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Management and outcomes in critically ill nonagenarian versus octogenarian patients

Abstract

Background

Intensive care unit (ICU) patients age 90 years or older represent a growing subgroup and place a huge financial burden on health care resources despite the benefit being unclear. This leads to ethical problems. The present investigation assessed the differences in outcome between nonagenarian and octogenarian ICU patients.

Methods

We included 7900 acutely admitted older critically ill patients from two large, multinational studies. The primary outcome was 30-day-mortality, and the secondary outcome was ICU-mortality. Baseline characteristics consisted of frailty assessed by the Clinical Frailty Scale (CFS), ICU-management, and outcomes were compared between octogenarian (80–89.9 years) and nonagenarian (> 90 years) patients. We used multilevel logistic regression to evaluate differences between octogenarians and nonagenarians.

Results

The nonagenarians were 10% of the entire cohort. They experienced a higher percentage of frailty (58% vs 42%; p < 0.001), but lower SOFA scores at admission (6 + 5 vs. 7 + 6; p < 0.001). ICU-management strategies were different. Octogenarians required higher rates of organ support and nonagenarians received higher rates of life-sustaining treatment limitations (40% vs. 33%; p < 0.001). ICU mortality was comparable (27% vs. 27%; p = 0.973) but a higher 30-day-mortality (45% vs. 40%; p = 0.029) was seen in the nonagenarians. After multivariable adjustment nonagenarians had no significantly increased risk for 30-day-mortality (aOR 1.25 (95% CI 0.90–1.74; p = 0.19)).

Conclusion

After adjustment for confounders, nonagenarians demonstrated no higher 30-day mortality than octogenarian patients. In this study, being age 90 years or more is no particular risk factor for an adverse outcome. This should be considered– together with illness severity and pre-existing functional capacity - to effectively guide triage decisions.

Trial registration

NCT03134807 and NCT03370692.

Peer Review reports

Introduction

The proportion of older patients has increased significantly over time. In 2030, there will be more than 30 million people over the age of 90 (nonagenarians) in 35 industrialised countries [1]. Consequently, health care providers nowadays perform medical procedures on very old patients (from surgery to oncological therapies), which were previously considered unfeasible because of age or age-related deterioration in physical and mental performance [2]. Similarly, the rate of older patients (> 80 years) in intensive care units (ICU) is increasing [3,4,5,6]. Today, older patients utilise a disproportionate amount of health care resources compared to their relative proportion of the total population [3, 7].

In particular, the extent to which “old age” per se is a risk factor and the extent to which different groups of old patients differ from one another regarding the prognosis is the subject of continuing debate. Older patients suffer worse outcomes than younger patients undergoing intensive care [8, 9], but some studies failed to establish age as an independent predictor of mortality in older ICU patients [10, 11]. However, most prognostic studies demonstrated an almost linear relationship between chronological age and mortality after the age of 40 [12]. In this respect, patients ageing 80 years and more represent a particular challenge to intensive care medicine [13, 14]. Still, there are no large studies that further differentiate this group of very old ICU patients and it is unclear if being a nonagenarian is a risk factor for adverse outcomes. We hypothesize that critically ill nonagenarians have an elevated 30-day mortality compared to octogenarians. To address this hypothesis, we performed a retrospective cohort study comprised of two large, multinational prospective observational cohorts [13,14,15]. This post-hoc analysis combined data from the VIP-1 and VIP-2 studies to compare octo- and nonagenarians regarding 30-day mortality (primary outcome) and ICU mortality (secondary outcome), the distribution of risk factors, and the intensive care management [13,14,15].

Methods

Study subjects

The very old intensive care patients (VIP) studies, VIP1 and VIP2, were prospective, multi-centre studies, registered on ClinicalTrials.gov (ID: NTC03134807, NCT03370692). Both studies included very old intensive care patients (VIPs), defined as patients admitted to an ICU and aged 80 years or older. The main results from these studies have been published previously [1314, 16, 17]. In summary, for both studies, each participating ICU could include either consecutive patients admitted over a six-month period or the first 20 consecutive patients fulfilling the inclusion criteria (all patients aged 80 years or older). The data collection for VIP1 took place between October 2016 and February 2017 and between May 2018 to May 2019 for VIP2. Both studies used similar inclusion criteria as described elsewhere [13]. Informed consent was obtained from study participants. Local ethical committees might have waived the need of informed consent.

In this post-hoc analysis of these two studies, all patients admitted acutely (non-electively) with complete data on age, gender, clinical frailty score (CFS), sequential organ failure assessment (SOFA) score, and ICU mortality were included. For this study, the elective patients included in VIP1 were excluded as their outcomes differ significantly compared with those admitted acutely, as previously shown [18]. The primary endpoint of this study was ICU-mortality, and the secondary endpoint was 30-day-mortality.

Scales, scores, and limitations in life-sustaining therapy

The SOFA score was recorded on admission; it could be calculated manually or using an online calculator. Frailty was assessed by the clinical frailty scale (CFS). The CSF distinguishes nine classes of frailty from very fit (CFS 1) to terminally ill (CFS 9). The respective visual and simple description for this assessment tool was used with permission [19,20,21].

The Katz Activities of Daily Living (Katz ADL) scale is a widely used graded instrument to assess disability in chronically ill or older patients. It evaluates six primary and psychosocial functions: bathing, dressing, going to the toilet, transferring, feeding, and continence. The patient receives 1 point for every independent and 0 for every dependent activity (6 = independent patient, 0 = very dependent patient). For the patients in the VIP2 trial, disability was defined by Katz ADL score ≤ 4.

