Tuberculosis and Respiratory Diseases

The Korean Academy of Tuberculosis and Respiratory Diseases (대한결핵및호흡기학회)
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Clinical Characteristics and Prognosis of Elderly Patients Receiving Prolonged Mechanical Ventilation in the Medical Intensive Care Unit at a University Hospital

한 대학병원 내과계 중환자실에서 장기간 기계환기를 받은 노인 환자들의 특징 및 예후

  • Han, Min Soo (Department of Internal Medicine, Eulji University School of Medicine) ;
  • Moon, Kyoung Min (Department of Internal Medicine, Eulji University School of Medicine) ;
  • Lee, Yang Deok (Department of Internal Medicine, Eulji University School of Medicine) ;
  • Cho, Yongseon (Department of Internal Medicine, Eulji University School of Medicine) ;
  • Na, Dong Jib (Department of Internal Medicine, Eulji University School of Medicine)
  • 한민수 (을지대학교 의과대학 내과학교실) ;
  • 문경민 (을지대학교 의과대학 내과학교실) ;
  • 이양덕 (을지대학교 의과대학 내과학교실) ;
  • 조용선 (을지대학교 의과대학 내과학교실) ;
  • 나동집 (을지대학교 의과대학 내과학교실)
  • Received : 2008.03.11
  • Accepted : 2008.06.11
  • Published : 2008.06.30
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Abstract

Background: As the number of older-aged people increases, the number of elderly patients who receive critical care services is expected to increase substantially. The objective of this study was to examine the clinical characteristics and outcomes of elderly patients who receive mechanical ventilation for more than 30 days in the medical intensive care unit (MICU) at a university hospital. Methods: We retrospectively examined forty-one elderly patients (${\geq}65$ years old) who were receiving mechanical ventilation, from April 2004 to March 2007, for periods exceeding 30 days at the MICU at Eulji University Hospital. Results: The MICU and hospitalmortality rate were 60.9% and 65.9%, respectively. The mean length of the ICU stay was 57.5 days and the mean duration of mechanical ventilation was 49.3 days. The most common reason for MICU admission was acute respiratory failure (73.2%), followed by sepsis (12.2%), neurological problems (9.8%), and gastrointestinal bleeding (4.9%). The Acute Physiology and Chronic Health Evaluation (APACHE) II scores were higher for the nonsurvivors than for the survivors (28.0 vs. 25.0, respectively, p=0.03). The nonsurvivors received more red blood cell (RBC) transfusions during their ICU stay than did the survivors (84.0% vs. 43.8%, respectively p=0.007). The factors associated with hospital death were the APACHE II score and if the patient had received a RBC transfusion. Conclusion: The APACHE II score and a RBC transfusion were predictors of increased hospital mortality for the elderly patients who were on prolonged mechanical ventilation. These predictors may assist physicians to make clinical decisions for this patient population.

연구배경: 최근 노인 인구가 급격히 증가하면서 중환자실로 입원하는 노인 환자도 증가하는 추세이다. 내과계 중환자실에서 30일 이상 장기간 기계환기를 받은 노인 환자들의 임상적 특징 및 예후에 대하여 알아보고자 하였다. 방 법: 2004년 4월부터 2007년 3월까지 을지대학병원 내과계 중환자실에 입원했던 환자들 중에서 연속해서 30일 이상 기계환기를 받았던 65세 이상 환자 41명을 대상으로 임상적 특징과 예후에 대하여 후향적으로 조사하였다. 결 과: 대상 환자 41명의 평균 연령은 $74.6{\pm}6.0$세이었고, 남자가 27명(65.9%)이었다. 중환자실로 입원한 주된 이유는 급성호흡부전 30명(73.2%)으로 가장 많았고 패혈증 5명(12.2%), 신경계장애 4명(9.8%), 위장관출혈 2명 (4.9%) 순이었다. 평균 APACHE II 점수는 $26.9{\pm}4.5$이었다. 중환자실 평균 입원 기간은 $49.3{\pm}23.0$일 이었으며 기계환기의 평균 기간은 $57.5{\pm}32.8$일이었다. 사망한 환자는 25명(60.9%)이었으며 사망과 관련있는 인자는 APACHE II 점수(p=0.038)와 수혈(p=0.007) 등이었다. 결 론: 장기간 기계환기 치료를 받은 노인 환자들에서 호흡부전이 가장 흔한 중환자실 입원 이유이었으며 사망률은 60.9%이었고 사망에 영향을 주는 인자는 APACHE II 점수와 수혈 등이었다.

