Frailty is associated with long-term outcome in patients with sepsis who are over 80 years old: results from an observational study in 241 European ICUs

BACKGROUND

Sepsis is one of the most frequent reasons for acute intensive care unit (ICU) admission of very old patients and mortality rates are high. However, the impact of pre-existing physical and cognitive function on long-term outcome of ICU patients ≥ 80 years old (very old intensive care patients (VIPs)) with sepsis is unclear.

OBJECTIVE

To investigate both the short- and long-term mortality of VIPs admitted with sepsis and assess the relation of mortality with pre-existing physical and cognitive function.

DESIGN

Prospective cohort study.

SETTING

241 ICUs from 22 European countries in a six-month period between May 2018 and May 2019.

SUBJECTS

Acutely admitted ICU patients aged ≥80 years with sequential organ failure assessment (SOFA) score ≥ 2.

METHODS

Sepsis was defined according to the sepsis 3.0 criteria. Patients with sepsis as an admission diagnosis were compared with other acutely admitted patients. In addition to patients' characteristics, disease severity, information about comorbidity and polypharmacy and pre-existing physical and cognitive function were collected.

RESULTS

Out of 3,596 acutely admitted VIPs with SOFA score ≥ 2, a group of 532 patients with sepsis were compared to other admissions. Predictors for 6-month mortality were age (per 5 years): Hazard ratio (HR, 1.16 (95% confidence interval (CI), 1.09-1.25, P < 0.0001), SOFA (per one-point): HR, 1.16 (95% CI, 1.14-1.17, P < 0.0001) and frailty (CFS > 4): HR, 1.34 (95% CI, 1.18-1.51, P < 0.0001).

CONCLUSIONS

There is substantial long-term mortality in VIPs admitted with sepsis. Frailty, age and disease severity were identified as predictors of long-term mortality in VIPs admitted with sepsis.

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial

IMPORTANCE

Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited.

OBJECTIVE

To determine whether hydrocortisone improves outcome for patients with severe COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020.

INTERVENTIONS

The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108).

MAIN OUTCOMES AND MEASURES

The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%).

RESULTS

After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively.

CONCLUSIONS AND RELEVANCE

Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02735707.

Effect of Hydrocortisone on Mortality and Organ Support in Patients With Severe COVID-19: The REMAP-CAP COVID-19 Corticosteroid Domain Randomized Clinical Trial

IMPORTANCE

Evidence regarding corticosteroid use for severe coronavirus disease 2019 (COVID-19) is limited.

OBJECTIVE

To determine whether hydrocortisone improves outcome for patients with severe COVID-19.

DESIGN, SETTING, AND PARTICIPANTS

An ongoing adaptive platform trial testing multiple interventions within multiple therapeutic domains, for example, antiviral agents, corticosteroids, or immunoglobulin. Between March 9 and June 17, 2020, 614 adult patients with suspected or confirmed COVID-19 were enrolled and randomized within at least 1 domain following admission to an intensive care unit (ICU) for respiratory or cardiovascular organ support at 121 sites in 8 countries. Of these, 403 were randomized to open-label interventions within the corticosteroid domain. The domain was halted after results from another trial were released. Follow-up ended August 12, 2020.

INTERVENTIONS

The corticosteroid domain randomized participants to a fixed 7-day course of intravenous hydrocortisone (50 mg or 100 mg every 6 hours) (n = 143), a shock-dependent course (50 mg every 6 hours when shock was clinically evident) (n = 152), or no hydrocortisone (n = 108).

MAIN OUTCOMES AND MEASURES

The primary end point was organ support-free days (days alive and free of ICU-based respiratory or cardiovascular support) within 21 days, where patients who died were assigned -1 day. The primary analysis was a bayesian cumulative logistic model that included all patients enrolled with severe COVID-19, adjusting for age, sex, site, region, time, assignment to interventions within other domains, and domain and intervention eligibility. Superiority was defined as the posterior probability of an odds ratio greater than 1 (threshold for trial conclusion of superiority >99%).

RESULTS

After excluding 19 participants who withdrew consent, there were 384 patients (mean age, 60 years; 29% female) randomized to the fixed-dose (n = 137), shock-dependent (n = 146), and no (n = 101) hydrocortisone groups; 379 (99%) completed the study and were included in the analysis. The mean age for the 3 groups ranged between 59.5 and 60.4 years; most patients were male (range, 70.6%-71.5%); mean body mass index ranged between 29.7 and 30.9; and patients receiving mechanical ventilation ranged between 50.0% and 63.5%. For the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively, the median organ support-free days were 0 (IQR, -1 to 15), 0 (IQR, -1 to 13), and 0 (-1 to 11) days (composed of 30%, 26%, and 33% mortality rates and 11.5, 9.5, and 6 median organ support-free days among survivors). The median adjusted odds ratio and bayesian probability of superiority were 1.43 (95% credible interval, 0.91-2.27) and 93% for fixed-dose hydrocortisone, respectively, and were 1.22 (95% credible interval, 0.76-1.94) and 80% for shock-dependent hydrocortisone compared with no hydrocortisone. Serious adverse events were reported in 4 (3%), 5 (3%), and 1 (1%) patients in the fixed-dose, shock-dependent, and no hydrocortisone groups, respectively.

