Clinical Frailty Scale Score Before ICU Admission Is Associated With Mobility Disability in Septic Patients Receiving Early Rehabilitation

Prognostic factors in mobility disability among elderly patients in the emergency department: A single-center retrospective study

Aim

We aimed to evaluate the clinical characteristics and outcomes of elderly critically ill patients and identify prognostic factors for mobility disability at discharge.

Methods

This single-center, retrospective cohort study investigated the period from April 2020 to January 2021. Patients ≥75 years old transferred to our emergency department and admitted to the intensive care unit (ICU) or intermediate unit in our hospital were eligible. Demographics, clinical characteristics, nutritional indicators, and nutritional screening scores were collected from chart reviews and analyzed. The primary outcome was the prevalence of mobility disability, compared to that of no mobility disability.

Results

A total of 124 patients were included in this present study. Median age was 83.0 years (interquartile range [IQR], 79.8-87.0 years) and 48 patients (38.7%) were female. Fifty-two patients (41.9%) could not walk independently at discharge (mobility disability group). The remaining 72 patients were in the no mobility disability group. Multiple logistic regression analyses revealed clinical frailty scale (CFS) score ≥5 (odds ratio [OR] = 6.63, 95% confidence interval [CI] = 2.51-17.52, p < 0.001), SOFA score ≥6 (OR = 6.11, 95% CI = 1.57-23.77, p = 0.009), and neurological disorder as the main cause on admission (OR = 4.48, 95% CI = 1.52-13.20, p = 0.006) were independent and significant prognostic factors for mobility disability at discharge.

Conclusion

Among elderly patients admitted to the emergency department, CFS ≥5, SOFA ≥6, and neurological disorders were associated with mobility disability at hospital discharge.

Impact of frailty on the short-term outcomes of elderly intensive care unit patients

BACKGROUND

Frailty leads to multiple unfavourable outcomes in older adults. However, few studies have investigated correlations between frailty and its impacts on morbidity and mortality of elderly patients in intensive care units (ICUs) in Taiwan.

AIMS

To investigate the impact of frailty on the risk of hospital and 30-day mortality and functional outcomes of elderly Taiwanese ICU patients.

STUDY DESIGN

A prospective observational study was conducted. Patients aged 65 years or older were recruited from three medical ICUs. We defined 'frailty' according to the Clinical Frailty Scale (CFS) higher than 4 within 1 month prior to admission. The primary outcomes were hospital and 30-day mortality. The secondary outcome was CFS changes at ICU admission, hospital discharge, and 30-day follow-up. Logistic/Cox regression was used to analyse the data.

RESULTS

We recruited a total of 106 patients, 57 (54%) of whom were classified as frail. The overall mortality rate was 21%. Hospital mortality and mortality within 30 days after discharge were higher in the frail patients without a significant statistical difference (hospital mortality: 17.5% vs. 12.2%, p = .626; 30-day mortality: 26.3% vs. 14.3%, p = .200). The risk of 30-day mortality for frail patients was up to 2.84 times greater than that of non-frail patients in the Cox model (hazard ratio = 2.84, 95% confidence interval [0.96, 8.38]). Both non-frail and frail patients had a worse CFS score on admission, but the CFS score of surviving non-frail patients improved significantly over the medium term.

CONCLUSION

Frailty tended to increase short-term ICU mortality risk and worsen functional outcomes in the elderly Taiwanese population. This information might guide critical medical decisions.

RELEVANCE TO CLINICAL PRACTICE

Frailty could be included in the prognostic evaluation of either mortality risk or functional outcome. Prompt palliative care might be one last piece of holistic elder care.

Predictive factors and clinical impact of ICU-acquired weakness on functional disability in mechanically ventilated patients with COVID-19

BACKGROUND

Patients with critical COVID-19 often require invasive mechanical ventilation (IMV) and admission to the intensive care unit (ICU), resulting in a higher incidence of ICU-acquired weakness (ICU-AW) and functional decline.

