Prognosis of stroke patients requiring mechanical ventilation in a neurological critical care unit

Benefits of early tracheostomy in ventilated stroke patients? Current evidence and study protocol of the randomized pilot trial SETPOINT (Stroke-related Early Tracheostomy vs. Prolonged Orotracheal Intubation in Neurocritical care Trial)

RATIONALE

Ventilated intensive care patients with ischemic or hemorrhagic strokes have a poor prognosis. Early tracheostomy has led to advantages in selected groups of non-cerebrovascular intensive care patients, including shorter ventilation time, shorter intensive care unit length of stay, and reduced complications. It is completely unclear whether ventilated stroke patients might benefit from early tracheostomy, too.

AIM

Stroke-related Early Tracheostomy vs. Prolonged Orotracheal Intubation in Neurocritical care Trial (SETPOINT) is a pilot trial aiming to investigate the safety, feasibility, and potential benefits of early tracheostomy vs. prolonged intubation (and possibly late tracheostomy) in patients with severe ischemic stroke, intracerebral hemorrhage, or subarachnoid hemorrhage. The primary objective is to compare early tracheostomy and prolonged intubation with respect to the intensive care unit - length of stay and the time until the start of rehabilitation in these patients.

DESIGN

SETPOINT is a prospective, randomized, controlled, outcome observer-blinded, monocenter trial. Patients with severe ischemic stroke, intracerebral or subarachnoid hemorrhage requiring intubation and ventilation are eligible. After passing predefined criteria, enrolled patients are randomized to either percutaneous tracheostomy within the first three-days from intubation or to weaning/extubation attempts or percutaneous tracheostomy between days 7 and 14 from intubation (n = 30 per group).

STUDY OUTCOMES

The primary end-point is the intensive care unit length of stay. Secondary end-points are functional outcome and mortality at discharge and after six-months, duration to transferability, duration of ventilation, duration and quality of weaning from respirator, need of analgesia and sedation, procedure-related complications, frequency of pneumonia and sepsis, and costs of treatment.

DISCUSSION

To clarify the potential benefit of early tracheostomy in critical care ventilated stroke patients, a randomized multicenter trial in a larger patient population is clearly needed. If this monocentric pilot gives promising safety, feasibility, and benefit results, such a multicenter trial will be planned. The results will have a relevant direct impact on the critical care of stroke.

Predictors of short-term mortality in patients undergoing percutaneous dilatational tracheostomy

PURPOSE

The purpose of the study was to identify the predictors of short-term mortality in patients undergoing percutaneous dilatational tracheostomy (PDT).

MATERIALS AND METHODS

Retrospective analysis of data pertaining to adult patients who underwent PDT between July 2005 and June 2008 in an urban, academic, tertiary care medical center was done. Clinical and demographic data were analyzed for 483 patients undergoing PDT via multivariate logistic regression.

RESULTS

Mortality data were examined at in-hospital, 14, 30, and 180 days postprocedure. Overall mortality rates were 11% at 14 days, 19% at 30 days, and 40% at 180 days. In-hospital mortality was 30%.

CONCLUSIONS

Patients undergoing PDT have significant short-term mortality with 11% dying within 14 days and an in-hospital mortality rate of 30%. We identified an index diagnosis of ventilator-associated pneumonia and trauma to be associated with a higher survival rate, whereas older age, oncological diagnosis, cardiogenic shock, and ventricular-assist devices were associated with higher mortality. There is significant heterogeneity in both underlying diagnosis and patient outcomes, and these factors should be considered when deciding to perform this procedure and discussed with patients/family members to provide a realistic expectation of potential prognosis.

Management and outcome of mechanically ventilated neurologic patients

OBJECTIVE

To describe and compare characteristics, ventilatory practices, and associated outcomes among mechanically ventilated patients with different types of brain injury and between neurologic and nonneurologic patients.

DESIGN

Secondary analysis of a prospective, observational, and multicenter study on mechanical ventilation.

SETTING

Three hundred forty-nine intensive care units from 23 countries.

PATIENTS

We included 552 mechanically ventilated neurologic patients (362 patients with stroke and 190 patients with brain trauma). For comparison we used a control group of 4,030 mixed patients who were ventilated for nonneurologic reasons.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We collected demographics, ventilatory settings, organ failures, and complications arising during ventilation and outcomes. Multivariate logistic regression analysis was performed with intensive care unit mortality as the dependent variable. At admission, a Glasgow Coma Scale score ≤8 was observed in 68% of the stroke, 77% of the brain trauma, and 29% of the nonneurologic patients. Modes of ventilation and use of a lung-protective strategy within the first week of mechanical ventilation were similar between groups. In comparison with nonneurologic patients, patients with neurologic disease developed fewer complications over the course of mechanical ventilation with the exception of a higher rate of ventilator-associated pneumonia in the brain trauma cohort. Neurologic patients showed higher rates of tracheotomy and longer duration of mechanical ventilation. Mortality in the intensive care unit was significantly (p < .001) higher in patients with stroke (45%) than in brain trauma (29%) and nonneurologic disease (30%). Factors associated with mortality were: stroke (in comparison to brain trauma), Glasgow Coma Scale score on day 1, and severity at admission in the intensive care unit.

CONCLUSIONS

In our study, one of every five mechanically ventilated patients received this therapy as a result of a neurologic disease. This cohort of patients showed a higher mortality rate than nonneurologic patients despite a lower incidence of extracerebral organ dysfunction.

[Severe stroke: prognosis, intensive care admission and withhold and withdrawal treatment decisions]

INTRODUCTION

Stroke can produce irreversible brain damage of massive proportion leading to severe disability and poor quality of life. Resuscitation and mechanical ventilation of these patients remain controversial because of the high mortality and severe disability involved.

