Acute Physiology and Chronic Health Evaluation (APACHE II) score and outcome in the surgical intensive care unit: an analysis of multiple intervention and outcome variables in 1,238 patients

Predictors of Treatment Failure and Mortality among Patients with Septic Shock Treated with Meropenem in the Intensive Care Unit

Background

The aim of the study was to determine the predictors of meropenem treatment failure and mortality in the Intensive Care Unit (ICU).

Methods

This was a retrospective study, involving sepsis and septic shock patients who were admitted to the ICU and received intravenous meropenem. Treatment failure is defined as evidence of non-resolved fever, non-reduced total white cell (TWC), non-reduced C-reactive protein (CRP), subsequent culture negative and death in ICU.

Results

An Acute Physiology and Chronic Health Evaluation II (APACHE II) and duration of antibiotic treatment less than 5 days were associated with treatment failure with adjusted OR = 1.24 (95% CI: 1.15, 1.33; P < 0.001), OR = 65.43 (95% CI: 21.70, 197.23; P < 0.001). A higher risk of mortality was observed with higher APACHE and Sequential Organ Failure Assessment (SOFA) scores, initiating antibiotics > 72 h of sepsis, duration of antibiotic treatment less than 5 days and meropenem with renal adjustment dose with an adjusted OR = 1.21 (95% CI: 1.12, 1.30; P < 0.001), adjusted OR = 1.23 (95% CI: 1.08, 1.41; P < 0.001), adjusted OR = 6.38 (95% CI: 1.67, 24.50; P = 0.007), adjusted OR = 0.03 (95% CI: 0.01, 0.14; P < 0.001), adjusted OR = 0.30 (95% CI: 0.14, 0.64; P = 0.002).

Conclusion

A total of 50 (14.12%) patients had a treatment failure with meropenem with 120 (48.02%) ICU mortality. The predictors of meropenem failure are higher APACHE score and shorter duration of meropenem treatment. The high APACHE, high SOFA score, initiating antibiotics more than 72 h of sepsis, shorter duration of treatment and meropenem with renal adjustment dose were predictors of mortality.

Drotrecogin Alfa (Activated) in Sepsis: Initial Experience With Patient Selection, Cost, and Clinical Outcomes

During a 1-year period, the authors examined clinical experience with drotrecogin alfa, activated for sepsis in a 24-bed medical-surgical intensive care unit. Drotrecogin alfa, activated was administered 46 times to 44 patients (3% of all intensive care unit admissions). Eighty-six percent of patients were on vasopressors; 95% were mechanically ventilated. Mean Acute Physiology and Chronic Health Evaluation II score was 22.0 at admission and 21.9 during the 24 hours before drug administration. The 28-day all-cause mortality was 36.4% and hospital mortality was 43.2%, trending higher ( P= .10) than in the PROWESS study, which can be attributed to clinical use in patients who would not have met PROWESS study inclusion criteria. Failure to complete a 96-hour infusion of drotrecogin alfa, activated and transfer from another hospital or nursing home before treatment were associated with poor outcome. Total cost of hospital care, including mean drotrecogin alfa, activated drug cost of $7312, exceeded reimbursement by a mean of $18 227.

Comparison of different scoring systems in predicting short-term mortality after liver transplantation

BACKGROUND

Many scoring systems have been used in predicting the outcomes of liver transplantations. The aim of this study was to compare between 4 scoring systems-Sequential Organ Failure Assessment (SOFA), Model for End-Stage Liver Disease, Acute Physiology and Chronic Health Evaluation II, and Child Turcotte-Pugh -among patients who underwent living-donor liver transplantation (LDLT) seeking to evaluate the best system to correlate with post-operative outcomes.

METHODS

This study retrospectively reviewed the medical records of 53 patients who had received LDLT in a tertiary care hospital from January 2005 to December 2010. Demographic, clinical, and laboratory data were recorded. Each patient was assessed by use of 4 scoring systems before transplantation and on post-operative days 1 to 7 and at 3 months.

