Long-term survival and health status after prolonged mechanical ventilation after cardiac surgery

Risk factors and clinical prediction models for prolonged mechanical ventilation after heart valve surgery

OBJECTIVES

Prolonged mechanical ventilation (PMV) is a common complication following cardiac surgery linked to unfavorable patient prognosis and increased mortality. This study aimed to search for the factors associated with the occurrence of PMV after valve surgery and to develop a risk prediction model.

METHODS

The patient cohort was divided into two groups based on the presence or absence of PMV post-surgery. Comprehensive preoperative and intraoperative clinical data were collected. Univariate and multivariate logistic regression analyses were employed to identify risk factors contributing to the incidence of PMV. Based on the logistic regression results, a clinical nomogram was developed.

RESULTS

The study included 550 patients who underwent valve surgery, among whom 62 (11.27%) developed PMV. Multivariate logistic regression analysis revealed that age (odds ratio [OR] = 1.082, 95% confidence interval [CI] = 1.042-1.125; P < 0.000), current smokers (OR = 1.953, 95% CI = 1.007-3.787; P = 0.047), left atrial internal diameter index (OR = 1.04, 95% CI = 1.002-1.081; P = 0.041), red blood cell count (OR = 0.49, 95% CI = 0.275-0.876; P = 0.016), and aortic clamping time (OR = 1.031, 95% CI = 1.005-1.057; P < 0.017) independently influenced the occurrence of PMV. A nomogram was constructed based on these factors. In addition, a receiver operating characteristic (ROC) curve was plotted, with an area under the curve (AUC) of 0.782 and an accuracy of 0.884.

CONCLUSION

Age, current smokers, left atrial diameter index, red blood cell count, and aortic clamping time are independent risk factors for PMV in patients undergoing valve surgery. Furthermore, the nomogram based on these factors demonstrates the potential for predicting the risk of PMV in patients following valve surgery.

The impact of prolonged mechanical ventilation after acute type A aortic dissection repair

OBJECTIVE

Patients with type A aortic dissection have increased resource use. The objective of this study was to describe the relationship between prolonged mechanical ventilation and longitudinal survival in patients undergoing type A aortic dissection repair.

METHODS

We conducted a retrospective analysis of patients with type A aortic dissection undergoing repair from 2010 to 2018; Kaplan-Meier function and adjusted Cox regression analysis were used to compare in-hospital mortality and longitudinal survival accounting for time on mechanical ventilatory support.

RESULTS

A total of 552 patients were included. The study population was divided into 12 hours or less (n = 291), more than 12 to 24 or less hours (n = 101), more than 24 to 48 hours or less (n = 60), and more than 48 hours (n = 100) groups. Patients within the 12 or less hours group were the youngest (60.0 vs 63.5 years vs 63.6 vs 62.8 years; P = .03) and less likely to be female (31.6% vs 43.6% vs 46.7% vs 56.0%; P < .001). On the other hand, the more than 48 hours group presented with malperfusion syndrome at admission more often (24.4% vs 29.7% vs 28.3% vs 53.0%; P < .001) and had longer cardiopulmonary and ischemic times (P < .05). In-hospital mortality was significantly higher in the more than 48 hours group (5.2% vs 6.9% vs 3.3% vs 30.0%; P < .001). Multivariable analysis demonstrated worse longitudinal survival for the 24 to 48 hours group (hazard ratio, 1.94, confidence interval, 1.10-3.43) and more than 48 hours ventilation group (hazard ratio, 2.25, confidence interval, 1.30-3.92).

CONCLUSIONS

The need for prolonged mechanical ventilatory support is prevalent and associated with other perioperative complications. More important, after adjusting for other covariates, prolonged mechanical ventilation is an independent factor associated with increased longitudinal mortality.

Persistent diaphragm dysfunction after cardiac surgery is associated with adverse respiratory outcomes: a prospective observational ultrasound study

BACKGROUND

Transient diaphragm dysfunction is common during the first week after cardiac surgery; however, the precise incidence, risk factors, and outcomes of persistent diaphragm dysfunction are not well described.

METHODS

In a single-centre prospective cohort study, we included all consecutive patients over 18 yr who underwent elective cardiac surgery. Diaphragm function was evaluated with ultrasound (M-mode) by recording the excursion of both hemidiaphragms at two different time points: preoperatively and after the seventh postoperative day in patients breathing without assistance. Significant diaphragm dysfunction after the seventh day of the index cardiac surgery was defined as a decrease in diaphragm excursion below the lower limit of normal: at rest, < 9 mm for women and < 10 mm for men; after a sniff test, < 16 mm for women and < 18 mm for men.

RESULTS

Overall, 122 patients were included in the analysis. The median [interquartile range (IQR)] age was 69 [59-74] years and 96/122 (79%) were men. Ten (8%) patients had diaphragm dysfunction after the seventh postoperative day. We did not identify risk factors for persistent diaphragm dysfunction. Persistent diaphragm dysfunction was associated with a longer median [IQR] duration of noninvasive (8 [0-34] vs 0 [0-0] hr; difference in medians, 8 hr; 95% confidence interval [CI], 0 to 22; P < 0.001) and invasive mechanical ventilation (5 [3-257] vs 3[2-4] hr; difference in medians, 2 hr; 95% CI, 0.5 to 41; P = 0.008); a higher reintubation rate (4/10, 40% vs 1/112, 0.9%; relative risk, 45; 95% CI, 7.1 to 278; P < 0.0001), a higher incidence of pneumonia (4/10 [40%] vs 7/112 [6%]; relative risk, 6; 95% CI, 2 to 16; P < 0.001), and longer median [IQR] length of stay in the intensive care unit (8 [5-29] vs 4 [2-6] days; difference in medians, 4 days; 95% CI, 2 to 12; P = 0.002).

CONCLUSION

The incidence of persistent diaphragm dysfunction was 8% in patients undergoing elective cardiac surgery and was associated with adverse respiratory outcomes.

STUDY REGISTRATION

ClinicalTrials.gov (NCT04276844); prospectively registered 19 February 2020.

Protocol for a randomised controlled trial: reducing reintubation among high-risk cardiac surgery patients with high-flow nasal cannula (I-CAN)

INTRODUCTION

Heated, humidified, high-flow nasal cannula oxygen therapy has been used as a therapy for hypoxic respiratory failure in numerous clinical settings. To date, limited data exist to guide appropriate use following cardiac surgery, particularly among patients at risk for experiencing reintubation. We hypothesised that postextubation treatment with high-flow nasal cannula would decrease the all-cause reintubation rate within the 48 hours following initial extubation, compared with usual care.

METHODS AND ANALYSIS

Adult patients undergoing cardiac surgery (open surgery on the heart or thoracic aorta) will be automatically enrolled, randomised and allocated to one of two treatment arms in a pragmatic randomised controlled trial at the time of initial extubation. The two treatment arms are administration of heated, humidified, high-flow nasal cannula oxygen postextubation and usual care (treatment at the discretion of the treating provider). The primary outcome will be all-cause reintubation within 48 hours of initial extubation. Secondary outcomes include all-cause 30-day mortality, hospital length of stay, intensive care unit length of stay and ventilator-free days. Interaction analyses will be conducted to assess the differential impact of the intervention within strata of predicted risk of reintubation, calculated according to our previously published and validated prognostic model.

ETHICS AND DISSEMINATION

Vanderbilt University Medical Center IRB approval, 15 March 2021 with waiver of written informed consent. Plan for publication of study protocol prior to study completion, as well as publication of results.

TRIAL REGISTRATION NUMBER

clinicaltrials.gov, NCT04782817 submitted 25 February 2021.

DATE OF PROTOCOL

29 August 2022. Version 2.0.

Prolonged mechanical ventilation after cardiac surgery: substudy of the Transfusion Requirements in Cardiac Surgery III trial

PURPOSE

Prolonged mechanical ventilation (MV) is a major complication following cardiac surgery. We conducted a secondary analysis of the Transfusion Requirements in Cardiac Surgery (TRICTS) III trial to describe MV duration, identify factors associated with prolonged MV, and examine associations of prolonged MV with mortality and complications.

