Outcomes In Intensive Care Unit Patients Research Articles

Renal failure in the ICU: Comparison of the impact of acute renal failure and end-stage renal disease on ICU outcomes

Acute renal failure (ARF) is associated with a persistent high mortality in critically ill patients in intensive care units (ICUs). Most studies to date have focused on patients with established, intrinsic ARF or relatively severe ARF due to multiple factors. None have examined outcomes of dialysis-dependent chronic renal failure [end-stage renal disease (ESRD)] patients in the ICU. We examined the incidence and outcomes of ARF in the ICU using a standard definition and compared these to outcomes of ICU patients with either ESRD or no renal failure. We sought to determine the impact of renal dysfunction and/or loss of organ function on outcome. We prospectively scored 1530 admissions to eight ICUs over a 10-month period for illness severity at ICU admission using the Acute Physiological and Chronic Health Evaluation (APACHE III) evaluation tool. Patients were defined as having ARF based on the definition of Hou et al (Am J Med 74:243-248,1983) designed to detect significant measurable declines in renal function based on serum creatinine. ESRD patients were identified as being chronically dialysis-dependent prior to ICU admission and the remainder had no renal failure. Clinical characteristics at ICU admission and ICU and hospital outcomes were compared between the three groups. We identified 254 cases of ARF, 57 cases of ESRD and 1219 cases of no renal failure for an incidence of ARF of 17%. Roughly half the ARF patients had ARF at ICU admission and the remainder developed ARF during their ICU stay. Only 11% of ARF patients required dialysis support. ARF patients had significantly higher acute illness severity scores than those with no renal failure, whereas patients with ESRD had intermediate severity scores. ICU mortality was 23% for patients with ARF, 11% for those with ESRD, and 5% for those with no renal failure. There was no difference in outcome between patients who had ARF at ICU admission and those who developed ARF in the ICU. Patients with ARF severe enough to require dialysis had a mortality of 57%. APACHE III predicted outcome very well in patients with no renal failure and patients with ARF at the time of scoring but underpredicted mortality in those who developed ARF after ICU admission and overestimated mortality in patients with ESRD. ARF is common in ICU patients and has a persistent negative impact on outcomes, although the majority of ARF is not severe enough to require dialysis support. The mortality of patients with ARF from all causes is almost exactly similar to that noted using the same criteria two decades ago. More profound ARF requiring dialysis continues to have an even greater mortality. Nevertheless, acute declines in renal function are associated with a mortality that is not well explained simply by loss of organ function. The majority of ARF patients who did not require dialysis still had a considerably higher mortality than the ESRD patients, all of whom required dialysis; while ARF patients who did require dialysis had a much higher morality than ESRD patients. APACHE III performs well and captures the mortality of patients with ARF at the time of scoring. Development of ARF after scoring has a profound effect on standardized mortality. We were unable to identify a unique mortality associated with ARF, but the presence of measurable renal insufficiency continues to be a sensitive marker for poor outcome.

Thrombocytopenia and prognosis in intensive care.

To study the incidence and prognosis of thrombocytopenia in adult intensive care unit (ICU) patients. Prospective observational cohort study. The medical ICU of a university hospital and the combined medical-surgical ICU of a regional hospital. All patients consecutively admitted during a 5-month period. Patient surveillance and data collection. The primary outcome measure was ICU mortality. Data of 329 patients were analyzed. Overall ICU mortality rate was 19.5%. A total of 136 patients (41.3%) had at least one platelet count <150 x 10(9)/L. These patients had higher Multiple Organ Dysfunction Score (MODS), Simplified Acute Physiology Score (SAPS) II, and Acute Physiology and Chronic Health Evaluation (APACHE) II scores at admission, longer ICU stay (8 [4-16] days vs. 5 [2-9] days) (median [interquartile range]), and higher ICU mortality (crude odds ratio [OR], 5.0; 95% confidence interval [CI], 2.7-9.1) and hospital mortality than patients with daily platelet counts >150 x 10(9)/L (p < .0005 for all comparisons). Bleeding incidence rose from 4.1% in nonthrombocytopenic patients to 21.4% in patients with minimal platelet counts between 101 x 10(9)/L and 149 x 10(9)/L (p = .0002) and to 52.6% in patients with minimal platelet counts <100 x 10(9)/L (p < .0001). In all quartiles of admission APACHE II and SAPS II scores, a nadir platelet count <150 x 10(9)/L was related with a substantially poorer vital prognosis. Similarly, a drop in platelet count to < or =50% of admission was associated with higher death rates (OR, 6.0; 95% CI, 3.0-12.0; p < .0001). In a logistic regression analysis with ICU mortality as the dependent variable, the occurrence of thrombocytopenia had more explanatory power than admission variables, including APACHE II, SAPS II, and MODS scores (adjusted OR, 4.2; 95% CI, 1.8-10.2). Thrombocytopenia is common in ICUs and constitutes a simple and readily available risk marker for mortality, independent of and complementary to established severity of disease indices. Both a low nadir platelet count and a large fall of platelet count predict a poor vital outcome in adult ICU patients.

