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.     

视觉诱发电位对危重患者病情评估及预后判断的研究

目的 探讨危重患者闪光视觉诱发电位(fVEP)变化与病情严重程度及预后的关系.方法 将69例危重病患者按28 d临床结局分为死亡组和存活组,比较两组患者fVEP N2波峰潜伏期差异及其与病情严重程度和预后相关评分的关系.根据原发病情况将患者分为原发颅内病变组和其他意识障碍组,分别进行病情严重程度和预后相关分析,评价fVEP及相关临床评分对预后预测的效果.结果 死亡组fVEP N2波峰潜伏期明显较存活组延迟[(228.6±41.7)ms比(190.5±49.2)ms,P＜0.01];死亡组急性生理学与慢性健康状况评分系统I(APACHEⅡ)评分((25.9±6.4)分比(22.5±6.7)分]和感染相关器官衰竭评分系统(SOFA)评分[(6.7±2.0)分比(5.4±2.5)分]高于存活组(P均＜0.05),死亡组格拉斯哥昏迷评分(GCS)低于存活组[(6.3±2.4)分比(7.0±3.0)分,P＜0.05];N2波峰潜伏期与GCS呈显著负相关(r=-0.332,P＜0,01).原发颅内病变组与总体病死趋势类似.其他意识障碍组死亡患者N2波峰潜伏期明显长于存活组[(226.0±46.7)ms比(1 68.8±54.1)ms,P＜0.05],N2波峰潜伏期与SOFA评分呈显著正相关(r=0.526,P＜0.05);N2波峰潜伏期和SOFA评分预测死亡的受试者工作特征曲线(ROC曲线)下面积分别为0.800±0.104(P＜0.05)和0.6504-0.131(P＞0.05),N 2波峰潜伏期用于判断预后有显著意义.结论 fVEP的变化在一定程度上反映了危重患者病情严重程度和预后;对非原发颅内病变意识障碍患者,fVEP在预测多器官功能障碍综合征(MODS)的发生和死亡上有一定意义.     

APACHE II score and mortality in respiratory failure due to cardiogenic pulmonary edema

We reviewed retrospectively 88 patients to assess whether the APACHE II severity of disease classification system can predict mortality in patients with respiratory failure due to cardiac pulmonary edema. Mean score for survivors was higher than for nonsurvivors (24.5 +/- 6.7 vs. 20.7 +/- 5.7, p less than .01), and increasing APACHE II scores were not associated with increasing mortality. Mortality was 54% for APACHE II scores less than or equal to 18, 43% for scores greater than 18 and less than or equal to 24, 22% for scores greater than 24 and less than or equal to 31, and 25% for scores between 32 and 40. The relationship of APACHE II scores to mortality did not improve when the 25 patients with ICU stays less than 48 h were analyzed; the mean score of survivors in this group was 24.3 +/- 5.2 vs. 18.8 +/- 4.6 for nonsurvivors, p less than .001. The presence of myocardial infarction (MI) was associated with a high mortality. Mortality in the 51 MI patients was 52.9% vs. 13.5% in the 37 patients without MI (p less than .001), but APACHE II scores were similar (22.6 +/- 6.6 and 23.7 +/- 6.4, respectively). The relationship between APACHE II scores and mortality did not improve if patients with and without MI are analyzed separately. For patients with MI, mortality was 78.6% for scores between 12 and 17, 56.2% for scores between 18 and 23, 33.3% for scores between 24 and 29, and 33.3% for scores greater than 29.(ABSTRACT TRUNCATED AT 250 WORDS)     

Outcome of patients with end-stage renal disease admitted to the intensive care unit

