Use of the Sequential Organ Failure Assessment score as a severity score

Prediction of 30-day mortality for ICU patients with Sepsis-3

BACKGROUND

There is a growing demand for advanced methods to improve the understanding and prediction of illnesses. This study focuses on Sepsis, a critical response to infection, aiming to enhance early detection and mortality prediction for Sepsis-3 patients to improve hospital resource allocation.

METHODS

In this study, we developed a Machine Learning (ML) framework to predict the 30-day mortality rate of ICU patients with Sepsis-3 using the MIMIC-III database. Advanced big data extraction tools like Snowflake were used to identify eligible patients. Decision tree models and Entropy Analyses helped refine feature selection, resulting in 30 relevant features curated with clinical experts. We employed the Light Gradient Boosting Machine (LightGBM) model for its efficiency and predictive power.

RESULTS

The study comprised a cohort of 9118 Sepsis-3 patients. Our preprocessing techniques significantly improved both the AUC and accuracy metrics. The LightGBM model achieved an impressive AUC of 0.983 (95% CI: [0.980-0.990]), an accuracy of 0.966, and an F1-score of 0.910. Notably, LightGBM showed a substantial 6% improvement over our best baseline model and a 14% enhancement over the best existing literature. These advancements are attributed to (I) the inclusion of the novel and pivotal feature Hospital Length of Stay (HOSP_LOS), absent in previous studies, and (II) LightGBM's gradient boosting architecture, enabling robust predictions with high-dimensional data while maintaining computational efficiency, as demonstrated by its learning curve.

CONCLUSIONS

Our preprocessing methodology reduced the number of relevant features and identified a crucial feature overlooked in previous studies. The proposed model demonstrated high predictive power and generalization capability, highlighting the potential of ML in ICU settings. This model can streamline ICU resource allocation and provide tailored interventions for Sepsis-3 patients.

Palliative Care Consultation and Family-Centered Outcomes in Patients With Unplanned Intensive Care Unit Admissions

Context: Hospitalized patients who experience unplanned intensive care unit (ICU) admissions face significant challenges, and their family members have unique palliative care needs. Objectives: To identify predictors of palliative care consultation among hospitalized patients with unplanned ICU admissions and to examine the association between palliative care consultation and family outcomes. Methods: We conducted a prospective cohort study of patients with unplanned ICU admissions at two medical centers in Seattle, WA. This study was approved by the institutional review board at the University of Washington (STUDY00008182). Using multivariable logistic regression, we examined associations between patient characteristics and palliative care consultation. Family members completed surveys assessing psychological distress within 90 days of patient discharge. Adjusted ordinal probit or binary logistic regression models were used to identify associations between palliative care consultation and family symptoms of psychological distress. Results: In our cohort (n = 413 patients and 272 family members), palliative care was consulted for 24% of patients during hospitalization (n = 100), with the majority (93%) of these consultations occurring after ICU admission. Factors associated with palliative care consultation after ICU transfer included enrollment site (OR, 2.29; 95% CI: 1.17-4.50), Sequential Organ Failure Assessment score at ICU admission (OR, 1.12; 95% CI: 1.05-1.19), and reason for hospital admission (kidney dysfunction [OR, 7.02; 95% CI: 1.08-45.69]). There was no significant difference in family symptoms of depression or posttraumatic stress based on palliative care consultation status. Conclusions: For patients experiencing unplanned ICU admission, palliative care consultation often happened after transfer and was associated with illness severity, comorbid illness, and hospital site. Patient death was associated with family symptoms of psychological distress.

Microbiological characteristics and risk factors on prognosis associated with Acinetobacter baumannii bacteremia in general hospital: A single-center retrospective study

OBJECTIVE

Acinetobacter baumannii is one of the most important pathogenic bacteria causing nosocomial infections and has a high mortality rate. Assessment of the microbiological characteristics and risk factors on prognosis associated with A.baumannii is essential. In this study, we aimed to investigate the clinical characteristics and prognostic risk factors of patients with A.baumannii bacteremia.

PATIENTS AND METHODS

This study retrospectively analyzed the antibiotic resistance of pathogens based on the clinical data of A.baumannii bacteremia patients presented in a tertiary teaching hospital from 2017 to 2022. Logistic regression and decision tree identified the prognostic risk factors for patients with baumannemia. Kaplan-Meier method was used for survival analysis between MDR and Non-MDR groups. The area under receiver-operating characteristic curve (ROC curve) was used to compare the predictive value of the APACHE II score and Sequential Organ Failure Assessment (SOFA) score.

RESULTS

A total of 110 patients with positive A. Baumannii blood cultures were included. Most of the patients were from intensive care unit (ICU) wards. The drug sensitivity results showed that the resistance rate of A. baumannii to colistin was the lowest (1.1%), followed by tigecycline (3.6%).The survival time of MDR group was significantly shorter than that of Non-MDR group. Multivariate analysis showed that, APACHE II score and SOFA score were independent risk factors affecting the prognosis of 28 days of A.baumannii bacteremia. And both scores displayed excellent AUROCs (SOFA: 0.909, APACHE II: 0.895 in predicting 28-day mortality). The two scoring systems were highly correlated and predicted no significant difference (r 2 = 0.4410, P < 0.001). We found that SOFA > 7 and APACHE II > 21 are associated with significantly higher mortality rates.

CONCLUSION

A.baumannii bacteremia have the highest incidence in the ICU, with high drug resistance and mortality rates. The survival time of patients with MDR A. Baumannii bacteremia was significantly shortened. The SOFA score and APACHE II score can reflect the severity of A.baumannii bacteremia patients and evaluate the 28-day prognosis. In addition, for the convenience of calculation, the SOFA score may be more clinically useful than the APACHE II score in predicting the mortality rate of A.baumannii bacteremia.

Association of Sequential Organ Failure Assessment (SOFA) components with mortality

BACKGROUND

Sequential Organ Failure Assessment (SOFA) is a practical method to describe and quantify the presence and severity of organ system dysfunctions and failures. Some proposals suggest that SOFA could be employed as an endpoint in trials. To justify this, all SOFA component scores should reflect organ dysfunctions of comparable severity. We aimed to investigate whether the associations of different SOFA components with in-hospital mortality are comparable.

METHODS

We performed a study based on nationwide register data on adult patients admitted to 26 Finnish intensive care units (ICUs) during 2012-2015. We determined the SOFA score as the maximum score in the first 24 hours after ICU admission. We defined organ failure (OF) as an organ-specific SOFA score of three or higher. We evaluated the association of different SOFA component scores with mortality.

RESULTS

Our study population comprised 63,756 ICU patients. Overall hospital mortality was 10.7%. In-hospital mortality was 22.5% for patients with respiratory failure, 34.8% for those with coagulation failure, 40.1% for those with hepatic failure, 14.9% for those with cardiovascular failure, 26.9% for those with neurologic failure and 34.6% for the patients with renal failure. Among patients with comparable total SOFA scores, the risk of death was lower in patients with cardiovascular OF compared with patients with other OFs.

CONCLUSIONS

All SOFA components are associated with mortality, but their weights are not comparable. High scores of other organ systems mean a higher risk of death than high cardiovascular scores. The scoring of cardiovascular dysfunction needs to be updated.

Aerobic exercise capacity in long-term survivors of critical illness: secondary analysis of the post-EPaNIC follow-up study

Purpose

To evaluate aerobic exercise capacity in 5-year intensive care unit (ICU) survivors and to assess the association between severity of organ failure in ICU and exercise capacity up to 5-year follow-up.

Methods

Secondary analysis of the EPaNIC follow-up cohort (NCT00512122) including 433 patients screened with cardiopulmonary exercise testing (CPET) between 1 and 5 years following ICU admission. Exercise capacity in 5-year ICU survivors (N = 361) was referenced to a historic sedentary population and further compared to demographically matched controls (N = 49). In 5-year ICU survivors performing a maximal CPET (respiratory exchange ratio > 1.05, N = 313), abnormal exercise capacity was defined as peak oxygen consumption (VO₂peak) < 85% of predicted peak oxygen consumption (%predVO₂peak), based on the historic sedentary population. Exercise liming factors were identified. To study the association between severity of organ failure, quantified as the maximal Sequential Organ Failure Assessment score during ICU-stay (SOFA-max), and exercise capacity as assessed with VO₂peak, a linear mixed model was built, adjusting for predefined confounders and including all follow-up CPET studies.

Results

Exercise capacity was abnormal in 118/313 (37.7%) 5-year survivors versus 1/48 (2.1%) controls with a maximal CPET, p < 0.001. Aerobic exercise capacity was lower in 5-year survivors than in controls (VO₂peak: 24.0 ± 9.7 ml/min/kg versus 31.7 ± 8.4 ml/min/kg, p < 0.001; %predVO₂peak: 94% ± 31% versus 123% ± 25%, p < 0.001). Muscular limitation frequently contributed to impaired exercise capacity at 5-year [71/118 (60.2%)]. SOFA-max independently associated with VO₂peak throughout follow-up.

