Fluid and electrolyte balance in children

Intravenous fluid and electrolyte management in paediatrics requires an understanding of the indication for intravenous fluid therapy and the underlying pathophysiology in order to meet requirements and avoid adverse events. Careful consideration needs to be given to the rate as well as the composition of intravenous therapy, and children's ongoing need should be reviewed regularly. Fluid therapy can be separated into maintenance fluids, replacement fluids that address electrolyte deficits and ongoing losses, and resuscitation fluids. We review the critical considerations when prescribing intravenous fluid for children and consider the challenges of non-osmotic secretion of anti-diuretic hormone (ADH), hyponatraemic encephalopathy and other electrolyte abnormalities. Fluid management in children with diabetic ketoacidosis is also reviewed.     

Early patient deaths after transfer to a regional burn center

IntroductionPatients who sustain burn injuries are frequently transferred to regional burn centers. Severely injured patients, unlikely to survive, may be transported far from home and family to die shortly after arrival. An examination of early deaths, those that happen within a week of transfer, may offer an opportunity to revise the way we think about critical burns and consider the best way to provide regional care.MethodsThis is a focused review of burn patients who survived ≤1 week after transfer to a regional center from 2013–2017. Originating location data such as city, state, population at origin were obtained. Transfer data, including mode of transport and distance traveled, as well as patient characteristics, Total Body Surface Area (TBSA) burned, inhalation injury, medical history with calculation of revised-Baux (r-Baux) score were analyzed.Results25 patients (1.2%) met inclusion criteria. Patients were transferred from a wide geographic area with population ranges of 1000 to 279,000. 21 patients met criteria for burn resuscitation by TBSA; 4 (19%) were placed on comfort care upon arrival, 7 (33%) were placed on comfort care after discussion with the patient's family, and 10 (48%) received full resuscitation efforts. Of these 10 patients, 2 died as “full code”, 8 were transitioned to comfort care after failed resuscitation or other events. Code status was not always addressed prior to the decision to transfer. Two patients were transferred after cardiac arrest in the field both of which had significant medical comorbidities in addition to their burn.ConclusionsRegional burn centers support a variety of populations. Transferring patients for which care is futile may have a profound impact on resource utilization from a variety of perspectives including transferring centers, receiving centers, regional Emergency Medical Services and families. Referring providers need to be supported in identifying these severely injured, potentially expectant patients. Transfer of patients may negatively impact families as a loved one may die far from home, before family can arrive. With our increasing ability to utilize telemedicine, transfer may not always provide the best support we can offer for providers, patients, and families.Applicability of research to practiceEarly deaths after transfer to a regional burn center, especially those that do not undergo a full resuscitation, should be critically examined to determine the appropriateness of transfer in a palliative, patient and family centered approach.     

Quality in paediatric anaesthesia

The delivery of the highest quality anaesthetic services to children depends on many factors. All staff should be adequately trained and have appropriate continuing experience. Though facilities should be as accessible as possible, they must conform to nationally recognized standards. These cover not only the skills of surgeons, anaesthetists, nursing and ancillary staff but also the provision of paediatric medical support, emergency treatment and intensive care. Standards have also been set in relation to day-care and inpatient facilities, perioperative care, acute pain management and resuscitation services. Where possible, children's surgery should be performed on dedicated operating lists, where it may be easier to create a child-orientated environment and where teaching can be effective. There should be effective links with the nearest tertiary paediatric centre and appropriate arrangements for interhospital transfer.Most children's surgery will continue to be carried out in District Hospitals, where a multidisciplinary team should agree local practice and devise protocols based on national guidelines. The concept of acceptable continuing experience should be applied flexibly, using criteria based on children's age, number of cases performed by an individual per year and case mix.In this age of risk management, professional self-regulation and clinical governance, those providing surgical services for children must be able to justify their policies.     

