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Background: Septic shock causing or complicating critical surgical illness results in high mortality. Drotrecogin alfa (activated), known also as recombinant human activated protein C (rhAPC) has become controversial as therapy, owing to persisting questions of efficacy and safety. We hypothesized rhAPC to be effective therapy for critically ill surgical patients with septic shock.Methods: Open-label therapy with rhAPC (by predefined criteria) of 108 critically ill surgical patients. Treated patients were matched individually in prospect for age, gender, Acute Physiology and Chronic Health Evaluation (APACHE)-II and -III scores, site of infection, and organism (0-2 points each, maximum 12 points) with 108 patients from our 15,000-patient surgical intensive care unit database who did not receive rhAPC. No match was accepted if <6 points. Multiple organ dysfunction (MOD) scores and data regarding cortisol concentrations, bleeding complications, and transfusion requirements were collected. The primary endpoint was 28-day mortality, with mortality for hospitalization and resolution of organ dysfunction as secondary endpoints. Statistical analyses included ANOVA, c statistic, binary logistic regression, and Kaplan-Meier time-to-event and Cox proportional hazards analyses; α=0.05.Results: The mean match score was 9.2±0.1 points (range, 6-12 points). Patients were well matched by all criteria, including baseline MOD score (9.5±0.7 vs. 9.8±0.3 points, p=0.66). Mean age was 68.1±1.1 years (p=0.49), Mean APACHE-III score was 99.6±1.5 points (p=0.87). Mean time to rhAPC administration was 25±3 h. Survival at 28 days after rhAPC was 71.3% vs. 49.1% (p=0.001); hospital survival was 57.4% vs. 40.7% (p=0.02). By logistic regression, rhAPC therapy resulted in improved 28-day survival (OR 2.57, 95% CI 1.46-4.52, p=0.001) (model χ2 11.244, p=0.001); and hospital survival (OR 1.96, 95% CI 1.14-3.36, p=0.015) (model χ2 6.03, p=0.014). The MOD score decreased significantly (p=0.012) during rhAPC therapy.Conclusion: Therapy with rhAPC appeared to improve survival in surgical ICU patients with life-threatening infection characterized by septic shock and organ dysfunction. [ABSTRACT FROM AUTHOR]

Background: The Surgical Infection Society (SIS) through its foundation (FDTN) confers awards to individuals who demonstrate interest in researching infection in the surgical setting. We sought to characterize the research output from prior award recipients and determine the impact of these awards on the individual and the SIS., Methods: The SIS website was queried for the names of all past award recipients. A MEDLINE search of the recipients was performed. Total number of publications and publications in the society's journal, Surgical Infections (SI), were identified. Gender and leadership positions within SIS were determined. Meeting attendance and participation were assessed. Donations by scholarship recipient to the FDTN were evaluated., Results: Between 1984 and 2012, 116 individuals received an SIS award or scholarship. Of these, 72% were male. There were 101 scholarships awarded, totaling nearly $3 million. Of the 19 new Junior Faculty Scholarships awarded, four were to consecutive recipients (CR). There were 11 clinical evaluative award scholarships awarded, three to CR. There were 100 Resident/Fellow scholarships awarded, and of these, 22 were awarded to CR. Past recipients had multiple publications (median total publications = 27; interquartile range (IQR): Nine to 62) and published multiple papers on the topic for which they received an award (median two; IQR: Zero to four). Recipients did not publish in SI (median SI publications = zero; IQR: Zero to one). There was no substantial difference in the number of publications by gender. Multiple awards (MA) were conferred to 26 (22%) individuals. Six (5.1%) assumed an executive position within SIS, two (1.7%) became SIS president. Those who received MA were more likely to serve as an officer than those who only received one award (15% vs. 2%, p = 0.02)., Conclusions: Scholarships have a large benefit for individual recipients; however, the benefit to the society remains harder to quantify.

Background: Multiple organ dysfunction syndrome (MODS) is the leading cause of death in surgical patients and in trauma patients who survive the first 24 h. First observed systematically among Vietnam War-era battle casualties who began to survive previously fatal injuries owing to improved evacuation, triage, and resuscitation, only to develop catastrophic manifestations of organ failure never before seen, the syndrome was recognized formally in 1975 as "multiple organ failure." Ensuing observations and investigations, undertaken in large part by surgeon-scientists, have refined our current understanding of MODS, yielding better outcomes., Methods: Review and synthesis of pertinent literature with personal observations and recollections of the senior investigator., Results: The MODS is now recognized as a continuum of physiologic derangements, rather than an all-or-nothing phenomenon. The most common precipitant appears to be ischemia-reperfusion injury, although severe sepsis also is commonplace. Descriptive biology has enhanced the understanding of the pathogenesis and outcomes of MODS, although the therapy is largely supportive, making prevention of paramount importance. Measures such as drotrecogin alfa (activated), intensive insulin therapy, corticosteroids, and low tidal volume ventilation may be effective., Conclusions: Although current treatment of MODS remains primarily supportive, the mortality rate appears to be decreasing. Appreciation of the interrelations between the inflammatory and coagulation systems provides hope in the battle against this frequent, elusive, deadly, and costly syndrome.

Background: Critical illness is characterized by hypoferremia, iron-deficient erythropoiesis (IDE), and anemia. The relative risks and benefits of iron supplementation in this setting are unknown., Methods: Anemic, critically ill surgical patients with an expected intensive care unit length of stay (ULOS) >or= 5 days were randomized to either enteral iron supplementation (ferrous sulfate 325 mg three times daily) or placebo until hospital discharge. Outcomes included hematocrit, iron markers (i.e., serum concentrations of iron, ferritin, and erythrocyte zinc protoporphyrin [eZPP]), red blood cell (RBC) transfusion, transfusion rate (mL RBC/study day), nosocomial infection, antibiotic days, study length of stay (LOS), ULOS, and death. Iron-deficient erythropoiesis was defined as an elevated eZPP concentration., Results: Two hundred patients were randomized; 97 received iron, and 103 received placebo. Socio-demographics, baseline acuity, hematocrit, and iron markers were similar in the two groups. No differences were observed between the iron and placebo groups with respect to either hematocrit or iron markers following up to 28 days. However, patients treated with iron were significantly less likely to receive an RBC transfusion (29.9% vs. 44.7%, respectively; p = 0.03) and had a significantly lower transfusion rate (22.0 mL/day vs. 29.9 mL/day; p = 0.03). Subgroup analysis revealed that these differences were observed in patients with baseline IDE only. Iron and placebo groups did not differ with respect to incidence of infection (46.8% vs. 48.9%; p = 0.98), antibiotic days (14 vs. 16; p = 0.45), LOS (14 vs. 16 days; p = 0.24), ULOS (12 vs. 14 days; p = 0.69), or mortality rate (9.4% vs. 9.9%; p = 0.62)., Conclusions: Enteral iron supplementation of anemic, critically ill surgical patients does not increase the risk of infection and may benefit those with baseline IDE by decreasing the risk of RBC transfusion. A trial comparing enteral and parenteral iron supplementation in this setting is warranted (ClinicalTrials.gov number, NCT00450177).

Background: Multiple organ dysfunction syndrome (MODS) remains prevalent and the leading cause of mortality in the surgical intensive care unit (ICU). Improvements in ICU care in the last 10 years (e.g., tight glycemic control, activated protein C, fewer transfusions causing fewer nosocomial infections) may have decreased the incidence, magnitude, and mortality of MODS, as hypothesized in this study., Methods: Longitudinal 17-year prospective study of 11,314 ICU patients (academic/tertiary unit, Level I trauma center), 5,157 (45.5%) of whom developed any degree of MODS (Marshall score, cumulative). Data collected included Admission Acute Physiology and Chronic Health Evaluation (APACHE)-II and APACHE-III scores, MOD score (MODsc), hospital mortality, and the incidence and magnitude of MODS. The ratio of MODsc: APACHE III was calculated. Analyses (X +/- SEM, chi2, repeated-measures ANOVA, linear and polynomial regression, c-statistic) were performed for calendar-year intervals beginning in 1990 through 2006., Results: Among MODS patients, the mean MODsc was 6.3 +/- 0.1 points, and the mortality rate was 22%. The APACHE III score increased significantly (p < 0.0001) over time, but the mortality rate was unchanged (r2 = 0.02). Adjusted for illness severity (MODsc:A3), the magnitude of MODS decreased significantly (p < 0.0001) during the time period., Conclusions: Despite significant increases in admission APACHE III score over 17 years, the adjusted magnitude of MODS (MODsc:A3) decreased. Given the strong association between MODS and mortality for critically ill surgical patients, it is likely that the unchanged risk-adjusted mortality observed over time is due to the reduced magnitude of MODS.

