The status of intensive care medicine research and a future agenda for very old patients in the ICU

Critically Ill Older Adults' Representation in Intervention Trials: A Systematic Review

OBJECTIVES

Older adults may be under-represented in critical care research, and results may not apply to this specific population. Our primary objective was to evaluate the prevalence of inclusion of older adults across critical care trials focused on common ICU conditions or interventions. Our secondary objective was to evaluate whether older age was used as a stratification variable for randomization or outcome analysis.

DESIGN SETTING AND SUBJECTS

We performed a systematic review of previously published systematic reviews of randomized controlled trials (RCTs) in critical care. We searched PubMed, Ovid, CENTRAL, and Cochrane from 2009 to 2022. Systematic reviews of any interventions across five topics: acute respiratory distress syndrome (ARDS), sepsis/shock, nutrition, sedation, and mobilization were eligible.

MAIN RESULTS

We identified 216 systematic reviews and included a total of 253 RCTs and 113,090 patients. We extracted baseline characteristics and the reported proportion of older adults. We assessed whether any upper age limit was an exclusion criterion for trials, whether age was used for stratification during randomization or data analysis, and if age-specific subgroup analysis was present. The most prevalent topic was sepsis (78 trials, 31%), followed by nutrition (62 trials, 25%), ARDS (39 trials, 15%), mobilization (38 trials, 15%), and sedation (36 trials, 14%). Eighteen trials (7%) had exclusion criteria based on older age. Age distribution with information on older adults prevalence was given in six trials (2%). Age was considered in the analysis of ten trials (5%) using analytic methods to evaluate the outcome stratified by age.

Conclusions

In this systematic review, the proportion of older critically ill patients is undetermined, and it is unclear how age is or is not an effect modifier or to what extent the results are valid for older adult groups. Reporting age is important to guide clinicians in personalizing care. These results highlight the importance of incorporating older critically ill patients in future trials to ensure the results are generalizable to this growing population.

Age Distribution and Clinical Results of Critically Ill Patients above 65-Year-Old in an Aging Society: A Retrospective Cohort Study

BACKGROUND

Increasing age has been observed among patients admitted to the intensive care unit (ICU). Age traditionally considered a risk factor for ICU mortality. We investigated how the epidemiology and clinical outcomes of older ICU patients have changed over a decade.

METHODS

We analyzed patients admitted to the ICU at a university hospital in Seoul, South Korea. We defined patients aged 65 and older as older patients. Changes in age groups and mortality risk factors over the study period were analyzed.

RESULTS

A total of 32,322 patients were enrolled who aged ≥65 years admitted to the ICUs between January 1, 2007, and December 31, 2017. Patients aged ≥65 years accounted for 35% and of these, the older (O, 65 to 74 years) comprised 19,630 (66.5%), very older (VO, 75 to 84 years) group 8,573 (29.1%), and very very older (VVO, ≥85 years) group 1,300 (4.4%). The mean age of ICU patients over the study period increased (71.9±5.6 years in 2007 vs. 73.2±6.1 years in 2017) and the proportions of the VO and VVO group both increased. Over the period, the proportion of female increased (37.9% in 2007 vs. 43.3% in 2017), and increased ICU admissions for medical reasons (39.7% in 2007 vs. 40.2% in 2017). In-hospital mortality declined across all older age groups, from 10.3% in 2007 to 7.6% in 2017. Hospital length of stay (LOS) decreased in all groups, but ICU LOS decreased only in the O and VO groups.

CONCLUSION

The study indicates a changing demographic in ICUs with an increase in older patients, and suggests a need for customized ICU treatment strategies and resources.

Prognosticating the outcome of intensive care in older patients-a narrative review

Prognosis determines major decisions regarding treatment for critically ill patients. Statistical models have been developed to predict the probability of survival and other outcomes of intensive care. Although they were trained on the characteristics of large patient cohorts, they often do not represent very old patients (age ≥ 80 years) appropriately. Moreover, the heterogeneity within this particular group impairs the utility of statistical predictions for informing decision-making in very old individuals. In addition to these methodological problems, the diversity of cultural attitudes, available resources as well as variations of legal and professional norms limit the generalisability of prediction models, especially in patients with complex multi-morbidity and pre-existing functional impairments. Thus, current approaches to prognosticating outcomes in very old patients are imperfect and can generate substantial uncertainty about optimal trajectories of critical care in the individual. This article presents the state of the art and new approaches to predicting outcomes of intensive care for these patients. Special emphasis has been given to the integration of predictions into the decision-making for individual patients. This requires quantification of prognostic uncertainty and a careful alignment of decisions with the preferences of patients, who might prioritise functional outcomes over survival. Since the performance of outcome predictions for the individual patient may improve over time, time-limited trials in intensive care may be an appropriate way to increase the confidence in decisions about life-sustaining treatment.

Usefulness of the 4A's test for detecting delirium in critically ill patients: a multicenter prospective observation study

The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) is a robust and reliable instrument for discerning delirium within the specific context of the intensive care unit (ICU). Nonetheless, the CAM-ICU is burdened by various limitations, including a protracted learning curve and the need for frequent daily administration. The 4 A's Test (4AT) was formulated to assess delirium in hospitalized patients and may have distinct advantages over the CAM-ICU, particularly regarding practical applicability within the ICU bundle. This study was performed to assess the utility of the 4AT in detecting delirium in critically ill patients. This multicenter prospective observational study involved critically ill patients at four academic tertiary care hospitals in South Korea from June 2021 to September 2022. In total, 274 patients (median age, 64 years; 56.9% men) were included, and 75 (27.4%) developed delirium. The 4AT showed good performance in detecting ICU delirium (area under the curve, 0.879; P < 0.001). The 4AT showed a sensitivity of 74.0%, specificity of 95.4%, positive predictive value of 77.5%, negative predictive value of 94.6%, and accuracy of 91.7% for ICU detection of delirium. The sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of the CAM-ICU for detecting ICU delirium were 71.3%, 97.1%, 83.8%, 94.1%, and 92.6%, respectively. The 4AT showed acceptable reliability and validity for detecting ICU delirium in critically ill patients. Because the 4AT is simpler and easier to learn, this scale could be a useful alternative to the CAM-ICU for detecting delirium in critically ill patients.

Development and validation of an interpretable model for predicting sepsis mortality across care settings

There are numerous prognostic predictive models for evaluating mortality risk, but current scoring models might not fully cater to sepsis patients' needs. This study developed and validated a new model for sepsis patients that is suitable for any care setting and accurately forecasts 28-day mortality. The derivation dataset, gathered from 20 hospitals between September 2019 and December 2021, contrasted with the validation dataset, collected from 15 hospitals from January 2022 to December 2022. In this study, 7436 patients were classified as members of the derivation dataset, and 2284 patients were classified as members of the validation dataset. The point system model emerged as the optimal model among the tested predictive models for foreseeing sepsis mortality. For community-acquired sepsis, the model's performance was satisfactory (derivation dataset AUC: 0.779, 95% CI 0.765-0.792; validation dataset AUC: 0.787, 95% CI 0.765-0.810). Similarly, for hospital-acquired sepsis, it performed well (derivation dataset AUC: 0.768, 95% CI 0.748-0.788; validation dataset AUC: 0.729, 95% CI 0.687-0.770). The calculator, accessible at https://avonlea76.shinyapps.io/shiny_app_up/ , is user-friendly and compatible. The new predictive model of sepsis mortality is user-friendly and satisfactorily forecasts 28-day mortality. Its versatility lies in its applicability to all patients, encompassing both community-acquired and hospital-acquired sepsis.

[Nurses' common experiences of old age and intensive care: A qualitative study]

Nurses' common experiences of old age and intensive care: A qualitative study Abstract. Background: Increasingly more people in the 80+ age group are receiving treatment in the ICU-setting. The related critical care nurses' experience has been the subject of very few studies. Aim: To better understand the everyday nursing practice in the care of old patients in the ICU setting, the knowledge of critical care nurses that guides their actions will be examined and presented in terms of their orientations and typologies. Method: Within the interpretative paradigm, three guideline-based group discussions were conducted with a total of 14 critical care nurses from an Austrian clinic. Data was analyzed using the documentary method according to Bohnsack. Results: Five orientations characterize the knowledge and the actions of critical care nurses relating to old patients: the respect for the patients' will, the search for ethical justification, the beauty of the job, the own reflection of professional actions as well as the perception of a partly misguided health care system. The superior action-guiding typology is advocacy in the representation of the very old patients' interests. Conclusions: The multi-faceted experiences of critical care nurses are characterized by personal, interpersonal, and structural challenges, but also by positive experiences. The findings offer approaches to improve the care situation for nurses as well as for old people in intensive care units.

