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The ethical and legal aspects of palliative sedation in severely brain-injured patients: a French perspective
Antoine Baumann, Frédérique Claudot, Gérard Audibert, Paul-Michel Mertes, Louis Puybasset
Philosophy, Ethics, and Humanities in Medicine , 2011, DOI: 10.1186/1747-5341-6-4
Abstract: Every year, millions of people with serious diseases, as well as their loved ones, are confronted with decisions relating to the quality of the time that remains to be lived. The quality of the end of life may be severely altered by pain or other distressing symptoms. Physicians have a duty to relieve suffering in their patients. However, in most countries, they are not allowed to intentionally shorten life, although treatments given to relieve suffering are permitted even if they are also expected to shorten life (double-effect principle). A major challenge faced by physicians is to honour their patients' wishes and values and to help them safeguard their dignity and peace at the end of life.Some seriously ill patients, such as those with severe brain injuries, are unable to communicate their suffering. In these patients, the effectiveness of palliative care cannot be assessed: the possibility of persistent suffering cannot be ruled out [1]. There is a wide consensus that palliative sedation is appropriate as a last resort in this situation [2]. However, palliative sedation is a complex intervention that is closer to physician-assisted suicide and voluntary active euthanasia than is ordinarily acknowledged. Safeguards are needed whenever a medical intervention may hasten death. Legislation stating which practices are permissible would reassure the numerous patients who fear a "bad" death and would improve practice uniformity among physicians [3]. The French law on patients' rights and the end of life passed on April 22, 2005 (Law n° 2005-370, known as the Leonetti law) [4] indicates that patients should be allowed to die as comfortably and peacefully as possible but should not be made to die. This law reflects the evolution of French medical thinking about the best means of protecting patients' well-being and dignity while refraining from intentionally causing death. It has also led to further ethical discussions, most notably about palliative sedation after treatm
Monitoring the injured brain in the intensive care unit.  [cached]
Gupta A
Journal of Postgraduate Medicine , 2002,
Abstract: The primary aim of managing patients with acute brain injury in the intensive care unit is to minimise secondary injury by maintaining cerebral perfusion and oxygenation. The mechanisms of secondary injury are frequently triggered by secondary insults, which may be subtle and remain undetected by the usual systemic physiological monitoring. Continuous monitoring of the central nervous system in the intensive care unit can serve two functions. Firstly it will help early detection of these secondary cerebral insults so that appropriate interventions can be instituted. Secondly, it can help to monitor therapeutic interventions and provide online feedback. This review focuses on the monitoring of intracranial pressure, blood flow to the brain (Transcranial Doppler), cerebral oxygenation using the methods of jugular bulb oximetry, near infrared spectroscopy and implantable sensors, and the monitoring of function using electrophysiological techniques.
The beneficial effects of inhaled nitric oxide in patients with severe traumatic brain injury complicated by acute respiratory distress syndrome: a hypothesis
Thomas J Papadimos
Journal of Trauma Management & Outcomes , 2008, DOI: 10.1186/1752-2897-2-1
Abstract: Use of inhaled nitric oxide in patients with severe traumatic brain injury and acute respiratory distress syndrome will show a benefit through improved physiological parameters, a decrease in biochemical markers of inflammation and brain injury, thus leading to better outcomes.A prospective, randomized, non-blinded clinical trial may be performed in which patients meeting the case definition could be entered into the study. The hypothesis may be confirmed by: (1) demonstrating an improvement in physiologic parameters, intracranial pressure, and brain oxygenation with inhaled nitric oxide use in severely head injured patients, and (2) demonstrating a decrease in biochemical serum markers in such patients; specifically, glial fibrillary acidic protein, inflammatory cytokines, and biomarkers of the hypothalamic-pituitary-adrenal axis, and (3) documentation of outcomes.Inhaled nitric oxide therapy in traumatic brain injury patients with acute respiratory distress syndrome could result in increased numbers of lives saved, decreased patient morbidity, decreased hospital costs, decreased insurance carrier and government rehabilitation costs, increased tax revenue secondary to occupational rehabilitation, and families could still have their loved ones among them.Traumatic brain injury (TBI) affects 1.4 million Americans annually, which includes 1.1 million emergency department visits, 235,000 hospitalizations, and 50,000 deaths [1]. Approximately 5.3 million Americans are disabled with TBI [2] at a cost of $60 billion annually [3]. The Iraq war has provided additional cases and cost. At least 28% of wounded personnel have TBI resulting in $600,000 to $4,300,000 of care per patient [4-6]. This is based on 2824 wounded personnel as of August 2005 [6].Complications occur frequently in TBI, and respiratory dysfunction represents a primary non-neurological system failure [7]. These patients are confronted with a massive inflammatory response with the release of cytokines [8] and