STATE OF ART

When prognosis is very poor, do-not-resuscitate orders (DNR orders) and withhold or withdrawal of treatment may be discussed. Studies have shown that DNR orders are relatively frequent in acute stroke: up to 30% of all patients, and 50% of which are given upon admission. DNR orders are closely associated with severity of the neurological deficit and age. Precise estimates of withhold and withdrawal of treatment are not available, but terminal extubations in severe stroke could contribute to 40,000 to 60,000 acute stage deaths per year. Little is known about the decision making process and palliative care in these situations. The neurological prognosis is the main explicit criterion. However, evaluation of neurological outcome is highly uncertain and difficult, and does not always reflect quality of life. Several studies have raised the issue of this disability paradox. Thus, physician estimation of prognosis has a profound impact on decisions for life sustaining therapies, and may lead to self-fulfilling prophecies in case of false appreciation of published evidence. Other criteria could influence the withhold and withdrawal of treatment decision, such as social conditions and patient values.

PERSPECTIVES AND CONCLUSION

Decisions for life-sustaining therapies in severe stroke are always difficult and often based on subjective and uncertain criteria. We have to improve prognosis estimation and our understanding of patient preferences to promote patient-centered care. An ethical approach may guide these complex decisions.

Long-term survival in older critically ill patients with acute ischemic stroke

OBJECTIVES

To compare survival in older patients with acute ischemic stroke admitted to intensive care units (ICUs) with those not requiring ICU care and to assess the impact of mechanical ventilation (MV) and percutaneous gastrostomy tubes (PEG) on long-term mortality.

DESIGN

Multicentered retrospective cohort study.

SETTING

Administrative data from the Centers for Medicare and Medicaid Services covering 93 metropolitan counties primarily in the eastern half of the United States.

PATIENTS

31,301 patients discharged with acute ischemic stroke in 2000.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Mortality from the time of index hospitalization up to the end of the follow-up period of 12 months. Information was also gathered on use of mechanical ventilation, percutaneous gastrostomy, sociodemographic variables and a host of comorbid conditions. Of all patients with acute ischemic stroke, 26% required ICU admission. The crude death rate for ICU stroke patients was 21% at 30 days and 40% at 1-yr follow-up. At 30 days, after adjustment of sociodemographic variables and comorbidities, ICU patients had a 29% higher mortality hazard compared with non-ICU patients. MV was associated with a five-fold higher mortality hazard (hazard ratio 5.59, confidence interval [CI] 4.93-6.34). The use of PEG was not associated with mortality at 30 days. By contrast, at 1-yr follow up in 30-day survivors, ICU admission was not associated with mortality hazard (hazard ratio 1.01, 95% CI 0.93-1.09). MV still had a higher risk of death (hazard ratio 1.88, 95% CI 1.57-2.25), and PEG patients had a 2.59-fold greater mortality hazard (95% CI 2.38-2.82).

CONCLUSIONS

Both short-term and long-term mortality in older patients with acute ischemic stroke admitted to ICUs is lower than previously reported. The need for MV and PEG are markers for poor long-term outcome. Future research should focus on the identification of clinical factors that lead to increased mortality in long-term survivors and efforts to reduce those risks.

[Survival of comatose stroke victims in a neurological department in Dakar]

BACKGROUND

In Dakar, stroke is the most frequent neurological disease with the highest mortality. Victims may present in a critical state of coma. The objective of this study was to evaluate survival among comatose stroke patients in Dakar, Senegal.

METHODS

This was a longitudinal prospective study from April 2006 to July 2007 conducted in the Neurological Intensive Care Unit (NICU) of Fann University Teaching Hospital in Senegal. Were included in the study, all stroke patients confirmed by CT scan with a Glasgow coma score less than or equal to 8/15. Patients with subarachnoid hemorrhage were excluded.

RESULTS

A total of 105 patients were evaluated with 54 cases of ischemic stroke among them. The mean age was 61.87+/-14.16 years. The mean duration of hospital stay in the NICU was 10.82+/-11 days with an estimated mortality of 82.9%; the three-month survival was 9.52%. The median overall survival was 7+/-1 days (CI(95%): 5-9).

CONCLUSION

Comatose stroke patients have a poor prognosis, emphasizing the crucial importance of primary prevention.

Predictors of survival and functional outcome in acute stroke patients admitted to the stroke intensive care unit

Multivariate models have not been widely used to predict the outcome of acute stroke patients admitted to the intensive care unit (ICU). The purpose of this study was to determine potential measures observed in the first 12 h post-stroke that predict early mortality and functional outcomes in ICU-admitted stroke patients. Eight hundred and fifty acute stroke patients (ischemic stroke, 508; intracerebral hemorrhage, 342) were included in this analysis between November 2002 and December 2006. Measures of interest were obtained in the first 12 h after onset of stroke were analyzed for three types of outcome: 3-month mortality, 3-month mortality or institutional care, and poor functional outcomes at discharge. Poor functional outcomes were defined as a Barthel index <80 or a Rankin scale >2. Multivariate regression models were used to determine the predictive value of the observed measures. After 3 months, 17% of patients had died; 21% were alive but being cared for in institutional settings; and 62% were alive and living at home. Functional status at discharge indicated 16% of patients had died, poor function in 50%, and good function in 34% of patients. Initial stroke severity, measured by National Institute of Health Stroke Scale, and dependence on a ventilator predicts 3-month mortality and poor outcome in all stroke patients. In addition, old age, previous stroke, and total anterior circulatory infarct were associated with poor outcome in ischemic stroke patients; old age, low body mass index and the presence of intraventricular hemorrhage were associated with poor outcomes in intracerebral hemorrhage patients. In conclusion, early stroke mortality and outcome at discharge can be predicted in the first few hours following an acute stroke for moderate to severe ICU-admitted stroke patients.

