Protocol for a prospective cohort study on the use of clinical nutrition and assessment of long-term clinical and functional outcomes in critically ill adult patients.

BACKGROUND AND AIMS: Limited data are available on the impact of clinical nutrition over the course of critical illness and post-discharge outcomes. The present study aims to characterize the use of nutrition support in patients admitted to European intensive care units (ICUs), and its impact on clinical outcomes. Here we present the procedures of data collection and evaluation. METHODS: Around 100 medical, surgical, or trauma ICUs in 11 countries (Austria, Belgium, Czech Republic, Germany, France, Hungary, Italy, Poland, Spain, Sweden, United Kingdom) participate in the study. In defined months between November 2019 and April 2020, approximately 1250 patients are enrolled if staying in ICU for at least five consecutive days. Data from ICU day 1-4 are collected retrospectively, followed by a prospective observation period from day 5-90 after ICU admission. Data collection includes patient characteristics, nutrition parameters, complications, ICU and hospital length of stay, discharge status, and functional outcomes. For data analysis, the target is 1000 patients with complete data. Statistical analyses will be descriptive, with multivariate analyses adjusted for potential confounders to explore associations between nutritional balance and change in functional status, time-to-weaning from invasive mechanical ventilation, time to first clinical complication, and overall 15, 30 and 90-day survival. ETHICS AND DISSEMINATION: This non-interventional study was reviewed and approved by the ethics committee of the Medical University Vienna, Vienna, Austria (approval number 1678/2019), and the respective ethical committees from participating sites at country and/or local level, as required. Results will be shared with investigators on a country level, and a publication and results presentation at the 2021 ESPEN Congress is planned. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT04143503.

Fluid resuscitation after severe trauma injury : U-shaped associations between tetrastarch dose and survival time or frequency of acute kidney failure.

BACKGROUND: Using tetrastarch for fluid resuscitation after a severe trauma injury may increase risks of death and acute kidney injury. The importance of tetrastarch dose, however, is unknown. METHODS: A retrospective observational study was performed in two trauma centres using data on type and amount of fluids (balanced crystalloids or tetrastarch) used for pre- and acute in-hospital shock management. We evaluate independent associations between the relative and absolute volumes of tetrastarch and 90-day survival time or the frequency of severe acute kidney failure (AKF). RESULTS: We studied 271 patients who had sustained a severe blunt trauma injury (average predicted mortality according to the Revised Injury Severity Classification Score (RISC) 15.1 ± 1.4% [mean, standard deviation]), and who had required more than 2 days of intensive care therapy. In all, 75.3% of patients had received tetrastarch with a crystalloid/colloid ratio of 2.93 ± 2.60. The 90-day mortality was 11.1%, and 7.8% of the patients developed severe AKF. After adjusting for confounders, we found a U-shaped, nonlinear association between absolute or relative volumes of tetrastarch and survival time (p = 0.003 and 0.025, respectively). Optimal relative volumes of tetrastarch approximately ranged from 20 to 30% of total fluids. Giving less than about 1000 ml, or more than about 2000 ml tetrastarch was significantly associated with an increased risk of developing severe AKF (p = 0.023). CONCLUSIONS: There was a complex U­shaped association between the tetrastarch dose and morbidity/mortality of patients after a severe trauma injury. The optimal crystalloid/tetrastarch ratio for acute shock management appears to range from about 2.5 to 4.0.

[Cost analysis as a tool for assessing the efficacy of intensive care units]. / Kosten als Instrument zur Effizienzbeurteilung intensivmedizinischer Funktionseinheiten.

BACKGROUND: The German "Hospital Structure Act" intends to align the state hospital planning on quality criteria. Within this process cost-utility analyses (CUAs) shall be used to assess the efficacy of medical care. To be objective, CUAs of intensive care units (ICUs) require standardization (adjustment) of costs. The present study analyzed the extent to which treatment costs are related to patient-specific baseline variables (such as type and severity of the primary disease). METHODS: From 2000-2004, a bottom-up procedure was used to quantify total costs on 14 ICUs in nine German university hospitals. Results were combined with demographic data, and data indicating type (ICD-10 codes) and severity (ICU scoring systems) of the primary disease at ICU admission. Various statistical models were tested to identify that which best described the associations between baseline variables and costs. RESULTS: In all, 3803 critically ill patients could be examined. The median of treatment costs per patient was 3199 € (IQR 1768-6659 €). No model allowed an acceptably precise adjustment of costs; the estimated mean absolute prognostic error was at least 3860 € (mean relative prognostic error 66%), when we tested an Extreme Gradient Boosting Model. CONCLUSION: Instruments which are currently available (cost adjustment based on patient-specific baseline variables) do not allow a standardization of costs, and an objective CUA of ICUs. Factors unknown at baseline may cause a large portion of treatment costs.

