Nature and impact of in-hospital complications associated with persistent critical illness

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Persistent critical illness (PerCI) is a relatively novel term to describe a clinical syndrome.1 This term applies to a heterogeneous group of patients who receive prolonged intensive care unit (ICU) support and have been previously arbitrarily referred to as having "chronic" or "prolonged" critical illness.PerCI consumes a disproportionate amount of resources, 1-4 presents unique challenges, and appears associated with high morbidity and mortality.[1][2][3] Past descriptions of such patients have been variably based on either the need for organ support (eg, mechanical ventilation), 2 the development of specific complications (eg, severe ICUacquired weakness), 5 the timing of elective tracheostomy, 2,3 or the need to remain in the ICU after the reason for admission has been treated and is no longer active.5 In a 2015 survey, ICU clinicians estimated that the transition point from acute to persistent critical illness occurs after about 10 days in the ICU.6 In support of this estimate, a large population-based retrospective multicentre observational study of over one million patients admitted to Australian and New Zealand ICUs empirically confirmed this time frame. 1 Specifically, it found that beyond 10 days in the ICU (averaged across various patient subgroups), chronic pre-admission patient characteristics (age, gender and comorbidities) predicted subsequent hospital mortality more accurately than did their combined admission diagnosis and admission illness severity, as assessed by the Acute Physiology and Chronic Health Evaluation (APACHE) score.Thus, this study logically, statistically and epidemiologically defined a transition point for the onset of PerCI.However, the reasons why some patients have such prolonged ICU admissions remain unclear.In particular, it remains unknown whether these patients experience more complications, a greater rate of complications, or particular types of complications which may have contributed to a protracted ICU stay.Accordingly, we performed a retrospective case-control study to identify, describe and quantify the prevalence, rate and nature of in-hospital complications in a cohort of PerCI ABSTRACT Background: Persistent critical illness (PerCI) is defined as an intensive care unit (ICU) admission lasting ≥ 10 days.The in-hospital complications associated with its development are poorly understood.Aims: To test whether PerCI is associated with a greater prevalence, rate and specific types of in-hospital complications.Methods: Single-centre, retrospective, observational casecontrol study.Results: We studied 1200 patients admitted to a tertiary ICU from 2010 to 2015.Median ICU length of stay was 16 days (interquartile range [IQR], 12-23) for PerCI patients v 2.3 days (IQR, 1.1-3.7)for controls, and median hospital length of stay was 41 days (IQR, 22-75) v 8 days (IQR, 4-17) respectively.A greater proportion of PerCI patients received acute renal replacement therapy (37% v 6.8%) or underwent reintubation (17% v 1%) and/or tracheostomy (36% v 0.6%); P < 0.0001.Despite these complications, PerCI patients had similar hospital mortality (29% v 27%; P = 0.53).PerCI patients experienced a greater absolute number of complications (12.1 v 4.0 complications per patient; P < 0.0001) but had fewer exposure-adjusted complications (202 v 272 complications per 1000 hospital bed-days; P < 0.001) and a particularly high overall prevalence of specific complications.Conclusions: PerCI patients experience a higher prevalence, but not a higher rate, of exposure-adjusted complications.Some of these complications appear amenable to prevention, helping to define intervention targets in patients at risk of PerCI.

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