Mortality risk factors and validation of severity scoring systems in critically ill patients with acute renal failure

BACKGROUND: Risk stratification and prediction of outcome in acute renal failure patients in the intensive care unit are important determinants for improvement of patient care and design of clinical trials. METHODS: In order to identify mortality risks factors and validate general and specific predictive models for acute renal failure (ARF) patients in the intensive care unit (ICU), 324 patients were prospectively evaluated. Multivariate analysis by logistic regression was utilized for identification of mortality risk factors. Discrimination and calibration were used to evaluate the performance of the following models at referral to nephrologist and at initiation of renal replacement therapy: APACHE II, SAPS II, LODS, and ATN-ISI. Organ failure was assessed by SOFA and OSF. RESULTS: The hospital mortality rate was 85%. The identified mortality risk factors were: age > or = 65 yr, BUN > or = 70 mg/dL, ARF of septic origin, and previous hypertension. Serum creatinine > or = 3.5 mg/dL, systolic blood pressure > or = 100 mm Hg, and normal consciousness were associated with mortality risk reduction. Performance of all prognostic models was disappointing with unsatisfactory calibration and underestimation of mortality on the day of referral to the nephrologist and at initiation of renal replacement therapy. CONCLUSIONS: Cross-validation of prognostic models for ARF resulted in poor performance of all studied scores. Therefore, a specific model is still warranted for the design of clinical trials, comparison of studies, and for prediction of outcome in ARF patients, especially in the ICU.     

Mortality Risk Factors and Validation of Severity Scoring Systems in Critically Ill Patients with Acute Renal Failure

Background. Risk stratification and prediction of outcome in acute renal failure patients in the intensive care unit are important determinants for improvement of patient care and design of clinical trials. Methods. In order to identify mortality risks factors and validate general and specific predictive models for acute renal failure (ARF) patients in the intensive care unit (ICU), 324 patients were prospectively evaluated. Multivariate analysis by logistic regression was utilized for identification of mortality risk factors. Discrimination and calibration were used to evaluate the performance of the following models at referral to nephrologist and at initiation of renal replacement therapy: APACHE II, SAPS II, LODS, and ATN-ISI. Organ failure was assessed by SOFA and OSF. Results. The hospital mortality rate was 85%. The identified mortality risk factors were: age ≥ 65 yr, BUN ≥ 70 mg/dL, ARF of septic origin, and previous hypertension. Serum creatinine ≥ 3.5 mg/dL, systolic blood pressure ≥ 100 mm Hg, and normal consciousness were associated with mortality risk reduction. Performance of all prognostic models was disappointing with unsatisfactory calibration and underestimation of mortality on the day of referral to the nephrologist and at initiation of renal replacement therapy. Conclusions. Cross-validation of prognostic models for ARF resulted in poor performance of all studied scores. Therefore, a specific model is still warranted for the design of clinical trials, comparison of studies, and for prediction of outcome in ARF patients, especially in the ICU.     

The acute physiology and chronic health evaluation III outcome prediction in patients admitted to the intensive care unit after pneumonectomy

PURPOSE: The Acute Physiology and Chronic Health Evaluation (APACHE) III prognostic system has not been previously validated in patients admitted to the intensive care unit (ICU) after pneumonectomy. The purpose of this study was to determine if the APACHE III predicts hospital mortality after pneumonectomy. METHODS: A retrospective review of all adult patients admitted to a single thoracic surgical intensive care unit after pneumonectomy between October 1994 and December 2004. Patient demographics, ICU admission day APACHE III score, actual and predicted hospital mortality, and length of hospital and ICU stay data were collected. Data on preoperative pulmonary function tests and smoking habits were also collected. Univariate statistical methods and logistic regression were used. The performance of the APACHE III prognostic system was assessed by the Hosmer-Lemeshow statistic for calibration and area under receiver operating characteristic curve (AUC) for discrimination. RESULTS: There were 417 pneumonectomies performed during the study period, of which 281 patients were admitted to the ICU. The mean age was 61.1 years, and 67.2% were men; 88.2% were smokers with a median of 40.0 (interquartile range, 18-62) pack-years of tobacco use. The mean APACHE III score on the day of ICU admission was 37.7 (+/- standard deviation 17.8), and the mean predicted hospital mortality rate was 6.4% (+/-10.4). The median (and interquartile range) lengths of ICU and hospital stay were 1.7 (0.9-3.1) and 9.0 (7.0-17.0) days, respectively. The observed ICU and hospital mortality rates were 4.6% (13/281 patients) and 8.2% (23/281), respectively. The standardized ICU and hospital mortality ratios with their 95% confidence intervals (CIs) were 1.55 (0.71-2.39) and 1.27 (0.75-1.78), respectively. There were significant differences in the mean APACHE III score (p < 0.001) and the predicted mortality rate (p < .001) between survivors and nonsurvivors. In predicting mortality, the AUC of APACHE III prediction was 0.801 (95% CI, 0.711-0.891), and the Hosmer-Lemeshow statistic was 9.898 with a p value of 0.272. Diffusion capacity of the lung for carbon monoxide (DLCO) and percentage predicted DLCO were higher in survivors, but the addition of either of these variables to a logistic regression model did not improve APACHE III mortality prediction. CONCLUSIONS: In patients admitted to the ICU after pneumonectomy, the APACHE III discriminates moderately well between survivors and nonsurvivors. The calibration of the model appears to be good, although the low number of deaths limits the power of the calibration analysis. The use of APACHE III data in outcomes research involving patients who have undergone pneumonectomy is acceptable.     

