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Beil M, Moreno R, Fronczek J, Kogan Y, Moreno RPJ, Flaatten H, Guidet B, de Lange D, Leaver S, Nachshon A, van Heerden PV, Joskowicz L, Sviri S, Jung C, Szczeklik W. Prognosticating the outcome of intensive care in older patients-a narrative review. Ann Intensive Care 2024; 14:97. [PMID: 38907141 PMCID: PMC11192712 DOI: 10.1186/s13613-024-01330-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 06/10/2024] [Indexed: 06/23/2024] Open
Abstract
Prognosis determines major decisions regarding treatment for critically ill patients. Statistical models have been developed to predict the probability of survival and other outcomes of intensive care. Although they were trained on the characteristics of large patient cohorts, they often do not represent very old patients (age ≥ 80 years) appropriately. Moreover, the heterogeneity within this particular group impairs the utility of statistical predictions for informing decision-making in very old individuals. In addition to these methodological problems, the diversity of cultural attitudes, available resources as well as variations of legal and professional norms limit the generalisability of prediction models, especially in patients with complex multi-morbidity and pre-existing functional impairments. Thus, current approaches to prognosticating outcomes in very old patients are imperfect and can generate substantial uncertainty about optimal trajectories of critical care in the individual. This article presents the state of the art and new approaches to predicting outcomes of intensive care for these patients. Special emphasis has been given to the integration of predictions into the decision-making for individual patients. This requires quantification of prognostic uncertainty and a careful alignment of decisions with the preferences of patients, who might prioritise functional outcomes over survival. Since the performance of outcome predictions for the individual patient may improve over time, time-limited trials in intensive care may be an appropriate way to increase the confidence in decisions about life-sustaining treatment.
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Affiliation(s)
- Michael Beil
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Rui Moreno
- Unidade Local de Saúde São José, Hospital de São José, Lisbon, Portugal
- Centro Clínico Académico de Lisboa, Lisbon, Portugal
- Faculdade de Ciências da Saúde, Universidade da Beira Interior, Covilhã, Portugal
| | - Jakub Fronczek
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Yuri Kogan
- Institute for Medical Biomathematics, Bene Ataroth, Israel
| | | | - Hans Flaatten
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway
| | - Bertrand Guidet
- INSERM, Institut Pierre Louis d'Epidémiologie Et de Santé Publique, AP-HP, Hôpital Saint Antoine, Sorbonne Université, Service MIR, Paris, France
| | - Dylan de Lange
- Department of Intensive Care Medicine, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Susannah Leaver
- General Intensive Care, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Akiva Nachshon
- General Intensive Care Unit, Department of Anaesthesiology, Critical Care and Pain Medicine, Faculty of Medicine, Hebrew University and, Hadassah University Medical Center, Jerusalem, Israel
| | - Peter Vernon van Heerden
- General Intensive Care Unit, Department of Anaesthesiology, Critical Care and Pain Medicine, Faculty of Medicine, Hebrew University and, Hadassah University Medical Center, Jerusalem, Israel
| | - Leo Joskowicz
- School of Computer Science and Engineering and Center for Computational Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Sigal Sviri
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Christian Jung
- Department of Cardiology, Pulmonology and Vascular Medicine, Faculty of Medicine, Heinrich-Heine-University, University Duesseldorf, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
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Hong G, Kang DH, Park S, Lee SH, Park O, Kim T, Yeo HJ, Jang JH, Cho WH, Lee SI. Clinical Characteristics and Prognosis of Older Patients with Coronavirus Disease 2019 Requiring Mechanical Ventilation. J Pers Med 2024; 14:657. [PMID: 38929878 PMCID: PMC11204506 DOI: 10.3390/jpm14060657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2024] [Revised: 06/14/2024] [Accepted: 06/17/2024] [Indexed: 06/28/2024] Open
Abstract
An older age is associated with severe progression and poor prognosis in coronavirus disease 2019 (COVID-19), and mechanical ventilation is often required. The specific characteristics of older patients undergoing mechanical ventilation and their prognostic factors are largely unknown. We aimed to identify potential prognostic factors in this group to inform treatment decisions. This retrospective cohort study collected data from patients with COVID-19 at 22 medical centers. Univariate and multivariate Cox regression analyses were performed to assess factors that influence mortality. We allocated 434 patients in geriatric (≥80 years) and elderly (65-79 years) groups. The former group scored significantly higher than the elderly group in the clinical frailty scale and sequential organ failure assessment, indicating more severe organ dysfunction. Significantly lower administration rates of tocilizumab and extracorporeal membrane oxygenation and higher intensive care unit (ICU) and in-hospital mortality were noted in the geriatric group. The factors associated with ICU and in-hospital mortality included high creatinine levels, the use of continuous renal replacement therapy, prone positioning, and the administration of life-sustaining treatments. These results highlight significant age-related differences in the management and prognosis of critically ill older patients with COVID-19. Increased mortality rates and organ dysfunction in geriatric patients undergoing mechanical ventilation necessitate age-appropriate treatment strategies to improve their prognoses.
