101
|
Huang CT, Chuang YC, Tsai YJ, Ko WJ, Yu CJ. High Mortality in Severe Sepsis and Septic Shock Patients with Do-Not-Resuscitate Orders in East Asia. PLoS One 2016; 11:e0159501. [PMID: 27416064 PMCID: PMC4944975 DOI: 10.1371/journal.pone.0159501] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2016] [Accepted: 07/05/2016] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Severe sepsis is a potentially deadly illness and always requires intensive care. Do-not-resuscitate (DNR) orders remain a debated issue in critical care and limited data exist about its impact on care of septic patients, particularly in East Asia. We sought to assess outcome of severe sepsis patients with regard to DNR status in Taiwan. METHODS A retrospective cohort study was conducted in intensive care units (ICUs) between 2008 and 2010. All severe sepsis patients were included for analysis. Primary outcome was association between DNR orders and ICU mortality. Volume of interventions was used as proxy indicator to indicate aggressiveness of care. RESULTS Sixty-seven (9.4%) of 712 patients had DNR orders on ICU admission, and these patients were older and had higher disease severity compared with patients without DNR orders. Notably, DNR patients experienced high ICU mortality (90%). Multivariate analysis revealed that the presence of DNR orders was independently associated with ICU mortality (odds ratio: 6.13; 95% confidence interval: 2.66-14.10). In propensity score-matched cohort, ICU mortality rate (91%) in the DNR group was statistically higher than that (62%) in the non-DNR group (p <0.001). Regarding ICU interventions, arterial and central venous catheterization were more commonly used in DNR patients than in non-DNR patients. CONCLUSIONS From the Asian perspective, septic patients placed on DNR orders on ICU admission had exceptionally high mortality. In contrast to Western reports, DNR patients received more ICU interventions, reflecting more aggressive approach to dealing with this patient population. The findings in some ways reflect differences between East and West cultures and suggest that DNR status is an important confounder in ICU studies involving severely septic patients.
Collapse
Affiliation(s)
- Chun-Ta Huang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
- Department of Traumatology, National Taiwan University Hospital, Taipei, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
- * E-mail:
| | - Yu-Chung Chuang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yi-Ju Tsai
- Graduate Institute of Biomedical and Pharmaceutical Science, College of Medicine, Fu Jen Catholic University, New Taipei City, Taiwan
| | - Wen-Je Ko
- Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Chong-Jen Yu
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| |
Collapse
|
102
|
Palliative Care Utilization in Nontraumatic Intracerebral Hemorrhage in the United States. Crit Care Med 2016; 44:575-82. [PMID: 26496450 DOI: 10.1097/ccm.0000000000001391] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Palliative care is now recognized as an essential component of comprehensive care in serious illness that interferes with quality of life. We explored utilization of palliative care in spontaneous intracerebral hemorrhage at a population level using a large national database. DESIGN Population based cross-sectional study. SETTING Inpatient hospital admissions from the Nationwide Inpatient Sample. PATIENTS A total of 311,217 patients with intracerebral hemorrhage. INTERVENTIONS Palliative care use. MEASUREMENTS AND MAIN RESULTS Intracerebral hemorrhage patients with and without palliative care were identified from the 2007-2011 Nationwide Inpatient Sample using International Classification of Diseases, 9th Revision, codes. Demographics, comorbidities, surgical procedures, and hospital characteristics were compared between patients receiving and not receiving palliative care (code V66.7). Resource utilization measures were inflation-adjusted cost of care and length of stay. Pearson chi square and Wilcoxon-Mann-Whitney tests were used for categorical and continuous variables respectively. Logistic regression was used to construct a predictive model of palliative care. Of the 311,217 intracerebral hemorrhage patients, 32,159 (10.3%) received palliative care. Utilization of palliative care increased from 4.3% in 2007 to 16.2% in 2011 (trend p < 0.001). Patients receiving palliative care had higher Charlson comorbidity scores (p < 0.001), higher all-patient refined diagnosis-related group mortality risk (p < 0.001), and lower resource utilization measures compared with those without palliative care. Independent predictors of palliative care use were older age (odds ratio, 4.06; 95% CI, 3.87-4.23; p < 0.001), female sex (odds ratio, 1.17; 95% CI, 1.14-1.20; p < 0.001), Caucasian race (p < 0.001), Medicare insurance (p < 0.001), hospitals in the west and mid-west (p < 0.001), hospital transfer (odds ratio, 1.23; 95% CI, 1.18-1.30; p < 0.001), high intracerebral hemorrhage case volume (p < 0.001), anticoagulant use (odds ratio, 1.24; 95% CI, 1.19-1.31; p < 0.001), higher Charlson comorbidity score, ventriculostomy placement (odds ratio, 1.18; 95% CI, 1.13-1.29; p < 0.001), and mechanical ventilation (odds ratio, 1.44; 95% CI, 1.39-1.49; p < 0.001). Cerebral angiogram, craniotomy, and gastrostomy were independently associated with absence of palliative care use. CONCLUSIONS An apparent increasing trend of palliative care utilization in intracerebral hemorrhage has occurred over the last decade. After clinical severity adjustment, gender and racial differences and hospital characteristics appear to influence palliative care use among intracerebral hemorrhage patients in the United States.
Collapse
|
103
|
Hiraoka E, Homma Y, Norisue Y, Naito T, Kataoka Y, Hamada O, Den Y, Takahashi O, Fujitani S. What is the true definition of a "Do-Not-Resuscitate" order? A Japanese perspective. Int J Gen Med 2016; 9:213-20. [PMID: 27418851 PMCID: PMC4935165 DOI: 10.2147/ijgm.s105302] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background Japan has no official guidelines for do-not-resuscitate (DNR) orders. Therefore, we investigated the effect of DNR orders on physician decision making in relation to performing noncardiopulmonary resuscitation (CPR) and CPR procedures. Methods A case-scenario-based questionnaire that included a case of advanced cancer, a case of advanced dementia, and a case of nonadvanced heart failure was administered to physicians. The questions determined whether physicians would perform different non-CPR procedures and CPR procedures in the presence or absence of DNR orders. The number of non-CPR procedures each physician would perform and the number of physicians who would perform each non-CPR and CPR procedure in the absence and presence of DNR ocrders were compared. Physicians from three Japanese municipal acute care hospitals participated. Results We analyzed 111 of 161 (69%) questionnaires. Physicians would perform significantly fewer non-CPR procedures in the presence of DNR orders than in the absence of DNR orders for all three case scenarios (median [interquartile range] percentages: Case 1: 72% [45%–90%] vs 100% [90%–100%]; Case 2: 55% [36%–72%] vs 91% [63%–100%]; Case 3: 78% [55%–88%] vs 100% [88%–100%]). Fewer physicians would perform non-CPR and CPR procedures in the presence of DNR orders than in the absence of DNR orders. However, considerable numbers of physicians would perform electric shock treatment for ventricular fibrillation in the presence of DNR orders (Case 1: 26%; Case 2: 16%; Case 3: 20%). Conclusion DNR orders affect physician decision making about performing non-CPR procedures. Although some physicians would perform CPR for ventricular fibrillation in the presence of DNR orders, others would not. Therefore, a consensus definition for DNR orders should be developed in Japan, otherwise DNR orders may cause harm.
Collapse
Affiliation(s)
| | | | - Yasuhiro Norisue
- Department of Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | | | | | | | - Yo Den
- Department of Internal Medicine
| | - Osamu Takahashi
- Department of Internal Medicine, St Luke's International Hospital, Tokyo, Japan
| | - Shigeki Fujitani
- Department of Critical Care Medicine, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| |
Collapse
|
104
|
Abstract
After decades of relative neglect, the past few years have been particularly eventful for clinical research into spontaneous intracerebral hemorrhage (ICH). Most importantly, we have seen completion of the first large randomized trial of surgical clot evacuation for supratentorial ICH, and also the first trial to demonstrate the efficacy of systemic recombinant factor 7 to stop parenchymal bleeding and prevent clinical worsening. Other important advances include new insights into risk factors, diagnostic imaging, pathophysiology of cellular injury, brain edema and blood flow, blood pressure management, aspiration of parenchymal and intraventricular clots; stem cell therapy, and outcome. Taken together, the impressive scope and progress of ongoing clinical and basic research demonstrate that there is no longer a place for nihilism in the approach to ICH.
Collapse
|
105
|
Muehlschlegel S, Shutter L, Col N, Goldberg R. Decision Aids and Shared Decision-Making in Neurocritical Care: An Unmet Need in Our NeuroICUs. Neurocrit Care 2016; 23:127-30. [PMID: 25561435 DOI: 10.1007/s12028-014-0097-2] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Improved resuscitation methods and advances in critical care have significantly increased the survival of patients presenting with devastating brain injuries compared to prior decades. After the patient's stabilization phase, families and patients are faced with "goals-of-care" decisions about continuation of aggressive intensive care unit care or comfort care only (CMO). Highly varying rates of CMO between centers raise the question of "self-fulfilling prophecies." Disease severity, the physician's communication and the family's understanding of projected outcomes, their uncertainties, complication risks with continued care, physician bias, and the patient's and surrogate's wishes and values all influence a CMO decision. Disease-specific decision support interventions, decision aids (DAs), may remedy these issues in the neurocritical care unit, potentially leading to better-informed and less-biased goals-of-care decisions in neurocritically ill patients, while increasing decision knowledge, confidence, and realistic expectations and decreasing decisional conflict and regret. Shared decision-making (SDM) is a collaborative process that enhances patients' and proxies' understanding about prognosis, encourages them to actively weigh the risks and benefits of a treatment, and considers the patient's preferences and values to make better decisions. DAs are SDM tools, which have been successfully implemented for many other conditions to assist difficult decision-making. In this article, we summarize the purposes of SDM, the derivation of DAs, and their potential application in neurocritical care.
Collapse
Affiliation(s)
- Susanne Muehlschlegel
- Departments of Neurology (Neurocritical Care), Anesthesia/Critical Care and Surgery, University of Massachusetts Medical School, 55 Lake Ave. North, S5, Worcester, MA, 01655, USA,
| | | | | | | |
Collapse
|
106
|
Manara AR, Thomas I, Harding R. A case for stopping the early withdrawal of life sustaining therapies in patients with devastating brain injuries. J Intensive Care Soc 2016; 17:295-301. [PMID: 28979514 DOI: 10.1177/1751143716647980] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Early prognostication in patients with a devastating brain injury is not always accurate and can lead to inappropriate decisions. We present case histories to support the recent recommendations of the Neurocritical Care Society that treatment withdrawal decisions should be delayed by up to 72 h in these patients. Development of pathways incorporating these recommendations can improve prognostication, enhance end of life care given to these patients and their families, and increase the opportunities to explore the donation wishes of more patients. They may also standardise the approach to decision making in the same way as the recommendations for management of patients after out of hospital cardiac arrest have done.
Collapse
Affiliation(s)
| | | | - Richard Harding
- Wye Valley NHS Trust, Hereford, UK.,University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| |
Collapse
|
107
|
Zahuranec DB, Fagerlin A, Sánchez BN, Roney ME, Thompson BB, Fuhrel-Forbis A, Morgenstern LB. Variability in physician prognosis and recommendations after intracerebral hemorrhage. Neurology 2016; 86:1864-71. [PMID: 27164665 DOI: 10.1212/wnl.0000000000002676] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 01/14/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To assess physician prognosis and treatment recommendations for intracerebral hemorrhage (ICH) and to determine the effect of providing physicians a validated prognostic score. METHODS A written survey with 2 ICH scenarios was completed by practicing neurologists and neurosurgeons. Selected factors were randomly varied (patient older vs middle age, Glasgow Coma Scale [GCS] score 7T vs 11, and presence vs absence of a validated prognostic score). Outcomes included predicted 30-day mortality and recommendations for initial treatment intensity (6-point scale ranging from 1 = comfort only to 6 = full treatment). RESULTS A total of 742 physicians were included (mean age 52, 32% neurosurgeons, 17% female). Physician predictions of 30-day mortality varied widely (mean [range] for the 4 possible combinations of age and GCS were 23% [0%-80%], 35% [0%-100%], 48% [0%-100%], and 58% [5%-100%]). Treatment recommendations also varied widely, with responses encompassing the full range of response options for each case. No physician demographic or personality characteristics were associated with treatment recommendations. Providing a prognostic score changed treatment recommendations, and the effect differed across cases. When the prognostic score suggested 0% chance of functional independence (76-year-old with GCS 7T), the likelihood of treatment limitations was increased (odds ratio [OR] 1.61, 95% confidence interval [CI] 1.12-2.33) compared to no prognostic score. Conversely, if the score suggested a 66% chance of independence (63-year-old with GCS 11), treatment limitations were less likely (OR 0.62, 95% CI 0.43-0.88). CONCLUSIONS Physicians vary substantially in ICH prognostic estimates and treatment recommendations. This variability could have a profound effect on life and death decision-making and treatment for ICH.
