Long-term survival after surgical critical illness: the impact of prolonged preceding organ support therapy.

OBJECTIVE: To identify the prognostic importance of preceding invasive ventilation, renal replacement therapy, and catecholamine therapy for long-term survivors after surgical critical illness. SUMMARY BACKGROUND DATA: Nothing is known about the effect of preceding intensive care unit (ICU)-related therapies on long-term outcome. METHODS: We performed a retrospective analysis of prospectively collected data of an ICU patient cohort linked to a local database. Adult patients (n = 1462) admitted to a 12-bed ICU between 1993 and 2005, who had an ICU length of stay of more than 4 days, were followed up until the end of the second year after ICU admission. Hazard function was explored by Weibull modeling and likelihood ratio tests. Cox-type structured hazard regression models were used to analyze linear, nonlinear, or time-varying associations of therapeutic variables with 2-year survival time of a patient subgroup, which had survived the period of high hazard. RESULTS: Hazard rate declined exponentially up to day 195 after ICU admission, and became constant thereafter. A total of 808 patients reached this stable stage of their disease forming the study population. Of these patients, 648 (80.2%) were still alive at the end of the second year after ICU admission. Underlying diseases were major determinants for long-term outcome. Long-term mortality was significantly associated with the acute extent of physiological derangement during ICU stay (maximum Apache II score), but was independent from the duration of preceding invasive organ support. CONCLUSION: In surgical patients with a prolonged ICU length of stay, an exorbitant mortality exists for about half a year after ICU admission. Later on, life expectancy of surviving patients is largely determined by the underlying disease and, to a minor degree, by the acute extent of homeostatic disturbance during ICU stay. The duration of preceding invasive therapies does not limit long-term survival.

Independent determinants of early death in critically ill surgical patients.

Abnormalities in cardiocirculatory, respiratory, or coagulatory parameters are frequent after major surgery, but so far, no study has investigated their predictive value for early intensive care unit (ICU) mortality. We aimed to describe and quantify the relation between these parameters that are routinely determined on ICU admission and early death after complex surgery. Individual patient data were available from a local ICU database. We performed a retrospective observational cohort study using prospectively collected data from March 1, 1993, through February 28, 2005. A cohort of 4,214 cases who were admitted to the ICU immediately after operation was analyzed. We studied age, sex, number of red blood cell units transfused on admission day, and admission values for heart rate, systolic blood pressure, hemoglobin concentration, partial thromboplastin time, prothrombin time, respiratory function (Pao2/Fio2 ratio), and body temperature for their association with 4-day mortality. Effects were adjusted for the underlying disease and for disease severity during the first 24 h after admission. We used generalized additive models to fit continuous variables individually before combining them into the final generalized model. We found an independent linear association between the number of transfused red blood cell units, partial thromboplastin time, and body temperature with acute outcome. A smoothed model described the independent interaction between admission blood pressure and early death. Only values of less than 80 mmHg were associated with an increased risk of 4-day mortality. According to these results, bleeding complications after ICU admission should be treated aggressively to prevent early death of the patient. However, normotensive conditions do not seem to be required to prevent early mortality. Whether rapid rewarming may improve outcome needs further rigorous study.

Prognostic factors in critically ill surgical patients requiring continuous renal replacement therapy.

BACKGROUND: Acute mortality of unselected critically ill patients has improved during the last 15 years. Whether these benefits also affect long-term survival of critically ill surgical patients with severe acute renal failure is unclear, as are the prognostic factors relevant for survival time or mortality. METHODS: We performed a retrospective analysis of data collected prospectively from March 1993, through February 2005. Data from a cohort of 170 consecutive postoperative patients without preceding kidney diseases but requiring continuous renal replacement therapy (CRRT) during intensive care unit (ICU) stay were analyzed. RESULTS: Six-month survival rate after ICU admission was 20.6%. In patients surviving more than 6 months, 5-year survival was 71.6%. After adjustment for relevant covariates, older age, disease severity at ICU admission, peritonitis and a large number of red cell units transfused during ICU stay were associated with worse 6-month prognosis. Duration of CRRT, and the origin and type of kidney failure were unimportant for prognosis, as was ICU admission date. CONCLUSION: Six-month prognosis of critically ill surgical patients with severe acute renal failure is poor and mostly determined by the disease severity at ICU admission and by the frequency of surgical complications. Outcome had not improved over the study period, but after successful surgical and intensive care therapy, long-term survival appears to be reasonably good.

