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PubMed2000

Automated computerized intensive care unit severity of illness measure in the Department of Veterans Affairs: preliminary results. SISVistA Investigators. Scrutiny of ICU Severity Veterans Health Sysyems Technology Architecture.

OBJECTIVE: To evaluate the feasibility of an automated intensive care unit (ICU) risk adjustment tool (acronym: SISVistA) developed by selecting a subset of predictor variables from the Acute Physiology and Chronic Health Evaluation (APACHE) III available in the existing computerized database of the Department of Veterans Affairs (VA) healthcare system and modifying the APACHE diagnostic and comorbidity approach. DESIGN: Retrospective cohort study. SETTING: Six ICUs in three Ohio Veterans Affairs hospitals. PATIENT SELECTION: The first ICU admission of all patients from February 1996 through July 1997. OUTCOME MEASURE: Mortality at hospital discharge. METHODS: The predictor variables, including age, comorbidity, diagnosis, admission source (direct or transfer), and laboratory results (from the +/- 24-hr period surrounding admission), were extracted from computerized VA databases, and APACHE III weights were applied using customized software. The weights of all laboratory variables were added and treated as a single variable in the model. A logistic regression model was fitted to predict the outcome and the model was validated using a boot-strapping technique (1,000 repetitions). MAIN RESULTS: The analysis included all 4,651 eligible cases (442 deaths). The cohort was predominantly male (97.5%) and elderly (63.6 +/- 12.0 yrs). In multivariate analysis, significant predictors of hospital mortality included age (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.04-1.09), comorbidity (OR, 1.11; 95% CI, 1.08-1.15), total laboratory score (OR, 1.07; 95% CI, 1.06-1.08), direct ICU admission (OR, 0.39; 95% CI, 0.31-0.49), and several broad ICU diagnostic categories. The SISVistA model had excellent discrimination and calibration (C statistic = 0.86, goodness-of-fit statistics; p > .20). The area under the receiver operating characteristic curve of the validated model was 0.86. CONCLUSIONS: Using common data elements often found in hospital computer systems, SISVistA predicts hospital mortality among patients in Ohio VA ICUs. This preliminary study supports the development of an automated ICU risk prediction system on a more diverse population.

APACHE↗

PubMed2003

Relationship of pulmonary artery catheter use to mortality and resource utilization in patients with severe sepsis.

OBJECTIVE: To examine the relationship of pulmonary artery catheter (PAC) use to patient outcomes, including mortality rate and resource utilization, in patients with severe sepsis in eight academic medical centers. DESIGN: Case-control, nested within a prospective cohort study. SETTING: Eight academic tertiary care centers. PATIENTS: Stratified random sample of 1,010 adult admissions with severe sepsis. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The main outcome measures were in-hospital mortality, total hospital charge, and length of stay (LOS) for patients with and without PAC use. The case-matched subset of patients included 141 pairs managed with and without the use of a PAC. The mortality rate was slightly but not statistically significantly lower among the PAC use group compared with those not using a PAC (41.1% vs. 46.8%, p =.34). Even this trend disappeared after we adjusted for the Charlson comorbidity score and sepsis-specific Acute Physiology and Chronic Health Evaluation (APACHE) III (adjusted odds ratio, 1.02; 95% confidence interval, 0.61-1.72). In linear regression models adjusted for the Charlson comorbidity score, sepsis-specific APACHE III, surgical status, receipt of a steroid before sepsis onset, presence of a Hickman catheter, and preonset LOS, no significant differences were found for total hospital charges (139,207 US dollars vs. 148,190, adjusted mean comparing PAC and non-PAC group, p =.57), postonset LOS (23.4 vs. 26.9 days, adjusted mean, p =.32), or total LOS in intensive care unit (18.2 vs. 18.8 days, adjusted mean, p =.82). CONCLUSIONS: Among patients with severe sepsis, PAC placement was not associated with a change in mortality rate or resource utilization, although small nonsignificant trends toward lower resource utilization were present in the PAC group.

