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PubMed2005

[Assessment of the release of thyroid hormones in septic shock--prognostic significance].

UNLABELLED: Septic shock is the reason of human body organs dysfunctions including the hormonal system. There are abnormal thyroid hormones releasing as well. It is also noticed that sepsis caused serious disturbances in pituitary-thyroid axis functions. This is called euthyroid sick syndrom - (ESS). THE AIM: To qualify the prognostic value of thyroid hormones serum levels changes in patients with septic shock. MATERIAL AND METHODS: 20 patients with septic shock were included into study. Septic shock was diagnosed according to AACP/SCCM criteria. The study group was divided into two subgroups: survivors (n = 10) and nonsurvivors (n = 10). 20 healthy volunteers were the control group. Blood for analysis was taken at the moment of septic shock recognition and on the 1st, 2nd, 5th and 10th day of the observation between 8 a.m. and 9 a.m. We studied thyrotropin (TSH), free triiodothyronine fraction (fT3) and free thyroxin fraction (fT4) serum levels, APACHE II and APACHE III score, acute lung injury (ALI) or acute respiratory distress syndrome (ARDS). RESULTS: During our study we noticed significant decrease of fT3 and TSH serum levels (respectively 2.36 +/- 0.79 pg/ml and 0.76 +/- 1.12mU/I) according to the control group (respectively 3.28 +/- 0.61 pg/ml and 0.95 +/- 0.46mU/l). Nonsurvivors had significantly lower TSH serum level (0.37 +/- 0.62 mU/I) in comparison to survivors (1.27 +/- 1.45 mU/I) in spite of very similar fT3 serum level (respectively 2.45 +/- 0.87 pg/ml and 2.22 +/- 0.66 pg/ml). It could mean that there were disturbances in the pituitary-thyroid axis function in patients who did not survive. Our study did not show any correlations between thyroid hormones serum levels and APACHE II score, APACHE III score, ALI or ARDS. CONCLUSIONS: This study show that low TSH serum level could be a significant prognostic factor of death in patient with septic shock especially with low fT3 serum level. The results also suggest that ESS could be a consequence of pituitary TSH releasing disturbances.

Adult↗

PubMed2006

Six-year mortality and quality of life in critically ill patients with chronic obstructive pulmonary disease.

OBJECTIVE: To study the mortality and quality of life (QOL) of survivors at 6 yrs after intensive care unit (ICU) admission for chronic obstructive pulmonary disease. DESIGN: Prospective, multiple-center cohort study. SETTING: A total of 86 ICUs throughout Spain. PATIENTS: Patients in the Project for the Epidemiological Analysis of Critical Care Patients (PAEEC) project with chronic obstructive pulmonary disease were included. MEASUREMENTS AND MAIN RESULTS: The sample comprised 742 patients; 508 of them were admitted for acute exacerbation of chronic obstructive pulmonary disease, and 379 of these required intermittent positive-pressure ventilation. The mean age of the patients was 65.2 +/- 9.89 yrs, Acute Physiology and Chronic Health Evaluation (APACHE) III score was 66.6 +/- 21.04; preadmission QOL questionnaire score was 7 +/- 4.82 points, and hospital mortality was 31.8%. At 6 yrs, 32.2% had died after hospital discharge, 21.6% could not be traced, and 107 patients were alive (18.3% of the 582 followed-up patients). QOL of survivors was worse than preadmission (6.55 +/- 5.6 vs. 4.92 +/- 4.5 points, p < .05), but 72% of patients were self-sufficient. Among the 379 patients admitted to the ICU for acute chronic obstructive pulmonary disease exacerbation and requiring intermittent positive-pressure ventilation, 36.7% died in the hospital; at 6 yrs after hospital discharge, 31.4% had died, 18.7% could not be traced, and 50 patients (16.2% of followed-up patients) were alive. Multivariate analysis with logistic regression showed that the mortality at 6 yrs was related to age (odds ratio, 1.046; 95% confidence interval, 1.023-1.071), APACHE III score (odds ratio, 1.013; 95% confidence interval, 1.001-1.024), and preadmission QOL score (odds ratio, 1.139; 95% confidence interval, 1.078-1.204). CONCLUSION: The 6-yr mortality of patients with chronic obstructive pulmonary disease requiring ICU admission is high. Mortality is mainly influenced by pre-ICU admission QOL. At 6 yrs, at least 15% are alive; survivors have a worse QOL compared with pre-ICU admission, although three quarters of them are self-sufficient.

