Avaliação da mortalidade de uma UTI de Sergipe segundo escore fisiológico agudo simplificado 3 (SAPS 3) / Assessment of mortality in a intensive care unit in Sergipe, according simplified acute physiology score 3 (SAPS 3) / Evaluación de la mortalidade en una Unidad de Cuidados Intensivos en Sergipe, según la puntuación fisiológica aguda simplificada (SAPS 3)

Justificativa e Objetivos: A avaliação da gravidade dos pacientes admitidos e suposição de prognósticos são características essenciais na medicina intensiva. O objetivo desse artigo é descrever o perfil epidemiológico e avaliar a mortalidade dos pacientes de uma unidade de terapia intensiva (UTI), segundo o cálculo do índice prognóstico Simplified Acute Physiology Score (SAPS) 3 por meio da sua equação global e da customizada para a América Latina. Métodos: Trata-se de uma coorte prospectiva realizada em uma UTI de Sergipe, com os casos admitidos entre setembro de 2018 e março de 2019. Os dados clínicos, demográficos e parâmetros para o cálculo do escore foram coletados em prontuários. A Standardized Mortality Ratio (SMR), a discriminação e a calibração foram calculadas para ambas as equações. Resultados: Foram incluídos 78 pacientes, sendo 60% do sexo masculino. A idade média foi 61,7 ± 17,2 anos. As infecções respiratórias foram a principais causas de internação (32,1%). O menor valor do SAPS 3 foi 13 e o maior 90, média de 65,9 ± 25,5. A mortalidade observada foi de 61,5%, e a média presumida foi de 47,4% pela equação global (SMR= 1,3) e 57,8% pela customizada (SMR= 1,04). O SAPS 3 demonstrou adequadas discriminação e calibração. Conclusão: Foi identificada uma alta taxa de mortalidade no estudo, no entanto, a média do escore SAPS 3 encontrado também, foi superior à maioria das publicações. O perfil epidemiológico encontrado mostrou-se próximo aos de outras unidades semelhantes. Ambas as equações apresentaram calibração e discriminação adequadas, com desempenho superior da equação customizada.(AU)

Background and Objectives: Assessment of the severity of admitted patients and assumption of prognoses are essential features in intensive care medicine. To describe the epidemiological profile and evaluate the mortality of the patients admitted to a intensive care unit (ICU) according to the prognostic index Simplified Acute Physiology Score (SAPS) 3 calculation through its global and customized equation for Latin America. Methods: It is a prospective cohort performed at a ICU in Sergipe, with cases admitted between September 2018 and March 2019. The clinical and demographic data, besides the variables for the score calculation were collected in medical records. The Standardized Mortality Ratio (SMR), discrimination and calibration were calculated for both equations. Results: We included 78 patients, 60% of them male. The mean age was 61.7 ± 17.2 years. Respiratory infections were the main causes of hospitalization (32.1%). The lowest value of SAPS 3 was 13 and the highest 90, mean of 65.9 ± 25.5. The observed mortality rate was 61.5%, and the assumed average was 47.4% for the global equation (SMR = 1.3) and 57.8% for the customized (SMR = 1.04). SAPS 3 demonstrated adequate discrimination and calibration. Conclusion: A high mortality rate was identified in the study, however, the average SAPS 3 score found was also superior to most publications. The epidemiological profile observed was close to those of other similar units. Both equations presented adequate calibration and discrimination, the customized one showing superior performance.(AU)

Justificación y Objetivos: La evaluación de la gravedad de los pacientes ingresados y la suposición de pronósticos son características esenciales en la medicina de cuidados intensivos. El objetivo de esta investigación es describir el perfil epidemiológico y evaluar la mortalidad de los pacientes de una unidad de cuidados intensivos (UCI) según el cálculo del índice de pronóstico de la puntuación de fisiología aguda simplificada 3 (SAPS 3) a través de su ecuación global y personalizada para América Latina. Método: Esta fue una cohorte prospectiva realizada en una UCI en Sergipe, con casos admitidos entre septiembre de 2018 y marzo de 2019. Los datos clínicos, demográficos y de parámetros para el cálculo de la puntuación se recopilaron en los registros médicos. La tasa de mortalidad estandarizada (SMR), la discriminación y la calibración se calcularon para ambas ecuaciones. Resultados: se incluyeron 78 pacientes, el 60% de ellos varones. La edad media fue de 61,7 ± 17,2 años. Las infecciones respiratorias fueron las principales causas de hospitalización (32,1%). El valor más bajo de SAPS 3 fue 13 y el más alto 90, promedio de 65.9 ± 25.5. La tasa de mortalidad observada fue de 61.5% y el promedio asumido fue de 47.4% para la ecuación global (SMR = 1.3) y de 57.8% para los personalizados (SMR = 1.04). Las SAPS 3 demostraron una adecuada discriminación y calibración. Conclusiones: Se identificó una alta tasa de mortalidad en el estudio, sin embargo, la puntuación promedio SAPS 3 encontrada también fue superior a la mayoría de las publicaciones. El perfil epidemiológico encontrado fue cercano al de otras unidades similares. Ambas ecuaciones presentaron una adecuada calibración y discriminación, con un rendimiento superior del personalizado.(AU)

