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The Surgical Clinics of North America Oct 2019Surgeons, anesthesiologists, and nurses are frequently asked to operate on patients with an existing Do Not Resuscitate (DNR) order, resulting in confusion about the... (Review)
Review
Surgeons, anesthesiologists, and nurses are frequently asked to operate on patients with an existing Do Not Resuscitate (DNR) order, resulting in confusion about the proper approach. We discuss the origins of decisions not to attempt resuscitation, the special circumstances surrounding the need for resuscitation intraoperatively, and reasons to suspend, or not suspend, the DNR order during the perioperative period. DNR should be part of a comprehensive discussion of a patient and family's goals of care. A clear understanding of those goals will lead the care team to a better understand the role of perioperative resuscitation for that individual patient.
Topics: Advance Directives; Cardiopulmonary Resuscitation; Heart Arrest; Humans; Operating Rooms; Palliative Care; Resuscitation Orders
PubMed: 31446914
DOI: 10.1016/j.suc.2019.06.006 -
Frontiers in Public Health 2021Ethics are considered a basic aptitude in healthcare, and the capacity to handle ethical dilemmas in tough times calls for an adequate, responsible, and blame-free... (Review)
Review
Ethics are considered a basic aptitude in healthcare, and the capacity to handle ethical dilemmas in tough times calls for an adequate, responsible, and blame-free environment. While do-not-resuscitate (DNR) decisions are made in advance in certain medical situations, in particular in the setting of poor prognosis like in advanced oncology, the discussion of DNR in relation to acute medical conditions, the COVID-19 pandemic in this example, might impose ethical dilemmas to the patient and family, healthcare providers (HCPs) including physicians and nurses, and to the institution. The literature on DNR decisions in the more recent pandemics and outbreaks is scarce. DNR was only discussed amid the H1N1 influenza pandemic in 2009, with clear global recommendations. The unprecedented condition of the COVID-19 pandemic leaves healthcare systems worldwide confronting tough decisions. DNR has been implemented in some countries where the healthcare system is limited in capacity to admit, and thus intubating and resuscitating patients when needed is jeopardized. Some countries were forced to adopt a unilateral DNR policy for certain patient groups. Younger age was used as a discriminator in some, while general medical condition with anticipated good outcome was used in others. The ethical challenge of how to balance patient autonomy vs. beneficence, equality vs. equity, is a pressing concern. In the current difficult situation, when cases top 100 million globally and the death toll surges past 2.7 million, difficult decisions are to be made. Societal rather than individual benefits might prevail. Pre-hospital triaging of cases, engagement of other sectors including mental health specialists and religious scholars to support patients, families, and HCPs in the frontline might help in addressing the psychological stress these groups might encounter in addressing DNR in the current situation.
Topics: COVID-19; Humans; Influenza A Virus, H1N1 Subtype; Pandemics; Resuscitation Orders; SARS-CoV-2
PubMed: 34055703
DOI: 10.3389/fpubh.2021.560405 -
Sensors (Basel, Switzerland) Jan 2022Future military conflicts will require new solutions to manage combat casualties. The use of automated medical systems can potentially address this need by streamlining...
Future military conflicts will require new solutions to manage combat casualties. The use of automated medical systems can potentially address this need by streamlining and augmenting the delivery of medical care in both emergency and combat trauma environments. However, in many situations, these systems may need to operate in conjunction with other autonomous and semi-autonomous devices. Management of complex patients may require multiple automated systems operating simultaneously and potentially competing with each other. Supervisory controllers capable of harmonizing multiple closed-loop systems are thus essential before multiple automated medical systems can be deployed in managing complex medical situations. The objective for this study was to develop a Supervisory Algorithm for Casualty Management (SACM) that manages decisions and interplay between two automated systems designed for management of hemorrhage control and resuscitation: an automatic extremity tourniquet system and an adaptive resuscitation controller. SACM monitors the required physiological inputs for both systems and synchronizes each respective system as needed. We present a series of trauma experiments carried out in a physiologically relevant benchtop circulatory system in which SACM must recognize extremity or internal hemorrhage, activate the corresponding algorithm to apply a tourniquet, and then resuscitate back to the target pressure setpoint. SACM continues monitoring after the initial stabilization so that additional medical changes can be quickly identified and addressed, essential to extending automation algorithms past initial trauma resuscitation into extended monitoring. Overall, SACM is an important step in transitioning automated medical systems into emergency and combat trauma situations. Future work will address further interplay between these systems and integrate additional medical systems.