Ethical issues surrounding appropriate care for older persons in the Intensive Care Unit

Increasing numbers of older patients are being admitted to the Intensive Care Unit (ICU) as the world's population ages. The biological process of ageing, senescence, results in altered ability to maintain normal homeostasis and organ function, including of the cardiovascular, immune, and neuromuscular systems. This contributes towards increased frailty in older patients, associated with functional limitations and increased vulnerability. Although widely defined using chronological age, the concept of "old age" is thus multifactorial, including biological, but also psychological and sociocultural aspects, which should all be taken into account when considering what is appropriate in terms of ICU admission and management. As for all patients, but perhaps particularly in this subgroup, decisions regarding ICU admission and treatment and the withdrawing and withholding of life support must be individualized.

Patient characteristics associated with posttraumatic stress symptoms in intensive care unit survivors during a one-year follow-up: A multicenter study

BACKGROUND

Intensive care unit (ICU) patients are at risk of suffering from posttraumatic stress symptoms (PTSS) after ICU survival.

OBJECTIVES

To describe the prevalence of high levels of PTSS the first year after ICU admission. Further, to identify specific combinations of patient characteristics (latent classes based on pre-ICU data, demographics, and clinical characteristics), and to investigate possible associations among these classes and PTSS at 3, 6, and 12 months after ICU admission.

METHODS

Self-reported PTSS were measured with Impact of Event Scale-Revised (IES-R). PTSS and possible predictive factors (pre-ICU data, demographics, and clinical characteristics) were analyzed using descriptive statistics, latent class analysis, and linear mixed model for repeated measures.

RESULTS

High PTSS levels (IES-R ≥ 33) were reported by 14.9 % (95 % confidence interval [CI] [10.0; 21.1]), 16.7 % (95 % CI [11.5; 23.1]), and 18.4 % (95 % CI [12.9; 25.0]) of patients (sample 1, n = 174) at 3, 6, and 12 months, respectively. Three latent classes were identified (sample 2, n = 417). PTSS were significantly associated with class 2 (male with longer hospital stay) at 6 months and class 3 (age≥70, lower level of education, higher Simplified Acute Physiology Score, being mechanically ventilated) at all three measurement times.

CONCLUSIONS

The prevalence of high levels of PTSS is the greatest 12 months after ICU admission. Health professionals can use this information to be aware of specific groups of ICU patients reporting PTSS during the first year and follow up on these.

Regional Variation in End-of-Life Care just before Death among the oldest old in Japan : A descriptive study

BACKGROUND

The use of life-sustaining treatment (LST) in the final stage of life is a major policy concern due to increased costs, while its intensity does not correlate with quality. Previous reports have shown declining trends in LST use in Japan. However, regional practice variations remain unclear. This study aims to describe regional variations in LST use before death among the oldest old in Japan.

METHODS

A descriptive study was conducted among patients aged 85 or older who passed away between April 2013 and March 2014. The study utilized health insurance claims from Japan's National Database (NDB) to examine the use of cardiopulmonary resuscitation (CPR), mechanical ventilation (MV), and admission to the acute care ward (ACW) in the last 7 days of life.

RESULTS

Among 224,391 patients, the proportion of patients receiving LST varied by region. CPR ranged from 8.6% (Chubu) to 12.9% (Shikoku), MV ranged from 7.1% (Chubu) to 12.3% (Shikoku), and admission to ACW ranged from 4.5% (Chubu) to 10.1% (Kyushu-Okinawa). The adjusted odds ratios (AOR) for regional variation compared with Kanto were as follows: CPR (in Shikoku, 1.85 [95% CI 1.73 - 1.98]), MV (in Shikoku, 1.75 [1.63 - 1.87]), and ACW admission (in Kyushu-Okinawa, 1.69 [1.52 - 1.88]).

CONCLUSION

The study presents descriptive information regarding regional differences in the utilization of LST for the oldest old. Further research is necessary to identify the factors that contribute to these variations and to address the challenge of improving the quality of end-of-life care.

Comparison of the Incidence of Post-intensive Care Syndrome (PICS) Between Elderly and Non-elderly Patients: A Subgroup Analysis of the Japan-PICS Study

AIM

The aging society is expanding, and more elderly patients are admitted to intensive care units (ICUs). Elderly patients may have increased ICU mortality and are thought to have a high incidence of post-intensive care syndrome (PICS). There are few studies of PICS in the elderly. This study hypothesized that the elderly have an increased incidence of PICS compared to the non-elderly.

METHODS

This is a subgroup analysis of a previous multicenter prospective observational study (Prevalence of post-intensive care syndrome among Japanese intensive care unit patients: The Japan-PICS study) conducted from April 2019 to September 2019. Ninety-six patients were included who were over 18 years old, admitted to the ICU, and expected to require mechanical ventilation for more than 48 hours. Physical component scales (PCS), mental component scales (MCS), and Short-Memory Questionnaire (SMQ) scores of included patients were compared before admission to the ICU and six months later. The diagnosis of PICS required one of the following: (1) the PCS score decreased ≧10 points, (2) the MCS score decreased ≧10 points, or (3) the SMQ score decreased by >40 points. Patients were classified as non-elderly (<65 years old) or elderly (≧65 years old), and the incidence of PICS was compared between these two groups.

RESULTS

The non-elderly (N=27) and elderly (N=69) groups had incidences of PICS: 67% and 62% (p=0.69), respectively.

CONCLUSION

There is no statistically significant difference in the incidence of PICS in the non-elderly and elderly.

30-Day Mortality among Very Old Patients Admitted to European Intensive Care Units for Major Trauma

INTRODUCTION

Cases of major trauma in the very old (over 80 years) are increasingly common in the intensive care unit (ICU). Predicting outcome is challenging in this group of patients as chronological age is a poor marker of health and poor predictor of outcome. Increasingly, decisions are guided by the use of organ dysfunction scores of both acute conditions (e.g., sequential organ failure assessment [SOFA] score) and chronic health issues (e.g., clinical frailty scale [CFS]). Recent work suggests that increased CFS is associated with a worse outcome in elderly major trauma patients. We aimed to test whether this association held true in the very old (over 80) or whether SOFA had a stronger association with 30-day outcome.

METHODS

Data from the very elderly intensive care patient (VIP)-1 and VIP-2 studies for patients over 80 years old with major trauma admissions were merged. These participants were recruited from 20 countries across Europe. Baseline characteristics, level of care provided, and outcome (ICU and 30-day mortality) were summarised. Uni- and multivariable regression analyses were undertaken to determine associations between CFS and SOFA score in the first 24 h, type of major trauma, and outcomes.

RESULTS

Of the 8,062 acute patients recruited to the two VIP studies, 498 patients were admitted to intensive care because of major trauma. Median age was 84 years, median SOFA score was 6 (IQR 3, 9), and median CFS was 3 (IQR 2, 5). Survival for 30 days was 54%. Median and interquartile range of CFS were the same for survivors and non-survivors. In the logistic regression analysis, CFS was not associated with increased mortality. SOFA score (p < 0.001) and trauma with head injury (p < 0.01) were associated with increased mortality.

CONCLUSIONS

Major trauma admissions in the very old are not uncommon, and 30-day mortality is high. We found that CFS was not a helpful predictor of mortality. SOFA and trauma with head injury were associated with worse outcomes in this patient group.

The trajectory of very old critically ill patients

The demographic shift, together with financial constraint, justify a re-evaluation of the trajectory of care of very old critically ill patients (VIP), defined as older than 80 years. We must avoid over- as well as under-utilisation of critical care interventions in this patient group and ensure the inclusion of health care professionals, the patient and their caregivers in the decision process. This new integrative approach mobilises expertise at each step of the process beginning prior to intensive care unit (ICU) admission and extending to long-term follow-up. In this review, several international experts have contributed to provide recommendations that can be universally applied. Our aim is to define a minimum core dataset of information to be shared and discussed prior to ICU admission and to facilitate the shared-decision-making process with the patient and their caregivers, throughout the patient journey. Documentation of uncertainty may contribute to a tailored level of care and ultimately to discussions around possible limitations of life sustaining treatments. The goal of ICU care is not only to avoid death, but more importantly to maintain an acceptable quality of life and functional autonomy after hospital discharge. Societal consideration is important to highlight, together with alternatives to ICU admission. We discuss challenges for the future and potential areas of research. In summary, this review provides a state-of-the-art current overview and aims to outline future directions to address the challenges in the treatment of VIP.

The critically ill older patient with sepsis: a narrative review

Sepsis is a significant public health concern, particularly affecting individuals above 70 years in developed countries. This is a crucial fact due to the increasing aging population, their heightened vulnerability to sepsis, and the associated high mortality rates. However, the morbidity and long-term outcomes are even more notable. While many patients respond well to timely and appropriate interventions, it is imperative to enhance efforts in identifying, documenting, preventing, and treating sepsis. Managing sepsis in older patients poses greater challenges and necessitates a comprehensive understanding of predisposing factors and a heightened suspicion for diagnosing infections and assessing the risk of sudden deterioration into sepsis. Despite age often being considered an independent risk factor for mortality and morbidity, recent research emphasizes the pivotal roles of frailty, disease severity, and comorbid conditions in influencing health outcomes. In addition, it is important to inquire about the patient's preferences and establish a personalized treatment plan that considers their potential for recovery with quality of life and functional outcomes. This review provides a summary of the most crucial aspects to consider when dealing with an old critically ill patient with sepsis.

