The OPALS Major Trauma Study: impact of advanced life-support on survival and morbidity

Background

To date, the benefit of prehospital advanced life-support programs on trauma-related mortality and morbidity has not been established

Methods

The Ontario Prehospital Advanced Life Support (OPALS) Major Trauma Study was a before–after systemwide controlled clinical trial conducted in 17 cities. We enrolled adult patients who had experienced major trauma in a basic life-support phase and a subsequent advanced life-support phase (during which paramedics were able to perform endotracheal intubation and administer fluids and drugs intravenously). The primary outcome was survival to hospital discharge.

Results

Among the 2867 patients enrolled in the basic life-support (n = 1373) and advanced life-support (n = 1494) phases, characteristics were similar, including mean age (44.8 v. 47.5 years), frequency of blunt injury (92.0% v. 91.4%), median injury severity score (24 v. 22) and percentage of patients with Glasgow Coma Scale score less than 9 (27.2% v. 22.1%). Survival did not differ overall (81.1% among patients in the advanced life-support phase v. 81.8% among those in the basic life-support phase; p = 0.65). Among patients with Glasgow Coma Scale score less than 9, survival was lower among those in the advanced life-support phase (50.9% v. 60.0%; p = 0.02). The adjusted odds of death for the advanced life-support v. basic life-support phases were nonsignificant (1.2, 95% confidence interval 0.9–1.7; p = 0.16).

Interpretation

The OPALS Major Trauma Study showed that systemwide implementation of full advanced life-support programs did not decrease mortality or morbidity for major trauma patients. We also found that during the advanced life-support phase, mortality was greater among patients with Glasgow Coma Scale scores less than 9. We believe that emergency medical services should carefully re-evaluate the indications for and application of prehospital advanced life-support measures for patients who have experienced major trauma.Each year in the United States, an estimated 500 000 adult patients are transported to hospital after experiencing major trauma.^1,2 Major trauma can be described as life-or limb-threatening injury due to blunt force, penetrating injury or burn injury. Considering both frequency and associated mortality, major trauma is the second most important condition for children and the fourth most important condition for adults treated by emergency medical service providers.² About 20% of these patients die, and many survivors are left with permanent disability.Throughout most urban areas of the United States and Canada, paramedics provide prehospital advanced life-support to many of these critically injured patients. Advanced life-support protocols include advanced airway management (endotracheal intubation) and intravenous fluid therapy. In contrast, basic life-support providers administer oxygen, ventilate with a bag valve mask, and provide immobilization and dressings. The relative effectiveness of community-based advanced life-support programs for major trauma patients has not been clearly established, and there have been calls for larger and more rigorously designed studies.^3–5Endotracheal intubation in the field has not been proven to reduce mortality and morbidity among severely injured patients, and there are concerns that performing this difficult task under trying conditions may cause harm.^6,7 The value of prehospital intravenous resuscitation has also been questioned.^8,9 In addition, there are concerns that the on-scene time spent providing advanced life-support measures may actually delay life-saving expeditious transfer to the hospital and the operating room.¹⁰ To date, no large controlled clinical trials have been conducted to evaluate the impact of prehospital advanced life-support programs on trauma-related mortality and morbidity.³As part of the Ontario Prehospital Advanced Life Support (OPALS) studies, we recently demonstrated that advanced life-support programs had no impact on the outcomes of patients who had experienced cardiac arrest, but they did lead to significant improvement in survival among patients with respiratory distress.^11,12 The primary objective of the current study, the OPALS Major Trauma Study, was to assess any change in survival that might result from the systemwide introduction of prehospital advanced life-support programs in multiple cities with existing basic life-support programs provided through emergency medical services. We also evaluated the impact of advanced life-support on morbidity and processes of care.     

‘THEY SAY ISLAM HAS A SOLUTION FOR EVERYTHING,SO WHY ARE THERE NO GUIDELINES FOR THIS?’ ETHICAL DILEMMAS ASSOCIATED WITH THE BIRTHS AND DEATHS OF INFANTS WITH FATAL ABNORMALITIES FROM A SMALL SAMPLE OF PAKISTANI MUSLIM COUPLES IN BRITAIN

