ADQI 7: the clinical management of the Cardio-Renal syndromes: work group statements from the 7th ADQI consensus conference.

Many patients with heart failure have underlying renal dysfunction, and similarly, patients with kidney failure are prone to cardiac failure. This has led to the concept of cardio-renal syndromes, which can be an acute or chronic cardio-renal syndrome, when cardiac failure causes deterioration in renal function, or acute and/or chronic Reno-Cardiac syndrome, when renal dysfunction leads to cardiac failure. Patients who develop these syndromes have increased risk of hospital admission and mortality. Although there are clinical guidelines for managing both heart failure and chronic kidney disease, there are no agreed guidelines for managing patients with cardio-renal and/or Reno-Cardiac syndromes, as these patients have typically been excluded from clinical trials. We have therefore reviewed the currently available published literature to outline a consensus of current best clinical practice for these patients.

Treatment of patients with cardiac surgery associated-acute kidney injury.

Members of the Acute Dialysis Quality Initiative (ADQI) participated in a 3-day conference in Vicenza in May 2007 to evaluate the available literature on this topic and draft consensus recommendations for research studies in this area. This report summarizes the available evidence and describes the key questions that will need to be addressed with the goal of standardizing the care of patients with cardiac surgery-associated acute kidney injury (CSA-AKI) and improving outcomes.

Informed consent for therapy and research in continuous renal replacement therapy: an international survey.

OBJECTIVE: To study the approach of health care workers (HCW) to informed consent for therapy and research in the field of continuous renal replacement therapy (CRRT). DESIGN: Administration of questionnaire. SETTING: Two International Courses on Critical Care Nephrology (CCN) held in Vicenza and Melbourne. PARTICIPANTS: Eight hundred and twenty one course participants. RESULTS: We obtained 349 analysable questionnaires (42.5% of participants). Only 22.5% of responders always obtain informed consent for CRRT; 70.3% just inform patients/relatives without seeking consent, 7.1% never obtain informed consent. In ICU patients, informed consent is considered 'good, correct and feasible' for therapy and for research by only 13% and 27% of responders, respectively. Consent for clinical research obtained from the next of kin or legal guardian is considered good, correct and feasible' by 56.3% of respondents, while 39.1% believe that next of kin or legal guardians can not really make informed decisions. Finally, nearly half of responders think that present rules hamper research in ICU. For many questions, significant variability of responses was found according to profession, specialty and origin of responders. CONCLUSIONS: In the field of CRRT, stated practice, beliefs and currently accepted ethical standards vary greatly according to profession, specialty and origin. A significant disagreement between what is widely promoted to be the 'correct' approach and what is currently done is evident.

Bioethical issues related to continuous renal replacement therapy in intensive care patients.

OBJECTIVE: To examine the ethical approach of intensivists and nephrologists to continuous renal replacement therapy (CRRT). DESIGN: A questionnaire. SETTING: The First International Course on Critical Care Nephrology. PARTICIPANTS: The participants in the course (around 500). RESULTS: Most participants think that establishing ethical criteria for managing CRRT is a medical task, as clinicians have adequate criteria for defining futility. However, many responders would grant the request of starting futile CRRT or would maintain it if requested by the family. Only 55% believe that informed consent is necessary for initiating CRRT; one out of four would start or maintain unwanted life-saving CRRT. In case of lack of equipment, the majority would select the patients, excluding the worst one or on a "first-come, first-served" basis. Withholding and withdrawing are regarded differently by most responders. Again, most think that every vital support should be withdrawn when futile, but practical and psychological aspects still influence the final decision. Responders think that ethics critical care committees can help in the management of ethical problems in ICU. CONCLUSIONS: Our results show that several ethical questions are still unsolved and that practical and psychological aspects of the treatment process can be stronger than bioethical principles.

End of life in the Intensive Care Unit.

A bio-social revolution has been prompted by the capacity of artificial organ support technology to effectively sustain and/or replace many of the functions of vital organs. The consequent possibility of manipulating the dying process has generated many problems, which range from the necessity of rationing scarce and expensive resources to the definition of optimal care for dying people and the necessity of redefining death itself. In all of these situations, facts and values are strictly interconnected, and actions should be accompanied by careful bioethical reflection. In this text, we will briefly explore these issues in an attempt to illustrate the main problems related to the management of end-of-life care in the intensive care environment. We also present the protocol we use to make and implement difficult end-of-life decisions in our intensive care unit.

