Poor prognosis indicated by nucleated red blood cells in peripheral blood is not associated with organ failure of the liver or kidney

Nucleated red blood cells for characterization of systemic inflammatory response syndrome in dogs

BACKGROUND

Nucleated red blood cells (nRBCs) are increased by disease processes and hematopoietic stress.

OBJECTIVES

To evaluate the utility of nRBCs as a marker of disease severity and prognosis in dogs with systemic inflammatory response syndrome (SIRS).

ANIMALS

Sixty-two client-owned dogs met the criteria of SIRS without anemia.

METHODS

nRBC-positive (nRBCs: ≥5/500, n = 32) and nRBC-negative (nRBCs: <5/500, n = 30) dogs were classified, and clinicopathological data, Acute Patient Physiologic and Laboratory Evaluation (APPLEfast) scores, cytokines, 2- and 4-weeks survival were compared.

RESULTS

The median WBC (17.63, interquartile range [IQR]: 11.72-20.24 × 109/L), neutrophils (12.28, IQR: 7.17-16.88 × 109/L), band neutrophils (1288.5, IQR: 252.5-2575 cells/μL), serum IL-6 (731.80, IQR: 299.79-5522.05 pg/mL), and plasma C-reactive protein (4.10, IQR: 1.00-8.58 mg/L) were significantly higher in nRBC-positive dogs than negative dogs (11.27, IQR: 7.63-15.13 × 109/L; 7.57, IQR: 4.96-11.71 × 109/L; 62.5, IQR: 0-350.25 cells/μL; 232.30, IQR: 99.33-447.01 pg/mL; 0.40, IQR: 0.10-3.00 mg/L, respectively; P < .05). The median reticulocyte count (87.95, IQR: 52.45-130.55 × 103/μL) and serum IL-3 (40.94, IQR: 29.85-53.52 ng/L) were also significantly greater in nRBC-positive dogs than nRBC-negative dogs (46.00, IQR: 26.43-68.15 × 103/μL; 25.24, IQR: 21.65-37.40 ng/L, respectively; P < .01). The presence of circulating nRBCs, but not the reticulocyte count, at admission was predictive of death in dogs with SIRS at 2 weeks (P = .01, AUC: 0.729) and 4 weeks (P = .002, AUC: 0.731). The overall survival time was shorter in nRBC-positive dogs (95% CI, 47.35-113.90) than nRBC-negative dogs (95% CI, 90.92-135.55; P = .03).

CONCLUSIONS AND CLINICAL IMPORTANCE

Measuring peripheral nRBCs in dogs with SIRS is rapid and clinically applicable, reflecting disease severity and associated prognosis.

Nucleated red blood cell distribution in critically ill patients with acute pancreatitis: a retrospective cohort study

OBJECTIVES

This study examined the potential association between nucleated red blood cell (NRBC) levels and mortality in critically ill patients with acute pancreatitis (AP) in the intensive care unit, due to limited existing research on this correlation.

METHODS

This retrospective cohort study utilized data from the MIMIC-IV v2.0 and MIMIC-III v1.4 databases to investigate the potential relationship between NRBC levels and patient outcomes. The study employed restricted cubic splines (RCS) regression analysis to explore non-linear associations. The impact of NRBC on prognosis was assessed using a generalized linear model (GLM) with a logit link, adjusted for potential confounders. Furthermore, four machine learning models, including Gradient Boosting Classifier (GBC), Random Forest, Gaussian Naive Bayes, and Decision Tree Classifier model, were constructed using NRBC data to generate risk scores and evaluate the potential of NRBC in predicting patient prognosis.

