Application of SOFA score to trauma patients

Objective: To assess the ability of the SOFA score (Sequential Organ Failure Assessment) to describe the evolution of organ dysfunction/failure in trauma patients over time in intensive care units (ICU). Design: Retrospective analysis of a prospectively collected database. Setting: 40 ICUs in 16 countries. Patients: All trauma patients admitted to the ICU in May 1995. Main outcome measures and results: Incidence of dysfunction/failure of different organs during the first 10 days of stay and the relation between the dysfunction, outcome, and length of stay. Included in the SOFA study were 181 trauma patients (140 males and 41 females).The non-survivors were significantly older than the survivors (51 years ± 20 vs 38 ± 16 years, p < 0.05) and had a higher global SOFA score on admission (8 ± 4 vs 4 ± 3, p < 0.05) and throughout the 10-day stay. On admission, the non-survivors had higher scores for respiratory ( > 3 in 47 % of non-survivors vs 17 % of survivors), cardiovascular ( > 3 in 24 % of non-survivors vs 5.7 % of survivors), and neurological systems ( > 4 in 41 % of non-survivors vs 16 % of survivors); although the trend was maintained over the whole study period, the differences were greater during the first 4–5 days. After the first 4 days, only respiratory dysfunction was significantly related to outcome. A higher SOFA score, admission to the ICU from the same hospital, and the presence of infection on admission were the three major variables associated with a longer length of stay in the ICU (additive regression coefficients: 0.85 days for each SOFA point, 4.4 for admission from the same hospital, 7.26 for infection on admission). Conclusions: The SOFA score can reliably describe organ dysfunction/failure in trauma patients. Regular and repeated scoring may be helpful for identifying categories of patients at major risk of prolonged ICU stay or death. Received: 3 March 1998 Accepted: 21 December 1998     

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

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

Serial measurement of Therapeutic Intervention Scoring System-28 (TISS-28) in a surgical intensive care unit

PurposeThe aim of the study was to assess the use of the Therapeutic Intervention Scoring System-28 (TISS-28) in surgical intensive care unit (ICU) patients and the relationship of the score to the type of surgery, severity of illness, and outcome in these patients.Materials and MethodsProspectively collected data from all patients admitted to a postoperative ICU between March 1, 2004, and June 30, 2006, were analyzed retrospectively.ResultsA total of 6903 patients were admitted during the study period (63.5% male; mean age, 62.3 years) constituting 29 140 observation days. The mean Simplified Acute Physiology Score (SAPS) II, Sequential Organ Failure Assessment (SOFA), and TISS-28 scores on the day of ICU admission were 36.9 ± 18.2, 5.8 ± 3.9, and 43.2 ± 10.8, respectively. The highest admission TISS-28 was observed in patients who underwent cardiothoracic surgery (47.7 ± 10.1), the lowest in neurosurgical patients (40 ± 9.6), and both declined during the 2 weeks after ICU admission; however, in trauma patients and those admitted after gastrointestinal surgery, TISS scores increased gradually after the first 2 to 5 days in the ICU. The TISS-28 score was moderately correlated to SAPS II (R² = 0.42; P < .001) and SOFA score (R² = 0.48; P < .001) throughout the ICU stay and was consistently higher in nonsurvivors than in survivors during the first 2 weeks in the ICU.ConclusionsThere are marked variations in TISS-28 scores according to the type of surgery. Therapeutic Intervention Scoring System-28 correlates with the severity of illness and outcome in these patients.     

冠脉搭桥病人术后器官功能评分和预后分析

目的　采用序贯器官衰竭估计 (SOFA)评价急诊和择期冠状动脉搭桥 (CABG)术后的器官功能并对预后进行分析。方法　急诊CABG和择期CABG病人各 4 2例 ,进行回顾性分析。根据SOFA评分标准 ,确定术后在重症监护病房 (ICU)期间每天的器官功能评分 ,比较两组病人SOFA总分 (totalSOFAscore) ,分析总的最高SOFA评分 (TMS)以及各器官最差SOFA评分与预后的关系。结果　急诊组的死亡率高于择期组 (P <0 0 5 )。急诊组术后前 5d的SOFA总分均高于择期组 (P <0 0 1) ,死亡病例的TMS、除肝脏外的器官最差评分均高于存活病例 (P <0 0 5或 P <0 0 1) ,Logistic回归分析发现呼吸、心血管和中枢神经系统与死亡相关 (P <0 0 1)。急诊组存活病例的TMS高于择期组 (P <0 0 1) ,心血管支持时间和ICU停留时间较长 (P <0 0 5或P <0 0 1)。存活病例的ICU停留时间和TMS之间存在相关性 ,相关系数为 0 4 5 2 (P <0 0 1)。结论　SOFA是反映CABG病人预后的指标。急诊CABG术后器官功能评分较高 ,预后较差 ,与呼吸、心血管和中枢神经系统功能障碍有关。     

