Intensity of treatment, end-of-life care, and mortality for older patients with severe traumatic brain injury
Elizabeth J. LilleyKatherine J. WilliamsEric B. SchneiderKhaled HammoudaAlí SalimAdil H. HaiderZara Cooper
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Abstract:
The Eastern Association for the Surgery of Trauma (EAST) recommends that clinicians consider limiting further aggressive treatment in geriatric patients with severe traumatic brain injury (TBI) who do not improve in 72 hours (nonresponders) owing to their poor prognosis. However, little is known about how these guidelines are followed in practice. This study compared mortality and patient care among geriatric patients with severe TBI classified as "responders" and "nonresponders" 72 hours after injury.Retrospective review of patients 65 years or older at a Level I trauma center with severe TBI (GCS < 8) from 2011 to 2014. We compared in-hospital mortality, end-of-life (EOL) decision making, discharge functional status, and 12-month survival in responders (GCS > 8 at 72 hours) and nonresponders (GCS ≤ 8 at 72 hours).Of 90 patients, 29 (32%) died within 3 days of injury, 29 (32%) were nonresponders, and 32 (34%) were responders. An additional 19 patients (21%) died before hospital discharge, of whom 17 (89%) were nonresponders. Nonresponders had higher odds of in-hospital death (odds ratio, 31.8; 95% confidence interval [CI], 3.71-272.9; p = 0.002). Family meetings to discuss goals of care were more common in the nonresponder group (p < 0.001) and fewer nonresponders were full code at discharge or death (p < 0.001). There were no significant differences in functional status at discharge. Among patients discharged alive, there were no differences in 12-month survival.The responder/nonresponder dichotomy identifies patients with higher in-hospital mortality outcomes and is associated with differences in EOL decision making. However, functional impairment and poor survival were prevalent, irrespective of neurologic status at 72 hours.Prognostic/epidemiologic study, level III; therapeutic study, level IV.Cite
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Seperti pada dewasa, teknik regional anestesi pada pediatrik kini makin popular digunakan oleh ahli anestesikarena keuntungannya. Namun demikian selalu ada risiko dan kemungkinan timbulnya komplikasi dari setiap tindakan yang dilakukan, termasuk tindakan anestesi regional pada pediatrik. Insidensi komplikasi anestesi regional pada pediatrik tidak banyak, dan kalaupun terjadi komplikasi adalah minor. Komplikasi bisa diakibatkan dari identifikasi ruang saraf, alat, obat, teknis tindakan anestesi regionalnya dan komplikasi lainnya.Walaupun tidak banyak kejadian komplikasi regional anestesi yang dilaporkan pada pediatrik, dan bukanlah komplikasi yang fatal, teknik regional anestesi pada pediatrik harus dilakukan dengan lebih hatihati, pertimbangan risiko dan keuntungannya untuk menghindari terjadinya komplikasi, terlebih karena kebanyakan komplikasi dapat dihindari dengan mempelajari teknik yang benar, menggunakan peralatan yang sesuai, dan sangat menerapkan prinsip keamanan pada pasien dengan baik.
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Genentech is partnering with the German cancer company Affimed to develop immunotherapies for multiple kinds of solid and blood cancers. Affimed is developing therapies that engage natural killer cells of the innate immune system to help direct them to attack cancer cells. Genentech will pay Affimed $96 million up front and up to $5 billion more in potential payments.
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ABSTRACT Airway management is particularly difficult in children with severe congenital anomalies. Such patients are extre- mely sensitive to the respiratory depressant effects of anaesthetic agents. We describe the successful and safe app- lication of caudal anaesthesia for inguinal hernia repair in three cases with severe congenital anomalies (Joubert syndrome, I-cell syndrome). The three patients concerned had congenital anomalies including serious facial defor- mity, respiratory failure and cardiovascular defects. They were administered a single dose of caudal epidural anaest- hesia for inguinal hernia surgery in order to avoid complications associated with general anaesthesia. Caudal block was performed and 1 mL/kg levobupivacaine 0.25% administered. We conclude that caudal epidural anaesthesia can be an effective, suitable and safe anaesthetic technique for inguinal herniotomy without the need for general anaesthesia or endotracheal intubation in children with severe congenital anomalies. Key Words: Caudal anaesthesia, children, congenital anomaly OZET Havayolu yonetimi, ciddi konjenital anomalileri olan cocuklarda ozellikle zordur. Bu tur hastalar anestezik ilaclarin solunum depresan etkilerine karsi asiri derecede duyarlidir. Kaudal anestezinin inguinal herni onarimindaki basarili ve guvenli uygulamasi konjenital anomalileri (Joubert sendromu, I-cell hastaligi) olan uc olguda gosterilmistir. Ilgili uc cocuk hastada, ciddi yuz deformitesi, solunum yetmezligi ve kardiyovaskuler bozukluk dahil konjenital bozuk- luklar vardi. Genel anesteziyle iliskili komplikasyonlari onlemek icin inguinal herni cerrahisinde tek doz kaudal epi- dural anestezi uygulandi. Kaudal anestezide %0.25 levobupivakain 1 mL/kg kullanildi. Kaudal epidural anestezinin, ciddi konjenital bozukluklari olan cocuklarda inguinal herni onarimi acisindan genel anesteziye veya endotrakeal entubasyona gerek duyulmadan etkili, uygun ve guvenli bir alternatif anestezi teknigi olabilecegi sonucuna varildi. A na h ta r Sozcukler: Kaudal anestezi, cocuk, konjenital bozukluk
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