Epidemiology of acute renal failure and outcome of haemodiafiltration in intensive care

Objective: To examine the epidemiology of acute renal failure (ARF) and to identify predictors of mortality in patients treated by continuous venovenous haemodiafiltration (CVVHDF). Design: Uncontrolled observational study. Setting: One intensive care unit (ICU) at a surgical and trauma centre. Patients: A consecutive sample of 3591 ICU treatments. Measurements and results: Demographic data, indications for ICU admission, severity scores and organ system failure at the beginning of CVVHDF were set against the occurrence of ARF and ICU mortality. 154 (4.3 % of ICU patients and 0.6 % of the hospital population) developed ARF and were treated with CVVHDF. Higher American Society of Anesthesiologists (ASA) status and higher Apache II score were associated with ICU incidence of ARF. However, these criteria were not able to predict outcome in ARF. A simplified predictive model was derived using multivariate logistic regression modelling. The mortality rates were 12 % with one failing organ system (OSF), 38 % with two OSF, 72 % with three OSF, 90 % with four OSF and 100 % with five OSF. The adjusted odds ratio (OR) of death was 7.7 for cardiovascular failure, 6.3 for hepatic failure, 3.6 for respiratory failure, 3.0 for neurologic failure, 5.3 for massive transfusion and 3.7 for age of 60 years or more. Conclusion: General measures of severity are not useful in predicting the outcome of ARF. Only the nature and number of dysfunctioning organ systems and massive transfusion at the beginning of CVVHDF and the age of the patients gave a reliable prognosis in this group of patients. Received: 8 July 1996 Accepted: 21 August 1997     

Continuous venovenous haemofiltration in cancer patients with renal failure: a single-centre experience

Objective To assess the effect of continuous venovenous hemodiafiltration (CVVHDF) in cancer patients with acute renal failure.Patients and methods Retrospective study of all patients with acute renal failure requiring dialysis and treated with CVVHDF in a medical intensive care unit (ICU) from a cancer hospital.Results From January 1997 until December 2002, 32 cancer patients were treated with CVVHDF for acute renal failure. Their characteristics were: male/female 23/9, median age 61 years, haematological/solid tumours 16/16, and median APACHE II and IGS II scores 31/67. The number of organ failures was 1/2/3/4 in respectively 10/6/13/2 patients. Complete, partial or absence of resolution of acute renal failure was noted in 13, 8 and 11 patients. Sixteen patients (50%) died in the ICU and 15 (47%) were discharged alive from the hospital. In univariate analysis, variables statistically significantly adversely associated with hospital mortality were renal failure of renal origin, bone marrow transplant, increasing number of organ failures, reduced lymphocyte count, elevated bilirubin and lower creatinine levels, increased thromboplastin time, younger age, increased APACHE II and IGS II, ARDS and mechanical ventilation. In multivariate analysis, two models were used including either APACHE II or IGS II. The number of organ failures was found as the only significant prognostic factor in both models (p=0.01). Elevated phosphate level was a poor prognostic factor for hospital mortality (p=0.04) in the model including APACHE II.Conclusions In the experience of a single centre, CVVHDF is effective in the treatment of acute renal failure in cancer patients. The increasing number of organ failures was the single independent poor predictive factor for hospital mortality. Cancer characteristics and general gravity scores were not predictive factors.     

Acute renal failure in the ICU: risk factors and outcome evaluated by the SOFA score

