急性呼吸衰竭患者限时试验应用特征分析：一项前瞻性单中心观察性研究
Characterizing the Use of Time-Limited Trials in Patients With Acute Respiratory Failure: A Prospective, Single-Center Observational Study.
作者信息
Moy Joy X, Law Anica C, Stalter Lily N, Peliska Michael D, Palmer Geralyn, Hanlon Bret M, Mortenson Sean, Viglianti Elizabeth M, Wiegmann Douglas A, Kruser Jacqueline M
机构信息
Department of Medicine, Division of Allergy, Pulmonary, and Critical Care, University of Wisconsin School of Medicine and Public Health, Madison, WI.
Department of Medicine, Pulmonary, Allergy, Sleep & Critical Care Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, MA.
出版信息
Crit Care Explor. 2024 Sep 16;6(9):e1148. doi: 10.1097/CCE.0000000000001148. eCollection 2024 Sep 1.
IMPORTANCE
A time-limited trial (TLT) is a collaborative plan among clinicians, patients, and families to use life-sustaining therapy for a defined duration, after which the patient's response informs whether to continue care directed toward recovery or shift the focus toward comfort. TLTs are a promising approach to help navigate uncertainty in critical illness, yet little is known about their current use.
OBJECTIVES
To characterize TLT use in patients with acute respiratory failure (ARF).
DESIGN, SETTING, AND PARTICIPANTS: Prospective 12-month observational cohort study at an U.S. academic medical center of adult ICU patients with ARF receiving invasive mechanical ventilation for greater than or equal to 48 hours.
MAIN OUTCOMES AND MEASURES
Primary exposure was TLT participation, identified by patients' ICU physician. Patient characteristics, care delivery elements, and hospital outcomes were extracted from the electronic medical record.
RESULTS
Among 176 eligible patients, 36 (20.5%) participated in a TLT. Among 18 ICU attending physicians, nine (50%) participated in greater than or equal to 1 TLT (frequency 0-39% of patients cared for). Median TLT duration was 3.0 days (interquartile range [IQR], 3.0-4.5 d). TLT patients had a higher mean age (67.4 yr [sd, 12.0 yr] vs. 60.0 yr [sd, 16.0 yr]; p < 0.01), higher Charlson Comorbidity Index (5.1 [sd, 2.2] vs. 3.8 [sd, 2.6]; p < 0.01), and similar Sequential Organ Failure Assessment score (9.6 [sd, 3.3] vs. 9.5 [sd, 3.7]; p = 0.93), compared with non-TLT patients. TLT patients were more likely to die or be discharged to hospice (80.6% vs. 42.1%; p < 0.05) and had shorter ICU length of stay (median, 5.7 d [IQR, 4.0-9.0 d] vs. 10.3 d [IQR, 5.5-14.5 d]; p < 0.01).
CONCLUSIONS AND RELEVANCE
In this study, approximately one in five patients with ARF participated in a TLT. Our findings suggest TLTs are used primarily in patients near end of life but with substantial physician variation, highlighting a need for evidence to guide optimal use.
重要性
限时试验（TLT）是临床医生、患者及其家属之间的一项协作计划，在规定的时间段内使用维持生命的治疗方法，之后根据患者的反应来决定是继续针对康复的治疗还是将重点转向舒适护理。限时试验是一种很有前景的方法，有助于应对危重病中的不确定性，但目前对其使用情况了解甚少。
目的
描述急性呼吸衰竭（ARF）患者中限时试验的使用情况。
设计、地点和参与者：在美国一家学术医疗中心进行的为期12个月的前瞻性观察队列研究，研究对象为接受有创机械通气≥48小时的成年ARF重症监护病房患者。
主要结局和测量指标
主要暴露因素为限时试验参与情况，由患者的重症监护病房医生确定。从电子病历中提取患者特征、护理提供要素和医院结局。
结果
在176名符合条件的患者中，36名（20.5%）参与了限时试验。在18名重症监护病房主治医生中，9名（50%）参与了≥1次限时试验（参与频率为所护理患者的0 - 39%）。限时试验的中位持续时间为3.0天（四分位间距[IQR]，3.0 - 4.5天）。与未参与限时试验的患者相比，参与限时试验的患者平均年龄更高（67.4岁[标准差，12.0岁]对60.0岁[标准差，16.0岁]；p < 0.01），Charlson合并症指数更高（5.1[标准差，2.2]对3.8[标准差，2.6]；p < 0.01），序贯器官衰竭评估评分相似（9.6[标准差，3.3]对9.5[标准差，3.7]；p = 0.93）。参与限时试验的患者死亡或出院至临终关怀机构的可能性更高（80.6%对42.1%；p < 0.05），重症监护病房住院时间更短（中位时间，5.7天[IQR，4.0 - 9.0天]对10.3天[IQR，5.5 - 14.5天]；p < 0.01）。
结论及意义
在本研究中，约五分之一的急性呼吸衰竭患者参与了限时试验。我们的研究结果表明，限时试验主要用于接近生命末期的患者，但医生之间存在很大差异，这凸显了需要有证据来指导最佳使用。
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