Hypoxia-inducible factor-1α is a biomarker for predicting patients with sepsis

OBJECTIVE

This study aimed to investigate the potential value of serum hypoxia-inducible factor-1α (HIF-1α) concentrations as a biomarker in patients with sepsis.

METHODS

The enrolled patients were divided into the following four groups: the intensive care unit (ICU) control group (n = 33), infection group (n = 29), septic nonshock group (n = 40), and septic shock group (n = 94). An enzyme-linked immunosorbent assay was used to measure serum HIF-1α concentrations on ICU admission. Clinical parameters and laboratory test results were also collected.

RESULTS

Serum HIF-1α concentrations were significantly higher in the infection group, septic nonshock group, and septic shock group than in the ICU control group. Moreover, HIF-1α concentrations were associated with a better predictive ability for diagnosing sepsis than the Acute Physiology and Chronic Health Evaluation II score, procalcitonin concentrations, and lactate concentrations. Patients with sepsis and HIF-1α concentrations >161.14 pg/mL had a poor prognosis.

CONCLUSIONS

Serum HIF-1α concentrations are a useful biomarker for the diagnosis of sepsis and predicting the prognosis of patients.

Comparison of the National Early Warning Scores and Rapid Emergency Medicine Scores with the APACHE II Scores as a Prediction of Mortality in Patients with Medical Emergency Team Activation: a Single-centre Retrospective Cohort Study

Introduction

The medical emergency team enables the limitation of patients’ progression to critical illness in the general ward. The early warning scoring system (EWS) is one of the criteria for medical emergency team activation; however, it is not a valid criterion to predict the prognosis of patients with MET activation.

Aim

In this study, the National Early Warning Score (NEWS) and Rapid Emergency Medicine Score (REMS) was compared with that of the Acute Physiology and Chronic Health Evaluation II (APACHE II) score in predicting the prognosis of patients who had been treated a medical emergency team.

Material and Methods

In this single-centre retrospective cohort study, patients treated by a medical emergency team between April 2013 and March 2019 and the 28-day prognosis of MET-activated patients were assessed using APACHE II, NEWS, and REMS.

Results

Of the 196 patients enrolled, 152 (77.5%) were men, and 44 (22.5%) were women. Their median age was 68 years (interquartile range: 57-76 years). The most common cause of medical emergency team activation was respiratory failure (43.4%). Univariate analysis showed that APACHE II score, NEWS, and REMS were associated with 28-day prognostic mortality. There was no significant difference in the area under the receiver operating characteristic curve of APACHE II (0.76), NEWS (0.67), and REMS (0.70); however, the sensitivity of NEWS (0.70) was superior to that of REMS (0.47).

Conclusion

NEWS is a more sensitive screening tool like APACHE II than REMS for predicting the prognosis of patients with medical emergency team activation. However, because the accuracy of NEWS was not sufficient compared with that of APACHE II score, it is necessary to develop a screening tool with higher sensitivity and accuracy that can be easily calculated at the bedside in the general ward.

Predictors of Mortality in Critically Ill Patients With Antineutrophil Cytoplasmic Antibody-Associated Vasculitis

Background: Patients with antineutrophil cytoplasmic antibody-associated vasculitis (AAV) may require intensive care unit (ICU) admission due to different reasons, and the in-ICU mortality is high among AAV patients. The aim of this study was to explore the clinical features and risk factors of mortality of patients with AAV in the ICU.

Methods: A retrospective study was conducted based on 83 AAV patients admitted to the ICU in a tertiary medical institution in China. Data on clinical characteristics, laboratory tests, treatment in ICU and outcomes were collected. The data were analyzed using univariate and multivariate logistic regression analysis to explore the variables that were independently related to mortality. Kaplan–Meier method was used to assess the long-term survival.

Results: Among the 83 patients, 41 (49.4%) were female. The mean age of patients was 66 ± 13 years. Forty-four patients deceased, with the in-ICU mortality of 53%. The most common cause for ICU admission was active vasculitis (40/83, 48.2%). The main cause of death was infection (27/44, 61.4%) followed by active vasculitis (15/44, 34.1%). A multivariate analysis revealed that the Acute Physiology and Chronic Health Evaluation II (APACHE II) at ICU admission (OR = 1.333, 95% CI: 1.031–1.722) and respiratory failure (OR = 620.452, 95% CI: 11.495–33490.306) were independent risk factors of in-ICU death. However, hemoglobin (OR = 0.919, 95% CI: 0.849–0.995) was an independent protective factor. The nomogram established in this study was practical in predicting the risk of in-ICU mortality for AAV patients. Moreover, for 39 patients survived to the ICU stay, the cumulative survival rates at 0.5, 1, and 5 years were 58.3%, 54.2%, and 33.9%, respectively, and the median survival time was 14 months.

Conclusion: In our study, active vasculitis was the most frequent reason for ICU admission, and the main cause of death was infection. APACHE II and respiratory failure were independent risk factors while hemoglobin was an independent protective factor of in-ICU mortality for AAV patients admitted to the ICU. The risk prediction model developed in this study may be a useful tool for clinicians in early recognition of high-risk patients and applying appropriate management.

