Occurrence Of Organ Failure Research Articles

The Clinical Courses and Prognosis of Cirrhotic Patients after First Acute Decompensation: Prospective Cohort Study.

The European Foundation for the Study of Chronic Liver Failure (EF-CLIF) consortium suggested that the clinical courses after acute decompensation (AD) stratify the long-term prognosis: stable decompensated cirrhosis (SDC), unstable decompensated cirrhosis (UDC), pre acute-on-chronic liver failure (pre ACLF), and ACLF. However, previous studies included patients with a history of previous AD and had limitations associated with identifying the clinical factors related to prognosis after the first AD. The prospective Korean Acute-on-Chronic Liver Failure (KACLiF) cohort included cirrhotic patients who were hospitalised with first AD between July 2015 and August 2018. We analysed the factors associated with readmission after the first AD and compared the characteristics and prognosis among each subgroup to evaluate the risk factors for the occurrence of pre ACLF after AD. A total of 746 cirrhotic patients who were hospitalised with first AD were enrolled. The subgroups consisted of SDC (n = 565), UDC (n = 29), pre ACLF (n = 28), and ACLF (n = 124). Of note, pre ACLF showed a poorer prognosis than ACLF. The risk factors associated with readmission within 3 months of first AD were non-variceal gastrointestinal (GI) bleeding, hepatic encephalopathy (HE), and high MELD score. Viral aetiology was associated with the occurrence of pre ACLF compared with alcohol aetiology regardless of baseline liver function status. Cirrhotic patients with first AD who present as non-variceal GI bleeding and HE can easily relapse. Interestingly, the occurrence of AD with organ failure within 3 months of first AD (pre ACLF) has worse prognosis compared with the occurrence of organ failure at first AD (ACLF). In particular, cirrhotic patients with viral hepatitis with/without alcohol consumption showed poor prognosis compared to other aetiologies. Therefore, patients with ACLF after AD within 3 months should be treated more carefully and definitive treatment through LT should be considered.

Septic shock: incidence, mortality and hospital readmission rates in French intensive care units from 2014 to 2018

IntroductionSeptic shock is responsible for high morbidity and mortality rates and its incidence is increasing worldwide. Its evolution over the last few years and the leverage points for action to improve associated outcomes remain unclear. Our aim was to determine trends in the incidence and mortality of septic shock and associated risk factors in intensive care unit (ICU) patients and readmission rates after hospital discharge. MethodsWe performed a retrospective cohort study using data from the French national hospitalisation database, including adult patients with septic shock from 2014 to 2018. Primary outcomes were the incidence of septic shock and the hospital mortality rate at 30, 90 and 365 days. Secondary outcomes were all-cause hospital readmission. ResultsSeptic shock was identified in 187,587 ICU stays. The age- and sex-adjusted incidence rate of septic shock per 100 ICU admissions increased from 6.5% to 6.8% (P < .001); age- and sex-adjusted hospital mortality rates decreased from 47.3% to 44.5% (P < .001). The hospital readmission rate at 365 days was 65.0%. Older age, higher Charlson score, occurrence of organ failure and previous hospitalisation were associated with increased risk of mortality. Identification of a specific microorganism and a time between hospitalisation and ICU admission of less than one day were associated with a decreased risk of death. ConclusionsOur study revealed an increase in the incidence of septic shock and a decrease in mortality rates. Pathogen identification and rapid admission to the ICU were associated with better outcomes. The rate of hospital readmission increased, raising questions about the discharge criteria for these patients.

The Neutrophil to Lymphocyte Ratio (Nlr) as an Early Predictor of Severity and Outcomes in Acute Pancreatitis

Background: Acute pancreatitis is still one of the common causes of emergency hospital admissions in India. Accurate predictors of the severity are important because they influence intervention and management. Many indices of severity including Ranson's, Modified Glasgow, and APACHE II scores have been described. These multiple factors scoring systems are difficult to use, cumbersome, and hence not feasible in the rural Indian setup. This study was done to determine the severity at an early stage using the Neutrophil to Lymphocyte ratio (NLR). Also, to demonstrate the usefulness of NLR in predicting the length of hospital stay, ICU admission and to predict manifestations of adverse outcomes including organ failure. Methodology: We retrospectively analyzed 107 patients diagnosed with acute pancreatitis. Patients were grouped according to the severity and occurrence of organ failure. A comparative analysis was performed to compare the NLR between groups. Results: The severe acute pancreatitis group had a significantly higher median NLR than the mild and moderate groups (p <0.001). NLR significantly correlated to the length of hospital stay and ICU admission among the patients. NLR at admission correlated to modified Marshall's score in predicting organ failure. The ROC curve analyses showed the optimal cut-off values of NLR >8.5 at admission correlated with adverse outcomes. Conclusion: NLR can be used as a predictor to identify patients with high-risk progression to develop severe acute pancreatitis in the early stage, including organ failure. NLR can be used as a tool to refer at-risk patients to tertiary centers needing ICU admission.

