Relationship between functional status prior to onset of critical illness and mortality: a prospective multicentre cohort study.

This prospective study aimed to assess the association between prior functional status and hospital mortality for patients admitted to four intensive care units in Spain between 2006 and 2012. Prior functional status was classified into three groups, using a modification of the Glasgow Outcome Scale (GOS), including group 1 with no limitations on activities of daily living; group 2 with some limitations but self-sufficient; and group 3 who were dependent on others for their activities of daily living. Of the 1,757 patients considered (mean Simplified Acute Physiology Score [SAPS] predicted mortality 14.8% and hospital mortality 13.7%), group 1 had the lowest observed hospital mortality (8.3%) compared to the SAPS 3 predicted mortality (11.6%). The observed mortality for group 2 (20.6%) and group 3 (27.4%) were both higher than predicted (19.2% and 21.2% respectively; odds ratio [OR] 1.97, 95% confidence interval [CI] 1.38-2.82 for group 2 and OR 2.90, 95% CI 1.78-4.72 for group 3 compared to group 1). Combining prior functional status and Sequential Organ Failure Assessment (SOFA) score with SAPS 3 further improved the ability of the SAPS 3 scores in predicting hospital mortality (area under the receiver operating characteristic curve 0.85 [95% CI 0.82-0.88] versus 0.84 [95% CI 0.81-0.87] respectively). In summary, patients with limited functional status prior to ICU admission had a higher risk of observed hospital mortality than predicted. Assessing prior functional status using a relatively simple questionnaire, such as a modified GOS, has the potential to improve the accuracy of existing prognostic models.

Preoperative use of statins does not improve outcomes and development of acute renal failure after cardiac surgery. A propensity score analysis of ARIAM-Andalucía database.

BACKGROUND: Statin use prior to cardiac surgery has been reported to improve outcomes in the postoperative period because of other effects apart from decreasing lipid levels. Objective of the study was to analyse mortality and acute renal failure (ARF) during the cardiac surgery postoperative period in patients treated with or without statins. METHODS: This prospective cohort study comprised adult patients who underwent cardiac surgery at 11 institutions in the Andalusian community from March 2008 to July 2012 included in the ARIAM adult cardiac surgery project. We performed a first analysis in the whole cohort and in a second analysis statin users prior to surgery were pair matched with non-users according to their propensity score based on demographics, comorbidities, medication and surgical data. We analysed differences in outcomes, ARF, need for renal replacement therapy (RRT) and a composite end point with mortality or major morbidity in both groups. RESULTS: The study included 7276 patients, of whom 3749 were treated with statins. Overall, hospital mortality was 10.1%, 10.5% developed ARF and 2.5% required RRT. In the whole non-matched cohort, statins were associated with lower hospital mortality (OR 0.79; 95% CI, 0.67-0.93) and less ARF (OR 0.79; 95% CI, 0.68-0.93). However, after propensity score analysis in the matched cohort of 3056 patients (1528 in each group), statin use was not consistently associated with less ARF (OR 0.94; 95% CI, 0.74-1.19), hospital mortality (OR 0.83; 95% CI, 0.68-1.1) or composite outcome (OR 0.857; 95% CI, 0.723-1.015). CONCLUSION: Despite better outcomes for the statin users in the whole cohort, the matched analysis showed that statin use before cardiac surgery was not associated with a lower risk of ARF. Nor was presurgery statin use associated with lower hospital mortality.

External validation of the Simplified Acute Physiology Score (SAPS) 3 in Spain

OBJECTIVE: To evaluate SAPS 3 performance in Spain, assessing discrimination and calibration in a multicenter study. DESIGN: A prospective, multicenter study was carried out. Patients and setting: A prospective cohort study was performed in Spanish hospitals between 2006 and 2011. Measurements and results: A total of 2171 patients were included in the study. The mean age was 61.4 ± 16.09 years, the ICU mortality was 11.6%, and hospital mortality 16.03%. The SAPS 3 score was 46.29 ± 14.34 points, with a probability of death for our geographical area of 18.57%, and 17.97% for the general equation. The differences between observed-to-predicted mortality were analyzed with the Hosmer-Lemeshow test, which yielded H = 31.71 (p < 0.05) for our geographical area and H = 20.05 (p < 0.05) for the general equation. SAPS 3 discrimination with regard to hospital mortality, tested using the area under the ROC curve, was 0.845 (0.821-0.869). CONCLUSION: Our study shows good discrimination of the SAPS 3 system in Spain, but also inadequate calibration, with differences between predicted and observed mortality. There are more similarities with regard to the general equation than with respect to our geographical area equation, and in both cases the SAPS 3 system overestimates mortality. According to our results, Spanish ICU mortality is lower than in other hospitals included in the multicenter study that developed the SAPS 3 system, in patients with similar characteristics and severity of illness

