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(Chest. 2004;126:1299-1306.)
© 2004 American College of Chest Physicians

Outcome in Noninvasively and Invasively Ventilated Hematologic Patients With Acute Respiratory Failure*

Pieter O. Depuydt, MD; Dominique D. Benoit, MD; Koenraad H. Vandewoude, MD; Johan M. Decruyenaere, MD, PhD and Francis A. Colardyn, MD

* From the Department of Intensive Care, Ghent University Hospital, Ghent, Belgium.

Correspondence to: Pieter Depuydt, MD, Department of Intensive Care, Ghent University Hospital, De Pintelaan 185, 9000 Ghent, Belgium; e-mail: pdepuydt{at}msn.com


   Abstract
TOP
 Abstract
Introduction
 Patients and Methods
 Results
 Discussion
 References
 
Study objectives: The survival rate of patients with a hematologic malignancy requiring mechanical ventilation (MV) in the ICU has improved over the last few decades. The objective of this study was to identify the factors affecting the in-hospital mortality of these particular patients, and to assess whether the use of noninvasive positive pressure ventilation (NPPV) was protective in our study population.

Design: We retrospectively collected variables in 166 consecutive patients with hematologic malignancies who had acute respiratory failure (ARF) requiring MV, and identified factors obtained within 24 h of ICU admission affecting in-hospital mortality in univariate and multivariate stepwise logistic regression analyses. The effect of NPPV on mortality was assessed using a pair-wise matched exposed-unexposed analysis.

Results: The mean simplified acute physiology score (SAPS) II was 58.9. The in-hospital mortality rate was 71%. In a multivariate logistic regression analysis, the in-hospital mortality rate was predicted by increasing severity of illness, as measured by SAPS II (odds ratio [OR] per point of increase, 1.07; 95% confidence interval [CI], 1.04 to 1.11) and a diagnosis of acute myelogenous leukemia (OR, 2.73; 95% CI, 1.05 to 7.11). Female sex (OR, 0.36; 95% CI, 0.16 to 0.82), endotracheal intubation (ETI) within 24 h of ICU admission (OR, 0.29; 95% CI, 0.11 to 0.78), and recent bacteremia (defined as blood cultures positive for bacteria < 48h before or < 24h after ICU admission) [OR, 0.22; 95% CI, 0.08 to 0.61] were associated with a lower mortality rate. Twenty-seven patients who received NPPV were matched for SAPS II (± 3) with 52 patients who required immediate ETI on a 1:2 basis. The crude in-hospital mortality rate was 65.4% in both groups.

Conclusion: Although the in-hospital mortality rate in hematologic patients who develop ARF remains high, the reluctance to intubate and start treatment with invasive MV in this population is unjustified, especially when bacteremia has precipitated ICU admission.

Key Words: acute respiratory failure • hematologic malignancy • ICU • mechanical ventilation • mortality • noninvasive positive pressure ventilation


   Introduction
TOP
 Abstract
 Introduction
Patients and Methods
 Results
 Discussion
 References
 
The disease-free and overall survival times in patients with hematologic malignancies are increasing because of new chemotherapeutic regimens with or without treatment with bone marrow transplantation (BMT) or peripheral blood stem cell transplantation (PBSCT) on one hand, and advances in supportive therapy on the other hand. However, this intensification of therapy also has resulted in an increasing number of referrals of hematologic patients to the ICU at one or other stage of their disease because of disease-related or therapy-related complications.1 Acute respiratory failure (ARF) and subsequent treatment with mechanical ventilation (MV) have been found to carry a grim prognosis in these patients.2345678910111213 Some publications, however, have reported that the overall outcome in critically ill hematologic patients is improving1415 and that this trend also translates into an improved survival rate in the subgroup of patients receiving MV.16171819 This has been attributed partly to the protective effect of the use of noninvasive positive-pressure ventilation (NPPV).1820 Whereas these studies clearly have questioned the reluctance to treat hematologic patients with MV, more data are needed to try to identify which factors determine prognosis as well as which treatment options could have an impact on survival. The decisions to admit hematologic patients to the ICU and to start treatment with MV are exceptionally complex, as the potential for curing the patient with therapy for the underlying disease as well as for the critical illness must be balanced against the risk of embarking on a costly, lengthy, and eventually futile treatment.12212223 In this light, it has become important to try to identify, preferably at an early stage of ICU treatment, certain subgroups of patients in whom aggressive and prolonged ICU treatment is demanded, as well as subgroups that are so unlikely to survive despite intensive care, that the limitation of life support or it withdrawal can be justified at an earlier time. Whereas some studies tackling this problem clearly have demonstrated improving outcomes, most of them included patients with hematologic as well as solid malignancies and yielded conflicting results about factors predicting mortality.12141516232425

