TISS Scores Research Articles

Psychological Outcomes in Children Following Pediatric Intensive Care Unit Hospitalization

Abstract Background Critically ill children may be at risk for developing negative psychological sequel following pediatric intensive care unit (PICU) hospitalization. The highly invasive technological interventions, lack of control over events, the severity of the child’s illness, and high levels of parental distress have been identified as particularly salient factors Aim of the Work To assess the psychological impact of admission to PICU among children and their parents Methods In this cross-sectional study, 100 children admitted to the PICU or ward and their parents completed the Strength and Difficulties Questionnaire (SDQ) and Hospital Anxiety and Depression Scale (HADS) at admission, 6 weeks, and 6 months after discharge. Results The PICU group (n = 50) had significantly higher disease severity scores than the ward group (n = 50) based on mean PRISM (9.5 vs 3.0, p < 0.001) and mean TISS scores (14.98 vs 6.7, p < 0.001). PICU children had a longer mean length of stay (9.8 vs 4.6 days, p < 0.001). At 6 weeks, 38% of PICU children scored in the high or very high risk range on the SDQ total difficulties score compared to 8% of ward children. At 6 months, 28% of PICU children remained at high or very high risk versus 4% of ward children. The SDQ emotional symptoms subscale was most affected. Regarding parental stress, at 6 weeks 12% of PICU parents had abnormal depression scores on the HADS versus 2% of ward parents, while 14% of PICU parents had abnormal anxiety scores versus 4% of ward parents. Multivariate regression found number of previous admissions, severity scores, and invasive procedures predicted SDQ scores at follow-up. Conclusion PICU admission has a significant psychological impact on children and parents lasting at least 6 months. Screening for those at high risk is recommended.

Intensive care\u2013treated cardiac arrest: a retrospective study on the impact of extended age on mortality, neurological outcome, received treatments and healthcare-associated costs

BackgroundCardiac arrest (CA) is a leading cause of death worldwide. As population ages, the need for research focusing on CA in elderly increases. This study investigated treatment intensity, 12-month neurological outcome, mortality and healthcare-associated costs for patients aged over 75 years treated for CA in an intensive care unit (ICU) of a tertiary hospital.MethodsThis single-centre retrospective study included adult CA patients treated in a Finnish tertiary hospital’s ICU between 2005 and 2013. We stratified the study population into two age groups: <75 and ge75 years. We compared interventions defined by the median daily therapeutic scoring system (TISS-76) between the age groups to find differences in treatment intensity. We calculated cost-effectiveness by dividing the total one-year healthcare-associated costs of all patients by the number of survivors with a favourable neurological outcome. Favourable outcome was defined as a cerebral performance category (CPC) of 1–2 at 12 months after cardiac arrest. Logistic regression analysis was used to identify independent associations between age group, mortality and neurological outcome.ResultsThis study included a total of 1,285 patients, of which 212 (16 %) were ge75 years of age. Treatment intensity was lower for the elderly compared to the younger group, with median TISS scores of 116 and 147, respectively (p < 0.001). The effective cost in euros for patients with a good one-year neurological outcome was €168,000 for the elderly and €120,000 for the younger group. At 12 months after CA 24 % of the patients in the elderly group and 47 % of the patients in the younger group had a CPC of 1–2 (p < 0.001). Age was an independent predictor of mortality (multivariate OR = 2.90, 95 % CI: 1.94–4.31, p < 0.001) and neurological outcome (multivariate OR = 3.15, 95 % CI: 2.04–4.86, p < 0.001).ConclusionsThe elderly ICU-treated CA patients in this study had worse neurological outcomes, higher mortality and lower cost-effectiveness than younger patients. Elderly received less intense treatment. Further efforts are needed to recognize the tools for assessing which elderly patients benefit from a more aggressive treatment approach in order to improve the cost-effectiveness of post-CA management.

