Acute Physiology, Age, And Chronic Health Evaluation Research Articles

An interpretable machine learning model to predict off-pump coronary artery bypass grafting-associated acute kidney injury.

Off-pump coronary artery bypass grafting-associated acute kidney injury (OPCAB-AKI) is related to 30-day perioperative mortality. Existing mathematical models cannot be applied to help clinicians make early diagnosis and intervention decisions. This study used an interpretable machine learning method to establish and screen an optimized OPCAB-AKI prediction model. Clinical data of 1110 patients who underwent OPCAB in the Department of Cardiac Surgery of General Hospital of Northern Theater Command (Shenyang, China) from January 2018 to December 2020 were collected retrospectively. Four machine learning models were used, including logistic regression (LR), decision tree (DT), random forest (RF), and eXtreme Gradient Boosting (XGBoost). The SHapley Additive exPlanation (SHAP) tool was used for explanatory analysis of the black-box model. The mean absolute value of the characteristic SHAP parameter was defined and sorted. The correlation between the characteristic parameters and OPCAB-AKI was determined based on the SHAP value. A quantitative analysis of a single characteristic and an interaction analysis of multiple characteristics were carried out for the main risk factors. The RF prediction model had the best performance, with an area under the curve (AUC) of 0.90, a precision rate of 0.80, an accuracy rate of 0.83, a recall rate of 0.74, and an F1 score of 0.78 for positive samples. The interpretation analysis of the SHAP model results showed that intraoperative urine volume contributed to the greatest extent to the RF model, and other parameters included intraoperative sufentanil dosage, intraoperative dexmedetomidine dosage, cyclic variation coefficient during the induction period, intraoperative hypotension duration, age, preoperative baseline serum creatinine, body mass index (BMI), and Acute Physiology, Age and Chronic Health Evaluation (APACHE) II score. The model constructed by the RF ensemble learning algorithm predicted OPCAB-AKI, and indicators such as intraoperative urine volume were closely related to OPCAB-AKI.

A comparison of bilateral and unilateral cerebral perfusion for total arch replacement surgery for non-marfan, type A aortic dissection.

Acknowledging lacking of consensus exist in total aortic arch (TAA) surgery for acute type A aortic dissection (AAD), this study aimed to investigate the neurologic injury rate between bilateral and unilateral cerebrum perfusion on the specific population. A total of 595 AAD patients other than Marfan syndrome receiving TAA surgery since March 2013 to March 2022 were included. Among them, 276 received unilateral cerebral perfusion (via right axillary artery, RCP) and 319 for bilateral cerebral perfusion (BCP). The primary outcome was neurologic injury rate. Secondary outcomes were 30-day mortality, serum inflammation response (high sensitivity C reaction protein, hs-CRP; Interleukin-6, IL-6; cold-inducible RNA binding protein, CIRBP) and neuroprotection (RNA-binding motif 3, RBM3) indexes. The BCP group reported a significantly lower permanent neurologic deficits [odds ratio: 0.481, Confidence interval (CI): 0.296-0.782, p = 0.003] and 30-day mortality (odds ratio: 0.353, CI: 0.194-0.640, p < 0.001) than those received RCP treatment. There were also lower inflammation cytokines (hr-CRP: 114 ± 17 vs. 101 ± 16mg/L; IL-6: 130 [103,170] vs. 81 [69,99] pg/ml; CIRBP: 1076 [889, 1296] vs. 854 [774, 991] pg/ml, all p < 0.001), but a higher neuroprotective cytokine (RBM3: 4381 ± 1362 vs 2445 ± 1008pg/mL, p < 0.001) at 24h after procedure in BCP group. Meanwhile, BCP resulted in a significantly lower Acute Physiology, Age and Chronic Health Evaluation (APACHE) Ⅱscore (18 ± 6 vs 17 ± 6, p < 0.001) and short stay in intensive care unit (4 [3,5] vs. 3 [2,3] days, p < 0.001) and hospital (16 ± 4 vs 14 ± 3days, p < 0.001). This present study indicated that BCP compared with RCP was associated with lower permanent neurologic deficits and 30-day mortality in AAD patients other than Marfan syndrome receiving TAA surgery.

Role of Acute Physiology, Age, and Chronic Health Evaluation (APACHE) II Score in Predicting Outcomes of Peritonitis Due to Hollow Viscous Perforation: A Prospective Observational Study.

