICU住院的所有肺部感染患者,计算CRB-65、CURB-65、快速SOFA评分(qSOFA)、序贯器官衰竭评估(SOFA)评分,采用受试者工作曲线(ROC曲线)及趋势2检验比较不同评分对I...     

Microalbuminuria in the intensive care unit: Clinical correlates and association with outcomes in 431 patients

OBJECTIVE: Comparison of urine albumin within 6 hrs of intensive care unit (ICU) admission with demography, clinical classification, outcome, inotrope/vasopressor requirement, clinical assessment of mortality risk, and Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE) II scores. DESIGN: Urine albumin-creatinine ratio (ACR) was measured on ICU admission (ACR 1) and after 4-6 hrs (ACR 2). SETTING: A 17-bed general ICU in a university teaching hospital. PATIENTS: Unselected medical (206) and surgical (225) patients recruited prospectively. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Bedside urine ACR was measured by nurses using a Bayer DCA 2000 analyzer and expressed in mg/mmol (reference range <2.3). ACR 1 in medical and surgical patients was 15.5 (12.4-19.5) and 8.2 (5.9-11.1) mg/mmol, respectively (p = .0002), and ACR 2 was 9.0 (5.8-12.5) and 4.6 (3.6-5.3), respectively (p < .0001). For all patients, median (95% confidence interval) ACR fell from 11.2 (8.7-13.2) to 5.4 (4.7-6.8) mg/mmol 4-6 hrs after ICU admission (p < .0001). ACR 1 for nonsurvivors (n = 90) and survivors (n = 341) was 16.1 (11.2-21.3) and 8.8 (6.9-11.9), respectively (p = .0002) and ACR 2, 12.4 (8.2-18.9) and 4.8 (3.9-5.4), respectively (p < .0001). In both medical and surgical patients who died on the ICU, median ACR failed to decrease significantly following admission. ACR1 and ACR 2 were higher in patients who required inotropic or vasopressor support and correlated with duration of therapy. ACR 1 and 2 were inversely correlated with mean Po2/Fio2 ratio 48 hrs after ICU admission and positively correlated with duration of mechanical ventilation and ACR 1 with ICU stay. ACR 2 predicted mortality and ACR 1 inotrope requirement independent of clinical mortality risk assessment and APACHE II and SOFA scores. CONCLUSIONS: Urine albumin changes rapidly within the first 6 hrs following ICU admission and predicts ICU mortality and inotrope requirement as well as or better than APACHE II and SOFA scores. Serial urine albumin measurement may provide a means of monitoring the microvascular effects of systemic inflammation.     

Accuracy of a composite score using daily SAPS II and LOD scores for predicting hospital mortality in ICU patients hospitalized for more than 72 h

In most databases used to build general severity scores the median duration of intensive care unit (ICU) stay is less than 3 days. Consequently, these scores are not the most appropriate tools for measuring prognosis in studies dealing with ICU patients hospitalized for more than 72 h. PURPOSE: To develop a new prognostic model based on a general severity score (SAPS II), an organ dysfunction score (LOD) and evolution of both scores during the first 3 days of ICU stay. DESIGN: Prospective multicenter study. SETTING: Twenty-eight intensive care units (ICUs) in France. PATIENTS: A training data-set was created with four ICUs during an 18-month period (893 patients). Seventy percent of the patients were medical (628) aged 66 years. The median SAPS II was 38. The ICU and hospital mortality rates were 22.7% and 30%, respectively. Forty-seven percent (420 patients) were transferred from hospital wards. In this population, the calibration (Hosmer-Lemeshow chi-square: 37.4, P = 0.001) and the discrimination [area under the ROC curves: 0.744 (95 % CI: 0.714-0.773)] of the original SAPS II were relatively poor. A validation data set was created with a random panel of 24 French ICUs during March 1999 (312 patients). MEASUREMENTS AND MAIN RESULTS: The LOD and SAPS II scores were calculated during the first (SAPS1, LOD1), second (SAPS2, LOD2), and third (SAPS3, LOD3) calendar days. The LOD and SAPS scores alterations were assigned the value "1" when scores increased with time and "0" otherwise. A multivariable logistic regression model was used to select variables measured during the first three calendar days, and independently associated with death. Selected variables were: SAPS II at admission [OR: 1.04 (95 % CI: 1.027-1.053) per point], LOD [OR: 1.16 (95 % CI: 1.085-1.253) per point], transfer from ward [OR: 1.74 (95 % CI: 1.25-2.42)], as well as SAPS3-SAPS2 alterations [OR: 1.516 (95 % CI: 1.04-2.22)], and LOD3-LOD2 alterations [OR: 2.00 (95 % CI: 1.29-3.11)]. The final model has good calibration and discrimination properties in the training data set [area under the ROC curve: 0.794 (95 % CI: 0.766-0.820), Hosmer-Lemeshow C statistic: 5.56, P = 0.7]. In the validation data set, the model maintained good accuracy [area under the ROC curve: 0.826 (95 % CI: 0.780-0.867), Hosmer-Lemeshow C statistic: 7.14, P = 0.5]. CONCLUSIONS: The new model using SAPS II and LOD and their evolution during the first calendar days has good discrimination and calibration properties. We propose its use for benchmarking and evaluating the over-risk of death associated with ICU-acquired nosocomial infections.     

