Organ Failure Score Research Articles

The Epidemiology of Chronic Critical Illness After Severe Traumatic Injury at Two Level-One Trauma Centers.

To determine the incidence and risk factors of chronic critical illness after severe blunt trauma. Prospective observational cohort study (NCT01810328). Two level-one trauma centers in the United States. One hundred thirty-five adult blunt trauma patients with hemorrhagic shock who survived beyond 48 hours after injury. None. Chronic critical illness was defined as an ICU stay lasting 14 days or more with evidence of persistent organ dysfunction. Three subjects (2%) died within the first 7 days, 107 (79%) exhibited rapid recovery and 25 (19%) progressed to chronic critical illness. Patients who developed chronic critical illness were older (55 vs 44-year-old; p = 0.01), had more severe shock (base deficit, -9.2 vs -5.5; p = 0.005), greater organ failure severity (Denver multiple organ failure score, 3.5 ± 2.4 vs 0.8 ± 1.1; p < 0.0001) and developed more infectious complications (84% vs 35%; p < 0.0001). Chronic critical illness patients were more likely to be discharged to a long-term care setting (56% vs 34%; p = 0.008) than to a rehabilitation facility/home. At 4 months, chronic critical illness patients had higher mortality (16.0% vs 1.9%; p < 0.05), with survivors scoring lower in general health measures (p < 0.005). Multivariate analysis revealed age greater than or equal to 55 years, systolic hypotension less than or equal to 70 mm Hg, transfusion greater than or equal to 5 units packed red blood cells within 24 hours, and Denver multiple organ failure score at 72 hours as independent predictors of chronic critical illness (area under the receiver operating curve, 0.87; 95% CI, 0.75-0.95). Although early mortality is low after severe trauma, chronic critical illness is a common trajectory in survivors and is associated with poor long-term outcomes. Advancing age, shock severity, and persistent organ dysfunction are predictive of chronic critical illness. Early identification may facilitate targeted interventions to change the trajectory of this morbid phenotype.

Elevated serum levels of lipoprotein‑associated phospholipaseA2 predict mortality rates in patients with sepsis.

Sepsis remains one of the leading contributors to mortality rates in the intensive care unit (ICU) and emergency intensive care unit (EICU). Therefore, any treatments against the agents which produce sepsis in a medical emergency, are welcome. Elevated serum levels of lipoprotein‑associated phospholipase A2 (Lp‑PLA2) have been reported in a small cohort of patients with inflammation. The present study evaluated serum levels of Lp‑PLA2 in patients with sepsis and investigated the role of Lp‑PLA2 in sepsis. The investigation involved the selection of 151patients with sepsis admitted to the emergency department of the Affiliated Hospital of Nantong University (Nantong, China) and 30 healthy controls. All patients (39 with sepsis, 55 with severe sepsis and 57 with septic shock) were examined on admission to the EICU. A complete blood count was performed, and serum levels of Lp‑PLA2, C‑reactive protein, procalcitonin, and interleukin 6, sequential organ failure (SOFA) scores and Acute Physiology and Chronic Health Evaluation II (APACHE II) scores were determined on hospital admission. The EICU and overall mortality rates were evaluated at baseline. The present study also assessed various laboratory parameters, clinical data and inflammatory cytokines. The patient follow up duration was 90days. The data suggested that the serum levels of Lp‑PLA2 on admission to the EICU in patients with sepsis were elevated, compared with those in healthy controls. The concentrations of Lp‑PLA2 were correlated with the severity of disease, and were significantly associated with experimental markers of inflammation and established prognostic scores. In the total cohort, persistently elevated levels of Lp‑PLA2 on admission for EICU treatment was a predictor of poor prognosis, and provided superior diagnostic use, compared with the prognostic scoring systems, including SOFA or APACHE II scores. Taken together, the results suggested that Lp‑PLA2, with respect to other markers of inflammation, may have a role as a prognostic marker in sepsis, and provide background evidence for further trials to evaluate the clinical and pathophysiologic roles of Lp‑PLA2 in sepsis. Persistently elevated serum concentrations of Lp‑PLA2 indicated an unfavorable outcome in patients with sepsis. In addition, the results indicated the potential role of Lp‑PLA2 as a prognostic biomarker in patients with sepsis during the early course of EICU treatment.

Acute alcoholic hepatitis: a literature review and proposal of treatment.

Severe acute alcoholic hepatitis (AAH) can lead to a clinical picture with a six-month mortality rate in more than 70% of cases. This clinical picture is characterized by: jaundice with a duration of less than three months, jaundice at the first failure event, serum bilirubin greater than 5 mg/dL, ratio AST/ALT>2/1, AST less than 500 IU/L, ALT<300 IU/L, neutrophil leukocytosis and a GGT increase. In addition, encephalopathy, fever, asthenia and coagulopathy may be present. Its onset may also be characterized by portal-hypertension-related complications, particularly bleeding and hepato-renal syndrome. In cases where there is an overlapping of an acute form characterized by an etiological factor other than that of the base hepatopathy, acute on chronic liver failure (ACLF) is obtained. This can result in systemic inflammation response syndrome (SIRS) with a multi-organ systemic involvement. Several indices are used to evaluate the prognosis, in particular Maddrey's discriminant function (mDF) and the model of end stage liver disease (MELD). In our clinical practice, we use the MELD routinely. In cases of ACLF, a consortium organ failure score (CLIF-COFs) is used. Therapy is characterized by abstention in cases of severe forms (mDF>32 and MELD>21); in the absence of contraindications, steroid therapy is possible. In cases of an unresponsive liver, transplantation is premature. In our view, this possibility, after proper selection, must be offered for both prognostic and ethical reasons.

