SOFA评分对多器官功能障碍综合征患者的预后评价作用

目的 :探讨序贯器官衰竭估计 (SOFA)评分与多器官功能障碍综合征 (MODS)患者预后的关系。方法 :应用欧洲重症监护医学协会 (ESICM)感染相关问题工作组制订的 SOFA评分体系 ,进行回顾性统计分析 ,比较存活组与死亡组患者入院时 SOFA评分、最大 SOFA评分、Δ SOFA评分的差异 ,评价 SOFA评分在预后估计中的作用。结果 :累计最大 SOFA评分、累计ΔSOFA评分存活组与死亡组相比显著差异 (P均 <0 .0 1) ,入院时累计 SOFA评分无显著差异 (P >0 .0 5 )。各单个器官系统相比 ,存活组与死亡组最大 SOFA评分和ΔSOFA评分中除肝、肾外 ,余均有显著差异 (P均 <0 .0 5 ) ;而入院时各单个器官 SOFA评分仍无显著差异。存活组在入院最初 7日每日平均评分逐渐下降 ,而死亡组每日平均评分逐渐升高 ,7日内 2组有显著差异的变化出现在入院后 4 8小时 (P<0 .0 5 )。随器官衰竭个数的增加 ,病死率急剧增加 ,累计最大 SOFA评分呈直线上升 ,组间有非常显著差异 (P<0 .0 1)。结论 :最大 SOFA评分和 ΔSOFA评分对 MODS有良好的预后评价作用     

慢性肾衰及并发多脏器功能衰竭患者的护理

目的探讨护理在肾衰及并发多脏器功能衰竭治疗中的作用。方法对慢性肾衰及并发多脏器功能衰竭30例患者在正常治疗的同时配合以综合、饮食及心理护理。结果 29例患者积极配合治疗,1例患者因经济原因放弃治疗,治疗过程中无严重不良反应。结论对慢性肾衰及并发多脏器功能衰竭患者在正常治疗的同时配合以综合、饮食及心理护理,极大地提高了患者的生活质量。     

Dynamic lactate indices as predictors of outcome in critically ill patients

Introduction  

Dynamic changes in lactate concentrations in the critically ill may predict patient outcome more accurately than static indices. We aimed to compare the predictive value of dynamic indices of lactatemia in the first 24 hours of intensive care unit (ICU) admission with the value of more commonly used static indices.     

老年多器官功能衰竭患者的护理

目的总结老年多器官功能衰竭患者的护理要点,以促进患者康复。方法对收治的48例老年多器官功能衰竭患者实施精心的护理,包括心理护理,基础护理,呼吸道护理,心功能护理,肾脏的护理,肝,脑,消化脏器的护理等,观察治疗护理效果。结果 48例患者中,19例好转,占39.6%。结论对老年多器官功能衰竭患者进行精心的护理,可以使患者预后良好,降低死亡率。     

重症胰腺炎合并多器官功能衰竭患者的监护要点

笔介绍30例重症胰腺炎合并多器官功能衰竭患的监护要点。重点介绍合并呼吸衰竭的监护。强调使用呼吸机时．护士要熟练掌握呼吸机性能，精通呼吸道管理，正确掌握吸痰时间和方法。严密监护心血管、肾等功能。护士通过严密监护，准确提供病情动态信息，积极预防并发症，在抢救生命过程中起到重要作用。     

重症心衰患者血浆N端脑钠肽前体测定的价值

目的:探讨重症心衰患者血浆N端脑钠肽前体(NT-proBNP)与心功能的关系,评价其对死亡的预测价值.方法:入选31例ICU重症心力衰竭患者,测定血浆NT-proBNP水平,同时行心脏彩超及无创血流动力学检查测定心室射血分数(EF)、心脏指数(CI)、左心做功指数(LCWI)、加速指数(ACI)等心功能指标,并将其与NT-proBNP水平行相关性分析.根据28 d预后将入选患者分为存活组和死亡组,比较两组患者的一般情况、NT-proBNP水平、急性生理和慢性健康状况(APACHE Ⅱ)评分等指标的差异,其后以Logistic回归分析确定其中影响28 d预后的独立危险因素,并以ROC曲线评价NT-proBNP水平对重症心衰患者预后的预测作用.结果:CI、LCWI、ACI、EF正常患者组的NT-proBNP水平均低于异常患者组.死亡组血浆NT-proBNP明显高于存活组[(7 056.1±1 354.8) ng/L比(2 516.8±450.9) ng/L,P<0.05],Logistic回归分析显示NT-proBNP水平、APACHE Ⅱ评分、并发严重感染为重症心衰患者28 d死亡的独立危险因素.28 d死亡的ROC曲线分析示NT-proBNP水平曲线下面积为0.759(95%CI 0.584～0.935,P<0.05).结论:重症心衰患者的血浆NT-proBNP水平与传统心功能指标相关,并对预后判断有重要参考价值.     

