Noninvasive ventilation use in French out-of-hospital settings: a preliminary national survey.

OBJECTIVE: The objective of our study was to describe noninvasive ventilation (NIV) practices (pressure support ventilation and continuous positive airway pressure) in French out-of-hospital mobile intensive care units (SMUR) and their compliance with national consensus guidelines. METHOD: Online inquiry into practices of NIV among managers of French SMUR. Analyzed data include types of NIV devices and use of NIV. RESULTS: Upon 218 SMUR referenced within the SAMU de France database, 118 questionnaires (54%) were processed. Noninvasive ventilation equipment: 91% of the SMUR with at least one type of NIV device (continuous positive airway pressure only=82%; pressure support ventilation only=59%; both=50%) but frequently not with recommended devices. Use of NIV: for acute cardiogenic pulmonary edema, practices were compliant with recommendations in 80% of cases, although there was still room for improvement. For other pathologies, practices were very heterogeneous, not always properly assessed, and frequently not compliant with recommendations. CONCLUSION: To conclude, NIV use in the out-of-hospital setting in France seems to meet current recommendations for acute cardiogenic pulmonary edema but not for other pathologies. This could be improved by the use of written procedures, conduction of further studies, and promotion of compliance through education.

Identification of potential organ donors of advanced age in EDs.

OBJECTIVE: In France and in Belgium, as in many countries, there is a shortage of organs for transplantation, which has led to strategies to recruit older potential donors who may die of stroke. METHODS: We conducted a post hoc analysis to identify potential organ donors with cardiac function among a population of dying patients in emergency departments. This population had been selected for a separate multicenter prospective observational study. We identified patients who died of a neurologic cause but had no clinical findings affecting their donor status. RESULTS: Of 2420 patients in the study, 407 died of a neurologic cause; and 233 of these were excluded because of clinical factors that made them ineligible as organ donors. The remaining 174 patients (7.2% of dying patients) could be considered potential organ donors. Their mean age was 75.2 ± 11 years. Sixty-eight (39%) were intubated, and 60 of these (34.5%) were mechanically ventilated. In addition, 94 patients (54%) died within 12 hours (median, 9.3 hours) after admission; and 13 (7%) died while receiving a maximum level of care. No diagnostic procedures were performed to assess brain death. CONCLUSION: A significant number of patients who die in emergency departments could be organ donors, including approximately 7% between 60 and 85 years of age with life-threatening neurologic diseases. However, this percentage may be reduced by family opposition. Emergency physicians should collaborate with intensive care units and local organ donation teams to optimize end-of-life care and maximize the number of potential donors.

Death in emergency departments: a multicenter cross-sectional survey with analysis of withholding and withdrawing life support.

PURPOSE: To describe the characteristics of patients who die in emergency departments and the decisions to withhold or withdraw life support. METHODS: We undertook a 4-month prospective survey in 174 emergency departments in France and Belgium to describe patients who died and the decisions to limit life-support therapies. RESULTS: Of 2,512 patients enrolled, 92 (3.7%) were excluded prior to analysis because of missing data; 1,196 were men and 1,224 were women (mean age 77.3 +/- 15 years). Of patients, 1,970 (81.4%) had chronic underlying diseases, and 1,114 (46%) had a previous functional limitation. Principal acute presenting disorders were cardiovascular, neurological, and respiratory. Life-support therapy was initiated in 1,781 patients (73.6%). Palliative care was undertaken for 1,373 patients (56.7%). A decision to withhold or withdraw life-sustaining treatments was taken for 1,907 patients (78.8%) and mostly concerned patients over 80 years old, with underlying metastatic cancer or previous functional limitation. Decisions were discussed with family or relatives in 58.4% of cases. The decision was made by a single ED physician in 379 cases (19.9%), and by at least two ED physicians in 1,528 cases (80.1%). CONCLUSIONS: Death occurring in emergency departments mainly concerned elderly patients with multiple chronic diseases and was frequently preceded by a decision to withdraw and/or withhold life-support therapies. Training of future ED physicians must be aimed at improving the level of care of dying patients, with particular emphasis on collegial decision-taking and institution of palliative care.