Diagnostic value of citrulline and intestinal fatty acid binding protein on acute gastrointestinal injury in critical patients: a prospective study of 530 patients

To observe the incidence of acute gastrointestinal injury (AGI) in intensive care unit (ICU) patients, and to approach the value of serum citrulline and intestinal fatty acid binding protein (IFABP) on diagnosis of AGI in critical patients. A prospective study was conducted. 576 critical patients admitted to ICU of Yantai Yuhuangding Hospital from February 2016 to February 2017 were enrolled. According to the AGI classification proposed by European Society of Intensive Care Medicine (ESICM) in 2012, the AGI and severity of the patients were observed. The general data, severity and prognosis of patients with different AGI grades were recorded. According to the random number table, 20 patients with normal kidney function from AGI I to IV were selected. The femoral artery blood was collected within 12 hours of ICU admission, and serum citrulline level was detected by high performance liquid chromatography (HPLC). Serum IFABP level was determined by enzyme-linked immunosorbent assay (ELISA). Twenty healthy subjects were selected as controls. The receiver operating characteristic curve (ROC) was drawn, and the predictive values of citrulline and IFABP for AGI diagnosis were evaluated. (1) 576 patients were enrolled in the analysis. Of which 530 patients (92.0%) had AGI, and 289 patients with grade I (54.5%), 154 with grade II (29.1%), 64 with grade III (12.1%), and 23 with grade IV (4.3%). With the increase in AGI classification, acute physiology and chronic health evaluation system II (APACHE II) score, sequential organ failure score (SOFA), the length of ICU stay and 28-day mortality were gradually increased. (2) Compared with health control group, the levels of serum citrulline in patients with different AGI grades were significantly decreased, and IFABP was significantly increased. With the increase in AGI classification, the citrulline level was gradually decreased, and IFABP level was gradually increased [citrulline levels (μmol/L) in AGI I,II,III,IV groups were 14.1±3.6, 12.7±3.1, 8.3±2.7, and 5.6±3.4, F = 3.287, P = 0.027, and IFABP levels (ng/L) were 526.7±204.9, 698.4±273.8, 894.7±455.9, and 1 062.8±532.2, F = 2.903, P = 0.043]. ROC curve analysis showed that citrulline had a higher predictive value for AGI diagnosis. The area under the ROC curve (AUC) was 0.927. When the cut-off value of citrulline was 9.7 μmol/L, the sensitivity and specificity were 87.5% and 87.5%, respectively. The AUC of IFABP was 0.043, which has no predictive value for the diagnosis of AGI. The AGI is extremely common in ICU. The higher the AGI grade is, the worse the prognosis is. Citrulline has high diagnostic value for AGI in critical patients, but IFABP has no predictive value on the diagnosis of AGI.

Adaptation of the Acute Organ Failure Score for Use in a Medicare Population.

Without widely available physiologic data, a need exists for ICU risk adjustment methods that can be applied to administrative data. We sought to expand the generalizability of the Acute Organ Failure Score by adapting it to a commonly used administrative database. Retrospective cohort study. One hundred fifty-one hospitals in Pennsylvania. A total of 90,733 ICU admissions among 77,040 unique patients between January 1, 2009, and December 1, 2009, in the Medicare Provider Analysis and Review database. We used multivariable logistic regression on a random split cohort to predict 30-day mortality, and to examine the impact of using different comorbidity measures in the model and adding historical claims data. Overall 30-day mortality was 17.6%. In the validation cohort, using the original Acute Organ Failure Score model's β coefficients resulted in poor discrimination (C-statistic, 0.644; 95% CI, 0.639-0.649). The model's C-statistic improved to 0.721 (95% CI, 0.711-0.730) when the Medicare cohort was used to recalibrate the β coefficients. Model discrimination improved further when comorbidity was expressed as the COmorbidity Point Score 2 (C-statistic, 0.737; 95% CI, 0.728-0.747; p < 0.001) or the Elixhauser index (C-statistic, 0.748; 95% CI, 0.739-0.757) instead of the Charlson index. Adding historical claims data increased the number of comorbidities identified, but did not enhance model performance. Modification of the Acute Organ Failure Score resulted in good model discrimination among a diverse population regardless of comorbidity measure used. This study expands the use of the Acute Organ Failure Score for risk adjustment in ICU research and outcomes reporting using standard administrative data.

Predictive value of quick Sepsis-Related Organ Failure Scores following sepsis-related Medical Emergency Team calls: a retrospective cohort study.

