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Serial Daily Organ Failure Assessment Beyond ICU Day 5 Does Not Independently Add Precision to ICU Risk-of-Death Prediction.

ABSTRACT: OBJECTIVES:To identify circumstances in which repeated measures of organ failure would improve mortality prediction in ICU patients. DESIGN:Retrospective cohort study, with external validation in a deidentified ICU database. SETTING:Eleven ICUs in three university hospitals within an academic healthcare system in 2014. PATIENTS:Adults (18 yr old or older) who satisfied the following criteria: 1) two of four systemic inflammatory response syndrome criteria plus an ordered blood culture, all within 24 hours of hospital admission; and 2) ICU admission for at least 2 calendar days, within 72 hours of emergency department presentation. INTERVENTION:NoneMEASUREMENTS AND MAIN RESULTS:: Data were collected until death, ICU discharge, or the seventh ICU day, whichever came first. The highest Sequential Organ Failure Assessment score from the ICU admission day (ICU day 1) was included in a multivariable model controlling for other covariates. The worst Sequential Organ Failure Assessment scores from the first 7 days after ICU admission were incrementally added and retained if they obtained statistical significance (p < 0.05). The cohort was divided into seven subcohorts to facilitate statistical comparison using the integrated discriminatory index. Of the 1,290 derivation cohort patients, 83 patients (6.4%) died in the ICU, compared with 949 of the 8,441 patients (11.2%) in the validation cohort. Incremental addition of Sequential Organ Failure Assessment data up to ICU day 5 improved the integrated discriminatory index in the validation cohort. Adding ICU day 6 or 7 Sequential Organ Failure Assessment data did not further improve model performance. CONCLUSIONS:Serial organ failure data improve prediction of ICU mortality, but a point exists after which further data no longer improve ICU mortality prediction of early sepsis.

SUBMITTER: Holder AL

PROVIDER: S-EPMC5693776 | biostudies-literature | 2017 Dec

REPOSITORIES: biostudies-literature

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Serial Daily Organ Failure Assessment Beyond ICU Day 5 Does Not Independently Add Precision to ICU Risk-of-Death Prediction.

Holder Andre L AL Overton Elizabeth E Lyu Peter P Kempker Jordan A JA Nemati Shamim S Razmi Fereshteh F Martin Greg S GS Buchman Timothy G TG Murphy David J DJ

Critical care medicine 20171201 12

<h4>Objectives</h4>To identify circumstances in which repeated measures of organ failure would improve mortality prediction in ICU patients.<h4>Design</h4>Retrospective cohort study, with external validation in a deidentified ICU database.<h4>Setting</h4>Eleven ICUs in three university hospitals within an academic healthcare system in 2014.<h4>Patients</h4>Adults (18 yr old or older) who satisfied the following criteria: 1) two of four systemic inflammatory response syndrome criteria plus an ord ...[more]

PMID: 28906286

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Project description:BACKGROUND:High glycemic variability (GV) is common in critically ill patients; however, the prevalence and mortality association with early GV in patients with sepsis remains unclear. METHODS:This retrospective cohort study was conducted in a medical intensive care unit (ICU) in central Taiwan. Patients in the ICU with sepsis between January 2014 and December 2015 were included for analysis. All of these patients received protocol-based management, including blood sugar monitoring every 2 h for the first 24 h of ICU admission. Mean amplitude of glycemic excursions (MAGE) and coefficient of variation (CoV) were used to assess GV. RESULTS:A total of 452 patients (mean age 71.4?±?14.7 years; 76.7% men) were enrolled for analysis. They were divided into high GV (43.4%, 196/452) and low GV (56.6%, 256/512) groups using MAGE 65 mg/dL as the cut-off point. Patients with high GV tended to have higher HbA1c (6.7?±?1.8% vs. 5.9?±?0.9%, p?<?0.01) and were more likely to have diabetes mellitus (DM) (50.0% vs. 23.4%, p?<?0.01) compared with those in the low GV group. Kaplan-Meier analysis showed that a high GV was associated with increased 30-day mortality (log-rank test, p?=?0.018). The association remained strong in the non-DM (log-rank test, p?=?0.035), but not in the DM (log-rank test, p?=?0.254) group. Multivariate Cox proportional hazard regression analysis identified that high APACHE II score (adjusted hazard ratio (aHR) 1.045, 95% confidence interval (CI) 1.013-1.078), high serum lactate level at 0 h (aHR 1.009, 95% CI 1.003-1.014), having chronic airway disease (aHR 0.478, 95% CI 0.302-0.756), high mean day 1 glucose (aHR 1.008, 95% CI 1.000-1.016), and high MAGE (aHR 1.607, 95% CI 1.008-2.563) were independently associated with increased 30-day mortality. The association with 30-day mortality remained consistent when using CoV to assess GV. CONCLUSIONS:We found that approximately 40% of the septic patients had a high early GV, defined as MAGE >?65 mg/dL. Higher GV within 24 h of ICU admission was independently associated with increased 30-day mortality. These findings highlight the need to monitor GV in septic patients early during an ICU admission.

Project description:BackgroundUncertainty surrounding COVID-19 regarding rapid progression to acute respiratory distress syndrome and unusual clinical characteristics make discharge from a monitored setting challenging. A clinical risk score to predict 14-day occurrence of hypoxia, ICU admission, and death is unavailable.ObjectiveDerive and validate a risk score to predict suitability for discharge from a monitored setting among an early cohort of patients with COVID-19.DesignModel derivation and validation in a retrospective cohort. We built a manual forward stepwise logistic regression model to identify variables associated with suitability for discharge and assigned points to each variable. Event-free patients were included after at least 14 days of follow-up.ParticipantsAll adult patients with a COVID-19 diagnosis between March 1, 2020, and April 12, 2020, in 10 hospitals in Massachusetts, USA.Main measuresFourteen-day composite predicting hypoxia, ICU admission, and death. We calculated a risk score for each patient as a predictor of suitability for discharge evaluated by area under the curve.Key resultsOf 2059 patients with COVID-19, 1326 met inclusion. The 1014-patient training cohort had a mean age of 58 years, was 56% female, and 65% had at least one comorbidity. A total of 255 (25%) patients were suitable for discharge. Variables associated with suitability for discharge were age, oxygen saturation, and albumin level, yielding a risk score between 0 and 55. At a cut point of 30, the score had a sensitivity of 83% and specificity of 82%. The respective c-statistic for the derivation and validation cohorts were 0.8939 (95% CI, 0.8687 to 0.9192) and 0.8685 (95% CI, 0.8095 to 0.9275). The score performed similarly for inpatients and emergency department patients.ConclusionsA 3-item risk score for patients with COVID-19 consisting of age, oxygen saturation, and an acute phase reactant (albumin) using point of care data predicts suitability for discharge and may optimize scarce resources.

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Serial Daily Organ Failure Assessment Beyond ICU Day 5 Does Not Independently Add Precision to ICU Risk-of-Death Prediction.

Publications

Serial Daily Organ Failure Assessment Beyond ICU Day 5 Does Not Independently Add Precision to ICU Risk-of-Death Prediction.

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