Clinical review: Therapy for refractory intracranial hypertension in ischaemic stroke

The treatment of patients with large hemispheric ischaemic stroke accompanied by massive space-occupying oedema represents one of the major unsolved problems in neurocritical care medicine. Despite maximum intensive care, the prognosis of these patients is poor, with case fatality rates as high as 80%. Therefore, the term 'malignant brain infarction' was coined. Because conservative treatment strategies to limit brain tissue shift almost consistently fail, these massive infarctions often are regarded as an untreatable disease. The introduction of decompressive surgery (hemicraniectomy) has completely changed this point of view, suggesting that mortality rates may be reduced to approximately 20%. However, critics have always argued that the reduction in mortality may be outweighed by an accompanying increase in severe disability. Due to the lack of conclusive evidence of efficacy from randomised trials, controversy over the benefit of these treatment strategies remained, leading to large regional differences in the application of this procedure. Meanwhile, data from randomised trials confirm the results of former observational studies, demonstrating that hemicraniectomy not only significantly reduces mortality but also significantly improves clinical outcome without increasing the number of completely dependent patients. Hypothermia is another promising treatment option but still needs evidence of efficacy from randomised controlled trials before it may be recommended for clinical routine use. This review gives the reader an integrated view of the current status of treatment options in massive hemispheric brain infarction, based on the available data of clinical trials, including the most recent data from randomised trials published in 2007.

Determinants of early outcome in spontaneous lobar cerebral hemorrhage

OBJECTIVE

To identify determinants of early outcome in spontaneous lobar hemorrhage.

MATERIALS AND METHODS

From 2500 acute stroke patients included in a prospective hospital-based stroke registry over a 12-year period, 97 cases of lobar hematoma were selected. Determinants of in-hospital mortality were studied in multiple regression models.

RESULTS

Lobar hematomas accounted for 3.9% of all acute stroke patients and 35.9% of intracerebral hemorrhages. The presence of chronic obstructive pulmonary disease (COPD) was a significant predictive variable in the model based on demographic variables and vascular risk factors [odds ratio (OR): 17.18; 95% CI: 1.77-166.22] and in the model based on these variables plus clinical data (OR: 15.12; 95% CI: 1.27-179.59). Other predictive variables included altered consciousness, previous cerebral infarct and chronic liver disease.

CONCLUSIONS

COPD appeared as the most important predictor of death during hospitalization after lobar cerebral hemorrhage, a finding not generally acknowledged earlier.

Approach to the comatose patient

BACKGROUND

Coma is a medical emergency and may constitute a diagnostic and therapeutic challenge for the intensivist.

OBJECTIVE

To review currently available data on the etiology, diagnosis, and outcome of coma. To propose an evidence-based approach for the clinical management of the comatose patient.

DATA SOURCE

Search of Medline and Cochrane databases; manual review of bibliographies from selected articles and monographs.

DATA SYNTHESIS AND CONCLUSIONS

Coma and other states of impaired consciousness are signs of extensive dysfunction or injury involving the brainstem, diencephalon, or cerebral cortex and are associated with a substantial risk of death and disability. Management of impaired consciousness includes prompt stabilization of vital physiologic functions to prevent secondary neurologic injury, etiological diagnosis, and the institution of brain-directed therapeutic or preventive measures. Neurologic prognosis is determined by the underlying etiology and may be predicted by the combination of clinical signs and electrophysiological tests.

Update on respiratory management of critically ill neurologic patients

Respiratory failure complicates a number of acute neurologic conditions, most notably neuromuscular diseases (eg, Guillain-Barré syndrome and myasthenia gravis) and stroke. In addition, pulmonary complications, particularly pneumonia and atelectasis, are fairly common in patients with these diagnoses; their prevention and early recognition are crucial to avoid detrimental consequences. This review discusses recent studies related to predictors of respiratory failure and pneumonia, strategies of respiratory care and ventilatory support, functional prognosis, and withdrawal of mechanical ventilation in patients with acute neuromuscular respiratory failure and stroke.

Mortality prediction in critical care for acute stroke: Severity of illness-score or coma-scale?

BACKGROUND AND PURPOSE

The use of early prognostic data provided by various scores in critically ill stroke patients remains unclear. We tested the performance of the Simplified Acute Physiology Score (SAPS) II in prediction of mortality of acute stroke patients in the NeuroCriticalCareUnit (NCCU).

METHODS

During one year every patient admitted to the NCCUs at 2 University hospitals for cerebral ischemia (CI) or intracerebral hemorrhage (ICH) and intubated was included in this study. Data for SAPS (I)/II and the Glasgow Coma Scale (GCS) were collected, and mortality at 10 days, 90 days and 1 year was determined. Prognostic performance of all scores was tested by calculation of receiver operating curve (ROC) and by Cox regression analysis.

RESULTS

90 patients were included in the study, 49 with ICH and 41 with CI. Mortality after 10 days was 32.2%, after 3 months 58.9% and after 1 year 67.8%. Compared by their area under curve the predictive values were overall quite good for both SAPS (I) (0.77) and SAPS II (0.77) as well as GCS. Motor subscore was equal to total GCS (0.75 vs. 0.73). In Cox regression models all three scores were independent predictors of fatal outcome.

CONCLUSION

SAPS II and SAPS (I) but also the GCS are valuable tools for prediction of short and long-term mortality in acute stroke patients treated in NCCU. The GCS as a predictor for mortality in stroke patients could be further simplified by using its subscore "best motor response" alone.

The management of large hemispheric cerebral infarcts

Large hemispheric cerebral infarcts have significant morbidity and mortality. Our understanding of this pathophysiological process involved with secondary neurological deterioration in large hemispheric infarctions has increased in the past few decades. New experimental strategies designed to improve outcome are reviewed.

Influence of old age on survival after prolonged mechanical ventilation

BACKGROUND: While the proportion of elderly people in society is increasing, little is known about the influence of old age on survival after prolonged mechanical ventilation. METHODS: A retrospective follow-up study of 120 patients who had been mechanically ventilated for at least 10 days was performed with a follow-up of up to 5 years. In-hospital survival and post-hospital survival were documented. Also, the functional status of survivors was recorded. The predictive value of age and several other clinical and laboratory parameters for outcome was analyzed. RESULTS: The in-hospital survival of the 120 patients studied was 35%. While age below 50 years was associated with improved survival, age was not predictive of in-hospital survival for patients over 50 years of age. The post-hospital survival was 77% 1 year after discharge, with almost all survivors being functionally independent. Again, old age was not predictive of survival. CONCLUSIONS: For patients aged 50 years or older, patient age does not predict survival after prolonged mechanical ventilation. Even very old survivors have a reasonable life expectancy and regain full functional status.

