Serial evaluation of the SOFA score to predict outcome in critically ill patients

CONTEXT: Evaluation of trends in organ dysfunction in critically ill patients may help predict outcome. OBJECTIVE: To determine the usefulness of repeated measurement the Sequential Organ Failure Assessment (SOFA) score for prediction of mortality in intensive care unit (ICU) patients. DESIGN: Prospective, observational cohort study conducted from April 1 to July 31, 1999. SETTING: A 31-bed medicosurgical ICU at a university hospital in Belgium. PATIENTS: Three hundred fifty-two consecutive patients (mean age, 59 years) admitted to the ICU for more than 24 hours for whom the SOFA score was calculated on admission and every 48 hours until discharge. MAIN OUTCOME MEASURES: Initial SOFA score (0-24), Delta-SOFA scores (differences between subsequent scores), and the highest and mean SOFA scores obtained during the ICU stay and their correlations with mortality. RESULTS: The initial, highest, and mean SOFA scores correlated well with mortality. Initial and highest scores of more than 11 or mean scores of more than 5 corresponded to mortality of more than 80%. The predictive value of the mean score was independent of the length of ICU stay. In univariate analysis, mean and highest SOFA scores had the strongest correlation with mortality, followed by Delta-SOFA and initial SOFA scores. The area under the receiver operating characteristic curve was largest for highest scores (0.90; SE, 0.02; P<.001 vs initial score). When analyzing trends in the SOFA score during the first 96 hours, regardless of the initial score, the mortality rate was at least 50% when the score increased, 27% to 35% when it remained unchanged, and less than 27% when it decreased. Differences in mortality were better predicted in the first 48 hours than in the subsequent 48 hours. There was no significant difference in the length of stay among these groups. Except for initial scores of more than 11 (mortality rate >90%), a decreasing score during the first 48 hours was associated with a mortality rate of less than 6%, while an unchanged or increasing score was associated with a mortality rate of 37% when the initial score was 2 to 7 and 60% when the initial score was 8 to 11. CONCLUSIONS: Sequential assessment of organ dysfunction during the first few days of ICU admission is a good indicator of prognosis. Both the mean and highest SOFA scores are particularly useful predictors of outcome. Independent of the initial score, an increase in SOFA score during the first 48 hours in the ICU predicts a mortality rate of at least 50%.     

危重疾病患者的高血糖反应及其处理

近年来,危重疾病当中的高血糖反应受到广泛关注,研究表明通过控制高血糖可以减少并发症并降低死亡率。与单纯糖尿病不同,在危重疾病患者,反应性高血糖的发生机制尚未完全清楚,治疗困难;且常同时伴随水、电解质、酸碱平衡紊乱及多脏器功能损伤,其处理有一定的特殊性。一、反应性高血糖的形成在健康个体中,通过胰岛素、胰高血糖素等激素,神经和肝脏等的自身调节,血糖浓度基本上是恒定的,即使餐后有所升高,但有一定限度,通过调节也可恢复至适当水平。但在危重疾病患者,机体调节异常,高血糖发生的机会显著增加。1.体内因素:创伤和危重病患者常存…     

Intrahospital transport of critically ill patients

目的:探讨实施外科危重患者院内安全转运管理后的效果.方法:2010年我院外科加强院内安全转运管理的113例危重症患者为实验组,2009年常规院内转运管理的102例为对照组,观察两组的转运时间、转运过程中不良事件和意外事件的发生率.结果:2010年院内转运时间为(30.2±7.9)min,2009年为(39.8±5.5) min,两组比较(P＜0.01)统计学有显著性差异,2010年院内转运时间比2009年有明显缩短.2010年不良事件的例数:脱管3例、窒息0例、坠床0例、病情恶化1例,不良事件发生率3.53％; 2009年不良事件的例数:脱管5例、窒息3例、坠床2例、病情恶化7例,不良事件发生率16.67％,两组比较(P＜0.01)统计学有显著性差异,2010年不良事件的发生比2009年有明显减少.结论:实施外科危重患者院内安全转运管理,可缩短转运时间,提高转运效率,减少转运过程中不良事件及意外事件的发生率.     