Objectives: To describe risk factors for the development of acute renal failure (ARF) in a population of intensive care unit (ICU) patients, and the association of ARF with multiple organ failure (MOF) and outcome using the sequential organ failure assessment (SOFA) score. Design: Prospective, multicenter, observational cohort analysis. Setting: Forty ICUs in 16 countries. Patients: All patients admitted to one of the participating ICUs in May 1995, except those who stayed in the ICU for less than 48 h after uncomplicated surgery, were included. After the exclusion of 38 patients with a history of chronic renal failure requiring renal replacement therapy, a total of 1411 patients were studied. Measurements and results: Of the patients, 348 (24.7 %) developed ARF, as diagnosed by a serum creatinine of 300 μmol/l (3.5 mg/dl) or more and/or a urine output of less than 500 ml/day. The most important risk factors for the development of ARF present on admission were acute circulatory or respiratory failure; age more than 65 years, presence of infection, past history of chronic heart failure (CHF), lymphoma or leukemia, or cirrhosis. ARF patients developed MOF earlier than non-ARF patients (median 24 vs 48 h after ICU admission, p < 0.05). ARF patients older than 65 years with a past history of CHF or with any organ failure on admission were most likely to develop MOF. ICU mortality was 3 times higher in ARF than in other patients (42.8 % vs 14.0 %, p < 0.01). Oliguric ARF was an independent risk factor for overall mortality as determined by a multivariate regression analysis (OR = 1.59 [CI 95 %: 1.23–2.06], p < 0.01). Infection increased the risk of death associated with all factors. Factors that increased the ICU mortality of ARF patients were a past history of hematologic malignancy, age more than 65 years, the number of failing organs on admission and the presence of acute cardiovascular failure. Conclusion: In ICU patients, the most important risk factors for ARF or mortality from ARF are often present on admission. During the ICU stay, other organ failures (especially cardiovascular) are important risk factors. Oliguric ARF was an independent risk factor for ICU mortality, and infection increased the contribution to mortality by other factors. The severity of circulatory shock was the most important factor influencing outcome in ARF patients. Received: 9 August 1999/Final revision received: 24 January 2000/Accepted: 6 April 2000     

Impact of anemia on outcome in critically ill patients with severe acute renal failure

Objective To evaluate the prognostic value of hemoglobin levels in critically ill patients with acute renal failure (ARF) requiring dialysis.Design and setting A prospective observational cohort study in two adult medical ICUs.Patients 206 consecutive patients with ARF who required dialysis. Overall 28-day mortality was 48%.Measurements and results At ICU admission mean hemoglobin level was 9.1±2.1 g/dl. By ROC curve analysis the threshold value of hemoglobin with the highest sensibility/specificity was 9 g/dl. At baseline 63% of patients had anemia, defined as initial hemoglobin below 9 g/dl. Kaplan-Meier analysis showed that these patients had lower survival rate than those with hemoglobin above 9 g/dl. By multivariable analysis three factors were independently associated with 28-day death: hemoglobin lower than 9 g/dl (adjusted odds ratio 2.4, 95% CI 1.1–5.2), age, and SOFA score. Based on age and SOFA a matched cohort analysis of 67 pairs of ARF patients with or without anemia found similar results regarding the negative impact of anemia on outcome. Finally, a multivariable logistic regression analysis on matched cohort identified hemoglobin level below 9 g/dl (adjusted odds ratio 1.32, 95%CI 1.15–1.46), continuous renal replacement therapy, and vasoactive therapy as independent predictors of 28-day death.Conclusions These results suggest that initial hemoglobin level could be helpful in identifying patients with ARF requiring dialysis at high risk of death.This article refers to the editorial     

Costs of care, long-term prognosis and quality of life in patients requiring renal replacement therapy during intensive care

OBJECTIVE: To assess (1) the long-term outcome of patients requiring renal replacement therapy (RRT) in terms of 6-month and 5-year mortality, (2) quality of life and (3) costs of the intensive care. DESIGN: A retrospective observational cohort study. SETTING: Twenty-three-bed multidisciplinary intensive care unit (ICU) in a tertiary care center. PATIENTS AND PARTICIPANTS: Out of 3,447 intensive care patients admitted, 62 patients with no end-stage renal failure required RRT. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: The incidence rate of acute renal failure (ARF) was 8/100,000 inhabitants/ year. The majority of patients (71%) had ARF in conjunction with multiple organ failure. The mortality in the ICU and in the hospital was 34 % and 45%, respectively. Mortality was 55% at 6 months and 65 % at 5 years. Renal function recovered in 82 % of the survivors during hospitalization. Loss of energy and limitations of physical mobility assessed by Nottingham Health Profile were the most frequently reported complaints at 6 months. Functional ability, as assessed by the Activities of Daily Living score was fairly good at 6 months. The cost per ARF 6-month survivor was $80,000. CONCLUSIONS: There was only a minor increase in mortality after discharge from hospital among patients treated for ARF in intensive care. The costs related to ARF in intensive care are high, but the almost complete physical and functional recovery seen in ARF survivors should be noted in cost-effective analyses.     