Background: Prospective data addressing end-of-life care in the surgical ICU are lacking. We determined factors surrounding life-sustaining therapy discussions (LSTDs) in our surgical ICU as experienced by housestaff., Study Design: Housestaff were interviewed daily about the occurrence of an LSTD between themselves and either a patient or surrogate. Patients for whom at least one LSTD occurred were compared with patients for whom an LSTD never occurred. Housestaff also completed a standardized questionnaire that captured events surrounding each LSTD., Results: Eighty LSTDs occurred among 50 patients. Lack of decision-making capacity (p = 0.04), age (p = 0.02), and acuity (p = 0.01) predicted independently the occurrence of an LSTD. Housestaff were significantly more likely to both report recent clinical deterioration (p < 0.01) and to assign a worse prognosis (p < 0.01) to patients for whom an LSTD occurred. Housestaff initiated the majority of LSTDs (70.0%) and usually did so because of clinical deterioration (60.7%); patient surrogates were most commonly believed to initiate LSTDs because of lack of improvement (60.1%). In no instance did a patient initiate an LSTD. For 39 of 50 patients (78.0%), changes in end-of-life care plans were eventually enacted as proposed originally. Housestaff reported that the likelihood of enactment depended on both the preexisting end-of-life care plan and the proposed change in end-of-life care plan., Conclusions: Age, acuity, and lack of decision-making capacity were the most important factors involved in the initiation of an LSTD. Housestaff reported that they initiated LSTDs for different reasons and proposed different end-of-life care plans relative to both patients and their surrogates. These disparities can contribute to failed enactment of proposed changes in end-of-life care plans.

Background: Mycobacterium avium-intracellulare (MAI) is a well-described pathogen in patients with acquired immune deficiency syndrome (AIDS). However, peritonitis and severe sepsis as a complication of disseminated MAI is rare. We report a case that represents the first successful use of recombinant human activated protein C (rhAPC) in the treatment of severe sepsis secondary to mycobacterial infection and only the second reported case of MAI peritonitis with no known predisposing factor other than AIDS., Methods: Case report and review of the pertinent literature., Results: A 36-year-old man with AIDS presented to the emergency department with acute-onset right-sided abdominal pain, fever, and chills. Abdominal computed tomography revealed multiple rim-enhancing fluid collections. Despite immediate surgical drainage and debridement and appropriate antimicrobial therapy targeting the non-tuberculous acid-fast bacilli found in intraperitoneal fluid, the patient developed severe sepsis and septic shock. Clinical improvement occurred after infusion of recombinant human activated protein C (rhAPC) and specific antimicrobial chemotherapy directed against MAI., Conclusions: Treatment with rhAPC decreases the mortality rate of bacterial sepsis of abdominal origin and may confer a similar benefit in the treatment of abdominal mycobacterial sepsis.

Objective: Despite improved resuscitation and sepsis care, acute renal failure (ARF) remains common in critically ill surgical patients. New methods of renal replacement therapy (RRT) are being used in surgical intensive care units (SICUs), including high-flux hemodialysis (HD) and continuous RRT (CRRT). RRT is being used increasingly early in the course of ARF, but data are scant to suggest that mortality is improved. Consequently, we determined whether outcomes were improved with CRRT in SICU patients, and hypothesized that CRRT lowers mortality for patients with ARF., Methods: Patients who developed ARF (acute increase in serum creatinine concentration >or=2.4 mg/dL) in the SICU from 1993 to 2004 were identified. Data collected prospectively included year of admission, age, gender, Acute Physiology and Chronic Health Evaluation (APACHE) III score, cumulative multiple organ dysfunction score and its individual components, cumulative nonrenal organ dysfunction score, and need for RRT. Patients were stratified January 1994 to January 2001 (pre-CRRT) and February 2001 to December 2004 (post-CRRT). The primary endpoint was mortality., Results: Among 8,505 SICU patients, 530 (6.2%) developed ARF. Three hundred and eleven patients were treated pre-CRRT and 219 thereafter. Female patients comprised 35% of ARF patients. The mean age was 69 years +/- 2 years, and the mean APACHE III score was 81 +/- 1 point for ARF patients. HD was performed in 15.6% of ARF patients before 2001 and 5.5% of ARF patients in 2001 and thereafter. CRRT was performed in 20.1% of ARF patients in 2001 and thereafter. Overall mortality for ARF patients was 45% (APACHE III normative predicted mortality: 55%) with no difference over time (pre-CRRT = 46.3%, post-CRRT = 45.2%, p = 0.86). Patients who required RRT had a mean APACHE III score of 91 +/- 1 point, with 61% mortality (predicted mortality: 67%), with no difference over time. Independent predictors of mortality overall and for ARF patients included age and the magnitude of renal, cardiovascular, hepatic, and neurologic dysfunction. In comparison with CRRT, HD was associated with a decreased risk of death., Conclusions: Despite more frequent RRT and the use of CRRT, the mortality of ARF in critically ill surgical patients remains high because of nonrenal organ dysfunction. Considering that ARF-related mortality was decreased by intermittent HD, and that intermittent RRT is less costly, patients who need RRT should be treated preferentially with HD.

Background: Previous studies addressing the relationship between anticoagulation and risk of traumatic intracranial hemorrhage (ICH) have provided conflicting results, and have examined infrequently elderly patients after falls. We used a statewide hospital discharge database to test the hypothesis that long-term anticoagulation (LTA) increases the likelihood of traumatic ICH and subsequent mortality in this patient population., Methods: Patients aged 65 years or older and hospitalized as the result of a fall were extracted from the New York State Statewide Planning and Cooperative Systems Database for the year 2004. LTA, ICH, and additional injuries including skull fracture, vertebral fracture, rib fracture, lower extremity fracture, thoracic visceral injury, and abdominal visceral injury were defined using corresponding International Classification for Disease, Ninth Edition coding. Covariates included age, gender, and comorbidity. Additional outcomes included length of stay and mortality. Multivariable logistic regression was used to identify independent predictors of traumatic ICH and subsequent mortality., Results: A total of 47,717 patients met the inclusion criteria. Falls were associated with a traumatic ICH in 2,517 patients (5.1%), and the mortality rate of patients with a fall-related, traumatic ICH was 15.5% (n = 394). A total of 1,511 (3.2%) patients hospitalized after a fall used LTA. Based on univariate analysis, ICH was the only injury that occurred more commonly in patients who used LTA, when compared with those who did not (8.0% vs. 5.3%, respectively, p < 0.0001). Furthermore, although overall mortality did not differ by use of LTA, mortality after ICH was significantly higher in patients who used LTA when compared with those who did not (21.9% vs. 15.2%, respectively, p = 0.04). Controlling for age, gender, and comorbidity, patients on LTA were 50% more likely to sustain a traumatic ICH after a fall (odds ratio = 1.50; 95% confidence interval, 1.23-1.81; p < 0.0001). Furthermore, among patients who sustained an ICH, mortality was 1.57-fold greater in patients on LTA (odds ratio = 1.57; 95% confidence interval, 1.02-2.45; p = 0.04)., Conclusions: These data indicate that use of LTA is independently associated with traumatic ICH and subsequent mortality in elderly patients hospitalized after a fall.

