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Deulkar P, Singam A, Jain A. A Comprehensive Review of the Role of Biomarkers in the Early Detection of Endocrine Disorders in Critical Illnesses. Cureus 2024; 16:e61409. [PMID: 38947617 PMCID: PMC11214685 DOI: 10.7759/cureus.61409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 05/31/2024] [Indexed: 07/02/2024] Open
Abstract
Endocrine disorders pose significant challenges in the management of critically ill patients, contributing to morbidity and mortality in intensive care settings. Timely detection of these disorders is essential to optimizing patient outcomes. Biomarkers, as measurable indicators of biological processes or disease states, play a crucial role in the early identification and monitoring of endocrine dysfunction. This comprehensive review examines the role of biomarkers in the early detection of endocrine disorders in critical illnesses. We provide an overview of common endocrine disorders encountered in the intensive care unit (ICU) and discuss the impact of endocrine dysregulation on patient outcomes. Additionally, we classify biomarkers and explore their significance in diagnosing and monitoring endocrine disorders, including thyroid dysfunction, adrenal insufficiency, and hypopituitarism. Furthermore, we discuss the clinical applications of biomarkers, including their utility in guiding therapeutic interventions, monitoring disease progression, and predicting outcomes in critical illnesses. Emerging trends and future directions in biomarker research are also highlighted, emphasizing the need for continued investigation into novel biomarkers and technological advancements. Finally, we underscore the potential of biomarkers to revolutionize the early detection and management of endocrine disorders in critical illnesses, ultimately improving patient care and outcomes in the ICU.
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Affiliation(s)
- Pallavi Deulkar
- Critical Care Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Amol Singam
- Critical Care Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
| | - Abhishek Jain
- Critical Care Medicine, Jawaharlal Nehru Medical College, Datta Meghe Institute of Higher Education and Research, Wardha, IND
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Keats K, Deng S, Chen X, Zhang T, Devlin JW, Murphy DJ, Smith SE, Murray B, Kamaleswaran R, Sikora A. Unsupervised machine learning analysis to identify patterns of ICU medication use for fluid overload prediction. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.03.21.24304663. [PMID: 38562806 PMCID: PMC10984037 DOI: 10.1101/2024.03.21.24304663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
INTRODUCTION Intravenous (IV) medications are a fundamental cause of fluid overload (FO) in the intensive care unit (ICU); however, the association between IV medication use (including volume), administration timing, and FO occurrence remains unclear. METHODS This retrospective cohort study included consecutive adults admitted to an ICU ≥72 hours with available fluid balance data. FO was defined as a positive fluid balance ≥7% of admission body weight within 72 hours of ICU admission. After reviewing medication administration record (MAR) data in three-hour periods, IV medication exposure was categorized into clusters using principal component analysis (PCA) and Restricted Boltzmann Machine (RBM). Medication regimens of patients with and without FO were compared within clusters to assess for temporal clusters associated with FO using the Wilcoxon rank sum test. Exploratory analyses of the medication cluster most associated with FO for medications frequently appearing and used in the first 24 hours was conducted. RESULTS FO occurred in 127/927 (13.7%) of the patients enrolled. Patients received a median (IQR) of 31 (13-65) discrete IV medication administrations over the 72-hour period. Across all 47,803 IV medication administrations, ten unique IV medication clusters were identified with 121-130 medications in each cluster. Among the ten clusters, cluster 7 had the greatest association with FO; the mean number of cluster 7 medications received was significantly greater in patients in the FO cohort compared to patients who did not experience FO (25.6 vs.10.9. p<0.0001). 51 of the 127 medications in cluster 7 (40.2%) appeared in > 5 separate 3-hour periods during the 72-hour study window. The most common cluster 7 medications included continuous infusions, antibiotics, and sedatives/analgesics. Addition of cluster 7 medications to a prediction model with APACHE II score and receipt of diuretics improved the ability for the model to predict fluid overload (AUROC 5.65, p =0.0004). CONCLUSIONS Using ML approaches, a unique IV medication cluster was strongly associated with FO. Incorporation of this cluster improved the ability to predict development of fluid overload in ICU patients compared with traditional prediction models. This method may be further developed into real-time clinical applications to improve early detection of adverse outcomes.