Functional, cognitive and emotional long–term outcome of patients with ischemic stroke requiring mechanical ventilation

Prognosis of patients with ischemic stroke requiring mechanical ventilation (MV) has been reported to be poor. However, longterm survival and functional outcome have scarcely been studied and nothing is known about the prevalence of cognitive impairment or depression in survivors and their quality of life (QoL). We identified all patients treated for acute ischemic stroke on a Neurological Intensive Care Unit during 3.5 years who required MV for more than 24 hours. Early mortality rate at 2 months and survival rates at 1 and 2 years were determined. Survivors were examined for functional outcome (modified Rankin Scale (mRS), Barthel Index), cognitive impairment (Mini Mental State Examination (MMSE)), depression (Beck Depression Inventory, BDI) and QoL (Short Form-36). Clinical characteristics on admission were analyzed for prognostic significance. Of 101 consecutive patients, 44% died within 60 days. Survival rates at 1 and 2 years were 40% and 33%, respectively. Age > 60 years (p = 0.002) and Glasgow Coma Scale score < 10 on admission (p = 0.002) were independent predictors of early and late mortality. History of myocardial infarction (p = 0.007) independently predicted late mortality at 2 years. Of 33 surviving patients, nine (27%) had a good functional outcome (mRS 0-2). Of 27 survivors who could be interviewed, 17 (63%) had no cognitive impairment (MMSE > 24) and 20 (74%) did not suffer from relevant depression (BDI < 19). In conclusion, longer-term survival of patients with ischemic stroke requiring MV was 33% and every fourth survivor resumed an independent life without dementia or depression. Older patients comatose on admission and with concomitant cardiovascular disease had the lowest probability of a favorable outcome.

Outcome of Survivors of Acute Stroke Who Require Prolonged Ventilatory Assistance and Tracheostomy

BACKGROUND AND PURPOSE

Mechanical ventilation after stroke is associated with high mortality. However, little is known about survivors who require prolonged ventilatory assistance and tracheostomy. Our goal was to assess the rate of pulmonary complication, effect of early tracheostomy and prognosis of patients with stroke requiring prolonged ventilatory support.

METHODS

Retrospective review of 97 patients with stroke who required ventilatory assistance and tracheostomy admitted to a single teaching hospital between 1976 and 2000. Outcome was defined using the Glasgow Outcome Scale (GOS).

RESULTS

Poor outcome (GOS 1-3) occurred in 74% of patients at 1 year and it was associated with older age (p = 0.03), prior history of brain damage (p = 0.02), and neurological worsening after intubation (p < 0.01). However, long-term functional recovery (GOS 4-5) was possible and more likely after strokes involving the posterior circulation (p = 0.03). Pulmonary complications were prevalent and more frequent before tracheostomy (68 vs. 20% after tracheostomy) but did not determine functional outcome. Mean duration of mechanical ventilation was 11 +/- 19 days and did not significantly differ between outcome groups. Early tracheostomy correlated with shorter ICU and hospital stays (p < 0.01 in both cases).

CONCLUSIONS

Surviving patients with stroke who require prolonged ventilatory assistance and tracheostomy can have a better outcome than previously reported. Aggressive care is justified in patients who do not continue to deteriorate neurologically. Pulmonary complications are frequent but treatable. Early tracheostomy can shorten ICU and hospital stays and reduce costs.

Survival and quality of life outcome after mechanical ventilation in elderly stroke patients

OBJECTIVES

Mortality is high and functional outcome poor in mechanically ventilated stroke patients. In addition, age >65 years is an independent predictor of death at 2 months among these patients. Our objective was to determine survival rates, functional outcome, and quality of life (QoL) in stroke patients older than 65 years requiring mechanical ventilation.

METHODS

A prospective cohort study with an additional cross-sectional survey in 65 patients aged 65 years and older (mean age (SD): 75.6 (6.0) years) with ischaemic or haemorrhagic stroke who underwent mechanical ventilation. Main outcome measures were survival rate at 6 months, and Barthel Index (BI), modified Rankin Scale, and QoL at 15.8 (SD 8.0) months.

RESULTS

Survival rate at 6 months was 40%. Elective intubation (odds ratio (OR) 13.6; p = 0.002) was the only independent positive predictor for survival, while age >77.5 years (OR 0.1; p = 0.004) and white blood count >10/nl at admission (OR 0.31; p = 0.032) were independent negative predictors for survival at 6 months. At the time of the cross-sectional survey, BI was >70 in five out of 22 patients, 35-70 in three and <35 in the remaining 14 patients. QoL was impaired primarily in the physical domain, whereas the psychosocial domain was less affected.

CONCLUSIONS

Although only 40% of elderly patients intubated in the acute phase of stroke survived at least 6 months, one in four survivors recovered to a good functional outcome with a reasonable QoL. Elderly stroke patients need to be selected carefully for intensive care treatment, but elective intubation to allow diagnostic procedures should not be withheld primarily based on their age.

Mechanical ventilation in ischemic stroke

OBJECTIVE

Coma or respiratory failure in patients with acute ischemic stroke (IS) may require mechanical ventilation (MV). The inclusion criteria used in previous studies on MV for patients with stroke have been very heterogeneous. We carried out this prospective study in our neurologic stroke and intensive care department to assess clinical and radiologic features, mortality, outcome, and prognosis factors for patients presenting with acute IS involving the middle cerebral artery (MCA) and requiring MV.

METHODS

Of 470 patients admitted with acute IS involving the MCA territory, we prospectively enrolled 50 patients requiring MV. Indications for intubation were a Glasgow coma score <10 or respiratory failure.