APACHE↗

PubMed1999

Analysis of the effect of conversion from open to closed surgical intensive care unit.

OBJECTIVE: To compare the effect on clinical outcome of changing a surgical intensive care unit from an open to a closed unit. DESIGN: The study was carried out at a surgical intensive care unit in a large tertiary care hospital, which was changed on January 1, 1996, from an open unit, where private attending physicians contributed and controlled the care of their patients, to a closed unit, where patients' medical care was provided only by the surgical critical care team (ABS or ABA board-certified intensivists). A retrospective review was undertaken over 6 consecutive months in each system, encompassing 274 patients (125 in the open-unit period, 149 in the closed-unit period). Morbidity and mortality were compared between the two periods, along with length-of-stay (LOS) and number of consults obtained. A set of independent variables was also evaluated, including age, gender, APACHE III scores, the presence of preexisting medical conditions, the use of invasive monitoring (Swan-Ganz catheters, central and arterial lines), and the use of antibiotics, low-dose dopamine (LDD) for renal protection, vasopressors, TPN, and enteral feeding. RESULTS: Mortality (14.4% vs. 6.04%, p = 0.012) and the overall complication rate (55.84% vs. 44.14%, p = 0.002) were higher in the open-unit group versus the closed-unit group, respectively. The number of consults obtained was decreased (0.6 vs. 0.4 per patient, p = 0.036), and the rate of occurrence of renal failure was higher in the open-unit group (12.8% vs. 2.67%, p = 0.001). The mean age of the patients was similar in both groups (66.48 years vs. 66.40, p = 0.96). APACHE III scores were slightly higher in the open-unit group but did not reach statistical significance (39.02 vs. 36.16, p = 0.222). There were more men in the first group (63.2% vs. 51.3%). The use of Swan-Ganz catheters or central and arterial lines were identical, as was the use of antibiotics, TPN, and enteral feedings. The use of LDD was higher in the first group, but the LOS was identical. CONCLUSIONS: Conversion of a tertiary care surgical intensive care unit from an open to closed environment reduced dopamine usage and overall complication and mortality rates. These results support the concept that, when possible, patients in surgical intensive care units should be managed by board-certified intensivists in a closed environment.

Aged↗

PubMed1995

Effect of race on survival following in-hospital cardiopulmonary resuscitation.

BACKGROUND: Race has been shown to be a significant predictive factor in a number of treatment decisions and outcomes, including survival following out-of-hospital cardiopulmonary resuscitation (CPR). The goal of this study was to determine whether race is associated with the rate of survival to discharge following in-hospital CPR. METHODS: Consecutive adult patients undergoing attempted CPR at three teaching hospitals were identified. Demographic, clinical, and laboratory data from the time of admission, information about the resuscitation attempt, and the outcome of CPR were recorded for each patient. The characteristics of black and non-black patients were compared. Logistic regression was used to determine whether race was a significant independent predictor of CPR outcome. RESULTS: A total of 656 patients were identified. Black patients had a higher mean severity of illness as measured by the Acute Physiology and Chronic Health Evaluation (APACHE) III score, were more likely to have an initial rhythm of electromechanical dissociation or asystole, were less likely to have an admitting diagnosis of myocardial infarction or a history of coronary artery disease, and had a higher serum creatinine level, lower serum albumin value, and lower 24-hour urine output for the first 24 hours. There was no difference between black and nonblack patients regarding the rate of survival of the resuscitative effort itself. However, black patients were significantly less likely than nonblack patients to survive to discharge following resuscitation (Mantel-Haenszel odds ratio, 0.31; 95% confidence interval, 0.15 to 0.68). This relationship persisted after adjusting for potential confounders such as age, sex, initial cardiac rhythm, diagnosis of pneumonia, serum creatinine level, hospital, and APACHE III score. CONCLUSIONS: Black race is significantly associated with a lower rate of survival to discharge following in-hospital CPR. Further work is needed to explore this association in other settings; to examine the effect of other possible confounding variables, such as tobacco use, socioeconomic status, and marital status; and to further study the determinants of physician decision-making about resuscitation.