This paper presents ethical dilemmas concerning the termination of pregnancy, the management of childbirth, and the withdrawal of life-support from infants in special care, for a small sample of British Pakistani Muslim parents of babies diagnosed with fatal abnormalities. Case studies illustrating these dilemmas are taken from a qualitative study of 66 families of Pakistani origin referred to a genetics clinic in Southern England. The paper shows how parents negotiated between the authoritative knowledge of their doctors, religious experts, and senior family members in response to the ethical dilemmas they faced. There was little knowledge or open discussion of the view that Islam permits the termination of pregnancy for serious or fatal abnormality within 120 days and there was considerable disquiet over the idea of ending a pregnancy. For some parents, whether their newborn baby would draw breath was a main worry, with implications for the baby's Muslim identity and for the recognition of loss the parents would receive from family and community. This concern sometimes conflicted with doctors' concerns to minimize risk to future pregnancies by not performing a Caesarean delivery if a baby is sure to die. The paper also identifies parents' concerns and feelings of wrong-doing regarding the withdrawal of artificial life-support from infants with multiple abnormalities. The conclusion considers some of the implications of these observations for the counselling and support of Muslim parents following the pre- or neo-natal diagnosis of fatal abnormalities in their children.     

ICU 患者焦虑状况及其相关因素分析

目的:调查ICU患者的焦虑状况,并分析其相关因素,以明确ICU患者心理健康状况及常见的引起ICU患者不良情绪反应的因素。方法:在转出ICU前12小时内,对108名患者进行焦虑自评量表、一般情况调查表的调查。结果:ICU患者焦虑自评量表标准分高于国内常模(P<0.001),焦虑发生率为37.0%;女性、未镇静镇痛、感到孤独渴望家属陪护的患者评分较高(P<0.05);患者评分随年龄、住ICU天数、戴呼吸机天数、管路数量、受教育程度、疾病严重程度增加而增高(P<0.05);不同职业的患者评分不同(P<0.05);能否自由表达和不同医保类型的患者评分无显著差异(P>0.05)。结论:ICU患者存在明显的焦虑状况,女性、未予镇静镇痛、感到孤独渴望家属陪护的患者更易出现焦虑;随年龄、住ICU天数、戴呼吸机天数、管路数量、受教育程度、疾病严重程度增加焦虑状况加重,不同职业患者焦虑状况不同。     

Withholding and withdrawing life sustaining treatment from elderly people: towards formal guidelines.

Clinicians often decide either to withhold or to withdraw lifesaving treatment in elderly patients. Considerable disagreement exists about the circumstances in which such actions can be defended. Debates about the scarcity of resources in the NHS add urgency to the need to resolve this disagreement. Competent elderly patients have a legal and moral right to decide whether to receive life sustaining treatment. Such treatment should not be withheld or withdrawn on the basis of a patient''s age alone. Principles for making decisions about life sustaining treatment in incompetent elderly patients can be defended and should exist as written guidelines.     

E-PASS评分系统用于评估老龄患者消化道手术后并发症和转归的临床价值研究

目的:评价日常活动和手术应激评估(Estimation of physiologic ability and surgical stress,E-PASS)系统用于评估老龄患者消化道手术后并发症和转归的临床价值。方法:回顾性分析2011年7月至2013年7月西京医院消化外科所有65岁以上的患者的临床资料,计算其中行消化道手术者的E-PASS评分,并记录这些患者术后并发症的发生情况和患者术后的住院时间。分析E-PASS评分和几项该评分未涉及的因素与老龄患者消化道手术后并发症的发病率、死亡率、住院时间的相关性。结果:研究共纳入1236例老龄行消化道手术的患者,其中521例发生术后并发症(42.15%),8例死亡(0.65%)。患者术前E-PASS评分系统中,三项评分均与术后住院时间相关,术前风险评分(Preoperative risk score,PRS)和综合风险评分(Comprehensive risk score,CRS)与术后并发症的发病率和死亡率显著相关(P均0.05)。E-PASS评分系统未包含的指标中,麻醉方法与术后并发症发生和住院时间无关,术后入ICU、术中使用血管活性药物和急诊手术与术后发病率、死亡率和住院时间相关(P均0.05)。结论:E-PASS评分系统可用于预测老龄患者行消化道手术后并发症的发生情况和转归,纳入术后入ICU、术中使用血管活性药物和急诊手术三项指标可能进一步提高E-PASS评分系统的预测准确性。     

Análisis de los factores implicados en la evolución de los pacientes mayores de 80 años,ingresados en la unidad de cuidados intensivos: ¿debemos cambiar nuestro proceder?