National ICU Registries as Enablers of Clinical Research and Quality Improvement

OBJECTIVES

Clinical quality registries (CQRs) have been implemented worldwide by several medical specialties aiming to generate a better characterization of epidemiology, treatments, and outcomes of patients. National ICU registries were created almost 3 decades ago to improve the understanding of case-mix, resource use, and outcomes of critically ill patients. This narrative review describes the challenges, proposed solutions, and evidence generated by National ICU registries as facilitators for research and quality improvement.

DATA SOURCES

English language articles were identified in PubMed using phrases related to ICU registries, CQRs, outcomes, and case-mix.

STUDY SELECTION

Original research, review articles, letters, and commentaries, were considered.

DATA EXTRACTION

Data from relevant literature were identified, reviewed, and integrated into a concise narrative review.

DATA SYNTHESIS

CQRs have been implemented worldwide by several medical specialties aiming to generate a better characterization of epidemiology, treatments, and outcomes of patients. National ICU registries were created almost 3 decades ago to improve the understanding of case-mix, resource use, and outcomes of critically ill patients. The initial experience in European countries and in Oceania ensured that through locally generated data, ICUs could assess their performances by using risk-adjusted measures and compare their results through fair and validated benchmarking metrics with other ICUs contributing to the CQR. The accomplishment of these initiatives, coupled with the increasing adoption of information technology, resulted in a broad geographic expansion of CQRs as well as their use in quality improvement studies, clinical trials as well as international comparisons, and benchmarking for ICUs.

CONCLUSIONS

ICU registries have provided increased knowledge of case-mix and outcomes of ICU patients based on real-world data and contributed to improve care delivery through quality improvement initiatives and trials. Recent increases in adoption of new technologies (i.e., cloud-based structures, artificial intelligence, machine learning) will ensure a broader and better use of data for epidemiology, healthcare policies, quality improvement, and clinical trials.

Non-linear association between aspartate aminotransferase to alanine aminotransferase ratio and mortality in critically ill older patients: A retrospective cohort study

BACKGROUND

The aspartate aminotransferase to alanine aminotransferase (AST/ALT) ratio has been shown to be associated with poor clinical outcomes across various patient groups. However, little is unclear about the association between the two in critically ill older patients. Therefore, we aim to investigate the association of the AST/ALT ratio with hospital mortality in this special population.

METHODS

In this retrospective cohort study, we extracted elderly patients (age ≥ 65 years) from the Medical Information Mart for Intensive Care IV (MIMIC-IV) database. The primary outcome was in-hospital mortality. The association between the AST/ALT ratio and hospital mortality was studied using univariable and multivariable Cox regression analysis, as well as restricted cubic splines (RCS). Survival analysis was performed using the Kaplan-Meier (KM) method according to the AST/ALT ratio.

RESULTS

Among the 13,358 eligible patients, the mean age was 77.6 years, 7,077 patients (52.9%) were male, and 2,511 patients (18.8%) died in hospital. The AST/ALT ratio was found to be independently associated with in-hospital mortality (HR = 1.05, 95% CI: 1.01-1.09, P = 0.022) after adjusting for potential confounders. Furthermore, a non-linear relationship and saturation effect were observed between them, with the inflection point being 1.80. When the AST/ALT ratio was less than 1.80, we found that every 1 unit increase in the AST/ALT ratio resulted in a 39% increased risk of in-hospital mortality (HR = 1.39, 95% CI: 1.18-1.64, P < 0.001). However, when the AST/ALT ratio was greater than 1.80, the association became saturated (HR = 1.01, 95% CI: 0.96-1.07, P = 0.609). Sensitivity and subgroup analyses showed the results were robust.

CONCLUSION

In critically ill older patients, the association between the AST/ALT ratio and in-hospital mortality was non-linear and showed a saturation effect. An elevated AST/ALT ratio was significantly associated with increased in-hospital mortality when the AST/ALT ratio was less than 1.80.

Limiting life-sustaining treatment for very old ICU patients: cultural challenges and diverse practices

BACKGROUND

Decisions about life-sustaining therapy (LST) in the intensive care unit (ICU) depend on predictions of survival as well as the expected functional capacity and self-perceived quality of life after discharge, especially in very old patients. However, prognostication for individual patients in this cohort is hampered by substantial uncertainty which can lead to a large variability of opinions and, eventually, decisions about LST. Moreover, decision-making processes are often embedded in a framework of ethical and legal recommendations which may vary between countries resulting in divergent management strategies.

METHODS

Based on a vignette scenario of a multi-morbid 87-year-old patient, this article illustrates the spectrum of opinions about LST among intensivsts with a special interest in very old patients, from ten countries/regions, representing diverse cultures and healthcare systems.

RESULTS

This survey of expert opinions and national recommendations demonstrates shared principles in the management of very old ICU patients. Some guidelines also acknowledge cultural differences between population groups. Although consensus with families should be sought, shared decision-making is not formally required or practised in all countries.

CONCLUSIONS

This article shows similarities and differences in the decision-making for LST in very old ICU patients and recommends strategies to deal with prognostic uncertainty. Conflicts should be anticipated in situations where stakeholders have different cultural beliefs. There is a need for more collaborative research and training in this field.

Potential Role and Prognostic Value of Interleukin-15 for Mortality Among Elderly Patients with Sepsis

Background

To investigate the potential role and prognostic value of interleukin-15 (IL-15) in predicting 28-day mortality in elderly patients with sepsis.

Methods

According to the Sepsis-3.0 diagnostic criteria for sepsis, elderly patients with sepsis who were admitted to the emergency department of the Shi jingshan branch of Beijing Chaoyang Hospital between October 2021 and June 2022 were enrolled in this retrospective cohort study. After observation for 28 days, patients were divided into a survival group and a nonsurvival group. Samples for laboratory tests, baseline characteristic data, and SOFA and Acute Physiology and Chronic Health Evaluation (APACHE II) scores were collected or recorded within 24 h after admission to the emergency department. Quantitative detection of IL-15 was performed with a Luminex assay. Logistic regression analysis and receiver operating characteristic curve (ROC) analysis were conducted for comparison.

Results

In total, 220 elderly patients with sepsis were enrolled, 69 of whom were in the survival group and 151 of whom were in the nonsurvival group at the 28-day interval. Systolic pressure, high-density lipoprotein (HDL), platelets (PLT) and albumin (ALB) were significantly higher in the survival group (P<0.05), while IL-15, SOFA, and APACHE II were significantly higher in the nonsurvival group (P<0.05). IL-15 was an independent risk factor associated with 28-day mortality (OR=1.842, 95% CI [1.323, 2.565]). The area under the receiver operating characteristic curve (AUROC) of IL-15 alone was 0.691 (95% CI [0.618, 0.764]), with a sensitivity of 46.67% and a specificity of 85.81%. The AUROC of the combined IL-15 and SOFA reached 0.880 (95% CI [0.672, 0.812]), for which the sensitivity and specificity were 80.95% and 85.08%, respectively.

Conclusion

IL-15 possesses the prognostic value for predicting 28-day mortality in elderly patients with sepsis.

Characteristics and Outcomes of Very Elderly Patients Admitted to Intensive Care: A Retrospective Multicenter Cohort Analysis

OBJECTIVES

To characterize and compare trends in ICU admission, hospital outcomes, and resource utilization for critically ill very elderly patients (≥ 80 yr old) compared with the younger cohort (16-79 yr old).

DESIGN

A retrospective multicenter cohort study.

SETTING

One-hundred ninety-four ICUs contributing data to the Australian and New Zealand Intensive Care Society Centre for Outcome and Resource Evaluation Adult Patient Database between January 2006 and December 2018.

PATIENTS

Adult (≥ 16 yr) patients admitted to Australian and New Zealand ICUs.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Very elderly patients with a mean ± sd age of 84.8 ± 3.7 years accounted for 14.8% (232,582/1,568,959) of all adult ICU admissions. They had higher comorbid disease burden and illness severity scores compared with the younger cohort. Hospital (15.4% vs 7.8%, p < 0.001) and ICU mortality (8.5% vs 5.2%, p < 0.001) were higher in the very elderly. They stayed fewer days in ICU, but longer in hospital and had more ICU readmissions. Among survivors, a lower proportion of very elderly was discharged home (65.2% vs 82.4%, p < 0.001), and a higher proportion was discharged to chronic care/nursing home facilities (20.1% vs 7.8%, p < 0.001). Although there was no change in the proportion of very elderly ICU admissions over the study period, they showed a greater decline in risk-adjusted mortality (6.3% [95% CI, 5.9%-6.7%] vs 4.0% [95% CI, 3.7%-4.2%] relative reduction per year, p < 0.001) compared with the younger cohort. The mortality of very elderly unplanned ICU admissions improved faster than the younger cohort ( p < 0.001), whereas improvements in mortality among elective surgical ICU admissions were similar in both groups ( p = 0.45).