Bioethical aspects of end-of-life care.

Managing end-of-life care can be difficult because of the particular nature of intensive care support, which can separate the biological and the biographical aspects of life. Artificial organ support can temporarily delay death but, at the same time, may fail to restore a quality of life that the patient judges acceptable. For this reason, two concepts must be considered: that the mission of the healthcare system should be to care for patients according to their interests and wishes and that quality of care is related above all to the careful commitment of healthcare workers to the patient's best interests. Keeping these concepts in mind, the rule of the five Cs (competence, collegiality, communication, continuity of care and compassion) might be helpful in the management of end-of-life care. Unfortunately, neither the rule of the five Cs nor the careful use of moral principles in order to promote the patients' dignity can assure a universally acceptable decision. A reasonable level of 'moral certainty', however, might be achieved using a deliberative approach, which provides for the inclusion of all the different subjects involved in the decision-making process (patient, family, doctors, nurses and other carers), in order to reach the best possible decision in a specific situation.

Managing intensive supports. The attitudes of the health care workers of five Italian Hospitals to institution of CPR and admission to the ICU.

AIM: The aim of the paper was to examine the attitudes of the health care workers (HCW) of five Italian Hospitals towards intensive supports, in the hypothesis that a large involvement could help to solve the problems of a more adequate management of vital supports. DESIGN: Hospital HCWs' attitudes towards cardiopulmonary resuscitation (CPR) and ICU admission were investigated using a self-administered questionnaire. SETTING: five Italian Hospitals. PARTICIPANTS: all the doctors (MD) and nurses (RN), except those working in obstetrics and in paediatrics. INTERVENTION: a questionnaire was offered to all eligible participants (4903 HCW) and 2466 analysable files (50.3%) were obtained. RESULTS: In spite of a great variation in responses among health care givers, the majority of answers is almost in line with current professional and bioethical documents, at both international and national level. This, also when the proposed solution is not clearly recognised by the Italian laws. The statistically significant differences depend on profession (RN/MD), on working area and experiential working characteristics. A strict minority of workers would trust their colleagues in case of hypothetical personal critical illness. CONCLUSIONS: Our data confirm both the importance of communication among HCW, in order to reach the best decision for every patient, and the great need of continuous educational programs which could compensate for lack of experience and help to create/maintain a strong bioethical and patient-oriented attitude.

Defining death in non-heart beating organ donors.

Protocols for retrieving vital organs in consenting patients in cardiovascular arrest (non-heart beating donors, NHBD) rest on the assumptions that irreversible asystole a) identifies the instant of biological death, and b) is clinically assessable at the time when retrieval of vital organs is possible. Unfortunately both assumptions are flawed. We argue that traditional life/death definitions could be actually inadequate to represent the reality of dying under intensive support, and we suggest redefining NHBD protocols on moral, social, and anthropological criteria, admitting that irreversible (however defined) asystole can only equate a clinically determinable point of no return in the process of dying, where organ retrieval can be morally and socially accepted in previously consenting patients.

Principles, protocols and patients: the practical management of a limit in ICU.

The definition and management of a limit is a common but sometimes extremely complex problem in the Intensive Care Unit (ICU). Guidelines and consensus documents have been published in order to help clinicians. Yet, many controversial issues are brought into question. Legal rules are sometimes vague and derive more from the interpretation of various and unrelated principles (which vary from country to country) than from a clear ad hoc law. In this sense, the practical management of a limit in ICU is usually run by a dual normativity: an external one, which derives from the cultural, moral and legal values of the society, and an internal one, which depends on the particular clinical and human situation, namely the values of everybody involved in (the patient, his/her relatives, the health staff) and the relationships among these people. The considerable freedom left for the decision by an open communication is a great and favourable potential which must be used in the interest of the patient's and of his/her family.

[Progression of DMF index--DMF from 3 to 12 years: need for preventive intervention]. / Andamento indice DMF--DMF fra i 3 e i 12 anni: necessità di intervento preventivo.

To evaluate the prevalence of soft deposits and the trend of dmf/DMF index, a group of children between 3 and 12 years of age has been examined. A DMF Index of 5.74 at 12 proves the need to promote educational and prevention programmes in the Ulss 34 area since the WHO program "Health for all in the year 2000" sets a target of a DMF Index below 3 at 12.

