The APACHE III Score and Multiple Organ Failure(MOF) Score in Patients who were Recipients of Decision-Making Do-Not- Resuscitate / 성인간호학회지

PURPOSE: The purpose of this study was to identify characteristics of patients who were recipients of decision-making DNR, to describe the situations of DNR, and to analyze the APACHE III and MOF scores. METHOD: Data collection was conducted through reviews of medical records of 51 patients and through interviews with families of patients who were decision-makers for DNR at C university K Hospital located in Seoul from April to September 2002. RESULTS: The men's APACHE III and MOF scores were higher than the women's and the non cancer patients were higher than cancer patients. Some 80.4% of DNR orders was by communication, while 11.8% of consents were written. Each of APACHE III and MOF scores of patients in the intensive care unit was higher than the patients in general ward at both points of admission and decision-making of DNR. APACHE III and MOF scores positively correlated statistically with each other. CONCLUSIONS: The findings of this study suggest that APACHE III and MOF scores be useful for decision-making of DNR as a tool measuring severity.

Discharge Decision-Making by Intensivists on Readmission to the Intensive Care Unit

Patients readmitted to the intensive care unit (ICU) have a significantly higher mortality rate. The role of intensivists in judging when to discharge patients from the ICU is very important. We undertook this study to evaluate the effect of the intensivists' discharge decision-making on readmission to ICU. The intensivists actively participated in the discharge decision-making, with the discharge guideline taken into consideration, in respect of group 1 patients, but not in respect of group 2. The readmission rate in group 1 was lower than that in group 2. The readmission in patients in each group was associated with higher mortality rates and longer lengths of stay at the ICU. Respiratory failure was the major cause of readmission. In the non-survivors out of the readmitted patients, the Acute Physiology and Chronic Health Evaluation (APACHE) III scores on the initial discharge and readmission, the multiple organ dysfunction syndrome (MODS) scores on the initial admission, discharge and readmission were higher than the corresponding indices in the survivors. We conclude that the readmission rate was lower when intensivists participated in the discharge decision-making, and that APACHE III and MODS scores on the first discharge and readmission were significant prognostic factors in respect of the readmitted patients.

Clinical Features and Risk Factors of Patients Readmitted to ICU / 대한마취과학회지

BACKGROUND: Premature discharge from the intensive care unit (ICU) results in ICU readmission and poor outcome. Understanding the clinical features of the readmitted patients may be helpful for intensivists to improve ICU care. We performed this study to determine the causes, outcomes, and risk factors of patients readmitted to the ICU. METHODS: Data was collected from the patients admitted to medical and surgical ICUs of Severance Hospital between January, 1999 and July, 2001 retrospectively. Readmission cause, source, indication, length of ICU stay, Acute Physiology and Chronic Health Evaluation (APACHE) III score, and multiple-organ failure (MOF) score of readmitted patients were evaluated. Non-survivors and survivors after ICU readmission were compared. RESULTS: One hundred and thirty-seven readmitted and 2,412 non-readmitted patients were examined and the readmission rate was 6.3%. Respiratory disease was the major cause of readmission. Readmitted patients had longer initial ICU lengths of stay than non-readmitted patients (13.6 vs 9.4 days, p<0.05). The ICU mortality rate was not significantly higher in the readmitted patients compared with the non-readmitted patients. The MOF score on readmission (5.4 vs 3.1) and APACHE III score on initial discharge (40.7 vs 30.4) and readmission (76.3 vs 44.4), in non-survivors were higher than survivors of the readmitted patients, respectively (p<0.05). CONCLUSIONS: ICU readmission was associated with longer ICU stay and respiratory disease was the major cause of readmission. The MOF score at readmission and APACHE III score at discharge and readmission were significant risk factors of the outcome in readmitted patients.

The Effect of Discharge Decision-Making of the Intensivist on Readmission to the Intensive Care Unit / 대한구급학회지

BACKGROUND: Patients readmitted to intensive care unit (ICU) have significantly higher mortality. The role of intensivists to judge when to discharge from ICU may be important. We performed this study to assess the effect of intensivist's discharge decision-making on readmission to ICU. METHODS: Data were collected prospectively from patients admitted to ICUs (group 1). Another data were collected retrospectively from the patients' record (group 2). Discharge of the patients in group 1 were based on intensivist's discharge decision-making but not in group 2. We encouraged deep breathing and expectoration to patients of group 1 at risk of pulmonary complication during ICU stay and used a guideline for making discharge decisions. Readmission cause, length of ICU stay, Acute Physiology and Chronic Health Evaluation (APACHE) III score, and multiple organ dysfunction syndrome (MODS) score of readmitted patients were evaluated. RESULTS: Readmission rate of group 1 was lower than that of group 2 (p<0.05). The mortality of readmitted patients in each group was higher than that of non-readmitted patients (p<0.05). Respiratory disease was the major cause of readmission. In non-survivors of readmitted patients, APACHE III score on initial discharge and readmission, MODS score on initial admission, discharge and readmission were higher than those of survivors (p<0.05). CONCLUSIONS: Readmission rate was lower when intensivists participated in discharge decision- making. ICU readmission was associated with higher hospital mortality and longer ICU stay. MODS and APACHE III score at first discharge and readmission were significant prognostic factors of the outcome in readmitted patients.