CONCLUSIONS AND RELEVANCE

Among patients with severe COVID-19, treatment with a 7-day fixed-dose course of hydrocortisone or shock-dependent dosing of hydrocortisone, compared with no hydrocortisone, resulted in 93% and 80% probabilities of superiority with regard to the odds of improvement in organ support-free days within 21 days. However, the trial was stopped early and no treatment strategy met prespecified criteria for statistical superiority, precluding definitive conclusions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02735707.

Have we enough glutamine and how does it work? A clinician's view

There is a gap between the scientific basis of the claim that in several disease states glutamine is lacking and the widespread belief that supplementation of glutamine to the nutritional regimen is beneficial in severely ill patients. Glutamine shortage exists when consuming tissues, playing a crucial role in the response to trauma and disease, receive insufficient amounts of glutamine. In these tissues (immune system, wound), glutamine is only partly oxidized but has more specific roles as nontoxic nitrogen carrier, precursor of several crucial metabolites required for cell proliferation and for maintenance of the redox potential, and as osmolyte. In inflammatory states, glutamine concentrations in plasma and tissues are decreased due to many disease-related factors, precluding its use as a reliable indicator of shortage. Isotope studies have yielded equivocal results, precluding their use as a reliable indicator of glutamine shortage or adequacy. The increase in the net release of glutamine from peripheral tissues to central tissues (immune system, liver, spleen, wound) in inflammatory states provides a better basis for the necessity to supplement the organism with extra glutamine in these conditions. Glutamine supplementation was beneficial in a few studies in burn or trauma patients. The clinical benefit of parenteral glutamine supplementation in patients with severe inflammation has been demonstrated more convincingly. The amounts of glutamine supplemented approximate the amounts released by peripheral tissues and utilized by central organs operative in host defense and are therefore in the physiological range.

How nutritional risk is assessed and managed in European hospitals: a survey of 21,007 patients findings from the 2007-2008 cross-sectional nutritionDay survey

BACKGROUND & AIMS

Recognition and treatment of undernutrition in hospitalized patients are not often a priority in clinical practice.

OBJECTIVES

We investigated how the nutritional risk of patients is determined and whether such assessment influences daily nutritional care across Europe and in Israeli hospitals.

METHODS

1217 units from 325 hospitals in 25 countries with 21,007 patients participated in a longitudinal survey "nutritionDay" 2007/2008 undertaken in Europe and Israel. Screening practice, the type of tools used and whether energy requirements and intake are assessed and monitored were surveyed using standardized questionnaires.

RESULTS

Fifty-two percent (range 21-73%) of the units in the different regions reported a screening routine which was most often performed with locally developed methods and less often with national tools, the Nutrition Risk Screening-2002, or the Malnutrition Universal Screening Tool. Twenty-seven percent of the patients were subjectively classified as being "at nutritional risk", with substantial differences existing between regions. Independent factors influencing the classification of nutritional risk included age, BMI <18.5 kg/m(2), unintentional weight loss, reduced food intake in the previous week and on nutritionDay (for all parameters, p < 0.0001). The energy goal was defined as >=1500 kcal in 76% of the patients, but 43% of patients did not reach this goal.

CONCLUSIONS

The process of nutrition risk assessment varied between units and countries. Additionally, energy goals were frequently not met. More effort is needed to implement current guidelines within daily clinical practice.

[Multimodal analgesia in elective laparoscopic cholecystectomy. A double-blind randomized controlled trial]

BACKGROUND

The aim of this study was to test the effects of preincisional parietal and intraperitoneal infiltration with ropivacaine (R) on postoperative pain after elective laparoscopic cholecystectomy.

METHODS

60 patients scheduled for laparoscopic cholecystectomy performed by the same surgeon were enrolled in a randomized, controlled double-blind trial. All patients received the same general anesthesia protocol and Ig i.v. paracetamol was infused after induction of anesthesia for postoperative analgesia, repeated postoperatively each 6 hours, up to 4 g/ 24 h. After induction of anesthesia, the patients were randomized in 4 groups (15 patients each): group A received preincisional parietal infiltration of 20 ml normal saline (NS) solution and 20 ml R0, 25% intraperitoneal instillation; group B, 20 ml R0, 0.25% preincisional parietal and 20 ml NS intraperitoneal; group C, 20 ml R0, 25% preincisional parietal and 20 ml R0, 25% intraperitoneal; group D (control), 20 ml NS preincisional local and 20 ml NS intraperitoneal. Tramadol was used as a rescue analgesic Primary end points: were postoperative pain at Oh, 2h, 6h, 12h, 24h on visual analogue scale (VAS 0-100 mm) score and rescue analgesic requirements.

