Admission Sequential Organ Failure Assessment Research Articles

The early change of SOFA score as a prognostic marker of 28-day sepsis mortality: analysis through a derivation and a validation cohort

BackgroundSince the Sepsis-3 criteria, change in Sequential Organ Failure Assessment (SOFA) score has become a key component of sepsis identification. Thus, it could be argued that reversal of this change (ΔSOFA) may reflect sepsis response and could be used as measure of efficacy in interventional trials. We aimed to assess the predictive performance of ΔSOFA for 28-day mortality.MethodsData from two previously published randomized controlled trials were studied: the first reporting on patients with severe Gram-negative infections as a derivation cohort and the second reporting on patients with ventilator-associated pneumonia as a validation cohort. Only patients with sepsis according to the Sepsis-3 definition were included in this analysis. SOFA scores were calculated on days 1, 2, 3, 5, 7, 14, and 28.ResultsWe included 448 patients within the derivation cohort and 199 within the validation cohort. Mean SOFA scores on day 1 were 6.06 ± 4.07 and 7.84 ± 3.39, and 28 day mortality 22.8% and 29.6%, respectively. In the derivation cohort, the earliest time point where ΔSOFA score predicted mortality was day 7 (AUROC (95% CI) 0.84 (0.80–0.89); p < 0.001). The best tradeoff for prediction was found with 25% changes (78% sensitivity, 80% specificity); less than 25% decrease of admission SOFA was associated with increased mortality (odds ratio for death 14.87). This finding was confirmed in the validation cohort.ConclusionsΔSOFA on day 7 is a useful early prognostic marker of 28-day mortality and could serve as an endpoint in future sepsis trials alongside mortality.Trial registrationClinicalTrials.gov numbers NCT01223690 and NCT00297674

Patient Harm from Repetitive Blood Draws and Blood Waste in the ICU: A Retrospective Cohort Study

Introduction: Frequent blood testing in the intensive care unit (ICU) is instrumental to patient diagnosis, monitoring, and titration of invasive therapies. However, there is a growing appreciation that a significant proportion of ICU blood tests are reflexive and unnecessary.1,2 Serial phlebotomy is associated with extended hospital length of stay and acquired anemia in the general hospital population.3 Since patients in the ICU are prone to developing anemia,4,5 they are likely at increased risk of harm from serial phlebotomy. In response, multiple recent campaigns advocate for physician restraint in laboratory test ordering.6,7 However, relatively little is known about the effect of excessive phlebotomy on outcomes in critically ill patients. Better understanding of ICU phlebotomy practices, and harms associated with serial testing, is important in planning, implementing, and evaluating phlebotomy reduction interventions. Objectives: 1) Quantify average daily phlebotomy volume for ICU patients including blood discarded as waste when accessing vascular devices. 2) Identify if average daily phlebotomy volume is an independent risk factor for ICU acquired anemia (hemoglobin &amp;lt; 80 g/L) or the need for red blood cell transfusion. 3) Explore the relationship between daily phlebotomy volume and hospital mortality. Methods: This was a retrospective cohort study at an academic tertiary care center in Toronto, Ontario, utilizing hospital administrative data, laboratory data, and select chart review. Index Medical Surgical ICU admissions between September 2014 and August 2015 with an ICU stay of three days or greater were included. Major bleeding events were defined as a hemoglobin drop of 30 g/L within a 24 hour period. Average daily phlebotomy volumes were calculated using the number of samples received by the lab multiplied by standard blood volumes required for each sample type. A bedside prospective audit was conducted in March 2018 to quantify average blood volume discarded as waste during phlebotomy. Blood discard/waste data were summarized with descriptive statistics, but not included in further analysis. Multivariable logistic regression was used to study the association between average daily phlebotomy volume and each of: nadir hemoglobin (&amp;lt; 80 g/L), the need for red blood cell transfusion, and hospital mortality. Patients with a major bleeding event were excluded from the regression. Control variables included sex, age, ICU length of stay, admission hemoglobin, and admission Sequential Organ Failure Assessment (SOFA) score. Results: There were a total of 525 index patient admissions, mean age 62.1 yr, 41% female (Table 1). Fifty-two (52) patients had a major bleeding event in the ICU. Mean phlebotomy volume per patient day was 28.3 mL (95% CI 27.4 - 29.1 mL, stdev 10.1 mL). Mean bedside waste during the phlebotomy audit (total of 144 blood draws) varied by vascular access: 3.9 mL for arterial, 5.5 mL for central venous, and 6.25 mL for peripherally inserted catheters. The mean estimated daily bedside waste for phlebotomy was 14.8 mL per patient day. Outcomes of logistical regression, excluding patients with major bleeding events, are summarized in Table 2. Average daily phlebotomy volume (mL) was predictive of nadir hemoglobin &amp;lt; 80 g/L (parameter estimate 0.091, p &amp;lt;0.001), the need for red blood cell transfusion (0.092, p&amp;lt;0.001), and inpatient mortality (0.053, &amp;lt;0.001). For every 5 mL increase in average daily phlebotomy, the odds ratio (OR) for nadir hemoglobin &amp;lt; 80 g/L was 1.58 (95% CI 1.31 - 1.90) and the OR for a red cell transfusion was 1.58 (95% CI 1.33 - 1.87). Conclusion: Daily ICU phlebotomy volume is associated with ICU acquired anemia and the need for red blood cell transfusion, including in a multivariable model with patient demographics, major bleeding events, and severity of illness as estimated by day 1 SOFA score. However, the ICU admission SOFA score was only weakly predictive of mortality, and the unexpected association between average daily phlebotomy and mortality needs to be further explored. It is possible that in this data set day 1 SOFA score did not completely control for severity of illness. Our findings support the need for ongoing phlebotomy stewardship interventions in the ICU. We suggest ICU acquired anemia and the need for red blood cell transfusion are appropriate patient outcome measures to evaluate stewardship interventions. Disclosures No relevant conflicts of interest to declare.

