Current status of pediatric home mechanical ventilation in Japan]

The first nationwide survey of pediatric home mechanical ventilation (HMV) was conducted. From 35 out of 149 medical centers investigated, 49 cases of HVM were reported. The patients ranged in age from 1 to 20 years, and the causes of respiratory failure were neuromuscular diseases (51%), central hypoventilation (33%), respiratory disorders (10%) and cervical cord injury (6%). Since 1983 when 2 patients were discharged home on mechanical ventilation, more and more ventilator-dependent children have been sent home every year. However, home mechanical ventilation is not yet well recognized in Japan as an option for pediatric patients with chronic respiratory failure, and there are many problems to be solved. Firstly, very few, if any, hospitals have a designated home care team composed of physicians and other specialists. Secondly, the current health insurance system scarcely covers the cost of home ventilation. Thirdly, development of home use equipment, in particular, portable ventilators and monitors is imperative. There are 107 hospitalized patients in 56 institutions who are reportedly able to go home if a support system is established. A program for pediatric home mechanical ventilation should be urgently developed on a national basis.     

Calls on reproductive and developmental toxicants to a regional poison center

OBJECTIVES/HYPOTHESIS: Rehabilitation following head and neck cancer surgery has steadily moved into the outpatient realm and become dependent on caregivers with no formal medical background (lay caregivers.) Satisfactory rehabilitation and quality of life (QOL) depend on successful relationships between patients and the lay caregivers. This study evaluates the QOL assessments of patients by themselves and their primary lay caregivers before head and neck surgery. STUDY DESIGN: Institutional Review Board-approved study using validated QOL assessment instrument. MATERIALS AND METHODS: The preoperative QOL status in 50 patients undergoing extensive head and neck surgery was evaluated using the self-administered Medical Outcomes Survey Short Form 36 (SF-36). The patient's primary lay caregiver (spouse, child, or friend) completed a similar questionnaire evaluating the patient's status. RESULTS: Thirty-three (66%) questionnaires were returned. Twenty-five (50%) questionnaire sets were successfully completed by both parties and employable for comparison. Sixty percent of the caregivers were within the 90% confidence interval of the patient's assessment for six or more of the eight parameters evaluated by the SF-36. Likewise, caregiver assessments for specific parameters were consistently congruent with patient evaluation, except for the parameters of bodily pain and general health, for which caregivers demonstrated a trend for overrating pain and underestimating general health. Caregivers of the same generation as the patient demonstrated significantly higher congruence (P = .007). Similarly, a trend for higher congruence was noted in patients with recurrent disease. CONCLUSIONS: The importance of the lay caregiver has increased in the era of greater outpatient rehabilitation. This pilot study indicates that QOL assessment by lay caregivers may be examined with existing instruments and highlights QOL parameters critical to both the head and neck surgery patient and his or her primary lay caregiver.     

Comparison of noninvasive positive pressure ventilation with standard medical therapy in hypercapnic acute respiratory failure

STUDY OBJECTIVE: To compare the efficacy of standard medical therapy (ST) and noninvasive mechanical ventilation additional to standard medical therapy in hypercapnic acute respiratory failure (HARF). DESIGN: Single center, prospective, randomized, controlled study. SETTING: Pulmonary medicine directed critical care unit in a university hospital. PATIENTS: Between March 1993 and November 1996, 30 HARF patients were randomized to receive ST or noninvasive positive pressure ventilation (NPPV) in addition to ST. INTERVENTIONS: NPPV was given with an air-cushioned face via a mechanical ventilator (Puritan Bennett 7200) with initial setting of 5 cm H2O continuous positive airway pressure and 15 cm H2O pressure support. RESULTS: At the time of randomization, patients in the ST group had (mean+/-SD) PaO2 of 54+/-13 mm Hg, PaCO2 of 67+/-11 mm Hg, pH of 7.28+/-0.02, and respiratory rate of 35.0+/-5.8 breaths/min. Patients in the NPPV group had PaO2 of 55+/-14, PaCO2 of 69+/-15, pH of 7.27+/-0.07, and respiratory rate of 34.0+/-8.1 breaths/min. With ST, there was significant improvement of only respiratory rate (p < 0.05). However, with NPPV, PaO2 (p < 0.001), PaCO2 (p < 0.001), pH (p < 0.001), and respiratory rate (p < 0.001) improved significantly compared with baseline. Six hours after randomization, pH (p < 0.01) and respiratory rate (p < 0.01) in NPPV patients were significantly better than with ST. Hospital stay for NPPV vs ST patients was, respectively, 11.7+/-3.5 and 14.6+/-4.7 days (p < 0.05). One patient in the NPPV group required invasive mechanical ventilation. The conditions of six patients in the ST group deteriorated and they were switched to NPPV; this was successful in four patients, two failures were invasively ventilated. CONCLUSION: This study suggests that early application of NPPV in HARF patients facilitates improvement, decreases need for invasive mechanical ventilation, and decreases the duration of hospitalization.     

