High APACHE Score Research Articles

Noninvasive Ventilation for Acute Respiratory Failure due to Noncystic Fibrosis Bronchiectasis.

Purpose of the Study:Data regarding the use of noninvasive ventilation (NIV) for treatment of acute respiratory failure (ARF) among patients with noncystic fibrosis (CF) bronchiectasis are limited. We intend to describe our experience with NIV use in this setting.Methodology:This was a retrospective study which included 99 patients with bronchiectasis and ARF who required either NIV or invasive mechanical ventilation (IMV).Results:NIV was started as the primary modality of ventilatory support in 81 (66.3%) patients. Fifty-three (65.4%) patients were managed successfully with NIV. Twenty-eight (34.56%) patients failed NIV and required endotracheal intubation. Reasons for NIV failure were worsening or nonimprovement of ventilatory or oxygenation parameters (n = 15), hypotension (n = 6), worsening of sensorium (n = 3), and intolerance (n = 4). None of the patients failed NIV due to excessive respiratory secretions. The rate of correction of arterial blood gases was comparable between NIV and IMV groups. The total duration of stay (median [interquartile range] days) in hospital was comparable between patients treated with NIV and IMV (8 [7–10] vs. 11 [5–11]; P = 0.99), respectively. The mortality rate between NIV and IMV groups were statistically comparable (8.64% vs. 16.6%; P = 0.08). High APACHE score at admission was associated with NIV failure (odd's ratio [95% confidence interval]: 1.21 (1.07–1.38)].Conclusions:NIV is feasible for management of ARF with non-CF bronchiectasis. High APACHE may predict NIV failure among these patients.

The Impact of Comorbidities on the Outcome of Tuberculous Patient in Respiratory Intensive Care Unit

Aim of the work: there are limited data regarding active pulmonary tuberculosis (APTB) patients requiring ICU admission.This study aimed to determine the mortality rate and risk factors associated with TB patients with comorbidities requiring respiratory intensive care unit (RICU) admission. Patients and methods: a combined retrospective-prospective study was conducted from November 2014 to October 2016 and from November 2016 to April 2017 on adult patients with APTB admit to the RICU of Abbassia Chest Hospital for a period of more than 24 h. Demographic, clinical and therapeutics characteristics as well as outcome (RICU morality) were obtained from the medical records. Results: in this study a total of 43 patients were considered (median age 45 years for non survived patients and 36 years for survived patients). The RICU morality rate was 81.4%. Respiratory failure was the most common cause of admission to RICU 37,2% (16 patient). Mechanical ventilation (MV) was needed in 69.8% of patients (30 patients). Death rate in the diabetic patients was14.29%, in patients with renal disease it was 20% , in case of HIVit was 17.14% and in case of malignancy it was 8.57%.There was highly significant mortality rate accompanying LCF and the ratio was 31.43%,in case of respiratory failure type II it was 94.28% and in mechanical ventilation it was 80%. Non survived patients had high significant APACHE SCORE 21.4±6.2 and the main cause of death was mainly ventilatory 80%(28 patients). Conclusion: the present study showed a very high mortality rate among TB patients with comorbidities requiring respiratory intensive care unit (RICU) admission and identified associated co morbidities, risk factors and a predictor of RICU mortality.

Fever, thrombocytopenia, and AKI-A profile of malaria, dengue, and leptospirosis with renal failure in a South Indian tertiary-care hospital.

In the tropics, the triad of fever, thrombocytopenia, and AKI portends a grim prognosis with high mortality and a severe strain on already-stretched resources. Malaria, dengue, and leptospirosis account for most cases. We undertook a review of cases to determine factors accounting for adverse prognosis. All patients presenting to the emergency room (ER) with a history of fever, thrombocytopenia, and renal failure were included in the study. Patients were followed until discharge or death, and end points looked at were 1-week and 30-day mortality, and renal function upon discharge. Parameters like liver function test (LFT), renal function, and platelet count upon discharge were also documented. A total of 43 patients was included in the study. Mean age was 42.5 years with 86% males. Mean APACHE and SOFA scores on admission were 23.89 and 15.42, respectively. Mean admission platelet counts were 41,000. Mean serum creatinine was 4.1, and bilirubin was 9.94. A platelet count of <34,000, serum creatinine of >4, albumin of >2.3, SOFA score of >20, and APACHE score of >32.2 were significantly predictive of 1week mortality. Need for mechanical ventilation, oliguria on admission, and need for dialysis all were highly predictive of 30-day mortality. In addition, a serum bicarbonate of <12, INR of >1.5, hemoglobin of <9.5 were highly predictive of higher 30 day mortality. Overall, 1-week mortality was 16.3%, of which 48% was accounted for by patients with leptospirosis. Factors like low platelet count, oliguria, need for dialysis, high APACHE and SOFA scores on admission, need for mechanical ventilation, and low serum albumin portend a grave prognosis. There is need for randomized control trials (RCT) to further determine adverse prognostic factors in this subsect of patients.

