Intensive Care Unit Scoring Systems

Background Illness severity scoring systems are commonly used in critical care. When applied to the populations for whom they were developed and validated, these tools can facilitate mortality prediction and risk stratification, optimize resource use, and improve patient outcomes. Objective To describe the characteristics and applications of the scoring systems most frequently applied to critically ill patients. Methods A literature search was performed using MEDLINE to identify original articles on intensive care unit scoring systems published in the English language from 1980 to 2020. Search terms associated with critical care scoring systems were used alone or in combination to find relevant publications. Results Two types of scoring systems are most frequently applied to critically ill patients: those that predict risk of in-hospital mortality at the time of intensive care unit admission (Acute Physiology and Chronic Health Evaluation, Simplified Acute Physiology Score, and Mortality Probability Models) and those that assess and characterize current degree of organ dysfunction (Multiple Organ Dysfunction Score, Sequential Organ Failure Assessment, and Logistic Organ Dysfunction System). This article details these systems’ differing features and timing of use, score calculation, patient populations, and comparative performance data. Conclusion Critical care nurses must be aware of the strengths, limitations, and specific characteristics of severity scoring systems commonly used in intensive care unit patients to effectively employ these tools in clinical practice and critically appraise research findings based on their use.

Nurse Prompting for Prescriber-Led Review of Antimicrobial Use in the Critical Care Unit

Background Developing a sustainable strategy for prescriber-led review of antimicrobial use in a critical care unit may improve antimicrobial use without the need for additional resources. Methods Using a quality improvement framework, the researchers created a prompt for prescriber-led review of antimicrobial use. The outcome measure was antimicrobial use (days of therapy per 1000 patient days). The process measure was the proportion of relevant cases for which an antimicrobial prompt was provided. Balancing measures included mortality rate, length of stay, 48-hour readmission rates, and multiple organ dysfunction score. Interrupted time series with segmented regression analysis was used for the outcome measure. Results Process analysis identified critical care unit nurses for antimicrobial use prompting. A standard script was developed to incorporate a days of therapy prompt into nurse rounds, with primed prescriber responses. Before the intervention, monthly antimicrobial use was 804 days of therapy per 1000 patient days, with a positive trend (7.3 days of therapy per 1000 patient days, P < .05). After the intervention, there was an immediate reduction of 217 days of therapy per 1000 patient days (P < .05), with a nonsignificant negative trend, representing a 20% (95% CI, −15% to −25%) reduction. No significant change was noted in use of the control class of medications. The proportion of relevant cases for which an antimicrobial prompt was provided increased from 21% to 48% during the intervention period. Balancing measures were comparable before and after the intervention. Conclusions Nurse prompting can lead to significant reductions in antimicrobial use, providing a sustainable mechanism for independent antimicrobial reassessment.

Performance assessment of age-adapted SOFA, qSOFA, and PELOD-2, PCIS, P-MODS for Hand, Foot and Mouth Disease

ObjectivesHand, foot and mouth disease (HFMD) is a common infectious disease in children caused by intestinal virus and an important cause of child death. Early identification of critical HFMD and timely intervention are the key to reduce mortality. However, there is no available unified critical HFMD screening standard. This study aimed to explore the predictive evaluation of HFMD with critical illness scoring systems.MethodsA total of 31 patients with mild HFMD, 30 with severe HFMD, and 25 with critical HFMD were included. The platelet index in age-adapted sequential organ failure assessment score (SOFA) was re-assigned to constitute the SOFA for HFMD (H-SOFA). The results of age-adapted SOFA, quick SOFA (qSOFA), and pediatric logistic organ dysfunction score-2 (PELOD-2), pediatric multiple organ dysfunction score (P-MODS), pediatric critical illness score (PCIS), H-SOFA of the three groups were compared.ResultsSignificant differences in the following parameters were found between severe group and critical group: enterovirus 71 positive, heart rate, respiration, vomiting, cold sweat, moist rales, disturbance in consciousness, platelet, and blood glucose (P<0.05), as well as all critical illness scoring data (P<0.001). age-adapted SOFA, qSOFA, and PELOD-2, P-MODS, H-SOFA were positively correlated with critical HFMD (odds ratio (OR): 3.213, 8.66, 2.64, 2.56, and 4.297 respectively; P<0.01), with area under the curve (AUC) values of 0.938, 0.823, 0.848, 0.910, and 0.956, respectively. PCIS was negatively correlated with critical HFMD (OR=0.76, P<0.001), with an AUC value of 0.865.ConclusionIncrease in platelet count was related to the severity of HFMD. Age-adapted SOFA, qSOFA, and PELOD-2, P-MODS, PCIS, H-SOFA had high predictive value on critical HFMD, with H-SOFA being the highest.

