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PubMed2006

Intensive care unit length of stay: Benchmarking based on Acute Physiology and Chronic Health Evaluation (APACHE) IV.

OBJECTIVE: To revise and update the Acute Physiology and Chronic Health Evaluation (APACHE) model for predicting intensive care unit (ICU) length of stay. DESIGN: Observational cohort study. SETTING: One hundred and four ICUs in 45 U.S. hospitals. PATIENTS: Patients included 131,618 consecutive ICU admissions during 2002 and 2003, of which 116,209 met inclusion criteria. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The APACHE IV model for predicting ICU length of stay was developed using ICU day 1 patient data and a multivariate linear regression procedure to estimate the precise ICU stay for randomly selected patients who comprised 60% of the database. New variables were added to the previous APACHE III model, and advanced statistical modeling techniques were used. Accuracy was assessed by comparing mean observed and mean predicted ICU stay for the excluded 40% of patients. Aggregate mean observed ICU stay was 3.86 days and mean predicted 3.78 days (p < .001), a difference of 1.9 hrs. For 108 (93%) of 116 diagnoses, there was no significant difference between mean observed and mean predicted ICU stay. The model accounted for 21.5% of the variation in ICU stay across individual patients and 62% across ICUs. Correspondence between mean observed and mean predicted length of stay was reduced for patients with a short (< or =1.7 days) or long (> or =9.4 days) ICU stay and a low (<20%) or high (>80%) risk of death on ICU day 1. CONCLUSIONS: The APACHE IV model provides clinically useful ICU length of stay predictions for critically ill patient groups, but its accuracy and utility are limited for individual patients. APACHE IV benchmarks for ICU stay are useful for assessing the efficiency of unit throughput and support examination of structural, managerial, and patient factors that affect ICU stay.

APACHE↗

PubMed1999

Amphotericin B with and without itraconazole for invasive aspergillosis: A three-year retrospective study.

BACKGROUND: Treatment of invasive aspergillosis is frequently unsuccessful, so innovations in therapy are needed. Clinical studies demonstrate that itraconazole may be an effective alternative to amphotericin B. Itraconazole also has been combined with amphotericin B in animal models of aspergillosis, but this regimen produced antagonistic effects. OBJECTIVES: To determine the role of itraconazole in the adjunctive treatment of invasive aspergillosis. METHODS: A review was conducted of all patients with definite or probable aspergillosis from January 1995 to December 1997 who were treated with conventional amphotericin B alone or in combination with itraconazole. RESULTS: Of 21 patients, 10 received amphotericin B and 11 received the combination. The two groups of patients were comparable clinically at baseline (including similar mean APACHE III scores). Both groups received similar doses and days of amphotericin B treatment. Of the patients who received combination therapy, nine (82%) were cured or improved, and of those who received only amphotericin B, five (50%) were cured or improved. CONCLUSIONS: This study demonstrates that itraconazole and amphotericin B given together are not clinically antagonistic and that the promise of combination therapy for aspergillosis should be evaluated further in a randomized clinical trial.

APACHE↗

PubMed2006

Failure of non-invasive ventilation in patients with acute lung injury: observational cohort study.

INTRODUCTION: The role of non-invasive positive pressure ventilation (NIPPV) in the treatment of acute lung injury (ALI) is controversial. We sought to assess the outcome of ALI that was initially treated with NIPPV and to identify specific risk factors for NIPPV failure. METHODS: In this observational cohort study at the two intensive care units of a tertiary center, we identified consecutive patients with ALI who were initially treated with NIPPV. Data on demographics, APACHE III scores, degree of hypoxemia, ALI risk factors and NIPPV respiratory parameters were recorded. Univariate and multivariate regression analyses were performed to identify risk factors for NIPPV failure. RESULTS: Of 79 consecutive patients who met the inclusion criteria, 23 were excluded because of a do not resuscitate order and two did not give research authorization. Of the remaining 54 patients, 38 (70.3%) failed NIPPV, among them all 19 patients with shock. In a stepwise logistic regression restricted to patients without shock, metabolic acidosis (odds ratio 1.27, 95% confidence interval (CI) 1.03 to 0.07 per unit of base deficit) and severe hypoxemia (odds ratio 1.03, 95%CI 1.01 to 1.05 per unit decrease in ratio of arterial partial pressure of O2 and inspired O2 concentration--PaO2/FiO2) predicted NIPPV failure. In patients who failed NIPPV, the observed mortality was higher than APACHE predicted mortality (68% versus 39%, p < 0.01). CONCLUSION: NIPPV should be tried very cautiously or not at all in patients with ALI who have shock, metabolic acidosis or profound hypoxemia.