BackgroundThe Acute Physiology and Chronic Health Evaluation II (APACHE II) is the most commonly used severity-of-disease scoring system in ICUs worldwide. There is a paucity of data describing the role of APACHE II score in predicting outcomes of peritonitis due to hollow viscous perforation. This study aims at identifying the importance of the APACHE II score in predicting outcomes of patients with peritonitis secondary to hollow viscus perforation.MethodsThe study is a prospective, observational study that included all the patients diagnosed with perforation peritonitis who underwent emergency laparotomy and were admitted to the Department of Surgery from May 2017 to May 2018. APACHE II scores were assigned to all patients in order to calculate their individual risk of mortality before undergoing emergency surgery. The accuracy in outcome prediction of the APACHE II system was assessed by means of receiver operating characteristic (ROC) curve and Pearson correlation coefficient and its significance test.ResultA total of 50 patients with perforation peritonitis were included in this study. Peptic ulcer disease was the major etiology leading to perforation in 54% of patients, followed by gangrenous bowel. The mean APACHE II score was 9.54. Out of the 50 patients, seven patients succumbed to the illness. All the seven patients whose APACHE II score > 16 developed systemic complications, and three of them developed a local complication.ConclusionAPACHE II score correlated well with the outcome in the current study, and APACHE II score also correlated well with the hospital and ICU stay.

Role of Scoring Systems Calculation in Predicting Extracorporeal Life Support Patients’ Outcomes: A Single Centre Experience

Purpose To investigate the predictive value of Acute Physiology, Age and Chronic Health Evaluation (APACHE) II, Simplified Acute Physiology (SAPS) II and Sequential Organ Failure Assessment (SOFA) scores for patient selection and timing to Extracorporeal Life Support (ECLS) as treatment of refractory cardiogenic shock. Methods Retrospective analysis of a prospectively-maintained operative dataset. Results Our study population included 185 patients receiving ECLS at our department between 2006 and 2018. Patient median age was 50.6 years; 62% were male. The most frequent reason for ECLS need, in our subset of patients, was post-cardiotomy syndrome (52.4%) followed by acute decompensation of chronic heart failure (17.5%), isolated right ventricular dysfunction (16.2%), acute myocardial infarction (10.2%) and myocarditis (3.7%). Median duration of ECLS was 8.9 days. Forty-one patients (22.2%) received heart transplantation. In-hospital mortality was 34.6% on ECLS running and 25.9% after ECLS removal. Multivariate regression analysis showed patient age, ECLS duration and bridge to transplantation (BTT) category as indipendent predictors of death (p Conclusion This study confirms the poor prognosis of critically ill patients receiving ECLS support. The APACHE II and SOFA scores, mainly, proved to be a reproducible evaluation tool with high prognostic abilities. In our population, age >65 years, ECLS duration >10 days and BTT ECLS intention appear to impact negatively.

The predictive validity for mortality of the driving pressure and the mechanical power of ventilation

BackgroundOutcome prediction in critically ill patients under invasive ventilation remains extremely challenging. The driving pressure (ΔP) and the mechanical power of ventilation (MP) are associated with patient-centered outcomes like mortality and duration of ventilation. The objective of this study was to assess the predictive validity for mortality of the ΔP and the MP at 24 h after start of invasive ventilation.MethodsThis is a post hoc analysis of an observational study in intensive care unit patients, restricted to critically ill patients receiving invasive ventilation for at least 24 h. The two exposures of interest were the modified ΔP and the MP at 24 h after start of invasive ventilation. The primary outcome was 90-day mortality; secondary outcomes were ICU and hospital mortality. The predictive validity was measured as incremental 90-day mortality beyond that predicted by the Acute Physiology, Age and Chronic Health Evaluation (APACHE) IV score and the Simplified Acute Physiology Score (SAPS) II.ResultsThe analysis included 839 patients with a 90-day mortality of 42%. The median modified ΔP at 24 h was 15 [interquartile range 12 to 19] cm H2O; the median MP at 24 h was 206 [interquartile range 145 to 298] 10−3 J/min/kg predicted body weight (PBW). Both parameters were associated with 90-day mortality (odds ratio (OR) for 1 cm H2O increase in the modified ΔP, 1.05 [95% confidence interval (CI) 1.03 to 1.08]; P < 0.001; OR for 100 10−3 J/min/kg PBW increase in the MP, 1.20 [95% CI 1.09 to 1.33]; P < 0.001). Area under the ROC for 90-day mortality of the modified ΔP and the MP were 0.70 [95% CI 0.66 to 0.74] and 0.69 [95% CI 0.65 to 0.73], which was neither different from that of the APACHE IV score nor that of the SAPS II.ConclusionsIn adult patients under invasive ventilation, the modified ΔP and the MP at 24 h are associated with 90 day mortality. Neither the modified ΔP nor the MP at 24 h has predictive validity beyond the APACHE IV score and the SAPS II.

