急性需要机械通气的脑卒中患者的一年结局。

One-Year Outcomes in Patients With Acute Stroke Requiring Mechanical Ventilation.

机构信息

Université de Paris, INSERM UMR 1148, F-75018 Paris, France (R.S., M. Mazighi).

APHP, Department of Intensive Care Medicine, Bichat-Claude Bernard University Hospital, F75018 Paris, France (R.S., G.P., F.L., J.-F.T.).

出版信息

Stroke. 2023 Sep;54(9):2328-2337. doi: 10.1161/STROKEAHA.123.042910. Epub 2023 Jul 27.

DOI:10.1161/STROKEAHA.123.042910

PMID:37497675

Abstract

BACKGROUND

Long-term outcomes of patients with severe stroke remain poorly documented. We aimed to characterize one-year outcomes of patients with stroke requiring mechanical ventilation in the intensive care unit (ICU).

METHODS

We conducted a prospective multicenter cohort study in 33 ICUs in France (2017-2019) on patients with consecutive strokes requiring mechanical ventilation for at least 24 hours. Outcomes were collected via telephone interviews by an independent research assistant. The primary end point was poor functional outcome, defined by a modified Rankin Scale score of 4 to 6 at 1 year. Multivariable mixed models investigated variables associated with the primary end point. Secondary end points included quality of life, activities of daily living, and anxiety and depression in 1-year survivors.

RESULTS

Among the 364 patients included, 244 patients (66.5% [95% CI, 61.7%-71.3%]) had a poor functional outcome, including 190 deaths (52.2%). After adjustment for non-neurological organ failure, age ≥70 years (odds ratio [OR], 2.38 [95% CI, 1.26-4.49]), Charlson comorbidity index ≥2 (OR, 2.01 [95% CI, 1.16-3.49]), a score on the Glasgow Coma Scale <8 at ICU admission (OR, 3.43 [95% CI, 1.98-5.96]), stroke subtype (intracerebral hemorrhage: OR, 2.44 [95% CI, 1.29-4.63] versus ischemic stroke: OR, 2.06 [95% CI, 1.06-4.00] versus subarachnoid hemorrhage: reference) remained independently associated with poor functional outcome. In contrast, a time between stroke diagnosis and initiation of mechanical ventilation >1 day was protective (OR, 0.56 [95% CI, 0.33-0.94]). A sensitivity analysis conducted after exclusion of patients with early decisions of withholding/withdrawal of care yielded similar results. We observed persistent physical and psychological problems at 1 year in >50% of survivors.

CONCLUSIONS

In patients with severe stroke requiring mechanical ventilation, several ICU admission variables may inform caregivers, patients, and their families on post-ICU trajectories and functional outcomes. The burden of persistent sequelae at 1 year reinforces the need for a personalized, multi-disciplinary, prolonged follow-up of these patients after ICU discharge.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT03335995.

摘要

背景

重症脑卒中患者的长期预后仍记录不佳。我们旨在描述重症监护病房（ICU）中需要机械通气的脑卒中患者的一年预后。

方法

我们在法国的 33 家 ICU 进行了一项前瞻性多中心队列研究（2017-2019 年），纳入了连续发生需要机械通气至少 24 小时的脑卒中患者。结局通过独立的研究助理进行电话访谈收集。主要结局是 1 年时功能不良的预后，定义为改良 Rankin 量表评分为 4-6 分。多变量混合模型探讨了与主要结局相关的变量。次要结局包括 1 年幸存者的生活质量、日常生活活动能力以及焦虑和抑郁。

结果

在纳入的 364 例患者中，244 例（66.5%[95%CI，61.7%-71.3%]）存在功能不良的预后，包括 190 例死亡（52.2%）。在校正非神经器官衰竭、年龄≥70 岁（比值比[OR]，2.38[95%CI，1.26-4.49]）、Charlson 合并症指数≥2（OR，2.01[95%CI，1.16-3.49]）、ICU 入院时格拉斯哥昏迷量表评分<8（OR，3.43[95%CI，1.98-5.96]）、脑卒中亚型（脑出血：OR，2.44[95%CI，1.29-4.63] vs 缺血性脑卒中：OR，2.06[95%CI，1.06-4.00] vs 蛛网膜下腔出血：参照）后，仍与功能不良的预后独立相关。相反，脑卒中诊断与开始机械通气之间的时间>1 天是保护因素（OR，0.56[95%CI，0.33-0.94]）。排除早期决定放弃/撤回治疗的患者后进行敏感性分析，结果相似。我们观察到，>50%的幸存者在 1 年内仍存在持续的身体和心理问题。