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Affiliation(s)
- Kelli Keats
- Augusta University Medical Center, Department of Pharmacy, Augusta, GA
| | - Shiyuan Deng
- University of Georgia Franklin College of Arts and Sciences, Department of Statistics, Athens, GA, USA
| | - Xianyan Chen
- University of Georgia Franklin College of Arts and Sciences, Department of Statistics, Athens, GA, USA
| | - Tianyi Zhang
- University of Georgia Franklin College of Arts and Sciences, Department of Statistics, Athens, GA, USA
| | - John W Devlin
- Northeastern University School of Pharmacy, Boston, MA
- Brigham and Women's Hospital, Division of Pulmonary and Critical Care Medicine, Boston, MA
| | - David J Murphy
- Emory University, Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Atlanta, GA, USA
| | - Susan E Smith
- University of Georgia College of Pharmacy, Department of Clinical and Administrative Pharmacy, Athens, GA, USA
| | - Brian Murray
- University of Colorado Skaggs School of Pharmacy, Aurora, CO, USA
| | - Rishikesan Kamaleswaran
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, GA, USA
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Andrea Sikora
- 1120 15th Street, HM-118 Augusta, GA 30912
- University of Georgia College of Pharmacy, Department of Clinical and Administrative Pharmacy, Augusta, GA, USA
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Pietiläinen L, Hästbacka J, Bäcklund M, Selander T, Reinikainen M. A novel score for predicting 1-year mortality of intensive care patients. Acta Anaesthesiol Scand 2024; 68:195-205. [PMID: 37771172 DOI: 10.1111/aas.14336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 08/22/2023] [Accepted: 09/18/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND We aimed to develop a simple scoring table for predicting probability of death within 1-year after admission to an intensive care unit. We analysed data on emergency admissions from the nationwide Finnish intensive care quality registry. METHODS We included first admissions of adult patients with data available on 1-year vital status (dead or alive) and all five variables included in a premorbid functional status score, which is the number of activities the person can manage independently of the following five: get out of bed, move indoors, dress, climb stairs and walk 400 m. We analysed data on patient characteristics and admission-associated factors from 2012 to 2014 to find predictors of 1-year mortality and to develop a score for predicting probability of death. We tested the performance of this score in data from 2015. We assessed the 1-year functional status score of survivors with data available. RESULTS Out of 25,261 patients, 20,628 (81.7%) patients were able to perform all five functional activities independently prior to the intensive care unit admission. At 1-year post admission, 19,625 (77.7%) patients were alive. 1-year functional status score was known for 11,011 patients and 8970 (81.5%) patients achieved functional status score 5, managing all five activities independently. The score based on age, sex, preceding functional status, type of intensive care unit admission, severity of acute illness and the most significant diagnoses predicted 1-year mortality with an area under the receiver operating characteristic curve 0.78 (95% CI, 0.76-0.79). The calibration of our prediction model was good, with calibration intercept -0.01 (-0.07 to 0.05) and calibration slope 0.96 (0.90 to 1.02). CONCLUSION Our score based on data available at intensive care unit admission predicted 1-year mortality with fairly good discrimination. Most survivors achieved good functional recovery.
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Affiliation(s)
- Laura Pietiläinen
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital, Kuopio, Finland
- University of Eastern Finland, Kuopio, Finland
| | - Johanna Hästbacka
- Department of Anesthesia and Intensive Care, Tampere University Hospital, and Tampere University, Tampere, Finland
| | - Minna Bäcklund
- Division of Intensive Care Medicine, Department of Perioperative, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Tuomas Selander
- Science Service Center, Kuopio University Hospital, Kuopio, Finland
| | - Matti Reinikainen
- Department of Anaesthesiology and Intensive Care, Kuopio University Hospital, Kuopio, Finland
- University of Eastern Finland, Kuopio, Finland
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4
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Sikora A, Zhang T, Murphy DJ, Smith SE, Murray B, Kamaleswaran R, Chen X, Buckley MS, Rowe S, Devlin JW. Machine learning vs. traditional regression analysis for fluid overload prediction in the ICU. Sci Rep 2023; 13:19654. [PMID: 37949982 PMCID: PMC10638304 DOI: 10.1038/s41598-023-46735-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 11/04/2023] [Indexed: 11/12/2023] Open
Abstract
Fluid overload, while common in the ICU and associated with serious sequelae, is hard to predict and may be influenced by ICU medication use. Machine learning (ML) approaches may offer advantages over traditional regression techniques to predict it. We compared the ability of traditional regression techniques and different ML-based modeling approaches to identify clinically meaningful fluid overload predictors. This was a retrospective, observational cohort study of adult patients admitted to an ICU ≥ 72 h between 10/1/2015 and 10/31/2020 with available fluid balance data. Models to predict fluid overload (a positive fluid balance ≥ 10% of the admission body weight) in the 48-72 h after ICU admission were created. Potential patient and medication fluid overload predictor variables (n = 28) were collected at either baseline or 24 h after ICU admission. The optimal traditional logistic regression model was created using backward selection. Supervised, classification-based ML models were trained and optimized, including a meta-modeling approach. Area under the receiver operating characteristic (AUROC), positive predictive value (PPV), and negative predictive value (NPV) were compared between the traditional and ML fluid prediction models. A total of 49 of the 391 (12.5%) patients developed fluid overload. Among the ML models, the XGBoost model had the highest performance (AUROC 0.78, PPV 0.27, NPV 0.94) for fluid overload prediction. The XGBoost model performed similarly to the final traditional logistic regression model (AUROC 0.70; PPV 0.20, NPV 0.94). Feature importance analysis revealed severity of illness scores and medication-related data were the most important predictors of fluid overload. In the context of our study, ML and traditional models appear to perform similarly to predict fluid overload in the ICU. Baseline severity of illness and ICU medication regimen complexity are important predictors of fluid overload.
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Affiliation(s)
- Andrea Sikora
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, 1120 15th Street, HM-118, Augusta, GA, 30912, USA
| | - Tianyi Zhang
- Department of Statistics, University of Georgia Franklin College of Arts and Sciences, Athens, GA, USA
| | - David J Murphy
- Division of Pulmonary, Allergy, Critical Care and Sleep Medicine, Emory University, Atlanta, GA, USA
| | - Susan E Smith
- Department of Clinical and Administrative Pharmacy, University of Georgia College of Pharmacy, 1120 15th Street, HM-118, Augusta, GA, 30912, USA
| | - Brian Murray
- Department of Pharmacy, University of North Carolina Medical Center, Chapel Hill, NC, USA
| | - Rishikesan Kamaleswaran
- Department of Biomedical Informatics, Emory University School of Medicine, Atlanta, GA, USA
- Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, GA, USA
| | - Xianyan Chen
- Department of Statistics, University of Georgia Franklin College of Arts and Sciences, Athens, GA, USA
| | | | - Sandra Rowe
- Department of Pharmacy, Oregon Health and Science University, Portland, OR, USA
| | - John W Devlin
- Northeastern University School of Pharmacy, Boston, MA, USA.
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA, USA.