Describing organ dysfunction in the intensive care unit: a cohort study of 20,000 patients

BackgroundMultiple organ dysfunction is a common cause of morbidity and mortality in intensive care units (ICUs). Original development of the Sequential Organ Failure Assessment (SOFA) score was not to predict outcome, but to describe temporal changes in organ dysfunction in critically ill patients. Organ dysfunction scoring may be a reasonable surrogate outcome in clinical trials but further exploration of the impact of case mix on the temporal sequence of organ dysfunction is required. Our aim was to compare temporal changes in SOFA scores between hospital survivors and non-survivors.MethodsWe performed a population-based observational retrospective cohort study of critically ill patients admitted from January 1, 2004, to December 31, 2013, to 4 multisystem adult intensive care units (ICUs) in Calgary, Canada. The primary outcome was temporal changes in daily SOFA scores during the first 14 days of ICU admission. SOFA scores were modeled between hospital survivors and non-survivors using generalized estimating equations (GEE) and were also stratified by admission SOFA (≤ 11 versus > 11).ResultsThe cohort consisted of 20,007 patients with at least one SOFA score and was mostly male (58.2%) with a median age of 59 (interquartile range [IQR] 44–72). Median ICU length of stay was 3.5 (IQR 1.7–7.5) days. ICU and hospital mortality were 18.5% and 25.5%, respectively. Temporal change in SOFA scores varied by survival and admission SOFA score in a complicated relationship. Area under the receiver operating characteristic (ROC) curve using admission SOFA as a predictor of hospital mortality was 0.77. The hospital mortality rate was 5.6% for patients with an admission SOFA of 0–2 and 94.4% with an admission SOFA of 20–24. There was an approximately linear increase in hospital mortality for SOFA scores of 3–19 (range 8.7–84.7%).ConclusionsExamining the clinical course of organ dysfunction in a large non-selective cohort of patients provides insight into the utility of SOFA. We have demonstrated that hospital outcome is associated with both admission SOFA and the temporal rate of change in SOFA after admission. It is necessary to further explore the impact of additional clinical factors on the clinical course of SOFA with large datasets.

Risk factors for infection and evaluation of Sepsis-3 in patients with trauma

BackgroundWe aim to examine the risk factors associated with infection in trauma patients and the Sepsis-3 definition. MethodsThis was a retrospective cohort study of adult trauma patients admitted to a Level I trauma center between January 2014 and January 2016. ResultsA total of 1499 trauma patients met inclusion criteria and 15% (n = 232) had an infection. Only 19.8% (n = 46) of infected patients met criteria for Sepsis-3, with the majority (43%) of infected cases having a Sequential Organ Failure Assessment (SOFA) score greater on admission compared to the time of suspected infection. In-hospital death was 7% vs 9% (p = 0.65) between Sepsis-3 and infected patients, respectively. Risk factors associated with infection were female sex, admission SOFA score, Elixhauser score, and severe injury (P < 0.05). ConclusionPatients with trauma often arrive with organ dysfunction, which adds complexity and inaccuracy to the operational definition of Sepsis-3 using changes in SOFA scores. Injury severity score, comorbidities, SOFA score, and sex are risk factors associated with developing an infection after trauma.

Septic shock patients admitted to the intensive care unit with higher SOFA score tend to have higher incidence of abdominal compartment syndrome - a preliminary analysis.

