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.

Withdrawal of life support in the neurological intensive care unit.

OBJECTIVE: To describe the frequency and clinical course of terminal extubation in the neurological intensive care unit, to identify factors that influence the decision to withdraw life support, and to evaluate the experiences of surrogate decision-makers. BACKGROUND: The right of patients to refuse life-prolonging treatment is widely accepted. However, it is unknown how frequently critically ill neurologic patients are removed from life support, and practice guidelines for withdrawing mechanical ventilation remain poorly defined. METHODS: We reviewed the medical records of all patients cared for by the Columbia-Presbyterian neurocritical care service over a 3-year period who died, and identified a subgroup of non-brain-dead patients who were terminally extubated. We retrospectively analyzed the clinical course of these patients and interviewed their surrogate decision-makers. RESULTS: Of 74 non-brain-dead patients, 32 (43%) were terminally extubated. Hispanic and white patients were more likely to be extubated than were African American patients (p = 0.02). The median duration of survival after extubation was 7.5 hours; 25% died within 1 hour, and 69% within 24 hours. Depth of coma did not predict the duration of survival after extubation. The most frequent signs after extubation were agonal or labored breathing (59%) and tachypnea (34%). Morphine or fentanyl was given to relieve respiratory distress in 68% of cases; the average dose of morphine was 6.3 mg/hour (range 2.5 to 20 mg/hour). In a structured interview of 24 surrogate decision-makers, 88% were satisfied or very satisfied with the overall process, and 75% felt the patient suffered minimally before death; all but one (96%) said that they would repeat the decision to withdraw life support. CONCLUSIONS: Forty-three percent of our non-brain-dead patients who died were terminally extubated. The duration of survival after extubation exceeded 24 hours in one third, and was not predicted by level of consciousness. Two thirds of patients were treated with opioids for agonal respiratory distress. Most surrogate decision-makers were comfortable and satisfied with the process of withdrawing care.

Anticoagulation and induced hypertension after endovascular treatment for ruptured intracranial aneurysms.

OBJECTIVE: Guglielmi detachable coil (GDC) embolization may be used to prevent early rebleeding after aneurysmal subarachnoid hemorrhage, but anticoagulation and induced hypertension may increase this risk. We sought to determine retrospectively the relationship between levels of induced hypertension and anticoagulation and incidence of rebleeding in GDC-treated patients. METHODS: Twenty-five consecutive patients with acute (<14 days) subarachnoid hemorrhage who underwent GDC embolization were retrospectively analyzed with regard to percent obliteration of an aneurysm on postprocedure angiogram, the duration and intensity of anticoagulation, the duration and level of induced hypertension, and the frequency of thromboembolic and rebleeding complications. RESULTS: Complete angiographic obliteration of the aneurysm was achieved in five cases (20%). In some cases (n = 2), only the dome of the aneurysm was coiled to allow eventual surgical clipping. Heparin was given to 23 patients (92%) for an average of 6 days (range, 8 hrs to 22 days); the mean dose was 588 units/hr, and the mean partial thromboplastin time was 37 secs. Seven patients (28%) were treated with vasopressors for symptomatic vasospasm for a mean duration of 5 days (range, 8 hrs to 9 days); mean arterial blood pressure averaged 118 mm Hg, and peak systolic blood pressures ranged from 195 to 250 mm Hg. There were no episodes of aneurysm rebleeding. Three patients (12%) suffered intraoperative thromboembolic complications, which in one instance was fatal; two of these cases were associated with subtherapeutic partial thromboplastin time values. CONCLUSION: Induced hypertension (mean arterial blood pressure, 120 mm Hg) and heparinization do not appear to increase the risk of early rebleeding after GDC embolization. In a select group of patients, use of anticoagulation in the immediate perioperative period to prevent thromboembolic complications appears to be safe.