OBJETIVO: Analizar el funcionamiento del sistema SAPS3 en España, evaluando la discriminación y calibración en un estudio multicéntrico. DISEÑO: Estudio prospectivo de cohortes, multicéntrico. Ámbito: Hospitales españoles entre 2006 y 2011. Variables de interés y resultados: Se incluyó en el estudio a un total de 2171 pacientes. La edad media fue 61,4 ± 16,09 años, la mortalidad en UCI fue del 11,6% y la mortalidad hospitalaria 16,03%. El score SAPS 3 fue de 46,29 ± 14,34 puntos, con la probabilidad de morir por la ecuación de nuestra área geográfica 18.57%, y 17.97% para la ecuación general. Las diferencias entre la mortalidad observada y la predicha se analizaron mediante el test de Hosmer-Lemeshow. Este test mostró H = 31,71 (p < 0,05) para nuestra área geográfica y H = 20,05 (p < 0,05) para la ecuación general. La discriminación del SAPS 3 con respecto a la mortalidad hospitalaria, testada mediante el área bajo la curva ROC, fue 0.845 (0,821-0,869). CONCLUSIÓN: Nuestro estudio muestra, en España, una buena discriminación del sistema pronóstico SAPS 3 pero una inadecuada calibración, con diferencias entre la mortalidad predicha y, la observada. Hay más similitudes con respecto a la ecuación general que con la ecuación de nuestra zona geográfica, y en ambos casos, el sistema SAPS 3 sobreestima la mortalidad. De acuerdo con los resultados, la mortalidad en UCI es menor que la de otros hospitales incluidos en el estudio multicéntrico que se utilizaron para desarrollar el sistema SAPS 3, en pacientes con similares características y severidad de la enfermedad

External validation of the Simplified Acute Physiology Score (SAPS) 3 in Spain.

OBJECTIVE: To evaluate SAPS 3 performance in Spain, assessing discrimination and calibration in a multicenter study. DESIGN: A prospective, multicenter study was carried out. PATIENTS AND SETTING: A prospective cohort study was performed in Spanish hospitals between 2006 and 2011. MEASUREMENTS AND RESULTS: A total of 2171 patients were included in the study. The mean age was 61.4±16.09 years, the ICU mortality was 11.6%, and hospital mortality 16.03%. The SAPS 3 score was 46.29±14.34 points, with a probability of death for our geographical area of 18.57%, and 17.97% for the general equation. The differences between observed-to-predicted mortality were analyzed with the Hosmer-Lemeshow test, which yielded H=31.71 (p<0.05) for our geographical area and H=20.05 (p<0.05) for the general equation. SAPS 3 discrimination with regard to hospital mortality, tested using the area under the ROC curve, was 0.845 (0.821-0.869). CONCLUSION: Our study shows good discrimination of the SAPS 3 system in Spain, but also inadequate calibration, with differences between predicted and observed mortality. There are more similarities with regard to the general equation than with respect to our geographical area equation, and in both cases the SAPS 3 system overestimates mortality. According to our results, Spanish ICU mortality is lower than in other hospitals included in the multicenter study that developed the SAPS 3 system, in patients with similar characteristics and severity of illness.

Relationship between mortality and first-day events index from routinely gathered physiological variables in ICU patients

Objective: To test the hypothesis that the degree and duration of alterations in physiological variables routinely gathered by intensive care unit (ICU) monitoring systems during the first day of admission to the ICU, together with a few additional routinely recorded data, yield information similar to that obtained by traditional mortality prediction systems. Design: A prospective observational multicenter study (EURICUS II) was carried out. Setting: Fifty-five European ICUs. Patients: A total of 17,598 consecutive patients admitted to the ICU over a 10-month period. Interventions: None. Main variables of interest: Hourly data were manually gathered on alterations or "events" in systolic blood pressure, heart rate and oxygen saturation throughout ICU stay to construct an events index and mortality prediction models. Results: The mean first-day events index was 6.37±10.47 points, and was significantly associated to mortality (p: <0.001), with a discrimination capacity for hospital mortality of 0.666 (area under the ROC curve). A second index included this first-day events index, age, pre-admission location, and the Glasgow coma score. A model constructed with this second index plus diagnosis upon admission was validated by using the Jackknife method (Hosmer-Lemeshow,H: =13.8554, insignificant); the area under ROC curve was 0.818. Conclusions: A prognostic index with performance very similar to that of habitual systems can be constructed from routine ICU data with only a few patient characteristics. These results may serve as a guide for the possible automated construction of ICU prognostic indexes (AU)

