Sin Sooim, Lee Sang-Min, Lee Jinwoo
Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea.
Acute Crit Care. 2019 Feb;34(1):46-52. doi: 10.4266/acc.2018.00388. Epub 2019 Feb 28.
Admission of patients perceived as potentially inappropriate for intensive care is a very sensitive and controversial issue. We aimed to evaluate the use of medical resources in the intensive care unit (ICU) and outcomes of patients according to a physician's judgment of appropriateness.
ICU physicians classified patients who were admitted to the medical ICU of a tertiary hospital as appropriate or inappropriate for intensive care within 24 hours of admission. Patient outcomes including mortality were analyzed according to appropriateness. Additionally, the usage and duration of mechanical ventilation (MV), renal replacement therapy (RRT), and extracorporeal membrane oxygenation (ECMO) were analyzed according to appropriateness.
In total, 105 patients (male, 55.4%; mean age, 62 years) were included. Twelve (11.4%) patients were considered inappropriate for intensive care based on guidance published by the Society of Critical Care Medicine through a questionnaire survey of physicians. There was no significant difference between patients considered inappropriate or appropriate for ICU admission regarding the use and duration of MV, RRT, and ECMO. In contrast, the ICU, in-hospital, 28-day, 90-day, and total mortality rates were significantly higher among patients with inappropriate admission than among patients with appropriate admission (ICU mortality: 50.0% vs. 25.8%, P=0.008; in-hospital mortality: 58.3% vs. 43.0%, P=0.028; 28-day mortality: 58.3% vs. 33.3%, P=0.019; 90-day mortality: 66.7% vs. 44.1%, P=0.023).
Despite higher mortality, the amount of medical resources used for patients considered potentially inappropriate for intensive care did not differ from the resources used for patients considered suitable for ICU care.
收治那些被认为可能不适合重症监护的患者是一个非常敏感且有争议的问题。我们旨在根据医生对适宜性的判断，评估重症监护病房（ICU）内医疗资源的使用情况以及患者的预后。
ICU医生在患者入院24小时内将入住三级医院内科ICU的患者分类为适合或不适合重症监护。根据适宜性分析包括死亡率在内的患者预后。此外，根据适宜性分析机械通气（MV）、肾脏替代治疗（RRT）和体外膜肺氧合（ECMO）的使用情况和持续时间。
共纳入105例患者（男性，55.4%；平均年龄62岁）。根据危重病医学会发布的指南，通过对医生的问卷调查，12例（11.4%）患者被认为不适合重症监护。在MV、RRT和ECMO的使用情况及持续时间方面，被认为不适合或适合入住ICU的患者之间无显著差异。相比之下，不适当入院患者的ICU死亡率、住院死亡率、28天死亡率、90天死亡率和总死亡率显著高于适当入院患者（ICU死亡率：50.0%对25.8%，P = 0.008；住院死亡率：58.3%对43.0%，P = 0.028；28天死亡率：58.3%对33.3%，P = 0.019；90天死亡率：66.7%对44.1%，P = 0.023）。
尽管死亡率较高，但用于那些被认为可能不适合重症监护的患者的医疗资源量与用于适合ICU治疗的患者的资源量并无差异。
