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.     

Outcome of patients with idiopathic pulmonary fibrosis admitted to the intensive care unit

This retrospective study describes the clinical course of 38 patients with idiopathic pulmonary fibrosis (IPF) admitted to the intensive care unit (ICU). There were 25 males and 13 females who were the mean age of 68.3 +/- 11.5 years. Twenty patients were on corticosteroids at the time of admission to the hospital, and 24 had been on home oxygen therapy. The most common reason for ICU admission was respiratory failure. The Acute Physiology and Chronic Health Evaluation III-predicted ICU and hospital mortality rates were 12% and 26%, whereas the actual ICU and hospital mortality rates were 45% and 61%, respectively. We did not find significant differences in pulmonary function or echocardiogram findings between survivors and nonsurvivors. Mechanical ventilation was used in 19 patients (50%). Sepsis developed in nine patients. Multiple organ failure developed in 14% of the survivors and in 43% of the nonsurvivors (p = 0.14). Ninety-two percent of the hospital survivors died at a median of 2 months after discharge. These findings suggest that patients with IPF admitted to the ICU have poor short- and long-term prognosis. Patients with IPF and their families should be informed about the overall outlook when they make decisions about life support and ICU care.     

The impact of critical illness on perceived health-related quality of life during ICU treatment, hospital stay, and after hospital discharge: a long-term follow-up study

BACKGROUND: The time course of changes in health-related quality of life (HRQOL) following discharge from the ICU and during a general ward stay has not been studied. We therefore studied the immediate impact of critical illness on HRQOL and its recovery over time. METHODS: In a prospective study, all patients admitted to the ICU for > 48 h who ultimately survived to follow-up at 6 months were included. The Medical Outcomes Study 36-item short form was used to measure HRQOL before ICU admission, at discharge from the ICU and hospital, and at 3 and 6 months following discharge from the ICU and hospital. An age-matched healthy Dutch population was used as a reference. RESULTS: Of the 451 included patients, 252 could be evaluated at 6 months (40 were lost to follow-up, and 159 died). Pre-ICU admission HRQOL in survivors was significantly worse compared to the healthy population. Patients who died between ICU admission and long-term follow-up had significantly worse HRQOL in all dimensions already at ICU admission when compared to the long-term survivors. HRQOL decreased in all dimensions (p < 0.001) during ICU stay followed by a rapid improvement during hospital stay, gradually improving to near pre-ICU admission HRQOL at 6 months following ICU discharge. Physical functioning (PF), general health (GH), and social functioning (SF) remained significantly lower than pre-ICU admission values. Compared to the healthy Dutch population, ICU survivors had significantly lower HRQOL 6 months following ICU discharge (except for the bodily pain score). CONCLUSIONS: A sharp multidimensional decline in HRQOL occurs during ICU admission where recovery already starts following ICU discharge to the general ward. Recovery is incomplete for PF, GH, and SF when compared to baseline values and the healthy population.     

Outcome of older patients requiring ventilatory support in intensive care: impact of nutritional status

OBJECTIVES: To determine predictors of mortality in the intensive care unit (ICU) and at 6 months after discharge; to assess the lifestyles of survivors 6 months after discharge. DESIGN: Prospective cohort study of patients screened upon admission and 6 months after discharge from the ICU. SETTING: The ICU of a university hospital. PARTICIPANTS: One hundred sixteen consecutive patients age 70 and older admitted to the ICU and treated by mechanical ventilation for at least 24 hours. MEASUREMENTS: A comprehensive medical, functional, nutritional, and social assessment was undertaken for each patient upon admission to the ICU. Functional status and residence were recorded for patients still living 6 months after discharge from the ICU. RESULTS: Mortality in the ICU and 6 months after discharge was 31% and 52%, respectively. The predictors of in-ICU mortality on multivariate analysis were a high omega score per day in the ICU and a high simplified acute physiologic score corrected for points related to age (SAPS IIc). The predictors of mortality at 6 months were a high omega score per day in the ICU, a high SAPS IIc, and a mid-arm circumference (MAC) under the 10th percentile for the older French population in good health. Six months after discharge from the ICU, 91% of the surviving patients had the same residential status and 89% had a similar or improved functional status compared with pre-admission status. CONCLUSIONS: Although severity of illness remains an important predictor of in-ICU mortality and mortality at 6 months after release from ICU, we found that impaired nutritional status upon admission was related to 6-month mortality. These results emphasize the need for a systematic nutritional assessment in older patients admitted to the ICU and treated by mechanical ventilation.     

