01.04.2009 | Research | Ausgabe 2/2009 Open Access

Very old patients admitted to intensive care in Australia and New Zealand: a multi-centre cohort analysis
- Zeitschrift:
- Critical Care > Ausgabe 2/2009
Electronic supplementary material
Competing interests
Authors' contributions
Introduction
Materials and methods
Study population and setting
Data collection
Outcome measures
Statistical analysis
Results
Patient characteristics
Characteristics
|
Total (n = 120,123)
|
Age strata
|
P value
|
|||
---|---|---|---|---|---|---|
18 to 40 years (n = 16,732)
|
40.1 to 64.9 years (n = 42,285)
|
65 to 79.9 years (n = 45,466)
|
≥ 80 years (n = 15,640)
|
|||
Age (years)
|
61.7 (17.5)
|
29.4 (6.5)
|
54.4 (7.0)
|
72.7 (4.2)
|
84.2 (3.5)
|
<0.0001
|
Male sex
|
59.5
|
57.0
|
61.5
|
61.4
|
51.1
|
<0.0001
|
Hospital admission source
|
||||||
Home
|
79.2
|
74.4
|
79.0
|
81.0
|
79.8
|
<0.001
|
Other acute care hospital
|
17.2
|
22.3
|
18.3
|
16.3
|
15.6
|
|
Chronic care facility
|
1.3
|
0.6
|
0.8
|
1.2
|
3.3
|
|
Other intensive care unit
|
1.8
|
2.6
|
1.9
|
1.6
|
1.3
|
|
Co-morbid disease
|
||||||
Any
|
28.6
|
11.0
|
28.3
|
34.1
|
32.1
|
<0.001
|
≥ 2
|
6.5
|
2.5
|
6.3
|
7.8
|
7.3
|
<0.001
|
Specific co-morbid diseases
|
||||||
Cardiovascular
|
15.6
|
2.3
|
12.0
|
21.1
|
23.5
|
<0.001
|
Respiratory
|
8.4
|
3.2
|
7.6
|
10.7
|
9.5
|
<0.001
|
Immunocompromised
|
4.9
|
3.8
|
6.1
|
4.8
|
3.2
|
<0.001
|
Metastatic cancer
|
2.9
|
1.0
|
3.5
|
3.3
|
2.3
|
<0.001
|
Hepatic
|
2.3
|
2.3
|
4.1
|
1.2
|
0.5
|
<0.001
|
End-stage kidney disease
|
3.4
|
1.5
|
3.1
|
4.0
|
4.1
|
<0.001
|
Haematologic malignancy
|
1.7
|
1.3
|
2.1
|
1.7
|
1.1
|
<0.001
|
Admission details
|
||||||
Nonelective admission
|
61.0
|
83.4
|
60.5
|
53.0
|
61.8
|
<0.001
|
Surgical admission
|
49.7
|
29.8
|
48.6
|
56.8
|
53.0
|
<0.001
|
Cardiovascular
|
46.1
|
13.5
|
44.5
|
55.6
|
39.5
|
<0.001
|
Trauma
|
7.9
|
24.9
|
6.7
|
3.4
|
5.6
|
<0.001
|
Emergency surgical
|
31.3
|
62.5
|
28.6
|
25.3
|
38.1
|
<0.001
|
Primary diagnosis
|
||||||
Sepsis/septic shock
|
27.8
|
28.7
|
28.4
|
27.0
|
27.5
|
<0.001
|
Respiratory
|
11.7
|
12.0
|
12.5
|
11.4
|
10.0
|
<0.001
|
Neurologic
|
9.3
|
13.3
|
12.2
|
6.6
|
5.1
|
<0.001
|
Cardiac
|
9.3
|
4.7
|
8.6
|
10.5
|
12.3
|
<0.001
|
Gastrointestinal (other)
|
8.8
|
2.5
|
7.2
|
10.4
|
15.0
|
<0.001
|
Hepatic
|
5.9
|
4.0
|
6.5
|
5.5
|
7.4
|
<0.001
|
Metabolic/poisoning
|
5.3
|
16.8
|
5.9
|
1.7
|
1.7
|
<0.001
|
Gastrointestinal bleeding
|
2.3
|
1.3
|
2.3
|
2.2
|
4.0
|
<0.001
|
Characteristic
|
Total (n = 120,123)
|
Age strata
|
