Vitamin B6 intakes and status of mechanically ventilated critically ill patients in Taiwan.
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OBJECTIVE: To assess vitamin B6 intake and status of critically ill patients. The relationship between vitamin B6 status indicators and the severity of illness and outcome in these patients was also examined. DESIGN: Prospective clinical study. SETTING: The study was performed at the Taichung Veteran General Hospital, in the central part of Taiwan. SUBJECTS: Ninety-four patients in the intensive care unit (ICU) entered the study and 46 patients successfully completed this study. INTERVENTIONS: No intervention. MAIN OUTCOME MEASURES: Vitamin B6 intake was recorded for 14 days. Vitamin B6 status was assessed by direct measures (plasma pyridoxal 5'-phosphate (PLP), pyridoxal (PL), and urinary 4-pyridoxic acid (4-PA)) and indirect measures (erythrocyte alanine (EALT-AC) and aspartate (EAST-AC) aminotransaminase activity coefficient). The severity of illness (APACHE II score), the length of ventilation dependency, and the length of ICU and hospital stay were recorded. RESULTS: Patients had an adequate mean vitamin B6 intake (16.26+/-19.39 mg) during the 14 day study. Mean vitamin B6 intake was significantly higher on day 14 than on day 1 (P<0.001). However, plasma PLP and PL concentrations significantly decreased at the 14th day after admission (P<0.05). Erythrocyte alanine aminotransaminase activity coefficient and EAST-AC did not change significantly. Urinary 4-PA significantly increased at the 14th day (P<0.001). No significant relationships were found between APACHE II scores and clinical outcomes (the length of ICU and hospital stay, the length of ventilation dependency) of patients, vitamin B6 intake or status indicators. CONCLUSIONS: Critically ill patients received nutritional support in the ICU, and had sufficient mean vitamin B6 intake and adequate vitamin B6 status. Therefore, the severity of illness and the results should not be affected by vitamin B6 status. However, we have noted that plasma PLP and PL concentrations significantly decreased while vitamin B6 intake significantly increased on day 14. Critical clinical conditions and complex metabolism in the critically ill may account for the reduction of plasma PLP and PL. Since vitamin B6 deficiency causes profound effects on immune system function, dietary or supplemented vitamin B6 intake is suggested for hospitalized patients. (+info)
The customization of APACHE II for patients receiving orthotopic liver transplants.
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General outcome prediction models developed for use with large, multicenter databases of critically ill patients may not correctly estimate mortality if applied to a particular group of patients that was under-represented in the original database. The development of new diagnostic weights has been proposed as a method of adapting the general model - the Acute Physiology and Chronic Health Evaluation (APACHE) II in this case - to a new group of patients. Such customization must be empirically tested, because the original model cannot contain an appropriate set of predictive variables for the particular group. In this issue of Critical Care, Arabi and co-workers present the results of the validation of a modified model of the APACHE II system for patients receiving orthotopic liver transplants. The use of a highly heterogeneous database for which not all important variables were taken into account and of a sample too small to use the Hosmer-Lemeshow goodness-of-fit test appropriately makes their conclusions uncertain. (+info)
External validation of a modified model of Acute Physiology and Chronic Health Evaluation (APACHE) II for orthotopic liver transplant patients.
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INTRODUCTION: The purpose of the study was to validate the newly derived postoperative orthotopic liver transplantation (OLTX)-specific diagnostic weight for the Acute Physiology and Chronic Health Evaluation (APACHE) II mortality prediction system in independent databases. METHODS: Medical records of 174 liver transplantation patients admitted postoperatively to the adult intensive care units at King Fahad National Guard Hospital and the University of Wisconsin were reviewed, and data on age, sex, the underlying liver disease, APACHE II scores and the hospital outcome were collected. Predicted mortality was calculated using: 1) the original APACHE II diagnostic weight of postoperative other gastrointestinal surgery and 2) the newly derived OLTX-specific diagnostic category weight. Standardized mortality ratio and 95% confidence intervals were calculated. Calibration was evaluated with the Hosmer-Lemeshow goodness-of-fit C-statistic. Discrimination was tested by 2 x 2 classification matrices and by computing the areas under the receiver operating characteristic curves. Patient characteristics and outcome data were compared between the two hospitals. RESULTS: APACHE II significantly overestimated mortality when the original diagnostic weight was used, but provided a closer estimate of mortality with the OTLX-specific diagnostic weight. The C-statistic analysis showed better calibration for the new approach; discrimination was also improved. The performances of the prediction systems were similar in the two hospitals. The new model provided more accurate estimates of hospital mortality in each hospital. DISCUSSION: APACHE II provided an accurate estimate of mortality in liver transplant patients when the OLTX-specific diagnostic weight was used. With the new model, APACHE II can be used as a valid mortality prediction system in this group of patients. (+info)
Renal failure in the ICU: comparison of the impact of acute renal failure and end-stage renal disease on ICU outcomes.