METHODS

Four thousand, eight hundred and nine participants undergoing cardiac surgery at 71 hospitals worldwide were included. Prolonged MV was defined based on the Society of Thoracic Surgeons definition as MV lasting 24 hr or longer. Adjusted associations of patient and surgical factors with prolonged MV were examined using multivariable logistic regression. Associations of prolonged MV with complications were assessed using odds ratios, and adjusted associations between prolonged MV and mortality were evaluated using multinomial regression. Associations of shorter durations of MV with survival and complications were explored.

RESULTS

Prolonged MV occurred in 15% (725/4,809) of participants. Prolonged MV was associated with surgical factors indicative of complexity, such as previous cardiac surgery, cardiopulmonary bypass duration, and separation attempts; and patient factors such as critical preoperative state, left ventricular impairment, renal failure, and pulmonary hypertension. Prolonged MV was associated with perioperative but not long-term complications. After risk adjustment, prolonged MV was associated with perioperative mortality; its association with long-term mortality among survivors was weaker. Shorter durations of MV were not associated with increased risk of mortality or complications.

CONCLUSION

In this substudy of the TRICS III trial, prolonged MV was common after cardiac surgery and was associated with patient and surgical risk factors. Although prolonged MV showed strong associations with perioperative complications and mortality, it was not associated with long-term complications and had weaker association with long-term mortality among survivors.

STUDY REGISTRATION

www.

CLINICALTRIALS

gov (NCT02042898); registered 23 January 2014. This is a substudy of the Transfusion Requirements in Cardiac Surgery (TRICS) III trial.

The initial validation of a novel outcome measure in severe burns- the Persistent Organ Dysfunction +Death: Results from a multicenter evaluation

INTRODUCTION

A need exists to improve the efficiency of clinical trials in burn care. The objective of this study was to validate "Persistent Organ Dysfunction" plus death as endpoint in burn patients and to demonstrate its statistical efficiency.

METHODS

This secondary outcome analysis of a dataset from a prospective international multicenter RCT (RE-ENERGIZE) included patients with burned total body surface area >20% and a 6-month follow-up. Persistent organ dysfunction was defined as persistence of organ dysfunction with life-supportiing technologies and ICU care.

RESULTS

In the 539 included patients, the prevalence of 0p p+ pdeath was 40% at day 14 and of 27% at day 28. At both timepoints, survivors with POD (vs. survivors without POD) had a higher mortality rate, longer ICU- and hospital-stays, and a reduced quality of life. POD + death as an endpoint could result in reduced sample size requirements for clinical trials. Detecting a 25% relative risk reduction in 28-day mortality would require a sample size of 4492 patients, whereas 1236 patients would be required were 28-day POD + death used.

CONCLUSIONS

POD + death represents a promising composite outcome measure that may reduce the sample size requirements of clinical trials in severe burns patients. Further validation in larger clinical trials is warranted.

STUDY TYPE

Prospective cohort study, level of evidence: II.

Sonographically Measured Improvement in Diaphragmatic Mobility and Outcomes Among Patients Requiring Prolonged Weaning from the Ventilator

Background:

The need of prolonged weaning from the ventilator is a well-known predictor of an unfavorable patients` outcome. Diaphragmatic dysfunction is a serious problem for these patients. We wanted to determine the survival in patients who were already intubated for more than 4 weeks before they were admitted to our weaning unit. In this prospective study, we wanted to investigate if the diaphragmatic function could improve or was related to survival over an 18 months follow up period.

Methods:

84 patients were included when they were able to breathe at least 10 minutes over a t-piece and sit upright for at least 5 minutes. The diaphragmatic function was estimated sonographically using the up and downward movement of the lung silhouette. Sonographic follow-ups were performed for over 18 months. The survival rate, outcome and changes in diaphragm mobility were investigated.

Results:

a) Survival: 49 patients (58%) survived the 18 months follow up period - 30 had a good outcome; 19 needed assistance. b) Survival in relation to diaphragm mobility: If diaphragmatic mobility improved ≥ 15.5 mm on the left side, the probability of survival was 94% with a probability of 76% to have a satisfying outcome.

Conclusion:

Survival and outcome of prolonged weaning were significantly better when sonographically measured the mobility of left hemidiaphragm improved.

The Effects of Escalation of Respiratory Support and Prolonged Invasive Ventilation on Outcomes of Cardiac Surgical Patients: A Retrospective Cohort Study

Objectives

The aim of this study was to determine the effects of escalation of respiratory support and prolonged postoperative invasive ventilation on patient-centered outcomes, and identify perioperative factors associated with these 2 respiratory complications.

Design

A retrospective cohort analysis of cardiac surgical patients admitted to the cardiothoracic intensive care unit (ICU) between August 2015 and January 2018. Escalation of respiratory support was defined as “unplanned continuous positive airway pressure,” “non-invasive ventilation,” or “reintubation” after surgery; prolonged invasive ventilation was defined as “invasive ventilation beyond the first 12 hours following surgery.” The primary endpoint was the composite of escalation of respiratory support and prolonged ventilation.

Setting

Tertiary cardiothoracic ICU.

Participants

A total of 2,098 patients were included and analyzed.

Interventions

None.

Measurements and Main Results

The composite of escalation of support or prolonged ventilation occurred in 509 patients (24.3%). Patients who met the composite had higher mortality (2.9% v 0.1%; p < 0.001) and longer median [interquartile range] length of ICU (2.1 [1.0-4.9] v 0.9 [0.8-1.0] days; p < 0.0001) and hospital (10.6 [8.0-16.0] v 7.2 [6.2-10.0] days; p < 0.0001) stay. Hypoxemia and anemia on admission to ICU were the only 2 factors independently associated with the need for escalation of respiratory support or prolonged invasive ventilation.

Conclusions

Escalation of respiratory support or prolonged invasive ventilation is frequently seen in cardiac surgery patients and is highly associated with increased mortality and morbidity. Hypoxemia and anemia on admission to the ICU are potentially modifiable factors associated with escalation of respiratory support or prolonged invasive ventilation.

Survival, Quality of Life, and Functional Status Following Prolonged ICU Stay in Cardiac Surgical Patients: A Systematic Review

OBJECTIVES

Compared with noncardiac critical illness, critically ill postoperative cardiac surgical patients have different underlying pathophysiologies, are exposed to different processes of care, and thus may experience different outcome trajectories. Our objective was to systematically review the outcomes of cardiac surgical patients requiring prolonged intensive care with respect to survival, residential status, functional recovery, and quality of life in both hospital and long-term follow-up.

DATA SOURCES

MEDLINE, Embase, CINAHL, Web of Science, and Dissertations and Theses Global up to July 21, 2017.

STUDY SELECTION

Studies were included if they assessed hospital or long-term survival and/or patient-centered outcomes in adult patients with prolonged ICU stays following major cardiac surgery. After screening 10,159 citations, 114 articles were reviewed in full; a final 34 articles met criteria for data extraction.

DATA EXTRACTION

Two reviewers independently extracted data and assessed risk of bias using the National Institutes of Health Quality Assessment Tool for Observational Studies. Extracted data included the used definition of prolonged ICU stay, number and characteristics of prolonged ICU stay patients, and any comparator short stay group, length of follow-up, hospital and long-term survival, residential status, patient-centered outcome measure used, and relevant score.

DATA SYNTHESIS

The definition of prolonged ICU stay varied from 2 days to greater than 14 days. Twenty-eight studies observed greater in-hospital mortality among all levels of prolonged ICU stay. Twenty-five studies observed greater long-term mortality among all levels of prolonged ICU stay. Multiple tools were used to assess patient-centered outcomes. Long-term health-related quality of life and function was equivalent or worse with prolonged ICU stay.

CONCLUSIONS

We found consistent evidence that patients with increases in ICU length of stay beyond 48 hours have significantly increasing risk of hospital and long-term mortality. The significant heterogeneity in exposure and outcome definitions leave us unable to precisely quantify the risk of prolonged ICU stay on mortality and patient-centered outcomes.

