Mortality risk factors in critical surgical patients

OBJECTIVE: To determine mortality risk factors for critically ill postoperative patients. PATIENTS: Two hundred eleven patients undergoing any type of surgery admitted to the intensive care unit (ICU) over a period of one year were enrolled. METHOD: We performed a cross-sectional study that was retrospective for pre- and intraoperative observations and prospective for ICU observations. A univariate analysis was performed and relative risk (95% CI) was calculated. Multivariate analysis was also performed and the adjusted odds ratio calculated (95% CI). The end point of measurement was death in the ICU. RESULTS: The independent risk factors for mortality were age 60 years (OR: 2.8; 95% CI 1.36-5.09), physical status ASA-V (OR: 9.66; 95% CI 5.62-14.31), intracranial surgery to treat severe head injury (OR: 5.33; 95% CI 3.08-9.47), hemorrhagic shock during surgery (OR: 5.20; 95% CI 4.16-8.29), arterial hypotension during surgery (OR: 4.0; 95% CI 2.78-11.65), APACHE III score upon admission to the ICU (OR: 9.29; 95% CI 3.62-21.38), multiple organ dysfunction syndrome (OR: 7.96; 95% CI 3.73-13.92), and cardiopulmonary arrest in the ICU (OR: 5.85; 95% CI 2.21-10.43). The APACHE III score demonstrated high sensitivity (87%) and positive predictive value (96%). CONCLUSIONS: Surgical patients in critical condition continue to account for a large number of admissions to and death in the ICU. The variables analyzed were sufficient to explain patient outcome, such that risk factors for mortality in surgical patients admitted to the ICU could be determined.     

Disease risk and mortality prediction in intensive care patients with pneumonia. Australian and New Zealand practice in intensive care (ANZPIC II)

This study of ventilated patients investigated pneumonia risk factors and outcome predictors in 476 episodes of pneumonia (48% community-acquired pneumonia, 24% hospital-acquired pneumonia, 28% ventilator-associated pneumonia) using a prospective survey in 14 intensive care units within Australia and New Zealand. For community acquired pneumonia, mortality increased with immunosuppression (OR 5.32, CI 95% 1.58-1799, P<0.01), clinical signs of consolidation (OR 2.43, CI 95% 1.09-5.44, P=0.03) and Sepsis-Related Organ Failure Assessment (SOFA) scores (OR 1.19, CI 95% 1.08-1.30, P<0.001) but improved if appropriate antibiotic changes were made within three days of intensive care unit admission (OR 0.42, CI 95% 0.20-0.86, P=0.02). For hospital-acquired pneumonia, immunosuppression (OR 6.98, CI 95% 1.16-42.2, P=0.03) and non-metastatic cancer (OR 3.78, CI 95% 1.20-11.93, P=0.02) were the principal mortality predictors. Alcoholism (OR 7.80, CI 95% 1.20-17.50, P<0.001), high SOFA scores (OR 1.44, CI 95% 1.20-1.75, P=0.001) and the isolation of "high risk" organisms including Pseudomonas aeruginosa, Acinetobacter spp, Stenotrophomonas spp and methicillin resistant Staphylococcus aureus (OR 4.79, CI 95% 1.43-16.03, P=0.01), were associated with increased mortality in ventilator-associated pneumonia. The use of non-invasive ventilation was independently protective against mortality for patients with community-acquired and hospital-acquired pneumonia (OR 0.35, CI 95% 0.18-0.68, P=0.002). Mortality was similar for patients requiring both invasive and non-invasive ventilation and non-invasive ventilation alone (21% compared with 20% respectively, P=0.56). Pneumonia risks and mortality predictors in Australian and New Zealand ICUs vary with pneumonia type. A history of alcoholism is a major risk factor for mortality in ventilator-associated pneumonia, greater in magnitude than the mortality effect of immunosuppression in hospital-acquired pneumonia or community-acquired pneumonia. Non-invasive ventilation is associated with reduced ICU mortality. Clinical signs of consolidation worsen, while rationalising antibiotic therapy within three days of ICU admission improves mortality for community-acquired pneumonia patients.     

Early complications of high-dose methylprednisolone in acute spinal cord injury patients

BACKGROUND: To evaluate the early complications and effect on neurological outcome of methylprednisolone (MP) treatment in spinal cord injury (SCI) patients during the acute phase. METHODS: We retrospectively reviewed the whole cohort of patients admitted to our ICU between January 1994 and December 2005 due to acute SCI. Patients were grouped according to the medical treatment received (MP group versus no-MP group). Patient data as age, gender, Glasgow coma score (GCS), APACHE II, injury severity score (ISS) and ICU stay were recorded. Outcome at ICU discharge and neurological function based on Frankel grade was recorded at ICU admission and at ICU discharge. Early complications were also noted. RESULTS: There were no differences between both groups in ICU mortality (OR=0.48; 95% CI: 0.08-3.64) nor neurological function at ICU discharge. (OR=1.09; 95% CI: 0.35-3.66). MP group presented an increase in respiratory tract infections (OR=8.19; 95% CI: 1.10-358.6) and in total infections (OR=4.90; 95% CI: 1.46-18.83) compared to no-MP group during the ICU stay. There was a significant increase in the incidence of hyperglycaemia in the MP group (OR=17.0; 95% CI: 4.52-66.3). CONCLUSIONS: The use of MP in patients with acute SCI is not associated with an improvement in outcome or neurological function at ICU discharge. Moreover, the use of MP is associated with an increased risk of infectious and metabolic complications during ICU stay.     