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BACKGROUND: Acute renal failure (ARF) is associated with a persistent high mortality in critically ill patients in intensive care units (ICUs). Most studies to date have focused on patients with established, intrinsic ARF or relatively severe ARF due to multiple factors. None have examined outcomes of dialysis-dependent chronic renal failure [end-stage renal disease (ESRD)] patients in the ICU. We examined the incidence and outcomes of ARF in the ICU using a standard definition and compared these to outcomes of ICU patients with either ESRD or no renal failure. We sought to determine the impact of renal dysfunction and/or loss of organ function on outcome. METHODS: We prospectively scored 1530 admissions to eight ICUs over a 10-month period for illness severity at ICU admission using the Acute Physiological and Chronic Health Evaluation (APACHE III) evaluation tool. Patients were defined as having ARF based on the definition of Hou et al (Am J Med 74:243-248,1983) designed to detect significant measurable declines in renal function based on serum creatinine. ESRD patients were identified as being chronically dialysis-dependent prior to ICU admission and the remainder had no renal failure. Clinical characteristics at ICU admission and ICU and hospital outcomes were compared between the three groups. RESULTS: We identified 254 cases of ARF, 57 cases of ESRD and 1219 cases of no renal failure for an incidence of ARF of 17%. Roughly half the ARF patients had ARF at ICU admission and the remainder developed ARF during their ICU stay. Only 11% of ARF patients required dialysis support. ARF patients had significantly higher acute illness severity scores than those with no renal failure, whereas patients with ESRD had intermediate severity scores. ICU mortality was 23% for patients with ARF, 11% for those with ESRD, and 5% for those with no renal failure. There was no difference in outcome between patients who had ARF at ICU admission and those who developed ARF in the ICU. Patients with ARF severe enough to require dialysis had a mortality of 57%. APACHE III predicted outcome very well in patients with no renal failure and patients with ARF at the time of scoring but underpredicted mortality in those who developed ARF after ICU admission and overestimated mortality in patients with ESRD. CONCLUSIONS: ARF is common in ICU patients and has a persistent negative impact on outcomes, although the majority of ARF is not severe enough to require dialysis support. The mortality of patients with ARF from all causes is almost exactly similar to that noted using the same criteria two decades ago. More profound ARF requiring dialysis continues to have an even greater mortality. Nevertheless, acute declines in renal function are associated with a mortality that is not well explained simply by loss of organ function. The majority of ARF patients who did not require dialysis still had a considerably higher mortality than the ESRD patients, all of whom required dialysis; while ARF patients who did require dialysis had a much higher morality than ESRD patients. APACHE III performs well and captures the mortality of patients with ARF at the time of scoring. Development of ARF after scoring has a profound effect on standardized mortality. We were unable to identify a unique mortality associated with ARF, but the presence of measurable renal insufficiency continues to be a sensitive marker for poor outcome. (+info)
Risk factors and predictors of mortality of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia in HIV-infected patients.
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OBJECTIVES: To define the incidence, risk factors and short-term predictors of mortality of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia in HIV-infected patients. PATIENTS AND METHODS: All HIV-infected subjects with S. aureus bacteraemia were consecutively enrolled in a case-control study between January 1, 1991 and December 31, 2000 and prospectively followed up. RESULTS: In the study period, 129 of 419 (31%) HIV-infected patients with bacteraemia had a diagnosis of S. aureus bacteraemia. The comparative analysis of incidence of S. aureus bacteraemia in the period 1991-96 and 1997-2000 showed a significant decrease (P < 0.001). The same trend was observed for MRSA bacteraemia (P = 0.002). The analysis of antimicrobial resistance showed that among 129 S. aureus strains, 88 (68%) were methicillin susceptible and 41 (32%) were methicillin resistant. The majority of MRSA bacteraemia was hospital acquired (78%). Previous administration of beta-lactams (P < 0.001), multiple previous hospital admissions (P < 0.001) and low numbers of CD4+ peripheral cells (P < 0.001) were found to be independent risk factors of methicillin resistance at multivariate analysis. The mortality rate was 34% in the cases and 11% in the controls (P = 0.002). Multivariate analysis indicated that a high Acute Physiology and Chronic Health Evaluation (APACHE) III score (P < 0.001) and high HIV viraemia (P = 0.02), but not methicillin resistance, predicted an increased risk of death in patients with S. aureus bacteraemia. CONCLUSION: Individual exposure to beta-lactams, in association with a history of multiple hospitalizations and low CD4+ cell number, plays a pivotal role as a risk factor for the development of methicillin resistance in HIV-infected patients. Methicillin resistance does not influence the outcome of S. aureus bacteraemia when included in a multivariate analysis. (+info)
Measurement of endotoxin activity in critically ill patients using whole blood neutrophil dependent chemiluminescence.