Collapse
Affiliation(s)
- Darin B Zahuranec
- From the Stroke Program, Department of Neurology (D.B.Z., L.B.M.), Center for Bioethics and Social Sciences in Medicine (D.B.Z., A.F., M.E.R., A.F.-F.), Department of Internal Medicine (A.F.), and Department of Emergency Medicine (L.B.M.), University of Michigan Medical School, Ann Arbor; VA Ann Arbor Center for Clinical Management Research (A.F.); Departments of Biostatistics (B.N.S.) and Epidemiology (L.B.M.), University of Michigan School of Public Health, Ann Arbor; and Departments of Neurology and Neurosurgery (B.B.T.), Alpert Medical School at Brown University, Providence, RI.
| | - Angela Fagerlin
- From the Stroke Program, Department of Neurology (D.B.Z., L.B.M.), Center for Bioethics and Social Sciences in Medicine (D.B.Z., A.F., M.E.R., A.F.-F.), Department of Internal Medicine (A.F.), and Department of Emergency Medicine (L.B.M.), University of Michigan Medical School, Ann Arbor; VA Ann Arbor Center for Clinical Management Research (A.F.); Departments of Biostatistics (B.N.S.) and Epidemiology (L.B.M.), University of Michigan School of Public Health, Ann Arbor; and Departments of Neurology and Neurosurgery (B.B.T.), Alpert Medical School at Brown University, Providence, RI
| | - Brisa N Sánchez
- From the Stroke Program, Department of Neurology (D.B.Z., L.B.M.), Center for Bioethics and Social Sciences in Medicine (D.B.Z., A.F., M.E.R., A.F.-F.), Department of Internal Medicine (A.F.), and Department of Emergency Medicine (L.B.M.), University of Michigan Medical School, Ann Arbor; VA Ann Arbor Center for Clinical Management Research (A.F.); Departments of Biostatistics (B.N.S.) and Epidemiology (L.B.M.), University of Michigan School of Public Health, Ann Arbor; and Departments of Neurology and Neurosurgery (B.B.T.), Alpert Medical School at Brown University, Providence, RI
| | - Meghan E Roney
- From the Stroke Program, Department of Neurology (D.B.Z., L.B.M.), Center for Bioethics and Social Sciences in Medicine (D.B.Z., A.F., M.E.R., A.F.-F.), Department of Internal Medicine (A.F.), and Department of Emergency Medicine (L.B.M.), University of Michigan Medical School, Ann Arbor; VA Ann Arbor Center for Clinical Management Research (A.F.); Departments of Biostatistics (B.N.S.) and Epidemiology (L.B.M.), University of Michigan School of Public Health, Ann Arbor; and Departments of Neurology and Neurosurgery (B.B.T.), Alpert Medical School at Brown University, Providence, RI
| | - Bradford B Thompson
- From the Stroke Program, Department of Neurology (D.B.Z., L.B.M.), Center for Bioethics and Social Sciences in Medicine (D.B.Z., A.F., M.E.R., A.F.-F.), Department of Internal Medicine (A.F.), and Department of Emergency Medicine (L.B.M.), University of Michigan Medical School, Ann Arbor; VA Ann Arbor Center for Clinical Management Research (A.F.); Departments of Biostatistics (B.N.S.) and Epidemiology (L.B.M.), University of Michigan School of Public Health, Ann Arbor; and Departments of Neurology and Neurosurgery (B.B.T.), Alpert Medical School at Brown University, Providence, RI
| | - Andrea Fuhrel-Forbis
- From the Stroke Program, Department of Neurology (D.B.Z., L.B.M.), Center for Bioethics and Social Sciences in Medicine (D.B.Z., A.F., M.E.R., A.F.-F.), Department of Internal Medicine (A.F.), and Department of Emergency Medicine (L.B.M.), University of Michigan Medical School, Ann Arbor; VA Ann Arbor Center for Clinical Management Research (A.F.); Departments of Biostatistics (B.N.S.) and Epidemiology (L.B.M.), University of Michigan School of Public Health, Ann Arbor; and Departments of Neurology and Neurosurgery (B.B.T.), Alpert Medical School at Brown University, Providence, RI
| | - Lewis B Morgenstern
- From the Stroke Program, Department of Neurology (D.B.Z., L.B.M.), Center for Bioethics and Social Sciences in Medicine (D.B.Z., A.F., M.E.R., A.F.-F.), Department of Internal Medicine (A.F.), and Department of Emergency Medicine (L.B.M.), University of Michigan Medical School, Ann Arbor; VA Ann Arbor Center for Clinical Management Research (A.F.); Departments of Biostatistics (B.N.S.) and Epidemiology (L.B.M.), University of Michigan School of Public Health, Ann Arbor; and Departments of Neurology and Neurosurgery (B.B.T.), Alpert Medical School at Brown University, Providence, RI
| |
Collapse
|
108
|
Alonso A, Ebert AD, Dörr D, Buchheidt D, Hennerici MG, Szabo K. End-of-life decisions in acute stroke patients: an observational cohort study. BMC Palliat Care 2016; 15:38. [PMID: 27044257 PMCID: PMC4820928 DOI: 10.1186/s12904-016-0113-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 03/23/2016] [Indexed: 11/11/2022] Open
Abstract
Background Crucial issues of modern stroke care include best practice end-of-life-decision (EOLD)-making procedures and the provision of high-quality palliative care for dying stroke patients. Methods We retrospectively analyzed records of those patients who died over a 4-year period (2011–2014) on our Stroke Unit concerning EOLD, focusing on the factors that most probably guided decisions to induce limitation of life-sustaining therapy and subsequently end-of-life-care procedures thereafter. Results Of all patients treated at our Stroke Unit, 120 (2.71 %) died. In 101 (86.3 %), a do-not-resuscitate-order (DNRO) was made during early treatment. A decision to withdraw/withhold further life supportive therapy was made in 40 patients (34.2 %) after a mean of 5.0 days (range 0–29). Overall patient death occurred after a mean time of 7.0 days (range 1–30) and 2.6 days after therapy restrictions. Disturbance of consciousness at presentation, dysphagia on day 1 and large supratentorial stroke were possible indicators of decisions to therapeutic withdrawing/withholding. Proceedings of EOL care in these patients were heterogeneous; in most cases monitoring (95 %), medical procedures (90 %), oral medication (88 %), parenteral nutrition (98 %) and antibiotic therapy (86 %) were either not ordered or withdrawn, however IV fluids were continued in all patients. Conclusions A high percentage of stroke patients were rated as terminally ill and died in the course of caregiving. Disturbance of consciousness at presentation, dysphagia on day 1 and large supratentorial stroke facilitated decisions to change therapeutic goals thus initiating end-of-life-care. However, there is further need to foster research on this field in order to ameliorate outcome prognostication, to understand the dynamics of EOLD-making procedures and to educate staff to provide high-quality patient-centred palliative care in stroke medicine. Electronic supplementary material The online version of this article (doi:10.1186/s12904-016-0113-8) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Angelika Alonso
- Department of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg, 68167, Mannheim, Germany.
| | - Anne D Ebert
- Department of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg, 68167, Mannheim, Germany
| | - Dorothee Dörr
- Health Care Ethics Committee, UniversitätsMedizin Mannheim, University of Heidelberg, 68167, Mannheim, Germany
| | - Dieter Buchheidt
- Department of Hematology and Oncology, UniversitätsMedizin Mannheim, University of Heidelberg, 68167, Mannheim, Germany
| | - Michael G Hennerici
- Department of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg, 68167, Mannheim, Germany
| | - Kristina Szabo
- Department of Neurology, UniversitätsMedizin Mannheim, University of Heidelberg, 68167, Mannheim, Germany
| |
Collapse
|
109
|
Further deliberating the relationship between do-not-resuscitate and the increased risk of death. Sci Rep 2016; 6:23182. [PMID: 26987301 PMCID: PMC4796796 DOI: 10.1038/srep23182] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2015] [Accepted: 02/25/2016] [Indexed: 12/21/2022] Open
Abstract
Few studies have examined the outcome of do-not-resuscitate (DNR) patients in surgical intensive care units (SICUs). This study deliberated the association between a DNR decision and the increased risk of death methodologically and ethically. This study was conducted in three SICUs. We collected patients’ demographic characteristics, clinical characteristics, and the status of death/survival at SICU and hospital discharge. We used Kaplan–Meier survival curves to compare the time from SICU admission to the end of SICU stay for the DNR and non-DNR patients. Differences in the Kaplan-Meier curves were tested using log-rank tests. We also conducted a Cox proportional hazards model to account for the effect of a DNR decision on mortality. We found that having a DNR order was associated with an increased risk of death during the SICU stay (aRR = 2.39, p < 0.01) after adjusting for severity of illness upon SICU admission and other confounding variables. To make the conclusion that a DNR order is causally related to an increased risk of death, or that a DNR order increases the risk of death is absolutely questionable. By clarifying this key point, we expect that the discussion of DNR between healthcare professionals and patients/surrogate decision-makers will not be hampered or delayed.
Collapse
|
110
|
|
111
|
Faigle R, Marsh EB, Llinas RH, Urrutia VC, Gottesman RF. ICAT: a simple score predicting critical care needs after thrombolysis in stroke patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2016; 20:26. [PMID: 26818069 PMCID: PMC4730614 DOI: 10.1186/s13054-016-1195-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 01/15/2016] [Indexed: 12/20/2022]
Abstract
Background Patients receiving intravenous thrombolysis (IVT) for acute ischemic stroke are at risk of developing complications, commonly necessitating admission to an intensive care unit (ICU). At present, most IVT is administered in the Emergency Department or in dedicated stroke units, but no evidence-based criteria exist that allow for early identification of patients at increased risk of developing ICU needs. The present study describes a novel prediction score aiming to identify a subpopulation of post-IVT patients at high risk for critical care interventions. Methods We retrospectively analyzed data from 301 patients undergoing IVT at our institutions during a 5-year period. Two hundred and ninety patients met inclusion criteria. The sample was randomly divided into a development and a validation cohort. Logistic regression was used to develop a risk score by weighting predictors of critical care needs based on strength of association. Results Seventy-two patients (24.8 %) required critical care interventions. Black race (odds ratio [OR] 3.81, p =0.006), male sex (OR 3.79, p =0.008), systolic blood pressure (SBP; OR 1.45 per 10 mm Hg increase in SBP, p <0.001), and NIH stroke scale (NIHSS; OR 1.09 per 1 point increase in NIHSS, p =0.071) were independent predictors of critical care needs. The optimal model for score development, predicting critical care needs, achieved an AUC of 0.782 in the validation group. The score was named the ICAT (Intensive Care After Thrombolysis) score, assigning the following points: black race (1 point), male sex (1 point), SBP (2 points if 160–200 mm Hg; 4 points if >200 mm Hg), and NIHSS (1 point if 7–12; 2 points if >12). Each 1-point increase in the score was associated with 2.22-fold increased odds for critical care needs (95 % CI 1.78–2.76, p <0.001). A score ≥2 was associated with over 13 times higher odds of critical care needs compared to a score <2 (OR 13.60, 95 % CI 3.23–57.19), predicting critical care with 97.2 % sensitivity and 28.0 % specificity. Conclusion The ICAT score, combining information about race, sex, SBP, and NIHSS, predicts critical care needs in post-IVT patients and may be helpful when triaging post-IVT patients to the appropriate monitoring environment. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1195-7) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Roland Faigle
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 484, Baltimore, MD, 21287, USA.
| | - Elisabeth B Marsh
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 484, Baltimore, MD, 21287, USA
| | - Rafael H Llinas
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 484, Baltimore, MD, 21287, USA
| | - Victor C Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 484, Baltimore, MD, 21287, USA
| | - Rebecca F Gottesman
- Department of Neurology, Johns Hopkins University School of Medicine, 600 N Wolfe Street, Phipps 484, Baltimore, MD, 21287, USA
| |
Collapse
|
112
|
Parry-Jones AR, Paley L, Bray BD, Hoffman AM, James M, Cloud GC, Tyrrell PJ, Rudd AG. Care-limiting decisions in acute stroke and association with survival: analyses of UK national quality register data. Int J Stroke 2016; 11:321-31. [DOI: 10.1177/1747493015620806] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 11/08/2015] [Indexed: 12/21/2022]
Abstract
Background Prognosis after intracerebral hemorrhage (ICH) is poor and care-limiting decisions may worsen outcomes. Aims To determine whether in current UK stroke practice, key acute care decisions are associated with stroke subtype (ICH/ischemic) and whether these decisions are independently associated with survival. Methods We extracted data describing all stroke patients included in a UK quality register between 1 April 2013 and 31 March 2014. Key care decisions in our analyses were transfer to higher level care on admission and palliation in the first 72 h. We used multivariable regression models to test for associations between stroke subtype (ICH/ischemic), key care decisions, and survival. Results A total of 65,818 patients were included in the final analysis. After ICH ( n = 7020/65,818, 10.7%), 10.5% were palliated on the day of admission and 19.3% by 72 h (vs. 0.7% and 3.3% for ischemic stroke). Although a greater proportion were admitted directly to higher level care after ICH (3.7% vs. 1.5% for ischemic stroke), ICH was not independently associated with the decision to admit to higher level care (adjusted odds ratio (OR): 1.12, 95% confidence interval (95%CI): 0.95–1.31, p = 0.183). However, ICH was strongly associated with the decision to commence palliative care on the day of admission (OR: 7.27, 95%CI: 6.31–8.37, p < 0.001). Palliative care was independently associated with risk of death by 30 days regardless of stroke subtype. Conclusions When compared to ischemic stroke, patients with ICH are much more likely to commence palliative care during the first 72 h of their care, independent of level of consciousness, age, and premorbid health.
