Long-term outcome of prolonged critical illness: A multicentered study in North Brisbane, Australia

Predicting a strongly positive fluid balance in critically ill patients with acute kidney injury: A multicentre, international study

BACKGROUND

In critically ill patients with acute kidney injury (AKI), a fluid balance (FB) > 2 L at 72 h after AKI diagnosis is associated with adverse outcomes. Identification of patients at high-risk for such fluid accumulation may help prevent it.

METHODS

We used Australian electronic medical record (EMR)-based clinical data to develop the "AKI-FB risk score", validated it in a British cohort and used it to predict a positive FB >2 L at 72 h after AKI diagnosis.

RESULTS

We developed the AKI-FB score in 32,030 patients with a median age of 63 years and a median APACHE 2 score of 16. We validated it in 4465 patients, with significant differences in admission diagnoses and interventions. The key score variables were admission after trauma, sepsis or septic shock, and, on the day of AKI diagnosis, highest creatinine, daily cumulative FB, mechanical ventilation, noradrenaline use, noradrenaline equivalent dose >0.07 μg/kg/min, lactate ≥2 mmol/L, transfusion, and nutritional support. A score threshold of 32 had a sensitivity of 75 % and a specificity of 72 % for predicting a > 2 L positive FB with an AUC-ROC of 0.805; 95 % CI 0.799 to 0.810. External validation demonstrated an AUC of 0.761 (95 % CI 0.746 to 0.775).

CONCLUSION

We developed and validated the "AKI-FB risk score" to predict patients who developed a positive FB >2 L within 72 h of AKI diagnosis. This prediction score was robust and facilitated the identification of high-risk AKI patients who could be the tarted for preventive measures and be included in future clinical trials of FB management.

Association between enteral carboxymethyllysine intake and daily glycemic variability in critically ill adults: A retrospective cohort study

BACKGROUND

Advanced glycation end-products (AGEs) can enter patients' circulation through exogenous sources, such as enteral nutrition formulae. Circulating AGEs, specifically carboxymethyllysine, can promote insulin resistance and activation of pro-inflammatory pathways leading to oxidative stress, cell death, and organ failure. Suboptimal kidney function increases the risk of elevated circulating AGEs because levels are controlled through urinary excretion. Our aim was to determine associations between carboxymethyllysine intake and glycemic control as well as clinical outcomes in critically ill patients and explore these in the subset of patients with an acute kidney injury (AKI).

METHODS

This was a retrospective cohort study. Data were extracted from electronic medical records. Patients were eligible if they were ≥18 years and received enteral nutrition, with known carboxymethyllysine content, for ≥3 days. AKI was defined using the Kidney Disease: Improving Global Outcomes guidelines. Linear and logistic regression models were used to determine adjusted associations.

RESULTS

Between 2015 and 2021, 2636 patients met the eligibility criteria, with 848 (32%) patients having an AKI. Most were male (n = 1752, 67%) with a median (interquartile range) Acute Physiology And Chronic Health Evaluation III score of 59 (45-77). For every 10-μmol increase in carboxymethyllysine provision, mean blood glucose increased by 0.05 mmol (95% CI, 0.03-0.07), and the odds of dying increased by 16% (odds ratio = 1.16; 95% CI, 1.06-1.27). A subgroup analysis indicated these associations persisted in patients with AKI but not in those without.

CONCLUSION

Carboxymethyllysine intake was associated with increased mean blood glucose and odds of dying in our study cohort.

Risk factors and economic impact of long-term nursing care after major trauma

Introduction

The public could bear a heavy economic burden for trauma survivors needing long-term nursing care, especially in countries such as Taiwan that have universal health insurance coverage. The purpose of this study was to analyze the data from the National Health Insurance Research Database and to assess reimbursement to trauma patients with long-term sequelae who need nursing care.

Methods

This study included all patients who suffered major trauma (injury severity score ≥ 16) in Taiwan from 2003 to 2007. Ten years of follow-up were analyzed. Patients aged 18 to 70 who survived for more than 1 year after the index admission were enrolled. Patients who needed long-term nursing care (LTC) were compared with those who did not (non-LTC). Basic demographics and short-term outcomes were analyzed, and the 10-year healthcare expenditure was calculated.

