Prognosis of stroke patients undergoing mechanical ventilation

Analysis of short-term ventilation weaning for patients in spontaneous supratentorial intracranial hemorrhage

Prolonged ventilation is a complication of spontaneous supratentorial hemorrhage patients, but the predictive relationship with successful weaning in this patient cohort is not understood. Here, we evaluate the incidence and factors of ventilation weaning in case of spontaneous supratentorial hemorrhage. We retrospectively studied data from 166 patients in the same hospital from January 2015 to March 2021 and analyzed factors for ventilation weaning. The clinical data recorded included patient age, gender, timing of operation, initial Glasgow Coma Scale (GCS), Intracranial hemorrhage (ICH) score, alcohol drinking, cigarette smoking, medical comorbidity, and the blood data. Predictors of patient outcomes were determined by the Student t test, chi-square test, and logistic regression. We recruited and followed 166 patients who received operation for spontaneous supratentorial hemorrhage with cerebral herniation. The group of successful weaning had 84 patients and the group of weaning failed had 82 patients. The patient's age, type of operation, GCS on admission to the Intensive care unit (ICU), GCS at discharge from the ICU, medical comorbidity was significantly associated with successful weaning, according to Student t test and the chi-square test. According to our findings, patients with stereotaxic surgery, less history of cardiovascular or prior cerebral infarction, GCS >8 before admission to the hospital for craniotomy, and a blood albumin value >3.5 g/dL have a higher chance of being successfully weaned off the ventilator within 14 days.

One-Year Survival of Ischemic Stroke Patients Requiring Mechanical Ventilation

BACKGROUND

The outcome of patients with acute ischemic stroke who require mechanical ventilation has been poor. Intubation due to a reversible condition could be associated with better 1-year survival.

METHODS

All adult patients treated in Helsinki University Hospital in 2016-2020 who were admitted because of an ischemic stroke (either stroke or thrombosis seen on imaging) and needed mechanical ventilation were included in this retrospective cohort study. Data on demographics, medical history, index stroke, and indication for intubation were collected. The primary outcome was 1-year mortality. Secondary outcomes were modified Rankin Scale (mRS) score at 3 months and living arrangements at 1 year.

RESULTS

The mean age of the cohort (N = 121) was 66 ± 11 (mean ± SD) years, and the mean admission National Institutes of Health Stroke Scale score was 17 ± 10. Forty-four (36%) patients were male. The most common indication for intubation was unconsciousness (51%), followed by respiratory failure or airway compromise (28%). One-year mortality was 55%. Three-month mRS scores were available for 114 (94%) patients, with the following distribution: 0-2, 18%; 3-5, 28%; and 6 (dead), 54%. Of the 1-year survivors, 72% were living at home. In the multivariate analysis, only age over 75 years and intubation due to unconsciousness, respiratory failure, or cardiac arrest remained significantly associated with mortality.

CONCLUSIONS

The indication for intubation seems to significantly affect outcome. Functional outcome at 3 months is often poor, but a great majority of 1-year survivors are able to live at home.

Risk factors of mortality and severe disability in the patients with cerebrovascular diseases treated with perioperative mechanical ventilation

BACKGROUND

The prognosis of cerebrovascular diseases treated with mechanical ventilation during perioperative has not been clearly reported.

AIM

To analyze mortality and functional disability and to determine predictors of unfavorable outcome in the patients with cerebrovascular diseases treated with mechanical ventilation.

METHODS

A retrospective follow-up study of 111 cerebrovascular disease patients who underwent mechanical ventilation during the perioperative period in the First Hospital of Jilin University from June 2016 to June 2019 was performed. Main measurements were mortality and functional outcome in-hospital and after 3-month follow-up. According to the modified rankin scale (mRS), the functional outcome was divided into three groups: Good recovery (mRS ≤ 3), severe disability (mRS = 4 or 5) and death (mRS = 6). Univariate analysis was used to compare the differences between three functional outcomes. Multivariate logistic regression analysis was used to for risk factors of mortality and severe disability.

RESULTS

The average age of 111 patients was 56.46 ± 12.53 years, 59 (53.15%) were males. The mortality of in-hospital and 3-month follow-up were 36.9% and 45.0%, respectively. Of 71 discharged patients, 46.47% were seriously disabled and 12.67% died after three months follow-up. Univariate analysis showed that preoperative glasgow coma scale, operation start time and ventilation reasons had statistically significant differences in different functional outcomes. Multiple logistic regression analysis showed that the cause of ventilation was related to the death and poor prognosis of patients with cerebrovascular diseases. Compared with brainstem compression, the risk of death or severe disability of pulmonary disease, status epilepticus, impaired respiratory center function, and shock were 0.096 (95%CI: 0.028-0.328), 0.026 (95%CI: 0.004-0.163), 0.095 (95%CI: 0.013-0.709), 0.095 (95%CI: 0.020-0.444), respectively.