Collapse
Affiliation(s)
- Adrian R Parry-Jones
- Manchester Academic Health Sciences Centre, Salford Royal NHS Foundation Trust, UK
| | | | - Benjamin D Bray
- Division of Health and Social Care Research, Kings College London, UK
| | | | | | | | - Pippa J Tyrrell
- Manchester Academic Health Sciences Centre, Salford Royal NHS Foundation Trust, UK
| | - Anthony G Rudd
- Royal College of Physicians, London, UK
- Division of Health and Social Care Research, Kings College London, UK
- Guy’s and St Thomas’ NHS Foundation Trust, UK
| | | |
Collapse
|
113
|
Zahuranec DB, Morgenstern LB. Medical Therapy of Intracerebral and Intraventricular Hemorrhage. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00057-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
114
|
Hwang DY, Dell CA, Sparks MJ, Watson TD, Langefeld CD, Comeau ME, Rosand J, Battey TWK, Koch S, Perez ML, James ML, McFarlin J, Osborne JL, Woo D, Kittner SJ, Sheth KN. Clinician judgment vs formal scales for predicting intracerebral hemorrhage outcomes. Neurology 2015; 86:126-33. [PMID: 26674335 DOI: 10.1212/wnl.0000000000002266] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2015] [Accepted: 09/03/2015] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To compare the performance of formal prognostic instruments vs subjective clinical judgment with regards to predicting functional outcome in patients with spontaneous intracerebral hemorrhage (ICH). METHODS This prospective observational study enrolled 121 ICH patients hospitalized at 5 US tertiary care centers. Within 24 hours of each patient's admission to the hospital, one physician and one nurse on each patient's clinical team were each asked to predict the patient's modified Rankin Scale (mRS) score at 3 months and to indicate whether he or she would recommend comfort measures. The admission ICH score and FUNC score, 2 prognostic scales selected for their common use in neurologic practice, were calculated for each patient. Spearman rank correlation coefficients (r) with respect to patients' actual 3-month mRS for the physician and nursing predictions were compared against the same correlation coefficients for the ICH score and FUNC score. RESULTS The absolute value of the correlation coefficient for physician predictions with respect to actual outcome (0.75) was higher than that of either the ICH score (0.62, p = 0.057) or the FUNC score (0.56, p = 0.01). The nursing predictions of outcome (r = 0.72) also trended towards an accuracy advantage over the ICH score (p = 0.09) and FUNC score (p = 0.03). In an analysis that excluded patients for whom comfort care was recommended, the 65 available attending physician predictions retained greater accuracy (r = 0.73) than either the ICH score (r = 0.50, p = 0.02) or the FUNC score (r = 0.42, p = 0.004). CONCLUSIONS Early subjective clinical judgment of physicians correlates more closely with 3-month outcome after ICH than prognostic scales.
Collapse
Affiliation(s)
- David Y Hwang
- From the Division of Neurocritical Care and Emergency Neurology (D.Y.H., K.N.S.), Department of Neurology, Yale School of Medicine, New Haven, CT; the Maryland Stroke Center (C.A.D., M.J.S., T.D.W.), Baltimore; the Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L., M.E.C.), Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC; the Center for Human Genetic Research (J.R., T.W.K.B.), Boston, MA; the University of Miami (S.K., M.L.P.), Miller School of Medicine, FL; Duke University Medical Center (M.L.J., J.M.), Durham, NC; the Department of Neurology (J.L.O., D.W.), University of Cincinnati College of Medicine, OH; and the Baltimore Veterans Administration Medical Center and University of Maryland School of Medicine (S.J.K.).
| | - Cameron A Dell
- From the Division of Neurocritical Care and Emergency Neurology (D.Y.H., K.N.S.), Department of Neurology, Yale School of Medicine, New Haven, CT; the Maryland Stroke Center (C.A.D., M.J.S., T.D.W.), Baltimore; the Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L., M.E.C.), Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC; the Center for Human Genetic Research (J.R., T.W.K.B.), Boston, MA; the University of Miami (S.K., M.L.P.), Miller School of Medicine, FL; Duke University Medical Center (M.L.J., J.M.), Durham, NC; the Department of Neurology (J.L.O., D.W.), University of Cincinnati College of Medicine, OH; and the Baltimore Veterans Administration Medical Center and University of Maryland School of Medicine (S.J.K.)
| | - Mary J Sparks
- From the Division of Neurocritical Care and Emergency Neurology (D.Y.H., K.N.S.), Department of Neurology, Yale School of Medicine, New Haven, CT; the Maryland Stroke Center (C.A.D., M.J.S., T.D.W.), Baltimore; the Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L., M.E.C.), Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC; the Center for Human Genetic Research (J.R., T.W.K.B.), Boston, MA; the University of Miami (S.K., M.L.P.), Miller School of Medicine, FL; Duke University Medical Center (M.L.J., J.M.), Durham, NC; the Department of Neurology (J.L.O., D.W.), University of Cincinnati College of Medicine, OH; and the Baltimore Veterans Administration Medical Center and University of Maryland School of Medicine (S.J.K.)
| | - Tiffany D Watson
- From the Division of Neurocritical Care and Emergency Neurology (D.Y.H., K.N.S.), Department of Neurology, Yale School of Medicine, New Haven, CT; the Maryland Stroke Center (C.A.D., M.J.S., T.D.W.), Baltimore; the Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L., M.E.C.), Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC; the Center for Human Genetic Research (J.R., T.W.K.B.), Boston, MA; the University of Miami (S.K., M.L.P.), Miller School of Medicine, FL; Duke University Medical Center (M.L.J., J.M.), Durham, NC; the Department of Neurology (J.L.O., D.W.), University of Cincinnati College of Medicine, OH; and the Baltimore Veterans Administration Medical Center and University of Maryland School of Medicine (S.J.K.)
| | - Carl D Langefeld
- From the Division of Neurocritical Care and Emergency Neurology (D.Y.H., K.N.S.), Department of Neurology, Yale School of Medicine, New Haven, CT; the Maryland Stroke Center (C.A.D., M.J.S., T.D.W.), Baltimore; the Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L., M.E.C.), Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC; the Center for Human Genetic Research (J.R., T.W.K.B.), Boston, MA; the University of Miami (S.K., M.L.P.), Miller School of Medicine, FL; Duke University Medical Center (M.L.J., J.M.), Durham, NC; the Department of Neurology (J.L.O., D.W.), University of Cincinnati College of Medicine, OH; and the Baltimore Veterans Administration Medical Center and University of Maryland School of Medicine (S.J.K.)
| | - Mary E Comeau
- From the Division of Neurocritical Care and Emergency Neurology (D.Y.H., K.N.S.), Department of Neurology, Yale School of Medicine, New Haven, CT; the Maryland Stroke Center (C.A.D., M.J.S., T.D.W.), Baltimore; the Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L., M.E.C.), Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC; the Center for Human Genetic Research (J.R., T.W.K.B.), Boston, MA; the University of Miami (S.K., M.L.P.), Miller School of Medicine, FL; Duke University Medical Center (M.L.J., J.M.), Durham, NC; the Department of Neurology (J.L.O., D.W.), University of Cincinnati College of Medicine, OH; and the Baltimore Veterans Administration Medical Center and University of Maryland School of Medicine (S.J.K.)
| | - Jonathan Rosand
- From the Division of Neurocritical Care and Emergency Neurology (D.Y.H., K.N.S.), Department of Neurology, Yale School of Medicine, New Haven, CT; the Maryland Stroke Center (C.A.D., M.J.S., T.D.W.), Baltimore; the Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L., M.E.C.), Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC; the Center for Human Genetic Research (J.R., T.W.K.B.), Boston, MA; the University of Miami (S.K., M.L.P.), Miller School of Medicine, FL; Duke University Medical Center (M.L.J., J.M.), Durham, NC; the Department of Neurology (J.L.O., D.W.), University of Cincinnati College of Medicine, OH; and the Baltimore Veterans Administration Medical Center and University of Maryland School of Medicine (S.J.K.)
| | - Thomas W K Battey
- From the Division of Neurocritical Care and Emergency Neurology (D.Y.H., K.N.S.), Department of Neurology, Yale School of Medicine, New Haven, CT; the Maryland Stroke Center (C.A.D., M.J.S., T.D.W.), Baltimore; the Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L., M.E.C.), Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC; the Center for Human Genetic Research (J.R., T.W.K.B.), Boston, MA; the University of Miami (S.K., M.L.P.), Miller School of Medicine, FL; Duke University Medical Center (M.L.J., J.M.), Durham, NC; the Department of Neurology (J.L.O., D.W.), University of Cincinnati College of Medicine, OH; and the Baltimore Veterans Administration Medical Center and University of Maryland School of Medicine (S.J.K.)
| | - Sebastian Koch
- From the Division of Neurocritical Care and Emergency Neurology (D.Y.H., K.N.S.), Department of Neurology, Yale School of Medicine, New Haven, CT; the Maryland Stroke Center (C.A.D., M.J.S., T.D.W.), Baltimore; the Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L., M.E.C.), Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC; the Center for Human Genetic Research (J.R., T.W.K.B.), Boston, MA; the University of Miami (S.K., M.L.P.), Miller School of Medicine, FL; Duke University Medical Center (M.L.J., J.M.), Durham, NC; the Department of Neurology (J.L.O., D.W.), University of Cincinnati College of Medicine, OH; and the Baltimore Veterans Administration Medical Center and University of Maryland School of Medicine (S.J.K.)
| | - Mario L Perez
- From the Division of Neurocritical Care and Emergency Neurology (D.Y.H., K.N.S.), Department of Neurology, Yale School of Medicine, New Haven, CT; the Maryland Stroke Center (C.A.D., M.J.S., T.D.W.), Baltimore; the Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L., M.E.C.), Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC; the Center for Human Genetic Research (J.R., T.W.K.B.), Boston, MA; the University of Miami (S.K., M.L.P.), Miller School of Medicine, FL; Duke University Medical Center (M.L.J., J.M.), Durham, NC; the Department of Neurology (J.L.O., D.W.), University of Cincinnati College of Medicine, OH; and the Baltimore Veterans Administration Medical Center and University of Maryland School of Medicine (S.J.K.)
| | - Michael L James
- From the Division of Neurocritical Care and Emergency Neurology (D.Y.H., K.N.S.), Department of Neurology, Yale School of Medicine, New Haven, CT; the Maryland Stroke Center (C.A.D., M.J.S., T.D.W.), Baltimore; the Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L., M.E.C.), Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC; the Center for Human Genetic Research (J.R., T.W.K.B.), Boston, MA; the University of Miami (S.K., M.L.P.), Miller School of Medicine, FL; Duke University Medical Center (M.L.J., J.M.), Durham, NC; the Department of Neurology (J.L.O., D.W.), University of Cincinnati College of Medicine, OH; and the Baltimore Veterans Administration Medical Center and University of Maryland School of Medicine (S.J.K.)
| | - Jessica McFarlin
- From the Division of Neurocritical Care and Emergency Neurology (D.Y.H., K.N.S.), Department of Neurology, Yale School of Medicine, New Haven, CT; the Maryland Stroke Center (C.A.D., M.J.S., T.D.W.), Baltimore; the Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L., M.E.C.), Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC; the Center for Human Genetic Research (J.R., T.W.K.B.), Boston, MA; the University of Miami (S.K., M.L.P.), Miller School of Medicine, FL; Duke University Medical Center (M.L.J., J.M.), Durham, NC; the Department of Neurology (J.L.O., D.W.), University of Cincinnati College of Medicine, OH; and the Baltimore Veterans Administration Medical Center and University of Maryland School of Medicine (S.J.K.)
| | - Jennifer L Osborne
- From the Division of Neurocritical Care and Emergency Neurology (D.Y.H., K.N.S.), Department of Neurology, Yale School of Medicine, New Haven, CT; the Maryland Stroke Center (C.A.D., M.J.S., T.D.W.), Baltimore; the Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L., M.E.C.), Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC; the Center for Human Genetic Research (J.R., T.W.K.B.), Boston, MA; the University of Miami (S.K., M.L.P.), Miller School of Medicine, FL; Duke University Medical Center (M.L.J., J.M.), Durham, NC; the Department of Neurology (J.L.O., D.W.), University of Cincinnati College of Medicine, OH; and the Baltimore Veterans Administration Medical Center and University of Maryland School of Medicine (S.J.K.)
| | - Daniel Woo
- From the Division of Neurocritical Care and Emergency Neurology (D.Y.H., K.N.S.), Department of Neurology, Yale School of Medicine, New Haven, CT; the Maryland Stroke Center (C.A.D., M.J.S., T.D.W.), Baltimore; the Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L., M.E.C.), Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC; the Center for Human Genetic Research (J.R., T.W.K.B.), Boston, MA; the University of Miami (S.K., M.L.P.), Miller School of Medicine, FL; Duke University Medical Center (M.L.J., J.M.), Durham, NC; the Department of Neurology (J.L.O., D.W.), University of Cincinnati College of Medicine, OH; and the Baltimore Veterans Administration Medical Center and University of Maryland School of Medicine (S.J.K.)
| | - Steven J Kittner
- From the Division of Neurocritical Care and Emergency Neurology (D.Y.H., K.N.S.), Department of Neurology, Yale School of Medicine, New Haven, CT; the Maryland Stroke Center (C.A.D., M.J.S., T.D.W.), Baltimore; the Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L., M.E.C.), Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC; the Center for Human Genetic Research (J.R., T.W.K.B.), Boston, MA; the University of Miami (S.K., M.L.P.), Miller School of Medicine, FL; Duke University Medical Center (M.L.J., J.M.), Durham, NC; the Department of Neurology (J.L.O., D.W.), University of Cincinnati College of Medicine, OH; and the Baltimore Veterans Administration Medical Center and University of Maryland School of Medicine (S.J.K.)
