Colloid solutions in the critically ill

All patients admitted to an Intensive Care Unit were randomised to receive all volume replacement fluid as either human albumin solution or a synthetic colloid. A total of 475 patients were admitted during the study period. Patients' age, sex, APACHE score and calculated risk of death were assessed on admission. Outcome was assessed as length of Intensive Care stay and mortality. There was no difference between the groups. Subgroups of patients with APACHE score greater than 10, calculated risk of death greater than 50% and length of stay greater than 5 days were also evaluated but not significant differences were found between treatment groups. The use of albumin rather than 3.5% polygeline for volume replacement in the Intensive Care Unit has no influence on outcome.     

Effects of APACHE II score on mechanical ventilation; prediction and outcome

AIM: To evaluate the influence of Acute Physiology and Chronic Health Evaluation (APACHE II) score on the choice of mechanical ventilation method and treatment outcome. METHODS: A prospective, randomized trial was carried out at the multidisciplinary Intensive Care Unit over 22 months. Research sample consisted of 129 patients who required mechanical ventilation, divided in two groups: APACHE II < or = 20 and APACHE II > 20. Both groups were than randomized for either noninvasive or invasive mechanical ventilation. Comparison was made based on patient characteristics, objective parameters and influence of APACHE II score on treatment success and failure. RESULTS: APACHE II scoring was shown to have statistical significance on outcome assessment. Statistical significance was in favour of patients with APACHE II score < or = 20 vs > 20 (ventilator associated pneumonia 0 vs. 10, tracheotomy 0 vs. 16, Intensive Care Unit mortality 0 vs 12). Furthermore, in the group with APACHE II score > 20, after randomization, there was a statistical significance in favour of noninvasive mechanical ventilation in need for tracheotomy 2 (4%) vs. 14 (28%) (p < 0.001). CONCLUSION: Using good patient selection and applying strict protocols, in the group of patients with APACHE II < or = 20 all patients had successful mechanical ventilation, while in the group of patients with APACHE II > 20, noninvasive mechanical ventilation can be applied.     

A comparison of APACHE II and a clinical sickness score

The aim of this study was to compare the predictive power of a simple illness severity score (Clinical Sickness Score) to that of APACHE II in a District General Hospital intensive therapy unit. A prospective comparison was carried out on 97 consecutive adult patients whose severity of illness was scored one hour after admission using both the Clinical Sickness Score and APACHE II. Intensive Therapy Unit and hospital outcomes were recorded for each patient. The Clinical Sickness Score and APACHE II identified survivors and nonsurvivors with similar power (p less than 0.001). There was a highly significant correlation between the two scoring systems for hospital survivors and nonsurvivors together (r = 0.5418, r2 = 0.28, p = less than 0.0001) and for hospital survivors alone (r = 0.6102, r2 = 0.37, p = 0.0001). Correlation for hospital nonsurvivors was not significant (r = 0.1629, r2 = 0.027, p = 0.3134). The positive predictive values of APACHE II were between 5% and 10% more sensitive than the Clinical Sickness Score for hospital outcome. Admission Clinical Sickness Score and APACHE II scores had similar predictive power in this study.     

重型颅脑外伤患者术后早期营养支持策略的选择与疗效分析

目的 研究三种不同早期营养支持方案下重型颅脑外伤患者术后营养状况及短期预后的差异.方法 回顾性分析2014年7月-2016年7月苏北人民医院神经外科重症监护室收治的60例重型颅脑外伤术后患者,依据不同营养支持方案分为早期联合营养组、早期肠内营养组和早期肠外营养组.记录三组患者治疗前的基础临床特征、治疗后两周内的营养数据以及神经外科重症监护室住院时间、并发症情况和GCS评分.结果 早期营养支持中,早期联合营养组患者空腹血糖、血清前白蛋白、血清总蛋白、全血血红蛋白、C-反应蛋白分别为(5.74±0.64)mmol/L、(203.80±10.45) mg/L、(61.99±1.34) g/L、(114.53 ± 2.69) g/L、(0.37±0.06) mg/dl,以上数据改善情况均优于早期肠内营养组及早期肠外营养组.早期联合营养组神经外科重症监护室住院时间(11.6±0.42)d明显低于早期肠内营养组(13.20±0.42)d及早期肠外营养组(14.65±0.42)d.早期联合营养组并发症发病率最低.早期联合营养组GCS评分(11.40±1.60)分改善最显著,差异均具有统计学意义(P＜0.05).结论 重型颅脑外伤术后早期施行肠内外联合营养治疗能显著促进患者营养指标提升,同时降低并发症发病率,缩短神经外科重症监护室住院时间,减轻昏迷程度,值得临床推广.     

