ABO blood types and major outcomes in patients with acute hypoxaemic respiratory failure: A multicenter retrospective cohort study.
Rezoagli Emanuele,Gatti Stefano,Villa Silvia,Villa Giulia,Muttini Stefano,Rossi Fabio,Faraldi Loredana,Fumagalli Roberto,Grasselli Giacomo,Foti Giuseppe,Bellani Giacomo
INTRODUCTION:ABO blood type A was reported to correlate with an increased risk of acute respiratory distress syndrome (ARDS) in white patients with severe sepsis and major trauma compared with patients with other blood types. Information regarding ABO phenotypes and major outcomes in patients with ARDS is unavailable. The primary aim was to determine the relationship between ABO blood type A and intensive care unit (ICU) mortality in patients with acute hypoxemic respiratory failure (AHRF). The secondary aim was to describe the association between ABO blood type A and ICU length of stay (LOS) in this study population. METHODS:In a multicenter, retrospective cohort study, we collected the clinical records of patients admitted from January 2012 to December 2014 in five ICUs of Northern Italy. We included adult white patients admitted to the ICU who were diagnosed with AHRF requiring mechanical ventilation. RESULTS:The electronic records of 1732 patients with AHRF were reviewed. The proportion of patients with ABO blood type A versus other blood types was 39.9% versus 60.1%. ICU mortality (25%) and ICU LOS (median [interquartile range], 5 [2-12] days) were not different when stratified by ABO blood type (ICU mortality, overall p value = 0.905; ICU LOS, overall p value = 0.609). SAPSII was a positive predictor of ICU mortality (odds ration [OR], 32.80; 95% confidence interval [CI], 18.80-57.24; p < 0.001) and ICU LOS (β coefficient, 0.55; 95% CI, 0.35-0.75; p < 0.001) at multivariate analyses, whereas ABO blood type did not predict ICU outcome when forced into the model. CONCLUSION:ABO blood type did not correlate with ICU mortality and ICU LOS in adult patients with AHRF who were mechanically ventilated.
[Comparison of different scoring systems in prognosis evaluation of acute poisoning].
Zhou Y R,Hu X Y,Yuan C,Zhao G J,Hong G L,Li M F,Zhi S C,Lu Z Q
Zhonghua lao dong wei sheng zhi ye bing za zhi = Zhonghua laodong weisheng zhiyebing zazhi = Chinese journal of industrial hygiene and occupational diseases
To compare the predictive value of PSS, APACHEII, SAPSII and SOFA in the prognosis evaluation of acute poisoning. Clinical data (including PSS score, APACHEII score, SAPSII score and SOFA score, within 24 hours after admission) of 231 acute poisoning patients admitted to the emergency intensive care unit EICU of our hospital from January 2015 to October 2016 was retrospectively analyzed. The patients were divided into the survival group and the dead group according to the 28-day clinical outcomes, comparing the differences of clinical data in each group. To analyze the correlation between PSS score, APACHEII score, SAPSII score and SOFA score in each group, comparing the value and the area under the ROC curve of four scoring systems and evaluate the predictive value of the four scoring systems. Comparing with the survival group and the dead group, PSS score, APACHEII score, SAPSII score and SOFA score were significantly different (<0.01) . PSS score, APACHEII score, SAPSII score and SOFA score were significantly positive correlation (<0.01) , the area under the ROC curve (AUC) of the four scoring systems were 0.833, 0.887, 0.843 and 0.843 respectively. The area under the ROC curve (AUC) of APACHEII score was higher than PSS score, SAPSII score and SOFA score, the difference was statistically significant (=2.351, 2.317, 2.217; =0.019, 0.021, 0.027) , there was no significant difference in the area (AUC) between the three scoring curves (>0.05) . The cutoff value (cut-off) , sensitivity, specificity and accuracy rates of PSS score, APACHEII score, SAPSII score and SOFA score were (2.5, 93.1%, 50.9%, 61.5%) , (14.5, 82.8%, 75.7%, 77.48%) , (31.5, 77.6%, 76.90%, 77.08%) , (5.5, 77.60%, 74.60%, 75.35%) . PSS score, APACHEII score, SAPSII score and SOFA score can evaluate the prognosis of patients with acute poisoning, but the APACHEII score is better than the other three scoring systems in evaluating the prognosis for its evaluation ability and accuracy rate.
Risk Factors for Acute Mesenteric Ischemia in Critically Ill Burns Patients-A Matched Case-Control Study.
Soussi Sabri,Taccori Marina,De Tymowski Christian,Depret François,Chaussard Maïté,Fratani Alexandre,Jully Marion,Cupaciu Alexandru,Ferry Axelle,Benyamina Mourad,Serror Kevin,Boccara David,Chaouat Marc,Mimoun Maurice,Cattan Pierre,Zagdanski Anne-Marie,Anstey James,Mebazaa Alexandre,Legrand Matthieu,
Shock (Augusta, Ga.)
OBJECTIVE:Burn-induced shock can lead to tissue hypoperfusion, including the gut. We performed this study to describe burn patients at risk of acute mesenteric ischemia (AMI) with the aim to identify potential modifiable risk factors. METHODS:Retrospective case-control study including adult severely burned patients between August 2012 and March 2017. Patients who developed AMI were matched to severely burned patients without AMI at a ratio of 1:3 (same year of admission, Abbreviated Burn Severity Index [ABSI], and Simplified Acute Physiology Score II [SAPSII]). Univariate and multiple regression analyses were performed. RESULTS:Of 282 severely burned patients, 15 (5%) were diagnosed with AMI. In the AMI group, patients had a median (interquartile range) total body surface area (TBSA), SAPSII, and ABSI of 55 (25-63)%, 53 (39-70), and 11 (8-13), respectively. The AMI mechanism in all patients was nonocclusive. Decreased cardiac index within the first 24 h (H24 CI), higher sequential organ failure assessment score on day 1 (D1 SOFA), and hydroxocobalamin use were associated with AMI. Odds ratios were 0.18 (95% confidence interval [CI], 0.03-0.94), 1.6 (95% CI, 1.2-2.1), and 4.6 (95% CI, 1.3-15.9), respectively, after matching. Multiple regression analysis showed that only decreased H24 CI and higher D1 SOFA were independently associated with AMI. Ninety-day mortality was higher in the AMI group (93% vs. 46% [P = 0.001]). CONCLUSIONS:Burns patients with initial low cardiac output and early multiple organ dysfunction are at high risk of nonocclusive AMI.
Mid-regional pro-adrenomedullin predicts poor outcome in non-selected patients admitted to an intensive care unit.
Bellia Chiara,Agnello Luisa,Lo Sasso Bruna,Bivona Giulia,Raineri Maurizio Santi,Giarratano Antonino,Ciaccio Marcello
Clinical chemistry and laboratory medicine
Background Mortality risk and outcome in critically ill patients can be predicted by scoring systems, such as APACHE and SAPS. The identification of prognostic biomarkers, simple to measure upon admission to an intensive care unit (ICU) is an open issue. The aim of this observational study was to assess the prognostic value of plasma mid-regional pro-adrenomedullin (MR-proADM) at ICU admission in non-selected patients in comparison to Acute Physiology and Chronic Health Evaluation II (APACHEII) and Simplified Acute Physiology Score II (SAPSII) scores. Methods APACHEII and SAPSII scores were calculated after 24 h from ICU admission. Plasma MR-proADM levels were measured by TRACE-Kryptor on admission (T0) and after 24 h (T24). The primary endpoint was intra-hospital mortality; secondary endpoint was length of stay (LOS). Results One hundred and twenty-six consecutive non-selected patients admitted to an ICU were enrolled. Plasma MR-proADM levels were correlated with LOS (r=0.28; p=0.0014 at T0; r=0.26; p=0.005 at T24). Multivariate analysis showed that T0 MR-proADM was a significant predictor of mortality (odds ratio [OR]: 1.27; 95% confidence interval [95%CI]: 1.03-1.55; p=0.022). Receiver operating characteristic curves analysis revealed that MR-proADM on ICU admission identified non-survivors with high accuracy, not inferior to the one of APACHEII and SAPSII scores (area under the curve [AUC]: 0.71; 95%CI: 0.62-0.78; p=0.0002 for MR-proADM; AUC: 0.71; 95%CI: 0.62-0.79; p<0.0001 for APACHEII; AUC: 0.8; 95%CI: 0.71-0.87; p<0.0001 for SAPSII). Conclusions Our findings point out a role of MR-proADM as a prognostic tool in non-selected patients in ICUs being a reliable predictor of mortality and LOS and support its use on admission to an ICU to help the management of critically ill patients.
Metabolic and Nutritional Characteristics of Long-Stay Critically Ill Patients.
Viana Marina V,Pantet Olivier,Bagnoud Geraldine,Martinez Arianne,Favre Eva,Charrière Mélanie,Favre Doris,Eckert Philippe,Berger Mette M
Journal of clinical medicine
BACKGROUND:insufficient feeding is frequent in the intensive care unit (ICU), which results in poor outcomes. Little is known about the nutrition pattern of patients requiring prolonged ICU stays. The aims of our study are to describe the demographic, metabolic, and nutritional specificities of chronically critically ill (CCI) patients defined by an ICU stay >2 weeks, and to identify an early risk factor. METHODS:analysis of consecutive patients prospectively admitted to the CCI program, with the following variables: demographic characteristics, Nutrition Risk Screening (NRS-2002) score, total daily energy from nutritional and non-nutritional sources, protein and glucose intakes, all arterial blood glucose values, length of ICU and hospital stay, and outcome (ICU and 90-day survival). Two phases were considered for the analysis: the first 10 days, and the next 20 days of the ICU stay. STATISTICS:parametric and non-parametric tests. RESULTS:150 patients, aged 60 ± 15 years were prospectively included. Median (Q1, Q3) length of ICU stay was 31 (26, 46) days. The mortality was 18% at ICU discharge and 35.3% at 90 days. Non-survivors were older ( = 0.024), tended to have a higher SAPSII score ( = 0.072), with a significantly higher NRS score ( = 0.033). Enteral nutrition predominated, while combined feeding was minimally used. All patients received energy and protein below the ICU's protocol recommendation. The proportion of days with fasting was 10.8%, being significantly higher in non-survivors (2 versus 3 days; = 0.038). Higher protein delivery was associated with an increase in prealbumin over time ( = 0.19, = 0.027). CONCLUSIONS:High NRS scores may identify patients at highest risk of poor outcome when exposed to underfeeding. Further studies are required to evaluate a nutrition strategy for patients with high NRS, addressing combined parenteral nutrition and protein delivery.
