Assisted suicide in an acute care hospital: 18 months' experience

QUESTION UNDER STUDY: In 2006 the University Hospital of Lausanne (CHUV) introduced an institutional directive specifying the conditions for assisted suicide, in accordance with professional guidelines and the recommendation of the Swiss National Advisory Commission on Biomedical Ethics that every acute care hospital take up a position on this subject. METHODS: 18-months follow-up analysis of patient requests and application of the directive by hospital staff. RESULTS: Of the 54,000 patients hospitalised between January 1, 2006, and June 30, 2007, six requests were recorded, all within the first 7 months after introduction of the directive and in the context of severe and life-threatening diseases. However, only one of the six patients, living in a nursing home belonging to the hospital, died by assisted suicide. Two patients died from their diseases, one during the assessment procedure and the other shortly after. One patient withdrew his request after pain control, returned home and died several weeks later. Another patient, although she was severely ill and died several months later, was denied the procedure because her condition was improving. Only one patient was declared incompetent and his request refused. The time distribution of requests seems to be associated with initial media coverage of the assisted-suicide directive's introduction. Only minor amendments to the directive were needed. CONCLUSIONS: The recommendations of the Swiss National Advisory Commission on Biomedical Ethics are applicable in an acute care hospital

In memoriam - Xavier Leverve

SCOPUS: ed.jinfo:eu-repo/semantics/publishe

Are terminally ill patients dying in the ICU suitable for non-heart beating organ donation?

Objective: To evaluate the feasibility of implementing aprogram of controlled non-heart beating organ donation, in patients undergoing the withdrawal of intensive care treatment. Design and setting: Prospective observational study. Medical and Surgical ICUs in atertiary university hospital. Patients: Consecutive patients younger than 70 years dying in the ICU after treatment withdrawal for dire neurological prognosis. Measurements and results: We analyzed prospectively collected data from the ICU clinical information system. Seventy-three of 516 ICU deaths (13%) were identified, equally distributed among traumatic, stroke, and anoxic brain injury. The management and the course in these three diagnostic categories were similar. All patients underwent withdrawal of mechanical ventilation and half were extubated. Median time to death was of 4.8 h (IQR 1.4-11.5). In 70% of cases the patient received analgesia and 30% sedation. Such treatment was not related to earlier death. Hypotension was observed in 50% of patients during the 30 min preceding cardiac death. Conclusions: With our current management of terminal patients controlled non-heart beating organ procedure may be difficult due to the duration and variability of the dying process. This observation suggests that we can perform better by evaluating this process moreclosel

P-440: Losartan but not irbesartan reduces serum uric acid in hypertensive patients with hyperuricemia and/or gout

Losartan has unique uricosuric properties and has been shown to decrease serum uric acid (SUA) levels in normal subjects as well as in hypertensive patients. The purpose of the present study was to compare the effects of losartan and irbesartan on serum uric acid in hypertensive hyperuricemic patients with or without gout. Twelve hyperuricemic (SUA>420mmol/L), hypertensive patients (mean age: 58 yr) participated in this randomized, double-blind, crossover study. After a 3-week run-in period during which patients received enalapril 20 mg o.d, patients were randomized to receive either losartan 50 mg o.d for 4 weeks followed by losartan 50 mg bid for another 4 week period or irbesartan 150 mg o.d followed by irbesartan 150 mg bid for 4 weeks. The losartan and irbesartan phases were separated by 3 weeks of the ACE inhibitor. All drugs were provided in an electronic pill container allowing to monitor compliance (MEMS system). Losartan decreased SUA significantly from 539±28 mmol/L to 490±22 mmol/L (p1 month). Hence, the uricosuric effect tends to decrease with time as SUA is reduced. Increasing the dose of losartan to 50 mg bid does not appear to induce a further decrease in serum uric aci

Blunting the response to endotoxin in healthy subjects: effects of various doses of intravenous fish oil

