STROKE OUTCOME IN ICU: AN EXPERIENCE FROM CMS-TH, CHITWAN. Hemorrhagic Ischemic
STROKE outcome IN icu: AN EXPERIENCE FROM CMS-TH, CHITWAN Thapa LJ1,Paudel R1, Shilpakar R1, Dewan KR1, Rana PVS1 1College Of Medical Sciences-Teaching Hospital Chitwan, Nepal 1
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BACKGROUND AND AIMS
Stroke is the second most common cause of death and major cause of disability worldwide. Donnan GA, Fisher M, Macleod M, Davis SM. Stroke. Lancet 2008 May 10;371(9624):1612-23. About a quarter of stroke patients are dead within a month, about a third by 6 months, and a half by 1 year. Hankey GJ, Jamrozik K, Broadhurst RJ, et al. Five-year survival after first-ever stroke and related prognostic factors in the Perth Community Stroke Study. Stroke 2000; 31: 2080–86. 3 STROKE OUTCOME IN ICU: AN EXPERIENCE FROM CMS-TH, CHITWAN.
Most substantial advance in stroke: Stroke care units (SCU) Choice for stroke patients’ care in developing countries Intensive care unit (ICU) Donnan GA, Fisher M, Macleod M, Davis SM. Stroke. Lancet 2008 May 10;371(9624):1612-23. This study explores the mortality of stroke patients in ICU setting in tertiary care neurological centre in developing country.
BACKGROUND AND AIMS 4 STROKE OUTCOME IN ICU: AN EXPERIENCE FROM CMS-TH, CHITWAN.
Although the most substantial advance in stroke has been the routine management of patients in stroke care units (SCU), intensive care unit (ICU) has remained the choice for stroke patients’ care in developing countries. This study explores the mortality of stroke patients in ICU setting in tertiary care neurological centre in developing country. ‹#›
METHODS
Hospital based descriptive study Prospective data collection from August 2009 - August 2010 All these patients received standard neurological ICU management. The patients’ details including Clinical features Imaging findings Outcome (death or discharged) were recorded and analyzed 5 STROKE OUTCOME IN ICU: AN EXPERIENCE FROM CMS-TH, CHITWAN.
We prospectively collected data of stroke patients admitted in our ICU from August 2009 till August 2010. The details of the patients, their clinical features and imaging findings and outcome were recorded and analyzed. Author by himself actively took part in care of all the cases, with the help of his senior and professor and experienced ICU team. ‹#›
RESULTS 6 STROKE OUTCOME IN ICU: AN EXPERIENCE FROM CMS-TH, CHITWAN.
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STROKE OUTCOME IN ICU: AN EXPERIENCE FROM CMS-TH, CHITWAN. Hemorrhagic Ischemic
RESULTS
Total admission: 44 patients (11.4%) Age range: 17-93 years M:F:: 29:15 (1.9:1) Hemorrhagic : 23 patients (52.3%) Ischemic : 21 patients (47.7%) Common indications for admission Uncontrolled hypertension Aspiration pneumonia Low GCS 8 STROKE OUTCOME IN ICU: AN EXPERIENCE FROM CMS-TH, CHITWAN.
44 patients (11.4%) were admitted for acute stroke. Age of patients ranged from 17-93 years. 29 were male and 15 were female patients. 23 patients (52.3%) had hemorrhagic stroke and 21(47.7%) patients had ischemic stroke. Uncontrolled hypertension, aspiration pneumonia and Low GCS were common indications for admission in ICU. ‹#›
AGE (YEARS) DISTRIBUTION
9 STROKE OUTCOME IN ICU: AN EXPERIENCE FROM CMS-TH, CHITWAN.
LOCATION BASED OUTCOME OF HEMORRHAGIC STROKE
10 STROKE OUTCOME IN ICU: AN EXPERIENCE FROM CMS-TH, CHITWAN.
LOCATION BASED OUTCOME OF ISCHEMIC STROKE
11 STROKE OUTCOME IN ICU: AN EXPERIENCE FROM CMS-TH, CHITWAN.
RESULTS
TABLE 1: CHARACTERISTICS OF STROKE PATIENTS ADMITTED TO ICU Admitted in ICU (n=44) Died in ICU (n=28) Discharged from ICU (n=16) Age 64.045 ± 15.31 63.14 ± 16.43 65.62 ± 13 Gender [M:F] 29:15 (1.93) 20:8 (2.5) 9:7 (1.28) Previous stroke 5 4 (1+3) 1 DM 2 1 1 Hypertension 14 11 (8+3) 3 GCS 8.43±2.15 8.07±2.22 9.06±1.91 12 STROKE OUTCOME IN ICU: AN EXPERIENCE FROM CMS-TH, CHITWAN.
07 days Mortality
MORTALITY: 13 (29.54%) 07 days mortality for Hemorrhagic stroke: 9 patients (69.23%) 07 days mortality for Ischemic stroke: 4 patients (30.76%) LAMA: 15 (34%) Ischemic stroke: 6 (13.63%) Hemorrhagic stroke: 9 (20.4%) 13 STROKE OUTCOME IN ICU: AN EXPERIENCE FROM CMS-TH, CHITWAN.