Measuring the health outcomes of general ICU patients: a systematic review of methods and findings

Studies that have measured patient outcomes following a critical illness and admission to a general intensive care unit (ICU) have used a variety of methods and variables. Traditionally, the measures have been mortality and morbidity, but they now also include assessment of indices such as functional status, health status, quality of life and patient satisfaction. This review paper examines 31 previously published primary studies that measured patient outcomes from adult general ICUs. Inclusion criteria for the review process included papers with explicit measurement of patient outcomes beyond mortality rates: functional status, health status and quality of life. The paper includes summative descriptions of the reviewed papers, discussion of the various methods, results and limitations, and some synthesis of the pooled findings. The review indicated that the health status and activities of the majority of survivors who responded to the follow-up measures were similar to what they were before their critical illness. However, whether these subjects are representative of ICU survivors in general is not conclusive, as lack of methodological control over exclusions and losses to follow-up were evident. In addition, the heterogeneity of the ICU population in terms of age, acuity and diagnoses complicates any potential comparisons. There is an opportunity for further studies in this area by nurse researchers, in either intra- or multidisciplinary teams. Future studies should incorporate rigorous methodologies and a triangulated approach, in order to adequately examine patient outcomes following a critical illness and admission to a general ICU.

Hospital outcome of ICU patients in multi-organ failure

Objective: To assess hospital outcome of intensive care unit (ICU) patients in multi-organ failure. Design: Prospective study. Setting: Multi-disciplinary ICU in a tertiary level post-graduate centre. Subjects: All patients (n=907) admitted to the ICU between April 1989 and September 1992. Interventions: None. Measurements and main results: The number and duration of organ system failures (OSFs) were related to outcome at hospital discharge. The hospital mortality of patients in acute OSF was as follows: one OSF 21%, two OSFs 44% and three or more OSFs 69%. The duration of OSF from one to seven days did not significantly alter the percentage mortality. In patients with three or more OSFs for three or more days, neurological failure (GCS ≤⃒ 6) adversely affected hospital outcome unlike the combined presence of cardiovascular, respiratory and renal failure which had no effect on outcome. Mortality rates for patients in acute OSF were lower than previously reported and 13 patients (33%) with three or more OSFs for three or more days were discharged alive from hospital. Conclusion: Neurological failure significantly increases the mortality of ICU patients. Though the number of OSF correlated with mortality, it is not a good prognostic indicator of hospital outcome of ICU patients. These results do not indicate which patients in multi-organ failure syndrome (MOFS) should be actively supported and for how long. Further comparable studies can help delineate which patients could benefit from continuing therapy.

Hospital outcome of ICU patients in multi-organ failure

Objective: To assess hospital outcome of intensive care unit (ICU) patients in multi-organ failure. Design: Prospective study. Setting: Multi-disciplinary ICU in a tertiary level post-graduate centre. Subjects: All patients (n=907) admitted to the ICU between April 1989 and September 1992. Interventions: None. Measurements and main results: The number and duration of organ system failures (OSFs) were related to outcome at hospital discharge. The hospital mortality of patients in acute OSF was as follows: one OSF 21%, two OSFs 44% and three or more OSFs 69%. The duration of OSF from one to seven days did not significantly alter the percentage mortality. In patients with three or more OSFs for three or more days, neurological failure (GCS ≤ 6) adversely affected hospital outcome unlike the combined presence of cardiovascular, respiratory and renal failure which had no effect on outcome. Mortality rates for patients in acute OSF were lower than previously reported and 13 patients (33%) with three or more OS...