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。     

Colchicine-related death presenting as an unknown case of multiple organ failure

A 45-year-old man presented to the emergency department (ED) with acute renal and hepatic failure as well as hypotension and metabolic acidosis. Despite aggressive intensive care, he had continued hypotension, leukocytosis, fever, renal and hepatic failure, and lactic acidosis. On hospital day 3, pancytopenia was noted. Bone marrow biopsy showed marked aplasia without a specific etiology being elucidated. He received granulocyte colony-stimulating factor and antibiotics, but died on hospital day 12 after a cardiac arrest. The patient repeatedly denied intentional drug ingestion. Due to his clinical course, the poison center recommended obtaining a colchicine level. The plasma colchicine level, 72 h after admission, was 6.1 ng/mL (GC/MS). This level exceeds acute levels reported in some cases of prior fatalities. This case is novel in that the patient’s multiple organ dysfunction remained unexplained for several days before occult colchicine toxicity was implicated as the probable cause by the colchicine level. Also, there was a paucity of gastrointestinal symptoms on presentation, the opposite of what is expected in colchicine toxicity.     

谷氨酰胺缺乏对危重病患者免疫及脏器功能的影响

目的探讨谷氨酰胺(G ln)缺乏对危重病患者免疫和脏器功能的影响。方法2005年1—6月急诊进入外科重症监护室(S ICU)的危重病患者40例,其急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)≥8分;同期健康志愿者10名作为对照。留取患者入S ICU后48 h内凌晨6时空腹静脉血,观察患者血G ln水平、免疫功能及各脏器指标的变化。结果危重病患者血G ln明显低于健康对照组,并与APACHEⅡ评分呈明显负相关(r=0.572,P<0.05)。免疫指标中CD 4/CD 8比例(T辅助淋巴细胞与T抑制淋巴细胞)与血G ln浓度呈明显正相关(r=0.704,P<0.05),而其他免疫指标未见明显相关性。患者单核细胞中人白细胞DR抗原(HLA DR)表达明显低于健康对照组,血G ln浓度正常组(≥420μm o l/L)单核细胞HLA DR表达也较G ln缺乏组增高,但差异无显著性。G ln正常组血浆总胆红素>19μm o l/L、氧合指数<300 mm Hg(1 mm Hg=0.133 kPa)及血肌酐>110μm o l/L的发生率均低于G ln缺乏组。死亡组血G ln浓度平均为(333.2±95.1)μm o l/L,与存活组(466.1±125.2)μm o l/L相比明显降低(P<0.05)。结论危重病患者存在G ln缺乏,血G ln水平的下降对机体免疫功能、脏器功能及预后有一定影响。     

脑出血继发多器官功能衰竭76例临床分析

目的 :探讨脑出血继发多器官功能衰竭 (MOF)的病因及防治措施。方法 :收集继发MOF病例 76例 ,与同期无MOF的 2 40例脑出血相对照 ,从病死率、发病年龄、发病机理等方面进行分析。结果 :MOF组病死率 61 8% ,而同期无MOF者 2 40例脑出血病死率为 5 42 % (P <0 0 1)。且脏器衰竭数目越多 ,病死率越高 ,高龄、有慢性疾病、意识障碍严重、脑出血量大者易并发MOF。结论 :MOF是脑出血死亡的重要原因之一 ,在防止脑功能衰竭的同时要积极治疗其它慢性基础疾病     