Strategies in the treatment of infections with antibiotics in intensive care medicine

The treatment of infections is one of the central elements in post-operative intensive care and contributes significantly to outcome. Measures of quality of antibiotic therapy include survival, duration of ICU or in-patient stay and rates of organ failure, antibiotic resistance or nosocomial infection. The pre-requisites for antibiotic prescribing in the intensive care unit are as follows: the treatment has to be started early, the antibiotic must be effective against probable causative organisms, the patient's risk factors for infection with multi-drug resistant organisms must be taken into account, local patterns of resistance must be known, an effective dosage must be used and the duration of therapy should be adjusted to the patient's risk factors and probable causative organisms. The multiplicity of factors which must be taken into account when determining timely empirical therapy and the fact that this must be possible at any time of the day, make local standard operating procedures for antibiotic prescribing imperative. These standards should reflect local resistance patterns and should be regularly reviewed. The aim of this educational article is to portray a selection of the pre-requisites and strategies available in the treatment of infections with antibiotics in intensive care medicine.     

The management of acute pain

Unrelieved acute pain produces undesirable effects that may influence a patient's recovery and even survival after surgery. It may also lead to the long-term problem of chronic post-surgical pain. Pain management techniques themselves carry risks so a careful consideration of the risk:benefit ratio is essential. An acute pain service should provide education and training to all staff members involved in pain control and advice on the management of more complex problems. The responsibility for assessing and addressing pain lies with the whole of the team, and the patient themselves play an important part in this process. Pain should be anticipated wherever possible and appropriate measures taken to prevent it. Communication is an essential part of optimizing safe, effective pain control. There are many simple measures using familiar drugs and techniques that can enhance pain control. Sometimes pain control measures fail and a suitable response should be implemented to address severe pain. Some patient groups offer particular challenges, but understanding possible difficulties often helps in managing these challenges. Pain should be considered the fifth vital sign.     

Apparative Organersatztherapie in der unfallchirurgischen Intensivmedizin

Extracorporeal organ assist systems have an important role in the intensive care management of trauma patients. In many cases, they can offer a survival benefit for severely injured patents and also minimize late sequelae. Various strategies of conventional mechanical ventilation are available for the treatment of acute respiratory failure associated with trauma. However, when extensive lung injury is present, with the attendant risk of life-threatening hypoxemia, extracorporeal gas exchange devices can offer an additional treatment modality; they should also be used in critically injured patients to prevent lung failure. However, despite all efforts, the mortality of severely injured patients remains high, rising with increasing length of stay in intensive care, especially when there are such complications as sepsis and multiorgan failure. This article gives a brief overview of the different extracorporeal organ assist devices currently available. When these are used early in the course a higher survival rate can be achieved in patients with severe trauma.     

Samter's triad in childhood: a warning for those prescribing NSAIDs

Aspirin‐exacerbated respiratory disease (AERD) has been recognized in adults with chronic asthma. Samter's triad is a subset of AERD where adult patients develop nasal polyps, asthma, and sensitivity to aspirin. This condition is thought not to occur before the third decade of life. We report a 13‐year‐old boy with nasal polyps who suffered a life‐threatening exacerbation of asthma during a graded aspirin challenge. Resuscitation required positive pressure ventilation and inotropic support. Our observations confirm that classical Samter's triad can occur in children. We suggest that graded aspirin challenges in children are undertaken in a facility with equipment and staff trained for resuscitation. Consideration should be given to this rare complication when prescribing nonsteroidal anti‐inflammatory drugs in the perioperative period. Suspicion of this condition merits referral to an immunologist for desensitization to aspirin.     

Knowledge and opinions of orthopaedic surgeons concerning medical evaluation and treatment of patients with osteoporotic fracture

