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.

[The effect of the administration of an amino acid solution enriched with branched-chain amino acids on the nutritional assessment of patients with stress who require total parenteral nutrition]. / Influencia de la administración de una solución de aminoácidos enriquecida en aminoácidos de cadena ramificada en la valoración nutricional de pacientes con estrés que precisan nutrición parenteral total.

The effects of two solutions of amino acids (AA) were compared in the nutritional assessment of stressed patients requiring total parenteral nutrition (TPN) by finding anthropometric, biochemical and immune parameters on day 0 and day 8. In addition, calculations were made to find the nutritional prognosis index, stress index nitrogenated balance (NB) and net protein use (NPU). A double-blind prospective study was run in which 35 patients with moderate to high stress were divided at random into two groups to receive, for seven days, TPN that was both isonitrogenated (1.56 g/Kg/day of AA) and isocaloric (115.6 +/- 13.6 non-protein Kcal/g. nitrogen), 37% as lipids (LCT), differing only in the AA solution used, one being 15.6% and the other, 45% BCAA. Twenty-eight patients finished the study, 14 in each group. No significant differences were found between the groups in the parameters under study; however, the patients who received the 45% BCAA solution obtained superior development of the parameters evaluating nutritional status and an increase in their NB (p = 0.0213) and NPU (p = 0.0497). Total lymphocytes increased significantly in both groups. Disturbances in hepatic enzymes and alkaline phosphatase (AF) were higher than in the standard group. Gamma glutamyl transferase (GGT) increased in group I (p = 0.0168), while in group II there were increases of GGT (p < or = 0.05), glutamic pyruvic transaminase (GPT) (p < or = 0.025) and AF (p = 0.0213). In the standard group, plasma urea increased (p = 0.0117), and the creatine/size ratio decreased (p = 0.0094). Anthropometric measurements were not valid in this study. The results do not allow the conclusion to be drawn that the 45% BCAA solution is the most effective, but it does make clear that its use is suitable in patients with moderate and high levels of stress, changing to standard AA solutions when the patients improve.

[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.