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Multicenter Study
. 2014 Feb;42(2):296-302.
doi: 10.1097/CCM.0b013e3182a272db.

Timing of limitations in life support in acute lung injury patients: a multisite study*

Alison E Turnbull  1 , A Parker Ruhl, Bryan M Lau, Pedro A Mendez-Tellez, Carl B Shanholtz, Dale M Needham
Affiliations
Multicenter Study

Timing of limitations in life support in acute lung injury patients: a multisite study*

Alison E Turnbull et al. Crit Care Med. 2014 Feb.

Abstract

Objective: Substantial variability exists in the timing of limitations in life support for critically ill patients. Our objective was to investigate how the timing of limitations in life support varies with changes in organ failure status and time since acute lung injury onset.

Design, setting, and patients: This evaluation was performed as part of a prospective cohort study evaluating 490 consecutive acute lung injury patients recruited from 11 ICUs at three teaching hospitals in Baltimore, MD.

Interventions: None.

Measurements: The primary exposure was proportion of days without improvement in Sequential Organ Failure Assessment score, evaluated as a daily time-varying exposure. The outcome of interest was a documented limitation in life support defined as any of the following: 1) no cardiopulmonary resuscitation, 2) do not reintubate, 3) no vasopressors, 4) no hemodialysis, 5) do not escalate care, or 6) other limitations (e.g., "comfort care only").

Main results: For medical ICU patients without improvement in daily Sequential Organ Failure Assessment score, the rate of limitation in life support tripled in the first 3 days after acute lung injury onset, increased again after day 5, and peaked at day 19. Compared with medical ICU patients, surgical ICU patients had a rate of limitations that was significantly lower during the first 5 days after acute lung injury onset. In all patients, more days without improvement in Sequential Organ Failure Assessment scores was associated with limitations in life support, independent of the absolute magnitude of the Sequential Organ Failure Assessment score.

Conclusions: Persistent organ failure is associated with an increase in the rate of limitations in life support independent of the absolute magnitude of Sequential Organ Failure Assessment score, and this association strengthens during the first weeks of treatment. During the first 5 days after acute lung injury onset, limitations were significantly more common in medical ICUs than surgical ICUs.

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Conflict of interest statement

The remaining authors have disclosed that they do not have any potential conflicts of interest.

Figures

Figure 1
Figure 1. Rate of Limitations in Life Support Over 21 Days After Acute Lung Injury Onset
Estimates for the rate of limitations in life support over 21 days among prototypical patients in this acute lung injury cohort, assuming median values for continuous covariates and mode values for binary covariates. Abbreviations: MICU, Medical Intensive Care Unit; SICU, Surgical Intensive Care Unit; SOFA, Sequential Organ Failure Assessment score; ALI, acute lung injury
Figure 2
Figure 2. Time-Dependent Relative Hazards of Limitations in Life Support Over 21 Days After Acute Lung Injury Onset
Time dependent relative hazards (dotted line) and 95% confidence intervals (shaded areas) for limitations in life support over 21 days of follow-up for prototypical patients in this acute lung injury cohort. Horizontal solid line at a relative hazard of 1.0 indicates no difference in the rate of limitations in life support for compared groups. Abbreviations: ICU, intensive care unit; MICU, medical intensive care unit; SICU, surgical intensive care unit; SOFA, sequential organ failure assessment; ALI, acute lung injury
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