Intra-abdominal hypertension (IAH) is relatively frequent in critical patients. According to the most recent consensus of the World Society of Abdominal Compartment Society (WSACS), there are no predictive factors for IAH diagnosis. Risk factors are the only motivators to date for early IAH diagnosis. Abdominal compartment syndrome (ACS) is defined as sustained intra-abdominal pressure (IAP) maintained above 20 mm Hg (> 3 kPa), with or without abdominal perfusion pressure below 60 mm Hg (< 8 kPa), associated with a new organ dysfunction. Sepsis is a recognized cause of secondary ACS, but to date there is no correlation with admission SOFA (sequential organ failure assessment) score and ACS onset incidence. The objective of the present study is to determine the profile of extra-abdominal septic shock patients with IAH/ACS admitted to the intensive care unit (ICU) and correlating with admission SOFA score. Better understanding of this population may bring to light clinical predictive factors for IAH/ACS early diagnosis. In this observational study IAH/ACS incidence was correlated with SOFA score calculated at ICU admission. The study enrolled all critically ill patients more than 18 years old admitted to the Medical Intensive Care Unit (MICU) of a university teaching hospital between April and October 2016, who had been diagnosed with extra-abdominal septic shock, according to the Surviving Sepsis Campaign and SEPSIS-3. Twenty-five patients were evaluated during 10 hospitalization days. The average age was 51.13 ± 16.52 years, and 64% of the patients were male. Most patients (76%) had pneumonia. On admission, the SOFA score was 6.54 ± 2.71. Mortality rate in the population studied was 52%. The incidence of IAH was 43.5%, while the incidence of ACS in the IAH population was 28%. SOFA admission score in patients with the diagnosis of ACS was of 8.42 ± 1.27. In this study SOFA score higher than 7 is correlated with IAH, with an accuracy of 68.8% (P < 0.03). The incidence of ACS in patients with extra-abdominal septic shock admitted to a university teaching hospital MICU was higher than those found in the literature. Higher admission and consecutive SOFA score of more than 7 was associated with higher ACS incidence and higher mortality rate.

Predictors of Survival in Patients with Advanced Gastrointestinal Malignancies Admitted to the Intensive Care Unit.

Patients with cancer have a high use of health care utilization at the end of life, which can frequently involve admissions to the intensive care unit (ICU). We sought to evaluate the predictors for outcome in patients with gastrointestinal (GI) cancer admitted to the ICU for nonsurgical conditions. The primary objective was to determine the predictors of hospital mortality. Secondary objectives included investigating the predictors of ICU mortality and hospital overall survival (OS). All patients with GI cancer admitted to the ICU at the University of Texas MD Anderson Cancer Center between November 2012 and February 2015 were retrospectively analyzed. Cancer characteristics, treatment characteristics, and Sequential Organ Failure Assessment (SOFA) scores were analyzed for their effects on survival. The characteristics of the 200 patients were as follows: 64.5% male, mean age of 60 years, median SOFA score of 6.7, and tumor types of intestinal (37.5%), hepatobiliary/pancreatic (36%), and gastroesophageal (24%). The hospital mortality was 41%, and overall 6-month mortality was 75%. In multivariate analysis, high admission SOFA score > 5, poor tumor differentiation, and duration of metastatic disease ≤7 months were associated with increased hospital mortality. For OS, high admission SOFA score > 5, poor tumor differentiation, and patients who were not on active chemotherapy because of poor performance had worse outcome. In multivariate analysis, SOFA score remained significant for OS even after excluding patients who died in the ICU. For patients with metastatic GI cancer admitted to the ICU, SOFA score was predictive for both acute and long-term survival. A patient's chemotherapy treatment status was not predictive for hospital mortality but was for OS. The SOFA score should be utilized in all patients with GI cancer upon ICU admission for prognostication. Patients with cancer have a high use of health care utilization at the end of life, which can frequently involve admissions to the intensive care unit (ICU). Although there have been substantial increases in duration of survival for patients with advanced metastatic cancer, their mortality after an ICU admission remains high. GI malignancy is considered one of the top three lethal cancers estimated in 2017. Survival of critically ill patients with advanced GI cancer should be evaluated to help guide treatment planning.

Relative tachycardia is associated with poor outcomes in post-cardiac arrest patients regardless of therapeutic hypothermia

BackgroundTo investigate whether the relationship between heart rate and neurological outcome is independent of therapeutic hypothermia (TH) and whether heart rate is related to hemodynamic instability post-cardiac arrest. MethodsRetrospective review of an out-of-hospital cardiac arrest registry was performed. The primary exposure was heart rate quartiles at 24 h post-cardiac arrest. The primary outcome was a poor neurological outcome, which was defined as having a cerebral performance category (CPC) of 3–5 at 28 days. Secondary outcomes were mean blood pressure and serum lactate at 24 h and Sequential Organ Failure Assessment (SOFA) scores at admission. ResultsIn total, 155 patients were enrolled. The proportion of patients with a poor CPC was significantly greater in higher heart rate quartiles; similar results were observed in patients who did and did not undergo TH. Serum lactate levels at 24 h were significantly higher in the 3rd and 4th quartile groups than in the 1st quartile group. Additionally, SOFA scores were significantly higher in the 4th quartile group than in the 1st and 3rd quartile groups. ConclusionsRelative tachycardia is associated with poor neurological outcomes in post-cardiac arrest patients, independent of TH, and with higher serum lactate levels and admission SOFA scores.

Value of SOFA, APACHE IV and SAPS II scoring systems in predicting short-term mortality in patients with acute myocarditis.

