1 Department of Critical Care Medicine and.
6 Trauma, Emergency and Critical Care Program, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada.
Am J Respir Crit Care Med. 2016 Nov 1;194(9):1083-1091. doi: 10.1164/rccm.201602-0397OC.
Predictions about neurologic prognosis that are based on early clinical findings after out-of-hospital cardiac arrest (OHCA) are often inaccurate and may lead to premature decisions to withdraw life-sustaining treatments (LST) in patients who might otherwise survive with good neurologic outcomes.
To improve adherence to recommendations for appropriate neurologic prognostication after OHCA and reduce deaths from premature decisions to withdraw LST.
This was a pragmatic stepped wedge cluster randomized controlled trial evaluating a multifaceted quality intervention (education, pathways, local champions, audit-feedback). The primary outcome was appropriate neurologic prognostication, defined as (1a) no early withdrawal of LST (WLST) (within 72 h) based on estimates of poor neurologic prognosis and (1b) no WLST between 72 hours and 7 days in absence of clinical predictors of poor neurologic prognosis or (2) surviving beyond 7 days. Secondary outcomes were deaths from early WLST and survival with good neurologic outcome.
Between June 1, 2011, and June 30, 2014, a total of 905 patients with OHCA were enrolled from ICUs of 18 Ontario hospitals. Rates of appropriate neurologic prognostication increased after the intervention (68% vs. 74% patients; odds ratio [OR], 1.79; 95% confidence interval [CI], 1.01-3.19; P = 0.05). However, rates of survival to hospital discharge (46% vs. 50%; OR, 1.71; 95% CI, 0.97-3.01; P = 0.06) and survival with good neurologic outcome remained similar (38% vs. 43%; OR, 1.43; 95% CI, 0.84-2.86; P = 0.19).
A multicenter quality intervention improved rates of appropriate neurologic prognostication after OHCA but did not increase survival with good neurologic outcome. Clinical trial registered with www.clinicaltrials.gov (NCT 01472458).
基于院外心脏骤停（OHCA）后早期临床发现对神经预后的预测往往不准确，可能导致过早决定停止生命支持治疗（LST），而这些患者如果能有良好的神经预后，可能会存活下来。
提高 OHCA 后进行适当神经预后预测的依从性，并减少因过早决定停止 LST 而导致的死亡。
这是一项实用的阶梯式楔形集群随机对照试验，评估了一种多方面的质量干预措施（教育、途径、当地冠军、审核反馈）。主要结局是适当的神经预后预测，定义为（1a）根据不良神经预后的估计，没有早期停止 LST（WLST）（72 小时内），和（1b）在没有不良神经预后的临床预测因素或（2）存活超过 7 天的情况下，在 72 小时至 7 天之间没有 WLST。次要结局是因早期 WLST 导致的死亡和存活良好的神经预后。
2011 年 6 月 1 日至 2014 年 6 月 30 日，从 18 家安大略省医院的 ICU 共纳入了 905 名 OHCA 患者。干预后，适当神经预后预测的比例增加（68%比 74%的患者；比值比[OR]，1.79；95%置信区间[CI]，1.01-3.19；P=0.05）。然而，出院时存活的比例（46%比 50%；OR，1.71；95%CI，0.97-3.01；P=0.06）和存活良好的神经预后的比例保持相似（38%比 43%；OR，1.43；95%CI，0.84-2.86；P=0.19）。
多中心质量干预措施提高了 OHCA 后适当神经预后预测的比例，但并未增加存活良好的神经预后的比例。该研究已在 www.clinicaltrials.gov 注册（NCT 01472458）。