We conducted a cohort study of adult ward patients who had a Medical Emergency Team (MET) call triggered by confirmed or suspected sepsis in an Australian tertiary centre to assess the predictive utility of systemic inflammatory response syndrome (SIRS) and quick Sepsis-Related Organ Failure Assessment (qSOFA) scores for 28-day mortality over a 12-month period. Sepsis was the causative aetiology in 970 MET calls for 646 patients with a mean age of 68 years and median Charlson Comorbidity score (CCS) of 3.0. Four hundred and seven (63%) patients had microbiological identification of a causative organism with 35 (9%) demonstrating multi-drug resistance. The 28-day mortality rate was 22%. Independent risk factors for 28-day mortality included age (incidence rate ratio [IRR] 1.038; <i>P</i> <0.001) and CCS (IRR 1.102; <i>P</i> <0.001). qSOFA positive patients had a three-fold risk of 28 day mortality compared to those who were negative (IRR 3.15; <i>P</i>=0.02). Both the SIRS and qSOFA score had poor sensitivity (86% versus 62%, respectively) for mortality as a sole diagnostic tool and should be investigated as part of a multiparameter panel within a large prospective study.

Prone Positioning in Moderate-Severe ARDS: Preliminary Data From a Community-Based Teaching Hospital

SESSION TITLE: ARDS and Acute Lung Injury SESSION TYPE: Original Investigation Poster PRESENTED ON: Wednesday, November 1, 2017 at 01:30 PM - 02:30 PM PURPOSE: In 2013, after publication of a randomized controlled trial that demonstrated a mortality benefit to ventilation in the prone versus supine position in ARDS, critical care physicians at our institution began to implement this approach. Prior to this, we rarely used prone positioning in our medical ICU and we did not know if the mortality and low complication rate observed in the trial, at centers with >5 years of experience with proning, could be replicated at our institution or what impact this intervention would have on functional outcomes. METHODS: We conducted a retrospective cohort study of all proned patients from June 2013 to November 2014 at Christiana Care Health System. Patients were identified by respiratory care data. We collected demographic data, pre- and post- proning data, respiratory mechanics, diagnoses, complications, and outcomes including mortality, length of stay, and distance walked prior to discharge. Descriptive statistics are used to describe our cohort. RESULTS: Thirty seven patients underwent ventilation in the prone position. Of these, 23 (62%) survived to hospital discharge. The mean age was 56.3 years and 60% were male. The mean sequential organ failure score was 8.6. Immediately prior to proning, the mean positive end expiratory pressure was 14, mean driving pressure was 14 centimeters of water, mean partial pressure of arterial oxygen to fraction of inspired oxygen was 100 and mean tidal volume was 5.5 ml/kg of predicted body weight. Patients were proned for a mean of 41 hours. One patient received extracorporal membrane oxygenation, 31 (84%) received neuromuscular blocking agents, 6 (16.2%) received inhaled nitric oxide, and 21(57%) received steroids. None developed ventilator associated pneumonia or had cardiac arrests while proned. In terms of complications, 6 patients had dependent edema, 7 had dislodged devices, and 2 had skin breakdown. The mean hospital and ICU length of stays were 23 and 14, respectively. A total of 23 patients were able to ambulate a mean of 138 feet prior to hospital discharge. CONCLUSIONS: Hospital mortality was higher in this cohort than the 28-day mortality reported in the trial. However, serious complications from prone positioning were uncommon. The higher mortality rate could be due to differences in clinical care including use of adjuvent therapies or differences in patient selection. Additionally, during our study period in December 2013, we implemented a protocol for ventilation in the prone position. We plan additional data collection and analysis to determine is outcomes differ before and after protocol implementation.All of the survivors were ambulatory prior to hospital discharge. CLINICAL IMPLICATIONS: It is feasible to implement a proning protocol at a community hospital with limited prior experience; however, close monitoring of outcomes is needed to determine whether expected benefits are achieved. DISCLOSURE: The following authors have nothing to disclose: Fahmida Khan, Christa Fistler, Jefferson Mixell, Patricia McGraw, Michael Vest No Product/Research Disclosure Information

The MIMIC Code Repository: enabling reproducibility in critical care research.

ObjectiveLack of reproducibility in medical studies is a barrier to the generation of a robust knowledge base to support clinical decision-making. In this paper we outline the Medical Information Mart for Intensive Care (MIMIC) Code Repository, a centralized code base for generating reproducible studies on an openly available critical care dataset.Materials and MethodsCode is provided to load the data into a relational structure, create extractions of the data, and reproduce entire analysis plans including research studies.ResultsConcepts extracted include severity of illness scores, comorbid status, administrative definitions of sepsis, physiologic criteria for sepsis, organ failure scores, treatment administration, and more. Executable documents are used for tutorials and reproduce published studies end-to-end, providing a template for future researchers to replicate. The repository’s issue tracker enables community discussion about the data and concepts, allowing users to collaboratively improve the resource.DiscussionThe centralized repository provides a platform for users of the data to interact directly with the data generators, facilitating greater understanding of the data. It also provides a location for the community to collaborate on necessary concepts for research progress and share them with a larger audience. Consistent application of the same code for underlying concepts is a key step in ensuring that research studies on the MIMIC database are comparable and reproducible.ConclusionBy providing open source code alongside the freely accessible MIMIC-III database, we enable end-to-end reproducible analysis of electronic health records.