Relationships among initial hospital triage,disease progression and mortality in community‐acquired pneumonia

Background and objective: Appropriate triage of patients with community‐acquired pneumonia (CAP) may improve morbidity, mortality and use of hospital resources. Worse outcomes from delayed intensive care unit (ICU) admission have long been suspected but have not been verified. Methods: In a retrospective study of consecutive patients with CAP admitted from 1996–2006 to the ICUs of a tertiary care hospital, we measured serial severity scores, intensive therapies received, ICU‐free days, and 30‐day mortality. Primary outcome was mortality. We developed a regression model of mortality with ward triage (and subsequent ICU transfer within 72 h) as the predictor, controlled by propensity for ward triage and radiographic progression. Results: Of 1059 hospital‐admitted patients, 269 (25%) were admitted to the ICU during hospitalization. Of those, 167 were directly admitted to the ICU without current requirement for life support, while 61 (23%) were initially admitted to the hospital ward, 50 of those undergoing ICU transfer within 72 h. Ward triage was associated with increased mortality (OR 2.6, P = 0.056) after propensity adjustment. The effect was less (OR 2.2, P = 0.12) after controlling for radiographic progression. The effect probably increased (OR 4.1, P = 0.07) among patients with ≥ 3 severity predictors at admission. Conclusions: Initial ward triage among patients transferred to the ICU is associated with twofold higher 30‐day mortality. This effect is most apparent among patients with ≥ 3 severity predictors at admission and is attenuated by controlling for radiographic progression. Intensive monitoring of ward‐admitted patients with CAP seems warranted. Further research is needed to optimize triage in CAP.     

Intensive care for the elderly: outcome of elective and nonelective admissions

Survival, quality of life, and need for continuing medical care were evaluated for 134 elderly patients admitted to the intensive care units (ICU) at Stanford University Hospital and for a control group. Of the patient group, 57.5% were admitted to the ICU following elective surgery; 42.5% were emergency surgical and medical patients. Hospital mortality was 3.9% for elective and 22.8% for nonelective patients; 18-month mortality was 13.0% and 47.4%, respectively. Fifty-nine patients (60.8% of survivors) completed follow-up questionnaires. Subjective and objective quality of life was good. Quality of life was slightly worse for ICU survivors than for controls; elective and nonelective patients did not differ significantly. Although the cost of ICU hospitalization was high, additional medical care was not excessive. Nonelective patients required more continuing care than elective patients, and both groups required more than controls.     

Autoimmune rheumatic diseases in the intensive care unit: experience from a tertiary referral hospital and review of the literature

Autoimmune rheumatic diseases (AIRD) are not uncommon in the general population and up to one third of hospitalized patients with AIRD may need admission to intensive care unit (ICU). This paper describes the causes of admission, the clinical features and outcome of 24 AIRD patients admitted to a medical ICU from a third level hospital. Thirteen patients had systemic lupus erythematosus (54.2%), three rheumatoid arthritis (12.5%), three pulmonary renal syndrome (12.5%), two dermatopolymyositis (8.3%), two scleroderma (8.3%) and one antiphospholipid syndrome (4.2%). The main causes for ICU admission were rheumatic disease flare-up (37.5%), infection (37.5%) and complications derived from rheumatic disease (29.1%). Mortality during ICU stay was 16.7% (four patients). Excluding shock requiring vasopressor support, no statistical difference was found between survivors and nonsurvivors; although there was a trend to higher test severity scores (APACHE II, ODIN) in nonsurvivors. Our results reveal a lower mortality rate in AIRD patients admitted to the ICU than reported previously. Severity scores such as APACHE II are predictors of mortality in patients with AIRD in the ICU.     