Objetivo: Comprobar si el grado y duración de las alteraciones en las variables fisiológicas recogidas en la monitorización rutinaria en UCI durante el primer día de estancia, junto con pocos datos adicionales, proporcionan información similar a la obtenida con los sistemas tradicionales de predicción de mortalidad. Diseño: Estudio observacional, prospectivo y multicéntrico (EURICUS-II). Ámbito: 55 UCIs de Europa. Pacientes: 17.598 pacientes consecutivos, ingresados durante 10 meses. Intervenciones: ninguna. Variables de interés principales: se recogieron manualmente datos horarios sobre alteraciones o "eventos" en la presión arterial sistólica, frecuencia cardiaca y saturación de oxígeno, para construir un índice basado en estos eventos y un modelo de predicción de mortalidad. Resultados: El índice de eventos el primer día fue 6,37±10,47 puntos y se asoció significativamente con la mortalidad (p<0,001), con una capacidad de discriminación (área bajo la curva ROC) para la mortalidad de 0.666. Se construyó un segundo índice que incluye este índice de eventos en el primer día, la edad, procedencia del ingreso y puntuación de la Escala de Coma de Glasgow. Un modelo construido con este segundo índice más el diagnóstico fue validado mediante el método jackknife (Hosmer-Lemeshow, H=13.8554, no significativo), con un área bajo la curva ROC de 0,818. Conclusiones: Se puede construir un índice pronóstico con rendimiento similar al de los sistemas habituales a partir de los datos de monitorización de los pacientes en la UCI junto a escasas características del paciente. Nuestros resultados pueden servir de guía para la posible construcción automatizada de índices pronósticos (AU)

Relationship between mortality and first-day events index from routinely gathered physiological variables in ICU patients.

OBJECTIVE: To test the hypothesis that the degree and duration of alterations in physiological variables routinely gathered by intensive care unit (ICU) monitoring systems during the first day of admission to the ICU, together with a few additional routinely recorded data, yield information similar to that obtained by traditional mortality prediction systems. DESIGN: A prospective observational multicenter study (EURICUS II) was carried out. SETTING: Fifty-five European ICUs. PATIENTS: A total of 17,598 consecutive patients admitted to the ICU over a 10-month period. INTERVENTIONS: None. MAIN VARIABLES OF INTEREST: Hourly data were manually gathered on alterations or "events" in systolic blood pressure, heart rate and oxygen saturation throughout ICU stay to construct an events index and mortality prediction models. RESULTS: The mean first-day events index was 6.37±10.47 points, and was significantly associated to mortality (p<0.001), with a discrimination capacity for hospital mortality of 0.666 (area under the ROC curve). A second index included this first-day events index, age, pre-admission location, and the Glasgow coma score. A model constructed with this second index plus diagnosis upon admission was validated by using the Jackknife method (Hosmer-Lemeshow, H=13.8554, insignificant); the area under ROC curve was 0.818. CONCLUSIONS: A prognostic index with performance very similar to that of habitual systems can be constructed from routine ICU data with only a few patient characteristics. These results may serve as a guide for the possible automated construction of ICU prognostic indexes.

[Secondary prevention of alcohol and/or drug abuse in trauma patients: results of a national survey in Spain]. / Prevención secundaria en traumatizados relacionados con alcohol y drogas. Resultados de una encuesta nacional.

OBJECTIVE: To determine the degree of activity in the field of secondary prevention of alcohol and/or drug abuse in trauma patients in Spain. MATERIAL AND METHODS: We surveyed 76 hospitals located in all the autonomous regions of Spain. We collected information about the number of severe trauma patients admitted to the ICU per year, the detection of alcohol and drugs in these patients, and the activity for secondary prevention through motivational intervention among other approaches. RESULTS: Of the 76 hospitals surveyed, 66 responded and only one carried out any secondary prevention activity through motivational intervention. Most of the hospitals surveyed (64.5%, 40/62) did not know of the possibility of secondary prevention through motivational intervention and (29%, 18/62) did not have the resources to carry it out. Asked whether they screened trauma patients for drugs and/or alcohol, 15.6% of centers responded "always" 37.5% (24/64) "usually", and 40.6% only "sometimes". CONCLUSION: Most centers surveyed are unaware of the usefulness of secondary prevention in trauma patients. This lack of awareness may be responsible for the lack of activity in this field in Spain. A plan to increase awareness, including educational interventions, is necessary to promote secondary prevention of alcohol and drug abuse among trauma patients.

