Elderly Patients and Management in Intensive Care Units (ICU): Clinical Challenges

Comparison of two metabolomics-platforms to discover biomarkers in critically ill patients from serum analysis

Serum metabolome analysis is essential for identifying disease biomarkers and predicting patient outcomes in precision medicine. Thus, this study aims to compare Ultra-High Performance Liquid Chromatography-High-Resolution Mass Spectrometry (UHPLC-HRMS) with Fourier Transform Infrared (FTIR) spectroscopy in acquiring the serum metabolome of critically ill patients, associated with invasive mechanical ventilation (IMV), and predicting death. Three groups of 8 patients were considered. Group A did not require IMV and survived hospitalization, while Groups B and C required IMV. Group C patients died a median of 5 days after sample harvest. Good prediction models were achieved when comparing groups A to B and B to C using both platforms' data, with UHPLC-HRMS showing 8-17 % higher accuracies (≥83 %). However, developing predictive models using metabolite sets was not feasible when comparing unbalanced populations, i.e., Groups A and B combined to Group C. Alternatively, FTIR-spectroscopy enabled the development of a model with 83 % accuracy. Overall, UHPLC-HRMS data yields more robust prediction models when comparing homogenous populations, potentially enhancing understanding of metabolic mechanisms and improving patient therapy adjustments. FTIR-spectroscopy is more suitable for unbalanced populations. Its simplicity, speed, cost-effectiveness, and high-throughput operation make it ideal for large-scale studies and clinical translation in complex populations.

Enhancing Nursing Practices in Critical Care for Older Adults: A Systematic Review of Age-Friendly Nursing Interventions

OBJECTIVES

To synthesize evidence on the implementation and effectiveness of age-friendly interventions in intensive care units (ICUs) to optimize care for older adults.

DESIGN

Systematic review of studies published up to February 2024, focusing on interventions tailored to meet the needs of older adults in ICU settings.

SETTING AND PARTICIPANTS

Comparative studies conducted in ICUs worldwide, involving older adults receiving critical care, were reviewed.

METHODS

A systematic search of databases including Embase, MEDLINE, and Cochrane was performed. The quality of studies was assessed using the ROSVIS-II tool, and findings were synthesized narratively and thematically.

RESULTS

Out of 1200 articles initially identified, 45 studies met inclusion criteria. Age-friendly interventions (eg, geriatric assessment teams, multimodal care bundles) demonstrated significant benefits, including a 19% reduction in major in-hospital complications and shorter hospital stays by an average of 3 days.

CONCLUSIONS AND IMPLICATIONS

The review supports the effectiveness of age-friendly interventions in improving clinical outcomes for older ICU patients. However, consistent reporting of effect sizes was lacking, and more high-quality comparative effectiveness research is needed. Implications for practice include integrating these interventions into standard ICU protocols to enhance older adult care. Policy implications involve advocating for health care policies that support the dissemination and implementation of effective age-friendly practices. Further research should focus on establishing a robust evidence base to guide implementation and policy decisions.

Challenges in Obstructive Sleep Apnea Management in Elderly Patients

With the aging of the population, obstructive sleep apnea (OSA) in elderly patients is now more commonly seen in clinical practice. In older people, sleepiness is less marked than in younger patients, but insomnia symptoms are more common. Comorbidities are numerous and related to cardiometabolic and cognitive conditions. Polygraphy can be used to establish the diagnosis in the vast majority of cases, but polysomnography is indicated in cases of comorbid sleep disorders. Continuous positive airway pressure (CPAP) remains the cornerstone of treatment, but compliance decreases with age, especially in those over 80, and when cognitive disorders are also present. In these patients, CPAP can be beneficial in terms of nighttime symptoms, sleepiness, mood, and cognition but can also prevent cardiovascular and cerebrovascular disorders, especially in severeOSA patients. For this reason, we should offer this treatment to elderly patients and devise strategies to support them with treatment difficulties (e.g., therapeutic education, adapted masks, and telemonitoring). In the future, we need prospective studies to help identify elderly patients who will gain the greatest long-term benefit from treatment. Dedicated sleep testing, OSA severity markers, and specific questionnaires need to be developed in this older, but large, OSA population.

Frailty and fear of death among geriatric patients in critical care units: A mixed methods study

BACKGROUND

Frailty, a geriatric syndrome characterized by decreased resilience, is a known risk factor for mortality in critical care settings and can significantly impact a patient's perception of their own health and prognosis.

AIM

To explore the relationship between frailty and fear of death in geriatric patients admitted to critical care units.

STUDY DESIGN

A convergent parallel mixed methods design was applied.

METHODS

Data were collected from 247 geriatric patients in critical care units from March 2023 to February 2024. Quantitative data included clinical frailty score and death anxiety questionnaire. Qualitative data were gathered through semi-structured interviews with a subset of 34 participants. Quantitative analysis involved descriptive statistics, correlation analysis and multiple linear regression. Qualitative data were analysed thematically using Braun and Clarke's approach.

RESULTS

Quantitative analysis revealed a positive significant correlation between frailty and death anxiety (r = 0.19, p = 0.003). Additionally, regression analysis identified age (B = 0.69, 95% CI [0.22, 1.15], p = 0.004), lack of social support (B = 2.88, 95% CI [0.28, 5.47], p = 0.030), lower income (B = -5.33, 95% CI [-9.03, -1.63], p = 0.005) and higher frailty scores (B = 0.83, 95% CI [0.10, 1.56], p = 0.025) as significant predictors of increased death anxiety. Qualitative findings yielded four key themes: the impact of frailty on perception of mortality, the psychological and emotional dimensions of fear of death, the role of the critical care unit environment on fear of death and coping mechanisms and support.

CONCLUSION

Frailty in geriatric critically ill patients heightened death anxiety due to physical decline, existential worries and the overwhelming critical care environment.

