Mortality, Functional Status, and Quality of Life after 5 Years of Patients Admitted to Critical Care for Spontaneous Intracerebral Hemorrhage

BACKGROUND

The objective of this study was to assess long-term outcome in patients with spontaneous intracerebral hemorrhage admitted to the intensive care unit.

METHODS

Mortality and Glasgow Outcome Scale, Barthel Index, and 5-level EQ-5D version (EQ-5D-5L) scores were analyzed in a multicenter cohort study of three Spanish hospitals (336 patients). Mortality was also analyzed in the Medical Information Mart for Intensive Care III (MIMIC-III) database.

RESULTS

The median (25th percentile-75th percentile) age was 62 (50-70) years, the median Glasgow Coma Score was 7 (4-11) points, and the median Acute Physiology and Chronic Health disease Classification System II (APACHE-II) score was 21 (15-26) points. Hospital mortality was 54.17%, mortality at 90 days was 56%, mortality at 1 year was 59.2%, and mortality at 5 years was 66.4%. In the Glasgow Outcome Scale, a normal or disabled self-sufficient situation was recorded in 21.5% of patients at 6 months, in 25.5% of patients after 1 year, and in 22.1% of patients after 5 years of follow-up (4.5% missing). The Barthel Index score of survivors improved over time: 50 (25-80) points at 6 months, 70 (35-95) points at 1 year, and 90 (40-100) points at 5 years (p < 0.001). Quality of life evaluated with the EQ-5D-5L at 1 year and 5 years indicated that greater than 50% of patients had no problems or slight problems in all items (mobility, self-care, usual activities, pain/discomfort, and anxiety/depression). In the MIMIC-III study (N = 1354), hospital mortality was 31.83% and was 40.5% at 90 days and 56.2% after 5 years.

CONCLUSIONS

In patients admitted to the intensive care unit with a diagnosis of nontraumatic intracerebral hemorrhage, hospital mortality up to 90 days after admission is very high. Between 90 days and 5 years after admission, mortality is not high. A large percentage of survivors presented a significant deficit in quality of life and functional status, although with progressive improvement over time. Five years after the hemorrhagic stroke, a survival of 30% was observed, with a good functional status seen in 20% of patients who had been admitted to the hospital.

High Incidence of Cataracts in the Follow-Up of Patients Undergoing Percutaneous Coronary Intervention for Chronic Coronary Total Occlusion

Development of cataracts is a well-known adverse effect of ionizing radiation, but little information is available on their incidence in patients after other medical procedures, such as cardiac catheterizations. The study objective was to determine the incidence of cataracts in a cohort of patients undergoing percutaneous coronary intervention (PCI) for chronic coronary total occlusion (CTO) and its association with radiation dose. The study analyzed the incidence of cataracts during the follow-up of 126 patients who underwent chronic total coronary PCI, using Cox regression to identify predictive factors of cataract development. The study included 126 patients, 86.9% male, with a mean age of 60.5 years (range, 55.0-68.0 years). Twenty-three (18.2% n = 23) developed cataracts during a mean follow-up of 49.5 months (range 37.3-64.5 months). A higher incidence was observed in patients who received more than 5 Gy (29.0% vs. 14.7%, Hazard ratio (HR = 2.84 [1.19-6.77]). Multivariate analysis revealed a relationship between cataract development during the follow-up and a receipt of radiation dose >5 Gy (HR = 2.60, 95% confidence interval [CI 1.03-6.61]; p = 0.03), presence or history of predisposing eye disease (HR = 4.42, CI:1.57-12.40), diabetes (HR = 3.33 [1.22-9.24]), and older age, as in >57 (HR, 6.40 [1.81-22.61]). An elevated incidence of cataracts was observed in patients after PCI for CTO. The onset of cataracts is related to the radiation dose during catheterization, which is a potentially avoidable effect of which operators should be aware.

Improvement of quality of life (QOL) between 1 and 3-4 years after traumatic brain injury (TBI) in ICU patients

BACKGROUND

Evaluation of changes in quality of life (QOL) in ICU patients several years after traumatic brain injury (TBI) is not well documented.

METHODS

A prospective cohort study was conducted in all patients with TBI admitted between 2004 and 2008 to the ICU of Regional Hospital of Malaga (Spain). Functional status was evaluated by Glasgow Outcome Scale (GOS) and QOL by PAECC (Project for the Epidemiologic Analysis of Critical Care patients) questionnaire between 0 (normal QOL) to 29 points (worst QOL).

