Logistic Organ Dysfunction System Score Research Articles

Logistic organ dysfunction system as an early risk stratification tool after aneurysmal subarachnoid hemorrhage

Aneurysmal subarachnoid hemorrhage (aSAH) not only causes neurological deficits but also influences extracerebral organ functions. The Logistic Organ Dysfunction System (LODS) reliably captures organ dysfunctions and predicts mortality of critically ill patients. This study investigated LODS in the setting of aSAH as a surrogate marker for early brain injury (EBI). Patients with aSAH treated between 2012 and 2020 were retrospectively analyzed. LODS was calculated within 24 h upon admission applying functional parameters for each organ system. The EBI was evaluated based on 1-persistent loss of consciousness, 2-global cerebral edema, and 3-intracranial blood burden. The outcome was assessed with the modified Rankin scale (mRS) at 3-months after ictus (mRS > 2 = unfavorable outcome). A total of 324 patients with a mean age of 55.9 years were included. Severe EBI (EBI grade ≥ 3) was found in 38% (124/324) of patients. Higher LODS score correlated with severe EBI (p < 0.0001) and poor outcome (p < 0.0001). LODS with a cutoff of 7 allowed a reliable discrimination (AUC 78%, p < 0.0001) of patients with severe from those with mild EBI. The LODS-calculation as an early risk stratification and prognostic tool reliably reflected the severity of EBI after aSAH and correlated with outcome.

Predicting mortality of elderly patients undergoing open heart surgery with delirium using sequential organ failure assessment (SOFA), multi-organ dysfunction (MODS), and logistic organ dysfunction system (LODS) scores

PurposeThis study aims to assess the predictive accuracy of SOFA, MODS, and LODS scores in determining the mortality of elderly undergoing open heart surgery with delirium. MethodsA prospective study involved 111 elderly patients who met the inclusion criteria. Data were collected using scoring systems: SOFA, MODS, and LODS. ResultsUpon final follow-up, 86.5 % of the patients had recovered, 13.5 % had died. Sensitivity, specificity, negative, and positive predictive values for predicting mortality in elderly patients were calculated for the SOFA score as 99 %, 73 %, 98 %, and 76 %, respectively. For the MODS score, these values were 95 %, 60 %, 95 %, and 67 %; for the LODS score, they were 92 %, 73 %, 92 %, and 75 %, respectively. The overall accuracy of the three scores—SOFA, MODS, and LODS—was 84 %, 76 %, and 82 %, respectively. ConclusionThe results indicated that the SOFA score exhibited the highest sensitivity and specificity in predicting mortality among elderly individuals

Early Warning Models Using Machine Learning to Predict Sepsis-Associated Chronic Critical Illness: A Study Based on the Medical Information Mart for Intensive Care Database.

Background Patients with chronic critical illness (CCI) experience poor prognoses and incur high medical costs. However, there is currently limited clinical awareness of sepsis-associated CCI, resulting in insufficient vigilance.Therefore, it is necessary to build a machine learning model that can predict whether sepsis patients will developCCI. Methods Clinical data on19,077 sepsis patients from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database were analyzed. Predictive factors were identified using the Student's t-test, Mann-Whitney Utest, or χ 2test. Six machine learning classification models, namely, the logistic regression, support vector machine, decision tree, random forest, extreme gradient enhancement, and artificial neural network, were established. The optimal model was selected on the basis of its performance. Calibration curves wereused to evaluate the accuracy of model classification, while the external validation dataset was used to evaluate the performance of the model. Results Thirty-seven characteristics,such as elevated alanine aminotransferase, rapid heart rate, and high Logistic Organ Dysfunction System scores, were identified as risk factors for developingCCI. The area under the receiver operating characteristic curve (AUROC) values forall models were above 0.73 onthe internal test set. Among them, the extreme gradient enhancement model exhibited superior performance (F1score=0.91, AUROC=0.91, Brierscore=0.052). It alsoexhibited stable prediction performance onthe external validation set (AUROC =0.72). Conclusion A machine learning model was established to predict whether sepsis patients will develop CCI. It can provide useful predictive information for clinical decision-making.

Predictive Value of Multiple Scoring Systems in the Prognosis of Septic Patients with Different Infection Sites: Analysis of the Medical Information Mart for the Intensive Care IV Database.

