Acute Physiology And Chronic Health Evaluation II Research Articles

English

BACKGROUND Hypomagnesaemia is associated with other electrolyte abnormalities like hypokalaemia, hyponatremia, and hypophosphatemia. We wanted to study the serum magnesium levels in critically ill patients, and correlate the serum magnesium levels with patient outcome and other parameters like duration of stay in ICU, ventilator support and APACHE-II (Acute Physiology and Chronic Health Evaluation-II) score. METHODS The study included all the cases admitted in the ICU of Narayan Medical College & Hospital, with variable medical conditions within 6 months fulfilling the inclusion criteria. Demographic data (age and sex), medical history, surgical history, medications administrated and length of ICU stay were recorded for each patient. The severity scoring system used was Acute Physiology and Chronic Health Evaluation-II (APACHE-II). RESULTS Prevalence of Hypomagnesaemia in the present study was 60.2 %. Mortality and mechanical ventilator support (2.7 % and 28.4 %) in normomagnesemia subjects were significantly lesser than hypomagnesaemia subjects (33.9 % and 54.5 % respectively). CONCLUSIONS Hypomagnesaemia is a common electrolyte imbalance in critically ill patients. It is associated with higher mortality and morbidity in critically ill patients and is also associated with more frequent and more prolonged ventilatory support. KEYWORDS Critically Ill, Hypomagnesaemia, APACHE-II Score, Mortality, Ventilator Support

Dysbiosis of Gut Microbiota and Short-Chain Fatty Acids in Encephalitis: A Chinese Pilot Study.

BackgroundEncephalitis, the inflammation of the brain, may be caused by an infection or an autoimmune reaction. However, few researches were focused on the gut microbiome characteristics in encephalitis patients.MethodsA prospective observational study was conducted in an academic hospital in Guangzhou from February 2017 to February 2018. Patients with encephalitis were recruited. Fecal and serum samples were collected at admission. Healthy volunteers were enrolled from a community. Disease severity scores were recorded by specialized physicians, including Glasgow Coma Scale (GCS), Sequential Organ Failure Assessment (SOFA), and Acute Physiology and Chronic Health Evaluation-II (APACHE-II). 16S rRNA sequence was performed to analyze the gut microbiome, then the α-diversities and β-diversities were estimated. Short-chain fatty acids (SCFAs) were extracted from fecal samples and determined by gas chromatography-mass spectrometry. Serum D-lactate (D-LA), intestinal fatty acid-binding protein (iFABP), lipopolysaccharide (LPS), and lipopolysaccharide-binding protein (LBP) were measured by enzyme-linked immunosorbent assay (ELISA). The associations among microbial indexes and clinical parameters were evaluated by Spearman correlation analysis.ResultsIn total, twenty-eight patients were recruited for analysis (median age 46 years; 82.1% male; median GCS 6.5; median SOFA 6.5; median APACHE-II 14.5). Twenty-eight age- and sex-matched healthy subjects were selected as controls. The β-diversities between patients and healthy subjects were significantly different. The α-diversities did not show significant differences between these two groups. In the patient group, the abundances of Bacteroidetes, Proteobacteria, and Bacilli were significantly enriched. Accordingly, fecal SCFA levels were decreased in the patient group, whereas serum D-LA, iFABP, LPS, and LBP levels were increased compared with those in healthy subjects. Correlation analyses showed that disease severity had positive correlations with Proteobacteria and Akkermansia but negative correlations with Firmicutes, Clostridia, and Ruminococcaceae abundances. The cerebrospinal fluid albumin-to-serum albumin ratio (CSAR) was positively related to the α-diversity but negatively correlated with the fecal butyrate concentration.ConclusionGut microbiota disruption was observed in encephalitis patients, which manifested as pathogen dominance and health-promoting commensal depletion. Disease severity and brain damage may have associations with the gut microbiota or its metabolites. The causal relationship should be further explored in future studies.

Evaluating and improving current risk prediction tools in emergency laparotomy.

Emergency laparotomy (EL) encompasses a high-risk group of operations, which are increasingly performed on a heterogeneous population of patients, making preoperative risk assessment potentially difficult. The UK National Emergency Laparotomy Audit (NELA) recently produced a risk predictive tool for EL that has not yet been externally validated. We aimed to externally validate and potentially improve the NELA tool for mortality prediction after EL. We reviewed computer and paper records of EL patients from May 2012 to June 2017 at Middlemore Hospital (New Zealand). The inclusion criteria mirrored the UK NELA. We examined the NELA, Portsmouth Physiological and Operative Severity Score for the enUmeration of Mortality (P-POSSUM), Acute Physiology and Chronic Health Evaluation II (APACHE-II), and American College of Surgeons National Surgical Quality Improvement Programs risk predictive tools for 30-day mortality. The Hosmer-Lemeshow test was used to assess calibration, and the c statistic, to evaluate discrimination (accuracy) of the tools. We added the modified frailty index (mFI) and nutrition to improve the accuracy of risk predictive tools. A total of 758 patients met the inclusion criteria, with an observed 30-day mortality of 7.9%. The NELA was the only well calibrated tool, with predicted 30-day mortality of 7.4% (p = 0.22). When combined with mFI and nutritional status, the c statistic for NELA improved from 0.83 to 0.88. American College of Surgeons National Surgical Quality Improvement Programs, APACHE-II, and P-POSSUM had lower c statistics, albeit also showing an improvement (0.84, 0.81, and 0.74, respectively). We have demonstrated the NELA tool to be most predictive of mortality after EL. The NELA tool would therefore facilitate preoperative risk assessment and operative decision making most precisely in EL. Future research should consider adding mFI and nutritional status to the NELA tool. Level IV; Retrospective observational cohort study.

