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PubMed2003

Comparison of family stresses, strengths, and outcomes after trauma and surgery.

This study aimed to compare family stresses, strengths, and outcomes after motor vehicle crashes, gunshot wounds, and coronary artery bypass graft surgery. A multivariate descriptive design based on the resiliency model of family stress was used. A convenience sample of 127 family members participated within 2 days of admission to the intensive care unit. Family stresses were measured using the Family Inventory of Life Events and the Acute Physiology, Age, and Chronic Health Evaluation Scale (APACHE III). Family strengths were measured by the Family Hardiness Index and the Family Crisis Oriented Personal Evaluation Scale. Family outcomes were measured by the Family Member Well-Being Index and the Family Adaptation Scale. Family members ranged in age from 18 to 80 years (Mean, 42 years). Most of the participants in the study were women (64%) with previous intensive care unit experience (83%). The patients ranged in age from 19 to 78 years (Mean, 44 years). Multivariate analysis of variance was used to control for group differences in family member age, education, and income along with patient age and race. The results indicated that family members of patients who have experienced motor vehicle crashes, gunshot wounds, or coronary artery bypass graft surgery reported no significant differences in family strengths of hardiness and family outcomes of well-being and adaptation. However, families of patients with gunshot wounds reported significantly more stress (F = 7.94; P< 0.01) and less use of coping strategies (F = 4.33; P< 0.01) than families of patients who have experienced motor vehicle crashes or coronary artery bypass graft surgery. Interventions that address family stress and develop or mobilize coping are needed for selected families after admission of a family member to the intensive care unit.

Accidents, Traffic↗

PubMed2003

A prospective multicenter study of Staphylococcus aureus bacteremia: incidence of endocarditis, risk factors for mortality, and clinical impact of methicillin resistance.

Our objectives were to determine the incidence of endocarditis in patients whose Staphylococcus aureus bacteremia was community-acquired, related to hemodialysis, or hospital-acquired; to assess clinical factors that would reliably distinguished between S. aureus bacteremia and S. aureus endocarditis; to assess the emergence of methicillin-resistant S. aureus (MRSA) as a cause of endocarditis; and to examine risk factors for mortality in patients with S. aureus endocarditis. We conducted a prospective observational study in 6 university teaching hospitals; we evaluated 505 consecutive patients with Staphylococcus aureus bacteremia. Thirteen percent of patients with S. aureus bacteremia were found to have endocarditis, including 21% with community-acquired S. aureus bacteremia, 5% with hospital-acquired bacteremia, and 12% on hemodialysis. Infection was due to MRSA in 31%. Factors predictive of endocarditis included underlying valvular heart disease, history of prior endocarditis, intravenous drug use, community acquisition of bacteremia, and an unrecognized source. Twelve patients with bacteremia had a prosthetic valve; 17% developed endocarditis. Unexpectedly, nonwhite race proved to be an independent risk factor for endocarditis by both univariate and multivariate analyses. Persistent bacteremia (positive blood cultures at day 3 of appropriate therapy) was identified as an independent risk factor for both endocarditis and mortality, a unique observation not reported in other prospective studies of S. aureus bacteremia. Patients with endocarditis due to MRSA were significantly more likely to have complicating renal insufficiency and to experience persistent bacteremia than those with endocarditis due to MSSA. The 30-day mortality was 31% among patients with endocarditis compared to 21% in patients who had bacteremia without endocarditis (p = 0.055). Risk factors for death due to endocarditis included severity of illness at onset of bacteremia (as measured by Apache III and Pitt bacteremia score), MRSA infection, and presence of atrioventricular block on electrocardiogram. Patients with S. aureus bacteremia who have community acquisition of infection, underlying valvular heart disease, intravenous drug use, unknown portal of entry, history of prior endocarditis, and possibly, nonwhite race should undergo echocardiography to screen for the presence of endocarditis. We recommend that blood cultures be repeated 3 days following initiation of antistaphylococcal antibiotic therapy in all patients with S. aureus bacteremia. Positive blood cultures at 3 days may prove to be a useful marker in promoting more aggressive management, including more potent antibiotic therapy and surgical resection of the valve in endocarditis cases. MRSA as the infecting organism should be added to the list of risk factors for consideration of valvular resection in cases of endocarditis.

Bacteremia↗

PubMed2003

Factors associated with the time nurses spend at the bedsides of seriously ill patients with poor prognoses.