CONCLUSIONS

The proportion of ICU admissions greater than or equal to 80 years old did not change over the 13-year study period. Although their mortality was higher, they showed improved survivorship over time, especially in the unplanned ICU admission subgroup. A higher proportion of survivors were discharged to chronic care facilities.

Patient Characteristics and Clinical and Economic Outcomes Associated with Unplanned Medical and Surgical Intensive Care Unit Admissions: A Retrospective Analysis

Purpose

To characterize medical and surgical patient characteristics, as well as clinical and economic outcomes, associated with unplanned intensive care unit (ICU) admissions.

Patients and Methods

This was a retrospective matched cohort analysis that utilized the PINC AITM Healthcare Database, which collects deidentified data from 25% of United States (US) hospital admissions. Discharge records were assessed for medical and surgical admissions in 2021. An unplanned ICU admission was defined as direct transfer from a medical, surgical, or telemetry unit to the ICU. Patients with and without an unplanned ICU admission were 1:1 propensity score matched. Differences between patients with and without unplanned ICU admissions were assessed using two-sample t-tests for continuous measures and Chi-square tests for categorical measures.

Results

A total of 3,807,124 qualifying admissions were identified. Medical admissions with unplanned ICU transfers were more likely to be urgent/emergent (odds ratio [OR] 2.9, 95% confidence interval [CI 2.7-3.0], p<0.0001), with patient characteristics including male sex (1.4, [1.4-1.4], p<0.0001), obesity (1.7, [1.6-1.7], p<0.0001), and increased Charlson Comorbidity Index (CCI=1: 1.8, [1.8-1.9], p<0.0001; CCI≥5: 3.2, [3.1-3.3], p<0.0001). Surgical admissions with unplanned ICU transfers were more likely to be urgent/emergent (3.1, [2.9-3.2], p<0.0001) and with patients of higher CCI (2.5, [2.3-2.6], p<0.0001 to a CCI of≥5 (7.9, [7.4-8.4], p<0.0001). Between matched medical patients, mean differences in length of stay, cost, and mortality were 4.1 days (p<0.0001), $13,424 (p<0.0001), and 21% (p<0.0001), respectively. Between matched surgical patients, mean differences in these outcomes were 6.4 days (p<0.0001), $21,448 (p<0.0001), and 14% (p<0.0001), respectively.

Conclusion

Emergency care in patients with a higher co-morbid burden is more likely to lead to unplanned ICU admission, putting patients at a significantly increased chance of mortality, longer length of stay, and increased costs. Improving care and monitoring of patients outside the ICU may help detect early changes in pathophysiology and enable early intervention.

Outcomes in Patients Perceived as Receiving Excessive Care by ICU Physicians and Nurses: Differences Between Patients < 75 and ≥ 75 Years of Age?

BACKGROUND

The benefit of the ICU for older patients is often debated. There is little knowledge on subjective impressions of excessive care in ICU nurses and physicians combined with objective patient data in real-life cases.

RESEARCH QUESTION

Is there a difference in treatment limitation decisions and 1-year outcomes in patients < 75 and ≥ 75 years of age, with and without concordant perceptions of excessive care by two or more ICU nurses and physicians?

STUDY DESIGN AND METHODS

This was a reanalysis of the prospective observational DISPROPRICUS study, performed in 56 ICUs. Nurses and physicians completed a daily questionnaire about the appropriateness of care for each of their patients during a 28-day period in 2014. We compared the cumulative incidence of patients with concordant perceptions of excessive care, treatment limitation decisions, and the proportion of patients attaining the combined end point (death, poor quality of life, or not being at home) at 1 year across age groups via Cox regression with propensity score weighting and Fisher exact tests.

RESULTS

Of 1,641 patients, 405 (25%) were ≥ 75 years of age. The cumulative incidence of concordant perceptions of excessive care was higher in older patients (13.6% vs 8.5%; P < .001). In patients with concordant perceptions of excessive care, we found no difference between age groups in risk of death (1-year mortality, 83% in both groups; P > .99; hazard ratio [HR] after weighting, 1.11; 95% CI, 0.74-1.65), treatment limitation decisions (33% vs 31%; HR after weighting, 1.11; 95% CI, 0.69-2.17), and reaching the combined end point at 1 year (90% vs 93%; P = .546). In patients without concordant perceptions of excessive care, we found a difference in risk of death (1-year mortality, 41% vs 30%; P < .001; HR after weighting, 1.38; 95% CI, 1.11-1.73) and treatment limitation decisions (11% vs 5%; P < .001; HR, 2.11; 95% CI, 1.37-3.27); however, treatment limitation decisions were mostly documented prior to ICU admission. The risk of reaching the combined end point was higher in the older adults (61.6% vs 52.8%; P < .001).

INTERPRETATION

Although the incidence of perceptions of excessive care is slightly higher in older patients, there is no difference in treatment limitation decisions and 1-year outcomes between older and younger patients once patients are identified by concordant perceptions of excessive care. Additionally, in patients without concordant perceptions, the outcomes are worse in the older adults, pleading against ageism in ICU nurses and physicians.

A Simple Nomogram for Predicting Hospital Mortality of Patients Over 80 Years in ICU: An International Multicenter Retrospective Study

OBJECTIVES

This study aimed to develop and validate an easy-to-use intensive care unit (ICU) illness scoring system to evaluate the in-hospital mortality for very old patients (VOPs, over 80 years old).

METHODS

We performed a multicenter retrospective study based on the electronic ICU (eICU) Collaborative Research Database (eICU-CRD), Medical Information Mart for Intensive Care Database (MIMIC-III CareVue and MIMIC-IV), and the Amsterdam University Medical Centers Database (AmsterdamUMCdb). Least Absolute Shrinkage and Selection Operator regression was applied to variables selection. The logistic regression algorithm was used to develop the risk score and a nomogram was further generated to explain the score.

RESULTS

We analyzed 23 704 VOPs, including 3 726 deaths (10 183 [13.5% mortality] from eICU-CRD [development set], 12 703 [17.2%] from the MIMIC, and 818 [20.8%] from the AmsterdamUMC [external validation sets]). Thirty-four variables were extracted on the first day of ICU admission, and 10 variables were finally chosen including Glasgow Coma Scale, shock index, respiratory rate, partial pressure of carbon dioxide, lactate, mechanical ventilation (yes vs no), oxygen saturation, Charlson Comorbidity Index, blood urea nitrogen, and urine output. The nomogram was developed based on the 10 variables (area under the receiver operating characteristic curve: training of 0.792, testing of 0.788, MIMIC of 0.764, and AmsterdamUMC of 0.808 [external validating]), which consistently outperformed the Sequential Organ Failure Assessment, acute physiology score III, and simplified acute physiology score II.

CONCLUSIONS

We developed and externally validated a nomogram for predicting mortality in VOPs based on 10 commonly measured variables on the first day of ICU admission. It could be a useful tool for clinicians to identify potentially high risks of VOPs.

The Clinical Frailty Scale for mortality prediction of old acutely admitted intensive care patients: a meta-analysis of individual patient-level data

BACKGROUND

This large-scale analysis pools individual data about the Clinical Frailty Scale (CFS) to predict outcome in the intensive care unit (ICU).

METHODS

A systematic search identified all clinical trials that used the CFS in the ICU (PubMed searched until 24th June 2020). All patients who were electively admitted were excluded. The primary outcome was ICU mortality. Regression models were estimated on the complete data set, and for missing data, multiple imputations were utilised. Cox models were adjusted for age, sex, and illness acuity score (SOFA, SAPS II or APACHE II).

RESULTS

12 studies from 30 countries with anonymised individualised patient data were included (n = 23,989 patients). In the univariate analysis for all patients, being frail (CFS ≥ 5) was associated with an increased risk of ICU mortality, but not after adjustment. In older patients (≥ 65 years) there was an independent association with ICU mortality both in the complete case analysis (HR 1.34 (95% CI 1.25-1.44), p < 0.0001) and in the multiple imputation analysis (HR 1.35 (95% CI 1.26-1.45), p < 0.0001, adjusted for SOFA). In older patients, being vulnerable (CFS 4) alone did not significantly differ from being frail. After adjustment, a CFS of 4-5, 6, and ≥ 7 was associated with a significantly worse outcome compared to CFS of 1-3.

CONCLUSIONS

Being frail is associated with a significantly increased risk for ICU mortality in older patients, while being vulnerable alone did not significantly differ. New Frailty categories might reflect its "continuum" better and predict ICU outcome more accurately.