Comparison of Acute Physiology and Chronic Health Evaluation (APACHE) II score with organ failure scores to predict hospital mortality

This study compared the performance of the Acute Physiology and Chronic Health Evaluation (APACHE) II score with two organ failure scores in predicting hospital mortality of critically ill patients. A total of 1311 consecutive adult patients in a tertiary 22-bed multidisciplinary intensive care unit (ICU) in Western Australia were considered. The APACHE II score had a better calibration and discrimination than the Max Sequential Organ Failure Score (Max SOFA) (area under receiver operating characteristic (ROC) curve 0.858 vs 0.829), Admission SOFA (area under ROC 0.858 vs 0.791), and the first day or cumulative 5-day Royal Perth Hospital Intensive Care Unit (RPHICU) organ failure score (area under ROC 0.858 vs 0.822 and 0.819, respectively) in predicting hospital mortality. The APACHE II score predicted hospital mortality of critically ill patients better than the SOFA and RPHICU organ failure scores in our ICU.     

Validación de las escalas de APACHE II y SOFA en 2 cohortes de pacientes con sospecha de infección y sepsis,no ingresados en unidades de cuidados críticos

ObjectiveTo validate the APACHE II and SOFA scores in patients with suspected infection in clinical settings other than intensive care units.Materials and methodsA secondary analysis was performed on 2,530 adult patients participating in 2 cohort studies, with suspected infection as admission diagnosis within the first 24 h of hospitalization. The performance of both scoring systems was studied in order to set calibration and discrimination, respectively, on the outcomes such as mortality, admission to Intensive Care Unit, development of septic shock, or multiple organ dysfunctions.ResultsThe AUC-ROC values for mortality at discharge and on day 28 in the first cohort were around 0.50 for the SOFA and APACHE II scores; whereas for the second cohort the discrimination value was around 0.70. Calibration of both scoring systems for primary outcomes, according to Hosmer-Lemeshow test, showed p > .05 in the first cohort; while in the second cohort calibration it only showed a p > .05 in the case of the SOFA for mortality at hospital discharge.ConclusionThis validation study of SOFA and APACHE II scores in patients with suspected infection in-hospital units other than the Intensive Care Unit, showed no consistent performance for calibration and discrimination. Its application in emergency and in-hospital patients is limited.     

Prognostic systems in intensive care: TRISS, SAPS II, APACHE III

BACKGROUND: To validate the accuracy of SAPS II, APACHE III and TRISS for the prediction of mortality in Intensive Care Unit (ICU) at polytrauma patients admission. The outcome of multiple trauma patients is often linked to the degree of physiologic dysfunction and to the extension of anatomic lesions, the age of the patient and the lesion mechanism. METHODS: The study population consisted of 93 cases of multiple injured patients hospitalised at the ICU of the Padua hospital from October 1998 to October 1999; the term polytraumatized patient is referred to patients who have multiple lesions of which at least one potentially endangers, immediately or in a short term, their life. These cases were evaluated with the APACHE III, SAPS II, Revised Trauma Score and Injury Severity Score. The predictive power of each system was evaluated by using decision matrix analysis to compare observed and predicted outcome with a decision criterion of 0.50 and 0.40 for risk of hospital death. RESULTS: All trauma score systems under study showed high accuracy rates, above all if they are used with a 40% positive test. CONCLUSIONS: The prognostic scales used in this study showed a good correlation between expected and observed cases, particularly with TRISS and APACHE III systems. The APACHE III system seems to be the most reliable of the different methods analysed. These prognostic systems are seldom or occasionally used in the ICU, in Padua and in the whole of Italy, so Italian data are not suitable to be compared to international ones. Due to urgency, the importance of the evaluation scales is often underestimated, but even if they require time and attention, they surely can be useful in the evaluation of the treatment, and not only of a polytraumatized patient.     

