Department of Pathology, Stanford University, Stanford, CA, United States of America.
Departments of Medicine and Medical Education, Division of Pulmonary and Critical Care, Mount Auburn Hospital, Cambridge, MA, United States of America.
PLoS One. 2019 Feb 14;14(2):e0212439. doi: 10.1371/journal.pone.0212439. eCollection 2019.
Critically ill patients may die despite invasive intervention. In this study, we examine trends in the application of two such treatments over a decade, namely, endotracheal ventilation and vasopressors and inotropes administration, as well as the impact of these trends on survival durations in patients who die within a month of ICU admission.
We considered observational data available from the MIMIC-III open-access ICU database and collected within a study period between year 2002 up to 2011. If a patient had multiple admissions to the ICU during the 30 days before death, only the first stay was analyzed, leading to a final set of 6,436 unique ICU admissions during the study period. We tested two hypotheses: (i) administration of invasive intervention during the ICU stay immediately preceding end-of-life would decrease over the study time period and (ii) time-to-death from ICU admission would also decrease, due to the decrease in invasive intervention administration. To investigate the latter hypothesis, we performed a subgroups analysis by considering patients with lowest and highest severity. To do so, we stratified the patients based on their SAPS I scores, and we considered patients within the first and the third tertiles of the score. We then assessed differences in trends within these groups between years 2002-05 vs. 2008-11.
Comparing the period 2002-2005 vs. 2008-2011, we found a reduction in endotracheal ventilation among patients who died within 30 days of ICU admission (120.8 vs. 68.5 hours for the lowest severity patients, p<0.001; 47.7 vs. 46.0 hours for the highest severity patients, p = 0.004). This is explained in part by an increase in the use of non-invasive ventilation. Comparing the period 2002-2005 vs. 2008-2011, we found a reduction in the use of vasopressors and inotropes among patients with the lowest severity who died within 30 days of ICU admission (41.8 vs. 36.2 hours, p<0.001) but not among those with the highest severity. Despite a reduction in the use of invasive interventions, we did not find a reduction in the time to death between 2002-2005 vs. 2008-2011 (7.8 days vs. 8.2 days for the lowest severity patients, p = 0.32; 2.1 days vs. 2.0 days for the highest severity patients, p = 0.74).
We found that the reduction in the use of invasive treatments over time in patients with very poor prognosis did not shorten the time-to-death. These findings may be useful for goals of care discussions.
尽管进行了有创干预，危重症患者仍可能死亡。在这项研究中，我们考察了在十年间两种此类治疗方法（即气管内插管通气和血管加压素及正性肌力药物的应用）的应用趋势，以及这些趋势对 ICU 入住后一个月内死亡患者的生存时间的影响。
我们考虑了从 2002 年到 2011 年在 MIMIC-III 开放 ICU 数据库中收集的观察性数据。如果患者在死亡前 30 天内多次入住 ICU，则只分析第一次入住，导致研究期间共有 6436 例独特的 ICU 入住。我们检验了两个假设：（i）在生命末期之前的 ICU 入住期间，有创干预的应用会随着研究时间的推移而减少；（ii）由于有创干预的应用减少，从 ICU 入院到死亡的时间也会减少。为了研究第二个假设，我们通过考虑最低和最高严重程度的患者进行了亚组分析。为此，我们根据 SAPS I 评分对患者进行分层，并考虑了评分的前三个三分位数的患者。然后，我们评估了这两个组内，2002-05 年与 2008-11 年之间的趋势差异。
与 2002-2005 年相比，我们发现，在 ICU 入住后 30 天内死亡的患者中，气管内插管通气的使用减少（最低严重程度患者为 120.8 小时与 68.5 小时，p<0.001；最高严重程度患者为 47.7 小时与 46.0 小时，p=0.004）。这部分是由于无创通气的使用增加。与 2002-2005 年相比，我们发现，在 ICU 入住后 30 天内死亡的最低严重程度患者中，血管加压素和正性肌力药物的使用减少（41.8 小时与 36.2 小时，p<0.001），但在最高严重程度患者中没有减少。尽管有创干预的使用减少，但我们没有发现 2002-2005 年与 2008-2011 年之间的死亡时间缩短（最低严重程度患者为 7.8 天与 8.2 天，p=0.32；最高严重程度患者为 2.1 天与 2.0 天，p=0.74）。
我们发现，随着时间的推移，预后极差的患者中，有创治疗的使用减少并未缩短死亡时间。这些发现可能对目标治疗讨论有用。
