FORUM MŁODYCH Isolated coronary artery bypass grafting in extracorporeal circulation in patients over 65 years old – does age still matter?
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Coronary artery bypass grafting (CABG) is conducted more and more commonly in patients in advanced age.To analyze the influence of age and concurrent risk factors on the complications and early mortality after CABG.Medical records of 2194 patients were analyzed retrospectively. A group of 1303 patients who had undergone isolated CABG was selected. 106 (4.8%) patients were excluded due to missing data in their medical records. The remaining 1197 patients were divided into two subgroups by age: 1(st) group < 65 years (n = 662; 55.3%); 2(nd) group ≥ 65 years (n = 535; 44.7%).The total 30-day mortality was 3.93% and was six times higher in the older group (1.21 vs. 7.29%; p < 0.001). Complications were observed in 176 (14.70%) patients, more often in the older group (10.42% vs. 20.0%; p < 0.001). In this group all kinds of complications were noted more often and in particular: postoperative myocardial infarction (1.96% vs. 5.42%; p = 0.001), respiratory dysfunction (1.36% vs. 4.11%; p = 0.005), neurological complications (1.81% vs. 3.74%; p = 0.04) and multi-organ dysfunction syndrome (0.30% vs. 1.68%, p = 0.03). The older patients required longer time under mechanical ventilation (24.0 ± 27.9 vs. 37.0 ± 74.1 hours; p = 0.004) and stayed longer in the intensive care unit: 2.5 ± 3.0 vs. 4.1 ± 7.84 days; p < 0.001. Independent predictors of death were: female sex [OR (95% CI) = 2.4 (1.2-4.5)], age ≥ 65 years [OR = 4.9 (2.1-11.1)], eGFR < 60 mL/min/1.73 m(2) [OR = 2.2 (1.0-4.7)], time at extracorporeal circulation > 72 minutes [OR = 5.5 (2.7-10.9)] and left main stem stenosis (> 50%) [OR = 2.4 (1.3-4.6)].Age still significantly influences postoperative complications and mortality after isolated CABG.Pomostowaniu aortalno-wieńcowemu (PAW) w ostatnich latach poddawani są pacjenci w coraz bardziej zaawansowanym wieku.Ocena wpływu wieku i współistniejących czynników ryzyka na wystąpienie powikłań pooperacyjnych oraz wczesną śmiertelność pooperacyjną po izolowanym PAW.Retrospektywnie przeanalizowano dokumentację medyczną 2194 pacjentów. Wyselekcjonowano grupę 1303 zabiegów izolowanego PAW. Z analizy wykluczono pacjentów bez kompletnego zestawu danych klinicznych (n = 106; 4,8%). Pozostałych 1197 pacjentów podzielono na dwie podgrupy według wieku: grupa 1 – osoby < 65. roku życia (n = 662; 55,3%); grupa 2 – osoby ≥ 65. roku życia (n = 535; 44,7%).Śmiertelność 30-dniowa wyniosła 3,93% i była ponad 6-krotnie wyższa u osób starszych (1,21 vs 7,29%; p < 0,001). Powikłania wystąpiły ogółem u 176 (14,70%) pacjentów, częściej u osób w starszej grupie wiekowej (10,42% vs 20,0%; p < 0,001). W tej grupie odnotowano również większą częstość występowania wszystkich rodzajów powikłań, w szczególności: świeżego pooperacyjnego zawału serca (1,96% vs 5,42%; p = 0,001), powikłań oddechowych (1,36% vs 4,11%; p = 0,005), powikłań neurologicznych (1,81% vs 3,74%; p = 0,04) oraz niewydolności wielonarządowej (0,30% vs 1,68%; p = 0,03). Starsi pacjenci wymagali dłuższego mechanicznego wspomagania wentylacji (24,0 ± 27,9 vs 37,0 ± 74,1 godz.; p = 0,004) oraz dłużej przebywali na oddziale intensywnej opieki medycznej (2,5 ± 3,0 vs 4,1 ± 7,84 dnia; p < 0,001). Niezależnymi predyktorami zgonu były: płeć żeńska [OR (95% CI) = 2,4 (1,2–4,5)], wiek ≥ 65 lat [OR = 4,9 (2,1–11,1)], eGFR < 60 ml/min/1,73 m2 [OR = 2,2 (1,0-4,7)], czas trwania krążenia pozaustrojowego > 72 minut [OR = 5,5 (2,7–10,9)] oraz obecność zwężenia pnia lewej tętnicy wieńcowej (> 50%) [OR = 2,4 (1,3–4,6)].Wiek wciąż istotnie wpływa na śmiertelność i częstość występowania powikłań po izolowanym PAW.Keywords:
Extracorporeal circulation
Medical record
Extracorporeal circulation
Extracorporeal
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Abstract The impact of mechanical ventilation on the daily costs of intensive care unit (ICU) care is largely unknown. We thus conducted a systematic search for studies measuring the daily costs of ICU stays for general populations of adults (age ≥18 years) and the added costs of mechanical ventilation. The relative increase in the daily costs was estimated using random effects meta regression. The results of the analyses were applied to a recent study calculating the excess length-of-stay associated with ICU-acquired (ventilator-associated) pneumonia, a major complication of mechanical ventilation. The search identified five eligible studies including a total of 54 766 patients and ~238 037 patient days in the ICU. Overall, mechanical ventilation was associated with a 25.8% (95% CI 4.7%–51.2%) increase in the daily costs of ICU care. A combination of these estimates with standardised unit costs results in approximate daily costs of a single ventilated ICU day of €1654 and €1580 in France and Germany, respectively. Mechanical ventilation is a major driver of ICU costs and should be taken into account when measuring the financial burden of adverse events in ICU settings.