RESULTS

A total of 531 patients. Median(Quartile1,Quartile 3) age: 35 (22, 56) years. After 3-4 years, 175 died (33%). Survivor QOL was deteriorated (median total PAECC score: 5 (0, 11) points) although 75.76% of patients who survived showed good functional situation (GOS normal or mild dysfunction). An improvement in QOL scores between 1 and 3-4 years was observed (median PAECC score differences between 3-4 years and 1 year: - 1(- 4, 0) points). QOL score improved during this interval of time: 62.6% of patients. Change in QOL was related by multivariate analysis to admission cranial-computed tomography scan (Marshall's classification), age, and Injury Severity Score (ISS), with the biggest improvement seen in younger patients and with more severe ISS. Basic physiological activities were maintained in the majority of patients. Subjective aspects and working activities improved between 1 and 3-4 years but with a high proportion still impaired in these items after 3-4 years.

CONCLUSIONS

ICU patients with TBI after 1 year show improvement in QOL between 1 and 3-4 years, with the biggest improvement in QOL seen in younger patients and in those with more severe ISS.

Validation of the ICH score in patients with spontaneous intracerebral haemorrhage admitted to the intensive care unit in Southern Spain

OBJECTIVE

Validation of the intracerebral haemorrhage (ICH) score in patients with a diagnosis of spontaneous ICH admitted to the intensive care unit (ICU).

METHODS

A multicentre cohort study was conducted in all consecutive patients with ICH admitted to the ICUs of three hospitals with a neurosurgery department between 2009 and 2012 in Andalusia, Spain. Data collected included ICH, Glasgow Coma Scale (GCS) and Acute Physiology and Chronic Health Evaluation II (APACHE-II) scores. Demographic data, location and volume of haematoma and 30-day mortality rate were also collated.

RESULTS

A total of 336 patients were included. 105 of whom underwent surgery. Median (IQR) age: 62 (50-70) years.

APACHE-II

21(15-26) points, GCS: 7 (4-11) points, ICH score: 2 (2-3) points. 11.1% presented with bilateral mydriasis on admission (mortality rate=100%). Intraventricular haemorrhage was observed in 58.9% of patients. In-hospital mortality was 54.17% while the APACHE-II predicted mortality was 57.22% with a standardised mortality ratio (SMR) of 0.95 (95% CI 0.81 to 1.09) and a Hosmer-Lemenshow test value (H) of 3.62 (no significant statistical difference, n.s.). 30-day mortality was 52.38% compared with the ICH score predicted mortality of 48.79%, SMR: 1.07 (95% CI 0.91 to 1.23), n.s. Mortality was higher than predicted at the lowest scores and lower than predicted in the more severe patients, (H=55.89, p<0.001), Gruppo Italiano per la Valutazione degli Interventi in Terapia Intensiva calibration belt (p<0.001). The area under a receiver operating characteristic (ROC) curve was 0.74 (95% CI 0.69 to 0.79).

CONCLUSIONS

ICH score shows an acceptable discrimination as a tool to predict mortality rates in patients with spontaneous ICH admitted to the ICU, but its calibration is suboptimal.

Soluble membrane receptors, interleukin 6, procalcitonin and C reactive protein as prognostic markers in patients with severe sepsis and septic shock

Background

The objective of this study was to explore the diagnostic and prognostic value of soluble triggering receptor expressed on myeloid cell 1 (sTREM-1), soluble cluster of differentiation 14 (sCD14), soluble cluster of differentiation 163 (sCD163), interleukin-6 (IL-6), procalcitonin (PCT), and C-reactive protein (CRP) serum levels for patients with severe sepsis and septic shock in an intensive care unit (ICU).

Methods

Fifty patients admitted at the ICU with the diagnosis of severe sepsis or septic shock were studied. SOFA and APACHE II scores as well as serum biomarkers were measured at days 0, 2 and 5. The influence of these variables on 28-day mortality was analyzed. Twenty healthy individuals served as controls.

Results

Baseline serum concentrations of sTREM-1, sCD163, IL-6 and PCT correlated with SOFA score. Only sTREM-1 levels correlated with APACHE II score. The 28-day mortality rate for all patients was 42%. The absence of risk factors for infection, presence of septic shock, baseline values of sCD14 and decrease of PCT and IL-6 from baseline to day 5 were variables associated to mortality in the univariate analysis. The unique independent factor associated to mortality in the multivariate analysis was a decrease of PCT higher than 50% from days 0 to 5.

Conclusions

Serum levels of sTREM-1 are correlated with the severity of sepsis. A 50% decrease of PCT was the unique variable associated with survival in the multivariate analysis.

Relationship between quality-of-life after 1-year follow-up and severity of traumatic brain injury assessed by computerized tomography

PURPOSE

This paper studies the relationship between computed tomography (CT) scan on admission, according to Marshall's tomographic classification, and quality-of-life (QoL) after 1 year in patients admitted to the Intensive Care Unit (ICU) with traumatic brain injury (TBI).

METHODS

This study used validated scales including the Glasgow Outcome Scale and the PAECC (Project for the Epidemiologic Analysis of Critical Care Patients) QoL questionnaire.