[Quality of dying processes after commencement of the German Living Will Act : Experiences of a surgical intensive care unit]. / Versterben vor und nach dem "Patientenverfügungsgesetz" : Erfahrungen einer chirurgischen Intensivstation.

BACKGROUND: There is so far no information on how the third act on amendment of the German guardianship law from 29 July 2009 has affected dying processes of critically ill patients. METHODS: This retrospective study analyzed the patterns of dying processes in postoperative critically ill patients treated from 2009 to 2012 (period II after the commencement of the German Living Will Act) and 10 years before (period I, 1999-2002). Independent associations were calculated by logistic regression. RESULTS: In the observation period II (n = 137 dying patients) time until death significantly decreased to 19.3 days (95% CI 14.8-23.8, p = 0.008) vs. 29.2 days (95% CI 23.7-34.6) in period I (n = 163). In period II respect of the patient's will preceded death in 42.3% of the dying patients (period I: 8.6%, p < 0.001). Simultaneously, the frequency of patients with a severe preoperative comorbidity (failure of more than one organ) increased (26.8% of dying patients vs. 5.5% in period I, p = 0.001). The treatment during period II was, in addition to high age and a severe comorbidity, a significant independent predictor for the possibility that respect of the patient's will preceded death (odds ratio 7.42; 95% CI 3.77-14.60). CONCLUSION: Independent of various covariables, treatment after the commencement of the German Living Will Act was associated with a broader and earlier respect of the patient's will, thereby shortening the time until death.

Nutritional screening for risk prediction in patients scheduled for abdominal operations.

BACKGROUND: Increased risks related to surgery might reflect the nutritional status of some patients. Such a group might benefit from perioperative nutritional support. The purpose of this study was to identify the relative importance of nutritional risk screening along with established medical, anaesthetic and surgical predictors of postoperative morbidity and mortality. METHODS: This prospective observational study enrolled consecutive eligible patients scheduled for elective abdominal operations. Data were collected on nutritional variables (body mass index, weight loss, food intake), age, sex, type and extent of operation, underlying disease, American Society of Anesthesiologists grade and co-morbidities. A modified composite nutritional screening tool (Nutritional Risk Screening, NRS 2002) currently recommended by European guidelines was used. Relative complication rates were calculated with multiple logistic regression and cumulative proportional odds models. RESULTS: Some 653 patients were enrolled of whom 132 (20.2 per cent) sustained one or more postoperative complications. The frequency of this event increased significantly with a lower food intake before hospital admission. No other individual or composite nutritional variable provided comparable or better risk prediction (including NRS 2002). Other factors significantly associated with severe postoperative complications were ASA grade, male sex, underlying disease, extent of surgical procedure and volume of transfused red cell concentrates. CONCLUSION: In abdominal surgery, preoperative investigation of feeding habits may be sufficient to identify patients at increased risk of complications. Nutritional risk alone, however, is not sufficient to predict individual risk of complications reliably.

[Secondary peritonitis]. / Sekundäre Peritonitis.

BACKGROUND: There is some controversy regarding concepts currently propagated for an optimal surgical and antibiotic therapy in patients with secondary peritonitis and organ failure. It is not known whether the recent general progress in critical care ("Surviving Sepsis Campaign") has also improved outcome of this particular patient group. METHODS: MEDLINE, EMBASE and Cochrane databases were non-systematically searched from 1985 through January 2010 using the words "source control", "peritonitis", "operation", "critical care" and "antibiotics". We also present experiences in corresponding high risk patients from our institution. RESULTS: The inability to obtain source control and an inadequate initial antibiotic therapy were -associated with a clearly higher mortality. De-pending on the initial intraoperative finding, planned and on demand relaparotomy do not conflict, but complement one another. The importance of the number of surgical revisions remains to be determined. Treatment after 2002 was associated with an improved prognosis. In contrast to source control, the mechanisms of increasing mortality with an inadequate initial antibiotic therapy remain controversial. CONCLUSION: Source control is the most important determinant for acute survival and has to be placed on top of the therapeutic priority list. The number of revisions needed to obtain source control, however, does not vary with survival and cannot guide decisions on therapy withdrawal or continuation. The recent prognostic improvement indicates the efficiency of new adjuvant therapeutic measures in unselected surgical high-risk patients.

