美国五家教学医院儿科重症监护病房的死亡流行病学*
Epidemiology of death in the PICU at five U.S. teaching hospitals*.
作者信息
Burns Jeffrey P, Sellers Deborah E, Meyer Elaine C, Lewis-Newby Mithya, Truog Robert D
机构信息
1Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, MA. 2Department of Anesthesia, Harvard Medical School, Boston, MA. 3Bronfenbrenner Center for Translational Research, College of Human Ecology, Cornell University, Ithaca, NY. 4Institute for Professionalism and Ethical Practice, Boston Children's Hospital, Boston, MA. 5Department of Psychiatry, Harvard Medical School, Boston, MA. 6Division of Pediatric Critical Care Medicine, Seattle Children's Hospital, Seattle, WA. 7Department of Pediatrics, University of Washington, Seattle, WA. 8Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA.
出版信息
Crit Care Med. 2014 Sep;42(9):2101-8. doi: 10.1097/CCM.0000000000000498.
OBJECTIVE
To determine the epidemiology of death in PICUs at 5 geographically diverse teaching hospitals across the United States.
DESIGN
Prospective case series.
SETTING
Five U.S. teaching hospitals.
SUBJECTS
We concurrently identified 192 consecutive patients who died prior to discharge from the PICU. Each site enrolled between 24 and 50 patients. Each PICU had similar organizational and staffing structures.
INTERVENTIONS
None.
MEASUREMENTS AND MAIN RESULTS
The overall mortality rate was 2.39% (range, 1.85-3.38%). One hundred thirty-three patients (70%) died following the withholding or withdrawal of life-sustaining treatments, 30 (16%) were diagnosed as brain dead, and 26 (14%) died following an unsuccessful resuscitation attempt. Fifty-seven percent of all deaths occurred within the first week of admission; these patients, who were more likely to have new onset illnesses or injuries, included the majority of those who died following unsuccessful cardiopulmonary resuscitation attempts or brain death diagnoses. Patients who died beyond 1-week length of stay in the PICU were more likely to have preexisting diagnoses, to be technology dependent prior to admission, and to have died following the withdrawal of life-sustaining treatment. Only 64% of the patients who died following the withholding or withdrawing of life support had a formal do-not-resuscitate order in place at the time of their death.
CONCLUSIONS
The mode of death in the PICU is proportionally similar to that reported over the past two decades, while the mortality rate has nearly halved. Death is largely characterized by two fairly distinct profiles that are associated with whether death occurs within or beyond 1-week length of stay. Decisions not to resuscitate are often made in the absence of a formal do-not-resuscitate order. These data have implications for future quality improvement initiatives, especially around palliative care, end-of-life decision making, and organ donation.
目的
确定美国5家地理位置不同的教学医院儿科重症监护病房（PICU）的死亡流行病学情况。
设计
前瞻性病例系列研究。
地点
5家美国教学医院。
研究对象
我们同时确定了192例在PICU出院前死亡的连续患者。每个地点纳入24至50例患者。每个PICU都有相似的组织和人员配置结构。
干预措施
无。
测量指标及主要结果
总体死亡率为2.39%（范围为1.85%-3.38%）。133例患者（70%）在停止或撤除维持生命治疗后死亡，30例（16%）被诊断为脑死亡，26例（14%）在复苏尝试失败后死亡。所有死亡病例中有57%发生在入院第一周内；这些患者更有可能患有新发疾病或损伤，包括大多数在心肺复苏尝试失败或脑死亡诊断后死亡的患者。在PICU住院时间超过1周后死亡的患者更有可能有既往诊断，入院前依赖技术支持，并且在撤除维持生命治疗后死亡。在停止或撤除生命支持后死亡的患者中，只有64%在死亡时拥有正式的不要复苏医嘱。
结论
PICU的死亡模式与过去二十年报道的情况比例相似，而死亡率几乎减半。死亡在很大程度上具有两种相当不同的特征，这与死亡发生在住院1周内还是超过1周有关。不进行复苏的决定往往在没有正式的不要复苏医嘱的情况下做出。这些数据对未来的质量改进举措有影响，特别是在姑息治疗、临终决策和器官捐赠方面。
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