Prognosis in the intensive care unit: finding accurate and useful estimates for counseling patients

The GERtality Score: The Development of a Simple Tool to Help Predict in-Hospital Mortality in Geriatric Trauma Patients

Feasible and predictive scoring systems for severely injured geriatric patients are lacking. Therefore, the aim of this study was to develop a scoring system for the prediction of in-hospital mortality in severely injured geriatric trauma patients. The TraumaRegister DGU^® (TR-DGU) was utilized. European geriatric patients (≥65 years) admitted between 2008 and 2017 were included. Relevant patient variables were implemented in the GERtality score. By conducting a receiver operating characteristic (ROC) analysis, a comparison with the Geriatric Trauma Outcome Score (GTOS) and the Revised Injury Severity Classification II (RISC-II) Score was performed. A total of 58,055 geriatric trauma patients (mean age: 77 years) were included. Univariable analysis led to the following variables: age ≥ 80 years, need for packed red blood cells (PRBC) transfusion prior to intensive care unit (ICU), American Society of Anesthesiologists (ASA) score ≥ 3, Glasgow Coma Scale (GCS) ≤ 13, Abbreviated Injury Scale (AIS) in any body region ≥ 4. The maximum GERtality score was 5 points. A mortality rate of 72.4% was calculated in patients with the maximum GERtality score. Mortality rates of 65.1 and 47.5% were encountered in patients with GERtality scores of 4 and 3 points, respectively. The area under the curve (AUC) of the novel GERtality score was 0.803 (GTOS: 0.784; RISC-II: 0.879). The novel GERtality score is a simple and feasible score that enables an adequate prediction of the probability of mortality in polytraumatized geriatric patients by using only five specific parameters.

The practice of evidence-based medicine involves the care of whole persons

In this issue of the Journal, Dr. Fava posits that evidence-based medicine (EBM) was bound to fail. I share some of the concerns he expresses, yet I see more reasons for optimism. Having been on rounds with both Drs. Engel and Sackett, I reckon they would have agreed more than they disagreed. Their central teaching was the compassionate and well-informed care of sick persons. The model that emerged from these rounds was that patient care could be both person-centered and evidence-based, that clinical judgment was essential to both, and the decisions could and should be shared. Both clinicians and patients can bring knowledge from several sources into the shared decision making process in the clinical encounter, including evidence from clinical care research. I thank Dr. Fava for expressing legitimate doubts and providing useful criticism, yet I am cautiously optimistic that the model of EBM described here is robust enough to meet the challenges and is not doomed to fail.

Lipopolysaccharide-binding protein for monitoring of postoperative sepsis: complemental to C-reactive protein or redundant?

INTRODUCTION

To prospectively evaluate the performance of Lipopolysaccharide-Binding Protein (LBP) in prediction of hospital mortality and its correlation to C-reactive Protein (CRP), we studied sixty consecutive, postoperative patients with sepsis admitted to the university hospital intensive care unit.

MEASUREMENTS AND METHODS

Plasma LBP and CRP were serially measured from day(d)1 (onset of sepsis) to d14 in parallel with clinical data until d28. Predictive value and correlation of LBP and CRP were analyzed by Receiver Operating Characteristic (ROC) curve analysis and Pearson's test, respectively.

MAIN RESULTS

LBP and CRP showed the highest levels on d2 or d3 after the onset of sepsis with no significant difference between survivors and nonsurvivors. Only at d7, nonsurvivors had significantly (p = .03) higher levels of CRP than survivors. Accordingly, in ROC analysis, concentration of CRP and LBP on d7 poorly discriminated survivors from nonsurvivors (area under curve = .62 and .55, respectively) without significant difference between LBP- and CRP-ROC curves for paired comparison. LBP and CRP plasma levels allocated to quartiles correlated well with each other (r(2) = .95; p = .02). Likewise, changes in plasma concentrations of LBP and CRP from one observation to the next showed a marked concordance as both parameters concomitantly increased or decreased in 76% of all cases.

CONCLUSIONS

During the first 14 days of postoperative sepsis, LBP plasma concentrations showed a time course that was very similar to CRP with a high concordance in the pattern of day-to-day changes. Furthermore, like CRP, LBP does not provide a reliable clue for outcome in this setting.

Predictive value of procalcitonin, interleukin-6, and C-reactive protein for survival in postoperative patients with severe sepsis

PURPOSE

To prospectively evaluate the performance of procalcitonin (PCT), interleukin-6 (IL-6), and C-reactive protein (CRP) as percentage of baseline (POB) in predicting hospital survival, we studied 64 consecutive, postoperative patients with severe sepsis.