Background: The relationship between preinjury warfarin use and outcomes after traumatic brain injury in elderly trauma patients remains controversial. We hypothesized that, among elderly warfarin users, the degree of anticoagulation, rather than warfarin therapy itself, would predict the severity of traumatic brain injury., Methods: Retrospective study (2004-2006) of all elderly trauma patients (age >/=65 years) who were evaluated by the trauma service at a Level I trauma center and underwent computed tomography of the head for suspicion of an intracranial injury was performed. Three cohorts were grouped: (1) warfarin users with an admission International Normalized Ratio >/=2 (therapeutic group), (2) warfarin users with an admission International Normalized Ratio <2 (nontherapeutic group), and (3) warfarin nonusers. Main outcome variables were presenting with a Glasgow Coma Scale (GCS) score

Background: Elderly patients have become an increasingly prevalent proportion of the intensive care unit population. Outcomes of patients with acute respiratory distress syndrome (ARDS) have been improving in recent years, but studies of ARDS rarely include substantial numbers of elderly patients. Historically, the mortality rate for ARDS has been 69% to 80% among elderly patients. We reviewed our experience with ARDS to determine whether outcomes were improving over time, and in particular whether outcomes were equally favorable among our elderly patients aged 65 years or older., Methods: Patients who developed ARDS in a university surgical intensive care unit from 1993 to 2003 were identified and their data were collected prospectively. Data collected included age, gender, cause of ARDS, Acute Physiology and Chronic Health Evaluation (APACHE) III score (AIII), initial Pao2:FIO2, lung injury score (LIS), maximum positive end-expiratory pressure, multiple organ dysfunction pulmonary and nonpulmonary organ dysfunction scores (MODnp), vasopressor dependence, and development of ventilator-associated pneumonia. Outcomes of patients >65 years old with ARDS were compared with those of patients <65 years old., Results: In the study period, 343 patients developed ARDS, 210 of whom were >65 years old. Overall, age was 65.2 +/- 0.2 years, with a mean APACHE III score of 83.4 +/- 2.0 points. Sixty-six percent were men. The initial Pao2:FIO2 for the entire group was 104.3 +/- 4.1, and was less in younger patients. Maximum positive end-expiratory pressure was 15.6 +/- 0.5 cm H2O, and mean LIS was 3.3 +/- 0.6 points; these values did not differ between cohorts. Elderly patients had a mortality of 51.9% when compared with 41.7% for younger patients (p = not significant). By logistic regression analysis, factors predicting mortality included APACHE III score (each point, odds ratio [OR], 1.022; 95% confidence interval [CI], 1.008-1.035; p < 0.01) and nonpulmonary multiple organ dysfunction score (each point, OR, 1.366; 95% CI, 1.223-1.526; p < 0.0001), but neither age (p = 0.37), LIS (p = 0.49), multiple organ dysfunction pulmonary (p = 0.90), nor year of treatment (p = 0.74) had any effect on mortality., Conclusions: The mortality rate for elderly patients with ARDS is lower in our experience when compared with historical series, even though illness severity may be higher, and comparable to that of other patients. Careful hemodynamic monitoring and resuscitation combined with other strategies to ameliorate nonpulmonary organ dysfunction achieved good outcomes in high-risk patients and could contribute in the future to further improved outcomes of elderly patients with ARDS.

Background: The efficacy of therapy with drotrecogin alfa (activated) (DrotAA) (recombinant human activated protein C) for surgical patients with severe sepsis has been questioned, and there is concern that patients who have undergone surgery recently may be at increased risk of bleeding complications from the drug. This review was performed to analyze recent data and clinical trends in the management of surgical patients with severe sepsis with respect to the efficacy and safety of therapy with DrotAA., Methods: Review and synthesis of the pertinent English-language literature., Results: Source control is the mainstay of therapy for surgical infections, including intraabdominal infections, whereas antibiotics, fluid resuscitation, and support of visceral organ function are necessary adjuncts. Therapy with DrotAA can be given to surgical patients, albeit with some delay (most protocols specify a 12-h wait after major surgery to mitigate the perceived increased risk of bleeding), but efficacy as well as safety have been questioned. In the pivotal PROWESS clinical trial, DrotAA therapy did not appear to be efficacious for surgical sepsis, but rigorous scrutiny of surgical indications and adequacy of source control by blinded reappraisal of the PROWESS database suggested that DrotAA therapy may be effective for surgical patients at high risk of death (Acute Physiology and Chronic Health Evaluation [APACHE] II score>or=25 points). Several comparable studies have now been aggregated in the INDEPTH database, which shows a significant reduction in mortality (OR 0.66; 95% CI 0.45-0.97) for therapy with DrotAA of surgical patients with severe sepsis and a high risk of death. The risk of bleeding is higher in surgical patients compared with DrotAA-treated non-surgical patients, but there is a substantial improvement in survival with DrotAA treatment. In contrast, surgical patients at a lower risk of death do not benefit from therapy with DrotAA but are placed at risk for bleeding., Conclusion: Accumulating experience indicates that surgical patients with severe sepsis and a high risk of death (APACHE II>or=25 points) have a significantly lower mortality rate if treated with DrotAA. The increased risk of bleeding associated with therapy is acceptable given the clear improvement in survival. Surgical patients with sepsis who are at lower risk of death do not appear to benefit from therapy with DrotAA, which should be withheld in most circumstances because of the increased risk of bleeding.

Background: Conceptually, appropriateness of antibiotic therapy includes choice of agent relative to susceptibility of pathogens as well as dosing, timing of onset, and duration of therapy, but is most commonly considered in terms of choice of antibiotic. It has been suggested that inappropriate antibiotic selection can result in increased mortality. This study was performed to elucidate the role of scheduled, rotating antibiotic therapy in defining mortality among febrile, infected surgical ICU patients., Methods: Prospective inception-cohort study of 356 patients during their initial episode of fever (temperature > 38.2 degrees C), caused by infection diagnosed by positive cultures or direct inspection (some cases of peritonitis). Collected data included age, gender, admission APACHE III score, peak temperature, microbial isolates and susceptibility, source of infection, multiple organ dysfunction score, mortality, and several time intervals (time that cultures were collected, time from collection to antibiotic prescription, time from collection to antibiotic administration, duration of therapy)., Results: The mean age was 63 +/- 1 years, the mean APACHE III score was 74 +/- 2 points, the mean multiple organ dysfunction score was 8 +/- 1 points, and overall mortality was 31%. Neither the source of infection nor the specific isolate influenced mortality. Antibiotic therapy was appropriate (covered the isolates) in 94% of cases, and did not influence mortality. Duration of therapy was identical between groups (5.1 +/- 0.3 vs. 5.4 +/- 0.3 days, p = 0.61). By logistic regression (dependent variable = mortality), APACHE III score OR 1.025, 95% C.I. 1.021-1.04) and delayed antibiotic administration (30-min intervals, OR 1.021, 95% C.I. 1.003-1.038) were independent predictors of mortality., Conclusions: The use of scheduled monthly antibiotic cycling in the surgical ICU is associated with a high rate of "appropriate" antibiotic therapy, and appears to maintain or improve resistance patterns. Because antibiotic therapy was mostly appropriate for isolates, initial inappropriate therapy could not be identified as a risk factor for mortality. However, in the setting of appropriate antibiotic choice, the prompt initial administration of antibiotics appears to be crucial for survival, but neither site of infection nor specific pathogen are influential.

