Background Goal-directed therapy has been used for severe sepsis and septic shock in the intensive care unit. This approach involves adjustments of cardiac preload, afterload, and contractility to balance oxygen delivery with oxygen demand. The purpose of this study was to evaluate the efficacy of early goal-directed therapy before admission to the intensive care unit. Methods We randomly assigned patients who arrived at an urban emergency department with severe sepsis or septic shock to receive either six hours of early goal-directed therapy or standard therapy (as a control) before admission to the intensive care unit. Clinicians who subsequently assumed the care of the patients were blinded to the treatment assignment. In-hospital mortality (the primary efficacy outcome), end points with respect to resuscitation, and Acute Physiology and Chronic Health Evaluation (APACHE II) scores were obtained serially for 72 hours and compared between the study groups. Results Of the 263 enrolled patients, 130 were ...

Early Goal-Directed Therapy in the Treatment of Severe Sepsis and Septic Shock

There is no consensus definition of acute renal failure (ARF) in critically ill patients. More than 30 different definitions have been used in the literature, creating much confusion and making comparisons difficult. Similarly, strong debate exists on the validity and clinical relevance of animal models of ARF; on choices of fluid management and of end-points for trials of new interventions in this field; and on how information technology can be used to assist this process. Accordingly, we sought to review the available evidence, make recommendations and delineate key questions for future studies. We undertook a systematic review of the literature using Medline and PubMed searches. We determined a list of key questions and convened a 2-day consensus conference to develop summary statements via a series of alternating breakout and plenary sessions. In these sessions, we identified supporting evidence and generated recommendations and/or directions for future research. We found sufficient consensus on 47 questions to allow the development of recommendations. Importantly, we were able to develop a consensus definition for ARF. In some cases it was also possible to issue useful consensus recommendations for future investigations. We present a summary of the findings. (Full versions of the six workgroups' findings are available on the internet at http://www.ADQI.net
 ) Despite limited data, broad areas of consensus exist for the physiological and clinical principles needed to guide the development of consensus recommendations for defining ARF, selection of animal models, methods of monitoring fluid therapy, choice of physiological and clinical end-points for trials, and the possible role of information technology.

/pdf/acute-renal-failure-definition-outcome-measures-animal-3m4l0j5jsf.pdf

Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group.

ContextAlthough acute renal failure (ARF) is believed to be common in the setting
of critical illness and is associated with a high risk of death, little is
known about its epidemiology and outcome or how these vary in different regions
of the world.ObjectivesTo determine the period prevalence of ARF in intensive care unit (ICU)
patients in multiple countries; to characterize differences in etiology, illness
severity, and clinical practice; and to determine the impact of these differences
on patient outcomes.Design, Setting, and PatientsProspective observational study of ICU patients who either were treated
with renal replacement therapy (RRT) or fulfilled at least 1 of the predefined
criteria for ARF from September 2000 to December 2001 at 54 hospitals in 23
countries.Main Outcome MeasuresOccurrence of ARF, factors contributing to etiology, illness severity,
treatment, need for renal support after hospital discharge, and hospital mortality.ResultsOf 29 269 critically ill patients admitted during the study period,
1738 (5.7%; 95% confidence interval [CI], 5.5%-6.0%) had ARF during their
ICU stay, including 1260 who were treated with RRT. The most common contributing
factor to ARF was septic shock (47.5%; 95% CI, 45.2%-49.5%). Approximately
30% of patients had preadmission renal dysfunction. Overall hospital mortality
was 60.3% (95% CI, 58.0%-62.6%). Dialysis dependence at hospital discharge
was 13.8% (95% CI, 11.2%-16.3%) for survivors. Independent risk factors for
hospital mortality included use of vasopressors (odds ratio [OR], 1.95; 95%
CI, 1.50-2.55; P<.001), mechanical ventilation
(OR, 2.11; 95% CI, 1.58-2.82; P<.001), septic
shock (OR, 1.36; 95% CI, 1.03-1.79; P = .03),
cardiogenic shock (OR, 1.41; 95% CI, 1.05-1.90; P = .02),
and hepatorenal syndrome (OR, 1.87; 95% CI, 1.07-3.28; P = .03).ConclusionIn this multinational study, the period prevalence of ARF requiring
RRT in the ICU was between 5% and 6% and was associated with a high hospital
mortality rate.