For cognitive decline, VIP2 utilised the Short form of Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE). IQCODE is a questionnaire, completed by carers, with 16 questions about cognitive decline over the past 10 years. For each question, 1 to 5 points can be assigned. An average of 3 points per question is considered “normal”. A cumulative IQCODE of ≥3.5 is regarded as “cognitive decline” [19,20,21].

The burden of co-morbidity was assessed using the co-morbidity and polypharmacy score (CPS) [22]. The CPS calculates the total number of chronic diagnoses and drugs taken. Standard ICU procedures were also documented.

In addition, limitations of therapy, such as withholding or withdrawing treatment, were recorded. Withholding life-sustaining therapy (e.g. mechanical ventilation, renal replacement therapy, cardiopulmonary resuscitation) was defined as not performing a measure that was indicated; withdrawing was defined as stopping any kind of life-sustaining therapy. All these decisions were at the discretion of the treating physicians and documented according to international recommendations. VIP2 recorded the exact date of treatment limitation, but VIP1 did not give specific details. Thus, the present analysis used withholding or withdrawing treatment as binary information at any time during the ICU-stay.

Statistical analysis

Post-hoc power calculations using the 7110 octogenarians and 790 nonagenarians, primary outcome event rates of 40% versus 45%, and an alpha of 0.05, the power of the study to detect differences in 30-day mortality is 77%. Continuous data points are expressed as median ± interquartile range. Differences between independent groups were calculated using the Mann Whitney U-test. Categorical data are expressed as numbers (percentage). The chi-square test was applied to calculate differences between groups. Sensitivity analysis, analysing only patients with SOFA scores below the 75th percentile SOFA score of 10 (i.e. all patients with SOFA < 10) was performed. Univariable and multivariable logistic regression analysis was performed to assess associations with treatment limitations and mortality. Odds ratios (OR) and adjusted odds ratios (aOR) with respective 95% confidence intervals (CI) were calculated. Two sequential random effects, multilevel logistic regression models were used to evaluate the impact of being a nonagenarian on ICU- and 30-days- mortality. All patients with valid data on ICU-mortality were included. First, a baseline model with being nonagenarian as a fixed effect and ICU as random effect (model-1) was fitted. Second, to model-1, patient characteristics (SOFA, CFS, sex) (model-2) were added to the model. Adjusted odds ratios (aOR) with respective 95% confidence intervals (CI) were calculated. Sensitivity analysis, analysing only patients with and without any treatment limitation was performed. All tests were two-sided, and a p-value of < 0.05 was considered statistically significant. SPSS version 23.0 (IBM, USA) and MedCalc Statistical Software version 19.1.3 (MedCalc Software bv, Ostend, Belgium; https://www.medcalc.org; 2019) were used for all statistical analyses.

Results

Study population

This study included 7900 patients. 10% of the patients were nonagenarians. Table 1 displays the baseline characteristics of nonagenarians versus octogenarians. Nonagenarians were predominantly female (57% versus 46%, p < 0.001), evidenced higher rates of frailty (58% vs 42%; p < 0.001), disability (44% vs. 26%; p < 0.001) and cognitive decline (50% vs. 31%; p < 0.001) but lower SOFA scores at admission (6 + 5 vs. 7 + 6; p < 0.001). Specific ICU-treatment strategies were used, with octogenarians receiving higher rates of organ support (renal replacement therapy, mechanical ventilation, vasoactive drugs), while for nonagenarians there were higher rates of treatment limitation (40% vs. 33%; p < 0.001; Table 1). After discharge from the ICU, most patients had a treatment limitation; 1053 octogenarians (55% of all octogenarians leaving the ICU alive) and 182 (85%) nonagenarians left the ICU with treatment limitations in place.

Table 1 Baseline characteristics in the total cohort, nonagenarians versus octogenarians

Survival analysis in the total cohort

The overall ICU mortality was 27% (N = 2134 of 7900 patients), the 30-day-mortality was 39% (N = 3080 of 7555 patients). Compared to the octogenarians the nonagenarians had a similar ICU mortality (27% vs. 27%; p = 0.973), but a higher 30-day-mortality (45% vs. 40%; p = 0.029, Fig. 1). Nonagenarians showed a significantly longer length of ICU-stay (84 h versus 54 h, p < 0.001).

Fig. 1
figure 1

Comparison of 30-day and ICU-mortality. A: ICU-mortality [%], B: 30-day-mortality [%]. * = p < 0.05

Comparison of nonagenarians versus octogenarians in the multilevel logistic regression models

After the adjustment for the ICU cluster as a random effect (model-1), nonagenarians had an increased risk for withholding life-sustaining therapy (aOR 1.54 (95% CI 1.22–1.94; p = < 0.001)), but not for withdrawal (aOR 1.03 (95% CI 0.77–1.39; p = 0,82)). Nonagenarians received significantly less mechanical ventilation, renal replacement therapy and vasoactive drugs. There was no difference between both age groups regarding the use of mechanical ventilation, vasopressors, and ICU-mortality, but an increased risk for 30-day-mortality (aOR 1.39 (95% CI 1.13–1.72); p = 0.002). After adding patient-specific confounders (model-2), nonagenarians demonstrated no significant risks compared to octogenarians (Table 2)

Table 2 Associations of primary exposure (being nonagenarian) with mortality and management strategies in a multilevel logistic regression model

Discussion

This study examines the largest multi-centre prospectively recruited group of intensive care patients of 90 years and older published to date. Nonagenarians differ in their baseline risk distribution, management, and clinical outcomes from octogenarians. Nonagenarians had higher rates of frailty, cognitive impairment, and disability. However, when compared with octogenarians, nonagenarians had a lower illness severity and required less organ support. After adjustment for relevant confounders, the 30-day mortality did not differ between both groups.

