Original article
Critically ill patients with high predicted mortality: Incidence and outcome
Pacientes en cuidados intensivos con alta mortalidad prevista: Incidencia y evolución
André Oliveiraa, Tatiana Vieirab, Ana Rodriguesc, Núria Jorgeb, Luís Tavaresd, Laura Costae, José Artur Paivab,f,g, João Gonçalves Pereiraa,f,h,
Autor para correspondencia
a Intensive Care Medicine Department, Hospital de Vila Franca de Xira, Estrada Carlos Lima Costa Nº2, 2600-009 Vila Franca de Xira, Portugal
b Intensive Care Medicine Department, Centro Hospitalar e Universitário de São João, Alameda Prof. Hernâni Monteiro, 4200–319 Porto, Portugal
c Intensive Care Medicine Department, Hospital Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, Av. Prof. Egas Moniz, 1649-028 Lisboa, Portugal
d Intensive Care Medicine Department, Hospital Santo Espírito, Av. D. Manuel I, 9500-370 Ponta Delgada, Portugal
e Intensive Care Medicine Department, Hospital de Braga, R. das Comunidades Lusíadas 133, Braga, Portugal
f Grupo de Investigação e Desenvolvimento em Infeção e Sépsis (GISID), Rua Heróis de África, 381, Leça da Palmeira, 4450-681 Matosinhos, Portugal
g Faculdade de Medicina, Universidade do Porto, Al. Prof. Hernâni Monteiro, 4200 - 319 Porto, Portugal
h Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal
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"afiliaciones" => array:8 [ 0 => array:3 [ "entidad" => "Intensive Care Medicine Department, Hospital de Vila Franca de Xira, Estrada Carlos Lima Costa Nº2, 2600-009 Vila Franca de Xira, Portugal" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Intensive Care Medicine Department, Centro Hospitalar e Universitário de São João, Alameda Prof. Hernâni Monteiro, 4200–319 Porto, Portugal" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Intensive Care Medicine Department, Hospital Santa Maria, Centro Hospitalar Universitário de Lisboa Norte, Av. Prof. Egas Moniz, 1649-028 Lisboa, Portugal" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Intensive Care Medicine Department, Hospital Santo Espírito, Av. D. Manuel I, 9500-370 Ponta Delgada, Portugal" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Intensive Care Medicine Department, Hospital de Braga, R. das Comunidades Lusíadas 133, Braga, Portugal" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Grupo de Investigação e Desenvolvimento em Infeção e Sépsis (GISID), Rua Heróis de África, 381, Leça da Palmeira, 4450-681 Matosinhos, Portugal" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Faculdade de Medicina, Universidade do Porto, Al. Prof. Hernâni Monteiro, 4200 - 319 Porto, Portugal" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Faculdade de Medicina, Universidade de Lisboa, Avenida Professor Egas Moniz, 1649-028 Lisboa, Portugal" "etiqueta" => "h" "identificador" => "aff0040" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Pacientes en cuidados intensivos con alta mortalidad prevista: Incidencia y evolución" ] ] "resumenGrafico" => array:2 [ "original" => 1 "multimedia" => array:5 [ "identificador" => "fig0015" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 740 "Ancho" => 1333 "Tamanyo" => 118758 ] ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0110">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Critical care medicine is designed for patients with critical illnesses at different stages of their condition. There is an identifiable ongoing morbidity and mortality attributable to the acute severe illness event, to older age, and to a growing number of comorbidities.</p><p id="par0010" class="elsevierStylePara elsevierViewall">All-cause mortality is a common outcome measure in the Intensive Care Unit (ICU), used as a major primary endpoint in several cohort studies and benchmarking analyses, and as a surrogate of the quality of care.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Scoring systems, like the commonly used Simplified Acute Physiology Score (SAPS) II,<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> help to describe ICU populations and interpret the outcome measures between different populations and ICUs.<a class="elsevierStyleCrossRefs" href="#bib0015"><span class="elsevierStyleSup">3–6</span></a></p><p id="par0015" class="elsevierStylePara elsevierViewall">A growing number of patients have a very severe disease on ICU admission and a very high risk of death, as predicted by the severity scores, due both to older age and age-related syndromes, especially comorbidities.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">This most severely ill population is poorly studied in clinical studies, due to predicted worst outcomes, and their prognosis is largely unknown.<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">8,9</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">A better knowledge of their ICU and Hospital outcomes, along with the identification of risk factors for short- and long-term mortality is warranted.</p><p id="par0030" class="elsevierStylePara elsevierViewall">This study's goal was to assess short-term (hospital and 30-day) and long-term (one and two years) outcomes of critically ill patients with SAPS II predicted mortality above 80% admitted to ICU in Portugal. We intend to quantify their mortality risk at different time points to support prognostication and to help patients (or their relatives) and doctors to inform realistic goals of care.