Choosing life support for suddenly severely ill elderly relatives.

OBJECTIVE: To determine whether relatives are more likely to request intensive treatment for elderly relatives than the elderly parents would wish for themselves, and to explore the reasons which drive this behaviour. METHODS: A potential end-of-life scenario was presented to 30 elderly people and also to their next generation relative who could be required to be a surrogate decision-maker for their elderly relative in the future. A semi-structured interview (which was designed to avoid the use of leading questions) was undertaken by a trained psychology researcher to ascertain the views of the subjects with regard to treatment choices and the motivation underlying these views. RESULTS: Of the potential patients, 83% reported that they would not want intensive treatment in the hypothetical situation. However, while 76% of surrogates also stated that they believed that treatment was inappropriate, all of the surrogates elected to initiate treatment. The need for time to get the family together, the need to reach family consensus and the need to be more certain of prognosis, were major influences which led the surrogates to request initiation of intensive treatment. CONCLUSIONS: Better understanding of the factors which motivate surrogate decision-makers may help the development of measures to avoid the inappropriate use of high technology treatment at the end of life and to achieve outcomes which better match the wishes of the patients whom we treat. Measures which encourage elderly, chronically ill patients to determine their treatment (e.g. by advance directives), rather than delegating the responsibility to relatives, are likely to result in less demand for inappropriate intensive care treatment.

How doctors discuss major interventions with high risk patients: an observational study.

OBJECTIVE: To investigate the difficulties doctors face in discussing treatment options with patients with acute, life threatening illness and major comorbidities. DESIGN: Observational study of doctor-patient interviews based on a standardised clinical scenario involving high risk surgery in a hypothetical patient (played by an actor) with serious comorbidities. PARTICIPANTS: 30 trainee doctors 3-5 years after graduation. MAIN OUTCOME MEASURES: Adequacy of coverage of various aspects was scored from 3 (good) to 0 (not discussed). RESULTS: The medical situation was considered to be well described (median score 2.7 (interquartile range 2.1-3.0)), whereas the patient's functional status, values, and fears were poorly or minimally addressed (scores 0.5 (0.0-1.0), 0.5 (0.0-1.0), and 0.0 (0.0-1.5), respectively; all P < 0.001 v score for describing the medical situation). Twenty nine of the doctors indicated that they wished to include the patient's family in the discussion, but none identified a preferred surrogate decision maker. Six doctors suggested that the patient alone should speak with his family to reach a decision without the doctor being present. The doctors were reluctant to give advice, despite it being directly requested: two doctors stated that a doctor could not give advice, while 17 simply restated the medical risks, without advocating any particular course. Of the 11 who did offer advice, eight advocated intervention. CONCLUSIONS: Doctors focused on technical medical issues and placed much less emphasis on patient issues such as functional status, values, wishes, and fears. This limits doctors' ability to offer suitable advice about treatment options. Doctors need to improve their communication skills in this difficult but common clinical situation.

Pyroglutamic acidemia: a cause of high anion gap metabolic acidosis.

OBJECTIVE: To report four cases of pyroglutamic acidemia in adults causing clinically significant acidosis. DATA SOURCES: Patients admitted to the intensive care units of the Alfred Hospital (a quaternary referral center) and Geelong Hospital (a major regional center) with an unexplained high anion gap acidosis. CONCLUSIONS: Pyroglutamic acidemia (5-oxoprolinemia) is a rare cause of high anion gap metabolic acidosis that should be suspected in patients presenting with sepsis, hepatic, and/or renal dysfunction who are receiving drugs such as acetaminophen, flucloxacillin, and vigabatrin after the more common causes of a high anion gap acidosis have been excluded. Should pyroglutamic aciduria be present, known precipitants should be ceased, infection should be managed aggressively, and supportive management should be instituted.

A simple method for frequent monitoring of gastric carbon dioxide.

Intragastric PCO2 has been recognized to rise in states of gastric hypoperfusion. A device including a gas-permeable balloon on a conventional sump nasogastric tube (TRIP catheter, Tonometrics) has permitted simple measurement of the intragastric PCO2 following equilibration of intragastric PCO2 with saline in the balloon. This method is slow to equilibrate and time-consuming. We describe an automated method using air instead of saline in the balloon with measurement using capnography. Equilibration is much faster using air and the automated system permits measurements to be taken at regular intervals (10 minutes) without additional workload.

A comparison of five devices for the bedside monitoring of heparin therapy.