BACKGROUND: Little is known about the time health professionals spend with inpatients that are close to the end of life. SUBJECTS AND METHODS: We asked day-shift nurses to use a standardized log sheet to record how much time they spent in various categories of activity for 146 seriously ill medical inpatients with poor prognoses at 2 teaching hospitals. RESULTS: The mean patient age was 68, and the mean APACHE-III physiology score 28; 59% were white, 56% were women, 41% had cancer or HIV, and 81% had do not resuscitate (DNR) orders. The mean amount of time nurses spent with patients per 12-hour day shift was 53 min. In bivariate analyses, sex, religion, diagnosis and insurance status were not associated with nursing bedside time. In an ANOVA model, patients with DNR orders received more time than those without DNR orders (56 vs. 39 min, P = 0.04), and white patients received more bedside time than nonwhites (57 vs. 46 min, P = 0.01), even after controlling for severity of illness and DNR status. Among the 47 mentally alert patients who could be interviewed, symptom severity, quality of care, and satisfaction ratings were not associated with nursing bedside time. CONCLUSIONS: In this population, nurses spent less time with nonwhite patients and more time with patients with DNR orders. That patients with DNR orders received more time may be reassuring. However, further investigation will be required to confirm these results, to understand why nonwhite patients appear to have received less bedside nursing time, and to investigate further the relationship between time, satisfaction, and quality of care.

Age Factors↗

PubMed2006

Sex differences in creation of do-not-resuscitate orders for critically ill elderly patients following emergency surgery.

BACKGROUND: Emergency surgery patients are older, often critically ill, and at high risk of morbidity and mortality. We studied factors associated with issuance of a do-not-resuscitate (DNR) order and impact on morbidity and mortality in emergency surgery patients. METHODS: Prospective study of all patients since January 1, 2000 who underwent emergency surgery before admission to the intensive care unit. Data collected were: age, sex, admission diagnosis (case-mix), raw- (AIII) and age-adjusted (aAIII) APACHE III scores, issuance of a DNR order, and morbidity and mortality. Primary outcomes were DNR status and morbidity and mortality. Groups were stratified by age (patients >75 years versus younger) and sex. Statistics were calculated by chi(2) test, analysis of variance, and logistic regression. RESULTS: In all, 723 emergency surgery patients (gastrointestinal: 35%; traumatic: 20%; neurologic: 17%) met study criteria and had morbidity and mortality of 17.8% (AIII-predicted: 31%). Ninety-two patients (12%) were made DNR, of whom 82.6% died. Women received DNR status more often (16.4% versus 9.5%, p < 0.01) but morbidity and mortality was the same for women and men (18.2% versus 17.5%, p = 0.85). By logistic regression, sex most predicted new DNR status (odds ratio [OR] 2.512, p = 0.005) compared with Multiple Organ Dysfunction score (OR 1.410, p < 0.0001), Age (OR 1.054, p < 0.0001) and aAIII (OR 0.995, 0.355), with goodness of fit of 3.876 (p = 0.868) and Nagelkerke R(2) of 0.511. Percent correct was 88.9, implying good discrimination. CONCLUSIONS: Female sex and, to a lesser extent, age were associated with issuance of DNR in series of patients who received emergency surgery. The association of DNR with female sex is an unexpected finding and may indicate clinician bias and necessitate the performance of further analysis.

Age Factors↗

PubMed1995

Lignocaine metabolite formation: an indicator for liver dysfunction and predictor of survival in surgical intensive care patients.

Formation of the lignocaine metabolite monoethyl-glycine-xylidide (MEGX) by hepatic cytochrome P450 enzymes is a new method for evaluating liver function. The purpose of this study was to compare MEGX formation with other liver function parameters in surgical intensive care unit patients. The study include 29 critically ill patients who had been admitted to the unit for more than 3 days with a median APACHE III score-predicted mortality > 30%. On day 4, lignocaine was given intravenously at a dose of 1 mg.kg-1 over 2 min and MEGX formation was measured 15 min later. Eighty-nine percent of the patients had MEGX values below 90 micrograms.l-1 indicating impaired liver function. Eleven patients died, 18 patients survived. The group of patients with fatal outcome had significantly lower MEGX values (median: 23 micrograms.l-1) than the group of survivors (median: 53 micrograms.l-1, p < 0.01). Bilirubin values were elevated in the non-survivor group (median: 2.8 mg.dl-1) compared to the survivors (median: 0.9 mg.dl-1, p < 0.05). There was no significant difference between two groups in the other liver function tests. We conclude from our results that the MEGX test can be considered an indicator for hepatic dysfunction and predictor of survival in critically ill patients.

