Outcomes after Critical Illness

Herridge, Margaret S.; Azoulay, Élie

doi:10.1056/nejmra2104669

Cited by 126 publications

(76 citation statements)

References 85 publications

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“…The median length of stay in all extreme-risk groups was 1 month, double the median length of stay of the high-risk patient (13 days). Patients who survived the first 30 days spent an average of 1 week of that time in intensive care, putting them at high risk of postintensive care syndrome such as post-traumatic stress disorder, intensive care unit acquired weakness and cognitive dysfunction [24,25].…”

Section: Discussionmentioning

confidence: 99%

Beyond high‐risk: analysis of the outcomes of extreme‐risk patients in the National Emergency Laparotomy Audit

Javanmard‐Emamghissi,

Doleman,

Lund

et al. 2023

Anaesthesia

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SummaryPatients who require emergency laparotomy are defined as high risk if their 30‐day predicted risk of mortality is ≥ 5%. Despite a large difference in the characteristics of patients with a mortality risk score of between 5% and 50%, these outcomes are aggregated by the National Emergency Laparotomy Audit (NELA). Our aim was to describe the outcomes of the cohort of patients at extreme risk of death, which we defined as having a NELA‐predicted 30‐day mortality of ≥ 50%. All patients enrolled in the NELA database between December 2012 and 2020 were included. We compared patient characteristics; length of hospital stay; rates of unplanned return to the operating theatre; and 90‐day survival in extreme‐risk groups (predicted ≥ 50%) and high‐risk patients (predicted 5–49%). Of 161,337 patients, 5193 (3.2%) had a predicted mortality of ≥ 50%. When patients were further subdivided, 2437 (47%) had predicted mortality of 50–59% (group 50–59); 1484 (29%) predicted mortality of 60–69% (group 60–69); 840 (16%) predicted mortality of 70–79% (group 70–79); and 423 (8%) predicted mortality of ≥ 80% (group 80+). Extreme‐risk patients were significantly more likely to have been admitted electively than high‐risk patients (p < 0.001). Length of stay increased from a median (IQR [range]) of 26 (16–43 [0–271]) days in group 50–59 to 35 (21–56 [0–368]) days in group 80+, compared with 17 (10–30 [0–1136]) days for high‐risk patients. Rates of unplanned return to the operating theatre were higher in extreme‐risk groups compared with high‐risk patients (11% vs. 8%). The 90‐day survival was 43% in group 50–59, 34% in group 60–69, 27% in group 70–79 and 17% in group 80+. These data underscore the need for a differentiated approach when discussing risk with patients at extreme risk of mortality following an emergency laparotomy. Clinicians should focus on patient priorities on quantity and quality of life during informed consent discussions before surgery. Future work should extend beyond the immediate postoperative period to encompass the longer‐term outcomes (survival and function) of patients who have emergency laparotomies.

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Section: Discussionmentioning

confidence: 99%

Beyond high‐risk: analysis of the outcomes of extreme‐risk patients in the National Emergency Laparotomy Audit

Javanmard‐Emamghissi,

Doleman,

Lund

et al. 2023

Anaesthesia

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“…Moreover, follow-up was limited to survival at 30 days. Data on survival beyond that time and quality of life, which may be impaired by new disabilities and post-ICU syndrome [ 30 ], could further support the decision-making about LST in very old patients. Lastly, patients for the VIP2 study were mostly recruited in Europe [ 14 ].…”

Section: Discussionmentioning

confidence: 99%

The role of clinical phenotypes in decisions to limit life-sustaining treatment for very old patients in the ICU

