Department of Anesthesia Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA,
Neurocrit Care. 2013 Dec;19(3):269-75. doi: 10.1007/s12028-013-9929-8.
Prognostication of mortality or severe disability often prompts withdrawal of technological life support in patients following aneurysmal subarachnoid hemorrhage (aSAH). We assessed admission factors impacting decisions to withdraw treatment after aSAH.
Prospectively collected data of aSAH patients admitted to our institution between 1991 and 2009 were reviewed. Patients given comfort care measures were identified, including early withdrawal of treatment (<72 h after admission). Independent predictors of treatment withdrawal were assessed with multivariable analysis.
The study included 1,134 patients, of whom 72 % were female, 58 % white, and 38 % black or African-American. Mean age was 52.5 ± 14.0 years. In-hospital mortality was 18.3 %. Of the 207 patients who died, treatment was withdrawn in 72 (35 %) and comfort measures instituted early in 31 (15 %). Among patients who died, WOLST was associated with older age (63.6 ± 14.2 years, WOLST vs. 55.6 ± 13.7 years, no WOLST, p < 0.001); GCS score <8 (62 % of WOLST vs. 44 % with no WOLST, p = 0.010); HH >3 (72 % of WOLST vs. 53 % with no WOLST, p = 0.008); and hydrocephalus (81 % of WOLST vs. 63 % with no WOLST, p = 0.009). Independent predictors of WOLST were poorer Hunt and Hess grade (AOR 1.520, 95 % CI 1.160-1.992, p = 0.002) and older age (AOR 1.045, 95 % CI 1.022-1.068, p < 0.001) with the latter also impacting early WOLST decisions.
Older age and poor clinical grade on presentation predicted WOLST, and age predicted decisions to withdraw treatment earlier following aSAH. While based on prognosis, and in some cases patient wishes, this may also constitute a self-fulfilling prophecy in others.
在患有蛛网膜下腔出血（aSAH）的患者中，预测死亡率或严重残疾通常会促使停止使用技术生命支持。我们评估了影响 aSAH 后停止治疗决策的入院因素。
回顾了 1991 年至 2009 年期间我院收治的 aSAH 患者的前瞻性收集数据。确定了接受舒适护理措施的患者，包括在入院后 72 小时内（<72 h）早期停止治疗。使用多变量分析评估治疗停止的独立预测因素。
该研究共纳入 1134 例患者，其中 72%为女性，58%为白人，38%为黑人和非裔美国人。平均年龄为 52.5±14.0 岁。院内死亡率为 18.3%。在 207 例死亡患者中，72 例（35%）停止治疗，31 例（15%）早期采用舒适措施。在死亡患者中，WOLST 与年龄较大有关（63.6±14.2 岁，WOLST 与无 WOLST 组，55.6±13.7 岁，p<0.001）；GCS 评分<8（62%的 WOLST 与无 WOLST 组的 44%，p=0.010）；HH>3（72%的 WOLST 与无 WOLST 组的 53%，p=0.008）；和脑积水（81%的 WOLST 与无 WOLST 组的 63%，p=0.009）。WOLST 的独立预测因素是较差的 Hunt 和 Hess 分级（AOR 1.520，95%CI 1.160-1.992，p=0.002）和年龄较大（AOR 1.045，95%CI 1.022-1.068，p<0.001），后者也会影响 aSAH 后早期 WOLST 决策。
发病时年龄较大和临床分级较差预测 WOLST，年龄预测 aSAH 后更早停止治疗的决策。虽然这是基于预后，在某些情况下是基于患者的意愿，但在其他情况下，这也可能构成自我实现的预言。