Probing brain oxygenation with near infrared spectroscopy  [PDF]
Alexander Gersten,Jacqueline Perle,Amir Raz,Robert Fried
Physics , 2011,
Abstract: The fundamentals of near infrared spectroscopy (NIRS) are reviewed. This technique allows to measure the oxygenation of the brain tissue. The particular problems involved in detecting regional brain oxygenation (rSO2) are discussed. The dominant chromophore (light absorber) in tissue is water. Only in the NIR light region of 650-1000 nm, the overall absorption is sufficiently low, and the NIR light can be detected across a thick layer of tissues, among them the skin, the scull and the brain. In this region, there are many absorbing light chromophores, but only three are important as far as the oxygenation is concerned. They are the hemoglobin (HbO2), the deoxy-hemoglobin (Hb) and cytochrome oxidase (CtOx). In the last 20 years there was an enormous growth in the instrumentation and applications of NIRS. . The devices that were used in our experiments were : Somanetics's INVOS Brain Oximeter (IBO) and Toomim's HEG spectrophotometer. The performances of both devices were compared including their merits and drawbacks. The IBO is based on extensive efforts of an R&D group to develop a reliable device, which measures well the rSO2. It is now used efficiently in operating rooms, saving human lives and expenses. Its use for research however has two drawbacks: the sampling rate is too small and the readings are limited to only two significant digits. The HEG device does not have these drawbacks, but is not developed sufficiently at this time to measure rSO2. We have measured the HEG readings and compared them with the rSO2 readings of the IBO. Our findings show that the HEG can be used to measure relative changes of rSO2.
Hyperbaric oxygen therapy for traumatic brain injury
Lei Huang, Andre Obenaus
Medical Gas Research , 2011, DOI: 10.1186/2045-9912-1-21
Abstract: Hyperbaric oxygen therapy (HBOT) is a treatment by which 100% oxygen is administered to a patient at a pressure greater than atmospheric pressure at sea level (i.e. one atmosphere absolute, ATA) [1]. The increased partial pressure of oxygen (pO2) within the blood and subsequent improved mitochondrial metabolism/tissue oxygenation constitutes the net effect of HBOT [2-6]. Given that the dissolved oxygen content in the plasma increases linearly after hemoglobin is 100% saturated [7,8], plasma bound oxygen can be used more readily than that bound to hemoglobin which enables tissue oxygen delivery even in the absence of red blood cells [7,9].Thus, HBOT induces a much larger oxygen-carrying capacity in the blood that dramatically increases the driving force of oxygen diffusion to tissues. Although HBOT-induced cerebral vasoconstriction appears to be undesirable within the context of ischemic conditions [10,11] this may not be necessarily deleterious due to increased oxygen availability to injured tissues. HBOT may also counter vasodilation of the capillaries within hypoxic tissues, thereby minimizing collection of extravascular fluids (edema) which ultimately reduces brain vasogenic edema and the ensuing decrease in intracranial pressure (ICP) [5,12-14].Emerging evidence has shown the neuroprotective effects of HBOT in a range of multiple injuries and/or disorders (Additional file 1, Table S1) [15]. The most common clinical applications include decompression sickness, carbon monoxide poisoning, minimization of radiation therapy induced tissue damage and enhancing skin grafts [1,16], which are all covered by insurance/Medicare. There are numerous "unapproved" uses of HBOT that focus on more complex neurological disorders, including autism, multiple sclerosis and stroke, which have shown promising results in experimental settings, but clinical efficacy is still elusive. Recent efforts have applied HBOT to traumatic brain injury [5,14,17]. While significant research on HBOT
The utility of scores in the decision to salvage or amputation in severely injured limbs  [cached]
Rajasekaran Shanmuganathan
Indian Journal of Orthopaedics , 2008,
Abstract: The decision to amputate or salvage a severely injured limb can be very challenging to the trauma surgeon. A misjudgment will result in either an unnecessary amputation of a valuable limb or a secondary amputation after failed salvage. Numerous scores have been proposed to provide guidelines to the treating surgeon, the notable of which are Mangled extremity severity score (MESS); the predictive salvage index (PSI); the Limb Salvage Index (LSI); the Nerve Injury, Ischemia, Soft tissue injury, Skeletal injury, Shock and Age of patient (NISSSA) score; and the Hannover fracture scale-97 (HFS-97). These scores have all been designed to evaluate limbs with combined orthopaedic and vascular injuries and have a poor sensitivity and specificity in evaluating IIIB injuries. Recently the Ganga Hospital Score (GHS) has been proposed which is specifically designed to evaluate a IIIB injury. Another notable feature of GHS is that it offers guidelines in the choice of the appropriate reconstruction protocol.The basis of the commonly used scores with their utility have been discussed in this paper.