| | - Kevin N Sheth
- From the Division of Neurocritical Care and Emergency Neurology (D.Y.H., K.N.S.), Department of Neurology, Yale School of Medicine, New Haven, CT; the Maryland Stroke Center (C.A.D., M.J.S., T.D.W.), Baltimore; the Center for Public Health Genomics and Department of Biostatistical Sciences (C.D.L., M.E.C.), Division of Public Health Sciences, Wake Forest School of Medicine, Winston-Salem, NC; the Center for Human Genetic Research (J.R., T.W.K.B.), Boston, MA; the University of Miami (S.K., M.L.P.), Miller School of Medicine, FL; Duke University Medical Center (M.L.J., J.M.), Durham, NC; the Department of Neurology (J.L.O., D.W.), University of Cincinnati College of Medicine, OH; and the Baltimore Veterans Administration Medical Center and University of Maryland School of Medicine (S.J.K.)
| |
Collapse
|
115
|
Hansen BM, Morgan TC, Betz JF, Sundgren PC, Norrving B, Hanley DF, Lindgren A. Intraventricular Extension of Supratentorial Intracerebral Hemorrhage: The Modified Graeb Scale Improves Outcome Prediction in Lund Stroke Register. Neuroepidemiology 2015; 46:43-50. [PMID: 26668048 DOI: 10.1159/000442575] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2015] [Accepted: 11/16/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND/AIMS The modified Graeb Scale (mGS) is a semi-quantitative method to assess the extension of intraventricular hemorrhage (IVH) in patients with intracerebral hemorrhage (ICH). The mGS has been shown to prognosticate outcome after ICH in cohorts derived from convenience samples. We evaluated the external validity of mGS in supratentorial ICH-patients from an unselected cohort. METHODS ICH-patients were included prospectively and consecutively in Lund Stroke Register. Follow-up survival status was obtained from the National Census Office; functional outcome was obtained from the Swedish Stroke Register or medical records. Using multivariate analyses, we examined if mGS was related to 30-day survival or poor functional outcome (modified Rankin Scale ≥4) at 90 days. RESULTS Of 198 supratentorial ICH-patients, 86 (43%) had IVH (median mGS 12, range 1-28). In multivariate regression analyses, the mGS independently predicted 30-day mortality (per point; OR 1.16; 95% CI 1.06-1.27; p = 0.002) and poor functional outcome (OR 1.11; 95% CI 1.02-1.20; p = 0.011) after ICH. In receiver-operator characteristic analysis, the addition of mGS tended to be associated with a higher prognostic accuracy for survival (area under curve 0.886 vs. not including mGS 0.812; p = 0.053). CONCLUSIONS The mGS improves outcome prediction after supratentorial ICH beyond other previously established factors in an unselected population.
Collapse
Affiliation(s)
- Björn M Hansen
- Department of Clinical Sciences Lund, Neurology, Lund University, Lund, Sweden
| | | | | | | | | | | | | |
Collapse
|
116
|
Triage practices in stroke units: Physicians' perceptions and ethical issues. Rev Neurol (Paris) 2015; 172:146-51. [PMID: 26563667 DOI: 10.1016/j.neurol.2015.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2015] [Revised: 08/06/2015] [Accepted: 09/01/2015] [Indexed: 11/21/2022]
Abstract
OBJECTIVE We aimed to explore acute stroke admission decisions and to discuss ethical issues in triage practices in stroke units (SUs) in France. METHODS In this study, 337 questionnaires were sent to physicians involved in acute admission to SUs in Île-de-France (neurologists and physicians from emergency medical services). The questionnaires comprised questions about physicians' perceptions of the reasonable allocation of SU beds and admission criteria for patients in SU in clinical vignettes illustrating complex situations. RESULTS In total, 162 questionnaires were fully completed. There were some discrepancies in perceptions and reporting practices between emergency physicians and neurologists concerning patient admission criteria. Triage choices were more frequently declared by emergency physicians than by neurologists and were related to the difficulty of obtaining a positive response for the admission of certain complex patients (particularly those with comorbidities). CONCLUSIONS Despite recommendations stating that all patients with stroke should be admitted to SUs, this study has shown that triage practices exist in stroke admission decisions. The triage depends on the role and perceptions of each physician in acute stroke management. These decisions suggest reflections on the applicability of distributive justice theories and on ethical issues in triage practices in medicine.
Collapse
|
117
|
Abstract
Intracerebral hemorrhage (ICH) is a stroke subtype with high mortality and significant disability among survivors. The management of ICH has been influenced by the results of several major trials completed in the last decade. It is now recognized that hematoma expansion is a major cause of morbidity and mortality. However, efforts to improve clinical outcome through mitigation of hematoma expansion have so far been unsuccessful. Acute blood pressure management has recently been shown to be safe in the setting of acute ICH but there was no reduction in mortality with early blood pressure (BP) lowering. Two large trials of surgical evacuation of supratentorial ICH have not shown improvement in outcome with surgery, thus minimally invasive surgical strategies are currently being studied. Lastly, a better understanding of the pathophysiology of ICH has led to the identification of several new mechanisms of injury that could be potential therapeutic targets.
Collapse
Affiliation(s)
- Venkatesh Aiyagari
- a Department of Neurological Surgery and Neurology and Neurotherapeutics , University of Texas Southwestern Medical Center , Dallas , TX , USA
| |
Collapse
|
118
|
Venous thromboembolism prevention during the acute phase of intracerebral hemorrhage. J Neurol Sci 2015; 358:3-8. [DOI: 10.1016/j.jns.2015.08.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 07/24/2015] [Accepted: 08/14/2015] [Indexed: 11/23/2022]
|
119
|
Chen YY, Gordon NH, Jr AFC, Garland A, Chu TS, Youngner SJ. The Outcome of Patients With 2 Different Protocols of Do-Not-Resuscitate Orders: An Observational Cohort Study. Medicine (Baltimore) 2015; 94:e1789. [PMID: 26496311 PMCID: PMC4620758 DOI: 10.1097/md.0000000000001789] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Lack of clarity about the exact clinical implications of do-not-resuscitate (DNR) has caused confusion that has been addressed repeatedly in the literature. To provide improved understanding about the portability of DNR and the medical care provided to DNR patients, the state of Ohio passed a Do-Not-Resuscitate Law in 1998, which clearly pointed out 2 different protocols of do-not-resuscitate: DNR comfort care (DNRCC) and DNR comfort care arrest (DNRCC-Arrest). The objective of this study was to examine the outcome of patients with the 2 different protocols of DNR orders.This is a retrospective observational study conducted in a medical intensive care unit (MICU) in a hospital located in Northeast Ohio. The medical records of the initial admissions to the MICU during data collection period were concurrently and retrospectively reviewed. The association between 2 variables was examined using Chi-squared test or Student's t-test. The outcome of DNRCC, DNRCC-Arrest, and No-DNR patients were compared using multivariate logistic regression analysis.The total of 188 DNRCC-Arrest, 88 DNRCC, and 2051 No-DNR patients were included in this study. Compared with the No-DNR patients, the DNRCC (odds ratio = 20.77, P < 0.01) and DNRCC-Arrest (odds ratio = 3.69, P < 0.01) patients were more likely to die in the MICU. Furthermore, the odds of dying during MICU stay for DNRCC patients were 7.85 times significantly higher than that for DNRCC-Arrest patients (odds ratio = 7.85, P < 0.01).Given Do-Not-Resuscitate Law in Ohio, we examined the outcome of the 2 different protocols of DNR orders, and to compare with the conventional DNR orders. Similar to conventional DNR, DNDCC and DNRCC-Arrest were both associated with the increased risk of death. Patients with DNRCC were more likely to be associated with increased risk of death than those with DNRCC-Arrest.
Collapse
Affiliation(s)
- Yen-Yuan Chen
- From the Graduate Institute of Medical Education and Bioethics, National Taiwan University College of Medicine, Department of Medical Education, National Taiwan University Hospital, Taipei, Taiwan (Y-YC, T-SC); Case Western Reserve University School of Nursing (NHG); Department of Medicine, Case Western Reserve University School of Medicine at MetroHealth Medical CenterCleveland, OH, USA (AFC); Department of Community Health Services; Department of Medicine, University of Manitoba, Winnipeg, Canada (AG); and Department of Bioethics, Case Western Reserve University School of Medicine, 10900 Euclid Avenue, Cleveland, OH, USA (SJY)
| | | | | | | | | | | |
Collapse
|
120
|
Godoy DA, Piñero GR, Koller P, Masotti L, Napoli MD. Steps to consider in the approach and management of critically ill patient with spontaneous intracerebral hemorrhage. World J Crit Care Med 2015; 4:213-229. [PMID: 26261773 PMCID: PMC4524818 DOI: 10.5492/wjccm.v4.i3.213] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2014] [Revised: 03/03/2015] [Accepted: 06/08/2015] [Indexed: 02/06/2023] Open
Abstract
Spontaneous intracerebral hemorrhage is a type of stroke associated with poor outcomes. Mortality is elevated, especially in the acute phase. From a pathophysiological point of view the bleeding must traverse different stages dominated by the possibility of re-bleeding, edema, intracranial hypertension, inflammation and neurotoxicity due to blood degradation products, mainly hemoglobin and thrombin. Neurological deterioration and death are common in early hours, so it is a true neurological-neurosurgical emergency. Time is brain so that action should be taken fast and accurately. The most significant prognostic factors are level of consciousness, location, volume and ventricular extension of the bleeding. Nihilism and early withdrawal of active therapy undoubtedly influence the final result. Although there are no proven therapeutic measures, treatment should be individualized and guided preferably by pathophysiology. The multidisciplinary teamwork is essential. Results of recently completed studies have birth to promising new strategies. For correct management it’s important to establish an orderly and systematic strategy based on clinical stabilization, evaluation and establishment of prognosis, avoiding secondary insults and adoption of specific individualized therapies, including hemostatic therapy and intensive control of elevated blood pressure. Uncertainty continues regarding the role of surgery.
Collapse
|
121
|
Creutzfeldt CJ, Holloway RG, Curtis JR. Palliative Care: A Core Competency for Stroke Neurologists. Stroke 2015; 46:2714-9. [PMID: 26243219 DOI: 10.1161/strokeaha.115.008224] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 07/01/2015] [Indexed: 12/28/2022]
Affiliation(s)
- Claire J Creutzfeldt
- From the Harborview Medical Center, Department of Neurology, University of Washington, Seattle, WA (C.J.C.); Department of Neurology, University of Rochester Medical Center, Rochester, NY (R.G.H.); and Cambia Palliative Care Center of Excellence, Harborview Medical Center, Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle, WA (J.R.C.).
| | - Robert G Holloway
- From the Harborview Medical Center, Department of Neurology, University of Washington, Seattle, WA (C.J.C.); Department of Neurology, University of Rochester Medical Center, Rochester, NY (R.G.H.); and Cambia Palliative Care Center of Excellence, Harborview Medical Center, Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle, WA (J.R.C.)
| | - J Randall Curtis
- From the Harborview Medical Center, Department of Neurology, University of Washington, Seattle, WA (C.J.C.); Department of Neurology, University of Rochester Medical Center, Rochester, NY (R.G.H.); and Cambia Palliative Care Center of Excellence, Harborview Medical Center, Division of Pulmonary and Critical Care, Department of Medicine, University of Washington, Seattle, WA (J.R.C.)
| |
Collapse
|
122
|
Jawa RS, Shapiro MJ, McCormack JE, Huang EC, Rutigliano DN, Vosswinkel JA. Preadmission Do Not Resuscitate advanced directive is associated with adverse outcomes following acute traumatic injury. Am J Surg 2015; 210:814-21. [PMID: 26116324 DOI: 10.1016/j.amjsurg.2015.04.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2015] [Revised: 04/17/2015] [Accepted: 04/18/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Do Not Resuscitate (DNR) orders have been associated with poor outcomes in surgical patients. There is limited literature on admitted trauma patients with advanced directives indicating DNR status before admission (preadmission DNR [PADNR]). METHODS A retrospective review of the trauma registry of a suburban county was carried out for admitted trauma patients with age ≥41 years, who were admitted between 2008 and 2013. RESULTS Of 7,937 admitted patients, 327 had a preadmission advanced directive indicating DNR. PADNR patients were significantly older (87 vs 69 years), with more frequent comorbidities, and were more often admitted after a fall (94.2% vs 65.8%). PADNR patients had a higher Injury Severity Score (14 vs 11). They also had significantly increased rates of pneumonia, sepsis, myocardial infarction, and death (33.6% vs 5.9%). On multivariate logistic regression, the presence of a preadmission advanced directive indicating DNR status was independently associated with a 5.2-fold increased odds of mortality. CONCLUSION An advanced directive indicating DNR is associated with adverse outcomes following trauma.