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0115">Patients and methods</span><p id="par0035" class="elsevierStylePara elsevierViewall">This is a post hoc analysis of Critically ill Mortality by age long-term (CIMbA LT) study, a multicenter, cohort, longitudinal, observational, retrospective study, that included 16 different Portuguese intensive care departments. The study protocol has been published elsewhere.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> Briefly, data from all adult patients admitted to one of the 16 participating ICUs, for more than 24<span class="elsevierStyleHsp" style=""></span>h, between January 1, 2015, and June 10, 2019, were included. Only the first ICU admission of any patient was considered. Demographic, clinical, and outcome data, along with the SAPS II score, were collected. The SAPS II score is largely used in Portugal including for ICU benchmarking and locally measured data was included in the study. Nevertheless, all participating ICUs were specifically recommended to confirm all unplausible, or missing data. A final check was performed on the whole data, plotting SAPS II against hospital mortality, to find potential incongruencies. The one and two-year follow-up was accomplished through direct patient or relatives contact, hospital registries, or from the National Health Directory database. At least, one year of follow-up was completed for each patient.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Anonymized data were introduced in a file created specifically for this study and all patients were identified by a consecutive number. Missing data on age or SAPS-II score led to database exclusion.</p><p id="par0045" class="elsevierStylePara elsevierViewall">We calculated the standardized mortality rate (SMR, that is the ratio between observed and predicted hospital mortality according to the SAPS II score) for patients admitted with each SAPS II score, both at hospital discharge and at one year of follow-up. We plot the results to evaluate if there was a cut-off point (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0050" class="elsevierStylePara elsevierViewall">Accordingly, we arbitrarily defined the most severe group as those with a SAPS II score≥ 67 (corresponding to predicted hospital mortality of 80%). These were segregated for further analysis. Their first 30 days' cumulative ICU mortality was mapped, to envisage the days with higher mortality (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">We calculated the ICU and the Hospital length of stay (LOS) and the all-cause mortality for the group with higher SAPS II predicted mortality and the remaining patients. Survival curves for both groups were plotted separately, for both the whole population and according to the presence of sepsis on admission to the ICU. Sub-analyses of the first 30 days and for the 31st to 365th days after ICU admission were also obtained. The relationship between age and mortality during these two time periods was calculated.</p><p id="par0060" class="elsevierStylePara elsevierViewall">The study was approved by the local Research and Ethics Committees of all the participating centers. According to the study design, informed consent was waived.</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0120">Statistical analysis</span><p id="par0065" class="elsevierStylePara elsevierViewall">Descriptive statistics were calculated. Data were summarized as mean<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>standard deviation or median [percentile 25 and 75, p25–p75], according to data distribution. Categorical variables were described as N (%).</p><p id="par0070" class="elsevierStylePara elsevierViewall">The chi-square test was used to compare categorical variables, whilst continuous variables were evaluated with the Student T test or the Mann-Whitney U test, according to data distribution.</p><p id="par0075" class="elsevierStylePara elsevierViewall">The Cox proportional hazard was used to compare the group with higher SAPS II predicted mortality with the remaining patients. The hazards ratio, adjusted to age, type of ICU admission, and the presence of sepsis (aHR), with the respective 95% confidence interval (CI) were computed, both for the first 30 days after ICU admission and, for the 30-day survivors, for the 31st–365th days of follow-up. The log-rank test was calculated for comparisons between sub-groups in patients with or without sepsis. The impact of age on mortality at each of the defined time points was calculated with the Chi-square test.</p><p id="par0080" class="elsevierStylePara elsevierViewall">Statistical analysis was performed using IBM SPSS Statistics v.25.0 (IBM, Somers, NY, USA). All statistics were 2-tailed and the significance level was defined as <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.05.</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0125">Results</span><p id="par0085" class="elsevierStylePara elsevierViewall">We evaluated 37,118 patients, of whom 4546 (12.2%) had a SAPS II<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>67 (the high-risk group). Their demographic characteristics are presented in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>. More than 70% were older than 65 years (compared with 50.0% of the remaining population, <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001) and 61% were male (vs. 59.9%, <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.17). A medical reason for admission and the presence of sepsis were both significantly more common in the high-risk group (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> and Supp Table 3).