RESULTS

The survival at 1 year was 30%. The mortality (70%) was independent of the reason for ventilation. Survivors had a mean Barthel index of 59 +/- 25 and a mean modified Rankin score of 4 +/- 1. Logistic regression showed that survivors were characterized by incomplete MCA territory involvement and atherosclerosis origin.

CONCLUSION

Patients with MCA IS who require MV have high mortality regardless of the cause of intubation. Survival is associated with incomplete MCA territory involvement and atherosclerosis origin.

Outcome of older patients receiving mechanical ventilation

OBJECTIVE

To determine the threshold of age that best discriminates the survival of mechanically ventilated patients and to estimate the outcome of mechanically ventilated older patients.

DESIGN

International prospective cohort study.

SETTING

Three hundred sixty-one intensive care units from 20 countries. PATIENTS AND PARTICIPANTS. Five thousand one hundred eighty-three patients mechanically ventilated for more than 12 h.

INTERVENTIONS

None.

MEASUREMENTS AND RESULTS

Recursive partitioning and logistic regression were used and an outcome model was derived and validated using independent subgroups of the cohort. Two age thresholds (43 and 70 years) were found, by partitioning recursive analysis, to be associated with outcome. This study focuses on the analysis of patients older than 43 years of age, divided in two subgroups: between 43 and 70 years (middle age group) and older than 70 years (elderly group). Survival in hospital was 45% (95% C.I.: 43-48) for the elderly group and 55% (53-57) for the middle age group ( p<0.001). Advanced age was not associated with prolongation of mechanical ventilation, weaning or length of stay in the ICU and in hospital ( p>0.05). Variables associated with mortality in the elderly were: acute renal failure, shock, Simplified Acute Physiology Score II and a ratio of PaO(2) to FIO(2) more than 150.

CONCLUSIONS

Older mechanically ventilated patients (age >70 years) had a lower ICU and hospital survival, but the duration of mechanical ventilation, ICU and hospital stay were similar to younger patients. Factors associated with the highest risk of mortality in patients older than 70 were the development of complications during the course of mechanical ventilation, such as acute renal failure and shock.

Long-term outcome in intensive care unit survivors after mechanical ventilation for intracerebral hemorrhage

OBJECTIVE

To evaluate long-term survival and functional outcome in intensive care unit survivors after mechanical ventilation for intracerebral hemorrhage.

DESIGN

Retrospective chart review and prospective follow-up study.

SETTING

Outpatient follow-up.

PATIENTS

Between 1997 and 2000, 120 patients were mechanically ventilated for an intracerebral hemorrhage at our intensive care unit. Sixty-two patients were discharged from hospital (in-hospital mortality = 48%). Sixty patients were evaluated for survival and functional outcome (two were lost to follow-up). Time between discharge and follow-up was > or =1 yr and was a mean of 27 +/- 14 months (range, 12-56).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patients' physicians were first asked about survival, and patients or proxies were interviewed by phone. Barthel Index and modified Rankin Scale scores were collected, and demographic information and general data were reviewed. The estimated life-table survival curve after discharge was 64.6% at 1 yr and 57% at 3 yrs. In the 24 patients who died, the mean time between discharge and death was 5 +/- 6 months. Probability of death after discharge significantly increased if age at admission was >65 yrs (p <.01; odds ratio, 3.5; 95% confidence interval, 1.4-9.1) and if Glasgow Coma Scale score at discharge was <15 (p <.01; odds ratio, 3.9; 95% confidence interval, 1.6-9.5). In the 36 long-term survivors, Barthel Index was 67.5 +/- 15 (median +/- median absolute dispersion) and modified Rankin Scale score was 2.6 +/- 0.5. Fifteen patients (42%) had a slight or no disability (Barthel Index > or =90 and modified Rankin Scale score < or =2), whereas 21 patients (58%) had moderate or severe disability (Barthel Index < or =85 and modified Rankin Scale score >2).

CONCLUSIONS

Probability of survival at 3 yrs after mechanical ventilation for an intracerebral hemorrhage was >50%. Age was an important determinant of long-term survival. Forty-two percent of long-term survivors were independent for activities of daily living. Only a few long-term survivors had a very high degree of disability.

Respiratory failure in elderly patients

Elderly individuals comprise an increasing proportion of the population and represent a progressively expanding number of patients admitted to the ICU. Because of underlying pulmonary disease, loss of muscle mass, and other comorbid conditions, older persons are at increased risk of developing respiratory failure. Recognition of this vulnerability and the adoption of proactive measures to prevent decompensation requiring intrusive support are major priorities together with clear delineation of patients' wishes regarding the extent of support desired should clinical deterioration occur. Further, the development of coordinated approaches to identify patients at risk for respiratory failure and strategies to prevent the need for intubation, such as the use of NIV in appropriate patients, are crucial. As soon as endotracheal intubation and mechanical ventilation are implemented strategies that facilitate the liberation of elderly patients from the ventilator are especially important. The emphasis on a team approach, which characterizes geriatric medicine, is essential in coordinating the skills of multiple health care professionals in this setting. Respiratory failure can neither be effectively diagnosed nor managed in isolation. Integration with all other aspects of care is essential. Patient vulnerability to nosocomial complications and the "cascade effect" of these problems such as the effects of medications and invasive supportive procedures all impact on respiratory care of elderly patients. For example, prolonged mechanical ventilation may be required long after resolution of the underlying cause of respiratory failure because of unrecognized and untreated delirium or residual effects of small doses of sedative and/or analgesic agents or other medications in elderly patients with altered drug metabolism. The deleterious impact of the foreign and sometimes threatening ICU environment and/or sleep deprivation on the patient's course are too often overlooked because the physician focuses management on physiologic measurements, mechanical ventilator settings, and other technologic nuances of care [40]. Review of the literature suggests that the development of respiratory failure in patients with certain disease processes such as COPD, IPF, and ARDS in elderly patients may lead to worsened outcome but it appears that the disease process itself, rather than the age of the patient, is the major determinant of outcome. Additional studies suggest that other comorbid factors may be more important than age. Only when comorbid processes are taken into account should decisions be made about the efficacy of instituting mechanical ventilation. In addition, because outcome prediction appears to be more accurate for groups of patients rather than for individual patients a well-structured therapeutic trial of instituting mechanical ventilation, even if comorbidities are present, may be indicated in certain patients if appropriately informed patients wish to pursue this course. This approach requires careful and realistic definition of potential outcomes, focus on optimizing treatment of the reversible components of the illness, and continuous communication with the patient and family. Although many clinicians share a nihilistic view regarding the potential usefulness of mechanical ventilation in elderly patients few data warrant this negative prognostication and more outcome studies are needed to delineate the optimum application of this element of supportive care. As with other interventions individualization of the decision must take into account the patient's premorbid status, concomitant conditions, the nature of the precipitating illness and its prospects for improvement, and most important, patient preferences. In this determination pursuing the course most consistent with the patient's wishes is essential and it must be appreciated that caregivers' impressions regarding the vigor of support desired by the patient are often erroneous. The SUPPORT investigators observed that clinicians often underestimated the degree of intervention desired by older patients assuming that less care would be desired [13]. Thus, as in other circumstances, effective communication and elicitation of patients' preferences regarding management options is crucial in the management of respiratory failure. The frequent discordance between patient preferences and the wishes of family members or other surrogate decision makers impose major clinical challenges and also mandates further investigation.