RESULTS

The overall 3-month survival rate was 64%. The pre-transplant SOFA score had the best discriminatory power; moreover, the SOFA score on post-operative day 7 had the best Youden index (.875). The survival rate at 3-month follow-up after liver transplantation differed significantly (P = .00023, highest area under the receiver operator characteristic curve = .952) between patients who had SOFA scores <8 and those had SOFA score >8 on post-liver transplant day 7. This study also demonstrated that respiratory rate (P = .017) and serum bilirubin level (P = .048) and duration of intensive care unit stay (P = .04) are significant risk factors related to early mortality after LDLT.

CONCLUSIONS

The pre-transplant SOFA score was a statistically significant predictor of 3-month mortality; SOFA score on post-liver transplant day 7 had the best discriminative power for predicting 3-month mortality.

Results of a prospective, randomized, controlled study of the use of carboxymethylcellulose sodium hyaluronate adhesion barrier in trauma open abdomens

INTRODUCTION

The open abdominal (OA) approach is a management strategy used in the most severely injured trauma patients. In addition to the morbidity and mortality, a major challenge is the gradual development of dense adhesions that make reoperations progressively more difficult. This randomized, prospective, proof-of-concept study was conducted to determine the effect of carboxymethylcellulose sodium hyaluronate adhesion barrier (CMHAB; Seprafilm, Genzyme Biosurgery, Bridgewater, NJ) on abdominal adhesions and wound characteristics in trauma open abdomens.

METHODS

A prospective, randomized, controlled study of wound and adhesion characteristics with or without CMHAB was conducted at 5 level I trauma centers. Consenting patients were randomized to either CMHAB or no adhesion barrier (NAB) groups. We evaluated patient demographics, injury characteristics/severity, reason for OA management, wound sizes (transverse/longitudinal), Zuhlke adhesion score, abdominal contamination score, hospital/intensive care durations of stay, morbidity, and mortality.

RESULTS

Thirty patients were enrolled (17 randomized to CMHAB; 13 randomized to NAB) with mean age of 40.3, Injury Severity Score of 30, Abbreviated Injury Score (AIS)-abdomen of 3.68, APACHE II score of 14.4, and 67% blunt trauma mechanism. The groups were well-matched with regard to age, sex, Injury Severity Score/abdominal AIS, penetrating/blunt injury rates, initial lactate/base deficit, mortality, OA indications, and contamination scores. There were no differences in nonabdominal or abdominal complications (ie, fistula, abscess, wound related) between the groups. Patients with CMHAB had shorter intensive care unit durations of stay (15 vs 22 days; P < .05). Intraoperative adhesion scores were not different during the first four operations but diverged significantly at the 5th operative intervention or after about 1 week of OA therapy. After the 5th operation, adhesion scores in the NAB group were 67% greater (approximately 1 Zuhlke point) than the CMHAB group. We did not note differences between wound sizes over time, closure types, or wound closure characteristics between CMHAB and NAB.

CONCLUSION

Although CMHAB did not eliminate adhesions in this proof-of-concept study, it limited their severity, particularly in abdomens left open >9 days or requiring ≥5 operations. There was no difference in wound sizes, overall or abdominal complications, or mortality between the groups. Further research is warranted to better delineate potential benefits of CMHAB, especially in the setting of reoperations in post-OA patients.

Compliance with and effects of preoperative immunonutrition in patients undergoing pancreaticoduodenectomy

BACKGROUND/PURPOSE

This study was conducted to ascertain the feasibility and effectiveness of preoperative enteral immunonutrition using an immune-enhanced formula (Impact) in patients undergoing pancreaticoduodenectomy.