BACKGROUND: With the exponential increase in osteoporotic fractures, orthopaedic surgeons are in a logical position to become more involved in the medical treatment of this disease. However, it has been hypothesized that surgeons may not be inclined to initiate such treatment if they do not view medical interventions as an extension of their surgical opportunities. The objective of this study was to determine the knowledge and opinions of orthopaedic surgeons with regard to their opportunities for initiating medical treatment of patients with an osteoporotic fracture. METHODS: A survey consisting of twenty-two questions was administered to 171 orthopaedic surgeons in Utah, Idaho, and Wyoming. RESULTS: Of the 171 surveys that were mailed, 107 usable surveys were returned (a 63% response rate). A majority of the orthopaedic surgeons thought that it was appropriate to expand their orthopaedic practice to include prescribing pharmacological treatments for osteoporosis (68% agreed or strongly agreed with that statement). However, 47% were concerned enough about adverse events related to some conventional pharmacological treatments that they would rather avoid prescribing them. Of the surgeons who were willing to prescribe these treatments, 74% felt most comfortable prescribing bisphosphonates and >77% felt most comfortable prescribing calcium and vitamin-D supplements. Fifty-one percent considered an apparent osteoporotic fracture and several other clinical risk factors for osteoporosis as sufficient evidence for initiating pharmacological treatments, whereas 72% thought that a bone-density scan should be made before initiating treatment. Although 32% thought that all nonoperative treatment should be the responsibility of a primary care provider, 63% thought that the orthopaedic surgeon should initiate a workup to look for secondary causes of the osteoporosis and should begin medical treatment of patients with an osteoporotic fracture before referring them. CONCLUSIONS: Although a majority of orthopaedic surgeons believe that they should expand their role in the medical treatment of patients with an osteoporotic fracture, many do not institute medical treatment and think that the patient's primary care providers should be responsible for medical care.     

End-of-life care in the intensive care unit

End-of-life care in the intensive care unit (ICU) is an oxymoron. Intensive care units appeared in the 1980s only admitting patients for ‘intensive care’. Nowadays the ICU has become one of the few places in the hospital that can provide comfort care to the dying patient. For many doctors on ICU it remains a difficult and problematic area. Yet it is conceptually simple. The difficulty for the doctor is making the decision, for the patient and family, coming to terms with it. This article will focus on how this decision should be made and then on the care that should be provided for the patient. Many of the considerations in decision making are in the General Medical Council guidelines, Treatment and Care Towards the End of Life and this is essential reading before embarking of the process.     

La contrainte est-elle compatible avec le care ? Le cas de l’aide et du soin à domicile

Defending the autonomy of people and respecting their will has legitimately led to fight against any resort to constraint in care activities, by controlling and strictly defining its use if necessary, and by promoting a positive ethics of care, centred on people's needs and wills. Nevertheless, beyond extreme cases of and violence, if one more realistically views constraint not only in a binary mode as an action involving people without their consent, it is crucial to acknowledge that constraint lies everywhere inside care activities. It is not a matter of remaining misconducts or perversion. It is due to the necessity of also protecting people, especially when their ability to evaluate what is good for them may be altered. Leaning on several minute case studies carried out at disabled people's home, this paper describes the diverse forms that may take such an ordinary, silent constraint, ceaselessly present in care activities. It concludes by addressing its possible compatibility with care.     

Patient satisfaction with care in the intensive care unit: can we rely on proxies?

Background: To investigate whether next of kin can be addressed as proxy to assess patients' satisfaction with care in the intensive care unit (ICU). Methods: Prospective observational multicentre study. Two hundred and thirty‐five patients with an ICU length of stay of ≥2 days and 266 of their adult next of kin participated. Patient satisfaction was assessed by a questionnaire, distributed upon discharge from an ICU and compared with next of kin's answers. The possible range of answers was 0–100, with higher numbers indicating higher satisfaction. The main outcome measure was the extent of agreement between patients' satisfaction with care and the ratings of their next of kin. Results: Patients were most satisfied concerning physicians' competence (86.7±16.3), while least satisfaction was observed for the management of agitation and restlessness (78.2±23.5). There was no significant difference between next of kin's and patients' ratings. Agreement between patients and proxies was the highest concerning overall satisfaction (Cohen's κ 0.40) and the lowest for coordination of care (0.24). Spouses/partners had a higher agreement with the patients' ratings than other proxies. Conclusions: If the patient is unable to rate his satisfaction with care in the ICU, next of kin may be taken as an appropriate surrogate. Trial registration: The study has been registered at ClinicalTrials.gov, Reg No: NTC 00890513.     