We have studied the outcome and the predictors of in-hospital mortality in a subgroup of 166 patients who received MV (both invasive MV and NPPV) in a total population of 230 patients with hematologic malignancies who were referred to our ICU between 1997 and 2002, focusing on factors that are easily obtainable at ICU admission or within the first 24 h of the patient’s ICU stay. We have assessed whether the use of NPPV was associated with a better outcome.


   Patients and Methods
TOP
 Abstract
 Introduction
 Patients and Methods
Results
 Discussion
 References
 
Study Location and Subjects
We have studied a cohort of 230 consecutive patients with hematologic malignancies or aplastic anemia who were admitted to the medical ICU of the Ghent University Hospital between January 1, 1997, and June 30, 2002. This 14-bed unit admits critically ill patients who are at least 15 years old. Of these 230 patients, 166 (72.2%) received MV. Twenty-six patients received NPPV. Demographic, clinical, laboratory, and physiologic data were recorded retrospectively in 68 patients (within the period from January 1, 1997, and August 31, 2000) by reviewing the charts and the computerized hospital laboratory and administrative database, and prospectively in 98 patients (from September 1, 2000, to June 30, 2002).

Decisions regarding the initiation and termination of therapy with NPPV were made by a senior ICU staff member who was experienced in the use of NPPV, and took in account one or a combination of the signs and parameters mentioned below. This policy conforms to recommended practice that was eventually condensed in international guidelines.2627

At our ICU, patients who present with respiratory failure are considered for a trial of NPPV if they present with respiratory failure while hemodynamically stable (ie, if they do not require vasopressor therapy), and are awake and cooperative, and able to clear their secretions adequately, and when no signs of imminent respiratory arrest are present. Patients are considered to have not responded to NPPV therapy when they develop increasing obtundation, do not tolerate NPPV despite adaptations of the mask and ventilator settings, develop severe hemodynamic instability, or develop increasing hypoxemia and/or hypercapnia despite the use of maximal tolerated ventilator settings.

Before July 1999, therapy with NPPV was administered as continuous positive airway pressure (positive end-expiratory pressure [PEEP], 5 cm H2O) delivered by a flow generator with a high-pressure gas source through a full-face mask, with the use of NPPV restricted to patients with hypoxemic ARF without hypercapnia. From July 1, 1999, to the present, treatment with NPPV has been achieved through pressure-support ventilation using a full-face mask. The ventilator settings used are a PEEP between 3 and 8 cm H2O, to which inspiratory pressures up to 10 cm H2O (eg, bilevel pressure ventilation [BIPAP vision; Respironics; Murrysville, PA] or assisted spontaneous breathing [Evita 4; Dräger Medical; Telford, PA]) are added.

Cohort Study
Variables collected within 24 h of ICU admission included age, sex, underlying hematologic malignancy, disease status, BMT/PBSCT and number of weeks since transplantation, recent high-dose chemotherapy, the major reason for ICU admission, the presence of ARF with a need for MV, endotracheal intubation (ETI), vasopressor need, and, if available, the duration of leukopenia before ICU admission. Severity of illness was assessed by the simplified acute physiology score (SAPS) II. Laboratory data included WBC count, lowest PaO2/fraction of inspired oxygen (FIO2), most aberrant values of pH, PaO2, and PaCO2, as well as all parameters necessary to calculate the SAPS II. Only the worst laboratory values from the first 24 h were considered. The Glasgow coma scale (GCS) was routinely available in patients with suspected serious neurologic disorders, and all other patients were considered to have a normal score.