Results

The study included 10,642 patients, 1,718 in the LTC group and 8,924 in the non-LTC group. Age, comorbidities, spinal cord injury, longer mechanical ventilation, longer ICU length of stay (LOS), and longer hospital LOS were identified as independent risk factors for LTC. The median 10-year healthcare expenditure was 43,979 USD in the LTC group vs. 9,057 USD in the non-LTC group (p < 0.001).

Conclusions

16.14% of major trauma patients needed LTC at least 1 year after being discharged. The resource they receive in Taiwan is prominently less than the same patient group in the US. The NHI should invest more in post-discharge care for major trauma patients to optimize their care.

The interplay between frailty status and persistent critical illness on the outcomes of patients with critical COVID-19: A population-based retrospective cohort study

OBJECTIVES

Persistent critical illness (PerCI) occurs when the patient's prolonged intensive care unit (ICU) stay results in complications that become the primary drivers of their condition, rather than the initial reason for their admission. Patients with frailty have a higher risk of developing and dying from PerCI. We aimed to investigate the interplay of frailty and PerCI in critically ill patients with COVID-19.

METHOD

We conducted a retrospective multicentre cohort study including 103 Australian and New Zealand ICUs over the period of January 2020 to December 2021. We included all adult patients with COVID-19 and documented the Clinical Frailty Scale (frail ≥ 5). PerCI is defined as an ICU length of stay of ≥10 days. We aimed to investigate the hospital mortality with and without PerCI across varying degrees of frailty and examined the potential interaction effect between frailty status and PerCI.

RESULTS

The prevalence of PerCI was similar between patients with and without frailty (25.4% vs. 27.9%; p = 0.44). Hospital mortality was higher in patients with PerCI than in those without (28.8% vs. 9.3%; p < 0.001). Mortality in patients with PerCI also increased with increasing frailty (p < 0.001). Frailty independently predicted hospital mortality. When adjusted for Australia and New Zealand risk of death mortality prediction model and sex, the impact of frailty was no different in patients with and without PerCI (odds ratio = 1.30 [95% confidence interval: 1.14-1.49] vs. (odds ratio = 1.46 [95% confidence interval: 1.29-1.64]). Furthermore, increasing frailty did not influence mortality in patients with PerCI more (or less) than in those without PerCI (pinteraction = 0.82).

CONCLUSIONS

The presence of frailty independently predicted hospital mortality in patients with PerCI with COVID-19, but the impact of frailty on mortality was no different in those who developed PerCI from those without PerCI.

Definitions, epidemiology, and outcomes of persistent/chronic critical illness: a scoping review for translation to clinical practice

BACKGROUND

Medical advances in intensive care units (ICUs) have resulted in the emergence of a new patient population-those who survive the initial acute phase of critical illness, but require prolonged ICU stays and develop chronic critical symptoms. This condition, often termed Persistent Critical Illness (PerCI) or Chronic Critical Illness (CCI), remains poorly understood and inconsistently reported across studies, resulting in a lack of clinical practice use. This scoping review aims to systematically review and synthesize the existing literature on PerCI/CCI, with a focus on definitions, epidemiology, and outcomes for its translation to clinical practice.

METHODS

A scoping review was conducted using MEDLINE and Scopus, adhering to the PRISMA-ScR guidelines. Peer-reviewed original research articles published until May 31, 2024 that described adult PerCI/CCI in their definitions of patient populations, covariates, and outcomes were included. Data on definitions, epidemiology, and outcomes were extracted by a data charting process from eligible studies and synthesized.

RESULTS

Ninety-nine studies met the inclusion criteria. Of these studies, 64 used the term CCI, 18 used PerCI, and 17 used other terms. CCI definitions showed greater variability, while PerCI definitions remained relatively consistent, with an ICU stay ≥ 14 days for CCI and ≥ 10 days for PerCI being the most common. A meta-analysis of the prevalence of PerCI/CCI among the denominators of "all ICU patients", "sepsis", "trauma", and "COVID-19" showed 11% (95% confidence interval 10-12%), 28% (22-34%), 24% (15-33%), and 35% (20-50%), respectively. A meta-analysis of in-hospital mortality was 27% (26-29%) and that of one-year mortality was 45% (32-58%). Meta-analyses of the prevalence of CCI and PerCI showed 17% (16-18%) and 18% (16-20%), respectively, and those for in-hospital mortality were 28% (26-30%) and 26% (24-29%), respectively. Functional outcomes were generally poor, with many survivors requiring long-term care.

