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

Bharath Kumar Tirupakuzhi Vijayaraghavan; Aasiyah Rashan; Nagarajan Ramakrishnan; Rashan Haniffa; Abi Beane; Neill K. J. Adhikari; Nazir Lone; Nicolette de Keizer; Kavita Ramesh; Swagata Tripathy; Kasturi Sanyal; Zubair Umer Mohamed; Anna Paul; Dedeepiya Devaprasad; Rohit Aravindakshan Kooloth; Sandeep Shyamsundar; Harish Muthusamy; Ashwin Mani; Meghena Mathew; Preethika Ravichandran; Ramesh Venkataraman; Augustian James; Sruthi Mano; Mithilesh Devaraj; Raymond Dominic Savio; Suresh Kumar Sundaramurthy; Vinisha Varadharajan; Ebenezer Rabindrarajan; Vanishree Chandran; Mohana Priya; Pratheema Ramachandran; Swedha Vasudevan; Devachandran Jayakumar; Sucharita Yanamandra; Lavanya Elumalai; Kishore Mangal; Vaibhav Bhargav; Seema Gupta; Niyaz Ashraf; Chinni Krisha Kasi; Durga Madhap Tripathi; Deepak Vijayan; Yatin Mehta; Joby V. George; Shaheen Sheikh; Jaganathan Selvanayagam; Thirumalai Sambath; Rakesh Lakshmappa; Mathew Pulicken; Ruchira Khasne; Namesh Ananp; Darshana Rathod; Urvi Shukla; Chetan Pande; Amol Bali; Chinmayee A. Bhise; Shivanjali Kadagam; Prajakta Dahitule; Atul Kulkarni; Anjana Shrivastava; Nikita Kulaye; Karuna Panahle; Balaji Venkatachalam; Pavan Kumar Vecham; Mariswari Raja; Aditi Jain; Shubham Dhokiya; Jignesh Shah

doi:10.1097/CCM.0000000000006743

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

Bharath Kumar Tirupakuzhi Vijayaraghavan^*
, Aasiyah Rashan
, Nagarajan Ramakrishnan
, Rashan Haniffa
, Abi Beane
, Neill K. J. Adhikari
, Nazir Lone
, Nicolette de Keizer
, Kavita Ramesh
, Swagata Tripathy
, Kasturi Sanyal
, Zubair Umer Mohamed
, Anna Paul
, Dedeepiya Devaprasad
, Rohit Aravindakshan Kooloth
, Sandeep Shyamsundar
, Harish Muthusamy
, Ashwin Mani
, Meghena Mathew
, Preethika Ravichandran

Ramesh Venkataraman, Augustian James, Sruthi Mano, Mithilesh Devaraj, Raymond Dominic Savio, Suresh Kumar Sundaramurthy, Vinisha Varadharajan, Ebenezer Rabindrarajan, Vanishree Chandran, Mohana Priya, Pratheema Ramachandran, Swedha Vasudevan, Devachandran Jayakumar, Sucharita Yanamandra, Lavanya Elumalai, Kishore Mangal, Vaibhav Bhargav, Seema Gupta, Niyaz Ashraf, Chinni Krisha Kasi, Durga Madhap Tripathi, Deepak Vijayan, Yatin Mehta, Joby V. George, Shaheen Sheikh, Jaganathan Selvanayagam, Thirumalai Sambath, Rakesh Lakshmappa, Mathew Pulicken, Ruchira Khasne, Namesh Ananp, Darshana Rathod, Urvi Shukla, Chetan Pande, Amol Bali, Chinmayee A. Bhise, Shivanjali Kadagam, Prajakta Dahitule, Atul Kulkarni, Anjana Shrivastava, Nikita Kulaye, Karuna Panahle, Balaji Venkatachalam, Pavan Kumar Vecham, Mariswari Raja, Aditi Jain, Shubham Dhokiya, Jignesh Shah

^*Corresponding author for this work

Research output: Contribution to journal › Article › Academic › peer-review

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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.