Background and objectivesThe care of older patients in intensive care units (ICU) is becoming more frequent.To describe characteristics of elderly patients admitted to the ICU and to analyze the factors associated with mortality.Patients and methodsRetrospective cross-sectional study, with patients ≥80 years, admitted to the ICU of the Rey Juan Carlos University Hospital, from March 2012 to December 2018. Demographic variables, comorbidities and mortality in the ICU, in hospital and at one year were collected, analyzed by univariate analysis and binary logistic regression.ResultsSix hundred twenty patients, mean age 83.6 years (SD: 3.25), 31% required invasive mechanical ventilation (IMV), 25% vasopressors and 29% renal replacement therapy (RRT) due to acute renal failure (ARF). The 60% were admissions of medical origin. In-hospital mortality was 156 patients (25%), 91 died in the ICU and 65 on the ward, with shorter ICU stays for the survivors (2.72; SD: 0.22) compared to the deceased (3.74; SD: 0.38), with statistically significant differences. 63% remained alive one year after ICU discharge.An explanatory model of ICU mortality was obtained by logistic regression that included the following factors: IMV (OR: 5.78, 95% CI 2.73-12.22), vasopressors (OR: 2.54, 95% CI 1.24-5.19), AKI/TRS (OR: 2.69, 95% CI 1.35-5.35), medical admission (OR: 2.88, 95% CI 1.40-5.92), urgent admission (OR: 2.33, 95% CI 1.30-4.18) and limitation of life support (LTSV) (OR: 47.35, 95% CI 22.96-97.68). The days in the ICU (OR: 0.93, 95% CI 0.87-0.99) would be inversely related to mortality.ConclusionsIn older patients, there is no increase in mortality, with a 1-year survival >63%. The need for IMV, the use of vasopressor drugs and ARF/RTS were factors associated with mortality in the multivariate analysis.     

Opiate Modulation of Striatal Dopamine and Hippocampal Norepinephrine Release Following Morphine Withdrawal

When opiates are abruptly withdrawn after chronic treatment, increases in hippocampal noradre-nergic function are observed which are accompanied by decreases in striatal dopamine release. The latter effects have to shown to persist for several weeks following the onset of opiate withdrawal. We examined the long-term effects of opiate withdrawal on 4-aminopyridine and potassium stimulated release of striatal dopamine and hippocampal norepinephrine. Tissue samples were obtained either from rats that had been exposed to opiate withdrawal following a seven day morphine infusion or sham treated control subjects. At 48 hours after the onset of withdrawal (cessation of morphine infusions), slices were loaded with [³H] neurotransmitter, washed extensively, and exposed to different drug treatments. 4-aminopyridine induced concentration related increases in striatal dopamine release, which was 36% calcium independent. Similar values for fractional release of striatal dopamine were obtained in morphine withdrawn and control subjects, for both potassium and 4-aminopyridine induced release. In addition, thresholds for 4-aminopyridine or potassium induced release of striatal dopamine did not differ between control and morphine withdrawn subjects. Treatment with 1.0 M morphine sulfate potentiated potassium evoked release of norepinephrine to an equal extent in both morphine withdrawn and sham treated hippocampal tissue. Exposure to a threshold concentration of potassium (8.0 mM), stimulated increased release of hippocampal norepinephrine in a significantly greater fraction of tissue samples obtained from morphine withdrawn animals. Although these results do not support changes in striatal dopamine release following opiate withdrawal, opiate mechanisms appear to be important determinants of in vitro hippocampal norepinephrine release.     

Postnatal abstinence or acute toxicity can account for morbidity in developmental studies with opiates

The incidence of neonatal morbidity and mortality in rats exposed to opiates $\text{in utero}$ is generally high. To determine the extent to which neonatal opioid intoxication and/or withdrawal contribute to this effect, addicted pups from dams treated chronically with the long-acting opioid levo-alpha-acetylmethadol (LAAM) and appropriate controls were injected within 12 h of birth with saline, an opioid agonist (LAAM and metabolites) or an antagonist (naloxone). The incidence of neonatal mortality for pups born to dams maintained on a high dose of LAAM was 52%. A single injection of agonist on the first day of life reduced mortality in this group to 29% while a single injection of the antagonist increased mortality to 88%. In contrast, administration of the agonist to control pups and pups born to dams maintained on lower doses of LAAM resulted in increased mortality. Naloxone was apparently innocuous in non-dependent neonates. These data show that, despite LAAM's long duration of action in the mature rat, newborn rats experience withdrawal soon after drug exposure is terminated. These data also indicate that continued opioid exposure is a highly effective means of treating/preventing severe spontaneous withdrawal in the newborn.     

