急性呼吸衰竭患者使用限时试验的特点:一项前瞻性单中心观察研究。

Q4 Medicine Critical care explorations Pub Date : 2024-09-16 eCollection Date: 2024-09-01 DOI:10.1097/CCE.0000000000001148
Joy X Moy, Anica C Law, Lily N Stalter, Michael D Peliska, Geralyn Palmer, Bret M Hanlon, Sean Mortenson, Elizabeth M Viglianti, Douglas A Wiegmann, Jacqueline M Kruser
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引用次数: 0

摘要

重要性:有时间限制的试验(TLT)是临床医生、患者和家属之间的一项合作计划,在规定的时间内使用维持生命疗法,之后根据患者的反应决定是继续以康复为目标的护理,还是将重点转向舒适。TLT是一种很有前景的方法,有助于应对危重病中的不确定性,但人们对其目前的使用情况知之甚少:描述急性呼吸衰竭(ARF)患者使用 TLT 的情况:美国一家学术医疗中心对接受有创机械通气超过或等于 48 小时的急性呼吸衰竭成人 ICU 患者进行了为期 12 个月的前瞻性队列观察研究:主要暴露是参与 TLT,由患者的 ICU 医生确定。从电子病历中提取患者特征、护理服务要素和住院结果:在 176 名符合条件的患者中,36 人(20.5%)参加了 TLT。在 18 位重症监护室主治医生中,有 9 位(50%)参与了大于或等于 1 次 TLT(频率为所护理患者的 0-39%)。TLT 的中位持续时间为 3.0 天(四分位数间距 [IQR],3.0-4.5 天)。TLT患者的平均年龄较高(67.4 岁 [sd,12.0 岁] vs. 60.0 岁 [sd,16.0 岁];P < 0.01),Charlson合并症指数较高(5.1 [sd,2.2] vs. 3.8[sd,2.6];p < 0.01),与非 TLT 患者相比,器官功能衰竭序列评估评分相似(9.6 [sd, 3.3] vs. 9.5 [sd, 3.7];p = 0.93)。TLT患者更有可能死亡或出院接受临终关怀(80.6% vs. 42.1%;p < 0.05),ICU住院时间更短(中位数,5.7 d [IQR, 4.0-9.0 d] vs. 10.3 d [IQR, 5.5-14.5 d];p < 0.01):在这项研究中,约五分之一的 ARF 患者参加了 TLT。我们的研究结果表明,TLT 主要用于临近生命末期的患者,但医生的使用情况存在很大差异,因此需要证据来指导最佳使用。
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Characterizing the Use of Time-Limited Trials in Patients With Acute Respiratory Failure: A Prospective, Single-Center Observational Study.

Importance: A time-limited trial (TLT) is a collaborative plan among clinicians, patients, and families to use life-sustaining therapy for a defined duration, after which the patient's response informs whether to continue care directed toward recovery or shift the focus toward comfort. TLTs are a promising approach to help navigate uncertainty in critical illness, yet little is known about their current use.

Objectives: To characterize TLT use in patients with acute respiratory failure (ARF).

Design, setting, and participants: Prospective 12-month observational cohort study at an U.S. academic medical center of adult ICU patients with ARF receiving invasive mechanical ventilation for greater than or equal to 48 hours.

Main outcomes and measures: Primary exposure was TLT participation, identified by patients' ICU physician. Patient characteristics, care delivery elements, and hospital outcomes were extracted from the electronic medical record.

Results: Among 176 eligible patients, 36 (20.5%) participated in a TLT. Among 18 ICU attending physicians, nine (50%) participated in greater than or equal to 1 TLT (frequency 0-39% of patients cared for). Median TLT duration was 3.0 days (interquartile range [IQR], 3.0-4.5 d). TLT patients had a higher mean age (67.4 yr [sd, 12.0 yr] vs. 60.0 yr [sd, 16.0 yr]; p < 0.01), higher Charlson Comorbidity Index (5.1 [sd, 2.2] vs. 3.8 [sd, 2.6]; p < 0.01), and similar Sequential Organ Failure Assessment score (9.6 [sd, 3.3] vs. 9.5 [sd, 3.7]; p = 0.93), compared with non-TLT patients. TLT patients were more likely to die or be discharged to hospice (80.6% vs. 42.1%; p < 0.05) and had shorter ICU length of stay (median, 5.7 d [IQR, 4.0-9.0 d] vs. 10.3 d [IQR, 5.5-14.5 d]; p < 0.01).

Conclusions and relevance: In this study, approximately one in five patients with ARF participated in a TLT. Our findings suggest TLTs are used primarily in patients near end of life but with substantial physician variation, highlighting a need for evidence to guide optimal use.

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