RESULTS

We enrolled 531 patients. After 1 year, 171 patients (32.2%) had died (missing data = 6.6%). Good recovery was seen in 22.7% of the patients, while 20% presented moderate disability. The PAECC score after 1 year was 9.43 ± 8.72 points (high deterioration). Patients with diffuse injury I had a mean of 5.08 points vs 7.82 in those with diffuse injury II, 11.76 in those with diffuse injury III and 19.29 in those with diffuse injury IV (p < 0.001). Multivariate analysis found that QoL after 1 year was associated with CT Marshall classification, depth of coma, age, length of stay, spinal injury and tracheostomy.

CONCLUSIONS

Patients with TBI had a high mortality rate 1 year after admission, deterioration in QoL and significant impairment of functional status, although more than 40% were normal or self-sufficient. QoL after 1 year was strongly related to cranial CT findings on admission.

Evaluation of prognostic scale Thrombolysis In Myocardial Infarction and Killip. An ST-elevation myocardial infarction new scale

BACKGROUND

Prognostic systems are complex. So it is necessary to find tools, which are easy to use and have good calibration and discrimination.

OBJECTIVES

The objective of this study is to evaluate the usefulness of Killip, Thrombolysis In Myocardial Infarction (TIMI), and age to develop a new prognostic scale for patients with ST-elevation myocardial infarction (STEMI).

METHODS

The study population included all patients with STEMI consecutively admitted to the Intensive Care Unit of Carlos Haya Hospital, Malaga, Spain. Top variables included are Killip and TIMI, hospital mortality, intensive care unit stay, treatment received, and care times intervals.

RESULTS

The results are 806 patients; 75.6% men; age 63.11 ± 12.83 years old; TIMI, 3.57 ± 2.38; Killip I, 81.4%; and hospital mortality, 11.3%. Mortality increased in relation to age, TIMI, and Killip (P < .001). Receiver operating characteristic (ROC) area for TIMI is 0.832 (0.786-0.878) and Killip, 0.757 (0.698-0.822). Thrombolysis In Myocardial Infarction classification was associated with Killip and age by multiple linear regression. Patients were stratified into 5 groups according to Killip and age: Killip I and younger than 65 years (n = 369; mortality, 1.4%; odds ratio [OR], 1), Killip I and 65 to 75 years old (n = 173; mortality, 6.9%; OR, 5.43 [1.88-15.66]), Killip I and older than 75 years (n = 112; mortality, 18.9%; OR, 13.03 [4.69-36.21]), Killip II to III (n = 129; mortality, 31%; OR, 22.72 [12.55-85.29]), Killip IV (n = 20; mortality, 80%; OR, 291.2 [71.32-1189]). ROC area is 0.84 (0.798-0.883). We created a scale with scores based on the β coefficient of logistical regression.

CONCLUSIONS

The TIMI scale discriminated hospital mortality correctly for STEMI. It performed better than Killip alone and similar to a simple model that included age and Killip. The 2-variable model consists of a simple scale with 5 categories.

Relationship between mortality and first-day events index from routinely gathered physiological variables in ICU patients

OBJECTIVE

To test the hypothesis that the degree and duration of alterations in physiological variables routinely gathered by intensive care unit (ICU) monitoring systems during the first day of admission to the ICU, together with a few additional routinely recorded data, yield information similar to that obtained by traditional mortality prediction systems.

DESIGN

A prospective observational multicenter study (EURICUS II) was carried out.

SETTING

Fifty-five European ICUs.

PATIENTS

A total of 17,598 consecutive patients admitted to the ICU over a 10-month period.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

Hourly data were manually gathered on alterations or "events" in systolic blood pressure, heart rate and oxygen saturation throughout ICU stay to construct an events index and mortality prediction models.

RESULTS

The mean first-day events index was 6.37±10.47 points, and was significantly associated to mortality (p<0.001), with a discrimination capacity for hospital mortality of 0.666 (area under the ROC curve). A second index included this first-day events index, age, pre-admission location, and the Glasgow coma score. A model constructed with this second index plus diagnosis upon admission was validated by using the Jackknife method (Hosmer-Lemeshow, H=13.8554, insignificant); the area under ROC curve was 0.818.

CONCLUSIONS

A prognostic index with performance very similar to that of habitual systems can be constructed from routine ICU data with only a few patient characteristics. These results may serve as a guide for the possible automated construction of ICU prognostic indexes.

[Prognostic capacity of brain herniation signs in patients with structural neurological injury]

OBJECTIVE

To determine whether the usual mortality prediction systems (APACHE and SAPS) can be complemented by cranial computed tomography (CT) brain herniation findings in patients with structural neurological involvement.

DESIGN

Prospective cohort study.