Comparison of Various Severity Assessment Scoring Systems in Patients with Sepsis in a Tertiary Care Teaching Hospital

BACKGROUND

Sepsis is a complex condition defined by the systemic response to infection. Severity assessment scoring systems are used to aid the physician in deciding whether aggressive treatment is needed or not. In this study, various severity assessment scoring systems, namely Acute Physiology and Chronic Health Evaluation II (APACHE II), Rapid Emergency Medicine Score (REMS), Sequential Organ Failure Assessment (SOFA), Multiple Organ Dysfunction Score (MODS), Predisposition, Infection, Response, and Organ Dysfunction (PIRO), and Mortality in Emergency Department Sepsis (MEDS), were compared to assess their sensitivity and specificity.

MATERIALS AND METHODS

A prospective cohort study was conducted over 6 months. The study was conducted in the intensive care unit (ICU) of a tertiary care teaching hospital. All patients above 18 years of age with confirmed sepsis diagnosis and a well-defined outcome were included in the study.

RESULTS

A total of 193 patients were included in the study. The mean age was 57.2 ± 15.3 (mean ± standard deviation) years. Majority of the patients were male, 125 (64.76%). Overall mortality was 108 (55.9%). The calculated area under the receiver operating characteristic curve was 0.86 (95% confidence interval [CI]: 0.80-0.90) for APACHE II, 0.81 (95% CI: 0.75-0.87) for REMS, 0.80 (95% CI: 0.74-0.86) for SOFA, 0.74 (95% CI: 0.67-0.80) for MODS, 0.78 (95% CI: 0.71-0.84) for PIRO, and 0.77 (95% CI: 0.71-0.83) for MEDS. Sensitivity and specificity for APACHE II were 81.5 and 75.3, respectively.

CONCLUSIONS

In our study, APACHE II score was found to be the most sensitive and specific in predicting the severity of sepsis compared to other scores.

Mortality Prediction Using Acute Physiology and Chronic Health Evaluation II and Acute Physiology and Chronic Health Evaluation IV Scoring Systems: Is There a Difference?

Background:

Mortality prediction in the Intensive Care Unit (ICU) setting is complex, and there are several scoring systems utilized for this process. The Acute Physiology and Chronic Health Evaluation (APACHE) II has been the most widely used scoring system; although, the more recent APACHE IV is considered an updated and advanced prediction model. However, these two systems may not give similar mortality predictions.

Objectives:

The aim of this study is to compare the mortality prediction ability of APACHE II and APACHE IV scoring systems among patients admitted to a tertiary care ICU.

Methods:

In this prospective longitudinal observational study, APACHE II and APACHE IV scores of ICU patients were computed using an online calculator. The outcome of the ICU admissions for all the patients was collected as discharged or deceased. The data were analyzed to compare the discrimination and calibration of the mortality prediction ability of the two scores.

Results:

Out of the 1670 patients' data analyzed, the area under the receiver operating characteristic of APACHE II score was 0.906 (95% confidence interval [CI] – 0.890–0.992), and APACHE IV score was 0.881 (95% CI – 0.862–0.890). The mean predicted mortality rate of the study population as given by the APACHE II scoring system was 44.8 ± 26.7 and as given by APACHE IV scoring system was 29.1 ± 28.5. The observed mortality rate was 22.4%.

Conclusions:

The APACHE II and IV scoring systems have comparable discrimination ability, but the calibration of APACHE IV seems to be better than that of APACHE II. There is a need to recalibrate the scales with weights derived from the Indian population.

Impact of Targeted Preoperative Optimization on Clinical Outcome in Emergency Abdominal Surgeries: A Prospective Randomized Trial

Background:

Perforation peritonitis continues to be one of the most common surgical emergencies that need a surgical intervention most of the times. Anesthesiologists are invariably involved in managing such cases efficiently in perioperative period.

Aims:

The assessment and evaluation of Acute Physiology and Chronic Health Evaluation II (APACHE II) score at presentation and 24 h after goal-directed optimization, administration of empirical broad-spectrum antibiotics, and definitive source control postoperatively. Outcome assessment in terms of duration of hospital stay and mortality in with or without optimization was also measured.

Settings/Design:

It is a prospective, randomized, double-blind controlled study in hospital setting.

Materials and Methods:

One hundred and one patients aged ≥18 years, of the American Society of Anesthesiologists physical Status I and II (E) with clinical diagnosis of perforation peritonitis posted for surgery were enrolled. Enrolled patients were randomly divided into two groups. Group A is optimized by goal-directed optimization protocol in the preoperative holding room by anesthesiology residents whereas in Group S, managed by surgery residents in the surgical wards without any fixed algorithm. The assessment of APACHE II score was done as a first step on admission and 24 h postoperatively. Duration of hospital stay and mortality in both the groups were also measured and compared.

Statistical Analysis:

Categorical data are presented as frequency counts (percent) and compared using the Chi-square or Fisher's exact test. The statistical significance for categorical variables was determined by Chi-square analysis. For continuous variables, a two-sample t-test was applied.

Results:

The mean APACHE II score on admission in case and control groups was comparable. Significant lowering of serial scores in case group was observed as compared to control group (P = 0.02). There was a significant lowering of mean duration of hospital stay seen in case group (9.8 ± 1.7 days) as compared to control group (P = 0.007). Furthermore, a significant decline in death rate was noted in case group as compared to control group (P = 0.03).

Conclusion:

Goal-directed optimized patients with perforation peritonitis were discharged early as compared to control group with significantly lesser mortality as compared with randomly optimized patients in the perioperative period.