Red cell transfusion: an essential factor for patient prognosis in surgical critical illness?

In contrast to randomized studies, previous cohort studies identified red cell transfusion as an independent predictor of mortality in critically ill patients. However, these cohort studies did not adjust for disease severity during intensive care unit (ICU) stay. We performed a retrospective, observational cohort study using prospectively collected data from March 1, 1993, through February 28, 2005. A cohort of 3037 consecutive surgical cases requiring intensive care therapy for more than one day was analyzed. We used two different sets of potentially confounding covariables (admission variables only or in combination with variables reflecting number and extent of organ dysfunction during ICU stay). We found that the total number of red cell units which a case had received during ICU stay, and the maximum number of units given on a single day, were independently associated with an increase in ICU mortality when only admission variables were considered for the analysis. After controlling for the additional effect of variables reflecting organ dysfunction during ICU stay, we found that red cell transfusion was no longer an independent risk factor for death. However, there was a significant effect of red cell transfusion on ICU LOS in survivors irrespective of the covariable sets used. We conclude that red cell transfusion during ICU stay may be only a surrogate marker for disease severity and is not causally related to ICU mortality. Relevant side effects of red cell transfusion are presumably small and may be only recognizable in surviving cases.

Acute and long-term survival in chronically critically ill surgical patients: a retrospective observational study.

INTRODUCTION: Various cohort studies have shown that acute (short-term) mortality rates in unselected critically ill patients may have improved during the past 15 years. Whether these benefits also affect acute and long-term prognosis in chronically critically ill patients is unclear, as are determinants relevant to prognosis. METHODS: We conducted a retrospective analysis of data collected from March 1993 to February 2005. A cohort of 390 consecutive surgical patients requiring intensive care therapy for more than 28 days was analyzed. RESULTS: The intensive care unit (ICU) survival rate was 53.6%. Survival rates at one, three and five years were 61.8%, 44.7% and 37.0% among ICU survivors. After adjustment for relevant covariates, acute and long-term survival rates did not differ significantly between 1993 to 1999 and 1999 to 2005 intervals. Acute prognosis was determined by disease severity during ICU stay and by primary diagnosis. However, only the latter was independently associated with long-term prognosis. Advanced age was an independent prognostic determinant of poor short-term and long-term survival. CONCLUSION: Acute and long-term prognosis in chronically critically ill surgical patients has remained unchanged throughout the past 12 years. After successful surgical intervention and intensive care, long-term outcome is reasonably good and is mainly determined by age and underlying disease.

Effects of a web-based follow-up intervention on self-efficacy in obesity treatment for women.

Obesity is a chronic disease requiring long-term care. The purpose of the current study was the evaluation of a web-based intervention (WBI), subsequent to an initial face to face life style treatment. In a randomized trial, 84 women received an introduction phase (4 months) and a training phase (2 months) where one group was trained in using WBI whereas the other arm received a printed manual (PMI). During the self-monitoring phase (6 months) participants either used the WBI or the PMI for follow-up support. Anthropometric parameters could be significantly reduced and self-efficacy was significantly increased in the first 6 months. At 12 months, values of self-efficacy of the WBI were not superior compared to results of the PMI; however, feedback on acceptability of the intervention did show higher ratings of the WBI and also facilitated contact with the program supervisor. No significant differences regarding the engagement in follow-up tools could be found between the intervention groups. Subgroup analysis indicated a positive effect of involvement in both forms of self-monitoring aftercare.

Short-term prognosis of critically ill surgical patients: the impact of duration of invasive organ support therapies.

PURPOSE: We wanted to identify the importance of the duration of invasive ventilation and of renal replacement therapy for short-term prognosis of surgical patients treated in an intensive care unit (ICU). METHODS: We analyzed adult patients (n = 1462) who had an ICU length of stay of more than 4 days and who were followed up until the end of the short-term phase after ICU admission. Duration of different invasive therapies was evaluated by constructing specific vectors that tested effects of time-dependent variables on outcome after a lag time of 7 days. MEASUREMENTS AND MAIN RESULTS: Eight hundred eight patients (56.6%) were still alive at the end of the short-term phase. During the short-term phase, 85.3% of the 1462 patients required invasive ventilation, and 16.1%, a continuous renal replacement therapy. Besides the underlying disease and disease severity at ICU admission, the need for invasive ventilation or renal replacement therapy was associated with poorer outcome. Duration of invasive ventilation shortened survival if treatment lasted for more than 11 days (nonlinear association). In contrast, duration of renal replacement therapy was unimportant for short-term prognosis. CONCLUSION: Prolonged duration of invasive ventilation but not of renal replacement therapy is inversely related to short-term survival.

