Sedation-Paralysis as Cornerstone on Rabies Management (Milwaukee Protocol)

Rabies is a viral infection involving the central nervous system that is almost always fatal without proper post exposure prophylaxis. Here, we present a 38 years-old male with dog-bite and late attention whom, managed in intensive care unit. After 21 days, the disease progressed to serious neurologic and hemodynamic damage including motor disorders and imbalance in blood pressure and cardiac rhythm. Clinical management of the patient consisted of antiviral agents (Amantadine and Ribavirin), neuroprotection, sedation-paralysis and supportive care. Patient was survived 43 days from the clinical disease onset. Although our patient died in spite of intensive care, advances in the use of sedation-paralysis and early prescription of antiviral agents raised hopes that it may eventually be possible to save rabies patients.

Use of a Deprescribing Tool in an Interdisciplinary Primary-Care Patient-Aligned Care Team

Objective: To pilot the VIONE approach in a single Primary Care Patient Aligned Care Team (PACT). The authors aim for the Clinical Pharmacy Specialist (CPS) to perform 20 comprehensive medication reviews (CMRs) and the pilot PACT physician (PCP) to complete 200 VIONE discontinuations. Cost avoidance and CPS recommendations will also be analyzed. Polypharmacy is associated with increased risk of adverse drug events, falls, hospitalizations, and death. VIONE is a deprescribing tool that assists providers in identifying inappropriate medications. Design: Quality Improvement Setting: Single VA Health Care System (VAHCS) Participants: High-risk veterans in pilot PACT Interventions: The CPS educated the PCP regarding VIONE methodology and assisted with CMRs. When deprescribing was warranted, VIONE discontinuation reasons were selected in the Computerized Patient Record System (CPRS). Data were electronically stored in a national dashboard. Results: The authors identified 231 veterans at risk for polypharmacy-related adverse events. The PCP and CPS were able to reach 99 veterans and make 136 medication discontinuations between September 1, 2019, and March 1, 2020. The CPS performed 20 CMRs, resulting in 90 deprescribing recommendations. Thirty-eight CPS recommendations were accepted and contributed $18,835.95 to the sum annualized cost avoidance of $21,904.80. Conclusion: The VIONE methodology was successfully implemented in the pilot PACT. The utilization of the CPS was associated with an increased average number of medication discontinuations per veteran and contributed to cost avoidance.

Adapting Interprofessional Acute Care Simulations to a Virtual Platform

This chapter addresses the innovative solutions implemented by faculty members at Regis University to pivot simulation experiences to a virtual platform during a global pandemic. Healthcare faculty ensured nursing and pharmacy students actively engaged in content and with one another without sacrificing the necessary interprofessional knowledge. The authors adapted a previously in-person acute care simulation to a virtual platform by utilizing technology and specific, intentional pre-simulation, during simulation, and post-stimulation knowledge checks. By following the standards for interprofessional, nursing, and pharmacy education, the authors were able to execute this simulation and implement meaningful feedback for continued advancement for future students. The continued goal of the simulation will be to provide students with high-stress, low-occurrence acute care patient experiences while working closely with other members of the healthcare team to enable students to experience required, necessary curriculum before graduation and working on the frontlines of healthcare.

Dopamine Use and Its Consequences in The Intensive Care Unit: a Cohort Study Utilizing the Japanese Intensive care Patient Database

Background: Dopamine is used to treat patients with shock in intensive care units (ICU) throughout the world, despite recent evidence against its use. Current practice patterns for the use of dopamine have not been reported.Methods: The Japanese Intensive Care PAtient Database (JIPAD), the largest intensive care database in Japan, was utilized. Inclusion criteria included: 1) age 18 years or older, 2) admitted to the ICU for reasons other than procedures, 3) ICU length of stay of 24 hours or more, and 4) treatment with either dopamine or noradrenaline within 24 hours of admission. The primary outcome was in-hospital mortality. Multivariable regression analysis was performed, followed by a pre-planned propensity score-matched analysis.Results: Of the 132,354 case records, 14594 records from 56 facilities were included in this analysis. Dopamine was administered to 4653 patients and noradrenaline to 11844. There was no statistically significant difference in facility characteristics between frequent dopamine users (N = 28) and infrequent users (N = 28). Patients receiving dopamine had more cardiovascular diagnosis codes (70% vs. 42%; p<0.01), more post-elective surgery status (60% vs. 31%), and lower APACHE III scores compared to patients given noradrenaline alone (70.7 vs. 83.0; p<0.01). Multivariable analysis showed an odds ratio for in-hospital mortality of 0.86 [95% CI: 0.71-1.04] in the dopamine <=5 μg/kg/min group, 1.50 [95% CI: 1.18-1.82] in the 5-15 μg/kg/min group, and 3.30 [95% CI: 1.19-9.20] in the >15 μg/kg/min group. In 1:1 propensity score matching for dopamine use (3322 pairs), there was no statistically significant difference for in-hospital mortality between the dopamine group and no dopamine group (13.0% vs. 12.0%, p=0.21), but ICU length of stay was significantly longer in the dopamine group (mean 7.4 days vs. 6.6 days, p<0.01).Conclusion: Dopamine is still widely used in Japan. The results of this study suggest detrimental effects of dopamine use specifically at a high dose, although there is no significant association with increased in-hospital mortality.Trial registration: Retrospectively registered upon approval of the Institutional Review Board and the administration office of JIPAD.

