Francis Colardyn

Use of the Sofa score to assess the incidence of organ dysfunction/failure in intensive care units: Results of a multicenter, prospective study

OBJECTIVE To evaluate the use of the Sequential Organ Failure Assessment (SOFA) score in assessing the incidence and severity of organ dysfunction in critically ill patients. DESIGN Prospective, multicenter study. SETTING Forty intensive care units (ICUs) in 16 countries. PATIENTS Patients admitted to the ICU in May 1995 (n = 1,449), excluding patients who underwent uncomplicated elective surgery with an ICU length of stay <48 hrs. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The main outcome measures included incidence of dysfunction/failure of different organs and the relationship of this dysfunction with outcome. In this cohort of patients, the median length of ICU stay was 5 days, and the ICU mortality rate was 22%. Multiple organ dysfunction and high SOFA scores for any individual organ were associated with increased mortality. The presence of infection on admission (28.7% of patients) was associated with higher SOFA scores for each organ. The evaluation of a subgroup of 544 patients who stayed in the ICU for at least 1 wk showed that survivors and nonsurvivors followed a different course. This subgroup had greater respiratory, cardiovascular, and neurologic scores than the other patients. In this subgroup, the total SOFA score increased in 44% of the nonsurvivors but in only 20% of the survivors (p < .001). Conversely, the total SOFA score decreased in 33% of the survivors compared with 21% of the nonsurvivors (p < .001). CONCLUSIONS The SOFA score is a simple, but effective method to describe organ dysfunction/failure in critically ill patients. Regular, repeated scoring enables patient condition and disease development to be monitored and better understood. The SOFA score may enable comparison between patients that would benefit clinical trials.

Acute Renal Failure in Patients with Sepsis in a Surgical ICU: Predictive Factors, Incidence, Comorbidity, and Outcome

Acute renal failure (ARF) is a common complication in intensive care unit (ICU) patients. Although there are several reports on outcome of septic patients with ARF, there are no data regarding predisposing factors for ARF. Therefore, the incidence of ARF was investigated in 185 sepsis patients admitted in a surgical ICU during a 16-mo period. Variables predisposing to ARF on day 1 of sepsis were evaluated with univariate and multivariable analyses. APACHE II and SOFA scores were compared during a 14-d period. Additionally, the impact of organ failure on mortality was evaluated. ARF developed in 16.2% of the patients, and 70.0% of these needed renal replacement therapy (RRT). Patients with ARF were more severely ill and had a higher mortality. Remarkably, serum creatinine was already increased on day 1. Creatinine > 1 mg/dl and pH < 7.30, both on day 1 of sepsis, were independently associated with ARF. Age, need for vasoactive therapy, mechanical ventilation, and RRT, but not ARF itself, were associated with mortality. In conclusion, ARF was a frequent complication in sepsis. Sepsis patients with ARF were more severely ill and had a higher mortality. Need for RRT was independently associated with mortality. A simple risk model for ARF, on basis of two readily available parameters on day 1 of sepsis, was developed. This model allows initiating specific therapeutic measures earlier in the course of sepsis, hopefully resulting in a lower incidence of ARF and needi for RRT, thereby lowering mortality.

Clinical and Economic Outcomes in Critically Ill Patients with Nosocomial Catheter-Related Bloodstream Infections

BACKGROUND Central venous catheters are universally used during the treatment of critically ill patients. Their use, however, is associated with a substantial infection risk, potentially leading to increased mortality and costs. We evaluate clinical and economic outcomes associated with nosocomial central venous catheter-related bloodstream infection (CR-BSI) in intensive care unit (ICU) patients. METHODS A retrospective (1992-2002), pairwise-matched (ratio of case patients to control subjects, 1:2 or 1:1), risk-adjusted cohort study was performed at a 54-bed general ICU at a university hospital. ICU patients with microbiologically documented CR-BSI (n = 176) were matched with control subjects (n = 315) on the basis of disease severity, diagnostic category, and length of ICU stay (equivalent or longer) before the onset of CR-BSI in the index case patient. Clinical outcome was principally evaluated by in-hospital mortality. Economic outcome was evaluated on the basis of duration of mechanical ventilation, length of ICU and hospital stays, and total hospital costs, as derived from the patients hospital invoices. RESULTS The attributable mortality rate for CR-BSI was estimated to be 1.8% (95% confidence interval, -6.4% to 10.0%); in-hospital mortality rates for patients with CR-BSI and matched control subjects were 27.8% and 26.0%, respectively. CR-BSI was associated with significant excesses in duration of mechanical ventilation, duration of ICU and hospital stays, and a significant increase in total hospital cost. Linear regression analysis with adjustment for duration of hospitalization and clinical covariates, revealed that CR-BSI is independently associated with higher costs. CONCLUSIONS In ICU patients, CR-BSI does not result in increased mortality. It is, however, associated with a significant economic burden, emphasizing the importance of continuous efforts in prevention.