Background: Critically ill surgical patients remain at high risk of adverse outcomes as a result of intra-abdominal infections, including prolonged length of stay, organ dysfunction, and death despite advances in critical care and innovations in management of the peritoneal cavity. We evaluated the causes and consequences of intra-abdominal infections among critically ill surgical patients in a single tertiary-care intensive care unit (ICU) over a decade., Methods: Prospective study of 465 critically ill surgical patients with hollow viscus perforation and peritonitis or abscess from 1991-2002. Data collected were age, gender, admission APACHE III score, multiple organ dysfunction score, ICU and hospital length of stay, abscess (yes/no), site and type of perforation (colon vs. other), de novo vs. nosocomial origin, and mortality. Statistical analysis was by univariate ANOVA for coordinate data, Fisher exact test for continuous data, and logistic regression analysis., Results: The incidence of intra-abdominal infection was 5.75%, 73.7% of the patients developed organ dysfunction, and mortality was 22.6%. Females comprised 46.8% of the patients. De novo infection represented 71.8% of cases, whereas nosocomial infection comprised 28.2% of cases. Perforations were of the colon (including the appendix) 49.9% of the time. An abscess formed in 22.3% of patients; the remainder had peritonitis but no abscess. Patients in the cohort with peritonitis were older (p = 0.0157), sicker on admission (p = 0.0411) and developed more organ dysfunction (p = 0.0072), but had the same rate of mortality. Despite steadily increasing acuity since 1991 (r(2) = .71, p < 0.0001), the magnitude of organ dysfunction (r(2) = 0.11) and the mortality rate remained constant (r(2) = .01). By logistic regression, abscess correlated with less severe organ dysfunction (score > or = 5 [odds ratio 0.54, 95% CI 0.33-0.90] and > or =9 points [odds ratio 0.38, 95% CI 0.20-0.74]), and increasing magnitude of organ dysfunction was associated with mortality (each point [odds ratio 1.46, 95% CI 1.32-1.61])., Conclusions: Although outcomes are improving, generalized peritonitis still causes high organ dysfunction-related mortality among critically ill surgical patients. Further improvements in resuscitation, surgical technique, and pharmacotherapy of severe intra-abdominal infections are needed.

Background: Appendiceal computed tomography (CTA) for the diagnosis of acute appendicitis (AA) has become popular, with a growing body of literature reporting excellent rates of sensitivity, specificity, and accuracy (S/S/A). However, several studies indicate that the true S/S/A of CTA is lower than the best results reported, especially if the white blood count is normal, the reader is inexperienced, or the study is obtained in the absence of surgical consultation. Thus, it is possible that skepticism of the value of CTA to diagnose AA may exist. Our objective was to determine the current knowledge of and attitudes regarding CTA among practicing surgeons., Methods: Two thousand questionnaires were sent randomly to general surgeon Fellows of the American College of Surgeons. Questions detailed the surgeon's practice, experience, hospital characteristics, and opinion regarding the utility and use of CTA. The existence of a formal CTA protocol, its characteristics, and radiologist availability for CT interpretation were determined. Data were analyzed by x(2) with Fisher exact test, multiple-group x(2), and univariate ANOVA as appropriate. Results are reported as mean +/- SEM with significance accepted at p < 0.05., Results: The response rate was 27%. Mean age was 51 +/- 1 years, 60% of respondents were general surgeons, and 9% were laparoscopic surgeons. Seventy-four percent of respondents believe the accuracy rate of CTA is less than the originally reported 98%; those who disbelieve are less likely to utilize CTA (p < 0.0001). Sixty-two percent of respondents believe CTA is over-utilized; 43% obtain CTA in

Background: Regional enteritis may present in the setting of a variety of clinical symptoms. These symptoms range from mild to severe., Methods: Here we describe two different presentations of regional enteritis (Crohn's disease): one in the setting of Clostridium perfringens sepsis and the second in association with hemolytic-uremic syndrome. Both presentations resulted in life-threatening multiple organ dysfunction syndrome., Results: Following appropriate surgical management and intensive physiologic support, both patients recovered, despite a MODS-predicted risk of mortality of 100% and 91%, respectively., Conclusions: Fulminant presentations of regional enteritis of this magnitude are rare, and highlight the resolution of severe multiple organ dysfunction for each presentation.

Background: Fever may have malign consequences in the postoperative period. This study was performed to determine the causes and consequences of fever in critically ill surgical patients. The specific hypothesis tested is that postoperative fever is associated with adverse clinical outcomes, including increased organ dysfunction and risk of death., Methods: Inception-cohort study of critically ill surgical patients who manifested a core temperature of >/=38.2 degrees C for the first time. The episode of fever was monitored until resolution, which was defined as a core temperature of <38.2 degrees C for at least 72 consecutive h. Demographic data collected included age, gender, admission diagnosis, admission status (elective/emergency), severity of illness (APACHE III), the systemic inflammatory response syndrome (SIRS) score, the cumulative multiple organ dysfunction score, cause of fever (infectious/non-infectious), ICU and hospital length of stay, and mortality. The day of onset of fever in the ICU, peak temperature, ICU day of peak temperature, and duration of fever episode were recorded. All diagnostic and therapeutic interventions were recorded, including the type and duration of antibiotic therapy. Univariate results of possible significance (alpha < 0.15) were tested in logistic regression models for independence of effect upon mortality after auto-correlation was excluded by matrix correlations and the Durbin-Watson statistic. Cases where both non-infectious and infectious causes of fever were present were analyzed as part of the infectious group, whereas the cumulative MOD score was dichotomized (< 5, >/=5 points) at a value known to be associated with increased mortality., Results: Among 2,419 screened patients, 626 patients (26%) developed fever. Febrile patients were older, sicker, more likely to have undergone emergency surgery, more likely to develop organ dysfunction, and more likely to die (all, p < 0.0001). The mean day of onset of fever was day 1 and the mean peak temperature for the episode was 39.1 +/- 0.1 degrees C. For most patients, it was their only episode of fever, with a mean of 1.4 +/- 0.1 episodes/patient. Forty-six percent of febrile patients were found to have an infectious cause of fever. Nearly all patients had SIRS, and nearly all developed organ dysfunction to some degree. By logistic regression, the presence of SIRS (as opposed to fever in isolation), emergency status, higher APACHE III score and the peak temperature were associated with increased mortality, with peak temperature being the most powerful predictor in the model (OR 2.20, 95% Cl 1.57-3.19). Gender had no bearing on outcome, and there was a trend toward a protective effect from an infectious etiology of fever., Conclusions: Postoperative fever is deleterious to critically ill patients. The magnitude of fever is a determinant of mortality, whereas an infectious etiology of fever may not be. The impacts of nosocomial infection and suppression of fever on critically surgical patients deserve further study.

Background: Decreased concentrations of total cholesterol, lipoproteins, and lipoprotein cholesterols occur early in the course of critical illness. Low cholesterol concentrations correlate with high concentrations of cytokines such as interleukin (IL)-6 and IL-10, and may be due to decreased synthesis or increased catabolism of cholesterol. Low cholesterol concentrations have been associated clinically with several adverse outcomes, including the development of nosocomial infections. The study was performed to test the hypothesis that a low cholesterol concentration predicts mortality and secondarily predicts the development of organ dysfunction in critical surgical illness., Methods: A prospective study was undertaken of 215 patients admitted to a university surgical ICU with systemic inflammatory response syndrome (SIRS). Serial blood samples were collected within 24 h of admission, as well as on the morning of days 2, 4, and 7 of the ICU stay for as long as the patients were in the ICU. Demographic data and predetermined outcomes were noted., Results: One hundred nine patients had at least two samples drawn and form the population for analysis. Sixty-two of the patients had three samples obtained, whereas 42 patients had four samples obtained. By univariate analysis, non-survivors were more severely ill on admission (APACHE III), more likely to have been admitted to the ICU as an emergency, more likely to develop a nosocomial infection, and more likely to develop severe organ dysfunction (MODS) (all, p < 0.05). Death was associated on day 1 with increased concentrations of sIL2R, IL-6, IL-10, and sTNFR-p75 (all, p < 0.01), but there were initially no differences in serum lipid concentrations. However, by day 2, concentrations of IL-6, IL-10, and cholesterol had decreased significantly (all, p < 0.05) from day 1 in non-survivors but not in survivors; the difference in serum cholesterol concentration persisted to day 7 (p < 0.05). Persistently elevated concentrations of IL-6 and IL-10 were observed in patients who developed severe MODS. By logistic regression, increased APACHE III score, development of a nosocomial infection, and decreased cholesterol concentration were independently associated with mortality., Conclusions: Decreased serum cholesterol concentration is an independent predictor of mortality in critically ill surgical patients. Repletion of serum lipids is a feasible therapeutic approach for the management of critical illness.

