Cook Deborah, Rocker Graeme, Marshall John, Sjokvist Peter, Dodek Peter, Griffith Lauren, Freitag Andreas, Varon Joseph, Bradley Christine, Levy Mitchell, Finfer Simon, Hamielec Cindy, McMullin Joseph, Weaver Bruce, Walter Stephen, Guyatt Gordon
Department of Medicine, McMaster University, Hamilton, Ont, Canada.
N Engl J Med. 2003 Sep 18;349(12):1123-32. doi: 10.1056/NEJMoa030083.
In critically ill patients who are receiving mechanical ventilation, the factors associated with physicians' decisions to withdraw ventilation in anticipation of death are unclear. The objective of this study was to examine the clinical determinants that were associated with the withdrawal of mechanical ventilation.
We studied adults who were receiving mechanical ventilation in 15 intensive care units, recording base-line physiological characteristics, daily Multiple Organ Dysfunction Scores, the patient's decision-making ability, the type of life support administered, the use of do-not-resuscitate orders, the physician's prediction of the patient's status, and the physician's perceptions of the patient's preferences about the use of life support. We examined the relation between these factors and withdrawal of mechanical ventilation, using Cox proportional-hazards regression analysis.
Of 851 patients who were receiving mechanical ventilation, 539 (63.3 percent) were successfully weaned, 146 (17.2 percent) died while receiving mechanical ventilation, and 166 (19.5 percent) had mechanical ventilation withdrawn. The need for inotropes or vasopressors was associated with withdrawal of the ventilator (hazard ratio, 1.78; 95 percent confidence interval, 1.20 to 2.66; P=0.004), as were the physician's prediction that the patient's likelihood of survival in the intensive care unit was less than 10 percent (hazard ratio, 3.49; 95 percent confidence interval, 1.39 to 8.79; P=0.002), the physician's prediction that future cognitive function would be severely impaired (hazard ratio, 2.51; 95 percent confidence interval, 1.28 to 4.94; P=0.04), and the physician's perception that the patient did not want life support used (hazard ratio, 4.19; 95 percent confidence interval, 2.57 to 6.81; P<0.001).
Rather than age or the severity of the illness and organ dysfunction, the strongest determinants of the withdrawal of ventilation in critically ill patients were the physician's perception that the patient preferred not to use life support, the physician's predictions of a low likelihood of survival in the intensive care unit and a high likelihood of poor cognitive function, and the use of inotropes or vasopressors.
在接受机械通气的重症患者中，与医生预期患者死亡而决定撤机相关的因素尚不清楚。本研究的目的是探讨与机械通气撤机相关的临床决定因素。
我们研究了在15个重症监护病房接受机械通气的成年人，记录基线生理特征、每日多器官功能障碍评分、患者的决策能力、给予的生命支持类型、不进行心肺复苏医嘱的使用情况、医生对患者状况的预测以及医生对患者关于使用生命支持的偏好的看法。我们使用Cox比例风险回归分析来研究这些因素与机械通气撤机之间的关系。
在851例接受机械通气的患者中，539例（63.3%）成功脱机，146例（17.2%）在接受机械通气时死亡，166例（19.5%）撤机。使用血管活性药物与撤机相关（风险比，1.78；95%置信区间，1.20至2.66；P = 0.004），医生预测患者在重症监护病房的生存可能性小于10%（风险比，3.49；95%置信区间，1.39至8.79；P = 0.002）、医生预测未来认知功能将严重受损（风险比，2.51；95%置信区间，1.28至4.94；P = 0.04）以及医生认为患者不希望使用生命支持（风险比，4.19；95%置信区间，2.57至6.81；P < 0.001）也与撤机相关。
在重症患者中，撤机的最强决定因素不是年龄、疾病严重程度和器官功能障碍，而是医生认为患者不希望使用生命支持、医生预测患者在重症监护病房生存可能性低且认知功能差的可能性高，以及使用血管活性药物。
