Average Acute Physiology And Chronic Health Evaluation Research Articles

Novel Glycemic Index Based on Continuous Glucose Monitoring to Predict Poor Clinical Outcomes in Critically Ill Patients: A Pilot Study.

AimWe explored the prospective relationship between continuous glucose monitoring (CGM) metrics and clinical outcomes in patients admitted to the intensive care unit (ICU).Materials and MethodsWe enrolled critically ill patients admitted to the medical ICU. Patients with an Acute Physiology and Chronic Health Evaluation (APACHE) score ≤9 or ICU stay ≤48 h were excluded. CGM was performed for five days, and standardized CGM metrics were analyzed. The duration of ICU stay and 28-day mortality rate were evaluated as outcomes.ResultsA total of 36 patients were included in this study (age [range], 49–88 years; men, 55.6%). The average APACHE score was 25.4 ± 8.3; 33 (91.7%) patients required ventilator support, and 16 (44.4%) patients had diabetes. The duration of ICU stay showed a positive correlation with the average blood glucose level, glucose management indicator (GMI), time above range, and GMI minus (-) glycated hemoglobin (HbA1c). Eight (22.2%) patients died within 28 days, and their average blood glucose levels, GMI, and GMI-HbA1c were significantly higher than those of survivors (p<0.05). After adjustments for age, sex, presence of diabetes, APACHE score, and dose of steroid administered, the GMI-HbA1c was associated with the risk of longer ICU stay (coefficient=2.34, 95% CI 0.54-4.14, p=0.017) and higher 28-day mortality rate (HR=2.42, 95% CI 1.01-5.76, p=0.046).ConclusionThe acute glycemic gap, assessed as GMI-HbA1c, is an independent risk factor for longer ICU stay and 28-day mortality rate. In the ICU setting, CGM of critically ill patients might be beneficial, irrespective of the presence of diabetes.

Predictors of mortality in patients with carbapenem-resistant Klebsiella pneumoniae infection: a meta-analysis and a systematic review.

Cases of carbapenem-resistant Klebsiella pneumoniae infection have been increasing. Patients with carbapenem-resistant Klebsiella pneumoniae infection have a poor prognosis and a high mortality rate. Identification of potential risk factors associated with carbapenem-resistant Klebsiella pneumoniae infection-related mortality may help improve patient outcomes. Embase, PubMed, and the Cochrane Library databases were searched to identify articles describing predictors of mortality in patients with carbapenem-resistant Klebsiella pneumoniae infection. The quality of articles was assessed with the Newcastle-Ottawa Scale score (NOS). Review Manager was used for statistical analyses. Twenty-seven observational studies were included in the analysis. Factors associated with higher mortality were septic shock [odds ratio (OR): 4.41, 95% CI: 3.17-6.15], congestive heart failure (OR: 2.65, 95% CI: 1.71-4.13), chronic obstructive pulmonary disease (COPD; OR: 2.43, 95% CI: 1.87-3.15), chronic kidney disease (CKD; OR: 1.78, 95% CI: 1.43-2.22), diabetes mellitus (OR: 1.41, 95% CI: 1.16-1.72), mechanical ventilation (OR: 1.65, 95% CI: 1.25-2.18), and inappropriate empirical antimicrobial treatment (OR: 1.25, 95% CI: 1.03-1.52). The average Acute Physiology and Chronic Health Evaluation (APACHE) II score at the time of diagnosis of carbapenem-resistant Klebsiella pneumoniae infection was considerably higher in patients who did not survive than in those who survived (weighted mean difference: 5.86, 95% CI: 2.46-9.26). Patient condition, timing appropriate antimicrobial treatment, and disease severity according to the APACHE II score are the most important risk factors for death in patients with carbapenem-resistant Klebsiella pneumoniae infection. Our finding may help predict patients' outcomes and improve management for them. 20210417EuEGX/INPLASY2020100037.

Intracolonic Administration of Vancomycin in Intensive Care Unit Patients with Severe Clostridium Difficile Colitis.

Background: Clostridium difficile infection (CDI) is a major cause of antibiotic-associated diarrhea worldwide. The incidence of sepsis has been shown to be increasing due to severe or fulminant colitis. Oral vancomycin is the treatment of choice for CDI, but it is often ineffective in patients in the intensive care unit (ICU) due to poor intestinal motility. We present a review of eight cases with severe to fulminant CDI treated with adjunctive intracolonic vancomycin (ICV) administration.Methods: A retrospective chart review identified patients in sepsis with severe colitis and positive Clostridium difficile toxin A or B. Patients who had failed standard therapy for CDI were given adjunctive ICV through an enteric tube, which was inserted via colonoscopy. To indicate the severity of patients, the patients selected had required vasopressor support.Results: Eight patients (37.5% females) received this adjunctive treatment; the mean age was 73.25. The average Acute Physiology and Chronic Health Evaluation (APACHE) 2 score at the time of the procedure was 39. The median length of stay was 5.5 days, with in-hospital mortality of 37.5% and an average time to death of 1.33 days from the day of colonoscopy. Conclusion: Colonoscopic decompression and administration of vancomycin for fulminant CDI using an enteric tube can have favorable outcomes in severely ill patients whose surgical options carry a high risk of mortality. Further larger randomized controlled trials are needed to evaluate its efficacy.

