Hospital survival of older patients admitted to a medical intensive care unit

BACKGROUND AND AIMS: It is not well-known whether age or the severity of underlying conditions affects mortality in critically ill patients. The aim of this study was therefore to determine whether age is an independent predictor of hospital survival for critically ill patients. METHODS: Patients consecutively admitted to the intensive care unit from December 1 1999 to July 31 2001 were included in the study. Patients were stratified into 3 groups (< or = 65 years old, 66-75 years old, > 75 years old) and were compared, by both bivariate and multivariate analyses, to ascertain whether older critically ill patients had poorer hospital survival than younger patients. RESULTS: Of 331 patients, 178 (53.8%) patients were < or = 65 years old, 100 (30.2%) were 66-75 years old, and 53 (16%) were > 75 years old. Multivariate logistic regression analysis revealed that older age, presence of fatal comorbidities, mechanical ventilation, central venous catheterization, and higher acute physiology and chronic health evaluation score II (excluding the score obtained from age) were independent predictors of hospital mortality in the study population. Kaplan-Meier survival analysis revealed that patients < or = 65 years old had better hospital survival than older patients (p=0.02). CONCLUSIONS: Older critically ill patients have poorer hospital survival than patients < or = 65 years old, when other confounding factors such as disease severity score, invasive procedures and comorbidities were controlled for.     

Determinants of outcome in elderly patients admitted to the intensive care unit

BACKGROUND: Age is thought to be strongly associated with intensive care outcomes, but this relationship may be confounded by many clinical variables. OBJECTIVES: To compare clinical characteristics of elderly patients (> or = 65 years) admitted to the intensive care unit (ICU) with those in younger patients and to identify the risk factors which independently could predict mortality in patients aged > or = 75 years. DESIGN: Prospective observational cohort study. SETTING: Medical-surgical ICU in a university hospital. SUBJECTS: 2,067 adult patients admitted to the ICU. METHODS: Comparison of clinical characteristics of patients divided into groups according to their age. RESULTS: Elderly patients comprised 51% of the study population. Compared with younger patients, elderly patients were more severely ill on admission, had shock and renal dysfunction. The presence of infection on admission and the incidence rate of infection acquired during stay in the ICU also significantly increased with age. Hospital mortality increased with age: for patients aged > or = 75 years, it was more than double that of patients aged <65 years (39% versus 19%, P < 0.001). Using multivariate logistic regression analysis we determined the independent risk factors of hospital mortality for the patients aged > or = 75 years: impaired level of consciousness, infection on admission, ICU-acquired infection and severity of illness score. CONCLUSIONS: Morbidity and mortality in elderly patients admitted to the ICU are higher than in younger patients. The most important factors independently associated with the highest risk of death are the severity of illness, impaired level of consciousness and infection.     

Predictive factors of in-hospital mortality in older patients admitted to a medical intensive care unit

OBJECTIVES: To identify prognostic factors that are independently predictive of in-hospital mortality in older patients hospitalized in a medical intensive care unit (MICU). DESIGN: Prospective cohort study. SETTING: A MICU in an Italian university hospital. PARTICIPANTS: Patients aged 65 and older consecutively admitted to the MICU directly from the first-aid unit. MEASUREMENTS: Upon admission, the following variables were examined: demographics, clinical history (diabetes mellitus, active neoplasm, cognitive impairment, immobilization, pressure ulcers, use of nutritional support, home oxygen therapy), physiopathology (Acute Physiology and Chronic Health Evaluation (APACHE) II), and cognition/function (activity of daily living (ADL), instrumental activity of daily living (IADL), Short Portable Mental Status Questionnaire (SPMSQ)). The vital status of the patient at the end of hospitalization was recorded. RESULTS: Over a period of 10 months, 659 patients were recruited (mean age +/- standard deviation = 76.6 +/- 7.5; 352 men and 307 women). There were 97 deaths (14.71%). The following factors proved to be significantly associated with in-hospital mortality: old age, low body mass index (BMI) values, low values of albumin, high scores on APACHE II, functional impairment (ADL, IADL), cognitive impairment (SPMSQ), history of cognitive deterioration, history of confinement to bed, and presence of pressure ulcers. Using multivariate analysis, the following variables were independently predictive of in-hospital mortality: lack of independence in ADLs (P <.001), moderate-to-severe cognitive impairment on SPMSQ (P <.001), score on APACHE II (P =.002), and low BMI values (P =.031). CONCLUSION: The prognosis of older patients hospitalized in medical intensive care units depends not only on the acute physiological impairments, but also on a series of preexisting conditions, such as loss of functional independence, severe and moderate cognitive impairment, and low BMI.     