TRIAL REGISTRATION

Open Science Framework (OSF: https://osf.io/8buwk/ ).

The clinical frailty scale - does it predict outcome of the very-old in UK ICUs?

Introduction

The age of patients admitted into critical care in the UK is increasing. Clinical decisions for very-old patients, usually defined as over 80, can be challenging. Clinicians are frequently asked to predict outcomes as part of discussions around the pros and cons of an intensive care unit (ICU) admission. Measures of overall health in old age, such as the clinical frailty scale (CFS), are increasingly used to help guide these discussions. We aimed to understand the characteristics of the very-old critically unwell population in the UK and the associations between frailty and outcome of an ICU admission in our healthcare system (National Health Service, NHS).

Methods

Baseline characteristics, ICU interventions and outcomes (ICU- and 30-day mortality) were recorded for sequential admissions of very old patients to UK ICUs as part of the European VIP 1 and 2 studies. Patient characteristics, interventions and outcome measures were compared by frailty group using standard statistical tests. Multivariable logistic regression modelling was undertaken to test association between baseline characteristics, admission type and outcome.

Results

1858 participants were enrolled from 95 ICUs in the UK. The median age was 83. The median CFS was 4 (IQR 3-5). 30-day survival was significantly lower in the frail group (CFS > 4, 58%) compared to vulnerable (CFS = 4, 65%) and fit (CFS < 4 68%, p = .004). Sequential organ failure assessment (SOFA) score, reason for admission and CFS were all independently associated with increased 30-day mortality (p < .01).

Conclusion

In the UK, frailty is associated with an increase in mortality at 30-days following an ICU admission. At moderate frailty (CFS 5-6), three out of every five patients admitted survived to 30-days. This is a similar mortality to septic shock.

Target attainment and population pharmacokinetics of flucloxacillin in critically ill patients: a multicenter study

PURPOSE

Insufficient antimicrobial exposure has been associated with worse clinical outcomes. Reportedly, flucloxacillin target attainment in critically ill patients was heterogeneous considering the study population selection and reported target attainment percentages. Therefore, we assessed flucloxacillin population pharmacokinetics (PK) and target attainment in critically ill patients.

METHODS

This prospective, multicenter, observational study was conducted from May 2017 to October 2019 and included adult, critically ill patients administered flucloxacillin intravenously. Patients with renal replacement therapy or liver cirrhosis were excluded. We developed and qualified an integrated PK model for total and unbound serum flucloxacillin concentrations. Monte Carlo dosing simulations were performed to assess target attainment. The unbound target serum concentration was four times the minimum inhibitory concentration (MIC) for ≥ 50% of the dosing interval (ƒT_>4xMIC ≥ 50%).

RESULTS

We analyzed 163 blood samples from 31 patients. A one-compartment model with linear plasma protein binding was selected as most appropriate. Dosing simulations revealed 26% ƒT_>2 mg/L ≥ 50% following continuous infusion of 12 g flucloxacillin and 51% ƒT_>2 mg/L ≥ 50% for 24 g.

CONCLUSION

Based on our dosing simulations, standard flucloxacillin daily doses of up to 12 g may substantially enhance the risk of underdosing in critically ill patients. Prospective validation of these model predictions is needed.

Whole transcriptome analysis to explore the impaired immunological features in critically ill elderly patients with sepsis

BACKGROUND

Sepsis is a frequent complication in critically ill patients, is highly heterogeneous and is associated with high morbidity and mortality rates, especially in the elderly population. Utilizing RNA sequencing (RNA-Seq) to analyze biological pathways is widely used in clinical and molecular genetic studies, but studies in elderly patients with sepsis are still lacking. Hence, we investigated the mortality-relevant biological features and transcriptomic features in elderly patients who were admitted to the intensive care unit (ICU) for sepsis.

METHODS

We enrolled 37 elderly patients with sepsis from the ICU at Taichung Veterans General Hospital. On day-1 and day-8, clinical and laboratory data, as well as blood samples, were collected for RNA-Seq analysis. We identified the dynamic transcriptome and enriched pathways of differentially expressed genes between day-8 and day-1 through DVID enrichment analysis and Gene Set Enrichment Analysis. Then, the diversity of the T cell repertoire was analyzed with MiXCR.

RESULTS

Overall, 37 patients had sepsis, and responders and non-responders were grouped through principal component analysis. Significantly higher SOFA scores at day-7, longer ventilator days, ICU lengths of stay and hospital mortality were found in the non-responder group, than in the responder group. On day-8 in elderly ICU patients with sepsis, genes related to innate immunity and inflammation, such as ZDHCC19, ALOX15, FCER1A, HDC, PRSS33, and PCSK9, were upregulated. The differentially expressed genes (DEGs) were enriched in the regulation of transcription, adaptive immune response, immunoglobulin production, negative regulation of transcription, and immune response. Moreover, there was a higher diversity of T-cell receptors on day-8 in the responder group, than on day-1, indicating that they had better regulated recovery from sepsis compared with the non-response patients.

CONCLUSION

Sepsis mortality and incidence were both high in elderly individuals. We identified mortality-relevant biological features and transcriptomic features with functional pathway and MiXCR analyses based on RNA-Seq data; and found that the responder group had upregulated innate immunity and increased T cell diversity; compared with the non-responder group. RNA-Seq may be able to offer additional complementary information for the accurate and early prediction of treatment outcome.

Contribution of information about acute and geriatric characteristics to decisions about life-sustaining treatment for old patients in intensive care

BACKGROUND

Life-sustaining treatment (LST) in the intensive care unit (ICU) is withheld or withdrawn when there is no reasonable expectation of beneficial outcome. This is especially relevant in old patients where further functional decline might be detrimental for the self-perceived quality of life. However, there still is substantial uncertainty involved in decisions about LST. We used the framework of information theory to assess that uncertainty by measuring information processed during decision-making.

METHODS

Datasets from two multicentre studies (VIP1, VIP2) with a total of 7488 ICU patients aged 80 years or older were analysed concerning the contribution of information about the acute illness, age, gender, frailty and other geriatric characteristics to decisions about LST. The role of these characteristics in the decision-making process was quantified by the entropy of likelihood distributions and the Kullback-Leibler divergence with regard to withholding or withdrawing decisions.

RESULTS

Decisions to withhold or withdraw LST were made in 2186 and 1110 patients, respectively. Both in VIP1 and VIP2, information about the acute illness had the lowest entropy and largest Kullback-Leibler divergence with respect to decisions about withdrawing LST. Age, gender and geriatric characteristics contributed to that decision only to a smaller degree.

CONCLUSIONS

Information about the severity of the acute illness and, thereby, short-term prognosis dominated decisions about LST in old ICU patients. The smaller contribution of geriatric features suggests persistent uncertainty about the importance of functional outcome. There still remains a gap to fully explain decision-making about LST and further research involving contextual information is required.

TRIAL REGISTRATION

VIP1 study: NCT03134807 (1 May 2017), VIP2 study: NCT03370692 (12 December 2017).

Validation of IDSA/ATS Guidelines for ICU Admission in Adults Over 80 Years Old With Community-Acquired Pneumonia

INTRODUCTION

The 2007 IDSA/ATS guidelines for community-acquired pneumonia (CAP) recommended intensive care unit (ICU) admission for adults meeting severe CAP criteria. We aimed to validate the accuracy of IDSA/ATS criteria in patients≥80 years old (very elderly patients, VEP) with CAP.

METHODS

Prospective cohort study of VEP with CAP admitted to three Spanish hospitals between 1996 and 2019. We compared patients who did and did not require ICU admission. We also assessed factors independently associated with ICU admission, as well as the accuracy of severe CAP criteria for ICU admission and mortality. Major criteria include septic shock and invasive mechanical ventilation while minor criteria encompass other variables related to hemodynamics and respiratory insufficiency as well as level of consciousness, renal function, blood parameters indicative of sepsis and body temperature.

RESULTS

Of the 2006 VEP with CAP, 519 (26%) met severe CAP criteria, while 204 (10%) required ICU admission. Concordance between severe CAP criteria and the decision to admit the patient to the ICU occurred in 1591 (79%) cases (k coefficient, 0.33), with a sensitivity of 75% and specificity of 80% in predicting ICU admission. All patients with invasive mechanical ventilation received care in ICUs, while 45 (44%) patients with septic shock-previously stabilized in the emergency room-did not. Thirty-day mortality of ICU-admitted patients with septic shock was lower than that of patients in wards (30% vs. 60%, p=0.013). In contrast, patients with severe CAP and only minor criteria had similar mortality.

CONCLUSIONS

IDSA/ATS criteria for severe CAP predict ICU admission in VEP moderately well. While patients with septic shock and invasive mechanical ventilation warrant ICU admission, severe CAP without major severity criteria in VEP may be acceptably manageable in wards.