Hypothesis: Many surgical intensive care units (SICUs) face bed shortages for acutely ill patients that may result from a large proportion of bed occupation by chronically ill patients. We hypothesized that the introduction of a new intermediate care or step-down unit (SDU) managed by surgically trained intensivists would allow the admission of more acutely ill patients while maintaining satisfactory outcomes., Design: Prospective retrospective comparison of SICU patient populations before and after the introduction of an SDU., Setting: The SICU of New York-Presbyterian Hospital, New York Weill Cornell Center, a university hospital containing a level I trauma center., Patients and Interventions: All patients in the SICU admitted from August 1, 1996, through June 30, 1997, were SICU patients prior to the introduction of the SDU. Patients admitted from August 1, 1997, through June 30, 1998, were SICU post-SDU patients, and SDU patients included those admitted to the SDU from August 1, 1997, through July 1, 1998., Main Outcome Measures: For each of the 2 eras, patients were compared for age, sources of admission, Acute Physiology and Chronic Health Evaluation (APACHE) II and III scores, unit length of stay, and mortality. Other data collected included origin of admission, nature of admission, and diagnosis., Results: Six hundred sixty-six patients were admitted during the pre-SDU era, while a total of 1117 patients (619 SICU and 498 SDU patients) were admitted in the post-SDU era. After the introduction of the SDU, the mean (standard deviation) APACHE II scores of the SICU and SDU patients increased (14.2 vs 13.4, P =.04) without affecting mortality (6.0% in the post-SDU era vs 8.2% in the pre-SDU era, P =.07). The post-SDU era had a higher proportion of emergency admissions (42.3% vs 48.6%, P<.05) and interhospital transfers (7% vs 1%)., Conclusions: Opening an SDU resulted in a significant increase in the overall severity of the SICU population. Creation of an SDU managed by surgically trained intensivists may optimize the use of a hospital's resources, permit the expansion of emergency or tertiary care services, and improve outcomes for critically ill surgical patients.

Objective: Prehospital transport, resuscitation, and operative intervention are all critical to the care of the penetrating trauma victim. We determined which factors most affected mortality in patients with penetrating abdominal vascular injuries., Methods: Consecutive patients with penetrating abdominal vascular injuries from an urban Level I trauma center from January 1993 to December 1998 were identified from the trauma registry and their charts reviewed. All patients who died prior to operative intervention were excluded. Data collected included mortality, age, scene time (ST), EMS transport time (TT), time in the emergency department (ED), initial systolic blood pressure in the ED (BP), operating time, intraoperative estimated blood loss (EBL), and worst base deficit in the first 24 h (BD). These variables were compared between nonsurvivors and survivors by univariate ANOVA. Multivariate ANOVA (MANOVA) determined independent effects on mortality., Results: Forty-six penetrating abdominal vascular injuries were identified in 31 patients, 11 of whom died (38.7%). Examining prehospital parameters, mean ST averaged 16.5 +/- 3.6 min, while TT was 31.8 +/- 7.1 min. For ED parameters, initial BP was 94.8 +/- 6.4 mm Hg and initial heart rate was 109 +/- 7 beats per minute. Mean operative EBL for all patients was 3518 +/- 433 ml. The mean BD for all patients was -12.9 +/- 1.8. Significant differences were noted in the univariate analysis between survivors and nonsurvivors for BD (P < 0.0001), BP (P = 0.0062) and EBL (P = 0.0002). MANOVA revealed that only base deficit (P < 0.0001) had an independent effect on mortality., Conclusions: In patients with penetrating abdominal vascular injuries who survive their ED stay, adverse physiologic parameters reflecting the adequacy of resuscitation are more predictive of mortality than identifiable prehospital parameters.

Background: Despite a paucity of validation, the Ranson score is still the most popular method for gauging the severity of pancreatitis., Hypotheses: The Ranson score more accurately predicts outcomes in patients with severe acute pancreatitis (SAP) when compared with APACHE (Acute Physiology and Chronic Health Evaluation) III scores, and the individual components of the Ranson score differ in their capacities to predict outcome in patients with SAP., Methods: Patients admitted with SAP to a university surgical intensive care unit (ICU) were studied prospectively. Each component and the total Ranson score were recorded. Also recorded were the APACHE II and III scores. These Ranson variables were compared using univariate analysis of variance for mortality, need for operative debridement, and need for an ICU stay for longer than 7 days. Significant variables were then analyzed by a multivariate analysis of variance to assess independent predictors of mortality, the need for debridement, and prolonged length of stay. Data are given as the mean +/- SEM., Results: Seventy-six patients (21.1% mortality), aged 61.8 +/- 1.9 years, were studied. The mean APACHE III score was 48.2 +/- 3.3, and the mean ICU stay was 10.4 +/- 2.1 days. The number of positive Ranson variables was significantly higher in nonsurvivors compared with survivors (5.6 +/- 0.5 vs 3.4 +/- 0.2; P<.001), as were the APACHE III score (76.9 +/- 9.9 vs 40.5 +/- 2.5; P<.001) and ICU stay (24.9 +/- 7.5 vs 76.5 +/- 1.9 days; P =.002). Ranson variables that predicted mortality included values for blood urea nitrogen, calcium, base deficit, and fluid sequestration., Conclusions: The Ranson score remains a valid predictor of outcomes in patients with SAP, and individual Ranson variables determined 48 hours after hospital admission predicted adverse outcomes more accurately than early Ranson variables in patients with SAP.

Background: Computed tomography (CT) is used increasingly to evaluate suspected cases of acute appendicitis (AA) in the emergency department (ED). This prospective study was performed to test the hypothesis that the evaluation of AA by CT in the ED remains suboptimal and that erroneous interpretation diminishes its utility., Methods: Consecutive patients 18 years of age or older were enrolled prospectively if AA was among the first three differential diagnoses listed in the record of patients undergoing evaluation of abdominal pain in the ED. Imaging of the abdomen and pelvis was obtained at the discretion of the ED staff or consultant surgeon. Initial CT interpretation was by a radiology resident or fellow along with the surgical staff, but final review by an attending radiologist occurred later. Age, gender, presenting symptoms, white blood cell (WBC) count, final CT results, and final pathology (for patients undergoing operation) were recorded. X +/- SEM, p < 0.05 by chi(2), ANOVA, or MANOVA was used for statistical analysis as appropriate., Results: A CT scan was performed in 104 patients (83% of those meeting entry criteria), 35 of whom were male (mean age, 37 +/- 2 years) and 69 of whom were female (mean age, 39 +/- 3 years). Thirty-five patients had pathologically proved appendicitis, 28 of whom were diagnosed prospectively by CT. There were seven false-negative scans. Sensitivity, specificity, and positive predictive value for the initial CT reading were 80%, 91%, and 82%, respectively. Gender (p < 0.03), WBC count (p < 0.0002), and a positive initial CT reading (p < 0.0001) correlated with operative management. However, although final CT interpretation did correlate with pathologic confirmation of AA (p < 0.0001), initial CT interpretation did not correlate with the presence of AA (p = 0.52)., Conclusion: The ability of CT to predict AA is dependent on the interpretative skill of the individual interpreting the images. Widespread use of CT in the evaluation of patients for AA should be implemented with caution until institution-specific protocols are validated.