CONCLUSION

The survival rate and prognostic outcomes of patients with cerebrovascular diseases treated with mechanical ventilation during the perioperative period were poor. The reason for mechanical ventilation was a statistically significant predictor for mortality and severe disability.

Related Factors and a Threshold of the Maximum Neuron-Specific Enolase Value Affecting the Prognosis of Patients with Aneurysmal Subarachnoid Hemorrhage

Background

The prognosis of patients with subarachnoid hemorrhage is influenced by many factors. Neuron-specific enolase (NSE) is a biological marker of neurological damage. This study aimed to determine the related prognostic factors and whether or not the maximum NSE value (NSEmax) has a threshold between good and poor prognosis in aneurysmal subarachnoid hemorrhage (aSAH).

Methods

A total of 259 patients admitted following aSAH were treated by appropriate methods. Initial neurological severity was evaluated by using the initial Glasgow coma scale and Hunt-Hess grades. NSE plasma concentration was measured during the patient's stay in the neurosurgical intensive care unit, and NSEmax was selected for further study. The primary endpoint of the study was Glasgow outcome score (GOS), which was dichotomized as poor outcome (GOS 1-3) or good outcome (GOS 4-5) at discharge.

Results

A poor outcome of patients with aSAH at discharge was associated with mild hypothermia treatment, Hunt-Hess grade, rehemorrhagia, neurogenic pulmonary edema, and pneumonia, which were independent risk factors affecting the prognosis of patients. The best threshold of the maximum value of NSE for poor or good prognosis was 26.255 μg/L (specificity 0.908).

Conclusions

Poor neurological score, pulmonary complications, aneurysm rerupture, and mild hypothermia indicate a poor prognosis. NSEmax>26.255 μg/L is an independent predicting factor of poor neurological outcome at discharge after aSAH. This threshold value could help clinicians make the appropriate decision and prognosis.

High In-Hospital Mortality Incidence Rate and Its Predictors in Patients with Intracranial Hemorrhage Undergoing Endotracheal Intubation

(1) Background: The goal of this study was to determine the incidence of in-hospital mortality and to investigate its predictors in patients with a primary intracranial hemorrhage (ICH) undergoing endotracheal intubation. (2) Methods: This retrospective study, between July 2018 to July 2019, recruited patients who were diagnosed with a primary ICH and who were intubated during treatment in our institution. The outcome variable was in-hospital mortality, known as 30-day mortality, in patients with ICH undergoing endotracheal intubation. Multivariable analyses were performed to identify the prediction of in-hospital mortality. (3) Results: A total of 180 patients with ICH undergoing endotracheal intubation were included, with a mean (SD) age of 62.64 (13.82) years. A total of 73.33% were female, and 71.11% of the patients were indicated for intubation due to neurological reasons. The in-hospital mortality rate, following endotracheal intubation, was 58.33%. In a reduced model using a stepwise backward selection strategy with p values < 0.2, independent predictors of in-hospital mortality were brain herniations on cranial CT scans (OR: 10.268, 95% CI: 2.749–38.344), lower Glasgow coma scale (CGS) scores before intubation (OR: 0.614, 95% CI: 0.482–0.782), and the loss of the vertical oculocephalic reflex before intubation (OR: 6.288, 95% CI: 2.473–15.985). Conclusions: The in-hospital mortality rate was comparable to that in the early evidence, but was significantly higher compared to recent reports. We infer that brain herniations on cranial CT imaging, lower CGS scores before intubation, and the loss of the vertical oculocephalic reflex before intubation could be used to approximately predict in-hospital mortality in patients with primary ICH undergoing endotracheal intubation. These considerations can help guide clinical decisions and community stroke discussions.

Prognosis of patients with tracheal intubation in the emergency department

Background

Intubation of critically ill patients is one of the increasing emergency procedures. We designed this study to determine age and sex-related mortality rates after emergency intubation.

Methods

This retrospective study collected and analyzed non-trauma intubated patients in a referral hospital from the years 2017-2019 and before the appearance of COVID-19. Patients who were intubated outside of emergency by EMS technicians were excluded. We recorded data of intubated patients, like sex, age, length of being intubated and final diagnosis. P values of less than 0.05 were significant.

Results

Data of 520 non-trauma intubated patients were collected and analyzed. More than 64% of the patients were over 65 years old and had a higher mortality rate (86.7%; P < 0.001) than younger patients. The overall in-hospital mortality rate was 80%. More than three quarters of the decedents died within a week of intubation (P < 0.001). There was no significant relationship between sex and mortality rate (P = 0.535).

Conclusion

Our data showed that with increased age there was a decrease in the chance of being extubated.

