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Jansen G, Entz S, Holland FO, Lamprinaki S, Thies KC, Borgstedt R, Krüger M, Abu-Tair M, May TW, Rehberg S. A comparison of Simplified Acute Physiology Score II and Sepsis-related Organ Failure Assessment Score for prediction of mortality after Intensive Care Unit cardiac arrest. Minerva Anestesiol 2024; 90:359-368. [PMID: 38656085 DOI: 10.23736/s0375-9393.24.17825-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
BACKGROUND This study investigates the predictive value and suitable cutoff values of the Sepsis-related Organ Failure Assessment Score (SOFA) and Simplified Acute Physiology Score II (SAPS-II) to predict mortality during or after Intensive Care Unit Cardiac Arrest (ICU-CA). METHODS In this secondary analysis the ICU database of a German university hospital with five ICU was screened for all ICU-CA between 2016-2019. SOFA and SAPS-II were used for prediction of mortality during ICU-CA, hospital-stay and one-year-mortality. Receiver operating characteristic curves (ROC), area under the ROC (AUROC) and its confidence intervals were calculated. If the AUROC was significant and considered "acceptable," cutoff values were determined for SOFA and SAPS-II by Youden Index. Odds ratios and sensitivity, specificity, positive and negative predictive values were calculated for the cutoff values. RESULTS A total of 114 (78 male; mean age: 72.8±12.5 years) ICU-CA were observed out of 14,264 ICU-admissions (incidence: 0.8%; 95% CI: 0.7-1.0%). 29.8% (N.=34; 95% CI: 21.6-39.1%) died during ICU-CA. SOFA and SAPS-II were not predictive for mortality during ICU-CA (P>0.05). Hospital-mortality was 78.1% (N.=89; 95% CI: 69.3-85.3%). SAPS-II (recorded within 24 hours before and after ICU-CA) indicated a better discrimination between survival and death during hospital stay than SOFA (AUROC: 0.81 [95% CI: 0.70-0.92] vs. 0.70 [95% CI: 0.58-0.83]). A SAPS-II-cutoff-value of 43.5 seems to be suitable for prognosis of hospital mortality after ICU-CA (specificity: 87.5%, sensitivity: 65.6%; SAPS-II>43.5: 87.5% died in hospital; SAPS-II<43.5: 65.6% survived; odds ratio:13.4 [95% CI: 3.25-54.9]). Also for 1-year-mortality (89.5%; 95% CI: 82.3-94.4) SAPS-II showed a better discrimination between survival and death than SOFA: AUROC: 0.78 (95% CI: 0.65-0.91) vs. 0.69 (95% CI: 0.52-0.87) with a cutoff value of the SAPS-II of 40.5 (specificity: 91.7%, sensitivity: 64.3%; SAPS-II>40.5: 96.4% died; SAPS-II<40.5: 42.3% survived; odd ratio: 19.8 [95% CI: 2.3-168.7]). CONCLUSIONS Compared to SOFA, SAPS-II seems to be more suitable for prediction of hospital and 1-year-mortality after ICU-CA.
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Affiliation(s)
- Gerrit Jansen
- University Department of Anesthesiology, Intensive Care Medicine and Emergency Medicine, Johannes Wesling Klinikum Minden, Ruhr University Bochum, Minden, Germany -
- Bielefeld University, Medical School OWL, Bielefeld, Germany -
- Department of Medical and Emergency Services, Study Institute Westfalen-Lippe, Bielefeld, Germany -
| | - Stefanie Entz
- Clinic for Internal Medicine and Gastroenterology, Protestant Hospital of the Bethel Foundation, University Hospital OWL, University of Bielefeld, Bielefeld, Germany
| | - Fee O Holland
- Clinic for Internal Medicine and Nephrology, Protestant Hospital of the Bethel Foundation, University Hospital OWL, University of Bielefeld, Bielefeld, Germany
| | - Styliani Lamprinaki
- Clinic for Internal Medicine and Gastroenterology, Lukas Hospital Bünde, Bünde, Germany
| | - Karl-Christian Thies
- Department of Anesthesiology, Intensive Care, Emergency Medicine, Transfusion Medicine, and Pain Therapy, Protestant Hospital of the Bethel Foundation, University Hospital OWL, University of Bielefeld, Bielefeld, Germany
| | - Rainer Borgstedt
- Department of Anesthesiology, Intensive Care, Emergency Medicine, Transfusion Medicine, and Pain Therapy, Protestant Hospital of the Bethel Foundation, University Hospital OWL, University of Bielefeld, Bielefeld, Germany
| | - Martin Krüger
- Clinic for Internal Medicine and Gastroenterology, Protestant Hospital of the Bethel Foundation, University Hospital OWL, University of Bielefeld, Bielefeld, Germany
| | - Mariam Abu-Tair
- Clinic for Internal Medicine and Nephrology, Protestant Hospital of the Bethel Foundation, University Hospital OWL, University of Bielefeld, Bielefeld, Germany
| | - Theodor W May
- Coordination Office for Studies in Biomedicine and Preclinical and Clinical Research, Protestant Hospital of the Bethel Foundation, University Hospital OWL, University of Bielefeld, Bielefeld, Germany
| | - Sebastian Rehberg
- Department of Anesthesiology, Intensive Care, Emergency Medicine, Transfusion Medicine, and Pain Therapy, Protestant Hospital of the Bethel Foundation, University Hospital OWL, University of Bielefeld, Bielefeld, Germany
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2
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Lascarrou JB, Bougouin W, Chelly J, Bourenne J, Daubin C, Lesieur O, Asfar P, Colin G, Paul M, Chudeau N, Muller G, Geri G, Jacquier S, Pichon N, Klein T, Sauneuf B, Klouche K, Cour M, Sejourne C, Annoni F, Raphalen JH, Galbois A, Bruel C, Mongardon N, Aissaoui N, Deye N, Maizel J, Dumas F, Legriel S, Cariou A. Prospective comparison of prognostic scores for prediction of outcome after out-of-hospital cardiac arrest: results of the AfterROSC1 multicentric study. Ann Intensive Care 2023; 13:100. [PMID: 37819544 PMCID: PMC10567621 DOI: 10.1186/s13613-023-01195-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/26/2023] [Indexed: 10/13/2023] Open
Abstract
BACKGROUND Out-of-hospital cardiac arrest (OHCA) is a heterogeneous entity with multiple origins and prognoses. An early, reliable assessment of the prognosis is useful to adapt therapeutic strategy, tailor intensity of care, and inform relatives. We aimed primarily to undertake a prospective multicentric study to evaluate predictive performance of the Cardiac Arrest Prognosis (CAHP) Score as compare to historical dataset systematically collected after OHCA (Utstein style criteria). Our secondary aim was to evaluate other dedicated scores for predicting outcome after OHCA and to compare them to Utstein style criteria. METHODS We prospectively collected data from 24 French and Belgium Intensive Care Units (ICUs) between August 2020 and June 2022. All cases of non-traumatic OHCA (cardiac and non-cardiac causes) patients with stable return of spontaneous circulation (ROSC) and comatose at ICU admission (defined by Glasgow coma score ≤ 8) on ICU admission were included. The primary outcome was the modified Rankin scale (mRS) at day 90 after cardiac arrest, assessed by phone interviews. A wide range of developed scores (CAHP, OHCA, CREST, C-Graph, TTM, CAST, NULL-PLEASE, and MIRACLE2) were included, and their accuracies in predicting poor outcome at 90 days after OHCA (defined as mRS ≥ 4) were determined using the area under the receiving operating characteristic curve (AUROC) and the calibration belt. RESULTS During the study period, 907 patients were screened, and 658 were included in the study. Patients were predominantly male (72%), with a mean age of 61 ± 15, most having collapsed from a supposed cardiac cause (64%). The mortality rate at day 90 was 63% and unfavorable neurological outcomes were observed in 66%. The performance (AUROC) of Utstein criteria for poor outcome prediction was moderate at 0.79 [0.76-0.83], whereas AUROCs from other scores varied from 0.79 [0.75-0.83] to 0.88 [0.86-0.91]. For each score, the proportion of patients for whom individual values could not be calculated varied from 1.4% to 17.4%. CONCLUSIONS In patients admitted to ICUs after a successfully resuscitated OHCA, most of the scores available for the evaluation of the subsequent prognosis are more efficient than the usual Utstein criteria but calibration is unacceptable for some of them. Our results show that some scores (CAHP, sCAHP, mCAHP, OHCA, rCAST) have superior performance, and that their ease and speed of determination should encourage their use. Trial registration https://clinicaltrials.gov/ct2/show/NCT04167891.
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Affiliation(s)
- Jean Baptiste Lascarrou
- AfterROSC Network Group, Paris, France.
- Université de Paris Cité, Inserm, Paris Cardiovascular Research Center, Paris, France.
- Service de Médecine Intensive Réanimation, University Hospital Center, 30 Boulevard Jean Monet, 44093, Nantes Cedex 9, France.
| | - Wulfran Bougouin
- AfterROSC Network Group, Paris, France
- Université de Paris Cité, Inserm, Paris Cardiovascular Research Center, Paris, France
- Médecine Intensive Réanimation, Hôpital Jacques Cartier, Massy, France
| | - Jonathan Chelly
- AfterROSC Network Group, Paris, France
- Médecine Intensive Réanimation, CH Toulon, Toulon, France
| | - Jeremy Bourenne
- AfterROSC Network Group, Paris, France
- Réanimation des Urgences et Déchocage, CHU La Timone, APHM, Marseille, France
| | - Cedric Daubin
- AfterROSC Network Group, Paris, France
- Médecine Intensive Réanimation, CHU Caen, Caen, France
| | - Olivier Lesieur
- AfterROSC Network Group, Paris, France
- Médecine Intensive Réanimation, CH La Rochelle, La Rochelle, France
| | - Pierre Asfar
- AfterROSC Network Group, Paris, France
- Médecine Intensive Réanimation, CHU Angers, Angers, France
| | - Gwenhael Colin
- AfterROSC Network Group, Paris, France
- Médecine Intensive Réanimation, CHD Vendée, La Roche-Sur-Yon, France
| | - Marine Paul
- AfterROSC Network Group, Paris, France
- Médecine Intensive Réanimation, CH Versailles, Le Chesnay, France
| | - Nicolas Chudeau
- AfterROSC Network Group, Paris, France
- Médecine Intensive Réanimation, CH Le Mans, Le Mans, France
| | - Gregoire Muller
- AfterROSC Network Group, Paris, France
- Médecine Intensive Réanimation, CHR Orléans, Orléans, France
| | - Guillaume Geri
- AfterROSC Network Group, Paris, France
- Médecine Intensive Réanimation, APHP, CHU Ambroise Pare, Boulogne-Billancourt, France
| | - Sophier Jacquier
- AfterROSC Network Group, Paris, France
- Médecine Intensive Réanimation, CHU Tours, Tours, France
| | - Nicolas Pichon
- AfterROSC Network Group, Paris, France
- Médecine Intensive Réanimation, CH Brive-La-Gaillard, Bourges, France
| | - Thomas Klein
- AfterROSC Network Group, Paris, France
- Médecine Intensive Réanimation, CHU Nancy, Nancy, France
| | - Bertrand Sauneuf
- AfterROSC Network Group, Paris, France
- Médecine Intensive Réanimation, CH Cherbourg-en-Cotentin, Cherbourg, France
| | - Kada Klouche
- AfterROSC Network Group, Paris, France
- Médecine Intensive Réanimation, CHU Montpellier, Montpellier, France
| | - Martin Cour
- AfterROSC Network Group, Paris, France
- Médecine Intensive Réanimation, Hospices Civils Lyon, Lyon, France
| | - Caroline Sejourne
- AfterROSC Network Group, Paris, France
- Médecine Intensive Réanimation, CH Bethune, Bethune, France
| | - Filippo Annoni
- AfterROSC Network Group, Paris, France
- Réanimation, ERASME, Brussels, Belgium
| | - Jean-Herle Raphalen
- AfterROSC Network Group, Paris, France
- Médecine Intensive Réanimation, APHP, CHU Necker, Paris, France
| | - Arnaud Galbois
- AfterROSC Network Group, Paris, France
- Service de Réanimation Polyvalente, Hôpital Privé Claude Galien, Quincy-Sous-Sénart, France
| | - Cedric Bruel
- AfterROSC Network Group, Paris, France
- Service de Réanimation Polyvalente, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Nicolas Mongardon
- AfterROSC Network Group, Paris, France
- Service d'Anesthésie-Réanimation Chirurgicale, APHP, CHU Henri Mondor, Créteil, France
| | - Nadia Aissaoui
- AfterROSC Network Group, Paris, France
- Médecine Intensive Réanimation, APHP, HEGP, Paris, France
| | - Nicolas Deye
- AfterROSC Network Group, Paris, France
- Médecine Intensive Réanimation, APHP, CHU Lariboisière, Paris, France
| | - Julien Maizel
- AfterROSC Network Group, Paris, France
- Médecine Intensive Réanimation, CHU Amiens, Amiens, France
| | | | - Stephane Legriel
- AfterROSC Network Group, Paris, France
- Médecine Intensive Réanimation, CH Versailles, Le Chesnay, France
| | - Alain Cariou
- AfterROSC Network Group, Paris, France
- Médecine Intensive Réanimation, APHP, CHU Cochin, Paris, France
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Bao C, Deng F, Zhao S. Machine-learning models for prediction of sepsis patients mortality. Med Intensiva 2023; 47:315-325. [PMID: 36344339 DOI: 10.1016/j.medine.2022.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 06/07/2022] [Indexed: 05/29/2023]
Abstract
OBJECTIVES Sepsis is an infection-caused syndrome, that leads to life-threatening organ damage. We aim to develop machine learning models with large-scale data to predict sepsis patients' mortality. DESIGN we extracted sepsis patients from two databases, Medical Information Mart for Intensive Care IV (MIMIC-IV) as a train set and Philips eICU Collaborative Research Database as a test set. SETTING ICUs in multicenter hospitals in the USA during 2012-2019. PATIENTS OR PARTICIPANTS A total of 21,680 sepsis-3 patients are included in the study, in which, 3771 patients were dead and 17,909 survived during hospitalization, respectively. INTERVENTIONS No interventions. MAIN VARIABLES OF INTEREST Basic information, examination items during hospitalization and some medication and treatment information are incorporated into analyzed. Seven different models were built with a Support vector machine, Decision Tree Classifier, Random Forest, Gradients Boosting, Multiple Layer Perception, Xgboost, light Gradients Boosting to predict dead or live during hospitalization. RESULTS Algorithms with an AUC value in the test set of the top three: light GBM, GBM, Xgboost. Considering the performance of the training set and the test set, the light GBM model performs best, and then the parameters of the model were adjusted, after that the AUC value was 0.99 in the train set, 0.96 in the test set, respectively. CONCLUSIONS Models built with light GBM algorithm from real-world sepsis patients from electronic health records accurately predict whether sepsis patients are dead and can be incorporated into clinical decision tools to enhance the prognosis of the patient and prevent adverse outcomes.