Adult↗

PubMed2001

Multicenter study of obstetric admissions to 14 intensive care units in southern England.

OBJECTIVES: To identify pregnant and postpartum patients admitted to intensive care units (ICUs), the cause for their admission, and the proportion that might be appropriately managed in a high-dependency environment (HDU) by using an existing database. To estimate the goodness-of-fit for the Simplified Acute Physiology Score II, the Acute Physiology and Chronic Health Evaluation (APACHE) II, and the APACHE III scoring systems in the obstetrical population. DESIGN: Retrospective analysis of demographic, diagnostic, treatment, and severity of illness data. SETTING: Fourteen ICUs in Southern England. PATIENTS: Pregnant or postpartum (<42 days) admissions between January 1, 1994, and December 31, 1996. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We identified 210 patients, constituting 1.84% (210 of 11,385) of all ICU admissions and 0.17% (210 of 122,850) of all deliveries. Most admissions followed postpartum complications (hypertensive disease of pregnancy [39.5%] and major hemorrhage [33.3%]). Seven women were transferred to specialist ICUs. There was considerable variation between ICUs with respect to the number and type of interventions required by patients. Some 35.7% of patients stayed in ICU for <2 days and received no specific ICU interventions; these patients might have been safely managed in an HDU. There were seven maternal deaths (3.3%); fetal mortality rate was 20%. The area under the receiver operator characteristic curve and the standardized mortality ratio were 0.92 (confidence interval [CI], 0.85-0.99) and 0.43 for the Simplified Acute Physiology Score II, 0.94 (CI, 0.86-1.0) and 0.24 for APACHE II, and 0.98 (CI, 0.96-1.0) and 0.43 for APACHE III, respectively. CONCLUSIONS: Existing databases can both identify critically ill obstetrical patients and provide important information about them. Obstetrical ICU admissions often require minimal intervention and are associated with low mortality rates. Many might be more appropriately managed in an HDU. The commonly used severity of illness scoring systems are good discriminators of outcome from intensive care admission in this group but may overestimate mortality rates. Severity of illness scoring systems may require modification in obstetrical patients to adjust for the normal physiologic responses to pregnancy.

APACHE↗

PubMed1992

Evaluation of definitions for sepsis.

OBJECTIVE: To evaluate the current definitions for sepsis and clarify and quantify the risk for intensive care unit (ICU) patients with sepsis. DESIGN: A prospective cohort analysis of 519 patients with a primary clinical diagnosis of sepsis treated in the ICUs of 40 US hospitals drawn from a nationally representative sample of 17,440 admissions. MEASUREMENTS: Patient's age, treatment location prior to ICU admission, comorbidities, origin of sepsis, daily physiologic measurements, therapeutic intensity, and subsequent hospital mortality rate. INTERVENTION: Patients were categorized into subgroups by important risk factors and into current clinical definitions of sepsis. Patients also were provided an individual risk of hospital mortality based on their individual predicted risk by using the first ICU day APACHE III score, treatment location prior to ICU admission, and etiology of sepsis. RESULTS: Patients with a designated urinary source of sepsis had a significantly lower baseline risk of death (30 percent) than patients with other causes (54 percent, p less than 0.01). Patients admitted to the ICU from the emergency department also had significantly lower mortality (37 percent) than patients admitted from hospital wards, other units within the hospital, or transferred from other hospitals (55 percent, p less than 0.01). Recognized definitions such as "sepsis syndrome" and "septic shock" identified groups of patients with significantly different mortality rates, 40 percent and 64 percent, respectively (p less than 0.01), but the range of individual patient risks within these groups were indistinguishable from the 211 patients (41 percent) that did not meet these definitions during the initial seven days of ICU treatment. Multivariate analysis using initial APACHE III score, etiology (urosepsis or other), and treatment location prior to ICU admission provided the greatest degree of discrimination (ROC = 0.82) of patients by risk of hospital death. CONCLUSIONS: Sepsis is a complex clinical entity and could be viewed as a continuum with substantial variation in initial severity and risk of hospital death. One accurate description of sepsis is the continuous measure of hospital mortality risk estimated primarily from physiologic abnormalities.