Mousai

Tafoureau

Yovell

et al. 2023

Ann. Intensive Care

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Background Limiting life-sustaining treatment (LST) in the intensive care unit (ICU) by withholding or withdrawing interventional therapies is considered appropriate if there is no expectation of beneficial outcome. Prognostication for very old patients is challenging due to the substantial biological and functional heterogeneity in that group. We have previously identified seven phenotypes in that cohort with distinct patterns of acute and geriatric characteristics. This study investigates the relationship between these phenotypes and decisions to limit LST in the ICU. Methods This study is a post hoc analysis of the prospective observational VIP2 study in patients aged 80 years or older admitted to ICUs in 22 countries. The VIP2 study documented demographic, acute and geriatric characteristics as well as organ support and decisions to limit LST in the ICU. Phenotypes were identified by clustering analysis of admission characteristics. Patients who were assigned to one of seven phenotypes (n = 1268) were analysed with regard to limitations of LST. Results The incidence of decisions to withhold or withdraw LST was 26.5% and 8.1%, respectively. The two phenotypes describing patients with prominent geriatric features and a phenotype representing the oldest old patients with low severity of the critical condition had the largest odds for withholding decisions. The discriminatory performance of logistic regression models in predicting limitations of LST after admission to the ICU was the best after combining phenotype, ventilatory support and country as independent variables. Conclusions Clinical phenotypes on ICU admission predict limitations of LST in the context of cultural norms (country). These findings can guide further research into biases and preferences involved in the decision-making about LST. Trial registration Clinical Trials NCT03370692 registered on 12 December 2017.

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“…Composite outcomes address the competing risk of death, but they do so by assigning equal importance to dissimilar outcomes (e.g., death and 28 days of mechanical ventilation, for a commonly-used composite outcome). Finally, multiple reliable measures of cognitive, functional, and health-related quality-oflife outcomes exist; in ICU survivors, however, quality of life may be driven more by quality-of-life prior to critical illness than by the ICU course itself [145][146][147][148]. Importantly, none of these items measures ''goal-concordant care'' -whether treatment decisions made and care delivered actually aligned with an individual patient's values and priorities.…”

Section: Oncologic Critical Care Outcomes: Measuring What Mattersmentioning

confidence: 99%

Sepsis and acute respiratory failure in patients with cancer: how can we improve care and outcomes even further?

Lyons,

McEvoy,

Hayes-Lattin

2023

Current Opinion in Critical Care

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Purpose of review Care and outcomes of critically ill patients with cancer have improved over the past decade. This selective review will discuss recent updates in sepsis and acute respiratory failure among patients with cancer, with particular focus on important opportunities to improve outcomes further through attention to phenotyping, predictive analytics, and improved outcome measures. Recent findings The prevalence of cancer diagnoses in intensive care units (ICUs) is nontrivial and increasing. Sepsis and acute respiratory failure remain the most common critical illness syndromes affecting these patients, although other complications are also frequent. Recent research in oncologic sepsis has described outcome variation – including ICU, hospital, and 28-day mortality – across different types of cancer (e.g., solid vs. hematologic malignancies) and different sepsis definitions (e.g., Sepsis-3 vs. prior definitions). Research in acute respiratory failure in oncology patients has highlighted continued uncertainty in the value of diagnostic bronchoscopy for some patients and in the optimal respiratory support strategy. For both of these syndromes, specific challenges include multifactorial heterogeneity (e.g. in etiology and/or underlying cancer), delayed recognition of clinical deterioration, and complex outcomes measurement. Summary Improving outcomes in oncologic critical care requires attention to the heterogeneity of cancer diagnoses, timely recognition and management of critical illness, and defining appropriate ICU outcomes.

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Outcomes after Critical Illness

Cited by 126 publications

References 85 publications

Beyond high‐risk: analysis of the outcomes of extreme‐risk patients in the National Emergency Laparotomy Audit

Beyond high‐risk: analysis of the outcomes of extreme‐risk patients in the National Emergency Laparotomy Audit

The role of clinical phenotypes in decisions to limit life-sustaining treatment for very old patients in the ICU

Sepsis and acute respiratory failure in patients with cancer: how can we improve care and outcomes even further?

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