Tracheostomy decannulation outcomes in 131 consecutive neurosurgical patients

OBJECTIVES

This study was a retrospective study to investigate factors related to difficult tracheostomy decannulation, and to evaluate outcomes of tracheostomized neurosurgical patients.

METHODS

All consecutive tracheostomized neurosurgical patients in the Prince of Wales Hospital between 1st September 2016 and 31st August 2019 were reviewed retrospectively. Patients were grouped into easy decannulation and difficult decannulation groups using 3 months as cut-off time. Risk factors were analysed and outcomes were compared.

RESULTS

One hundred thirty-one patients were included. In univariate analyses, male gender, GCS less than or equal to 8 on admission, the presence of vocal cord palsy at 3 months, and pneumonia within 1-month post-tracheostomy were associated with difficult decannulation. In multivariable logistic regression for difficult decannulation, GCS on admission, the presence of vocal cord palsy at 3 months, and the presence of pneumonia within 1-month post-tracheostomy remained statistically significant. The easy decannulation group had a shorter length of in-patient stay, higher survival rate, and more favourable neurological outcome (GOS 4-5) than the difficult decannulation group at both 6 months and 1 year. The majority of easy decannulation group patients (54%) were discharged to home, while the majority of the difficult decannulation group (42%) of patients were discharged to the infirmary.

CONCLUSION

GCS less than or equal to 8 on admission, the presence of vocal cord palsy, and the presence of pneumonia were associated with difficult tracheostomy decannulation in neurosurgical patients. Difficult decannulation is associated with a longer length of in-patient stay and poor neurological outcomes.

The Long-Term Survival of Intracranial Hemorrhage Patients Successfully Weaned from Prolonged Mechanical Ventilation

Background

Ninety-one intracranial hemorrhage prolonged mechanical ventilation patients were successfully weaned from the ventilator. No article had discussed the factors related to 1-year survival in successfully weaned prolonged mechanical ventilation patients with intracranial hemorrhage. This study aimed to evaluate the factors influencing the one-year survival of successfully weaned intracranial hemorrhage prolonged mechanical ventilation patients. The identification of patients with a poor long-term prognosis could guide long-term care decisions after discharge in such patients.

Patients and Methods

We performed this retrospective study on the respiratory care center of Dalin Tzu Chi hospital and enrolled all successfully weaned intracranial hemorrhage prolonged mechanical ventilation patients between 1 January 2012 and 31 December 2017. We analyzed data including age, gender, comorbidities, intracranial hemorrhage type, spontaneous or traumatic intracranial hemorrhage, location of intracerebral hemorrhage, presence or not of an intraventricular hemorrhage, Glasgow Coma Scale, receipt or not of intracranial hemorrhage surgery, receipt or not of tracheostomy, long-term survival, and end-of-life decisions.

Results

We had long-term follow-up data on 69 of these successfully weaned intracranial hemorrhage prolonged mechanical ventilation patients. The 1-year survival rate of successfully weaned patients was 43.5%. The factors unrelated to the 1-year survival rate were comorbidities, intracranial hemorrhage type, spontaneous or traumatic intracranial hemorrhage, location of the intracerebral hemorrhage, presence or not of an intraventricular hemorrhage, intracranial hemorrhage surgery, and tracheostomy. Four factors were independently associated with the 1-year survival rate of these patients: Glasgow Coma Scale score at discharge from the respiratory care center, age ≥ 65 years, signed do-not-resuscitate and do-not-intubate orders, and the absence of comorbidity.

Conclusion

This study emphasizes an important key factor in terms of the survival of successfully weaned intracranial hemorrhage prolonged mechanical ventilation patients. The patient’s Glasgow Coma Scale score at discharge from the respiratory care center is an important predictor of outcomes. These results can help physician better plan the clinical course for intracranial hemorrhage prolonged mechanical ventilation patients.

A Reassessment of Weaning Parameters in Patients With Spontaneous Intracerebral Hemorrhage

Background and purpose

Patients with spontaneous intracerebral haemorrhage have significant morbidity and mortality. One aspect of their care is the need for mechanical ventilation. Extubating a patient safely and efficiently is important in advancing their care; however, traditional extubation criteria using the rapid shallow breathing index and negative inspiratory force do not predict success in these patients as well as they do in other intubated patients. This study aimed to evaluate these criteria in patients with spontaneous intracerebral haemorrhage to improve the extubation success rate.

Methods

We conducted a retrospective chart review of patients with spontaneous intracerebral haemorrhage (sICH) who underwent spontaneous breathing trials from 2018 to 2020. Twenty-nine patients met the inclusion criteria, and of these 29, 20 had a trial of extubation. Rapid shallow breathing index (RSBI), negative inspiratory force (NIF), and cuff leak were recorded to analyze breathing parameters at the time of extubation. Patients who required reintubation were noted.

