Is there a role for REBOA? A system assessment.

INTRODUCTION: To analyze our experience to quantify potential need for resuscitative endovascular balloon occlusion of the aorta (REBOA). METHODS: Retrospective review of patients over a three-year period who presented as a trauma with hemorrhagic shock. Patients were divided into two groups: REBOA Candidate vs. Non-candidates. Injuries, outcomes, and interventions were compared. RESULTS: Of 7643 trauma activations, only 37 (0.44%) fit inclusion criteria, of which 16 met criteria for candidacy for potential REBOA placement. The groups did not differ in terms of injury severity, physiology, age, timing of intervention, nor massive transfusion. Survival was linked to TRISS (p = 0.01) and Emergency Room Thoracotomy (p = 0.002). Of Candidates, 8 (50%) had injuries that could have benefited from REBOA, while 7 (44%) had injuries that could be associated with potential harm. DISCUSSION: The volume of patients who would potentially benefit from REBOA appears to be small and does not appear to support system wide adoption in the studied region. LEVEL OF EVIDENCE: IV.

Cost-effectiveness evaluation of the PROPPR trial transfusion protocols.

BACKGROUND: There have been no prior investigations of the cost effectiveness of transfusion strategies for trauma resuscitation. The Pragmatic, Randomized, Optimal Platelet and Plasma Ratios (PROPPR) study was a Phase III multisite, randomized trial in 680 subjects comparing the efficacy of 1:1:1 transfusion ratios of plasma and platelets to red blood cells with the 1:1:2 ratio. We hypothesized that 1:1:1 transfusion results in an acceptable incremental cost-effectiveness ratio, when estimated using patients' age-specific life expectancy and cost of care during the 30-day PROPPR trial period. STUDY DESIGN AND METHODS: International Classification of Diseases, Ninth Revision codes were prospectively collected, and subjects were matched 1:2 to subjects in the Healthcare Utilization Program State Inpatient Data to estimate cost weights. We used a decision tree analysis, combined with standard costs and estimated years of expected survival to determine the cost effectiveness of the two treatments. RESULTS: The 1:1:1 group had higher overall costs for the blood products but were more likely to achieve hemostasis and decreased hemorrhagic death by 24 hours (p = 0.006). For every 100 patients treated in the 1:1:1 group, eight more achieved hemostasis than in the 1:1:2 group. At 30 days, the total hospital cost per 100 patients was $5.6 million in the 1:1:1 group compared with $5.0 million in the 1:1:2 group. For each 100 patients, the 1:1:1 group had 218.5 more years of life expectancy. This was at a cost of $2994 per year gained. CONCLUSION: The 1:1:1 transfusion ratio in severely injured hemorrhaging trauma patients is a very cost-effective strategy for increasing hemostasis and decreasing trauma deaths.

Assessment of body water distribution in patients with sepsis during fluid resuscitation using multi-frequency direct segmental bioelectrical impedance analysis.

BACKGROUND & AIMS: Although initial fluid resuscitation in sepsis is critical for the treatment of tissue hypoperfusion, little evidence supports the distribution of infused fluid in patients with sepsis. This study was designed to assess the body water distribution in patients with sepsis using bioelectrical impedance analysis and correlate the trend in body water distribution during fluid treatment with the prognosis of patients with sepsis. METHODS: A prospective study in a single emergency department was performed, and adult patients suspected of having sepsis were enrolled. Multi-frequency direct segmental bioelectrical impedance analysis (InBody S10, InBody) measuring total body water (TBW), intracellular water (ICW), and extracellular water (ECW) was applied to patients with sepsis at three periods: before, immediately after, and 1 hour after the fluid treatment. Survival data at 28 days after the fluid treatment were obtained. RESULTS: Forty-two patients were enrolled in this study. Overall, the ratios of TBW, ICW, and ECW to body weight increased throughout the fluid treatment except the ratio of ICW to body weight at 1 hour in non-survivors. While the ratio of ECW to TBW (ECW/TBW) and the ratio of ICW to TBW (ICW/TBW) in survivors remained stable over the period, the trend of ECW/TBW increased with corresponding decline of ICW/TBW in non-survivors (p = 0.0085 and p = 0.0034 between times and groups, respectively) such that ECW/TBW and ICW/TBW were significantly different at 1 hour after the fluid loading period (p = 0.0120 and p = 0.0085, respectively). This contrast pattern was equivalent with the trend of ECW/TBW in trunk but not that of the other extremities. CONCLUSIONS: During fluid resuscitation, the trend in ECW/TBW significantly increased with corresponding decrease of ICW/TBW in non-survivors compared with that in survivors, which suggests fluid resuscitation results intracellular dehydration and extracellular edema in non-survivors of patients with sepsis.