ICU Telemedicine Implementation and Risk-Adjusted Mortality Differences Between Daytime and Nighttime Coverage

ICU telemedicine augmentation has been associated with improvements in clinical and financial outcomes in many cases, but not all. Understanding this discrepancy is of interest given the clinical impact and intervention cost. A recent meta-analysis noted an association with mortality reduction and standardized mortality ratio (SMR) before ICU telemedicine implementation of >1. Does ICU telemedicine implementation affect adjusted mortality outcomes? If so, in what context? We performed a retrospective pre-post analysis comparing before vsafter ICU telemedicine implementation on the outcome of risk-adjusted ICU mortality during am vspm admissions as well as other objective measures of ICU telemedicine involvement. One thousand five hundred eighty-one patient-stays and 14,584 patient-stays were available for analysis in the implementation period before vsafter ICU telemedicine implementation, respectively. The average Acute Physiology and Chronic Health Evaluation (APACHE) IVa score was 46.6 vs54.8 (P< .01) in the am group before ICU telemedicine implementation vsthe am group after ICU telemedicine implementation, respectively. The average APACHE IVa score was 47.2 vs56.3 (P< .01) in the pm group before ICU telemedicine implementation vsthe pm group after ICU telemedicine implementation, respectively. Overall, the risk-adjusted ICU mortality was 8.7%before ICU telemedicine implementation vs6.5%(P< .01) after implementation. When stratified by am and pm admission groups, no significant difference in risk-adjusted ICU mortality was seen in the am stratum. In the pm stratum, risk-adjusted mortality was 10.8%before ICU telemedicine implementation vs7.0%(P< .01) after ICU telemedicine implementation. The preimplementation SMR in the am admission stratum was 0.95 vs1.30 in the pm stratum. We found a reduction in risk-adjusted ICU mortality with implementation of ICU telemedicine driven predominantly within the pm admission group. The pm admission SMR was 1.30, which may suggest an association with SMR of > 1 before ICU telemedicine implementation and mortality reduction. Future studies should seek to confirm this finding and should explore other important ICU telemedicine outcomes in the context of observed-to-expected ratios.

Oxidative stress is important in the pathogenesis of stress-related mucosal disease.

Stress-related mucosal disease (SRMD) is a common complication in patients in the intensive care unit (ICU). The aim of the present study was to investigate the possible mechanisms for the pathogenesis of SRMD. In total, 38 patients with SRMD were enrolled from an ICU, as well as 15 healthy volunteers. The disease severity of patients in ICU was evaluated using the Acute Physiology and Chronic Health Evaluation (APACHE) II score. Gastric mucosa with the most severe lesions were biopsied for hematoxylin and eosin staining and then assessed by pathological damage scoring. The serum levels of malondialdehyde (MDA), superoxide dismutase (SOD) and ischemic modified albumin (IMA) were also detected. In addition, claudin-3 and inducible nitric oxide (NO) synthase (iNOS) in the gastric mucosa were assessed by western blotting and immunohistochemistry. The average APACHE II score of the patients with SRMD was significantly higher compared with the controls. Moreover, the levels of MDA (4.74±2.89 nmol/ml) and IMA (93.61±10.78 U/ml) in patients with SRMD were significantly higher compared with the controls (P<0.001), while those of SOD (89.66±12.85 U/ml) in the patients with SRMD were significantly lower compared with the controls (P<0.001). Furthermore, compared with the control, iNOS expression was significantly higher (P=0.034), while the expression of claudin-3 was significantly lower in patients with SRMD (P<0.001). The results indicated that APACHE II score was positively correlated with pathological damage score (r=0.639, P<0.001) and levels of MDA (r=0.743, P<0.001), but negatively correlated with the level of SOD (r=-0.392, P=0.015). In addition, MDA was positively correlated with IMA (r=0.380, P=0.018), but negatively correlated with claudin-3 (r=-0.377, P=0.020). Therefore, it was speculated that oxidative stress may play an important role in the pathogenesis of SRMD, and NO levels and cell membrane permeability are altered during this process.

