How long in intensive care after a stroke

A study was made of 62 ICU patients suffering from severe ischemic or haemorrhagic CVA entering the ICU via the emergency or neurology departments, or other hospital departments over a retrospective period of 30 months July to January and 12 months prospectively January to January Exclusion criteria included patients who had suffered from sub-arachnoidal haemorrhage, extra-dural haematoma or transient ischemic attack.

Patient survival was determined using Kaplan-Meier survival tables. The patients' state of dependence and functional abilities were measured using stroke impact scale SIS [ 20 , 21 ], which provides a measurement of a patient's capacity to perform daily activities. Additionally, their general health status was assessed using a Karnofsky Score range 0 to [ 22 , 23 ] before ICU admission, at hospital discharge, and at 3 months and 1 year post-CVA.

Continuous variables were expressed as means with their standard deviation SD , whereas categorical variables were expressed as actual numbers and percentages. For quantitative variables, a student t -test was used to compare the means of two categories. For more than two categories, an analysis of variance was used, and if there were statistically significant differences a post-hoc test was performed. Categorical variables were analyzed using a Chi-square test. A repeated-measures ANOVA was made to study the evolution of quantitative variables over time, and a Spearman correlation was used to study the relationship between neurological and general health severity scores.

Determination of independent variables predicting a CVA patient's physical dependency at discharge and after one year was made using a univariate analysis, supplemented by a multivariate linear regression. Survival analysis tables were used to assess CVA patient survival. Univariate qualitative variables were compared using the log rank method. A multivariate analysis of survival predictive factors was made using the Cox proportional hazards technique. To adjust for testing multiple hypotheses we performed the Holm stepdown Sidak procedure for multiple comparisons P' sds.

Of the 62 patients studied, 47 The male: female ratio was with a mean SD age of Thirty three patients Half the CVA cases were in the carotid artery territory, The majority of patients were completely independent with an average Karnofsky score higher than 90 for both ischemic and haemorrhagic CVA.

A univariate comparison between survivors and non-survivors with respect of all risk factors studied was made and is presented in Table 1. Continuous normal data are represented as mean SD , continuous non-normal data and ordinal data are represented as median 1st—3rd quartile and categorical data are represented as frequencies. Additionally, it was found that; 10 After discharge from hospital there was a continuous but less marked improvement in the GCS.

The SIS was used to provide an indication of a patient's state of dependency Figure 3. The Karnofsky score, which was used to give an indication of the patient's functional status, showed a similar evolution to the SIS for both types of CVA.

Univariate analysis indicated that the patient's functional state SIS at discharge from hospital was influenced by age, GCS at hospital admission, type of CVA and duration of hospital stay, whereas other variables had little influence. Multivariate analysis incorporating linear regression was used to determine the definitive significant factors Table 3.

Complementary factors in the ischemic group were: patient age OR: Complementary factors in the haemorrhagic group were: arterial hypertension OR: Among the 62 patients studied, 16 For the study period a Kaplan-Meier plot Figure 4 showed a steady decline in patient numbers up to Day with no further decline up to day The significant factors determined by univariate analysis influencing survival were: patient age, history of smoking and cardiac insufficiency, delay between onset of symptoms and ICU admission, APACHE II and GCS at hospital admission, hospital length of stay, thrombolysis, and the requirement for sedation, anti-epileptic treatment, osmotic diuresis, naso-gastric intubation, mechanical ventilation and surgery.

Univariate analysis of ventilation confirmed a bad prognosis with a risk ratio RR of 2. Multivariate analysis using a Cox regression provided the three final independent variables shown below Table 4. Using a multivariate analysis we also examined the effect of each day of mechanical ventilation on worsening the CVA patients' prognosis Table 4. Although the development of new stroke units and treatment modalities have reduced the disabilities and mortalities caused by acute severe strokes, the real clinical benefits for the most severely affected group of patients remain highly speculative.

This study analyzed the benefits and implications of the therapeutic resources used in treating critical stroke patients ischemic and haemorrhagic in respect to their survival and functional abilities. Disability was measured by the ordinal variable SIS, but was better predicted by linear regression.

Prognosis was studied by taking into consideration both the time factor and Kaplan-Meier survival tables. The decision to admit a patient into the ICU was determined primarily by their level of consciousness, and for the urgency to use intensive therapeutic procedures, such as mechanical ventilation, sedation, anti-epileptics, diuretics, osmotic or steroid treatment and surgical interventions.

Pre-stroke the patients were completely independent with a Karnofsky score higher than 90 for both types of CVA. After examining the GCS on admission, we found an average score of less than 10 for both ischemic and haemorrhagic CVAs, which had probably influenced their ICU admission [ 24 ]. Once admitted, patients underwent intensive therapeutic procedures such as; thrombolysis, unblocking respiratory airways, mechanical ventilation, haemodynamic monitoring and treatment for intracranial hypertension.

However, most of these studies take place before the year while the intensive care management of acute stroke patients has rapidly evolved [ 20 ], and none of the studies conducted after report long-term survival [ 8 , 9 , 10 ]. Furthermore, most of these studies all have limitations to some extent, including single-center, retrospective designs with a small number of patients.

Thus, we aimed to study the association of intensive care unit ICU admission factors, including the reason for intubation, with survival 1 year after ICU admission in acute stroke patients requiring mechanical ventilation.