Critical Illness Scoring Systems: Sequential Organ Failure Assessment, Acute Physiology and Chronic Health Evaluation II, and Quick Sequential Organ Failure Assessment to Predict the Clinical Outcomes in Scrub Typhus Patients with Organ Dysfunctions

Background and Aim

Scrub typhus (ST) is an acute infectious disease of variable severity caused by Orientia (formerly Rickettsia) tsutsugamushi. The disease can be complicated by organ dysfunctions and the case fatality rate (CFR) is approximately 15%, which further rises with the development of severe complications. We studied the clinical features of the ST and the performance of critical illness scoring systems (CISSs) - Acute Physiology and Chronic Health Evaluation (APACHE) II, sequential organ failure assessment (SOFA), and quick SOFA (qSOFA) in predicting the clinical outcomes in complicated ST (cST) patients admitted to the emergency department.

Study Design and Methods

A prospective observational study was done in 50 patients diagnosed to have cST with one or more organ dysfunctions. Clinical features and laboratory parameters were recorded and the patients were followed up until the end of their stay in the hospital. APACHE II, SOFA, and qSOFA scores at admission were calculated and were analyzed in predicting the clinical outcomes.

Results

The median SOFA, APACHE II, and qSOFA scores of the cohort were 7 (interquartile range [IQR] = 13-22), 8 (IQR = 5-11), and 2 (IQR = 1-3), respectively. The median duration of in-hospital stay was 9 (IQR 5-11) days and overall CFR was 8%. On bivariate analysis, both SOFA (P = 0.031) and qSOFA (P = 0.001) predicted mortality. However, only SOFA score correlated with the in-hospital stay duration (Pearson's correlation = 0.311, P = 0.028).

Conclusion

Among the three CISSs studied, the SOFA score correlated with in-hospital stay duration and mortality, whereas the qSOFA score formed a simple as well as a convenient tool in predicting the mortality in patients of cST with organ dysfunction.

Mortality prediction in status epilepticus with the APACHE II score

A retrospective study was performed of adults admitted to the intensive care unit in order to determine the utility of the Acute Physiology and Chronic Health Evaluation II (APACHE II) score in predicting in-hospital mortality in intensive care unit patients with non-cardiac status epilepticus. The cohort consisted of 104 subjects, 50 (48.1%) male, 39 (37.5%) aged ≥65 years, with a mean APACHE II score of 17.88. Four models of the APACHE II system were assessed: numerical score, adjusted score mortality, category, and category mortality. All models demonstrated poor calibration and discrimination, even after adjustment for significantly different covariates. There were independent associations between mortality and acute or toxic-metabolic seizure etiologies, myoclonic seizures, and postoperative status. After multivariate adjustment, only the association with toxic-metabolic seizure etiologies remained. The APACHE II score is a poor predictor of mortality in intensive care unit patients with status epilepticus. Further investigation is warranted to develop better measures of acute physiological disease severity in status epilepticus and its impact on mortality.

Association of serum interleukin-6, interleukin-8, and Acute Physiology and Chronic Health Evaluation II score with clinical outcome in patients with acute respiratory distress syndrome

Background and Aim:

Studies on potential biomarkers in experimental models of acute lung injury (ALI) and clinical samples from patients with ALI have provided evidence to the pathophysiology of the mechanisms of lung injury and predictor of clinical outcome. Because of the high mortality and substantial variability in outcomes in patients with acute respiratory distress syndrome (ARDS), identification of biomarkers such as cytokines is important to determine prognosis and guide clinical decision-making.

Materials and Methods:

In this study, we have included thirty patients admitted to Intensive Care Unit diagnosed with ARDS, and serum samples were collected on day 1 and 7 and were analyzed for serum interleukin-6 (IL-6) and IL-8 by ELISA method, and Acute Physiology and Chronic Health Evaluation II (APACHE II) scoring was done on day 1.

Results:

The mortality in the patients observed with ARDS was 34%. APACHE II score was significantly higher in nonsurvivors as compared to survivors. There were no significant differences in gender and biochemical and hematological parameters among the survivors and nonsurvivors. Serum IL-6 and IL-8 levels on day 1 were significantly higher in all the ARDS patients as compared to healthy controls and these levels were returned to near-normal basal levels on day 7. The serum IL-6 and IL-8 levels measured on day 7 were of survivors. As compared to survivors, the IL-6 and IL-8 levels were significantly higher in nonsurvivors measured on day 1. Spearman's rank correlation analysis indicated a significant positive correlation of APACHE II with IL-8. By using APACHE II score, IL-6, and IL-8, the receiver operating characteristic curve was plotted and the provided predictable accuracy of mortality (outcome) was 94%.

Conclusion:

The present study highlighted the importance of measuring the cytokines such as IL-6 and IL-8 in patients with ARDS in predicting the clinical outcome.

The Usefulness of the APACHE II Score in Obstetric Critical Care: A Structured Review

OBJECTIVE

To assess the performance of the Acute Physiology and Chronic Health Evaluation II (APACHE II) mortality prediction model in pregnant and recently pregnant women receiving critical care in low-, middle-, and high-income countries during the study period (1985-2015), using a structured literature review.

DATA SOURCES

Ovid MEDLINE, Embase, Web of Science, and Evidence-Based Medicine Reviews, searched for articles published between 1985 and 2015.

STUDY SELECTION

Twenty-five studies (24 publications), of which two were prospective, were included in the analyses. Ten studies were from high-income countries (HICs), and 15 were from low- and middle-income countries (LMICs). Median study duration and size were six years and 124 women, respectively.

