ABSTRACT
BACKGROUND AND CHALLENGE: Injuries, especially traumatic brain injury, or specific illnesses and their respective sequelae can result in the demise of the patients afflicted despite all efforts of modern intensive care medicine. If in principle organ donation is an option after a patient's death, intensive therapeutic measures are regularly required in order to maintain the homeostasis of the organs. These measures, however, cannot benefit the patient afflicted anymore-which in turn might lead to an ethical conflict between dignified palliative care for him/her and expanded intensive treatment to facilitate organ donation for others, especially if the patient has opted for the limitation of life-sustaining therapies in an advance directive. METHOD: The Ethics Section and the Organ Donation and Transplantation Section of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) have convened several meetings and a telephone conference and have arrived at a decision-making aid as to the extent of treatment for potential organ donors. This instrument focusses first on the assessment of five individual dimensions regarding organ donation, namely the certitude of a complete and irreversible loss of all brain function, the patient's wishes as to organ donation, his or her wishes as to limiting life-sustaining therapies, the intensity of expanded intensive treatment for organ protection and the odds of its successful attainment. Then, the combination of the individual assessments, as graphically shown in a {Netzdiagramm}, will allow for a judgement as to whether a continuation or possibly an expansion of intensive care measures is ethically justified, questionable or even inappropriate. RESULT: The aid described can help mitigate ethical conflicts as to the extent of intensive care treatment for moribund patients, when organ donation is a medically sound option. NOTE: Gerald Neitzke und Annette Rogge contributed equally to this paper and should be considered co-first authors.
Subject(s)
Decision Making , Emergency Medicine , Organ Transplantation , Tissue and Organ Procurement , Critical Care , Humans , Organ Transplantation/ethics , Tissue Donors , Tissue and Organ Procurement/ethicsABSTRACT
The Ethics Section of the German Interdisciplinary Association of Critical Care and Emergency Medicine (DIVI) recently published a documentation for decisions to withhold or withdraw life-sustaining therapies. The wish to donate organs was not considered explicitly. Therefore the Ethics Section and the Organ Donation and Transplantation Section of the DIVI together with the Ethics Section of the German Society of Medical Intensive Care Medicine and Emergency Medicine worked out a supplementary footnote for the documentation form to address the individual case of a patient's wish to donate organs.
Subject(s)
Critical Care , Emergency Medicine , Medical Overuse , Critical Care/statistics & numerical data , Germany , HumansSubject(s)
Critical Care , Decision Making , Emergency Medicine , Withholding Treatment , Documentation , HumansSubject(s)
Cooperative Behavior , Critical Care/ethics , Ethics, Medical , Interdisciplinary Communication , Advance Directive Adherence/ethics , Beneficence , Decision Support Techniques , Germany , Humans , Informed Consent/ethics , Medical Futility/ethics , Personal Autonomy , Societies, Medical , Terminal Care/ethics , Third-Party Consent/ethicsABSTRACT
The task of physicians is to maintain life, to protect and re-establish health as well as to alleviate suffering and to accompany the dying until death, under consideration of the self-determination rights of patients. Increasingly more and differentiated options for this are becoming available in intensive care medicine. Within the framework of professional responsibility physicians must decide which of the available treatment options are indicated. This process of decision-making is determined by answering the following question: when and under which circumstances is induction or continuation of intensive care treatment justified? In addition to the indications, the advance directive of the patient is the deciding factor. Medical indications represent a scientifically based estimation that a therapeutic measure is suitable in order to achieve a defined therapy target with a given probability. The ascertainment of the patient directive is achieved in a graded process depending on the state of consciousness of the patient. The present article offers orientation assistance to physicians for these decisions which are an individual responsibility.
Subject(s)
Critical Care/ethics , Case Management/ethics , Case Management/standards , Critical Care/standards , Emergency Medicine , Germany , Humans , Interdisciplinary Communication , Physician's Role , PhysiciansABSTRACT
We describe the use of low molecular weight heparin to treat venous thrombosis in two very low-birth-weight pre-term infants (GA: 30 and 27 weeks) both with genetic and acquired prothrombotic risk factors. Initially both infants were treated with unfractionated heparin. Since in one infant no effect on the thrombus size was observed and in the other infant there was an increase in size, the anticoagulation therapy was switched to subcutaneously injected low molecular heparin (Enoxaparin). During enoxaparin therapy the anti-Xa-level was carefully monitored and dosages were adjusted accordingly. Partial resolution of the thrombosis was achieved in both infants during enoxaparin therapy. No clot extension or recurrence of thrombosis occurred. An accidental overdose of Enoxaparin (100 times the required dosage) was administered to one infant without any consequences. Our data suggest that the use of low molecular weight heparin (Enoxaparin) for treatment of venous thrombosis in our two preterm infants was practical, safe and effective.