The types of hematologic malignancies recorded were acute myelogenous leukemia (AML), acute lymphoblastic leukemia (ALL), high-grade non-Hodgkin lymphoma (NHL), low-grade NHL, or chronic lymphatic leukemia (CLL), multiple myeloma (MM), and other diagnosis. The latter category included patients with Hodgkin disease, myelodysplastic syndrome, and aplastic anemia. Disease status was categorized into active or stable disease. Patients with a relapse or disease progression requiring chemotherapy within 4 weeks before ICU admission were categorized as having active disease. Stable patients who were in partial remission were not considered as having active disease. Patients who received myeloablative therapy in the context of BMT or PBSCT, or who had received > 2 g cytosine arabinoside per m2 at least 4 weeks before ICU admission were defined as having received high-dose chemotherapy. Leukopenia was defined as a total WBC count of < 1.0 x 109 cells/L. The use of vasopressor therapy was defined as treatment with any vasopressor or inotropic drug that was started within 24 h of ICU admission. At our institution, the use of vasopressor and inotropic drugs is restricted to those patients with hypotension (ie, systolic BP, < 90 mm Hg) who are not responding to adequate fluid challenge, or to patients with proven cardiac failure on echocardiography or pulmonary artery catheterization and signs of organ failure (ie, oliguria [defined as a urinary output of ≤ 500 mL per 24-h period], renal failure, neurologic impairment, and lactic acidosis). Recent bacteremia was defined as at least two blood culture results positive for coagulase-negative staphylococci or Corynebacterium species, or at least one blood culture result positive for other bacteria < 48 h before ICU admission or within 24 h of ICU admission.

The variables recorded during the ICU stay included the presence of ARF with the need for MV occurring after 24 h, the use of NPPV, the need for renal replacement therapy (RRT), the duration of leukopenia, the duration of ventilation, the presence of a do-not-resuscitate (DNR) option, and length of stay. ICU, in-hospital, and 6-month mortality rates, and the total number of survival days since ICU admission were also noted.

Exposed-Unexposed Nested Cohort Study
We defined exposed patients as those who received a trial of NPPV, irrespective of whether they required ETI at a later stage. Unexposed patients were defined as those who received ETI followed by invasive MV as the only MV technique. The selection of unexposed patients was made without knowledge of the outcomes. Each exposed patient was matched with two unexposed patients by SAPS II score (± 3) on ICU admission.

Statistical Analysis
Results are reported as the mean ± SD, the median (interquartile range), or No. (%), as appropriate. The major response variable used in the analyses was vital status (ie, alive or dead) at hospital discharge. In the univariate analysis, both groups were compared by the Student t test or the Mann-Whitney U test for continuous variables, depending on whether there was a normal or a nonnormal distribution of the data. For categoric variables, the Pearson {chi}2 test or the Fisher exact test was used, as appropriate. Logistic regression analysis was used to assess the multivariate relationship between multiple patient characteristics and the probability of in-hospital mortality. Stepwise forward and backward regression analyses were used. Predictors included in the analysis were those that showed a p < 0.25 association with in-hospital mortality in univariate analysis as well as those variables that seemed to be clinically important. When appropriate, odds ratios (ORs) and 95% confidence intervals (CIs) are given. All reported p values are two-tailed.


   Results
TOP
 Abstract
 Introduction
 Patients and Methods
 Results
Discussion
 References
 
Patients
A total of 166 patients with a hematologic malignancy received MV in our ICU between January 1, 1997, and June 30, 2002. Patient characteristics, as well as the principal reasons for ICU admission are summarized in Table 1 . However, it is important to note that most patients had a combination of ICU admission reasons. The PaO2/FIO2 ratio was < 300 in 141 patients (85%) and < 200 in 118 patients (71%). Data on PaCO2 and pH were available in 96 patients. In 35 patients (41%), hypercapnia (ie, PaCO2, > 45 mm Hg) was present. Fifty-two patients were acidemic (ie, pH, < 7.35). In 11 patients (21%), this was due to acute respiratory acidosis, in 12 patients (23%) to lactic acidosis, and in 23 patients (44%) to a combination of both.


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  		Table 1. Patient Characteristics at ICU Admission*

 
Within the first 24 h of ICU admission, 102 patients (61.5%) required ETI and invasive MV, and 96 (58.0%) required vasopressor therapy because of circulatory shock. Patients who required MV within 24 h of ICU admission were more severely ill than were patients who required MV later on, as documented by a higher SAPS II (mean, 64 vs 45, respectively; p < 0.001) and were more hemodynamically unstable. The PaO2/FIO2 ratio, on the other hand, was not significantly lower in these patients, suggesting that ARF occurring early (ie, < 24 h after ICU admission) was induced by circulatory shock rather than by respiratory disease.