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Affiliation(s)
- Green Hong
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon 35015, Republic of Korea; (G.H.); (D.H.K.)
| | - Da Hyun Kang
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon 35015, Republic of Korea; (G.H.); (D.H.K.)
| | - Sunghoon Park
- Department of Pulmonary, Allergy, and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang 14068, Republic of Korea;
| | - Su Hwan Lee
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul 03722, Republic of Korea;
| | - Onyu Park
- College of Nursing, Research Institute of Nursing Science, Pusan National University, Yangsan 50612, Republic of Korea;
| | - Taehwa Kim
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Busan 50612, Republic of Korea; (T.K.); (H.J.Y.); (J.H.J.); (W.H.C.)
| | - Hye Ju Yeo
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Busan 50612, Republic of Korea; (T.K.); (H.J.Y.); (J.H.J.); (W.H.C.)
| | - Jin Ho Jang
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Busan 50612, Republic of Korea; (T.K.); (H.J.Y.); (J.H.J.); (W.H.C.)
| | - Woo Hyun Cho
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Internal Medicine, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Busan 50612, Republic of Korea; (T.K.); (H.J.Y.); (J.H.J.); (W.H.C.)
| | - Song I Lee
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon 35015, Republic of Korea; (G.H.); (D.H.K.)
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Moïsi L, Mino JC, Guidet B, Vallet H. Frailty assessment in critically ill older adults: a narrative review. Ann Intensive Care 2024; 14:93. [PMID: 38888743 PMCID: PMC11189387 DOI: 10.1186/s13613-024-01315-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 05/17/2024] [Indexed: 06/20/2024] Open
Abstract
Frailty, a condition that was first defined 20 years ago, is now assessed via multiple different tools. The Frailty Phenotype was initially used to identify a population of "pre-frail" and "frail" older adults, so as to prevent falls, loss of mobility, and hospitalizations. A different definition of frailty, via the Clinical Frailty Scale, is now actively used in critical care situations to evaluate over 65 year-old patients, whether it be for Intensive Care Unit (ICU) admissions, limitation of life-sustaining treatments or prognostication. Confusion remains when mentioning "frailty" in older adults, as to which tools are used, and what the impact or the bias of using these tools might be. In addition, it is essential to clarify which tools are appropriate in medical emergencies. In this review, we clarify various concepts and differences between frailty, functional autonomy and comorbidities; then focus on the current use of frailty scales in critically ill older adults. Finally, we discuss the benefits and risks of using standardized scales to describe patients, and suggest ways to maintain a complex, three-dimensional, patient evaluation, despite time constraints. Frailty in the ICU is common, involving around 40% of patients over 75. The most commonly used scale is the Clinical Frailty Scale (CFS), a rapid substitute for Comprehensive Geriatric Assessment (CGA). Significant associations exist between the CFS-scale and both short and long-term mortality, as well as long-term outcomes, such as loss of functional ability and being discharged home. The CFS became a mainstream tool newly used for triage during the Covid-19 pandemic, in response to the pressure on healthcare systems. It was found to be significantly associated with in-hospital mortality. The improper use of scales may lead to hastened decision-making, especially when there are strains on healthcare resources or time-constraints. Being aware of theses biases is essential to facilitate older adults' access to equitable decision-making regarding critical care. The aim is to help counteract assessments which may be abridged by time and organisational constraints.