Five instruments were tested for their capacity to monitor heparin therapy on whole blood at the bedside. The instruments were 512 Coagulation Monitor (Ciba-Corning), Thrombotrack (Nycomed), Automated Coagulation Timer (Hemotec), Hemochron-ACT and Hemochron-APTT (International Technidyne Corporation). Fifty subjects with various levels of heparinisation were tested on each instrument and were also assayed for antithrombin III, fibrinogen, haematocrit, platelet count and plasma heparin level. The results were compared with a reference APTT performed on the Automated Coagulation Laboratory 300R (Instrumentation Laboratories). The Hemochron-ACT correlated least well. The Hemotec and Thrombotrack were unsuitable in a clinical setting because of pipetting requirements, although the Thrombotrack did correlate well with the reference parameters. The 512 Coagulation Monitor was the simplest to use, but its maximum response corresponded to the midpoint of the reference APTT therapeutic range. The Hemochron-APTT was simple to use, had an adequate response range and correlated well with reference parameters.

Extracorporeal circulation in the management of massive propranolol overdose.

A case of refractory hypotension following propranolol overdose is reported. Management included isoprenaline, glucagon and extracorporeal circulatory support using femoral vein-femoral artery bypass. The unreliability of neurological observations, especially unreactive pupils, in the presence of drug overdose is reiterated.

Minitracheotomy Seldinger--assessment of a new technique.

A multicentre, prospective study of 26 patients was undertaken for the assessment of insertion of minitracheotomy tubes by the Seldinger technique. The technique of insertion is described. There were two misplacements, three blockages of the inserting Tuohy needle with fat, and six cases of difficulty in passing the minitracheotomy tube.

Double-blind comparison of epidural diamorphine and intramuscular morphine after elective caesarean section, with computerised analysis of continuous pulse oximetry.

A randomised, double-blind comparison of the efficacy, duration of action and side effects of two analgesic regimens following elective epidural Caesarean section is described. Patients received epidural diamorphine 3 mg or intramuscular morphine 10 mg in the immediate postoperative period. Time to next analgesia was longer after epidural diamorphine (11.0 hours) compared to intramuscular morphine (6.5 hours) (p less than 0.05). In addition, a greater number of patients in the diamorphine group had a pain score less than 2.5 cm at 5 hours (p less than 0.05). However, more patients in the diamorphine group required catheterisation and suffered emetic sequelae, whereas more patients in the morphine group were sedated at 8 hours. Ten patients in each group had continuous pulse oximetry performed overnight after administration of the trial medications. Neither group demonstrated evidence of hypoxia.

Respiratory depression complicating epidural diamorphine. Two case reports of administration after dural puncture.

Two cases of severe respiratory depression complicating epidural diamorphine administration are reported. In both cases, the dura had been punctured. The risk of epidural opiate administration in association with a breach in the dura is reiterated.

Enhancement of colloidal clearance in normal rats by sodium diethyl dithiocarbamate (DTC).

Enhancement of colloidal clearance in normal rats is induced by sodium diethyldithiocarbamate, administered by the oral route. Enhancement is only observed after a lag period of greater than seven days. The study evidences the efficacy of oral administration of DTC and a weekly frequency of dosing in this clearance model.

The influence of diethyl-dithiocarbamate ('Imuthiol') on mononuclear cells in vitro.

Diethyl-dithiocarbamate ('Imuthiol') has been shown to enhance various immune functions in vivo but is toxic in vitro. Macrophages were observed to show evidence of toxicity when exposed to lower concentrations of Imuthiol than inhibited thymidine incorporation by the Raji lymphoid cell line. Inhibition of the mitogenic response of human mononuclear cells to phytohaemaglutinin (PHA) occurred after preincubation of adherent or non-adherent mononuclear cells with Imuthiol. This finding contrasts with the results with gold salts where preincubation of adherent cells inhibits the response to mitogens, while preincubation of non-adherent cells has no effect. The specific toxicity of gold on monocyte/macrophages in vitro is not a feature of Imuthiol.

Increased numbers of active B cells in the circulation of patients with rheumatoid arthritis.

Increased numbers of cells secreting immunoglobulins of class G, M and A have been demonstrated in the peripheral blood of patients with active rheumatoid arthritis using the reverse haemolytic plaque assay. Lower numbers of secreting cells were detected in rheumatoid patients in spontaneous remission. Culture of the peripheral blood mononuclear cells was associated with a fall in the number of immunoglobulin secreting cells. Values for rheumatoid and normal cells did no differ significantly after 3 days of culture. The presence of an activating factor in th rheumatoid patients is postulated.

The influence of D-penicillamine therapy on numbers of circulating immunoglobulin secreting cells in rheumatoid arthritis.

Higher numbers of plaque forming (immunoglobulin secreting) cells have been reported among peripheral blood mononuclear cells from patients with active rheumatoid arthritis than from patients with spontaneously inactive disease. Patients treated with D-penicillamine who showed a good clinical response were found to have lower numbers of circulating plaque forming cells than were detected in the active rheumatoid group. Similar numbers of plaque forming cells were detected in patients who showed a poor clinical response to D-penicillamine as in the active rheumatoid group (untreated with 'second line' drugs). Active rheumatoid arthritis is associated with increased numbers of plaque forming cells in the peripheral blood, changes in the numbers of these cells providing an index of disease activity.