Early prediction of in-hospital mortality in acute pancreatitis: a retrospective observational cohort study based on a large multicentre critical care database

ObjectiveTo develop and validate a prediction model for predicting in-hospital mortality in patients with acute pancreatitis (AP).DesignA retrospective observational cohort study based on a large multicentre critical care database.SettingAll subject...

Aminoglycoside Dosing and Volume of Distribution in Critically Ill Surgery Patients.

Background: At a tertiary referral and Level I trauma center, current institutional guidelines suggest initial aminoglycoside doses of gentamicin or tobramycin 4 mg/kg and amikacin 16 mg/kg for patients admitted to surgical intensive care units (SICUs) with suspected gram-negative infection. The objective of this study was to evaluate initial aminoglycoside dosing and peak serum drug concentrations in critically ill surgery patients to characterize the aminoglycoside volume of distribution (Vd) and determine an optimal standardized dosing strategy. Methods: This retrospective, observational, single-center study included adult SICU patients who received an aminoglycoside for additional gram-negative coverage. Descriptive statistics were used to evaluate the patient population, aminoglycoside dosing, and Vd. Multivariable linear regression was applied to determine variables associated with greater aminoglycoside Vd. The mortality rate was compared in patients who achieved adequate initial peak concentrations versus those who did not. Results: One hundred seventeen patients received an aminoglycoside in the SICUs, of whom 58 had an appropriately timed peak concentration measurement. The mean Acute Physiology, Age, and Chronic Health Evaluation (APACHE) II score was 27.8 ± 8.9. The Vd in patients receiving gentamicin, tobramycin, and amikacin was 0.49 ± 0.10, 0.41 ± 0.09, and 0.53 ± 0.13 L/kg, respectively. Together, the mean aminoglycoside Vd was 0.50 ± 0.12 L/kg. Gentamicin or tobramycin 5 mg/kg achieved goal peak concentrations in 24 patients (63.2%), and amikacin 20 mg/kg achieved the desired concentrations in nine patients (50.0%). Net fluid status, Body Mass Index, and vasopressor use were not predictive of Vd. There was no difference in the in-hospital mortality rate in patients who achieved adequate peak concentrations versus those who did not (26.8% versus 26.7%; p = 0.99). Conclusion: High aminoglycoside doses are needed in critically ill surgery patients to achieve adequate initial peak concentrations because of the high Vd. Goal peak concentrations were optimized at doses of gentamicin or tobramycin 5 mg/kg, and amikacin 20 mg/kg.

Sjögren Syndrome in the Intensive Care Unit: An Observational Study.

Studies on the clinical characteristics, prognosis, and factors associated with mortality in patients with Sjögren syndrome (SS), particularly those in the intensive care unit (ICU), are limited. The present study aimed to describe clinical and immunological variables associated with mortality in patients with SS admitted to ICU at a single center in Cali, Colombia. An observational, medical records review study was performed between 2011 and 2019 by reviewing the clinical records of patients with SS admitted to ICU at a high-complexity center. Seventy-two patients were included with a total of 117 ICU admissions (17 cases required readmission and 1 case required 17 readmissions): 103 (86.32%) were attributable to medical issues, and 14 corresponded to surgical admissions. Major causes of ICU medical admission were infection (44/103) followed by organ involvement. Only 5 admissions were related to SS due to neurological involvement. The APACHE (Acute Physiology, Age, and Chronic Health Evaluation) score was 10 (interquartile range [IQR], 7-16), the SOFA (Sequential Organ Failure Assessment) score was 2 (IQR, 0-14), and the EULAR Sjögren's Syndrome Disease Activity Index (ESSDAI) score was 0 (IQR, 0-12) with higher values in the nonsurvivor group. Intensive care unit mortality was 12/72 (16.67%). The main cause of ICU admission was infection. Patients with increased medical requirements, such as mechanical ventilation and vasopressor support, and with higher APACHE, SOFA, and ESSDAI scores were more susceptible to poor outcomes. Moreover, 50% of deaths were attributable to SS and 25% to infection.