Step-up mini invasive surgical treatment of patients with different morphological forms of acute necrotizing pancreatitis

Introduction: Despite significant progress in the treatment strategy of acute necrotizing pancreatitis (ANP), mortality in cases of its severe form remains high. There is no single point of view concerning the indications for the use of mini invasive interventions depending on the nature, extension and localization of the pathological foci of ANP. Material: We performed a prospective observational cohort study of efficacy of elaborated algorithmic mini invasive step-up approach of surgical treatment of 317 patients with different morphological forms of ANP. The following parameters were collected for each episode: length of hospital stay, mortality, occurrence of organ failure and local complications. Results: Transcutaneous punction/drainages were applied as the first step in 37 patients with acute necrotic collections (ANC). In the presence of walled-off pancreatic necrosis (WOPN) EUS procedures were preferred in case their close localization to the stomach or duodenum in 65 observations. Initial surgical treatment wasn't effective in 18.8% and video-assisted retroperitoneal debridement (VARD) in patients with ANC or necrosectomies under EUS control in cases of WOPN were applied. Necessary for laparotomic necrosectomies occurred in 14.5% of patients and was the final step of proposed algorithmic approach. During postoperative period complications occurred in 28.3% of patients. They included 7 new episodes of organ failure, 4 cases of arosive hemorrhage, and 5 observations of pancreatic and duodenal fistulas. Overall mortality rate was 3.3%, after interventional treatment - 6.5%. Conclusion: Surgical treatment in patients with ANP based on elaborated algorithmic step-up approach is followed by acceptable complication and mortality level.

Effects of Fluid Resuscitation on the Occurrence of Organ Failure and Mortality in Patients With Acute Pancreatitis.

Acute pancreatitis (AP) is a serious gastroenterological condition requiring urgent fluid resuscitation and emergent intensive care. However, the benefit of fluid resuscitation is inconsistent. Therefore, this study aimed to examine the effects of fluid resuscitation on the occurrence of organ failure and mortality in patients with AP. The data were retrospectively extracted from the Medical Information Mart for Intensive Care III 2002-2012 database. The fluid resuscitation and fluid balance were calculated at 12, 24, 36, and 48 hours after intensive care unit admission. Multivariate analysis models were used. A total of 317 patients with AP were included. Odds of organ failure increased significantly with increased fluid input at 0 to 12 hours [adjusted odds ratio (aOR), 1.124; 95% confidence interval (CI), 1.015-1.244] and with increased fluid balance at 36 to 48 hours (aOR, 1.184; 95% CI, 1.009-1.389). Odds of in-hospital mortality increased significantly with increased fluid balance at 24 to 36 hours (aOR, 1.201; 95% CI, 1.052-1.371). Odds of 30-day mortality increased significantly with increased fluid balance at 24 to 36 hours (aOR, 1.189; 95% CI, 1.039-1.361). Increased fluid balance was associated with increased risk of organ failure and mortality. Increased fluid output may decrease mortality.

Epidemiology of intensive care unit cardiac arrest: Characteristics, comorbidities, and post-cardiac arrest organ failure — A prospective observational study