Objective: To test the dose response effect of infused fish oil (FO) rich in n-3 PUFAs on the inflammatory response to endotoxin (LPS) and on membrane incorporation of fatty acids in healthy subjects. Design: Prospective, sequential investigation comparing three different FO doses. Subjects: Three groups of male subjects aged 26.8±3.2years (BMI 22.5±2.1). Intervention: One of three FO doses (Omegaven®10%) as a slow infusion before LPS: 0.5g/kg 1day before LPS, 0.2g/kg 1day before, or 0.2g/kg 2h before. Measurements and results: Temperature, hemodynamic variables, indirect calorimetry and blood samples (TNF-α, stress hormones) were collected. After LPS temperature, ACTH and TNF-α concentrations increased in the three groups: the responses were significantly blunted (p<0.0001) compared with the control group of the Pluess et al. trial. Cortisol was unchanged. Lowest plasma ACTH, TNF-α and temperature AUC values were observed after a single 0.2g/kg dose of FO. EPA incorporation into platelet membranes was dose-dependent. Conclusions: Having previously shown that the response to LPS was reproducible, this study shows that three FO doses blunted it to various degrees. The 0.2g/kg perfusion immediately before LPS was the most efficient in blunting the responses, suggesting LPS capture in addition to the systemic and membrane effect

Can the impact of bed closure in intensive care units be reliably monitored?

Objective: To assess the properties of various indicators aimed at monitoring the impact on the activity and patient outcome of a bed closure in a surgical intensive care unit (ICU). Design: Comparison before and after the intervention. Setting: A surgical ICU at a university hospital. Patients: All patients admitted to the unit over two periods of 10months. Intervention: Closure of one bed out of 17. Measurements and results: Activity and outcome indicators in the ICU and the structures upstream from it (emergency department, operative theater, recovery room) and downstream from it (intermediate care units). After the bed closure, the monthly medians of admitted patients and ICU hospital days increased from 107 (interquartile range 94-112) to 113 (106-121, P=0.07) and from 360 (325-443) to 395 (345-436, P=0.48), respectively, along with the linear trend observed in our institution. All indicators of workload, patient severity, and outcome remained stable except for SAPS II score, emergency admissions, and ICU readmissions, which increased not only transiently but also on a mid-term basis (10months), indicating that the process of patient care delivery was no longer predictable. Conclusions: Health care systems, including ICUs, are extraordinary flexible, and can adapt to multiple external constraints without altering commonly used activity and outcome indicators. It is therefore necessary to set up multiple indicators to be able to reliably monitor the impact of external interventions and intervene rapidly when the system is no longer under contro

Influence of early antioxidant supplements on clinical evolution and organ function in critically ill cardiac surgery, major trauma, and subarachnoid hemorrhage patients

INTRODUCTION: Oxidative stress is involved in the development of secondary tissue damage and organ failure. Micronutrients contributing to the antioxidant (AOX) defense exhibit low plasma levels during critical illness. The aim of this study was to investigate the impact of early AOX micronutrients on clinical outcome in intensive care unit (ICU) patients with conditions characterized by oxidative stress. METHODS: We conducted a prospective, randomized, double-blind, placebo-controlled, single-center trial in patients admitted to a university hospital ICU with organ failure after complicated cardiac surgery, major trauma, or subarachnoid hemorrhage. Stratification by diagnosis was performed before randomization. The intervention was intravenous supplements for 5 days (selenium 270 microg, zinc 30 mg, vitamin C 1.1 g, and vitamin B1 100 mg) with a double-loading dose on days 1 and 2 or placebo. RESULTS: Two hundred patients were included (102 AOX and 98 placebo). While age and gender did not differ, brain injury was more severe in the AOX trauma group (P = 0.019). Organ function endpoints did not differ: incidence of acute kidney failure and sequential organ failure assessment score decrease were similar (-3.2 +/- 3.2 versus -4.2 +/- 2.3 over the course of 5 days). Plasma concentrations of selenium, zinc, and glutathione peroxidase, low on admission, increased significantly to within normal values in the AOX group. C-reactive protein decreased faster in the AOX group (P = 0.039). Infectious complications did not differ. Length of hospital stay did not differ (16.5 versus 20 days), being shorter only in surviving AOX trauma patients (-10 days; P = 0.045). CONCLUSION: The AOX intervention did not reduce early organ dysfunction but significantly reduced the inflammatory response in cardiac surgery and trauma patients, which may prove beneficial in conditions with an intense inflammation. TRIALS REGISTRATION: Clinical Trials.gov RCT Register: NCT00515736