Prediction of outcome in intensive care unit trauma patients: a multicenter study of Acute Physiology and Chronic Health Evaluation (APACHE), Trauma and Injury Severity Score (TRISS), and a 24-hour intensive care unit (ICU) point system.

OBJECTIVE: To conduct a multicenter study to validate the accuracy of the Acute Physiology and Chronic Health Evaluation (APACHE) II system, APACHE III system, Trauma and Injury Severity Score (TRISS) methodology, and a 24-hour intensive care unit (ICU) point system for prediction of mortality in ICU trauma patient admissions. METHODS: The study population consisted of retrospectively identified, consecutive ICU trauma admissions (n = 2,414) from six Level I trauma centers. Probabilities of death were calculated by using logistic regression analysis. The predictive power of each system was evaluated by using decision matrix analysis to compare observed and predicted outcomes with a decision criterion of 0.50 for risk of hospital death. The Youden Index (YI) was used to compare the proportion of patients correctly classified by each system. Measures of model calibration were based on goodness-of-fit testing (Hosmer-Lemeshow statistic less than 15.5) and model discrimination were based on the area under the receiver operating characteristic curve (AUC). RESULTS: Overall, APACHE II (sensitivity, 38%; specificity, 99%; YI, 37%; H-L statistic, 92.6; AUC, 0.87) and TRISS (sensitivity, 52%; specificity, 94%; YI, 46%; H-L statistic, 228.1; AUC, 0.82) were poor predictors of aggregate mortality, because they did not meet the acceptable thresholds for both model calibration and discrimination. APACHE III (sensitivity, 60%; specificity, 98%; YI, 58%; H-L statistic, 7.0; AUC, 0.89) was comparable to the 24-hour ICU point system (sensitivity, 51%; specificity, 98%; YI, 50%; H-L statistic, 14.7; AUC, 0.89) with both systems showing strong agreement between the observed and predicted outcomes based on acceptable thresholds for both model calibration and discrimination. The APACHE III system significantly improved upon APACHE II for estimating risk of death in ICU trauma patients (p < 0.001). Compared with the overall performance, for the subset of patients with nonoperative head trauma, the percentage correctly classified was decreased to 46% for APACHE II; increased to 71% for APACHE III (p < 0.001 vs. APACHE II); increased to 59% for TRISS; and increased to 62% for 24-hour ICU points. For operative head trauma, the percentage correctly classified was increased to 60% for APACHE II; increased to 61% for APACHE III; decreased to 43% for TRISS (p < 0.004 vs. APACHE III); and increased to 54% for 24-hour ICU points. For patients without head injuries, all of the systems were unreliable and considerably underestimated the risk of death. The percentage of nonoperative and operative patients without head trauma who were correctly classified was decreased, respectively, to 26% and 30% for APACHE II; 33% and 29% for APACHE III; 33% and 19% for TRISS; 20% and 23% for 24-hour ICU points. CONCLUSION: For the overall estimation of aggregate ICU mortality, the APACHE III system was the most reliable; however, performance was most accurate for subsets of patients with head trauma. The 24-hour ICU point system also demonstrated acceptable overall performance with improved performance for patients with head trauma. Overall, APACHE II and TRISS did not meet acceptable thresholds of performance. When estimating ICU mortality for subsets of patients without head trauma, none of these systems had an acceptable level of performance. Further multicenter studies aimed at developing better outcome prediction models for patients without head injuries are warranted, which would allow trauma care providers to set uniform standards for judging institutional performance.     