Subject(s)
Enoxaparin/administration & dosage , Fibrinolytic Agents/administration & dosage , Infant, Premature, Diseases/drug therapy , Infant, Premature, Diseases/genetics , Infant, Very Low Birth Weight , Thrombophilia/drug therapy , Thrombophilia/genetics , Venous Thrombosis/drug therapy , Venous Thrombosis/genetics , Dose-Response Relationship, Drug , Drug Administration Schedule , Factor V/genetics , Female , Genetic Carrier Screening , Humans , Infant , Infant, Newborn , Injections, Subcutaneous , Male , Mutation/genetics , Prothrombin/genetics , TripletsABSTRACT
BACKGROUND: Prematurity is a main issue in modern obstetrical care. The purpose of the present study was to evaluate the perinatal outcome of premature infants weighing less than 1500 g according to the mode of delivery. PATIENTS AND METHODS: 122 patients with infants weighing less than 1500 g were enrolled in this retrospective study (26 to 32 weeks of gestation). The perinatal outcomes of 26 infants born by vaginal delivery were compared to 96 infants delivered by caesarean section. RESULTS: The rates of rupture of membranes, preterm labour and intravenous tocolysis were significantly increased in patients after vaginal delivery. Preeclampsia and pathological cardiotocograms were increased in patients after caesarean section. Infants born by vaginal delivery showed a significant increase of peri- and intraventricular haemorrhage grade III, periventricular leukomalacia, C-reactive protein 24 hours postpartum and mortality until the seventh day of life. However, the rate of bronchopulmonary dysplasia was significantly increased in infants born by caesarean section (p < 0.05). CONCLUSIONS: These data suggest that the mode of delivery affects the perinatal outcome of infants weighing less than 1500 g. Based on the results of the present study, it appears unclear which mode of delivery should be preferred, depending on particular material and fetal factors.
Subject(s)
Cesarean Section/mortality , Infant Mortality , Infant, Premature, Diseases/mortality , Infant, Very Low Birth Weight , Natural Childbirth/mortality , Risk Assessment/methods , Germany/epidemiology , Humans , Infant, Newborn , Risk Factors , Survival AnalysisABSTRACT
Hypotension is diagnosed in a high percentage of very low birth weight infants, particularly in the first 24 hours after birth and the resultant clinical approach is to support the blood pressure vigorously. However, the research base is not yet available to give a definite answer to the question, which blood pressure is really unacceptable in a given clinical situation. The clinical approach usually relies on reference blood pressure data or on clinical considerations. Reference blood pressure ranges established from observations of rather stable preterm infants and commonly used in "normal" premature infants are age- and weight related so-called "normal" blood pressures and "rules of thumb" while cerebral autoregulation adapted or outcome related lower limits of arterial blood pressure could be promising alternatives. Clinical signs, results of laboratory studies and cardiac function monitoring are tools used in stable and unstable premature infants for assessing if an acute blood pressure is adequate to prevent tissue malperfusion. In this rather unsatisfactory situation there is a growing body of evidence that also in premature infants systemic or regional blood flow and not blood pressure are the crucial hemodynamic parameters and that also in this age group there is at best a weak correlation between mean arterial blood pressure and left ventricular output or regional blood flow.