Reduction of nosocomial pneumonia after major burns by trace element supplementation: aggregation of two randomised trials

INTRODUCTION: Nosocomial pneumonia is a major source of morbidity and mortality after severe burns. Burned patients suffer trace element deficiencies and depressed antioxidant and immune defences. This study aimed at determining the effect of trace element supplementation on nosocomial or intensive care unit (ICU)-acquired pneumonia. METHODS: Two consecutive, randomised, double-blinded, supplementation studies including two homogeneous groups of 41 severely burned patients (20 placebo and 21 intervention) admitted to the burn centre of a university hospital were combined. Intervention consisted of intravenous trace element supplements (copper 2.5 to 3.1 mg/day, selenium 315 to 380 μg/day, and zinc 26.2 to 31.4 mg/day) for 8 to 21 days versus placebo. Endpoints were infections during the first 30 days (predefined criteria for pneumonia, bacteraemia, wound, urine, and other), wound healing, and length of ICU stay. Plasma and skin (study 2) concentrations of selenium and zinc were determined on days 3, 10, and 20. RESULTS: The patients, 42 ± 15 years old, were burned on 46% ± 19% of body surface: the combined characteristics of the patients did not differ between the groups. Plasma trace element concentrations and antioxidative capacity were significantly enhanced with normalisation of plasma selenium, zinc, and glutathione peroxidase concentrations in plasma and skin in the trace element-supplemented group. A significant reduction in number of infections was observed in the supplemented patients, which decreased from 3.5 ± 1.2 to 2.0 ± 1.0 episodes per patient in placebo group (p < 0.001). This was related to a reduction of nosocomial pneumonia, which occurred in 16 (80%) patients versus seven (33%) patients, respectively (p < 0.001), and of ventilator-associated pneumonia from 13 to six episodes, respectively (p = 0.023). CONCLUSION: Enhancing trace element status and antioxidant defences by selenium, zinc, and copper supplementation was associated with a decrease of nosocomial pneumonia in critically ill, severely burned patients

Effects of endotoxin on lactate metabolism in humans.

ABSTRACT: INTRODUCTION: Hyperlactatemia represents one prominent component of the metabolic response to sepsis. In critically ill patients, hyperlactatemia is related to the severity of the underlying condition. Both an increased production and a decreased utilization and clearance might be involved in this process, but their relative contribution remains unknown. The present study aimed at assessing systemic and muscle lactate production and systemic lactate clearance in healthy human volunteers, using intravenous endotoxin (LPS) challenge. METHODS: Fourteen healthy male volunteers were enrolled in 2 consecutive studies (n = 6 in trial 1 and n = 8 in trial 2). Each subject took part in one of two investigation days (LPS-day with endotoxin injection and placebo-day with saline injection) separated by one week at least and in a random order. In trial 1, their muscle lactate metabolism was monitored using microdialysis. In trial 2, their systemic lactate metabolism was monitored by means of a constant infusion of exogenous lactate. Energy metabolism was monitored by indirect calorimetry and glucose kinetics was measured with 6,6-H2 glucose. RESULTS: In both trials, LPS increased energy expenditure (p = 0.011), lipid oxidation (p&lt;0.0001), and plasma lactate concentration (p = 0.016). In trial 1, lactate concentration in the muscle microdialysate was higher than in blood, indicating lactate production by muscles. This was, however, similar with and without LPS. In trial 2, calculated systemic lactate production increased after LPS (p = 0.031), while lactate clearance remained unchanged. CONCLUSIONS: LPS administration increases lactatemia by increasing lactate production rather than by decreasing lactate clearance. Muscle is, however, unlikely to be a major contributor to this increase in lactate production. TRIAL REGISTRATION: ClinicalTrials.gov NCT01647997