Results

All trials of extubation required a cuff leak. Using RSBI, patients with values <105 or <85, as the only other extubation criteria, were associated with a 70.6% and 71.4% success rate, respectively. With RSBI <105 and NIF <-25 cm water, the success rate was 88.9%. Any patient with a cuff leak that had a NIF <-30 had a success rate of 100%, regardless of RSBI.

Conclusion

The RSBI was not a reliable isolated measure to predict 100% extubation success. Using a NIF <-30 predicts a 100% extubation success rate if a cuff leak is present. This demonstrates that the NIF may be a more useful metric in sICH patients, as it accounts for patient participation and innate ability to draw a breath spontaneously. Future studies are warranted to evaluate further and optimize the extubation criteria in these patients.

One-year survival in acute stroke patients requiring mechanical ventilation: a multicenter cohort study

Background

Most prognostic studies in acute stroke patients requiring invasive mechanical ventilation are outdated and have limitations such as single-center retrospective designs. We aimed to study the association of ICU admission factors, including the reason for intubation, with 1-year survival of acute stroke patients requiring mechanical ventilation.

Methods

We conducted a secondary data use analysis of a prospective multicenter database (14 ICUs) between 1997 and 2016 on consecutive ICU stroke patients requiring mechanical ventilation at admission. We excluded patients with stroke of traumatic origin, subdural hematoma or cerebral venous thrombosis. The primary outcome was survival 1 year after ICU admission. Factors associated with the primary outcome were identified using a multivariable Cox model stratified on inclusion center.

Results

We identified 419 patients (age 68 [58–76] years, males 60%) with a Glasgow coma score (GCS) of 4 [3–8] at admission. Stroke subtypes were acute ischemic stroke (AIS, 46%), intracranial hemorrhage (ICH, 42%) and subarachnoid hemorrhage (SAH, 12%). At 1 year, 96 (23%) patients were alive. Factors independently associated with decreased 1-year survival were ICH and SAH stroke subtypes, a lower GCS score at admission, a higher non-neurological SOFA score. Conversely, patients receiving acute-phase therapy had improved 1-year survival. Intubation for acute respiratory failure or coma was associated with comparable survival hazard ratios, whereas intubation for seizure was not associated with a worse prognosis than for elective procedure. Survival did not improve over the study period, but patients included in the most recent period had more comorbidities and presented higher severity scores at admission.

Conclusions

In acute stroke patients requiring mechanical ventilation, the reason for intubation and the opportunity to receive acute-phase stroke therapy were independently associated with 1-year survival. These variables could assist in the decision process regarding the initiation of mechanical ventilation in acute stroke patients.

Validation of APACHE II scoring system at 24 hours after admission as a prognostic tool in urosepsis: A prospective observational study

Purpose

Urosepsis implies clinically evident severe infection of urinary tract with features of systemic inflammatory response syndrome (SIRS). We validate the role of a single Acute Physiology and Chronic Health Evaluation II (APACHE II) score at 24 hours after admission in predicting mortality in urosepsis.

Materials and Methods

A prospective observational study was done in 178 patients admitted with urosepsis in the Department of Urology, in a tertiary care institute from January 2015 to August 2016. Patients >18 years diagnosed as urosepsis using SIRS criteria with positive urine or blood culture for bacteria were included. At 24 hours after admission to intensive care unit, APACHE II score was calculated using 12 physiological variables, age and chronic health.

Results

Mean±standard deviation (SD) APACHE II score was 26.03±7.03. It was 24.31±6.48 in survivors and 32.39±5.09 in those expired (p<0.001). Among patients undergoing surgery, mean±SD score was higher (30.74±4.85) than among survivors (24.30±6.54) (p<0.001). Receiver operating characteristic (ROC) analysis revealed area under curve (AUC) of 0.825 with cutoff 25.5 being 94.7% sensitive and 56.4% specific to predict mortality. Mean±SD score in those undergoing surgery was 25.22±6.70 and was lesser than those who did not undergo surgery (28.44±7.49) (p=0.007). ROC analysis revealed AUC of 0.760 with cutoff 25.5 being 94.7% sensitive and 45.6% specific to predict mortality even after surgery.

Conclusions

A single APACHE II score assessed at 24 hours after admission was able to predict morbidity, mortality, need for surgical intervention, length of hospitalization, treatment success and outcome in urosepsis patients.