红细胞分布宽度对ICU急性呼吸衰竭患者预后的评估

目的探讨红细胞分布宽度（RDW）对急性呼吸衰竭（ARF）患者预后的评估价值。 方法提取来源于MIMIC-Ⅲ数据库的数据,根据国际ICD9-CODE诊断编码,查询ARF患者相关信息。用SQL语言提取患者的一般资料、并发症、评分、实验室检查结果等,并以患者28 d病死率、90 d病死率为主要指标,ICU病死率、院内病死率、入ICU时间和院内时间为次要指标。所有研究对象根据受试者工作特征曲线（ROC）最佳截断值分为高RDW组和正常RDW组,比较2组患者的基线数据及临床结局,采用Kaplan-Meier生存曲线分析2组患者28 d、90 d的累积生存率,Cox比例风险回归模型分析ARF患者28 d、90 d的死亡风险,并计算ROC的曲线下面积（AUC）。 结果共纳入6286例ARF的患者,正常RDW组和高RDW组28 d病死率分别为21.3%、33.7%,90 d病死率分别为27.8%、44.8%,倾向性评分匹配（PSM）后2组28 d病死率分别为25.9%、31.9%,90 d病死率分别为33.5%、43.1%,组间比较差异均有统计学意义（P＜0.001）;进行累积生存分析时发现,高RDW组28 d和90 d的累积生存率较正常RDW组均明显降低,差异有统计学意义（P＜0.001）;采用Cox比例风险回归模型进行分析,RDW每升高1%,ARF患者28 d、90 d的死亡风险显著增加。在28 d病死率预测价值上,RDW、序贯器官衰竭评估（SOFA）评分的ROC的AUC无明显差异（0.663 vs 0.662,P=0.926）,但在90 d病死率上,RDW的ROC的AUC高于SOFA评分,差异有统计学意义（0.678 vs 0.651,P=0.003）。 结论RDW升高可能是ARF患者预后的一个有价值的指标。     

两种基础疾病评分预测肺炎患者预后的比较

目的 比较慢性健康状态评分(chronic health score,CHS)和查尔森合并症指数(Charlson's weighted index of comorbidities,WIC)对ICU肺部感染患者住院死亡风险的影响.方法 回顾性分析多中心2013年9月至2014年9月肺炎患者的临床资料;记录性别、年龄、既往基础疾病、是否严重脓毒症;计算入院时WIC、入院后24h急性生理与慢性健康状况(APACHE)评分Ⅱ,包括CHS、急性生理状况评分(acute physiology score,APS)和脓毒症相关性器官功能衰竭评分(sepsis related organ failure assessment,SOFA).结果 在293名入组患者中,男性195例(66.6％),女性98例(33.4％),存活197例(67.2％),死亡96例(32.8％).年龄(62.5±17.0)岁.与存活组比较,死亡组的WIC评分较高.而两组的CHS评分比较无统计学意义.随着WIC和CHS分值的增高,患者的病死率呈增高趋势.单因素Logistic回归分析显示年龄、APACHEⅡ、SOFA、APS、CHS、WIC、是否严重脓毒症、基础疾病中Ⅱ型糖尿病、卒中、充血性心力衰竭与患者的预后相关.CHS(方程1)和WIC评分(方程2)分别联合入院急性生理状况评分及年龄等因素建立方程行多因素Logistic回归分析提示年龄、APS、CHS、WIC、是否严重脓毒症与患者的28 d预后独立相关.CHS评分的受试者工作曲线下面积(AUC)为0.557,95％ CI:(0.49～0.623)低于(P =0.021 7,Z=2.296) WIC评分的AUC =0.649 95％CI:(0.586 ～0.712),联合多变量建立方程后的AUC明显优于APACHEⅡ评分(P ＜0.001).结论 WIC评分是预测ICU肺炎患者住院病死率的独立风险因素;WIC评分较CHS评分可以更好的评价基础疾病对患者病死率的影响.     

The Multiple Organ Dysfunction Score as a descriptor of patient outcome in septic shock compared with two other scoring systems.

