| 1. |
- Bruno, Raphael Romano, et al.
(författare)
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The Clinical Frailty Scale for mortality prediction of old acutely admitted intensive care patients: a meta-analysis of individual patient-level data
- 2023
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Ingår i: Annals of Intensive Care. - : SPRINGER. - 2110-5820. ; 13:1
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Tidskriftsartikel (refereegranskat)abstract
- Background This large-scale analysis pools individual data about the Clinical Frailty Scale (CFS) to predict outcome in the intensive care unit (ICU). Methods A systematic search identified all clinical trials that used the CFS in the ICU (PubMed searched until 24th June 2020). All patients who were electively admitted were excluded. The primary outcome was ICU mortality. Regression models were estimated on the complete data set, and for missing data, multiple imputations were utilised. Cox models were adjusted for age, sex, and illness acuity score (SOFA, SAPS II or APACHE II). Results 12 studies from 30 countries with anonymised individualised patient data were included (n = 23,989 patients). In the univariate analysis for all patients, being frail (CFS >= 5) was associated with an increased risk of ICU mortality, but not after adjustment. In older patients (>= 65 years) there was an independent association with ICU mortality both in the complete case analysis (HR 1.34 (95% CI 1.25-1.44), p < 0.0001) and in the multiple imputation analysis (HR 1.35 (95% CI 1.26-1.45), p < 0.0001, adjusted for SOFA). In older patients, being vulnerable (CFS 4) alone did not significantly differ from being frail. After adjustment, a CFS of 4-5, 6, and >= 7 was associated with a significantly worse outcome compared to CFS of 1-3. Conclusions Being frail is associated with a significantly increased risk for ICU mortality in older patients, while being vulnerable alone did not significantly differ. New Frailty categories might reflect its "continuum" better and predict ICU outcome more accurately.
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| 2. |
- Andreasen, Anne Sofie, et al.
(författare)
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New-onset atrial fibrillation in critically ill adult patients-an SSAI clinical practice guideline
- 2023
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Ingår i: Acta Anaesthesiologica Scandinavica. - : WILEY. - 0001-5172 .- 1399-6576. ; 67:8, s. 1110-1117
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Tidskriftsartikel (refereegranskat)abstract
- Background: Acute or new-onset atrial fibrillation (NOAF) is the most common cardiac arrhythmia in critically ill adult patients, and observational data suggests that NOAF is associated to adverse outcomes. Methods: We prepared this guideline according to the Grading of Recommendations Assessment, Development and Evaluation methodology. We posed the following clinical questions: (1) what is the better first-line pharmacological agent for the treatment of NOAF in critically ill adult patients?, (2) should we use direct current (DC) cardioversion in critically ill adult patients with NOAF and hemodynamic instability caused by atrial fibrillation?, (3) should we use anticoagulant therapy in critically ill adult patients with NOAF?, and (4) should critically ill adult patients with NOAF receive follow-up after discharge from hospital? We assessed patient-important outcomes, including mortality, thromboembolic events, and adverse events. Patients and relatives were part of the guideline panel. Results: The quantity and quality of evidence on the management of NOAF in critically ill adults was very limited, and we did not identify any relevant direct or indirect evidence from randomized clinical trials for the prespecified PICO questions. We were able to propose one weak recommendation against routine use of therapeutic dose anticoagulant therapy, and one best practice statement for routine follow-up by a cardiologist after hospital discharge. We were not able to propose any recommendations on the better first-line pharmacological agent or whether to use DC cardioversion in critically ill patients with hemodynamic instability induced by NOAF. An electronic version of this guideline in layered and interactive format is available in MAGIC: https://app.magicapp.org/#/guideline/7197. Conclusions: The body of evidence on the management of NOAF in critically ill adults is very limited and not informed by direct evidence from randomized clinical trials. Practice variation appears considerable.
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| 3. |
- Blixt Johansson, Patrik, et al.