RELEVANCE TO CLINICAL PRACTICE

This study can help nurses provide more personalized care to geriatric patients by addressing both their physical frailty and psychological needs related to fear of death. This, in turn, can improve the quality of care and enhance patient satisfaction.

Association between the levels of urinary cell cycle biomarkers and non-recovery of renal function among critically ill geriatric patients with acute kidney injury

The lack of early renal function recovery among geriatric patients with acute kidney injury (AKI) in the intensive care unit (ICU) is a commonly observed and acknowledged poor prognostic factor, especially for older adults. However, no reliable prognostic biomarker is available for identifying individuals at risk of renal non-recovery or mortality in older adults. In this prospective observational cohort study, we enrolled critically ill older adults (aged ≥ 60 years) with AKI from the ICU and followed their disease progression. The primary endpoint was renal non-recovery within seven days of follow-up, while the secondary endpoint was the determinants of 30-day mortality after AKI. We assessed the predictive accuracy using receiver operating characteristic curves and performed between-group comparisons using the log-rank test. Among 209 older adults, 117 (56.0%) experienced renal recovery. Multiple regression analysis revealed that urine levels of tissue inhibitor of metalloproteinase-2 (TIMP-2) multiplied by insulin-like growth factor-binding protein 7 (IGFBP7) ([TIMP-2]*[IGFBP7]), AKI stages 2-3, and the Acute Physiology and Chronic Health Evaluation (APACHE II) score were independently associated with renal non-recovery. The regression model incorporating [TIMP-2]*[IGFBP7] demonstrated a fair predictive value (AUC 0.774, p < 0.001), with the optimal threshold set at 0.81 (ng/mL)2/1000. When [TIMP-2]*[IGFBP7] was combined with AKI severity and the APACHE score, the AUC increased to 0.851. In conclusion, urine [TIMP-2]*[IGFBP7] is a reliable biomarker associated with renal non-recovery in critically ill older adults, and its predictive efficacy can be further enhanced when combined with AKI severity and the APACHE score.

Experiences of Intensive Care Unit Patients as They Transition to the Ward: A Thematic Synthesis

BACKGROUND

During the transfer of intensive care unit (ICU) patients to general wards, patients often experience transfer anxiety due to changes in the healthcare environment, staff and unfamiliarity with the new ward. However, the experiences of ICU patients during this transition period have received less attention.

AIMS

A systematic review and synthesis of the experiences of patients transitioning from the ICU to the ward.

DESIGN

Thematic synthesis of qualitative studies.

DATA SOURCES

We searched the PubMed, Embase, CINAHL and Web of Science databases for qualitative research on the transition-to-ward experience of patients in ICUs for the year 2023 February.

REVIEW METHODS

The quality of the literature was evaluated according to the qualitative research quality assessment criteria of the Joanna Briggs Institute, as outlined by the Australian Centre for Evidence-Based Healthcare. The data were then extracted from the studies, analysed and synthesised using a thematic synthesis approach.

RESULTS

A total of 12 papers were included and the 32 findings were distilled and consolidated into three themes: emotional reactions; imperfections in the transition process; differences between wards and ICUs; and eight sub-themes: optimism; pessimism; emotionlessness; inadequate information; inadequate communication; physical condition; differences in care; differences in environment.

CONCLUSIONS

The transfer from an ICU to a general ward is a major change of environment for the patient and can trigger upset and anxiety. Planning for turn-out, meeting patients' information needs and easing patients' emotions are critical in this process.

Prediction of adverse drug reactions in geriatric patients admitted to intensive care units

INTRODUCTION

Intensive care units (ICUs) pose challenges in managing critically ill patients with polypharmacy, potentially leading to adverse drug reactions (ADRs), particularly in the elderly.

OBJECTIVE

To evaluate whether the severity and clinical prognosis scores used in ICUs correlate with the prediction of ADRs in aged patients admitted to an ICU.

METHODS

A cohort study was conducted in a Brazilian University Hospital ICU. APACHE II and SAPS 3 assessed clinical prognosis, while GerontoNet ADR Risk Score and BADRI evaluated ADR risk at ICU admission. Severity of the patients' clinical conditions was evaluated daily based on the SOFA score. ADR screening was performed daily through the identification of ADR triggers.

RESULTS

1295 triggers were identified (median 30 per patient, IQR=28), with 15 suspected ADRs. No correlation was observed between patient severity and ADRs at admission (p=0.26), during hospitalization (p=0.91), or at follow-up (p=0.77). There was also no association between death and ADRs (p=0.28) or worse prognosis and ADRs (p>0.05). Higher BADRI scores correlated with more ADRs (p=0.001).

CONCLUSIONS

These data suggest that employing the severity and clinical prognosis scores used in ICUs is not sufficient to direct active pharmacovigilance efforts, which are therefore indicated for critically ill patients.

Integrating frailty management into cardiac intensive care unit nursing practice: A qualitative study

BACKGROUND

Frailty is prevalent among older patients in intensive care units (ICUs) and poses significant challenges to recovery. Despite its importance, there is limited research on effective nurse-led frailty management strategies in this context.

OBJECTIVE

The purpose of this qualitative study was to explore nurses' perceptions of frailty management in cardiac ICUs through the lens of the Wuli-Shili-Renli (WSR) system approach.

METHODS

Sixteen nurses from two tertiary hospitals in Shandong province, China, participated in semi-structured interviews. Participants were selected based on their involvement in frailty training, educational background, and cardiac ICU work experience. Thematic analysis was conducted to identify key themes and sub-themes.

RESULTS

Analysis in three categories revealed the need for foundational support, including the need for appropriate screening tools, updated evidence-based practices, and institutional support. Closed-loop management involved frailty screening, personalized program implementation, information management, and follow-up assessment. Personnel training and coordination emphasized enhancing nurses' professionalism, multidisciplinary teamwork, and cooperation from patients and their caregivers.

CONCLUSION

The insights gained can inform evidence-based practices and improve the quality of care provided to frail patients in cardiac ICUs. There is a need for future research to empirically investigate these strategies.

Prediction of adverse drug reactions in geriatric patients admitted to intensive care units

INTRODUCTION

Intensive Care Units (ICUs) pose challenges in managing critically-ill patients with polypharmacy, potentially leading to Adverse Drug Reactions (ADRs), particularly in the elderly.

OBJECTIVE

To evaluate whether the severity and clinical prognosis scores used in ICUs correlate with the prediction of ADRs in aged patients admitted to an ICU.

METHODS

A cohort study was conducted in a Brazilian University Hospital ICU. APACHE II and SAPS 3 assessed clinical prognosis, while GerontoNet ADR Risk Score and BADRI evaluated ADR risk at ICU admission. Severity of the patients' clinical conditions was evaluated daily based on the SOFA score. Adverse Drug Reaction (ADR) screening was performed daily through the identification of ADR triggers.

RESULTS

1295 triggers were identified (median 30 per patient, IQR = 28), with 15 suspected ADRs. No correlation was observed between patient severity and ADRs at admission (p=0.26), during hospitalization (p=0.91), or at follow-up (p=0.77). There was also no association between death and ADRs (p=0.28) or worse prognosis and ADRs (p>0.05). Higher BADRI scores correlated with more ADRs (p=0.001).

CONCLUSIONS

The data suggest that employing the severity and clinical prognosis scores used in Intensive Care Units is not sufficient to direct active pharmacovigilance efforts, which are therefore indicated for critically ill patients.

Interpretable machine learning model for new-onset atrial fibrillation prediction in critically ill patients: a multi-center study

BACKGROUND

New-onset atrial fibrillation (NOAF) is the most common arrhythmia in critically ill patients admitted to intensive care and is associated with poor prognosis and disease burden. Identifying high-risk individuals early is crucial. This study aims to create and validate a NOAF prediction model for critically ill patients using machine learning (ML).

METHODS

The data came from two non-overlapping datasets from the Medical Information Mart for Intensive Care (MIMIC), with MIMIC-IV used for training and subset of MIMIC-III used as external validation. LASSO regression was used for feature selection. Eight ML algorithms were employed to construct the prediction model. Model performance was evaluated based on identification, calibration, and clinical application. The SHapley Additive exPlanations (SHAP) method was used for visualizing model characteristics and individual case predictions.

RESULTS

Among 16,528 MIMIC-IV patients, 1520 (9.2%) developed AF post-ICU admission. A model with 23 variables was built, with XGBoost performing best, achieving an AUC of 0.891 (0.873-0.888) in validation and 0.769 (0.756-0.782) in external validation. Key predictors included age, mechanical ventilation, urine output, sepsis, blood urea nitrogen, percutaneous arterial oxygen saturation, continuous renal replacement therapy and weight. A risk probability greater than 0.6 was defined as high risk. A friendly user interface had been developed for clinician use.

CONCLUSION

We developed a ML model to predict the risk of NOAF in critically ill patients without cardiac surgery and validated its potential as a clinically reliable tool. SHAP improves the interpretability of the model, enables clinicians to better understand the causes of NOAF, helps clinicians to prevent it in advance and improves patient outcomes.

Weaning Failure in Elderly Patients: A Systematic Review and Meta-Analysis

Background/Objectives: Weaning failure in elderly patients undergoing mechanical ventilation presents a complex clinical challenge due to age-related physiological changes and comorbidities. Understanding the dynamics of this phenomenon through systematic analysis can provide valuable insights for clinical management. This meta-analysis aims to investigate the factors contributing to weaning failure in elderly patients and to assess the efficacy of different strategies in mitigating this challenge. Design: The design of this study is a systematic review and meta-analysis. Methods: A systematic search of electronic databases was conducted to identify relevant studies focusing on weaning failure in elderly patients. Studies reporting outcomes related to mechanical ventilation weaning failure were included. Data extraction, quality assessment, and statistical analysis were performed following established guidelines. Results: A total of 15 studies met the inclusion criteria and were included in the meta-analysis. The average age of participants throughout the studies was 66.24 ± 10.21 years. This suggests that the study population largely consisted of older adults and displayed a moderate range of ages centered around the mean. The rate of weaning failure across these studies was slightly above 31.56%, indicating a significant occurrence of this complication in the patient cohorts. The analysis revealed age-related physiological changes, such as decreased respiratory muscle strength and increased chest wall stiffness, as significant contributors to weaning failure in elderly patients. Comorbidities, including chronic pulmonary diseases and cardiovascular conditions, further exacerbated the challenge. Various interventions, including tailored weaning protocols and respiratory therapies, showed promising results in improving weaning outcomes in this population. Conclusions: Weaning failure in elderly patients undergoing mechanical ventilation is influenced by a combination of age-related physiological changes and comorbidities. Tailored interventions addressing these factors are essential for optimizing weaning success rates in this vulnerable population. Further research is warranted to refine the strategies and enhance outcomes in elderly patients requiring mechanical ventilation.