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Affiliation(s)
- C Bao
- Xiangya Hospital, Department of Critical Care Medicine & National Clinical Research Center for Geriatric Disorders, Central South University, Hainan General Hospital, Department of Emergency, Hainan Medical University, Haikou, Hainan, China
| | - F Deng
- Xiangya Hospital, Department of Oncology, Central South University, Changsha, China
| | - S Zhao
- Xiangya Hospital, Department of Critical Care Medicine & National Clinical Research Center for Geriatric Disorders, Central South University, Hunan Intensive Care Medicine Research Centre, China.
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Williams Roberson S, Azeez NA, Fulton JN, Zhang KC, Lee AXT, Ye F, Pandharipande P, Brummel NE, Patel MB, Ely EW. Quantitative EEG signatures of delirium and coma in mechanically ventilated ICU patients. Clin Neurophysiol 2023; 146:40-48. [PMID: 36529066 PMCID: PMC9889081 DOI: 10.1016/j.clinph.2022.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 11/18/2022] [Accepted: 11/25/2022] [Indexed: 12/05/2022]
Abstract
OBJECTIVE To identify quantitative electroencephalography (EEG)-based indicators of delirium or coma in mechanically ventilated patients. METHODS We prospectively enrolled 28 mechanically ventilated intensive care unit (ICU) patients to undergo 24-hour continuous EEG, 25 of whom completed the study. We assessed patients twice daily using the Richmond Agitation-Sedation Scale (RASS) and Confusion Assessment Method for the ICU (CAM-ICU). We evaluated the spectral profile, regional connectivity and complexity of 5-minute EEG segments after each assessment. We used penalized regression to select EEG metrics associated with delirium or coma, and compared mixed-effects models predicting delirium with and without the selected EEG metrics. RESULTS Delta variability, high-beta variability, relative theta power, and relative alpha power contributed independently to EEG-based identification of delirium or coma. A model with these metrics achieved better prediction of delirium or coma than a model with clinical variables alone (Akaike Information Criterion: 36 vs 43, p = 0.006 by likelihood ratio test). The area under the receiver operating characteristic curve for an ad hoc hypothetical delirium score using these metrics was 0.94 (95%CI 0.83-0.99). CONCLUSIONS We identified four EEG metrics that, in combination, provided excellent discrimination between delirious/comatose and non-delirious mechanically ventilated ICU patients. SIGNIFICANCE Our findings give insight to neurophysiologic changes underlying delirium and provide a basis for pragmatic, EEG-based delirium monitoring technology.
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Affiliation(s)
- Shawniqua Williams Roberson
- Critical Illness, Brain dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Neurology, Epilepsy Division, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Biomedical Engineering, Vanderbilt University, Nashville, TN, USA.
| | - Naureen A Azeez
- Critical Illness, Brain dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Neurology, Epilepsy Division, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Jenna N Fulton
- Critical Illness, Brain dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Neurology, Epilepsy Division, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Kevin C Zhang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Aaron X T Lee
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Fei Ye
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA.
| | - Pratik Pandharipande
- Critical Illness, Brain dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Nathan E Brummel
- Critical Illness, Brain dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA; Department of Pulmonary Critical Care, The Ohio State University, Columbus, OH, USA
| | - Mayur B Patel
- Critical Illness, Brain dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA; Departments of Surgery, Neurosurgery, and Hearing & Speech Sciences, Vanderbilt University Medical Center, Nashville, TN, USA; Vanderbilt Brain Institute, Vanderbilt University, Nashville, TN, USA; Department of General Surgery, VA Tennessee Valley Healthcare System, Nashville, TN, USA; Geriatric Research, Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA
| | - E Wesley Ely
- Critical Illness, Brain dysfunction and Survivorship (CIBS) Center, Vanderbilt University Medical Center, Nashville, TN, USA; Geriatric Research, Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN, USA; Department of Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
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5
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McGuigan PJ, Giallongo E, Blackwood B, Doidge J, Harrison DA, Nichol AD, Rowan KM, Shankar-Hari M, Skrifvars MB, Thomas K, McAuley DF. The effect of blood pressure on mortality following out-of-hospital cardiac arrest: a retrospective cohort study of the United Kingdom Intensive Care National Audit and Research Centre database. Crit Care 2023; 27:4. [PMID: 36604745 PMCID: PMC9817239 DOI: 10.1186/s13054-022-04289-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 12/20/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Hypotension following out-of-hospital cardiac arrest (OHCA) may cause secondary brain injury and increase mortality rates. Current guidelines recommend avoiding hypotension. However, the optimal blood pressure following OHCA is unknown. We hypothesised that exposure to hypotension and hypertension in the first 24 h in ICU would be associated with mortality following OHCA. METHODS We conducted a retrospective analysis of OHCA patients included in the Intensive Care National Audit and Research Centre Case Mix Programme from 1 January 2010 to 31 December 2019. Restricted cubic splines were created following adjustment for important prognostic variables. We report the adjusted odds ratio for associations between lowest and highest mean arterial pressure (MAP) and systolic blood pressure (SBP) in the first 24 h of ICU care and hospital mortality. RESULTS A total of 32,349 patients were included in the analysis. Hospital mortality was 56.2%. The median lowest and highest MAP and SBP were similar in survivors and non-survivors. Both hypotension and hypertension were associated with increased mortality. Patients who had a lowest recorded MAP in the range 60-63 mmHg had the lowest associated mortality. Patients who had a highest recorded MAP in the range 95-104 mmHg had the lowest associated mortality. The association between SBP and mortality followed a similar pattern to MAP. CONCLUSIONS We found an association between hypotension and hypertension in the first 24 h in ICU and mortality following OHCA. The inability to distinguish between the median blood pressure of survivors and non-survivors indicates the need for research into individualised blood pressure targets for survivors following OHCA.
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Affiliation(s)
- Peter J McGuigan
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK.
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK.
| | - Elisa Giallongo
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - Bronagh Blackwood
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
| | - James Doidge
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - David A Harrison
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - Alistair D Nichol
- University College Dublin Clinical Research Centre, St Vincent's University Hospital, Dublin, Ireland
- The Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, Australia
- The Alfred Hospital, Melbourne, Australia
| | - Kathryn M Rowan
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - Manu Shankar-Hari
- Centre for Inflammation Research, Institute of Regeneration and Repair, University of Edinburgh, Edinburgh, UK
- Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, UK
| | - Markus B Skrifvars
- Department of Emergency Care and Services, University of Helsinki, Helsinki, Finland
- Helsinki University Hospital, Helsinki, Finland
| | - Karen Thomas
- Intensive Care National Audit and Research Centre, Napier House, 24 High Holborn, London, UK
| | - Danny F McAuley
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, Belfast, UK
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6
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Blatter R, Amacher SA, Bohren C, Becker C, Beck K, Gross S, Tisljar K, Sutter R, Marsch S, Hunziker S. Comparison of different clinical risk scores to predict long-term survival and neurological outcome in adults after cardiac arrest: results from a prospective cohort study. Ann Intensive Care 2022; 12:77. [PMID: 35978065 PMCID: PMC9385915 DOI: 10.1186/s13613-022-01048-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 07/18/2022] [Indexed: 11/17/2022] Open
Abstract
Background Several scoring systems have been used to predict short-term outcome in patients with out-of-hospital cardiac arrest (OHCA), including the disease-specific OHCA and CAHP (Cardiac Arrest Hospital Prognosis) scores, as well as the general severity-of-illness scores Acute Physiology and Chronic Health Evaluation II (APACHE II) and Simplified Acute Physiology Score II (SAPS II). This study aimed to assess the prognostic performance of these four scores to predict long-term outcomes (≥ 2 years) in adult cardiac arrest patients. Methods This is a prospective single-centre cohort study including consecutive cardiac arrest patients admitted to intensive care in a Swiss tertiary academic medical centre. The primary endpoint was 2-year mortality. Secondary endpoints were neurological outcome at 2 years post-arrest assessed by Cerebral Performance Category with CPC 1–2 defined as good and CPC 3–5 as poor neurological outcome, and 6-year mortality. Results In 415 patients admitted to intensive care, the 2-year mortality was 58.1%, with 96.7% of survivors showing good neurological outcome. The 6-year mortality was 82.5%. All four scores showed good discriminatory performance for 2-year mortality, with areas under the receiver operating characteristics curve (AUROC) of 0.82, 0.87, 0.83 and 0.81 for the OHCA, CAHP, APACHE II and SAPS II scores. The results were similar for poor neurological outcome at 2 years and 6-year mortality. Conclusion This study suggests that two established cardiac arrest-specific scores and two severity-of-illness scores provide good prognostic value to predict long-term outcome after cardiac arrest and thus may help in early goals-of-care discussions. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-01048-y.
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Affiliation(s)
- René Blatter
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland
| | - Simon A Amacher
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland.,Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | - Chantal Bohren
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland
| | - Christoph Becker
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland.,Department of Emergency Medicine, University Hospital Basel, Basel, Switzerland
| | - Katharina Beck
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland
| | - Sebastian Gross
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland
| | - Kai Tisljar
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland
| | - Raoul Sutter
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland.,Medical Faculty, University of Basel, Basel, Switzerland
| | - Stephan Marsch
- Intensive Care Unit, University Hospital Basel, Basel, Switzerland.,Medical Faculty, University of Basel, Basel, Switzerland
| | - Sabina Hunziker
- Medical Communication and Psychosomatic Medicine, University Hospital Basel, Klingelbergstrasse 23, 4031, Basel, Switzerland. .,Medical Faculty, University of Basel, Basel, Switzerland.
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7
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Bao C, Deng F, Zhao S. Machine-learning models for prediction of sepsis patients mortality. Med Intensiva 2022. [DOI: 10.1016/j.medin.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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8
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Zhou P, Xu H, Li B, Yang C, Zhou Z, Shi J, Li Z. Neurological outcomes in adult drowning patients in China. Ann Saudi Med 2022; 42:127-138. [PMID: 35380055 PMCID: PMC8982001 DOI: 10.5144/0256-4947.2022.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Drowning is the third leading cause of unintentional death worldwide. The epidemiological characteristics of adult drownings are rarely reported. OBJECTIVE Investigate factors associated with neurological prognosis in adult drowning inpatients. DESIGN Multicenter medical record review. SETTING Tertiary health care institutions. PATIENTS AND METHODS We collected demographic and clinical data on patients who drowned but survived between September 2006 and January 2020. Neurological prognosis was compared in patients with and without cardiac arrest. MAIN OUTCOME MEASURES Neurological outcomes. SAMPLE SIZE AND CHARACTERISTICS 142 patients with mean age of 50.6 (19.8) years, male/female ratio of 1.54:1. RESULT Forty-five patients (31.7%) received CPR, 90 patients (63.4%) experienced unconsciousness, and 59 patients (41.5%) received endotracheal intubation and mechanical ventilation. Multivariate logistic regression analysis showed that the initial blood lactic acid level (OR: 7.67, 95%CI: 1.23-47.82, P=.029) was associated with a poor neurological prognosis in patients without cardiac arrest. The incidence of ICU admission (OR: 16.604, 95%CI: 1.15-239.49, P=.039) was associated with a poor neurologic prognosis in patients with cardiac arrest. CONCLUSIONS For the drowning patients with cardiac arrest, ICU admission was associated with neurological function prognosis in these patients. Among the patients without cardiac arrest, the initial lactate value was associated with neurological function prognosis of these patients. LIMITATIONS Retrospective. CONFLICT OF INTEREST None.