The role of noninvasive ventilation in mild to moderate acute respiratory distress syndrome.

Sir, We read with great interest the research article, “A study on the role of NIV in mild to moderate acute respiratory distress syndrome,” published in the previous issue.[1] It was alarming to note that only 44% had successful noninvasive ventilation (NIV) use while the rest of the patients had to be intubated. The mortality quoted for NIV failure group was 46.3% (19 out of 23), which is rather high in the present scenario. The mortality of moderate adult respiratory distress syndrome (ARDS) in a study done by Thille et al. was only 32%.[2] The author suggests high APACHE scores and delay in intubations as the reasons of the high mortality. The mortality rate is unacceptable and could have been reduced if they were not subjected to further trial of NIV after 1 h. A retrospective study of NIV role in moderate ARDS in esophagectomy patients concluded that it would be an effective option to consider invasive mechanical ventilation in those with P/F ratio 150.[2] Patients who have P/F ratio of 1.5 have to be taken into consideration to go for invasive ventilation.[4] We manage large number of ARDS patients in our department. ARDS patients (P/F ratio >150) can be treated with NIV while moderate to severe ARDS (P/F ratio <150) should be managed with pressure-controlled mechanical ventilation. Our mortality rates have been 11.4% in the past 3 years.[4] NIV for ARDS has to be chosen cautiously and needs vigilant monitoring as it can lead to high mortality, even when one makes a decision to shift from NIV to invasive ventilation quickly. I entirely agree with editorial remarks that the acute inflammation of lung can spread very quickly making the recruitment process slow and delayed. One has to be extremely careful when you choose NIV for ARDS. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Serum Cytokine Profile in Patients with Septic Shock/Severe Sepsis and Thrombocytopenia

IntroductionSepsis is the result of an uncontrolled inflammatory response to various stimuli such as bacterial infections. Sepsis can be complicated by hemodynamic instability, multi-organ dysfunction and hematological abnormalities. Patients with severe sepsis usually develop thrombocytopenia due to various reasons, and the presence of thrombocytopenia is considered as a negative prognostic marker. The aim of the present study was to determine the cytokine profile in serum of patients with severe sepsis and thrombocytopenia.Patients and MethodsSerum cytokine profile was analyzed in a cohort of 112 consecutive patients with severe sepsis and/or septic shock treated in the intensive care unit (ICU) of our institute from October/2009 to September/2012. Patients were divided in two groups (A and B). Group A consisted of 43 patients with severe sepsis and thrombocytopenia (platelet count below 70X103/ìl), while group B consisted of 69 patients without thrombocytopenia. Patients with thrombocytopenia due to disseminated intravascular coagulation (DIC), suspected drug etiology, or due to any obvious etiology such as hematologic malignancy were excluded from our analysis. A cohort of 10 healthy volunteers served as control group.Serum levels of IFNã, IL-8, ICAM, VCAM, and SUPAR (soluble urokinase plasminogen activation receptor) were estimated by using Luminex xMAP technology. Statistical analyses were performed using NCSS software. The following variables were entered in a multiple logistic regression model: 1) age and sex, 2) active malignancy vs. not, 3) septic shock vs. severe sepsis, 4) APACHEII score, 5) SOFA score, 6) serum IFNã, ICAM, VCAM, IL-8, and SUPAR levels, and 7) platelet number. All parameters were estimated on day of admission.ResultsHospital Mortality: Overall 65 out of 112 patients died during their hospital stay. The overall hospital mortality was 58%. In multivariate analysis non-survivors had higher APACHE score (p=0.01) and had lower platelet counts (p<0.001) as compared with survivors.Plasma cytokine levels in patients with and without thrombocytopenia: Patients in group A had a different cytokine profile as compared with patients in group B. Serum levels of VCAM and IFNã were not different between group A and B. However, patients with sepsis and thrombocytopenia had statistically significantly higher serum levels of ICAM, IL-8 and SUPAR (p<0.0001) in comparison with patients with severe sepsis and normal PLT count.Predictive value of serum cytokine for thrombocytopenia: Serum levels of ICAM, IL-8, and SUPAR were good predictors of the presence of thrombocytopenia in patients with sepsis. The ROC curves of ICAM, IL-8, and SUPAR serum levels in predicting thrombocytopenia in patients with sepsis are shown in Figure 1. The AUCs were 0.785 (95% CI, 0.696 – 0.857, p<0.001), 0.729 (95% CI, 0.637 – 0.809, p<0.001), 0.789 (95% CI, 0.701 – 0.861, p<0.001) for ICAM, IL-8 and SUPAR levels respectively. However in multiple logistic regression analysis serum levels of ICAM was the most powerful predictor of thrombocytopenia.ConclusionThrombocytopenia is not an uncommon finding in patients with severe sepsis. Although DIC or drug reactions are well known causes of low PLT counts, the pathogenesis of thrombocytopenia in patients with sepsis remains poorly understood. High levels of ICAM, IL-8 and SUPAR are usually associated with severe endothelial dysfunction. In our study, we showed that patients with thrombocytopenia have a specific serum cytokine profile expression consistent with the presence of endothelial damage. [Display omitted] DisclosuresNo relevant conflicts of interest to declare.

