Robert C. McDermid

Association between frailty and short- and long-term outcomes among critically ill patients: a multicentre prospective cohort study

Background: Frailty is a multidimensional syndrome characterized by loss of physiologic and cognitive reserves that confers vulnerability to adverse outcomes. We determined the prevalence, correlates and outcomes associated with frailty among adults admitted to intensive care. Methods: We prospectively enrolled 421 critically ill adults aged 50 or more at 6 hospitals across the province of Alberta. The primary exposure was frailty, defined by a score greater than 4 on the Clinical Frailty Scale. The primary outcome measure was in-hospital mortality. Secondary outcome measures included adverse events, 1-year mortality and quality of life. Results: The prevalence of frailty was 32.8% (95% confidence interval [CI] 28.3%–37.5%). Frail patients were older, were more likely to be female, and had more comorbidities and greater functional dependence than those who were not frail. In-hospital mortality was higher among frail patients than among non-frail patients (32% v. 16%; adjusted odds ratio [OR] 1.81, 95% CI 1.09–3.01) and remained higher at 1 year (48% v. 25%; adjusted hazard ratio 1.82, 95% CI 1.28–2.60). Major adverse events were more common among frail patients (39% v. 29%; OR 1.54, 95% CI 1.01–2.37). Compared with nonfrail survivors, frail survivors were more likely to become functionally dependent (71% v. 52%; OR 2.25, 95% CI 1.03–4.89), had significantly lower quality of life and were more often readmitted to hospital (56% v. 39%; OR 1.98, 95% CI 1.22–3.23) in the 12 months following enrolment. Interpretation: Frailty was common among critically ill adults aged 50 and older and identified a population at increased risk of adverse events, morbidity and mortality. Diagnosis of frailty could improve prognostication and identify a vulnerable population that might benefit from follow-up and intervention.

Frailty in the critically ill: a novel concept

The concept of frailty has been defined as a multidimensional syndrome characterized by the loss of physical and cognitive reserve that predisposes to the accumulation of deficits and increased vulnerability to adverse events. Frailty is strongly correlated with age, and overlaps with and extends aspects of a patients disability status (that is, functional limitation) and/or burden of comorbid disease. The frail phenotype has more specifically been characterized by adverse changes to a patients mobility, muscle mass, nutritional status, strength and endurance. We contend that, in selected circumstances, the critically ill patient may be analogous to the frail geriatric patient. The prevalence of frailty amongst critically ill patients is currently unknown; however, it is probably increasing, based on data showing that the utilization of intensive care unit (ICU) resources by older people is rising. Owing to the theoretical similarities in frailty between geriatric and critically ill patients, this concept may have clinical relevance and may be predictive of outcomes, along with showing important interaction with several factors including illness severity, comorbid disease, and the social and structural environment. We believe studies of frailty in critically ill patients are needed to evaluate how it correlates with outcomes such as survival and quality of life, and how it relates to resource utilization, such as length of mechanical ventilation, ICU stay and duration of hospitalization. We hypothesize that the objective measurement of frailty may provide additional support and reinforcement to clinicians confronted with end-of-life decisions on the appropriateness of ICU support and/or withholding of life-sustaining therapies.

Long-term association between frailty and health-related quality of life among survivors of critical illness: a prospective multicenter cohort study.

