Usefulness of intra-abdominal pressure in a predominantly medical intensive care unit

Background

The deleterious effects of elevated intra-abdominal pressure (IAP) have been known for more than a century. The proposed objectives were to measure changes in IAP and analyze increase-related factors and complications and whether high IAP and its persistence are related to complications and mortality in a predominantly medical intensive care unit.

Methods

Over a 1-year period, we conducted a prospective cohort study in which IAP was measured using the bladder method. Hospitalization time, demographic variables, diagnosis on admission, APACHE II score, and clinical complications were recorded.

Results

A total of 130 patients were studied. Overall mean IAP was 12.3 mm Hg (standard deviation [SD], 3.79; 95% confidence interval [CI], 11.7-13), and on the first day, 12.68 mm Hg (SD, 5.32; 95% CI, 11.8-13.6); maximum IAP was 16.4 mm Hg (SD, 4.6; 95% CI, 15.6-17.2). A positive correlation was found between IAP, APACHE (Acute Physiology And Chronic Health Evaluation) II, and age. Higher IAP values were independently associated with higher age, prolonged activated partial thromboplastin time, need for dialysis, and intolerance to enteral feeding. The value showing the best sensitivity and specificity in predicting mortality was persistence of IAP 20 mm Hg or greater for 4 days or more. The number of days with IAP 20 mm Hg or greater was a factor associated with a higher risk of death (odds ratio, 2.3). Patients who died showed a tendency to increased IAP.

Conclusion

In this study, a threshold IAP of 20 mm Hg and its permanence over time were the best predictive factors of complications and mortality. Among other relationships, we also observed that older patients had higher IAP. High IAP was a cause of intolerance to enteral nutrition.     

Validation of the multiple organ dysfunction (MOD) score in critically ill medical and surgical patients

Objective To validate the Multiple Organ Dysfunction (MOD) score externally.Design Prospective observational cohort study.Setting Mixed medical/surgical ICU in a tertiary referral university hospital.Patients and participants Thousand eight hundred and nine patients admitted to ICU for more than 24 h over a 3-year period.Interventions None.Measurements and results The MOD score was calculated daily for all patients. The criterion validity of the individual organ scores, the maximal MOD score and the change in MOD score were assessed by examining the relationship between increasing scores and ICU mortality. Increased maximal MOD scores and each of the six individual organ scores, and change in MOD scores were associated with increased mortality.Conclusions Maximal and individual organ scores have criterion validity when tested in a different ICU from that in which the scores were derived, indicating that the scoring systems are reproducible. The association of change in MOD score with mortality indicates that the score is responsive. These data, combined with previous data establishing concept and content validity, indicate that the MOD score is a valid measure of multi-organ dysfunction.     

Association of cell-free plasma DNA with hospital mortality and organ dysfunction in intensive care unit patients

Objective To investigate the concentration of cell-free plasma DNA and its association with organ dysfunction and hospital mortality in intensive care unit patients. Design and setting Prospective cohort study in a medical and two medical-surgical intensive care units in a university hospital. Patients 228 critically ill patients admitted to the ICUs between January 2004 and July 2005. Measurements and results Blood samples were collected as soon as possible after ICU admission, the following morning, and 48 h after the second sample. The cell-free plasma DNA was measured by real-time quantitative PCR assay for the β-globin gene. Physiological and mortality data were collected to the clinical database. Hospital mortality rate and SOFA scores were primary outcome measures. The maximum plasma DNA concentrations were correlated significantly with APACHE II points and with maximum SOFA scores. Cell-free plasma DNA concentrations were higher in hospital non-survivors than in survivors (median 9,366 vs. 6,506 GE/ml). Using logistic regression analysis, the maximum plasma DNA was an independent predictor of hospital mortality. Conclusions The maximum plasma DNA concentration measured during the first 96 h of intensive care is associated with the degree of organ dysfunction and disease severity. Moreover, the maximum DNA concentration is independently associated with hospital mortality. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Reliability of intensive care unit admitting and comorbid diagnoses, race, elements of Acute Physiology and Chronic Health Evaluation II score, and predicted probability of mortality in an electronic intensive care unit database

Background

Although reliability of severity of illness and predicted probability of hospital mortality have been assessed, interrater reliability of the abstraction of primary and other intensive care unit (ICU) admitting diagnoses and underlying comorbidities has not been studied.

