Critical Care Explorations (Feb 2021)

Life Support Limitations in Mechanically Ventilated Stroke Patients

  • Etienne de Montmollin, MD, PhD,
  • Carole Schwebel, MD, PhD,
  • Claire Dupuis, MD, PhD,
  • Maité Garrouste-Orgeas, MD,
  • Daniel da Silva, MD,
  • Elie Azoulay, MD, PhD,
  • Virginie Laurent, MD,
  • Guillaume Thiéry, MD, PhD,
  • Alexandra Grinea, MD,
  • Guillaume Marcotte, MD,
  • Johanna Oziel, MD,
  • Marc Gainnier, MD,
  • Shidasp Siami, MD, PhD,
  • Jean Reignier, MD, PhD,
  • Benjamin Sztrymf, MD, PhD,
  • Christophe Adrie, MD,
  • Stephane Ruckly, MSc,
  • Romain Sonneville, MD, PhD,
  • Jean-François Timsit, MD, PhD,
  • on behalf of the OUTCOMEREA Study Group,
  • Jean-François Timsit,
  • Elie Azoulay,
  • Jean-Ralph Zahar,
  • Bruno Mourvillier,
  • Michael Darmon,
  • Jean-Francois Timsit,
  • Corinne Albert,
  • Stephane Ruckly,
  • Sébastien Bailly,
  • Aurélien Vannieuwenhuyze,
  • Christophe Adrie,
  • Carole Agasse,
  • Bernard Allaouchiche,
  • Olivier Andremont,
  • Pascal Andreu,
  • Laurent Argaud,
  • Claire Ara-Somohano,
  • Elie Azoulay,
  • Francois Barbier,
  • Jean-Pierre Bedos,
  • Thomas Baudry,
  • Jérome Bedel,
  • Julien Bohé,
  • Lila Bouadma,
  • Jeremy Bourenne,
  • Noel Brule,
  • Frank Chemouni,
  • Julien Carvelli,
  • Elisabeth Coupez,
  • Martin Cour,
  • Michael Darmon,
  • Claire Dupuis,
  • Etienne de Montmollin,
  • Loa Dopeux,
  • Anne-Sylvie Dumenil,
  • Jean-Marc Forel,
  • Marc Gainnier,
  • Charlotte Garret,
  • Dany Goldgran-Tonedano,
  • Steven Grangé,
  • Antoine Gros,
  • Hédia Hammed,
  • Akim Haouache,
  • Tarik Hissem,
  • Vivien Hong Tuan Ha,
  • Sébastien Jochman,
  • Jean-Baptiste Joffredo,
  • Hatem Kallel,
  • Guillaume Lacave,
  • Virgine Laurent,
  • Alexandre Lautrette,
  • Clément Le Bihan,
  • Virgine Lemiale,
  • David Luis,
  • Guillaume Marcotte,
  • Jordane Lebut,
  • Bruno Mourvillier,
  • Mathild Neuville,
  • Laurent Nicolet,
  • Johanna Oziel,
  • Laurent Papazian,
  • Juliette Patrier,
  • Benjamin Planquette,
  • Aguila Radjou,
  • Marie Simon,
  • Romain Sonneville,
  • Jean Reignier,
  • Bertrand Souweine,
  • Carole Schwebel,
  • Shidasp Siami,
  • Nicolas Terzi,
  • Gilles Troché,
  • Fabrice Thiollieres,
  • Guillaume Thierry,
  • Guillaume Van Der Meersch,
  • Marion Venot,
  • Florent Wallet,
  • Sondes Yaacoubi,
  • Olivier Zambon,
  • Jonathan Zarka,
  • Mireille Adda,
  • Vanessa Vindrieux,
  • Marion Provent,
  • Sylvie de la Salle,
  • Pauline Enguerrand,
  • Vincent Gobert,
  • Stéphane Guessens,
  • Helene Merle,
  • Nadira Kaddour,
  • Boris Berthe,
  • Samir Bekkhouche,
  • Kaouttar Mellouk,
  • Mélaine Lebrazic,
  • Carole Ouisse,
  • Diane Maugars,
  • Christelle Aparicio,
  • Igor Theodose,
  • Manal Nouacer,
  • Veronique Deiler,
  • Fariza Lamara,
  • Myriam Moussa,
  • Atika Mouaci,
  • Nassima Viguier

DOI
https://doi.org/10.1097/CCE.0000000000000341
Journal volume & issue
Vol. 3, no. 2
p. e0341

Abstract

Read online

Objectives:. The determinants of decisions to limit life support (withholding or withdrawal) in ventilated stroke patients have been evaluated mainly for patients with intracranial hemorrhages. We aimed to evaluate the frequency of life support limitations in ventilated ischemic and hemorrhagic stroke patients compared with a nonbrain-injured population and to determine factors associated with such decisions. Design:. Multicenter prospective French observational study. Setting:. Fourteen ICUs of the French OutcomeRea network. PATIENTS:. From 2005 to 2016, we included stroke patients and nonbrain-injured patients requiring invasive ventilation within 24 hours of ICU admission. INTERVENTION:. None. MEASUREMENTS AND MAIN RESULTS:. We identified 373 stroke patients (ischemic, n = 167 [45%]; hemorrhagic, n = 206 [55%]) and 5,683 nonbrain-injured patients. Decisions to limit life support were taken in 41% of ischemic stroke cases (vs nonbrain-injured patients, subdistribution hazard ratio, 3.59 [95% CI, 2.78–4.65]) and in 33% of hemorrhagic stroke cases (vs nonbrain-injured patients, subdistribution hazard ratio, 3.9 [95% CI, 2.97–5.11]). Time from ICU admission to the first limitation was longer in ischemic than in hemorrhagic stroke (5 [3–9] vs 2 d [1–6] d; p < 0.01). Limitation of life support preceded ICU death in 70% of ischemic strokes and 45% of hemorrhagic strokes (p < 0.01). Life support limitations in ischemic stroke were increased by a vertebrobasilar location (vs anterior circulation, subdistribution hazard ratio, 1.61 [95% CI, 1.01–2.59]) and a prestroke modified Rankin score greater than 2 (2.38 [1.27–4.55]). In hemorrhagic stroke, an age greater than 70 years (2.29 [1.43–3.69]) and a Glasgow Coma Scale score less than 8 (2.15 [1.08–4.3]) were associated with an increased risk of limitation, whereas a higher nonneurologic admission Sequential Organ Failure Assessment score was associated with a reduced risk (per point, 0.89 [0.82–0.97]). Conclusions:. In ventilated stroke patients, decisions to limit life support are more than three times more frequent than in nonbrain-injured patients, with different timing and associated risk factors between ischemic and hemorrhagic strokes.