Interpretable Machine Learning to Optimize Early In-Hospital Mortality Prediction for Elderly Patients with Sepsis: A Discovery Study

Sepsis-related mortality rates are high among elderly patients, especially those in intensive care units (ICUs). Early prediction of the prognosis of sepsis is critical, as prompt and effective treatment can improve prognosis. Researchers have predicted mortality and the development of sepsis using machine learning algorithms; however, few studies specifically focus on elderly patients with sepsis. This paper proposes a viable model for early prediction of in-hospital mortality among elderly patients diagnosed with sepsis. We extracted patient information from the Medical Information Mart for Intensive Care IV database. We employed several machine learning algorithms to predict the in-hospital mortality of elderly ICU patients with sepsis. The performance of the model was evaluated by using the AUROC and F1 score. Furthermore, the SHAP algorithm was used to explain the model, analyze how the individual features affect the model output, and visualize the Shapley value for a single individual. Our study included 18522 elderly patients, with a mortality of 15.4%. After screening, 59 clinical variables were extracted to develop models. Feature importance analysis showed that age, PO2, RDW, SPO2, WBC, and urine output were significantly related to the in-hospital mortality. According to the results of AUROC (0.871 (95% CI: 0.854-0.888)) and F1 score (0.547 (95% CI: 0.539-0.661)) analyses, the extreme gradient boosting (XGBoost) model outperformed the other models (i.e., LGBM, LR, RF, DT, and KNN). Furthermore, SHAP force analysis illustrated how the constructed model visualized the individualized prediction of death. XGBoost machine learning framework gives good in-hospital mortality prediction of elderly patients with sepsis and can maximize prediction model accuracy. The XGBoost model could be an effective tool to assist doctors in identifying high-risk cases of in-hospital mortality among elderly patients with sepsis. This could be used to create a clinical decision support system in the future.

Clustering analysis of geriatric and acute characteristics in a cohort of very old patients on admission to ICU

PURPOSE

The biological and functional heterogeneity in very old patients constitutes a major challenge to prognostication and patient management in intensive care units (ICUs). In addition to the characteristics of acute diseases, geriatric conditions such as frailty, multimorbidity, cognitive impairment and functional disabilities were shown to influence outcome in that population. The goal of this study was to identify new and robust phenotypes based on the combination of these features to facilitate early outcome prediction.

METHODS

Patients aged 80 years old or older with and without limitations of life-sustaining treatment and with complete data were recruited from the VIP2 study for phenotyping and from the COVIP study for external validation. The sequential organ failure assessment (SOFA) score and its sub-scores taken on admission to ICU as well as demographic and geriatric patient characteristics were subjected to clustering analysis. Phenotypes were identified after repeated bootstrapping and clustering runs.

RESULTS

In patients from the VIP2 study without limitations of life-sustaining treatment (n = 1977), ICU mortality was 12% and 30-day mortality 19%. Seven phenotypes with distinct profiles of acute and geriatric characteristics were identified in that cohort. Phenotype-specific mortality within 30 days ranged from 3 to 57%. Among the patients assigned to a phenotype with pronounced geriatric features and high SOFA scores, 50% died in ICU and 57% within 30 days. Mortality differences between phenotypes were confirmed in the COVIP study cohort (n = 280).

CONCLUSIONS

Phenotyping of very old patients on admission to ICU revealed new phenotypes with different mortality and potential need for anticipatory intervention.

The Prediction Value of D-Dimer on Prognosis in Intensive Care Unit among Old Patients ( ≥65 Years): A 9-Year Single-Center Retrospective Study of 9261 Cases

Background

D-dimer (DD) has been indicated as a potential indicator due to its connection with the prognosis of the COVID-19 pandemic. Aging is linked to elevated DD levels in coagulation activation. However, few studies have investigated the correlation of DD with prognosis, especially in the old population. Therefore, this study aims at investigating the correlation of DD with prognosis in shock and perioperative populations over 65 years of age.

Methods

We analyzed 9261 old patients admitted to intensive care units (ICUs) with either confirmed shock or in perioperative period of high-risk surgery, with 8813 of them had DD levels determined on admission. In-hospital mortality, length of ICU stay and ventilation time (VT) associated variables were assessed using generalized linear models.

Results

Although DD levels had no positive correlations with in-hospital mortality (RR, 1.006; 95% CI, 0.998-1.014) and length of ICU stay (RR, 1.012; 95% CI, 0.997-1.028) in Model 3, they were strongly correlated with VT (RR, 1.577; 95% CI, 1.024-2.064). Higher DD levels in females (RR, 1.804; 95% CI, 1.116-2.602), those who used antibiotics (RR, 1.736; 95% CI, 1.092-2.453), those with surgery (RR, 1.640; 95% CI, 1.273-2.114), and those with shock (RR, 1.740; 95% CI, 1.001-2.687) had stronger correlation with longer VT than the counterparts. While patients who were between 65 and 74 years old (RR, 1.023; 95% CI, 1.003–1.043), with no use of antibiotics (RR, 1.007; 95% CI, 1.001–1.013) nor shock (RR, 1.011; 95% CI, 1.002–1.021), but had undergone surgical procedures (RR, 1.030; 95% CI, 1.012–1.048) were correlated with a longer ICU length of stay.

Conclusion

DD levels at ICU admission are highly related to increased VT and length of ICU stay in the old population with either confirmed shock or after high-risk surgery, indicating the strong potential of DD as a marker with prognostic utility for all ICU patients in the future.

Validation of IDSA/ATS Guidelines for ICU Admission in Adults Over 80 Years Old With Community-acquired Pneumonia

INTRODUCTION

The 2007 IDSA/ATS guidelines for community-acquired pneumonia (CAP) recommended intensive care unit (ICU) admission for adults meeting severe CAP criteria. We aimed to validate the accuracy of IDSA/ATS criteria in patients ≥80 years old (very elderly patients, VEP) with CAP.

METHODS

Prospective cohort study of VEP with CAP admitted to three Spanish hospitals between 1996 and 2019. We compared patients who did and did not require ICU admission. We also assessed factors independently associated with ICU admission, as well as the accuracy of severe CAP criteria for ICU admission and mortality. Major criteria include septic shock and invasive mechanical ventilation while minor criteria encompass other variables related to hemodynamics and respiratory insufficiency as well as level of consciousness, renal function, blood parameters indicative of sepsis and body temperature.

RESULTS

Of the 2006 VEP with CAP, 519 (26%) met severe CAP criteria, while 204 (10%) required ICU admission. Concordance between severe CAP criteria and the decision to admit the patient to the ICU occurred in 1591 (79%) cases (k coefficient, 0.33), with a sensitivity of 75% and specificity of 80% in predicting ICU admission. All patients with invasive mechanical ventilation received care in ICUs, while 45 (44%) patients with septic shock-previously stabilized in the emergency room-did not. Thirty-day mortality of ICU-admitted patients with septic shock was lower than that of patients in wards (30% vs. 60%, P=0.013). In contrast, patients with severe CAP and only minor criteria had similar mortality.

CONCLUSIONS

IDSA/ATS criteria for severe CAP predict ICU admission in VEP moderately well. While patients with septic shock and invasive mechanical ventilation warrant ICU admission, severe CAP without major severity criteria in VEP may be acceptably manageable in wards.

Association between nursing cost and patient outcomes in intensive care units: A retrospective cohort study of Belgian hospitals

INTRODUCTION

Hospitals with better nursing resources report more favourable patient outcomes with almost no difference in cost as compared to those with worse nursing resources. The aim of this study was to assess the association between nursing cost per intensive care unit bed and patient outcomes (mortality, readmission, and length of stay).

METHODOLOGY

This was a retrospective cohort study using data collected from the intensive care units of 17 Belgian hospitals from January 01 to December 31, 2018. Hospitals were dichotomized using median annual nursing cost per bed. A total of 18,235 intensive care unit stays were included in the study with 5,664 stays in the low-cost nursing group and 12,571 in the high-cost nursing group.

RESULTS

The rate of high length of stay outliers in the intensive care unit was significantly lower in the high-cost nursing group (9.2% vs 14.4%) compared to the low-cost nursing group. Intensive care unit readmission was not significantly different in the two groups. Mortality was lower in the high-cost nursing group for intensive care unit (9.9% vs 11.3%) and hospital (13.1% vs 14.6%) mortality. The nursing cost per intensive care bed was different in the two groups, with a median [IQR] cost of 159,387€ [140,307-166,690] for the low-cost nursing group and 214,032€ [198,094-230,058] for the high-cost group. In multivariate analysis, intensive care unit mortality (OR = 0.80, 95% CI: 0.69-0.92, p < 0.0001), in-hospital mortality (OR = 0.82, 95% CI: 0.72-0.93, p < 0.0001), and high length of stay outliers (OR = 0.48, 95% CI: 0.42-0.55, p < 0.0001) were lower in the high-cost nursing group. However, there was no significant effect on intensive care readmission between the two groups (OR = 1.24, 95% CI: 0.97-1.51, p > 0.05).

