1Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD. 2Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University School of Medicine, Baltimore, MD. 3Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. 4Critical Care Medicine Department, National Institutes of Health, Bethesda, MD. 5Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. 6Division of Pulmonary and Critical Care Medicine, University of Maryland, Baltimore, MD. 7Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD.
Crit Care Med. 2014 Feb;42(2):296-302. doi: 10.1097/CCM.0b013e3182a272db.
Substantial variability exists in the timing of limitations in life support for critically ill patients. Our objective was to investigate how the timing of limitations in life support varies with changes in organ failure status and time since acute lung injury onset.
DESIGN, SETTING, AND PATIENTS: This evaluation was performed as part of a prospective cohort study evaluating 490 consecutive acute lung injury patients recruited from 11 ICUs at three teaching hospitals in Baltimore, MD.
None.
The primary exposure was proportion of days without improvement in Sequential Organ Failure Assessment score, evaluated as a daily time-varying exposure. The outcome of interest was a documented limitation in life support defined as any of the following: 1) no cardiopulmonary resuscitation, 2) do not reintubate, 3) no vasopressors, 4) no hemodialysis, 5) do not escalate care, or 6) other limitations (e.g., "comfort care only").
For medical ICU patients without improvement in daily Sequential Organ Failure Assessment score, the rate of limitation in life support tripled in the first 3 days after acute lung injury onset, increased again after day 5, and peaked at day 19. Compared with medical ICU patients, surgical ICU patients had a rate of limitations that was significantly lower during the first 5 days after acute lung injury onset. In all patients, more days without improvement in Sequential Organ Failure Assessment scores was associated with limitations in life support, independent of the absolute magnitude of the Sequential Organ Failure Assessment score.
Persistent organ failure is associated with an increase in the rate of limitations in life support independent of the absolute magnitude of Sequential Organ Failure Assessment score, and this association strengthens during the first weeks of treatment. During the first 5 days after acute lung injury onset, limitations were significantly more common in medical ICUs than surgical ICUs.
危重病患者生命支持限制的时机存在很大差异。我们的目的是研究生命支持限制的时机如何随器官衰竭状态的变化和急性肺损伤发病后的时间而变化。
设计、地点和患者：这项评估是作为评估马里兰州巴尔的摩三家教学医院 11 个 ICU 中连续 490 例急性肺损伤患者的前瞻性队列研究的一部分进行的。
无。
主要暴露是序贯器官衰竭评估评分无改善天数的比例，作为每日时变暴露进行评估。感兴趣的结局是记录的生命支持限制，定义为以下任何一种情况：1）无心肺复苏，2）不重新插管，3）无血管加压素，4）无血液透析，5）不升级治疗，或 6）其他限制（例如，“仅提供舒适护理”）。
对于每日序贯器官衰竭评估评分无改善的内科 ICU 患者，急性肺损伤发病后 3 天内生命支持限制的发生率增加了两倍，发病后第 5 天再次增加，并在第 19 天达到峰值。与内科 ICU 患者相比，外科 ICU 患者在急性肺损伤发病后前 5 天的限制发生率明显较低。在所有患者中，序贯器官衰竭评估评分无改善的天数越多，与生命支持限制相关，而与序贯器官衰竭评估评分的绝对值无关。
持续的器官衰竭与生命支持限制率的增加相关，而与序贯器官衰竭评估评分的绝对值无关，这种相关性在治疗的最初几周内会增强。急性肺损伤发病后 5 天内，内科 ICU 中的限制明显比外科 ICU 更常见。