Analysis of the status and influencing factors of dignity impairment symptoms in critically ill patients after ICU treatment

To investigate the status of dignity impairment symptoms in critically ill patients after ICU treatment and conduct a systematic analysis of its influencing factors, aiming to provide reference for clinical medical decision-making by healthcare professionals. A cross-sectional survey study. From April 15th to 21st, 2024, a cross-sectional survey was conducted in 40 tertiary Grade A comprehensive hospitals in 9 provinces, municipalities, and autonomous regions including Sichuan Province, Zhejiang Province, and Chongqing Municipality. Various critically ill patients who were admitted to ICU treatment were surveyed using a general information questionnaire and the Dignity Inventory. A total of 346 questionnaires were collected in this survey, with 333 valid questionnaires and an effective response rate of 96%. The incidence rate of dignity impairment symptoms in critically ill patients after ICU treatment was 39%. Multifactor logistic regression analysis showed that age [OR = 1.124, 95%CI=(1.067-1.184)], frequency of visits [OR = 1.875, 95%CI=(1.075-3.269)], length of ICU stay [OR = 1.352, 95%CI=(1.108-1.649)], and tracheotomy upon discharge [OR = 2.269, 95%CI=(1.273-4.044)] were risk factors for dignity impairment symptoms in critically ill patients after ICU treatment. Number of children [OR = 0.247, 95%CI=(0.106-0.576)] was a protective factor for dignity impairment symptoms in critically ill patients after ICU treatment. Although the incidence of dignity impairment symptoms in critically ill patients after ICU treatment is relatively low, the psychological trauma it causes cannot be ignored. Healthcare professionals must actively establish and improve its prevention and management system.

Practical exploration of BOPPPS model combined with situational teaching method in clinical training of intensive medicine: novel pedagogy and perception

Objective

To explore the application value of bridge-in, learning objective, pre-assessment, participatory learning, post-assessment, and summary (BOPPPS) model combined with situational teaching method in the clinical teaching of intensive care unit (ICU), and to provide experience for the reform of ICU clinical teaching and standardized training of intensive medicine.

Methods

A randomized trial was conducted using a multi-center, prospective cohort study. A total of 293 residential physicians in ICU of Fujian Medical University Union Hospital, the Affiliated Hospital of Putian University and the First Affiliated Hospital of Gannan Medical University from January 2021 to December 2023 were selected as subjects, and the residential physicians in ICU in each medical center were divided into control group and experimental group using random number table method. The control group adopted bedside teaching and demonstration teaching method, and the experimental group adopted BOPPPS model combined with situational teaching method. Clinical teaching performance was evaluated by ICU admission examination, and study process questionnaire (SPQ) and the critical thinking disposition inventory-Chinese version (CTDI-CV) was used to evaluate the learning motivation and critical thinking ability of the two groups. At the same time, the effect evaluation and satisfaction questionnaire of ICU training (EESQ) was used to evaluate the teaching satisfaction.

Results

The scores of the experimental group in ICU theoretical knowledge, clinical thinking and skills, and the treatment of clinical critical cases were higher than those of the control group [(87.31 ± 13.15), (92.86 ± 12.35), (81.45 ± 11.28)] vs. [(83.94 ± 12.73), (88.37 ± 12.61), (78.83 ± 10.47)], the difference between the two groups was statistically significant (p < 0.05). The scores of surface motivation, deep motivation, achievement motivation and SPQ total scores of the experimental group were all higher than those in control group (p < 0.05), and the scores of seek truth, open mind, analytical ability, systematic ability, self-confidence of critical thinking and intellectual curiosity of the experimental group were also higher than those in the control group, and the CTDI total score was statistically significant (p < 0.05). In addition, the results of the questionnaire showed that the experimental group was better than the control group in terms of learning interest in ICU, improvement of humanistic care and doctor-patient communication ability, improvement of teamwork ability, improvement of job identity, ICU training harvest and satisfaction with teacher style (p < 0.05).

Conclusion

The combination of BOPPPS model and situational teaching method is likely a more effective and helpful which may improve the clinical comprehensive ability and training quality of residential physicians, and it may be worth learning and promoting.

Comparison of different eye care methods to prevent dry eye and corneal ulcer in older critically ill patients: A three-arm randomised clinical trial

BACKGROUND

As the population ages, the number of older patient admitted to intensive care units (ICUs) will increase. This age group is at higher risk for developing eye problems because of higher prevalence of dry eye among older people. Inconsistency of early studies' results and less attention to eye care guidelines for older patients in the ICU pose severe consequences such as dry eye and corneal ulcer.

OBJECTIVE

The objective of this study was to investigate the effectiveness of artificial tear gel, polyethylene cover, and conventional eye care methods for preventing dry eye and corneal ulcer in older patients admitted to an ICU.

METHODS

In this three-arm randomised clinical trial, 99 older ICU patients with Glasgow Coma Scale scores measuring <7 were randomly assigned to one of three treatment groups: (i) participants who received artificial tear gel in one eye and polyethylene cover on the other; (ii) these interventions were applied in the opposite eyes; and (iii) participants who received conventional eye care including antiallergic adhesive to closed eyelids. Development of dry eye and corneal ulcer was assessed based on Schirmer's and the fluorescein tests for 5 days. Repeated measures analysis of variance was used to detect differences between groups.

RESULTS

The mean age of the participants was 70.91 (±9.47). No statistically significant difference was observed between the groups regarding baseline demographic and disease characteristics. While there was a nonsignificant difference between artificial tear gel and polyethylene cover in reducing dry eye and corneal ulcer, each of these methods could reduce dry eye and corneal ulcer significantly (P < 0.001) compared with conventional eye care.

CONCLUSIONS

The results revealed that artificial tear gel eye care and polyethylene cover methods were more effective in prevention of dry eye and corneal ulcer than antiallergic adhesive eye care. Nurses can choose an appropriate care method based on clinical conditions, costs, and care burden in older ICU patients.

REGISTRATION

Iranian Clinical Trial Registry (IRCT20200711048079N1). The first recruitment was conducted in October 2021.