Collapse
Affiliation(s)
- Randeep S Jawa
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, NY, USA.
| | - Marc J Shapiro
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, NY, USA
| | - Jane E McCormack
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, NY, USA
| | - Emily C Huang
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, NY, USA
| | - Daniel N Rutigliano
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, NY, USA
| | - James A Vosswinkel
- Division of Trauma, Department of Surgery, Stony Brook University School of Medicine, Stony Brook, NY, USA
| |
Collapse
|
123
|
Hemphill JC, Greenberg SM, Anderson CS, Becker K, Bendok BR, Cushman M, Fung GL, Goldstein JN, Macdonald RL, Mitchell PH, Scott PA, Selim MH, Woo D. Guidelines for the Management of Spontaneous Intracerebral Hemorrhage: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2015; 46:2032-60. [PMID: 26022637 DOI: 10.1161/str.0000000000000069] [Citation(s) in RCA: 2007] [Impact Index Per Article: 223.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of spontaneous intracerebral hemorrhage. METHODS A formal literature search of PubMed was performed through the end of August 2013. The writing committee met by teleconference to discuss narrative text and recommendations. Recommendations follow the American Heart Association/American Stroke Association methods of classifying the level of certainty of the treatment effect and the class of evidence. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Oversight Committee and Stroke Council Leadership Committee. RESULTS Evidence-based guidelines are presented for the care of patients with acute intracerebral hemorrhage. Topics focused on diagnosis, management of coagulopathy and blood pressure, prevention and control of secondary brain injury and intracranial pressure, the role of surgery, outcome prediction, rehabilitation, secondary prevention, and future considerations. Results of new phase 3 trials were incorporated. CONCLUSIONS Intracerebral hemorrhage remains a serious condition for which early aggressive care is warranted. These guidelines provide a framework for goal-directed treatment of the patient with intracerebral hemorrhage.
Collapse
|
124
|
Souter MJ, Blissitt PA, Blosser S, Bonomo J, Greer D, Jichici D, Mahanes D, Marcolini EG, Miller C, Sangha K, Yeager S. Recommendations for the Critical Care Management of Devastating Brain Injury: Prognostication, Psychosocial, and Ethical Management. Neurocrit Care 2015; 23:4-13. [DOI: 10.1007/s12028-015-0137-6] [Citation(s) in RCA: 106] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
125
|
Morgenstern LB, Zahuranec DB, Sánchez BN, Becker KJ, Geraghty M, Hughes R, Norris G, Hemphill JC. Full medical support for intracerebral hemorrhage. Neurology 2015; 84:1739-44. [PMID: 25817842 DOI: 10.1212/wnl.0000000000001525] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 01/20/2015] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE This study tested the hypothesis that patients without placement of new do-not-resuscitate (DNR) orders during the first 5 days after intracerebral hemorrhage (ICH) have lower 30-day mortality than predicted by the ICH Score without an increase in severe disability at 90 days. METHODS This was a prospective, multicenter, observational cohort study at 4 academic medical centers and one community hospital. Adults (18 years or older) with nontraumatic spontaneous ICH, Glasgow Coma Scale score of 12 or less, who did not have preexisting DNR orders were included. RESULTS One hundred nine subjects were enrolled. Mean age was 62 years; median Glasgow Coma Scale score was 7, and mean hematoma volume was 39 cm(3). Based on ICH Score prediction, the expected overall 30-day mortality rate was 50%. Observed mortality was substantially lower at 20.2%, absolute average difference 29.8% (95% confidence interval: 21.5%-37.7%). At 90 days, 27.1% had died, 21.5% had a modified Rankin Scale score = 5 (severe disability). A good outcome (modified Rankin Scale score 0-3) was achieved by 29.9% and an additional 21.5% fell into the moderately severe disability range (modified Rankin Scale score = 4). CONCLUSIONS Avoidance of early DNR orders along with guideline concordant ICH care results in substantially lower mortality than predicted. The observed functional outcomes in this study provide clinicians and families with data to determine the appropriate goals of treatment based on patients' wishes.
Collapse
Affiliation(s)
- Lewis B Morgenstern
- From Stroke Program, Department of Neurology (L.B.M., D.B.Z., R.H.), and Department of Neurosurgery (L.B.M.), University of Michigan Health System, Ann Arbor; Departments of Epidemiology (L.B.M.) and Biostatistics (B.N.S.), University of Michigan School of Public Health, Ann Arbor; Department of Neurology (K.J.B.), University of Washington School of Medicine, Seattle; Department of Neurology (M.G.), Providence Sacred Heart Hospital, Spokane, WA; Department of Neurology (G.N.), Wayne State School of Medicine, Detroit, MI; Departments of Neurology (J.C.H.) and Neurological Surgery (J.C.H.), University of California, San Francisco School of Medicine.
| | - Darin B Zahuranec
- From Stroke Program, Department of Neurology (L.B.M., D.B.Z., R.H.), and Department of Neurosurgery (L.B.M.), University of Michigan Health System, Ann Arbor; Departments of Epidemiology (L.B.M.) and Biostatistics (B.N.S.), University of Michigan School of Public Health, Ann Arbor; Department of Neurology (K.J.B.), University of Washington School of Medicine, Seattle; Department of Neurology (M.G.), Providence Sacred Heart Hospital, Spokane, WA; Department of Neurology (G.N.), Wayne State School of Medicine, Detroit, MI; Departments of Neurology (J.C.H.) and Neurological Surgery (J.C.H.), University of California, San Francisco School of Medicine
| | - Brisa N Sánchez
- From Stroke Program, Department of Neurology (L.B.M., D.B.Z., R.H.), and Department of Neurosurgery (L.B.M.), University of Michigan Health System, Ann Arbor; Departments of Epidemiology (L.B.M.) and Biostatistics (B.N.S.), University of Michigan School of Public Health, Ann Arbor; Department of Neurology (K.J.B.), University of Washington School of Medicine, Seattle; Department of Neurology (M.G.), Providence Sacred Heart Hospital, Spokane, WA; Department of Neurology (G.N.), Wayne State School of Medicine, Detroit, MI; Departments of Neurology (J.C.H.) and Neurological Surgery (J.C.H.), University of California, San Francisco School of Medicine
| | - Kyra J Becker
- From Stroke Program, Department of Neurology (L.B.M., D.B.Z., R.H.), and Department of Neurosurgery (L.B.M.), University of Michigan Health System, Ann Arbor; Departments of Epidemiology (L.B.M.) and Biostatistics (B.N.S.), University of Michigan School of Public Health, Ann Arbor; Department of Neurology (K.J.B.), University of Washington School of Medicine, Seattle; Department of Neurology (M.G.), Providence Sacred Heart Hospital, Spokane, WA; Department of Neurology (G.N.), Wayne State School of Medicine, Detroit, MI; Departments of Neurology (J.C.H.) and Neurological Surgery (J.C.H.), University of California, San Francisco School of Medicine
| | - Madeleine Geraghty
- From Stroke Program, Department of Neurology (L.B.M., D.B.Z., R.H.), and Department of Neurosurgery (L.B.M.), University of Michigan Health System, Ann Arbor; Departments of Epidemiology (L.B.M.) and Biostatistics (B.N.S.), University of Michigan School of Public Health, Ann Arbor; Department of Neurology (K.J.B.), University of Washington School of Medicine, Seattle; Department of Neurology (M.G.), Providence Sacred Heart Hospital, Spokane, WA; Department of Neurology (G.N.), Wayne State School of Medicine, Detroit, MI; Departments of Neurology (J.C.H.) and Neurological Surgery (J.C.H.), University of California, San Francisco School of Medicine
| | - Rebecca Hughes
- From Stroke Program, Department of Neurology (L.B.M., D.B.Z., R.H.), and Department of Neurosurgery (L.B.M.), University of Michigan Health System, Ann Arbor; Departments of Epidemiology (L.B.M.) and Biostatistics (B.N.S.), University of Michigan School of Public Health, Ann Arbor; Department of Neurology (K.J.B.), University of Washington School of Medicine, Seattle; Department of Neurology (M.G.), Providence Sacred Heart Hospital, Spokane, WA; Department of Neurology (G.N.), Wayne State School of Medicine, Detroit, MI; Departments of Neurology (J.C.H.) and Neurological Surgery (J.C.H.), University of California, San Francisco School of Medicine
| | - Gregory Norris
- From Stroke Program, Department of Neurology (L.B.M., D.B.Z., R.H.), and Department of Neurosurgery (L.B.M.), University of Michigan Health System, Ann Arbor; Departments of Epidemiology (L.B.M.) and Biostatistics (B.N.S.), University of Michigan School of Public Health, Ann Arbor; Department of Neurology (K.J.B.), University of Washington School of Medicine, Seattle; Department of Neurology (M.G.), Providence Sacred Heart Hospital, Spokane, WA; Department of Neurology (G.N.), Wayne State School of Medicine, Detroit, MI; Departments of Neurology (J.C.H.) and Neurological Surgery (J.C.H.), University of California, San Francisco School of Medicine
| | - J Claude Hemphill
- From Stroke Program, Department of Neurology (L.B.M., D.B.Z., R.H.), and Department of Neurosurgery (L.B.M.), University of Michigan Health System, Ann Arbor; Departments of Epidemiology (L.B.M.) and Biostatistics (B.N.S.), University of Michigan School of Public Health, Ann Arbor; Department of Neurology (K.J.B.), University of Washington School of Medicine, Seattle; Department of Neurology (M.G.), Providence Sacred Heart Hospital, Spokane, WA; Department of Neurology (G.N.), Wayne State School of Medicine, Detroit, MI; Departments of Neurology (J.C.H.) and Neurological Surgery (J.C.H.), University of California, San Francisco School of Medicine
| |
Collapse
|
126
|
Salottolo K, Offner PJ, Orlando A, Slone DS, Mains CW, Carrick M, Bar-Or D. The epidemiology of do-not-resuscitate orders in patients with trauma: a community level one trauma center observational experience. Scand J Trauma Resusc Emerg Med 2015; 23:9. [PMID: 25645242 PMCID: PMC4333154 DOI: 10.1186/s13049-015-0094-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 01/19/2015] [Indexed: 12/20/2022] Open
Abstract
Background Do-Not-Resuscitate (DNR) orders in patients with traumatic injury are insufficiently described. The objective is to describe the epidemiology and outcomes of DNR orders in trauma patients. Methods We included all adults with trauma to a community Level I Trauma Center over 6 years (2008–2013). We used chi-square, Wilcoxon rank-sum, and multivariate stepwise logistic regression tests to characterize DNR (established in-house vs. pre-existing), describe predictors of establishing an in-house DNR, timing of an in-house DNR (early [within 1 day] vs late), and outcomes (death, ICU stay, major complications). Results Included were 10,053 patients with trauma, of which 1523 had a DNR order in place (15%); 715 (7%) had a pre-existing DNR and 808 (8%) had a DNR established in-house. Increases were observed over time in both the proportions of patients with DNRs established in-house (p = 0.008) and age ≥65 (p < 0.001). Over 90% of patients with an in-house DNR were ≥65 years. The following covariates were independently associated with establishing a DNR in-house: age ≥65, severe neurologic deficit (GCS 3–8), fall mechanism of injury, ED tachycardia, female gender, and comorbidities (p < 0.05 for all). Age ≥65, female gender, non-surgical service admission and transfers-in were associated with a DNR established early (p < 0.05 for all). As expected, mortality was greater in patients with DNR than those without (22% vs. 1%), as was the development of a major complication (8% vs. 5%), while ICU admission was similar (19% vs. 17%). Poor outcomes were greatest in patients with DNR orders executed later in the hospital stay. Conclusions Our analysis of a broad cohort of patients with traumatic injury establishes the relationship between DNR and patient characteristics and outcomes. At 15%, DNR orders are prevalent in our general trauma population, particularly in patients ≥65 years, and are placed early after arrival. Established prognostic factors, including age and physiologic severity, were determinants for in-house DNR orders. These data may improve physician predictions of outcomes with DNR and help inform patient preferences, particularly in an environment with increasing use of DNR and increasing age of patients with trauma. Electronic supplementary material The online version of this article (doi:10.1186/s13049-015-0094-2) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Kristin Salottolo
- Trauma Research Department, Swedish Medical Center, Englewood, CO, 80113, USA. .,Trauma Research Department, St. Anthony Hospital, Lakewood, CO, 80228, USA.
| | - Patrick J Offner
- Trauma Services Department, St. Anthony Hospital, Lakewood, CO, 80228, USA.
| | - Alessandro Orlando
- Trauma Research Department, Swedish Medical Center, Englewood, CO, 80113, USA. .,Trauma Research Department, St. Anthony Hospital, Lakewood, CO, 80228, USA.
| | - Denetta S Slone
- Trauma Services Department, Swedish Medical Center, Englewood, CO, 80113, USA. .,Rocky Vista University, Aurora, CO, 80011, USA.
| | - Charles W Mains
- Trauma Services Department, St. Anthony Hospital, Lakewood, CO, 80228, USA. .,Rocky Vista University, Aurora, CO, 80011, USA.
| | - Matthew Carrick
- Trauma Services Department, Medical Center of Plano, Plano, TX, 75075, USA.
| | - David Bar-Or
- Trauma Research Department, Swedish Medical Center, Englewood, CO, 80113, USA. .,Trauma Research Department, St. Anthony Hospital, Lakewood, CO, 80228, USA. .,Rocky Vista University, Aurora, CO, 80011, USA.
| |
Collapse
|
127
|
Limitation et arrêt de traitements à la phase aiguë des AVC graves : peut-on aller jusqu’à l’arrêt de la nutrition et l’hydratation artificielles ? Rev Neurol (Paris) 2015; 171:115-7. [DOI: 10.1016/j.neurol.2015.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
|
128
|
Yang TC, Li JG, Guo W. Do not resuscitate orders for patients with intracerebral hemorrhage: experience from a Chinese tertiary care center. Eur Neurol 2015; 73:144-9. [PMID: 25573228 DOI: 10.1159/000369792] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2014] [Accepted: 11/09/2014] [Indexed: 11/19/2022]
Abstract
AIM This study aimed to determine the frequency and determinant factors of do not resuscitate (DNR) orders in patients with intracerebral hemorrhage (ICH) at a university hospital in China. METHODS Data collected from June 2010 to December 2012 for patients with ICH were retrospectively reviewed. The characteristics and care of patients with and without DNR orders and those with early (≤24 h) and late (>24 h) DNR establishment were compared. RESULTS Formal DNR orders were filed during hospitalization for 64/759 (8.4%) patients with complete medical records enrolled in this study. Patients with DNR orders were older on average (73.1 ± 10.1 vs. 56.0 ± 13.2 years; p < 0.001) and a larger proportion had pre-ICH comorbidity impacting dependency (87.5 vs. 17.0%; p < 0.001) than did those with no DNR order. Patients with DNR orders were in worse clinical condition on arrival than those without a DNR order, as judged by Glasgow Coma Scale scores, and more frequently had large hematoma volumes (78.1 vs. 39.7%; p < 0.001). CONCLUSIONS DNR orders were not used commonly for patients with ICH in this Chinese sample. No relationship between ICH severity and DNR decision making was observed.