CORRELATION BETWEEN LEVEL OF SOLUBLE FAS AND DEGREE OF SEPSIS SEVERITY BASED ON APACHE II SCORE

A widely used scoring system to assess the severity of sepsis is Acute Physiology, Age, and Chronic Health Evaluation (APACHE) II scoring system, however there are some disadvantages in using this. Other parameters are needed to predict severity and outcome of sepsis. Proinflammatory cytokines and Fas receptors are increased in sepsis and their concentration elevations are correlated with disease severity. An increase of soluble Fas level will follow increasing Fas receptors. This study aimed to prove any correlation between the level of soluble Fas and degree of sepsis severity based on APACHE II score. A cross-sectional observational study was conducted in January-June 2015 on 30 septic patients. APACHE II scores were calculated from the patients'physiological data, age, and chronic health problem status. Levels of soluble Fas were measured using the ELISA method (Human FAS/ CD95 (Factor-Related Apoptosis) ELISA Kit, Elabscience Biotechnology). Levels of soluble Fas ranged between 1,049-2,783 pg/mL (1,855.7 ± 477.27 pg/mL). APACHE II scores varied between 4-29 (17.2 ± 5.82). Significant positive correlations between levels of soluble Fas and APACHE II score (r=0.347, p=0.03) were found. A prediction model of soluble Fas levels based on APACHE II score was made. Linear regression analysis produced a prediction model of soluble Fas levels based on APACHE II score, in which soluble Fas level= 1,365.8 + 28.485 x APACHE II score.

Low Risk Monitoring in Neurocritical Care.

Background/Rationale: Patients are admitted to Intensive care units (ICUs) either because they need close monitoring despite a low risk of hospital mortality (LRM group) or to receive ICU specific active treatments (AT group). The characteristics and differential outcomes of LRM patients vs. AT patients in Neurocritical Care Units are poorly understood.Methods: We classified 1,702 patients admitted to our tertiary and quaternary care center Neuroscience-ICU in 2016 and 2017 into LRM vs. AT groups. We compared demographics, admission diagnosis, goal of care status, readmission rates and managing attending specialty extracted from the medical record between groups. Acute Physiology, Age and Chronic Health Evaluation (APACHE) IVa risk predictive modeling was used to assess comparative risks for ICU and hospital mortality and length of stay between groups.Results: 56.9% of patients admitted to our Neuroscience-ICU in 2016 and 2017 were classified as LRM, whereas 43.1% of patients were classified as AT. While demographically similar, the groups differed significantly in all risk predictive outcome measures [APACHE IVa scores, actual and predicted ICU and hospital mortality (p < 0.0001 for all metrics)]. The most common admitting diagnosis overall, cerebrovascular accident/stroke, was represented in the LRM and AT groups with similar frequency [24.3 vs. 21.3%, respectively (p = 0.15)], illustrating that further differentiating factors like symptom duration, neurologic status and its dynamic changes and neuro-imaging characteristics determine the indication for active treatment vs. observation. Patients with intracranial hemorrhage/hematoma were significantly more likely to receive active treatments as opposed to having a primary focus on monitoring [13.6 vs. 9.8%, respectively (p = 0.017)].Conclusion: The majority of patients admitted to our Neuroscience ICU (56.9%) had <10% hospital mortality risk and a focus on monitoring, whereas the remaining 43.1% of patients received active treatments in their first ICU day. LRM Patients exhibited significantly lower APACHE IVa scores, ICU and hospital mortality rates compared to AT patients. Observed-over-expected ICU and hospital mortality ratios were better than predicted by APACHE IVa for low risk monitored patients and close to prediction for actively treated patients, suggesting that at least a subset of LRM patients may safely and more cost effectively be cared for in intermediate level care settings.