Subject(s)
Blood Pressure , Infant, Premature/physiology , Age Factors , Birth Weight , Blood Circulation , Cardiac Output , Cerebrovascular Circulation , Coronary Circulation , Heart Rate , Hemodynamics , Homeostasis , Humans , Infant, Low Birth Weight , Infant, Newborn , Prognosis , Reference Values , Regional Blood Flow , Skin/blood supply , Ventricular Function, LeftABSTRACT
OBJECTIVE: To obtain normal M mode (one dimensional) echocardiographic values in a substantial sample of normal infants and children. DESIGN: Data were obtained over three years from a single centre in central Europe. PATIENTS: 2036 healthy infants and children aged one day to 18 years. METHODS: In line with recommendations for standardising measurements from M mode echocardiograms, and using digital echocardiographic equipment, measurements were obtained of the following: right ventricular anterior wall thickness at end diastole, right ventricular end diastolic dimension, thickness of interventricular septum at end diastole and end systole, thickness of posterior wall of the left ventricle at end diastole and end systole, left ventricular dimension at end diastole and end systole, pulmonary and aortic valve diameter, and left atrial dimension. RESULTS: Measurements are presented graphically on centile charts with respect to body surface area, and as tables with mean and 2 SD values for newborns in relation to body weight, and for infants and children in relation to body surface area. Best fitting regression equations are given for each measured variable, using the 50th centile values. CONCLUSION: In comparison with previously published normal values, the presented charts and tables make it possible to judge echocardiographic measurements of a particular patient as normal or abnormal.
Subject(s)
Echocardiography/standards , Adolescent , Adult , Body Surface Area , Child , Child, Preschool , Humans , Infant , Infant, Newborn , Reference Values , Regression AnalysisABSTRACT
OBJECTIVE: The purpose of this study was to assess the value of biometric lung measurements for the prediction of severe fetal pulmonary hypoplasia in congenital diaphragmatic hernia and to determine whether a correlation between lung measurements and autopsy findings or neonatal outcome could be established. DESIGN: Prospective study, between 1991 and 1997. SUBJECTS: Nineteen fetuses with congenital diaphragmatic hernia. METHODS: In addition to standard biometry, sonographic measurement of the transverse thoracic diameter, sagittal thoracic diameter, fetal lung diameters at the level of the four-chamber view and lung/thoracic circumference ratio were performed. These were compared with the standard curves defined by Merz and colleagues. Autopsy examinations were performed to determine lung weight, lung weight/body weight ratio and radial alveolar count. RESULTS: Five fetuses (26%) were terminated before 24 weeks of gestation. All of these fetuses had lung measurement values below the 5th centile. Eleven of 14 fetuses (78.6%) with pulmonary hypoplasia diagnosed after 24 weeks of gestation died postnatally. The mortality rate was 70% (7/10) in the fetuses without associated anomalies. The sonographic diagnosis of fetal pulmonary hypoplasia was made in all fetuses who died postnatally. All fetuses with a lung diameter/thoracic circumference ratio below 0.09 died. Three fetuses, which had values within the normal range, survived. In contrast, measurements of the bony thorax (transverse and sagittal thoracic diameters, thoracic circumference) did not provide an indication of the presence of fetal pulmonary hypoplasia. Pulmonary hypoplasia was confirmed at autopsy in all fetuses on the basis of lung weight, lung/body weight ratio or radial alveolar count. Concomitant with pulmonary hypoplasia was polyhydramnios in ten fetuses (71.4%), mediastinal shift in 11 fetuses (78.6%), intrathoracic herniated stomach in six fetuses (42.9%) and associated malformations in four fetuses (28.6%). Postnatal mortality for these conditions was 80%, 78.6%, 100% and 100%, respectively. Postnatal mortality was 75%, 70% and 100% in the fetuses with an isolated diaphragmatic hernia. CONCLUSION: The results of this investigation suggest that the assessment of fetal lung diameter and the use of the lung diameter/thoracic circumference ratio are further useful prognostic parameters in the management of congenital diaphragmatic hernia.
Subject(s)
Fetal Diseases/diagnostic imaging , Hernia, Diaphragmatic/diagnostic imaging , Lung/diagnostic imaging , Ultrasonography, Prenatal , Biometry , Female , Gestational Age , Hernia, Diaphragmatic/mortality , Hernias, Diaphragmatic, Congenital , Humans , Lung/embryology , Lung/pathology , Pregnancy , Prognosis , Prospective Studies , Survival AnalysisABSTRACT
OBJECTIVE: To determine incidence and management of prehospital emergencies in children. METHODS: Between November 15, 1994 and March 14, 1995 in the City of Mainz (200,000 inhabitants) children with the diagnosis of a prehospital emergency were identified. RESULTS: 390 children were discovered, 62% in the age group 0-3 years. 85% of the emergency conditions occurred at home. In 71% the medical practitioner providing prehospital care was a paediatrician, in 14% an emergency physician. 48% of the children were transported to the Children's Hospital by the parents. 32 different types of emergency were diagnosed, 8 types more than 10 times. A retrospective analysis of 386 emergencies demonstrated an acute life-threatening situation in 12%. Lacking a final diagnosis in 19%, first and final diagnosis were identical in 64% of all children evaluated. CONCLUSIONS: In Germany acute life-threatening emergencies are rare. Paediatricians are mainly involved also in the care of children with emergency conditions. Most pediatricians and nonpaediatricians are familiar with the relevant prehospital emergency conditions in the young children mainly concerned.