Effect of Allocetra-OTS (off-the-shelf apoptotic cells) Therapy in Sepsis

Background & Aim Sepsis, which has been identified by the World Health Organization (WHO) as a global health priority, has no proven pharmacologic treatment other than appropriate antibiotic agents, fluids, vasopressors as needed, and possibly corticosteroids. Reported death rates among hospitalized patients are up to 45%. In sepsis, binding of either pathogen-associated molecular patterns (PAMPs) or damage-associated molecular patterns (DAMPs) among others, induces a complex intracellular signaling system with redundant and complementary activities. Allocetra-OTS (early apoptotic cells) was shown to have a beneficial effect on cytokine storms with downregulation of both anti- and pro-inflammatory cytokines and was prepared from a non-matched donor as described (Mevorach et al. BBMT, 2014) and 140 × 106 cells/kg I.V. in one or two doses were given within 24 hours of diagnosis to 10 patients with sepsis (ClinicalTrials.gov Identifier: NCT03925857).The primary aim was to determine the safety profile and the secondary aims were to determine the preliminary efficacy. Serum cytokine/chemokine and immune modulators measurement was performed sequentially using the Luminex MAGPIX system. Methods, Results & Conclusion All patients were with GCS of at least 13, verbal 5/5, due to the consent requirement. The average Acute Physiology and Chronic Health Evaluation (APACHE) II score was 12.3 (range 8–21) and the average SOFA score upon presentation was 3.4 (range 2–6) in treated patients. All patients fulfilled inclusion and exclusion criteria and met the 2016 definition of sepsis (Singer et al., 2016). All were hospitalized at admission in ICU and experienced a recovery from the septic condition and were discharged alive from the hospital following the resolution of sepsis and completed 28 days of follow-up. No SAEs were reported. No AEs were related to the investigational product. The predicted mortality by the APACHE II score was 18.1% and predicted probability of no death in these 10 patients was 0.15. The predicted mortality by SOFA score at presentation was > 10%, and in 36 matched-historical controls was 27.7%. The study population would have expected to have a mortality rate between 10–27%. Resolution of >20 pro- and anti-inflammatory cytokines was documented. Length of stay in ICU was significantly shorter (p The results of 0% mortality and rapid resolution of sepsis show no safety concerns with a potential preliminary efficacy.

Estimating severity of influenza epidemics from severe acute respiratory infections (SARI) in intensive care units

BackgroundWhile influenza-like-illness (ILI) surveillance is well-organized at primary care level in Europe, few data are available on more severe cases. With retrospective data from intensive care units (ICU) we aim to fill this current knowledge gap. Using multiple parameters proposed by the World Health Organization we estimate the burden of severe acute respiratory infections (SARI) in the ICU and how this varies between influenza epidemics.MethodsWe analyzed weekly ICU admissions in the Netherlands (2007–2016) from the National Intensive Care Evaluation (NICE) quality registry (100% coverage of adult ICUs in 2016; population size 14 million) to calculate SARI incidence, SARI peak levels, ICU SARI mortality, SARI mean Acute Physiology and Chronic Health Evaluation (APACHE) IV score, and the ICU SARI/ILI ratio. These parameters were calculated both yearly and per separate influenza epidemic (defined epidemic weeks). A SARI syndrome was defined as admission diagnosis being any of six pneumonia or pulmonary sepsis codes in the APACHE IV prognostic model. Influenza epidemic periods were retrieved from primary care sentinel influenza surveillance data.ResultsAnnually, an average of 13% of medical admissions to adult ICUs were for a SARI but varied widely between weeks (minimum 5% to maximum 25% per week). Admissions for bacterial pneumonia (59%) and pulmonary sepsis (25%) contributed most to ICU SARI. Between the eight different influenza epidemics under study, the value of each of the severity parameters varied. Per parameter the minimum and maximum of those eight values were as follows: ICU SARI incidence 558–2400 cumulated admissions nationwide, rate 0.40–1.71/10,000 inhabitants; average APACHE score 71–78; ICU SARI mortality 13–20%; ICU SARI/ILI ratio 8–17 cases per 1000 expected medically attended ILI in primary care); peak-incidence 101–188 ICU SARI admissions in highest-incidence week, rate 0.07–0.13/10,000 population).ConclusionsIn the ICU there is great variation between the yearly influenza epidemic periods in terms of different influenza severity parameters. The parameters also complement each other by reflecting different aspects of severity. Prospective syndromic ICU SARI surveillance, as proposed by the World Health Organization, thereby would provide insight into the severity of ongoing influenza epidemics, which differ from season to season.