(författare)
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Left ventricular longitudinal wall fractional shortening accurately predicts longitudinal strain in critically ill patients with septic shock
- 2021
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Ingår i: Annals of Intensive Care. - : Springer. - 2110-5820. ; 11:1
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Tidskriftsartikel (refereegranskat)abstract
- Background Left ventricular longitudinal strain (LVLS) may be a sensitive indicator of left ventricular (LV) systolic function in patients with sepsis, but is dependent on high image quality and analysis software. Mitral annular plane systolic excursion (MAPSE) and the novel left ventricular longitudinal wall fractional shortening (LV-LWFS) are bedside echocardiographic indicators of LV systolic function that are less dependent on image quality. Both are sparsely investigated in the critically ill population, and may potentially be used as surrogates for LVLS. We assessed if LVLS may be predicted by LV-LWFS and MAPSE in patients with septic shock. We also assessed the repeatability and inter-rater agreement of LVLS, LV-LWFS and MAPSE measurements. Results 122 TTE studies from 3 echocardiographic data repositories of patients admitted to ICU with septic shock were retrospectively assessed, of which 73 were suitable for LVLS analysis using speckle tracking. The correlations between LVLS vs. LV-LWFS and LVLS vs. MAPSE were 0.89 (p < 0.001) and 0.81 (p < 0.001) with mean squared errors of 5.8% and 9.1%, respectively. Using the generated regression equation, LV-LWFS predicted LVLS with a high degree of accuracy and precision, with bias and limits of agreement of -0.044 +/- 4.7% and mean squared prediction error of 5.8%. Interobserver repeatability was good, with high intraclass correlation coefficients (0.96-0.97), small bias and tight limits of agreement (<= 4.1% for all analyses) between observers for all measurements. Conclusions LV-LWFS may be used to estimate LVLS in patients with septic shock. MAPSE also performed well, but was slightly inferior compared to LV-LWFS in estimating LVLS. Feasibility of MAPSE and LV-LWFS was excellent, as was interobserver repeatability.
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| 4. |
- Chew, Michelle S., et al.
(författare)
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Identification of myocardial injury using perioperative troponin surveillance in major noncardiac surgery and net benefit over the Revised Cardiac Risk Index
- 2022
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Ingår i: British Journal of Anaesthesia. - : Elsevier. - 0007-0912 .- 1471-6771. ; 128:1, s. 26-36
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Patients with perioperative myocardial injury are at risk of death and major adverse cardiovascular and cerebrovascular events (MACCE). The primary aim of this study was to determine optimal thresholds of preoperative and perioperative changes in high-sensitivity cardiac troponin T (hs-cTnT) to predict MACCE and mortality.METHODS: Prospective, observational, cohort study in patients ≥50 yr of age undergoing elective major noncardiac surgery at seven hospitals in Sweden. The exposures were hs-cTnT measured before and days 0-3 after surgery. Two previously published thresholds for myocardial injury and two thresholds identified using receiver operating characteristic analyses were evaluated using multivariable logistic regression models and externally validated. The weighted comparison net benefit method was applied to determine the additional value of hs-cTnT thresholds when compared with the Revised Cardiac Risk Index (RCRI). The primary outcome was a composite of 30-day all-cause mortality and MACCE.RESULTS: We included 1291 patients between April 2017 and December 2020. The primary outcome occurred in 124 patients (9.6%). Perioperative increase in hs-cTnT ≥14 ng L-1 above preoperative values provided statistically optimal model performance and was associated with the highest risk for the primary outcome (adjusted odds ratio 2.9, 95% confidence interval 1.8-4.7). Validation in an independent, external cohort confirmed these findings. A net benefit over RCRI was demonstrated across a range of clinical thresholds.CONCLUSIONS: Perioperative increases in hsTnT ≥14 ng L-1 above baseline values identifies acute perioperative myocardial injury and provides a net prognostic benefit when added to RCRI for the identification of patients at high risk of death and MACCE.CLINICAL TRIAL REGISTRATION: NCT03436238.
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| 5. |
- de Geer, Lina, et al.
(författare)
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Frailty is a stronger predictor of death in younger intensive care patients than in older patients: a prospective observational study
- 2022
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Ingår i: Annals of Intensive Care. - : SPRINGER. - 2110-5820. ; 12:1
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Tidskriftsartikel (refereegranskat)abstract
- Background: While frailty is a known predictor of adverse outcomes in older patients, its effect in younger populations is unknown. This prospective observational study was conducted in a tertiary-level mixed ICU to assess the impact of frailty on long-term survival in intensive care patients of different ages. Methods: Data on premorbid frailty (Clinical Frailty Score; CFS), severity of illness (the Simplified Acute Physiology Score, third version; SAPS3), limitations of care and outcome were collected in 817 adult ICU patients. Hazard ratios (HR) for death within 180 days after ICU admission were calculated. Unadjusted and adjusted analyses were used to evaluate the association of frailty with outcome in different age groups. Results: Patients were classified into predefined age groups (18-49 years (n = 241), 50-64 (n = 188), 65-79 (n = 311) and 80 years or older (n = 77)). The proportion of frail (CFS >= 5) patients was 41% (n = 333) in the overall population and increased with each age strata (n = 46 (19%) vs. n = 67 (36%) vs. n = 174 (56%) vs. n = 46 (60%), P < 0.05). Frail patients had higher SAPS3, more treatment restrictions and higher ICU mortality. Frailty was associated with an increased risk of 180-day mortality in all age groups (HR 5.7 (95% CI 2.8-11.4), P < 0.05; 8.0 (4.0-16.2), P < 0.05; 4.1 (2.2-6.6), P < 0.05; 2.4 (1.1-5.0), P = 0.02). The effect remained significant after adjustment for SAPS3, comorbidity and limitations of treatment only in patients aged 50-64 (2.1 (1.1-3.1), P < 0.05). Conclusions: Premorbid frailty is common in ICU patients of all ages and was found in 55% of patients aged under 64 years. Frailty was independently associated with mortality only among middle-aged patients, where the risk of death was increased twofold. Our study supports the use of frailty assessment in identifying younger ICU patients at a higher risk of death.