Comparison of mannheim peritonitis index and revised multiple organ failure score in predicting mortality and morbidity of patients with secondary peritonitis

Background: Secondary peritonitis carries high mortality and morbidity. Many scoring systems have been designed to assess its severity. This study was undertaken to compare the Mannheim peritonitis index (MPI) and revised multiple organ failure score (Revised MOFS) in predicting the mortality and morbidity.Methods: A prospective observational study was undertaken in adults operated for gastrointestinal perforation. Clinical and biochemical parameters as required for MPI and Revised MOFS were recorded. Each of the scores were divided under four categories; MPI &lt;14, 14-21, 22-29 and &gt;29; Revised MOFS 0, 1, 2 and &gt;2. Data was compared for predicting mortality and morbidity. P-value, ROC curve and 95% CI were used as statistical tools.Results: Two thirds of 120 patients studied presented after 48 hours. MPI score of &lt;14, 14-21, 21-29 and &gt;29 had mortality of 0%, 2.2%, 27.2% and 50% respectively. ROC curve showed highest sensitivity and specificity of 79% and 70% respectively at MPI of 25. Significant value for mortality was obtained with MPI &gt;25 (p= 0.000012) and with Revised MOFS &gt;1 (p&lt; 0.001); for morbidity with MPI &gt;21 (p= 0.010) and with Revised MOFS &gt;1 (p&lt; 0.001). 20% patients with Revised MOFS zero were also morbid.Conclusions: Both MPI and Revised MOFS systems are good in predicting the mortality, but MPI is easy scoring system and a better option for predicting morbidity. MPI score &gt;25 for mortality and &gt;21 for morbidity are significant.

Acute alcoholic hepatitis.

Chronic alcohol related liver disease is characterized by a cascade of events defined as follows: steatosis, steatohepatitis/steatofibrosi, cirrhosis and hepatocellular carcinoma. On one of these histologic patterns may overlap acute alcoholic hepatitis (AAE) (mild, moderate, severe). Severe AAE can cause a severe clinical picture: jaundice with a duration of less than three months, jaundice in the first decompensation event, serum bilirubin higher than 5 mg/dL, ratio AST/ALT >2:1, AST less than 500 IU/L ALT <300 IU/L, neutrophil leukocytosis and increased GGT. In addition, it is possible the presence of encephalopathy, fever, fatigue, coagulopathy. The onset can also be characterized by portal hypertension-related complications. An extremely severe clinical condition is the superposition of an acute insult to a chronic framework, not necessarily a cirrhotic one. This condition has been termed acute on chronic (acute on chronic liver failure - ACLF:), and it is possible to have a SIRS (systemic inflammation response syndrome) with a multi-organ system involvement. The diagnosis, in selected cases, can be confirmed by a transjugular biopsy that allows to reach a histologic prognostic stratification. Several indices are used for the assessment of prognosis and in particular the MDF and the MELD. In our clinical practice we use the MELD. In case of ACLF, the consortium organ failure score (CLIF-C OFS) is used. The therapy is characterized by alcohol abstention, and, in severe forms (MDF >32 and MELD >21) with absence of contraindications, it is possible to use steroids therapy. If a positive answers cannot be obtained, an early liver transplantation is proposed. This possibility, after a careful selection, now is promoted by several authors.

Efficacy and safety of argatroban in patients with acute respiratory distress syndrome and extracorporeal lung support

BackgroundExtracorporeal membrane oxygenation (ECMO) or pumpless extracorporeal lung assist (pECLA) requires effective anticoagulation. Knowledge on the use of argatroban in patients with acute respiratory distress syndrome (ARDS) undergoing ECMO or pECLA is limited. Therefore, this study assessed the feasibility, efficacy and safety of argatroban in critically ill ARDS patients undergoing extracorporeal lung support.MethodsThis retrospective analysis included ARDS patients on extracorporeal lung support who received argatroban between 2007 and 2014 in a single ARDS referral center. As controls, patients who received heparin were matched for age, sex, body mass index and severity of illness scores. Major and minor bleeding complications, thromboembolic events, administered number of erythrocyte concentrates, thrombocytes and fresh-frozen plasmas were assessed. The number of extracorporeal circuit systems and extracorporeal lung support cannulas needed due to clotting was recorded. Also assessed was the efficacy to reach the targeted activated partial thromboplastin time (aPTT) in the first consecutive 14 days of therapy, and the controllability of aPTT values is within a therapeutic range of 50–75 s. Fisher’s exact test, Mann–Whitney U tests, Friedman tests and multivariate nonparametric analyses for longitudinal data (MANOVA; Brunner’s analysis) were applied where appropriate.ResultsOf the 535 patients who met the inclusion criteria, 39 receiving argatroban and 39 matched patients receiving heparin (controls) were included. Baseline characteristics were similar between the two groups, including severity of illness and organ failure scores. There were no significant differences in major and minor bleeding complications. Rates of thromboembolic events were generally low and were similar between the two groups, as were the rates of transfusions required and device-associated complications. The controllability of both argatroban and heparin improved over time, with a significantly increasing probability to reach the targeted aPTT corridor over the first days (p < 0.001). Over time, there were significantly fewer aPTT values below the targeted aPTT goal in the argatroban group than in the heparin group (p < 0.05). Both argatroban and heparin reached therapeutic aPTT values for adequate application of extracorporeal lung support.ConclusionsArgatroban appears to be a feasible, effective and safe anticoagulant for critically ill ARDS patients undergoing extracorporeal lung support.