METHODS

Twenty-five patients undergoing an elective pancreaticoduodenectomy were asked to ingest Impact for 5 days (750 mL/day) prior to surgery in addition to their normal diets. We retrospectively compared the early postoperative outcomes of the Impact group (n = 18), which consisted of patients who fully complied with the study protocol, and a control group (n = 13), which consisted of patients who had not ingested Impact prior to surgery.

RESULTS

Overall, 82.6% of the patients complied with the preoperative oral ingestion of Impact; all but four patients tolerated a daily intake of 750 mL. While the clinical backgrounds of the Impact and control groups were not significantly different, the frequency of incisional wound infection was lower (0 vs. 30.8%, p = 0.012) and the change in systemic severity as evaluated using the acute physiology and chronic health evaluation (APACHE)-II scoring system was milder (p = 0.033) in the Impact group than in the control group.

CONCLUSION

The preoperative oral ingestion of Impact was well tolerated and appeared to be effective for preventing incisional wound infection and reducing the response to surgical stress in patients undergoing a pancreaticoduodenectomy.

History of right heart catheterization: 100 years of experimentation and methodology development

The development of right heart catheterization has provided the clinician the ability to diagnose patients with congenital and acquired right heart disease, and to monitor patients in the intensive care unit with significant cardiovascular illnesses. The development of bedside pulmonary artery catheterization has become a standard of care for the critically ill patient since its introduction into the intensive care unit almost 40 years ago. However, adoption of this procedure into the mainstream of clinical practice occurred without prior evaluation or demonstration of its clinical or cost-effectiveness. Moreover, current randomized, controlled trials provide little evidence in support of the clinical utility of pulmonary artery catheterization in the management of critically ill patients. Nevertheless, the right heart catheter is an important diagnostic tool to assist the clinician in the diagnosis of congenital heart disease and acquired right heart disease, and moreover, when catheter placement is proximal to the right auricle (atria), this catheter provides an important and safe route for administration of fluids, medications, and parenteral nutrition. The purpose of this manuscript is to review the development of right heart catheterization that led to the ability to conduct physiologic studies in cardiovascular dynamics in normal individuals and in patients with cardiovascular diseases, and to review current controversies of the extension of the right heart catheter, the pulmonary artery catheter.

Survival after intestinal perforation: can it be predicted?

OBJECTIVE

Intestinal perforation is associated with high morbidity and mortality in gynecologic oncology patients. We investigated potential factors associated with survival after perforation which may influence treatment recommendations.

METHODS

A retrospective review of all gynecologic oncology patients experiencing intestinal perforation between 1993 and 2007 was performed. Demographics, cancer history, presenting symptoms, vital signs, laboratory values, and management of perforation were collected, and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were calculated for each patient. Factors affecting survival from the time of perforation were analyzed using Kaplan-Meier method and univariate and multivariate Cox proportional hazard models. Student's t-test and chi(2) analysis were also utilized to evaluate potential associations.

RESULTS

Fifty-three patients met the inclusion criteria. No difference in survival was found based on disease site, history of radiation therapy, presenting symptoms, smoking history, or presence of bowel procedures performed during the most recent abdominal surgery prior to perforation. APACHE II score, disease status, body mass index, and treatment method of perforation were found to be significant prognostic factors for survival. After multivariate Cox regression analysis, only APACHE II scores remained significantly associated with an increased risk of death. Median survival of patients with APACHE II scores <15 was 28.13 months compared to 2.90 months in patients with scores> or =15 (P<0.0001).

CONCLUSION

Many factors must be examined when determining the management of intestinal perforation in gynecologic oncology patients. Clinicians should consider the APACHE II score in their assessment to assist risk stratification and treatment planning of these patients.