Effects of nosocomial candidemia on outcomes of critically ill patients

PURPOSE To determine whether nosocomial candidemia is associated with increased mortality in intensive care unit (ICU) patients. SUBJECTS AND METHODS We performed a retrospective (1992 to 2000) cohort study of 73 ICU patients with candidemia and 146 matched controls. Controls were matched based on disease severity as measured by the Acute Physiology and Chronic Health Evaluation (APACHE) II score (+/- 1 point), diagnostic category, and length of ICU stay before onset of candidemia. RESULTS In comparison with the control group, patients with candidemia developed more acute respiratory failure (97% [n = 71] vs. 88% [n = 129], P = 0.03) during their ICU stay. They were mechanically ventilated for a longer period (29 +/- 26 days vs. 19 +/- 19 days, P<0.01) and had a longer stay in the ICU (36 +/- 33 days vs. 25 +/- 23 days, P = 0.02) as well as in the hospital (77 +/- 81 days vs. 64 +/- 69 days, P = 0.04). There was no difference in in-hospital mortality between the groups (48% [n = 35] vs. 43% [n = 62], P = 0.44), a difference of 5% (95% confidence interval [CI]: -8% to 19%). In a multivariate analysis, older age (hazard ratio [HR] = 1.13 per 10 years; 95% CI: 1.04 to 1.23; P = 0.004), acute renal failure (HR = 1.4; 95% CI: 1.1 to 2.0; P = 0.02), and unfavorable APACHE II scores (HR = 1.10 per 5 points; 95% CI: 1.00 to 1.20; P = 0.05) were independent predictors of mortality. Candidemia was not associated with mortality in a model that adjusted for these factors (HR = 0.9; 95% CI: 0.7 to 1.2; P = 0.53). CONCLUSION Nosocomial candidemia does not adversely affect the outcome in ICU patients in whom mortality is attributable to age, the severity of underlying disease, and acute illness.

Use of continuous bispectral EEG monitoring to assess depth of sedation in ICU patients

Abstract Monitoring the depth of sedation in patients under intensive care is difficult. Clinical assessment by the different scoring systems produces insufficient information, especially once deeply sedated patients become unresponsive to any external stimulation. Recently, the bispectral index (BIS), the result of computerized bispectral electroencephalographic monitoring, was found to be the best predictor of depth of anaesthesia during surgical intervention. This report concerns BIS monitoring in 18 randomly selected, deeply sedated, surgical patients in the intensive care unit, who were unresponsive to standard clinical stimulation (Ramsay sedation score). A wide range of BIS was observed, with 15 of the patients having a BIS below 60, indicating a state of deep sedation (or possibly oversedation). Therefore, further studies using BIS monitoring in patients under intensive care are needed to determine if this method can guide sedation and prevent oversedation in this context and, most importantly, to analyse its final cost – benefit ratio.

Left ventricular systolic and diastolic function in septic shock.

SummaryObjective: The identification of myocardial dysfunction in septic shock has not yet been fully elucidated. We therefore studied patients with persistently vasopressor-dependent septic shock, both with invasive haemodynamic monitoring and transoesophageal two-dimensional and Doppler echocardiography (TEE). Design: Prospective study. Setting: General ICU in University Hospital. Patients and methods: All patients were monitored with arterial and pulmonary artery catheters. Haemodynamics were obtained concomitantly with TEE measurements. TEE was performed at three levels: a) a midpapillary short axis view of the left ventricle (LV) in order to measure end-systolic and end-diastolic areas; b) at the level of both the mitral valve for early (E) and late (A) filling parameters and c) the level of the right upper pulmonary vein for systolic (S) and diastolic (D) filling characteristics. Each parameter was characterised by maximal flow velocity and time velocity integral. Results: Although the measurements of cardiac index demonstrated a wide range, three subsets of patients were identified post hoc after analysis on the basis of different Doppler patterns: first, patients with a LV without regional wall motion abnormalities and both E/A and S/D greater than 1 (group 1); second, patients with a comparable haemodynamic condition, apparently normal LV systolic function but with altered Doppler patterns: S/D less than 1 in conjunction with E/A more than 1 (group 2); finally, patients with compromised global LV systolic function, E/A less than 1 and S/D less than (group 3). Conclusions: Notwithstanding the known various interfering factors which limit the broad applicability of TEE to determine LV function in septic shock, our data suggest that cardiac dysfunction in septic shock shows a continuum from isolated diastolic dysfunction to both diastolic and systolic ventricular failure. These data strengthen the need of including the evaluation of pulmonary venous Doppler parameters in each investigation in order to obtain supplementary information to interpret diastolic function of the LV in septic shock patients.