Conclusions

Critical illness survivors often display abnormal aerobic exercise capacity, frequently involving muscular limitation. Severity of organ failure throughout the ICU stay independently associates with these impairments.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00134-021-06541-9.

Facilitating communication for critically ill patients and their family members: Study protocol for two randomized trials implemented in the U.S. and France

BACKGROUND

Critically-ill patients and their families suffer a high burden of psychological symptoms due, in part, to many transitions among clinicians and settings during and after critical illness, resulting in fragmented care. Communication facilitators may help.

DESIGN AND INTERVENTION

We are conducting two cluster-randomized trials, one in the U.S. and one in France, with the goal of evaluating a nurse facilitator trained to support, model, and teach communication strategies enabling patients and families to secure care consistent with patients' goals, beginning in ICU and continuing for 3 months.

PARTICIPANTS

We will randomize 376 critically-ill patients in the US and 400 in France to intervention or usual care. Eligible patients have a risk of hospital mortality of greater than15% or a chronic illness with a median survival of approximately 2 years or less.

OUTCOMES

We assess effectiveness with patient- and family-centered outcomes, including symptoms of depression, anxiety, and post-traumatic stress, as well as assessments of goal-concordant care, at 1-, 3-, and 6-months post-randomization. The primary outcome is family symptoms of depression over 6 months. We also evaluate whether the intervention improves value by reducing utilization while improving outcomes. Finally, we use mixed methods to explore implementation factors associated with implementation outcomes (acceptability, fidelity, acceptability, penetration) to inform dissemination. Conducting the trial in U.S. and France will provide insights into differences and similarities between countries.

CONCLUSIONS

We describe the design of two randomized trials of a communication facilitator for improving outcomes for critically ill patients and their families in two countries.

Current Utility of Sequential Organ Failure Assessment Score: A Literature Review and Future Directions

The Sequential Organ Failure Assessment (SOFA) score is commonly used in the Intensive Care Unit (ICU) to evaluate, prognosticate and assess patients. Since its validation, the SOFA score has served in various settings, including medical, trauma, surgical, cardiac, and neurological ICUs. It has been a strong mortality predictor and literature over the years has documented the ability of the SOFA score to accurately distinguish survivors from non-survivors on admission. Over the years, multiple variations have been proposed to the SOFA score, which have led to the evolution of alternate validated scoring models replacing one or more components of the SOFA scoring system. Various SOFA based models have been used to evaluate specific clinical populations, such as patients with cardiac dysfunction, hepatic failure, renal failure, different races and public health illnesses, etc. This study is aimed to conduct a review of modifications in SOFA score in the past several years. We review the literature evaluating various modifications to the SOFA score such as modified SOFA, Modified SOFA, modified Cardiovascular SOFA, Extra-renal SOFA, Chronic Liver Failure SOFA, Mexican SOFA, quick SOFA, Lactic acid quick SOFA (LqSOFA), SOFA in hematological malignancies, SOFA with Richmond Agitation-Sedation scale and Pediatric SOFA. Various organ systems, their relevant scoring and the proposed modifications in each of these systems are presented in detail. There is a need to incorporate the most recent literature into the SOFA scoring system to make it more relevant and accurate in this rapidly evolving critical care environment. For future directions, we plan to put together most if not all updates in SOFA score and probably validate it in a large database a single institution and validate it in multisite data base.

Effect of Vitamin C Infusion on Organ Failure and Biomarkers of Inflammation and Vascular Injury in Patients With Sepsis and Severe Acute Respiratory Failure: The CITRIS-ALI Randomized Clinical Trial

IMPORTANCE

Experimental data suggest that intravenous vitamin C may attenuate inflammation and vascular injury associated with sepsis and acute respiratory distress syndrome (ARDS).

OBJECTIVE

To determine the effect of intravenous vitamin C infusion on organ failure scores and biological markers of inflammation and vascular injury in patients with sepsis and ARDS.

DESIGN, SETTING, AND PARTICIPANTS

The CITRIS-ALI trial was a randomized, double-blind, placebo-controlled, multicenter trial conducted in 7 medical intensive care units in the United States, enrolling patients (N = 167) with sepsis and ARDS present for less than 24 hours. The study was conducted from September 2014 to November 2017, and final follow-up was January 2018.

INTERVENTIONS

Patients were randomly assigned to receive intravenous infusion of vitamin C (50 mg/kg in dextrose 5% in water, n = 84) or placebo (dextrose 5% in water only, n = 83) every 6 hours for 96 hours.

MAIN OUTCOMES AND MEASURES

The primary outcomes were change in organ failure as assessed by a modified Sequential Organ Failure Assessment score (range, 0-20, with higher scores indicating more dysfunction) from baseline to 96 hours, and plasma biomarkers of inflammation (C-reactive protein levels) and vascular injury (thrombomodulin levels) measured at 0, 48, 96, and 168 hours.

RESULTS

Among 167 randomized patients (mean [SD] age, 54.8 years [16.7]; 90 men [54%]), 103 (62%) completed the study to day 60. There were no significant differences between the vitamin C and placebo groups in the primary end points of change in mean modified Sequential Organ Failure Assessment score from baseline to 96 hours (from 9.8 to 6.8 in the vitamin C group [3 points] and from 10.3 to 6.8 in the placebo group [3.5 points]; difference, -0.10; 95% CI, -1.23 to 1.03; P = .86) or in C-reactive protein levels (54.1 vs 46.1 μg/mL; difference, 7.94 μg/mL; 95% CI, -8.2 to 24.11; P = .33) and thrombomodulin levels (14.5 vs 13.8 ng/mL; difference, 0.69 ng/mL; 95% CI, -2.8 to 4.2; P = .70) at 168 hours.

CONCLUSIONS AND RELEVANCE

In this preliminary study of patients with sepsis and ARDS, a 96-hour infusion of vitamin C compared with placebo did not significantly improve organ dysfunction scores or alter markers of inflammation and vascular injury. Further research is needed to evaluate the potential role of vitamin C for other outcomes in sepsis and ARDS.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02106975.

Performance of SAPS II according to ICU length of stay: Protocol for an observational study

BACKGROUND

Severity scores, including the Simplified Acute Physiology Score (SAPS) II, are widely used in the intensive care unit (ICU) to predict mortality outcomes using data from ICU admission or shortly hereafter. For patients with longer ICU length of stay (LOS), the predictive performance of admission-based severity scores may deteriorate compared to patients with shorter ICU LOS. This protocol and statistical analysis plan outlines a study that will assess the influence of ICU LOS on the performance of SAPS II for predicting 90-day post-ICU mortality.

METHODS

A Danish nationwide cohort study including adult (≥18 years) ICU patients admitted to a Danish ICU between 1 January 2012 and 30 June 2016. The study will be conducted using the Danish Intensive Care Database (DID), which contains data routinely, prospectively, and consecutively reported for all Danish ICU admissions. Discrimination of SAPS II for predicting 90-day post-ICU mortality will be assessed for the entire cohort and stratified according to ICU LOS. A first-level recalibration of SAPS II will be performed, and if adequate, standardised mortality ratios and calibration stratified according to ICU LOS will be reported.

CONCLUSIONS

The outlined large, nationwide cohort study will provide important, contemporary information about the influence of ICU LOS on severity score performance relevant for ICU clinicians, researchers, and administrators. Publication of the protocol and statistical analysis plan prior to study conduct ensures transparency, and limits the risk of publication bias, post hoc changes in analyses, and challenges with multiple comparisons.

Development of a Malawi Intensive care Mortality risk Evaluation (MIME) model, a prospective cohort study

INTRODUCTION

Intensive care medicine can contribute to population health in low-income countries by reducing premature mortality related to surgery, trauma, obstetrical and other medical emergencies. Quality improvement is guided by risk stratification models, which are developed primarily within high-income settings. Models validated for use in low-income countries are needed.

METHODS

This prospective cohort study consisted of 261 patients admitted to the intensive care unit (ICU) of Kamuzu Central Hospital in Malawi, from September 2016 to March 2018. The primary outcome was in-hospital mortality. We performed univariable analyses on putative predictors and included those with a significance of 0.15 in the Malawi Intensive care Mortality risk Evaluation model (MIME). Model discrimination was evaluated using the area under the curve.

RESULTS

Males made up 37.9% of the study sample and the mean age was 34.4 years. A majority (73.9%) were admitted to the ICU after a recent surgical procedure, and 59% came directly from the operating theater. In-hospital mortality was 60.5%. The MIME based on age, sex, admitting service, systolic pressure, altered mental status, and fever during the ICU course had a fairly good discrimination, with an AUC of 0.70 (95% CI 0.63-0.76).