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Despite decades of experience in tracheotomy, there still exists a controversy over its ideal timing.The aim of our study was to compare the impact of early and late percutaneous tracheotomy in terms of their ability to reduce mechanical ventilation duration and length of stay in Intensive Care Unit, as well as the frequency of ventilator-associated pneumonia and mortality rates in tracheotomized patients.This retrospective observational study indicated that early tracheotomy in surgical and neurosurgical patients was associated with a reduced duration of mechanical ventilation and reduced length of stay in Intensive Care Unit, but was unable to reduce the frequency of ventilator-associated pneumonia and mortality.The reason behind the shorter duration of mechanical ventilation and shorter length of stay in Intensive Care Unit in the early tracheotomy arm was shorter duration of mechanical ventilation carried out prior to tracheotomy, while the duration of mechanical ventilation and the length of stay in Intensive Care Unit after tracheotomy were similar in both groups, suggesting that the procedure itself and not its timing influenced the duration of mechanical ventilation and the length of stay in Intensive Care Unit of tracheotomized patients.
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DONALD, DAVID E. B.V.S., M.R.C.V.S.; HARSHBARGER, HERRY G. M.D.; KIRKLIN, JOHN W. M.D. Author Information
Extracorporeal circulation
Circulation (fluid dynamics)
Blood circulation
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Factors associated with survival in patients undergoing invasive mechanical ventilation in an intensive care unit in Colombia Objective: To determine the clinical characteristics and outcomes of critically ill patients who required invasive mechanical ventilation in an intensive care unit of a high-complexity hospital in Colombia. Methods: This was a retrospective follow-up study of a cohort of adult patients who required invasive mechanical ventilation in an intensive care unit. Sociodemographic, clinical, and pharmacological variables were identified. Using Cox regression, variables associated with survival and complications were identified. Results: A total of 357 patients were analyzed. They had an average age of 64.8±18.9 years, and 52.9% were male. The most frequent diagnoses were sepsis/septic shock (38.4%) and trauma (17.4%). The main factors associated with shorter survival were advanced age (HR:0.97, 95%CI:0.96–0.99), a diagnosis of septic shock (HR:0.29; 95%CI:0.18–0.48) or diabetes mellitus at admission (HR:0.57; 95%CI:0.33–0.98), suffering from a healthcare-associated infection (HR: HR:0.51; 95%CI:0.33–0.80), and the need for vasopressors (HR:0.36; 95%CI:0.22–0.59). The administration of systemic corticosteroids was associated with a higher probability of survival (HR:1.93; 95%CI:1.15–3.25). Conclusions: The use of systemic corticosteroids was associated with a greater probability of survival in critically ill patients who required invasive mechanical ventilation in an intensive care unit. The identification of the variables associated with a higher risk of dying should allow care protocols to be improved, thereby extending the life expectancy of these patients.