/pdf/acute-renal-failure-in-critically-ill-patients-a-2xpk2gbmbh.pdf

Acute Renal Failure in Critically Ill Patients: A Multinational, Multicenter Study

ObjectiveTo evaluate the use of the Sequential Organ Failure Assessment (SOFA) score in assessing the incidence and severity of organ dysfunction in critically ill patients.DesignProspective, multicenter study.SettingForty intensive care units (ICUs) in 16 countries.PatientsPatients admitted to the

Use of the SOFA score to assess the incidence of organ dysfunction/failure in intensive care units: Results of a multicenter, prospective study

In this multicenter, prospective, randomized, controlled trial, we randomly as signed 466 patients with severe ARDS to undergo prone-positioning sessions of at least 16 hours or to be left in the supine position. Severe ARDS was defined as a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen (Fio2) of less than 150 mm Hg, with an F io2 of at least 0.6, a positive end-expira tory pressure of at least 5 cm of water, and a tidal volume close to 6 ml per kilogram of predicted body weight. The primary outcome was the proportion of patients who died from any cause within 28 days after inclusion. Results A total of 237 patients were assigned to the prone group, and 229 patients were as signed to the supine group. The 28-day mortality was 16.0% in the prone group and 32.8% in the supine group (P<0.001). The hazard ratio for death with prone position ing was 0.39 (95% confidence interval [CI], 0.25 to 0.63). Unadjusted 90-day mortal ity was 23.6% in the prone group versus 41.0% in the supine group (P<0.001), with a hazard ratio of 0.44 (95% CI, 0.29 to 0.67). The incidence of complications did not differ significantly between the groups, except for the incidence of cardiac arrests, which was higher in the supine group. Conclusions In patients with severe ARDS, early application of prolonged prone-positioning ses sions significantly decreased 28-day and 90-day mortality. (Funded by the Programme Hospitalier de Recherche Clinique National 2006 and 2010 of the French Ministry of Health; PROSEVA ClinicalTrials.gov number, NCT00527813.)

http://bcrt.ca/wp-content/uploads/2013/05/proning-in-ARDS.pdf

Prone Positioning in Severe Acute Respiratory Distress Syndrome

Objective. —To develop and validate a new Simplified Acute Physiology Score, the SAPS II, from a large sample of surgical and medical patients, and to provide a method to convert the score to a probability of hospital mortality. Design and Setting. —The SAPS II and the probability of hospital mortality were developed and validated using data from consecutive admissions to 137 adult medical and/or surgical intensive care units in 12 countries. Patients. —The 13 152 patients were randomly divided into developmental (65%) and validation (35%) samples. Patients younger than 18 years, burn patients, coronary care patients, and cardiac surgery patients were excluded. Outcome Measure. —Vital status at hospital discharge. Results. —The SAPS II includes only 17 variables: 12 physiology variables, age, type of admission (scheduled surgical, unscheduled surgical, or medical), and three underlying disease variables (acquired immunodeficiency syndrome, metastatic cancer, and hematologic malignancy). Goodness-of-fit tests indicated that the model performed well in the developmental sample and validated well in an independent sample of patients (P=.883 andP=.104 in the developmental and validation samples, respectively). The area under the receiver operating characteristic curve was 0.88 in the developmental sample and 0.86 in the validation sample. Conclusion. —The SAPS II, based on a large international sample of patients, provides an estimate of the risk of death without having to specify a primary diagnosis. This is a starting point for future evaluation of the efficiency of intensive care units. (JAMA. 1993;270:2957-2963)

https://jamanetwork.com/HttpHandlers/ArticlePdfHandler.ashx?journal=JAMA&articleId=409979&pdfFileName=jama_270_24_035.pdf

J R Le Gall

Papers

A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study