Prevención secundaria en traumatizados relacionados con alcohol y drogas. Resultados de una encuesta nacional / Secondary prevention of alcohol and/or drug abuse in trauma patients: Results of a national survey in Spain

Objetivo: Averiguar cuál es el grado de actividad en el campo de la prevención secundaria en traumatizados relacionados con alcohol y drogas en el territorio español. Material y métodoEncuesta a 76 hospitales de todas las comunidades autónomas del país, solicitando información sobre número de pacientes traumatizados graves que requerían ingreso en UCI por año, la detección de alcohol y drogas en estos pacientes y la actividad en prevención secundaria mediante intervención motivacional, entre otras. Resultados: De los 76 hospitales encuestados, 66 respondieron y tan sólo uno realizaba alguna actividad de prevención secundaria mediante intervención motivacional. La mayoría de los encuestados (64,5% [40/62]) desconocían esta posibilidad y el 29% no la realizaba por falta de medios (18/62). El 15,6% de los centros realiza siempre análisis de alcohol y drogas en traumatizados. El 37,5% (24/64) admite realizar estas pruebas en la «mayoría» de los pacientes, y un 40,6% sólo lo realiza «a veces». Conclusión: La mayoría de los encuestados desconoce la utilidad de la prevención secundaria en traumatizados. Este desconocimiento puede ser causante de la nula actividad que se detecta en España en este campo. Es necesario un plan de difusión con acciones educacionales para promocionar este tipo de actividades (AU)

ObjectiveTo determine the degree of activity in the field of secondary prevention of alcohol and/or drug abuse in trauma patients in Spain. Material and methods: We surveyed 76 hospitals located in all the autonomous regions of Spain. We collected information about the number of severe trauma patients admitted to the ICU per year, the detection of alcohol and drugs in these patients, and the activity for secondary prevention through motivational intervention among other approaches. Results: Of the 76 hospitals surveyed, 66 responded and only one carried out any secondary prevention activity through motivational intervention. Most of the hospitals surveyed (64.5%, 40/62) did not know of the possibility of secondary prevention through motivational intervention and (29%, 18/62) did not have the resources to carry it out. Asked whether they screened trauma patients for drugs and/or alcohol, 15.6% of centers responded «always» 37.5% (24/64) «usually», and 40.6% only «sometimes». Conclusion: Most centers surveyed are unaware of the usefulness of secondary prevention in trauma patients. This lack of awareness may be responsible for the lack of activity in this field in Spain. A plan to increase awareness, including educational interventions, is necessary to promote secondary prevention of alcohol and drug abuse among trauma patients (AU)

[Prognostic capacity of brain herniation signs in patients with structural neurological injury]. / Capacidad pronóstica de los signos de herniación cerebral en pacientes con afectación neurológica estructural.

OBJECTIVE: To determine whether the usual mortality prediction systems (APACHE and SAPS) can be complemented by cranial computed tomography (CT) brain herniation findings in patients with structural neurological involvement. DESIGN: Prospective cohort study. SETTING: Trauma ICU in university hospital. PATIENTS: One hundred and fifty five patients admitted to ICU in 2003 with cranial trauma or acute stroke. MAIN VARIABLES OF INTEREST: Data were collected on age, diagnosis, mortality, admission cranial CT findings and on APACHE II, APACHE III and SAPS II scores. RESULTS: Mean age was 47.8 +/- 19.4 years; APACHE II, 17.1 +/- 7.2 points; SAPS II, 43.7 +/- 17.7 points; and APACHE III, 55.8 +/- 29.7 points. Hospital mortality was 36% and mortality predicted by SAPS II was 38%, by APACHE II 30% and by APACHE III 36%. The 56 non-survivors showed greater midline shift on cranial CT scan versus survivors (4.2 +/- 5.5 vs. 1.6 +/- 3.22 mm, p = 0.002) and higher severity as assessed by SAPS II, APACHE II and APACHE III. The mortality rate was significantly higher in patients with subfalcial herniation (61% vs. 30%, p < 0.001). In the multivariate logistic regression analysis, hospital mortality was associated with the likelihood of death according to APACHE III (OR 1.07; 95% CI: 1.05-1.09) and with presence of subfalcial herniation (OR 3.15; 95% CI: 1.07-9.25). CONCLUSIONS: In critical care patients with structural neurological involvement, cranial CT signs of subfalcial herniation complement the prognostic information given by the usual severity indexes.

Capacidad pronóstica de los signos de herniación cerebral en pacientes con afectación neurológica estructural / Prognostic capacity of brain herniation signs in patients with structural neurological injury