CONCLUSIONS

This scoping review synthesized many studies on PerCI/CCI, highlighting the serious impact of PerCI/CCI on patients' long-term outcomes. The results obtained underscore the need for consistent terminology with high-quality research for PerCI/CCI. The results obtained provide important information to be used in discussions with patients and families regarding prognosis and care options.

ICU-acquired hypernatremia: Prevalence, patient characteristics, trajectory, risk factors, and outcomes

Objective

Knowledge of intensive care unit (ICU) acquired hypernatremia (ICU-AH) has been hampered by the absence of granular data and confounded by variable definitions and inclusion criteria.

Design

Multicentre retrospective cohort study.

Setting

Twelve ICUs in Queensland (QLD), Australia.

Participants

Adult patients admitted to ICU from 2015 to 2021. Only the first ICU admission was considered, and we categorised patients into mild (146-150 mmol·L-1), moderate (151-155 mmol·L-1) and severe (>155 mmol·L-1) ICU-acquired hypernatremia.

Main outcome measure

We aimed to study the prevalence of ICU-AH, patient characteristics, trajectory, risk factors, and outcomes.

Results

Data from 55,255 ICU admissions were included in the analysis, of which 4146 (7.5 %) patients had ICU-AH. These were subcategorised into mild (n = 2,670, 4.8 %), moderate (n = 1,073, 1.9 %) and severe (n = 403, 0.73 %) forms. Median time to diagnosis was 4 (2-6) d after ICU admission, while median time to peak serum sodium level was 5 (3-8) d. The median maximum sodium level across the cohort was 149 (147-152) mmol·L-1. The sodium correction rate was 1 mmol·L-1 per day, taking a median of 3 d (1-5) for sodium levels to return below 145 mmol·L-1. APACHE III score, invasive ventilation, fever, and diuretic use on the day before hypernatremia were independent risk factors for moderate or severe ICU-AH. After adjusting for confounders, all levels of hypernatremia were independently associated with an increased risk of 30-d in-hospital mortality.

Conclusions

In a large multicentric study of critically ill patients, ICU-acquired hypernatremia occurred in one in eight admissions after a median of four days in the ICU and was preceded by identifiable and modifiable risk factors. If severe, its correction was slow, and normalisation was delayed. After adjusting for other factors, all levels of hypernatremia were an independent risk factor for 30-d in-hospital mortality.

Sepsis-associated acute kidney injury in patients with chronic kidney disease: Patient characteristics, prevalence, timing, trajectory, treatment and associated outcomes

AIM

The features and outcomes of sepsis-associated acute kidney injury (SA-AKI) may be affected by chronic kidney disease (CKD). Accordingly, we aimed to compare SA-AKI in patients with or without CKD.

METHODS

Retrospective cohort study in 12 intensive care units (ICU). We studied the prevalence, patient characteristics, timing, trajectory, treatment and outcomes of SA-AKI with and without CKD.

RESULTS

Of 84 240 admissions, 7255 (8.6%) involved patients with CKD. SA-AKI was more common in patients with CKD (21% vs 14%; p < .001). CKD patients were older (70 vs. 60 years; p < .001), had a higher median Charlson co-morbidity index (5 vs. 3; p < .001) and acute physiology and chronic health evaluation (APACHE) III score (78 vs. 60; p < .001) and were more likely to receive renal replacement therapy (RRT) (25% vs. 17%; p < .001). They had less complete return to baseline function at ICU discharge (48% vs. 60%; p < .001), higher major adverse kidney events at day 30 (MAKE-30) (38% vs. 27%; p < .001), and higher hospital and 90-day mortality (21% vs. 13%; p < .001, and 27% vs. 16%; p < .001, respectively). After adjustment for patient characteristics and severity of illness, however, CKD was not an independent risk factor for increased 90-day mortality (OR 0.88; 95% CI 0.76-1.02; p = .08) or MAKE-30 (OR 0.98; 95% CI 0.80-1.09; p = .4).

