Management of the hopelessly ill patient: to stop or not to start?

The paper discusses the subject of futile treatment in the case of a hopelessly ill patient. The topic has many facets, among them the ethical precepts of preventing futile treatment, but also the economic and logistic impact of treating patients who do not have a fair chance of benefitting from managing their medical condition. A 75-year old patient, suffering from an advanced stage of Alzheimer's disease and a clinical picture of acute surgical abdomen, is presented and two approaches are discussed.

Detection of endobronchial intubation by monitoring the CO2 level above the endotracheal cuff.

Early detection of accidental endobronchial intubation (EBI) is still an unsolved problem in anesthesia and critical care daily practice. The aim of this study was to evaluate the ability of monitoring above cuff CO2 to detect EBI (the working hypothesis was that the origin of CO2 is from the unventilated, but still perfused, lung). Six goats were intubated under general anesthesia and the ETT positioning was verified by a flexible bronchoscope.

Factors encouraging and inhibiting organ donation in Israel: the public view and the contribution of legislation and public policy.

Although transplantation surgeries are relatively successful and save the lives of many, only few are willing to donate organs. In order to better understand the reasons for donation or refusing donation and their implications on and influence by public policy, we conducted a survey examining public views on this issue in Israel. Between January and June 2010, an anonymous questionnaire based on published literature was distributed among random and selected parts of Israeli society and included organ recipients, organ donors, soldiers, university and high school students, and the general population.

Do waking salivary cortisol levels correlate with anesthesiologist's job involvement?

Anesthetists' work carries great responsibility and can be very stressful. Cognitive appraisal plays a central role in stress responses; however, little is known about the relationship between stress appraisal and biological markers of stress, particularly among anesthesiologists. Stress response may be associated with increased levels of systemic cortisol, which can be conveniently measured in saliva and used as a marker for the extent of stress.

Endotracheal tube cuff--small important part of a big issue.

Many of the complications related to prolonged ventilation are related to inappropriate handling of endotracheal tube (ETT) cuff. This article reviews the possible complications associated with the ETT cuff, and the landmark development made in that field. The article challenges the present paradigm of cuff use and reviews the current clinical practice in that area.

Professional stress in anesthesiology: a review.

Anesthesiology is a stressful medical profession. While anesthesia in particular has become safer for the patient in the last decades, anesthesiology as a profession represents a medical field in which the professionals are permanently tense. The various reasons for this situation include the fact that anesthesiology is a team profession that requires perfect cooperation with other specialists.

Ventilator-associated pneumonia: current status and future recommendations.

Objective: Ventilator-associated pneumonia (VAP) is a common hazardous complication in ICU patients. The aim of the current review is to give an update on the current status and future recommendations for VAP prevention.

Methods: This article gives an updated review of the current literature on VAP.

Tracheal pressure and endotracheal tube obstruction can be detected by continuous cuff pressure monitoring: in vitro pilot study.

Purpose: To evaluate whether the degree of endotracheal tube (ETT) obstruction can be predicted by changes of ETT cuff pressure (P (c)) as a function of peak inspiratory pressure.

Methods: The study was conducted in three phases: phase I evaluated the correlation between peak tracheal pressure (P (tr)) and P (c); phase II evaluated the relation between P (c) versus ventilator pressure (P (v)) and ETT obstruction (range of obstruction 0-58%). In phase III the analytical model developed in phase II was used to predict the degree of obstruction of five ETTs removed from intensive care unit (ICU) patients.

[Organ transplantation in Israel of 2007--reality and vision].

The situation of organ transplantation in Israel has currently reached a crossroad. The number of patients on the waiting list increases from one year to another, but the availability of organs remains, more or less, the same as in the last decade. As a result, the medical condition of the patients on the waiting list deteriorates and each year some 7% of these patients died before an organ could be procured for saving their lives.

Terlipressin facilitates transport of septic patients treated with norepinephrine.

Background: Transport of hemodynamic unstable septic patients for diagnostic or therapeutic interventions outside the intensive care unit is complex but sometimes contributes to increasing the chance of survival.

Objectives: To report our experience with terlipressin treatment for facilitation of transport to distant facilities for diagnostic or therapeutic procedures in septic patients treated with norepinephrine.

Methods: We conducted a retrospective analysis of the records of our ICU, identifying the patients with septic shock who required norepinephrine for hemodynamic support.

Acoustic monitoring of double-lumen ventilated lungs for the detection of selective unilateral lung ventilation.

One-lung intubation (OLI) is among the most common complications of endotracheal intubation. None of the monitoring tools now available has proved effective for its early detection. In this study we investigated the efficacy of acoustic analysis for the detection of OLI.

Is penile block better than caudal epidural block for postcircumcision analgesia?

Purpose: To compare caudal and penile block for post-operative analgesia in children undergoing circumcision with respect to efficacy, complication rates, and parental satisfaction.

Methods: The study population consisted of 100 ASA 1 and 2 boys aged 3 to 8 years who were undergoing circumcision for religious reasons. In all participants, inhalation anesthesia was administered with oxygen : nitrous oxide (1 : 2) and halothane.

Helmet noninvasive ventilation for weaning from mechanical ventilation.

We saw a patient who presented with carbon dioxide narcosis and acute respiratory failure due to an exacerbation of chronic obstructive pulmonary disease. We intubated and 12 hours later he had recovered consciousness and could cooperate with noninvasive ventilation, at which point we extubated and used a helmet to provide noninvasive positive-pressure ventilation in assist/control mode, and then during the ventilator-weaning process, pressure support, and finally continuous positive airway pressure. The patient had no complications from the helmet, and he was discharged from intensive care 48 hours after helmet ventilation was initiated.

Emergency percutaneous tracheostomy is feasable in experienced hands.

One of most stressful situations for a physician occurs when a patient is unable to breathe and endotracheal intubation is not possible. The establishment of an open airway by surgery is indicated only if the physician is unable to do so with an endotracheal tube. Surgical tracheostomy is not indicated in emergency situations because it takes a long time and can result in death if respiratory support cannot be provided during the procedure.

Fatal metabolic acidosis caused by thiamine deficiency.

Acute thiamine deficiency, an uncommon cause of hemodynamic instability in Western countries, may be manifested by acute heart failure and neurological deficits. Severe metabolic acidosis is one of its least recognized features. We present a report of foreign workers who complained of weakness and lower limb edema and were found to have acute thiamine deficiency.

The dilemma of immediate preoperative hypertension: to treat and operate, or to postpone surgery?

Study Objective: To evaluate the efficacy and complications of immediate preoperative reduction of arterial blood pressure (BP) in patients with well-controlled hypertension but with diastolic blood pressure (DBP) between 110 and 130 mmHg on arrival at the operating room (OR).

Design: Prospective, randomized, large-sample study.

Setting: University-affiliated, 550-bed community hospital.