Withholding and Withdrawal of Life Support from Critically Ill Patients

Background: Extracorporeal membrane oxygenation (ECMO) life support has become an integral part of intensive care. The endotoxin activity assay (EAA) is a useful test to measure endotoxemia severity in whole blood. To date, no information is available regarding the EAA levels and their effect on clinical outcomes in critically ill patients with ECMO support.Methods: This prospective observational pilot study enrolled adult critically ill patients with ECMO support from August 2019 to December 2020. The EAA levels were measured within 24 h (T1), and at 25–48 (T2), 49–72 (T3), and 73–96 h (T4) after ECMO initiation. This study primarily aimed to investigate the incidence of high EAA levels (≥0.6) at each time point. Subsequent exploratory analyses were conducted to compare the EAA levels of venoarterial ECMO (VA-ECMO) patients between 30-day survivors and non-survivors. Post-hoc analysis was performed to compare the clinical outcomes of VA-ECMO patients with elevated EAA levels at T3 (vs. T1) and those without elevated EAA levels.Results: A total of 39 VA-ECMO patients and 15 venovenous ECMO (VV-ECMO) patients were enrolled. At T1, the incidence of high EAA level (≥0.6) was 42% in VV-ECMO patients and 9% in VA-ECMO patients (P = 0.02). At T2, the incidence of high EAA level was 40% in VV-ECMO patients and 5% in VA-ECMO patients (P = 0.005). In VA-ECMO patients, EAA levels at T3 were significantly higher in 30-day non-survivors than in survivors (median [interquartile range]: 0.49 [0.37–0.93] vs. 0.31 [0.19–0.51], median difference 0.16 [95% confidence interval [CI], 0.02–0.31]; P = 0.024). Moreover, VA-ECMO patients with elevated EAA levels at T3 (vs. T1) had lower 30-day survival than patients without elevated EAA levels (39 vs. 83%, P = 0.026) and fewer ECMO free days by day 30 (median: 3 vs. 23 days, median difference 12 days [95% CI, 0–22]; P = 0.028).Conclusions: A certain proportion of patients experienced high EAA levels (≥0.6) after VV-ECMO or VA-ECMO initiation. VA-ECMO patients with an elevated EAA level at 49–72 h were associated with poor clinical outcomes.

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Experiences of the Intensive Care Unit of Hospital Raja PerempuanZainab II in handling the Massive Evacuation of Critically-Ill Patients during Flood Disaster.

International Journal of Human and Health Sciences (IJHHS) ◽

10.31344/ijhhs.v2i4.60 ◽

2018 ◽

Vol 2 (4) ◽

pp. 224

Author(s):

WI Wan Nasruddin ◽

ZA Nor Hidayah ◽

A Nazri ◽

WI Wan Azzlan ◽

I Ruwaida ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Critically Ill ◽

Critically Ill Patients ◽

Life Support ◽

The State ◽

Flood Disaster ◽

Water Levels ◽

Tertiary Centre ◽

Set Up

In December 2014, Malaysia had suffered nationwide floods after unprecedented monsoon rains overwhelmed several parts of the country. The East Coast areas of Malaysia were especially badly affected, specifically for the state of Kelantan, whereby a total of 170,000 victims were evacuated to the evacuation centres. This was the worst flood in the last 40 years and has been referred to by the locals as ‘Bah Kuning’. As a tertiary centre for the state of Kelantan with a total number of hospital beds of 937, HRPZ II was also badly compromised during this time. The electricity supply to the main hospital building was shut-down during this period and the hospital had managed to maintain its operations hUP_(ÛT_e power from a generator which had faced the risk of being shut down if the water levels had increased further. These issues might have caused a worse impact viaa possible loss of electrical and oxygen supply and non-functional life support systems. In relation to this flood disaster, the Anaesthesiology and Intensive Care Unit of HRPZ II would like to share the experiences of handling ventilated and critically ill-patients for evacuation during the massive floods in 2014 from the ICU of Hospital Raja Perempuan Zainab II to “an open stage with no facilities”. During this time, we had a total of 19 patients in our 21-bedded Intensive Care Unit. The challenge was the need to evacuate all the critically ill patients and to set-up a new ICU in a safer place immediately at the time.International Journal of Human and Health Sciences Vol. 02 No. 04 October’18. Page : 224-227

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Oncologists’ and Intensivists’ Attitudes Toward the Care of Critically Ill Patients with Cancer

Journal of Intensive Care Medicine ◽

10.1177/0885066617716105 ◽

2017 ◽

Vol 34 (10) ◽

pp. 811-817 ◽

Cited By ~ 5

Author(s):

Antonio Paulo Nassar ◽

Aldo Lourenço Abadde Dettino ◽

Cristina Prata Amendola ◽

Rodrigo Alves dos Santos ◽

Daniel Neves Forte ◽

...