DATA SYNTHESIS

ICU admission complicates 0.48% of deliveries, and pregnant and recently pregnant women account for 1.49% of ICU admissions. One quarter were admitted while pregnant, three quarters of these for an obstetric indication and for a median of three days. The median APACHE II score was 10.9, with a median APACHE II-predicted mortality of 16.6%. Observed mortality was 4.6%, and the median standardized mortality ratio was 0.36 (interquartile range 0.23 to 0.73). The standardized mortality ratio was < 0.9 in 24 of 25 studies. Women in HICs were more frequently admitted with a medical comorbidity but were less likely to die than were women in LMICs.

CONCLUSION

The APACHE II score consistently overestimates mortality risks for pregnant and recently pregnant women receiving critical care, whether they reside in HICs or LMICs. There is a need for a pregnancy-specific outcome prediction model for these women.

An Evaluation of the Usefulness of Extracorporeal Liver Support Techniques in Patients Hospitalized in the ICU for Severe Liver Dysfunction Secondary to Alcoholic Liver Disease

BACKGROUND

The mortality rate in patients with severe liver dysfunction secondary to alcoholic liver disease (ALD) who do not respond to the standard treatment is exceptionally high.

OBJECTIVES

The main aim of this study was to evaluate the usefulness of applying extracorporeal liver support techniques to treat this group of patients.

PATIENTS AND METHODS

The data from 23 hospital admissions of 21 patients with ALD who were admitted to the department of anesthesiology and intensive therapy (A&IT) at the Dr Wł. Biegański Regional Specialist Hospital in Łódź between March 2013 and July 2015 were retrospectively analyzed.

RESULTS

A total of 111 liver dialysis procedures were performed during the 23 hospitalizations, including 13 dialyses using fractionated plasma separation and adsorption (FPSA) with the Prometheus® system, and 98 procedures using the single pass albumin dialysis (SPAD) system. Upon admission to the intensive care unit (ICU), the median (interquartile range [IQR]) Glasgow coma scale (GCS), sequential organ failure assessment (SOFA), acute physiology and chronic health evaluation (APACHE) II, and simplified acute physiology score (SAPS) II scores were 15 (14 - 15), 9 (7 - 13), 17 (14 - 24), and 32 (22 - 50), respectively. The ICU, 30-day, and three-month mortality rates were 43.48%, 39.13%, and 73.91%, respectively. As determined by the receiver operative characteristic (ROC) analysis for single-factor models, the significant predictors of death in the ICU included the patients' SOFA, APACHE II, SAPS II, and model of end-stage liver disease modified by the united network for organ sharing (MELD UNOS Modification) scores; the duration of stay (in days) in the A&IT Department; and bile acid, creatinine and albumin levels upon ICU admission. The ROC analysis indicated the significant discriminating power of the SOFA, APACHE II, SAPS II, and MELD UNOS modification scores on the three-month mortality rate.

CONCLUSIONS

The application of extracorporeal liver support techniques in patients with severe liver dysfunction secondary to ALD appears justified in the subset of patients with MELD UNOS Modification scores of 18 - 30.

Predictive value of the APACHE II, SAPS II, SOFA and GCS scoring systems in patients with severe purulent bacterial meningitis

BACKGROUND

Scoring systems in critical care patients are essential for predicting of the patient outcome and evaluating the therapy. In this study, we determined the value of the Acute Physiology and Chronic Health Evaluation II (APACHE II), Simplified Acute Physiology Score II (SAPS II), Sequential Organ Failure Assessment (SOFA) and Glasgow Coma Scale (GCS) scoring systems in the prediction of mortality in adult patients admitted to the intensive care unit (ICU) with severe purulent bacterial meningitis.

METHODS

We retrospectively analysed data from 98 adult patients with severe purulent bacterial meningitis who were admitted to the single ICU between March 2006 and September 2015.

RESULTS

Univariate logistic regression identified the following risk factors of death in patients with severe purulent bacterial meningitis: APACHE II, SAPS II, SOFA, and GCS scores, and the lengths of ICU stay and hospital stay. The independent risk factors of patient death in multivariate analysis were the SAPS II score, the length of ICU stay and the length of hospital stay. In the prediction of mortality according to the area under the curve, the SAPS II score had the highest accuracy followed by the APACHE II, GCS and SOFA scores.

CONCLUSIONS

For the prediction of mortality in a patient with severe purulent bacterial meningitis, SAPS II had the highest accuracy.

Evaluation of Acute Physiology and Chronic Health Evaluation II and sequential organ failure assessment scoring systems for prognostication of outcomes among Intensive Care Unit's patients

Context:

Acute Physiology and Chronic Health Evaluation II (APACHE II) and sequential organ failure assessment (SOFA) are of the most validated and prevalent general scoring systems over the world.

Aims:

The aim of the current study was to evaluate APACHE II and SOFA ability in predicting the outcomes (survivors, nonsurvivors) in surgical and medical Intensive Care Unit (ICU).

Setting and Design:

This was an observational and prospective study of 300 consecutive patients admitted in surgical and medical ICU during a 6-month period.

Materials and Methods:

APACHE II and SOFA scores and demographic characteristics were recorded for each patient separately in the first admission 24 h.

Statistical Analysis Used:

Receiver operator characteristic (ROC) curves, Hosmer–Lemeshow test, and logistic regression were used in the statistical analysis (95% confidence interval).