P value
|
|||
---|---|---|---|---|---|---|
18 to 40 years (n = 16,732)
|
40.1 to 64.9 years (n = 42,285)
|
65 to 79.9 years (n = 45,466)
|
≥ 80 years (n = 15,640)
|
|||
Illness severity scores
|
||||||
APACHE II
|
16.9 (7.7)
|
13.0 (7.4)
|
15.3 (7.6)
|
18.7 (7.2)
|
19.8 (7.1)
|
<0.001
|
Nonage-related APACHE
a
|
13.3 (7.3)
|
13.1 (7.4)
|
13.1 (7.6)
|
13.4 (7.2)
|
13.8 (7.1)
|
<0.001
|
APACHE III
|
55.1 (27.5)
|
42.3 (26.8)
|
49.4 (27.2)
|
60.8 (25.6)
|
67.5 (25.0)
|
<0.001
|
Mechanical ventilation (%)
|
52.0
|
52.9
|
53.7
|
53.1
|
43.7
|
<0.001
|
Creatinine (μmol/l)
|
90 (68 to 130)
|
75 (56 to 98)
|
80 (61 to 111)
|
98 (71 to 141)
|
110 (80 to 160)
|
<0.001
|
Urea (mmol/l)
|
6.6 (4.6 to 10.8)
|
4.5 (3.2 to 6.4)
|
5.9 (4.2 to 9.0)
|
7.6 (5.4 to 12)
|
9.4 (6.5 to 14.7)
|
<0.001
|
Urine output (l/24 hours)
|
1.9 (1.3 to 2.7)
|
2.3 (1.5 to 3.4)
|
2.0 (1.3 to 2.9)
|
1.8 (1.2 to 2.6)
|
1.6 (1.0 to 2.3)
|
<0.001
|
Acute kidney injury (%)
|
36.1
|
17.7
|
27.4
|
44.1
|
56.4
|
<0.001
|
Survival
Age strata
|
Crude mortality (%)
|
Predicted mortality (%)
|
ICU mortality (odds ratio (95% confidence interval))
|
Hospital mortality (odds ratio (95% confidence interval))
|
||||
---|---|---|---|---|---|---|---|---|
ICU
|
Hospital
|
APACHE II
|
APACHE III
|
Crude
|
Adjusted
a
|
Crude
|
Adjusted
b
|
|
18 to 40 years
c
|
5.6
|
7.1
|
14.6
|
10.1
|
1.0
|
1.0
|
1.0
|
1.0
|
40.1 to 64.9 years
|
7.6
|
11.4
|
22.5
|
15.3
|
1.39 (1.3 to 1.5)
|
1.44 (1.3 to 1.6)
|
1.69 (1.6 to 1.8)
|
1.77 (1.6 to 1.9)
|
65 to 79.9 years
|
9.8
|
16.6
|
30.1
|
21.7
|
1.85 (1.7 to 2.0)
|
2.13 (1.9 to 2.3)
|
2.62 (2.5 to 2.8)
|
3.17 (2.9 to 3.4)
|
≥ 80 years
|
12.0
|
24.0
|
32.7
|
25.3
|
2.30 (2.1 to 2.5)
|
2.70 (2.4 to 3.0)
|
4.16 (3.9 to 4.5)
|
5.37 (4.9 to 5.9)
|
Factor
|
Odds ratio (95% confidence interval)
|
P value
|
---|---|---|
Admission from chronic care facility
|
1.35 (1.09 to 1.67)
|
0.005
|
Co-morbid disease (present)
|
||
≤ 1
|
1.0
a
|
|
≥ 2
|
1.31 (1.12 to 1.52)
|
0.001
|
Admission type (present)
|
||
Elective surgical
|
1.0
a
|
|
Emergency surgical
|
1.83 (1.58 to 2.13)
|
<0.001
|
Medical
|
2.58 (2.22 to 3.00)
|
<0.001
|
Admission diagnosis (present)
|
||
Sepsis
|
1.24 (1.10 to 1.40)
|
<0.001
|
Trauma
|
1.28 (1.05 to 1.57)
|
0.016
|
Hepatic
|
1.21 (1.02 to 1.44)
|
0.025
|
Gastrointestinal (nonbleeding)
|
1.72 (1.48 to 1.99)
|
<0.001
|
Cardiac
|
1.54 (1.34 to 1.77)
|
<0.001
|
Neurologic
|
1.92 (1.59 to 2.33)
|
<0.001
|
Respiratory
|
1.29 (1.11 to 1.49)
|
0.01
|
Metabolic
|
0.53 (0.36 to 0.76)
|
0.01
|
