探讨创伤患者停止生命支持治疗的独立风险因素。
Examining the independent risk factors for withdrawal of life sustaining treatment in trauma patients.
机构信息
Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA.
Division of Trauma and Surgical Critical Care, Los Angeles General Medical Center, Keck School of Medicine of the University of Southern California, 2051 Marengo St C5L100, Los Angeles, CA, USA.
出版信息
Injury. 2023 Dec;54(12):111088. doi: 10.1016/j.injury.2023.111088. Epub 2023 Oct 5.
INTRODUCTION
Withdrawal of life sustaining treatment (WLST) occurs when medical intervention no longer benefits a patient's acute goals for care. The incidence of WLST in the trauma patient population is not well understood. The purpose of this study was to examine the incidence and independent risk factors associated with WLST.
METHODS
The Trauma Quality Improvement Program (2017-2018) was utilized. Patients arrived without signs of life or without mortality or WLST data were excluded. Demographics, injury data, and outcomes were analyzed. Categorical variables are presented as number (percentage) and continuous variables as median [interquartile range]. WLST and non-WLST patients were compared. Early (<24 h) WLST patients were compared to all other WLST patients.
RESULTS
Of 749,754 patients, 35,464 (4.7 %) died. Of these, 19,424 (2.6 %) died after WLST, constituting 54.8 % of all deaths. Median age was 67 [50-79], 67.6 % male, 17,557 (90.4 %) blunt injuries, 11,334 (58.4 %) GCS < 9. Median ISS 26 [17-30]. Median head AIS 4 (3-5). The WLST group had a much higher incidence of elderly (60+) patients (65.1% vs 41.0 %), blunt mechanism of injury (90.4% vs 76.9 %) and hypertension (43.5% vs 26.5 %). Black patients (8.2% vs 19.5 %) and Hispanic patients (7.9% vs 12.2 %) were less likely to undergo WLST. On multivariate analysis, patients 80+ years old (OR 12.939, p < 0.001), GCS < 9 (OR 15.621, p < 0.001), and head AIS = 5, head AIS = 6 (OR 3.886, p < 0.001 and OR 5.283, p < 0.001) were independently associated with WLST. GCS < 9 (OR 4.006, p < 0.001) and penetrating injury (OR 2.825, p < 0.001) were independently associated with early WLST within 24 h.
CONCLUSIONS
More than half who die from trauma undergo withdrawal of life sustaining treatment. Elderly patients and those with severe TBI and low GCS scores are at high risk of experiencing withdrawal of life sustaining treatment. Further prospective evaluation is warranted.
介绍
当医疗干预不再有益于患者急性治疗目标时，就会进行生命支持治疗的撤除（WLST）。创伤患者人群中 WLST 的发生率尚不清楚。本研究的目的是研究与 WLST 相关的发生率和独立危险因素。
方法
利用创伤质量改进计划（2017-2018 年）。排除无生命迹象或无死亡或 WLST 数据的患者。分析人口统计学、损伤数据和结果。分类变量以数字（百分比）表示，连续变量以中位数[四分位距]表示。比较 WLST 和非 WLST 患者。比较早期（<24 小时）WLST 患者与所有其他 WLST 患者。
结果
在 749754 名患者中，35464 名（4.7%）死亡。其中，19424 名（2.6%）在 WLST 后死亡，占所有死亡人数的 54.8%。中位年龄为 67[50-79]岁，67.6%为男性，17557 名（90.4%）为钝性损伤，11334 名（58.4%）GCS<9。ISS 中位数为 26[17-30]。头部 AIS 中位数为 4（3-5）。WLST 组高龄（60+）患者的发生率更高（65.1%比 41.0%），钝性损伤机制（90.4%比 76.9%）和高血压（43.5%比 26.5%）。黑人患者（8.2%比 19.5%）和西班牙裔患者（7.9%比 12.2%）接受 WLST 的可能性较小。多变量分析显示，80 岁以上患者（OR 12.939，p<0.001）、GCS<9（OR 15.621，p<0.001）和头部 AIS=5，头部 AIS=6（OR 3.886，p<0.001 和 OR 5.283，p<0.001）与 WLST 独立相关。GCS<9（OR 4.006，p<0.001）和穿透性损伤（OR 2.825，p<0.001）与 24 小时内早期 WLST 独立相关。
结论
超过一半死于创伤的患者接受了生命支持治疗的撤除。高龄患者和那些有严重颅脑损伤和低 GCS 评分的患者有经历生命支持治疗撤除的高风险。需要进一步的前瞻性评估。
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