Critical care in older adults: Research landscape and hotspots from a bibliometric perspective

As the population ages, there will be an increasing demand for health care resources, particularly in intensive care. Therefore, critically ill older adults are receiving increasing attention and have been extensively studied. However, the research landscape, dynamic patterns, and emerging topics in this area have scarcely been reviewed. This study aimed to delve into the current status and emerging trends (publication volume and research topics) in critical care for older adults (including interventions, outcomes, and complications) using bibliometric analysis. We retrieved original articles and reviews focusing on critical care for older adults published between 2013 and 2022 from the Web of Science core database. To examine and present the research trends, we employed VOSviewer and CiteSpace software for analysis and visualization. The cooperative network of countries and institutions, cocited authorship network, cocited references, and cooccurrence network of keywords were analyzed. Overall, 6356 articles and reviews published between 2013 and 2022 were analyzed, revealing a noticeable upward trend in the number of publications focused on critical care for older adults. In total, 34,654 authors from 7989 institutions across 131 countries collaborated to publish 6356 papers related to critical care for older adults in 1715 academic journals. The United States of America and China were the top contributors in terms of research studies, while Bertrand Guidet was the most prolific author with the highest number of articles. A dual-map overlay of the literature revealed that research papers published in Molecular/Biology/Genetics and Health/Nursing/Medicine journals were frequently referenced in Medicine/Medical/Clinical journals. Older patients with coronavirus disease 2019, delirium, and frailty were new trends and developing areas of interest. This is the first bibliometric study focusing on critical care in older adults. The research topics indicate that a comprehensive geriatric assessment, tailored interventions, and specific therapeutic algorithms among older adults are recommended to improve outcomes. Furthermore, this study provides valuable insights for clinical decision-making, guideline development, and resource allocation in critical care settings.

Risk factors for postoperative delirium in adult patients undergoing cardiopulmonary bypass in cardiac surgery

OBJECTIVE

To identify risk factors for postoperative delirium in adult patients undergoing cardiopulmonary bypass.

METHODS

The medical records of 214 patients who underwent cardiopulmonary bypass at the First Affiliated Hospital of Hunan Normal University from January 2022 to January 2024 were retrospectively analyzed. Based on the occurrence of postoperative delirium, patients were divided into a delirium group (49 cases) and a non-delirium group (165 cases). Outcome measures, including clinical baseline data, preoperative left ventricular ejection fraction (LVEF), preoperative Acute Physiology and Chronic Health Evaluation II (APACHE II) score, anesthesia duration, surgery duration, aortic cross-clamp duration, intraoperative mean arterial pressure (MAP), intraoperative blood loss, length of intensive care unit (ICU) stay, postoperative mechanical ventilation duration, as well as postoperative MAP, were compared between the two groups. Logistic regression analysis was performed to identify the potential factors associated with post-operative delirium in patients.

RESULTS

Of the included 214 patients, 49 patients experienced delirium, resulting in an incidence of 22.90%. The delirium group had significantly lower LVEF and significantly higher APACHE II scores compared to the non-delirium group (all P<0.001). No significant difference was observed between the two groups in terms of anesthesia duration, surgery duration, aortic cross-clamp duration, intraoperative MAP, and intraoperative blood loss (all P>0.05). The delirium group experienced significantly longer length of ICU stay and postoperative mechanical ventilation duration as compared to the non-delirium group (all P<0.001), but no significant difference was observed in terms of postoperative MAP between the two groups (P>0.05). Logistic regression analysis identified preoperative New York Heart Association classification (NYHA) (OR: 6.755, 95% CI: 2.529-18.039, P<0.001), preoperative LVEF (OR: 6.886, 95% CI: 2.383-19.899, P<0.001), preoperative APACHE II score (OR: 7.788, 95% CI: 2.740-22.135, P<0.001), length of ICU stay (OR: 9.463, 95% CI: 3.563-25.135, P<0.001), and postoperative mechanical ventilation duration (OR: 9.744, 95% CI: 3.419-27.768, P<0.001) as independent factors influencing the occurrence of delirium in adult patients undergoing cardiopulmonary bypass.

CONCLUSION

Postoperative delirium is a prevalent complication among patients undergoing cardiac surgery. Independent risk factors for postoperative delirium in adult patients undergoing cardiopulmonary bypass during cardiac surgery include preoperative NYHA class III or IV, lower LVEF, higher APACHE II score, an extended length of stay in the ICU, and prolonged postoperative mechanical ventilation duration.

A prolonged intensive care unit stay defines a worse long-term prognosis - Insights from the critically ill mortality by age (Cimba) study

BACKGROUND

Patients with critical illness often survive the intensive care unit (ICU) at a cost of prolonged length of stay (LOS) and slow recovery. This chronic critically ill disease may lead to long-term poor outcomes, especially in older or frail patients.

OBJECTIVES

The main goal of this study was to address the characteristics and outcomes of patients with prolonged ICU LOS. Mainly, short- and long-term admissions were compared to identify risk factors for persistent critical illness and to characterise the impact on ICU, hospital, and long-term mortality.

METHODS

Subanalysis of a retrospective, multicentric, observational study addressing the 2-year outcome of patients admitted to Portuguese ICUs (the Cimba study). Patients were segregated according to an ICU LOS of ≥14 days.

RESULTS

Data from 37 118 patients were analysed, featuring a median ICU LOS of 4 days (percentile: 25-75 2-9), and a mortality of 16.1% in the ICU, 24.0% in the hospital, and 38.7% after 2 years. A total of 5334 patients (14.4%) had an ICU LOS of ≥14 days (corresponding to 48.9% of all ICU patients/days). Patients with prolonged LOS were more often younger (52.8% vs 46.4%, were ≤65 years of age , p < 0.001), although more severe (Simplified Acute Physiology Score II: 49.1 ± 16.9 vs 41.8 ± 19.5, p < 0.001), and had higher ICU and hospital mortality (18.3% vs 15.7%, and 31.2 vs 22.8%, respectively). Prolonged ICU LOS was linked to an increased risk of dying during the 2-year follow-up (adjusted Cox proportional hazard: 1.65, p < 0.001).

CONCLUSION

Prolonged LOS is associated with a long-term impact on patient prognosis. More careful planning of care should incorporate these data.