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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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6
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Flaatten H, Beil M. Predicting ICU Outcomes: Beyond Severity Scores. Chest 2023; 164:570-571. [PMID: 37689467 DOI: 10.1016/j.chest.2023.04.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 04/28/2023] [Indexed: 09/11/2023] Open
Affiliation(s)
- Hans Flaatten
- Department of Research and Development, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, Faculty of Medicine, University of Bergen, Bergen, Norway.
| | - Michael Beil
- Department of Medical Intensive Care, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel
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Rubin MA, Riecke J, Heitman E. Futility and Shared Decision-Making. Neurol Clin 2023; 41:455-467. [PMID: 37407099 DOI: 10.1016/j.ncl.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
Medical futility is an ancient and yet consistent challenge in clinical medicine. The means of balancing conflicting priorities and stakeholders' preferences has changed as much as the science that powers the understanding and treatment of disease. The introduction of patient self-determination and choice in medical decision-making shifted the locus of power in the physician-patient relationship but did not obviate the physician's responsibilities to provide benefit and prevent harm. As we have refined the process in time, new paradigms, specialists, and tools have been developed to help navigate the ever-changing landscape.
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Affiliation(s)
- Michael A Rubin
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8855, USA; Department of Neurological Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8855, USA.
| | - Jenny Riecke
- Department of Neurology, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8855, USA; Department of Palliative Care, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-8855, USA
| | - Elizabeth Heitman
- Program in Ethics in Science and Medicine, Department of Psychiatry, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, NC5.832, Dallas, TX 75390-9070, USA; Department of Applied Clinical Research, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, NC5.832, Dallas, TX 75390-9070, USA
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Mousai O, Tafoureau L, Yovell T, Flaatten H, Guidet B, Beil M, de Lange D, Leaver S, Szczeklik W, Fjolner J, Nachshon A, van Heerden PV, Joskowicz L, Jung C, Hyams G, Sviri S. The role of clinical phenotypes in decisions to limit life-sustaining treatment for very old patients in the ICU. Ann Intensive Care 2023; 13:40. [PMID: 37162595 PMCID: PMC10170430 DOI: 10.1186/s13613-023-01136-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 05/02/2023] [Indexed: 05/11/2023] Open
Abstract
BACKGROUND Limiting life-sustaining treatment (LST) in the intensive care unit (ICU) by withholding or withdrawing interventional therapies is considered appropriate if there is no expectation of beneficial outcome. Prognostication for very old patients is challenging due to the substantial biological and functional heterogeneity in that group. We have previously identified seven phenotypes in that cohort with distinct patterns of acute and geriatric characteristics. This study investigates the relationship between these phenotypes and decisions to limit LST in the ICU. METHODS This study is a post hoc analysis of the prospective observational VIP2 study in patients aged 80 years or older admitted to ICUs in 22 countries. The VIP2 study documented demographic, acute and geriatric characteristics as well as organ support and decisions to limit LST in the ICU. Phenotypes were identified by clustering analysis of admission characteristics. Patients who were assigned to one of seven phenotypes (n = 1268) were analysed with regard to limitations of LST. RESULTS The incidence of decisions to withhold or withdraw LST was 26.5% and 8.1%, respectively. The two phenotypes describing patients with prominent geriatric features and a phenotype representing the oldest old patients with low severity of the critical condition had the largest odds for withholding decisions. The discriminatory performance of logistic regression models in predicting limitations of LST after admission to the ICU was the best after combining phenotype, ventilatory support and country as independent variables. CONCLUSIONS Clinical phenotypes on ICU admission predict limitations of LST in the context of cultural norms (country). These findings can guide further research into biases and preferences involved in the decision-making about LST. Trial registration Clinical Trials NCT03370692 registered on 12 December 2017.
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Affiliation(s)
- Oded Mousai
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Lola Tafoureau
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Tamar Yovell
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Hans Flaatten
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Bertrand Guidet
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Saint Antoine, service MIR, Paris, France
| | - Michael Beil
- Department of Medical Intensive Care, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel
| | - 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
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Jesper Fjolner
- Department of Anaesthesia and Intensive Care, Viborg Regional Hospital, Viborg, Denmark
| | - 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, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Christian Jung
- Division of Cardiology, Department of Cardiology, Pulmonology and Vascular Medicine, Faculty of Medicine, Heinrich-Heine-University, Moorenstraße 5, 40225, Düsseldorf, Germany.
| | - Gal Hyams
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Sigal Sviri
- Department of Medical Intensive Care, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel
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Beil M, van Heerden PV, de Lange DW, Szczeklik W, Leaver S, Guidet B, Flaatten H, Jung C, Sviri S, Joskowicz L. Contribution of information about acute and geriatric characteristics to decisions about life-sustaining treatment for old patients in intensive care. BMC Med Inform Decis Mak 2023; 23:1. [PMID: 36609257 PMCID: PMC9818057 DOI: 10.1186/s12911-022-02094-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 12/23/2022] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Life-sustaining treatment (LST) in the intensive care unit (ICU) is withheld or withdrawn when there is no reasonable expectation of beneficial outcome. This is especially relevant in old patients where further functional decline might be detrimental for the self-perceived quality of life. However, there still is substantial uncertainty involved in decisions about LST. We used the framework of information theory to assess that uncertainty by measuring information processed during decision-making. METHODS Datasets from two multicentre studies (VIP1, VIP2) with a total of 7488 ICU patients aged 80 years or older were analysed concerning the contribution of information about the acute illness, age, gender, frailty and other geriatric characteristics to decisions about LST. The role of these characteristics in the decision-making process was quantified by the entropy of likelihood distributions and the Kullback-Leibler divergence with regard to withholding or withdrawing decisions. RESULTS Decisions to withhold or withdraw LST were made in 2186 and 1110 patients, respectively. Both in VIP1 and VIP2, information about the acute illness had the lowest entropy and largest Kullback-Leibler divergence with respect to decisions about withdrawing LST. Age, gender and geriatric characteristics contributed to that decision only to a smaller degree. CONCLUSIONS Information about the severity of the acute illness and, thereby, short-term prognosis dominated decisions about LST in old ICU patients. The smaller contribution of geriatric features suggests persistent uncertainty about the importance of functional outcome. There still remains a gap to fully explain decision-making about LST and further research involving contextual information is required. TRIAL REGISTRATION VIP1 study: NCT03134807 (1 May 2017), VIP2 study: NCT03370692 (12 December 2017).