Results:

Data analysis showed a significant statistical difference in APACHE II and SOFA scores between survivor and nonsurvivor patients (P < 0.0001, P = 0.001; respectively). The discrimination power was acceptable for APACHE II and poor for SOFA (area under ROC [AUC] curve: 73.7% (standard error [SE]: 3.2%), 63.4% [SE: 3.6%]; respectively). The acceptable calibration was seen just for SOFA (χ² = 11.018, P = 0.051).

Conclusions:

Both APACHE II and SOFA showed good predictive accuracy for results in surgical and medical ICUs; however, the SOFA is the choice to select, because of being simpler and easier to record data.

Mortality profile across our Intensive Care Units: A 5-year database report from a Singapore restructured hospital

Intensive care remains an area of high acuity and high mortality across the globe. With a rapidly aging population, the disease burden requiring intensive care is growing. The cost of critical care also is rising with new technology becoming available rapidly. We present the all-cause mortality results of 5 years database established in a restructured, large public hospital in Singapore, looking at all three types of Intensive Care Units present in our hospital. These include medical, surgical, and coronary care units.

Age influences the predictive value of Acute Physiology and Chronic Health Evaluation II and Intensive Care National Audit and Research Centre scoring models in patients admitted to Intensive Care Units after in-hospital cardiac arrest

INTRODUCTION

Outcomes following in-hospital cardiac arrest (IHCA) are generally poor though different patient populations may benefit to different degrees from admission to Intensive Care Units (ICUs). Risk stratification algorithms may be useful in identifying patients who are most likely to benefit from ICU admission and so may aid allocation of this scarce resource. We aimed to compare the performance of the Acute Physiology and Chronic Health Evaluation II (APACHE II) and Intensive Care National Audit and Research Centre (ICNARC) scoring systems in predicting outcome following ICU admission after IHCA in younger (≤69 years) and older (≥70 years) patients.

MATERIALS AND METHODS

We performed a retrospective observational study in two adult ICUs from January 2006 to February 2010 inclusive. Patients were divided into younger (≤69 years) and older (≥70 years) patients. The primary outcome measures were acute hospital mortality and area under the curve (AUC) calculation for receiver operating characteristic (ROC) analysis.

RESULTS

Two hundred and sixty-one adult consecutive adult patients admitted following IHCA. Hospital mortality was 58.6%. ROC analysis demonstrated that ICNARC was more accurate than APACHE II in predicting acute hospital outcomes in the adult population (AUC 0.734 vs. 0.706). Both scoring systems performed weaker when predicting outcomes in younger patients compared to older patients (ICNARC AUC 0.655 vs. 0.810; APACHE II AUC 0.660 vs. 0.759).

DISCUSSION

Both APACHE II and ICNARC predict outcome well in older patients. In younger patients, their value is less clear, and so they must be used with caution.

Comparing the APACHE II score and IBM-10 score for predicting mortality in patients with ventilator-associated pneumonia

Background:

VAP is defined as pneumonia in patients who use ventilators. The acute physiology and chronic health evaluation (APACHE II) scoring system was originally developed for predicting mortality in patients who were admitted to the intensive care unit. Due to the complexity, a simpler score called IBMP-10 was developed. We designed the study to confirm and further investigate these two methods.

Materials and Methods:

This cross-sectional and analysis-descriptive study was done at the moment of VAP diagnosis on 60 patients in intensive care units. APACHE II and the IBMP-10 scores were calculated. ROC curves were generated to compare the new prediction rule with the APACHE II score. Results were reported as adjusted odds ratios with 95% confidence intervals (CIs). Analyses were performed using SPSS, version 20 and P values of 0.05 were considered to be statistically significant.

Results:

APACHE II Score means (P < 0.001) and IBMP-10 score (P < 0.001) means had significant increase in Non-survivor patient than in patients who survived. APACHE II can be used as a good prediction measure for mortality rate. In IBMP-10 method, specificity and PPV were greater than APACHE II, but in mc-nemar test, there was no significant difference between the two methods (P = 0.55). Both prediction rules had high NPV. In our study, survivors’ prediction value in APACHE II was 46.7%, and in IBMP-10, it was 46.7%.

Conclusion:

IBMP-10, compared to APACHE II, has greater sensitivity, specificity, and AUC to predict mortality. So the consequence of the use of IBMP-10 was better than APACHE II.

Prospective evaluation of maternal morbidity and mortality in post-cesarean section patients admitted to postanesthesia intensive care unit

BACKGROUND AND AIMS

Critical illness may complicate any pregnancy. Timely intensive care management of critically ill obstetric patients has better outcomes than expected from the initial severity of illness. The aim was to study the indications of transfer of post-cesarean section patients to post-anesthesia intensive care unit (PACU). (PACU transfer indicated that the patient required intensive care).

MATERIALS AND METHODS

This was a prospective observational study carried out in the PACU of a tertiary care teaching public hospital over a period of 2 years. Sixty-one postoperative lower segment cesarean section (LSCS) females admitted consecutively in PACU were studied. The study included obstetric PACU utilization rate, intensive care unit interventions, outcome of mother, Acute Physiology and Chronic Health Evaluation (APACHE II) score, and its correlation with mortality.