RESULTS

A total of 354 patients were enrolled in the study, with 162 (45.8%) individuals aged 60 years or older and 204 (57.6%) males. RCS regression analysis demonstrated a non-linear relationship between NRBC levels and 90-day mortality. Receiver Operating Characteristic (ROC) analysis identified a 1.7% NRBC cutoff to distinguish survivor from non-survivor patients for 90-day mortality, yielding an Area Under the Curve (AUC) of 0.599, with a sensitivity of 0.475 and specificity of 0.711. Elevated NRBC levels were associated with increased risks of 90-day mortality in both unadjusted and adjusted models (all Odds Ratios > 1, P < 0.05). Assessment of various machine learning models with nine variables, including NRBC, Sex, Age, Simplified Acute Physiology Score II, Acute Physiology Score III, Congestive Heart Failure, Vasopressin, Norepinephrine, and Mean Arterial Pressure, indicated that the GBC model displayed the highest predictive accuracy for 90-day mortality, with an AUC of 0.982 (95% CI 0.970-0.994). Post hoc power analysis showed a statistical power of 0.880 in the study.

CONCLUSIONS

Elevated levels of NRBC are linked to an increased mortality risk in critically ill patients with AP, suggesting its potential for predicting mortality.

Prognostic Value of Nucleated RBCs for Patients With Suspected Sepsis in the Emergency Department: A Single-Center Prospective Cohort Study

Supplemental Digital Content is available in the text.

OBJECTIVES:

Increase of nucleated RBCs in peripheral blood has been shown to be predictive of mortality in ICU patients. The aim of this study was to explore the prognostic value of nucleated RBCs in the first blood sample taken at admission to the emergency department from patients with suspected sepsis.

DESIGN:

Single-center prospective cohort study.

SETTING:

Emergency department.

PATIENTS:

One-thousand two-hundred thirty-one consecutive adult patients with suspected sepsis were included in a prospective quality register-based cohort study. Inclusion criteria were as follows: patients received in rapid response team with blood cultures taken and immediate antibiotics given in the emergency department.

Intervention:

Not applicable.

MEASUREMENT AND MAIN RESULTS:

Nucleated RBCs, Sequential Organ Failure Assessment score, Quick Sequential Organ Failure Assessment, Charlson Comorbidity Index, and commonly used laboratory tests measured in the emergency department were compared with 30-day mortality. Nvaucleated RBC counts were divided into five groups, called “Nucleated RBC score,” according to nucleated RBC count levels and analyzed with logistic regression together with the Sequential Organ Failure Assessment score and Charlson Comorbidity Index. Of the 262 patients with nucleated RBCs equal to or higher than the detection limit (0.01 × 10⁹/L), 26% died within 30 days, compared with 12% of the 969 patients with nucleated RBCs below the detection limit (p < 0.0001). Mortality was significantly higher for each increase in Nucleated RBC score, except from score 2 to 3, and was 62% in the highest group. In multivariate logistic regression, odds ratios for 30-day mortality were as follows: Nucleated RBC score: 1.33 (95% CI, 1.13–1.56), Sequential Organ Failure Assessment score: 1.32 (1.29–1.56), and Charlson Comorbidity Index: 1.17 (1.09–1.25).

CONCLUSIONS:

Most patients with suspected sepsis in emergency department had undetectable nucleated RBCs at admission to the emergency department. However, increased nucleated RBCs significantly predicted 30-day mortality. Nucleated RBCs may provide additional prognostic information to Sequential Organ Failure Assessment score and other laboratory tests.

Prognostic impacts of peripheral blood erythroblasts after single-unit cord blood transplantation

INTRODUCTION

The appearance of erythroblasts (EBLs) in peripheral blood occurs in a variety of serious conditions and has been associated with mortality in critically ill patients. However, the incidence, risk factor, and outcomes of EBLs after cord blood transplantation (CBT) remain unclear.

METHODS

We have investigated the impact of EBLs on transplant outcomes on 225 adult patients who underwent single-unit CBT at our single institute.

