The New England Journal of Medicine is conducting a poll on an ICU case. Read the case below and decide how decisions should be made about this patient’s further treatment. Participate in the poll and, if you like, submit a comment supporting your choice. The editors’ recommendations will appear on the NEJM site along with a link to the related review article, on June 26.
Presentation of Case
A 77-year-old man whose medical history includes treated hypertension and hypercholesterolemia, previous heavy alcohol intake, and mild cognitive impairment required 15 days of treatment in the intensive care unit (ICU) of a university hospital for septic shock due to fecal peritonitis from a perforated sigmoid colon. After surgery, he was placed on a mechanical ventilator.
Complications during his ICU stay included mild disseminated intravascular coagulation and acute hepatic necrosis associated with acetaminophen treatment. After being transferred to the surgical floor, he had an unwitnessed fall from his bed, and cranial computed tomography showed an acute subdural hematoma with underlying hemorrhagic contusion on the left side and 5-mm displacement of the midline intracranial structures.
(In the previous installment of this case, there were 2898 votes on how to treat the patient’s traumatic brain injury. More than two thirds of the respondents [67%] favored evacuation of the acute subdural hematoma, placement of an external ventricular drain, and admission to the ICU for active management of increased intracranial pressure. Another 26% favored evacuation of the acute subdural hematoma and admission to the ICU without monitoring of intracranial pressure, whereas 6% opted for conservative management with the rationale that there was no prospect for functional recovery.)
He was taken to the operating room and underwent a craniotomy for evacuation of the subdural hematoma. Twelve days after this procedure, during which he received no sedative medications, he remains in a coma with a best motor response of abnormal flexion on the left side. He is still receiving mechanical ventilation. The consensus opinion of treating clinicians is that he will most likely not make a functional recovery.