Early changes in diaphragmatic function evaluated using ultrasound in cardiac surgery patients: a cohort study

Little is known about the evolution of diaphragmatic function in the early post-cardiac surgery period. The main purpose of this work is to describe its evolution using ultrasound measurements of muscular excursion and thickening fraction (TF). Single-center prospective study of 79 consecutive uncomplicated elective cardiac surgery patients, using motion-mode during quiet unassisted breathing. Excursion and TF were measured sequentially for each patient [pre-operative (D1), 1 day (D2) and 5 days (D3) after surgery]. Pre-operative median for right and left hemidiaphragmatic excursions were 1.8 (IQR 1.6 to 2.1) cm and 1.7 (1.4 to 2.0) cm, respectively. Pre-operative median right and left thickening fractions were 28 (19 to 36) % and 33 (22 to 51) %, respectively. At D2, there was a reduction in both excursion (right: 1.5 (1.1 to 1.8) cm, p < 0.001, left: 1.5 (1.1 to 1.8), p = 0.003) and thickening fractions (right: 20 (15 to 34) %, p = 0.021, left: 24 (17 to 39) %, p = 0.002), followed by a return to pre-operative values at D3. A positive moderate correlation was found between excursion and thickening fraction (Spearman's rho 0.518 for right and 0.548 for left hemidiaphragm, p < 0.001). Interobserver reliability yielded a bias below 0.1 cm with limits of agreement (LOA) of ± 0.3 cm for excursion and - 2% with LOA of ± 21% for thickening fractions. After cardiac surgery, the evolution of diaphragmatic function is characterized by a transient impairment followed by a quick recovery. Although ultrasound diaphragmatic excursion and thickening fraction are correlated, excursion seems to be a more feasible and reproducible method in this population.

Reduced post-operative DPP4 activity associated with worse patient outcome after cardiac surgery

Cardiac surgery with cardiopulmonary bypass (CPB) triggers myocardial ischemia/reperfusion injury contributing to organ dysfunction. Preclinical studies revealed that dipeptidyl peptidase (DPP4) inhibition is protective during myocardial infarction. Here, we assessed for the first time the relation of peri-operative DPP4-activity in serum of 46 patients undergoing cardiac surgery with patients' post-operative organ dysfunction during intensive care unit (ICU) stay. Whereas a prior myocardial infarction significantly reduced pre-operative DDP4-activity, patients with preserved left ventricular function showed an intra-operative decrease of DPP4-activity. The latter correlated with aortic cross clamping time, indicative for the duration of surgery-induced myocardial ischemia. As underlying mechanism, mass-spectrometry revealed increased DPP4 oxidation by cardiac surgery, with DPP4 oxidation reducing DPP4-activity in vitro. Further, post-operative DPP4-activity was negatively correlated with the extent of post-operative organ injury as measured by SAPS II and SOFA scoring, circulating levels of creatinine and lactate, as well as patients' stay on the ICU. In conclusion, cardiac surgery reduces DPP4-activity through oxidation, with low post-operative DPP4-activity being associated with organ dysfunction and worse outcome of patients during the post-operative ICU stay. This likely reflects the severity of myocardial ischemia/reperfusion injury and may suggest potential beneficial effects of anti-oxidative treatments during cardiac surgery.

Expensive care? Resource-based thresholds for potentially inappropriate treatment in intensive care

In intensive care, disputes sometimes arise when patients or surrogates strongly desire treatment, yet health professionals regard it as potentially inappropriate. While professional guidelines confirm that physicians are not always obliged to provide requested treatment, determining when treatment would be inappropriate is extremely challenging. One potential reason for refusing to provide a desired and potentially beneficial treatment is because (within the setting of limited resources) this would harm other patients. Elsewhere in public health systems, cost effectiveness analysis is sometimes used to decide between different priorities for funding. In this paper, we explore whether cost-effectiveness could be used to determine the appropriateness of providing intensive care. We explore a set of treatment thresholds: the probability threshold (a minimum probability of survival for providing treatment), the cost threshold (a maximum cost of treatment), the duration threshold (the maximum duration of intensive care), and the quality threshold (a minimum quality of life). One common objection to cost-effectiveness analysis is that it might lead to rationing of life-saving treatment. The analysis in this paper might be used to inform debate about the implications of applying cost-effectiveness thresholds to clinical decisions around potentially inappropriate treatment.

Determinants of prolonged intensive care unit stay in patients after cardiac surgery: a prospective observational study

BACKGROUND

Prolonged intensive care unit (ICU) stay of patients after cardiac surgery has a major impact on overall cost and resource utilization. The aim of this study was to identify perioperative factors which prolong stay in ICU.

METHODS

All adult patients from a single, specialized cardiac center who were admitted to the ICU after cardiac surgery during a 2-month period were included. Demographic and clinical characteristics, comorbidities, preoperative use of drugs, intraoperative variables, and postoperative course were recorded. Hemodynamic and blood gas measurements were recorded at four time intervals during the first 24 postoperative hours. Routine hematologic and biochemical laboratory results were recorded preoperatively and in the first postoperative hours.

RESULTS

During the study period 145 adult patients underwent cardiac surgery: 65 (45%) underwent coronary artery bypass graft surgery, 38 (26%) valve surgery, 26 (18%) combined surgery and 16 (11%) other types of cardiac operation. Seventy nine (54%) patients had an ICU stay of less than 24 hours. Random forests analysis identified four variables that had a major impact on the length of stay (LOS) in ICU; these variables were subsequently entered in a logistic regression model: preoperative hemoglobin [odds ratio (OR) =0.68], duration of aortic clamping (OR =1.01) and ratio of arterial oxygen partial pressure to inspired oxygen fraction (PaO₂/FiO₂) (OR =0.99) and blood glucose during the first four postoperative hours (OR =1.02). ROC curve analysis showed an AUC =0.79, P<0.001, 95% CI: 0.71-0.86.

CONCLUSIONS

Low preoperative hemoglobin, prolonged aortic clamping time and low PaO₂/FiO₂ ratio and blood glucose measured within the first postoperative hours, were strongly related with prolonged LOS in ICU.

Short- and long-term prognosis of critically-ill patients referred to the ICU from the Emergency Department of a tertiary hospital

BACKGROUND AND OBJECTIVE

A frequent source of critically-ill patients admitted to the ICU is the Emergency Department. It is essential to analyse the short-term prognosis of these patients, but also their evolution after their discharge from the hospital, since this is one of the major concerns of these patients. The aim of this study is to describe the epidemiological characteristics of patients admitted to the ICU from the Emergency Department and to analyse their outcome.

PATIENTS AND METHOD

This consisted of an observational prospective cohorts study which included 269 Emergency Department patients consecutively admitted to the ICU over an 18-month period. Factors associated with hospital mortality were presented as an odds ratio (OR) and factors associated with long-term mortality were presented as a hazard ratio (HR). A P-value lower than .05 was accepted as significant. The overall survival was analysed on the basis of the Kaplan-Meier curves.

RESULTS

Hospital mortality was 15%, ICU complications where the variables with the greatest impact on short-term mortality: acute renal failure (OR 22.7) and respiratory distress syndrome (OR 51.2). After hospital discharge, the cumulative mortality at 12, 24 and 36 months was 6, 11 and 15%, respectively. The degree of functional dependence (HR 3.7), cancer (HR 3.4) and arrhythmias (HR 2.4) were factors related to long-term mortality.

CONCLUSIONS

The short-term outcome of ICU patients is related to age and comorbidity, but more significantly to the characteristics of the acute illness. However, the long-term outcome is more closely associated with the patients' characteristics.

Years of Life Lost After Complications of Coronary Artery Bypass Operations

BACKGROUND

We currently have an incomplete understanding of which postoperative complications after coronary artery bypass grafting (CABG) are associated with long-term death. The purpose of this study was to find the associations between complications and attributable death.

METHODS

Prospectively collected data on patient characteristics, risk factors, and complications of patients undergoing isolated CABG with 20-year follow-up were analyzed with a Cox regression model to calculate the overall hazard of dying associated with each postoperative complication. An individual's age and hazard of dying from each complication were then used to calculate years of life lost to each complication.

