Optimal fluid therapy in the perioperative and critical care settings depends on understanding the underlying cardiovascular physiology and individualizing assessment of the dynamic patient state.
...The Perioperative Quality Initiative (POQI-5) consensus conference brought together an international team of multidisciplinary experts to survey and evaluate the literature on the physiology of volume responsiveness and perioperative fluid management. The group used a modified Delphi method to develop consensus statements applicable to the physiologically based management of intravenous fluid therapy in the perioperative setting.
We discussed the clinical and physiological evidence underlying fluid responsiveness and venous capacitance as relevant factors in fluid management and developed consensus statements with clinical implications for a broad group of clinicians involved in intravenous fluid therapy. Two key concepts emerged as follows: (1) The ultimate goal of fluid therapy and hemodynamic management is to support the conditions that enable normal cellular metabolic function in order to produce optimal patient outcomes, and (2) optimal fluid and hemodynamic management is dependent on an understanding of the relationship between pressure, volume, and flow in a dynamic system which is distensible with variable elastance and capacitance properties.
To examine end-of-life (EOL) practices in European ICUs: who makes these decisions, how they are made, communication of these decisions and questions on communication between the physicians, nurses, ...patients and families.
Data collected prospectively on EOL decisions facilitated by a questionnaire including EOL decision categories, geographical regions, mental competency, information about patient wishes, and discussions with patients, families and health care professionals.
37 European ICUs in 17 countries.
ICU physicians collected data on 4,248 patients.
95% of patients lacked decision making capacity at the time of EOL decision and patient's wishes were known in only 20% of cases. EOL decisions were discussed with the family in 68% of cases. Physicians reported having more information about patients' wishes and discussions in the northern countries (31%, 88%) than central (16%, 70%) or southern (13%, 48%) countries. The family was more often told (88%) than asked (38%) about EOL decisions. Physicians' reasons for not discussing EOL care with the family included the fact that the patient was unresponsive to therapy (39%), the family was unavailable (28%), and the family was thought not to understand (25%).
ICU patients typically lack decision-making capacity, and physicians know patients' wishes in only 20% of EOL decisions. There were regional differences in discussions of EOL decisions with families and other physicians. In European ICUs there seems to be a need to improve communication.
Background: Dehydration appears prevalent, costly and associated with adverse outcomes. We sought to generate consensus on such key issues and elucidate need for further scientific enquiry.
Materials ...and methods: A modified Delphi process combined expert opinion and evidence appraisal. Twelve relevant experts addressed dehydration's definition, objective markers and impact on physiology and outcome.
Results: Fifteen consensus statements and seven research recommendations were generated. Key findings, evidenced in detail, were that there is no universally accepted definition for dehydration; hydration assessment is complex and requires combining physiological and laboratory variables; "dehydration" and "hypovolaemia" are incorrectly used interchangeably; abnormal hydration status includes relative and/or absolute abnormalities in body water and serum/plasma osmolality (pOsm); raised pOsm usually indicates dehydration; direct measurement of pOsm is the gold standard for determining dehydration; pOsm >300 and ≤280 mOsm/kg classifies a person as hyper or hypo-osmolar; outside extremes, signs of adult dehydration are subtle and unreliable; dehydration is common in hospitals and care homes and associated with poorer outcomes.
Discussion: Dehydration poses risk to public health. Dehydration is under-recognized and poorly managed in hospital and community-based care. Further research is required to improve assessment and management of dehydration and the authors have made recommendations to focus academic endeavours.
Key messages
Dehydration assessment is a major clinical challenge due to a complex, varying pathophysiology, non-specific clinical presentations and the lack of international consensus on definition and diagnosis.
Plasma osmolality represents a valuable, objective surrogate marker of hypertonic dehydration which is underutilized in clinical practice.
Dehydration is prevalent within the healthcare setting and in the community, and appears associated with increased morbidity and mortality.