Keywords

References

  1. Jakob SM, Rothen HU. Intensive care 1980-1995: changes in patient characteristics, nursing workload and outcome. Intensive Care Med 1997;23:1165-70 https://doi.org/10.1007/s001340050474
  2. Angus DC, Kelley MA, Schmitz RJ, White A, Popovich J Jr. Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA 2000; 284:2762-70 https://doi.org/10.1001/jama.284.21.2762
  3. Hobbs F, Damon BL, Taeuber CM. Sixty-five plus in United States. Washington, D.C.: Bureau of the Census, U.S. Department of Commerce, Economics and Statistics Administration; 1996
  4. Leaf A. Sounding board. Medicine and the aged. N Engl J Med 1977;297:887-90 https://doi.org/10.1056/NEJM197710202971612
  5. Sage WM, Hurst CR, Silverman JF, Bortz WM 2nd. Intensive care for elderly: outcome of elective and non-elective admissions. J Am Geriatr Soc 1987;35: 312-8 https://doi.org/10.1111/j.1532-5415.1987.tb04637.x
  6. Hamel MB, Phillips RS, Teno JM, Lynn J, Galanos AN, Davis RB, et al. Seriously ill hospitalized adults: do we spend less on older patients? Support Investigators. Study to Understand Prognoses and Preference for Outcomes and Risks of Treatments. J Am Geriatr Soc 1996;44:1043-8 https://doi.org/10.1111/j.1532-5415.1996.tb02935.x
  7. Ely EW, Evans GW, Haponik EF. Mechanical ventilation in a cohort of elderly patients admitted to an intensive care unit. Ann Intern Med 1999;131:96-104 https://doi.org/10.7326/0003-4819-131-2-199907200-00004
  8. Esteban A, Anzueto A, Frutos-Vivar F, Alia I, Ely EW, Brochard L, et al. Outcome of older patients receiving mechanical ventilation. Intensive Care Med 2004;30: 639-46 https://doi.org/10.1007/s00134-004-2160-5
  9. Cho KH. The long-term care management for the elderly in Korea. J Korean Med Assoc 2005;48:39-47 https://doi.org/10.5124/jkma.2005.48.1.39
  10. Carson SS. The epidemiology of critical illness in the elderly. Crit Care Clin 2003;19:605-17 https://doi.org/10.1016/S0749-0704(03)00051-4
  11. Montuclard L, Garrouste-Orgeas M, Timsit JF, Misset B, De Jonghe B, Carlet J. Outcome, functional autonomy, and quality of life of elderly patients with a long-term intensive care unit stay. Crit Care Med 2000;28:3389-95 https://doi.org/10.1097/00003246-200010000-00002
  12. Lipsett PA, Swoboda SM, Dickerson J, Ylitalo M, Gordon T, Breslow M, et al. Survival and functional outcome after prolonged intensive care unit stay. Ann Surg 2000;231:262-8 https://doi.org/10.1097/00000658-200002000-00016
  13. Combes A, Costa MA, Trouillet JL, Baudot J, Mokhtari M, Gibert C, et al. Morbidity, mortality, and quality- of-life outcomes of patients requiring $\geq$ 14 days of mechanical ventilation. Crit Care Med 2003;31:1373-81 https://doi.org/10.1097/01.CCM.0000065188.87029.C3
  14. Higgins TL, McGee WT, Steingrub JS, Rapoport J, Lemeshow S, Teres D. Early indicators of prolonged intensive care unit stay: impact of illness severity, physician staffing, and pre-intensive care unit length of stay. Crit Care Med 2003;31:45-51 https://doi.org/10.1097/00003246-200301000-00007
  15. Laupland KB, Kirkpatrick AW, Kortbeek JB, Zuege DJ. Long-term mortality outcome associated with prolonged admission to the ICU. Chest 2006;129:954-9 https://doi.org/10.1378/chest.129.4.954
  16. Boumendil A, Guidet B. Elderly patients and intensive care medicine. Intensive Care Med 2006;32:965-7 https://doi.org/10.1007/s00134-006-0172-z
  17. Torres OH, Francia E, Longobardi V, Gich I, Benito S, Ruiz D. Short and long-term outcomes of older patients in intermediate care units. Intensive Care Med 2006;32: 1052-9 https://doi.org/10.1007/s00134-006-0170-1