RESULTS

The postoperative mortality rate was 0.79% (69 of 8,773) at 30 days, 2.85% (250 of 8,773) at 180 days, and 6.38% (560 of 8,773) at 2 years. At a median follow-up of 9.8 years, 1,891 patients (21.6%) had died. Postoperative complications occurred in 3,438 patients (39.2%). Cardiac arrest (hazard ratio, 2.153), reoperation (hazard ratio, 1.679), and new dialysis (hazard ratio, 1.64) were the complications with the greatest hazard of death. After adjusting for complication incidence and patient age, cardiac arrest (703 years), reoperation (544 years), atrial fibrillation (470 years), and prolonged mechanical ventilation (371 years) were associated with the greatest number of years of life lost.

CONCLUSIONS

Acute cardiac arrest, reoperation for other cardiac reasons, new dialysis, atrial fibrillation, and prolonged mechanical ventilation are associated with the largest increase in attributable deaths. Prevention and treatment of these complications may improve mortality rates after cardiac operations.

Does the APACHE II score predict performance of activities of daily living in patients discharged from a weaning center?

INTRODUCTION

Data regarding the functional status of patients after prolonged mechanical ventilation are scarce, and little is known about its clinical predictors.

AIM

To investigate whether the Acute Physiology and Chronic Health Evaluation (APACHE) II score on admission may predict performance in activities of daily living on discharge from a weaning center.

MATERIAL AND METHODS

All consecutive patients admitted between January 1, 2012 and December 31, 2013 were enrolled (n = 130). During this period, 15 subjects died, and 115 were successfully discharged (34 women; 81 men). APACHE II was calculated based on the worst values taken during the first 24 hours after admission. On discharge, the Barthel Index (BI) and its extended version, the Early Rehabilitation Barthel Index (ERBI), were assessed.

RESULTS

Median BI was 20 points (IQR 5; 40), and ERBI was 20 points (-50; 40). There was no correlation between APACHE II and either BI (R = -0.07; p = 0.47) or ERBI (R = -0.07; p = 0.44). APACHE II predicted the need for assistance with bathing (AUROC = 0.833; p < 0.001), grooming (AUROC = 0.823; p < 0.001), toilet use (AUROC = 0.887; p < 0.001), and urination (AUROC = 0.658; p = 0.04). APACHE II had no impact on any ERBI items associated with ventilator weaning, including the need of further mechanical ventilation (AUROC = 0.534; p = 0.65) or tracheostomy (AUROC = 0.544; p = 0.42).

CONCLUSIONS

Although APACHE II cannot predict the overall functional status in patients discharged from a weaning center, it helps identify subjects who will need support with bathing, grooming, and toilet use. The APACHE II score is inadequate to predict performance in activities associated with further respiratory support.

Management of the chronically ventilated patient with a tracheostomy

Tracheostomy is the most common surgical procedure performed on critically ill patients. For those who survive their critical illnesses but remain ventilator-dependent, tracheostomy provides patients with a secure airway that frees the mouth for oral nutrition, enhances verbalized speech, and promotes generalized comfort. Avoiding complications from tracheostomy requires a skilled multi-disciplinary approach to ensure that the benefits outweigh the risks of the procedure.

Outcome After Tracheostomy for Respiratory Failure in the Elderly

The purpose of this study was to determine hospital and postdischarge survival and functional status at follow-up in elderly patients receiving tracheostomy for respiratory failure and to determine if these outcomes differed between the younger elderly (65-74 years) and the older elderly (= 75 years). This was a retrospective chart review with prospective administration of the SF-36 conducted in 228 patients aged 65 years or older who had undergone tracheostomy to facilitate mechanical ventilation for respiratory failure at a tertiary care, university-affiliated, urban medical center. Demographics, comorbidities, hospital survival, liberation from mechanical ventilation, long-term survival, and functional status were determined. Combined hospital and hospice mortality did not differ by age, being 34% and 26% in the 65- to 74-year and = 75-year groups, respectively ( P> .05). However, older patients (= 75 years old) were more likely to be discharged still requiring mechanical ventilation (62% vs 45%, P< .05). Only one half of hospital survivors survived for 1 additional year. Those discharged ventilator-dependent were more likely to die. Of the 20 participants in the SF-36 portion of the study, most had fair to good emotional and social functioning but were extremely limited physically.

Outcomes of Patients With Prolonged Intensive Care Unit Length of Stay After Cardiac Surgery

OBJECTIVE

To determine in-hospital and post-discharge long-term survival in patients with prolonged intensive care unit (ICU) stays after cardiac surgery.

DESIGN

Retrospective, cohort study of cardiac surgery patients from May 2007 to June 2012.

SETTING

Single-center cardiac surgery ICU.

PARTICIPANTS

Patients were grouped according to length of ICU stay: between 1 and 2 weeks, between 2 and 4 weeks, and>4 weeks.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 4,963 patients, 3.3%, 1.6%, and 2.9% of patients stayed 1 to 2 weeks, 2 to 4 weeks, and>4 weeks in the ICU, respectively. In-hospital mortality was 11.1%, 26.6%, and 31.0% for patients with 1 to 2 weeks, 2 to 4 weeks, and>4 weeks ICU stay, respectively. Patients with ICU stays between 1 and 2 weeks had 6 months, 1 year, and 2 year survival rates of 84.4%, 80.0%, and 75.3% after discharge, respectively. Patients with ICU stay between 2 and 4 weeks had similar 6 months, 1 year, and 2 year survival rates of 84.7%, 79.9%, and 74.1%, respectively. In contrast, patients with>4 week ICU stays had significantly lower postdischarge survival rates of 63.3%, 56.4%, and 41.1% at 6 months, 1 year, and 2 years, respectively. Postoperative stroke conferred the greatest risk of death within 1 year after discharge (odds ratio 7.6, p = 0.0140).

CONCLUSIONS

In-hospital mortality rates post-cardiac surgery correlate with length of ICU stay but appear to plateau after 4 weeks. However, a>4 week ICU length of stay confers a worse long-term outcome post-hospital discharge, especially in patients with postoperative stroke.

Postoperative Critical Care of the Adult Cardiac Surgical Patient. Part I: Routine Postoperative Care

OBJECTIVES

Cardiac surgery, including coronary artery bypass, cardiac valve, and aortic procedures, is among the most common surgical procedures performed in the United States. Successful outcomes after cardiac surgery depend on optimum postoperative critical care. The cardiac intensivist must have a comprehensive understanding of cardiopulmonary physiology and the sequelae of cardiopulmonary bypass. In this concise review, targeted at intensivists and surgeons, we discuss the routine management of the postoperative cardiac surgical patient.

DATA SOURCE AND SYNTHESIS

Narrative review of relevant English-language peer-reviewed medical literature.

CONCLUSIONS

Critical care of the cardiac surgical patient is a complex and dynamic endeavor. Adequate fluid resuscitation, appropriate inotropic support, attention to rewarming, and ventilator management are key components. Patient safety is enhanced by experienced personnel, a structured handover between the operating room and ICU teams, and appropriate transfusion strategies.

Evaluation of Persistent Organ Dysfunction Plus Death As a Novel Composite Outcome in Cardiac Surgical Patients

OBJECTIVES

Validated composite outcomes after complicated cardiac surgery are poorly established. Therefore, the authors evaluated a novel composite endpoint, persistent organ dysfunction (POD)+death, which is defined as any need for life-sustaining therapies or death at any time within 28 days from surgery.

DESIGN

Secondary analysis extracted from a large-scale prospective randomized trial of critically ill cardiac surgery patients.

SETTING

Multi-institutional, university hospitals.

PARTICIPANTS

Ninety-five cardiac surgery patients with complicated postoperative courses.

INTERVENTIONS

Cardiac surgery with cardiopulmonary bypass.