CONCLUSIONS

This study found that higher-cost nursing per bed was associated with significantly lower intensive care unit and in-hospital mortality rates, as well as fewer high length of stay outliers, but had no significant effect on readmission to the intensive care unit. .

In-hospital end-of-life care in the old: a retrospective study of intensive care unit use and do-not-resuscitate forms in patients deceased in a Belgian university hospital

OBJECTIVES

To explore the quality of in-hospital end-of-life care in adult patients with special attention to those 75 years and older and to make a comparison with the situation 10 years ago.

METHODS

Data were retrospectively collected on adult patients who deceased at Ghent University Hospital between September 2018 and December 2019. The main outcome measures were 'ICU use' and 'presence of DNR forms on non-ICU units' in the final hospitalization. In order to identify possible risk factors for ICU use, logistic regression was performed.

RESULTS

In total, 762 people died, of whom 35% were 75 or older. Just as 10 years ago, one-third (31%) died in the ICU versus 49% of those younger than 75 years (p < 0.001). Of people ≥75 years, 38%, compared to 42% 10 years ago, received an ICU treatment during their final hospitalization. The median length of an ICU stay was 4 versus 3 days 10 years ago. After adjusting for gender, comorbidities and the Charlson Comorbidity Index, factors associated with less ICU use were higher age, active malignancy and dementia (OR 0.838, 0.116 and 0.098 respectively). Seventy-nine percent of older patients on non-ICU wards died with a DNR form (versus 87% 10 years ago).

CONCLUSION

Although there was an increase in the presence of DNR forms in the final hospitalization, no significant differences were seen in actual ICU use compared to 10 years ago. Factors associated with less ICU use were higher age, active malignancy and dementia.

Impact on 6-month outcomes of hospital trajectory in critically ill older patients: analysis of the ICE-CUB2 clinical trial

Background

Little is known about the impact of hospital trajectory on survival and functional decline of older critically ill patients. We evaluate 6-month outcomes after admission to: intensive care units (ICU), intermediate care units (IMCU) or acute medical wards (AMW).

Methods

Data from the randomised prospective multicentre clinical trial ICE-CUB2 was secondarily analysed. Inclusion criteria were: presenting at emergency departments in critical condition; age ≥ 75 years; activity of daily living (ADL) ≥ 4; preserved nutritional status; and no active cancer. A Cox model was fitted to compare survival according to admission destination adjusting for patient characteristics. Sensitivity analysis using multiple imputation for missing data and propensity score matching were performed.

Results

Among 3036 patients, 1675 (55%) were women; median age was 85 [81–99] years; simplified acute physiology score (SAPS-3) 62 [55–69]; 1448 (47%) were hospitalised in an ICU, 504 in IMCU (17%), and 1084 (36%) in AMW. Six-month mortality was 629 (44%), 155 (31%) and 489 (45%) after admission in an ICU, IMCU and AMW (p < 0.001), respectively. In multivariate analysis, AMW admission was associated with worse 6-month survival (HR 1.31, 95% CI 1.04–1.63) in comparison with IMCU admission, after adjusting for age, gender, comorbidities, ADL, SAPS-3 and diagnosis. Survival was not significantly different between patients admitted in an ICU and an IMCU (HR 1.17, 95% CI 0.95–1.46). Sensitivity analysis using multiple imputation for missing data and propensity score matching found similar results. Hospital destination was not significantly associated with the composite criterion loss of 1-point ADL or mortality. Physical and mental components of the 12-Item Short-Form Health Survey were significantly lower in the acute medical ward group (34.3 [27.5–41.7], p = 0.037 and 44.3 [38.6–48.6], p = 0.028, respectively) than in the ICU group (34.7 [28.4–45.3] and 45.5 [40.0–50.0], respectively) and IMCU group (35.7 [29.7–43.8] and 44.5 [39.7–48.4], respectively).

Conclusions

Admission in an AMW was associated with worse 6-month survival in older critically ill patients in comparison with IMCU admission, with no difference of survival between ICU and IMCU admission. There were no clinically relevant differences in quality of life in each group. These results should be confirmed in specific studies and raise the question of dedicated geriatric IMCUs.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-022-01042-4.

Early prediction of in-hospital mortality in patients with congestive heart failure in intensive care unit: a retrospective observational cohort study

Objective

Congestive heart failure (CHF) is a clinical syndrome in which the heart disease progresses to a severe stage. Early diagnosis and risk assessment of death of patients with CHF are critical to prognosis and treatment. The purpose of this study was to establish a nomogram that predicts the in-hospital death of patients with CHF in the intensive care unit (ICU).

Design

A retrospective observational cohort study.

Setting and participants

Data for the study were from 30 411 patients with CHF in the Medical Information Mart for Intensive Care database and the eICU Collaborative Research Database (eICU-CRD).

Primary outcome

In-hospital mortality.

Methods

Univariate logistic regression analysis was used to select risk factors associated with in-hospital mortality of patients with CHF, and multivariate logistic regression was used to build the prediction model. Discrimination, calibration and clinical validity of the model were evaluated by AUC, calibration curve, Hosmer-Lemeshow χ² test and decision curve analysis, respectively. Finally, data from 15 503 patients with CHF in the multicentre eICU-CRD were used for external validation of the established nomogram.

Results

The inclusion criteria were met by 15 983 subjects, whose in-hospital mortality rate was 12.4%. Multivariate analysis determined that the independent risk factors were age, race, norepinephrine, dopamine, phenylephrine, vasopressin, mechanical ventilation, intubation, hepatic failure (HepF), heart rate, respiratory rate, temperature, systolic blood pressure (SBP), anion gap (AG), blood urea nitrogen (BUN), creatinine, chloride, mean corpuscular volume (MCV), red blood cell distribution width (RDW) and white cell count (WCC). The C-index of the nomogram (0.767, 95% CI 0.759 to 0.779) was superior to that of the traditional Sequential Organ Failure Assessment, Acute Physiology Score III and Get With The Guidelines Heart Failure scores, indicating its discrimination power. Calibration plots demonstrated that the predicted results are in good agreement with the observed results. The decision curves of the derivation and validation sets both had net benefits.

Conclusion

The 20 independent risk factors for in-hospital mortality of patients with CHF were age, race, norepinephrine, dopamine, phenylephrine, vasopressin, mechanical ventilation, intubation, HepF, heart rate, respiratory rate, temperature, SBP, AG, BUN, creatinine, chloride, MCV, RDW and WCC. The nomogram, which included these factors, accurately predicted the in-hospital mortality of patients with CHF. The novel nomogram has the potential for use in clinical practice as a tool to predict and assess mortality of patients with CHF in the ICU.

Geriatric Nutritional Risk Index is Associated with Hospital Death in Elderly Patients with Multiple Organ Dysfunction Syndrome: A Retrospective Study Based on the MIMIC-III Database

Purpose

Elderly patients with multiple organ dysfunction syndrome (MODS) have a higher mortality during hospitalization in the intensive care unit (ICU). Elderly patients often suffer from malnutrition. On the basis of the MIMIC-III database, this study analyzed the effect of the baseline nutritional status on the death of elderly patients with MODS during hospitalization.

Materials and Methods

Elderly patients with MODS were screened out from MIMIC-III 1.4 database. The geriatric nutritional risk index (GNRI) was calculated and used to group patients into: normal nutrition (GNRI > 98) and malnutrition (GNRI ≤ 98) groups. The malnutrition group was divided into mild (92–98), moderate (82–91), and severe (≤81) groups. The differences in the baseline data and the incidence of adverse events between groups were compared. The GAM model was used to determine whether a curve relationship was present between the hospital death of elderly patients with MODS and GNRI and analyze the threshold saturation effect. The multivariate logistic regression was used to calculate the odds ratio (OR) of in-hospital deaths in different GNRI groups. The interaction test was performed to find subgroups with differences.

Results

A total of 2456 elderly patients with MODS were enrolled. A total of 1,273 (51.8%) and 1183 (48.2%) patients were in the normal nutrition and malnutrition groups, respectively. The mortality rate of patients in the normal nutrition group during hospitalization was lower than that in the malnutrition group (206/1273 vs. 292/1183, X2 = 27.410, P < 0.001; OR = 0.59, 95% CI: 0.48–0.72). The GAM model fitting analysis showed a threshold saturation effect at GNRI = 92. Adjusted OR values with GNRI ≥ 92 began to change to 1, and GNRI and death had no association. At GNRI < 92, high GNRI related to low risk of death. Subgroup analysis of patients with GNRI < 92 showed that the risk of death in elderly male patients was lower than that of female patients.

Conclusion

GNRI is related to the severity of illness in elderly patients with MODS. At GNRI < 92, moderate to severe malnutrition increases the risk of death in elderly patients with MODS during hospitalization.

