Philippe Loirat

Acute renal failure in intensive care units--causes, outcome, and prognostic factors of hospital mortality: A prospective, multicenter study

ObjectiveTo assess the causes, the prognostic factors, and the outcome of patients with severe acute renal failure.DesignProspective, multicenter study.SettingTwenty French multidisciplinary intensive care units (ICUs).PatientsAll patients with severe acute renal failure were prospectively enrolled

A COMPARISON OF INTENSIVE CARE IN THE U.S.A. AND FRANCE

Abstract 1260 emergency admissions to the intensive-care units (ICUs) of five U.S.A. and seven French tertiary-care hospitals were surveyed by means of a standard severity-of-illness classification system. The 586 patients admitted to French ICUs were significantly younger than the 674 U.S.A. patients, more had been transferred from another hospital, and they remained in the ICU twice as long. Although actual death rates, severity of illness, and the amount of treatment were extremely similar, fewer French than U.S.A. patients were admitted for observation and monitoring. Invasive monitoring was used less in French patients than in U.S.A. patients. The mortality predicted for French patients if they had been treated in the U.S.A. was similar to the observed mortality in the three most frequent indications for ICU admission (cardiovascular, respiratory, and neurological organ-system failure) but was lower than the observed death rate for French gastrointestinal patients. These results suggest that future international studies within separate diagnostic groups would provide insights into the value of many services now commonly used in the treatment of acutely ill patients.

Quality of life 6 months after intensive care: results of a prospective multicenter study using a generic health status scale and a satisfaction scale

Objective: To assess the quality of life of intensive care survivors 6 months after discharge. Design: Multicenter prospective study. Setting: Medical-surgical intensive care units (ICUs) of four French university hospitals. Patients: Among the 589 patients admitted to the four ICUs between 1 January and 31 March 1989, 329 were investigated. Measurements and results: A generic scale assessing health-related quality of life, the Nottingham Health Profile (NHP), a satisfaction scale, the Perceived Quality of Life scale (PQOL) and a questionnaire on professional status were sent by mail 6 months after discharge. Data concerning age, severity of acute illness (assessed by the Simplified Acute Physiology Score) and main diagnosis were recorded. A total of 223 questionnaires (67.8 %) were analysable. The professional status remained unchanged in 79.7 % of the patients, despite a significant (p < 0.01) increase (15.3 vs 22.1 %) in sick leave. Quality of life, assessed with NHP, was fair (50th percentile = 0.73 on a 0 to 1 scale), whereas satisfaction measured by PQOL was lower (50th percentile = 0.61). Both scales correlated well (z = 9.853; p = 0.0001) but with a large dispersion. The NHP scale showed a severe reduction in energy, sleep and emotional reactions, whereas social isolation, pain and physical handicap were infrequent. Family support was rated with the PQOL score as very good, whereas dissatisfaction concerning recreational and professional activities was expressed. Subsequent sick leave was associated with a poor quality of life (p < 0.05). Quality of life was mainly a function of the diagnosis, not of age and severity of illness: patients admitted for suicide attempt or chronic obstructive pulmonary disease fared poorly. Conclusions: Quality of life measured with a health-related quality of life scale and a satisfaction scale 6 months after an ICU stay depended on the admission diagnosis. Different dimensions of quality of life were variably affected.

Influence of patients' age on survival, level of therapy and length of stay in intensive care units

The influence of patients age on survival, level of therapy and length of stay was analyzed from data collected in 792 consecutive admissions to eight intensive care units. Mortality rate increased progressively with age; over 65 years of age, it was more than double that of patients under 45 years (36.8% versus 14.8%). However, mortality rate in patients over 75 years was equal to that observed in the 55 to 59 years group. There was a significant relationship between age and acute physiology score (APS) and the influence of age upon outcome decreased when APS increased. The number of TISS (therapeutic intervention scoring system) points delivered to patients increased slightly but significantly with age (r=0.14). Standard care was responsible for the main part of this increase. Both in survivors and in non-survivors the length of stay was not different comparing the stay of the oldest patients with that of the younger age groups. We conclude that, in ICU patients, age is an important factor of prognosis but not as important as the severity of illness, and that there is no major difference in outcome of patients over 65 years of age compared to the entire study group of ICU patients.

Evaluation of severity scoring systems in ICUs—translation, conversion and definition ambiguities as a source of inter-observer variability in Apache II, SAPS and OSF

ObjectiveTo explore translation, conversion and definition ambiguities, when using severity scoring systems in patients admitted to intensive care units (ICUs).DesignA prospective study of the prognosis of acute renal failure in ICUs.SettingThe study was conducted in 20 French ICUs.Patients360 patients presenting with severe acute renal failure were studied during their ICU stay.Measurements and resultsThe inter-observer variability of Apache II (acute physiology and chronic health evaluation), SAPS (simplified acute physiology score), and OSF (organ-system failure) was considered. For Apache II, we explored the uncertainty of measurements arising from conversion into SI units, the rounding procedures used for the non-inclusive intervals defined for quatitative parameters such as age, mean arterial pressure (MAP) or serum creatinite, the absence of definition of acute renal failure (ARF) and its consequence on doubling serum creatinine values, and the absence of guidelines in the case of spontaneous ventilation when arterial blood gases (ABG) and forced inspiratory oxygen (FIO2) were not measured. The resulting variability was evaluated, calculating the lowest and the highest value of the scoring system for each patient. The mean difference by patient was greater than 1.5 (p<0.0001). Other examples were presented and discussed for SAPS and OSF.ConclusionsTranslation, conversion and definition ambiguities are a source of inter-observer variability and increase the risk of classification and/or selection biases. This gives rise to particular concern in the design and analysis of multicenter trials or meta-analysis, and improvement of these scoring systems should be envisaged in the future.

