Prognosis of Patients with AIDS Requiring Intensive Care

doi:10.1378/chest.96.4.857

Chest

Volume 96, Issue 4, October 1989, Pages 857-861

https://doi.org/10.1378/chest.96.4.857 Get rights and content

The Acute Physiology and Chronic Health Evaluation (APACHE) II classification, a measure of severity of illness in patients requiring intensive care, was devised before the rapid expansion of the acquired immunodeficiency syndrome (AIDS) epidemic. To determine the applicability of the APACHE II system to AIDS, we related observed in-hospital death rates to those predicted by APACHE II in S3 patients with AIDS. In a control group of patients without AIDS (n = 166) mean predicted and observed death rates (34.1 vs 31.3 percent) were similar. For the AIDS group overall observed mortality (63.9 percent) was significantly greater than that predicted by APACHE II (45.8 percent). The subgroup with Pneumocystis pneumonia requiring mechanical ventilation (n=37) had an observed mortality (86.5 percent) that significantly exceeded the predicted value (44.3 percent), whereas all other AIDS patients (n = 46) showed similar predicted and observed death rates (47.0 vs 45.7 percent). APACHE II prediction of death rate also matched observed mortality in mechanically ventilated patients without Pneumocystis infection. The discrepancy between predicted and observed mortality in patients with Pneumocystis pneumonia requiring mechanical ventilation is most likely due to the lack of an APACHE II diagnostic category that accurately reflects the severity of this disease. A new diagnostic category that provides accurate outcome prediction in this patient group would form a basis for evaluation of new therapeutic interventions.

Section snippets

Setting

The Medical Service of the New York Veterans Administration Medical Center consists of 120 ward beds, 6 cardiac care unit beds, and 12 medical ICU beds. In January 1988, the Medical Center opened an additional 16-bed ward for care of patients with AIDS. Bed occupancy by patients with AIDS has steadily increased, accounting for 13.8, 14.0, and 17.7 percent of Medical Service patient-days in 1985, 1986, and 1987, respectively. In contrast, medical ICU bed occupancy by patients with AIDS has shown

RESULTS

For the control group without AIDS (n = 166), predicted and observed death rates were closely matched, resulting in an observed/predicted mortality ratio not significantly different from 1 (Table 1, Fig 1). The subgroup of patients without AIDS requiring mechanical ventilation (n = 25) also had similar observed and predicted mortality. The mean APACHE II score of survivors among the patients without AIDS was significantly less than that of nonsurvivors (Table 2).

In contrast, the AIDS patient

DISCUSSION

This study was designed to evaluate the APACHE II classification, a measure of severity of illness, when applied to patients with AIDS requiring intensive care. For control patients without AIDS, the death rate predicted from the APACHE II regression equation closely corresponded to observed mortality. Among 83 patients with AIDS, observed mortality significantly exceeded that predicted by APACHE II. This excess mortality was largely explained by the failure of APACHE II to accurately predict

ACKNOWLEDGMENT

The authors wish to thank Dr. Norton Spritz for his critical review of the manuscript.

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RL Smith et al.
APACHE II outcome prediction of HIV-positive patients requiring admission to an intensive care unit [Abstract]
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There are more references available in the full text version of this article.

Cited by (55)