Acute renal failure in intensive care burn patients (ARF in burn patients).

The purpose of this study was to establish the incidence and mortality of burn patients with acute renal failure (ARF) at the Helsinki Burn Centre and to analyze the associated factors. The files of 238 intensive care (ICU) patients of a total of 1380 burn patients admitted to our institution between November 1988 and December 2001 were studied retrospectively. Of all admitted burn patients, 17.2% needed ICU. According to our criteria (S-Cr >120 micromol/l = 1.4 mg/dl), 39.1% of the ICU patients suffered from ARF and one in three of these required renal replacement therapy. The proportion of all admitted burn patients requiring renal replacement therapy was 2.3%. The mortality of ICU patients with ARF was 44.1% whereas that of patients without ARF was only 6.9%. Renal function recovered in all survivors. The nonsurvivors had a larger burned total body surface area, were older, and had more inhalation injuries and a higher abbreviated burn severity index score. The prognosis for patients with early ARF was worse than that for patients with late ARF. Rhabdomyolysis caused by flame injury was associated with high mortality. In this study we observed that ARF is associated with higher mortality even in minor burns when compared with patients without ARF. Flame burn with rhabdomyolysis and subsequent ARF predicts very poor survival. If a patient with severe ARF survives, the renal failure recovers over time.     

Acute renal failure requiring renal replacement therapy in the intensive care unit: impact on prognostic assessment for shared decision making

A 69-year-old female was receiving renal replacement therapy (RRT) for acute renal failure (ARF) in an intensive care unit (ICU). Consultation was requested from the palliative medicine service to facilitate a shared decision-making process regarding goals of care. Clinician responsibility in shared decision making includes the formulation and expression of a prognostic assessment providing the necessary perspective for a spokesperson to match patient values with treatment options. For this patient, ARF requiring RRT in the ICU was used as a focal point for preparing a prognostic assessment. A prognostic assessment should include the outcomes of most importance to a discussion of goals of care: mortality risk and survivor functional status, in this case including renal recovery. A systematic review of the literature was conducted to document published data regarding these outcomes for adult patients receiving RRT for ARF in the ICU. Forty-one studies met the inclusion criteria. The combined mean values for short-term mortality, long-term mortality, renal-function recovery of short-term survivors, and renal-function recovery of long-term survivors were 51.7%, 68.6%, 82.0%, and 88.4%, respectively. This case example illustrates a process for formulating and expressing a prognostic assessment for an ICU patient requiring RRT for ARF. Data from the literature review provide baseline information that requires adjustment to reflect specific patient circumstances. The nature of the acute primary process, comorbidities, and severity of illness are key modifiers. Finally, the prognostic assessment is expressed during a family meeting using recommended principles of communication.     

The attributable mortality of acute renal failure in critically ill patients with liver cirrhosis

