Authors: Maurizia Capuzzo Maité GarrousteOrgeas Ignacio MartinLoeches
Publish Date: 2016/10/31
Volume: 43, Issue: 1, Pages: 104-106
Abstract
Mortality which is the most robust outcome in critically ill patients depends on risk factors such as comorbid conditions age and severity of the acute illness Whilst these risk factors are widely accepted in severity scores for predicting hospital mortality there is a lack of information about the baseline performance status PS of the patients when being admitted to the intensive care unit ICU To allow an adequate clinical decisionmaking process and further discussion with patients or relatives accurate prognostication of a patient’s outcome seems to be mandatory however difficult and emotionally charged the task is for the physicianZampieri et al in an article recently published in Intensive Care Medicine add some insight into the value of PS in the outcome 6 This is a secondary analysis of a multicentre retrospective cohort study of 59693 patients admitted to 78 Brazilian ICUs in 2013 7 The authors 6 aimed to evaluate the impact of PS assessed by the Eastern Cooperative Oncology Group ECOG scale on the hospital mortality of 59693 ICU patients PS impairment was absent/minor in 758 moderate in 173 and severe in 69 of the patients Increasing PS impairment was associated with an increase of mortality according to severity of illness comorbidities age and admission type The logistic regression analysis showed that PS was independently associated with hospital mortality Adding the PS assessment to the calculated SAPS3 score slightly improved the discrimination with small changes in Bier score and without visual impact on the SAPS3 calibration curve This may happen because the shortterm prognosis after intensive care is most likely the result of the interplay between illness severity baseline patient characteristics comorbidities PS and the quality of care As Zampieri et al 6 pointed out “the full picture of a patient’s chronic health status” is not entirely captured by variables commonly included in illness severity score such as age and major comorbidities Interestingly another recent study 8 found that duration of ICU stay prior to death in critically ill patients was longer in older patients but comorbidities did not represent a significant risk factor for the length of stay prior to death This has important implications in current clinical practice and suggests using a PS index or a frailty index instead of only comorbidities when discussing futility of support careCredit must be given to the authors who measured a variable that intensivists generally include in the clinical evaluation but do not quantify The large population involved and the robust statistical analyses are the major strengths of the study This complex analysis included the imputation of the few missing values 58 There are also some weaknesses The assessment of PS referred to 1 week before hospital admission We cannot exclude that for some patients the poor PS in the week before hospital admission could be related to the clinical deterioration due to the illness responsible for the hospital and ICU admission Therefore the full picture of chronic health status or frailty in the study patients may be overrepresented as correctly stated by the authors One concern from the study lies in the use of only three categories to classify PS impairment with a grading system that comprised absent/minor ECOG 01 moderate ECOG 2 or severe ECOG 34 However the three categories seem to allow for the increase of PS impairment in the groups because odds ratio for adjusted hospital mortality was 196 95 CI 163–235 for moderate and 422 95 CI 332–535 for severe impairment However we need to verify the generalizability of the results in countries with national health systems Although on the basis of its current gross national income Brazil is an “upper middle income” country most of the study patients 92 were from private hospitals 6 We cannot exclude that intensivists working in private hospitals may be more willing to accept patients with poor PS in ICU when requested by ward physicians or families Conversely ICUs in public hospitals may not admit some patients with very poor PS as a result of resource constraints The patient severity of illness SAPS3 430 ± 149 was similar to that reported in Spain 4629 ± 1434 9 but lower than in Italy 658 ± 171 10 and the percentage of mechanically ventilated patients was low 19 A weakness of the study 6 is the lack of report of endoflife decision practices This aspect needs to be considered for future clinical implementation of PSCharacterization of the PS on ICU admission will become an immediate need in the near future for the whole ICU population Since intensivists have more and more accessible and complex technologies to provide life support performance status information will improve the clinical decisionmaking process for the entire ICU population Nevertheless several questions must be debated before integrating PS in severity tools or in our daily ICU admission process Which measure can we use What time period before hospital admission do we have to consider Who must report the PS Future studies should address these questions
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