MEASUREMENTS AND MAIN RESULTS

At 28 days following surgery, the prevalence of POD was 15%, and 23% of patients had died (POD+death = 38%). Patients alive with POD at day 28 exhibited a significantly higher extent of organ injury and longer ICU (33 v 7 days; p<0.001) and hospital lengths of stay (49 v 21 days; p<0.001) compared to patients without POD at day 28. At 3 and 6 months, quality-of-life scores (by Short Form 36 questionnaire) showed a significantly reduced rating for most components in patients with POD at day 28 compared to those without POD. The 6-month mortality rate was 21% among patients alive with POD at day 28 compared to 5% among patients alive without POD (p = 0.05). The calculated number of patients needed per arm to detect a 25% relative risk reduction for mortality alone was 762 compared to 386 per arm for POD+ death.

CONCLUSIONS

POD+death at day 28 following cardiac surgery may be a valid composite endpoint and offers statistical efficiencies in terms of sample size calculations for cardiac surgical trials.

Inclusion of 'ICU-Day' in a Logistic Scoring System Improves Mortality Prediction in Cardiac Surgery

Background

Prolonged intensive care unit (ICU) stay is a predictor of mortality. The length of ICU stay has never been considered as a variable in an additive scoring system. How could this variable be integrated into a scoring system? Does this integration improve mortality prediction?

Material/Methods

The ‘modified CArdiac SUrgery Score’ (CASUS) was generated by implementing the length of stay as a new variable to the ‘additive CASUS’. The ‘logistic CASUS’ already considers this variable. We defined outcome as ICU mortality and statistically compared the three CASUS models. Discrimination, comparison of receiver operating characteristic curves (DeLong’s method), and calibration (observed/expected ratio) were analyzed on days 1–13.

Results

Between 2007 and 2010, we included 5207 cardiac surgery patients in this prospective study. The mean age was 67.2±10.9 years. The mean length of ICU stay was 4.6±7.0 days and ICU mortality was 5.9%. All scores had good discrimination, with a mean area under the curve of 0.883 for the additive and modified, and 0.895 for the ‘logistic CASUS’. DeLong analysis showed superiority in favor of the logistic model as from day 5. The calibration of the logistic model was good. We identified overestimation (days 1–5) and accurate (days 6–9) calibration for the additive and ‘modified CASUS’. The ‘modified CASUS’ remained accurate but the ‘additive CASUS’ tended to underestimate the risk of mortality (days 10–13).

Conclusions

The integration of length of ICU stay as a variable improves mortality prediction significantly. An ‘ICU-day’ variable should be included into a logistic but not an additive model.

Factors influencing prolonged ICU stay after open heart surgery

Background:

There are different risk factors that affect the intensive care unit (ICU) stay after cardiac surgery.

Objectives:

The aim of this study was to evaluate possible risk factors influencing prolonged ICU stay in a large referral hospital.

Patients and Methods:

We conducted a case-control study to determinate causes of prolonged ICU stay in 280 adult patients undergoing cardiac surgery in a tertiary care center for cardiovascular patients, Tehran, Iran. These patients were divided into two groups according to ICU stay ≤ 96 and > 96 hours. We evaluated perioperative risk factors of ICU stay > 96 hours.

Results:

Among the 280 patients studied, 184 (65.7%) had stayed ≤ 96 hours and 96 (34.3%) had stayed > 96 hours in ICU. Frequency of prolonged ICU stay was 34.2% in patients undergoing coronary artery bypass graft (CABG), 30.8% in patients with valve surgery, and 44.8% in patients with CABG plus valve surgery. Patients with > 96 hours of ICU stay received more blood transfusion and intravenous inotropes. They also had longer anesthesia, cardiopulmonary bypass, and postoperative intubation time. There were higher incidence of postoperative tamponade, re-exploration, re-intubation, hemodialysis, and hypotension in this group (P < 0.05 for all comparisons).

Conclusions:

In this study, about one-third of patients had prolonged ICU stay. Factors influencing prolonged ICU stay were medical and some non-medical factors. In the present study, up to 30% of the patients had a prolonged ICU stay of > 96 hours. Additional data from well-designed investigations are needed for further assessment of the factors influencing prolonged ICU stay after cardiac surgery.

Longer in-hospital wait times do not result in worse outcomes for patients requiring urgent coronary artery bypass graft surgery

BACKGROUND

In certain health care systems, patients wait for non-emergency services. Although waiting may not be considered acceptable, the delay may allow for patient optimization, such as giving time for "toxic" agents to be cleared, that could improve outcomes. We sought to determine the relationship between wait times and outcomes in in-hospital patients undergoing urgent coronary artery bypass graft (CABG) surgery.

METHODS AND RESULTS

A prospectively collected database of consecutive, medically urgent, but clinically stable patients undergoing CABG surgery from 1995 to 2007, was analyzed. A total of 3067 patients with need for urgent CABG surgery with various in-hospital wait times (n = 440, 0-2 days; n = 799, 3-5 days; n = 1317, 6-10 days; n = 511, 11-15 days) were included. There were no differences in mortality, intensive care unit (ICU) or post-surgery hospital length of stay (LOS) among the patient groups. Multivariate logistic regression analysis revealed that wait time was not associated with mortality (P = 0.625). Due to changes in the nonsurgical management of coronary artery disease, a separate analysis of patients, from 2002 to 2007, was also performed to explore contemporary results. In the latter subset, 1495 patients (n = 175, 341, 720, 259, in the same 4 respective wait-time groups) were included; the 0-2 days patient group underwent more blood transfusions (50% vs 38%; P = 0.01), prolonged ventilation (6% vs 2%; P = 0.05), post-operative dialysis (2% vs 0%; P = 0.08), and longer ICU LOS (26 vs 23 hours; P = 0.02) compared with the 3-5 days patient group. The Society of Thoracic Surgeons mortality risk scores of the 0-2 days and 3-5 days groups were the same (1.5%). Multivariate regression analysis revealed that increased wait time was associated with fewer patients requiring blood transfusion (P < 0.05) for CABG surgery.

CONCLUSION

Waiting for in-hospital urgent CABG surgery does not lead to worse patient outcomes and may, in fact, reduce the procedural and medical risks of postoperative blood transfusions, prolonged ventilation, dialysis, and shorten ICU LOS.

Predictors of operative mortality in cardiac surgical patients with prolonged intensive care unit duration

BACKGROUND

Several systems have been developed to predict mortality after intensive care unit (ICU) admission in medical and surgical patients. However, a similar tool specific to cardiac surgical patients with prolonged ICU duration does not exist. The purpose of the current study was to identify independent perioperative predictors of operative mortality among cardiac surgical patients with prolonged ICU duration.

STUDY DESIGN

From 2003 to 2008, a total of 13,105 cardiac surgical patients with ICU durations >48 hours were identified within a statewide database. Perioperative factors, including Society of Thoracic Surgeons Predicted Risk of Mortality, were evaluated. Univariate and multivariate analyses identified significant correlates of operative mortality and their relative strength of association as determined by the Wald chi-square statistic.

RESULTS

Mean patient age was 66.8 ± 11.2 years, median ICU duration was 76.5 hours (range 56.0 to 124.0 hours), and mean Society of Thoracic Surgeons predicted risk of mortality was 4.4% ± 6.2%. Among preoperative and operative factors, intra-aortic balloon pump use, patient age, immunosuppressive therapy, hemodialysis requirement, cardiopulmonary bypass time, and heart failure proved to be the strongest correlates of mortality (all p < 0.05) on risk-adjusted multivariate analysis. Type of cardiac procedure had no significant association with mortality after risk adjustment. Among postoperative complications, cardiac arrest, prolonged mechanical ventilation (>24 hours), and stroke were the strongest predictors of risk-adjusted mortality (all p < 0.001).

CONCLUSIONS

Operative mortality can be predicted by select risk factors for cardiac surgical patients with prolonged ICU duration. Patient age, preoperative intra-aortic balloon pump, postoperative cardiac arrest, prolonged ventilation, and stroke have the strongest association with mortality. Identification of these factors in the perioperative setting can enhance resource use and improve mortality after cardiac surgery.