CONCLUSION

SA-AKI is more common in patients with CKD. Such patients are older, more co-morbid, have higher disease severity, receive different ICU therapies and have different trajectories of renal recovery and greater unadjusted mortality. However, after adjustment day-90 mortality and MAKE-30 risk were not increased by CKD.

Point-of-care creatinine vs. central laboratory creatinine in the critically ill

Objective

Frequent measurement of creatinine by point-of-care testing (POCT) may facilitate the earlier detection of acute kidney injury (AKI) in critically ill patients. However, no robust data exist to confirm its equivalence to central laboratory testing. We aimed to conduct a multicenter study to compare POCT with central laboratory creatinine (CrC) measurement.

Design

Retrospective observational study, using hospital electronic medical records. Obtained paired point-of-care creatinine (CrP) from arterial blood gas machines and CrC.

Setting

Four intensive care units in Queensland, Australia.

Participants

Critically ill patients, where greater than 50% of POCT contained creatinine.

Main outcome measures

Mean difference, bias, and limits of agreement between two methods, and biochemical confounders.

Results

We studied 79,767 paired measurements in 19,118 patients, with a median Acute Physiology and Chronic Health Evaluation 3 score of 51. The mean CrC was 115.5 μmol/L (standard deviation: 100.2) compared to a CrP mean of 115 μmol/L (standard deviation: 100.7) (Pearson coefficient of 0.99). The mean difference between CrP and CrC was 0.49 μmol/L with 95% limits of agreement of -27 μmol/L and +28 μmol/L. Several biochemical variables were independently associated with the difference between tests (e.g., pH, potassium, lactate, glucose, and bilirubin), but their impact was small.

Conclusion

In critically ill patients, measurement of creatinine by POCT yields clinically equivalent values to those obtained by central laboratory measurement and can be easily used for more frequent monitoring of kidney function in such patients. These findings open the door to the use of POCT for the earlier detection of acute kidney injury in critically ill patients.

Determinants of 90-day case fatality among older patients admitted to intensive care units: A retrospective cohort study

BACKGROUND

A recent systematic review identified highly variable case-fatality rates among studies of older patients admitted to intensive care units (ICUs). However, structural and process determinants including patient resident status, tertiary ICU status, and treatment limitations were unavailable.

OBJECTIVE

The objective of this study was to evaluate the role of determinants such as resident status, tertiary ICU, and treatment limitations on 90-day case fatality among older ICU patients.

METHODS

A retrospective cohort of all Queensland residents aged 75 years and older admitted to four ICUs within the Metro North Hospital and Health Service was included. The impact of Metro North Hospital and Health Service resident status, tertiary ICU, treatment limitations, and other known determinants on 90-day all-cause case fatality (case-fatality) was assessed.

RESULTS

Of the 2144 eligible first admissions included, 1365 were residents, and 893 were nonelective admissions. The case-fatality rates were higher in residents (21% vs 12%, p < 0.001), nonelective admissions (32% vs 7%, p < 0.001), and non-tertiary ICU admissions (27% vs 16%, p < 0.001). The case fatality increased progressively with age, being highest (29.6%) in the >90 years age-group. Multivariable mixedeffects logistic regression modelling demonstrated that presence of treatment limitations was strongly associated with case fatality, but neither resident status nor the tertiary ICU was associated.

CONCLUSION

The presence of treatment limitations should be considered when evaluating variations in case fatality among cohorts of older ICU patients, in addition to variables with well-established association with case fatality such as comorbidities and illness severity.

Long-term survival after major trauma: a retrospective nationwide cohort study from the National Health Insurance Research Database

BACKGROUND

Most trauma-related studies are focused on short-term survival and complications within the index admission, and the long-term outcomes beyond discharge are mainly unknown. The purpose of this study was to analyze the data from the National Health Insurance Research Database (NHIRD) and to assess the long-term survival of major trauma patients after being discharged from the index admission.

MATERIAL AND METHODS

This retrospective, observational study included all patients with major trauma (injury severity score ≥16) in Taiwan from 2003 to 2007, and a 10-year follow-up was conducted on this cohort. Patients aged 18-70 who survived the index admission were enrolled. Patients who survived less than one year after discharge (short survival, SS) and those who survived for more than one year (long survival, LS) were compared. Variables, including preexisting factors, injury types, and short-term outcomes and complications, were analyzed, and the 10-year Kaplan-Meier survival analysis was conducted.