Predicting patient outcome from acute renal failure comparing three general severity of illness scoring systems

BACKGROUND: A major problem of studies on acute renal failure (ARF) arises from a lack of prognostic tools able to express the medical complexity of the syndrome adequately and to predict patient outcome accurately. Our study was thus aimed at evaluating the predictive ability of three general prognostic models [version II of the Acute Physiology and Chronic Health Evaluation (APACHE II), version II of the Simplified Acute Physiology Score (SAPS II), and version II of the Mortality Probability Model at 24 hours (MPM24 II)] in a prospective, single-center cohort of patients with ARF in an intermediate nephrology care unit. METHODS: Four hundred twenty-five patients consecutively admitted for ARF to the Nephrology and Internal Medicine Department over a five-year period were studied (272 males and 153 females, median age 71 years, interquartile range 61 to 78, median APACHE II score 23, interquartile range 18 to 28). Acute tubular necrosis (ATN) accounted for 68.7% (292 out of 425) of patients. Renal replacement therapies (hemodialysis or continuous hemofiltration) were used in 64% (272 out of 425) of ARF patients. RESULTS: Observed mortality was 39.1% (166 out of 425). The mean predicted mortality was 36.2% with APACHE II (P = 0.571 vs. observed mortality), 39.3% with SAPS II (P = 0.232), and 45.1% with MPM24 II (P < 0.0001). Lemeshow-Hosmer goodness-of-fit C and H statistics were 15.67 (P = 0.047) and 12.05 (P = 0.15) with APACHE II, 32.53 (P = 0.0001), 39.8 (P = 0.0001) with SAPS II, 21.86 (P = 0.005), and 20. 24 (P = 0.009) with MPM24 II, respectively. Areas under the receiver operating characteristic (ROC) curve were 0.75, 0.77, and 0.85, respectively. CONCLUSIONS: The APACHE II model was a slightly better calibrated predictor of group outcome in ARF patients, as compared with the SAPS II and MPM24 II outcome prediction models. The MPM24 II model showed the best discrimination capacity, in comparison with both APACHE II and SAPS II models, but it constantly and significantly overestimated mean predicted mortality in ARF patients. None of the models provided sufficient confidence for the prediction of outcome in individual patients. A high degree of caution must be exerted in the application of existing general prognostic models for outcome prediction in ARF patients.     

Risk stratification in emergency surgical patients: is the APACHE II score a reliable marker of physiological impairment?

HYPOTHESES: The APACHE II (Acute Physiology and Chronic Health Evaluation II) score used as an intensive care unit (ICU) admission score in emergency surgical patients is not independent of the effects of treatment and might lead to considerable bias in the comparability of defined groups of patients and in the evaluation of treatment policies. Postoperative monitoring with the APACHE II score is clinically irrelevant. DESIGN: Inception cohort study. SETTING: Secondary referral center. PATIENTS: Eighty-five consecutive emergency surgical patients admitted to the surgical ICU in 1999. The APACHE II score was calculated before surgery; after admission to the ICU; and on postoperative days 3, 7, and 10. MAIN OUTCOME MEASURES: APACHE II scores and predicted and observed mortality rates. RESULTS: The mean +/- SD APACHE II score of 24.2 +/- 8.3 at admission to the ICU was approximately 36% greater than the initial APACHE II score of 17.8 +/- 7.7, a difference that was highly statistically significant (P<.001). The overall mortality of 32% favorably corresponds with the predicted mortality of 34% according to the initial APACHE II score. However, the predicted mortality of 50% according to the APACHE II score at admission to the ICU was significantly different from the observed mortality rate (P =.02). In 40 long-term patients (>/=10 days in the ICU), the difference between the APACHE II scores of survivors and patients who died was statistically significant on day 10 (P =.04). CONCLUSIONS: For risk stratification in emergency surgical patients, it is essential to measure the APACHE II score before surgical treatment. Longitudinal APACHE II scoring reveals continuous improvement of the score in surviving patients but has no therapeutic relevance in the individual patient.     

Long-term survival following intensive care: subgroup analysis and comparison with the general population

This study aimed to compare the very long-term survival of critically ill patients with that of the general population, and examine the association among age, sex, admission diagnosis, APACHE II score and mortality. In a retrospective observational cohort study of prospectively gathered data, 2104 adult patients admitted to the intensive care unit (ICU) of a teaching hospital in Glasgow from 1985 to 1992, were followed until 1997. Vital status at five years was compared with that of an age- and sex-matched Scottish population. Five-year mortality for the ICU patients was 47.1%, 3.4 times higher than that of the general population. For those surviving intensive care the five-year mortality was 33.4%. Mortality was greater than that of the general population for four years following intensive care unit admission (95% confidence interval included 1.0 at four years). Multivariate analysis showed that risk factors for mortality in those admitted to ICU were age, APACHE II score on admission and diagnostic category. Mortality was higher for those admitted with haematological (87.5%) and neurological diseases (61.7%) and septic shock (62.9%). A risk score was produced: Risk Score = 10 (age hazard ratio + APACHE II hazard ratio + diagnosis hazard ratio). None of the patients with a risk score > 100 survived more than five years and for those who survived to five years the mean risk score was 57. Long-term survival following intensive care is not only related to age and severity of illness but also diagnostic category. The risk of mortality in survivors of critical illness matches that of the normal population after four years. Age, severity of illness and diagnosis can be combined to provide an estimate of five-year survival.     