RESULTS

The cumulative incidences of EBL ≥200 × 10⁶ /L and EBL ≥1000 × 10⁶ /L at 60 days after CBT were 17% and 4%, respectively, detected after a median of 35 days and 36.5 days. Multivariate analysis using erythroblastosis as time-dependent covariates demonstrated the significant association of EBL ≥1000 × 10⁶ /L, but not EBL ≥200 × 10⁶ /L, with the development of grade III-IV acute graft-versus-host disease (GVHD, hazard ratio [HR]: 18.56; P < .001), higher nonrelapse mortality (HR: 13.38; P < .001), and overall mortality (HR: 4.97; P = .001).

CONCLUSION

These data suggested that higher levels of EBLs were recognized as a significant risk factor for severe acute GVHD and mortality after single-unit CBT. Higher levels of EBLs may serve as a surrogate marker for poor single CBT outcomes.

Do we need to conduct full-thickness closure after endoscopic full-thickness resection of gastric submucosal tumors?

BACKGROUND/AIMS

Successful closure of gastric wall defects is a pivotal step for endoscopic full-thickness resection (EFTR). Our study indicates that for submucosal tumors (SMTs) smaller than 2.5 cm, closing the mucosal layer is safe and feasible when the modified method, ZIP, is used.

MATERIALS AND METHODS

We retrospectively analyzed 37 patients with gastric SMTs arising from the muscularis propria (MP) who underwent EFTR with defect closure of the mucosal layer. The main procedure involved: (1) making a longitudinal incision of the mucosal and submucosal layers above the lesion, (2) fully exposing the lesion and symmetrically punching holes on both sides of the incision into the submucosal layer, (3) en bloc resection of the lesion using an electrosurgical snare or knife, (4) hooking of metallic clips into the holes and clipping of the mucosal layer successively to close the gastric wall defect. This modified method was named ZIP.

RESULTS

Successful complete resection by EFTR was achieved in 37 cases (100%). The median procedure time was 60 min (range: 30-120 min), whereas the closure procedure took a median of 8 min (range: 5-20 min). The median lesion size was 1.0 cm (range: 0.5-2.5 cm). No patients had severe complications. No residual lesions or tumor recurrence were found during the follow-up period.

CONCLUSION

Closing the mucosal layer of gastric wall defects after EFTR by ZIP is feasible and effective.

Establishment of a predictive model for outcomes in patients with severe acute pancreatitis by nucleated red blood cells combined with Charlson complication index and APACHE II score

BACKGROUND/AIMS

Nucleated red blood cell (NRBC) is an immature red blood cell, which can appear in the peripheral blood of newborns but not in normal adults. However, in the presence of hemorrhage, severe hypoxia, or severe infection, NRBCs may exist in adult blood and are associated with prognosis. The aims of this study were to establish a predictive model for the outcome of patients with severe acute pancreatitis (SAP) based on NRBCs.

MATERIALS AND METHODS

Data from 92 patients with SAP were retrospectively collected for the study. We used chi-square automatic interaction detection (CHAID) to explore a prediction model of mortality in patients with SAP by NRBCs.

RESULTS

During the 90-day follow-up, 11 participants (12.0%) died. The NRBC-positive rate of nonsurvivors was much higher than survivors (90.9% vs. 23.5%). Charlson Comorbidity Index (CCI), Acute Physiology and Chronic Health Evaluation II (APACHE II), Ranson score, and serum C-reactive protein were higher in nonsurvivors (5.0, 29.0, 6.0, and 140.0 g/L) than survivors (3.0, 13.0, 4.0, and 54.7 g/L). A CHAID model including NRBC, CCI, APACHE II score, and Ranson score showed that NRBCs differentiated well between nonsurvivors and survivors. All patients with SAP survived when they had a negative test result for NRBCs and CCI was below 7. All patients died when they had a positive test result for NRBCs and APACHE II score exceeded 30. Among patients whose NRBC test result was positive and APACHE II score was below 30, if the Ranson score was less than 5, the mortality rate was only 5.6%, whereas the mortality rate was 66.7% if the Ranson score exceeded 5. A validated population of 32 patients showed that the accuracy of the prediction model was 100%.

