Retrospective agreement and consent to neurocritical care is influenced by functional outcome

Kiphuth, Ines C.; Köhrmann, Martin; Kuramatsu, Joji B.; Mauer, Christoph; Breuer, Lorenz; Schellinger, Peter D.; Schwab, Stefan; Huttner, Hagen B.

doi:10.1186/cc9210

Cited by 23 publications

(22 citation statements)

References 31 publications

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“…However, functional outcome was poor especially in older patients with either hemorrhagic stroke or need of MV, leaving barely all survivors in a dependent state. Several studies have shown that retrospective consent to neurointensive care depends on the functional outcome [36,37] . In a cohort of 704 patients admitted to a neurocritical care unit, only 19% of patients with an outcome mRS of 4 or 5 retrospectively consented to ICU management [36] .…”

Section: Discussion and Review Of The Literaturementioning

confidence: 99%

“…Several studies have shown that retrospective consent to neurointensive care depends on the functional outcome [36,37] . In a cohort of 704 patients admitted to a neurocritical care unit, only 19% of patients with an outcome mRS of 4 or 5 retrospectively consented to ICU management [36] . Further decisions about when to admit stroke patients to ICU will thus have to focus on the potential functional outcome, taking account of accepted predictors of poor outcome.…”

Section: Discussion and Review Of The Literaturementioning

confidence: 99%

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Outcome Predictors of Acute Stroke Patients in Need of Intensive Care Treatment

Alonso¹,

Ebert²,

Kern³

et al. 2015

Cerebrovasc Dis

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Background: The prognosis of stroke patients admitted to intensive care units (ICU) is commonly regarded to be poor. However, only limited data regarding outcome predictors are available. Patients and Methods: Out of 4,958 consecutive patients admitted to our stroke unit with the diagnosis of acute stroke, after analysis we identified 347 patients (164 male) in need of ICU management. In-hospital and post-rehabilitation mortality as well as functional outcome at discharge and after rehabilitation were analyzed. Results: Ischemic stroke was diagnosed in 252 patients (72.6%) and intracerebral hemorrhage occurred in 95 patients (27.4%). The mean age in our cohort was considerably high (70.8 years). One hundred patients were comatose at admission. The median NIHSS score at admission in the remaining patients was 12. Apart from stroke-related disturbances of consciousness (47.1%), the most common reasons for ICU treatment were cardiac (23.4%) and respiratory (12.1%) complications or interventional procedures requiring mechanical ventilation (11%). In all, 231/347 patients (66.6%) were mechanically ventilated (mean 84 h). In-hospital mortality (143/347; 41.2%) was associated with old age, poor NIHSS score at admission, intracerebral hemorrhage and mechanical ventilation (p < 0.001 in all). Further, admission to ICU because of stroke-related impairment of consciousness increased in-hospital mortality (p < 0.001). Similarly, poor outcome after rehabilitation was associated with old age (p = 0.029) and mechanical ventilation (p < 0.001). In patients ≥80 years with either intracerebral hemorrhage or need of mechanical ventilation, outcome was unfavorable in nearly any case. However, the overall post-rehabilitation outcome did not differ between patients with intracerebral hemorrhage and ischemic stroke (p = 0.275). Conclusion: The stroke population in our study was associated with an increased early mortality; however, given the same conditions, it was old with a high percentage of patients requiring mechanical ventilation. This did not result in increased in-hospital mortality rates compared to younger and less severely affected cohorts. Thus, ICU management is a life-saving initiative even among the elderly. However, the functional outcome was poor in older patients, thus limiting the benefits of ICU care in these patients.

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Section: Discussion and Review Of The Literaturementioning

confidence: 99%

Section: Discussion and Review Of The Literaturementioning

confidence: 99%

Outcome Predictors of Acute Stroke Patients in Need of Intensive Care Treatment

Alonso¹,

Ebert²,

Kern³

et al. 2015

Cerebrovasc Dis

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“…Given that only ICHs with a volume 1 20 cm 3 were included in the study, functional outcomes were classified into favorable (mRS 0-2), acceptable (mRS 0-4) and unfavorable (mRS 5-6) outcomes. The cut-off point between acceptable and unfavorable outcomes was chosen according to the results of studies evaluating the opinions of the patients and their relatives on acceptable outcomes in a comparable intensive-care patient cohort [19,20] .…”

