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Withholding and Withdrawing in critical dialysis

Withholding and Withdrawing in critical dialysis. 2011-09-19 2012-03-26 蔡壁如. Outline. Case presentation: 現況 Paper review Data report Guideline 初稿. Case presentation. 59yrs male transferred from 雙和醫院

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Withholding and Withdrawing in critical dialysis

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  1. Withholding and Withdrawing in critical dialysis 2011-09-19 2012-03-26 蔡壁如

  2. Outline Case presentation:現況 Paper review Data report Guideline 初稿

  3. Case presentation • 59yrs male transferred from 雙和醫院 • Bowel perforation, status post explore laparotomy , T-colostomy creation, primary closure of bowel perforation (three times: 5/26, 6/26 , 8/10) • Peri-anal abscess, status post debridement • Intra-abdominal abscess, status post CT-guided pigtail insertion drainage (three times: 7/22, 7/26, 8/15) • Tuberculosis of lung

  4. Case presentation ----SICU History • 2011-07-16 transferred from 雙和醫院 • Perianal abscess, bowel perforation, IAI ( GI bleeding) • Severe sepsis • 2011-8-10 • Op due to bowel perforation and intra-abdominal abscess • 2011-8-12轉回 9A • 2011-8-14 • CT guided : L’t abdominal wall abscess • 2011-8-18轉回9A • 2011-8-29 • Respiratory failure  intubation on 8/30 • Run sepsis check list  early goal  Xigirs use • 2011-9-1 03:00 Expired

  5. Case presentation----CVVH • 2011-8-30 12:40 ~ 2011-9-1 02:25 • Total duration : 36hr 45min

  6. Case presentation-5635578 診斷: Fever of unknown origin Shock status post ECMO implantation • 2010/10/20.羅東醫院轉診 • ED, ID was consulted first : SLE, HIV, infection, • Atypical pnuemonia or infection were considered. • Chest CT was performed on 10/20 • showed patches of consolidations in bilateral lungs and bilateral pleural effusion, pneumonia was suspected

  7. Case presentation-5635578 • emergent inbutaion and con’s loss. • Septic shock with inotropes used (IE: ?) • CV consulted for suspection of myocarditis. The bedside cardiac echo showed LVEF 11%. • ECMO insertion, EMB was performed. • 8/22 17:15 入4A2

  8. Case presentation-5635578 • IVIG was prescribed under the suspicion of acute myocarditis • CAVH on ECMO • DNR • Expired at 8/23 9:29 • ECMO duration:16.2hr • CAVH duration: 11hr

  9. 洗腎和ECMO • 無效醫療 • 醫生用來表達盡心盡力的工具 • 問題是它太昂貴 • ???

  10. Muscle man OHCA-4 5807892 • BH: 176 cm, BW:107.9 kg • Collapse Time:2012-02-25 17:35 • Call EMT:2012-02-25 17:38 • EMT arrived : 2012-02-25 17:40 • NTUH ER time:2012-02-25 18:00 • ER CPR time:2012-02-25 18:00 • ER rhythmic : VT • On ECMO time :02-25 18:45 • ROSC time:02-25 18:45 • HR:72, RR:22, BP:163/122, SpO2:100% • Total CPR time:65 min

  11. Muscle man OHCA-4 5807892

  12. OHCA-1 2302658 • 53yrs, Male, BH:168cm, BW:72.2Kg • 入院診斷 : OHCA, r/o AMI • Collapse time:2012-02-15 09:56 • Call EMT time：2012-02-15 09:57 • EMT arrived time：2012-02-15 09:59 • EMT到達醫院時間: 2012-02-15 10:08 • ER rhythmic : Vf • ECMO run time:2012-02-15 10:43 • Total CPR time:45 min

  13. WBC

  14. OHCA-1 2302658 • POBAS  LAD • Shock related with AKI  CAVH on ECMO • Con’s : E1M3VT • Removed ECMO: 2012-2-21 • Urine amount increased and con’s clear • Extubation and transport to general ward