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Affiliation(s)
- Peisen Zhou
- From the Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Zhejiang, China
| | - Huaqing Xu
- From the Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Zhejiang, China
| | - Bingccan Li
- From the Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Zhejiang, China
| | - Chenbing Yang
- From the Department of Emergency Medicine, The First Affiliated Hospital of Wenzhou Medical University, Zhejiang, China
| | - Zhiliang Zhou
- From the Department of Emergency Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Zhejiang, China
| | - Jincun Shi
- From the Department of Emergency Medicine, Wenzhou Central Hospital, Zhejiang, China
| | - Zhangping Li
- From the The Quzhou Affiliated Hospital of Wenzhou Medical University, Quzhou People's Hospital, Zhejiang, China
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9
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Sato M, Mutai H, Yamamoto S, Tsukakoshi D, Takeda S, Oguchi N, Ichimura H, Ikegami S, Wada Y, Seto T, Horiuchi H. Decreased activities of daily living at discharge predict mortality and readmission in elderly patients after cardiac and aortic surgery: A retrospective cohort study. Medicine (Baltimore) 2021; 100:e26819. [PMID: 34397842 PMCID: PMC8341368 DOI: 10.1097/md.0000000000026819] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 07/15/2021] [Indexed: 01/04/2023] Open
Abstract
Recently, activities of daily living (ADL) were identified as a prognostic factor among elderly patients with heart disease; however, a specific association between ADL and prognosis after cardiac and aortic surgery is not well established. We aimed to clarify the impact of ADL capacity at discharge on prognosis in elderly patients after cardiac and aortic surgery.This retrospective cohort study included 171 elderly patients who underwent open operation for cardiovascular disease in a single center (median age: 74 years; men: 70%). We used the Barthel Index (BI) as an indicator for ADL. Patients were classified into 2 groups according to the BI at discharge, indicating a high (BI ≥ 85) or low (BI < 85) ADL status. All-cause mortality and unplanned readmission events were observed after discharge.Thirteen all-cause mortality and 44 all-cause unplanned readmission events occurred during the median follow-up of 365 days. Using Kaplan-Meier analysis, a low ADL status was determined to be significantly associated with all-cause mortality and unplanned readmission. In the multivariable Cox proportional hazard models, a low ADL status was an independent predictor of all-cause mortality and unplanned readmission after adjusting for age, sex, length of hospital stay, and other variables (including preoperative status, surgical parameter, and postoperative course).A low ADL status at discharge predicted all-cause mortality and unplanned readmission in elderly patients after cardiac and aortic surgery. A comprehensive approach from the time of admission to postdischarge to improve ADL capacity in elderly patients undergoing cardiac and aortic surgery may improve patient outcomes.
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Affiliation(s)
- Masaaki Sato
- Division of Occupational Therapy, Shinshu University School of Health Sciences, Matsumoto, Japan
- Department of Rehabilitation, Shinshu University Hospital, Matsumoto, Japan
| | - Hitoshi Mutai
- Division of Occupational Therapy, Shinshu University School of Health Sciences, Matsumoto, Japan
| | - Shuhei Yamamoto
- Department of Rehabilitation, Shinshu University Hospital, Matsumoto, Japan
| | - Daichi Tsukakoshi
- Department of Rehabilitation, Shinshu University Hospital, Matsumoto, Japan
| | - Shuhei Takeda
- Department of Rehabilitation, Shinshu University Hospital, Matsumoto, Japan
| | - Natsuko Oguchi
- Department of Rehabilitation, Shinshu University Hospital, Matsumoto, Japan
| | - Hajime Ichimura
- Division of Cardiovascular Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Shota Ikegami
- Department of Rehabilitation, Shinshu University Hospital, Matsumoto, Japan
| | - Yuko Wada
- Division of Cardiovascular Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Tatsuichiro Seto
- Division of Cardiovascular Surgery, Department of Surgery, Shinshu University School of Medicine, Matsumoto, Japan
| | - Hiroshi Horiuchi
- Department of Rehabilitation, Shinshu University Hospital, Matsumoto, Japan
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10
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McGuigan PJ, Shankar-Hari M, Harrison DA, Laffey JG, McAuley DF. The interaction between arterial oxygenation and carbon dioxide and hospital mortality following out of hospital cardiac arrest: a cohort study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:336. [PMID: 32532312 PMCID: PMC7290139 DOI: 10.1186/s13054-020-03039-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 05/27/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Outcomes following out of hospital cardiac arrest (OHCA) are poor. The optimal arterial oxygen and carbon dioxide (PaCO2) levels for managing patients following OHCA are unknown. We hypothesized that abnormalities in arterial oxygenation (PaO2/FiO2 ratio or PaO2) and PaCO2 would be associated with hospital mortality following OHCA. We hypothesized that PaCO2 would significantly modify the oxygenation-mortality relationship. METHODS This was an observational cohort study using data from OHCA survivors admitted to adult critical care units in England, Wales and Northern Ireland from 2011 to 2018. Logistic regression analyses were performed to assess the relationship between hospital mortality and oxygenation and PaCO2. RESULTS The analysis included 23,625 patients. In comparison with patients with a PaO2/FiO2 > 300 mmHg, those with a PaO2/FiO2 ≤ 100 mmHg had higher mortality (adjusted OR, 1.79; 95% CI, 1.48 to 2.15; P < 0.001). In comparison to hyperoxemia (PaO2 > 100 mmHg), patients with hypoxemia (PaO2 < 60 mmHg) had higher mortality (adjusted OR, 1.34; 95% CI, 1.10 to 1.65; P = 0.004). In comparison with normocapnia, hypercapnia was associated with lower mortality. Hypocapnia (PaCO2 ≤ 35 mmHg) was associated with higher mortality (adjusted OR, 1.91; 95% CI, 1.63 to 2.24; P < 0.001). PaCO2 modified the PaO2/FiO2-mortality and PaO2-mortality relationships, though these relationships were complex. Patients who were both hyperoxic and hypercapnic had the lowest mortality. CONCLUSIONS Low PaO2/FiO2 ratio, hypoxemia and hypocapnia are associated with higher mortality following OHCA. PaCO2 modifies the relationship between oxygenation and mortality following OHCA; future studies examining this interaction are required.
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Affiliation(s)
- Peter J McGuigan
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, BT12 6BA, UK.
| | - Manu Shankar-Hari
- Guy's and St Thomas' NHS Foundation Trust, ICU support Offices, St Thomas' Hospital, 1st Floor, East Wing, London, SE1 7EH, UK.,School of Immunology & Microbial Sciences, Kings College London, London, SE1 9RT, UK.,Intensive Care National Audit & Research Centre, Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - David A Harrison
- Intensive Care National Audit & Research Centre, Napier House, 24 High Holborn, London, WC1V 6AZ, UK
| | - John G Laffey
- Anaesthesia and Intensive Care Medicine, School of Medicine, Regenerative Medicine Institute (REMEDI), CÚRAM Centre for Research in Medical Devices National University of Ireland Galway, Galway, Ireland.,Department of Anaesthesia, Galway University Hospitals, Galway, Ireland
| | - Danny F McAuley
- Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, BT12 6BA, UK.,Centre for Experimental Medicine, Wellcome-Wolfson Institute for Experimental Medicine, Belfast, BT9 7AE, UK
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11
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Plasma Adipokines in Patients Resuscitated from Cardiac Arrest: Difference of Visfatin between Survivors and Nonsurvivors. DISEASE MARKERS 2020; 2020:9608276. [PMID: 32015774 PMCID: PMC6988666 DOI: 10.1155/2020/9608276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Revised: 11/26/2019] [Accepted: 12/24/2019] [Indexed: 11/17/2022]
Abstract
Background Adipokines are a group of cytokines or peptides secreted by adipose tissue to exert numerous biological functions. In the present study, we measured the plasma levels of four adipokines (adiponectin, leptin, fatty acid-binding protein 4 (FABP4), and visfatin) in cardiac arrest patients following return of spontaneous circulation (ROSC). Methods Totally, 21 patients who experienced cardiac arrest and successful ROSC with expected survival of at least 48 hours (from January 2016 to December 2017) were consecutively enrolled into this prospective observational clinical study. Of the 21 enrolled patients, ten survived, and other eleven died between 2 days and 6 months post ROSC. Venous blood was drawn at three time points: baseline (<1 hour post ROSC), 2 days post ROSC, and 7 days post ROSC. Plasma concentrations of adiponectin, leptin, FABP4, and visfatin were determined using commercial enzyme-linked immunosorbent assays. Results The plasma visfatin levels at 2 or 7 days post ROSC increased significantly compared with the baseline (P < 0.01), while plasma levels of adiponectin, leptin, and FABP4 did not change. Moreover, plasma visfatin levels in survivors at 2 or 7 days post ROSC were higher than those in nonsurvivors (P < 0.01). Plasma visfatin levels at 2 or 7 days post ROSC were negatively correlated with Acute Physiology and Chronic Health Evaluation (APACHE) II score and time to ROSC. Moreover, receiver operating characteristic curve analysis showed that the plasma visfatin levels at 2 or 7 days post ROSC were good predictors for survival of the patients. Conclusion Elevated plasma visfatin levels may be a marker for better outcome of cardiac arrest patients post ROSC.
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12
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13
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Isenschmid C, Luescher T, Rasiah R, Kalt J, Tondorf T, Gamp M, Becker C, Tisljar K, Sutter R, Schuetz P, Hochstrasser S, Metzger K, Marsch S, Hunziker S. Performance of clinical risk scores to predict mortality and neurological outcome in cardiac arrest patients. Resuscitation 2018; 136:21-29. [PMID: 30391369 DOI: 10.1016/j.resuscitation.2018.10.022] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 10/21/2018] [Accepted: 10/24/2018] [Indexed: 12/27/2022]
Abstract
AIM Several scores are available to predict mortality and neurological outcome in cardiac arrest patients admitted to the intensive care unit (ICU). The aim of the study was to externally validate the prognostic value of four previously published risk scores. METHODS For this observational, single-center study, we prospectively included 349 consecutive adult cardiac arrest patients upon ICU admission. We calculated two cardiac arrest specific risk scores (OHCA and CAHP) and two general severity of illness scores (APACHE II and SAPS II). The primary endpoint was in-hospital mortality. Secondary endpoints were neurological outcome at hospital discharge and 30-day mortality. RESULTS 170 patients (49%) died until hospital discharge. All scores were independently associated with outcomes in logistic regression analysis and showed acceptable discrimination for in-hospital mortality with highest AUCs of the cardiac arrest specific risk scores (OHCA: 0.80 (95%CI 0.75-0.85) and CAHP: 0.84 (95%CI 0.79-0.88) compared to the severity of illness scores (APACHE II: 0.78 (95%CI 0.73-0.83) and SAPS II: 0.77 (95%CI 0.72-0.82). Results were robust in subgroup analysis except for worse performance in elderly patients (>75 years) and patients with respiratory cause of cardiac arrest. Results were similar for 30-days mortality and slightly higher for neurological outcome. CONCLUSIONS This study confirms the good prognostic performance of cardiac arrest specific scores to predict mortality and neurological outcomes in cardiac arrest patients. Routine use of OHCA or CAHP score helps to objectively risk stratify these vulnerable patients and thereby may improve therapeutic decisions.
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Affiliation(s)
- Cyril Isenschmid
- Medical Intensive Care Unit, University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Switzerland; Medical Communication and psychosomatic medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland
| | - Tanja Luescher
- Medical Intensive Care Unit, University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Switzerland; Medical Communication and psychosomatic medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland
| | - Roshaani Rasiah
- Medical Intensive Care Unit, University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Switzerland; Medical Communication and psychosomatic medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland
| | - Jeanice Kalt
- Medical Intensive Care Unit, University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Switzerland; Medical Communication and psychosomatic medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland
| | - Theresa Tondorf
- Medical Communication and psychosomatic medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland
| | - Martina Gamp
- Medical Communication and psychosomatic medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland
| | - Christoph Becker
- Medical Communication and psychosomatic medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland
| | - Kai Tisljar
- Medical Intensive Care Unit, University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Raoul Sutter
- Medical Intensive Care Unit, University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Switzerland; Division of Clinical Neurophysiology, Department of Neurology, University Hospital Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Philipp Schuetz
- Medical Faculty of the University of Basel, Klingelbergstrasse 61, 4056 Basel, Switzerland; Department of Internal Medicine, Kantonsspital Aarau, Tellstrasse 25, 5001 Aarau, Switzerland
| | - Seraina Hochstrasser
- Medical Communication and psychosomatic medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland
| | - Kerstin Metzger
- Medical Communication and psychosomatic medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland
| | - Stephan Marsch
- Medical Intensive Care Unit, University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Switzerland; Medical Faculty of the University of Basel, Klingelbergstrasse 61, 4056 Basel, Switzerland
| | - Sabina Hunziker
- Medical Intensive Care Unit, University Hospital Basel, University of Basel, Petersgraben 4, 4031 Basel, Switzerland; Medical Communication and psychosomatic medicine, University Hospital Basel, Klingelbergstrasse 23, 4031 Basel, Switzerland; Medical Faculty of the University of Basel, Klingelbergstrasse 61, 4056 Basel, Switzerland.