Initial and delayed onset of acute respiratory failure: factors associated with development and outcome

In a prospective observational study of 1038 adult admissions to a 31-bed medical/surgical intensive care unit (ICU), acute respiratory failure (ARF, defined as a Pao(2)/Fio(2) ratio 48 h after ICU admission) in 49 (16%). On admission, the cardiovascular sequential organ failure assessment (SOFA) score was higher in initial than in delayed onset ARF (1.1 +/- 1.5 vs 0.6 +/- 1.2, P < 0.05). High admission serum C-reactive protein concentrations (OR 1.08, 95% CI 1.04-1.12, P = 0.0001) and SOFA scores (OR 1.20, 95% CI 1.08-1.33, P = 0.0007) were the factors independently associated with initial ARF, and a low Glasgow coma scale (GCS) score (OR 1.13, 95% CI 1.04-1.21, P = 0.0018) was associated with delayed onset ARF. In initial ARF, a high SOFA score (OR 1.24, 95% CI 1.12-1.38, P = 0.0001) and a low GCS score (OR 0.89, 95% CI 0.83-0.96, P = 0.0013) on admission, and in delayed onset ARF, a low GCS score at 48 h (OR 0.67, 95% CI 0.54-0.84, P = 0.0011) were independently associated with death. The mortality rate was similar for initial and delayed onset ARF.     

Preservation of renal function with surgical revascularization in patients with atherosclerotic renovascular disease

OBJECTIVE: Clinical and anatomic factors predictive of a favorable response to renal revascularization performed for renal function salvage remain poorly defined. To clarify decision making in such patients we reviewed a contemporary experience of surgical renal artery revascularization (RAR) performed primarily for preservation of renal function. METHODS: Between June 1990 and March 2001 (ensuring 1 year minimum follow-up), 96 patients with renal insufficiency (serum creatinine [Cr] concentration >or=1.5 mg/dL) and hypertension underwent RAR for preservation of renal function. Study end points included early and late renal function response, progression to dialysis dependence, and long-term survival. Variables potentially associated with these end points were assessed with univariate analysis, Cox regression analysis, and logistic regression analysis, and survival was assessed with the Kaplan-Meier method. RESULTS: Perioperative failure of RAR occurred in 3 patients (3%), with perioperative mortality in 4 patients (4.1%); thus 92 patients were available for long-term follow-up (mean, 39 months). Mean patient age was 70 +/- 9 years with a mean baseline Cr of 2.6 mg/dL (range, 1.5-7.8 mg/dL). Operative management consisted of aortorenal bypass in 38% of patients, extraanatomic bypass in 38% of patients, and endarterectomy in 24% of patients; 32% of patients required combined aortic revascularization and RAR, and 27% underwent bilateral RAR. At hospital discharge renal function had improved (20% decrement in Cr) in 41 (43%) patients, including 7 patients who were removed from dialysis; remained unchanged in 40 (41%) patients; and declined (20% increase in Cr) in 15 (16%) patients. At last follow-up renal function was either improved or unchanged in 72% of patients. Predictors of a favorable response to RAR at last follow-up included stable Cr at hospital discharge (odds ratio [OR], 7.1; 95% confidence interval [CI], 2.5-21.8; P =.0004) and decreased Cr at hospital discharge (OR, 16; 95% CI, 1.6-307.8; P <.0001); bilateral renal artery repair (OR, 3.1; 95% CI, 0.9-10.6; P =.07) approached clinical significance. Predictors of worsened excretory function at last follow-up included decline of renal function at hospital discharge (OR, 28.9; 95% CI, 5.0-165.4; P =.0002), intervention to treat unilateral renal artery stenosis (OR, 3.8; 95% CI, 0.8-16.6; P =.05), and level of baseline Cr (OR, 3.0; 95% CI, 1.0-4.0; P =.04). Progression to dialysis occurred in 16 (17%) patients. Dialysis-free survival at 5 years was 50%, and overall actuarial survival at 5 years was 59%. Predictors of progression to dialysis during follow-up included treatment of complete renal artery occlusion (OR, 6.2; 95% CI, 1.3-29.5; P =.02), early failure of RAR (OR, 3.1; 95% CI, 0.7-14.2; P =.04) and baseline Cr (OR, 2.9; 95% CI, 1.3-6.1; P =.006). CONCLUSION: Long-term clinical success in the preservation of renal function, noted in 70% of patients, can be predicted by the initial response to RAR and by anatomic factors, in particular, bilateral repair. While extreme (mean Cr >or=3.2 mg/dL) renal dysfunction generally is predictive of poor long-term outcome, a subset of patients will experience favorable results, even to the extent of rescue from dialysis. These results may facilitate clinical decision making in the application of RAR for renal function salvage.     