The appropriateness of coronary investigation in myocardial injury and type 2 myocardial infarction (ACT-2): A randomized trial design

Elevated troponin level findings among patients presenting with suspected acute coronary syndrome (ACS) or another intercurrent illness undeniably identifies patients at increased risk of mortality. Whilst enhancing our capacity to discriminate risk, the use of high-sensitivity troponin assays frequently identifies patients with myocardial injury (i.e. troponin rise without acute signs of myocardial ischemia) or type 2 myocardial infarction (T2MI; oxygen supply-demand imbalance). This leads to the clinically challenging task of distinguishing type 1 myocardial infarction (T1MI; coronary plaque rupture) from myocardial injury and T2MI in the context of concurrent acute illness. Diagnostic discernment in this context is crucial because MI classification has implications for further investigation and care. Early invasive management is of well-established benefit among patients with T1MI. However, the appropriateness of this investigation in the heterogeneous context of T2MI, where there is high competing mortality risk, remains unknown. Although coronary angiography in T2MI is advocated by some, there is insufficient evidence in existing literature to support this opinion as highlighted by current national guidelines. The objective is to evaluate the clinical and economic impact of early invasive management with coronary angiography in T2MI in terms of all-cause mortality and cost effectiveness. This prospective, pragmatic, multicenter, randomized trial among patients with suspected supply demand ischemia leading to troponin elevation (n=1,800; T2MI [1,500], chronic myocardial injury [300]) compares the impact of invasive angiography (or computed tomography angiography as per local preference) within 5 days of randomization versus conservative management (with or without functional testing at clinician discretion) on all-cause mortality by 2 years. Randomized treatment allocation will be stratified by baseline estimated risk of mortality using the Acute Physiology, Age, and Chronic Health Evaluation (APACHE) III risk score. Cost-effectiveness will be evaluated by follow-up on clinical events, quality of life, and resource utilization over 24 months. Ascertaining the most appropriate first-line investigative strategy for these commonly encountered high-risk T2MI patients in a randomized comparative study will be pivotal in informing evidence-based guidelines that lead to better patient and health care outcomes.

Assessment of postoperative complications using E-PASS and APACHE II in patients undergoing oral and maxillofacial surgery

BackgroundThe prediction of postoperative complications is important for oral and maxillofacial surgeons. We herein aimed to evaluate the efficacy of the Estimation of Physiologic Ability and Surgical Stress (E-PASS) and Acute Physiology, Age, and Chronic Health Evaluation (APACHE) II scoring systems to predict postoperative complications in patients undergoing oral and maxillofacial surgery.MethodsThirty patients (22 males, 8 females; mean age: 65.1 ± 12.9 years) who underwent major oral surgeries and stayed in the intensive care unit for postoperative management were enrolled in this study. Postoperative complications were discriminated according to the necessity of the therapeutic intervention by the Medical Department, i.e. according to the Clavien–Dingo classification. E-PASS and APACHE II scores as well as laboratory test values were compared between patients with/without postoperative complications.ResultsPostoperative complications were developed in seven patients. The comprehensive risk score (CRS: 1.13 ± 0.24) and APACHE II score (13.0 ± 2.58) were significantly higher in patients with postoperative complications than in those without ones (p < 0.01, p < 0.05, respectively). The CRS showed an appropriate discriminatory power for predicting postoperative complications (area under the curve: 0.814). Furthermore, a correlation was detected between APACHE II scores and postoperative data until C-reactive protein levels decreased to < 1.0 mg/L (r = 0.43, p < 0.05).ConclusionThe E-PASS and APACHE II scoring systems were both shown to be useful to predict postoperative complications after oral and maxillofacial surgery.

Predicting Mortality of Patients With Sepsis: A Comparison of APACHE II and APACHE III Scoring Systems.

BackgroundAcute Physiology, Age and Chronic Health Evaluation (APACHE) II and III scores were developed in 1985 and 1991, respectively, and are used mainly for critically ill patients of all disease categories admitted to the intensive care unit (ICU). They differ in how chronic health status is assessed, in the number of physiologic variables included (12 vs. 17), and in the total score. These two scoring systems have not been compared in predicting hospital mortality in patients with sepsis.MethodsWe retrospectively identified all septic patients admitted to our 54-bed medical-surgical ICU between June 2009 and February 2014 using the APACHE outcomes database. We calculated correlation coefficients for APACHE II and APACHE III scores in predicting hospital mortality. Receiver-operating characteristic (ROC) curves were also used to assess the mortality predictions.ResultsWe identified a total of 2,054 septic patients. Average APACHE II score was 19 ± 7, and average APACHE III score was 68 ± 28. ICU mortality was 11.8% and hospital mortality was 18.3%. Both APACHE II (r = 0.41) and APACHE III scores (r = 0.44) had good correlations with hospital mortality. There was no statistically significant difference between the two correlations (P = 0.1). ROC area under the curve (AUC) was 0.80 (95% confidence interval (CI): 0.78 - 0.82) for APACHE II, and 0.83 (95% CI: 0.81 - 0.85) for APACHE III, suggesting that both scores have very good discriminative powers for predicting hospital mortality.ConclusionsThis study shows that both APACHE II and APACHE III scores in septic patients were very strong predictors of hospital mortality. APACHE II was as good as APACHE III in predicting hospital mortality in septic patients.