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14
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Kim SI, Kim YJ, Lee YJ, Ryoo SM, Sohn CH, Seo DW, Lee YS, Lee JH, Lim KS, Kim WY. APACHE II Score Immediately after Cardiac Arrest as a Predictor of Good Neurological Outcome in Out-of-Hospital Cardiac Arrest Patients Receiving Targeted Temperature Management. Acute Crit Care 2018; 33:83-88. [PMID: 31723867 PMCID: PMC6849058 DOI: 10.4266/acc.2017.00514] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 03/19/2018] [Accepted: 03/21/2018] [Indexed: 11/30/2022] Open
Abstract
Background This study assessed the association between the initial Acute Physiology and Chronic Health Evaluation (APACHE) II score and good neurological outcome in comatose survivors of out-of-hospital cardiac arrest who received targeted temperature management (TTM). Methods Data from survivors of cardiac arrest who received TTM between January 2011 and June 2016 were retrospectively analyzed. The initial APACHE II score was determined using the data immediately collected after return of spontaneous circulation rather than within 24 hours after being admitted to the intensive care unit. Good neurological outcome, defined as Cerebral Performance Category 1 or 2 on day 28, was the primary outcome of this study. Results Among 143 survivors of cardiac arrest who received TTM, 62 (43.4%) survived, and 34 (23.8%) exhibited good neurological outcome on day 28. The initial APACHE II score was significantly lower in the patients with good neurological outcome than in those with poor neurological outcome (23.71 ± 4.39 vs. 27.62 ± 6.16, P = 0.001). The predictive ability of the initial APACHE II score for good neurological outcome, assessed using the area under the receiver operating characteristic curve, was 0.697 (95% confidence interval [CI], 0.599 to 0.795; P = 0.001). The initial APACHE II score was associated with good neurological outcome after adjusting for confounders (odds ratio, 0.878; 95% CI, 0.792 to 0.974; P = 0.014). Conclusions In the present study, the APACHE II score calculated in the immediate post-cardiac arrest period was associated with good neurological outcome. The initial APACHE II score might be useful for early identification of good neurological outcome.
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Affiliation(s)
- Sang-Il Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Youn-Jung Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - You-Jin Lee
- Department of Emergency Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Seung Mok Ryoo
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chang Hwan Sohn
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Woo Seo
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yoon-Seon Lee
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Ho Lee
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyoung Soo Lim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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15
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Martinell L, Nielsen N, Herlitz J, Karlsson T, Horn J, Wise MP, Undén J, Rylander C. Early predictors of poor outcome after out-of-hospital cardiac arrest. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:96. [PMID: 28410590 PMCID: PMC5391587 DOI: 10.1186/s13054-017-1677-2] [Citation(s) in RCA: 152] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Accepted: 03/22/2017] [Indexed: 12/24/2022]
Abstract
Background Early identification of predictors for a poor long-term outcome in patients who survive the initial phase of out-of-hospital cardiac arrest (OHCA) may facilitate future clinical research, the process of care and information provided to relatives. The aim of this study was to determine the association between variables available from the patient’s history and status at intensive care admission with outcome in unconscious survivors of OHCA. Methods Using the cohort of the Target Temperature Management trial, we performed a post hoc analysis of 933 unconscious patients with OHCA of presumed cardiac cause who had a complete 6-month follow-up. Outcomes were survival and neurological function as defined by the Cerebral Performance Category (CPC) scale at 6 months after OHCA. After multiple imputations to compensate for missing data, backward stepwise multivariable logistic regression was applied to identify factors independently predictive of a poor outcome (CPC 3–5). On the basis of these factors, a risk score for poor outcome was constructed. Results We identified ten independent predictors of a poor outcome: older age, cardiac arrest occurring at home, initial rhythm other than ventricular fibrillation/tachycardia, longer duration of no flow, longer duration of low flow, administration of adrenaline, bilateral absence of corneal and pupillary reflexes, Glasgow Coma Scale motor response 1, lower pH and a partial pressure of carbon dioxide in arterial blood value lower than 4.5 kPa at hospital admission. A risk score based on the impact of each of these variables in the model yielded a median (range) AUC of 0.842 (0.840–0.845) and good calibration. Internal validation of the score using bootstrapping yielded a median (range) AUC corrected for optimism of 0.818 (0.816–0.821). Conclusions Among variables available at admission to intensive care, we identified ten independent predictors of a poor outcome at 6 months for initial survivors of OHCA. They reflected pre-hospital circumstances (six variables) and patient status on hospital admission (four variables). By using a simple and easy-to-use risk scoring system based on these variables, patients at high risk for a poor outcome after OHCA may be identified early.
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Affiliation(s)
- Louise Martinell
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SE-413 45, Gothenburg, Sweden.
| | - Niklas Nielsen
- Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Johan Herlitz
- The Centre for Pre-hospital Research in Western Sweden, University College of Borås and Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Thomas Karlsson
- Health Metrics at Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Janneke Horn
- Department of Intensive Care, Academic Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Matt P Wise
- Adult Critical Care, University Hospital of Wales, Cardiff, UK
| | - Johan Undén
- Department of Intensive Care and Perioperative Medicine, Lund University, Malmö, Sweden
| | - Christian Rylander
- Department of Anaesthesiology and Intensive Care Medicine, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, SE-413 45, Gothenburg, Sweden
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16
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Şahutoğlu C, Uyar M, Demirağ K, İsayev H, Moral AR. Predictive Value of Brain Arrest Neurological Outcome Scale (BrANOS) on Mortality and Morbidity After Cardiac Arrest. Turk J Anaesthesiol Reanim 2017; 44:295-300. [PMID: 28058140 DOI: 10.5152/tjar.2016.38802] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Accepted: 11/03/2016] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE There are several prediction scales and parameters for prognosis after a cardiac arrest. One of these scales is the brain arrest neurological outcome scale (BrANOS), which consists of duration of cardiac arrest, Glasgow Coma Scale score and Hounsfield unit measured on cranial computed tomography (CT) scan. The objective of this study is to investigate the effectiveness of BrANOS on predicting the mortality and disability after a cardiac arrest. METHODS We retrospectively investigated cardiac arrest patients who were hospitalized in our intensive care unit (ICU) within a 3-year period. Inclusion criteria were age over 18 years old, survival of more than 24 hours after cardiac arrest and availability of cranial CT. We recorded the age, sex, diagnosis, duration of cardiac arrest and hospital stay, mortality, Glasgow Outcome Score (GOS) and BrANOS score. The primary endpoint of the study was to establish the relationship between mortality and BrANOS score in patients who survived for more than 24 hours after a cardiac arrest. The secondary endpoint of the study was to determine the 2-year life expectancy and GOS after cardiac arrest. RESULTS The mean age of the patients was 57±17 years (33 females, 67 males). ICU mortality rate was 57%. The BrANOS mean score was 10.3±3.2. There was a significant difference between survivors and non-survivors in terms of the BrANOS score (8.8±3.2 vs. 11.6±2.7; p<0.001). BrANOS reliably predicted the survival with a ROC area under the curve of 0.733. The scale of >14 predicted death with 100% accuracy. All the patients without disability had a BrANOS score of <10. The BrANOS score also correlated well with GOS (p<0.001). The 2-year life expectancy rate was 31% in patients who survived more than 24 hours after a cardiac arrest. CONCLUSION In this study, we demonstrated that BrANOS provided reliable data for prognostic evaluation after a cardiac arrest.
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Affiliation(s)
- Cengiz Şahutoğlu
- Department of Anaesthesiology and Reanimation, Ege University School of Medicine, İzmir, Turkey
| | - Mehmet Uyar
- Department of Anaesthesiology and Reanimation, Ege University School of Medicine, İzmir, Turkey
| | - Kubilay Demirağ
- Department of Anaesthesiology and Reanimation, Ege University School of Medicine, İzmir, Turkey
| | - Hasan İsayev
- Department of Radiology, Ege University School of Medicine, İzmir, Turkey
| | - Ali Reşat Moral
- Department of Anaesthesiology and Reanimation, Ege University School of Medicine, İzmir, Turkey
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17
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Cheng K, Bassil R, Carandang R, Hall W, Muehlschlegel S. The Estimated Verbal GCS Subscore in Intubated Traumatic Brain Injury Patients: Is it Really Better? J Neurotrauma 2016; 34:1603-1609. [PMID: 27774844 DOI: 10.1089/neu.2016.4657] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
The Glasgow Coma Scale (GCS) has limited utility in intubated patients due to the inability to assign verbal subscores. The verbal subscore can be derived from the eye and motor subscores using a mathematical model, but the advantage of this method and its use in outcome prognostication in traumatic brain injury (TBI) patients remains unknown. We compared the validated "Core+CT"-IMPACT-model performance in 251 intubated TBI patients prospectively enrolled in the longitudinal OPTIMISM study between November 2009 and May 2015 when substituting the original motor GCS (mGCS) with the total estimated GCS (teGCS; with estimated verbal subscore). We hypothesized that model performance would improve with teGCS. Glasgow Outcome Scale (GOS) scores were assessed at 3 and 12 months by trained interviewers. In the complete case analysis, there was no statistically or clinically significant difference in the discrimination (C-statistic) at either time-point using the mGCS versus the teGCS (3 months: 0.893 vs. 0.871;12 months: 0.926 vs. 0.92). At 3 months, IMPACT-model calibration was excellent with mGCS and teGCS (Hosmer-Lemeshow "goodness-of-fit" chi square p value 0.9293 and 0.9934, respectively); it was adequate at 12 months with teGCS (0.5893) but low with mGCS (0.0158), possibly related to diminished power at 12 months. At both time-points, motor GCS contributed more to the variability of outcome (Nagelkerke ΔR2) than teGCS (3 months: 5.8% vs. 0.4%; 12 months: 5% vs. 2.6%). The sensitivity analysis with imputed missing outcomes yielded similar results, with improved calibration for both GCS variants. In our cohort of intubated TBI patients, there was no statistically or clinically meaningful improvement in the IMPACT-model performance by substituting the original mGCS with teGCS.