Outcome predictors of cirrhosis patients admitted to the intensive care unit

OBJECTIVE: To evaluate outcome predictors of patients with cirrhosis admitted to an intensive care unit (ICU). METHODS: One hundred and twenty-nine consecutive patients with cirrhosis admitted to the ICU at a tertiary care transplant centre in Saudi Arabia between March 1999 and December 2000 were entered prospectively in an ICU database. Liver transplantation patients and readmissions to the ICU were excluded. The following data were documented: demographic features, severity of illness measures, parameters of organ failure, presence of gastrointestinal bleeding, and sepsis. The need for mechanical ventilation, renal replacement therapy and pulmonary artery catheter placement was recorded. The primary endpoint was hospital outcome. RESULTS: Cirrhotic patients admitted to the ICU had high hospital mortality (73.6%). However, the actual mortality was not significantly different from the predicted mortality using prediction systems. There was an association between the number of organs failing and mortality. Coma and acute renal failure emerged as independent predictors of mortality. All patients who were monitored with pulmonary artery catheterisation in this study died. Patients requiring mechanical ventilation and renal replacement therapy had very high mortalities (84% and 89%, respectively). All 13 cirrhotic patients admitted to ICU immediately post-cardiac arrest in this study died. CONCLUSIONS: Cirrhotic patients admitted to ICU have a poor prognosis, especially when admitted with coma, acute renal failure or post-cardiac arrest. The consistently poor prognosis associated with certain ICU interventions should raise new awareness regarding limitations of medical therapy. These mortality statistics compel a critical re-examination of uniformly aggressive life support for the critically ill cirrhotic patient, a percentage of whom will not benefit from invasive measures.     

Prognosis of patients with acute myeloid leukaemia admitted to intensive care

This retrospective study assessed the prognostic factors associated with early and long-term outcome in consecutive patients with acute myeloid leukaemia (AML) admitted to the intensive care unit (ICU) over a 9-year period. A total of 83 patients were studied (age 48 +/- 16 years), among whom 60% were neutropenic on admission. For 68%, admission occurred within the first month following diagnosis of AML. The main reason for ICU admission was an acute respiratory disease in 82% of cases. Mechanical ventilation (MV) was required in 57% of patients. In-ICU mortality was 34%. Among patients discharged alive from ICU, 49% died within a year after discharge. Factors significantly associated with in-ICU death in multivariate analysis were simplified acute physiology score II and need for invasive MV (IMV). Age, performance status, AML3 subtype and complete remission were significantly associated with 1-year survival. Patients with acute respiratory failure initially supported with non-invasive MV had significantly better ICU outcome than patients initially supported with IMV. In conclusion, ICU admission is justified for selected patients with AML. The ICU mortality rate is highly predictable by the acute illness severity score. A 1-year survival is predicted by haematological prognostic factors.     

Outcome of patients having dermatomyositis admitted to the intensive care unit

Patients having systemic rheumatic diseases constitute a small percentage of admissions to the medical intensive care units (ICUs). Dermatomyositis (DM) is one of the rheumatic diseases that have secondary complications that may lead to a critical illness requiring hospitalization in the ICU. Herein, we present the features, clinical course, and outcome of critically ill patients having DM who were admitted to the ICU. The medical records of six DM patients admitted to the ICU in a large tertiary hospital in a 12-year period were reviewed. The mean age of patients at time of admission to the ICU was 38 (range 16–37). Mean disease duration from diagnosis to admission to the ICU was 1.6 years (range 1 month–8 years), while the main reason for admission to the ICU was acute respiratory failure. Two of six patients died during the hospitalization. The main causes of death were respiratory complications and sepsis. The outcome of DM patients admitted to the ICU was generally not different from the outcome of other patients hospitalized in the ICU. The main reason for hospitalization was acute respiratory failure. As there are many reasons for respiratory failure in DM, an early diagnosis and aggressive appropriate treatment may help to further reduce the mortality in these patients.     