Increased incidence of postoperative infections during prophylaxis with cephalothin compared to doxycycline in intestinal surgery

Background

The Acute Physiology and Chronic Health Evaluation (APACHE) III prognostic system has not been previously validated in patients admitted to the intensive care unit (ICU) after orthotopic liver transplantation (OLT). We hypothesized that APACHE III would perform satisfactorily in patients after OLT

Methods

A retrospective cohort study was performed. Patients admitted to the ICU after OLT between July 1996 and May 2008 were identified. Data were abstracted from the institutional APACHE III and liver transplantation databases and individual patient medical records. Standardized mortality ratios (with 95% confidence intervals) were calculated by dividing the observed mortality rates by the rates predicted by APACHE III. The area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow C statistic were used to assess, respectively, discrimination and calibration of APACHE III.

Results

APACHE III data were available for 918 admissions after OLT. Mean (standard deviation [SD]) APACHE III (APIII) and Acute Physiology (APS) scores on the day of transplant were 60.5 (25.8) and 50.8 (23.6), respectively. Mean (SD) predicted ICU and hospital mortality rates were 7.3% (15.4) and 10.6% (18.9), respectively. The observed ICU and hospital mortality rates were 1.1% and 3.4%, respectively. The standardized ICU and hospital mortality ratios with their 95% C.I. were 0.15 (0.07 to 0.27) and 0.32 (0.22 to 0.45), respectively. There were statistically significant differences in APS, APIII, predicted ICU and predicted hospital mortality between survivors and non-survivors. In predicting mortality, the AUC of APACHE III prediction of hospital death was 0.65 (95% CI, 0.62 to 0.68). The Hosmer-Lemeshow C statistic was 5.288 with a p value of 0.871 (10 degrees of freedom).

Conclusion

APACHE III discriminates poorly between survivors and non-survivors of patients admitted to the ICU after OLT. Though APACHE III has been shown to be valid in heterogenous populations and in certain groups of patients with specific diagnoses, it should be used with caution – if used at all – in recipients of liver transplantation.     

Prediction of acute renal failure by "bedside formula" in medical and surgical intensive care patients

BACKGROUND: Prediction of which intensive care unit (ICU) patients are likely to develop acute renal failure (ARF) would be useful. However, scoring systems such as APACHE have been disappointing in this regard. We previously developed a bedside formula to predict ARF using only 3 parameters: serum albumin, urine osmolality, and presence of sepsis. METHODS: We prospectively evaluated 115 consecutive medical ICU (MICU) patients, comparing the bedside formula to APACHE II AND APACHE III as predictors of ARF or death and looking at nutritional parameters such as iron binding capacity, triceps skin fold, mid-arm circumference, and total lymphocyte count. We then evaluated 123 additional consecutive MICU and 98 consecutive surgical ICU (SICU) patients, comparing the bedside formula to APACHE II. RESULTS: The bedside formula was consistently more accurate than APACHE II in predicting ARF or in-hospital death in MICU patients. However, in SICU neither formula predicted ARF, and APACHE II predicted in-hospital death slightly better. No nutritional parameter other than albumin correlated with ARF. CONCLUSION: The bedside formula appears superior to APACHE II in predicting ARF or death in MICU but not SICU. This suggests that these two ICU populations are different.     

Comparison of Intensive Care and Trauma-specific Scoring Systems in Critically Ill Patients