RESULTS

In our study, 9896 patients were included, with 2736 in the SS group and 7160 in the LS group. Age, sex, comorbidities, low income, cardiopulmonary resuscitation event, prolonged mechanical ventilation, prolonged ICU length of stay (LOS), and prolonged hospital LOS were identified as the independent risk factors of SS. The 10-year cumulative survival for major trauma patients was 63.71%, and the most mortality (27.64%) occurred within the first year after discharge.

CONCLUSION

27.64% of patients would die one year after being discharged from major trauma. Major trauma patients who survived the index admission still had significantly worse long-term survival than the general population, but the curve flattened and resembled the general population after one year.

Frailty and long-term survival among patients in Australian intensive care units with metastatic cancer (FRAIL-CANCER study): a retrospective registry-based cohort study

BACKGROUND

Recent advances in cancer therapeutics have improved outcomes, resulting in increasing candidacy of patients with metastatic cancer being admitted to intensive care units (ICUs). A large proportion of patients also have frailty, predisposing them to poor outcomes, yet the literature reporting on this is scarce. We aimed to assess the impact of frailty on survival in patients with metastatic cancer admitted to the ICU.

METHODS

In this retrospective registry-based cohort study, we used data from the Australia and New Zealand Intensive Care Society Adult Patient (age ≥16 years) database to identify patients with advanced (solid and haematological cancer) and a documented Clinical Frailty scale (CFS) admitted to 166 Australian ICUs. Patients without metastatic cancer were excluded. We analysed the effect of frailty (CFS 5-8) on long-term survival, and how this effect changed in specific subgroups (cancer subtypes, age [<65 years or ≥65 years], and those who survived hospitalisation). Because estimates tend to cluster within centres and vary between them, we used Cox proportional hazards regression models with robust sandwich variance estimators to assess the effect of frailty on survival time up to 4 years after ICU admission between groups.

FINDINGS

Between Jan 1, 2018, and March 31, 2022, 30 026 patients were eligible, and after exclusions 21 174 patients were included in the analysis; of these, 6806 (32·1%) had frailty, and 11 662 (55·1%) were male, 9489 (44·8%) were female, and 23 (0·1%) were intersex or self-reported indeterminate sex. The overall survival was lower for patients with frailty at 4 years compared with patients without frailty (29·5% vs 10·9%; p<0·0001). Frailty was associated with shorter 4-year survival times (adjusted hazard ratio 1·52 [95% CI 1·43-1·60]), and this effect was seen across all cancer subtypes. Frailty was associated with shorter survival times in patients younger than 65 years (1·66 [1·51-1·83]) and aged 65 years or older (1·40 [1·38-1·56]), but its effects were larger in patients younger than 65 years (pinteraction<0·0001). Frailty was also associated with shorter survival times in patients who survived hospitalisation (1·49 [1·40-1·59]).

INTERPRETATION

In patients with metastatic cancer admitted to the ICU, frailty was associated with poorer long-term survival. Patients with frailty might benefit from a goal-concordant time-limited trial in the ICU and will need suitable post-intensive care supportive management.

FUNDING

None.

Passive Movements Do not Appear to Prevent or Reduce Joint Stiffness in Medium to Long-Stay ICU Patients: A Randomized, Controlled, Within-Participant Trial

OBJECTIVES

ICU patients have an increased risk of joint stiffness because of their critical illness and reduced mobility. There is a paucity of evidence evaluating the efficacy of passive movements (PMs). We investigated whether PMs prevent or reduce joint stiffness in ICU patients.

DESIGN

A randomized, controlled, within-participant, assessor-blinded study.

SETTING

A 48-bed tertiary care adult ICU.

PATIENTS

Intubated patients who were expected to be invasively mechanically ventilated for greater than 48 hours with an ICU length of stay greater than or equal to 5 days, and unable to voluntarily move their limbs through full range of motion (ROM).

INTERVENTIONS

The ankle and elbow on one side of each participant's body received PMs (10 min each joint, morning and afternoon, 5 d/wk). The other side acted as the control. The PMs intervention continued for as long as clinically indicated to a maximum of 4 weeks.