Intensive care unit acquired infection and organ failure

Objective To assess the temporal relationship between ICU-acquired infection (IAI) and the prevalence and severity of organ dysfunction or failure (OD/F). Design and setting Observational, single center study in a mixed intensive care unit of a university hospital. Patients We analyzed 1,191 patients hospitalized for more than 2 days during a 2-year observation period: 845 did not acquire IAI, 306 of whom had infection on admission (IOA); 346 did acquire IAI, 125 of whom had IOA. Measurements and results The SOFA score was calculated daily, both SOFAmax, the sum of the worst OD/F during the ICU stay, and SOFApreinf, the sum of the worst OD/F existing before the occurrence of the first IAI. The SAPS II and SOFA score of the first 24 h were significantly higher in patients with than in those without IAI. SOFApreinf of IAI patients was also higher than the SOFAmax of patients without IAI both in patients with (12.1 ± 4.6 vs. 8.9 ± 4.7) and those without IOA (9.2 ± 4.0 vs. 6.7 ± 3.5). SOFApreinf represented 85.7% of the value of SOFAmax in patients with IAI. SOFApreinf increased significantly with the occurrence of sepsis, severe sepsis, or septic shock during ICU stay. Severe sepsis and septic shock during ICU stay as well as SOFApreinf were part of the factors associated with hospital mortality. Conclusions IAI is significantly associated with hospital mortality; however, its contribution to OD/F is minor. Moreover, severity of IAI seems to be related to previous health status. This article is discussed in the editorial available at: .     

Statin administration did not influence the progression of lung injury or associated organ failures in a cohort of patients with acute lung injury

Purpose  Preclinical studies suggest that HMG-CoA reductase inhibitors (statins) may attenuate organ dysfunction. We evaluated whether statins are associated with attenuation of lung injury and prevention of associated organ failure in patients with ALI/ARDS. Methods  From a database of patients with ALI/ARDS, we determined the presence and timing of statin administration. Main outcome measures were the development and progression of pulmonary and nonpulmonary organ failures as assessed by changes in PaO₂/FiO₂ ratio and Sequential Organ Failure Assessment score (SOFA) between days 1 and 7 after the onset of ALI/ARDS. Secondary outcomes included ventilator free days, ICU and hospital mortality, and lengths of ICU and hospital stay. Results  From 178 patients with ALI/ARDS, 45 (25%) received statin therapy. From day 1 to day 7, the statin group showed less improvement in their PaO₂/FiO₂ ratio (27 vs. 55, P = 0.042). Ventilator free days (median 21 vs. 16 days, P = 0.158), development or progression of organ failures (median ΔSOFA 1 vs. 2, P = 0.275), ICU mortality (20% vs. 23%, P = 0.643), and hospital mortality (27 vs. 37%, P = 0.207) were not significantly different in the statin and non-statin groups. After adjustment for baseline characteristics and propensity for statin administration, there were no differences in ICU or hospital lengths of stay. Conclusion  In this retrospective cohort study, statin use was not associated with improved outcome in patients with ALI/ARDS. We were unable to find evidence for protection against pulmonary or nonpulmonary organ dysfunction. Electronic supplementary material  The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Treatment of severe acute respiratory distress syndrome: role of extracorporeal gas exchange

Objective To evaluate the effect of extracorporeal gas exchange (ECMO) on mortality of patients referred with severe acute respiratory distress syndrome (ARDS).Design and setting Prospective observational study in a university hospital ICU.Patients 150 patients with severe ARDS.Interventions Multimodal treatment with and without ECMO.Measurements and main results We treated 118 patients (78.7%) conservatively and 32 patients with ECMO. Patients in the ECMO group presented with significantly more severe disease (lung injury score 3.8 ± 0.3 vs. 3.3 ± 0.4; SOFA score 52 ± 14 vs. 43 ± 12; and SAPS score 14 ± 3.3 vs. 10 ± 3.5). Mortality in ECMO-treated patients tended to be higher than that with conservative treatment (46.9% vs. 28.8%, p = 0.059). Multivariate logistic regression analyses with backward selection excluded ECMO as predictor of mortality (p = 0.79). Independent predictors of mortality were age (odds ratio 1.044, 95% confidence interval 1.014–1.075, p = 0.004), mean pulmonary artery pressure (1.082, 1.026–1.141, p = 0.036), sequential organ failure assessment score (1.148, 1.018–1.294, p = 0.024), and days of mechanical ventilation prior to referral (1.064, 1.008–1.123, p = 0.025).Conclusion ECMO treatment does not predict mortality in patients with most severe ARDS.     