Our results are in line with other studies looking at older ICU patients: Fuchs et al. evaluated a cohort of more than 7000 surgical and medical ICU patients and found age, especially above 75 years, to be an independent risk factor for mortality [9, 23]. In a large retrospective analysis of 1,807,531 patients admitted to an ICU between 1997 and 2016, Jones et al. reported increased mortality in patients older than 84 years, although they had a similar illness severity at ICU admission compared to younger patients [23]. Conversely, in a study evaluating 5882 patients after cardiac arrest, age alone was only a weak predictor of mortality [24]. In a recent study by Roedl et al., a survival rate of 46% with a good neurological outcome was reported for nonagenarians after cardiac arrest [11]. Recently, Druwé et al. performed a subgroup analysis on out-of-hospital cardiac arrests with a special interest in the resuscitation attempts in octogenarians: Most physicians considered cardiopulmonary resuscitation to be appropriate even in older patients with poor outcome perspectives [25]. Furthermore, in another study by Becker et al., the ICU mortality of nonagenarians was low at 30% and, importantly, the one-year survival was 50%, indicating outcomes “better than expected” in nonagenarians [26]. Of note, the study by Becker et al. was a single-centre study, and the number of patients who received vasoactive drugs was lower when compared to the patients in our multi-centre study. Therefore, we propose the higher mortality rates reported in the present study may be more representative of a “real-world scenario”.

Demoule et al. performed a matched case-control study in 36 nonagenarians admitted to an ICU. They were matched according to sex with 72 controls: ICU admissions chosen from the 20- to 69-year age range. They found no differences in the reason for admission, but nonagenarians suffered significantly less from pre-existing co-morbidities. Advanced life-support interventions were used equally. ICU and intra-hospital mortality, as well as the length of stay, did not differ significantly between nonagenarians and the control group [27]. Despite differences in the absolute length of stay, the trend of a shorter length of stay for older (nonagenarian) intensive care patients is consistent with previous studies [28].

Interestingly, being a nonagenarian was independently associated with the decision for withholding life-sustaining therapy, but not for withdrawing it. After adjustment for patient characteristics, nonagenarians evidenced no particular risk for treatment limitations compared to octogenarians. These findings contradict the usual expectation that physicians in general tend to be more reluctant to provide organ support to nonagenarians compared to similarly sick octogenarians. In nonagenarians, ICU re-triage should be emphasised: after an initial intensive care treatment for up to 48 h, patients should be critically evaluated in cooperation with their family and/ or carers and discharged to a normal ward for best-supportive care if further intensive care seems unethical, unjustified, or unlikely to improve outcomes. However, modern intensive care medicine is not limited to life-sustaining measures. Even beyond invasive ventilation, renal replacement therapy or cardiopulmonary resuscitation, intensive care medicine can provide valuable treatment for the patient, which might be intensified palliative therapy. Based on our data, being a nonagenarian does not represent a particular risk factor for adverse outcomes. Application of ICU re-triage could help to reduce the economic burden of ICU care in very old patients, in addition to unethical intensive care and distress caused to health care providers.

Mortality was similar between octogenarians and nonagenarians at ICU discharge and after 30 days. The long-term outcomes of the VIP2 study are awaited and will answer the question of whether this effect remains stable further over time.

An important limitation is, that we have no information about pre-ICU triage decisions, although this might be an important factor for the differences in disease illness scores and frailty between nonagenarians and octogenarians. Furthermore, this study only provides detailed information up to ICU-discharge and there was a significant rise in mortality during the 30 days after ICU-discharge, but we do not have detailed data on decisions made and developments during this period. Another limitation is that no a priori sample size calculation was made to detect a difference in the mortality between nonagenarians and octogenarians. Our post-hoc power calculation shows that the present study is likely underpowered for the primary outcome, and thus the reporting results that are at a higher risk of false positive results. However, this was counterbalanced by using a multilevel model to adjust for relevant confounders.

Conclusion

Nonagenarian ICU patients demonstrated higher rates of frailty but had less acute organ dysfunction than octogenarians. After adjustment for multiple relevant confounders, nonagenarians did not suffer from worse outcomes compared to octogenarian ICU patients. Rather than being a nonagenarian, the severity of illness, functional capacity – and of course the patients’ will - should guide triage decisions.

Availability of data and materials

The anonymised data can be requested from the authors if required. The datasets analysed during the current study are not publicly available due to the different local institutional and/or licensing committees but are available from the corresponding author on reasonable request.