Arterial blood pressure correlates with 90-day mortality in sepsis patients: a retrospective multicenter derivation and validation study using high-frequency continuous data.
Kobayashi Naoya,Nakagawa Atsuhiro,Kudo Daisuke,Ishigaki Tsukasa,Ishizuka Haruya,Saito Kohji,Ejima Yutaka,Wagatsuma Toshihiro,Toyama Hiroaki,Kawaguchi Tomohiro,Niizuma Kuniyasu,Ando Kokichi,Kurotaki Kenji,Kumagai Michio,Kushimoto Shigeki,Tominaga Teiji,Yamauchi Masanori
Blood pressure monitoring
OBJECTIVE:To identify the outcome of patients with sepsis using high-frequency blood pressure data. MATERIALS AND METHODS:This retrospective observational study was conducted at a university hospital ICU (derivation study) and at two urban hospitals (validation study) with data from adult sepsis patients who visited the centers during the same period. The area under the curve (AUC) of blood pressure falling below threshold was calculated. The predictive 90-day mortality (primary endpoint) area under threshold (AUT) and critical blood pressure were calculated as the maximum area under the curve of the receiver operating characteristic curve (AUCROC) and the threshold minus average AUT (derivation study), respectively. For the validation study, the derived 90-day mortality AUCROC (using critical blood pressure) was compared with Sequential Organ Failure Assessment (SOFA), Simplified Acute Physiology Score (SAPS) II, Acute Physiology and Chronic Health Evaluation (APACHE) II, and APACHE III. RESULTS:Derivation cohort (N = 137): the drop area from the mean blood pressure of 70 mmHg at 24-48 hours most accurately predicted 90-day mortality [critical blood pressure, 67.8 mmHg; AUCROC, 0.763; 95% confidence interval (CI), 0.653-0.890]. Validation cohort (N = 141): the 90-day mortality AUCROC (0.776) compared with the AUCROC for SOFA (0.711), SAPSII (0.771), APACHE II (0.745), and APACHE III (0.710) was not significantly different from the critical blood pressure 67.8 mmHg (P = 0.420). CONCLUSION:High-frequency arterial blood pressure data of the period and extent of blood pressure depression can be useful in predicting the clinical outcomes of patients with sepsis.
Prognostic factors and outcome of adult allogeneic hematopoietic stem cell transplantation patients admitted to intensive care unit during transplant hospitalization.
Michel Christian S,Teschner Daniel,Schmidtmann Irene,Theobald Matthias,Hauptrock Beate,Wagner-Drouet Eva M,Radsak Markus P
Patients undergoing allogeneic hematopoietic stem cell transplantation have a high morbidity and mortality, especially after admission to intensive care unit (ICU) during peri-transplant period. The objective of this study was to identify new clinical and biological parameters and validate prognostic scores associated with ICU, short-and long-term survival. Significant differences between ICU survivors and ICU non-survivors for the clinical parameters invasive mechanical ventilation, urine output, heart rate, mean arterial pressure, and amount of vasopressors have been measured. Among prognostic scores (SOFA, SAPSII, PICAT, APACHE II, APACHE IV) assessing severity of disease and predicting outcome of critically ill patients on ICU, the APACHE II score has shown most significant difference (p = 0.002) and the highest discriminative power (area under the ROC curve (AUC) 0.74). An elevated level of lactate at day of admission was associated with poor survival on ICU and the most significant independent parameter (p < 0.001). In our cohort kidney damage with low urine output has a highly relevant impact on ICU, short- and long-term overall survival. The APACHE II score was superior predicting ICU mortality compared to all other tested prognostic scores for patients on ICU during peri-transplant period.
Prevalence and development of chronic critical illness in acute patients admitted to a respiratory intensive care setting.
Marchioni A,Tonelli R,Sdanganelli A,Gozzi F,Musarò L,Fantini R,Tabbì L,Andreani A,Cappiello G,Costi S,Castaniere I,Clini E
INTRODUCTION:Chronic Critical Illness (chronic CI) is a condition associated to patients surviving an episode of acute respiratory failure (ARF). The prevalence and the factors associated with the development of chronic CI in the population admitted to a Respiratory Intensive Care Unit (RICU) have not yet been clarified. METHODS:An observational prospective cohort study was undertaken at the RICU of the University Hospital of Modena (Italy). Patients mechanically ventilated with ARF in RICU were enrolled. Demographics, severity scores (APACHEII, SOFA, SAPSII), and clinical condition (septic shock, pneumonia, ARDS) were recorded on admission. Respiratory mechanics and inflammatory-metabolic blood parameters were measured both on admission and over the first week of stay. All variables were tested as predictors of chronic CI through univariate and multivariate analysis. RESULTS:Chronic CI occurred in 33 out of 100 patients observed. Higher APACHEII, the presence of septic shock, diaphragmatic dysfunction (DD) at sonography, multidrug-resistant (MDR) bacterial infection, the occurrence of a second infection during stay, and a C-reactive protein (CRP) serum level inceasing 7 days over admission were associated with chronic CI. Septic shock was the strongest predictor of chronic CI (AUC = 0.92 p < 0.0001). CONCLUSIONS:Chronic CI is frequent in patients admitted to RICU and mechanically ventilated due to ARF. Infection-related factors seem to play a major role as predictors of this syndrome.
Influence of deprivation on initial severity and prognosis of patients admitted to the ICU: the prospective, multicentre, observational IVOIRE cohort study.
Quenot Jean-Pierre,Helms Julie,Labro Guylaine,Dargent Auguste,Meunier-Beillard Nicolas,Ksiazek Elea,Bollaert Pierre-Edouard,Louis Guillaume,Large Audrey,Andreu Pascal,Bein Christophe,Rigaud Jean-Philippe,Perez Pierre,Clere-Jehl Raphaël,Merdji Hamid,Devilliers Hervé,Binquet Christine,Meziani Ferhat,Fournel Isabelle,
Annals of intensive care
BACKGROUND:The influence of socioeconomic status on patient outcomes is unclear. We assessed the impact of socioeconomic deprivation on severity of illness at intensive care unit (ICU) admission, and on the risk of death at 3 months after ICU admission. METHODS:The IVOIRE study was a prospective, observational, multicentre cohort study in the ICU of 8 participating hospitals in France, including patients aged ≥ 18 years admitted to the ICU and receiving at least one life support therapy for organ failure. The primary outcomes were severity at admission (assessed by SAPSII score), and mortality at 3 months. Socioeconomic data were obtained from interviews with patients or family. Deprivation was assessed using the EPICES score. RESULTS:Among 1294 patents included between 2013 and 2016, 629 (48.6%) were classed as deprived and differed significantly from non-deprived subjects in terms of sociodemographic characteristics and pre-existing conditions. The mean SAPS II score at admission was 50.1 ± 19.4 in deprived patients and 52.3 ± 17.3 in non-deprived patients, with no significant difference by multivariable analysis (β = - 1.85 [95% CI - 3.86; + 0.16, p = 0.072]). The proportion of death was 31.1% at 3 months, without significant differences between deprived and non-deprived patients, even after adjustment for confounders. CONCLUSIONS:Deprivation is frequent in patients admitted to the ICU and is not associated with disease severity at admission, or with mortality at 3 months between deprived and non-deprived patients. Trial registration The IVOIRE cohort is registered with ClinicalTrials.gov under the identifier NCT01907581, registration date 17/7/2013.
High risk of thrombosis in patients with severe SARS-CoV-2 infection: a multicenter prospective cohort study.
Helms Julie,Tacquard Charles,Severac François,Leonard-Lorant Ian,Ohana Mickaël,Delabranche Xavier,Merdji Hamid,Clere-Jehl Raphaël,Schenck Malika,Fagot Gandet Florence,Fafi-Kremer Samira,Castelain Vincent,Schneider Francis,Grunebaum Lélia,Anglés-Cano Eduardo,Sattler Laurent,Mertes Paul-Michel,Meziani Ferhat,
Intensive care medicine
PURPOSE:Little evidence of increased thrombotic risk is available in COVID-19 patients. Our purpose was to assess thrombotic risk in severe forms of SARS-CoV-2 infection. METHODS:All patients referred to 4 intensive care units (ICUs) from two centers of a French tertiary hospital for acute respiratory distress syndrome (ARDS) due to COVID-19 between March 3rd and 31st 2020 were included. Medical history, symptoms, biological data and imaging were prospectively collected. Propensity score matching was performed to analyze the occurrence of thromboembolic events between non-COVID-19 ARDS and COVID-19 ARDS patients. RESULTS:150 COVID-19 patients were included (122 men, median age 63 [53; 71] years, SAPSII 49 [37; 64] points). Sixty-four clinically relevant thrombotic complications were diagnosed in 150 patients, mainly pulmonary embolisms (16.7%). 28/29 patients (96.6%) receiving continuous renal replacement therapy experienced circuit clotting. Three thrombotic occlusions (in 2 patients) of centrifugal pump occurred in 12 patients (8%) supported by ECMO. Most patients (> 95%) had elevated D-dimer and fibrinogen. No patient developed disseminated intravascular coagulation. Von Willebrand (vWF) activity, vWF antigen and FVIII were considerably increased, and 50/57 tested patients (87.7%) had positive lupus anticoagulant. Comparison with non-COVID-19 ARDS patients (n = 145) confirmed that COVID-19 ARDS patients (n = 77) developed significantly more thrombotic complications, mainly pulmonary embolisms (11.7 vs. 2.1%, p < 0.008). Coagulation parameters significantly differed between the two groups. CONCLUSION:Despite anticoagulation, a high number of patients with ARDS secondary to COVID-19 developed life-threatening thrombotic complications. Higher anticoagulation targets than in usual critically ill patients should therefore probably be suggested.