RESULTS

We found no differences in demographics, length of surgery time and hospital stay (total 3.38 +/- 0.22 days). VAS was significantly lower at all intervals in groups C versus D and at Oh, 6h and 12 h in group C versus group A and B (p < 0.05). We found no influence on shoulder pain. Tramadol doses required were significantly lower in group C vs. D (0,73 +/- 1.10 vs 1,93 +/- 1.03, p = 0.017).

CONCLUSION

Ropivacaine shows significant favorable effects on postoperative pain after laparoscopic cholecystectomy when using both parietal and intraperitoneal instillation in combination with perioperative i.v. paracetamol.

[Disease-related malnutrition and its influence on perioperative outcome]

Disease-related malnutrition is highly prevalent among surgical patients and has important deleterious effects on postoperative outcome: increased complications rate, length of hospital stay, mortality and costs. Malnutrition (equivalent with undernutrition in the surgical patients) can be present already on admission, could rapidly develop or aggravate during hospital stay. The determination of malnutrition in this high-risk group of patients in multifactorial: decreased intake (anorexia, gastrointestinal symptoms, prolonged perioperative fasting) and increased demands (hyper-catabolism due to underlying disease, surgical stress, eventual postoperative complications). The identification of patients at nutritional risk by screening on admission and whenever the patient situation changes throughout hospitalization is the first, mandatory step for developing an accurate nutritional care plan in these patients, in order to positively influence postoperative outcome.

[Needle catheter jejunostomy versus "Witzel" tube jejunostomy for early postoperative enteral nutrition in surgical patients. Prospective randomized study]

Malnutrition in surgical patients can be present since their admission into hospital or can appear in the postoperative period. Early postoperative enteral nutrition (EPEN) is recommended to these patients as often as possible. In cases where the patients are severely malnourished with major digestive surgical interventions which we estimate that will be unable to feed orally efficient minimum 7-10 days postoperatively, we recommend EPEN on jejunostomy. Prospective randomized evaluation of 37 patients (75.6% severely malnourished): 19 with needle catheter jejunostomy (NCJ), group A, respectively 18 with standard "Witzel" tube jejunostomy (STJ), group B. 22 patients presented malignant tumors and 15 serious benign problems. On 7 patients the jejunostomy was done at the reoperation. Postoperative major complications were observed on 54.05% of the patients (independent of the jejunostomy) and the postoperative mortality rate was of 13.33% on the patients that had jejunostomy and EPEN on their first operation, and 57.14 respectively on the patients where jejunostomy was done at the reoperation. The two groups were similar with respect to age, sex, length of EPEN and hospital stay, presence of malnutrition, complications and mortality. Postoperative complications were statistically more frequent in anemic patients (68.8%) respectively anemic and severely malnourished (76.47). Minor complication related to the jejunostomy occurred in 5.6% of the group A and 22.2% of the group B. NCJ was done rapidly the same as STJ (7 min vs. 15 min). In conclusion, EPEN on jejunostomy on surgically malnourished patients, who have suffered major superior digestive interventions is beneficial. Postoperative complications have been more frequent on anemic and severely malnourished. NCJ is easier to perform and safer.

[Laparoscopic jejunostomy in malnourished surgical patients: indications and technique]

Laparoscopic jejunostomy (LJ) represents a new way of enteral nutrition (EN) for surgical malnourished patients. LJ is an alternative form of therapy, with restricted indications to the few cases when classical way for EN (nosogastroenteral tube feeding, PEG/PEJ, surgical gastrostomy), are contraindicated or can not be used, and the patient is unable to eat. This technique is also preferred to the open surgical jejunostomy. The paper describes our LJ technique, indications and contraindications. We used JL in two surgical severely malnourished patients, within 11 and 14 days, before the elective, open, curative operations. In this period the patients where exclusively nourished with special feeding solutions through the LJ catheter. The main pathologic lesions were: extrinsec antral obstruction from a perforated transverse colon carcinoma in the omental pouch, in the first case, and proximal inflammatory stenosis of efferent loop, after gastric resection with Billroth II anastomosis for duodenal ulcer, in the second case. LJ gives the opportunity for the exploration of the whole abdominal cavity, and for the direct imaging of the pathological lesions. With EN being delivered before the open, elective operations, we get an amelioration of serum albumin values, and we have no morbidity related to the LJ or open, curative operation. EN was administrated after open surgery in the same way, and in the first case, during chemotherapy. LJ is an efficient, miniinvasive way for EN, in selected surgical severe malnourished patients with proximal digestive obstructions, especially oncologic ones, the aim being an amelioration of the nutritional status and a reduction of postoperative morbidity. A continuous study on a larger number of cases is imperative necessary.