危重病人手术后肝脏能量代谢与多器官衰竭的关系

目的测定反映危重病人手术后肝脏能量代谢的有关指标,并研究其变化与多器官衰竭（ＭＯＦ）的关系,探讨其临床价值。方法测定术后病人动脉血酮体比率（ＡＫＢＲ）,根据ＡＫＢＲ变化将１５８例病人分成３组：Ａ组９４例,Ｂ组５５例,Ｃ组９例。并比较各组病人术后病情变化。结果术后ＡＫＢＲ一直保持在０７以上的Ａ组中,仅２例病人（占２１％）发生单个器官衰竭;ＡＫＢＲ在０４～０７,但在短时间内逐渐回升到０７以上的Ｂ组中,有１９例病人（占３４５％）共２７个器官发生功能衰竭;术后ＡＫＢＲ逐渐下降到０４以下的Ｃ组中,所有９例病人（占１００％）,共３２个器官发生功能衰竭,且９例病人均死于ＭＯＦ。结论通过临床观察证明ＡＫＢＲ的变化与ＭＯＦ的发生有直接关系,而ＡＫＢＲ是评价肝脏能量代谢的可靠指标。由此可见,肝脏能量代谢障碍在术后ＭＯＦ的发生过程中起着关键性作用。     

40例多器官衰竭时急性肾功能衰竭的临床分析

目的：探讨多器官衰竭（ＭＯＦ）时急性肾功能衰竭（ＡＲＦ）的更为有效的防治手段，防止和阻断其进一步发展，改善ＭＯＦ的预后。方法：对４０例ＭＯＦ合并ＡＲＦ的病例资料进行临床分析。结果：ＭＯＦ的主要原发病因是感染（７０．０％），其次是创伤（２２．５％），其它占７．５％；本组患者的病死率６５．０％，且随衰竭器官的数目增多而病死率升高。ＡＲＦ表现为少尿型８７．５％，非少尿型１２．５％。采用血液透析（ＨＤ）治疗２２例中存活１２例，死亡１０例，病死率５４．５％；非ＨＤ治疗１８例中存活２例，死亡１６例，病死率８８．９％，比较此两种治疗方法的疗效ＨＤ组明显高于非ＨＤ组（Ｐ＜０．０１）。结论：对于ＭＯＦ时ＡＲＦ的治疗，首先应针对各器官衰竭的治疗；积极有效地控制感染是抢救成功的关键；早期充分的血液净化是治疗的重要环节；辅助支持疗法，提高免疫功能，改善组织缺氧，禁止应用对肾脏有损害的药物，对改善本病的预后具有重要意义。     

Changes in severity and organ failure scores as prognostic factors in onco-hematological malignancy patients admitted to the ICU

Objective To determine whether severity and organ failure scores over the first 3 days in an ICU predict in-hospital mortality in onco-hematological malignancy patients.Design and setting Retrospective study in a 22-bed medical ICU.Patients 92 consecutive patients with onco-hematological malignancies including 20 hematopoietic stem cell transplantation (HSCT) patients (11 with allogenic HSCT).Measurements Simplified Acute Physiology Score (SAPS) II, Organ Dysfunction and/or Infection (ODIN) score, Logistic Organ Dysfunction System (LODS), and Sequential Organ Failure Assessment (SOFA) score were recorded on admission. The change in each score (Δ score) during the first 3 days in the ICU was calculated as follows: severity or organ failure score on day 3 minus severity or organ failure score on day 1, divided by severity or organ failure score on day 1.Results In-hospital mortality was 58%. Using multivariate analysis in-hospital mortality was predicted by all scores on day 1 and all Δ scores. Areas under the receiver operating characteristics curves were similar for SAPS II (0.78), ODIN (0.78), LODS (0.83), and SOFA (0.78) scores at day 1. They were also similar for ΔSAPS II, ΔODIN, ΔLODS, and ΔSOFA. Similar results were observed when excluding patients with allogenic HSCT.Conclusion Severity and three organ failure scores on day 1 and Δ scores perform similarly in predicting in-hospital mortality in ICU onco-hematological malignancy patients but do not predict individual outcome. Decision to admit such patients to the ICU or to forgo life-sustaining therapies should not be based on these scores.Electronic supplementary material Supplementary material is available in the online version of this article at and is accesible for authorized users.     