Background: Computed tomography (CT) has been used more frequently to diagnose acute appendicitis in children. The purpose of this study was to determine whether the use of CT has any influence on negative appendectomy or perforation rates., Methods: Review of a prospective database of children having appendectomy for suspected acute appendicitis. Negative appendectomy and perforation rates were determined by correlation with final pathology reports., Results: Eighty-five consecutive patients underwent appendectomy for the suspicion of acute appendicitis. The overall negative appendectomy rate was 17.6%, being 19.4% in females and 16.6% in males (p = 0.75). The overall accuracy, sensitivity and positive predictive value of CT were 75%, 91%, and 81%, respectively. Patients that had CT did not have a significantly lower rate of negative appendectomy (17.9% vs. 19.3%, p > 0.99) or perforation (26% vs. 17%; p = 0.53)., Conclusions: The use of CT for the diagnosis of appendicitis in children does not change the negative appendectomy rate. Results of studies performed in adults may not be extrapolated to the evaluation of children with suspected acute appendicitis.

Multiple organ dysfunction syndrome (MODS) is a major cause of morbidity and mortality in surgical intensive care units (SICUs). Multiple organ dysfunction syndrome remains the most important factor associated with mortality in the SICU. Illness severity scores such as the Acute Physiology and Chronic Health Evaluation-III (APACHE III) and the magnitude of the systemic inflammatory response syndrome (SIRS) at the time of SICU admission are useful in stratifying patients at risk for MODS and subsequent mortality. Assessment of key organ systems shows that mortality correlates with the overall severity of organ dysfunction and the number of involved organ systems, as well as to individual organs that fail. Despite the prognostic utility of SIRS/MODS, definitions of dysfunction of individual organs have shortcomings. The problem with quantitating MODS lies in the inability to adequately define organ dysfunction, especially of the gastrointestinal tract, liver, and central nervous system. Biological indicators of organ dysfunction may prove to be better markers for MODS in the future.

Background: Computed tomography (CT) is used increasingly to diagnose acute appendicitis, despite variable technique and interpretation. We hypothesized that CT interpretation would not reflect actual clinical-pathologic findings in all demographic patient groups., Methods: A prospective university hospital database of 625 consecutive patients (1995-1999), all of whom were operated on for appendicitis (261, or 41.8%, within 24 hours of discretionary CT), was reviewed. CT and pathology data were obtained from final, written reports. CT criteria included free fluid or air, appendiceal visualization, mesenteric fat stranding, and blurred pericecal fat. Appendix pathology included acute, gangrenous, and perforated organs. Statistics were performed with the Fisher exact test (coordinate data) and univariate analysis of variance (continuous data); multivariate analysis of variance for independent effects on dependent variable (positive CT or pathology; P <.05)., Results: The mean age was 35 +/- 1 years with 46.6% being female patients. CT was done more often in women and after 1997 (both P <.05). The sensitivity and specificity of CT were 96.1% and 16.1%, respectively. The positive predictive value (PPV) and accuracy rate (A) were 90%, and 88%, respectively. After CT, the incidence of finding a normal appendix was lower (19.3% vs 12.3%, P <.05), especially if the white blood cell count (WBC) was normal (< or = 11K/microL, 6.1% vs 23.2%, P <.001). If the WBC was < or = 11K/microL with positive CT, PPV/A was 73. 7%/71.3%, whereas with WBC > 11K/microL and positive CT, PPV/A was 99.4%/93.3%. Multivariate analysis of variance showed that none of the individual variables used by the radiologist to determine a positive CT scan correlated with outcome determined by surgical pathology. A healthy appendix was predicted by a CT interpreted as negative and younger age (both P <.05), and especially by lower WBC (P <.0001), but not by gender or surgeon., Conclusions: Although the negative appendectomy rate was decreased by CT, there was no correlation between CT findings and pathologically proved disease. Other factors such as more precise patient selection by clinical criteria may also be improving outcome. A positive CT scan in a patient with a normal WBC should be interpreted with caution.

Several studies indicate that norepinephrine (NE) may be more effective than dopamine for the treatment of septic shock. Nonetheless, many consider dopamine to be the pressor of choice for shock refractory to volume resuscitation. Owing to fear of excessive vasoconstriction, accentuated end-organ hypoperfusion, and the development of multiple organ dysfunction syndrome (MODS), it is contended that NE may be deleterious. We analyzed the duration of NE use and the variables that predict mortality in a consecutive cohort of 406 surgical intensive care unit patients treated with NE for shock. Study parameters included age, acute physiology and chronic health evaluation (APACHE) II and APACHE III scores, hospital (HLOS) and intensive care unit (ULOS) length of stay, maximal and daily multiple organ dysfunction (MOD) scores, MOD score minus cardiovascular points (MOD-CV), duration of NE infusion, and survival. The duration of NE infusion was stratified into six subsets (1, 2, 3-5, 6-10, 11-20, and > or =21 days). An age- and APACHE II and III score-matched cohort of 195 patients, in whom NE was not utilized, was identified retrospectively for comparison. The prevalence of NE use was 10.9%. NE patients developed MODS to a greater degree (11.7 +/- .3 vs. 5.9 +/- .4 points, p < .0001). NE patients had a greater degree (p < .0001) of noncardiovascular MOD as well. When stratified by survival, a greater degree of MOD occurred in both nonsurvivors and survivors of NE (both, p < .0001) compared with comparably ill patients without pressor-dependent shock. MOD scores, ULOS, and HLOS increased progressively with prolonged NE therapy (all, p < .0005), whereas mortality increased significantly only when the duration of NE infusion exceeded 10 days (p = .05). By multivariate analysis of variance (ANOVA), MOD score (p < .0001), and APACHE III (p < .01) predicted mortality, but notably the duration of NE therapy failed to attain predictive value (p = .3192). Only the MOD score was predictive of HLOS (p = .0001) and ULOS (p = .003). Daily MOD scores revealed that nonsurvivors of NE therapy were admitted to the intensive care unit with a greater degree of baseline organ dysfunction than NE survivors (7.5 +/- .4 vs. 5.1 +/- .2 for survivors, p < .0001). In addition, whereas survivors showed significant improvement by Day 5 (p < .01), MOD amongst nonsurvivors remained unchanged (p = .993). Although critically ill surgical patients requiring NE support have significantly greater degrees of organ dysfunction than patients not requiring pressors, much of the organ dysfunction is present on admission. The data contradict the notion that NE facilitates the development of MODS.

Recent interest in cutting cost and improving utilization and delivery of perioperative services has prompted surgeons to identify patient populations that would benefit from care in an intensive care unit as opposed to intermediate or standard care. The purpose of this study was to evaluate patients admitted to the surgical intensive care unit (SICU) after major plastic/reconstructive surgical procedures in order to determine appropriate perioperative management strategies for these patients. We reviewed retrospectively the data from 2,805 consecutive admissions to the SICU between 1990 and 1996. Forty-two patients (1.5%) who had undergone major plastic/reconstructive procedures were identified. Outcomes (mortality, length of stay in the SICU and hospital, and the degree of organ dysfunction) were compared between this population, an illness severity-matched (Acute Physiology and Chronic Health Evaluation [APACHE]-II and APACHE III) population of patients recovering from vascular surgical procedures, and a similarly matched population of SICU patients who were randomly assigned to serve as a second control group. The hospital mortality of the plastic surgical patient population (9.5%) was significantly higher than the zero mortality of the random cohort (p < 0.05). A second analysis compared the SICU plastics group to a case-controlled group of patients who were admitted to the postanesthesia care unit (PACU) for at least 24 hours of perioperative monitoring. SICU patients had significantly higher APACHE II scores (10.9) when compared to PACU patients (7.2; p < 0.01). Based on severity of illness scoring and eventual mortality, patients admitted to our SICU after major reconstructive surgery were selected appropriately for that setting. In contrast, the patients who stayed in the PACU for perioperative monitoring did not require life-supporting therapy and, therefore, were overmonitored. Care could be provided in a specialized unit with dedicated nursing specifically trained for that purpose.