BackgroundCritically ill patients in intensive care units can frequently suffer from cardiac arrest (ICU-CA), the incidence of ICU-CA is associated with high mortality. Most studies on ICU-CA focused on risk factors and intra-arrest determinants. However, there is a lack of data on organ failure after ICU-CA and its clinical implications for outcome. This study aimed to investigate ICU-CA incidence, outcome and the occurrence of organ failure after ICU-CA. MethodsWe conducted a prospective observational study over a 1-year at 12 intensive care units of a tertiary care university hospital. We included all consecutive adult patients suffering cardiac arrest (CA) during the ICU stay. Incidence, clinical and neurological outcome, as well as organ failure and support were assessed. ResultsOut of 7690 patients, 176 (2%) with ICU-CA were identified during the study period. Male patients comprised 63% and the median age was 70 (58–78) years. The median ICU stay before ICU-CA was 3 (1–8) days. The initial cardiac rhythm was shockable (VT/VF) in 23% of patients; defibrillation during CPR was performed in 19%. The presumed cause of CA was cardiac in 24%, and sustained ROSC was observed in 80% of patients. Before CA 57% (n = 100) of patients were sedated, 63% (n = 110) mechanically ventilated, 70% needed vasopressor therapy and renal replacement therapy was necessary in 27% (n = 48) of patients. Organ failure after ICU-CA was common, 70% suffered from post-CA cardiac failure, renal replacement therapy was newly initiated in 26% of patients and liver failure occurred in 24% of patients. Mortality at ICU-discharge and at hospital discharge was 66 % and 68 %, respectively. Multivariate regression analysis identified the SOFA score [HR 1.09, 95% CI (0.92–3.18); p < 0.05] and liver failure [HR 2.44, 95% CI (1.39–4.26); p < 0.001] after ICU-CA as independent predictors of mortality. ConclusionThe incidence of ICU-CA is rare in critically ill patients. Organ failure before and after ICU-CA is common; liver failure incidence and severity of illness after ICU-CA are independent predictors of mortality and should be considered in further decisions on ICU therapy.

Assessment of acute pancreatitis using CT severity index and modified CT severity index: A tertiary care hospital based observational study

Background: This study was conducted to assess the correlation with patient outcome and interobserver variability of a modified CT severity index in the evaluation of patients with acute pancreatitis compared with the currently accepted CT severity index. Material and Methods: This is a prospective study, conducted from January 2019 to December 2019, in the Department of Radio Diagnosis, Noor Hospital, Indian Institute of Medical Science and Research (IIMS&R), Warudi, Badnapur. A total of 63 patients referred from the Department of Medicine and Department of Surgery, IIMS & R presented with the chief complaint of epigastric pain, nausea and vomiting and CECT abdomen were suggestive of acute pancreatitis were included in this study. Assessment of Severity: Assessment of severity of acute pancreatitis was done in all cases by Balthazar CTSI scoring and Mortele Modified CTSI scoring. Results: In our study total 63 cases of acute pancreatitis cases were included in the study. These patients underwent CT abdomen and pelvis, later images were reviewed by radiologist. The maximum patients were in the age group of 21 to 40 years [n=31 (49.2%)]. We found that acute pancreatitis was found three times more common in males than in females. Cholelithiasis was found to be most common aetiological factor for acute pancreatitis in 46% cases followed by alcoholic pancreatitis was seen in 28.5% of cases. Majority of the cases were categorized as mild pancreatitis according Balthazar CTSI score. Majority of the cases were categorized as severe pancreatitis using the Modified Mortele CTS score. Whereas, organ failure, moderate and severe category in modified Mortele CTSI, mild, moderate, severe category in Balthazar CTSI. Conclusion: In conclusion CECT was found to be an excellent imaging modality for diagnosis, establishing the extent of disease process and in grading its severity. The Modified CT Severity Index is a simpler scoring tool and more accurate than the Balthazar CT Severity Index. In this study, it had a stronger statistical correlation with the clinical outcome, be it the length of hospital stay, development of infection and occurrence of organ failure. It could also predict the need for interventional procedures.

Antithrombin deficiency is associated with mortality and impaired organ function in septic pediatric patients: a retrospective study.