Analysis of Inflammatory Mediator Profiles in Sepsis Patients Reveals That Extracellular Histones Are Strongly Elevated in Nonsurvivors

The timely recognition of sepsis and the prediction of its clinical course are challenging due to the complex molecular mechanisms leading to organ failure and to the heterogeneity of sepsis patients. Treatment strategies relying on a “one-fits-all” approach have failed to reduce mortality, suggesting that therapeutic targets differ between patient subgroups and highlighting the need for accurate analysis of the molecular cascades to assess the highly variable host response. Here, we characterized a panel of 44 inflammatory mediators, including cytokines, chemokines, damage-associated molecular patterns, and coagulation-related factors, as well as markers of endothelial activation in 30 patients suffering from renal failure in the course of sepsis. All patients received continuous veno-venous hemodialysis with either high cut-off filters or with standard filters, and mediators were quantified for all patients at the initiation of dialysis and after 24 h and 48 h. Mediator concentrations in individual patients ranged widely, demonstrating the heterogeneity of sepsis patients. None of the mediators correlated with SAPS III or TISS scores. The overall in-hospital mortality of the study population was 56.7% (57.1% vs. 56.3% for high cut-off vs. standard filter). The two filter groups differed regarding most of the mediator levels at baseline, prohibiting conclusions regarding the effect of standard filters versus high cut-off filters on mediator depletion. The elevation and correlation of damage-associated molecular patterns and markers of endothelial activation gave evidence of severe tissue damage. In particular, extracellular histones were strongly increased and were almost 30-fold higher in nonsurvivors as compared to survivors, indicating their diagnostic and prognostic potential.

Injury Assessment of Individuals Wounded in the Lushan Earthquake and the Emergency Department Workload: A Corresponding Correlation Study.

In this study, we aimed to evaluate the correlation between the trauma score of individuals wounded in the Lushan earthquake and emergency workload for treatment. We further created a trauma score-emergency workload calculation model. We included data from patients wounded in the Lushan earthquake and treated at West China Hospital, Sichuan University. We calculated scores per the following models separately: Revised Trauma Score (RTS), Prehospital Index (PHI), Circulation Respiration Abdominal Movement Speech (CRAMS), Therapeutic Intervention Scoring System (TISS-28), and Nursing Activities Score (NAS). We assessed the association between values for CRAMS, PHI, and RTS and those for TISS-28 and NAS. Subsequently, we built a trauma score-emergency workload calculation model to quantitative workload estimation. Significant correlations were observed for all pairs of trauma scoring models with emergency workload scoring models. TISS-28 score was significantly associated with PHI score and RTS; however, no significant correlation was observed between the TISS-28 score and CRAMS score. CRAMS, PHI, and RTS were consistent in evaluating the injury condition of wounded individuals; TISS-28 and NAS scores were consistent in evaluating the required treatment workload. Dynamic changes in emergency workload in unit time were closely associated with wounded patient visits.

Readmissions to General ICUs in a Geographic Area of Poland Are Seemingly Associated with Better Outcomes.

Background: Various factors can contribute to high mortality rates in intensive care units (ICUs). Here, we intended to define a population of patients readmitted to general ICUs in Poland and to identify independent predictors of ICU readmission. Methods: Data derived from adult ICU admissions from the Silesian region of Poland were analyzed. First-time ICU readmissions (≤30 days from ICU discharge after index admissions) were compared with first-time ICU admissions. Pre-admission and admission variables that independently influenced the need for ICU readmission were identified. Results: Among the 21,495 ICU admissions, 839 were first-time readmissions (3.9%). Patients readmitted to the ICU had lower mean APACHE II (21.2 ± 8.0 vs. 23.2 ± 8.8, p < 0.001) and TISS-28 scores (33.7 ± 7.4 vs. 35.2 ± 7.8, p < 0.001) in the initial 24 h following ICU admission, compared to first-time admissions. ICU readmissions were associated with lower mortality vs. first-time admissions (39.2% vs. 44.3%, p = 0.004). Independent predictors for ICU readmission included the admission from a surgical ward (among admission sources), chronic respiratory failure, cachexia, previous stroke, chronic neurological diseases (among co-morbidities), and multiple trauma or infection (among primary reasons for ICU admission). Conclusions: High mortality associated with first-time ICU admissions is associated with a lower mortality rate during ICU readmissions.