The heterogeneity nature of sepsis is significantly impacted by the site of infection. This study aims to explore the predictive value of multiple scoring systems in assessing the prognosis of septic patients across different infection sites. Data for this retrospective cohort study were extracted from the Medical Information Mart for Intensive Care IV database (MIMIC-IV) (v2.2). Adult patients meeting the criteria for sepsis 3.0 and admitted to the intensive care unit (ICU) were enrolled. Infection sites included were pneumonia, urinary tract infection (UTI), cellulitis, abdominal infection, and bacteremia. The primary outcome assessed was 28-day mortality. The sequential Organ Failure Assessment (SOFA) score, Oxford Acute Severity of Illness Score (OASIS), and Logistic Organ Dysfunction System (LODS) score were compared. Binomial logistic regression analysis was conducted to evaluate the association between these variables and mortality. Additionally, differences in the area under the curve (AUC) of receiver operating characteristic (ROC) among the scoring systems were analyzed. A total of 4721 patients were included in the analysis. The average 28-day mortality rate was 9.4%. Significant differences were observed in LODS, OASIS, and SOFA scores between the 28-day survival and non-survival groups across different infection sites (p < 0.01). In the pneumonia group and abdominal infection group, both the LODS and OASIS scoring systems emerged as independent risk factors for mortality in septic patients (odds ratio [OR]: 1.165, 95% confidence interval [CI]: 1.109-1.224, p < 0.001; OR: 1.047, 95% CI: 1.028-1.065, p < 0.001) (OR: 1.200, 95% CI: 1.091-1.319, p < 0.001; OR: 1.060, 95% CI: 1.025-1.095, p < 0.001). For patients with UTI, the LODS, OASIS, and SOFA scoring systems were identified as independent risk factors for mortality (OR: 1.142, 95% CI: 1.068-1.220, p < 0.001; OR: 1.062, 95% CI: 1.037-1.087, p < 0.001; OR: 1.146, 95% CI: 1.046-1.255, p = 0.004), with the AUC of LODS score and OASIS significantly higher than that of the SOFA score (p = 0.006). Among patients with cellulitis, the OASIS and SOFA scoring systems were identified as independent risk factors for mortality (OR: 1.055, 95% CI: 1.007-1.106, p = 0.025; OR: 1.187, 95% CI: 1.005-1.403, p = 0.044), with no significant difference in prognosis prediction observed (p = 0.243). In the bacteremia group, the LODS scoring system was identified as an independent risk factor for mortality (OR: 1.165, 95% CI: 1.109-1.224, p < 0.001). The findings suggest that LODS scores offer better prognostic accuracy for predicting the mortality risk in septic patients with pneumonia, abdominal infections, bacteremia, and UTI compared to SOFA scores.

Accuracy of different scoring systems in cardiogenic shock patients treated with micro-axial percutaneous left ventricular assist device

Abstract Background Cardiogenic shock (CS) is the most severe form of acute heart failure characterized by high mortality. Micro-axial percutaneous left ventricular assist devices (pLVAD) might improve outcome. The utilization of these devices increased lately but is associated with high material and personnel costs and unknown impact on prognosis. Therefore, a precise assessment of prognosis is of immanent interest to determine upfront, who might benefit from the device. For this purpose, different scoring systems were developed. Purpose In the current study, we investigated accuracy of 9 different scoring systems predicting all-cause mortality at 30 days. Methods Data were collected from our ongoing Impella registry including more than 740 patients treated for different indications since 2014. Among them, 434 patients received a micro-axial pLVAD in CS. Acute Physiology and Chronic Health Evaluation (APACHE) II score (APA), Simplified Acute Physiology Score II (SAPS), Multiple Organ Dysfunction Score (MODS), Sequential Organ Failure Assessment (SOFA), Logistic Organ Dysfunction System (LODS) score, Organ Dysfunctions or Infection score (ODIN), ENCOURAGE score, CardShock score, and IABP-SHOCK II risk score were calculated. All-cause mortality was characterized with the use of Kaplan-Meier plots. A receiver operating characteristic (ROC) curve was generated, and the area under the curve (AUC) was estimated to determine the predictive value of the different scores for 30-day-mortality. Subgroup analyses were performed for CS caused by acute myocardial infarction (AMI), CS caused not by AMI, and cardiopulmonary resuscitation (CPR). Results Patients were 68±1 years old with predominance of male gender (73.5% [n=319]). CS was mainly caused by AMI (55.8% [n=242]). A CPR before pLVAD was performed in 49.5% [n=215] with a mean duration of 36±3 minutes. Initial serum lactate was 7.5±0.3 mmol/l. Further baseline characteristics are shown in Table 1. All-cause mortality at 30 days was 65.0±2.3% (Figure 1A). Survivors’ mean stay at hospital was 18±3 days. ROC analyses revealed a positive prediction of 30-day-mortality of all scores (Figure 1B). The SAPS showed the best, ODIN and IABP-SHOCK II risk score the lowest accuracies (ROC AUC [95% CI] SAPS 0.757 [0.704-0.810; p&amp;lt;0.001], ODIN 0.647 [0.585-0.708; p&amp;lt;0.001], IABP SHOCK II 0.649 [0.588-0.709; p&amp;lt;0.001]). In the subgroup analyses, comparable results were reached except for patients receiving a CPR. Among those patients, only SAPS, LODS and ENCOURAGE score significantly predicted 30-day-mortality, but accuracies were low (Figure 1C). Conclusion In CS patients treated with pLVAD, the examined scoring systems significantly predicted 30-day-mortality with relevant differences in accuracy. The best prediction was revealed by SAPS. None of the scores showed an acceptable prediction in patients receiving a CPR indicating a specific patient cohort in need for better prognostic tools.Table 1Figure 1