外科危重病人院内安全转运的管理

目的:探讨实施外科危重患者院内安全转运管理后的效果。方法:2010年我院外科加强院内安全转运管理的113例危重症患者为实验组,2009年常规院内转运管理的102例为对照组,观察两组的转运时间、转运过程中不良事件和意外事件的发生率。结果:2010年院内转运时间为(30.2±7.9)min,2009年为(39.8±5.5)min,两组比较(P<0.01)统计学有显著性差异,2010年院内转运时间比2009年有明显缩短。2010年不良事件的例数:脱管3例、窒息0例、坠床0例、病情恶化1例,不良事件发生率3.53%;2009年不良事件的例数:脱管5例、窒息3例、坠床2例、病情恶化7例,不良事件发生率16.67%,两组比较(P<0.01)统计学有显著性差异,2010年不良事件的发生比2009年有明显减少。结论:实施外科危重患者院内安全转运管理,可缩短转运时间,提高转运效率,减少转运过程中不良事件及意外事件的发生率。     

危重病患者菌血症75例分析

目的了解危重病患者菌血症的流行病学概况和死亡的危险因素,并对抗生素治疗进行评估。方法对１９８９～１９９６年间北京协和医院加强医疗病房７５例危重病患者发生的１１６次菌血症进行回顾性分析。结果菌血症患者的病死率４３％。致病菌多为高度耐药的病原菌,如葡萄球菌（２９％）、肠球菌（１２％）、产Ｉ型诱导酶的肠杆菌（１２％）和产超广谱酶的肠杆菌（１０％）。其中革兰阳性球菌检出率较高。受累脏器按呼吸（７７％）、肝脏（５３％）、循环（５３％）、消化道（５０％）、肾脏（４７％）、中枢神经（３６％）和血液系统（２７％）依次减少。其中多器官功能衰竭为７６％。单因素分析显示原发病严重程度、多器官功能衰竭、感染性休克、肝功能衰竭、肾功能衰竭以及感染灶部位均显著影响患者的死亡（Ｐ＜０．０５）。Ｃｏｘ比例风险模型分析提示中枢神经系统功能衰竭、感染性休克、血液系统功能衰竭、肝功能衰竭和呼吸道操作均显著影响菌血症患者的生存时间。结论革兰阳性球菌是危重病患者菌血症的重要致病菌。抗生素治疗不能预防菌血症,亦不能改变菌血症患者的预后。     

选择性脑亚低温治疗在危重症中的应用

目的：为探讨选择性脑亚低温治疗在危重症中的应用。方法：将41例危重症合并脑功能障碍患者，随机的分为2组（选择性脑亚低温治疗组，不采用选择性脑亚低温治疗为对照组），2组患者常规治疗及加强重要脏器功能监测和支持方案相同．结果：治疗组意识状态的恢复较对照组好．GCS评分较对照组明显为好，临床疗效高于对照组，有显著性差异．结论：选择性脑亚低温治疗具有显著脑保护作用．而又避免了全身亚低温治疗的缺陷，可战少全身降温引起的并发症，提高危重症合并脑功能障碍患者救治成功率，战少死亡率．     

高容量血液滤过在危重患者中的疗效观察

目的探讨高容量血液滤过（high volume hemofiltration,HVHF）在多器官功能障碍综合征（multiple organ dysfunc-tion syndrome,MODS）危重病患者中的疗效。方法选择21例ICU的危重病患者,行APACHE II评分,测定血滤治疗前和治疗后24小时、48小时（其中18例另外监测72小时）的生命体征、氮质血症、血流动力学指标。结果治疗后48小时血肌酐（Cr）下降（P〈0.05）,血pH值在24小时（P〈0.05）及48小时（P〈0.01）后也逐渐恢复正常;氧合指数（PaO2/FiO2）治疗24小时（P〈0.05）及48小时（P〈0.01）后即慢慢上升。坚持治疗72小时的18例患者,BUN、血肌酐（Cr）与治疗前比较明显下降（P〈0.05）,K＋下降,氧合指数上升,血PH值恢复正常（均P〈0.01）,APACHE II评分降低（P〈0.01）。治疗后与治疗前HR、MAP、CVP均无统计学意义（P〉0.05）,说明治疗前后患者的血流动力学较为稳定。结论高容量血液滤过在多器官功能障碍综合征危重患者中疗效肯定,有待于建立对照组和增加病例进行更深入的研究。     

