Life Support Limitations in Mechanically Ventilated Stroke Patients

Abstract

Objectives: The determinants of decisions to limit life support (withholding or withdrawal) in ventilated stroke patients have been evaluated mainly for patients with intracranial hemorrhages. We aimed to evaluate the frequency of life support limitations in ventilated ischemic and hemorrhagic stroke patients compared with a nonbrain-injured population and to determine factors associated with such decisions.

Design: Multicenter prospective French observational study.

Setting: Fourteen ICUs of the French OutcomeRea network.

Patients: From 2005 to 2016, we included stroke patients and nonbrain-injured patients requiring invasive ventilation within 24 hours of ICU admission.

Intervention: None.

Measurements and main results: We identified 373 stroke patients (ischemic, n = 167 [45%]; hemorrhagic, n = 206 [55%]) and 5,683 nonbrain-injured patients. Decisions to limit life support were taken in 41% of ischemic stroke cases (vs nonbrain-injured patients, subdistribution hazard ratio, 3.59 [95% CI, 2.78-4.65]) and in 33% of hemorrhagic stroke cases (vs nonbrain-injured patients, subdistribution hazard ratio, 3.9 [95% CI, 2.97-5.11]). Time from ICU admission to the first limitation was longer in ischemic than in hemorrhagic stroke (5 [3-9] vs 2 d [1-6] d; p < 0.01). Limitation of life support preceded ICU death in 70% of ischemic strokes and 45% of hemorrhagic strokes (p < 0.01). Life support limitations in ischemic stroke were increased by a vertebrobasilar location (vs anterior circulation, subdistribution hazard ratio, 1.61 [95% CI, 1.01-2.59]) and a prestroke modified Rankin score greater than 2 (2.38 [1.27-4.55]). In hemorrhagic stroke, an age greater than 70 years (2.29 [1.43-3.69]) and a Glasgow Coma Scale score less than 8 (2.15 [1.08-4.3]) were associated with an increased risk of limitation, whereas a higher nonneurologic admission Sequential Organ Failure Assessment score was associated with a reduced risk (per point, 0.89 [0.82-0.97]).

Conclusions: In ventilated stroke patients, decisions to limit life support are more than three times more frequent than in nonbrain-injured patients, with different timing and associated risk factors between ischemic and hemorrhagic strokes.

Keywords: critical care; end-of-life care; intracerebral hemorrhage; ischemic stroke; subarachnoid hemorrhage.

Figure 1.

Daily ICU occurence rate of life support limitations according to stroke subtype or absence of brain injury.

Figure 2.

End-of-life outcome according to length of ICU stay (d): comparison between nonbrain-injured patients and stroke subtypes. A, Nonbrain-injured patients. B, Ischemic stroke patients. C, Hemorrhagic stroke patients.

Figure 3.

Fine and Gray subdistribution hazard analysis for the occurrence of life support limitations, and death without such limitation as the competing event. A, Ischemic stroke patients. B, Hemorrhagic stroke patients. ^amodified Rankin Score, ^bversus anterior circulation location, ^cthrombolysis or endovascular thrombectomy, ^dper SOFA point. HR = hazard ratio, sHR = subdistribution hazard ratio, SOFA = Sequential Organ Failure Assessment.