Acute Disease↗

PubMed2004

The quality of care plans for patients with do-not-resuscitate orders.

BACKGROUND: Care plans for patients with do-not-resuscitate (DNR) orders often fail to define limits other than cardiopulmonary resuscitation and fail to address other patient care needs. We studied the explicitness and comprehensiveness of care plans for patients with DNR orders and what factors were associated with this aspect of the quality of their care. METHODS: A cross-sectional study was conducted at Georgetown University Medical Center (GUMC), Washington, DC, and St Vincent Catholic Medical Centers (SVCMC), St Vincent's Hospital-Manhattan, New York, NY. Participants included 189 consecutive medical inpatients with DNR orders. RESULTS: A previously validated medical chart review technique termed concurrent care concerns (CCCs) measured whether 11 possible patient care needs had been addressed within 2 days of the DNR order. Reasons for the DNR order were documented in only 55% of cases, and a consent conversation was documented in only 69%. The mean number of total CCCs per DNR order was 1.55 (1.84 at GUMC and 1.29 at SVCMC; (P =.007). In a multivariate logistic regression analysis of low ( or=2) CCCs, patients with malignancy (P =.002), higher APACHE III (Acute Physiology and Chronic Health Evaluation III) scores (P =.007), and a documented consent conversation (P =.009) and those at Georgetown (P =.005) were more likely to have high attention to CCCs. Patients with dementia were the least likely to have high attention to CCCs. CONCLUSIONS: Documented consent conversations and care plans for patients with DNR orders are less than ideal. Care plans differ in quality by diagnosis, institution, and whether or not a consent conversation is documented. These observations might help to guide interventions that aim to improve the care of patients with DNR orders.

APACHE↗

PubMed2002

Risk factors and predictors of mortality of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia in HIV-infected patients.

OBJECTIVES: To define the incidence, risk factors and short-term predictors of mortality of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia in HIV-infected patients. PATIENTS AND METHODS: All HIV-infected subjects with S. aureus bacteraemia were consecutively enrolled in a case-control study between January 1, 1991 and December 31, 2000 and prospectively followed up. RESULTS: In the study period, 129 of 419 (31%) HIV-infected patients with bacteraemia had a diagnosis of S. aureus bacteraemia. The comparative analysis of incidence of S. aureus bacteraemia in the period 1991-96 and 1997-2000 showed a significant decrease (P < 0.001). The same trend was observed for MRSA bacteraemia (P = 0.002). The analysis of antimicrobial resistance showed that among 129 S. aureus strains, 88 (68%) were methicillin susceptible and 41 (32%) were methicillin resistant. The majority of MRSA bacteraemia was hospital acquired (78%). Previous administration of beta-lactams (P < 0.001), multiple previous hospital admissions (P < 0.001) and low numbers of CD4+ peripheral cells (P < 0.001) were found to be independent risk factors of methicillin resistance at multivariate analysis. The mortality rate was 34% in the cases and 11% in the controls (P = 0.002). Multivariate analysis indicated that a high Acute Physiology and Chronic Health Evaluation (APACHE) III score (P < 0.001) and high HIV viraemia (P = 0.02), but not methicillin resistance, predicted an increased risk of death in patients with S. aureus bacteraemia. CONCLUSION: Individual exposure to beta-lactams, in association with a history of multiple hospitalizations and low CD4+ cell number, plays a pivotal role as a risk factor for the development of methicillin resistance in HIV-infected patients. Methicillin resistance does not influence the outcome of S. aureus bacteraemia when included in a multivariate analysis.