Changes in gene expression in Arabidopsis shoots during phosphate starvation and the potential for developing smart plants

Our aim was to generate and prove the concept of "smart" plants to monitor plant phosphorus (P) status in Arabidopsis. Smart plants can be genetically engineered by transformation with a construct containing the promoter of a gene up-regulated specifically by P starvation in an accessible tissue upstream of a marker gene such as beta-glucuronidase (GUS). First, using microarrays, we identified genes whose expression changed more than 2.5-fold in shoots of plants growing hydroponically when P, but not N or K, was withheld from the nutrient solution. The transient changes in gene expression occurring immediately (4 h) after P withdrawal were highly variable, and many nonspecific, shock-induced genes were up-regulated during this period. However, two common putative cis-regulatory elements (a PHO-like element and a TATA box-like element) were present significantly more often in the promoters of genes whose expression increased 4 h after the withdrawal of P compared with their general occurrence in the promoters of all genes represented on the microarray. Surprisingly, the expression of only four genes differed between shoots of P-starved and -replete plants 28 h after P was withdrawn. This lull in differential gene expression preceded the differential expression of a new group of 61 genes 100 h after withdrawing P. A literature survey indicated that the expression of many of these "late" genes responded specifically to P starvation. Shoots had reduced P after 100 h, but growth was unaffected. The expression of SQD1, a gene involved in the synthesis of sulfolipids, responded specifically to P starvation and was increased 100 h after withdrawing P. Leaves of Arabidopsis bearing a SQD1::GUS construct showed increased GUS activity after P withdrawal, which was detectable before P starvation limited growth. Hence, smart plants can monitor plant P status. Transferring this technology to crops would allow precision management of P fertilization, thereby maintaining yields while reducing costs, conserving natural resources, and preventing pollution.     

Current Situation and Associated Factors of Withdrawing or Withholding Life Support to Patients in an Intensive Care Unit of Cancer Center in China

Objectives

To investigate the current situation and analyze the associated factors of withdrawing or withholding life support in the intensive care unit (ICU) of our cancer center.

Methods

Three hundred and twenty-two cancer patients in critical status were admitted to our ICU in 2010 and 2011. They were included in the study and were classified into two groups: withdrawing or withholding life support (WWLS), and full life support (FLS). Demographic information and clinical data were collected and compared between the two groups. Factors associated with withdrawing or withholding life support were analyzed with univariate and multivariate logistic regression analysis.

Results

Eighty-two of the 322 cases (25.5% of all) made the decisions to withdraw or withhold life support. Emergency or critical condition at hospital admission, higher scores of Acute Physiology and Chronic Health Evaluation II (APACHE II) in 12 hours after ICU admission, financial difficulties and humanistic care requirements are important factors associated with withdrawing or withholding life support.

Conclusions

Withdrawing or withholding life support is not uncommon in critically ill cancer patients in China. Characteristics and associated factors of the decision-making are related to the current medical system, medical resources and traditional culture of the country.     

Assessment of trace elements in critically ill patients with systemic inflammatory response syndrome: A systematic review

BackgroundZinc (Zn), copper (Cu), and selenium (Se) are involved in immune and antioxidant defense. Their role in systemic inflammatory response syndrome (SIRS) treatment and outcomes remains unclear. This systematic review aimed to describe trace element concentrations in different types of biological samples and their relationship with morbidity and mortality in patients with SIRS. Methods: Literature was systematically reviewed according to the preferred reporting items for systematic reviews and meta-analyses (PRISMA). The search results were screened and evaluated for eligibility, and data were extracted and summarized in tables and figures. Results: Most of the 38 included studies evaluated Se (75%), followed by Zn (42%) and Cu (22%). Plasma was the main biological sample evaluated (58%). Thirteen studies found lower plasma/serum concentrations of Zn, Se, and Cu in SIRS patients than in controls upon admission, 11 studies on adults (intensive care unit-ICU) and two in pediatric ICU (PICU). Three ICU studies found no difference in erythrocyte trace element concentrations in patients with SIRS. In all studies, the two main outcomes investigated were organ failure and mortality. In seven ICU studies, patients with lower plasma or serum Zn/Se levels had higher mortality rates. A study conducted in the PICU reported an association between increased Se variation and lower 28-day mortality. In an ICU study, lower erythrocyte selenium levels were associated with higher ICU/hospital mortality, after adjustment. Five ICU studies associated lower plasma/serum Zn/Se levels with higher organ failure scores and one PICU study showed an association between higher erythrocyte Se levels and lower organ dysfunction scores. Conclusion: There was no difference in erythrocyte Se levels in patients with SIRS. Serum/Plasma Zn and serum/plasma/erythrocyte Se are associated with organ dysfunction, mortality, and inflammation. Trace element deficiencies should be diagnosed by erythrocyte, or complementary measurements in the presence of inflammation.     