APACHE↗

PubMed2006

Is there a role for inhaled nitric oxide as a rescue therapy in respiratory failure associated with hematologic malignancies?

Inhaled nitric oxide has been demonstrated to improve oxygenation in critically ill patients requiring mechanical ventilation. We therefore performed a retrospective review to determine the outcome of patients with hematological malignancies and acute respiratory failure who received inhaled nitric oxide (INO) in a multidisciplinary intensive care unit of a single tertiary referral medical center. Thirteen patients with hematological malignancies who required endotracheal intubation and mechanical ventilation and received INO for acute respiratory failure between January 1998 and December 2002 were identified. Mean +/- standard deviation (SD) age was 47.6 (+/-13.2) years. The mean +/- SD Acute Physiology and Chronic Health Evaluation (APACHE) III score on the day of ICU admission was 94.1 +/- 33.7 with a mean (SD) predicted probability of ICU death of 42.4% (+/-28.6). Mean APACHE III score on the day of initiating INO was 107.6 (+/-34.4) with a predicted mortality in the intensive care unit of 72.7% (+/-23.3). Mean PaO(2) to FiO(2) (PF) ratios (+/-SD) prior to, and immediately after, the initiation of INO were 62.6 (+/-28.2) and 111 (+/-65.1), respectively (P < 0.001). The median duration of INO therapy was 41.8 h (interquartile range, 6.3-98.2). Patients with hematological malignancies and acute respiratory failure to whom INO was administered had clinical deterioration since ICU admission. Despite a marked initial improvement in arterial oxygen tension, all patients ultimately died in the intensive care unit, 8 of them within 48 h of initiating INO. Therefore, despite initial improvement in oxygenation, we did not observe any survival benefit to INO in this setting.

APACHE↗

PubMed1999

The imbalance between coagulation and fibrinolysis is related to the severity of the illness and the prognosis in sepsis.

OBJECTIVES: The coagulation and fibrinolytic system appears to be activated by the septic process independently, leading to the syndrome of disseminated intravascular coagulation (DIC). In this study, we investigated the changes within the hemostatic system related to the severity of the illness and the prognosis in patients with sepsis. METHODS: Plasma thrombin-antithrombin III (TAT) and plasmin-alpha 2-antiplasmin (PAP) complexes were measured using ELISA methods in 32 patients with sepsis and 20 controls and were analyzed according to the APACHE III scores and survival of the patients. RESULTS: Plasma TAT and PAP in patients with sepsis were significantly higher than controls. Nonsurvivors showed greater levels of TAT (21.7 +/- 22.3 ng/mL) and lower levels of PAP (628.4 +/- 378.1 ng/mL) than survivors (TAT: 11.1 +/- 11.2 ng/mL; PAP: 857.1 +/- 364.1 ng/mL). The imbalance between coagulation and fibrinolysis described as TAT/PAP ratio was closely related with APACHE III scores in patients with sepsis (r = 0.47) and the TAT/PAP ratio in nonsurvivors was significantly higher compared with survivors (34.4 +/- 21.4 vs. 14.4 +/- 13.8). CONCLUSION: In sepsis, both coagulation and the fibrinolysis system are activated and the imbalance between coagulation and fibrinolysis predisposes to the hypercoagulation state and is closely related to the severity of the disease and the prognosis.

Adult↗

PubMed1997

[Selenium administration in sepsis patients].

