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INTRODUCTION: The need for end-of-life care is common in intensive care units (ICUs). Although guidelines exist, little is known about actual end-of-life care practices in Hong Kong ICUs. The study aim was to provide a detailed description of these practices. METHODS: This prospective, multicentre observational sub-analysis of the Ethicus-2 study explored end-of-life practices in eight participating Hong Kong ICUs. Consecutive adult ICU patients admitted during a 6-month period with life-sustaining treatment (LST) limitation or death were included. Follow-up continued until death or 2 months from the initial decision to limit LST. RESULTS: Of 4922 screened patients, 548 (11.1%) had LST limitation (withholding or withdrawal) or died (failed cardiopulmonary resuscitation/brain death). Life-sustaining treatment limitation occurred in 455 (83.0%) patients: 353 (77.6%) had decisions to withhold LST and 102 (22.4%) had decisions to withdraw LST. Of those who died without LST limitation, 80 (86.0%) had failed cardiopulmonary resuscitation and 13 (14.0%) were declared brain dead. Discussions of LST limitation were initiated by ICU physicians in most (86.2%) cases. Shared decision-making between ICU physicians and families was the predominant model; only 6.0% of patients retained decision-making capacity. Primary medical reasons for LST limitation were unresponsiveness to maximal therapy (49.2%) and multiorgan failure (17.1%). The most important consideration for decision-making was the patient's best interest (81.5%). CONCLUSION: Life-sustaining treatment limitations are common in Hong Kong ICUs; shared decision-making between physicians and families in the patient's best interest is the predominant model. Loss of decision-making capacity is common at the end of life. Patients should be encouraged to communicate end-of-life treatment preferences to family members/surrogates, or through advance directives.
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BACKGROUND: End-of-life care is common in German intensive care units (ICUs) but little is known about daily practice. OBJECTIVES: To study the practice of end-of-life care. METHODS: Prospectively planned, secondary analysis comprising the German subset of the worldwide Ethicus2 Study (2015-2016) including consecutive ICU patients with limitation of life-sustaining therapy or who died. RESULTS: Among 1092 (13.7%) of 7966 patients from 11 multidisciplinary ICUs, 967 (88.6%) had treatment limitations, 92 (8.4%) died with failed CPR, and 33 (3%) with brain death. Among patients with treatment limitations, 22.3% (216/967) patients were discharged alive from the ICU. More patients had treatments withdrawn than withheld (556 [57.5%] vs. 411 [42.5%], pâ¯< 0.001). Patients with treatment limitations were older (median 73 years [interquartile range (IQR) 61-80] vs. 68 years [IQR 54-77]) and more had mental decision-making capacity (12.9 vs. 0.8%), advance directives (28.6 vs. 11.2%), and information about treatment wishes (82.7 vs 33.3%, all pâ¯< 0.001). Physicians reported discussing treatment limitations with patients with mental decision-making capacity and families (91.3 and 82.6%, respectively). Patient wishes were unknown in 41.3% of patients. The major reason for decision-making was unresponsiveness to maximal therapy (34.6%). CONCLUSIONS: Treatment limitations are common, based on information about patients' wishes and discussion between stakeholders, patients and families. However, our findings suggest that treatment preferences of nearly half the patients remain unknown which affects guidance for treatment decisions.