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Affiliation(s)
- Michael Beil
- grid.9619.70000 0004 1937 0538Department of Medical Intensive Care, Hadassah Medical Centre and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - P. Vernon van Heerden
- grid.9619.70000 0004 1937 0538Department of Anaesthesia, Intensive Care and Pain Medicine, Hadassah Medical Centre and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Dylan W. de Lange
- grid.7692.a0000000090126352Department of Intensive Care Medicine, University Medical Centre, University Utrecht, Utrecht, The Netherlands
| | - Wojciech Szczeklik
- grid.5522.00000 0001 2162 9631Department of Intensive Care, Jagiellonian University Medical College, Kraków, Poland
| | - Susannah Leaver
- grid.451349.eIntensive Care, St George’s University Hospitals NHS Foundation Trust, London, UK
| | - Bertrand Guidet
- grid.50550.350000 0001 2175 4109Service de Réanimation Médicale, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Paris, France
| | - Hans Flaatten
- grid.412008.f0000 0000 9753 1393Intensive Care, Department of Clinical Medicine, Haukeland Universitetssjukehus, Bergen, Norway
| | - Christian Jung
- grid.411327.20000 0001 2176 9917Department of Cardiology, Pulmonology and Vascular Medicine, Faculty of Medicine, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225 Duesseldorf, Germany
| | - Sigal Sviri
- grid.9619.70000 0004 1937 0538Department of Medical Intensive Care, Hadassah Medical Centre and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Leo Joskowicz
- grid.9619.70000 0004 1937 0538School of Computer Science and Engineering, The Hebrew University of Jerusalem, Jerusalem, Israel
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Mousai O, Tafoureau L, Yovell T, Flaatten H, Guidet B, Jung C, de Lange D, Leaver S, Szczeklik W, Fjolner J, van Heerden PV, Joskowicz L, Beil M, Hyams G, Sviri S. Clustering analysis of geriatric and acute characteristics in a cohort of very old patients on admission to ICU. Intensive Care Med 2022; 48:1726-1735. [PMID: 36056194 PMCID: PMC9439274 DOI: 10.1007/s00134-022-06868-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 08/11/2022] [Indexed: 11/05/2022]
Abstract
PURPOSE The biological and functional heterogeneity in very old patients constitutes a major challenge to prognostication and patient management in intensive care units (ICUs). In addition to the characteristics of acute diseases, geriatric conditions such as frailty, multimorbidity, cognitive impairment and functional disabilities were shown to influence outcome in that population. The goal of this study was to identify new and robust phenotypes based on the combination of these features to facilitate early outcome prediction. METHODS Patients aged 80 years old or older with and without limitations of life-sustaining treatment and with complete data were recruited from the VIP2 study for phenotyping and from the COVIP study for external validation. The sequential organ failure assessment (SOFA) score and its sub-scores taken on admission to ICU as well as demographic and geriatric patient characteristics were subjected to clustering analysis. Phenotypes were identified after repeated bootstrapping and clustering runs. RESULTS In patients from the VIP2 study without limitations of life-sustaining treatment (n = 1977), ICU mortality was 12% and 30-day mortality 19%. Seven phenotypes with distinct profiles of acute and geriatric characteristics were identified in that cohort. Phenotype-specific mortality within 30 days ranged from 3 to 57%. Among the patients assigned to a phenotype with pronounced geriatric features and high SOFA scores, 50% died in ICU and 57% within 30 days. Mortality differences between phenotypes were confirmed in the COVIP study cohort (n = 280). CONCLUSIONS Phenotyping of very old patients on admission to ICU revealed new phenotypes with different mortality and potential need for anticipatory intervention.
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Affiliation(s)
- Oded Mousai
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Lola Tafoureau
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Tamar Yovell
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Hans Flaatten
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Bertrand Guidet
- Assistance Publique-Hôpitaux de Paris, Hôpital Saint-Antoine, Service de Réanimation Médicale, Paris, France
| | - Christian Jung
- Department of Cardiology, Pulmonology and Vascular Medicine, Faculty of Medicine, Heinrich-Heine-University, Dusseldorf, Germany
| | - 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
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Jesper Fjolner
- Department of Anaesthesia and Intensive Care, Viborg Regional Hospital, Viborg, Denmark
| | - 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, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Michael Beil
- Department of Medical Intensive Care, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel
| | - Gal Hyams
- School of Computer Science and Engineering, The Hebrew University of Jerusalem, Givat Ram, Jerusalem, Israel
| | - Sigal Sviri
- Department of Medical Intensive Care, Faculty of Medicine, Hebrew University and Hadassah University Medical Center, Jerusalem, Israel.