Outcome of stroke patients admitted to intensive care: experience from an Australian teaching hospital

The objective of this study was to determine the mortality rate and the functional outcomes of stroke patients admitted to the intensive care unit (ICU) and to identify predictors of poor outcome in this population. The records of all patients admitted to the ICU with the diagnosis of stroke between January 1994 and December 1999 were reviewed. Patients with subarachnoid haemorrhage were excluded. Data were collected on clinical and biological variables, risk factors for stroke and the presence of comorbidities. Mortality (ICU, in-hospital and three-month) and functional outcome were used as end-points. In the six-year-period, 61 patients were admitted to the ICU with either haemorrhagic or ischaemic stroke. Medical records were available for only 58 patients. There were 23 ischaemic and 35 haemorrhagic strokes. The ICU, in-hospital and three-month mortality rates were 36%, 47% and 52% respectively. There were no significant differences in the prevalence of premorbid risk factors between survivors and non-survivors. The mean Barthel score was significantly different between the independent and dependent survivors (94+/-6 vs 45+/-26, P<0.001). A substantial number of patients with good functional outcomes had lower Rankin scores (92% vs 11%, P<0.001). Only 46% of those who were alive at three months were functionally independent. Intensive care admission was associated with a high mortality rate and a high likelihood of dependent lifestyle after hospital discharge. Haemorrhagic stroke, fixed dilated pupil(s) and GCS <10 during assessment were associated with increased mortality and poor functional outcome.

Effect of dexmedetomidine, an alpha2-adrenoceptor agonist, on human pupillary reflexes during general anaesthesia

AIMS

To test the hypothesis that the alpha2-adrenergic agonist, dexmedetomidine, dilates the pupil and does not alter the pupillary light reflex of anaesthetized patients.

METHODS

Eight volunteers were administered general anaesthesia with propofol, nitrous oxide and alfentanil. One hour and 25 min after induction of anaesthesia, a 45 min infusion of dexmedetomidine was begun, targeting a plasma concentration of 0.6 ng x ml(-1). Pupil size, pupillary light reflex amplitude, light reflex recovery time, and reflex dilation were measured before and during dexmedetomidine infusion.

RESULTS

Dexmedetomidine produced no change in pupil size and light reflex recovery time, increased the light reflex from 0.30 +/- 0.14 to 0.37 +/- 0.12 mm and significantly reduced pupillary reflex dilation by 72 +/- 62%.

CONCLUSIONS

These pupillary effects of dexmedetomidine in humans are difficult to reconcile with the findings obtained in cats and rats that have demonstrated a direct inhibitory effect of alpha2-adrenergic agonists on the pupilloconstrictor nucleus. The increase in the magnitude of the light reflex in response to dexmedetomidine does not necessarily involve an anxiolytic mechanism.

Factors influencing a communitywide campaign to administer hepatitis A vaccine to men who have sex with men

OBJECTIVES

A hepatitis A outbreak among men who have sex with men (MSM) led to a publicly funded vaccination campaign. We evaluated the MSM community's response.

METHODS

A cohort of MSM from 5 community sites was surveyed.

RESULTS

Thirty-four (19%) of 178 potential vaccine candidates received the vaccine during the campaign. We found a linear relation between the number of exposures to campaign information and the likelihood of vaccination (P < .001). Vaccination was independently associated with awareness of the outbreak and the vaccine, having had sexual relations with men for 12 years or longer, having recently consulted a physician, and routinely reading a local gay newspaper.

CONCLUSIONS

The difficult task of vaccinating MSM can be aided by repetitive promotional messages, especially via the gay media.

European Stroke Initiative (EUSI) recommendations for stroke management. The European Stroke Initiative Writing Committee

The European Stroke Initiative (EUSI) is the common body of stroke-related activities within the European Federation of Neurological Societies (EFNS), the European Neurological Society (ENS) and the European Stroke Council (ESC). The Executive committee of the EUSI has authorized the writing committee of the EUSI to create recommendations for stroke management covering all areas of stroke treatment. The recommendations are listed according to levels of evidence pre-specified and modified according to several proposals in the literature. The recommendations have been approved by the executive committees of the EUSI, the ESC, the EFNS and the ENS. They are called recommendations rather than guidelines in order to underline the large amount of individual decision making due to the fact that for many important questions, no data of high evidence level is available. The EUSI plans to review and update the recommendations on a regular basis.

