The relationship between treatment limitations and pressure on intensive care units in elderly patients

Jung, Christian; Lange, Dylan W. de; Beil, Michael; Guidet, Bertrand

doi:10.1007/s00134-021-06553-5

Cited by 6 publications

(7 citation statements)

References 4 publications

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“…The difference was even more pronounced in the matched pair analysis with almost twice as many decisions to withhold treatment in COVID compared with non-COVID patients. The results in the non-COVID patients agree with our previous study [ 28 ] and with other recent international studies [ 29 , 30 ] and are in line with a documented relation between treatment limitations and pressure on intensive care units in elderly patients [ 27 ]. We provide additional information about the timing of LLST.…”

Section: Discussionsupporting

confidence: 93%

“…Decisions to limit life-sustaining treatment in ICU seem to increase in parallel with the pressure to admit patients to ICU during the pandemic [ 27 ].…”

Section: Discussionmentioning

confidence: 99%

“…Decisions to institute LST might have also contributed to the high mortality of COVID patients [ 35 , 36 ], considering that intensivists would have to work under considerable pressure to increase bed availability [ 27 , 37 ]. However, in the matched analysis including patients without any limitation of LST, the survival was still lower among COVID patients suggesting that COVID per se carried a higher risk of mortality compared to other causes of acute respiratory failure (Fig.…”

Section: Discussionmentioning

confidence: 99%

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Increased 30-day mortality in very old ICU patients with COVID-19 compared to patients with respiratory failure without COVID-19

Guidet

Jung²,

Flaatten³

et al. 2022

Intensive Care Med

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Purpose The number of patients ≥ 80 years admitted into critical care is increasing. Coronavirus disease 2019 (COVID-19) added another challenge for clinical decisions for both admission and limitation of life-sustaining treatments (LLST). We aimed to compare the characteristics and mortality of very old critically ill patients with or without COVID-19 with a focus on LLST. Methods Patients 80 years or older with acute respiratory failure were recruited from the VIP2 and COVIP studies. Baseline patient characteristics, interventions in intensive care unit (ICU) and outcomes (30-day survival) were recorded. COVID patients were matched to non-COVID patients based on the following factors: age (± 2 years), Sequential Organ Failure Assessment (SOFA) score (± 2 points), clinical frailty scale (± 1 point), gender and region on a 1:2 ratio. Specific ICU procedures and LLST were compared between the cohorts by means of cumulative incidence curves taking into account the competing risk of discharge and death. Results 693 COVID patients were compared to 1393 non-COVID patients. COVID patients were younger, less frail, less severely ill with lower SOFA score, but were treated more often with invasive mechanical ventilation (MV) and had a lower 30-day survival. 404 COVID patients could be matched to 666 non-COVID patients. For COVID patients, withholding and withdrawing of LST were more frequent than for non-COVID and the 30-day survival was almost half compared to non-COVID patients. Conclusion Very old COVID patients have a different trajectory than non-COVID patients. Whether this finding is due to a decision policy with more active treatment limitation or to an inherent higher risk of death due to COVID-19 is unclear. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-022-06642-z.

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Section: Discussionsupporting

confidence: 93%

“…Decisions to limit life-sustaining treatment in ICU seem to increase in parallel with the pressure to admit patients to ICU during the pandemic [ 27 ].…”

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

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Increased 30-day mortality in very old ICU patients with COVID-19 compared to patients with respiratory failure without COVID-19

Guidet

Jung²,

Flaatten³

et al. 2022

Intensive Care Med

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“…This proportion is markedly higher compared to a cohort of merged VIP1 and VIP2 studies in which therapy limitation was introduced in 32% of patients [19,25]. We believe that this difference is yet another consequence of the ICUs being overflown by a staggering number of critically ill patients during the ongoing pandemic [26]. As a result, more advanced treatment modalities such as IMV and extracorporeal membrane oxygenation became reserved for younger and healthier patients with a more favourable prognosis.…”

Section: Discussionmentioning

confidence: 87%

Noninvasive ventilation in COVID-19 patients aged ≥ 70 years—a prospective multicentre cohort study