Delirium in the intensive care unit: occurrence and clinical course in older patients

OBJECTIVES: To describe the occurrence of delirium in a cohort of older medical intensive care unit (ICU) patients and its short-term duration in the hospital and to determine the association between preexisting dementia and the occurrence of delirium. DESIGN: Prospective cohort study. SETTING: Fourteen-bed medical ICU of an 800-bed university teaching hospital. PARTICIPANTS: One hundred eighteen consecutive patients aged 65 and older admitted to the ICU. MEASUREMENTS: Baseline characteristics were obtained through surrogate interviews and medical chart review. Dementia was determined using two validated surrogate-rated instruments. Delirium was assessed daily in the ICU using the Confusion Assessment Method (CAM) for the ICU (CAM-ICU). After discharge from the ICU, patients were followed for up to 7 days using the CAM. RESULTS: Delirium was present in 37 of 118 (31%) patients on admission. Only 45 patients had a normal mental status on admission, of whom 14 (31%) became delirious during their hospital stay. In the post-ICU period, delirium occurred in 40% of patients. Almost half of patients with delirium in the ICU had persistent delirium in the post-ICU period. Overall, 83 of 118 (70%) had delirium during hospitalization. Stupor or coma occurred in 44% of the patients overall, and 89% of survivors of stupor/coma progressed to delirium. Patients with dementia were 40% more likely to be delirious (relative risk = 1.4, 95% confidence interval = 1.1-1.7), even after controlling for comorbidity, baseline functional status, severity of illness, and invasive procedures. CONCLUSION: Delirium is a frequent complication in older ICU patients and often persists beyond their ICU stay. Delirium in older ICU persons is a dynamic and complex process. Dementia is an important predisposing risk factor for the development of delirium in this population during and after the ICU stay.     

Family satisfaction in the ICU: differences between families of survivors and nonsurvivors

BACKGROUND: We previously noted that the families of patients dying in the ICU reported higher satisfaction with their ICU experience than the families of survivors. However, the reasons for this finding were unclear. In the current study, we sought to confirm these findings and identify specific aspects of care that were rated more highly by the family members of patients dying in the ICU compared to family members of ICU survivors. METHODS: A total of 539 family members with a patient in the ICU were surveyed. Family satisfaction was measured using the 24-item family satisfaction in the ICU questionnaire. Ordinal logistic regression identified which components of family satisfaction were associated with the patient's outcome (ie, whether the patient lived or died). RESULTS: A total of 51% of respondents had a loved one die in the ICU. Overall, the families of patients dying in the ICU were more satisfied with their ICU experience than were families of ICU survivors, and the largest differences were noted for care aspects directly affecting family members. Significant differences were found for inclusion in decision making, communication, emotional support, respect and compassion shown to family, and consideration of family needs (p<0.01). CONCLUSIONS: The families of patients dying in the ICU were more satisfied with their ICU experience than were the families of ICU survivors. The reasons for this difference were higher ratings on family-centered aspects of care. These findings suggest that efforts to improve the support of ICU family members should focus not only on the families of dying patients but also on the families of patients who survive their ICU stay.     

Two-year outcomes, health care use, and costs of survivors of acute respiratory distress syndrome

RATIONALE: Little is known about the long-term outcomes and costs of survivors of acute respiratory distress syndrome (ARDS). OBJECTIVES: To describe functional and quality of life outcomes, health care use, and costs of survivors of ARDS 2 yr after intensive care unit (ICU) discharge. METHODS: We recruited a cohort of ARDS survivors from four academic tertiary care ICUs in Toronto, Canada, and prospectively monitored them from ICU admission to 2 yr after ICU discharge. MEASUREMENTS: Clinical and functional outcomes, health care use, and direct medical costs. RESULTS: Eighty-five percent of patients with ARDS discharged from the ICU survived to 2 yr; overall 2-yr mortality was 49%. At 2 yr, survivors continued to have exercise limitation although 65% had returned to work. There was no statistically significant improvement in health-related quality of life as measured by Short-Form General Health Survey between 1 and 2 yr, although there was a trend toward better physical role at 2 yr (p = 0.0586). Apart from emotional role and mental health, all other domains remained below that of the normal population. From ICU admission to 2 yr after ICU discharge, the largest portion of health care costs for a survivor of ARDS was the initial hospital stay, with ICU costs accounting for 76% of these costs. After the initial hospital stay, health care costs were related to hospital readmissions and inpatient rehabilitation. CONCLUSIONS: Survivors of ARDS continued to have functional impairment and compromised health-related quality of life 2 yr after discharge from the ICU. Health care use and costs after the initial hospitalization were driven by hospital readmissions and inpatient rehabilitation.     