Acute myocarditis is an uncommon and potentially life-threatening disease. Scoring systems are essential for predicting outcome and evaluating the therapy effect of adult patients with acute myocarditis. The aim of this study was to determine the value of the Sequential Organ Failure Assessment (SOFA), Acute Physiology and Chronic Health Evaluation IV (APACHE IV) and second Simplified Acute Physiology Score (SAPS II) scoring systems in predicting short-term mortality of these patients. We retrospectively analyzed data from 305 adult patients suffering from acute myocarditis between April 2005 and August 2016. The association between the value of admission SOFA, APACHE IV and SAPS II scores and risk of short-term mortality was determined. Multivariate Cox analysis showed that SOFA, APACHE IV and SAPS II scores were independent risk factors of death in patients with acute myocarditis. For each scoring system, Kaplan–Meier analysis showed that the cumulative short-term mortality was significantly higher in patients with higher admission scores compared with those with lower admission scores. For the prediction of short-term mortality in a patient with acute myocarditis, SAPS II had the highest accuracy followed by the APACHE IV and SOFA scores.

The Association Between Visiting Intensivists and ICU Outcomes.

We hypothesized that intensivists unfamiliar with an ICU team and the context of that ICU would affect patient outcomes. We examined differences in mortality when ICU patients were admitted under intensivists routinely working in that ICU and compared with those admitted by intensivists familiar with an ICU elsewhere in the same hospital. A 5-year natural experimental crossover study involving patients admitted to four ICUs in a large U.K. teaching hospital. During a period of service reconfiguration, intensivists routinely rostered to work in one ICU worked in another of the hospital's four ICUs. "Home" intensivists were those who continued to work in their usual ICU; "visitor" intensivists were those who delivered care in an unfamiliar ICU. Patient data were obtained from electronic patient records to provide analysis on sex, age, admission Sequential Organ Failure Assessment score, date and time of admission, and admission type (elective, transfer, or unplanned). We analyzed 9,981 admissions to four separate ICUs over a 5-year period. In total, 34.5% of patients were admitted by intensivists working in nonfamiliar surroundings. Visitor intensivists admitted patients with similar age and gender distributions but with greater physiologic derangement (mean Sequential Organ Failure Assessment score, 4.1 ± 2.8 vs 3.9 ± 2.8; p < 0.001) than home intensivists. Overall ICU mortality rates were higher in visitor intensivists, albeit not significantly so (11.5% vs 10.2%; p = 0.052). However, when the ICUs were analyzed separately, visitor mortality rates were found to be significantly higher than for home intensivists in two of the four ICUs (p = 0.017, 0.006). A multivariable analysis adjusting for confounding factors and the clustering of consultants revealed that the overall mortality rate was significantly higher for visitors (odds ratio, 1.18; 95% CI, 1.02-1.37; p = 0.024). A significant interaction between the ICU and visitor status was also detected (p = 0.046), with the visitor effect remaining significant in the two ICUs identified previously (both p = 0.009). Visitor intensivists in some ICUs were associated with higher mortality. The reasons are unknown but could relate to intensivists' practices, unfamiliarity with the patients, or the interaction with the interprofessional team.

Predictors of survival in patients with gastrointestinal malignancies admitted to the intensive care unit.

e18050 Background: Cancer patients have a high use of healthcare utilization at the end of life which can frequently involve admissions to the intensive care unit (ICU). We sought to evaluate the predictors for outcome in gastrointestinal (GI) cancer patients admitted to the ICU for non-surgical conditions. Methods: The objective of this study was to determine the factors associated with ICU mortality, hospital mortality and overall survival (OS). A total of 200 patients with GI cancer admitted to the ICU at The University of Texas MD Anderson Cancer Center between November 2012 and February 2015 were retrospectively analyzed. Cancer characteristics, treatment characteristics, and Sequential Organ Failure Assessment (SOFA) scores defining severity based on 6 organ systems with scores ranging from 0 to 24 were analyzed for their effects on survival endpoints using multivariate logistic regression models and a multivariate Cox proportional hazards regression model. Results: The characteristics of the 200 patients were: 64.5% male, mean age of 60 years, median admission SOFA score of 6.0, and tumor types of primary intestinal (37.5%), hepatobiliary/pancreatic (36%), and gastroesophageal (GE) (24%). The ICU mortality was 26%, hospital mortality was 41%, and 6-month OS estimate was 25%. In multivariate analysis, ICU admission SOFA score &gt; 10 (odds ratio (OR) 17.1, p &lt; 0.0001), poorly differentiated tumor grade (OR 3.2, p = 0.02), and shorter duration of metastatic disease (OR 2.3, p = 0.07) were associated with increased odds of ICU mortality. These same variables were associated with increased odds of hospital mortality. In multivariate OS analysis, SOFA score 6-10 (hazard ratio (HR) 2.1, p = 0.0006) and SOFA score &gt; 10 (HR 4.4, p &lt; 0.0001), patients with GE primary (HR 2.2, p = 0.002) and patients with a poor outpatient performance status that precluded active chemotherapy (HR 2.2, p = 0.01) were associated with increased risk of death. Conclusions: The SOFA score was the most predictive factor for ICU mortality, hospital mortality, and OS for GI cancer patients admitted to the ICU. It should be utilized in all GI cancer patients upon ICU admission to improve both acute and longer-term prognostication.

Analysis of Anthrax Immune Globulin Intravenous with Antimicrobial Treatment in Injection Drug Users, Scotland, 2009-2010.