Nonage-related APACHE II score (per point)
|
1.11 (1.10 to 1.11)
|
<0.001
|
Mechanical ventilation (present)
|
1.18 (1.07 to 1.30)
|
0.001
|
Acute kidney injury (present)
|
1.38 (1.25 to 1.51)
|
<0.001
|
ICU length of stay (log-transformed) (per day)
|
1.17 (1.11 to 1.24)
|
<0.001
|
Secondary outcomes
Clinical outcome
|
Total (n = 120,123)
|
Age strata
|
P value
|
|||
---|---|---|---|---|---|---|
18 to 40 years (n = 16,732)
|
40.1 to 64.9 years (n = 42,285)
|
65 to 79.9 years (n = 45,466)
|
≥ 80 years (n = 15,640)
|
|||
ICU length of stay (days)
|
||||||
Dead
|
3.9 (2.0 to 8.7)
|
4.4 (2.1 to 9.0)
|
4.0 (2.0 to 8.7)
|
3.9 (2.0 to 8.6)
|
3.5 (1.9 to 7.0)
|
0.0003
|
Alive
|
2.5 (1.7 to 4.8)
|
2.4 (1.6 to 4.9)
|
2.3 (1.6 to 4.6)
|
2.3 (1.7 to 4.3)
|
2.6 (1.7 to 4.5)
|
0.0001
|
Hospital length of stay (days)
|
||||||
Dead
|
9.7 (4.0 to 21.6)
|
6.7 (2.9 to 17.3)
|
9.0 (3.7 to 20.9)
|
10.3 (4.2 to 22.9)
|
10.0 (4.5 to 20.7)
|
0.0001
|
Alive
|
11.8 (7.1 to 21.8)
|
9.0 (4.6 to 19.3)
|
10.9 (6.9 to 20.6)
|
12.7 (8.0 to 22.0)
|
14.9 (9.1 to 25.8)
|
0.0001
|
Discharge location of survivors (%)
|
||||||
Home
|
83.2
|
84.9
|
86.0
|
83.1
|
72.2
|
|
Transfer to other hospital
|
11.1
|
11.2
|
9.9
|
10.9
|
15.1
|
<0.001
|
Rehabilitation/long-term care
|
5.7
|
3.8
|
4.1
|
6.1
|
12.3
|
Subgroup of ICU admissions in patients aged ≥ 85 years
Subgroup of ICU admissions in patients aged ≥ 90 years
Age strata
|
Crude mortality (%)
|
ICU mortality (odds ratio (95% confidence interval))
|
Hospital mortality (odds ratio (95% confidence interval))
|
|||
---|---|---|---|---|---|---|
ICU
|
Hospital
|
Crude
|
Adjusted
a
|
Crude
|
Adjusted
b
|
|
80 to 84.9 years
|
11.6
|
22.4
|
1.0
c
|
1.0
c
|
1.0
c
|
1.0
c
|
85 to 89.9 years
|
13.0
|
27.0
|
1.14 (1.02 to 1.27)
|
1.19 (1.04 to 1.36)
|
1.28 (1.18 to 1.40)
|
1.32 (1.20 to 1.46)
|
≥ 90 years
|
11.9
|
29.6
|
1.03 (0.85 to 1.25)
|
1.16 (0.93 to 1.46)
|
1.46 (1.27 to 1.68)
|
1.71 (1.46 to 2.01)
|
Sensitivity analysis and resource projection
Discussion
Conclusions
Key messages
-
Very old patients represented 13.0% of all patients admitted to the ICU and increased by 5.6% annually during the study.
-
Very old patients had lower short-term survival that was modified by prehospital function, co-morbid illness, surgical status, primary diagnosis, and illness severity.
-
Survivors of critical illness were more likely to be transitioned to rehabilitation or long-term care facilities.
-
These data imply a large projected need for ICU and hospital bed-days for very old patients within a decade.