SETTING

Trauma ICU in university hospital.

PATIENTS

One hundred and fifty five patients admitted to ICU in 2003 with cranial trauma or acute stroke.

MAIN VARIABLES OF INTEREST

Data were collected on age, diagnosis, mortality, admission cranial CT findings and on APACHE II, APACHE III and SAPS II scores.

RESULTS

Mean age was 47.8 +/- 19.4 years; APACHE II, 17.1 +/- 7.2 points; SAPS II, 43.7 +/- 17.7 points; and APACHE III, 55.8 +/- 29.7 points. Hospital mortality was 36% and mortality predicted by SAPS II was 38%, by APACHE II 30% and by APACHE III 36%. The 56 non-survivors showed greater midline shift on cranial CT scan versus survivors (4.2 +/- 5.5 vs. 1.6 +/- 3.22 mm, p = 0.002) and higher severity as assessed by SAPS II, APACHE II and APACHE III. The mortality rate was significantly higher in patients with subfalcial herniation (61% vs. 30%, p < 0.001). In the multivariate logistic regression analysis, hospital mortality was associated with the likelihood of death according to APACHE III (OR 1.07; 95% CI: 1.05-1.09) and with presence of subfalcial herniation (OR 3.15; 95% CI: 1.07-9.25).

CONCLUSIONS

In critical care patients with structural neurological involvement, cranial CT signs of subfalcial herniation complement the prognostic information given by the usual severity indexes.

Critical care medicine in the hospital: lessons from the EURICUS-studies

We have performed a retrospective analysis of the EURICUS-studies using their database at the Foundation for Research on Intensive Care in Europe (FRICE) and other related documents, among which the various reports produced to the European Union which granted the studies, with the following purposes: a) to select and describe the most relevant observational and experimental results of the EURICUS studies; b) to inventory the main obstacles to the appropriate organization of intensive care medicine in the Hospital and c) to highlight amid the acquired knowledge those subjects which could have a direct and primary impact for improving the organization and management of intensive care units (ICUs). The EURICUS-studies have shown a rather non-systematic variation on the variables of the organization and management, resulting in a significant waste of resources and in a generally perceived insufficient performance of ICUs in Europe. Three major roadblocks were found: a) the lack of a clear concept of Critical Care Medicine; b) the lack of defined objectives both regarding the planning of the facilities and the activities to be developed in the ICU and c) the lack of a purposeful organization and management of work in the ICU. The further development and integration of each ICU in the Hospital should consider the following: a) the system approach to the analysis and standardization of processes of care; b) the redefinition of all jobs in each ICU; c) the definition of patient/nurse ratios in each ICU and sibling departments and d) to professionalize the organization and management of the ICU.

Analysis of physiologic alterations in intensive care unit patients and their relationship with mortality

PURPOSE

To analyze patient physiologic alterations (events) and multiple organ failure during intensive care unit (ICU) stay and examine their relationship with ICU mortality.

MATERIAL AND METHODS

A total of 17598 consecutive patients were studied for 10 months (1997-1998) in 55 European ICUs (EURICUS-II). Hourly data were collected on critical and noncritical systolic blood pressure, heart rate, oxygen saturation, and urinary events throughout ICU stay. Sepsis-related Organ Failure Assessment (SOFA) score was collected daily (6409 patients).

RESULTS

SAPS-II was 31.2 +/- 18.4 and ICU mortality 13.9%. There were 3.4 +/- 9.2 noncritical (duration, 3.9 +/- 11.4 hours) and 2 +/- 7.5 critical (3.8 +/- 13.1 hours) systolic blood pressure events per patient. Heart rate, oxygen saturation, and urinary events had similar values. Nonsurvivors had significantly more and longer physiologic alterations vs survivors. Mortality was significantly related to mean daily duration of events and mean and maximum daily SOFA. Discrimination capacity to predict ICU mortality was measured using various models: with SAPS II, area under the receiver operating characteristic curve was 0.80; with APACHE III-classified diagnosis added, 0.84; with mean duration of events/ICU day, 0.91; and with mean and maximum SOFA scores, 0.95.

CONCLUSION

Routinely gathered ICU data on physiologic variables and multiple organ failure can offer considerable complementary information not provided by usual mortality prediction systems; and their weight in daily care policy decisions may need to be revisited.

Early markers of acute respiratory distress syndrome development in severe trauma patients

PURPOSE

The aim of the study was to identify early risk factors for development of acute respiratory distress syndrome (ARDS) in severe trauma patients.

MATERIALS AND METHODS

This was a prospective observational study of 693 severe trauma patients (Injury Severity Score >or=16 and/or Revised Trauma Score <or=11) in 17 hospitals in a Spanish region of 8 million inhabitants from July 2002 to December 2002.

