RESUMO
BACKGROUND: Very elderly critically ill patients (ie, those older than 75 or 80 years) are an increasing population in intensive care units. However, patients with cancer have encompassed only a minority in epidemiological studies of very old critically-ill patients. We aimed to describe clinical characteristics and identify factors associated with hospital mortality in a cohort of patients aged 80 or older with cancer admitted to intensive care units (ICUs). METHODS: This was a retrospective cohort study in 94 ICUs in Brazil. We included patients aged 80 years or older with active cancer who had an unplanned admission. We performed a mixed effect logistic regression model to identify variables independently associated with hospital mortality. RESULTS: Of 4604 included patients, 1807 (39.2%) died in hospital. Solid metastatic (OR = 2.46; CI 95%, 2.01-3.00), hematological cancer (OR = 2.32; CI 95%, 1.75-3.09), moderate/severe performance status impairment (OR = 1.59; CI 95%, 1.33-1.90) and use of vasopressors (OR = 4.74; CI 95%, 3.88-5.79), mechanical ventilation (OR = 1.54; CI 95%, 1.25-1.89) and renal replacement (OR = 1.81; CI 95%, 1.29-2.55) therapy were independently associated with increased hospital mortality. Emergency surgical admissions were associated with lower mortality compared to medical admissions (OR = 0.71; CI 95%, 0.52-0.96). CONCLUSIONS: Hospital mortality rate in very elderly critically ill patients with cancer with unplanned ICU admissions are lower than expected a priori. Cancer characteristics, performance status impairment and acute organ dysfunctions are associated with increased mortality.
Assuntos
Estado Terminal/mortalidade , Mortalidade Hospitalar/tendências , Neoplasias/mortalidade , APACHE , Idoso de 80 Anos ou mais , Brasil , Estudos de Coortes , Feminino , Neoplasias Hematológicas/mortalidade , Neoplasias Hematológicas/patologia , Hospitalização , Humanos , Unidades de Terapia Intensiva , Modelos Logísticos , Masculino , Neoplasias/patologia , Estudos Retrospectivos , Fatores de RiscoRESUMO
Introdução: Com o envelhecimento da população e aumento na incidência de doenças crônicas como o câncer, tornou-se indiscutível o aumento na demanda por serviços de alta complexidade como as Unidades de Terapia Intensiva pelos pacientes muito idosos. Metodologia: O presente estudo, fundamentado na análise retrospectiva e descritiva de prontuários de pacientes, com abordagem quantitativa dos dados, tem como objetivo principal descrever as características clínicas e a sobrevida a curto (90 dias) e longo prazo (1 ano) de pacientes muito idosos (80 anos ou mais) admitidos nas Unidades de Terapia Intensiva do A.C.Camargo Cancer Center no período entre março/2011 a dezembro/2017. Secundariamente, objetivamos identificar fatores de risco para a mortalidade nestes dois períodos. Resultados: Foram incluídos 1.679 pacientes no estudo, com idade média de 84,2 anos, e predomínio do sexo masculino (52,5%). Os tipos de tumores sólidos locorregionais (56,9%) e sólidos metastáticos (37%) foram os mais prevalentes e as localizações mais comuns foram Câncer Colorretal e canal anal (18,1%) e Cavidade oral/faringe/laringe (9,2%). A maioria dos pacientes eram provenientes do Centro Cirúrgico (59,7%), seguidos da Enfermaria (20,4%). A maioria das internações foi secundária a procedimentos pós-operatórios eletivos (54,6%). Durante a estadia na UTI, o delirium ocorreu em 541 (32,2%) pacientes, 188 (11,2%) pacientes necessitaram de ventilação mecânica invasiva por 24h ou mais, 286 (17%) necessitaram de vasopressores por 24h ou mais e 59 (3,5%) pacientes necessitaram de Terapia de Substituição renal. As taxas de mortalidade hospitalar, em 90 dias e em 1 ano foram de 26,2%, 32,7% e 41,3%, respectivamente. Na regressão logística, os tipos de tumores sólidos metastáticos (OR: 2,93, IC 95% 2,30 - 3,73) e hematológicos (OR: 1,97, IC 95% 1,22 - 3,23) em relação ao tipo de câncer sólido locorregional e delirium (OR: 2,17, IC 95% 1,70 - 2,77) em relação ao paciente que não teve delirium na UTI, foram associados a mortalidade em 90 dias, enquanto que, internação clínica (OR: 4,50, IC 95% 3,51 - 5,76) em relação à cirurgia eletiva, tumores sólidos metastáticos (OR: 2,95, IC 95% 2,31 - 3,76) e tumores hematológicos (OR: 1,97, IC 95% 1,21 - 3,21) em relação aos tumores sólidos locorregionais e delirium (OR: 2,13, IC 95% 1,67 - 2,72) em relação ao paciente que não teve delirium na UTI, foram associados a mortalidade em 1 ano. Conclusão: Pacientes muito idosos com câncer admitidos na UTI não parecem ter piores desfechos em pacientes idosos não oncológicos, quando comparados com os dados da literatura. Admissões não eletivas e disfunções orgânicas durante a estadia na UTI são independentemente associadas a maior mortalidade hospitalar (AU)
Introduction: With the aging of the population and an increase in the incidence of chronic diseases such as cancer, there has been an indisputable increase in the demand for highly complex services such as Intensive Care Units by very elderly patients. Methodology: The present study, based on a retrospective and descriptive analysis of patient records, with a quantitative approach to the data, aims to describe the clinical characteristics and the short (90 days) and long-term (1 year) survival of very elderly (80 years or older) admitted to the Intensive Care Units of A.C.Camargo Cancer Center between March / 2011 to December / 2017. Secondly, we aim to identify risk factors for mortality in these two periods. Results: 1,679 patients were included in the study, with a mean age of 84.2 years, with a predominance of males (52.5%). The types of locoregional solid tumors (56,9%) and metastatic solids (37%) were the most prevalent and the most common locations were Colorectal Cancer and anal canal (18,1%) and Oral / pharynx / larynx (9,2%). Most patients were from the Surgical Center (59.7%), followed by the Infirmary (20.4%). Most hospitalizations were secondary to elective postoperative (54,6%). During the ICU stay, delirium occurred in 541 (32.2%) patients, 188 (11.2%) patients required invasive mechanical ventilation for 24 hours or more, 286 (17%) required vasopressors for 24 hours or more and 59 (3.5%) patients required renal replacement therapy. The hospital mortality rates, in 90 days and in 1 year, were 26.2%, 32.7% and 41.3%, respectively. In logistic regression, the types of metastatic (OR: 2.93, 95% CI 2.30 - 3.73) and hematological (OR: 1.97, 95% CI 1.22 - 3.23) tumors in relation to the type of solid regional cancer and delirium (OR: 2.17, 95% CI 1.70 - 2.77) in relation to the patient who did not have delirium in the ICU, were associated with 90-day mortality, while clinical hospitalization ( OR: 4.50, 95% CI 3.51 - 5.76) in relation to elective surgery, metastatic tumors (OR: 2.95, 95% CI 2.31 - 3.76) and hematological tumors (OR: 1.97, 95% CI 1.21 - 3.21) in relation to solid regional cancer and delirium (OR: 2.13, 95% CI 1.67 - 2.72) in relation to the patient who did not have delirium in the ICU, were associated with 1-year mortality. Conclusion: Very elderly cancer patients admitted to the ICU do not appear to have worse outcomes than elderly non-cancer patients, when compared with literature data. Non-elective admissions and organ dysfunctions during ICU stay are independently associated with highest hospital mortality.