Do-not-attempt-resuscitation orders and prognostic models for intraparenchymal hemorrhage.
Do-not-attempt-resuscitation orders and prognostic models for intraparenchymal hemorrhage.
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DOI：
10.1097/ccm.0b013e3181fb7b49
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发表时间：
2011-01
影响因子：
8.8
通讯作者：
Tirschwell DL
中科院分区：
文献类型：
--
作者：
Creutzfeldt CJ;Becker KJ;Weinstein JR;Khot SP;McPharlin TO;Ton TG;Longstreth WT Jr;Tirschwell DL
预测脑实质内出血（IPH）后结局的统计模型包括不考虑不接受复苏（DNAR）顺序的患者。我们建立了一个模型，以探讨如何纳入患者的DNAR订单影响IPH预后模型。从2001年5月至2003年9月的回顾性、观察性队列研究，位于华盛顿西雅图的大学附属三级转诊医院，连续424例自发性脑实质内出血患者。使用多变量logistic回归分析临床特征，而不是DNAR状态，我们生成了有利结局的预后评分（FO，定义为中度残疾或出院时更好）。我们比较了观察到的FO的概率与预测，分层的DNAR状态。然后，我们仅使用非DNAR患者生成修改的预后评分。回顾了424例患者的记录：44%有FO，43%有DNAR命令，38%在医院死亡。观察和预测的FO概率与所有患者一致。在非DNAR患者中观察到的FO概率显著高于预测值，而在DNAR患者中显著低于预测值。当应用先前发表和验证的预后评分时，结果相似。我们的改良预后评分在非DNAR患者中不再悲观，但在DNAR患者中仍然过于乐观。尽管我们的预后模型在评估所有IPH患者时都得到了很好的校准，但在没有DNAR订单的患者中，预测结果显着悲观，而在那些有DNAR订单的患者中，预测结果显着乐观。这种悲观情绪可能会促使患者做出DNAR的决定，其中可能有FO，从而创造了一个自我实现的预言。为了在临床决策中最有用，IPH预后模型应该被校准到不使用DNAR命令的大型IPH队列。
Statistical models predicting outcome after intraparenchymal hemorrhage (IPH) include patients irrespective of do-not-attempt-resuscitation (DNAR) orders. We built a model to explore how the inclusion of patients with DNAR orders affects IPH prognostic models. Retrospective, observational cohort study from May 2001 until September 2003 University-affiliated tertiary referral hospital in Seattle, Washington 424 consecutive patients with spontaneous intraparenchymal hemorrhage We retrospectively abstracted information from medical records of IPH patients admitted to a single hospital. Using multivariate logistic regression of presenting clinical characteristics, but not DNAR status, we generated a prognostic score for favorable outcome (FO, defined as moderate disability or better at discharge). We compared observed probability of FO with that predicted, stratified by DNAR-status. We then generated a modified prognostic score using only non-DNAR patients. Records of 424 patients were reviewed: 44% had FO, 43% had a DNAR-order and 38% died in hospital. Observed and predicted probability of FO agreed well with all patients taken together. Observed probability of FO was significantly higher than predicted in non-DNAR patients and significantly lower in DNAR patients. Results were similar when applying a previously published and validated prognostic score. Our modified prognostic score was no longer pessimistic in non-DNAR patients, but remained overly optimistic in DNAR patients. Although our prognostic model was well calibrated when assessing all IPH patients, predictions were significantly pessimistic in patients without, and optimistic in those with DNAR orders. Such pessimism may drive decisions to make patients DNAR in whom a FO may have been possible, thereby creating a self-fulfilling prophecy. To be most useful in clinical decision-making, IPH prognostic models should be calibrated to large IPH cohorts in whom DNAR orders were not used.