Age versus comorbidities as risk factors for complications after elective abdominal aortic reconstructive surgery

PURPOSE: This study estimated the association between age and in-hospital postoperative complications, controlling for known or suspected risk factors, in a series of patients undergoing elective abdominal aortic reconstructive surgery (AAR). METHODS: This retrospective cohort study of outcome data with multivariate logistic regression analysis was conducted at Emory University Hospital, a tertiary care, university-affiliated hospital. All patients undergoing elective AAR between Jan 1, 1986, and Aug 1, 1996, were included (n = 856). An estimate of the odds ratio (OR) and 95% CI for the association between patient age and in-hospital major morbidity or mortality after elective AAR was made, controlling for significant risk factors. RESULTS: Among the 856 patients, 170 had a nonfatal complication (136 with major and 34 with minor complications), and 11 patients (1.3%) died. The final logistic regression model demonstrated a mild association between increasing age and rate of major postoperative complications, including death (for each increase in age of 10 years: OR, 1.23; 95% CI, 1.00-1.52; P =.052). Other significant covariates in the final model included cardiac disease (OR, 2.84; 95% CI, 1.18-6.86; P =.020), pulmonary disease (OR, 1.96; 95% CI, 1.35-2.84; P =.0004), and renal disease (OR, 2.57; 95% CI, 1.66-3.99; P =.0001). Increasing age was associated with a moderate increase in the rate of death (for each increase in age of 10 years: OR, 2.74; 95% CI, 1.22-6.16; P =.015) in a model with cardiac disease as the only significant covariate (OR, 14.67; 95% CI, 3.46-62.16; P =.0003). CONCLUSION: For patients undergoing elective AAR, increasing patient age is associated with a small increase in risk for in-hospital morbidity or mortality. However, significant cardiac, pulmonary, or renal disease is associated with a much greater risk of postoperative complications, and, therefore, advanced age should not be the sole basis of exclusion for otherwise suitable candidates for elective AAR.     

Outcome from intensive care after cardiac arrest: comparison between two patient samples treated in 1986-87 and 1999-2001 in Finnish ICUs

BACKGROUND: The aim of the study was to find out whether the characteristics of patients and the outcome from intensive care after cardiac arrest have changed over time. METHODS: Two nationwide databases were compared: (i) The Finnish National Intensive Care Study data in 1986-87 and (ii) data on 28,640 admissions to Finnish ICUs in 1999-2001. Patients whose reason for ICU admission was cardiac arrest were included. The former study included 604 patients treated in 18 medical and surgical ICUs in and the latter 1036 patients in 25 medical and surgical ICUs. Data on the components of Acute Physiology and Chronic Health Evaluation (APACHE II) were prospectively collected in both study periods. Logistic regression analysis was used to test the independent contribution of the study period on hospital mortality. RESULTS: In 1986-87, patients were younger and the proportion of males was lower than in 1999-2001. The hospital mortality in 1986-87 was 61.3% and in 1999-2001 59.1% (P= 0.396). Among patients aged < 57 years, the hospital mortality in 1986-87 was 62.1% and in 1999-2001 48.8% (P < 0.01). In multivariate analysis, controlling for age, gender, Glasgow coma score (GCS), chronic health evaluation points and source of admission, treatment during 1986-87 was an independent predictor for hospital death among all patients (OR 1.273; 95% CI 1.015-1.594), those aged < 57 years (OR 1.959; 95% CI 1.270-3.021) and among males (OR 1.384; 95% CI 1.050-1.825). CONCLUSION: Since the late 1980s, the outcome from intensive care after cardiac arrest may have improved especially among younger patients and males.     

Perioperative outcomes after open and endovascular repair of intact abdominal aortic aneurysms in the United States during 2001