Methods

Patient data from one ICU were originally abstracted and entered into an electronic database by an ICU nurse. A research assistant reabstracted patient demographics, ICU admitting diagnoses and underlying comorbidities, and elements of Acute Physiology and Chronic Health Evaluation II (APACHE II) score from 100 random patients of 474 admitted during 2005 using an identical electronic database. Chamberlain's percent positive agreement was used to compare diagnoses and comorbidities between the 2 data abstractors. A κ statistic was calculated for demographic variables, Glasgow Coma Score, APACHE II chronic health points, and HIV status. Intraclass correlation was calculated for acute physiology points and predicted probability of hospital mortality.

Results

Percent positive agreement for ICU primary and other admitting diagnoses ranged from 0% (primary brain injury) to 71% (sepsis), and for underlying comorbidities, from 40% (coronary artery bypass graft) to 100% (HIV). Agreement as measured by κ statistic was strong for race (0.81) and age points (0.95), moderate for chronic health points (0.50) and HIV (0.66), and poor for Glasgow Coma Score (0.36). Intraclass correlation showed a moderate-high agreement for acute physiology points (0.88) and predicted probability of hospital mortality (0.71).

Conclusion

Reliability for ICU diagnoses and elements of the APACHE II score is related to the objectivity of primary data in the medical charts.     

Cross-validation of a modified score to predict mortality in cancer patients admitted to the intensive care unit

Purpose

The aim of this study was to cross-validate an automated and customized severity of illness score as a means of predicting death among adult cancer patients admitted to the intensive care unit (ICU).

Materials and Methods

We conducted a retrospective study of ICU discharges between January 1, 2001, and December 31, 2005, in a university comprehensive cancer center. We randomly selected training and validation samples in 2 ICU groups (medical and surgical patients). We used logistic regression to calculate the probabilities of death in the ICU and in-hospital death in training samples and applied these probabilities to the validation samples to calculate sensitivity and specificity, construct curves, and determined the areas under the receiver operating characteristic curve (AUC).

Results

We included 6880 patients. In predicting ICU mortality, the AUC was 0.77 (95% confidence interval [CI], 0.73-0.82) for the medical validation group and 0.8207 (95% CI, 0.7304-0.9109) for the surgical validation group. For in-hospital mortality, the AUCs for the groups of medical and surgical patients were 0.73 (95% CI, 0.69-0.76) and 0.77 (95% CI, 0.73-0.80), respectively.

Conclusions

The modified Sequential Organ Failure Assessment score is a good and valid predictor of cancer patients' risk of dying in the ICU and/or hospital despite the modifications needed to automate the score using existing electronic data.     

Outcome of critically ill patients treated with intermittent high-volume haemofiltration: a prospective cohort analysis

Objective: To evaluate intervention and outcome in critically ill patients treated with high-volume haemofiltration (HV-HF). Design: Prospective cohort analysis. Setting: 18-bed closed format general intensive care unit (ICU) of a teaching hospital. Patients: 30-month cohort of ICU patients treated with HV-HF. Interventions: Intermittent high-volume venovenous haemofiltration. Endpoints: Observed and predicted mortality in prospectively stratified prognostic groups. Measurements and results: Clinical and filtration data, Acute Physiology and Chronic Health Evaluation (APACHE) II, Simplified Acute Physiology Score (SAPS) II and the Madrid Acute Renal Failure (ARF) score and predicted mortality. A total of 306 patients were haemofiltrated (140 medical, 166 surgical), 52 % were oliguric. Mean APACHE II score was 31 (SD 8) and mean SAPS II score 60 (SD 16). Mean ultrafiltrate rate was 63 ml/min (SD 20). A median total of 160 litres (90 % range 49 to 453) were filtrated per patient, material costs were 565 ECU (90 % range 199 to 1514). ICU mortality was 33 %, hospital mortality 40 % [95 % confidence interval (CI) 34 to 45], predicted mortality by the ARF score 67 % (CI 66 to 69). Non-cardiac surgery mortality was 47 % (CI 39 to 54), 73 % (CI 70 to 76) predicted by APACHE II and 67 % (CI 64 to 70) by SAPS II. Observed mortality was significantly lower than predicted in all prognostic groups. The standardised mortality ratio (SMR) was no higher than the SMR in the overall ICU population. Conclusions: Mortality in HV-HF patients was lower than that predicted by illness severity scores, as was the case in all patients in our ICU. Treatment with HV-HF appears to be safe and feasible. The efficacy of HV-HF should be tested in randomised, controlled trials of suitable power. Received: 4 December 1998 Final revision received: 20 April 1999 Accepted: 17 May 1999     

Opening the doors of the intensive care unit to cancer patients: A current perspective

The introduction of new treatments for cancer and advances in the intensive care of critically ill cancer patients has improved the prognosis and survival. In recent years, the classical intensive care unit(ICU) admission comorbidity criteria used for this group of patients have been discouraged since the risk factors for death that have been studied, mainly the number and severity of organic failures, allow us to understand the determinants of the prognosis inside the ICU. However, the availability of intensive care resources is dissimilar by country, and these differences are known to alter the indications for admission to critical care setting. Three to five days of ICU management is warranted before making a final decision(ICU trial) to consider keep down intensive management of critically ill cancer patients. Nowadays, taking into account only the diagnosis of cancer to consider ICU admission of patients who need full-supporting management is no longer justified.     