Neonatal resuscitation using a supraglottic airway device for improved mortality and morbidity outcomes in a low-income country: study protocol for a randomized trial.

BACKGROUND: Intrapartum-related death is the third leading cause of under-5 mortality. Effective ventilation during neonatal resuscitation has the potential to reduce 40% of these deaths. Face-mask ventilation performed by midwives is globally the most common method of resuscitating neonates. It requires considerable operator skills and continuous training because of its complexity. The i-gel® is a cuffless supraglottic airway which is easy to insert and provides an efficient seal that prevents air leakage; it has the potential to enhance performance in neonatal resuscitation. A pilot study in Uganda demonstrated that midwives could safely resuscitate newborns with the i-gel® after a short training session. The aim of the present trial is to investigate whether the use of a cuffless supraglottic airway device compared with face-mask ventilation during neonatal resuscitation can reduce mortality and morbidity in asphyxiated neonates. METHODS: A randomized phase III open-label superiority controlled clinical trial will be conducted at Mulago Hospital, Kampala, Uganda, in asphyxiated neonates in the delivery units. Prior to the intervention, health staff performing resuscitation will receive training in accordance with the Helping Babies Breathe curriculum with a special module for training on supraglottic airway insertion. A total of 1150 to 1240 babies (depending on cluster size) that need positive pressure ventilation and that have an expected gestational age of more than 34 weeks and an expected birth weight of more than 2000 g will be ventilated by daily unmasked randomization with a supraglottic airway device (i-gel®) (intervention group) or with a face mask (control group). The primary outcome will be a composite outcome of 7-day mortality and admission to neonatal intensive care unit (NICU) with neonatal encephalopathy. DISCUSSION: Although indications for the beneficial effect of a supraglottic airway device in the context of neonatal resuscitation exist, so far no large studies powered to assess mortality and morbidity have been carried out. We hypothesize that effective ventilation will be easier to achieve with a supraglottic airway device than with a face mask, decreasing early neonatal mortality and brain injury from neonatal encephalopathy. The findings of this trial will be important for low and middle-resource settings where the majority of intrapartum-related events occur. TRIAL REGISTRATION: ClinicalTrials.gov. Identifier: NCT03133572 . Registered April 28, 2017.

Incorporating Dynamic Assessment of Fluid Responsiveness Into Goal-Directed Therapy: A Systematic Review and Meta-Analysis.

OBJECTIVE: Dynamic tests of fluid responsiveness have been developed and investigated in clinical trials of goal-directed therapy. The impact of this approach on clinically relevant outcomes is unknown. We performed a systematic review and meta-analysis to evaluate whether fluid therapy guided by dynamic assessment of fluid responsiveness compared with standard care improves clinically relevant outcomes in adults admitted to the ICU. DATA SOURCES: Randomized controlled trials from MEDLINE, EMBASE, CENTRAL, clinicaltrials.gov, and the International Clinical Trials Registry Platform from inception to December 2016, conference proceedings, and reference lists of relevant articles. STUDY SELECTION: Two reviewers independently identified randomized controlled trials comparing dynamic assessment of fluid responsiveness with standard care for acute volume resuscitation in adults admitted to the ICU. DATA EXTRACTION: Two reviewers independently abstracted trial-level data including population characteristics, interventions, clinical outcomes, and source of funding. Our primary outcome was mortality at longest duration of follow-up. Our secondary outcomes were ICU and hospital length of stay, duration of mechanical ventilation, and frequency of renal complications. The internal validity of trials was assessed in duplicate using the Cochrane Collaboration's Risk of Bias tool. DATA SYNTHESIS: We included 13 trials enrolling 1,652 patients. Methods used to assess fluid responsiveness included stroke volume variation (nine trials), pulse pressure variation (one trial), and stroke volume change with passive leg raise/fluid challenge (three trials). In 12 trials reporting mortality, the risk ratio for death associated with dynamic assessment of fluid responsiveness was 0.59 (95% CI, 0.42-0.83; I = 0%; n = 1,586). The absolute risk reduction in mortality associated with dynamic assessment of fluid responsiveness was -2.9% (95% CI, -5.6% to -0.2%). Dynamic assessment of fluid responsiveness was associated with reduced duration of ICU length of stay (weighted mean difference, -1.16 d [95% CI, -1.97 to -0.36]; I = 74%; n = 394, six trials) and mechanical ventilation (weighted mean difference, -2.98 hr [95% CI, -5.08 to -0.89]; I = 34%; n = 334, five trials). Three trials were adjudicated at unclear risk of bias; the remaining trials were at high risk of bias. CONCLUSIONS: In adult patients admitted to intensive care who required acute volume resuscitation, goal-directed therapy guided by assessment of fluid responsiveness appears to be associated with reduced mortality, ICU length of stay, and duration of mechanical ventilation. High-quality clinical trials in both medical and surgical ICU populations are warranted to inform routine care.