DRGs and outliers in surgical critical care

The authors evaluated the charges, outcome, and characteristics of patients requiring prolonged stay in the Surgical Intensive Care Unit (SICU) as if all reimbursement was from the Medicare DRG system. The records of patients staying in the SICU longer than 20 days over an 18 month period were reviewed. Age, mortality, service, length of stay, hospital charge, and projected DRG reimbursement were recorded. Patients whose hospital stay exceeded the maximum expected for their DRG were considered day outliers. The 51 study patients had a mean age of 59 +/- 17.6 years. They comprised 1.3 per cent of all patients in the SICU and 30.7 per cent of all SICU patient days during the study period. Mortality was 39.2 per cent. Thirty-two patients (62.7%) were day outliers. The mean hospital charge per patient was $59,552 while the mean projected DRG reimbursement was $10,435, for a total projected loss in billed charges of $2,504,428. DRG reimbursement for patients requiring prolonged SICU stay is inadequate to meet their charges and may severely limit future SICU use.     

Effect of antithrombin concentrate on haemostatic variables in critically ill patients

In a controlled pilot study of 32 critically ill patients, we have attempted prospectively to identify laboratory variables which can be used to select and monitor patients on antithrombin (AT) therapy. Patients with plasma AT levels less than 70% of normal were randomized to receive (AT group) or not to receive AT concentrate (non-AT group). The groups did not differ in median age, sex, median APACHE II and TISS scores, number of days spent in the Intensive Care Unit or mortality rate. At the time of inclusion all patients had activated coagulation and fibrinolysis demonstrated as high levels of soluble fibrin, thrombin-antithrombin complexes and fibrin-D-dimers (twice, four and ten times the upper reference range, respectively). In the AT group these levels decreased faster and the prothrombin complex concentration increased more rapidly to normal (i.e. the prothrombin time decreased). The level of C-reactive protein which was high in both groups on inclusion (139 and 98 mg/l, respectively) decreased by 40% in the AT group but did not change in the control group. Our study indicates that laboratory variables normalize faster in seriously ill patients who have activated coagulation and fibrinolysis when they receive AT concentrate and that the variables mentioned above seem to be useful for monitoring the treatment.     

Association of obesity with increased mortality in the critically ill patient

The impact of obesity on critical care outcomes has been an issue for debate in the literature. Variable data and conflicting results have been reported. The purpose of our study is to examine the impact of obesity on the outcome of patients admitted to a tertiary closed Intensive Care Unit (ICU) in Saudi Arabia. Data was obtained from a prospectively collected database from September 2001 to May 2004. Patients younger than 18, those with burns, brain death and readmissions were excluded. The study population was stratified into six groups according to their Body Mass Index (BMI). Primary endpoints were ICU and hospital mortality, duration of mechanical ventilation and ICU length of stay. A total of 1835 patients were included in the analysis. Baseline characteristics were similar among the six groups including severity of illness scores, reflected by Acute Physiology and Chronic Health Evaluation II (APACHE II) scores. The ICU mortality was not statistically different among the groups. Hospital mortality was lower in patients with BMI 35-39.9 kg/m2 and BMI >40 kg/m2 compared to those with BMI 18.5-24.9 kg/m2. Multivariate analysis showed that a BMI >40 kg/m2 was an independent predictor of lower hospital mortality (odds ratio 0.51, 95% confidence interval 0.28-0.92, P 0.025) after adjustment for other confounding factors. In conclusion, mortality of obese critically ill patients was not higher than patients with normal weight. In fact, the hospital mortality was lower for patients with BMI >40 kg/m2 compared to the normal BMI group despite similar severity of illness. Obesity might have a protective effect, although further studies are needed to substantiate this finding.     

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.     

