title: Are there accurate predictors of long-term vital and functional outcomes in cardiac surgical patients requiring prolonged intensive care?
abstract: OBJECTIVE
  The decision to maintain intensive treatment in cardiac surgical patients with poor initial outcome is mostly based on individual experience. The risk scoring systems used in cardiac surgery have no prognostic value for individuals. This study aims to assess (a) factors possibly related to poor survival and functional outcomes in cardiac surgery patients requiring prolonged (> or = 5 days) intensive care unit (ICU) treatment, (b) conditions in which treatment withdrawal might be justified, and (c) the patient's perception of the benefits and drawbacks of long intensive treatments.
  
  
  METHODS
  The computerized data prospectively recorded for every patient in the intensive care unit over a 3-year period were reviewed and analyzed (n=1859). Survival and quality of life (QOL) outcomes were determined in all patients having required > or =5 consecutive days of intensive treatment (n=194/10.4%). Long-term survivors were interviewed at yearly intervals in a standardized manner and quality of life was assessed using the dependency score of Karnofsky. No interventions or treatments were given, withhold, or withdrawn as part of this study.
  
  
  RESULTS
  In-hospital, 1-, and 3-year cumulative survival rates reached 91.3%, 85.6%, and 75.1%, respectively. Quality of life assessed 1 year postoperatively by the score of Karnofsky was good in 119/165 patients, fair in 32 and poor in 14. Multivariate logistic regression analysis of 19 potential predictors of poor outcome identified dialysis as the sole factor significantly (p=0.027) - albeit moderately - reducing long-term survival, and sustained neurological deficit as an inconstant predictor of poor functional outcome (p=0.028). One year postoperatively 0.63% of patients still reminded of severe suffering in the intensive station and 20% of discomfort. Only 7.7% of patients would definitely refuse redo surgery.
  
  
  CONCLUSIONS
  This study of cardiac surgical patients requiring > or =5 days of intensive treatment did not identify factors unequivocally justifying early treatment limitation in individuals. It found that 1-year mortality and disability rates can be maintained at a low level in this subset of patients, and that severe suffering in the ICU is infrequent.
authors.affiliation: Department of Cardiovascular Surgery, University Hospital Lausanne, Switzerland. Philippe.Gersbach@chuv.hospvd.ch
authors.forename: Philippe
authors.initials: P
authors.lastname: Gersbach
authors.forename: Hendriks
authors.initials: H
authors.lastname: Tevaearai
authors.forename: Jean-Pierre
authors.initials: JP
authors.lastname: Revelly
authors.forename: Pierre
authors.initials: P
authors.lastname: Bize
authors.forename: René
authors.initials: R
authors.lastname: Chioléro
authors.forename: Ludwig Karl
authors.initials: LK
authors.lastname: von Segesser
mesh_terms: D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D001294:Attitude to Health; D006348:Cardiac Surgical Procedures / Q000009:adverse effects; D002423:Cause of Death; D003422:Critical Care; D004812:Epidemiologic Methods; D005260:Female; D006801:Humans; D017567:Karnofsky Performance Status; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010359:Patient Readmission; D011182:Postoperative Care; D011183:Postoperative Complications / Q000628:therapy; D011379:Prognosis; D011788:Quality of Life; D028761:Withholding Treatment