Aged↗

PubMed2000

Prediction of survival for older hospitalized patients: the HELP survival model. Hospitalized Elderly Longitudinal Project.

OBJECTIVE: To develop and validate a model estimating the survival time of hospitalized persons aged 80 years and older. DESIGN: A prospective cohort study with mortality follow-up using the National Death Index. SETTING: Four teaching hospitals in the US. PARTICIPANTS: Hospitalized patients enrolled between January 1993 and November 1994 in the Hospitalized Elderly Longitudinal Project (HELP). Patients were excluded if their length of hospital stay was 48 hours or less or if admitted electively for planned surgery. MEASUREMENTS: A log-normal model of survival time up to 711 days was developed with the following variables: patient demographics, disease category, nursing home residence, severity of physiologic imbalance, chart documentation of weight loss, current quality of life, exercise capacity, and functional status. We assessed whether model accuracy could be improved by including symptoms of depression or history of recent fall, serum albumin, physician's subjective estimate of prognosis, and physician and patient preferences for general approach to care. RESULTS: A total of 1266 patients were enrolled over a 10-month period, (median age 84.9, 61% female, 68% with one or more dependency), and 505 (40%) died during an average follow-up of more than 2 years. Important prognostic factors included the Acute Physiology Score of APACHE III collected on the third hospital day, modified Glasgow coma score, major diagnosis (ICU categories together, congestive heart failure, cancer, orthopedic, and all other), age, activities of daily living, exercise capacity, chart documentation of weight loss, and global quality of life. The Somers' Dxy for a model including these factors was 0.48 (equivalent to a receiver-operator curve (ROC) area of 0.74, suggesting good discrimination). Bootstrap estimation indicated good model validation (corrected Dxy of 0.46, ROC of 0.73). A nomogram based on this log-normal model is presented to facilitate calculation of median survival time and 10th and 90th percentile of survival time. A count of geriatric syndromes or comorbidities did not add explanatory power to the model, nor did the hospital of patient recruitment, depression, or the patient preferences for general approach to care. The physician's perception of the patient's preferences and the physician's subjective estimate of the patient's prognosis improved the estimate of survival time significantly. CONCLUSIONS: Accurate estimation of length of life for older hospitalized persons may be calculated using a limited amount of clinical information available from the medical chart plus a brief interview with the patient or surrogate. The accuracy of this model can be improved by including measures of the physician's perception of the patient's preferences for care and the physician's subjective estimate of prognosis.

Activities of Daily Living↗

PubMed2005

Extracorporal liver support with molecular adsorbents recirculating system in patients with hepatitis B-associated fulminant hepatic failure.

Hepatitis B virus (HBV) infection is the most prevalent cause of fulminant hepatic failure (FHF) in the Far East. HBV-associated FHF is characterised by rapidly progressive end organ dysfunction/failure and a very poor prognosis. To investigate how molecular adsorbent recirculating system (MARS) treatment impacts multiple organ system function in HBV-associated FHF. Ten consecutive patients were treated with MARS in a period of 12 months. Clinical, biochemical and haemodynamic parameters were assessed before and after MARS. Various disease severity scoring systems including model for end-stage liver disease, APACHE II, APACHE III, sequential organ failure assessment and organ system failure scores were also assessed. There were significant improvements in hepatic encephalopathy grading (p < 0.001), mean arterial pressure (p < 0.001), plasma renin activity (p = 0.027), bilirubin (p < 0.001), ammonia (p = 0.001) and creatinine levels (p < 0.001). There were also significant improvements in all the scoring systems evaluated. Meanwhile, platelet count was significantly decreased (p < 0.001). One patient was successfully bridged to liver transplantation. Three patients were alive at 3 months of follow-up. MARS can improve multiple organ functions in HBV-associated FHF. On the basis of these findings, randomised controlled studies are indicated and justified.

Adult↗

PubMed2003

Plasma surfactant protein levels and clinical outcomes in patients with acute lung injury.