The CAPS Study: incidence, management and outcomes of cardiac arrest in pregnancy in the UK: a prospective, descriptive study.

OBJECTIVE: To describe the incidence, risks, management and outcomes of cardiac arrest in pregnancy in the UK population, with specific focus on the use of perimortem caesarean section (PMCS). DESIGN: A prospective, descriptive study using the UK Obstetric Surveillance System (UKOSS). SETTING: All UK hospitals with maternity units. POPULATION: All women who received basic life support in pregnancy in the UK between 1 July 2011 and 30 June 2014 (n = 66). METHODS: Prospective case identification through UKOSS monthly mailing. MAIN OUTCOME MEASURES: Cardiac arrest in pregnancy, PMCS, maternal death. RESULTS: There were 66 cardiac arrests in pregnancy, resulting in an incidence of 2.78 per 100 000 maternities (1:36 000; 95% CI 2.2-3.6). In all, 28 women died (case fatality rate 42%); 16 women arrested solely as a consequence of obstetric anaesthesia, 12 of whom were obese. Basic and advanced life support were rapidly delivered. Those who died were more likely to have collapsed at home. Perimortem caesarean section was performed in 49 women, 11 in the emergency department. The time from collapse to PMCS was significantly shorter in women who survived (median interval 3 versus 12 minutes, P = 0.001). Forty-six of 58 babies were born alive; 32 babies to surviving mothers and 14 to women who died. CONCLUSION: Cardiac arrest is rare in the pregnant UK population, however, nearly a quarter of cases are precipitated by obstetric anaesthesia, suggesting an opportunity to reduce the incidence further. Maternal survival rates of 58% were achieved with timely resuscitation, including PMCS, delay in which was associated with maternal death. Inpatient arrests were associated with higher survival rates than arrests that occurred outside the hospital setting. TWEETABLE ABSTRACT: 25% of cardiac arrest in pregnancy is caused by anaesthesia. Rapid perimortem section improves survival.

Ethnic differences in sudden cardiac arrest resuscitation.

