脑损伤患者神经死亡的发生率：加拿大一个卫生区域的队列研究。
Incidence of neurologic death among patients with brain injury: a cohort study in a Canadian health region.
出版信息
CMAJ. 2013 Dec 10;185(18):E838-45. doi: 10.1503/cmaj.130271. Epub 2013 Oct 28.
BACKGROUND
Hospital mortality has decreased over time for critically ill patients with various forms of brain injury. We hypothesized that the proportion of patients who progress to neurologic death may have also decreased.
METHODS
We performed a prospective cohort study involving consecutive adult patients with traumatic brain injury, subarachnoid hemorrhage, intracerebral hemorrhage or anoxic brain injury admitted to regional intensive care units in southern Alberta over a 10.5-year period. We used multivariable logistic regression to adjust for patient age and score on the Glasgow Coma Scale at admission, and to assess whether the proportion of patients who progress to neurologic death has changed over time.
RESULTS
The cohort consisted of 2788 patients. The proportion of patients who progressed to neurologic death was 8.1% at the start of the study period, and the adjusted odds of progressing to neurologic death decreased over the study period (odds ratio [OR] per yr 0.92, 95% confidence interval [CI] 0.87-0.98, p = 0.006). This change was most pronounced among patients with traumatic brain injury (OR per yr 0.87, 95% CI 0.78-0.96, p = 0.005); there was no change among patients with anoxic injury (OR per yr 0.96, 95% CI 0.85-1.09, p = 0.6). A review of the medical records suggests that missed cases of neurologic death were rare (≤ 0.5% of deaths).
INTERPRETATION
The proportion of patients with brain injury who progress to neurologic death has decreased over time, especially among those with head trauma. This finding may reflect positive developments in the prevention and care of brain injury. However, organ donation after neurologic death represents the major source of organs for transplantation. Thus, these findings may help explain the relatively stagnant rates of deceased organ donation in some regions of Canada, which in turn has important implications for the care of patients with end-stage organ failure.
背景
患有各种形式脑损伤的重症患者的住院死亡率随着时间的推移而降低。我们假设进展为神经死亡的患者比例也可能降低。
方法
我们进行了一项前瞻性队列研究，纳入了在过去 10.5 年期间在艾伯塔省南部地区的区域重症监护病房住院的成年创伤性脑损伤、蛛网膜下腔出血、脑出血或缺氧性脑损伤患者。我们使用多变量逻辑回归来调整患者年龄和入院时格拉斯哥昏迷量表评分，并评估进展为神经死亡的患者比例是否随时间发生变化。
结果
该队列包括 2788 名患者。在研究开始时，进展为神经死亡的患者比例为 8.1%，在研究期间，进展为神经死亡的调整后 odds 呈下降趋势（每年的比值比 [OR] 为 0.92，95%置信区间 [CI] 为 0.87-0.98，p = 0.006）。这种变化在创伤性脑损伤患者中最为明显（每年的 OR 为 0.87，95%CI 为 0.78-0.96，p = 0.005）；在缺氧性损伤患者中无变化（每年的 OR 为 0.96，95%CI 为 0.85-1.09，p = 0.6）。对病历的审查表明，神经死亡漏诊病例很少（死亡人数的 ≤0.5%）。
解释
进展为神经死亡的脑损伤患者比例随时间的推移而降低，尤其是在头部创伤患者中。这一发现可能反映了在预防和治疗脑损伤方面的积极进展。然而，神经死亡后的器官捐献是移植器官的主要来源。因此，这些发现可能有助于解释加拿大一些地区死亡器官捐献率相对停滞的原因，这反过来对终末期器官衰竭患者的护理有重要影响。
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