Association of Frailty, Organ Support, and Long-Term Survival in Critically Ill Patients With COVID-19

Leandro Utino Taniguchi; Thiago Junqueira Avelino-Silva; Murilo Bacchini Dias; Wilson Jacob-Filho; Márlon Juliano Romero Aliberti

doi:10.1097/CCE.0000000000000712

Association of Frailty, Organ Support, and Long-Term Survival in Critically Ill Patients With COVID-19

Crit Care Explor. 2022 May 25;4(6):e0712. doi: 10.1097/CCE.0000000000000712. eCollection 2022 Jun.

Authors

Leandro Utino Taniguchi^{1

2

3}, Thiago Junqueira Avelino-Silva^{4

5}, Murilo Bacchini Dias⁴, Wilson Jacob-Filho⁴, Márlon Juliano Romero Aliberti^{2

4}

Affiliations

¹ Emergency Medicine Discipline, Medical Department, Hospital das Clinicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
² Intensive care medicine department, Hospital Sirio LIbanes, São Paulo, Brazil.
³ Brazilian Research in Intensive Care Network (BRICNet), São Paulo, Brazil.
⁴ Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Serviço de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
⁵ Faculdade Israelita de Ciencias da Saude Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, Brazil.

Abstract

Few studies have explored the effect of frailty on the long-term survival of COVID-19 patients after ICU admission. Furthermore, the Clinical Frailty Scale (CFS) validity in critical care patients remains debated. We investigated the association between frailty and 6-month survival in critically ill COVID-19 patients. We also explored whether ICU resource utilization varied according to frailty status and examined the concurrent validity of the CFS in this setting.

Design: Ancillary study of a longitudinal prospective cohort.

Setting: University hospital in São Paulo.

Patients: Patients with severe COVID-19 admitted to ICU.

Interventions: None.

Measurements and main results: We assessed baseline frailty using the CFS (1-9; frail ≥ 5) and used validated procedures to compute a Frailty Index (0-1; frail > 0.25). We used Cox models to estimate associations of frailty status with 6-month survival after ICU admission and area under the receiver operating characteristic curves (AUCs) to estimate CFS's accuracy in identifying frailty according to Frailty Index. We included 1,028 patients (mean age, 66 yr; male, 61%). Overall, 224 (22%) patients were frail (CFS ≥ 5), and 608 (59%) died over the 6-month follow-up. Frailty was independently associated with lower 6-month survival and further stratified mortality in patients with similar age and Sequential Organ Failure Assessment scores. We additionally verified that the CFS was highly accurate in identifying frailty as defined by the Frailty Index (AUC, 0.91; 95% CI, 0.89-0.93). Although treatment modalities did not diverge according to frailty status, higher CFS scores were associated with withholding organ support due to refractory organ failure.

Conclusions: One in five COVID-19 patients admitted to the ICU was frail. CFS scores greater than or equal to 5 were associated with lower long-term survival and decisions on withholding further escalation of invasive support for multiple organ failure in the ICU. Clinicians should consider frailty alongside sociodemographic and clinical measures to have a fuller picture of COVID-19 prognosis in critical care.

Keywords: COVID-19; frailty; intensive care; mortality; prognosis.