BACKGROUND: It has been hypothesized that low serum selenium concentrations, associated with low glutathione peroxidase activities in critical ill patients may contribute to decreased cleavage from free radicals and deteriorate the clinical outcome. PATIENTS AND METHODS: We therefore performed a controlled, prospective study including 42 patients with inflammatory response syndrome and an APACHE-II score > or = 15. Whereas the controls (Se-, n = 21) received 35 micrograms sodium selenite during the whole treatment period the selenium substitution group (Se+, n = 21) received additional 500 micrograms, 250 micrograms and 125 micrograms sodium selenite, each amount for 3 days. Clinical outcome was monitored by APACHE-III score, documentation of acute renal failure, respiratory insufficiency and the mortality rate until discharge from the hospital. RESULTS: The mean APACHE-II(III) score on admission was 20.6 (68.3) in the Se- versus 20.1 (61.0) in the Se+ group. Age, sex, underlying diseases, the serum selenium levels and glutathione peroxidase activities on admission were equally distributed in both groups. Selenium substitution was followed by a significant increase in serum selenium levels and glutathione peroxidase activity to normal levels, whereas in controls both parameters remained low. The APACHE-III score significantly improved on day 7 (p = 0.018) and 14 (p = 0.041) in the Se+ group. Hemodialysis because of acute renal failure was necessary in 9 (Se-) versus 3 (Se +) patients (p < 0.04). Overall mortality rate in the Se+ group was 33.5% versus 55% in the Se- group (p = 0.13). A subanalysis of those patients with an APACHE-II score > 20 (n = 10) in each group revealed a significant reduction in mortality from 70% to 30% (p = 0.013). No negative side effects of selenium were seen. CONCLUSION: Selenium substitution significantly improves clinical outcome and reduces the incidence of acute renal failure.

APACHE↗

PubMed2003

Nosocomial infection of malnourished patients in an intensive care unit.

Malnutrition is one of the most important factors for the development of nosocomial infection (NI). We performed a study of the correlation between abnormal nutritional factors and NI risk by investigating the patients who stayed longer than 3 days in the intensive care unit (ICU) of our university hospital. The patients were classified into three groups based on serum albumin levels and total lymphocyte counts (TLC). The criteria of Group I (well nourished group) were serum albumin level of 3.5 g/dl or higher and TLC of 1,400/mm3 or higher. The criteria of Group III (severely malnourished group) were serum albumin of less than 2.8 g/dl and TLC of less than 1,000/mm3. The other patients were classified as Group II (moderately malnourished group). The occurrences of NI were monitored during the study period and the APACHE III Score was calculated. The probability of first NI infection in Group III was 2.4 times higher than that in Groups I and II. The mortality rate of 20.5% was more significantly correlated with APACHE III Score than nutritional status. Nineteen (53%) of the total 36 NI patients were infected within 10 days after ICU admission and they all belonged to Group III. When we compared the gap period between infections, the time to first infection was significant.

Cross Infection↗

PubMed2007

Severity of insulin resistance in critically ill medical patients.

Critical illness is characterized by a hypermetabolic state associated with increased mortality, which is partly ascribed to the occurrence of hyperglycemia caused by enhanced endogenous glucose production and insulin resistance (IR). Insulin resistance is well described in patients after surgery and trauma. However, it is less clearly quantified in critically ill medical patients. In this clinical cohort study, IR (M value) was quantified in 40 critically ill medical patients and 25 matched, healthy controls by isoglycemic hyperinsulinemic clamps after an overnight fast on the day after admission to a medical intensive care unit. Energy and substrate metabolism were measured by using indirect calorimetry in the patients before and during the clamp. The severity of illness was assessed by the acute physiology and chronic health evaluation (APACHE) III score. M values of critically ill medical patients were significantly lower compared with healthy controls (2.29 +/- 1.0 and 7.6 +/- 2.9 mg/kg per minute, respectively; P < .001) and were closely related to APACHE III scores (r = -0.43, P < .01), body mass index (r = -0.41, P < .01), and resting energy expenditure (r = 0.40, P < .05). The M value was not associated with age, basal glucose concentrations, and respiratory quotient, and it did not differ among patients with various admission diagnoses. In conclusion, insulin sensitivity was found to be reduced by 70% in critically ill medical patients. The severity of IR was associated with the severity of illness, body mass index, and resting energy expenditure, but not with substrate oxidation rates. In addition, the severity of IR did not vary among patients with different admission diagnoses.

APACHE↗

PubMed2001

Changes in incidence and risk factors of Mycobacterium avium complex infections in patients with AIDS in the era of new antiretroviral therapies.

