Kurt Lenz

Prognostic performance and customization of the SAPS II: results of a multicenter Austrian study

Objectives: To evaluate the prognostic performance of the original Simplified Acute Physiology Score (SAPS) II in Austrian intensive care patients and to evaluate the impact of customization. Design: Analysis of the database of a multicenter study. Setting: Nine adult medical, surgical, and mixed intensive care units (ICUs) in Austria. Patients: A total of 1733 patients consecutively admitted to the ICUs. Measurements and results: The database included admission data, SAPS II, length of stay, and hospital mortality. The Hosmer–Lemeshow goodness-of-fit test for the SAPS II showed a lack of uniformity of fit (H = 89.1, 10 df, p < 0.0001; C = 91.8, 10 df, p < 0.0001). Subgroup analysis showed good performance in patients with cardiovascular (medical and surgical) diseases as the primary reasons for admission. A new predictive equation was derived by means of the logistic regression. Goodness-of-fit was excellent for the customized model (SAPS IIAM) (H = 11.2, 9 df, p = 0.33, C = 11.6, 9 df, p = 0.24). The mean standardized mortality ratio (SMR) changed from 0.81 ± 0.26 to 0.93 ± 0.29 with customization. Conclusions: SAPS II was not well calibrated when applied to all patients. However, it performed well for patients with cardiovascular diseases as the primary reason for admission and may thus be applied to these patients. Standardized mortality ratios that are calculated from scoring systems without known calibration must be viewed with skepticism.

Evaluation of an interdisciplinary data set for national intensive care unit assessment

OBJECTIVES To evaluate the ability of an interdisciplinary data set (recently defined by the Austrian Working Group for the Standardization of a Documentation System for Intensive Care [ASDI]) to assess intensive care units (ICUs) by means of the Simplified Acute Physiology Score II (SAPS II) for the severity of illness and the simplified Therapeutic Intervention Scoring System (TISS-28) for the level of provided care. DESIGN A prospective, multicentric study. SETTING Nine adult medical, surgical, and mixed ICUs in Austria. PATIENTS A total of 1234 patients consecutively admitted to the ICUs. INTERVENTIONS Collection of data for the ASDI data set. MEASUREMENTS AND MAIN RESULTS The overall mean SAPS II score was 33.1+/-2.1 points. SAPS II overestimated hospital mortality by predicting mortality of 22.2%+/-2.9%, whereas observed mortality was only 16.8%+/-2.2%. The Hosmer-Lemeshow goodness-of-fit test for SAPS II scores showed lacking uniformity of fit (H = 53.78, 8 degrees of freedom; p < .0001). TISS-28 scores were recorded on 8616 days (30.6+/-1.5 points). TISS-28 scores were higher in nonsurvivors than in survivors (30.4+/-0.9 vs. 25.7+/-0.4, respectively; p < .05). No significant correlation between mean TISS-28 per patient per unit on the day of admission and mean predicted hospital mortality (r2 = .23; p < .54) or standardized mortality ratio per unit (r2 = -.22; p < .56) was found. CONCLUSIONS Implementation of an interdisciplinary data set for ICUs provided data with which to evaluate performance in terms of severity of illness and provided care. The SAPS II did not accurately predict outcomes in Austrian ICUs and must, therefore, be customized for this population. A combination of indicators for both severity of illness and amount of provided care is necessary to evaluate ICU performance. Further data acquisition is needed to customize the SAPS II and to validate the TISS-28.

Short-term prognosis in critically ill patients with liver cirrhosis: an evaluation of a new scoring system.