OBJECTIVE: Ethnic differences in sudden cardiac arrest resuscitation have not been fully explored and studies have yielded inconsistent results. We examined the association of ethnicity with factors affecting sudden cardiac arrest outcomes. METHODS: Retrospective cohort study of 3551 white, 440 black and 297 Asian sudden cardiac arrest cases in Seattle and King County, Washington, USA. RESULTS: Compared with whites, blacks and Asians were younger, had lower socioeconomic status and were more likely to have diabetes, hypertension and end-stage renal disease (all p<0.001). Blacks and Asians were less likely to have a witnessed arrest (whites 57.6%, blacks 52.1%, Asians 46.1%, p<0.001) or receive bystander cardiopulmonary resuscitation (whites 50.9%, blacks 41.4%, Asians 47.1%, p=0.001), but had shorter average emergency medical services response time (mean in minutes: whites 5.18, blacks 4.75, Asians 4.85, p<0.001). Compared with whites, blacks were more likely to be found in pulseless electrical activity (blacks 20.9% vs whites 16.6%, p<0.001), and Asians were more likely to be found in asystole (Asians 41.1% vs whites 30.0%, p<0.001). One of the strongest predictors of resuscitation outcomes was initial cardiac rhythm with 25% of ventricular fibrillation, 4% of patients with pulseless electrical activity and 1% of patients with asystole surviving to hospital discharge (adjusted OR of resuscitation in pulseless electrical activity compared with ventricular fibrillation: 0.30, 95% CI 0.24 to 0.34, p<0.001, adjusted OR of resuscitation in asystole relative to ventricular fibrillation 0.21, 95% CI 0.17 to 0.26, p<0.001). Survival to hospital discharge was similar across all three ethnicities. CONCLUSIONS: While there were differences in some prognostic characteristics between blacks, whites and Asians, we did not detect a significant difference in survival following sudden cardiac arrest between the three ethnic groups. There was, however, an ethnic difference in presenting rhythm, with pulseless electrical activity more prevalent in blacks and asystole more prevalent in Asians.

Early Appropriate Care: A Protocol to Standardize Resuscitation Assessment and to Expedite Fracture Care Reduces Hospital Stay and Enhances Revenue.

OBJECTIVES: We hypothesized that a standardized protocol for fracture care would enhance revenue by reducing complications and length of stay. DESIGN: Prospective consecutive series. SETTING: Level 1 trauma center. PATIENTS/PARTICIPANTS: Two hundread and fifty-three adult patients with a mean age of 40.7 years and mean Injury Severity Score of 26.0. INTERVENTION: Femur, pelvis, or spine fractures treated surgically. MAIN OUTCOME MEASUREMENTS: Hospital and professional charges and collections were analyzed. Fixation was defined as early (<36 hours) or delayed. Complications and hospital stay were recorded. RESULTS: Mean charges were US $180,145 with a mean of US $66,871 collected (37%). The revenue multiplier was US $59,882/$6989 (8.57), indicating hospital collection of US $8.57 for every professional dollar, less than half of which went to orthopaedic surgeons. Delayed fracture care was associated with more intensive care unit (4.5 vs. 9.4) and total hospital days (9.4 vs. 15.3), with mean loss of actual revenue US $6380/patient delayed (n = 47), because of the costs of longer length of stay. Complications were associated with the highest expenses: mean of US $291,846 charges and US $101,005 collections, with facility collections decreased by 5.1%. An uncomplicated course of care was associated with the most favorable total collections: (US $60,017/$158,454 = 38%) and the shortest mean stay (8.7 days). CONCLUSIONS: Facility collections were nearly 9 times more than professional collections. Delayed fixation was associated with more complications, and facility collections decreased 5% with a complication. Furthermore, delayed fixation was associated with longer hospital stay, accounting for US $300K more in actual costs during the study. A standardized protocol to expedite definitive fixation enhances the profitability of the trauma service line. LEVEL OF EVIDENCE: Economic Level IV. See Instructions for Authors for a complete description of levels of evidence.

[Early goal directed therapy in severe sepsis]. / Frühe zielorientierte Therapie bei schwerer Sepsis.

BACKGOUND: The treatment of patients with severe sepsis and septic shock continues to evolve. Recent studies have enunciated the benefit of early goal-directed therapy (EGDT) during the first 6 h after recognition of the condition. With EGDT a reduction in mortality of over 16% was shown over standard care. Thereafter the components of the EGDT were consequently implemented in the international Surviving Sepsis Campaign as well as the German sepsis guidelines. Nevertheless the medical community's enthusiasm for EGDT has remained indecisive. There remains a profound skepticism about treatment targets such as central venous pressure or mean arterial pressure as well as central venous oxygen saturation. Moreover multiple barriers such as critical shortage of nursing staff, problems in obtaining central venous pressure monitoring or lack of agreement with the EGDT resuscitation protocol may lead to non-adherence to EGDT early in the course of sepsis. RECENT STUDY RESULTS: In a recent multicenter trial, protocol-based resuscitation of patients in whom septic shock was diagnosed in the emergency department did not improve outcomes. RECOMMENDATION: The Severe Sepsis 3-Hour Resuscitation Bundle and the 6-Hour Septic Shock Bundle represent a distillation of the concepts and recommendations found in the practice guidelines published by the Surviving Sepsis Campaign. The bundles are designed to allow teams to follow the timing, sequence, and goals of the individual elements of care. Early recognition, early mobilization of resources, and multidisciplinary collaboration are imperative to enhance the prognosis of patients with sepsis.

