Factors related to limitation of life support within 48h of intensive care unit admission: A multicenter study / Factores relacionados con la limitación del tratamiento de soporte vital en las primeras 48h de ingreso en unidades de cuidados intensivos: estudio multicéntrico

Objective: To determine factors related to limitations on life support within 48h of intensive care unit (ICU) admission. Study design: Prospective multicenter study. Setting: Eleven ICUs. Patients: All patients who died and/or had limitations on life support after ICU admission during a four-month period. Variables: Patient characteristics, hospital characteristics, characteristics of limitations on life support. Time-to-first-limitation was classified as early (<48h of admission) or late (≥48h). We performed univariate, multivariate analyses and CHAID (chi-square automatic interaction detection) analysis of variables associated with limitation of life support within 48h of ICU admission. Results: 3335 patients were admitted; 326 (9.8%) had limitations on life support. A total of 344 patients died; 247 (71.8%) had limitations on life support (range among centers, 58.6%-84.2%). The median (p25-p75) time from admission to initial limitation was 2 (0-7) days. CHAID analysis found that the modified Rankin score was the variable most closely related with early limitations. Among patients with Rankin >2, early limitations were implemented in 71.7% (OR=2.5; 95% CI: 1.5-4.4) and lung disease was the variable most strongly associated with early limitations (OR=12.29; 95% CI: 1.63-255.91). Among patients with Rankin ≤2, 48.8% had early limitations; patients admitted after emergency surgery had the highest rate of early limitations (66.7%; OR=2.4; 95% CI: 1.1-5.5). Conclusion: Limitations on life support are common, but the practice varies. Quality of life has the greatest impact on decisions to limit life support within 48h of admission

Objetivo: Determinar los factores relacionados con la limitación del tratamiento de soporte vital (LTSV) en las primeras 48h de ingreso en Unidades de Cuidados Intensivos (UCI). Diseño: Multicéntrico prospectivo. Ámbito: Once UCI. Pacientes: Pacientes fallecidos y/o en los que se aplicó LTSV durante 4 meses. Variables de interés: Características de pacientes, hospital y LTSV. Se definió LTSV precoz la que ocurría en las primeras 48h de ingreso y tardía >48h. Realizamos análisis univariado, multivariado y árbol de decisión chi-square automatic interaction detection (CHAID) con las variables asociadas con LTSV en las primeras 48h. Resultados: Incluidos 3.335 pacientes, en 326 (9,8%) se aplicó LTSV y 344 fallecieron; de estos 247 (71,8%) se limitaron (variabilidad interhospitalaria: 58,6-84,2%). La mediana de tiempo (p25-p75) entre el ingreso y la LTSV inicial fue de 2 (0-7) días. El análisis CHAID evidenció que la escala de Rankin modificada fue la variable más estrechamente relacionada con la limitación precoz. Entre los pacientes con Rankin>2 la LTSV precoz se realizó en el 71,7% (OR=2,5; IC 95%: 1,5-4,4) y la enfermedad pulmonar fue la variable más relacionada con la LTSV precoz (OR=12,29; IC 95%: 1,63-255,91). Entre los pacientes con Rankin≤2, la LTSV precoz ocurrió en el 48,8% siendo los pacientes con cirugía urgente aquellos con mayor LTSV precoz (66,7%; OR=2,4; IC 95%: 1,1-5,5). Conclusión: La LTSV es común pero la práctica es variable. La calidad de vida es la variable que mayor impacto tiene sobre la LTSV en las primeras 48h del ingreso en la UCI

Factors related to limitation of life support within 48h of intensive care unit admission: A multicenter study.

OBJECTIVE: To determine factors related to limitations on life support within 48h of intensive care unit (ICU) admission. STUDY DESIGN: Prospective multicenter study. SETTING: Eleven ICUs. PATIENTS: All patients who died and/or had limitations on life support after ICU admission during a four-month period. VARIABLES: Patient characteristics, hospital characteristics, characteristics of limitations on life support. Time-to-first-limitation was classified as early (<48h of admission) or late (≥48h). We performed univariate, multivariate analyses and CHAID (chi-square automatic interaction detection) analysis of variables associated with limitation of life support within 48h of ICU admission. RESULTS: 3335 patients were admitted; 326 (9.8%) had limitations on life support. A total of 344 patients died; 247 (71.8%) had limitations on life support (range among centers, 58.6%-84.2%). The median (p25-p75) time from admission to initial limitation was 2 (0-7) days. CHAID analysis found that the modified Rankin score was the variable most closely related with early limitations. Among patients with Rankin >2, early limitations were implemented in 71.7% (OR=2.5; 95% CI: 1.5-4.4) and lung disease was the variable most strongly associated with early limitations (OR=12.29; 95% CI: 1.63-255.91). Among patients with Rankin ≤2, 48.8% had early limitations; patients admitted after emergency surgery had the highest rate of early limitations (66.7%; OR=2.4; 95% CI: 1.1-5.5). CONCLUSION: Limitations on life support are common, but the practice varies. Quality of life has the greatest impact on decisions to limit life support within 48h of admission.

Peripheral venous blood gases and pulse-oximetry in acute cardiogenic pulmonary oedema.

BACKGROUND: The role of venous blood gases as an alternative to arterial blood gases in patients with severe acute heart failure has not been established. OBJECTIVE: To assess the correlation between arterial and peripheral venous blood gases together with pulse-oximetry (SpO2), as well as to estimate arterial values from venous samples in the first hours upon admission of patients with acute cardiogenic pulmonary oedema. METHODS: Simultaneous venous and arterial blood samples were extracted on admission and over the next 1, 2, 3, 4, and 10 hours. SpO2 was also registered at the same intervals. RESULTS: A total of 178 pairs of samples were obtained from 34 consecutive patients with acute cardiogenic pulmonary oedema. Arterial and venous blood gases followed a parallel course in the first hours, showing high correlation rates at all time intervals. Venous samples underestimated pH (mean difference -0.028) and overestimated CO2 (+5.1 mmHg) and bicarbonate (+1 mEq/l). Conversely, SpO2 tended to underestimate SaO2 (mean±SD: 93.1±9.1 vs. 94.2±8.4). Applying simple mathematical formulae based on these differences, arterial values were empirically calculated from venous samples, showing acceptable agreement in the Bland-Altman test. Likewise, a venous pH <7.32, pCO2 >51.3 mmHg, and bicarbonate <22.8 mEq/l could fairly identify arterial acidosis, either respiratory or metabolic, with a test accuracy of 92, 68, and 91%, respectively. CONCLUSIONS: In patients with cardiogenic pulmonary oedema, arterial blood gas disturbances may be estimated from peripheral venous samples. By monitoring SpO2 simultaneously, arterial punctures could often be avoided.