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Cuidados para Prolongar a Vida , Assistência Terminal , Humanos , Unidades de Terapia Intensiva , Suspensão de Tratamento , Morte Encefálica , Tomada de DecisõesRESUMO
OBJECTIVE: To summarise our experience with maggot debridement therapy (MDT) in relation to pain observed in patients treated in 16 departments and units of the Hadassah Hospital in Jerusalem, Israel. METHOD: A secondary analysis of data from 435 patients. Maggots were either placed directly on the wound using a cage-like dressing (DA), or they were applied to the wound encased in a previously prepared hermetic tea-bag like pouch (TBA). During each treatment, patients were asked whether they felt any difference in the level of pain before and during MDT treatment. RESULTS: Overall, 165 patients (38%) reported increased pain during MDT. Seventeen patients (41%), who were treated with the TBA technique, and 148 patients (38%), who were treated with the DA technique, reported increased pain and were treated with analgesics before or during MDT. In five patients, the treatment had to be discontinued due to uncontrolled pain during MDT. Pain control measures were undertaken in patients who were already in intense pain prior to the initiation of MDT and in those patients who reported intense pain during DA treatment. The measures included shorter periods of application of maggots, use of the TBA rather than DA technique, and applying relatively small maggots as well as a smaller number of maggots during an MDT session. In patients who continued reporting intense pain, systemic analgesic medications and peripheral nerve blocks were used. CONCLUSION: Since a full debridement requires an average of 2-3 maggot cycles, which last 3-5 days, and since a large percentage of patients treated with MDT complain of pain that may last throughout the therapy period, it is deemed worthwhile and even essential to titrate analgesics as needed and be prepared to treat patients even with potent analgesics, such as opioids. In cases when pain is intense and uncontrolled with systemic medications, peripheral nerve blocks should be considered. DECLARATION OF INTEREST: There were no external sources of funding for this study. The authors have no conflicts of interest to declare.
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Desbridamento/efeitos adversos , Desbridamento/métodos , Dípteros , Larva , Manejo da Dor/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Analgésicos/uso terapêutico , Animais , Feminino , Humanos , Israel , Masculino , Pessoa de Meia-Idade , Bloqueio NervosoRESUMO
Originating in the 1920' s and 1930's, two distinct fluidization arts have emerged, one for treating coarse solids and the other for fine powders. Fluidization research has tended to focus on bubbling beds of coarse solids, but designers of such beds for burning coal have learned to appreciate the importance of combustion of fine char particles in the freeboard. Designers of successful processes for powders have focused on bubble suppression. Since about 1980, combustion fluid beds of both types are challenging the conventional pulverized-coal boiler; they provide better means for controlling emissions from the combustion of high-sulfur fuels. Progress in the "bubbleless" fluidization of fine powders is increasing the fluid bed's competitiveness with the fixed-bed catalytic reactor. Efforts to advance the fluid bed for catalysis, besides increasing gas velocities beyond levels that most researchers have used in the past, must include systematic study of the level of fine particles smaller than 40 micrometers.
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When the desires of a patient are unknown or cannot be ascertained, cardio-pulmonary resuscitation (CPR) is the default procedure. Explicit, Do Not Resuscitate (DNR), orders are required to prevent implementation of CPR. We studied the response of general medical internists in specific clinical situations demanding consideration of DNR orders and respect for patient preferences; their current practice regarding slow codes and participation in CPR attempts considered futile provide information as to how often they discuss DNR issues with patients or families. Eighty-five internists attending the monthly meeting of the Internal Medicine Forum participated in the study. The physicians demonstrated their consent to participate by accepting a remote transmitter that elicited a response 2-3 minutes following the presentation of case vignettes or practice-related questions. The survey showed that 73% of the physicians agreed to assign a DNR order for a terminally ill patient unable to express her preferences. Only 55% agreed to do the same for a competent patient who specifically requested that CPR be withheld in the event of a cardiopulmonary arrest (p<0.05). 77% reported to have performed CPR, at least three times, in situations where they expected no benefit. 59% affirmed that their team had performed a partial CPR (slow code) at least once. Only 28% discussed the subject of DNR with patients or family more than 5 times a year. Paternalism, disregard for patients' preferences and poor communication skills influence normative behaviour in end-of-life decision-making.