Outcomes and prognostic factors of patients with lung cancer and pneumonia-induced respiratory failure in a medical intensive care unit: A single-center study

Purpose

To evaluate the outcomes and prognostic factors of 28-day mortality following medical intensive care unit (MICU) admission of patients with lung cancer and pneumonia-induced respiratory failure.

Materials and methods

Patients admitted to the MICU of a tertiary referral hospital between 2000 and 2009 were retrospectively studied.

Results

In total, 143 patients were included. Their mean age was 65 ± 8 years and 94% were male. The 28-day mortality rate was 57%. Multivariate analysis was performed to identify variables associated with 28-day mortality. At 72 hours after admission, a history of radiotherapy (OR = 2.80, 95% CI: 1.15-6.78), Pao₂/Fio₂ (P/F) ratio at admission of < 100 mmHg (OR = 5.62, 95% CI: 2.10-15.07), P/F ratio after 72 hours of < 100 mmHg (OR = 4.61, 95% CI: 1.24-17.15), and arterial pH after 72 hours of < 7.30 (OR = 5.78, 95% CI: 1.15-28.89) were associated with increased mortality.

Conclusions

The prognosis of patients with lung cancer and severe pneumonia after 72 hours of MICU management mainly depends on the severity of the underlying lung injury, which is reflected by a history of radiotherapy and a low P/F ratio, rather than on cancer stage or disease status.     

Acinetobacter baumannii infection in patients with hematologic malignancies in intensive care unit: risk factors and impact on mortality

Purpose

We investigated the characteristics of Acinetobacter baumannii infection in critically ill patients with hematologic malignancies.

Materials and Methods

The prospectively collected data of patients with hematologic malignancies admitted to a medical intensive care unit of a university hospital from 2007 through 2010 were reviewed retrospectively.

Results

One hundred twenty-eight patients were included in the study, among whom 35 (27%) developed 39 A baumannii infections. Pneumonia was the most common infection site of A baumannii. Presence of neutropenia, underlying hematologic malignancy, and the disease status did not affect the acquisition of the infection. Advancing age, prior exposure to aminoglycosides, central venous catheterization, and presence of nasogastric tube were the independent risk factors for the development of A baumannii infections. The mortality rate was higher in patients with A baumannii infections compared with the ones without (P = .009). However, in multivariate analysis, low Glasgow coma scale, prior immunosuppressive treatment, neutropenia, invasive mechanical ventilation, and severe sepsis were independently associated with mortality, whereas presence of A baumannii infection was not.

Conclusions

Despite the high mortality rate in critically ill patients with hematologic malignancies, presence of A baumannii infection was not an independent risk factor for mortality.     

Interhospital transfer of critically ill patients: demographic and outcomes comparison with nontransferred intensive care unit patients

PURPOSE: We examined the association between access to intensive care services and mortality in a cohort of critically ill patients. MATERIALS AND METHODS: We conducted an observational study involving 6298 consecutive admissions to the intensive care units (ICUs) of a tertiary care hospital. Data including demographics, admission source, and outcomes were collected on all patients. Admission source was classified as "transfer" for patients admitted to the ICU from other hospitals, "ER" for patients admitted from the emergency room, and "ward" for patients admitted from non-ICU inpatient wards. RESULTS: Transfer patients had higher crude ICU and hospital mortality rates compared with emergency room admissions (crude odds ratio [OR], 1.51; 95% confidence interval [CI], 1.32-1.75). After adjusting for age, sex, diagnosis, comorbidities, and acute physiology scores, the difference in ICU mortality remained significant (OR, 1.30; 95% CI, 1.09-1.56); however, hospital mortality did not (OR, 1.19; 95% CI, 1.00-1.41). Compared with ward patients, transfer from other hospitals was associated with lower hospital mortality after adjusting for severity of illness and other case-mix variables (OR, 0.81; 95% CI, 0.68-0.95). CONCLUSIONS: We found some evidence to suggest that differential access to intensive care services impacts mortality within this case mix of patients. These findings may have implications for current efforts to centralize and regionalize critical care services.     