BACKGROUND: Because injury to the alveolar epithelial barrier is a characteristic feature of acute lung injury (ALI) and the acute respiratory distress syndrome (ARDS), plasma surfactant protein levels may have prognostic value. To test this hypothesis plasma surfactant proteins A and D (SP-A and SP-D) levels were measured in patients with ALI or ARDS enrolled in the NHLBI sponsored multicentre ARDS Network randomised controlled trial of a 6 ml/kg v 12 ml/kg tidal volume strategy. METHODS: Data from 565 participants in the clinical trial were used. Plasma levels of SP-A and SP-D were measured at baseline and on day 3 after the start of the mechanical ventilation protocol. The longitudinal impact of baseline plasma surfactant protein levels on clinical outcomes was examined by multivariate analysis, controlling for mechanical ventilation group, APACHE III score, and other clinical covariates. The effect of 6 ml/kg tidal volume ventilation on plasma SP-A and SP-D levels was evaluated using analysis of covariance. RESULTS: Baseline plasma SP-A levels were not related to any clinical outcome. In contrast, higher baseline plasma SP-D levels were associated with a greater risk of death (OR 1.21 per 100 ng/ml increment; 95% CI 1.08 to 1.35), fewer ventilator-free days (mean decrease -0.88 days; p=0.001), and fewer organ failure-free days (mean decrease -1.06 days; p<0.0001). The 6 ml/kg tidal volume strategy had no effect on the rise in plasma SP-A levels (p=0.91) but attenuated the rise in plasma SP-D levels (p=0.0006). CONCLUSIONS: Early in the course of ALI/ARDS an increased level of plasma SP-D is associated with a worse clinical outcome. The 6 ml/kg tidal volume strategy attenuated the rise of SP-D early in the clinical course. Taken together, these observations indicate that plasma SP-D, a product of alveolar type II cells, is a valuable biomarker in ALI/ARDS.

Enzyme-Linked Immunosorbent Assay↗

PubMed2005

Vascular endothelial growth factor gene polymorphism and acute respiratory distress syndrome.

BACKGROUND: Non-cardiogenic pulmonary oedema is a characteristic feature of the acute respiratory distress syndrome (ARDS). The properties of vascular endothelial growth factor (VEGF) as a potent vascular permogen and mitogen have led to investigation of its potential role in this condition. Lower VEGF plasma levels have been linked to the presence of the T allele in the +936 CT polymorphism. We hypothesised that the presence of the T allele would be associated with the development and severity of ARDS. METHODS: A cohort of 137 normal subjects, 117 ventilated patients with ARDS, and 103 "at risk" of ARDS were genotyped for the VEGF+936 CT polymorphism. The severity of physiological disturbance and mortality was determined in the ventilated cohorts. RESULTS: The CT and TT genotype frequencies were increased in ARDS patients compared with both normal subjects (OR 2.01, 95% CI 1.13 to 3.58, p = 0.02) and those "at risk" (OR 2.05, 95% CI 1.02 to 2.20, p = 0.03). In patients with ARDS but not those "at risk", CT and TT genotypes were associated with a higher mean APACHE III score (80.9 (4.3) v 69.3 (2.9), p<0.05). CONCLUSION: These data support a role for VEGF in the pathogenesis of ARDS and its associated physiological derangement.

Cohort Studies↗

PubMed2006

Prognosis in critical care.

Prognostic risk prediction models have been employed in the intensive care unit (ICU) setting since the 1980s and provide health care providers with important information to help inform decisions related to treatment and prognosis, as well as to compare outcomes across institutions. Prognostic models for critical care are among the most widely utilized and tested predictive models in healthcare. In this article, we review and compare mortality prediction models, including the APACHE (1981), SAPS (1984), APACHE-II (1985), MPM (1987), APACHE-III (1991), SAPS-II (1993), and MPM-II (1993). We emphasize the importance of model calibration in this domain. In addition, we present a brief review of the statistical methodology, multiple logistic regression, which underlies most of the models currently used in critical care.

Artificial Intelligence↗

PubMedDate not supplied

Achievement of steady state optimizes results when performing indirect calorimetry.

