Changes in health-related quality of life and factors predicting long-term outcomes in older adults admitted to intensive care units.

OBJECTIVES: The aims of this study were to determine predictors of survival after hospital discharge and to describe the impact of intensive care unit admission on health-related quality of life at 6 months after hospital discharge in older adults admitted to intensive care units. DESIGN: Prospective longitudinal observational study with administered questionnaire. SETTINGS AND PATIENTS: Patients 65 yrs of age and older who were admitted to the medical, surgical, and coronary intensive care units for >24 hrs in a large urban teaching hospital system from August 2007 to May 2008 with a follow-up period ending April 2009. INTERVENTIONS: Administered questionnaire to patients or proxies. MEASUREMENTS AND MAIN RESULTS: Four hundred eighty-four patients 65 yrs old and older were enrolled. Data were collected on demographics, comorbidities, intensive care unit admission diagnoses, Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment score, Glasgow Coma Scale score at intensive care unit admission, intensive care unit interventions, and disposition after hospital discharge. A health-related quality of life survey was administered to patients, their proxies, or caregivers at intensive care unit admission, and to hospital survivors at 6 months after hospital discharge. Three hundred sixty-seven (75.8%) and 318 (65.7%) of enrolled patients were alive at hospital discharge and at 6 months, respectively. Mean age of survivors was 77.8 ± 8.5. Independent predictors of death at 6 months were: number of days during the 30 days before hospitalization that the patient felt their "physical health was not good" on the health-related quality of life survey [odds ratio = 1.08; confidence interval 1.04-1.12], a higher Acute Physiology and Chronic Health Evaluation II score [odds ratio = 1.09; 95% confidence interval 1.06-1.12], and chronic pulmonary disease as a comorbidity [odds ratio = 2.22; 95% confidence interval 1.04-4.78]. Of the 318 survivors at 6 months after hospital discharge, 297 (93.4%) completed the health-related quality of life questionnaire. When assessing whether changes in health-related quality of life over time were affected by age in our study cohort of 65 yrs old and older, we found that the oldest survivors, age 86.3 yrs old and older, had worse health-related quality of life over time, including more days spent with poor physical health (p < .004) and mental health (p < .001), while the youngest survivors, age 65-69.3 yrs old, showed improvement in health-related quality of life with fewer days spent with poor physical health (p < .004) and mental health (p < .001) at follow-up compared to baseline. These differences remained after adjusting for severity of illness and other potential confounders. CONCLUSIONS: One-third of adults 65 yrs old and older admitted to the intensive care unit die within 6 months of hospital discharge. Among survivors at 6 months, health-related quality of life has significantly worsened over time in the oldest patients but improved in the youngest. Our study in a large cohort of mixed intensive care unit patients identifies additional prognostic factors and significant quality of life information in intensive care unit survivors well after hospital discharge. This additional information may guide clinicians in their discussions with patients, families, and other providers as they decide on what treatments and interventions to pursue.

Parathyroid surgery and methylene blue: a review with guidelines for safe intraoperative use.

Methylene blue has been used to help facilitate parathyroid surgery for over 30 years. Its use has been widely considered both safe and cost effective. Twenty-six cases of a toxic metabolic encephalopathy, however, have been reported with its use. As a result, some surgeons have stopped using this technique altogether. It is now known that methylene blue is a monoamine oxidase inhibitor. When combined with drugs that increase central serotonin neurotransmission, serotonin toxicity results. This is the cause of the encephalopathy described in the literature. A case report, review of the literature, and guidelines as to its proper use are presented so as to allow for safe parathyroid surgery.