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Objectives: To study the factors that influence the intensive care unit (ICU) mortality of trauma patients who develop acute respiratory distress syndrome (ARDS) and to evaluate determinants of length of ICU stay among these patients. Design: Study on a prospective cohort of 59 trauma patients that developed ARDS. Setting: ICU of a referral trauma center. Fifty-nine patients were included during the study period from 1994 to 1997. Methods: The dependent variables studied were the mortality and length of ICU stay. The main independent variables studied included the general severity score APACHE III, the revised trauma and injury severity scores (RTS, ISS), emergency treatment measures, the gas exchange index (PaO2/FIO2) recorded after the onset of ARDS and the development of multiple system organ failure (MSOF). Univariate and multivariate analyses were performed. Results: The mean age of patients was 42.1±16.7 years, 49 patients (83%) were male, the mean APACHE III score was 52.7±33.7 points, the ISS 28.5±11.4 points and the RTS 8.9±2.5 points. ICU length of stay was 28.5±24.5 days and the mortality rate 31.7% (19 deaths). Mortality was associated with the following: PaO2/FIO2 ratio on the 3rd, 5th and 7th days post-ARDS; high volume of crystalloid/colloid infusion during resuscitation; the APACHE III score; and the development of MSOF. According to the multivariate analysis, the mortality of these patients was correlated with the PaO2/FIO2 ratio on the 3rd day of ARDS, the APACHE III score and the development of MSOF. This analysis also showed days on mechanical ventilation to be the only variable that predicted ICU length of stay. Conclusions: The ICU mortality of trauma patients with ARDS is related to the APACHE III score, the gas exchange evolution as measured by the PaO2/FIO2 on the 3rd day and the progressive complications indicated by the onset of MSOF. The length of ICU stay of these patients is related to the number of days on mechanical ventilation. [ABSTRACT FROM AUTHOR]

The concept of continuity of care by intensivists as an element of quality control in the medical care of Intensive Care Unit (ICU) patients surviving multiple organ dysfunction syndrome has led to a rethinking of the ICU model in recent years. We discuss the rationale to design and implement a hospital-based, prospective, randomized, multicenter Intervention/Control study in order to estimate the impact of an interdisciplinary intervention during the post-ICU recovery phase on medium-term medical outcomes in ICU patients with multiple organ dysfunction.

Purpose: To analyze patient physiologic alterations (events) and multiple organ failure during intensive care unit (ICU) stay and examine their relationship with ICU mortality., Material and Methods: A total of 17598 consecutive patients were studied for 10 months (1997-1998) in 55 European ICUs (EURICUS-II). Hourly data were collected on critical and noncritical systolic blood pressure, heart rate, oxygen saturation, and urinary events throughout ICU stay. Sepsis-related Organ Failure Assessment (SOFA) score was collected daily (6409 patients)., Results: SAPS-II was 31.2 +/- 18.4 and ICU mortality 13.9%. There were 3.4 +/- 9.2 noncritical (duration, 3.9 +/- 11.4 hours) and 2 +/- 7.5 critical (3.8 +/- 13.1 hours) systolic blood pressure events per patient. Heart rate, oxygen saturation, and urinary events had similar values. Nonsurvivors had significantly more and longer physiologic alterations vs survivors. Mortality was significantly related to mean daily duration of events and mean and maximum daily SOFA. Discrimination capacity to predict ICU mortality was measured using various models: with SAPS II, area under the receiver operating characteristic curve was 0.80; with APACHE III-classified diagnosis added, 0.84; with mean duration of events/ICU day, 0.91; and with mean and maximum SOFA scores, 0.95., Conclusion: Routinely gathered ICU data on physiologic variables and multiple organ failure can offer considerable complementary information not provided by usual mortality prediction systems; and their weight in daily care policy decisions may need to be revisited.

Objectives: To analyse 1-year mortality and functional disability outcomes and resource use in critical stroke patients admitted to ICU., Design and Setting: Multi-centre, prospective, observational study in 28 Spanish hospitals. PATIENTS. Patients admitted for acute stroke from March-August 1999., Intervention: Collection of data on: severity by Apache III and Glasgow Coma Score; neurological lesion, hospital and 1-year mortality; functional disability at 1 year by Barthel Index and Glasgow Outcome Scale; ICU length of stay, life support techniques, and neurosurgical interventions., Measurement and Results: We studied 132 patients: 21% with subarachnoid haemorrhage (SAH), 58% intracerebral haemorrhage (ICH), 20% ischaemic stroke (ISC); Apache III 63+/-29 ICU stay 13+/-12 days; 74% required mechanical ventilation. Hospital and 1-year mortality was 33% (22%:ISC, 32%:SAH, 37%:ICH) and 53.8% (66%:ISC, 39%:SAH, 54%:ICH), respectively. Age, APACHE III, and diagnosis defined hospital mortality. Age, APACHE III, and Glasgow Coma Score defined 1-year mortality. Barthel Index score improved ( P<0.001) between discharge and 1 year; 73% of patients presented severe disability at discharge vs. 26% at 1 year; 8% minimal/no disability at discharge vs. 43.3% at 1 year. Only 17% of subarachnoid haemorrhage patients presented severe disability at 1 year. Admission Apache III and hospital-discharge Barthel Index scores were related to functional outcome at 1 year., Conclusions: Critical stroke patients are characterized by high severity of illness, elevated resource consumption, and poor outcomes that are mainly influenced by severity and age. Glasgow Coma Score-measured neurological severity is the main determinant of future functional capacity, which is greater at 1 year.

