Thread by @gretchemaben

My last tweetucation session for #ATS2022 😢😢😢 will be “Current Controversies in Geriatric Critical Care”!

First up we have Dr. Sean Morrison with “Does Advance Care Planning Have Any Effect on Reducing High-Intensity Care?” #ATS2022

Hint: It does not.

He spent years studying advance care planning (ACP). #ATS2022

His most recent paper showed that ACP does not lead to less life sustaining treatment. #ATS2022

The goal of ACP is to ensure goal concord at care near the end of life. #ATS2022

What does ACP include? #ATS2022

Why is ACP so attractive? There’s a ton of support and encouragement to do it. #ATS2022

We also have more data on ACP than we know what to do with! #ATS2022

There is evidence that we can accomplish these things. #ATS2022

We have NOT shown that ACP does these things. #ATS2022

So why does ACP persist and why is it so controversial? #ATS2022

What is the harm in doing ACP? #ATS2022

What are the alternatives to ACP? #ATS2022

Next we have Dr. Ramona Hopkins with “Should Prognostication in the ICU Be Based on Age, Disability, and Frailty?” #ATS2022

Making predictions is hard. This meta-analysis showed a huge range of mortality and substantial heterogeneity in outcome. #ATS2022

A systematic review of frailty found that it was associated with higher mortality, but there was a lot of heterogeneity in patients and their outcomes. #ATS2022

Looking at longer outcomes post-COVID-19 there are a wide range of outcomes. #ATS2022

A lot of these symptoms persist over time. #ATS2022

This paper tried to identify factors within COVID patients and compared them to patients with sepsis. #ATS2022

#Quote #ATS2022

There is not a ton of difference in cognitive impairment across different age groups. #ATS2022

This study looked at young healthy patients with COVID and they found impaired concentration and memory were common. #ATS2022

COVID-19 associated psychosis #ATS2022

These are other challenges to using functional outcome data to make predictions.
#ATS2022

Conclusions #ATS2022

Next up is Dr. Thanh Neville (@thanh_neville) with “Should Admission to the ICU Be Conditional on a Time-Limited Trial?” #ATS2022

State of critical care #ATS2022

What is a time-limited trial? #ATS2022

Why should we use time-limited trials in the ICU? #ATS2022

Framework for a time-limited trial
#ATS2022

This study looked at time-limited trials as the default framework for family meetings. #ATS2022

Now let’s walk through the steps involved in the framework. First you define the patient’s acute care needs and prognosis. #ATS2022

Clarify the patient’s goals, values, and preferences. #ATS2022

Identify objective markers for improvement or deterioration. #ATS2022

Identify a time-frame for reevaluation of the patient’s condition. #ATS2022

Define potential actions to take at the end of the trial based on potential outcomes. #ATS2022

So why use a TLT framework for all patients? #ATS2022

Next we have “Is It Ethical and Legal to Include Age in Triage Protocols During a Pabdemic?” with Dr. Douglas White! #ATS2022

This study looked at variation in ventilator allocation guidelines by US state. #ATS2022

Example of PA’s framework. #ATS2022

What does age have to do with it? #ATS2022

The two main goals in creating crisis standards of care. #ATS2022

These theories apply to the concept of whether age should factor into these equations. #ATS2022

The goal is to show equal respect for everyone. #ATS2022

Dying young is a severe form of disadvantage because they have the least chance to flourish and carry out their life plans. #ATS2022

So that was the ethical viewpoint. But is it legal to consider age in triage? #ATS2022

What are the public views of this?
#ATS2022

Objections to considering age in triage protocols. #ATS2022

Conclusions! #ATS2022

And our last speaker of the day will be Dr. Bram Rochwerg (@Bram_Rochwerg) with “Do Older Adults Respond Differently to ICU Interventions?” #ATS2022

ICU demographics are shifting
#ATS2022

So do the interventions that we use in younger adults also work in order adults? There are very few trials looking at this. #ATS2022

There is a difference between having a different baseline risk versus subgroup effect modification. In the first the intervention works the same in the groups (there is just differing risks), and in the 2nd the intervention works differently between the groups. #ATS2022

This systematic review looked at subgroup effects. #ATS2022

There are different criteria to judge whether subgroup effects are trustworthy or not. #ATS2022

What did they find? Only 4 trials found an effect modification by age. #ATS2022

HYBERNATUS looked at vented patients in status epilepticus with an intervention of hypothermia. #ATS2022

TRICS looked at transfusion goals in CV surgery patients. Older patients did better with the restrictive strategy (liberal was better for younger patients). #ATS2022

SPICE III looked at vented patients and evaluated Precedex as the primary sedative. Older patients seemed to do better with Precedex. #ATS2022

COACT looks at OHCA without ST elevation with an intervention of immediate vs delayed angiography. Older patients seemed to do better with early angiography. #ATS2022

So do interventions work in older adults? Yes! Don’t use their age as a rationale for withholding interventions if they otherwise would want the intervention. #ATS2022

Where do we go from here? #ATS2022