Increased need for interventions predicts mortality in the critically ill

Predictors of treatment limitations in Finnish intensive care units

BACKGROUND

Few studies have examined the factors that predict the limitations of life-sustaining treatment (LST) to patients in intensive care units (ICUs). We aimed to identify variables associated with the decision of withholding of life support (WHLS) at admission, WHLS during ICU stay and the withdrawal of ongoing life support (WDLS).

METHODS

This retrospective observational study comprised 17,772 adult ICU patients who were included in the nationwide Finnish ICU Registry in 2016. Factors associated with LST limitations were identified using hierarchical logistic regression.

RESULTS

The decision of WHLS at admission was made for 822 (4.6%) patients, WHLS during ICU stay for 949 (5.3%) patients, and WDLS for 669 (3.8%) patients. Factors strongly predicting WHLS at admission included old age (adjusted odds ratio [OR] for patients aged 90 years or older in reference to those younger than 40 years was 95.6; 95% confidence interval [CI], 47.2-193.5), dependence on help for activities of daily living (OR, 3.55; 95% CI, 3.01-4.2), and metastatic cancer (OR, 4.34; 95% CI, 3.16-5.95). A high severity of illness predicted later decisions to limit LST. Diagnoses strongly associated with WHLS at admission were cardiac arrest, hepatic failure and chronic obstructive pulmonary disease. Later decisions were strongly associated with cardiac arrest, hepatic failure, non-traumatic intracranial hemorrhage, head trauma and stroke.

CONCLUSION

Early decisions to limit LST were typically associated with old age and chronic poor health whereas later decisions were related to the severity of illness. Limitations are common for certain diagnoses, particularly cardiac arrest and hepatic failure.

Costs, outcome and cost-effectiveness of neurocritical care: a multi-center observational study

BACKGROUND

Neurocritical illness is a growing healthcare problem with profound socioeconomic effects. We assessed differences in healthcare costs and long-term outcome for different forms of neurocritical illnesses treated in the intensive care unit (ICU).

METHODS

We used the prospective Finnish Intensive Care Consortium database to identify all adult patients treated for traumatic brain injury (TBI), intracerebral hemorrhage (ICH), subarachnoid hemorrhage (SAH) and acute ischemic stroke (AIS) at university hospital ICUs in Finland during 2003-2013. Outcome variables were one-year mortality and permanent disability. Total healthcare costs included the index university hospital costs, rehabilitation hospital costs and social security costs up to one year. All costs were converted to euros based on the 2013 currency rate.

RESULTS

In total 7044 patients were included (44% with TBI, 13% with ICH, 27% with SAH, 16% with AIS). In comparison to TBI, ICH was associated with the highest risk of death and permanent disability (OR 2.6, 95% CI 2.1-3.2 and OR 1.7, 95% CI 1.4-2.1), followed by AIS (OR 1.9, 95% CI 1.5-2.3 and OR 1.5, 95% CI 1.3-1.8) and SAH (OR 1.8, 95% CI 1.5-2.1 and OR 0.8, 95% CI 0.6-0.9), after adjusting for severity of illness. SAH was associated with the highest mean total costs (€51,906) followed by ICH (€47,661), TBI (€43,916) and AIS (€39,222). Cost per independent survivor was lower for TBI (€58,497) and SAH (€96,369) compared to AIS (€104,374) and ICH (€178,071).

CONCLUSION

Neurocritical illnesses are costly and resource-demanding diseases associated with poor outcomes. Intensive care of patients with TBI or SAH more commonly result in independent survivors and is associated with lower total treatments costs compared to ICH and AIS.

Análisis de mortalidad de pacientes en unidad de cuidados intensivos en un hospital del departamento del Meta, Colombia

El número de unidades de cuidado intensivo ha aumentado en Colombia en los últimos 15 años. Esto ha permitido el acceso de pacientes de áreas apartadas a este recurso. El manejo especializado disminuye la mortalidad, sin embargo, aún es elevada. El objetivo del estudio fue evaluar los factores asociados a la mortalidad en una UCI mixta de un hospital regional.Se realizó un estudio de corte transversal con los datos de los pacientes que ingresaron en la unidad de cuidados intensivos del Hospital de Granada, Meta, Colombia; entre septiembre y diciembre de 2013.Se revisaron los registros de 134 pacientes que ingresaron en el periodo de estudio. El 32% de ellos falleció. Los factores asociados con la mortalidad fueron la gravedad, nivel de intervención terapéutica y necesidad de ventilación mecánica. Los pacientes críticos con puntajes altos de APACHE II y TISS-28 tienen mayor riesgo de fallecer, especialmente de forma temprana.