[Validation of APACHE II and SOFA scores in 2 cohorts of patients with suspected infection and sepsis, not admitted to critical care units]

Towards better mortality prediction in cancer patients in the ICU: a comparative analysis of prognostic scales: systematic literature review

OBJECTIVE

To evaluate the predictive ability of mortality prediction scales in cancer patients admitted to intensive care units (ICUs).

DESIGN

A systematic review of the literature was conducted using a search algorithm in October 2022. The following databases were searched: PubMed, Scopus, Virtual Health Library (BVS), and Medrxiv. The risk of bias was assessed using the QUADAS-2 scale.

SETTING

ICUs admitting cancer patients.

PARTICIPANTS

Studies that included adult patients with an active cancer diagnosis who were admitted to the ICU.

INTERVENTIONS

Integrative study without interventions.

MAIN VARIABLES OF INTEREST

Mortality prediction, standardized mortality, discrimination, and calibration.

RESULTS

Seven mortality risk prediction models were analyzed in cancer patients in the ICU. Most models (APACHE II, APACHE IV, SOFA, SAPS-II, SAPS-III, and MPM II) underestimated mortality, while the ICMM overestimated it. The APACHE II had the SMR (Standardized Mortality Ratio) value closest to 1, suggesting a better prognostic ability compared to the other models.

CONCLUSIONS

Predicting mortality in ICU cancer patients remains an intricate challenge due to the lack of a definitive superior model and the inherent limitations of available prediction tools. For evidence-based informed clinical decision-making, it is crucial to consider the healthcare team's familiarity with each tool and its inherent limitations. Developing novel instruments or conducting large-scale validation studies is essential to enhance prediction accuracy and optimize patient care in this population.

Prediction of short-term mortality in elderly patients with sepsis using immunoglobulin G2: An observational study

Background

Sepsis is a global healthcare issue and continues to cause high mortality especially in elderly patients. The humoral immune system plays an important role in protecting from microbial contamination. The goal of this study is to investigate the immune status and prognostic evaluation of elderly patients with sepsis.

Methods

A single-center, prospective observational study has been conducted, with the endpoint being the 28-day mortality. Patients 65 years and older who met the diagnostic criteria of Sepsis-3 in the Emergency Department of Beijing Chao-Yang Hospital were divided into survivors and non-survivors groups. Levels of immunoglobulin (Ig) A, IgG, IgM and their subclasses as well as clinical indicators were collected upon enrollment, and the results were statistically analyzed.

Results

This study finally enrolled 106 elderly patients, including 68 survivors and 38 non-survivors. Compared with survivors, IgG2 level and IgG4 level were lower in non-survivors ( P < 0.05 ). IgG2 could be regarded as an independent predictor of the 28-day mortality in elderly septic patients. IgG2 had a higher predictive value than other immunoglobulins, lactate, procalcitonin, SOFA score and APACHE II score for mortality in elderly septic patients, and the ratio of IgG2 to IgG had a slightly larger area under the ROC curve compared to IgG2 only (AUC: 0.776 v.s. 0.741).

Conclusion

IgG subclasses play important roles in the prognosis of elderly septic patients, with IgG2 being the main component. IgG2 was found to outperform other immunoglobulins, lactate, procalcitonin, SOFA score and APACHE II score in terms of predicting the mortality. A complete immunological evaluation is helpful to guide the prognosis and treatment of patients with age-related infection.

Prediction of Mortality in the Medical Intensive Care Unit with Serial Full Outline of Unresponsiveness Score in Elderly Patients

Background

Advanced age is one of the key risk factors for mortality and morbidity in intensive care units. The full outline of unresponsiveness (FOUR) score has been developed and introduced to address the limitations of the Glasgow Coma Scale (GCS). The current study aimed to evaluate the ability of the FOUR score in predicting the outcomes (survivors, nonsurvivors).

Materials and methods

This observational study of 168 consecutive elderly patients admitted to medical intensive care during the 14 months carried out prospectively. FOUR score in the 24, 48, and 72 hours of admission, and demographic characteristics of all elderly patients were calculated, then recorded. The receiver operating characteristic (ROC) curve, logistic regression, and Hosmer-Lemeshow test were used (95% confidence interval) for statistical analysis.

Results

FOUR scores in 24, 48, and 72 hours between survivors and nonsurvivors (p <0.0001, p <0.0001, and p <0.0001, respectively) were statistically different. The discrimination power of FOUR score 24 hours of admission was excellent [area under ROC (AUC): 85.7% [standard error (SE)]: 2.8%]; it was acceptable for 48 and 72 hours of admission [AUC: 76.3% (SE: 3.6%), AUC: 75/0% (SE: 3.8%), respectively]. The FOUR score of 24 and 48 hours (x² = 10.06, p = 0.261, x² = 6.82, p = 0.448, respectively) showed acceptable calibration.