OBJECTIVES: To describe the clinical course of patients with end-stage renal disease (ESRD) admitted to the intensive care unit (ICU) and to compare the performance of Acute Physiology and Chronic Health Evaluation (APACHE) III and Sequential Organ Failure Assessment (SOFA) in predicting their outcome. PATIENTS AND METHODS: This retrospective cohort study consisted of patients with ESRD admitted to 3 ICUs between January 1, 1997, and November 30, 2002. Data on demographics, APACHE III score, SOFA score, development of sepsis and organ failure, use of mechanical ventilation, and mortality were collected. RESULTS: Of the 476 patients with ESRD who underwent dialysis during the study period, 93 (20%) required admission to the ICU. The most common ICU admission diagnosis was gastrointestinal bleeding. The first day median (Interquartile range) APACHE III score, SOFA score, and APACHE III predicted hospital mortality rate were 64 (47-79), 6 (5-8), and 12.9% (4.2%-30.8%), respectively. The observed ICU, hospital, and 30-day mortality rates were 9%, 16%, and 22%, respectively. Nonrenal organ failure developed in 48 patients (52%) and sepsis in 15 patients (16%). Mechanical ventilation was required In 26 patients (28%). The area under the receiver operating characteristic curve for the first-day APACHE III probability of hospital death in predicting 30-day mortality was 0.78 (95% confidence interval, 0.68-0.86) compared with 0.66 (95% confidence interval, 0.55-0.76) for the SOFA score (P = .16). CONCLUSIONS: The observed hospital mortality of patients with ESRD admitted to the ICU is relatively low. There is no statistically significant difference in the performance of APACHE III and SOFA prognostic models in discriminating between 30-day survivors and nonsurvivors.     

Critical Care in the Emergency Department A Physiologic Assessment and Outcome Evaluation

OBJECTIVES: The changing landscape of health care in this country has seen an increase in the delivery of care to critically ill patients in the emergency department (ED). However, methodologies to assess care and outcomes similar to those used in the intensive care unit (ICU) are currently lacking in this setting. This study examined the impact of ED intervention on morbidity and mortality using the Acute Physiology and Chronic Health Evaluation (APACHE II), the Simplified Acute Physiology Score (SAPS II), and the Multiple Organ Dysfunction Score (MODS). METHODS: This was a prospective, observational cohort study over a three-month period. Critically ill adult patients presenting to a large urban ED and requiring ICU admission were enrolled. APACHE II, SAPS II, and MODS scores and predicted mortality were obtained at ED admission, ED discharge, and 24, 48, and 72 hours in the ICU. In-hospital mortality was recorded. RESULTS: Eighty-one patients aged 64 +/- 18 years were enrolled during the study period, with a 30.9% in-hospital mortality. The ED length of stay was 5.9 +/- 2.7 hours and the hospital length of stay was 12.2 +/- 16.6 days. Nine (11.1%) patients initially accepted for ICU admission were later admitted to the general ward after ED intervention. Septic shock was the predominant admitting diagnosis. At ED admission, there was a significantly higher APACHE II score in nonsurvivors (23.0 +/- 6.0) vs survivors (19.8 +/- 6.5, p = 0.04), while there was no significant difference in SAPS II or MODS scores. The APACHE II, SAPS II, and MODS scores were significantly lower in survivors than nonsurvivors throughout the hospital stay (p 相似文献   

Prognostic factors,clinical course,and hospital outcome of patients with chronic obstructive pulmonary disease admitted to an intensive care unit for acute respiratory failure

