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E-letters: Electronic letters published:
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Predicting mortality in critically ill octogenarian surgical patients
- William H Konarzewski, Nick Ward (10 January 2008)
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Are Treatment limitations the unwritten conclusion?
- Jack Parry-Jones (10 January 2008)
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William H Konarzewski, Consultant Anaesthetist Colchester General Hospital, Nick Ward
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We read with particular interest the article by Ford et al [1] on outcome determinants in critically ill octogenarians after surgery since we have just completed a retrospective audit of 146 octogenarians admitted to our intensive care unit following emergency laparotomy. Our purpose was, similarly, to identify factors associated with a high chance of dying. Like Ford et al, we noted significantly higher hospital mortality in patients who needed inotropes or prolonged respiratory support, although we were wary of attaching too much weight to predictors that are influenced by clinicians’ decisions, since these introduce an element of bias. One of the main difficulties in doing this kind of work with total objectivity, as Ford et al pointed out, is the “self-fulfilling prophecy” factor which leads to withdrawal of treatment in patients who appear moribund. This is especially relevant when studying the impact of inotropes and respiratory support on survival. However, it is inevitable that any study of critically ill octogenarians will have to accommodate this factor. In our experience, most decisions regarding withdrawal of treatment are clinically appropriate and should not be allowed to invalidate the results. It would, none-the-less, have been helpful if Ford et al had given more data on the mean blood pressures of survivors and non -survivors. We also studied, as a predictor of outcome, the lowest temperature corrected pH of arterial blood gas samples taken within the first 24 hours of admission since this data was available in all but 4 or our patients. (Lactate levels might have been more sensitive had they been available). We found that, for patients whose surgery was for obstruction or peritonitis, a pH below 7.200, regardless of PaCO2, was associated with 100% mortality (18/18 died) whilst for patients with a pH of 7.200 or above, the mortality was 51% (47/92 died). The range for survivors was 7.21-7.40, and for non-survivors 6.95-7.49. However, when the laparotomy was for intra-abdominal bleeding, a pH of below 7.200 was a poor predictor of death compared with a higher pH (mortality 66% vs. 62%: 8/12 vs. 15/24). The range for survivors was 6.87-7.38, and 7.00-7.47 for non- survivors. We would like to suggest that a temperature corrected pH <7.2 might be a simple and quick predictor of poor outcome for octogenarians with obstruction or peritonitis, although it should not be used to influence decisions regarding withdrawal of treatment until more work has been done on a much larger sample of patients. 1 Ford PNR, Thomas I, Cook TM, Whitley E and Peden CJ Determinants of outcome in critically ill octogenarians after surgery: an observational study British Journal of Anaesthesia 2007; 99: 824-829 Conflict of Interest:None declared |
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Jack Parry-Jones, Intensive Care Consultant University Hospital of Wales, Cardiff
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Editor-I read with great interest the paper by Ford et al on the determinants of outcome in critically ill octogenarians after surgery. As the authors point out, octogenarian critical care is a growth area. The authors also point out it is severity of illness that best predicts survival in this group and not age. Unfortunately however, their conclusion that the strongest predictor of hospital mortality is the requirement for i.v. vasoactive drugs in the first and second 24 h is unlikely to have a significant impact on how we practice Critical Care in this age group. To do so would require refusal of admission, the setting of treatment limitations, or withdrawal of support to take place, on the basis of on-going i.v vasoactive drug requirement. It would be interesting to know whether the authors recommend any such limitations in practice? The provision of critical care is itself limited, and an expanding elderly population, having more medical and surgical intervention than ever before, will inevitably, and increasingly, stretch this expensive resource. Whilst Critical care physicians are best placed to assess the survivability of critical illness they are often not in a position to best assess pre-morbid functional status and the patient’s wishes based on truly informed consent in the case of elective surgery. Functional status is best assessed by primary healthcare professionals or hospital physicians/surgeons, with the patient and their family. It is likely to be here that the biggest impact can be made on both the number of octogenarians operated on and referred to critical care, and also the appropriateness of those referrals. If necessary informed treatment limitations can then be set before they may be required. Conflict of Interest:None declared |
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