Validation of the multiple organ dysfunction (MOD) score in critically ill medical and surgical patients

Objective To validate the Multiple Organ Dysfunction (MOD) score externally.Design Prospective observational cohort study.Setting Mixed medical/surgical ICU in a tertiary referral university hospital.Patients and participants Thousand eight hundred and nine patients admitted to ICU for more than 24 h over a 3-year period.Interventions None.Measurements and results The MOD score was calculated daily for all patients. The criterion validity of the individual organ scores, the maximal MOD score and the change in MOD score were assessed by examining the relationship between increasing scores and ICU mortality. Increased maximal MOD scores and each of the six individual organ scores, and change in MOD scores were associated with increased mortality.Conclusions Maximal and individual organ scores have criterion validity when tested in a different ICU from that in which the scores were derived, indicating that the scoring systems are reproducible. The association of change in MOD score with mortality indicates that the score is responsive. These data, combined with previous data establishing concept and content validity, indicate that the MOD score is a valid measure of multi-organ dysfunction.     

Model for End-Stage Liver Disease score predicts mortality in critically ill cirrhotic patients

Purpose

Cirrhosis is a common condition that complicates the management of patients who require critical care. There is interest in identifying scoring systems that may be used to predict outcome because of the poor odds for recovery despite high-intensity care. We sought to evaluate how Model for End-Stage Liver Disease (MELD), an organ-specific scoring system, compares with other severity of illness scoring systems in predicting short- and long-term mortality for critically ill cirrhotic patients.

Materials and methods

This was a retrospective cohort study involving seven intensive care units (ICUs) in a tertiary care, academic medical center. Adult patients with cirrhosis who were admitted to an ICU between 2001 and 2008 were evaluated. Severity of illness scores (MELD and Sequential Organ Failure Assessment [SOFA]) were calculated on admission and at 24 and 48 hours. The primary end points were 28-day and 1-year all-cause mortality.

Results

Of 19 742 ICU hospitalizations, 848 had cirrhosis. Relevant data were available for 521 patients (73%). Of these cases, 353 patients (69.5%) were admitted to medical ICU (MICU), and the other 155 (30.5%), to surgical unit. Alcohol abuse and hepatitis C were the most common reasons for cirrhosis. Patients who died within 28 days were more likely to receive mechanical ventilation, pressors, and renal replacement therapy. Among 353 medical admissions, both MELD and SOFA were found to be significantly associated with both 28-day and 1-year mortality. Among the 155 surgical admissions, both scores were found to be not significant for 28-day mortality but were significant for 1 year.

Conclusions

Our results demonstrate that the prognostic ability of a variety of scoring systems strongly depends on the patient population. In the MICU population, each model (MELD + SOFA, MELD, and SOFA) demonstrates excellent discrimination for 28-day and 1-year mortality. However, these scoring systems did not predict 28-day mortality in the surgical ICU group but were significant for 1-year mortality. This suggests that patients admitted to a surgical ICU will behave similarly to their MICU cohort if they survive the perioperative period.     

The use of propofol for sedation of critically ill patients undergoing haemodiafiltration

Objective To assess the requirement for propofol to provide sedation in critically ill patients in established renal failure during the commencement of haemodiafiltration.Design Prospective clinical study.Setting ICU, University Hospital.Patients 10 adult patients. All were mechanically ventilated, had acute oliguric renal failure which necessitated continuous veno-venous haemodiafiltration and were receiving a continuous intravenous infusion of propofol for sedation. Sedation was assessed using a scoring system.Intervention Veno-venous haemodiafiltration.Measurements and results Connection of the extracorporeal circuit produced a reduction in plasma propofol concentration in 7 out of 9 patients (one sample misplaced) with subsequent awakening in 3 of these 7 patients. The commencement of haemodiafiltration itself did not significantly influence the requirement for propofol (8 out of 10 patients).Conclusion Haemodiafiltration does not substantially influence the requirement for propofol but the initial introduction of the extracorporeal circuit will reduce plasma concentrations in the majority of patients. This may be due to haemodilution alone or absorption of plasma albumin (with propofol) onto the membrane.