Risk factors for postoperative delirium in patients with triple-branched stent graft implantation

BackgroundNeurological complications is a common complication following novel triple-branched stent graft implantation in patients with Stanford type A aortic dissection (AAD). But the incidence and risk factors of postoperative delirium (POD) are not completely clear. The aim of this study was to investigate the incidence and risk factors of POD after novel triple-branched stent graft implantation.MethodsAn observational study of AAD patients who underwent novel triple-branched stent graft implantation between January 2017 and July 2019 were followed up after surgery. Patients’ delirium was screened by the Richmond Agitation-Sedation Scale and the Confusion Assessment Method for the intensive care unit from the first day after the operation, lasted 5 days. The risk factors of POD were analyzed by the Cox proportional hazard models.ResultsA total of 280 AAD patients were enrolled in this research, the incidence of POD was 37.86%. Adjusting for age, body mass index, and mechanical ventilation duration, multivariate Cox regression analysis model revealed that non-manual work (adjusted hazard ratio [AHR] = .554; 95% CI: 0.335–0.915; P = .021), Acute Physiology and Chronic Health Evaluation II (APACHE-II) scores > 20 (AHR = 3.359, 95% CI: 1.707–6.609, P < .001), hypoxemia (AHR = 1.846, 95% CI: 1.118–3.048, P = .017), and more than two types of analgesics and sedatives were independently associated with POD.ConclusionsThis study showed that risk factors independently associated with POD were APACHE-II score > 20, hypoxemia, and more types of analgesics and sedatives, and non-manual work was the protective factor.Trial registrationThis study was retrospectively registered in the Chinese Clinical Trial Registry (Registration number: ChiCTR1900022408; Date: 2019/4/10).

Mortality prediction of serum neutrophil gelatinase-associated lipocalin in patients requiring continuous renal replacement therapy.

Background/AimsWe investigated whether serum neutrophil gelatinase-associated lipocalin (NGAL) can predict mortality in patients with acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT).MethodsThis study enrolled 169 patients who underwent serum NGAL testing at CRRT initiation from June 2017 to January 2019. The predictive power of serum NGAL level for 28-day mortality was compared to the Acute Physiology and Chronic Health Evaluation-II (APACHE-II) score and Sequential Organ Failure Assessment (SOFA) score via area under the receiver operating characteristic curve (AuROC) value.ResultsThere were 55 survivors and 114 non-survivors at 28 days post-CRRT initiation. Median serum NGAL level was significantly higher in the non-survivor group than in the survivor group (743.0 ng/mL vs. 504.0 ng/mL, p = 0.003). The AuROC value of serum NGAL level was 0.640, which was lower than APACHE-II score and SOFA score values (0.767 and 0.715, respectively). However, in the low APACHE-II score group (< 27.5), AuROC value of serum NGAL was significantly increased (0.698), and it was an independent risk factor for 28 day-mortality (hazard ratio, 2.405; 95% confidence interval, 1.209 to 4.783; p = 0.012).ConclusionsIn patients with AKI requiring CRRT, serum NGAL levels may be useful for predicting short-term mortality in those with low APACHE-II scores.

Comparative study of procalcitonin and C-reactive protein in patients with sepsis

Background: The early diagnosis and appropriate therapy of sepsis is a challenge in intensive care units in spite of the advances in critical care medicine. Aim of the study: The aim is to study and compare procalcitonin (PCT) and C-reactive protein (CRP) levels in patients admitted with the diagnosis of sepsis to the critical care unit. Materials and Methods: This was a prospective observational study conducted at the teaching hospital over a period of 1 year. All patients with evidence of sepsis were enrolled for this study and were underwent relevant history, laboratory biochemical and imaging investigations including PCT and CRP levels. Results: A total of 64 patients with the diagnosis of sepsis were enrolled in this study. A total of 43 (67.19%) were male and 21 (32.81%) were female. The mean and standard deviation for the Acute Physiology and Chronic Health Evaluation II (APACHE-II) score was 18 (±7), Sepsis-Related Organ Failure Assessment (SOFA) score was 9 (±5), papillary thyroid cancer as 19.07 (±7.02 ng/ml), and CRP was 33.5 (±15.7 mg/l). About 56.25% of patients had PCT in the range of 2–10 ng/ml, 28.13% had >10 ng/ml, and 14.06% had between 0.5 and 1.9 ng/ml. A total of 43 (67.19%) patients had a positive culture for organisms and 21 (32.81%) had sterile with no growth on culture with P

Reduced Monocytic Human Leukocyte Antigen-DR Expression Indicates Immunosuppression in Critically Ill COVID-19 Patients.