</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0090" class="elsevierStylePara elsevierViewall">More than half of the deaths (51.1%) during the first month after ICU admission occurred during the first 4 days (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>, panel A).</p><p id="par0095" class="elsevierStylePara elsevierViewall">The predicted hospital mortality (according to the SAPS II score) in this group was very high, 89.0<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.8%. The observed hospital mortality was lower, 61.1%, with an SMR of 0.69, and this was similar to the SMR of the less severe population (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a> and <a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>).</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0100" class="elsevierStylePara elsevierViewall">The aHR for 30-day all-cause mortality for this high-risk population was 3.52 (95% CI 3.34–3.71). When addressing only the 30-day survivors, the mortality risk remained significantly higher during the first year of follow-up, days 31st–365th aHR 1.14 (95%CI 1.04–1.26) (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>, panel B).</p><p id="par0105" class="elsevierStylePara elsevierViewall">After the first year of follow-up, 70.0% of the population with a SAPS II predicted hospital mortality above 80% had died (<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>), a figure which remained, however, well below the SAPS II initial predicted mortality.</p><p id="par0110" class="elsevierStylePara elsevierViewall">This group had slightly longer ICU LOS but shorter Hospital LOS (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). However, this difference was related to early mortality. When addressing only survivors, this high-risk group has longer ICU and hospital LOS (8 [1.9–31.4] vs 4 [1–23.7], <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001 and 21.5 [5.0–96.6] vs. 14 [3–73], <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001, respectively).</p><p id="par0115" class="elsevierStylePara elsevierViewall">Of the whole population, 30.8% of patients were admitted to the ICU with sepsis, and this diagnosis was associated with worst outcomes (Suppl Table 3). However, this difference was much more striking in the less severe, group (odds ratio 1.78, 95% CI 1.68–1.89), than in the population with the higher SAPS II predicted mortality (odds ratio 1.12, 95%CI 0.99–1.27). Curiously, the mortality rate during the first 30 days was also not influenced by age in this high-risk group (<span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.924), as opposed to what was noted during the late period and in the less severe patients (Supp Figs. 3 and 4).</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0130">Discussion</span><p id="par0120" class="elsevierStylePara elsevierViewall">In this study, we evaluated the 12.2% of the most severely critically ill patients admitted to the participating ICUs, with a SAPS II predicted hospital mortality of 89.0<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.8%. Their hospital mortality, albeit lower, was still 61.0%. More than half of the first-month deaths of this group occurred during the first 4 days of ICU stay. Despite this high, and early, mortality rate, their hospital standardized mortality ratio was 0.69, in line with what was found in the remaining, less severe patients. Despite their high severity at ICU admission, at one year of follow-up, roughly 30% of this population were still alive.</p><p id="par0125" class="elsevierStylePara elsevierViewall">Different risk factors for early and late mortality of critically ill patients have been identified. Those often include sepsis and infection (either on admission or complicating the course of stay), the severity of illness at ICU admission (measured by different scores), age, the presence of comorbidities, functional status at ICU admission, and the need for ICU readmission. All these were significantly associated with both early (30 days) and late (31–365 days) mortality in a recently published observational study,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> results which were similar to ours. Interestingly, in our population, in patients with high SAPS II predicted mortality, sepsis only impacted late mortality (Supp Table 3 and Fig. 4).</p><p id="par0130" class="elsevierStylePara elsevierViewall">Differences in ICU outcomes may be related to the available resources, as recently shown by Martin-Loeches et al.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">12</span></a> In their study, late deaths were associated with older age and infection. Significantly, patients from higher-income countries have a higher rate of late deaths, probably related to the higher availability of ICU beds that allow treatment of a more chronically diseased and frail group of patients. Portugal is a middle-income country with a relatively short number of ICU beds (increasing from 4.2 beds per 100,000 inhabitants in 2012<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> to 6.4 at the end of the study period<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a>), and this may have influenced our results. The lack of availability of ICU beds is associated with a worse prognosis, even when a delayed admission is possible.