Mortality after discharge from intensive care: the impact of organ system failure and nursing workload use at discharge

OBJECTIVES: Mortality after ICU discharge accounts for approx. 20-30% of deaths. We examined whether post-ICU discharge mortality is associated with the presence and severity of organ dysfunction/failure just before ICU discharge. PATIENTS AND METHODS: The study used the database of the EURICUS-II study, with a total of 4,621 patients, including 2,958 discharged alive to the general wards (post-ICU mortality 8.6%). Over a 4-month period we collected clinical and demographic characteristics, including the Simplified Acute Physiology Score (SAPS II), Nine Equivalents of Nursing Manpower Use Score, and Sequential Organ Failure Assessment (SOFA) score. RESULTS: Those who died in the hospital after ICU discharge had a higher SAPS II score, were more frequently nonoperative, admitted from the ward, and had stayed longer in the ICU. Their degree of organ dysfunction/failure was higher (admission, maximum, and delta SOFA scores). They required more nursing workload resources while in the ICU. Both the amount of organ dysfunction/failure (especially cardiovascular, neurological, renal, and respiratory) and the amount of nursing workload that they required on the day before discharge were higher. The presence of residual CNS and renal dysfunction/failure were especially prognostic factors at ICU discharge. Multivariate analysis showed only predischarge organ dysfunction/failure to be important; thus the increased use of nursing workload resources before discharge probably reflects only the underlying organ dysfunction/failure. CONCLUSIONS: It is better to delay the discharge of a patient with organ dysfunction/failure from the ICU, unless adequate monitoring and therapeutic resources are available in the ward.     

Septic shock in patients with the acquired immunodeficiency syndrome

Objective: To evaluate the prognosis of patients with septic shock admitted to an intensive care unit (ICU), according to their HIV serostatus. Design: Retrospective study. Setting: Medical ICU of a university hospital. Patients: 76 patients with septic shock admitted to the same ICU, of whom 28 were HIV positive and 48 were HIV negative. Measurements and results: Severity scores, number and type of organ failures, and survival rates were assessed in the two groups of patients. Glasgow Coma Scale and general severity scores [Acute Physiology and Chronic Health Evaluation II and Simplified Acute Physiology Score (SAPS)] were significantly worse in HIV-infected patients. The total number of organ failures was also higher in the HIV-positive group: 3.7 ± 0.2 vs 3.1 ± 0.2 in the HIV-negative group (p < 0.001). On day 28, 21 (46 %) HIV-negative patients were dead compared to 26 (93 %) patients in the HIV-positive group (p < 0.001). In the multivariate analysis, HIV infection was an independent risk factor for mortality, as were the SAPS score, use of mechanical ventilation, and the McCabe score. Conclusions: This study reports a considerable excess mortality in HIV-infected patients with septic shock. Although severity of illness was clearly much more pronounced in HIV-positive patients, retroviral infection was independently associated with death. Improving survival in HIV-positive patients with septic shock may require earlier diagnosis and treatment of the causative infection. Received: 30 September 1996 Accepted: 8 July 1997     

Is C-reactive protein a good prognostic marker in septic patients?

