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A5132 - Respiratory Failure Patterns in Persistently Critically Ill Patients
Author Block: E. M. Viglianti1, R. D. Kramer2, M. W. Sjoding1, C. L. Hodgson3, R. Bellomo3, T. J. Iwashyna1; 1Internal Medicine, Division of Pulmonary-Critical Care, University of Michigan, Ann Arbor, MI, United States, 2University of Michigan, Ann Arbor, MI, United States, 3Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive, Monash University, Melbourne, Australia.
Rationale: Many patients remain in the intensive care unit (ICU) for a prolonged period. Although it is commonly assumed this is the result of simply non-resolving respiratory failure, there are few data to test this assumption —despite the fact that the assumption undergirds care protocols, research trials, and the formation of long-term acute care hospitals in the United States. Our purpose was to characterize duration of mechanical ventilation and degree of hypoxemia in patients with persistent critical illness.
Methods: We retrospectively studied a cohort of consecutive patients from a university hospital who were in an ICU for a minimum of 14 days during 2014-2016. We identified their specific daily patterns of organ failure from admission to ICU to day 14. New late organ failure was defined as a worsening by 2 Sequential Organ Failure Assessment points in a single organ component from ICU day 4 to 14. The primary outcome was respiratory failure requiring mechanical ventilation.
Results: During the assessment period, the study ICUs admitted a total of 5377 patients. Of these, 50 patients met inclusion criteria, and they used 1975 hospital-bed-days. Their median age was 64 (IQR 58,74), 60% were male and in-hospital mortality was 30%. At some point during their ICU stay, all the patients were mechanically ventilated. Of the 50 patients, 32% (N=16) were persistently intubated and never extubated during the first 14 days in the ICU, with 87.5% (N=14/16) of them having P/F ratios 200 on ICU day 14. Of the 34 patients who were extubated at some point in the first 14 days, 52.9% (N=18) were successfully extubated for the remainder of the first 14 days and 47.1% (N=16) were re-intubated during that period. Of those 16 who were re-intubated, four were successfully extubated again and 12 remained intubated with 66.7% (N=8) having P/F ratios 200 on ICU day 14. The 22 patients extubated yet still in the ICU on day 14 had been extubated for a median of 5 days at that point (range 1 to 12 days; IQR 3, 8).
Conclusions: Respiratory failure and the need for mechanical ventilation were present in only half of all long-staying patients and, in most such cases, it was marked by ongoing hypoxemia. Our findings imply that utilizing mechanical ventilation to define persistent critical illness and target interventions to these patients will underestimate the number of patients who have ongoing needs for prolonged ICU care.