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11
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Wernly B, Flaatten H, Beil M, Fjølner J, Bruno RR, Artigas A, Pinto BB, Schefold JC, Kelm M, Sigal S, van Heerden PV, Szczeklik W, Elhadi M, Joannidis M, Rezar R, Oeyen S, Wolff G, Marsh B, Andersen FH, Moreno R, Wernly S, Leaver S, Boumendil A, De Lange DW, Guidet B, Perings S, Jung C. A retrospective cohort study comparing differences in 30-day mortality among critically ill patients aged ≥ 70 years treated in European tax-based healthcare systems (THS) versus social health insurance systems. Sci Rep 2022; 12:17460. [PMID: 36261587 PMCID: PMC9580441 DOI: 10.1038/s41598-022-21580-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 09/29/2022] [Indexed: 01/12/2023] Open
Abstract
In Europe, tax-based healthcare systems (THS) and social health insurance systems (SHI) coexist. We examined differences in 30-day mortality among critically ill patients aged ≥ 70 years treated in intensive care units in a THS or SHI. Retrospective cohort study. 2406 (THS n = 886; SHI n = 1520) critically ill ≥ 70 years patients in 129 ICUs. Generalized estimation equations with robust standard errors were chosen to create population average adjusted odds ratios (aOR). Data were adjusted for patient-specific variables, organ support and health economic data. The primary outcome was 30-day-mortality. Numerical differences between SHI and THS in SOFA scores (6 ± 3 vs. 5 ± 3; p = 0.002) were observed, but clinical frailty scores were similar (> 4; 17% vs. 14%; p = 0.09). Higher rates of renal replacement therapy (18% vs. 11%; p < 0.001) were found in SHI (aOR 0.61 95%CI 0.40-0.92; p = 0.02). No differences regarding intubation rates (68% vs. 70%; p = 0.33), vasopressor use (67% vs. 67%; p = 0.90) and 30-day-mortality rates (47% vs. 50%; p = 0.16) were found. Mortality remained similar between both systems after multivariable adjustment and sensitivity analyses. The retrospective character of this study. Baseline risk and mortality rates were similar between SHI and THS. The type of health care system does not appear to have played a role in the intensive care treatment of critically ill patients ≥ 70 years with COVID-19 in Europe.
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Affiliation(s)
- Bernhard Wernly
- grid.21604.310000 0004 0523 5263Center for Public Health and Healthcare Research, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria ,grid.21604.310000 0004 0523 5263Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University Salzburg, 5020 Salzburg, Austria
| | - Hans Flaatten
- grid.7914.b0000 0004 1936 7443Department of Clinical Medicine, University of Bergen, Bergen, Norway ,grid.412008.f0000 0000 9753 1393Department of Anaestesia and Intensive Care, Haukeland University Hospital, 5021 Bergen, Norway
| | - Michael Beil
- grid.9619.70000 0004 1937 0538Deptartment of Medical Intensive Care, Faculty of Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, 91120 Jersualem, Israel
| | - Jesper Fjølner
- grid.416838.00000 0004 0646 9184Department of Anesthesia and Intensive Care, Viborg Regional Hospital, 8800 Viborg, Denmark
| | - Raphael Romano Bruno
- grid.411327.20000 0001 2176 9917Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Antonio Artigas
- grid.7080.f0000 0001 2296 0625Department of Intensive Care Medicine, CIBER Enfermedades Respiratorias, Corporacion Sanitaria Universitaria Parc Tauli, Autonomous University of Barcelona, 08208 Sabadell, Spain
| | - Bernardo Bollen Pinto
- grid.150338.c0000 0001 0721 9812Department of Acute Medicine, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Joerg C. Schefold
- grid.411656.10000 0004 0479 0855Department of Intensive Care Medicine, Inselspital, Universitätsspital, University of Bern, 3010 Bern, Switzerland
| | - Malte Kelm
- grid.411327.20000 0001 2176 9917Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Sviri Sigal
- grid.9619.70000 0004 1937 0538Deptartment of Medical Intensive Care, Faculty of Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, 91120 Jersualem, Israel
| | - Peter Vernon van Heerden
- grid.17788.310000 0001 2221 2926Deptartment of Anesthesia, Intensive Care and Pain Medicine, Faculty of Medicine, Hadassah Medical Center, Hebrew University of Jerusalem, 91120 Jerusalem, Israel
| | - Wojciech Szczeklik
- grid.5522.00000 0001 2162 9631Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, 31-008 Krakow, Poland
| | - Muhammed Elhadi
- grid.411306.10000 0000 8728 1538Faculty of Medicine, University of Tripoli, R6XF+46G, Tripoli, Libya
| | - Michael Joannidis
- grid.5361.10000 0000 8853 2677Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, 6020 Innsbruck, Austria
| | - Richard Rezar
- grid.21604.310000 0004 0523 5263Clinic of Internal Medicine II, Department of Cardiology and Intensive Care, Paracelsus Medical University of Salzburg, 5020 Salzburg, Austria
| | - Sandra Oeyen
- grid.410566.00000 0004 0626 3303Department of Intensive Care 1K12IC, Ghent University Hospital, 9000 Ghent, Belgium
| | - Georg Wolff
- grid.411327.20000 0001 2176 9917Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Brian Marsh
- grid.411596.e0000 0004 0488 8430Mater Misericordiae University Hospital, Dublin, D07 R2WY Ireland
| | - Finn H. Andersen
- grid.459807.7Department of Anaesthesia and Intensive Care, Ålesund Hospital, 6017 Ålesund, Norway ,grid.5947.f0000 0001 1516 2393Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, 7491 Trondheim, Norway
| | - Rui Moreno
- grid.418334.90000 0004 0625 3076Centro Hospitalar de Lisboa Central, Lisbon, Portugal ,grid.10772.330000000121511713Faculdade de Ciências Médicas de Lisboa, Nova Medical School, Lisbon, Portugal ,grid.7427.60000 0001 2220 7094Faculdade de Ciências da Saúde, Universidade da Beira Interior, Covilha, Portugal
| | - Sarah Wernly
- grid.21604.310000 0004 0523 5263Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University Salzburg, 5020 Salzburg, Austria
| | - Susannah Leaver
- grid.264200.20000 0000 8546 682XGeneral Intensive Care, St. George´s University Hospital NHS Foundation Trust, London, SW17 0QT UK
| | - Ariane Boumendil
- grid.412370.30000 0004 1937 1100Inserm, Service de réanimation, Institut Pierre-Louis d’épidémiologie et de Santé Publique, Hôpital Saint-Antoine, AP-HP, Sorbonne Université, 184, Rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Dylan W. De Lange
- grid.5477.10000000120346234Department of Intensive Care Medicine, University Medical Center, University Utrecht, 3584 CX Utrecht, The Netherlands
| | - Bertrand Guidet
