Ethics and law in the intensive care unit.

Intensive Care Medicine epitomises the difficulties inherent in modern medicine. In this chapter we examine some key medicolegal and ethical areas that are evolving. The principles of autonomy and consent are well established, but developments in UK caselaw have shown that the courts may be moving away from their traditional deference of the medical profession. We examine some recent cases and discuss the impact that these cases may have on practice in Intensive Care.

Skin tethering after dilatational percutaneous tracheostomy.

Percutaneous tracheostomy is increasingly preferred for patients in the Intensive Care Unit. It is a convenient method with a low incidence of complications. Skin tethering has not previously been emphasized as a complication of this technique and, although primarily cosmetic, may result in significant morbidity.

The use of pulmonary artery catheters in intensive care: time for reappraisal?

The precise role of the pulmonary artery catheter (PAC) in reducing the morbidity and mortality of intensive care patients remains uncertain. Future studies of the different patient groups who possibly benefit from their use may well require multicentre trials in order to include sufficient numbers and produce significant conclusions. This would suggest a need for a consensus opinion on how PACs are actually used to obtain the different physiological variables which can influence patient management. A questionnaire was designed to assess the degree of conformity of PAC use in intensive care; the questions were derived from a Medline search and considered by the authors to represent a cross-section of the different aspects and potential errors of PAC use. A postal questionnaire was sent from a District General Hospital to 42 adult Intensive Care Units (ICUs) requesting information on the use of PACs in each ICU. The reply rate was 93%, with all but one of the respondents using PACs. The questionnaire obtained information in different areas of PAC use: 1. General usage of PACs. 2. Measurement of patient height and weight. 3. Confirmation of position of PAC tip. 4. Measurement of pulmonary artery wedge pressure (PAWP). 5. Measurement of cardiac output (CO). 6. Derived values. 7. Monitoring for PAC-related sepsis. The results of the questionnaire demonstrated a considerable lack of standardisation in the use of PACs in the United Kingdom.(ABSTRACT TRUNCATED AT 250 WORDS)

Metabolic acidosis and fatal myocardial failure after propofol infusion in children: five case reports.

OBJECTIVE: To examine the possible contribution of sedation with propofol in the deaths of children who were intubated and required intensive care. DESIGN: Case note review. SETTING: Three intensive care units. SUBJECTS: Five children with upper respiratory tract infections aged between 4 weeks and 6 years. RESULTS: Four patients had laryngotracheo-bronchitis and one had bronchiolitis. All were sedated with propofol. The clinical course in all five cases was remarkably similar: an increasing metabolic acidosis was associated with brady-arrhythmia and progressive myocardial failure, which did not respond to resuscitative measures. All children developed lipaemic serum after starting propofol. These features are not usually associated with respiratory tract infections. No evidence was found of viral myocarditis, which was considered as a possible cause of death. CONCLUSION: Although the exact cause of death in these children could not be defined, propofol may have been a contributing factor.

Hemodynamic effects of atracurium, vecuronium and pancuronium during sufentanil anesthesia for coronary artery bypass.

A study was undertaken to evaluate the cardiovascular effects of sufentanil, in combination with three different muscle relaxants, used as sole anesthetic with 100% O2 in 30 patients undergoing elective coronary artery vein graft surgery. Patients were randomly allocated to receive pancuronium (P), vecuronium (V) or atracurium (A) for muscle relaxation. All patients received 15 micrograms/kg sufentanil at induction followed by 5-10 micrograms/kg sufentanil prior to sternotomy. At the 95% level of significance no statistical difference was found for any of the measured and derived cardiovascular parameters between groups P, V and A, except for a decreased systolic blood pressure in the atracurium group after induction. Sufentanil in combination with pancuronium or vecuronium provided stable hemodynamic conditions throughout anesthesia. Atracurium was less satisfactory. We conclude that there is no advantage to be gained, in the presence of beta blockade, from the use of the new generation muscle relaxants as compared to pancuronium during high-dose sufentanil anesthesia for coronary artery vein grafting.

The evaluation of domperidone and metoclopramide as antiemetics in day care abortion patients.

A randomised double-blind investigation was undertaken to assess the value of domperidone and metoclopramide as prophylactic anti-emetics in unpremedicated patients undergoing general anaesthesia for therapeutic abortion on a day care basis. Sixty patients were divided into three groups, and received, at induction, one of three drugs intravenously. The incidences of postoperative nausea and vomiting were 35% in the group receiving normal saline as placebo, 30% in the group receiving 10 mg domperidone and 25% in the group receiving 10 mg metoclopramide; these were not statistically significantly different. Furthermore, there was no statistically significant difference in the incidence of postoperative nausea and vomiting as influenced by age, weight, length of gestation, anaesthetic time and a history of nausea and vomiting during the pregnancy.

Serum morphine levels. A comparison between continuous subcutaneous infusion and continuous intravenous infusion in postoperative patients.

A study was undertaken to compare continuous subcutaneous infusions of morphine with continuous intravenous infusions in patients whose lungs were mechanically ventilated for 24 hours postoperatively. Serum morphine levels were measured after the end of surgery and at 6, 12, 18 and 24 hours in nine patients receiving continuous subcutaneous morphine and in four patients receiving continuous intravenous morphine given at the same rate. At 6, 12, 18 and 24 hours the means of serum morphine levels in the intravenous group were 20 ng/ml, 17.75 ng/ml, 18.5 ng/ml and 18 ng/ml, respectively, the corresponding figures in the subcutaneous group being 23.2 ng/ml, 20 ng/ml, 20.7 ng/ml and 20 ng/ml. For the intravenous route the mean dose of supplementary analgesia was 14 mg of phenoperidine in the first 24 postoperative hours, whereas for the subcutaneous route the mean dose was 11.66 mg. The differences in the serum morphine levels and in the requirements of phenoperidine were not statistically significant. We conclude that a continuous subcutaneous infusion of morphine is a simple and effective means of achieving postoperative analgesia.