OBJECTIVE

This study aimed to examine the causes of ICU-AW and functional outcomes in critically ill patients with COVID-19 who required IMV.

METHODS

This prospective, single-center, observational study included COVID-19 patients who required IMV for ≥48 h in the ICU between July 2020 and July 2021. ICU-AW was defined as a Medical Research Council sum score <48 points. The primary outcome was functional independence during hospitalization, defined as an ICU mobility score ≥9 points.

RESULTS

A total of 157 patients (age: 68 [59-73] years, men: 72.6%) were divided into two groups (ICU-AW group; n = 80 versus non-ICU-AW; n = 77). Older age (adjusted odds ratio [95% confidence interval]: 1.05 [1.01-1.11], p = 0.036), administration of neuromuscular blocking agents (7.79 [2.87-23.3], p < 0.001), pulse steroid therapy (3.78 [1.49-10.1], p = 0.006), and sepsis (7.79 [2.87-24.0], p < 0.001) were significantly associated with ICU-AW development. In addition, patients with ICU-AW had significantly longer time to functional independence than those without ICU-AW (41 [30-54] vs 19 [17-23] days, p < 0.001). The development of ICU-AW was associated with delayed time to functional independence (adjusted hazard ratio: 6.08; 95% CI: 3.05-12.1; p < 0.001).

CONCLUSIONS

Approximately half of the patients with COVID-19 requiring IMV developed ICU-AW, which was associated with delayed functional independence during hospitalization.

Preoperative Considerations for the Frail Patient

Frailty is a common geriatric syndrome, the relevance of which is becoming increasingly apparent in the clinical setting. It is often accompanied by varying degrees of sarcopenia and/or osteoporosis, leading to a decline in physical function, decreased levels of physical activity, and overall poorer health outcomes in older adults. Identifying this cohort of patients before stressor events such as spinal surgery can prove paramount to improving the postoperative outcomes of these patients. This review provides a pertinent descriptive analysis to aid identification of frailty in a clinical setting, in addition to outlining methods of preoperative intervention that may improve postoperative outcomes.

Emergency General Surgery: Predicting Morbidity and Mortality in the Geriatric Population

Introduction  Numerous scoring systems have been created to predict the risk of morbidity and mortality in patients undergoing emergency general surgery (EGS). In this article, we compared the different scoring systems utilized at Humanitas Research Hospital and analyzed which one performed the best when assessing geriatric patients (>65 years of age). The scoring systems that were utilized were the APACHE II (Acute Physiology and Chronic Health Evaluation II), ASA (American Society of Anesthesiologists), ACS-NSQIP (American College of Surgeons-National Surgical Quality Improvement Program), Clinical Frailty Score, and the Clavien-Dindo classification as control. Materials and Methods  We compiled a database consisting of all patients over the age of 65 who underwent EGS in a consecutive 24-month period between January 1, 2017 and December 31, 2018. We used the biostatistical program "Stata Version 15" to analyze our results. Results  We found 213 patients who matched our inclusion criteria. Regarding death, we found that the ACS-NSQIP death calculator performed the best with an area under the curve of 0.9017 (odds ratio: 1.09; 95% confidence interval: 1.06-1.12). The APACHE II score had the lowest discriminator when predicting death. Considering short-term complications, the Clavien-Dindo classification scored highly, while both the APACHE II score and Clinical Frailty Score produced the lowest results. Conclusion  The results obtained from our research showed that scoring systems and classifications produced different results depending on whether they were used to predict deaths or short-term complications among geriatric patients undergoing EGS.

Preoperative measures predicting outcome after pancreatic resection in aged patients

BACKGROUND AND OBJECTIVE

High-risk surgery on aged patients raises challenging ethical and clinical issues. The aim of this study was to analyze the preoperative factors associated with severe complications and returning home after pancreatic resection among patients aged ⩾ 75 years.