BACKGROUND: The use of steady state as the endpoint for performance of indirect calorimetry (IC) is controversial. We designed this prospective study to evaluate the necessity and significance of achieving steady state. METHODS: Patients with respiratory failure placed on mechanical ventilation in a short- or long-term acute care unit at any 1 of 3 university-based urban hospitals were eligible for the study. The 24-hour total energy expenditure (TEE) was determined by a Nellcor Puritan Bennett 7250 continuous IC monitor. Measured gas exchange parameters were obtained and averaged every 1 minute for the initial hour and then every 15 minutes for the next 23 hours. Over the initial hour, resting energy expenditure (REE) was averaged for intervals over the first 20, 30, 40, and 60 minutes, and for various definitions of steady state where oxygen consumption (VO2) and carbon dioxide production (VCO2) changed by <10%, 15%, and 20%. Coefficient of variation (CV) was calculated for VO2 over the first 30 minutes of study. RESULTS: Twenty-two patients (mean age, 52.8 years, 59% male, mean Acute Physiology and Chronic Health Evaluation (APACHE III) score 42.0) were entered in the study. The best correlation between short-term "snapshot" REE and the 24-hour TEE was achieved by the steady-state period defined by the most stringent criteria (change in VO2 and VCO2 by <10%). The average REE for all steady-state and interval periods correlated significantly to TEE with no significant difference in the absolute values for REE and TEE. Adding 10% for an activity factor to the average REE for each steady-state and interval period again correlated to TEE in a similar fashion with the same R value, but the absolute values for REE + 10% for all steady-state and interval periods were significantly different than the corresponding TEE. In those patients with less variation (CV for VO2 < or = 9.0), the REE obtained for the steady-state period defined by the most stringent criteria still had the best correlation, but similar correlation could be obtained by interval testing of > or = 30-minute duration. In those patients with greater variation (CV for VO2 >9.0), interval testing of at least 60 minutes or more was required to attain levels of correlation similar to that achieved by the steady-state period defined by the most stringent criteria. CONCLUSIONS: These data support the use of steady state, best defined as an interval of 5 consecutive minutes whereby VO2 and VCO2 change by <10%. The mean REE from this period correlates best to the 24-hour TEE regardless of CV. IC testing can be completed after achievement of steady state. Activity factors of 10% to 15% should not be added to the steady-state REE, because this practice significantly decreases the accuracy. In patients who fail to achieve steady state, the CV helps to determine the appropriate duration of IC testing. In those patients with a low CV (< or = 9.0), 30-minute test duration is adequate. In patients with CV >9.0, test duration of at least 60 minutes may be required. These latter patients should be considered for 24-hour IC testing.

Adolescent↗

PubMed1998

Sepsis-related organ failure assessment and withholding or withdrawing life support from critically ill patients.

BACKGROUND: We studied the incidence of withholding or withdrawing therapeutic measures in intensive care unit (ICU) patients, as well as the possible implications of sepsis-related organ failure assessment (SOFA) in the decision-making process and the ethical conflicts emerging from these measures. METHODS: The patients (n = 372) were placed in different groups: those surviving 1 year after ICU admission (S; n = 301), deaths at home (DH; n = 2), deaths in the hospital after ICU discharge (DIH; n = 13) and deaths in the ICU (DI; n = 56). The last group was divided into the following subgroups: two cardiovascular deaths (CVD), 20 brain deaths (BD), 25 deaths after withholding of life support (DWH) and nine deaths after withdrawal of life support (DWD). RESULTS: APACHE III, daily therapeutic intervention scoring system (TISS) and daily SOFA scores were good mortality predictors. The length of ICU stay in DIH (20 days) and in DWH (14 days) was significantly greater than in BD (5 days) or in S (7 days). The number of days with a maximum SOFA score was greater in DWD (5 days) than in S, BD or DWH (2 days). CONCLUSIONS: Daily SOFA is a useful parameter when the decision to withhold or withdraw treatment has to be considered, especially if the established measures do not improve the clinical condition of the patient. Although making decisions based on the use of severity parameters may cause ethical problems, it may reduce the anxiety level. Additionally, it may help when considering the need for extraordinary measures or new investigative protocols for better management of resources.

Journal Article↗

PubMed2005

Predictive mortality models are not like fine wine.

The authors of a recent paper have described an updated simplified acute physiology score (SAPS) II mortality model developed on patient data from 1998 to 1999. Hospital mortality models have a limited range of applicability. SAPS II, Acute Physiology, Age, and Chronic Health Evaluation (APACHE) III, and mortality probability model (MPM)-II, which were developed in the early 1990s, have shown a decline in predictive accuracy as the models age. The deterioration in accuracy is manifested by a decline in the models' calibration. In particular, mortality tends to get over predicted when older models are applied to more contemporary data, which in turn leads to 'grade inflation' when benchmarking intensive care unit (ICU) performance. Although the authors claim that their updated SAPS II can be used for benchmarking ICU performance, it seems likely that this model might already be out of calibration for patient data collected in 2005 and beyond. Thus, the updated SAPS II model may be interesting for historical purposes, but it is doubtful that it can be an accurate tool for benchmarking data from contemporary populations.