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The number of patients who require prolonged mechanical ventilation increased during the last decade, which generated a large population of chronically ill patients. This study established the incidence of prolonged mechanical ventilation in four intensive care units and reported different characteristics, hospital outcomes, and the impact of costs and services of prolonged mechanical ventilation patients (mechanical ventilation dependency ≥ 21 days) compared with non-prolonged mechanical ventilation patients (mechanical ventilation dependency < 21 days).This study was a multicenter cohort study of all patients who were admitted to four intensive care units. The main outcome measures were length of stay in the intensive care unit, hospital, complications during intensive care unit stay, and intensive care unit and hospital mortality.There were 5,287 admissions to the intensive care units during study period. Some of these patients (41.5%) needed ventilatory support (n = 2,197), and 218 of the patients met criteria for prolonged mechanical ventilation (9.9%). Some complications developed during intensive care unit stay, such as muscle weakness, pressure ulcers, bacterial nosocomial sepsis, candidemia, pulmonary embolism, and hyperactive delirium, were associated with a significantly higher risk of prolonged mechanical ventilation. Prolonged mechanical ventilation patients had a significant increase in intensive care unit mortality (absolute difference = 14.2%, p < 0.001) and hospital mortality (absolute difference = 19.1%, p < 0.001). The prolonged mechanical ventilation group spent more days in the hospital after intensive care unit discharge (26.9 ± 29.3 versus 10.3 ± 20.4 days, p < 0.001) with higher costs.The classification of chronically critically ill patients according to the definition of prolonged mechanical ventilation adopted by our study (mechanical ventilation dependency ≥ 21 days) identified patients with a high risk for complications during intensive care unit stay, longer intensive care unit and hospital stays, high death rates, and higher costs.
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To quantify the mean daily cost of intensive care, identify key factors associated with increased cost, and determine the incremental cost of mechanical ventilation during a day in the intensive care unit.Retrospective cohort analysis using data from NDCHealth's Hospital Patient Level Database.A total of 253 geographically diverse U.S. hospitals.The study included 51,009 patients >/=18 yrs of age admitted to an intensive care unit between October 1, 2002, and December 31, 2002.None.Days of intensive care and mechanical ventilation were identified using billing data, and daily costs were calculated as the sum of daily charges multiplied by hospital-specific cost-to-charge ratios. Cost data are presented as mean (+/-sd). Incremental daily cost of mechanical ventilation was calculated using log-linear regression, adjusting for patient and hospital characteristics. Approximately 36% of identified patients were mechanically ventilated at some point during their intensive care unit stay. Mechanically ventilated patients were older (63.5 yrs vs. 61.7 yrs, p < .0001) and more likely to be male (56.1% vs. 51.8%, p < 0.0001), compared with patients who were not mechanically ventilated, and required mechanical ventilation for a mean duration of 5.6 days +/- 9.6. Mean intensive care unit cost and length of stay were 31,574 +/- 42,570 dollars and 14.4 days +/- 15.8 for patients requiring mechanical ventilation and 12,931 +/- 20,569 dollars and 8.5 days +/- 10.5 for those not requiring mechanical ventilation. Daily costs were greatest on intensive care unit day 1 (mechanical ventilation, 10,794 dollars; no mechanical ventilation, 6,667 dollars), decreased on day 2 (mechanical ventilation:, 4,796 dollars; no mechanical ventilation, 3,496 dollars), and became stable after day 3 (mechanical ventilation, 3,968 dollars; no mechanical ventilation, 3,184 dollars). Adjusting for patient and hospital characteristics, the mean incremental cost of mechanical ventilation in intensive care unit patients was 1,522 dollars per day (p < .001).Intensive care unit costs are highest during the first 2 days of admission, stabilizing at a lower level thereafter. Mechanical ventilation is associated with significantly higher daily costs for patients receiving treatment in the intensive care unit throughout their entire intensive care unit stay. Interventions that result in reduced intensive care unit length of stay and/or duration of mechanical ventilation could lead to substantial reductions in total inpatient cost.
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This study aimed to characterize which are the early determinants of immediate failure of the use of noninvasive mechanical ventilation (NIMV) outside the ICU.This prospective study included patients who were admitted to the Military Hospital in Guayaquil, Ecuador. Each variable was analyzed independently by using a multiple logistic regression model toward establishing an association with the event.A total of 249 cases of NIMV over a 10 year period of its application outside the ICU was included in the study. Fifty-five (22.10%) patients were transferred to the ICU, A multivariate analysis showed that the determinants of immediate NIMV failure outside the ICU were the following: age (OR: 1.12; P = 0.03); SBP (OR: 1.04; P = 0.001); HR (OR: 1.66; P < 0.0001); pCO₂ (OR: 1.16; P = 0.007); pO2 (OR: 1.35; P = 0.003); levels of IPAP (OR: 1.35; P < 0.0001); and the number of quadrants affected, as shown in a chest X-ray (OR: 1.40; P < 0.0001).The number of affected quadrants in a chest X-ray, tachyarrhythmia and hypoxemia may be useful in the initial decision in the use of NIMV outside the ICU. High values of IPAP, the persistence of elevated pCO₂, arterial hypotension, and age could be useful as a second screening associated with immediate NIMV failure outside the ICU.
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