Analysis of risk factors for urinary catheter-associated urinary tract infections in patients in aged intensive care unit

Objectives To investigate the risk factors associated with catheter-associated urinary tract infections(CAUTIs)in patients in aged intensive care unit(ICU). Methods 226 cases of patients over 65 years old with CAUTIs in aged ICU from December 2013 to September 2015 were retrospectively analyzed.CAUTIs occurred in 49 cases, with an average age of(84±6.8)years, ranging from 65 to 101 years.The clinical data were collected and risk factors for CAUTIs were explored. Results Among all 226 cases, the average length of stay in intensive care unit was(38.6±48.4)days.The mean number of hospital days were(88.7±101.8)days.The average acute physiology and chronic health evaluation(APACHE)Ⅱ score was 22.9±7.6 on admission to ICU.Rate of anus swabs(P<0.05), transfusion(P<0.01), intensive care unit length of stay(P<0.05)coloclysis(P<0.05), bladder irrigation(P<0.01), catheterization(P<0.01), indwelling catheter time(P<0.01), duration of mechanical ventilation(P<0.01), and gastrointestinal decompression(P<0.01)were all higher in patients with CAUTIs than in CAUTIs-free patients(P<0.05). Multivariable logistic regression analysis showed that age(P<0.01), bladder irrigation(P<0.05), mechanical ventilation(P<0.01)and gastrointestinal decompression(P<0.05)were the risk factors for CAUTIs(P<0.05). And according to COX regression analysis, the intensive care unit length of stay(P<0.01), transfusion(P=0.002), indwelling catheter time(P<0.01), catheterization(P<0.05)and mechanical ventilation(P<0.01)remained significantly associated with patient survival time. Conclusions Age, bladder irrigation, mechanical ventilation and gastrointestinal decompression are risk factors for CAUTIs.The incidence of urinary tract infection is increased with ageing.Morbidity of CAUTIs is increased when length of stay in intensive care unit is more than 90 days and mechanical ventilation time is more than 90 days. Key words: Urinary catheterization; Urinary tract infections; Risk factors

Double filtration plasmapheresis in the treatment of pancreatitis due to severe hypertriglyceridemia

Severe hypertriglyceridemia (HTG) leads to major complications such as acute pancreatitis. Lipoprotein apheresis has been proposed as a therapeutic tool for decreasing triglyceride levels, although experience is limited. To describe our experience with double filtration plasmapheresis (DFPP) in patients with severe HTG and pancreatitis in the plasmapheresis unit of a tertiary hospital in Spain. We recruited 4 patients with severe HTG (triglycerides [TGs] >1000 mg/dL) and acute pancreatitis. All the patients underwent DFPP as part of their treatment. Epidemiologic and laboratory data were collected before and after each plasmapheresis session. The average TG level before plasmapheresis was 3136 mg/dL (35.44 mmol/L; range, 1306-6693 mg/dL, 14.76-75.63 mmol/L), and the average Acute Physiology And Chronic Health Evaluation (APACHE) II level before the first session was 6 (range, 3-8). All patients made a full recovery, with a significant improvement in TG levels after plasmapheresis. The mean number of sessions was 2.1 (range, 1-3), and mean TG level after plasmapheresis was 428 mg/dL (4.84 mmol/L; range, 169-515 mg/dL; 1.91-5.82 mmol/L). After the first session, the mean decrease in TG levels was 69.16% (2169 mg/dL, range, 945-5925 mg/dL; 24.51 mmol/L, range, 10.78-66.95 mmol/L), and after the last session, TG levels fell by 89.09% (2794 mg/dL, range, 945-6198 mg/dL; 31.57 mmol/L, range, 10.68-70.04 mmol/L). None of the patients developed complications related to plasmapheresis. According to available evidence and our own experience, DFPP can be an effective and rapid treatment option in patients with severe HTG and complications. However, further research, including randomized controlled studies, is necessary.

Resistance and infection analysis of multidrug-resistant Acinetobacter baumannii in intensive care unit

Objective In order to prevent the infection of Acinetobacter baumannii and use antibiotics rationally, the clinical infection and drug resistant data of multi-drug resistance Acinetobacter baumannii (MRAB) detected in intensive care unit (ICU) of Beijing Friendship Hospital from 2011 to 2013were analyzed. Methods This study is a retrospective study. One hundred and eighty five strains of MRAB were collected from the patients in ICU from January 2011 to December 2013. Identificationand antibiotic susceptibility of strains were determined with Vitek-2 Compact automatic bacteria identification system. The annual infection rate of MRAB was counted. PCR was used to detect the resistance genes. The clinical features of the patients with MRAB were analyzed. The average age, acute physiology and chronic health evaluation (APACHE) Ⅱ score, duration in ICU and mortality ratio of the MRAB patients were compared with the patients without MRAB. Rank-sum test was used to analyze the average age, APACHE Ⅱscore and duration in ICU. Chi-squared test was used to analyze the mortality ratio and annual infection rate. Results The average age [(67±17) vs (59±19) years old, Z=-5.365, P=0], APACHEⅡ score [(25.68±7.93) vs (17.62±8.39), Z=-14.821, P=0], duration in ICU [(27±29) vs (5±8) d, Z=-4.342, P=0] and mortality ratio [10.82% (53/185) vs 28.65% (147/1 359), χ2=45.92, P=0] of the patients infected by MRAB were significantly higher than those without the infection. The MRAB was found mostly in sputum and bronchial precipitates (83.78%, 155/185). Though detection rate reduced yearly and there was a significant reduction in 2013 compared with 2011 [11.07% (69/469) vs 8.37% (52/621), χ2=8.755, P=0.003], the drug resistant rate was in high level and did not show any change in the 3 years. OXA-23 and OXA-51 were detected in all MRAB. Conclusions The main drug resistant mechanism of MRAB in ICU is related to OXA-23. More active methods of control and prevention of MRAB should be used in elderly and severely pneumonic patients. Intensive disinfection and isolation measures can decrease MRAB detection rate. Combined antibiotics should be used in patients with MRAB infection. (Chin J Lab Med, 2015, 38: 55-58) Key words: Acinetobacter baumannii; Drug resistance, multiple, bacterial; Intensive care units