A safety study of extremely early rehabilitation in patients with myocardial infarction

Theoretically, early rehabilitation intervention may be helpful for patients with acute myocardial infarction; however, safety concerns are always an issue. The aim of the study was to evaluate the safety of extremely early rehabilitation intervention in patients with acute myocardial infarction. We evaluated 100 cardiac ICU patients (50 study group, 50 control group) with myocardial infarction. All patients have undergone cardiac catheterization with stenting. Phase I cardiac rehabilitation within 8 hours of stent placement was administered. The following data were collected and calculated by statistical methods: vital signs, conscious level (GCS) and APACHE, TISS, SOFA, KILLIP scores during patients’ stay in cardiac ICU. We used SPSS 23.0 statistic software to analyze the data. We compared the two groups of patients to see if there is any significant difference. The two groups did not significantly differ in their demographic (e.g., sex, age) data; neither did they differ in the following parameters: vital sign variability, conscious levels, APACHE, TISS, SOFA and KILLIP scores. Length of stay in cardiac ICU between the two groups showed no significant differences, either. Early rehabilitation intervention in patients with acute myocardial infarction did not increase risks of unstable vital signs, lower conscious levels, and bad general condition. Our data support the safety of extremely early rehabilitation intervention in this special group of patients.

Efficacy and Safety of Caregiver-Mediated Exercise in Post-stroke Rehabilitation.

ObjectiveTo assess the efficacy and safety of our 4-week caregiver-mediated exercise (CME) in improving trunk control capacity, gait, and balance and in decreasing concerns about post-stroke falls when there is an increase in its efficacy.MethodsAcute or subacute stroke survivors were assigned to either the trial group (n=35) or the control group (n=37). Changes in Modified Barthel Index (MBI), Functional Ambulation Categories (FAC), Berg Balance Scale (BBS), and Trunk Impairment Scale (TIS) scores at 4 weeks from baseline served as primary outcome measures. Correlations of primary outcome measures with changes in Fall Efficacy Scale-International (FES-I) scores at 4 weeks from baseline in the trial group served as secondary outcome measures. Treatment-emergent adverse events (TEAEs) served as safety outcome measures.ResultsThere were significant differences in changes in MBI, FAC, BBS, TIS-T, TIS-D, TIS-C, and FES-I scores at 4 weeks from baseline between the two groups (all p<0.0001). There were no significant (p=0.0755) differences in changes in TIS-S scores at 4 weeks from baseline between the two groups. MBI, FAC, BBS, and TIS scores showed significantly inverse correlations with FES-I scores in patients receiving CME. There were no TEAEs in our series.ConclusionCME was effective and safe in improving the degree of independence, ambulation status, dynamic and static balance, trunk function, and concerns about post-stroke falls in stroke survivors.

Evaluation of the simplified therapeutic intervention scoring system: Chinese version

ObjectiveTo prepare the Simplified Therapeutic Intervention Scoring System (TISS-28) to measure nursing workload in Intensive Care Units in Guangdong Province of China. MethodsA non-experimental descriptive study was conducted in the intensive care units in the Province. TISS-28, TISS-76, Acute Physiology and Chronic Health Evaluation (APACHE II) were all measured. ResultsThere were significant positive correlations between TISS-28 and APACHE II (n=91, r=0.432, p<0.001), TISS-76 scores (n=83, r=0.764, p<0.001). A significant difference was found between the mean TISS-28 score in the first day of the intensive care stay and the last day (30.76±6.86 vs 24.67±5.48, p<0.001). A significant intra-class correlation was found between TISS-28 scores collected by the researcher and research associates (ICC=0.959, p<0.001). ConclusionThe reliability and validity of TISS-28 were shown in Chinese intensive care units. It is a practical tool for estimating the nursing workload and providing opportunities to compare the data between intensive care units in different facilities. The TISS-28 Chinese version is recommended to guide the allocation of nursing manpower in Chinese intensive care units.

The exploration of risk factors of concurrent bacteraemia in patients critically ill with severe dengue.

We investigated the clinical features of intensive care unit (ICU) patients with concomitant severe dengue infection and bacteraemia to identify risk factors for this comorbidity. The records of all ICU dengue patients admitted during the period of 31 July–30 November 2015 were reviewed. Patients with ‘concurrent bacteremia’ (positive bacterial blood culture within 72 h of ICU admission) were identified. ICU admission was required for 142 patients, of which 22 (15.5 %) had concurrent bacteraemia. Species of the genus Streptococcus was the most common pathogens, followed by Escherichia coli then species of the genus Staphylococcus. Patients with a severe dengue infection and bacteraemia had higher APACHE II and TISS scores, C-reactive protein (CRP) levels and leukocyte counts, positive fluid balances, longer activated partial thromboplastin times (APTTs), higher lactate levels and more kidney failure, but controls (severe dengue patients without bacteraemia) had higher Glasgow Coma Scale (GCS) scores, higher albumin levels and more abdominal pain (all P<0.05). Patients with bacteraemia had a higher mortality rate than did ontrols (40.9 vs 18.3 %; P=0.018). Multiple logistic regression analysis showed that bacteraemia was significantly positively associated with the following independent predictors: higher CRP levels [adjusted odds ratio (aOR): 1.026; 95 % confidence interval (CI): 1.008–1.044; P=0.005], and longer APTTs (aOR: 1.034; 95 CI: 1.004–1.065; P=0.027). Concurrent bacteraemia is not uncommon in severe dengue patients in the ICU, and it is associated with high mortality. Higher CRP levels and longer APTTs were two independent risk factors associated with bacteraemia.

