有或无急性脑损伤患者撤销或停止维持生命治疗的决定：两项前瞻性队列研究的二次分析

IF 38.7 1区医学 Q1 CRITICAL CARE MEDICINE

Lancet Respiratory Medicine Pub Date : 2025-03-17 DOI:10.1016/s2213-2600(24)00404-1

Shaurya Taran, Kuan Liu, Victoria A McCredie, Oscar Penuelas, Karen E A Burns, Fernando Frutos-Vivar, Damon C Scales, Niall D Ferguson, Jeffrey M Singh, Armaan K Malhotra, Neill K J Adhikari

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引用次数: 0

摘要

背景：重症监护病房（ICU）的许多死亡发生在决定撤销或停止生命维持治疗（WLSTs）之后。我们旨在探讨急性脑损伤（ABIs）患者和非急性脑损伤患者之间WLST发生率和时间的差异。方法：我们对两项前瞻性国际研究进行了二次分析，这些研究招募了2004年至2016年间来自40个国家的有创或无创通气患者。ABI被定义为脑外伤、缺血性中风、颅内出血、癫痫发作或脑膜炎-脑炎。比较组包括非abi条件。利用累积入射曲线评估到达最低温度的时间。采用多水平逻辑回归分析WLST的差异。在2004年3月11日至2016年12月17日期间，我们招募了21 970例患者（WLST分析中为16 791例），其中13 526例（61.6%）为男性，8444例（38.4%）为女性，2896例（13.2%）为ABI。16791例患者中有2056例（12.2%）发生WLST， ABI患者比非ABI患者更常见(2191例中有372例[17.0%]对14600例中有1684例[11.5%]；风险差5.5%；95% ci 3.8 - 7.1；优势比[OR] 2·42；1·89 - 3·12)。ABI患者比无ABI患者更早做出WLST决定(中位数，ICU入院后4天[IQR 2-9]对6天[2-13]；绝对差，2天；95% ci 1-3)。不同ABI亚组、世界地区和队列年份的研究结果相似。icu对ABI患者和非ABI患者的WLST决策的变异性很高(中位OR分别为3.04；95% CI 2.54 - 3.67，中位OR 2.59；2·38-2·78)。我们的研究结果表明，与非ABI患者相比，ABI患者的WLST决定明显更常见，并且在该组中发生得更早。ABI后早期WLST的基本原理值得进一步探索，考虑到目前分析中无法获得的其他神经学因素。资助加拿大卫生研究所。

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Decisions to withdraw or withhold life-sustaining therapies in patients with and without acute brain injury: a secondary analysis of two prospective cohort studies

Background

Many deaths in the intensive care unit (ICU) occur after a decision to withdraw or withhold life-sustaining therapies (WLSTs). We aimed to explore the differences in the incidence and timing of WLST between patients with and without acute brain injuries (ABIs).

Methods

We did a secondary analysis of two prospective, international studies that recruited patients who were invasively or non-invasively ventilated between 2004 and 2016 from 40 countries. ABI was defined as brain trauma, ischaemic stroke, intracranial haemorrhage, seizures, or meningitis–encephalitis. The comparator group included non-ABI conditions. Time to WLST was evaluated by use of cumulative incidence curves. Differences in WLST were analysed by use of multilevel logistic regression.

Findings

Between March 11, 2004, and Dec 17, 2016, we recruited 21 970 patients (16 791 in the WLST analysis), of whom 13 526 (61·6%) were male and 8444 (38·4%) were female and 2896 (13·2%) had ABI. WLST occurred in 2056 (12·2%) of 16 791 patients) and was more common in patients with ABI versus without (372 [17·0%] of 2191 vs 1684 [11·5%] of 14 600; risk difference 5·5%; 95% CI 3·8–7·1; odds ratio [OR] 2·42; 1·89–3·12). WLST decisions occurred earlier in patients with ABI versus patients without ABI (median, 4 days [IQR 2–9] versus 6 days [2–13] after ICU admission; absolute difference, 2 days; 95% CI 1–3). Findings were similar across different ABI subgroups, world regions, and cohort years. Variability among ICUs in WLST decisions for patients with ABI and patients without ABI was high (respectively, median OR, 3·04; 95% CI 2·54–3·67, and median OR 2·59; 2·38–2·78).

Interpretation

Our findings suggest that WLST decisions are significantly more common in patients with ABI versus patients without ABI and occur earlier in this group. The rationale for early WLST following ABI warrants further exploration, accounting for additional neurological factors that were not available in the present analysis.

Funding

Canadian Institutes of Health Research.

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来源期刊

Lancet Respiratory Medicine RESPIRATORY SYSTEM-RESPIRATORY SYSTEM

CiteScore

87.10

自引率

0.70%

发文量

572

期刊介绍： The Lancet Respiratory Medicine is a renowned journal specializing in respiratory medicine and critical care. Our publication features original research that aims to advocate for change or shed light on clinical practices in the field. Additionally, we provide informative reviews on various topics related to respiratory medicine and critical care, ensuring a comprehensive coverage of the subject. The journal covers a wide range of topics including but not limited to asthma, acute respiratory distress syndrome (ARDS), chronic obstructive pulmonary disease (COPD), tobacco control, intensive care medicine, lung cancer, cystic fibrosis, pneumonia, sarcoidosis, sepsis, mesothelioma, sleep medicine, thoracic and reconstructive surgery, tuberculosis, palliative medicine, influenza, pulmonary hypertension, pulmonary vascular disease, and respiratory infections. By encompassing such a broad spectrum of subjects, we strive to address the diverse needs and interests of our readership.