  18. Walther SM, Jonasson U. Outcome of the elderly critically ill after intensive care in an era of cost containment. Acta Anaesthesiol Scand 2004;48:417-22 https://doi.org/10.1111/j.0001-5172.2004.00355.x
  19. Somme D, Maillet JM, Gisselbrecht M, Novara A, Ract C, Fagon JY. Critically ill old and the oldest-old patients in intensive care: short- and long-term outcomes. Intensive Care Med 2003;29:2137-43 https://doi.org/10.1007/s00134-003-1929-2
  20. Rellos K, Falagas ME, Vardakas KZ, Sermaides G, Michalopoulos A. Outcome of critically ill oldest-old patients (aged 90 and older) admitted to the intensive care unit. J Am Geriatr Soc 2006;54:110-4 https://doi.org/10.1111/j.1532-5415.2005.00544.x
  21. Vosylius S, Sipylaite J, Ivaskevicius J. Determinants of outcome in elderly patients admitted to the intensive care unit. Age Ageing 2005;34:157-62 https://doi.org/10.1093/ageing/afi037
  22. De Rooij SE, Govers A, Korevaar JC, Abu-Hanna A, Levi M, de Jonge E. Short-term and long-term mortality in very elderly patients admitted to an intensive care unit. Intensive Care Med 2006;32:1039-44 https://doi.org/10.1007/s00134-006-0171-0
  23. Chelluri L, Pinsky MR, Grenvik AN. Outcome of intensive care of the "oldest-old" cirtically ill patients. Crit Care Med 1992;20:757-61 https://doi.org/10.1097/00003246-199206000-00010
  24. Vincent JL, Piagnerelli M. Transfusion in the intensive care unit. Crit Care Med 2006;34:S96-101 https://doi.org/10.1097/01.CCM.0000194536.89694.06
  25. Vincent JL, Baron JF, Reinhart K, Gattinoni L, Thijs L, Webb A, et al. Anemia and blood transfusion in critically ill patients. JAMA 2002;288:1499-507 https://doi.org/10.1001/jama.288.12.1499
  26. Corwin HL, Gettinger A, Pearl RG, Fink MP, Levy MM, Abraham E, et al. The CRIT study: anemia and blood transfusion in the critically ill--current clinical practice in the United States. Crit Care Med 2004;32:39-52 https://doi.org/10.1097/01.CCM.0000104112.34142.79
  27. Talyor RW, Manganaro L, O'Brien J, Trottier SJ, Parkar N, Veremakis C. Impact of allogenic packed red blood cell tranfsufion on nosocomial infection rates in the critically ill patient. Crit Care Med 2002;30:2249-54 https://doi.org/10.1097/00003246-200210000-00012
  28. Moore FA, Moore EE, Sauaia A. Blood transfusion: an independent risk factor for postinjury multiple organ failure. Arch Surg 1997;132:620-4 https://doi.org/10.1001/archsurg.1997.01430300062013
  29. Khamiees M, Raju P, DeGirolamo A, Amoateng-Adjepong Y, Manthous CA. Predictors of extubation outcome in patients who have successfully completed a spontaneous breathing trial. Chest 2001;120:1262-70 https://doi.org/10.1378/chest.120.4.1262
  30. Hebert PC, Blajchman MA, Cook DJ, Yetisir E, Wells G, Marshall J. Do blood transfusions improve outcomes related to mechanical ventilation? Chest 2001; 119:1850-7 https://doi.org/10.1378/chest.119.6.1850
  31. MacIntyre NR, Epstein SK, Carson S, Scheinhorn D, Christopher K, Muldoon S. Management of patients requiring prolonged mechanical ventilation: report of a NAMDRC consensus conference. Chest 2005;128:3937-54 https://doi.org/10.1378/chest.128.6.3937
  32. Chatila W, Kreimer D, Criner G. Quality of life in survivors of prolonged mechanical ventilatory support. Crit Care Med 2001;29:737-42 https://doi.org/10.1097/00003246-200104000-00007
  33. Niskanen M, Ruokonen E, Takala J, Rissanen P, Kari A. Quality of life after prolonged intensive care. Crit Care Med 1999;27:1132-9 https://doi.org/10.1097/00003246-199906000-00035