Outcomes of patients treated with noninvasive ventilation by a medical emergency team on the wards.

BACKGROUND: Initiation of noninvasive ventilation (NIV) on the wards is not universally accepted. Medical emergency teams (METs) provide acute care and monitoring to deteriorating patients on the general wards. Whether it is safe for an MET to start NIV in ward patients with respiratory distress remains unclear. METHODS: We evaluated 1,123 MET calls in 30,217 ward patients between January 2009 and June 2011 from the prospectively maintained MET database in our tertiary care hospital. We identified ward patients with acute desaturation (< 90%) and tachypnea (breathing frequency > 28 breaths/min), for whom an MET was called. Subjects transferred to the ICU at the end of an MET call were excluded. The remaining ward subjects were divided into 2 groups: patients who were not started on NIV by the MET; versus patients who were started on NIV by the MET. The primary outcome was endotracheal intubation or ICU transfer within 48 hours of MET activation. Secondary outcome measures were 28-day mortality and ICU mortality. RESULTS: Two hundred thirty-eight MET subjects met the study criteria, and 109 immediate ICU transfers were excluded. Of the remaining 129 ward subjects, 54 were in the NIV group, and 75 in the no-NIV group. The NIV group subjects were sicker (mean Acute Physiology and Chronic Health Evaluation II score 17.6 ± 5.1 versus 14.4 ± 5, P < .001). Subjects with pulmonary edema, COPD exacerbation, or asthma exacerbation were more likely, while those with pneumonia were less likely to be placed on NIV. The primary outcome was reached in 2/54 (3.7%) of the NIV subjects and 12/75 (16%) of the no-NIV subjects (P = .03). There was no significant difference (P > .30) between the groups in 28-day mortality (7.4% vs. 13.3%) or ICU mortality (3.7% vs 8%). CONCLUSIONS: In selected ward patients, especially those with COPD or pulmonary edema, NIV can be safely initiated by an MET.

Outcome of hypotensive ward patients who re-deteriorate after initial stabilization by the Medical Emergency Team.

PURPOSE: We evaluated the outcome of hypotensive ward patients who re-deteriorated after initial stabilization by the Medical Emergency Team (MET) in our hospital, due to limited data in this regard. METHODS: One thousand one hundred seventy-nine MET calls in 32184 ward patients from January 2009 to August 2011 were evaluated. Four hundred ten hypotensive patients met study criteria and were divided into: (1)"Immediate Transfers (IT), n = 136":admitted by MET to intensive care unit (ICU) immediately; (2)"Re-deteriorated Transfers (RDT) n = 72":initially stabilized and signed off by MET, but later re-deteriorated within 48-hours and admitted to ICU; (3)"Ward Patients (WP) n = 202": remained stable on ward after treatment. RESULTS: The RDT and IT had similar APACHE II scores (20.2 ± 5.1 vs. 19.8 ± 4.8; P=.57], but RDT showed hemodynamic stabilization with initial MET resuscitation. Patients who re-deteriorated were younger, took longer for eventual ICU transfer, had higher initial lactic acid and delayed normalization as compared to IT (P < .04). The re-deterioration predominantly occurred within 8-hours of MET evaluation. RDT had higher 28-day mortality than IT and WP; 42% vs. 27% vs. 7% respectively (P < .03). RDT also had a higher rate of endotracheal intubation and worse ICU mortality (P < .01). CONCLUSION: Hypotensive ward patients who re-deteriorate after initial stabilization have higher mortality. METs should consider implementing at least an 8-hour follow-up in patients who are deemed stable to remain on the wards after hypotensive episodes.

End-of-life care in Muslim brain-dead patients: a 10-year experience.

BACKGROUND: In Muslim countries, end-of-life practices in Muslim brain-dead patients are unknown. We conducted this study to evaluate this issue. RESULTS: We identified 42 brain-dead patients between 2001 and 2011. The expectant terminal extubation occurred only in 5. Largely due to family opposition, 2 patients remained "full code," and rests were "do not attempt resuscitation" with varying usage of "life-sustaining" therapies. Only 2 out of 24 eligible patients donated organs. There was minimal involvement of social worker, palliative team, or Muslim chaplain in the end-of-life discussions. CONCLUSION: In Muslim patients, the concept of terminal withdrawal and organ donation after brain death is still not well accepted. Future multicenter studies, involving palliative teams, should focus on improving these issues.