CONCLUSIONS

The MIME has modest ability to predict in-hospital mortality in a Malawian ICU. Multicenter research is needed to validate the MIME and assess its clinical utility.

Mortality of adult intensive care units in Turkey using the APACHE II and SOFA systems (outcome assessment in Turkish intensive care units)

INTRODUCTION

The aim of this study was to evaluate intensive care unit (ICU) performance using risk-adjusted ICU mortality rates nationally, assessing patients who died or had been discharged from the ICU. For this purpose, this study analyzed the Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) databases, containing detailed clinical and physiological information and mortality of mixed critically ill patients in a medical ICU at secondary and tertiary referral ICUs in Turkey.

MATERIAL AND METHODS

A total of 690 adult intensive care units in Turkey were included in the study. Among 690 ICUs evaluated, 39.7% were secondary and 60.3% were tertiary ICUs. A total of 4188 patients were enrolled in this study. Intensive care units of ministry, university, and private hospitals were evaluated all over Turkey. During the study period, clinical data that were collected concurrently for each patient contained demographic details and the diagnostic category leading to ICU admission. APACHE II and SOFA scores following ICU admission were calculated and recorded. Patients were followed up for outcome data until death or ICU discharge.

RESULTS

The mean age of patients was 68.8 ±19 and 54% of them were male. The mean APACHE II score was 20 ±8.7. The ICUs' mortality rate was 46.3%, and mean predicted mortality was 37.2% for APACHE II. The standardized mortality ratio was 1.28 (95% confidence interval: 1.21-1.31).

CONCLUSIONS

There was a wide difference in outcome for patients admitted to different ICUs and severity of illness using risk adjustment methods. The high mortality rate in patients could be related to comorbid diseases, high mechanical ventilation rates and older ages.

Economic Feasibility of Staffing the Intensive Care Unit with a Communication Facilitator

RATIONALE

In the intensive care unit (ICU), complex decision making by clinicians and families requires good communication to ensure that care is consistent with the patients' values and goals.

OBJECTIVES

To assess the economic feasibility of staffing ICUs with a communication facilitator.

METHODS

Data were from a randomized trial of an "ICU communication facilitator" linked to hospital financial records; eligible patients (n = 135) were admitted to the ICU at a single hospital with predicted mortality ≥30% and a surrogate decision maker. Adjusted regression analyses assessed differences in ICU total and direct variable costs between intervention and control patients. A bootstrap-based simulation assessed the cost efficiency of a facilitator while varying the full-time equivalent of the facilitator and the ICU mortality risk.

MEASUREMENTS AND MAIN RESULTS

Total ICU costs (mean 22.8k; 95% CI, -42.0k to -3.6k; P = 0.02) and average daily ICU costs (mean, -0.38k; 95% CI, -0.65k to -0.11k; P = 0.006)] were reduced significantly with the intervention. Despite more contacts, families of survivors spent less time per encounter with facilitators than did families of decedents (mean, 25 [SD, 11] min vs. 36 [SD, 14] min). Simulation demonstrated maximal weekly savings with a 1.0 full-time equivalent facilitator and a predicted ICU mortality of 15% (total weekly ICU cost savings, $58.4k [95% CI, $57.7k-59.2k]; weekly direct variable savings, $5.7k [95% CI, $5.5k-5.8k]) after incorporating facilitator costs.

CONCLUSIONS

Adding a full-time trained communication facilitator in the ICU may improve the quality of care while simultaneously reducing short-term (direct variable) and long-term (total) health care costs. This intervention is likely to be more cost effective in a lower-mortality population.

Acute Physiology and Chronic Health Evaluation II Score and Sequential Organ Failure Assessment Score as Predictors for Severe Trauma Patients in the Intensive Care Unit

Background

The Acute Physiology and Chronic Health Evaluation (APACHE) II scoring system and the Sequential Organ Failure Assessment (SOFA) scoring system are widely used for critically ill patients. We evaluated whether APACHE II score and SOFA score predict the outcome for trauma patients in the intensive care unit (ICU).

Methods

We retrospectively analyzed trauma patients admitted to the ICU in a single trauma center between January 2014 and December 2015. The APACHE II score was figured out based on the data acquired from the first 24 hours of admission; the SOFA score was evaluated based on the first 3 days in the ICU. A total of 241 patients were available for analysis. Injury Severity score, APACHE II score, and SOFA score were evaluated.

Results

The overall survival rate was 83.4%. The non-survival group had a significantly high APACHE II score (24.1 ± 8.1 vs. 12.3 ± 7.2, P < 0.001) and SOFA score (7.7 ± 1.7 vs. 4.3 ± 1.9, P < 0.001) at admission. SOFA score had the highest areas under the curve (0.904). During the first 3 days, SOFA score remained high in the non-survival group. In the non-survival group, cardiovascular system, neurological system, renal system, and coagulation system scores were significantly higher.

Conclusions

In ICU trauma patients, both SOFA and APACHE II scores were good predictors of outcome, with the SOFA score being the most effective. In trauma ICU patients, the trauma scoring system should be complemented, recognizing that multi-organ failure is an important factor for mortality.

Understanding Response Rates to Surveys About Family Members' Psychological Symptoms After Patients' Critical Illness

CONTEXT

Achieving adequate response rates from family members of critically ill patients can be challenging, especially when assessing psychological symptoms.

OBJECTIVES

To identify factors associated with completion of surveys about psychological symptoms among family members of critically ill patients.

METHODS

Using data from a randomized trial of an intervention to improve communication between clinicians and families of critically ill patients, we examined patient-level and family-level predictors of the return of usable surveys at baseline, three months, and six months (n = 181, 171, and 155, respectively). Family-level predictors included baseline symptoms of psychological distress, decisional independence preference, and attachment style. We hypothesized that family with fewer symptoms of psychological distress, a preference for less decisional independence, and secure attachment style would be more likely to return questionnaires.

RESULTS

We identified several predictors of the return of usable questionnaires. Better self-assessed family member health status was associated with a higher likelihood and stronger agreement with a support-seeking attachment style with a lower likelihood, of obtaining usable baseline surveys. At three months, family-level predictors of return of usable surveys included having usable baseline surveys, status as the patient's legal next of kin, and stronger agreement with a secure attachment style. The only predictor of receipt of surveys at six months was the presence of usable surveys at three months.

CONCLUSION

We identified several predictors of the receipt of surveys assessing psychological symptoms in family of critically ill patients, including family member health status and attachment style. Using these characteristics to inform follow-up mailings and reminders may enhance response rates.

Randomized Trial of Communication Facilitators to Reduce Family Distress and Intensity of End-of-Life Care

RATIONALE

Communication with family of critically ill patients is often poor and associated with family distress.

OBJECTIVES

To determine if an intensive care unit (ICU) communication facilitator reduces family distress and intensity of end-of-life care.

METHODS

We conducted a randomized trial at two hospitals. Eligible patients had a predicted mortality greater than or equal to 30% and a surrogate decision maker. Facilitators supported communication between clinicians and families, adapted communication to family needs, and mediated conflict.

MEASUREMENTS AND MAIN RESULTS

Outcomes included depression, anxiety, and post-traumatic stress disorder (PTSD) among family 3 and 6 months after ICU and resource use. We identified 488 eligible patients and randomized 168. Of 352 eligible family members, 268 participated (76%). Family follow-up at 3 and 6 months ranged from 42 to 47%. The intervention was associated with decreased depressive symptoms at 6 months (P = 0.017), but there were no significant differences in psychological symptoms at 3 months or anxiety or PTSD at 6 months. The intervention was not associated with ICU mortality (25% control vs. 21% intervention; P = 0.615) but decreased ICU costs among all patients (per patient: $75,850 control, $51,060 intervention; P = 0.042) and particularly among decedents ($98,220 control, $22,690 intervention; P = 0.028). Among decedents, the intervention reduced ICU and hospital length of stay (28.5 vs. 7.7 d and 31.8 vs. 8.0 d, respectively; P < 0.001).

CONCLUSIONS

Communication facilitators may be associated with decreased family depressive symptoms at 6 months, but we found no significant difference at 3 months or in anxiety or PTSD. The intervention reduced costs and length of stay, especially among decedents. This is the first study to find a reduction in intensity of end-of-life care with similar or improved family distress. Clinical trial registered with www.clinicaltrials.gov (NCT 00720200).