Subject(s)
Emergencies , Acute Disease , Adolescent , Age Distribution , Child , Child, Preschool , Diagnosis, Differential , Female , Germany/epidemiology , Humans , Incidence , Infant , Infant, Newborn , Male , Prospective Studies , Retrospective StudiesSubject(s)
Enteral Nutrition/methods , Enteral Nutrition/nursing , Intubation, Gastrointestinal/methods , Intubation, Gastrointestinal/nursing , Neonatal Nursing/methods , Enteral Nutrition/instrumentation , Humans , Infant Food , Infant, Newborn , Infant, Premature , Intubation, Gastrointestinal/instrumentation , Neonatal Nursing/instrumentationABSTRACT
UNLABELLED: The aim of this study was to assess the physical performance in long-term survivors of acute leukaemia in childhood and to evaluate the effects of anthracycline therapy. Electrocardiography, echocardiography and spiroergometry were carried out on 56 patients aged 9-28 years, of whom 44 patients had been treated with 15-483 mg/m2 doxorubicin (or equivalent). Acute leukaemia had been diagnosed 1.5-16 years earlier. Of the patients 75% reached normal maximal oxygen uptake, 69% normal oxygen uptake at the anaerobic threshold and 95% normal maximal work rate. Of the patients 75% achieved adequate values for maximal heart rate and 78% normal blood lactate concentration. No difference was seen between patients treated with and without anthracyclines. CONCLUSION: The results of this study provide little evidence for cardiopulmonary impairment in long-term survivors of ALL. Both the cardiac function, as evaluated by ECG and echocardiography, and the physical performance in spiroergometry are normal in a large number of these patients. Anthracycline treatment does not appear to have a negative effect on these parameters.
Subject(s)
Antibiotics, Antineoplastic/adverse effects , Daunorubicin/adverse effects , Doxorubicin/adverse effects , Leukemia, Myeloid, Acute/physiopathology , Precursor Cell Lymphoblastic Leukemia-Lymphoma/physiopathology , Adolescent , Antibiotics, Antineoplastic/administration & dosage , Child , Child, Preschool , Daunorubicin/administration & dosage , Doxorubicin/administration & dosage , Echocardiography , Electrocardiography , Female , Heart Rate , Humans , Infant , Leukemia, Myeloid, Acute/drug therapy , Male , Oxygen Consumption , Precursor Cell Lymphoblastic Leukemia-Lymphoma/drug therapy , Quality of Life , Spirometry , Time FactorsABSTRACT
Antenatal ultrasound screening for birth defects is increasingly becoming a routine procedure of prenatal care. Prenatal detection of malformations and subsequent adjustment of obstetric management are essential for secondary prevention. It is unknown whether ultrasound screening is effective in all pregnant women, or should only be performed in high risk populations. From 1990-1994, 20,248 livebirths, stillbirths and abortions underwent physical and sonographic examinations and anamnestic data were collected. To identify the high risk group, case control analyses of births with one of the 23 selected major malformations (controls) were performed with respect to anamnestic risk factors. All women had at least three routine ultrasound scans. The selected malformations were diagnosed in 298 children; 95 (30.3 per cent) were diagnosed antenatally. Detection rates were: CNS (68.6 per cent), gastro-intestinal tract (42.3 per cent), urinary system (24.1) per cent), heart (5.9 per cent). Complications during pregnancy were calculated as indicators of congenital anomalies: premature labour (< 28 week) OR 4.7 (3.8-5.9), placental insufficiency OR 1.9 (1.1-2.7) and vaginal bleeding OR 1.5 (1.2-1.8), etc. Antenatal routine ultrasound screening is not effective risk populations. Anamnestic risk factors risk factors during pregnancy may be essential indicators for identifying high risk populations. We propose screening of the described high risk pregnancies (about 22 per cent of all pregnancies) to be performed by specially trained and highly experienced ultrasonographers to increase sensitivity rates and benefit cost effectiveness.
