ABSTRACT
We study the decisions taken in five real cases by 178 doctors working in hospital emergency services and compare their decisions with those proposed a reference group composed of professionals with a master's degree in bioethics. The findings of our study point to an increased ability to take difficult decisions in critical situations involving the use of life-support measures in the emergency room. The group of professionals chosen as "gold standard", despite lacking the training and clinical preparation of emergency doctors, made decisions that were technically very close to the most suitable. In this respect, an adequate ethical training facilitated the taking of decisions that required the involvement of personally held values, underlining the need for such training in the case of professionals who will work in hospital emergency services.
Subject(s)
Bioethics/education , Decision Making , Education, Medical/standards , Emergency Service, Hospital/standards , Physicians/standards , Adult , Attitude of Health Personnel , Data Collection , Female , Humans , Interdisciplinary Communication , MaleABSTRACT
OBJECTIVE: To analyze the influence of prognosis, life quality or previous instructions in the decision making of applying an invasive (intubation/mechanical ventilation), conservative or palliative procedure. MATERIAL AND METHODS: "Casuistry" methodology: opinion on the appropriate decision regarding five clinical histories representative of ethic conflicts with 542 health professionals (220 intensive care specialist, 150 emergency department professionals, 76 nurses, and 96 students). As control group, 26 students enrolled in a International Master on Bioethics. RESULTS: A great inter-group variability was observed (p = 0.005) with a higher agreement with control group between students and lower with intensivists. The agreement observed was highest in cases with "total support" as the appropriate option (kappa 0.85, 0.69, and 0.66) than in cases with "palliative measures" as appropriate option (kappa 0.22 and 0.46). CONCLUSIONS: 1) A high variability was observed regarding decisions on instituting respiratory support. 2) Decisions regarding the restriction of therapeutic efforts are not accepted in the main, even in scenarios merging into futility, as permanent vegetative status. 3) Among severely deteriorated and handicapped patients, perceived life quality is more appreciated by the patient than that estimated objectively. 4) There is no a consensus opinion for the respect of previous guidelines of vital support refusal. 5) Age and deep psychic deficiency are not considered as cause of discrimination. These features may be considered typical of the mediterranean ethics, in which paternalism and charity are more appreciated values than autonomy.
Subject(s)
Attitude of Health Personnel , Ethics, Medical , Respiration, Artificial , Critical Care , Emergency Service, Hospital , Humans , Spain , Students, MedicalABSTRACT
Objetivo. Analizar la influencia del pronóstico, calidad de vida o instrucciones previas en la decisión de aplicar procedimiento invasivo (intubación/ventilación mecánica), conservador o paliativo. Metodología casuística: opinión sobre la decisión adecuada ante 5 historias representativas de conflictos éticos de 542 profesionales (220 intensivistas, 150 emergenciólogos, 76 enfermeras y 96 alumnos). Como grupo control, 26 alumnos de un Máster Internacional de Bioética. Resultados. Se observa gran variabilidad intergrupos (p = 0,005), con mayor coincidencia con el grupo control entre los alumnos y menor en los intensivistas. La concordancia es más elevada en los casos en que la opción adecuada es soporte total (Kappa 0,85, 0,69 y 0,66) que cuando lo apropiado es medidas paliativas (Kappa 0,22 y 0,46). Conclusiones. 1) Se observa una gran variabilidad en las decisiones sobre instauración de soporte respiratorio.2) Las decisiones de limitación del esfuerzo terapéutico no son mayoritariamente aceptadas, incluso en escenarios que entran en el terreno de la futilidad, como el estado vegetativo permanente. 3) En enfermos muy evolucionados y con grandes limitaciones se valora más la calidad de vida percibida por el paciente que la estimada objetivamente. 4) No existe una opinión mayoritaria por el respeto de directrices previas de rechazo al soporte vital.5) No son tenidas en cuenta la edad y la deficiencia psíquica profunda como causa de discriminación. Estos rasgos quizá puedan considerarse característicos de la ética mediterránea, en la que el paternalismo y la beneficencia constituyen valores más apreciados que la autonomía (AU)
Subject(s)
Humans , Respiration, Artificial , Attitude of Health Personnel , Ethics, Medical , Spain , Students, Medical , Critical Care , Emergency Service, HospitalABSTRACT
The withdrawal or withholding of life support measures in irreversible situations is an accepted practice among clinicians all over the world. Nonetheless, with respect to nutrition and tube feeding, notable differences can be found between the literature coming from the United States and the opinions of clinicians in Spain, probably due to the differing social and cultural traditions. Whereas the dominant criteria in the United States is to consider tube feeding and hydration as "extraordinary" or "disproportionate" measures, and thereby potentially omitted in such situations, the most widespread opinion in Spain is that they must be included as part of basic care, must be maintained at all times and that their suppression might represent severe discrimination in the case of weaker patients. As a result, a prudent strategy to cope with this problem might be first to consider the two indications of artificial nutrition and hydration: as a procedure to combat hypercatabolic problems and organ failures or as a maintenance measure in patients with normal needs where the oral route is not available. Although the first deserves to be considered as a life support measure and could be omitted in the same circumstances as mechanical ventilation or dialysis, the second case can be considered as part of personal care on a similar level as body hygiene, in which case omission could eventually breach the ethical principles of Justice and No Maleficence.