Increased need for interventions predicts mortality in the critically ill.

The aim of this study was to determine the association of early treatment intensity with hospital mortality of intensive care unit (ICU) patients. We performed an observational study based on a national ICU registry. We included adult patients treated in Finnish ICUs between 2003 and 2013 with the length of ICU stay of more than 3 days. We measured treatment intensity with the Therapeutic Intervention Scoring System (TISS-76). We assessed mean and daily TISS scores. To define the change in treatment intensity during the first days in the ICU, we calculated the difference between the TISS score on day 3 and the score on day 1 (ΔTISS). We used multivariate logistic regression to adjust for baseline differences and continuous net reclassification improvement (NRI) to determine the impact of adding TISS data to the baseline prediction model on its prognostic performance. We identified 42,493 patients eligible for the study. For 71% of the patients, ΔTISS was ≤ 0 and crude hospital mortality was 18%. ΔTISS > 0 was observed for 29% of the patients, with a hospital mortality of 23%. When compared to the group ΔTISS ≤ 0, the category ΔTISS > 0 was independently associated with substantially increased mortality. Adding TISS data to the prediction model resulted in the improvement of prognostic performance particularly in the patients with the lowest initial baseline risk. Early increase in TISS scores was associated with increased risk of death, especially in patients with a lower initial severity of illness.

Application of different scoring systems and their value in pediatric intensive care unit

BackgroundLittle is known on the impact of risk factors that may complicate the course of critical illness. Scoring systems in ICUs allow assessment of the severity of diseases and predicting mortality. ObjectivesApply commonly used scores for assessment of illness severity and identify the combination of factors predicting patient’s outcome. MethodsWe included 231 patients admitted to PICU of Cairo University, Pediatric Hospital. PRISM III, PIM2, PEMOD, PELOD, TISS and SOFA scores were applied on the day of admission. Follow up was done using SOFA score and TISS. ResultsThere were positive correlations between PRISM III, PIM2, PELOD, PEMOD, SOFA and TISS on the day of admission, and the mortality rate (p<0.0001). TISS and SOFA score had the highest discrimination ability (AUC: 0.81, 0.765, respectively). Significant positive correlations were found between SOFA score and TISS scores on days 1, 3 and 7 and PICU mortality rate (p<0.0001). TISS had more ability of discrimination than SOFA score on day 1 (AUC: 0.843, 0.787, respectively). ConclusionScoring systems applied in PICU had good discrimination ability. TISS was a good tool for follow up. LOS, mechanical ventilation and inotropes were risk factors of mortality.

Intervention- versus physiology-based risk assessment scores for predicting cardiac arrest: a pilot study

There is increasing interest in predicting and avoiding cardiac arrest in hospitalized patients. Multiple studies have used vital signs or scores based upon them, such as the Modified Early Warning Score (MEWS). Scoring systems that measure supportive care, such as the Sequential Organ Failure Assessment (SOFA) and the 28-item Therapeutic Interventions Scoring System (TISS-28) might be superior to systems used in previous studies. This study was performed to determine if a system using SOFA and/or TISS would be superior in detecting clinical deterioration prior to cardiac arrest.Using a retrospective chart review, MEWS, SOFA and TISS-28 scores were calculated for twenty patients at baseline and then in the 24 hours prior to their cardiac arrest. Supportive interventions and nursing care (SOFA and TISS-28) changed more than measures of physiology (MEWS) in the period prior to cardiac arrest, likely due to the fact that vital sign deterioration can be delayed by supportive measures. These results support the idea that a SOFA and/or TISS-28 scoring system might be superior to the MEWS, which could be used to make hospital rapid response teams more effective.

