Number Of Organ System Failures Research Articles

The French National Registry of HA-1A (Centoxin) in septic shock. A cohort study of 600 patients. The National Committee for the Evaluation of Centoxin

Antiendotoxin monoclonal antibodies are under investigation as adjunctive therapy for severe sepsis. One of these antibodies (the human IgM monoclonal antibody HA-1A) was marketed in Europe during 1992 for treatment of patients with severe sepsis, especially those with shock, and probable gram-negative bacilli (GNB) bacteremia, after a placebo-controlled trial showed improved outcome in such patients. This cohort study was designed to assess characteristics and determinants of outcome of patients through a nationwide registry of all adult patients hospitalized in intensive care units of French hospitals and treated with HA-1A. Main outcome measures included (1) survival at 14 days, 28 days, and hospital discharge, with comparison of observed with expected hospital mortality according to the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and (2) analysis of risk factors for death using a Cox proportional hazards model. Of 600 patients who received HA-1A in a 1-year period, 75% had documented GNB infection and 39% had GNB bacteremia; 94% had hypotension and 54% had refractory shock. Crude overall mortality rates were 49% and 61.3% (P < 10(-4)) at day 14 after therapy and hospital discharge, respectively. Hospital mortality tended to be higher than expected from the APACHE II score (61.3% vs 56%, P = .06), especially in patients without GNB infection (68.1% vs 58.3%). Independent risk factors for death were the APACHE II score (P < 10(-4)), the number of organ system failures (P = 10(-4)), the prognosis of underlying disease (P = .001), and non-GNB infection (relative risk, 1.32 [95% confidence interval, 1.05 to 1.66]; P = .02). This cohort study did not confirm decreased mortality in patients with GNB bacteremia, as reported in the first placebo-controlled HA-1A trial, and it further suggests excess mortality in the subgroup of patients with non-GNB infection. In clinical trials of patients with severe sepsis, controlling for both the severity of acute illness score and the number of organ system failures, as well as for the severity of underlying disease and the source of infection, should be considered, especially when subgroups are analyzed.

Timing and predictors of death in pediatric patients with multiple organ system failure.

To describe the timing of onset of organ system failure, multiple organ system failure diagnosis, and the subsequent death in children admitted to a pediatric intensive care unit (ICU). Second, to identify independent risk markers of death in pediatric patients with multiple organ system failure. Review of a database. Pediatric ICU within a tertiary care center. We analyzed the pediatric ICU course of 777 consecutive patients aged < 18 yrs. Eighty-five (10.9%) of 777 children had multiple organ system failure, defined as the simultaneous occurrence of at least two organ system failures. Of 85 children, 37 (43.5%) were postoperative cardiac surgery patients and 48 (56.5%) patients were in the ICU for other reasons. The diagnostic criteria for multiple organ system failure were met on the day of admission by 73 (86%) of 85 patients. The maximum number of organ system failures occurred within 72 hrs in 74 (87%) children. The mortality rate for all patients with multiple organ system failure was 50.6%. Thirty-eight (88.4%) of deaths occurred within 7 days after the diagnosis of multiple organ system failure. Survival analysis was comparable for both postoperative cardiac surgery patients and patients with other diagnoses. Multivariate analysis identified three factors as independent risk markers of death in pediatric patients with multiple organ system failure: maximum number of simultaneous organ system failures during the pediatric ICU stay: odds ratio, 55.9 (95% confidence interval, 7.9 to 396.1); age < or = 12 months: odds ratio, 17.1 (95% confidence interval, 1.8 to 158.7); and the Pediatric Risk of Mortality (PRISM) score on the day of admission: odds ratio, 1.25 (95% confidence interval, 1.1 to 1.5). The mortality rate associated with multiple organ system failure in pediatric patients is high. The maximum number of simultaneous organ system failures during pediatric ICU stay, age < or = 12 months, and the PRISM score on the day of admission are independent risk markers of death. Diagnosis of multiple organ system failures, development of maximum number of organ system failures, and deaths occur remarkably early after pediatric ICU admission; the rationale for using prophylactic therapy under such circumstances is unclear.