Collapse
Affiliation(s)
- Tie-Cheng Yang
- Emergency Department, Beijing Tiantan Hospital, Capital Medical University/Beijing Neurosurgical Institute, China
| | | | | |
Collapse
|
129
|
Elizabeth Sandel M. Stroke, Disability, and Unconscious Bias: Interrelationships and Overdetermination in Medical Decisions. Top Stroke Rehabil 2015; 18:70-3. [DOI: 10.1310/tsr1801-70] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
|
130
|
Dean D, Martinez MS, Newgard CD. Variability in early do not attempt resuscitation orders among patients with serious traumatic brain injury. Acad Emerg Med 2015; 22:54-60. [PMID: 25545694 DOI: 10.1111/acem.12555] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 07/21/2014] [Accepted: 07/27/2014] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The objective was describe the use of early do not attempt resuscitation (DNAR) orders in patients with serious traumatic brain injury (TBI) and its association with outcomes. METHODS This was a retrospective cohort study of all serious TBI patients admitted through the emergency department (ED) to acute care hospitals in California between 2002 and 2010 using ED International Classification of Diseases, 9th revision (ICD-9), admitting diagnosis codes specifying intracranial hemorrhage. DNAR placement within 24 hours of admission was the primary variable of interest. Outcomes included neurosurgical procedures and in-hospital mortality. Hospital and patient characteristics were analyzed using descriptive statistics and multivariable generalized estimation equation regression models to account for hospital-level clustering. RESULTS Of all 76,962 patients with serious TBI, 71,275 were admitted at 141 hospitals that each cared for at least 10 serious TBI patients annually and formed the primary sample. Early DNAR orders were placed in 7.5% of patients (range = 0 to 36.1% by hospital). Early DNAR use varied by trauma designation: Level I, 4.0% (95% confidence interval [CI] = 3.8% to 4.4%); Level II, 6.7% (95% CI = 6.5% to 7.1%); Level III, 9.7% (95% CI = 8.4% to 11.3%); and nontrauma hospitals, 10.8% (95% CI = 10.6% to 11.3%). Early DNAR was also less likely in teaching hospitals (9.3% vs. 4.3%). These results persisted after accounting for age, year, and hospital-level clustering. In-hospital mortality (39.4% vs. 8.7%) and neurosurgical interventions (14.5% vs. 19.7%) also differed for patients with versus without early DNAR orders. Patients 65 years of age and older constituted 87.7% of those with early DNAR orders; our findings remained qualitatively unchanged when restricted to older adults. CONCLUSIONS Use of early DNAR orders among patients with serious TBI is highly variable by individual hospital and hospital type, suggesting substantial practice variation. Associations with fewer surgical intervention and higher mortality suggest that such practice variation may be contributing to differences in TBI outcomes, particularly among older adults.
Collapse
Affiliation(s)
- Dylan Dean
- The Center for Policy and Research in Emergency Medicine; Division of Emergency Medicine; Oregon Health and Science University (OHSU); Portland OR
| | - Michael S. Martinez
- The Center for Policy and Research in Emergency Medicine; Division of Emergency Medicine; Oregon Health and Science University (OHSU); Portland OR
| | - Craig D. Newgard
- The Center for Policy and Research in Emergency Medicine; Division of Emergency Medicine; Oregon Health and Science University (OHSU); Portland OR
| |
Collapse
|
131
|
Abstract
PURPOSE OF REVIEW The care of critically ill brain-injured patients is complex and requires careful balancing of cerebral and systemic treatment priorities. A growing number of studies have reported improved outcomes when patients are admitted to dedicated neurocritical care units (NCCUs). The reasons for this observation have not been definitively clarified. RECENT FINDINGS When recently published articles are combined with older literature, there have been more than 40 000 patients assessed in observational studies that compare neurological and general ICUs. Although results are heterogeneous, admission to NCCUs is associated with lower mortality and a greater chance of favorable recovery. These findings are remarkable considering that there are few interventions in neurocritical care that have been demonstrated to be efficacious in randomized trials. Whether the relationship is causal is still being elucidated but potential explanations include higher patient volume and, in turn, greater clinician experience; more emphasis on and adherence to protocols to avoid secondary brain injury; practice differences related to prognostication and withdrawal of life-sustaining interventions; and differences in the use and interpretation of neuroimaging and neuromonitoring data. SUMMARY Neurocritical care is an evolving field that is associated with improvements in outcomes over the past decade. Further research is required to determine how monitoring and treatment protocols can be optimized.
Collapse
|
132
|
Xian Y, Holloway RG, Smith EE, Schwamm LH, Reeves MJ, Bhatt DL, Schulte PJ, Cox M, Olson DM, Hernandez AF, Lytle BL, Anstrom KJ, Fonarow GC, Peterson ED. Racial/Ethnic differences in process of care and outcomes among patients hospitalized with intracerebral hemorrhage. Stroke 2014; 45:3243-50. [PMID: 25213344 DOI: 10.1161/strokeaha.114.005620] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Although racial/ethnic differences in care are pervasive in many areas of medicine, little is known whether intracerebral hemorrhage (ICH) care processes or outcomes differ by race/ethnicity. METHODS We analyzed 123 623 patients with ICH (83 216 white, 22 147 black, 10 519 Hispanic, and 7741 Asian) hospitalized at 1199 Get With The Guidelines-Stroke hospitals between 2003 and 2012. Multivariable logistic regression with generalized estimating equation was used to evaluate the association among race, stroke performance measures, and in-hospital outcomes. RESULTS Relative to white patients, black, Hispanic, and Asian patients were significantly younger, but more frequently had more severe stroke (median National Institutes of Health Stroke Scale, 9, 10, 10, and 11, respectively; P<0.001). After adjustment for both patient and hospital-level characteristics, black patients were more likely to receive deep venous thrombosis prophylaxis, rehabilitation assessment, dysphagia screening, and stroke education, but less likely to have door to computed tomographic time ≤25 minutes and smoking cessation counseling than whites. Both Hispanic and Asian patients had higher odds of dysphagia screening but lower odds of smoking cessation counseling. In-hospital all-cause mortality was lower for blacks (23.0%), Hispanics (22.8%), and Asians (25.3%) than for white patients (27.6%). After risk adjustment, all minority groups had lower odds of death, of receiving comfort measures only or of being discharged to hospice. In contrast, they were more likely to exceed the median length of stay when compared with white patients. CONCLUSIONS Although individual quality indicators in ICH varied by race/ethnicity, black, Hispanic, and Asian patients with ICH had lower risk-adjusted in-hospital mortality than white patients with ICH.
Collapse
Affiliation(s)
- Ying Xian
- From the Duke Clinical Research Institute, Durham, NC (Y.X., P.J.S., M.C., A.F.H., B.L.L., E.D.P.); Department of Neurology, University of Rochester Medical Center, NY (R.G.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); and Division of Cardiology, University of California, Los Angeles (G.C.F.).
| | - Robert G Holloway
- From the Duke Clinical Research Institute, Durham, NC (Y.X., P.J.S., M.C., A.F.H., B.L.L., E.D.P.); Department of Neurology, University of Rochester Medical Center, NY (R.G.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); and Division of Cardiology, University of California, Los Angeles (G.C.F.)
| | - Eric E Smith
- From the Duke Clinical Research Institute, Durham, NC (Y.X., P.J.S., M.C., A.F.H., B.L.L., E.D.P.); Department of Neurology, University of Rochester Medical Center, NY (R.G.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); and Division of Cardiology, University of California, Los Angeles (G.C.F.)
| | - Lee H Schwamm
- From the Duke Clinical Research Institute, Durham, NC (Y.X., P.J.S., M.C., A.F.H., B.L.L., E.D.P.); Department of Neurology, University of Rochester Medical Center, NY (R.G.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); and Division of Cardiology, University of California, Los Angeles (G.C.F.)
| | - Mathew J Reeves
- From the Duke Clinical Research Institute, Durham, NC (Y.X., P.J.S., M.C., A.F.H., B.L.L., E.D.P.); Department of Neurology, University of Rochester Medical Center, NY (R.G.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); and Division of Cardiology, University of California, Los Angeles (G.C.F.)
| | - Deepak L Bhatt
- From the Duke Clinical Research Institute, Durham, NC (Y.X., P.J.S., M.C., A.F.H., B.L.L., E.D.P.); Department of Neurology, University of Rochester Medical Center, NY (R.G.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); and Division of Cardiology, University of California, Los Angeles (G.C.F.)
| | - Phillip J Schulte
- From the Duke Clinical Research Institute, Durham, NC (Y.X., P.J.S., M.C., A.F.H., B.L.L., E.D.P.); Department of Neurology, University of Rochester Medical Center, NY (R.G.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); and Division of Cardiology, University of California, Los Angeles (G.C.F.)
| | - Margueritte Cox
- From the Duke Clinical Research Institute, Durham, NC (Y.X., P.J.S., M.C., A.F.H., B.L.L., E.D.P.); Department of Neurology, University of Rochester Medical Center, NY (R.G.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); and Division of Cardiology, University of California, Los Angeles (G.C.F.)
| | - DaiWai M Olson
- From the Duke Clinical Research Institute, Durham, NC (Y.X., P.J.S., M.C., A.F.H., B.L.L., E.D.P.); Department of Neurology, University of Rochester Medical Center, NY (R.G.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); and Division of Cardiology, University of California, Los Angeles (G.C.F.)
| | - Adrian F Hernandez
- From the Duke Clinical Research Institute, Durham, NC (Y.X., P.J.S., M.C., A.F.H., B.L.L., E.D.P.); Department of Neurology, University of Rochester Medical Center, NY (R.G.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); and Division of Cardiology, University of California, Los Angeles (G.C.F.)
| | - Barbara L Lytle
- From the Duke Clinical Research Institute, Durham, NC (Y.X., P.J.S., M.C., A.F.H., B.L.L., E.D.P.); Department of Neurology, University of Rochester Medical Center, NY (R.G.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); and Division of Cardiology, University of California, Los Angeles (G.C.F.)
| | - Kevin J Anstrom
- From the Duke Clinical Research Institute, Durham, NC (Y.X., P.J.S., M.C., A.F.H., B.L.L., E.D.P.); Department of Neurology, University of Rochester Medical Center, NY (R.G.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); and Division of Cardiology, University of California, Los Angeles (G.C.F.)
| | - Gregg C Fonarow
- From the Duke Clinical Research Institute, Durham, NC (Y.X., P.J.S., M.C., A.F.H., B.L.L., E.D.P.); Department of Neurology, University of Rochester Medical Center, NY (R.G.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); and Division of Cardiology, University of California, Los Angeles (G.C.F.)
| | - Eric D Peterson
- From the Duke Clinical Research Institute, Durham, NC (Y.X., P.J.S., M.C., A.F.H., B.L.L., E.D.P.); Department of Neurology, University of Rochester Medical Center, NY (R.G.H.); Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Boston (L.H.S.); Department of Epidemiology, Michigan State University, East Lansing (M.J.R.); Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.); Neurology & Neurotherapeutics, Neurological Surgery, University of Texas Southwestern Medical Center, Dallas (D.M.O.); and Division of Cardiology, University of California, Los Angeles (G.C.F.)
| |
Collapse
|
133
|
Bradford MA, Lindenauer PK, Wiener RS, Walkey AJ. Do-not-resuscitate status and observational comparative effectiveness research in patients with septic shock*. Crit Care Med 2014; 42:2042-7. [PMID: 24810532 PMCID: PMC4266548 DOI: 10.1097/ccm.0000000000000403] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVES To assess the importance of including do-not-resuscitate status in critical care observational comparative effectiveness research. DESIGN Retrospective analysis. SETTING All California hospitals participating in the 2007 California State Inpatient Database, which provides do-not-resuscitate status within the first 24 hours of admission. PATIENTS Septic shock present at admission. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We investigated the association of early do-not-resuscitate status with in-hospital mortality among patients with septic shock. We also examined the strength of confounding of do-not-resuscitate status on the association between activated protein C therapy and mortality, an association with conflicting results between observational and randomized studies. We identified 24,408 patients with septic shock; 19.6% had a do-not-resuscitate order. Compared with patients without a do-not-resuscitate order, those with a do-not-resuscitate order were significantly more likely to be older (75 ± 14 vs 67 ± 16 yr) and white (62% vs 53%), with more acute organ failures (1.44 ± 1.15 vs 1.38 ± 1.15), but fewer inpatient interventions (1.0 ± 1.0 vs 1.4 ± 1.1). Adding do-not-resuscitate status to a model with 47 covariates improved mortality discrimination (c-statistic, 0.73-0.76; p < 0.001). Addition of do-not-resuscitate status to a multivariable model assessing the association between activated protein C and mortality resulted in a 9% shift in the activated protein C effect estimate toward the null (odds ratio from 0.78 [95% CI, 0.62-0.99], p = 0.04, to 0.85 [0.67-1.08], p = 0.18). CONCLUSIONS Among patients with septic shock, do-not-resuscitate status acts as a strong confounder that may inform past discrepancies between observational and randomized studies of activated protein C. Inclusion of early do-not-resuscitate status into more administrative databases may improve observational comparative effectiveness methodology.