Background: To assess the performance of the prediction equation of the APACHE(Acute Physiology Age and Chronic Health Evaluation) III prognostic scoring system when applied in Spain., Patients and Method: Prospective multicenter cohort study that included 10786 adult patients from 86 Spanish intensive care units (ICU). Data collection during first 24 hours of admission: acute physiology score, age and comorbilties,for calculating APACHE III score; treatment location prior to ICU admission and main diagnosis admission category for applying the mortality prediction equation of APACHE III system. Main outcome was observed hospital mortality., Results: Age was 57.74 (0.16); 68% males. Non-operative patients represented 76% of sample. APACHE III score was 53.75(0.26); observed and predicted hospital mortality were 21.2% and 19.8% respectively, with a standardized mortality ration of 1.07. The Chi2 Hosmer-Lemershow statistic was (H) 135.6, (C) 133.91: p < 0.001. The area under the Receiver Operating Curve (ROC) was 0.808, and correct classification at mortality risk of 50% was 82%. Uniformity of fit was better for non-operative diagnoses and for patients admitted from the emergency area. Calibration was excellent for risk lower than 60% but slightly underestimated observed risks above this level., Conclusions: The American APACHE III equation fit well when applied to Spanish critical patients but with limitations. Discrepancies could be attributed to differences in case-mix and variations in practice style.

Purpose: The purpose of this study was to compare resource consumption and mortality between (ARDS) patients with adult respiratory distress syndrome treated at our center in 1985 (45 patients) and those treated in 1995., Materials and Methods: This was a retrospective observational study, considering trauma and nontrauma ARDS separately. We recorded severity index scores (APACHE III), infectious complications and multiorgan failure, intensive care unit (ICU) resource consumption (TISS 28), length of stay, time on mechanical ventilation, and ICU mortality., Results: We found no variation in overall ARDS mortality and no reduction in mortality in the ARDS trauma group (43.5% in 1985 vs. 38.5% in 1995, not significant) but a significant increase in mortality among nontrauma septic ARDS patients (68.2% vs. 82.9%, P < .001), largely attributable to the new comorbidities of human immunodeficiency virus (HIV) infection and hematologic malignancy. TISS-28 showed an overall reduction over this time period (49.7 +/- 6.6 vs. 38.3 +/- 9.7, P < .001), due to fewer monitoring measures, particularly a lower use of pulmonary artery catheter. There were no overall changes in length of stay or days on mechanical ventilation between 1985 and 1995, but these variables did increase among the trauma subgroup., Conclusion: In our setting, mortality remained constant from 1985 to 1995 among ARDS trauma patients but not among nontrauma ARDS patients because of the new case-mix of the latter population, which now includes HIV and other immunodepressed patients.

Objective: To determine the utility of thoracic computed tomography (TCT) in the initial assessment of critically ill patients with chest injuries., Design: Prospective observational study of cohorts., Setting: Trauma intensive care unit (ICU) of a Spanish Level III hospital (US equivalent Level I)., Patients: Three hundred seventy-five patients with chest injuries were studied, grouped into two cohorts according to whether they underwent admission TCT (exposed cohort, group I, n = 104) or not (unexposed cohort, group II, n = 271)., Interventions: None., Measurements and Main Results: Demographic data, initial severity scores, and chest radiograph (CXR)-based diagnosis were collected in all patients as independent variables. In patients of group I, we also recorded the TCT-based diagnosis and any incidents, complications, or therapy changes resulting from the TCT. The need for and duration of mechanical ventilation, length of ICU stay, and ICU mortality were gathered in the whole sample as dependent variables. The admission data were similar in the two groups, except for a higher Injury Severity Score (ISS) and thoracic ISS in group I. TCT proved to be more sensitive than CXR in detecting pulmonary contusion, hemothorax, pneumothorax, and vertebral fractures and in identifying the faulty placement of chest drainage tubes. TCT findings induced therapy changes in approximately 30% of patients in group I. In the other dependent variables studied, there were no differences between the two groups. In the multivariate analysis, the TCT screening had no effects on the time on mechanical ventilation, length of ICU stay, or mortality., Conclusions: TCT detects more chest injuries in trauma patients than does CXR and induces therapy changes in a considerable number of patients. However, this does not translate into an improvement in clinical outcomes.