Outcome evaluation in a surgical intensive care unit in Barbados

The performance of the Acute Physiology and Chronic Health Evaluation II scoring system was prospectively assessed in the surgical intensive care unit at the Queen Elizabeth Hospital, Barbados. A total of 309 patients admitted consecutively during a 2-year period (1999-2001) were evaluated. Demographic data, diagnosis, Acute Physiology and Chronic Health Evaluation II score, duration of stay and hospital outcome were recorded. The predicted mortality for every patient and the costs incurred were also calculated. The overall observed mortality rate was 15.9% while the mean predicted mortality rate for our case-mix was 16.4%, which is comparable to results from developed countries. The cost incurred per patient was much lower at $13,636 (Barbados), compared to the patients' cost in North America ($60,000 Barbados).

The end of the Injury Severity Score (ISS) and the Trauma and Injury Severity Score (TRISS): ICISS, an International Classification of Diseases, ninth revision-based prediction tool, outperforms both ISS and TRISS as predictors of trauma patient survival, hospital charges, and hospital length of stay

INTRODUCTION

Since their inception, the Injury Severity Score (ISS) and the Trauma and Injury Severity Score (TRISS) have been suggested as measures of the quality of trauma care. In concept, they are designed to accurately assess injury severity and predict expected outcomes. ICISS, an injury severity methodology based on International Classification of Diseases, Ninth Revision, codes, has been demonstrated to be superior to ISS and TRISS. The purpose of the present study was to compare the ability of TRISS to ICISS as predictors of survival and other outcomes of injury (hospital length of stay and hospital charges). It was our hypothesis that ICISS would outperform ISS and TRISS in each of these outcome predictions.

METHODS

"Training" data for creation of ICISS predictions were obtained from a state hospital discharge data base. "Test" data were obtained from a state trauma registry. ISS, TRISS, and ICISS were compared as predictors of patient survival. They were also compared as indicators of resource utilization by assessing their ability to predict patient hospital length of stay and hospital charges. Finally, a neural network was trained on the ICISS values and applied to the test data set in an effort to further improve predictive power. The techniques were compared by comparing each patient's outcome as predicted by the model to the actual outcome.

RESULTS

Seven thousand seven hundred five patients had complete data available for analysis. The ICISS was far more likely than ISS or TRISS to accurately predict every measure of outcome of injured patients tested, and the neural network further improved predictive power.

CONCLUSION

In addition to predicting mortality, quality tools that can accurately predict resource utilization are necessary for effective trauma center quality-improvement programs. ICISS-derived predictions of survival, hospital charges, and hospital length of stay consistently outperformed those of ISS and TRISS. The neural network-augmented ICISS was even better. This and previous studies demonstrate that TRISS is a limited technique in predicting survival resource utilization. Because of the limitations of TRISS, it should be superseded by ICISS.

Analyzing intensive care unit length of stay data: problems and possible solutions

OBJECTIVES

To explore methods of evaluating the length of stay patterns of intensive care unit (ICU) patients. It was hypothesized that the mean does not adequately describe the typical length of stay (central tendency) because distribution patterns are often markedly skewed by patients with extended stays. Therefore, other descriptors are needed. In addition, ways are needed to identify outliers-patients with stays longer or shorter than the bulk of the data.

DESIGN

Review of retrospective data.

SETTING

University hospital surgical ICU.

PATIENTS

Representative data included all (4,499) patients admitted over a 6-yr period. Each was assigned to a diagnostic group that represented either a frequently performed surgical procedure (e.g., thymectomy) or in cases where there was no predominant procedure, a surgical discipline (e.g., otolaryngology).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The frequency distributions were usually skewed to the right and included two populations of interest: The portion with the majority of observations ("body"), which described "typical" behavior, and the "tail", which provided information on outliers. The average of the mean lengths of stay of all diagnostic groups was higher than the average of the medians (3.9 +/- 1.8 [SD] vs. 2.7 +/- 1.1 days, p < .001) and modes (2.1 +/- 1.2 days, p < .001), reflecting the rightward skewness of the length of stay frequency distributions. The median +/- 1 day included 75 +/- 13% of the patients, thus confirming that the median was the most useful descriptor of central tendency. Various methods were used to identify outliers. Histograms of the frequency distributions were examined and outliers visually identified. Conventional outlier analysis labeled as outliers patients staying greater than two standard deviations from the mean stay. This method underestimated the number of outliers when the distributions were skewed to the right. Another method involved designating a specific length of stay (e.g., 7 or 10 days) or percentage of patients as the outlier threshold. Each method designated different numbers of patients as outliers.