Options for long-term ventilatory support

Long-term mechanical ventilator support for patients with chronic respiratory failure is becoming more common. This article reviews the common causes for chronic ventilator dependence, and offers an approach to weaning these patients from the ventilator. In addition, the details for preparing these patients for prolonged mechanical ventilation outside of the acute-care hospital setting are discussed. Appropriate education of the patient's caregivers is key to the success of long-term ventilatory support outside of the acute-care hospital.     

Contribution of bronchoalveolar lavage and transbronchial biopsy to diagnosis and prognosis of drug-induced pneumopathies

OBJECTIVE: The purpose of this study was to evaluate three ventilator weaning strategies and to evaluate whether the use of continuous positive airway pressure (CPAP) via a nasopharyngeal or endotracheal tube would increase the likelihood of extubation failure in very low birth weight (VLBW) infants. STUDY DESIGN: We studied prospectively 87 preterm infants (mean +/- SD; birth weight: 1078 +/- 188 g; gestational age: 28.8 +/- 2.2 weeks) who were in the process of being weaned from intermittent mandatory ventilation (IMV). Infants were assigned by systematic sampling to one of the following three treatment groups: (1) direct extubation from IMV (D.EXT) (n = 30); (2) preextubation endotracheal CPAP (ET-CPAP) for 12-24 hr (n = 28); or (3) postextubation nasopharyngeal CPAP (NP-CPAP) for 12-24 hr (n = 29). Failure was defined as the need for resumption of mechanical ventilation within 72 hr of extubation due to frequent or severe apnea and/or respiratory failure (pH < 7.25, PaCO2 > 60 mm Hg, and/or requirement for oxygen FiO2 > 60%). RESULTS: There were no significant differences in failure rates among the three procedures. Failures were 2/30 (7%) in D.EXT; 4/28 (14%) in ET-CPAP; and 7/29 (24%) in the NP-CPAP. There were also no differences in FiO2, PaO2, and respiratory rates before and after discontinuation of IMV among the three groups. PaCO2 values were slightly higher in the NP-CPAP group 12-24 hr after weaning from IMV. CONCLUSION: We were unable to demonstrate a clear difference in extubation outcome by use of CPAP administered via an endotracheal or nasopharyngeal tube when compared to direct extubation from low-rate IMV in VLBW infants.     

Extracorporeal membrane oxygenation for acute respiratory failure induced by Legionella pneumoniae. (Case report)

We report a case of severe legionella pneumonia with acute respiratory failure, successfully managed with veno-venous extracorporeal membrane oxygenation (VV-ECMO). The patient presented with 4-day history of fever and cough. He was in critical condition, with exacerbated respiratory failure. Mechanical ventilation, volume replacement and antibiotic therapy were initiated. Despite increasing mechanical ventilatory support (FiO2 100%, TV 10 ml/kg, f 30/min, PEEP 5 cmH20), PaO2 fell below 40Torr and life sustaining measures were undertaken. VV-ECMO (flow 30 ml/kg/min) was commenced, and the patient responded well, with an elevation of PaO2. Erythromycin therapy was effective against the pneumonia. VV-ECMO was maintained for 92 hours, mechanical ventilation was successfully discontinued 11 days after and the patient was discharged 82 days after cessation of ventilator support. Serum antibody examination proved legionella infection. VV-ECMO may have a role in the management of patients with acute respiratory failure caused by bacterial pneumonia.     