Erradicación de un brote nosocomial de infecciones por Acinetobacter baumannii multirresistente tras el ajuste de cargas de trabajo y refuerzo de precauciones específicas

IntroductionDuring 2009, an outbreak of multidrug-resistant Acinetobacter baumannii (MDR A. baumannii) infections was detected in a 27-bed intensive care unit, resulting in 25 cases being infected. MethodsA matched case-control study was conducted to identify risk factors for infection. The colonization pressure, or the proportion of other patients colonized by MDR A. baumannii, was estimated. TISS-28 and Omega scores of each patient were calculated to evaluate nursing work requirements. Conditional logistic regression analyses were carried out. ResultsBreakdowns in hand washing and glove use were observed. Infected patients (cases) were more likely than paired controls to have had longer exposure to invasive devices and antimicrobial treatment. The independent risk factors identified by the multivariate analysis were, mechanical ventilation [odds ratio (OR)=1.03; 95% confidence interval (CI), 1.01-1.05; P=.01], and exposure to an infected or colonized patient [OR=1.7; 95%CI, 1.1-2.6; P=.02). A combined infection control strategy was implemented, including strict compliance with isolation precautions, grouping of patients, reinforcing cleaning and disinfection of surfaces, and a decrease in work load. Subsequently, a sharp reduction in the incidence MDR A. baumannii infections was shown. Therapeutic activity scores were significantly higher for cases than for controls. ConclusionThe results suggest patient-to-patient transmission of MDR A. baumannii. Reinforcement of specific procedures and work load adjustment were essential to eradicate this outbreak.

Demand for Nursing Care from Elderly People Hospitalised at an Intensive Care Unit

Background: The work aimed at assessing the demand for nursing care from elderly patients at ICUs, based on the TISS-28 scale. Objective: The research was based on the patients’ classification method employing the TISS-28 scale. Methods: The investigation involved 100 assessment sheets of elderly patients staying at a randomly selected ICU in Lublin from February to April 2010. Results: Data analysis proved elderly patients’ TISS-28 scores were highest for basic activities- 9.31 (SD-2.14), however, lower scores were reported for respiratory therapy 3.45 (SD-1.89). A general TISS-28 assessment for the whole research cohort was 23.64. This means that patients should be provided with nursing care level of one nurse per two patients per shift. Conclusions: The more advanced the patients’ age the lower the assessment of therapeutic interventions within the scope of basic activities and circulation therapy, but at the same time, the higher the assessment of respiratory therapy and other interventions.

Relación entre la carga laboral de enfermería y la gravedad del paciente en unidades de cuidado intensivo de adultos

Objective: To determine the relationship between the demands of the nursing workload and the severity of the patient’s condition in adult intensive care units in the city of Cartagena during July 2008. Methodo: This is a longitudinal study with a sample comprised of 42 patients. TISS-28 (Therapeutic Intervention Scoring System) and Apache II (Acute Physiology and Chronic Health Evaluation) records were obtained. Arithmetic average, standard deviation and proportions were calculated, as was the Pearson correlation coefficient. Results: In this study involving a total of 42 patients, the average age was 58.2 years (IC 95% 52.1-64.4), and 51.3 percent of the patients in the sample were women. Forty-two (42) Apache II evaluations were obtained when the patients were admitted to the ICU, with an average of 28.9, and 66.7 percent if the patients (28) have a poor prognosis. There were 188 TISS-28 scores, with an average of 28.7 (IC 95% 25.7 - 31.7) per patient. The average TISS upon release from the ICU was 25.7 (95% CI 22.4 to 28.9) per patient. In all, 61.9 per cent of the patients were Class III. The nurse/ Class IV patient ratio was 0.57 less than 1:1. The study found a relationship of 0.55 between Apache II and TISS-28. (0.501-0.75) and a coefficient of determination equal to 0.38 (p<0.05). Conclusions: There is a moderate correlation between TISS-28 and Apache II that shows an overload of nursing work in intensive care units. This has repercussions on the direct care provided to critical patients.