OBJECTIVE: To describe prognostic factors, clinical course, and hospital outcome of patients with chronic obstructive pulmonary disease admitted to an intensive care unit for acute respiratory failure. DESIGN: Analysis of prospectively collected data. SETTING: A multidisciplinary intensive care unit of an inner-city university hospital. PATIENTS: Patients with chronic obstructive pulmonary disease admitted to an intensive care unit for acute respiratory failure from August 1995 through July 1998. MEASUREMENTS AND MAIN RESULTS: Data were obtained concerning demographics, arterial blood gas, Acute Physiology and Chronic Health Evaluation (APACHE) II score, sepsis, mechanical ventilation, organ failure, complications, and hospital mortality rate. Fifty-nine percent of patients were male, 63% white, and 36% African-American; the mean age was 63.1 +/- 8.9 yrs. Noninvasive mechanical ventilation was tried in 40% of patients and was successful in 54% of them. Invasive mechanical ventilation was required in 61% of the 250 admissions. Sepsis developed in 31% of patients, nonpulmonary organ failure in 20%, pneumothorax in 3%, and acute respiratory distress syndrome in 2%. Multiple organ failure developed in 31% of patients with sepsis compared with 3% without sepsis (p <.0001). Predicted and observed hospital mortality rates were 30% and 15%, respectively. Differences in age and arterial carbon dioxide and oxygen tensions between survivors and nonsurvivors were not significant. Arterial pH was lower in nonsurvivors than in survivors (7.21 vs. 7.25, p =.0408). The APACHE II-predicted mortality rate (p =.0001; odds ratio, 1.046; 95% confidence interval, 1.022-1.070) and number of organ failures (p <.0001; odds ratio, 5.524; 95% confidence interval, 3.041-10.031) were independent predictors of hospital outcome; invasive mechanical ventilation was not an independent predictor. CONCLUSIONS: Physiologic abnormalities at admission to an intensive care unit and development of nonrespiratory organ failure are important predictors of hospital outcome for critically ill patients with chronic obstructive pulmonary disease who have acute respiratory failure. Improved outcome would require prevention and appropriate treatment of sepsis and multiple organ failure.     

Acute Physiology and Chronic Health Evaluation (APACHE II) score and outcome in the surgical intensive care unit: an analysis of multiple intervention and outcome variables in 1,238 patients

OBJECTIVE: To assess the statistical association of the Acute Physiology and Chronic Health Evaluation (APACHE II) score with multiple intervention and outcome variables in surgical ICU patients. DESIGN: Continuous data collection on every patient admitted to the surgical ICU for a 21-month period. MATERIALS AND METHODS: For every admitted patient in the surgical ICU, APACHE II scores were calculated and the relationship between APACHE II score as an independent predictor of outcome was assessed with multiple outcome variables selected for study. The outcome and intervention variables tested included: treatment intervention measures such as days on ventilator; days with an arterial catheter, central venous catheter, triple lumen catheter, pulmonary artery catheter; days receiving total parenteral nutrition; days receiving tube feedings; number of transducers per days in the ICU; number of infusion pumps per ICU days, days in the hospital, number of complete blood counts; number of electrolyte determinations; number of blood gases; number of units of blood transfused; ICU and hospital mortality rates in the presence of complications, including: respiratory distress syndrome, renal failure, congestive heart failure, coma, requirement of cardiopulmonary resuscitation, and others. RESULTS: The APACHE II score was statistically associated with each intervention and outcome variable tested. Unfortunately, the associations, although consistent, were weak with r2 values ranging from .03 to a maximum of .22 for Pearson's correlation coefficients. CONCLUSION: The APACHE II score was statistically associated with all the variables examined in our surgical patients, but its predictive power for the individual surgical patient was limited. These findings suggest that the score may be useful for retrospective analyses of large cohorts of patients but should not be used as a triage tool or as a predictor of outcome for the individual patient. Triage decisions should continue to be based on the best available clinical judgment.     