RESULTS

Acute respiratory distress syndrome developed in 6.9% of patients who were more severely ill with higher APACHE II (P < .001) and Injury Severity Score (P = .002) scores vs patients not developing ARDS. Acute respiratory distress syndrome development was associated (P < .001) with fractures of femur (International Classification of Diseases, Ninth Revision [ICD-9] codes 820, 821), tibia (ICD-9 code 823), humerus, and pelvis, with a number (>or=2) of long bone fractures, and with chest injuries (rib/sternal fracture [ICD-9 code 807] and hemo/pneumothorax [ICD-9 code 860/861]). Patients with ARDS required more colloids (P = .005) and red blood cell units (P = .02) than patients without ARDS during the first 24 hours. Multivariate analysis showed that ARDS was related to chest trauma diagnosis (ICD-9 code 807) (odds ratio [OR], 3.85), femoral fracture (OR, 3.16), APACHE II score (OR, 1.05), and blood transfusion during resuscitation (OR, 1.32).

CONCLUSIONS

Risk of ARDS development is related to the first 24-hour admission variables, including severe physiologic derangements and specific ICD-9-classified injuries. Blood transfusion may play an independent role.

Six-year mortality and quality of life in critically ill patients with chronic obstructive pulmonary disease

OBJECTIVE

To study the mortality and quality of life (QOL) of survivors at 6 yrs after intensive care unit (ICU) admission for chronic obstructive pulmonary disease.

DESIGN

Prospective, multiple-center cohort study.

SETTING

A total of 86 ICUs throughout Spain.

PATIENTS

Patients in the Project for the Epidemiological Analysis of Critical Care Patients (PAEEC) project with chronic obstructive pulmonary disease were included.

MEASUREMENTS AND MAIN RESULTS

The sample comprised 742 patients; 508 of them were admitted for acute exacerbation of chronic obstructive pulmonary disease, and 379 of these required intermittent positive-pressure ventilation. The mean age of the patients was 65.2 +/- 9.89 yrs, Acute Physiology and Chronic Health Evaluation (APACHE) III score was 66.6 +/- 21.04; preadmission QOL questionnaire score was 7 +/- 4.82 points, and hospital mortality was 31.8%. At 6 yrs, 32.2% had died after hospital discharge, 21.6% could not be traced, and 107 patients were alive (18.3% of the 582 followed-up patients). QOL of survivors was worse than preadmission (6.55 +/- 5.6 vs. 4.92 +/- 4.5 points, p < .05), but 72% of patients were self-sufficient. Among the 379 patients admitted to the ICU for acute chronic obstructive pulmonary disease exacerbation and requiring intermittent positive-pressure ventilation, 36.7% died in the hospital; at 6 yrs after hospital discharge, 31.4% had died, 18.7% could not be traced, and 50 patients (16.2% of followed-up patients) were alive. Multivariate analysis with logistic regression showed that the mortality at 6 yrs was related to age (odds ratio, 1.046; 95% confidence interval, 1.023-1.071), APACHE III score (odds ratio, 1.013; 95% confidence interval, 1.001-1.024), and preadmission QOL score (odds ratio, 1.139; 95% confidence interval, 1.078-1.204).

CONCLUSION

The 6-yr mortality of patients with chronic obstructive pulmonary disease requiring ICU admission is high. Mortality is mainly influenced by pre-ICU admission QOL. At 6 yrs, at least 15% are alive; survivors have a worse QOL compared with pre-ICU admission, although three quarters of them are self-sufficient.

Small increases in extravascular lung water are accurately detected by transpulmonary thermodilution

BACKGROUND

Detection of small (10-20%) increases in lung water may be relevant to detect incipient pulmonary edema but no clinically usable method has demonstrated this capability to date.

METHODS

In six pigs weighing 28 to 35 kg, we performed 18 determinations of extravascular lung water (EVLW; transpulmonary thermodilution method) before and immediately after the intratracheal introduction of 50 mL of saline solution. Six determinations were performed in normal lung and 12 in edematous lung.

RESULTS

In normal lung, the mean of EVLW increased from 245 +/- 18 mL to 288 +/- 19 mL (p < 0.001) after the intratracheal introduction of 50 mL of saline solution; therefore, 43 of the 50 mL (84%) were detected (range, 37-48 mL). In edematous lung, the EVLW increased from 491 +/- 106 mL to 530 +/- 108 mL after the introduction of 50 mL of saline solution; therefore, 39 of the 50 mL (77%) were detected (range, 15-67 mL).

CONCLUSION

The transpulmonary thermodilution technique accurately detects small increases in extravascular lung water and may permit accurate diagnosis of incipient pulmonary edema.

Quantification of lung water by transpulmonary thermodilution in normal and edematous lung

PURPOSE

To analyze the accuracy of the transpulmonary thermodilution method in the determination of extravascular lung water (EVLW).