IntroductionAmongst critically ill trauma patients admitted to ICU and still alive and in ICU after 24 hours, it is unclear which trauma scoring system offers the best performance in predicting in-hospital mortality.MethodsThe Australia and New Zealand Intensive Care Society Adult Patient Database and Victorian State Trauma Registry were linked using a unique patient identification number. Six scoring systems were evaluated: the Australian and New Zealand Risk of Death (ANZROD), Acute Physiology and Chronic Health Evaluation III (APACHE III) score and associated APACHE III Risk of Death (ROD), Trauma and Injury Severity Score (TRISS), Injury Severity Score (ISS), New Injury Severity Score (NISS) and the Revised Trauma Score (RTS). Patients who were admitted to ICU for longer than 24 hours were analysed. Performance of each scoring system was assessed primarily by examining the area under the receiver operating characteristic curve (AUROC) and in addition using standardised mortality ratios, Brier score and Hosmer-Lemeshow C statistics where appropriate. Subgroup assessments were made for patients aged 65 years and older, patients between 18 and 40 years of age, major trauma centre and head injury.ResultsOverall, 5,237 major trauma patients who were still alive and in ICU after 24 hours were studied from 25 ICUs in Victoria, Australia between July 2008 and January 2018. Hospital mortality was 10.7%. ANZROD (AUROC 0.91; 95% CI 0.90-0.92), APACHE III ROD (AUROC 0.88; 95% CI 0.87-0.90), and APACHE III (AUROC 0.88; 95% CI 0.87-0.89) were the best performing tools for predicting hospital mortality. TRISS had acceptable overall performance (AUROC 0.78; 95% CI 0.76-0.80) while ISS (AUROC 0.61; 95% CI 0.59-0.64), NISS (AUROC 0.68; 95% CI 0.65-0.70) and RTS (AUROC 0.69; 95% CI 0.67-0.72) performed poorly. The performance of each scoring system was highest in younger adults and poorest in older adults.ConclusionIn ICU patients admitted with a trauma diagnosis and still alive and in ICU after 24 hours, ANZROD and APACHE III had a superior performance when compared with traditional trauma-specific scoring systems in predicting hospital mortality. This was observed both overall and in each of the subgroup analyses. The anatomical scoring systems all performed poorly in the ICU population of Victoria, Australia.     

Serum osmolality and outcome in intensive care unit patients

BACKGROUND: The aim of the present study was to compare 16 routine clinical and laboratory parameters, acute physiologic and chronic health evaluation (APACHE) and sequential organ failure assessment (SOFA) score for their value in predicting mortality during hospital stay in patients admitted to a general intensive care unit (ICU). METHODS: A retrospective observational clinical study was carried out in a 15-bed ICU in a university hospital. Nine hundred and thirty-three consecutive patients with ICU stay > 24 h (36.2% surgical, 29.1% medical and 34.7% trauma) were observed. Blood sampling, patient surveillance and data collection were performed. The primary outcome was mortality in the hospital. We used receiver operating characteristic (ROC) analyses and logistic regression to compare the 16 relevant parameters, APACHE II and SOFA scores. RESULTS: Two hundred and thirty-three out of the 933 patients died (mortality 25.0%). One laboratory parameter, serum osmolality [area under the curve (AUC) 0.732] had a predictive value for mortality which lay between that of APACHE II (AUC 0.784) and SOFA (AUC 0.720) scores. When outcome prediction was restricted to long-term patients (ICU stay > 5 days), serum osmolality (AUC 0.711) performed better than either of the standard scores (APACHE AUC 0.655, SOFA AUC 0.636). Using logistic regression analysis, the association of clinical parameters, age and diagnosis group with mortality was determined. CONCLUSION: Elevated serum osmolality at ICU admission is associated with an increased mortality risk in critically ill patients. Serum osmolality is cheaper and more rapid to determine than the scoring systems. However, further studies are needed to evaluate the predictive value of serum osmolality in different patient populations.     

The use of APACHE II prognostic system in difficult-to-wean patients after long-term mechanical ventilation

BACKGROUND AND OBJECTIVE: To examine the calibration of the prognostic system Acute Physiology and Chronic Health Evaluation Score (APACHE II) regarding hospital mortality and predicting weaning outcome after long-term mechanical ventilation of the lungs. METHODS: Prospective observational cohort study performed in a respiratory intensive care unit including 246 patients whose lungs were ventilated for 42.1+/-37.8 (median 30) days in the referring hospital. APACHE II (24 h after admission to our respiratory intensive care unit) and the cause of respiratory failure, underlying disease, prior duration of mechanical ventilation and gender were recorded. The predictive power was evaluated with sensitivity and specificity for different cut-off points and summarized in a receiver operating characteristic curve. RESULTS: No difference was found between survivors (APACHE II 16.0+/-4.3) and non-survivors (APACHE II 16.9+/-5.1). In a mean time of 8.0+/-10.3 days, 146 patients (59.3%) were successfully weaned (APACHE II 15.2+/-3.5). One-hundred patients (40.7%) were considered unweanable (APACHE II 17.7+/-5.3). Recalibration of APACHE II to predict weaning failure was possible, resulting in an area under the receiver operating characteristic curve (AUC) of 0.638. Furthermore the AUC improved to 0.723 by changing the weights of selected APACHE items and introducing external factors. Diagnostic accuracy fell from group with mechanical ventilation < or =25 days (AUC 0.770) to group with mechanical ventilation >50 days (AUC 0.517). CONCLUSIONS: APACHE II did not predict hospital mortality after long-term mechanical ventilation of the lungs. Not the original APACHE II but a recalibrated and adapted APACHE II can be useful to predict weaning outcome in patients with less than 25 days of prior lung ventilation.     

