Critically ill geriatrics. Marianne Kirrane Staff Specialist Intensive Care Royal Brisbane & Women s Hospital

Transcription

1 Critically ill geriatrics Marianne Kirrane Staff Specialist Intensive Care Royal Brisbane & Women s Hospital

2 A typical conundrum at F Nancy Alert and orientated Symptoms + signs consistent with UTI Investigations consistent with UTI PMH = myelodysplasia Assistance with heavy housework but SBP dipping to 90 despite fluid (MAP ~60)

3 Dilemma To give vasopressors or not to give vasopressors but this entails: Admission to ICU Continuous blood pressure monitoring Arterial line Central access

4 Images borrowed from BASIC lecture Basic haemodynamic monitoring.

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6 What is old? >65 >70 >80 >85 >90

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9 In Australia, a dying person will have: 8 hospital admissions in the last year 2 ED visits A 60 70% chance of dying in hospital

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11 >=80

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18 2017

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20 Usually described as Frailty a clinical state of increased vulnerability to poor resolution of homoeostasis after a stressor event which increases the risk of adverse outcomes, including falls, delirium, and disability

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26 For frail patients = 5 or more on Clinical Frailty Scale No difference in ICU LoS or mortality Hospital Mortality 33% vs 23% Discharge to NH 33% vs 12% 12m Mortality 55% vs 35%

27 Nancy 92F Alert and orientated Symptoms + signs consistent with UTI Investigations consistent with UTI PMH = myelodysplasia Assistance with heavy housework but SBP dipping to 90 despite fluid (MAP ~60)

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29 Benefit vs risk My approach = What will the overall cost to her be? Will she need an intervention? If she needs an intervention, how long for? What will her outcome be at ICU discharge? What will her outcome be at hospital discharge? What will her outcome be at 6 months? What will her outcome be at 12 months?

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31 So I ask what they want from this healthcare episode and what they would accept

32 Yes Would I admit her? only if she wants it knowing the quality of life impact longer-term only for a rapidly reversible condition eg urosepsis PNEUMONIA TRAUMA MALIGNANCY COMPLICATIONS PERITONITIS BURNS AFTER A #NOF AFTER ELECTIVE SURGERY

33 State variations This conversation is crucial. A rushed conversation and decision the do you want us to do everything talk is very hard to undo.

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35 References Nguyen Y-L, Angus DC, Boumendil A, Guidet B. The challenge of admitting the very elderly to intensive care. Annals of Intensive Care. 2011;1:29. doi: / Rosenwax LK, McNamara BA, Murray K et al. Hospital and emergency department use in the last year of life: a baseline for future modifications to end-of-life care. Med J Aust 2011;194(11): Hoffman KR, Loong B, van Haren F. Very old patients urgently referred to the intensive care unit: Long-term outcomes for admitted and declined patients. CCR 2016;18(3): Kramer AA, Zimmerman JE. Institutional variations in frequency of discharge of elderly intensive care survivors to postacute care facilities. CCM 2010;38(12): doi: /CCM.0b013e3181fa02e4 Heyland DK, Garland A, Bagshaw SM, et al. Recovery after critical illness in patients aged 80 years or older: a multi-center prospective observational cohort study. Intensive Care Med 2015;41(11): doi: /s Moitra VK, Guerra C, Linde-Zwirble WT, et al. Relationship Between ICU Length of Stay and Long-Term Mortality for Elderly ICU Survivors. CCM 2016;44(4): doi: /CCM Biston P, Aldecoa C, Devriendt J, et al. Outcome of elderly patients with circulatory failure. Intensive Care Med. 2014;40(1):50-6. doi: /s

36 References (2) Heyland D, Cook D, Bagshaw SM, et al. The Very Elderly Admitted to ICU: A Quality Finish? Crit Care Med Jul;43(7): doi: /CCM Guidet B, Leblanc G, Simon T, et al. Effect of Systematic Intensive Care Unit Triage on Long-term Mortality Among Critically Ill Elderly Patients in France A Randomized Clinical Trial. JAMA. 2017;318(15): doi: /jama Angus DC. Admitting Elderly Patients to the Intensive Care Unit Is it the Right Decision?. JAMA. 2017;318(15): doi: /jama Catharine R. Gale, Cyrus Cooper, Avan Aihie Sayer; Prevalence of frailty and disability: findings from the English Longitudinal Study of Ageing, Age and Ageing, Volume 44, Issue 1, 1 January 2015, Pages , Flaatten, H., De Lange, D.W., Morandi, A. et al. The impact of frailty on ICU and 30-day mortality and the level of care in very elderly patients ( 80 years) Intensive Care Med (2017) 43: