Frailty assessment in critically ill older adults: a narrative review.

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.

[Intensive care and Covid]. / Réanimation et Covid.

The health crisis linked to COVID-19 has put the whole hospital under stress. Intensive care units (ICU) have been on the front line to manage the most serious cases. The number of new admissions together with cumulative number of occupied intensive care beds have been and still are a key element in measuring the intensity of the crisis. Intensive care is a specialty largely unknown to the general public which is problematic when dealing with such difficult questions as should we give priority to health or to the economy; is there a loss of chance for non-COVID patients due to deprogramming? The increase in the demand for critical care has necessitated an extension of hospitalization capacities by transforming intermediate care beds into ICU beds, by creating neo-ICU, or in some regions by carrying out critical care, usually performed in ICU, in regular wards. Among the several limiting factors, human resources with qualified personnel was a key element together with the relative shortage of drugs. The mismatch between demand and supply has led to the establishment of rules for prioritizing access to ICU. This review deals with all these issues and can contribute to a reflection on the adaptation of the critical care department to cope with major sanitary crisis.

Attitudes of physicians towards the care of critically ill elderly patients - a European survey.

BACKGROUND: Very elderly patients are one of the fastest growing population in ICUs worldwide. There are lots of controversies regarding admission, discharge of critically ill elderly patients, and also on treatment intensity during the ICU stay. As a consequence, practices vary considerably from one ICU to another. In that perspective, we collected opinions of experienced ICU physicians across Europe on statements focusing on patients older than 80. METHODS: We sent an online questionnaire to the coordinator ICU physician of all participating ICUs of an recent European, observational study of Very old critically Ill Patients (VIP1 study). This questionnaire contained 12 statements about admission, triage, treatment and discharge of patients older than 80. RESULTS: We received answers from 162 ICUs (52% of VIP1-study) spanning 20 different European countries. There were major disagreements between ICUs. Responders disagree that: there is clear evidence that ICU admission is beneficial (37%); seeking relatives' opinion is mandatory (17%); written triage guidelines must be available either at the hospital or ICU level (20%); level of care should be reduced (25%); a consultation of a geriatrician should be sought (34%) and a geriatrician should be part of the post-ICU trail (11%). The percentage of disagreement varies between statements and European regions. CONCLUSION: There are major differences in the attitude of European ICU physicians on the admission, triage and treatment policies of patients older than 80 emphasizing the lack of consensus and poor level of evidence for most of the statements and outlining the need for future interventional studies.

The status of intensive care medicine research and a future agenda for very old patients in the ICU.

The "very old intensive care patients" (abbreviated to VOPs; greater than 80 years old) are probably the fastest expanding subgroup of all intensive care unit (ICU) patients. Up until recently most ICU physicians have been reluctant to admit these VOPs. The general consensus was that there was little survival to gain and the incremental life expectancy of ICU admission was considered too small. Several publications have questioned this belief, but others have confirmed the poor long-term mortality rates in VOPs. More appropriate triage (resource limitation enforced decisions), admission decisions based on shared decision-making and improved prediction models are also needed for this particular patient group. Here, an expert panel proposes a research agenda for VOPs for the coming years.

[Diagnostic ultrasound in pneumothorax]. / Diagnostic échographique du pneumothorax.

For a long time the lung has been regarded as inaccessible to ultrasound. However, recent clinical studies have shown that this organ can be examined by this technique, which appears, in some situations, to be superior to thoracic radiography. The examination does not require special equipment and is possible using a combination of simple qualitative signs: lung sliding, the presence of B lines and the demonstration of the lung point. The lung sliding corresponds to the artefact produced by the movement of the two pleural layers, one against the other. The B lines indicate the presence of an interstitial syndrome. The presence of lung sliding and/or B lines has a negative predictive value of 100% and formally excludes a pneumothorax in the area where the probe has been applied. The presence of the lung point is pathognomonic of pneumothorax but the sensitivity is no more than 60%. Ultrasound is therefore a rapid and simple means of excluding a pneumothorax (lung sliding or B lines) and of confirming a pneumothorax when the lung point is visible. The question that remains is whether ultrasound can totally replace radiography in the management of this disorder.

Severe Extra-Cerebral Anticoagulant-Related Bleeding in Intensive Care Unit: A Retrospective Study From 2000 to 2013.