Objective To determine outcome and mortality risk related to acute renal failure (ARF) in critically ill patients with cirrhosis.Design and setting A retrospective cohort analysis and two independent case-control analyses in a medical ICU.Patients 41 and 32 patients who developed mild and severe ARF, respectively, matched (1:2 ratio) with cirrhotic patients without ARF during their ICU stay.Measurements and results Cirrhotic patients with ARF had higher MELD, APACHE II, and SOFA scores at baseline that those without ARF. They had more respiratory failure and cardiovascular failure during ICU stay, longer stay in ICU, and a greater crude hospital mortality rate (65% vs. 32%). Multivariate survival analysis identified ARF (hazard ratio, HR, 4.1), alcohol abuse or dependency, and severe sepsis or septic shock as independent predictors of death. In case-control studies both mild and severe ARF were independently associated with mortality (HR, 2.6, and 4.2, respectively). Cirrhotic patients with mild ARF patients had a higher risk of death than those without ARF (relative risk, RR, 2.0). Severe ARF was associated with an increase matched risk of death (RR 2.6), higher mortality of 51%, and higher risk-adjusted mortality rate (2.1 vs. 0.9).Conclusions ICU patients with liver cirrhosis still have a high crude mortality. In this specific population ARF is associated with an excess mortality, depending on the severity of renal dysfunction.Electronic Supplementary Material Electronic supplementary material to this paper can be obtained by using the Springer Link server located at     

Intermittent versus continuous renal replacement therapy in the ICU: impact on electrolyte and acid-base balance

OBJECTIVES: The maintenance of normal serum sodium, potassium and bicarbonate concentrations is a therapeutic goal of renal replacement therapy (RRT) in acute renal failure (ARF). The aim of this study was to determine whether this goal is best achieved with intermittent hemodialysis (IHD) or continuous venovenous hemodiafiltration (CVVHDF). DESIGN: Retrospective controlled study. SETTING: Tertiary intensive care unit. PATIENTS: Consecutive patients with ARF treated with IHD (n = 47) or CVVHDF (n = 49). INTERVENTIONS: Measurement of daily morning sodium, potassium and bicarbonate concentrations after the initiation of RRT for up to 2 weeks of treatment. MEASUREMENTS AND RESULTS: Before RRT, abnormal (high or low) values were frequently observed for sodium (42.6% vs 39.6%; NS) potassium (23.4% vs 45.8%; NS) and bicarbonate (63.2 % vs 54.3 %; NS). After treatment, however, CVVHDF, but not IHD, significantly increased mean sodium concentrations (p = 0.0001). CVVHDF was also more likely to normalize the serum sodium than IHD (76.2 % vs 47.8% p = 0.0001). The mean potassium concentrations of both groups significantly decreased (p = 0.019 vs p = 0.0075, difference: NS). However, CVVHDF more frequently reduced the incidence of hypokalemia (1.9 % vs 7.1%, p = 0.0006). CVVHDF but not IHD significantly increased mean bicarbonate concentrations (p = 0.016) in the first 48 h, and more frequently normalized them (71.5% vs 59.2, p = 0.0073). CONCLUSIONS: Serum sodium and potassium, and arterial bicarbonate, concentrations are frequently abnormal in ARF patients before and during renal replacement. Normalization of these values, however, is achieved more frequently with CVVHDF than with IHD.     

Acute respiratory failure in immunosuppressed patients admitted to ICU

IntroductionThe number of hospitalized immunosuppressed adults is a growing and often develop severe complications that require admission to an Intensive Care Unit (ICU). The main cause of admission is acute respiratory failure (ARF). The goal of the study was to determine if ARF represents an independent risk factor for hospital mortality and in particular, we sought to ascertain if any risk factors were independently and identifiably associated with a bad outcome.MethodsWe perform a retrospective study of a prospectively collected data from patients admitted to an ICU. Adult patients with known immunosuppressive condition admitted to ICU were included.ResultsA total of 248 patients were included. Of 248 patients, 117 (47.2%) had a diagnosis of ARF at the time of ICU admission. Patients with ARF had a significantly higher in-hospital mortality (53.4% vs. 28.2% p = 0.001). Factors independently associated with hospital mortality were diagnosis of ARF at ICU admission, the presence of septic shock, use of continuous renal replacement therapy and failure of high-flow nasal canula(HFNC)/non-invasive (NIV) respiratory therapies.ConclusionWe identified ARF on admission and failure of HFNC/NIV to be independently associated with increased hospital mortality in immunosuppressed patients.     