BACKGROUND:The cellular immune system is of pivotal importance with regard to the response to severe infections. Monocytes/macrophages are considered key immune cells in infections and downregulation of the surface expression of monocytic human leukocyte antigen-DR (mHLA-DR) within the major histocompatibility complex class II reflects a state of immunosuppression, also referred to as injury-associated immunosuppression. As the role of immunosuppression in coronavirus disease 2019 (COVID-19) is currently unclear, we seek to explore the level of mHLA-DR expression in COVID-19 patients.METHODS:In a preliminary prospective monocentric observational study, 16 COVID-19–positive patients (75% male, median age: 68 [interquartile range 59–75]) requiring hospitalization were included. The median Acute Physiology and Chronic Health Evaluation-II (APACHE-II) score in 9 intensive care unit (ICU) patients with acute respiratory failure was 30 (interquartile range 25–32). Standardized quantitative assessment of HLA-DR on monocytes (cluster of differentiation 14+ cells) was performed using calibrated flow cytometry at baseline (ICU/hospital admission) and at days 3 and 5 after ICU admission. Baseline data were compared to hospitalized noncritically ill COVID-19 patients.RESULTS:While normal mHLA-DR expression was observed in all hospitalized noncritically ill patients (n = 7), 89% (8 of 9) critically ill patients with COVID-19–induced acute respiratory failure showed signs of downregulation of mHLA-DR at ICU admission. mHLA-DR expression at admission was significantly lower in critically ill patients (median, [quartiles]: 9280 antibodies/cell [6114, 16,567]) as compared to the noncritically ill patients (30,900 antibodies/cell [26,777, 52,251]), with a median difference of 21,508 antibodies/cell (95% confidence interval [CI], 14,118–42,971), P = .002. Reduced mHLA-DR expression was observed to persist until day 5 after ICU admission.CONCLUSIONS:When compared to noncritically ill hospitalized COVID-19 patients, ICU patients with severe COVID-19 disease showed reduced mHLA-DR expression on circulating CD14+ monocytes at ICU admission, indicating a dysfunctional immune response. This immunosuppressive (monocytic) phenotype remained unchanged over the ensuing days after ICU admission. Strategies aiming for immunomodulation in this population of critically ill patients should be guided by an immune-monitoring program in an effort to determine who might benefit best from a given immunological intervention.

Correlation Between Pulmonary Vascular Permeability Index, Shock Index, and Severity of Septic Shock and Their Evaluation Values for Prognosis

Background: The changes before and after fluid resuscitation in patients with septic shock and their relationship with prognosis have rarely been reported. Objectives: We aimed to observe the correlation between pulmonary vascular permeability index (PVPI), shock index (SI), and severity of septic shock. Methods: This case-control study retrospectively analyzed the clinical data of 154 patients with septic shock treated at our hospital (Weifang, China) from October 2016 to October 2018. They were divided into a survival group or a death group according to the 28-day prognosis. Univariate analysis was performed for vital signs, the acute physiology and chronic health evaluation II (APACHE-II) score, the sequential organ failure assessment (SOFA) score at admission, SI at admission (SI1), SI at 3 h after fluid resuscitation (SI2), PVPI at admission (PVPI1), PVPI at 3 h after fluid resuscitation (PVPI2), and lactate clearance rate (LCR). The correlations of PVPI and SI with the APACHE-II score, SOFA score, and LCR were analyzed by plotting the receiver operating characteristic curves. Results: Among the 154 cases, 70 survived after 28 days and 84 died. We observed that SI1, SI2, PVPI1, PVPI2, APACHE-II score, and SOFA score were significantly lower in the survival group than in the death group, while LCR was significantly higher (P < 0.05). Also, SI1, SI2, PVPI1, and PVPI2 were positively correlated with APSCHE-II and SOFA scores of patients with septic shock, but negatively correlated with LCR (P < 0.05). Moreover, SI2 predicted the prognosis of patients with septic shock significantly better than SI1, PVPI1, and PVPI2 did. When SI2 was 1.22, the Youden index was 0.822, the sensitivity was 91.23%, the specificity was 89.47%, the positive predictive value was 0.912, and the negative predictive value was 0.924. The positive and negative likelihood ratios were 0.897 and 0.375, respectively. Conclusions: Based on the study, SI after fluid resuscitation was more valuable for evaluating the prognosis of patients with septic shock than SI at admission, as well as PVPI values at admission and after fluid resuscitation.