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Affiliation(s)
- Katarina Cheng
- 1 Department of Neurology, University of Massachusetts Medical School , Worcester, Massachusetts
| | - Ribal Bassil
- 1 Department of Neurology, University of Massachusetts Medical School , Worcester, Massachusetts
| | - Raphael Carandang
- 1 Department of Neurology, University of Massachusetts Medical School , Worcester, Massachusetts.,2 Department of Surgery, University of Massachusetts Medical School , Worcester, Massachusetts.,3 Department of Anesthesiology/Critical Care, University of Massachusetts Medical School , Worcester, Massachusetts
| | - Wiley Hall
- 1 Department of Neurology, University of Massachusetts Medical School , Worcester, Massachusetts.,2 Department of Surgery, University of Massachusetts Medical School , Worcester, Massachusetts
| | - Susanne Muehlschlegel
- 1 Department of Neurology, University of Massachusetts Medical School , Worcester, Massachusetts.,2 Department of Surgery, University of Massachusetts Medical School , Worcester, Massachusetts.,3 Department of Anesthesiology/Critical Care, University of Massachusetts Medical School , Worcester, Massachusetts
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Nobile L, Taccone FS, Szakmany T, Sakr Y, Jakob SM, Pellis T, Antonelli M, Leone M, Wittebole X, Pickkers P, Vincent JL. The impact of extracerebral organ failure on outcome of patients after cardiac arrest: an observational study from the ICON database. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:368. [PMID: 27839517 PMCID: PMC5108077 DOI: 10.1186/s13054-016-1528-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2016] [Accepted: 10/14/2016] [Indexed: 12/26/2022]
Abstract
Background We used data from a large international database to assess the incidence and impact of extracerebral organ dysfunction on prognosis of patients admitted after cardiac arrest (CA). Methods This was a sub-analysis of the Intensive Care Over Nations (ICON) database, which contains data from all adult patients admitted to one of 730 participating intensive care units (ICUs) in 84 countries from 8–18 May 2012, except admissions for routine postoperative surveillance. For this analysis, patients admitted after CA (defined as those with “post-anoxic coma” or “cardiac arrest” as the reason for ICU admission) were included. Data were collected daily in the ICU for a maximum of 28 days; patients were followed up for outcome data until death, hospital discharge, or a maximum of 60 days in-hospital. Favorable neurological outcome was defined as alive at hospital discharge with a last available neurological Sequential Organ Failure Assessment (SOFA) subscore of 0–2. Results Among the 469 patients admitted after CA, 250 (53 %) had had out-of-hospital CA; 210 (45 %) patients died in the ICU and 357 (76 %) had an unfavorable neurological outcome. Non-survivors had a higher incidence of renal (43 vs. 16 %), cardiovascular (56 vs. 45 %), and respiratory (62 vs. 48 %) failure on admission and during the ICU stay than survivors (all p < 0.05). Similar results were found for patients with unfavorable vs. favorable neurological outcomes. In multivariable analysis, independent predictors of ICU mortality were renal failure on admission, high admission Simplified Acute Physiology Score (SAPS) II, high maximum serum lactate levels within the first 24 h after ICU admission, and development of sepsis. Independent predictors of unfavorable neurological outcome were mechanical ventilation on admission, high admission SAPS II score, and neurological dysfunction on admission. Conclusions In this multicenter cohort, extracerebral organ dysfunction was common in CA patients. Renal failure on admission was the only extracerebral organ dysfunction independently associated with higher ICU mortality. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1528-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Leda Nobile
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Tamas Szakmany
- Department of Critical Care, Royal Gwent Hospital, Newport, Wales, UK.,Department of Anaesthetics, Intensive Care and Pain Medicine, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Yasser Sakr
- Department of Anesthesiology and Intensive Care, Uniklinikum Jena, Jena, Germany
| | - Stephan M Jakob
- Department of Intensive Care Medicine, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Tommaso Pellis
- Anesthesia and Intensive Care, Santa Maria degli Angeli Hospital, Pordenone, Italy
| | - Massimo Antonelli
- Department of Intensive Care and Anesthesiology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marc Leone
- Department of Anesthesia and Intensive Care, Hôpital Nord, AP-HM Aix Marseille Université, Marseille, France
| | - Xavier Wittebole
- Critical Care Department, Cliniques Universitaires St Luc, UCL, Brussels, Belgium
| | - Peter Pickkers
- Department of Intensive Care, Nijmegen Institute for Infection, Inflammation and Immunity, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
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Clinical Course Score (CCS): a new clinical score to evaluate efficacy of neurotrauma treatment in traumatic brain injury and subarachnoid hemorrhage. J Neurosurg Anesthesiol 2016; 27:26-30. [PMID: 24879534 DOI: 10.1097/ana.0000000000000083] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Neurotrauma continues to represent a challenging public health issue requiring continual improvement in therapeutic approaches. As no such current system exists, we present in this study the Clinical Course Score (CCS) as a new clinical score to evaluate the efficacy of neurotrauma treatment. METHODS The CCS was calculated in neurotrauma patients to be the difference between the grade of the Glasgow Outcome Scale 6 months after discharge from our department and the grade of a 1 to 5 point reduced Glasgow Coma Scale on admission. We assessed the CCS in a total of 248 patients (196 traumatic brain injury [TBI] patients and 52 subarachnoid hemorrhage [SAH] patients) who were treated in our Department of Neurosurgery between January 2011 and December 2012. RESULTS We found negative CCS grades both in mild TBI and in mild SAH patients. In patients with severe TBI or SAH, we found positive CCS grades. In SAH patients, we found higher CCS scores in younger patients compared with elderly subjects in both mild and severe cases. CONCLUSIONS The CCS can be useful in evaluating different therapeutic approaches during neurotrauma therapy. This new score might improve assessment of beneficial effects of therapeutic procedures.
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Serrano M, Rodríguez J, Espejo A, del Olmo R, Llanos S, del Castillo J, López-Herce J. Relationship between previous severity of illness and outcome of in-hospital cardiac arrest. An Pediatr (Barc) 2014. [DOI: 10.1016/j.anpede.2013.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Serrano M, Rodríguez J, Espejo A, del Olmo R, Llanos S, Del Castillo J, López-Herce J. [Relationship between previous severity of illness and outcome of in-hospital cardiac arrest]. An Pediatr (Barc) 2014; 81:9-15. [PMID: 24286880 DOI: 10.1016/j.anpedi.2013.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2013] [Revised: 09/09/2013] [Accepted: 09/26/2013] [Indexed: 12/27/2022] Open
Abstract
OBJECTIVES To analyze the relationship between previous severity of illness, lactic acid, creatinine and inotropic index with mortality of in-hospital cardiac arrest (CA) in children, and the value of a prognostic index designed for adults. METHODS The study included total of 44 children aged from 1 month to 18 years old who suffered a cardiac arrest while in hospital. The relationship between previous severity of illness scores (PRIMS and PELOD), lactic acid, creatinine, treatment with vasoactive drugs, inotropic index with return of spontaneous circulation and survival at hospital discharge was analyzed. RESULTS The large majority (90.3%) of patients had a return of spontaneous circulation, and 59% survived at hospital discharge. More than two-thirds (68.2%) were treated with inotropic drugs at the time of the CA. The patients who died had a higher lactic acid before the CA (3.4 mmol/L) than survivors (1.4 mmol/L), P=.04. There were no significant differences in PRIMS, PELOD, creatinine, inotropic drugs, and inotropic index before CA between patients who died and survivors. CONCLUSION A high lactic acid previous to cardiac arrest could be a prognostic factor of in-hospital cardiac arrest in children.
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Affiliation(s)
- M Serrano
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Instituto de Investigación, Hospital General Universitario Gregorio Marañón, Madrid, Red de Salud Maternoinfantil y del Desarrollo (Red SAMID), Madrid, España
| | - J Rodríguez
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Instituto de Investigación, Hospital General Universitario Gregorio Marañón, Madrid, Red de Salud Maternoinfantil y del Desarrollo (Red SAMID), Madrid, España
| | - A Espejo
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Instituto de Investigación, Hospital General Universitario Gregorio Marañón, Madrid, Red de Salud Maternoinfantil y del Desarrollo (Red SAMID), Madrid, España
| | - R del Olmo
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Instituto de Investigación, Hospital General Universitario Gregorio Marañón, Madrid, Red de Salud Maternoinfantil y del Desarrollo (Red SAMID), Madrid, España
| | - S Llanos
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Instituto de Investigación, Hospital General Universitario Gregorio Marañón, Madrid, Red de Salud Maternoinfantil y del Desarrollo (Red SAMID), Madrid, España
| | - J Del Castillo
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Instituto de Investigación, Hospital General Universitario Gregorio Marañón, Madrid, Red de Salud Maternoinfantil y del Desarrollo (Red SAMID), Madrid, España
| | - J López-Herce
- Servicio de Cuidados Intensivos Pediátricos, Hospital General Universitario Gregorio Marañón, Instituto de Investigación, Hospital General Universitario Gregorio Marañón, Madrid, Red de Salud Maternoinfantil y del Desarrollo (Red SAMID), Madrid, España.
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Hyperoxia is associated with increased mortality in patients treated with mild therapeutic hypothermia after sudden cardiac arrest. Crit Care Med 2013; 40:3135-9. [PMID: 22971589 DOI: 10.1097/ccm.0b013e3182656976] [Citation(s) in RCA: 147] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To determine whether higher levels of PaO2 are associated with in-hospital mortality and poor neurological status at hospital discharge in patients treated with mild therapeutic hypothermia after sudden cardiac arrest. DESIGN Retrospective analysis of a prospective cohort. PATIENTS A total of 170 consecutive patients treated with therapeutic hypothermia in the cardiovascular care unit of an academic tertiary care hospital. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 170 patients, 77 (45.2%) survived to hospital discharge. Survivors had a significantly lower maximum PaO2 (198 mm Hg; interquartile range, 152.5-282) measured in the first 24 hrs following cardiac arrest compared to nonsurvivors (254 mm Hg; interquartile range, 172-363; p = .022). A multivariable analysis including age, time to return of spontaneous circulation, the presence of shock, bystander cardiopulmonary resuscitation, and initial rhythm revealed that higher levels of PaO2 were significantly associated with increased in-hospital mortality (odds ratio 1.439; 95% confidence interval 1.028-2.015; p = .034) and poor neurological status at hospital discharge (odds ratio 1.485; 95% confidence interval 1.032-2.136; p = .033). CONCLUSIONS Higher levels of the maximum measured PaO2 are associated with increased in-hospital mortality and poor neurological status on hospital discharge in patients treated with mild therapeutic hypothermia after sudden cardiac arrest.
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Postresuscitation treatment targets—Time to emphasize normoxia?*. Crit Care Med 2012; 40:3306-7. [DOI: 10.1097/ccm.0b013e318270e715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Donnino MW, Salciccioli JD, Dejam A, Giberson T, Giberson B, Cristia C, Gautam S, Cocchi MN. APACHE II scoring to predict outcome in post-cardiac arrest. Resuscitation 2012. [PMID: 23178739 DOI: 10.1016/j.resuscitation.2012.10.024] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Despite advancements in management of cardiac arrest, mortality remains high and few severity of illness scoring systems have been calibrated in this population. The goal of the current investigation was to assess the Acute Physiology and Chronic Health Evaluation II score in post-cardiac arrest. MEASUREMENTS This is a prospective observational study of adult post-cardiac arrest patients at a tertiary-care center. The primary outcome variable was in-hospital mortality and secondary outcome variable was neurologic outcome. APACHE II scores were used to predict outcomes using logistic modeling. MAIN RESULTS A total of 228 subjects were included in the analysis. The median age of the cohort was 70 (IQR: 64-71) and 32% (72/228) of the patients were female. The median downtime was 15 min (IQR: 7-27) and initial lactate 5.9 mmol/L (IQR: 3.5-8.4). 71 (57%) of deaths occurred prior to the 72-h follow-up and overall in-hospital mortality was 55% (125/228). Discrimination of APACHE II score in all cardiac arrest patients increased in stepwise fashion from 0-h to 72-h follow-up (AUC: 0-h: 0.62; 24-h: 0.75; 48-h: 0.82; 72-h: 0.86). CONCLUSIONS APACHE II score is a poor predictor of outcome at time zero for out-of-hospital cardiac arrest (OHCA) post-arrest patients consistent with the original development of the score in the critically ill. For in-hospital cardiac arrest (IHCA) at time zero and for both IHCA and OHCA at 24h and beyond, the APACHE II score was a modest indicator of illness severity and predictor of mortality/neurologic morbidity.
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Affiliation(s)
- Michael W Donnino
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA.
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Skrifvars M, Varghese B, Parr M. Survival and outcome prediction using the Apache III and the out-of-hospital cardiac arrest (OHCA) score in patients treated in the intensive care unit (ICU) following out-of-hospital, in-hospital or ICU cardiac arrest. Resuscitation 2012; 83:728-33. [DOI: 10.1016/j.resuscitation.2011.11.036] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Revised: 11/23/2011] [Accepted: 11/29/2011] [Indexed: 11/15/2022]
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Furtado GH, Wiskirchen DE, Kuti JL, Nicolau DP. Performance of the PIRO score for predicting mortality in patients with ventilator-associated pneumonia. Anaesth Intensive Care 2012; 40:285-91. [PMID: 22417023 DOI: 10.1177/0310057x1204000211] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The ventilator-associated pneumonia (VAP) PIRO score is a new scoring system based on the PIRO concept. The aim of this study was to validate the PIRO score against the Acute Physiology and Chronic Health Evaluation (APACHE) II and VAP APACHE II in an independent group of VAP patients. Areas under the receiver operating characteristic curves were compared to determine the tests' abilities to predict intensive care unit and 28-day mortality. Variables associated with intensive care unit mortality were evaluated. One hundred and forty-eight intensive care unit patients who met radiographic and clinical criteria for VAP were included. The area under the receiver operating characteristic curves for predicting intensive care unit mortality with the PIRO, APACHE II and VAP APACHE II scores were 0.605 (P=0.03), 0.631 (P=0.01) and 0.724 (P <0.0001), respectively. Areas under the receiver operating characteristic curve for predicting 28-day mortality were 0.614 (P=0.01) for PIRO, 0.633 (P=0.01) for APACHE II and 0.697 (P=0.002) for VAP APACHE II. No differences in area under the receiver operating characteristic curve between scores were found at either endpoint. Variables independently associated with intensive care unit mortality were bacteraemia (adjusted odds ratio 7.16, 95% confidence interval 1.19 to 42.98, P=0.03) and APACHE II (1.06, 1.01 to 1.11, P=0.006). VAP PIRO score was not a good predictor of intensive care unit and 28-day mortality. The low sensitivity and specificity of VAP PIRO score preclude its use clinically.
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Affiliation(s)
- G H Furtado
- Center for Anti-Infective Research and Development, Division of Infectious Diseases, Hartford Hospital, Connecticut, USA.
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CHO DY, WANG YC, LEE MJ. Comparison of APACHE III, II and the Glasgow Coma Scale for prediction of mortality in a neurosurgical intensive care unit. ACTA ACUST UNITED AC 2011. [DOI: 10.3109/tcic.6.1.9.14] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Seo KD, Choi YC, Kim WJ. The assessment of routine electroencephalography in patients with altered mental status. Yonsei Med J 2011; 52:933-8. [PMID: 22028156 PMCID: PMC3220250 DOI: 10.3349/ymj.2011.52.6.933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
PURPOSE Changes in electroencephalography (EEG) patterns may offer a clue to the cause of altered mental status and suggest the prognoses of patients with such mental status. We aimed to identify the EEG patterns in patients with altered mental status and to correlate EEG findings with clinical prognoses. MATERIALS AND METHODS We included 105 patients with altered mental status who underwent EEG. EEG and clinical chart reviews with ongoing patient follow-ups were performed to determine the clinical prognosis of the patients. Clinical data were sorted using the Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS). EEG findings were classified according to a method suggested by Scollo-Lavizzari. The EEGs were analyzed to find out whether any correlation existed with the prognoses of patients. RESULTS Nonconvulsive status epilepticus (NCSE) was detected in only three patients (2.9%). Specific EEG patterns were observed in 28 patients. Twenty-nine (27.6%) patients expired, and 45 (42.9%) patients were in a vegetative state. EEG grade and GCS significantly correlated with GOS. EEG grade alone had a correlation with GCS. Patients with a severe EEG finding had a poor prognosis. CONCLUSION EEG findings reflect the mental status of patients, and EEG grades are correlated with the clinical prognosis of patients. Although EEG is not frequently performed on patients with altered mental state, it can play a supplemental role in establishing a prognosis. Thus, the use of EEG should be emphasized in clinical setting.