Role of renal sonography in the intensive care unit

PURPOSE: This study was conducted to evaluate the role of portable renal sonography in the intensive care unit (ICU). METHODS: We conducted a retrospective study of 402 ICU patients who underwent renal sonography. We recorded demographic data, underlying disease, type of ICU, renal function test results, etiology of renal failure, need for dialysis, and outcome for patients with acute renal failure (ARF). The indications for and results of sonography were analyzed. RESULTS: The most common indication for a renal sonographic examination was ARF (320/402, 79.6%). Hydronephrosis was found in 5 patients with ARF. Chronic renal failure was confirmed by sonography in 40% of the patients with an indeterminate cause of renal failure. In 33% of cases of complicated urinary tract infections, sonography revealed abnormalities. Renal sonography was also useful for follow-up assessment of patients treated with percutaneous nephrostomy and patients with a history of renal tumor, hydronephrosis, adrenal tumor, hematuria of unknown cause, or fever of unknown origin. CONCLUSIONS: Since renal disease is common in the ICU, renal sonography is a convenient and useful diagnostic tool in this setting.     

Outcome and prognostic features of intensive care unit treatment in patients with hematological malignancies

OBJECTIVE: To assess the outcome of intensive care unit (ICU) treatment in patients with hematological malignancies. DESIGN AND SETTING: Retrospective cohort study in the medical ICU of a university hospital. PATIENTS: 104 critically ill patients after receiving conventional chemotherapy or autologous hematopoietic stem cell transplantation. INTERVENTIONS: We analyzed demographic data, underlying disease, intensity of antineoplastic regimen, cause of admission, need for mechanical ventilation, and hemofiltration, ICU survival, and survival after discharge, furthermore neutrophil count, C-reactive protein (150 mg/l), antithrombin III, prothrombin time, and SAPS II (50) at ICU admission. All recorded variables were evaluated for prognostic relevance by univariate and multivariate analyses. MEASUREMENTS AND RESULTS: Overall ICU mortality was 44%, with significantly higher mortality in ventilated patients (74% vs. 12% in nonventilated patients, p<0.001). Overall survival for the entire group 6 months and 1 year after ICU admission was 33% and 29%, respectively. Multivariate analysis revealed mechanical ventilation and SAPS II as independent prognostic factors of both ICU mortality and long-term survival, while C-reactive protein predicted only ICU mortality. CONCLUSIONS: The outcome of patients not requiring ventilatory support in this study was encouraging, while invasive ventilation was again confirmed as predicting a dismal prognosis in this population. Efforts should be directed to avoiding this procedure by reducing the pulmonary toxicity of antineoplastic treatment and to making ventilatory support more tolerable.     

The epidemiology of acute respiratory failure in hospitalized patients: a Brazilian prospective cohort study

Purpose

The purpose of this study was to assess risk factors associated with the development of acute respiratory failure (ARF) and death in a general intensive care unit (ICU).

Materials and Methods

Adults who were hospitalized at 12 surgical and nonsurgical ICUs were prospectively followed up. Multivariable analyses were realized to determine the risk factors for ARF and point out the prognostic factors for mortality in these patients.

Results

A total of 1732 patients were evaluated, with an ARF prevalence of 57%. Of the 889 patients who were admitted without ARF, 141 (16%) developed this syndrome in the ICU. The independent risk factors for developing ARF were 64 years of age or older, longer time between hospital and ICU admission, unscheduled surgical or clinical reason for ICU admission, and severity of illness. Of the 984 patients with ARF, 475 (48%) died during the ICU stay. Independent prognostic factors for death were age older than 64 years, time between hospital and ICU admission of more than 4 days, history of hematologic malignancy or AIDS, the development of ARF in ICU, acute lung injury, and severity of illness.

Conclusions

Acute respiratory failure represents a large percentage of all ICU patients, and the high mortality is related to some preventable factors such as the time to ICU admission.     