In 29 patients (17.5%), recent bacteremia was deemed to have triggered ICU admission, and this bacteremia was Gram-positive in 18 patients, Gram-negative in 10 patients, and polymicrobial in 1 patient. Fifty-five patients (33.0%) required RRT during their ICU stay.

Twenty-six patients were treated with NPPV as the initial mode of ventilation. Patients who had undergone a trial of NPPV were more frequently hemodynamically stable (26.9% vs 63.6%, respectively, of patients required vasopressor therapy for < 24 h [p = 0.001]), and had a higher GCS score (median, 15 vs 14, respectively [p < 0.001]) and a lower mean SAPS II score (46 ± 9.7 vs 61 ± 18.7, respectively [p < 0.001]) than patients who received MV only. On the other hand, patients who had been treated with NPPV had more severe hypoxemia at ICU admission, as reflected by a lower PaO2/FIO2 ratio (median, 71 vs 141, respectively; p < 0.001). Two of 12 NPPV patients for whom data about PaCO2 were known were hypercapnic (17%). The median pH was higher in patients who had undergone a trial of NPPV compared with patients who were immediately intubated (pH, 7.42 vs 7.30, respectively), but this difference failed to reach statistical significance (p = 0.08).

Cohort Study
Outcome:
The in-hospital mortality rate was 71% (118 deaths), and 100 patients (62%) died in the ICU. A DNR order was written in 57 patients (35%), all but 1 of whom died in the ICU. Patients with a DNR decision were more likely to have active disease or relapse (p = 0.01). Neither ICU length of stay nor duration of MV differed significantly between patients with and without a DNR decision. Also, no difference was found in the frequency of DNR decisions between patients who received a trial of NPPV and those who did not.

Univariate Analysis:
Predictors of in-hospital mortality in the univariate analysis are summarized in Table 2 . As factors at ICU admission, only the presence of active disease or relapse and leukopenia were significantly associated with mortality (p = 0.016 and p = 0.022, respectively). There was only a trend toward a statistically significant higher mortality rate in men (p = 0.054) as well as in patients who had recently received high-dose chemotherapy (p = 0.058). The median age in nonsurvivors was higher than that in survivors, although this difference was not significant (p = 0.09). Nonsurvivors had a significantly higher SAPS II (p < 0.002). The presence of bacteremia precipitating ICU admission was significantly associated with better survival (p = 0.04). As factors during further ICU stay, the need for RRT (p < 0.001) and the presence of leukopenia during ICU stay (p = 0.011) were associated with a worse outcome. In 55 patients requiring RRT, 49 (89%) died in the ICU, and only 4 were discharged from the hospital alive (in-hospital mortality rate, 92.7%). Two further patients died within 6 months after ICU admission. The in-hospital mortality rate in leukopenic patients was 84.2%, regardless of the duration of leukopenia.


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  		Table 2. Univariate Predictors of In-Hospital Mortality For Surviving and Nonsurviving Patients*

 
Multivariate Analysis:
The result of the multivariable logistic regression analysis based on all variables obtained within 24 h of ICU admission (Table 2) is presented in Table 3 . In addition to increasing severity of illness, as assessed by the SAPS II (OR, 1.07; 95% CI, 1.04 to 1.11), a diagnosis of AML (OR, 2.73; 95% CI, 1.05 to 7.11) was associated with an increased mortality rate, whereas the following three variables were associated with a lower one: female gender (OR, 0.36; 95% CI, 0.16 to 0.82); ETI for < 24 h (OR, 0.28; 95% CI, 0.11 to 0.78); and bacteremia (OR, 0.22; 95% CI, 0.08 to 0.61).


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  		Table 3. Results From Stepwise Logistic Regression Procedure*

 
Matched Exposed-Unexposed Nested Cohort Study
Matching:
The 26 patients who underwent a trial of NPPV (ie, the exposed patients) were matched for severity of illness (as assessed by SAPS II) with 52 patients who received immediate ETI and therapy with invasive MV (ie, the unexposed patients), on a 1:2 basis. The main characteristics of the exposed and unexposed patients are shown in Table 4 . Respiratory failure was the main reason for ICU referral in the large majority of exposed patients (24 of 26 patients; 92.3%) vs 53.8% in unexposed patients; p = 0.04).