Neumonía por Pneumocystis jiroveci: características clínicas y factores de riesgo asociados a mortalidad en una Unidad de Cuidados Intensivos

ObjectiveTo describe the epidemiological characteristics of the population with Pneumocystis jiroveci (P. jiroveci) pneumonia, analyzing risk factors associated with the disease, predisposing factors for admission to an intensive care unit (ICU), and prognostic factors of mortality. Design and patientsA retrospective observational study was carried out, involving a cohort of patients consecutively admitted to a hospital in Spain from 1 January 2007 to 31 December 2011, with a final diagnosis of P. jiroveci pneumonia. SettingThe ICU and hospitalization service of Hospital del Mar, Barcelona (Spain). ResultsWe included 36 patients with pneumonia due to P. jiroveci. Of these subjects, 16 required ICU admission (44.4%). The average age of the patients was 41.3±12 years, and 23 were men (63.9%). A total of 86.1% had a history of human immunodeficiency virus (HIV) infection, and the remaining 13.9% presented immune-based disease subjected to immunosuppressive therapy. Risk factors associated to hospital mortality were age (51.8 vs. 37.3 years, P=.002), a higher APACHE score upon admission (17 vs. 13 points, P=.009), the need for invasive mechanical ventilation (27.8% vs. 11.1%, P=.000), requirement of vasoactive drugs (25.0% vs. 11.1%, P=.000), fungal coinfection (22.2% vs. 11.1%, P=.001), pneumothorax (16.7% vs. 83.3%, P=.000) and admission to the ICU (27.8% vs. 72.2% P=.000). ConclusionsThe high requirement of mechanical ventilation and vasoactive drugs associated with fungal coinfection and pneumothorax in patients admitted to the ICU remain as risk factors associated with mortality in patients with P. jiroveci pneumonia.

Incidence of adrenal insufficiency and its relation to mortality in patients with septic shock

Background: The hypothalamic pituitary adrenal axis has a pivotal role in combating acute insults. Glucocorticoids play a role directly or indirectly in the maintenance of normal vascular tone and in potentiating the vasoconstrictor action of catecholamine, associated with septic shock. Aims: The aim was to determine the incidence of adrenal insufficiency (AI) and its relation to mortality in patients with septic shock. Settings and Design: A prospective observational study carried out at Tertiary Care Center. Materials and Methods: In patients of septic shock, acute physiology and chronic health evaluation II (APACHE II) score was calculated and serum cortisol was measured at the time of admission and 1 h after giving 250 μg adrenocorticotrophin hormone (ACTH). Hydrocortisone was added to inotropics in all patients after drawing second blood sample for serum cortisol and was continued till 7 days or less. In our study, the patients with inadequate adrenal response were divided into two groups: (1) Absolute AI - baseline cortisol Statistical Analysis Used: Data were analyzed with SPSS version 17 and were presented in the values of mean, median, and percentages. P Results: The incidence of AI in septic shock was ( N = 100) was 42% (in absolute 14%, relative 28%).The incidence of AI in septic shock was 42% (absolute 14%, relative 28%). The mortality rate was 48%, and it was higher in patients with AI than in patients without AI ( P = 0.017). The APACHE II score >25 carried higher mortality rate than a score of ≤25 ( P ≤ 0.001). Baseline serum cortisol >45 μg/dl had exceptionally high likelihood of mortality (OR: 50, P ≤ 0.001). Among those who survived, inotropic support was required for a longer period in relative when compared to absolute AI and to non-AI. Conclusions: AI is prevalent among patients with septic shock. We found that higher APACHE scores were associated with higher rates of adrenal failure and mortality in patients with septic shock. There also appears to be a bimodal distribution of mortality with adrenal status in patients with septic shock.

