Lung Injury Prediction Score in Hospitalized Patients at Risk of Acute Respiratory Distress Syndrome.

OBJECTIVE: The Lung Injury Prediction Score identifies patients at risk for acute respiratory distress syndrome in the emergency department, but it has not been validated in non-emergency department hospitalized patients. We aimed to evaluate whether Lung Injury Prediction Score identifies non-emergency department hospitalized patients at risk of developing acute respiratory distress syndrome at the time of critical care contact. DESIGN: Retrospective study. SETTING: Five academic medical centers. PATIENTS: Nine hundred consecutive patients (≥ 18 yr old) with at least one acute respiratory distress syndrome risk factor at the time of critical care contact. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Lung Injury Prediction Score was calculated using the worst values within the 12 hours before initial critical care contact. Patients with acute respiratory distress syndrome at the time of initial contact were excluded. Acute respiratory distress syndrome developed in 124 patients (13.7%) a median of 2 days (interquartile range, 2-3) after critical care contact. Hospital mortality was 22% and was significantly higher in acute respiratory distress syndrome than non-acute respiratory distress syndrome patients (48% vs 18%; p < 0.001). Increasing Lung Injury Prediction Score was significantly associated with development of acute respiratory distress syndrome (odds ratio, 1.31; 95% CI, 1.21-1.42) and the composite outcome of acute respiratory distress syndrome or death (odds ratio, 1.26; 95% CI, 1.18-1.34). A Lung Injury Prediction Score greater than or equal to 4 was associated with the development of acute respiratory distress syndrome (odds ratio, 4.17; 95% CI, 2.26-7.72), composite outcome of acute respiratory distress syndrome or death (odds ratio, 2.43; 95% CI, 1.68-3.49), and acute respiratory distress syndrome after accounting for the competing risk of death (hazard ratio, 3.71; 95% CI, 2.05-6.72). For acute respiratory distress syndrome development, the Lung Injury Prediction Score has an area under the receiver operating characteristic curve of 0.70 and a Lung Injury Prediction Score greater than or equal to 4 has 90% sensitivity (misses only 10% of acute respiratory distress syndrome cases), 31% specificity, 17% positive predictive value, and 95% negative predictive value. CONCLUSIONS: In a cohort of non-emergency department hospitalized patients, the Lung Injury Prediction Score and Lung Injury Prediction Score greater than or equal to 4 can identify patients at increased risk of acute respiratory distress syndrome and/or death at the time of critical care contact but it does not perform as well as in the original emergency department cohort.

The association between acute respiratory distress syndrome, delirium, and in-hospital mortality in intensive care unit patients.

RATIONALE: Both acute respiratory distress syndrome (ARDS) and intensive care unit (ICU) delirium are associated with significant morbidity and mortality. However, the risk of delirium and its impact on mortality in ARDS patients is unknown. OBJECTIVES: To determine if ARDS is associated with a higher risk for delirium compared with respiratory failure without ARDS, and to determine the association between ARDS and in-hospital mortality after adjusting for delirium. METHODS: Prospective observational cohort study of adult ICU patients admitted to two urban academic hospitals. MEASUREMENTS AND MAIN RESULTS: Delirium was assessed daily using the Confusion Assessment Method for the ICU and Richmond Agitation and Sedation Scale. Of the 564 patients in our cohort, 48 had ARDS (9%). Intubated patients with ARDS had the highest prevalence of delirium compared with intubated patients without ARDS and nonintubated patients (73% vs. 52% vs. 21%, respectively; P < 0.001). After adjusting for common risk factors for delirium, ARDS was associated with a higher risk for delirium compared with mechanical ventilation without ARDS (odds ratio [OR], 6.55 [1.56-27.54]; P = 0.01 vs. OR, 1.98 [1.16-3.40]; P < 0.013); reference was nonintubated patients. Although ARDS was significantly associated with hospital mortality (OR, 10.44 [3.16-34.50]), the effect was largely reduced after adjusting for delirium and persistent coma (OR, 5.63 [1.55-20.45]). CONCLUSIONS: Our findings suggest that ARDS is associated with a greater risk for ICU delirium than mechanical ventilation alone, and that the association between ARDS and in-hospital mortality is weakened after adjusting for delirium and coma. Future studies are needed to determine if prevention and reduction of delirium in ARDS patients can improve outcomes.

Comparison of risk prediction scoring systems for ward patients: a retrospective nested case-control study.

INTRODUCTION: The rising prevalence of rapid response teams has led to a demand for risk-stratification tools that can estimate a ward patient's risk of clinical deterioration and subsequent need for intensive care unit (ICU) admission. Finding such a risk-stratification tool is crucial for maximizing the utility of rapid response teams. This study compares the ability of nine risk prediction scores in detecting clinical deterioration among non-ICU ward patients. We also measured each score serially to characterize how these scores changed with time. METHODS: In a retrospective nested case-control study, we calculated nine well-validated prediction scores for 328 cases and 328 matched controls. Our cohort included non-ICU ward patients admitted to the hospital with a diagnosis of infection, and cases were patients in this cohort who experienced clinical deterioration, defined as requiring a critical care consult, ICU admission, or death. We then compared each prediction score's ability, over the course of 72 hours, to discriminate between cases and controls. RESULTS: At 0 to 12 hours before clinical deterioration, seven of the nine scores performed with acceptable discrimination: Sequential Organ Failure Assessment (SOFA) score area under the curve of 0.78, Predisposition/Infection/Response/Organ Dysfunction Score of 0.76, VitalPac Early Warning Score of 0.75, Simple Clinical Score of 0.74, Mortality in Emergency Department Sepsis of 0.74, Modified Early Warning Score of 0.73, Simplified Acute Physiology Score II of 0.73, Acute Physiology and Chronic Health Evaluation II of 0.72, and Rapid Emergency Medicine Score of 0.67. By measuring scores over time, it was found that average SOFA scores of cases increased as early as 24 to 48 hours prior to deterioration (P = 0.01). Finally, a clinical prediction rule which also accounted for the change in SOFA score was constructed and found to perform with a sensitivity of 75% and a specificity of 72%, and this performance is better than that of any SOFA scoring model based on a single set of physiologic variables. CONCLUSIONS: ICU- and emergency room-based prediction scores can also be used to prognosticate risk of clinical deterioration for non-ICU ward patients. In addition, scoring models that take advantage of a score's change over time may have increased prognostic value over models that use only a single set of physiologic measurements.