Prognostic Implication of Serial Blood Lactate Concentrations in SIRS Patient / 대한구급학회지

Introduction: Lactic acid in circulating blood should provide an index between balance of oxygen consumption and metabolic rate in sepsis or any state of shock. The purpose of the study was to determine the prognostic power of the lactate, the time factor of the blood lactate levels between survivors and non-survivors and the correlation between APACHE III score and blood lactate level in SIRS patients. METHOD: The study was performed on 99 patients over 16 years old who were admitted to the SICU with the criteria of SIRS. The blood lactate concentrations were assayed with arterial blood drawn in intervals ranging from 4 to 24 hours and the APACHE III scoring was done in the first 24 hours of SICU admission and daily until discharge or death for 2 weeks. The highest lactate level of the day was recorded. They were divided into two groups, survivors (n=61) and non-survivors (n=38), according to the outcome. RESULT: There were significant difference of the first day (D1) as well as peak lactate level between the survivors and the non-survivors (3.02 3.05 vs 7.41 4.78, 3.24 2.70 vs 7.82 4.88 mmol/L). Significant difference of the lactate as well as APACHE III were identified between the survivors and the non-survivors during a 14-days of observation period. Significant correlations were shown between lactate and APACHE III while the study was being conducted. The peak lactate presented superior to the D1 lactate in mortality prediction. CONCLUSION: Blood lactate concentration could be used as a prognostic index as well as APACHE III score. Serial blood lactate concentration assays are necessary to predict the outcome.

The Predictable Factors for the Mortality of Fatal Asthma with Acute Respiratory Failure / 결핵

BACKGROUNDS: Previous reports have revealed a high morbidity and mortality in fatal asthma patients, especially those treated in the medical intensive care unit(MICU). But it has not been well known about the predictable factors for the mortality of fatal asthma(FA) with acute respiratory failure. In order to define the predictable factors for the mortality of FA at the admission to MICU, we analyzed the relationship between the clinical parameters and the prognosis of FA patients. METHODS: A retrospective analysis of all medical records of 59 patients who had admitted for FA to MICU at a tertiary care MICU from January 1992 to March 1997 was performed. RESULTS: Over all mortality rate was 32.2% and 43 patients were mechanically ventilated. In uni-variate analysis, the death group had significantly older age (66.2 +/- 10.5 vs. 51.0 +/- 18.8 year), lower FVC(59.2 +/- 21.1 vs. 77.6 +/- 23.3%) and lower FEV1(41.4 +/- 18.8 vs. 61.1 +/- 23.30%), and longer total ventilation time (255.0 +/- 236.3 vs. 98.1 +/- 120.4 hour)(por=40) and PaO2/FiO2 ratio (<200) on the second day of MICU, which might reflect the response of treatment, rather than initially presented clinical parameters would be more important predictable factors of mortality in patients with FA.

Outcomes in Relation to Time of Tracheostomy in Patients with Mechanical Ventilation / 결핵

BACKGROUND: Despite widespread use of tracheostomy in intensive care unit, it is still controversial to define the best timing from endotracheal intubation to tracheostomy under prolonged mechanical ventilation. Early tracheostomy has an advantage of easy airway maintenance and enhanced patient mobility whereas a disadvantage in view of nosocomial infection and tracheal stenosis. However, there is a controversy about the proper timing of tracheostomy. METHODS: We conducted a retrospective study of the 35 medical and 15 surgical ICU patients who had admitted to Ewha Womans University Mokdong Hospital from January 1996 to August 1998 with the observation of APACHE III score, occurrence of nosocomial infections, and clinical outcomes during 28 days from tracheostomy in terms of early (n=25) vs. late (n=25) tracheostomy. We defined the reference day of early and late tracheostomy as 7th day from intubation. RESULTS: 1. The number of patients were 25 each in early and late tracheostomy group. The mean age were 48 +/- 18 years in early tracheostomy group and 63 +/- 17 years in late tracheostomy group, showing younger in early tracheostomy group. The median duration of intubation prior to tracheostomy was 3 days and 13 days in early and late tracheostomy groups. Organs that caused primary problem were nervous system in 27 cases(54%), pulmonary 14(28%), cardiovascular 4(8%), gastrointestinal 4(8%) and genitourinary 1(2%) in the decreasing order. Prolonged ventilation was the most common reason for purpose of tracheostomy in both groups. 2. APACHE III scores at each time of intubation and tracheostomy were slightly higher in late tracheostomy group but not significant statistically. Day to day APACHE III scores were not different between two groups with observation upto 7th day after tracheostomy. 3. Occurrence of nosocomial infections, weaning from mechanical ventilation, and mortality showed no significant difference between two groups with observation of 28days from tracheostomy. 4. The mortality was increased as the APACHE III score up to 7 days after tracheostomy increased, but there were no increment for the mortality in terms of the time of tracheostomy and the days of ventilator use before tracheostomy. CONCLUSION: The early tracheostomy seems to have no benefit with respect to severity of illness, nosocomial infection, duration of ventilatory support, and mortality. It suggests that the time of tracheostomy is better to be decided on clinical judgement in each case. And in near future, prospective, randomized case-control study is required to confirm these results.