The Differences in the Epidemiology and Predictors of Death between Candidemia Acquired in Intensive Care Units and Other Hospital Settings.

The burden of candidemia is shifting from intensive care units (ICU) to non-ICU settings. This study aimed to define the differences in epidemiology and predictors of death between ICU-acquired candidemia (ICUAC) and non-ICUAC. We conducted a retrospective study of 80 patients with ICUAC and 147 patients with non-IUCAC at five hospitals. The distribution of Candida species and resistance to antifungal agents did not differ between the ICUAC and non-ICUAC groups. ICUAC patients received more echinocandins and less triazoles, as well as more adequate antifungal therapy than non-ICUAC patients (all p<0.05). ICUAC patients had a significantly higher average acute physiology and chronic health evaluation (APACHE) II score (21.0±7.9 vs. 17.8±8.6; p<0.01), Sequential Organ Failure Assessment score (9.2±5.5 vs. 7.4±3.9; p<0.05) and day-90 mortality rate (52.5% vs. 36.7%; p<0.05) when compared to non-ICUAC patients. Using a multivariate logistic analysis, adequate antifungal therapy was found to be the only protective factor for death in both groups. Respiratory failure supported with invasive mechanical ventilation, renal failure supported with replacement therapy and an APACHE II score ≥20 were independent predictors of death in ICUAC patients, while age ≥60 years, concurrent bacteremia and APACHE II score ≥20 were independent predictors of death in non-ICUAC patients. The Candida species and antifungal resistance profiles in patients with ICUAC were similar to non-ICUAC patients, but led to worse outcomes. The protective and risk factors for death may therefore be relevant for the clinical management of patients with candidemia in ICU and non-ICU settings.

Drug-Susceptible S. aureus Still Dangerous

Bruce Jancin is with the Denver bureau of Elsevier Global Medical News. VIENNA – Methicillin-resistant Staphylococcus aureus bloodstream infections grab the headlines and are the focus of many infection-prevention directives, but methicillin-susceptible S. aureus infections, which receive far less attention, have comparable morbidity and mortality, according to two European studies. “MSSA bloodstream infection is MRSA's evil twin,” Michael Laum, MD, said at the European Congress of Clinical Microbiology and Infectious Diseases. He compared key outcomes for 52 patients with MSSA bloodstream infection and 16 with MRSA bloodstream infection at Blackpool Victoria Hospital in Lancashire, England, during a 20-month period starting in November 2007. There were far fewer cases of MRSA infection because incidence plunged by 78% in the year after the hospital introduced a comprehensive MRSA containment program. The average length of stay was 23.2 days for patients with MSSA infection and 26.3 days with MRSA. The MSSA patients averaged 61 years of age, the MRSA patients 71. Eighteen percent of MSSA patients were admitted to intensive care, as were 19% with MRSA. In-hospital mortality was 34% in the MSSA patients and 44% in the MRSA group. The average Acute Physiology and Chronic Health Evaluation (APACHE) II score at the time blood cultures were obtained was 13 points in the MSSA group and 16 for the MRSA patients. Eighty-four percent of the MSSA patients had optimal antibiotics initiated before their blood culture results were known, as did just 54% of those with MRSA. Seventy-one percent of MSSA infections and 80% of MRSA infections had their onset less than 48 hours after patient hospitalization, strongly suggesting community-acquired infection. The lesson of the study is mandatory MRSA screening and surveillance program ought to be expanded to incorporate MSSA, concluded Dr. Lau of the hospital's general surgery department. A similar point was made in the Burden of Resistance and Disease in European Nations (BURDEN) study presented by Marlieke de Kraker of the National Institute for Public Health and the Environment, Bilthoven, the Netherlands. BURDEN included all adult patients with MRSA or MSSA bloodstream infection at a tertiary care hospital in each of 13 European countries during a 1-year period. The study population comprised 248 patients with MRSA and 453 controls matched for age, Charlson Comorbidity Index score, and duration of hospital stay before infection, along with 618 patients with MSSA and 1,170 matched controls. Patients with MSSA often present with a different clinical picture than do those with MRSA, Ms. de Kraker said. Patients with MRSA infection tend to be older and have more comorbidities. In-hospital mortality occurred in 36% of the MRSA group and 9% of their controls, and in 23% of the MSSA group and 7% of their controls. In a multivariate analysis, MRSA infection was associated with a 3.5-fold increased risk of in-hospital mortality, and MSSA carried a 3.1-fold increased mortality risk compared with controls. Another multivariate analysis demonstrated that bloodstream infection with MRSA added an average of 9.2 days to the length of a hospital stay, while MSSA resulted in an extra 8.6 days, she reported. “The burden of S. aureus bloodstream infections in the hospital is high, for MRSA as well as MSSA. Methicillin resistance does not seem to be associated with excess length of stay or mortality. Infection prevention should be aimed at decreasing the number of S. aureus bloodstream infections, irrespective of methicillin susceptibility,” Ms. de Kraker said. Dr. Lau and Ms. de Kraker each reported having no financial conflict.

