对于意识障碍的脑出血患者，停止生命支持治疗可降低死亡率。
Withdrawal of Life-Sustaining Treatment Mediates Mortality in Patients With Intracerebral Hemorrhage With Impaired Consciousness.
机构信息
Department of Neurology, University of Miami, FL (A.A., A.J.B., N.A., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.).
Department of Neurology, Jackson Memorial Hospital, Miami, FL (A.A., A.J.B., N.A., E.M.-L., C.M.G., D.S., E.S., M.K., A.M., S.K., J.G.R., K.O., R.L.S., T.R.).
出版信息
Stroke. 2021 Dec;52(12):3891-3898. doi: 10.1161/STROKEAHA.121.035233. Epub 2021 Sep 29.
BACKGROUND AND PURPOSE
Impaired level of consciousness (LOC) on presentation at hospital admission in patients with intracerebral hemorrhage (ICH) may affect outcomes and the decision to withhold or withdraw life-sustaining treatment (WOLST).
METHODS
Patients with ICH were included across 121 Florida hospitals participating in the Florida Stroke Registry from 2010 to 2019. We studied the effect of LOC on presentation on in-hospital mortality (primary outcome), WOLST, ambulation status on discharge, hospital length of stay, and discharge disposition.
RESULTS
Among 37 613 cases with ICH (mean age 71, 46% women, 61% White, 20% Black, 15% Hispanic), 12 272 (33%) had impaired LOC at onset. Compared with cases with preserved LOC, patients with impaired LOC were older (72 versus 70 years), more women (49% versus 45%), more likely to have aphasia (38% versus 16%), had greater ICH score (3 versus 1), greater risk of WOLST (41% versus 18%), and had an increased in-hospital mortality (32% versus 12%). In the multivariable-logistic regression with generalized estimating equations accounting for basic demographics, comorbidities, ICH severity, hospital size and teaching status, impaired LOC was associated with greater mortality (odds ratio, 3.7 [95% CI, 3.1-4.3], <0.0001) and less likely discharged home or to rehab (odds ratio, 0.3 [95% CI, 0.3-0.4], <0.0001). WOLST significantly mediated the effect of impaired LOC on mortality (mediation effect, 190 [95% CI, 152-229], <0.0001). Early WOLST (<2 days) occurred among 51% of patients. A reduction in early WOLST was observed in patients with impaired LOC after the 2015 American Heart Association/American Stroke Association ICH guidelines recommending aggressive treatment and against early do-not-resuscitate.
CONCLUSIONS
In this large multicenter stroke registry, a third of ICH cases presented with impaired LOC. Impaired LOC was associated with greater in-hospital mortality and worse disposition at discharge, largely influenced by early decision to withhold or WOLST.
背景与目的
入院时意识水平受损（LOC）可能会影响颅内出血（ICH）患者的结局，并影响是否进行维持生命治疗（WOLST）的决策。
方法
纳入 2010 年至 2019 年期间参与佛罗里达州中风登记处的 121 家佛罗里达州医院的 ICH 患者。我们研究了 LOC 对入院时的影响对院内死亡率（主要结局）、WOLST、出院时的活动能力、住院时间和出院去向的影响。
结果
在 37613 例 ICH 患者中（平均年龄 71 岁，46%为女性，61%为白人，20%为黑人，15%为西班牙裔），12272 例（33%）入院时 LOC 受损。与 LOC 正常的患者相比，LOC 受损的患者年龄更大（72 岁比 70 岁），女性更多（49%比 45%），更有可能出现失语症（38%比 16%），ICH 评分更高（3 分比 1 分），WOLST 风险更高（41%比 18%），院内死亡率更高（32%比 12%）。在多变量逻辑回归中，使用广义估计方程考虑基本人口统计学、合并症、ICH 严重程度、医院规模和教学地位，LOC 受损与更高的死亡率相关（比值比，3.7[95%置信区间，3.1-4.3]，<0.0001），出院回家或康复的可能性更低（比值比，0.3[95%置信区间，0.3-0.4]，<0.0001）。WOLST 显著调节了 LOC 受损对死亡率的影响（中介效应，190[95%置信区间，152-229]，<0.0001）。51%的患者在早期进行了 WOLST。在 2015 年美国心脏协会/美国中风协会 ICH 指南建议积极治疗和反对早期不复苏后，LOC 受损患者的早期 WOLST 减少。
结论
在这项大型多中心中风登记研究中，三分之一的 ICH 患者入院时 LOC 受损。LOC 受损与更高的院内死亡率和出院时更差的转归相关，主要受早期决定是否停止或进行 WOLST 的影响。
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