Sequential organ failure predicts mortality of patients with a haematological malignancy needing intensive care

OBJECTIVES: Poor survival of patients with a haematological malignancy admitted to the intensive care unit (ICU) prompts for proper admission triage and prediction of ICU treatment failure and long-term mortality. We therefore tried to find predictors of the latter outcomes. METHODS: A retrospective analysis of charts and a prospective follow-up study were done, of haemato-oncological patients, admitted to our ICU in a 7-year period with a follow-up until 2 yr thereafter. Clinical parameters during the first four consecutive days were taken to calculate the simplified acute physiology (SAPS II) and the sequential organ failure assessment (SOFA) scores, of proven predictive value in general ICU populations. RESULTS: From a total of 58 patients (n = 47 with acute myelogenous leukaemia or non-Hodgkin lymphoma), admitted into ICU mostly because of respiratory insufficiency, sepsis, shock or combinations, 36 patients had died during their stay in the ICU. Of ICU survivors (n = 22), 20 patients died during follow-up so that the 1-year survival rate was only 12%. The SAPS II and particularly the SOFA scores were of high predictive value for ICU and long-term mortality. CONCLUSIONS: Patients with life-threatening complications of haematological malignancy admitted to ICU ran a high risk for death in the ICU and on the long-term, and the risk can be well predicted by SOFA. The latter may help us to decide on intensive care in individual cases, in order to avoid potentially futile care for patients with a SOFA score of 15 or higher.     

Strict blood glucose control with insulin during intensive care after cardiac surgery: impact on 4-years survival, dependency on medical care, and quality-of-life.

AIMS: To document the impact of intensive insulin therapy during intensive care on long-term (4 years) outcome of high-risk cardiac surgery patients. METHODS AND RESULTS: In this pre-planned sub-analysis and follow-up study of a large, randomized controlled trial on the effects of intensive insulin therapy during critical illness, we assessed long-term outcome in the 970 patients who had been admitted after high-risk cardiac surgery (mean+/-SD EuroSCORE of 6.0+/-3.7; EuroSCORE-predicted hospital mortality of 9.9%; observed hospital mortality of 7.5% in the conventional insulin group and 3.4% in the intensive insulin group). Long-term outcome was quantified as: (a) 4 years survival; (b) incidence of hospital re-admission; (c) level of activity and medical care requirements at 4 years as assessed by the Karnofsky score; and (d) perceived health-related quality-of-life at 4 years as assessed by the Nottingham Health Profile. Four years after ICU admission, the number of post-hospital discharge deaths was similar in the two study groups, reflecting maintenance of the acute survival benefit with intensive insulin therapy. Survivors who had been treated with intensive insulin during ICU stay revealed a similar risk for hospital re-admission and a comparable level of dependency on medical care. There was no effect on quality-of-life in the total group, whereas the increased survival of sicker patients with at least 3 days of insulin therapy evoked a more compromised perceived quality-of-life, in particular regarding social and family life. CONCLUSION: The short-term survival benefit obtained with insulin-titrated glycaemic control during intensive care after cardiac surgery was maintained after 4 years, without inducing increased medical care requirements but possibly at the expense of compromised perceived quality of social and family life.     

Clinical outcomes and need for intensive care after non-ST-segment-elevation myocardial infarction

BackgroundThe decision on whether non-ST-segment elevation myocardial infarction (NSTEMI) patients should be admitted to intensive care units (ICU) takes into account several factors including hospital routines. The Acute Coronary Treatment and Intervention Outcomes Network (ACTION) ICU score was developed to predict complications requiring ICU care post-NSTEMI.MethodsWe described patient characteristics and clinical outcomes of 1263 NSTEMI patients admitted to a private hospital in Sao Paulo, Brazil, from 2014 to 2018. We also aimed to retrospectively identify NSTEMI patients who might not have needed to be admitted to the ICU based on the ACTION ICU risk score. We defined complications requiring ICU care post-NSTEMI as cardiac arrest, cardiogenic shock, stroke, re-infarction, death, heart block requiring pacemaker placement, respiratory failure, or sepsis.ResultsMean age was 62.3 years and 35.8% were female. A total of 94.6% of NSTEMI patients were admitted to the ICU. Most NSTEMI patients (91.9%) underwent coronary angiography. Percutaneous coronary intervention was performed in 47.1% and coronary artery bypass graft surgery in 10.3%. Complications requiring ICU care occurred in 62 patients (4.9%). In-hospital mortality rate was 1.3%. Overall, 70.4% had an ACTION ICU score ≤ 5. The C-statistics for the ACTION risk score to predict complications was 0.55 (95% confidence interval 0.47–0.63).ConclusionsComplications requiring ICU care were infrequent in a cohort of NSTEMI patients who were routinely admitted to the ICU over a 4-year period. The ACTION risk score had low accuracy in the prediction of complications requiring ICU care in our population.     