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Affiliation(s)
- Kwon Duk Seo
- Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young-Chul Choi
- Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Won-Joo Kim
- Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Samborska-Sablik A, Sablik Z, Gaszynski W. The role of the immuno-inflammatory response in patients after cardiac arrest. Arch Med Sci 2011; 7:619-26. [PMID: 22291797 PMCID: PMC3258769 DOI: 10.5114/aoms.2011.24131] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2009] [Revised: 12/10/2009] [Accepted: 01/12/2010] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION The aim of the research was to assess whether concentrations of inflammatory markers in blood of patients after cardiac arrest (CA) are related to their clinical state and survival. MATERIAL AND METHODS Forty-six patients, aged 63 ±12 years, 21 of them after out-of-hospital CA and 25 after in-hospital CA, were enrolled in the study. Twenty-five patients survived and were discharged from hospital (CA-S); 21 died during hospitalization (CA-D). The clinical state of the patients was evaluated by the Glasgow Coma Scale (GCS) and the Acute Physiology and Chronic Health Evaluation II (APACHE II). On the day immediately after CA (day 1) and on the following day (day 2) the plasma concentration of high specific C-reactive protein (hs-CRP), tumour necrosis factor (TNF)-α, interleukin-10 and interleukin-6 (Ile-6) were measured. RESULTS In CA-D patients, compared with CA-S, a significantly higher concentration of hs-CRP (on day 1, 19 ±5 vs. 15 ±4; on day 2, 21 ±3 vs. 16 ±5 mg/l, p < 0.001) and Ile-6 (on day 1, 24.9 ±19.8 vs. 9.2 ±11.3; on day 2, 24.2 ±19.7 vs. 6.9 ±6.8 IU/ml, p < 0.001) was found. The level of TNF-α was greater in CA-D on day 1 (0.42 ±0.75 vs. 0.18 ±0.21 IU/ml, p < 0.04). Concentrations of hs-CRP and Ile-6 were correlated with the scores of GCS and APACHE II. Using logistic regression analysis and ROC curves the prognostic value of hs-CRP and Ile-6 for survival was proven. CONCLUSIONS Post-cardiac arrest immuno-inflammatory response, reflected mainly in elevated plasma concentration of hs-CRP and Ile-6, is not only correlated with patients' clinical state but also with prediction of survival.
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Affiliation(s)
- Anna Samborska-Sablik
- Department of Emergency Medicine and Disaster Medicine, Chair of Anaesthesiology and Intensive Therapy, Medical University of Lodz, Poland
| | - Zbigniew Sablik
- Department of Cardiology, First Chair of Cardiology and Cardiac Surgery, Medical University of Lodz, Poland
| | - Wojciech Gaszynski
- Chair of Anaesthesiology and Intensive Therapy, Medical University of Lodz, Poland
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Abstract
Numerous scoring scales have been proposed and validated to evaluate coma for rapid pre-hospital assessment and triage, disease severity, and prognosis for morbidity and mortality. These scoring systems have been predicated on core features that serve as a basis for this review and include ease of use, inter-rater reliability, reproducibility, and predictive value. Here we review the benefits and limitations of the most popular coma scoring systems. The methods include search of Medline, databases, and manual review of article bibliographies. Few of the many available coma scales have gained widespread approval and popularity. The best known and widely accepted scale is the Glasgow Coma Scale (GCS). The Reaction Level Scale (RLS85) has utility and proven benefit, but little acceptance outside of Scandinavia. The newer Full Outline of UnResponsiveness (FOUR) score provides an attractive replacement for all patients with fluctuating levels of consciousness and is gradually gaining wide acceptance.
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PIRO score for community-acquired pneumonia: a new prediction rule for assessment of severity in intensive care unit patients with community-acquired pneumonia. Crit Care Med 2009; 37:456-62. [PMID: 19114916 DOI: 10.1097/ccm.0b013e318194b021] [Citation(s) in RCA: 118] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To develop a severity assessment tool to predict mortality in community-acquired pneumonia (CAP) patients in intensive care unit (ICU), comparing its performance with Acute Physiology and Chronic Health Evaluation (APACHE) II score and American Thoracic Society/Infectious Disease Society of America (ATS/IDSA) criteria as a prognostic index in CAP patients requiring ICU admission. DESIGN Secondary analysis of prospective observational cohort study. SETTING Thirty-three ICUs. PATIENTS Five hundred and twenty-nine adult patients with CAP requiring ICU admission. MEASUREMENTS AND MAIN RESULTS A severity assessment score was developed based on the PIRO (predisposition, insult, response, and organ dysfunction) concept including the presence of the following variables: Comorbidities (chronic obstructive pulmonary disease, immunocompromise); age >70 years; multilobar opacities in chest radiograph; shock, severe hypoxemia; acute renal failure; bacteremia and acute respiratory distress syndrome. PIRO score was obtained at ICU within 24 hours from admission, and one point was given for each present feature (range, 0-8 points). The mean PIRO score was significantly higher in nonsurvivors than in survivors (4.6 +/- 1.2 vs. 2.3 +/- 1.4). Considering the observed mortality for each PIRO score, the patients were stratified in four levels of risk: a) Low, 0-2 points; b) Mild, 3 points; c) high, 4 points; and d) Very high, 5-8 points. Mild-risk (hazard ratio [HR] 1.8; 95% confidence interval [CI] 1.1-2.9; p < 0.05), high-risk (HR 3.1; 95% CI = 2.0-4.7; p < 0.001), and very high risk levels (HR 6.3; 95% CI = 4.2-9.4; p < 0.001) were significantly associated with higher risk of death in Cox proportional hazards regression analysis. Furthermore, analysis of variance showed that higher levels of PIRO score were significantly associated with higher mortality (p < 0.001), prolonged length of stay in the ICU (p < 0.001), and days of mechanical ventilation (p < 0.001). Receiver operating characteristic curves showed that PIRO score (area under the curve [AUC] = 0.88) performed better than APACHE II (AUC = 0.75, p < 0.001) and ATS/IDSA criteria (AUC = 0.80, p < 0.001) to predict 28-day mortality. CONCLUSIONS The PIRO score performed well as 28-day mortality prediction tool in CAP patients requiring ICU admission with a better performance than APACHE II and ATS/IDSA criteria in this subset of patients. Furthermore, PIRO score also is associated with increased healthcare resource utilization in CAP patients admitted in the ICU.
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Abstract
A cursory evaluation of the Acute Physiology and Chronic Health Evaluation, commonly known as the APACHE scoring system, validates its relevancy as the most widely used method for assessing severity and prognosis in intensive care unit patients. The APACHE system works and the evolution from APACHE I to APACHE IV reveal that each version has its positives and negatives. It would behoove critical care nurses to know differences and how each could be best utilized.
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Sanz-García M, Fernández-Cruz A, Rodríguez-Créixems M, Cercenado E, Marin M, Muñoz P, Bouza E. Recurrent Escherichia coli bloodstream infections: epidemiology and risk factors. Medicine (Baltimore) 2009; 88:77-82. [PMID: 19282697 DOI: 10.1097/md.0b013e31819dd0cf] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Patients with recurrent episodes of Escherichia coli bloodstream infection (REC-BSI) have been described previously only in small studies. We report on the incidence, clinical significance, and predisposing conditions of REC-BSI in a general hospital from 1992 to 2005. All patients with E. coli bloodstream infection (EC-BSI) were retrieved from our database. We defined recurrent episodes as those occurring at least 1 month apart after a clinical response (cases). To study risk factors for REC-BSI, we randomly selected a third of the REC-BSI cases and a similar number of controls (patients with a single EC-BSI). Available E. coli isolates from initial and recurrent episodes were typed using repetitive-extragenic-palindromic-sequences to distinguish between relapse and reinfection. During the study period there were 4287 episodes of EC-BSI in 3970 patients; of these, 251 (6.3%) patients had 568 episodes of recurrence (13.3%). We selected 81 cases and 81 controls for study. The underlying conditions of patients with REC-BSI included immunosuppression (33%), urinary (24%) or biliary obstruction (16%), chronic liver disease (16%), presence of a central venous catheter (8%), and miscellaneous entities (3%). Male sex, presence of hematologic malignancy, inadequate antibiotic treatment, and an extraurinary source of the BSI were independent risk factors for recurrence in the multivariate analysis. Molecular typing performed in 88 infections from 44 patients showed that 47% of REC-BSI were relapses rather than reinfections. Recurrence of E. coli BSI is not an uncommon phenomenon and includes relapses (47%) and reinfections (53%). Recurrence should suggest not only the presence of urinary or biliary obstruction, but also the presence of immunosuppression.
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Affiliation(s)
- Marta Sanz-García
- From the Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón, CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
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Storm C, Steffen I, Schefold JC, Krueger A, Oppert M, Jörres A, Hasper D. Mild therapeutic hypothermia shortens intensive care unit stay of survivors after out-of-hospital cardiac arrest compared to historical controls. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2008; 12:R78. [PMID: 18554414 PMCID: PMC2481476 DOI: 10.1186/cc6925] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/07/2008] [Revised: 05/28/2008] [Accepted: 06/14/2008] [Indexed: 11/24/2022]
Abstract
Introduction Persistent coma is a common finding after cardiac arrest and has profound ethical and economic implications. Evidence suggests that therapeutic hypothermia improves neurological outcome in these patients. In this analysis, we investigate whether therapeutic hypothermia influences the length of intensive care unit (ICU) stay and ventilator time in patients surviving out-of-hospital cardiac arrest. Methods A prospective observational study with historical controls was conducted at our medical ICU. Fifty-two consecutive patients (median age 62.6 years, 43 males, 34 ventricular fibrillation) submitted to therapeutic hypothermia after out-of-hospital cardiac arrest were included. They were compared with a historical cohort (n = 74, median age 63.8 years, 53 males, 43 ventricular fibrillation) treated in the era prior to hypothermia treatment. All patients received the same standard of care. Neurological outcome was assessed using the Pittsburgh cerebral performance category (CPC) score. Univariate analyses and multiple regression models were used. Results In survivors, therapeutic hypothermia and baseline disease severity (Acute Physiology and Chronic Health Evaluation II [APACHE II] score) were both found to significantly influence ICU stay and ventilator time (all P < 0.01). ICU stay was shorter in survivors receiving therapeutic hypothermia (median 14 days [interquartile range (IQR) 8 to 26] versus 21 days [IQR 15 to 30] in the control group; P = 0.017). ICU length of stay and time on ventilator were prolonged in patients with CPC 3 or 4 compared with patients with CPC 1 or 2 (P = 0.003 and P = 0.034, respectively). Kaplan-Meier analysis showed improved probability for 1-year survival in the hypothermia group compared with the controls (log-rank test P = 0.013). Conclusion Therapeutic hypothermia was found to significantly shorten ICU stay and time of mechanical ventilation in survivors after out-of-hospital cardiac arrest. Moreover, profound improvements in both neurological outcome and 1-year survival were observed.
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Affiliation(s)
- Christian Storm
- Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Department of Nephrology and Medical Intensive Care Medicine, Augustenburger Platz 1, 13353 Berlin, Germany
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Ekmektzoglou KA, Xanthos T, Papadimitriou L. Biochemical markers (NSE, S-100, IL-8) as predictors of neurological outcome in patients after cardiac arrest and return of spontaneous circulation. Resuscitation 2007; 75:219-28. [PMID: 17482335 DOI: 10.1016/j.resuscitation.2007.03.016] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2007] [Revised: 03/24/2007] [Accepted: 03/29/2007] [Indexed: 10/23/2022]
Abstract
Predicting the neurological outcome after resuscitation and a return of spontaneous circulation of resuscitated patients still remains a difficult issue. Over the past decade numerous studies have been elaborated to provide the physician with tools to assess as early as possible the neurological outcome of patients with cardiac arrest and return of spontaneous circulation and to decide about further therapeutic management. We summarise the most important ones, giving special focus to three biochemical markers (neuron specific enolase, a protein soluble in 100% ammonium sulfate and interleukin-8), which, when combined with standard neuro-functional and imaging techniques, can serve as potent predictors of neurological outcome in these patients. Despite current limitations about the prognostic significance of these markers - their inferior sensitivity, the different cut-off levels used by several investigators and their variable unequal rise over time - they can give useful information about short and long-term neurological outcome. A comprehensive set of clinical, electrophysiological, biochemical and imaging measures, obtained in a uniform manner in a cohort of patients without limitations in care, could provide a more objective set of comprehensive prognostic indicators.