Serial estimations of blood lactate predict postoperative outcome in cancer patients undergoing head and neck surgeries

To determine predictability of serial estimations of blood lactate levels for postoperative outcome of head and neck cancer patients and determine validity of single versus serial estimations for accurate prediction of outcome.The study included 322 cancer patients assigned for major head and neck surgeries and admitted to ICU. Data collection included age, sex, and associated comorbidities, and clinical status was determined using APACHE II score. Arterial lactate was measured at time of admission (T0), and 8-hourly (T8, T16, T24), and percentage of change of blood lactate level was calculated versus T0 level. Patients were categorized as survivor and non-survivors, and among each group, patients were categorized according to estimated level of blood lactate into four categories.The mean of APACHE score at ICU admission was 16.6 ± 3.1, and mean duration of ICU and hospital stay was 3.2 ± 1.2 and 19.3 ± 5.5 days, respectively. Fifty-two patients died for postoperative mortality rate 16.1%. Non-survivors were significantly older and had significantly higher APACHE score and significantly longer ICU and hospital stay. At admission blood lactate level was significantly higher in non-survivors compared to survivors. All patients showed progressive increase of blood lactate level, but non-survivors showed significantly higher frequency of elevated blood lactate strata compared to survivors with significantly higher difference between both groups at T8, T16, and T24. There was positive significant correlation between high at admission blood lactate level and APACHE score. Regression analysis defined % of change of blood lactate at T16, high APACHE score, high at admission blood lactate and old age as specific predictors for postoperative mortality in descending order of specificity. Serial estimations of blood lactate are conclusive test for follow-up of patients undergoing major surgical procedures requiring ICU admission. Combined high APACHE score and percentage of change of blood lactate could discriminate survivors from non-survivors especially 16-h after ICU admission.

Factors Associated within 28 Days In-Hospital Mortality of Patients with Acute Respiratory Distress Syndrome

Objective. To determine the factors leading to in-hospital mortality within 28 days in hospitalized patients with ARDS. It was a prospective observational cohort study conducted in Intensive Care Unit of Aga Khan University Hospital Karachi from March to August 2011. Methodology. Data was collected from patients admitted in the intensive care unit on the basis of inclusion and exclusion criteria. The patients were followed daily for 28 days to record any in-hospital complications and the outcome of patients. Results. Total of 46 patients were included during this period out of which 56% (26) were males and 43% (20) were females. Mean age was 44 ± 19 years. There were 11 (23.9%) patients with age >65 and 35 (76%) had age <65 years. There were 21 (45.6%) patients with pulmonary ARDS and 25 (54.3%) had extrapulmonary ARDS. APACHE II score of >20 was present in 23 (50%) patients while the rest had score of <20. Regarding in-hospital complications, 23 (50%) patients developed sepsis, 31 (67.4%) had multiorgan failure, 14 (30%) had refractory shock, and 15 (32.6%) developed refractory hypoxemia. Out of 46 patients, 26 (56.5%) died within 28 days. On univariate analysis, high APACHE score, multiorgan failure, refractory shock, and refractory hypoxemia were main causes of death. Conclusion. ARDS is a syndrome of high mortality with mortality rate of 56.5% in this study. High APACHE, sepsis, multiorgan failure, refractory shock, and refractory hypoxemia are the leading causes of death in our patients.

Long-term neuromuscular sequelae of critical illness

In this observational study, we analyzed the long-term neuromuscular deficits of survivors of critical illness. Intensive care unit-acquired muscular weakness (ICU-AW) is a very common complication of critical illness. Critical illness polyneuropathy (CIP) and critical illness myopathy (CIM) are two main contributors to ICU-AW. ICU-AW is associated with an increased mortality and leads to rehabilitation problems. However, the long-term outcome of ICU-AW and factors influencing it are not well known. We analyzed the medical records of 490 survivors of critical illness, aged 18-75 years and located in the area of the study center. Intensive care unit (ICU) survivors with comorbidities that might influence neuromuscular follow-up examinations, muscle strength, or results of nerve conduction studies, such as renal or hepatic insufficiency, diabetes mellitus, or vitamin deficiency were excluded. A total of 51 patients were finally included in the study. Six to 24 months after discharge from the ICU, we measured the Medical Research Council (MRC) sum score, the Overall Disability Sum score (ODSS), and also performed nerve conduction studies and EMG. For all ICU survivors, the median MRC sum score was 60 (range 47-60) and the median ODSS score was 0 (range 0-8). CIP was diagnosed in 21 patients (41 %). No patient was diagnosed with CIM. Patients with diagnosis of CIP showed a higher median ODSS scores 1 (range 0-8) versus 0 (range 0-5); p < 0.001 and lower median MRC sum scores 56 (range 47-60) versus 60 (range 58-60); p < 0.001. The three main outcome variables MRC sum score, ODSS score and diagnosis of CIP were not related to age, gender, or diagnosis of sepsis. The MRC sum score (r = -0.33; p = 0.02) and the ODSS score (r = 0.31; p = 0.029) were correlated with the APACHE score. There was a trend for an increased APACHE score in patients with diagnosis of CIP 19 (range 6-33) versus 16.5 (range 6-28); p = 0.065. Patients with the diagnosis of CIP had more days of ICU treatment 11 days (range 2-74) versus 4 days (range 1-61); p = 0.015, and had more days of ventilator support 8 days (range 1-59) versus 2 days (range 1-46); p = 0.006. The MRC sum score and the ODSS score were correlated with the days of ICU treatment and with the days of ventilator support. The neuromuscular long-term consequences of critical illness were not severe in our study population. As patients with concomitant diseases and old patients were excluded from this study the result of an overall favorable prognosis of ICU-acquired weakness may not be true for other patient's case-mix. Risk factors for the development of long-term critical illness neuropathy are duration of ICU treatment, duration of ventilator support, and a high APACHE score, but not diagnosis of sepsis. Although ICU-AW can be serious complication of ICU treatment, this should not influence therapeutic decisions, given its favorable long-term prognosis, at least in relatively young patients with no concomitant diseases.