A Simple Multiple System Organ Failure Scoring System Predicts Mortality of Patients Who Have Sepsis Syndrome

A simple multiple system organ failure (MSOF) score may predict mortality of patients who have sepsis syndrome. Using an MSOF scoring system, we prospectively determined the presence or absence of respiratory, cardiovascular, renal, hepatic, gastrointestinal, hematologic, and neurologic organ failure on day 1 of sepsis syndrome in 154 consecutive patients who had sepsis syndrome in the ICU of a tertiary care, teaching hospital. We used 30-day hospital mortality as the primary outcome variable. Overall 30-day mortality was 34 percent. There was a strong linear association between number of organ system failures and 30-day mortality (p < 0.0001). Mortality was 20 percent in patients who had less than 3 organ system failures (n = 111) and 70 percent in patients who had 3 or more organ system failures (n = 43). Survival was assessed using the Cox proportional hazards model and was found to be significantly different (p < 0.01) between the two groups defined by the aforementioned dichotomy after adjustment for age and sex using time to death as the primary outcome. The increase in relative risk of death associated with 3 or more organ system failures was 2.77 (95 percent confidence interval, 2.74 to 2.83). Using logistic regression, the adjusted odds ratios (OR) for covariates most predictive of mortality were hematologic (OR = 6.2), neurologic (OR = 4.4), hepatic (OR = 3.4), cardiovascular (OR = 2.6), and age (1.05 per year). The logistic model using the seven organ system failures and age as covariates accurately predicted outcome 75 percent of the time with a sensitivity of 51 percent and specificity of 87 percent. In conclusion, a simple scoring system tabulating the number of organ system failures present on day 1 of sepsis syndrome predicts the mortality of patients who have sepsis syndrome with reasonable accuracy.

Intensive care unit outcome in the very elderly

To determine if age, previous functional status, or acute severity of illness affect the acute and long-term mortality rates and functional status of the very elderly (> or = 85 yrs) after an ICU admission. Cohort study (retrospective entry for the first year of the study and prospective entry thereafter with prospective follow-up throughout). An ICU in a community teaching hospital with follow-up at home or at a skilled nursing facility. All (n = 105) patients > or = 85 yrs admitted to the ICU over a 2-yr period. ICU, 30-day posthospital discharge, and 1-yr mortality rates, activities of daily living scores, organ system failure score at the time of ICU admission. The ICU, 30-day posthospital discharge, and the 1-yr mortality rates were 30%, 43%, and 64%, respectively. Mortality rates significantly increased between the ICU stay or 30 days posthospital discharge and 1-yr follow-up periods. Of those patients who lived up to 6 months after hospital discharge, 86% survived to 1 yr with little change in functional status from baseline. In the patients with > or = 2 organ system failures, there were 88% 30-day posthospital discharge and 100% 1-yr mortality rates. Severity of illness, as measured by the number of organ system failures, was associated with increased ICU (odds ratio 3.38; 95% confidence interval, 1.51 to 7.60; p < .005) and 1 yr (odds ratio 5.76; 95% confidence interval, 2.49 to 13.29; p < .0001) mortality rates, while age within this group and preadmission functional status were not. Within the very elderly population, acute severity of illness is the most significant predictor of mortality after an ICU admission. For most very elderly patients, surviving 1 yr after an ICU admission, there is little change in functional status.

Septic shock and multiple organ failure

To assess the frequency and mortality rates of septic shock in ICU patients and the clinical course of multiple organ failure associated with septic shock. Retrospective case survey. Tertiary care center. During a 2-yr period, 2,469 consecutive intensive care patients were studied regarding the frequency and hospital mortality rates of septic shock. A subset of 1,311 patients was further analyzed for the occurrence of organ system failures within 48 hrs of the onset of septic shock and again 4 to 7 days later. The frequency rate of septic shock was 1.9% (n = 48), with a mortality rate of 72.9% (n = 35) in patients with septic shock. Deaths due to septic shock represented 14.6% of all deaths in the ICU during the study period. Eighteen patients died within 72 hrs of the onset of septic shock. Refractory hypotension was the cause of death in 15 of these 18 patients. Beyond 72 hrs, multiple organ failure accounted for eight of 17 deaths. The mean +/- SD number of organ systems failing at 48 hrs was 3.3 +/- 1.3 in survivors and 4.0 +/- 1.1 in nonsurvivors, and at 4 to 7 days was 2.1 +/- 1.5 in survivors and 4.0 +/- 1.5 in nonsurvivors (p less than .05). None of the specific organ system failures had prognostic value. The number of organ system failures was not related to the duration of hypotension, but had a weak correlation (r2 = .26, p less than .05) with the duration of vasoactive treatment at 4 to 7 days. The prolonged need for norepinephrine therapy was associated with an increased occurrence of renal failure. Thirty (62.5%) patients had positive blood cultures and a mortality rate similar to the mortality rate of patients with negative blood cultures. Patients with negative blood cultures died more often with hypotension (p less than .02). Septic shock is a major cause of death in intensive care patients. Refractory hypotension is a main cause of early deaths. Later on, multiple organ failure becomes the primary clinical problem and cause of mortality.