Collapse
Affiliation(s)
- Mark A. Bradford
- Pulmonary Center and the Section of Pulmonary and Critical Care Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Peter K. Lindenauer
- Center for Quality of Care Research and Division of General Internal Medicine, Baystate Medical Center, Springfield MA, and Department of Medicine Tufts University School of Medicine, Boston MA USA
| | - Renda Soylemez Wiener
- Pulmonary Center and the Section of Pulmonary and Critical Care Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
- Center for Healthcare Organization & Implementation Research, ENRM VA Hospital, Bedford, MA
- The Dartmouth Institute for Healthcare Policy & Clinical Practice, Hanover, NH
| | - Allan J. Walkey
- Pulmonary Center and the Section of Pulmonary and Critical Care Medicine, Department of Medicine, Boston University School of Medicine, Boston, Massachusetts
| |
Collapse
|
134
|
Abstract
BACKGROUND Prognostication of mortality or severe disability often prompts withdrawal of technological life support in patients following aneurysmal subarachnoid hemorrhage (aSAH). We assessed admission factors impacting decisions to withdraw treatment after aSAH. METHODS Prospectively collected data of aSAH patients admitted to our institution between 1991 and 2009 were reviewed. Patients given comfort care measures were identified, including early withdrawal of treatment (<72 h after admission). Independent predictors of treatment withdrawal were assessed with multivariable analysis. RESULTS The study included 1,134 patients, of whom 72 % were female, 58 % white, and 38 % black or African-American. Mean age was 52.5 ± 14.0 years. In-hospital mortality was 18.3 %. Of the 207 patients who died, treatment was withdrawn in 72 (35 %) and comfort measures instituted early in 31 (15 %). Among patients who died, WOLST was associated with older age (63.6 ± 14.2 years, WOLST vs. 55.6 ± 13.7 years, no WOLST, p < 0.001); GCS score <8 (62 % of WOLST vs. 44 % with no WOLST, p = 0.010); HH >3 (72 % of WOLST vs. 53 % with no WOLST, p = 0.008); and hydrocephalus (81 % of WOLST vs. 63 % with no WOLST, p = 0.009). Independent predictors of WOLST were poorer Hunt and Hess grade (AOR 1.520, 95 % CI 1.160-1.992, p = 0.002) and older age (AOR 1.045, 95 % CI 1.022-1.068, p < 0.001) with the latter also impacting early WOLST decisions. CONCLUSIONS Older age and poor clinical grade on presentation predicted WOLST, and age predicted decisions to withdraw treatment earlier following aSAH. While based on prognosis, and in some cases patient wishes, this may also constitute a self-fulfilling prophecy in others.
Collapse
|
135
|
Jain A, Jain M, Bellolio MF, Schears RM, Rabinstein AA, Ganti L. Is early DNR a self-fulfilling prophecy for patients with spontaneous intracerebral hemorrhage? Neurocrit Care 2014; 19:342-6. [PMID: 23884512 DOI: 10.1007/s12028-013-9878-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
BACKGROUND To investigate differences in outcome of patients with intracerebral hemorrhage (ICH) based on institution of do-not-resuscitate (DNR) order within first 24 h of admission. METHODS A prospective registry of patients presenting with ICH from Jan 2006 to Dec 2008 was created. Patients with and without DNR orders instituted within 24 h of admission were classified as cases and controls respectively and were matched based on age and stroke severity. Demographics, intracerebral volume of hematoma, intraventricular extension of hemorrhage (IVH), invasive treatments, and outcomes at discharge were collected. All patients were followed up at least for 1 year, to determine mortality outcomes. RESULTS Of a total of 245 subjects, 18 % had DNR order instituted within 24 h of admission. After matching, a total of 69 controls were available for 44 cases. There was no difference in demographics, IVH extension, volume of hemorrhage, and length of stay among cases and controls. Higher proportions of controls had surgical evacuation of the hematoma (p = 0.0125) and mechanical ventilation (p = 0.0001). There was no significant difference in functional outcome and survival rates among cases and controls at the end of 1 week, 1 month, and 1 year. CONCLUSIONS DNR institution and restriction of resuscitation was not associated with poor outcome or difference in survival within 1 year after ICH. This indicates an early DNR probably does not lead to a self-fulfilling prophecy in this population, and might be explained by our practice, were DNR orders do not impact the level of supportive medical care we provide.
Collapse
Affiliation(s)
- A Jain
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | | | | | | | | | | |
Collapse
|
136
|
Fukuhara T, Aoi M, Namba Y. Mechanical ventilation for comatose patients with inoperative acute intracerebral hemorrhage: possible futility of treatment. PLoS One 2014; 9:e103531. [PMID: 25062014 PMCID: PMC4111623 DOI: 10.1371/journal.pone.0103531] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 06/30/2014] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Comatose patients with acute intracerebral hemorrhage (ICH) diagnosed as inoperative due to their severe comorbidity will be treated differently between countries. In certain countries including Japan, aggressive medical care may be performed according to the patients' family requests although the effects on the outcome are obscure. For respiratory distress in comatose patients with inoperative acute ICH, the role of mechanical ventilation on the outcome is unknown. We speculated that the efficacy of a ventilator in such a specific condition is limited and possibly futile. METHODS We retrospectively evaluated the in-hospital mortality and further outcome of 65 comatose patients with inoperative ICH. Among the patients, 56 manifested respiratory distress, and the effect of the ventilator was evaluated by comparing the patients treated with and without the ventilator. RESULTS The in-hospital mortality was calculated as 80%. A statistically significant parameter affecting the mortality independently was the motor subset on the Glasgow Coma Scale (P = 0.015). Among the patients who manifested respiratory distress, 7.7% of patients treated with a ventilator and 14.0% of patients not treated with a ventilator survived; an outcome is not significantly different. The mean survival duration of patients treated with a ventilator was significantly longer than the mean survival duration of patients not treated with a ventilator (P = 0.021). Among the surviving 13 patients, 7 patients died 5 to 29 months after onset without significant consciousness recovery. Another 6 patients suffered continuous disablement due to prolonged severe consciousness disturbances. CONCLUSION The current results indicate that treating comatose patients resulting from inoperative acute ICH may be futile. In particular, treating these patients with a ventilator only has the effect of prolonging unresponsive life, and the treatment may be criticized from the perspective of the appropriate use of public medical resources.
Collapse
Affiliation(s)
- Toru Fukuhara
- Department of Neurological Surgery, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Mizuho Aoi
- Department of Neurological Surgery, National Hospital Organization Okayama Medical Center, Okayama, Japan
| | - Yoichiro Namba
- Department of Neurological Surgery, National Hospital Organization Okayama Medical Center, Okayama, Japan
| |
Collapse
|
137
|
Han J, King NK, Neilson SJ, Gandhi MP, Ng I. External Validation of the CRASH and IMPACT Prognostic Models in Severe Traumatic Brain Injury. J Neurotrauma 2014; 31:1146-52. [DOI: 10.1089/neu.2013.3003] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Julian Han
- Department of Neurosurgery, National Neuroscience Institute, Singapore
| | - Nicolas K.K. King
- Department of Neurosurgery, National Neuroscience Institute, Singapore
| | - Sam J. Neilson
- Manchester Medical School, University of Manchester, Manchester, United Kingdom
| | - Mihir P. Gandhi
- Centre of Quantitative Medicine, Duke-National University of Singapore Graduate Medical School, Singapore
- Department of Biostatistics, Singapore Clinical Research Institute, Singapore
| | - Ivan Ng
- Department of Neurosurgery, National Neuroscience Institute, Singapore
| |
Collapse
|
138
|
Holloway RG, Arnold RM, Creutzfeldt CJ, Lewis EF, Lutz BJ, McCann RM, Rabinstein AA, Saposnik G, Sheth KN, Zahuranec DB, Zipfel GJ, Zorowitz RD. Palliative and End-of-Life Care in Stroke. Stroke 2014; 45:1887-916. [DOI: 10.1161/str.0000000000000015] [Citation(s) in RCA: 179] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
139
|
Geurts M, Macleod MR, van Thiel GJMW, van Gijn J, Kappelle LJ, van der Worp HB. End-of-life decisions in patients with severe acute brain injury. Lancet Neurol 2014; 13:515-24. [PMID: 24675048 DOI: 10.1016/s1474-4422(14)70030-4] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Most in-hospital deaths of patients with stroke, traumatic brain injury, or postanoxic encephalopathy after cardiac arrest occur after a decision to withhold or withdraw life-sustaining treatments. Decisions on treatment restrictions in these patients are generally complex and are based only in part on evidence from published work. Prognostic models to be used in this decision-making process should have a strong discriminative power. However, for most causes of acute brain injury, prognostic models are not sufficiently accurate to serve as the sole basis of decisions to limit treatment. These decisions are also complicated because patients often do not have the capacity to communicate their preferences. Additionally, surrogate decision makers might not accurately represent the patient's preferences. Finally, in the acute stage, prediction of how a patient would adapt to a life with major disability is difficult.
Collapse
Affiliation(s)
- Marjolein Geurts
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands.
| | - Malcolm R Macleod
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Jan van Gijn
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, Netherlands
| |
Collapse
|
140
|
Geriatric experience following cardiac arrest at six interventional cardiology centers in the United States 2006-2011: interplay of age, do-not-resuscitate order, and outcomes. Crit Care Med 2014; 42:289-95. [PMID: 24107639 DOI: 10.1097/ccm.0b013e3182a26ec6] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES It is not known if aggressive postresuscitation care, including therapeutic hypothermia and percutaneous coronary intervention, benefits cardiac arrest survivors more than 75 years old. We compared treatments and outcomes of patients at six regional percutaneous coronary intervention centers in the United States to determine if aggressive care of elderly patients was warranted. DESIGN Retrospective evaluation of registry data. SETTING Six interventional cardiology centers in the United States. PATIENTS Six hundred and twenty-five unresponsive cardiac arrest survivors aged 18-75 were compared with 129 similar patients aged more than 75. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Cardiac arrest survivors aged more than 75 had more comorbidities (3.0 ± 1.6 vs 2.0 ± 1.6, p < 0.001), but were matched to younger patients in initial heart rhythm, witnessed arrests, bystander cardiopulmonary resuscitation, and total ischemic time. Patients aged more than 75 frequently underwent therapeutic hypothermia (97.7%), urgent coronary angiography (44.2%), and urgent percutaneous coronary intervention (24%). They had more sustained hyperglycemia (70.5% vs 59%, p = 0.015), less postcooling fever (25.2% vs 35.2%, p = 0.03), were more likely to have do-not-resuscitate orders (65.9% vs 48.2%, p < 0.001), and undergo withdrawal of life support (61.2% vs 47.5%, p = 0.005). Good functional outcome at 6 months (Cerebral Performance Category 1-2) was seen in 27.9% elderly versus 40.4% younger patients overall (p = 0.01) and in 44% versus 55% (p = 0.13) of patients with an initial shockable rhythm. Of 35 survivors more than 75 years old, 33 (94.8%) were classified as Cerebral Performance Category 1 or 2 at (mean) 6.5-month follow-up. In multivariable logistic regression modeling, age more than 75 was significantly associated with outcome only when the presence of a do-not-resuscitate order was excluded from the model. CONCLUSIONS Elderly patients were more likely to have do-not-resuscitate orders and to undergo withdrawal of life support. Age was independently associated with outcome only when correction for do-not-resuscitate status was excluded, and functional outcomes of elderly survivors were similar to younger patients. Exclusion of patients more than 75 years old from aggressive care is not warranted on the basis of age alone.
Collapse
|
141
|
Kramer AH, Zygun DA. Donation after Circulatory Determination of Death: We Need to Respect and Protect Brain-injured Patients. Am J Respir Crit Care Med 2014; 189:504-5. [DOI: 10.1164/rccm.201308-1524le] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
|
142
|
Sadek AR, Eynon CA. The role of neurosciences intensive care in trauma and neurosurgical conditions. Br J Hosp Med (Lond) 2014; 74:552-7. [PMID: 24105307 DOI: 10.12968/hmed.2013.74.10.552] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The creation of neurosciences intensive care units was born out of the awareness that a group of neurological and neurosurgical patients required specialized intensive medical and nursing care. This first of two articles describes the role of neurosciences intensive care in the management of trauma and neurosurgical conditions.
