Graw Jan A, Spies Claudia D, Wernecke Klaus-D, Braun Jan-P
Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Germany.
Department of Anesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Germany.
Transfus Apher Sci. 2016 Jun;54(3):416-20. doi: 10.1016/j.transci.2016.03.005. Epub 2016 Mar 24.
End-of-life decisions (EOLDs) are common in the intensive care unit (ICU). EOLDs underlie a dynamic process and limitation of ICU-therapies is often done sequentially. Questionnaire-based and observational studies on medical ICUs and in palliative care reveal blood transfusions as the first therapy physicians withhold as an EOLD.
To test whether this practice also applies to surgical ICU-patients, in an observational study, all deceased patients (n = 303) admitted to an academic surgical ICU in a three-year period were analyzed for the process of limiting ICU-therapies.
Restriction of further surgery (85.4%) and limiting doses of vasopressors (75.8%) were the most frequent forms of limitations in surgical ICU therapies. Surgical patients, who had blood transfusions withheld (44.6%), had more ICU-therapies withheld or withdrawn simultaneously than patients who had transfusions maintained (5 ± 2 vs. 2 ± 1, p < 0.001). Secondary EOLDs and subsequent limitations occurred less frequently in patients who had transfusions withheld with their first EOLD (17.1% vs. 35.6%, p < 0.05).
Limitation orders for blood transfusions are not a prioritized decision in EOLDs of surgical ICU patients. Withholding blood transfusions correlates with discontinuation of further significant life-support therapies. This suggests that EOLDs to withhold blood transfusions are part of the most advanced limitations of therapy on the surgical ICU.
临终决策（EOLDs）在重症监护病房（ICU）很常见。临终决策是一个动态过程，ICU治疗的限制通常是循序渐进的。基于问卷调查和观察性研究的针对内科ICU及姑息治疗的研究表明，输血是医生作为临终决策而首先停止的治疗方法。
为了检验这种做法是否也适用于外科ICU患者，在一项观察性研究中，对一所学术性外科ICU在三年期间收治的所有死亡患者（n = 303）的ICU治疗限制过程进行了分析。
限制进一步手术（85.4%）和限制血管升压药剂量（75.8%）是外科ICU治疗中最常见的限制形式。停止输血的外科患者（44.6%）比维持输血的患者同时停止或撤回更多的ICU治疗（5±2比2±1，p<0.001）。在首次临终决策时就停止输血的患者中，二次临终决策及随后的治疗限制发生频率较低（17.1%对35.6%，p<0.05）。
在外科ICU患者的临终决策中，输血限制医嘱并非优先决策。停止输血与停止进一步的重要生命支持治疗相关。这表明，停止输血的临终决策是外科ICU最晚期治疗限制的一部分。