Relação entre parâmetros hemostáticos, evolução clínica e desfecho de pacientes diagnosticados com sepse / Relationship between hemostatic parameters, clinical evolution and outcome of patients diagnosed with sepsis

Sepse é definida como uma resposta inflamatória sistêmica frente a um microrganismo, sendo uma das principais causas de morte em pacientes internados em unidades de terapia intensiva (UTI). Na sepse, a cascata de coagulação é ativada, contribuindo na formação de tromboembolismo venoso localizado e coagulação intravascular disseminada, uma das responsáveis pela síndrome da disfunção orgânica múltipla; além disso, o consumo de plaquetas e de proteínas de coagulação pode resultar em hemorragias graves. Pacientes com sepse internados em UTI têm como principais prestadores de assistência a equipe de enfermagem que pode ter suas atividades organizadas pela Sistematização da Assistência de Enfermagem (SAE). A SAE possibilita perspectivas em relação ao cuidado, guia e normatiza mais precisamente a assistência de enfermagem direcionando a resolução dos problemas dos pacientes, pois mobiliza competências profissionais específicas no cuidado, resultando na qualidade da assistência. Esse estudo objetivou avaliar a relação de dois componentes do sistema hemostático (contagem de plaquetas e International Normalized Ratio - INR) com a gravidade clínica e com o desfecho em pacientes diagnosticados com sepse internados na UTI. Trata-se de um estudo quantitativo, exploratório e correlacional no qual os dados foram coletados de maneira pregressa. O estudo desenvolveu-se num hospital público de cuidados de alta complexidade em nível ambulatorial e hospitalar, por meio da análise de prontuários de pacientes diagnosticados com sepse internados na UTI no período de janeiro a dezembro de 2017. As variáveis relacionadas às características sócio- demográficas, clínicas e o tempo de assistência de enfermagem foram coletadas do prontuário eletrônico dos pacientes utilizando-se formulário específico. Foram incluídos 176 prontuários. Não foram observadas diferenças estatisticamente significantes em relação ao sexo, idade ou raça dos pacientes, contudo, os resultados mostram que pacientes com desfecho óbito apresentaram piores valores dos parâmetros clínicos e laboratoriais, demandaram mais cuidados de enfermagem e apresentaram contagem de plaquetas menor e INR maior do que os pacientes que tiveram alta; além disso, observou-se que a contagem de plaquetas <100.000 mm3 e o INR>1,5 estão associados à maior frequência do desfecho óbito. Foi analisada a capacidade da contagem de plaquetas e do INR para predizerem o óbito por meio de uma curva ROC que indicaram a contagem de plaquetas como um preditor não adequado e o INR um preditor fraco para o desfecho óbito. Assim, este estudo mostrou que os pacientes diagnosticados com sepse que foram a óbito apresentaram maior comprometimento orgânico e demandaram mais cuidados de enfermagem do que aqueles que tiveram como desfecho a alta hospitalar, além disso, a contagem de plaquetas e o INR indicam um comprometimento do sistema hemostático, sinalizando um quadro fibrinolítico. Tanto a contagem de plaquetas quanto o INR foram associados ao óbito, no entanto, não se mostraram bons preditores para tal. O dimensionamento do trabalho de enfermagem utilizando o NAS, a avaliação dos exames laboratoriais e da gravidade através dos SAPS 3, realizados pelo enfermeiro com conhecimento específico, facilita a elaboração e evolução da SAE. Quanto mais dados, mais acurada a análise, levando a modificações do planejamento da assistência de enfermagem