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Acknowledgements

VIP-2-STUDY GROUP:

Hospital

City

ICU

Name

Austria

Medical University Innsbruck

Innsbruck

Division of Intensive Care and Emergency Medicine, Department of Internal Medicine

Michael Joannidis

Medical University Graz

Graz

Allgemeine Medizin Intensivstation

Philipp Eller

Medical University of Innsbruck

Innsbruck

Department of Neurology, Neurocritical Care Unit

Raimund Helbok

Hospital of St. John of God

Wienna

ICU B5

René Schmutz

Belgium

AZ Maria Middelares Ghent

Ghent

Department of Intensive Care

Joke Nollet

OLVrouw Hospital Aalst

Aalst

Department of Intensive Care

Nikolaas de Neve

AZ Sint-Lucas

Ghent

Department of Intensive Care

Pieter De Buysscher

Ghent University Hospital

Ghent

Department of Intensive Care

Sandra Oeyen

AZ Sint-Blasius

Dendermonde

Department of Intensive Care

Walter Swinnen

Croatia

Clinical Hospital Centre Split

Split

Institute for Intensive Medicine

Marijana Mikačić

Denmark

Bispebjerg Hospital

Copenhagen

Intensiv Terapi Afsnit

Anders Bastiansen

Regionshospitalet Randers

Randers

ITA

Andreas Husted

Sygehus Lillebælt, Kolding Sygehus

Kolding

Bedøvelse og Intensiv

Bård E. S. Dahle

Aarhus University Hospital

Aarhus

Intensive Care East

Christine Cramer

Viborg Regional Hospital

Viborg

Department of Anaesthesiology and Intensive Care

Christoffer Sølling

Nordsjællands Hospital, University of Copenhagen

Hillerød

Department of Anaesthesiology and Intensive Care

Dorthe Ørsnes

Regions Hospital Herning

Herning

Intensiv Herning

Jakob Edelberg Thomsen

Vejle

Vejle

A710 Vejle

Jonas Juul Pedersen

Regionshospital Nordjylland Hjørring

Hjørring

Intensiv

Mathilde Hummelmose Enevoldsen

Aarhus University Hospital

Aarhus

Intensive Care North

Thomas Elkmann

England

Yeovil District Hospital

Yeovil

Intensive Care Unit

Agnieszka Kubisz-Pudelko

Peterborough City Hospital

Petersborough

Critical Care Unit

Alan Pope

Queen Elizabeth Hospital

 

Critical Care Queen Elizabeth Hospital

Amy Collins

Croydon University Hospital

Croydon

Croydon University Hospital ITU

Ashok S. Raj

Royal Devon & Exeter NHS Foundation Trust

Exeter

Intensive Care Unit

Carole Boulanger

South Tyneside District Hospital

South Shields

ITU

Christian Frey

Maidstone

Maidstone

Intensive Care/High Dependency

Ciaran Hart

University Hospital Southampton

Southampton

General Intensive Care Unit

Clare Bolger

St George’s University Hospitals NHS Foundation trust

London

Cardiothoracic Intensive Care Unit (CTICU)

Dominic Spray

Norfolk and Norwich University Hospital

Norwich

Critical care complex

Georgina Randell

Royal Free Hospital NHS Foundation Trust

London

ICU 4

Helder Filipe

Royal Liverpool University Hospital

Liverpool

Intensive care

Ingeborg D Welters

Royal Hampshire County Hospital

Winchester

ICU

Irina Grecu

St George’s University Hospitals NHS Foundation trust

London

Acute Dependency Unit

Jane Evans

Blackpool Victoria Hospital

Blackpool

General Critical Care Unit

Jason Cupitt

Worthing Hospital

Worthing

ICU

Jenny Lord

James Cook University Hospital

Midlesbrough

ICU 2 and 2

Jeremy Henning

Tunbridge Wells Hospital

Pembury

Intensive care unit

Joanne Jones

St George’s University Hospitals NHS Foundation trust

London

Neuro Intensive Care

Jonathan Ball

James Paget University Hospital

Norfolk

ICU/HDU

Julie North

Royal Papworth Hospital NHS Foundation Trust

Cambridge

ICU

Kiran Salaunkey

Royal Sussex County Hospital

Brighton

Level 7

Laura Ortiz-Ruiz De Gordoa

Salisbury

Salisbury

Radnor

Louise Bell

Royal Bolton Hospital

Bolton

Royal Bolton CRITICAL CARE

Madhu Balasubramaniam

Chelsea and Westminster Hospital

London

Adult Intensive Care Unit

Marcela Vizcaychipi

Countess of Chester Hospital

Chester

Intensive Care Unit

Maria Faulkner

Hampshire Hospitals Foundation Trust

Basingstoke

Basingstoke and North Hampshire Hospital

McDonald Mupudzi

Hinchingbrooke Hospital

Huntingdon

Critical Care

Megan Lea-Hagerty

Russells Hall Hospital

Dudley

Intensive Care Unit Russells Hall

Michael Reay

Royal Cornwall Hospital Trust

Cornwall

Critical Care Unit

Michael Spivey

Northern Devon Healthcare NHS Trust

Barnstaple

North Devon District Hospital

Nicholas Love

Chesterfield Royal Hospital

Chesterfield

Intensive Care Unit

Nick Spittle Nick Spittle

Royal Bournemouth Hospital

Bournemouth

Bournemouth Critical Care Unit

Nigel White

Dorset County

Dorchester

ICU DCH

Patricia Williams

Surrey and Sussex Healthcare NHS Trust

Redhill

East Surrey Hospital

Patrick Morgan

Darent Valley

Dartford

ICU

Phillipa Wakefield

Royal Surrey County Hospital

Guildford

Royal Surrey

Rachel Savine

Wirral University Teaching Hospital

Birkenhead

Critical care

Reni Jacob

Musgrove Park Hospital

Taunton

Critical care Unit

Richard Innes

Kent and Canterbury Hospital

Canterbury

K&C ITU

Ritoo Kapoor

West Suffolk NHS Foundation Trust

Bury St Edmunds

Critical Care

Sally Humphreys

QAH

Portsmouth

Dept Critical Care QAH (DCCQ)