Risk factors and outcome of patients with periprosthetic joint infection admitted to intensive care unit.
Pöll Alexandra Margarete,Baecker Hinnerk,Yilmaz Emre,Jansen Oliver,Waydhas Christian,Schildhauer Thomas Armin,Hamsen Uwe
Archives of orthopaedic and trauma surgery
INTRODUCTION:Prosthetic joint infection (PJI) is a severe complication after total joint replacement surgery. The current study analyzes the outcome and mortality of patients admitted to an intensive care unit following PJI. METHODS:Retrospective analysis of all patients treated between 2012 and 2016 due to PJI in the surgical intensive care unit of a university hospital. RESULTS:A total of 124 patients were included. The mean age was 75 ± 11 years. Of those 124 patients, 85 patients (68.5%) suffered a prosthetic infection of the hip, 33 patients (27.3%) of the knee, six patients (4.8%) of hip and knee. 52 patients were male (40.9%). The assessed mean Simplified Acute Physiology Score II (SAPSII) was 29.6 ± 5.9. The mortality rate was 21% (26/124). Of surviving patients, 53.1% were discharged home, 25.5% were transferred to a nursing home, and 21.4% were transferred to a geriatric rehabilitation center. Comparing survivors to non-survivors, the non-survivor group showed a higher incidence of renal replacement therapy (46.1 vs 3.0%; p < 0.01), higher SAPSII on admission (35.7 vs. 29.0; p = 0.01) and higher Charlson Comorbidity Indices (CCI) (5.5 vs. 2.82; p < 0.01). The multivariate regression identified CCI (odds ratio 1.49; p < 0.01) and renal replacement therapy (odds ratio 12.4; p < 0.01) as independent risk factors for increased mortality. CONCLUSIONS:Admission to an intensive care unit was associated with a mortality rate of 21%. Factors associated with poor outcomes included renal replacement therapy, higher admission SAPII scores, and higher admission Charlson comorbidity index. These factors could be used for individual risk assessment on admission to the ICU.
Invasive Tracheobronchial Aspergillosis in Critically Ill Patients with Severe Influenza. A Clinical Trial.
Nyga Remy,Maizel Julien,Nseir Saad,Chouaki Taieb,Milic Ivona,Roger Pierre-Alexandre,Van Grunderbeeck Nicolas,Lemyze Malcolm,Totet Anne,Castelain Sandrine,Slama Michel,Dupont Hervé,Sendid Boualem,Zogheib Elie
American journal of respiratory and critical care medicine
Invasive tracheobronchial aspergillosis (ITBA) is an uncommon but severe clinical form of invasive pulmonary aspergillosis in which the fungal infection is entirely or predominantly confined to the tracheobronchial tree. To analyze the diagnostic and prognostic differences between tracheobronchial aspergillosis and pulmonary aspergillosis without tracheobronchial lesions among patients admitted to the ICU with severe influenza. This retrospective, observational study included critically ill patients with influenza associated with pulmonary aspergillosis from three hospital ICUs between 2010 and 2019. Patient characteristics and clinical and mycologic data at admission and during ICU stay were collected in a database to evaluate variables in the two groups. Thirty-five patients admitted to the ICU with severe influenza and pulmonary aspergillosis were included. Ten patients were included in the group with ITBA ( = 10 of 35; 28.6%), and 25 patients were included in the group without ITBA. The group with ITBA comprised more patients with active smoking, diabetes mellitus, and higher severity scores (Simplified Acute Physiology Score II). Ninety-day mortality rates in the groups with and without ITBA were 90% and 44%, respectively ( = 0.02). Moreover, significantly higher serum 1,3-β-d-glucan and galactomannan and BAL fluid galactomannan concentrations were observed in the group with ITBA compared with the group without ITBA ( < 0.0001, = 0.003, and = 0.008, respectively). ITBA was associated with higher severity scores, mortality, and serum and BAL fluid galactomannan and 1,3-β-d-glucan concentrations than invasive pulmonary aspergillosis without tracheobronchial lesions. ITBA should be systematically researched by bronchoscopic examination in ICU patients with concomitant pulmonary aspergillosis and influenza.Clinical trial registered with www.clinicaltrials.gov (NCT04077697).
Impact of ceftazidime restriction on gram-negative bacterial resistance in an intensive care unit.
Brahmi Nozha,Blel Youssef,Kouraichi Nadia,Lahdhiri Salma,Thabet Hafedh,Hedhili Abderrazek,Amamou Mouldi
Journal of infection and chemotherapy : official journal of the Japan Society of Chemotherapy
The present study included three periods: (1) a 12-month pre-restriction and control period in 2001; (2) a 12-month restriction period with reduced ceftazidime prescribing in favor of piperacillin-tazobactam (2002); (3) and a 24 month post-restriction period (2003-2004). Note that, for results, P represents the difference between 2002 and 2001; P', the difference between 2003 and 2001; and P'', the difference between 2004 and 2001. No changes in hygiene practices were observed during these three periods. The purpose of this study was to assess the effect of reducing ceftazidime use in an intensive care unit (ICU) upon Gram-negative bacterial resistance, particularly as regards Pseudomonas aeruginosa. During the three periods of the study, patients were similar concerning age, Simplified Acute Physiology Score (SAPSII), the site of nosocomial infection, and the requirements for mechanical ventilation (75% in 2001, 76% in 2002, 74% in 2003, and 85% in 2004). The most commonly isolated pathogens were P. aeruginosa, Acinetobacter baumannii, and Enterobacteriaceae. The use of ceftazidime decreased significantly from 12.6% in 2001 to 9% in 2002, to 3% in 2003 (P' = 0.0009), and 2.6% in 2004 (P'' = 0.0001) in favor of piperacillin-tazobactam (0% 2001 to 3.7% in 2003; P' = 0.002; and 5% in 2004; P'' = 0.0001). Simultaneously, we observed a significant decrease in isolates of P. aeruginosa resistant to piperacillin-tazobactam (P = 0.03; P' = 0.004; P'' = 0.009), and those resistant to imipenem in 2003 (P' = 0.008). We also noted a significant decrease in A. baumannii isolates resistant to ceftazidime (P' = 0.01; P'' = 0.0004) and those resistant to imipenem in both 2002 and 2004 (P = 0.03; P'' = 0.04), and a considerable decrease in isolates of Klebsiella pneumoniae producing expanded spectrum betalactamase (ESBL) in 2003 and 2004 (P' = 0.04; P'' = 6.10(-5)). In contrast, we noted an increase in penicillinase-producing isolates of K. pneumoniae, from 6% in 2001 to 16% in 2002 (p = 0.01), 20% in 2003 (P' = 0.001), and 32% in 2004 (P'' = 10(-6)). We concluded that restriction of ceftazidime use was demonstrated to be efficient in reducing antimicrobial resistance, especially to K. pneumoniae ESBL.
[Initial serum lactate level as predictor of morbidity after major abdominal surgery].
Li Sheng-Hua,Liu Fen,Zhang Ying-Tian
Zhonghua yi xue za zhi
OBJECTIVE:To evaluate the value of immediate postoperative arterial lactate level to predict morbidity after major abdominal surgery. METHODS:139 patients, 73 males and 66 females, aged (64 +/- 14) (26 - 87), who underwent major abdominal surgery had their levels of arterial lactate, blood routine, blood gas and electrolytes measured after they were sent to the ICU. The physiological and operative severity score for the enumeration of mortality and morbidity (POSSUM) and the simplified acute physiology score II (SAPSII) levels in the first 24-hour postoperative period were calculated Multivariate logistic regression analysis was utilized to examine the independent relationship of the initial lactate, blood gas values, and anion gap with the morbidity. RESULTS:Sixty-one cases of postoperative complications were recorded in the 47 patients (34%). The median initial lactate level of the patients with postoperative complications was 1.7 mmol/L, significantly higher than that of the patients without complication (1.2 mmol/L, P = 0.001). Multivariate analysis showed that lactate level (odds ratio: 1.81, 95% confidence interval: 1.14 - 2.89; P = 0.013) and Simplified Acute Physiology Score II (SAPSII (odds ratio:1.14; 95% confidence interval:1.08-1.21, P < 0.001) were significantly predictive of postoperative morbidity. The optimal value of lactate to discriminate between the patients who did or did not develop postoperative complications was 2.7 mmol/L as associated with the highest sum of sensitivity and specificity (29.8% and 95.7% respectively). The lactate level more than 2.7 mmol/L was associated with 9.3-fold-higher odds for postoperative complications (95% confidence interval: 2.9 - 30.4, P < 0.001). After adjustment for SAPII, the lactate level > 2.7 mmol/L remained strongly associated with morbidity (odds ratio: 5.9; 95% confidence interval: 1.6 - 21.7; P = 0.007). CONCLUSION:Initial serum lactate level is significantly associated with postoperative complications and can independently predict in-hospital morbidity after major abdominal surgery. When hyperlactatemia means the presence of oxygen debt, strategies to resuscitate patients during surgery should include reversing ongoing tissue hypoxia by increasing oxygen delivery.
