PubMed · 9824062
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J Rapoport, D Teres, S Lemeshow. 1998. Can futility be defined numerically?. https://doi.org/10.1097/00003246-199811000-00009
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OBJECTIVE: To evaluate the effectiveness of a specific oncologic scoring system-the ICU Cancer Mortality model (ICM)-in predicting hospital mortality in comparison to two general severity scores-the Acute Physiology and Chronic Health Evaluation (APACHE II) and the Simplified Acute Physiology Score (SAPS II). PATIENTS AND METHODS: All 247 patients admitted for a medical acute complication over an 18-month period in an oncological medical intensive care unit were prospectively registered. Their data, including type of complication, vital status at discharge and cancer characteristics as well as other variables necessary to calculate the three scoring systems were retrospectively assessed. RESULTS: Observed in-hospital mortality was 34%. The predicted in-hospital mortality rate for APACHE II was 32%; SAPS II, 24%; and ICM, 28%. The goodness of fit was inadequate except for the ICM score. Comparison of the area under the ROC curves revealed a better fit for ICM (area 0.79). The maximum correct classification rate was 72% for APACHE II, 74% for SAPS II and 77% for ICM. APACHE II and SAPS II were better at predicting outcome for survivors to hospital discharge, although ICM was better for non-survivors. Two variables were independently predicting the risk of death during hospitalisation: ICM (OR=2.31) and SAPS II (OR=1.05). CONCLUSIONS: Gravity scores were the single independent predictors for hospital mortality, and ICM was equivalent to APACHE II and SAPS II.
OBJECTIVE: To investigate in clinical practice the role of non-invasive mechanical ventilation in the treatment of acute respiratory failure on chronic respiratory disorders. DESIGN: An 18 months prospective cohort study. SETTING: A specialised respiratory intensive care unit in a university-affiliated hospital. PATIENTS: A total of 258 consecutive patients with acute respiratory failure on chronic respiratory disorders. INTERVENTIONS: Criteria for starting non-invasive mechanical ventilation and for endotracheal intubation were predefined. Non-invasive mechanical ventilation was provided by positive pressure (NPPV) ventilators or iron lung (NPV). RESULTS: The main characteristics of patients (70% with chronic obstructive pulmonary disease) on admission were (mean, SD or median, 25th-75th centiles): pH 7.29 (0.07), PaCO(2) 83 mm Hg (19), PaO(2)/FiO(2) 198 (77), APACHE II score 19 (15-24). Among the 258 patients, 200 (77%) were treated exclusively with non-invasive mechanical ventilation (40% with NPV, 23% with NPPV, and 14% with the sequential use of both), and 35 (14%) with invasive mechanical ventilation. In patients in whom NPV or NPPV failed, the sequential use of the alternative non-invasive ventilatory technique allowed a significant reduction in the failure of non-invasive mechanical ventilation (from 23.4 to 8.8%, p=0.002, and from 25.3 to 5%, p=0.0001, respectively). In patients as a whole, the hospital mortality (21%) was lower than that estimated by APACHE II score (28%). CONCLUSIONS: Using NPV and NPPV it was possible in clinical practice to avoid endotracheal intubation in the large majority of unselected patients with acute respiratory failure on chronic respiratory disorders needing ventilatory support. The sequential use of both modalities may increase further the effectiveness of non-invasive mechanical ventilation.
BACKGROUND: The provision of nutritional support for patients in intensive care units (ICUs) varies widely both within and between institutions. We tested the hypothesis that evidence-based algorithms to improve nutritional support in the ICU would improve patient outcomes. METHODS: A cluster-randomized controlled trial was performed in the ICUs of 11 community and 3 teaching hospitals between October 1997 and September 1998. Hospital ICUs were stratified by hospital type and randomized to the intervention or control arm. Patients at least 16 years of age with an expected ICU stay of at least 48 hours were enrolled in the study (n = 499). Evidence-based recommendations were introduced in the 7 intervention hospitals by means of in-service education sessions, reminders (local dietitian, posters) and academic detailing that stressed early institution of nutritional support, preferably enteral. RESULTS: Two hospitals crossed over and were excluded from the primary analysis. Compared with the patients in the control hospitals (n = 214), the patients in the intervention hospitals (n = 248) received significantly more days of enteral nutrition (6.7 v. 5.4 per 10 patient-days; p = 0.042), had a significantly shorter mean stay in hospital (25 v. 35 days; p = 0.003) and showed a trend toward reduced mortality (27% v. 37%; p = 0.058). The mean stay in the ICU did not differ between the control and intervention groups (10.9 v. 11.8 days; p = 0.7). INTERPRETATION: Implementation of evidence-based recommendations improved the provision of nutritional support and was associated with improved clinical outcomes.