Acute renal failure in bone marrow transplant patients admitted to the intensive care unit

BACKGROUND/AIMS: Review of bone marrow transplant (BMT) cases admitted to our intensive care unit (ICU) and to compare co-morbidity and outcome of BMT patients developing or not developing acute renal failure (ARF). METHODS: A case review of BMT patients admitted to the ICU (a 16-bed medico-surgical ICU in a tertiary care teaching institution) over a 4-year period. RESULTS: Between January 1994 and December 1998, 57 among 441 BMT patients (12.9%) were admitted to the ICU, mainly for respiratory distress (58%) and hypotension (32%). Forty-two patients (73.7%) presented ARF as defined as a doubling of serum creatinine. Compared to the 15 other patients, ARF patients had a higher APACHE II score (30 +/- 8 vs. 25 +/- 7, p < 0.05). For ARF vs. non-ARF patients, there was no difference in age (43.8 +/- 10.8 vs. 44.3 +/- 11.1 years), in requirement for mechanical ventilation (76 vs. 73%) and vasopressors (69 vs. 60%), and in prevalence of graft-versus-host disease (19 vs. 13%) or neutropenia (69 vs. 67%), but the prevalence of sepsis (83 vs. 60%) and liver failure (69 vs. 40%) was higher. Maximum serum bilirubin was markedly increased in ARF compared to non-ARF patients (p < 0.005). For both subgroups, no difference in the administration of potential nephrotoxic agents was identified. Usually, ARF was considered multifactorial by clinicians, with ATN being the most frequent diagnosis (55%). Maximum serum creatinine reached a mean of 330 +/- 130 micromol/l. In 74% of cases, ARF occurred concomitantly or after admission to the ICU. Oligoanuria was present in 38%, whereas polyuria was observed in 17%. Fourteen ARF patients (33%) required dialytic support. Mortality rates were significantly different in ARF vs. non-ARF patients (88 vs. 60%, p < 0.05). Predictive factors for the development of ARF were liver failure (odds ratio (OR) 5.9), low serum albumin (OR 1.2) and APACHE II score (OR 1.1), whereas variables predictive of mortality were mechanical ventilation (OR 14.8), ARF (OR 5.8), liver failure (OR 3.7), and APACHE II score (OR 1.2). CONCLUSIONS: This study confirms that ARF in BMT patients admitted to the ICU is frequent, multifactorial, related to liver failure, and that its development has a negative impact on outcome.     

Preoperative and ICU Scoring Models for Predicting the In-Hospital Mortality of Patients With Ruptured Abdominal Aortic Aneurysms

ObjectivesThis study’s objective was to compare several preoperative and intensive care unit (ICU) prognostic scoring systems for predicting the in-hospital mortality of ruptured abdominal aortic aneurysms (RAAAs).DesignRetrospective cohort study.SettingSingle tertiary university center.ParticipantsThe study comprised 157 patients.InterventionsNone.Measurements and Main ResultsA total of 157 patients (82% male) presented with RAAA at Charité University Hospital from January 2011 to December 2020. The mean age was 74 years (standard deviation ten years). In-hospital mortality was 29% (n = 45), of whom nine patients (6%) died en route to the operating room, 13 (8%) on the operating table, and 23 (15%) in the ICU. A total of 135 patients (86%) were admitted to the ICU. All six models demonstrated good discriminating performance between survivors and nonsurvivors. Overall, the area under the curve (AUC) for RAAA preoperative scores was greater than those for ICU scores. The largest AUC was achieved with the Vascular Study Group of New England (VSGNE) RAAA risk score (AUC = 0.87 for all patients, AUC = 0.84 for patients admitted to the ICU), followed by Hardman Index (AUC = 0.83 for all patients, AUC = 0.81 for patients admitted to the ICU), and Glasgow Aneurysm Score (AUC = 0.74 for all patients, AUC = 0.83 for patients admitted to the ICU). The largest AUC for ICU scores (only patients admitted to the ICU) was achieved with Simplified Acute Physiology Score II (0.75), followed by Sepsis-related Organ Failure Assessment (0.73), and Acute Physiology and Chronic Health Evaluation II (0.71).ConclusionsPreoperative and ICU scores can predict the mortality of patients presenting with RAAA. In addition, the discriminatory ability of preoperative scores between survivors and nonsurvivors was larger than that for ICU scores.     

