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Garraud O. Transfusion at the border of the "intention-to-treat", in the very aged person and in palliative care: A debate. Transfus Clin Biol 2021; 28:367-369. [PMID: 34464710 DOI: 10.1016/j.tracli.2021.08.350] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/25/2021] [Indexed: 12/17/2022]
Abstract
In both palliative care and in the very aged person i.e. at the end of life, transfusion aims at bringing supportive care; it has indeed no intention to treat. It can occasionally be compassionate as to bring oxygen to a patient or a resident in nursing home wishing to enjoy some exercise or entertainment. Transfusion in this condition is not consensual, for reasons that are medical and/or societal. The present essay aims at discussing the main options to provide transfusion in such extreme, though non-exceptional, conditions.
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Affiliation(s)
- O Garraud
- INSERM_U1059, Faculty of medicine of Saint-Etienne, University of Lyon, Saint-Étienne, France.
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Farrell MS, Moore EE, Thomas AV, Coleman JR, Thomas S, Vande Lune S, Marconi T, Cohen MJ, Chapman MP, Moore HB, Walsh MM, Sixta S. "Death Diamond" Tracing on Thromboelastography as a Marker of Poor Survival After Trauma. Am Surg 2021; 88:1689-1693. [PMID: 33629880 DOI: 10.1177/0003134821998684] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Improvements in health care innovations have resulted in an enhanced ability to extend patient viability. As a consequence, resources are being increasingly utilized at an unsustainable level. As we implement novel treatments, identifying futility should be a focus. The "death diamond" (DD) is a unique thrombelastography (TEG) tracing that is indicative of failure of the coagulation system, with a mortality rate exceeding 90%. The purpose of this study was to determine if the DD was a consistent marker of poor survival in a multicenter study population. We hypothesize that the DD, while an infrequent occurrence, predicts poor survival and can be used to stratify patients in whom resuscitation efforts are futile. METHODS A retrospective multi-institutional study of trauma patients presenting with TEG DDs between 8/2008 and 12/2018 at four American College of Surgeons trauma centers was completed. Demographics, injury mechanisms, TEG results, management, and survival were examined. RESULTS A total of 50 trauma patients presented with DD tracings, with a 94% (n = 47) mortality rate. Twenty-six (52%) patients received a repeat TEG with 10 patients re-demonstrating the DD tracing. There was 100% mortality in patients with serial DD tracings. The median use of total blood products was 18 units (interquartile range 6, 34.25) per patient. DISCUSSION The DD is highly predictive of trauma-associated mortality. This multicenter study highlights that serial DDs may represent a possible biomarker of futility.
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Affiliation(s)
- Michael S Farrell
- Departments of Trauma, Surgery, and Critical Care Medicine, 5973Christiana Care Health Services, Wilmington, DE, USA
| | - Ernest E Moore
- Department of Surgery, 129263University of Colorado-Anschutz Medical Campus, Aurora, CO, USA.,Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO, USA
| | - Anthony V Thomas
- 158720Notre Dame Campus, Indiana University School of Medicine, South Bend, IN, USA.,Departments of Emergency and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, USA
| | - Julia R Coleman
- Department of Surgery, 129263University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | - Scott Thomas
- Memorial Trauma Center, Memorial Hospital, South Bend, IN, USA
| | - Stefani Vande Lune
- Emergency Medicine Department, Navy Medicine Readiness and Training Command, Portsmouth, VA, USA
| | - Thomas Marconi
- Departments of Trauma, Surgery, and Critical Care Medicine, 5973Christiana Care Health Services, Wilmington, DE, USA
| | - Mitchell J Cohen
- Department of Surgery, 129263University of Colorado-Anschutz Medical Campus, Aurora, CO, USA.,Department of Surgery, Ernest E. Moore Shock Trauma Center at Denver Health, Denver, CO, USA
| | - Michael P Chapman
- Department of Radiology, University of Colorado-Denver, Denver, CO, USA
| | - Hunter B Moore
- Department of Surgery, 129263University of Colorado-Anschutz Medical Campus, Aurora, CO, USA
| | - Mark M Walsh
- 158720Notre Dame Campus, Indiana University School of Medicine, South Bend, IN, USA.,Departments of Emergency and Internal Medicine, Saint Joseph Regional Medical Center, Mishawaka, IN, USA
| | - Sherry Sixta
- Departments of Trauma, Surgery, and Critical Care Medicine, 5973Christiana Care Health Services, Wilmington, DE, USA
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Sin S, Lee SM, Lee J. Characteristics and Outcomes of Potentially Inappropriate Admissions to the Intensive Care Unit. Acute Crit Care 2019; 34:46-52. [PMID: 31723904 PMCID: PMC6849049 DOI: 10.4266/acc.2018.00388] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/29/2019] [Accepted: 02/14/2019] [Indexed: 01/14/2023] Open
Abstract
Background Admission of patients perceived as potentially inappropriate for intensive care is a very sensitive and controversial issue. We aimed to evaluate the use of medical resources in the intensive care unit (ICU) and outcomes of patients according to a physician’s judgment of appropriateness. Methods ICU physicians classified patients who were admitted to the medical ICU of a tertiary hospital as appropriate or inappropriate for intensive care within 24 hours of admission. Patient outcomes including mortality were analyzed according to appropriateness. Additionally, the usage and duration of mechanical ventilation (MV), renal replacement therapy (RRT), and extracorporeal membrane oxygenation (ECMO) were analyzed according to appropriateness. Results In total, 105 patients (male, 55.4%; mean age, 62 years) were included. Twelve (11.4%) patients were considered inappropriate for intensive care based on guidance published by the Society of Critical Care Medicine through a questionnaire survey of physicians. There was no significant difference between patients considered inappropriate or appropriate for ICU admission regarding the use and duration of MV, RRT, and ECMO. In contrast, the ICU, in-hospital, 28-day, 90-day, and total mortality rates were significantly higher among patients with inappropriate admission than among patients with appropriate admission (ICU mortality: 50.0% vs. 25.8%, P=0.008; in-hospital mortality: 58.3% vs. 43.0%, P=0.028; 28-day mortality: 58.3% vs. 33.3%, P=0.019; 90-day mortality: 66.7% vs. 44.1%, P=0.023). Conclusions Despite higher mortality, the amount of medical resources used for patients considered potentially inappropriate for intensive care did not differ from the resources used for patients considered suitable for ICU care.
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Affiliation(s)
- Sooim Sin
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Sang-Min Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| | - Jinwoo Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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