Bacteremia↗

PubMed2004

Underweight is independently associated with mortality in post-operative and non-operative patients admitted to the intensive care unit: a retrospective study.

BACKGROUND: Low and high body mass index (BMI) have been recently shown to be associated with increased and decreased mortality after ICU admission, respectively. The objective of this study was to determine the impact of BMI on mortality and length of stay in patients admitted to the intensive care unit (ICU). METHODS: In this retrospective cohort study, the Acute Physiology and Chronic Health Evaluation (APACHE) III database of patients admitted to the ICUs of a tertiary academic medical center, from January 1997 to September 2002, was crossed with a Hospital Rule-based Systems database to obtain the height and weight of the patients on admission to the ICU. The cohort was divided in post-operative and non-operative groups. We created the following five subgroups based on the BMI: <18.5, 18.5 to 24.9, 25 to 29.9, 30.0 to 39.9, >/= 40.0 Kg/m2. A multiple logistic regression analysis was used to determine the independent impact of BMI on hospital mortality. The ICU length of stay ratio was defined as the ratio of the observed to the predicted LOS. P-value < 0.05 was considered significant. The 95% confidence interval (CI) was calculated for the odds ratio (OR). RESULTS: BMI was available in 19,669 of the 21,790 patients in the APACHE III database; 11,215 (57%) of the patients were admitted post-operatively. BMI < 18.5 was associated with increased mortality in both post-operative (OR = 2.14, 95% CI, 1.39 to 3.28) and non-operative (OR = 1.51, 95% CI, 1.13 to 2.01) patients. Post-operative patients with a BMI between 30.0 to 39.9 had a lower mortality rate (OR = 0.68, 95% CI, 0.49 to 0.94). Post-operative patients with BMI <18.5 or BMI >/= 40 had an ICU length of stay ratio significantly higher than patients with BMI between 18.5 to 24.9. The addition of BMI < 18.5 did not improve significantly the accuracy of our prognostic model in predicting hospital mortality. CONCLUSIONS: Low BMI is associated with higher mortality in both post- and non-operative patients admitted to the ICU. LOS is increased in post-operative patients with low and high BMIs.

Journal Article↗

PubMed2006

Acute renal failure in the intensive care unit.

BACKGROUND: Acute renal failure (ARF) in the intensive care unit (ICU) is associated with high mortality. A thorough understanding of the clinical spectrum of the disease is needed in order to devise methods to improve the final outcome due to this problem. AIMS AND OBJECTIVES: The aim of the present study was to analyze the clinical spectrum, causes, risk and prognostic factors and final outcome of ARF in the setting of ICU. METHOD: This prospective study involved patients admitted to ICU during the period between September 2003 to January 2005 (17 months). Patients who developed ARF during the ICU stay were included in the study. The clinical and laboratory data were collected at admission and then on daily basis. Data recorded included; patient characteristics, underlying medical conditions responsible for ICU admission, dialytic status, need for ventilation, total duration of ICU stay, APACHE-III score and final outcome, and these data were analyzed for predicting survival using univariate and multivariate analysis. RESULTS: Twelve hundred and fifteen (1215) patients were admitted to ICU from September 2003 to January, 2005 and 46 (3.79%) patients developed ARF after admission to ICU. Mean age of patients was 44.9 +/- 17 years and 56.5% were males. Comorbidity was seen in 24 (52%) patients; hypertension (34.7%), diabetes mellitus (28.3%), coronary artery disease (30.4%) and chronic kidney disease (13%). ARF had developed complicating medical and surgical conditions in 33 (71.7%) and 11 (23.7%) patients respectively. The etiology of ARF was multifactorial and included; hypotension (71.74%), volume depletion (17.4%), nephrotoxic drugs (67.39%), and sepsis (69.5%). Multiple organ system failure (MOSF) was noted in 63% of cases and dialysis was required in 25 (54.3%) patients. Mortality occurred in 63% of patients. MOSF and sepsis were found to be significant adverse prognostic factors when multiple logistic regression analysis was done. CONCLUSIONS: ARF was seen in 3.79% of cases in our ICU and associated with poor prognosis. Presence of sepsis, MOSF, higher APACHE--III scores and ventilation need were correlated with higher mortality in ARF patients in the intensive care unit.