[Psychologists working as members of the intensive care team could reduce the length of stay].
K Szilágyi Adrienn,Diószeghy Csaba,Varga Katalin
UNLABELLED:Both short and long term outcome of mechanically ventilated patients are dependent on the time spent on ventilator and on the intensive care unit. Health related quality of life of the survival of intensive care has been proved to be related with the physical and psychological effects of the intensive care itself. In our previous multicenter randomized trial we have demonstrated the effect of psychological support delivered at the time of intensive care. AIM:The aim of this post hoc analysis is to demonstrate the effect of the psychological support given by an ICU staff psychologist providing continuous care by the same therapist. METHODS:36 patients were included in the post hoc analysis, 17 in the control and 19 in the treatment group. The treatment group received daily psychological support based on positive suggestions delivered by the same therapist at least in 50% of the time. The control group received the same ICU care but without the involvement of the psychologist. There were no differences between the two groups in age, sex, SAPSII score and basic medical treatment. RESULTS:RESULTS showed a significant reduction in mechanical ventilation (3.6 days shorter, p < 0.014) and length of stay (4.2 days shorter, p < 0.022) of the treatment group compared to the control. CONCLUSIONS:These results suggest the value of a psychologist working as a full member of the ICU team and providing supplementary psychological support of patients.
[Impact on morbidity and costs of methicillin-resistant Staphylococcus aureus nosocomial pneumonia in intensive care patients].
Larue Alexandrine,Loos-Ayav Carole,Jay Nicolas,Commun Nathalie,Rabaud Christian,Bollaert Pierre-Edouard
Presse medicale (Paris, France : 1983)
OBJECTIVES:Prevention of methicillin-resistant Staphylococcus aureus (MRSA) nosocomial infections in the intensive care units (ICU) has been recommended for several years. However, the workload and the costs of these programs are to be weighed against the benefit obtained in terms of reduction of morbidity and costs induced by the infection. The purpose of this study was to evaluate the cost and the current morbidity of the infection with MRSA in the ICU. METHODS:In a retrospective case-control study carried out in 2004, all patients of the 6 intensive care units of a teaching hospital having developed a MRSA nosocomial infection were included. They were paired with controls on the following criteria: department, Simplified Acute Physiology Score II (SAPSII), age (+/- 5 years), type of surgery (for the surgical intensive care units). The duration of hospitalization of the paired control had to be at least equal to the time from admission to infection of the infected patient. The costs were evaluated using the following parameters: scores omega 1, 2 and 3, duration of artificial ventilation, hemodialysis, length of ICU stay, radiological procedures, surgical procedures, total antibiotic cost and other expensive drugs. RESULTS:Twenty-one patients with MRSA infection were included. All had nosocomial pneumonia. The 21 paired patients were similar with regard to both initial criteria and sex. Hospital mortality was not different between the 2 groups (cases=8; controls=6; p=0.41), as well as median duration of hospital stay (cases=41 days; controls=43 days; p=0.9). The duration of mechanical ventilation, number of hemodialysis or hemofiltration sessions, number of radiological procedures were similar in both groups. The total omega score was not significantly different between cases (median 435; IQR: 218-579) and controls (median 281, IQR: 231-419; p=0.55). The median duration of isolation was 12 days for cases and 0 day for controls (p=0.0007). The pharmaceutical expenditure was significantly higher in cases (median: 1414euro; IQR: 795-4349), by comparison with the controls (median: 877euro, IQR: 687-2496) (p=0.049). CONCLUSION:In the ICU having set up a policy intended to reduce the risk of MRSA nosocomial infections, MRSA pneumonia does not seem to involve major additional morbidity, as compared to a control population matched for similar severity of illness. It increases modestly the use of the medical resources.
Prospective validation of the "fifty-fifty" criteria as an early and accurate predictor of death after liver resection in intensive care unit patients.
Paugam-Burtz Catherine,Janny Sylvie,Delefosse Didier,Dahmani Souhayl,Dondero Federica,Mantz Jean,Belghiti Jacques
Annals of surgery
BACKGROUND:Postoperative liver failure after hepatectomy has been identified by the association of prothrombin time <50% and serum bilirubin >50 micromol/L (the "50-50" criteria). Whether these criteria are of prognostic value in a prospective study remains unknown. OBJECTIVE:To determine prospectively the prognostic value of the 50-50 criteria on day 3 and day 5 in intensive care unit (ICU) patients after hepatectomy. METHODS:From January 2005 to February 2007, among 436 elective liver resections, 99 (23%) consecutive patients aged 58 +/- 17 years were admitted postoperatively in ICU with a mean SAPSII 25 +/- 10. Malignant disease was present in 87 and major resections (< or =3 segments) were performed in 79 (80%) cases. The underlying liver parenchyma was abnormal in 59 (59%) cases including cirrhosis, fibrosis, or steatosis >30% in 19, 23, and 17 patients, respectively. RESULTS:The 50-50 criteria were present on day 3 in 10 patients and on day 5 in 13. Ten patients (10, 6%) died in ICU. Survivors with these criteria were characterized by early aggressive support including reoperation and/or liver assist system. Nonsurvivors were more often cirrhotic, had significantly higher SAPS II and more frequently postoperative prolonged mechanical ventilation. The 50-50 criteria on days 3 and 5 were predictors of death on multivariate analysis [OR (95% CI): 12.7 (2.3-71.4), OR (95% CI): 29.4 (4.9-167), respectively]. CONCLUSIONS:After hepatic resection, results of this prospective study validate the 50-50 criteria as a predictive factor of mortality in ICU on both days 3 and 5. These criteria allow an early diagnosis of postoperative liver failure, which may contribute to reduce mortality in ICU patients after hepatectomy.
Pharmacokinetics of epinephrine in patients with septic shock: modelization and interaction with endogenous neurohormonal status.
Abboud Imad,Lerolle Nicolas,Urien Saik,Tadié Jean-Marc,Leviel Françoise,Fagon Jean-Yves,Faisy Christophe
Critical care (London, England)
INTRODUCTION:In septic patients, an unpredictable response to epinephrine may be due to pharmacodynamic factors or to non-linear pharmacokinetics. The purpose of this study was to investigate the pharmacokinetics of epinephrine and its determinants in patients with septic shock. METHODS:Thirty-eight consecutive adult patients with septic shock were prospectively recruited immediately before epinephrine infusion. A baseline blood sample (C0) was taken to assess endogenous epinephrine, norepinephrine, renin, aldosterone, and plasma cortisol levels before epinephrine infusion. At a fixed cumulative epinephrine dose adjusted to body weight and under steady-state infusion, a second blood sample (C1) was taken to assess epinephrine and norepinephrine concentrations. Data were analyzed using the nonlinear mixed effect modeling software program NONMEM. RESULTS:Plasma epinephrine concentrations ranged from 4.4 to 540 nmol/L at steady-state infusion (range 0.1 to 7 mg/hr; 0.026 to 1.67 microg/kg/min). A one-compartment model adequately described the data. Only body weight (BW) and New Simplified Acute Physiologic Score (SAPSII) at intensive care unit admission significantly influenced epinephrine clearance: CL (L/hr) = 127 x (BW/70)0.60 x (SAPS II/50)-0.67. The corresponding half-life was 3.5 minutes. Endogenous norepinephrine plasma concentration significantly decreased during epinephrine infusion (median (range) 8.8 (1 - 56.7) at C0 vs. 4.5 (0.3 - 38.9) nmol/L at C1, P < 0.001). CONCLUSIONS:Epinephrine pharmacokinetics is linear in septic shock patients, without any saturation at high doses. Basal neurohormonal status does not influence epinephrine pharmacokinetics. Exogenous epinephrine may alter the endogenous norepinephrine metabolism in septic patients.
Specificity and reliability of prognostic indexes in intensive care evaluation: the spontaneous cerebral haemorrhage case.
Barbieri Alberto,Pinna Cristina,Basso Gian Paolo,Molinari Rosella,Giuliani Enrico,Fruggeri Luca,Nolli Massimo
Journal of evaluation in clinical practice
OBJECTIVE:To determine the reliability of a generic index such as Simplified Acute Physiology Score II (SAPSII), compared with a specific one Intra Cerebral Haemorrhage score (ICH score), as an intensive care unit (ICU) outcome predictor when evaluating a general facility that frequently treats a specific type of patients - those with spontaneous cerebral haemorrhage. METHODS:The study cohort consisted of a random sample of patients (81) admitted to Modena's Policlinico Teaching Hospital's ICU with spontaneous ICH over a 24-month period. Main outcome measure SAPSII, ICH score, overall mortality. RESULTS:The mean ICH score for the 32 surviving patients was 3.41 +/- 1.012 while for the 49 deceased patients was of 4.24 +/- 0.855 (P = 0.000). The mean SAPSII value for the 32 surviving patients was 49.09 +/- 16.58 while for the 49 deceased patients was 49.51 +/- 15.93. SAPSII, ICH scores were analysed for mortality, by receiver operating characteristic curves: the area under the curve was significant for ICH, not-significant for SAPSII. CONCLUSIONS:Regional quality controls use generic prognostic indexes (SAPSII) in relation to mortality and outcome to assess ICUs, which is appropriate when dealing with a general facility when there is not a predominant type of patient, but it may bias the evaluation if the population with specific pathologies (ICH), not included in the general index, is statistically considerable, leading to an incorrect criticality assessment, an inappropriate strategic plan and the subsequent inefficient resource allocation.