- grid.412370.30000 0004 1937 1100Inserm, Service de réanimation, Institut Pierre-Louis d’épidémiologie et de Santé Publique, Hôpital Saint-Antoine, AP-HP, Sorbonne Université, 184, Rue du Faubourg-Saint-Antoine, 75012 Paris, France
| | - Stefan Perings
- grid.411327.20000 0001 2176 9917Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
| | - Christian Jung
- grid.411327.20000 0001 2176 9917Department of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, Heinrich-Heine-University Duesseldorf, Moorenstraße 5, 40225 Düsseldorf, Germany
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12
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Beil M, Flaatten H, Guidet B, Joskowicz L, Jung C, de Lange D, Leaver S, Fjølner J, Szczeklik W, Sviri S, van Heerden PV. Time-dependent uncertainty of critical care transitions in very old patients - lessons for time-limited trials. J Crit Care 2022; 71:154067. [DOI: 10.1016/j.jcrc.2022.154067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 05/10/2022] [Accepted: 05/12/2022] [Indexed: 11/17/2022]
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13
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Wernly B, Rezar R, Flaatten H, Beil M, Fjølner J, Bruno RR, Artigas A, Pinto BB, Schefold JC, Kelm M, Sigal S, van Heerden PV, Szczeklik W, Elhadi M, Joannidis M, Oeyen S, Wolff G, Marsh B, Andersen FH, Moreno R, Leaver S, Wernly S, Boumendil A, De Lange DW, Guidet B, Jung C. Variations in end-of-life care practices in older critically ill patients with COVID-19 in Europe. J Intern Med 2022; 292:438-449. [PMID: 35398948 PMCID: PMC9115222 DOI: 10.1111/joim.13492] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Previous studies reported regional differences in end-of-life care (EoLC) for critically ill patients in Europe. OBJECTIVES The purpose of this post-hoc analysis of the prospective multicentre COVIP study was to investigate variations in EoLC practices among older patients in intensive care units during the coronavirus disease 2019 pandemic. METHODS A total of 3105 critically ill patients aged 70 years and older were enrolled in this study (Central Europe: n = 1573; Northern Europe: n = 821; Southern Europe: n = 711). Generalised estimation equations were used to calculate adjusted odds ratios (aORs) to population averages. Data were adjusted for patient-specific variables (demographic, disease-specific) and health economic data (gross domestic product, health expenditure per capita). The primary outcome was any treatment limitation, and 90-day mortality was a secondary outcome. RESULTS The frequency of the primary endpoint (treatment limitation) was highest in Northern Europe (48%), intermediate in Central Europe (39%) and lowest in Southern Europe (24%). The likelihood for treatment limitations was lower in Southern than in Central Europe (aOR 0.39; 95% confidence interval [CI] 0.21-0.73; p = 0.004), even after multivariable adjustment, whereas no statistically significant differences were observed between Northern and Central Europe (aOR 0.57; 95%CI 0.27-1.22; p = 0.15). After multivariable adjustment, no statistically relevant mortality differences were found between Northern and Central Europe (aOR 1.29; 95%CI 0.80-2.09; p = 0.30) or between Southern and Central Europe (aOR 1.07; 95%CI 0.66-1.73; p = 0.78). CONCLUSION This study shows a north-to-south gradient in rates of treatment limitation in Europe, highlighting the heterogeneity of EoLC practices across countries. However, mortality rates were not affected by these results.
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Affiliation(s)
- Bernhard Wernly
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg, Austria.,Center for Public Health and Healthcare Research, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Richard Rezar
- Clinic of Internal Medicine II, Department of Cardiology and Intensive Care Medicine, Paracelsus Medical University, Salzburg, Austria
| | - Hans Flaatten
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
| | - Michael Beil
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Jesper Fjølner
- Department of Anesthesia and Intensive Care, Viborg Regional Hospital, Viborg, Denmark
| | - Raphael R Bruno
- Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Antonio Artigas
- Department of Intensive Care Medicine, CIBER Enfermedades Respiratorias, Corporacion Sanitaria Universitaria Parc Tauli, Autonomous University of Barcelona, Sabadell, Spain
| | - Bernardo B Pinto
- Department of Acute Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Joerg C Schefold
- Department of Intensive Care Medicine, Inselspital, Universitätsspital, University of Bern, Bern, Switzerland
| | - Malte Kelm
- Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Sviri Sigal
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Peter V van Heerden
- Department of Anesthesia, Intensive Care and Pain Medicine, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Krakow, Poland
| | | | - Michael Joannidis
- Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
| | - Sandra Oeyen
- Department of Intensive Care 1K12IC, Ghent University Hospital, Ghent, Belgium
| | - Georg Wolff
- Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | - Brian Marsh
- Department of Critical Care Medicine, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Finn H Andersen
- Department Of Anaesthesia and Intensive Care, Ålesund Hospital, Ålesund, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Rui Moreno
- Faculdade de Ciências Médicas de Lisboa, Nova Médical School, Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, FCSaude-Universidade da Beira Interior, Lisbon, Portugal
| | - Susannah Leaver
- General Intensive Care, St. George's University Hospital NHS Foundation Trust, London, UK
| | - Sarah Wernly
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg, Austria.,Center for Public Health and Healthcare Research, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Ariane Boumendil
- Inserm, Service de réanimation, Institut Pierre-Louis d'épidémiologie et de santé publique, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - Dylan W De Lange
- Department of Intensive Care Medicine, University Medical Center, University Utrecht, Utrecht, The Netherlands
| | - Bertrand Guidet
- Inserm, Service de réanimation, Institut Pierre-Louis d'épidémiologie et de santé publique, Hôpital Saint-Antoine, Sorbonne Université, Paris, France
| | - Christian Jung
- Medical Faculty, Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine University Düsseldorf, Düsseldorf, Germany
| | -
- Department of Internal Medicine, General Hospital Oberndorf, Teaching Hospital of the Paracelsus Medical University Salzburg, Salzburg, Austria
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14