Recovery from Sepsis: Management beyond Acute Care

Recovery from sepsis is a key global health issue, impacting 38 million sepsis survivors worldwide per year. Sepsis survivors face a wide range of physical, cognitive, and psychosocial sequelae. Readmissions to hospital following sepsis are an important driver of global healthcare utilization and cost. Family members of sepsis survivors also experience significant stressors related to their role as informal caregivers. Increasing recognition of the burdens of sepsis survivorship has led to the development of postsepsis recovery programs to better support survivors and their families, although optimal models of care remain uncertain. The goal of this article is to perform a narrative review of recovery from sepsis from the perspective of patients, families, and health systems.

A shift towards targeted post-ICU treatment: Multidisciplinary care for cardiac arrest survivors

Intensive Care Unit (ICU) survivorship comprises a burgeoning area of critical care medicine, largely due to our improved understanding of and concern for patients' recovery trajectory, and efforts to mitigate the post-acute complications of critical illness. Expansion of care beyond hospitalization is necessary, yet evidence for post-ICU clinics remains limited and mixed, as both interventions and target populations studied to date are too heterogenous to meaningfully demonstrate efficacy. Here, we briefly present the existing evidence and limitations related to post-ICU clinics, identify cardiac arrest survivors as a unique ICU subpopulation warranting further investigation and treatment, and propose a clinical framework that addresses the multifaceted needs of this well-defined patient population.

Use of resources in elderly patients consulting the emergency department: analysis of the Emergency Department and Elder Needs Cohort (EDEN-21)

The elderly population frequently consults the emergency department (ED). This population could have greater use of EDs and hospital health resources. The EDEN cohort of patients aged 65 years or older visiting the ED allowed this association to be investigated. To analyse the association between healthcare resource use and the characteristics of patients over 65 years of age who consult hospital EDs. We performed an analysis of the EDEN cohort, a retrospective, analytical, and multipurpose registry that includes patients over 65 years of age who consulted in 52 Spanish EDs. The impact of age, sex, and characteristics of ageing on the following outcomes was studied: need for hospital admission (primary outcome) and need for observation, stay in the ED > 12 h, prolonged hospital stay > 7 days, need for intensive care unit (ICU) and return to the ED at 30 days related to the index visit (secondary outcomes). The association was analysed by calculating the adjusted odds ratios (aOR) and their 95% confidence intervals (CI), using a logistic regression model. A total of 25,557 patients with a mean age of 78.3 years were analysed, 45% were males. Of note was the presence of comorbidity, a Charlson index ≥ 3 (33%), and polypharmacy (66%). Observation in the ED was required by 26%, 25.4% were admitted to the hospital, and 0.9% were admitted to the ICU. The ED stay was > 12 h in 12.5% and hospital stay > 7 days in 13.5% of cases. There was a progressive increase in healthcare resource use based on age, with an aOR for the need for observation of 2.189 (95% CI 2.038-2.352), ED stay > 12 h 2.136 (95% CI 1.942-2.349) and hospital admission 2.579 (95% CI 2.399-2.772) in the group ≥ 85 years old. Most of the characteristics inherent to ageing (cognitive impairment, falls in the previous 6 months, polypharmacy, functional dependence, and comorbidity) were associated with significant increases in the use of healthcare resources, except for ICU admission, which was less in all the variables studied. Age and the characteristics inherent to ageing are associated with greater use of structural healthcare resources.

Impact of a prospective feedback loop aimed at reducing non-beneficial treatments in older people admitted to hospital and potentially nearing the end of life. A cluster stepped-wedge randomised controlled trial

OBJECTIVES

To investigate if a prospective feedback loop that flags older patients at risk of death can reduce non-beneficial treatment at end of life.

DESIGN

Prospective stepped-wedge cluster randomised trial with usual care and intervention phases.

SETTING

Three large tertiary public hospitals in south-east Queensland, Australia.

PARTICIPANTS

14 clinical teams were recruited across the three hospitals. Teams were recruited based on a consistent history of admitting patients aged 75+ years, and needed a nominated lead specialist consultant. Under the care of these teams, there were 4,268 patients (median age 84 years) who were potentially near the end of life and flagged at risk of non-beneficial treatment.

INTERVENTION

The intervention notified clinicians of patients under their care determined as at-risk of non-beneficial treatment. There were two notification flags: a real-time notification and an email sent to clinicians about the at-risk patients at the end of each screening day. The nudge intervention ran for 16-35 weeks across the three hospitals.

MAIN OUTCOME MEASURES

The primary outcome was the proportion of patients with one or more intensive care unit (ICU) admissions. The secondary outcomes examined times from patients being flagged at-risk.

RESULTS

There was no improvement in the primary outcome of reduced ICU admissions (mean probability difference [intervention minus usual care] = -0.01, 95% confidence interval -0.08 to 0.01). There were no differences for the times to death, discharge, or medical emergency call. There was a reduction in the probability of re-admission to hospital during the intervention phase (mean probability difference -0.08, 95% confidence interval -0.13 to -0.03).

CONCLUSIONS

This nudge intervention was not sufficient to reduce the trial's non-beneficial treatment outcomes in older hospital patients.

TRIAL REGISTRATION

Australia New Zealand Clinical Trial Registry, ACTRN12619000675123 (registered 6 May 2019).

Diaphragm Ultrasound in Different Clinical Scenarios: A Review with a Focus on Older Patients

Diaphragm muscle dysfunction is increasingly recognized as a fundamental marker of several age-related diseases and conditions including chronic obstructive pulmonary disease, heart failure and critical illness with respiratory failure. In older individuals with physical frailty and sarcopenia, the loss of muscle mass and function may also involve the diaphragm, contributing to respiratory dysfunction. Ultrasound has recently emerged as a feasible and reliable strategy to visualize diaphragm structure and function. In particular, it can help to predict the timing of extubation in patients undergoing mechanical ventilation in intensive care units (ICUs). Ultrasonographic evaluation of diaphragmatic function is relatively cheap, safe and quick and can provide useful information for real-time monitoring of respiratory function. In this review, we aim to present the current state of scientific evidence on the usefulness of ultrasound in the assessment of diaphragm dysfunction in different clinical settings, with a particular focus on older patients. We highlight the importance of the qualitative information gathered by ultrasound to assess the integrity, excursion, thickness and thickening of the diaphragm. The implementation of bedside diaphragm ultrasound could be useful for improving the quality and appropriateness of care, especially in older subjects with sarcopenia who experience acute respiratory failure, not only in the ICU setting.

