Limiting futile therapy as part of end-of-life care in intensive care units.

The debate about medical futility often involves intensive care units where life-support procedures are routinely applied. Futile therapy is part of end-of-life therapy. In the discussion about medical futility it is important to distinguish the effect of therapy from the benefit for the patient. The goal of treatment is not to maintain the function of an organ, body part or physiological activity, but to maintain health as a whole. Prolonging ineffective treatment violates the standard of good medical practice. In 2014, the first Polish guidelines on limiting futile therapy in patients treated in intensive care units were published. This document presents the official position of intensive care experts consulted by medical societies of other medical disciplines. Limitation of futile therapy by withdrawing from already used treatments or withholding new therapies does not mean that the role of medical personnel has ended. Intensive care turns into palliative care. The list of comorbidities showing a statistically significant correlation with medical futility has been refined. These include heart failure (NYHA III/IV), neoplastic disease and disseminated neoplastic process, and failure of two or more organs. The published survey results are devastating; 66-89% of intensive care nurses have provided futile treatment in their careers. Intensivists estimated that, on average, 20% of patients in intensive care units receive futile therapy. There is a need to disseminate standards and procedures related to end-of-life care in Polish intensive care units.

Comparison of propofol-ketamine versuspropofol-remifentanil in children anaesthetized for gastroscopy.

BACKGROUND: The search for ideal anaesthesia is still an open research issue. The aim of the study was to evaluate and compare two methods of general anaesthesia with preserved own breath - propofol with ketamine and propofol with remifentanil - in children anaesthetized for gastroscopy. METHODS: The study included 90 children enrolled for elective endoscopy of the upper gastrointestinal tract under general anaesthesia. The patients were randomized to one of two groups: Group K consisted of children anesthetized with propofol and ketamine, Group R included children anesthetized with propofol and remifentanil. Parameters monitored during anaesthesia were induction time, respiratory and circulatory parameters, adverse events, waking time and the child's condition after regaining consciousness. RESULTS: The groups differed significantly in time of induction of anaesthesia (Group K 3 ± 1 min vs. Group R 4 ± 2.5 min; P < 0.001), waking time (Group R 4 ± 4.5 min vs. Group K 6 ± 5 min; P < 0.01), condition of the child after regaining consciousness (Group R 90.9% calm, Group of K 54% confused; P < 0.001) and evaluation of test conditions in the opinion of the gastroenterologist (in favour of Group K; P < 0.05). CONCLUSIONS: Both methods of anaesthesia presented in the paper are safe and can be used in children to perform endoscopy. Combining propofol with ketamine allows fast induction of anaesthesia and creates very good conditions for the examination. Combining propofol with remifentanil allows fast and full return of consciousness after anaesthesia.

[Radiographic assessment of accuracy of tracheal tube placement in children]. / Ocena prawidlowego polozenia rurki dotchawiczej u dzieci na podstawie radiogramu klatki piersiowej.

BACKGROUND: Accidental migration of endotracheal tubes has been recognized by the European Resuscitation Council (ERC) as an important morbidity factor in ventilated children. Several equations have been proposed for prediction of the ideal position of the endotracheal tube, but none of them was found to be ideal. METHODS: We have retrospectively assessed the positions of endotracheal tubes in 108 intubated children. Infants were nasally intubated and oral intubation was used in older children. We compared the measured distances with theoretical lengths, obtained from various equations. RESULTS: We found that if the tube was placed according to the Lau equation (age/2+13 mm) or the ALS group equation (age/2+12 mm), the estimation was correct in 83% (Lau equation) and in 94.7% (ALS recommendations). CONCLUSION: Since results depended very much on the age and route of intubation, we suggest that extended studies may be recommended.

[Abdominal compartment syndrome as advanced abdominal hypertension]. / Zespól przedzialu brzusznego jako zaawansowana postac nadcisnienia w jamie brzusznej.

The aim of the article is to present the definition and criteria of diagnosis of abdominal compartment syndrome (ACS) due to abdominal hypertension. Epidemiology of ACS is discussed. Secondary ACS is described. There is also an overview of clinical consequences and a scheme for ACS management.

[Ebstein syndrome--various forms, clinical view and treatment results in children]. / Zespól Ebsteina--postacie, przebieg kliniczny oraz wyniki leczenia u dzieci.