Development of a nomogram for predicting 90-day mortality in patients with sepsis-associated liver injury

The high mortality rate in sepsis patients is related to sepsis-associated liver injury (SALI). We sought to develop an accurate forecasting nomogram to estimate individual 90-day mortality in SALI patients. Data from 34,329 patients were extracted from the public Medical Information Mart for Intensive Care (MIMIC-IV) database. SALI was defined by total bilirubin (TBIL) > 2 mg/dL and the occurrence of an international normalized ratio (INR) > 1.5 in the presence of sepsis. Logistic regression analysis was performed to establish a prediction model called the nomogram based on the training set (n = 727), which was subsequently subjected to internal validation. Multivariate logistic regression analysis showed that SALI was an independent risk factor for mortality in patients with sepsis. The Kaplan‒Meier curves for 90-day survival were different between the SALI and non-SALI groups after propensity score matching (PSM) (log rank: P < 0.001 versus P = 0.038), regardless of PSM balance. The nomogram demonstrated better discrimination than the sequential organ failure assessment (SOFA) score, logistic organ dysfunction system (LODS) score, simplified acute physiology II (SAPS II) score, and Albumin–Bilirubin (ALBI) score in the training and validation sets, with areas under the receiver operating characteristic curve (AUROC) of 0.778 (95% CI 0.730–0.799, P < 0.001) and 0.804 (95% CI 0.713–0.820, P < 0.001), respectively. The calibration plot showed that the nomogram was sufficiently successful to predict the probability of 90-day mortality in both groups. The DCA of the nomogram demonstrated a higher net benefit regarding clinical usefulness than SOFA, LODS, SAPSII, and ALBI scores in the two groups. The nomogram performs exceptionally well in predicting the 90-day mortality rate in SALI patients, which can be used to assess the prognosis of patients with SALI and may assist in guiding clinical practice to enhance patient outcomes.

Prognostic values of SOFA score, qSOFA score, and LODS score for patients with sepsis.

Sepsis continues to carry a high rate of mortality, which makes effective and simple evaluation methods for predicting the prognosis of septic patients especially important. In this study, we retrospectively analyzed the relationships between three scoring systems including Sequential Organ Failure Assessment (SOFA) score, Quick SOFA (qSOFA) score, and Logistic Organ Dysfunction System (LODS) score and the prognoses of septic patients. The baseline data, SOFA score, qSOFA score, LODS score, 28-day prognosis, and 90-day prognosis of patients who met the diagnostic criteria of sepsis were retrieved from the Medical Information Mart for Intensive Care III (MIMIC-III) database. Receiver operating characteristic (ROC) curves were drawn for various indicators, and comparisons were drawn between the areas under the ROC curves (AUC) of the different scoring systems. The 28-day AUC was 0.661 (0.652, 0.670) for SOFA, 0.558 (0.548, 0.568) for qSOFA, and 0.668 (0.658, 0.677) for LODS; AUC-qSOFA vs. AUC-LODS was 0.103 (0.087, 0.120) (P<0.001), and AUC-qSOFA vs. AUC-LODS was 0.110 (0.094, 0.125) (P<0.001). The 90-day AUC was 0.630 (0.621, 0.640) for SOFA, 0.551 (0.541, 0.560) for qSOFA, and 0.644 (0.635, 0.653) for LODS; AUC-SOFA vs. AUC-qSOFA was 0.079 (0.065, 0.094) (P<0.001), and AUC-qSOFA vs. AUC-LODS was 0.093 (0.079, 0.107) (P<0.001). SOFA score, qSOFA score, and LODS score can all be used to predict the prognosis of septic patients. LODS score and SOFA score have higher accuracy than qSOFA score; however, qSOFA is simpler to use, making it a more suitable tool in an emergency setting.