Relationships between mortality, morbidity, and physical function in adults who survived a period of prolonged mechanical ventilation

PURPOSE

This study aimed to report mortality, morbidity, and the relationship between these outcomes with physical function in patients who survived prolonged mechanical ventilation during an intensive care unit (ICU) admission.

METHODS AND MATERIALS

Records were reviewed for Western Australian residents admitted to an ICU in 2007 or 2008 who were ventilated for 7 days or longer and survived their acute care stay. Records were linked with data maintained by the Department of Health.

RESULTS

A total of 181 patients (aged 52 ± 19 years) were included in this study. In the 12 months after discharge, 159 (88%) survived and 148 (82%) had been hospitalized. Compared with those who were ambulating independently when discharged from acute care, those who were not had more admissions (incident rate ratio, 1.81; 95% confidence interval, 1.28-2.57) and a greater cumulative length of hospital stay (10 [37] vs 57 [115] days, P < .001) over the first 12 months after discharge. Time between admission to ICU and when the patient first stood correlated with the number of admissions (Rs = 0.320, P < .001) and cumulative length of stay (Rs = 0.426, P < .001) in the 12 months after discharge.

CONCLUSIONS

For survivors of prolonged mechanical ventilation, physical function during acute care was associated with hospitalization over the following 12 months.

Clinical outcomes in patients with prolonged intensive care unit length of stay after cardiac surgical procedures

BACKGROUND

Advances in critical care medicine have allowed for improved care of patients requiring prolonged intensive care unit length of stay (prICULOS) after cardiac operations, yet little is known regarding their eventual outcomes. The purpose of this study was to examine short- and long-term outcomes in patients undergoing cardiac operations with prICULOS.

METHODS

All cases of coronary artery bypass grafting (CABG), aortic valve, mitral valve, and combined CABG/valve surgical procedures performed at a single institution from July 2002 to July 2007 were identified. All-cause mortality in patients discharged alive from the hospital was determined until December 2007 through linkage with the Social Security Death Index. Patients who experienced intraoperative death or those with missing or invalid social security numbers were excluded. The definition of prICULOS was total ICULOS greater than 7 days.

RESULTS

A total of 3,478 patients met inclusion criteria. One hundred thirty-seven of three thousand four hundred seventy-eight patients (3.9%) experienced prICULOS. These patients were more likely to be older than 70 years (55.5% versus 30.5%; p<0.0001) and to have had recent myocardial infarction (28.5% versus 20.1%; p=0.02), previous cardiac operation (18.3% versus 6.9%; p<0.0001), and emergent status (9.5% versus 1.6%; p<0.0001). They experienced greater in-hospital mortality (37.2% versus 1.7%; p<0.0001) and those who were discharged alive had worse long-term survival (log-rank, p<0.0001). After risk adjustment, prICULOS emerged as a significant predictor of in-hospital death (odds ratio [OR] 20.9; 95% confidence interval [CI], 12.9-33.7) and decreased long-term survival (hazard ratio [HR] 2.9; 95% CI, 2.0-4.3).

CONCLUSIONS

Patients with prICULOS after cardiac operations have worse overall outcomes. These data may be used to inform these patients and their families of realistic expectations regarding their clinical course.

Long-term survival after surgical critical illness: the impact of prolonged preceding organ support therapy

OBJECTIVE

To identify the prognostic importance of preceding invasive ventilation, renal replacement therapy, and catecholamine therapy for long-term survivors after surgical critical illness.

SUMMARY BACKGROUND DATA

Nothing is known about the effect of preceding intensive care unit (ICU)-related therapies on long-term outcome.

METHODS

We performed a retrospective analysis of prospectively collected data of an ICU patient cohort linked to a local database. Adult patients (n = 1462) admitted to a 12-bed ICU between 1993 and 2005, who had an ICU length of stay of more than 4 days, were followed up until the end of the second year after ICU admission. Hazard function was explored by Weibull modeling and likelihood ratio tests. Cox-type structured hazard regression models were used to analyze linear, nonlinear, or time-varying associations of therapeutic variables with 2-year survival time of a patient subgroup, which had survived the period of high hazard.

RESULTS

Hazard rate declined exponentially up to day 195 after ICU admission, and became constant thereafter. A total of 808 patients reached this stable stage of their disease forming the study population. Of these patients, 648 (80.2%) were still alive at the end of the second year after ICU admission. Underlying diseases were major determinants for long-term outcome. Long-term mortality was significantly associated with the acute extent of physiological derangement during ICU stay (maximum Apache II score), but was independent from the duration of preceding invasive organ support.

CONCLUSION

In surgical patients with a prolonged ICU length of stay, an exorbitant mortality exists for about half a year after ICU admission. Later on, life expectancy of surviving patients is largely determined by the underlying disease and, to a minor degree, by the acute extent of homeostatic disturbance during ICU stay. The duration of preceding invasive therapies does not limit long-term survival.

Effect of an episode of critical illness on subsequent hospitalisation: a linked data study

Healthcare utilisation can affect quality of life and is important in assessing the cost-effectiveness of medical interventions. A clinical database was linked to two Australian state administrative databases to assess the difference in incidence of healthcare utilisation of 19,921 patients who survived their first episode of critical illness. The number of hospital admissions and days of hospitalisation per patient-year was respectively 150% and 220% greater after than before an episode of critical illness (assessed over the same time period). This was the case regardless of age or type of surgery (i.e. cardiac vs non-cardiac). After adjusting for the ageing effect of the cohort as a whole, there was still an unexplained two to four-fold increase in hospital admissions per patient-year after an episode of critical illness. We conclude that an episode of critical illness is a robust predictor of subsequent healthcare utilisation.

Sequential organ failure assessment score and comorbidity: valuable prognostic indicators in chronically critically ill patients

Chronically critically ill patients are defined as those who survive initial life-threatening, possibly reversible organ failure(s) but are unable to recover rapidly to a point at which they are fully independent of life support. Accordingly, these patients require mechanical ventilation and medical resources for a long time in an intensive care unit (ICU). The present study analysed demographic, clinical and survival data of chronically critically ill patients, to identify condition(s) related to poor prognosis. A total of 141 chronically critically ill patients were studied retrospectively over a two-year period (July 1, 2003 to June 30, 2005). Their mean lengths of stay in the ICU and in the hospital were 42.9+/-36.4 and 83.9+/-100.5 days respectively. ICU and six-month cumulative mortality rates were 42.6% and 75.9% respectively. Non-survivors had a significantly higher Sequential Organ Failure Assessment (SOFA) score than survivors on day 21 of ICU admission, as well as having significantly lower changes of SOFA scores between days three and 21. Multivariate analysis demonstrated that the SOFA score on day 21 and the Charlson Comorbidity Index were the best predictor of survival for six months after hospital discharge. The SOFA score on day 21 and comorbidity in the ICU appears to be a valuable prognostic indicators in chronically critically ill patients.

Ultrasonographic diagnostic criterion for severe diaphragmatic dysfunction after cardiac surgery

BACKGROUND

Severe diaphragmatic dysfunction can prolong mechanical ventilation after cardiac surgery. An ultrasonographic criterion for diagnosing severe diaphragmatic dysfunction defined by a reference technique such as transdiaphragmatic pressure measurements has never been determined.

METHODS

Twenty-eight patients requiring mechanical ventilation > 7 days postoperatively were studied. Esophageal and gastric pressures were measured to calculate transdiaphragmatic pressure during maximal inspiratory effort and the Gilbert index, which evaluates the diaphragm contribution to respiratory pressure swings during quiet ventilation. Ultrasonography allowed measuring right and left hemidiaphragmatic excursions during maximal inspiratory effort. Best E is the greatest positive value from either hemidiaphragm. Twenty cardiac surgery patients with uncomplicated postoperative course were also evaluated with ultrasonography preoperatively and postoperatively. Measurements were performed in semirecumbent position.