Steve Rose

Whiston Hospital

Liverpool

Ward 4E

Susan Dowling

St George’s University Hospitals NHS Foundation trust

London

General Intensive care

Susannah Leaver

North Tees University Hospital

Stockton on Tees

Critical Care Unit

Tarkeshwari Mane

Bradford Teaching Hospitals NHS Foundation Trust

Bradford

Bradford Royal Infirmary

Tom Lawton

Medway Maritime Hospital

Medway

Adult Intensive Care Unit

Vongayi Ogbeide

University Hospital Lewisham

Lewisham

ICU/HDU Lewisham

Waqas Khaliq

St Richards Hospital

Chichester

Itchenor

Yolanda Baird

France

CH Francois Mitterand

Pau

Reanimation polyvalente

Antoine Romen

Hôpital Privé Claude Galien

Quincy sous Sénart

Polyvalente

Arnaud Galbois

Saint Antoine

Paris

Medecine Intensive Reanimation

Bertrand Guidet

Germon and Gauthier

Béthune

Médecine Intensive Réanimation

Christophe Vinsonneau

Hôpital Ambroise Paré

Boulogne Billancourt

Medecine Intensive Reanimation

Cyril Charron

CH Dr. Schaffner

Lens

Reanimation polyvalente

Didier Thevenin

Hopital Européen Georges Pompidou

Paris

Médecine Intensive Réanimation

Emmanuel Guerot

CHU de Besançon

Besançon

Département de Anesthésie Réanimation Chirurgicale

Guillaume Besch

Hôpital Cochin

Paris

Médecine Intensive Réanimation

Guillaume Savary

Victor Dupouy

Argenteuil

Service de Réanimation Polyvalente et USC

Hervé Mentec

Centre Hospitalier Général

Cambrai

Réanimation polyvalente

Jean-Luc Chagnon

Dieppe General Hospital

Dieppe

Médecine Intensive Réanimation

Jean-Philippe Rigaud

CHU Dijon Bourgogne

Dijon

Medecine intensive-Réanimation

Jean-Pierre Quenot

CH Bigorre

Tarbes

service de réanimation polyvalente

Jeremy Castanera

CH de Charleville-Mézières

Charleville-Mezieres

Medecine Intensive Reanimation

Jérémy Rosman

CHU Amiens

Amiens

Reanimaiton medicale

Julien Maizel

Groupe Hospitalier Paris Saint Joseph

Paris

Réanimation polyvalente

Kelly Tiercelet

CHU de Besançon

Besancon

Réanimation Médicale

Lucie Vettoretti

CH DAX

Dax

Réanimation polyvalente

Maud Mousset Hovaere

Louis Mourier

Colombes

Réanimation médico-chirurgicale

Messika Messika

Tenon

Paris

Service de Réanimation Médico Chirurgicale

Michel Djibré

Groupe Hospitalier Sud Ile de France

Melun

Département de médecine intensive

Nathalie Rolin

Clinique Du Millenaire

Montpellier

Reanimation Chirurugicale II et III

Philippe Burtin

Marne La Vallee

Jossigny

Reanimation Polyvalente

Pierre Garcon

CHU Lille

Lille

Critical Care Center

Saad Nseir

CHU de Caen

Caen

Service de Réanimation Médicale

Xavier Valette

Germany

Klinikum rechts der Isar TU München

München

Toxikologische Intensivstation

Christian Rabe

University Hospital Ulm

Ulm

Anesthesiologic Intensive Care Department

Eberhard Barth

Katholisches Krankenhaus St. Johann Nepomuk

Erfurt

Klinik für Innere Medizin II/ Kardiologie und Internistische Intensivmedizin

Henning Ebelt

Klinikum rechts der Isar, School of Medicine, Technical University of Munich

München

Intensivstation IS2/L2a

Kristina Fuest

Jena University Hospital, Department of Internal Medicine I

Jena

Internistische Intensivstation

Marcus Franz

West German Heart and Vascular Center Essen (WHGZ)

