Angotti Lauren B, Richards Jeremy B, Fisher Daniel F, Sankoff Jeffrey D, Seigel Todd A, Al Ashry Haitham S, Wilcox Susan R
Medical University of South Carolina, Division of Pulmonary, Critical Care, Allergy and Sleep Medicine, Charleston, South Carolina.
Massachusetts General Hospital, Respiratory Care Services, Boston, Massachusetts.
West J Emerg Med. 2017 Aug;18(5):972-979. doi: 10.5811/westjem.2017.5.34099. Epub 2017 Jul 11.
Due to hospital crowding, mechanically ventilated patients are increasingly spending hours boarding in emergency departments (ED) before intensive care unit (ICU) admission. This study aims to evaluate the association between time ventilated in the ED and in-hospital mortality, duration of mechanical ventilation, ICU and hospital length of stay (LOS).
This was a multi-center, prospective, observational study of patients ventilated in the ED, conducted at three academic Level I Trauma Centers from July 2011 to March 2013. All consecutive adult patients on invasive mechanical ventilation were eligible for enrollment. We performed a Cox regression to assess for a mortality effect for mechanically ventilated patients with each hour of increasing LOS in the ED and multivariable regression analyses to assess for independently significant contributors to in-hospital mortality. Our primary outcome was in-hospital mortality, with secondary outcomes of ventilator days, ICU LOS and hospital LOS. We further commented on use of lung protective ventilation and frequency of ventilator changes made in this cohort.
We enrolled 535 patients, of whom 525 met all inclusion criteria. Altered mental status without respiratory pathology was the most common reason for intubation, followed by trauma and respiratory failure. Using iterated Cox regression, a mortality effect occurred at ED time of mechanical ventilation > 7 hours, and the longer ED stay was also associated with a longer total duration of intubation. However, adjusted multivariable regression analysis demonstrated only older age and admission to the neurosciences ICU as independently associated with increased mortality. Of interest, only 23.8% of patients ventilated in the ED for over seven hours had changes made to their ventilator.
In a prospective observational study of patients mechanically ventilated in the ED, there was a significant mortality benefit to expedited transfer of patients into an appropriate ICU setting.
由于医院拥挤，机械通气患者在重症监护病房（ICU）收治前在急诊科（ED）等待数小时的情况日益增多。本研究旨在评估在急诊科进行机械通气的时间与院内死亡率、机械通气持续时间、ICU及住院时间（LOS）之间的关联。
这是一项多中心、前瞻性、观察性研究，对2011年7月至2013年3月在三家一级学术创伤中心急诊科接受机械通气的患者进行研究。所有接受有创机械通气的连续成年患者均符合纳入标准。我们进行了Cox回归分析，以评估急诊科机械通气时间每增加一小时对机械通气患者死亡率的影响，并进行多变量回归分析，以评估对院内死亡率有独立显著影响的因素。我们的主要结局是院内死亡率，次要结局包括呼吸机使用天数、ICU住院时间和住院时间。我们还进一步阐述了该队列中肺保护性通气的使用情况及呼吸机更换频率。
我们纳入了535例患者，其中525例符合所有纳入标准。无呼吸疾病的意识状态改变是插管最常见的原因，其次是创伤和呼吸衰竭。通过迭代Cox回归分析，发现急诊科机械通气时间>7小时会产生死亡率影响，且在急诊科停留时间越长，插管总持续时间也越长。然而，校正后的多变量回归分析表明，只有年龄较大和入住神经科学ICU与死亡率增加独立相关。有趣的是，在急诊科机械通气超过7小时的患者中，只有23.8%的患者更换了呼吸机。
在一项对急诊科接受机械通气患者的前瞻性观察性研究中，将患者快速转入合适的ICU环境可显著降低死亡率。