Performance assessment of Acute Physiology and Chronic Health Evaluation II and Simplified Acute Physiology Score II in a referral respiratory intensive care unit in Iran
2012, Acta Anaesthesiologica Taiwanica
Citation Excerpt :
The two most popular systems introduced to date are APACHE and SAPS, which are based on multiple logistic regression equations describing abnormalities of physiologic variables during the first 24 hours of ICU admission.3,6 These scores have been evaluated in a wide range of patient populations and in many specialty- and subspecialty-related ICUs.7–19 However, because studies performed in respiratory diseases setting are scarce and because the ICU of our hospital is solely dedicated to patients with respiratory problems (medical and surgical), evaluating the prediction power of these scores became the goal of this study.
Nowadays, Acute Physiology and Chronic Health Evaluation II (APACHE II) and Simplified Acute Physiology Score II (SAPS II) scoring systems have drawn much attention for the evaluation and prediction of disease process in patients admitted to intensive care units (ICUs). To use these scoring tools, their predicting power must be initially validated for the target patients. This study was conducted to evaluate the performance of these two scoring systems in an ICU for respiratory diseases in Iran.
All records of patients admitted during a 1-year period were retrospectively reviewed, and the APACHE II and SAPS II scores were calculated accordingly. Information gathering was performed using a questionnaire.
A total of 415 records were used. The mean age of patients was 49.28 ± 0.94 years. Using receiver operating-characteristic curve, cutoff points for 80% sensitivity and specificity of mortality prediction for APACHE and SAPS scores were 13.5 and 27.5, respectively. Calibration and discrimination studies indicated an acceptable status for both scales, but APACHE II scoring system seemed to show rewarding outcomes.
Results indicate that APACHE II scoring system can be considered as a reliable method for predicting mortality in our referral respiratory ICU.
Intensive care unit outcomes in elderly cancer patients
2003, Critical Care Clinics
Prognosis of HIV/positive patients admitted to the intensive care unit
2000, Medicina Intensiva
Desde el diagnóstico de los primeros casos de infección por el virus de la inmunodeficiencia humana (VIH) en nuestro país, y a medida que la epidemia progresa, aumenta el número de personas infectadas por el VIH que necesitan tratamiento en UCI. Sin embargo, la idoneidad de su ingreso es objeto de amplio debate, con componentes médicos, sociales, emocionales, legales y económicos no resueltos en la actualidad. Por ello hemos querido conocer las características de pacientes VIH positivos ingresados en UCI en los primeros 12 años de la epidemia y determinar factores pronósticos que ayuden al intensivista a la hora de adoptar la decisión del ingreso de este grupo de enfermos.
Estudio epidemiológico observacional, transversal, de morbimortalidad. Variables: se analizaron diferentes variables epidemiológicas, clínicas y analíticas medidas el día del ingreso.
Se estudiaron 102 enfermos VIH positivos ingresados en UCI desde enero de 1985 a enero de 1997. La mayoría de los enfermos fueron varones (80/102), con una edad media de 32 años. El 60,8% cumplía criterios de sida-1987 y un 65,7 los ampliados de 1993. El 77,5% se había infectado por el uso de drogas por vía parenteral. Un 56,9% ingresó por insuficiencia respiratoria, siendo la mayoría neumonías por Pneumocystis carinii (NCP). La mortalidad en UCI fue del 48%. Los factores que se asociaron con un incremento significativo de la mortalidad (p < 0,05) fueron: sexo femenino, cumplimiento de criterios de sida, falta de conocimiento de infección VIH, ausencia de diagnóstico etiológico o presencia al ingreso de hipotensión, taquipnea, hipoxia severa, acidosis, anemia y un menor número de linfocitos CD4.
La determinación de factores pronósticos en los pacientes infectados por el VIH que requieren tratamiento en UCI es importante, tanto para informar adecuadamente a enfermos y familiares como para tomar decisiones clínicas y terapéuticas. Los continuos avances en el tratamiento de la infección VIH y enfermedades asociadas hacen necesario la realizacion de una puesta al día continua y la realización de nuevos estudios.
Since the first cases of human immunodeficiency virus (HIV) were diagnosed in Spain and as the epidemic develops, the number of HIV-infected individuals requiring treatment in intensive care units (ICUs) is increasing. However, the advisability of admitting these patients is debatable and involves medical, social, emotional, legal and economic issues that currently remain unresolved. Consequently, we decided to determine the characteristics of HIV-positive patients admitted to the ICU during the first 12 years of the epidemic and to determine the prognostic factors that are of use to intensivists when deciding to admit these patients.
Observational transversal epidemiological study of morbidity and mortality. Various epidemiological, clinical and analytical variables noted on admission were analyzed.
A total of 102 HIV-positive individuals admitted to the ICU from January 1985 to January 1997 were studied. Most of the patients were male (80/102) with a mean age of 32 years. Criteria for acquired immunodeficiency syndrome (AIDS) were fulfilled by 60.8% of the patients in 1987 and by 65.7% in 1993. In 77.5% transmission was through parenteral drug use. Cause of admission was respiratory insufficiency in 56.9%, the majority being due to Pneumocystic carinii pneumonia. Mortality in the ICU was 48%. Factors associated with a significantly increased mortality (p < 0.05) were femenine sex, fulfilling the criteria for AIDS, lack of awareness of HIV-infection, absence of etiologic diagnosis or presence on admission of hypotension, tachypnea, severe hypoxia, acidosis, anemia ans depletion of CD4 lymphocytes.
Determination of prognostic factors in HIV- patients requiring treatment in ICUs is important in order to the appropriately inform the patients and their relatives as well as to be able to take clinical and therapeutic decisions. Because of the continual advances in the treatment of HIV infection and associated diseases, keeping up to date new studies are required.
Clinical course prognostic factors and outcome prediction for HIV patients in the ICU: The PIP (Pulmonary complications, ICU support, and prognostic factors in hospitalized patients with HIV) study