Objetivo. Analizar en los pacientes con afectación neurológica estructural si los sistemas de predicción de mortalidad habitualmente usados (APACHE y SAPS) pueden ser complementados con los hallazgos de herniación cerebral encontrados en la tomografía computarizada (TC) craneal. Diseño. Estudio prospectivo de cohortes. Ámbito. Unidad de Cuidados Intensivos (UCI) de Traumatología de un hospital universitario. Pacientes. Ciento cincuenta y cinco pacientes ingresados en UCI durante el 2003 con traumatismo craneoencefálico (TCE) o accidente cerebrovascular agudo (ACVA). Variables de interés principales. Se recogió información sobre la edad, el diagnóstico, la mortalidad, los hallazgos en la TC craneal al ingreso, APACHE II, APACHE III y SAPS II. Resultados. La edad fue de 47,8 ± 19,4 años, el APACHE II 17,1 ± 7,2 puntos, el SAPS II 43,7 ± 17,7 puntos y el APACHE III de 55,8 ± 29,7 puntos. La mortalidad hospitalaria fue del 36% y la predicha por el SAPS II fue del 38%, por el APACHE II 30% y por el APACHE III 36%. Los 56 pacientes que fallecieron presentaban mayor desviación de la línea media en la TC craneal que los supervivientes: 4,2 ± 5,5 frente a 1,7 ± 3,2 mm (p = 0,002) y mayor gravedad evaluada con el SAPS II, APACHE II y APACHE III. La mortalidad fue significativamente mayor en los pacientes con herniación subfalcial (61% frente a 30%, p < 0,001). En el análisis multivariante con regresión logística se encontró que la mortalidad hospitalaria se asoció con la probabilidad de fallecer según el APACHE III (OR 1,07; IC 95%: 1,05-1,09) y con la presencia de herniación subfalcial (OR 3,15; IC 95%: 1,07-9,25). Conclusiones. En los pacientes críticos con afectación estructural neurológica, la presencia de signos de herniación subfalcial en la TC craneal complementan la información pronóstica de los índices de gravedad normalmente utilizados

Objective. To determine whether the usual mortality prediction systems (APACHE and SAPS) can be complemented by cranial computed tomography (CT) brain herniation findings in patients with structural neurological involvement. Design. Prospective cohort study. Setting. Trauma ICU in university hospital. Patients. One hundred and fifty five patients admitted to ICU in 2003 with cranial trauma or acute stroke. Main variables of interest. Data were collected on age, diagnosis, mortality, admission cranial CT findings and on APACHE II, APACHE III and SAPS II scores. Results. Mean age was 47.8 ± 19.4 years; APACHE II, 17.1 ± 7.2 points; SAPS II, 43.7 ± 17.7 points; and APACHE III, 55.8 ± 29.7 points. Hospital mortality was 36% and mortality predicted by SAPS II was 38%, by APACHE II 30% and by APACHE III 36%. The 56 non-survivors showed greater midline shift on cranial CT scan versus survivors (4.2 ± 5.5 vs. 1.6 ± 3.22 mm, p = 0.002) and higher severity as assessed by SAPS II, APACHE II and APACHE III. The mortality rate was significantly higher in patients with subfalcial herniation (61% vs. 30%, p < 0.001). In the multivariate logistic regression analysis, hospital mortality was associated with the likelihood of death according to APACHE III (OR 1.07; 95% CI: 1.05-1.09) and with presence of subfalcial herniation (OR 3.15; 95% CI: 1.07-9.25). Conclusions. In critical care patients with structural neurological involvement, cranial CT signs of subfalcial herniation complement the prognostic information given by the usual severity indexes

Critical care medicine in the hospital: lessons from the EURICUS-studies.

We have performed a retrospective analysis of the EURICUS-studies using their database at the Foundation for Research on Intensive Care in Europe (FRICE) and other related documents, among which the various reports produced to the European Union which granted the studies, with the following purposes: a) to select and describe the most relevant observational and experimental results of the EURICUS studies; b) to inventory the main obstacles to the appropriate organization of intensive care medicine in the Hospital and c) to highlight amid the acquired knowledge those subjects which could have a direct and primary impact for improving the organization and management of intensive care units (ICUs). The EURICUS-studies have shown a rather non-systematic variation on the variables of the organization and management, resulting in a significant waste of resources and in a generally perceived insufficient performance of ICUs in Europe. Three major roadblocks were found: a) the lack of a clear concept of Critical Care Medicine; b) the lack of defined objectives both regarding the planning of the facilities and the activities to be developed in the ICU and c) the lack of a purposeful organization and management of work in the ICU. The further development and integration of each ICU in the Hospital should consider the following: a) the system approach to the analysis and standardization of processes of care; b) the redefinition of all jobs in each ICU; c) the definition of patient/nurse ratios in each ICU and sibling departments and d) to professionalize the organization and management of the ICU.