PATIENTS AND METHODS

Patients aged ⩾ 75 years undergoing pancreatic resection in 2012-2019 were retrospectively searched from the hospital database. Preoperative indices (Clinical Frailty Scale, Skeletal Muscle Index, Geriatric Nutritional Risk Index, Charlson Comorbidity Index, and National Surgical Quality Improvement Program risk for severe complications) were determined. Postoperative outcome was evaluated by incidence of Clavien-Dindo 3b-5 complications, rate of returning home, and 1-year survival.

RESULTS

A total of 95 patients were included. American Society of Anesthesiologists Class 3-4 covered 50%, Clinical Frailty Scale > 3 22%, Charlson Comorbidity Index > 6 53%, and a sarcopenic Skeletal Muscle Index 51% of these patients. The National Surgical Quality Improvement Program risk for severe complications was higher than average among 21% of patients. Geriatric Nutritional Risk Index showed high risk among 3% of them. In total, 19 patients (20%) experienced a severe (Clavien-Dindo 3b-5) complication. However, 30- and 90-day mortality was 2.1%. Preoperative indices were not associated with severe complications. Most patients (79%) had returned home within 8 weeks of surgery. Not returning home was associated with severe complications (p = 0.010).

CONCLUSIONS

The short-term outcome after pancreatic resection of fit older patients is similar to that of younger, unselected patient groups. In these selected patients, the commonly used preoperative indexes were not associated with severe complications or returning home.

Association between out-of-bed mobilization during the ICU stay of elderly patients and long-term autonomy: A cohort study

PURPOSE

Our objective was to estimate the impact of the absence of Out-of-Bed (OoB) mobilization during intensive care unit (ICU) stay among patients ≥70 years on their long-term autonomy.

METHODS

We conducted an ancillary study of the multicenter FRAGIREA study, including patients aged over 70 years, admitted to ICU for more than 48 h. We excluded the patients who died before day 180, who were lost to follow-up, and for whom the baseline autonomy (ADL) score was not available. Patients were classified into the OoB or non-OoB-mobilization group, and the impact of OoB mobilization on the decreased 6-month autonomy was estimated.

RESULTS

Among the 548 patients of the FRAGIREA cohort, 276 were included in the present study. Among them, 226 had OoB mobilization and 50 did not. 220/276 (80%) patients experienced the transfer to chair as rehabilitation therapy, passive mobilization and transfer to upright sitting were also frequently performed. A decrease in the 6-month autonomy was observed for 63 (23%) patients. After the elimination of potential confounders, non-OoB-mobilization patients had a greater risk of 6-month decreased autonomy (aOR 2.43 [1.18; 4.98]).

CONCLUSIONS

Mobilization during the ICU stay of elderly ICU patient survivors was associated with a lower decreased autonomy at 6 months.

Impact on Mental, Physical and Cognitive functioning of a Critical care sTay during the COVID-19 pandemic (IMPACCT COVID-19): protocol for a prospective, multicentre, mixed-methods cohort study

INTRODUCTION

The ongoing pandemic could affect the duration, variety and severity of the mental, physical, and cognitive impairments intensive care unit (ICU) survivors and their families frequently present. We aim to determine the impact of the COVID-19 pandemic on the mental, physical, and cognitive health of survivors, the experience of their families and their treating healthcare professionals.

METHODS AND ANALYSIS

Prospective, multicentre, mixed-methods cohort study in seven Chilean ICUs.

SAMPLE

450 adults, able to walk independently prior to admission, in ICU and mechanical ventilation >48 hours with and without COVID-19. Clinical Frailty Scale, Charlson comorbidity index, mobility (Functional Status Score for the Status Score for the Intensive Care Unit) and muscle strength (Medical Research Council Sum Score) will be assessed at ICU discharge. Cognitive functioning (Montreal Cognitive Assessment-blind), anxiety and depression (Hospital Anxiety and Depression Scale), post-traumatic stress (Impact of Event Scale-Revised) symptoms, disability (WHO Disability Assessment Schedule 2.0), quality of life (European Quality of Life Health Questionnaire), employment and survival will be assessed at ICU discharge, 3 months and 6 months. A sample will be assessed using actigraphy and the Global Physical Activity Questionnaire at 6 months after ICU discharge. Trajectories of mental, physical, and cognitive impairments will be estimated using multilevel longitudinal modelling. A sensitivity analysis using multiple imputations will be performed to account for missing data and loss-to-follow-up. Survival will be analysed using Kaplan-Meier curves. The perceptions of family members regarding the ICU stay and the later recovery will be explored 3 months after discharge. Healthcare professionals will be invited to discuss the challenges faced during the pandemic using semistructured interviews. Interviews will be thematically analysed by two independent coders to identify the main themes of the experience of family members and healthcare professionals.