Mechanical ventilation in patients with hemispheric ischemic stroke

OBJECTIVE

Whether stroke patients should be ventilated mechanically is still a contentious issue, because their outcome is very poor. We wanted to investigate how often mechanical ventilation is indicated in patients with hemispheric ischemic stroke as well as the outcome of these patients and the factors by which outcome is influenced.

DESIGN

Prospective case series.

SETTING

University hospital, neurocritical care unit.

SUBJECTS

Subjects were 218 patients who met the following inclusion criteria: age 18-85 yrs, acute hemispheric ischemic infarction, clinical examination, and computed tomography within 6 hrs after the onset of symptoms.

INTERVENTIONS

Mechanical ventilation was instituted with one or more of the following conditions: deterioration of consciousness with the inability to protect the airway; PaO2 of <60; P(CO2) of >60 mm Hg; breath rate of >40 breaths/min; and left heart insufficiency with definitive or impending pulmonary edema.

MEASUREMENTS AND MAIN RESULTS

Mechanical ventilation was indicated for 52 (24%) of the 218 patients: in 47 (90%) patients because of deterioration of consciousness, and in five (10%) patients because of heart insufficiency and/or pneumonia. In a logistic regression model, the history of hypertension and a size of infarction exceeding two thirds of the middle cerebral artery territory were independent variables for the application of mechanical ventilation. After 3 months, 42 (81%) of these 52 patients had died. The most common cause of death was fatal midbrain herniation caused by complete middle cerebral artery infarction. Patients who survived had a good-to-fair outcome.

CONCLUSIONS

New therapeutic strategies (e.g., hemicraniectomy) must be developed to reduce mortality and improve the outcome for this subgroup of ischemic stroke patients. Mechanical ventilation is and will remain a crucial element within such new concepts.

Prognostic factors in artificially ventilated stroke patients

OBJECTIVES

To evaluate the reasons for implementing artificial ventilation (AV) in patients with acute ischemic stroke (AIS), determine their outcome and characterize prognostic variables in these patients.

METHODS

Consecutive patients presenting with AIS were evaluated. All patients who received AV were treated in a neurological semi-intensive care setting.

RESULTS

Of the 173 patients included in the study, 27 (16%) needed AV, 16 (9%) received AV and five of these patients (31%) survived. The mean NIH stroke scale score prior to AV was 14.5+/-5.6 (vs. 9.1+/-6.2 in non-intubated patients, P=0.001). Six patients were ventilated because of neurological deterioration. Most of these patients had large hemispheric infarctions with evident herniation and midline shift on CT scans. The only one who survived the acute hospitalization did not recover and died within 3 months. In the other 10 patients, AV was instituted during cardiopulmonary decompensation (CPD). These patients generally fared better; four of them survived and were discharged after a lengthier hospital stay when compared to non-intubated patients. Variables associated with survival among intubated patients were a lower neurological disability score on admission and on day 7 after the stroke, and intubation during CPD.

CONCLUSIONS

Implementing AV in semi-intensive care settings does not seem to improve survival in AIS patients with neurological deterioration. Stroke patients who need AV during CPD and those that have less severe neurological deficits may have better chances for survival.

Intensive care unit management of the stroke patient

Although the majority of patients with acute stroke do not require intensive care, it is important to recognize when admission to an intensive care unit (ICU) is warranted. Patients undergoing thrombolytic therapy, those with brainstem infarcts referable to the basilar artery, those with large space occupying hemispheric infarcts, and those with fluctuating neurological examinations should be admitted to the ICU for monitoring and treatment.

Predictors of mortality in stroke patients admitted to an intensive care unit

OBJECTIVE

Improved pathophysiologic insight and prognostic information regarding in-hospital risk of mortality among stroke patients admitted to an intensive care unit.

DESIGN

Retrospective analysis.

SETTING

Neurology/neurosurgery intensive care unit in a tertiary care university medical center.

PATIENTS

A total of 63 consecutive ischemic stroke patients.

INTERVENTIONS

Patients were classified according to in-hospital mortality. Charts were reviewed to retrospectively generate an admitting Acute Physiology and Chronic Health Evaluation (APACHE) II score. The APACHE II score and its individual components were assessed for predicting subsequent death.

MEASUREMENTS AND MAIN RESULTS

Of 63 patients, 13 died and 50 survived to either discharge or surgical intervention. The mean admitting APACHE II score of survivors (6.9) was lower than that of patients who died (17.2; p < .0001). None of the 33 patients with a score <9 died, compared with 43% of those with a score > or =9. A score > or =18 was uniformly associated with fatal outcome (n = 8). Univariate analysis identified APACHE II total score, Glasgow Coma Scale score, temperature, pH, and white blood cell count as significant predictors of death. Among multivariate logistic regression models examining the components of the APACHE II score, the model containing white blood cells, temperature, and creatinine best predicted death.

CONCLUSIONS

Several features of the APACHE II score are associated with risk of death in this patient population. The findings suggest particular physiologic derangements that are associated with, and may contribute to, increased mortality in critically ill patients with acute ischemic stroke.

Prediction and timing of tracheostomy in patients with infratentorial lesions requiring mechanical ventilatory support

OBJECTIVES

To determine the frequency and predictors of successful extubations and tracheostomy in patients with infratentorial lesions requiring mechanical ventilation and to determine the optimal time for tracheostomy based on probability of successful extubation and in-hospital survival according to the duration of translaryngeal intubation.

DESIGN

Retrospective chart review.

SETTINGS

A neurocritical care unit at a university hospital.

PATIENTS

A total of 69 patients with infratentorial lesions who were mechanically ventilated during their intensive care unit stay.