MATERIAL AND METHODS

Acute lung injury was produced in eight adolescent pigs weighing 28 to 35 kg by bronchoalveolar lung lavage. EVLW was measured by transpulmonary thermodilution method before and after the intratracheal introduction of 250 or 500 mL of saline solution in different lung injury conditions. No corrections for anatomic dead space were made.

RESULTS

When 250 mL was introduced, 195 +/- 17 mL was detected in normal (uninjured) lungs versus 74 +/- 57 mL in edematous (injured) lungs (P <.05). When 500 mL was introduced, 343 +/- 67 mL was detected in normal lungs versus 160 +/- 51 mL in edematous lungs (P <.001). Considering all determinations together, there was a very high negative correlation between the baseline EVLW and the percentage of EVLW detected (r = -0.92, P <.001).

CONCLUSION

The transpulmonary thermodilution method is very accurate to detect changes in EVLW in normal lungs. In edematous lung, this method may underestimate the EVLW.

Outcome prediction in terms of functional disability and mortality at 1 year among ICU-admitted severe stroke patients: a prospective epidemiological study in the south of the European Union (Evascan Project, Andalusia, Spain)

OBJECTIVES

To analyse 1-year mortality and functional disability outcomes and resource use in critical stroke patients admitted to ICU.

DESIGN AND SETTING

Multi-centre, prospective, observational study in 28 Spanish hospitals. PATIENTS. Patients admitted for acute stroke from March-August 1999.

INTERVENTION

Collection of data on: severity by Apache III and Glasgow Coma Score; neurological lesion, hospital and 1-year mortality; functional disability at 1 year by Barthel Index and Glasgow Outcome Scale; ICU length of stay, life support techniques, and neurosurgical interventions.

MEASUREMENT AND RESULTS

We studied 132 patients: 21% with subarachnoid haemorrhage (SAH), 58% intracerebral haemorrhage (ICH), 20% ischaemic stroke (ISC); Apache III 63+/-29 ICU stay 13+/-12 days; 74% required mechanical ventilation. Hospital and 1-year mortality was 33% (22%:ISC, 32%:SAH, 37%:ICH) and 53.8% (66%:ISC, 39%:SAH, 54%:ICH), respectively. Age, APACHE III, and diagnosis defined hospital mortality. Age, APACHE III, and Glasgow Coma Score defined 1-year mortality. Barthel Index score improved ( P<0.001) between discharge and 1 year; 73% of patients presented severe disability at discharge vs. 26% at 1 year; 8% minimal/no disability at discharge vs. 43.3% at 1 year. Only 17% of subarachnoid haemorrhage patients presented severe disability at 1 year. Admission Apache III and hospital-discharge Barthel Index scores were related to functional outcome at 1 year.

CONCLUSIONS

Critical stroke patients are characterized by high severity of illness, elevated resource consumption, and poor outcomes that are mainly influenced by severity and age. Glasgow Coma Score-measured neurological severity is the main determinant of future functional capacity, which is greater at 1 year.

Quality of life before intensive care unit admission and its influence on resource utilization and mortality rate

OBJECTIVE

To analyze the quality of life of critically ill patients before their intensive care admission and its relation to age, variables measured in the intensive care unit (ICU; severity of illness, therapeutic effort, resource utilization, and length of stay), and in-hospital mortality rate.

DESIGN

Observational prospective multicenter study.

SETTING

Eighty-six medical-surgical ICUs in Spain, including coronary patients.

PATIENTS

We studied 8,685 patients between 1992 and 1993. Patients <16 yrs old and those dying within the first 6 hrs were excluded.

MEASUREMENTS AND MAIN RESULTS

Data collection included age, gender, admission diagnosis, severity level by Acute Physiology and Chronic Health Evaluation (APACHE) III, quality of life survey score, therapeutic activity level by Therapeutic Intervention Scoring System (TISS), and ICU and hospital mortality rate. Pre-ICU quality-of-life score was 3.74 +/- 4.42 points; 33.24% of patients had a normal quality of life (0 points), and numbers of patients declined logarithmically in relationship to increasing quality-of-life scores, with only 189 patients having a score >15 points. Pre-ICU quality-of-life score correlated with age (r =.289, p <.001), with severity level by APACHE III score (r =.217, p <.001), and weakly with TISS (r =.067, p <.001). There was no correlation between quality of life and length of ICU stay. Patients dying in hospital after ICU discharge (n = 429) had worse quality of life (5.88 +/- 5.38 points) than those dying in the ICU (n = 1,453, 4.8 +/- 4.94), who themselves had a worse quality of life than hospital survivors (n = 6,803, 5.05 +/- 5.07; p <.0001 by analysis of variance), with significant differences between all three groups. In the multivariate analysis, pre-ICU quality-of-life was related to age, APACHE III score, and hospital mortality rate but not to TISS or ICU length of stay. Pre-ICU quality of life was introduced as a variable in the APACHE III prediction model and entered the model after acute physiology score, diagnosis, and age and before prior patient location and comorbidities. The area under the receiver operating characteristics curve was 0.834 when quality-of-life was included and 0.83 when not.