Critical care medicine in the hospital: lessons from the EURICUS-studies

We have performed a retrospective analysis of the EURICUS-studies using their database at the Foundation for Research on Intensive Care in Europe (FRICE) and other related documents, among which the various reports produced to the European Union which granted the studies, with the following purposes: a) to select and describe the most relevant observational and experimental results of the EURICUS studies; b) to inventory the main obstacles to the appropriate organization of intensive care medicine in the Hospital and c) to highlight amid the acquired knowledge those subjects which could have a direct and primary impact for improving the organization and management of intensive care units (ICUs). The EURICUS-studies have shown a rather non-systematic variation on the variables of the organization and management, resulting in a significant waste of resources and in a generally perceived insufficient performance of ICUs in Europe. Three major roadblocks were found: a) the lack of a clear concept of Critical Care Medicine; b) the lack of defined objectives both regarding the planning of the facilities and the activities to be developed in the ICU and c) the lack of a purposeful organization and management of work in the ICU. The further development and integration of each ICU in the Hospital should consider the following: a) the system approach to the analysis and standardization of processes of care; b) the redefinition of all jobs in each ICU; c) the definition of patient/nurse ratios in each ICU and sibling departments and d) to professionalize the organization and management of the ICU

Hemos hecho un análisis retrospectivo de los estudios EURICUS, usando la base de datos de la Fundación para la Investigación en Medicina Intensiva en Europa (FRICE) y otros documentos relacionados, incluyendo los diferentes informes dirigidos a la Unión Europea, la cual financió los estudios, con los siguientes objetivos: a) seleccionar y describir los resultados más relevantes de los estudios tanto observacionales como experimentales EURICUS; b) hacer un inventario de los principales obstáculos a la organización óptima de la medicina intensiva en los hospitales y c) destacar los temas entre los conocimientos adquiridos que puedan tener un impacto directo y primario en la mejora de la organización y dirección de las Unidades de Cuidados Intensivos (UCI). Los estudios EURICUS han revelado una variación considerablemente no sistemática en las variables relacionadas con la organización y dirección, con el resultado de un malgasto importante de recursos y un rendimiento de las UCI en Europa que generalmente se considera insuficiente. Se encontraron tres obstáculos mayores: a) la falta de un concepto claro de la medicina intensiva; b) la falta de objetivos definidos, tanto en la planificación de las instalaciones como en las actividades a desarrollar en la UCI y c) la falta de una organización y dirección decisiva del trabajo en la UCI. En el desarrollo y la integración de la UCI en los hospitales se debería considerar cada uno de los siguientes: a) el abordaje sistemático integrado (system approach) al análisis y estandardización de los procesos médicos; b) la redefinición de todos los trabajos en la UCI; c) la definición de la ratio paciente/enfermera en cada UCI y departamentos relacionados y d) la profesionalización de la organización y dirección de la UCI

Mortalidad e índices pronósticos en pacientes obesos que ingresan en la UCI / Mortality and prognostic indexes in obese patients admitted to the intensive care unit

No disponible

[Severity assessment by APACHE III system in Spain]. / Objetivación de la gravedad mediante el sistema APACHE-III aplicado en España.

BACKGROUND: To assess the performance of the prediction equation of the APACHE(Acute Physiology Age and Chronic Health Evaluation) III prognostic scoring system when applied in Spain. PATIENTS AND METHOD: Prospective multicenter cohort study that included 10786 adult patients from 86 Spanish intensive care units (ICU). Data collection during first 24 hours of admission: acute physiology score, age and comorbilties,for calculating APACHE III score; treatment location prior to ICU admission and main diagnosis admission category for applying the mortality prediction equation of APACHE III system. Main outcome was observed hospital mortality. RESULTS: Age was 57.74 (0.16); 68% males. Non-operative patients represented 76% of sample. APACHE III score was 53.75(0.26); observed and predicted hospital mortality were 21.2% and 19.8% respectively, with a standardized mortality ration of 1.07. The Chi2 Hosmer-Lemershow statistic was (H) 135.6, (C) 133.91: p < 0.001. The area under the Receiver Operating Curve (ROC) was 0.808, and correct classification at mortality risk of 50% was 82%. Uniformity of fit was better for non-operative diagnoses and for patients admitted from the emergency area. Calibration was excellent for risk lower than 60% but slightly underestimated observed risks above this level. CONCLUSIONS: The American APACHE III equation fit well when applied to Spanish critical patients but with limitations. Discrepancies could be attributed to differences in case-mix and variations in practice style.

Quality of life before intensive care unit admission and its influence on resource utilization and mortality rate.