BackgroundSepsis remains a major problem in intensive care medicine. It is often accompanied by coagulopathies, leading to thrombotic occlusion of small vessels with subsequent organ damage and even fatal multi-organ failure. Prediction of the clinical course and outcome—especially in the heterogeneous group of pediatric patients—is difficult. Antithrombin, as an endogenous anticoagulant enzyme with anti-inflammatory properties, plays a central role in controling coagulation and infections. We investigated the relationship between antithrombin levels and organ failure as well as mortality in pediatric patients with sepsis.MethodsData from 164 patients under the age of 18, diagnosed with sepsis, were retrospectively reviewed. Antithrombin levels were recorded three days before to three days after peak C-reactive protein to correlate antithrombin levels with inflammatory activity. Using the concept of developmental haemostasis, patients were divided into groups <1 yr and ≥1 yr of age.ResultsIn both age groups, survivors had significantly higher levels of antithrombin than did deceased patients. An optimal threshold level for antithrombin was calculated by ROC analysis for survival: 41.5% (<1 yr) and 67.5% (≥1 yr). The mortality rate above this level was 3.3% (<1 yr) and 9.5% (≥1 yr), and below this level 41.7% (<1 yr) and 32.2% (≥1 yr); OR 18.8 (1.74 to 1005.02), p = 0.0047, and OR 4.46 (1.54 to 14.89), p = 0.003. In children <1 yr with antithrombin levels <41.5% the rate of respiratory failure (66.7%) was significantly higher than in patients with antithrombin levels above this threshold level (23.3%), OR 6.23 (1.23 to 37.81), p = 0.0132. In children ≥1 yr, both liver failure (20.3% vs 1.6%, OR 15.55 (2.16 to 685.01), p = 0.0008) and a dysfunctional intestinal tract (16.9% vs 4.8%, OR 4.04 (0.97 to 24.08), p = 0.0395) occurred more frequently above the antithrombin threshold level of 67.5%.ConclusionIn pediatric septic patients, significantly increased mortality and levels of organ failure were found below an age-dependent antithrombin threshold level. Antithrombin could be useful as a prognostic marker for survival and occurrence of organ failure in pediatric sepsis.

Management of Acute-on-Chronic Liver Failure.

Acute-on-chronic liver failure (ACLF) is defined by the occurrence of organ failure(s) other than the liver in patients with cirrhosis. Even though mortality rates are high, there should no longer be reluctance to admit patients with ACLF in the intensive care unit. The prevalence of multidrug-resistant bacteria is high and broad spectrum antibiotics should be initiated as soon as infection is suspected. In patients with circulatory failure, the assessment of circulatory status is challenging due to the hyperkinetic state and an imbalance between the splanchnic and systemic blood volume. Acute kidney injury is common in patients with ACLF. Acute tubular necrosis should be differentiated from hepatorenal syndrome, which justifies vasoconstrictive agents. Renal replacement therapy and mechanical ventilation should be decided on clinical grounds. Recent trials on extracorporeal liver support failed to demonstrate a survival benefit. Aggressive management may serve as a bridge to transplantation provided patients are likely to survive after transplantation.

CT Evaluation of Acute Pancreatitis and its Prognostic Correlation with CT Severity Index.

Pancreatitis is one of most complex and clinically challenging of all abdominal disorders. USG and abdominal CT are the most commonly used diagnostic imaging modalities for the evaluation of pancreas. Computed Tomography (CT) is highly accurate and sensitive than USG in both diagnosing as well as demonstrating the extent. Early assessment of the cause and severity of acute pancreatitis is of utmost importance for prompt treatment and close monitoring of patient with severe disease. CT is the imaging method of choice for assessing the extent of acute pancreatitis and for evaluating complications. To assess prognostic correlation and clinical outcome of acute pancreatitis on the basis of CT severity index. A prospective study of 50 cases was carried out in the Department of Radio Diagnosis, with complaint suggestive of acute pancreatitis on the basis of clinical/laboratory/ultrasonography findings were evaluated in Siemens somatom 40 slice CT. The severity of pancreatitis was scored using CT severity index, modified severity index and revised Atlanta classification and classified into mild, moderate, severe categories. Clinical follow-up of the patients was done in terms of the following parameters: Length of hospital stay, Need for surgery or percutaneous intervention, Evidence of infection in any organ system, Occurrence of organ failure- respiratory, cardiovascular, renal, hepatic and haematological system, death. The clinical outcome was compared with the currently accepted Balthazar's CTSI and Modified Mortele's CTSI and revised Atlanta classification in all the cases. Gall stone disease was most common aetiological factor seen in 40% cases, it was more common in females than males. Alcohol was second most common aetiological factor seen in 38% cases and was noted only in males. Pleural effusion was the most common extra-pancreatic complication seen in 46% cases. Balthazar grade C was the most common (40%) followed by grade D and E (25% each). Acute peri-pancreatic collection was the most common findings seen in 72% cases. Majority of the cases (42%) were categorized as mild pancreatitis according Balthazar CTSI score. Majority of the cases (44%) were categorized as severe pancreatitis according modified CTSI. Majority of the cases were categorized as mild pancreatitis according revised Atlanta classification. Organ system failure, death were more seen in severe grade in modified CTSI and revised Atlanta classification. Modified CT severity index makes the score easier to calculate and reduces the inter-observer variation. Scores obtained with the modified Mortele index, show a stronger statistical correlation for all clinical outcome parameters in all the patients better than the Balthazar index.

