Strategies to prevent organ failure.

The gastrointestinal tract and the generalized inflammatory response initiated by severe injury or infection have been implicated in the pathophysiology of multiple-organ system failure. Once multiple-organ system failure has occurred, treatment focuses on supporting end-organ function. Recent studies have shown, however, that it may be possible to reduce the incidence and prevalence of multiple-organ system failure by controlling the reperfusion injury cascade, normalizing gastrointestinal blood flow and preserving the integrity of the gastrointestinal immune barrier.

Preoperative intensive care unit consultations: accurate and effective.

OBJECTIVES: To determine if a structured preoperative ICU consultation would correctly assign patients to preoperative invasive monitoring, postoperative ICU care, or recovery room care, and to compare morbidity, mortality, and resource utilization among all groups. DESIGN: Prospective, observational study. SETTING: A university hospital. PATIENTS: A total of 475 patients who were referred preoperatively by surgeons for ICU consultation and were evaluated by ICU physicians. INTERVENTIONS: Patients assessed to have clinical evidence of cardiovascular compromise were admitted preoperatively to the ICU for invasive hemodynamic monitoring and optimization. Patients without such evidence, but who were to undergo major operations or had anticipated major fluid replacement were independently selected for invasive monitoring by anesthesiologists. Patients who developed physiologic instability or became unstable due to hemorrhage also underwent invasive monitoring. Nonmonitored patients who remained stable were given postoperative ICU care or went to the recovery room based on an assessment by the surgeon and anesthesiologist at the end of the operation. MEASUREMENTS AND MAIN RESULTS: Of 8,916 elective surgical cases, ICU physicians were consulted in 475 (5.3%) patients preoperatively. Sixty-seven patients were admitted preoperatively to the ICU for invasive hemodynamic monitoring and optimization; 60 patients had surgery (0.7% of elective cases, 12.6% of ICU consultations). Patients selected for ICU preoperative monitoring were older than non-monitored patients and had higher numbers of cardiovascular and total risk factors than any other group. They had higher Acute Physiology and Chronic Health Evaluation (APACHE II) scores, higher Therapeutic Intervention Scoring System (TISS) points, a higher number of complications, and longer ICU stays than non-monitored postoperative ICU patients. In addition, they had a higher number of complications than nonmonitored recovery room patients. APACHE II scores, TISS points, number of complications, and ICU days in the preoperative ICU admission group were not increased when compared with all other monitored patients. Neither hospital days nor total hospital charges were increased when compared with the other elective ICU patients. Patients selected for ICU preoperative monitoring who underwent surgery had an 11.7% mortality rate and accounted for four of five cardiovascular-related deaths. CONCLUSIONS: A small number of high-risk patients can be selected for preoperative monitoring on the basis of clinical assessment without increasing ICU stay or hospital bills. A structured preoperative consultation correctly identifies those patients who need monitoring and ICU care, but does not overutilize scarce and expensive ICU beds.

Further appraisal of APACHE II limitations and potential.

Hemodynamically unstable patients selected for invasive cardiovascular monitoring were divided into APACHE II subgroups for risk stratification to study interrelationships among monitoring, therapy, resulting cardiovascular function and outcome. When compared by regression analysis, there were no clinically relevant relationships between APACHE II scores and total intervention points (r2 = 0.02), days of invasive monitoring (r2 = 0.000001), initial cardiovascular function (r2 = 0.069) and final cardiovascular function (r2 = 0.05). Analysis of variance (ANOVA) was done between APACHE subgroups and total points (zero of 20 intragroup comparisons were different by the Scheffé test; p = 0.33), days of monitoring (zero of 20 were different; p = 0.61), initial cardiovascular function (three of 20 comparisons were different; p = 0.003) and final cardiovascular function (zero of 20 were different; p = 0.24). Opposite relationships in patients who lived and died were noted between total intervention points and APACHE II subgroups (p = 0.028, two-way ANOVA). There was an increasing number of total intervention points in patients who ultimately lived in ascending initial APACHE II subgroups. In contrast, there was a decreasing number of total intervention points in patients who ultimately died in the same APACHE II subgroups. APACHE II stratification failed to help understand the relationships among clinically important parameters. At the same time, while APACHE scores are claimed to be independent of therapy, the score seemed to be extremely sensitive to interventions, especially important in surgical populations. Should the APACHE II scores remain high in the face of continued maximal intervention, fatal outcome can be predicted. This pattern is remarkably similar across the entire initial APACHE spectrum. The predicated attributes of APACHE II scores, that is, risk stratification and independence from therapy, are neither necessary or desirable. Understanding patterns that are associated with survival or death may require alternative mathematic approaches, such as group and set theory manipulated by principles of Boolean algebra. New approaches may be more fruitful than further attempts to refine existing systems.