[Epidemiological study of the prevalence of caries, periodontal diseases and malocclusion in a school population]. / Indagine epidemiologica sulla prevalenza di carie, parodontopatie e malocclusioni in una populazione scolastica.

A randomized stratified sample of children 3 to 12 years of age has been examined, DMFT, CPITN, soft deposits and malocclusion have been analyzed. The prevalence of caries, periodontal involvement and malocclusion has been observed to be rather high, thus requiring the organizing of detailed preventive programs to reach the W H O target set for the year 2000.

When the ICU patient refuses vital supports.

The aim of this paper is to discuss the problem of caring for ICU patients who request forgoing of intensive supports; in particular, evaluating their competence and building effective relationships among the patients themselves, their relatives and the health care team. The histories of 2 adult competent ICU patients 2 asked that vital intervention be forgone are presented, together with the discussion of problems posed by such a request and of possible solutions which respect patients' autonomy and bystanders needs. These patients were hospitalized in an Italian general 14 bed ICU. The patients' request were weighted against their prognosis and their view of life, in order to evaluate their reliability. Also the refusal of either treatment or outcome was evaluated, in order to effectively safeguard the patients' interests. The request of one patient was satisfied and he was allowed to die, after all the involved people had understood and accepted the final decision. The second patient, who was somehow forced to undergo intensive treatment, is alive and satisfied with having been cured. In Italy too, autonomy is an increasingly applied principle in end-of-life decisions in ICUs. It is usually tempered by a consideration about the patients' best interest as perceived by involved bystanders.

Results from ethical international surveys on the management of the continuous renal replacement therapy.

OBJECTIVE: To examine the ethical approach of clinicians to the continuous renal replacement therapy (CRRT). DESIGN: Review of international surveys. RESULTS: Many surveys have been carried out in order to evaluate the clinical approach and management of the continuous renal replacement therapy (CRRT). Nothing has been proposed in order to evaluate it from a bioethical point of view, even if many surveys dealt with the problem of the ethically correct administration of vital supports. These data demonstrate that an ethically correct approach to the management of life-saving support can be sometimes difficult. Results of a recent study on the ethical approach of intensivists and nephrologists to CRRT will be shown and discussed. CONCLUSIONS: Several ethical questions in the management of CRRT and other vital support are still unsolved. Practical and psychological aspects of the curing process are sometimes stronger than bioethical principles.

The transcranial Doppler ultrasonography in the evaluation of vasospasm and of intracranial hypertension after subarachnoid hemorrhage.

The transcranial doppler (T.C.D.) is a non-invasive technique useful for the evaluation of vasospasm and intracranial hypertension in patients with subarachnoid hemorrhage (S.A.H.). Eighteen patients with recent S.A.H. were studied by means of T.C.D. device: in 14 patients the source of bleeding was a ruptured aneurysm of the circle of Willis, while the remaining 4 presented a negative four-vessels angiography. All the patients were studied 5 and 10 days after the bleeding. Our data showed that the ultrasonographic demonstration of vasospasm and/or I.C.H. is clearly related to the clinical status of the patients. No significant T.C.D. difference was noticed between the "sine materia" S.A.H. patients and the ones with ruptured aneurysm.

Serological survey of hepatitis B infection in Tanzania.

In 1992, the prevalence of hepatitis B virus (HBV) markers was evaluated in 1004 subjects aged one to 76 years living in urban and rural areas in Tanzania. The overall prevalence rates of hepatitis B surface antigen (HBsAg) and of any HBV marker were 4.4% and 37.0%, respectively. No statistically significant difference by sex was found. The HBsAg prevalence among pregnant women was 4.3% (20/463). The proportion of HBeAg positive among HBsAg positive pregnant women was 10% (2/20). The HBsAg age-specific prevalence was 2.1% in the 1-5 year age-group; peak prevalence (12.1%) occurred in the 6-15 year age-group. Markers of HBV infection were 4.1% by age five years; they increased with advancing age (P < 0.01). Subjects residing in urban areas had statistically significant higher HBV exposure than those residing in rural areas (43.9% vs 27.4%, P < 0.01). Subjects belonging to the largest family size (seven or more members) showed increasing risk (OR 2.9; 95% CI = 1.96-4.28) of HBV exposure. Because maternal HBV transmission early in life appears to be of minor impact and children are mostly infected later in infancy, HBV vaccination at birth is not indicated, while vaccination of all infants at 2-3 months of age with other paediatric vaccinations is the first priority.