Application of the Sequential Organ Failure Assessment (SOFA) Score to Bacteremic ICU Patients

Abstract Background: Patients admitted to intensive care units (ICUs) are at a high risk of acquiring blood stream infections. We examined whether SOFA score on ICU admission and on the day of bacteremia can predict the occurrence of bacteremia and the outcome of bacteremic ICU patients. Patients and Methods: All patients admitted to a multidisciplinary ICU for more than 48 h from January 1, 2002 to December 31, 2004, were prospectively studied. Demographic, clinical and laboratory data were recorded on admission for all patients and additionally, on the day of the first bacteremic episode for those patients who developed bacteremia. Accordingly, APACHE II and SOFA scores were calculated on the same day. Results: A total of 185 patients developed one or more episodes of bacteremia, giving an incidence of 9.6 per 1,000 ICU days. The ICU mortality rate was 43.9% for bacteremic and 25.8% for the remaining patients (p < 0.001). Admission SOFA score was independently associated with the occurrence of bacteremia (OR = 1.20, 95% CI: 1.11–1.26, p < 0.001). Among bacteremic patients, SOFA score on the day of bacteremia was the only independent prognostic factor for outcome (OR = 1.44, 95% CI: 1.21–1.71, p < 0.001). When all patients were included in the multivariate analysis, admission SOFA (OR = 1.3, CI: 1.16–1.38, p < 0.001), APACHE II (OR = 1.1, CI: 1.02–1.11, p = 0.003) score and the presence of bacteremia (OR = 1.8, CI: 1.1–2.9, p = 0.023) were independently associated with the outcome. Conclusion: Admission SOFA score is independently associated with the occurrence of ICU-acquired bacteremia, whereas it is not sufficient to predict the outcome of patients who subsequently will develop this complication. However, SOFA score on the first day of bacteremia is an independent prognostic factor for outcome in these patients.     

Predictors of mortality and resource utilization in cirrhotic patients admitted to the medical ICU

BACKGROUND AND OBJECTIVE: Cirrhotic patients admitted to the medical ICU (MICU) are associated with high mortality rates and high resource utilization. This study identifies specific predictors of increased mortality and resource utilization and uses them to develop and validate prognostic models in cirrhotic patients admitted to the MICU. METHODS: Cirrhotic patients admitted to the MICU were identified from the Critical Care Section database (January 1993 to October 1998). Clinical data were extracted from chart review including hospital course variables, mortality, and length of stay (LOS). Total cost per case (TCPC) was obtained from the Transition System INC: Multivariate logistic and linear regression analyses identified the independent predictors of increased mortality and resource utilization used for model building (MB) and model validation (MV). RESULTS: A total of 582 cases were randomized to the MB and MV groups. Each group contained 240 cases after exclusion criteria were applied. The MICU mortality rate was 36.6%, and the in-hospital mortality rate was 49.0%. Acute physiology, age, and chronic health evaluation (APACHE) III score (odds ratio [OR], 4.7; 95% confidence interval [CI], 2.70 to 8.16; p < 0.001), mechanical ventilation (OR, 4.57; 95% CI, 2.35 to 8.34); p < 0.001), and the use of pressors (OR, 7.57; 95% CI, 4.35 to 13.18; p < 0.001) were independent predictors of MICU mortality. APACHE III score (OR, 4.96; 95% CI, 2.97 to 8.29; p < 0.001), the use of pressors (OR, 6.55; 95% CI, 3.66 to 11.72; p < 0.001), and acute renal failure (ARF) (OR, 4.31; 95% CI, 2.41 to 7.71; p < 0.001) were independent predictors of in-hospital mortality. Increased LOS in the MICU was associated with mechanical ventilation, ARF, bronchoscopy, bacteremia, use of pressors, transjugular intrahepatic portosystemic shunt (TIPS), and never received cardiopulmonary resuscitation (CPR) (p < 0.005). Source of admission, platelet transfusion, bacteremia, pneumonia, and never received CPR were independently associated with increased total LOS (p < 0.001). Mechanical ventilation, platelet transfusion, bronchoscopy, TIPS, sepsis, and never received CPR were independent predictors of increased TCPC (p < 0.001). CONCLUSION: Simple prognostic models for mortality and resource utilization have been developed for cirrhotic patients admitted to the MICU.     