OBJECTIVE: Small patient numbers, mixed data from clinical trials, and longitudinal series representing institutional learning curves have characterized previous studies of early outcomes after endovascular abdominal aortic aneurysm (AAA) repair. We compared the perioperative outcomes of endovascular and open surgical AAA repair in an unselected sample of patients in a single calendar year using a national administrative database. METHODS: The 2001 National Inpatient Sample database was retrospectively reviewed. This database represents 20% of all-payer stratified sample of non-federal US hospitals. Patients older than 49 years were identified by primary diagnostic codes (International Classification of Disease, ninth revision [ICD-9], 441.4, intact, nonruptured AAA) and procedure codes (ICD-9 38.44 for open, 39.71 for endovascular repair). Patient demographic data (age, sex), comorbid conditions (ICD-9 coded), inpatient complications (ICD-9 coded), length of stay, final discharge disposition (home vs institution vs death), and hospital charges were examined with univariate and multivariate analyses. RESULTS: In calendar year 2001, 7172 patients underwent either open (64%) or endovascular (36%) repair of intact, nonruptured AAAs. Despite comparable rates of preoperative comorbid conditions and a greater proportion of octogenarians (23% vs 16%%; P =.0001), morbidity (18% vs 29%; P =.0001) and mortality (1.3% vs 3.8%; P =.0001) were significantly lower for endovascular repair than for open repair. The median length of stay (2 vs 7 days; P =.0001) and the rate of discharge to an institutional facility versus home (6% vs 14%; P =.0001) were also much lower in the endovascular group than in the open repair group. At multivariate analysis, open AAA repair and age older than 80 years were strong independent predictors (P =.0001 for all) for death (open repair: odds ratio [OR], 3.3; 95% confidence interval [CI], 2.3-4.9; age: OR, 14.2; 95% CI, 3.5-58.1), complications (open repair: OR, 1.9; 95% CI, 1.7-2.1; age: OR, 1.9; 95% CI, 1.5-2.5), and not being discharged to home (open repair: OR, 3.4; 95% CI, 2.9-4.1; age: OR, 12.0; 95% CI, 7.0-20.4). Mean hospital charges were significantly greater (difference, $3337; P =.0009) for endovascular repair than for open repair. Extrapolated to the total number of endovascular AAA repairs performed during the single 2001 calendar year, this resulted in a staggering $50.3 million in additional hospital charges. CONCLUSIONS: Endovascular repair of intact AAAs results in a significantly lower number of complications and deaths, shorter hospital stay, and improved likelihood of discharge to home, even in older patients, when compared with open surgical repair. These impressive gains in clinical outcome, however, are achieved at similarly impressive increases in health care costs.     

Hospital volume-related differences in aorto-bifemoral bypass operative mortality in the United States

PURPOSE: Aorto-bifemoral bypass (AFB) is commonly performed in US hospitals. Durable long-term outcome is achieved after AFB performed to treat aortoiliac occlusive disease. However, short-term outcome for complex surgical procedures is not uniform across medical centers. The objective of the current study was to define the relationship of hospital volume to operative mortality after AFB. METHODS: The study included 3073 patients with a primary procedure code for AFB and a diagnostic code for peripheral vascular occlusive disease who received treatment during 1997 at 483 hospitals in the Nationwide Inpatient Sample (NIS). The NIS represents a 20% stratified random sample representative of all US hospitals. Unadjusted and case mix-adjusted analyses were performed. RESULTS: Overall AFB-related mortality was 3.3%. Hospitals that performed more than 25 AFB per year (33% of patients at 37 hospitals in the NIS) had a lower crude mortality rate (3.7% vs 2.2%) compared with hospitals that performed fewer AFB. In a multivariate analysis adjusting for case mix, AFB at a high- volume hospital was associated with 42% decreased risk for in-hospital mortality (odds ratio [OR], 0.58; 95% confidence interval [CI], 0.34-0.97; P =.04) compared with low-volume hospitals. Two other important risk factors associated with increased mortality in the multivariate analysis included age more than 65 years (OR, 3.3; 95% CI, 2.0-5.4) and history of chronic pulmonary disease (OR, 1.9; 95% CI, 1.2-2.9). CONCLUSIONS: AFB operative mortality was significantly lower at high-volume hospitals in this nationally representative database. The effect of hospital volume of AFB procedures on outcome should be of importance to patients, providers, and health policy makers.     

Blood transfusion,independent of shock severity,is associated with worse outcome in trauma

BACKGROUND: We have previously shown that blood transfusion in the first 24 hours is an independent predictor of mortality, intensive care unit (ICU) admission, and increased ICU length of stay in the acute trauma setting when controlling for Injury Severity Score, Glasgow Coma Scale score, and age. Indices of shock such as base deficit, serum lactate level, and admission hemodynamic status (systolic blood pressure, heart rate) and admission hematocrit were considered potential confounding variables in that study. The objectives of this study were to evaluate admission anemia and blood transfusion within the first 24 hours as independent predictors of mortality, ICU admission, ICU length of stay (LOS), and hospital LOS, with serum lactate level, base deficit, and shock index (heart rate/systolic blood pressure) as covariates. METHODS: Prospective data were collected on 15,534 patients admitted to a Level I trauma center over a 3-year period (1998-2000) and stratified by age, gender, race, Glasgow Coma Scale score, and Injury Severity Score. Admission anemia and blood transfusion were assessed as independent predictors of mortality, ICU admission, ICU LOS, and hospital LOS by logistic regression analysis, with base deficit, serum lactate, and shock index as covariates. RESULTS: Blood transfusion was a strong independent predictor of mortality (odds ratio [OR], 2.83; 95% confidence interval [CI], 1.82-4.40; p < 0.001), ICU admission (OR, 3.27; 95% CI, 2.69-3.99; p < 0.001), ICU LOS (p < 0.001), and hospital LOS (Coef, 4.37; 95% CI, 2.79-5.94; p < 0.001) when stratified by indices of shock (base deficit, serum lactate, shock index, and anemia). Patients who underwent blood transfusion were almost three times more likely to die and greater than three times more likely to be admitted to the ICU. Admission anemia (hematocrit < 36%) was an independent predictor of ICU admission (p = 0.008), ICU LOS (p = 0.012), and hospital LOS (p < 0.001). CONCLUSION: Blood transfusion is confirmed as an independent predictor of mortality, ICU admission, ICU LOS, and hospital LOS in trauma after controlling for severity of shock by admission base deficit, lactate, shock index, and anemia. The use of other hemoglobin-based oxygen-carrying resuscitation fluids (such as human or bovine hemoglobin substitutes) in the acute postinjury period warrants further investigation.     