CONCLUSIONS

In Spain, the quality of life of critically ill patients before their ICU admission is good, and only a small proportion of patients have a low quality of life before admission. Previous quality of life is related to hospital mortality rate but contributes very little to the discriminatory ability of the APACHE III prediction model and has little influence on ICU resource utilization as measured by length of stay and therapeutic activity.

Acute respiratory distress syndrome in trauma patients: ICU mortality and prediction factors

OBJECTIVES

To study the factors that influence the intensive care unit (ICU) mortality of trauma patients who develop acute respiratory distress syndrome (ARDS) and to evaluate determinants of length of ICU stay among these patients.

DESIGN

Study on a prospective cohort of 59 trauma patients that developed ARDS.

SETTING

ICU of a referral trauma center. Fifty-nine patients were included during the study period from 1994 to 1997.

METHODS

The dependent variables studied were the mortality and length of ICU stay. The main independent variables studied included the general severity score APACHE III, the revised trauma and injury severity scores (RTS, ISS), emergency treatment measures, the gas exchange index (PaO2/FIO2) recorded after the onset of ARDS and the development of multiple system organ failure (MSOF). Univariate and multivariate analyses were performed.

RESULTS

The mean age of patients was 42.1 +/- 16.7 years, 49 patients (83 %) were male, the mean APACHE III score was 52.7 +/- 33.7 points, the ISS 28.5 +/- 11.4 points and the RTS 8.9 +/- 2.5 points. ICU length of stay was 28.5 +/- 24.5 days and the mortality rate 31.7 % (19 deaths). Mortality was associated with the following: PaO2/FIO2 ratio on the 3rd, 5th and 7th days post-ARDS; high volume of crystalloid/colloid infusion during resuscitation; the APACHE III score; and the development of MSOF According to the multivariate analysis, the mortality of these patients was correlated with the PaO2/FIO2 ratio on the 3rd day of ARDS, the APACHE III score and the development of MSOF. This analysis also showed days on mechanical ventilation to be the only variable that predicted ICU length of stay.

CONCLUSIONS

The ICU mortality of trauma patients with ARDS is related to the APACHE III score, the gas exchange evolution as measured by the PaO2/FIO2 on the 3rd day and the progressive complications indicated by the onset of MSOF. The length of ICU stay of these patients is related to the number of days on mechanical ventilation.

Immediate application of positive-end expiratory pressure is more effective than delayed positive-end expiratory pressure to reduce extravascular lung water

OBJECTIVE

To determine by the measurement of extravascular lung water (EVLW) whether the timing of positive-end expiratory pressure (PEEP) application influences the intensity of lung injury.

DESIGN

Animal experimental study.

SETTING

Animal experimental laboratory.

SUBJECTS

Mixed-breed pigs (n = 18), aged 4 to 5 mos, weighing 25 to 30 kg.

INTERVENTIONS

The animals were anesthetized and tracheotomized, after which a permeability pulmonary edema was instigated by infusing oleic acid (0.1/kg) into the central vein. All animals were then randomly divided into three groups. In group 1 (n = 5), 10 cm H2O of PEEP was applied immediately after the oleic acid infusion and maintained throughout the 6 hrs of the experiment. Group 2 (n = 7) received the same level of PEEP 120 mins after the insult for 4 hrs. Group 3 (n = 6), the control group, was ventilated without PEEP for the six hrs of the experiment.

MEASUREMENTS AND MAIN RESULTS

At the end of the experiment, EVLW was calculated by gravimetric method. EVLW in group 1 (11.46+/-2.00 mL/kg) was significantly less than in group 2 (19.12+/-2.62 mL/kg) and group 3 (25.81+/-1.57 mL/kg), (p<.0001). Oxygenation also showed important differences by the end of the experiment when the Pao2/Fio2 ratio was significantly better in group 1 (467+/-73) than in group 2 (180+/-82) and group 3 (39+/-9), (p<.0001).

CONCLUSIONS

The application of 10 cm H2O of PEEP reduces EVLW in a time-dependent manner and maximum protective effect is achieved if it is applied immediately after lung injury production.

The Apache III prognostic system: customized mortality predictions for Spanish ICU patients

OBJECTIVE

To customize the Acute Physiology and Chronic Health Evaluation (APACHE) III mortality equation for Spanish admissions to the intensive care unit (ICU) and evaluate its discrimination and calibration.

DESIGN

Prospective multicenter inception cohort study.