CONCLUSIONS

When analyzing length of stay data it is important to visually examine the frequency distribution because it is often skewed to the right. This skewness renders traditional parameters such as the mean and standard deviation less useful for describing the typical length of stay. Instead, the median, mode, and harmonic mean should be used. When reporting length of stay, some indication of the characteristics of the data should be presented. A graph of the frequency distribution rapidly allows the reader to determine its shape. A simple method is to report the mean, median, and range.

Comparison of the Injury Severity Score and ICD-9 diagnosis codes as predictors of outcome in injury: analysis of 44,032 patients

INTRODUCTION

Appropriate stratification of injury severity is a critical tool in the assessment of the treatment and the prevention of injury. Since its inception, the Injury Severity Score (ISS) has been the generally recognized "gold standard" for anatomic injury severity assessment. However, there is considerable time and expense involved in the collection of the information required to calculate an accurate ISS. In addition, the predictive power of the ISS has been shown to be limited. Previous work has demonstrated that the anatomic information about injury contained in the International Classification of Diseases Version 9 (ICD-9) can be a significant predictor of survival in trauma patients. The goal of this study was to utilize the San Diego County Trauma Registry (SDTR), one of the nation's leading trauma registries, to compare the predictive power of the ISS with the predictive power of the information contained in the injured patients' ICD-9 diagnoses codes. It was our primary hypothesis that survival risk ratios derived from patients' ICD-9 diagnoses codes would be equal or better predictors of survival than the Injury Severity Score. The implications of such a finding would have the potential for significant cost savings in the care of injured patients.

METHODS

Data for the test population were obtained from the SDTR, which contains data from 1985 through 1993 from five participating hospitals. Four data sources were utilized to estimate the expected survival rate/mortality rate for each ICD-9 code in the SDTR. These were (1) the SDTR patients themselves, (2) the North Carolina State Hospital Discharge Database, (3) the North Carolina Trauma Registry Database, and (4) the Agency for Health Care Policy Research's Health Care Utilization Project Database. Each of these data sources was separately utilized to develop a survival risk ratio (SRR) for each ICD-9 diagnoses code. The SRR was calculated by dividing the number of survivors for patients with each ICD-9 code by the total number of all patients with the particular ICD-9 diagnoses code. The four groups of SRRs derived from our four data sources were used as predictors of survival and the ability of the SRRs to predict survival was compared with the predictive power of the ISS using measures of accuracy, sensitivity, specificity, and receiver operator characteristic curves.

RESULTS

During the years 1985 through 1993, complete data were available for analysis on 44,032 patients. Of these, 2,848 patients died during their hospitalization (6%). Survival risk ratios were calculated for each of the diagnoses in the data base. Logistic regression, using the SAS System for statistical analysis, was used to assess the relative predictive power of the ISS and the survival risk ratios derived from the ICD-9 diagnoses codes from each of the four data bases. The analyses demonstrated that the regression models using the SRRs were generally as good or better than ISS as predictors of survival. The predictive power of the SRRs derived from the SDTR data, the North Carolina Trauma Registry data and the Health Care Utilization Report data were the best. In a subsequent analysis, the SRR values and the ISS were added to the patient's age and the revised Trauma Scores to create new predictive models in the mode of TRISS methodology. The analyses again indicated that the models using SRRs had as good or better predictive power than the model using the ISS.

CONCLUSIONS

The present study confirms previous work showing that survival risk ratios derived from injured patients' ICD-9 diagnoses codes are as good as or better than ISS as predictors of survival.