Acute Kidney Injury↗

PubMed2004

Causes and consequences of fever complicating critical surgical illness.

BACKGROUND: Fever may have malign consequences in the postoperative period. This study was performed to determine the causes and consequences of fever in critically ill surgical patients. The specific hypothesis tested is that postoperative fever is associated with adverse clinical outcomes, including increased organ dysfunction and risk of death. METHODS: Inception-cohort study of critically ill surgical patients who manifested a core temperature of >/=38.2 degrees C for the first time. The episode of fever was monitored until resolution, which was defined as a core temperature of <38.2 degrees C for at least 72 consecutive h. Demographic data collected included age, gender, admission diagnosis, admission status (elective/emergency), severity of illness (APACHE III), the systemic inflammatory response syndrome (SIRS) score, the cumulative multiple organ dysfunction score, cause of fever (infectious/non-infectious), ICU and hospital length of stay, and mortality. The day of onset of fever in the ICU, peak temperature, ICU day of peak temperature, and duration of fever episode were recorded. All diagnostic and therapeutic interventions were recorded, including the type and duration of antibiotic therapy. Univariate results of possible significance (alpha < 0.15) were tested in logistic regression models for independence of effect upon mortality after auto-correlation was excluded by matrix correlations and the Durbin-Watson statistic. Cases where both non-infectious and infectious causes of fever were present were analyzed as part of the infectious group, whereas the cumulative MOD score was dichotomized (< 5, >/=5 points) at a value known to be associated with increased mortality. RESULTS: Among 2,419 screened patients, 626 patients (26%) developed fever. Febrile patients were older, sicker, more likely to have undergone emergency surgery, more likely to develop organ dysfunction, and more likely to die (all, p < 0.0001). The mean day of onset of fever was day 1 and the mean peak temperature for the episode was 39.1 +/- 0.1 degrees C. For most patients, it was their only episode of fever, with a mean of 1.4 +/- 0.1 episodes/patient. Forty-six percent of febrile patients were found to have an infectious cause of fever. Nearly all patients had SIRS, and nearly all developed organ dysfunction to some degree. By logistic regression, the presence of SIRS (as opposed to fever in isolation), emergency status, higher APACHE III score and the peak temperature were associated with increased mortality, with peak temperature being the most powerful predictor in the model (OR 2.20, 95% Cl 1.57-3.19). Gender had no bearing on outcome, and there was a trend toward a protective effect from an infectious etiology of fever. CONCLUSIONS: Postoperative fever is deleterious to critically ill patients. The magnitude of fever is a determinant of mortality, whereas an infectious etiology of fever may not be. The impacts of nosocomial infection and suppression of fever on critically surgical patients deserve further study.

APACHE↗

PubMed2003

Feasibility of acute physiology and chronic health evaluation (APACHE) II and III score-based screening in patients receiving allogeneic hematopoietic stem-cell transplantation.

Patients who require management in the intensive care unit (ICU) for complications after allogeneic hematopoietic stem-cell transplantation (HSCT) generally have a poor outcome. We retrospectively studied whether the risk-prediction stratification systems commonly used for patients admitted to the ICU, that is, the Acute Physiology and Chronic Health Evaluation (APACHE) II and APACHE III systems, could be useful for identifying patients who should receive intensive care earlier. We reviewed the medical records of 210 patients who underwent allogeneic HSCT and found that 18 (8.6%) had been admitted to the ICU for acute respiratory failure (n=9), acute renal failure (n=7), and septic shock (n=2). The median APACHE II and III scores were, respectively, 16 (10-27) and 55 (22-87) at the onset of complications and 26 (15-43) and 101 (65-157) upon admission to the ICU. Thus, both the APACHE II and APACHE III scores at ICU admission were higher than those at the onset of complications (P <0.0001). Seventeen patients (94%) subsequently died, with a median ICU stay of 7.5 days (1-51 days), as a result of multiorgan failure (n=14), respiratory failure (n=2), and septic shock (n=1). The APACHE II and III scores of the sole surviving patient were, respectively, 21 and 71 at the onset and 24 and 86 upon transfer to the ICU. Thus, the APACHE scores in this study were lower than those reported for other surgical or medical patients treated in the ICU, despite their uniform poor prognosis. Although nine patients had developed grade III to IV acute graft-versus-host disease, which is the most common cause of morbidity and mortality after allogeneic HSCT, this was not fully evaluated in the current scoring systems. Application of these systems to HSCT will require adequate modification, with particular attention to organ dysfunction secondary to graft-versus-host disease.

