Extracorporeal life support for adults with severe acute respiratory failure.

Extracorporeal life support (ECLS) is an artificial means of maintaining adequate oxygenation and carbon dioxide elimination to enable injured lungs to recover from underlying disease. Technological advances have made ECLS devices smaller, less invasive, and easier to use. ECLS might, therefore, represent an important step towards improved management and outcomes of patients with acute respiratory distress syndrome. Nevertheless, rigorous evidence of the ability of ECLS to improve short-term and long-term outcomes is needed before it can be widely implemented. Moreover, how to select patients and the timing and indications for ECLS in severe acute respiratory distress syndrome remain unclear. We describe the physiological principles, the putative risks and benefits, and the clinical evidence supporting the use of ECLS in patients with acute respiratory distress syndrome. Additionally, we discuss controversies and future directions, such as novel technologies and indications, mechanical ventilation of the native lung during ECLS, and ethics considerations.

Limitación del esfuerzo terapéutico en Pediatría / Limitation of therapeutic effort in Pediatrics

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[Ethical conflicts in the surgical intensive care setting - impact of ethics consultations]. / Ethische Grenzsituationen in der chirurgischen Intensivmedizin - Bedeutung einer ethischen Fallberatung.

INTRODUCTION: In surgical intensive care medicine an increase in ethical conflicts regarding treatment plans has been observed due to marked changes in medical possibilities and social epidemiology resulting in intensive care treatment of old and oldest patients following surgery, trauma or transplantation. Without ethical support, physicians, nurses, and families are not able to come to a decision about medical treatment when value conflicts are involved. METHODS: We present a report on the basis of medical ethics and personal experience and provide an overview on the impact of ethics consultations. RESULTS: Ethical conflicts are common in the surgical intensive care setting, since the patient's preferences often are not known exactly, and in modern "high-tech" intensive care medicine the prognosis of recovery and / or quality of life of (old) patients seems to be hard to assess. Ethical definitions of treatment perspectives will find an important and increasing place in intensive care competence in the future, although nowadays there is a lack of theoretical and practical instruction in ethics. The goal of ethics consultations is to help physicians, nurses and family members by structuring the problem and by a moderation of discussion and problem resolution including a special "ethical workflow". Ethics consultations seem to be useful in resolving conflicts that may inappropriately prolong unwanted treatments. CONCLUSIONS: The incidence of ethical conflicts increases even in surgical intensive care units and ethics consultations may help in the integration of ethics principles in clinical practice.

[Ten myths about withdrawal of mechanical ventilation in terminal patients]. / Diez mitos sobre el retiro de la ventilación mecánica en enfermos terminales.

The most difficult of treatment limitation decisions, both for physicians and families, is the withdrawal of mechanical ventilation (MV). Many fears and uncertainties appear in this decision. They are described as ten myths whose falseness is argued in this article. The myths are: 1) Withdrawing MV causes the patients death; 2) Withdrawing MV is euthanasia; 3) Withholding and withdrawing MV are morally different; 4) MV can be withdrawn only when the patient has asked for it; 5) Chilean law only authorizes to withdraw VM when brain death has occurred; 6) Withdrawing MV cannot be done if the patient is not an organ donor; 7) Physicians who withdraw MV are in high risk of legal claims; 8) To withdraw MV the physician needs an authorization from the hospital ethics committee, lawyer or institutional authority; 9) There is only one way to withdraw MV; 10) Withdrawing MV produces great suffering to the patients family. Making clear that these myths are false facilitates appropriate decisions, therefore preventing therapeutic obstinacy and more suffering of terminally ill patients, which favors their peaceful death. For the physician this goal should be as rewarding as preventing the death of a curable patient.

Hippocrates is alive and weaning in Brazil.

In a group of postoperative patients, Taniguchi and coworkers compared the effect of a computerized system for weaning against 'manual care'. The computerized system involved automatic adjustments to the level of pressure support to achieve a target respiratory rate. Manual care involved adjustments to the level of pressure support to keep the ratio of respiratory frequency to tidal volume below 80. The duration of ventilator weaning was equivalent with the two approaches. The level of pressure support, however, was lower with manual care than with computerized ventilation. The study adds support to the notion that ventilator duration is shortened when weaning is contemplated at the earliest possible time. The findings also emphasize the importance of the Hippocratic dictum that patient outcome is improved when care is individualized rather than delivered according to a protocol.

El caso de Inmaculada Echevarría: implicaciones éticas / The case of Inmaculada Echevarría: ethical and legal implications

Inmaculada Echevarría padecía una distrofía muscular progresiva dependiente de ventilación mecánica. En octubre de 2006 solicitó ser sedada y desconectada del ventilador. En la primera parte del trabajo se exponen los datos clínicos y biográficos del caso. Luego se presentan las decisiones de la Comisión Autonómica de Ética e Investigación de Andalucía y el Consejo Consultivo de Andalucía, que evaluaron el caso, y el desenlace final. La segunda parte señala los antecedentes del debate, con casos como los de Ramón Sampedro, Jorge León o Madeleine Z. Luego se presentan los cuatro escenarios diferentes sobre la toma de decisiones al final de la vida que el debate ha ido clarificando en estos años: eutanasia y suicidio asistido, limitación del esfuerzo terapéutico, rechazo de tratamiento y sedación paliativa. El artículo concluye que, tras el caso de Inmaculada Echevarría, pueden darse por aclarados los tres últimos. Es el primero lo que la sociedad española deberá afrontar en los próximos años

Inmaculada Echevarría was a woman withProgressive Muscular Dystrophy who was totallydependent on mechanical ventilation. In October2006, she publicly asked to be disconnected ofthe ventilator. The clinical and biographical dataof the case are presented in the first part of thework. The paper goes on to explain the decisionsof the two committees that evaluated her request,that is the Regional Ethics Committee and theConsultative Council of Andalusia. Finally, theoutcome of the case is presented. The secondpart analyzes the background of the debate onend-of-life decision making in Spain in cases suchas those of Ramon Sampedro, Jorge Leon orMadeleine Z. It then presents four different settingsof end-of-life decision making that havebeen clarified over these last years: euthanasiaand assisted suicide, limitation of life-prolongingtreatment, treatment refusal and palliative sedation.The article concludes that the latter threecan be considered as sufficiently clarified afterthe case of Inmaculada Echevarría. However, thefirst one, that is euthanasia and assisted suicide,must be confronted by the Spanish society inforthcoming years

How to withdraw mechanical ventilation: a systematic review of the literature.

Eight published accounts about ventilator withdrawal spanning 1992-2004 were selected for review. Articles were selected if they contained data that described the processes comprising the withdrawal of mechanical ventilation as a terminal illness event. The purpose of this article is to synthesize the existing evidence about processes for the compassionate withdrawal of mechanical ventilation from intensive care unit patients, including measures of distress, premedication, medication during withdrawal, withdrawal methods, extubation considerations, duration of survival, and relationship of opioids or benzodiazepines to duration of survival. Practice recommendations will be suggested.

Critical incident: reflection on the process of terminal weaning.

The article uses critical incident analysis to reflect on the process of terminal weaning. Terminal weaning is defined in the context of withdrawing ventilatory support when the expected outcome is the patient's death. Basic ethical concepts are identified, and the role of the nurse in ethical decision making is discussed in relation to the associated professional and legal issues. Conflict exists between professional and legal accountability in relation to advocacy. Caution is advised with regard to nurses becoming involved in the decision to terminally wean, and its practice.