OBJECTIVE: To analyze the quality of life of critically ill patients before their intensive care admission and its relation to age, variables measured in the intensive care unit (ICU; severity of illness, therapeutic effort, resource utilization, and length of stay), and in-hospital mortality rate. DESIGN: Observational prospective multicenter study. SETTING: Eighty-six medical-surgical ICUs in Spain, including coronary patients. PATIENTS: We studied 8,685 patients between 1992 and 1993. Patients <16 yrs old and those dying within the first 6 hrs were excluded. MEASUREMENTS AND MAIN RESULTS: Data collection included age, gender, admission diagnosis, severity level by Acute Physiology and Chronic Health Evaluation (APACHE) III, quality of life survey score, therapeutic activity level by Therapeutic Intervention Scoring System (TISS), and ICU and hospital mortality rate. Pre-ICU quality-of-life score was 3.74 +/- 4.42 points; 33.24% of patients had a normal quality of life (0 points), and numbers of patients declined logarithmically in relationship to increasing quality-of-life scores, with only 189 patients having a score >15 points. Pre-ICU quality-of-life score correlated with age (r =.289, p <.001), with severity level by APACHE III score (r =.217, p <.001), and weakly with TISS (r =.067, p <.001). There was no correlation between quality of life and length of ICU stay. Patients dying in hospital after ICU discharge (n = 429) had worse quality of life (5.88 +/- 5.38 points) than those dying in the ICU (n = 1,453, 4.8 +/- 4.94), who themselves had a worse quality of life than hospital survivors (n = 6,803, 5.05 +/- 5.07; p <.0001 by analysis of variance), with significant differences between all three groups. In the multivariate analysis, pre-ICU quality-of-life was related to age, APACHE III score, and hospital mortality rate but not to TISS or ICU length of stay. Pre-ICU quality of life was introduced as a variable in the APACHE III prediction model and entered the model after acute physiology score, diagnosis, and age and before prior patient location and comorbidities. The area under the receiver operating characteristics curve was 0.834 when quality-of-life was included and 0.83 when not. CONCLUSIONS: In Spain, the quality of life of critically ill patients before their ICU admission is good, and only a small proportion of patients have a low quality of life before admission. Previous quality of life is related to hospital mortality rate but contributes very little to the discriminatory ability of the APACHE III prediction model and has little influence on ICU resource utilization as measured by length of stay and therapeutic activity.

La patología cerebrovascular aguda en las áreas de cuidados críticos y urgencias de Andalucía. Análisis clínicos-epidemiológicos y de práctica médica / Acute cerebrovascular disease in andalousian critical care and emergency areas. An analysis on clinical, epidemiological and medical practice aspects. EVASCAN Project

Fundamento. Estudio en Andalucía de la epidemiología de la enfermedad cerebrovascular aguda (ECVA), su práctica médica y resultados, identificando áreas de mejora. Método. Estudio observacional prospectivo en 27 hospitales, de muestreo consecutivo en pacientes ingresados en Urgencias y Unidades de Cuidados Intensivos (UCI) aplicando tres cortes transversales mensuales de 24 horas de duración (días 5,15 y 25) del 5 de marzo al 25 de agosto de 1998. Criterios de inclusión: perfil clínico agudo compatible con tomografía computarizada (TC) diagnóstica. Resultados. Población de Urgencias: n = 347,81 por ciento origen isquémico, edad 71 por ciento > 65 años, factores de riesgo: 55,8 por ciento con hipertensión arterial y 16,5 por ciento con fibrilación auricular. Medios de acceso al hospital : 48,7 por ciento medios propios. Tiempo de inicio de los síntomas a su llegada en Urgencias (T1) < 3 h, tiempo de ingreso en Urgencias - TC (T2): 56,8 por ciento < 3 h. Población de UCI: n = 133 (16/27 UCI y 5,9 por ciento total pacientes), 83,9 por ciento origen hemorrágico, edad < 65 años en 67,3 por ciento, medios acceso: 43,8 por ciento por el 061. Tiempos: T1 64,4 por ciento < 3h y T2 79,8 por ciento < 3 h. APACHE III 63,2 (29,2), consumos de recursos estancia: 12 (9,5) días, ventilación mecánica: 74,2 por ciento. Mortalidad hospitalaria: 33,3 por ciento y 53 por ciento a los 12 meses. Conclusiones. La ECVA de origen isquémico queda demorada en su manejo respecto a la forma hemorrágica. Los tiempos y circuitos de manejo intra y extrahospitalarios deben reducirse. En las UCI de hospitales de referencia ingresa la ECVA hemorrágica, globalmente es una causa de ingreso muy baja, caracterizada por una alta gravedad y consumos de recursos así como muy elevada mortalidad evolutiva. (AU)

Tiss 76 and Tiss 28: correlation of two therapeutic activity indices on a Spanish multicenter ICU database.