不同预后评分在老年呼吸衰竭患者中的应用

目的 比较不同评分系统对老年呼吸衰竭患者预后的评价能力.方法 收集解放军总医院2009年1月至2010年3月收住的老年呼吸衰竭患者159例,均存在2个或以上器官功能不全,符合老年多器官功能障碍综合征(MODSE)诊断标准,分别在入院时用急性生理学与慢性健康状况评分系统(APACHE Ⅱ、APACHE Ⅲ)、简化急性生理学评分Ⅱ(SAPS Ⅱ)、多器官功能障碍评分(Marshall评分)预测患者预后,并比较其诊断能力.结果 159例呼吸衰竭患者平均年龄(75.26±7.87)岁,28 d病死率为53.5%.死亡组患者各种预后评分、器官衰竭发生率均明显高于存活组[APACHE Ⅱ评分(分):27.88±8.19比17.73±6.21;APACHE Ⅲ评分(分):101.10±29.81比64.24±21.98;SAPS Ⅱ评分(分):59.70±17.68比38.05±12.10 ;Marshall评分(分):8.59±3.15比4.90±2.66;器官衰竭数目(个):4.60±1.14比2.88±0.88,均P＜0.01＝;4种评分中敏感性以SAPS Ⅱ最佳,为91.76%;特异性以APACHE Ⅲ最佳,为91.89%;各评分曲线下面积均可达0.820或以上(APACHE Ⅱ为0.829,APACHE Ⅲ为0.836,SAPS Ⅱ为0.844,Marshall评分0.820).结论 现行APACHE Ⅱ、APACHEⅢ、SAPS Ⅱ、Marshall评分4种评分均可较好地预测老年呼吸衰竭患者的预后情况.

Abstract：

Objective To evaluate the predictive power of current scoring systems applied in elderly patients with respiratory failure. Methods Data of 159 elderly patients with respiratory failure, also meeting the criteria of multiple organ dysfunction syndrome in the elderly (MODSE), being admitted to PLA General Hospital from January 2009 to March 2010 were analyzed with four scoring systems, i.e. acute physiology and chronic health evaluation (APACHE Ⅱ , APACHE Ⅲ ), simplified acute physiology score Ⅱ (SAPS Ⅱ ),as well as multiple organ dysfunction score (Marshall score), for the prediction of their outcome on the first day after admission, and the predictive power of respective system was compared. Results One hundred and fifty-nine patients were involved, with a mean age of (75.26±7. 87) years, and a 28-day mortality of 53. 5%. Incidence of organ failure and prognosis scores in nonsurvivors were significantly higher than those in survivors (APACHE Ⅱ score: 27. 88 ± 8. 19 vs. 17.73 ± 6.21; APACHE Ⅲ score: 101.10 ± 29. 81 vs.64. 24±21.98; SAPS Ⅱ score: 59. 70±17.68 vs. 38. 05±12. 10; Marshall score: 8. 59±3. 15 vs. 4. 90±2. 66; organ failure: 4. 60±1.14 vs. 2. 88±0. 88, all P＜0. 01). Among the four scoring systems, SAPS Ⅱpresented excellence in sensitivity (91.76 % ), while APACHE Ⅲ in specificity (91.89 % ). Area under curve of receiver operator characteristic of all scoring systems reached 0. 820 (0. 829 for APACHE Ⅱ , 0. 836 for APACHE Ⅲ , 0. 844 for SAPS Ⅱ , 0. 820 for Marshall score). Conclusion All the four current scoring systems, i.e. APACHE Ⅱ , APACHE Ⅲ , SAPS Ⅱ and Marshall score, presented satisfactory predictive power in prognosis of elderly patients with respiratory failure.     