Nosocomial Outbreak Caused by a Multiresistant Clone of Acinetobacter baumannii: Results of the Case- Control and Molecular Epidemiologic Investigations

To describe a nosocomial outbreak caused by multiresistant Acinetobacter baumannii. Descriptive and case-control study. Antibiotic susceptibilities and pulsed-field gel electrophoresis (PFGE) of genomic DNA digested with SfiI and also with ApaI were used as markers of strain identity. A large medical school-affiliated hospital in the city of Houston, Texas. During a 10-week period, A baumannii was isolated from 25 patients admitted to the intensive care unit (ICU). The attack rate was 14.3 per 100 ICU admissions. Case patients were intubated more frequently and for longer periods, and had longer ICU and hospital stays (P < 0.05 for each of these characteristics). Multivariate logistic regression analysis identified the length of ICU stay and the use of third-generation cephalosporins as associated with the acquisition of A baumannii. Patients infected with A baumannii had a higher mortality rate than colonized patients and control patients (P < 0.01). Sixteen isolates recovered from these 25 patients were susceptible only to imipenem/cilastatin, and PFGE confirmed that a single clone was the cause of this outbreak. Nine isolates of A baumannii from patients infected or colonized in two other hospitals in Houston during the same period, differed from the outbreak isolates by their susceptibility to ciprofloxacin. However, PFGE results were identical, indicating unsuscepted genetic relatedness among isolates from three different hospitals. A baumannii is an important nosocomial opportunistic pathogen and can adversely affect the outcome of ICU patients who acquire this organism. This outbreak was caused by a single clone that was isolated concurrently from three hospitals.

Glasgow Coma Scale score in the evaluation of outcome in the intensive care unit

To investigate the ability of the Glasgow Coma Scale score to predict hospital mortality rate for adult medical-surgical intensive care unit (ICU) patients without trauma. A prospective cohort analysis of adult medical-surgical patients from a nationally representative sample of 40 U.S. hospitals. 15,973 consecutive, nontraumatic ICU admissions and a comparison group of 687 head trauma admissions. None. Patients' gender, age, treatment location before ICU admission, comorbidities, admission diagnosis, daily physiologic measurements, Glasgow Coma Scale score, Acute Physiology and Chronic Health Evaluation (APACHE III) score, subsequent hospital mortality rate, and unit-specific sedation practices were noted. Hospital mortality rates were stratified by the first ICU day Glasgow Coma Scale score for all admissions. The relationship between the Glasgow Coma Scale score and outcome for two high mortality medical diagnoses (post-cardiac arrest and sepsis) were also examined and compared to the relationship found in patients with head trauma. The Glasgow Coma Scale score on ICU admission had a highly significant (r2 = .922, p < .0001) but nonlinear relationship with subsequent outcome in ICU patients without trauma. Discrimination of patients into high- or low-risk prognostic groups was good, but discrimination in the intermediate levels (Glasgow Coma Scale score of 7 to 11) was reduced. This relationship varied within the operative and nonoperative groups, and also within different disease categories, various age groups, and certain ranges of the Glasgow Coma Scale score. A reduced initial Glasgow Coma Scale score associated with sepsis was a combination of factors associated with a higher mortality rate than that found in patients with head trauma. The proportion of patients who could not be assigned a Glasgow Coma Scale score because of sedation/paralysis varied widely across ICUs. The overall predictive capability of the APACHE III Prognostic Scoring System was improved by incorporating the Glasgow Coma Scale score. We demonstrated the prognostic importance of admission levels of consciousness as measured by the Glasgow Coma Scale score on ICU and hospital mortality rates. We concluded that the Glasgow Coma Scale score may be used to stratify and predict mortality risk in general intensive care patients, but lack of sensitivity in the intermediate range of Glasgow Coma Scale Score should be noted. Ideally, the Glasgow Coma Scale score should also be applied in the context of other physiologic information and the patient's specific diagnosis. Variation in the use of sedatives in different ICUs means that imputing or substituting a value other than normal for an unobtainable Glasgow Coma Scale score may introduce a substantial treatment bias into subsequent outcome predictions.

The role of hemofiltration in the critically-ill intensive care unit patient: present and future.

The development of acute renal failure (ARF) in intensive care unit (ICU) patients carries a poor prognosis. Today, most cases are no longer an isolated organ dysfunction but are part of a multiple system organ failure syndrome. Recently developed renal replacement therapies allow adequate metabolic control, even in highly catabolic and hemodynamically unstable patients. Whether these newer continuous techniques have resulted in a better outcome of these patients is unclear. Recent data suggest a possible beneficial effect of hemofiltration on outcome of ICU patients and the course of human and experimental septic shock, which may be ascribed to the removal of inflammatory mediators. The purpose of this paper is to review the history of hemofiltration techniques and to assess their present and future role in the management of ICU patients. Although hemofiltration has been shown to improve hemodynamics of experimental septic shock, convincing evidence that hemofiltration improves outcome of ICU patients is lacking. Available data suggest that high ultrafiltrate volumes may be needed to achieve clinically important beneficial effects of hemofiltration in these patients. Prospective, randomized trials in homogeneous patient groups are needed to assess the role of hemofiltration in patients with septic shock or multiple system organ failure.