Department of Anaesthesia & Operative Intensive Care, University Hospital Regensburg, Germany.
Department of Anaesthesiology and Intensive Care Medicine, Charité - University Medicine Berlin, Germany.
Ger Med Sci. 2020 Jan 20;18:Doc01. doi: 10.3205/000277. eCollection 2020.
Initial treatment (ventilator settings, rescue therapy, supportive measures), and prevention of critical events improve survival in ARDS patients, but little data exists on its effect on health-related quality of life (HRQOL) and return to work (RtW) in survivors. We analyzed the association of the intensity of treatment at ARDS onset and the incidence of critical events on HRQOL and RtW a year after ICU discharge. In a prospective multi-centre cohort study, the intensity of treatment and the incidence of critical events were determined at 61 ICUs in Germany. At 3, 6, and 12 months, 396 survivors reported their HRQOL (Short-Form 12) and RtW. The parameters of the intensity of acute management (lung protective ventilation, prone position, hemodynamic stabilization, neuromuscular blocking agents), and critical events (hypoxemia, hypoglycemia, hypotension) were associated with HRQOL and RtW. Patients ventilated at ARDS onset with a low tidal volume (VT≤7 ml/kg) had higher arterial carbon dioxide levels (PaCO=57.5±17 mmHg) compared to patients ventilated with VT>7ml/kg (45.7±12, p=0.001). In a multivariate adjusted dichotomized analysis, a better mental 3-month SF-12 was observed in the higher VT-group (mean 43.1±12) compared to the lower VT-group (39.5±9, p=0.042), while a dichotomized analysis for driving pressures (≤14 mbar vs >14 mbar) did not show any difference neither in PaCO levels nor in HRQOL parameters. A decrease in the mental (6-month: 40.0±11 vs 44.8±13, p=0.038) and physical SF-12 (12-month: 38.3±11 vs 43.0±13, p=0.015) was reported from patients with hypoglycemia (blood glucose <70 mg/dl) compared to those without hypoglycemic episodes. More frequent vasopressor use with mean arterial pressure ≥65 mmHg was associated with an impaired physical SF-12 (6-month: 38.8±10) compared to less vasopressor use (43.0±11, p=0.019). In acute management of ARDS, a lower VT strategy associated with hypercapnia, as well as the frequent usage of catecholamines and the management of blood glucose may influence short-term HRQOL of survivors. The awareness of these findings is of clinical importance for the acute and post-ICU care.
初始治疗（呼吸机设置、抢救治疗、支持措施）和预防危急事件可改善 ARDS 患者的生存率，但有关其对幸存者健康相关生活质量（HRQOL）和重返工作（RtW）的影响的数据很少。我们分析了 ARDS 发病时治疗强度和危急事件的发生与 ICU 出院后 1 年 HRQOL 和 RtW 的关系。 在一项前瞻性多中心队列研究中，德国 61 个 ICU 确定了治疗强度和危急事件的发生情况。在 3、6 和 12 个月时，396 名幸存者报告了他们的 HRQOL（短式 12 项）和 RtW。急性管理（肺保护性通气、俯卧位、血流动力学稳定、神经肌肉阻滞剂）和危急事件（低氧血症、低血糖症、低血压）的参数与 HRQOL 和 RtW 相关。 ARDS 发病时接受小潮气量（VT≤7ml/kg）通气的患者的动脉二氧化碳水平（PaCO=57.5±17mmHg）高于接受 VT>7ml/kg 通气的患者（45.7±12mmHg，p=0.001）。在多变量调整后的二分类分析中，较高 VT 组的精神状态 3 个月 SF-12 更好（均值 43.1±12），而较低 VT 组（39.5±9mmHg，p=0.042）。而对于驱动压力（≤14 mbar vs >14 mbar）的二分类分析，在 PaCO 水平或 HRQOL 参数方面没有显示出任何差异。与没有低血糖发作的患者相比，有低血糖（血糖<70mg/dl）的患者精神（6 个月：40.0±11 vs 44.8±13，p=0.038）和身体 SF-12（12 个月：38.3±11 vs 43.0±13，p=0.015）恶化。与较少使用血管加压药（平均动脉压≥65mmHg）相比，频繁使用血管加压药与身体 SF-12 受损相关（6 个月：38.8±10）。 在 ARDS 的急性治疗中，与高碳酸血症相关的较低 VT 策略以及儿茶酚胺的频繁使用和血糖的管理可能会影响幸存者的短期 HRQOL。了解这些发现对于急性和 ICU 后护理具有临床重要性。