Occurrence of polycyclic musks in wastewater and receiving water bodies and fate during wastewater treatment.

The occurrence of cashmerane (DPMI), celestolide, phantolide, traesolide (ATII), galaxolide (HHCB) and tonalide (AHTN) in sewage and surface waters and their fate during wastewater treatment and anaerobic sludge digestion is investigated. AHTN and HHCB are the most important representatives and influent concentrations of 0.41-1.8 and 0.9-13 µgL(-1) are observed. DPMI is detected in influent and effluent samples but in notably lower concentrations than AHTN and HHCB. Major sources of polycyclic musks are households, whereas industrial emitters seem to be of minor importance. This conclusion is supported by the analysis of selected industrial wastewaters (metal, textile and paper industry). Specific emissions of 0.36 ± 0.19 and 1.6 ± 1.0 mg cap(-1)d(-1) for AHTN and HHCB are calculated. Overall removal efficiencies between approx 50% and more than 95% are observed during biological wastewater treatment and removal with the excess sludge is the major removal pathway. Log K(D) values of 3.73-4.3 for AHTN, 3.87-4.34 for HHCB and 2.42-3.22 for DPMI are observed in secondary sludge. During sludge digestion no or only slight removal occurred. Mean polycyclic musk concentrations in digested sludge amounted to 1.9 ± 0.9 (AHTN), 14.2 ± 5.8 (HHCB), 0.8 ± 0.4 (ATII) and 0.2 ± 0.09 (DPMI) mgkg(-1) dry matter. In the receiving water systems a comparable distribution as during wastewater treatment is observed. AHTN, HHCB and DPMI are detected in surface waters (ND (not detected) - <0.04, ND - 0.32 and ND - 0.02 µg L(-1)) as well as AHTN and HHCB in sediments (ND - 20, ND - 120 µg kg(-1)). For HHCB an apparent K(OC) value of 4.1-4.4 is calculated for sediments. Major source for polycyclic musks in surface waters are discharges from wastewater treatment plants. For HHCB and DPMI 100% of the load observed in the sampled surface waters derive from discharges of treated wastewater.

Occurrence of phthalates in surface runoff, untreated and treated wastewater and fate during wastewater treatment.

Dimethyl phthalate, diethyl phthalate, dibuthyl phthalate, butylbenzyl phthalate, bis(2-ethylbenzyl) phthalate (DEHP) and dioctyl phthalate were analysed in raw and treated wastewater as well as in surface runoff samples from traffic roads. All six investigated phthalates have been detected in all raw sewage samples, in nearly all wastewater treatment plant (WWTP) effluent samples and in all road runoff samples, with DEHP being the most abundant compound. DEHP inflow concentrations ranged 3.4-34 microg L(-1) and effluent concentrations 0.083-6.6 microg L(-1). In two WWTPs the fate of the phthalates was assessed by performing mass balances. Overall removal efficiencies of approx 95% were calculated. Removal is attributed to biotransformation and adsorption and the relevance of the removal via adsorption to sludge increased with increasing molecular weight and increasing lipophilic character of the compound. Except DEHP phthalate concentrations were higher in treated effluent samples than in road runoff. The environmental quality standard (EQS) for DEHP in surface waters is exceeded only in a few effluent samples, whereas nearly all road runoff samples were higher than the EQS. An assessment based on pure concentrations is not feasible and a mass balance based approach is required. Nevertheless the observations highlight the relevance of stormwater emissions and direct emissions from separated sewer systems to surface waters in relation to emissions from WWTPs and the necessity to consider all potential influences in the assessment of the status of surface water bodies with reference to xenobiotics.

Higher blood concentrations of synthetic musks in women above fifty years than in younger women.