Healthcare disparities in critical illness.

OBJECTIVE: To summarize the current literature on racial and gender disparities in critical care and the mechanisms underlying these disparities in the course of acute critical illness. DATA SOURCES: MEDLINE search on the published literature addressing racial, ethnic, or gender disparities in acute critical illness, such as sepsis, acute lung injury, pneumonia, venous thromboembolism, and cardiac arrest. STUDY SELECTION: Clinical studies that evaluated general critically ill patient populations in the United States as well as specific critical care conditions were reviewed with a focus on studies evaluating factors and contributors to health disparities. DATA EXTRACTION: Study findings are presented according to their association with the prevalence, clinical presentation, management, and outcomes in acute critical illness. DATA SYNTHESIS: This review presents potential contributors for racial and gender disparities related to genetic susceptibility, comorbidities, preventive health services, socioeconomic factors, cultural differences, and access to care. The data are organized along the course of acute critical illness. CONCLUSIONS: The literature to date shows that disparities in critical care are most likely multifactorial involving individual, community, and hospital-level factors at several points in the continuum of acute critical illness. The data presented identify potential targets as interventions to reduce disparities in critical care and future avenues for research.

Body mass index and acute kidney injury in the acute respiratory distress syndrome.

OBJECTIVES: Obesity is increasingly encountered in intensive care units but the relationship between obesity and acute kidney injury is unclear. We aimed to evaluate whether body mass index was associated with acute kidney injury in the acute respiratory distress syndrome and to examine the association between acute kidney injury and mortality in patients with and without obesity. DESIGN: Retrospective study. SETTING: Massachusetts General Hospital and Beth Israel Deaconess Medical Center. PATIENTS: Seven hundred fifty-one patients with acute respiratory distress syndrome. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Acute kidney injury was defined as meeting the "Risk" category according to modified Risk, Injury, Failure, Loss, End-stage criteria based on creatinine and glomerular filtration rate because urine output was only available on the day of intensive care unit admission. Body mass index was calculated from height and weight at intensive care unit admission. The prevalence of acute kidney injury increased significantly with increasing weight (p = .01). The odds of acute kidney injury were twice in obese and severely obese patients compared to patients with normal body mass index, after adjusting for predictors of acute kidney injury (age, diabetes, Acute Physiology and Chronic Health Evaluation III, aspiration, vasopressor use, and thrombocytopenia [platelets ≤ 80,000/mm]). After adjusting for the same predictors, body mass index was significantly associated with acute kidney injury (odds ratio(adj) 1.20 per 5 kg/m increase in body mass index, 95% confidence interval 1.07-1.33). On multivariate analysis, acute kidney injury was associated with increased acute respiratory distress syndrome mortality (odds ratio(adj) 2.76, 95% confidence interval 1.72-4.42) whereas body mass index was associated with decreased mortality (odds ratio(adj) 0.81 per 5 kg/m increase in body mass index, 95% confidence interval 0.71-0.93) after adjusting for mortality predictors. CONCLUSIONS: In acute respiratory distress syndrome patients, obesity is associated with increased development of acute kidney injury, which is not completely explained by severity of illness or shock. Although increased body mass index is associated with decreased mortality, acute kidney injury remained associated with higher mortality even after adjusting for body mass index.

Diagnostic strategies for nosocomial pneumonia.

PURPOSE OF REVIEW: This review describes advances in clinical and microbiological modalities for diagnosis of nosocomial pneumonia and the role of biological markers. RECENT FINDINGS: Serial assessments with the clinical pulmonary infection score identifies nonsurvivors and allows discontinuation of antibiotics when there is low suspicion of pneumonia. Studies evaluating its clinical utility show mixed results. A meta-analysis revealed that an invasive approach does not affect mortality but reduces costs, antibiotic exposure, and multidrug resistance. In contrast to these findings, a recent trial comparing nonquantitative endotracheal aspirate and quantitative bronchoalveolar lavage cultures showed similar clinical outcomes and antibiotic utilization. The role of quantitative endotracheal aspirate for diagnosis of pneumonia not related to mechanical ventilation was recently evaluated. Procalcitonin and soluble triggering receptor expressed on myeloid cells-1 aid in diagnosis, identify sepsis related to ventilator-associated pneumonia and patients with worst outcomes. SUMMARY: The diagnostic modality chosen depends on availability, personnel experience, and the patient's clinical status. Recent guidelines support the use of quantitative cultures in an integrated clinical and microbiological algorithm. The decision to adjust antibiotics involves clinical reassessment and interpretation of culture results. Biological markers have a potential role as screening and prognostic tools.