Clinical relevance of Aspergillus isolation from respiratory tract samples in critically ill patients

IntroductionThe diagnosis of invasive pulmonary aspergillosis, according to the criteria as defined by the European Organisation for the Research and Treatment of Cancer/Mycoses Study Group (EORTC/MSG), is difficult to establish in critically ill patients. The aim of this study is to address the clinical significance of isolation of Aspergillus spp. from lower respiratory tract samples in critically ill patients on the basis of medical and radiological files using an adapted diagnostic algorithm to discriminate proven and probable invasive pulmonary aspergillosis from Aspergillus colonisation.MethodsUsing a historical cohort (January 1997 to December 2003), all critically ill patients with respiratory tract samples positive for Aspergillus were studied. In comparison to the EORTC/MSG criteria, a different appreciation was given to radiological features and microbiological data, including semiquantitative cultures and direct microscopic examination of broncho-alveolar lavage samples.ResultsOver a 7 year period, 172 patients were identified with a positive culture. Of these, 83 patients were classified as invasive aspergillosis. In 50 of these patients (60%), no high risk predisposing conditions (neutropenia, hematologic cancer and stem cell or bone marrow transplantation) were found. Typical radiological imaging (halo and air-crescent sign) occurred in only 5% of patients. In 26 patients, histological examination either by ante-mortem lung biopsy (n = 10) or necropsy (n = 16) was performed, allowing a rough estimation of the predictive value of the diagnostic algorithm. In all patients with histology, all cases of clinical probable pulmonary aspergillosis were confirmed (n = 17). Conversely, all cases classified as colonisation had negative histology (n = 9).ConclusionA respiratory tract sample positive for Aspergillus spp. in the critically ill should always prompt further diagnostic assessment, even in the absence of the typical hematological and immunological host risk factors. In a minority of patients, the value of the clinical diagnostic algorithm was confirmed by histological findings, supporting its predictive value. The proposed diagnostic algorithm needs prospective validation.

Nosocomial Bacteremia Caused by Antibiotic-Resistant Gram-Negative Bacteria in Critically Ill Patients: Clinical Outcome and Length of Hospitalization

Population characteristics and outcomes were retrospectively compared for critically ill patients with nosocomial bacteremia caused by antibiotic-susceptible (AB-S; n=208) or antibiotic-resistant (AB-R; n=120) gram-negative bacteria. No significant differences in severity of illness and comorbidity factors were seen between groups. Patients with bacteremia caused by AB-R strains had a longer hospitalization before the onset of the bacteremia. The in-hospital mortality for patients with bacteremia caused by AB-S strains was 41.8%; for patients infected with AB-R strains, it was 45.0% (P=.576). A multivariate survival analysis demonstrated that older age (P=.009), a high-risk source of bacteremia (abdominal and lower respiratory tract; P=.031), and a high acute physiology and chronic health evaluation II-related expected mortality (P=.032) were independently associated with in-hospital mortality (P<.05). Antibiotic resistance in nosocomial bacteremia caused by gram-negative bacteria does not adversely affect the outcome for critically ill patients.

Nosocomial bacteremia involving Acinetobacter baumannii in critically ill patients: a matched cohort study

ObjectiveTo determine outcome and attributable mortality in critically ill patients with nosocomial bacteremia involving A. baumannii.DesignA retrospective matched cohort study in which all ICU patients with microbiologically documented A. baumannii bacteremia were defined as cases. Matching of the controls was based on equivalent APACHE II score (±2 points) and diagnostic category. Control patients were required to have an ICU stay equivalent to or longer than the case prior to onset of the bacteremia.SettingThe 54–bed ICU of the 1060-bed Ghent University Hospital.Patients45 ICU patients with A. baumannii bacteremia and 90 matched control subjects without clinical or microbiological evidence of blood stream infection.MeasurementsPopulation characteristics and in-hospital mortality rates of patients with A. baumannii bacteremia and their controls were compared. Attributable mortality is determined by subtracting the crude mortality rate of the controls from the crude mortality rate of the cases.ResultsPatients with A. baumannii bacteremia had significantly more hemodynamic instability, longer ICU stay, and longer length of ventilator dependence than controls. In-hospital mortality rates for cases and controls were, respectively, 42.2% and 34.4%; thus the attributable mortality was 7.8%.ConclusionIn critically ill patients A. baumannii bacteremia is not associated with a significantly increased mortality rate.

Fungal Infections in Patients with Severe Acute Pancreatitis and the Use of Prophylactic Therapy

Data from an 8-year period for 46 patients with severe acute pancreatitis and infected pancreatic necrosis were analyzed to determine the incidence of fungal infection, to identify risk factors for the development of fungal infection, and to assess the use of early fluconazole treatment. Intraabdominal fungal infection was found in 17 (37%) of 46 patients. Candida albicans was isolated most frequently (15 patients); Candida tropicalis and Candida krusei were found in 1 patient each. Characteristics of patients with fungal infection were not different from patients without fungal infection. The difference in mortality was not statistically significant between patients with fungal infection and patients without fungal infection. Early antifungal therapy (prophylactic or preemptive antifungal therapy) was administered to 18 patients, and only 3 of them developed fungal infection. In this cohort of critically ill patients, no risk factors for fungal infection could be demonstrated, and mortality among patients who received early antifungal therapy was not different. Early treatment with fluconazole seems to prevent fungal infection in these high-risk patients.