Effect of prolonged sedation with propofol and dexmedetomidine on acute gastrointestinal dysfunction injury and prognosis in ICU patients

Objective To investigate the effect of prolonged sedation with propofol and dexmedetomidine on acute gastrointestinal dysfunction injury(AGI) and prognosis in intensive care unit(ICU) patients. Methods A prospective cohort study was conducted to collect 200 cases of mechanical ventilation patients admitted to ICU in the Second People's Hospital of Hefei, and the patients were divided into two groups according to the simple random grouping principle, with 100 cases in each group.The control group was given propofol sedation, and the research group was given propofol combined with dexmedetomidine sedation.Both two groups were given sufentanil for analgesia, and the basic clinical data of the patients were recorded, including age, gender, weight, BMI index, serum albumin levels, acute physiology and chronic health evaluation Ⅱ(APACHEⅡ) score, triglycerides (TG), total cholesterol (TC), alanine aminotransferase (ALT), aspartate aminotransferase (AST). On the 0th and 7th day after the use of sedatives, the intestinal singing score, cases of acute gastrointestinal dysfunction injury, cases of delirium, length of stay in the ICU and hospitalization costs, TG, TC, ALT and AST in the two groups were observed and compared. Results The TG, TC, ALT and AST levels were all increased in the two groups compared with those at the 0d, but the increase degree in the study group was lower than that in the control group, and the differences were statistically significant (t=3.87, 4.58, 5.26, 4.38, P=0.00, 0.00, 0.00, 0.00). A total of 85 patients in the control group developed AGI, and 70 patients in the study group developed AGI.The difference between the two groups was statistically significant (χ2=8.62, P=0.03), and the difference in intestinal sound score between the two groups was statistically significant (χ2=11.48, P=0.00). There were 13 delirium cases in the control group and 2 delirium cases in the study group, and the difference was statistically significant (χ2=11.83, P=0.00). There were no statistically significant differences in the length of hospital stay(t=1.64, P=0.10) and hospital expenses(t=1.28, P=0.20) between the two groups. Conclusion For ICU patients requiring long-term mechanical ventilation, dexmedetomidine can significantly reduce the incidence of delirium and the occurrence of AGI, especially for obese patients, the use of dexmedetomidine sedation has little impact on their liver function and blood lipid metabolism, and can significantly improve the prognosis. Key words: Drug therapy, combination; Deep sedation; Intensive care units; Critical illness; Respiration, artificial; Gastrointestinal dysfunction; Delirium; Propofol; Dexmedetomidine

SOFA score is superior to APACHE-II score in predicting the prognosis of critically ill patients with acute kidney injury undergoing continuous renal replacement therapy

Background Acute kidney injury (AKI) is the most common cause of organ failure in multiple organ dysfunction syndrome (MODS) and is associated with increased mortality. This study aimed at determining the efficacy of sequential organ failure assessment (SOFA), and acute physiology and chronic health evaluation II (APACHE-II) scoring systems in assessing the prognosis of critically ill patients with AKI undergoing continuous renal replacement therapy (CRRT). At present, APACHE-II score and SOFA score were also used to evaluate and predict the prognosis of critically ill patients with AKI. Methods The predictive value of SOFA and APACHE-II scores for 28- and 90-d mortality in patients with AKI undergoing CRRT were determined by multivariate analysis, sensitivity analysis, and curve-fitting analysis. Results A total of 836 cases were included in this study. Multivariate Cox logistic regression analysis showed that SOFA scores were associated with 28- and 90-d mortality in patients with AKI undergoing CRRT. The adjusted HR of SOFA for 28-d mortality were 1.18 (1.14, 1.21), 1.24 (1.18, 1.31), and 1.19 (1.13, 1.24) in the three models, respectively, and the adjusted HR of SOFA for 90-d mortality was 1.12 (1.09, 1.16), 1.15 (1.10, 1.19), and 1.15 (1.10, 1.19), respectively. The subgroup analysis showed that the SOFA score was associated with 28-d and 90-d mortality in patients with AKI undergoing CRRT. APACHE-II score was not associated with 28- and 90-d mortality patients with AKI undergoing CRRT. Curve fitting analysis showed that SOFA scores increased had a higher prediction accuracy for 28- and 90-d than APACHE-II. Conclusions The SOFA score showed a higher accuracy of mortality prediction in critically ill patients with AKI undergoing CRRT than the APACHE-II score.

CT quantification of pneumonia lesions in early days predicts progression to severe illness in a cohort of COVID-19 patients.