Socioeconomic disparities in mortality after cancer surgery: failure to rescue.

IMPORTANCE: Disparities in operative mortality due to socioeconomic status (SES) have been consistently demonstrated, but the mechanisms underlying this disparity are not well understood. OBJECTIVE: To determine whether variations in failure to rescue (FTR) contribute to socioeconomic disparities in mortality after major cancer surgery. DESIGN, SETTING, AND PARTICIPANTS: We performed a retrospective cohort study using the Medicare Provider Analysis and Review File and the Medicare Denominator File. A summary measure of SES was created for each zip code using 2000 US Census data linked to residence. Multivariable logistic regression was used to examine the influence of SES on rates of FTR, and fixed-effects hierarchical regression was used to evaluate the extent to which disparities could be attributed to differences among hospitals. A total of 596,222 patients undergoing esophagectomy, pancreatectomy, partial or total gastrectomy, colectomy, lung resection, and cystectomy for cancer from 2003 through 2007 were studied. MAIN OUTCOMES AND MEASURES: Operative mortality, postoperative complications, and FTR (case fatality after ≥1 major complication). RESULTS: Patients in the lowest quintile of SES had mildly increased rates of complications (25.6% in the lowest quintile vs 23.8% in the highest quintile, P = .003), a larger increase in mortality (10.2% vs 7.7%, P = .0009), and the greatest increase in rates of FTR (26.7% vs 23.2%, P = .007). Analysis of hospitals revealed a higher FTR rate for all patients (regardless of SES) at centers treating the largest proportion of patients with low SES. The adjusted odds ratios (95% CIs) of FTR according to SES ranged from 1.04 (0.95-1.14) for gastrectomy to 1.45 (1.21-1.73) for pancreatectomy. Additional adjustment for hospital effect nearly eliminated the disparity observed in FTR across levels of SES. CONCLUSIONS AND RELEVANCE: Patients in the lowest quintile of SES have significantly increased rates of FTR. This finding appears to be in part a function of the hospital where patients with low SES are treated. Future efforts to improve socioeconomic disparities should concentrate on hospital processes and characteristics that contribute to successful rescue.

Insurance status predicts survival for trauma patients undergoing urgent intervention.

BACKGROUND: The purpose of this study was to investigate the relationship between insurance status and outcomes for trauma patients presenting without vital signs undergoing urgent intervention. MATERIALS AND METHODS: The National Trauma Data Bank was queried for patients presenting with a systolic blood pressure equal to zero and a Glasgow Coma Scale score of three ("clinically dead"), who underwent urgent thoracotomy and-or laparotomy (UTL). Insured patients were compared with uninsured (INS [-]) patients. RESULTS: There were 18,171 patients presenting clinically dead having a payment source documented. INS (-) patients were more likely to undergo UTL (5.4% [416-7704] versus 2.7% [285-10,467], 1.481 [1.390-1.577], <0.001). Out of 689 patients who underwent UTL and meeting inclusion criteria, 416 (60.4%) were INS (-). Patients with insurance demonstrated a significantly greater survival (9.9% [27-273] versus 1.7% [7-416], 5.878 [2.596-13.307] P < 0.001). Adjusting for mechanism, race, age, injury severity, and comorbidities, insured status was independently associated with survival. CONCLUSIONS: The presence of health insurance is independently associated with survival in trauma patients presenting with cardiovascular collapse who undergo urgent surgical intervention.

Initial assessment on the impact of crystalloids versus colloids during damage control resuscitation.

