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      Severe Community-Acquired Pneumonia

      review-article
      , MD, MSc, FRCPC a , , , MD, FRCPC, MACP b
      Critical Care Clinics
      Elsevier Inc.
      Community-acquired pneumonia, Respiratory failure, Lung, Pulmonary sepsis, Intensive care

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          Abstract

          Severe community-acquired pneumonia necessitating intensive care unit admission is associated with high morbidity, mortality, and health-care cost. This review article serves to summarize the epidemiology, diagnosis, treatment, and prognosis of this common life-threatening condition. Current practice guidelines as well as the role of several scoring systems (such as the PSI, CURB-65, and IDSA/ATS criteria) used to predict CAP severity, prognosis, and site of care are reviewed. In addition, common complications and prevention strategies are discussed.

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          Most cited references209

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          A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study.

          To develop and validate a new Simplified Acute Physiology Score, the SAPS II, from a large sample of surgical and medical patients, and to provide a method to convert the score to a probability of hospital mortality. The SAPS II and the probability of hospital mortality were developed and validated using data from consecutive admissions to 137 adult medical and/or surgical intensive care units in 12 countries. The 13,152 patients were randomly divided into developmental (65%) and validation (35%) samples. Patients younger than 18 years, burn patients, coronary care patients, and cardiac surgery patients were excluded. Vital status at hospital discharge. The SAPS II includes only 17 variables: 12 physiology variables, age, type of admission (scheduled surgical, unscheduled surgical, or medical), and three underlying disease variables (acquired immunodeficiency syndrome, metastatic cancer, and hematologic malignancy). Goodness-of-fit tests indicated that the model performed well in the developmental sample and validated well in an independent sample of patients (P = .883 and P = .104 in the developmental and validation samples, respectively). The area under the receiver operating characteristic curve was 0.88 in the developmental sample and 0.86 in the validation sample. The SAPS II, based on a large international sample of patients, provides an estimate of the risk of death without having to specify a primary diagnosis. This is a starting point for future evaluation of the efficiency of intensive care units.
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            BTS guidelines for the management of community acquired pneumonia in adults: update 2009.

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              Multiple organ dysfunction score: a reliable descriptor of a complex clinical outcome.

              To develop an objective scale to measure the severity of the multiple organ dysfunction syndrome as an outcome in critical illness. Systematic literature review; prospective cohort study. Surgical intensive care unit (ICU) of a tertiary-level teaching hospital. All patients (n = 692) admitted for > 24 hrs between May 1988 and March 1990. None. Computerized database review of MEDLINE identified clinical studies of multiple organ failure that were published between 1969 and 1993. Variables from these studies were evaluated for construct and content validity to identify optimal descriptors of organ dysfunction. Clinical and laboratory data were collected daily to evaluate the performance of these variables individually and in aggregate as an organ dysfunction score. Seven systems defined the multiple organ dysfunction syndrome in more than half of the 30 published reports reviewed. Descriptors meeting criteria for construct and content validity could be identified for five of these seven systems: a) the respiratory system (Po2/FIO2 ratio); b) the renal system (serum creatinine concentration); c) the hepatic system (serum bilirubin concentration); d) the hematologic system (platelet count); and e) the central nervous system (Glasgow Coma Scale). In the absence of an adequate descriptor of cardiovascular dysfunction, we developed a new variable, the pressure-adjusted heart rate, which is calculated as the product of the heart rate and the ratio of central venous pressure to mean arterial pressure. These candidate descriptors of organ dysfunction were then evaluated for criterion validity (ICU mortality rate) using the clinical database. From the first half of the database (the development set), intervals for the most abnormal value of each variable were constructed on a scale from 0 to 4 so that a value of 0 represented essentially normal function and was associated with an ICU mortality rate of or = 50%. These intervals were then tested on the second half of the data set (the validation set). Maximal scores for each variable were summed to yield a Multiple Organ Dysfunction Score (maximum of 24). This score correlated in a graded fashion with the ICU mortality rate, both when applied on the first day of ICU admission as a prognostic indicator and when calculated over the ICU stay as an outcome measure. For the latter, ICU mortality was approximately 25% at 9 to 12 points, 50% at 13 to 16 points, 75% at 17 to 20 points, and 100% at levels of > 20 points. The score showed excellent discrimination, as reflected in areas under the receiver operating characteristic curve of 0.936 in the development set and 0.928 in the validation set. The incremental increase in scores over the course of the ICU stay (calculated as the difference between maximal scores and those scores obtained on the first day [i.e., the delta Multiple Organ Dysfunction Score]) also demonstrated a strong correlation with the ICU mortality rate. In a logistic regression model, this incremental increase in scores accounted for more of the explanatory power than admission severity indices. This multiple organ dysfunction score, constructed using simple physiologic measures of dysfunction in six organ systems, mirrors organ dysfunction as the intensivist sees it and correlates strongly with the ultimate risk of ICU mortality and hospital mortality. The variable, delta Multiple Organ Dysfunction Score, reflects organ dysfunction developing during the ICU stay, which therefore is potentially amenable to therapeutic manipulation. (ABSTRACT TRUNCATED)
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                Author and article information

                Contributors
                Journal
                Crit Care Clin
                Crit Care Clin
                Critical Care Clinics
                Elsevier Inc.
                0749-0704
                1557-8232
                4 July 2013
                July 2013
                4 July 2013
                : 29
                : 3
                : 563-601
                Affiliations
                [a ]Division of Infectious Diseases and Critical Care Medicine, University of Alberta, 3C1.12 WMC 8440 112 Street, Edmonton, Alberta T6G 2B7, Canada
                [b ]Dalhousie University, Halifax, Nova Scotia B3H 4R2, Canada
                Author notes
                []Corresponding author. wsligl@ 123456ualberta.ca
                Article
                S0749-0704(13)00026-2
                10.1016/j.ccc.2013.03.009
                7126707
                23830654
                d79cd7c8-c9d3-4455-b1cd-46a2d7b7349c
                Copyright © 2013 Elsevier Inc. All rights reserved.

                Since January 2020 Elsevier has created a COVID-19 resource centre with free information in English and Mandarin on the novel coronavirus COVID-19. The COVID-19 resource centre is hosted on Elsevier Connect, the company's public news and information website. Elsevier hereby grants permission to make all its COVID-19-related research that is available on the COVID-19 resource centre - including this research content - immediately available in PubMed Central and other publicly funded repositories, such as the WHO COVID database with rights for unrestricted research re-use and analyses in any form or by any means with acknowledgement of the original source. These permissions are granted for free by Elsevier for as long as the COVID-19 resource centre remains active.

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                community-acquired pneumonia,respiratory failure,lung,pulmonary sepsis,intensive care

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