We included adult patients with acute stroke, admitted to the intensive care unit ICU and requiring invasive mechanical ventilation within 24 h of ICU admission. ICU stays were considered as related to acute stroke in cases of 1 direct ICU admission following stroke onset, or 2 ICU admission during the initial acute care hospital stay following stroke onset. We excluded patients without hospitalization reports, and if the stroke was related to traumatic brain injury.

Functional status at ICU discharge was graded retrospectively using the modified Rankin Scale mRS [ 26 ], using a simplified questionnaire based on medical charts [ 27 ]. Data were prospectively collected at admission demographics, chronic disease, admission features, baseline severity indexes, admission diagnosis, and admission type , and daily throughout the ICU stay clinical and biological parameters, assessment of organ functions, requirement for MV, length of stay LOS , WLST decision, and vital status at ICU and hospital discharge , through an anonymized electronic case report form using the Vigirea, Rhea, and e-Rhea softwares OutcomeRea, Aulnay-sous-Bois, France.

Long-term survival after hospital discharge was collected by each local investigator. For each stay, we collected the following retrospective data in the medical charts: 1 stroke history, including date of stroke, location, acute-phase stroke therapy i. Quantitative variables are presented as median, 1st and 3rd quartiles, and compared between groups with the Wilcoxon test.

Qualitative variables are presented as frequency and corresponding percentage and compared with the Chi-square test or Fisher exact test as appropriate. The primary outcome was long-term survival, assessed by survival 1-year after ICU admission. We considered that determinants of 1-year survival were not affected by competing risks, and we identified variables associated with 1-year survival using a Cox proportional hazard model stratified on inclusion center, with a backward selection procedure threshold of 0.

We also entered in the model clinically pertinent factors associated with stroke survival in the literature. All statistical analyses were carried out with SAS 9. A p value of 0. Among ICU admissions from 30 French ICUs over the study period, we identified stays corresponding to unique patients from 14 ICUs, involving acute stroke and where mechanical ventilation was initiated within 24 h of admission Additional file 1.

The characteristics of each participating center are detailed in Additional file 2. The baseline characteristics of patients are presented in Table 1. Patients characteristics and outcomes according to stroke subtype are presented in Table 2. The duration of invasive mechanical ventilation was 4 [2, 9] days. ICU and hospital lengths of stay were 5 [2, 11] and 9 [3, 27] days, respectively.

Univariate analysis of variables associated with 1-year survival is presented in Table 1. Similarly, the presence of a stroke unit on site, and the period of inclusion were not associated with 1-year survival. Multivariate analysis of variables associated with 1-year survival is presented in Table 3. In contrast, implementation of an acute-phase stroke therapy was the only variable associated with improved 1-year outcome. Survival rates according to stroke type and reason for endotracheal intubation are presented in Fig.

Age and sex were considered clinically important factors and were forced into the model. Characteristics of patients according to the period of inclusion are presented in the Additional file 4. One-year survival rates, GCS and stroke type repartition according to the period of inclusion are presented in the Additional file 5.

Over the 3 study periods, the duration of mechanical ventilation decreased significantly, as well as ICU length of stay and hospital length of stay. After adjustment for stroke subtype, neurological presentation and the extent of non-neurological organ failure, the reason for intubation remained independently associated with survival. By contrast, receiving an acute-phase therapy was associated with improved survival. Although 1-year survival did not improve over the study period, stroke patients included in the most recent period had more comorbidities and presented higher ICU admission SOFA scores.

However, these studies have included patients admitted before the year and do not embrace the improvement in stroke care of the past 2 decades. To the best of our knowledge, there has been no study reporting long-term survival i. In our study, we show that from to , with a stable stroke case mix over time, 1-year survival did not improve. This finding is surprising as the use of acute-phase stroke therapies increased over the study period from 2.

However, patients admitted to the ICU in the third period appeared to have more comorbidities and had more organ failures than in the previous 2, suggesting a modification of ICU admission policy over time.

Thus, we hypothesize that the expected gain in survival brought by acute stroke therapies has been mitigated by increased severity of admitted stroke patients. Despite this increase in patient severity, ICU and hospital length of stay decreased both in the whole population and in survivors.

Those figures are difficult to compare, as the case-mix of stroke subtype and the distribution of reason for intubation may be different. Thus, we can hypothesize that the proportion of patients deemed neurologically too severe to be eligible for acute-phase stroke therapy or out of the window of therapeutic opportunity was higher in our cohort than in the most recently studied cohorts [ 8 , 9 , 10 ]. Among the factors associated with 1-year survival identified in our study, the reason for intubation appears to be a strong predictor.

We found that intubation for a cardiac arrest or an altered mental status is associated with worse 1-year survival compared to intubation for an elective procedure. In particular, it is striking to note that in our cohort, there were no survivors in patients admitted for cardiac arrest following stroke.

By contrast, intubation for a seizure was not associated with impaired outcome. The objective of this study was to determine the mortality rate and the functional outcomes of stroke patients admitted to the intensive care unit ICU and to identify predictors of poor outcome in this population.

The records of all patients admitted to the ICU with the diagnosis of stroke between January and December were reviewed. Patients with subarachnoid haemorrhage were excluded. Out of these, the cookies that are categorized as necessary are stored on your browser as they are essential for the working of basic functionalities of the website.

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