Synthetic musk compounds are widely used as fragrance ingredients in many consumer products. Little is known about their accumulation in humans and especially in older persons. In this study, we determined concentrations of 11 synthetic musks in women above fifty years and compared the results with earlier results from samples of young females. Blood was taken from 53 women above 50 years of age, visiting outpatients of the Department of Angiology at the Hanusch-Krankenhaus in Vienna, Austria. The used analytical methods consist of an extraction and clean-up step and a chromatographic analysis by GC/MS. Tonalide-D3 was used as recovery standard in all samples. Hexachlorobenzene (13)C(6) was used as internal standard. Study participants also completed a questionnaire on the use of cosmetics, about nutrition and other life-style aspects. The two substances which could be detected in higher percentages of the blood plasma samples were galaxolide (89 percent, maximum concentration 6900 ng/L) and musk xylene (62 percent, maximum concentration 190 ng/L). Regression analysis revealed a significant association of galaxolide concentration with frequent use of perfumes, deodorants and shampoos. Frequent use of soaps and fabric softener was associated with higher plasma concentrations of musk xylene. Nutrition habits, skin type, body mass index or surface area were not related to plasma concentration of these musk compounds. From the study group investigated older persons showed higher plasma concentrations. These findings could be due to the higher use of lotions and crèmes on face and hands and a more frequent use of skin care products because older persons reported more frequently dry skin. In addition, physiological aging related changes might be responsible for higher dermal absorption of synthetic musks. These results indicate that more focus on aging tissues is needed.

Interlaboratory trial on the analysis of alkylphenols, alkylphenol ethoxylates, and bisphenol A in water samples according to ISO/CD 18857-2.

ISO/CD 18857-2 (International Organization for Standardization, Geneva) describes a new international standard method for the determination of octylphenol, nonylphenol, their mono- and diethyoxylates, and bisphenol A in nonfiltered samples of drinking, ground, surface, and wastewater. The method is based on the extraction of the analytes from an acidified water sample by solid phase extraction, solvent elution, derivatization, and determination by gas chromatography with mass spectrometric detection. For validation of this method, 14 laboratories from 4 different countries in Europe and Canada participated in an interlaboratory trial to determine the performance characteristics of the method, which are intended for publication in the corresponding standard. The interlaboratory trial was evaluated according to ISO 5725-2 and included two duplicate nonfiltered water samples: surface water containing the target compounds in an analyte concentration range from 0.05 to 0.4 microg/L and wastewater containing the target compounds in a concentration ranged from 0.1 to 5 microg/L. The repeatability variation coefficients (within-laboratory precision) varied for all samples and compounds between 1.9 and 7.8%, showing a sufficiently high repeatability of the method. The reproducibility variation coefficients (between-laboratory precision) were found to vary within a satisfactory range of 10.0-29.5% for surface water and 10.8-22.5% for wastewater. The recoveries as a measure of accuracy varied from 98.0 to 144.1% for surface water and from 95.4 to 108.6% for wastewater. The determined concentrations of the samples compared well to the "true" values, thus showing very satisfactory accuracy of the method. In the chromatogram of the surface water sample, a high unresolved background made up of coextractable matrix compounds was apparent. It is conceivable that compounds from this background may be responsible for enhanced recoveries of 144.1% for 4-nonylphenol (mixture of isomers) and of 123.4% for 4-nonylphenol monoethoxylate (mixture of isomers) in the surface water samples. The isotope-marked standard compounds developed in this context proved to be reliable internal standards that allow a precise and accurate quantitation of all compounds specified in ISO/CD 18857-2. The results of the interlaboratory trial confirmed that the analytical method is robust and reliable and can be used as a standard method to analyze the target compounds in water samples.

Synthetic musks in blood of healthy young adults: relationship to cosmetics use.

Production of polycyclic musk compounds is increasing accompanied by a decline in nitro musk production. Although it can be assumed that due to this reduction nitro musks are less prevalent in human body fluids, there are no data available from the last decade. This study examined the concentrations of five nitro musks and six polycyclic musks in blood samples from young healthy volunteers. Blood was taken from 100 healthy students of the Medical University of Vienna. The lipophilic fraction was extracted and after purification analyzed by GC-MS. Study participants also completed a questionnaire on the use of cosmetics, about nutrition and other life-style aspects. Highest percentages of synthetic musks in blood plasma samples were found for galaxolide (91%, median 420 ng L(-1)) and musk xylene (79%, median 11 ng L(-1)). Both musk ketone and tonalide were found in 17%. In two cases musk ambrette was detected. In a multivariate approach only younger age, use of lotion and perfumes did significantly predict blood concentrations of polycyclic musks. For nitro musks except body surface area no significant predictor could be found. High percentage of the population is still exposed to nitro musk compounds although blood concentrations of nitro musks are generally lower than those of polycyclic musks. Compared to earlier investigations performed in the 1990s nitro musks were detected in lower percentages and concentrations. There seems to be no dominant source of nitro musk uptake although relationship to body surface area indicates cosmetic products applied to the skin as the likely origin of plasma concentrations.