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Affiliation(s)
- L Moïsi
- Department of Geriatrics, Hopital Saint-Antoine, Assistance Publique Hôpitaux de Paris (AP-HP), Sorbonne Université, 75012, Paris, France.
- UVSQ, INSERM, Centre de Recherche en Epidémiologie Et Santé Des Populations, UMR 1018, Université Paris-Saclay, Université Paris-Sud, Villejuif, France.
- Département d'éthique, Faculté de Médecine, Sorbonne Université, Paris, France.
- Service de Gériatrie Aigue, Hopital St Antoine, 184 rue du Fbg St Antoine, 75012, Paris, France.
| | - J-C Mino
- UVSQ, INSERM, Centre de Recherche en Epidémiologie Et Santé Des Populations, UMR 1018, Université Paris-Saclay, Université Paris-Sud, Villejuif, France
- Département d'éthique, Faculté de Médecine, Sorbonne Université, Paris, France
| | - B Guidet
- Service de Réanimation Médicale, Hopital Saint-Antoine, Assistance Publique Hôpitaux de Paris (AP-HP), 184 Rue du Faubourg Saint-Antoine, 75012, Paris, France
- INSERM, UMRS 1136, Institute Pierre Louis d'Épidémiologie Et de Santé Publique, 75013, Paris, France
| | - H Vallet
- Department of Geriatrics, Hopital Saint-Antoine, Assistance Publique Hôpitaux de Paris (AP-HP), Sorbonne Université, 75012, Paris, France
- UMRS 1135, Centre d'immunologie Et de Maladies Infectieuses (CIMI), Institut National de La Santé Et de La Recherche Médicale (INSERM), Paris, France
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Zimmermann CJ, Kuchta K, Amundson JR, VanDruff VN, Joseph S, Che S, Hedberg HM, Ujiki M. Personalized anti-reflux surgery: connecting GERD phenotypes in 690 patients to outcomes. Surg Endosc 2024; 38:3273-3278. [PMID: 38658390 DOI: 10.1007/s00464-024-10756-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 02/16/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Anti-reflux operations are effective treatments for GERD. Despite standardized surgical techniques, variability in post-operative outcomes persists. Most patients with GERD possess one or more characteristics that augment their disease and may affect post-operative outcomes-a GERD "phenotype". We sought to define these phenotypes and to compare their post-operative outcomes. METHODS We performed a retrospective review of a prospective gastroesophageal database at our institution, selecting all patients who underwent an anti-reflux procedure for GERD. Patients were grouped into different phenotypes based on the presence of four characteristics known to play a role in GERD: hiatal or paraesophageal hernia (PEH), hypotensive LES, esophageal dysmotility, delayed gastric emptying (DGE), and obesity. Patient-reported outcomes (GERD-HRQL, dysphagia, and reflux symptom index (RSI) scores) were compared across phenotypes using the Wilcoxon rank-sum test. RESULTS 690 patients underwent an anti-reflux procedure between 2008 and 2022. Most patients underwent a Nissen fundoplication (302, 54%), followed by a Toupet or Dor fundoplication (205, 37%). Twelve distinct phenotypes emerged. Non-obese patients with normal esophageal motility, normotensive LES, no DGE, with a PEH represented the most common phenotype (134, 24%). The phenotype with the best post-operative GERD-HRQL scores at one year was defined by obesity, hypotensive LES, and PEH, while the phenotype with the worst scores was defined by obesity, ineffective motility, and PEH (1.5 ± 2.4 vs 9.8 ± 11.4, p = 0.010). There was no statistically significant difference in GERD-HRQL, dysphagia, or RSI scores between phenotypes after five years. CONCLUSIONS We have identified distinct phenotypes based on common GERD-associated patient characteristics. With further study these phenotypes may aid surgeons in prognosticating outcomes to individual patients considering an anti-reflux procedure.