Integration of APACHE II and III scoring systems in extremely high risk patients with acute renal failure treated by dialysis

OBJECTIVE: Acute physiology, age, chronic health evaluation II and III (APACHE II and III) scoring systems obtained on the day of the initiation of dialysis were compared the mortality rate among in critically ill patients with acute renal failure requiring dialysis. DESIGN: Retrospective study. SETTING: Intensive care units in a tertiary care university hospital in Taiwan. PATIENTS: 100 patients diagnosed with acute renal failure and requiring dialysis were admitted to intensive care units from January 1997 through December 1998. INTERVENTIONS: Information deemed necessary to compute the APACHE II and APACHE III score on the day of dialysis initiation was collected. MEASUREMENTS AND RESULTS: The overall hospital mortality rate was 71%. The relationship between APACHE II and APACHE III scores for patients was linear and correlated significantly in all subgroups. Goodness-of-fit was good for APACHE II and APACHE III models. Both reported good areas under receiver operating characteristic curve. Death in most patients was related to a higher APACHE II or APACHE III score during the 24 h immediately preceding the initiation of acute hemodialysis. Our results indicated a significant rise in mortality rates associated with higher APACHE II or III scores among all patients. Although less than 60%, the mortality rates markedly increased extent when APACHE II score of 24 or higher or APACHE III score above 90 had mortality rates exceeding 85%. CONCLUSION: Both predictive models demonstrated a similar degree of overall goodness-of-fit. Although APACHE II showed better calibration, APACHE III was better in terms of discrimination. The prediction accuracy of the APACHE II score for extremely high-risk patients is further enhanced by specific utility of APACHE III scoring as a second prediction model when the AII score is 24 or higher.     

Night-shift discharge from intensive care unit increases the mortality-risk of ICU survivors

Intensive Care (ICU) survivors discharged from ICU to the general ward at night have a higher mortality. We sought to clarify which factors, including night-shift discharge, influence outcome following ICU discharge in a metropolitan hospital, using a cohort study of critically-ill patients between 1/1/1999-30/4/2003. Patients were excluded from analysis if they (a) died in ICU, (b) were transferred to another hospital, (c) had an ICU length of stay <8 hours, or (d) age <16 years. Logistic regression was used to derive a predictive model based on the following variables: patient demographics, severity of illness following ICU admission (APACHE II mortality-risk, p(m)), final diagnosis, discharge timing including premature or delayed (>4 hours) ICU discharge, and "limitation of medical treatment" orders. The outcome measures were patient status at hospital discharge and ICU readmission rate. Of the 1870 ICU survivors, 92 (4.9%) died after discharge from ICU. Patients discharged to the ward during the night-shift (2200-0730 hours) had a higher APACHE II score and crude mortality. The difference in APACHE II p(m) did not reach statistical significance. No significant calendar or seasonal pattern was identified. Logistic regression identified night-shift discharge (RR=1.7; 95% CI 1.03-2.9; P=0.03), limited medical treatment order (RR=5.1; 95% CI 2.2-12) and admission APACHE II p(m) (RR=3.3; 95% CI 1.3-7.6) as independent predictors of patient outcome following ICU transfer to the ward. Conclusion: At the time of ICU discharge to the ward three factors are predictive of hospital outcome: timing of ICU discharge, limited medical treatment orders and initial illness severity.     

Costs, severity of illness and outcome in intensive care

Severity of illness (Therapeutic Index Severity Score, Classes 1-4) and direct clinical costs (labour costs, diagnostic costs, drugs, disposables, etc.) were determined for 100 consecutive patients admitted to Royal Newcastle Hospital Intensive Care Unit over six weeks. Outcome was assessed using mortality, quality of life, functional status, productivity and mental status one month after separation from the Unit. The mean total admission cost was $1,357 (Class 4 mean = $3,706) but for over 70% of patients costs were less than $1,000. The main component of cost was labour (about 60% for all classes). TISS proved a strong predictor (P less than 0.001) of total admission costs. Survival to one month was 89% and optimal association between cost and survival was found with those with low costs more likely to survive (P less than 0.001). On the other hand, no association was found between total admission cost and resulting quality of life. However, there was an association between pre-admission and follow-up quality of life (P less than 0.0005).     

Prediction of outcome in acute pancreatitis: a comparative study of APACHE II, clinical assessment and multiple factor scoring systems

The APACHE II severity of disease classification system has been examined prospectively in 160 patients with acute pancreatitis. Using clinical and simple laboratory data APACHE II was able to provide useful discrimination between uncomplicated, complicated and fatal attacks within a few hours of admission. Peak APACHE II scores (recorded during the first 3 days) had a prognostic accuracy similar to the multiple factor scoring systems, but then incurred a similar delay. Patients could be graded according to their risk of death or of developing a major complication; no deaths occurred in patients with a peak APACHE II score less than 10. APACHE II can be repeated daily, uncomplicated attacks demonstrating falling scores in association with clinical improvement, in contrast to the rising scores associated with clinical deterioration in those dying early. APACHE II appears to reflect any continuing disease activity and may prove a useful means of monitoring the course of the illness and response to therapy.     