Rationale  Several studies have shown that C-reactive protein (CRP) is a marker of infection. The aim of this study was to evaluate CRP as marker of prognosis outcome in septic patients and to assess the correlation of CRP with severity of sepsis. Methods  During a 14-month period, we prospectively included all patients with sepsis admitted to an intensive care unit (ICU). Patients were categorized into sepsis, severe sepsis and septic shock. Acute Physiology and Chronic Health Evaluation (APACHE) II score, Simplified Acute Physiology Score (SAPS) II, Sequential Organ Failure Assessment (SOFA) score, CRP, body temperature and white cell count (WCC) of the day of sepsis diagnosis were collected. Results  One hundred and fifty-eight consecutive septic patients (mean age 59 years, 98 men, ICU mortality 34%) were studied. The area under the receiver operating characteristics curves of APACHE II, SAPS II, SOFA, CRP, body temperature and WCC as prognostic markers of sepsis were 0.75 [95% confidence interval (CI) 0.67–0.83], 0.82 (95% CI 0.75–0.89), 0.8 (95% CI 0.72–0.88), 0.55 (95% CI 0.45–0.65), 0.48 (95% CI 0.38–0.58) and 0.46 (95% CI 0.35–0.56), respectively. In the subgroup of patients with documented sepsis we obtained similar results. The ICU mortality rate of septic patients with CRP < 10, 10–20, 20–30, 30–40 and >40 mg/dL was 20, 34, 30.8, 42.3 and 39.1%, respectively (P = 0.7). No correlation was found between CRP concentrations and severity of sepsis. Conclusions  In septic patients, CRP of the day of sepsis diagnosis is not a good marker of prognosis.     

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     

Red cell distribution width as a novel predictor of mortality in ICU patients

Abstract

Background. The red cell distribution width (RDW) in ICU patients has never been investigated. Methods. A total of 602 consecutive patients were prospectively enrolled. We collected each patient's base-line characteristics including the Acute Physiology and Chronic Health Evaluation II (APACHE-II) score, RDW, and C-reactive protein (CRP). The primary outcome for this analysis was ICU mortality, and secondary outcome was the total length of stay in hospital (TLSH). Potential predictors were analyzed for possible association with outcomes. Results. There was a significantly graded increase in APACHE-II score (tertile I = 10.7 ± 6.5 versus tertile II = 13.3 ± 6.2 versus tertile III = 15.8 ± 7.2; all P < 0.001) and ICU mortality rate (tertile I = 11.2% versus tertile II = 18.8% versus tertile III = 33.8%; all P < 0.001) across increasing of RDW tertile. As compared with APACHE-II score, combination of RDW and APACHE-II score increased the area under the curve (AUC) for predicting ICU mortality from 0.832 ± 0.020 to 0.885 ± 0.017 (P < 0.05). Multivariate analysis demonstrated that RDW, APACHE-II score, and CRP were independent predictors of ICU mortality (P < 0.05). RDW was also independently associated with TLSH in patients alive (P < 0.05). Conclusion. We found a graded independent relation between higher RDW and adverse outcomes in ICU patients. RDW has the potentially clinical utility to predict outcome in ICU patients.     

Daily evaluation of organ function during renal replacement therapy in intensive care unit patients with acute renal failure

PurposeThe aim of this study was to assess changes in organ function in acute renal failure patients during renal replacement therapy and relate them to outcome.Materials and MethodsMedical and nursing charts from 111 patients with acute renal failure who underwent renal replacement therapy (hemodialysis or hemofiltration) from July 2000 until July 2002 on a 31-bed medicosurgical intensive care unit (ICU) at a university hospital in Belgium and in whom the Sequential Organ Failure Assessment (SOFA) score was calculated daily before the start of therapy until the seventh day, or the end of therapy, were analyzed. Changes in SOFA score over time (Δ SOFA) were calculated.ResultsOf 111 patients, 63 (57%) died in the ICU. Nonsurvivors were older (68 [52-76] vs 59 [48-70] years, P = .017) and had initially higher respiratory, cardiovascular, and total SOFA scores compared with survivors. A greater Δ renal SOFA at 24 hours was associated univariantly with a higher risk of ICU mortality (odds ratio, 1.7; 95% confidence interval, 1.2-2.6; P = .013). In a multivariate analysis with ICU outcome as the dependent variable, only age, cardiovascular SOFA score on admission, and the change in total SOFA score over the first 24 hours were independently associated with a greater risk of death.ConclusionsAssessment of these factors in the first 24 hours of renal replacement therapy could help identify patients at higher risk of mortality early during their ICU admission.     

Urinary biomarker of oxidative stress correlating with outcome in critically septic patients