Evidence-based guidelines for the management of large hemispheric infarction : a statement for health care professionals from the Neurocritical Care Society and the German Society for Neuro-intensive Care and Emergency Medicine

Large hemispheric infarction (LHI), also known as malignant middle cerebral infarction, is a devastating disease associated with significant disability and mortality. Clinicians and family members are often faced with a paucity of high quality clinical data as they attempt to determine the most appropriate course of treatment for patients with LHI, and current stroke guidelines do not provide a detailed approach regarding the day-to-day management of these complicated patients. To address this need, the Neurocritical Care Society organized an international multidisciplinary consensus conference on the critical care management of LHI. Experts from neurocritical care, neurosurgery, neurology, interventional neuroradiology, and neuroanesthesiology from Europe and North America were recruited based on their publications and expertise. The panel devised a series of clinical questions related to LHI, and assessed the quality of data related to these questions using the Grading of Recommendation Assessment, Development and Evaluation guideline system. They then developed recommendations (denoted as strong or weak) based on the quality of the evidence, as well as the balance of benefits and harms of the studied interventions, the values and preferences of patients, and resource considerations.

Outcome of Intensive Care Unit-Dependent, Tracheotomized Patients with Cerebrovascular Diseases

BACKGROUND

Outcome studies in intensive care unit -dependent, tracheotomized, and mechanical ventilated patients with cerebrovascular disease (CVD) are scarce.

METHODS

In a retrospective approach, we analyzed the outcome of 143 patients with ischemic stroke (IS), primary intracerebral hemorrhage (PICH), and subarachnoid hemorrhage (SAH). To measure the potential benefit of in-patient rehabilitation, we used the Functional Independence Measure (FIM). In addition, weaning and rehabilitation duration, duration of mechanical ventilation (MV) in the acute care hospital (preweaning), and mortality rates were assessed.

RESULTS

Approximately 50% of all patients were transferred home. These patients were fully independent or under nursing support. We found no differences regarding weaning and rehabilitation durations, or FIM scores in between each entity. Log-regression analyses showed that every day on MV generates a 3.2% reduction of the possibility to achieve a beneficial outcome (FIM ≥ 50 points [only moderate assistance necessary]), whereas every day in-patient rehabilitation without MV increases the chance for favorable outcome by 1.9%. Mortality rates were 5% for IS and 10% for PICH and SAH, respectively.

CONCLUSIONS

This study shows that even severely affected, tracheotomized patients with CVD benefit from early in-patient rehabilitation, irrespective of the etiology of vascular brain injury. Mortality rates of early rehabilitation in CVD are low. Until no validated outcome predictors are available, all efforts should be undertaken to enable in-patient rehabilitation, even in severe cases of CVD to improve outcome and to prevent accommodation in long-time-care facilities.

Effects of PaCO2 derangements on clinical outcomes after cerebral injury: A systematic review

OBJECTIVE

Partial pressure of arterial carbon dioxide (PaCO2) is a major regulator of cerebral blood flow (CBF). Derangements in PaCO2 have been thought to worsen clinical outcomes after many forms of cerebral injury by altering CBF. Our aim was to systematically analyze the biomedical literature to determine the effects of PaCO2 derangements on clinical outcomes after cerebral injury.

METHODS

We performed a search of Cochrane Library, PUBMED, CINHAL, conference proceedings, and other sources using a comprehensive strategy. Study inclusion criteria were (1) human subjects; (2) cerebral injury; (3) mechanical ventilation post-injury; (4) measurement of PaCO2; and (5) comparison of a clinical outcome measure (e.g. mortality) between different PaCO2 exposures. We performed a qualitative analysis to collate and summarize effects of PaCO2 derangements according to the recommended methodology from the Cochrane Handbook.

RESULTS

Seventeen studies involving different etiologies of cerebral injury (six traumatic brain injury, six post-cardiac arrest syndrome, two cerebral vascular accident, three neonatal ischemic encephalopathy) met all inclusion and no exclusion criteria. Three randomized control trials were identified and only one was considered a high quality study as per the Cochrane criteria for assessing risk of bias. In 13/17 (76%) studies examining hypocapnia, and 7/10 (70%) studies examining hypercapnia, the exposed group (hypercapnia or hypocapnia) was associated with poor clinical outcome.

CONCLUSION

The majority of studies in this report found exposure to hypocapnia and hypercapnia after cerebral injury to be associated with poor clinical outcome. However, the optimal PaCO2 range associated with good clinical outcome remains unclear.

Outcomes in severe middle cerebral artery ischemic stroke

BACKGROUND

Severe middle cerebral artery stroke (MCA) is associated with a high rate of morbidity and mortality. We assessed the hypothesis that patient-specific variables may be associated with outcomes. We also sought to describe under-recognized patient-centered outcomes.

METHODS

A consecutive, multi-institution, retrospective cohort of adult patients (≤70 years) was established from 2009 to 2011. We included patients with NIHSS score ≥15 and infarct volume ≥60 mL measured within 48 h of symptom onset. Malignant edema was defined as the development of midline brain shift of ≥5 mm in the first 5 days. Exclusion criterion was enrollment in any experimental trial. A univariate and multivariate logistic regression analysis was performed to model and predict the factors related to outcomes.

