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PubMedDate not supplied

Severity of illness: APACHE II analysis of an ICU population.

We reviewed the population of a surgical intensive care unit from July 1, 1987 to June 30, 1988, adjusting for severity of illness using the APACHE II system. Nineteen different departments admitted a total of 613 patients to the surgical intensive care unit. Predicted mortality was 22.9%; actual mortality was 15.7%. APACHE II generated reports which included analysis by age, mortality risk, department, primary physician, and diagnosis. We recommend reporting intensive care unit outcome by APACHE criteria to allow more meaningful comparisons of data and standardization of quality assurance programs. Finally, we present a critical review of the current APACHE II system and describe developments to be included in APACHE III.

Adolescent↗
PubMed2000

[Surgery in the cirrhotic patient. Prognosis and risk factors].

Patients with cirrhosis have reduced life expectancy. Surgery is often associated with clinical decompensation in this group of patients. The purpose of this paper is to study the surgical risk in cirrhotic patients undergoing nonderivative operations. Unfortunately, most of the studies in the literature about this problem are retrospective reviews with limitations. The conditions increasing surgical risk in cirrhotic patients are analysed. These include changes in the pharmacokinetics and pharmacodynamics of various drugs, altered hemostasis, poor resistance to infections, water retention, suture line insufficiency, chronic renal failure and congestive heart failure. Assessment of the disease stage in cirrhosis is very important, because the severity of hepatic abnormalities influences the prognosis. The Child-Pugh classification has been used extensively to risk-stratify patients with cirrhosis. However, the disregard for cardiorespiratory, renal, electrolyte balance and acid-base status limits its predictive accuracy. Recently a new scoring system, the Acute Physiology and Chronic Health Evaluation (APACHE III), has been introduced and seems to be superior to Child-Pugh for prognosticating short term survival of cirrhotic patients. In conclusion, surgery can be done safely only in cirrhotic patients with a good hepatic function. On the contrary, in patients with advanced cirrhosis, surgery causes a very high mortality. Finally, the patients with moderate hepatic failure can be operated only after a careful study of the disease and an adequate correction of the reversible risk factors.

Blood Coagulation↗
PubMed2001

Efficacy of cefepime versus ceftazidime in the treatment of adult pneumonia.

Effective empiric treatment of pneumonia requires antibiotic coverage against gram-negative and gram-positive pathogens, including drug-resistant isolates. This study evaluated the efficacy of cefepime treatment in 20 patients with community-acquired pneumonia (CAP) and 21 patients with hospital-acquired pneumonia (HAP), and ceftazidime treatment in 20 patients with HAP. The mean age of patients was over 70 years. More than half of the patients had multiple lobe involvement. There was no significant difference in the severity of illness according to the acute physiology, age, chronic health evaluation (APACHE) III score between the HAP-cefepime and HAP-ceftazidime group. The most common bacteria isolated from sputum of patients with CAP were Streptococcus pneumoniae (n = 7), Klebsiella pneumoniae (n = 4), and Pseudomonas aeruginosa (n = 2). In patients with HAP, P. aeruginosa (n = 13), Acinetobacter baumannii (n = 11), Serratia marcescens (n = 6), K. pneumoniae (n = 5), Stenotrophomonas maltophilia (n = 5), Enterobacter cloacae (n = 3), Citrobacter spp. (n = 2), and Escherichia coli (n = 2) were isolated. The cure rates were 95%, 76%, and 60% in the CAP-cefepime group, the HAP-cefepime group, and the HAP-ceftazidime group, respectively. The increased rates of antimicrobial resistance commonly found among isolates causing CAP and HAP indicate that extended-spectrum antimicrobial agents, such as cefepime, would be more appropriate therapeutic agents.

Adult↗
PubMed2001

Severity-of-illness scoring systems and models: neurological and neurosurgical intensive care units.