60例危重病人肠外营养治疗结果观察

目的探讨危重症患者急性期全肠外营养(TPN)的临床应用价值。方法对60例危重病人,39例使用TPN,21例先用TPN支持,后改用肠外营养(PN)加肠内营养(EN),再过渡到全肠内营养(TEN)或口服饮食。结果7例因原发病而死亡,其余53例病情得到不同程度的改善或治愈出院。结论TPN在危重病治疗中具有极其重要的应用价值。     

Cytomegalovirus reactivation in critically ill immunocompetent patients

Ajit P. Limaye, MD; Katharine A. Kirby, MSc; Gordon D. Rubenfeld, MD; Wendy M. Leisenring, ScD; Eileen M. Bulger, MD; Margaret J. Neff, MD; Nicole S. Gibran, MD; Meei-Li Huang, PhD; Tracy K. Santo Hayes, BSc; Lawrence Corey, MD; Michael Boeckh, MD

JAMA. 2008;300(4):413-422.

Context  Cytomegalovirus (CMV) infection is associated with adverse clinical outcomes in immunosuppressed persons, but the incidence and association of CMV reactivation with adverse outcomes in critically ill persons lacking evidence of immunosuppression have not been well defined.

Objective  To determine the association of CMV reactivation with intensive care unit (ICU) and hospital length of stay in critically ill immunocompetent persons.

Design, Setting, and Participants  We prospectively assessed CMV plasma DNAemia by thrice-weekly real-time polymerase chain reaction (PCR) and clinical outcomes in a cohort of 120 CMV-seropositive, immunocompetent adults admitted to 1 of 6 ICUs at 2 separate hospitals at a large US tertiary care academic medical center between 2004 and 2006. Clinical measurements were assessed by personnel blinded to CMV PCR results. Risk factors for CMV reactivation and association with hospital and ICU length of stay were assessed by multivariable logistic regression and proportional odds models.

Main Outcome Measures  Association of CMV reactivation with prolonged hospital length of stay or death.

Results  The primary composite end point of continued hospitalization (n = 35) or death (n = 10) by 30 days occurred in 45 (35%) of the 120 patients. Cytomegalovirus viremia at any level occurred in 33% (39/120; 95% confidence interval [CI], 24%-41%) at a median of 12 days (range, 3-57 days) and CMV viremia greater than 1000 copies/mL occurred in 20% (24/120; 95% CI, 13%-28%) at a median of 26 days (range, 9-56 days). By logistic regression, CMV infection at any level (adjusted odds ratio [OR], 4.3; 95% CI, 1.6-11.9; P = .005) and at greater than 1000 copies/mL (adjusted OR, 13.9; 95% CI, 3.2-60; P < .001) and the average CMV area under the curve (AUC) in log₁₀ copies per milliliter (adjusted OR, 2.1; 95% CI, 1.3-3.2; P < .001) were independently associated with hospitalization or death by 30 days. In multivariable partial proportional odds models, both CMV 7-day moving average (OR, 5.1; 95% CI, 2.9-9.1; P < .001) and CMV AUC (OR, 3.2; 95% CI, 2.1-4.7; P < .001) were independently associated with a hospital length of stay of at least 14 days.

Conclusions  These preliminary findings suggest that reactivation of CMV occurs frequently in critically ill immunocompetent patients and is associated with prolonged hospitalization or death. A controlled trial of CMV prophylaxis in this setting is warranted.

     

胃张力测定在内科危重症患者的应用

组织氧合状态监测是近年来对危重病人监测的重要内容.临床和实验研究证明,危重症患者胃肠道是脓毒血症、全身炎症反应综合征(SIRS)和多器官功能障碍综合征(MODS)的重要器官.它既是缺氧、低灌注损伤的"靶"器官,又是损伤的始动因素[1].许多学者认为,胃肠道缺氧发生在其它缺氧监测指标(如动脉血乳酸升高或氧耗量VO2下降)发生之前[2,3].研究也证实胃肠缺血与预后有关,如果纠正胃肠缺血可以改善预后[4].因此,危重症患者胃肠道的监测日益受到重视.胃张力测定的应用和发展使得这一功能监测成为可能[5,6].现将胃张力测定技术进展及其在内科危重症病人监测中的临床应用作一综述.     