OBJECTIVES: To evaluate the performance of the Simplified Therapeutic Intervention Scoring System (TISS 28) on an independent database and to determine its relation to the original Therapeutic Intervention Scoring System (TISS 76). DESIGN: Analysis of the database of the Spanish prospective multicenter study PAEEC (Project for the Epidemiological Analysis of Critical Care Patients). SETTING: 86 intensive care units (ICUs) in Spain. PATIENTS: Data on 8838 patients admitted to the ICUs. MEASUREMENTS AND RESULTS: Administrative data, main diagnostic category, severity score [Acute Physiology and Chronic Health Evaluation (APACHE) II and III] and data for the calculation of the TISS 76 and TISS 28 were collected during the first 24 h after the patient's ICU admission. TISS 76 and TISS 28 scores were calculated and analyzed on how they varied according to other variables (diagnostic group, severity level, hospital size and age). The association between TISS 76 and TISS 28 was studied. The TISS 76 score was 21 +/- 10.5 points and the TISS 28 score 23.3 +/- 8.8 points. There was a good correlation between TISS 76 and TISS 28 (r = 0.85). The regression equation was: TISS 28 = 8.35 + (0.712 x TISS 76). The TISS 28 score behaved similarly to the TISS 76 score in relation to the other variables, with a positive correlation between the therapeutic and the severity level (APACHE II and III) and a negative correlation between therapeutic activity and age, with very similar correlation coefficients. Both TISS 28 and TISS 76 scores were higher in larger hospitals. CONCLUSIONS: There is a strong correlation between TISS 28 and TISS 76 scores in the PAEEC database and TISS 28 works correctly in our setting.

Acute respiratory distress syndrome in trauma patients: ICU mortality and prediction factors.

OBJECTIVES: To study the factors that influence the intensive care unit (ICU) mortality of trauma patients who develop acute respiratory distress syndrome (ARDS) and to evaluate determinants of length of ICU stay among these patients. DESIGN: Study on a prospective cohort of 59 trauma patients that developed ARDS. SETTING: ICU of a referral trauma center. Fifty-nine patients were included during the study period from 1994 to 1997. METHODS: The dependent variables studied were the mortality and length of ICU stay. The main independent variables studied included the general severity score APACHE III, the revised trauma and injury severity scores (RTS, ISS), emergency treatment measures, the gas exchange index (PaO2/FIO2) recorded after the onset of ARDS and the development of multiple system organ failure (MSOF). Univariate and multivariate analyses were performed. RESULTS: The mean age of patients was 42.1 +/- 16.7 years, 49 patients (83 %) were male, the mean APACHE III score was 52.7 +/- 33.7 points, the ISS 28.5 +/- 11.4 points and the RTS 8.9 +/- 2.5 points. ICU length of stay was 28.5 +/- 24.5 days and the mortality rate 31.7 % (19 deaths). Mortality was associated with the following: PaO2/FIO2 ratio on the 3rd, 5th and 7th days post-ARDS; high volume of crystalloid/colloid infusion during resuscitation; the APACHE III score; and the development of MSOF According to the multivariate analysis, the mortality of these patients was correlated with the PaO2/FIO2 ratio on the 3rd day of ARDS, the APACHE III score and the development of MSOF. This analysis also showed days on mechanical ventilation to be the only variable that predicted ICU length of stay. CONCLUSIONS: The ICU mortality of trauma patients with ARDS is related to the APACHE III score, the gas exchange evolution as measured by the PaO2/FIO2 on the 3rd day and the progressive complications indicated by the onset of MSOF. The length of ICU stay of these patients is related to the number of days on mechanical ventilation.

Immediate application of positive-end expiratory pressure is more effective than delayed positive-end expiratory pressure to reduce extravascular lung water.

OBJECTIVE: To determine by the measurement of extravascular lung water (EVLW) whether the timing of positive-end expiratory pressure (PEEP) application influences the intensity of lung injury. DESIGN: Animal experimental study. SETTING: Animal experimental laboratory. SUBJECTS: Mixed-breed pigs (n = 18), aged 4 to 5 mos, weighing 25 to 30 kg. INTERVENTIONS: The animals were anesthetized and tracheotomized, after which a permeability pulmonary edema was instigated by infusing oleic acid (0.1/kg) into the central vein. All animals were then randomly divided into three groups. In group 1 (n = 5), 10 cm H2O of PEEP was applied immediately after the oleic acid infusion and maintained throughout the 6 hrs of the experiment. Group 2 (n = 7) received the same level of PEEP 120 mins after the insult for 4 hrs. Group 3 (n = 6), the control group, was ventilated without PEEP for the six hrs of the experiment. MEASUREMENTS AND MAIN RESULTS: At the end of the experiment, EVLW was calculated by gravimetric method. EVLW in group 1 (11.46+/-2.00 mL/kg) was significantly less than in group 2 (19.12+/-2.62 mL/kg) and group 3 (25.81+/-1.57 mL/kg), (p<.0001). Oxygenation also showed important differences by the end of the experiment when the Pao2/Fio2 ratio was significantly better in group 1 (467+/-73) than in group 2 (180+/-82) and group 3 (39+/-9), (p<.0001). CONCLUSIONS: The application of 10 cm H2O of PEEP reduces EVLW in a time-dependent manner and maximum protective effect is achieved if it is applied immediately after lung injury production.