The Clinical Course of Cirrhosis Patients Hospitalized for Acute Hepatic Deterioration

Patients with cirrhosis are vulnerable to acute hepatic insults and are more likely to develop rapid hepatic deterioration. The aim of this study is to describe the clinical course of patients with cirrhosis and hospitalized for acute hepatic deterioration (AHD).This is a prospective study involving 163 patients with cirrhosis and AHD. The occurrence of organ failures, systemic inflammatory response syndrome (SIRS), and infections during hospital stay were recorded and the relationship between organ failure and death or SIRS/infection was subsequently analyzed.Of 163 patients, 35 did not develop any organ failure during in-hospital follow-ups (90-day mortality: 0%); 84 had intrahepatic organ failures (IH-OFs, defined by liver and/or coagulation failure) (90-day mortality: 22.0%); and 44 patients developed extra-hepatic organ failures (EH-OFs, defined by kidney, cerebral, circulation, and respiratory failure) on the basis of IH-OF with a 90-day mortality of 90.9%. On multivariable analysis by a Cox proportion hazard model, age, WBC, presence of IH-OF, and EH-OF all predicted 90-day death. A logistic regression analysis identified SIRS being associated with the development of EH-OF. Furthermore, IH-OF at admission and infections occurred during the hospital stay were shown to be another 2 potential risk factors.The clinical course of cirrhosis patients with acute hepatic injury was characterized by 3 consecutive stages (AHD, IH-OF, and EH-OF), which provided a clear risk stratification. The PIRO criteria provided an accurate frame for prognostication of those patients. The systemic inflammatory response syndrome may be a target for blocking the progression to the EH-OF stage.

Modified Computed Tomography Severity Index for Evaluation of Acute Pancreatitis and its Correlation with Clinical Outcome: A Tertiary Care Hospital Based Observational Study.

Acute Pancreatitis is a very common condition leading to the emergency visits in both developed and developing countries. Computed Tomography plays a pivotal role in the diagnosis and subsequent management of pancreatitis. The modified CT severity index includes a simplified assessment of pancreatic inflammation and necrosis as well as an assessment of extra pancreatic complications. To study role of modified computed tomography severity index in evaluation of acute pancreatitis and its correlation with clinical outcome. This was a hospital based prospective correlative study done on patients of all age groups referred to the Department of Radio diagnosis from the various indoor and outdoor departments of the hospital, with clinical/Laboratory/ultrasonography findings suggestive of acute pancreatitis. The severity of pancreatitis was scored using Modified CT severity index & CT severity index and classified into mild, moderate and severe categories. Total of 50 patients of acute pancreatitis presenting to the emergency department of our hospital were included in the study. Clinical outcome parameters for correlation collected from respective referral departments included, the length of hospital stay (in days), need for surgical intervention, need for percutaneous intervention (aspiration and drainage), evidence of infection in any organ system (combination of a fever > 100°F and elevated WBC >15,000/ mm(3)), evidence of organ failure (PaO2 < 60 mm Hg or need of ventilation, systolic BP of < 90 mm Hg, serum creatinine of >300μmoles/L or urine output of < 500 ml / 24 h) and death. The age of the patients in the study group was in the range of 17 to 80 years. Maximum patients were in the age group 40-50 years (42.0%). The mean age was 42.32 years. Out of 50 cases, 33 (66%) were male and 17 (34%) were females with a male to female ratio of 2:1. Cholelithiasis was found to be most common aetiological factor for acute pancreatitis in 40% cases. Alcoholic pancreatitis was seen in 36% of cases. Together cholelithiasis and alcoholism accounted for 76% of cases. Pleural effusion was the most common extra-pancreatic complication, 28 patients (56%), followed by ascites. Majority of patients were categorized as severe pancreatitis (44%). 38% patients were grouped into moderate pancreatitis and 18% were categorized in mild pancreatitis. The outcome parameters in terms of length of hospital stay, need of intervention, development of infection, and development of organ failure were more in patients with higher modified CT severity index. In conclusion CECT was found to be an excellent imaging modality for diagnosis, establishing the extent of disease process and in grading its severity. The Modified CT Severity Index is a simpler scoring tool and more accurate than the Balthazar CT Severity Index. In this study, it had a stronger statistical correlation with the clinical outcome, be it the length of hospital stay, development of infection, occurrence of organ failure and overall mortality. It could also predict the need for interventional procedures.

