Update and recommendations in decision making referred to limitation of advanced life support treatment. / Puesta al día y recomendaciones en la toma de decisiones de limitación de tratamientos de soporte vital.

The Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC) Bioethics Working Group has developed recommendations on the Limitation of Advanced Life Support Treatment (LLST) decisions, with the aim of reducing variability in clinical practice and of improving end of life care in critically ill patients. The conceptual framework of LLST and futility are explained. Recommendations referred to new forms of LLST encompassing also the adequacy of other treatments and diagnostic methods are developed. In addition, planning of the possible clinical courses following the decision of LLST is commented. The importance of advanced care planning in decision-making is emphasized, and intensive care oriented towards organ donation at end of life in the critically ill patient is described. The integration of palliative care in the critical patient treatment is promoted in end of life stages in the Intensive Care Unit.

Cranioplasty with bandaging. New forms of limitation of life support and organ donation.

Most of transplanted organs are obtained from brain death (BD) donors. In neurocritical patients with catastrophic injuries and decompressive craniectomy (DC), which show a dreadful development in spite of this treatment, DC could be a futile tool to avoid natural progress to BD. We propose if cranial compressive bandage (cranioplasty with bandage) could be an ethically correct practice, similar to other life-sustaining treatment limitation (LSTL) common methods. Based on a clinical case, we contacted with the Assistance Ethics Committee and some bioethics professionals asking them two questions: 1) Is ethically correct to perform a cranioplasty with bandage in those patients with LSTL indication? 2) Thinking in organ donation possibility, is this option preferable? Conclusions 1) Cranioplasty with bandage could be considered an ethically acceptable LSTL practice, similar to other procedures. 2) It facilitates organ donation for transplant, which provides value-added because of its own social good. 3) In these cases, it is necessary to know previous patient's will or, in absentia, to obtain family consent after a detailed procedure report.

[Ethics of the cardiopulmonary resuscitation decisions]. / Ética de las decisiones en resucitación cardiopulmonar.

Cardiopulmonary Resuscitation (CPR) must be attempted if indicated, not done if it is not indicated or if the patient does not accept or has previously rejected it and withdrawn it if it is ineffective. If CPR is considered futile, a Do-Not-Resuscitate Order (DNR) will be recorded. This should be made known to all physicians and nurses involved in patient care. It may be appropriate to limit life-sustaining-treatments for patients with severe anoxic encephalopathy, if the possibility of clinical evolution to brain death is ruled out. After CPR it is necessary to inform and support families and then review the process in order to make future improvements. After limitation of vital support, certain type of non-heart-beating-organ donation can be proposed. In order to acquire CPR skills, it is necessary to practice with simulators and, sometimes, with recently deceased, always with the consent of the family. Research on CPR is essential and must be conducted according to ethical rules and legal frameworks.

Masses and pseudomasses of the hand and wrist: MR findings in 134 cases.

OBJECTIVE: To assess the utility of magnetic resonance imaging (MRI) in the investigation of palpable masses in the hand or wrist. DESIGN AND PATIENTS. We retrospectively reviewed the MRI examinations and case records of 134 patients referred because of a palpable mass in the hand or wrist. MRI was performed on a 1.0 T magnet using an extremity coil. Intravenous gadolinium-DTPA was injected when considered appropriate. RESULTS AND CONCLUSIONS: MRI demonstrated the cause of the palpable mass in 126 cases (94.02%). Soft tissue neoplasms were found in 34 cases (25.37%). The majority were benign and included giant cell tumours of tendon sheath, lipomas and hemangiomas and had a characteristic appearance. There were three malignant tumours (myxoid liposarcoma, malignant fibroushistiocytoma and rhabdomyosarcoma). Ganglia were found in 36 cases (26.86%) and non-tumour tendon pathology in 31 cases (23.13%). Less common causes included articular diseases (5.97%) and anatomical variants (4.47%). No focal lesion was present in 8 cases (5.97%). In conclusion, MRI is an accurate diagnostic technique in patients who present with a palpable mass of the hand and wrist.

The effect of rescuer fatigue on the quality of chest compressions.

OBJECTIVE: The aim of this study was to evaluate the influence of rescuer fatigue on the quality of chest compressions and the influence of the rescuer's gender, age, weight, height or professional status on the reduction of quality of chest compressions caused by fatigue. MATERIAL AND METHODS: The study was carried out with the Laerdal Skillmeter Resusci Anne manikin. The participants were doctors and nurses who work in the Intensive Care and Emergency departments, with an age ranging from 25 to 45 years and trained in cardiopulmonary resuscitation (CPR). Statistical analysis of results includes analysis variance and three models of multiple linear regression. RESULTS: Thirty-eight people took part in the experiment; 20 (52.6%) were females; 15 (39.5%) staff physicians, 15 (39.5%) nurses and eight residents. Mean age was 34.1 years (SD = 4.1). We found a significant reduction in correct compression performance over the course of time: in the first minute 79.7%, in the second 24.9%, in the third 18%, in the fourth 17.7% and in the last minute 18.5%. There were no differences related to the rescuer's gender or profession. The median interval until rescuers appreciated the effect of the fatigue on chest compressions quality was 186 s (SD = 84.1); that appreciation was not influenced by gender, age, weight, height or profession. There were no differences in the percentage of correct compressions related to gender (P = 0.07), insufficient sternal depression (P = 0.23) or total number of compressions in the first minute. DISCUSSION: A decrease of compressions quality after the first minute of CPR is produced. This effect does not depend on gender, age, weight, height or rescuer's profession and it is not adequately perceived by the person who performs the chest compressions.

Competence of health professionals to check the carotid pulse.

Our objective was to establish the proportion of Emergency Room and Intensive Care doctors and nurses able to locate the carotid pulse in less than 5 s, and identify the variables that influence this ability. The method followed was locating the carotid pulse in a healthy male adult volunteer with normal blood pressure in two situations (stretcher or floor) and with the neck in either a neutral or in an extended position. We recorded the gender, age, and previous training in cardiopulmonary resuscitation (CPR) of each participant and the time spent in detecting the pulse in each of the four possible positions. A model of logistic regression was constructed to determine if the patient's position had any influence on the proportion of health workers capable of finding the pulse within 5 s. The average age of the 72 subjects studied was 33.4 years (SD = 6.6); 80% of the participants had CPR training. Thirty-one participants (43.1%; CI 95%, 31.4-55.3%) required more than 5 s to detect the pulse, although only three (4.2%; CI 95%, 0.9-11.7%) required more than 10 s. The variable 'no CPR training' was associated with the inability to detect the pulse within 5 s. The detection of the pulse was easier with an extended neck. A significant proportion of nurses and doctors were slow to locate the carotid pulse on a healthy, young volunteer with normal blood pressure. No relation was found between gender or age of the participants. More attention should be given to carotid pulse detection in CPR training.

Magnetic resonance cholangiopancreatography in the evaluation of pancreatic duct pathology.

MR cholangiopancreatography (MRCP) may replace direct pancreatography in the evaluation of the pancreatic duct. The aim of this pictorial review is to demonstrate the usefulness of MRCP in the evaluation of pancreatic duct pathology. The examination technique included coronal, sagittal and axial breath-hold HASTE 2D imaging using a body phase array coil. We present the diagnostic features on MRCP of a variety of benign and malignant disorders of the pancreatic duct, and conclude that MRCP is a suitable method for imaging the pancreatic duct system.