Objective: To determine by the measurement of extravascular lung water (EVLW) whether the timing of positive-end expiratory pressure (PEEP) application influences the intensity of lung injury., Design: Animal experimental study., Setting: Animal experimental laboratory., Subjects: Mixed-breed pigs (n = 18), aged 4 to 5 mos, weighing 25 to 30 kg., Interventions: The animals were anesthetized and tracheotomized, after which a permeability pulmonary edema was instigated by infusing oleic acid (0.1/kg) into the central vein. All animals were then randomly divided into three groups. In group 1 (n = 5), 10 cm H2O of PEEP was applied immediately after the oleic acid infusion and maintained throughout the 6 hrs of the experiment. Group 2 (n = 7) received the same level of PEEP 120 mins after the insult for 4 hrs. Group 3 (n = 6), the control group, was ventilated without PEEP for the six hrs of the experiment., Measurements and Main Results: At the end of the experiment, EVLW was calculated by gravimetric method. EVLW in group 1 (11.46+/-2.00 mL/kg) was significantly less than in group 2 (19.12+/-2.62 mL/kg) and group 3 (25.81+/-1.57 mL/kg), (p<.0001). Oxygenation also showed important differences by the end of the experiment when the Pao2/Fio2 ratio was significantly better in group 1 (467+/-73) than in group 2 (180+/-82) and group 3 (39+/-9), (p<.0001)., Conclusions: The application of 10 cm H2O of PEEP reduces EVLW in a time-dependent manner and maximum protective effect is achieved if it is applied immediately after lung injury production.

Objective: To establish whether the age of patients admitted into the intensive care unit (ICU) influences the amount of therapy received., Design: Observational, prospective, multicenter study., Setting: Eighty-six multidisciplinary ICUs in Spain, including coronary patients., Patients: The patients (n = 8,838) were studied during a 6-month period between 1992 and 1993. Patients < 16 yrs of age and patients dying within the first 6 hrs were excluded from the study., Measurements and Main Results: We collected data on age, gender, type of diagnosis at the time of admission, severity level by Acute Physiology and Chronic Health Evaluation (APACHE) II and III, quality of life survey score, therapeutic activity during the first 24 hrs by Therapeutic Intervention Scoring System, and ICU and hospital mortality rates. In the sample of patients, 12.5% were > 75 yrs of age. Compared with younger patients, these patients had higher APACHE II (18.41 +/- 0.23 vs. 15.14 +/- 0.09 points, p < .001) and APACHE III (65.8 +/- 0.81 vs. 53.32 +/- 0.33 points, p < .001) scores, a higher quality of life survey score (i.e., worse quality of life, 7.19 +/- 0.19 vs. 3.86 +/- 0.05 points, p < .001), and a greater ICU mortality rate (21.9% vs. 15.3%, p < .00001) and hospital mortality rate (30.8% vs. 19.3%, p < .00001). However, patients > 75 yrs had a lower Therapeutic Intervention Scoring System score (19.83 +/- 0.28 vs. 21.17 +/- 0.12 points, p < .001). Multivariate analysis showed that once severity, need for mechanical ventilation, diagnostic group, and mortality rate were taken into account, there was less therapeutic activity in patients > 75 yrs of age., Conclusions: Patients > 75 yrs of age represent a large proportion of patients in Spanish ICUs. Although their mortality rate and severity scores were higher than those values in younger patients, patients > 75 yrs of age received less therapy.

Background: The evaluation of the costs of intensive care is a subject of interest at present, due to the high resources required by this area of health care services and the rhythm at which these costs increase. Such an evaluation has rarely been carried out in Spain. The aim of this study was to quantify the cost of medical care to critical patients in an Intensive Care Unit (ICU) in addition to evaluate the relationship between the severity of the disease and the short term result of intensive health care., Methods: A prospective study was carried out in 1,184 patients admitted (February 1985-February 1986) to the ICU of the Hospital General de Especialidades Virgen de las Nieves in Granada (Spain). Variables collected were the severity of the patient (APACHE II), therapeutic intensity (TISS) received, diagnosis on admission and state on discharge. A detailed and individualized evaluation was performed concerning the costs of hospital stay and treatment in the ICU., Results: The cost per patient per day in the ICU was found to 54,438 pesetas in 1988. A significant association was demonstrated with age, severity, therapeutic intensity and the result of the stay in the unit, being much higher in the patients who died in the ICU, particularly in those in whom the prognosis "a priori" was good., Conclusions: A significant relation was found between the cost and severity of the disease, with the maximum costs being found in patients in whom survival was expected but who died and vice versa.

The binding of theophylline to plasma proteins was studied in samples from healthy adults at different pH values and drug concentrations and in samples from patients with chronic obstructive pulmonary disease (COPD). Binding determinations were performed by ultrafiltration and drug concentrations were measured by high performance liquid chromatography. Total plasma levels of theophylline did not influence the degree of the binding. The percentage of bound theophylline was positively correlated with pH both in vitro (r = 0.998, p less than 0.005) and in vivo (r = 0.579, p less than 0.005). Mean theophylline binding values in vivo (mean 56.3 +/- 12.5) and in vitro (mean 48.3 +/- 9.4) were significantly different. The increase in theophylline free levels detected in COPD patients was partially dependent on low pH values but the influence of other factors must also be considered. The therapeutic implications of altered theophylline binding are discussed.

We present the results gleaned from a study using retinol-transporting prealbumin and protein determination as a technic for assessing the nutritional status of 14 patients on parenteral feeding following an aggressive surgical procedure. We can conclude from the findings of the present study that these parameters are statistically significant.