Mortalidad e índices pronósticos en pacientes obesos que ingresan en la UCI

APACHE-II score and Killip class for patients with acute myocardial infarction

OBJECTIVE

To analyse the influence on the prognosis of intensive care unit (ICU) patients with acute myocardial infarction (AMI): prognostic index score, Killip class, AMI site, thrombolysis and other variables that might improve prognostic capacity and functioning of the APACHE-II index.

DESIGN

Cohort study using prospectively gathered ARIAM project data.

SETTING

ICUs from 129 Spanish hospitals.

PATIENTS

ICU-admitted AMI patients in ARIAM database during 4-year period were retrospectively studied.

MEASUREMENTS AND MAIN RESULTS

The sample comprised 6,458 patients, 76.8% males, age 64.97 +/- 12.56 years, APACHE-II score 9.49 +/- 7.03 points and ICU mortality 8.9%. Mortality was higher for females (p < 0.001), anterior AMI site (p < 0.001), previous AMI (p < 0.001), delay-to-hospital arrival >180 min (p = 0.003) and non-receipt of thrombolysis (p = 0.015). ICU mortality was related to age (p < 0.001) and APACHE-II score (p < 0.001). In multivariate analysis, it was related to APACHE-II (OR 1.16), age (OR 1.05), gender (OR 1.64), previous AMI (OR 1.57), anterior AMI (OR 2.05) and delay >180 min (OR 1.37). Killip class, gathered in 1,893 patients, was significantly associated with ICU mortality, and two predictive models were constructed for this group using multivariate analysis. Area under ROC curve was 0.94 in one (Killip class, age, gender, APACHE-II) versus 0.92 in the other (same variables without APACHE-II).

CONCLUSIONS

APACHE-II score and Killip class are useful for assessing the severity of patients with AMI and are complementary. Each can be used with a few commonly gathered clinical variables to construct prognostic models to assess severity. Their joint application yields a model with excellent discrimination capacity.

Effect of obesity on intensive care morbidity and mortality: a meta-analysis

OBJECTIVE

To evaluate the effect of obesity on intensive care unit mortality, duration of mechanical ventilation, and intensive care unit length of stay among critically ill medical and surgical patients.

DESIGN

Meta-analysis of studies comparing outcomes in obese (body mass index of > or = 30 kg/m2) and nonobese (body mass index of < 30 kg/m2) critically ill patients in intensive care settings.

DATA SOURCE

MEDLINE, BIOSIS Previews, PubMed, Cochrane library, citation review of relevant primary and review articles, and contact with expert informants.

SETTING

Not applicable.

PATIENTS

A total of 62,045 critically ill subjects.

INTERVENTIONS

Descriptive and outcome data regarding intensive care unit mortality and morbidity were extracted by two independent reviewers, according to predetermined criteria. Data were analyzed using a random-effects model.

MEASUREMENTS AND MAIN RESULTS

Fourteen studies met inclusion criteria, with 15,347 obese patients representing 25% of the pooled study population. Data analysis revealed that obesity was not associated with an increased risk of intensive care unit mortality (relative risk, 1.00; 95% confidence interval, 0.86-1.16; p = .97). However, duration of mechanical ventilation and intensive care unit length of stay were significantly longer in the obese group by 1.48 days (95% confidence interval, 0.07-2.89; p = .04) and 1.08 days (95% confidence interval, 0.27-1.88; p = .009), respectively, compared with the nonobese group. In a subgroup analysis, an improved survival was observed in obese patients with body mass index ranging between 30 and 39.9 kg/m2 compared with nonobese patients (relative risk, 0.86; 95% confidence interval, 0.81-0.91; p < .001).

CONCLUSION

Obesity in critically ill patients is not associated with excess mortality but is significantly related to prolonged duration of mechanical ventilation and intensive care unit length of stay. Future studies should target this population for intervention studies to reduce their greater resource utilization.