withholding and withdrawing in critical dialysis 2011-09-19 2012-03-26 蔡壁如

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 – 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

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

Case presentation----CVVH

• 2011-8-30 12:40 ~ 2011-9-1 02:25– Total duration : 36hr 45min

Case presentation-5635578

診斷 :Fever of unknown originShock 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


• 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


• 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

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•???

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

Muscle man OHCA-4 5807892

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

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 　

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

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

OHCA-3 5806964

• Q10

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

Withholding and withdrawing in critical dialysis

dialysis database data 2008年 2009年 2010年 2011年

SICU轉入人數 3508 3685 4110 4430

AcuteDialysis （人／%）

182 ( 5.18%)

157( 4.26%)

201 (4.89%

)

226 (5.10%)

＜ 48hr （人／%）

36 (19.78%

)

35 (22.29%)

44 (21.89%)

34(15.04%)

其中 ECMO + CAVH2009: 22010: 52011 : 10

ECMO data

年度 2003 2004 2005 2006 2007 2008 2009 2010 2011

人數 87 98 113 99 150 133 168 165 180

X 14 16 14 12 16 15 16 31 23

%16.0

%16.3

%12.3

%14.1

%10.6

%11.2

% 9.5%18.7

%12.7

%

黨中央不批准比率

ECMO meeting 決議

Mortality, DNR and length of stay in SICU

DNR早講，配套措施？？？

AND : Allow-nature-death• “Allow natural death” is not equivalent to “d

o not resuscitate”

• 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.

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

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

Withholding vs withdrawing

Withholding withdrawingType of act Act of omission Act of commission

Prognosis More uncertain More likely to be known

Time for making decisions

Less opportunity for informed decisions

More time for decision marking

Family expectation

Lower Higher

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

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

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 …..)

Conclusions:High severity of illness and prolonged intensive care without improvement beyond 2 weeks presage decisions to withdraw treatment and signal patients and caregivers that death is imminent and that further aggressive care should be reconsidered or limited.

The Frequency of Withdrawal from Acute Care Is Impacted by Severe Acute Renal Failure

JOURNAL OF PALLIATIVE MEDICINEVolume 7, Number 5, 2004

Withdrawing, 48hr death more than 90%

預期 48 小時死亡 aggressive care should be limited

Time-limited trials of dialysis Trial 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

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

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

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

Conclusions

• Risk assessment prediction scores

• 要那些 Scoring ?– Guideline – Data base statistics and analysis

withholding and withdrawing in critical dialysis 2011-09-19 2012-03-26 蔡壁如

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