MEASUREMENTS AND MAIN RESULTS

Of the 69 patients who were mechanically ventilated, 23 (33%) were successfully extubated. In logistic regression analysis, both the presence of a Glasgow Coma Scale score >7 at time of intubation (odds ratio, 4.8; 95% confidence interval, 1.2-21.7) and the absence of brainstem deficits (odds ratio, 4.3; 95% confidence interval, 1.3-16.7), were independently associated with successful extubation. After extubation, 11 patients were reintubated; seven were reintubated within the same day because of poor control over secretions, airway spasm, or hypoventilation. Tracheostomy was performed in 23 (33%) patients, of whom 19 were successfully weaned off mechanical ventilatory support over a mean period of 3.7+/-4.0 days after tracheostomy. Patients undergoing tracheostomy had a significantly longer intensive care unit stay (19.1+/-9.0 vs. 8.7+/-6.6 days, p < .01) and total hospital stay (34.8+/-18.7 vs. 20.1+/-9.9 days, p < .01) compared with patients who were successfully extubated. The probability of successful extubation or death before extubation or tracheostomy was 67% on the day of intubation, which decreased to 5.8% after translaryngeal intubation for >8 days.

CONCLUSIONS

An aggressive policy toward tracheostomy is justified based on the low frequency of successful extubations and high frequency of extubation failures and tracheostomies in patients with infratentorial lesions. The decision regarding tracheostomy should be made on day 8 of mechanical ventilatory support because of the low probability of subsequent extubation or in-hospital death.

Mechanical ventilation in a cohort of elderly patients admitted to an intensive care unit

BACKGROUND

It has been argued that life support for the elderly should be limited to conserve resources. As this population increases, so will the importance of evaluating appropriate use of mechanical ventilation in this group.

OBJECTIVE

To determine whether age has an independent effect on the outcomes of patients treated with mechanical ventilation after admission to an intensive care unit (ICU).

DESIGN

Prospective cohort study.

SETTING

University-based tertiary care medical center.

PATIENTS

63 patients 75 years of age or older and 237 patients younger than 75 years of age enrolled from medical and coronary ICUs.

MEASUREMENTS

In-hospital mortality rate, duration of mechanical ventilation, lengths of stay in the ICU and in the hospital, and cost of care.

RESULTS

Median duration of mechanical ventilation was 4.2 days (interquartile range, 2.1 to 9.3 days) for patients 75 years of age or older and 6.4 days (interquartile range, 3.4 to 11.4 days) for patients younger than 75 years of age (P = 0.14). When the length of time required to "pass" a daily screening test of weaning variables was used as an indicator of recovery from respiratory failure, elderly patients passed earlier than younger patients (risk ratio, 1.58 [95% CI, 1.13 to 2.22]; P = 0.03). The cost of ICU care was lower for older ($12,822 [CI, $9821 to $26,313] than for younger ($19,316 [CI, $9699 to $39,950]) patients (P = 0.03). Median hospital costs tended to be lower in the older group ($21,292 compared with $29,049; P = 0.17). After adjustment for ethnicity, sex, and severity of illness in a multivariate logistic regression analysis, patient age of 75 years or older was predictive of 1 less day on the ventilator (CI, -2.8 to 1.2 days). Lengths of stay in the ICU (beta-coefficient, -0.5 days [CI, -3.0 to 2.7 days]) and in the hospital (beta-coefficient, 0.3 days [CI, -3.7 to 5.5 days]) did not differ for persons 75 years of age or older after these adjustments (P > 0.1). Intensive care unit and hospital costs, however, were lower for elderly persons (P = 0.02). The in-hospital mortality rate was 38.1% among elderly patients and 38.8% among younger patients (P > 0.2); Cox proportional hazards analysis confirmed that survival did not differ between the two groups (relative risk for older patients, 0.82 [CI, 0.52 to 1.29]).

CONCLUSIONS

After adjustment for severity of illness, elderly patients spent similar time on mechanical ventilation and in the ICU and hospital but had a lower cost of care than younger patients. These outcomes are not explained by differences in mortality rate and suggest that mechanical ventilation should not be restricted in elderly patients with respiratory failure on the basis of chronologic age.

Survival and outcome after endotracheal intubation for acute stroke

OBJECTIVE

To assess survival and functional outcome in patients endotracheally intubated after ischemic stroke (IS) or spontaneous intracerebral hemorrhage (ICH).

BACKGROUND

Endotracheal intubation is both a necessary life support intervention and a measure of severity in IS or ICH. Knowledge of associated clinical variables may improve the estimation of early prognosis and guide management in these patients.

METHODS

We reviewed 131 charts of patients with IS or ICH who were admitted to the Neurosciences Intensive Care Unit at Duke University Medical Center between July 1994 and June 1997 and required endotracheal intubation. Stroke risk factors, stroke type (IS or ICH) and location (hemispheric, brainstem, or cerebellum), circumstances surrounding intubation, neurologic assessment (Glasgow Coma Score [GCS] and brainstem reflexes), comorbidities, and disposition at discharge were documented. Survivors were interviewed for Barthel Index (BI) scores.

RESULTS

Survival was 51% at 30 days and 39% overall. Variables that significantly correlated with 30-day survival in multivariate analysis included GCS at intubation (p = 0.03) and absent pupillary light response (p = 0.008). Increase in the GCS also correlated with improved functional outcome measured by the BI (p = 0.0003). In patients with IS, age and GCS at intubation predicted survival, and in patients with ICH, absent pupillary light response predicted survival.

CONCLUSIONS

Predictors for mortality differ between patients with IS and ICH; however, decreased level of consciousness is the most important determinant of increased mortality and poor functional outcome. Absent pupillary light responses also correspond with a poor prognosis for survival, but further validation of this finding is needed.

The role of futility judgments in improperly limiting the scope of clinical research

In medical research, the gathering and presenting of data can be limited in accordance with the futility judgments of the researchers. In that case, research results falling below the threshold of what the researchers deem beneficial would not to be reported in detail. As a result, the reported information would tend to be useful only to those who share the valuational assumptions of the researchers. Should this practice become entrenched, it would reduce public confidence in the medical establishment, aggravate factionalism within the research community, and unduly influence treatment decisions. I suggest alternative frameworks for measuring survival outcomes.