Evaluating the positive predictive values of antidote signals to detect potential adverse drug reactions (ADRs) in the medical intensive care unit (ICU).
Kane-Gill Sandra L,Bellamy Cassandra J,Verrico Margaret M,Handler Steven M,Weber Robert J
Pharmacoepidemiology and drug safety
PURPOSE:Signals are used to alert clinicians of potential ADRs. Positive predictive values (PPVs) of antidote signals in ICUs are unknown. The primary purpose was to determine PPVs of six signals. The secondary objective was to determine the sensitivity of various ADR detection strategies including manual chart review, administrative data review, and voluntary reporting at identifying the same ADRs discovered using antidotes as a signal. METHODS:Adult patients admitted to a medical ICU from July 1, 2005 to June 30, 2006 who were prescribed select signals were eligible. Evaluated antidote signals included injectable diphenhydramine, protamine, phytonadione, dextrose 50%, injectable methylprednisolone, and sodium polystyrene. For each signal, a random sample of 50 patients was evaluated for the presence of an ADR. ADR occurrences were determined using two objective causality instruments through retrospective chart review. Agreement between the instruments was required for ADR consideration. PPVs were determined for each signal. RESULTS:Two hundred and twenty three patients (52% male) were evaluated, with a mean +/- SD age of 60 +/- 17 years, and a median simplified acute physiology score (SAPSII) of 48. PPVs were 0.64, 0.50, 0.38, 0.26, 0.24, and 0.02 for protamine, sodium polystyrene, dextrose 50%, diphenhydramine, phytonadione, and methylprednisolone, respectively. Sensitivity of other detection strategies from highest to lowest was chart review for explicit documentation, administrative database review, and voluntary reporting. CONCLUSIONS:Protamine and sodium polystyrene performed the best by detecting ADRs in at least one out of two evaluations. Detection strategies other than signals were not as sensitive at identifying the same ADRs as antidote signals.
A simplified acute physiology score in the prediction of acute aluminum phosphide poisoning outcome.
Shadnia Shahin,Mehrpour Omid,Soltaninejad Kambiz
Indian journal of medical sciences
BACKGROUND:Aluminum phosphide (AlP) is used as a fumigant. It produces phosphine gas, which is a mitochondrial poison. Unfortunately, there is no known antidote for AlP intoxication, and also, there are few data about its prognostic factors. AIMS:The aim of this study was to determine the impact of the Simplified Acute Physiology Score II (SAPS II ) in the prediction of outcome in patients with acute AlP poisoning requiring admission to the Intensive Care Unit (ICU). MATERIALS AND METHODS:This was a prospective study in patients with acute AlP poisoning, admitted to the ICU over a period of 12 months. The demographic data were collected and SAPSII was recorded. The patients were divided into survival and non-survival groups due to outcome. STATISTICAL ANALYSIS:The data were expressed as mean ± SD for continuous or discrete variables and as frequency and percentage for categorical variables. The results were compared between the two groups using SPSS software. Results : During the study period, 39 subjects were admitted to the ICU with acute AlP poisoning. All 39 patients required endotracheal intubation and mechanical ventilation in addition to gastric decontamination with sodium bicarbonate, permanganate potassium, and activated charcoal, therapy with MgSO 4 and calcium gluconate and adequate hydration. Among these patients, 26 (66.7%) died. SAPSII was significantly higher in the non-survival group than in the survival group (11.88 ± 4.22 vs. 4.31 ± 2.06, respectively) (P < 0.001). CONCLUSION:SAPSII calculated within the first 24 hours was recognized as a good prognostic indicator among patients with acute AlP poisoning requiring ICU admission.
[Prediction of outcome of elderly patients with respiratory failure: comparison of current scoring systems].
Guo Chao,Xie Li-Xin,Feng Dan
Zhongguo wei zhong bing ji jiu yi xue = Chinese critical care medicine = Zhongguo weizhongbing jijiuyixue
OBJECTIVE:To evaluate the predictive power of current scoring systems applied in elderly patients with respiratory failure. METHODS:Data of 159 elderly patients with respiratory failure, also meeting the criteria of multiple organ dysfunction syndrome in the elderly (MODSE), being admitted to PLA General Hospital from January 2009 to March 2010 were analyzed with four scoring systems, i.e. acute physiology and chronic health evaluation (APACHE II, APACHE III), simplified acute physiology scoreII (SAPSII), as well as multiple organ dysfunction score (Marshall score), for the prediction of their outcome on the first day after admission, and the predictive power of respective system was compared. RESULTS:One hundred and fifty nine patients were involved, with a mean age of (75.26±7.87) years, and a 28-day mortality of 53.5%. Incidence of organ failure and prognosis scores in nonsurvivors were significantly higher than those in survivors (APACHE II score: 27.88±8.19 vs. 17.73±6.21; APACHE III score: 101.10±29.81 vs. 64.24±21.98; SAPSII score: 59.70±17.68 vs. 38.05±12.10; Marshall score: 8.59±3.15 vs. 4.90±2.66; organ failure: 4.60±1.14 vs. 2.88±0.88, all P<0.01). Among the four scoring systems, SAPSII presented excellence in sensitivity (91.76%), while APACHE III in specificity (91.89%). Area under curve of receiver operator characteristic of all scoring systems reached 0.820 (0.829 for APACHE II , 0.836 for APACHE III , 0.844 for SAPSII, 0.820 for Marshall score). CONCLUSION:All the four current scoring systems , i.e. APACHE II, APACHE III, SAPSII and Marshall score, presented satisfactory predictive power in prognosis of elderly patients with respiratory failure.
Diagnostic accuracy of procalcitonin in critically ill immunocompromised patients.
Bele Nicolas,Darmon Michael,Coquet Isaline,Feugeas Jean-Paul,Legriel Stéphane,Adaoui Nadir,Schlemmer Benoît,Azoulay Elie
BMC infectious diseases
BACKGROUND:Recognizing infection is crucial in immunocompromised patients with organ dysfunction. Our objective was to assess the diagnostic accuracy of procalcitonin (PCT) in critically ill immunocompromised patients. METHODS:This prospective, observational study included patients with suspected sepsis. Patients were classified into one of three diagnostic groups: no infection, bacterial sepsis, and nonbacterial sepsis. RESULTS:We included 119 patients with a median age of 54 years (interquartile range [IQR], 42-68 years). The general severity (SAPSII) and organ dysfunction (LOD) scores on day 1 were 45 (35-62.7) and 4 (2-6), respectively, and overall hospital mortality was 32.8%. Causes of immunodepression were hematological disorders (64 patients, 53.8%), HIV infection (31 patients, 26%), and solid cancers (26 patients, 21.8%). Bacterial sepsis was diagnosed in 58 patients and nonbacterial infections in nine patients (7.6%); 52 patients (43.7%) had no infection. PCT concentrations on the first ICU day were higher in the group with bacterial sepsis (4.42 [1.60-22.14] vs. 0.26 [0.09-1.26] ng/ml in patients without bacterial infection, P < 0.0001). PCT concentrations on day 1 that were > 0.5 ng/ml had 100% sensitivity but only 63% specificity for diagnosing bacterial sepsis. The area under the receiver operating characteristic (ROC) curve was 0.851 (0.78-0.92). In multivariate analyses, PCT concentrations > 0.5 ng/ml on day 1 independently predicted bacterial sepsis (odds ratio, 8.6; 95% confidence interval, 2.53-29.3; P = 0.0006). PCT concentrations were not significantly correlated with hospital mortality. CONCLUSION:Despite limited specificity in critically ill immunocompromised patients, PCT concentrations may help to rule out bacterial infection.
[Clinical analysis of non-invasive positive pressure ventilation in immunocompromised host with acute respiratory failure].
Zhang Xin,Wang Hui-juan,Mo Guo-xin,Zhao Tie-mei,Jia Yan-hong,Xie Li-xin
Zhongguo wei zhong bing ji jiu yi xue = Chinese critical care medicine = Zhongguo weizhongbing jijiuyixue
OBJECTIVE:To evaluate the value of non-invasive positive pressure ventilation (NPPV) in immunocompromised host (ICH) complicated by acute respiratory failure (ARF), and to investigate predictive variables of success with NPPV in ICH with ARF. METHODS:A retrospective study of immunocompromised patients with ARF, who were admitted to respiratory intensive care unit (RICU) from March 2008 to March 2011, was performed. Based on clinical data, univariate Logistic regression was done for prediction for independent factors affecting the success of NPPV treatment. Immunization status was assessed according to clinical outcome. RESULTS:NPPV was instituted in all 33 cases with ARF initially. Among these patients, 9 patients (27.3%) received sequential invasive mechanical ventilation (IMV, failure group) and all of them died finally; among 24 cases (72.7%) who only received NPPV (success group), 7 patients died (29.2%). There was significant difference between the two groups in mortality (P<0.01). The simplified acute physiology scoreII (SAPSII) in the success group was lower than that in the failure group (33±9 vs. 43±5, P<0.01). However, other clinical data showed no statistical significance between two groups. Univariate Logistic regression analysis identified SAPSII was the independent factor associated with the success of NPPV treatment [odds ratio (OR) =0.83, 95% confidence interval (95% CI) 0.709-0.964, P<0.05]. And SAPSII≥38 was a risk factor for the failure of NPPV [area under receiver operating characteristic (ROC) curve 0.73]. In addition, the lung injury scores (LIS) in the survival group was significantly lower than that of the death group (1.95±0.48 vs. 2.57±0.52, P<0.01), the difference was statistically significant. CD3(+) and CD8(+) T counts in the survivors were higher than that of non-survivors (CD3(+):0.73±0.16 vs. 0.41±0.20; CD8(+): 0.51±0.18 vs. 0.21±0.15, both P<0.01), and the difference was statistically significant. CONCLUSION:As an early treatment for ICH with pulmonary infections suffering from ARF, NPPV can be effective for the ICH patients suffering from severe pulmonary infection through improving hypoxemia, ameliorating respiratory distress symptoms, and avoiding complications associated with IMV when SAPSIIis less than 38. CD3(+), CD8(+), and the LIS can be used to evaluate the prognosis of those patients.