Background: Multiple organ dysfunction syndrome (MODS) is the leading cause of death in the general surgery intensive care unit (SICU). The development of MODS is a powerful predictor of prolonged SICU stay in survivors and nonsurvivors of critical illness, but its relation to less severe illness and briefer duration of care is unknown., Objectives: To determine the relation between modest degrees of MODS and length of stay in the SICU and hospital and whether daily MOD score calculations can distinguish survivors from nonsurvivors before the SICU stay becomes prolonged., Setting: An SICU of a university tertiary care medical center., Design: Prospective inception-cohort study. Illness severity data were collected in retrospect only for the calendar year 1991., Patients: Of 2646 consecutive patients studied, 115 stayed in the SICU more than 21 days., Methods: Acute Physiology and Chronic Health Evaluation (APACHE) II and III scores were calculated after 24 hours, with daily and cumulative MOD scores (0-4 points for 6 organs, 24 points maximum). Patients were followed up until hospital discharge or death. Data analysis was performed by unpaired 2-tailed t test, exact contingency analysis for multiple groups, univariate 1- or 2-way analysis of variance with repeated measures, or linear or polynomial regression tests as appropriate, alpha = .05., Results: The mean (+/-SEM) age of the patients was 65 +/- 1 years; mean (+/-SEM) APACHE II score, 13.8 +/- 0.2; APACHE III score, 44.2 +/- 0.7; incidence of MODS, 1173 of 2646 patients, 44.3%; and hospital mortality rate, 9.2%. Cumulative MOD scores correlated closely with SICU length of stay in survivors, especially for SICU stays of less than 10 days (R2 = 0.99, P < .001). Similar correlations existed between the prevalence of MODS related to the increasing length of the SICU stay (R2 = 0.98, P < .001) and between the length of hospital stay and the cumulative MOD score (R2 = 0.79, P < .05). Daily MOD scores in patients whose SICU stay was more than 21 days distinguished survivors from nonsurvivors by day 2 of the SICU stay (P < .05) and thereafter., Conclusions: Modest degrees of MODS correlate closely with the duration of care in less severely ill patients. Early identification and daily quantitation of MODS may help identify patients at risk for prolonged illness and death. Prevention of outcomes that contribute to organ dysfunction is critical for reduction of length of stay and cost of care.

Objective: Compelling internal and external influences are stimulating global re-evaluations of care standards for efficacy and cost. Critical care uses huge amounts of resources despite widespread shortages of beds and nurses. This study tested the hypothesis that ancillary expenditures can be decreased without compromising care., Methods: Costs for laboratory tests, radiographs, blood products, nutritional supplements, and drugs were compared prospectively for all surgical intensive care unit care for two 4-month periods (January 1 to April 30, 1994 and January 1 to April 30, 1995) at a urban university center. A systematic, multidisciplinary cost-reduction program began May 1, 1994, with emphasis on laboratory and radiographic testing and procedures, and blood product, nutritional, and drug therapies. Cohorts were compared by age, Acute Physiology and Chronic Health Evaluation (APACHE) II and III admission scores, and case mix. Outcome variables were hospital mortality, days in the intensive care unit and hospital, the development of multiple organ dysfunction syndrome, and expenditures. Cost data were taken weekly from the hospital's clinical information system. No new equipment was introduced during the study period except for pumps for patient-controlled analgesia, and there were no new critical pathways or other patient care guidelines., Results: Case mix and all noncost variables were identical. Overall costs were reduced by 29% when normalized by the number of patient-days in each period. Laboratory testing was reduced in frequency by 24 to 32%, and cost by 26 to 28%. Comparable reductions in the cost of blood products (32%) were exceeded by the reductions in expenditures for nutritional supplements (49%) and pharmaceuticals (45%) (all, p < 0.01 or less). Modestly increased (2%) x-ray charges in 1995 were owing entirely to insertion of prophylactic inferior vena cava filters (each, $2,800, n = 5) and computed tomography scans for sinusitis (each, $350, n = 5), although the 7% reduction in portable chest radiographs that was achieved did not meet expectations., Conclusions: Substantial reductions in physician-ordered ancillary expenditures are possible without compromising the standard of care of critically ill patients, or the support of an elaborate framework of defined care plans. With additional experience, incremental savings may accrue from refinement of successful strategies and new approaches to intractable problems.

Objective: To determine whether APACHE III and multiple organ dysfunction syndrome scores can predict a prolonged length of stay for critically ill surgical patients in the intensive care unit., Design: Prospective, inception-cohort study., Setting: Surgical intensive care unit (SICU) of an urban, tertiary care hospital., Patients: 2,295 consecutive admissions for critical surgical illness, postoperative complications, or postoperative monitoring in 2,058 patients., Interventions: Calculation of Acute Physiology and Chronic Health Evaluation (APACHE) II and APACHE III scores 24 hours after admission to the SICU. Serial quantitation of organ dysfunction for the duration of hospitalization according to the multiple organ dysfunction score. Patients were stratified by survival and time intervals for the duration of critical care, and followed until discharge or death., Main Outcome Measures: Hospital mortality and length of stay in the SICU., Results: The mean APACHE II and APACHE III scores were 14.0 +/- 0.2 and 45.2 +/- 0.6 points, respectively (mean +/- SEM). The incidence of organ dysfunction was 43%, and the hospital mortality was 9.7%. The mean ICU length of stay was 6.1 +/- 0.2 days, but decreased progressively from 6.8 +/- 0.5 days in 1991 to 5.3 +/- 0.6 days in 1995 (p < 0.01) with no change in either illness severity or the number of admissions. By univariate analysis, increased length of stay in the ICU was associated with increasing APACHE scores, an increased incidence of emergency admissions, and the incidence and magnitude of organ dysfunction (all p < 0.01). Severity indices appeared to plateau in magnitude in patients whose ICU stay ultimately exceeded 21 days. By multivariate analysis of variance (MANOVA), independent predictors of a prolonged stay in the SICU were APACHE III (p = 0.0023), emergency admission (p = 0.0007), and the magnitude of organ dysfunction (p < 0.00001), but not APACHE II. Only an emergency admission (p = 0.0005) and the magnitude of organ dysfunction (p < 0.00001) predicted a prolonged stay independently in survivors. In contrast, only the admission APACHE III score(p = < 0.0001) and the magnitude of organ dysfunction (p = 0.0001) were independently predictive of mortality by MANOVA., Conclusions: The development of multiple organ dysfunction syndrome is a powerful predictor of a prolonged ICU course in critical surgical illness, even in survivors. Increased risk of a prolonged stay in the ICU plateaued at 21 days, making 21 days an appropriate definition of prolonged care for future studies. Predictive models should account for organ dysfunction and very long stays in future estimations. The combined use of APACHE III and the multiple organ dysfunction score may provide improved prediction of a prolonged stay in the ICU, but further enhancements are needed before prediction of outcome in individual patients is reliable.

Objective: To determine whether scoring on the Acute Physiology and Chronic Health Evaluation (APACHE) III at admission can predict the development of multiple organ dysfunction syndrome and mortality in critically ill surgical patients., Design: Prospective, inception-cohort study., Setting: Surgical intensive care unit of an urban, tertiary-care hospital., Patients: One hundred fourteen critically ill patients with surgically treated perforated gastrointestinal viscus., Interventions: Calculation of APACHE II and APACHE III scores 24 hours after admission to the surgical intensive care unit and serial quantitation of organ dysfunction for the duration of critical care according to two different predefined scoring systems. Patients were stratified by survival, the development of organ dysfunction, and colon vs noncolonic perforation., Main Outcome Measures: Hospital mortality, length of stay in the surgical intensive care unit, and the development of organ dysfunction or overt organ failure., Results: The mean (+/- SEM) APACHE II and APACHE III scores were 17.4 +/- 0.6 (range, 6 to 37) and 59.0 +/- 2.2 (range, 15 to 141), respectively. The incidence of organ dysfunction was 73% (64% in survivors). All severity scores were identical for colon perforation and noncolonic perforation subgroups. Nonsurvivors invariably had organ dysfunction. Overall length of stay in the intensive care unit was 12.0 +/- 1.6 days (8.7 +/- 1.2 days for survivors and 22.7 +/- 5.0 days for nonsurvivors). The APACHE scores and organ dysfunction or failure scores were significantly higher in nonsurvivors, and APACHE scores were higher in survivors with organ dysfunction than in those without it. Significant linear relationships were identified for APACHE II vs APACHE III scores (R2 = .66) and for all four combinations of APACHE scores and organ dysfunction or failure scores (R2 = .43 to .52). By multivariate analysis of variance, independent predictors of organ dysfunction or failure were APACHE III, increased age, and a prolonged stay in the surgical intensive care unit, but not the type of perforation. Neither APACHE II or APACHE III predicted mortality independently., Conclusions: The development of multiple organ dysfunction syndrome correlated with higher APACHE III scores but was independent of the type of perforation. Only the development of overt multiple organ failure predicted death. Combined use of APACHE III and the multiple organ dysfunction score provides improved prediction of multiple organ dysfunction syndrome, but further enhancements are needed before prediction of outcome in individual patients is reliable.

