Golestanian Ellie, Liou Jinn-Ing, Smith Maureen A
Departments of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI, USA.
Crit Care Med. 2009 Dec;37(12):3107-13. doi: 10.1097/CCM.0b013e3181b079b2.
To compare survival in older patients with acute ischemic stroke admitted to intensive care units (ICUs) with those not requiring ICU care and to assess the impact of mechanical ventilation (MV) and percutaneous gastrostomy tubes (PEG) on long-term mortality.
Multicentered retrospective cohort study.
Administrative data from the Centers for Medicare and Medicaid Services covering 93 metropolitan counties primarily in the eastern half of the United States.
31,301 patients discharged with acute ischemic stroke in 2000.
None.
Mortality from the time of index hospitalization up to the end of the follow-up period of 12 months. Information was also gathered on use of mechanical ventilation, percutaneous gastrostomy, sociodemographic variables and a host of comorbid conditions. Of all patients with acute ischemic stroke, 26% required ICU admission. The crude death rate for ICU stroke patients was 21% at 30 days and 40% at 1-yr follow-up. At 30 days, after adjustment of sociodemographic variables and comorbidities, ICU patients had a 29% higher mortality hazard compared with non-ICU patients. MV was associated with a five-fold higher mortality hazard (hazard ratio 5.59, confidence interval [CI] 4.93-6.34). The use of PEG was not associated with mortality at 30 days. By contrast, at 1-yr follow up in 30-day survivors, ICU admission was not associated with mortality hazard (hazard ratio 1.01, 95% CI 0.93-1.09). MV still had a higher risk of death (hazard ratio 1.88, 95% CI 1.57-2.25), and PEG patients had a 2.59-fold greater mortality hazard (95% CI 2.38-2.82).
Both short-term and long-term mortality in older patients with acute ischemic stroke admitted to ICUs is lower than previously reported. The need for MV and PEG are markers for poor long-term outcome. Future research should focus on the identification of clinical factors that lead to increased mortality in long-term survivors and efforts to reduce those risks.
比较入住重症监护病房(ICU)的老年急性缺血性卒中患者与无需ICU治疗的患者的生存率,并评估机械通气(MV)和经皮胃造瘘管(PEG)对长期死亡率的影响。
多中心回顾性队列研究。
来自医疗保险和医疗补助服务中心的行政数据,涵盖主要位于美国东半部的93个大都市县。
2000年因急性缺血性卒中出院的31301例患者。
无。
从首次住院至12个月随访期结束的死亡率。还收集了有关机械通气、经皮胃造瘘术的使用情况、社会人口统计学变量以及一系列合并症的信息。在所有急性缺血性卒中患者中,26%需要入住ICU。ICU卒中患者的30天粗死亡率为21%,1年随访时为40%。在调整社会人口统计学变量和合并症后,30天时,ICU患者的死亡风险比非ICU患者高29%。MV与死亡风险高出五倍相关(风险比5.59,置信区间[CI]4.93 - 6.34)。PEG的使用在30天时与死亡率无关。相比之下,在30天幸存者的1年随访中,入住ICU与死亡风险无关(风险比1.01,95%CI 0.93 - 1.09)。MV仍然具有较高的死亡风险(风险比1.88,95%CI 1.57 - 2.25),且PEG患者的死亡风险高出2.59倍(95%CI 2.38 - 2.82)。
入住ICU的老年急性缺血性卒中患者的短期和长期死亡率均低于先前报道。MV和PEG的需求是长期预后不良的标志。未来的研究应侧重于确定导致长期幸存者死亡率增加的临床因素,并努力降低这些风险。