Philipp Metnitz

Ratios of observed to expected mortality are affected by differences in case mix and quality of care

Abstract Objectives: To validate SAPSxa0II-AM, a recently customized version of the Simplified Acute Physiology Score II (SAPSxa0II) in a larger cohort of Austrian intensive care patients and to evaluate the effect of the customization process on the ratio of observed to expected mortality.n Design: Prospective, multicentric cohort study.n Patients and setting: A total of 2901xa0patients consecutively admitted to 13 adult medical, surgical, and mixed intensive care units (ICUs) in Austria.n Measurements and results: After the database was divided randomly into a development sample (n=1450) and a validation sample (n=1451), logistic regression was used to develop a new model (SAPSxa0II-AM2). The original SAPSxa0II, the SAPSxa0II-AM, and the newly developed SAPSxa0II-AM2 were then compared by means of calibration, discrimination and O/E ratios. Differences in O/E ratios before and after customization (ΔO/E) were calculated. The Hosmer-Lemeshow goodness-of-fit Ĥ and Ĉ statistics revealed poor calibration of the original SAPSxa0II on the database. The new model, SAPSxa0II-AM2, performed better than the SAPSxa0II-AM and excellent in the validation data set. However, mean O/E ratios varied widely among diagnostic categories (range 0.55–1.05 for the SAPSxa0II). Moreover, the ΔO/E of the 13 ICUs ranged from –3.6% to +25%.n Conclusions: Todays severity scoring systems, such as the SAPSxa0II, are limited by not measuring (and adjusting for) a profound part of what constitutes case mix. Changes in the distribution of patient characteristics (known and unknown) therefore affect prognostic accuracy. First-level customization was not able to solve all these problems. Using O/E ratios for quality of care comparisons one must therefore be critical when using these data and should search for possible confounding factors. In the case of unsatisfactory calibration, customized severity of illness models may be useful as an adjunct for quality control.

Evaluation of the logistic organ dysfunction system for the assessment of organ dysfunction and mortality in critically ill patients

Abstract. Objectives: To evaluate the performance of the logistic organ dysfunction (LOD) system for the assessment of morbidity and mortality in multiple organ dysfunction/failure (MOD/F) in an independent database and to evaluate the use of sequential LOD measurements for the prediction of outcome. Design and setting: Prospective, multicentric cohort study in 13 adult medical, surgical, and mixed intensive care units (ICUs) in Austria. Patients: A total of 2893 consecutive admissions to the ICUs. Measurements and main results: Patient vital status at ICU and hospital discharge was recorded. Univariate analysis showed that the LOD was able to distinguish between survivors and nonsurvivors (2 vs. 6 median score). Within organ systems, higher levels of the severity of organ dysfunction were consistently associated with higher mortality. For the prediction of hospital mortality, the original prognostic LOD model did not perform well in our patients, as indicated by the goodness-of-fit Ĉ statistic. Using multiple logistic regression we developed a prognostic model with a satisfactory fit in our patients. The integration of further measurements during the ICU stay increased discrimination but not calibration. Conclusions: The LOD system is well correlated well with the numbers and levels of organ dysfunctions and discriminates well between survivors and nonsurvivors. It can thus be used to quantify the baseline severity of organ dysfunction. Moreover, after customization of the predictive equation the LOD predicted hospital mortality in our patients with high precision. It thus provides a combined measure of morbidity and mortality for critically ill patients with MOD/F.

Year in review in Intensive Care Medicine, 2008: II. Experimental, acute respiratory failure and ARDS, mechanical ventilation and endotracheal intubation

Year in review in Intensive Care Medicine, 2008 : II. Experimental, acute respiratory failure and ARDS, mechanical ventilation and endotracheal intubation

Year in Review in Intensive Care Medicine, 2006. III. Circulation, ethics, cancer, outcome, education, nutrition, and pediatric and neonatal critical care.