APACHE↗

PubMed2002

Comparison of predictive accuracy among six prognosis prediction systems for patient mortality in intensive care units.

BACKGROUND AND PURPOSE: This study compared the goodness-of-fit of six prognostic prediction systems. METHODS: A total of 1,170 patients in the medical and surgical intensive care units of a public tertiary care hospital were included in this study. Data from the Acute Physiology and Chronic Health Evaluation (APACHE) II, APACHE III, Simplified Acute Physiology Score II (SAPS II), Condition Index Score (CIS), and Mortality Probability Models II (MPM II; at admission MPM IIadm and 24-hours later MPM II24 h) prediction systems were collected. The scores or death-risks from these systems were compared between survivors and non-survivors. Lemeshow-Hosmer (LH) statistics, calibration curve, classification matrix, and receiver operating characteristic (ROC) curve for the whole study group were determined. Mortality ratio, LH statistics, and ROC curve for individual disease categories and operative states were compared. A model with good fit was defined as having an LH chi-square value close to the degrees of freedom and yielding a corresponding p value of greater than 0.05, conformation to the ideal calibration diagonal (low deviation value), high classification matrix overall accuracy, a large area under the ROC curve (> 0.8), and a mortality ratio close to 1. RESULTS: LH chi-square value was 12.37 for APACHE II and 8.61 for MPM II24 h. The calibration curve deviation value was 1.5069 for APACHE II and 1.4308 for MPM II24 h. Classification matrix overall accuracy was 78.88% for APACHE II and 79.54% for MPM II24 h. The area under the ROC curve was 0.779 for APACHE II and 0.790 for MPM II24 h. The mortality ratios of trauma were 1.00 for both APACHE II and MPM IIadm. The mortality ratios for respiratory diseases and rare diseases were both 1.02 for MPM II24 h. The other systems studied did not provide good-fit data. CONCLUSION: In this study, MPM II or APACHE II had the best predictive model of the tested systems for critically ill patients.

APACHE↗

PubMed2000

Factors predicting survival for HIV-infected patients with respiratory failure.

BACKGROUND: Despite improved treatment modalities, the mortality of HIV infected patients admitted to the intensive care unit with respiratory failure remains high. To help ICU physicians in advising HIV infected patients whether to undergo mechanical ventilation, we retrospectively investigated prognostic factors predicting hospital outcome for HIV-infected patients, admitted to a medical intensive care unit with respiratory failure before the era of highly-active anti-retroviral therapy. METHODS: A retrospective chart review was carried out of all HIV-infected patients with respiratory failure admitted to the medical ICU of a Dutch University Hospital between 1991 and 1997. RESULTS: In the six year period, 29 HIV-infected patients were admitted to the ICU for respiratory failure. Mechanical ventilation, CD4 cell count, APACHE II score, APACHE III score, ARDS and length of ICU stay all differed significantly between survivors and non-survivors. However, a multivariate analysis only showed the need for mechanical ventilation as an independent risk factor for mortality. The only combination of factors able to accurately predict mortality for the individual patient was the development of ARDS and the requirement of mechanical ventilation. CONCLUSIONS: The combination of mechanical ventilation and ARDS accurately predicts hospital outcome in HIV-infected patients presenting with respiratory failure before the HAART era.

AIDS-Related Opportunistic Infections↗

PubMed2003

Relationships of circulating nitrite/nitrate levels to severity and multiple organ dysfunction syndrome in systemic inflammatory response syndrome.