The aim of the study presented here was to determine the incidence, risk factors and prognostic indicators of Mycobacterium avium complex (MAC) infection in HIV-infected subjects prior to and after the introduction of highly active antiretroviral therapy (HAART). In the HAART era, the incidence of MAC infection decreased significantly from 3.7 to 0.9 per 100 person-years. Using logistic regression analysis, a high acute physiology and chronic health evaluation (APACHE) III score, a low number of CD4+ cells/ mm3 and a high level of HIV viremia were found to be independent predictors of the risk to develop MAC disease; however, a high APACHE III score was the only prognostic indicator associated with an unfavourable outcome of a disseminated MAC infection. These results indicate that MAC infections, although considerably less frequent in the HAART era, are still responsible for cases of severe disease.

AIDS-Related Opportunistic Infections↗

PubMedDate not supplied

[Mortality risk factors in critical surgical patients].

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

Adult↗

PubMed1999

Right heart catheterization in acute lung injury: an observational study.

Right heart catheterization (RHC) is commonly used in the diagnosis and management of acute lung injury (ALI). However, controversy exists regarding RHC. We examined RHC use during the first 3 d of ALI in an observational study of 135 patients defined by American-European Consensus Conference criteria. Study parameters examined for association with RHC included the Acute Physiology and Chronic Health Evaluation (APACHE) III score, lung injury score (LIS), and 20 additional epidemiologic, clinical, and laboratory parameters. RHC was performed in 70 patients (52%) within the first 3 d of ALI. RHC was positively associated (p < 0.05) with a diagnosis of sepsis, APACHE III score, blood urea nitrogen (BUN), creatinine, net fluid balance, and positive end-expiratory pressure. RHC was negatively associated (p < 0.05) with mean arterial pressure (Pa) and PaO2/FIO2. Logistic regression identified four predictors for RHC placement: sepsis, PaO2/FIO2, BUN, and Pa. Initial right atrial and pulmonary artery occlusion pressure measurements demonstrated a moderately strong correlation (r = 0.72). Use of RHC was associated with a change in one or more therapeutic interventions (intravascular fluids, vasopressors, diuretics) in 78% of patients. In summary, patients receiving RHC during the first 3 d of ALI were more severely ill than those who did not receive RHC, and RHC was associated with a change in therapy in most patients.

APACHE↗

PubMed1994

Evaluation of definitions for adult respiratory distress syndrome.

We conducted a cohort study of 423 intensive care unit (ICU) admissions with a primary clinical diagnosis of acute respiratory failure, a PaO2/FIO2 on ICU admission of < 300 mm Hg, and an ICD-9 discharge diagnosis of adult respiratory distress syndrome (ARDS) (518.5 or 518.82) drawn from a nationally representative database of 17,440 ICU admissions to evaluate current and proposed revisions for definitions of ARDS. A variety of nonpulmonary physiologic risk factors, from shock to elevated serum bilirubin measurements, were significant (p < 0.01) for hospital mortality. Multivariable analysis using the admission APACHE III score, primary ICU admission diagnosis, and treatment location before ICU admission provided greater accuracy in prediction (ROC = 0.80) than the individual PaO2/FIO2 (ROC = 0.68). Patients were given an individual risk of hospital mortality based on their admission APACHE III score, treatment location before ICU admission, and ICU admitting diagnosis. Dividing the patient population into groups using a PaO2/FIO2 < or = 150 resulted in a wide range of individual risk for hospital mortality, from < 10 to > 90% in both groups. We conclude that ARDS is a complex clinical entity with a variety of pulmonary and nonpulmonary risk factors for both its development and its prognosis. Current and proposed categorical definitions based on the severity of hypoxemia result in a wide distribution of individual patient risks. Use of these findings in the design and conduct of future clinical trials would improve the evaluation of new therapies.

Adolescent↗

PubMed1994

Cleveland Health Quality Choice (CHQC)--an ongoing collaborative, community-based outcomes assessment program.