Benchmarking↗

PubMed1993

Analysis of indications for early discharge from the intensive care unit. Clinical efficacy assessment project: American College of Physicians.

OBJECTIVE: To formulate recommendations for the development of early intensive care unit (ICU) discharge criteria for low-risk monitor patients. DESIGN: Literature review of published reports over the period 1966 to 1991 pertaining to ICU discharge criteria. PATIENTS: Studies identifying patients admitted to ICUs who could be characterized as low risk. Patient populations of interest included adults (> or = 18 years of age) with low-risk medical or mixed medical/surgical conditions; cardiac care unit and burn patients were excluded. MEASUREMENTS AND MAIN RESULTS: Of 1,492 articles identified as being pertinent to ICU discharge, only 2 studies (by the same group of investigators) were found that distinguished low-risk populations among medical and mixed medical/surgical ICU patients. The physiologic component of the Acute Physiology and Chronic Health Evaluation (APACHE) was used in both of these studies to ascertain the degree of risk. No studies were found that compared outcomes of low-risk patients remaining in the ICU after 24 h with those transferred to other hospital locations. CONCLUSIONS: Objective methods (such as APACHE III) should be used to identify low-risk patients at 24 h post-ICU admission. A multicenter study should be conducted to compare outcomes on patients identified as low risk who are randomly assigned to alternative hospital locations for treatment versus those assigned to continued ICU treatment until routine ICU discharge. Mortality and quality of life data should be used as outcome measures (prior to ICU admission and 6 months post-ICU discharge).

Adult↗

PubMed1995

Determinants of mortality and multiorgan dysfunction in cardiac surgery patients requiring prolonged mechanical ventilation.

OBJECTIVES: To identify characteristics associated with mortality and the development of multiorgan dysfunction in patients who had undergone cardiac surgery and required prolonged mechanical ventilation, ie, > 48 h. DESIGN: A prospective cohort study. SETTING: Barnes Hospital, St. Louis, an academic tertiary care center. PATIENTS OR OTHER PARTICIPANTS: A total of 107 consecutive patients undergoing cardiac surgery and requiring prolonged mechanical ventilation. INTERVENTIONS: Prospective patients surveillance and data collection. MAIN OUTCOME MEASURES: ICU mortality and multiorgan dysfunction. RESULTS: Among 472 consecutive patients admitted to the cardiac surgery ICU following surgery, 107 (22.7%) required prolonged mechanical ventilation. Twenty-one of these patients (19.6%) died during their hospitalization. In a logistic-regression analysis, the development of an organ system failure index (OSFI) of 3 or greater was the only characteristic independently associated with ICU mortality (p < 0.001). The occurrence of an antibiotic-resistant infection (adjusted odds ratio [AOR] = 6.1, 95% confidence interval [CI] = 2.5 to 14.6 p = 0.006), an aortic cross-clamp time equal to or greater than 1.25 h (AOR = 3.9, CI = 2.3 to 6.8, p = 0.016), the development of ventilator-associated pneumonia (AOR = 3.6, CI = 2.4 to 5.3, p < 0.001), and an APACHE III score equal to or greater than 30 (AOR = 3.1, CI = 1.8 to 5.3, p = 0.036) were independently associated with the development of an OSFI of 3 or greater. CONCLUSIONS: These data confirm that acquired multiorgan dysfunction is the best predictor of mortality in patients requiring prolonged mechanical ventilation following cardiac surgery. Additionally, they identify potential determinants of multiorgan dysfunction and suggest possible interventions for its reduction in this patient population.

Aged↗

PubMed2005

Noninvasive positive pressure ventilation in patients with acute exacerbations of COPD and varying levels of consciousness.