Predicting Mortality in Low-Income Country ICUs: The Rwanda Mortality Probability Model (R-MPM)

Introduction

Intensive Care Unit (ICU) risk prediction models are used to compare outcomes for quality improvement initiatives, benchmarking, and research. While such models provide robust tools in high-income countries, an ICU risk prediction model has not been validated in a low-income country where ICU population characteristics are different from those in high-income countries, and where laboratory-based patient data are often unavailable. We sought to validate the Mortality Probability Admission Model, version III (MPM₀-III) in two public ICUs in Rwanda and to develop a new Rwanda Mortality Probability Model (R-MPM) for use in low-income countries.

Methods

We prospectively collected data on all adult patients admitted to Rwanda’s two public ICUs between August 19, 2013 and October 6, 2014. We described demographic and presenting characteristics and outcomes. We assessed the discrimination and calibration of the MPM₀-III model. Using stepwise selection, we developed a new logistic model for risk prediction, the R-MPM, and used bootstrapping techniques to test for optimism in the model.

Results

Among 427 consecutive adults, the median age was 34 (IQR 25–47) years and mortality was 48.7%. Mechanical ventilation was initiated for 85.3%, and 41.9% received vasopressors. The MPM₀-III predicted mortality with area under the receiver operating characteristic curve of 0.72 and Hosmer-Lemeshow chi-square statistic p = 0.024. We developed a new model using five variables: age, suspected or confirmed infection within 24 hours of ICU admission, hypotension or shock as a reason for ICU admission, Glasgow Coma Scale score at ICU admission, and heart rate at ICU admission. Using these five variables, the R-MPM predicted outcomes with area under the ROC curve of 0.81 with 95% confidence interval of (0.77, 0.86), and Hosmer-Lemeshow chi-square statistic p = 0.154.

Conclusions

The MPM₀-III has modest ability to predict mortality in a population of Rwandan ICU patients. The R-MPM is an alternative risk prediction model with fewer variables and better predictive power. If validated in other critically ill patients in a broad range of settings, the model has the potential to improve the reliability of comparisons used for critical care research and quality improvement initiatives in low-income countries.

ADAMTS-13 in Critically Ill Patients With Septic Syndromes and Noninfectious Systemic Inflammatory Response Syndrome

PURPOSE

Decreased ADAMTS-13 (A Disintegrin and Metalloprotease with a ThromboSpondin type 1 motif, member 13) seems to be associated with a poor prognosis in sepsis. However, its role in different septic syndromes and other causes of systemic inflammatory response syndrome (SIRS) remains unclear. The aims of this study were to assess ADAMTS-13 levels in patients with septic syndromes or noninfectious SIRS and to determine their association with morbidity and mortality.

METHODS

The study population consisted of 178 patients admitted to the medical intensive care unit presenting either septic syndromes or noninfectious SIRS. ADAMTS-13 levels were analyzed.

RESULTS

Patients with septic syndromes showed significantly lower levels of ADAMTS-13 compared with those with noninfectious SIRS (P = 0.014). Patients with severe sepsis or septic shock presented lower levels than those of patients with sepsis (P = 0.086). A significant negative correlation was found between ADAMTS-13 levels and delta Sequential Organ Failure Assessment and Acute Physiology and Chronic Health Evaluation II scores at admission in the septic patients. Patients who died had significantly lower levels of ADAMTS-13 compared with survivors, both in the whole population and among the septic patients (P = 0.002 and P = 0.009, respectively). Logistic regression analysis showed that decreased ADAMTS-13 levels were associated with an increased risk of in-intensive care unit mortality (odds ratio, 0.985; 95% confidence interval, 0.973-0.998; P = 0.023).

CONCLUSIONS

Septic patients have lower levels of ADAMTS-13 than do patients with noninfectious SIRS. Levels of ADAMTS-13 are correlated with illness severity in patients with septic syndromes. ADAMTS-13 levels were associated with an increased risk of mortality in critically ill patients with SIRS especially those with septic syndromes.

A multiscale entropy-based tool for scoring severity of systemic inflammation

OBJECTIVE

Early detection and start of appropriate treatment are highly correlated with survival of sepsis and septic shock, but the currently available predictive tools are not sensitive enough to identify patients at risk.

DESIGN

Linear (time and frequency domain) and nonlinear (unifractal and multiscale complexity dynamics) measures of beat-to-beat interval variability were analyzed in two mouse models of inflammatory shock to determine if they are sensitive enough to predict outcome.

SETTING

University research laboratory.

SUBJECTS

Blood pressure transmitter-implanted female C57BL/6J mice.

INTERVENTIONS

IV administration of tumor necrosis factor (n = 11) or lipopolysaccharide (n = 14).

MEASUREMENTS AND MAIN RESULTS

Contrary to linear indices of variability, unifractal dynamics, and absolute heart rate or blood pressure, quantification of complex beat-to-beat dynamics using multiscale entropy was able to predict survival outcome starting as early as 40 minutes after induction of inflammatory shock. Based on these results, a new and clinically relevant index of multiscale entropy was developed that scores the key features of a multiscale entropy profile. Contrary to multiscale entropy, multiscale entropy scoring can be followed as a function of time to monitor disease progression with limited loss of information.

CONCLUSIONS

Analysis of multiscale complexity of beat-to-beat dynamics at high temporal resolution has potential as a sensitive prognostic tool with translational power that can predict survival outcome in systemic inflammatory conditions such as sepsis and septic shock.

Procalcitonin, MR-Proadrenomedullin, and Cytokines Measurement in Sepsis Diagnosis: Advantages from Test Combination

BACKGROUND

Elevated cytokines levels correlate with sepsis severity and mortality but their role in the diagnosis is controversial, whereas Procalcitonin (PCT) has been largely used. Recently, the mid-regional proadrenomedullin (MR-proADM) has been combined with PCT for diagnosis optimization. In this study the combined measurement of PCT, MR-proADM, and cytokines in patients with sepsis was evaluated.

METHODS

One hundred and four septic patients and 101 controls were enrolled. Receiver operating characteristic (ROC) analysis and multiple logistic regression were used to evaluate applicant markers for sepsis diagnosis. Markers with best Odds Ratio (OR) were combined, and the posttest probability and a composite score were computed.

RESULTS

Based upon ROC curves analysis, PCT, MR-proADM, IL-6, IL-10, TNF-α, and MCP-1 were considered applicant for sepsis diagnosis. Among these PCT, MR-proADM , IL-6, and TNF-α showed the best OR. A better posttest probability was found with the combination of PCT with MR-proADM and PCT with IL-6 or TNF-α compared to the single marker. A composite score of PCT, MR-proADM, and TNF-α showed the best ROC curve in the early diagnosis of sepsis.

CONCLUSION

The combination of PCT with other markers should expedite diagnosis and treatment of sepsis optimizing clinical management.

Pattern of soluble CD5 and CD6 lymphocyte receptors in critically ill patients with septic syndromes

PURPOSE

Soluble forms of CD5 and CD6 lymphocyte surface receptors (sCD5 and sCD6) are molecules that seem to prevent experimental sepsis when exogenously administered. The aim of this study was to assess sCD5 and sCD6 levels in patients with septic syndromes.

MATERIALS AND METHODS

The study population consisted of 218 patients admitted to the medical intensive care unit (ICU) presenting either septic syndromes or noninfectious systemic inflammatory response syndrome at admission or within the first 48 hours. The sCD5 and sCD6 levels were analyzed by sandwich enzyme-linked immunosorbent assay.

RESULTS

Almost 50% of the patients had undetectable levels of sCD5 or sCD6, with no differences in clinical or biological variables with detectable patients. There was a correlation between the delta Sequential Organ Failure Assessment score and both sCD6 and sCD5 levels in all groups. Patients with sCD5 or sCD6 levels greater than 1500 ng/mL presented a higher in-ICU mortality (P < .05). Logistic regression analysis showed that increased sCD6 levels were associated with an increased risk of in-ICU mortality.

CONCLUSIONS

Levels of sCD5 and sCD6 in critically ill patients with systemic inflammatory response syndrome present a high variation and an elevated proportion of undetectability. Levels of sCD6 are associated with an increased risk of mortality in these patients.

Glasgow Coma Scale score dominates the association between admission Sequential Organ Failure Assessment score and 30-day mortality in a mixed intensive care unit population

OBJECTIVE

The Sequential Organ Failure Assessment (SOFA) score, a measure of multiple-organ dysfunction syndrome, is used to predict mortality in critically ill patients by assigning equally weighted scores across 6 different organ systems. We hypothesized that specific organ systems would have a greater association with mortality than others.

DESIGN

We retrospectively studied patients admitted over a period of 4.2 years to a mixed-profile intensive care unit (ICU). We recorded age and comorbidities, and calculated SOFA organ scores. The primary outcome was 30-day all-cause mortality. We determined which organ subscores of the SOFA score were most associated with mortality using multiple analytic methods: random forests, conditional inference trees, distanced-based clustering techniques, and logistic regression.