严重创伤患者早期N末端B型利钠肽原的检测

目的 观察严重患者创伤早期N末端B型利钠肽原(NT-proBNP)的水平,探讨其可能的影响因素及应用价值。方法 采用前瞻性观察研究,测定60例收住急诊ICU的严重创伤患者伤后24h的血清NT-proBNP,比较不同预后组的NT-proBNP水平,绘制受试者特征(ROC)曲线分析其对预后判断的价值;分析预后良好组患者NT-proBNP水平与ICU住院时间、机械通气时间的相关性。分析NT-proBNP与损伤严重度评分(ISS)、头部简明创伤评分(AIS)、急性生理和慢性健康评分(APACHE)Ⅱ、格拉斯哥昏迷评分(GcS)、心肌型肌酸激酶同功酶(CK-MB)、肌钙蛋白-Ⅰ (cTn-Ⅰ)、中心静脉压(CVP)等指标的相关性,应用逐步线性回归分析筛选主要的相关因素。结果 预后不良组伤后24h的NT-proBNP中位数水平明显高于预后良好组(762 pg/mL vs.200 pg/mL,Z=-3.972,P＜0.01),其判断预后的价值与ISS、APACHEⅡ等传统指标相似,最佳阈值为384 pg/mL(灵敏度0.846,特异度0.766)。预后良好组患者NT-proBNP水平与ICU住院时间(r =0.32,P＜0.05)、机械通气时间具有正相关性(r=0.37,P＜0.05)。逐步线性回归分析提示APACHEⅡ、CK-MB与NT-proBNP的相关性具有统计学意义。结论 严重创伤后24h的NT-proBNP水平与病情严重度及预后有一定的相关性,可作为严重创伤救治中病情评估的简单参考指标。     

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     

APACHEⅡ评分在ICU铜绿假单胞菌下呼吸道感染患者中的应用

目的 :应用急性生理学及慢性健康状况评分 (acute physiology and chronic health evaluation ,APACHE )系统评估重症监护病房 (intensive care unit,ICU )中铜绿假单胞菌 (PA)下呼吸道感染患者的疾病的危重程度、感染治疗效果、入住 ICU时间和预后。方法 :对比观察入住 ICU并且合并下呼吸道 PA感染的12 2例患者 ,按 Knaus法进行 APACHE 评分 ,并进行临床对比。结果 :全部患者共死亡 2 9例 ,APACHE 分值为 (18.78± 7.13)分 ;未死亡者 93例 ,APACHE 分值为 (11.70± 5 .79)分 ,两者差异显著 (t=5 .4 3,P<0 .0 1)。合并感染者较非合并感染者 APACHE 评分高〔(14 .76± 6 .89)分比 (10 .0 8± 6 .14 )分 ,P<0 .0 1〕,预后差 (2 7.91%比 13.89% ,P<0 .0 1) ;重症肺炎患者较非重症肺炎患者 APACHE 评分高〔(15 .5 7± 6 .97)分比(11.81± 6 .0 3)分 ,P<0 .0 1〕,预后差 (39.2 2 %比 12 .6 8% ,P<0 .0 1)。随 APACHE 分值的升高 ,患者的重症肺炎例数增多 ,感染治疗效果差 ,病死率升高 ;预计病死率和实际病死率均与 APACHE 分值呈显著正相关 ,APACHE 分值以 5分阶增加时 ,实际和预计病死率亦增加 ,预测死亡概率的敏感性和阳性率分别为10 0 .0 0 %和 86 .72 %。结论 :在 PA下呼吸道感染的 ICU患者中 ,APACHE      

Adjustment of intensive care unit outcomes for severity of illness and comorbidity scores

PURPOSE: Comparison of outcomes among intensive care units (ICUs) requires adjustment for patient variables. Severity of illness scores are associated with hospital mortality, but administrative databases rarely include the elements of these scores. However, these databases include the elements of comorbidity scores. The purpose of this study was to compare the value of these scores as adjustment variables in statistical models of hospital mortality and hospital and ICU length of stay after adjustment for other covariates. MATERIALS AND METHODS: We used multivariable regression to study 1808 patients admitted to a 13-bed medical-surgical ICU in a 400-bed tertiary hospital between December 1998 and August 2003. RESULTS: For all patients, after adjusting for age, sex, major clinical category, source of admission, and socioeconomic determinants of health, we found that Acute Physiology and Chronic Health Evaluation (APACHE) II and comorbidity scores were significantly associated with hospital mortality and that comorbidity but not APACHE II was significantly associated with hospital length of stay. Separate analysis of hospital survivors and nonsurvivors showed that both APACHE II and comorbidity scores were significantly associated with hospital length of stay and APACHE II score was associated with ICU length of stay. CONCLUSION: The value of APACHE II and comorbidity scores as adjustment variables depends on the outcome and population of interest.     