Oxygenation and Blood Volume Periodic Waveforms in the Brain  [PDF]
Alexander Gersten,Dov Heimer,Amir Raz
Physics , 2011,
Abstract: Results of an experiment are presented whose aim is to explore the relationship between respiration and cerebral oxygenation. Measurements of end tidal CO2 (EtCO2) were taken simultaneously with cerebral oxygen saturation (rSO2) using the INVOS Cerebral Oximeter of Somanetics. Due to the device limitations we could explore only subjects who could perform with a breathing rate of around 2/min or less. Six subjects were used who were experienced in yoga breathing techniques. They performed an identical periodic breathing exercise including periodicity of about 2/min. The results of all six subjects clearly show a periodic change of cerebral oxygenation with the same period as the breathing exercises. Similar periodic changes in blood volume index were observed as well.
Prehospital Intubation in Patients with Isolated Severe Traumatic Brain Injury: A 4-Year Observational Study  [PDF]
Mazin Tuma,Ayman El-Menyar,Husham Abdelrahman,Hassan Al-Thani,Ahmad Zarour,Ashok Parchani,Sherwan Khoshnaw,Ruben Peralta,Rifat Latifi
Critical Care Research and Practice , 2014, DOI: 10.1155/2014/135986
Abstract: Objectives. To study the effect of prehospital intubation (PHI) on survival of patients with isolated severe traumatic brain injury (ISTBI). Method. Retrospective analyses of all intubated patients with ISTBI between 2008 and 2011 were studied. Comparison was made between those who were intubated in the PHI versus in the trauma resuscitation unit (TRU). Results. Among 1665 TBI patients, 160 met the inclusion criteria (105 underwent PHI, and 55 patients were intubated in TRU). PHI group was younger in age and had lower median scene motor GCS ( ). Ventilator days and hospital length of stay ( and 0.006, resp.) were higher in TRUI group. Mean ISS, length of stay, initial blood pressure, pneumonia, and ARDS were comparable among the two groups. Mortality rate was higher in the PHI group (54% versus 31%, ). On multivariate regression analysis, scene motor GCS (OR 0.55; 95% CI 0.41–0.73) was an independent predictor for mortality. Conclusion. PHI did not offer survival benefit in our group of patients with ISTBI based on the head AIS and the scene motor GCS. However, more studies are warranted to prove this finding and identify patients who may benefit from this intervention. 1. Introduction Prehospital intubation (PHI) is a standard approach for early critical care management among severe trauma patients. In particular, establishment of definitive airway is an integral part in the optimal care and management of severe traumatic brain injury (STBI) patients [1]. Several data showed that early prevention of hypoxia at the scene has favorable effect on the survival in patients with STBI [2–5]. An earlier study demonstrated that PHI in isolated STBI patients significantly reduced the mortality from 50% to 23%, with an absolute survival benefit of 27% [6]. However, other data found PHI in head injury patients to be associated with worse outcomes [7–10], even with the use of Rapid Sequence Intubation (RSI) [11]. Many factors have been postulated to be responsible for such adverse outcome. These factors include higher risk of aspiration pneumonia, the effect of laryngoscopy on raising the intracranial pressure, the deleterious effect of hyperventilation and hypocapnia, and the potentially harmful effect of supra normal oxygen tension (hyperoxia) on the injured brain [12–15]. Helm et al. [16], in a prospective study, evaluated the effect of quality of controlled ventilation and airway protection in head injury patients. The authors did not find PHI effective for maintaining optimal oxygenation and ventilation in these patients. Despite high incidence of head
Tumor necrosis factor-mediated inhibition of interleukin-18 in the brain: a clinical and experimental study in head-injured patients and in a murine model of closed head injury.
