Acute Spontaneous Intracerebral Hemorrhage and Traumatic Brain
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Zhou et al. BMC Neurology (2018) 18:127 https://doi.org/10.1186/s12883-018-1127-z RESEARCH ARTICLE Open Access Acute spontaneous intracerebral hemorrhage and traumatic brain injury are the most common causes of critical illness in the ICU and have high early mortality Ye-Ting Zhou1†, Dao-Ming Tong2*†, Shao-Dan Wang3, Song Ye1, Ben-Wen Xu1 and Chen-Xi Yang1 Abstract Background: Critical care covers multiple disciplines. However, the causes of critical illness in the ICU, particularly the most common causes, remain unclear. We aimed to investigate the incidence and the most common causes of critical illness and the corresponding early mortality rates in ICU patients. Methods: A retrospective cohort study was performed to examine critically ill patients (aged over 15 years) in the general ICU in Shuyang County in northern China (1/2014–12/2015). The incidences and causes of critical illnesses and their corresponding early mortality rates in the ICU were determined by an expert panel. Results: During the 2-year study period, 1,211,138 person-years (PY) and 1645 critically ill patients (mean age, 61.8 years) were documented. The median Glasgow ComaScale(GCS)scorewas6(range,3–15). The mean acute physiology and chronic health evaluation II (APACHE II) score was 21.2 ± 6.8. The median length of the ICU stay was 4 days (range, 1–29 days). The most common causes of critical illness in the ICU were spontaneous intracerebral hemorrhage (SICH) (26%, 17.6/100,000 PY) and traumatic brain injury (TBI) (16.8%, 11.4/100,000 PY). During the first 7 days in the ICU, SICH was the most common cause of death (42.2%, 7.4/10,000 PY), followed by TBI (36.6%, 4.2/100,000 PY). Based on a logistic analysis, older patients had a significantly higher risk of death from TBI (risk ratio [RR], 1.7; 95% CI, 1.034–2.635), heart failure/cardiovascular crisis (RR, 0.2; 95% CI, 0.083–0.484), cerebral infarction (RR, 0.15; 95% CI, 0.050–0.486), or respiratory failure (RR, 0.35; 95% CI, 0.185–0.784) than younger patients. However, the risk of death from SICH in the two groups was similar. Conclusions: The most common causes of critical illness in the ICU were SICH and TBI, and both critical illnesses showed a higher risk of death during the first 7 days in the ICU. Keywords: Critical illness, Causes, Incidence, Mortality, Epidemiology, Intracerebral hemorrhage, Head injury Background common [4–6]. Multiple epidemiological studies on pre- Twenty years ago, patients with organ failure accounted hospital emergency medical services have been con- for most intensive care unit (ICU) cases [1], and a high ducted [7, 8]; however, the causes of critical illnesses in mortality rate was observed in patients who refused ICU the ICU, especially the most common causes, remain care [2, 3]. Today, with improvements in living standards unclear. Moreover, it is important to determine the most and the aging of the general population, management of common illnesses that require management in an ICU critically ill patients using intensive nursing care is more and to understand the early mortality rates associated with these illnesses during the ICU stay. The aim of this study was to investigate the incidences and causes of * Correspondence: [email protected] † critical illnesses and the corresponding early mortality rates Ye-Ting Zhou and Dao-Ming Tong contributed equally to this work. 2Department of Neurology, Affiliated Shuyang Hospital, Xuzhou Medical among patients admitted to the ICU from the general University, Xuzhou, Jiangsu, China population of Shuyang County in northern China. Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Zhou et al. BMC Neurology (2018) 18:127 Page 2 of 7 Methods and required monitoring in the ICU. We used the following Study design and participants exclusion criteria: (1) age < 15 years, (2) an additional visit We retrospectively analyzed data that were collected to the ICU within 2 weeks, and (3) residence in the county from January 2014 to December 2015 for critically ill for < 6 months. We collected the critically ill patient data patients who were admitted to a general ICU (17 beds) from the prospective registration of their primary diagnosis in a tertiary teaching hospital—the unique three-general in the ICU patient out-of-hospital registry. Registration was hospital. The hospital has a referral center (with 10 the responsibility of the physician in charge of the ICU. ambulances) and was responsible for all critical or emer- The data registry annual volumes included sex, age, gency work within Shuyang