Study of etiology and scoring system in acute lung injury and acute respiratory distress syndrome patients

Background: The acute respiratory distress syndrome (ARDS) is a clinical disorder characterized by injury to the alveolar epithelium and endothelial barriers of the lung, acute inflammation, and protein rich pulmonary edema leading to respiratory failure. Present study was carried out to investigate the mortality pattern of ALI/ARDS in the patients and to study the etiological factors leading to ALI/ARDS also to study the clinical pattern in patients with ALI/ARDS.Methods: All patients fulfilling the inclusion criteria as per the 1994 American European Consensus Conference on ARDS/ALI definition of ARDS/ALI were included in the study. On clinical examination the vital parameters were recorded. The respiratory system, abdominal, cardiovascular and central nervous systems were examined in detail. The severity of the illness was measured by the acute physiology and Chronic Health Evaluation (APACHE) Score, Multiple Organ Dysfunction score (MODS), lung injury score (LIS) and Sequential Organ Dysfunction Assessment (SOFA score). These scores were calculated on admission to our intensive care unit.Results: Out of the 65 patients 35 survived and 30 died. A multiple organ dysfunction Score of less than or equal to 4 was seen in 29 patients and more than 4 in 36 patient and a score of less than or equal to 4 was seen in 21 survivors and 8 dead patients, while a score of more than four was found in 14 patients who survived versus 22 patients who died. A lung injury score of less than or equal to 2 was seen in patients and more than 2 in 46 patients and a score of less than or equal to 2 was seen in 14 survivors and 5 non-survivors patients, while a score of more than 2 was found in 21 patients who survived versus 25 patients who died.Conclusions: The commonest etiological conditions leading to ALI/ARDS are pneumonia and tropical diseases including malaria, leptospirosis and dengue. The scoring systems, MODS, LIS and APACHE II are good indicators of the outcome of this condition. They are useful in tropical diseases as well.

Perkembangan diagnosis sepsis pada anak

Sepsis merupakan salah satu penyebab utama morbiditas dan mortalitas bayi dan anak di seluruh dunia. Sepsis awalnya didefinisikan sebagai kecurigaan atau infeksi yang terbukti, disertai kondisi klinis SIRS (systemic inflammatory response syndrome), tetapi definisi tersebut kini ditinggalkan. Sesuai konsensus mengenai sepsis terbaru, sepsis didefinisikan sebagai keadaan disfungsi/gagal organ yang mengancam nyawa, disebabkan oleh respon pejamu yang tidak teregulasi terhadap infeksi. Penilaian disfungsi/gagal organ pada anak menggunakan beberapa sistem penilaian, antara lain, Pediatric Multiple Organ Dysfunction Score (P-MODS), Pediatric Logistic Organ Dysfunction (PELOD), Pediatric Logistic Organ Dysfunction–2 (PELOD-2), dan pada konsensus terbaru diperkenalkannya sistem Pediatric Sequential Organ Failure Assessment (pSOFA) yang diadaptasi dari sistem Sequential Organ Failure Assessment (SOFA) dengan hasil validasi menunjukkan bahwa pSOFA memberikan hasil yang sama baik dengan sistem penilaian yang lain. Di Indonesia saat ini, PELOD-2 merupakan sistem penilaian disfungsi organ yang direkomendasikan oleh Ikatan Dokter Anak Indonesia (IDAI) dalam mendiagnosis sepsis pada anak.

Evaluation of illness severity scoring systems and risk prediction in vascular intensive care admissions

IntroductionThis study examines the predictive value of intensive care unit (ICU) scoring systems in a vascular ICU population.MethodsFrom April 2005 to September 2011, we examined 363 consecutive ICU admissions. Simplified Acute Physiology Score II (SAPS II), Acute Physiology and Chronic Health Evaluation II (APACHE II), APACHE IV, Multiple Organ Dysfunction Score (MODS), organ dysfunctions and/or infection (ODIN), mortality prediction model (MPM) and physiologic and operative severity score for the enumeration of mortality and morbidity (POSSUM) were calculated. The Glasgow Aneurysm Score (GAS) was calculated for patients with aneurysm-related admissions.ResultsOverall mortality for complex vascular intervention was 11.6%. At admission, the areas under the receiver operating characteristic curve (AUCs) was 0.884 for SAPS II, 0.894 for APACHE II, 0.895 for APACHE IV, 0.902 for MODS, 0.891 for ODIN and 0.903 for MPM. At 24 h, model discrimination was best for POSSUM (AUC = 0.906) and MPM (AUC = 0.912).ConclusionThe good discrimination of these scoring systems indicates their value as an adjunct to clinical assessment but should not be used on an individual basis as a clinical decision-making tool.

Organ failure scoring

The general outcome prediction models were not, by design, developed to track individual patients. They provided an indication of death risks for groups of ICU patients. Hence, investigators created organ failure scores. Instruments, such as Sequential Organ Failure Assessment (SOFA), Multiple Organ Dysfunction Score, or Logistic Organ Dysfunction Score are designed to evaluate separately the six most important organ systems in critically-ill patients sequentially, taken on a daily basis. Easy to perform, designed to be done at bedside, they do not forecast ICU or hospital mortality (apart from the SOFA score), but are very useful in describing the patient and his response to therapy.