The clinical course of patients with septic abortion admitted to an intensive care unit

Objective The purpose of this study was to describe the clinical course, complications, and outcome of patients with septic abortion admitted to the intensive care unit (ICU).Design, setting, and patients In this retrospective study, the records of 63 patients with septic abortion admitted to the ICU of a university hospital in Argentina between 1985 and 1995 were reviewed.Results The mean age of the patients was 28.5 years, and 33% had had previous abortions. The mean gestational age was 10.5 weeks. The first ICU day Acute Physiology and Chronic Health Evaluation (APACHE) II mean score was 13.9. Acute renal failure developed in 73% (46 of 63) of the patients, disseminated intravascular coagulation (DIC) in 31% (15 of 49), and septic shock in 32% (20 of 63). Blood cultures were positive in 24% (15 of 62). Twelve patients died (19%). Eight of the deaths occurred during the first 48 h of the ICU admission. Compared with survivors, non-survivors had higher median number of organ failures (1.0 vs 4.0, p<0.0001), mean first ICU day SOFA scores (6.6 vs 10.0, p=0.0059), and mean APACHE II scores (12.7 vs 20.2, p=0.0003), and were more likely to have septic shock (18 vs 92%, p<0.0001), and receive dopamine (37 vs 83%, p=0.0040), mechanical ventilation (8 vs 83%, p<0.0001), and pulmonary artery catheter (8 vs 41%, p=0.0026).Conclusions Although it is an avoidable complication, septic abortion requiring admission to the ICU is associated with high morbidity and mortality.     

The Multiple Organ Dysfunction Score (MODS) versus the Sequential Organ Failure Assessment (SOFA) score in outcome prediction

OBJECTIVE: To compare outcome prediction using the Multiple Organ Dysfunction Score (MODS) and the Sequential Organ Failure Assessment (SOFA), two of the systems most commonly used to evaluate organ dysfunction in the intensive care unit (ICU). DESIGN: Prospective, observational study. SETTING: Thirty-one-bed, university hospital ICU. PATIENTS AND PARTICIPANTS: Nine hundred forty-nine ICU patients. MEASUREMENTS AND RESULTS: The MODS and the SOFA score were calculated on admission and every 48 h until ICU discharge. The Acute Physiology and Chronic Health Evaluation (APACHE) II score was calculated on admission. Areas under receiver operating characteristic (AUROC) curves were used to compare initial, 48 h, 96 h, maximum and final scores. Of the 949 patients, 277 died (mortality rate 29.1%). Shock was observed in 329 patients (mortality rate 55.3%). There were no significant differences between the two scores in terms of mortality prediction. Outcome prediction of the APACHE II score was similar to the initial MODS and SOFA score in all patients, and slightly worse in patients with shock. Using the scores' cardiovascular components (CV), outcome prediction was better for the SOFA score at all time intervals (initial AUROC SOFA CV 0.750 vs MODS CV 0.694, p<0.01; 48 h AUROC SOFA CV 0.732 vs MODS CV 0.675, p<0.01; and final AUROC SOFA CV 0.781 vs MODS CV 0.674, p<0.01). The same tendency was observed in patients with shock. There were no significant differences in outcome prediction for the other five organ systems. CONCLUSIONS: MODS and SOFA are reliable outcome predictors. Cardiovascular dysfunction is better related to outcome with the SOFA score than with the MODS.     