Evaluation of APACHE II for cost containment and quality assurance.

APACHE II (an acronym formed from acute physiology score and chronic health evaluation) has been proposed to limit intensive care unit (ICU) admissions ('cost containment') and to judge outcome ('quality assurance') of surgical patients. To judge its performance, a 6-month study of 372 surgical ICU patients was performed. When patients were divided by mean duration of stay, mortality rates rose from 1% (short stay) to 19% (long stay) (p less than 0.001) for patients with APACHE II scores less than 10, but decreased from 94% (short stay) to 60% (long stay) (p less than 0.01) for patients with APACHE II scores more than 24. Exclusion of patients by high or low APACHE scores would 'save' 6% of ICU days but risk increasing morbidity, hospital costs, and deaths. Grouped APACHE II scores did not correlate with total hospital charges (r = 0.05, p = 0.89) or ICU days used (r = 0.42, p = 0.17). Grouping by APACHE II score and duration of ICU stay showed neither symmetry nor uniformity of mortality rates. Surgical patients would not be well served by APACHE II for quality assurance or cost containment.

Risk and detection of pulmonary artery catheter-related infection in septic surgical patients.

Specimen cultures were evaluated in 49 catheterized patients who had a known focus of infection (primarily intra-abdominal peritonitis). Bacteria were recovered from 2% of flush solutions, 14% of transducer domes, 18% of diaphragms, and 24% of cardiac output fluids; however, these bacteria were not found in cultures of the pulmonary artery (PA) catheter segments. The rates of positive PA catheter-aspirate cultures were 30.6% on day 1, 20.4% on day 2, and 32.7% on day 3 (not statistically different). PA catheter-aspirate cultures had a sensitivity of 5.7% and a positive predictive value of 30% for catheter-related infection, and 15% sensitivity and 40% positive predictive value for peripheral bacteremia. While 95% (55 of 58) of the catheter-aspirate cultures were false-positives, only 0.5% (3 of 588) were true-positives. Peripheral blood cultures were positive in 10% of the patients, but the catheter segments were sterile or grew different organisms. Arterial line cultures had zero sensitivity and predictive value to detect catheter-related infection, and 15% sensitivity and 40% predictive value to detect peripheral bacteremia. Thus, PA catheter-aspirate cultures, routine peripheral blood cultures, and arterial cultures cannot be recommended to detect PA catheter-related infection. Catheter-related infection confirmed by catheter-segment cultures was 10.2% when the PA catheters were removed after 73 +/- 6.5 (SD) h. Bacteria from catheter-segment cultures corresponded to those from the primary infection site.

Maintaining quality of care while reducing charges in the ICU. Ten ways.

We believed that the dilemma of controlling costs yet maintaining quality of care might be approached in 10 ways designed to improve efficiency of care: principles of management, elimination of standing orders, classification of patients, written guidelines, mandatory communication, no repetitive orders, single order for single test, removal of monitoring catheters, constant administrative attention, and feedback. We monitored quality of care using the therapeutic intervention scoring system (TISS), mortality, utilization of bed days in the ICU, and the total hospitalization of 50 patients treated in April 1983 and, 8 months after the interventions, 50 patients treated in February 1984. There were no differences in the patient population, severity, outcome, or days. The total lab bills were $10,000 in 1983 and $6300 in 1984 (p less than 0.01). The total number of tests decreased by 2803 (42%) from 6685 to 3882, or 56 per patient per admission. Calculated ICU laboratory charges per patient decreased $3226 (53%) from $6210 to $2894. In 1983, while patients spent 15% of their hospital days in the ICU, they accumulated 61% of their total laboratory charges. In 1984, ICU days were 19% and ICU laboratory charges were 46% of the total. If the decrease of $3226 per patient is extrapolated to a year's population, this would decrease charges by over $2,000,000 in one 12-bed surgical ICU.