Multiple organ failure after spontaneous return of circulation in cardiac arrest in children

Abstract Objective To assess the frequency of the multiple organ failure and the prognostic value of multiple organ failure scores in children who have recovered from an in-hospital cardiac arrest. Patients and methods A single centre, observational, and retrospective study was conducted on children between 1 month and 16 years old who suffered an in-hospital cardiac arrest and achieved return of spontaneous circulation (ROSC). In the first 24–48 h and between the fifth and the seventh day after ROSC, a record was made of the scores on paediatric severity (PRISM and PIM II) and multiple organ failure scales (PELOD and P-MODS), along with the clinical and analytical data, and including monitoring and treatment, mortality and cause of death. Results Of the total of 41 children studied, 70.7% were male, and the median age was 38 months. The overall mortality during admission was 41.5%, with 14.6% dying in the first 48 h, and 7.6% in the following 3–5 days. In the first 48 h, clinical severity and multiple organ failure scores were higher in the patients that died than in survivors (PRISM 29 vs. 21) p = 0.125, PIM II (26.8% vs. 9.2%) p = 0.02, PELOD (21 vs. 12) p = 0.005, and P-MODS (9 vs. 6) p = 0.001. Between the fifth and seventh day, the scores on the four scales were also higher in patients who died, but only those of the PELOD (20.5 vs. 11) p = 0.002 and P-MODS (6.5 vs. 3) p = 0.003 reached statistical significance. Conclusions Mortality in children after return of spontaneous circulation after cardiac arrest is high. The multiple organ failure after return of spontaneous circulation after cardiac arrest in children is associated with increased mortality.

Refeeding hypophosphataemia after enteral nutrition in a Malaysian intensive care unit: risk factors and outcome.

Refeeding hypophosphataemia (RH) is characterized by an acute electrolyte derangement following nutrition therapy. Complications associated include heart failure, respiratory failure, paraesthesia, seizure and death. We aim to assess its incidence, risk factors, and outcome in our local intensive care unit (ICU). A prospective observational cohort study was conducted at the mixed medical- surgical of a tertiary ICU in Kuantan, Malaysia. The study was registered under the National Medical Research Register (NMRR-14-803-19813) and has received ethical approval. Inclusion criteria include adult admission longer than 48 hours who were started on enteral feeding. Chronic renal failure patients and those receiving dialysis were excluded. RH was defined as plasma phosphate less than 0.65 mmol/L and a drop of more than 0.16 mmol/L following feeding. A total of 109 patients were recruited, of which 44 (42.6%) had RH. Patients with RH had higher SOFA score compared to those without (p=0.04). There were no differences in the APACHE II and NUTRIC scores. Serum albumin was lower in those with RH (p=0.04). After refeeding, patients with RH had lower serum phosphate, magnesium and albumin, and higher supplementation of phosphate, potassium and calcium. There were no differences in mortality, length of hospital or ICU stay. Refeeding hypophosphataemia occurs in almost half of ICU admission. Risk factors for refeeding include high organ failure score and low albumin. Refeeding was associated with imbalances in phosphate, magnesium, potassium and calcium. Future larger study may further investigate these risk factors and long-term outcomes.