Cleveland Health Quality Choice (CHQC) is a unique community-based program designed to provide more efficient delivery of healthcare services through routine collection and dissemination of selected patient interventions and outcomes. This effort, coordinated by a consortium of business, hospital, and medical leaders, provides comparative public data on hospital performance. In the ICU, this effort involves collection of Acute Physiology and Chronic Health Evaluation (APACHE) III, as well as severity and prognostic data. To date, results suggest that a higher percentage of patients admitted to the ICU are at low risk of death or adverse outcome when compared with a national benchmark using APACHE III. Risk-adjusted mortality rates are lower and length of stay is shorter than predicted. CHQC demonstrates that cooperative public efforts, undertaken by groups with often divergent interests and using objective risk estimates, can provide useful data for hospital quality improvement activities and market-based health reform efforts.

Data Collection↗

PubMed1999

Selenium replacement in patients with severe systemic inflammatory response syndrome improves clinical outcome.

OBJECTIVE: To determine the effect of selenium replacement on morbidity and mortality in patients with systemic inflammatory response syndrome (SIRS). DESIGN: Controlled, randomized prospective open-label pilot study comparing patients with and without selenium replacement. SETTING: Intensive care unit of a university hospital for internal medicine. PATIENTS: Forty-two patients with SIRS caused by infection and a minimal Acute Physiology and Chronic Health Evaluation (APACHE) II score of 15 points on the day of admission were included. The selenium replacement group of patients (Se+; n = 21) received sodium selenite for 9 days (535 microg [6.77 micromol] for 3 days, 285 microg [3.61 micromol] for 3 days, and 155 microg [1.96 micromol] for 3 days) and thereafter, 35 microg (0.44 micromol) per day iv. The control group (Se-, n = 21) received 35 microg of sodium selenite throughout the total treatment period. INTERVENTIONS: Morbidity and clinical outcome was monitored by scoring using the APACHE III score, occurrence of acute renal failure, need and length of mechanical ventilation, and hospital mortality. Blood samples on days 0, 3, 7, and 14 were analyzed for serum selenium concentration and glutathione peroxidase (GSH-Px) activity. MEASUREMENTS AND MAIN RESULTS: The median APACHE II score at admission, age, gender, underlying diseases, serum selenium levels, and GSH-Px activities at admission were identical in both groups. In Se+ patients, serum selenium levels and GSH-Px activity normalized within 3 days, whereas in controls, both variables remained significantly low (p < .0001). The APACHE III score decreased significantly in both groups but was significantly lower in the Se+ group (day 3, p > .05; day 7, p = .018; and day 14, p = .045 Se+ compared with Se-). Hemodialysis with continuous veno-venous hemodialysis because of acute renal failure was necessary in nine Se- compared with three Se+ patients (p = .035). Overall mortality in the Se- group was 52% vs. 33.5% in the Se+ group (p = .13). CONCLUSIONS: Selenium replacement in patients with SIRS seems to improve clinical outcome and to reduce the incidence of acute renal failure requiring hemodialysis.

APACHE↗

PubMed1998

[Evaluation of the use of the pulmonary artery catheter in patients with acute myocardial infarct: The PAEEC study. Project of the Epidemiologic Analysis of Critical Illness].

BACKGROUND: The aim of the study was to evaluate the impact of the use of the pulmonary artery catheter on hospital mortality in patients admitted to hospital for acute myocardial infarction. PATIENTS AND METHODS: This retrospective cohort study, included 1,721 patients whose main diagnosis was acute myocardial infarction and who were registered in the PAEEC study (a multicenter study including 86 intensive care units throughout Spain). RESULTS: A pulmonary artery catheter was implanted in 82 patients (4.8%). The mortality of the group with the catheter was 51.2%, being greater than that of the control group which did not receive the catheter (odds ratio [OR] = 8.56, 95% confidence interval [CI] range 5.25-13.93; p < 0.001). This excessive mortality persisted on adjusting for the APACHE-III, age, sex, diabetes, use of mechanical ventilation, vasoactive drugs and thrombolytic treatment (adjusted OR = 3.11; CI 1.59-5.57; p < 0.001). The TISS values of the patients in whom the catheter was implanted were greater than those expected for their age and APACHE-III level, being interpreted as an indicator of occult severity. On inclusion of the TISS values in the logistic regression model, the differences in mortality between the catheter and the control group decreased, but remained statistically significant (OR = 2.05; CI: 1.04-4.0; p = 0.039). CONCLUSIONS: The use of the pulmonary artery catheter was not found to contribute to reducing the mortality of patients with acute myocardial infarction. In fact, these results questions its use, particularly in less severe patients.