APACHE↗

PubMed1998

Factors influencing outcome of prolonged norepinephrine therapy for shock in critical surgical illness.

Several studies indicate that norepinephrine (NE) may be more effective than dopamine for the treatment of septic shock. Nonetheless, many consider dopamine to be the pressor of choice for shock refractory to volume resuscitation. Owing to fear of excessive vasoconstriction, accentuated end-organ hypoperfusion, and the development of multiple organ dysfunction syndrome (MODS), it is contended that NE may be deleterious. We analyzed the duration of NE use and the variables that predict mortality in a consecutive cohort of 406 surgical intensive care unit patients treated with NE for shock. Study parameters included age, acute physiology and chronic health evaluation (APACHE) II and APACHE III scores, hospital (HLOS) and intensive care unit (ULOS) length of stay, maximal and daily multiple organ dysfunction (MOD) scores, MOD score minus cardiovascular points (MOD-CV), duration of NE infusion, and survival. The duration of NE infusion was stratified into six subsets (1, 2, 3-5, 6-10, 11-20, and > or =21 days). An age- and APACHE II and III score-matched cohort of 195 patients, in whom NE was not utilized, was identified retrospectively for comparison. The prevalence of NE use was 10.9%. NE patients developed MODS to a greater degree (11.7 +/- .3 vs. 5.9 +/- .4 points, p < .0001). NE patients had a greater degree (p < .0001) of noncardiovascular MOD as well. When stratified by survival, a greater degree of MOD occurred in both nonsurvivors and survivors of NE (both, p < .0001) compared with comparably ill patients without pressor-dependent shock. MOD scores, ULOS, and HLOS increased progressively with prolonged NE therapy (all, p < .0005), whereas mortality increased significantly only when the duration of NE infusion exceeded 10 days (p = .05). By multivariate analysis of variance (ANOVA), MOD score (p < .0001), and APACHE III (p < .01) predicted mortality, but notably the duration of NE therapy failed to attain predictive value (p = .3192). Only the MOD score was predictive of HLOS (p = .0001) and ULOS (p = .003). Daily MOD scores revealed that nonsurvivors of NE therapy were admitted to the intensive care unit with a greater degree of baseline organ dysfunction than NE survivors (7.5 +/- .4 vs. 5.1 +/- .2 for survivors, p < .0001). In addition, whereas survivors showed significant improvement by Day 5 (p < .01), MOD amongst nonsurvivors remained unchanged (p = .993). Although critically ill surgical patients requiring NE support have significantly greater degrees of organ dysfunction than patients not requiring pressors, much of the organ dysfunction is present on admission. The data contradict the notion that NE facilitates the development of MODS.

APACHE↗

PubMed2003

Increased risk associated with pulmonary artery catheterization in the medical intensive care unit.

PURPOSE: To determine whether the frequency of use of a pulmonary artery catheter (PAC) was declining over a 5-year period in a medical intensive care unit (ICU), and to assess whether mortality was higher in patients in whom a PAC was used on the day of ICU admission compared with matched controls. METHODS: Observational, retrospective, matched-set study using prospectively collected Acute Pysiology, Age and Chronic Health Evaluation (APACHE) III data during a 5-year period, from 1995 to 2000, at a 15-bed medical ICU in an academic referral center. A total of 360 patients, 202 men and 158 women, in whom a PAC was placed on the first ICU day, were compared with 690 controls without a PAC, matched by primary diagnosis group and APACHE III-predicted hospital mortality. RESULTS: A PAC was used during the first day in 7.7% of ICU admissions (yearly range, 5.7% to 9.1%) and did not change significantly during the study period. A total of 187 study patients (27.0%) without a PAC and 132 (36.7%) with a PAC died during their hospital stay. PAC use was a significant risk factor for hospital death from a univariate analysis (odds ratio = 1.5; 95% confidence interval (CI), 1.1-2.1; P =.006). From multivariate analysis, the use of a pulmonary artery catheter was a significant risk factor for hospital death after adjusting for age, date of ICU admission, and predicted hospital mortality (odds ratio = 1.5; 95% CI; 1.1-2.0; P =.016). CONCLUSION: PAC use on the day of admission to a medical ICU was associated with an increased risk for hospital death.