Objective: Frailty is a multidimensional syndrome characterized by loss of physiologic reserve that gives rise to vulnerability to poor outcomes. We aimed to examine the association between frailty and long-term health-related quality of life among survivors of critical illness. Design: Prospective multicenter observational cohort study. Setting: ICUs in six hospitals from across Alberta, Canada. Patients: Four hundred twenty-one critically ill patients who were 50 years or older. Interventions: None. Measurements and Main Results: Frailty was operationalized by a score of more than 4 on the Clinical Frailty Scale. Health-related quality of life was measured by the EuroQol Health Questionnaire and Short-Form 12 Physical and Mental Component Scores at 6 and 12 months. Multiple logistic and linear regression with generalized estimating equations was used to explore the association between frailty and health-related quality of life. In total, frailty was diagnosed in 33% (95% CI, 28–38). Frail patients were older, had more comorbidities, and higher illness severity. EuroQol-visual analogue scale scores were lower for frail compared with not frail patients at 6 months (52.2 ± 22.5 vs 64.6 ± 19.4; p < 0.001) and 12 months (54.4 ± 23.1 vs 68.0 ± 17.8; p < 0.001). Frail patients reported greater problems with mobility (71% vs 45%; odds ratio, 3.1 [1.6–6.1]; p = 0.001), self-care (49% vs 15%; odds ratio, 5.8 [2.9–11.7]; p < 0.001), usual activities (80% vs 52%; odds ratio, 3.9 [1.8–8.2]; p < 0.001), pain/discomfort (68% vs 47%; odds ratio, 2.0 [1.1–3.8]; p = 0.03), and anxiety/depression (51% vs 27%; odds ratio, 2.8 [1.5–5.3]; p = 0.001) compared with not frail patients. Frail patients described lower health-related quality of life on both physical component score (34.7 ± 7.8 vs 37.8 ± 6.7; p = 0.012) and mental component score (33.8 ± 7.0 vs 38.6 ± 7.7; p < 0.001) at 12 months. Conclusions: Frail survivors of critical illness experienced greater impairment in health-related quality of life, functional dependence, and disability compared with those not frail. The systematic assessment of frailty may assist in better informing patients and families on the complexities of survivorship and recovery.

Seeking Worldwide Professional Consensus on the Principles of End-of-Life Care for the Critically Ill. The Consensus for Worldwide End-of-Life Practice for Patients in Intensive Care Units (WELPICUS) Study

Great differences in end-of-life practices in treating the critically ill around the world warrant agreement regarding the major ethical principles. This analysis determines the extent of worldwide consensus for end-of-life practices, delineates where there is and is not consensus, and analyzes reasons for lack of consensus. Critical care societies worldwide were invited to participate. Country coordinators were identified and draft statements were developed for major end-of-life issues and translated into six languages. Multidisciplinary responses using a web-based survey assessed agreement or disagreement with definitions and statements linked to anonymous demographic information. Consensus was prospectively defined as >80% agreement. Definitions and statements not obtaining consensus were revised based on comments of respondents, and then translated and redistributed. Of the initial 1,283 responses from 32 countries, consensus was found for 66 (81%) of the 81 definitions and statements; 26 (32%) had >90% agreement. With 83 additional responses to the original questionnaire (1,366 total) and 604 responses to the revised statements, consensus could be obtained for another 11 of the 15 statements. Consensus was obtained for informed consent, withholding and withdrawing life-sustaining treatment, legal requirements, intensive care unit therapies, cardiopulmonary resuscitation, shared decision making, medical and nursing consensus, brain death, and palliative care. Consensus was obtained for 77 of 81 (95%) statements. Worldwide consensus could be developed for the majority of definitions and statements about end-of-life practices. Statements achieving consensus provide standards of practice for end-of-life care; statements without consensus identify important areas for future research.

Human rabies encephalitis following bat exposure: failure of therapeutic coma

The case: A healthy 73-year-old man had pain in his left shoulder. He presented to a regional hospital 1 week later with fever, dysphagia, muscle spasms and progressive generalized weakness. His neurologic status deteriorated, which prompted transfer to a tertiary care hospital. Upon the patients

The role of frailty in outcomes from critical illness.

Purpose of reviewFrailty is a multidimensional syndrome characterized by loss of physiologic reserves that gives rise to vulnerability to adverse events. Recent findingsFrailty has been described in older patients undergoing geriatric assessment and in noncardiac and cardiac surgical settings, in which it closely correlates with heightened risk for major morbidity including functional decline, postoperative complications, institutionalization, and short-term and long-term mortality. Critically ill patients may represent a population with similar vulnerabilities to older frail patients. Prior data have described the association with less favorable outcomes and poor premorbid functional status (i.e., activities of daily living, cognitive impairment, body mass index), used perhaps as a surrogate for frailty. Preliminary epidemiologic data suggest the prevalence of frailty (and intermediate frail states) among critically ill patients is high and likely to increase with the greater demand placed on ICU resources associated with population demographic transition. SummaryThe concept of frailty, as a marker of biologic age and physiologic reserve, may have direct relevance to critical care, and clearly identifies a population at greater risk of adverse events, morbidity, and mortality. Its recognition in critical care settings may enable improved prognostication and shared decision-making and identify vulnerable subgroups with specific needs who might benefit from targeted follow-up.