RESULTS

Transdiaphragmatic pressure during maximal inspiratory effort was below normal value in 27 of the 28 patients receiving prolonged mechanical ventilation (median, 39 cm H(2)O; interquartile range [IQR] 28 cm H(2)O). Eight patients had Gilbert indexes <or= 0 indicating severe diaphragmatic dysfunction. Best E was lower in patients with Gilbert index <or= 0 than > 0 (30 mm; IQR, 10 mm; vs 19 mm; IQR, 7 mm, respectively; p = 0.001). Best E < 25 mm had a positive likelihood ratio of 6.7 (95% confidence interval [CI], 2.4 to 19) and a negative likelihood ratio of 0 (95% CI, 0 to 1.1) for having a Gilbert index <or= 0. None of the patients with uncomplicated course had Best E < 25 mm either preoperatively or postoperatively.

CONCLUSIONS

Ultrasonographic-based determination of hemidiaphragm excursions in patients requiring prolonged mechanical ventilation after cardiac surgery may help identify those with and without severe diaphragmatic dysfunction as defined by the Gilbert index.

Determinants of long-term mortality after prolonged mechanical ventilation

STUDY OBJECTIVES

The poor long-term survival of patients requiring prolonged mechanical ventilation may be due to potentially modifiable factors. We therefore sought to assess the early determinants of long-term survival after discharge from a specialized respiratory unit.

METHODS

Eighty of 113 patients (71%) admitted to a respiratory care unit from June 2001 to August 2003 survived to discharge. Mortality outcomes and dates of death were determined by review of the records and survey in April 2005 of a national Death Master File. Potential determinants of survival after discharge were collected during the admission to the unit.

RESULTS

Fifty-five percent of patients died within the first year after discharge. Age of 65 years or older, sacral ulcers, a serum creatinine >124 micromol/L, and failure to wean were each individually associated with shorter survival. Age, skin integrity, and wean status on discharge remained independent determinants of survival in a multivariable analysis. In a post-hoc analysis, chronic irreversible neurologic diseases were also independently associated with poor long-term survival.

CONCLUSIONS

Mortality after discharge from a respiratory care unit is high. Interventions that may favorably impact long-term survival in these patients could target the modifiable factors identified, including measures that facilitate weaning and prevent or treat renal dysfunction and skin breakdown.

Age differences in survival outcomes and resource use for chronically critically ill patients

PURPOSE

Chronically critically ill (CCI) patients use a disproportionate amount of resources, yet little research has examined outcomes for older CCI patients. The purpose of this study was to compare outcomes (mortality, disposition, posthospital resource use) between older (> or =65 years) and middle-aged (45-64 years) patients who require more than 96 hours of mechanical ventilation while in the intensive care unit.

METHODS

Data from 2 prospective studies were combined for the present examination. In-hospital as well as posthospital discharge data were obtained via chart abstraction and interviews.

RESULTS

One thousand one hundred twenty-one subjects were enrolled; 62.4% (n = 700) were older. Older subjects had a 1.3 greater risk for overall mortality (from admission to 4 months posthospital discharge) than middle-aged subjects. The Acute Physiology Score (odds ratio [OR], 1.009), presence of diabetes (OR, 2.37), mechanical ventilation at discharge (OR, 3.17), and being older (OR, 2.20) were statistically significant predictors of death at 4 months postdischarge. Older subjects had significantly higher charges for home care services, although they spent less time at home (mean, 22.1 days) than middle-aged subjects (mean, 31.3 days) (P = .03).

CONCLUSION

Older subjects were at higher risk of overall mortality and used, on average, more postdischarge services per patient when compared with middle-aged subjects.

Cognitive, functional, and quality-of-life outcomes of patients aged 80 and older who survived at least 1 year after planned or unplanned surgery or medical intensive care treatment

OBJECTIVES

To investigate long-term cognitive, functional, and quality-of-life outcomes in very elderly survivors at least 1 year after planned or unplanned surgery or medical intensive care treatment.

DESIGN

Retrospective cohort study.

SETTING

General, 1,024-bed, tertiary university teaching hospital in The Netherlands.

PARTICIPANTS

Two hundred four survivors of a cohort of 578 patients admitted to the medical-surgical intensive care unit (ICU) between January 1997 and December 2002 and alive in December 2003. The majority of survivors underwent elective surgery.

MEASUREMENTS

From December 2003 until February 2004, data were collected from 190 patients and 169 relatives. The measures were: Informant Questionnaire on Cognitive Decline short form (IQCODE-SF) (cognition), modified Katz index of activities of daily living (ADLs) (functional status), and EuroQol (EQ-5D) (health-related quality of life). The patients themselves completed the modified Katz ADL index and EQ-5D forms; their caregivers completed the ADL caregiver version and IQCODE-SF.

RESULTS

The mean age at admission+/-standard deviation was 81.7+/-2.4, and the median time after discharge was 3.7 years (range 1-5.9 years). Of the ICU patients who had planned surgery, 57% survived, compared with 11% of the unplanned surgical admissions and 10% of the medical patients. Three-quarters (74.3%) of the patients who lived at home before ICU admission remained at home at follow-up. Eighty-three percent had no severe cognitive impairment, and 76% had no severe physical limitations (33% had moderate, 40% had mild, and 3% had no limitations). The perceived quality of life was similar to that of an age-matched general population.

CONCLUSION

Long-term survivors of ICU treatment received at the age of 80 and older showed fair-to-good cognitive and physical functioning and quality of life, although few patients who underwent unplanned surgery or who were admitted to the ICU for medical reasons survived.

Chronically Critically Ill Patients: Health-Related Quality of Life and Resource Use After a Disease Management Intervention

Background Chronically critically ill patients often have high costs of care and poor outcomes and thus might benefit from a disease management program.

Objectives To evaluate how adding a disease management program to the usual care system affects outcomes after discharge from the hospital (mortality, health-related quality of life, resource use) in chronically critically ill patients.

Methods In a prospective experimental design, 335 intensive care patients who received more than 3 days of mechanical ventilation at a university medical center were recruited. For 8 weeks after discharge, advanced practice nurses provided an intervention that focused on case management and interdisciplinary communication to patients in the experimental group.

Results A total of 74.0% of the patients survived and completed the study. Significant predictors of death were age (P = .001), duration of mechanical ventilation (P = .001), and history of diabetes (P = .04). The disease management program did not have a significant impact on health-related quality of life; however, a greater percentage of patients in the experimental group than in the control group had “improved” physical health-related quality of life at the end of the intervention period (P = .02). The only significant effect of the intervention was a reduction in the number of days of hospital readmission and thus a reduction in charges associated with readmission.

Conclusion The intervention was not associated with significant changes in any outcomes other than duration of readmission, but the supportive care coordination program could be provided without increasing overall charges.

Long-term outcomes in patients requiring stay of more than 48 hours in the intensive care unit following coronary bypass surgery

BACKGROUND

The primary objective of this study was to determine the long-term outcomes of all patients requiring prolonged intensive care unit (ICU) stay following coronary bypass surgery (CABG) surgery.

METHODS

All patients undergoing CABG surgery between 1998 and 2002 were reviewed. Prolonged ICU stay was defined as more than 48 hours. Short-term (in-hospital) and long-term (postdischarge) outcomes were evaluated using available databases.

RESULTS

Of 3139 patients who underwent CABG surgery, 598 required an ICU stay of more than 48 hours (19%). The in-hospital mortality for patients requiring prolonged ICU stay was 10.0% as compared with 1.2% for the remainder of patients (P < .0001). The median length of hospitalization for patients requiring prolonged stay was 11 days (IQR 7-18) as compared to 6 days (IQR 5-7). The median follow-up of patients who survived to discharge was 31 months with a 100% follow-up. Using Cox proportional hazard ratio, patients who required a prolonged ICU stay were found to have a significant lower survival and freedom from cardiac readmission to the hospital. Prolonged ICU stay was an independent predictor of composite outcome (death + readmission) with a hazard ratio of 1.8 (1.5-2.1).

CONCLUSIONS

Prolonged ICU stay following CABG resulted in increased early and late mortality and lower freedom from readmission to hospital for cardiac reasons.