Keyword(s):

Breast Cancer ◽

Pancreatic Cancer ◽

Multiple Organ Failure ◽

Organ Failure ◽

Critically Ill ◽

Critically Ill Patients ◽

Life Support ◽

Multiple Organ ◽

Patients With Cancer ◽

Support Measures

Background: Patients with cancer represent an important proportion of intensive care unit (ICU) admissions. Oncologists and intensivists have distinct knowledge backgrounds, and conflicts about the appropriate management of these patients may emerge. Methods: We surveyed oncologists and intensivists at 2 academic cancer centers regarding their management of 2 hypothetical patients with different cancer types (metastatic pancreatic cancer and metastatic breast cancer with positive receptors for estrogen, progesterone, and HER-2) who develop septic shock and multiple organ failure. Results: Sixty intensivists and 46 oncologists responded to the survey. Oncologists and intensivists similarly favored withdrawal of life support measures for the patient with pancreatic cancer (33/46 [72%] vs 48/60 [80%], P = .45). On the other hand, intensivists favored more withdrawal of life support measures for the patient with breast cancer compared to oncologists (32/59 [54%] vs 9/44 [21%], P < .001). In the multinomial logistic regression, the oncology specialists were more likely to advocate for a full-code status for the patient with breast cancer (OR = 5.931; CI 95%, 1.762-19.956; P = .004). Conclusions: Oncologists and intensivists share different views regarding life support measures in critically ill patients with cancer. Oncologists tend to focus on the cancer characteristics, whereas intensivists focus on multiple organ failure when weighing in on the same decisions. Regular meetings between oncologists and intensivists may reduce possible conflicts regarding the critical care of patients with cancer.

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Pain management during the withholding and withdrawal of life support in critically ill patients at the end-of-life: a systematic review and meta-analysis

Intensive Care Medicine ◽

10.1007/s00134-020-06139-7 ◽

2020 ◽

Vol 46 (9) ◽

pp. 1671-1682

Author(s):

Andres Laserna ◽

Alejandro Durán-Crane ◽

María A. López-Olivo ◽

John A. Cuenca ◽

Cosmo Fowler ◽

...

Keyword(s):

Systematic Review ◽

Pain Management ◽

End Of Life ◽

Critically Ill ◽

Critically Ill Patients ◽

Life Support ◽

Meta Analysis

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The Safety and Efficacy of Bedside Tracheotomy

Otolaryngology ◽

10.1177/019459989310900412 ◽

1993 ◽

Vol 109 (4) ◽

pp. 707-711 ◽

Cited By ~ 23

Author(s):

Neal D. Futran ◽

Paul O. Dutcher ◽

Jay K. Roberts

Keyword(s):

Intensive Care ◽

Head And Neck ◽

Operating Room ◽

Critically Ill ◽

Critically Ill Patients ◽

Life Support ◽

Safety And Efficacy ◽

Patients Âgés ◽

Perioperative Bleeding ◽

The University

Many institutions require that tracheotomies be performed in the operating room. Movement of critically ill patients dependent on multiple life support systems is technically difficult, labor intensive, and potentially dangerous for the patients. Between 1983 and 1992, 1088 tracheotomies were performed on patients ages 1 week to 94 years at the University of Rochester affiliated hospitals on critically ill patients as isolated procedures. The procedure was performed in the Intensive Care Units (ICU) on 996 patients, (92.9%), whereas 92 patients (7.1%) had tracheotomies in the operating room (OR1). An additional 346 tracheotomies took place in the operating room in conjunction with other head and neck procedures (OR2). Incidence of perioperative bleeding (within 48 hours) was 2.3% in the ICU group, 2.1% in the ORI group, and 2.0% in the OR2 group. Incidence of stomal infection was also similar among the three groups at 1.8%, 2.1%, and 1.5%, respectively. Tube dislodgement in all groups was a complication. No statistical differences were noted among the three groups (ICU, OR1, OR2) at the p < 0.01 level. Criteria for performing the tracheotomy in the ICU are delineated and discussed.

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Do-not-resuscitate orders for critically ill patients in intensive care

Nursing Ethics ◽

10.1177/0969733010364893 ◽

2010 ◽

Vol 17 (4) ◽

pp. 445-455 ◽

Cited By ~ 23

Author(s):

Yuanmay Chang ◽

Chin-Feng Huang ◽

Chia-Chin Lin

Keyword(s):

Intensive Care ◽

Critically Ill ◽

Critically Ill Patients ◽

Life Support ◽

Adult Child ◽

Do Not Resuscitate ◽

Lack Of Information ◽

Surrogate Decision ◽

End Of Life Decision ◽

To Receive

End-of-life decision making frequently occurs in the intensive care unit (ICU). There is a lack of information on how a do-not-resuscitate (DNR) order affects treatments received by critically ill patients in ICUs. The objectives of this study were: (1) to compare the use of life support therapies between patients with a DNR order and those without; (2) to examine life support therapies prior to and after the issuance of a DNR order; and (3) to determine the clinical factors that influence the initiation of a DNR order in ICUs in Taiwan. A prospective, descriptive, and correlational study was conducted. A total of 202 patients comprising 133 (65.8%) who had a DNR order, and 69 (34.1%) who did not, participated in this study. In the last 48 hours of their lives, patients who had a DNR order were less likely to receive life support therapies than those who did not have a DNR order. Older age, being unmarried, the presence of an adult child as a surrogate decision maker, a perceived inability to survive ultimate discharge from the ICU, and longer hospitalization in the ICU were significant predictors of issuing a DNR order for critically ill patients. This study will draw attention to how, when, and by whom, critically ill patients’ preferences about DNR are elicited and honored.

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