Sunday, November 22, 2009

Survival in critically ill stroke patients

I'm posting tonight, relatively succinctly (yes, it's possible), on three different articles. This will be my last post for me, and I suspect Christian and Lyle, until after the Thanksgiving holiday. Happy Thanksgiving, and safe travels, to our readers this week. For those of you who use Thanksgiving as a time of reflection, I think this week's article from The Onion captures the national mood well.

Critical Care Medicine has a paper about the prognosis of critically ill stroke patients.

The study (retrospective; N=~31000; used Medicare claims data from 11 metropolitan regions in the US in 2000) looks at short and long-term prognosis in older patients (Medicare beneficiaries) discharged after a hospital stay for an ischemic stroke (so, while considering the actual survival numbers below, recall that these don't include patients who died during their hospitalization for a stroke). Survival, among other things, was compared between stroke patients who were admitted to an ICU during their hospitalization vs. those who weren't.

26% of patients were admitted to an ICU - these tended to be older, and not surprisingly were more likely to be mechanically ventilated (11%) and receive PEG tubes (11% of ICU patients vs. 6% of non-ICU patients). ICU patients overall had more comorbidities, although certain comorbidities seemed to 'protect' some patients from the ICU, presumably because of differences in chosen treatment intensity (e.g. dementia, history of prior stroke).

General survival data are presented. Overall 30 day mortality was 15%; 21% for ICU patients. 30 day mortality for mechanically ventilated patients was 65%, and 24% for those given PEG tubes. 1 year mortality was markedly worse for patients who were mechanically ventilated or received a PEG tube - 82% for MV, 65% for receiving a PEG - compared to an overall 1 year mortality of 32%. (PEG tube insertion wasn't particularly associated with a worse survival at 30 days).

The authors' discussion of the PEG outcomes:

If it is assumed that patients requiring a PEG have either a greater severity of dysphagia or a greater severity of stroke itself, then one may postulate that PEG offers a short-term survival advantage, because these patients may otherwise be expected to have a higher death rate. We believe, however, that our findings are the result of a selection effect, whereby the decision to place a PEG by the clinician staff, patients, and families is made only in those who are deemed to have a reasonable chance of survival, at least in the short term. Certainly, this advantage is not evident at 12-month follow-up, when the adjusted HR increased to 2.59. Thus, in those who survive the initial 30 days, the need for a PEG appears to be a better predictor of long-term mortality.
Thanks to Dr. Bob Arnold for alerting me to this.

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