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  		Table 4. Characteristics of Matched Patients With and Without Exposure to NPPV*

 
Outcome:
Treatment with NPPV successfully averted the need for ETI in eight patients (31%), five of whom (62.5%) survived their hospital stay. The overall in-hospital mortality rate in patients who received a trial of NPPV was 65.4%. In patients who did not respond to NPPV therapy and had to be switched to invasive MV within 24 h, the mortality rate was as high as 91.7%. In survivors, the use of NPPV was not associated with a difference in length of stay in the ICU and the number of ventilator-dependent days. Conditional logistic regression showed no significant association between the in-hospital mortality rate or the ICU mortality rate and the use of NPPV (OR, 1.08; 95% CI, 0.34 to 3.38). The model could not identify prognostic factors, although recent bacteremia showed a trend for significance (p < 0.1).


   Discussion
TOP
 Abstract
 Introduction
 Patients and Methods
 Results
 Discussion
References
 
The in-hospital mortality rate in our population of hematologic patients with ARF was 70.5%. Although we could not compare this mortality rate with earlier data from our institution, this figure is well in accordance with mortality rates for mechanically ventilated cancer patients that have been reported in the literature.14161824 Those studies illustrate that improving survival in critically ill hematologic patients also reflects a modest gain in survival in those patients who develop ARF requiring MV, since earlier reports mentioned mortality rates of > 80%.2345911

In addition to the severity of illness, as assessed by the SAPS II, we identified four additional variables that independently predicted the in-hospital mortality rate. Whereas in our population, in contrast to several previous studies, age did not influence mortality, female sex was independently associated with a better outcome, with women having a threefold increased chance to survive their hospital stay. This protective effect may be related to the lower cardiovascular risk in women, as is suggested by a significantly lower risk for developing cardiac failure during their ICU stay (data not shown).

Our finding that ETI within 24 h of ICU admission predicted a better outcome may seem surprising at first, although Groeger and colleagues1224 arrived at the same result, since in their analysis ETI after 24 h was associated with a worse outcome. This was explained as the effect of prior medical treatment, in which patients who developed ARF in the hospital, having not responded to intensive in-hospital treatment, fared worse. Although in our study patients who required ETI within 24 h of ICU referral had a similar duration of hospital stay, degree of leukopenia, and antibiotic exposure, it is tempting to hypothesize that they experienced acute and potentially reversible critical illness more frequently than did patients who became respiratory-insufficient at a later time in their ICU stay.

An important finding in our multivariate logistic analysis was the diagnosis of AML being independently associated with a worse prognosis once ARF was present, regardless of disease status. In a study by Massion et al,14 the in-hospital mortality rate of critically ill hematologic patients was not influenced by the prognosis of their underlying disease, as expressed by a division into three categories based on specific-disease prognostic factors and related published survival curves, although a clear trend was observed with the 6-month mortality rate as an end point (p = 0.058). Moreover, in this study only 48 patients (57%) received MV. In the analysis of Groeger et al,12 a diagnosis of acute leukemia was associated with an almost doubled in-hospital mortality rate in ventilated patients, although this diagnosis apparently included patients with ALL as well as those with AML.

No significant association between allogeneic BMT and in-hospital mortality rate could be found in our study. This is at variance with the results of several earlier reports1324 and is probably due to underpowering, since only 28 patients had undergone BMT. Still, it is striking to note that the in-hospital mortality rate in these patients was 81.4%, a rate that compares favorably to the mortality rate of ≥ 90% given in earlier reports.81023 This same trend toward the improving survival of BMT patients with ARF also has been illustrated by the study of Kress et al16

In a previous multivariate logistic regression analysis15 of the factors determining outcome in hematologic patients admitted to the ICU, we have already shown that recent bacteremia was associated with a lower in-hospital mortality rate (adjusted OR, 0.17; 95% CI, 0.05 to 0.58). In this subgroup analysis of patients with ARF, this significant association is maintained with the same adjusted OR, which further confirms the value of recent bacteremia as a predictor of outcome. Again, the better outcome in patients with bacteremia could mainly be attributed to a lower observed mortality rate in patients with Gram-positive bacteremia compared with those with Gram-negative bacteremia. In this population, Gram-positive bacteremia could not be considered as a minor Gram-positive infection (eg, uncomplicated catheter sepsis), since it was thought to have triggered ICU admission and the subsequent need for ventilatory support in all cases.