Effectiveness of endoscopy in patients admitted to the intensive care unit with upper GI hemorrhage

BACKGROUND: Esophagogastroduodenoscopy (EGD) is generally indicated for the management of patients admitted to intensive care units (ICUs) with upper gastrointestinal (GI) hemorrhage but its impact in community practice has not been measured. Thus, the effectiveness of 3 EGD factors, viz., accurate initial diagnosis, performance within 24 hours of admission (early EGD), and appropriate intervention, was examined. METHODS: Records of 214 patients admitted to the ICU of 10 metropolitan hospitals with upper GI hemorrhage were reviewed. Unadjusted and severity-adjusted associations of the 3 EGD factors with length of hospital stay, length of ICU stay, readmission to ICU, recurrent bleeding, surgery, and death were evaluated. RESULTS: Inaccurate diagnosis occurred in 10% of patients at initial EGD and was associated with significant increases in risk of recurrent bleeding (70% vs. 11%, p < 0.001), rate of surgery (20% vs. 4%, p < 0.05), length of hospital stay (median 7.5 vs. 5 days, p < 0.005), length of ICU stay (median 4 vs. 2 days, p < 0.005), and rate of readmission to ICU (20% vs. 0.6%, p < 0.001). These associations persisted after adjusting for severity of illness. Early EGD performed in 82% of patients was associated with significant severity-adjusted reductions in hospital (-33%: 95% CI [-45%, -18%]) and ICU (-20%: 95% CI [-24%, -3%]) stay. Appropriate intervention at initial EGD, performed in 84% of patients, was associated with reductions in severity-adjusted length of ICU stay (-18%: 95% CI [-32%, 0%]) and rate of recurrent bleeding (odds ratio = 0.37, 95% CI [0.13, 1.06]). CONCLUSIONS: Early, accurate EGD with appropriate therapeutic intervention is effective as practiced in the community and is associated with improved outcomes for patients with upper GI hemorrhage admitted to the ICU. Inaccurate diagnosis at initial EGD is uncommon but has a significant adverse association with all outcome measures.     

Intensive care unit staff preparedness as an independent factor for death of patients during COVID-19 pandemic: An observational cohort study

The pandemic of COVID-19 brought to the world an unprecedented challenge. This single center observational study aimed to evaluate the impact of staff preparedness by comparing the outcomes between two intensive care units (ICUs) from a hospital that had to expand ICU beds to deal with an incremented volume of critical patients. Patients consecutively admitted to these ICUs with suspected COVID-19, from March 1st until April 30th, 2020, were included. Both ICUs attended a similar population and had the same facilities, what differed was the staff: one previously well-established (ICU-1) and another recently assembled (ICU-2). 114 patients with severe respiratory syndrome were included. In-hospital mortality was 40%. Compared with patients in the well-established ICU-1, patients in the recently assembled ICU-2 were older (54 versus 61.5, p=0.045), received more antibiotics (93% versus 98%, p=0.001) and chloroquine/hydroxychloroquine 6% versus 30%, p=0.001), had a higher proportion of invasive mechanical ventilation (44% versus 52%, p=0.008) and had greater in-hospital mortality (30% versus 50%, p=0.017). The proportion of patients considered at high risk for death according to PSI was similar between the two ICU populations. Age ≥ 60 years (adjusted OR 2.33; 95% CI 1.02-5.31), need of invasive mechanical ventilation (adjusted OR 2.79; 95% CI 1.22-6.37), and ICU type (recently assembled) (adjusted OR 2.38; 95% CI 1.04-5.44) were independently associated with in-hospital mortality . This finding highlights the importance of developing support strategies to improve preparedness of staff recently assembled to deal with emergencies.     

Characteristics associated with delirium in older patients in a medical intensive care unit

BACKGROUND: Delirium is a highly prevalent disorder among older patients in the intensive care unit. METHODS: We performed a prospective cohort study of 304 patients 60 years or older admitted from September 5, 2002, through September 30, 2004, to a 14-bed ICU in an urban university teaching hospital. The main outcome measure was ICU delirium that developed within 48 hours of ICU admission. Patients were assessed for delirium with the Confusion Assessment Method for the ICU and medical record review. Risk factors for delirium were assessed on ICU admission by interview with proxies and medical record review. A model was developed using multivariate logistic regression and internally validated with bootstrapping methods. RESULTS: Delirium occurred in 214 study participants (70.4%) within the first 48 hours of ICU admission. In a multivariate regression model, 4 admission risk factors for delirium were identified. These risk factors included dementia (odds ratio [OR], 6.3; 95% confidence interval [CI], 2.9-13.8), receipt of benzodiazepines before ICU admission (OR, 3.4; 95% CI, 1.6-7.0), elevated creatinine level (OR, 2.1; 95% CI, 1.1-4.0), and low arterial pH (OR, 2.1; 95% CI, 1.1-3.9). The C statistic was 0.78. CONCLUSIONS: Delirium is frequent among older ICU patients. Admission characteristics can be important markers for delirium in these patients. Knowledge of these admission risk factors can prompt early correction of metabolic abnormalities and may subsequently reduce delirium duration.     

Morbid obesity in the medical ICU.