SETTING

A 24-bed mixed-profile adult ICU that cares for medical, surgical, and trauma (level 1) patients at an academic referral center.

PATIENTS

All patients' first admission to the study ICU during the study period.

MEASUREMENTS AND MAIN RESULTS

We identified 9120 first admissions during the study period. Overall 30-day mortality was 12%. Multiple analytical methods all demonstrated that the best initial prediction variables were age and the central nervous system SOFA subscore, which is determined solely by Glasgow Coma Scale score.

CONCLUSIONS

In a mixed population of critically ill patients, the Glasgow Coma Scale score dominates the association between admission SOFA score and 30-day mortality. Future research into outcomes from multiple-organ dysfunction may benefit from new models for measuring organ dysfunction with special attention to neurologic dysfunction.

Sepsis mortality prediction with the Quotient Basis Kernel

OBJECTIVE

This paper presents an algorithm to assess the risk of death in patients with sepsis. Sepsis is a common clinical syndrome in the intensive care unit (ICU) that can lead to severe sepsis, a severe state of septic shock or multi-organ failure. The proposed algorithm may be implemented as part of a clinical decision support system that can be used in combination with the scores deployed in the ICU to improve the accuracy, sensitivity and specificity of mortality prediction for patients with sepsis.

METHODOLOGY

In this paper, we used the Simplified Acute Physiology Score (SAPS) for ICU patients and the Sequential Organ Failure Assessment (SOFA) to build our kernels and algorithms. In the proposed method, we embed the available data in a suitable feature space and use algorithms based on linear algebra, geometry and statistics for inference. We present a simplified version of the Fisher kernel (practical Fisher kernel for multinomial distributions), as well as a novel kernel that we named the Quotient Basis Kernel (QBK). These kernels are used as the basis for mortality prediction using soft-margin support vector machines. The two new kernels presented are compared against other generative kernels based on the Jensen-Shannon metric (centred, exponential and inverse) and other widely used kernels (linear, polynomial and Gaussian). Clinical relevance is also evaluated by comparing these results with logistic regression and the standard clinical prediction method based on the initial SAPS score.

RESULTS

As described in this paper, we tested the new methods via cross-validation with a cohort of 400 test patients. The results obtained using our methods compare favourably with those obtained using alternative kernels (80.18% accuracy for the QBK) and the standard clinical prediction method, which are based on the basal SAPS score or logistic regression (71.32% and 71.55%, respectively). The QBK presented a sensitivity and specificity of 79.34% and 83.24%, which outperformed the other kernels analysed, logistic regression and the standard clinical prediction method based on the basal SAPS score.

CONCLUSION

Several scoring systems for patients with sepsis have been introduced and developed over the last 30 years. They allow for the assessment of the severity of disease and provide an estimate of in-hospital mortality. Physiology-based scoring systems are applied to critically ill patients and have a number of advantages over diagnosis-based systems. Severity score systems are often used to stratify critically ill patients for possible inclusion in clinical trials. In this paper, we present an effective algorithm that combines both scoring methodologies for the assessment of death in patients with sepsis that can be used to improve the sensitivity and specificity of the currently available methods.

Observational study of intra-abdominal pressure monitoring in acute pancreatitis

BACKGROUND

Intra-abdominal hypertension (IAH) is predictive of adverse outcome in critically ill patients; however, its role in acute pancreatitis is unclear, and prospective studies are lacking. We aimed to determine the overall incidence and predictive value of IAH on mortality in acute pancreatitis.

METHODS

Transvesical IAP was measured on admission and every 4 hours within high-dependency unit/intensive care unit. Serum biochemistry and physiologic parameters permitted calculation of Acute Physiology and Chronic Health Evaluation II, Sequential Organ Failure Assessment, Imrie, and Ranson scores. The primary end point was 30-day mortality.

RESULTS

A total of 218 patients with acute pancreatitis were recruited; 30-day mortality was greater in patients with IAH (IAP ≥12 mmHg; 37%) than no IAH (2%; P < .001). A total of 14% of patients had IAH on admission; another 3% developed IAH in hospital. Mortality was greater in the latter group (37% vs 50%; P < .01). In the majority of cases IAH developed in line with other organ failure; however, there were several patients in whom the development of IAH appeared to be the sentinel event before rapid clinical decline. An IAP threshold of 9 mmHg had best predictive value for mortality (sensitivity 86%, specificity 87%; area under the ROC curve 0.91). This finding was comparable with other validated markers of severe pancreatitis (Imrie ≥3: sensitivity 51%, specificity 70%; Acute Physiology and Chronic Health Evaluation II: sensitivity 67%, specificity 96%; C-reactive protein >150: sensitivity 89%, specificity 83%).

CONCLUSION

IAP is a good predictor of mortality and organ failure in acute pancreatitis and compares favorably with other validated prognostic scores. Whether IAH is a phenomenon causative of organ failure or an epiphenomenon, occurring in conjunction with other organ dysfunction, remains unclear.

Rationale and methodology for a multicentre randomised trial of fibrinolysis for pulmonary embolism that includes quality of life outcomes

BACKGROUND

Submassive pulmonary embolism (PE) has a low mortality rate but can degrade functional capacity.

OBJECTIVE

The present study aims to provide rationale, methodology, and initial findings of a multicentre, randomised trial of fibrinolysis for PE that used a composite end-point, including quality of life measures.

METHODS

This investigator-initiated study was funded by a contract between a corporate partner and the investigator's hospital (the prime site). The investigator was the Food and Drug Administration (FDA) sponsor. The prime site subcontracted, indemnified, and trained consortia members. Consenting, normotensive patients with PE and right ventricular strain (by echocardiography or biomarkers) received low-molecular-weight heparin and random assignment to a single bolus of tenecteplase or placebo in double-blinded fashion. The outcomes were: (i) in-hospital rate of intubation, vasopressor support, and major haemorrhage, or (ii) at 90 days, death, recurrent PE, or composite that defined poor quality of life (echocardiography, 6 min walk test and surveys). The planned sample size was n = 200.

RESULTS

Eight sites enrolled 87 patients over 5 years. The ratio of patients screened for each enrolled was 7.4 to 1, equating to 11 h screening time per patient enrolled. Primary barrier to enrolment was the cost of screening. Two patients died (2.5%, 95%CI [0-8%]), one developed shock, but 18 (22%, 95%CI: [13-30%]) had a poor quality of life.

CONCLUSIONS

An investigator-initiated, FDA-regulated, multicentre trial of fibrinolysis for submassive PE was conducted, but was limited by screening costs and a low mortality rate. Quality of life measurements might represent a more important patient-centred end-point.

Consideration of additional factors in Sequential Organ Failure Assessment score

PURPOSE

The Sequential Organ Failure Assessment (SOFA) score, originally developed to assess organ failure status, is widely used as a prognostic indicator in intensive care unit patients. Additional prognostic factors, such as age and comorbidities, may complement the predictive performance of the SOFA.

METHODS

In total, 1049 consecutive patients were enrolled prospectively. SOFA and other admission-based intensive care unit scores were recorded during the first 24 hours. A complemented SOFA (cSOFA) score model was constructed by adding age and comorbidity scores to the original SOFA score, based on logistic regression analysis. The predictive performance was evaluated with regard to hospital mortality by receiver operating characteristics analysis. The Hosmer-Lemeshow goodness-of-fit test was used to assess calibration of the model, and leave-one-out cross-validation was performed.

RESULTS

The cSOFA score (maximum 30 points) was calculated as the SOFA score (24 points) + age score (2 points) + comorbidity score (4 points). The cSOFA score model showed satisfactory calibration and cross-validation performance. The AUC (95% CI) of the cSOFA score (0.812 [0.787-0.835]) was higher than the SOFA score (0.743 [0.715-0.769], P < .0001).

CONCLUSION

The performance of the SOFA score to predict hospital mortality can be improved by considering age and comorbidity factors.

Application of a modified sequential organ failure assessment score to critically ill patients

The purpose of the present study was to explore the usefulness of the Mexican sequential organ failure assessment (MEXSOFA) score for assessing the risk of mortality for critically ill patients in the ICU. A total of 232 consecutive patients admitted to an ICU were included in the study. The MEXSOFA was calculated using the original SOFA scoring system with two modifications: the PaO₂/FiO₂ ratio was replaced with the SpO₂/FiO₂ ratio, and the evaluation of neurologic dysfunction was excluded. The ICU mortality rate was 20.2%. Patients with an initial MEXSOFA score of 9 points or less calculated during the first 24 h after admission to the ICU had a mortality rate of 14.8%, while those with an initial MEXSOFA score of 10 points or more had a mortality rate of 40%. The MEXSOFA score at 48 h was also associated with mortality: patients with a score of 9 points or less had a mortality rate of 14.1%, while those with a score of 10 points or more had a mortality rate of 50%. In a multivariate analysis, only the MEXSOFA score at 48 h was an independent predictor for in-ICU death with an OR = 1.35 (95%CI = 1.14-1.59, P < 0.001). The SOFA and MEXSOFA scores calculated 24 h after admission to the ICU demonstrated a good level of discrimination for predicting the in-ICU mortality risk in critically ill patients. The MEXSOFA score at 48 h was an independent predictor of death; with each 1-point increase, the odds of death increased by 35%.