In contrast to several earlier reports, we could not demonstrate the presence of a survival benefit for the use of NPPV.1820 As only 26 of 166 patients underwent a trial of NPPV, we performed a matched exposed-unexposed nested cohort study to limit the potential for underpowering. As the blood gas measurement results in our patients treated with NPPV suggested (median PaO2/FIO2 ratio, 71; hypercapnia, < 20% of patients), NPPV was mainly used for the treatment of patients with acute severe hypoxic failure, reflecting a practice advocated for this patient population.28 The low number of our NPPV candidates, however, may well reflect reality in a general albeit university hospital-based, hematologic patient population, in which patients are referred to the ICU in an unstable condition or decompensated stage of their ARF. As can be observed from our patient characteristics, a majority of them (61.4%) required immediate ETI (ie, after < 24 h of ICU admission) as well as vasopressor therapy because of circulatory shock (57.8%). In the study of Azoulay et al,18 circulatory shock at ICU admission was present in only 28.3 patients.

It seems therefore likely that a potential benefit attributable to the use of NPPV can be lost when patients arrive in an advanced stage of respiratory failure. Although the retrospective nature of our study precludes definitive conclusions about the impact of NPPV, the results suggest that, outside a well-designed and well-conducted trial, NPPV may be a valuable option in only a minority of hematology patients who have been admitted to the ICU with ARF, and that the protective effect of NPPV might be exerted only if applied immediately in an early, more compensated, phase of their critical illness.2028

Our analysis has several limitations. First, it is based on a retrospective analysis of both retrospectively and prospectively recorded data. To exclude possible bias by the inclusion of the latter, we analyzed for differences between the two data collections. However, no statistically significant differences in patient characteristics or outcome parameters could be found. To limit the possibility of biasing the outcome by the incorrect classification or incorrect recording of data, we chose to include factors in our model that are easily and reliably retrievable from the medical files. For that reason, we also did not include variables such as the reason for ICU referral or the type of ARF. The retrospective nature of our analysis makes bias in treatment decisions a possible confounding factor. We have tried to evaluate for this bias by looking at the DNR decisions that were taken. Whereas the presence of active disease or relapse was associated with an increased chance for a DNR decision, active disease does not appear as an independent factor in our model. Although a significant difference existed between different categories of ICU admission reasons, with it being less likely that patients who were referred with a prime diagnosis of sepsis had a DNR decision, no difference could be found between categories when looking at the length of ICU stay or the number of ventilator-dependent days. This suggests that patients, irrespective of their reason for ICU admission, at least received an equal amount of life support. Finally, since this regression analysis is based on a population of hematologic patients with ARF who were treated in one center, its results may not be extrapolated to other hematologic patients because of possible selection bias due to ICU admission, DNR order policy, or treatment strategies.

In conclusion, we concur with other authors that MV cannot be considered as futile therapy in hematologic patients. Improving prognosis was observed in patients who needed ETI (ie, those who had been excluded from NPPV therapy or had not responded to a trial of NPPV), which was probably due to advances in critical care and invasive MV. Even in the subgroup of ARF patients with AML, 16.3% were discharged from the hospital alive. At the other side of the spectrum, the in-hospital mortality rate decreased to 55.2% when ICU admission and ARF were precipitated by bacterial sepsis. Clearly, ongoing study is warranted to be able to predict outcomes more reliably. Until then, critically ill hematologic patients should be denied neither MV nor ETI, especially when their ARF has been triggered by bacterial sepsis.


   Footnotes
 
Abbreviations: ALL = acute lymphoblastic leukemia; AML = acute myelogenous leukemia; ARF = acute respiratory failure; BMT = bone marrow transplantation; CI = confidence interval; DNR = do not resuscitate; ETI = endotracheal intubation; FIO2 = fraction of inspired oxygen; GCS = Glasgow coma scale; MM = multiple myeloma; MV = mechanical ventilation; NHL = non-Hodgkin lymphoma; NPPV = noninvasive positive-pressure ventilation; OR = odds ratio; PBSCT = peripheral blood stem cell transplantation; PEEP = positive end-expiratory pressure; RRT = renal replacement therapy; SAPS = simplified acute physiology score

Received for publication October 24, 2003. Accepted for publication April 29, 2004.


   References
TOP
 Abstract
 Introduction
 Patients and Methods
 Results
 Discussion
 References
 

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