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Timing of Limitations in Life Support in Acute Lung Injury Patients: A Multisite Study*

Turnbull, Alison E. DVM, MPH1,2; Ruhl, A. Parker MD2,3,4; Lau, Bryan M. ScM, MHS, PhD1; Mendez-Tellez, Pedro A. MD2,5; Shanholtz, Carl B. MD6; Needham, Dale M. FCA, MD, PhD2,3,7

doi: 10.1097/CCM.0b013e3182a272db
Clinical Investigations

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.

1Department of Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD.

2Outcomes After Critical Illness and Surgery (OACIS) Group, Johns Hopkins University School of Medicine, Baltimore, MD.

3Division of Pulmonary and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

4Critical Care Medicine Department, National Institutes of Health, Bethesda, MD.

5Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD.

6Division of Pulmonary and Critical Care Medicine, University of Maryland, Baltimore, MD.

7Department of Physical Medicine and Rehabilitation, Johns Hopkins University School of Medicine, Baltimore, MD.

* See also p. 455.

All authors contributed to the conception and design of the study. Drs. Turnbull and Lau analyzed the data. Dr. Turnbull drafted the article. All authors contributed to the interpretation of analyses, critically revised the article for important intellectual content and gave final approval of the manuscript version to be published. Drs. Needham and Turnbull are responsible for the overall content as guarantors.

Dr. Turnbull received grant support from the Johns Hopkins University Summer Scholars Program (scholarship for graduate students in public health). Dr. Turnbull’s institution received grant support from the National Institutes of Health (NIH), National Institute on Aging (T32AG000247—postdoctoral training grant). Dr. Shanholtz and his institution received grant support from the NIH. Dr. Shanholtz received support for article research from the NIH. Dr. Needham and his institution received grant support from the NIH (Acute Lung Injury Specialized Centers of Clinically Oriented Research grant—P050 HL 73994). The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: turnbull@jhmi.edu

© 2014 by the Society of Critical Care Medicine and Lippincott Williams & Wilkins