Prognosis for 70-Year-Old Male with Post-Operative GCS 2T on Ventilator for 35 Days
The prognosis for this 70-year-old male with a post-operative GCS of 2T on ventilator support in SIMV mode for 35 days is extremely poor, with high likelihood of mortality or severe disability if survival occurs.
Prognostic Assessment
Key Negative Prognostic Factors
- Age over 65 years: For each year increase beyond 65, mortality risk increases by approximately 6.8% in geriatric trauma patients 1
- Prolonged mechanical ventilation: 35 days on ventilator indicates a prolonged course with increased risk of complications
- Very low GCS score: GCS 2T indicates profound neurological impairment
- The "T" indicates intubation, preventing verbal assessment
- Motor score of 2 indicates extension to painful stimuli (decerebrate posturing)
- Failure to improve: The Eastern Association for the Surgery of Trauma (EAST) guidelines emphasize that failure to improve GCS within 72 hours from treatment initiation is a negative prognostic factor 2
Evidence-Based Mortality Risk
- Studies show that patients with GCS scores ≤5 have significantly higher mortality rates 3
- Advanced age (>65 years) is an independent predictor of death in ventilated stroke patients (P = .03) 3
- The combination of advanced age and low GCS score compounds the poor prognosis
Management Considerations
Ventilation Strategy
- Current evidence shows protective ventilation strategies are commonly used in acute brain injury patients 4
- For this patient on SIMV mode:
Neurological Assessment
- Regular assessment using standardized tools is essential
- The GCS should be used in conjunction with pupillary responses for more accurate prognostication 2
- The FOUR score may provide more complete assessment of brainstem function in intubated patients 2
Palliative Care Consideration
- Given the extremely poor prognosis, early involvement of palliative care team is strongly recommended 2
- Benefits of palliative care consultation include:
- Improved communication with family
- Reduced in-hospital mortality and length of stay
- Avoidance of unnecessary interventions 2
Decision-Making Algorithm
Reassess neurological status:
- If any improvement in GCS motor score occurs → continue current management
- If no improvement after 72 hours → consider goals of care discussion
Evaluate for potentially reversible causes:
- Metabolic derangements
- Medication effects
- Seizures
- Increased intracranial pressure
Family discussion regarding prognosis:
- Present the evidence-based poor prognosis
- Discuss quality of life considerations
- Consider palliative care consultation
Decision point:
- Continue aggressive care if there are signs of neurological improvement
- Consider transition to comfort-focused care if no improvement and consistent with patient's values
Pitfalls to Avoid
Delayed palliative care involvement: Early involvement improves outcomes and family communication 2
Focusing solely on survival without considering quality of life: Functional outcomes are equally important as mortality in prognostication
Overlooking patient's pre-existing wishes: Advanced directives or previously expressed wishes should guide decision-making
Failure to reassess regularly: Neurological status can change, requiring ongoing assessment
Overlooking the impact of frailty: Frailty is a superior predictor of poor outcome compared to age alone 1
In this challenging case, the combination of advanced age, very low GCS score, and prolonged ventilator dependence indicates an extremely poor prognosis. A goals-of-care discussion with family members is urgently needed, with strong consideration for palliative approaches.