Predicting the outcome of critically ill patients admitted to intensive care units (ICU) has undergone considerable evolution over the last two decades. Various general purpose severity-of-illness scoring systems, Acute Physiology and Chronic Health Evaluation score (APACHE II, APACHE III), Mortality Predicting Model (MPM II), and Simplified Acute Physiology Score (SAPS II), have been extensively validated for large groups of critical care patients with mixed diagnoses and found to correlate well with observed outcome in general. The general hypothesis underlying the use of severity-of-illness scoring systems is that clinical variables that can be assessed on ICU admission and subsequent days of stay in the ICU predict survival and other outcomes of critically ill patients. Variables included in severity-of-illness scoring systems measure specific clinical and physiological functions that are major determinants of mortality. These scoring systems may be used alone within a single disease category or any other independently defined patient group to perform relative risk stratification. Variation in death rates by disease reflects the nature of the underlying process. There is a need for using these scoring systems in specialized ICUs like neurological and neurosurgical ICU as they allow, in addition to predicting outcome, evaluation of new therapies, monitoring of resource utilization and quality assessment of intensive care units.

Critical Care↗
PubMed2000

[Dynamic changes of serum pro-inflammatory cytokines and anti-inflammatory cytokines in patients with acute infection and the effect of Chinese herbal medicine intervention].

OBJECTIVE: To study the dynamic changes of serum pro-inflammatory cytokines and anti-inflammatory cytokines in patients with acute infection and to explore the effect of 912 compound, a Chinese herbal preparation for intervention. METHODS: Forty patients with acute infection were randomly divided into 2 groups, 20 in the 912 group and 20 in the control group, and the levels of plasma endotoxin (lipopolysaccharide, LPS), serum pro-inflammatory cytokines, including tumor necrosis factor alpha (TNF alpha) and interleukin-6 (IL-6) and anti-inflammatory cytokines, including soluble TNF-RI, IL-4 and IL-10 were measured before and after treatment by using limulus reagent stroma azo-colored quantitative method and enzyme-linked immunosorbent assay (ELISA). RESULTS: The level of LPS increased at the early stage of acute infection, the levels of pro- and anti-inflammatory cytokines were all elevated in various degrees, particularly obvious in IL-6, sTNF-RI, IL-4 and IL-10 and the elevations of the two were basically parallel. The TNF alpha, IL-6 and sTNF-RI were positively related with APACHE III scoring. The levels of LPS and inflammatory cytokines reduced to a different extent in accord with the improvement of condition after treatment, the levels of LPS, TNF alpha, IL-6 and IL-10 lowered more significantly in the 912 group than those in the control group (P < 0.05). CONCLUSIONS: LPS, pro-inflammatory and anti-inflammatory cytokines play important roles in the acute infection process, they were important indexes for evaluating severity of infectious diseases. The Chinese herbal preparation 912 compound could reduce the blood levels of LPS, TNF alpha, IL-6, IL-10 and prevent the decrease of sTNF-RI so as to promote the recovery of patients.

Adult↗
PubMed2002

[Therapeutic and diagnostic tactics in complication of ulcer disease in elderly and aged].

In 78% of cases the ulcerative disease in elderly age proceeds with complications and presents a serious surgical problem. The specificity of elderly patients is the combination of several pathologies, on background of which the ulcerative disease proceeds. The level of an expressiveness of accompanying pathology influences on the prognosis of disease course and on the choice of medical tactics. Therefore for objectivization of state heaviness of the patient group mark systems of an estimation MODS and APACHE III are used. The interventions in gastroduodenal bleedings for the patients of elderly age should be differentiated and depended on a risk degree of bleeding relapse and adequate estimation of MODS heaviness. In 55.4% of the elderly patients the ulcerative perforation occur without antecedent history. Therefore indications to sewing of ulcers, including little-invasive interventions, should be extended in this group of the patients. The size of radical surgical interventions in absence of manifestation of the polyorganic insufficiency for the elderly patients should be the same, as for the younger patients.

Aged↗
PubMed2002

[Validation of organ failure scoring systems in objective illness characterization].

Multiple organ failure syndrome is the leading cause of death in intensive care units. Medical scales and scoring systems are used for objective characterization of patients, quantitation of illness severity, prognosis, identification of high-risk patients, determination of treatment effectiveness and final outcome. We reviewed some data about the most frequently used scoring systems describing organ failure. Multiple Organ Dysfunction score (MODs) grades increasing severity of dysfunction of vital significant organ systems and it reflects intensity of SIRS.APACHE II and APACHE III scoring systems and SOFA score are used widely in clinical practice.