Immediate postoperative care of cardiac surgical patients

Anesthetic care of the cardiac surgery patient is a continuum, beginning with the preoperative visit and ending when the patient is ambulatory and breathing well on the postoperative floor. Anesthesiologists are well-suited to provide postoperative care because the respiratory and cardiovascular management techniques are an extension of OR management. Attention to details is as important in the ICU as in the OR and offers the opportunity to forestall or reduce morbidity.

Does Acute Physiologic and Chronic Health Evaluation (APACHE II) scoring predict need for prolonged support after coronary revascularization?

Significant intensive care unit (ICU) resources are allocated to patients recovering from coronary artery bypass graft (CABG) procedures, suggesting that a system to identify patients at risk for prolonged ICU therapy would help to enhance the use of this resource. To test the hypothesis that post-CABG patients likely to require prolonged ICU stay could be identified at the time of admission using the Acute Physiologic and Chronic Health Evaluation (APACHE II) system for scoring the severity of illness, we retrospectively reviewed the length of ICU stay for all patients recovering from CABG procedures over 1 yr, comparing the APACHE II scores assigned to patients requiring the longest stay with scores for patients with the briefest stay to determine whether a difference in score corresponded with the difference in length of stay. All medical records were reviewed and the physiologic variables (n = 12) used to assess acute physiologic status were recorded. Perioperative therapeutic interventions having significant impact on the physiologic variables used to derive the APACHE II score also were recorded. The study group was defined as patients requiring ICU care lasting between 14 and 84 days (n = 20); a control group of 23 patients was randomly selected from 124 patients having an ICU stay of 48 h or less. The overall APACHE II scores, and the component scores used to derive the overall scores, were calculated for both groups and were compared. The mean APACHE II score for the study group was 23.5 compared with 13.2 (P < 0.001) for the control group.(ABSTRACT TRUNCATED AT 250 WORDS)

Injury severity and probability of survival assessment in trauma patients using a predictive hierarchical network model derived from ICD-9 codes

Accurate assessment of injury severity is critical for decision making related to the prevention, triage, and treatment of injured patients. Presently, the standard method of controlling for variations of injury severity between groups has been based upon the Injury Severity Score (ISS) and the Trauma Score and the Trauma and Injury Severity Score (TRISS) methodology. The purpose of this study was to attempt to build upon previous work using International Classification of Diseases, ninth revision (ICD-9) coded diagnosis, and procedure information available from standard hospital discharge abstracts (UB-82 Billing format) to create a hierarchical network to provide a tool for predicting injury severity and probability of survival.

METHODS

Data were obtained for this analysis from the North Carolina Medical Database. Data were available on all trauma patients admitted to hospitals in North Carolina from January 1, 1988 until June 30, 1992. The dependent variable of interest was the patient's survival after injury, coded as live or die. The independent variables used in the study included the ISS derived using the technique described by MacKenzie Abbreviated Injury Score (AIS) and body system maximum AIS scores, mortality risk ratios derived from the ICD-9-DM primary, secondary, and tertiary diagnoses, primary and secondary procedures as described in previous work, age and gender. Network generation used a commercial software package, AIM (Abtech Corp., Charlottesville, Va.), which is a numeric modeling tool that automatically "learns" knowledge from a data base of examples.

RESULTS

In the test data set an ISS and a prediction of survival based upon the derived network were calculated for each and every patient. The relative predictive power of these two scores were compared by calculating the overall accuracy, sensitivity, and specificity and the false positive and false negative rates. The receiver operator characteristic curves demonstrate that the network is a more effective tool in predicting the outcome of trauma patients. All the measures of predictive power show that the network was the better predictor of outcome than the ISS.