Excessive nitric oxide (NO) production has been implicated to be responsible for the development of septic shock. To determine whether plasma nitrite/nitrate (NOx) levels are related to the severity of systemic inflammatory response syndrome (SIRS) and the degree of multiple organ dysfunction, we studied plasma NOx levels in 70 patients with SIRS consisting of noninfectious SIRS (n = 32), sepsis (n = 23), and septic shock (n = 15). Infection is a microbial phenomenon characterized by an inflammatory response to the presence of microorganism. Positive culture for microorganism is regarded as infectious SIRS (sepsis and septic shock) and negative culture is regarded as noninfectious SIRS. Plasma samples collected from each patient within 24 h from admission to the intensive care unit were subjected for measurement of NOx levels, the stable end products of NO, by the high performance liquid chromatography-Greiss system. Mean plasma NOx levels in patients with SIRS were 52.8 +/- 44 microM/L, ranging from 8.1 to 186.2 microM/L. Plasma NOx levels were positively correlated with Acute Physiology, Age, and Chronic Health Evaluation (APACHE) III score (r = 0.414, P < 0.01) and sequential organ failure assessment (SOFA) score (r = 0.433, P < 0.01). Plasma NOx levels in patients with sepsis (51.0 +/- 38.5 microM/L) and septic shock (94.5 +/- 53.7 microM/L) were significantly (P < 0.01) higher than those in patients with noninfectious SIRS (25.8 +/- 16.9 microM/L) and healthy subjects (29.6 +/- 8.9 microM/L). Our study shows that plasma NOx levels are increased in patients with infectious, but not noninfectious SIRS, which increase as the severity of SIRS and the development of multiple organ dysfunction syndrome, suggesting its possible pathogenic role in SIRS.

APACHE↗

PubMed2003

[Quality of inpatient care and risk of early readmission in acute exacerbation of COPD].

BACKGROUND: Chronic Obstructive Pulmonary Disease (COPD) is one of the diseases that causes more readmissions in our hospitals. The objective of our study was to establish the influence of quality of inpatient care on the risk of early readmission in the acute exacerbation of COPD. MATERIAL AND METHODS DESIGN: case and controls study. SETTING: general acute care hospital. SUBJECTS OF STUDY: random sample of admissions with acute exacerbation of COPD and discharged alive. CASES: patients who were readmitted within 30 days with a related diagnosis. CONTROLS: patients who were not readmitted and finished alive the mentioned period. INTERVENTIONS: audit of clinical charts with evaluation of clinical severity and adherence to explicit criteria of quality of inpatient care in OCFA. Bivariate and multivariate logistic regression (LR) analysis. RESULTS: 45 cases and 45 controls were analyzed. LR model detected the risk of readmission within 1 month was explained by the higher severity of patients (Apache III: OR 1,03) and their principal diagnosis(emphysema: OR 6,9 and bronchiectasias: OR 2,2, respect to chronic bronchitis). The less score of quality of care scale was predictive of the risk of readmission in the subgroup of patients who were readmitted within 1 week (OR 0,9). CONCLUSIONS: Risk of readmission within 1 month in the acute exacerbation of COPD were explained mainly by the clinical characteristics of patients. Otherwise, readmissions within 1 week were related to quality of care, so it could be a valid indicator of quality of inpatient care.

APACHE↗

PubMed2004

Correlation of glomerular permeability, endothelial injury, and postoperative multiple organ dysfunction.

PURPOSE: To determine whether the degree of microalbuminuria correlates with the extent of endothelial cell injury, the severity of illness, and the magnitude of multiple organ dysfunction in patients who undergo emergency surgery. METHODS: We measured the urinary albumin : creatinine ratio (ACR) within 24 h after surgery in 31 patients and examined its relationship with various clinical measurements. RESULTS: The ACR increased during the first 24 h postoperatively. The log ACR correlated with the serum thrombomodulin concentration measured on the same day, but not with the level of plasma von Willebrand factor antigen. The increase in the log ACR correlated with the acute physiology and chronic health evaluation score (APACHE III), the simplified acute physiology score, the multiple organ dysfunction score, and the score of sequential organ failure assessment (SOFA) calculated on the same day, and the blood volume lost during the operation. The log ACR did not correlate with the white blood cell count or the serum C-reactive protein measured at the same time. The log ACR correlated with SOFA on postoperative days 3, 7, and 10, and mortality increased in accordance with the increase in log ACR. CONCLUSIONS: The urinary ACR correlated with the extent of endothelial cell injury, the severity of illness, and the magnitude of multiple organ dysfunction.