Oliver I Schmidt, Maria Morganti-Kossmann, Christoph E Heyde, Daniel Perez, Ido Yatsiv, Esther Shohami, Wolfgang Ertel, Philip F Stahel
Journal of Neuroinflammation , 2004, DOI: 10.1186/1742-2094-1-13
Abstract: Closed head injury (CHI) is the leading cause of mortality and persisting neurological impairment in young people in industrialized countries [1,2]. The neuropathological sequelae of brain injury are mediated in large part by a profound host-mediated intracranial inflammatory response [3-5]. The pro-inflammatory cytokines tumor necrosis factor (TNF) and interleukin (IL)-18 have been identified as crucial mediators of neuroinflammation after brain injury [6-9]. This notion has been supported by experimental studies in rodents which demonstrated neuroprotective effects by pharmacological inhibition of either TNF or IL-18 after CHI [9-11]. In recent years, the concept of a "dual role" evolved with regard to concomitant beneficial and adverse effects of pro-inflammatory mediators, depending on the kinetic of their expression and posttraumatic regulation in the injured brain [3,12,13]. However, the TNF-dependent regulation of IL-18 in the injured brain has not yet been investigated. We sought to determine the interrelationship between intracranial TNF and IL-18 levels in a clinical study on patients with severe CHI and in an experimental model in mice.Patients with isolated severe closed head injury (n = 10, Glasgow Coma Scale score ≤ 8) and indication for intraventricular catheters for cerebrospinal fluid (CSF) drainage due to increased intracranial pressure (ICP > 15 mm Hg) were included in this study. Drained CSF was collected daily for up to 14 days after trauma or until catheters were removed. The patient characteristics are shown in Table 1. No patient was treated with steroids. The protocol for daily CSF collection is in compliance with the Helsinki Declaration and was approved by the University's Ethics Board Committee. Control CSF was collected from patients undergoing diagnostic spinal tap (n = 10) and revealed no inflammatory CNS disease, based on normal CSF protein and glucose levels and normal white cell counts. All samples were kept on ice at 4°C and immedi
Corticotherapy for traumatic brain-injured Patients - The Corti-TC trial: study protocol for a randomized controlled trial
Karim Asehnoune, Antoine Roquilly, Véronique Sebille, The Corti-TC trial group
Trials , 2011, DOI: 10.1186/1745-6215-12-228
Abstract: The CORTI-TC (Corticotherapy in traumatic brain-injured patients) trial is a multicenter, randomized, placebo controlled, double-blind, two-arms study. Three hundred and seventy six patients hospitalized in Intensive Care Unit with a severe traumatic brain injury (Glasgow Coma Scale ≤ 8) are randomized in the first 24 hours following trauma to hydrocortisone (200 mg.day-1 for 7 days, 100 mg on days 8-9 and 50 mg on day-10) with fludrocortisone (50 μg for 10 days) or double placebo. The treatment is stopped if patients have an appropriate adrenal response. The primary endpoint is HAP on day-28. The endpoint of the ancillary study is the neurological status on 6 and 12 months.The CORTI-TC trial is the first randomized controlled trial powered to investigate whether hydrocortisone with fludrocortisone in TBI patients with CI prevent HAP and improve long term recovery.NCT01093261Traumatic brain injury (TBI) is a leading cause of prolonged disability in young patients. The rate of hospital acquired pneumonia (HAP) varies from 30 to 50% [1-3]. Post traumatic HAP increases the risk of intracranial hypertension [4], prolongs duration of mechanical ventilation and Intensive Care Unit (ICU) length of stay [5,6] and may increase the rate of death [7]. Prevention of one episode of HAP may save 20,000$ [8].Critical Illness Related Corticosteroid Insufficiency (CIRCI) reaches up to 50 to 70% of trauma patients [9-11]. CIRCI increases systemic inflammation and vasopressive requirement [9,12]. Hydrocortisone decreases rate of HAP and duration of mechanical ventilation in multiple trauma patients with CIRCI [10]. In a sub-group analysis of the HYPOLYTE trial, hydrocortisone appears particularly efficient in multiple trauma patients with TBI [10]. Fludrocortisone was proposed in association with hydrocortisone for the treatment of CIRCI in septic patients [13] and is recommended in BI patients with spontaneous subarachnoid hemorrhage who experience hyponatremia [14]. No data regardin
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