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> That calls for action aiming at judicious resource use and providing the optimal intensity of care according to patients' potential benefit.</p><p id="par0135" class="elsevierStylePara elsevierViewall">Roughly 30% of our high-risk patients were alive after one year, unveiling a lasting benefit of their ICU admission. Pintado et al. evaluated 88 patients who were refused ICU admission because they were “too ill to benefit”. Those patients had more comorbidities and worse mental and functional outcomes but roughly one quarter were alive after one year,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> suggesting that prognostication during the acute disease may be problematic,<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> even in more severe patients. In fact, our study showed an SMR lower than one, translating into an improved prognosis compared to SAPS II predicted hospital mortality. This benefit was similar in the whole spectrum of disease severity, with no obvious cut-off point. Even patients older than 75 years may have a long-term (one year) benefit of ICU admission, although prolonged ICU stay may jeopardize this benefit, leading to lower survival and poor quality of life.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a></p><p id="par0140" class="elsevierStylePara elsevierViewall">Consequently, an ICU trial,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> that is, admitting and treating the patient for a predefined short period, followed by withdrawal if no benefit is found, may help to surpass this dilemma. This may also help to reduce the provision of excessive critical care resources to patients who appropriately enter the ICU.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> It may also facilitate an early definition of realistic goals of care, which may improve patients’ and families’ satisfaction and contribute to better use of resources.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21,22</span></a></p><p id="par0145" class="elsevierStylePara elsevierViewall">Andersen et al.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> focused on advanced age as an independent predictor of ICU mortality. In his study, most of the ICU deaths occurred very early, during the first 2 days after admission, mostly related to life-supporting withdrawal. In our cohort, more than half of the deaths of the severest patients happened during the first four days after admission (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Of note, we excluded patients who died during the first 24<span class="elsevierStyleHsp" style=""></span>h in the ICU, and the high-risk group was selected based on severity (assessed by SAPS II score) and not only by age. Consequently, an early withdrawal decision was probably less likely to happen.</p><p id="par0150" class="elsevierStylePara elsevierViewall">Our data seems to suggest that even very severe patients, who survive after the fourth day, do not necessarily have a dismal prognosis, and may experience long-term survival. Accordingly, we think that no withdrawal decisions should be based only on clinical severity during the ICU stay.</p><p id="par0155" class="elsevierStylePara elsevierViewall">Clinical severity, age, comorbidities, and length of ICU stay have also been related to post-ICU mortality.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a> Similarly, in our population, there were more late deaths in our high-risk group (aHR 1.14, 95%CI 1.04–1.26), even after being discharged alive from the hospital.</p><p id="par0160" class="elsevierStylePara elsevierViewall">These observations may have important organizational implications and challenge admission policies. Future research should focus on the improvement of patient-centered prognostic scores, including individual characteristics (such as frailty, and comorbidities), assessing not only hospital outcomes but also short- and long-term morbidity and mortality, and facilitating patients' own choices. The development and evaluation of interventions aiming to improve the long-term outcome of high-risk patients admitted to the ICU should also be a priority.</p><p id="par0165" class="elsevierStylePara elsevierViewall">We acknowledge that our study has several limitations. First, our sample was limited to a group of ICUs in a single country, and the short and long-term outcomes of severe patients admitted to ICU may differ across countries. Second, our database does not include information on functional status before admission, although severely dependent patients are usually excluded from admission.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> Third, we excluded patients with less than 24<span class="elsevierStyleHsp" style=""></span>h of ICU stay, including those who died. Fourth, the SAPS II score may fail to capture all the severity of patients, including their frailty, that may influence the outcomes,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> and we were not able to formally check the local accuracy of the SAPS II calculation. Fifth, we did not include other severity scores. Finally, we did not collect data on the level of life-support, treatment limitations, end-of-life decisions, the policy of ICU trials,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> and causes of death after ICU discharge.