Leucopenia is an independent predictor in cancer patients requiring invasive mechanical ventilation: a prognostic factor analysis in a series of 168 patients

OBJECTIVE: To determine prognostic factors predicting success of invasive mechanical ventilation in medical cancer patients admitted to ICU for a complication, in terms of extubation and ICU and hospital discharges. DESIGN: Retrospective study SETTING: Medical ICU of an European cancer hospital. SUBJECTS: A total of 168 consecutive cancer patients who were admitted to ICU for an acute medical complication requiring immediate mechanical ventilation or who later needed mechanical ventilation. MEASUREMENTS: Variables related to the demographic, cancer, scores and complication characteristics. Extubation rates, ICU and hospital mortalities and duration of survival were measured. RESULTS: Respectively, 26%, 22% and 17% of the patients were extubated, discharged from the ICU and discharged from hospital. For weaning from mechanical ventilation, a higher APACHE II score and leucopenia were poor prognostic factors in univariate analysis, but leucopenia remained the only significant one in multivariate analysis. For ICU mortality, no significant prognostic feature was identified. For hospital mortality, leucopenia was the only significant factor in univariate as well as in multivariate analyses. CONCLUSION: Leucopenia appeared to be the only independent poor prognostic factor for both extubation and hospital discharge. None of the variables related to the cancer disease process was shown to be a predictor of success.     

Severe acute renal failure in adults: place of care, incidence and outcomes

BACKGROUND: Department of Health guidelines recommend specialist critical care facilities for patients with severe single-organ failure such as acute renal failure (ARF). Prospective studies examining incidence, causes and outcomes of ARF outside of intensive care settings are lacking. AIM: To determine the incidence, causes, place of care and outcomes of severe single-organ ARF. DESIGN: Prospective observational study. METHODS: For 6 weeks in June-July 2003, renal physicians were contacted daily, and ICUs on alternate days, to identify cases of severe single-organ ARF in the Greater Manchester area. All patients with serum creatinine >or=500 micromol/l and not requiring other organ support were included. Patients with end-stage renal disease were excluded. Survivors were followed up at 90 days and 1 year from admission. Two independent consultant nephrologists assessed each case using anonymized summaries. RESULTS: Eighty-five patients had multi-organ ARF and 28 had severe single-organ ARF (380 and 125 pmp/year, respectively). Of those with single-organ ARF, 10 (36%) had known pre-existing chronic kidney disease. Renal replacement therapy (RRT) was required in 15 (54%). Total bed occupancy on ICUs relating to single-organ ARF was 59 days (range per patient 1-21). At 90 days, 18 (64%) were alive, and 17 (94%) had independent renal function. At 1 year, 4/18 had died, none receiving RRT at the time of death. Survivors all had independent renal function. In 13 (46%) cases there was an unacceptable delay in patient transfer and in 7 (25%), delays in assessment or commencement of RRT may have adversely affected patient outcome. DISCUSSION: The incidence of ARF treated with RRT is rising. Delays in transfer to renal services may result in inappropriate ICU bed use, and may adversely affect patient outcomes. There are serious problems regarding the appropriate use of expensive and limited medical resources in the critical care area, and in providing safe and effective treatment of patients with ARF.     