Long term mortality in critically ill burn survivors

IntroductionLittle is known about long term survival risk factors in critically ill burn patients who survive hospitalization. We hypothesized that patients with major burns who survive hospitalization would have favorable long term outcomes. MethodsWe performed a two center observational cohort study in 365 critically ill adult burn patients who survived to hospital discharge. The exposure of interest was major burn defined a priori as >20% total body surface area burned [TBSA]. The modified Baux score was determined by age + %TBSA+ 17(inhalational injury). The primary outcome was all-cause 5year mortality based on the US Social Security Administration Death Master File. Adjusted associations were estimated through fitting of multivariable logistic regression models. Our final model included adjustment for inhalational injury, presence of 3rd degree burn, gender and the acute organ failure score, a validated ICU risk-prediction score derived from age, ethnicity, surgery vs. medical patient type, comorbidity, sepsis and acute organ failure covariates. Time-to-event analysis was performed using Cox proportional hazard regression. ResultsOf the cohort patients studied, 76% were male, 29% were non white, 14% were over 65, 32% had TBSA >20%, and 45% had inhalational injury. The mean age was 45, 92% had 2nd degree burns, 60% had 3rd degree burns, 21% received vasopressors, and 26% had sepsis. The mean TBSA was 20.1%. The mean modified Baux score was 72.8. Post hospital discharge 5year mortality rate was 9.0%. The 30day hospital readmission rate was 4%. Patients with major burns were significantly younger (41 vs. 47 years) had a significantly higher modified Baux score (89 vs. 62), and had significantly higher comorbidity, acute organ failure, inhalational injury and sepsis (all P<0.05). There were no differences in gender and the acute organ failure score between major and non-major burns. In the multivariable logistic regression model, major burn was associated with a 3 fold decreased odds of 5year post-discharge mortality compared to patients with TBSA<20% [OR=0.29 (95%CI 0.11–0.78; P=0.014)]. The adjusted model showed good discrimination [AUC 0.81 (95%CI 0.74–0.89)] and calibration (Hosmer–Lemeshow χ2 P=0.67). Cox proportional hazard multivariable regression modeling, adjusting for inhalational injury, presence of 3rd degree burn, gender and the acute organ failure score, showed that major burn was predictive of lower mortality following hospital admission [HR=0.34 (95% CI 0.15–0.76; P=0.009)]. The modified Baux score was not predictive for mortality following hospital discharge [OR 5year post-discharge mortality=1.00 (95%CI 0.99–1.02; P=0.74); HR for post-discharge mortality=1.00 (95% CI 0.99–1.02; P=0.55)]. ConclusionsCritically ill patients with major burns who survive to hospital discharge have decreased 5year mortality compared to those with less severe burns. ICU Burn unit patients who survive to hospital discharge are younger with less comorbidities. The observed relationship is likely due to the relatively higher physiological reserve present in those who survive a Burn ICU course which may provide for a survival advantage during recovery after major burn.

Effect of global end diastolic volume index guidance fluid resuscitation in elderly patients with septic shock

To evaluate the effect of global end diastolic volume index (GEDVI) on fluid resuscitation in elderly patients with septic shock. A prospective randomized controlled trial (RCT) was conducted. Septic shock patients over 65 years admitted to intensive care unit (ICU) of Shandong Province, Zibo Central Hospital from January 2013 to December 2015 were enrolled. The patients were randomly divided into control group and observation group, 20 cases in each group. In accordance with the guidelines for the treatment of septic shock, early goal-directed therapy (EGDT), rehydration in the control group was treated with the guide of central venous pressure (CVP); observation group was received pulse indicator continuous cardiac output (PiCCO) monitoring, and rehydration was treated according to the GEDVI and extravascular lung water index (EVLWI), i.e. GEDVI was maintained in 650-800 mL/m2, EVLWI was not obviously increased compared with the basic value and without the emphasis of CVP. Initial acute physiology and chronic health evaluation II (APACHE II) score, sequential organ failure score (SOFA), procalcitonin (PCT), mean arterial pressure (MAP), lactic acid (Lac) and oxygenation index (PaO2/FiO2); serial Lac, central venous to arterial carbon dioxide pressure (Pcv-aCO2), fluid balance, the amount of noradrenaline accumulation, PaO2/FiO2 after 6, 24 and 48 hours resuscitation; mechanical ventilation time, incidence of acute heart failure, ICU hospitalization time and 28-day mortality were recorded. There was no significant difference in gender, age, APACHE II score, SOFA score, primary disease, infection site and basal PCT, MAP, Lac, PaO2/FiO2 between the two groups. Compared with the control group, 6 hours Lac, Pcv-aCO2 recovery, positive fluid balance, noradrenaline accumulation and PaO2/FiO2 of the observation group showed no significant difference; positive fluid balance 24 hours in the recovery was significantly reduced (mL: 2 919.80±986.44 vs. 3 991.40±933.53), Pcv-aCO2 significantly decreased [mmHg (1 mmHg = 0.133 kPa): 5.55±1.43 vs. 7.10±2.38], PaO2/FiO2 significantly improved (mmHg: 194.80±28.57 vs. 177.65±23.46), and noradrenaline accumulation was increased significantly (mg: 40.99±20.69 vs. 27.31±19.34) with statistically significant difference (all P < 0.05); the blood level of Lac 48 hours in the recovery was significantly decreased (mmol/L: 1.16±0.89 vs. 1.85±1.01), Pcv-aCO2 (mmHg: 5.35±1.18 vs. 6.70±2.34), and PaO2/FiO2 (mmHg: 215.75±33.84 vs. 190.60±32.89) were further improved, the positive fluid balance was significantly reduced (mL: 3 141.55±1 245.69 vs. 4 533.85±1 416.67, all P < 0.05). Compared with the control group, mechanical ventilation time (days: 3.65±1.31 vs. 4.50±1.19), ICU hospitalization time (days: 5.80±1.67 vs. 7.15±2.30) was significantly shorter in the observation group (both P < 0.05), acute heart failure rate was decreased significantly (5.0% vs. 30.0%, P < 0.05), but the 28-day mortality showed no statistical significance (25.0% vs. 40.0%, P = 0.311). Compared to the conventional EGDT methods, fluid resuscitation under the guidance of GEDVI in elderly patients with septic shock with less liquid loading, can achieve better oxygenation and reduce heart failure, shorten the duration of mechanical ventilation and ICU stay, and play an important significant guidance for elderly patients' fluid resuscitation with septic shock.

Risk of different precipitating events for progressing to acute-on-chronic liver failure in HBV-related cirrhotic patients.