Asthma treatment and outcomes for children in the emergency department and hospital

Objective: To describe and compare the treatment of acute asthma exacerbations in children given in the emergency department (ED) and admitted to acute care floor in the hospital or intensive care unit (ICU). Methods: A retrospective chart review of visits for acute exacerbation of asthma treated at Phoenix Children's Hospital between January 1, 2014 and December 31, 2016. Results: A total of 287 asthma exacerbation cases were identified including 106 (37%) ED visits, 134 (47%) hospital floor and 47 (16%) ICU admissions. A history of a previous ED visit (ED 88%, Floor 60% and ICU 68%; p < 0.0001) and prior pulmonology inpatient consultation (ED 30%, Floor 19% and ICU 15%; p = 0.05) varied significantly. Pulmonology inpatient consultations were performed more frequently in the ICU than on the hospital floor (54% versus 8%; p < 0.0001). Although overall 145 (51%) of the cases were already on inhaled corticosteroids (ICS) at the time of visit with no differences across locations, ICS initiation/step-up was greater in the ICU (72%) than on the hospital floor (54%) and ED (2%) (p < 0.0001). A recommendation given to the family for follow-up with pulmonology was more frequent for patients who had been admitted to the ICU (68%) as compared to those only admitted to the floor (31%) or ED (4%) (p < 0.0001). Readmission rates were similar for patients previously admitted to the hospital (Floor 42%; ICU 40%), but significantly higher for previous ED visits (77%) (p < 0.0001). Conclusions: Physicians in the ED have an opportunity to provide preventative care in the acute care setting and should be encouraged to initiate treatment with ICS. Consideration should be given to develop a program or clinical pathway focused on long-term asthma management and maintenance to reduce readmissions and long hospital stays.     

Mechanically assisted ventilation in a community hospital. Immediate outcome, hospital charges, and follow-up of patients

In 100 consecutive patients undergoing mechanically assisted ventilation, we prospectively determined immediate survival, hospitalization charges, and subsequent one-year outcome. Sixty percent of the patients survived the episode of assisted ventilation. This survival decreased to 50% at the time of hospital discharge and to 33% one year after hospitalization. There were no posthospitalization deaths in patients less than age 50 years. In those patients older than 70 years, however, 51% were dead by the time of hospital discharge and 73% died by one year following discharge. Comparison of features that reflect the magnitude of intensive respiratory care, such as hours of ventilation and intensive care unit (ICU) length of stay, disclosed no statistically significant differences between survivors and nonsurvivors at discharge. Hospitalization charges averaged $10,968 per patient. The total charge for respiratory therapy services (including arterial blood gas determinations) averaged $2,200. Respiratory care service charges were only marginally different between survivors and nonsurvivors. By contrast, total charges and total length of stay were greater for the survivors. Resource use in the intensive care setting as reflected by hours of mechanical ventilation and ICU length of stay was similar in both survivors and nonsurvivors, with the larger total cost for survivors relating primarily to care outside the ICU. Also, we confirm that prognosis is excellent in patients less than 50 years of age who survive mechanically assisted ventilation for acute respiratory failure and that extubation in elderly patients is not necessarily indicative of a good prognosis.     

