A prognostic model for one-year mortality in patients requiring prolonged mechanical ventilation

Department of Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
Critical care medicine (Impact Factor: 6.31). 07/2008; 36(7):2061-9. DOI: 10.1097/CCM.0b013e31817b8925
Source: PubMed


A measure that identifies patients who are at high risk of mortality after prolonged ventilation will help physicians communicate prognoses to patients or surrogate decision makers. Our objective was to develop and validate a prognostic model for 1-yr mortality in patients ventilated for 21 days or more.
The authors conducted a prospective cohort study.
The study took place at a university-based tertiary care hospital.
Three hundred consecutive medical, surgical, and trauma patients requiring mechanical ventilation for at least 21 days were prospectively enrolled.
Predictive variables were measured on day 21 of ventilation for the first 200 patients and entered into logistic regression models with 1-yr and 3-mo mortality as outcomes. Final models were validated using data from 100 subsequent patients. One-year mortality was 51% in the development set and 58% in the validation set. Independent predictors of mortality included requirement for vasopressors, hemodialysis, platelet count < or = 150 x 10(9)/L, and age > or = 50 yrs. Areas under the receiver operating characteristic curve for the development model and validation model were .82 (SE .03) and .82 (SE .05), respectively. The model had sensitivity of .42 (SE .12) and specificity of .99 (SE .01) for identifying patients who had > or = 90% risk of death at 1 yr. Observed mortality was highly consistent with both 3- and 12-mo predicted mortality. These four predictive variables can be used in a simple prognostic score that clearly identifies low-risk patients (no risk factors, 15% mortality) and high-risk patients (three or four risk factors, 97% mortality).
Simple clinical variables measured on day 21 of mechanical ventilation can identify patients at highest and lowest risk of death from prolonged ventilation.

  • Source
    • "Several studies reported that these patients consumed a disproportionately high amount of healthcare resources and medical expenses both in the intensive care unit (ICU) and after hospital discharge1-10. There were also several reports regarding prognostic factors for these patients to help physicians determine prognoses by communicating with patients or their surrogates3,11,12. "
    [Show abstract] [Hide abstract]
    ABSTRACT: We evaluated the clinical outcomes and prognostic factors of patients requiring prolonged mechanical ventilation (PMV), defined as ventilator care for ≥21 days, who were admitted to the medical intensive care unit (ICU) of a university hospital in Korea. During the study period, a total of 2,644 patients were admitted to the medical ICU, and 136 patients (5.1%) were enrolled between 2005 and 2010. The mean age of the patients was 61.3±14.5 years, and 94 (69.1%) were male. The ICU and six-month cumulative mortality rates were 45.6 and 58.8%, respectively. There were 96 patients with tracheostomy placement after admission and their mean period from admission to the day of tracheostomy was 21.3±8.4 days. Sixty-three patients (46.3%) were successfully weaned from ventilator care. Of the ICU survivors (n=74), 34 patients (45.9%) were transferred to other hospitals (not university hospitals). Two variables (thrombocytopenia [hazard ratio (HR), 1.964; 95% confidence interval (CI), 1.225~3.148; p=0.005] and the requirement for vasopressors [HR, 1.822; 95% CI, 1.111~2.986; p=0.017] on day 21) were found to be independent factors of survival on based on the Cox proportional hazard model. We found that patients requiring PMV had high six-month cumulative mortality rates, and that two clinical variables (measured on day 21), thrombocytopenia and requirement for vasopressors, may be associated with prognostic indicators.
    Full-text · Article · Oct 2012
  • Source
    • "Our study found 3-month and 1-year survival rates (51.4% and 31.9%, respectively) similar to those observed in a U.S. university-based tertiary-care hospital [30], suggesting that patients with PMV have poor survival even in societies with high levels of providing MV care. Persistent poor functional status after a PMV incidence was observed among most patients in a U.S. study that was based on 5 intensive care units [13]. "
    [Show abstract] [Hide abstract]
    ABSTRACT: This study investigated prognosis among patients under prolonged mechanical ventilation (PMV) through exploring the following issues: (1) post-PMV survival rates, (2) factors associated with survival after PMV, and (3) the number of days alive free of hospital stays requiring mechanical ventilation (MV) care after PMV. This is a retrospective cohort study based on secondary analysis of prospectively collected data in the national health insurance system and governmental data on death registry in Taiwan. It used data for a nationally representative sample of 25,482 patients becoming under PMV (> = 21 days) during 1998-2003. We calculated survival rates for the 4 years after PMV, and adopted logistic regression to construct prediction models for 3-month, 6-month, 1-year, and 2-year survival, with data of 1998-2002 for model estimation and the 2003 data for examination of model performance. We estimated the number of days alive free of hospital stays requiring MV care in the immediate 4-year period after PMV, and contrasted patients who had low survival probability with all PMV patients. Among these patients, the 3-month survival rate was 51.4%, and the 1-year survival rate was 31.9%. Common health conditions with significant associations with poor survival included neoplasm, acute and unspecific renal failure, chronic renal failure, non-alcoholic liver disease, shock and septicaemia (odd ratio < 0.7, p < 0.05). During a 4-year follow-up period for patients of year 2003, the mean number of days free of hospital stays requiring MV was 66.0 in those with a predicted 6-month survival rate < 10%, and 111.3 in those with a predicted 2-year survival rate < 10%. In contrast, the mean number of days was 256.9 in the whole sample of patients in 2003. Neoplasm, acute and unspecific renal failure, shock, chronic renal failure, septicemia, and non-alcoholic liver disease are significantly associated with lower survival among PMV patients. Patients with anticipated death in a near future tend to spend most of the rest of their life staying in hospital using MV services. This calls for further research into assessing PMV care need among patients at different prognosis stages of diseases listed above.
    Full-text · Article · Apr 2012 · BMC Health Services Research
  • Source
    • "This is most likely due to a smaller sample size (VAD, n = 23, and cardiogenic shock, n = 33). Nevertheless, our findings of decreased survival with VAD and cardiogenic shock are supported by other studies showing that prolonged hemodynamic compromise, cardiac dysfunction, and vasopressor requirements are associated with increased mortality in the cardiac surgery and general ICU populations [2] [12] [23] [24] [25] [26]. Our findings likely represent the significant short-term mortality of terminal and irreversible disease processes similar to those with profound cardiac dysfunction. "
    [Show abstract] [Hide abstract]
    ABSTRACT: The purpose of the study was to identify the predictors of short-term mortality in patients undergoing percutaneous dilatational tracheostomy (PDT). Retrospective analysis of data pertaining to adult patients who underwent PDT between July 2005 and June 2008 in an urban, academic, tertiary care medical center was done. Clinical and demographic data were analyzed for 483 patients undergoing PDT via multivariate logistic regression. Mortality data were examined at in-hospital, 14, 30, and 180 days postprocedure. Overall mortality rates were 11% at 14 days, 19% at 30 days, and 40% at 180 days. In-hospital mortality was 30%. Patients undergoing PDT have significant short-term mortality with 11% dying within 14 days and an in-hospital mortality rate of 30%. We identified an index diagnosis of ventilator-associated pneumonia and trauma to be associated with a higher survival rate, whereas older age, oncological diagnosis, cardiogenic shock, and ventricular-assist devices were associated with higher mortality. There is significant heterogeneity in both underlying diagnosis and patient outcomes, and these factors should be considered when deciding to perform this procedure and discussed with patients/family members to provide a realistic expectation of potential prognosis.
    Full-text · Article · Dec 2011 · Journal of critical care
Show more