We studied anthrax immune globulin intravenous (AIG-IV) use from a 2009-2010 outbreak of Bacillus anthracis soft tissue infection in injection drug users in Scotland, UK, and we compared findings from 15 AIG-IV recipients with findings from 28 nonrecipients. Death rates did not differ significantly between recipients and nonrecipients (33% vs. 21%). However, whereas only 8 (27%) of 30 patients at low risk for death (admission sequential organ failure assessment score of 0-5) received AIG-IV, 7 (54%) of the 13 patients at high risk for death (sequential organ failure assessment score of 6-11) received treatment. AIG-IV recipients had surgery more often and, among survivors, had longer hospital stays than did nonrecipients. AIG-IV recipients were sicker than nonrecipients. This difference and the small number of higher risk patients confound assessment of AIG-IV effectiveness in this outbreak.

Outcome of Noncardiac Surgical Patients Admitted to a Multidisciplinary Intensive Care Unit.

Context:Surgical procedures carry significant morbidity and mortality depending on the type of surgery and patients. There is a dearth of evidence from India on the outcome of surgical patients admitted to an Intensive Care Unit (ICU).Aims:We aimed to describe the incidence and risk factors of postoperative complications and mortality in noncardiac surgical patients admitted to the ICU.Settings and Design:This was a prospective observational study on all perioperative patients admitted to a multidisciplinary ICU for 18 months.Subjects and Methods:Data on demography, admission Acute Physiology and Chronic Health Evaluation II (APACHE-II), Sequential Organ Failure Assessment (SOFA) scores, perioperative course, type and duration of surgery, reason for ICU admission, ICU interventions, and perioperative complications were recorded. The primary outcomes analyzed were perioperative complications and mortality.Results:The study included 762 patients with a mean age of (mean ± standard deviation [SD]) 50.5 ± 18 years and a male (58.4%) preponderance. The mean (±SD) admission APACHE-II and SOFA scores were 15 (±5.0) and 4.26 (±2.6), respectively. The most common reason for ICU admission was elective mechanical ventilation 50%, followed by prolonged surgery 26.2% and hemodynamic instability 21.2%. Most (51.1%) patients belonged to American Society of Anaesthesiologists physical Status III or IV and Lee's surgical risk Category I and II (66.8%). The most common surgical procedures performed were gastro-intestinal (28.5%) followed by interventional Neuro-radiology (14.0%) and orthopedic (13.9%). Overall perioperative complications were observed in 51.4% (n = 392). Common complications observed were hemodynamic instability 24%, hypothermia 17.2%, sepsis 17.3%, poor glycemic control 11.2%, perioperative myocardial infarction 7.1%, cardiac arrest 0.13%, and acute kidney injury (AKI) 10.1%. The overall hospital mortality was 7.9%. Multivariate logistic regression analysis showed that admission APACHE-II score, sepsis, AKI, and ICU length of stay were independent predictors for mortality.Conclusions:High risk perioperative patients after noncardiac surgery have significant mortality and morbidity.

Outcomes of elderly critically ill medical and surgical patients: a multicentre cohort study.

Very elderly (over 80yr of age) critically ill patients admitted to medical-surgical intensive care units (ICUs) have a high incidence of mortality, prolonged hospital length of stay, and dependent living conditions should they survive. The primary purpose of this study is to describe the outcomes and differences in outcomes between very elderly medical patients and their surgical counterparts admitted to Canadian ICUs, thereby informing decision-making for clinicians and substitute decision-makers. This was a prospective multicentre cohort study of very elderly medical and surgical patients admitted to 22 Canadian academic and non-academic ICUs. Outcome measures included ICU length of stay and mortality, hospital length of stay and mortality, and disposition following hospital discharge. There were 1,671 patients evaluated in this study. Patient demographics included a mean age of 84.5yr, baseline Acute Physiology and Chronic Health Evaluation (APACHE) II score of 22.4, baseline Sequential Organ Failure Assessment (SOFA) score of 5.3, overall ICU mortality of 21.8%, and overall hospital mortality of 35.0%. Medical patient median ICU length of stay was 4.1days, hospital length of stay was 16.2days, ICU mortality was 26.5%, and hospital mortality was 41.5%. Surgical patient median ICU length of stay was 3.8days, hospital length of stay was 20.1days, ICU mortality was 18.7%, and hospital mortality was 31.6%. Only 45.0% of medical patients and 41.6% of surgical emergency patients were able to return home to live. In this large sample of critically ill medical and surgical patients, the admission SOFA score and hospital lengths of stay were not different between the two groups, but medical patients had longer ICU lengths of stay and higher ICU and hospital mortality than surgical patients.

Cumulative Fluid Balance and Mortality in Septic Patients With or Without Acute Kidney Injury and Chronic Kidney Disease.

