Darvall Jai N, Bellomo Rinaldo, Paul Eldho, Bailey Michael, Young Paul J, Reid Alice, Rockwood Kenneth, Pilcher David
Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia; Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia.
Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia; Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia; Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, VIC, Australia; Data Analytics Research & Evaluation Centre, The University of Melbourne and Austin Hospital, Melbourne, VIC, Australia.
Chest. 2021 Oct;160(4):1292-1303. doi: 10.1016/j.chest.2021.05.049. Epub 2021 Jun 4.
Frailty is associated with poor outcomes in critical illness. However, it is unclear whether frailty screening on admission to the ICU can be conducted routinely at the population level and whether it has prognostic importance.
Can population-scale frailty screening with the Clinical Frailty Scale (CFS) be implemented for critically ill adults in Australia and New Zealand (ANZ) and can it identify patients at risk of negative outcomes?
We conducted a binational prospective cohort study of critically ill adult patients admitted between July 1, 2018, and June 30, 2020, in 175 ICUs in ANZ. We classified frailty with the CFS on admission to the ICU. The primary outcome was in-hospital mortality; secondary outcomes were length of stay (LOS), discharge destination, complications (delirium, pressure injury), and duration of survival.
We included 234,568 critically ill patients; 45,245 (19%) were diagnosed as living with frailty before ICU admission. Patients with vs without frailty had higher in-hospital mortality (16% vs 5%; P < .001), delirium (10% vs 4%; P < .001), longer LOS in the ICU and hospital, and increased new chronic care discharge (3% vs 1%; P < .001), with worse outcomes associated with increasing CFS category. Of patients with very severe frailty (CFS score, 8), 39% died in hospital vs 2% of very fit patients (CFS score, 1; multivariate categorical CFS score, 8 [reference, 1]; OR, 7.83 [95% CI, 6.39-9.59]; P < .001). After adjustment for illness severity, frailty remained highly significantly predictive of mortality, including among patients younger than 50 years, with improvement in the area under the receiver operating characteristic curve of the Acute Physiology and Chronic Health Evaluation III-j score to 0.882 (95% CI, 0.879-0.885) from 0.868 (95% CI, 0.866-0.871) with the addition of frailty (P < .001).
Large-scale population screening for frailty degree in critical illness was possible and prognostically important, with greater frailty (especially CFS score of ≥ 6) associated with worse outcomes, including among younger patients.
衰弱与危重症患者的不良预后相关。然而，目前尚不清楚在重症监护病房（ICU）入院时进行衰弱筛查是否可以在人群层面常规开展，以及其是否具有预后意义。
澳大利亚和新西兰（ANZ）的成年危重症患者能否采用临床衰弱量表（CFS）进行人群规模的衰弱筛查，以及该筛查能否识别出有不良结局风险的患者？
我们对2018年7月1日至2020年6月30日期间在ANZ的175个ICU收治的成年危重症患者进行了一项跨两国的前瞻性队列研究。在患者入住ICU时，我们使用CFS对其衰弱程度进行分类。主要结局是院内死亡率；次要结局包括住院时间（LOS）、出院去向、并发症（谵妄、压疮）以及生存时长。
我们纳入了234,568例危重症患者；其中45,245例（19%）在入住ICU前被诊断为衰弱。与非衰弱患者相比，衰弱患者的院内死亡率更高（16%对5%；P <.001）、谵妄发生率更高（10%对4%；P <.001）、在ICU和医院的住院时间更长，且新出现的慢性护理出院情况增加（3%对1%；P <.001），CFS类别越高，结局越差。在非常严重衰弱（CFS评分8分）的患者中，39%在医院死亡，而身体状况非常良好（CFS评分1分）的患者中这一比例为2%（多变量分类CFS评分，8[参考值，1]；比值比，7.83[95%置信区间，6.39 - 9.59]；P <.001）。在对疾病严重程度进行调整后，衰弱仍然是死亡率的高度显著预测因素，包括在50岁以下的患者中，急性生理与慢性健康状况评估III-j评分的受试者工作特征曲线下面积从0.868（95%置信区间，0.866 - 0.871）提高到0.882（95%置信区间，0.879 - 0.885），加入衰弱因素后差异有统计学意义（P <.001）。
在危重症中进行大规模人群衰弱程度筛查是可行的且具有预后意义，衰弱程度越高（尤其是CFS评分≥6分），结局越差，包括年轻患者。