The ISTH DIC score predicts outcome in non-septic patients admitted to a cardiovascular intensive care unit

BackgroundThe International Society of Thrombosis and Haemostasis (ISTH) disseminated intravascular coagulation (DIC) score is widely used to predict mortality in critically ill - typically septic - patients. The objective of this study was to investigate whether the ISTH DIC-2001 and DIC-2018 score can be used to predict the 30-day mortality in non-septic patients in an intensive care unit (ICU).MethodsIn this single-center, prospective observational study we included all patients ≥18 years of age who were admitted to a medical ICU with a focus on cardiovascular diseases between August 2012 and 2013. The DIC-2001 and DIC-2018 scores were calculated on admission (DIC-2001-0h and DIC-2018-0h) and 72 hours thereafter (DIC-2001-72h and DIC-2018-72h) and were classified as overt when ≥ 5 for DIC-2001 and ≥ 4 for DIC-2018.ResultsA total of 233 patients were included in this study. Excluding septic patients and patients after routine surgery/procedures, we calculated the DIC score for 167 patients (32.4% female; median age 64.9 years). Overt DIC-2001-0h, DIC-2018-0h and overt DIC-2001-72h scores were associated with a significantly higher 30-day mortality rate (52.9% vs. 25.0%, 46.2% vs 21.2%, and 57.1% vs. 23.7%; p < 0.04). The DIC-2001 scores and the DIC-2018-0h score significantly predicted the 30-day mortality.ConclusionThis study suggests that the DIC score may be applied to non-septic ICU populations, and indicates that it is a useful tool for mortality prediction, regardless of the underlying disease.     

Outcome of adult umbilical cord blood transplant patients admitted to a medical intensive care unit

Umbilical cord blood transplant (UCBT) has emerged as an alternate source of stem cells for transplantation in patients with hematologic malignancies. However, outcomes of adult UCBT patients requiring ICU admission remain unknown. In order to identify predictors of ICU transfer and mortality in UCBT patients, the course and outcome of all adult (> or = 16 years old) patients who underwent UCBT between 1 January 1998 and 31 December 2003 at University Hospitals of Cleveland were analyzed. Forty-four patients underwent UCBT during the study period and 25 (57%) required ICU transfer. Use of a myeloablative preparative regimen was a significant predictor of ICU transfer (P = 0.03). An infusion of higher numbers of nucleated cells was protective from ICU transfer (P = 0.05). For those patients transferred to the ICU, mortality was 72%. The univariate predictors of mortality, at the time of ICU admission were a high APACHE III score (P = 0.0004), use of vasopressors (P = 0.03), and a low platelet count (P = 0.03). We conclude that transfer of UCBT patients to an ICU may be predicted by their preparative regimen, while ICU mortality may be predicted by physiologic parameters upon admission.     

Hepatocyte growth factor and cardiovascular thrombosis in patients admitted to the intensive care unit.

BACKGROUND: Hepatocyte growth factor (HGF) has been reported as a marker of atherosclerosis and of thrombi synthesis, but the relationship between HGF and proven coronary thrombi has not been described. The aim of this study was to investigate this relationship in patients with chest pain. METHODS AND RESULTS: The study group comprised 107 patients with chest pain (61 acute myocardial infarction (AMI), 18 unstable angina, 15 stable angina, and 13 others; 65 males, 42 females; 66+/-11 years old). The presence of thrombi was evaluated by angiography, intravascular ultrasonography, angioscopy, and computed tomography. Serum HGF concentrations were measured using a new enzyme-linked immunosorbent assay. Serum HGF was significantly higher in the patients with AMI (335.0 +/-197.5 pg/ml), unstable angina (269.1+/-152.7 pg/ml), acute aortic dissection (320.3+/-116.5 pg/ml), and pulmonary thromboembolism (292.5+/-101.9 pg/ml), than in those with stable angina (171.2+/-56.1 pg/ml). Serum HGF concentration was also higher in those patients with proven thrombi than in those patients without (326.7+/-189.7 pg/ml vs 226.9+/-110.8 pg/ml). CONCLUSION: Increased serum HGF concentrations correlate with the presence of thrombi in patients with acute coronary syndrome, acute aortic dissection, and pulmonary thromboembolism.     