Objective: Intrahospital transport of critically ill patients is often necessary for optimal patient care. However, transport of intensive care unit (ICU) patients within the hospital has been associated with a high rate of potentially detrimental complications. This study was designed to determine the occurrence rate of transport-related complications and to determine if these complications have any effect on patient morbidity and mortality., Design: Prospective, cohort-matched study., Setting: A 780-bed urban, university teaching hospital., Patients: Seven hundred fifty-nine surgical ICU patients., Interventions: One hundred seventy-five patients were transported out of the surgical ICU for diagnostic testing or operative interventions deemed necessary by their surgical or critical care team., Measurements and Main Results: Acute Physiology and Chronic Health Evaluation (APACHE) II and APACHE III scores were determined 24 hrs after admission. Transport patients were stratified into low-risk and high-risk transport groups. Patients were considered a high-risk transport if they required positive end-expiratory pressure of > 5 cm H2O, a continuous infusion of dobutamine, or a continuous infusion of norepinephrine. The high-risk group was further stratified into three groups based on the number of defined treatment regimens required to maintain the patient during transport. The patients were then followed during their transport for any potentially detrimental complications, such as a need for an increased dose of vasoactive medications, loss of intravenous access, a need for additional ventilatory support, or cardiopulmonary arrest. APACHE-matched control cohorts were identified as patients who did not leave the surgical ICU. The overall occurrence rate of complications was similar in the two groups (low-risk group, 6.3%; high-risk group, 5.5%). The mortality rate for all transport patients was 28.6%, which was statistically higher (p < .01) than the mortality rate for all control patients (11.4%). However, there was no mortality as a direct result of a transport. The overall mortality rate (10.9%) of the low-risk group was not significantly different from the APACHE-matched controls (6.0%). The overall mortality rate (51.4%) in the high-risk group was significantly higher (p < .01) than the APACHE-matched controls, but was not statistically higher than predicted mortality (p = .416). Both the low-risk and the high-risk groups stayed in the surgical ICU three times as long as the APACHE-matched control cohorts., Conclusions: Intrahospital transport of critically ill patients is safe and carries a low risk of detrimental complications. Although patients requiring "high-risk" interventions experienced a higher mortality rate than did APACHE-matched controls, the increase in mortality does not appear to be directly related to the intrahospital transport. Patients requiring transport out of the surgical ICU are a more critically ill group of patients. These patients require a greater length of stay in the surgical ICU and may experience an increased mortality rate by virtue of the severity of their illness.

Purpose: Adverse outcomes apparently associated with hypothermia led us to examine patients undergoing elective abdominal aortic aneurysm (AAA) repairs to test the hypothesis that hypothermia (temperature less than 34.5 degrees C) is associated with increased morbidity and excess mortality rates., Methods: Two hundred sixty-two elective AAA repairs were retrospectively reviewed for preoperative and intraoperative risk factors. Core temperature, age, Acute Physiology and Chronic Health Evaluation (APACHE) II and APACHE III scores (raw and temperature-adjusted), fluid resuscitation, and perioperative organ dysfunction were recorded prospectively. Outcome measures included lengths of stay in the intensive care unit and in the hospital, and hospital mortality rates., Results: Except for a higher risk of hypothermia in women (p < 0.05), by univariate analysis, preoperative risk factors were similar in patients in the hypothermic and normothermic groups. After operation, patients with hypothermia had significantly greater APACHE scores (p < 0.0001), and patients in the hypothermic nonsurvivor group took significantly longer to rewarm (p < 0.05), suggesting marked hypoperfusion. Patients with hypothermia had significantly greater fluid (p < 0.05), transfusion (p < 0.01), vasopressor (p < 0.05), and inotrope (p < 0.05) requirements, resulting in significantly higher incidences of organ dysfunction (53.0% vs 28.7%, p < 0.01) and death (12.1% vs 1.5%, p < 0.01) and markedly prolonged lengths of stay in the unit (9.2 +/- 2.0 vs 5.3 +/- 0.6, p < 0.05) and in the hospital (24.3 +/- 2.9 vs 15.0 +/- 0.08, p < 0.01). By multivariate analysis, female gender (p = 0.004) was the only predictor of intraoperative hypothermia, whereas initial hypothermia was significantly predictive of both prolonged hypothermia and development of organ failure (p < 0.05). Organ failure (p < 0.05) and acute myocardial infarction (p < 0.01) were independent predictors of death., Conclusions: After AAA repair, patients with hypothermia have multiple physiologic derangements associated with adverse outcomes. Although multiple etiologic factors are interacting, body temperature is one variable that should be controlled during aortic surgery.

Objective: To determine whether the Acute Physiology and Chronic Health Evaluation III (APACHE III), an updated version of APACHE II that contains a larger number of postoperative patients in the normative database, offers better prediction in critical surgical illness., Design: Prospective cohort study., Setting: Surgical intensive care unit of an urban, tertiary-care university hospital., Participants: Eight hundred forty-four consecutive patients in the surgical intensive care unit. Overall scores were determined, as well as scores for survivor, nonsurvivor, trauma, nontrauma, postoperative, and nonoperative patient subgroups., Main Outcome Measures: Survival to hospital discharge, and survival compared with published normative APACHE II and III databases., Results: Mean age was 65.1 +/- 0.5 years. Overall mortality was 7.0% in the surgical intensive care unit and 9.1% in the hospital. The relationship between APACHE II and APACHE III scores for individual patients was linear and correlated significantly (P < .0001) (range of correlation coefficients, .72 to .86) overall and in all subgroups. Both scoring systems overestimated our mortality, but estimations made by APACHE III were significantly (P < .01) higher overall and in all subgroups., Conclusions: In institutions or groups of patients where APACHE II underestimates mortality, APACHE III may be corrective. However, the differences are subtle and may be difficult to detect in smaller studies.

Multiple organ failure (MOF) is the primary cause of death in surgical intensive care units (SICU). Mortality increases with an increasing number of failed organs, but it has been recognized that lesser degrees of organ dysfunction occur commonly. Such gradations of the multiple organ dysfunction syndrome (MODS) are postulated to provide more descriptive and predictive power. We analyzed and compared two different MODS/MOF scoring systems and determined the utility of gradations of organ dysfunction for prediction of mortality in MODS/MOF. One of the scoring systems defines organ failure as an all-or-nothing phenomenon for each organ, whereas the other scoring system describes increasing organ dysfunction on a 24-point scale. Each scoring system assesses the same six organs. Admission APACHE II (AII) and AIII scores were calculated as independent estimates of mortality. In 867 consecutive SICU admissions, 261 patients (30%) had some degree of organ dysfunction, of whom 142 patients (54%) met criteria for single or multiple organ failure. The mean admission AII score was 19 (25 for nonsurvivors), and the AIII score was 62 (91 for nonsurvivors). Overall mortality was 5.8%, but among those patients with organ dysfunction, mortality was 19%. Death was equally likely for comparable degrees of organ dysfunction and failure. Mortality increased (p < 0.01, ANOVA) with higher scores in both systems. In patients with 9-12 organ dysfunction points, the number of failed organs was 1.5 +/- 0.2 in 34 survivors, versus 2.9 +/- 0.3 in the 14 nonsurvivors (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)