Fluid challenges in intensive care: the FENICE study A global inception cohort study

Fluid challenges (FCs) are one of the most commonly used therapies in critically ill patients and represent the cornerstone of hemodynamic management in intensive care units. There are clear benefits and harms from fluid therapy. Limited data on the indication, type, amount and rate of an FC in critically ill patients exist in the literature. The primary aim was to evaluate how physicians conduct FCs in terms of type, volume, and rate of given fluid; the secondary aim was to evaluate variables used to trigger an FC and to compare the proportion of patients receiving further fluid administration based on the response to the FC.This was an observational study conducted in ICUs around the world. Each participating unit entered a maximum of 20 patients with one FC.2213 patients were enrolled and analyzed in the study. The median [interquartile range] amount of fluid given during an FC was 500 ml (500-1000). The median time was 24 min (40-60 min), and the median rate of FC was 1000 [500-1333] ml/h. The main indication for FC was hypotension in 1211 (59 %, CI 57-61 %). In 43 % (CI 41-45 %) of the cases no hemodynamic variable was used. Static markers of preload were used in 785 of 2213 cases (36 %, CI 34-37 %). Dynamic indices of preload responsiveness were used in 483 of 2213 cases (22 %, CI 20-24 %). No safety variable for the FC was used in 72 % (CI 70-74 %) of the cases. There was no statistically significant difference in the proportion of patients who received further fluids after the FC between those with a positive, with an uncertain or with a negatively judged response.The current practice and evaluation of FC in critically ill patients are highly variable. Prediction of fluid responsiveness is not used routinely, safety limits are rarely used, and information from previous failed FCs is not always taken into account

Neuroscience and End-of-Life Decisions: What Kind of Coexistence?

One of the most far-reaching challenges posed to the law by the development of neuroscience is the possibility to unveil some of the interior elements of human beings in the absence of external manifestations. The perception of pain, the presence of consciousness and the wishes of incompetent patients, once unfathomable because they could not be externalized, are nowadays accessible also from persons unable to express themselves (such as infants, people in comas, severely disabled people, etc.). These new frontiers raise an anthropological question and place heavy demands for lawyers embroiled in end-of-life matters, especially for constitutional lawyers. The present paper aims to highlight how the search for a balanced relationship between neuroscientific acquisitions and end-of-life decisions is weakened by at least two risks: the utmost deference towards science and scientific authority and the maximization of self-determination. In view of all this, the paper will provide, at the beginning, a framework of case law and end-of-life regulatory attempts with a specific focus on the recent law on informed consent and living will approved by the Italian Parliament; it will follow the analysis of the main challenges posed to law by advances in neuroscience. In the final part of this paper, we will offer food for thought on the role of neuroscience and\u2014in a broader perspective\u2014of science in law