败血症并发急性肾功能衰竭患者的临床特点和影响预后的因素

目的：探讨败血症伴急性肾功能衰竭（ARF）患者的临床特点和影响预后的因素。方法：回顾分析近10年败血症ARF患者的临床资料，分别计算APACHE Ⅱ和ATN－ISI积分，并与非败血症ARF进行对比，运用多因素回归分析观察由败血症引起ARF的临床和主要生化指标与预后的关系。结果：败血症并发ARF者66例，占同期ARF患者的15．6％。多脏器衰竭发生率为87．9％，病死率高达69．7％。单因素分析发现外科原因的败血症、并发呼吸衰竭、肝功能衰竭、辅助呼吸、少尿、昏迷、多脏器衰竭、在ICU中出现ARF以及慢性疾病数目为影响其预后的因素。多因素logistic回归分析结果显示少尿、在ICU中出现的ARF、慢性疾病数目和多脏器衰竭为其独立危险因素。结论：败血症所致ARF患者预后差，其高病死率与少尿，在ICU中出现ARF、合并慢性疾病数目和多脏器衰竭有关。     

Prognostic factors for cancer patients in the postanesthetic recovery unit

OBJECTIVE: To assess the prognosis of cancer patients in an intensive care unit (ICU), to compare the capabilities of severity scoring systems to predict hospital death, and to improve prediction by adding new variables. PATIENTS AND METHODS: Cohort study in a medical-surgical ICU of a university hospital. Demographic and oncologic characteristics were collected along with death records for all nonsurgical cancer patients admitted between January 1995 and June 2000. Severity scores and risk of death were calculated. RESULTS: In the cohort of 250 patients studied, the hospital mortality rate was 58% and the ICU mortality rate was 38.8%. The best predictions were made with the third version of the Acute Physiology and Chronic Health Evaluation (APACHE III), the total maximum Sequential Organ Failure Assessment (SOFA) score, and the total maximum Multiple Organ Dysfunction Score (MODS). The APACHE II and the Simplified Acute Physiology Score (SAPS), version II, were good predictors, whereas the systems of the International Council on Mining and Metals overestimated hospital mortality and the Modality Prediction Model at 0 and 24 hours (MPM0 and MPM24) and the Logistic Organ Dysfunction System underestimated it. The total maximum SOFA and MODS scores had the greatest discriminating capability and the SOFA0, the MODS0, MPM0, and MPM24 had the poorest. All assessment systems except the APACHE III improved when we added new mortality-associated variables: prior functional status, diabetes, radiographic lung infiltrates, mechanical ventilation, and vasoactive support. CONCLUSIONS: Medical oncology patients should not all be denied intensive care. None of the systems assessed offer clinically relevant advantages for predicting hospital mortality in nonsurgical oncology patients in the ICU, although we recommend the SAPS II because it includes oncologic variables, is easy to score, and has good prognostic capability.     

Validierung des Acute Physiology and Chronic Health Evaluation (APACHE) III Scoringsystems und Vergleich mit APACHE II auf einer deutschen Intensivstation

Objectives: The aim of the study was to systematically validate the APACHE III scoring system concerning severity of illness classification and prediction of hospital mortality. Such data have not yet been determined in a large population of critically ill patients in germany. Methods: 531 patients (ICU stay >4?hours) were prospectively and consecutively investigated. The day-1-scores and risk-of-death predictions of APACHE III and APACHE II were determined. A comparison was performed between both scoring systems, and the correlation with the observed hospital mortality was examined. Results: For both main validation criteria, as were discrimination (areas under the ROC-curves: APACHE III 0.873; APACHE II 0.859) and calibration (goodness-of-fit testings; p>0.05), both scoring systems provided satisfying results concerning hospital mortality, no system showing a significantly superior performance. Compared to the observed hospital mortality (13.4%), the prediction of APACHE III (13.2%) was extremely accurate, whereas the prediction of APACHE II was higher (16.8%). The standard (mortality index not significantly <or>1.0) provided by APACHE III was fulfilled, while the standard given by APACHE II was surpassed. The mean scores and the mean risk-of-death predictions for non-survivors were significantly higher compared to survivors (p<0.001). The individual score values of both systems were found to have a strong correlation (r=0.922). Conclusions: APACHE III (like APACHE II) provides a sufficient severity of disease classification and accurately predicts overall hospital mortality in a representatively large german population of a medical ICU. Therefore APACHE III can be regarded as validated for the use in comparable german ICUs. For use as a standard the more recently introduced APACHE III seems to be superior to the established but older APACHE II. However, each user will – depending on the particular questions to be addressed – carefully have to evaluate, if the improvement of prognostic accuracy really justifies the increased amount of workload necessary for calculating APACHE III score and risk prediction.     