Soluble CD40L (CD154) is increased in patients with shock

Recent data suggest that soluble CD40L (sCD40L) plays an important role in murine sepsis. The aim of the present study was to determine plasma levels of CD40L in critically ill patients with systemic inflammatory response syndrome (SIRS) and shock, with and without sepsis. A prospective observational one-centre cohort study in a mixed-bed ICU of an university hospital. Fifty-three consecutive patients fulfilling the criteria for SIRS with shock as well as seven age-matched controls were included. ELISA was used to determine sCD40L in the plasma. The level of sCD40L in plasma from healthy controls was 0.18 ± 0.03 ng/ml. It was found that sCD40L levels were significantly higher in patients with non-septic shock (0.72 ± 0.18 ng/ml) and septic shock (0.50 ± 0.1 ng/ml). However, the levels of sCD40L were not different between these two groups of patients, or in those with low and high APACHE scores. Our data show that sCD40L is increased in patients with shock from septic and non-septic etiologies. However, further studies are needed to delineate the functional significance of sCD40L in the clinical outcome in shock patients.

Percutaneous tracheostomy in critically ill patients: 24 months experience at a tertiary care hospital in United Arab Emirates

OBJECTIVE:We assessed the safety and complications related to percutaneous tracheostomy (PCT) without bronchoscopic guidance in our intensive care unit (ICU).METHODS:The prospective data over a period of 24 months were collected for patients who underwent PCT. Major, minor and long-term complications were recorded. The parameters recorded were: age, gender, Glasgow Coma Scale (GCS) score on the day of tracheostomy, acute physiology and chronic health evaluation II (APACHE) score, and predicted mortality based on score on admission and on the day of procedure, number of days on ventilator before and after the procedure, total number of days in the hospital before the final outcome, number of successful decannulations and mortality. The patients were stratified in two groups of survivors and nonsurvivors.RESULTS:A total of 117 patients underwent PCT. Overall mean GCS and APACHE-II scores before PCT were 7 ± 3 and 16 ± 5, respectively. The only significant difference was APACHE-II score and the predicted mortality based on APACHE-II score on the day of PCT, which was higher amongst the nonsurvivors (P = 0.008 and P = 0.006). All 57 (49%) survivors were successfully decannulated with mean post tracheostomy days of 24 ± 15. The major complication observed was three episodes of major bleeding. Only six patients had an episode of desaturation during the procedure and there were three episode of accidental puncturing of endotracheal (ET) tube pressure cuff. During subsequent follow-up in hospital, six patients developed stomal cellulitis.CONCLUSIONS:PCT without bronchoscopic guidance can be performed safely by carefully selecting patients and having an experienced team High APACHE score on the day of procedure may lead to poor outcome.

Statins are associated with improved outcomes of bloodstream infection in solid-organ transplant recipients

Among recipients of intra-abdominal solid-organ transplants, bloodstream infections (BSIs) are a major cause of mortality. We undertook a retrospective cohort study of recipients of kidney, pancreas, and/or liver transplants with BSIs at a single center over an 11-year period. Multivariate analysis using logistic regression was used to determine independent predictors of 15-day mortality and clinical cure, with a focus on the use of statins. Three hundred and eleven recipients of solid-organ transplants had 604 episodes of BSI. Forty-four (14%) died within 15 days of BSI. Sixteen percent did not achieve clinical cure. In the multivariate model, each one point increase in the APACHE score was associated with a 1.09-fold increased risk of death (95% confidence interval [CI] 1.00-1.18, P = 0.03). The lack of appropriate antibiotic therapy was associated with a four-fold higher risk of death within 15 days (odds ratio [OR] 4.65, 95% CI 1.46-14.78, P = 0.009). Statin use was protective (OR 0.18, 95% CI 0.04-0.78). Patients with high APACHE scores, nosocomial rather than community source of BSI, lack of appropriate antibiotic therapy, and mental status changes were less likely to achieve clinical cure of their BSIs. In conclusion, appropriate antibiotic therapy and statin use are associated with lower risk of mortality from BSIs in this patient population.