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a></p><p id="par0170" class="elsevierStylePara elsevierViewall">Our work had also some strengths: it included a large ICU database and focused on a generally poorly studied sub-group. To our knowledge, this is the first study to analyze a large database of the long-term outcome of a population with a very high predicted risk of death admitted to an ICU.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0135">Conclusion</span><p id="par0175" class="elsevierStylePara elsevierViewall">More than 12% of patients admitted to the ICU had very high predicted hospital mortality according to SAPS II. These patients often died during the first 4 days after ICU admission and had a short- but also long-term increase in the risk of death. Nevertheless, roughly 30% were alive after one year of follow-up.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0140">Funding</span><p id="par0180" class="elsevierStylePara elsevierViewall">None.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0145">Conflict of interest</span><p id="par0185" class="elsevierStylePara elsevierViewall">None.</p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0150">Contribution of the authors</span><p id="par0190" class="elsevierStylePara elsevierViewall">AO, JGP designed the study; AO, TV, ARR, NJ, LT, and LC acquired the data and performed a literature search; AO, JGP check the data for missing or implausible values; AO, JGP, TV, JAP analyze and interpret the data; JGP, AO, JAP drafted the manuscript; AO, JGP; TV; NJ, LT, LC, JAP revised the manuscript for important intellectual content; JGP, AO provided the statistical expertise. JGP acts as the guarantor of the integrity and accuracy of the data. All authors read and approved the final manuscript.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:3 [ "identificador" => "xres2083027" "titulo" => "Graphical abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:3 [ "identificador" => "xres2083026" "titulo" => "Abstract" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0015" "titulo" => "Design" ] 2 => array:2 [ "identificador" => "abst0020" "titulo" => "Setting" ] 3 => array:2 [ "identificador" => "abst0025" "titulo" => "Patients" ] 4 => array:2 [ "identificador" => "abst0030" "titulo" => "Interventions" ] 5 => array:2 [ "identificador" => "abst0035" "titulo" => "Main Variables of Interest" ] 6 => array:2 [ "identificador" => "abst0040" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "abst0045" "titulo" => "Conclusions" ] ] ] 2 => array:2 [ "identificador" => "xpalclavsec1776990" "titulo" => "Keywords" ] 3 => array:3 [ "identificador" => "xres2083028" "titulo" => "Resumen" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "abst0050" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0055" "titulo" => "Diseño" ] 2 => array:2 [ "identificador" => "abst0060" "titulo" => "Âmbito" ] 3 => array:2 [ "identificador" => "abst0065" "titulo" => "Pacientes" ] 4 => array:2 [ "identificador" => "abst0070" "titulo" => "Intervenciones" ] 5 => array:2 [ "identificador" => "abst0075" "titulo" => "Variables de interés principals" ] 6 => array:2 [ "identificador" => "abst0080" "titulo" => "Resultados" ] 7 => array:2 [ "identificador" => "abst0085" "titulo" => "Conclusiones" ] ] ] 4 => array:2 [ "identificador" => "xpalclavsec1776989" "titulo" => "Palabras clave" ] 5 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 6 => array:3 [ "identificador" => "sec0010" "titulo" => "Patients and methods" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Statistical analysis" ] ] ] 7 => array:2 [ "identificador" => "sec0020" "titulo" => "Results" ] 8 => array:2 [ "identificador" => "sec0025" "titulo" => "Discussion" ] 9 => array:2 [ "identificador" => "sec0030" "titulo" => "Conclusion" ] 10 => array:2 [ "identificador" => "sec0035" "titulo" => "Funding" ] 11 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflict of interest" ] 12 => array:2 [ "identificador" => "sec0045" "titulo" => "Contribution of the authors" ] 13 => array:2 [ "identificador" => "xack725734" "titulo" => "Acknowledgements" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2023-06-22" "fechaAceptado" => "2023-10-08" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec1776990" "palabras" => array:6 [ 0 => "Epidemiology" 1 => "Mortality" 2 => "Intensive care" 3 => "Follow up" 4 => "SAPS II" 5 => "High-risk" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec1776989" "palabras" => array:6 [ 0 => "Epidemiología" 1 => "Mortalidad" 2 => "Cuidados intensivos" 3 => "Seguimiento" 4 => "SAPS II" 5 => "Alto riesgo" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:3 [ "titulo" => "Abstract" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Objective</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">As calculated by the severity scores, an unknown number of patients are admitted to the Intensive Care Unit (ICU) with a very high risk of death. Clinical studies have poorly addressed this population, and their prognosis is largely unknown.