Bedside rationing in cancer care: Patient advocate perspective

Rationing in healthcare remains very much a taboo topic. Before COVID-19, it rarely received public attention, even when it occurred in everyday practices, mainly in the form of implicit rationing, as it continues to do today. There are different definitions, types and levels of healthcare rationing, according to different perspectives. With the aim of contributing to a more coherent debate on such a highly emotional healthcare issue as rationing, here are provided a number of reflections from a patient advocate perspective which are specifically focused on bedside rationing, the most troublesome level, both for patients and clinicians, particularly in regard to cancer care. Oncology, with its numerous expensive therapies and increasing number of patients, is undeniably one of the main areas contributing to the increase in healthcare costs. However, the fixed budgets of today's publicly financed health systems cannot allow unlimited access to the potentially beneficial treatments to all patients. Bedside rationing constitutes the last phase of many decision-making processes occurring at different interrelated levels (macro-levels), both inside and outside healthcare systems, which implicitly and inevitably result in a bottleneck determined by the upstream decisions themselves. Shifting from implicit to explicit bedside rationing essentially means moving from a paternalistic to a citizen-before-patient approach; this implies, first of all, a cultural change. Practical bedside rationing is an ethically complex topic, but one that needs to be urgently addressed in a transparent and open debate. In this scenario, the oncological community – patients, patient advocates and clinicians – can and should play an important role.

Case Report: Traumatic Stress and Developmental Regression: An Unintended Consequence of Complex Cardiac Care

This brief case report outlines a novel approach to supporting the development of a pediatric complex cardiac care patient. Patient X is a 19-month old patient who spent 5.5 months in hospital and underwent multiple surgeries including heart transplantation. This case report explores the impacts of his condition and care on his development and family functioning within the framework of an integrated care model. This case report is uniquely complimented by outpatient neurodevelopmental follow up, dyadic trauma-informed intervention and use of telemedicine allowing for a deeper understanding of the family adaptation that provide novel insight into long-term trajectory beyond discharge. Throughout care Patient X met criteria for both a traumatic stress disorder and global developmental delay. This case study highlights the threat complex care poses to neurodevelopment, pediatric mental health and family dynamics as well as opportunities for intervention.

Oral Candidiasis with Subcutaneaous Emphyema Associated With Sari Following Post COVID 19: A Case Report

Background: Over the last few decades, the covid 19 has increased all over the world. More issues are likely to be observed as covid 19 rate increases. The major cause of morbidity and mortality is infection. Oral Candidiasis With Subcutaneaous Emphyema and SARI are very rare complications in Covid 19 patient. The final cause is infection, but sometimes it causes due to allergic or inflammatory reaction of the drugs. If it occurs after post covid 19 then creates very serious issues with the peoples health. Case Presentation: Here we are mentioning a very rare case of Oral Candidiasis With Subcutaneaous Emphyema and SARI after Covid 19 positive patient. In this case, on physical examination and investigation, it was found that, after covid 19 patient has developed Oral Candidiasis, Subcutaneous Emphysema , severe breathlessness, cough, fever, nausea, vomiting, throat infection and loss of appetide. To overcome this sudden issue, emergency exploratory medical and surgical treatment was done. During Covid 19 treament her HRCT Score was 21/25 and the infection was severe. There was no any sign of oral candidiasis, subcutaneous emphysema, or tissue or organ damage or no any other abnormality was detected during Covid 19 tratment. No bacterial growth or fungal growth observed on investigation. After some days and treatment of covid 19 the patient was developed a Oral Candidiasis and Subcutaneous Emphysema and SARI. The working diagnosis was finalized by doctors i.e. Oral Candidiasis With Subcutaneaous Emphyema and SARI. After expert medical management and excellent nursing care patient was discharged with full recovery. Conclusion: In this study, we mainly focus on expert medical management and excellent nursing care helped in managing the complicated case very nicely. All the patient response was positive for conservative and nursing management and after treatment the patient was discharged without any complications and satisfaction with full recovery.

The patient's order as a separate manifestation of his will

The article analyzes the issues of the patient's will in medical relations, it is proved that it is due to the expression of will to the proposed treatment (consent or refusal) that the patient is a full active participant in this relationship. However, his inability to express his will, temporary or irreversible, caused by the development of the disease, the peculiarity of its course may be an obstacle to determining his real desire for future treatment, medical intervention and jeopardize the violation or inability to exercise the patient's right to consent or refuse medical intervention. To avoid this, there is a certain legal institution in the legislation of a number of countries around the world, through which it is possible to plan your treatment in advance, to refuse it, in case of inability to do so in the future. In some legal systems, this institution has different names - "wishes made earlier", "medical will", "patient's will", "power of attorney to make decisions on health care", "patient orders" and so on. The paper analyzes the content of this institute, considers the views of scholars on it, made a comparative analysis with the legal construction of the "testament" and concluded that there are significant differences between these constructions, which makes it impossible, from the author's point of view, to call this will "testament". . It is proposed to consider such a will as one of the patient's rights - "patient order", which is made in writing by an adult - the patient, regardless of the type and stage of the disease in case of possible future inability to consent to medical examination, intervention or treatment. The patient has at his disposal not only his will for the future (list of medical procedures that are allowed to be performed in relation to his health, which are not), but also the case when it can be used (for example, coma, autonomic state). It is impossible to conclude it through a representative, because in this case the will of the patient is unknown. This order is executed by proxies (relatives, close persons, representatives, doctors, etc.). Despite the fact that in Ukraine today this legal institution is absent, the main directions of recoding of civil legislation indicate the possibility of its appearance in the updated legislation