Study objective: To describe the clinical course, complications, and prognostic factors of morbidly obese patients admitted to the ICU compared to a control group of nonobese patients. DESIGN: A retrospective study. SETTING: Two university-affiliated hospitals. METHODS: We reviewed the medical records of 117 morbidly obese patients (body mass index >/= 40 kg/m(2)) admitted to the medical ICU between January 1994 and June 2000. Data collected included demographic information, comorbid condition, APACHE (acute physiology and chronic health evaluation) II score, invasive procedures, organ failure, and in-hospital mortality. RESULTS: Obstructive airway disease, pneumonia, and sepsis were the main reasons for admission to the ICU in the morbidly obese group. Sixty-one percent of the morbidly obese patients and 46% of the nonobese group required mechanical ventilation (p = 0.02). The mean lengths of mechanical ventilation and ICU stay were significantly longer for the morbidly obese group (7.7 +/- 9.6 days and 9.3 +/- 10.5 days vs 4.6 +/- 7.1 days and 5.8 +/- 8.2 days, respectively; p < 0.001). APACHE II scores were not significantly different in the two groups (19.1 +/- 7.6 and 20.6 +/- 12.2; p = 0.6). Overall mortality was 30% for the morbidly obese patients and 17% for the nonobese group (p = 0.019). By multivariate analysis, multiorgan failure (odds ratio [OR], 4.6; 95% confidence interval [CI], 2.1 to 16.6), PaO(2)/fraction of inspired oxygen < 200 for > 48 h (OR, 2.3; 95% CI, 1.2 to 7.8), and depressed left ventricular ejection fraction < 40% (OR, 1.4; 95% CI, 1.03 to 13.8) were independently associated with ICU mortality in the morbidly obese group. CONCLUSION: We conclude that critically ill morbidly obese patients are at increased risk of morbidity and mortality compared to the nonobese patients.     

Severity-of-illness markers as predictors of nosocomial infection in adult intensive care unit patients

BACKGROUND: Patients admitted to intensive care units (ICUs) are at high risk for acquiring nosocomial infections. We examined the association between markers of severity of illness at ICU admission and the development of ICU-attributable nosocomial infections. METHODS: Retrospective cohort study of 851 patients admitted to the medical or surgical ICU in an urban teaching hospital from January 1997 to January 1998. Logistic regression analysis was used to identify predictors of nosocomial infection, including the Acute Physiology, Age, Chronic Health Evaluation III severity-of-illness scoring system. RESULTS: Patients receiving mechanical ventilation on day 1 of ICU admission (OR, 1.99; 95% CI, 1.29-3.06) and patients transferred to the ICU from another unit within the same hospital (OR, 2.04; 95% CI, 1.24-3.34) were twice as likely to acquire an ICU-attributable nosocomial infection compared with patients admitted from other sources. The day-1 Acute Physiology, Age, Chronic Health Evaluation III score was not a significant predictor of nosocomial infection. CONCLUSION: The need for mechanical ventilation on ICU day 1 and transfer to the ICU from another unit are independent predictors of ICU-attributable nosocomial infections. Up to 50% of ICU patients who develop nosocomial infections could be easily identified at ICU admission, allowing for targeted use of preventive strategies to reduce the risk of nosocomial infections.     

The prognosis of acute respiratory failure in critically ill cancer patients

Acute respiratory failure (ARF) in patients with cancer is frequently a fatal event. To identify factors associated with survival of cancer patients admitted to an intensive care unit (ICU) for ARF, we conducted a prospective 5-year observational study in a medical ICU in a teaching hospital in Paris, France. The patients were 203 cancer patients with ARF mainly due to infectious pneumonia (58%), but also noninfectious pneumonia (9%), congestive heart failure (12%), and no identifiable cause (21%). We measured clinical characteristics and ICU and hospital mortality rates.ICU mortality was 44.8% and hospital mortality was 47.8%. Noninvasive mechanical ventilation was used in 79 (39%) patients and conventional mechanical ventilation in 114 (56%), the mortality rates being 48.1% and 75.4%, respectively. Among the 14 patients with late noninvasive mechanical ventilation failure (>48 hours), only 1 survived. The mortality rate was 100% in the 19 noncardiac patients in whom conventional mechanical ventilation was started after 72 hours. By multivariable analysis, factors associated with increased mortality were documented invasive aspergillosis (odds ratio [OR], 2.13; 95% confidence intervals [CI], 1.05-14.74), no definite diagnosis (OR, 3.85; 95% CI, 1.26-11.70), vasopressors (OR, 3.19; 95% CI, 1.28-7.95), first-line conventional mechanical ventilation (OR, 8.75; 95% CI, 2.35-35.24), conventional mechanical ventilation after noninvasive mechanical ventilation failure (OR, 17.46; 95% CI, 5.04-60.52), and late noninvasive mechanical ventilation failure (OR, 10.64; 95% CI, 1.05-107.83). Hospital mortality was lower in patients with cardiac pulmonary edema (OR, 0.16; 95% CI, 0.03-0.72).Survival gains achieved in critically ill cancer patients in recent years extend to patients requiring ventilatory assistance. The impact of conventional mechanical ventilation on survival depends on the time from ICU admission to conventional mechanical ventilation and on the patient's response to noninvasive mechanical ventilation.     