Effect of noninvasive mechanical ventilation in elderly patients with hypercapnic acute-on-chronic respiratory failure and a do-not-intubate order

Noninvasive mechanical ventilation (NIMV) is effective in the treatment of patients with acute respiratory failure (ARF). It proved to reduce the need of endotracheal intubation (ETI), the incidence of ETI-associated pneumonia, and mortality compared to nonventilated patients. A particular aspect concerns the outcome of NIMV in patients referring to an emergency room (ER) for ARF, and with a do-not-intubate (DNI) status due to advanced age or critical conditions. The aim of our study is to assess the outcome of NIMV in a group of elderly patients with acute hypercapnic ARF who had a DNI status. An overall number of 62 subjects (30 males, 32 females, mean age 81 +/- 4.8 years, range 79-91 years) referred to our semi-intensive respiratory department were enrolled in the study. The underlying diseases were severe chronic obstructive pulmonary disease (COPD) in 50/62 subjects, restrictive thoracic disorders in 7/62 subjects, and multiorgan failure in 5/62 subjects. Fifty-four/62 patients were successfully treated with NIMV while 2/62 did not respond to NIMV and were therefore submitted to ETI (one survived). Among NIMV-treated patients, death occurred in 6 patients after a mean of 9.9 days; the overall rate of NIMV failure was 12.9%. Negative prognostic factors for NIMV response proved to be: an older age, a low Glasgow Coma Score, a high APACHE score at admission, a high PaCO2 after 12 hours and a low pH both after 1 and 12 hours of NIMV. We conclude that elderly patients with acute hypercapnic ARF with a DNI status can be successfully treated by NIMV.

Survival of Patients with Hematological Malignancy Admitted to the Intensive Care Unit (ICU): Prognostic Factors and Outcome Compared to Unselected Medical ICU Admissions.

Cancer patients have historically had a very poor outcome following ICU admission. Outcome has however improved over the last decade. We aim to identify factors that predict survival for critically ill patients with hematological malignancy and which can be readily identified prior to admission. This would improve selection of patients suitable for ICU admission, which represents a limited resource. We also assessed the ability of the APACHE II score to predict prognosis in these patients. Since the ICU admission case mix will vary between hospitals, one non-surgical admission within +/− 1 week of each hematological admission acted as a control group. Factors which might affect outcome were assessed by multivariate regression analysis. Factors included were age, hematological diagnosis (acute or chronic leukemia, myeloma, lymphoma), time from hematological diagnosis to ICU admission (0–6 months, 6–12 months, >12 months), degree of prior treatment (admission prior to diagnosis, during first line therapy, after first line), remission status, prior stem cell transplant, documented infection and length of neutropenia (none, 1–10 days, >10 days). For hematology patients, predicted hospital mortality was calculated from the APACHE II score by the formula of Knaus et al (Critical Care Medicine 1985). The APACHE scores of hematology patients were compared to controls by a two-sample t test. Predicted and actual mortalities were compared using a one sample test of proportion. The impact of mechanical ventilation (MV) on mortality was assessed by risk ratios. We identified 111 patients with hematological malignancy (acute leukemia n=42, chronic leukemia n=11, myeloma n=19 and lymphoma n=39) admitted to ICU in one teaching and three district general hospitals (November 2000 - January 2006). Median age of hematological patients was 59 years (range 17–84) and M: F ratio 1.22:1. Control patients (n=111) were similar with median age 63 years (range 17–86) and M: F ratio 1.09:1. For control patients, overall ICU and hospital survival rates were 70% and 55% respectively while survival for hematology patients was approximately half at 44% and 24% respectively. In multivariate regression analysis, only increasing age predicted poor outcome (p=0.016). There was a trend to poor outcome if patients were not in complete remission (p=0.066) or had documented infection (p=0.06). All other variables were not significant. APACHE scores were significantly higher in hematology patients (median 27) compared to controls (median 19) p<0.001. Predicted hospital mortality for hematology patients was 56%, significantly lower than actual mortality (77%) p<0.001. For controls, hospital survival was slightly reduced for MV v's not receiving MV (risk ratio = 1.37; 95% C.I. = 0.91, 2.05). Hematology patients hospital survival was significantly worse for MV - 5/55, 9% v's no MV 20/44, 45% (risk ratio = 5.00; 95% CI = 2.04, 12.50). The pre-admission variables assessed did not predict mortality and should not be used for this. Despite high APACHE scores, predicted hospital mortality underestimated mortality for patients with hematological malignancy. Need for MV still predicts poor outcome in this group but without MV nearly half survive to hospital discharge.