Three short perioperative infusions of n-3 PUFAs reduce systemic inflammation induced by cardiopulmonary bypass surgery: a randomized controlled trial

BACKGROUND

Fish oil (FO) has antiinflammatory effects, which might reduce systemic inflammation induced by a cardiopulmonary bypass (CPB).

OBJECTIVE

We tested whether perioperative infusions of FO modify the cell membrane composition, inflammatory responses, and clinical course of patients undergoing elective coronary artery bypass surgery.

DESIGN

A prospective randomized controlled trial was conducted in cardiac surgery patients who received 3 infusions of 0.2 g/kg FO emulsion or saline (control) 12 and 2 h before and immediately after surgery. Blood samples (7 time points) and an atrial biopsy (during surgery) were obtained to assess the membrane incorporation of PUFAs. Hemodynamic data, catecholamine requirements, and core temperatures were recorded at 10-min intervals; blood triglycerides, nonesterified fatty acids, glucose, lactate, inflammatory cytokines, and carboxyhemoglobin concentrations were measured at selected time points.

RESULTS

Twenty-eight patients, with a mean ± SD age of 65.5 ± 9.9 y, were enrolled with no baseline differences between groups. Significant increases in platelet EPA (+0.86%; P = 0.0001) and DHA (+0.87%; P = 0.019) were observed after FO consumption compared with at baseline. Atrial tissue EPA concentrations were higher after FO than after control treatments (+0.5%; P < 0.0001). FO did not significantly alter core temperature but decreased the postoperative rise in IL-6 (P = 0.018). Plasma triglycerides increased transiently after each FO infusion. Plasma concentrations of glucose, lactate, and blood carboxyhemoglobin were lower in the FO than in the control group on the day after surgery. Arrhythmia incidence was low with no significant difference between groups. No adverse effect of FO was detected.

CONCLUSIONS

Perioperative FO infusions significantly increased PUFA concentrations in platelet and atrial tissue membranes within 12 h of the first FO administration and decreased biological and clinical signs of inflammation. These results suggest that perioperative FO may be beneficial in elective cardiac surgery with CPB.

Development and evaluation of an interprofessional communication intervention to improve family outcomes in the ICU

The intensive care unit (ICU), where death is common and even survivors of an ICU stay face the risk of long-term morbidity and re-admissions to the ICU, represents an important setting for improving communication about palliative and end-of-life care. Communication about the goals of care in this setting should be a high priority since studies suggest that the current quality of ICU communication is often poor and is associated with psychological distress among family members of critically ill patients. This paper describes the development and evaluation of an intervention designed to improve the quality of care in the ICU by improving communication among the ICU team and with family members of critically ill patients. We developed a multi-faceted, interprofessional intervention based on self-efficacy theory. The intervention involves a "communication facilitator" - a nurse or social worker - trained to facilitate communication among the interprofessional ICU team and with the critically ill patient's family. The facilitators are trained using three specific content areas: a) evidence-based approaches to improving clinician-family communication in the ICU, b) attachment theory allowing clinicians to adapt communication to meet individual family member's communication needs, and c) mediation to facilitate identification and resolution of conflict including clinician-family, clinician-clinician, and intra-family conflict. The outcomes assessed in this randomized trial focus on psychological distress among family members including anxiety, depression, and post-traumatic stress disorder at 3 and 6 months after the ICU stay. This manuscript also reports some of the lessons that we have learned early in this study.

Reactive thrombocytosis and risk of subsequent venous thromboembolism: a cohort study

BACKGROUND

It is uncertain whether reactive thrombocytosis is associated with an increased risk of venous thromboembolism. This study assessed the incidence of reactive thrombocytosis, defined as platelet count ≥ 500 × 10(9)  L(-1) , at intensive care unit discharge and its association with subsequent venous thromboembolism.

METHODS AND RESULTS

This cohort study involved linkage of routinely collected intensive care unit, laboratory, radiology and death registry data of critically ill patients admitted to the intensive care unit between January 2009 and March 2010. The census date for survival and radiologically confirmed venous thromboembolism was 31 October 2011. Of the 1446 patients who survived to intensive care unit discharge, 139 patients had reactive thrombocytosis (9.6%, 95% confidence interval [CI] 8.2-11.2%). Twenty-nine patients developed venous thromboembolism after discharge (2%, 95% CI 1.4-2.9%; 67 per 100 person-years, 95% CI 45-97) and the median time to develop venous thromboembolism was 25 days (interquartile range 8-148). Reactive thrombocytosis was associated with an increased risk of subsequent venous thromboembolism (hazard ratio 5.3, 95% CI 1.7-16.4), after adjusting for other covariates. Platelet counts explained about 34% of the variability in the risk of venous thromboembolism and had a relatively linear relationship with the risk of venous thromboembolism when the platelet counts were > 400 × 10(9)  L(-1) . Venous thromboembolism after intensive care unit discharge was associated with an increased risk of mortality (hazard ratio 2.0, 95% CI 1.1-3.9), after adjusting for reactive thrombocytosis.

CONCLUSIONS

Reactive thrombocytosis during the recovery phase of critical illness was associated with an increased risk of subsequent venous thromboembolism.

Cross-validation of a Sequential Organ Failure Assessment score-based model to predict mortality in patients with cancer admitted to the intensive care unit

PURPOSE

This study aims to validate the performance of the Sequential Organ Failure Assessment (SOFA) score to predict death of critically ill patients with cancer.

MATERIAL AND METHODS

We conducted a retrospective observational study including adults admitted to the intensive care unit (ICU) between January 1, 2006, and December 31, 2008. We randomly selected training and validation samples in medical and surgical admissions to predict ICU and in-hospital mortality. By using logistic regression, we calculated the probabilities of death in the training samples and applied them to the validation samples to test the goodness-of-fit of the models, construct receiver operator characteristics curves, and calculate the areas under the curve (AUCs).

RESULTS

In predicting mortality at discharge from the unit, the AUC from the validation group of medical admissions was 0.7851 (95% confidence interval [CI], 0.7437-0.8264), and the AUC from the surgical admissions was 0.7847 (95% CI, 0.6319-0.937). The AUCs of the SOFA score to predict mortality in the hospital after ICU admission were 0.7789 (95% CI, 0.74-0.8177) and 0.7572 (95% CI, 0.6719-0.8424) for the medical and surgical validations groups, respectively.

CONCLUSIONS

The SOFA score had good discrimination to predict ICU and hospital mortality. However, the observed underestimation of ICU deaths and unsatisfactory goodness-of-fit test of the model in surgical patients to indicate calibration of the score to predict ICU mortality is advised in this group.

Effects of probiotics on serum levels of Th1/Th2 cytokine and clinical outcomes in severe traumatic brain-injured patients: a prospective randomized pilot study

INTRODUCTION

Traumatic brain injury (TBI) is associated with a profound immunological dysfunction manifested by a severe shift from T-helper type 1 (Th1) to T-helper type 2 (Th2) response. This predisposes patients to infections, sepsis, and adverse outcomes. Probiotic bacteria have been shown to balance the Th1/Th2 cytokines in allergic murine models and patients. For the present study, we hypothesized that the enteral administration of probiotics would adjust the Th1/Th2 imbalance and improve clinical outcomes in TBI patients.

METHODS

We designed a prospective, randomized, single-blind study. Patients with severe TBI and Glasgow Coma Scale scores between 5 and 8 were included, resulting in 26 patients in the control group and 26 patients in the probiotic group. All patients received enteral nutrition via a nasogastric tube within 24 to 48 hours following admission. In addition, the probiotic group received 109 bacteria of viable probiotics per day for 21 days. The associated serum levels of Th1/Th2 cytokines, Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment (SOFA) scores, nosocomial infections, length of ICU stay, and 28-day mortality rate were studied.

RESULTS

The patients responded to viable probiotics, and showed a significantly higher increase in serum IL-12p70 and IFNγ levels while also experiencing a dramatic decrease in IL-4 and IL-10 concentrations. APACHE II and SOFA scores were not significantly affected by probiotic treatment. Patients in the probiotic group experienced a decreased incidence of nosocomial infections towards the end of the study. Shorter ICU stays were also observed among patients treated with probiotic therapy. However, the 28-day mortality rate was unaffected.