Relación entre la carga laboral de enfermería y la gravedad del paciente en unidades de cuidado intensivo de adultos

Objetivo: determinar la relación entre la demanda de carga laboral de enfermería y la gravedad del paciente en unidades de cuidados intensivos de adultos en la ciudad de Cartagena, en el mes de julio de 2008. Método: investigación de corte longitudinal. Muestra de 42 pacientes, se obtuvieron registros TISS-28 y registros Apache II. Se realizó el cálculo de media aritmética, desviación estándar y proporciones, así como el cálculo del coeficiente de correlación de Pearson. Resultados: participaron 42 pacientes; la media para la edad fue 58,2 años (IC 95% 52,1-64,4). El 51,3% fueron mujeres. Se obtuvieron 42 calificaciones del Apache II al ingreso de los pacientes a la UCI con un promedio de 28,9, de los cuales el 66,7% (28) tienen un mal pronóstico, y 188 calificaciones de TISS-28, con un promedio de 28,7 (IC 95% 25,7-31,7). El promedio de TISS de egreso fue de 25,7 (IC 95% 22,4-28,9) por paciente. El 61,9% de los pacientes perteneció a la clase III. La razón enfermera/paciente clase IV fue de 0,57 inferior a 1:1(1). Se encontró una asociación entre el Apache II y TISS-28 de 0,55 (0,501-0,75) y un coeficiente de determinación de 0,38 (p&lt;0,05). Conclusiones: existe una moderada correlación entre el TISS-28 y el Apache II dejando ver sobrecarga de trabajo de enfermería en las UCI, lo que repercute en la atención directa al paciente crítico.

Serial measurement of Therapeutic Intervention Scoring System-28 (TISS-28) in a surgical intensive care unit

Purpose The aim of the study was to assess the use of the Therapeutic Intervention Scoring System-28 (TISS-28) in surgical intensive care unit (ICU) patients and the relationship of the score to the type of surgery, severity of illness, and outcome in these patients. Materials and Methods Prospectively collected data from all patients admitted to a postoperative ICU between March 1, 2004, and June 30, 2006, were analyzed retrospectively. Results A total of 6903 patients were admitted during the study period (63.5% male; mean age, 62.3 years) constituting 29 140 observation days. The mean Simplified Acute Physiology Score (SAPS) II, Sequential Organ Failure Assessment (SOFA), and TISS-28 scores on the day of ICU admission were 36.9 ± 18.2, 5.8 ± 3.9, and 43.2 ± 10.8, respectively. The highest admission TISS-28 was observed in patients who underwent cardiothoracic surgery (47.7 ± 10.1), the lowest in neurosurgical patients (40 ± 9.6), and both declined during the 2 weeks after ICU admission; however, in trauma patients and those admitted after gastrointestinal surgery, TISS scores increased gradually after the first 2 to 5 days in the ICU. The TISS-28 score was moderately correlated to SAPS II ( R 2 = 0.42; P < .001) and SOFA score ( R 2 = 0.48; P < .001) throughout the ICU stay and was consistently higher in nonsurvivors than in survivors during the first 2 weeks in the ICU. Conclusions There are marked variations in TISS-28 scores according to the type of surgery. Therapeutic Intervention Scoring System-28 correlates with the severity of illness and outcome in these patients.

Validity and reliability of the simplified Therapeutic Intervention Scoring System in intensive care units of a public sector hospital in Johannesburg

Purpose. To introduce the simplified Therapeutic Intervention Scoring System (TISS-28) and to employ the original Therapeutic Intervention Scoring System (TISS-76) and Simplified Acute Physiological Score (SAPS) version II in critically ill adult patients in order to describe the validity and reliability of TISS-28 as a suitable measure of quantifying nursing workload in the adult intensive care units (ICUs) of a public sector hospital in Johannesburg. Objectives. To describe the profile of patient admissions to the ICUs, to investigate the impact of the patients’ profile on the requirements for nursing workload, and to validate the use of the TISS-28 as a measure for quantifying nursing workload in this setting. Design. A non-experimental, comparative, correlation and prospective two-staged design was utilised to meet the study objectives. Stage I involved face and content validation of TISS-28 by a panel of 6 ICU nurse experts. Stage II involved assessment of concurrent and construct validity as well as inter-rater reliability of TISS-28 using 105 participants drawn from trauma, cardiothoracic and multidisciplinary ICUs. Data necessary for the calculation of TISS-28, TISS-76 and SAPS II were recorded for each patient in the ICU at 24 and 48 hours after admission and in the wards after discharge within 24 - 48 hours. Descriptive and inferential statistics were used to analyse data. Results. A content validity index (CVI) of 0.93 was found for TISS-28. A significant positive correlation was found between TISS-28 and TISS-76 scores (r=0.7857, p=0.0001). Although the correlation between TISS-28 and SAPS II was significant (p=0.0317), it was small (r=0.2098). A significant intra-class correlation (ICC) was found for the data collected from a sample of patients by the researcher and expert assistant researcher (ICC=0.99; p=0.0001). Conclusions. The findings support the validity and reliability of TISS-28 and hence its feasibility for use in South African ICUs. Recommendations for nursing education, practice, management and research are proposed.