危重患者早期血糖波动与预后的相关性研究

目的 探讨危重患者早期血糖波动与预后的相关性.方法 回顾性分析95例危重患者的临床资料,根据入重症监护病房( ICU )28 d预后分为死亡组(43例)和存活组(52例),监测住ICU 72 h内的血糖,比较两组入ICU时血糖(BGadm)、平均血糖(MBG)、高血糖指数(HGI)、血糖不稳定指数(GLI)、低血糖发生率、胰岛素总用量;通过多因素logistic回归分析确定独立危险因素,并应用受试者工作特征曲线(ROC曲线)下面积(AUC)比较预测价值.结果 死亡组BGadm(mmol/L)、MBG(mmol/L)、HGI、低血糖发生率与存活组比较差异均无统计学意义(BGadm:9.87±4.48比9.26±3.07,MBG:8.59±1.23比847±1.01,HGI6.0:2.45±0.94比1.68±1.05,HGI83:0.84±0.70比0.68±0.51,低血糖发生率:9.30％比5.77％,均P＞0.05);急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分(分)、GLI、胰岛素72 h总用量(U)均显著高于存活组[APACHEⅡ评分:23 +6比19±6,GLI:56.96(65.43)比23.87(41.62),胰岛素72 h总用量:65.5( 130.5)比12.5(90.0),均P＜0.05].多因素logistic回归分析显示,APACHEⅡ评分与GLI为死亡独立危险因素[APACHEⅡ评分:优势比(OR)=1.09,95％可信区间(95％CI) 1.01～ 1.17; GLI:OR=1.03,95％口1.01～1.06,均P＜0.05];APACHEⅡ评分与GLI的AUC分别为0.69、0.71,二者无显著差异(P＞0.05).结论 危重患者早期血糖波动是患者入ICU 28 d死亡的独立危险因素,控制早期血糖波动可能有利于改善预后.     

Outcome prediction for critically ill cirrhotic patients: a comparison of APACHE II and Child-Pugh scoring systems

Cirrhotic patients admitted to the medical intensive care unit (ICU) are associated with high mortality rates. The prognosis of critically ill cirrhotic patients is determined by the extent of hepatic and extrahepatic organ dysfunction. This study was conducted to assess and compare the accuracy of the Child-Pugh classification and APACHE II scores, obtained on the first day of ICU admission, in predicting hospital mortality in critically ill cirrhotic patients. One hundred thirty-five patients diagnosed with liver cirrhosis were admitted to the medical ICU between January 2002 and March 2003. Information considered necessary to compute the Child-Pugh and APACHE II scores on the first day of ICU admission was prospectively collected. The overall hospital mortality rate was 66.6%. Liver disease was most commonly attributed to hepatitis B viral infection. The APACHE II scores demonstrate a good fit using the Hosmer and Lemeshow goodness-of-fit test. Furthermore, by using the areas under receiver operating characteristic (AUROC) curve, the APACHE II scores demonstrated a better discriminative power (AUROC 0.833 +/- 0.039) than Child-Pugh scores (AUROC 0.75 +/- 0.05) (P=.024). This investigation confirms the grave prognosis for the cirrhotic patients admitted to the ICU. While both Child-Pugh and the APACHE II scores can satisfactorily predict the outcomes for critically ill cirrhotic patients, APACHE II is more powerful in discriminating the survivors from the nonsurvivors.     

Evaluation of the consistency of Acute Physiology and Chronic Health Evaluation (APACHE II) scoring in a surgical intensive care unit.