MEASUREMENTS

The primary outcome was ankle dorsiflexion ROM at cessation of PMs. Plantarflexion, elbow flexion and extension ROM, and participant-reported joint pain and stiffness (verbal analog scale [VAS]) were also measured. Outcomes were recorded at baseline and cessation of PMs. For participants whose PMs intervention ceased early due to recovery, additional post-early-cessation of PMs review measurements were undertaken as near as possible to 4 weeks.

MAIN RESULTS

We analyzed data from 25 participants with a median (interquartile range) ICU stay of 15.6 days (11.3-25.4). The mean (95% CI) between-side difference for dorsiflexion ROM (with knee extension) at cessation of PMs was 0.4 degrees (-4.4 to 5.2; p = 0.882), favoring the intervention side, indicating there was not a clinically meaningful effect of 5 degrees. No statistically significant differences were found between the intervention and control sides for any ROM or VAS data.

CONCLUSIONS

PMs, as provided to this sample of medium to long-stay ICU patients, did not prevent or reduce joint stiffness.

Factors Affecting the Length of Stay in the Intensive Care Unit among Adults in Saudi Arabia: A Cross-Sectional Study

This study aimed to assess patient-related factors associated with the LOS among adults admitted to the ICU in Saudi Arabia. The Ministry of Health provided a cross-sectional dataset for 2021, which served as the data source for this study. The data included data on adults admitted to different ICUs at various hospitals. The number of days spent in the ICU was the outcome variable of interest. The potential predictors were age, sex, and nationality, as well as clinical data from the time of admission. Descriptive statistics and bivariate analysis were used to analyse the association between the predictors and the ICU LOS and characterize how they were distributed. We used negative binomial regression to examine the relationship between the study predictors and the ICU LOS. A total of 42,884 individuals were included in this study, of whom 25,520 were men and 17,362 were women. The overall median ICU LOS was three days. This study showed that the ICU LOS was highly influenced by the patient's age, sex, nationality, source of admission, and clinical history. Several predictors that affect how long adults stay in the ICU in Saudi Arabian hospitals were identified in this study. These factors can be attributed to variances in health care delivery systems, patient demographics, and cultural considerations. To allocate resources efficiently, enhance patient outcomes, and create focused treatments to reduce ICU LOS, it is essential to comprehend these elements.

Institution-free days after critical illness: A multicenter retrospective study

BACKGROUND

Patient-centered outcomes beyond mortality such as institution-free days (IFD) are becoming increasingly relevant in critical care trials.

METHODS

We calculated IFD using three definitions which differed in the way death and censoring of after-hospital deaths were handled analysing data from adult patient databases admitted to four ICUs of North Brisbane, Australia. Differences in distribution of IFD using different definitions were explored with descriptive statistics and histograms. Six pre-specified variables (age, illness severity, comorbidities index, elective status, surgical/medical admission and treatment limitations) were assessed and reported as determinants of IFDs for the proposed definitions.

RESULTS

Data from 25,371 ICU admissions was analysed. The density distribution of IFD was bimodal with a peak at 0 days and a variable right-sided peak depending on the definition used. The mean IFD varied from 253 (standard deviation(SD) 151.3) to 295 (SD 116.2) depending on definition used. Multivariable zero-inflated negative binomial regression modelling showed that the six pre-specified variables had significant associations with IFD and their magnitude of effect varied with the definition used.

CONCLUSIONS

IFD is a simple, easily measurable patient-centered outcome that varies depending on the definition used. Patient input should be sought to define the optimum definition and clinical use of IFD.

A protocol for exploring patients' and support peoples' experiences after prolonged critical illness

BACKGROUND

Improved survival of critically ill people has increased the number of patients who experience an extended stay in intensive care units (ICU). Evidence suggests the complexities, vulnerabilities, and traumas created by critical illness are substantial for both patients and their support people with a number experiencing devastating impairments across multiple domains of health and function including physical, mental, cognitive, and social health. However, research on survivors predominantly focuses on those who have experienced a relatively short length of stay; only a limited number of studies seek to explore the experiences of survivors and their support people who have had a prolonged stay in intensive care.

