Taran Shaurya, Liu Kuan, McCredie Victoria A, Penuelas Oscar, Burns Karen E A, Frutos-Vivar Fernando, Scales Damon C, Ferguson Niall D, Singh Jeffrey M, Malhotra Armaan K, Adhikari Neill K J
Department of Medicine, University Health Network, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada; Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.
Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada.
Lancet Respir Med. 2025 Apr;13(4):338-347. doi: 10.1016/S2213-2600(24)00404-1. Epub 2025 Mar 17.
Many deaths in the intensive care unit (ICU) occur after a decision to withdraw or withhold life-sustaining therapies (WLSTs). We aimed to explore the differences in the incidence and timing of WLST between patients with and without acute brain injuries (ABIs).
We did a secondary analysis of two prospective, international studies that recruited patients who were invasively or non-invasively ventilated between 2004 and 2016 from 40 countries. ABI was defined as brain trauma, ischaemic stroke, intracranial haemorrhage, seizures, or meningitis-encephalitis. The comparator group included non-ABI conditions. Time to WLST was evaluated by use of cumulative incidence curves. Differences in WLST were analysed by use of multilevel logistic regression.
Between March 11, 2004, and Dec 17, 2016, we recruited 21 970 patients (16 791 in the WLST analysis), of whom 13 526 (61·6%) were male and 8444 (38·4%) were female and 2896 (13·2%) had ABI. WLST occurred in 2056 (12·2%) of 16 791 patients) and was more common in patients with ABI versus without (372 [17·0%] of 2191 vs 1684 [11·5%] of 14 600; risk difference 5·5%; 95% CI 3·8-7·1; odds ratio [OR] 2·42; 1·89-3·12). WLST decisions occurred earlier in patients with ABI versus patients without ABI (median, 4 days [IQR 2-9] versus 6 days [2-13] after ICU admission; absolute difference, 2 days; 95% CI 1-3). Findings were similar across different ABI subgroups, world regions, and cohort years. Variability among ICUs in WLST decisions for patients with ABI and patients without ABI was high (respectively, median OR, 3·04; 95% CI 2·54-3·67, and median OR 2·59; 2·38-2·78).
Our findings suggest that WLST decisions are significantly more common in patients with ABI versus patients without ABI and occur earlier in this group. The rationale for early WLST following ABI warrants further exploration, accounting for additional neurological factors that were not available in the present analysis.
Canadian Institutes of Health Research.
重症监护病房（ICU）中的许多死亡发生在决定撤除或 withhold 维持生命治疗（WLST）之后。我们旨在探讨有和没有急性脑损伤（ABI）的患者在 WLST 的发生率和时机上的差异。
我们对两项前瞻性国际研究进行了二次分析，这两项研究招募了 来自 40 个国家在 2004 年至 2016 年间接受有创或无创通气的患者。ABI 被定义为脑外伤、缺血性中风、颅内出血、癫痫发作或脑膜炎 - 脑炎。比较组包括非 ABI 情况。通过累积发病率曲线评估至 WLST 的时间。使用多水平逻辑回归分析 WLST 的差异。
在 2004 年 3 月 11 日至 2016 年 12 月 17 日期间，我们招募了 21970 名患者（WLST 分析中有 16791 名），其中 13526 名（61.6%）为男性，8444 名（38.4%）为女性，2896 名（13.2%）有 ABI。16791 名患者中有 2056 名（12.2%）发生了 WLST，在有 ABI 的患者中比没有 ABI 的患者更常见（2191 名中有 372 名[17.0%] vs 14600 名中有 1684 名[11.5%]；风险差异 5.5%；95%CI 3.8 - 7.1；比值比[OR]2.42；1.89 - 3.12）。与没有 ABI 的患者相比，有 ABI 的患者做出 WLST 决定更早（中位数，ICU 入院后 4 天[IQR 2 - 9] 对 6 天[2 - 13]；绝对差异，2 天；95%CI 1 - 3）。在不同的 ABI 亚组、世界区域和队列年份中结果相似。ICU 对有 ABI 和没有 ABI 的患者做出 WLST 决定的变异性很高（分别为，中位数 OR，3.04；95%CI 2.54 - 3.67，以及中位数 OR 2.59；2.38 - 2.78）。
我们的研究结果表明，与没有 ABI 的患者相比，有 ABI 的患者做出 WLST 决定明显更常见，且在该组中发生得更早。ABI 后早期 WLST 的基本原理值得进一步探索，同时考虑本分析中未有的其他神经学因素。
加拿大卫生研究院。