Brain death after severe traumatic brain injury: the role of systemic secondary brain insults

Secondary brain insults predominantly due to hypotension are frequent among patients with fatal traumatic brain injury. We assessed the correlation between different systemic secondary brain insults and brain death in 404 patients admitted to our intensive care unit (ICU) after severe traumatic brain injury. We collated data on hypoxemia and hypotension prior to as well as the occurrence of hypoxemia, hypotension, shock, anemia, hyperglycemia, and hyperthermia within the first 24 hours after ICU admission. We also considered both the presence of extracranial injuries and the category of traumatic brain injury using computerized tomography. The 59 patients (14.6%) who developed brain death, were significantly older than patients without a fatal neurological outcome (46.1 +/- 22 vs 29.5 +/- 14.9 years; P < .0001). Intracranial mass lesions, whether surgically evacuated were more frequent among brain-dead patients. The systemic secondary brain insults significantly associated with brain death were hypoxemia, hypotension, shock, anemia, and hyperglycemia within the first 24 hours after ICU admission. After multivariate analysis, the factors that independently predicted brain death were the occurrence of shock (odds ratio [OR], 6.74; 95% confidence interval [CI], 2.85-15.84; P = .001) and older age (OR, 1.05; 95% CI, 1.03-1.07; P = .003). In conclusion, early shock seems to be the major systemic secondary brain insult associated with brain death in patients with severe traumatic brain injury. Prevention of or correction of shock might help to either decrease the occurrence of a fatal neurological outcome or in brain-dead patients to preserve organs in better condition for procurement.     

Contemporary results of juxtarenal aneurysm repair

OBJECTIVE: The increasing use of aortic endografts predictably will add to the complexity of open abdominal aortic aneurysm (AAA) repair and, therefore, the proportion of surgically treated infrarenal AAAs that are juxtarenal in location (JRA) will grow. This study reviews a single-center experience with JRAs. METHODS: Between June 1994 and December 2000, 138 patients underwent elective repair of a JRA, comprising 16.1% of 859 consecutive asymptomatic and intact symptomatic nonruptured infrarenal AAAs repaired over the same period. All patients with JRA needed proximal suprarenal clamping (SRC) or supravisceral (SVC) clamping. Patient demographics, selected risk factors, and operative details were recorded. Univariate analyses of selected risk factors for an adverse perioperative event were assessed, and multivariate analyses were performed with linear and logistic regression with backwards selection. RESULTS: SRC was used in 95 patients (69%), and 43 patients (31%) underwent SVC. The mortality rate was 5.1% (7/138) for JRA repair, and 2.8% (20/720) for infrarenal AAA repair (P =.03). The mortality rate was significantly greater for those patients who received SVC compared with SRC (11.6% versus 2.1%; P =.02). Multivariate analysis identified SVC position as the only independent predictor of mortality (odds ratio [OR], 6.1; 95% CI, 1.1 to 32.9; P =.035). Transient renal insufficiency occurred in 39 patients (28.3%), but only eight patients (5.8%) needed dialysis. Patients who had SVC had a significantly greater rate of renal insufficiency than those who received SRC (41.9% versus 22.1%; P =.02). Multivariate analysis showed SVC position (OR, 3.3; 95% CI, 1.4 to 7.8; P =.008), diabetes (OR, 3.7; 95% CI, 1.1 to 12.9; P =.04), and preoperative renal insufficiency (OR, 5.8; 95% CI, 2.2 to 15.4; P <.001) were independent predictors of postoperative renal insufficiency. Renal ischemia during proximal clamping cannot alone explain renal complications because clamp time was shorter in patients with SVC (24.9 +/- 2.4 minutes versus 32.2 +/- 1.5 minutes; P =.009). CONCLUSION: JRA repair can be accomplished with a low mortality rate, but a more proximal clamp position may adversely affect outcome in these patients. Postoperative renal insufficiency is related to diabetes, preoperative renal insufficiency, and SVC position. These results suggest SRC is safer than SVC for proximal aortic clamp control of JRAs. Although clamp level must be tailored to patient anatomy, outcome may be improved if the clamp level can be kept distal to the superior mesenteric artery origin.     