Kyphosis secondary to tuberculosis osteomyelitis as a cause of ventilatory failure. Clinical features, mechanisms, and management

STUDY OBJECTIVES: To investigate the relationship of thoracic kyphosis following tuberculosis to the development of ventilatory failure and to assess the efficacy on nocturnal noninvasive ventilatory support. DESIGN: Retrospective consecutive case series with crossover from a phase without noninvasive ventilatory support to a phase with this treatment. SETTING: The Respiratory Support and Sleep Centre, Papworth, Hospital, Cambridge, England. PATIENTS: Seven patients with thoracic kyphosis following tuberculous osteomyelitis which had been contracted by the age of 4 years were studied. Their mean age was 53 (SD 7.1) years and the mean angle of kyphosis was 113.60. All patients were in ventilatory failure. INTERVENTIONS: The patients were treated with nocturnal noninvasive ventilation with either an individually constructed cuirass shell and a negative pressure pump or nasal intermittent positive pressure ventilation using a volume preset ventilator. MEASUREMENT AND RESULTS: Each patient underwent an initial clinical assessment along with radiologic studies of the spine, pulmonary function tests, daytime arterial blood gas tensions, and overnight recordings of arterial saturation, and transcutaneous carbon dioxide tension. They were reassessed in detail at a mean of 5 years after starting ventilatory support. Symptoms, vital capacity, daytime carbon dioxide tension, and overnight oximetry had all improved following treatment. Temporary withdrawal of ventilatory support led to severe sleep fragmentation in four patients and the appearance of central apneas and hypopneas in the other three. Six of the 7 patients were alive at a mean of 5.7 years after starting nocturnal ventilation. CONCLUSION: These results show that ventilatory failure may develop, after an interval of many years, in patients with a severe thoracic kyphosis due to tuberculosis in childhood. Noninvasive nocturnal ventilatory support can control the symptoms of ventilatory failure, improve the physiologic abnormalities, and is associated with prolonged survival.     

Characterizations of elderly recipient of home-care and their caregivers. A questionnaire survey of elderly members of a health insurance union

The characteristics of elderly being cared for at home and their caregivers were analyzed based on a questionnaire about health and care for the elderly. We also assessed the problems of home care in view of activities of daily living (ADL) of the home-care recipient. Subjects were members of a health insurance union or their families and ages were more than 65 years old. Results were as follows; 1. The total number of released questionnaires was 5,472, of which responses totally 2,567 (46.9%) were received. Frequencies of the elderly at home without care, at home with care, and in hospitals or nursing home were 86.3%, 9.6% and 4.1%, respectively. 2. We categorized the home care recipient according to their ADL and analyzed their status. The frequency of using health care equipment for home care was significantly higher in the low ADL groups than in the high ADL groups. Caregivers in low ADL groups felt much more care burden than those in high ADL groups. 3. There was a tendency for differences in the use of community welfare services such as visiting nurses or short-stay between the home care recipient with dementia (group D) and the bedfast home care recipient (group C). Approximately 30% of caregivers in group D wanted to transfer the care of the elderly to hospitals or nursing home. 4. In Tokyo and nearby prefectures, there was a highly frequency that main caregivers were recipients' children. In the rural prefecture it was more frequent that the main caregiver was recipients' wife or husband only.     

Unfavorable mechanical effects of heat and moisture exchangers in ventilated patients

OBJECTIVE: To investigate the mechanical effects of artificial noses. SETTING: A general intensive care unit of a university hospital. PATIENTS: 10 patients in pressure support ventilation for acute respiratory failure. INTERVENTIONS: The following three conditions were randomly tested on each patient: the use of a heated humidifier (control condition), the use of a heat and moisture exchanger without filtering function (HME), and the use of a combined heat and moisture exchanger and mechanical filter (HMEF). The pressure support level was automatically adapted by means of a closed-loop control in order to obtain constancy, throughout the study, of patient inspiratory effort as evaluated from airway occlusion pressure at 0.1 s (P0.1). Patient's ventilatory pattern, P0.1, work of breathing, and blood gases were recorded. MEASUREMENTS AND MAIN RESULTS: The artificial noses increased different components of the inspiratory load: inspiratory resistance, ventilation requirements (due to increased dead space ventilation), and dynamic intrinsic positive end-expiratory pressure (PEEP). The additional load imposed by the artificial noses was entirely undertaken by the ventilator, being the closed-loop control of P0.1 effective to maintain constancy of patient inspiratory work by means of adequate increases in pressure support level. CONCLUSIONS: The artificial noses cause unfavorable mechanical effects by increasing inspiratory resistance, ventilation requirements, and dynamic intrinsic PEEP. Clinicians should consider these effects when setting mechanical ventilation and when assessing patients' ability to breathe spontaneously.     

