tetano
Editor, Senior Moderator
Br J Anaesth
. 2020 Sep 2;S0007-0912(20)30642-5.
doi: 10.1016/j.bja.2020.07.049. Online ahead of print.
Frailty and outcomes from pneumonia in critical illness: a population-based cohort study
Jai N Darvall[SUP] 1 [/SUP], Rinaldo Bellomo[SUP] 2 [/SUP], Michael Bailey[SUP] 3 [/SUP], Eldho Paul[SUP] 4 [/SUP], Paul J Young[SUP] 5 [/SUP], Kenneth Rockwood[SUP] 6 [/SUP], David Pilcher[SUP] 7 [/SUP]
Affiliations
Abstract
Background: A threshold Clinical Frailty Scale (CFS) of 5 (indicating mild frailty) has been proposed to guide ICU admission for UK patients with coronavirus disease 2019 (COVID-19) pneumonia. However, the impact of frailty on mortality with (non-COVID-19) pneumonia in critical illness is unknown. We examined the triage utility of the CFS in patients with pneumonia requiring ICU.
Methods: We conducted a retrospective cohort study of adult patients admitted with pneumonia to 170 ICUs in Australia and New Zealand from January 1, 2018 to September 31, 2019. We classified patients as: non-frail (CFS 1-4) frail (CFS 5-8), mild/moderately frail (CFS 5-6),and severe/very severely frail (CFS 7-8). We evaluated mortality (primary outcome) adjusting for site, age, sex, mechanical ventilation, pneumonia type and illness severity. We also compared the proportion of ICU bed-days occupied between frailty categories.
Results: 1852/5607 (33%) patients were classified as frail, including1291/3056 (42%) of patients aged >65 yr, who would potentially be excluded from ICU admission under UK-based COVID-19 triage guidelines. Only severe/very severe frailty scores were associated with mortality (adjusted odds ratio [aOR] for CFS=7: 3.2; 95% confidence interval [CI]: 1.3-7.8; CFS=8 [aOR: 7.2; 95% CI: 2.6-20.0]). These patients accounted for 7% of ICU bed days. Vulnerability (CFS=4) and mild frailty (CFS=5) were associated with a similar mortality risk (CFS=4 [OR: 1.6; 95% CI: 0.7-3.8]; CFS=5 [OR: 1.6; 95% CI: 0.7-3.9]).
Conclusions: Patients with severe and very severe frailty account for relatively few ICU bed days as a result of pneumonia, whilst adjusted mortality analysis indicated little difference in risk between patients in vulnerable, mild, and moderate frailty categories. These data do not support CFS ≥5 to guide ICU admission for pneumonia.
Keywords: COVID-19; frailty; intensive care unit; mortality; observational study; pneumonia; respiratory failure.
. 2020 Sep 2;S0007-0912(20)30642-5.
doi: 10.1016/j.bja.2020.07.049. Online ahead of print.
Frailty and outcomes from pneumonia in critical illness: a population-based cohort study
Jai N Darvall[SUP] 1 [/SUP], Rinaldo Bellomo[SUP] 2 [/SUP], Michael Bailey[SUP] 3 [/SUP], Eldho Paul[SUP] 4 [/SUP], Paul J Young[SUP] 5 [/SUP], Kenneth Rockwood[SUP] 6 [/SUP], David Pilcher[SUP] 7 [/SUP]
Affiliations
- PMID: 32891413
- DOI: 10.1016/j.bja.2020.07.049
Abstract
Background: A threshold Clinical Frailty Scale (CFS) of 5 (indicating mild frailty) has been proposed to guide ICU admission for UK patients with coronavirus disease 2019 (COVID-19) pneumonia. However, the impact of frailty on mortality with (non-COVID-19) pneumonia in critical illness is unknown. We examined the triage utility of the CFS in patients with pneumonia requiring ICU.
Methods: We conducted a retrospective cohort study of adult patients admitted with pneumonia to 170 ICUs in Australia and New Zealand from January 1, 2018 to September 31, 2019. We classified patients as: non-frail (CFS 1-4) frail (CFS 5-8), mild/moderately frail (CFS 5-6),and severe/very severely frail (CFS 7-8). We evaluated mortality (primary outcome) adjusting for site, age, sex, mechanical ventilation, pneumonia type and illness severity. We also compared the proportion of ICU bed-days occupied between frailty categories.
Results: 1852/5607 (33%) patients were classified as frail, including1291/3056 (42%) of patients aged >65 yr, who would potentially be excluded from ICU admission under UK-based COVID-19 triage guidelines. Only severe/very severe frailty scores were associated with mortality (adjusted odds ratio [aOR] for CFS=7: 3.2; 95% confidence interval [CI]: 1.3-7.8; CFS=8 [aOR: 7.2; 95% CI: 2.6-20.0]). These patients accounted for 7% of ICU bed days. Vulnerability (CFS=4) and mild frailty (CFS=5) were associated with a similar mortality risk (CFS=4 [OR: 1.6; 95% CI: 0.7-3.8]; CFS=5 [OR: 1.6; 95% CI: 0.7-3.9]).
Conclusions: Patients with severe and very severe frailty account for relatively few ICU bed days as a result of pneumonia, whilst adjusted mortality analysis indicated little difference in risk between patients in vulnerable, mild, and moderate frailty categories. These data do not support CFS ≥5 to guide ICU admission for pneumonia.
Keywords: COVID-19; frailty; intensive care unit; mortality; observational study; pneumonia; respiratory failure.