Definition of ACLF and inclusion criteria for extra-hepatic organ failure.

A prominent characteristic of ACLF is rapid hepatic disease progression with subsequent extra-hepatic organ failure, manifesting as either hepatic coma or hepatorenal syndrome, which is associated with a high mortality rate in a short time. The APASL definition mainly emphasizes recognizing patients with hepatic failure. These patients may subsequently develop extra-hepatic multisystem organ failure leading to high mortality. It is therefore worthwhile to identify the short interim period between the development of liver failure and the onset of extra-hepatic organ failure, the potential therapeutic 'golden window.' Interventions during this period may prevent the development of complications and eventually change the course of the illness. Organ failure is suggested to be a central component of ACLF and may behave differently from chronic decompensated liver disease. Clear and practical criteria for the inclusion of organ failure are urgently needed so that patients with these life-threatening complications can be treated in a timely and appropriate manner. Recent studies suggested that the scoring systems evaluating organ failure [acute physiology, age and chronic health evaluation (APACHE) and sequential organ failure assessment (SOFA) scores] work better than those addressing the severity of liver disease [Child-Pugh and model of end-stage liver disease (MELD) scores] in ACLF. However, a key problem remains that the former scoring systems are reflective of organ failure and not predictive, thus limiting their value as an early indication for intervention.

Blood Lactate/ATP Ratio, as an Alarm Index and Real-Time Biomarker in Critical Illness

ObjectiveThe acute physiology, age and chronic health evaluation (APACHE) II score and other related scores have been used for evaluation of illness severity in the intensive care unit (ICU), but there is still a need for real-time and sensitive prognostic biomarkers. Recently, alarmins from damaged tissues have been reported as alarm-signaling molecules. Although ATP is a member of the alarmins and its depletion in tissues closely correlates with multiple-organ failure, blood ATP level has not been evaluated in critical illness. To identify real-time prognostic biomarker of critical illness, we measured blood ATP levels and the lactate/ATP ratio (ATP-lactate energy risk score, A-LES) in critically ill patients.Methods and ResultsBlood samples were collected from 42 consecutive critically ill ICU patients and 155 healthy subjects. The prognostic values of blood ATP levels and A-LES were compared with APACHE II score. The mean ATP level (SD) in healthy subjects was 0.62 (0.19) mM with no significant age or gender differences. The median ATP level in severely ill patients at ICU admission was significantly low at 0.31 mM (interquartile range 0.25 to 0.44) than the level in moderately ill patient at 0.56 mM (0.38 to 0.70) (P<0.01). Assessment with ATP was further corrected by lactate and expressed as A-LES. The median A-LES was 2.7 (2.1 to 3.3) in patients with satisfactory outcome at discharge but was significantly higher in non-survivors at 38.9 (21.0 to 67.9) (P<0.01). Receiver operating characteristic analysis indicated that measurement of blood ATP and A-LES at ICU admission are as useful as APACHE II score for prediction of mortality.ConclusionBlood ATP levels and A-LES are sensitive prognostic biomarkers of mortality at ICU admission. In addition, A-LES provided further real-time evaluation score of illness severity during ICU stay particularly for critically ill patients with APACHE II scores of ≥20.0.

