Association of early withdrawal of life-sustaining therapy for perceived neurological prognosis with mortality after cardiac arrest.
Association of early withdrawal of life-sustaining therapy for perceived neurological prognosis with mortality after cardiac arrest.
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DOI：
10.1016/j.resuscitation.2016.01.016
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发表时间：
2016-05
期刊：
影响因子：
6.5
通讯作者：
Resuscitation Outcomes Consortium
中科院分区：
文献类型：
--
作者：
Elmer J;Torres C;Aufderheide TP;Austin MA;Callaway CW;Golan E;Herren H;Jasti J;Kudenchuk PJ;Scales DC;Stub D;Richardson DK;Zive DM;Resuscitation Outcomes Consortium
由于感觉神经预后不良（WLST-N）而停止维持生命的治疗是院外心脏骤停（OHCA）后医院死亡的常见原因。虽然目前的指南建议不要在72小时前（WLST-N<72）进行WLST-N手术，但这种做法很常见，可能会增加死亡率。我们试图量化这些影响。在一项多中心OHCA试验的二次分析中，我们评估了入院后存活b>小时的成人至出院的生存率和功能状态良好的生存率（修正Rankin评分≤3）。基于暴露前协变量建模WLST-N<72暴露概率的倾向评分将未暴露的受试者与WLST-N<72暴露的受试者进行匹配。我们确定了未暴露的匹配队列的生存概率和功能有利生存，拟合调整的逻辑回归模型来预测该组的结果，然后使用这些模型来预测暴露队列的结果。将这些发现与当前流行病学统计数据相结合，我们估计了与WLST-N<72相关的全国死亡率。在16875例OHCA受试者中，4265例（25%）符合纳入标准。三分之一的住院死亡患者发生WLST-N<72。调整后的分析预测，如果WLST-N未发生<72，暴露受试者的生存率为26%，功能有利生存率为16%。在全国范围内推断，每年约有2300名美国人的WLST-N<72可能与死亡率相关，其中近1500人（64%）可能有功能恢复。在OHCA后，WLST-N<72的死亡可能是常见的，并且可能是可以避免的。降低WLST-N<72具有国家公共卫生意义，并可能提供降低OHCA后死亡率的机会。
Withdrawing life-sustaining therapy because of perceived poor neurological prognosis (WLST-N) is a common cause of hospital death after out-of-hospital cardiac arrest (OHCA). Although current guidelines recommend against WLST-N before 72 h (WLST-N<72), this practice is common and may increase mortality. We sought to quantify these effects. In a secondary analysis of a multicenter OHCA trial, we evaluated survival to hospital discharge and survival with favorable functional status (modified Rankin Score ≤ 3) in adults alive >1h after hospital admission. Propensity score modeling the probability of exposure to WLST-N<72 based on pre-exposure covariates was used to match unexposed subjects with those exposed to WLST-N<72. We determined the probability of survival and functionally favorable survival in the unexposed matched cohort, fit adjusted logistic regression models to predict outcomes in this group, and then used these models to predict outcomes in the exposed cohort. Combining these findings with current epidemiologic statistics we estimated mortality nationally that is associated with WLST-N<72. Of 16,875 OHCA subjects, 4,265 (25%) met inclusion criteria. WLST-N<72 occurred in one-third of subjects who died in-hospital. Adjusted analyses predicted that exposed subjects would have 26% survival and 16% functionally favorable survival if WLST-N<72 did not occur. Extrapolated nationally, WLST-N<72 may be associated with mortality in approximately 2,300 Americans each year of whom nearly 1,500 (64%) might have had functional recovery. After OHCA, death following WLST-N<72 may be common and is potentially avoidable. Reducing WLST-N<72 has national public health implications and may afford an opportunity to decrease mortality after OHCA.