Usefulness of a clinical diagnosis of ICU-acquired paresis to predict outcome in patients with SIRS and acute respiratory failure

Neuromuscular abnormalities are common in ICU patients. We aimed to assess the incidence of clinically diagnosed ICU-acquired paresis (ICUAP) and its impact on outcome. Forty-two patients with systemic inflammatory response syndrome on mechanical ventilation for >or=48 h were prospectively studied. Diagnosis of ICUAP was defined as symmetric limb muscle weakness in at least two muscle groups at ICU discharge without other explanation. The threshold Medical Research Council (MRC) Score was set at 35 (of 50) points. Activities in daily living were scored using the Barthel Index 28 and 180 days after ICU discharge. Three patients died before sedation was stopped. ICUAP was diagnosed in 13 of the 39 patients (33%). Multivariate regression analysis yielded five ICUAP-predicting variables (P < 0.05): SAPS II at ICU admission, treatment with steroids, muscle relaxants or norepinephrine, and days with sepsis. Patients with ICUAP had lower admission SAPS II scores [37 +/- 13 vs. 49 +/- 15 (P = 0.018)], lower Barthel Index at 28 days and lower survival at 180 days after ICU discharge (38 vs. 77%, P = 0.033) than patients without ICUAP. Daily TISS-28 scores were similar but cumulative TISS-28 scores were higher in patients with ICUAP (664 +/- 275) than in patients without ICUAP (417 +/- 236; P = 0.008). The only independent risk factor for death before day 180 was the presence of ICUAP. A clinical diagnosis of ICUAP was frequently established in this patient group. Despite lower SAPS II scores, these patients needed more resources and had high mortality and prolonged recovery periods after ICU discharge.

Macrophage Migration Inhibitory Factor in Pediatric Patients Undergoing Surgery for Congenital Heart Repair

Macrophage migration inhibitory factor (MIF), a proinflammatory mediator, has been shown to be elevated following heart surgery in adults and may be associated with several postoperative complications, including cardiac and pulmonary dysfunction. In this study, we aimed to measure perioperative plasma MIF, interleukin (IL)-8, and free T4 in 20 children age <4 years undergoing surgical repair of congenital heart lesions with left ventricular volume overload, and to determine whether the response of these mediators determined postoperative outcomes. Plasma samples were obtained preoperatively, immediately on arrival in the pediatric intensive care unit (PICU), and at 12, 24, and 48 h. Patients were continuously monitored in the PICU, and data were recorded daily for therapeutic and monitoring procedures that reflected the invasiveness, intensity, and complexity of care rendered (therapeutic interventional scoring system, TISS). Preoperative plasma MIF, IL-8, and free T4 were not different from age-matched healthy children. However, plasma MIF and IL-8 increased significantly 2 h after completion of cardiopulmonary bypass, and then normalized within 24 h. Peak postoperative levels of MIF (48 +/- 24 ng/mL) and IL-8 (79 +/- 57 pg/mL) correlated significantly with duration of cardiopulmonary bypass. The magnitude of the postoperative increase in plasma MIF was associated with increased number of days required for mechanical ventilation (r = 0.553; P = 0.012), and peak plasma IL-8 correlated significantly with the fraction of inhaled oxygen (FiO(2)) required immediately after surgery (r = 0.510; P = 0.02). Higher circulating MIF levels correlated significantly with increased inotropic support requirements on the second postoperative day, whereas higher postoperative IL-8 levels were associated with higher TISS scores, suggesting increased need for postoperative medical care. These data suggest a potential negative effect of high circulating levels of MIF in the immediate postoperative period on respiratory and cardiovascular functions, and support the development of therapeutic strategies targeting MIF function in this clinical setting.