Severe acidosis in patients taking metformin—rapid reversal and survival despite high APACHE score

Metformin has been shown to reduce complications and mortality from Type 2 diabetes mellitus, and is increasingly used to treat this condition. This agent is, however, associated with a rare but serious risk of lactic acidosis. We present cases of 10 patients with Type 2 diabetes mellitus who developed acute renal failure and severe lactic acidosis. Despite the severity of their illness, all patients but one survived. The increasing prevalence of Type 2 diabetes and its treatment with metformin might result in more cases of lactic acidosis. However our case report demonstrates that early and aggressive treatment with haemofiltration can improve outcomes even in the presence of severe acidosis.

A Case of Acquired Hemophilia Post Treatment with Recombinant Human Activated Protein C (rh APC).

A 87-year old male without a diagnosis of hemophilia presented to the ER with a large shoulder hematoma, developing after a minor fall. Activated partial thromboplastin time (aPTT) was 79.4 sec, not correcting on mixing studies.Factor assays showed a factor VIII of 11.9 %, factor IX of 74.7 %, factor XI of 82.2 % and factor XII of 65.5 %. Anticardiolipin IgG, IgM antibodies and lupus anticoagulant were negative.Factor VIII inhibitor was found and initially measured at 14 Bethesda Unit (BU). A diagnosis of Acquired Hemophilia was made and the patient was treated with recombinant factor VII (rVIIa) and factor VII concentrates, FFP, PRBC transfusions and steroids.The patient had 4 bleeding episodes during hospitalization. First episode was not treated because of the lack of correct diagnosis. However, rVIIa was administered for all bleeding episodes and prior to surgical procedures like tracheostomy.Interestingly, despite immunosupression with steroids, the inhibitor titer did not decrease, rather it displayed a greater variation in the BU values ranging from 14 to 67.The patient bled unpredictably at different titers of inhibitor, without any concordance between the bleeding or the aPTT or the BU value. Finally,he succumbed to uncontrolled bleeding from the tracheostomy site and expired on operating table on day 30 of his fateful admission.This is a unique case of Acquired Hemophilia as 8 months ago this patient had received rhAPC, also known as Drotrecogin Alfa Activated (DAA) for severe sepsis with APACHE score of 25.DAA has a newly established therapeutic role in the inhibitor of factors Va and VIIIa, limiting the thrombotic effect and thus the mortality of sepsis. However, cost-effectiveness and safety of DAA remain somewhat controversial.Despite its recent entry into the medical armamentarium of our fight against sepsis, there exist several references in the published literature about the need of a confirmatory prospective trial about its role even in patients with a high APACHE score. Although neutralizing antibody against APC have not been detected in any patient and there are no published reports about DAA induced antibodies to factor VIII, it remains a viable hypothesis nonetheless.Unknown mechanisms such as exposure of new epitopes of factor VIII degraded by rhAPC could precipitate factor VIII antibodies. Further, the unpredictable titer of factor VIII inhibitor may be secondary to the unique mode of antibody formation in this instance.Lack of Correlation between Factor VIII inhibitor Titers and Clinical SequelaeDatesPTTPTHb/HtF VIII inhibitor(BU)Bleeding Episodes2/01/05151.4327.1/22.4On admission: soft tissue hematoma2/02/0579.414.86.2/18.2142/04/0584.616.29.3/27.729.82/05/0575.21011/32.92/06/0574.816.19.8/29.72/07/0590.417.59.2/26.5672/08/05162.017.08.8/26.7GI bleeding, hematuria2/10/0597.414.17.5/222/13/0511914.67.4/22.73/01/05113.814.19.4/29.8353/02/059.2/28.8Hematuria, rectal bleeding3/03/0586.2127/21.2Bleeding from tracheostomy site

Neumonía en el anciano. Factores relacionados con la mortalidad durante el episodio y tras el alta hospitalaria