Development and validation of a parsimonious and pragmatic CHARM score to predict mortality in patients with suspected sepsis

Background

We aimed to derive and validate a parsimonious and pragmatic clinical prediction rule using the concepts of Predisposition, Infection, Response, and Organ Dysfunction to predict in-hospital mortality; and to compare it with other prediction rules, as well as with conventional biomarkers for evaluating the mortality risk of patients with suspected sepsis in the emergency department (ED).

A retrospective study of 130 consecutive multiple trauma patients in an intensive care unit

A retrospective study of 130 multiple trauma patients admitted to an intensive care unit is presented. Overall mortality was 33% for a mean ISS of 39.4. Craniocerebral trauma, multiple organ failure, sepsis and ARDS are the main causes of death, although there is no statistical difference for these between survivors and non-survivors. There is a good correlation between ISS and mortality (r=0.86). Patients developing MOF, sepsis and ARDS have significantly higher ISS. Mortality from complications such as sepsis, MOF, ARDS and aspiration pneumonia seems more related to age.     

Significance of new-onset prolonged sinus tachycardia in a medical intensive care unit: a prospective observational study

Objective

Few data are available on sinus tachycardia among medical intensive care unit (ICU) patients. We investigated new critical illnesses related to new-onset prolonged sinus tachycardia (NOPST) and the relationship of NOPST with ICU mortality.

Methods

The heart rate (HR) of all enrolled patients was monitored hourly over a 12-month period, and NOPST was defined as sinus tachycardia (>100 beats/min) with an increase in HR of more than 20% from the baseline value lasting longer than 6 hours.

Results

Among the 522 patients enrolled, the average mean HR was 96.1 ± 18.4 beats/min. Fifty-two (10.0%) patients met the criteria for NOPST; pneumonia, delirium, septic shock, acute respiratory distress syndrome, catheter-related infections, and mechanical ventilator–related problems were related to the occurrence of NOPST. The ICU mortality rate in patients with a NOPST duration of more than 72 hours was higher compared with other patients with NOPST (60.0% vs 18.5%; P = .002). A high daily mean HR rather than NOPST was a significant predictor of ICU mortality (odds ratio, 1.415; 95% confidence interval, 1.177-1.700).

Conclusions

Although NOPST was not associated with ICU mortality, it indicates the presence of new critical events in the medical ICU setting.     

重症加强治疗病房妊娠期急性肾衰竭危险因素分析

目的 分析导致重症加强治疗病房(ICU)危重孕产妇妊娠期急性肾衰竭(ARF)的危险因素.方法 采用回顾性分析方法,选择因产后并发症入住ICU的危重孕产妇192例,排除3例因羊水栓塞死亡,7例 因记录不完整者,共182例纳入本研究.将患者根据是否合并ARF分为ARF组(68例)和非ARF组(114例),采集两组患者发生先兆子痫、HELLP综合征(溶血、肝酶升高、血小板减少)、妊娠急性脂肪肝、产后出血、脓毒症等指标;以及产后4 d内使用的主要药物: ① 血浆体积膨胀剂:液体(晶体液、人工胶体、高渗白蛋白、4%白蛋白)和血液制品(浓集红细胞、浓缩血小板、纤维蛋白原、新鲜冷冻血浆、活化因子Ⅶ); ② 抗纤溶药:氨甲环酸; ③ 抗高血压药物:血管紧张素转换酶抑制剂(ACEI),利尿剂; ④ 肾毒性药物:氨基糖苷类,造影剂等.对上述指标先进行单因素分析,将有统计学意义的危险因素进行多因素logistic回归分析,筛选出ICU危重孕产妇妊娠期发生急性肾衰竭的危险因素.结果 单因素分析表明:HELLP综合征、产后4 h使用氨甲环酸和高渗白蛋白是ARF的危险因素(χ2值分别为4.92、4.29、5.53,均P<0.05).多因素logistic回归分析表明:HELLP综合征〔优势比(OR)=10.478,95%可信区间(95%CI)为1.248~17.953,P=0.030〕和产后4 h使用高渗白蛋白(OR=6.632,95%CI为1.211~16.328;P=0.029)是ARF发生的独立危险因素.结论 ICU危重孕产妇ARF是多因素参与的过程,应充分认识各种危险因素对ARF的影响,存在HELLP综合征和产后4 h使用高渗白蛋白是ARF发生的独立危险因素,对存在危险因素的患者实施重点防护以减少ARF的发生.     