</p></span> <span id="abst0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Design</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Post hoc analysis of a multicenter, cohort, longitudinal, observational, retrospective study (CIMbA).</p></span> <span id="abst0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Setting</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Sixteen Portuguese multipurpose ICUs.</p></span> <span id="abst0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Patients</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Patients with a Simplified Acute Physiology Score II (SAPS II) predicted hospital mortality above 80% on admission to the ICU (high-risk group); A comparison with the remaining patients was obtained.</p></span> <span id="abst0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Interventions</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">None.</p></span> <span id="abst0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Main Variables of Interest</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Hospital, 30 days, 1 year mortality.</p></span> <span id="abst0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Results</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">We identified 4546 patients (59.9% male), 12.2% of the whole population. Their SAPS II predicted hospital mortality was 89.0<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.8%, whilst the observed mortality was lower, 61.0%. This group had higher mortality, both during the first 30 days (aHR 3.52 [95% CI 3.34–3.71]) and from day 31 to day 365 after ICU admission (aHR 1.14 [95%CI 1.04–1.26]), respectively. However, their hospital standardized mortality ratio was similar to the other patients (0.69 vs. 0.69, <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.92). At one year of follow-up, 30% of patients in the high-risk group were alive.</p></span> <span id="abst0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conclusions</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">Roughly 12% of patients admitted to the ICU for more than 24<span class="elsevierStyleHsp" style=""></span>h had a SAPS II score predicted mortality above 80%. Their hospital standardized mortality was similar to the less severe population and 30% were alive after one year of follow-up.</p></span>" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "abst0010" "titulo" => "Objective" ] 1 => array:2 [ "identificador" => "abst0015" "titulo" => "Design" ] 2 => array:2 [ "identificador" => "abst0020" "titulo" => "Setting" ] 3 => array:2 [ "identificador" => "abst0025" "titulo" => "Patients" ] 4 => array:2 [ "identificador" => "abst0030" "titulo" => "Interventions" ] 5 => array:2 [ "identificador" => "abst0035" "titulo" => "Main Variables of Interest" ] 6 => array:2 [ "identificador" => "abst0040" "titulo" => "Results" ] 7 => array:2 [ "identificador" => "abst0045" "titulo" => "Conclusions" ] ] ] "es" => array:3 [ "titulo" => "Resumen" "resumen" => "<span id="abst0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Objetivo</span><p id="spar0080" class="elsevierStyleSimplePara elsevierViewall">Según las escalas de gravedad, un número indeterminado de pacientes ingresan en la Unidad de Cuidados Intensivos (UCI) con riesgo de muerte muy elevado. Este grupo ha sido poco abordado en los estudios clínicos y se desconoce en gran medida su pronóstico.</p></span> <span id="abst0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Diseño</span><p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Análisis post-hoc de estudio multicéntrico, de cohortes, longitudinal, observacional y retrospectivo (CIMbA).</p></span> <span id="abst0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Âmbito</span><p id="spar0090" class="elsevierStyleSimplePara elsevierViewall">Dieciséis UCI polivalentes portuguesas.</p></span> <span id="abst0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Pacientes</span><p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Pacientes con mortalidad hospitalaria prevista en el Simplified Acute Physiology Score II (SAPS II) superior al 80% nel ingreso en la UCI (grupo de alto riesgo); se compararon con los restantes.</p></span> <span id="abst0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Intervenciones</span><p id="spar0100" class="elsevierStyleSimplePara elsevierViewall">Ninguna.</p></span> <span id="abst0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Variables de interés principals</span><p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Mortalidad hospitalaria, a 30 días y 1 año.</p></span> <span id="abst0080" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Resultados</span><p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">Se identificaron 4546 pacientes (59.9% hombres), 12.2% da población. La mortalidad hospitalaria estimada por lo SAPS II fue de 89.0<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.8%, aunque la observada fue inferior, 61.0%. Este grupo presentó mayor mortalidad, tanto durante los primeros 30 días (aHR 3.52 [IC 95%: 3.34–3.71]) y desde el día 31 hasta el día 365 después del ingreso en UCI (aHR 1.14 [IC 95%: 1.04–1.26]). Sin embargo, su índice de mortalidad hospitalaria estandarizada fue similar a los otros pacientes (0.69 vs. 0.69; <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>.92). Al primer año de seguimiento, 30% de los pacientes de alto riesgo estaban vivos.