ETHICS AND DISSEMINATION

The study was approved by the Clinica Alemana Universidad del Desarrollo Ethics Committee (2020-78) and each participating site. Study findings will be published in peer-reviewed journals and disseminated through social media and conference meetings.

TRIAL REGISTRATION NUMBER

NCT04979897.

Prevalence and predictors of hospital-acquired functional decline in patients with sepsis admitted to the intensive care unit

Although sepsis is known to cause functional decline, the prevalence and predictors of hospital-acquired functional decline (HAFD) in patients with sepsis are unclear. The purpose of this study was to investigate the prevalence and predictors of HAFD in patients with sepsis admitted to the ICU. This study is a single-center retrospective observational study from January 2014 to December 2019. We included all consecutive patients with sepsis who received rehabilitation in our ICU. The primary outcome was HAFD, which was defined as a decrease in at least five points of the Barthel index mobility score from prehospital to hospital discharge. We described the prevalence of HAFD and investigated the predictors of HAFD using the multivariate logistic regression analysis adjusting for potential confounders. Among 134 patients, 57 patients (42.5%) had HAFD. The longer time to initial ambulation and lower prehospital walking ability were associated with HAFD (adjusted odds ratio [OR] 1.07; 95% confidence interval [CI], 1.03-1.10 and adjusted OR 0.79; 95% CI, 0.66-0.95, respectively). In conclusion, nearly half of the patients with sepsis who received rehabilitation developed HAFD. Lower functional status prior to hospitalization and the longer time to initial ambulation was associated with HAFD, indicating the potential importance of early ambulation among septic patients in the ICU.

Guidance for the care of neuromuscular patients during the COVID-19 pandemic outbreak from the French Rare Health Care for Neuromuscular Diseases Network

In France, the epidemic phase of COVID-19 caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) began in February 2020 and resulted in the implementation of emergency measures and a degradation in the organization of neuromuscular reference centers. In this special context, the French Rare Health Care for Neuromuscular Diseases Network (FILNEMUS) has established guidance in an attempt to homogenize the management of neuromuscular (NM) patients within the French territory. Hospitalization should be reserved for emergencies, the conduct of treatments that cannot be postponed, check-ups for which the diagnostic delay may result in a loss of survival chance, and cardiorespiratory assessments for which the delay could be detrimental to the patient. A national strategy was adopted during a period of 1 to 2 months concerning treatments usually administered in hospitalization. NM patients treated with steroid/immunosuppressants for a dysimmune pathology should continue all of their treatments in the absence of any manifestations suggestive of COVID-19. A frequently asked questions (FAQ) sheet has been compiled and updated on the FILNEMUS website. Various support systems for self-rehabilitation and guided exercises have been also provided on the website. In the context of NM diseases, particular attention must be paid to two experimental COVID-19 treatments, hydroxycholoroquine and azithromycin: risk of exacerbation of myasthenia gravis and QT prolongation in patients with pre-existing cardiac involvement. The unfavorable emergency context related to COVID-19 may specially affect the potential for intensive care admission (ICU) for people with NMD. In order to preserve the fairest medical decision, a multidisciplinary working group has listed the neuromuscular diseases with a good prognosis, usually eligible for resuscitation admission in ICU and, for other NM conditions, the positive criteria suggesting a good prognosis. Adaptation of the use of noninvasive ventilation (NIV) make it possible to limit nebulization and continue using NIV in ventilator-dependent patients.