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Canadian Journal of Anesthesia/Journal canadien d'anesthésie
Published in: Canadian Journal of Anesthesia/Journal canadien d'anesthésie 10/2013

01-10-2013 | Reports of Original Investigations

Declining mortality in neurocritical care patients: a cohort study in Southern Alberta over eleven years

Authors: Andreas H. Kramer, MD, David A. Zygun, MD

Published in: Canadian Journal of Anesthesia/Journal canadien d'anesthésie | Issue 10/2013

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Abstract

Purpose

Few interventions have been proven to improve outcomes in neurocritical care patients. It is unknown whether outcomes in Canada have changed over time. We performed a cohort study in Southern Alberta to determine whether survival and discharge disposition have improved.

Methods

Using prospectively collected data, we identified patients admitted to regional intensive care units (ICUs) over a more than 11-year period with traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), intracerebral hemorrhage, anoxic encephalopathy, central nervous system infection, or status epilepticus. Four sequential time periods of 2.8 years were compared, as were periods before and after various practice modifications were introduced. Logistic regression was used to adjust for patient age, Glasgow Coma Scale score, and case mix.

Results

A total of 4,097 patients were assessed. The odds of death were lowest in the most recent time quartile (odds ratio [OR] 0.70, 95% confidence interval [CI] 0.56 to 0.88, P < 0.01). The odds of being discharged home without the need for support services increased over time (OR 1.45, 95% CI 1.38 to 1.85, P = 0.003). Improvements were not the same for all diagnostic subgroups. They were statistically significant for patients with TBI and SAH. Neurocritical care consultative services, evidence-based protocols, and clustering of patients within a multidisciplinary ICU were associated with improved outcomes. Length of stay in an ICU increased among hospital survivors (4.6 vs 3.8 days, P < 0.01).