Rosiglitazone May Assist With Glycemic Control in the ICU

Hyperglycemia is a frequent sequela of critical illness. Rosiglitazone is an oral hypoglycemic agent of the thiazolinedione class. Thiazolinediones are known to activate peroxisome proliferator-activated receptor gamma (PPAR-gamma) that decreases inflammation in humans and decreases shock induced by zymosan in mice. Rosiglitazone can assist with hyperglycemic control in the intensive care unit (ICU). A hospital billing query identified patients prescribed rosiglitazone while in a major university ICU. Patients who received rosiglitazone as an outpatient prior to hospitalization were excluded. Glycemic control was determined by average daily blood glucose, 24-hour insulin dose, and number of patients requiring an insulin drip. Glycemic control was evaluated on days 0, 3, and 7. Student t test was used to compare means. Fisher exact testing was used to compare insulin regimen before and after starting rosiglitazone. 34 patients were identified. The average Acute Physiology and Chronic Health Evaluation (APACHE) II score was 17.2 +/- 4.4. Sixty-five percent were male, 62% were preexisting diabetics. The mean daily blood glucose was 159 +/- 30 mg/dL on day 0, 146 +/- 37 mg/dL on day 3, and 140 +/- 33 mg/dL on day 7 (P < .03 vs day 0). The mean 24-hour insulin dose was 80.6 +/- 87.9 U on day 0, 72.2 +/- 73.4 U on day 3, and 46.3 +/- 57.2 U on day 7 (P < .003 vs day 0). There was 1 major hypoglycemic event. Rosiglitazone may assist glycemic control in the ICU. Despite recent concerns of cardiac safety, further research should be done to evaluate its potential as a short-term therapeutic agent in the ICU, given its anti-inflammatory and antishock profile.

Near-Infrared Spectroscopy in Patients with Severe Sepsis: Correlation with Invasive Hemodynamic Measurements

Clinicians have begun using near-infrared spectroscopy (NIRS) to monitor tissue perfusion in hemorrhagic shock, as the technique allows continuous noninvasive monitoring of tissue hemoglobin oxygen saturation (StO(2)) and the tissue hemoglobin index (THI). We hypothesized that StO(2) measurements in patients with severe sepsis would be associated with the severity of their illness and would correlate with invasive hemodynamic measurements. We measured mean arterial pressure (MAP), serum lactate concentration, blood hemoglobin concentration, StO(2), and THI in nine healthy volunteers and ten patients with septic shock in a surgical intensive care unit (ICU). Enrolled patients had a pulmonary artery catheter, and had family able to give informed consent. The average Acute Physiology and Chronic Health Evaluation (APACHE) II score at enrollment for the patients was 19 +/- 5 (standard deviation) points. Volunteers and patients were similar with respect to age and sex. To collect NIRS data, we used the InSpectra Tissue Spectrometer, Model 325 (Hutchinson Technology, Inc., Hutchinson, MN). For three consecutive days, we obtained invasive hemodynamic measurements three times daily, simultaneously with NIRS measurements, and metabolic cart measurements once daily. Patients with severe sepsis had significantly lower thenar muscle StO(2) values (p = 0.031) than healthy volunteers. Near-infrared spectroscopy-derived mixed venous oxygen saturation (NIRSvO(2)) and StO(2) measured from the thenar eminence in patients with severe sepsis correlated with SvO(2) from the pulmonary artery catheter (p < 0.05). In this group of patients, StO(2) did not correlate significantly with lactate concentration, base deficit, or APACHE II score. Near-infrared spectroscopic measurements of StO(2) correlated with invasive hemodynamic measurements in patients with severe sepsis but did not correlate with severity of illness. These findings suggest that NIRStO(2) may be a clinically useful measurement in monitoring patients with severe sepsis. Further study of this device in early resuscitation of patients with sepsis is necessary.