RESULTS

Postanesthesia intensive care unit admission rate was 2.8% and obstetric PACU utilization rate was 3.22%. Of 61 patients, four had expired. Obstetric indications (67.2%) were the most common cause of admission to PACU. Among the obstetric indications hemorrhage (36.1%) was found to be a statistically significant indication for PACU admission followed by hypertensive disorder of pregnancy (29.5%). Cardiovascular disease (16.4%) was the most common nonobstetric indication for PACU transfer and was associated with high mortality. The observed mortality was 6.557%, which was lower than predicted mortality by APACHE II Score.

CONCLUSION

Obstetric hemorrhage, hypertensive disorders of pregnancy and cardiovascular diseases are the leading causes of PACU admission in post LSCS patients. Prompt provision of intensive care to critically ill obstetric patients can lead to a significant drop in maternal morbidity and mortality.

Assessment of performance and utility of mortality prediction models in a single Indian mixed tertiary intensive care unit

OBJECTIVES

To assess the performance and utility of two mortality prediction models viz. Acute Physiology and Chronic Health Evaluation II (APACHE II) and Simplified Acute Physiology Score II (SAPS II) in a single Indian mixed tertiary intensive care unit (ICU). Secondary objectives were bench-marking and setting a base line for research.

MATERIALS AND METHODS

In this observational cohort, data needed for calculation of both scores were prospectively collected for all consecutive admissions to 28-bedded ICU in the year 2011. After excluding readmissions, discharges within 24 h and age <18 years, the records of 1543 patients were analyzed using appropriate statistical methods.

RESULTS

Both models overpredicted mortality in this cohort [standardized mortality ratio (SMR) 0.88 ± 0.05 and 0.95 ± 0.06 using APACHE II and SAPS II respectively]. Patterns of predicted mortality had strong association with true mortality (R (2) = 0.98 for APACHE II and R (2) = 0.99 for SAPS II). Both models performed poorly in formal Hosmer-Lemeshow goodness-of-fit testing (Chi-square = 12.8 (P = 0.03) for APACHE II, Chi-square = 26.6 (P = 0.001) for SAPS II) but showed good discrimination (area under receiver operating characteristic curve 0.86 ± 0.013 SE (P < 0.001) and 0.83 ± 0.013 SE (P < 0.001) for APACHE II and SAPS II, respectively). There were wide variations in SMRs calculated for subgroups based on International Classification of Disease, 10(th) edition (standard deviation ± 0.27 for APACHE II and 0.30 for SAPS II).

INTERPRETATION AND CONCLUSION

Lack of fit of data to the models and wide variation in SMRs in subgroups put a limitation on utility of these models as tools for assessing quality of care and comparing performances of different units without customization. Considering comparable performance and simplicity of use, efforts should be made to adapt SAPS II.

The effect of positive balance on the outcomes of critically ill noncardiac postsurgical patients: a retrospective cohort study

PURPOSE

Fluid balance remains a highly controversial topic in the critical care field, and no consensus has been reached about the fluid levels required by critically ill surgical patients. In this study, we investigated the relationship between fluid balance and in-hospital mortality in critically ill surgical patients.

METHODS

The medical records of adult patients managed in a surgical intensive care unit (ICU) for more than 48 hours after surgery from January 2010 to February 2011 were reviewed retrospectively. Abstracted data included body weights, Acute Physiology and Chronic Health Evaluation (APACHE) II scores, Sequential Organ Failure Assessment (SOFA) scores, fluid therapy values (intake, output, and balance) during the ICU stay, type of operation, length of stay in the ICU and hospital, and in-hospital mortality.

RESULTS

A total of 148 patients were enrolled. The in-hospital mortality rate was 20.8%, and the median length of stay in the ICU and hospital were 5.0 and 24 days, respectively. The median daily fluid balance over the first 3 postoperative days was positive 11.2 mL/kg. Fluid balances in the ICU were 19.2, 15.0, and -0.6 mL kg(-1) d(-1), respectively, during the first 3 days vs SOFA scores (6.8, 6.3, and 6.5). Comparing the nonsurvival group with the survival group, the univariate analysis showed that age (P = .05), APACHE II score (P < .001), and use of a vasopressor (norepinephrine) (P = .05) affect in-hospital mortality. In the overall patients, any of the fluid balances were not significantly associated with mortality. However, in critically ill patients whose APACHE II scores were greater than 20, the nonsurvivor group showed a significant tendency toward a positive balance compared with the survivor group on the second and third days of ICU stay. Nevertheless, the SOFA scores showed no difference between nonsurvivor and survivors during the initial 2 postoperative days.

CONCLUSION

In critically ill noncardiac postsurgical patients whose APAHCE II scores were greater than 20, a positive balance in the ICU can be associated with mortality risk. To determine the direct effect of positive fluid balance, a larger scaled, prospective randomized study will be required.

Software-guided insulin dosing: tight glycemic control and decreased glycemic derangements in critically ill patients

OBJECTIVE

To determine whether glycemic derangements are more effectively controlled using software-guided insulin dosing compared with paper-based protocols.

PATIENTS AND METHODS

We prospectively evaluated consecutive critically ill patients treated in a tertiary hospital surgical intensive care unit (ICU) between January 1 and June 30, 2008, and between January 1 and September 30, 2009. Paper-based protocol insulin dosing was evaluated as a baseline during the first period, followed by software-guided insulin dosing in the second period. We compared glycemic metrics related to hyperglycemia, hypoglycemia, and glycemic variability during the 2 periods.

