Current opinion in anaesthesiology
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Tattoos and medallions are examples of nonstandard do-not-resuscitate (DNR) orders that some people use to convey end-of-life wishes. These DNR orders are neither universally accepted nor understood for reasons discussed within this manuscript. ⋯ To improve conveyance of an individual's wishes for end-of-life care, the authors discuss nationwide adoption of Oregon's online registry where a person's account could comprehensively document end-of-life wishes, be universally available in all healthcare institutions, and be searchable by common patient identifiers. Facial recognition software could identify unconscious patients who present without identification.
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Curr Opin Anaesthesiol · Apr 2019
ReviewWithholding or withdrawing life support versus physician-assisted death: a distinction with a difference?
Withholding or withdrawing life-sustaining therapy is generally differentiated from physician-assisted suicide or euthanasia based on the distinction between intention and foresight. We reviewed the literature surrounding the validity of this distinction. ⋯ Several reasons may be given in favor of the distinction between intention and foresight. Given this distinction, the moral permissibility of withholding or withdrawing life-sustaining therapy does not necessarily entail the moral permissibility of physician-assisted suicide or euthanasia.
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Curr Opin Anaesthesiol · Apr 2019
ReviewTime-efficient, goal-directed, and evidence-based teaching in the ICU.
Teaching in the stressful, high-acuity environment of the ICU is challenging. The intensivist-educator must use teaching strategies that are both effective and time-efficient, as well as evidence-based approaches to the ICU curriculum. This review provides an overview of pertinent educational theories and their implications on educational practices, a selection of effective teaching techniques, and a review on feedback. ⋯ Direct teaching should be goal-oriented, sequential, and adjusted to the level of the learner. The ICU curriculum should optimize cognitive load, reduce stress that is unrelated to the activity, include resilience training, and help trainees deal with stressful clinical situations better. Simulation is a powerful tool to promote technical and nontechnical skills. Providing feedback is essential and a skill that can be taught and enhanced with structure, prompts, and tools.
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Sepsis-3 guidelines have implications in a deeper understanding of the biopathology of the disease. Further, the review focuses on timely topics and new literature on fluid resuscitation, the value of steroids in sepsis, and new therapeutic options such as angiotensin II, vitamin C, and thiamine as well as the emerging role of procalcitonin (PCT) in managing antibiotics. ⋯ Sepsis-3 shifts the focus from a noninfectious inflammatory process and an emphasis on a dysregulated host response to infection. Hyperchloremic crystalloid resuscitation is associated with poor clinical outcomes. Steroid administration can reverse shock physiology; however, mortality benefits remain uncertain. Angiotensin II, vitamin C, and thiamine are novel treatment options that need further validation. PCT assays can help discern between infectious and noninfectious inflammation.
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Curr Opin Anaesthesiol · Apr 2019
ReviewThe use of new procoagulants in blunt and penetrating trauma.
Uncontrolled bleeding in trauma secondary to a combination of surgical bleeding and trauma-induced complex coagulopathy is a leading cause of death. Prothrombin complex concentrates (PCCs), recombinant activated factor seven (rFVIIa) and recombinant human prothrombin act as procoagulants by increasing thrombin generation and fibrinogen concentrate aids stable clot formation. This review summarizes the current evidence for procoagulant use in the management of bleeding in trauma, and data and evidence gaps for routine clinical use. ⋯ There is increasing evidence that early correction of coagulopathy has survival benefits, and the use of procoagulants as first-line therapy has the potential benefit of rapid access and timely treatment. This requires confirmation in prospective studies.