Original language	English
Pages (from-to)	e1641-e1649
Journal	Critical care medicine
Volume	53
Issue number	8
Early online date	2025
DOIs	https://doi.org/10.1097/CCM.0000000000006743
Publication status	Published - 1 Aug 2025

Keywords

artificial respiration
critical illness
developing countries
registries
severity of illness index

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Tirupakuzhi Vijayaraghavan, B. K., Rashan, A., Ramakrishnan, N., Haniffa, R., Beane, A., Adhikari, N. K. J., Lone, N., de Keizer, N., Ramesh, K., Tripathy, S., Sanyal, K., Umer Mohamed, Z., Paul, A., Devaprasad, D., Kooloth, R. A., Shyamsundar, S., Muthusamy, H., Mani, A., Mathew, M., ... Shah, J. (2025). Persistent Critical Illness among Intensive Care Patients in India: A Registry-Embedded Cohort Study. Critical care medicine, 53(8), e1641-e1649. https://doi.org/10.1097/CCM.0000000000006743

@article{2cc0cf9d3c644cdf91717c91ccc29230,

title = "Persistent Critical Illness among Intensive Care Patients in India: A Registry-Embedded Cohort Study",

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",

author = "\{Tirupakuzhi Vijayaraghavan\}, \{Bharath Kumar\} and Aasiyah Rashan and Nagarajan Ramakrishnan and Rashan Haniffa and Abi Beane and Adhikari, \{Neill K. J.\} and Nazir Lone and \{de Keizer\}, Nicolette and Kavita Ramesh and Swagata Tripathy and Kasturi Sanyal and \{Umer Mohamed\}, Zubair and Anna Paul and Dedeepiya Devaprasad and Kooloth, \{Rohit Aravindakshan\} and Sandeep Shyamsundar and Harish Muthusamy and Ashwin Mani and Meghena Mathew and Preethika Ravichandran and Ramesh Venkataraman and Augustian James and Sruthi Mano and Mithilesh Devaraj and \{Dominic Savio\}, Raymond and Sundaramurthy, \{Suresh Kumar\} and Vinisha Varadharajan and Ebenezer Rabindrarajan and Vanishree Chandran and Mohana Priya and Pratheema Ramachandran and Swedha Vasudevan and Devachandran Jayakumar and Sucharita Yanamandra and Lavanya Elumalai and Kishore Mangal and Vaibhav Bhargav and Seema Gupta and Niyaz Ashraf and \{Krisha Kasi\}, Chinni and Tripathi, \{Durga Madhap\} and Deepak Vijayan and Yatin Mehta and George, \{Joby V.\} and Shaheen Sheikh and Jaganathan Selvanayagam and Thirumalai Sambath and Rakesh Lakshmappa and Mathew Pulicken and Ruchira Khasne and Namesh Ananp and Darshana Rathod and Urvi Shukla and Chetan Pande and Amol Bali and Bhise, \{Chinmayee A.\} and Shivanjali Kadagam and Prajakta Dahitule and Atul Kulkarni and Anjana Shrivastava and Nikita Kulaye and Karuna Panahle and Balaji Venkatachalam and Vecham, \{Pavan Kumar\} and Mariswari Raja and Aditi Jain and Shubham Dhokiya and Jignesh Shah",