Comparison of the severity of illness scoring systems for critically ill cirrhotic patients with renal failure

BACKGROUND: Mortality rates of cirrhotic patients with renal failure admitted to the medical intensive care unit (ICU) are high. End-stage liver disease is frequently complicated by disturbances of renal function. This investigation is aimed to compare the predicting ability of acute physiology, age, chronic health evaluation II and III (APACHE II and III), sequential organ failure assessment (SOFA), and Child-Pugh scoring systems, obtained on the first day of ICU admission, for hospital mortality in critically ill cirrhotic patients with renal failure. METHODS: Sixty-seven patients with liver cirrhosis and renal failure were admitted to ICU from April 2001-March 2002. Information considered necessary for computing the Child-Pugh, SOFA, APACHE II and APACHE III score on the first day of ICU admission was prospectively collected. RESULTS: The overall hospital mortality rate was 86.6%. Liver disease was most commonly attributed to hepatitis B viral infection. The development of renal failure was associated with a history of gastrointestinal bleeding. Goodness-of-fit was good for SOFA, APACHE II and APACHE III scores. The APACHE III and SOFA models reported good areas under receiver operating characteristic curve (0.878 +/- 0.050 and 0.868 +/- 0.051, respectively). CONCLUSION: Renal failure is common in critically ill patients with cirrhosis. The prognosis for cirrhotic patients with renal failure is poor. APACHE III and SOFA showed excellent discrimination power in this group of patients. They are superior to APACHE II and Child-Pugh scores in this homogenous group of patients.     

Outcome of Thirty Patients with ANCA-Associated Renal Vasculitis Admitted to the Intensive Care Unit

The natural course of as-yet-untreated ANCA-associated vasculitis (AAV) or complications of immunosuppressive treatment may result in rapid clinical deterioration with the need of admission to an intensive care unit (ICU). The aim of this retrospective study was to assess the outcome of patients with renal AAV admitted to the ICU in a single center. We reviewed the medical records of all 218 patients with AAV followed in our department between January 2001 and December 2006 and selected those admitted to the ICU. To assess the severity of critical illness, the Acute Physiology and Chronic Health Evaluation (APACHE II) and Sequential Organ Failure Assessment (SOFA) score on the first ICU day were calculated. Birmingham Vasculitis Activity Score (BVAS) was calculated to represent the total disease activity. Thirty patients with AAV (11 women, 19 men; mean age 61.5 ± 13.2 years; 20 × cANCA, 10 × pANCA positive) were included. The most common reasons for ICU admission were as follows: active vasculitis (13 patients, 43.3 %), infections (7 patients, 23.3%), and other causes (10 patients, 33.3%). The in-ICU mortality was 33.3% (10 patients). The most common cause of death was septic shock (in 5 patients). The APACHE II (33.5 vs. 23.8) and SOFA scores (11.9 vs. 6.6), but not BVAS (11.5 vs. 16.1), were statistically significantly higher in non-survivors than in survivors (p < 0.01). In conclusion, the in-ICU mortality in AAV patients may be predicted by APACHE II and SOFA scores. While active vasculitis is the most frequent reason for ICU admission, the mortality rate is highest in patients with infectious complications.     

Outcome of thirty patients with ANCA-associated renal vasculitis admitted to the intensive care unit

The natural course of as-yet-untreated ANCA-associated vasculitis (AAV) or complications of immunosuppressive treatment may result in rapid clinical deterioration with the need of admission to an intensive care unit (ICU). The aim of this retrospective study was to assess the outcome of patients with renal AAV admitted to the ICU in a single center. We reviewed the medical records of all 218 patients with AAV followed in our department between January 2001 and December 2006 and selected those admitted to the ICU. To assess the severity of critical illness, the Acute Physiology and Chronic Health Evaluation (APACHE II) and Sequential Organ Failure Assessment (SOFA) score on the first ICU day were calculated. Birmingham Vasculitis Activity Score (BVAS) was calculated to represent the total disease activity. Thirty patients with AAV (11 women, 19 men; mean age 61.5 +/- 13.2 years; 20 x cANCA, 10 x pANCA positive) were included. The most common reasons for ICU admission were as follows: active vasculitis (13 patients, 43.3 %), infections (7 patients, 23.3%), and other causes (10 patients, 33.3%). The in-ICU mortality was 33.3% (10 patients). The most common cause of death was septic shock (in 5 patients). The APACHE II (33.5 vs. 23.8) and SOFA scores (11.9 vs. 6.6), but not BVAS (11.5 vs. 16.1), were statistically significantly higher in non-survivors than in survivors (p < 0.01). In conclusion, the in-ICU mortality in AAV patients may be predicted by APACHE II and SOFA scores. While active vasculitis is the most frequent reason for ICU admission, the mortality rate is highest in patients with infectious complications.