Critical Illness↗
PubMed1994

Improving intensive care unit discharge decisions: supplementing physician judgment with predictions of next day risk for life support.

OBJECTIVE: To develop predictive equations, estimating the probability that an individual intensive care unit (ICU) patient will receive life support within the next 24 hrs. DESIGN: Prospective, multicenter, inception cohort study. SETTING: Forty-two ICUs in 40 U.S. hospitals, including 26 that were randomly selected and 14 volunteer hospitals, primarily university or large tertiary care centers. PATIENTS: A consecutive sample of 17,440 ICU admissions. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: A series of multivariate equations were developed to create daily estimates of probability of life support in the next 24 hrs. These equations used demographic, physiologic, and treatment information obtained at the time of ICU admission and during the first 7 ICU days. The most important determinants of next day risk for life support were the current day's therapy and Acute Physiology Score of the Acute Physiology and Chronic Health Evaluation (APACHE) III score. Other predictor variables included diagnosis, age, chronic health status, emergency surgery, previous day Acute Physiology Score, and hospital stay and location before ICU admission. The cross-validated ICU day 1, 2, and 3 predictive equations had receiver operating characteristic areas of 0.90. Survival, ICU readmission rate, and the number and type of therapies received by patients predicted at < 10% risk for active treatment suggest that discharge of patients meeting these criteria to an intermediate care unit or hospital ward could reduce ICU bed demand without compromising patient safety. CONCLUSIONS: Accurate, objective predictions of next day risk for life support can be developed, using readily available patient information. Supplementing physician judgment with these objective risk assessments deserves evaluation for the role of these assessments in enhancing patient safety and improving ICU resource utilization.

Adolescent↗
PubMed1994

Objective data and quality assurance programs. Current and future trends.

As CCM has grown, the diversity of ICU patients, as well as that of ICU organization and structure, has grown. This growth has led to numerous questions regarding health care delivery in the ICU. These questions contributed to the development of systems that objectively evaluate the quality of health care delivery in ICUs. Severity of disease scoring systems have been developed and allow for a valid analysis of ICU performance at several levels. These systems should help intensivists determine how health care delivery can be optimized in ICUs. Despite the controversy that surrounds severity of disease scoring and prognostic systems, it is not unreasonable to suggest that, because of the feedback these systems would provide, health care delivery in the ICU would be improved through more extensive use of them at the present time. The information acquired through the use of objective scoring systems ultimately must be used to improve the efficiency of ICUs. The structure and organization of ICUs in the United States, as well as the training of those who treat ICU patients, are excessively diverse, and a more standardized approach to health care delivery in the ICU ultimately will be required. Present information suggests that decentralized ICUs with part-time ICU physicians result in poorer outcomes. The APACHE III study intends to explore these relationships in more detail. Certainly, more studies looking at these issues are needed, but we are at least beginning to answer the questions that resulted from the rapid growth of critical care in the 1980s. The SCCM data suggest two possible alternatives, not necessarily exclusive of each other: (1) A large percentage of ICUs may be obligated to undergo structural changes in the near future. (2) Regionalization of critical care, already present, may continue. Certain rural areas may find it more expedient to send the most critically ill patients to tertiary centers in nearby cities, as opposed to a wholesale upgrading of the delivery of care in their own ICUs. Ultimately, all hospitals will be obligated to provide patients access to the highest quality of critical care.

Certification↗
PubMedDate not supplied

Bar code documentation of pharmacotherapy services in intensive care units.

Bar code technology has been used for 5 years to improve the efficiency of identifying and documenting clinical pharmacy services at our institution. Data for an entire year (1993) were analyzed to quantify the nature and magnitude of pharmacy services provided for critically ill patients in intensive care units (ICU). Patients in the medical (MICU), respiratory (RICU), intermediate (IMU), and surgical (SICU) units (3234/3743 patients, 86%) were reviewed. Clinical interventions and expected outcomes were documented by pharmacists using an automated bar code system. There were 11,628 pharmacotherapy interventions, 3.6/patient; 12/pharmacist work day. Of patients whose drug therapy was reviewed at least once, 50% (1610/3234) received at least one intervention. The mean number of interventions/patient was 7.2 in the MICU, 6.1 in RICU, 3.4 in IMU, and 2.4 in the SICU, corresponding to APACHE III scores of 71.2, 66.2, 42.8, and 43.3, respectively. The majority of interventions were to modify dosages of antimicrobial agents, and were performed to achieve optimum efficacy (42%) and to minimize toxicity (46.2%). These data support the necessity for pharmacists to provide individualized care to critically ill patients.