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| 6. |
- de Geer, Lina, et al.
(författare)
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Frailty predicts 30-day mortality in intensive care patients A prospective prediction study
- 2020
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Ingår i: European Journal of Anaesthesiology. - : LIPPINCOTT WILLIAMS & WILKINS. - 0265-0215 .- 1365-2346. ; 37:11, s. 1058-1065
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND Frailty is a multidimensional syndrome characterised by a loss of reserve and an increased risk of adverse outcomes. OBJECTIVE To study the impact of frailty on mortality in unselected intensive care patients, and to compare its discriminatory ability to an established model for outcome prediction in intensive care. DESIGN A prospective study with a comparison of two prediction models. SETTING A tertiary mixed ICU, from January 2017 to June 2018. PATIENTS AND MAIN OUTCOME MEASURES Data on premorbid frailty (clinical frailty scale; CFS), severity of illness (the simplified acute physiology score, third version; SAPS3), therapeutic procedures, limitations of care and outcome were collected in 872 adult ICU patients. A cut-off level of CFS for predicting death within 30 days was identified and unadjusted and adjusted analyses were used to evaluate the association of frailty to outcome. RESULTS The receiver operating curve, area under the curve of CFS [0.74 (95% confidence interval, 0.69 to 0.79)] did not differ significantly from that of SAPS3 [0.79 (0.75 to 0.83), P = 0.53], whereas combining the two resulted in an improved discriminatory ability [area under the curve = 0.82 (0.79 to 0.86), CFS + SAPS3 vs. SAPS3 alone, P = 0.02]. The correlation of CFS to SAPS3 was moderate (r = 0.4). A cut-off level was identified at CFS at least 5, defining 43% (n=375) of the patients as frail. Frail patients were older with higher SAPS3 and more comorbidities. Treatment in the ICU was more often withheld or withdrawn in frail patients, and mortality was higher. After adjustment for SAPS3, comorbidities, limitations of treatment, age and sex, frailty remained a strong predictor of death within 30 days [hazard ratio 2.12 (95% confidence interval, 1.44 to 3.14), P < 0.001]. CONCLUSION Premorbid frailty was common in general ICU patients and was an independent predictor of death. Our study suggests that frailty could be a valuable addition in outcome prediction in intensive care.
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| 7. |
- Ekerstad, Niklas, et al.
(författare)
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Clinical frailty scale – skörhet är ett sätt att skatta biologisk ålder
- 2022
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Ingår i: Lakartidningen. - 0023-7205. ; 119, s. 1-5
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Forskningsöversikt (refereegranskat)abstract
- The term frailty denotes a multi-dimensional syndrome characterised by reduced physiological reserves and increased vulnerability. Frailty may be used as a marker of biological age, distinct from chronological age. There are several instruments for frailty assessment. The Clinical Frailty Scale (CFS) is probably the most commonly used in the acute care context. It is a 9-level scale, derived from the accumulated deficit model of frailty, which combines comorbidity, disability, and cognitive impairment. The CFS assessment is fast and easy to implement in daily clinical practice. The CFS is relevant for risk stratification, and may also be used as a screening instrument to identify frail patients suitable for further geriatric evaluation, i.e. a comprehensive geriatric assessment (CGA). By providing information on long-term prognosis, it may improve informed decision-making on an individual basis.
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| 8. |
- Ekerstad, Niklas, 1969-, et al.
(författare)
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Clinical frailty scale – skörhet ärett sätt att skatta biologisk ålder : [Clinical Frailty Scale - a proxy estimate of biological age]
- 2022
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Ingår i: Läkartidningen. - : Sveriges Läkarforbund. - 0023-7205 .- 1652-7518. ; 119
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Forskningsöversikt (refereegranskat)abstract
- The term frailty denotes a multi-dimensional syndrome characterised by reduced physiological reserves and increased vulnerability. Frailty may be used as a marker of biological age, distinct from chronological age. There are several instruments for frailty assessment. The Clinical Frailty Scale (CFS) is probably the most commonly used in the acute care context. It is a 9-level scale, derived from the accumulated deficit model of frailty, which combines comorbidity, disability, and cognitive impairment. The CFS assessment is fast and easy to implement in daily clinical practice. The CFS is relevant for risk stratification, and may also be used as a screening instrument to identify frail patients suitable for further geriatric evaluation, i.e. a comprehensive geriatric assessment (CGA). By providing information on long-term prognosis, it may improve informed decision-making on an individual basis.