Essen

INTK

Michael Horacek

Universitätsmedizin der Johannes Gutenberg-Universität Mainz

Mainz

Anästhesie-Intensivstation

Michael Schuster

University Hospital Frankfurt

Frankfurt am Main

Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy

Patrick Meybohm

University Hospital Düsseldorf

Düsseldorf

MI1/2

Raphael Romano Bruno

Robert-Bosch-Krankenhaus

Stuttgart

1D

Sebastian Allgäuer

Heidelberg University Hospital

Heidelberg

Station 13 IOPIS

Simon Dubler

Klinikum rechts der Isar, School of Medicine, Technical University of Munich

München

Intensivstation IS1 / M2b

Stefan J Schaller

University Hospital Leipzig

Leipzig

Department of Anesthesiology and Intensive Care Medicine

Stefan Schering

St Vincenz Hospital

Limburg/Lahn

Intensive care unit

Stephan Steiner

Hannover Medical School

Hannover

44

Thorben Dieck

Universitätsklinikum Knappschaftskrankenhaus Bochum

Bochum

Operative IBA

Tim Rahmel

Universitätsklinikum Schleswig-Holstein

Lübeck

IKI 12a

Tobias Graf

Greece

Asklepieio Voulas

Athens

ICU

Anastasia Koutsikou

Xanthi General Hospital

Xanthi

Xanthi ICU

Aristeidis Vakalos

Sismanoglio - Amallia Fleming G. H

Marousi - Athens Attika

Sismanoglio

Bogdan Raitsiou

General Hospital Agios Pavlos

Thessaloniki

ICU Agios Pavlos

Elli Niki Flioni

General Hospital of Larissa

Larissa

General ICU

Evangelia Neou

Lamia General Hospita

Lamia

Lamia ICU

Fotios Tsimpoukas

University Hospital of Ioannina

Ioannina

Intensive Care Unit

Georgios Papathanakos

General Hospital of Athens Korgialeneio Mbenakeio Red Cross

Athens

ICU

Giorgos Marinakis

General Hospital of Eleusis Thriassio

Eleusis

ICU Latsio

Ioannis Koutsodimitropoulos

KONSTANTOPOULEION GEN. HOSPITAL

Athens

General ICU

Kounougeri Aikaterini

Sotiria Hospital

Athens

ICU 1st Department of Pulmonary Medicine Athens Medical School, National and Kapodistrian University of Athens

Nikoletta Rovina

General Hospital of Patra

Achaia

ICU

Stylliani Kourelea

G Gennimatas Hospital of Thessaloniki

Thessaloniki

ICU G GENNIMATAS

Polychronis Tasioudis

Agioi Anargiroi Hospital

Athens

General ICU

Vasiiios Zidianakis

Theagenio

Theassaloniki

Meth Theagenio

Vryza Konstantinia

University General Hospital Ahepa

Thessaloniki

Metha

Zoi Aidoni

Ireland

Mater Misericordiae University Hospital

Dublin

Department of Critical Care Medicine

Brian Marsh

University Hospital Limerick

Limerick

UHL ICU

Catherine Motherway

University Hospital Galway

Galway

General ICU

Chris Read

St James’s Hospital

Dublin

ICU

Ignacio Martin-Loeches

Italy

Arnas Ospedale Civico De Christina Benfratelli

Palermo

Terapia Intensiva Polivalente Con Trauma Center

Andrea Neville Cracchiolo

Istituto Ortopedico Rizzoli

Bologna

TIPO

Aristide Morigi

San Giuseppe

Empoli

Terapia Intensiva

Italo Calamai

Humanitas Reseach Hospital

Milan

General ICU

Stefania Brusa

Libya

Al-Zawia University Hospital

Al-Zawia

ICU

Ahmed Elhadi

Alkhums Hospital

Alkhums

ICU

Ahmed Tarek

Elkhadra Hospital

Tripoli

ICU

Ala Khaled

Abo Selim Trauma Hospital

Tripoli

ICU

Hazem Ahmed

Tripoli Medical Center

Tripoli

CCU

Wesal Ali Belkhair

Netherland

Medisch Spectrum Twente

Enschede

Intensive Care Center

Alexander D. Cornet

Erasmus Medical Center

Rotterdam

ICU adults

Diederik Gommers

UMC Utrecht

Utrecht

ICU departement

Dylan de Lange

Albert Schweitzer Ziekenhuis

Dordrecht

ICU asz

Eva van Boven

Isala Hospital

Zwolle

Intensive Care

Jasper Haringman

Diakonessenhuis Utrecht

Utrecht

Intensive care

Lenneke Haas

Haga Ziekenhuis

The Hague

ICU

Lettie van den Berg

Canisius Wilhelmina Ziekenhuis

Nijmegen

C38

Oscar Hoiting

Jeroen Bosch Ziekenhuis

Den Bosch

IC JBZ

Peter de Jager

Medical Centre Leeuwarden

Leeuwarden

Department of Intensive Care

Rik T. Gerritsen

Zuyderland Medical Center

Heerlen

Zuyderland Heerlen

Tom Dormans

University Medical Center Groningen

Groningen

Department of Critical Care

Willem Dieperink

Norway

Førde Central Hospital

Førde

Department of Emergency Medicine and Inensive Care

Alena Breidablik Alena Breidablik

Kongsberg

Kongsberg

Intensivavdelingen

Anita Slapgard

Sykehuset Østfold

Grålum

Intensiv

Anne-Karin Rime

Sykehuset Telemark

Skien

Intensiv Skien

Bente Jannestad

Haukeland University Hospital

Bergen

General ICU

Britt Sjøbøe

Ålesund

Ålesund

Medisinsk intensiv

Eva Rice

Ålesund hospital

Ålesund

Dept. Anesthesia and Intensive Care, Surgical ICU

Finn H. Andersen

Kristiansund sykehus Helse Møre og Romsdal HF

Kristiansund N

Intensiv Kristiansund

Hans Frank Strietzel

Namsos Sykehus

Namsos

Intensivavdeling

Jan Peter Jensen

Haukeland University Hospital

Bergen

Medisinsk intensiv og overvåkning (MIO)

Jørund Langørgen

Oslo University Hospital

Oslo

Intensive Care section Ullevaal

Kirsti Tøien

Stavanger University Hospital

Stavanger

Department of Intensive Care

Kristian Strand

Haugesund sjukehus

Haugesund

Intensivavdelingen

Michael Hahn

St Olavs University Hospital

Oslo

Hovedintensiv

Pål Klepstad

Poland

Szpital Wojewódzki w Bełchatowie

Bełchatów

Oddział Intensywnej Terapii

Aleksandra Biernacka

Heliodor Swiecicki Clinical Hospital at the Karol Marcinkowski Medical University in Poznan