RABBIT risk score and ICU admission due to infection in patients with rheumatoid arthritis

Rheumatoid arthritis (RA) patients are at increased risk of infection. Aim of the present study was to investigate whether RA patients admitted to an intensive care unit (ICU) due to infection have higher Rheumatoid Arthritis Observation of Biologic Therapy (RABBIT) risk scores compared to control RA patients. Seventy-four RA patients (32.4% male) admitted to an ICU due to infection (from January 2002 to December 2013) and 74 frequency-matched control RA patients (16.2% male) were included in this cross-sectional study. There was strong evidence for a higher RABBIT risk score in ICU patients (median 2.0; IQR 1.3–3.2) as compared to controls (1.3; IQR 0.8–2.0; p < 0.0001). Traditional disease-modifying anti-rheumatic drugs (DMARDs) (82.4 vs 64.9%; p = 0.015) and biological DMARDs (28.4 vs 14.9%; p = 0.012) were more frequently given to RA patients without ICU admission. Glucocorticoid users were more frequently found in the ICU group (51.4 vs 31.1%; p = 0.012). In a multivariable analysis tDMARD use was associated with lower (OR 0.38; 95% CI 0.15–0.93; p = 0.034) and glucocorticoid use with borderline higher odds of ICU admission (OR 2.05; 95% CI 0.92–4.58; p = 0.078). Chronic obstructive pulmonary disease (OR 2.89; 95% CI 1.10–7.54; p = 0.03), chronic kidney disease (OR 16.08; 95% CI 2.00–129.48; p = 0.009), and age category (OR 2.67; 95% CI 1.46–4.87; p = 0.001) were strongly associated with ICU admission. There was a strong trend towards higher odds of ICU admission with increasing RABBIT risk score. Use of tDMARDs was associated with lower odds of ICU admission. In an adjusted analysis, bDMARDs were not associated with ICU admission. COPD, CKD, and age were strong risk factors for ICU admission.     

Outcome of coal worker's pneumoconiosis with acute respiratory failure

STUDY OBJECTIVE: To investigate the clinical features and prognosis of patients with coal worker's pneumoconiosis (CWP) requiring invasive mechanical ventilation (MV) in the ICU for their first episode of acute respiratory failure (ARF), with special attention to the prognostic implication of radiographic progressive massive fibrosis (PMF). DESIGN: Retrospective study. SETTING: A 16-bed medical ICU at a community hospital. PATIENTS AND METHODS: We reviewed 53 patients with CWP and ARF requiring invasive MV in the ICU for the first time between August 1998 and March 2002. RESULTS: Of the 53 patients with CWP, 28 patients (53%) with PMF had their first ARF at a younger age than those without PMF (69.1 +/- 7.9 years vs 74.8 +/- 7.2 years, p = 0.008 [mean +/- SD]). Pneumonia (49%) was the most common cause of ARF. The mean APACHE (acute physiology and chronic health evaluation) II score was 26.0 +/- 9.9, and the mean ICU stay was 14.7 +/- 16.1 days. Twenty-one patients (40%) were weaned successfully in the ICU, with mean ventilator time of 17.0 +/- 25.1 days. The ICU and in-hospital mortality rates were 40% and 43%, respectively. The median survivals for all patients and the ICU survivors were 2.6 months and 14.3 months, respectively. Multivariate analysis showed the following risk (or protective) factors for the ICU mortality: PaCO(2) > 45 mm Hg at the time of intubation (adjusted odds ratio [OR], 0.04; 95% confidence interval [CI], 0.003 to 0.44), PaO(2)/fraction of inspired oxygen ratio < 200 mm Hg at the time of intubation (OR, 8.78; 95% CI, 1.36 to 56.48), and APACHE II score >or= 25 (OR, 11.99; 95% CI, 1.49 to 96.78). PMF was not associated with the ICU mortality (OR, 1.18; 95% CI, 0.20 to 7.10). CONCLUSIONS: Radiographic PMF was not associated with the ICU mortality in patients with CWP and ARF receiving invasive MV in the ICU. Although a substantial proportion of them could be weaned from the ventilator and discharged from the hospital, their long-term prognosis was poor.     

Predictors of major postoperative cardiac complications in a surgical ICU.