Topics: Algorithms; Hemodynamics; Humans; Military Medicine; Resuscitation; Tourniquets
PubMed: 35062489
DOI: 10.3390/s22020529 -
Critical Care (London, England) Apr 2016Indications for intra-osseous (IO) infusion are increasing in adults requiring administration of fluids and medications during initial resuscitation. However, this route... (Review)
Review
BACKGROUND
Indications for intra-osseous (IO) infusion are increasing in adults requiring administration of fluids and medications during initial resuscitation. However, this route is rarely used nowadays due to a lack of knowledge and training. We reviewed the current evidence for its use in adults requiring resuscitative procedures, the contraindications of the technique, and modalities for catheter implementation and skill acquisition.
METHODS
A PubMed search for all articles published up to December 2015 was performed by using the terms "Intra-osseous" AND "Adult". Additional articles were included by using the "related citations" feature of PubMed or checking references of selected articles. Editorials, comments and case reports were excluded. Abstracts of all the articles that the search yielded were independently screened for eligibility by two authors and included in the analysis after mutual consensus. In total, 84 full-text articles were reviewed and 49 of these were useful for answering the following question "when, how, and for which population should an IO infusion be used in adults" were selected to prepare independent drafts. Once this step had been completed, all authors met, reviewed the drafts together, resolved disagreements by consensus with all the authors, and decided on the final version.
RESULTS
IO infusion should be implemented in all critical situations when peripheral venous access is not easily obtainable. Contraindications are few and complications are uncommon, most of the time bound to prolonged use. The IO infusion allows for blood sampling and administration of virtually all types of fluids and medications including vasopressors, with a bioavailability close to the intravenous route. Unfortunately, IO infusion remains underused in adults even though learning the technique is rapid and easy.
CONCLUSIONS
Indications for IO infusion use in adults requiring urgent parenteral access and having difficult intravenous access are increasing. Physicians working in emergency departments or intensive care units should learn the procedures for catheter insertion and maintenance, the contraindications of the technique, and the possibilities this access offers.
Topics: Adult; Emergency Medical Services; Humans; Infusions, Intraosseous; Injections, Intravenous; Resuscitation
PubMed: 27075364
DOI: 10.1186/s13054-016-1277-6 -
Critical Care (London, England) 2009The purpose of the present review is to review our experience with near-infrared spectroscopy (NIRS) monitoring in shock resuscitation and predicting clinical outcomes. (Review)
Review
INTRODUCTION
The purpose of the present review is to review our experience with near-infrared spectroscopy (NIRS) monitoring in shock resuscitation and predicting clinical outcomes.
METHODS
The management of critically ill patients with goal-oriented intensive care unit (ICU) resuscitation continues to evolve as our understanding of the appropriate physiologic targets improves. It is now recognized that resuscitation to achieve supranormal indices is not beneficial in all patients and may precipitate abdominal compartment syndrome.
RESULTS
Over the years, ICU technology has provided physicians with specific physiologic parameters to guide shock resuscitation. Throughout this time, the tissue hemoglobin oxygen saturation (StO2) monitor has emerged as a non-invasive means to obtain reliable physiologic parameters to guide clinicians' resuscitative efforts. StO2 monitors have been shown to aid in early identification of nonresponders and to predict outcomes in hemorrhagic shock and ICU resuscitation. These data have also been used to better understand and refine existing resuscitation protocols. More recently, use of NIRS technology to guide resuscitation in septic shock has been shown to predict outcomes in high-risk patients.
CONCLUSIONS
StO2 is an important tool in identifying high-risk patients in septic and hemorrhagic shock. It is a non-invasive means of obtaining vital information regarding outcome and adequacy of resuscitation.