Aged↗

PubMed2004

Predictors of long-term mortality in patients with cirrhosis of the liver admitted to a medical ICU.

CONTEXT: The long-term survival of patients with cirrhosis of the liver admitted to the ICU has not been described. OBJECTIVE: The main objectives were to determine the 1-year and 5-year mortality rates of a cohort of patients admitted to a medical ICU (MICU), and to identify the risk factors that may predict long-term outcomes. DESIGN: This is a cohort study. We used a model-building (MB) and model validation (MV) procedure that has previously been described to determine the risk factors for overall mortality. SETTINGS: An MICU in a major referral medical center. PATIENTS: Four hundred twenty consecutive patients admitted to the ICU from January 1, 1993, through October 31, 1998, met the inclusion criteria of diagnosis of liver failure, cirrhosis, chronic liver disease, variceal bleeding, hepatic encephalopathy, or hepatorenal syndrome. Patients with acute liver failure who had undergone liver transplantation, or candidates for orthotopic liver transplantation were excluded. INTERVENTION: None. RESULTS: The 1-year mortality rate was 69%, and the 5-year mortality rate was 77%. The median survival time was 1 month. The independent predictors of mortality in patients in the MB group who retained their significance in the MV group were as follows: an acute physiology, age, and chronic health evaluation (APACHE) III score of >/= 90 (hazard ratio [HR], 2.2; 95% confidence interval [CI], 1.6 to 2.8; p < 0.0001), the use of pressors (HR, 2.5; 95% CI, 1.9 to 3.2; p < 0.0001), and jaundice (HR, 1.7; 95% CI, 1.4 to 2.2; p < 0.0001). Patients with all three risk factors (ie, APACHE III score >/= 90, use of pressors, and jaundice) had a 92% 1-month mortality rate compared to 11.2% for patients with no risk factors. CONCLUSIONS: Patients admitted to an MICU with underlying cirrhosis who are not eligible for liver transplantation have a poor long-term prognosis, even if they survive the ICU admission, particularly as the number of risk factors increases.

APACHE↗

PubMed2001

Predictors of mortality and resource utilization in cirrhotic patients admitted to the medical ICU.

BACKGROUND AND OBJECTIVE: Cirrhotic patients admitted to the medical ICU (MICU) are associated with high mortality rates and high resource utilization. This study identifies specific predictors of increased mortality and resource utilization and uses them to develop and validate prognostic models in cirrhotic patients admitted to the MICU. METHODS: Cirrhotic patients admitted to the MICU were identified from the Critical Care Section database (January 1993 to October 1998). Clinical data were extracted from chart review including hospital course variables, mortality, and length of stay (LOS). Total cost per case (TCPC) was obtained from the Transition System INC: Multivariate logistic and linear regression analyses identified the independent predictors of increased mortality and resource utilization used for model building (MB) and model validation (MV). RESULTS: A total of 582 cases were randomized to the MB and MV groups. Each group contained 240 cases after exclusion criteria were applied. The MICU mortality rate was 36.6%, and the in-hospital mortality rate was 49.0%. Acute physiology, age, and chronic health evaluation (APACHE) III score (odds ratio [OR], 4.7; 95% confidence interval [CI], 2.70 to 8.16; p < 0.001), mechanical ventilation (OR, 4.57; 95% CI, 2.35 to 8.34); p < 0.001), and the use of pressors (OR, 7.57; 95% CI, 4.35 to 13.18; p < 0.001) were independent predictors of MICU mortality. APACHE III score (OR, 4.96; 95% CI, 2.97 to 8.29; p < 0.001), the use of pressors (OR, 6.55; 95% CI, 3.66 to 11.72; p < 0.001), and acute renal failure (ARF) (OR, 4.31; 95% CI, 2.41 to 7.71; p < 0.001) were independent predictors of in-hospital mortality. Increased LOS in the MICU was associated with mechanical ventilation, ARF, bronchoscopy, bacteremia, use of pressors, transjugular intrahepatic portosystemic shunt (TIPS), and never received cardiopulmonary resuscitation (CPR) (p < 0.005). Source of admission, platelet transfusion, bacteremia, pneumonia, and never received CPR were independently associated with increased total LOS (p < 0.001). Mechanical ventilation, platelet transfusion, bronchoscopy, TIPS, sepsis, and never received CPR were independent predictors of increased TCPC (p < 0.001). CONCLUSION: Simple prognostic models for mortality and resource utilization have been developed for cirrhotic patients admitted to the MICU.

