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| Correspondence
Difficult decisions P. A. Ward* London, UK *E-mail:
[email protected]
have identified the potential for clinical decline and predict the need for escalation in treatment before the patient reaches extremis. This reluctance/failure of medical and surgical teams to make these decisions on limits of care/DNAR orders may reflect a failure to recognize clinical deterioration (critical care outreach were involved in only three of 22 patients referred in the audit), an unwillingness or unfamiliarity with making such difficult decisions (the referral teams were unaware of premorbid function in 36% of the patients referred), an over-reliance upon critical care colleagues, a fear of litigation, unrealistic expectations of critical care (only 45% of the patients referred were accepted for admission), or a desire to follow the path of least resistance where everyone is considered a candidate for ICU admission (and cardiopulmonary resuscitation). Regardless of the reason, our medical and surgical colleagues should be encouraged to take increased responsibility for these decisions and to consider carefully the appropriateness of these interventions themselves (with assistance/advice from the ICU where necessary) at the earliest possible juncture; ideally, before they are prompted to do so by their critical care colleagues at the inevitable cardiac arrest call!
Declaration of interest None declared.
References 1. Brindley PG, Beed M. Adult cardiopulmonary resuscitation: ‘who’ rather than ‘how’. Br J Anaesth 2014; 112: 777–9 doi:10.1093/bja/aev052
Do not resuscitate and the intensive care unit: time to talk P. G. Brindley1, * and M. Beed2 1
Alberta, Canada, and 2Nottingham, UK
*E-mail:
[email protected]
Editor—We sincerely thank Dr Ward for his interest in our editorial1 and agree with his comments. For both intensive care unit (ICU) admission and cardiopulmonary resuscitation (CPR) there is an increasing presumption of maximal intervention ( just say ‘yes’), coupled with an increasing reliance on ICU practitioners to become responsible for many discussions, decisions, and deaths. Both cardiac arrest and ICU admission are usually (though not always) presaged by gradual, recognizable, and reversible physiological derangement. In-hospital cardiac arrest may not always be avoidable, but is often associated with the
following factors: failure to discuss, failure to document, failure to alert, failure to respond, failure to rescue, and even failure to stop. Consideration of both ICU escalation and CPR status should be considered earlier for deteriorating patients. Indeed, the National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report goes further, and recommends that resuscitation status be considered upon hospital admission for all acutely ill patients.2 Resuscitation is central to modern acute care, and as such, all practitioners (not only ICU practitioners) need a better
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Editor—I read with interest the recent editorial by Brindley and Beed1 on the importance of carefully considering the appropriateness of cardiopulmonary resuscitation (CPR) in each patient before attempting it. The authors draw a parallel between CPR and the intensive care unit (ICU) and the capacity of each of these interventions to cause more harm than good when employed inappropriately. A further parallel can be drawn from the relative absence of prior decision making in CPR/do not attempt resuscitation (DNAR) situations that is often mirrored in the ICU referral process. The decision whether to attempt CPR can be extremely difficult, not least because it is dependent upon a myriad of factors, much like the decision whether to admit a patient to the ICU. It is therefore hugely surprising how frequently both of these difficult decisions are considered for the first time when the patients are in extremis (in often rather stressful circumstances), and the decisions are invariably left to anaesthetists/intensivists to make (usually on their first encounter with the patient) rather than being made in advance in a timely, considered fashion by the surgical or medical team/ Consultant responsible for the patient’s’ care. Indeed, an audit of the ICU referral process at St Mary’s Hospital Adult Intensive Care Unit, London (October 2012–January 2013) demonstrated that none of the 22 patients (mean age 59 yr, range 23–88 yr) referred to the ICU during this period had DNAR orders completed by their responsible medical or surgical teams, and in only 9% of patients had the referring team considered any limits of care. Of course, there are some patients who experience a catastrophic decline or unexpected event that precludes such prior decision making, but it is often possible in the vast majority of patients requiring ICU admission/higher levels of care/CPR to
Correspondence
understanding of its nuances . . . and its limits. However, we also need to reach out ( pre-emptively) to our non-ICU colleagues and not criticize them for not knowing our specialty as well as us. It is part of our job to emphasize that ICU works best when arresting a patient’s deterioration, not when a deteriorated patient arrests. With certain exceptions, CPR is often a last-ditch attempt. In contrast, ICU resuscitation (without chest compressions) affords the possibility to revisit a patient’s trajectory after therapy (‘a trial of life’). As such, it might be entirely appropriate to offer ICU admission and resuscitation (e.g. inotropes, mechanical ventilation), whilst precluding chest compressions or defibrillation should this fail. Several hospitals already use ‘goals of care’ or ‘ceiling of care’ documents. These allow ‘do not resuscitate’ (DNR) decisions to be considered separately from other, less binary, escalation decisions (no more ‘all or none’).2 3 It also emphasizes that DNR does not mean ‘do not respond’ or ‘do not care’. It is prudent to set sail with an anchor.