Collapse
Affiliation(s)
- Ahmed-Ramadan Sadek
- Walport Academic Clinical Fellow in Neurosurgery and Jason Brice Fellow in Neurosurgical Research
| | | |
Collapse
|
143
|
Lee VH, Ouyang B, John S, Conners JJ, Garg R, Bleck TP, Temes RE, Cutting S, Prabhakaran S. Risk Stratification for the In-Hospital Mortality in Subarachnoid Hemorrhage: The HAIR Score. Neurocrit Care 2014; 21:14-9. [DOI: 10.1007/s12028-013-9952-9] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
|
144
|
Abstract
In face of any severe stroke, the questions for health professionals in charge of the patient are: will the handicap be acceptable for the patient? But can we predict an acceptable handicap for the patient? For his family? When we know that the cognitive disorders, consequences of severe stroke often modify, in a major way, the behaviour of these patients? Given these difficulties for estimate vital and functional prognosis and even more the quality of life of patients with severe stroke, collective reflexions between physicians and nurses are essential, reflexions taking into account preferences and values of patients. Use of resuscitation resources for severe stroke patients implies to offer them the best rehabilitation. So, questions about health pathways for severe stroke are essential: which structures for these patients, which technologies, which medical, medico-social and social supports, which human accompaniment the society can propose to the patients and to their family, so that they have an acceptable quality of life.
Collapse
Affiliation(s)
- F Woimant
- Service de neurologie, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France; Agence régionale de santé Île-de-France, 35, rue de la Gare, 75019 Paris, France.
| | - Y Biteye
- Agence régionale de santé Île-de-France, 35, rue de la Gare, 75019 Paris, France
| | - P Chaine
- Service de neurologie, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France
| | - S Crozier
- Service des urgences cérébrovasculaires, groupe hospitalier Pitié-Salpêtrière, AP-HP, 47-83, boulevard de l'Hôpital, 75013 Paris, France
| |
Collapse
|
145
|
Abid KA, Vail A, Patel HC, King AT, Tyrrell PJ, Parry-Jones AR. Which factors influence decisions to transfer and treat patients with acute intracerebral haemorrhage and which are associated with prognosis? A retrospective cohort study. BMJ Open 2013; 3:e003684. [PMID: 24345898 PMCID: PMC3884585 DOI: 10.1136/bmjopen-2013-003684] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES To identify factors associated with the decision to transfer and/or operate on patients with intracerebral haemorrhage (ICH) at a UK regional neurosurgical centre and test whether these decisions were associated with patient survival. DESIGN Retrospective cohort study. SETTING 14 acute and specialist hospitals served by the neurosurgical unit at Salford Royal NHS Foundation Trust, Salford, UK. PARTICIPANTS All patients referred acutely to neurosurgery from January 2008 to October 2010. OUTCOME MEASURES Primary outcome was survival and secondary outcomes were transfer to the neurosurgical centre and acute neurosurgery. RESULTS We obtained clinical data from 1364 consecutive spontaneous patients with ICH and 1175 cases were included in the final analysis. 140 (12%) patients were transferred and 75 (6%) had surgery. In a multifactorial analysis, the decision to transfer was more likely with younger age, women, brainstem and cerebellar location and larger haematomas. Risk of death in the following year was higher with advancing age, lower Glasgow Coma Scale, larger haematomas, brainstem ICH and intraventricular haemorrhage. The transferred patients had a lower risk of death relative to those remaining at the referring centre whether they had surgery (HR 0.46, 95% CI 0.32 to 0.67) or not (HR 0.41, 95% CI 0.22 to 0.73). Acute management decisions were included in the regression model for the 227 patients under either stroke medicine or neurosurgery at the neurosurgical centre and early do-not-resuscitate orders accounted for much of the observed difference, independently associated with an increased risk of death (HR 4.8, 95% CI 2.7 to 8.6). CONCLUSIONS The clear association between transfer to a specialist centre and survival, independent of established prognostic factors, suggests aggressive supportive care at a specialist centre may improve survival in ICH and warrants further investigation in prospective studies.
Collapse
Affiliation(s)
- Kamran A Abid
- Department of Neurosurgery, Salford Royal NHS Foundation Trust, Salford, UK
| | | | | | | | | | | |
Collapse
|
146
|
Gilmore EJ, Sheth KN. Improving ascertainment and communication of prognosis in intracerebral hemorrhage. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:1021. [PMID: 24321182 PMCID: PMC4059379 DOI: 10.1186/cc13144] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
Prognostication after intracerebral hemorrhage remains a significant challenge for the field of neurocritical care. Despite several available tools that can predict mortality and, to some degree, functional outcomes, deciding which prediction score to use and how best to translate the resultant population-based value to the individual level is not always clear. As more and more scores are published, we need to give due attention to the qualitative aspect of prognostication and explore how best to move this critical aspect of our field forward.
Collapse
|
147
|
Kelly ML, Sulmasy DP, Weil RJ. Spontaneous intracerebral hemorrhage and the challenge of surgical decision making: a review. Neurosurg Focus 2013; 34:E1. [PMID: 23634913 DOI: 10.3171/2013.2.focus1319] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Decision making for patients with spontaneous intracerebral hemorrhage (ICH) poses several challenges. Outcomes in this patient population are generally poor, prognostication is often uncertain, and treatment strategies offer limited benefits. Studies demonstrate variability in the type and intensity of treatment offered, which is attributed to clinical uncertainty and habits of training. Research has focused on new techniques and more stringent evidence-based selection criteria to improve outcomes and produce consensus around treatment strategies for patients with ICH. Such focus, however, offers little description of how ICH treatment decisions are made and how such decisions reflect patient preferences regarding medical care. A growing body of literature suggests that the process of decision making in ICH is laden with bias, value assumptions, and subjective impressions. Factors such as geography, cognitive biases, patient perceptions, and physician characteristics can all shape decision making and the selection of treatment. Such factors often serve as a barrier to providing patient-centered medical care. In this article, the authors review how surgical decision making for patients with ICH is shaped by these decisional factors and suggest future research pathways to study decision making in ICH. Such research efforts are important for establishing quality guidelines and pay-for-performance measures that reflect the preferences of individual patients and the contextual nature of medical decision making.
Collapse
Affiliation(s)
- Michael L Kelly
- Department of Neurosurgery, Neurological Institute, Cleveland Clinic Foundation, Cleveland, Ohio 44195, USA.
| | | | | |
Collapse
|
148
|
Leslie-Mazwi TM, Chandra RV, Simonsen CZ, Yoo AJ. Elderly patients and intra-arterial stroke therapy. Expert Rev Cardiovasc Ther 2013; 11:1713-23. [PMID: 24195443 DOI: 10.1586/14779072.2013.839219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Ischemic stroke disproportionately affects the elderly, particularly those over the age of 80 years. Rates of stroke are expected to increase over the next several decades due to increasing numbers of elderly individuals, making understanding stroke treatment in this population an imperative. The only proven acute stroke therapy is early reperfusion, accomplished through intravenous or intra-arterial means. Intra-arterial stroke therapy (IAT) offers higher recanalization rates than intravenous tissue plasminogen activator, but has yet to show clear superiority over intravenous tissue plasminogen activator alone. Existing data suggest that elderly stroke patients suffer worse outcomes following IAT, despite similar rates of recanalization and symptomatic intracranial hemorrhage. This article reviews the application of IAT in the elderly population and summarizes the available studies that investigate the response of elderly patients to IAT.
Collapse
Affiliation(s)
- Thabele M Leslie-Mazwi
- Neuroendovascular, Neurologic Critical Care, Massachusetts General Hospital, Boston, USA
| | | | | | | |
Collapse
|
149
|
Silvennoinen K, Meretoja A, Strbian D, Putaala J, Kaste M, Tatlisumak T. Do-not-resuscitate (DNR) orders in patients with intracerebral hemorrhage. Int J Stroke 2013; 9:53-8. [PMID: 24148872 DOI: 10.1111/ijs.12161] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE Do-not-resuscitate orders may be associated with poor outcome in patients with intracerebral hemorrhage because of less active management. AIMS We sought to characterize the practice of issuing do-not-resuscitate orders in intracerebral hemorrhage. We also aimed to identify possible differences in care according to do-not-resuscitate status. METHODS We conducted a retrospective study of all consecutive intracerebral hemorrhage patients admitted to the Meilahti Hospital of the Helsinki University Central Hospital between January 2005 and March 2010. Data obtained from medical records allowed comparison of characteristics of patients and care of do-not-resuscitate and non-do-not-resuscitate patients as well as patients with early (within 24 h) and late (>24 h) do-not-resuscitate decisions. Logistic regression was used to identify factors independently associated with do-not-resuscitate decisions. RESULTS Of our 1013 patients, a do-not-resuscitate order was issued in 368 (35%), of which 262 (73%) occurred within 24 h from admission. Advanced age (odds ratio 1·06 per year; 95% confidence interval 1·04-1·08), more severe stroke (1·09 per National Institutes of Health Stroke Scale point; 1·06-1·13), and deterioration soon after admission (5·12, 3·33-7·87) had the strongest associations with do-not-resuscitate decisions. Patients with do-not-resuscitate orders received recommended care including stroke unit care (43% vs. 64%; P < 0·001) and prophylaxis for deep venous thrombosis (45% vs. 54%; P = 0·027) less often than non-do-not-resuscitate patients. This was especially the case when the do-not-resuscitate order was issued early. CONCLUSIONS In addition to confirming the role of known intracerebral hemorrhage prognostic factors in do-not-resuscitate decision-making, our results demonstrate that do-not-resuscitate orders led to less active care of intracerebral hemorrhage patients.
Collapse
Affiliation(s)
- Katri Silvennoinen
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | | | | | | | | | | |
Collapse
|
150
|
Rincon F, Patel U, Schorr C, Lee E, Ross S, Dellinger RP, Zanotti-Cavazzoni S. Brain Injury as a Risk Factor for Fever Upon Admission to the Intensive Care Unit and Association With In-Hospital Case Fatality. J Intensive Care Med 2013; 30:107-14. [DOI: 10.1177/0885066613508266] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Purpose: To test the hypothesis that fever was more frequent in critically ill patients with brain injury when compared to nonneurological patients and to study its effect on in-hospital case fatality. Methods: Retrospective matched cohort study utilizing a single-center prospectively compiled registry. Critically ill neurological patients ≥18 years and consecutively admitted to the intensive care unit (ICU) with acute ischemic stroke (AIS), intracerebral hemorrhage (ICH), and traumatic brain injury (TBI) were selected. Patients were matched by sex, age, and Acute Physiology and Chronic Health Evaluation II (APACHE-II) to a cohort of nonneurological patients. Fever was defined as any temperature ≥37.5°C within the first 24 hours upon admission to the ICU. The primary outcome measure was in-hospital case fatality. Results: Mean age among neurological patients was 65.6 ± 15 years, 46% were men, and median APACHE-II was 15 (interquartile range 11-20). There were 18% AIS, 27% ICH, and 6% TBI. More neurological patients experienced fever than nonneurological patients (59% vs 47%, P = .007). The mean hospital length of stay was higher for nonneurological patients (18 ± 20 vs 14 ± 15 days, P = .007), and more neurological patients were dead at hospital discharge (29% vs 20%, P < .0001). After risk factor adjustment, diagnosis (neurological vs nonneurological), and the probability of being exposed to fever (propensity score), the following variables were associated with higher in-hospital case fatality: APACHE-II, neurological diagnosis, mean arterial pressure, cardiovascular and respiratory dysfunction in ICU, and fever (odds ratio 1.9, 95% confidence interval 1.04-3.6, P = .04). Conclusion: These data suggest that fever is a frequent occurrence after brain injury, and that it is independently associated with in-hospital case fatality.
Collapse
Affiliation(s)
- Fred Rincon
- Department of Medicine, Division of Critical Care and Cardiovascular Medicine, Robert Wood Johnson Medical School, Cooper University Hospital, UMDNJ, Camden, NJ, USA
| | - Utkal Patel
- Department of Medicine, Division of Critical Care and Cardiovascular Medicine, Robert Wood Johnson Medical School, Cooper University Hospital, UMDNJ, Camden, NJ, USA
| | - Christa Schorr
- Department of Medicine, Division of Critical Care and Cardiovascular Medicine, Robert Wood Johnson Medical School, Cooper University Hospital, UMDNJ, Camden, NJ, USA
| | - Elizabeth Lee
- Department of Medicine, Division of Critical Care and Cardiovascular Medicine, Robert Wood Johnson Medical School, Cooper University Hospital, UMDNJ, Camden, NJ, USA
| | - Steven Ross
- Department of Surgery, Division of Trauma and Critical Care, Robert Wood Johnson Medical School, Cooper University Hospital, UMDNJ, Camden, NJ, USA
| | - R. Phillip Dellinger
- Department of Medicine, Division of Critical Care and Cardiovascular Medicine, Robert Wood Johnson Medical School, Cooper University Hospital, UMDNJ, Camden, NJ, USA
| | - Sergio Zanotti-Cavazzoni
- Department of Medicine, Division of Critical Care and Cardiovascular Medicine, Robert Wood Johnson Medical School, Cooper University Hospital, UMDNJ, Camden, NJ, USA
| |
Collapse
|