Elsevier

Journal of Critical Care

Volume 27, Issue 6, December 2012, Pages 739.e7-739.e13
Journal of Critical Care

Prognostic factors and outcomes of patients with pulmonary hypertension admitted to the intensive care unit,☆☆

https://doi.org/10.1016/j.jcrc.2012.08.006Get rights and content

Abstract

Purpose

Patients with pulmonary hypertension (PH) can decompensate to the point where they require care in the intensive care unit (ICU). Our objective is to examine the outcomes and characteristics of patients with PH admitted to the ICU.

Methods

This is a retrospective study of 99 patients with PH who were admitted to the medical ICU of a single tertiary care center. Baseline characteristics, interventions during ICU admission, and ICU and 6-month outcome were documented. Univariate and multivariate logistic regressions were used to evaluate association of patient characteristics with mortality.

Results

Intensive care unit mortality was 30%, and 6-month mortality was 40%. Acute Physiology and Chronic Health Evaluation II score, World Health Organization Group 3 PH, and preexisting treatment with a prostacyclin at time of ICU admission were associated with worse outcome. Patients who received cardiopulmonary resuscitation had 100% mortality. The requirement for mechanical ventilation and dialysis was also associated with increased mortality. Pulmonary artery catheter placement was associated with reduced mortality, specifically if it was placed early during ICU admission and if associated with a change in the present management.

Conclusions

Mortality is high in critically ill patients with PH. The identification of prognostic baseline characteristics and interventions in the ICU is important and warrants further investigation.

Introduction

Pulmonary hypertension (PH) is a progressive disease characterized by sustained elevations in pulmonary arterial pressures and increased pulmonary vascular resistance [1], [2]. This results in right heart failure (RHF); impairment in oxygenation; exercise limitation; and, ultimately, death. Therapeutic improvements have targeted reduction in pulmonary vascular resistance in an effort to unload the right ventricle and improve cardiac output [3]. Three classes of medications, phospodiesterase inhibitors, endothelin receptor antagonists, and prostacyclin analogs increase exercise capacity and stabilize disease progression [3], [4], [5], [6]. Despite these advances, patients with PH continue to require admission to the hospital and often to the intensive care unit (ICU), most commonly for decompensated RHF [7], [8].

The management of a critically ill PH patient is challenging. With very little physiologic reserve, they may deteriorate rapidly into irreversible hemodynamic collapse [9]. Treatment often involves high-dose intravenous diuretics; vasopressor support; escalation or initiation of new PH therapy; and, possibly, mechanical ventilation and hemodialysis. Few studies describe the prognostic factors, course, and outcomes of these patients or the ICU management [10], [11], and none evaluate the efficacy of the various interventions initiated in the critical care setting. Evaluation of the impact of these interventions on mortality is important, especially because they are often costly and invasive. In an effort to address these questions, we retrospectively assessed the clinical characteristics and mortality outcome of a group of patients with PH who required admission to the ICU.

Section snippets

Study design

This is a retrospective study at a single tertiary care center to identify the characteristics and the ICU interventions associated with in-hospital and 6-month mortality after admission to the ICU. Our study was approved by the UCLA Institutional Review Board (IRB no. 11-001695).

Patients

The first admission of all patients with PH who required admission to the UCLA medical ICU between July 2004 and June 2009 was identified via International Classification of Diseases, Ninth Revision, codes (416.0 and

Baseline characteristics

After excluding elective and repeated admissions, 99 patients were included in the study (Table 1). Most were female (64/99) and had pulmonary arterial hypertension (Dana Point Group 1) (72/99). The median length of stay in the ICU was 10 days (interquartile range [IQR], 5-16 days). The mean APACHE II score was 17.2 (SD, 7.1). The primary reasons for ICU admission were RHF (52%) and respiratory failure from causes other than RHF (23%). There were 4 patients who were admitted with arrhythmias.

Discussion

Patients with PH who require admission to the ICU often have a dismal prognosis; our study revealed a 30% ICU mortality rate and 40% 6-month mortality, which is higher than that of the general ICU population [13]. Given the high mortality, it is particularly important to identify the characteristics that will provide clinicians with prognostic information and interventions that may improve survival. This is the first study to generate a mortality model after identifying the factors that are

Conclusions

In conclusion, our study shows that the mortality of patients with PH who require admission to the ICU is high. Patients with high APACHE scores, Dana Point Group 3 PH, and patients already on treatment with prostacyclins are at increased risk for death. Pulmonary artery catheter placement within 3 days of admission that leads to a change in medical management may be associated with reduced mortality. Nonetheless, our study is retrospective, small, and at a single center. Intensive care unit

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Institution where work was performed: University of California, Los Angeles.

☆☆

There is no financial support or conflicts of interest to disclose.

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