Predictors for mortality following acute pancreatitis in children.

Although there are several studies focusing on pancreatitis etiology and clinical outcome, no previous report has examined the risk factors for death in children. We reviewed the medical records of all children (ages 0-18 years) admitted to West China Hospital with acute pancreatitis between 2002 and 2012. Independent predictors for death following acute pancreatitis in children were identified using a multivariate logistic regression analysis. Biliary diseases (23%), medications (20%), idiopathic (19%), and trauma (11%) were the most common etiologies for acute pancreatitis in children. The death rate was 5% and the mean duration of hospital stay was 13 days. Organ failure during admission occurred in 24 of 371 patients and most of them started in 3 days of onset (19/24). Multivariate analysis with logistic regression confirmed that occurrence of SIRS in the first week of onset (OR = 2.12, 95% CI 1.14-6.32, P < 0.001), occurrence of organ failure within 3 days of onset (OR = 8.0, 95% CI 2.2-12.3, P < 0.001), occurrence of MOF in the first week of onset (OR = 9.4, 95% CI 2.3-14.6, P < 0.001), infected necrosis (OR = 1.28, 95% CI 1.08-1.52, P = 0.02), and idiopathic cause (OR = 17.3, 95% CI 2.0-60.5, P < 0.001) were independent risk factors for death in cases with pancreatitis. Mortality rate and complication rate of acute pancreatitis in children remains low. Patients with SIRS, early organ failure, MOF, infected necrosis, or idiopathic cause should be well evaluated because they have higher risk of death.

De-escalation versus continuation of empirical antimicrobial treatment in severe sepsis: a multicenter non-blinded randomized noninferiority trial.

In patients with severe sepsis, no randomized clinical trial has tested the concept of de-escalation of empirical antimicrobial therapy. This study aimed to compare the de-escalation strategy with the continuation of an appropriate empirical treatment in those patients. This was a multicenter non-blinded randomized noninferiority trial of patients with severe sepsis who were randomly assigned to de-escalation or continuation of empirical antimicrobial treatment. Recruitment began in February 2012 and ended in April 2013 in nine intensive care units (ICUs) in France. Patients with severe sepsis were assigned to de-escalation (n = 59) or continuation of empirical antimicrobial treatment (n = 57). The primary outcome was to measure the duration of ICU stay. We defined a noninferiority margin of 2 days. If the lower boundary of the 95 % confidence interval (CI) for the difference in patients assigned to the de-escalation group was less than 2 days, as compared with that of patients assigned to the continuation group, de-escalation was considered to be noninferior to the continuation strategy. Secondary outcomes included mortality at 90 days, occurrence of organ failure, number of superinfections, and number of days with antibiotics during the ICU stay. The median duration of ICU stay was 9 [interquartile range (IQR) 5-22] days in the de-escalation group and 8 [IQR 4-15] days in the continuation group, respectively (P = 0.71). The mean difference was 3.4 (95 % CI -1.7 to 8.5). A superinfection occurred in 16 (27 %) patients in the de-escalation group and six (11 %) patients in the continuation group (P = 0.03). The numbers of antibiotic days were 9 [7-15] and 7.5 [6-13] in the de-escalation group and continuation group, respectively (P = 0.03). Mortality was similar in both groups. As compared to the continuation of the empirical antimicrobial treatment, a strategy based on de-escalation of antibiotics resulted in prolonged duration of ICU stay. However, it did not affect the mortality rate.