Incident acute kidney injury and prevalent chronic kidney disease are commonly encountered in septic patients. We examined the differential effect of acute kidney injury and chronic kidney disease on the association between cumulative fluid balance and hospital mortality in critically ill septic patients. Retrospective cohort study. Urban academic medical center ICU. ICU adult patients with severe sepsis or septic shock and serum creatinine measured within 3 months prior to and 72 hours of ICU admission. Patients with estimated glomerular filtration rate less than 15 mL/min/1.73 m or receiving chronic dialysis were excluded. None. A total of 2,632 patients, 1,211 with chronic kidney disease, were followed up until hospital death or discharge. Acute kidney injury occurred in 1,525 patients (57.9%), of whom 679 (44.5%) had chronic kidney disease. Hospital mortality occurred in 603 patients (22.9%). Every 1-L increase in cumulative fluid balance at 72 hours of ICU admission was independently associated with hospital mortality in all patients (adjusted odds ratio, 1.06 [95% CI] 1.04-1.08; p < 0.001), and in each acute kidney injury/chronic kidney disease subgroup (adjusted odds ratio, 1.06 [1.03-1.09] for acute kidney injury+/chronic kidney disease+; 1.09 [1.05-1.13] for acute kidney injury-/chronic kidney disease+; 1.05 [1.03-1.08] for acute kidney injury+/chronic kidney disease-; and 1.07 [1.02-1.11] for acute kidney injury-/chronic kidney disease-). There was a significant interaction between acute kidney injury and chronic kidney disease on cumulative fluid balance (p =0.005) such that different cumulative fluid balance cut-offs with the best prognostic accuracy for hospital mortality were identified: 5.9 L for acute kidney injury+/chronic kidney disease+; 3.8 L for acute kidney injury-/chronic kidney disease+; 4.3 L for acute kidney injury+/chronic kidney disease-; and 1.5 L for acute kidney injury-/chronic kidney disease-. The addition of cumulative fluid balance to the admission Sequential Organ Failure Assessment score had increased prognostic utility for hospital mortality when compared with Sequential Organ Failure Assessment alone, particularly in patients with acute kidney injury. Higher cumulative fluid balance at 72 hours of ICU admission was independently associated with hospital mortality regardless of acute kidney injury or chronic kidney disease presence. We characterized cumulative fluid balance cut-offs associated with hospital mortality based on acute kidney injury/chronic kidney disease status, underpinning the heterogeneity of fluid regulation in sepsis and kidney disease.

Spectrum and outcome of acute infectious encephalitis/encephalopathy in an intensive care unit from India.

To evaluate the spectrum of acute infectious encephalitis/encephalopathy syndrome (AIES) in intensive care unit (ICU) and the predictors of mechanical ventilation (MV) and outcome of these patients. AIES patients diagnosed on the basis of fever, altered sensorium, seizure and cerebrospinal fluid pleocytosis admitted to the neurology ICU were prospectively included. The demographic and clinical details, hematological, biochemical, MRI and etiological findings of the patients were noted. Need of MV, death in hospital and 3-month functional outcome were analyzed. One hundred sixty-four out of 258 (64%) AIES patients needed ICU admission. Their median age was 35 (2-85) years and 71 (43%) were females. The etiology was viral in 44 (herpes and Japanese encephalitis in 12 each, dengue in 17, mumps, measles and varicella in 1 patient each), non-viral in 64 (scrub typhus in 48, falciparum malaria in 6, leptospira in 3 and bacterial in 7) and undetermined etiology in 56 (34%) patients. Sixty-nine (42%) patients needed MV. On multivariate analysis, Glasgow Coma Scale (GCS) score, Sequential Organ Failure Assessment (SOFA) score and raised intracranial pressure were independent predictors of MV. Forty-three (26%) patients died, and all were in the MV group. Higher SOFA score and untreatable etiology were independent predictors of mortality. At 3-month follow-up, 14% had poor and 86% had good outcome. Low GCS score, focal weakness and status epilepticus independently predicted poor outcome. Twenty-six percent patients with AIES died in ICU, and 86% had good recovery at 3 months. Admission SOFA scores and untreatable etiology predicted mortality.

Two Decades of ICU Utilization and Hospital Outcomes in a Comprehensive Cancer Center.

To investigate ICU utilization and hospital outcomes of oncological patients admitted to a comprehensive cancer center. Observational cohort study. The University of Texas MD Anderson Cancer Center. Consecutive adults with cancer discharged over a 20-year period. None. The Cochran-Armitage test for trend was used to evaluate ICU utilization and hospital mortality rates by primary service over time. A negative binomial log linear regression model was fitted to the data to investigate length of stay over time. Among 387,306 adult hospitalized patients, the ICU utilization rate was 12.9%. The overall hospital mortality rate was 3.6%: 16.2% among patients with an ICU stay and 1.8% among non-ICU patients. Among those admitted to the ICU, the mean (SD) admission Sequential Organ Failure Assessment score was 6.1 (3.8) for all ICU patients: 7.3 (4.4) for medical ICU patients and 4.9 (2.8) for surgical ICU patients. Hematologic disorders were associated with the highest hospital mortality rate in ICU patients (42.8%); metastatic disease had the highest mortality rate in non-ICU patients (4.2%); sepsis, pneumonia, and other infections had the highest mortality rate for all inpatients (8.5%). This study provides a longitudinal view of ICU utilization rates, hospital and ICU length of stay, and severity-adjusted mortality rates. Although the data arise from a single institution, it encompasses a large number of hospital admissions over two decades and can serve as a point of comparison for future oncological studies at similar institutions. More studies of this nature are needed to determine whether consolidation of cancer care into specialized large-volume facilities may improve outcomes, while simultaneously sustaining appropriate resource utilization and reducing unnecessary healthcare costs.