Impact of emergency colectomy on survival of patients with fulminant Clostridium difficile colitis during an epidemic caused by a hypervirulent strain

OBJECTIVES: To determine whether emergency colectomy reduces mortality in patients with fulminant Clostridium difficile-associated disease (CDAD), and to identify subgroups of patients more likely to benefit from the procedure. SUMMARY BACKGROUND DATA: Many hospitals in Quebec, Canada, have noted since 2003 a dramatic increase in CDAD incidence and in the proportion of cases severe enough to require intensive care unit (ICU) admission. The decision to perform an emergency colectomy remains largely empirical. METHODS: Retrospective observational cohort study of 165 cases of CDAD that required ICU admission or prolongation of ICU stay between January 2003 and June 2005 in 2 tertiary care hospitals of Quebec. Multivariate analysis was performed through logistic regression; adjusted odds ratios (AOR) and their 95% confidence intervals (CI) were calculated. The primary outcome was mortality within 30 days of ICU admission. RESULTS: Eighty-seven (53%) cases resulted in death within 30 days of ICU admission, almost half (38 of 87, 44%) within 48 hours of ICU admission. The independent predictors of 30-day mortality were: leukocytosis >or=50 x 10(9)/L (AOR, 18.6; 95% CI, 3.7-94.7), lactate >or=5 mmol/L (AOR, 12.4; 95% CI, 2.4-63.7), age >or=75 years (AOR, 6.5; 95% CI, 1.7-24.3), immunosuppression (AOR, 7.9; 95% CI, 2.3-27.2) and shock requiring vasopressors (AOR, 3.4; 95% CI, 1.3-8.7). After adjustment for these confounders, patients who had an emergency colectomy were less likely to die (AOR, 0.22; 95% CI, 0.07-0.67, P = 0.008) than those treated medically. Colectomy seemed more beneficial in patients aged 65 years or more, in those immunocompetent, those with a leukocytosis >or=20 x 10(9)/L or lactate between 2.2 and 4.9 mmol/L. CONCLUSION: Emergency colectomy reduces mortality in some patients with fulminant CDAD.     

Relationship between intracranial pressure monitoring and outcomes in severe traumatic brain injury patients

Intracranial pressure (ICP) monitoring is recommended in patients with a severe traumatic brain injury (TBI) and an abnormal computed tomography (CT) scan. However, there is contradicting evidence about whether ICP monitoring improves outcome. The purpose of this study was to examine the relationship between ICP monitoring and outcomes in patients with severe TBI. From February 2001 to December 2008, a total of 477 consecutive adult (> or =18 years) patients with severe TBI were included retrospectively in the study. Patients who underwent ICP monitoring (n=52) were compared with those who did not (n=425). The primary outcome was hospital mortality. Secondary outcomes were ICU mortality, mechanical ventilation duration, the need for tracheostomy, and ICU and hospital length of stay (LOS). After adjustment for multiple potential confounding factors, ICP monitoring was not associated with significant difference in hospital or ICU mortality (odds ratio [OR] = 1.71, 95% confidence interval [CI] = 0.79 to 3.70, P = 0.17; OR = 1.01, 95% CI = 0.41 to 2.45, P = 0.99, respectively). ICP monitoring was associated with a significant increase in mechanical ventilation duration (coefficient = 5.66, 95% CI = 3.45 to 7.88, P < 0.0001), need for tracheostomy (OR = 2.02, 95% CI = 1.02 to 4.03, P = 0.04), and ICU LOS (coefficient = 5.62, 95% CI = 3.27 to 7.98, P < 0.0001), with no significant difference in hospital LOS (coefficient = 8.32, 95% CI = -82.6 to 99.25, P = 0.86). Stratified by the Glasgow Coma Scale score, ICP monitoring was associated with a significant increase in hospital mortality in the group of patients with Glasgow Coma Scale 7 to 8 (adjusted OR = 12.89, 95% CI = 3.14 to 52.95, P = 0.0004). In patients with severe TBI, ICP monitoring was not associated with reduced hospital mortality, however with a significant increase in mechanical ventilation duration, need for tracheostomy, and ICU LOS.     

Blood alcohol concentration and management of road trauma patients in the emergency department

BACKGROUND: The effects of blood alcohol on injury after crash are controversial, and safe limits are not settled. We examined if a positive blood alcohol concentration, even in a nontoxic range, affects management and outcome of injured patients after road crashes. METHODS: In this prospective cohort study, we recruited all adult subjects admitted to an emergency department within 4 hours after a road crash. Outcomes were mortality or expected permanent disability, and data related to patients' management. RESULTS: Alcohol-positive trauma patients were more frequently critical at admission (odds ratio [OR], 1.89; 95% confidence interval [CI], 1.18-3.02), and had an increased risk of combined mortality or expected permanent disability (OR, 1.67; 95% CI, 1.08-2.58), need for intensive care (OR, 1.87; 95% CI, 1.01-3.46), surgery (OR, 1.91; 95% CI, 1.37-2.66) and blood transfusions (OR, 2.09; 95% CI, 1.20-3.64), and acute medical complications (OR, 1.94; 95% CI, 1.33-2.85). All these events were explained by higher trauma severity. Only the risk of unsuspected injuries, diagnosed only at final evaluation, was independently associated with a positive blood alcohol concentration (OR, 4.98; 95% CI, 3.62-6.87), in addition to trauma severity and preexisting chronic conditions. Blood alcohol measurement significantly improved the accuracy in predicting unsuspected injuries, from 81.3% to 86.2%. CONCLUSION: In injured patients after a road crash, a positive blood alcohol concentration increases the chance that the final diagnosis will include more injuries than initially documented. More careful monitoring is needed in alcohol-positive trauma patients, independent of clinical status, injury severity, and overt symptoms of alcohol intoxication.     