CONCLUSION

NRBC combined with CCI, APACHE II, and Ranson score can predict 90-day mortality of patients with SAP.

The Presence of Nucleated Red Blood Cells as an Indicator for Increased Mortality and Morbidity in Burn Patients

Nucleated red blood cells (NRBCs) have been studied in critically ill and injured patients as a predictor of increased in-hospital mortality and poor clinical outcomes. While prior studies have demonstrated the prognostic power of NRBCs in the critical patient, there has been a paucity of literature available describing their value as a prognostic indicator in the severely burned patient. This retrospective observational study was conducted from 2012 to 2017. Inclusion criteria for this study included all burn patients with total body surface area > 10% who were aged ≥ 15 years. Demographic and clinical data were collected from the electronic medical record system. Data analysis consisted of descriptive and comparative analysis using SPSS. Two hundred and nineteen patients (17.5%) met inclusion criteria with 51 (23.3%) patients positive for NRBCs. The presence of NRBCs had an increased mortality rate with an odds ratio of 6.0 (P = .001; 2.5, 14.5); was more likely to appear in older patients (P < .001); and was associated with increased hospital length of stay (P < .001), injury severity scores (P < .001), and complications. The presence of NRBCs even at the low concentrations reported in our study showed a 6-fold increase in the rate of mortality. With the current improvements in burn care leading to higher survival rates, the need to improve upon the numerous models that have been developed to predict mortality in severe burn patients is clear given the significantly increased risk of death that the presence of NRBCs portends.

Improvement of mortality prediction accuracy in critically ill patients through combination of SOFA and APACHE II score with markers of stress haematopoiesis

INTRODUCTION

In critically ill patients nucleated red blood cells (NRBC) and immature granulocytes (IG) appear in the peripheral blood as the consequence of stress haematopoesis. The aim of this retrospective study was to evaluate the diagnostic value of NRBC and IG and to propose a model of improved mortality prediction including these parameters in the assessment of critically ill patients.

METHODS

The study included 338 critically ill adult patients hospitalized at Department of Anaesthesiology and Intensive Medicine, Louis Pasteur University Hospital in Kosice. As NRBC positive patients were considered patients with peripheral NRBC > 0.01 × 10⁹ /L and IG positivity as >0.03 × 10⁹ /L. Apache II index was calculated 24 hours after admission and Systemic Organ Failure Assessment (SOFA) on the day with the worst clinical condition.

RESULTS

NRBC positivity was found in 27.6% of patients. The mortality of NRBC positive patients was 48.38%, significantly higher than 23.7% of NRBC negative patients. IG positivity was 79.0% and their mortality was also higher as compared with that of IG negative patients (69.3% vs 33.8%). Three regression models predicting mortality including stress haematopoiesis markers, APACHE II, SOFA scores and age had sufficient level of sensitivity and specificity.

CONCLUSION

The presence of NRBC in the peripheral blood and the IG increase are available early risk predictors of mortality in critically ill patients. Regression models designed by combination of SOFA, APACHE II, and the new haematological parameters increase the accuracy and effectivity of diagnostic process in predicting prognosis and risk of mortality with high sensitivity and specificity.

Neutrophil-to-lymphocyte ratio, nucleated red blood cells and erythrocyte abnormalities in canine systemic inflammatory response syndrome