</p></span> <span id="abst0085" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conclusiones</span><p id="spar0115" class="elsevierStyleSimplePara elsevierViewall">Aproximadamente 12% de los pacientes ingresados en la UCI durante más de 24 horas tenían una mortalidad prevista por SAPS II superior al 80%. Su mortalidad hospitalaria estandarizada fue similar a la de la población menos grave y el 30% estaban vivos después de un año de seguimiento.</p></span>" "secciones" => array:8 [ 0 => array:2 [ "identificador" => "abst0050" "titulo" => "Objetivo" ] 1 => array:2 [ "identificador" => "abst0055" "titulo" => "Diseño" ] 2 => array:2 [ "identificador" => "abst0060" "titulo" => "Âmbito" ] 3 => array:2 [ "identificador" => "abst0065" "titulo" => "Pacientes" ] 4 => array:2 [ "identificador" => "abst0070" "titulo" => "Intervenciones" ] 5 => array:2 [ "identificador" => "abst0075" "titulo" => "Variables de interés principals" ] 6 => array:2 [ "identificador" => "abst0080" "titulo" => "Resultados" ] 7 => array:2 [ "identificador" => "abst0085" "titulo" => "Conclusiones" ] ] ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0210" class="elsevierStylePara elsevierViewall">The following is Supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0055" ] ] ] ] "multimedia" => array:6 [ 0 => array:8 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1109 "Ancho" => 2515 "Tamanyo" => 151164 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0355" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Standard mortality ratio according to severity of disease on Intensive care Unit admission (measured by the SAPS II), calculated at hospital discharge. The non-continuous line represents polynomial function for the SMR dispersion trend (y<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0,0019x<span class="elsevierStyleSup">2</span><span class="elsevierStyleHsp" style=""></span>−<span class="elsevierStyleHsp" style=""></span>0,0494x<span class="elsevierStyleHsp" style=""></span>+<span class="elsevierStyleHsp" style=""></span>0,941). ICU, Intensive Care Unit; SAPS, Simplified Acute Physiology Score; SMR, Standardized Mortality Ratio.</p>" ] ] 1 => array:8 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2414 "Ancho" => 1684 "Tamanyo" => 189544 ] ] "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0360" "detalle" => "Figure " "rol" => "short" ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Survival curves according to the severity of disease on the Intensive Care Unit admission. Panel A: Survival during the first 30 days after admission. Panel B: Long-term cumulative survival in 30-day survivors (from the 31st to the 365th day of follow-up). Log Rank test <span class="elsevierStyleItalic">P</span><span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>.001 for both. SAPS, Simplified Acute Physiology Score; ICU, Intensive Care Unit.</p>" ] ] 2 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0365" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">SAPS II, Simplified Acute Physiology Score II; ICU, Intensive Care Unit; LOS, Length of Stay; p25–p75, Percentiles 25 and 75.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SAPS<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>67 (N 4546) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SAPS<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>67 (N 32,572) \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>-value \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Age(years) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">18−50 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">341 (7.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">7291 (22.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="4" align="left" valign="middle"><.001</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">51−65 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">935 (20.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8998 (27.6%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">66−80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2205 (48.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">11,462 (35.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">>80 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1065 (23.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4821 (14.8%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Gender \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Male \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2773 (61%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">19,521 (59.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="2" align="left" valign="middle">.17</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Female \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1773 (39%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13,051 (40.1%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead rowgroup " rowspan="3" align="left" valign="middle">Type of admission</td><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Medical \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3197 (70.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">20,173 (61.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " rowspan="3" align="left" valign="middle"><.001</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Unscheduled Surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1244 (27.