Objective To determine whether urinary 8-hydroxy-2′-deoxyguanosine (8-OHdG), an in vivo parameter of oxidative stress, is correlated with the outcome of critically septic patients. Design and setting Clinical outcome study in an adult medical ICU. Patients Eighty-five consecutive septic patients: 59 men and 26 women. Measurements and results Urinary 8-OHdG was analyzed using isotope-dilution liquid chromatography with tandem mass spectrometry (LC/MS/MS). ICU mortality in these 85 septic patients was 25.9% (n = 22) and hospital mortality 38.8% (n = 33). APACHE II scores of survivors on day 1, on day 3, and the difference between them differed significantly from those of nonsurvivors (day 1, 21.0 ± 7.1 vs. 25.9 ± 8.0; day 3, 15.0 ± 5.8 vs. 23.2 ± 8.3; difference, 6.0 ± 5.5 vs. 1.7 ± 6.6). Urinary 8-OHdG was significantly lower in survivors than in nonsurvivors on day 1 (1.8 ± 2.4 vs. 3.0 ± 2.4). The area under receiver operating characteristic curve analysis for the association between day 1 urinary 8-OHdG and ICU mortality was 0.71. The comparison performed upon discharge from hospital revealed similar results. Conclusions This is a preliminary study. The excretion of the urinary 8-OHdG, as measured using isotope-dilution LC/MS/MS, as the APACHE II score, were correlated with the outcome of critically septic patients in medical ICU. An erratum to this article can be found at     

Strong vasopressor support may be futile in the intensive care unit patient with multiple organ failure

OBJECTIVE: The aim of the study was to determine the prognosis in patients who needed norepinephrine treatment in our institution in relation to the degree of organ failure and the evolution of the disease process. DESIGN: Retrospective case note analysis of outcome of those patients who needed norepinephrine according to our institutional regimen. PATIENTS: A total of 100 consecutive patients admitted to our 31-bed medical-surgical intensive care unit (ICU) who were treated with norepinephrine for severe hypotension and evidence of end-organ hypoperfusion unresponsive to both fluid resuscitation and dopamine treatment at 20 microg/kg/min. MEASUREMENTS: The degree of organ dysfunction at the time of starting norepinephrine treatment was assessed by the sequential organ failure assessment (SOFA) score. The time before starting norepinephrine treatment was defined as the time elapsed between ICU admission and that of starting norepinephrine administration. The patients were defined as survivors or nonsurvivors according to their ICU outcome. RESULTS: There were relationships between mortality and the degree of organ dysfunction and mortality and the duration of ICU stay before starting norepinephrine treatment. The mortality rate was 100% in the 30 patients with a total SOFA score of >12 and a delay before starting norepinephrine treatment of >1 day. The mortality rate of the other patients was 63%. The lowest mortality was seen in patients with lower SOFA scores and early norepinephrine administration after admission. CONCLUSIONS: Both the time of starting norepinephrine treatment after admission to the ICU and the degree of organ dysfunction have an important bearing on subsequent outcome. Although norepinephrine may be a lifesaving catecholamine in some cases, its administration to patients who have already developed multiple organ failure during their stay in the ICU is associated with a poor outcome.     

Thromboelastometry for the assessment of coagulation abnormalities in early and established adult sepsis: a prospective cohort study

Introduction

The inflammatory response to an invading pathogen in sepsis leads to complex alterations in hemostasis by dysregulation of procoagulant and anticoagulant factors. Recent treatment options to correct these abnormalities in patients with sepsis and organ dysfunction have yielded conflicting results. Using thromboelastometry (ROTEM^®), we assessed the course of hemostatic alterations in patients with sepsis and related these alterations to the severity of organ dysfunction.

Methods

This prospective cohort study included 30 consecutive critically ill patients with sepsis admitted to a 30-bed multidisciplinary intensive care unit (ICU). Hemostasis was analyzed with routine clotting tests as well as thromboelastometry every 12 hours for the first 48 hours, and at discharge from the ICU. Organ dysfunction was quantified using the Sequential Organ Failure Assessment (SOFA) score.

Results

Simplified Acute Physiology Score II and SOFA scores at ICU admission were 52 ± 15 and 9 ± 4, respectively. During the ICU stay the clotting time decreased from 65 ± 8 seconds to 57 ± 5 seconds (P = 0.021) and clot formation time (CFT) from 97 ± 63 seconds to 63 ± 31 seconds (P = 0.017), whereas maximal clot firmness (MCF) increased from 62 ± 11 mm to 67 ± 9 mm (P = 0.035). Classification by SOFA score revealed that CFT was slower (P = 0.017) and MCF weaker (P = 0.005) in patients with more severe organ failure (SOFA ≥ 10, CFT 125 ± 76 seconds, and MCF 57 ± 11 mm) as compared with patients who had lower SOFA scores (SOFA <10, CFT 69 ± 27, and MCF 68 ± 8). Along with increasing coagulation factor activity, the initially increased International Normalized Ratio (INR) and prolonged activated partial thromboplastin time (aPTT) corrected over time.