Drug Therapy, Computer-Assisted↗
PubMed1996

[The multiple organ failure syndrome--its pathophysiology and treatment].

Polyorganic deficiency syndrome (PODS) is a generalized response to the effect of a variety of agents hardly lending itself to control, becoming manifest with rapid proliferation within the body. The issues discussed include: epidemiology with a special reference to panendothelial trauma to pulmonary and other systems with impairment of oxygen utilization by the cells, microcirculation disorders, mediators, ARDS development, disturbed barrier function of the intestinal mucosa, enhanced glutamine consumption with ensuing villous atrophy. Symptoms presented by various organs, treatment consisting in block of stimulation and block of mediators, as well as selective decontamination and adequate diet are also dealt with. Against the background outlined above the prognostic point rating system (the so-called score rating) of PODS with simultaneous application of the APACHE III rating system are evaluated. Age-related factors and number of organs involved are likewise considered.

Humans↗
PubMed1997

[Potential and real drug interactions in critical care patients].

OBJECTIVES: To detect potential drug interactions occurring during treatment of critically ill patients and to evaluate the real clinical and analytical repercussions of such interactions. PATIENTS AND METHODS: Seventy consecutive patients in a six-bed medical-surgical intensive care unit (ICU) were studied prospectively over a period of five months. The pharmacological department of the hospital provided the drugs through a computerized unit dosing system, using a program that gave warnings of possible drug interactions as each patient's treatment was entered. Interactions were cataloged according to clinical importance following the criteria of Hansten. The repercussions were evaluated by clinical and analytical monitoring. RESULTS: On hundred two potential interactions were detected in 44.3% of patients (1.5 interactions per patient). In 6 patients (19.3%) analytical alterations were observed but only 2 (6.4%) of them presented clinical manifestations. Most of the interactions were cataloged as being of moderate clinical importance. Digoxin was the most frequently implicated drug. The number of drugs administered per patient was 14.7 and patients receiving the most drugs were the most likely to experience and interaction. We found a significant correlation (p < 0.05) between the number of interactions and age, APACHE III score, length of ICU stay and number of drugs administered. CONCLUSIONS: The frequently of drug interactions in critically ill patients can be high, given the large number of drugs they receive. Although the real clinical repercussions of interactions are few, physicians should watch for them and the act appropriately.

Critical Care↗
PubMed1998

Arterial oxygenation is unchanged during hemodialysis in patients mechanically ventilated in assist-control mode.

Dialysis-induced hypoxemia can occur in spontaneously breathing renal failure patients but whether it occurs during bicarbonate hemodialysis in critically ill patients receiving mechanical ventilation in assist-control mode is not clear. Twenty-one patients admitted to the medical intensive care unit who required mechanical ventilation and hemodialysis with the use of a cuprammonium dialyzer were enrolled and 25 sessions of hemodialysis were performed. Arterial blood gas, white blood cell count, minute ventilation, respiratory rate, and blood pressure were measured before dialysis (time 0) and at 15, 30, 60, 120, 180, and 240 minutes thereafter. The white blood cell count dropped immediately and reached the nadir 15 minutes after hemodialysis began. Thereafter, it recovered and overshot the predialysis value at the end of dialysis. The serum HCO3- concentration increased progressively after dialysis began and resulted in significant metabolic alkalosis. The P (A-a)O2 was not aggravated and minute ventilation was not depressed by rapid metabolic alkalosis under mechanical ventilatory support. The PaO2 remained stable throughout hemodialysis. No significant hypoxemia occurred in groups of varying predialysis cardiopulmonary dysfunction. These findings suggest that in renal failure patients ventilated in assist-control mode, l) hypoventilation and accompanying hypoxemia did not occur during bicarbonate (35 mEq/L) dialysis, despite significant metabolic alkalosis; and 2) patients with higher Acute Physiologic and Chronic Health Evaluation (APACHE) III scores and P(A-a)O2 levels were not more prone to dialysis-induced hypoxemia.

