Mechanical Ventilation for Comatose Patients with Inoperative Acute Intracerebral Hemorrhage: Possible Futility of Treatment

Abstract

BackgroundComatose patients with acute intracerebral hemorrhage (ICH) diagnosed as inoperative due to their severe comorbidity will be treated differently between countries. In certain countries including Japan, aggressive medical care may be performed according to the patients' family requests although the effects on the outcome are obscure. For respiratory distress in comatose patients with inoperative acute ICH, the role of mechanical ventilation on the outcome is unknown. We speculated that the efficacy of a ventilator in such a specific condition is limited and possibly futile.MethodsWe retrospectively evaluated the in-hospital mortality and further outcome of 65 comatose patients with inoperative ICH. Among the patients, 56 manifested respiratory distress, and the effect of the ventilator was evaluated by comparing the patients treated with and without the ventilator.ResultsThe in-hospital mortality was calculated as 80%. A statistically significant parameter affecting the mortality independently was the motor subset on the Glasgow Coma Scale (P = 0.015). Among the patients who manifested respiratory distress, 7.7% of patients treated with a ventilator and 14.0% of patients not treated with a ventilator survived; an outcome is not significantly different. The mean survival duration of patients treated with a ventilator was significantly longer than the mean survival duration of patients not treated with a ventilator (P = 0.021). Among the surviving 13 patients, 7 patients died 5 to 29 months after onset without significant consciousness recovery. Another 6 patients suffered continuous disablement due to prolonged severe consciousness disturbances.ConclusionThe current results indicate that treating comatose patients resulting from inoperative acute ICH may be futile. In particular, treating these patients with a ventilator only has the effect of prolonging unresponsive life, and the treatment may be criticized from the perspective of the appropriate use of public medical resources.

Risk factors of mortality and severe disability in the patients with cerebrovascular diseases treated with perioperative mechanical ventilation

“…Similarly, Fugate[ 19 ] also believe that preoperative GCS score could not predict the patient’s outcome because the intervention of surgical operation could affect the outcome, which could be good recovery, severe disability or even death. It has been reported that mechanical ventilation treatment in the comatose patients resulting from inoperative acute intracerebral hemorrhage, especially patients had brainstem compression due to brain herniation, could only prolong unresponsive life[ 20 ]. Brainstem compression causes changes in respiratory rhythm and even respiratory arrest, it is the second reason (24.3%) in this study for the patients required mechanical ventilation and majority of them (85.2%) died.…”

Medical futility treatment in intensive care units

“…Their purpose is to provide help in solving ethically complex situations and to give recommendations about managing certain cases (11). Based on the objective medical factors, a good assessment of treatment outcomes can be made and further medical procedures directed (13). Likewise, decision-making about further treatment should always take into account patients' quality of life (10).…”

Prefectural difference in spontaneous intracerebral hemorrhage incidence in Japan analyzed with publically accessible diagnosis procedure combination data: possibilities and limitations

“…This does not necessarily mean that the sICH incidence in the DPC database is unreliable, since the mortality is a different parameter from the incidence, as shown in Figure 1 . The mortality due to sICH was reported to be lower in Japan than in any other region [ 1 ], and this might result from an intensive medical intervention attitude even for comatose patients with sICH [ 12 ]. Further, we should be skeptical about the accuracy of the reported mortality number, since this also definitely contains errors due to misdiagnosis [ 13 , 14 ].…”