Subject(s)
Enteral Nutrition , Ethics, Medical , Euthanasia, Passive , Attitude , Cultural Characteristics , Humans , Mediterranean Region , Spain , United StatesABSTRACT
150 tetanus cases registered on the region of Murcia have been retrospectively analyzed, they have been collected from the patients admitted at a Intensive Care Unit during a period of 18 years; the clinical together with the epidemiological features, as well as their variations, have been studied through out the years. The impact of a vaccination program in adults which was performed in our region during 1981 has been also evaluated in relationship with the incidence of disease and the economical cost of it. Incidence remained homogeneous until 1982, from that date on a sudden decrease on the number of cases was observed, related with the vaccination program [Period previous to the vaccination program: mean 10 cases/year, versus 5 cases/year since it was started (p < 0.001)]. Regarding the epidemiological characteristics, it is remarkable the shift of the disease toward a more advanced age of onset together with a predominance on females beginning in 1978, but without reaching statically significance. More frequent route of infection is nowadays the intramuscular suppurative injection. Besides this fact the severity of the cases have been increasing (from 59% to 71%, p < 0.005), which has determined that the global mortality of the disease remains almost the same (38%). Mortality has no relationship with age, but is related with being a female (p < 0.05), with intramuscular injection as route of infection (p < 0.025), with the clinical stage (p < 0.001) and with a short incubation period (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)
Subject(s)
Tetanus/epidemiology , Adolescent , Adult , Age Factors , Aged , Chi-Square Distribution , Child , Female , Humans , Incidence , Male , Middle Aged , Retrospective Studies , Sex Factors , Spain/epidemiology , Tetanus/diagnosis , Tetanus/economics , Tetanus/prevention & control , Tetanus Toxoid/economics , Tetanus Toxoid/immunologyABSTRACT
BACKGROUND: The pneumonias associated to mechanical ventilation present great difficulty in diagnosis and have a high mortality. The invasive diagnostic technique of choice in these patients is bronchial curettage by a double telescopic catheter with distal occlusion (OTC) based on its good sensitivity/specificity relation. Recently, the use of a variant of the classical bronchoalveolar lavage (BRL), bronchoalveolar lavage or protected alveolar lavage (PAL) has appeared in the diagnosis of conventional bacterial pneumonia. This new technique provides good specificity of OTC by its use with "protected" catheters and a high sensitivity due to exploration of a greater area of the lung. METHODS: Twenty patients receiving mechanical ventilation (MV) suspected of pneumonia in whom 21 fibrobronchoscopies (FB) were performed with OTC and PAL were studied with quantification of the cultures obtained being carried out. The OTC was performed according to the usual technique and PAL by the instillation of 40 ml of saline serum administered through a Combicath type catheter. RESULTS: OTC and PAL provided diagnostic results which coincided in 8 cases: the same germs were isolated at significant concentrations in six patients and in the two remaining cases direct immunofluorescence for Legionella was positive. PAL was diagnosed in 4 more cases with the diagnosis of viral inclusion bodies being possible in one upon cytologic examination. The count of cells with intracellular bacteria (ICB) was greater than 7% and was always related with positivity in the PAL. CONCLUSIONS: A greater sensitivity was observed with the protected alveolar lavage technique. Moreover, this technique makes virologic investigation and the counting of cells with intracellular bacteria, which may be a marker of rapid diagnosis of bacterial pneumonia, possible.