A comparative study of community-acquired pneumonia patients admitted to the ward and the ICU

BACKGROUND: Limited information is available on the health-care utilization of hospitalized patients with community-acquired pneumonia (CAP) depending on the location of care. Our aim was to compare the clinical characteristics, etiologies, and outcomes of patients with CAP who were admitted to the ICU with those admitted who were to the ward service. METHODS: A retrospective cohort study, at two tertiary teaching hospitals, one of which was a Veterans Affairs hospital, and the other a county hospital. Eligible subjects had been admitted to the hospital with a diagnosis of CAP between January 1, 1999, and December 31, 2001, had a confirmatory chest radiograph, and a hospital discharge International Classification of Diseases, ninth revision, diagnosis of pneumonia. Subjects were excluded from the study if they had designated "comfort measures only" or had been transferred from another acute care hospital or were nursing home patients. Bivariate and multivariable analysis evaluated 30-day and 90-day mortality as the dependent measures. RESULTS: Data were abstracted on 730 patients (ICU, 145 patients; wards, 585 patients). Compared to ward patients, ICU patients were more likely to be male (p = 0.001), and to have congestive heart failure (p = 0.01) and COPD (p = 0.01). ICU patients also had higher mean pneumonia severity index scores (112 [SD, 35] vs 83 [SD, 30], respectively; p = 0.02). Patients admitted to the ICU had a longer mean length of hospital stay (12 days [SD, 10 days] vs 7 days [SD, 17 days], respectively; p = 0.07), and a higher 30-day mortality rate (23% vs 4%, respectively; p < 0.001) and 90-day mortality rate (28% vs 8%, respectively; p < 0.001) compared to ward patients. CONCLUSIONS: ICU patients present with more severe disease and more comorbidities. ICU patients stay longer in the hospital and have a much higher mortality rate when compared to ward patients. Management strategies should be designed to improve clinical outcomes in ICU patients.     

Patient-centered outcomes at hospital discharge in mechanically ventilated COVID-19 patients in Kobe,Japan: A single-center retrospective cohort study

BackgroundApart from saving the lives of coronavirus disease (COVID-19) patients on mechanical ventilation (MV), recovery from the sequelae of prolonged MV (PMV) is an emerging issue.cMethodsWe conducted a retrospective study among consecutive adult COVID-19 patients admitted to an intensive care unit (ICU) in Kobe, Japan, between March 3, 2020, and January 31, 2021, and received invasive MV. Clinical outcomes included in-hospital mortality and recovery from COVID-19 in survivors regarding organ dysfunction, respiratory symptoms, and functional status at discharge. We compared survivors’ outcomes with MV durations of >14 days and ≤14 days.ResultsWe included 85 patients with a median age of 69 years (interquartile range, 64–75 years); 76 (89%) patients had at least 1 comorbidity, 72 (85%) were non-frail, and 79 (93%) were functionally independent before COVID-19 infection. Eighteen patients (21%) died during hospitalization. At discharge, 59/67 survivors (88%) no longer required respiratory support, 50 (75%) complained of dyspnea, and 40 (60%) were functionally independent. Of the survivors, 23 patients receiving MV for >14 days had a worse recovery from COVID-19 at discharge compared with those on MV for ≤14 days, as observed using the Barthel index (median: 35 [5–65] vs. 100 [85–100]), ICU mobility scale (8 [5–9] vs. 10 [10-10]), and functional oral intake scale (3 [1–7] vs. 7 [7-7]) (P < 0.0001).ConclusionAlthough four-fifths of the patients survived and >50% of survivors demonstrated clinically important recovery in organ function and functional status during hospitalization, PMV was related to poor recovery from COVID-19 at discharge.     

Effect of pneumococcal vaccination in hospitalized adults with community-acquired pneumonia