CONCLUSIONS

The present study showed that daily prophylactic administration of probiotics could attenuate the deviated Th1/Th2 response induced by severe TBI, and could result in a decreased nosocomial infection rate, especially in the late period.

TRIAL REGISTRATION

ChiCTR-TRC-10000835.

An assessment of H1N1 influenza-associated acute respiratory distress syndrome severity after adjustment for treatment characteristics

Pandemic influenza caused significant increases in healthcare utilization across several continents including the use of high-intensity rescue therapies like extracorporeal membrane oxygenation (ECMO) or high-frequency oscillatory ventilation (HFOV). The severity of illness observed with pandemic influenza in 2009 strained healthcare resources. Because lung injury in ARDS can be influenced by daily management and multiple organ failure, we performed a retrospective cohort study to understand the severity of H1N1 associated ARDS after adjustment for treatment. Sixty subjects were identified in our hospital with ARDS from “direct injury” within 24 hours of ICU admission over a three month period. Twenty-three subjects (38.3%) were positive for H1N1 within 72 hours of hospitalization. These cases of H1N1-associated ARDS were compared to non-H1N1 associated ARDS patients. Subjects with H1N1-associated ARDS were younger and more likely to have a higher body mass index (BMI), present more rapidly and have worse oxygenation. Severity of illness (SOFA score) was directly related to worse oxygenation. Management was similar between the two groups on the day of admission and subsequent five days with respect to tidal volumes used, fluid balance and transfusion practices. There was, however, more frequent use of “rescue” therapy like prone ventilation, HFOV or ECMO in H1N1 patients. First morning set tidal volumes and BMI were significantly associated with increased severity of lung injury (Lung injury score, LIS) at presentation and over time while prior prescription of statins was protective. After assessment of the effect of these co-interventions LIS was significantly higher in H1N1 patients. Patients with pandemic influenza-associated ARDS had higher LIS both at presentation and over the course of the first six days of treatment when compared to non-H1N1 associated ARDS controls. The difference in LIS persisted over the duration of observation in patients with H1N1 possibly explaining the increased duration of mechanical ventilation.

Prediction of patient outcome from Acinetobacter baumannii bacteremia with Sequential Organ Failure Assessment (SOFA) and Acute Physiology and Chronic Health Evaluation (APACHE) II scores

OBJECTIVE

Acinetobacter baumannii is an important nosocomial pathogen associated with a high mortality rate. However, no objective and quantitative severity scores are available for the severity stratification. We aimed to assess the effectiveness of SOFA and APACHE II scores calculated at the onset of bacteremia in predicting the mortality of patients with A. baumannii bacteraemia.

PATIENTS AND METHODS

A total of 110 patients with A. baumannii bacteremia were included in this retrospective study during the 40-month study period. Information including clinical and laboratory data was collected.

RESULTS

Multivariate analysis showed that both SOFA and APACHE II scores were independent outcome predictors after adjustment for other parameters. Goodness-of-fit was good for SOFA and APACHE II, and both models displayed excellent AUROCs (SOFA: 0.83 ± 0.06, APACHE II: 0.82 ± 0.08 in predicting 14-day mortality; SOFA: 0.85 ± 0.04, APACHE II: 0.81 ± 0.04 in predicting in-hospital mortality). There was no significant difference in the predictions of the two scoring systems, and the scores were highly correlated (r(2)=0.724, p <0.001). We found that SOFA >8, APACHE II >29 and SOFA >7, APACHE II >23 are associated with significantly higher 14-day and in-hospital mortality rates, respectively.

CONCLUSION

SOFA and APACHE II scores assessed at the onset of bacteremia are reliable risk stratifying tools in predicting 14-day and in-hospital mortality in A. baumannii bacteremia. For ease of calculation, the use of SOFA rather than APACHE II score to predict mortality of A. baumannii bacteremia might have clinical application.

Prognostic value of Sequential Organ Failure Assessment and Simplified Acute Physiology II Score compared with trauma scores in the outcome of multiple-trauma patients

BACKGROUND

Prospective data regarding the prognostic value of the Sequential Organ Failure Assessment (SOFA) score in comparison with the Simplified Acute Physiology Score (SAPS II) and trauma scores on the outcome of multiple-trauma patients are lacking.

METHODS

Single-center evaluation (n = 237, Injury Severity Score [ISS] >16; mean ISS = 29). Uni- and multivariate analysis of SAPS II, SOFA, revised trauma, polytrauma, and trauma and ISS scores (TRISS) was performed.

RESULTS

The 30-day mortality was 22.8% (n = 54). SOFA day 1 was significantly higher in nonsurvivors compared with survivors (P < .001) and correlated well with the length of intensive care unit stay (r = .50, P < .001). Logistic regression revealed SAPS II to have the best predictive value of 30-day mortality (area under the receiver operating characteristic = .86 +/- .03). The SOFA score significantly added prognostic information with regard to mortality to both SAPS II and TRISS.

CONCLUSIONS

The combination of critically ill and trauma scores may increase the accuracy of mortality prediction in multiple-trauma patients.

Association between blood lactate levels, Sequential Organ Failure Assessment subscores, and 28-day mortality during early and late intensive care unit stay: a retrospective observational study

OBJECTIVES

To evaluate whether the level and duration of increased blood lactate levels are associated with daily Sequential Organ Failure Assessment (SOFA) scores and organ subscores and to evaluate these associations during the early and late phases of the intensive care unit stay.

DESIGN

Retrospective observational study.

SETTING

Mixed intensive care unit of a university hospital.

PATIENTS

134 heterogeneous intensive care unit patients.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We calculated the area under the lactate curve above 2.0 mmol/L (lactateAUC>2). Daily SOFA scores were collected during the first 28 days of intensive care unit stay to calculate initial (day 1), maximal, total and mean scores. Daily lactateAUC>2 values were related to both daily SOFA scores and organ subscores using mixed-model analysis of variance. This was also done separately during the early (<2.75 days) and late (>2.75 days) phase of the intensive care unit stay.Compared with normolactatemic patients (n = 78), all median SOFA variables were higher in patients with hyperlactatemia (n = 56) (initial SOFA: 9 [interquartile range 4-12] vs. 4 [2-7]; maximal SOFA: 10 [5-13] vs. 5 [2-9]; total SOFA: 28 [10-70] vs. 9 [3-41]; mean SOFA: 7 [4-10] vs. 4 [2-6], all p < .001). The overall relationship between daily lactateAUC>2 and daily SOFA was an increase of 0.62 SOFA-points per 1 day.mmol/L of lactateAUC>2 (95% confidence interval, 0.41-0.81, p < .00001). During early intensive care unit stay, the relationship between lactateAUC>2 and SOFA was 1.01 (95% confidence interval, 0.53-1.50, p < .0005), and during late intensive care unit stay, this was reduced to 0.50 (95% confidence interval, 0.28-0.72, p < .0005). Respiratory (0.30, 0.22-0.38, p < .001) and coagulation (0.13, 0.09-0.18, p < .001) subscores were most strongly associated with lactateAUC>2.

CONCLUSIONS

Blood lactate levels were strongly related to SOFA scores. This relationship was stronger during the early phase of intensive care unit stay, which provides additional indirect support for early resuscitation to prevent organ failure. The results confirm that hyperlactatemia can be considered as a warning signal for organ failure.

Incidence and outcome of ischemic hepatitis complicating septic shock

AIM

The specific incidence of ischemic hepatitis in septic shock patients remains unknown. The aim of this study was to evaluate the incidence of ischemic hepatitis in septic shock and its relationship with mortality.

METHODS

We retrospectively studied 181 patients with septic shock admitted to the intensive care unit (ICU). We defined ischemic hepatitis as having a value of serum aminotransferases equal to or higher than 1000 IU/L. We recorded the age, sex, comorbidity, site of infection, the Sequential Organ Failure Assessment (SOFA) score on admission to the ICU, maximum SOFA score and inadequate antibiotic therapy.

RESULTS

Twenty-five (13.8%) patients developed ischemic hepatitis. In-hospital mortality was 57% (103 patients). In the ischemic hepatitis group, mortality increased up to 84.0% (21 patients) compared with 52.6% (82 patients) in patients without ischemic hepatitis (control group) (odds ratio [OR]: 4.7; 95% confidence interval [CI]: 1.6-14.4; P = 0.003). The development of ischemic hepatitis, age, maximum SOFA score and inadequate antibiotic therapy were independently associated with an increased risk of death. The odds of death increased by 247% in ischemic hepatitis (OR: 3.47; 95% CI: 1.02-11.8; P = 0.047).