MATERIALS AND METHODS

Plasma PCT, IL-6, and CRP were serially measured from day 1 (onset of sepsis) to day 14 in parallel with clinical data until day 28. Multivariate logistic regression and univariate analysis of predictive accuracy of PCT-, IL-6-, and CRP-POB were performed. Newly derived binary prediction rules were evaluated by calculating sensitivity, specificity, positive predictive value, and negative predictive value.

RESULTS

In survivors, PCT and IL-6 significantly decreased from days 1 to 14, whereas CRP did not. In nonsurvivors, the inflammation markers mostly increased within the second week. At day 7, logistic regression analysis revealed PCT-POB as an independent determinant for survival. Especially, PCT-POB not exceeding 50% and PCT-POB not exceeding 25% with CRP-POB not exceeding 75% on day 7 indicated a favorable outcome with a positive predictive value/sensitivity of 75%/97% and 92%/67%, respectively. In comparison, pretest likelihood to survive by day 28 and observed survival rate were 60% and 67%, respectively.

CONCLUSIONS

Prediction rules of decrease in PCT-POB on day 7 in combination with CRP-POB may serve to monitor efficacy and guide duration of therapy in critically ill patients.

Factores asociados al pronóstico de los pacientes pediátricos ventilados mecánicamente. Un estudio internacional

OBJECTIVE

Identify factors associated with the survival of pediatric patients who are submitted to mechanical ventilation (MV) for more than 12 hours.

DESIGN

International prospective cohort study. It was performed between April 1 and May 31 1999. All patients were followed-up during 28 days or discharge to pediatric intensive care unit (PICU).

SETTING

36 PICUs from 7 countries.

PATIENTS

A total of 659 ventilated patients were enrolled but 15 patients were excluded because their vital status was unknown on discharge.

RESULTS

Overall in-UCIP mortality rate was 15,6%. Recursive partitioning and logistic regression were used and an outcome model was constructed. The variables significantly associated with mortality were: peak inspiratory pressure (PIP), acute renal failure (ARF), PRISM score and severe hypoxemia (PaO2/FiO2 < 100). The subgroup with best outcome (mortality 7%) included patients who were ventilated with a PIP < 35 cmH2O, without ARF, or PaO2/FiO2 > 100 and PRISM < 27. In patients with a mean PaO2/FiO2 < 100 during MV mortality increased to 26% (OR: 4.4; 95% CI 2.0 to 9.4). Patients with a PRISM score > 27 on admission to PICU had a mortality of 43% (OR: 9.6; 95% CI 4,2 to 25,8). Development of acute renal failure was associated with a mortality of 50% (OR: 12.7; 95% CI 6.3 to 25.7). Finally, the worst outcome (mortality 58%) was for patients with a mean PIP >/= 35 cmH2O (OR 17.3; 95% CI 8.5 to 36.3).

CONCLUSION

In a large cohort of mechanically ventilated pediatric patients we found that severity of illness at admission, high mean PIP, development of acute renal failure and severe hypoxemia over the course of MV were the factors associated with lower survival rate.

Prognosis in critical care

Prognostic risk prediction models have been employed in the intensive care unit (ICU) setting since the 1980s and provide health care providers with important information to help inform decisions related to treatment and prognosis, as well as to compare outcomes across institutions. Prognostic models for critical care are among the most widely utilized and tested predictive models in healthcare. In this article, we review and compare mortality prediction models, including the APACHE (1981), SAPS (1984), APACHE-II (1985), MPM (1987), APACHE-III (1991), SAPS-II (1993), and MPM-II (1993). We emphasize the importance of model calibration in this domain. In addition, we present a brief review of the statistical methodology, multiple logistic regression, which underlies most of the models currently used in critical care.

Procalcitonin for early prediction of survival outcome in postoperative critically ill patients with severe sepsis

BACKGROUND

Identification of postoperative patients at high risk of dying early after intensive care unit (ICU) admission through a fast and readily available parameter may help in determining therapeutic interventions or further diagnostic procedures that could have an impact on patients' outcome. The aim of our study was to assess the utility of procalcitonin (PCT) and other readily available parameters, as useful early (days 1-3) predictors of mortality in postoperative patients diagnosed with severe sepsis within 24 h preceding their operation.

METHODS

More than a period of 2 yr, subsets of 69 postoperative patients admitted with severe sepsis and 890 non-septic ICU patients were investigated. PCT, C-reactive protein (CRP) and sequential organ failure assessment (SOFA) score were recorded over the duration of ICU stay.

RESULTS

PCT area under receiver operating characteristic (ROC) curve was 0.78 on day 3 and was highly predictive of fatal outcome (0.90) at day 6. Area under ROC curve of SOFA score was 0.85 on day 3 and remained in this range until day 6. Area under ROC curves on day 3 of CRP (0.61) was non-predictive and remained non-predictive over the duration of ICU stay.