Comparative study of Balthazar Computed Tomography Severity Index and Modified Computed Tomography Severity Index in predicting the outcome of acute pancreatitis

ObjectiveTo compare the Balthazar CT Severity Index and Modified CT Severity Index in predicting the outcome of acute pancreatitis. Materials and methods150 cases of acute pancreatitis, underwent CECT. The scans were reviewed and scored using both CT indices. Severity parameters included length of hospital stay, need for intervention, occurrence of organ failure, evidence of infection, and mortality. Descriptive statistics were used for baseline characteristics. Chi-square or Fisher's exact tests were used to compare the two indices. ResultsUsing Balthazar CTSI with the patient outcome, statistically significant correlation was found between the grades and the length of hospital stay (p = 0.011), development of infection (p = 0.018), occurrence of organ failure (p = 0.027), and mortality (p = 0.019). No correlation, however, was obtained between the score and the need for an interventional procedure (p = 0.126). In contrast, the correlation between the grades under the Modified CT Severity Index and outcome was much stronger (p = 0.000 for length of hospital stay, p = 0.004 for development of infection, p = 0.024 for occurrence of organ failure and p = 0.013 for mortality). It could also accurately predict the need for interventions (p = 0.030). ConclusionThe modified CTSI correlates more closely with patient outcome than the CTSI.

Impaired microcirculation predicts poor outcome of patients with acute myocardial infarction complicated by cardiogenic shock

we investigated the relationship between sublingual perfused capillary density (PCD) as a measure of tissue perfusion and outcome (i.e. occurrence of organ failure and mortality) in patients with cardiogenic shock from acute myocardial infarction. we performed a prospective study in 68 patients. Using Sidestream Dark Field imaging, PCD was measured after hospital admission (T0, baseline) and 24 h later (T1). We compared patients with baseline PCD ≤ median to patients with baseline PCD > median. Sequential organ failure assessment (SOFA) scores were calculated at both time points. The Kaplan-Meier 30-day survival analyses were performed and predictors of 30-day mortality were identified. The baseline PCD was a predictor of the change in the SOFA score between T0 and T1 (ΔSOFA; ρ = -0.25, P = 0.04). Organ failure recovered more frequently in patients with PCD > median (>10.3 mm mm(-2); n = 33) than in patients with PCD ≤ median (n = 35; 52 vs. 29%, P < 0.05). Twenty-two patients (32%) died: 17 patients (49%) with PCD ≤ median vs. 5 patients (15%) with PCD > median (P = 0.004). After adjustment, the cardiac power index [odds ratio (OR): 0.48, 95% CI: 0.24-0.94) and PCD (OR: 0.65, 95% CI: 0.45-0.92) remained significant predictors of 30-day outcome. Patients with baseline sublingual PCD ≤ median that improved at T1 had a considerable better prognosis relative to patients who had a persistently low PCD. diminished sublingual PCD, at baseline or following treatment, is associated with development of multi-organ failure and is a predictor of poor outcome in patients with acute myocardial infarction complicated by cardiogenic shock.

Obstetric patients in a surgical intensive care unit: prognostic factors and outcome

SummaryThe objective of this study was to assess the incidence, prognostic factors and the outcome of obstetric patients admitted in a surgical intensive care unit (SICU) during the ante-partum or postpartum period (within 6 weeks of delivery). Between 1995 and 2002, the patients transferred from the department of obstetrics were retrospectively included into the study. Demographics included: obstetric data, medical and surgical histories, diagnosis, simplified acute physiology score (SAPS II), acute physiology and chronic health evaluation system APACHE II score; and the occurrence of organ failure, therapeutic interventions, length of stay in the SICU and outcome were recorded. During the study period, 364 obstetric patients were admitted to the SICU. Obstetric admissions to the SICU represented 0.6% of all deliveries and the SICU utilisation rate was 14.96%. The main indications for admission were eclampsia (70.6%) and postpartum haemorrhage (16.2%). The overall mortality rate was 16.7% (n = 61). In a logistic regression model, risk factors for death included organ system failure (odds ratio (OR) = 3.95 confidence interval (CI) [1.84 – 8.48], bilirubin >12 mg/l (OR = 1.017 CI [1.00 – 1.03]), and prolonged prothrombin time (OR = 0.97 CI [0.95 – 0.99]). Median length of stay was longer in non- survivors (6.5 ± 7.3 vs 5.5 ± 4.6 days). Maternal condition on admission and associated complications are the major determinant of maternal outcome.