INTRODUCTION: Cardiovascular complications are associated with increased mortality and morbidity during the postoperative period, resulting in longer hospital stay and higher treatment costs. OBJECTIVES: The aim of this study was to identify predictors of major postoperative cardiac complications. METHODS: 187 patients undergoing noncardiac surgery, admitted to a surgical intensive care unit (ICU) between November 2004 and April 2005. Variables recorded were age, gender, American Society of Anesthesiologists (ASA) physical status, type and magnitude of surgery, mortality, ICU and hospital length of stay (LOS), Simplified Acute Physiology Score II (SAPS II), cardiac troponin I (cTnI) at postoperative day 0, 1, 2 and 3, history of hypertension, hyperlipidemia, Revised Cardiac Risk Index (RCRI) score, major cardiac events (MCE): acute myocardial infarction (AMI), pulmonary edema (PE), ventricular fibrillation (VF) or primary cardiac arrest (PCA). Correlations between variables and MCE were made by univariate analysis by simple logistic regression with odds ratio (OR) and 95% confidence interval (95% CI). RESULTS: Total of 14 MCE: 9 AMI, 1 VF, 4 PE. Significant risk factors for MCE were high-risk surgery (OR 8.26, 95% CI 1.76-38.85, p = 0.008), RCRI > or = 2 (OR 4.0, 95% CI 1.22-13.16, p = 0.022), admission cTnI (OR 1.46, 95% CI 1.07-1.99, p = 0.018); day 1 cTnI (OR 1.75, 95% CI 1.27-2.41, p = 0.001); day 2 cTnI (OR 2.23, 95% CI 1.24-3.98, p = 0.007), SAPS II (OR 1.08, 95% CI 1.04-1.12, p < 0.001). Patients with MCE had longer ICU LOS (19.1 +/- 19.3 days against 3.4 +/- 4.9) (OR 1.15, 95% CI 1.08-1.22, p < 0.001) and higher ICU mortality (21.4% versus 4.6%) (OR 5.63, 95% CI 1.31-24.23, p = 0.02) in the ICU. CONCLUSIONS: High-risk surgery, RCRI > or = 2, cTnI levels and SAPS II were predictors of postoperative MCE. Patients with MCE had longer ICU stay and higher mortality rate.     

Pneumonia severity index class v patients with community-acquired pneumonia: characteristics, outcomes, and value of severity scores

BACKGROUND: Community-acquired pneumonia (CAP) with a pneumonia severity index (PSI) score in risk class V (PSI-V) is a potentially life-threatening condition, yet the majority of patients are not admitted to the ICU. The aim of this study was to characterize CAP patients in PSI-V to determine the risk factors for ICU admission and mortality, and to assess the performance of CAP severity scores in this population. METHODS: Prospective observational study including hospitalized adults with CAP in PSI-V from 1996 to 2003. Clinical and laboratory data, microbiological findings, and outcomes were recorded. The PSI score; modified American Thoracic Society (ATS) score; the confusion, urea, respiratory rate, low BP (CURB) score, and CURB plus age of >/= 65 years score were calculated. A reduced score based on the acute illness variables contained in the PSI was also obtained. RESULTS: A total of 457 patients were included in the study (mean [+/- SD] age, 79 +/- 11 years), of whom 92 (20%) were admitted to the ICU. Patients in the ward were older (mean age, 82 +/- 10 vs 70 +/- 10 years, respectively) and had more comorbidities. ICU patients experienced significantly more acute organ failures. The mortality rate was higher in ICU patients, but also was high for non-ICU patients (37% vs 20%, respectively; p = 0,003). A low level of consciousness (odds ratio [OR], 3.95; 95% confidence interval [CI], 2 to 5) and shock (OR, 24.7; 95% CI, 14 to 44) were associated with a higher risk of death. The modified ATS severity rule had the best accuracy in predicting ICU admission and mortality. CONCLUSIONS: Most CAP patients PSI-V were treated on a hospital ward. Those admitted to the ICU were younger and had findings of more acute illness. The PSI performed well as a mortality prediction tool but was less appropriate for guiding site-of-care decisions.     

Determinants of the length of mechanical ventilation in patients with COPD in the intensive care unit

BACKGROUND: About 10% of the patients with chronic obstructive pulmonary disease (COPD) are at high risk for prolonged mechanical ventilation (MV >21 days), and mortality ranges from 55 to 78% in these patients. OBJECTIVE: To determine the potential risk factors for MV over periods of 1, 2 and 3 weeks in patients with COPD. PATIENTS AND METHOD: The characteristics of patients during the stable period of their disease, on admission to the intensive care unit (ICU) and during the ICU stay were recorded prospectively and analyzed retrospectively for this study. t test, chi(2) test and logistic regression analysis were used for statistical analysis. RESULTS: 86 patients with COPD requiring MV were included in the study. 73, 33, and 13% of the patients required MV longer than 1, 2 and 3 weeks, respectively. There were no significant relationships between the duration of MV and bronchiectasis or the presence of community-acquired pneumonia on admission, baseline pulmonary function test results or blood gas parameters on admission. Development of ventilator-associated pneumonia (VAP; odds ratio, OR: 6; 95% confidence interval, CI: 2-23, p = 0.011) and sepsis (OR: 10; 95% CI: 2-54, p = 0.007) were independent predictors for MV >7 days. VAP was still a risk factor for MV >15 days with an OR of 14 (95% CI: 3-66, p = 0.001). On the other hand MV >21 days was primarily determined by increasing age (OR: 1.2; 95% CI: 1-1.3, p = 0.042), severity of the disease on admission measured by APACHE II score (OR: 1.4; 95% CI: 1-1.7, p = 0.002) and albumin levels (OR: 0.10, 95% CI: 0.01-0.54, p = 0.007). CONCLUSION: Advanced age, severity of disease on admission and development of VAP during ICU stay are the main determinants of MV duration in patients with COPD.     