Conclusions

Mortality and discharge disposition of neurocritical care patients in Southern Alberta have improved over time. Practice modifications in the region were associated with positive outcome trends. Longer ICU length of stay may imply that intensivists are increasingly delaying decisions about withdrawing life-sustaining interventions.
Appendix
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Literature
1.
Pelosi P, Ferguson ND, Frutos-Vivar F, et al. Management and outcome of mechanically ventilated neurologic patients. Crit Care Med 2011; 39: 1482-92.PubMedCrossRef
2.
Broessner G, Helbok R, Lackner P, et al. Survival and long-term functional outcome in 1,155 consecutive neurocritical care patients. Crit Care Med 2007; 35: 2025-30.PubMedCrossRef
3.
Gujjar AR, Deibert E, Manno EM, Duff S, Diringer MN. Mechanical ventilation for ischemic stroke and intracerebral hemorrhage: indications, timing, and outcome. Neurology 1998; 51: 447-51.PubMedCrossRef
4.
Christensen MC, Mayer S, Ferran JM. Quality of life after intracerebral hemorrhage: results of the Factor Seven for Acute Hemorrhagic Stroke (FAST) trial. Stroke 2009; 40: 1677-82.PubMedCrossRef
5.
Al-Khindi T, Macdonald RL, Schwiezer TA. Cognitive and functional outcome after aneurysmal subarachnoid hemorrhage. Stroke 2010; 41: e519-36.PubMedCrossRef
6.
Ruttan L, Martin K, Liu A, Colella B, Green RE. Long-term cognitive outcome in moderate to severe traumatic brain injury: a meta-analysis examining timed and untimed tests at 1 and 4.5 or more years after injury. Arch Phys Med Rehabil 2008; 89: S69-76.PubMedCrossRef
7.
Vaillancourt C. Stiell IG; Canadian Cardiovascular Outcomes Research Team. Cardiac arrest case and emergency medical services in Canada. Can J Cardiol 2004; 20: 1081-90.PubMed
8.
Mateen FJ, Josephs KA, Trenerry MR, et al. Long-term cognitive outcomes following out-of-hospital cardiac arrest: a population-based study. Neurology 2011; 77: 1438-45.PubMedCrossRef
9.
Molyneux A, Kerr R, Stratton I, et al. International Subarachnoid Aneurysmal Trial (ISAT) of neurosurgical clipping versus endovascular coiling in 2143 patients with ruptured intracranial aneurysms: a randomised trial. Lancet 2002; 360: 1267-72.PubMedCrossRef
10.
Vahedi K, Hofmeijer J, Juettler E, et al. Early decompressive surgery in malignant infarction of the middle cerebral artery: a pooled analysis of three randomised controlled trials. Lancet Neurol 2007; 6: 215-22.PubMedCrossRef
11.
Hypothermia after Cardiac Arrest Study Group. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 2002; 346: 549-56.CrossRef
12.
Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 2002; 346: 557-63.PubMedCrossRef
13.
De Gans J, van de Beek D. European Dexmethasone in Adulthood Bacterial Meningitis Study Investigators. Dexamethasone in adults with bacterial meningitis. N Engl J Med 2002; 347: 1549-56.PubMedCrossRef
14.
Bernard SA, Nguyen V, Cameron P, et al. Prehospital rapid sequence intubation improves functional outcome for patients with severe traumatic brain injury: a randomized controlled trial. Ann Surg 2010; 252: 959-65.PubMedCrossRef
15.
Diringer MN, Bleck TP. Claude Hemphioll J 3rd, et al. Critical care management of patients following aneurysmal subarachnoid hemorrhage: recommendations from the Neurocritical Care Society’s Multidisciplinary Consensus Conference. Neurocrit Care 2011; 15: 211-40.PubMedCrossRef
16.
Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, et al. Guidelines for the management of severe traumatic brain injury. J Neurotrauma 2007; 24(Suppl): S1-106.
17.
Morgenstern LB, Hemphill JC 3rd, Anderson C, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association / American Stroke Association. Stroke 2010; 41: 2108-29.PubMedCrossRef
18.
Brophy GM, Bell R, Claassen J, et al. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care 2012; 17: 3-23.PubMedCrossRef
19.
Peberdy MA, Callaway CW, Neumar RW, et al. Part 9: post-cardiac arrest care: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010; 122: S768-86.PubMedCrossRef
20.
21.
Kramer AH, Roberts DJ, Zygun DA. Optimal glycemic control in neurocritical care patients: a systematic review and meta-analysis. Crit Care 2012; 22: R203.CrossRef
22.
Wright WL. Sodium and fluid management in acute brain injury. Curr Neurol Neurosci Rep 2012; 12: 466-73.PubMedCrossRef
23.
Kramer AH, Zygun DA. Anemia and red blood cell transfusion in neurocritical care. Crit Care 2009; 13: R89.PubMedCrossRef
24.