Effectiveness of Continuous Hemodiafiltration Using a Polymethylmethacrylate Membrane Hemofilter After Polymyxin B-Immobilized Fiber Column Therapy of Septic Shock

Septic shock is a condition associated with diffuse coagulopathy and multiple organ failure, and frequently ends in death. Direct hemoperfusion using a polymyxin B-immobilized fiber column (DHP-PMX) was first developed in Japan in 1994 and has since been used for the treatment of septic shock. On the other hand, the effectiveness of continuous hemodiafiltration using a polymethylmethacrylate membrane hemofilter (PMMA- CHDF) for critically ill patients has also been reported. We treated 27 septic shock patients by DHP-PMX. The patients, except for the nine in whom CHDF was not performed after DHP-PMX, were divided into two groups: namely, a group in which PMMA-CHDF therapy was added after DHP-PMX (11 cases), and a group in which continuous hemodiafiltration using a polyacrylonitrile membrane hemofilter (PAN-CHDF) therapy was added after DHP-PMX (7 cases). The outcomes in the two groups were compared. The average Acute Physiology and Chronic Health Evaluation (APACHE) II score and the average sepsis-related organ failure assessment (SOFA) score were not significantly different between the two groups. The PMMA-CHDF group showed significantly better outcomes, with significant improvements of the serum PAI-1, protein C, IL-6 and N-arachidonoylethanolamine (AEA) levels. We conclude that PMMA-CHDF may be more effective than PAN-CHDF in the management of septic shock.

Does Body Mass Index Affect Infection-Related Outcomes in the Intensive Care Unit?

Obesity is a worldwide healthcare concern, but its impact on critical care (intensive care unit; ICU) outcomes is not well understood. The general hypothesis is that obesity worsens ICU outcomes, but published reports fail to demonstrate this effect consistently. We hypothesized that increasing BMI would be an independent predictor of higher mortality rates in the surgical/trauma ICU. Data on patients with infections, defined by U.S. Centers for Disease Control and Prevention criteria, were collected prospectively from a single university surgical/trauma ICU. From 1996 to 2003, 807 such patients had measurable BMIs on admission to the ICU and were divided into underweight (<18.5 kg/m(2)), normal weight (18.5-24.9 kg/m(2)), overweight (25.0-29.9 kg/m(2)), obese (30.0-39.9 kg/m(2)), and morbidly obese (> or =40.0 kg/m(2)). The primary outcome was in-hospital death. Bivariate and multivariate analyses were performed. In-hospital death was associated with increasing age, increasing average Acute Physiology and Chronic Health Evaluation (APACHE) II score, history of diabetes (p = 0.001), cardiac disease (p = 0.001), hypertension (p = 0.044), history of cerebrovascular disease (p = 0.021), renal insufficiency (p = 0.007), need for hemodialysis (p < 0.001), history of pulmonary disease (p = 0.012), requirement for mechanical ventilation while in the ICU (p = 0.107), history of malignant disease (p < 0.001), and history of liver disease (p < 0.001). The multivariate analysis selected age (odds ratio [OR] 1.03 per integer; confidence interval [CI] 1.0, 1.05), APACHE II score (OR 1.17 per integer; CI 1.12, 1.74), diabetes (OR 2.20; CI 1.32, 3.65), mechanical ventilation (OR 1.88; CI 1.21, 2.94), malignancy (OR 2.54; CI 1.43, 4.47), and liver disease (OR 5.01; CI 2.69, 9.32) as significant risk factors. When controlling for these variables, none of the BMI groups had an independent association with death compared with the normal weight group. Contrary to the hypothesis, the data suggest no discernable independent association of increasing BMI with heightened mortality rate in the surgical/trauma ICU patient with infection.

Gender and Status Asthmaticus

Background. Adult women may be more susceptible to asthma than men. Hypothesis. Women are more likely to develop status asthmaticus (SA) requiring critical care. Methods. The medical records of patients admitted to our medical intensive care unit (ICU) for SA between 1994 and 2000 were examined. A number of demographic and physiologic variables were extracted from the medical records. Results. Of 103 total admissions, 53 (of 37 patients) were age <50 years and had clinical evidence suggesting SA. Among these 37 patients, the average (±SE) age was 30.8 ± 1.0 y with average acute physiology and chronic health evaluation (APACHE) II of 9.5 ± 0.8. Seventeen patients were Hispanic, 13 were black, and 7 were white. Twenty-four patients (accounting for 37 admissions) were female and 13 patients (16 admissions) were male. Although women accounted for a greater absolute number of endotracheal intubations (ETI; 17 vs. 12) and were more likely to be admitted to ICU more than once (7 vs. 3), men had a higher incidence of ETI (RR = 1.6; 95%CI = 1.04–2.6). The need for using therapeutic permissive hypercapnia and lengths of stay (ventilator, ICU, and hospital) were similar between men and women. Two patients, both women, died of causes not related to treatment of SA. Conclusions. These data suggest that although women accounted for more ICU admissions for SA, men were more likely to require ETI.