Éducation thérapeutique

Any patient living with a chronic renal disease should be offered counselling, information and educational activities. Teaching and organisational endpoint are critical in order to be able to enlarge educational offer to meet the patient's needs. The healthcare system will also have to build educational programs pooling staff resources because no new financial support has been dedicated to Patient Education in hospitals. The aim of Educational programs is to improve patient's quality of life. Behaviours, professional practices and positions are changing throughout the process of implementing educational activities. Healthcare providers have to gain new skills to deal at the same time with the care and the cure.     

Is donating a kidney to a friend bad for your marriage?

Studies have shown that kidney donation to a spouse has a positive impact on marriage. This study was done to evaluate the impact on marriage when donation occurs to someone other than the spouse. Two groups of donors from our centre who donated around the same period were studied: donation to a spouse (spouse donor (SD)) or to someone other than the spouse (non‐spouse donor (ND)). A survey, the Revised Dyadic Adjustment Scale, was used to evaluate the effect of donation on the marriage. This tool consists of 14 questions that measure how satisfying and stable the relationship is. The results showed equal or better marriage scores in the ND group compared with the SD group. The NDs scored higher on two questions, one regarding agreement or disagreement on career choices (P = 0.05) and the other regarding the frequency of having stimulating exchanges of ideas with one's spouse (P = 0.02). With the highest possible total score of 69, NDs scored 53.4 and SDs scored 47.7 (P = 0.16). Scores of 47 and below indicate marital distress. In one final additional question, 97% of NDs reported ‘no change or good effect’ on the marriage, similar to 91% for SDs (P = 0.46). This is the first study to evaluate the effect of kidney donation on the state of marriage when the spouse is not the recipient. It appears that marriage is not impacted negatively when kidney donation occurs to someone other than the spouse.     

Supportive care after curative treatment for breast cancer (survivorship care): Resource allocations in low- and middle-income countries. A Breast Health Global Initiative 2013 consensus statement

Breast cancer survivors may experience long-term treatment complications, must live with the risk of cancer recurrence, and often experience psychosocial complications that require supportive care services. In low- and middle-income settings, supportive care services are frequently limited, and program development for survivorship care and long-term follow-up has not been well addressed.As part of the 5th Breast Health Global Initiative (BHGI) Global Summit, an expert panel identified nine key resources recommended for appropriate survivorship care, and developed resource-stratified recommendations to illustrate how health systems can provide supportive care services for breast cancer survivors after curative treatment, using available resources.Key recommendations include health professional education that focuses on the management of physical and psychosocial long-term treatment complications. Patient education can help survivors transition from a provider-intense cancer treatment program to a post-treatment provider partnership and self-management program, and should include: education on recognizing disease recurrence or metastases; management of treatment-related sequelae, and psychosocial complications; and the importance of maintaining a healthy lifestyle. Increasing community awareness of survivorship issues was also identified as an important part of supportive care programs. Other recommendations include screening and management of psychosocial distress; management of long-term treatment-related complications including lymphedema, fatigue, insomnia, pain, and women's health issues; and monitoring survivors for recurrences or development of second primary malignancies. Where possible, breast cancer survivors should implement healthy lifestyle modifications, including physical activity, and maintain a healthy weight. Health professionals should provide well-documented patient care records that can follow a patient as they transition from active treatment to follow-up care.     

Sang Froid in a time of trouble: is a vaccine against HIV possible?

Since the announcement of the STEP trial results in the past months, we have heard many sober pronouncements on the possibility of an HIV vaccine. On the other hand, optimistic quotations have been liberally used, from Shakespeare's Henry V's “Once more unto the breach, dear friends” to Winston Churchill's definition of success as “going from one failure to another with no loss of enthusiasm”. I will forgo optimistic quotations for the phrase “Sang Froid”, which translates literally from the French as “cold blood”; what it really means is to avoid panic when things look bad, to step back and coolly evaluate the situation. This is not to counsel easy optimism or to fly in face of the facts, but I believe that while the situation is serious, it is not desperate. I should stipulate at the outset that I am neither an immunologist nor an expert in HIV, but someone who has spent his life in vaccine development. What I will try to do is to provide a point of view from that experience. There is no doubt that the results of STEP were disappointing: not only did the vaccine fail to control viral load, but may have adversely affected susceptibility to infection. But HIV is not the only vaccine to experience difficulties; what lessons can we glean from prior vaccine development?     