2000, Chest
Citation Excerpt :
The APACHE III,32 simplified acute physiology score (SAPS) II,33 and mortality probability models II34 are current, updated scoring systems designed to estimate the probability of in-hospital mortality for adult ICU patients. SAPS I9,10 and APACHE II2,28,35,36 prognostic systems were used to predict mortality in some of the published studies dealing with HIV-infected ICU patients. However, both SAPS I and APACHE II are unlikely to have accurate prediction, because they were developed at a time when ICUs had few patients with HIV infection.
To describe the clinical course and prognostic factors in patients with HIV admitted to the ICU.
Prospective, observational.
A university-affiliated medical center.
We included 169 consecutive ICU admissions, from April 1995 through March 1999, of 141 adults with HIV. Data collected included APACHE (acute physiology and chronic health evaluation) II score, CD4⁺ lymphocyte count, serum albumin level, in-hospital mortality, and the development of organ failure, systemic inflammatory response syndrome (SIRS), and ARDS.
The ICU admission rate of hospitalized patients with HIV infection was 12%. The most common reason for ICU admission was respiratory failure, occurring in 65 patient admissions. Mechanical ventilation was required in 91 admissions (54%), ARDS developed in 37 admissions (22%), Pneumocystis carinii pneumonia was diagnosed in 24 admissions (14%), and SIRS developed in 126 admissions (75%). One or more organ failures developed in 131 admissions (78%). The actual and predicted mortality rates were 29.6% and 45.2%, respectively, with a standardized mortality ratio of 0.65. The most frequent immediate cause of death was bacterial infection. The CD4⁺ lymphocyte count (median, 27.5 cells/μL vs 59 cells/μL; p = 0.0310) and serum albumin level (median 2.2 g/dL vs 2.6 g/dL; p = 0.0355) of nonsurvivors were lower and the APACHE II score (median, 30 vs 21; p < 0.0001) was higher, compared to those of survivors. A higher APACHE II score (odds ratio [OR], 1.11; 95% confidence interval [CI], 1.05 to 1.16) and a transfer from another hospital ward (OR, 3.03; 95% CI, 1.20 to 7.68) were independently associated with increased mortality. The median number of organ failures that developed in survivors was one, compared to four in nonsurvivors (p < 0.0001).
The outcome of HIV-infected patients admitted to the ICU has improved over the years. The CD4 count does not correlate with in-hospital mortality. Higher APACHE II scores and a transfer from another hospital ward are associated with a poor outcome.
Factors predicting survival for HIV-infected patients with respiratory failure
2000, Netherlands Journal of Medicine
Background: Despite improved treatment modalities, the mortality of HIV infected patients admitted to the intensive care unit with respiratory failure remains high. To help ICU physicians in advising HIV infected patients whether to undergo mechanical ventilation, we retrospectively investigated prognostic factors predicting hospital outcome for HIV-infected patients, admitted to a medical intensive care unit with respiratory failure before the era of highly-active anti-retroviral therapy.
Methods: A retrospective chart review was carried out of all HIV-infected patients with respiratory failure admitted to the medical ICU of a Dutch University Hospital between 1991 and 1997.
Results: In the six year period, 29 HIV-infected patients were admitted to the ICU for respiratory failure. Mechanical ventilation, CD4 cell count, APACHE II score, APACHE III score, ARDS and length of ICU stay all differed significantly between survivors and non-survivors. However, a multivariate analysis only showed the need for mechanical ventilation as an independent risk factor for mortality. The only combination of factors able to accurately predict mortality for the individual patient was the development of ARDS and the requirement of mechanical ventilation.
Conclusions: The combination of mechanical ventilation and ARDS accurately predicts hospital outcome in HIV-infected patients presenting with respiratory failure before the HAART era.
CD4 lymphocyte counts and mortality in AIDS patients requiring mechanical ventilator support due to Pneumocystis carinii pneumonia
1998, Chest
To evaluate CD4 counts as a predictor of mortality in AIDS patients with respiratory failure due to Pneumocystis carinii pneumonia (PCP).
Retrospective chart review.
Urban university medical center.
Forty-eight patients admitted to the medical ICU from January 1993 to August 1996 with diagnosis of HIV/AIDS, PCP, CD4 count <200 cells per cubic millimeter, who required mechanical ventilation for respiratory failure.
Medical records were reviewed and age, CD4 count, lactate dehydrogenase, room air (RA) PaO₂, coinfections, and day of admission to day of intubation (DOA-DOI) data were recorded.
All 48 patients (12 women and 36 men) were treated with corticosteroids and IV trimethoprim-sulfamethoxazole. Age ranged from 21 to 65 years; CD4, 1 to 180, RA PaO₂, 27 to 93 mm Hg; and DOA-DOI, 0 to 20 days. Mortality varied significantly depending on CD4 counts: CD4 0 to 10 (100%); CD4 11 to 50 (88%); CD4 51 to 100 (50%); and CD4 >100 (25%). There were no significant difference in mortality between the groups with DOA-DOI <5 days (82%) vs >5 days (80%) or between the groups with PaO₂ <60 mm Hg (85%) vs PaO₂ >60 mm Hg (73%).
Even though overall mortality was 81%, the mortality rate was significantly different among the four groups. Most striking was the progressive increase in mortality as CD4 cells decreased from >100 (25% mortality) to <10 (100% mortality). Survivors had significantly higher CD4 cell counts than those who died. The CD4 cell count within 2 weeks of admission has significant prognostic value and may be helpful when counseling patients, families, and healthcare surrogates in end-of-life decision making.

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: Manuscript received June 20; revision accepted February 1.

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Chest

Prognosis of Patients with AIDS Requiring Intensive Care

Section snippets

Setting

RESULTS

DISCUSSION

ACKNOWLEDGMENT

Am J Med

An evaluation of outcome from intensive care in major medical centers

Ann Intern Med

APACHE II: a severity of disease classification system

Crit Care Med

APACHE II outcome prediction of HIV-positive patients requiring admission to an intensive care unit [Abstract]

Chest