CONCLUSIONS

PCT exhibited no discriminative power early after ICU admission for prediction of mortality in critically ill patients with severe sepsis, compared with a high predictive power of SOFA score on day 3. However, using PCT could still serve as a useful complementary comparator for prediction of survival outcome using the SOFA score.

[Age and survival likelihood of polytrauma patients. "Local tailoring" of the DGU prognosis model]

INTRODUCTION

Age is one of five prognostic parameters identified based on data of the trauma registry of the German Association for Trauma Surgery (DGU). We asked ourselves if the suggested prognostic model provides the same predictive power of data from an independent hospital. Furthermore, we investigated whether age itself or age-associated comorbidity causes an unfavorable prognostic effect.

METHODS

The investigation was based on data of 103 multiply injured patients (67 male, 36 female, mean age 35,4+/-SD 19,0 years, ISS 36,8+/-10,9). Data were collected prospectively following the guidelines of the trauma registry of the German Association for Trauma Surgery. Based on documented comorbidities, a risk calculation was performed using the ASA classification. Correlation between age and ASA was analyzed using Spearman's method. The prognostic value of the original model in our patient pool with or without ASA classification, possible interactions, and the discriminatory power of the model were estimated using logistic regression.

RESULTS

Attributable mortality was 31,7% (95% CI 22,7-41,7%). Age, ISS, GCS and ASA were included into the final logistic model. Odds ratios of the origin model were reproducible nearly identical in our patinet pool (OR: age 1,048; ISS 1,066; GCS 0,822). In spite of the fact that we have found a strong correlation between age and ASA-Classification (rho=0,60, p<0,0001) there was no prognostic value of comorbidity.

CONCLUSION

The suggested prognostic model based on multicenter data evaluation can be applied to a single center with only minimal loss of discriminatory power. In this context, age seems to have a prognostic value independent of comorbidity.

Neuroanesthesia and Intensive Care Limited ability of SOFA and MOD scores to discriminate outcome: a prospective evaluation in 1,436 patients

PURPOSE

The multiple organ dysfunction (MOD) score and sequential organ failure assessment (SOFA) score are measures of organ dysfunction and have been validated based on the association of these scores with mortality. We sought to compare the performance of the SOFA and MOD scores in a large cohort of consecutive multisystem intensive care unit (ICU) patients.

METHODS

Prospective automated daily measurements of MOD and SOFA scores were performed in 1,436 patients admitted to a multisystem ICU in the Calgary Health Region over a one-year period. Logistic regression modeling techniques were used to describe the association of SOFA and MODS with mortality. Receiver operator characteristic (ROC) curves were used to assess the model's discriminatory ability.

RESULTS

For ICU and hospital mortality, there was very little practical difference between the SOFA and MOD scores in their ability to discriminate outcome as determined by the area under the ROC. However, compared to previous literature, the discriminatory ability of both scores in this population was weak. As well, the calibration of the models was poor for both scores. The SOFA cardiovascular component score performed better than the MOD cardiovascular component score in the discrimination of both ICU and hospital mortality.

CONCLUSIONS

SOFA and MOD scores had only a modest ability to discriminate between survivors and non-survivors. These results question the appropriateness of using organ dysfunction scores as a 'surrogate' for mortality in clinical trials and suggest further work is necessary to better understand the temporal relationship and course of organ failure with mortality.

Impact of a family information leaflet on effectiveness of information provided to family members of intensive care unit patients: a multicenter, prospective, randomized, controlled trial

Comprehension and satisfaction are relevant criteria for evaluating the effectiveness of information provided to family members of intensive care unit (ICU) patients. We performed a prospective randomized trial in 34 French ICUs to compare comprehension of diagnosis, prognosis, treatment, and satisfaction with information provided by ICU caregivers, in ICU patient family representatives who did (n = 87) or did not (n = 88) receive a family information leaflet (FIL) in addition to standard information. An FIL designed specifically for this study was delivered at the first visit of the family representative: it provided general information on the ICU and hospital, the name of the ICU physician caring for the patient, a diagram of a typical ICU room with the names of all the devices, and a glossary of 12 terms commonly used in ICUs. Characteristics of the ICUs, patients, and family representatives were similar in the two groups. The FIL reduced the proportion of family members with poor comprehension from 40.9% to 11.5% (p < 0.0001). In the representatives with good comprehension, the FIL was associated with significantly better satisfaction (21 [18 to 24, quartiles] versus 27 [24 to 29, quartiles], p = 0.01). These results indicate that ICU caregivers should consider using an FIL to improve the effectiveness of the information they impart to families.

Half the families of intensive care unit patients experience inadequate communication with physicians

OBJECTIVE

Effective communication of simple, clear information to families of intensive care unit (ICU) patients is a vital component of quality care. The purpose of this study was to identify factors associated with poor comprehension by family members of the status of ICU patients.

DESIGN

Prospective study.

SETTING

University-affiliated medical intensive care unit.