Survival, Outcomes, and Use of Acuity Scoring Systems Following Tracheotomy in Veteran Patients.

To determine whether established prognosis tools used in the general population of critically ill patients will accurately predict tracheotomy-related outcomes and survival outcomes in critically ill patients undergoing tracheotomy. Retrospective chart review of 94 consecutive critically ill patients undergoing isolated tracheotomy. Logistic Organ Dysfunction System (LODS) and sepsis-related organ failure assessment (SOFA) scores, 2 validated measures of acuity in critically ill patients, were calculated for all patients. The only tracheotomy-related outcome of significance was the finding that patients with an LODS score ≤6 were more likely to become ventilator independent (P < .015). Higher LODS or SOFA scores were associated with in-house death (LODS, P = .001, SOFA, P = .008) and death within 90 days (LODS, P = .009, SOFA, P = .031), while death within 180 days was associated only with a higher LODS score (LODS, P = .018). When controlling for age, there was an association between both LODS (P = .015) and SOFA (P = .019) scores and death within 90 days of tracheotomy. The survival outcome for critically ill patients undergoing tracheotomy seems accurately predicted based on scoring systems designed for use in the general population of critically ill patients. Logistic Organ Dysfunction System may also be useful to predict the likelihood of the tracheotomy-related outcome of ventilator independence. This suggests that LODS scores may be helpful to palliative care clinicians as part of a shared decision-making aid in critically ill, ventilated patients for whom tracheotomy is being considered.

The logistic organ dysfunction system score predicts the prognosis of patients with alcoholic ketoacidosis

Alcoholic ketoacidosis (AKA) is occasionally associated with multiple complications leading to death. However, no study has yet evaluated prognostic factors in patients with AKA. It is known that the logistic organ dysfunction system (LODS) score is an objective and useful index to predict the prognosis. We used LODS score to predict prognosis of AKA. We retrospectively reviewed the medical records of 46 patients who were diagnosed as AKA in our hospital. The mean LODS score was 6.3. The probability of mortality based on the LODS score was 36.6%, and 16 patients (34.5%) did, in fact, die. The total LODS score and lactate dehydrogenase (LDH) were significantly higher in the non-survival group. Prothrombin activity, serum platelet number, and the serum albumin levels were significantly higher in the survival group. We found significant correlations between the LODS score and arterial pH, the albumin level, and the LDH concentration. Multivariate analysis showed that the serum albumin and LDH levels were independently associated with survival in AKA patients. AKA patients suffered high-level mortality and the LODS score was an accurate predictor of prognosis. Clinicians may use the LODS score to this end.

Metformin-associated lactic acidosis: A prognostic and therapeutic study*

Metformin-associated lactic acidosis is a rare and serious complication of biguanide treatment. It usually occurs when a precipitating disease induces an acute renal failure and an incidental overdose. Voluntary intoxication is rare. Bicarbonate hemodialysis (HD) is recommended to decrease metformin levels and correct acidosis but its optimal duration has not been determined. This study was designed to document the characteristics and prognostic factors of intentional and incidental metformin overdose and to determine the optimal duration of HD. Ten years retrospective analysis of patients admitted in intensive care unit for metformin-associated lactic acidosis. Two intensive care units (50 beds) in a university hospital. Clinical and biological characteristics, organ failures, and sequential metformin levels during HD were recorded. Forty-two patients were included (13 voluntary intoxications and 29 incidental overdoses); 74% of patients were in acute renal failure and needed HD. No death was observed in intentional overdose patients compared with 48.3% mortality in incidental overdose patients. The factors significantly associated with mortality were logistic organ dysfunction system score, pH, plasma lactate, and prothrombin activity. By multivariate analysis, a prothrombin activity <50% was the only independent predictive factor of mortality (relative risk: 59.8; confidence limits: 6.3-568; p < 0.0001). Sequential measurements of metformin levels during HD were consistent with a bicompartmental elimination pattern. A cumulative HD duration of 15 hours was associated with the return of metformin level to the therapeutic normal range. In our study, the outcome of MALA was uniformly favorable after intentional metformin overdose. The vital prognosis was mainly influenced by the occurrence of multiple organ dysfunctions, the best predictive factor of death being an acute liver dysfunction as assessed by PT activity. Prolonged HD was needed to correct metformin overdose.