Objective The mortality of patients with liver cirrhosis admitted to an intensive care unit (ICU) has been found to be high. This study was performed to assess the physiological and laboratory parameters which are able to identify on ICU admission the cirrhotic patients who are most likely to die. Design Prospective clinical trial. Methods Two groups of patients were analysed. Group A consisted of 196 consecutive cirrhotic patients admitted to our medical ICU for various reasons. For the detection of independent outcome predictors, we used a multiple logistic regression model. Based on these variables, the ‘intensive care cirrhosis outcome (ICCO) score’ was calculated. The ability to discriminate between survivors and non‐survivors was determined by receiver operating characteristic curves, and the area under the curve was calculated. Group B consisted of 70 consecutive cirrhotic patients for prospective validation of the ICCO score. Results Applying multiple logistic regression analysis, bilirubin, cholesterol, creatinine clearance and lactate were found to be independently associated with the hospital mortality. The ICCO score was 0.3707 + (0.0773 × bilirubin (mg/dl)) − (0.00849 × cholesterol (mg/dl)) − (0.0155 × creatinine clearance (ml/min)) + (0.1351 × lactate (mmol/l)), giving an area under a receiver operating characteristic curve of 0.9. Increasing score values were associated with an increase in mortality. All patients with an ICCO score > +2.6 died. Conclusions Application of the ICCO score is rapid and available at the patients bedside, and its application is simple and reproducible. In cirrhotic patients, the ICCO score has a high ability to discriminate between survivors and non‐survivors. The ICCO score may facilitate estimation on ICU admission of the prognosis of critically ill cirrhotic patients. Eur J Gastroenterol Hepatol 12:517‐522

Lactic acid kinetics in respiratory alkalosis

Objective:To evaluate the impact of respiratory alkalosis on the elimination of intravenously infused lactate. Design:Prospective, randomized, crossover study. Setting:Medical ICU of a university hospital. Patients:Eight patients treated by ventilatory support for neurologic or neuromuscular diseases. Interventions:Patients were investigated on two occasions: during normoventilation (pH7.42±0.1, Pco241 ± 2torr[5.5 ± 0.2kPa])and during respiratory alkalosis (pH 7.59 ± 0.1, Pco2 27 ± 2 torr [3.6 ± 0.2 kPa]) induced by controlled hyperventilation. To evaluate lactate elimination kinetics, 1 mmol/kg body weight of L-lactic acid was infused over 5 mins. Measurements and Main Results:Arterial lactate concentrations and blood gas values were determined before and repeatedly after the infusion. Lactate elimination variables were calculated from the plasma curve by using a two-compartment model. Respiratory alkalosis increased plasma lactate from 1.56 ± 0.1 to 2.49 ± 0.2 mmol/L (p < .001). The lactate elimination half-life increased from 4.57 ± 0.2 mins at pH 7.42, to 9.96 ± 1.1 mins during pH 7.59 (p < .01), and β half-life increased from 12.2 ± 1.9 to 44.1 ± 1 mins (p < .01). Whole-body clearance decreased 40% from 24.2 ± 2.9 to 14.3 ± 2.0 mL/kg body weight-min (p < .01). Conclusions:Respiratory alkalosis increases the basal concentration of plasma lactate and decreases clearance of infused lactic acid. These findings provide further evidence of the adverse effects of alkalosis.

Prognostic value of soluble ST2 in an unselected cohort of patients admitted to an intensive care unit — The Linz Intensive Care Unit (LICU) study

BACKGROUND Soluble ST2 (sST2) has emerged as a prognostic biomarker in patients with heart disease. We tested the hypothesis that sST2 is an independent predictor of mortality in patients admitted to an intensive care unit (ICU). METHODS We performed measurements of sST2 plasma concentrations in 530 consecutive patients admitted to a medical ICU of a tertiary care hospital during a study period of one year. The patients recruited during the first six months were used for the derivation cohort (n=274) and the patients recruited during the second six months were used for the validation cohort (n=256). The endpoint was defined as 90-day all-cause mortality. RESULTS In the derivation cohort, sST2 was higher among decedents (n=56; median, 146 U/mL) than survivors (n=218; median 42 U/mL, p<0.001). In multivariate Cox proportional-hazard regression analysis (offering age, sex, BMI, APACHE II score, SAPS II, CRP, IL-6, PCT, creatinine, total cholesterol, albumin, hs-cTnT, BNP and sST2 as independent variables), sST2 was a significant predictor of mortality (risk ratio 1.48, 95% CI 1.15-1.90; p=0.002 per 1 SD increase in log transformed values). In this statistical model, only sST2 and SAPS II contributed independently to mortality prediction. We further observed an additive effect of an sST2 plasma concentration of >84 U/mL and an increased SAPS II for mortality prediction. The findings from the derivation cohort were confirmed in the independent validation cohort. In those patients with a length of stay of >48 h at the ICU (n=225), sST2 obtained two days after baseline measurement had a better capability than baseline sST2 to predict mortality. CONCLUSIONS In an unselected cohort of patients admitted to the ICU, sST2 was an independent predictor of 90-day all-cause mortality and added prognostic information to the SAPS II.