15 patients LAMA= 34% LAMA 13 patients (29.54%) of stroke died within 7 days. 07 days mortality for hemorrhagic stroke: 9 patients (69.23%) of hemorrhagic stroke died within 6 days. 4 patients (30.76%) of ischemic stroke died within 7 days. 6 (13.63%) patients of ischemic stroke and 9 (20.4%) patients of hemorrhagic stroke left hospital against medical advice. ‹#›
CONDITION AT DISCHARGE
16 (36.36%) patients were successfully discharged from ICU to the ward. 100% made through to be ultimately discharged alive from hospital. 14 STROKE OUTCOME IN ICU: AN EXPERIENCE FROM CMS-TH, CHITWAN.
Total patients died plus left against medical advice were (12+15) = 28 (63.63%) 16 (36.36%) patients were successfully discharged from ICU to the ward, of which 100% made through to be ultimately discharged alive from hospital. 7 (43.75%) were bed ridden at the time of hospital discharge. ‹#›
MOST TALKED ABOUT THE “p- VALUE”
Male Vs. Female patients (outcome) NOT SIGNIFICANT (p=0.34) Hemorrhagic Vs. Ischemic (outcome) SIGNIFICANT (p=0.05) Basal ganglia bleed Vs. Thalamic bleed (outcome) NOT SIGNIFICANT (p=0.61) 15 STROKE OUTCOME IN ICU: AN EXPERIENCE FROM CMS-TH, CHITWAN.
Comparison of hemorrhagic and ischemic stroke group in relation with their outcome was not found to statistically significant (p=0.059). Similarly, outcome measures in male and female patients in form of discharge or death was also not statistically significant (p=0.34) Basal ganglia bleed when compared to thalamic bleed did not have statistically significant differences in outcome (p=0.61) ‹#›
OBSERVING AROUND THE WORLD!!!
Author Study, Country Journal Observation CMS-TH Warlow CP et al A practical approach to management of stroke patients. In : Stroke: a practical guide to management. Blackwell sciences, London. 1996; 360-384. 20% Mumtaz Ali Marwat et al 2006, Pakistan Gomal Journal of Medical Sciences January-June 2009, Vol. 7, No. 1 27.2% 29.54% Burtin P et al Prognosis of stroke patients undergoing mechanical ventilation. Int Care Med 1994; 20 32-6. (s) 52% 29.54% Bhalla et al Predicting mortality in stroke, India Neurol India 2002; 50:279. 34% 29.54% 16 STROKE OUTCOME IN ICU: AN EXPERIENCE FROM CMS-TH, CHITWAN.
A SINGLE STUDY….LOTS TO LEARN!!
N=74 in 1 year. [44] H'rgic= 40.5% [47.7%] Infarction=59.5% [52.3%] Death: H'rgic=56.6% [39.1%] Infarction=22.7% [19.04%] Overall mortality=34% [29.54%] Bhalla A, Gupta OP, Gupta SB. Predicting mortality in stroke. Neurol India [serial online] 2002 [cited 2011 Mar 8];50:279. Available from: http://www.neurologyindia.com/text.asp?2002/50/3/279/1442 17 STROKE OUTCOME IN ICU: AN EXPERIENCE FROM CMS-TH, CHITWAN. Bhalla A et al Thapa L et al
Seventy four patients were admitted with diagnosis of stroke in one year. 30 patients had intra cerebral hemorrhage (40.5%) and 44 had infarction (59.5%). Seventeen patients out of 30 in the hemorrhagic group (56.6%) and 10 out of 44 (22.7%) in the infarctions group died. The overall mortality observed was 34% in all the patients (27/ 74 patients). The sensitivity and specificity of APACHE III scoring system in predicting mortality was 94.12% and 53.85% respectively, in patients with hemorrhage [table II]. 90% and 73.53% respectively for ischemic stroke when a cut off point of 40 was taken [table III]. It was also observed that the likelihood of mortality increased as the score increased. Bhalla A, Gupta OP, Gupta SB. Predicting mortality in stroke. Neurol India [serial online] 2002 [cited 2011 Mar 8];50:279. Available from: http://www.neurologyindia.com/text.asp?2002/50/3/279/1442 Bhalla A, Gupta OP, Gupta SB Department of Medicine, MGIMS, Sevagram, Wardha (MS), India. ‹#›
JUST TO QUOTE!!!
Lower physician experience in stroke management was associated with higher case fatality. Saposnik et al. Variables Associated With Stroke Fatality. Stroke. 2008;39:2318-2324. 18 STROKE OUTCOME IN ICU: AN EXPERIENCE FROM CMS-TH, CHITWAN.
Seven-day case fatality was 6.9% (249/3631), 30-day case fatality was 12.6% (457/3631), and 1-year case fatality was 23.6% (856/3631) Lower physician experience in stroke management was associated with higher case fatality. Saposnik et al. Variables Associated With Stroke Fatality. Stroke. 2008;39:2318-2324. ‹#›
LIMITATIONS
Inherent limitations of a single center hospital based observational study. 19 STROKE OUTCOME IN ICU: AN EXPERIENCE FROM CMS-TH, CHITWAN.
TO CONCLUDE…….
Stroke mortality in ICU remains high despite of care in tertiary neurological center in resource poor settings. SCU, which would also help dissemination of knowledge of stroke management, is an option for improved outcome in developing countries. 20 STROKE OUTCOME IN ICU: AN EXPERIENCE FROM CMS-TH, CHITWAN. Acknowledgements: Residents: Internal medicine ICU staffs
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