Pneumonia in the elderly (PIE) is a growing disease that causes great morbidity and mortality with frequent admissions to hospital and increasing health costs. The objective of our study was yo analyze the characteristics of PIE in an internal medicine hospital ward, the influence of quality of life (Katz index and scale of Karnofsky) on its evolution and after the discharge and the factors of poor prognosis during the episode of PIE and throughout the ambulatory follow-up. All the patients suffering from PIE admitted to the internal medicine ward of our hospital during a two years period were included in the study (125). Five of them were referred from geriatric centers. Mean age was 77.9 years (range = 65-95). The most frequent chronic disease was COPD (53.6%) and 10.4% were taking oral corticosteroids. We studied the association of several factors laboratory, clinical and radiological with the evolution of PIE and after discharge. Patients rated high on the indicators of quality of life used (78.4% scored 5 or greater on the Katz index and 76% scored 80 or greater on the scale of Karnofsky) and their comorbidity was low (44% lesser than or equal to 1 and 6.4% greater than or equal to 5). Fever above 38 C was recorded in 40% of cases. Mean APACHE score was 12.8. 21.6% patients had pleural effusion and 20% had multilobar involvement. Overall mortality was 8.8% (11 patients). Fifteen patients suffered major complications during admission. One hundred patients out of the 114 who survived the episode of PIE were followed up on an ambulatory basis. Thirty of those died within 12 months after discharge. In our study, a poorer quality of life and a higher APACHE score were related to a greater mortality during the episode of PIE. After hospital discharge, a greater mortality was associated with a poor quality of life, comorbidity and low concentrations of albumin.

Outcome of patients with systemic lupus erythematosus in intensive care unit.

The objective of the study was to identify the causes, outcome and prognosis of severe illness in patients with systemic lupus erythematosus (SLE) requiring intensive care unit (ICU) care in a University Hospital over a five-year period. The design was a cohort study. Forty-eight SLE patients requiring ICU management over a five-year period (January 1997-December 2001) were studied prospectively. Of 48 patients, 14 (29.2%) died, predominantly with multiorgan dysfunction syndrome (MODS). Patients whose APACHE II score was equal to or greater than 20 had higher mortality than those with APACHE score below 20 (60 versus 7.1%; and P < 0.01). All the 18 patients whose health status rated as 'good' survived, while 46.7% of 30 patients whose health rated as 'poor' died (P < 0.01). Patients who had thrombocytopenia associated with sepsis and/or disseminated intravascular coagulopathy (DIC) had the highest mortality (75%, five-year survival). In conclusion, SLE patients admitted to the ICU had a lower mortality rate than some of the previous reports. Patients with SLE with high APACHE score, > or =20, poor health status, thrombocytopenia and multiorgan dysfunction syndrome had poor prognosis in the ICU.

Acute renal failure requiring dialysis in very old critically ill patients

Acute renal failure (ARF) is common in critical care patients. One risk factor for ARF is age. However, access to dialysis is often limited in older patients, due to their worse prognosis. We report our experience in dialyzing old patients, and compare them with younger patients with ARF in our unit. Since September 1994, we recorded all dialyzed patients, treated with intermittent dialysis (IHD), continuous dialysis (CRRT) or both, depending on clinical decisions. For IHD we use a Fresenius 4008 E machine and polysulfone dialyzers. For CRRT, we first used a DM 08 Fresenius machine and, from 2001, a Diapact-CRRT Braun machine, with polysulfone hemofilters. Since 1994, we have had 163 patients, 68.4% males, mean age 60 (range 15–92) years. Mean APACHE II score at admission was 21.6. Eighty-three percent needed mechanical ventilation, 53% were primarily surgical and in 74% there was a relevant infection or sepsis. From the total, 52 patients (32%) were older than 75 years (mean age 83 ± 4 years). In this group, 79% were male, 83% needed mechanical ventilation, 54% received nephrotoxic agents, including radiocontrast, 58% were primarily surgical and 72% had sepsis. Compared with younger patients, older patients were more often males, and had higher APACHE score (23.2 versus 20.6, P < 0.05) and mortality (55.8% versus 40.5%, P < 0.05). In the older group, the main differences between survivors and nonsurvivors were the incidence of sepsis (79% in nonsurvivors versus 60% in survivors), and the type of patient (nonsurvivors 69% surgical versus survivors 43% surgical). Age, use of mechanical ventilation, and APACHE score were not different between survivors and nonsurvivors. Regarding modality of dialysis, CRRT was used in 13 patients, with 11 deaths (84%). In contrast, the mortality of younger patients treated with CRRT was 47%. As for ARF outcome, 100% of nonsurvivors maintained ARF at death. In contrast, none of the survivors required dialysis at discharge of the hospital. Throughout the years, dialysis was more often considered: 52% of the older patients dialyzed were admitted after 2001, and more often also, CRRT was used (only two CRRT before 2001 in the older group). In conclusion, ARF is common in old patients. Even though ARF and dialysis are associated with high mortality, still 44% of old patients submitted to acute dialysis survive, and are discharged free of dialysis. With time, more old patients will be admitted to ICUs and treated with dialysis. As other authors have concluded, age should not be used as an isolated factor for deciding to treat ARF with dialysis.