Relationships between APACHE II and APACHE III Scores and Mortality Rate in Intensive Care Unit Patients / 대한마취과학회지

BACKGROUND: The APACHE II score system that evaluates prognosis has been widely applied for ICU patients. As the advent of APACHE III approaches, a comparison of effectiveness between APACHE II and APACHE III is demanded. The purpose of this study is to evaluate the relationships between APACHE II score and mortality rates, and between APACHE III scores and mortality rates in intensive care unit patients. METHODS: 289 adult ICU patients participated in this study. Their mortality rates and scores on APACHE II and APACHE III were calculated. The scores of the APACHE II and APACHE III systems were also compared between survivor and non-survivor groups. RESULTS: APACHE II scores at admission and discharge were 9+/-5, 6+/-4 in the survivor group and 20+/-9, 28+/-11 in the non-survivor group. APACHE III scores at admission and discharge were 29+/-19, 20+/-14 in the survivor group 75+/-37, 111+/-41 in the non-survivor group. The odds ratio between the mortality rate and the APACHE II score was EXP (0.2167) and the odds ratio between mortality rate and APACHE III score was EXP (0.0621). The determinant coefficient (R2) was 0.73 between the APACHE II and APACHE III scores. CONCLUSIONS: The results showed that both the APACHE II and APACHE III score systems are effective in predicting mortality rates in intensive care unit patients.

The Prognostic Value of the First Day and Daily Updated Scores of the APACHE III System in Sepsis / 결핵

BACKGROUND: The index which could predict the prognosis of critically ill patients is needed to find out high risk patients and to individualize their treatment. The APACHE III scoring system was established in 1991, but there has been only a few studies concerning its prognostic value. We wanted to know whether the APACHE III scores have prognostic value in discriminating survivors from nonsurvivors in sepsis. METHODS: In 48 patients meeting the Bones criteria for sepsis, we retrospectively surveyed the day 1 (Dl), day 2(D2) and day 3(D3) scores of patients who were admitted to intensive care unit. The scores of the sepsis survivors and nonsurvivors were compared in respect to the Dl score, and also in respect to the changes of the updated D2 and D3 scores. RESULTS: 1) Of the 48 sepsis patients, 21(43.5%) survived and 27(56.5%) died. The nonsurvivors were older(62.7+/-12.6 vs 51.1+/-18.1 yrs), presented with lower mean arterial pressure(56.9+/-26.2 vs 67.7 +/-14.2 mmHg) and showed greater number of multisystem organ failure(1.2+/-0.8 vs 0.2+/-0.4) than the survivors(p <0.05, respectively). There were no significant differences in sex and initial body temperature between the two groups. 2) The Dl score was lower in the survivors (n=21) than in the nonsurvivors (44.1 +/-14.6, 78.5+/- 18.6, p=0.0001). The D2 and D3 scores significantly decreased in the survivors (Dl vs D2, 44.1+/- 14.6: 37.9+/-15.0, p=0.035; D2 vs D3, 37.9+/-15.0: 30.1 +/-9.3, p=0.0001) but showed a tendency to increase in the nonsurvivors (Dl vs D2 (n=21), 78.5+/-18.6: 81.3+/-23.0, p=0.1337; D2 vs D3 (n=11), 68.2+/-19.3: 75.3+/-18.8, p=0.0078). 3) The D1 scores of 12 survivors and 6 nonsurvivors were in the same range of 42~67 (mean D1 score, 53.8+/-10.0 in the survivors, 55.3+/-10.3 in the nonsurvivors). The age, sex, initial body temperature, and mean arterial pressure were not different between the two groups. In this group, however, D2 and D3 was significantly decreased in the survivors(Dl vs D2, 53.3+/-10.0: 43.6+/- 16.4, p=0.0278; D2 vs D3, 43.6+/-16.4: 31.2+/-10.3, p=0.0005), but showed a tendency to increase in the nonsurvivors(Dl vs D2 (n=6), 55.3+/-10.3:66.7+/-13.9, p=0.1562; D2 vs D3 (n=4), 64.0+/- 16.4:74.3+/-18.6, p=0.1250). Among the individual items of the first day APACHE III score, only the score of respiratory rate was capable of discriminating the nonsurvivors from the survivors (5.5 +/-2.9 vs 1.9+/-3.7, p=0.046) in this group. CONCLUSION: In sepsis, nonsurvivors had higher first day APACHE III score and their updated scores on the following days failed to decline but showed a tendency to increase. Survivors, on the other hand, had lower first day score and showed decline in the updated APACHE scores. These results suggest that the first day and daily updated APACHE III scores are useful in predicting the outcome and assessing the response to management in patients with sepsis.