APACHE↗

PubMed2002

Acute abdomen in the medical intensive care unit.

OBJECTIVE: Acute abdominal complication in the medical intensive care unit may be underdiagnosed and can add significant risk of death. We hypothesize that delays in surgery because of atypical presentation, such as the absence of peritoneal signs, may contribute to mortality. DESIGN: Retrospective cohort study (1995-2000). SETTING: Medical intensive care unit in a tertiary care center. PATIENTS: Medical intensive care unit patients with clinical, surgical, or autopsy diagnosis of acute abdominal catastrophe (gangrenous or perforated viscus). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Seventy-seven patients (1.3%) met inclusion criteria. Ischemic bowel was the most common diagnosis, followed by perforated ulcer, bowel obstruction, and cholecystitis. Actual mortality rate was higher than predicted by Acute Physiology and Chronic Health Evaluation (APACHE) III scores at the time of medical intensive care unit admission (63% vs. 31%). Twenty-six patients (34%) did not have surgery, and none of these survived. Fifty-one patients underwent surgery and 28 survived (56%). Delay in surgical evaluation (p <.01) and intervention (p <.03), APACHE III scores (p <.01), renal insufficiency (p <.01), and a diagnosis of ischemic bowel (p <.01) were associated with increased mortality rates. Surgical delay was more likely to occur in patients with altered mental state (p <.01), no peritoneal signs (p <.01), previous opioids (p <.03), antibiotics (p <.02), and mechanical ventilation (p <.02). CONCLUSION: Delays in surgical evaluation and intervention are critical contributors to mortality rate in patients who develop acute abdominal complications in a medical intensive care unit.

APACHE↗

PubMed1997

Predicting mortality in intensive care patients with acute renal failure treated with dialysis.

Existing prognostic methods were compared in their ability to predict mortality in intensive care unit (ICU) patients on dialysis for acute renal failure (ARF). The clinical goal of this study was to determine whether these models could identify a group of patients where dialysis would provide no benefit because of a near 100% certainty of death even with dialysis treatment. This retrospective cohort study included 238 adult patients who received a first dialysis treatment for ARF in the ICU. This study examined the performance of seven general ICU mortality prediction models and four mortality prediction models developed for patients with ARF. These models were assessed for their ability to discriminate mortality form survival and for their ability to calibrate the observed mortality rate with the expected mortality rate. The observed in hospital mortality was 76% for our patient group. Areas under the receiver operating characteristic curve ranged from 0.50 to 0.78. With the Acute Physiology and Chronic Health Evaluation (APACHE) III and the Liano models, the observed mortality in the highest quintiles of risk were 97% and 98%. In conclusion, although none of the models examined in this study showed excellent discrimination between those patients who died in hospital and those who did not, some models (APACHE III, Liano) were able to identify a group of patients with a near 100% chance of mortality. This indicates that these models may have some use in supporting the decision not to initiate dialysis in a subgroup of patients.

Acute Kidney Injury↗