Incidence and predictors of missed injuries in trauma patients in the initial hot report of whole-body CT scan.
Eurin M,Haddad N,Zappa M,Lenoir T,Dauzac C,Vilgrain V,Mantz J,Paugam-Burtz C
BACKGROUND:Whole-body CT scan is the cornerstone of trauma-related injury assessment. Several lines of evidence indicate that significant number of injuries may remain undetected after the initial hot report of CT. Missed injuries (MI) represent an important issue in trauma patients, for they may increase morbidity, mortality and costs. The aim of this study was to examine incidence and predictors of MI in trauma patients undergoing whole-body CT scan. METHODS:177 CT scan performed upon admission of trauma patients during year 2005 were reviewed by a radiologist blinded to patient's initial data. MI was defined as injuries not written in the initial report. Patients with and without MI were compared to determine predictors of MI by multivariable analysis. RESULTS:157 MI were diagnosed in 85 (47%) patients. MI was predominantly encoded AIS 2 (57%) or 3 (29%). Patients with MI had significantly higher SAPSII, higher ISS and were more frequently sedated. Age over 50 years (OR: 4.37, p=0.003) and ISS over 14 (OR: 4.17, p<0.0001) were independent predictors of MI. Median ISS after encoding MI was significantly higher than initial ISS (22 vs. 20 p<0.0001). After adjustment for severity, mortality and length of stay were not different between patients with or without MI. CONCLUSION:Trauma patients, especially aged and severe, experienced a high rate of missed injuries in the initial hot report which appeared to be predominantly minor and musculoskeletal, advocating a CT scan second reading.
[Prognostic value of D-dimer in patients with sepsis in emergency department: a prospective study].
Zhan Zhi-gang,Li Chun-sheng
Zhongguo wei zhong bing ji jiu yi xue = Chinese critical care medicine = Zhongguo weizhongbing jijiuyixue
OBJECTIVE:To investigate the value of the concentration of D-dimer in predicting 28-day mortality of sepsis patients in emergency department in order to determine its prognostic values. METHODS:A prospective study was conducted. A total of 766 sepsis patients treated in the emergency department of Beijing Chaoyang Hospital of the Capital Medical University from October 2009 to July 2010 were enrolled, and admission blood samples were obtained for D-dimer measurement (solid phase immune chromatography). A variety of clinical and laboratory variables were recorded. With 28 days as end point, the D-dimer levels, acute physiology and chronic health evaluation II (APACHEII) score, and simplify acute physiology score II (SAPSII) were compared respectively between survivors and non-survivors. The status of each patient was ascertained, and the association between the concentration of D--dimer and 28-day mortality was assessed. RESULTS:Two hundred and thirty-three patients died during the 28--day observation period among 766 patients. D--dimer concentration (μg/L) among deceased were significantly higher than those of survivors [1220.0 (789.0, 1835.0) vs. 323.0 (158.0, 642.0), P < 0.01]. The level of D-dimer showed positive correlation with APACHEII score and SAPSII [r₁=0.643, r₂=0.632, both P < 0.01]. D-dimer concentration had an area under the receiver operating characteristic (ROC) curve (AUC) of 0.880 for predicting 28-day mortality, with 95% confidence interval (95%CI) 0.855-0.904, P < 0.001; the optimal D-dimer cut point for predicting 28-day mortality was 663.5 μg/L. D--dimer concentration higher than 663.5 μg/L, APACHEII score higher than 19.5 and SAPSII higher than 39.5 were the independent predictors of 28-day mortality [odds ratio (OR): 17.5, 15.7, 19.6, all P < 0.001]. The 28-day mortality (1.4%, 12.3%, 64.2%), APACHEII score [11 (9, 13), 13 (11, 16), 19 (15, 22)] and SAPSII [24 (18, 29), 31 (24, 36), 40 (33, 49)] showed statistically significant among D--dimer <250.0, 250.0--663.5, >663.5 μg/L three groups (all P < 0.01). CONCLUSIONS:D-dimer concentration is an independent predictor of 28--day mortality in patients with sepsis. D--dimer level shows a high predictive value in patients with sepsis, similar to APACHE II score and SAPSII. It can be helpful in risk stratification in septic patients.
Severe imported malaria in an intensive care unit: a review of 59 cases.
Santos Lurdes C,Abreu Cândida F,Xerinda Sandra M,Tavares Margarida,Lucas Raquel,Sarmento António C
BACKGROUND:In view of the close relationship of Portugal with African countries, particularly former Portuguese colonies, the diagnosis of malaria is not a rare thing. When a traveller returns ill from endemic areas, malaria should be the number one suspect. World Health Organization treatment guidelines recommend that adults with severe malaria should be admitted to an intensive care unit (ICU). METHODS:Severe cases of malaria in patients admitted to an ICU were reviewed retrospectively (1990-2011) and identification of variables associated with in-ICU mortality performed. Malaria prediction score (MPS), malaria score for adults (MSA), simplified acute physiology score (SAPSII) and a score based on WHO's malaria severe criteria were applied. Statistical analysis was performed using StataV12. RESULTS:Fifty nine patients were included in the study, all but three were adults; 47 (79,6%) were male; parasitaemia on admission, quantified in 48/59 (81.3%) patients, was equal or greater than 2% in 47 of them (97.9%); the most common complications were thrombocytopaenia in 54 (91.5%) patients, associated with disseminated intravascular coagulation (DIC) in seven (11.8%), renal failure in 31 (52.5%) patients, 18 of which (30.5%) oliguric, shock in 29 (49.1%) patients, liver dysfunction in 27 (45.7%) patients, acidaemia in 23 (38.9%) patients, cerebral dysfunction in 22 (37.2%) patients, 11 of whom with unrousable coma, pulmonary oedema/ARDS in 22 (37.2%) patients, hypoglycaemia in 18 (30.5%) patients; 29 (49.1%) patients presented five or more dysfunctions. The case fatality rate was 15.2%. Comparing the four scores, the SAPS II and the WHO score were the most sensitive to death prediction. In the univariate analysis, death was associated with the SAPS II score, cerebral malaria, acute renal and respiratory failure, DIC, spontaneous bleeding, acidosis and hypoglycaemia. Age, partial immunity to malaria, delay in malaria diagnosis and the level of parasitaemia were not associated with death in this cohort. CONCLUSION:Severe malaria cases should be continued monitored in the ICUs. SAPS II and the WHO score are good predictors of mortality in malaria patients, but other specific scores deserve to be studied prospectively.
Development of a low cost laparostomy technique. Two years experience in the Trauma Center of Cesena, Italy.
Ruscelli Paolo,Buccoliero Francesco
Annali italiani di chirurgia
BACKGROUND:In the last few years laparostomy has become an even more useful option for the surgeon due to the development of the experience in the critical abdominal trauma and in the severe surgical urgencies as PANE and peritonitis with the introduction of Damage Control as surgical strategy to prevent the abdominal compartimental syndrom (ACS). After a laparostomy the surgeon needs to provide a delayed fascial closure to achieve the best outcome for the patient. The aim of this paper is to illustrate the experience and the results after the introduction of a modified laparostomy technique in our surgical activity. METHODS:Protection of intestinal content, aspiration under sub-athmospheric pressure, control in quality and quantity of the drainage and skin temporary closure, rappresent the four principles of the PACS tecnique. In order to evaluate the rate of delayed fascial closure and the rate of ACS onset, we have retrospectively studied 31 patients over a period of 2 years treated with open abdomen with an amount of 36 PACS performed. Routinely IAP measurament was also performed. RESULTS:ACS was developed in no patients. IAP was measured on average at 19. DFC was achieved in 33 PACS of 36 (91.7%) after 5 days on average (20 hours as minimum; 20 days as maximum). Aspected mortality (SAPSII) in ICU for these patient was 76.5% on average. On 31 patients, 20 (64.5%) died and 11 (35.5%) survived. CONCLUSION:PACS seems to be an effective, easy and low cost technique for the management of open abdomen.
[Assessment of prognostic and influencing factors in elderly patients with multiple organ dysfunction syndrome].
Xiao Kun,Guo Chao,Su Long-xiang,Feng Lin,Jiang Zhao-xu,Chen Ke,Feng Dan,Jia Yan-hong,She Dan-yang,Xie Li-xin
Zhonghua yi xue za zhi
OBJECTIVE:To preliminarily assess the prognosis of patients with multiple organ dysfunction syndrome (MODSE) and analyze their influencing factors. METHODS:The clinical data of 365 MODSE patients admitted into Chinese PLA General Hospital during January 2009 to June 2012 were analyzed retrospectively. According to 28-day outcomes, they were divided into 2 groups (28-day survival and non-survival) while 4 groups according to age. Then these prognosis were evaluated with the current scoring systems ((acute physiology and chronic health evaluation II (APACHEII and III), sample acute physiological score (SAPSII) and multiple organ dysfunction score (MODS)). The predictive powers were compared by receiver operating characteristic (ROC) curve. Finally a binary Logistic regression analysis was performed to evaluate the relevant influencing prognostic factors of MODSE. RESULTS:The mean age was (77.8 ± 9.1) years, mean number of failed organs (3.6 ± 1.2) and a 28-day mortality 45.8%. The ages of non-survival group were older than those of survival group ((78.1 ± 9.1) vs (76.7 ± 11.0) years). The number of organ failures ((4.3 ± 1.1) vs (3.1 ± 1.0)) and scores (APACHEII: (28 ± 7) vs (20 ± 8), APACHE III: (106 ± 27) vs (75 ± 31), SAPSII: (64 ± 16) vs (46 ± 18), MODS: (9 ± 3) vs (6 ± 3)) of non-survivals were significantly higher than that of survivals. The area under ROC curve of these four score systems were 0.790, 0.781, 0.780 and 0.780 respectively. Compared to the above systems, SAPSII had the best performance in sensitivity while APACHEII was more valuable in specificity. All clinical data underwent binary Logistic regression and the results showed that plasma concentration of albumin and mean arterial pressure (MAP) offered beneficial outcomes while age and number of organ failures had unfavorable prognosis. The greater patient age, the higher their mortality. CONCLUSIONS:All four scoring systems have accurate prognostic predictions of MODSE patients. And the predictive power of APACHEII is the best. Plasma concentration of albumin, MAP, age and organ failure number are independent prognostic factors in MODSE patients.
