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Vol. 43. Issue 6.
Pages 352-361 (August - September 2019)
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Vol. 43. Issue 6.
Pages 352-361 (August - September 2019)
Original article
DOI: 10.1016/j.medine.2018.03.007
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
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V. Blazqueza, A. Rodríguezb, A. Sandiumengec, E. Oliverd, B. Cancioe, M. Ibañezf, G. Miróg, E. Navash, M. Badíai, M.D. Bosquej, M.T. Juradok, M. Lópezl, M. Llauradóm, N. Masnoun, T. Pontc, M. Bodíb,
Corresponding author
mbodi.hj23.ics@gencat.cat

Corresponding author.
a Intensive Care Unit, University Hospital Joan XXIII, Institut d’Investigació Sanitària Pere Virgili, Tarragona, Spain
b Intensive Care Unit, University Hospital Joan XXIII, Institut d’Investigació Sanitària Pere Virgili, University Rovira i Virgili, CIBERES, Tarragona, Spain
c Transplant Coordination, University Hospital Vall d’Hebron, Barcelona, Spain
d Transplant Coordination, University Hospital Bellvitge, Barcelona, Spain
e Intensive Care Unit, University Hospital Moises Broggi, Barcelona, Spain
f Intensive Care Unit, University Hospital Verge de la Cinta de Tortosa, Tortosa, Spain
g Intensive Care Unit, Consorci Sanitari del Maresme, Mataró, Spain
h Intensive Care Unit, University Hospital Mutua de Terrassa, Terrassa, Spain
i Intensive Care Unit, University Hospital Arnau de Vilanova, Lleida, Spain
j Intensive Care Unit, University Hospital General de Catalunya, Barcelona, Spain
k Intensive Care Unit, Hospital de Terrassa, Terrassa, Spain
l Intensive Care Unit, University Hospital de Vic, Vic, Spain
m International University of Catalunya, Barcelona, Spain
n Transplant Coordination, University Hospital Dr. Trueta, Girona, Spain
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Figures (2)
Tables (3)
Table 1. Characteristics of patients with limitations on life support.
Table 2. Type of life support treatment limitation.
Table 3. Characteristics of patients with early vs. late limitations on life support.
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Additional material (1)
Abstract
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.

Keywords:
Life-support treatment limitation
Intensive care unit
End-of-life decisions
Withholding
Withdrawing
Abbreviations:
LSTLe
LSTLl
IQR
CRA
CIT
CPR
MIR Teaching
COPD
Hypertension
Resumen
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 Rankin2, 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.

Palabras clave:
Limitación del tratamiento de soporte vital
Unidad de Cuidados Intensivos
Decisiones al final de la vida
Withholding
Withdrawing

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