Polok

Fronczek²,

Artigas³

et al. 2022

Crit Care

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Background Noninvasive ventilation (NIV) is a promising alternative to invasive mechanical ventilation (IMV) with a particular importance amidst the shortage of intensive care unit (ICU) beds during the COVID-19 pandemic. We aimed to evaluate the use of NIV in Europe and factors associated with outcomes of patients treated with NIV. Methods This is a substudy of COVIP study—an international prospective observational study enrolling patients aged ≥ 70 years with confirmed COVID-19 treated in ICU. We enrolled patients in 156 ICUs across 15 European countries between March 2020 and April 2021.The primary endpoint was 30-day mortality. Results Cohort included 3074 patients, most of whom were male (2197/3074, 71.4%) at the mean age of 75.7 years (SD 4.6). NIV frequency was 25.7% and varied from 1.1 to 62.0% between participating countries. Primary NIV failure, defined as need for endotracheal intubation or death within 30 days since ICU admission, occurred in 470/629 (74.7%) of patients. Factors associated with increased NIV failure risk were higher Sequential Organ Failure Assessment (SOFA) score (OR 3.73, 95% CI 2.36–5.90) and Clinical Frailty Scale (CFS) on admission (OR 1.46, 95% CI 1.06–2.00). Patients initially treated with NIV (n = 630) lived for 1.36 fewer days (95% CI − 2.27 to − 0.46 days) compared to primary IMV group (n = 1876). Conclusions Frequency of NIV use varies across European countries. Higher severity of illness and more severe frailty were associated with a risk of NIV failure among critically ill older adults with COVID-19. Primary IMV was associated with better outcomes than primary NIV. Clinical Trial RegistrationNCT04321265, registered 19 March 2020, https://clinicaltrials.gov.

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“…In the S3 guideline referred to above, it is stated that clinical factors, including age and comorbidities, should be considered when deciding whether to intubate a patient [ 16 ]. In addition to the assessment of severity, frailty is often used as a decision-making aid [ 2 , 19 , 20 ]. This approach raises the question of whether age and multimorbidity are not only risk factors for needing intensive care [ 1 , 2 , 3 , 4 , 5 , 6 , 8 , 21 , 22 , 23 , 24 ], but also influence the success of certain intensive care interventions.…”

Section: Discussionmentioning

confidence: 99%

Age and Comorbidity Burden of Patients Critically Ill with COVID-19 Affect Both Access to and Outcome of Ventilation Therapy in Intensive Care Units

Hesselle

Borgmann

Rieg

et al. 2023

JCM

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During the COVID-19 pandemic, large numbers of elderly, multimorbid people required treatment in intensive care units. This study investigated how the inherent patient factors age and comorbidity burden affected the treatment strategy and the outcome achieved. Retrospective analysis of data from intensive care patients enrolled in the Lean European Open Survey on SARS-CoV2-Infected Patients (LEOSS) cohort found that a patient’s age and comorbidity burden in fact influenced their mortality rate and the use of ventilation therapy. Evidence showed that advanced age and multimorbidity were associated with the restrictive use of invasive ventilation therapies, particularly ECMO. Geriatric patients with a high comorbidity burden were clustered in the sub-cohort of non-ventilated ICU patients characterized by a high mortality rate. The risk of death generally increased with older age and accumulating comorbidity burden. Here, the more aggressive an applied procedure, the younger the age in which a majority of patients died. Clearly, geriatric, multimorbid COVID-19 patients benefit less from invasive ventilation therapies. This implies the need for a holistic approach to therapy decisions, taking into account the patient’s wishes.

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The relationship between treatment limitations and pressure on intensive care units in elderly patients

Cited by 6 publications

References 4 publications

Increased 30-day mortality in very old ICU patients with COVID-19 compared to patients with respiratory failure without COVID-19

Increased 30-day mortality in very old ICU patients with COVID-19 compared to patients with respiratory failure without COVID-19

Noninvasive ventilation in COVID-19 patients aged ≥ 70 years—a prospective multicentre cohort study

Age and Comorbidity Burden of Patients Critically Ill with COVID-19 Affect Both Access to and Outcome of Ventilation Therapy in Intensive Care Units

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