RESULTS

We treated 110 patients by the paper-based protocol and 87 by the software-guided protocol during the before and after periods, respectively. The mean ICU admission blood glucose (BG) level was higher in patients receiving software-guided intensive insulin than for those receiving paper-based intensive insulin (181 vs 156 mg/dL; P=.003, mean of the per-patient mean). Patients treated with software-guided intensive insulin had lower mean BG levels (117 vs 135 mg/dL; P=.0008), sustained greater time in the desired BG target range (95-135 mg/dL; 68% vs 52%; P=.0001), had less frequent hypoglycemia (percentage of time BG level was <70 mg/dL: 0.51% vs 1.44%; P=.04), and showed decreased glycemic variability (BG level per-patient standard deviation from the mean: ±29 vs ±42 mg/dL; P=.01).

CONCLUSION

Surgical ICU patients whose intensive insulin infusions were managed using the software-guided program achieved tighter glycemic control and fewer glycemic derangements than those managed with the paper-based insulin dosing regimen.

The role of soluble thrombomodulin in the risk stratification and prognosis evaluation of septic patients in the emergency department

INTRODUCTION

Soluble thrombomodulin (sTM) is a sensitive marker of endothelial damage. In this study we investigated the role of sTM in the evaluation of the severity and prognosis of septic patients in the emergency department (ED).

MATERIALS AND METHODS

A prospective, observational cohort study was performed in the ED of an urban, university hospital. Patients who had suspected infection with two or more criteria of systemic inflammatory response syndrome were consecutively enrolled. sTM, D-Dimer and procalcitonin levels were measured on enrollment, and the Mortality in Emergency Department Sepsis (MEDS) score was calculated. A 30-day follow-up was performed for all patients.

RESULTS

A total of 372 patients with sepsis, 210 patients with severe sepsis and 98 patients with septic shock were enrolled in this study. According to the disease severity, patients were divided into sepsis subgroup and severe sepsis subgroup (including septic shock). In addition, patients were divided into survivors subgroup and non-survivors subgroup according to the 30-day mortality. Plasma sTM levels in patients with severe sepsis were higher than those with sepsis (P<0.001). Compared with survivors, non-survivors has higher plasma sTM levels (P<0.001). Multivariate logistic regression analysis showed that sTM was an independent predictor of severe sepsis (odds ratio 1.11) and 30-day mortality (odds ratio 1.059). Receiver operating characteristic curve analysis showed that sTM was a useful parameter in prediction of severe sepsis (0.859) and 30-day mortality (0.78). Compared with the MEDS score alone, combination of sTM and the MEDS score can improve the accuracy in prediction of severe sepsis and 30-day mortality.

CONCLUSIONS

sTM is a valuable biomarker in the risk stratification and prognosis evaluation of ED sepsis. Furthermore, sTM can enhance the ability of the MEDS score in prediction of severe sepsis and 30-day mortality.

Early levels in blood of immunoglobulin M and natural killer cells predict outcome in nonseptic critically ill patients

PURPOSE

Critical illness results in derangements of all components of the immune response. Nonetheless, most of the efforts evaluating immune status in critically ill patients have been done in the field of sepsis. Here we have evaluated the immunity status at intensive care unit (ICU) admission in a cohort of nonseptic critically ill patients and its influence on their outcome.

MATERIAL AND METHODS

Ninety patients 18 years and older admitted to our ICU were studied for levels of immunoglobulin (Ig) G, IgM, IgA, CD3(+)CD4(+) T cells, CD3(+)CD8(+) T cells, B cells, natural killer (NK) cells, and C3 and C4 complement factors in peripheral blood in the next 24 hours after admission to the ICU. Patients with infection, sepsis, immunodeficiency, or concomitant immunosuppressive therapy were excluded.

RESULTS

Levels of IgM, CD3(+) T cells, CD4(+) T cells, CD8(+) T cells, and B lymphocytes correlated inversely with age. In turn, levels of CD3(+) T cells, CD4(+) T cells, CD8(+) T cells, and C3 factor of the complement system correlated inversely with Acute Physiology and Chronic Health Evaluation II score. Multivariate Cox regression analysis censored at 28 days evidenced that levels of IgM played a protective role, whereas levels of NK cells behaved as a risk factor for mortality. Kaplan-Meier curves showed a cutoff of 58 mg/dL for IgM and 140 cells/mm(3) for NK cells.

CONCLUSIONS

In conclusion, our results demonstrate that IgM plays a protective role in critically ill patients with no sepsis, whereas NK cell counts seem to play a deleterious one. Aging and severity at admission affect levels of key factors of the immune system in the blood of these patients.

Stewart analysis of apparently normal acid-base state in the critically ill

PURPOSE

This study aimed to describe Stewart parameters in critically ill patients with an apparently normal acid-base state and to determine the incidence of mixed metabolic acid-base disorders in these patients.

MATERIALS AND METHODS

We conducted a prospective, observational multicenter study of 312 consecutive Dutch intensive care unit patients with normal pH (7.35 ≤ pH ≤ 7.45) on days 3 to 5. Apparent (SIDa) and effective strong ion difference (SIDe) and strong ion gap (SIG) were calculated from 3 consecutive arterial blood samples. Multivariate linear regression analysis was performed to analyze factors potentially associated with levels of SIDa and SIG.