[Diabetes mellitus - perioperative management]. / Perioperatives Management bei Diabetes mellitus.

The prevalence of diabetes in hospitalized adults is conservatively estimated at 12-25% and rising. Poor glucose control and presence of diabetes complications (e.g. diabetic nephropathy, diabetic neuropathy, atherosclerosis) are commonly regarded as risk factors for perioperative morbidity and mortality. Thus it is crucial to determine diabetes comorbidities preoperatively in order to avoid perioperative renal and cardiovascular complications. Perioperative glycemic control is challenging due to preoperative changes in diabetes treatment and the effects of surgery-associated stress hyperglycemia. For patients in general surgical units, evidence for specific glycemic goals is based on epidemiologic and physiologic data rather than clinical trials. According to guidelines of the German Society of Nutrition, the approximation of normoglycemia is reasonable as long as hypoglycemia is avoided (suggested range for plasma glucose 80-145 mg/dL).

Complications and monitoring - Guidelines on Parenteral Nutrition, Chapter 11.

Compared to enteral or hypocaloric oral nutrition, the use of PN (parenteral nutrition) is not associated with increased mortality, overall frequency of complications, or longer length of hospital stay (LOS). The risk of PN complications (e.g. refeeding-syndrome, hyperglycaemia, bone demineralisation, catheter infections) can be minimised by carefully monitoring patients and the use of nutrition support teams particularly during long-term PN. Occuring complications are e.g. the refeeding-syndrome in patients suffering from severe malnutrition with the initiation of refeeding or metabolic, hypertriglyceridemia, hyperglycaemia, osteomalacia and osteoporosis, and hepatic complications including fatty liver, non-alcoholic fatty liver disease, cholestasis, cholecystitis, and cholelithiasis. Efficient monitoring in all types of PN can result in reduced PN-associated complications and reduced costs. Water and electrolyte balance, blood sugar, and cardiovascular function should regularly be monitored during PN. Regular checks of serum electrolytes and triglycerides as well as additional monitoring measures are necessary in patients with altered renal function, electrolyte-free substrate intake, lipid infusions, and in intensive care patients. The metabolic monitoring of patients under long-term PN should be carried out according to standardised procedures. Monitoring metabolic determinants of bone metabolism is particularly important in patients receiving long-term PN. Markers of intermediary, electrolyte and trace element metabolism require regular checks.

Access technique and its problems in parenteral nutrition - Guidelines on Parenteral Nutrition, Chapter 9.

Catheter type, access technique, and the catheter position should be selected considering to the anticipated duration of PN aiming at the lowest complication risks (infectious and non-infectious). Long-term (>7-10 days) parenteral nutrition (PN) requires central venous access whereas for PN <3 weeks percutaneously inserted catheters and for PN >3 weeks subcutaneous tunnelled catheters or port systems are appropriate. CVC (central venous catheter) should be flushed with isotonic NaCl solution before and after PN application and during CVC occlusions. Strict indications are required for central venous access placement and the catheter should be removed as soon as possible if not required any more. Blood samples should not to be taken from the CVC. If catheter infection is suspected, peripheral blood-culture samples and culture samples from each catheter lumen should be taken simultaneously. Removal of the CVC should be carried out immediately if there are pronounced signs of local infection at the insertion site and/or clinical suspicion of catheter-induced sepsis. In case PN is indicated for a short period (max. 7-10 days), a peripheral venous access can be used if no hyperosmolar solutions (>800 mosm/L) or solutions with a high titration acidity or alkalinity are used. A peripheral venous catheter (PVC) can remain in situ for as long as it is clinically required unless there are signs of inflammation at the insertion site.

Endovascular treatment of an intramural aortic haematoma following cardiopulmonary resuscitation for myocardial ischemia with ventricular fibrillation.