Systemic inflammatory response syndrome (SIRS) is the manifestation of the systemic response to an infectious or non-infectious disease. We evaluated the association between erythrocyte parameters, including nucleated red blood cells (NRBCs) and leukocyte ratios (NLR, neutrophil-to-lymphocyte ratio; BLR, band neutrophil-to-lymphocyte ratio; BLNR, band neutrophil-to-neutrophil-to-lymphocyte ratio). A review of the medical records was conducted searching SIRS dogs among those admitted to our intensive care unit and a SIRS grading was obtained based on how many criteria were fulfilled. The Acute Patient Physiology and Laboratory Evaluation (APPLE_fast) score was assessed in each dog. Survival rate was assessed 15 days after admission. Dogs with clinical and/or clinicopathological signs of hemolytic or hemorrhagic disorders were excluded. Dogs with ≥2 criteria of SIRS along with a documented underlying infectious cause were recorded as septic (32/90, 35%). A SIRS grading >2 (p = .001) and an APPLE_fast score > 25 (p = .03) were associated with mortality. Twenty-two of SIRS dogs (24%) showed circulating NRBCs. The occurrence of circulating NRBCs was associated with the mortality in SIRS groups (p = .0025). The median NLR was 11.69 and NLR was lower in septic dogs compared to non-septic ones (p = .0272). APPLE_fast, SIRS grading and circulating NRBCs may be considered as negative prognostic factors in canine SIRS. NLR could be a useful tool in dogs with SIRS, which was significantly lower in the septic group. Further prospective, large-scale studies investigating BLR and BNLR in canine SIRS are warranted.

Nucleated red blood cells, critical illness survivors and postdischarge outcomes: a cohort study

Background

Little is known about risk factors associated with out-of-hospital outcomes in survivors of critical illness. We hypothesized that the presence of nucleated red blood cells in patients who survived critical care would be associated with adverse outcomes following hospital discharge.

Methods

We performed a two-center observational cohort study of patients treated in medical and surgical intensive care units in Boston, Massachusetts. All data were obtained from the Research Patient Data Registry at Partners HealthCare. We studied 2878 patients, age ≥ 18 years, who received critical care between 2011 and 2015 and survived hospitalization. The exposure of interest was nucleated red blood cells occurring from 2 days prior to 7 days after critical care initiation. The primary outcome was mortality in the 90 days following hospital discharge. Secondary outcome was unplanned 30-day hospital readmission. Adjusted odds ratios were estimated by multivariable logistic regression models with inclusion of covariate terms thought to plausibly interact with both nucleated red blood cells and outcome. Adjustment included age, race (white versus nonwhite), gender, Deyo–Charlson Index, patient type (medical versus surgical), sepsis and acute organ failure.

Results

In patients who received critical care and survived hospitalization, the absolute risk of 90-day postdischarge mortality was 5.9%, 11.7%, 15.8% and 21.9% in patients with 0/μl, 1–100/μl, 101–200/μl and more than 200/μl nucleated red blood cells respectively. Nucleated red blood cells were a robust predictor of postdischarge mortality and remained so following multivariable adjustment. The fully adjusted odds of 90-day postdischarge mortality in patients with 1–100/μl, 101–200/μl and more than 200/μl nucleated red blood cells were 1.77 (95% CI, 1.23–2.54), 2.51 (95% CI, 1.36–4.62) and 3.72 (95% CI, 2.16–6.39) respectively, relative to patients without nucleated red blood cells. Further, the presence of nucleated red blood cells is a significant predictor of the odds of unplanned 30-day hospital readmission.

Conclusion

In critically ill patients who survive hospitalization, the presence of nucleated red blood cells is a robust predictor of postdischarge mortality and unplanned hospital readmission.

Electronic supplementary material

The online version of this article (doi:10.1186/s13054-017-1724-z) contains supplementary material, which is available to authorized users.

