Department of Critical Care, MedStar Washington Hospital Center, Washington, DC.
Department of Clinical Ethics, Children's Minnesota, Minneapolis, MN.
Crit Care Med. 2019 Apr;47(4):591-598. doi: 10.1097/CCM.0000000000003647.
To describe the sources of uncertainty in prognosticating devastating brain injury, the role of the intensivist in prognostication, and ethical considerations in prognosticating devastating brain injury in the ICU.
A PubMed literature review was performed.
Articles relevant to prognosis in intracerebral hemorrhage, acute ischemic stroke, traumatic brain injury, subarachnoid hemorrhage, and postcardiac arrest anoxic encephalopathy were selected.
Data regarding definition and prognosis of devastating brain injury were extracted. Themes related to how clinicians perform prognostication and their accuracy were reviewed and extracted.
Although there are differences in pathophysiology and therefore prognosis in the various etiologies of devastating brain injury, some common themes emerge. Physicians tend to have fairly good prognostic accuracy, especially in severe cases with poor prognosis. Full supportive care is recommended for at least 72 hours from initial presentation to maximize the potential for recovery and minimize secondary injury. However, physician approaches to the timing of and recommendations for withdrawal of life-sustaining therapy have a significant impact on mortality from devastating brain injury.
Intensivists should consider the modern literature describing prognosis for devastating brain injury and provide appropriate time for patient recovery and for discussions with the patient's surrogates. Surrogates wish to have a prognosis enumerated even when uncertainty exists. These discussions must be handled with care and include admission of uncertainty when it exists. Respect for patient autonomy remains paramount, although physicians are not required to provide inappropriate medical therapies.
描述预测毁灭性脑损伤的不确定性来源、重症监护医师在预后中的作用以及在 ICU 预测毁灭性脑损伤的伦理考虑。
进行了 PubMed 文献回顾。
选择了与颅内出血、急性缺血性中风、创伤性脑损伤、蛛网膜下腔出血和心脏骤停后缺氧性脑病的预后相关的文章。
提取了有关毁灭性脑损伤的定义和预后的数据。回顾并提取了与临床医生进行预后判断及其准确性相关的主题。
尽管各种原因导致的毁灭性脑损伤的病理生理学不同，因此预后也不同，但出现了一些共同的主题。医生的预后准确性通常相当高，尤其是在预后较差的严重病例中。建议从初始表现开始至少提供 72 小时的全面支持性护理，以最大限度地提高恢复的可能性并最小化继发性损伤。然而，医生对停止生命支持治疗的时机和建议的方法对毁灭性脑损伤的死亡率有重大影响。
重症监护医师应考虑描述毁灭性脑损伤预后的现代文献，并为患者的恢复和与患者代理人的讨论提供适当的时间。代理人希望对预后进行详细说明，即使存在不确定性。在进行这些讨论时必须小心谨慎，并在存在不确定性时承认不确定性。尽管医生无需提供不适当的医疗治疗，但仍应尊重患者自主权。