Kramer AH, Jette N, Pillay N, Federico P, Zygun DA. Epileptiform activity in neurocritical care patients. Can J Neurol Sci 2012; 39: 328-37.PubMed
25.
Hemphill JC, Andrews P, De Georgia M. Multimodal monitoring and neurocritical care bioinformatics. Nat Rev Neurol 2011; 7: 451-60.PubMedCrossRef
26.
Stuart RM, Schmidt M, Kurtz P, et al. Intracranial multimodal monitoring for acute brain injury: a single institution review of current practices. Neurocrit Care 2010; 12: 188-98.PubMedCrossRef
27.
Tisdall MM, Smith M. Multimodal monitoring in traumatic brain injury: current status and future directions. Br J Anaesth 2007; 99: 61-7.PubMedCrossRef
28.
Kramer AH, Zygun DA. Do neurocritical care units save lives? Measuring the impact of specialized ICUs. Neurocrit Care 2011; 14: 329-33.PubMedCrossRef
29.
English SW, Turgeon AF, Owen E, Doucette S, Pagliarello G, McIntyre L. Protocol management of severe traumatic brain injury in intensive care units: a systematic review. Neurocrit Care 2013; 18: 131-42.PubMedCrossRef
30.
Diringer MN, Edwards DF. Admission to a neurologic/neurosurgical intensive care unit is associated with reduced mortality rate after intracerebral hemorrhage. Crit Care Med 2001; 29: 635-40.PubMedCrossRef
31.
Patel HC, Menon DK, Tebbs S, Hawker R, Hutchinson PJ, Kirkpatrick PJ. Specialist neurocritical care and outcome from head injury. Intensive Care Med 2002; 28: 547-53.PubMedCrossRef
32.
Elf K, Nilsson P, Enblad P. Outcome after traumatic brain injury improved by an organized secondary insult program and standardized neurointensive care. Crit Care Med 2002; 30: 2129-34.PubMedCrossRef
33.
Suarez JI, Zaidat OO, Suri MF, et al. Length of stay and mortality in neurocritically ill patients: impact of a specialized neurocritical care team. Crit Care Med 2004; 32: 2311-7.PubMed
34.
Varelas PN, Conti MM, Spanaki MV, et al. The impact of a neurointensivist-lead team on a semiclosed neurosciences intensive care unit. Crit Care Med 2004; 32: 2191-8.PubMed
35.
de Keizer NF, Bonsel GJ, Goldfad C, Rowan KM. The added value that increasing levels of diagnostic information provide in prognostic models to estimate hospital mortality for adult intensive care patients. Intensive Care Med 2000; 26: 577-84.PubMedCrossRef
36.
Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med 1985; 13: 818-29.PubMedCrossRef
37.
Laver S, Farrow C, Turner D, Nolan J. Mode of death after admission to an intensive care unit following cardiac arrest. Intensive Care Med 2004; 30: 2126-8.PubMedCrossRef
38.
Groenwold RH, Klungel OH, Altman DG, et al. Adjustment for continuous confounders: an example of how to prevent residual confounding. CMAJ 2013; 185: 401-6.PubMed
39.
Hemphill JC 3rd, Farrant M, Neill TA Jr. Prospective validation of the ICH score for 12-month functional outcome. Neurology 2009; 73: 1088-94.PubMedCrossRef
40.
Rosengart AJ, Schultheiss KE, Tolentino J, Macdonald RL. Prognostic factors for outcome in patients with aneurysmal subarachnoid hemorrhage. Stroke 2007; 38: 2315-21.PubMedCrossRef
41.
Steyerberg EW, Mushkudiani N, Perel P, et al. Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med 2008; 5: e165.PubMedCrossRef
42.
van de Beek D, de Gans J, Spanjaard L, Weisfelt M, Reitsma JB, Vermeulen M. Clinical features and prognostic factors in adults with bacterial meningitis. N Engl J Med 2004; 351: 1849-59.PubMedCrossRef
43.
Braga LH, Farrokhyar F, Bhandari M. Confounding: what is it and how do we deal with it? Can J Surg 2012; 55: 132-8.PubMed
44.
Clifton GL, Valadka A, Zygun D, et al. Very early hypothermia induction in patients with severe brain injury (the National Acute Brain Injury Study: Hypothermia II): a randomised trial. Lancet Neurol 2011; 10: 131-9.PubMedCrossRef
45.
Cooper DJ, Rosenfeld JV, Murray L, et al. Decompressive craniectomy in diffuse traumatic brain injury. N Engl J Med 2011; 364: 1493-502.PubMedCrossRef
46.
Chesnut RM, Temkin N, Carney N, et al. A trial of intracranial-pressure monitoring in traumatic brain injury. N Engl J Med 2012; 367: 2471-81.PubMedCrossRef
47.
Roozenbeek B, Maas AIR, Menon DK. Changing patterns in the epidemiology of traumatic brain injury. Nat Rev Neurol 2013; 9: 231-6.PubMedCrossRef
48.
Stein SC, Georgoff P, Meghan S, Mizra K, Sonnad SS. 150 years of treating severe traumatic brain injury: a systematic review of progress in mortality. J Neurotrauma 2010; 1343-53.
49.
van Asch CJ, Luitse MJ, Rinkel GJ, van der Tweel I, Algra A, Klijn CJ. Incidence, case fatality, and functional outcome of intracerebral haemorrhage over time, according to age, sex and ethnic origin: a systematic review and meta-analysis. Lancet Neurol 2010; 9: 167-76.PubMedCrossRef