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Declaration of interest None declared.
References
doi:10.1093/bja/aev051
Need for development of face-to-face orotracheal intubation using direct (Macintosh) laryngoscopy E. M. Rottenberg Ohio, USA E-mail:
[email protected]
Editor—Zraier and colleagues,1 based on a previous study of faceto-face orotracheal intubation (ftf-OTI) with a difficult airway manikin placed in the sitting position facing the operator,2 published a case series of patients intubated in the operating theatre using the Video-Airtraq™ laryngoscope (VAL) in difficult circumstances using a ftf-OTI technique. They reported that the airways of the seven [intubation difficulty score (IDS) >5] patients were rapidly, easily, and safely secured using the VAL-ftf-OTI technique and suggested that intubation in the sitting position is probably the safest position for airway management. They reported that clinical trials evaluating VAL-ftf-OTI as a primary airway management strategy are ongoing to confirm their observations. However, new evidence suggests that preclinical and clinical trials of Macintosh Laryngoscope (ML) ftf-OTI and video laryngoscopy (VL) ftf-OTI should also be included. Schober and colleagues3 recently published a manikin simulation study of ‘inverse intubation’ in entrapped trauma casualties comparing ML-ftf-OTI, McGrath (McGrath, Aircraft Medical, UK) VL-ftf-OTI, and VAL-ftf- OTI, with the manikin placed in a sitting position with the neck immobilized and accessible only from the left anterolateral side. They concluded that all three techniques have a high success rate, but the usefulness of the McGrath VL-ftf-OTI is limited because of the longer duration for intubation. However, intubation was always successful and
tended to be fastest with VAL-ftf-OTI, suggesting that this technique may be a promising option. They suggested that ML-ftf-OTI (or ‘inverse direct laryngoscopy’) showed reasonable intubation times and, given the widespread availability of Macintosh laryngoscopes, seems a useful technique.
Declaration of interest None declared.
References 1. Zraier S, Bloc S, Chemit M, Amathieu R, Dhonneur G. Intubation in the operating theatre using the Video-Airtraq™ laryngoscope in difficult circumstances by a face-to-face tracheal intubation technique. Br J Anaesth 2014; 112: 1118–9 2. Amathieu R, Sudrial J, Abdi W, et al. Simulating face-to-face tracheal intubation of a trapped patient: a randomized comparison of the LMA Fastrach™, the GlideScope™, and the Airtraq™ laryngoscope. Br J Anaesth 2012; 108: 140–5 3. Schober P, Krage R, van Groeningen D, Loer SA, Schwarte LA. Inverse intubation in entrapped trauma casualties: a simulator based, randomised cross-over comparison of direct, indirect and video laryngoscopy. Emerg Med J 2014; 31: 959–63 doi:10.1093/bja/aev053
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1. Brindley PG, Beed M. Adult cardiopulmonary resuscitation: ‘who’ rather than ‘how’. Br J Anaesth 2014; 112: 777–9 2. Findlay G, Shotton H, Kell K, Mason M, et al. Time to intervene? A review of patients who underwent cardiopulmonary resuscitation as a result of an in-hospital cardiorespiratory arrest. A report by the National Confidential Enquiry into Patient Outcome and Death. NCEPOD, London 2012. [internet]. http:// www.ncepod.org.uk/2012report1/downloads/CAP_summary. pdf [accessed Aug 20, 2013] 3. Dahill M, Powter L, Garland L, Mallett M, Nolan J. Improving documentation of treatment escalation decisions in acute care. BMJ Qual Improv Report 2013; 2: doi:10.1136/bmjquality. u200617.w1077