RESULTS

A total of 137 patients (44%) were identified with an apparently normal acid-base state (normal pH and -2 < base excess < 2 and 35 < PaCO2 < 45 mm Hg). In this group, SIDa values were 36.6 ± 3.6 mEq/L, resulting from hyperchloremia (109 ± 4.6 mEq/L, sodium-chloride difference 30.0 ± 3.6 mEq/L); SIDe values were 33.5 ± 2.3 mEq/L, resulting from hypoalbuminemia (24.0 ± 6.2 g/L); and SIG values were 3.1 ± 3.1 mEq/L. During admission, base excess increased secondary to a decrease in SIG levels and, subsequently, an increase in SIDa levels. Levels of SIDa were associated with positive cation load, chloride load, and admission SIDa (multivariate r(2) = 0.40, P < .001). Levels of SIG were associated with kidney function, sepsis, and SIG levels at intensive care unit admission (multivariate r(2) = 0.28, P < .001).

CONCLUSIONS

Intensive care unit patients with an apparently normal acid-base state have an underlying mixed metabolic acid-base disorder characterized by acidifying effects of a low SIDa (caused by hyperchloremia) and high SIG combined with the alkalinizing effect of hypoalbuminemia.

Modification of Acute Physiology and Chronic Health Evaluation II score through recalibration of risk prediction model in critical care patients of a respiratory disease referral center

Background:

Several models have been developed to measure the severity of illness in intensive care unit (ICU) patients, It is suggested that the models should be customized depending on the characteristics of different population of patients. This study is aimed to assess and modify the performance of Acute Physiology and Chronic Health Evaluation II (APACHE-II) model in a respiratory diseases referral center.

Materials and Methods:

A total of 730 patients, admitted to an intensive care unit during one year, were divided into two sets (71% training and 29% test). Our modified APACHE-II model was developed and calibrated on training set. Then, the integrity of the customized model was checked and compared to the original APACHE-II, on the test set. Logistic regression was used to develop ROC analysis, F-measure and kappa coefficient and were employed to calibrate the model.

Results:

Both Original and Our modified APACHE-II scores performed acceptable discriminative power (AUC = 0.908: 95%CI 0.861-0.854; and AUC = 0.856: 95%CI 0.789-0.923, respectively); the difference was not significant (P = 0.132). Our modified APACHE-II showed improved accuracy (87.9% vs. 84.1%) and sensitivity (56.4% vs. 16.3%) compared to the original model. F-measure and Kappa also gave the impression of improvement for our modified APACHE-II system.

Conclusion:

The results demonstrated that a modified APACHE-II system in a local ICU of respiratory disease could have similar discrimination and comparable calibration to the original model.

Augmented renal clearance is a common finding with worse clinical outcome in critically ill patients receiving antimicrobial therapy

INTRODUCTION

We describe incidence and patient factors associated with augmented renal clearance (ARC) in adult intensive care unit (ICU) patients.

MATERIALS AND METHODS

A prospective observational study in a mixed cohort of surgical and medical ICU patients receiving antimicrobial therapy at the Ghent University Hospital, Belgium. Kidney function was assessed by the 24-hour creatinine clearance (Ccr); ARC defined as at least one Ccr of >130 mL/min per 1.73 m2. Multivariate logistic regression analysis: to assess variables associated with ARC occurrence. Therapeutic failure (TF): an impaired clinical response and need for alternate antimicrobial therapy.

RESULTS

Of the 128 patients and 599 studied treatment days, ARC was present in 51.6% of the patients. Twelve percent permanently expressed ARC. ARC patients had a median Ccr of 144 mL/min per 1.73 m2 (IQR 98-196). Median serum creatinine concentration on the first day of ARC was 0.54 mg/dL (IQR 0.48-0.69). Patients with ARC were significantly younger (P<.001). Age and male gender were independently associated with ARC whereas the APACHE II score was not. ARC patients had more TF (18 (27.3%) vs. 8 (12.9%); P=.04).

CONCLUSION

ARC was documented in approximately 52% of a mixed ICU patient population receiving antibiotic treatment with worse clinical outcome. Young age and male gender were independently associated with ARC presence.

Use of a semiquantitative procalcitonin kit for evaluating severity and predicting mortality in patients with sepsis

Background

The aim of this study was to evaluate the clinical usefulness of a semiquantitative procalcitonin kit for assessing severity of sepsis and early determination of mortality in affected patients.

Methods

This was a prospective, observational study including 206 septic patients enrolled between June 2008 and August 2009. Disseminated intravascular coagulation (DIC), Sequential Organ Failure Assessment (SOFA), Acute Physiology and Chronic Health Evaluation (APACHE) II scores were measured, along with semiquantitative procalcitonin concentrations. Patients were divided into three groups based on their semiquantitative procalcitonin concentrations (group A, <2 ng/mL; group B ≥ 2 ng/mL < 10 ng/mL; group C ≥ 10 ng/mL).

Results

A significant difference in DIC, SOFA, and APACHE II scores was found between group A and group C and between group B and group C (P < 0.01). Patients with severe sepsis and septic shock had significantly higher procalcitonin concentrations than did patients with less severe disease. The rate of patients with septic shock with high procalcitonin concentrations showed an upward trend. There was a significant (P < 0.01) difference between the three groups with regard to numbers of patients and rates of severe sepsis, septic shock, DIC, and mortality.

Conclusion

Semiquantitative procalcitonin concentration testing can be helpful for early assessment of disease severity in patients with sepsis. Furthermore, it may also help in predicting early mortality in septic patients. Based on the level of semiquantitative procalcitonin measured in patients with suspected sepsis, a timely decision can be reliably made to transfer them to a tertiary hospital with an intensive care unit for optimal care.