Poznań

Anaesthesiology intensive care and pain treatment Department

Anna Kluzik

University Hospital in Zielona Góra

Zielona Góra

Clinical Department od Anesthesiology and Intensiv Care

Bartosz Kudlinski

Regional Teaching Hospital

Bielsko-Biała

Department of Anaesthesiology and Intensive Care

Dariusz Maciejewski

St. John Grande Hospital

Kraków

Oddział Anestezjologii i Intensywnej Terapii

Dorota Studzińska

The John Paul II Hospital

Krakow

Department of Anesthesiology and Intensive Care

Hubert Hymczak

Uniwersyteckie Centrum Kliniczne w Gdańsku

Gdańsk

Klinika Anestezjologii i Intensywnej Terapii

Jan Stefaniak

Pomeranian Medical University

Szczecin

Department of Anesthesiology and Intensive Care

Joanna Solek-Pastuszka

University Hospital in Cracow

Kraków

Anaesthesiology and Intensive Care Unit No.1

Joanna Zorska

Regionalne Centrum Zdrowia w Lubinie

Lubin

Oddział Anestezjologii i Intensywnej Terapii

Katarzyna Cwyl

University Clinical Center Katowice

Katowice

Department of Anaesthesiology and Intensive Care - School of Medicine in Katowice, Medical University of Silesia

Lukasz J. Krzych

Teching Hospital No 2

Szczecin

Department Anaesthesiology Intensive Therapy and Acute Poisoning

Maciej Zukowski

4th Military Hospital in Wrocław

Wrocław

Anesthesia and Intensive Care Unit

Małgorzata Lipińska-Gediga

Centrum Chorób Płuc

Łódź

Oddział Anestezjologii i Intensywnej Terapii

Marek Pietruszko

The Dr. Wł. Biegański Regional Specialist Hospital in Łódź

Łódź

Department of Anaesthesiology and Intensive Therapy - Centre for Artificial Extracorporeal Kidney and Liver Support

Mariusz Piechota

Central Clinical Hospital CKD - University Medical College in Lodz

Lodz

Anaesthesia and Intensive Care Clinic

Marta Serwa

First Independent Teaching Hospital No. 1

Lublin

II Department of Anesthesiology and Intensive Care

Miroslaw Czuczwar

Krakowski Szpital Specjalistyczny im. Jana Pawła II

Kraków

Thoracic Anaesthesia and Respiratory ICU

Mirosław Ziętkiewicz

Wroclaw Medical University

Wroclaw

Department of Anesthesiology and Intensve Therapy

Natalia Kozera

Szpital św.Anny W Miechowie

Miechów

Oddział Anestezjologii i Intensywnej Terapii

Paweł Nasiłowski

University Hospital in Krakow

Krakow

ICU Skawinska

Paweł Sendur

Infant Jesus Teaching Hospital

Warsaw

I Department of Anaesthesiology and Intensive Care

Paweł Zatorski

Regional Hospital in Bialystok

Bialystok

Department of Anaesthesiology and Intensive Care

Piotr Galkin

Opole University Hospital

Opole

Department of Anesthesiology and Intensive Care

Ryszard Gawda

University Hospital in Bialystok

Bialystok

Department of Anaesthesiology and Intensive Therapy

Urszula Kościuczuk

Dr Antoni Jurasz University Hospital in Bydgoszcz

Bydgoszcz

Department of Anesthesia and Critical Care

Waldemar Cyrankiewicz

Saint Lucas Hospital, Konskie

Konskie

Intensive Care Department

Wojciech Gola

Portugal.

Centro Hospitalar do Porto

Oporto

Serviço de Cuidados Intensivos 1

Alexandre Fernandes Pinto

Hospital S. José, CHULC EPE

Lisboa

UCI Neurocríticos e Trauma

Ana Margarida Fernandes

Hospital São Francisco Xavier

Lisbon

Unidade Cuidados Intensivos Polivalente

Ana Rita Santos

Hospital da Luz

Lisboa

UCI Hospital da Luz

Cristina Sousa

Hospital de Viseu

Viseu

UCIP

Inês Barros

Hospital Professor Doutor Fernando Fonseca EPE

Amadora

Serviço de Medicina Intensiva SMI

Isabel Amorim Ferreira

Hospital Garcia de Orta - HGO

Almada

Serviço de Medicina Intensiva

Jacobo Bacariza Blanco

Hospital São Bernardo - CH Setúbal

Setúbal

Serviço de Cuidados Intensivos

João Teles Carvalho

Centro Hospitalar de Trás Montes e Alto Douro

Vila Real

Serviço de Medicina Intensiva

Jose Maia

Lusiadas Lisboa

Lisboa

UCI- Lusiadas

Nuno Candeias

CHMT-Abrantes

Abrantes

SMI

Nuno Catorze

Russia.

Privolzhskiy District Medical Center

Nizhniy Novgorod

Department of Anesthesiology and Intensive Care

Vladislav Belskiy

Spain.