Subject(s)
Bronchoalveolar Lavage Fluid , Catheterization, Peripheral/instrumentation , Pneumonia/diagnosis , Respiration, Artificial , Adolescent , Adult , Bronchoalveolar Lavage Fluid/microbiology , Bronchoalveolar Lavage Fluid/pathology , Female , Humans , Male , Middle Aged , Pneumonia/microbiology , Pneumonia/pathology , Prospective StudiesABSTRACT
The negative effect of artificial ventilation with positive pressure on renal function, expresses itself as a decrease of water and sodium excretion, being directly related with the raise of intrathoracic pressure. Factors participating in this process are: lowering in cardiac output, arousal of sympathic nervous system, increase in vasopressin action, activation of renin-angiotensin-aldosterone system and decrease of atrial natriuretic peptide release. This disorder of hydromineral metabolism produces: Impairment of hemodynamic equilibrium, favors the increase of hypoxia and renal failure. The effects of mechanical ventilation on renal function can be attenuated with the adoption of the following measures: a) techniques (use of low levels of PEEP and early disconnection of respirator); b) therapeutic (dopamine 2-3 mcg/kg/min, rational use of diuretics and fluids); y c) monitoring of renal function and hydro-mineral equilibrium.
Subject(s)
Renal Insufficiency/etiology , Respiration, Artificial/adverse effects , Acute Disease , Animals , Humans , Kidney/physiology , Pulmonary Circulation/physiologyABSTRACT
In order to assess the bacteriology of bronchial secretion samples, 40 patients in the intensive care unit who had developed fever and pulmonary infiltrates during mechanical ventilation have been studied. In each patient bronchial secretion samples were obtained by a double lumen distally-plugged telescopic catheter (DTC) inserted under direct view through the fiber bronchoscope (FB) as well as from simple bronchial aspiration (SBA) done simultaneously. A week later DTC and SBA were repeated. A statistically significant difference was found between the positive cultures obtained by SBA and those obtained by DTC (p less than 0.005). However, in 9 samples (14.27%) other microorganisms were isolated with DTC which were not detected by SBA and a lower number of colonizing microorganisms were found by DTC (p less than 0.05). The isolation of microorganisms by DTC allowed more precise management and moreover, a better clinical course was observed in those patients in whom chemotherapy was based on the data given by DTC. The relationship between the cultures obtained by DTC and the previous antibiotic treatment was statistically significant, finding a greater number of positive cultures when they were taken 2 hours after the last doses of the antibiotic. This relationship was not found in the cultures obtained with SBA. The most frequently isolated microorganisms were diverse types of Pseudomonas and Acinetobacter. No complication caused by the techniques arose.
Subject(s)
Bronchi/metabolism , Catheterization, Peripheral/instrumentation , Lung Diseases/etiology , Respiration, Artificial/adverse effects , Adolescent , Adult , Aged , Catheterization, Peripheral/methods , Female , Humans , Lung Diseases/microbiology , Lung Diseases/pathology , Male , Middle AgedABSTRACT
We propose a procedure for assessing the pulmonary airway resistance of patients under mechanical ventilation with a volume-cycled respirator having a sine-wave flow curve and inspiration/expiration (I/E) ratio of 1/2. This simplified procedure requires only the respirator's manometer and spirometer. The method is based on Ohm's Law, dividing the pressure difference (as shown on the manometer) between the peak value and that obtained by occluding the expiratory outlet by one-tenth of the minute volume (Vm). The relationship between the Vm and flow is obtained by calculating the height of the triangle formed by the sine wave, given that the area approximates total volume and the base is derived from the frequency and I/E ratio. This method was tested in 296 measurements on 106 patients using as a control the determination of resistance with a pneumotachograph and differential manometer placed between the patient and respirator. There was a high correlation (r = 0.96) between both procedures. To further facilitate bedside use, we have prepared a graph relating common values of Vm and pressure to resistance.