50.
Nieuwkamp DJ, Setz LE, Algra A, Linn FH, de Rooij NK, Rinkel GJ. Changes in case fatality of aneurysmal subarachnoid haemorrhage over time, according to age, sex, and region: a meta-analysis. Lancet Neurol 2009; 8: 635-42.PubMedCrossRef
51.
Feigin VL, Lawes CM, Bennett DA, Barker-Collo SI, Parag V. Worldwide stroke incidence and early case fatality reported in 56 population-based studies: a systematic review. Lancet Neurol 2009; 8: 355-69.PubMedCrossRef
52.
Sandvei MS, Mathiesen EB, Vatten LJ, et al. Incidence and mortality of aneurysmal subarachnoid hemorrhage in two Norwegian cohorts, 1984-2007. Neurology 2011; 77: 1833-9.PubMedCrossRef
53.
Lovelock CE, Rinkel GJ, Rothwell PM. Time trends in outcome of subarachnoid hemorrhage: population-based study and systematic review. Neurology 2010; 74: 1494-501.PubMedCrossRef
54.
Redpath C, Sambell C, Stiell I, et al. In-hospital mortality in 13,263 survivors of out-of-hospital cardiac arrest in Canada. Am Heart J 2010; 159: 577-83.e1.CrossRef
55.
Colantonio A, Croxford R, Farooq S, Laporte A, Coyte PC. Trends in hospitalization associated with traumatic brain injury in a publicly insured population, 1992-2002. J Trauma 2009; 66: 179-83.PubMedCrossRef
56.
Ostbye T, Levy AR, Mayo NE. Hospitalization and case-fatality rates for subarachnoid hemorrhage in Canada from 1982 through 1991. The Canadian Collaborative Study Group of Stroke Hospitalizations. Stroke 1997; 28: 793-8.
57.
Mayo NE, Neville D, Kirkland S, et al. Hospitalization and case-fatality rates for stroke in Canada from 1982 through 1991. The Canadian Collaborative Study Group of Stroke Hospitalizations. Stroke 1996; 27: 1215-20.
58.
Cook D, Rocker G, Marshall J, et al. Withdrawal of mechanical ventilation in anticipation of death in the intensive care unit. N Engl J Med 2003; 349: 1123-32.PubMedCrossRef
59.
Rocker G, Cook D, Sjokvist P, et al. Clinician predictions of intensive care unit mortality. Crit Care Med 2004; 32: 1149-54.PubMedCrossRef
60.
Turgeon AF, Lauzier F, Simard JF, et al. Mortality associated with withdrawal of life-sustaining therapy for patients with severe traumatic brain injury: a Canadian multicentre cohort study. CMAJ 2011; 183: 1581-8.PubMed
61.
Cooper Z, Rivara FP, Wang J, MacKenzie EJ, Jurkovich GJ. Withdrawal of life-sustaining therapy in injured patients: variations between trauma centers and nontrauma centers. J Trauma 2009; 66: 1327-35.PubMedCrossRef
62.
Kelly AG, Hoskins KD, Holloway RG. Early stroke mortality, patient preferences, and the withdrawal of care bias. Neurology 2012; 79: 941-4.PubMedCrossRef
63.
Finley Caulfield A, Gabler L, Lansberg MG, et al. Outcome prediction in mechanically ventilated neurologic patients by junior neurointensivists. Neurology 2010; 74: 1096-101.PubMedCrossRef
64.
Racine E, Dion MJ, Wijman CA, Illes J, Lansberg MG. Profiles of neurological outcome prediction among intensivists. Neurocrit Care 2009; 11: 345-52.PubMedCrossRef
65.
Becker KJ, Baxter AB, Cohen WA, et al. Withdrawal of support in intracerebral hemorrhage may lead to self-fulfilling prophecies. Neurology 2001; 56: 766-72.PubMedCrossRef
66.
Zygun DA, Kortbeek JB, Fick GH, Laupland KB, Doig CJ. Non-neurologic organ dysfunction in severe traumatic brain injury. Crit Care Med 2005; 33: 654-60.PubMedCrossRef
67.
Murray GD, Butcher I, McHugh GS, et al. Multivariable prognostic analysis in traumatic brain injury: results from the IMPACT study. J Neurotrauma 2007; 24: 329-37.PubMedCrossRef
68.
Davis DP, Idris AH, Sise MJ, et al. Early ventilation and outcome in patients with moderate to severe traumatic brain injury. Crit Care Med 2006; 34: 1202-8.PubMedCrossRef
69.
Chesnut RM, Marshall LF, Klauber MR, et al. The role of secondary brain injury in determining outcome from severe head injury. J Trauma 1993; 34: 216-22.PubMedCrossRef
70.
Berthiaume LR, Peets AD, Schmidt U, et al. Time series analysis of use patterns for common invasive technologies in critically ill patients. J Crit Care 2009; 24: 471.e9-14.
Metadata
Title
Declining mortality in neurocritical care patients: a cohort study in Southern Alberta over eleven years
Authors
Andreas H. Kramer, MD
David A. Zygun, MD
Publication date
01-10-2013
Publisher
Springer US
Published in
Canadian Journal of Anesthesia/Journal canadien d'anesthésie / Issue 10/2013
Print ISSN: 0832-610X
Electronic ISSN: 1496-8975
DOI
https://doi.org/10.1007/s12630-013-0001-0

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