重症监护室中高龄危重病人心脏骤停--心肺复苏是否合理?

Markus Haar, Jakob Müller, Daniela Hartwig, Julia von Bargen, Rikus Daniels, Pauline Theile, Stefan Kluge, Kevin Roedl
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引用次数: 0

摘要

重症监护室(ICU)中高龄患者的比例预计将上升。此外,患者很可能更容易在重症监护病房内发生心脏骤停(CA)事件。重症监护病房心脏骤停(ICU-CA)的发生与高死亡率有关。迄今为止,在接受治疗的高龄(≥ 90 岁)患者中,ICU-CA 的发生率及其对预后的临床影响尚不清楚。对汉堡(德国)一家三级甲等大学医院重症监护室连续收治的所有年龄≥90岁的重症患者进行了回顾性分析。所有患有重症监护病房急性心肌梗死的患者均被纳入其中,并对急性心肌梗死的特征和功能预后进行了评估。对临床病程和预后进行了评估,并对患有和未患有 ICUCA 的亚组患者进行了比较。研究期间共收治了 1108 名年龄≥ 90 岁的重症患者。中位年龄为 92.3(91.0-94.2)岁,67%(n = 747)为女性。其中 2%(n = 25)的患者在入住 ICU 的中位时间为 0.5(0.2-3.2)天后发生了 ICU-CA。64%(16 人)的 ICU-CA 推测病因是心脏疾病。复苏时间中位数为 10(2-15)分钟,20% 的患者(5 人)的初始心律是可电击的。68%的患者(17 例)可恢复自主循环(ROSC)。在所有队列中,入住 ICU 的原因主要是内科(ICU-CA:48% vs. 无 ICU-CA:34%,p = 0.13)、外科 - 计划内(ICU-CA:32% vs. 无 ICU-CA:37%,p = 0.61)和外科 - 非计划内/急诊(ICU-CA:43% vs. 无 ICU-CA:28%,p = 0.34)。ICU-CA 患者的夏尔森合并症指数(CCI)中位数为 2(1-3)分,无 ICU-CA 患者为 1(0-2)分(P = 0.54)。根据 SAPS II,ICU-CA 患者的疾病严重程度更高(ICU-CA:54 分;无 ICU-CA:36 分,p < 0.001)。ICU-CA 患者的机械通气率更高(ICU-CA:64% 对非 ICU-CA:34%,p < 0.01),需要血管加压疗法的次数更多(ICU-CA:88% 对非 ICU-CA:41%,p < 0.001)。ICU-CA 患者的 ICU 和院内死亡率分别为 88%(22 人)和 100%(25 人),而无 ICU-CA 患者的 ICU 和院内死亡率分别为 17%(179 人)和 28%(306 人)。据观察,ICU-CA 患者在重症监护室的死亡率为 88%(22 人),在院内的死亡率为 100%(25 人)。相比之下,无 ICU-CA 患者的重症监护室内死亡率为 17%(n = 179),院内死亡率为 28%(n = 306)(均 p <0.001)。高龄患者发生重症监护室心肺复苏术的情况很少见,但死亡率却很高。在我们的中心,为该组患者提供心肺复苏并不能提高他们的长期存活率。入住重症监护室的高龄患者可能只能从支持性护理中获益,由于存活几率较低和伦理方面的考虑,可能不应实施复苏。根据患者和家属的意愿提供个性化的护理保证,可以在避免无用的维持生命干预措施的同时,优化体恤护理。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Intensive care unit cardiac arrest among very elderly critically ill patients – is cardiopulmonary resuscitation justified?
The proportion of very elderly patients in the intensive care unit (ICU) is expected to rise. Furthermore, patients are likely more prone to suffer a cardiac arrest (CA) event within the ICU. The occurrence of intensive care unit cardiac arrest (ICU-CA) is associated with high mortality. To date, the incidence of ICU-CA and its clinical impact on outcome in the very old (≥ 90 years) patients treated is unknown. Retrospective analysis of all consecutive critically ill patients ≥ 90 years admitted to the ICU of a tertiary care university hospital in Hamburg (Germany). All patients suffering ICU-CA were included and CA characteristics and functional outcome was assessed. Clinical course and outcome were assessed and compared between the subgroups of patients with and without ICU-CA. 1,108 critically ill patients aged ≥ 90 years were admitted during the study period. The median age was 92.3 (91.0–94.2) years and 67% (n = 747) were female. 2% (n = 25) of this cohort suffered ICU-CA after a median duration 0.5 (0.2–3.2) days of ICU admission. The presumed cause of ICU-CA was cardiac in 64% (n = 16). The median resuscitation time was 10 (2–15) minutes and the initial rhythm was shockable in 20% (n = 5). Return of spontaneous circulation (ROSC) could be achieved in 68% (n = 17). The cause of ICU admission was primarily medical in the total cohort (ICU-CA: 48% vs. No ICU-CA: 34%, p = 0.13), surgical - planned (ICU-CA: 32% vs. No ICU-CA: 37%, p = 0.61) and surgical - unplanned/emergency (ICU-CA: 43% vs. No ICU-CA: 28%, p = 0.34). The median Charlson Comorbidity Index (CCI) was 2 (1–3) points for patients with ICU-CA and 1 (0–2) for patients without ICU-CA (p = 0.54). Patients with ICU-CA had a higher disease severity according to SAPS II (ICU-CA: 54 vs. No ICU-CA: 36 points, p < 0.001). Patients with ICU-CA had a higher rate of mechanically ventilation (ICU-CA: 64% vs. No ICU-CA: 34%, p < 0.01) and required vasopressor therapy more often (ICU-CA: 88% vs. No ICU-CA: 41%, p < 0.001). The ICU and in-hospital mortality was 88% (n = 22) and 100% (n = 25) in patients with ICU-CA compared to 17% (n = 179) and 28% (n = 306) in patients without ICU-CA. The mortality rate for patients with ICU-CA was observed to be 88% (n = 22) in the ICU and 100% (n = 25) in-hospital. In contrast, patients without ICU-CA had an in-ICU mortality rate of 17% (n = 179) and an in-hospital mortality rate of 28% (n = 306) (both p < 0.001). The occurrence of ICU-CA in very elderly patients is rare but associated with high mortality. Providing CPR in this cohort did not lead to long-term survival at our centre. Very elderly patients admitted to the ICU likely benefit from supportive care only and should probably not be resuscitated due to poor chance of survival and ethical considerations. Providing personalized assurances that care will remain appropriate and in accordance with the patient’s and family’s wishes can optimise compassionate care while avoiding futile life-sustaining interventions.
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