ABSTRACTObjective: The Sequential Organ Failure Assessment (SOFA) score has been recommended for triage during a mass influx of critically ill patients, but it requires laboratory measurement of 4 parameters, which may be impractical with constrained resources. We hypothesized that a modified SOFA (MSOFA) score that requires only 1 laboratory measurement would predict patient outcome as effectively as the SOFA score.Methods: After a retrospective derivation in a prospective observational study in a 24-bed medical, surgical, and trauma intensive care unit, we determined serial SOFA and MSOFA scores on all patients admitted during the 2008 calendar year and compared the ability to predict mortality and the need for mechanical ventilation.Results: A total of 1770 patients (56% male patients) with a 30-day mortality of 10.5% were included in the study. Day 1 SOFA and MSOFA scores performed equally well at predicting mortality with an area under the receiver operating curve (AUC) of 0.83 (95% confidence interval 0.81-.85) and 0.84 (95% confidence interval 0.82-.85), respectively (P = .33 for comparison). Day 3 SOFA and MSOFA predicted mortality for the 828 patients remaining in the intensive care unit with an AUC of 0.78 and 0.79, respectively. Day 5 scores performed less well at predicting mortality. Day 1 SOFA and MSOFA predicted the need for mechanical ventilation on day 3, with an AUC of 0.83 and 0.82, respectively. Mortality for the highest category of SOFA and MSOFA score (>11 points) was 53% and 58%, respectively.Conclusions: The MSOFA predicts mortality as well as the SOFA and is easier to implement in resource-constrained settings, but using either score as a triage tool would exclude many patients who would otherwise survive.(Disaster Med Public Health Preparedness. 2010;4:277-284)

Design-Retrospective cohort study. Setting-LDS Hospital, an academic tertiary care facility in the Western United StatesPatients-Consecutive patients with ICD-9 codes and chest radiographs consistent with community-acquired pneumonia from 1996-2006 seen at LDS Hospital Interventions-NoneMeasurements and Main Results-We utilized the electronic medical record to examine intensive care unit admission, intensive therapies received, and predictors of severity, as well as 30-day mortality. We also developed logistic regression models of mortality and disease severity. We calculated the IDSA/ATS 2007 criteria as well as three other pneumonia severity scores. We defined SCAP as receipt of intensive therapy in the intensive care unit. In 2,413 episodes of pneumonia, 1,540 were admitted to the hospital, while 379 were admitted to the intensive care unit. Overall 30-day mortality was 3.7% but was 16% among ICU patients. The IDSA/ATS 2007 minor criteria predicted SCAP with a c-statistic of 0.88 (0.85-0.90), which improved to 0.90 (0.88 -0.92) with weighting. Competing models had c-statistics of 0.76-0.83. Using four rather than three minor criteria improved the positive predictive value from 54% to 81%, with a stable negative predictive value of 94-92%.Conclusions-The IDSA/ATS 2007 criteria predicted pneumonia severity better than other models. Using four rather than three minor criteria may be a superior cutoff, though this will depend on institutional characteristics.

QuestionIs broad-spectrum antibiotic use associated with poor outcomes in community-onset pneumonia after adjusting for confounders?MethodsWe performed a retrospective, observational cohort study of 1995 adults with pneumonia admitted from four US hospital emergency departments. We used multivariable regressions to investigate the effect of broad-spectrum antibiotics on 30-day mortality, length of stay, cost and Clostridioides difficile infection (CDI). To address indication bias, we developed a propensity score using multilevel (individual provider) generalised linear mixed models to perform inverse-probability of treatment weighting (IPTW) to estimate the average treatment effect in the treated. We also manually reviewed a sample of mortality cases for antibiotic-associated adverse events.Results39.7% of patients received broad-spectrum antibiotics, but drug-resistant pathogens were recovered in only 3%. Broad-spectrum antibiotics were associated with increased mortality in both the unweighted multivariable model (OR 3.8, 95% CI 2.5–5.9; p<0.001) and IPTW analysis (OR 4.6, 95% CI 2.9–7.5; p<0.001). Broad-spectrum antibiotic use by either analysis was also associated with longer hospital stay, greater cost and increased CDI. Healthcare-associated pneumonia was not associated with mortality independent of broad-spectrum antibiotic use. In manual review we identified antibiotic-associated events in 17.5% of mortality cases.ConclusionBroad-spectrum antibiotics appear to be associated with increased mortality and other poor outcomes in community-onset pneumonia.

Encephalopathy and other neurologic morbidities are common in critical illness, sepsis, and prolonged mechanical ventilation. We assessed structural changes on brain imaging and neuropsychological outcomes in critically ill patients who developed neurological changes during their intensive care unit (ICU) stay. Patients who underwent brain imaging for neurological changes were included in the study. Medical, neuroradiological, and outcome data were obtained from patient medical records. Sixty-four patients underwent brain imaging for neurological changes. Forty-one (64%) patients had abnormalities on brain imaging. There were no differences for age, hospital length of stay, ICU length of stay, duration of mechanical ventilation or APACHE II scores for patients with normal compared to abnormal brain imaging. Cognitive impairments occurred in 48% of survivors and 6% developed psychiatric disorders. Our study demonstrates that abnormalities on brain imaging are common in critically ill patients. We also confirm previous findings that survivors of critical illness have cognitive impairments post-ICU discharge. This study further illustrates the adverse effects of critical illness on the brain and highlights the need for additional research in this emerging area.