Asiri Abdulrahman, Alenezi Farhan Zayed, Tamim Hani, Sadat Musharaf, Bin Humaid Felwa, AlWehaibi Wedyan, Al-Dorzi Hasan M, Alzoubi Yasir Adnan, Alanazi Samiyah Alrawey, Naidu Brintha, Arabi Yaseen M
College of Medicine, King Saud bin Abdulaziz University for Health Sciences, King Abdullah International Medical Research Center, Intensive Care Department, King Abdulaziz Medical City, Ministry of National Guard-Health Affairs, Riyadh, Saudi Arabia.
American University of Beirut Medical Center, Clinical Research Institute, Beirut, Lebanon.
Crit Care Res Pract. 2024 May 6;2024:5516516. doi: 10.1155/2024/5516516. eCollection 2024.
The objective of this study was to describe Do-Not-Resuscitate (DNR) practices in a tertiary-care intensive care unit (ICU) in Saudi Arabia, and determine the predictors and outcomes of patients who had DNR orders.
This retrospective cohort study was based on a prospectively collected database for a medical-surgicalIntensive CareDepartment in a tertiary-care center in Riyadh, Saudi Arabia (1999-2017). We compared patients who had DNR orders during the ICU stay with those with "full code." The primary outcome was hospital mortality. The secondary outcomes included ICU mortality, tracheostomy, duration of mechanical ventilation, and length of stay in the ICU and hospital.
Among 24790 patients admitted to the ICU over the 19-year study period, 3217 (13%) had DNR orders during the ICU stay. Compared to patients with "full code," patients with DNR orders were older (median 67 years [Q1, Q3: 55, 76] versus 57 years [Q1, Q3: 33, 71], < 0.0001), were more likely to be females (43% versus 38%, < 0.0001), had worse premorbid functional status (WHO performance status scores 4-5: 606[18.9%] versus 1894[8.8%], < 0.0001), higher prevalence of comorbid conditions, and higher APACHE II score (median 28 [Q1, Q3: 23, 34] versus 19 [Q1, Q3: 13, 25], < 0.0001) and were more likely to be mechanically ventilated (83% versus 55%, < 0.0001). Patients had DNR orders were more likely to die in the ICU (67.8% versus 8.5%, < 0.0001) and hospital (82.4% versus 18.1%, < 0.0001). On multivariable logistic regression analysis, the following were associated with an increased likelihood of DNR status: increasing age (odds ratio (OR) 1.01, 95% confidence interval (CI) 1.01-1.02), higher APACHE II score (OR 1.09, 95% CI 1.08-1.10), and worse WHO performance status score. Patients admitted in recent years (2012-2017 versus 2002-2005) were less likely to have DNR orders (OR 0.35, 95% CI 0.32-0.39, < 0.0001). Patients with DNR orders had higher ICU mortality, more tracheostomies, longer duration of mechanical ventilation and length of ICU stay compared to patients with with "full code" but they had shorter length of hospital stay.
In a tertiary-care hospital in Saudi Arabia, 13% of critically ill patients had DNR orders during ICU stay. This study identified several predictors of DNR orders, including the severity of illness and poor premorbid functional status.
本研究的目的是描述沙特阿拉伯一家三级医疗重症监护病房（ICU）中的“不要复苏”（DNR）实践，并确定下达DNR医嘱的患者的预测因素和结局。
这项回顾性队列研究基于沙特阿拉伯利雅得一家三级医疗中心内科-外科重症监护科前瞻性收集的数据库（1999 - 2017年）。我们将在ICU住院期间下达DNR医嘱的患者与“全力抢救”的患者进行了比较。主要结局是医院死亡率。次要结局包括ICU死亡率、气管切开术、机械通气持续时间以及在ICU和医院的住院时间。
在19年的研究期间入住ICU的24790例患者中，3217例（13%）在ICU住院期间下达了DNR医嘱。与“全力抢救”的患者相比，下达DNR医嘱的患者年龄更大（中位数67岁[第一四分位数，第三四分位数：55，76] 对比57岁[第一四分位数，第三四分位数：33，71]，P < 0.0001），更可能为女性（43%对比38%，P < 0.0001），病前功能状态更差（世界卫生组织表现状态评分4 - 5分：606例[18.9%]对比1894例[8.8%]，P < 0.0001），合并症患病率更高，急性生理与慢性健康状况评分系统（APACHE II）得分更高（中位数28分[第一四分位数，第三四分位数：23，34] 对比19分[第一四分位数，第三四分位数：13，25]，P < 0.0001），且更可能接受机械通气（83%对比55%，P < 0.0001）。下达DNR医嘱的患者更可能在ICU死亡（67.8%对比8.5%，P < 0.0001）以及在医院死亡（82.4%对比18.1%，P < 0.0001）。多变量逻辑回归分析显示，以下因素与DNR状态的可能性增加相关：年龄增长（比值比（OR）1.01，95%置信区间（CI）1.01 - 1.02）、更高的APACHE II得分（OR 1.09，95% CI 1.08 - 1.10）以及更差的世界卫生组织表现状态评分。近年来（2012 - 2017年对比2002 - 2005年）入院的患者下达DNR医嘱的可能性更小（OR 0.35，95% CI 0.32 - 0.39，P < 0.0001）。与“全力抢救”的患者相比，下达DNR医嘱的患者ICU死亡率更高、气管切开术更多、机械通气持续时间更长且ICU住院时间更长，但他们的医院住院时间更短。
在沙特阿拉伯的一家三级医疗医院中，13%的重症患者在ICU住院期间下达了DNR医嘱。本研究确定了DNR医嘱的几个预测因素，包括疾病严重程度和病前功能状态差。