APACHE↗

PubMed2003

Balthazar computed tomography severity index is superior to Ranson criteria and APACHE II and III scoring systems in predicting acute pancreatitis outcome.

BACKGROUND AND GOALS: Acute pancreatitis runs an unpredictable course. We prospectively analyzed the prognostic usefulness of four different scoring systems in separately assessing three variables; acute pancreatitis severity, development of organ failure and pancreatic necrosis. STUDY: 78 patients with acute pancreatitis were studied prospectively. Data pertinent to scoring systems were recorded 24 hours (APACHE II and III scores), 48 hours (Ranson score) and 72 hours (Balthazar computed tomography severity index) after admission. Statistical analysis was performed by using receiver operating characteristic curves and by comparing likelihood ratios of positive test (LRPT) for all three outcome variables. RESULTS: 44 patients were classified as mild and 34 as severe pancreatitis. When we compared LRPT, only that for the Balthazar score (11.2157) was able to generate large and conclusive changes from pretest to post-test probability in acute pancreatitis severity prediction. LRPT were 2.4157 for Ranson, 4.0980 for APACHE II and 3.6670 for APACHE III score. The APACHE II and III scores and Ranson criteria performed slightly better than the Balthazar score in predicting organ failure (LRPT: 4.0667, 3.2892, 3.0362 and 1.7941 respectively), while when predicting pancreatic necrosis the APACHE II and III performed slightly better than the Ranson score (LRPT: 2.0769, 2.7500 and 1.7813 respectively). CONCLUSIONS: In all outcome measures the APACHE scores generate small and of similar extent changes in probability. The Balthazar score is superior to other scoring systems in predicting acute pancreatitis severity and pancreatic necrosis. However the Ranson and APACHE scores perform slightly better with respect to organ failure prediction.

APACHE↗

PubMed2005

[Efficiency of APACHE II and III scoring system in the prognostication of patients older than 75 years].

OBJECTIVE: To observe the efficiency of both the APACHE II/III scoring systems in predicting the prognosis of patients older than 75 years. METHODS: We calculated both the APACHE II and III scores in patients older than 75 years who were admitted to the geriatric intensive care unit (GICU) of our hospital in a duration of 6 months. The scores and predicting death rates were compared with the actual death rates. RESULTS: There was definite correlation between the APACHE II/III scores and the actual death rates. Sensitivity of the APACHE II/III systems are 66.7% and 41.7% respectively. Specificity of the APACHE II/III systems are 90.9% and 100% respectively. CONCLUSIONS: Both the APACHE II/III systems can do well in predicting the prognosis of ICU patients older than 75 years, but APACHE III tends to underestimate the hospital death rate of elderly patients.

APACHE↗

PubMed2005

Predictors of mortality in mechanically ventilated patients.

OBJECTIVES: There are scarce data from India validating scoring systems used to predict outcome in patients requiring mechanical ventilation. This study prospectively compared the organ system failure (OSF), the acute physiology and chronic health evaluation (APACHE) II, and the APACHE III, scores on patients requiring mechanical ventilation in the medical intensive care unit, to predict outcome. METHODS: 200 consecutive patients requiring mechanical ventilation in a medical intensive care unit were recruited. OSF, APACHE II, and APCHE III scores were calculated at admission and daily for one week or until discharge in all patients. Other variables recorded include age, sex, diagnosis, oxygen therapy before ventilation, complications on ventilation, duration in hospital before ventilation, duration of ventilation, type of respiratory failure, alveolar arterial oxygen gradient, P/F ratio, use of tracheostomy, time on ventilator before tracheostomy, muscle relaxant used, fluid balance, inotrope support. Logistic regression analysis and area under the curve were computed to determine which variables independently predict outcome. RESULTS: Of the 200 patients, at discharge 143 patients (71.5%) had died. The factors that independently predicted outcome among these patients on mechanical ventilation were the type of respiratory failure (type I) OR = 2.7 (p = 0.02), the use of inotropes OR 2.4 (p = 0.04), and the APACHE II score OR = 1.8 (p = 0.008) for every five point increase in APACHE II score. CONCLUSIONS: Type 1 respiratory failure, the use of inotropes, and the APACHE II score measured at admission are significant independent predictors of mortality in the patients on mechanical ventilation.