Adult↗
PubMed1998

[Predictive variables of early hospital readmission in cardiac failure].

BACKGROUND: Heart failure (HF) is one of the diagnosis leading to a high number of readmissions in our hospitals. There is some controversy about the role played by two groups of variables on the risk or readmissions: patient-dependent variables, such as clinical severity, and the characteristics of medical care during the previous admission, in terms of care quality. METHODS STUDY POPULATION: admissions due to HF with home discharge. DESIGN: case-control study. CASES: episodes followed by emergent admission within 30 days because of related diagnosis ("early readmission") (n = 51). CONTROLS: random sample of episodes not followed by an early readmission (n = 51). Information collected: review of clinical records. Groups of predictive variables studied: demographics, clinical severity, clinical parameters prognostic of HF and characteristics of medical care. Bivariate and multivariate statistical analysis: logistic regression (LR). RESULTS: LR analysis detected only one variable predicting early readmission, the ischemic etiology. Odds ratio = 4.78 (95% CI: 1.44; 15.88). There were no differences between the study groups regarding age, sex, clinical instability at discharge, hospital stay length, severity (APACHE III and other evaluation methods) and other prognostic parameters of HF (ejection fraction, functional degree, cardiomegaly, concurrent diabetes, valvular disease, atrial fibrillation, hyponatremia, and use of anti-arrhythmic drugs). CONCLUSIONS: The risk for an early readmission is mainly explained by the clinical variables of patients, basically ischemic etiology, and not by the characteristics of medical care: clinical instability at discharge or hospital stay length.

Aged↗
PubMed1997

Prediction of outcome from intensive care: a prospective cohort study comparing Acute Physiology and Chronic Health Evaluation II and III prognostic systems in a United Kingdom intensive care unit.

OBJECTIVE: To evaluate the ability of two prognostic systems to predict hospital mortality in adult intensive care patients. DESIGN: Prospective cohort study. SETTING: A mixed medical and surgical intensive care unit (ICU) in the United Kingdom. PATIENTS: A total of 1,144 patients consecutively admitted to the study. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Acute Physiology and Chronic Health Evaluation (APACHE) II and III prognostic systems were applied to assess probabilities of hospital mortality, which were compared with the actual outcome. The overall goodness-of-fit of both models was assessed. Hospital death rates were higher than those predicted by each system. Risk estimates showed a strong positive correlation between both systems (nonsurvivors r2 = 0.756, p < .0001; survivors r2 = 0.787, p < .0001). Calibration of APACHE II (chi 2 = 98.6, Lemeshow-Hosmer) was superior to that of APACHE III (chi 2 = 129.8, Lemeshow-Hosmer). The total correct classification rate of APACHE III was greater for all decision criteria applied; the best overall total correct classification rate was 80.6% for APACHE III and 77.9% for APACHE II (both for a decision criterion of 40%). The areas under the receiver operating characteristic curves were 0.806 and 0.847 for APACHE II and III, respectively, confirming the better discrimination of APACHE III. When patients were classified by diagnostic categories, risk predictions did not fit uniformly across the spectrum of disease groups. For both models, mortality ratios were highest for trauma patients and lowest for the group with respiratory disease. APACHE II predictions for patients with gastrointestinal disease were significantly better. Risk estimates for surgical admissions were superior with APACHE II (MR = 1.27) compared with APACHE III (MR = 1.56), but were similar for medical patients (1.22 vs. 1.28 for APACHE II and III, respectively). Bias induced by factors reflecting the clinical practice in an individual ICU (e.g., admission criteria, treatment before admission) may have considerable impact on risk estimates. The identification of such factors appears to be a prerequisite for the meaningful interpretation of observed and predicted death rates on the individual ICU level. CONCLUSIONS: Both predictive models demonstrated a similar degree of overall goodness-of-fit. APACHE II showed better calibration, but discrimination was better with APACHE III. Hospital mortality was higher than predicted by both models, but was underestimated to a greater degree by APACHE III. Risk estimates by both models showed considerable variation across the disease spectrum of ICU patients. Risk predictions for surgical patients and patients with gastrointestinal disease were better with APACHE II. Factors reflecting the clinical practice of an individual ICU are not accounted for by APACHE II and III. Overall, the performance of APACHE III was not superior to that of its predecessor for a cohort of United Kingdom ICU patients; for certain diagnostic categories, APACHE III performed worse than APACHE II despite an improved system of disease classification.