COMPARISON OF PATIENTS' ADMISSION, MEAN AND HIGHEST SOFA SCORES IN PREDICTION OF ICU MORTALITY: A PROSPECTIVE OBSERVATIONAL STUDY.

Background:Use of valid criteria for evaluation of patients admitted to intensive care unit (ICU) is essential to assess the quality of services provided. This study was conducted to evaluate admission, mean and the highest Sequential Organ Failure Assessment (SOFA) scores in predicting mortality and outcome of patients admitted to the ICU.Methods:This prospective observational study was conducted on 300 patients admitted to the ICU of Imam Khomeini Hospital, Sari, Iran, in 2015. The SOFA tool was applied at the beginning of the admission of patients in the ICU and then every 24 hours. Functions of six vital organs were recorded on a daily basis for scoring with SOFA. Demographic profile, the main diagnosis leading to hospitalization in the ICU, previous interventions, complications and hospital outcomes were recorded for each patient. The patients’ admission, mean and highest SOFA scores were also evaluated and recorded during the study period. These scores were compared between deceased and survived patients. ROC curve determined the best cut-off point of score calculated.Results:Among all 300 patients who were enrolled in the study, 189 (63%) cases were males. Trauma was the most common cause of hospitalization and mortality. Thirty point seven percent of 92 deceased patients needed to intubation. Mean length of ICU and hospital stay were significantly longer for deceased patients than the survivors (P <0.001). The admission, mean and highest SOFA scores were 11.72, 16.38 and 16.45 in deceased patients, as well as 6.52, 5.82 and 6.5 in survived patients, respectively. The area under the curve (AUC) for the admission, mean and highest SOFA scores were 0.875, 0.988 and 0982, respectively. All three models were able to predict the outcome of patients significantly (P <0.0001). The cut-off point of 10.6 for the mean SOFA had the highest sensitivity and specificity in predicting mortality.Conclusion:The results of this study showed that the mean SOFA score had the highest sensitivity and specificity in prediction of ICU mortality. Therefore, this criterion is a valuable indicator to better predictions of mortality and morbidity rate in the ICU patients, which can lead to appropriate health care and therapeutic interventions in these patients.

Validity of a Modified Sequential Organ Failure Assessment Score Using the Richmond Agitation-Sedation Scale.

The Sequential Organ Failure Assessment and other severity of illness scales rely on the Glasgow Coma Scale to measure acute neurologic dysfunction, but the Glasgow Coma Scale is unavailable or inconsistently applied in some institutions. The objective of this study was to assess the validity of a modified Sequential Organ Failure Assessment that uses the Richmond Agitation-Sedation Scale instead of Glasgow Coma Scale. Prospective cohort study. Medical and surgical ICUs within a large, tertiary care hospital. Critically ill medical/surgical ICU patients. We calculated daily Sequential Organ Failure Assessment scores by using electronic medical record-derived data. By using bedside nurse-recorded Glasgow Coma Scale and Richmond Agitation-Sedation Scale measures, we calculated neurologic Sequential Organ Failure Assessment scores using the original Glasgow Coma Scale-based approach and a novel Richmond Agitation-Sedation Scale-based approach, converting the 10-point Richmond Agitation-Sedation Scale to a 4-point neurologic Sequential Organ Failure Assessment score. We assessed construct validity of Richmond Agitation-Sedation Scale-based Sequential Organ Failure Assessment by analyzing correlations with established severity of illness constructs (Acute Physiology and Chronic Health Evaluation II and Glasgow Coma Scale-based Sequential Organ Failure Assessment) and predictive validity by using logistic regression to determine whether Richmond Agitation-Sedation Scale-based Sequential Organ Failure Assessment predicts ICU, hospital, and 1-year mortality. We assessed discriminative performance with c-statistics. Among 513 patients (5,199 patient-days), Richmond Agitation-Sedation Scale-based Sequential Organ Failure Assessment was strongly correlated with Acute Physiology and Chronic Health Evaluation II acute physiology score at enrollment (r = 0.583; 95% CI, 0.518-0.642) and daily Glasgow Coma Scale-based Sequential Organ Failure Assessment scores (r = 0.963; 95% CI, 0.956-0.968). Mean Richmond Agitation-Sedation Scale-based Sequential Organ Failure Assessment scores predicted ICU mortality (areas under the curve = 0.814)-as did mean Glasgow Coma Scale-based Sequential Organ Failure Assessment (0.799)-as well as hospital and 1-year mortality. Admission Sequential Organ Failure Assessment scores, whether using Richmond Agitation-Sedation Scale or Glasgow Coma Scale, were less accurate predictors of mortality; areas under the curves for ICU mortality for Richmond Agitation-Sedation Scale-based and Glasgow Coma Scale-based Sequential Organ Failure Assessment, for example, were 0.622 and 0.608, respectively. A modified Sequential Organ Failure Assessment score that uses bedside Richmond Agitation-Sedation Scale when Glasgow Coma Scale data are not available is a valid means of assessing daily severity of illness in the ICU and may be valuable for risk-adjustment and benchmarking purposes.