BACKGROUND: Although 23-valent polysaccharide pneumococcal vaccine (PPV) does not prevent community-acquired pneumonia (CAP), it might still improve outcomes in those who develop pneumonia. We tested this hypothesis using a population-based cohort of hospitalized patients with CAP. METHODS: From 2000 to 2002, we prospectively collected data on all adults with CAP admitted to 6 hospitals in Capital Health, the largest integrated health delivery system in Canada. Polysaccharide pneumococcal vaccine status was ascertained by interview, medical record review, and contact with physicians and community health offices. The primary outcome was the composite of in-hospital mortality or intensive care unit (ICU) admission. Multivariable regression was used to determine the independent association between PPV use and outcomes, after adjusting for patient characteristics, pneumonia severity, and propensity scores. RESULTS: Of the 3415 patients with CAP (median age, 75 years), 46% were female, 62% had severe pneumonia, and 22% had prior PPV. Overall, 624 patients died or were admitted to an ICU. Polysaccharide pneumococcal vaccine was protective from reaching this composite end point (73/760 [10%] vs 551/2655 [21%] for unvaccinated patients; P < .001), mostly a result of reduced ICU admission (2/760 [<1%] vs 349/2655 [13%]). The propensity-adjusted odds of death or ICU admission was 0.62 (95% confidence interval, 0.42-0.92; P = .02) for patients who had received PPV. Only 215 of 2416 patients (9%) eligible for PPV at hospital discharge were vaccinated. CONCLUSIONS: Patients with CAP who had prior PPV had about a 40% lower rate of mortality or ICU admission compared with those who were not vaccinated. This provides additional support for recommending PPV to those at risk of pneumonia.     

Coronary care unit utilization in Hamilton, Ontario, a city of 375,000 people

All cardiac admissions to coronary care unit (CCU) beds and all intensive care unit (ICU) overflow admissions in Hamilton, Ontario, a city of 375,000 people, were documented over a one-year period, 1979-80. There were 4180 such admissions, 89% of them to CCUs. In the CCUs, 22% of patients had acute myocardial infarction, 24% unstable angina and 21% other chest pain. For myocardial infarction, hospitalization rate was 224 per 100,000, hospital mortality 42 per 100,000 and 48% of all myocardial infarction deaths in the community occurred in hospital. Of all myocardial infarction patients admitted to the CCU, 69% were correctly diagnosed on admission (sensitivity) and of all the admission diagnoses of myocardial infarction, 72% were eventually found to be correct (positive predictive value). Mean values for CCU patients overall were age 62.5 years, CCU stay 2.88 days and hospital stay 9.7 days; and for acute myocardial infarction patients in CCUs, age 63.4 years, CCU stay 3.98 days and hospital stay 13.28 days. For myocardial infarction, CCU mortality was 10.9%, hospital mortality 15.2% and, with the inclusion of ICU overflow patients, hospital mortality was 17.6%. Age-specific mortality for myocardial infarction was 9.7% age 45 to 64 years, and 32.8% over 70 years.     

Extra-pulmonary complications of 45 critically ill patients with COVID-19 in Yichang,Hubei province,China: A single-centered,retrospective, observation study

Mortality of critically ill patients with coronavirus disease 2019 (COVID-19) was high. Aims to examine whether time from symptoms onset to intensive care unit (ICU) admission affects incidence of extra-pulmonary complications and prognosis in order to provide a new insight for reducing the mortality. A single-centered, retrospective, observational study investigated 45 critically ill patients with COVID-19 hospitalized in ICU of The Third People''s Hospital of Yichang from January 17 to March 29, 2020. Patients were divided into 2 groups according to time from symptoms onset to ICU admission (>7 and ≤7 days) and into 2 groups according to prognosis (survivors and non-survivors). Epidemiological, clinical, laboratory, radiological characteristics and treatment data were studied. Compared with patients who admitted to the ICU since symptoms onset ≤7 days (55.6%), patients who admitted to the ICU since symptoms onset >7 days (44.4%) were more likely to have extra-pulmonary complications (19 [95.0%] vs 16 [64.0%], P = .034), including acute kidney injury, cardiac injury, acute heart failure, liver dysfunction, gastrointestinal hemorrhage, hyperamylasemia, and hypernatremia. The incidence rates of acute respiratory distress syndrome, pneumothorax, and hospital-acquired pneumonia had no difference between the 2 groups. Except activated partial thromboplastin and Na⁺ concentration, the laboratory findings were worse in group of time from symptoms onset to ICU admission >7 days. There was no difference in mortality between the 2 groups. Of the 45 cases in the ICU, 19 (42.2%) were non-survivors, and 16 (35.6%) were with hospital-acquired pneumonia. Among these non-survivors, hospital-acquired pneumonia was up to 12 (63.2%) besides higher incidence of extra-pulmonary complications. However, hospital-acquired pneumonia occurred in only 4 (15.4%) survivors. Critically ill patients with COVID-19 who admitted to ICU at once might get benefit from intensive care via lower rate of extra-pulmonary complications.