APACHE↗
PubMed2003

Multiple organ failure in trauma patients.

SUMMARY: BACKGROUND As care of the critically ill patient has improved and definitions of organ failure have changed, it has been observed that the incidence of organ failure and the mortality associated with organ failure appear to be decreasing. In addition, many early studies included large heterogeneous populations of both medical and surgical patients that may have influenced the incidence and outcome of organ failure. The purpose of this study is to establish the current incidence and mortality of organ failure in a homogenous population of critically ill trauma patients. METHODS All trauma patients admitted to the intensive care unit (ICU) at an urban Level I trauma center were prospectively studied. Patients were evaluated for the presence of organ failure using definitions proposed by Knaus and by Fry. Newer definitions of organ failure incorporating organ dysfunction and severity-of-illness scores were also obtained in all patients in an attempt to predict outcome. These included lung injury scores (acute respiratory distress syndrome scores), Acute Physiology and Chronic Health Evaluation (APACHE) II and III scores, Injury Severity Score (ISS), and multiple organ dysfunction scores. Primary outcomes assessed were death and the occurrence of organ failure by the various definitions. RESULTS Eight hundred sixty-nine trauma patients were admitted to the ICU and survived longer than 48 hours. Mean APACHE II and APACHE III scores at admission to the ICU and ISS were 12.2 +/- 22, 30.5 +/- 22.7, and 19 +/- 10, respectively. Single organ failure (SOF) occurred in 163 patients (18.7%) and multiple organ failure occurred in 44 patients (5.1%). All SOF was caused by respiratory failure. Respiratory failure occurred first in the majority of patients with multiple organ failure. Mortality was 4.3% with one organ system failure, 32% with two, 67% with three, and 90% when four organ systems failed. None of the patients with SOF died secondary to respiratory failure. Multiple stepwise regression analysis was performed to determine which of the following risk factors are associated with the occurrence of organ failure: mechanism of injury, lactate at 24 hours, ISS, APACHE II, APACHE III, acute respiratory distress syndrome score at admission, multiple organ dysfunction score at admission and total blood products transfused in 24 hours. Of these factors, APACHE III, lactate at 24 hours, and total blood products transfused in 24 hours were associated with the occurrence of organ failure. CONCLUSION The overall incidence of organ failure in a homogeneous trauma population appears to be lower than that reported in studies performed in heterogeneous patient populations in the 1980s. Mortality for SOF is low and appears to be related primarily to the patient's underlying injuries and not to organ failure. Mortality for two or three organ system failures is lower than reported 15 to 20 years ago. Mortality for patients with four or more organ system failures remains high, approaching 100%.

APACHE↗
PubMedDate not supplied

[Choosing of scale for determining the condition severity in patients with acute blood loss].

Inefficiency of therapy for massive blood losses and hemorrhagic shock can be partially explained by inability to identify, as early as possible, the risk groups. The purpose of our case study was to investigate the significance of diagnostic systems in evaluating the condition severity of patients. One hundred and nine male patients (mean age 41.6 +/- 8.1) were examined within the randomized prospective study. Examinations were made at admission and in 24 and 72 hours after injury according to the protocols of condition severity evaluation--APACHE-II, III (Acute physiology and chronic health condition) and SAPS (Simplified Acute Physiology Score). The scales used in the study are described by a high reliability degree in differentiating the severity conditions of patients (p < 0.0001). The direct linear relation was observed in all cases between the severity condition of patients and the lethality rate (correlation factor r(X,Y) > 0.89). The highest specificity was noted for the APACHE-III diagnostic system.

APACHE↗