A Comparative Evaluation of Radiologic and Clinical Scoring Systems in the Early Prediction of Severity in Acute Pancreatitis

The early identification of clinically severe acute pancreatitis (AP) is critical for the triage and treatment of patients. The aim of this study was to compare the accuracy of computed tomography (CT) and clinical scoring systems for predicting the severity of AP on admission. Demographic, clinical, and laboratory data of all consecutive patients with a primary diagnosis of AP during a two-and-half-year period was prospectively collected for this study. A retrospective analysis of the abdominal CT data was performed. Seven CT scoring systems (CT severity index (CTSI), modified CT severity index (MCTSI), pancreatic size index (PSI), extrapancreatic score (EP), ''extrapancreatic inflammation on CT'' score (EPIC), ''mesenteric oedema and peritoneal fluid'' score (MOP), and Balthazar grade) as well as two clinical scoring systems: Acute Physiology, Age, and Chronic Health Evaluation (APACHE)-II and Bedside Index for Severity in AP (BISAP) were comparatively evaluated with regard to their ability to predict the severity of AP on admission (first 24 h of hospitalization). Clinically severe AP was defined as one or more of the following: mortality, persistent organ failure and/or the presence of local pancreatic complications that require intervention. All CT scans were reviewed in consensus by two radiologists, each blinded to patient outcome. The accuracy of each imaging and clinical scoring system for predicting the severity of AP was assessed using receiver operating curve analysis. Of 346 consecutive episodes of AP, there were 159 (46%) episodes in 150 patients (84 men, 66 women; mean age, 54 years; age range, 21-91 years) who were evaluated with a contrast-enhanced CT scan (n = 131 episodes) or an unenhanced CT scan (n = 28 episodes) on the first day of admission. Clinically severe AP was diagnosed in 29/159 (18%) episodes; 9 (6%) patients died. Overall, the Balthazar grading system (any CT technique) and CTSI (contrast-enhanced CT only) demonstrated the highest accuracy among the CT scoring systems for predicting severity, but this was not statistically significant. There were no statistically significant differences between the predictive accuracies of CT and clinical scoring systems. The predictive accuracy of CT scoring systems for severity of AP is similar to clinical scoring systems. Hence, a CT on admission solely for severity assessment in AP is not recommended.

Seizures following cardiac surgery: the impact of tranexamic acid and other risk factors

Seizures after cardiac surgery are a serious complication. The antifibrinolytic agent tranexamic acid (TA), which has known proconvulsant properties, may be associated with postoperative seizures. We sought to determine the association between TA and other risk factors for seizures after cardiac surgery. We analyzed a database of consecutive cardiac surgery patients (April 2003 to December 2009) using multivariable logistic regression analysis to assess for seizure risk factors. Seizures occurred in 56 of 5,958 patients (0.94%). TA use was associated with an increased risk of seizures (odds ratio 7.4, 95% confidence interval 2.8-19.3; P<0.001). Multivariable logistic regression analysis revealed that the following factors were significantly associated with seizures: TA exposure; Acute Physiology, Age, and Chronic Health Evaluation (APACHE) II score>20; preoperative cardiac arrest; preoperative neurological disease; open chamber surgery; cardiopulmonary bypass time>150min; and previous cardiac surgery. Seizures occurred at a median of 5.3 hr (interquartile range 2.4-15.1 hr) after the end of surgery. In all, 58.1% were grand mal, 14.5% were associated with a stroke, and 58.1% recurred in hospital. Altogether, 48.3% of the patients were able to discontinue anticonvulsant medications prior to discharge. Compared to the non-seizure group, seizure patients had an increased rate of postoperative neurological complications, defined as delirium and/or stroke (3.2% vs 19.6%, P<0.001), increased intensive care unit (ICU) length of stay (1.0 vs 4.7days, P<0.001), and increased ICU mortality (1.4 % vs 9.7 %, P=0.001). Our data suggest that multiple risk factors, including TA, are associated with seizures after cardiac surgery. Thus, the TA dose may be a readily modifiable risk factor for postoperative seizures.

Significance of Elevated Cardiac Troponin T Levels in Critically Ill Patients with Acute Respiratory Disease