Serial APACHE III Scoring for Acute Renal Failure in the Intensive Care Unit

Severity stratification and prediction models are important tools for gauging outcomes in critically ill patients. However, most severity scoring systems are inaccurate when attempting to predict mortality in individuals with acute renal failure (ARF), including the APACHE (Acute Physiology and Chronic Health Evaluation) II scoring system. APACHE III scoring encompasses a greater array of physiologic parameters that may better correlate with outcome in ARF. We evaluated APACHE II and APACHE III scoring in 27 individuals admitted to the intensive acre unit (ICU) with ARF requiring dialysis. We also evaluated the predictive value of serial APACHE III scoring on mortality. Sixteen of the study subjects were discharged alive from the ICU. APACHE II scores for ICU survivors versus nonsurvivors were not significantly different at the outset of dialysis treatment, though they did discriminate between survivors and nonsurvivors at 48 hours (survivors 15 ± 6.2; nonsurvivors 18.1 ± 6.9; p = 0.019). However, average APACHE III scores for survivors were significantly less than those for nonsurvivors on all days of score collection, including at the outset of dialysis (day 0 survivors 94.7 ± 22.1; nonsurvivors 106.8 ± 21.7; p = 0.03). APACHE III scores on day 2 also discriminated between those who recovered renal function (83.6 ± 16.7) compared to those who did not (105.6 ± 21.4) (p = 0.05). Serial APACHE III scoring provided rapid and reproducible scoring that differentiated between survivors and nonsurvivors in a group of critically ill patients with ARF. This study suggests that further investigations are warranted to confirm whether serial APACHE III scoring should be considered as an adjunct clinical tool in caring for individuals with ARF in the ICU.

Continuous infusion of haloperidol controls agitation in critically ill patients

To evaluate the safety and efficacy of continuous infusion of haloperidol in treating agitated critically ill adult patients. Case series of patients treated with continuous infusion of haloperidol and followed to hospital discharge, during a 6-month period. A 34-bed multidisciplinary intensive care unit (ICU) in a 598-bed nonuniversity, tertiary care teaching hospital. Consecutive sample of eight patients requiring mechanical ventilation who had severe agitation which was refractory to intermittent bolus treatment with benzodiazepines, narcotics, and haloperidol. Continuous infusions of haloperidol (range 3 to 25 mg/hr) were supplemented, as required, to maintain adequate sedation. The four men and four women averaged 47 yrs of age, and the average length of hospitalization was 33 days, with 25 days spent in the ICU. On the day continuous infusion of haloperidol was initiated, the average Acute Physiology and Chronic Health Evaluation (APACHE) II and Therapeutic Intervention Scoring System (TISS) scores were 24 and 47, respectively. The Sedation-Agitation Scale score averaged +2.4 (maximum agitation score being +3) before continuous infusion of haloperidol decreasing to +1.8 after 1 day (p = .38) and to +0.8 after 2 days (p = .06) of continuous infusion of haloperidol. The average daily haloperidol dose increased from 68 mg before continuous infusion of haloperidol to 269 mg (p < .008) after 1 day. The daily total of nonhaloperidol sedatives decreased from 18.3 to 10.9 sedation-equivalent units (p = .15) and the daily number of bolus administrations of sedatives decreased from 23 to 7 (p = .01) after 1 day of continuous infusion of haloperidol. Estimated nursing time to prepare, administer, and monitor these bolus medications decreased from 320 to 96 mins per 24 hrs (p = .01). Of the five patients discharged alive (37.5% mortality rate), four were successfully weaned from assisted ventilation during continuous infusion of haloperidol. Two of these four patients were difficult to wean because of agitation and oversedation. Four possible complications were noted: minor tremors (n = 2), atrial dysrhythmias with intermittent third-degree atrioventricular block and QT interval prolongation (n = 1), and ventricular tachycardia (n = 1). Continuous infusion of haloperidol effectively controls severe agitation in critically ill patients, reduces requirements for bolus administration of sedatives and nursing time lost to that task, and may facilitate ventilator weaning. Parenteral administration of haloperidol was associated with few complications in > 1,340 patient-hours of continuous administration.