Outcome and functional capacity after prolonged intensive care unit stay

BACKGROUND: An important proportion of critically ill patients who survives their acute illness remains in a critical state requiring intensive care management for weeks to months. Nevertheless, data on risk factors for in-hospital mortality and especially for long-term mortality and functional capacity are scarce. This study investigated outcome and prognostic factors in long-term critically ill patients. METHODS: This retrospective observational cohort study was performed at our mixed adult 8-bed cardiologic ICU at a 2200-bed University Hospital. Patient data from our local database connected to an Austrian multicenter program for quality assurance in intensive care were analyzed. Data were collected between March 1(st), 1998 and December 31(st), 2003. Patients with an ICU stay > or =30 days formed the long-term study group. Morbidity and functional capacity were assessed using the Barthel mobility index in telephone interviews. RESULTS: Patients spending > or =30 days in the ICU numbered 135 (10%) and occupied 5962 bed-days, representing 40.9% of the total bed-days. Compared with patients with an ICU stay <30 days, patients in the long-term group had a significantly higher SAPS II score during the first 24 hours after ICU admission (54 [IQR 41-65] vs. 38 [IQR 27-56], p < 0.001). There was a trend towards male preponderance in the long-term group (98/135 [82.6%] vs. 782/1215 [64.4%], p = 0.05). Differences in ICU and in-hospital mortality were not significant (28/135 (20.7%) vs. 295/1215 (24.3%), p = 0.620 and 46/135 [34.1%] vs. 360/1215 [29.6%], p = 0.285, respectively). After 12 and 48 months, the overall cumulative rates of death in hospital survivors were 14% and 26%, respectively in the short-term ICU group and 31% and 61% in the long-term group. A log-rank test revealed a significantly higher probability of survival in the short-term group after hospital discharge (log rank = 34.3, p < 0.001). Multivariate analysis of hospital survivors and non-survivors in the long-term group showed that the need for renal replacement therapy during the ICU stay was the sole independent predictor for in-hospital death and death within 1 year after ICU discharge (OR = 2.88; 95%CI 1.12-7.41, p = 0.028 and OR = 3.66, 95%CI 1.36-9.83, p = 0.01, respectively). In 28/31 long-term survivors (90%) in the long-term ICU group, the Barthel index indicated no or only moderate disability during daily activities. CONCLUSION: Hospital mortality rates in critically ill patients with a stay <30 or > or =30 days were comparable. The necessity for renal replacement therapy was the sole independent predictor for in-hospital and 1-year mortality in long-term ICU patients. Critically ill patients with a stay > or =30 days have a high and ongoing risk of death after hospital discharge; however, a substantial number of these patients are long-term survivors with no or only moderate disability during daily activities.     

Prognosis factors and outcome of community-acquired pneumonia needing mechanical ventilation

PURPOSE: To evaluate the variables associated with mortality of patients with community-acquired pneumonia who require mechanical ventilation and to determine the attributable morbidity and intensive care unit (ICU) mortality of community-acquired pneumonia. MATERIAL AND METHODS: Retrospective cohort study carried out in 361 ICUs from 20 countries including 124 patients who required mechanical ventilation on the first day of admission to the hospital due to acute respiratory failure secondary to severe community-acquired pneumonia. To assess the factors associated with outcome, a forward stepwise logistic regression analysis was performed, and to determine the attributable mortality of community-acquired pneumonia, a matched study design was used. RESULTS: We found 3 independent variables significantly associated with death in patients with community-acquired pneumonia requiring mechanical ventilation: simplified acute physiological score greater than 45 (odds ratio, 5.5 [95% confidence interval, 1.7-12.3]), shock (odds ratio, 5.7 [95% confidence interval, 1.7-10.1]), and acute renal failure (odds ratio, 3.0 [95% confidence interval, 1.1-4.0]). There was no statistically significant difference in ICU mortality among patients with or without community-acquired pneumonia (32% vs 35%; P=.59). CONCLUSIONS: Community-acquired pneumonia needing mechanical ventilation is not a disease associated with higher mortality. The main determinants of patient outcome were initial severity of illness and the development of shock and/or acute renal failure.     

Prognosis and 1-year mortality of intensive care unit patients with severe hepatic encephalopathy

Purpose

Data regarding outcome of patients with chronic liver disease with severe hepatic encephalopathy in intensive care unit are currently scarce.

Methods

This study is a retrospective observational case series in a medical intensive care unit (ICU) in a university hospital from 1995 to 2005. Patients with hepatic encephalopathy (HE) (admitted with or developing) were identified. Clinical and laboratory parameters were analyzed to determinate predictors of ICU and 1-year mortality.