RESULTS

46 patients (29 female, 17 male; mean age 57.3 ± 1.5 years) met study criteria. The mortality rate was 28% (n = 13). In a multivariate analysis, only concurrent anterior cerebral artery (ACA) involvement was associated with mortality (OR 9.78, 95% CI 1.15, 82.8, p = 0.04). In the malignant edema subgroup (n = 23, 58%), 4 died (17%), 7 underwent decompressive craniectomy (30%), 7 underwent tracheostomy (30%), and 15 underwent gastrostomy (65%).

CONCLUSIONS

Adverse outcomes after severe stroke are common. Concurrent ACA involvement predicts mortality in severe MCA stroke. It is useful to understand the incidence of life-sustaining procedures, such as tracheostomy and gastrostomy, as well as factors that contribute to their necessity.

Clinical predictors and outcome of patients of acute stroke requiring ventilatory support: a prospective hospital based cohort study

The purpose of this study was to identify clinical factors which may help in predicting the requirement of support of mechanical ventilation (MV) in patients with stroke. This was a prospective cohort study done at a tertiary referral center of India, from December 2008 to December 2009. All consecutive patients of acute stroke, who were admitted from emergency or through outpatient department, and were ≥ 18 years and in whom written consent was available, were considered for the study. Of 193 patients included in the study, 60 (31.08%) patients were intubated due to various reasons. Multivariate analysis of statistically significant and most clinically important variables showed that overall predictor accuracy of requirement of mechanical ventilation is 88% if patients had history of progression of symptoms (OR = 10.38; p<0.001), loss of consciousness at the time of onset (OR=3.18; p=0.011) and GCS motor score ≤ 5 (p < OR = 34.62; 0.001). The findings of this study suggest that factors including the presence of poor sensorium, the progression of symptom and low motor GCS are independent predictors of requirement of mechanical ventilation in patients with stroke and appropriate and cautious timely use of MV can help in improving mortality and morbidity from stroke.

Factors associated with death and predictors of one-month mortality from stroke in Kano, Northwestern Nigeria

BACKGROUND

In resource-poor setting, identification of predictors of death is of paramount importance for clinicians, so that specific therapies and management strategies can be applied to patients at high risk of dying. This study aims to determine the factors associated with death and predictors of in-patient mortality for stroke among a cohort of stroke patients in two tertiary centers in Northwestern Nigeria.

MATERIALS AND METHODS

This was a prospective study of consecutive patients with acute stroke who were admitted to tertiary hospitals in northwestern Nigeria. A single observer, using pre-defined diagnostic criteria, recorded the information of interest including length of stay, outcome (dead or alive all through 30 days), time of death.

RESULT

A total of 273 patients comprising 179 male and 94 female stroke patients were recruited. One hundred and seventy-four (63.7%) had infarctive stroke while 99 (36.3%) had hemorrhagic stroke (91 intracerebral and 8 sub-arachnoid hemorrhage). One-month mortality was 37%, and the majority was patients with hemorrhagic stroke (69.6%). About two-third (74.5%) of the mortalities occurred during the first week of the event. Logistic regression showed that severe systolic blood pressure, severe diastolic pressure, second or more episode of stroke, severe GCS, seizures, abnormal pupillary size, hemorrhagic stroke type, presence of aspiration pneumonitis, RBS > 200 mg/dl were independent predictors of mortality in stroke.

CONCLUSION

The present study provides information on factors associated with death in stroke. GCS < 8, seizures, abnormal pupillary size, hemorrhagic stroke, aspiration pneumonitis were independent predictors of mortality.

Prediction of evolution toward brain death upon admission to ICU in comatose patients with spontaneous intracerebral hemorrhage using simple signs

The aim of the study was to identify the predictors of brain death (BD) upon admission to the intensive care unit (ICU) of comatose patients with spontaneous intracerebral hemorrhage (ICH). Patients admitted in our ICU from 2002 to 2010 for spontaneous ICH and placed under mechanical ventilation were retrospectively analyzed. Of the 72 patients, 49% evolved to BD, 39% died after withdrawal of life support, and 12% were discharged alive. The most discriminating characteristics to predict BD were included in two models; Model 1 contained ≥3 abolished brainstem responses [adjusted odds ratios (OR) = 8.4 (2.4, 29.1)] and the swirl sign on the baseline CT-scan [adjusted OR = 5.0 (1.6, 15.9)] and Model 2 addressed the abolition of corneal reflexes [unilateral/bilateral: adjusted OR = 4.2 (0.9, 20.1)/8.8 (2.4, 32.3)] and the swirl sign on the baseline CT-scan [adjusted OR = 6.2 (1.9, 20.0)]. Two scores predicting BD were created (sensitivity: 0.89 and 0.88, specificity: 0.68 and 0.65). Risk of evolution toward BD was classified as low (corneal reflexes present and no swirl sign), high (≥1 corneal reflexes abolished and swirl sign), and intermediate. Simple signs at ICU admission can predict BD in comatose patients with ICH and could increase the potential for organ donation.