Characteristics, management, and mid-term prognosis of older adults with cardiogenic shock admitted to intensive care units: Insights from the FRENSHOCK registry

BACKGROUND

The incidence of heart failure and cardiogenic shock (CS) in older adults is continually increasing due to population aging. To date, prospective data detailing the specific characteristics, management and outcomes of CS in this population are scarce.

METHODS

FRENSHOCK is a prospective registry including 772 CS patients from 49 centers. We studied 1-month and 1-year mortality among patients over 75-year-old, adjusted for independent predictors of 1-month and 1-year mortalities.

RESULTS

Out of 772 patients included, 236 (30.6%) were 75 years old or more (mean age 81.9 ± 4.7 years, 63.6% male). Compared to patients <75 years old, older adults had a higher prevalence of comorbidities including hypertension, dyslipidemia, chronic kidney disease, and history of heart disease. Older adults were characterized by a lower blood pressure, as well as higher creatinine and lower haemoglobin levels at presentation. Yet, they were less likely to be treated with norepinephrine, epinephrine, invasive ventilation, and renal replacement therapy. They showed a higher 1-month (aHR: 2.5 [1.86-3.35], p < 0.01) and 1-year mortality (aHR: 2.01 [1.58-2.56], p < 0.01). Analysis of both 1-month and 1-year mortality stratified by age quartiles showed a gradual relationship between aging and mortality in CS patients.

CONCLUSION

A third of patient with CS in critical care unit are older than 75 years and their risk of death at one month and one year is more than double compared to the younger ones. Further research is essential to identify best therapeutic strategy in this population. NCT02703038.

Identification and Best Practice Management of Comorbid Geri-Psych Conditions in Critical Care

Mental illnesses among critically ill patients are approximately 2.5 times that of the general population. Although older adults with physical-mental multimorbidity represent more than 50% of critical care admissions, health-care professionals caring for geriatric patients are not adequately educated to effectively recognize and treat serious mental illness. Additionally, critical care nurses feel vulnerable, unsupported, and unable to provide the best and safest possible patient-centered care for patients with mental illness. Hospitals can reduce these burdens by creating critical care policies and practices that are inclusive of geriatric and mental health concepts, care, and continuing education to those providing care.

Transition of Care for Older Adults Undergoing General Surgery

The demand for surgical intervention and hospitalization is expected to increase with the growth of the older adult population. Despite advances in technology and minimally invasive surgical procedures, the needs of the older adult in the perioperative period are unique. Transitions of care from the decision to support surgery through surgical intervention, subsequent hospitalization, and postacute discharge must be supported to achieve optimal patient outcomes. The clinical nurse specialist is well suited to address care delivery and assure implementation of best practices across the continuum.

Exploring the Applicability of Pre-Anesthetic Cardiac POCUS in Unexpected Conditions: Could it be Helpful?

Formal preoperative echocardiography has traditionally been recommended when there is substantial cardiovascular disease without recent follow up, unexplained dyspnea, a functional class less than 4 METS or a Duke Activity Status Index less than 34. However, it is important to note that certain patients may present with a variety of cardiac abnormalities due to their preexisting condition or multiple treatments, and these individuals warrant consideration. The objective of pre-anesthetic cardiac POCUS is to provide clinical information in a timely manner. Although it does not aim to replace conventional echocardiography, cardiac POCUS can undoubtedly assist anesthesia practitioners in identifying asymptomatic and potentially hazardous conditions, allowing for more accurate risk allocation and individualized patient care.

Impact of lipopolysaccharide-induced acute lung injury in aged mice

Study Aim: As the geriatric population rapidly expands, there has been a concurrent increase in elderly admissions to intensive care units (ICUs). Acute lung injury (ALI) is a prevalent reason for these admissions and carries poorer survival rates for the aged population compared to younger counterparts. The aging lung is subject to physiological, cellular, and immunological changes. However, our understanding of how aging impacts the clinical progression of ALI is limited. This study explored the effect of aging using a murine model of ALI. Methods: Female C57BL/6J mice, aged 7-8 wk (young) and 18 months (aged), were divided into four groups: young controls, aged controls, young with ALI (YL), and aged with ALI (AL). ALI was induced via intratracheal administration of lipopolysaccharide (LPS, 0.5 mg/kg). The animals were euthanized 72 h after LPS exposure. Results: The AL group exhibited a significantly increased wet/dry ratio compared to the other three groups, including the YL group. The bronchoalveolar lavage (BAL) fluid in the AL group had more cells overall, including more neutrophils, than the other groups. Inflammatory cytokines in BAL fluid showed similar trends. Histological analyses demonstrated more severe lung injury and fibrosis in the AL group than in the other groups. Increased transcription of senescence-associated secretory phenotype markers, including PAI-1 and MUC5B, was more prominent in the AL group than in the other groups. This trend was also observed in BAL samples from humans with pneumonia. Conclusions: Aging may amplify lung damage and inflammatory responses in ALI. This suggests that physicians should exercise increased caution in the clinical management of aged patients with ALI.

In-Hospital Mortality Prediction Model for Critically Ill Older Adult Patients Transferred from the Emergency Department to the Intensive Care Unit

Purpose

Studies on the prognosis of critically ill older adult patients admitted to the emergency department (ED) but requiring immediate admission to the intensive care unit (ICU) remain limited. This study aimed to develop an in-hospital mortality prediction model for critically ill older adult patients transferred from the ED to the ICU.