The requirement for intensive care support for the pregnant population

Pregnancy-associated admissions to the Intensive Care Unit during the first 5 years of a newly established teaching hospital obstetric unit are reviewed. There were 23 such admissions; in the same period, 21,983 deliveries occurred. The most frequent cause for Intensive Care admission was hypertensive disease of pregnancy. Most patients required admission for less than 48 hours. Two patients died during the period of study.     

The RACHS-1 risk categories reflect mortality and length of stay in a Danish population of children operated for congenital heart disease

Objective: The Risk Adjusted classification for Congenital Heart Surgery (RACHS-1) was created in order to compare in-hospital mortality for groups of children undergoing surgery for congenital heart disease. The method was evaluated with two large multi-institutional data sets—the Paediatric Cardiac Care Consortium (PCCC) and Hospital Discharge (HD) data from three states in the USA. The RACHS-1 classification was later applied to a large German paediatric cardiac surgery population in Bad Oeynhausen (BO), where it was found that the RACHS-1 categories were also associated with length of stay. We applied the RACHS-1 classification to the 957 operations performed during January 1996 to December 2002 at Skejby Sygehus, Denmark and we examined the association between the RACHS-1 categories, in-hospital mortality and length of stay in the Intensive Care Unit. Methods: The operations were classified according to the six RACHS-1 categories by matching the procedure of each patient with a risk category. The ability of the RACHS-1 classification to predict mortality in our population was examined by estimating the area under the receiver operator characteristic (ROC) curve. Likelihood ratio χ² tests were used to compare the distribution of RACHS-1 categories and the distribution of mortality with PCCC, HD and BO. Linear regression was used to examine the correlation between the RACHS-1 categories and length of stay in the Intensive Care Unit. Results: The RACHS-1 category frequencies in our population were: category 1: 18.4%, category 2: 37.4%, category 3: 34.6%, category 4: 8.2%, category 5: 0% and category 6: 1.5%. The overall ability of the RACHS-1 classification to predict in-hospital mortality (area under the ROC curve 0.741; 95% confidence interval = 0.690; 0.791) was equal to the findings from larger populations. We found no differences in the category specific mortality when comparing with the larger reported series. There was a positive association between RACHS-1 category and length of stay in the Intensive Care Unit. Conclusions: The RACHS-1 classification can also be used to predict in-hospital mortality and length of stay in the Intensive Care Unit in a small volume centre.     

Fatores de risco para mortalidade após hemorragia subaracnoidea: estudo observacional retrospectivo

Background and objectivesSubarachnoid haemorrhage is an important cause of morbidity and mortality. The aim of the study was to determine predictors of mortality among patients with subarachnoid hemorrhage hospitalized in an Intensive Care Unit.MethodsThis is a retrospective study of patients with subarachnoid hemorrhage admitted to the Intensive Care Unit of our institution during a 7 year period (2009–2015). Data were collected from the Intensive Care Unit computerized database and the patients’ chart reviews.ResultsWe included in the study 107 patients with subarachnoid haemorrhage. A ruptured aneurysm was the cause of subarachnoid haemorrhage in 76 (71%) patients. The overall mortality was 40% (43 patients), and was significantly associated with septic shock, midline shift on CT scan, inter‐hospital transfer, aspiration pneumonia and hypernatraemia during the first 72 hours of Intensive Care Unit stay. Multivariate analysis of patients with subarachnoid hemorrhage following an aneurysm rupture revealed that mortality was significantly associated with septic shock and hypernatremia during the first 72 hours of Intensive Care Unit stay, while early treatment of aneurysm (clipping or endovascular coiling) within the first 72 hours was identified as a predictor of a good prognosis.ConclusionsTransferred patients with subarachnoid haemorrhage had lower survival rates. Septic shock and hypernatraemia were important complications among critically ill patients with subarachnoid haemorrhage and were associated increased mortality.