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Affiliation(s)
- Christopher J Zimmermann
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA.
- Surgery, UCHealth Northern Colorado, Fort Collins, USA.
| | - Kristine Kuchta
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | | | | | - Stephanie Joseph
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Simon Che
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - H Mason Hedberg
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
| | - Michael Ujiki
- Department of Surgery, NorthShore University HealthSystem, 2650 Ridge Avenue, GCSI Suite B665, Evanston, IL, 60201, USA
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Wozniak H, Beckmann TS, Dos Santos Rocha A, Pugin J, Heidegger CP, Cereghetti S. Long-stay ICU patients with frailty: mortality and recovery outcomes at 6 months. Ann Intensive Care 2024; 14:31. [PMID: 38401034 PMCID: PMC10894177 DOI: 10.1186/s13613-024-01261-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/09/2024] [Indexed: 02/26/2024] Open
Abstract
BACKGROUND Prolonged intensive care unit (ICU) stay is associated with physical, cognitive, and psychological disabilities. The impact of baseline frailty on long-stay ICU patients remains uncertain. This study aims to investigate how baseline frailty influences mortality and post-ICU disability 6 months after critical illness in long-stay ICU patients. METHODS In this retrospective cohort study, we assessed patients hospitalized for ≥ 7 days in the ICU between May 2018 and May 2021, following them for up to 6 months or until death. Based on the Clinical Frailty Scale (CFS) at ICU admissions, patients were categorized as frail (CFS ≥ 5), pre-frail (CFS 3-4) and non-frail (CFS 1-2). Kaplan-Meier curves and a multivariate Cox model were used to examine the association between frailty and mortality. At the 6 month follow-up, we assessed psychological, physical, cognitive outcomes, and health-related quality of life (QoL) using descriptive statistics and linear regressions. RESULTS We enrolled 531 patients, of which 178 (33.6%) were frail, 200 (37.6%) pre-frail and 153 (28.8%) non-frail. Frail patients were older, had more comorbidities, and greater disease severity at ICU admission. At 6 months, frail patients presented higher mortality rates than pre-frail and non-frail patients (34.3% (61/178) vs. 21% (42/200) vs. 13.1% (20/153) respectively, p < 0.01). The rate of withdrawing or withholding of care did not differ significantly between the groups. Compared with CFS 1-2, the adjusted hazard ratios of death at 6 months were 1.7 (95% CI 0.9-2.9) for CFS 3-4 and 2.9 (95% CI 1.7-4.9) for CFS ≥ 5. At 6 months, 192 patients were seen at a follow-up consultation. In multivariate linear regressions, CFS ≥ 5 was associated with poorer physical health-related QoL, but not with poorer mental health-related QoL, compared with CFS 1-2. CONCLUSION Frailty is associated with increased mortality and poorer physical health-related QoL in long-stay ICU patients at 6 months. The admission CFS can help inform patients and families about the complexities of survivorship during a prolonged ICU stay.
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Affiliation(s)
- Hannah Wozniak
- Division of Critical Care, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland.
- Division of Critical Care Medicine, University of Toronto, Toronto, Canada.