Patients supported by extracorporeal membrane oxygenation and acute dialysis: acute physiology and chronic health evaluation score in predicting hospital mortality

Extracorporeal membrane oxygenation (ECMO) can provide short-term cardiopulmonary support to critically ill patients. Among ECMO patients, acute renal failure requiring dialysis has an ominous prognosis. However, a prognostic scoring system and risk factors adjustment for hospital mortality in these patients have not been elucidated previously. A multicenter observational cohort study was conducted from January 2002 to December 2006. Information obtained included demographics, biochemical variables, Acute Physiology and Chronic Health Evaluation (APACHE) II, III, and IV scores at ICU admission and initial acute dialysis, and hospital mortality in 102 non-coronary artery bypass graft (CABG) patients receiving ECMO support with acute dialysis. This retrospective cohort study included 70 men and 32 women with a mean age of 47.9 ± 15.7 years. Seventy-two patients (70.6%) had hospital mortality. The area under the receiver operating characteristic curve showed APACHE IV (0.653) had a better discriminative power to predict hospital mortality than APACHE II (0.584) and APACHE III (0.634) at initializing dialysis. Hosmer-Lemeshow statistics showed good calibration for all three scores to predict hospital mortality at initializing dialysis (APACHE IV, P = 0.392; APACHE III, P = 0.094; and APACHE II, P = 0.673). Independent predictors for hospital mortality by multivariate logistic regression analysis were higher central venous pressure (odds ratio [OR], 1.11; confidence interval [CI] 95%, 1.02-1.20; P = 0.016), higher APACHE IV score at initializing dialysis (OR, 1.03; CI 95%, 1.01-1.05; P = 0.003), and latency from hospital admission to dialysis (OR, 1.04; CI 95%, 1.00-1.08; P = 0.033). High mortality rate was noted in non-CABG patients receiving ECMO and acute dialysis. Predialysis APACHE IV scores had good calibration and moderate discrimination in predicting hospital mortality in these patients. Because ECMO support could stabilize cardiopulmonary status, APACHE IV scores would likewise underestimate disease severity at lower score ranges in these patients.     

Avoidance of Cardiopulmonary Bypass Improves Early Survival in Multivessel Coronary Artery Bypass Patients with Poor Ventricular Function

Abstract Background: Patients with diminished ventricular function represent an increasing percentage of candidates for coronary artery bypass grafting (CABG). We have reviewed our recent experience in CABG in patients with ejection fractions (EF) 相似文献   

Validity of the Hardman index to predict outcome in ruptured abdominal aortic aneurysm

This study assessed the validity of the Hardman index in predicting outcome following open repair of ruptured abdominal aortic aneurysm and whether this scoring system can be used reliably to select patients for surgical repair. Patients undergoing open repair of ruptured abdominal aortic aneurysm in two university teaching hospitals over a 5-year period were identified from a computerized hospital database. Thirty-day mortality was the main outcome measure. Five Hardman index factors were calculated and related to outcome retrospectively. There were 178 patients with a mean age of 73.9 years (range 51-94) and a male to female ratio of 5.4:1. The overall in-hospital mortality was 57.3% (102/178). Univariate analysis of risk factors showed that age >76 years (P = 0.007, odds ratio [OR] 2.34, 95% confidence interval [CI] 1.26-4.37) and electrocardiograghic evidence of ischemia on admission (P = 0.002, OR 3.75, 95% CI 1.57-8.93) were associated with high mortality. However, loss of consciousness (P = 0.155, OR 1.56, 95% CI 0.85-2.86), hemoglobin <9 g/dL (P = 0.118, OR 1.89, 95% CI 0.85-4.22), and serum creatinine >0.19 mmol/L (P = 0.691, OR 1.25, 95% CI 0.42-3.70) were not significant predictors of mortality. Using a multivariate analysis, age >76 years (P = 0.043, OR 2.29, 95% CI 1.03-5.11) and myocardial ischemia (P = 0.029, OR 2.93, 95% CI 1.12-7.67) were again found to be the significant predictors of mortality. The operative mortality was 44%, 46%, 68%, 79%, and 100% for Hardman scores of 0, 1, 2, 3, and 4, respectively. No patient had a score of 5. The Hardman index is not a reliable predictor of outcome following repair of ruptured abdominal aortic aneurysm. High-risk patients may still survive and should not be denied surgical repair based on the scoring system alone. Further evaluation of the risk factors is required to reliably and justifiably exclude those patients in whom the intervention is inappropriate.     