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Hippocrates and prophecies: the unfulfilled promise of prediction rules. Can J Anaesth 2022; 69:289-292. [PMID: 35099773 PMCID: PMC8802535 DOI: 10.1007/s12630-021-02164-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 11/01/2021] [Accepted: 11/01/2021] [Indexed: 11/17/2022] Open
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15
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Downer K, Gustin J, Lincoln T, Goodman L, Barnett MD. Communicating About Time-Limited Trials. Chest 2022; 161:202-207. [PMID: 34499879 DOI: 10.1016/j.chest.2021.08.071] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/30/2021] [Accepted: 08/31/2021] [Indexed: 11/18/2022] Open
Abstract
Time-limited trials (TLTs) are used in the management of critical care patients undergoing potentially nonbeneficial interventions to improve prognostication and build trust and consensus between family and intensivists. When these trials are not well defined and executed, discordant views of the patient's prognosis, conflict, and continuation of nonbeneficial care can arise. The mnemonic TIME (truth about uncertainty in prognosis, interval of time, measurement of improvement, and end or extend) can help facilitate clear communication surrounding TLTs. This framework allows physicians and families to deal more effectively with the inherent uncertainty and required flexibility needed in caring for complex critical care patients. This can lead to patient-centered decision-making that improves patient-physician relationships and goal-concordant care and also potentially reduces nonbeneficial treatments at the end of life.
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Affiliation(s)
- Kendall Downer
- University of Alabama at Birmingham Medical Center, Birmingham, AL; UAB Center for Palliative & Supportive Care, University of Alabama at Birmingham Medical Center, Birmingham, AL
| | - Jillian Gustin
- Division of Palliative Medicine, Ohio State University Wexner Medical Center, Columbus, OH
| | | | - Lauren Goodman
- Division of Pulmonary, Critical Care and Sleep Medicine, Ohio State University Wexner Medical Center, Columbus, OH
| | - Michael D Barnett
- UAB Center for Palliative & Supportive Care, University of Alabama at Birmingham Medical Center, Birmingham, AL.
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16
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Beil M, Flaatten H, Guidet B, Sviri S, Jung C, de Lange D, Leaver S, Fjølner J, Szczeklik W, van Heerden PV. The management of multi-morbidity in elderly patients: Ready yet for precision medicine in intensive care? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:330. [PMID: 34507597 PMCID: PMC8431262 DOI: 10.1186/s13054-021-03750-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2021] [Accepted: 08/27/2021] [Indexed: 11/16/2022]
Abstract
There is ongoing demographic ageing and increasing longevity of the population, with previously devastating and often-fatal diseases now transformed into chronic conditions. This is turning multi-morbidity into a major challenge in the world of critical care. After many years of research and innovation, mainly in geriatric care, the concept of multi-morbidity now requires fine-tuning to support decision-making for patients along their whole trajectory in healthcare, including in the intensive care unit (ICU). This article will discuss current challenges and present approaches to adapt critical care services to the needs of these patients.
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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
| | - Hans Flaatten
- Department of Anaesthesia and Intensive Care Medicine, Haukeland University Hospital, Bergen, Norway
| | - Bertrand Guidet
- Service de Reanimation, Hopital Saint-Antoine, Paris, France
| | - 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 Duesseldorf, Duesseldorf, Germany
| | - Dylan de Lange
- Department of Intensive Care Medicine, University Medical Center, University of Utrecht, Utrecht, The Netherlands
| | - Susannah Leaver
- Department of Adult Critical Care, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Jesper Fjølner
- Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Peter Vernon van Heerden
- General Intensive Care Unit, Department of Anesthesiology, Critical Care and Pain Medicine, Hadassah Medical Center and Faculty of Medicine, Hadassah University Hospital, Hebrew University of Jerusalem, Jerusalem, Israel.
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17
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Bruno RR, Wernly B, Mamandipoor B, Rezar R, Binnebössel S, Baldia PH, Wolff G, Kelm M, Guidet B, De Lange DW, Dankl D, Koköfer A, Danninger T, Szczeklik W, Sigal S, van Heerden PV, Beil M, Fjølner J, Leaver S, Flaatten H, Osmani V, Jung C. ICU-Mortality in Old and Very Old Patients Suffering From Sepsis and Septic Shock. Front Med (Lausanne) 2021; 8:697884. [PMID: 34307423 PMCID: PMC8299710 DOI: 10.3389/fmed.2021.697884] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/11/2021] [Indexed: 01/09/2023] Open
Abstract
Purpose: Old (>64 years) and very old (>79 years) intensive care patients with sepsis have a high mortality. In the very old, the value of critical care has been questioned. We aimed to compare the mortality, rates of organ support, and the length of stay in old vs. very old patients with sepsis and septic shock in intensive care. Methods: This analysis included 9,385 patients, from the multi-center eICU Collaborative Research Database, with sepsis; 6184 were old (aged 65–79 years), and 3,201 were very old patients (aged 80 years and older). A multi-level logistic regression analysis was used to fit three sequential regression models for the binary primary outcome of ICU mortality. A sensitivity analysis in septic shock patients (n = 1054) was also conducted. Results: In the very old patients, the median length of stay was shorter (50 ± 67 vs. 56 ± 72 h; p < 0.001), and the rate of a prolonged ICU stay was lower (>168 h; 9 vs. 12%; p < 0.001) than the old patients. The mortality from sepsis was higher in very old patients (13 vs. 11%; p = 0.005), and after multi-variable adjustment being very old was associated with higher odds for ICU mortality (aOR 1.32, 95% CI 1.09–1.59; p = 0.004). In patients with septic shock, mortality was also higher in the very old patients (38 vs. 36%; aOR 1.50, 95% CI 1.10–2.06; p = 0.01). Conclusion: Very old ICU-patients suffer from a slightly higher ICU mortality compared with old ICU-patients. However, despite the statistically significant differences in mortality, the clinical relevance of such minor differences seems to be negligible.
