Age Distribution and Clinical Results of Critically Ill Patients above 65-Year-Old in an Aging Society: A Retrospective Cohort Study

Background Increasing age has been observed among patients admitted to the intensive care unit (ICU). Age traditionally considered a risk factor for ICU mortality. We investigated how the epidemiology and clinical outcomes of older ICU patients have changed over a decade. Methods We analyzed patients admitted to the ICU at a university hospital in Seoul, South Korea. We defined patients aged 65 and older as older patients. Changes in age groups and mortality risk factors over the study period were analyzed. Results A total of 32,322 patients were enrolled who aged ≥65 years admitted to the ICUs between January 1, 2007, and December 31, 2017. Patients aged ≥65 years accounted for 35% and of these, the older (O, 65 to 74 years) comprised 19,630 (66.5%), very older (VO, 75 to 84 years) group 8,573 (29.1%), and very very older (VVO, ≥85 years) group 1,300 (4.4%). The mean age of ICU patients over the study period increased (71.9±5.6 years in 2007 vs. 73.2±6.1 years in 2017) and the proportions of the VO and VVO group both increased. Over the period, the proportion of female increased (37.9% in 2007 vs. 43.3% in 2017), and increased ICU admissions for medical reasons (39.7% in 2007 vs. 40.2% in 2017). In-hospital mortality declined across all older age groups, from 10.3% in 2007 to 7.6% in 2017. Hospital length of stay (LOS) decreased in all groups, but ICU LOS decreased only in the O and VO groups. Conclusion The study indicates a changing demographic in ICUs with an increase in older patients, and suggests a need for customized ICU treatment strategies and resources

Outcomes of critically ill patients according to the perception of intensivists on the appropriateness of intensive care unit admission

Background It is important for intensivists to determine which patient may benefit from intensive care unit (ICU) admission. We aimed to assess the outcomes of patients perceived as non-beneficially or beneficially admitted to the ICU and evaluate whether their prognosis was consistent with the intensivists’ perception. Methods A prospective observational study was conducted on patients admitted to the medical ICU of a tertiary referral center between February and April 2014. The perceptions of four intensivists at admission (day 1) and on day 3 were investigated as non-beneficial admission, beneficial admission, or indeterminate state. Results A total of 210 patients were enrolled. On days 1 and 3, 22 (10%) and 23 (11%) patients were judged as having non-beneficial admission; 166 (79%) and 159 (79%), beneficial admission; and 22 (10%) and 21 (10%), indeterminate state, respectively. The ICU mortality rates of each group on day 1 were 59%, 23%, and 59%, respectively; their 6-month mortality rates were 100%, 48%, and 82%, respectively. The perceptions of non-beneficial admission or indeterminate state were the significant predictors of ICU mortality (day 3; odds ratio [OR], 4.049; 95% confidence interval [CI], 1.892–8.664; P<0.001) and 6-month mortality (day 1: OR, 4.983; 95% CI, 1.260–19.703; P=0.022; day 3: OR, 4.459; 95% CI, 1.162–17.121; P=0.029). Conclusions The outcomes of patients perceived as having non-beneficial admission were extremely poor. The intensivists’ perception was important in predicting patients’ outcomes and was more consistent with long-term prognosis than with immediate outcomes. The intensivists’ role can be reflected in limited ICU resource utilization

Anti-inflammatory Role of Mesenchymal Stem Cells in an Acute Lung Injury Mouse Model

Background Mesenchymal stem cells (MSCs) attenuate injury in various lung injury models through paracrine effects. We hypothesized that intratracheal transplantation of allogenic MSCs could attenuate lipopolysaccharide (LPS)-induced acute lung injury (ALI) in mice, mediated by anti-inflammatory responses. Methods Six-week-old male mice were randomized to either the control or the ALI group. ALI was induced by intratracheal LPS instillation. Four hours after LPS instillation, MSCs or phosphate-buffered saline was randomly intratracheally administered. Neutrophil count and protein concentration in bronchoalveolar lavage fluid (BALF); lung histology; levels of interleukin (IL)-1β, IL-6, tumor necrosis factor (TNF)-α, and macrophage inflammatory protein-2; and the expression of proliferation cell nuclear antigen (PCNA), caspase-3, and caspase-9 were evaluated at 48 hours after injury. Results Treatment with MSCs attenuated lung injury in ALI mice by decreasing protein level and neutrophil recruitment into the BALF and improving the histologic change. MSCs also decreased the protein levels of proinflammatory cytokines including IL-1β, IL-6, and TNF-α, but had little effect on the protein expression of PCNA, caspase-3, and caspase-9. Conclusions Intratracheal injection of bone marrow-derived allogenic MSCs attenuates LPS-induced ALI via immunomodulatory effects

The Durban World Congress Ethics Round Table Conference Report: II. Withholding or withdrawing of treatment in elderly patients admitted to the intensive care unit

Introduction: Life-sustaining treatment (LST) limitation for elderly patients is highly controversial. In that context, it is useful to evaluate the attitudes to LST in the elderly among experienced intensive care unit (ICU) physicians with different backgrounds and cultures. Methods: A panel of 22 international ICU physicians from 13 countries responded to a questionnaire related to withholding (WH) and withdrawing (WD) LST in elderly patients using a semi-Likert scale. Results: Most experts disagree or strongly disagree (77%) that age should be used as the sole criterion for WH or WD LST, and almost all disagree (91%) that there should be a specific age for such decision making. However, the vast majority (91%) acknowledge that age should be an important consideration in conjunction with other factors. Disagreement for consideration of prioritizing the young over the old in normal ICU operations was reported in 68%, whereas in an emergency triage situation, disagreement dropped to 18%. Conclusions: There is a consensus among ICU physicians that age cannot be the sole criterion on which health care decisions should be made. In that perspective, it is important to provide data showing that outcome differences between elderly and nonelderly patients are partly related to decisions to forgo LSTs

Fever and Total Mechanical Ventilation Time in Critically Ill Patients

This research aims to investigate the impact of fever on total mechanical ventilation time (TVT) in critically ill patients. Subgroup analysis was conducted using a previous prospective, multicenter observational study. We included mechanically ventilated patients for more than 24 hours from 10 Korean and 15 Japanese intensive care units (ICU), and recorded maximal body temperature under the support of mechanical ventilation (MAXMV). To assess the independent association of MAXMV with TVT, we used propensity-matched analysis in a total of 769 survived patients with medical or surgical admission, separately. Together with multiple linear regression analysis to evaluate the association between the severity of fever and TVT, the effect of MAXMV on ventilator-free days was also observed by quantile regression analysis in all subjects including non-survivors. After propensity score matching, a MAXMV ≥ 37.5°C was significantly associated with longer mean TVT by 5.4 days in medical admission, and by 1.2 days in surgical admission, compared to those with MAXMV of 36.5°C to 37.4°C. In multivariate linear regression analysis, patients with three categories of fever (MAXMV of 37.5°C to 38.4°C, 38.5°C to 39.4°C, and ≥ 39.5°C) sustained a significantly longer duration of TVT than those with normal range of MAXMV in both categories of ICU admission. A significant association between MAXMV and mechanical ventilator-free days was also observed in all enrolled subjects. Fever may be a detrimental factor to prolong TVT in mechanically ventilated patients. These findings suggest that fever in mechanically ventilated patients might be associated with worse mechanical ventilation outcome