OBJECTIVE: To demonstrate if daily Multiple Organ Dysfunction scoring could describe outcome groups in septic shock better than daily Acute Physiology and Chronic Health Evaluation (APACHE) II and Organ Failure scores. DESIGN: A prospective cohort study. SETTING: A medical and surgical adult intensive care unit (ICU) at a tertiary referral center. MEASUREMENTS AND MAIN RESULTS: Daily data collection over a 14-month period was performed on 368 ICU patients, 39 of whom developed septic shock while in the ICU. These data were entered into a computer programmed to calculate APACHE II, Organ Failure, and Multiple Organ Dysfunction scores. The admission Multiple Organ Dysfunction scores for nonsurvivors and survivors of septic shock in the ICU was 6.5 +/- 2.7 and 6.6 +/- 2.8 (SD), respectively. These patients deteriorated due to the development of septic shock during their ICU stay resulting in a maximum Multiple Organ Dysfunction score of 12.2 +/- 3.7 in nonsurvivors and 9.4 +/- 2.7 in survivors (p < .05). The difference between the maximum and initial Multiple Organ Dysfunction scores (delta score) was also significantly greater in nonsurvivors than in survivors (5.6 +/- 4.7 vs. 2.8 +/- 3.0) (p < .05). There were no significant differences between the maximum and delta scores in the outcome groups using the APACHE II and Organ Failure scoring systems. These results were mirrored by 2.3 +/- 0.7 and 1.7 +/- 0.5 organ failures in nonsurvivors and survivors, respectively (p < .01). For all 368 patients, the initial and maximum Multiple Organ Dysfunction scores were 3.5 +/- 2.5 and 10.5 +/- 3.6, respectively. CONCLUSION: Maximum and delta Multiple Organ Dysfunction scores mirrored organ dysfunction and could accurately describe the outcome groups, whereas daily APACHE II and Organ Failure scores could not.     

Use of the Sequential Organ Failure Assessment score as a severity score

Objective To evaluate whether the SOFA score can be used to develop a model to predict intensive care unit (ICU) mortality in different countries.Design and setting Analysis of a prospectively collected database. Patients with ICU stay longer than 2 days were studied to develop a mortality prediction model based on measurements of organ dysfunction.Patients 748 patients from six countries.Measurements and results Two logistic regression models were constructed, one based on the SOFA maximum (SOFA Max model) and the other on variables identified by multivariate regression (SOFA Max-infection model). The H and C statistics had a p value above 0.05 for both models, but the D statistics showed a poor performance on the SOFA Max model when stratified for the presence of infection. Subsequent analysis was performed with SOFA Max-infection model. The area under the curve was 0.853. There were no statistically significant differences in observed and predicted mortalities except for one country which had a higher than predicted ICU mortality both in the overall population (28.3 vs. 19.1%) and in the noninfected patients (21.4 vs. 12.6%).Conclusions The SOFA Max adjusted for age and the presence of infection can predict mortality in this population, but in one country the ICU mortality was higher than expected. Our data do not allow us to determine the reasons behind these differences, and further studies to detect differences in mortality between countries and to elucidate the basis for these differences should be encouraged.     

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     

Long-term outcome of delirium during intensive care unit stay in survivors of critical illness: a prospective cohort study

Introduction

Delirium is associated with impaired outcome, but it is unclear whether this relationship is limited to in-hospital outcomes and whether this relationship is independent of the severity of underlying conditions. The aim of this study was to investigate the association between delirium in the intensive care unit (ICU) and long-term mortality, self-reported health-related quality of life (HRQoL), and self-reported problems with cognitive functioning in survivors of critical illness, taking severity of illness at baseline and throughout ICU stay into account.

Methods

A prospective cohort study was conducted. We included patients who survived an ICU stay of at least a day; exclusions were neurocritical care patients and patients who sustained deep sedation during the entire ICU stay. Delirium was assessed twice daily with the Confusion Assessment Method for the ICU (CAM-ICU) and additionally, patients who received haloperidol were considered delirious. Twelve months after ICU admission, data on mortality were obtained and HRQoL and cognitive functioning were measured with the European Quality of Life – Six dimensions self-classifier (EQ-6D). Regression analyses were used to assess the associations between delirium and the outcome measures adjusted for gender, type of admission, the Acute Physiology And Chronic Health Evaluation IV (APACHE IV) score, and the cumulative Sequential Organ Failure Assessment (SOFA) score throughout ICU stay.

Results

Of 1101 survivors of critical illness, 412 persons (37%) had been delirious during ICU stay, and 198 (18%) died within twelve months. When correcting for confounders, no significant association between delirium and long-term mortality was found (hazard ratio: 1.26; 95% confidence interval (CI) 0.93 to 1.71). In multivariable analysis, delirium was not associated with HRQoL either (regression coefficient: -0.04; 95% CI -0.10 to 0.01). Yet, delirium remained associated with mild and severe problems with cognitive functioning in multivariable analysis (odds ratios: 2.41; 95% CI 1.57 to 3.69 and 3.10; 95% CI 1.10 to 8.74, respectively).

Conclusions

In this group of survivors of critical illness, delirium during ICU stay was not associated with long-term mortality or HRQoL after adjusting for confounding, including severity of illness throughout ICU stay. In contrast, delirium appears to be an independent risk factor for long-term self-reported problems with cognitive functioning.