Conclusions

Key variables of ROTEM^® remained within the reference ranges during the phase of critical illness in this cohort of patients with severe sepsis and septic shock without bleeding complications. Improved organ dysfunction upon discharge from the ICU was associated with shortened coagulation time, accelerated clot formation, and increased firmness of the formed blood clot when compared with values on admission. With increased severity of illness, changes of ROTEM^® variables were more pronounced.     

The influence of length of stay in the ICU on power of discrimination of a multipurpose severity score (SAPS)

Objective To assess how the power of discrimination of a multipurpose severity score (Simplified Acute Physiology Score; SAPS) changes in relation to the length of stay (LOS) in the intensive care unit (ICU).Design In order to compute the SAPS probability, a model derived from logistic regression was developed in a cohort of 8059 patients. Measures of calibration (goodness-of-fit statistics) and discrimination [receiver operating characteristic (ROC) curve and relative area under the curve (AUC)] were adopted in a developmental set (5389 patients) and a validation set (2670 patients), both randomly selected. Once the logit was developed and the model validated, the whole database (8059 patients) was again assembled. To evaluate the accuracy of first-day SAPS probability over time, area under the ROC curve was computed for each of the initial 10 days of ICU care and for day 15.Setting 24 Italian ICUs.Patients A total of 8059 patients out of 10065 consecutive admissions over a period of 3 years (1990–1992) were included in this study. Patients whose SAPS was not correctly compiled (n=687), patients younger than 18 years (n=442), and patients whose LOS was less than 24 h (n=877) were excluded from this analysis.Interventions None.Measurements and results The logistic model gave good results in terms of calibration and discrimination, both in the developmental set (goodness-of-fit:X ²=9.24,p=0.32; AUC=0.79±0.01) and in the validation set (goodness-of-fit:X ²=8.95,p=0.537; AUC=0.78±0.01). The AUC for the whole database showed a loss in discrimination closely related to LOS: 0.79±0.01 at a day 1 and 0.59±0.02 at day 15.Conclusion The logistic model that we developed meets high standards for discrimination and calibration. However, SAPS loses its discriminative power over time; accuracy of prediction is maintained at an acceptable level only in patients who stay in the ICU no longer than 5 days. The stay in the ICU represents a complex variable, which is not predictable, that influences the performance of SAPS on the first day.ARCHIDIA (Archivio Diagnostico): A complete list of study participants appears in theAppendix     

Pharmacokinetics of cefpirome in critically ill patients with renal failure treated by continuous veno-venous hemofiltration

Objective: To study the cefpirome pharmacokinetics of patients with sepsis and multiple organ failure treated with CVVH. Design: Measurements of serum and ultrafiltrate (UF) concentrations and in vitro sensitivity testing of isolated micro-organisms. Setting: University hospital-based, single ICU. Patients: Six critically ill CVVH- dependent patients with sepsis and multiple organ dysfunction syndrome in need of antimicrobial therapy. Age range: 60–75 years; APACHE II score for severity of illness on admission: 19–30. One patient survived. Interventions: Cefpirome i. v. was started at 2 g in 30 min, then continued 1 g i. v. b. i. d. Measurements: The UF rate was 27 ± 7 ml/min on day 1 and 34 ± 2 ml/min on day 2. Serum and ultrafiltrate samples were measured by a validated high performance liquid chromatography assay. Volume of distribution: 23 · 5(SD ± 4 · 6) l. Total cefpirome clearance was 32 ± 6 · 3 ml/min; cefpirome CVVH clearance (Cl_CVVH): 17 ± 4.2 ml/min; mean serum half-life (t^1/2): 8.8 ± 2.3 h; mass transfer on day 1: 660 ± 123 mg/12 h (33 ± 6 % of administered dose)and day 2: 642 ± 66 mg/12 h (64 ± 7 %). Estimated sieving coefficient (Cl_CVVH/UF rate): 64 ± 11 %. In vitro sensitivity of isolated microbes was excellent except for two non-sensitive enterococci and Candida spp. Conclusions: The sieving coefficient (64 %) indicates that a substantial fraction of the drug is not filtered; clearance by pathways other than CVVH mounted to 50 % of the total clearance and increased on day 2, indicating that the dosing schedule used is appropriate for this setting. Cefpirome appeared to be safe in these patients and effective for most of the nosocomial microbial isolates. During more than 90 % of the time, serum levels were maintained above killing concentrations for susceptible micro-organisms. Received: 23 July 1999 Accepted: 19 October 1999