APACHE↗

PubMed1997

Treatment of severe systemic inflammatory response syndrome and sepsis with a novel bradykinin antagonist, deltibant (CP-0127). Results of a randomized, double-blind, placebo-controlled trial. CP-0127 SIRS and Sepsis Study Group.

OBJECTIVE: To test the effect of a novel bradykinin antagonist, deltibant (CP-0127), on survival, organ dysfunction, and other outcomes in patients with the systemic inflammatory response syndrome (SIRS) and presumed sepsis. DESIGN: Multicenter, randomized, placebo-controlled, double-blind, parallel, dose-ranging trial. Follow-up for 28 days or until death. SETTING: A total of 47 US referral hospitals. PATIENTS: A total of 504 patients with SIRS and documented evidence of infection plus either hypotension or dysfunction of 2 organ systems. INTERVENTIONS: Three-day continuous intravenous infusion of either placebo or 1 of 3 doses (0.3, 1.0, or 3.0 microg x kg(-1) x min(-1)) of deltibant. Concurrent therapy at the discretion of the treating physician. MAIN OUTCOME MEASURE: Risk-adjusted, 28-day, log-normal intent-to-treat survival analysis. Risk adjustment was performed using a study-specific risk model derived from the APACHE III database. RESULTS: Deltibant had no significant effect on risk-adjusted 28-day survival. In a posthoc analysis, risk-adjusted 7-day survival showed a nonsignificant trend toward improvement (P=.09). The 28-day risk-adjusted survival in the prospectively defined subset of patients with gram-negative infections showed a statistically significant improvement (P=.005). CONCLUSIONS: Deltibant may have some effect on survival in patients with SIRS and gram-negative sepsis; however, additional studies would be required to prove this.

APACHE↗

PubMed2000

Correlation between physiological assessment and outcome after liver transplantation.

BACKGROUND: Critical shortages of organ donors for transplantation require appropriate utilization of this scarce resource. The purpose of this study was to assess whether use of physiological parameters of preliver transplant recipients is helpful in determining eventual outcome. METHODS: Between October 1989 and June 1999, 215 liver transplants were performed on 199 patients at the Vancouver Hospital nad Health Sciences Centre. Thirty-one patients undergoing transplantation between May 1993 and June 1994 were retrospectively evaluated to obtain a minimum 5-year follow-up. Variables examined included pretransplant activation status (status 1, at home; status 2, hospitalized; status 3, admitted to intensive care; status 4, mechanical ventilation), simplified acute physiological score (SAPS), Acute Physiology, Age, and Chronic Health Evaluation (APACHE) II, and APACHE III scores at the time of transplantation. The scores were correlated to posttransplant mortality and functional outcome. RESULTS: The 5-year mortality for status 1 patients was 14.3% versus 30% for patients listed as status 2 or greater (P = not significant). There were no significant differences in any of the physiological scoring assessments with regard to posttransplant mortality or functional assessment. Of the surviving patients, 18 of 22 who were employed, in school, or active at home pretransplant returned to their pretransplant activity. CONCLUSIONS: Detailed physiological scoring systems are no more accurate in predicting outcome after liver transplant than current listing status parameters.

APACHE↗

PubMedDate not supplied

Role of angiography and embolization for massive gastroduodenal hemorrhage.

