Impact of Pattern of Admission on ICH Outcomes
Impact of Pattern of Admission on ICH Outcomes
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DOI：
10.1007/s12028-009-9302-0
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发表时间：
2010-04-01
影响因子：
3.5
通讯作者：
Carhuapoma, J. Ricardo
中科院分区：
文献类型：
--
作者：
Naval, Neeraj Sunderrajan;Carhuapoma, J. Ricardo
脑出血（ICH）是所有卒中中死亡率最高的。与普通ICU相比，神经科学重症监护病房（NCCU）的入院与ICH后死亡率降低相关。这种关联导致几家医院将ICH患者转移到三级护理中心的神经ICU。然而，在转移之前和转移期间优化ICH管理的延迟可能导致有害后果。为了比较从艾德直接入院与院间转诊的脑出血患者的功能结局，我们回顾了连续的自发性幕上脑出血患者的记录，这些患者被收治到约翰霍普金斯医院的NCCU。排除了与创伤或基础病变（脑肿瘤、动脉瘤、AVM）相关的ICH患者。我们使用二分改良兰金量表（良好结局：mRS 0-3分）比较了直接从艾德和院间转运（IHT）入院的患者出院时的结局。其他可能影响结局的因素，如年龄、ICH体积、IVH体积和入院GCS，均纳入多元logistic回归分析。125例患者纳入分析（艾德61.6%; IHT 38.4%）。两组平均年龄无显著差异（艾德63.4 +/- A 13.1; IHT 63.4 +/- A 15.2，P = 0.96），ICH体积（艾德31.4 +/- A 37.6; IHT 33.5 +/- A 42.8，P = 0.76），IVH体积（艾德6.0 +/- A 11.2; IHT 8.0 +/- A 14.5，P = 0.38）和GCS（艾德11.3 +/- A 3.7，IHT 10.9 +/- A 3.5; P = 0.44）。57.2%的艾德患者出院时结局良好（mRS 0-3），而IHT患者为37.5%。在单变量（P = 0.034，95% CI .2151-.9416）和多变量分析（P = 0.028，95% CI .1338-.8896）后，该差异具有统计学显著性。艾德入院后有良好结果的几率（调整后）比IHT高3倍。神经功能恶化（GCS下降2分或以上）在IHT中更常见，在华法林相关ICH的IHT患者亚组分析中，血肿扩大的可能性明显高于直接艾德入院的患者。直接送到我们艾德的ICH患者的结局明显优于IHT;我们假设这可能是由于到达专门的Neuro-ICU之前优化管理的延迟造成的。尽管如此，其他同样合理的假设需要进行前瞻性测试。
Intracerebral hemorrhage (ICH) is associated with the highest mortality of all strokes. Admission to a Neurosciences Critical Care Unit (NCCU) compared to a general ICU has been associated with reduced mortality following ICH. Such association has led to several hospitals transferring ICH patients to Neuro-ICUs in tertiary care centers. However, delays in optimizing ICH management prior to and during transfer can lead to deleterious consequences. To compare functional outcomes in ICH patients admitted to our NCCU directly from the ED versus inter-hospital transfer admissions.Records of consecutive spontaneous supratentorial ICH patients admitted to The Johns Hopkins Hospital NCCU were reviewed. Patients with ICH related to trauma or underlying lesions (brain tumors, aneurysms, AVM) were excluded. We compared outcomes at discharge in patients admitted directly from the ED and inter-hospital transfers (IHT) using dichotomized modified Rankin Scale (Good outcomes: mRS 0-3). Other factors potentially impacting outcomes such as age, ICH volume, IVH volume, and admission GCS were included in the multiple logistic regression analysis.125 patients were included in the analysis (ED 61.6%; IHT 38.4%). There were no significant differences between the two groups in mean age (ED 63.4 +/- A 13.1; IHT 63.4 +/- A 15.2, P = 0.96), ICH volume (ED 31.4 +/- A 37.6; IHT 33.5 +/- A 42.8, P = 0.76), IVH volume (ED 6.0 +/- A 11.2; IHT 8.0 +/- A 14.5, P = 0.38), and GCS (ED 11.3 +/- A 3.7, IHT 10.9 +/- A 3.5; P = 0.44). 57.2% ED patients had good outcomes (mRS 0-3) at discharge compared to 37.5% IHT. This difference was statistically significant following univariate (P = 0.034, 95% CI .2151-.9416) and multivariate analysis (P = 0.028, 95% CI .1338-.8896). Odds (adjusted) of ED admissions having good outcomes was three times higher than IHT. Neurological deterioration (GCS decline 2 or more) was more common in IHT and, in subgroup analysis of IHT patients with warfarin-associated ICH, hematoma enlargement was significantly more likely than in direct ED admissions.Patients with ICH brought directly to our ED had significantly better outcomes than IHT; we hypothesize this may be caused by delays in optimizing management prior to arrival at the facility with a dedicated Neuro-ICU. Nevertheless, other equally plausible hypotheses need to be prospectively tested.