APACHE↗

PubMed2006

The politics of end-of-life decision-making: computerised decision-support tools, physicians' jurisdiction and morality.

With the increasing corporate and governmental rationalisation of medical care, the mandate of efficiency has caused many to fear that concern for the individual patient will be replaced with impersonal, rule-governed allocation of medical resources. Largely ignored is the role of moral principles in medical decision-making. This analysis comes from an ethnographic study conducted from 1999-2001 in three US Intensive Care Units, two of which were using the computerised decision-support tool, APACHE III (Acute Physiological and Chronic Health Evaluation III), which notably predicts the probability that a patient will die. It was found that the use of APACHE presents a paradox regarding concern for the individual patient. To maintain jurisdiction over the care of patients, physicians share the data with the payers and regulators of care to prove they are using resources effectively and efficiently, yet they use the system in conjunction with moral principles to justify treating each patient as unique. Thus, concern for the individual patient is not lessened with the use of this system. However, physicians do not share the data with patients or surrogate decision-makers because they fear they will be viewed as more interested in profits than patients.

APACHE↗

PubMed2002

Multivariate regression analysis on early mortality after orthotopic liver transplantation.

AIM: To identify the risk factors relating to early mortality after orthotopic liver transplantation. METHODS: Clinical data of 37 adult patients undergoing liver transplantation were retrospectively collected and divided into two groups: the survived group and the death group (survival time<30 d). The relationship between multivariate risk factors and early mortality after orthotopic liver transplantation were analyzed by stepwise logistic regression. RESULTS: The survival rate was 73%. Early mortality rate was 27%. APACAE III, preoperative serum creatinine level and interoperative bleeding quantity had a significant independent association with early mortality. (R=0.1841, 0.2056 and 0.3738). CONCLUSION: APACHE III,preoperative serum creatinine level and interoperative bleeding quantity are significant risk factors relating to early mortality after orthotopic liver transplantation. To improve the recipient's preoperative critical condition and renal function and to reduce interoperative bleeding quantity could lower the early mortality after orthotopic liver transplantation.

APACHE↗

PubMed1997

Scoring of severity in patients admitted to a respiratory intensive care unit.

A number of attempts have been made to develop measures of severity of illness for patients in the intensive care unit (ICU), but the impact of these indices in a Respiratory Intensive Care Unit (RICU) has not really been studied. At present, outcome can be accurately predicted in approximately 85% of ICU patients, while no data are available for the RICU. These indices will be reviewed in the article. The sophisticated Mortality Probability Model (MPM) II is used to predict the outcome of ICU patients. This technique is based on statistically-derived weights for its variables. The "most popular" indices are the Acute Physiology and Chronic Health Education (APACHE), the Simplified Acute Physiological Score (SAPS) and the Therapeutic Intervention Scoring System (TISS). Overall, the predictive accuracy of the latest APACHE III equation and score is rather good, but there are important limitations concerning its use in the RICU. The SAPS includes 17 variables, and can be considered as a simplified version of APACHE sharing with it the same problems of application. The TISS requires data on approximately 70 treatment variables and assigns each a score ranging 1-4. A high score represents serious intervention, while a low score illness requires much less medical or nursing intervention. The sum of these scores indicates severity of illness because more critical patients are presumed to require higher levels of interventions. The RICU is also characterized by the use of noninvasive mechanical ventilation (NMV) in the treatment of acute respiratory failure. Some indices able to predict the success of NMV, have been developed recently during a brief trial of NMV, and included the level of acidosis and hypercapnia.

APACHE↗