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Affiliation(s)
- Konstantinos A Ekmektzoglou
- Department of Experimental Surgery and Surgical Research N.S. Christeas, University of Athens, School of Medicine, 15B Agiou Thoma Street, 11527 Athens, Greece
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Niskanen M, Reinikainen M, Kurola J. Outcome from intensive care after cardiac arrest: comparison between two patient samples treated in 1986-87 and 1999-2001 in Finnish ICUs. Acta Anaesthesiol Scand 2007; 51:151-7. [PMID: 17073852 DOI: 10.1111/j.1399-6576.2006.01182.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The aim of the study was to find out whether the characteristics of patients and the outcome from intensive care after cardiac arrest have changed over time. METHODS Two nationwide databases were compared: (i) The Finnish National Intensive Care Study data in 1986-87 and (ii) data on 28,640 admissions to Finnish ICUs in 1999-2001. Patients whose reason for ICU admission was cardiac arrest were included. The former study included 604 patients treated in 18 medical and surgical ICUs in and the latter 1036 patients in 25 medical and surgical ICUs. Data on the components of Acute Physiology and Chronic Health Evaluation (APACHE II) were prospectively collected in both study periods. Logistic regression analysis was used to test the independent contribution of the study period on hospital mortality. RESULTS In 1986-87, patients were younger and the proportion of males was lower than in 1999-2001. The hospital mortality in 1986-87 was 61.3% and in 1999-2001 59.1% (P= 0.396). Among patients aged < 57 years, the hospital mortality in 1986-87 was 62.1% and in 1999-2001 48.8% (P < 0.01). In multivariate analysis, controlling for age, gender, Glasgow coma score (GCS), chronic health evaluation points and source of admission, treatment during 1986-87 was an independent predictor for hospital death among all patients (OR 1.273; 95% CI 1.015-1.594), those aged < 57 years (OR 1.959; 95% CI 1.270-3.021) and among males (OR 1.384; 95% CI 1.050-1.825). CONCLUSION Since the late 1980s, the outcome from intensive care after cardiac arrest may have improved especially among younger patients and males.
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Affiliation(s)
- M Niskanen
- Department of Anaesthesiology and Intensive Care, ENT Hospital, Helsinki University Central Hospital, Helsinki, Finland.
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Sandroni C, Nolan J, Cavallaro F, Antonelli M. In-hospital cardiac arrest: incidence, prognosis and possible measures to improve survival. Intensive Care Med 2006; 33:237-45. [PMID: 17019558 DOI: 10.1007/s00134-006-0326-z] [Citation(s) in RCA: 420] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2006] [Accepted: 07/20/2006] [Indexed: 12/31/2022]
Abstract
DESIGN Review. OBJECTIVE Medical literature on in-hospital cardiac arrest (IHCA) was reviewed to summarise: (a) the incidence of and survival after IHCA, (b) major prognostic factors, (c) possible interventions to improve survival. RESULTS AND CONCLUSIONS The incidence of IHCA is rarely reported in the literature. Values range between 1 and 5 events per 1,000 hospital admissions, or 0.175 events/bed annually. Reported survival to hospital discharge varies from 0% to 42%, the most common range being between 15% and 20%. Pre-arrest prognostic factors: the prognostic value of age is controversial. Among comorbidities, sepsis, cancer, renal failure and homebound lifestyle are significantly associated with poor survival. However, pre-arrest morbidity scores have not yet been prospectively validated as instruments to predict failure to survive after IHCA. Intra-arrest factors: ventricular fibrillation/ventricular tachycardia (VF/VT) as the first recorded rhythm and a shorter interval between IHCA and cardiopulmonary resuscitation or defibrillation are associated with higher survival. However, VF/VT is present in only 25-35% of IHCAs. Short-term survival is also higher in patients resuscitated with chest compression rates above 80/min. Interventions likely to improve survival include: early recognition and stabilisation of patients at risk of IHCA to enable prevention, faster and better in-hospital resuscitation and early defibrillation. Mild therapeutic hypothermia is effective as post-arrest treatment of out-of-hospital cardiac arrest due to VF/VT, but its benefit after IHCA and after cardiac arrest with non-VF/VT rhythms has not been clearly demonstrated.
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Affiliation(s)
- Claudio Sandroni
- Intensive Care Unit, Catholic University School of Medicine, Rome, Italy.
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Kaye P. Early prediction of individual outcome following cardiopulmonary resuscitation: systematic review. Emerg Med J 2006; 22:700-5. [PMID: 16189031 PMCID: PMC1726559 DOI: 10.1136/emj.2004.016253] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Following resuscitation from cardiorespiratory arrest 80% of patients are comatose. Of these patients, 20% will survive and regain consciousness. Is it possible to predict an individual's long term outcome at presentation and alter management accordingly? This review examines the current medical literature and demonstrates it is impossible to predict immediately outcome from hypoxic-ischaemic coma except in a small subgroup of patients with poor premorbid factors. As individual prognosis cannot be determined in the emergency department all patients who do not have significant premorbid features should proceed to a period of supportive care in the intensive care unit. Therapeutic hypothermia should be considered for these patients.
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Affiliation(s)
- P Kaye
- Frenchay Hospital, Bristol, UK.
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Larive LL, Rhoney DH, Parker D, Coplin WM, Carhuapoma JR. Introducing hypertonic saline for cerebral edema: an academic center experience. Neurocrit Care 2005; 1:435-40. [PMID: 16174946 DOI: 10.1385/ncc:1:4:435] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Use of hypertonic saline (HTS) is gaining acceptance in the neurosciences critical care unit (NCCU) based on its efficacy in reducing cerebral edema and its favorable hemodynamic profile. In the NCCU, unfamiliarity with the use of HTS may result in implementation difficulties. We report our initial experience using HTS, its ability to achieve a hypernatremic state, and adverse effects. METHODS Analysis of 19 consecutive patients who were admitted to the NCCU and treated with 2 or 3% HTS infusion for cerebral edema (target serum sodium: 145-155 mEq/L) included patient diagnoses, laboratory data, length of treatment, adverse effects, and outcome at discharge. We compared the adverse effects of those patients to a contemporary cohort of patients who received mannitol as the sole form of osmotherapy. RESULTS The HTS cohort had a median age of 46 years (range: 18-70). Median GCS and APACHE II scores were 11 (range: 3-15) and 18 (range: 8-30), respectively. Median length of HTS treatment was 5 days (range: 1-17). Target hypernatremia was achieved in 14 patients (74%), 7 of whom achieved hypernatremia within the first 24 hours. The median number of rescue interventions received for ICP control was 3 (range: 1-30). The adverse effects between the HTS and mannitol cohorts were not found to be significantly different. CONCLUSION The use of HTS for cerebral edema requires intensive efforts by the medical team to rapidly achieve and maintain a hypernatremic state. The continuous infusion of HTS was used safely.
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Affiliation(s)
- Lisa L Larive
- Department of Pharmacy Practice, Wayne State University, Detroit, Michigan, USA
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Riechers RG, Ramage A, Brown W, Kalehua A, Rhee P, Ecklund JM, Ling GSF. Physician Knowledge of the Glasgow Coma Scale. J Neurotrauma 2005; 22:1327-34. [PMID: 16305321 DOI: 10.1089/neu.2005.22.1327] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Appropriate triage is critical to optimizing outcome from battle related injuries. The Glasgow Coma Scale (GCS) is the primary means by which combat casualties, who have suffered head injury, are triaged. For the GCS to be reliable in this critical role, it must be applied accurately. To determine the level of knowledge of the GCS among military physicians with exposure and/or training in the scale we administered a prospective, voluntary, and anonymous survey to physicians of all levels of training at military medical centers with significant patient referral base. The main outcome measures were correct identification of title and categories of the GCS along with appropriate scoring of each category. Overall performance on the survey was marginal. Many were able to identify what "GCS" stands for, but far fewer were able to identify the titles of the specific categories, let alone identify the specific scoring of each category. When evaluated based on medical specialties, those in surgical specialties outperformed those in the medical specialties. When comparing the different levels of training, residents and fellows performed better than attending staff or interns. Finally, those with Advanced Trauma Life Support (ATLS) certification performed significantly better than those without the training. Physician knowledge of the GCS, as demonstrated in this study, is poor, even in a population of individuals with specific training in the use of the scale. It is concluded that, to optimize outcome from combat related head injury, methods for improving accurate quantitation of neurologic state need to be explored.
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Affiliation(s)
- Ronald G Riechers
- Department of Neurology, Walter Reed Army Medical Center, Washington, D.C. 20307, USA.
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Torbey MT, Geocadin R, Bhardwaj A. Brain arrest neurological outcome scale (BrANOS): predicting mortality and severe disability following cardiac arrest. Resuscitation 2005; 63:55-63. [PMID: 15451587 DOI: 10.1016/j.resuscitation.2004.03.021] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2003] [Revised: 03/12/2004] [Accepted: 03/12/2004] [Indexed: 11/29/2022]
Abstract
BACKGROUND To create a predictive scale of neurological outcome following cardiac arrest (CA) that incorporates radiological and clinical markers of brain injury. METHODS AND RESULTS Brain arrest neurologic outcome scale (BrANOS) is a prospective 16-point scale. It consisted of three variables: (1) duration of arrest (DAR), (2) reversed Glasgow coma scale (GCS), and (3) Hounsfield unit (HU) ratio on non-contrast CT scan of the head. Reversed GCS score was defined as 15-GCS (best GCS in the first 24 h). HU ratio was defined as the density ratio of the caudate nucleus over the posterior limb of the internal capsule measured on unenhanced CT scan of the brain. We identified 32 comatose patients who had: (1) CT scan performed within 48 h of event; (2) no previous history of either coma, severe head trauma, cardiac arrest or stroke. Primary outcome was defined as alive or dead. Secondary outcome was the Glasgow outcome score recorded on discharge. Patient demographics were collated from retrospective chart review. Patients' mean age was 63 +/- 3 years (mean +/- S.E.M.); 44% were females. Mortality rate was 81%. Mean DAR was 21 +/- 2 min. Survivors had a significantly lower BrANOS score (8 +/- 2 points) compared to non-survivors (13 +/- 1) (P = 0.006). BrANOS was a strong predictor of mortality alone (ROC = 0.86) and mortality with severe disability combined (ROC = 0.9). The scale had a 100% specificity and positive predictive value. CONCLUSIONS BrANOS is a reliable predictor of neurological outcome following CA. It is the first scale to incorporate clinical and radiological markers of brain injury.
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Affiliation(s)
- Michel T Torbey
- Department of Neurology and Neurosurgery, Medical College of Wisconsin, 9200 W. Wisconsin Ave., Milwaukee, WI 53226, USA.
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Colpan A, Akinci E, Erbay A, Balaban N, Bodur H. Evaluation of risk factors for mortality in intensive care units: a prospective study from a referral hospital in Turkey. Am J Infect Control 2005; 33:42-7. [PMID: 15685134 DOI: 10.1016/j.ajic.2004.09.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND The aim of the clinical practice is to decrease the mortality rate in intensive care units. Determination of the risk factors for mortality may provide useful guidance for intensive care patients. This study sought to find mortality-related risk factors in intensive care units. OBJECTIVE To investigate risk factors for mortality in intensive care units (ICUs). METHODS The prospective study was performed from May 2002 to November 2002 in the surgical and medical ICUs of the Ankara Numune Education and Research Hospital. Three hundred thirty-four patients who were followed in the ICUs for at least 48 hours were enrolled in this study. Those patients who died within 48 hours of ICU discharge were included in the mortality analysis. RESULTS The overall mortality rate in the ICUs was 46.7%. Among the 334 patients, 104 (31.1%) had ICU-acquired infections. The mortality rate was significantly higher in the patients with nosocomial infections (66.3%) than in the patients without nosocomial infections (37.8%) ( P < .001). The mean age, sex, acute physiology and chronic health evaluation (APACHE) II score, trauma and intraabdominal pathology, nosocomial infection, stay in the medical/surgical ICU, coma, TISS score, use of steroid or chemotherapy, use of antibiotic, and serum urea >50 mg/dL and creatinine >1.2 mg/dL levels were associated with mortality in the univariate analysis. Eight variables were determined as independent risk factors: presence of nosocomial infection (hazard ratio (HR) 0.40; 95% confidence interval (CI), 0.27-0.61), mean age (HR, 1.01; 95% CI, 1.00-1.02), mean APACHE II score (HR, 1.99; 95% CI, 1.50-2.64), mechanical ventilation (HR, 1.98; 95% CI, 1.33-2.95), stay in the medical/surgical ICU (HR, 0.41; 95% CI, 0.27-0.61), enteral nutrition (HR, 0.43; 95% CI, 0.29-0.65), tracheostomy (HR, 0.26; 95% CI, 0.094-0.75), and use of steroid or chemotherapy (HR, 1.61; 95% CI, 1.13-2.29). Nosocomial pneumonia (HR, 0.59; 95% CI, 0.38-0.92) and sepsis (HR, 0.29; 95% CI, 0.16-0.51) were related with mortality. CONCLUSION The most important risk factors of mortality were observed as nosocomial infection, older age, high APACHE II score, mechanical ventilation, enteral nutrition, tracheostomy, and use of steroids or chemotherapy.