Clinically Interpretable Machine Learning Models for Early Prediction of Mortality in Older Patients with Multiple Organ Dysfunction Syndrome (MODS): An International Multicenter Retrospective Study

BACKGROUND

Multiple organ dysfunction syndrome (MODS) is associated with a high risk of mortality among older patients. Current severity scores are limited in their ability to assist clinicians with triage and management decisions. We aim to develop mortality prediction models for older patients with MODS admitted to the ICU.

METHODS

The study analyzed older patients from 197 hospitals in the US and one hospital in the Netherlands. The cohort was divided into the young-old (65-80 years) and old-old (≥80 years), which were separately used to develop and evaluate models including internal, external and temporal validation. Demographic characteristics, comorbidities, vital signs, laboratory measurements, and treatments were used as predictors. We used the XGBoost algorithm to train models, and the SHAP method to interpret predictions.

RESULTS

34,497 young-old (11.3% mortality) and 21,330 old-old (15.7% mortality) patients were analyzed. Discrimination AUROC of internal validation models in 9,046 U.S. patients was as follows: 0.87 and 0.82, respectively; Discrimination of external validation models in 1,905 EUR patients was as follows: 0.86 and 0.85, respectively; and of temporal validation models in 8,690 U.S. patients: 0.85 and 0.78, respectively. These models outperformed standard clinical scores like SOFA and APSIII. The GCS, Charlson Comorbidity Index, and Code Status emerged as top predictors of mortality.

CONCLUSIONS

Our models integrate data spanning physiologic and geriatric-relevant variables that outperform existing scores used in older adults with MODS, which represents a proof of concept of how machine learning can streamline data analysis for busy ICU clinicians to potentially optimize prognostication and decision making.

“Impact of age on management and prognosis of resuscitated sudden cardiac death patients”

Background

Sudden cardiac death (SCD) has a great impact on healthcare due to cardiologic and neurological complications. Admissions of elderly people in Cardiology Intensive Care Units have increased. We assessed the impact of age in presentation, therapeutic management and in vital and neurological prognosis of SCD patients.

Methods

We carried out a retrospective, observational, multicenter registry of patients who were admitted with a SCD in 5 tertiary hospitals from January 2013 to December 2020. We divided our cohort into two groups (patients < 80 years and ≥ 80 years). Clinical, analytical and hemodynamic variables as well as in-hospital management were registered and compared between groups. The degree of neurological dysfunction, vital status at discharge and the influence of age on them were also reviewed.

Results

We reviewed 1160 patients admitted with a SCD. 11.3% were ≥ 80 years. Use of new antiplatelet agents, performance of a coronary angiography, use of pulmonary artery catheter and temperature control were less carried out in the elderly. Age, non-shockable rhythm, Killip class > 1 at admission, time to CPR initiation > 5 min, time to ROSC > 20 min and lactate > 2 mmol/L were independent predictors for in-hospital mortality. Non-shockable rhythm, Killip class > 1 at admission, time to CPR initiation > 5 min and time to ROSC > 20 min but not age were independent predictors for poor neurological outcomes.

Conclusions

Age determined a less aggressive management and it was associated with a worse vital prognosis in patients admitted with a SCD. Nevertheless, age was not associated with worse neurological outcomes.

Trends in Geriatric Conditions Among Older Adults Admitted to US ICUs Between 1998 and 2015

BACKGROUND

Older adults are increasingly admitted to the ICU, and those with disabilities, dementia, frailty, and multimorbidity are vulnerable to adverse outcomes. Little is known about how pre-existing geriatric conditions have changed over time.

RESEARCH QUESTION

How have changes in disability, dementia, frailty, and multimorbidity in older adults admitted to the ICU changed from 1998 through 2015?

STUDY DESIGN AND METHODS

Medicare-linked Health and Retirement Survey (HRS) data identifying patients 65 years of age and older admitted to an ICU between 1998 and 2015. ICU admission was the unit of analysis. Year of ICU admission was the exposure. Disability, dementia, frailty, and multimorbidity were identified based on responses to HRS surveys before ICU admission. Disability represented the need for assistance with ≥ 1 activity of daily living. Dementia used cognitive and functional measures. Frailty included deficits in ≥ 2 domains (physical, nutritive, cognitive, or sensory function). Multimorbidity represented ≥ 3 self-reported chronic diseases. Time trends in geriatric conditions were modeled as a function of year of ICU admission and were adjusted for age, sex, race or ethnicity, and proxy interview status.

RESULTS

Across 6,084 ICU patients, age at admission increased from 77.6 years (95% CI, 76.7-78.4 years) in 1998 to 78.7 years (95% CI, 77.5-79.8 years) in 2015 (P < .001 for trend). The adjusted proportion of ICU admissions with pre-existing disability rose from 15.5% (95% CI, 12.1%-18.8%) in 1998 to 24.0% (95% CI, 18.5%-29.6%) in 2015 (P = .001). Rates of dementia did not change significantly (P = .21). Frailty increased from 36.6% (95% CI, 30.9%-42.3%) in 1998 to 45.0% (95% CI, 39.7%-50.2%) in 2015 (P = .04); multimorbidity rose from 54.4% (95% CI, 49.2%-59.7%) in 1998 to 71.8% (95% CI, 66.3%-77.2%) in 2015 (P < .001).

INTERPRETATION

Rates of pre-existing disability, frailty, and multimorbidity in older adults admitted to ICUs increased over time. Geriatric principles need to be deeply integrated into the ICU setting.

Prognostic value of PaO2/FiO2, SOFA and D-dimer in elderly patients with sepsis

OBJECTIVE

To investigate the prognostic value for predicting mortality of partial pressure of oxygen/fraction of inspired oxygen (PaO2/FiO2), the Sequential Organ Failure Assessment (SOFA) score and D-dimer in elderly patients with sepsis.

METHODS

This retrospective cohort study enrolled elderly patients with sepsis admitted to the intensive care unit (ICU) between January 2019 and October 2020. Patients were divided into a survival group and a non-survival group. Biomarkers, SOFA, Acute Physiology and Chronic Health Evaluation II and Glasgow Coma Scale scores were recorded within 24 h after admission to the ICU.

RESULTS

A total of 135 elderly patients with sepsis were enrolled in the study: 89 were in the survival group and 46 were in the non-survival group at 28 days. Univariate and multivariate regression analyses demonstrated that PaO2/FiO2, SOFA and D-dimer were independently associated with 28-day mortality. The predictive performance for mortality of the combination of PaO2/FiO2, SOFA score and D-dimer (area under the receiver operating characteristic curve of 0.926) was higher than the values for the individual factors (0.761, 0.745 and 0.878, respectively).

CONCLUSION

The combination of PaO2/FiO2, SOFA score and D-dimer represents a promising tool and biomarker for predicting 28-day mortality of the elderly patients with sepsis.

[Analysis of the factors involved in the evolution of patients over 80 years of age admitted to the intensive care unit: Should we change our procedure?]

BACKGROUND AND OBJECTIVES

The care of older patients in intensive care units (ICU) is becoming more frequent. To describe characteristics of elderly patients admitted to the ICU and to analyze the factors associated with mortality.

PATIENTS AND METHODS

Retrospective cross-sectional study, with patients ≥80 years, admitted to the ICU of the Rey Juan Carlos University Hospital, from March 2012 to December 2018. Demographic variables, comorbidities and mortality in the ICU, in hospital and at one year were collected, analyzed by univariate analysis and binary logistic regression.

RESULTS

Six hundred twenty patients, mean age 83.6 years (SD: 3.25), 31% required invasive mechanical ventilation (IMV), 25% vasopressors and 29% renal replacement therapy (RRT) due to acute renal failure (ARF). The 60% were admissions of medical origin. In-hospital mortality was 156 patients (25%), 91 died in the ICU and 65 on the ward, with shorter ICU stays for the survivors (2.72; SD: 0.22) compared to the deceased (3.74; SD: 0.38), with statistically significant differences. 63% remained alive one year after ICU discharge. An explanatory model of ICU mortality was obtained by logistic regression that included the following factors: IMV (OR: 5.78, 95% CI 2.73-12.22), vasopressors (OR: 2.54, 95% CI 1.24-5.19), AKI/TRS (OR: 2.69, 95% CI 1.35-5.35), medical admission (OR: 2.88, 95% CI 1.40-5.92), urgent admission (OR: 2.33, 95% CI 1.30-4.18) and limitation of life support (LTSV) (OR: 47.35, 95% CI 22.96-97.68). The days in the ICU (OR: 0.93, 95% CI 0.87-0.99) would be inversely related to mortality.

CONCLUSIONS

In older patients, there is no increase in mortality, with a 1-year survival >63%. The need for IMV, the use of vasopressor drugs and ARF/RTS were factors associated with mortality in the multivariate analysis.