Rationale: Some patients with coronavirus disease 2019 (COVID-19) rapidly develop respiratory failure or even die, underscoring the need for early identification of patients at elevated risk of severe illness. This study aims to quantify pneumonia lesions by computed tomography (CT) in the early days to predict progression to severe illness in a cohort of COVID-19 patients.Methods: This retrospective cohort study included confirmed COVID-19 patients. Three quantitative CT features of pneumonia lesions were automatically calculated using artificial intelligence algorithms, representing the percentages of ground-glass opacity volume (PGV), semi-consolidation volume (PSV), and consolidation volume (PCV) in both lungs. CT features, acute physiology and chronic health evaluation II (APACHE-II) score, neutrophil-to-lymphocyte ratio (NLR), and d-dimer, on day 0 (hospital admission) and day 4, were collected to predict the occurrence of severe illness within a 28-day follow-up using both logistic regression and Cox proportional hazard models.Results: We included 134 patients, of whom 19 (14.2%) developed any severe illness. CT features on day 0 and day 4, as well as their changes from day 0 to day 4, showed predictive capability. Changes in CT features from day 0 to day 4 performed the best in the prediction (area under the receiver operating characteristic curve = 0.93, 95% confidence interval [CI] 0.87~0.99; C-index=0.88, 95% CI 0.81~0.95). The hazard ratios of PGV and PCV were 1.39 (95% CI 1.05~1.84, P=0.023) and 1.67 (95% CI 1.17~2.38, P=0.005), respectively. CT features, adjusted for age and gender, on day 4 and in terms of changes from day 0 to day 4 outperformed APACHE-II, NLR, and d-dimer.Conclusions: CT quantification of pneumonia lesions can early and non-invasively predict the progression to severe illness, providing a promising prognostic indicator for clinical management of COVID-19.

Comparative Prognostic Accuracy of Risk Prediction Models for Cardiogenic Shock.

Despite advances in medical therapy, reperfusion, and mechanical support, cardiogenic shock remains associated with excess morbidity and mortality. Accurate risk stratification may improve patient management. We compared the accuracy of established risk scores for cardiogenic shock. Patients admitted to tertiary care center cardiac care units in the province of Alberta in 2015 were assessed for cardiogenic shock. The Acute Physiology and Chronic Health Evaluation-II (APACHE-II), CardShock, intra-aortic balloon pump (IABP) Shock II, and sepsis-related organ failure assessment (SOFA) risk scores were compared. Receiver operating characteristic curves were used to assess discrimination of in-hospital mortality and compared using DeLong's method. Calibration was assessed using the Hosmer-Lemeshow goodness-of-fit test. The study included 3021 patients, among whom 510 (16.9%) had cardiogenic shock. Patients with cardiogenic shock had longer median hospital stays (median 11.0 vs 4.1 days, P < .001) and were more likely to die (29.0% vs 2.5%, P < .001). All risk scores were adequately calibrated for predicting hospital morality except for the APACHE-II score (Hosmer-Lemeshow P < .001). Discrimination of in-hospital mortality with the APACHE-II (area under the curve [AUC]: 0.72, 95% confidence interval [CI]: 0.66-0.76) and IABP-Shock II (AUC: 0.73, 95% CI: 0.68-0.77) scores were similar, while the CardShock (AUC: 0.76, 95% CI: 0.72-0.81) and SOFA (AUC: 0.76, 95%CI: 0.72-0.81) scores had better discrimination for predicting in-hospital mortality. In a real-world population of patients with cardiogenic shock, existing risk scores had modest prognostic accuracy, with no clear superior score. Further investigation is required to improve the discriminative abilities of existing models or establish novel methods.

Effect of dexmedetomidine on stress response and immune balance in mechanical ventilation patients with acute respiratory distress syndrome

Objective To investigate the effect of dexmedetomidine on stress response and immune balance in patients with acute respiratory distress syndrome(ARDS) undergoing mechanical ventilation. Methods From March 2016 to September 2018, 90 ARDS patients with mechanical ventilation in Chongqing Three Gorges Center Hospital were randomly divided into dexmedetomidine group(D group, 30 cases), propofol group(P group, 30 cases), midazolam group(M group, 30 cases) by random number table method.Another 30 healthy workers in our hospital were selected as normal control group(C group). In M, P and D groups, the sedative drugs were infused by micro-pump on the basis of analgesic treatment(fentanyl citrate). The heart rate(HR), mean arterial pressure(MAP), Murray score, acute physiology and chronic health evaluation Ⅱ(APACHEⅡ) score, plasma norepinephrine(NS), plasma cortisol(Cor), and blood T lymphocyte subsets(CD4+, CD8+, CD4+/CD8+) were observed in all patients at T0(the beginning of sedation), T1 (6h after sedation), T2 (24h after sedation), T3(48h after sedation). The levels of NS and Cor in plasma and blood T lymphocyte subsets(CD4+, CD8+, CD4+/CD8+) in C group were measured at 8∶00 a. m.the next day. Results The plasma NS and Cor at T0 in M, P and D group were higher than those in C group (all P 0.05). The levels of CD8+ at T2 and T3 in P and D groups were higher than that of M group (all P<0.05). The level of CD4+/CD8+ at T3 in D group were higher than that in M and P group[(1.46±0.30) vs.(1.26±0.33), (1.46±0.30) vs.(1.32±0.34)](t=0.21, 0.15, all P<0.05). Conclusion Sedation with dexmedetomidine or propofol can alleviate stress response and improve immune function in ARDS patients undergoing mechanical ventilation, and dexmedetomidine is better than propofol. Key words: Respiratory distress syndrome, Adult; Ventilators, mechanical; T-Lymphocytes; Dexmedetomidine; Propofol; Midazolam