The role of mesenteric angiography and embolization for massive gastroduodenal bleeding is unclear. We reviewed the records of patients who underwent angiography for acute, nonmalignant, and nonvariceal gastric or duodenal hemorrhage that was documented but not controlled by endoscopy. Fifty patients were identified over a 7-year period ending in March 1998. Only 17 patients (34%) were originally admitted to the hospital with gastrointestinal bleeding. All required treatment in the intensive care unit (mean 15 days) with a mean APACHE III score of 79 (29% predicted hospital mortality), and 32 (64%) had organ failure. A mean of 2.1 endoscopies were performed to locate the source of acute duodenal bleeding in 37 (74%) and gastric bleeding in 13 (26%). An average of 24.3 units of packed red blood cells were transfused per patient. Twenty-five patients (50%) were found to have active bleeding at angiography; all were treated by embolization as were 22 who underwent empiric embolization. Twenty-six patients (52%) were successfully treated by embolization and thus spared imminent surgery. Multiple variables were compared between those who were successfully treated by embolization and those considered failures. Time to angiography was considerably shorter (2.5 vs. 5.8 days, P<0. 017) and fewer total units of packed red blood cells were used (14.6 vs. 34, P<0.003) in those who were successfully treated. There was also a strong trend toward using fewer units of packed red blood cells for transfusion prior to angiography (11.2 vs. 17.1, P<0.08). No differences were found that could be attributed to gastric vs. duodenal sources, number of comorbid diseases, organ failure, APACHE score, age, or whether active bleeding was found at angiography. A total of 20 patients (40%) died including 9 of 17 patients operated on in an attempt to salvage angiographic failure. In summary, angiographic embolization should be performed early in the course of bleeding in otherwise critically ill patients.

APACHE↗

PubMed1996

Ventilator-associated pneumonia due to Pseudomonas aeruginosa.

OBJECTIVE: Ventilator-associated pneumonia (VAP) caused by Pseudomonas aeruginosa has been associated with higher case fatality rates than VAP caused by other bacterial etiologies. The causes of this excess mortality are unclear. DESIGN: Retrospective review of 38 consecutive ventilated patients with Pseudomonas pneumonia, documented by highly reliable methods. Charts of five additional patients were unavailable for review. SETTING: Medical ICUs of a university-affiliated Veterans Affairs Medical Center and a university-affiliated municipal hospital. MEASUREMENTS: Prospectively collected hospital admission acute physiologic and chronic health examination (APACHE) II scores and cause of ICU admission. Retrospectively calculated organ failure and APACHE scores, VAP score. Clinical and microbiologic variables. Antibiotic treatment and outcome. Direct cause of death by standard definitions. RESULTS: Overall mortality was 69% (26/38), significantly higher than the APACHE II predicted mortality of 42.6% (p=0.037). At least 38% (10/26) of deaths were directly attributable to Pseudomonas VAP. Multivariate analysis of factors associated with death found infectious cause for ICU admission (odds ratio [OR]=8.67; 95% confidence interval [CI], 0.86 to 85.94) and number of organ dysfunctions on the day of diagnosis (OR=1.73, 95% CI, 1.02 to 2.92) were significant. Septic shock from Pseudomonas VAP, septic shock from subsequent infection, and multiple organ dysfunction syndrome were the most common immediate causes of death. Mortality increased linearly with increasing APACHE III score on the day of diagnosis. Of initial antibiotic regimens, 67% (26/36) were considered failures. Persistent pneumonia occurred in 35% of patients while recurrent pneumonia was unusual (1/38). CONCLUSIONS: Development of Pseudomonas pneumonia results in a mortality rate in excess of that due to the presenting illness. The attributable mortality determined by several means appears to approach 40%. The excess mortality appears to be related to the host defense response to the pneumonia rather than any characteristic of the pneumonia. Even standard antibiotic regimens fail frequently and do not prevent the excess mortality. Since at least 38% of deaths can be directly attributable to the Pseudomonas pneumonia, improvement in therapy is needed.

APACHE↗

PubMed2004

Open abdomen management of intra-abdominal sepsis.