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BACKGROUND: Lipopolysaccharide (endotoxin) from the cell wall of Gram-negative bacteria is a potent trigger for the release of host-derived inflammatory mediators. The relationship between endotoxaemia, Gram-negative infection and the clinical syndrome of sepsis has been difficult to establish, in part because of the limitations of available endotoxin assays. METHODS: We performed an observational cohort study in critically ill patients in the medical/surgical intensive care unit (ICU) of a tertiary care hospital. Whole blood endotoxin levels on the day of ICU admission were measured using a novel chemiluminescent assay--the endotoxin activity assay (EAA)--and the chromogenic modification of the limulus amoebocyte lysate (LAL) assay. RESULTS: We studied 74 consecutive admissions. Endotoxin levels were higher in patients with a diagnosis of sepsis (470 +/- 57 pg/ml) than in patients admitted with a diagnosis other than sepsis (157 +/- 140 pg/ml; P < 0.001). Endotoxaemia was significantly associated with Gram-negative infection (P < 0.05); no patient with a Gram-negative infection had an endotoxin level below 50 pg/ml. White blood cell counts of patients with EAA-detected endotoxaemia were significantly higher (15.7 +/- 9.1 x 10(9) cells/l for endotoxaemic patients versus 10.8 +/- 6.2 x 10(9) cells/l for patients without endotoxaemia; P < 0.05). CONCLUSION: Endotoxaemia is associated with Gram-negative infection from any source, and with a diagnosis of sepsis and leukocytosis. These correlations were not apparent using the LAL method. The EAA may be a useful diagnostic tool for the investigation of invasive Gram-negative infection and incipient sepsis. (+info)
Quality of life effects of antithrombin III in sepsis survivors: results from the KyberSept trial [ISRCTN22931023].
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INTRODUCTION: Treatment of sepsis is aimed at increasing both the duration and quality of survival. A long-term focus on quality of life (QoL) in clinical trial evaluations of sepsis care should be a priority. METHOD: QoL data were used to evaluate the effects of intravenous antithrombin III treatment for severe sepsis measured for up to 90 days during the follow-up phase of the KyberSept phase III clinical trial. A visual analog scale and a Karnofsky scale were used to measure physical, psychologic, and social QoL at regular intervals. Changes from baseline between placebo and antithrombin III groups were assessed using Wilcoxon statistical tests, with additional analyses by severity of illness and admitting diagnosis. RESULTS: Among all sepsis survivors in the trial, there was a significant advantage on some attributes of QoL in the antithrombin III subgroup of patients who did not receive heparin as compared with the corresponding placebo group. DISCUSSION: The present study represents the first attempt to evaluate patient QoL over a relatively long period in a large, randomized, placebo-controlled sepsis trial. Over a 90-day period, survivors of severe sepsis receiving antithrombin III experienced significant improvements as compared with placebo on several attributes of QoL. In conclusion, the present study demonstrated that clinical improvements over an extended time period with antithrombin III were complemented by improvements in QoL, particularly in social and psychologic functioning, in many patients. (+info)
The effects of IgM-enriched immunoglobulin preparations in patients with severe sepsis [ISRCTN28863830].
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INTRODUCTION: In this prospective, randomized controlled study, we aimed to evaluate the effect of IgM-enriched immunoglobulin treatment on progression of organ failure and septic shock in patients with severe sepsis. MATERIALS AND METHODS: Forty-two patients with severe sepsis were enrolled in the study. Patients in the study group (n = 21) received an intravenous immunoglobulin preparation (Pentaglobin in addition to standard therapy. Pentaglobin therapy was commenced on the day of diagnosis of severe sepsis: 5 ml/kg per day Pentaglobin (38 g/l IgG, 6 g/l IgM, and 6 g/l IgA) was infused over 6 hours and repeated for 3 consecutive days. Patients in the control group (n = 18) received standard sepsis therapy, but no immunoglobulin administration. Blood samples for procalcitonin (PCT) measurements were taken daily for 8 days. Severity of critical illness and development of organ failure were assessed by obtaining daily acute physiological and chronic health evaluation (APACHE) II and sequential organ failure assessment (SOFA) scores. RESULTS AND DISCUSSION: Procalcitonin levels showed a statistically significant decrease in the Pentaglobin group (P < 0.001); however, an improvement in SOFA scores could not be demonstrated. Procalcitonin levels and SOFA scores did not change significantly in the control group. Septic shock incidence (38% versus 57%) and 28-day mortality rate (23.8% versus 33.3%) were found to be similar between the Pentaglobin and control groups. The evaluation of serial APACHE II scores did not demonstrate a difference between Pentaglobin and control groups either. CONCLUSION: Present data could not demonstrate any beneficial effects of polyclonal immunoglobulin preparation Pentaglobin on organ morbidity, septic shock incidence and mortality rate in patients with severe sepsis. (+info)