Current status of long term ventilation of children in the United Kingdom: questionnaire survey

OBJECTIVES: To identify the number and current location of children, aged 0 to 16 years, requiring long term ventilation in the United Kingdom, and to establish their underlying diagnoses and ventilatory needs. DESIGN: Postal questionnaires sent to consultant respiratory paediatricians and all lead clinicians of intensive care and special care baby units in the United Kingdom. SUBJECTS: All children in the United Kingdom who, when medically stable, continue to need a mechanical aid for breathing. RESULTS: 141 children requiring long term ventilation were identified from the initial questionnaire. Detailed information was then obtained on 136 children from 30 units. Thirty three children (24%) required continuous positive pressure ventilation by tracheostomy over 24 hours, and 103 received ventilation when asleep by a non-invasive mask (n=62; 46%), tracheostomy (n=32; 24%), or negative pressure ventilation (n=9; 7%). Underlying conditions included neuromuscular disease (n=62; 46%), congenital central hypoventilation syndrome (n=18; 13%), spinal injury (n=16; 12%), craniofacial syndromes (n=9; 7%), bronchopulmonary dysplasia (n=6; 4%), and others (n=25; 18%). 93 children were cared for at home. 43 children remained in hospital because of home circumstances, inadequate funding, or lack of provision of home carers. 96 children were of school age and 43 were attending mainstream school. CONCLUSIONS: A significant increase in the number of children requiring long term ventilation in the United Kingdom has occurred over the past decade. Contributing factors include improved technology, developments in paediatric non-invasive ventilatory support, and a change in attitude towards home care. Successful discharge home and return to school is occurring even for severely disabled patients. Funding and home carers are common obstacles to discharge.     

Randomised, controlled trial of nasal continuous positive airway pressure in the extubation of infants weighing 600 to 1250 g

AIM: To determine whether extubation to nasal continuous airway pressure (NCPAP) results in a greater proportion of infants remaining free of additional ventilatory support for one week after extubation compared with those extubated directly to headbox oxygen. METHODS: A randomised, controlled, clinical trial was conducted at the neonatal intensive care unit of the Royal Women's Hospital, Melbourne, of infants with birthweights between 600 and 1250 g, ventilated via an endotracheal tube for more than 12 hours, requiring less than 50% oxygen, a ventilator rate < or = 20/minute, considered by the clinical management team to be ready for extubation. Infants were randomly allocated either to NCPAP or to oxygen administered via a headbox. Success was defined by no requirement for additional ventilatory support over the week following extubation. Failure criteria were (i) apnoea; (ii) absolute increase in oxygen requirement greater than 15% above than required before extubation; or (iii) respiratory acidosis (pH < 7.25 with pCO2 > 6.67 kPa). RESULTS: Thirty one of 47 (66%) infants were successfully extubated to NCPAP compared with 18 of 45 (40%) for headbox oxygen. The increase in failure rate in the headbox group was due primarily to increased oxygen requirements in this group. Of the 27 who failed headbox oxygen, 26 were given a trial of NCPAP and 13 did not require endotracheal reintubation. There was no significant difference between the groups in the total number of days of assisted ventilation or the duration of inpatient stay. CONCLUSIONS: NCPAP applied prophylactically after endotracheal extubation reduces the incidence of adverse clinical events that lead to failure of extubation in the seven days after extubation. This reduction is clinically important. The benefits of NCPAP do not seem to be associated with an increased incidence of unwanted side effects.     

PSA screening--current controversy

OBJECTIVE: To evaluate treatment with noninvasive ventilation (NIV) by nasal mask as an alternative to endotracheal intubation and conventional mechanical ventilation in patients with hematologic malignancies complicated by acute respiratory failure to decrease the risk of hemorrhagic complications and increase clinical tolerance. DESIGN: Prospective clinical study. SETTING: Hematologic and general intensive care unit (ICU), University of Rome "La Sapienza". PATIENTS: 16 consecutive patients with acute respiratory failure complicating hematologic malignancies. INTERVENTIONS: NIV was delivered via nasal mask by means of a BiPAP ventilator (Respironics, USA); we evaluated the effects on blood gases, respiratory rate, and hemodynamics along with tolerance, complications, and outcome. MEASUREMENTS AND RESULTS: 15 of the 16 patients showed a significant improvement in blood gases and respiratory rate within the first 24 h of treatment. Arterial oxygen tension (PaO2), PaO2/FIO2 (fractional inspired oxygen) ratio, and arterial oxygen saturation significantly improved after 1 h of treatment (43+/-10 vs 88+/-37 mmHg; 87+/-22 vs 175+/-64; 81+/-9 vs 95+/-4%, respectively) and continued to improve in the following 24 h (p < 0.01). Five patients died in the ICU following complications independent of the respiratory failure, while 11 were discharged from the ICU in stable condition after a mean stay of 4.3+/-2.4 days and were discharged in good condition from the hospital. CONCLUSIONS: NIV by nasal mask proved to be feasible and appropriate for the treatment of respiratory failure in hematologic patients who were at high risk of intubation-related complications.     

