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. 2025 Aug 1;53(8):e1641-e1649.
doi: 10.1097/CCM.0000000000006743. Epub 2025 Jun 16.

Persistent Critical Illness Among Intensive Care Patients in India: A Registry-Embedded Cohort Study

Bharath Kumar Tirupakuzhi Vijayaraghavan  1   2 , Aasiyah Rashan  3 , Nagarajan Ramakrishnan  1 , Rashan Haniffa  2 , Abi Beane  2 , Neill K J Adhikari  4   5 , Nazir Lone  6 , Nicolette de Keizer  7 ; Indian Registry of Intensive Care (IRIS) Collaborators
Collaborators, Affiliations

Persistent Critical Illness Among Intensive Care Patients in India: A Registry-Embedded Cohort Study

Bharath Kumar Tirupakuzhi Vijayaraghavan et al. Crit Care Med. .

Abstract

Objectives: Among patients admitted to an ICU in high-income countries, persistent critical illness arises when the admission diagnosis and acute physiologic derangements no longer predict outcomes better than antecedent characteristics. We evaluated this phenomenon in India.

Design: Cohort study.

Setting: Fifty-six ICUs in India belonging to the Indian Registry of Intensive Care.

Patients: Adult critically ill patients.

Interventions: None.

Measurements and main results: We evaluated associations of acute illness characteristics (admission diagnoses and acute physiology variables), antecedent characteristics (age, sex, and Charlson Comorbidity Index), and their combination on hospital mortality. Analyses used generalized mixed-effects models. In post hoc analyses, we compared patients with or without a long ICU stay. We included 42,925 patients; hospital mortality was 17.4%. Prognostic performance of acute illness characteristics declined over time (area under the receiver operating characteristic curve [AUROC], 0.76 at admission; 0.69 at day 7) and was consistently poor for antecedent characteristics (AUROC, 0.56 at admission and day 7). Patients with ICU stay greater than 7 days were sicker (median [interquartile range (IQR)]; Acute Physiology and Chronic Health Evaluation II, 14 [9, 19] vs. 10 [6, 15]; p < 0.001), with higher hospital mortality (33.1% vs. 14.6%; odds ratio, 2.17; 95% CI, 2.03-2.31) and ICU mortality (30.3% vs. 13.2%); receipt of invasive ventilation (51.7% vs. 19.5%), noninvasive ventilation (18.4% vs. 7.6%), vasopressors (34.7% vs. 19.1%), and kidney replacement therapy (11.4% vs. 6.1%) were all significantly higher among those staying in ICU greater than 7 days.

Conclusions: In this cohort of critically ill patients in India, as ICU stay increased, the prognostic performance of acute illness characteristics decreased whereas that of antecedent characteristics remained poor. Although patients with ICU stay greater than 7 days had higher mortality and received more organ support, the definition of persistent critical illness from high-income country cohorts was not replicated.

Keywords: artificial respiration; critical illness; developing countries; registries; severity of illness index.

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Conflict of interest statement

Dr. Tirupakuzhi Vijayaraghavan serves as the National Coordinator for the Indian Registry of Intensive Care and received support for article research from the Wellcome Trust (224048/Z/21Z). Ms. Rashan, a PhD student funded by U.K. Research and Innovation, and Dr. Haniffa serves on expert committees for the World Health Organization, both received support from the Wellcome Trust for this article’s research. Ms. Rashan’s institution received funding from the U.K. Research Institute; they received support for article research from the Research Councils United Kingdom. Dr. Beane is partially funded by the Wellcome Trust, United Kingdom, for her salaries. Dr. Beane’s institution received funding from the Wellcome Innovations Critical Care Asia Africa award. Dr. de Keizer received support for article research from the Wellcome Trust, and serves on the board of The Netherlands Intensive Care Registry and Data Governance Committee, The Netherlands. Dr. de Keizer’s institution received funding from the National Intensive Care Evaluation foundation. The remaining authors have disclosed that they do not have any potential conflicts of interest.

References

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    1. Bagshaw S, Stelfox HT, Iwashyna TJ, et al.: Timing of onset of persistent critical illness: A multi-centre retrospective cohort study. Intensive Care Med 2018; 44:2134–2144
    1. Kerckhoffs MC, Brinkman S, de Keizer N, et al.: The performance of acute versus antecedent patient characteristics for 1-year mortality prediction during intensive care unit admission: A national cohort study. Crit Care 2020; 24:330
    1. Darvall JN, Bellomo R, Bailey M, et al.: Impact of frailty on persistent critical illness: A population-based cohort study. Intensive Care Med 2022; 48:343–351
    1. World Bank Group: The World Bank in India. Available at: https://www.worldbank.org/en/country/india/overview . 2024. Accessed February 25, 2025

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