BACKGROUND: High ratios of fresh frozen plasma:packed red blood cells in damage control resuscitation (DCR) are associated with increased survival. The impact of volume and type of resuscitative fluid used during high ratio transfusion has not been analyzed. We hypothesize a difference in outcomes based on the type and quantity of resuscitative fluid used in patients that received high ratio DCR. METHODS: A matched case control study of patients who received transfusions of ≥ four units of PRBC during damage control surgery over 4 1/2 y, was conducted at a Level I Trauma Center. All patients received a high ratio DCR, >1:2 of fresh frozen plasma:packed red blood cells. Demographics and outcomes of the type and quantity of resuscitative fluids used in combination with high ratio DCR were compared and analyzed. A Kaplan-Meier survival analysis was computed among four groups: colloid (median quantity = 1.0 L), <3 L crystalloid, 3-6 L crystalloid, and >6 L crystalloid. RESULTS: There were 56 patients included in the analysis (28 in the crystalloid group and 28 in the colloid group). Demographics were statistically similar. Intraoperative median units of PRBC: crystalloid versus colloid groups was 13 (IQR 8-21) versus 16 (IQR 12-19), P = 0.135; median units of FFP: 12 (IQR 7-18) versus 12 (IQR 10-18), P = 0.440. OR for 10-d mortality in the crystalloid group was 8.41 [95% CI 1.65-42.76 (P = 0.01)]. Kaplan-Meier survival analysis demonstrated lowest mortality in the colloid group and higher mortality with increasing amounts of crystalloid (P = 0.029). CONCLUSIONS: During high ratio DCR, resuscitation with higher volumes of crystalloids was associated with an overall decreased survival, whereas low volumes of colloid use were associated with increased survival. In order to improve outcomes without diluting the survival benefit of hemostatic resuscitation, guidelines should focus on effective low volume resuscitation when high ratio DCR is used. A multi-institutional analysis is needed in order to validate these results.

Comparison of Predisposition, Insult/Infection, Response, and Organ dysfunction, Acute Physiology And Chronic Health Evaluation II, and Mortality in Emergency Department Sepsis in patients meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle.

PURPOSE: The aim of the study was to examine the performance of the Predisposition, Insult/Infection, Response, and Organ dysfunction (PIRO) model compared with the Acute Physiology and Chronic Health Evaluation (APACHE) II and Mortality in Emergency Department Sepsis (MEDS) scoring systems in predicting in-hospital mortality for patients presenting to the emergency department (ED) with severe sepsis or septic shock. MATERIALS AND METHODS: This study was an analysis of a prospectively maintained registry including adult patients with severe sepsis or septic shock meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle over a 6-year period. The registry contains data on patient demographics, sepsis category, vital signs, laboratory values, ED length of stay, hospital length of stay, physiologic scores, and outcome status. The discrimination and calibration characteristics of PIRO, APACHE II, and MEDS were analyzed. RESULTS: Five-hundred forty-one patients with age 63.5 ± 18.5 years were enrolled, 61.9% in septic shock, 46.9% blood-culture positive, and 31.8% in-hospital mortality. Median (25th and 75th percentile) PIRO, APACHE II, and MEDS scores were 6 (5 and 8), 28 (22 and 34), and 12 (9 and 15), with predicted mortalities of 48.5% (40.1 and 63.9), 66.0% (42.0 and 83.0), and 16.0% (9.0 and 39.0), respectively. The area under the receiver operating characteristic curves for PIRO was 0.71 (95% confidence interval, 0.66-0.75); APACHE II, 0.71 (0.66-0.76); and MEDS, 0.63 (0.60-0.70). The standardized mortality ratio was 0.70 (0.08-1.41), 0.70 (-0.46 to 1.80), and 4.00 (-8.53 to 16.62), respectively. Actual mortality significantly increased with increasing PIRO score in patients with APACHE II 25 or more (P < .01). CONCLUSIONS: The PIRO, APACHE II, and MEDS have variable abilities to early discriminate and estimate in-hospital mortality of patients presenting to the ED meeting criteria for early goal-directed therapy and the severe sepsis resuscitation bundle. The PIRO may provide additional risk stratification in patients with APACHE II 25 or more. More studies are required to evaluate the clinical applicability of PIRO in high-risk patients with severe sepsis and septic shock.

[Save life--allow death. Collation of emergency missions for terminally ill patients]. / Leben retten--sterben zulassen. Erfassung notärztlicher Einsätze bei Patienten in der Terminalphase.

