A. R. J. Girbes

Accuracy and reliability of APACHE II scoring in two intensive care units Problems and pitfalls in the use of APACHE II and suggestions for improvement.

Acute Physiology and Chronic Health Evaluation (APACHE) II scoring is widely used as an index of illness severity, for outcome prediction, in research protocols and to assess intensive care unit performance and quality of care. Despite its widespread use, little is known about the reliability and validity of APACHE II scores generated in everyday clinical practice. We retrospectively re‐assessed APACHE II scores from the charts of 186 randomly selected patients admitted to our medical and surgical intensive care units. These ‘new’ scores were compared with the original scores calculated by the attending physician. We found that most scores calculated retrospectively were lower than the original scores; 51% of our patients would have received a lower score, 26% a higher score and only 23% would have remained unchanged. Overall, the original scores changed by an average of 6.4 points. We identified various sources of error and concluded that wide variability exists in APACHE II scoring in everyday clinical practice, with the score being generally overestimated. Accurate use of the APACHE II scoring system requires adherence to strict guidelines and regular training of medical staff using the system.

Intra-observer variability in APACHE II scoring

Abstract. Although the APACHE II score is the most widely used scoring system in intensive care units worldwide, its reliability and variability have not been extensively studied. Differences in case-mix may complicate comparison and interpretation of results. We hypothesised that a degree of variability might be inherent to use of the APACHE II scoring system, and decided to assess intra-observer variability in APACHE II scoring as a potential indicator of inherent score variability. APACHE II scores were assessed twice from the charts of 11 patients by 14 physicians, with a time interval of 4 (range 3.5–4.5) months between the two assessments. Intra-observer was found to be approximately 15%. These findings are in agreement with previous observations regarding inter-observer variability in APACHE II scoring, and strongly suggest that there is an inherent score variability of about 15%.

Long-term outcome after 60 days of intensive care

Patients with a long stay in the intensive care unit because of chronic critical illness consume many resources, and yet their outcome may be poor. We evaluated the long‐term outcome of patients spending more than 60 days in the intensive care unit. We performed a retrospective cohort and prospective follow‐up study of 78 patients staying more than 60 days in the 19–26 bed mixed intensive care unit of a university hospital from November 1995 to January 2003. The mortality in the intensive care unit was 38%; at 1 and 5 years it was 56% and 67%, respectively. Advanced age, prior pulmonary disease, long duration of renal replacement therapy, a low oxygenation ratio and platelet count and high Simplified Acute Physiology Score II and Sequential Organ Failure Assessment scores on day 60 influenced long‐term mortality. A Simplified Acute Physiology Score II of 50 or a Sequential Organ Failure Assessment score of 8 or higher was associated with 100% mortality during follow‐up. The overall 5‐year survival rate of 33% suggests that prolonged intensive care may be worth the effort in certain patients.

The continuing story of corticosteroids in the treatment of septic shock.

The use of corticosteroids in the treatment of septic shock has been a topic of controversy for many years. Based on theoretical grounds and the results of laboratory experiments, their use was initially widespread. However, after the publication of several large, prospective patient studies in the late 1980 s, demonstrating no beneficial and perhaps even deleterious effects, it was widely accepted that corticosteroids should not be used. Since then, however, several papers have been published demonstrating a beneficial effect of corticosteroids in the treatment of sepsis, suggesting that their use should be reconsidered. It may all be a matter of timing, duration of treatment and patient selection.

Risk factors and outcome of changes in adrenal response to ACTH in the course of critical illness.