Association of nucleated red blood cells with mortality in critically ill dogs

The occurrence of nucleated red blood cells (NRBC) in the peripheral blood of critically ill human patients is associated with increased mortality. In dogs, the presence of NRBCs in peripheral blood has been used as a sensitive and specific marker of complications and outcome associated with heatstroke. However, no study has investigated their prevalence in critically ill dogs. Thus, the aim of this study was to determine the prevalence of NRBCs in the peripheral blood, and to evaluate their occurrence as a prognostic factor in critically ill dogs. One hundred and one dogs were prospectively included; the presence of NRBCs was studied on a daily basis from the time of admission until day 3 in the intensive care unit (or less if discharged or death occurred earlier). Dogs fulfilled at least two systemic inflammatory response syndrome (SIRS) criteria and suffered from various diseases. Survival was defined as being alive 28 days postdischarge from hospital. In 42 dogs, NRBCs were detected at least once; 59 patients were NRBC negative. Mortality was significantly higher in NRBC-positive than NRBC-negative patients (54.8 v 30.5 per cent) (P=0.014). However, this association was not present when anaemic dogs were excluded from the analysis. Detection of NRBCs in the peripheral blood may be an indicator for regenerative anaemia and may have potential for use as a prognostic tool or in addition to established scoring systems in critically ill dogs.

Nucleated red blood cells are associated with a higher mortality rate in patients with surgical sepsis

BACKGROUND

Nucleated red blood cells (NRBCs) are present in certain non-oncologic disease states and are associated with a poor prognosis. The purpose of this study was to evaluate NRBCs as an early prognostic marker for death in patients with surgical sepsis.

METHODS

Retrospective evaluation of data collected prospectively from 275 patients from our Investigational Review Board-approved surgical sepsis database over a 27-mo period. The NRBC values were correlated with patient outcomes. The χ(2) test was used for testing of categorical variables and the Mann-Whitney U was used for testing of continuous variables. The level of significance was set at 0.05.

RESULTS

At sepsis recognition, 48 patients (17.5%) were NRBC-positive. The mortality rate was greater in patients who were NRBC positive while in the intensive care unit (ICU); (27% vs. 12%; p=0.007) and during the hospital stay (35.4% vs. 15%; p=0.001). When NRBC-values at all time points are considered, 116 patients (42.2%) were NRBC-positive. The mortality rate was greater in patients who were NRBC-positive in both the ICU (23.3% vs. 8.2%; p<0.001) and during the hospital stay (31% vs. 9.4%; p<0.001). In-hospital and ICU mortality rates increased with increasing NRBC-concentration. For the 153 patients with severe sepsis, NRBC positivity at any time was associated with a higher ICU mortality rate (20% vs. 3.2%; p=0.001). Significant mortality differences did not occur between NRBC-positive and NRBC-negative patients with sepsis (n=48) or septic shock (n=74).

CONCLUSIONS

Surgical sepsis patients with detectable NRBCs are at higher risk of ICU and in-hospital death than those with non-detectable NRBCs. The mortality difference is underscored in surgical patients with severe sepsis. This study suggests NRBCs may be a biomarker of outcomes in patients with surgical sepsis.

Association of nucleated red blood cells in blood and arterial oxygen partial tension

BACKGROUND

Several studies suggest that the detection of nucleated red blood cells (NRBCs) in hospitalized patients indicates an increased risk of mortality. This study evaluates the impact of low arterial oxygen partial tension (pO₂) on NRBC appearance and prognosis in NRBC positive patients.

METHODS

NRBCs in blood, arterial blood gases, and other laboratory parameters were monitored daily in 234 surgical intensive care patients. pO₂ was assessed in relation to mortality and the detection of NRBCs.

RESULTS

NRBCs were found in 67 patients (28.6%). Mortality was significantly higher in NRBC positive patients (41.8%, 28/67) than in those that were NRBC negative (3.0%, 5/167). Multivariate logistic regression showed an increased mortality in NRBC positive patients (odds ratio 5.79; 95% confidence interval (CI) 1.07-31.33, p < 0.05). NRBC positive patients showed significantly lower pO₂ levels during intensive care treatment than NRBC negative patients. Prior to the initial detection of NRBCs in the peripheral blood, pO₂ levels were significantly lower in patients who died than in surviving patients. After the first appearance of NRBCs, no significant difference in pO₂ between these groups was found.

CONCLUSIONS

The detection of NRBCs is of prognostic significance concerning patient mortality. In NRBC positive patients, hypoxemia occurs more frequently. Low-levels of pO₂ seem to precede the appearance of NRBCs, especially in those patients with high risk of mortality.