Sepsis is defined as a systemic inflammatory response to a microorganism, being a major cause of death in intensive care unit (ICU) patients. In sepsis, the coagulation cascade is activated, contributing to the formation of localized venous thromboembolism and disseminated intravascular coagulation, one of the causes of multiple organ dysfunction syndrome. In addition, the consumption of platelets and coagulation proteins may result in serious bleeding. Patients with sepsis admitted to the ICU have, as their main care providers, the nursing staff that may have their activities organized by the Nursing Care Systematization (NCS). NCS provides perspectives regarding care, guides and regulates more precisely nursing care, directing the resolution of patients' problems, as it mobilizes specific professional skills in care, resulting in the quality of care. This study aimed to evaluate the relationship of two components of the hemostatic system (platelet count and International Normalized Ratio - INR) with clinical severity and outcome in patients diagnosed with ICU sepsis. This is a quantitative, exploratory and correlational study in which data were previously collected. The study was developed in a public hospital of high complexity care at the outpatient and inpatient level through the analysis of medical records of patients diagnosed with sepsis admitted to the ICU from January to December 2017. The variables related to socio-demographic, clinical characteristics and length of nursing care were collected from the patients' electronic medical records using a specific form. We included 176 medical records. No statistically significant differences were observed regarding gender, age or race of patients; however, the results show that patients with death outcome had worse clinical and laboratory parameter values, required more nursing care and had lower platelet count and higher INR than patients who were discharged; in addition, platelet counts <100,000 mm3 and INR> 1.5 were associated with a higher frequency of death outcome. We analyzed the ability of platelet count and INR to predict death by means of a ROC curve that indicated platelet count as an inadequate predictor and INR as a weak predictor of death outcome. Thus, this study showed that patients diagnosed with sepsis who died had greater organic impairment and demanded more nursing care than those who were discharged from the hospital. In addition, the platelet counts and INR indicate a compromised hemostatic system, signaling a fibrinolytic picture. Both platelet count and INR were associated with death; however, they were not good predictors for it. The dimensioning of nursing work using the NAS, the evaluation of laboratory tests and severity on SAPS 3, performed by a nurse with specific knowledge, facilitates the elaboration and evolution of the NCS. The more data, the more accurate the analysis, leading to changes in nursing care planning

Comparison of SAPS 3-PIRO score with other four scoring systems for assessing sepsis / 中华急诊医学杂志

Objective To investigate the feasibility of SAPS 3-PIRO score for prediction of outcomes in severe sepsis patients in the intensive care units (ICU).The optimal scoring system was also evaluated in this study.Methods Data of 677 patients with sepsis,treated in ICU of the emergency department at the Beijing Chaoyang Hospital between January 2008 and December 2011,were analyzed.The inclusion criteria were:age ≥18 years and the diagnostic criteria of severe sepsis and organ damage recommended by the International Sepsis Definitions Conference in Washington DC,USA in 2001,as well as the criteria developed by the Conference as a reference.The patients,who did not meet the criteria were excluded from the study.Age,gender,underlying disease,main infection site,and duration of ventilator support of all cases were recorded.Vital signs,hematological findings (gases,biochemistry,coagulation) and causative pathogens and organ damage on day-1 in the ICU were also recorded.According to the data of the most unfavorable findings in the ICU on day-1,scores got from APACHE Ⅱ,SOFA (sequential organ failure assessment),SAPS Ⅲ(simplified acute physiological score Ⅲ),SAPS 3-PIRO (predisposition,infection,response,organ failure/dysfunction) and MEDS (mortality in emergency department sepsis score) scoring systems were calculated.All patients were followed up for 28 days.The outcome of survival and death at 28 days were the endpoints of this study.SPSS V13.0 (SPSS,Chicago,IL,USA) was used to analyze data.Continuous variables with normal distribution were expressed as mean ± standard deviation.The independentsample t test was applied when normality (and homogeneity of variance) assumptions were fulfilled otherwise the t' test would be used.The distribution of categorical variables in two groups was tested using the x2 test.Binary logistic regression models were also used according to the survival status.The values of scoring system in predicting outcomes and the determination of dividing value in predicting death were analyzed using receiver operating characteristic (ROC) curves.The area under the receiver operating characteristic (AUROC) curves was compared using Z test.P values less than 0.05 were considered statistically significant.Results The total 28-day mortality was 41.9％.APACHE Ⅱ,SOFA,SAPS Ⅲ,SAPS 3-PIRO and MEDS scoring systems were used to find the independent predictive factors of death within 28 hours in patients with severe sepsis.By using ROC curve and AUROC curve to compare the validity of these scoring systems,SAPS 3-PIRO score had comparable predictive capability in comparison with APACHE Ⅱ,SOFA and SAPS Ⅲ scores,and MEDS was superior to SAPS 3-PIRO,APACHE Ⅱ,SOFA and SAPS Ⅲ score.Conclusions For patients with severe sepsis admitted in ICU,MEDS was superior to SAPS 3-PIRO,APACHE Ⅱ,SOFA and SAPS Ⅲ score in predicting prognosis.MEDS has favorable capability in predicting death within 28 days.MEDS ≥ 11 was the sign of increased mortality.SAPS 3-PIRO score has comparable predictive capability in comparison with APACHE Ⅱ,SOFA and SAPS Ⅲ score and it may be suggested for clinical practice.