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Affiliation(s)
- Raphael Romano Bruno
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Bernhard Wernly
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University of Salzburg, Salzburg, Austria.,Center for Public Health and Healthcare Research, Paracelsus Medical University of Salzburg, Salzburg, Austria.,Department of Cardiology, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | | | - Richard Rezar
- Center for Public Health and Healthcare Research, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Stephan Binnebössel
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Philipp Heinrich Baldia
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Georg Wolff
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Malte Kelm
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
| | - Bertrand Guidet
- Hôpitaux de Paris, Hôpital Saint-Antoine, Service de Réanimation Médicale, Paris, France.,Sorbonne Universités, UPMC Univ Paris 06, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France.,INSERM, UMR_S 1136, Institut Pierre Louis d'Epidémiologie et de Santé Publique, Paris, France
| | - Dylan W De Lange
- Department of Intensive Care Medicine, University Medical Center, University Utrecht, Utrecht, Netherlands
| | - Daniel Dankl
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Andreas Koköfer
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Thomas Danninger
- Department of Anesthesiology, Perioperative Medicine and Intensive Care Medicine, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Wojciech Szczeklik
- Intensive Care and Perioperative Medicine Division, Jagiellonian University Medical College, Kraków, Poland
| | - Sviri Sigal
- Medical Intensive Care Unit, Hadassah University Hospital, Jerusalem, Israel
| | | | - Michael Beil
- Medical Intensive Care Unit, Hadassah University Hospital, Jerusalem, Israel
| | - Jesper Fjølner
- Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Susannah Leaver
- Research Lead Critical Care Directorate St George's Hospital, London, United Kingdom
| | - Hans Flaatten
- Department of Intensive Care, Anesthesia and Surgical Services, Haukeland University Hospital Bergen, Bergen, Norway
| | - Venet Osmani
- Fondazione Bruno Kessler Research Institute, Trento, Italy
| | - Christian Jung
- Division of Cardiology, Pulmonology and Vascular Medicine, Medical Faculty, University Hospital Düsseldorf, Heinrich-Heine-University Düsseldorf, Düsseldorf, Germany
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18
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Beil M, van Heerden PV, Sviri S, Flaatten H. Comment on: Rethinking ICU readmission and timelimited trial in the contingency capacity. J Crit Care 2021; 68:173. [PMID: 33579614 PMCID: PMC8902838 DOI: 10.1016/j.jcrc.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Accepted: 12/24/2020] [Indexed: 11/16/2022]
Affiliation(s)
- Michael Beil
- Medical Intensive Care Unit, Hadassah University Hospital, Jerusalem, Israel
| | | | - Sigal Sviri
- Medical Intensive Care Unit, Hadassah University Hospital, Jerusalem, Israel
| | - Hans Flaatten
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway
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van Heerden PV, Beil M, Guidet B, Sviri S, Jung C, de Lange D, Leaver S, Fjølner J, Szczeklik W, Flaatten H. A new multi-national network studying Very old Intensive care Patients (VIPs). Anaesthesiol Intensive Ther 2021; 53:290-295. [PMID: 35257561 PMCID: PMC10158490 DOI: 10.5114/ait.2021.108084] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Accepted: 07/15/2021] [Indexed: 09/13/2023] Open
Abstract
In Europe there are increasing numbers of old (more than 65 years old) and very old (more than 80 years old) patients (very old intensive care patients - VIPs) (Figure 1). In addition to combinations of chronic conditions (multi-morbidity), there are geriatric disabilities and functional limitations, with a profound impact on management in the ICU and afterwards [1].
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Affiliation(s)
- Peter V. van Heerden
- Department of Anesthesiology, Intensive Care and Pain Medicine, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Michael Beil
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Bertrand Guidet
- Service de Reanimation, Hopital Saint-Antoine, Paris, France
| | - Sigal Sviri
- Department of Medical Intensive Care, Hadassah Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Christian Jung
- Department of Cardiology, Pulmonology and Vascular Medicine, Faculty of Medicine, Heinrich-Heine-University Duesseldorf, Duesseldorf, Germany
| | - Dylan de Lange
- Department of Intensive Care Medicine, University Medical Center, University of Utrecht, Utrecht, The Netherlands
| | - Susannah Leaver
- Department of Adult Critical Care, St. George’s University Hospitals NHS Foundation Trust, London, United Kingdom
| | - Jesper Fjølner
- Department of Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Wojciech Szczeklik
- Center for Intensive Care and Perioperative Medicine, Jagiellonian University Medical College, Kraków, Poland
| | - Hans Flaatten
- Department of Anaesthesia and Intensive Care Medicine, Haukeland University Hospital, Bergen, Norway
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