Cardiopulmonary resuscitation by manual cardiac compression can restore cardiocirculatory function but can also injure patients. Commonly reported are skeletal fractures of the rips and sternum, while injuries to the large thoracic vessels will frequently be lethal. We report the case of a 57-year-old male patient with sudden cardiac arrest because of myocardial ischemia with ventricular fibrillation, successful cardiopulmonary resuscitation, associated with an intramural haematoma (IMH) of the descending thoracic aorta treated by endovascular aortic repair. Secondary coronary angiography revealed a severe three vessel coronary disease with an occlusion of the proximal anterior descending branch and a subtotal stenosis of the first segmental branch of the left coronary artery (LCA) and a high-grade stenosis of the posterolateral segmental branch of the circumflex left coronary artery. Stenotic segments of coronary arteries were treated successfully by implantation of three drug-eluting stents followed by dual antiplatelet therapy. The patients recovered almost completely and was discharged for further rehabilitation after 3 weeks.

Dynamics in dense suspensions of charge-stabilized colloidal particles.

The dynamic behavior of charge-stabilized colloidal particles in suspension was studied by photon correlation spectroscopy with coherent X-rays (XPCS). The short-time diffusion coefficient, D(Q) , was measured for volume concentrations phi < or = 0.18 and compared to the free particle diffusion constant D(0) and the static structure factor S(Q) . The data show that indirect, hydrodynamic interactions are relevant for the system and hydrodynamic functions were derived. The results are in striking contrast to the predictions of the PA (pairwise-additive approximation) model, but show features typical for a hard-sphere system. The observed mobility is however considerably smaller than the one of a respective hard-sphere system. The hydrodynamic functions can be modelled quantitatively if one allows for an increased effective viscosity relative to the hard-sphere case.

Secular trends in severe renal failure associated with the use of new antimicrobial agents in critically ill surgical patients.

Randomized controlled trials conducted since 2000 have shown that new antibacterial and antifungal agents may reduce the frequency of kidney injury in selected groups of critically ill patients, yet it is unclear whether these benefits translate to the clinical setting. The aim of the present study was to evaluate longitudinally the successive routine implementation of new antimicrobial agents (caspofungin, voriconazole, linezolid) after February 2002 and the association of these agents with the frequency of mechanical renal replacement therapy in postsurgical critically ill patients at risk of severe kidney failure. A retrospective, observational cohort study was performed using data collected prospectively from 1 March 1993 through 28 February 2005. A cohort of 2,123 consecutive cases who required intensive care therapy for more than 2 days was analysed. A statistically significant decrease in the frequency of renal replacement therapy was observed in the later years of the study. After adjustment for relevant covariates, treatment with new antimicrobial agents after February 2002 was identified as an independent factor linked with a reduced risk of severe kidney failure (odds ratio 0.244; 95% confidence interval 0.136-0.439). Thus, the implementation of new antimicrobial agents with reduced or no nephrotoxicity into routine care of critically ill surgical patients is associated with a reduced need for renal replacement therapy.

[Significance of multiple organ failure for the prognosis of surgical intensive care patients]. / Bedeutung des Mehrfachorganversagens für die Prognose des chirurgischen Intensivpatienten.

BACKGROUND: The association of multiple organ failure and acute prognosis is an established fact in intensive care medicine. However, it is unclear whether the number of failing organs is an independent determinant of acute mortality, and whether there are additional effects on long-term outcome. METHODS: We performed a retrospective, observational cohort study using prospectively collected data from March 1993, through February 2005. Three different cohorts were analysed: patients with a short-term intensive care unit (ICU) stay (group I, ICU length of stay > 4 days), with a long-term ICU stay (group II, ICU length of stay > 28 days), and all patients requiring renal replacement therapy during ICU stay (group III). Organ failure was defined according to a modified Goris score. An independent effect of the number of failing organs on patient prognosis was evaluated after adjusting for more than 15 covariables. Acute prognosis was analysed in group I, whereas long-term prognosis was studied in groups II and III. RESULTS: The maximum number of failing organs was an independent determinant of acute prognosis in patients of group I, and of long-term prognosis in groups II and III. CONCLUSION: The effect of multiple organ failure on long-term prognosis emphasizes the importance of this variable for patient outcome. Therefore, multiple organ failure must be part of all therapeutic concepts in critical care. Within those, preventive measures are definitively preferable to keep the number of failing organs as small as possible.