Diastolic Arterial Blood Pressure: A Reliable Early Predictor of Survival in Human Septic Shock

Emphasis in therapy of human septic shock is shifting towards reliable end points and predictors of survival. Rationale is to study whether the evolution of cardiovascular reactivity in view of the administered doses of norepinephrine is an early predictor of in-hospital survival and to determine the optimal threshold of norepinephrine therapy and its consequences on renal function. Observational study of a prospective cohort of patients in septic shock, hospitalized in intensive care unit at least 24 hours before requiring norepinephrine. Excluded were patients requiring <72 hours of continuous norepinephrine (16 patients) or who received corticosteroids. Hemodynamic parameters (heart rate, blood pressure, urinary output, and temperature) were continuously monitored. Of 68 patients, 45 survived [intensive care unit stay of 24 (12-36) days, hospital stay of 36 (27-66) days], and 23 died 5 (3-10) days after septic shock onset and norepinephrine treatment. Multivariate analysis revealed four independent positive predictive factors of short-term (10 days) outcome: Simplified Acute Physiology Score (SAPS) II <50 [odds ratio (OR) 6.4, 95% confidence interval (95% CI) 1.3-30.7, p < 0.011], and on day 3 Logistic Organ Dysfunction System (LODS) score <6 (OR 29.1, 95% CI 2.7-314.3, p = 0.0056), norepinephrine concentration <0.5 mug/kg/min (OR 17.6, 95% CI 2.2-142.0, p < 0.0007), diastolic arterial pressure >50 mm Hg (OR 24.8, 95% CI 2.9-215.9, p < 0.004), but not systolic arterial pressure. Septic shock survival increases when dose of 0.5 mug/kg/min of norepinephrine continuously improves vascular tone within the first 48 hours, or when diastolic arterial pressure (>50 mm Hg) is restored. Norepinephrine has beneficial effects on renal function. Predictive value of LODS score on day 3 is demonstrated, while SAPS II is confirmed as the only reliable predictive factor in first 24 hours.

Incidence, organ dysfunction and mortality in severe sepsis: a Spanish multicentre study

IntroductionSepsis is a leading cause of admission to non-cardiological intensive care units (ICUs) and the second leading cause of death among ICU patients. We present the first extensive dataset on the epidemiology of severe sepsis treated in ICUs in Spain.MethodsWe conducted a prospective, observational, multicentre cohort study, carried out over two 3-month periods in 2002. Our aims were to determine the incidence of severe sepsis among adults in ICUs in a specific area in Spain, to determine the early (48 h) ICU and hospital mortality rates, as well as factors associated with the risk of death.ResultsA total of 4,317 patients were admitted and 2,619 patients were eligible for the study; 311 (11.9%) of these presented at least 1 episode of severe sepsis, and 324 (12.4%) episodes of severe sepsis were recorded. The estimated accumulated incidence for the population was 25 cases of severe sepsis attended in ICUs per 100,000 inhabitants per year. The mean logistic organ dysfunction system (LODS) upon admission was 6.3; the mean sepsis-related organ failure assessment (SOFA) score on the first day was 9.6. Two or more organ failures were present at diagnosis in 78.1% of the patients. A microbiological diagnosis of the infection was reached in 209 episodes of sepsis (64.5%) and the most common clinical diagnosis was pneumonia (42.8%). A total of 169 patients (54.3%) died in hospital, 150 (48.2%) of these in the ICU. The mortality in the first 48 h was 14.8%. Factors associated with early death were haematological failure and liver failure at diagnosis, acquisition of the infection prior to ICU admission, and total LODS score on admission. Factors associated with death in the hospital were age, chronic alcohol abuse, increased McCabe score, higher LODS on admission, ΔSOFA 3-1 (defined as the difference in the total SOFA scores on day 3 and on day 1), and the difference of the area under the curve of the SOFA score throughout the first 15 days.ConclusionsWe found a high incidence of severe sepsis attended in the ICU and high ICU and hospital mortality rates. The high prevalence of multiple organ failure at diagnosis and the high mortality in the first 48 h suggests delays in diagnosis, in initial resuscitation, and/or in initiating appropriate antibiotic treatment.

