Search

Objective: To investigate the performance of the Acute Physiology and Chronic Health Evaluation (APACHE) III scoring system in patients admitted to the intensive care unit (ICU) after major vascular surgery. Design: Retrospective cohort study. Setting: A tertiary referral center. Participants: Three thousand one hundred forty-eight patients who underwent major vascular surgery between October 1994 and March 2006. Interventions: None. Measurements and Main Results: Data were abstracted from an institutional APACHE III database. Standardized mortality ratios (SMRs) (with 95% confidence intervals) were calculated. The area under the receiver operating characteristic curve (AUC) and Hosmer-Lemeshow C statistic were used to assess discrimination and calibration, respectively. The mean age of 3,148 patients studied was 70.5 years (±standard deviation 9.6). The mean Acute Physiology Score and the APACHE III score on the day of ICU admission were 31.0 (±17.5) and 45.1 (±18.8), respectively. The mean predicted ICU and hospital mortality rates were 3.2% (±7.8%) and 5.0% (±9.5%), respectively. The median (and interquartile range) ICU and hospital lengths of stay were 4.3 (3.6-5.1) and 14 days (11.9-16.8 days), respectively. The observed ICU mortality rate was 2.4% (75/3, 148 patients) and hospital mortality rate was 3.7% (116/3,148). The ICU and hospital SMRs were 0.74 (0.58-0.91) and 0.74 (0.61-0.88), respectively. The AUC of APACHE III–derived prediction of hospital mortality was 0.840 (95% confidence interval, 0.799-0.880), indicating excellent discrimination. The Hosmer-Lemeshow C statistic was 28.492, with a p value <0.01, indicating poor calibration. Conclusions: The APACHE III scoring system discriminates well between survivors and nonsurvivors after major vascular surgery, but calibration of the model is poor. [Copyright &y& Elsevier]

Objective: To evaluate how the presence and timing of statin therapy affect perioperative renal outcomes after major vascular surgery. Design: Retrospective cohort study. Setting: Surgical intensive care unit at a single academic medical center. Participants: Patients undergoing major vascular surgery between July 2004 and October 2005. Measurements and Main Results: The presence and timing of perioperative statin administration and the propensity for receiving such therapy were noted. Renal outcomes, lengths of stay, and mortality were reviewed. One hundred fifty-one procedures were performed. Eighty-nine patients (59%) received statin therapy. There was no evidence for renal protection with perioperative statin therapy (Δ creatinine 0.2 mg/dL v 0.2 mg/dL, p = 0.41; acute renal injury/acute renal failure 8% v 6%, p = 1.00; renal replacement therapy 3% v 3%, p = 1.00; all statin v no statin, respectively). With the possible exception of early reinstitution of statin therapy in chronic statin users, subgroup analyses failed to confirm an association between statin timing and prevention of postoperative renal dysfunction. Conclusions: In the present investigation, neither the presence nor timing of perioperative statin therapy was associated with improved renal outcomes in patients undergoing a range of major vascular procedures. A possible exception is early postoperative reinitiation of statin therapy in chronic statin users. The discrepant results of available literature preclude a definitive statement on the use of statin therapy as a means of preventing postoperative renal dysfunction. An adequately powered prospective trial is needed before advocating the routine use of statin therapy for perioperative renal protection. [Copyright &y& Elsevier]

Purpose: The Acute Physiology and Chronic Health Evaluation (APACHE) III prognostic system has not been previously validated in patients admitted to the intensive care unit (ICU) after pneumonectomy. The purpose of this study was to determine if the APACHE III predicts hospital mortality after pneumonectomy. Methods: A retrospective review of all adult patients admitted to a single thoracic surgical intensive care unit after pneumonectomy between October 1994 and December 2004. Patient demographics, ICU admission day APACHE III score, actual and predicted hospital mortality, and length of hospital and ICU stay data were collected. Data on preoperative pulmonary function tests and smoking habits were also collected. Univariate statistical methods and logistic regression were used. The performance of the APACHE III prognostic system was assessed by the Hosmer-Lemeshow statistic for calibration and area under receiver operating characteristic curve (AUC) for discrimination. Results: There were 417 pneumonectomies performed during the study period, of which 281 patients were admitted to the ICU. The mean age was 61.1 years, and 67.2% were men; 88.2% were smokers with a median of 40.0 (interquartile range, 18-62) pack-years of tobacco use. The mean APACHE III score on the day of ICU admission was 37.7 (± standard deviation 17.8), and the mean predicted hospital mortality rate was 6.4% (±10.4). The median (and interquartile range) lengths of ICU and hospital stay were 1.7 (0.9-3.1) and 9.0 (7.0-17.0) days, respectively. The observed ICU and hospital mortality rates were 4.6% (13/281 patients) and 8.2% (23/281), respectively. The standardized ICU and hospital mortality ratios with their 95% confidence intervals (CIs) were 1.55 (0.71-2.39) and 1.27 (0.75-1.78), respectively. There were significant differences in the mean APACHE III score (p < 0.001) and the predicted mortality rate (p < .001) between survivors and nonsurvivors. In predicting mortality, the AUC of APACHE III prediction was 0.801 (95% CI, 0.711-0.891), and the Hosmer-Lemeshow statistic was 9.898 with a p value of 0.272. Diffusion capacity of the lung for carbon monoxide (DLCO) and percentage predicted DLCO were higher in survivors, but the addition of either of these variables to a logistic regression model did not improve APACHE III mortality prediction. Conclusions: In patients admitted to the ICU after pneumonectomy, the APACHE III discriminates moderately well between survivors and nonsurvivors. The calibration of the model appears to be good, although the low number of deaths limits the power of the calibration analysis. The use of APACHE III data in outcomes research involving patients who have undergone pneumonectomy is acceptable. [Copyright &y& Elsevier]

Inhalational agents have played a pivotal role in anesthesia history. The first publicly demonstrated anesthetic of the modern era, diethyl ether, was an inhalational anesthetic. The attributes of a good agent, ability to rapidly induce anesthesia, with limited side effects has lead research efforts for over a hundred and fifty years. The explosion hazard was largely conquered with the development of the halogenated agents in the 1950s. Rapid emergence, with limited nausea and vomiting continue to drive discovery efforts, yet the ‘modern’ agents continue to improve upon those in the past. The future holds promise, but perhaps the most interesting contrast over time is the ability to rapidly introduce new agents into practice. From James Young Simpson''s dinner table one evening to the operating suite the next day, modern agents take decades from first synthesis to clinical introduction. [Copyright &y& Elsevier]