Outcome of older critically ill patients: a matched cohort study

Long-term survival of mechanically ventilated patients with severe COVID-19: an observational cohort study

Background

Information is lacking regarding long-term survival and predictive factors for mortality in patients with acute hypoxemic respiratory failure due to coronavirus disease 2019 (COVID-19) and undergoing invasive mechanical ventilation. We aimed to estimate 180-day mortality of patients with COVID-19 requiring invasive ventilation, and to develop a predictive model for long-term mortality.

Methods

Retrospective, multicentre, national cohort study between March 8 and April 30, 2020 in 16 intensive care units (ICU) in Spain. Participants were consecutive adults who received invasive mechanical ventilation for COVID-19. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection detected in positive testing of a nasopharyngeal sample and confirmed by real time reverse-transcriptase polymerase chain reaction (rt-PCR). The primary outcomes was 180-day survival after hospital admission. Secondary outcomes were length of ICU and hospital stay, and ICU and in-hospital mortality. A predictive model was developed to estimate the probability of 180-day mortality.

Results

868 patients were included (median age, 64 years [interquartile range [IQR], 56–71 years]; 72% male). Severity at ICU admission, estimated by SAPS3, was 56 points [IQR 50–63]. Prior to intubation, 26% received some type of noninvasive respiratory support. The unadjusted overall 180-day survival rates was 59% (95% CI 56–62%). The predictive factors measured during ICU stay, and associated with 180-day mortality were: age [Odds Ratio [OR] per 1-year increase 1.051, 95% CI 1.033–1.068)), SAPS3 (OR per 1-point increase 1.027, 95% CI 1.011–1.044), diabetes (OR 1.546, 95% CI 1.085–2.204), neutrophils to lymphocytes ratio (OR per 1-unit increase 1.008, 95% CI 1.001–1.016), failed attempt of noninvasive positive pressure ventilation prior to orotracheal intubation (OR 1.878 (95% CI 1.124–3.140), use of selective digestive decontamination strategy during ICU stay (OR 0.590 (95% CI 0.358–0.972) and administration of low dosage of corticosteroids (methylprednisolone 1 mg/kg) (OR 2.042 (95% CI 1.205–3.460).

Conclusion

The long-term survival of mechanically ventilated patients with severe COVID-19 reaches more than 50% and may help to provide individualized risk stratification and potential treatments.

Trial registration: ClinicalTrials.gov Identifier: NCT04379258. Registered 10 April 2020 (retrospectively registered)

Supplementary Information

The online version contains supplementary material available at 10.1186/s13613-021-00929-y.

Factors and Outcomes of Intensive Care Unit Readmission in Elderly Patients

INTRODUCTION

An increase in age has been observed among patients admitted to the intensive care unit (ICU). Age is a well-known risk factor for ICU readmission and mortality. However, clinical characteristics and risk factors of ICU readmission of elderly patients (≥65 years) have not been studied.

METHODS

This retrospective single-center cohort study was conducted in a total of 122-bed ICU of a tertiary care hospital in Seoul, Korea. A total of 85,413 patients were enrolled in this hospital between January 1, 2007, and December 31, 2017. The odds ratio of readmission and in-hospital mortality was calculated by logistic regression analysis.

RESULTS

Totally, 29,503 patients were included in the study group, of which 2,711 (9.2%) had ICU readmissions. Of the 2,711 readmitted patients, 472 patients were readmitted more than once (readmitted 2 or more times to the ICU, 17.4%). In the readmitted patient group, there were more males, higher sequential organ failure assessment (SOFA) scores, and hospitalized for medical reasons. Length of stay (LOS) in ICU and in-hospital were longer, and 28-day and in-hospital mortality was higher in readmitted patients than in nonreadmitted patients. Risk factors of ICU readmission included the ICU admission due to medical reason, SOFA score, presence of chronic heart disease, diabetes mellitus, chronic kidney disease, transplantation, use of mechanical ventilation, and initial ICU LOS. ICU readmission and age (over 85 years) were independent predictors of in-hospital mortality on multivariable analysis. The delayed ICU readmission group (>72 h) had higher in-hospital mortality than the early readmission group (≤72 h) (20.6 vs. 16.2%, p = 0.005).

CONCLUSIONS

ICU readmissions occurred in 9.2% of elderly patients and were associated with poor prognosis and higher mortality.

Outcome of elderly patients with circulatory failure

PURPOSE

The proportion of elderly patients admitted to the ICU is increasing. Mortality rates are known to increase with age but the impact of age on outcomes after circulatory shock has not been well defined.

METHODS

We performed a secondary analysis of data from a large randomized trial comparing the effects of dopamine and norepinephrine on outcome in the ICU. Patients were separated into not old (<75 years), old (75-84 years), and very old (≥85 years).