Despite surgical advances, antimicrobial therapy, and intensive care, the morbidity and mortality of intra-abdominal sepsis remains high. The primary purpose of this study was to determine whether open abdomen management of intra-abdominal sepsis reduces intensive care unit (ICU) and hospital mortality. The records of 81 consecutive patients with open abdomen management for intra-abdominal sepsis admitted to the surgical ICU from January 1998 to April 2002 were retrospectively reviewed. Outcomes were compared to a historical control group with primary abdominal closure, also admitted to the surgical ICU with intra-abdominal sepsis and matched for sex, age, source of sepsis, and APACHE III score. ICU mortality for the open abdomen group was 25 per cent versus 17 per cent for the control group. Hospital mortality was 33 per cent and 25 per cent for the open abdomen patients and historical controls, respectively. Both ICU and hospital length of stay were significantly longer for the open abdomen group. An overall fistula rate of 14.8 per cent was demonstrated in the open abdomen patients. A significant difference in overall ICU and hospital mortality was not demonstrated between patients treated with open abdomen management and historical controls. A prospective randomized study accounting for extent of sepsis may define a role for open abdomen management in selected subgroups of patients.

APACHE↗

PubMed2006

Drug utilization pattern in the intensive care unit of a tertiary care hospital.

The authors studied the factors affecting drug use pattern, cost of therapy, and the association between the pattern of drug use and survival as well as the duration of stay in a prospective, observational study in an intensive care unit between February and May 2005. Data were collected regarding drugs used, severity of the disease, and their outcome. The mean +/- SD of the Acute Physiology and Chronic Health Evaluation (APACHE III) and Glasgow Coma Scale (GCS) scores of 84 patients were 52.2 +/- 19.4 and 7.5 +/- 2.4, respectively. Although the mean number of drugs at the time of admission to the intensive care unit was 5.3, it increased to 12.9 on the first day and 22.2 during the entire stay. More than 50% of the average expenditure on drugs and nutrition was accounted by antibiotics. Requirement of insulin or inotropes signified an adverse outcome on mortality (odds ratios of 3.43 and 8.44, respectively). In conclusion, there is a tremendous impact of antibiotic use on the cost of therapy in the intensive care unit. The requirement of certain drugs such as insulin and inotropes is of prognostic significance.

APACHE↗

PubMed1996

[Results of critical care management of patients after bone marrow transplantation].

In a retrospective study we investigated the clinical course of patients who required intensive care support after bone marrow transplantation. Out of 25 patients only 5 (20%) survived treatment in the intensive care unit (ICU) and this group showed a significantly lower age, lower APACHE III and organ-failure scores and higher serum albumin values, as well as a longer interval between bone marrow transplantation and admission to intensive care. However, no patient requiring mechanical ventilation primarily for pneumonia or other infections arising as a complication of bone marrow transplantation survived intensive care. All patients requiring ventilation for more than 24 hours died in hospital. Of the 5 patients surviving ICU treatment only 3 were eventually discharged from hospital and only one single patient was alive after 6 months. Hence, current intensive care management appears to be indicated in only a small group of patients after bone marrow transplantation.

APACHE↗

PubMed2006

Recalibration of risk prediction models in a large multicenter cohort of admissions to adult, general critical care units in the United Kingdom.

OBJECTIVE: To assess the performance of published risk prediction models in common use in adult critical care in the United Kingdom and to recalibrate these models in a large representative database of critical care admissions. DESIGN: Prospective cohort study. SETTING: A total of 163 adult general critical care units in England, Wales, and Northern Ireland, during the period of December 1995 to August 2003. PATIENTS: A total of 231,930 admissions, of which 141,106 met inclusion criteria and had sufficient data recorded for all risk prediction models. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The published versions of the Acute Physiology and Chronic Health Evaluation (APACHE) II, APACHE II UK, APACHE III, Simplified Acute Physiology Score (SAPS) II, and Mortality Probability Models (MPM) II were evaluated for discrimination and calibration by means of a combination of appropriate statistical measures recommended by an expert steering committee. All models showed good discrimination (the c index varied from 0.803 to 0.832) but imperfect calibration. Recalibration of the models, which was performed by both the Cox method and re-estimating coefficients, led to improved discrimination and calibration, although all models still showed significant departures from perfect calibration. CONCLUSIONS: Risk prediction models developed in another country require validation and recalibration before being used to provide risk-adjusted outcomes within a new country setting. Periodic reassessment is beneficial to ensure calibration is maintained.

APACHE↗