Results

Seventy-one patients were included (53 male). Median Simplified Acute Physiology Score was 56 with Child-Pugh score 11 ± 2. Seventy-six percent of patients were admitted with coma (Glasgow Coma Scale, 7.7 ± 4). Eighty-two percent of patients required intubation, and 28% vasopressors. Thirty-five percent died during ICU stay. At 1 year, mortality was 54%. Univariate analysis identified arterial hypotension, mechanical ventilation, vasopressors at any time, acute renal failure, Simplified Acute Physiology Score, and sepsis associated with ICU mortality. In multivariate analysis, vasopressor use or acute renal failure was the main independent predictor of ICU death and 1-year mortality. Patients free of these risk factors, even requiring intubation, were identified as isolated HE, with lower mortality rates.

Conclusion

Predictors of outcome were similar to other groups of patients with liver disease admitted for other reasons. Intensive care unit mortality was lower than reported for other groups of patients with similar illness. Patients with severe HE admitted to ICU with no organ dysfunction other than mechanical ventilation had a better outcome and may require ICU admission.     

Red cell distribution width improves the simplified acute physiology score for risk prediction in unselected critically ill patients

ABSTRACT: INTRODUCTION: Recently, red cell distribution width (RDW), a measure of erythrocyte size variability, has been shown to be a prognostic marker in critical illness. The aim of this study was to investigate whether adding RDW has the potential to improve the prognostic performance of the simplified acute physiology score (SAPS) to predict short- and long-term mortality in an independent, large, and unselected population of intensive care unit (ICU) patients. METHODS: This observational cohort study includes 17,922 ICU patients with available RDW measurements from different types of ICUs. We modeled the association between RDW and mortality by using multivariable logistic regression, adjusting for demographic factors, comorbidities, hematocrit, and severity of illness by using the SAPS. RESULTS: ICU-, in-hospital-, and 1-year mortality rates in the 17,922 included patients were 7.6% (95% CI, 7.2 to 8.0), 11.2% (95% CI, 10.8 to 11.7), and 25.4% (95% CI, 24.8 to 26.1). RDW was significantly associated with in-hospital mortality (OR per 1% increase in RDW (95%CI)) (1.14 (1.08 to 1.19), P < 0.0001), ICU mortality (1.10 (1.06 to 1.15), P < 0.0001), and 1-year mortality (1.20 (95% CI, 1.14 to 1.26); P < 0.001). Adding RDW to SAPS significantly improved the AUC from 0.746 to 0.774 (P < 0.001) for in-hospital mortality and 0.793 to 0.805 (P < 0.001) for ICU mortality. Significant improvements in classification of SAPS were confirmed in reclassification analyses. Subgroups demonstrated robust results for gender, age categories, SAPS categories, anemia, hematocrit categories, and renal failure. CONCLUSIONS: RDW is a promising independent short- and long-term prognostic marker in ICU patients and significantly improves risk stratification of SAPS. Further research is needed the better to understand the pathophysiology underlying these effects.     

连续性静静脉血液透析滤过在儿童心脏术后急性肾衰竭中的应用

目的探讨连续性静静脉血液透析滤过（CVVHDF）对儿童心脏术后急性肾衰竭（ARF）的治疗效果。方法2004年7月至2008年7月应用PrismaTM机器行CVVHDF治疗11例心脏术后并发ARF患儿。结果11例患者开始CVVHDF治疗时的平均年龄是30.6个月（6个月～12.4岁）,平均体重是15Kg（9.4～30.8Kg）,肾脏替代治疗平均持续时间是62h（10～212h）。术后共8例（72.7%）患者死亡,其中4例在CVVHDF治疗期间死亡,均死于多器官功能障碍综合征（MODS）,并且肾功能未恢复;另外4例中2例死于心力衰竭,1例死于呼吸衰竭,1例死于蛛网膜下腔出血。治疗24h后存活患者血尿素氮（BUN）和肌酐（Scr）均明显降低（P〈0.05）,共7例（63.6%）患儿肾功能恢复。治疗48h后患者平均动脉压（MAP）明显上升,心率（HR）及中心静脉压（CVP）下降（P值均〈0.05）。结论CVVHDF是治疗心内直视术后合并ARF患儿的有效手段,可以改善患者肾功能,稳定血流动力学,但患儿预后仍主要取决于原发病及术后心力衰竭严重程度。