The occurrence of ventilator-associated pneumonia in a community hospital: risk factors and clinical outcomes

STUDY OBJECTIVES: To prospectively identify the occurrence of ventilator-associated pneumonia (VAP) in a community hospital, and to determine the risk factors for VAP and the influence of VAP on patient outcomes in a nonteaching institution. DESIGN: Prospective cohort study. SETTING: A medical ICU and a surgical ICU in a 500-bed private community nonteaching hospital: Missouri Baptist Hospital. PATIENTS: Between March 1998 and December 1999, all patients receiving mechanical ventilation who were admitted to the ICU setting were prospectively evaluated. INTERVENTION: Prospective patient surveillance and data collection. RESULTS: During a 22-month period, 3,171 patients were admitted to the medical and surgical ICUs. Eight hundred eighty patients (27.8%) received mechanical ventilation. VAP developed in 132 patients (15.0%) receiving mechanical ventilation. Three hundred one patients (34.2%) who received mechanical ventilation died during hospitalization. Logistic regression analysis demonstrated that tracheostomy (adjusted odds ratio [AOR], 6.71; 95% confidence interval [CI], 3.91 to 11.50; p < 0.001), multiple central venous line insertions (AOR, 4.20; 95% CI, 2.72 to 6.48; p < 0.001), reintubation (AOR, 2.88; 95% CI, 1.78 to 4.66; p < 0.001), and the use of antacids (AOR, 2.81; 95% CI, 1.19 to 6.64; p = 0.019) were independently associated with the development of VAP. The hospital mortality of patients with VAP was significantly greater than the mortality of patients without VAP (45.5% vs 32.2%, respectively; p = 0.004). The occurrence of bacteremia, compromised immune system, higher APACHE (acute physiology and chronic health evaluation) II scores, and older age were identified as independent predictors of hospital mortality. CONCLUSIONS: These data suggest that VAP is a common nosocomial infection in the community hospital setting. The risk factors for the development of VAP and risk factors for hospital mortality in a community hospital are similar to those identified from university-affiliated hospitals. These risk factors can potentially be employed to develop local strategies for the prevention of VAP. Clinical implications: ICU clinicians should be aware of the risk factors associated with the development of VAP and the impact of VAP on clinical outcomes. More importantly, they should cooperate in the development of local multidisciplinary strategies aimed at the prevention of VAP and other nosocomial infections.     

Prediction of cerebrovascular event risk following myocardial infarction

IntroductionPatients with coronary artery disease (CAD) are at increased risk of stroke. The aim of this study was to analyze the prognostic accuracy of selected clinical and laboratory variables in stroke risk prediction following discharge after myocardial infarction (MI).MethodsWe analyzed 404 consecutive patients (aged 68.1±13.7 years; 63.4% male; 37.4% with diabetes) without previous stroke who were discharged in sinus rhythm after being admitted for MI. The following data were collected: cardiovascular risk factors, admission blood glucose (BG), HbA1c, creatinine, peak troponin levels; glomerular filtration rate (GFR) by the MDRD formula; maximum Killip class; GRACE score for in-hospital and 6-month mortality; and extent of CAD. Patients were followed for two years and each variable was tested as a possible predictor of cerebrovascular events (stroke or transient ischemic attack [TIA]).ResultsDuring follow-up, 27 patients were admitted for stroke or TIA. The presence of diabetes, hypertension, dyslipidemia and previously known CAD, type of MI (STEMI vs NSTEMI) and extent of CAD did not predict cerebrovascular risk. The following variables were associated with higher stroke risk: GFR <60 ml/min/m² (p=0.029, OR 2.65, 95% CI 1.07-6.55); maximum Killip class >1 (p=0.025, OR 2.71, 95% CI 1.10-6.69); GRACE in-hospital mortality >180 (p=0.001, OR 4.09, 95% CI 1.64-10.22); admission BG >140 mg/dl (p=0.001, OR 5.74, 95% CI 1.87-17.58); GRACE 6-month mortality >150 (p=0.001, OR 4.50, 95% CI 1.80-6.27); and peak troponin >42 ng/ml (p=0.032, OR 2.64, 95% CI 1.06-6.59). Logistic regression analysis produced a model with the predictors GRACE 6-month mortality >150 (OR 3.26; p=0.014) and admission BG >7.7 mmol/l (OR 4.09; p=0.017) that fi tted the data well (Hosmer-Lemeshow: p=0.916).Discussion/conclusionsIn patients with MI, variables known to be predictors of in-hospital mortality, including admission BG, renal function, acute heart failure and GRACE score, were found to be useful predictors of stroke during 2-year follow-up. While both GRACE score for 6-month mortality >150 and admission BG >7.7 mmol/l were independent predictors of stroke, CV risk factors, previously known CAD, and extent of CAD assessed by coronary angiography did not improve stroke risk prediction. This study highlights the need for even more aggressive secondary prevention in patients most at risk.     