A Case-Control Study of Single-Pass Albumin Dialysis for Acetaminophen-Induced Acute Liver Failure

Background: Extracorporeal support with single-pass albumin dialysis (SPAD) may remove protein-bound toxins in acute liver failure. We evaluated the clinical, physiological and laboratory parameters of SPAD in acetaminophen-induced acute liver failure (AALF). Methods: Retrospective case-control studies of AALF patients were used. Results: We identified 13 AALF patients (6 SPAD-treated, 7 controls). The average age was 38 years, 92% were female, none had cirrhosis and the Model for End-Stage Liver Disease (MELD) scores were 43. Eleven patients (85%) fulfilled the King’s College criteria for a liver transplant. SPAD-treated patients received 21 sessions (total: 147 h, mean 3.5 runs or 24.5 h/patient). There were no complications. No significant changes in clinical, physiological or biochemical parameters occurred during SPAD. Compared with the controls, there were no significant differences in ICU or 1-year survival, liver recovery or referral for a liver transplant. Conclusion: SPAD was well-tolerated in AALF; however, it was not associated with differences in clinical outcomes. While SPAD may be an adjuvant supportive therapy in AALF, prospective trials are needed.

A Survey of Mechanical Ventilator Practices Across Burn Centers in North America.

Burn injury introduces unique clinical challenges that make it difficult to extrapolate mechanical ventilator (MV) practices designed for the management of general critical care patients to the burn population. We hypothesize that no consensus exists among North American burn centers with regard to optimal ventilator practices. The purpose of this study is to examine various MV practice patterns in the burn population and to identify potential opportunities for future research. A researcher designed, 24-item survey was sent electronically to 129 burn centers. The &khgr;2, Fisher’s exact, and Cochran–Mantel–Haenszel tests were used to determine if there were significant differences in practice patterns. We analyzed 46 questionnaires for a 36% response rate. More than 95% of the burn centers reported greater than 100 annual admissions. Pressure support and volume assist control were the most common initial MV modes used with or without inhalation injury. In the setting of Berlin defined mild acute respiratory distress syndrome (ARDS), ARDSNet protocol and optimal positive end-expiratory pressure were the top ventilator choices, along with fluid restriction/diuresis as a nonventilator adjunct. For severe ARDS, airway pressure release ventilation and neuromuscular blockade were the most popular. The most frequently reported time frame for mechanical ventilation before tracheostomy was 2 weeks (25 of 45, 55%); however, all respondents reported in the affirmative that there are certain clinical situations where early tracheostomy is warranted. Wide variations in clinical practice exist among North American burn centers. No single ventilator mode or adjunct prevails in the management of burn patients regardless of pulmonary insult. Movement toward American Burn Association–supported, multicenter studies to determine best practices and guidelines for ventilator management in burn patients is prudent in light of these findings.

Octogenarians in the ICU: are you ever too old?

Long-term morbidity and mortality rates for older patients admitted to the ICU remain substantial. In this issue of Critical Care, Roch and colleagues describe a retrospective study evaluating factors associated with survival and quality-of-life of octogenarians (aged ≥80 years) admitted to a medical ICU. This study proposes to address a highly relevant and increasingly encountered scenario in ICUs - what factors can best estimate prognosis for elderly patients at the time of evaluation for ICU admission? While perhaps not unique to octogenarians, such data have the potential to better inform on decision-making regarding advanced life support along with facilitating discussion on the perceived benefit and on patient treatment preferences concerning intensive care.

Drotrecogin Alpha (Activated) in Two Patients with the Hantavirus Cardiopulmonary Syndrome

Hantavirus cardiopulmonary syndrome (HCPS) is associated with rapid cardiopulmonary collapse from endothelial injury, resulting in massive capillary leak, shock and severe hypoxemic respiratory failure. To date, treatment remains supportive and includes mechanical ventilation, vasopressors and extracorporeal membrane oxygenation, with mortality approaching 50%. Two HCPS survivors initially given drotrecogin alpha (activated) (DAA) for presumed bacterial septic shock are described. Vasoactive medications were required for a maximum of 52 h, whereas creatinine levels and platelet counts normalized within seven to nine days. Given the similar presentations of HCPS and bacterial septic shock, empirical DAA therapy will likely be initiated before a definitive diagnosis of HCPS is made. Further observations of DAA in HCPS seem warranted.