Patients and Methods

The training cohort was taken from the Medical Information Mart for Intensive Care IV (version 2.2) database, and the external validation cohort was taken from the Affiliated Dongyang Hospital of Wenzhou Medical University. In the training cohort, class balance was addressed using Random Over Sampling Examples (ROSE). Univariate and multivariate Cox regression analyses were performed to identify independent risk factors. These were then integrated into the predictive nomogram. In the validation cohort, the predictive performance of the nomogram was evaluated using the area under the curve (AUC) of the receiver operating characteristic curve, calibration curve, clinical utility decision curve analysis (DCA), and clinical impact curve (CIC).

Results

In the ROSE-balanced training cohort, univariate and multivariate Cox regression analysis identified that age, sex, Glasgow coma scale score, malignant cancer, sepsis, use of mechanical ventilation, use of vasoactive agents, white blood cells, potassium, and creatinine were independent predictors of in-hospital mortality in critically ill older adult patients, and were included in the nomogram. The nomogram showed good predictive performance in the ROSE-balanced training cohort (AUC [95% confidence interval]: 0.792 [0.783-0.801]) and validation cohort (AUC [95% confidence interval]: 0.780 [0.727-0.834]). The calibration curves were well-fitted. DCA and CIC demonstrated that the nomogram has good clinical application value.

Conclusion

This study developed a predictive model for early prediction of in-hospital mortality in critically ill older adult patients transferred from the ED to the ICU, which was validated by external data and has good predictive performance.

The association between Geriatric Nutritional Risk Index and the risk of Invasive Candidiasis in critically ill older adults

BACKGROUND

Invasive candidiasis is the most common hospital-acquired fungal infection in intensive care units (ICU). The Geriatric Nutritional Risk Index (GNRI) score was developed to evaluate the nutritional status of elderly adults. We aimed to assess the association between the GNRI score and the risk of invasive candidiasis in elderly patients admitted to ICU.

METHODS

Hospitalization information of elderly patients with invasive candidiasis was collected retrospectively from Medical Information Mart for Intensive Care (MIMIC) IV and MIMIC-III Clinical Database CareVue subset from 2001 to 2019. The main outcome of this study was the diagnosis of invasive candidiasis in patients. We employed a multivariable Cox regression and propensity score matching to balance the influence of confounding factors on the outcome. Furthermore, we conducted sensitivity analyses by categorizing the GNRI into classes based on thresholds of 98, 92, and 81.

RESULTS

A total of 6739 patients were included in the study, among whom 134 individuals (2%) were diagnosed with invasive candidiasis. The GNRI scores of patients with invasive candidiasis upon admission to the ICU were significantly lower, measuring 88.67 [79.26-98.27], compared to the control group with a score of 99.36 [87.98-110.45] (P < 0.001). The results of the multivariable Cox regression analysis demonstrated a strong association between higher GNRI scores and a decreased risk of invasive candidiasis infection (HR: 0.98, 95% CI: 0.97-0.99, P = 0.002). Consistently, similar results were obtained when analyzing the propensity score-matched cohort (HR: 0.99, 95% CI: 0.98-1, P = 0.028). Sensitivity analyses further confirmed a significantly increased risk of invasive candidiasis infection with lower GNRI scores. Specifically, the following associations were observed: GNRI ≤ 98 (HR: 1.83, 95% CI: 1.23-2.72, P = 0.003), GNRI ≤ 92 (HR: 1.68, 95% CI: 1.17-2.4, P = 0.005), 82 ≤ GNRI ≤ 92 (HR: 1.63, 95% CI: 1.01-2.64, P = 0.046), GNRI ≤ 81 (HR: 2.31, 95% CI: 1.44-3.69, P < 0.001).

CONCLUSIONS

Lower GNRI score was significantly associated with an increased risk of invasive candidiasis in elderly patients in ICU. Further research is needed to validate whether improving nutrition can prevent invasive candidiasis.

A predictive scoring system for postoperative delirium in the elderly patients with intertrochanteric fracture

OBJECTIVE

To establish a scoring system to predict the postoperative delirium in elderly patients with intertrochanteric fracture.

MATERIALS AND METHODS

We retrospectively reviewed 159 elderly patients with a diagnosis of intertrochanteric fracture and underwent closed reduction and intramedullary nail fixation, and then divided them into two groups including the delirium group (23 cases) or non-delirium group (136 cases) in our hospital from January 2017 to December 2019. The following clinical characteristics were recorded and analyzed: age, gender, fracture classification, body mass index (BMI), history of diabetes mellitus, history of stroke, preoperative albumin, preoperative hemoglobin (Hb), preoperative arterial partial pressure of oxygen (PaO₂), time between admission and surgery, lower limb thrombosis, American Society of Anesthesiologists (ASA) grade, operative time, operative blood loss, and intraoperative blood transfusion. The prevalence of these clinical characteristics in delirium group was evaluated, and the scoring system was established using logistic regression analysis. The performance of the scoring system was also prospectively validated.

RESULTS

The predictive scoring system was based on five clinical characteristics confirmed as significant predictors of postoperative delirium, namely, age > 75 years, history of stroke, preoperative Hb ≤ 100 g/L, preoperative PaO₂ ≤ 60 mmHg, and time between admission to surgery > 3 days. Delirium group showed a significant higher score than non-delirium (6.26 vs. 2.29, P < 0.001), and the optimal cut-off value for the scoring system was 4 points. The sensitivity and specificity of the scoring system for predicting postoperative delirium were 82.61% and 81.62% in derivation set, respectively, and 72.71% and 75.00% in validation set.

CONCLUSION

The predictive scoring system confirmed with achieve satisfactory sensitivity and specificity in predicting postoperative delirium in the elderly with intertrochanteric fracture. The risk of postoperative delirium in patients with the score of 5 to 11 is high, while the score of 0 to 4 is low.