RESULTS

Of the 1,679 patients included in the initial trial, 1,651 had sufficient age data available: 1,157 (70%) were not old, 410 (25%) were old, and 84 (5%) were very old. There were minor differences among the age groups in the APACHE II score calculated without the age component (not old, 17 ± 9; old, 18 ± 9; very old, 19 ± 9; p = 0.047), but SOFA scores were similar (not old, 9 ± 4; old, 9 ± 3; very old, 9 ± 3; p = 0.76). Mortality rates were higher in old and very old patients at 28 days, at hospital discharge, and after 6 and 12 months. Most very old patients were dead at 6 (92%) and 12 months (97%). Mortality rates increased with age in all types of shock. Using multivariable analysis, the risk of death was higher in very old patients as compared to not old (adjusted OR 0.33, 95% CI 0.2-0.56, p < 0.001).

CONCLUSIONS

Ageing is independently associated with higher mortality rates in patients with circulatory failure, whatever the etiology. By 1 year after admission, most patients 85 years of age and older were dead.

Clinical evolution of adult, elderly and very elderly patients admitted in Intensive Care Units

This study compared clinical outcomes among adult, elderly and very elderly patients admitted to Intensive Care Units (ICUs) located in São Paulo, Brazil. This retrospective, longitudinal and comparative study included 279 adult (≥ 18 and <60 years), 216 elderly (≥ 60 and <80 years) and 105 very elderly (≥ 80 years) patients. Adult patients differed from other groups regarding the unit to which they were referred and severity, according to the Simplified Acute Physiology Score II. Adults were most frequently sent to hospitalization wards; elderly and very elderly patients who survived hospitalization in critical units showed sharper improvement before discharge. There were differences in relation to mortality between adult and elderly patients, with a higher rate in the elderly group; however, the mortality rate of very elderly and adult patients was similar. In general, the results indicated that older age was not associated with undesirable outcomes in ICUs.

Prognostic models for predicting mortality in elderly ICU patients: a systematic review

PURPOSE

To systematically review prognostic research literature on development and/or validation of mortality predictive models in elderly patients.

METHODS

We searched the Scopus database until June 2010 for articles aimed at validating prognostic models for survival or mortality in elderly intensive care unit (ICU) patients. We assessed the models' fitness for their intended purpose on the basis of barriers for use reported in the literature, using the following categories: (1) clinical credibility, (2) methodological quality (based on an existing quality assessment framework), (3) external validity, (4) model performance, and (5) clinical effectiveness.

RESULTS

Seven studies were identified which met our inclusion criteria, one of which was an external validation study. In total, 17 models were found of which six were developed for the general adult ICU population and eleven specifically for elderly patients. Cohorts ranged from 148 to 12,993 patients and only smaller ones were obtained prospectively. The area under the receiver operating characteristic curve (AUC) was most commonly used to measure performance (range 0.71-0.88). The median number of criteria met for clinical credibility was 4.5 out of 7 (range 2.5-5.5) and 17 out of 20 for methodological quality (range 15-20).

CONCLUSIONS

Although the models scored relatively well on methodological quality, none of them can be currently considered sufficiently credible or valid to be applicable in clinical practice for elderly patients. Future research should focus on external validation, addressing performance measures relevant for their intended use, and on clinical credibility including the incorporation of factors specific for the elderly population.

[Age as predictive factor of mortality in an intensive and intermediate care unit]

INTRODUCTION

Age by itself is not a criterion of biological prognosis. Scores for physiological variables on admission and multiorgan failure are better predictors of mortality.

PATIENTS AND METHODS

We performed a retrospective/ prospective observational study from September, 2005 to May, 2007. The following variables were analyzed: age, sex, Acute Physiology and Chronic Health Classification System (APACHE) II, modified APACHE II score (without the variable of age), Sequential Organ Failure Assessment (SOFA) score, length of hospital stay, type of disease and mortality, limitation of therapeutic effort (LTE), Katz index on admission, intensive and intermediate care unit (IICU) mortality and in-hospital mortality. Student's t-test was used to analyze continuous variables.

RESULTS

Of the 572 patients admitted to the IICU, we excluded 75 due to transfer to other hospitals, 142 due to direct admission to intermediate care, and 89 due to acute coronary syndrome. Of the 266 remaining patients with medical disease, mortality was higher when the APACHE II score was > 20 (OR = 9.4) and/or the SOFA score was >4 (OR = 15.41) but not when age was 3 76 years (OR = 2.04). Multivariate analysis of these parameters revealed higher mortality in the IICU (P=.01) in patients with a SOFA score > 4 and modified APACHE II score >16, independently of age or the Katz index. In addition to the SOFA and the APACHE II scores, in-hospital mortality was significantly influenced by the Katz index (P=.05). LTE was significantly greater in patients with a Katz index E-G.

CONCLUSIONS

Higher SOFA and APACHE II scores predicted higher IICU mortality, regardless of age. LTE was more frequent in patients with a greater degree of dependence.