UNLABELLED: Ebstein's anomaly is an uncommon lesion of the tricuspid valve characterized by downward displacement of the tricuspid valve. The aim of the study was an analysis of the form, clinical outcome and treatment results in patients (pts) diagnosed with Ebstein anomaly. METHODS: 28 pts were analysed. Material has been divided into 3 groups, depending on clinical symptoms. The group A was formed with mild shape of the defect, group B all pts presenting significant clinical symptoms requiring treatment, and group C made of pts having severe symptoms requiring intensive treatment including surgical intervention. RESULTS: Anomaly had been detected in 13 boys and in 15 girls. Group A consisted of 6 children, including one boy diagnosed with defect prenatally. Described patient currently is followed-up in pulmonology outpatient clinic due to asthma. Other children are doing well and require no treatment. Group B was represented by 8 children requiring treatment of: sepsis, arrhythmia due to WPW syndrome and in one case ASD 2. Group C consisted of 14 patients. In 7 pts Ebstein anomaly was part of a complex congenital heart defect. In 5 cases dominating symptoms were severe heart failure with cyanosis and arrhythmia and in two cases sepsis. 10 pts had been treated surgically (7 pts had Blalock-Taussig shunt, 1 pt artificial valve replacement, 1 pt Fontan op. and 1 pt ASD 2 suture) where 8 died. The causes of death were: right ventricle failure and arrhythmia in 4, sepsis in 2, and pulmonary artery hypoplasia and metabolic acidosis also in 2 cases. CONCLUSIONS: Ebstein anomaly includes wide spectrum of anatomical and clinical findings. The most severe forms require surgical intervention, however it can be a high risk procedure.

[Infections as a preoperative problem in patients with tetralogy of Fallot (TOF) associated with complete atrioventricular canal septal defect (AVC)]. / Infekcje jako problem przedoperacyjny u pacjentów z zespolem Fallota (TOF) skojarzonym z calkowitym kanalem przedsionkowo-komorowym (AVC).

UNLABELLED: Tetralogy of Fallot (TOF) coexisting with atrioventricular canal septal defect (AVC) is a rare combination of anomalies. Additionally, in cases with concomitant Down syndrome, recurrent infections can be a serious problem in patients (pts.) waiting for cardiosurgery treatment. The purpose of the study was an analysis of types of infections and other factors complicating the preoperative period in those patients. MATERIAL AND METHODS: The study group consisted of 17 pts. with TOF and AVC aged from 1 day to 9 years (mean 9.4 month). In this group there were 11 pts. with Down syndrome. All of them were subjected to physical examinations, blood analysis, ECG, chest X-ray and echocardiographic study. Additionally, in 8 pts. we performed catheterization. The signs of different types of infection were analyzed and results were compared in two groups: with and without Down syndrome. RESULTS: The differences were observed in the frequency of recurrent or chronic infections (21 v/s 4), time of hospitalization before surgery (17 v/s 9 days), necessity (11 v/s 3) and duration of antibiotic therapy (19 v/s 7 days) in the two studied groups. Elevated body temperature of unknown etiology was noted in 8 cases with Down syndrome, compared to 1 patient without trisomy 21. Also, the children with Down syndrome had to wait 11 days longer (19 v/s 8) for discharge after operation. CONCLUSIONS: Infections in children with TOF, AVC and Down syndrome significantly complicate the natural course of this anomaly. Prolonged preoperation time is characteristic of Down syndrome pts. compared to patients without chromosomal abnormalities.

[Flash visual evoked potentials (FVEP) examination under midazolam sedation of non-cooperating children]. / Zastosowanie midazolamu do sedacji w czasie badania wzrokowych potencjalów wywolanych blyskami (FVEP) u dzieci niewspólpracujacych.

PURPOSE: To find the optimal conditions for visual evoked potential (VEP) examination of non-cooperative children using midazolam maleate sedation. PATIENTS: 32 children aged from 8 months to 13 years (mean 3.5 years) with mental disorders, emotional problems and/or very low vision due to various reasons. METHODS: VEP--flash and bright flash according to ISCEV standards. Midazolam maleate sedation 0.4-0.5 mg per kilo body weight, given orally. RESULTS: Only 6 children aged from 11 months to 3.5 years (mean 2.5 years) required sedation for VEP examination. Midazolam sedation unabled VEP examination, was safe for children and well-tolerated. CONCLUSION: Second degree sedation in Ramsey score is effective for good VEP examination of non-cooperative children.