County in northern China address, the date of admission, the sole primary diagnosis, (38 county townships and a county town). Thus, 24 h a the ICU stay length, the outcome of the main processing, day, almost all critically ill patients were sent directly to and a contact telephone number for the ICU patient. All the ICU. Therefore, this hospital was a strong source of patients with craniocerebral disease were verified using critically ill patients, which ensured sufficient data avai- their electronic medical records (an emergency cranial CT lability. The study sample was compiled from the 2014 scan upon admission) and were assigned an initial GCS and 2015 data registries. During the study period, scoreandanacutephysiologyandchronichealthevalu- 1,211,138 people aged 15 years or older, including ation II (APACHE II) score. 697,615 women and 115,355 people aged 65 years or The time window of the ICU stay for most patients older, lived in the county [9]. The study was approved by was between 3 and 7 days. Early mortality was assessed the Ethical Committee on Clinical Research of the during the first 7 days of the critical illness. The World Shuyang People’s Hospital in China. Because the study Health Organization (WHO) defines a person who is involved care for critical illness, written informed con- over 65 years old as geriatric. Therefore, patients were sent was obtained from the nearest relative or a person divided into a geriatric group and a non-geriatric group who had been designated to provide consent by the to compare the risks of critical illness between age patient. groups. Death events in the ICU and their causes were identified Procedures through medical record notes and from follow-up informa- To date, there are no compulsory diagnostic criteria for tion. Follow-up information was from our physician who critical illness. Moreover, the codes for critical illnesses was conducted inquiries by phone to the patient’s closest per the International Classification of Diseases, 10th Re- living relative on day 7 of discharge from the ICU. Intensive vision (ICD-10), are not well established. The relevant care and neurology experts conducted a retrospective sta- code changes according to the condition of the critically tistical analysis of the data of the study population during ill patient, and these conditions include coma (R40.2), the 2-year period. cardiac arrest (I46.9), heart failure (I50), shock (R57.9), respiratory failure (J96), cardiovascular crisis and other Statistical analysis critical events. We also identified those patients who had All numeric variables are expressed as the mean ± SD or acute spontaneous intracerebral hemorrhage (SICH) by the median (interquartile range [IQR]) and N (%). The over- code I61.9, but in this study, SICH was only limited to those all incidence and causes were analyzed. The incidence with acutely non-traumatic coma. Similarly, traumatic brain rate per year in the population of critically ill patients injury (TBI) indicated a severe TBI (including traumatic was documented. Incidence rates for risk during 1 year subdural and epidural hematoma, or with intracerebral were also calculated by dividing the baseline population hematoma or subarachnoid hemorrhage) with sudden trau- by the number of annual cases. We used a logistic matic coma. Coma refers to a state of unconsciousness from regression analysis to determine the risk ratio (RR) for a which the patient cannot be aroused and is typified by the death event comparing the geriatric patients with the absence of language and motor function with a Glasgow non-geriatric patients. All p-values were 2-sided, and sig- Coma Scale (GCS) score of 3 to 8 (on a scale of 3 to 15, with nificance was set at p < 0.05. Data were analyzed using lower scores indicating a lower level of consciousness). SPSS version 17.0 (SPSS Inc., Chicago, IL, USA). Cardiovascular crisis includes cardiogenic shock, cardiac arrest, sudden chest pain, and hypertensive crisis. Here, our Results retrospective study of ICU patients used the following inclu- Overall analysis sion criteria: (1) the patient (age > 15 years) exhibited an During the 2-year study period, 1791 critically ill cases emergency- onset condition with unstable life signs or were registered in the ICU following hospital discharge. acute organ dysfunction and required transfer by emer- We excluded cases that did not meet the inclusion gency services to the ICU, and (2) the patient was hospita- criteria, including patients aged < 15 years (n = 126), lized due to the onset a life-threatening organ dysfunction patients who had another visitation to the ICU within Zhou et al.