Background Elevations in cardiac troponin have prognostic importance in critically ill patients. However, there are no data addressing the independent association between troponin levels and mortality, adjusted for the severity of the underlying disease, in patients hospitalized for acute respiratory disorders. We investigated whether troponin T (cTnT) elevations are independently associated with in-hospital mortality in patients in the intensive care unit (ICU) admitted for severe and acute respiratory conditions. After adjusting for the severity of disease measured by the Acute Physiology, Age, and Chronic Health Evaluation (APACHE) III prognostic system, we evaluated short-term (30 days) and long-term (3 years) mortality. Methods We studied the APACHE III database and cTnT levels from patients admitted consecutively to the ICU at Mayo Clinic, Rochester, Minnesota. Between January 2001 and December 2005, 2078 patients with respiratory conditions had cTnT measured at ICU admission. In-hospital, short-term (30 days) and long-term (3 years) all-cause mortality were determined. Results Of the study patients, 878 (42.3%) had elevated cTnT and 1200 patients (57.7%) had undetectable cTnT. During hospitalization, 1.1% of the patients with troponin T <0.01 ng/mL died compared to 21% of those with troponin T ≥0.01 ng/mL ( P <.0001). At 30 days, mortality was 18.6% in patients with elevations of cTnT and 1.5% in patients without elevations of cTnT ( P <.0001). The Kaplan-Meier probability of survival at 1-year follow-up was 71.0%, at 2-year follow-up was 48.3%, and 3-year follow-up was 39.4% with troponin T ≥0.01 ng/mL and at 1-year follow-up was 98.8%, at 2-year follow-up was 97.2%, and at 3-year follow-up was 95.5% with troponin T <0.01 μg/L ( P <.0001). After adjustment for severity of disease and baseline characteristics, cTnT levels remained associated with in-hospital, short-term and long-term mortality ( P <.0001). Conclusions In patients admitted to the ICU for respiratory disorders, cTnT elevations are independently associated with in-hospital, short-term and long-term mortality.

Recent Developments in Acute Pancreatitis

The incidence of acute pancreatitis (AP) has been increasing worldwide, but the major etiologies remain gallstones and alcohol. Several studies have reported that smoking is an independent risk factor for developing AP. Classification of AP has traditionally used the categories of mild and severe disease. However, a new intermediate category of moderately severe AP has been described with intermediate characteristics including a high incidence of local complications but a low mortality. Assessment criteria that can serve as early predictors of AP severity are often complex and not sufficiently accurate. However, several recently described criteria that rely on criteria such as the body mass index, physical findings, and simple laboratory measurements could prove useful if validated in large prospective studies. Many issues related to the therapy of AP are still unresolved. Although preliminary studies support the importance of early volume expansion for the treatment of acute pancreatitis, optimization of the amount and type of fluids will require further studies. Similarly, preliminary studies suggest that enteral nutrition might benefit patients with AP and could even be useful early in the course of disease. However, the timing and type of fluids as well as the intestinal infusion site require further study. Finally, issues related to the prophylactic use of antibiotics in patients with severe AP have not been resolved. While the process of clinical investigation moves slowly, progress has been made in clinical studies of AP.

Early Serum Procalcitonin, Interleukin‐6, and 24‐Hour Lactate Clearance: Useful Indicators of Septic Infections in Severely Traumatized Patients

Elevated lactate and interleukin-6 (IL-6) levels were shown to correlate with mortality and multiple organ dysfunction in severely traumatized patients. The purpose of this study was to test whether an association exists between 24-hour lactate clearance, IL-6 and procalcitonin (PCT) levels, and the development of infectious complications in trauma patients. A total of 1757 consecutive trauma patients with an Injury Severity Score (ISS) > 16 admitted over a 10-year period were retrospectively analyzed over a 21-day period. Exclusion criteria included death within 72 h of admission (24.5%), late admission > 12 h after injury (16%), and age < 16 years (0.5%). Data are stated as the median (range). Altogether, 1032 trauma patients (76.2% male) with an average age of 38 years, a median ISS of 29 (16-75), and an Acute Physiology, Age, and Chronic Health Evaluation (APACHE) II score of 14 (0-40) were evaluated. The in-hospital mortality (>3 days) was 10%. Patients with insufficient 24-hour lactate clearance had a high rate of overall mortality and infections. Elevated early serum procalcitonin on days 1 to 5 after trauma was strongly associated with the subsequent development of sepsis (p < 0.01) but not with nonseptic infections. The kinetics of IL-6 were similar to those of PCT but did differentiate between infected and noninfected patients after day 5. This study demonstrates that elevated early procalcitonin and IL-6 levels and inadequate 24-hour lactate clearance help identify trauma patients who develop septic and nonseptic infectious complications. Definition of specific cutoff values and early monitoring of these parameters may help direct early surgical and antibiotic therapy and reduce infectious mortality.