Bleeding is the most frequent complication of anticoagulant therapy, responsible for a number of hospitalizations or deaths. However, studies describing the management and prognosis factors of extra-cerebral anticoagulant-related bleedings in intensive care unit (ICU) are lacking.Retrospective observational study in an 18-bed ICU in a tertiary teaching hospital. From January 2000 to December 2013, all consecutive patients, older than 18 years, admitted for severe anticoagulant-related bleeding (SAB) except intracerebral site were included.A total of 100 patients were included, the mean age was 77 ± 11 years and 62% were women. SAB incidence in ICU doubled over 10 years (P = 0.03). In ICU, the average length of stay was 5 ± 6 days and mortality was 30%. Nonsurviving patients had a higher SAPS II (78 ± 24 vs 53 ± 24, P < 0.0001), a higher SOFA (9.0 ± 3.6 vs 4.7 ± 3.4, P < 0.0001) and received more frequently support therapy such as mechanical ventilation (87% vs 16%, P < 0.0001) and vasopressors (90% vs 27%, P < 0.0001). The volume of blood-derived products transfused was more important in nonsurvivors mainly during the first 24 hours of resuscitation. Rapid anticoagulant reversal therapy was associated with better prognosis (ICU survivors 66% vs 39%, Fisher test P = 0.04). Anterior abdominal wall was identified as a frequent site of bleeding (22%) due to epigastric artery injury during subcutaneous injection of heparin and was associated with a large mortality (55%).Extra-cerebral SAB is a life-threatening complication that requires rapid resuscitation and anticoagulant reversal therapy. Injection of heparin should be done carefully in the subcutaneous tissue thereby avoiding artery injury.

Capillary refill time exploration during septic shock.

BACKGROUND: During septic shock management, the evaluation of microvascular perfusion by skin analysis is of interest. We aimed to study the skin capillary refill time (CRT) in a selected septic shock population. METHODS: We conducted a prospective observational study in a tertiary teaching hospital. After a preliminary study to calculate CRT reproducibility, all consecutive patients with septic shock during a 10-month period were included. After initial resuscitation at 6 h (H6), we recorded hemodynamic parameters and analyzed their predictive value on 14-day mortality. CRT was measured on the index finger tip and on the knee area. RESULTS: CRT was highly reproducible with an excellent inter-rater concordance calculated at 80% [73-86] for index CRT and 95% [93-98] for knee CRT. A total of 59 patients were included, SOFA score was 10 [7-14], SAPS II was 61 [50-78] and 14-day mortality rate was 36%. CRT measured at both sites was significantly higher in non-survivors compared to survivors (respectively 5.6 ± 3.5 vs 2.3 ± 1.8 s, P < 0.0001 for index CRT and 7.6 ± 4.6 vs 2.9 ± 1.7 s, P < 0.0001 for knee CRT). The CRT at H6 was strongly predictive of 14-day mortality as the area under the curve was 84% [75-94] for the index measurement and was 90% [83-98] for the knee area. A threshold of index CRT at 2.4 s predicted 14-day outcome with a sensitivity of 82% (95% CI [60-95]) and a specificity of 73% (95% CI [56-86]). A threshold of knee CRT at 4.9 s predicted 14-day outcome with a sensitivity of 82% (95% CI [60-95]) and a specificity of 84% (95% CI [68-94]). CRT was significantly related to tissue perfusion parameters such as arterial lactate level and SOFA score. Finally, CRT changes during shock resuscitation were significantly associated with prognosis. CONCLUSION: CRT is a clinical reproducible parameter when measured on the index finger tip or the knee area. After initial resuscitation of septic shock, CRT is a strong predictive factor of 14-day mortality.

Peripheral microcirculatory exploration during mechanical ventilation weaning.

BACKGROUND: Weaning from mechanical ventilation is a daily challenge in intensive care patients. Our objective was to explore microcirculatory perfusion during mechanical ventilation weaning and to evaluate its predictive value on the weaning outcome. METHODS: Prospective observational study. All consecutive patients, older than 18 years, under mechanical ventilation that met the criteria for weaning were enrolled. Patients underwent a T-piece Spontaneous Breath Trial (SBT) for 60 minutes and the usual clinical parameters were recorded every 5 minutes. Microcirculatory perfusion was evaluated using the mottling score and the Tissue Oxygen Saturation (StO2) measured by Near Infrared Spectroscopy technology on the thenar and knee area. RESULTS: Seventy-three patients were studied (age: 67±15 years, men: 40, SAPS II: 47±15) after a duration of mechanical ventilation of 3 (1-6) days. Forty-five patients succeeded the first SBT. The mottling score severity recorded just before ventilator disconnection (baseline) was associated with weaning failure (P=0.03). Moreover, the mottling score increase during SBT was significantly associated with weaning failure (80% vs. 28%, P=0.001; Odds ratio 10.5 [2.0-54.8]). Baseline thenar StO2 was not different according to weaning outcome (failure 76±13% vs. success 77±7%, P=0.90) whereas baseline knee StO2 was significantly lower in patients who failed the first SBT (67±13% vs. 75±12%, P<0.01). This difference was apparent since the very beginning of the SBT and lasted throughout the trial (P=0.0001). CONCLUSION: In unselected mechanically ventilated patients undergoing SBT, mottling score and knee StO2 are early predictors of weaning failure.