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| 9. |
- Johansson Blixt, Patrik, et al.
(författare)
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Association between left ventricular systolic function parameters and myocardial injury, organ failure and mortality in patients with septic shock
- 2024
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Ingår i: Annals of Intensive Care. - : SPRINGER. - 2110-5820. ; 14:1
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Tidskriftsartikel (refereegranskat)abstract
- BackgroundLeft ventricular ejection fraction (LVEF) is inconsistently associated with poor outcomes in patients with sepsis. Newer parameters such as LV longitudinal strain (LVLS), mitral annular plane systolic excursion (MAPSE) and LV longitudinal wall fractional shortening (LV-LWFS) may be more sensitive indicators of LV dysfunction, but are sparsely investigated. Our objective was to evaluate the association between five traditional and novel echocardiographic parameters of LV systolic function (LVEF, peak tissue Doppler velocity at the mitral valve (s '), LVLS, MAPSE and LV-LWFS) and outcomes in patients admitted to the Intensive Care Unit (ICU) with septic shock.MethodsA total of 152 patients admitted to the ICU with septic shock from two data repositories were included. Transthoracic echocardiograms were performed within 24 h of ICU admission. The primary outcome was myocardial injury, defined as high-sensitivity troponin T >= 45 ng/L on ICU admission. Secondary outcomes were organ support-free days (OSFD) and 30-day mortality. We also tested for the prognostic value of the systolic function parameters using multivariable analysis.ResultsLVLS, MAPSE and LV-LWFS, but not LVEF and s ', differed between patients with and without myocardial injury. After adjustment for age, pre-existing cardiac disease, Simplified Acute Physiology (SAPS3) score, Sequential Organ Failure Assessment (SOFA) score, plasma creatinine and presence of right ventricular dysfunction, only MAPSE and LV-LWFS were independently associated with myocardial injury. None of the systolic function parameters were associated with OSFD or 30-day mortality.ConclusionsMAPSE and LV-LWFS are independently associated with myocardial injury and outperform LVEF, s ' and LVLS. Whether these parameters are associated with clinical outcomes such as the need for organ support and short-term mortality is still unclear.Trial registration NCT01747187 and NCT04695119.ConclusionsMAPSE and LV-LWFS are independently associated with myocardial injury and outperform LVEF, s ' and LVLS. Whether these parameters are associated with clinical outcomes such as the need for organ support and short-term mortality is still unclear.Trial registration NCT01747187 and NCT04695119.
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| 10. |
- Krifors, Anders, et al.
(författare)
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Influenza-associated invasive aspergillosis in patients admitted to the intensive care unit in Sweden : a prospective multicentre cohort study
- 2024
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Ingår i: Infectious Diseases. - : Taylor & Francis. - 2374-4235 .- 2374-4243. ; 56:2, s. 110-115
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: The purpose of this study was to prospectively investigate the incidence of influenza-associated pulmonary aspergillosis (IAPA) in influenza patients admitted to intensive care units in Sweden.METHODS: The study included consecutive adult patients with PCR-verified influenza A or B in 12 Swedish intensive care units (ICUs) over four influenza seasons (2019-2023). Patients were screened using serum galactomannan and β-d-glucan tests and fungal culture of a respiratory sample at inclusion and weekly during the ICU stay. Bronchoalveolar lavage was performed if clinically feasible. IAPA was classified according to recently proposed case definitions.RESULTS: The cohort included 55 patients; 42% were female, and the median age was 59 (IQR 48-71) years. All patients had at least one galactomannan test, β-d-glucan test and respiratory culture performed. Bronchoalveolar lavage was performed in 24 (44%) of the patients. Five (9%, 95% CI 3.8% - 20.4%) patients were classified as probable IAPA, of which four lacked classical risk factors. The overall ICU mortality was significantly higher among IAPA patients than non-IAPA patients (60% vs 8%, p = 0.01).CONCLUSIONS: The study represents the first prospective investigation of IAPA incidence. The 9% incidence of IAPA confirms the increased risk of invasive pulmonary aspergillosis among influenza patients admitted to the ICU. Therefore, it appears reasonable to implement a screening protocol for the early diagnosis and treatment of IAPA in influenza patients receiving intensive care.TRIAL REGISTRATION: ClinicalTrials.gov NCT04172610, registered November 21, 2019.
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