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OBJECTIVE: General anesthesia may be required for placenta accreta cesarean delivery. Intrauterine fetal anesthetic exposure should be minimized to avoid neonatal respiratory depression; opioids are often delayed until post-delivery. METHODS: In this observational study, we compared neonatal outcome using pre-delivery remifentanil versus post-delivery (deferred) opioids for placenta accreta cesarean delivery. Choice of anesthesia was discretionary. The primary outcome was Apgar score at 5 min comparing women who received pre-delivery remifentanil versus deferred opioid administration. We recorded maternal/obstetric characteristics, surgical characteristics, maternal hemodynamic data, neonatal outcomes: Apgar scores, umbilical vein pH and respiratory interventions at birth. RESULTS: Between February 2007 and April 2014 we identified 40 general anesthesia placenta accreta cesarean deliveries. The remifentanil dose rate ranged from 0.06 to 0.46 mcg kg(-1 )min(-1). Obstetric and maternal characteristics were similar. Neonatal Apgar, umbilical pH and respiratory intervention outcomes were similar in both groups; Apgar scores median (interquartile range IQR [range]) at 5 min were 9 (8-10) for pre-delivery remifentanil versus 9 (9-10) for deferred opioid administration, p = 0.18. CONCLUSIONS: We did not observe a significant effect on neonatal Apgar scores at 1 and 5 min, or respiratory interventions at birth when remifentanil infusion was administered pre-delivery.
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Analgésicos Opioides/efeitos adversos , Cesárea , Doenças do Recém-Nascido/induzido quimicamente , Piperidinas/efeitos adversos , Placenta Acreta , Adulto , Analgésicos Opioides/administração & dosagem , Índice de Apgar , Feminino , Humanos , Recém-Nascido , Piperidinas/administração & dosagem , Gravidez , Estudos Prospectivos , RemifentanilRESUMO
The effects of oral vanadyl sulfate administration for 9-12 days on carbohydrate and lipid metabolism in the basal state and on glucose dynamics during submaximal hyperinsulinemic clamps were investigated in nondiabetic and streptozocin-induced diabetic rats. Decreases in growth rate and water and food consumption were the only significant alterations noted in control animals receiving vanadyl. Administration of vanadyl to diabetic rats resulted in weight loss; a significant decrease in plasma glucose, triglyceride, and cholesterol levels; and decreases in food and water intake, without a concomitant change in plasma insulin concentrations. Vanadyl treatment did not modify either peripheral glucose utilization or hepatic glucose production in control rats during submaximal insulin clamps. In contrast, vanadyl therapy increased insulin-induced glucose utilization significantly and had a small but nonsignificant effect on insulin-mediated suppression of glucose production in diabetic rats. The tyrosine kinase activity of liver- and muscle-derived insulin receptors from diabetic rats that underwent clamp study, which reflected the in vivo phosphorylation state of insulin receptor, was not altered by vanadyl treatment. In conclusion, these results show that augmentation of peripheral glucose utilization is the major determinant of the antidiabetic action of vanadyl and support the notion that the action of vanadyl is independent of insulin-receptor kinase activity.
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Diabetes Mellitus Experimental/metabolismo , Hipoglicemiantes , Fígado/metabolismo , Proteínas Tirosina Quinases/metabolismo , Receptor de Insulina/metabolismo , Vanadatos/farmacologia , Animais , Glicemia/metabolismo , Diabetes Mellitus Experimental/enzimologia , Cinética , Masculino , Ratos , Ratos Endogâmicos , Receptor de Insulina/efeitos dos fármacos , Receptor de Insulina/isolamento & purificação , Valores de ReferênciaRESUMO
We describe a technique to bypass a defective part of an oxygenator unit (venous reservoir or oxygenator part) by connecting a second oxygenator instead of replacing the whole oxygenator unit. If only the oxygenator part has to be replaced, further hemodilution can be avoided. This technique can be performed in very short time and is probably associated with less air embolism.