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">8115 (24.9%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Scheduled Surgery \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">105 (2.3%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4284 (13.2%) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Sepsis</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1971 (43.4%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9477 (29.1%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ICU LOS (days) (median, p25–p75)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">5.4 [1−27] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">4 [1−24] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " colspan="2" align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hospital LOS (days) (median, p25–p75)</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9 [2−72] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">13 [1−67] \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3449813.png" ] ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Demographic characteristics.</p>" ] ] 3 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at0370" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">SAPS II, Simplified Acute Physiology Score II; ICU, Intensive Care Unit; SMR, Standardized mortality ratio.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SAPS<span class="elsevierStyleHsp" style=""></span>≥<span class="elsevierStyleHsp" style=""></span>67 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black">SAPS<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>67 \t\t\t\t\t\t\n \t\t\t\t\t\t</th><th class="td" title="\n \t\t\t\t\ttable-head\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>-value<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SAPS II predicted hospital mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">89.0<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>5.8% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">27.4<span class="elsevierStyleHsp" style=""></span>±<span class="elsevierStyleHsp" style=""></span>22.8% \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"> \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">ICU Mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2250 (49.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3731 (11.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">Hospital Mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">2775 (61.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">6141 (18.9%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">SMR \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">0.69 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">.92 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t ; entry_with_role_rowhead " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">1-year mortality \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">3184 (70.0%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t">9931 (30.5%) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="\n \t\t\t\t\ttable-entry\n \t\t\t\t " align="left" valign="\n \t\t\t\t\ttop\n \t\t\t\t"><.001 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab3449814.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Chi-square test.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Patients’ mortality at the different time points after Intensive Care Unit admission.</p>" ] ] 4 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 278455 ] ] 5 => array:5 [ "identificador" => "fig0015" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => false "mostrarDisplay" => true "figura" => array:1 [ 0 => array:4 [ "imagen" => "fx1.jpeg" "Alto" => 740 "Ancho" => 1333 "Tamanyo" => 118758 ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:25 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Severity-adjusted ICU mortality only tells half the truth-the impact of treatment limitation in a nationwide database" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. 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Hospital de Leiria: Filipa Sequeira. Centro Hospitalar Universitário de S. João (Porto): José-Artur Paiva; Tatiana Santos Vieira; Núria Jorge. Centro Hospital Universitário de Lisboa Norte (Lisboa): Ana Bento Rodrigues; Susana Fernandes; João Ribeiro. Hospital S. Francisco Xavier (Lisboa): Rui Morais; Pedro Póvoa; Luís Coelho. Centro Hospitalar Universitário de Coimbra: Ana Martinho; Iolanda Santos. Hospital Egas Moniz (Lisboa): Gabriela Almeida. Hospital de Beja: Alexandra Paula; Filipe Morais de Almeida. Centro Hospitalar Universitário do Algarve (Faro): Sofia Ribeiro.</p>" "vista" => "all" ] ] ] "idiomaDefecto" => "en" "url" => "/02105691/0000004800000002/v2_202402010636/S0210569123002851/v2_202402010636/en/main.assets" "Apartado" => array:4 [ "identificador" => "434" "tipo" => "SECCION" "es" => array:2 [ "titulo" => "Originales" "idiomaDefecto" => true ] "idiomaDefecto" => "es" ] "PDF" => "https://static.elsevier.es/multimedia/02105691/0000004800000002/v2_202402010636/S0210569123002851/v2_202402010636/en/main.pdf?idApp=WMIE&text.app=https://medintensiva.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0210569123002851?idApp=WMIE" ]
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