Initial bacterial colonization in patients admitted to a respiratory intensive care unit: bacteriological pattern and risk factors

BACKGROUND: Colonization is an important risk factor for consecutive infection, but little is known about incidence and initial pattern on admission to respiratory intensive care units (RICU). OBJECTIVE: To study the bacterial colonization during the first 24 h after admission to a RICU. METHODS: Endotracheal aspirates, gastric juice, and pharyngeal and rectal swabs of 55 consecutive patients were cultured (45 men, age 66 +/- 14 years, APACHE II 20.1 +/- 5.6, no parenchymal infection). All samples were taken within the first 24 h after admission to a RICU. Potentially pathogenic microorganisms were grouped as community (c-PPM) and hospital acquired (h-PPM), and risk factors for colonization of each body site as well as for overall colonization (all sites excluding rectum) were identified by logistic regression analysis. RESULTS: The trachea was colonized in 18% of the intubated patients with c-PPMs and in 11% with h-PPMs. Candida spp. were the most frequent c-PPMs isolated from trachea, pharynx, and stomach (excluding rectal swabs), and Pseudomonas aeruginosa was the most frequently isolated h-PPM in trachea. The incidence of overall colonization was 49% for c-PPMs (predominantly Escherichia coli) and 18% for h-PPMs (predominantly P. aeruginosa). Admission to the hospital > or = 48 h before ICU admission was an independent risk factor of colonization with h-PPMs in univariate (33 vs. 7%, p = 0.015) and multivariate analyses (odds ratio 7.2, 95% CI 1.4-38.3; p = 0.0197). CONCLUSIONS: Colonization of the trachea with c-PPMs was already present in every 5th and with h-PPMs in every 10th intubated patient during the first 24 h of RICU admission even in the absence of parenchymal infections. Hospitalization more than 48 h prior to RICU admission was a risk factor of colonization with h-PPMs.     

Predictors of outcome in patients with hematologic malignancies admitted to the intensive care unit

Purpose

Several studies showed conflicting results about prognosis and predictors of outcome of critically ill patients with hematological malignancies (HM). The aim of this study is to determine the hospital outcome of critically ill patients with HM and the factors predicting the outcome.

Prognostic score of short-term survival in HIV-infected patients admitted to medical intensive care units

A retrospective cohort was set up to identify prognostic factors associated with in-hospital survival in HIV-infected patients admitted to medical intensive care units (MICUs), from 1991 to 1994. Survival from MICU admission to hospital discharge (or in-hospital fatal issue) was estimated and a prognostic score at MICU admission was developed. One hundred and thirty patients were recruited of whom 20% were AIDS-free prior to admission. In-hospital mortality rate was 65%. Median survival was 20 days. The following variables were predictive of mortality: Simplified Acute Physioloy Score II (SAPS II): (hazard ratio [HR]=1.5 for 10 points higher, P<10(-3)), time between HIV diagnosis and admission >5 years (HR=2.7, P<10(-4)), hypoalbuminaemia (HR=1.2 per 5 g/l lower, P=0.03). The prognostic score developed was: SAPS II+25 (if time between HIV diagnosis and MICU admission >5 years) albuminaemia (g/l). A new prognostic score including SAPS II, prior HIV history and albuminaemia better reflected the in-hospital mortality than SAPS II alone. Our findings may still be useful to better evaluate the immediate prognosis of current HIV-infected patients admitted to MICU, particularly those naive to antiretroviral therapy or in treatment failure.     

Frequency of intensive statin therapy in patients with acute coronary syndrome admitted to a tertiary care center

Intensive statin therapy (IST) has been shown to decrease cardiovascular events in patients with acute coronary syndrome (ACS). Numerous studies have described statin use for secondary prevention; however, few data have highlighted IST use after ACS. The objective of the present study was to describe IST use in an ACS population before hospitalization, on discharge, and during early follow-up after discharge. A retrospective chart review was conducted of randomly selected patients admitted to a tertiary care center from November 1, 2007 to October 31, 2008. Eligible patients included adults admitted to cardiology with a most responsible diagnosis of ACS (International Classification of Diseases code 20-25). The exclusion criteria included transfer to another hospital or cardiovascular surgery ward and in-hospital death. Phase 1 included an inpatient chart review. Phase 2 was a follow-up cardiologist clinic letter review that included only patients who started IST in-hospital. Of 234 charts reviewed, 111 (47%) patients met the inclusion criteria (mean age 65 ± 11.7 years, 76% men). Most patients (93%) were discharged with a statin. However, although 72% of the study population were eligible for IST, only 52% had IST during hospitalization. Of the patients who started IST with clinic letters available (n = 31), 68% continued IST (mean interval to follow-up 85 days, range 33 to 208). In conclusion, although statin use is good, IST use after ACS is suboptimal. Additionally, newly initiated IST demonstrates poor persistence after discharge.