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Ponte Cardiopulmonar/instrumentação , Oxigenadores de Membrana , Idoso , Ponte de Artéria Coronária , Humanos , Masculino , Período Pós-OperatórioAssuntos
Apneia Obstrutiva do Sono , Ronco , Terapia Comportamental , Humanos , Avanço Mandibular , Placas Oclusais , Palato Mole/cirurgia , Faringe/cirurgia , Polissonografia , Respiração com Pressão Positiva , Encaminhamento e Consulta , Apneia Obstrutiva do Sono/diagnóstico , Apneia Obstrutiva do Sono/fisiopatologia , Apneia Obstrutiva do Sono/terapia , Ronco/diagnóstico , Ronco/fisiopatologia , Ronco/terapia , Terminologia como Assunto , Língua/fisiopatologia , Redução de PesoRESUMO
BACKGROUND: 1,1,1,2 Tetrafluoroethane is a hydrofluoroalkane (HFA) that is replacing chlorofluorocarbons (CFC) as a medical aerosol propellant in an attempt to reduce damage to the ozone layer. This study compared the effects of HFA- and CFC-based inhalers on four anaesthetic gas monitoring systems. METHODS: The HFA- and CFC-based inhalers were activated in close proximity to the sample line of two Datex Ohmeda, an Agilent and a Siemens infrared anaesthetic agent monitoring systems. The effects were recorded on each system for five common anaesthetic agents. RESULTS: The HFA inhaler caused either maximal false positive readings (with the exception of desflurane) or transient measurement failure on all systems. The Datex Ohmeda AS/3 system misidentified the HFA inhaler as carbon dioxide at low concentration (2 +/- 0 mm Hg). The CFC-based inhaler caused a minor false-positive reading (0.4 +/- 0%) for halothane only on the Datex Ohmeda AS/3 system only and was misidentified as carbon dioxide at 33.3 (sd 2.1) mm x Hg and 22.4 (8.9) mm x Hg by the Agilent and Siemens systems. CONCLUSIONS: The HFA inhaler adversely affected all equipment tested. The infrared spectra of HFA and the common anaesthetic gases have considerable overlap at the 8-12 microm range that is not shared by the CFCs. The differences in spectral overlap explain the different effects of the HFA and CFC propellants. Anaesthetic gas concentration data may be erroneous using the HFA-based inhalers.
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Propelentes de Aerossol/farmacologia , Anestesia por Inalação/instrumentação , Anestésicos Inalatórios/análise , Hidrocarbonetos Fluorados/farmacologia , Monitorização Intraoperatória/instrumentação , Albuterol/administração & dosagem , Albuterol/farmacologia , Broncodilatadores/administração & dosagem , Broncodilatadores/farmacologia , Clorofluorcarbonetos/farmacologia , Reações Falso-Positivas , Humanos , Ipratrópio/administração & dosagem , Ipratrópio/farmacologia , Nebulizadores e Vaporizadores , Espectrofotometria Infravermelho/instrumentaçãoRESUMO
Medullary sites at which the stable thyrotropin-releasing hormone (TRH) analogue, RX 77368 (p-Glu-His-[3,3'-dimethyl]-Pro-NH2), stimulates gastric contractility were investigated in rats under urethan anesthesia. The peptide analogue was microinjected in 50-100 nl of volume unilaterally into various brain stem nuclei using glass micropipettes (50 microns). Gastric contractility was recorded continuously with acutely implanted strain-gauge force transducers and traces analyzed by computer. RX 77368 (2.6-77 pmol) microinjected into the dorsal vagal complex (DVC) dose dependently stimulated gastric contractility. Peptide action (77 pmol) had a rapid onset with a peak response at 15 min, continued for 45 min after the microinjection, and was blocked by vagotomy. TRH microinjected into the DVC had a shorter duration of action. RX 77368 (0.7-77 pmol) microinjected into the nucleus ambiguus also dose dependently stimulated gastric contractions. In contrast, microinjection of RX 77368 (77 pmol) into the hypoglossal nucleus had no effect. These findings demonstrate that the DVC and nucleus ambiguus are sites of action for TRH-induced stimulation of gastric contractility in the rat. The effect is dose dependent, long lasting, site specific, and vagally mediated. These results are consistent with a possible physiological role for medullary TRH in the vagal regulation of gastric contractility.