A target for increased mortality risk in critically ill patients: The concept of perpetuity

Jarrod M. Mosier, Julia M. Fisher, Cameron D. Hypes, Edward J. Bedrick, Elizabeth Salvagio Campbell, Karen Lutrick, Charles B. Cairns

Research output: Contribution to journalArticlepeer-review

Abstract

Background: Emergency medicine is acuity-based and focuses on time-sensitive treatments for life-threatening diseases. Prolonged time in the emergency department, however, is associated with higher mortality in critically ill patients. Thus, we explored management after an acuity-based intervention, which we call perpetuity, as a potential mechanism for increased risk. To explore this concept, we evaluated the impact of each hour above a lung-protective tidal volume on risk of mortality. Methods: This cohort analysis includes all critically ill, non-trauma, adult patients admitted to two academic EDs between 1 November 2013 and 30 April 2017. Cox models with time-varying covariates were developed with time in perpetuity as a time-varying covariate, defined as hours above 8 mL/kg ideal body weight, adjusted for covariates. The primary outcome was the time to in-hospital death. Results: Our analysis included 2025 patients, 321 (16%) of whom had at least 1 h of perpetuity time. A partial likelihood-ratio test comparing models with and without hours in perpetuity was statistically significant (χ2 (3) = 13.83, p = 0.0031). There was an interaction between age and perpetuity (Relative risk (RR) 0.9995; 95% Confidence interval (CI95 ): 0.9991–0.9998). For example, for each hour above 8 mL/kg ideal body weight, a 20-year-old with 90% oxygen saturation has a relative risk of death of 1.02, but a 40-year-old with 90% oxygen saturation has a relative risk of 1.01. Conclusions: Perpetuity, illustrated through the lens of mechanical ventilation, may represent a target for improving outcomes in critically ill patients, starting in the emergency department. Research is needed to evaluate the types of patients and interventions in which perpetuity plays a role.

Original languageEnglish (US)
Article number3971
JournalJournal of Clinical Medicine
Volume10
Issue number17
DOIs
StatePublished - Sep 2021

Keywords

  • Acuity
  • Critical care
  • Critically ill
  • Emergency department
  • Intubation
  • Mechanical ventila-tion
  • Perpetuity

ASJC Scopus subject areas

  • Medicine(all)

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