year = "2025",

month = aug,

day = "1",

doi = "10.1097/CCM.0000000000006743",

language = "English",

volume = "53",

pages = "e1641--e1649",

journal = "Critical care medicine",

issn = "0090-3493",

publisher = "Lippincott Williams and Wilkins",

number = "8",

}

Tirupakuzhi Vijayaraghavan, BK, Rashan, A, Ramakrishnan, N, Haniffa, R, Beane, A, Adhikari, NKJ, Lone, N, de Keizer, N, Ramesh, K, Tripathy, S, Sanyal, K, Umer Mohamed, Z, Paul, A, Devaprasad, D, Kooloth, RA, Shyamsundar, S, Muthusamy, H, Mani, A, Mathew, M, Ravichandran, P, Venkataraman, R, James, A, Mano, S, Devaraj, M, Dominic Savio, R, Sundaramurthy, SK, Varadharajan, V, Rabindrarajan, E, Chandran, V, Priya, M, Ramachandran, P, Vasudevan, S, Jayakumar, D, Yanamandra, S, Elumalai, L, Mangal, K, Bhargav, V, Gupta, S, Ashraf, N, Krisha Kasi, C, Tripathi, DM, Vijayan, D, Mehta, Y, George, JV, Sheikh, S, Selvanayagam, J, Sambath, T, Lakshmappa, R, Pulicken, M, Khasne, R, Ananp, N, Rathod, D, Shukla, U, Pande, C, Bali, A, Bhise, CA, Kadagam, S, Dahitule, P, Kulkarni, A, Shrivastava, A, Kulaye, N, Panahle, K, Venkatachalam, B, Vecham, PK, Raja, M, Jain, A, Dhokiya, S & Shah, J 2025, 'Persistent Critical Illness among Intensive Care Patients in India: A Registry-Embedded Cohort Study', Critical care medicine, vol. 53, no. 8, pp. e1641-e1649. https://doi.org/10.1097/CCM.0000000000006743

TY - JOUR

T1 - Persistent Critical Illness among Intensive Care Patients in India

T2 - A Registry-Embedded Cohort Study

AU - Tirupakuzhi Vijayaraghavan, Bharath Kumar

AU - Rashan, Aasiyah

AU - Ramakrishnan, Nagarajan

AU - Haniffa, Rashan

AU - Beane, Abi

AU - Adhikari, Neill K. J.

AU - Lone, Nazir

AU - de Keizer, Nicolette

AU - Ramesh, Kavita

AU - Tripathy, Swagata

AU - Sanyal, Kasturi

AU - Umer Mohamed, Zubair

AU - Paul, Anna

AU - Devaprasad, Dedeepiya

AU - Kooloth, Rohit Aravindakshan

AU - Shyamsundar, Sandeep

AU - Muthusamy, Harish

AU - Mani, Ashwin

AU - Mathew, Meghena

AU - Ravichandran, Preethika

AU - Venkataraman, Ramesh

AU - James, Augustian

AU - Mano, Sruthi

AU - Devaraj, Mithilesh

AU - Dominic Savio, Raymond

AU - Sundaramurthy, Suresh Kumar

AU - Varadharajan, Vinisha

AU - Rabindrarajan, Ebenezer

AU - Chandran, Vanishree

AU - Priya, Mohana

AU - Ramachandran, Pratheema

AU - Vasudevan, Swedha

AU - Jayakumar, Devachandran

AU - Yanamandra, Sucharita

AU - Elumalai, Lavanya

AU - Mangal, Kishore

AU - Bhargav, Vaibhav

AU - Gupta, Seema

AU - Ashraf, Niyaz

AU - Krisha Kasi, Chinni

AU - Tripathi, Durga Madhap

AU - Vijayan, Deepak

AU - Mehta, Yatin

AU - George, Joby V.

AU - Sheikh, Shaheen

AU - Selvanayagam, Jaganathan

AU - Sambath, Thirumalai

AU - Lakshmappa, Rakesh

AU - Pulicken, Mathew

AU - Khasne, Ruchira

AU - Ananp, Namesh

AU - Rathod, Darshana

AU - Shukla, Urvi

AU - Pande, Chetan

AU - Bali, Amol

AU - Bhise, Chinmayee A.

AU - Kadagam, Shivanjali

AU - Dahitule, Prajakta

AU - Kulkarni, Atul

AU - Shrivastava, Anjana

AU - Kulaye, Nikita

AU - Panahle, Karuna

AU - Venkatachalam, Balaji

AU - Vecham, Pavan Kumar

AU - Raja, Mariswari

AU - Jain, Aditi

AU - Dhokiya, Shubham

AU - Shah, Jignesh

PY - 2025/8/1

Y1 - 2025/8/1

N2 - 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.

AB - 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.

KW - artificial respiration

KW - critical illness

KW - developing countries

KW - registries

KW - severity of illness index

UR - https://www.scopus.com/pages/publications/105009260411

U2 - 10.1097/CCM.0000000000006743

DO - 10.1097/CCM.0000000000006743

M3 - Article

C2 - 40521972

SN - 0090-3493

VL - 53

SP - e1641-e1649

JO - Critical care medicine

JF - Critical care medicine

IS - 8

ER -

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

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