Desempeño del APACHE II y el SAPS 3 Adaptación regional en una población de pacientes críticos de Colombia / Performance of APACHE II and SAPS 3 Regional adaptation in a population of critically Ill patients in Colombia

El puntaje fisiológico agudo simplificado, SAPS 3 (del inglés Simplified Acute Physiology Score 3) ha sido recientemente desarrollado con muestras de los cinco continentes, pero no ha sido validado en pacientes de las Unidades de Cuidados Intensivos (UCI) en Colombia. En este trabajo se comparó el desempeño del SAPS 3 con el APACHE II en pacientes colombianos de UCI. Métodos: en una población de una cohorte histórica de pacientes críticos admitidos a una UCI de un hospital universitario, entre enero 1º de 2006 a junio 30 de 2011, se midió el desempeño de los modelos de mortalidad. La probabilidad de muerte hospitalaria fue calculada con el APACHE II y el SAPS 3. Para mejorar la exactitud de los modelos fue realizada una adaptación de primer orden usandola regresión logística del puntaje original para el APACHE II, y para el SAPS 3 se hizo el cálculo de la probabilidad de muerte con las fórmulas para Europa oriental, Centro-Suramérica y Australasia. Resultados: el estudio incluye 2523 pacientes. La mortalidad hospitalaria fue 27%. La discriminación fue aceptable para todos los modelos, más baja para el APACHE II que mejora con la adaptación de 0.74 a 0.78. Para todas las formas de SAPS 3 el área bajo la curva ROC fue de 0.78. La calibración, medida con el estadístico de Hosmer-Lemeshow, fue pobre para el APACHE II, APACHE II adaptado,SAPS 3 adaptado para Centro-Suramérica, y Europa oriental, pero fue buena para el SAPS 3 global y el adaptado para Australasia. Conclusión: en una población de pacientes críticos colombianos, la adaptación logra mejorar la discriminación del APACHE II pero no su calibración. La calibración es adecuada sólo para el SAPS 3 global y el adaptado para Australasia. (Acta Med Colomb 2014; 39: 148-158).

The simplified acute physiological score (SAPS 3) has been recently developed with samples from the five continents, but has not been validated in patients in intensive care units (ICU) in Colombia. In this work the performance of SAPS 3 with APACHE II in Colombian ICU patients was compared. Methods: in a population of a historical cohort of critically ill patients admitted to an ICU of a university hospital between January 1°, 2006 to June 30, 2011, the performance of the mortality models was measured. The probability of hospital death was calculated with APACHE II and SAPS 3. To improve the accuracy of the models, a first order adaptation was realized, using the logistic regression of the original score for the APACHE II, and for SAPS 3 the calculation of the probability of death was done with the formulas for Eastern Europe, Central and South America and Australasia. Results: the study included 2523 patients. Hospital mortality was 27%. Discrimination was acceptable for all models, being lower for APACHE II, which improves with adaptation from 0.74 to 0.78. For all forms of SAPS 3, the area under the ROC curve was 0.78. Calibration, measured with the Hosmer-Lemeshow statistic was poor for the APACHE II, adjusted APACHE II, SAPS 3 adapted to Central South America and Eastern Europe, but it was good for the global SAPS 3 and for the one adapted to Australasia. Conclusion: in a population of Colombian critically ill patients, adaptation manages to improve discrimination of APACHE II but not its calibration. Calibration is appropriate only for the global SAPS 3 and the one adapted to Australasia. (Acta Med Colomb 2014; 39: 148-158).

Validation of the Simplified Acute Physiology Score 3 Scoring System in a Korean Intensive Care Unit

PURPOSE: The Simplified Acute Physiology Score (SAPS) 3 was recently proposed to reflect contemporary changes in intensive care practices. SAPS 3 features customized equations for the prediction of mortality in different geographic regions. However, the usefulness of SAPS 3 and its customized equation (Australasia SAPS 3) have never been externally validated in Korea. This study was designed to validate SAPS 3 and Australasia SAPS 3 for mortality prediction in Korea. MATERIALS AND METHODS: A retrospective analysis of the prospective intensive care unit (ICU) registry was conducted in the medical ICU of Samsung Medical Center. Calibration and discrimination were determined by the Hosmer-Lemeshow test and area under the receiver operating characteristic (aROC) curve from 633 patients. RESULTS: The mortalities (%) predicted by SAPS 3, Australasia SAPS 3, and SAPS II were 42 +/- 28, 39 +/- 27 and 37 +/- 31, respectively. The calibration of SAPS II was poor (p = 0.003). SAPS 3 and Australasia SAPS 3 were appropriate (p > 0.05). The discriminative power of all models yielded aROC values less than 0.8. CONCLUSION: In Korea, mortality rates predicted using general SAPS 3 and Australasia SAPS 3 exhibited good calibration and modest discrimination. However, Australasia SAPS 3 did not improve the mortality prediction. To better predict mortality in Korean ICUs, a new equation may be needed specifically for Korea.