CONCLUSIONS

Given the recognized limitations of the ISS, the widespread availability of the ICD-9 coded diagnoses and procedures, and the availability of many state and regional data bases that have no ISS or Trauma Score, the purpose of this study was to assess the ability of a network derived from limited but widely available hospital discharge data to predict the outcome of injured patients. The study confirms previous work showing that the ICD-9 codes were strongly associated with outcome. The study demonstrated that the network created from these data was a better predictor of outcome than the derived ISS. When the results of the network were compared with other published series, the network, created without access to physiologic information, was almost as accurate, sensitive, and specific as reported values for TRISS and A Severity Characterization of Trauma (ASCOT). Because the present study is the first of its type, further investigations are needed to validate these findings. If other studies corroborate this study, a network model based upon ICD-9 codes could become the principal method for grading injury severity. This would provide superior predictive power of injury severity with important cost savings and universal application.

Multiple organ failure after liver transplantation

OBJECTIVE

To examine the effect of multiple organ failure after liver transplantation on mortality and resource utilization.

DESIGN

Retrospective cohort study.

SETTING

Surgical intensive care unit in a tertiary care university hospital.

PATIENTS

Consecutive series of 113 adults undergoing liver transplantation between 1984 and 1992. Patients were excluded if they died intraoperatively (n = 2), required retransplantation (n = 8), or had incomplete records (n = 7).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We prospectively developed definitions for organ failure, and quantitated the frequency and related outcomes for mortality and resource utilization. Multiple organ failure was defined as the presence of two or more organ failures. Patients were grouped according to the presence (n = 31) or absence (n = 65) of multiple organ failure. Preoperative severity of illness was assessed by the Acute Physiology and Chronic Health Evaluation (APACHE II) and United Network for Organ Sharing (UNOS) scoring systems. Postoperative outcome data, including hospital survival rate, hospital length of stay, and charges were recorded. The frequency of multiple organ failure after liver transplantation was 32%. The mortality rate in the patients who developed multiple organ failure was 42% vs. only 2% in those patients without multiple organ failure (p < .0001). Patients with four or more organ failures had a 100% mortality rate. Postoperative multiple organ failure was associated with increased hospital length of stay (46 +/- 7 days vs. 29 +/- 2 days; p = .026) and increased hospital charges ($271,497 +/- 29,994 vs. $136,372 +/- 8,310; p < .0001). Higher preoperative APACHE II and UNOS scores predicted postoperative multiple organ failure, but were less accurate tools for predicting risk of death.

CONCLUSIONS

Multiple organ failure is associated with death and increased resource utilization in liver transplantation. Pretransplantation severity of illness, as measured by APACHE II and UNOS scoring systems, is an important determinant of postoperative multiple organ failure and outcome.

The predictive value of four scoring systems in liver transplant recipients

OBJECTIVE

To compare 4 general severity classification scoring systems concerning prognosis of outcome in 123 liver transplant recipients. The compared scoring systems were: the mortality prediction model (admission model and 24 h model); the simplified acute physiology score; the acute physiology and chronic health evaluation (Apache II) and the acute organ systems failure score.

DESIGN

Retrospective, consecutive sample.

SETTING

Adult intensive care unit in a university hospital.

PATIENTS

123 adult liver allograft recipients after admission to the intensive care unit.

MEASUREMENTS AND MAIN RESULTS

The scoring systems were calculated as described by the authors to classify the severity of illness after admission of the allograft recipients to the intensive care unit. The mean and median values of survivors and the group of patients, that died during hospital stay were compared. Receiver-operating characteristics were plotted for all scoring systems and the areas under the curves of receiver-operating characteristics were calculated. The predictive value of the 4 scoring systems was tested using a variety of sensitivity analyses. The mortality prediction model (24 h model) was found to have a high significance (p < 0.001) in predicting mortality and showed the greatest area under the curve (0.829). Simplified acute physiology score (p < 0.001) and acute physiology and chronic health evaluation (Apache II) (p < 0.01) had a high significance as well, but did not hit the level of prognosis of mortality prediction model, as shown in the area under the curves. Accordingly, sensitivity was highest in MPM-24 h (83%), followed by SAPS (72%) and Apache II (71%). MPM-24 h had a total misclassification rate of 22% (SAPS = 32%, Apache II = 33%). MPM-admission failed in predicting mortality (sensitivity = 52%). Organ systems failure score seemed not to be useful in liver transplant recipients.