Selenium in Intensive Care (SIC): Results of a prospective randomized, placebo-controlled, multiple-center study in patients with severe systemic inflammatory response syndrome, sepsis, and septic shock*

Sepsis is associated with an increase in reactive oxygen species and low endogenous antioxidative capacity. We postulated that high-dose supplementation of sodium-selenite would improve the outcome of patients with severe sepsis and septic shock. Prospective randomized, placebo-controlled, multiple-center trial. Eleven intensive care units in Germany. Patients were 249 patients with severe systemic inflammatory response syndrome, sepsis, and septic shock and an Acute Physiology and Chronic Health Evaluation (APACHE) III score >70. Patients received 1000 microg of sodium-selenite as a 30-min bolus injection, followed by 14 daily continuous infusions of 1000 microg intravenously, or placebo. The primary end point was 28-day mortality; secondary end points were survival time and clinical course of APACHE III and logistic organ dysfunction system scores. In addition, selenium levels in serum, whole blood, and urine as well as serum glutathione-peroxidase-3 activity were measured. From 249 patients included, 11 patients had to be excluded. The intention-to-treat analysis of the remaining 238 patients revealed a mortality rate of 50.0% in the placebo group and 39.7% in the selenium-treated group (p = .109; odds ratio, 0.66; confidence interval, 0.39-1.1). A further 49 patients had to be excluded before the final analysis because of severe violations of the study protocol. In the remaining 92 patients of the study group, the 28-day mortality rate was significantly reduced to 42.4% compared with 56.7% in 97 patients of the placebo group (p = .049, odds ratio, 0.56; confidence interval, 0.32-1.00). In predefined subgroup analyses, the mortality rate was significantly reduced in patients with septic shock with disseminated intravascular coagulation (n = 82, p = .018) as well as in the most critically ill patients with an APACHE III score > or =102 (>75% quartile, n = 54, p = .040) or in patients with more than three organ dysfunctions (n = 83, p = .039). Whole blood selenium concentrations and glutathione peroxidase-3 activity were within the upper normal range during selenium treatment, whereas they remained significantly low in the placebo group. There were no side effects observed due to high-dose sodium-selenite treatment. The adjuvant treatment of patients with high-dose sodium-selenite reduces mortality rate in patients with severe sepsis or septic shock.

Admission Hyperglycemia and Other Risk Factors as Predictors of Hospital Mortality in a Medical ICU Population

Tight glycemic control is recommended for patients in the ICU, as hyperglycemia is associated with increased morbidity and mortality. Observational cohort of patients admitted to a 12-bed, inner-city, medical ICU (MICU). A total of 1,185 of 1,506 patients from July 1, 1999, to December 31, 2002, selected based on a diagnosis other than diabetic ketoacidosis or glycemia > 280 mg/dL or < 80 mg/dL. To determine if the highest serum glucose level within 24 h after ICU admission is associated with increased hospital mortality when adjusted for confounders. Age, gender, race, worst values within 24 h after ICU admission to construct the acute physiology and chronic health evaluation (APACHE) II score, and highest glucose within 24 h after ICU admission. Hospital mortality was the primary outcome. Admitting diagnosis, MICU length of stay (LOS), and hospital LOS were obtained. Glucose, albumin (n = 867), and lactic acid (n = 319) were stratified for analysis. Univariate analysis identified factors included in the multivariate model. Patients were predominantly African-American (79%) and men (56%; mean age, 49.2 years). The mean ICU admission highest glucose level was 139 +/- 43.7 mg/dL (+/- SD). MICU LOS and hospital LOS were 6.2 days and 12.9 days, respectively, and 50% of patients received mechanical ventilation. MICU and hospital mortality were 18% and 20%, respectively; standardized mortality ratio was 66%. On univariate analysis, survivors (n = 945) and nonsurvivors (n = 240) showed APACHE II score, mechanical ventilation, hypoalbuminemia, lactic acidemia, and logistic organ dysfunction system score to be hospital mortality predictors; however, the highest admission serum glucose level was not. Logistic regression estimated APACHE II score/per point (odds ratio, 1.06; 95% confidence interval, 1.02 to 1.11), mechanical ventilation (odds ratio, 3.06; 95% confidence interval, 1.34 to 6.96), severe hypoalbuminemia (< 2 g/dL) [odds ratio, 2.98; 95% confidence interval, 1.3 to 7.02], and severe lactic acidemia (> or = 8 mmol/L) [odds ratio, 7.3; 95% confidence interval, 2.14 to 24.9], but not ICU admission hyperglycemia, to be associated with hospital mortality. Conventional factors of disease severity, but not highest glucose value during the first 24 h after ICU admission, predict hospital mortality in an inner-city MICU.