Background. To evaluate the concept of critical illness-related corticosteroid insufficiency (CIRCI) by studying the clinical significance, in terms of risk factors and outcome, of changes in the cortisol response to repeated adrenocorticotropic hormone (ACTH) testing in the course of critical illness. Patients and Methods. In a retrospective study in a medical–surgical intensive care unit (ICU) of a university hospital, we retrospectively included 54 consecutive patients during a 3-year period, who underwent 2 conventional 250 μg ACTH tests at an interval >24 hours, because of ≥6 hours hypotension requiring repeated fluid challenges or vasopressor/inotropic treatment, while corticosteroid treatment was not (yet) initiated. Serum cortisol was measured immediately before and 30 and 60 minutes after intravenous injection of 250 μg of ACTH. Patients were divided into those with an increase (≥0, n = 27) or a decrease (n = 27) in time in delta (Δ) cortisol in response to ACTH and with a Δcortisol <100 (n = 11) and ≥100 nmol/L (n = 43) at the second ACTH test. Results. Changes in Δcortisol in time were paralleled by changes in Δcortisol/albumin, with a higher frequency of septic shock, persistently high disease severity, increased renal replacement therapy, and decreased platelet counts in the course of disease with a decrease in Δcortisol in time. Similar trends in increased disease severity were observed when Δcortisol remained or fell to <100 nmol/L. A decrease in Δcortisol between the 2 tests, particularly to <100 nmol/L, was associated with increased mortality (18 nonsurvivors in the ICU). Conclusions. The findings favor the concept of dynamic adrenal function rather than poor reproducibility of the ACTH test, so that development of CIRCI, particularly in complicated septic shock and indicated by a fall in Δcortisol (to <100 nmol/L) upon ACTH, correlates to a poor prognosis, independently of baseline cortisol, cortisol binding in blood, and disease severity.

The electrolarynx improves communication in a selected group of mechanically ventilated critically ill patients: a feasibility study

Dear Editor, Ventilator-dependent patients in the intensive care unit (ICU) experience difficulties with communication, mainly due to intubation. Tube placement between the vocal cords induces loss of speech and concomitant communication problems, creating severe negative emotional reactions [1]. The magnitude of the problem is increasing as there is a trend towards less sedative use in critically ill patients, thereby increasing the number of awake patients on the mechanical ventilator [2, 3]. An electrolarynx (EL) is a batterypowered device which is commonly used in voice rehabilitation [3]. During phonation, the device is placed externally against the neck approximately at the level of the glottis, from where the vibrated sound is transmitted to the mouth, where the patient modulates it to create intelligible speech by movement of articulators (Fig. 1a). We hypothesized that the use of an EL improves communication for awake critically ill patients on the mechanical ventilator. As a corollary, it was our intention to develop a scoring system and instruction protocol to guide the use of EL in ventilated patients. The local ethics committee approved the protocol. In 15 awake and mechanically ventilated patients in an ICU, the use of the EL was tested. Feasibility was defined as enhanced communication experienced by patient, relatives, and staff. We designed a five-point Electrolarynx Effectivity Score (EES): (1) No improved intelligibility, because of insufficient mouth movement; (2) No effect, but sufficient mouth movement; (3) Improved lipreading by producing recognizable sounds; (4) Effective, can speak words; (5) Very effective, can make sentences; and related this to patient characteristics, including disease severity, patient demographics, and presence of delirium or ICU weakness. Patients, relatives, and staff scored communication and an average score was calculated. Some of the results were presented at the ESICM annual congress 2014 [4]. We included eight women and seven men with a mean age of 57.3 years and mean APACHE II score of 23. Twelve medical and three surgical patients were included. Thirteen patients were orally intubated and two patients were ventilated through a tracheostomy. In six out of 15 patients (40 %), the use of EL was effective or very effective (EES 4 and 5). For two additional patients, lipreading was improved by producing recognizable sounds (EES 3). In this small study, delirium was the only factor associated with unsuccessful use of the EL (Fisher’s exact test, p = 0.035), but disease severity, sedation, and ICU-acquired weakness showed a similar trend. If there is a poor connection with the neck, for example because of adipose neck tissue, there is always the option of the oral adaptor which transmits the vibrations directly into the oral cavity. We successfully used this type of EL in one patient. The use of an EL improved communication in this selected group of mechanically ventilated patients.