Predictive accuracy of severity scoring system: a prospective cohort study using APACHE III in a Korean intensive care unit

AIM: To evaluate the discrimination, calibration, and uniformity of fit by age group, operative status, and location before ICU admission of APACHE III in a single-center ICU population. DESIGN AND SETTING: Prospective data collection in a 25 bed mixed (surgical and medical) ICU of 850-bed teaching hospital in Pusan, South Korea. SUBJECTS AND METHODS: The worst values on APACHE III variables during 24h following ICU admission were collected from the patient's charts and clinical flow sheets of 284 consecutively admitted subjects. RESULTS: The mortality rate was 31.0%, and showed a strong positive correlation between APACHE III score (r=0.97, p<0.0001 for entire population, r=0.97, p<0.0001 for medical patients, r=0.91, p<0.0001 for surgical patients). Hospital mortality was significantly higher for medical patients than surgical patients (OR=7.23, 95% CI=3.76-13.88), and for patients located in the operating room than at ward before admitting ICU (OR=0.09, 95% CI=0.04-0.23). At the predicted risk of 0.5 (66 of APACHE III score), sensitivity was 0.72, specificity 0.91, and correct classification rate 0.85. Area under the ROC curve was 0.905 (95% CI=0.867-0.943). Correlation coefficient (r) between observed and expected mortality rate was 0.99. The value (chi-square) of Lemeshow-Hosmer (L-H) goodness-of-fit statistic was 6.54 (p=0.59). In patients stratified according to age groups, operative status, and location in the hospital before ICU admission, discrimination was generally good in all subgroups (area under the ROC curve >0.85), and the chi-squared of L-H goodness-of -fit statistic showed a good fit for all subgroup, especially for operative status. CONCLUSIONS: The predictive accuracy of the APACHE III scoring system showed better discrimination, as well as uniformity of fit. So, it was thought that could be utilized for the subject hospital.     

重症监护病房人工气道患者胃液真菌鉴定及意义

目的 通过分析与鉴定重症监护病房(ICU)建立人工气道的重症患者胃液pH值与真菌类型及耐药情况,探讨ICU患者胃液pH值与真菌的直接关系及临床意义.方法 采用前瞻性研究方法,选择160例深圳大学第一附属医院ICU 2008年12月至201 1年10月收治的建立人工气道＞48 h的重症患者.通过鼻胃管收集其胃液样本,用精密pH试纸测定胃液pH值;依胃液酸度将样本分为pH值≤2.0、pH值2.1～3.0、pH值3.1～ 4.0、pH值4.1～5.0、pH值5.1～6.0、pH值6.1～7.0组;同时进行胃液真菌培养及常用抗真菌药物敏感试验,分析胃液酸度对胃液真菌培养阳性率的影响;再按照患者28 d存活情况分成存活组(102例)和死亡组(58例),分析组间胃液真菌分布及临床意义.结果 ①胃液pH值＜4.0时,几乎无真菌生长;随着胃液pH值的增大,真菌培养阳性率明显升高.②胃液总样本真菌培养阳性率为27.9％(55/197),其中白色念珠菌与非白色念珠菌培养阳性率分别为38.2％(21/55)和61.8％( 34/55),差异有统计学意义(x2=4.16,P＜0.05).③存活组与死亡组真菌培养检出率分别为40.0％( 22/55)和60.0％( 33/55),其中存活组白色念珠菌与非白色念珠菌分别为54.5％(12/22)和45.5％( 10/22),死亡组白色念珠菌与非白色念珠菌分别为27.3％( 9/33)和72.7％(24/33).白色念珠菌与非白色念珠菌耐药率分别在4.7％～14.3％(平均10.1％)和0～ 60.0％(平均28.5％).结论 建立人工气道的重症患者胃液真菌培养阳性率随着胃液pH值的增大而明显升高;非白色念珠菌是胃液培养的主要真菌,其耐药率高于白色念珠菌,数量增加提示患者预后较差.     

Selective decontamination in intensive care practice: A review of clinical experience

Acquired infection is a common problem in intensive care and in a general ICU the infection rate can exceed 80% in patients ventilated beyond 5 days. SDD, adapted from regimes used in neutropenic patients, was first introduced to the ICU situation in Groningen. This article reviews 10 published trials of SDD in ICU. The trial designs vary but all show a significant reduction in both colonisation rates and acquired infection rates. Infection rates were reduced from 10%–78% to 3%–10% in the SDD treated groups. Of the 10 trials 2 showed an overall reduction in mortality 2 showed a reduction in infection-related mortality and 1 showed a reduction in mortality amongst trauma patients. Although further evaluation of trials is required SDD now appears to be of proven efficacy in certain groups of high risk patients within ICU.