Nonstandard do-not-resuscitate orders.

PURPOSE OF REVIEW: Tattoos and medallions are examples of nonstandard do-not-resuscitate (DNR) orders that some people use to convey end-of-life wishes. These DNR orders are neither universally accepted nor understood for reasons discussed within this manuscript. RECENT FINDINGS: Studies show both providers and patients confuse the meaning and implication of DNR orders. In the United States, out-of-hospital DNR orders are legislated at the state level. Most states standardized out-of-hospital DNR orders so caregivers can immediately recognize and accept the order and act on its behalf. These out-of-hospital orders are complicated by the need to be printed on paper that does not always accompany the individual. Oregon created an online system whereby individuals recorded their end-of-life wishes that medical personnel can access with an Internet connection. This system improved communication of end-of-life wishes in patients who selected comfort care only. SUMMARY: To improve conveyance of an individual's wishes for end-of-life care, the authors discuss nationwide adoption of Oregon's online registry where a person's account could comprehensively document end-of-life wishes, be universally available in all healthcare institutions, and be searchable by common patient identifiers. Facial recognition software could identify unconscious patients who present without identification.

Neuromonitoring with microdialysis in severe traumatic brain injury patients.

BACKGROUND: Neuromonitoring with microdialysis has the potential for early detection of metabolic derangements associated with TBI. METHODS: 1,260 microdialysis samples from 12 TBI patients were analyzed for glucose, -lactate, pyruvate, lactate/pyruvate ratio (LPR), and lactate/glucose ratio (LGR). Analytes were correlated with the Glasgow Coma Scale (GCS) before surgery and with the Glasgow Outcome Scale (GOS) at the time of discharge. The patients were divided into two groups for GCS: 3-6 and 7-9, and for GOS 1-3 and 4-5. Chi-squared test was performed for correlations. RESULTS: Glucose, lactate levels, and LGR were high in TBI patients with GCS 3-6 (p < 0.0001). Pyruvate level was lower in patients with GCS 7-9 (p < 0.001). LPR was higher in patients with GCS 3-6 (p < 0.05). High glucose, lactate level (p < 0.001), and LPR (p < 0.01) was observed in patients with GOS 1-3. Pyruvate level was low in patients with GOS 1-3 (p < 0.001). LGR was higher in patient with better outcome (GOS 4-5). CONCLUSION: After craniotomy extracellular glucose and lactate were good "biomarkers" of cerebral damage in TBI patients. We consider that high extracellular lactate and low glucose is an indicator of severe neurological damage and poor outcome, because of impaired brain metabolism.

Comparison of piperacillin/tazobactam and imipenem/cilastatin, both in combination with tobramycin, administered every 6 h for treatment of nosocomial pneumonia.

This randomized, double-blind, multicenter study compared the efficacy and safety of piperacillin/tazobactam (P/T) and imipenem/cilastatin (IMP), both in combination with an aminoglycoside, in hospitalized patients with acute nosocomial pneumonia (NP). Patients with acute NP, defined as pneumonia with symptoms > or = 48 h after admission or < or =7 days after hospital discharge, received infusions of 4 g/500 mg P/T or 500 mg/500 mg IMP every 6 h. Endpoints were clinical cure and microbiological response rates; pathogen eradication rates; length of hospital stay; hospital readmissions; and adverse events (AEs). Of 437 patients in the intent-to-treat population, 197 were efficacy evaluable. At test-of-cure, response rates were similar between groups. Within the efficacy evaluable population, 68% of P/T patients and 61% of IMP patients were clinically cured (P = 0.256). Microbiological responses for P/T and IMP patients were: eradication, 64% versus 59%; persistence, 29% versus 21%; relapse, 0% versus 5%; and superinfection, 7% versus 15%, respectively. Gram-positive isolates were eradicated in 83% of P/T patients and 75% of IMP patients; Gram-negative pathogens were eradicated in 72% of P/T patients and 77% of IMP patients. Treatment groups had similar number of mean hospital days, readmission rates, and frequency of AEs. This study showed that P/T administered four times per day was as safe and efficacious as IMP in treating hospitalized patients with NP.

The development of a method to measure head acceleration and motion in high-impact crashes.

OBJECTIVE: To establish a mechanism to obtain precise measurements of the accelerations of the head in the high-speed racing environment and during crash impacts. The long-term goal is to apply this system to the assessment of head injury in automobile racing drivers and then in participants in other helmeted sports. METHODS: A multidisciplinary team conceptualized, designed, and successfully tested a triaxial accelerometer system capable of measuring head acceleration and motion in high-impact crashes. The system has been implemented successfully in the professional racing environment. RESULTS: Accurate and reproducible data have been obtained from the accelerometer system in tests on manikins and cadavers and in actual racing events. The system has been implemented in two professional racing series in 2003. Information gained from the accelerometer system is currently being entered into a database. Eventually, the data should aid in the development of improved cockpit head protection in racing cars. Improved helmet design not only in motor sports but also in other helmeted sports should benefit from the data collected. These data will also aid the development of improved head injury protection in military aircraft and passenger vehicles. CONCLUSION: Although there has been a significant decrease in the overall rate of injury during the past 25 years, head injury remains a serious safety concern in motor sports and the greatest cause of death. Sports-related head injuries are also of great concern because repeated mild head injury has become an important health issue with potential long-term disability. True human tolerance to brain injury has yet to be established. Our scientific knowledge of brain injury is currently based on results derived from manikin, cadaver, and human volunteer testing, along with animal and computer models. The racing environment represents a venue to ethically measure and evaluate the forces involved in human brain injury.

Physiological responses to high-speed, open-wheel racecar driving.

UNLABELLED: High-speed auto racing has been demonstrated to produce accelerated heart rate (HR) during competition. However, it has not been determined whether the increase in HR was due to physical work efforts or a result of emotional stress. PURPOSE: The purpose of this investigation was to examine the physiological responses associated with open-wheel automobile driving at competitive speeds. METHODS: Oxygen consumption and HR were assessed in seven professional automobile racing drivers during two incrementally paced driving sessions. A portable metabolic analyzer and EKG were directly attached to the subjects as they participated in driving tests on an oval speedway and a roadway course. Maximal physiological responses of the subjects were also determined during a graded treadmill test. RESULTS: During treadmill testing, maximal oxygen consumption (VO2max) ranged from of 42.0 to 59.7 mL x kg(-1) x min(-1) (mean +/- SD = 47.6+/-8.1). The road course and oval speedway testing at competitive speeds elicited mean VO2 values of 38.5 and 21.9 mL x kg(-1) x min(-1), respectively, which correspond to 79% and 45% of VO2max. Road course driving produced mean HR values of 152 beats x min(-1) with 142 beats x min(-1) recorded when driving at competitive speed on the speedway course. CONCLUSIONS: Professional open-wheel race drivers possess cardiorespiratory capacity similar to athletes participating in sports such as basketball, football, and baseball. The VO2 and HR responses to road course driving were similar to those previously reported in traditional sports settings. The findings of this study suggest that professional open-wheel racing drivers should be regarded as athletes that encounter significant physiological stresses.(2)