Treatment and management of ascites and hepatorenal syndrome: an update

Ascites and renal dysfunction are frequent complications experienced by patients with cirrhosis of the liver. Ascites is the pathologic accumulation of fluid in the peritoneal cavity, and is one of the cardinal signs of portal hypertension. The diagnostic evaluation of ascites involves assessment of its granulocyte count and protein concentration to exclude complications such as infection or malignoma and to allow risk stratification for the development of spontaneous peritonitis. Although sodium restriction and diuretics remain the cornerstone of the management of ascites, many patients require additional therapy when they become refractory to this treatment. In this situation, the treatment of choice is repeated large-volume paracentesis. Alteration in splanchnic hemodynamics is one of the most important changes underlying the development of ascites. Further splanchnic dilation leads to changes in systemic hemodynamics, activating vasopressor agents and leading to decreased renal perfusion. Small alterations in renal function influence the prognosis, which depends on the cause of renal failure. Prerenal failure is evident in about 70% of patients, whereas in about 30% of patients the cause is hepatorenal syndrome (HRS), which is associated with a worse prognosis. Therefore, effective therapy is of great clinical importance. Recent data indicate that use of the new definition of acute kidney injury facilitates the identification and treatment of patients with renal insufficiency more rapidly than use of the current criteria for HRS. In this review article, we evaluate approaches to the management of patients with ascites and HRS.

Rapid transition from methadone maintenance to naltrexone

SIR,-Dr Brewer and Dr Mathew (Sept 16, p 683) combine clonidine and naltrexone for rapid induction to naltrexone maintenance, but report severe side-effects and do not discuss clean urine samples as a criterion for successful detoxification treatment. We have described a humane and effective method of detoxification, with the drawback that trained staff and complex technical equipment are needed.l,2 To produce a safe, rapid, successful, painless, and economic alternative treatment we used

Interleukin 6, galectin 3, growth differentiation factor 15, and soluble ST2 for mortality prediction in critically ill patients

PURPOSE The aim of this study was to compare the prognostic value of interleukin 6 (IL-6), galectin 3, growth differentiation factor 15 (GDF-15), and soluble ST2 (sST2) in an unselected cohort of critically ill patients. METHODS During a study period of 1 year, we recruited 530 consecutive patients admitted to a medical intensive care unit of a tertiary care hospital. We examined a combination of inflammatory, renal, and cardiac biomarkers for the prediction of 90-day all-cause mortality. RESULTS During follow-up, 118 patients died (22%). In univariate analyses, increased IL-6, galectin 3, GDF-15, and sST2 plasma concentrations at baseline were strong prognostic markers. However, in the multivariate models, only IL-6 and sST2 remained independent biomarkers adding additional prognostic information to the routinely used Simplified Acute Physiology Score (SAPS) II. Using a simple multimarker approach, patients with increased SAPS II, IL-6, and sST2 (ie, SAPS II >35, IL-6 >32.3pg/mL, and sST2 >103ng/mL) had the poorest outcome. CONCLUSIONS In this heterogeneous group of critically ill patients, only SAPS II, IL-6, and sST2 remained independent and additive prognostic markers for 90-day all-cause mortality. A combination of the SAPS II with the 2 complementary biomarkers might provide a valuable tool for risk stratification of critically ill patients.

[Steatohepatitis and cirrhosis: first manifestation 23 years after jejunoileal bypass surgery].