  15. OHCA-2 王謝月嬌4258693 • 入院診斷 : OHCA, r/o AMI • Collapse time:2012-02-18 10:43 • Call EMT time：2012-02-18 10:46 • EMT arrived time：2012-02-18 10:51 • EMT到達醫院時間: 2012-02-18 11:10 • 急診到院時間:2012-02-18 11:10 • ER rhythmic : Vf • ECMO run time:2012-02-18 11:51 • ROSC time:2012-02-18 11:51 • HR:64, RR: , BP: , SpO2: • Total CPR time:41 min

  16. WBC

  17. 健身房OHCA-3 5806964 • Collapse Time:2012-02-22 21:00, BCLS by coworker • Call EMT time: 2012-02-22 21:05 • EMT arrived time:2012-02-22 21:08 • NTUH time:2012-02-22 21:25 • ER CPR time:2012-02-22 21:25 • ER rhythmic :Vf • On ECMO time :2012-02-22 21:56 • ROSC time:2012-02-22 21:56 • HR:80, RR:8, BP:104/46, SpO2: ? • Total CPR time:54 min

  18. OHCA-3 5806964 • Q10

  19. 恩主公OHCA-5 3099370 • Collapse Time: • Call EMT: • EMT arrived : • NTUH ER time: 2012-02-29 06:13 • ER CPR time: 2012-02-29 16:13 • ER rhythmic : Vf  PEA • On ECMO time : 2012-02-29 06:45 • ROSC time: • HR:72, RR:22, BP:163/122, SpO2:100% • Total CPR time: min

  20. Withholding and withdrawing in critical dialysis

  21. dialysis database data 其中ECMO + CAVH 2009: 2 2010: 5 2011 : 10

  22. ECMO data 黨中央不批准比率 ECMO meeting決議

  23. Mortality, DNR and length of stay in SICU DNR早講，配套措施？？？

  24. AND : Allow-nature-death • “Allow natural death” is not equivalent to “do notresuscitate” • DNR is too vague, whereas ‘‘Allow natural death’’ provides an order with clear intent. • “Allow natural death’’ that is part of a growing call for change.

  25. Clin J Am Soc Nephrol 3: 587-593, 2008. doi: 10.2215/CJN.04040907

  26. Seminars in Dialysis—Vol 24, No 2 (March–April) 2011 pp. 208–214

  27. Withholding vs withdrawing Seminars in Dialysis—Vol 24, No 2 (March–April) 2011 pp. 208–214

  28. Evidence-based guideline of withholding or withdrawing dialysis : eight recommendations • shared decision making • informed consent or refusal • Estimating prognosis • conflict resolution • advance directives • special patient groups • Time-limited trials of dialysis • palliative care

  29. Dialysis Feasibility • Staring dialysis condition？ • Severe hypotension, difficulties vascular access, bleeding, hemorrhage diathesis, severe neurological impairment • Should offer to start and/or continue dialysis to everyone ? • involving prognosis and the ethical principles of beneficence • as well as the effect and interactions of others factors which are discussed. (social …..)

  30. The Frequency of Withdrawal from Acute Care Is Impacted by Severe Acute Renal Failure Conclusions: High severity ofillness and prolonged intensive care without improvement beyond 2 weeks presage decisionsto withdraw treatment and signal patients and caregivers that death is imminent and that furtheraggressive care should be reconsidered or limited. • Withdrawing, 48hr death more than 90% • 預期48小時死亡 aggressive care should be limited JOURNAL OF PALLIATIVE MEDICINE Volume 7, Number 5, 2004

  31. Time-limited trials of dialysisTrial of Therapy----Three elements to be evaluated • 1. Define goals of treatment. • 2. Endpoints have to be identified • Delineate criteria for evidence of improvement • Define a time point criteria will be evaluated • Define a magnitude of change accepted as evidence for improvement. • 3. The duration of dialysis trial should be established

  32. Cost Effectiveness of Acute Dialysis • SUPPORT trial • CRRT more expensive than IHD • Renal recovery vs Non-recovery (11.3 vs. 22.5 days, p < 0.001) • Renal recovery vs dependent dialysis (11,192 vs. 73,273 Canadian dollars, p < 0.001) over the year after hospital discharge

  33. Proposed algorithm to help in the decision-making process to withhold dialysis

  34. Proposed algorithm to help in the decision-making process to withdraw dialysis.

  35. Conclusions • Risk assessment prediction scores • 要那些 Scoring ? • Guideline • Data base statistics and analysis

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