Prognostic factors in patients with acute kidney injury requiring continuous renal replacement therapy

Objective To identify prognostic factors for mortality in patients with acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT). Methods A retrospective study was conducted in 138 patients with initiated CRRT due to AKI who were admitted to the Emergency Intensive Care Unit of Xinhua Hospital Affiliated to Shanghai Jiaotong University School of Medicine from May 2012 to December 2016. According to whether these patients survived after 28 days, they were divided into the death group (58 cases) and survived group (80 cases). Demographic and clinical parameters were retrieved and compared between the two groups. Logistic multivariate regression analysis was performed to determine the risk factors related to mortality. Results Of the 138 patients included, 58 patients (42.0%) died after 28 days. Patients in the death group were older, more likely to be male, had a higher score on the acute physiology and chronic health evaluation Ⅱ (APACHEⅡ), higher serum lactate level and lower serum creatinine level on admission, higher prevalence of coronary artery disease, and were more likely to be mechanically ventilated or treated with vasopressors. Multivariate logistic regression analysis revealed that age (OR=1.064, 95%CI: 1.022-1.108, P=0.002), APACHEⅡ score (OR=1.127, 95%CI: 1.003-1.265, P=0.044), mechanical ventilation (OR=7.432, 95%CI: 2.183-25.308, P=0.001) and use of vasopressors (OR=24.558, 95%CI: 7.651-78.825, P<0.01) were independent risk factors for mortality. Conclusions Older age, higher APACHEⅡ score, mechanical ventilation and use of vasopressors are risk factors for mortality in EICU patients with acute kidney injury requiring CRRT. Key words: Acute kidney injury; Continuous renal replacement therapy; Prognosis; ICU; Risk factors

Comparative analysis of APACHE-II and P-POSSUM scoring systems in predicting postoperative mortality in patients undergoing emergency laparotomy.

BACKGROUNDLaparotomy remains one of the commonest emergency surgical procedures. Early prognostic evaluation would aid in selecting the high-risk patients for an aggressive treatment. Awareness about risks could potentially contribute to the quality of perioperative care and optimum utilization of resources. Portsmouth modification of Physiological and operative severity for the enumeration of mortality and morbidity (P-POSSUM) and the acute physiology and chronic health evaluation II (APACHE-II) have been the most widely used scoring systems for emergency laparotomies. It is always better to have a single scoring system to predict outcomes and audit healthcare organizations.AIMTo compare the ability of APACHE-II and P-POSSUM to predict postoperative morbidity and mortality in patients undergoing emergency laparotomy.METHODSAll patients undergoing emergency laparotomy at the Tata Main Hospital, Jamshedpur between December 2013 and November 2014 were included in the study. In this observational study, P-POSSUM and APACHE-II scoring were done, and the outcome analysis evaluated with mortality being the primary outcome.RESULTSFor P-POSSUM, at a cut off value of 63 to predict mortality using receiver operating characteristics curve analysis, the area under the curve was 0.989; and for APACHE-II, at the cut off value of 24, the area under the curve was 0.965.CONCLUSIONBecause the ability of APACHE-II to predict mortality was similar to P-POSSUM and APACHE-II does not need scoring for intra-operative findings and histopathology reports, APACHE-II can be used pre-operatively to assess the risk in patients undergoing emergency laparotomy. However, for audit purposes, either of the two scoring systems can be used.

Predictive value of heparin-binding protein combined with sequential organ failure assessment score in patients with septic shock