Long-Term Outcome of Survivors of Prolonged Intensive Care Treatment After Cardiac Surgery

BACKGROUND

The relative impact of perioperative risk profile and postoperative complications on long-term outcome in cardiac surgical patients is currently unclear. The aim of this work was to assess the relative predictive value of the European System for Cardiac Operative Risk Evaluation (EuroSCORE) and Sequential Organ Failure Assessment (SOFA) on long-term event-free survival in this patient population.

METHODS

Preoperative and postoperative variables, EuroSCORE and SOFA, 30-day mortality, and long-term mortality or hospital admission for cardiovascular events were assessed in 115 consecutive cardiac surgical patients in whom multiorgan dysfunction syndrome developed postoperatively.

RESULTS

Mean age was 70 +/- 8 years, 41% were women, EuroSCORE averaged 7.87 +/- 3.99, and postoperative stay in the intensive care unit was 10.3 +/- 8.2 days. In-hospital 30-day mortality was 10.4% (n = 12). During 1998 person-months follow-up, 12 (11.6%) of 103 patients discharged alive died, and 46 (44.7%) met the combined end point of all-cause death or cardiovascular admission. By Cox multivariate analysis, maximum SOFA (hazard ratio [HR], 2.17; 95% confidence interval [CI], 1.34 to 3.51) and maximum cardiovascular score (HR, 2.35; 95% CI, 1.22 to 4.51) independently predicted all-cause mortality. EuroSCORE (HR, 1.33; 95% CI, 1.01 to 1.76), maximum cardiovascular score (HR 2.09; 95% CI 1.41 to 3.10), and maximum liver score (HR 2.67; 95% CI, 1.46 to 4.86) were independently associated with the combined end point.

CONCLUSIONS

High-risk cardiac surgical patients with postoperative multiorgan dysfunction syndrome show excess mortality and cardiovascular morbidity after hospital discharge. Combined preoperative and postoperative risk stratification identifies patients with the highest likelihood of death or early readmission.

Long-term outcomes and clinical predictors of hospital mortality in very long stay intensive care unit patients: a cohort study

Introduction

Little information is available on prognosis and outcomes of very long stay intensive care unit (ICU) patients. The purpose of this study was to identify long-term outcomes after hospital discharge and readily available clinical predictors of hospital mortality for patients requiring prolonged care in the ICU.

Method

Clinical data were collected from consecutive patients requiring at least 30 days of ICU care admitted over 3 calendar years (2001 to 2003) to a medical/surgical ICU in a university-affiliated tertiary care centre.

Results

A total of 182 patients met the inclusion criteria, with a mean age of 63 years, median ICU stay of 48.5 days (interquartile range 36–78 days) and ICU mortality of 32%. They accounted for 8% of total admissions and 48% of total occupied beds. Of these patients, 42% died in hospital, 44% returned to their previous place of residence, and 14% were transferred to long-term care institutions. By 6 months after hospital discharge a further 8% of the patients had died, 40% remained at their previous place of residence, and 10% were in long-term care. Predictors of hospital mortality, identified using multivariate logistic regression, included age (odds ratio [OR] 1.45 per additional decade, 95% confidence interval [CI] 1.10–1.91), any immunosuppression (OR 5.2, 95% CI 1.7–15.5), mechanical ventilation for longer than 90 days (OR 4.0, 95% CI 1.3–12.0), treatment with inotropes or vasopressors for more than 3 days at or after day 30 in the ICU (OR 7.1, 95% CI 2.6–19.3), and acute renal failure requiring dialysis at or after day 30 in the ICU (OR 6.3, 95% CI 2.0–19.7).

Conclusion

Patients with very long stays in the ICU appear to have a reasonable chance of survival, with most survivors in our cohort residing at their previous place of residence 6 months after hospital discharge. Prolonged requirement for life support therapies (ventilation, vasoactive agents, or acute dialysis) and a limited number of pre-existing co-morbidities (immunosuppression and, to a lesser extent, patient age) were predictors of increased hospital mortality. These predictors may assist in clinical decision making for this resource intensive patient population, and their reproducibility in other very long stay patient populations should be explored.

Quality of life after heart valve surgery with prolonged intensive care

BACKGROUND

A small proportion of patients undergoing heart valve operations require prolonged intensive care after surgery. Little is known about the quality of life that such patients attain after hospital discharge.

METHODS

All consecutive patients who underwent primary heart valve surgery from 1998 to 2003 and required 8 days or more of treatment in an intensive care unit (ICU) were included (n = 225). At follow-up on August 31, 2004, 154 of these patients were alive. A cohort (n = 154) matched for sex, age, type of procedure, and week of operation, with an uncomplicated postoperative course (ICU stay of 2 days or less), served as the control group. All patients received the Medical Outcomes Study Short-Form 36, the Nottingham Health Profile, and the Hospital Depression and Anxiety scale to evaluate their quality of life.

RESULTS

Survival at 5 years in the total ICU group was 68% (154 of 225). According to SF-36, the ICU study cohort reported poorer physical health but equal mental health compared with controls. On the Nottingham Health Profile, the ICU group reported more problems in all domains except emotional reactions and sleep. There was no difference in anxiety or depression between the groups. The ICU patients were in more advanced New York Heart Association functional classes preoperatively and postoperatively. No patient in the ICU study cohort regretted undergoing the operation, and 80% experienced improvement after surgery.

CONCLUSIONS

This study showed reduced quality of life in terms of physical health and equal mental health in patients who required prolonged intensive care after heart valve surgery compared with controls without complications.

Three-year survival after four major post–cardiac operative complications*

OBJECTIVE

After cardiac surgery, major morbidities known to be primary contributors to perioperative mortality are cardiac failure, respiratory failure, renal failure, and the need for mediastinal exploration. The first aim of this study was to ascertain long-term survival in cardiac surgery patients with and without the occurrence of major morbidities to investigate if long-term survival was comparable. The second aim of this study was to evaluate the prevalences and risk factors related to the four major morbidities in this patient population.

DESIGN

Retrospective observational outcome study.

SETTING

Cardiothoracic intensive care unit at a university hospital.

PATIENTS

We included 2,683 of 3,253 consecutive cardiac surgery patients cared for in a uniform fashion.

METHODS AND MAIN RESULTS

Perioperative mortality was significantly increased by the occurrence of major morbidity. In-hospital mortality was 0.7% in the absence of major morbidity compared with 72% when all major morbidities occurred. Three-year mortality for the entire study population was 15%, whereas the 3-yr long-term survival was significantly less for patients with morbidities compared with those without. Various independent perioperative risk factors were found for perioperative major morbidity and mortality.

CONCLUSIONS

Successful acute treatment and measures to identify and reduce the risk of major morbidities are necessary to improve outcome. In addition, long-term follow-up and management of morbidities are necessary to possibly improve long-term survival.

Prolonged Intensive Care Unit Stay in Cardiac Surgery: Risk Factors and Long-Term-Survival

BACKGROUND

Risk factors have been found for prolonged intensive care unit (ICU) stay in cardiac surgery patients in only a few studies; conflicting results have been described. The focus of this study was twofold: first, to evaluate preoperative, intraoperative, and postoperative risk factors for ICU stay greater than 3 days in a cardiac surgery patient population; second, to evaluate long-term survival in cardiac surgery patients with prolonged ICU stay.

METHODS

Records from 2,683 cardiac surgery patients were retrospectively evaluated. Univariate and multivariate analyses for risk factors were performed for an ICU stay greater than 3 days. Thereafter, 2,563 patients were enrolled in a follow-up study for an observational time of 3 years after surgery.

RESULTS

Mortality was dependent on renal, respiratory, and heart failure, as well as age, elevated APACHE II scores, and reexploration. Long-term survival analyses demonstrated a significantly lower survival in patients with longer ICU stay. However, the 6-month to 3-year long-term survival was comparable with survival in patients without prolonged ICU stay.

CONCLUSIONS

Because of the increasing acuity of patients needing cardiac surgery, it is important to identify those at risk for a prolonged ICU course. It is therefore of paramount interest to implement measures throughout their entire hospital stay that would maximize organ function to improve survival and resource utilization.