Peripheral nucleated red blood cells as a prognostic indicator in heatstroke in dogs

BACKGROUND

Heatstroke in dogs is often fatal and is associated with a high prevalence of secondary complications. Peripheral nucleated red blood cells (NRBC) occur in dogs with heatstroke, but their association with complications and the outcome is unclear.

HYPOTHESIS

Peripheral NRBC are common in dogs with heatstroke and have prognostic significance.

ANIMALS

Forty client-owned dogs with naturally occurring heatstroke.

METHODS

Prospective, observational study. Dogs were followed from presentation to discharge or death. Serum biochemistry and coagulation tests were performed at presentation. CBC and evaluation of peripheral blood smears were performed at presentation and every 12 hours. The relative and the absolute NRBC numbers were calculated.

RESULTS

Presence of NRBC was observed in 36/40 (90%) of the dogs at presentation. Median relative and absolute NRBC were 24 cells/100 leukocytes (range 0-124) and 1.48 x 10(3)/microL (range 0.0-19.6 x 10(3)/microL), respectively. Both were significantly higher in nonsurvivors (22) versus survivors (18) and in dogs with secondary renal failure and DIC versus those without these complications. Receiver operator curve analysis of relative NRBC at presentation as a predictor of death had an area under curve of 0.92. A cut-off point of 18 NRBC/100 leukocytes corresponded to a sensitivity and specificity of 91 and 88% for death.

CONCLUSIONS AND CLINICAL IMPORTANCE

Relative and absolute numbers of peripheral NRBC are clinically useful, correlate with the secondary complications, and are sensitive and specific markers of death in dogs with heatstroke, although they should never be used as a sole prognostic indicator nor should they replace clinical assessment.

Re-evaluation of established risk scores by measurement of nucleated red blood cells in blood of surgical intensive care patients

BACKGROUND

In adults, the appearance of nucleated red blood cells (NRBC) in the peripheral blood is associated with several severe diseases. When NRBC are detected in the blood, the prognosis is poor. The purpose of this study was to identify the impact of NRBC on the clinical outcomes of surgical intensive care patients under consideration of established risk models.

METHODS

In a prospective study, the detection of NRBC in the peripheral blood of surgical intensive care patients was analyzed with regard to the in- hospital mortality. NRBC were daily measured with a Sysmex XE-2100. The prognostic significance of NRBC in blood was analyzed under consideration of established risk scores for intensive care patients, i.e., the Acute Physiology and Chronic Health Evaluation (APACHE II) and the Simplified Acute Physiology Score (SAPS II).

RESULTS

Two hundred seventy-one surgical intensive care patients were included in this study. The mean age was 61.3 years +/- 1.2 years (range, 18-98 years). The average APACHE II and SAPS II scores were 20.6 +/- 0.6 and 44.1 +/- 1.2, respectively. The in-hospital mortality of NRBC-positive patients was 51.7% (45 of 87). This was significantly higher (p < 0.001) than the mortality of NRBC-negative patients (12.0%, 22 of 184). The area under curve (C-statistic) was 0.77. Mortality increased with the NRBC concentration. On average, in NRBC-positive patients who died, NRBC were detected for the first time 13.3 days +/- 3.1 days (n = 45, median = 6 days) before death. Multiple logistic regression analysis under consideration of the APACHE II or the SAPS II revealed a significant association between NRBC and increased mortality, the mean odds ratio being 1.97 for each increase in the NRBC category (0/microL; 1-40/microL; 41-80/microL; 81-240/microL, >240/microL). In contrast, under consideration of the NRBC-data the mean odds ratios for the increase of one score point of the APACHE II and SAPS II were 1.10 and 1.05, respectively. Therefore, each step-up in the NRBC category is equivalent to approximately 7 APACHE II-score points and 14 SAPS II-score points, respectively.