SummaryIntestinal shunting procedures followed by gastrointestinal bypass surgery have been used as therapeutic modalities in the treatment of morbid obesity since the mid 1950s. Enthusiasm reached its peak in the early 1960s with the introduction of the jejunoileal bypass, however began to vane as various complications were identified in the remote postoperative period and later. Finally, the jejunoileal bypass was abandoned in the 1980s. Apart from renal disorders, it frequently resulted in abnormal liver function and liver failure which are attributed to fatty infiltration. We report a 56-year-old woman, who underwent jejunoileal bypass surgery 23 years ago. She was admitted to our ICU because of hepatic encephalopathy IV, caused by upper gastrointestinal bleeding. Beside hepatic encephalopathy there were signs of severe liver failure (INR 2.8, cholesterol 32 mg/dl, ICG PDR 5%). Liver biopsy showed fatty infiltration and cirrhosis. Excluding other causes of liver disease, severe fatty liver disease following jejunoileal bypass surgery was diagnosed. The very late onset of severe liver disease emphasizes the importance of lifelong follow-up of these patients.ZusammenfassungGastrointestinale Shunt-Operationen werden seit Mitte der 50er Jahre zur Behandlung der Adipositas per magna durchgeführt. Der Jejunoileale Bypass kam zwischen den frühen 60er und 80er Jahren als bariatrisches Verfahren zum Einsatz, wurde jedoch aufgrund schwerer hepatischer und nephrologischer Komplikationen wieder verlassen. Eine bisher beschwerdefreie 56-jährige Patienten, die sich vor 23 Jahren einer Jejunoilealen Bypassoperation unterzogen hatte, wurde wegen eines akuten Leberversagens mit hepatischer Enzephalopathie IV im Rahmen einer akuten oberen gastrointestinalen Blutung auf die Intensivstation aufgenommen. Als Grunderkrankung fand sich in der histologischen Aufarbeitung der Leberbiopise eine Steatohepatitis mit zirrhotischem Umbau. Die Syntheseparameter (INR 2,8, Cholesterin 32 mg/dl) und die ICG PDR 5% zeigten das Bild einer schweren Leberinsuffizienz. Nach Ausschluss anderer Ursachen wurde die Steatohepatitis mit zirrhotischem Umbau als Folge des jejunoilealen Bypass interpretiert. Das ausgesprochen späte Auftreten dieser postoperativen Komplikation verdeutlicht die Notwendigkeit zur konsequenten, lebenslangen Überwachung von Patienten mit einem Jejunoilealen Bypass, auch bei subjektivem Wohlbefinden.Intestinal shunting procedures followed by gastrointestinal bypass surgery have been used as therapeutic modalities in the treatment of morbid obesity since the mid 1950s. Enthusiasm reached its peak in the early 1960s with the introduction of the jejunoileal bypass, however began to wane as various complications were identified in the remote postoperative period and later. Finally, the jejunoileal bypass was abandoned in the 1980s. Apart from renal disorders, it frequently resulted in abnormal liver function and liver failure which are attributed to fatty infiltration. We report a 56-year-old woman, who underwent jejunoileal bypass surgery 23 years ago. She was admitted to our ICU because of hepatic encephalopathy IV, caused by upper gastrointestinal bleeding. Beside hepatic encephalopathy there were signs of severe liver failure (INR 2.8, cholesterol 32 mg/dl, ICG PDR 5%). Liver biopsy showed fatty infiltration and cirrhosis. Excluding other causes of liver disease, severe fatty liver disease following jejunoileal bypass surgery was diagnosed. The very late onset of severe liver disease emphasizes the importance of lifelong follow-up of these patients.

Hemodynamic, pulmonary, and renal reactions to inadvertent transfusion of outdated blood.

A patient who received an erroneous transfusion of outdated and partly homogenized blood is reported. Although marked hemoglobinemia was present, only transient hemodynamic, pulmonary, and renal alterations were observed. Massive embolism of microaggregates and norepinephrine release might explain our findings. Dopamine (3 micrograms/kg . min) might have beneficial effects on renal function in this pseudohemolytic transfusion reaction.