To explore the predictive value of heparin-binding protein (HBP) combined with sequential organ failure assessment (SOFA) score in patients with septic shock. Seventy-eight patients with sepsis admitted to intensive care unit (ICU) of Henan Provincial People's Hospital from December 2016 to May 2017 were enrolled. Thirty healthy persons were enrolled as controls. The patient's gender, age, length of ICU stay, and blood culture results, white blood cell count (WBC), C-reactive protein (CRP), procalcitonin (PCT), blood lactate (Lac), HBP, SOFA score, acute physiology and chronic health evaluation II (APACHE II) score, organ failure and vasoactive agents usage within 24 hours of admission were recorded. The differences in the above indicators between the groups were compared, and the receiver operating characteristic (ROC) curve was drawn to evaluate the predictive value of HBP, SOFA score and their combination in patients with septic shock. All patients were enrolled in the final analysis, including 64 with sepsis and 14 with septic shock. Compared with the sepsis group, the proportion of patients with septic shock who were positive for blood culture, organ failure, and vasoactive agents was higher [57.1% (8/14) vs. 7.8% (5/64), 100.0% (14/14) vs. 65.6% (42/64), 100.0% (14/14) vs. 18.8% (12/64), all P < 0.01], SOFA and APACHE II scores were also higher (SOFA: 8.93±4.16 vs. 5.89±2.68, APACHE II: 22.29±4.89 vs. 15.28±5.14, both P < 0.01); however, there was no significant difference in gender, age or length of ICU stay between the two groups. Compared with the healthy control group, HBP, PCT, CRP and Lac levels were significantly increased in the sepsis group and the septic shock group. HBP in the septic shock group was significantly higher than that in the sepsis group (μg/L: 120.33±43.49 vs. 68.95±54.15, P < 0.05), but there was no significant difference in PCT, CRP or Lac between septic shock group and sepsis group [PCT (μg/L): 1.42 (0.47, 46.00) vs. 0.71 (0.19, 4.50), CRP (mg/L): 102.90±78.12 vs. 102.07±72.15, Lac (mmol/L): 1.81 (1.14, 3.65) vs. 1.59 (1.17, 2.24), all P > 0.05]. It was shown by ROC curve analysis that the area under the ROC curve (AUC) of SOFA score for predicting septic shock was 0.715 [95% confidence interval (95%CI) = 0.540-0.890, P = 0.012], and when the optimal cut-off value was 7.5, the sensitivity was 64.3%, the specificity was 76.6%. The AUC of HBP was 0.814 (95%CI = 0.714-0.913, P < 0.001), and when the optimal cut-off value was 89.43 μg/L, the sensitivity was 78.6%, the specificity was 76.6%; when the two were combined, the AUC was 0.829 (95%CI = 0.724-0.935, P < 0.001), the sensitivity was 92.9%, and the specificity was 61.9%. HBP can be used as a biological indicator for predicting septic shock, and the accuracy of predicting septic shock can be improved with the combination of SOFA score.

Utility of brain CT for predicting delayed encephalopathy after acute carbon monoxide poisoning.

Delayed encephalopathy after acute carbon monoxide poisoning (DEACMP) is a serious complication that occurs several days or weeks after carbon monoxide (CO) intoxication. This study identified computed tomography (CT) findings in the prediction of DEACMP development. Adults with CO poisoning admitted to Beijing Chaoyang Hospital, Shenyang Ninth People's Hospital, Shanxi Second People's Hospital and Shandong Provincial Hospital in China from January 2013 to January 2016 were retrospectively analyzed. Baseline demographic and clinical characteristics were extracted from the medical records. Brain CT imaging was carried out within 24 h of admission, and an integrated CT score was calculated to semi-quantify lesion severity. Patients were followed-up for 6 months. Baseline characteristics and CT findings were compared among patients who developed DEACMP (DEACMP group) and those who did not (non-DEACMP group). The receiver operating characteristic (ROC) curve analysis was used to examine the utility of integrated CT score for predicting DEACMP. Among the 123 patients included in the analysis, 27 (22.0%) developed DEACMP. The DEACMP and non-DEACMP groups did not differ with regard to age, sex and carboxyhemoglobin (COHb) level at admission. However, compared with the non-DEACMP group, the patients in the DEACMP group had longer onset time of symptoms and duration of exposure to CO, higher acute physiology and chronic health evaluation-II (APACHE-II) score, lower Glasgow Coma Scale (GCS) score, and there was a higher proportion of patients with severe symptoms and brain CT abnormalities (81.5 vs. 51.0%; P<0.05). Integrated CT score in the DEACMP group was significantly higher than that in the non-DEACMP group (73.63 vs. 51.39; P<0.01). ROC curve was used to analyze the utility of integrated CT score in the prediction of DEACMP. The area under the ROC curve was 0.700 (95% confidence interval, 0.584–0.817; P<0.01). In conclusion, brain integrated CT score has the potential to identify DEACMP in patients.

Relative efficacy and safety of early lactate clearance-guided therapy resuscitation in patients with sepsis: A meta-analysis.