Organ failure associated with acute pancreatitis in African American and Hispanic patients

Background and purpose Severe acute pancreatitis occurs in about 10% of cases of acute pancreatitis, and is associated with high mortality. Many studies have been published about acute pancreatitis and organ failure, but few address this issue among African Americans and Hispanics. As most of our patients belong to these two ethnic groups, we studied the relationship between acute pancreatitis and organ failure in this population. Methods Our study included all patients diagnosed with acute pancreatitis over 15 years. Medical records of 760 (417 African American & 343 Hispanic) patients, ages 19–85 years were reviewed retrospectively. We abstracted and analyzed data related to demographics, etiology and type of pancreatitis, organ failure, and mortality. Results Of the 760 patient, 47% were male, 42% had biliary stones, 18% had necrotizing pancreatitis, and 24% had organ failure. Of the 182 patients with organ failure, 125 patients (69%) had multiple organ failure, whereas 57 patients (31%) had dysfunction of a single organ system. Cardiovascular system failure was the most common organ dysfunction (26%) among patients with single organ failure. The occurrence of organ failure varied significantly by age and type of pancreatitis (P 0.05). Of the 760 patients, 109 patients (14.3%) died. Patients with organ failure had a higher mortality (34%) compared with those without organ failure (6%) (OR = 23.7, 95% CI = 13.7–41.2) Mortality was higher among those with multiple organ failure (38%) compared with those with single organ failure type (25%). Mortality varied significantly by type of organ failure, being highest among those with pulmonary dysfunction (60%), followed by central nervous system dysfunction (36%) (P = 0.003). Conclusion Organ failure is a serious complication in patients with acute pancreatitis. Patients with multiple organ failure and those with pulmonary failure have higher mortality relative to other groups. Prevention and active treatment of organ failure may improve the outcome of patients with acute pancreatitis.

Early abdominal and pulmonary neutrophil accumulation and activation in patients with secondary peritonitis: a compartmentalized response

The inflammatory response in secondary peritonitis is hypothesized to be compartmentalized. Occurrence of organ failure determines the outcome in patients with this disease. The lung is frequently involved in multiple organ failure. The aim of this study is to determine the role of neutrophil migration and activation in three different compartments (abdominal, circulatory, pulmonary) during secondary peritonitis.

Multiple organ failure in trauma patients.

BACKGROUND As care of the critically ill patient has improved and definitions of organ failure have changed, it has been observed that the incidence of organ failure and the mortality associated with organ failure appear to be decreasing. In addition, many early studies included large heterogeneous populations of both medical and surgical patients that may have influenced the incidence and outcome of organ failure. The purpose of this study is to establish the current incidence and mortality of organ failure in a homogenous population of critically ill trauma patients. METHODS All trauma patients admitted to the intensive care unit (ICU) at an urban Level I trauma center were prospectively studied. Patients were evaluated for the presence of organ failure using definitions proposed by Knaus and by Fry. Newer definitions of organ failure incorporating organ dysfunction and severity-of-illness scores were also obtained in all patients in an attempt to predict outcome. These included lung injury scores (acute respiratory distress syndrome scores), Acute Physiology and Chronic Health Evaluation (APACHE) II and III scores, Injury Severity Score (ISS), and multiple organ dysfunction scores. Primary outcomes assessed were death and the occurrence of organ failure by the various definitions. RESULTS Eight hundred sixty-nine trauma patients were admitted to the ICU and survived longer than 48 hours. Mean APACHE II and APACHE III scores at admission to the ICU and ISS were 12.2 +/- 22, 30.5 +/- 22.7, and 19 +/- 10, respectively. Single organ failure (SOF) occurred in 163 patients (18.7%) and multiple organ failure occurred in 44 patients (5.1%). All SOF was caused by respiratory failure. Respiratory failure occurred first in the majority of patients with multiple organ failure. Mortality was 4.3% with one organ system failure, 32% with two, 67% with three, and 90% when four organ systems failed. None of the patients with SOF died secondary to respiratory failure. Multiple stepwise regression analysis was performed to determine which of the following risk factors are associated with the occurrence of organ failure: mechanism of injury, lactate at 24 hours, ISS, APACHE II, APACHE III, acute respiratory distress syndrome score at admission, multiple organ dysfunction score at admission and total blood products transfused in 24 hours. Of these factors, APACHE III, lactate at 24 hours, and total blood products transfused in 24 hours were associated with the occurrence of organ failure. CONCLUSION The overall incidence of organ failure in a homogeneous trauma population appears to be lower than that reported in studies performed in heterogeneous patient populations in the 1980s. Mortality for SOF is low and appears to be related primarily to the patient's underlying injuries and not to organ failure. Mortality for two or three organ system failures is lower than reported 15 to 20 years ago. Mortality for patients with four or more organ system failures remains high, approaching 100%.