Section: Outcome Assessmentmentioning

confidence: 99%

Sonographic Monitoring of Midline Shift Predicts Outcome after Intracerebral Hemorrhage

Kiphuth¹,

Huttner²,

Breuer³

et al. 2012

Cerebrovasc Dis

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Background: Spontaneous intracerebral hemorrhage (ICH) and the evolution of subsequent perihemorrhagic edema lead to midline shift (MLS), which can be assessed by transcranial duplex sonography (TDS). In this observational study, we monitored MLS with TDS in patients with supratentorial ICH up to day 14 after the ictus, and then correlated MLS with the outcome 6 months after hospital discharge. Methods: Sixty-eight patients with spontaneous ICH (volume >20 cm3) were admitted during a 1-year period between April 2009 and April 2010. Sixty-one patients fulfilled the inclusion criteria and were eligible for analysis. TDS to measure MLS was performed upon admission and then subsequently, using serial examinations in 24-hour intervals up to day 14. Statistical tests were used to determine cut-off values for functional outcome and mortality after 6 months. Results: The median National Institutes of Health Stroke Scale (NIHSS) score upon admission was 21 and the mean hematoma volume was 52 cm3. NIHSS score, functional outcome, hematoma volume and MLS were correlated in the examined patient cohort. ICH score upon admission, hematoma volume and the extent of MLS on days 1–14 were predictive of functional outcome and death. Values of MLS showed two peaks, the first between day 2 and day 5 and the second between day 12 and day 14, indicating that edema progresses not only during the acute but also during the subacute phase. Depending on the time point, an MLS of 4.5–7.5 mm or greater indicated an impending failure of conservative therapy. An MLS of 12 mm or greater at any time indicated mortality with a sensitivity of 69%, a specificity of 100% and positive and negative predictive values of 100 and 74%, respectively. Conclusions: MLS seems to be a crucial factor for outcome after ICH. Apart from the hematoma volume itself, edema adds to the intracranial pressure. To monitor MLS in early patient management after ICH, TDS is a useful noninvasive bedside alternative, avoiding increased radiation exposure and repeated transportation of critically ill patients. Cut-off values may help to reliably predict functional outcome and treatment failure in patients undergoing maximal neurointensive therapy.

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“…35 Stroke survivors who have received aggressive life-prolonging neurointensive care have generally high rates of perceived satisfaction with quality of life, even as a significant percentage of the patients with worse functional outcomes in retrospect would have refused the care when offered. 36 Accuracy of prognosis is also a concern here; an older metaanalysis looking at outcomes and early prognosis in mechanically ventilated patients with both ischemic and hemorrhagic subtypes found less functional disability than predicted in the subset of patients who survived the initial 30 days after hospitalization. 37 The preceding concerns about prognostication, whether using various objective scales or a more subjective holistic view of the patient's clinical situation, are not intended to suggest that limiting treatment is inappropriate in all cases or that paternalistic application of principles of beneficence and nonmaleficence demands aggressive intervention in all patients regardless of their wishes.…”

Section: Prognostication Mortality and Limitations On Carementioning

confidence: 99%

Ethical Issues in Vascular Neurology

2018

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There are ethical aspects to each of the three phases of cerebrovascular disease: hyperacute management, acute prognostication and management of early complications, and long-term recovery and reintegration with the community. This article addresses ethical concerns pertinent to each phase. First, we discuss ethical issues regarding consent for thrombolysis and endovascular treatment for acute ischemic stroke, including a review of considerations regarding the provision of acute stroke treatment advice over the telephone. Next, we discuss capacity for consent and prognostication after ischemic stroke and intracranial hemorrhage, with a focus on the problems of the self-fulfilling prophecy. Finally, we discuss residual disability and patients' return to driving. Consideration of these ethical dimensions of cerebrovascular disease will assist neurologists in caring for patients and families suffering from this complex condition.

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Retrospective agreement and consent to neurocritical care is influenced by functional outcome

Cited by 23 publications

References 31 publications

Outcome Predictors of Acute Stroke Patients in Need of Intensive Care Treatment

Outcome Predictors of Acute Stroke Patients in Need of Intensive Care Treatment

Sonographic Monitoring of Midline Shift Predicts Outcome after Intracerebral Hemorrhage

Ethical Issues in Vascular Neurology

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