白蛋白在危重病人的循证应用

目的 通过对现有医学证据的检索和评价,指导白蛋白在危重病人中的应用。方法 针对合并低蛋白血症和Sepsis状态的危重病人应用白蛋白的利弊提出临床问题,然后用主题词“albumin”和“critically ill or,sepsis”检索Cochrane图书馆(2003年第2期)和MEDLINE寻找相关的证据。结果 通过检索,一共查到4篇系统评价．15篇随机临床研究。大多数研究表明对低蛋白血症的危重病人使用白蛋白不能减少死亡率,反而可能增加死亡风险。结论 通过检索和评价,我们对该患者选择了暂时停用白蛋白。     

血糖监测对危重症患者的作用

目的探讨危重症患者监测血糖的临床作用。方法对我院收治的危重症患者632例进行随机常规血糖监测,其中385例患者血糖升高,对血糖升高患者进行糖化血红蛋白(glycated hemoglobin,GHb)测定,根搌GHb结果,统计分析GHb正常组与GHb升高组患者的临床糖尿病确诊率及病死率。结果危重症血糖正常患者病死率明显低于血糖升高者(P<0.05);GHb正常组患者糖尿病确诊率及病死率显著低于GHb升高组患者(P<0.05);而GHb升高组患者中无糖尿病史较有糖尿病史患者的病死率升高,差异有统计学意义(P<0.05)。结论重视危重症患者血糖的测定及评估,可以为临床诊治提供科学的参考依据,并可以改善患者的预后。     

腹部外科危重病与血小板计数

目的 探讨腹部外科危重病患者血小板计数变化的意义。方法 对1CU病房收治的95例腹部外科危重病患者进行回顾性分析,按血小板计数分为三组,收集72h内资料计算急性生理学慢性健康状况评分Ⅱ（APACHE Ⅱ）,并随访出院情况,观察APACHEⅡ评分及病死率与血小板计数的关系。并将所有病例按有无感染分为感染组和非感染组,比较血小板减少发生率。结果（1）随着血小板计数降低APACHE Ⅱ分值升高,差异具有高度显著性（P〈0．01）。（2）随着血小板计数降低病死率增加,但差异无显著性（P〉0．05）。（3）感染组血小板减少发qi率高于非感染组,两组间差异具有显著性（P〈0．01）。结论 血小板计数可反映腹部外科危重病患者的病情严重程度。感染是血小板减少的重要影响因素。     

危重病患者细胞免疫功能的评价

目的探讨危重病患者外周血T淋巴细胞亚群及自然杀伤细胞(NK细胞)活性与APACHEⅡ评分及预后的关系.方法观察30例ICU的危重病患者(APACHEⅡ评分≥16)的细胞免疫功能、血清白蛋白水平.结果APACHEⅡ评分＞20患者的NK细胞活性低于APACHEⅡ评分≤20者(10.7±4.0与11.7±5.7,P＜0.05);经过加强治疗病情好转者,入ICU时外周血NK细胞活性、白蛋白水平高于病情恶化者[(14.3±5.1)%与(8.9±31)%,P＜0.01];(32.7±5.3)g/L与(29.0±2 5)g/L,P＜0.05];30例患者NK细胞活性与APACHEⅡ评分呈负相关(r=-0.387,P＜0.05);治疗好转的11例患者两周后外周血CD8水平、NK细胞活性较入ICU时升高[(28.2±5.8)%与(21.3±10.2)%;(19.4±9.3)%与(13.7±4.5)%,均P＜0.05],但CD4/CD8比值下降(1.64±0.45与2.15±0.89,P＜0.05).结论外周血NK细胞活性可以反映危重病患者免疫功能并提示预后;危重病患者即使预后较好,仍存在细胞免疫功能的抑制.