| | - Tal Sarah Beckmann
- Division of Anesthesiology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Andre Dos Santos Rocha
- Division of Anesthesiology, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Jérôme Pugin
- Division of Critical Care, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Claudia-Paula Heidegger
- Division of Critical Care, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland
| | - Sara Cereghetti
- Division of Critical Care, Department of Anesthesiology, Pharmacology and Intensive Care, Geneva University Hospitals, Geneva, Switzerland
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Guidet B, Vallet H, Flaatten H, Joynt G, Bagshaw SM, Leaver SK, Beil M, Du B, Forte DN, Angus DC, Sviri S, de Lange D, Herridge MS, Jung C. The trajectory of very old critically ill patients. Intensive Care Med 2024; 50:181-194. [PMID: 38236292 DOI: 10.1007/s00134-023-07298-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Accepted: 11/27/2023] [Indexed: 01/19/2024]
Abstract
The demographic shift, together with financial constraint, justify a re-evaluation of the trajectory of care of very old critically ill patients (VIP), defined as older than 80 years. We must avoid over- as well as under-utilisation of critical care interventions in this patient group and ensure the inclusion of health care professionals, the patient and their caregivers in the decision process. This new integrative approach mobilises expertise at each step of the process beginning prior to intensive care unit (ICU) admission and extending to long-term follow-up. In this review, several international experts have contributed to provide recommendations that can be universally applied. Our aim is to define a minimum core dataset of information to be shared and discussed prior to ICU admission and to facilitate the shared-decision-making process with the patient and their caregivers, throughout the patient journey. Documentation of uncertainty may contribute to a tailored level of care and ultimately to discussions around possible limitations of life sustaining treatments. The goal of ICU care is not only to avoid death, but more importantly to maintain an acceptable quality of life and functional autonomy after hospital discharge. Societal consideration is important to highlight, together with alternatives to ICU admission. We discuss challenges for the future and potential areas of research. In summary, this review provides a state-of-the-art current overview and aims to outline future directions to address the challenges in the treatment of VIP.
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Affiliation(s)
- Bertrand Guidet
- Medical ICU, Assistance Publique, Hôpitaux de Paris, Hôpital Saint-Antoine, Service de Réanimation Médicale, 75012, Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, 75013, Paris, France.
| | - Helene Vallet
- Department of Geriatrics, Sorbonne Université, Institut National de la Santé Et de la Recherche Médicale (INSERM), UMRS 1135, Centre d'immunologie et de Maladies Infectieuses (CIMI), Saint Antoine, Assistance Publique Hôpitaux de Paris (AP-HP), 75012, Paris, France
| | - Hans Flaatten
- Department of Clinical Medicine, Haukeland University Hospital, University of Bergen, Department of Research and Development, Haukeland University Hospital, Bergen, Norway
| | - Gavin Joynt
- Department of Anaesthesia and Intensive Care, Faculty of Medicine, The Chinese University of Hong Kong, Shatin, Hong Kong
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, Canada
| | | | - Michael Beil
- Department of Medical Intensive Care, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel
| | - Bin Du
- Medical Intensive Care Unit, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing, 100730, China
| | - Daniel N Forte
- Departament of Emergency Medicine, Faculdade de Medicina, Universidade de São Paulo, Hospital Sírio-Libanês, São Paulo, Brazil
| | - Derek C Angus
- Critical Care Medicine, UPMC and University of Pittsburgh, Pittsburgh, USA
| | - Sigal Sviri
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Dylan de Lange
- Department of Intensive Care Medicine, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Margaret S Herridge
- Interdepartmental Division of Critical Care Medicine, Critical Care and Respiratory Medicine, University Health Network, Toronto General Research Institute, Institute of Medical Sciences, University of Toronto, Toronto, Canada
| | - Christian Jung
- Department of Cardiology, Pulmonology and Angiology, University Hospital, Düsseldorf, Germany
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Ibarz M, Haas LEM, Ceccato A, Artigas A. The critically ill older patient with sepsis: a narrative review. Ann Intensive Care 2024; 14:6. [PMID: 38200360 PMCID: PMC10781658 DOI: 10.1186/s13613-023-01233-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Accepted: 12/18/2023] [Indexed: 01/12/2024] Open
Abstract
Sepsis is a significant public health concern, particularly affecting individuals above 70 years in developed countries. This is a crucial fact due to the increasing aging population, their heightened vulnerability to sepsis, and the associated high mortality rates. However, the morbidity and long-term outcomes are even more notable. While many patients respond well to timely and appropriate interventions, it is imperative to enhance efforts in identifying, documenting, preventing, and treating sepsis. Managing sepsis in older patients poses greater challenges and necessitates a comprehensive understanding of predisposing factors and a heightened suspicion for diagnosing infections and assessing the risk of sudden deterioration into sepsis. Despite age often being considered an independent risk factor for mortality and morbidity, recent research emphasizes the pivotal roles of frailty, disease severity, and comorbid conditions in influencing health outcomes. In addition, it is important to inquire about the patient's preferences and establish a personalized treatment plan that considers their potential for recovery with quality of life and functional outcomes. This review provides a summary of the most crucial aspects to consider when dealing with an old critically ill patient with sepsis.