Pressure ulcers in the intensive care unit: the relationship between nursing workload, illness severity and pressure ulcer risk.
Cremasco Mariana F,Wenzel Fernanda,Zanei Suely S V,Whitaker Iveth Y
Journal of clinical nursing
Aims and objective. To verify association between PU development with nursing workload and illness severity and to verify whether nursing workload and illness severity are related with Braden Scale scores. Background. Critically ill patients are more susceptible to treatment complications because of the severity of their clinical condition. Design. Prospective descriptive study. Methods. Patients consecutively admitted to three intensive care units (ICUs) of a public university hospital located in Sao Paulo, Brazil and without pressure ulcer (PU) at admission and a minimum stay of 24 hours were included in the sample. Prospective data collection included demographic, clinical and hospitalisation data, Nursing Activities Score (NAS), Simplified Acute Physiology Score (SAPSII) and Braden Scale. Multivariate linear regression analysis was applied to verify whether nursing workload and illness severity are related with Braden Scale scores. Multivariate logistic regression analysis was used to verify whether nursing workload and illness severity were risk factors associated with PU development. Results. The study sample included 160 patients. The mean Braden score was 12·0 and PU incidence was 34·4%. Multivariate linear regression analysis identified as factors related to variation of Braden scores: illness severity (SAPSII), nursing workload (NAS) and age. Multivariate logistic regression showed a model with risk factors associated with PU development: sex, length of ICU stay, illness severity and nursing workload. Conclusion. Nursing workload, severity of illness, sex and length of ICU stay were identified as risk factors associated with PU development. However, nursing workload acted as a protective factor. Illness severity, nursing workload and age were related to Braden scores. Relevance to clinical practice. Accurate identification of risk factors and the use of clinical judgment in skin assessment are prerequisites for determining appropriate strategies to prevent pressure ulcers, to improve quality of care for patient safety and to reduce length of ICU and hospital stay and costs.
Aspergillus in the lower respiratory tract of immunocompetent critically ill patients.
Lugosi Maxime,Alberti Corinne,Zahar Jean-Ralph,Garrouste Maité,Lemiale Virginie,Descorps-Desclère Adrien,Ricard Jean-Damien,Goldgran-Tolédano Dany,Cohen Yves,Schwebel Carole,Vésin Aurélien,Timsit Jean-François,Azoulay Elie
The Journal of infection
OBJECTIVES:To shed light on the meaning of Aspergillus-positive lower-respiratory-tract samples in non immunocompromized critically ill patients. METHODS:Multicentre matched case-control (1:5) study. We used prospectively collected data to identify risk factors for Aspergillus-positive specimens, as well as outcomes in Aspergillus-positive patients. RESULTS:66 cases (5 with definite invasive pulmonary aspergillosis (IPA), 18 with probable IPA, and 43 colonisations) were matched to 330 controls. In the multivariate conditional logistic model, independent risk factors for at least one Aspergillus-positive respiratory-tract specimen were worse SAPSII at admission [OR, 1.10; 95%CI, 1.00-1.21], ARDS [OR, 2.64; 95%CI, 1.29-5.40]; long-term steroid therapy [OR, 4.77; 95%CI, 1.49-15.23]; steroid therapy started in the ICU [OR, 11.03; 95%CI, 4.40-27.67]; and bacterial infection [OR, 2.73; 95%CI, 1.37-5.42]. The risk of death, compared to the controls, was not higher in the cases overall [HR, 0.66; 95%CI, 0.41-1.08; p = 0.1] or in the subgroups with definite IPA [HR, 1.60; 95%CI, 0.43-5.94; p = 0.48], probable IPA [HR, 0.84; 95%CI, 0.28-2.50; p = 0.76], or colonisation [HR, 0.58; 95%CI, 0.33-1.02; p = 0.06]. In cases who received antifungal therapy, mortality was not lower than in untreated cases [HR, 0.67; 95%CI, 0.36-1.24; p = 0.20]. CONCLUSIONS:In critically ill immunocompetent patients, risk factors for presence of Aspergillus in lower respiratory tract specimens are steroid therapy (either chronic or initiated in the ICU), ARDS, and high severity of the acute illness. Prospective studies are warranted to further examine these risk factors and to investigate immune functions as well as the impact of antifungal therapy on patient outcomes.
[Comparison of simplified acute physiology score III and other scoring systems in prediction of 28-day prognosis in patients with severe sepsis].
Li Yan,Li Chunsheng
Zhonghua wei zhong bing ji jiu yi xue
OBJECTIVE:To investigate the power of the simplified acute physiology score III (SAPSIII) for prediction of outcome for patients with severe sepsis admitted to the intensive care unit (ICU). METHODS:A retrospective study was conducted. 677 severe sepsis patients with age≥18 years old and the survival time in emergency ICU≥24 hours admitted to the emergency ICU of Beijing Chaoyang Hospital Affiliated to Capital Medical University from January 2008 to December 2011 were enrolled. The acute physiology and chronic health evaluation II (APACHEII), sequential organ failure assessment (SOFA), SAPSII, SAPSIII, and mortality in emergency department sepsis (MEDS) scores were recorded based on the poorest value within 24 hours of ICU admission. The 28-day result as denoted as survival or death was considered as the end point of the study. The ability to predict mortality by the score systems was assessed by using receiver operating characteristic (ROC) curve analysis and binary logistic regression models. RESULTS:Among the 677 patients with severe sepsis, 284 cases died within 28 days after admission, and the mortality rate was 41.9%. Compared with survivors, the patients in non-survival group was older with higher APACHEII, SOFA, SAPSII, SAPSIII, and MEDS scores and higher ratio of underlying diseases, such as primary hypertension and renal dysfunction, and they had more organ injury, higher ratio of lung infection and bacterial infection (P<0.05 or P<0.01). It was identified by logistic regression that the APACHEII, SOFA, SAPSII, SAPSIII and MEDS scores were significantly independent factors in 28-day death prediction in patients with severe sepsis (all P=0.000). The rank of areas under the ROC curve (AUC) from high to low were MEDS (0.970), APACHEII (0.893), SAPSIII (0.875), SOFA (0.871), and SAPSII (0.860), respectively. SAPSIII score and APACHEII, SOFA, SAPSII scores were found to have an equivalent capacity in predicting the prognosis (all P>0.05). The MEDS score in predicting the prognosis was obviously better than that of APACHEII, SOFA, SAPSII, and SAPSIII scores (all P<0.05 ). The MEDS score showed the best sensitivity (91.5%), and specificity (89.1%). The 28-day mortality in cases of MEDS≥11 was 85.8%. CONCLUSIONS:(1) For patients with severe sepsis who were admitted to ICU, MEDS was superior to APACHEII, SOFA, SAPSII, and SAPSIII scores in predicting prognosis. MEDS≥11 may indicate a higher mortality rate. (2) SAPSIII score has comparable predictive capability with APACHEII, SOFA and SAPSII scores may be recommended for prediction of the prognosis of patients with severe sepsis in ICU. But the SAPSIII score is unsuitable for predicting the prognosis of patients with acute sepsis in ICU options, and it is not superior to that of SAPSIII score in predicting prognosis of patients with sepsis in the emergency ICU than other score systems.
Pulse Wave Transit Time Measurements of Cardiac Output in Septic Shock Patients: A Comparison of the Estimated Continuous Cardiac Output System with Transthoracic Echocardiography.
Feissel Marc,Aho Ludwig Serge,Georgiev Stefan,Tapponnier Romain,Badie Julio,Bruyère Rémi,Quenot Jean-Pierre
BACKGROUND:We determined reliability of cardiac output (CO) measured by pulse wave transit time cardiac output system (esCCO system; COesCCO) vs transthoracic echocardiography (COTTE) in mechanically ventilated patients in the early phase of septic shock. A secondary objective was to assess ability of esCCO to detect change in CO after fluid infusion. METHODS:Mechanically ventilated patients admitted to the ICU, aged >18 years, in sinus rhythm, in the early phase of septic shock were prospectively included. We performed fluid infusion of 500 ml of crystalloid solution over 20 minutes and recorded CO by EsCCO and TTE immediately before (T0) and 5 minutes after (T1) fluid administration. Patients were divided into 2 groups (responders and non-responders) according to a threshold of 15% increase in COTTE in response to volume expansion. RESULTS:In total, 25 patients were included, average 64±15 years, 15 (60%) were men. Average SAPSII and SOFA scores were 55±21.3 and 13±2, respectively. ICU mortality was 36%. Mean cardiac output at T0 was 5.8±1.35 L/min by esCCO and 5.27±1.17 L/min by COTTE. At T1, respective values were 6.63 ± 1.57 L/min for esCCO and 6.10±1.29 L/min for COTTE. Overall, 12 patients were classified as responders, 13 as non-responders by the reference method. A threshold of 11% increase in COesCCO was found to discriminate responders from non-responders with a sensitivity of 83% (95% CI, 0.52-0.98) and a specificity of 77% (95% CI, 0.46-0.95). CONCLUSION:We show strong correlation esCCO and echocardiography for measuring CO, and change in CO after fluid infusion in ICU patients.