Objective:Compelling evidence has shown that aggressive resuscitation bundles are one of the cornerstones of the successful treatment of patients with sepsis. Recent studies suggest that lactate normalization during resuscitation is a more powerful indicator of resuscitative adequacy; however, early lactate clearance-guided therapy is still not recommended. We performed this meta-analysis to evaluate the effect of early lactate clearance-directed therapy as a potentially more effective resuscitation target.Methods:Studies were identified using PubMed, Embase, and the Cochrane Library without region, publication type, or language restrictions. Randomized trials were included when they compared the efficacy and safety of lactate clearance-guided resuscitation versus central venous oxygen saturation (ScvO2)-guided therapy. The primary outcome was mortality, and the secondary outcomes were intensive care unit (ICU) stay, length of hospital stay, mechanical ventilation time, Acute Physiology and Chronic Health Evaluation-II (APACHE-II) score, and Sepsis-related Organ Failure Assessment (SOFA) score.Results:Seven randomized controlled trials encompassing 1301 cases were reviewed. Compared with guided ScvO2 therapy, early lactate clearance-directed therapy was associated with decreased in-hospital mortality (relative ratio [RR] 0.68, 95% confidence interval [CI] 0.56 to 0.82), shorter ICU stay (mean difference [MD] −1.64 days, 95% CI −3.23 to −0.05), shorter mechanical ventilation time (MD −10.22 hours, 95% CI −15.94 to −4.5), and lower APACHE-II scores (MD −4.47, 95% CI −7.25 to −1.69). However, patients undergoing early lactate clearance-guided therapy had similar lengths of hospital stay and similar SOFA scores.Conclusions:As a specific indicator of resuscitation outcome, lactate clearance alone is superior to ScvO2 alone during a standard resuscitation paradigm. The optimal or desired rate of lactate clearance is still a contentious area. To guide resuscitation and normalize lactate levels in patients, repeating lactate measurements every 2 hours until the patient has met a lactate clearance of 10% or greater may be helpful.Trial registration number:PROSPERO CRD42018100515.

Value of APACHE.II score and DIC score in predicting the death of patients with heat stroke

Objective: To investigate the predictive values of the acute physiology and chronic health evaluation II (APACHE.II) score and disseminated intravascular coagulation (DIC) score on death in patients with heat stroke. Methods: A total of 76 patients with heat stroke who were treated in Emergency Department of Harrison International Peace Hospital from June 2013 to September 2017 were studied. According to the outcome of patients, we distributed the patients to death group and survival group. APACHE.II score and DIC score were calculated according to the clinical data and the test results at admission. Evaluate the correlation between the two indicators associated with death. Results: There were 76 patients, with 23 deaths (30.3%) and 53 survivors (69.7%) . The APACHE-II score and DIC score were 26.26±6.48 and 4.00±1.38 in the death group.significantly higher than 20.74±4.17 and 2.28±1.21 in the survival group, and there were significant difference (P< 0.01) . The APACHE. II score was positively correlated with the DIC score, and the higher the score, the higher the mortality rate.Both indicators are significant for the Logitic regression analysis of death (P<0.01) .The sensitivity and specificity of the APACHE.II score were 65.2% and 81.1% in prediction of mortality, The sensitivity and specificity of DIC score were 65.2% and 84.9% in prediction of mortality. The specificity of the APACHE II score plus DIC score were higher than that of single APACHE. II score or DIC score in prediction of mortality (P<0.05) . Conclusion: The APACHE.II score and DIC score are significantly increased in the early stage of the patients with heat stroke, and the APACHE. II score combined with DIC score may improve the value in prediction of mortality with heat stroke.

Analysis of the Treatment Efficacy of Percutaneous Catheter Drainage Under CT Guidance for Severe Acute Necrotizing Pancreatitis

Background: Percutaneous catheter drainage (PCD) therapy is an important treatment for severe acute pancreatitis. Objectives: The purpose of this retrospective study was to analyze the relevant risk factors of computed tomography (CT) guided PCD during the treatment of infected pancreatic necrosis (IPN) in severe acute pancreatitis. Patients and Methods: This is a retrospective study. From January 2013 to November 2016, 162 patients suffering from severe acute pancreatitis with IPN were assessed using CT-guided PCD. Abdominal CT scan was performed for the patients. The interventional therapist chose the location and puncture according to the image. Depending on the efficacy and process of the treatment, these patients were divided into a PCD success treatment group and a PCD combined with surgery group. Factors affecting the success of PCD treatment were analyzed by logistic regression analysis. Results: Among the 162 cases, 71 cases (43.82%) were in the PCD success group and 91 cases (56.17%) were in the PCD combined with surgery group. Through the course of treatment, CT values of piercing zone, acute physiology and chronic health evaluation II (APACHEII) scores and modified CT severity index (MCTSI) scores showed statistically significant correlation with the therapeutic effect of PCD under CT guidance. A further multivariate analysis found that the CT value of puncture area is the best predictor for efficacy and when the CT value got higher the PCD efficacy would become lower. We performed further analysis of the factors associated with the average CT value in the puncture area which was higher than 20 Hounsfield unit (HU), and found that the length of time from patient admission to drainage, APACHEII scores, MCTSI scores and C reactive protein (CRP) levels were risk factors for PCD treatment efficacy. Conclusion: CT values of piercing zone is the major risk factor affecting the curative effect of CT guidance PCD. For patients with higher CT values in the puncture area, the longer time from patient admission to drainage, the higher APACHEII scores and MCTSI scores. Higher levels of C reactive protein seem to lower the curative effect.