[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.

Recommendations for Comprehensive Stroke Centers

Background and Purpose— To develop recommendations for the establishment of comprehensive stroke centers capable of delivering the full spectrum of care to seriously ill patients with stroke and cerebrovascular disease. Recommendations were developed by members of the Brain Attack Coalition (BAC), which is a multidisciplinary group of members from major professional organizations involved with the care of patients with stroke and cerebrovascular disease.

Summary of Review— A comprehensive literature search was conducted from 1966 through December 2004 using Medline and Pub Med. Articles with information about clinical trials, meta-analyses, care guidelines, scientific guidelines, and other relevant clinical and research reports were examined and graded using established evidence-based medicine approaches for therapeutic and diagnostic modalities. Evidence was also obtained from a questionnaire survey sent to leaders in cerebrovascular disease. Members of BAC reviewed literature related to their field and graded the scientific evidence on the various diagnostic and treatment modalities for stroke. Input was obtained from the organizations represented by BAC. BAC met on several occasions to review each specific recommendation and reach a consensus about its importance in light of other medical, logistical, and financial factors.

Conclusions— There are a number of key areas supported by evidence-based medicine that are important for a comprehensive stroke center and its ability to deliver the wide variety of specialized care needed by patients with serious cerebrovascular disease. These areas include: (1) health care personnel with specific expertise in a number of disciplines, including neurosurgery and vascular neurology; (2) advanced neuroimaging capabilities such as MRI and various types of cerebral angiography; (3) surgical and endovascular techniques, including clipping and coiling of intracranial aneurysms, carotid endarterectomy, and intra-arterial thrombolytic therapy; and (4) other specific infrastructure and programmatic elements such as an intensive care unit and a stroke registry. Integration of these elements into a coordinated hospital-based program or system is likely to improve outcomes of patients with strokes and complex cerebrovascular disease who require the services of a comprehensive stroke center.

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.

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.

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.

Cost and outcome of mechanical ventilation for life-threatening stroke

BACKGROUND AND PURPOSE

Hospital mortality rates of 50% to 90% have been reported for stroke patients treated with mechanical ventilation. These data have raised serious questions about the cost-effectiveness of this intervention. We sought to determine how often stroke patients are mechanically ventilated, identify predictors of 30-day survival among ventilated patients, and evaluate the cost-effectiveness of this intervention.

METHODS

We identified mechanically ventilated patients in a population-based multiethnic cohort of 510 incidence stroke patients who were hospitalized between July 1993 and June 1996. Factors affecting 30-day survival were identified in a multiple logistic regression analysis. We calculated the cost per patient discharged alive, life-year saved, and quality-adjusted life-year saved using a zero-cost, zero-life assumption.

RESULTS

Ten percent of patients (n=52) were mechanically ventilated. Thirty-day mortality was 65% overall and did not differ significantly by stroke subtype. Glasgow Coma Scale score on the day of intubation (P:<0.01) and subsequent neurological deterioration (P:=0.02) were identified as predictors of 30-day mortality. The cost (1996 US dollars) of hospitalization per patient discharged alive was $89 400; the cost per year of life saved was $37 600; and the cost per quality-adjusted life-year saved was $174 200. Functional status of most survivors was poor; at 6 months, half were severely disabled and completely dependent. In a worst-case scenario of quality of life preferences, mechanical ventilation resulted in a net deficit of meaningful survival.

CONCLUSIONS

Two thirds of mechanically ventilated stroke patients die during their hospitalization, and most survivors are severely disabled. Survival is particularly unlikely if patients are deeply comatose or clinically deteriorate after intubation. In our multiethnic urban population, mechanical ventilation for stroke was relatively cost-effective for extending life but not for preserving quality of life.

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.

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.

Acceptable regret in medical decision making

When faced with medical decisions involving uncertain outcomes, the principles of decision theory hold that we should select the option with the highest expected utility to maximize health over time. Whether a decision proves right or wrong can be learned only in retrospect, when it may become apparent that another course of action would have been preferable. This realization may bring a sense of loss, or regret. When anticipated regret is compelling, a decision maker may choose to violate expected utility theory to avoid regret. We formulate a concept of acceptable regret in medical decision making that explicitly introduces the patient's attitude toward loss of health due to a mistaken decision into decision making. In most cases, minimizing expected regret results in the same decision as maximizing expected utility. However, when acceptable regret is taken into consideration, the threshold probability below which we can comfortably withhold treatment is a function only of the net benefit of the treatment, and the threshold probability above which we can comfortably administer the treatment depends only on the magnitude of the risks associated with the therapy. By considering acceptable regret, we develop new conceptual relations that can help decide whether treatment should be withheld or administered, especially when the diagnosis is uncertain. This may be particularly beneficial in deciding what constitutes futile medical care.