Acute respiratory distress syndrome. Liquid ventilation

In summary, the use of partial liquid ventilation with perfluorocarbon seems to be safe in neonates, children, and adults with ALI or ARDS. Partial liquid ventilation can be used for the following goals: recruitment of lung volume; enhancement or uniformity of lung inflation; improved oxygenation; improved lung compliance; and prevention or minimization of lung damage induced by mechanical ventilation. Partial liquid ventilation improved gas exchange and lung mechanics in test subjects. Cardiopulmonary interaction and long-term safety require further study. Extrapolations from animal data, however, suggest that there are no long-term undesired effects. The current clinical data strongly suggest that close monitoring and adjustment of ventilator parameters during drug instillation are necessary to reduce hypoxia, bradycardia, and pneumothorax. Further studies are required to explore the efficacy of partial liquid ventilation with perfluorocarbon in ALI or ARDS subjects, in particular, to evaluate the safety and efficacy of smaller doses; mechanical ventilation strategies; and outcomes. Additional research including large randomized studies is clearly required to answer these and other questions.     

Is there a role for video-assisted thoracoscopy in the staging of non-small cell lung cancer?

OBJECTIVE: To evaluate the effects of prolonged neuromuscular blockade (NMB) on oxygenation and duration of mechanical ventilation in children with respiratory failure. DESIGN: Retrospective case control study. SETTING: The pediatric intensive care unit (PICU) of a tertiary university hospital. PATIENTS: All children (n = 68) in the PICU ventilated for pulmonary parenchymal disease for 3 days or longer over a 4 1/2 year period. INTERVENTIONS: None. MEASUREMENTS AND RESULTS: Diagnoses, pediatric risk of mortality scoring, indications for, and duration of, mechanical ventilation and neuromuscular blockade, and blood gas data with corresponding ventilator parameters were extracted from the medical records. Twenty-eight patients received NMB at the initiation of mechanical ventilation and this was continued for 72 h or longer. Cessation of NMB was associated with a significant improvement in ventilator parameters and oxygenation index. The subset of children with respiratory syncytial virus disease (RSV) receiving prolonged NMB had longer ventilator courses compared to those in whom NMB was not used, despite similar demographics, severity of illness and oxygenation impairment. CONCLUSIONS: Stopping NMB is associated with a rapid improvement in oxygenation and prolonged use of NMB in children with RSV is associated with a protracted ventilatory course. DEFINITION: Oxygenation index (OI)*: Mean Airway Pressure x FiO2 x 100/PaO2* Higher scores represent deterioration in oxygenation.     

Ventilatory support during exercise in patients with pulmonary tuberculosis sequelae

STUDY OBJECTIVE: The aim of this study was to determine whether intermittent positive pressure ventilation through a nasal mask (NIPPV) applied during exercise in patients with pulmonary tuberculosis sequelae (PTS) could improve arterial blood gas measurements, ameliorate breathlessness, and increase exercise endurance. PATIENTS: Seven PTS patients with a severe restrictive ventilatory defect (mean [SD] vital capacity, 1.02 [0.25] I) enrolled in this study had experienced NIPPV previously, and were familiar with the procedure. DESIGN: The patients underwent four constant-load cycle ergometer tests in the supine position to tolerance. The tests were performed with and without NIPPV, while breathing normoxic air (Air) or supplemental oxygen (O2; 35%). NIPPV was delivered during exercise in a controlled, volume-cycled mechanical ventilation mode, and the ventilator settings were modulated manually to meet patients' respiratory demands as estimated from the airway pressure waveform and the patient's breathlessness. RESULTS: All patients matched their breathing to the ventilator cycle during most of the exercise while receiving NIPPV. NIPPV significantly prolonged their exercise endurance time, from a mean (SD) of 180 (58) s to 310 (96) s in Air, and from 227 (64) s to 465 (201) s in O2. During exercise, NIPPV effectively decreased their breathlessness and significantly improved arterial blood gas measurements. CONCLUSIONS: NIPPV applied during exercise can effectively support ventilation, significantly ameliorate breathlessness, and consequently improve exercise endurance in patients with PTS.     