Topics: Animals; Hemoglobins; Humans; Intensive Care Units; Monitoring, Physiologic; Oximetry; Oxygen Consumption; Resuscitation; Spectroscopy, Near-Infrared; Trauma Centers
PubMed: 19951382
DOI: 10.1186/cc8008 -
Polski Przeglad Chirurgiczny Oct 2019It is extremely difficult to provide non-compressible torso hemorrhage control particularly in trauma setting. A vast majority of cases present inability of successful... (Review)
Review
It is extremely difficult to provide non-compressible torso hemorrhage control particularly in trauma setting. A vast majority of cases present inability of successful exsanguination arrest, leading to cardiovascular collapse, myocardial and cerebral hypoperfusion and death eventually. The only possible treatment for these patients is prompt bleeding control, either open or endovascular. Aortic occlusion seems to be the most rapid and convenient way to restrain blood loss and possibly increase survival. However, it is not proven yet. Traditional aortic occlusion for trauma consisted of supradiaphragmatic thoracic aorta cross-clamping through resuscitative thoracotomy (RT). This complicated and devastating procedure triggered the necessity to work on a simpler, less invasive resuscitation bridge which can be implemented in emergency departments or even in prehospital setting. Resuscitative balloon occlusion of the aorta (REBOA) provides a novel method of hemorrhagic shock stabilization in bleeding below the diaphragm. The mechanism lies in improving myocardial and cerebral perfusion and ceasing major bleeding itself. This method together with invasive endovascular and surgical procedures creates a new approach of choice for trauma patients. It is called Endovascular Hybrid Trauma and Resuscitation Management (EVTM) and introduces this concept to modern clinical practice. Through a detailed review, this article aims to introduce REBOA procedure to a broader recipient and present REBOA details, benefits and limitations.
Topics: Balloon Occlusion; Endovascular Procedures; Humans; Resuscitation; Shock, Hemorrhagic; Thoracic Injuries; Treatment Outcome
PubMed: 32312913
DOI: 10.5604/01.3001.0013.5426 -
European Journal of Trauma and... Apr 2018Permissive hypotensive resuscitation (PHR) is an advancing concept aiming towards deliberative balanced resuscitation whilst treating severely injured patients, and its... (Review)
Review
BACKGROUND
Permissive hypotensive resuscitation (PHR) is an advancing concept aiming towards deliberative balanced resuscitation whilst treating severely injured patients, and its effectiveness on the survival rate remains unexplored. This detailed systematic review aims to critically evaluate the available literature that investigates the effects of PHR on survival rate.
METHODS
A systematic review design searched for comparative and non-comparative studies using EMBASE, MEDLINE, PubMed, Web-of-Science and CENTRAL. Full-text articles on adult trauma patients with low blood pressure were considered for inclusion. The risk of bias and a critical appraisal of the identified articles were performed to assess the quality of the selected studies. Included studies were sorted into comparative and non-comparative studies to ease the process of analysis. Mortality rates of PHR were calculated for both groups of studies.
RESULTS
From the 869 articles that were initially identified, ten studies were selected for review, including randomised control trials (RCTs) and cohort studies. By applying the risk of bias assessment and critique tools, the methodologies of the selected articles ranged from moderate to high quality. The mortality rates among patients resuscitated with low volume and large volume in the selected RCTs were 21.5% (123/570) and 28.6% (168/587) respectively, whilst the total mortality rate of the patients enrolled in three non-comparative studies was 9.97% (279/2797).
CONCLUSIONS
The death rate amongst post-trauma patients managed with conservative resuscitation was lower than standard aggressive resuscitation, which indicates that PHR can create better survival rate among traumatised patients. Therefore, PHR is a feasible and safely practiced fluid resuscitative strategy to manage haemorrhagic shock in pre-hospital and in-hospital settings. Further trials on PHR are required to assess its effectiveness on the survival rate.
LEVEL OF EVIDENCE
Systematic review, level III.
Topics: Adult; Humans; Multiple Trauma; Resuscitation; Shock, Hemorrhagic; Survival Analysis
PubMed: 29079917
DOI: 10.1007/s00068-017-0862-y -
European Journal of Pediatrics Jul 2018Only a minority of babies require extended resuscitation at birth. Resuscitations concerning babies who die or who survive with adverse outcomes are increasingly subject...