STUDY OBJECTIVES: A severely altered level of consciousness (ALC) has been considered a contraindication to noninvasive positive pressure ventilation (NPPV). We compared the clinical outcome of patients with acute respiratory failure (ARF) due to COPD exacerbations and different degrees of ALC. DESIGN: A 5-year case-control study with a prospective data collection. SETTING: Respiratory Monitoring Unit. PATIENTS: Eighty of 153 consecutive COPD patients requiring NPPV for ARF were divided into four groups, which were carefully matched for the main physiologic variables, according to the level of consciousness assessed with the Kelly-Matthay Score, in which 1 is normal (control subjects) and 6 is severely impaired. MEASUREMENT AND RESULTS: Changes from baseline in arterial blood gas (ABG) levels and Kelly score, the rate and causes of NPPV failure, the rate of nosocomial pneumonia, and the 90-day mortality rate were compared. NPPV significantly improved ABG levels and Kelly score in all groups after 1 to 2 h. NPPV failure (Kelly score 1 = 15%; Kelly score 2 = 25%; Kelly score 3 = 30%; Kelly score > 3 = 45%) and 90-day mortality rate (Kelly score 1 = 20%; Kelly score 2 = 35%; Kelly score 3 = 35%; Kelly score > 3 = 50%) significantly increased with the worsening of the level of consciousness. Using a multivariate analysis, the acute nonrespiratory component of the acute physiology and chronic health evaluation (APACHE) III score, and baseline pH independently predicted baseline Kelly score. After 1 to 2 h of NPPV, changes in the Kelly score were associated with those in pH. No correlation was found with Pa(CO2). CONCLUSIONS: This study confirms that NPPV may be successfully applied to patients experiencing COPD exacerbations with milder ALCs, whereas the rate of failure in patients with severely ALCs (ie, Kelly score > 3) is higher, even though better than expected, so that an initial and cautious attempt with NPPV may be performed even in this latter group. Changes in the level of consciousness induced by NPPV are not correlated with those in Pa(CO2).

Acid-Base Imbalance↗

PubMed1998

Neopterin plasma concentrations predict the course of severe acute pancreatitis.

In a prospective, descriptive study in 25 patients with acute pancreatitis neopterin plasma concentrations were found to be associated with the severity of the disease, which was assessed using weights of the worst 17 physiological abnormalities of the APACHE-III score over a 24 h-period after hospital admission. Neopterin concentrations were higher in severe pancreatitis (n = 10) compared to mild disease, and there existed a positive exponential correlation between neopterin and the Acute Physiology Score (r = 0.66). Higher neopterin concentrations were associated with the development of multiple organ failure (p = 0.012) and death (p = 0.019). At a cut-off concentration of 12 nmol/l the sensitivity (80%) and specificity (100%) of neopterin for the discrimination between mild and severe clinical course of pancreatitis was more accurate than C-reactive protein at a risk threshold of 1.2 g/l (70% and 87%). Development of pancreatic necrosis was associated with higher neopterin concentrations than edematous pancreatitis (p < 0.001).

Adult↗

PubMed2005

Urine IL-18 is an early diagnostic marker for acute kidney injury and predicts mortality in the intensive care unit.

Serum creatinine is not an ideal marker of renal function in patients with acute kidney injury (AKI). Previous studies demonstrated that urinary IL-18 is increased in human AKI. Thus, whether urine IL-18 is an early diagnostic marker of AKI was investigated. A nested case-control study was performed within the Acute Respiratory Distress Syndrome (ARDS) Network trial. AKI was defined as an increase in serum creatinine by at least 50% within the first 6 d of ARDS study enrollment. A total of 400 urine specimens that were collected on study days 0, 1, and 3 of the ARDS trial were available from 52 case patients and 86 control patients. The data were analyzed in a cross-sectional manner and according to the time before development of AKI. The median urine IL-18 levels were significantly different at 24 and 48 h before AKI in case patients as compared with control patients. On multivariable analysis, urine IL-18 values predicted development of AKI 24 and 48 h later after adjustment for demographics, sepsis, Acute Physiologic Assessment and Chronic Health Evaluation (APACHE) III score, serum creatinine, and urine output. Urine IL-18 levels of >100 pg/ml are associated with increased odds of AKI of 6.5 (95% confidence interval 2.1 to 20.4) in the next 24 h. On diagnostic performance testing, urine IL-18 demonstrates an area under the receiver operating characteristic curve of 73% to predict AKI in the next 24 h. The urine IL-18 values were also significantly different between survivors and nonsurvivors (P < 0.05), and on multivariable analysis, the urine IL-18 value on day 0 is an independent predictor of mortality. Urinary IL-18 levels can be used for the early diagnosis of AKI. Urine IL-18 levels also predict the mortality of patients who have ARDS and are in the intensive care unit.

Acute Kidney Injury↗