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Affiliation(s)
- Mercedes Ibarz
- Department of Intensive Care Medicine, Hospital Universitari Sagrat Cor, Quirón Salud, Viladomat 288, 08029, Barcelona, Spain.
| | - Lenneke E M Haas
- Department of Intensive Care Medicine, Diakonessenhuis Utrecht, Utrecht, the Netherlands
| | - Adrián Ceccato
- Department of Intensive Care Medicine, Hospital Universitari Sagrat Cor, Quirón Salud, Viladomat 288, 08029, Barcelona, Spain
- Department of Intensive Care Medicine, CIBER Enfermedades Respiratorias, Corporación Sanitaria Universitaria Parc Tauli, Autonomous University of Barcelona, Sabadell, Spain
| | - Antonio Artigas
- Department of Intensive Care Medicine, CIBER Enfermedades Respiratorias, Corporación Sanitaria Universitaria Parc Tauli, Autonomous University of Barcelona, Sabadell, Spain
- Institut d'investigació i innovació Parc Tauli (I3PT-CERCA), Sabadell, Spain
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8
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Beil M, van Heerden PV, Joynt GM, Lapinsky S, Flaatten H, Guidet B, de Lange D, Leaver S, Jung C, Forte DN, Bin D, Elhadi M, Szczeklik W, Sviri S. Limiting life-sustaining treatment for very old ICU patients: cultural challenges and diverse practices. Ann Intensive Care 2023; 13:107. [PMID: 37884827 PMCID: PMC10603016 DOI: 10.1186/s13613-023-01189-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 09/11/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Decisions about life-sustaining therapy (LST) in the intensive care unit (ICU) depend on predictions of survival as well as the expected functional capacity and self-perceived quality of life after discharge, especially in very old patients. However, prognostication for individual patients in this cohort is hampered by substantial uncertainty which can lead to a large variability of opinions and, eventually, decisions about LST. Moreover, decision-making processes are often embedded in a framework of ethical and legal recommendations which may vary between countries resulting in divergent management strategies. METHODS Based on a vignette scenario of a multi-morbid 87-year-old patient, this article illustrates the spectrum of opinions about LST among intensivsts with a special interest in very old patients, from ten countries/regions, representing diverse cultures and healthcare systems. RESULTS This survey of expert opinions and national recommendations demonstrates shared principles in the management of very old ICU patients. Some guidelines also acknowledge cultural differences between population groups. Although consensus with families should be sought, shared decision-making is not formally required or practised in all countries. CONCLUSIONS This article shows similarities and differences in the decision-making for LST in very old ICU patients and recommends strategies to deal with prognostic uncertainty. Conflicts should be anticipated in situations where stakeholders have different cultural beliefs. There is a need for more collaborative research and training in this field.
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Affiliation(s)
- Michael Beil
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Peter Vernon van Heerden
- General Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Gavin M Joynt
- Department of Anaesthesia and Intensive Care, Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong SAR, China
| | - Stephen Lapinsky
- Intensive Care Unit, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - Hans Flaatten
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway
| | - Bertrand Guidet
- INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint Antoine, Service MIR, Sorbonne Université, Paris, France
| | - Dylan de Lange
- Department of Intensive Care Medicine, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Susannah Leaver
- General Intensive Care, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Christian Jung
- Department of Cardiology, Pulmonology and Vascular Medicine, Faculty of Medicine, Heinrich-Heine-University, Düsseldorf, Germany
| | - Daniel Neves Forte
- Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Du Bin
- Medical Intensive Care Unit, Peking Union Medical College Hospital, Beijing, China
| | | | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Ul. Wrocławska 1-3, 30 - 901, Kraków, Poland.
| | - Sigal Sviri
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
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