Turkiye Klinikleri Cardiovascular Sciences

.: ORIGINAL RESEARCH
Electrocardiographic Changes in Intensive Care Unit Patients During Their Last Hours of Life: Can We Use These Parameters as Prognostic Indicators?
Yaşamın Son Saatlerinde Yoğun Bakım Hastalarında Görülen Elektrokardiyografik Değişiklikler: Bu Parametreleri Prognostik Göstergeler Olarak Kullanabilir miyiz?
Ashok PAUDELa, Orkhan MAMMADOVb, Erkan EKİCİBAŞIa, Nihan Yaman MAMMADOVc, Ararso Kedir JIMAb
aAcıbadem Altunizade Hospital, Acıbadem Healthcare Group, Clinic of Cardiology, İstanbul, TURKEY
bAcıbadem Altunizade Hospital, Acıbadem Healthcare Group, Clinic of Intensive Care, İstanbul, TURKEY
cVan Training and Research Hospital, Clinic of Anesthesiology, Van, TURKEY
Turkiye Klinikleri J Cardiovasc Sci. 2020;32(2):68-74
doi: 10.5336/cardiosci.2020-74783
Article Language: EN
Full Text
ABSTRACT
 Objective: QRS amplitude attenuation and prolonged QRS duration has been associated with increased mortality in various clinical conditions including critical care patients and general population. Relative bradycardia has been found to be associated with lower mortality in patients with septic shock, but there are no studies in literature evaluating the electrocardiographic (ECG) changes and changes in heart rate (HR) just before death. Our aim of this study is to calculate the gradual changes in these parameters in the last hours of life from II derivation telemetry records. Material and Methods: We included 30 patients who died in intensive care unit irrespective of their diagnosis during admission and follow up. HR, QRS amplitude and QRS duration were analysed from the telemetry recordings obtained from the last 10 hours of their life. Results: QRS duration prolongs and heart rate decreases during the last 10 hours of life and the changes in these parameters were more prominent in the last hours. QRS duration increased at rate of 5.43 ms per hour (p<0.001) and heart rate decreased at rate of 2.68/min each hour (p<0.001). QRS amplitude attenuation were more subtle (decreased by 0.23 mV per hour, p=0.02) compared to QRS duration and heart rate. Conclusion: During last 10 hours of life, there was widening of QRS complex, attenuation of QRS voltage and decrease in heart rate. Automated softwares could present these findings in graphics and can be used as a prognostic indicators to recognize a dying patient. This information could be used in certain acute reversible critical conditions such as fulminant myocarditis, anaphylactic shock, trauma patients as a sign of poor prognosis or on decision making regarding end-of-life in irreversible illness such as terminal cancer patients.

Keywords: Electrocardiography; heart rate; critical illness; terminal care
ÖZET
 Amaç: QRS amplitüdünde azalma ve uzun QRS süresi, yoğun bakım hastaları ve genel popülasyon dahil olmak üzere çeşitli klinik koşullarda artan mortalite ile ilişkilendirilmiştir. Rölatif bradikardi septik şokta olan hastalarda düşük mortalite ile ilgili saptanmıştır fakat ölüm öncesi kalp hızı değişkenliği ile ilgili yapılmış çalışma bulunmuyor. Bu çalışmadaki amacımız yaşamın son saatlerinde bu parametrelerdeki kademeli değişiklikleri II derivasyon telemetri kayıtlarından hesaplamaktır. Gereç ve Yöntemler: Yatış ve gözlem sırasındaki tanılarına bakılmaksızın yoğun bakım ünitesinde ölen 30 hasta çalışmaya alındı. Kalp hızı, QRS amplitüdü ve QRS süresi, yaşamlarının son 10 saatinden elde edilen telemetri kayıtlarından analiz edildi. Bulgular: Yaşamın son 10 saatinde QRS süresi artıyor ve kalp hızı azalıyor; bu değişiklikler son saatlerde daha belirgin hale geliyor. QRS süresi saatte 5,43 ms artıyor (p<0.001) ve kalp hızı saatte 2,68/dk kadar azalıyor (p<0.001). QRS amplitüdünde azalma QRS süresi ve kalp hızı değişikliklerine göre daha az belirgindi (saatte 0,23 mV azalma, p=0.02). Sonuç: Yaşamın son 10 saatinde hemodinamik bozulmanın kardiyak elektrik sistemi üzerindeki etkisi, QRS kompleksinde genişleme, QRS voltajında zayıflama ve kalp hızında azalma olarak kendini gösterir. Bu bulgular bilgisayar yazılımları yardımıyla grafik olarak gösterebilir ve ölen hastayı tanımak için bir belirteç olarak kullanılabilir. Bu bilgiler, fulminan miyokardit, anafilaktik şok, travma hastaları gibi bazı akut geri dönüşümlü kritik durumlarda hayat kurtarıcı bir alarm olarak veya terminal kanser hastaları gibi geri dönüşümsüz hastalıklarda yaşam sonu ile ilgili karar vermede kullanılabilir.

Anahtar Kelimeler: Elektrokardiyografi; kalp hızı; kritik hastalık; terminal dönem bakımı
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