Limitación de tratamiento de soporte vital en una Unidad de Cuidado Intensivo pediátrica chilena: 2004-2014 / Limitation of Vital Support in a Chilean Pediatric Intensive Care Unit: 2004-2014

Resumen Objetivo: Describir las frecuencias y características del proceso de Limitación de Tratamiento de So porte Vital (LTSV) en pacientes de la Unidad de Cuidados Intensivos Pediátricos (UCI) entre 2004 2014. Pacientes y Método: Estudio retrospectivo, observacional descriptivo a partir de dos registros de la UCI del Hospital Roberto del Río: 1) ficha clínica individual de seguimiento y 2) ficha de registro de indicadores de calidad incluida LTSV, ambos actualizados diariamente al iniciar la visita clínica. Desde estos registros se analizaron los casos con dilemas bioéticos en los que se propuso LTSV du rante su hospitalización en UCI ("LTSV intra-UCI"). Se menciona la población rechazada de ingresar a UCI ("LTSV pre-UCI") y los fallecidos con LTSV en cama básica. Resultados: De 7.821 ingresos a UCI en el 1,51% (118 pacientes) se establece una LTSV: ONI (Orden de No Innovación) en 78,8% de los casos, retiro de medidas terapéuticas en 14,4% y suspensión de ventilación mecánica en 6,8%. En 23,7% el diagnóstico de base fue neurológico u oncológico, para cada uno. La condición fisiopatológica predominante para una LTSV fue neurológica (39%). El tiempo de estadía en UCI triplica el promedio de estada de los egresos totales de UCI, pero es de amplia variabilidad. Conclusiones: Es factible realizar una LTSV en UCI cuando el equipo incorpora esta perspectiva al trabajo diario junto a la familia. Hay una amplia variabilidad individual en las características del proceso de LTSV, propio del ámbito de la ética clínica.

Abstract Objective: Describe the frequency and characteristics of PICU patients who undergo a process of withholding or withdrawing life-sustaining treatment (LTSV), between 2004 y 2014. Patients and Method: A retrospective, observational descriptive study, using two documents for quality assessment in the PICU of Hospital Roberto del Río: 1) daily individual patient tracking log and 2) daily record of quality indicators, including LTSV, both updated daily at the morning visit. All PICU patients with an ethical dilemma during their PICU stay in which a LTSV was proposed were included. We men tion patients rejected for admission in the ICU and those who died in basic units of the hospital with LTSV. Results: In 118 patients of 7821 PICU admissions (1,5%) we determined a LTSV: ONR (Non Resuscitation Order) for all of them, ONI (Non Innovation Order) in 78,8%, withdrawal of some therapeutics in 14,4% and withdrawal of active mechanical ventilation in 6,8%. The basic diagnosis was 23,7% for each neurologic and oncologic diseases. The predominant pathophysiologic condition leading to a LTSV was severe chronic neurologic damage (39%). The length of stay was threefold the mean PICU stay, with a large variability due to expectable individual factors when ethic decisions are involved. Conclusion: LTSV is feasible when the team is involved and this perspective is part of daily clinical analysis. The wide individual variability in the LTSV process is expectable in ethical decisions.

[Limitation of Vital Support in a Chilean Pediatric Intensive Care Unit: 2004-2014]. / Limitación de tratamiento de soporte vital en una Unidad de Cuidado Intensivo pediátrica chilena: 2004-2014.

OBJECTIVE: Describe the frequency and characteristics of PICU patients who undergo a process of withholding or withdrawing life-sustaining treatment (LTSV), between 2004 y 2014. PATIENTS AND METHOD: A retrospective, observational descriptive study, using two documents for quality assessment in the PICU of Hospital Roberto del Río: 1) daily individual patient tracking log and 2) daily record of quality indicators, including LTSV, both updated daily at the morning visit. All PICU patients with an ethical dilemma during their PICU stay in which a LTSV was proposed were included. We men tion patients rejected for admission in the ICU and those who died in basic units of the hospital with LTSV. RESULTS: In 118 patients of 7821 PICU admissions (1,5%) we determined a LTSV: ONR (Non Resuscitation Order) for all of them, ONI (Non Innovation Order) in 78,8%, withdrawal of some therapeutics in 14,4% and withdrawal of active mechanical ventilation in 6,8%. The basic diagnosis was 23,7% for each neurologic and oncologic diseases. The predominant pathophysiologic condition leading to a LTSV was severe chronic neurologic damage (39%). The length of stay was threefold the mean PICU stay, with a large variability due to expectable individual factors when ethic decisions are involved. CONCLUSION: LTSV is feasible when the team is involved and this perspective is part of daily clinical analysis. The wide individual variability in the LTSV process is expectable in ethical decisions.