Acute-on-chronic liver failure (ACLF) is a distinct syndrome that develops in patients with cirrhosis and acute decompensation (AD). This study focused on the precipitating events (PEs) of hepatitis B virus (HBV)-related cirrhotic patients diagnosed as ACLF based on the Chronic Liver Failure Consortium organ failure (CLIF-C OF) score. Hospitalized patients with HBV-related cirrhosis and AD were retrospectively included. The patients' characteristics, laboratory test results, PEs, CLIF-C OF score and short-term prognosis were evaluated. Of the 890 patients enrolled 300 (33.7%) were diagnosed as ACLF and 590 (66.3%) without ACLF. ACLF patients had a higher incidence of PEs than those without ACLF. The ACLF patients were more prone to having PEs of bacterial infection (P < 0.001), HBV reactivation (P < 0.001), active alcoholism (P = 0.036) and superimposed hepatitis virus infection (P = 0.031), whereas portal vein thrombosis (P = 0.002) were less common in the non-ACLF group. ACLF patients with the top four single PEs had diverse types of organ failures. However, they shared a similar short-term prognosis. While in patients without PEs the ACLF group had higher systemic inflammation and deterirated outcomes compared with the non-ACLF group. PEs of bacterial infection, HBV reactivation, active alcoholism and superimposed hepatitis virus infection, but not GI hemorrhage or portal vein thrombosis, were risk factors for ACLF. There may be two types of patients with ACLF based on the differences in the clinical manifestation of the disease.

Outcome of patients with septic shock and high-dose vasopressor therapy

BackgroundDespite the dissemination of international guidelines, mortality from septic shock remains high. Norepinephrine is recommended as first-line vasopressor therapy with a target mean arterial pressure of 65 mmHg. High-dose vasopressor (HDV) may also be required. This study aimed to assess survival in patients with septic shock requiring HDV. We conducted a retrospective study of patients admitted between January 2008 and December 2013 to a 13-bed ICU for septic shock and receiving high-dose vasopressor therapy (defined by a dose >1 µg/kg/min). Primary outcome was 28-day mortality (D28). Secondary outcomes were 90-day mortality (D90), organ failure score (SOFA), duration of organ failure, duration and dosage of vasopressor agent and ischemic complications.ResultsIn our cohort of 106 patients, mortality reached 60.4% at D28 and 66.3% at D90. One in two patients died before D10. The weight-based mean dose of vasopressor (WMD) represented the best prognostic factor. Using a cutoff of 0.75 µg/kg/min, WMD was associated with mortality with a sensitivity of 73% and specificity of 74%. The mortality rate reached 86.4% when WMD was above the cutoff value and associated with a SOFA score >10. Digital or limb necrosis was documented in 6 patients (5.7%).ConclusionsIn total, 40% of septic shock patients receiving high-dose vasopressor therapy survived at day 28 after admission. A WMD cutoff value of 0.75 µg/kg/min, associated with a >10 SOFA score, was a strong predictor of death. These results provide insights into outcome of refractory septic shock, showing that administration of high-dose vasopressor may indeed be useful in these patients.

Su1248 - The Systemic Inflammatory Response Syndrome (SIRS) and Quick Sequential Organ Failure (qSOFA) Score At Presentation are Associated with Poor Outcomes in Acute Pancreatitis

Su1248 - The Systemic Inflammatory Response Syndrome (SIRS) and Quick Sequential Organ Failure (qSOFA) Score At Presentation are Associated with Poor Outcomes in Acute Pancreatitis

Validation of prognostic scores to predict short-term mortality in patients with HBV-related acute-on-chronic liver failure: The CLIF-C OF is superior to MELD, CLIF SOFA, and CLIF-C ACLF.

Acute-on-chronic liver failure (ACLF) in chronic hepatitis B (CHB) patients has a high short-term mortality. Identification of effective models to predict the short-term mortality may enable early intervention and improve patients’ prognosis. We aim to assess the performance of the CLIF Consortium Organ Failure score (CLIF-C OFs), CLIF sequential organ failure assessment score (CLIF-SOFAs), CLIF Consortium ACLF score (CLIF-C ACLFs), ACLF grade, and model for end-stage liver disease score (MELDs) in predicting the short-term mortality in CHB patients with ACLF.Among the 155 consecutive adult patients with liver failure as a discharge diagnosis were screened, and all the patients were treated at the Department of Infectious Diseases, Huashan Hospital, Fudan University (Shanghai, China) from January 2010 to February 2016. The diagnosis of ACLF was based on the criteria formalized by the ACLF consensus recommendations of the Asian Pacific Association for the Study of the Liver (APASL). Diagnostic accuracy for predicting short-term (28-day) mortality was calculated for CLIF-C OFs, CLIF-SOFAs, CLIF-C ACLFs, ACLF grade, and MELDs in all patients.One hundred fifty-five consecutive adult liver failure patients were screened and 85 patients including 73 males and 12 females were enrolled. Overall, the 28-day transplant-free mortality was 32% in all patients, and 100% in those with severe early course (ACLF-3). The area under the receiver operating characteristic curve (AUROC) of CLIF-C OFs (AUROC: 0.906, P = .0306, compared with MELDs) was higher than those of CLIF-SOFAs (AUROC: 0.876), CLIF-C ACLFs (AUROC: 0.858), ACLF grade (AUROC: 0.857), and MELDs (AUROC: 0.838) for predicting short-term mortality. The cut-point for baseline CLIF-C OFs in predicting death was 8.5, with 67% sensitivity, 90% specificity, and AUROC of 0.906 (95% CI: 0.8450–0.9679).The results indicate that short-term mortality is high in patients with ACLF and CLIF Consortium Organ Failure score is superior to MELD, CLIF SOFA, and CLIF-C ACLF in predicting its short-term mortality.