SETTING

86 ICUs located in all regions of Spain.

PATIENTS

10,929 adult patients selected by a systematic sampling method. All types of critical care patients were included, including coronary bypass patients, but excluding those with burn injury, those admitted for pacemaker implants, patients under 16 years of age, and patients with length of ICU stay < 6 h.

MEASUREMENTS AND RESULTS

Data collection in the first 24 h after patient admission included: APACHE III score, treatment location prior to ICU admission, and main ICU admission diagnosis. Using these variables, a model for predicting hospital mortality was constructed, adapted to Spain, and its discriminating ability was assessed by the area below the ROC curve, which was 0.83. The model was validated using the jacknife method and the area below the receiver operating characteristic (ROC) curve for the cross-validated predictions was 0.82. The percentage of patients correctly classified at 0.50 risk of death was 82.3%. Model calibration was evaluated by analysis of the agreement between the observed and cross-validated predicted mortality using the Hosmer-Lemeshow test, which gave a value of (H) 12.27, with no statistical significance, i.e., good calibration.

CONCLUSIONS

We have customized the APACHE III mortality prediction system for the Spanish population. This adapted model has demonstrated the requisite validation, calibration, and discrimination for its use among Spanish critical care patients.

Limitation of therapeutic activity in elderly critically ill patients. Project for the Epidemiological Analysis of Critical Care Patients

OBJECTIVE

To establish whether the age of patients admitted into the intensive care unit (ICU) influences the amount of therapy received.

DESIGN

Observational, prospective, multicenter study.

SETTING

Eighty-six multidisciplinary ICUs in Spain, including coronary patients.

PATIENTS

The patients (n = 8,838) were studied during a 6-month period between 1992 and 1993. Patients < 16 yrs of age and patients dying within the first 6 hrs were excluded from the study.

MEASUREMENTS AND MAIN RESULTS

We collected data on age, gender, type of diagnosis at the time of admission, severity level by Acute Physiology and Chronic Health Evaluation (APACHE) II and III, quality of life survey score, therapeutic activity during the first 24 hrs by Therapeutic Intervention Scoring System, and ICU and hospital mortality rates. In the sample of patients, 12.5% were > 75 yrs of age. Compared with younger patients, these patients had higher APACHE II (18.41 +/- 0.23 vs. 15.14 +/- 0.09 points, p < .001) and APACHE III (65.8 +/- 0.81 vs. 53.32 +/- 0.33 points, p < .001) scores, a higher quality of life survey score (i.e., worse quality of life, 7.19 +/- 0.19 vs. 3.86 +/- 0.05 points, p < .001), and a greater ICU mortality rate (21.9% vs. 15.3%, p < .00001) and hospital mortality rate (30.8% vs. 19.3%, p < .00001). However, patients > 75 yrs had a lower Therapeutic Intervention Scoring System score (19.83 +/- 0.28 vs. 21.17 +/- 0.12 points, p < .001). Multivariate analysis showed that once severity, need for mechanical ventilation, diagnostic group, and mortality rate were taken into account, there was less therapeutic activity in patients > 75 yrs of age.

CONCLUSIONS

Patients > 75 yrs of age represent a large proportion of patients in Spanish ICUs. Although their mortality rate and severity scores were higher than those values in younger patients, patients > 75 yrs of age received less therapy.

PEEP and low tidal volume ventilation reduce lung water in porcine pulmonary edema

This study analyzed the effect of both positive end-expiratory pressure (PEEP) and reduction in tidal volume (VT) on extravascular lung water (EVLW) in a permeability model of pulmonary edema. Immediately after producing a pulmonary edema with oleic acid, 21 pigs were randomized into three groups. Group I (n = 8): PEEP of 0 cm H2O (ZEEP), VT of 12 ml/kg; Group II (n = 6): PEEP of 10 cm H2O, VT of 12 ml/kg; Group III (n = 7): PEEP of 10 cm H2O, VT of 6 ml/kg. EVLW was measured by the double indicator method (DI) at baseline (time 0) and after 30, 60, 120, 180, and 240 min and by the gravimetric method (G) at 240 min. Both methods correlated excellently (r = 0.94, p < 0.0001). EVLW-DI was significantly less with PEEP application (Group II versus Group I) at 180 min and thereafter. Likewise, EVLW-DI was less throughout the experimental period with reduced VT once PEEP was applied (Group III versus Group II). EVLW-G was less in Group II than in Group I at 16.3 +/- 2.7 and 23.2 +/- 4.2 ml/kg, respectively (p < 0.0001), and less in Group III than in Group II at 10.7 +/- 0.9 and 16.3 +/- 2.7 ml/kg (p < 0.0001). We conclude that early application of 10 cm H2O of PEEP reduces EVLW in permeability pulmonary edema. The lowering of VT reduced EVLW even further.