UNLABELLED
Only a minority of babies require extended resuscitation at birth. Resuscitations concerning babies who die or who survive with adverse outcomes are increasingly subject to medicolegal scrutiny. Our aim was to describe real-life timings of key resuscitation events observed in a historical series of newborns who required full resuscitation at birth. Twenty-seven babies born in our centre over a 10-year period had an Apgar score of 0 at 1 min and required full resuscitation. The median (95% confidence interval) postnatal age at achieving key events were commencing cardiac compressions, 2.0 (1.5-4.0) min; endotracheal intubation, 3.8 (2.0-6.0) min; umbilical venous catheterisation 9.0 (7.5-12.0) min; and administration of first adrenaline dose 10.0 (8.0-14.0) min.
CONCLUSION
The wide range of timings presented from real-life cases may prove useful to clinicians involved in medical negligence claims and provide a baseline for quality improvements in resuscitation training. What is Known: • Only a minority of babies require extended resuscitation at birth; these cases are often subject to medicolegal interrogation • Timings of key resuscitation events are poorly described and documentation of resuscitation events is often lacking yet is open to medicolegal scrutiny What is New: • We present a wide range of real-life timings of key resuscitation events during the era of routine newborn life support training • These timings may prove useful to clinicians involved in medical negligence claims and provide a baseline for quality improvements in resuscitation training.
Topics: Documentation; Female; Humans; Infant, Newborn; Male; Resuscitation; Retrospective Studies; Time Factors; Time-to-Treatment; United Kingdom
PubMed: 29713811
DOI: 10.1007/s00431-018-3160-8 -
BMC Medical Ethics Sep 2021Deciding whether to resuscitate extremely preterm infants (EPIs) is clinically and ethically problematic. The aim of the study was to understand neonatologists'...
BACKGROUND
Deciding whether to resuscitate extremely preterm infants (EPIs) is clinically and ethically problematic. The aim of the study was to understand neonatologists' clinical-ethical decision-making for resuscitation of EPIs.
METHODS
We conducted a qualitative study in Belgium, following a constructivist account of the Grounded Theory. We conducted 20 in-depth, face-to-face, semi-structured interviews with neonatologists. Data analysis followed the qualitative analysis guide of Leuven.
RESULTS
The main principles guiding participants' decision-making were EPIs' best interest and respect for parents' autonomy. Participants agreed that justice as resource allocation should not be considered in resuscitation decision-making. The main ethical challenge for participants was dealing with the conflict between EPIs' best interest and respect for parents' autonomy. This conflict was most prominent when parents and clinicians disagreed about births within the gray zone (24-25 weeks). Participants' coping strategies included setting limits on extent of EPI care provided and rigidly following established guidelines. However, these strategies were not always feasible or successful. Although rare, these situations often led to long-lasting moral distress.
CONCLUSIONS
Participants' clinical-ethical reasoning for resuscitation of EPIs can be mainly characterized as an attempt to balance EPIs' best interest and respect for parents' autonomy. This approach could explain why neonatologists considered conflicts between these principles as their main ethical challenge and why lack of resolution increases the risk of moral distress. Therefore, more research is needed to better understand moral distress in EPI resuscitation decisions.
CLINICAL TRIAL REGISTRATION
The study received ethical approval from the ethics committee of UZ/KU Leuven (S62867). Confidentiality of personal information and anonymity was guaranteed in accordance with the General Data Protection Regulation of 25 May 2018.
Topics: Decision Making; Humans; Infant, Extremely Premature; Infant, Newborn; Neonatologists; Parents; Qualitative Research; Resuscitation; Resuscitation Orders
PubMed: 34563198
DOI: 10.1186/s12910-021-00702-7 -
British Medical Journal (Clinical... Jul 1987
Topics: Humans; Medical Staff, Hospital; Resuscitation; State Medicine; United Kingdom
PubMed: 3113637
DOI: 10.1136/bmj.295.6590.71