AIMS AND OBJECTIVES

To describe the experiences of survivors of prolonged critical illness (invasively mechanically ventilated in ICU for ≥eight days) and their support people during the first 12 months following hospital discharge in New Zealand.

DESIGN

This research will be a multi-centre study recruiting from three intensive care units in New Zealand. A narrative inquiry methodology will be used to interview 6-8 former long stay patients and 6-8 support people of a former long stay patient. Each participant will be interviewed at 3-, 6-, 9-, and 12-months following hospital discharge.

METHODS

Data will be collected via narrative inquiry interviews. Data analysis will combine two theoretical frameworks: the Clandinin and Connelly narrative inquiry three-dimensional space and the Fairclough situation, discourse and context framework.

RESULTS

The phenomenon of investigation will be experiences after prolonged critical illness explored longitudinally across the first-year post-hospital discharge.

RELEVANCE TO CLINICAL PRACTICE

This protocol provides a methodological framework for exploring the lived experiences of survivors of prolonged critical illness and their support people. Data analysis will support understanding of the human journey of ICU survivorship and add to the body of knowledge on how to support post-ICU recovery in this population. The barriers and enablers of survivorship at the micro, meso, and macro levels of the health service will also be illuminated.

Impact of frailty on persistent critical illness: a population-based cohort study

PURPOSE

Acute illness severity predicts mortality in intensive care unit (ICU) patients, however, its predictive value decreases over time in ICU. Typically after 10 days, pre-ICU (antecedent) characteristics become more predictive of mortality, defining the onset of persistent critical illness (PerCI). How patient frailty affects development and death from PerCI is unknown.

METHODS

We conducted a secondary analysis of data from a prospective binational cohort study including 269,785 critically ill adults from 168 ICUs in Australia and New Zealand, investigating whether frailty measured with the Clinical Frailty Scale (CFS) changes the timing of onset and risk of developing PerCI and of subsequent in-hospital mortality. We assessed associations between frailty (CFS ≥ 5) and mortality prediction using logistic regression and area under the receiver operating characteristics (AUROC) curves.

RESULTS

2190 of 50,814 (4.3%) patients with frailty (CFS ≥ 5) versus 6624 of 218,971 (3%) patients without frailty (CFS ≤ 4) developed PerCI (P < 0.001). Among patients with PerCI, 669 of 2190 (30.5%) with frailty and 1194 of 6624 without frailty (18%) died in hospital (P < 0.001). The time point defining PerCI onset did not vary with frailty degree; however, with increasing length of ICU stay, inclusion of frailty progressively improved mortality discrimination (0.1% AUROC improvement on ICU day one versus 3.6% on ICU day 17).

CONCLUSION

Compared to patients without frailty, those with frailty have a higher chance of developing and dying from PerCI. Moreover the importance of frailty as a predictor of mortality increases with ICU length of stay. Future work should explore incorporation of frailty in prognostic models, particularly for long-staying patients.

Reconciling the obesity paradox: Obese patients suffer the highest critical illness associated mortality rates

The obesity paradox refers to the observation that obese patients admitted to intensive care units (ICU) have lower case fatality as compared to healthy weight patients. However, selection bias could explain the apparent paradox. Our objective was to assess whether obese people have a different overall burden of critical illness associated mortality. A retrospective population-based cohort study was conducted in North Brisbane ICUs during 2017-2019. Patients were classified as underweight, healthy weight, overweight, and obese according to BMIs <18.5, 18.5-24.9, 25-29.9, and ≥ 30 kg/m², respectively. ICU admission incidence rates were 245.6, 138.2, 178.9, and 421.9 per 100,000 population; 90-day all cause case fatalities were 24.0%, 17.0%, 18.1%, and 16.0%; and critical illness associated mortality rates were 58.8, 23.4, 32.4, and 67.7 per 100,000 population among underweight, healthy weight, overweight, and obese patients, respectively. As compared to patients of healthy weight, those who were underweight (relative risk; RR 2.51; 95% CI, 1.79-3.44), overweight (RR 1.38; 95% CI, 1.16-1.65), and obese (RR 2.89; 2.43-3.43) were each at significantly higher risk for critical illness associated mortality. While obese patients have lower case fatality they are at much higher risk for ICU admission and as result suffer the highest burden of critical illness associated mortality in our region.