PATIENTS AND METHODS

A total of 102 patients admitted to an ICU for >2 days.

INTERVENTION

The representatives of 76 patients who were visited by at least one person during their ICU stay were interviewed.

RESULTS

Mean patient age was 54+/-17 yrs and mean Simplified Acute Physiology Score II at admission was 40+/-20. The representative was the spouse in 47 cases (62%). Among representatives, 25 (33%) were of foreign descent and 12 (16%) did not speak French. Mean duration of the first meeting with a physician was 10+/-6 mins. In 34 cases (54%), the representative failed to comprehend the diagnosis, prognosis, or treatment of the patient. Factors associated with poor comprehension by representatives included patient-related, family-related, and physician-related factors. Patient-related factors included age <50 yrs (p = .03), unemployment (p = .01), referral from a hematology or oncology ward (p = .006), admission for acute respiratory failure (p = .005) or coma (p = .01), and a relatively favorable prognosis (p = .04). Family-related factors were foreign descent (p = .007), no knowledge of French (p = .03), representative not the spouse (p = .03), and no healthcare professional in the family (p = .01). Physician-related factors were first meeting with representative <10 mins (p = .03) and failure to give the representative an information brochure (p = .02). Moreover, after the first meeting, caregivers accurately predicted poor comprehension by representatives (p = .03).

CONCLUSIONS

Patient information is frequently not communicated effectively to family members by ICU physicians. Physicians should strive to identify patients and families who require special attention and to determine how their personal style of interrelating with family members may impair communication.

Ethical decisions in perioperative elder care

Settings involving the extremes of age and illness are the most complex in ethical deliberation and require sound principles that can be clearly applied to individual situations. This article discusses how one's view of the aging process effects clinical decision making. The basic principles of medical ethics (autonomy, beneficence, nonmaleficence, and justice) are discussed along with alternative ethical paradigms that may be more appropriate to the elderly population. Issues such as informed consent, do not resuscitate orders in the operating room, and controversies in end-of-life palliative care specifically impact the role of the anesthesiologist. Anesthesiologists, as medical professionals in a health care team, have a great stake in ethical decision making and the ethics of health care policy.

Understanding articles describing clinical prediction tools. Evidence Based Medicine in Critical Care Group

OBJECTIVES

Clinical prediction rules and models are developed by applying statistical techniques to find combinations of predictors that categorize a heterogeneous group of patients into subgroups of risk. Our goal is to teach clinicians how to evaluate the validity, results, and applicability of articles describing clinical prediction tools. CLINICAL EXAMPLE: An article describing a rule to predict the need for intensive care unit care admission in patients presenting to the emergency room with chest pain.

RECOMMENDATIONS

Valid clinical prediction tools are developed by completely following up a representative group of patients, by evaluating all potential predictors and testing the independent contribution of each predictor variable, and by ensuring that the outcomes were independent of the predictors. To evaluate the results of an article describing a clinical prediction tool, clinicians need to know what the prediction tool is, how well it categorizes patients into different levels of risk, and what the confidence intervals are around the risk estimates. Valid prediction tools are not applicable in every patient population. Before patient care application, the clinician should ensure that the tool maintains its prediction power in a new sample of patients, that the patients are similar to patients used to test the tool, and that the tool has been shown to improve clinical decision-making.

CONCLUSIONS

There has been an increase in the development and validation of clinical prediction rules and models. It is important to evaluate the validity and reliability of these prediction tools before application.

Understanding articles comparing outcomes among intensive care units to rate quality of care. Evidence Based Medicine in Critical Care Group

OBJECTIVES

Comparisons of risk-adjusted outcomes among intensive care units (ICUs) is a relatively new but rapidly expanding area of ICU health services research. By investigating those factors that lead ICUs to have patient outcomes that differ from the average, the overall quality of care across ICUs may be improved. Our goal is to teach clinicians how to evaluate these types of articles. CLINICAL EXAMPLE: An article describing the development and application of an index used to assess the clinical performance and cost-effectiveness of 25 ICUs.

RECOMMENDATIONS

Valid comparisons of the outcomes among ICUs are made when: a) the outcome measures are accurate and comprehensive; b) the ICUs being compared serve similar patients; c) the sampling of patients is sufficient and unbiased; d) appropriate risk adjustment is undertaken by applying a valid model to reliably collected data; and e) the comparisons focus on care delivered in the ICU. To evaluate the results of the study, clinicians must evaluate how confident they are that the outcome differences being described are clinically important. Before changes in ICU policy are made based on these outcome differences, it is important to clarify which factors might have resulted in these extreme outcomes and whether these results are applicable in the ICU population that will see the impact of the changes.

CONCLUSION

The potential for misinterpretation of outcome performance ratings may decrease if articles describing outcome differences are evaluated, using the criteria outlined in this article.