Rhabdomyolysis and acute kidney injury in patients with traumatic spinal cord injury.

Background:Patients with acute traumatic spinal cord injuries (SCIs) exhibit factors that, in other populations, have been associated with rhabdomyolysis.Purpose:The aim of the study is to determine the incidence of rhabdomyolysis in patients with acute traumatic SCI admitted to the Intensive Care Unit (ICU), as well as the development of secondary acute kidney injury and associated factors.Study Design and Setting:This was an observational, retrospective study.Patient Sample:All adult patients admitted to the ICU with acute traumatic SCI who presented rhabdomyolysis, diagnosed through creatine phosphokinase (CPK) levels >500 IU/L.Outcome Measures:Incidence of rhabdomyolysis and subsequent renal dysfunction was calculated.Materials and Methods:Data about demographic variables, comorbidity, rhabdomyolysis risk factors, and variables involving SCI, severity scores, and laboratory parameters were obtained from clinical records. Multivariate logistic regression was used to identify renal injury risk factors.Results:In 2006–2014, 200 patients with acute SCI were admitted to ICU. Of these, 103 had rhabdomyolysis (incidence = 51.5%; 95% confidence interval [CI]: 44.3%–58.7%). The most typical American Spinal Injury Association classification was A (70.3%). The injury severity score was 30.3 ± 12.1 and sequential organ failure assessment (SOFA) score was 5.6 ± 3.3 points. During their stay, 57 patients (55.3%; 95% CI: 45.2%–65.4%) presented renal dysfunction (creatinine ≥1.2 mg/dL). In the multivariate analysis, variables associated with renal dysfunction were creatinine at admission (odds ratio [OR] = 9.20; P = 0.006) and hemodynamic SOFA score the day following admission (OR = 1.33; P = 0.024). Creatinine was a better predictor of renal dysfunction than the peak CPK value during the rhabdomyolysis (area under the receiver operating characteristic curve: 0.91 vs. 0.63, respectively).Conclusions:Rhabdomyolysis is a frequent condition in patients with acute traumatic SCI admitted to the ICU, and renal dysfunction occurs in half of the cases. Creatinine values should be requested starting at the admission while neither the peak CPK values nor the hemodynamic SOFA scores could be used to properly discriminate between patients with and without renal dysfunction.

Abstract 18302: Left Ventricular Structure by Echocardiography is Associated With Vasopressor Requirements and Severity of Organ Failure After Cardiac Arrest

Introduction: Patients resuscitated from cardiac arrest (CA) often require vasopressors for hemodynamic support and frequently have cardiac dysfunction identified on transthoracic echocardiography (TTE). The association between TTE parameters and vasopressor requirements is not well-described. Hypothesis: Echocardiographic findings early after resuscitation from CA will predict vasopressor requirements. Methods: Prospective registry of patients resuscitated from CA underwent TTE within 24 hours after CA. We determined 2D measurements, LVEF, spectral Doppler of mitral inflow (E) and LV outflow and systolic and early diastolic (e’) tissue Doppler of the mitral annulus. Using Pearson correlation coefficients, we examined the association between TTE parameters and number of vasopressor drugs, cumulative vasopressor index (CVI) and Sequential Organ Failure Assessment (SOFA) score. Mean values of TTE parameters were compared in patients with high and low cardiovascular SOFA subscores using t-tests. Results: Among the 55 patients, LV end-diastolic diameter (LVEDD, r = -0.498 to -0.569, p = 0.0001 to 0.0003), LV end-systolic diameter (LVESD, r = -0.392 to -0.463, p = 0.0008 to 0.0053) and LV relative wall thickness (RWT, r = 0.452 to 0.503, p = 0.0002 to 0.0011) correlated significantly with admission and peak 24 hour number of vasopressor drugs and CVI. LVEDD (r = -0.324, p = 0.0229), LVESD (r = -0.290, p = 0.0431), RWT (0.429, p = 0.0021) and septal e’ velocity (r = -0.344, p = 0.037) correlated with admission SOFA score. Other TTE parameters including LVEF did not correlate with vasopressor requirements or SOFA score. Patients with cardiovascular SOFA subscore = 4 had lower LVEDD (4.16cm vs. 5.0cm, p = 0.0008), lower LVESD (3.07cm vs. 4.03cm, p = 0.0008), higher RWT (0.48 vs. 0.65, p = 0.0026) and lower E/e’ ratio (10.84 vs. 18.91, p = 0.0169) compared with patients with cardiovascular SOFA subscore &lt; 4. Conclusions: A smaller, thicker LV cavity by echocardiography at 24 hours after CA is associated with higher vasopressor requirements and more severe organ failure. Patients who required more vasopressor support had smaller, thicker LV cavities and a lower E/e’ ratio. LV systolic dysfunction was not a significant predictor of vasopressor requirements.