From the deep sea to the stars: human life support through minimal communities

Support of human life during long-distance exploratory space travel or in the creation of human habitats in extreme environments can be accomplished using the action of microbial consortia inhabiting interconnected bioreactors, designed for the purpose of reconversion of solid, liquid and gaseous wastes produced by the human crew or by one of the compartments of the bioregenerative loop, into nutritional biomass, oxygen and potable water. The microorganisms responsible for bioregenerative life support are part of Earth's own geomicrobial reconversion cycle. Depending on the resources and conditions available, minimal life support systems can be assembled using appropriately selected microorganisms that possess metabolic routes for each specific purpose in the transformation cycle. Under control of an engineered system, a reliable life-support system can hence be provided for.     

Economic modelling and indicators in life cycle sustainability assessment

Purpose

Sustainability assessment in life cycle assessment (LCA) addresses societal aspects of technologies or products to evaluate whether a technology/product helps to address important challenges faced by society or whether it causes problems to society or at least selected social groups. In this paper, we analyse how this has been, and can be addressed in the context of economic assessments. We discuss the need for systemic measures applicable in the macro-economic setting.

Methods

The modelling framework of life cycle costing (LCC) is analysed as a key component of the life cycle sustainability assessment (LCSA) framework. Supply chain analysis is applied to LCC in order to understand the relationships between societal concerns of value adding and the basic cost associated with a functional unit. Methods to link LCC as a foreground economic inventory to a background economy wide inventory such as an input–output table are shown. Other modelling frameworks designed to capture consequential effects in LCSA are discussed.

Results

LCC is a useful indicator in economic assessments, but it fails to capture the full dimension of economic sustainability. It has potential contradictions in system boundary to an environmental LCA, and includes normative judgements at the equivalent of the inventory level. Further, it has an inherent contradiction between user goals (minimisation of cost) and social goals (maximisation of value adding), and has no clear application in a consequential setting. LCC is focussed on the indicator of life cycle cost, to the exclusion of many relevant indicators that can be utilised in LCSA. As such, we propose the coverage of indicators in economic assessment to include the value adding to the economy by type of input, import dependency, indicators associated with the role of capital and labour, the innovation potential, linkages and the structural impact on economic sectors.

Conclusions

If the economic dimension of LCSA is to be equivalently addressed as the other pillars, formalisation of equivalent frameworks must be undertaken. Much can be advanced from other fields that could see LCSA to take a more central role in policy formation.     

Competing risk analysis for life table data with known observation times

"Several models have been proposed for the analysis of cohort mortality in the presence of competing risks.... This paper describes a maximum likelihood approach to the analysis of follow up data in life table format for the case of two competing risks--a specific cause and its competing complement. The model developed uses a robust survivorship assumption--the piecewise exponential--and takes into account information on time to death and time to withdrawal." (summary in GER)     

Evolution of emergency cardiac care in Canada.

Acute myocardial infarction is the most common cause of death in Canada. Most deaths occur within the first 2 hours of the onset of symptoms, before the person seeks or is able to obtain medical aid, and are due to arrhythmias rather than massive myocardial damage. Effective electrical and drug treatment of arrhythmias has reduced the hospital mortality but not the community mortality. If mortality from acute myocardial infarction and other causes of sudden unexpected death is to be reduced substantially a major reorganization of emergency medical services is needed so that the benefits of the modern coronary care unit can be provided to the patient as rapidly as possible. Public education in basic life support procedures to sustain life until advanced life support aid arrives is the first step towards the development of a more effective system of emergency cardiac care.     

Withdrawal of inhaled corticosteroids in individuals with COPD - a systematic review and comment on trial methodology