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Affiliation(s)
- Aylin Colpan
- Department of Infectious Diseases and Clinical Microbiology, Ankara Numune Education and Research Hospital, Ankara, Turkey.
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Feagan BG. Endoscopic scoring system for Crohn's disease: viva the evolution! Gastrointest Endosc 2004; 60:590-1. [PMID: 15472684 DOI: 10.1016/s0016-5107(04)01961-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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Claassen J, Vu A, Kreiter KT, Kowalski RG, Du EY, Ostapkovich N, Fitzsimmons BFM, Connolly ES, Mayer SA. Effect of acute physiologic derangements on outcome after subarachnoid hemorrhage. Crit Care Med 2004; 32:832-8. [PMID: 15090970 DOI: 10.1097/01.ccm.0000114830.48833.8a] [Citation(s) in RCA: 142] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE To determine the effect that acute physiologic derangements have on outcome after subarachnoid hemorrhage (SAH) and to design a composite score summarizing these abnormalities. DESIGN Prospective observational study. SETTING Neuroscience intensive care unit in a tertiary care academic center. PATIENTS Consecutive cohort of 413 patients with SAH admitted within 3 days of SAH onset with 3-month modified Rankin Scale scores. INTERVENTIONS None. RESULTS Among 20 physiologic variables assessed within 24 hrs of admission, four were independently associated with death or severe disability (modified Rankin Scale score, 4-6) at 3 months in a multivariate analysis: arterio-alveolar gradient of >125 mm Hg (odds ratio [OR], 4.5; 95% confidence interval [CI], 2.7-7.6), serum bicarbonate of <20 mmol/L (OR, 2.9; 95% CI, 1.6-5.6), serum glucose of >180 mg/dL (OR, 2.8; 95% CI, 1.6-4.8), and mean arterial pressure of <70 or >130 mm Hg (OR, 1.7; 95% CI, 1.0-2.9). Based on their proportional contribution to outcome, we constructed the SAH Physiologic Derangement Score (SAH-PDS; range, 0-8) by assigning the following weights for abnormal findings: arterio-alveolar gradient, 3 points; bicarbonate, 2 points; glucose, 2 points; and mean arterial pressure, 1 point. After controlling for known predictors of death or severe disability (age, admission neurologic status, loss of consciousness, aneurysm size, intraventricular hemorrhage, and rebleeding), the SAH Physiologic Derangement Score was independently associated with poor outcome (OR, 1.3 for each point increase; 95% CI, 1.1-1.6). By contrast, the systemic inflammatory response syndrome score and the Acute Physiology and Chronic Health Evaluation II physiologic subscore did not add predictive value to the model. CONCLUSION Acute interventions specifically targeting hypoxemia, metabolic acidosis, hyperglycemia, and cardiovascular instability may improve the outcome of SAH patients. The SAH Physiologic Derangement Score may prove useful for rapidly quantifying the severity of important physiologic derangements in acute SAH.
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Affiliation(s)
- Jan Claassen
- Division of Critical Care Neurology, Department of Neurology, College of Physicians and Surgeons, New York, NY, USA
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Hachimi-Idrissi S, Van der Auwera M, Schiettecatte J, Ebinger G, Michotte Y, Huyghens L. S-100 protein as early predictor of regaining consciousness after out of hospital cardiac arrest. Resuscitation 2002; 53:251-7. [PMID: 12062839 DOI: 10.1016/s0300-9572(02)00027-8] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Patients resuscitated from cardiac arrest (CA) have a high mortality rate. Prognostic evaluation based on clinical observations is uncertain and would benefit from the use of biochemical markers of hypoxic brain damage. The purpose of the study was to validate the use of the serum astroglial protein S-100 levels at admission with regard to regaining consciousness after out of hospital CA. METHODS Fifty-eight patients resuscitated from out-of-hospital CA were followed up until they regained consciousness or until their death or permanent vegetative state occurred. Serum samples for measurement of S-100, using an immunoradiometric assay, were obtained at admission. RESULTS At admission, the mean value+/-standard error of the mean of serum S-100 protein was significantly higher in patients who did not regain consciousness compared with patients who regained consciousness, respectively 4.66+/-0.61 microg/l and 0.84+/-0.21 microg/l. A serum S-100 value of >0.7 microg/l at admission was found to be a predictor that consciousness would not be regained, with a specificity of 85%, a sensitivity of 66.6%, a positive predictive value of 84%, a negative predictive value of 78% and an accuracy of 77.6%. CONCLUSIONS Serum S-100 protein at admission gives reliable and independent information concerning the short term neurological outcome after resuscitation; and could be a good marker of brain cell damage.
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Affiliation(s)
- Said Hachimi-Idrissi
- Department of Critical Care Medicine and Cerebral Resuscitation Research Group, Vrije Universiteit van Brussel, Laarbeeklaan, 101, Belgium.
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Rordorf G, Koroshetz W, Efird JT, Cramer SC. Predictors of mortality in stroke patients admitted to an intensive care unit. Crit Care Med 2000; 28:1301-5. [PMID: 10834669 DOI: 10.1097/00003246-200005000-00007] [Citation(s) in RCA: 46] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Improved pathophysiologic insight and prognostic information regarding in-hospital risk of mortality among stroke patients admitted to an intensive care unit. DESIGN Retrospective analysis. SETTING Neurology/neurosurgery intensive care unit in a tertiary care university medical center. PATIENTS A total of 63 consecutive ischemic stroke patients. INTERVENTIONS Patients were classified according to in-hospital mortality. Charts were reviewed to retrospectively generate an admitting Acute Physiology and Chronic Health Evaluation (APACHE) II score. The APACHE II score and its individual components were assessed for predicting subsequent death. MEASUREMENTS AND MAIN RESULTS Of 63 patients, 13 died and 50 survived to either discharge or surgical intervention. The mean admitting APACHE II score of survivors (6.9) was lower than that of patients who died (17.2; p < .0001). None of the 33 patients with a score <9 died, compared with 43% of those with a score > or =9. A score > or =18 was uniformly associated with fatal outcome (n = 8). Univariate analysis identified APACHE II total score, Glasgow Coma Scale score, temperature, pH, and white blood cell count as significant predictors of death. Among multivariate logistic regression models examining the components of the APACHE II score, the model containing white blood cells, temperature, and creatinine best predicted death. CONCLUSIONS Several features of the APACHE II score are associated with risk of death in this patient population. The findings suggest particular physiologic derangements that are associated with, and may contribute to, increased mortality in critically ill patients with acute ischemic stroke.
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Affiliation(s)
- G Rordorf
- Department of Neurology, Massachusetts General Hospital, Boston 02114-2696, USA.
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Pascual FE, Matthay MA, Bacchetti P, Wachter RM. Assessment of prognosis in patients with community-acquired pneumonia who require mechanical ventilation. Chest 2000; 117:503-12. [PMID: 10669697 DOI: 10.1378/chest.117.2.503] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES Knowing that mortality is high in patients who require mechanical ventilation patients with community-acquired pneumonia (CAP), we hypothesized that the severity of acute lung injury could be used along with nonpulmonary factors to identify patients with the highest risk of death. We formulated a prediction model to quantitate the risk of hospital mortality in this population of patients. DESIGN Historical prospective study using data collected over the first 24 h of mechanical ventilation. We utilized a hypoxemia index-(1 - lowest [PaO(2)/PAO(2)]) x (minimum fraction of inspired oxygen to maintain PaO(2) at > 60 mm Hg) x 100], where PAO(2) is the alveolar partial pressure of oxygen-to grade the severity of acute lung injury on a scale from 0 to 100. SETTING Tertiary care university hospital ICU. PATIENTS One hundred forty-four adult patients mechanically ventilated for respiratory failure caused by CAP. MEASUREMENTS AND RESULTS Hospital mortality was 46% (n = 66). Multivariate logistic regression analysis revealed five independent predictors of hospital mortality: (1) the extent of lung injury assessed by the hypoxemia index; (2) the number of nonpulmonary organs that failed; (3) immunosuppression; (4) age > 80 years; and (5) medical comorbidity with a prognosis for survival < 5 years. At a 50% mortality threshold, the prediction model correctly classified outcome in 88% of cases. All patients with > 95% predicted probability of death died in hospital. CONCLUSIONS Based on clinical parameters measured over the first 24 h of mechanical ventilation, this model accurately identified critically ill, mechanically ventilated patients with CAP for whom prolonged intensive care may not be of benefit.
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Affiliation(s)
- F E Pascual
- Cardiovascular Research Institute, Department of Medicine, University of California, San Francisco, USA.
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Fang JF, Chen RJ, Lin BC, Hsu YB, Kao JL, Kao YC, Chen MF. Prognosis in presumptive hypoxic-ischemic coma in nonneurologic trauma. THE JOURNAL OF TRAUMA 1999; 47:1122-5. [PMID: 10608544 DOI: 10.1097/00005373-199912000-00025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The neurologic outcome of comatose patients has a wide variation from complete reawakening to death. Methods of predicting the outcome of coma caused by either head injury or cardiac arrest have been the subject of much discussion in the literature. However, prediction of neurologic prognosis in comatose trauma patients without head injury has rarely been discussed. We reviewed our experience in treating patients with presumptive hypoxic-ischemic coma after trauma and tried to identify factors relating to their neurologic outcomes. METHODS Thirty-six patients with normal brain computed tomographic scans, who remained comatose 10 minutes after stabilization of their hemodynamic status, were studied. Serial motor response, verbal response, pupillary light reflex, presence of spontaneous breathing and seizure, and blood glucose level were recorded to evaluate their roles in predicting neurologic outcomes. RESULTS There were five deaths (mortality rate, 14%) and 11 patients (31%) with neurologic deficits. An absence of spontaneous breathing, a blood glucose level greater than 300 mg/dL during resuscitation, and a presence of seizure signified a poor prognosis. Initial neurologic evaluation at 10 minutes after stabilization of hemodynamic status was not accurate in predicting outcome. A motor response worse than withdrawal from painful stimuli at 24 hours after injury and an absence of pupillary light reflex at 48 hours after injury predicted a poor neurologic outcome, with a 100% accuracy rate. CONCLUSION Hypoxic-ischemic coma in patients sustaining major trauma yielded a significantly better survival and neurologic outcome than that induced by cardiac arrest or head injury. Decision-making in the first 24 hours after injury should not be affected by the patient's neurologic status at that time. A motor response worse than withdrawal at 24 hours after injury and an absence of pupillary light reflex at 48 hours after injury predicted a poor neurologic outcome.
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Affiliation(s)
- J F Fang
- Department of Surgery, Chang-Gung Memorial Hospital, Chang-Gung University, Taoyuan, Taiwan, Republic of China
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Abstract
OBJECTIVE To identify priorities for intensive care unit (ICU) intervention and research. DESIGN Analysis of a large intensive care database. SETTING Twenty-four ICUs in the North Thames region of the United Kingdom. PATIENTS All patients admitted to an ICU between January 1, 1992, and April 31, 1996, on whom data had been entered into the database. Patients who were admitted after cardiac surgery, who had burns, or were <16 yrs of age were excluded from the study, as were data from patients with a previous ICU admission within 6 mos or where ICU or hospital outcome was unknown. Data were excluded from units that had entered <300 patients into the database. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 23,331 admissions with complete records were available. After exclusions, 12,762 admissions from 15 ICUs were selected for analysis. Hospital mortality was 32.5% with a mortality ratio of 1.14 (95% confidence interval 1.10 to 1.17). Nonsurvivors were older than survivors and had longer ICU stays. Patients admitted from wards had a higher mortality than patients from the operating room/recovery or the emergency department. Observed percentage mortality increased linearly with mortality predicted by Acute Physiology and Chronic Health Evaluation II, although the number of patients who died remained broadly constant across the range of predicted mortality. Twenty-seven percent of all deaths occurred after discharge from the ICU. Patients admitted after cardiopulmonary resuscitation constituted 30% of all deaths. Thirty-four percent of patients were in the ICU for >2 days, and they accounted for nearly 81% of bed days. CONCLUSIONS Early identification of patients at risk, both before admission and after discharge from the ICU, may allow treatment to decrease mortality. Research and resources may be best directed at patients who die, despite a relatively low predicted mortality. Although these patients are a small percentage of the low-risk admissions, they constitute a large number of ICU deaths. Many patients die after discharge from ICU and this mortality may be decreased by minimizing inappropriate early discharge to the ward, by the provision of high-dependency and step-down units, and by continuing advice and follow-up by the ICU team after the patient has been discharged. Intervention before ICU admission and support of patients after discharge from the ICU should be part of the effort to decrease mortality for ICU patients. Inadequate provision of resources for critically ill patients may result in excess intensive care mortality that is not detected with ICU outcome prediction methods.
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Affiliation(s)
- D R Goldhill
- Department of Anesthetics, The Royal London Hospital, Whitechapel, UK
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