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.

[Outcome of intensive care]

BACKGROUND

The mean hospital mortality of patients after intensive therapy in Germany is about 15%, the mortality within the intensive care unit about 8%. Short-term prognosis is mainly determined by severity of disease, type of disease and patient age.

FACTORS IN INTENSIVE CARE

The impact of disease severity is measured by acute physiology score systems. The significance of disease categories becomes apparent in disease states with a continuing high mortality. Age is an independent risk factor. The higher risk of older patients cannot be explained by different diagnosis, and it is not secondary to a less aggressive therapy. The same factors mainly determine long-term prognosis. The 5-year-survival rate after intensive therapy is around 60%, a 3-fold increase as compared to the general population. Dependent upon the disease category, survival curves of intensive care patients parallel survival curves of the general population 2 years after admission. Analysis of quality of life is based upon objective measurement and subjective estimation of health-related life quality in the physical, psychological, and social life domain. Patients after intensive therapy experience a moderate but significant decrease in quality of life. This is the case in global estimations of quality of life as well as in investigations of different life domains.

CONCLUSION

The remaining quality of life is tolerable. This is in accordance with the positive overall judgement of intensive care by patients themselves. The chief problem of intensive care remain diseases with continuing high mortality.

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

BACKGROUND AND PURPOSE

Intubation and mechanical ventilation are sometimes necessary during treatment of acute stroke. Indications include neurological deterioration, pulmonary complications, and elective intubation for procedures and surgery. Prognosis in severe stroke patients requiring mechanical ventilation has often been reported to be poor. This study was performed to prospectively assess the prognosis of stroke patients who require ventilation in a neurological intensive care unit and to determine factors that may influence outcome.

METHODS

Analysis was made of 124 consecutive stroke patients who required mechanical ventilation over a 2-year period. We determined the survival rate at 1 year after admission. Initial clinical data, history of previous diseases, and indication for intubation were analyzed for prognostic significance by univariate and multiple logistic regression analysis.

RESULTS

The 1-year survival rate was 33.1% (n = 41). Sixty-five patients (52%) died in the neurological intensive care unit. Among 17 variables analyzed, seven were found to significantly influence 2-month fatality in the univariate analysis: age greater than 65 years, atrial fibrillation, bilateral absence of pupillary light reflex, bilateral absence of corneal reflex, bilateral Babinski's sign, infratentorial stroke, and Glasgow Coma Scale (GCS) score less than 10. Independent predictors of death at 2 months were age greater than 65 years (P = .03), GCS score less than 10 (P = .01), and intubation performed because of coma or acute respiratory failure (P = .04).

CONCLUSIONS

Overall prognosis of ventilated patients with severe stroke is better than previously reported. Older patients comatose on admission who need to be intubated because of neurological or respiratory deterioration have the poorest prognosis. We conclude that intubation and mechanical ventilation of severe stroke patients should be performed in a timely manner, before irreversible damage occurs.

Agreement on disease-specific criteria for do-not-resuscitate orders in acute stroke. Members of the Canadian and Western New York Stroke Consortiums

BACKGROUND AND PURPOSE

The do-not-resuscitate (DNR) order is a mechanism of withholding cardiopulmonary resuscitation (CPR). The lack of DNR guidelines specific for acute stroke may result in many stroke patients receiving unnecessary and futile resuscitation and ventilator-assisted breathing.

METHODS

A prospective multicenter evaluation of disease-specific criteria for DNR orders in acute stroke was initiated using a modified Delphi process. The participants were the Canadian and Western New York Stroke Consortium members who are closely involved in caring for acute stroke patients and conducting clinical trials at the academic centers. Previously published provisional criteria were reviewed by the participants. Modifications were made to the criteria until statistically significant agreement (P < .05, z score, or 67% similar answers) was achieved.

RESULTS

Disease-specific criteria for DNR orders in acute stroke were discussed by 26 physicians in three rounds of the opinion survey. An agreement was reached that a "no resuscitation" decision is appropriate when any two of the following three clinical criteria are present (the degree of agreement is given in parentheses): severe stroke (88%, P = .00007), life-threatening brain damage (73%, P < .01), and significant comorbidities (92%, P = .00003). The poor prognosis implied by these criteria should be discussed whenever possible among physician(s), the patient, and family members before the decision to withhold CPR is made. Eighty-one percent of the participants agreed that these disease-specific criteria are appropriate for clinical use (P = .0008).

CONCLUSIONS

Disease-specific criteria for DNR orders were developed to supplement general DNR policies for patients with hemispheric brain infarction and intracerebral hemorrhage during the first 2 weeks of stroke. A significant agreement was reached by a panel of physicians that patients with acute stroke should not be resuscitated if these disease-specific criteria are met.