Validated physiologic scoring systems are inadequate for predicting in-hospital mortality among critically ill emergency department patients

Study objectives: The New Simplified Acute Physiology Score (SAPS II), Morbidity Probability Models (MPM II), and Logistic Organ Dysfunction System (LODS) have all demonstrated high accuracy (>0.80 for area under the receiver operating characteristic [ROC] curve) for predicting mortality in ICU populations. We examined the prognostic utility of these 3 instruments in a cohort of prospectively studied critically ill emergency department (ED) patients. Methods: We performed a secondary analysis of 190 patients enrolled in a randomized controlled trial from January 2002 to October 2003. Inclusion criteria were age older than 18 years, no history of trauma, arterial hypotension (systolic blood pressure Results: Ninety-one (47%) of 190 patients were admitted to the ICU and analyzed in this study. The mean age was 56±16 years, 42% were female patients, the mean initial systolic blood pressure was 84±13 mm Hg, and the average length of stay in the ED was 4.2±2.0 hours. The inhospital mortality rate was 21%. The average SAPS II score was 40±14 points, the average LODS score was 5±3 points, and the average MPM II (using MPM 0 ) score was −1.058±1.242. The area under the ROC curve for calculated probability of inhospital mortality for SAPS II was 0.72 (95% confidence interval [CI] 0.57 to 0.87), for MPM 0 was 0.69 (95% CI 0.54 to 0.84), and for LODS was 0.60 (95% CI 0.45 to 0.76). Conclusion: Using variables available in the ED, 3 previously validated ICU scoring systems (SAPS II, MPM II, and LODS) demonstrated moderate accuracy. The lower limits of the CIs do not exclude poor prognostic accuracy (area under the curve

Dysregulation of apoptosis in scorpion envenomed children: its reflection on their outcome

In the present study, 46 children in Upper Egypt (less than 13 years old) were admitted to the Pediatric Intensive Care Unit for scorpion envenomation. They were compared with 20 apparently healthy children of matching age and sex as controls. Out of the studied victims, 25 children (54%) showed signs of severe envenomation and multiple organ dysfunction (MOD), while 21 victims (46%) showed signs of mild envenomation. The serum levels of apoptotic markers, soluble Fas (sFas), soluble Fas ligand (sFasL) and Bcl-2, were determined for both victims and controls. In addition, the serum levels of nitric oxide (NO) and lipid peroxides (LPO) were also measured. Scoring of MOD was evaluated using Logistic Organ Dysfunction System Score (LODS) for the severely envenomed victims. All victims (both severe and mild cases) showed significantly higher mean levels of sFas, LPO and NO and significantly lower serum levels of Bcl-2 in comparison to the controls. The level of sFasL was not detectable in the sera of the healthy control group. The case fatality rate was 15%. The severely envenomed children with MOD as well as the non-survivors showed significantly higher serum levels of sFas, sFasL, LPO and NO and significantly lower serum levels of Bcl-2 in comparison to the mild envenomed victims and the surviving victims of severe cases, respectively. The LODS score of the severely envenomed victims showed significant positive correlations with sFas and LPO and significant negative correlation with Bcl-2. In all victims, a significant positive correlation was detected between sFas and NO. On the other hand, Bcl-2 was significantly negatively correlated with both sFas and LPO. In conclusion, our study revealed that scorpion envenomation can increase apoptosis as shown by up-regulation of sFas/sFasL system and down-regulation of Bcl-2 that was associated by elevation of LPO and NO. This dysregulation of apoptosis was increased with the severity of scorpion envenomation and its extent increased as MOD score and outcome increased. Therefore, sFas and Bcl-2 may be of value in predicting the outcome of these cases. The increase of the extent of apoptosis detected in this study seems to play a role in the outcome of scorpion envenomation, and hence, should be taken into consideration for strategies of therapeutic regimen.

Sequential organ scoring as a measure of effectiveness of care in the high-dependency unit.