Effect of vitamin D3 on the severity and prognosis of patients with sepsis: a prospective randomized double-blind placebo study

To observe the relationship between vitamin D3 and the severity as well as prognosis in patients with sepsis, and to explore whether exogenous vitamin D3 can improve the prognosis in patients with sepsis. A prospective randomized double-blind placebo study was conducted. Fifty-seven patients with sepsis admitted to intensive care unit (ICU) of Shengjing Hospital Affiliated to China Medical University from March to November in 2015 were enrolled. Twenty patients with systemic inflammatory response syndrome (SIRS) and 20 healthy volunteers with normal physical examination as control were enrolled during the same time. Patients with sepsis were divided into general sepsis group and severe sepsis group (including septic shock) according to the criteria for the diagnosis of severe sepsis and septic shock in 2012. According to the diagnostic criteria established by the American Endocrine Society, and on the basis of 25-hydroxy vitamin D3 [25(OH)D3], the sepsis patients with deficiency [25(OH)D3 20-30 μg/L] or insufficiency [25(OH)D3 < 20 μg/L] of vitamin D were divided into D3 treatment group (supplemented 300 kU vitamin D3) and placebo group (injected 1 mL physiological saline). 28th day was set as the end point, and the patients with sepsis were divided into survival group and death group. The levels of serum 25(OH)D3 in each group were measured by electrochemical luminescence method, and the difference in 25(OH)D3 levels among patients with different severity, gender, and age were recorded. Procalcitonin (PCT), C-reactive protein (CRP), blood routine, liver and kidney function, electrolytes and arterial blood gas analysis, acute physiology and chronic health evaluation II (APACHE II) and sequential organ failure score (SOFA), duration of mechanical ventilation, and length of ICU stay of patients with sepsis were observed. Multivariate Cox proportional hazard regression analysis was used to analyze the risk factors of prognosis in patients with sepsis. (1) In 57 patients with sepsis, there were 15 patients in general sepsis group, and 42 in severe sepsis group; 29 in D3 treatment group, and 28 in the placebo group; 8 patients died within 28 days with mortality rate of 14.04%. (2) The levels of serum 25(OH)D3 in sepsis group and SIRS group were significantly lower than those in healthy control group [μg/L: 3.92 (< 3.00, 11.22), 6.99 (3.51, 9.77) vs. 17.25 (13.48, 22.50), both P < 0.01], but there was no significant difference in the serum 25(OH)D3 level between sepsis group and SIRS group as well as patients with different degrees of sepsis. The serum 25(OH)D3 level in female patients with sepsis (n = 24) was significantly lower than that in male (n = 33), and the difference was statistically significant [μg/L: <3.00 (<3.00, 3.87) vs. 11.96 (5.14, 17.29), Z = -4.020, P = 0.000]. There was no significant difference in serum 25(OH)D3 level between the young (age <60 years old, n = 30) and the old (age ≥ 60 years old, n = 27) patients with sepsis [μg/L: 4.54 (<3.00, 9.88) vs. 3.00 (<3.00, 15.08), Z = -0.601, P = 0.548]. (3) In patients with sepsis, there was no significant difference in the duration of mechanical ventilation [hours: 41.00 (7.50, 82.50) vs. 67.00 (4.75, 127.75)], length of ICU stay (days: 5.48±4.08 vs. 6.68±4.87) and 28-day mortality (10.34% vs. 17.86%) between D3 treatment group and placebo group (all P > 0.05). It was shown by Kaplan-Meier survival curve analysis that there was no significance in 28-day accumulated survived rate between the two groups [log-rank test: χ 2 = 0.222, P = 0.638]. It was shown by multivariate Cox regression analysis that APACHE II score [relative risk (RR) = 8.487, 95% confidence interval (95%CI) = 1.506-47.835, P = 0.015] and 25(OH)D3 < 20 μg/L (RR = 0.088, 95%CI = 0.013-0.592, P = 0.012) were the risk factors of prognosis in patients with sepsis. The serum 25(OH)D3 level in ICU patients with sepsis was lower than that in healthy people, but there was no significant difference between patients with sepsis and SIRS. The serum 25(OH)D3 level in sepsis patients was related with gender, and the level of the female was lower than that of the male, but was not related with age. Exogenous vitamin D3 supplementation cannot improve the prognosis of ICU patients with sepsis. APACHE II score and 25(OH)D3 < 20 μg/L were risk factors for the prognosis in ICU patients with sepsis.