Received: 22 January 2007Accepted: 22 January 2007Published online: 14 February 2007© Springer-Verlag 2007This review intends tosummarize all articlespublished in Intensive Care Medicine in2006, grouped by specific topicsP. AndrewsWestern General Hospital, Intensive CareMedicine Unit,Edinburgh, UKE. AzoulaySaint Louis Hospital, Intensive CareMedicine Unit,Paris, FranceM. AntonelliUniversita Cattolica del Sacre Cuore,Department of Intensive Care andAnesthesiology,Rome, ItalyL. Brochard (✉)AP-HP, Hopital Henri Mondor, UniversiteParis 12, Reanimation Medicale, INSERMU 651,94000 Creteil, Francee-mail: laurent.brochard@hmn.aphp.frTel.: +33-1-49812545Fax: +33-1-42079943C. Brun-BuissonAP-HP, Hopital Henri Mondor, UniversiteParis 12, Reanimation Medicale,Creteil, FranceD. De BackerErasme Hospital, Service des SoinsIntensifs,Brussels, BelgiumG. DobbRoyal Perth Hospital, Intensive CareMedicine Unit,Perth, AustraliaJ.-Y. FagonEuropean Georges Pompidou Hospital,Intensive Care Medicine Unit,H. GerlachVivantes-Klinikum Neukoelln, Departmentof Anesthesiology,Berlin, GermanyJ. GroeneveldVUMC, Intensive Care Medicine Unit,Amsterdam, The NetherlandsD. MacraeRoyal Brompton Hospital, PediatricIntensive Care Unit,London, UKJ. ManceboHospital Sant Pau, Intensive Care MedicineUnit,Barcelona, SpainP. MetnitzUniversity Hospital of Vienna, Departmentof Anesthesia and General Intensive CareMedicine,Vienna, AustriaS. NavaFondazione S. Maugeri, Intensive CareMedicine Unit,Pavia, ItalyJ. PuginUniversity Hospital of Geneva, IntensiveCare Medicine Unit,Geneva, SwitzerlandM. PinskyUniversity of Pittsburgh Medical Center,Intensive Care Medicine Unit,Pittsburgh Pennsylvania, USAP. RadermacherUniversity Medical School of Ulm,Department of Anesthesia,Ulm, GermanyC. RichardUniversity Hospital of Le Kremlin-Bicetre,Intensive Care Unit,Le Kremlin-Bicetre, France

Year in review in Intensive Care Medicine, 2006. I. Experimental studies. Clinical studies: brain injury, renal failure and endocrinology

Peter Andrews Elie Azoulay Massimo Antonelli Laurent Brochard Christian Brun-Buisson Daniel De Backer Geoffrey Dobb Jean-Yves Fagon Herwig Gerlach Johan Groeneveld Duncan Macrae Jordi Mancebo Philipp Metnitz Stefano Nava Jerôme Pugin Michael Pinsky Peter Radermacher Christian Richard Year in review in Intensive Care Medicine, 2006. I. Experimental studies. Clinical studies: brain injury, renal failure and endocrinology

Year in review in Intensive Care Medicine, 2007. III. Ethics and legislation, health services research, pharmacology and toxicology, nutrition and paediatrics.

Year in review in Intensive Care Medicine, 2007. III. Ethics and legislation, health services research, pharmacology and toxicology, nutrition and paediatrics

Year in review in Intensive Care Medicine, 2008 : III. Paediatrics, Ethics, outcome research and critical care organization, sedation, pharmacology and miscellanea

Year in review in Intensive Care Medicine, 2008 : III. Paediatrics, Ethics, outcome research and critical care organization, sedation, pharmacology and miscellanea

Year in review in Intensive Care Medicine, 2007. II. Haemodynamics, pneumonia, infections and sepsis, invasive and non-invasive mechanical ventilation, acute respiratory distress syndrome

Year in review in Intensive Care Medicine, 2007. II. Haemodynamics, pneumonia, infections and sepsis, invasive and non-invasive mechanical ventilation, acute respiratory distress syndrome

Metabolic Alterations in Burn Trauma - Pathophysiology and Therapy

Compared to other trauma patients, burn trauma victims show alterations that require special attention. The burn trauma modifies several physiologic processes. Metabolic regulation presents itself as one of the major problems. The first part of this review deals with the metabolic pathophysiology of severe burn trauma and its clinical impact. At the end we present possible therapeutic interventions with their mode of action and common side effects.

Year in review in Intensive Care Medicine, 2007. I. Experimental studies. Clinical studies : brain injury and neurology, renal failure and endocrinology

Year in review in Intensive Care Medicine, 2007. I. Experimental studies. Clinical studies : brain injury and neurology, renal failure and endocrinology