急性缺血性脑卒中患者意识急性改变与结局及早期停止治疗的关系。
Association of Acute Alteration of Consciousness in Patients With Acute Ischemic Stroke With Outcomes and Early Withdrawal of Care.
机构信息
From the Department of Neurology (A.A., A.J.B., N.A., H.Y., 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.), University of Miami; Department of Neurology (A.A., A.J.B., N.A., H.Y., 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.), Jackson Memorial Hospital, Miami, FL; Regional Director Quality Improvement (D.F.), American Heart Association, Marietta, GA; and Department of Neurology (J.C.), Columbia University, New York, NY.
出版信息
Neurology. 2022 Apr 5;98(14):e1470-e1478. doi: 10.1212/WNL.0000000000200018. Epub 2022 Feb 15.
BACKGROUND AND OBJECTIVES
Early consciousness disorder (ECD) after acute ischemic stroke (AIS) is understudied. ECD may influence outcomes and the decision to withhold or withdraw life-sustaining treatment.
METHODS
We studied patients with AIS from 2010 to 2019 across 122 hospitals participating in the Florida Stroke Registry. We studied the effect of ECD on in-hospital mortality, withholding or withdrawal of life-sustaining treatment (WLST), ambulation status on discharge, hospital length of stay, and discharge disposition.
RESULTS
Of 238,989 patients with AIS, 32,861 (14%) had ECD at stroke presentation. Overall, average age was 72 years (Q1 61, Q3 82), 49% were women, 63% were White, 18% were Black, and 14% were Hispanic. Compared to patients without ECD, patients with ECD were older (77 vs 72 years), were more often female (54% vs 48%), had more comorbidities, had greater stroke severity as assessed by the National Institutes of Health Stroke Scale (score ≥5 49% vs 27%), had higher WLST rates (21% vs 6%), and had greater in-hospital mortality (9% vs 3%). Using adjusted models accounting for basic characteristics, patients with ECD had greater in-hospital mortality (odds ratio [OR] 2.23, 95% CI 1.98-2.51), had longer hospitalization (OR 1.37, 95% CI 1.33-1.44), were less likely to be discharged home or to rehabilitation (OR 0.54, 95% CI 0.52-0.57), and were less likely to ambulate independently (OR 0.61, 95% CI 0.57-0.64). WLST significantly mediated the effect of ECD on mortality (mediation effect 265; 95% CI 217-314). In temporal trend analysis, we found a significant decrease in early WLST (<2 days) (R 0.7, = 0.002) and an increase in late WLST (≥2 days) (R 0.7, = 0.004).
DISCUSSION
In this large prospective multicenter stroke registry, patients with AIS presenting with ECD had greater mortality and worse discharge outcomes. Mortality was largely influenced by the WLST decision.
背景与目的
急性缺血性脑卒中（AIS）后早期意识障碍（ECD）的研究较少。ECD 可能会影响结果以及是否决定停止或撤销维持生命的治疗。
方法
我们研究了 2010 年至 2019 年期间，122 家参与佛罗里达州脑卒中登记处的医院中发生 AIS 的患者。我们研究了 ECD 对住院死亡率、停止或撤销维持生命的治疗（WLST）、出院时的活动能力、住院时间和出院去向的影响。
结果
在 238989 例 AIS 患者中，32861 例（14%）在脑卒中发作时存在 ECD。总体而言，平均年龄为 72 岁（Q1 为 61，Q3 为 82），49%为女性，63%为白人，18%为黑人，14%为西班牙裔。与没有 ECD 的患者相比，有 ECD 的患者年龄更大（77 岁 vs 72 岁），女性更多（54% vs 48%），合并症更多，国立卫生研究院脑卒中量表（NIHSS）评分更高（≥5 分的患者占 49% vs 27%），WLST 率更高（21% vs 6%），住院死亡率更高（9% vs 3%）。使用考虑基本特征的调整模型，有 ECD 的患者住院死亡率更高（优势比[OR] 2.23，95%置信区间[CI] 1.98-2.51），住院时间更长（OR 1.37，95% CI 1.33-1.44），更不可能出院回家或去康复（OR 0.54，95% CI 0.52-0.57），独立活动的可能性更小（OR 0.61，95% CI 0.57-0.64）。WLST 显著中介了 ECD 对死亡率的影响（中介效应 265；95% CI 217-314）。在时间趋势分析中，我们发现早期 WLST（<2 天）（R 0.7， = 0.002）显著减少，晚期 WLST（≥2 天）（R 0.7， = 0.004）增加。
讨论
在这项大型前瞻性多中心脑卒中登记研究中，患有 AIS 且伴有 ECD 的患者死亡率更高，出院结局更差。死亡率主要受 WLST 决策的影响。
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