Patients with microscopic and gross hematuria: practice and referral patterns among primary care physicians in a universal health care system

Background:

Hematuria is one of the most common findings on urinalysis in patients encountered by primary care physicians. In many instances it can also be the first presentation of a serious urological problem. As such, we sought to evaluate current practices adopted by primary care physicians in the workup and screening of hematuria.

Methods:

Questionnaires were mailed to all registered primary care physicians across Quebec. Questions covered each physician’s personal approach to men and postmenopausal women with painless gross hematuria or with asymptomatic microscopic hematuria, as well as screening techniques, general knowledge with regards to urine collection and sampling, and referral patterns.

Results:

Of the surveys mailed, 599 were returned. Annual routine screening urinalysis on all adult male and female patients was performed by 47% of respondents, regardless of age or risk factors. Of all the respondents, 95% stated microscopic hematuria was associated with bladder cancer. However, in an older male with painless gross hematuria, only 64% of respondents recommended further evaluation by urology. On the other hand, in a postmenopausal woman with 2 consecutive events of significant microscopic hematuria, only 48.6% recommended referral to urology. Findings were not associated with the gender of the respondent, experience or geographic location of practice (urban vs. rural).

Interpretation:

There seems to be reluctance amongst primary care physicians to refer patients with gross or significant microscopic hematuria to urology for further investigation. A higher level of suspicion and further education should be implemented to detect serious conditions and to offer earlier intervention when possible.     

Beliefs about back pain: The confluence of client,clinician and community

Patient beliefs play an important role in the development of back pain and disability, as well as subsequent recovery. Community beliefs about the back and back pain which are inconsistent with current research evidence have been found in a number of developed countries. These beliefs negatively influence people's back-related behaviour in general, and these effects may be amplified when someone experiences an episode of back pain.In-depth qualitative research has helped to shed light on why people hold the beliefs which they do about the back, and how these have been influenced. Clinicians appear to have a strong influence on patients' beliefs. These data may be used by clinicians to inform exploration of unhelpful beliefs which patients hold, mitigate potential negative influences as a result of receiving health care, and subsequently influence beliefs in a positive manner.     

Ethical and practical considerations of withdrawal of treatment in the Intensive Care Unit

Purpose

To discuss the medical, ethical and legal basis of decisions to discontinue life-support therapy in the adult intensive care unit (ICU), and to provide practical guidelines for the discontinuation of life support therapy.

Source

Relevant articles were retrieved through Medline (1991-present; terms: ethics, life support discontinuation, double effect, beneficence, non-maleficence). Other sources include legal references, and personal files.

Principal Findings

Understanding the legal and ethical principles of autonomy, beneficence, non-maleficence and double effect are crucial when withdrawing life support therapy. The law respects a competent patient’s right to direct his/her healthcare but does not uphold his/her right to demand futile care. Surrogate decision makers can be used when the patient is incompetent, provided they are acting in the patient’s best interest, Euthanasia is illegal and the distinction between discontinuation of therapy and euthanasia is legally clear. Skilful administration of palliative therapy cannot be construed as euthanasia when the aforementioned ethical principals are respected. The various practical methods of discontinuing therapy are discussed. Every ICU should develop its own guidelines and a checklist to help caregivers during this difficult time. Caregivers must anticipate the mechanism of death and direct interventions at the symptoms that are likely to cause discomfort. Drugs and dosages must be individualized, and depend on the underlying disease, anticipated mechanism of death, and the patient’s pharmacological history. When prescribing a drug, the intention should be clear.

Conclusions

Appropriate discontinuation of therapy in the ICU allows patients a dignified and comfortable death.