Conclusions

The FOUR score is a suitable scoring system for prognostication of outcomes in critically ill elderly patients. The FOUR score 24 hours of admission was superior in terms of discrimination power than 48 and 72 hours, but better calibration power belonged to FOUR score 48 hours.

How to cite this article

Ramazani J, Hosseini M. Prediction of Mortality in the Medical Intensive Care Unit with Serial Full Outline of Unresponsiveness Score in Elderly Patients. Indian J Crit Care Med 2022;26(1):94–99.

Comparison of full outline of unresponsiveness score and Glasgow Coma Scale in Medical Intensive Care Unit

Context:

The Glasgow Coma Scale (GCS) is the most commonly used scale, and Full Outline of Unresponsiveness (FOUR) score is new validated coma scale as an alternative to GCS in the evaluation of the level of consciousness.

Aim:

The aim of the current study was to evaluate FOUR score and GCS ability in predicting the outcomes (Survivors, nonsurvivors) in Medical Intensive Care Unit (MICU).

Setting and Design:

This was an observational and prospective study of 300 consecutive patients admitted to the MICU during a 14 months’ period.

Materials and Methods:

FOUR score, GCS score, and demographic characteristics of all patients were recorded in the first admission 24 h.

Statistical Analysis Used:

A receiver operator characteristic (ROC) curve, Hosmer–Lemeshow test, and Logistic regression were used in the statistical analysis (95% confidence interval).

Results:

Data analysis showed a significant statistical difference in FOUR score and GCS score between survivors and nonsurvivors (P < 0.0001, P < 0.0001; respectively). The discrimination power was good for both FOUR score and GCS (area under ROC curve: 87.3% (standard error [SE]: 2.1%), 82.6% [SE: 2.3%]; respectively). The acceptable calibration was seen just for FOUR score (χ² = 8.059, P = 0.428).

Conclusions:

Both FOUR score and GCS are valuable scales for predicting outcomes in patients are admitted to the MICU; however, the FOUR score showed better discrimination and calibration than GCS, so it is superior to GCS in predicting outcomes in this patients population.

Positive Culture and Prognosis in Patients With Sepsis: A Prospective Cohort Study

PURPOSE

To analyze the prognostic role of positive cultures in patients with sepsis.

METHODS

A prospective cohort study in a tertiary referral hospital in Medellín, Colombia. Adults older than 18 years of age with a bacterial infection diagnosis according to Centers for Disease Control criteria and sepsis (evidence of organ dysfunction) were included. A logistic regression model was used to determine the association between positive cultures and hospital mortality, and a Cox regression with a competing risk modeling approach was used to determine the association between positive cultures and hospital stay as well as secondary infections.

RESULTS

Overall, 408 patients had positive cultures, of which 257 were blood culture, and 153 had negative cultures. Patients with positive cultures had a lower risk of mortality (odds ratio [OR], 0.43; 95% confidence interval [CI], 0.27-0.68), but this association was not maintained after adjusting for confounding factors (OR, 0.56; 95% CI, 0.31-1.01). No association was found with the hospital stay (adjusted subhazard ratio [SHR], 1.06; 95% CI, 0.83-1.35). There was no association between positive cultures and the presence of secondary infections (adjusted SHR, 0.99; 95% CI, 0.58-1.71).

CONCLUSION

Positive cultures are not associated with prognosis in patients with sepsis.

Attenuation of the physiological response to infection on adults over 65 years old admitted to the emergency room (ER)

It has been considered that the elderly have clinical manifestations different from the ones observed in middle-age adults during an injury event. This hypothesis has not been extensively explored in sepsis and bacterial infections. Secondary analysis of two prospective studies including 2611 patients over 18 years of age admitted to the emergency room with confirmed or probable bacterial infections and sepsis. The outcome measures were heart rate, respiratory rate, systolic blood pressure, temperature, Glasgow Coma Scale, creatinine, PaO₂/FiO₂ and platelets daily during the first week. Compared to survivors younger than 65, the deceased under 65 had an average heart rate of 12.5 beats per minute per day higher (95% CI 9.32; 15.61), while patients over 65 who died barely had an average 5.7 beats per minute per day higher than the same reference group (95% CI 3.45; 8.06). The systolic blood pressure had a significant decreased in those who died younger than 65, compared to survivors with the same age, in both cohorts (-5.2 mmHg, 95% CI -8.17; -2.23 and -8.5 mmHg, 95% CI -13.48; -3.54, respectively), while those older than 65 who died had a nonsignificant increase (+1.6 mmHg, 95% CI -1.33; 4.62 and +0.1, 95% CI -6.48; 6.72, respectively) compared to the same reference group. The behavior of most clinical and laboratory variables suggests a less pronounced response of subjects above 65 years of age who died 28 days after being diagnosed with sepsis.