Hospital De Bellvitge

Barcelona

UCI

Africa Lores

Hospital General Universitario de Albacete

Albacete

UCI Polivalente

Angela Prado Mira

Hospital Clinic of Barcelona

Barcelona

Respiratory Intensive Care Unit

Catia Cilloniz

Hospital Universitario Río Hortega

Valladolid

UVI Polivalente y Coronaria

David Perez-Torres

Universitario La Paz

Madrid

Surgical ICU

Emilio Maseda

General Universitario de Castellón

Castellón

Servicio de Medicina Intensiva

Enver Rodriguez

Hospital Universitario Río Hortega

Valladolid

UVI Neurocríticos Trauma y Quemados

Estefania Prol-Silva

Hospital de Tortosa Verge de la Cinta

Tortosa

Servei de Medicina Intensiva

Gaspar Eixarch

Parc Taulí

Sabadell

Parc Taulí

Gemma Gomà

Clínico Universitario de Valencia

Valencia

Surgical Intensive Care Unit

Gerardo Aguilar

Hospital Universitario de Torrejon

Torrejon de Ardoz, Madrid

Intensive Care UNit

Gonzalo Navarro Velasco

Hospital General de Catalunya

Barcelona

HGC

Marián Irazábal Jaimes

Hospital Universitario Sagrado Corazon

Barcelona

Intensive Care Unit

Mercedes Ibarz Villamayor

Hospital reina Sofía

Murcia

Reina Sofía

Noemí Llamas Fernández

Complejo Hospitalario de Segovia

Segovia

ICU Segovia

Patricia Jimeno Cubero

Universitario de Getafe

Getafe

Intensive Care and Burn Unit

Sonia López-Cuenca

Germans Trias i Pujol Hospital

Badalona

General ICU

Teresa Tomasa

Centralsjukhuset i Karlstad

Karlstad

IVA

Anders Sjöqvist

Sweden.

Umeå University

Umeå

Department of Surgical and Perioperative Sciences, Anestesiology and Intensive Care Medicine

Camilla Brorsson

Vrinnevisjukhuset

Norrköping

IVA Norrköping

Fredrik Schiöler

Sundsvall Hospital

Sundsvall

Sundsvall ICU

Henrik Westberg

Blekingesjukhuset

Karlskrona

Intensivvårdsavdelning 31

Jessica Nauska

Alingsås Lasarett

Alingsås

Intensivvårdsavdelningen

Joakim Sivik

Västervikssjukhus

Västervik

IVA Västervikssjukhus

Johan Berkius

Sahlgrenska University Hospital/ Område 3/ Mölndals sjukhus

Göteborg

IVA avd 227

Karin Kleiven Thiringer

Linköping University Hospital

Linköping

ICU Linköping

Lina De Geer

Linköping University Hospital

Linköping

Cardiothoracic Intensive Care Unit

Sten Walther

Switzerland.

Hopitaux Universitaires de Genève

Geneva

Adult Intensive Care Unit

Filippo Boroli

University of Bern Inselspital

Bern

Department of Intensive Care Medicine

Joerg C. Schefold

Fribourg Hospital

Fribourg

Intensive Care Unit

Leila Hergafi

Centre Hospitalier Universitaire Vaudois

Lausanne

Service de médecine intensive adulte

Philippe Eckert

Turkey.

Ordu University Training and Research Hospital

Ordu

General ICU

Ismail Yıldız

Ukraine.

Dnipro Mechnikov Regional Clinical Hospital

Dnipro

Intensive Care Unit of Polytrauma

Ihor Yovenko

European Wellness Academy, Luhansk Regional Clinical Hospital

Luhansk

ICU 1

Yuriy Nalapko

European Wellness Academy, Luhansk Regional Clinical Hospital

Luhansk

ICU 2

Yuriy Nalapko

Wales.

Glan Clwyd Hospital

Bodelwyddan

Critical Care

Richard Pugh

Financial disclosure statement

No (industry) sponsorship has been received for this investigator-initiated study.

Funding

This study was endorsed by the ESICM. Free support for running the electronic database and was granted from the dep. of Epidemiology, University of Aarhus, Denmark. Financial support for creation of the e-CRF and maintenance of the database was possible from a grant (open project support) by Western Health region in Norway) 2018 who also funded the participating Norwegian ICUs. DRC Ile de France and URC Est helped conducting VIP2 in France. Open Access funding enabled and organized by Projekt DEAL.

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BW, RRB and CJ analysed the data and wrote the first draft of the manuscript. HF and BG and DL contributed to statistical analysis and improved the paper. MK and AB and AM and FA and AA and SF and MC and SC and LF and ML and JM and BM and RM SO and CÖ and BP and IS and WS and AV and XW and SL and CB and SW and JS and MJ and YN and ME JF and TZ gave guidance and improved the paper. All authors read and approved the final manuscript.

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Correspondence to Christian Jung.

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Ethics approval and consent to participate

The primary competent ethics committee was the Ethics Committee of the University of Bergen, Norway. A study protocol was provided to participating centres. Every participating centre obtained ethics approval according to local legislation. A copy of the ethics approval was sent to the study coordinator before start of the study. Institutional research ethic board approval was obtained from each study site. This was a prerequisite for participation in the study. All methods were carried out in accordance with relevant guidelines and regulations. All experimental protocols were approved by the local institutional and/or licensing committees. Written informed consent was obtained of all included subjects, except for patients from VIP2 of sites where study inclusion was explicitly granted without written informed consent. The inclusion of deceased patients was strictly in accordance with the requirements of the local competent ethics committees. In most cases, the consent of the patient or the legal guardian was mandatory (see above). The studies conducted were observational studies. No examinations (e.g. blood sampling) or tissue sampling took place.

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The authors declare that they have no competing interests.

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Bruno, R.R., Wernly, B., Kelm, M. et al. Management and outcomes in critically ill nonagenarian versus octogenarian patients. BMC Geriatr 21, 576 (2021). https://doi.org/10.1186/s12877-021-02476-4

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