Incidence and prevalence of intracranial aneurysms and hemorrhage in Olmsted County, Minnesota, 1965 to 1995

OBJECTIVE: To determine the risk of acquiring ventilator-associated pneumonia (VAP) and the impact on costs when extending ventilator circuit change intervals beyond 2 days to 7 and 30 days. DESIGN: Prospective 4-year review of mechanically ventilated patients. SETTING: The respiratory and medical ICUs of an 800-bed tertiary teaching Veterans Affairs hospital. PATIENTS: All adult patients receiving mechanical ventilation from January 1991 through December 1994. INTERVENTIONS: Ventilator circuits with active heated water humidifiers were changed at 2-day intervals during a 2-year control period, followed by 7-day and 30-day intervals (for 1 year each). Heated wire circuits were adopted with the 30-day interval. The rate of VAP per 1,000 ventilator days was calculated for each circuit change interval group. Survival analysis was used to model VAP with ventilator circuit change to determine risk. RESULTS: During the study period, 637 patients received mechanical ventilation. During the 2 years with 2-day change intervals, the VAP per 1,000 ventilator days was 11.88 (n=343), compared with 3.34 (n=137) and 6.28 (n=157) for 7-day and 30-day change intervals, respectively. The risk of acquiring a VAP for those with a circuit change every 2 days was significantly greater (relative risk, 3.1; p=0.0004; 95% confidence interval, 1.662, 5.812) than those with the 7- and 30-day circuit changes. Extending circuit change intervals reduced supply and labor costs averaging $4,231/yr for each ventilator in use. CONCLUSIONS: Circuit change intervals of 7 and 30 days have lower risks for VAP than the 2-day intervals, yielding substantial reductions in morbidity as well labor and supply costs.     

Long-term mechanical ventilation in amyotrophic lateral sclerosis

BACKGROUND: Acute respiratory insufficiency (ARI) with alveolar hypoventilation or incapacitating dyspnoea but without peripheral muscle involvement can be an early manifestation of respiratory involvement in amyotrophic lateral sclerosis (ALS). Some of these patients benefit from assisted ventilation. The object of this study was to analyse the results of long-term mechanical ventilation (LTMV) in ten patients with ALS. METHODS: A retrospective analysis of intensive care unit (ICU) or ambulant patients with ALS who underwent LTMV in a conventional hospital ward was performed. Erect and supine spirometry, blood gas analysis and pulse oximetry were performed before the start and during the course of ventilation. RESULTS: Ten patients on LTMV were included. Four from the ICU were ventilated via tracheostomy, and six ambulant patients had non-invasive (nasal) ventilation. In all cases, ventilation was performed in a conventional hospital ward. The ambulant patients improved symptomatically during ventilation, confirmed by measurement of gas exchange and of SaO2 by continuous pulse oximetry. Three of the ten patients survive in long-term care--two with nasal and one with tracheostomy ventilation. CONCLUSIONS: LTMV outside ICU was possible in ten patients, seven of whom returned home. Returning home is very difficult for patients dependent on a ventilator who lack family support.     

Alpha-thalassemia carrier identification by DNA analysis in the screening for thalassemia

Recent advances in technology have not substantially changed the high mortality rate associated with acute renal failure (ARF). To obtain a simple, valid prognostic index, we retrospectively evaluated the relative importance of demographic data, causes (acute insults) of renal failure, and comorbid clinical conditions for the outcome in 102 ARF patients who received renal replacement therapy with an overall mortality rate of 65% (66 of 102). There were no significant differences between survivors and nonsurvivors in age and gender. Mortality according to acute insults was similar to that of the whole population studied. Of the 10 clinical conditions at the time of the first renal replacement therapy, mechanical ventilation (p = 0.0002), cardiac failure (p = 0.0006), hepatic failure (p = 0.003), central nervous system dysfunction (p = 0.005), and oliguria (p = 0.04) were found to be significantly related to mortality by univariate analysis. Furthermore, multivariate analysis demonstrated that only mechanical ventilation, cardiac failure, and hepatic failure were significant risk factors. Survival was directly related to the number of significant variables in univariate analysis: zero, 89% (8 of 9); one, 62% (21 of 34); two, 19% (5 of 27); three, 10% (2 of 20); four, 0% (0 of 8); five, 0% (0 of 4). This simple and early prognostic index, derived from the assessment of clinical conditions which were easily determined at the patient's bedside, could be useful for outcome prediction in ARF patients requiring renal replacement therapy.