High-dependency units are of benefit to patients and to the associated intensive care unit. However, the effectiveness of high-dependency care has not been quantified. We studied 100 consecutive patients whose high-dependency unit admission was longer than 48 h. The Logistic Organ Dysfunction System was used to assess organ dysfunction on a daily basis in these patients. The median Logistic Organ Dysfunction System score on admission was 3. The mean duration of stay was 4.3 days, and the median Logistic Organ Dysfunction System score on day 4 was 1. Sixty-six per cent of patients had a lower Logistic Organ Dysfunction System score at discharge. In the remaining patients, the commonest reason for no change or a higher Logistic Organ Dysfunction System score was renal dysfunction. High-dependency care is effective in the majority of patients in terms of improved physiological status and most patients were discharged with minor physiological dysfunction. This level of physiological dysfunction could be applied as a discharge threshold. Poorer patient outcome is associated with increased age and a longer stay on the unit. This poor outcome was commonly due to renal system dysfunction, and invariably followed surgery.

Association of pulmonary artery catheter use with in-hospital mortality.

To determine the association of pulmonary artery catheter (PAC) use with in-hospital mortality. Prospective, observational study. The medical intensive care units (MICU) of two teaching hospitals. The study included 751 adults who were admitted to the MICU, excluding those who stayed for <24 hrs. Demographics and the worst Acute Physiology and Chronic Health Evaluation (APACHE) II score within the first 24 hrs of MICU admission were obtained. Daily logistic organ dysfunction system (LODS) scores were calculated. The associations of in-hospital mortality with the admission source, admission disease category, APACHE II scores, the worst LODS scores, mechanical ventilation, and PAC use were determined using chi-square, Mann-Whitney U, and multiple logistic regression analysis tests. p Values < 0.05 were considered significant. Mean patient age was 52.6 +/- 17.1 yrs; 425 (57%) were male; 464 (62%) were African-American, 275 (37%) Caucasian, 6 (1%) Asian, and 6 (1%) Hispanic. PAC was used in 119/751 (16%). The median APACHE II and worst LODS scores were 19 and 4, respectively. The in-hospital mortality rate was 159/751 (21%). The median APACHE II score for survivors was 17.5, compared with 28.0 for nonsurvivors (p <.0001). The worst median LODS score was 4 for survivors, compared with 11 for nonsurvivors (p <.0001). Sixty-four (54%) of the 119 patients with PAC died, compared with 95 (15%) of the 632 without PAC (p <.0001). Multiple logistic regression analysis showed that higher APACHE II-predicted mortality rate (p =.0088) and worst daily LODS score (p <.0001) were associated with increased mortality. The admission source, admission disease category, PAC use, and mechanical ventilation were not associated with in-hospital mortality. This study could not detect an association between PAC use and mortality. The APACHE II-predicted mortality rate and the development of multiple organ dysfunction were the main determinants of poor outcome in critically ill patients admitted to MICU.

Sequential organ scoring as a measure of effectiveness of critical care

We performed an observational nonrandomised study in a critical care unit of a large district general hospital in England to establish whether sequential organ scoring could be used as a measure of effectiveness of intensive care. The degree of organ dysfunction of 75 consecutive patients admitted to the critical care unit whose duration of stay exceeded 48 h was measured using the Logistic Organ Dysfunction System score. The trends in organ dysfunction of survivors and non-survivors were significantly different with function improving in survivors and remaining constant or worsening in non-survivors. In both groups, the degree of organ dysfunction decreased over the first three days of intensive care. On an individual patient basis, we achieved no change or an improvement in organ score over this period in 80% of patients. In terms of individual organ function, intensive care consistently improved scores relating to the cardiovascular, respiratory and renal systems over the first 72 h of care, but not the neurological, hepatic or haematological systems. In conclusion, daily organ scoring usefully reflects the ability of an intensive care unit to stabilise or reverse physiological dysfunction.

Sequential organ scoring as a measure of effectiveness of critical care

We performed an observational nonrandomised study in a critical care unit of a large district general hospital in England to establish whether sequential organ scoring could be used as a measure of effectiveness of intensive care. The degree of organ dysfunction of 75 consecutive patients admitted to the critical care unit whose duration of stay exceeded 48 h was measured using the Logistic Organ Dysfunction System score. The trends in organ dysfunction of survivors and non-survivors were significantly different with function improving in survivors and remaining constant or worsening in non-survivors. In both groups, the degree of organ dysfunction decreased over the first three days of intensive care. On an individual patient basis, we achieved no change or an improvement in organ score over this period in 80% of patients. In terms of individual organ function, intensive care consistently improved scores relating to the cardiovascular, respiratory and renal systems over the first 72 h of care, but not the neurological, hepatic or haematological systems. In conclusion, daily organ scoring usefully reflects the ability of an intensive care unit to stabilise or reverse physiological dysfunction.