Activity-guided antithrombin III therapy in severe surgical sepsis: efficacy and safety according to a retrospective data analysis.

Recent controlled studies that evaluated the efficacy of an adjuvant antithrombin (AT) III therapy in severe sepsis used a uniform AT-III dose and duration of therapy and did not adjust to the actual AT-III deficit. It was the aim of the present study to explore if surgical patients with severe sepsis might have a treatment benefit from an activity-guided AT-III therapy. We performed a retrospective cohort analysis using an intensive care unit (ICU) database. To examine the effect of AT-III on outcome and on red cell transfusion rate, multivariate generalized additive models (GAMs), Cox-type additive hazard regression models, and propensity score adjustments were used. Five hundred forty-five postoperative surgical patients requiring ICU therapy because of severe sepsis were analyzed. Antithrombin III was given to those patients believed to be at a high risk of dying. Antithrombin III therapy was guided by the individual AT-III activity and aimed at the maintenance of an activity of at least 100%. Antithrombin III supplementation was discontinued after the plasma AT-III activity had been persistently normal without simultaneous AT-III infusion. We found that patients receiving additional AT-III (n = 230) were sicker than those on standard therapy (n = 315; admission Acute physiology and chronic health evaluation II score, 19.8 +/- 7.3 vs. 17.9 +/- 7.1 [mean +/- SD]; P < 0.005). Correspondingly, 28-day mortality was higher in patients who had an additional AT-III therapy than in those on standard therapy (46.3% vs. 36.9%; P < 0.03), as was the number of red cell units transfused during ICU stay (21.5 +/- 26.7 vs. 9.3 +/- 12.1; P < 0.001). At multivariate analysis, there was no significant effect of AT-III therapy on 28-day mortality (GAM: odds ratio, 1.012; 95% confidence interval [CI], 0.651 - 1.573; P = 0.957) and 90-day survival time (Cox-type additive hazard regression: hazard ratio, 1.034; 95% CI, 0.779 - 1.387; P = 0.794). However, AT-III therapy was associated with a significantly higher frequency of red cell unit transfusion (GAM/zero-inflated Poisson: estimate, 1.26; 95% CI, 1.15 - 139; P < 0.001). Our results suggest that there seems to be no relevant effect of an activity-guided AT-III therapy on the prognosis of surgical patients with severe sepsis. However, transfusion frequency rises by AT-III therapy.

Secular trends in mortality associated with new therapeutic strategies in surgical critical illness.

BACKGROUND: Since 1999 randomized controlled trials have shown that new therapeutic strategies, such as strict glycemic control, increased use of noninvasive ventilation and of lung-protective ventilation, and early goal-oriented shock therapy, may reduce mortality in selected groups of critically ill patients. Whether these benefits can be translated to a surgical clinical setting is unclear. We wanted to evaluate longitudinally the successive routine implementation of new therapeutic measures and its effect on postsurgical patients admitted to the intensive care unit. METHODS: We performed a retrospective analysis on data collected prospectively from March 1, 1993 through February 28, 2005. RESULTS: A cohort of 1,802 consecutive cases requiring intensive care therapy for more than 4 days was analyzed. A significant decrease in mortality was observed in the last years of the study. With adjustment for relevant covariates, treatment after the implementation of new therapeutic strategies was identified as an independent factor linked with a reduced risk of death (odds ratio [OR] .518; 95% confidence interval [CI] .337-.796), whereas older age (OR 1.030; 95% CI 1.015-1.045), a high severity score on admission (OR 1.155; 95% CI 1.113-1.198) or during intensive care unit stay (OR 1.187; 95% CI 1.145-1.231), a high number of failing organs (OR 1.918; 95% CI 1.635-2.250), and peritonitis (OR 3.277; 95% CI 2.046-5.246) were independently associated with death. CONCLUSIONS: Implementing of a variety of new therapeutic measures into routine care of critically ill surgical patients was associated with improved survival after 2001.