OBJECTIVES: To determine the applicability of the Acute Physiology and Chronic Health Evaluation (APACHE II) scoring system in a Swiss ICU, and to evaluate its utility in evaluating data from 2 yrs of consecutive admissions to show that the predictability of outcome is similar to that predictability observed by Knaus et al. in 1985 (in 5,815 patients), with the provision that large numbers of patients are studied. DESIGN: Prospective clinical trial over 2 yrs, with statistical analysis of the Swiss patients, and between the Swiss patients and the patients studied by Knaus et al. Receiver operating characteristic curves were calculated. SETTING: Surgical ICU in a Swiss university hospital. PATIENTS: A total of 2,061 consecutive patients admitted to the surgical ICU who were classified as postoperative (elective or emergency) and nonoperative. Hospital mortality rate was considered. RESULTS: Patients were 53 +/- 16 yrs of age. Mean APACHE II score was 10.5 +/- 7.0. The mean APACHE II score was significantly (p < .001) lower in the 1,813 survivors (9.0 +/- 5.2) than in the 248 nonsurvivors (21.5 +/- 8.5). The mortality rate was higher among the Swiss patients when compared with the patients studied by Knaus et al. who had postoperative scores of 20 to 29 and nonoperative scores of > 24. The distribution of the scores and mortality rates were stable during the two study periods, as were the differences in mortality rates between the Swiss population and that population studied by Knaus et al. Sensitivity and specificity of the scores were highest in the emergency surgery group (87% and 78%), and lowest in the elective surgery group (76% and 73%). The APACHE equation underestimated the risk of death. CONCLUSIONS: The APACHE II score, because of its consistency over time and the stability of the mortality rates, can be used in our surgical ICU without modification. The calculated risk of death gives no additional information.     

Clinical profile, intensive care unit course, and outcome of patients admitted in intensive care unit with dengue

Purpose

The purpose of the study was to assess the clinical profile and course of dengue patients admitted to the intensive care unit (ICU) and to identify factors related to poor outcome.

Methods

All patients with dengue admitted to ICU over 2.5 years were included prospectively. Severity of illness was assessed by the Acute Physiology and Chronic Health Evaluation (APACHE) II score, and organ failure was determined by the Sequential Organ Failure Assessment score. Primary outcome measure was 28-day mortality. Logistic regression analysis was performed to identify factors predicting mortality.

Results

Data from 198 patients were analyzed. Mean age was 39.56 ± 17.1 years, and 61.1% were male. The commonest complaints were fever (96%) and rash (37.9%). Mean admission APACHE II and Sequential Organ Failure Assessment scores were 7.52 ± 7.8 and 4.52 ± 3.4, respectively. The commonest organ failure was coagulation (43.4%) followed by respiratory failure (13.1%). Vasopressors were required by 11.6%; and dialysis and mechanical ventilation were required by 7.6% and 9.1%, respectively. Mortality was 12 (6.1%); and on multivariate analysis, APACHE II score (odds ratio, 1.781; 95% confidence interval, 0.967-3.281; P = .048) could independently predict mortality.

Conclusions

Patients with dengue fever may require ICU admission for organ failure. Outcome is good if appropriate aggressive care and organ support are instituted. Admission APACHE II score may predict patients at higher risk of death.     

Prognosis of patients with systemic rheumatic diseases admitted to the intensive care unit

Objective To determine prognostic factors in patients with systemic rheumatic diseases admitted to the intensive care unit (ICU) and to examine whether the observed mortality rate is predicted using the Acute Physiology And Chronic Health Assessment II (APACHE II) score.Design and setting Retrospective study with historical controls in a 31-bed medicosurgical ICU at a university hospital.Patients and participants Seventy-one patients admitted to the ICU for an acute illness related to a systemic rheumatic disease and/or its treatment and 353 ICU control patients.Results Systemic rheumatic diseases were mainly rheumatoid arthritis and vasculitides. In-hospital mortality rate was 28/71 (39%), including 23 patients who died in the ICU. Multivariable logistic regression showed that poor prior health status (Berdits classification), APACHE II score, and admission for infection were associated with mortality, whereas prior use of immunosuppressive agents was not. APACHE II score at admission was higher in nonsurvivors (22±9) than in survivors (17±5) (p<0.01). The standard mortality ratio, i.e., the ratio between observed and predicted mortality, was 1.7 in the 71 study patients and 1.0 in the 353 control patients (p<0.0001).Conclusions In patients with systemic rheumatic diseases admitted to the ICU for at least 48 h, poor prior chronic health status, APACHE II score, and infection were prognostic factors for in-hospital mortality. SMR was higher than in a control ICU population.