BACKGROUND: Emergency missions can also be necessary for patients in the terminal phase of a progressive incurable disease. The emergency physician, accustomed to acting under strict procedures and whose training focuses on the restoration and stabilization of acutely threatened vital functions, can face severe difficulties when treating incurably ill patients in the terminal phase. This study investigates the number of such cases, patient symptoms and the events occurring during life-threatening emergencies of terminally ill patients. METHOD: All cases of emergency events involving terminally ill patients were analyzed prospectively. In addition to the standardized protocol (following DIVI/Mind 2) an enquiry sheet was used, which contained an 8-item checklist specifically for terminally ill patients, to be filled out by the responding physician. RESULTS: The total number of patients in the terminal phase identified by the emergency physician was 55 (0.72% of total cases) and of these patients 30 (55%) were tumor patients. The most frequent complaint observed was dyspnea (30 patients, 55%), followed by relatives of the patients experiencing the stress of caring for a terminally ill person (19 patients, 35%). The leading symptom of 6 patients (11%) was pain. Only 17 cases (30.9%) required transport of the patient to hospital for further treatment. CONCLUSION: Every emergency physician can be confronted with an emergency involving a patient with a progressive incurable disease. The condition of each patient must be assessed for each medical decision. Not only medical, but also psychosocial, ethical and legal aspects have to be considered.

Clinical assessment of extremely premature infants in the delivery room is a poor predictor of survival.

BACKGROUND: Some neonatologists state that at the delivery of extremely premature infants they rely on "how the baby looks" when deciding whether to initiate resuscitation. Previous studies have reported poor correlation between early clinical signs and prognosis. OBJECTIVE: To determine if neonatologists can accurately predict survival to discharge of extremely premature infants on the basis of observations in the first minutes after birth. METHODS: We showed videos of the resuscitation of 10 extremely premature infants (<26 weeks' gestation) to attending neonatologists and fellows from the 3 major perinatal centers in Melbourne, Australia. Antenatal information was available to the observers. A monitor visible in each video displayed the heart rate and oxygen saturation of the infant. Observers were asked to estimate the likelihood of survival to discharge for each infant at 3 time points: 20 seconds, 2 minutes, and 5 minutes after birth. The predictive ability of observers was expressed as the area (95% confidence interval [CI]) under the receiver-operating-characteristic curve. RESULTS: Seventeen attending neonatologists and 17 neonatal fellows completed the study. Receiver-operating-characteristic curves were generated for the combined and individual groups. Observers' ability to predict survival was poor (combined results): 0.61 (95% CI: 0.54-0.67) at 20 seconds, 0.59 (95% CI: 0.52-0.64) at 2 minutes, and 0.61 (95% CI: 0.55-0.67) at 5 minutes. Level of experience did not affect the observers' accuracy of predicting survival. CONCLUSION: Neonatologists' reliance on initial appearance and early response to resuscitation in predicting survival for extremely premature infants is misplaced.

Outcome and hospital cost for infants weighing less than 500 grams: a tertiary centre experience in Taiwan.

AIM: To determine the outcome and hospital cost for infants weighing < or =500 g at a tertiary centre in Taiwan. METHODS: We retrospectively reviewed the medical records of infants who were born alive with birthweight < or =500 g at the National Taiwan University Hospital from 1997 to 2004. Their outcome and hospital cost were analysed. RESULTS: A total of 168 infants were included for analysis that 146 of them died after compassionate care in the delivery room and 22 received postnatal resuscitation. The infants who received resuscitation were more likely to have higher birthweights, older gestational ages and multiple births compared with those who received compassionate care. After resuscitation, five of the infants died and 17 were admitted to neonatal intensive care unit (NICU) for further management. Subsequently, 12 infants died and five infants survived to discharge. Two infants were discharged against advice and died within days. After exclusion of those receiving compassionate care, the NICU survival rate was 22.7% and the long-term survival rate was 13.6%. The most common early morbidities were respiratory distress syndrome, intraventricular haemorrhage and patent ductus arteriosus, whereas the late morbidities included cholestatic jaundice, retinopathy of prematurity and chronic lung disease. The average total hospital costs for the NICU survivors with birthweight < or =500 g was US $42,411 and the average hospital cost per day was US $350. CONCLUSION: Exclusive compassionate care was given to the majority of the infants weighing < or =500 g in Taiwan. The survival rate remained low in these marginally viable infants.