Correlation between preoperative biliary drainage, bile duct contamination, and postoperative outcomes for pancreatic surgery

BACKGROUND: Although previously examined, the potential relationship between preoperative biliary drainage (PBD), intraoperative bile culture (IBC), and postoperative morbidity and mortality rate for pancreatic surgery remains unclear. METHODS: Two hundred twenty patients underwent operation for either benign pancreatic disease or malignant periampullary and pancreatic neoplasms, consisting of pylorus-preserving proximal pancreatoduodenectomy (n = 180), biliary bypass (n = 31), and total pancreatectomy (n = 9). An intraoperative bile specimen was prospectively collected immediately after division of the bile duct and sent for bacteriologic evaluation for both aerobic and anaerobic microorganisms. Morbidity and mortality rates were evaluated. RESULTS: Of 220 patients evaluated, 113 patients (51.4%) had a positive IBC. Factors associated with a positive IBC were age >70 years (odds ratio [OR], 5.9;95% confidence interval, [CI]: 1.6-22.1; P = .007), history of coronary artery disease (OR, 0.08; 95% CI, 0.01-0.5; P = .007), diagnosis of neoplasia (OR, 0.3; 95% CI, 0.1-0.9; P =. 03), and PBD (OR, 0.1; 95% CI, 0.06-0.2; P = .0001). Infectious complications (OR, 1.8; 95% CI, 1-3; P = .03), and wound infection (OR, 2.8; 95% CI,1.4-5.3; P = .002) were greater in patients with positive IBC. CONCLUSIONS: PBD predisposes to a positive IBC. Patients with a positive IBC have a clinically important increased risk of developing both infectious complications and wound infection after pancreatic surgery.     

Epidural cooling for spinal cord protection during thoracoabdominal aneurysm repair: A five-year experience

PURPOSE: We developed and applied a method for providing regional spinal cord hypothermia with epidural cooling (EC) during thoracoabdominal aneurysm (TAA) repair. Preliminary results indicated significant reduction in spinal cord ischemic complications (SCI), compared with historical controls, and a 5-year experience with EC was reviewed. METHODS: From July 1993 to September 1998, 170 patients with thoracic aneurysms (n = 14; 8.2%) or TAAs (types I and II, n = 83 [49%]; type III, n = 66 [39%]; type IV, n = 7 [4.1%]) were treated with EC. An earlier aneurysm resection was noted in 44% of patients, an emergent operation was noted in 20% of patients, and an aortic dissection was noted in 16% of patients. The EC was successful (mean cerebrospinal fluid [CSF] temperature at cross-clamp, 26.4 +/- 3 degrees C) in 97% of cases, with all 170 patients included in an intention-to-treat analysis. The operation was performed with a clamp/sew technique (98% patients) and selective (T(9) to L(1) region) reimplantation of intercostal vessels. Clinical and EC variables were examined for association with operative mortality and SCI by means of the Fischer exact test, and those variables with a P value less than.1 were included in multivariate logistic regression analysis. RESULTS: The operative mortality rate was 9.5% and was weakly associated (P =.07) with SCI; postoperative cardiac complications (odds ratio [OR], 35. 3; 95% CI, 5.3 to 233; P <.001) and renal failure (OR, 32.2; 95% CI, 6.6 to 157; P <.001) were the only independent predictors of postoperative death. SCI of any severity occurred in 7% of cases (type I/II, 10 of 83 [12%]; all other types, 2 of 87 [2.3%]), versus a predicted (Acher model) incidence of 18.5% for this cohort (P =. 003). Half the deficits were minor, with good functional recovery, and devastating paraplegia occurred in three patients (2.0%). Independent correlates of SCI included types I and II TAA (OR, 8.0; 95% CI, 1.4 to 46.3; P =.021), nonelective operation (OR, 8.3, 95% CI, 1.8 to 37.7; P =.006), oversewn T(9) to L(2) intercostal vessels (OR, 6.1; 95% CI, 1.3 to 28.8; P =.023), and postoperative renal failure (OR, 23.6; 95% CI, 4.4 to 126; P <.001). These same clinical variables of nonelective operations (OR, 7.7; 95% CI, 1.4 to 41.4; P =.017), oversewn T(9) to L(2) intercostal arteries (OR, 9.7; 95% CI, 1.5 to 61.2; P =.016), and postoperative renal failure (OR, 20.8; 95% CI, 3.0 to 142.1; P =.002) were independent predictors of SCI in the subgroup analysis of high-risk patients, ie, patients with type I/II TAA. CONCLUSION: EC has been effective in reducing immediate, devastating, total paraplegia after TAA repair. A strategy that combines the neuroprotective effect of regional cord hypothermia, avoiding the sacrifice of potential spinal cord blood supply, and postoperative adjuncts (eg, avoidance of hypotension, CSF drainage) appears necessary to minimize SCI after TAA repair.