Simplified Acute Physiology Score Ii for measuring severity of illness in intermediate care units

OBJECTIVES To assess the efficacy of the Simplified Acute Physiology Score (SAPS II) in intermediate care units. A number of patients hospitalized in the intensive care unit (ICU) could be hospitalized in alternative structures, intermediate care units, which are equipped to handle their monitoring needs and able to provide adequate treatment at a lower cost. Characterization of the patients relies on the assessment of their severity of illness by severity scores. The efficiency of severity scores has been established in ICU patients, but not in the setting of intermediate care units. DESIGN Prospective study. SETTING Intermediate care unit of a multidisciplinary hospital. PATIENTS Four hundred thirty-three patients admitted to the intermediate care unit. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 561 consecutive patients admitted to the intermediate care unit during a 12-mo period, 433 patients could be included in the analysis. Patients were admitted from the emergency ward (60.9%). Of the study patients, 60.9% were admitted from the emergency ward for mostly (96%) medical reasons. Average length of stay was 3.1 +/- 2.3 (SD) days. Death rate in the intermediate care unit was 2.7% (n = 11). Average SAPS II was 22.3 +/- 12.0 (range 6 to 73). Hospital death rate was 8.1%, whereas the expected mortality rate derived from SAPS II was 8.7%. To assess the performance of the system, a formal goodness-of-fit test was performed to evaluate calibration. Calibration was accurate using the C coefficient of Hosmer-Lemeshow statistics (C = 2.4; p> 0.5). The discriminant power of SAPS II, measured by the area under the receiver operating characteristic curve was excellent (0.85 +/- 0.04). CONCLUSIONS The SAPS II assessment of severity of illness in patients admitted to an intermediate care unit is reliable. These results will need to be confirmed, using different patient samplings from intermediate care units.

Do objectiue Estimates of chances for Survival Influence Decisions to Withhold or Withdraw Treatment

The authors studied the impact on clinical decision making of providing feedback of objective prognostic information describing the probability of survival for ICU patients with multiple organ system failure (OSF). The prognostic estimates, derived from a control period (1), were to be provided on a daily basis to physicians providing treatment in 25 French ICUs during a subsequent experimental period (2). The types of, frequencies of, and reasons for decisions to limit or stop treatment in the two periods were compared. In the experimental period 2, 17 ICUs participated in the feedback study. Within these 17 units, there was a small but significant (p <0.05) increase in decisions to stop active treatment and provide comfort care that was limited to patients with three or more OSFs. There was no change in decision making in the eight units that did not participate in the feedback study. Although these results suggest a direct causal relationship between the provision of objective prog nostic data and changes in physician decision making, the small increase in comfort care decisions (n = 14) between period 1 and period 2 and the fact that only 17 of the 25 original units participated in the feedback study make it difficult to eliminate other influences. There was no indication in this study, however, that explicit provision of prognostic data led to a sense of therapeutic futility. Key words: prediction; feedback; outcome; prognosis; organ system failure; treatment decisions. (Med Decis Making 1990;10:163-171)

Prognosis for Recovery from Multiple Organ system failure The Accuracy of Objective Estimates of Chances for Survival

This study evaluated the accuracy and reliability of predictions for recovery from multiple organ system failure (OSF). A previous analysis had provided estimates of the probabilities of recovery from various combinations of OSF for 2,843 intensive care unit (ICU) patients treated in 13 U.S. hospitals. These estimates were applied prospectively to 2,405 ICU admissions in 27 French hospitals. Despite variations in the incidences of underlying disease and the distributions of OSF between the two countries, clinical outcomes were similar for the 5,248 total patients. In both countries, two OSFs persisting for more than one day resulted in a hospital death rate of 60%. Hospital mortality rates for patients with three or more OSFs persisting after one day consistently exceeded 90%. Isolated neurologic failure had the poorest overall prognosis, but various other combinations of OSFs did not result in signifi cantly different outcomes. The stability of the prognostic estimates in the two countries suggests that, despite pathogenetic variations, persistent multiple OSF results in consistent clinical outcomes. These mortality projections provide firm reference data for assessing efficacy of new treatments within institutions with similar standards of care. The narrow confidence intervals associated with these estimates also provide objectively defined op portunities to review future treatment plans for individual patients. Key words: prediction; mortality; outcome; prognosis; organ system failure. (Med Decis Making 1990;10:155-162)

Biocompatible dialysis membrane in acute renal failure: The best choice

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