Inhaled corticosteroids (ICS) reduce COPD exacerbation frequency and slow decline in health related quality of life but have little effect on lung function, do not reduce mortality, and increase the risk of pneumonia. We systematically reviewed trials in which ICS have been withdrawn from patients with COPD, with the aim of determining the effect of withdrawal, understanding the differing results between trials, and making recommendations for improving methodology in future trials where medication is withdrawn. Trials were identified by two independent reviewers using MEDLINE, EMBASE and CINAHL, citations of identified studies were checked, and experts contacted to identify further studies. Data extraction was completed independently by two reviewers. The methodological quality of each trial was determined by assessing possible sources of systematic bias as recommended by the Cochrane collaboration. We included four trials; the quality of three was adequate. In all trials, outcomes were generally worse for patients who had had ICS withdrawn, but differences between outcomes for these patients and patients who continued with medication were mostly small and not statistically significant. Due to data paucity we performed only one meta-analysis; this indicated that patients who had had medication withdrawn were 1.11 (95% CI 0.84 to 1.46) times more likely to have an exacerbation in the following year, but the definition of exacerbations was not consistent between the three trials, and the impact of withdrawal was smaller in recent trials which were also trials conducted under conditions that reflected routine practice. There is no evidence from this review that withdrawing ICS in routine practice results in important deterioration in patient outcomes. Furthermore, the extent of increase in exacerbations depends on the way exacerbations are defined and managed and may depend on the use of other medication. In trials where medication is withdrawn, investigators should report other medication use, definitions of exacerbations and management of patients clearly. Intention to treat analyses should be used and interpreted appropriately.     

Impact of major life events on breast-cancer-specific mortality: A case fatality study on 8000 breast cancer patients

BackgroundIt has been suggested that long-term activation of the body’s stress–response system and subsequent overexposure to stress hormones may be associated with increased morbidity. However, evidence on the impact of major life events on mortality from breast cancer (BC) remains inconclusive. The main aim of this study is to investigate whether major negatively or positively experienced life events before or after diagnosis have an effect on BC-specific mortality in women who have survived with BC for at least 2 years.MethodsWe conducted a case fatality study with data on life events from a self-administered survey and data on BC from the Finnish Cancer Registry. Cox models were fitted to estimate BC mortality hazard ratios (MRs) between those who have undergone major life events and those who haven’t.ResultsNone of the pre-diagnostic negative life events had any effect on BC-specific mortality. Regarding post-diagnostic events, the effect was greatest in women with moderate scores of events. As for event-specific scores, increased BC mortality was observed with spouse unemployment, relationship problems, and death of a close friend. By contrast, falling in love and positive developments in hobbies were shown to be associated with lower BC mortality (MRs 0.67, 95%CI: 0.49–0.92 and 0.74, 95%CI: 0.57–0.96, respectively). In an analysis restricted to recently diagnosed cases (2007), also death of a child and of a mother was associated with increased BC mortality.ConclusionsSome major life events regarding close personal relationships may play a role in BC-specific mortality, with certain negative life events increasing BC mortality and positive events decreasing it. The observed favorable associations between positive developments in romantic relationships and hobbies and BC mortality are likely to reflect the importance of social interaction and support.     

Advanced technologies in plastic surgery: how new innovations can improve our training and practice

Over the last two decades, virtual reality, haptics, simulators, robotics, and other "advanced technologies" have emerged as important innovations in medical learning and practice. Reports on simulator applications in medicine now appear regularly in the medical, computer science, engineering, and popular literature. The goal of this article is to review the emerging intersection between advanced technologies and surgery and how new technology is being utilized in several surgical fields, particularly plastic surgery. The authors also discuss how plastic and reconstructive surgeons can benefit by working to further the development of multimedia and simulated environment technologies in surgical practice and training.     

Transfusion Patterns in All Patients Admitted to the Intensive Care Unit and in Those Who Die in Hospital: A Descriptive Analysis

While it is known that the use of health care resources increases at the end of life in patients admitted to the Intensive Care Unit (ICU), the allocation of blood products at the end of life has not been described. The objective of this study was to describe overall transfusion patterns in the ICU, and specifically in patients who die in hospital. We conducted a retrospective cohort study of adult patients admitted to the ICU of a university-affiliated hospital, who were discharged or died between November 1, 2006 and June 30, 2012. During the study period, 10,642 patients were admitted at least once to the ICU. Of these patients, 4079 (38.3%) received red blood cells (RBCs), plasma or platelets in the ICU. The ICU mortality rate was 28.1% and in-hospital mortality rate was 32.3%. Among 39,591 blood product units transfused over the course of the study in the ICU (18,144 RBC units, 16,920 plasma units and 4527 platelet units), 46.2% were administered to patients who later died within the same hospitalization (41.2% of RBCs, 50.4% of plasma and 50.8% of platelets). Of all blood product units (RBCs, plasma and platelets) administered in the ICU over the study period, 11% were given within the last 24 hours before death. A large proportion of blood products used in the ICU are administered to patients who ultimately succumb to their illness in hospital, and many of these blood units are given in close proximity to death.