Five years experience with continuous extracorporeal renal support in paediatric intensive care

Continuous arterio-venous haemofiltration (CAVH) and continuous veno-venous haemofiltration (CVVH) were used as renal support in 52 critically ill infants and children with acute renal failure. The majority of the patients were on mechanical ventilation (90%) and needed vasopressor support (85%). Uraemia was satisfactorily controlled with both treatment modes. Post-treatment serum urea levels were not different between survivors (94 +/- 8.8 mg/dl) and non-survivors (99.5 +/- 8.8 mg/dl). There were significant differences between survivors and non-survivors in the mean arterial pressure (64.7 +/- 3.8 vs 48.0 +/- 2.2 mmHg, p less than 0.001), the number of organ system failures (2.9 +/- 0.16 vs 3.8 +/- 0.21, p less than 0.025), and the severity of illness assessed by the acute physiologic score for children (APSC 19.4 +/- 1.9 vs 26.3 +/- 1.9, p less than 0.01). The overall mortality was 48%. The mortality in the CVVH group (65%) was higher than in the CAVH group (40%). Death was significantly related to sepsis (p less than 0.005) and multiple system organ failure (p less than 0.005). A major complication during CAVH was one femoral artery thrombosis after 12 days of treatment. Technical problems were only observed during CVVH. CAVH and CVVH are safe and effective methods of continuous renal support for critically ill paediatric patients with multiple system organ failure. CAVH is simpler, needs no specially trained staff and seems to the ideal renal replacement system for critically ill infants.

Contribution of arterial redox potential measurement to the care of critically ill patients.

175 arterial and 122 urinary samples from 20 patients admitted in ICU for organ system failure (OSF) were analysed. Besides arterial blood gases and lactate, electrolyte concentrations, pH, rH2 and specific resistance (R) in blood and urine were measured. Redox potential (E) and base excess were calculated from these data. Patients were defined as having MOSF if their organ systems met failure criteria during their ICU stay. Data were classified with corresponding number of OSF developed in the patients when samples were obtained. Acid-base balance or base excess alone could not be used to predict the severity of illness as assessed by increasing number of organ system failures. Significant elevations in blood lactate concentrations were observed only in patients with four, five or six OSF. A lack of correlation between blood lactate and severity of OSF indicates that blood lactate is not valid as a guide to ultimate outcome of the patients. Arterial redox potentials progressively decreased with increasing number of OSF, therefore, it can be stated that the serial measurements of arterial redox potential are useful in assessing the patient's status or predicting their ultimate outcome.

Why do patients with postsurgical acute tubular necrosis die?

We compared early (less than 70 days) cumulative survival, cause of death, and morbidity (defined as the number of organ system failures and reoperations) of 236 patients who needed dialysis for acute tubular necrosis (ATN) after transplantation with that of a control group of 215 transplant patients who had immediate renal function after transplantation. The patients were matched for age, number of transplants, time of transplantation, diabetic status, living-related vs cadaveric donor, and number of HLA matches. There were no differences in cumulative survival after transplantation, causes of death, organ system failure, or surgical complications as evident from the number of reoperations. The ATN patients' overall clinical course was similar to that described for other postsurgical patients with ATN in their native kidneys. We conclude that the poor survival and the surgical complications in patients with postoperative ATN are due to the basic disease and not to acute renal failure or to dialysis. To improve survival, research should be focused on the basic disease and the surgical procedures rather than on dialysis technique.