CONCLUSION

General disease classification systems, such as the mortality prediction model, simplified acute physiology score or acute physiology and chronic health evaluation are good mortality prediction models in patients after liver transplantation. We suggest that there is no need for improvement of a special scoring system.

Survival after in-hospital cardiopulmonary arrest of noncritically ill patients. A prospective study

BACKGROUND

The rising healthcare costs and the ethical and economic implications of cardiopulmonary resuscitation (CPR) have generated interest in defining criteria to predict the appropriateness of CPR in specific patients. Age has been proposed as one such a criterion.

METHODS

As part of a quality assurance program, all instances of CPR (code-500) at our VA Medical Center were prospectively studied over a period of 45 months. Only events in noncritical care hospital areas were included in this analysis. The CPR data were prospectively collected, and follow-up of initial survivors was continued until the end of the study period or until a patient died.

RESULTS

Of a total of 422 code-500 events, 387 (92 percent) met our study definition of cardiorespiratory arrest, and 255 of these occurred in a noncritical care area and were included in the study. Our immediate survival was 52 percent (n = 132), survival after intensive care unit (ICU) stay was 22 percent (n = 55), survival to hospital discharge was 11 percent (n = 28), and 4 percent of the patients (n = 10) were alive at the end of follow-up (mean, 22 months). None of the patients discharged alive had a significant new neurologic deficit, and all but one returned to their preadmission environment. The post-CPR hospital charges for each of the surviving patients was estimated at $63,000. Age, the admitting diagnosis, and main comorbidity did not predict long-term survival. The post-CPR Apache II score correlated with a patient surviving the ICU stay, but did not correlate with long-term survival either.

CONCLUSIONS

Age alone is not a valid criterion to decide whether a patient is a suitable candidate for CPR, and the principal diagnosis and main comorbidity at the time of admission do not appear to predict long-term survival either. Whether in-hospital CPR in noncritical care areas is cost-effective is an issue that society at large must eventually decide.

Adrenocortical function: an indicator of severity of disease and survival in chronic critically ill patients

Plasma cortisol levels and modified Apache II (Apache IIm-stay) severity of disease scores were determined at weekly intervals in 159 patients who were treated for at least 7 days at the Critical Care Unit of our hospital. The mean (+/- SD) plasma cortisol level (0.60 +/- 0.28 mumol/l) was clearly elevated in these patients. The highest plasma cortisol levels were measured in patients treated with vasoactive drugs (0.76 +/- 0.39 mumol/l). Non-survivors (n = 36) had a significantly higher mean plasma cortisol level and Apache IIm-stay score than survivors (respectively 0.78 +/- 0.40 vs. 0.54 +/- 0.21 mumol/l; p less than 0.0003 and 12.6 +/- 4.8 vs. 7.3 +/- 4.1; p less than 0.0001). A significant correlation was found between the individual weekly plasma cortisol levels and the Apache IIm-stay scores (r = 0.41; p less than 0.0001), especially in the subgroup of patients, who never received glucocorticoids during their stay at the ICU (r = 0.51; p less than 0.0001). During the 14-month study period only two patients showed a clinical picture of adrenocortical insufficiency and a blunted response of cortisol to 0.25 mg synthetic ACTH(1-24). In conclusion, our data suggest that a high plasma cortisol level, like a high Apache IIm-stay score, indicates severity of disease and poor survival in critically ill patients. De novo adrenocortical insufficiency is rare and therefore routine screening of adrenocortical function is superfluous.