Predicting outcome and survival in patients with Wegener's granulomatosis treated on the intensive care unit

OBJECTIVE: This study was designed to search for risk factors predicting mortality of patients with Wegener's granulomatosis (WG) treated on the intensive care unit (ICU). METHODS: Seventeen patients admitted to the ICU of an University Hospital for an acute illness related to WG were analysed retrospectively over 4 years. A variety of clinical and laboratory variables were recorded. Contingency table analyses, univariate logistic regression, and discriminate analysis were performed to determine which factors influenced a negative outcome. RESULTS: Reasons for ICU admission were respiratory failure (n = 10), severe haemoptysis (n = 13), sepsis (n = 9), acute renal failure (n = 6), and gastrointestinal bleeding (n = 1). Patients were treated for a median of 6 days (range 4-121 days). During the stay in the ICU, five patients died within 24-121 days (overall mortality 29.4%). Causes of death were cerebral haemorrhage (n = 2), pulmonary embolism (n = 1), and sepsis (n = 2). Significantly associated with death were: Acute Physiology and Chronic Health Evaluation II (APACHE II) score>24 [p = 0.004, odds ratio (OR) 0.568, 95% confidence interval (CI) 0.327-0.989], period of time in the ICU>10 days (p = 0.001, OR 0.795, 95% CI 0.589-1.072), and treatment with cyclophosphamide during the stay in the ICU (p = 0.013, OR 0.799, 95% CI 0.651-0.980). No association was found for higher age, C-reactive protein (CRP), pulmonary involvement, serum creatinine, and requirement of haemodialysis. CONCLUSIONS: The prognosis for WG patients in the ICU is serious, but the majority can survive. To achieve a more favourable outcome, patients should stay in the ICU for as short a time as possible. The occurrence of renal failure did not influence the outcome in our patients.     

Hospital volume-outcome relationships among medical admissions to ICUs

BACKGROUND: Positive relationships between hospital volume and outcomes have been demonstrated for several surgeries and medical conditions. However, little is known about the volume-outcome relationship in patients admitted to medical ICUs. OBJECTIVE: To determine the relationship between hospital volume and risk-adjusted in-hospital mortality for patients admitted to ICUs with respiratory, neurologic, and GI disorders. DESIGN: Retrospective cohort study. SETTING: Twenty-nine hospitals in a single metropolitan area. PATIENTS: Adult ICU admissions from 1991 through 1997. METHODS: Using Cox proportional hazards models, we compared in-hospital mortality between tertiles of hospital volume (high, medium, and low) for respiratory (n = 16,949), neurologic (n = 13,805), and GI (n = 12,881) diseases after adjusting for age, gender, admission severity of illness, admitting diagnosis, and source. Severity of illness was measured using the APACHE (acute physiology and chronic health evaluation) III methodology. RESULTS: Among respiratory and neurologic ICU admissions, hazard ratios were similar (p > or = 0.05) in patients in low-, medium-, and high-volume hospitals. However, among GI diagnoses, risk of mortality was lower in high-volume hospitals, relative to low-volume hospitals (hazard ratio, 0.68; 95% confidence interval [CI], 0.54 to 0.85; p < 0.001), and was somewhat lower in medium-volume hospitals (hazard ratio, 0.83; 95% CI, 0.68 to 1.01; p = 0.06). Among subgroups based on severity of illness, high-volume hospitals had lower mortality, relative to low-volume hospitals, among sicker patients (APACHE III score > 57) in the respiratory cohort (hazard ratio, 0.77; 95% CI, 0.59 to 0.99) and the GI cohort (hazard ratio, 0.67; 95% CI, 0.53 to 0.85). CONCLUSIONS: Associations between ICU volume and risk-adjusted mortality were significant for patients with GI diagnoses and for sicker patients with respiratory diagnoses. However, associations were not significant for patients with neurologic diagnoses. The lack of a consistent volume-outcome relationship may reflect unmeasured patient complexity in higher-volume hospitals, relative standardization of care across ICUs, or lack of efficacy of some accepted ICU processes of care.     

Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients

STUDY OBJECTIVE: To evaluate the relationship between inadequate antimicrobial treatment of infections (both community-acquired and nosocomial infections) and hospital mortality for patients requiring ICU admission. DESIGN: Prospective cohort study. SETTING: Barnes-Jewish Hospital, a university-affiliated urban teaching hospital. PATIENTS: Two thousand consecutive patients requiring admission to the medical or surgical ICU. INTERVENTIONS: Prospective patient surveillance and data collection. MEASUREMENTS AND RESULTS: One hundred sixty-nine (8.5%) infected patients received inadequate antimicrobial treatment of their infections. This represented 25.8% of the 655 patients assessed to have either community-acquired or nosocomial infections. The occurrence of inadequate antimicrobial treatment of infection was most common among patients with nosocomial infections, which developed after treatment of a community-acquired infection (45.2%), followed by patients with nosocomial infections alone (34.3%) and patients with community-acquired infections alone (17.1%) (p < 0.001). Multiple logistic regression analysis, using only the cohort of infected patients (n = 655), demonstrated that the prior administration of antibiotics (adjusted odds ratio [OR], 3.39; 95% confidence interval [CI], 2.88 to 4.23; p < 0.001), presence of a bloodstream infection (adjusted OR, 1.88; 95% CI, 1.52 to 2.32; p = 0.003), increasing acute physiology and chronic health evaluation (APACHE) II scores (adjusted OR, 1.04; 95% CI, 1.03 to 1.05; p = 0.002), and decreasing patient age (adjusted OR, 1.01; 95% CI, 1.01 to 1.02; p = 0.012) were independently associated with the administration of inadequate antimicrobial treatment. The hospital mortality rate of infected patients receiving inadequate antimicrobial treatment (52.1%) was statistically greater than the hospital mortality rate of the remaining patients in the cohort (n = 1,831) without this risk factor (12.2%) (relative risk [RR], 4.26; 95% CI, 3.52 to 5.15; p < 0.001). Similarly, the infection-related mortality rate for infected patients receiving inadequate antimicrobial treatment (42.0%) was significantly greater than the infection-related mortality rate of infected patients receiving adequate antimicrobial treatment (17.7%) (RR, 2.37; 95% CI, 1.83 to 3.08; p < 0.001). Using a logistic regression model, inadequate antimicrobial treatment of infection was found to be the most important independent determinant of hospital mortality for the entire patient cohort (adjusted OR, 4.27; 95% CI, 3.35 to 5.44; p < 0.001). The other identified independent determinants of hospital mortality included the number of acquired organ system derangements, use of vasopressor agents, the presence of an underlying malignancy, increasing APACHE II scores, increasing age, and having a nonsurgical diagnosis at the time of ICU admission. CONCLUSIONS: Inadequate treatment of infections among patients requiring ICU admission appears to be an important determinant of hospital mortality. These data suggest that clinical efforts aimed at reducing the occurrence of inadequate antimicrobial treatment could improve the outcomes of critically ill patients. Additionally, prior antimicrobial therapy should be recognized as an important risk factor for the administration of inadequate antimicrobial treatment among ICU patients with clinically suspected infections.     

A prospective study of agitation in a medical-surgical ICU: incidence, risk factors, and outcomes

STUDY OBJECTIVES: Although agitation is thought to be common in the ICU, it has been poorly studied. We evaluated the incidence, risks factors, and outcomes of agitation in ICU. DESIGN: Prospective observational study. INTERVENTIONS: None. METHOD: All consecutive ICU admissions over an 8-month period were analyzed. MEASUREMENTS AND RESULTS: Two hundred eleven patients were admitted a total of 216 times during the period of the study. Twenty-nine patients were excluded from the study because their pathology findings did not allow an evaluation of their level of consciousness; 182 patients were actually enrolled. Agitation developed in 95 of 182 patients (52%). Agitation began 4.4 +/- 5.6 days (+/- SD) after admission to the ICU and lasted 3.9 +/- 4.1 days. Patients with agitation had a higher Simplified Acute Physiology Score II on ICU admission than those who did not have agitation (40 +/- 16 vs 33 +/- 13, p < 0.01). By stepwise logistic regression, the independent risks factors for development of agitation included psychoactive drug use at the time of ICU admission (odds ratio, 5.63; 95% confidence interval [CI], 1.32 to 23.70), history of alcohol abuse (odds ratio, 3.32; 95% CI, 1.12 to 10.00), dysnatremia (odds ratio, 4.95; 95% CI, 1.95 to 12.54), fever (odds ratio, 4.52; 95% CI, 1.80 to 11.49), use of sedatives in the ICU (odds ratio, 4.03; 95% CI, 1.62 to 10.40), and sepsis (odds ratio, 2.61; 95% CI, 1.03 to 6.58). Agitation was associated with a prolonged ICU stay (16 +/- 19 days vs 6 +/- 6 days, p = 0.0001), nosocomial infections (34% vs 7%, p < 0.0001), unplanned extubations (17% vs 2%, p = 0.003), and unplanned central venous catheter removal (16% vs 1%, p = 0.001), but not with mortality (12% in the agitation group vs 8% in patients without agitation). CONCLUSIONS: Agitation is a common event in a mixed medical-surgical ICU. It is associated with adverse outcomes including prolonged stay, nosocomial infections, and unplanned extubations. A better knowledge of incidence and risk factors should facilitate identification of patients at risk and decrease the incidence of agitation.