CONTEXT While the adoption of practice guidelines is standardizing many aspects
of patient care, ethical dilemmas are occurring because of forgoing life-sustaining
therapies in intensive care and are ...dealt with in diverse ways between different
countries and cultures. OBJECTIVES To determine the frequency and types of actual end-of-life practices
in European intensive care units (ICUs) and to analyze the similarities and
differences. DESIGN AND SETTING A prospective, observational study of European ICUs. PARTICIPANTS Consecutive patients who died or had any limitation of therapy. INTERVENTION Prospectively defined end-of-life practices in 37 ICUs in 17 European
countries were studied from January 1, 1999, to June 30, 2000. MAIN OUTCOME MEASURES Comparison and analysis of the frequencies and patterns of end-of-life
care by geographic regions and different patients and professionals. RESULTS Of 31 417 patients admitted to ICUs, 4248 patients (13.5%) died
or had a limitation of life-sustaining therapy. Of these, 3086 patients (72.6%)
had limitations of treatments (10% of admissions). Substantial intercountry
variability was found in the limitations and the manner of dying: unsuccessful
cardiopulmonary resuscitation in 20% (range, 5%-48%), brain death in 8% (range,
0%-15%), withholding therapy in 38% (range, 16%-70%), withdrawing therapy
in 33% (range, 5%-69%), and active shortening of the dying process in 2% (range,
0%-19%). Shortening of the dying process was reported in 7 countries. Doses
of opioids and benzodiazepines reported for shortening of the dying process
were in the same range as those used for symptom relief in previous studies.
Limitation of therapy vs continuation of life-sustaining therapy was associated
with patient age, acute and chronic diagnoses, number of days in ICU, region,
and religion (P<.001). CONCLUSION The limiting of life-sustaining treatment in European ICUs is common
and variable. Limitations were associated with patient age, diagnoses, ICU
stay, and geographic and religious factors. Although shortening of the dying
process is rare, clarity between withdrawing therapies and shortening of the
dying process and between therapies intended to relieve pain and suffering
and those intended to shorten the dying process may be lacking.
3 There is no physiological reason why this should happen, and review of the published evidence shows that it is not true. 4 An important danger of persisting with this false premise is that more ...perceptive observers and critics of medical practice have already noticed the discrepancy and have concluded (inappropriately) that misdiagnoses are being made. 5 I suggest that it is time to revise the law, perhaps by a new Human Organ Transplant Act, to allow families to give informed consent to beating-heart organ donation under anaesthesia for patients certified to have irreversible loss of brain stem function.
This article in the series describes how UK law and medical ethics have evolved to accommodate developments in organ transplantation surgery. August committees have formulated definitions of the ...point of death of the person which are compatible with the lawful procurement of functioning vital organs from cadavers. Some of the complexities of dead donor rules are examined. Live donors are a major source of kidneys and the laws that protect them are considered. Financial inducements and other incentives to donate erode the noble concept of altruism, but should they be unlawful?
ObjectivesReliable reconciliation of medicines at admission and discharge from hospital is key to reducing unintentional prescribing discrepancies at transitions of healthcare. We introduced a team ...approach to the reconciliation process at an acute hospital with the aim of improving the provision of information and documentation of reliable medication lists to enable clear, timely communications on discharge.SettingAn acute 400-bedded teaching hospital in London, UK.ParticipantsThe effects of change were measured in a simple random sample of 10 adult patients a week on the acute admissions unit over 18 months.InterventionsQuality improvement methods were used throughout. Interventions included education and training of staff involved at ward level and in the pharmacy department, introduction of medication documentation templates for electronic prescribing and for communicating information on medicines in discharge summaries co-designed with patient representatives.ResultsStatistical process control analysis showed reliable documentation (complete, verified and intentional changes clarified) of current medication on 49.2% of patients' discharge summaries. This appears to have improved (to 85.2%) according to a poststudy audit the year after the project end. Pharmacist involvement in discharge reconciliation increased significantly, and improvements in the numbers of medicines prescribed in error, or omitted from the discharge prescription, are demonstrated. Variation in weekly measures is seen throughout but particularly at periods of changeover of new doctors and introduction of new systems.ConclusionsNew processes led to a sustained increase in reconciled medications and, thereby, an improvement in the number of patients discharged from hospital with unintentional discrepancies (errors or omissions) on their discharge prescription. The initiatives were pharmacist-led but involved close working and shared understanding about roles and responsibilities between doctors, nurses, therapists, patients and their carers.
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