CONCLUSIONS

The daily screening for NRBC in blood of surgical intensive care patients is of prognostic power with regard to the patients' in-hospital mortality. This prognostic significance of NRBC was independent of the scores APACHE II and SAPS II, respectively. Therefore, for prognostic purposes an adjustment of these established risk models by including the NRBC-results is feasible.

A laboratory-based risk score for medical intensive care patients

BACKGROUND

Established general risk score models for intensive care patients incorporate several clinical and laboratory data. However, the collection, documentation and classification of clinical data are time-consuming, incur labor-related costs, and are dependent on the experience of the examiner. Therefore, in the present study a general score for medical intensive care patients based solely on routine laboratory parameters is presented.

METHODS

Parameter selection was performed using stepwise logistic regression analysis. The maximum likelihood estimate of variable influence on mortality provided a relative weighting for each variable. The new score was compared to two established risk models (Acute Physiology And Chronic Health Evaluation II, APACHE II; and Simplified Acute Physiology Score II, SAPS II).

RESULTS

The study included 528 medical intensive care patients with a mean age of 65.4+/-0.7 years. The in-hospital mortality was 16.5% (87/528). Multiple logistic regression analysis revealed eight parameters with significant prognostic power: alanine aminotransferase, cholesterol, creatinine, leukocytes, sodium, thrombocytes, urea, and age. These parameters were used to build a new laboratory score called Critical Risk Evaluation by Early Keys (CREEK). The area under the receiver operating characteristics curve was 0.857 (0.814-0.900). Pearson correlation analysis showed significant correlation between CREEK and APACHE II (r=0.550) and SAPS II (r=0.516; p<0.001; n=387). The areas under curve of the APACHE II and the SAPS II were 0.869 and 0.874, respectively.

CONCLUSIONS

We show that a general risk score for medical intensive care patients on admission based solely on routine laboratory parameters is feasible. The quality of risk estimation using CREEK is comparable to established risk models. Furthermore, this new score is based on quality controlled low-cost laboratory parameters that are routinely measured on admission to the intensive care unit. Therefore, no additional costs are involved.

Nucleated red blood cells in the blood of medical intensive care patients indicate increased mortality risk: a prospective cohort study

Introduction

In critically ill patients, the appearance of nucleated red blood cells (NRBCs) in blood is associated with a variety of severe diseases. Generally, when NRBCs are detected in the patients' blood, the prognosis is poor.

Methods

In a prospective study, the detection of NRBCs was used for a daily monitoring of 383 medical intensive care patients.

Results

The incidence of NRBCs in medical intensive care patients was 17.5% (67/383). The mortality of NRBC-positive patients was 50.7% (34/67); this was significantly higher (p < 0.001) than the mortality of NRBC-negative patients (9.8%, 31/316). Mortality increased with increasing NRBC concentration. Seventy-eight point six percent of the patients with NRBCs of more than 200/μl died. The detection of NRBCs is highly predictive of death, the odds ratio after adjustment for other laboratory and clinical prognostic indicators being 1.987 (p < 0.01) for each increase in the NRBC category (0/μl, 1 to 100/μl, 101 to 200/μl, and more than 200/μl). Each step-up in the NRBC category increased the mortality risk as much as an increase in APACHE II (Acute Physiology and Chronic Health Evaluation II) score of approximately 4 points. The mortality of patients who were NRBC-positive on the day of relocation from the intensive care unit to a peripheral ward was 27.6% (8/27). This was significantly higher than the mortality of patients who were NRBC-negative on the relocation day (8.6%, 28/325; p < 0.01). On average, NRBCs were detected for the first time 14 days (median, 3 days) before death.

Conclusion

The routine analysis of NRBCs in blood is of high prognostic power with regard to mortality of critically ill patients. Therefore, this parameter may serve as a daily indicator of patients at high mortality risk. Furthermore, NRBC-positive intensive care patients should not be relocated to a normal ward but should obtain ongoing intensive care treatment.