Prototype of a computerized scale for the active search for potential organ donors

Objective:

to develop a prototype of a computerized scale for the active search for potential organ and tissue donors.

Method:

methodological study, with the analysis of 377 electronic medical records of patients who died due to encephalic death or cardiorespiratory arrest in the intensive care units of a tertiary hospital. Among the deaths due to cardiorespiratory arrest, the study aimed to identify factors indicating underreported encephalic death cases. The Acute Physiology and Chronic Health Evaluation II and Sepsis Related Organ Failure Assessment severity indexes were applied in the protocols. Based on this, a scale was built and sent to five experts for assessment of the scale content, and subsequently, it was computerized by using a prototyping model.

Results:

34 underreported encephalic death cases were identified in the medical records of patients with cardiorespiratory arrest. Statistically significant differences were found in the Wilcoxon test between the scores of hospital admissions in the intensive care unit and the opening of the encephalic death protocol for both severity indexes.

Conclusion:

the prototype was effective for identifying potential organ donors, as well as for the identification of the degree of organ dysfunction in patients with encephalic death.

Clinical study of a new Modified Early Warning System scoring system for rapidly evaluating shock in adults

OBJECTIVE

Shock, the most common severe emergency syndrome, has a complicated etiopathogenesis, is difficult to identify, progresses quickly, and is dangerous. Early identification and intervention play determining roles in the final outcomes of shock patients, but no specific scoring system for shock has been established to date.

METHODS

We collected 292 shock patients and analyzed the correlation between 28-day prognosis and the Acute Physiologic Assessment and Chronic Health Evaluation II (APACHE II), Modified Early Warning System (MEWS), and Sequential Organ Failure Assessment scoring systems. According to the previous result, we established a new MEWS scoring system based on the conventional MEWS, which also included age and transcutaneous oxygen saturation. Some of the items with a strong correlation with the 28-day prognosis were selected to establish the new MEWS scoring system. We then evaluated the predictive efficacy of the new MEWS scoring system on 28-day prognosis and the correlation with other scoring systems.

RESULTS

Some indexes, including age, transcutaneous oxygen saturation, arterial blood pH and blood lactic acid, serum sodium, serum potassium, HCO₃, and red blood cells deposited, differed significantly between the nonsurviving and surviving groups (P<.05). The area under the curve (AUC) of the APACHE II, MEWS, shock index, and Sequential Organ Failure Assessment scoring systems for 28-day prognosis indicated a critical predictive efficacy. Receiver operating characteristic curves indicated that the MEWS AUC was 0.614, new MEWS AUC was 0.696, and APACHE II AUC was 0.785, suggesting superiority of the new MEWS to the conventional MEWS but inferiority to the APACHE II. Interestingly, the correlation efficient of the traditional MEWS and the new MEWS was 0.81. The correlation efficient of these scoring systems with other indexes, including lactic acid and hemoglobin, was less than 0.3.

CONCLUSIONS

The new MEWS scoring system could be an independent indicator to reflect shock severity. It has higher predictive efficacy in septic shock, especially for 28-day prognosis.

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.

Comparison of acute physiology and chronic health evaluation II and Glasgow Coma Score in predicting the outcomes of Post Anesthesia Care Unit's patients

Context:

Acute physiology and chronic health evaluation II (APACHE II) is one of the most general classification systems of disease severity in Intensive Care Units and Glasgow Coma Score (GCS) is one of the most specific ones.

Aims:

The aim of the current study was to assess APACHE II and GCS ability in predicting the outcomes (survivors, non-survivors) in the Post Anesthesia Care Unit's (PACU).

Settings and Design:

This was an observational and prospective study of 150 consecutive patients admitted in the PACU during 6-month period.

Materials and Methods:

Demographic information recorded on a checklist, also information about severity of disease calculated based on APACHE II scoring system in the first admission 24 h and GCS scale.

Statistical Analysis Used:

Logistic regression, Hosmer-Lemeshow test and receiver operator characteristic (ROC) curves were used in statistical analysis (95% confidence interval).

Results:

Data analysis showed a significant statistical difference between outcomes and both APACHE II and Glasgow Coma Score (GCS) (P < 0.0001). The ROC-curve analysis suggested that the predictive ability of GCS is slightly better than APACHE II in this study. For GCS the area under the ROC curve was 86.1% (standard error [SE]: 3.8%), and for APACHE II it was 85.7% (SE: 3.5%), also the Hosmer-Lemeshow statistic revealed better calibration for GCS (χ² = 5.177, P = 0.521), than APACHE II (χ² = 10.203, P = 0.251).

Conclusions:

The survivors had significantly lower APACHE II and higher GCS compared with non-survivors, also GCS showed more predictive accuracy than APACHE II in prognosticating the outcomes in PACU.