Prognostics factors for mortality and renal recovery in critically ill patients with acute kidney injury and renal replacement therapy.
Gaião Sérgio Mina,Gomes André Amaral,Paiva José Artur Osório de Carvalho
Revista Brasileira de terapia intensiva
OBJECTIVE:Identify prognostic factors related to mortality and non-recovery of renal function. METHODS:A prospective single-center study was conducted at the intensive care medicine department of a university hospital between 2012 and 2015. Patients with acute kidney injury receiving continuous renal replacement therapy were included in the study. Clinical and analytical parameters were collected, and the reasons for initiation and discontinuation of renal replacement therapy were examined. RESULTS:A total of 41 patients were included in the study, of whom 43.9% had sepsis. The median Simplified Acute Physiology Score II (SAPSII) was 56 and the mortality was 53.7%, with a predicted mortality of 59.8%. The etiology of acute kidney injury was often multifactorial (56.1%). Survivors had lower cumulative fluid balance (median = 3,600mL, interquartile range [IQR] = 1,175 - 8,025) than non-survivors (median = 12,000mL, IQR = 6,625 - 17,875; p = 0.004). Patients who recovered renal function (median = 51.0, IQR = 45.8 - 56.2) had lower SAPS II than those who do not recover renal function (median = 73, IQR = 54 - 85; p = 0.005) as well as lower fluid balance (median = 3,850, IQR = 1,425 - 8,025 versus median = 11,500, IQR = 6,625 - 16,275; p = 0.004). CONCLUSIONS:SAPS II at admission and cumulative fluid balance during renal support therapy were risk factors for mortality and non-recovery of renal function among critically ill patients with acute kidney injury needing renal replacement therapy.
Patients with Acute Myeloid Leukemia Admitted to Intensive Care Units: Outcome Analysis and Risk Prediction.
Pohlen Michele,Thoennissen Nils H,Braess Jan,Thudium Johannes,Schmid Christoph,Kochanek Matthias,Kreuzer Karl-Anton,Lebiedz Pia,Görlich Dennis,Gerth Hans U,Rohde Christian,Kessler Torsten,Müller-Tidow Carsten,Stelljes Matthias,Hullermann Carsten,Büchner Thomas,Schlimok Günter,Hallek Michael,Waltenberger Johannes,Hiddemann Wolfgang,Berdel Wolfgang E,Heilmeier Bernhard,Krug Utz
BACKGROUND:This retrospective, multicenter study aimed to reveal risk predictors for mortality in the intensive care unit (ICU) as well as survival after ICU discharge in patients with acute myeloid leukemia (AML) requiring treatment in the ICU. METHODS AND RESULTS:Multivariate analysis of data for 187 adults with AML treated in the ICU in one institution revealed the following as independent prognostic factors for death in the ICU: arterial oxygen partial pressure below 72 mmHg, active AML and systemic inflammatory response syndrome upon ICU admission, and need for hemodialysis and mechanical ventilation in the ICU. Based on these variables, we developed an ICU mortality score and validated the score in an independent cohort of 264 patients treated in the ICU in three additional tertiary hospitals. Compared with the Simplified Acute Physiology Score (SAPS) II, the Logistic Organ Dysfunction (LOD) score, and the Sequential Organ Failure Assessment (SOFA) score, our score yielded a better prediction of ICU mortality in the receiver operator characteristics (ROC) analysis (AUC = 0.913 vs. AUC = 0.710 [SAPS II], AUC = 0.708 [LOD], and 0.770 [SOFA] in the training cohort; AUC = 0.841 for the developed score vs. AUC = 0.730 [SAPSII], AUC = 0.773 [LOD], and 0.783 [SOFA] in the validation cohort). Factors predicting decreased survival after ICU discharge were as follows: relapse or refractory disease, previous allogeneic stem cell transplantation, time between hospital admission and ICU admission, time spent in ICU, impaired diuresis, Glasgow Coma Scale <8 and hematocrit of ≥25% at ICU admission. Based on these factors, an ICU survival score was created and used for risk stratification into three risk groups. This stratification discriminated distinct survival rates after ICU discharge. CONCLUSIONS:Our data emphasize that although individual risks differ widely depending on the patient and disease status, a substantial portion of critically ill patients with AML benefit from intensive care.
Are scoring systems sufficient for predicting mortality due to sepsis in the emergency department?
Gunes Ozaydin Merve,Guneysel Ozlem,Saridogan Fatma,Ozaydin Vehbi
Turkish journal of emergency medicine
OBJECTIVES:Scoring systems have been used to risk stratify in intensive care units (ICU), but not routinely used in emergency departments. The aim of this study was to determine accuracy for predicting mortality in emergency medicine with Sequential Organ Failure Assessment (SOFA), Mortality in ED Sepsis (MEDS) score and Simplified Acute Physiology Score (SAPSII). METHODS:This is a prospective observational study. Patients presenting with evidence of sepsis were all included. SAPSII, MEDS, and SOFA scores were calculated. Analysis compared areas under the receiver operator characteristic (ROC) curves for 28-day mortality. RESULTS:Two hundred patients were included; consisting of 31 (14.3%) septic shock. 138 (69%) severe sepsis and 31 (15.5%) infection without organ dysfunction. 53 (26.5%) patients died within 28 days. Area under the ROC curve for mortality was 0.76 for MEDS (0.69-0.82), 0.70 for SAPSII (0.62-0.78); and 1.68 for SOFA (0.60-0.76) scores. Pair wise comparison of AUC between MEDS, SAPSII, SOFA and Lactate were not significant. CONCLUSION:According to our results; SOFA, SAPSII and MEDS were not sufficient to predict mortality. Also this result, MEDS was better than other scoring system.
Vitamin E as a novel therapy in the treatment of acute aluminum phosphide poisoning.
Halvaei Zahra,Tehrani Hiva,Soltaninejad Kambiz,Abdollahi Mohammad,Shadnia Shahin
Turkish journal of medical sciences
BACKGROUND/AIM:Aluminum phosphide (AlP) is commonly used as a fumigant in developing countries. Induction of oxidative stress is one of the most important mechanisms of its toxicity. In this regard, and considering that there is no specific antidote for its treatment, the aim of this study was to evaluate the effect of vitamin E in the treatment of acute AlP poisoning. MATERIALS AND METHODS:This was a clinical trial on acute AlP poisoned patients. All patients received supportive treatment. In addition, the treatment group received vitamin E (400 mg/BD/IM). Level of malondialdehyde (MDA) and total antioxidant capacity of plasma were measured. RESULTS:There was no significant difference between the treatment and control groups with regard to demographic, clinical, or paraclinical data or Simplified Acute Physiology Score II (SAPS) on admission. Systolic blood pressure significantly increased during the first 24 h in the treatment group (P < 0.05). The plasma MDA level significantly decreased in the treatment group (P < 0.05). Vitamin E administration decreased the necessity (30% vs. 62%, P < 0.05) and duration of intubation and mechanical ventilation (P < 0.05). It significantly reduced the mortality rate in the treatment group compared to the control group (15% vs. 50%, respectively, P < 0.05). CONCLUSION:Vitamin E along with supportive treatment could have a therapeutic effect in acute AlP poisoning.
Association of Microcirculation, Macrocirculation, and Severity of Illness in Septic Shock: A Prospective Observational Study to Identify Microcirculatory Targets Potentially Suitable for Guidance of Hemodynamic Therapy.
Sturm Timo,Leiblein Julia,Schneider-Lindner Verena,Kirschning Thomas,Thiel Manfred
Journal of intensive care medicine
PURPOSE:Clinically unapparent microcirculatory impairment is common and has a negative impact on septic shock, but specific therapy is not established so far. This prospective observational study aimed at identifying candidate parameters for microcirculatory-guided hemodynamic therapy. ClinicalTrials.gov : NCT01530932. MATERIALS AND METHODS:Microcirculatory flow and postcapillary venous oxygen saturation were detected during vaso-occlusive testing (VOT) on days 1 (T0), 2 (T24), and 4 (T72) in 20 patients with septic shock at a surgical intensive care unit using a laser Doppler spectrophotometry system (O2C). RESULTS:Reperfusional maximal venous capillary oxygen saturation (SvcOmax) showed negative correlations with Simplified Acute Physiology Score II (SAPSII)/Sequential Organ Failure Assessment (SOFA) score, norepinephrine dosage, and lactate concentration and showed positive correlations with cardiac index (CI). At T24 and T72, SvcOmax was also inversely linked to fluid balance. With respect to any predictive value, SvcOmax and CI determined on day 1 (T0) were negatively correlated with SAPS II/SOFA on day 4 (T72). Moreover, SvcOmax measured on day 1 or day 2 was negatively correlated with cumulated fluid balance on day 4 ( r= -.472, P < .05 and r = -.829, P < .001). By contrast, CI neither on day 1 nor on day 2 was correlated with cumulated fluid balance on day 4 ( r = -.343, P = .17 and r = -.365, P = .15). CONCLUSION:In patients with septic shock, microcirculatory reserve as assessed by SvcOmax following VOT was impaired and negatively correlated with severity of illness and fluid balance. In contrast to CI, SvcOmax determined on day 1 or day 2 was significantly negatively correlated with cumulative fluid balance on day 4. Therefore, early microcirculatory measurement of SvcOmax might be superior to CI in guidance of sepsis therapy to avoid fluid overload. This has to be addressed in future clinical studies.