CONCLUSION

Ischemic hepatitis is a common complication in septic shock patients, associated with a high mortality.

Monocyte activation by necrotic cells is promoted by mitochondrial proteins and formyl peptide receptors

OBJECTIVE

Necrotic cells evoke potent innate immune responses through unclear mechanisms. The mitochondrial fraction of the cell retains constituents of its bacterial ancestors, including N-formyl peptides, which are potentially immunogenic. Thus, we hypothesized that the mitochondrial fraction of the cell, particularly N-formyl peptides, contributes significantly to the activation of monocytes by necrotic cells.

DESIGN

Human peripheral blood monocytes were incubated with necrotic cell fractions and mitochondrial proteins to investigate their potential for immune cell activation.

SETTING

University Medical Center Research Laboratory.

SUBJECTS

Healthy human adults served as blood donors.

MEASUREMENTS AND MAIN RESULTS

Human blood monocyte activation was measured after treatment with cytosolic, nuclear and mitochondrial fractions of necrotic HepG2 cells or necrotic HepG2 cells depleted of N-formyl peptides [Rho(0) cells]. The specific role of the high affinity formyl peptide receptor (FPR) was then tested using specific pharmacologic inhibitors and RNA silencing. The capacity of mitochondrial N-formyl peptides to activate monocytes was confirmed using a synthetic peptide conforming to the N-terminus of mitochondrial nicotinamide adenine dinucleotide subunit 6. The results demonstrated that mitochondrial cell fractions most potently activated monocytes, and interleukin (IL)-8 was selectively released at low-protein concentrations. Mitochondria from Rho(0) cells induced minimal monocyte IL-8 release, and specific pharmacologic inhibitors and RNA-silencing confirmed that FPR contributes significantly to monocyte IL-8 responses to both necrotic cells and mitochondrial proteins. N-formyl peptides alone did not induce monocyte IL-8 release; whereas, the combination of mitochondrial N-formyl peptides and mitochondrial transcription factor A (TFAM) dramatically increased IL-8 release from monocytes. Likewise, high mobility group box 1, the nuclear homolog of TFAM, did not induce monocyte IL-8 release unless combined with mitochondrial N-formyl peptides.

CONCLUSIONS

Interactions between mitochondrial N-formyl peptides and FPR in the presence of other mitochondrial antigens (e.g., TFAM) contributes significantly to the activation of monocytes by necrotic cells.

Evaluation of SOFA-based models for predicting mortality in the ICU: A systematic review

Introduction

To systematically review studies evaluating the performance of Sequential Organ Failure Assessment (SOFA)-based models for predicting mortality in patients in the intensive care unit (ICU).

Methods

Medline, EMBASE and other databases were searched for English-language articles with the major objective of evaluating the prognostic performance of SOFA-based models in predicting mortality in surgical and/or medical ICU admissions. The quality of each study was assessed based on a quality framework for prognostic models.

Results

Eighteen articles met all inclusion criteria. The studies differed widely in the SOFA derivatives used and in their methods of evaluation. Ten studies reported about developing a probabilistic prognostic model, only five of which used an independent validation data set. The other studies used the SOFA-based score directly to discriminate between survivors and non-survivors without fitting a probabilistic model. In five of the six studies, admission-based models (Acute Physiology and Chronic Health Evaluation (APACHE) II/III) were reported to have a slightly better discrimination ability than SOFA-based models at admission (the receiver operating characteristic curve (AUC) of SOFA-based models ranged between 0.61 and 0.88), and in one study a SOFA model had higher AUC than the Simplified Acute Physiology Score (SAPS) II model. Four of these studies used the Hosmer-Lemeshow tests for calibration, none of which reported a lack of fit for the SOFA models. Models based on sequential SOFA scores were described in 11 studies including maximum SOFA scores and maximum sum of individual components of the SOFA score (AUC range: 0.69 to 0.92) and delta SOFA (AUC range: 0.51 to 0.83). Studies comparing SOFA with other organ failure scores did not consistently show superiority of one scoring system to another. Four studies combined SOFA-based derivatives with admission severity of illness scores, and they all reported on improved predictions for the combination. Quality of studies ranged from 11.5 to 19.5 points on a 20-point scale.

Conclusions

Models based on SOFA scores at admission had only slightly worse performance than APACHE II/III and were competitive with SAPS II models in predicting mortality in patients in the general medical and/or surgical ICU. Models with sequential SOFA scores seem to have a comparable performance with other organ failure scores. The combination of sequential SOFA derivatives with APACHE II/III and SAPS II models clearly improved prognostic performance of either model alone. Due to the heterogeneity of the studies, it is impossible to draw general conclusions on the optimal mathematical model and optimal derivatives of SOFA scores. Future studies should use a standard evaluation methodology with a standard set of outcome measures covering discrimination, calibration and accuracy.

Risk factors for and influence of bloodstream infections on mortality: a 1-year prospective study in a Greek intensive-care unit

To determine the incidence, risk factors for, and the influence of bloodstream infections (BSIs) on mortality of patients in intensive-care units (ICUs), prospectively collected data from all patients with a stay in an ICU >48 h, during a 1-year period, were analysed. Of 572 patients, 148 developed a total of 232 BSI episodes (incidence 16·3 episodes/1000 patient-days). Gram-negative organisms with high level of resistance to antibiotics were the most frequently isolated pathogens (157 strains, 67·8%). The severity of illness on admission, as estimated by APACHE II score (OR 1·07, 95% CI 1·04–1·1, P<0·001), the presence of acute respiratory distress syndrome (OR 3·57, 95% CI 1·92–6·64, P<0·001), and a history of diabetes mellitus (OR 2·37, 95% CI 1·36–4·11, P=0·002) were risk factors for the occurrence of BSI whereas the development of an ICU-acquired BSI was an independent risk factor for death (OR 1·76, 95% CI 1·11–2·78, P=0·015). Finally, the severity of organ dysfunction on the day of the first BSI episode, as estimated by SOFA score, and the level of serum albumin, independently affected the outcome (OR 1·44, 95% CI 1·22–1·7, P<0·001 and OR 0·47, 95% CI 0·23–0·97, P=0·04 respectively).

Design of a JAIN SLEE/ESB-based platform for routing medical data in the ICU

The importance of computer aided decision making is continuously increasing. In the ICU, medical decision support services gather and process medical data of patients and present results and suggestions to the medical staff. The medical decision support services can monitor for example blood pressure, creatinine levels or the usage of antibiotics. If certain levels are crossed, they raise alerts so that the medical staff can take appropriate actions if required. This significantly reduces the amount of data needing to be processed by the medical staff. To handle the large amount of data that is generated by the ICU on a daily basis, a platform for routing and processing this data is necessary. In this paper we propose a platform based on JAIN SLEE and an Enterprise Service Bus. The platform takes care of the routing of the data to the appropriate services and allows to easily deploy and manage services. In this paper, we present the design details and the evaluation results. Furthermore, it is shown that the platform is capable of routing and processing all the events generated by the ICU within strict time constraints.

Monitoring the clinical introduction of a glutamine and antioxidant solution in critically ill trauma and burn patients

OBJECTIVE

Enteral glutamine supplementation and antioxidants have been shown to be beneficial in some categories of critically ill patients. This study investigated the impact on organ function and clinical outcome of an enteral solution enriched with glutamine and antioxidant micronutrients in patients with trauma and with burns.

METHODS

This was a prospective study of a historical control group including critically ill, burned and major trauma patients (n = 86, 40 patients with burns and 46 with trauma, 43 in each group) on admission to an intensive care unit in a university hospital (matching for severity, age, and sex). The intervention aimed to deliver a 500-mL enteral solution containing 30 g of glutamine per day, selenium, zinc, and vitamin E (Gln-AOX) for a maximum of 10 d, in addition to control treatment consisting of enteral nutrition in all patients and intravenous trace elements in all burn patients.

RESULTS

Patients were comparable at baseline, except for more inhalation injuries in the burn-Gln-AOX group (P = 0.10) and greater neurologic impairment in the trauma-Gln-AOX group (P = 0.022). Intestinal tolerance was good. The full 500-mL dose was rarely delivered, resulting in a low mean glutamine daily dose (22 g for burn patients and 16 g for trauma patients). In burn patients intravenous trace element delivery was superior to the enteral dose. The evolution of the Sequential Organ Failure Assessment score and other outcome variables did not differ significantly between groups. C-reactive protein decreased faster in the Gln-AOX group.

CONCLUSION

The Gln-AOX supplement was well tolerated in critically ill, injured patients, but did not improve outcome significantly. The delivery of glutamine below the 0.5-g/kg recommended dose in association with high intravenous trace element substitution doses in burn patients are likely to have blunted the impact by not reaching an efficient treatment dose. Further trials testing higher doses of Gln are required.