Palliative sedation in Germany: how much do we know? A prospective survey.
Source
J Palliat Med. 2012 Jun;15(6):672-80.Department of Palliative Medicine, University of Bonn, Germany.
Friday, November 22, 2013
[Palliative care for patients with COPD: a challenge].
[Article in French]
Source
Rev Mal Respir. 2012 Nov;29(9):1088-94.Service de pneumologie, CHG de Saint-Nazaire, Saint-Nazaire cedex, France. l.ducouedic@ch-saintnazaire.fr
Abstract
INTRODUCTION:
The aim of our study was to examine the practices and performance of a team working in a respiratory unit concerning the palliative care of patients with COPD, in a group of patients who died in hospital as a result of their disease.
METHODOLOGY:
The
first step was focused on those patients who died in the respiratory
care unit of the General Hospital of Saint-Nazaire during the year 2008
and who received end-of-life care, and the reasons for their death. In
the second step, we selected and analysed retrospectively the records of
patients who died from COPD. In the third step semi-directive
interviews were held with a sample of nine care workers who were judged
to be representative of the staff working in the respiratory ward of
Saint-Nazaire Hospital. The interviews consisted of seven questions
related to palliative practices and professional experiences acquired during the care of patients with COPD.
RESULTS:
In
a population of 51 patients who received end-of-life care during the
year 2008, 34 were referred on account of lung cancer and only one was
referred for COPD. Bronchial carcinoma was the main cause of death (36
cases) then COPD (16 cases) in a total of 92 deaths (2008).
Retrospective analysis of the records of patients who died from COPD
showed a limitation of care in 43% of cases, midazolam induced sedation
in 43%, treatment with morphine in 37%, support for the family or
relatives in 62% and some anticipated decisions in 6%. Analysis of the
interviews showed that the subject of death is rarely or never discussed
with these patients in contrast to patients dying from bronchial
cancer.
CONCLUSION:
The practices of a respiratory team concerning palliative care in COPD patients appear to be limited to end-of-life care. This clearly reflects a need for palliative care education in workers of respiratory care units in order to deliver a global palliative approach at an earlier stage in the care of COPD patients and to improve communication concerning end-of-life treatments.
[Palliative sedation in a man with oral cancer; the Royal Dutch Medical Association guidelines not always sufficient].
[Article in Dutch]
Ned Tijdschr Geneeskd. 2013;157(16):A5941.
Source
Isala klinieken, Afd. Anesthesiologie, Zwolle, the Netherlands. w.l.h.smelt@isala.nlAbstract
BACKGROUND:
Palliative sedation is an effective treatment option in patients with refractory symptoms in the last phase of life. In 2009 the Royal Dutch Medical Association (KNMG) published revised guidelines. The dosage of propofol recommended in these guidelines is, however, based on one single study.CASE DESCRIPTION:
A 60-year-old patient with a history of psychiatric disease and alcohol abuse was admitted to the palliative care unit suffering from unbearable pain from a squamous carcinoma of the floor of the oral cavity. Adequate treatment of his symptoms was initially possible, but when his symptoms became refractory we initiated continual sedation. Adequate symptom control was only achieved when propofol was administered in a high dosage of 150 mg/h and levomepromazine administration was reinitiated.CONCLUSION:
In our opinion the advised starting dose of propofol is too low, especially in comparison with sedation in regional anaesthesia described in the literature. Furthermore, we advocate that administration of drugs from step 2, midazolam and levomepromazine, is not discontinued when propofol sedation is commenced in step 3.Palliative Sedation in Patients With Advanced Cancer Followed at Home: A Prospective Study.
J Pain Symptom Manage. 2013 Oct 5.
Source
Pain Relief and Palliative Care Unit, La Maddalena Cancer Center, Palermo, Italy; Palliative Medicine, Department of Anesthesia & Intensive Care, University of Palermo, Palermo, Italy. Electronic address: 03sebelle@gmail.com.Abstract
CONTEXT:
Home care programs in Italy.
OBJECTIVES:
The aim of this study was to assess a protocol for palliative sedation (PS) performed at home.
METHODS:
A
total of 219 patients were prospectively assessed to evaluate a PS
protocol in patients with advanced cancer followed at home by two home
care programs with different territorial facilities. The protocol was
based on stepwise administration of midazolam.
RESULTS:
A
total of 176 of the patients died at home, and PS was performed in 24
of these patients (13.6%). Younger patients received the procedure more
frequently than older patients (P=0.012).
The principal reasons to start
PS were agitated delirium (n=20) and dyspnea (n=4).
Mean duration of PS
was 42.2±30.4 hours, and the mean doses of midazolam
were 23-58mg/day.
Both the home care team and the patients' relatives
expressed optimal or good levels of satisfaction with the procedure in
all but one case, respectively.
CONCLUSION:
This protocol
for PS was feasible and effective in minimizing distress for a subgroup
of patients who died at home. The characteristics of patients who may
be effectively sedated at home should be better explored in future
studies.
Copyright © 2013 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.Use of Sedation and Neuromuscular Blockers in Critically Ill Adults Receiving High-Frequency Oscillatory Ventilation.
Source
Ann Pharmacother. 2013 Sep;47(9):1122-1129.Department of Pharmacy, Mount Sinai Hospital, New York, NY.
Abstract
BACKGROUND:
Nearly all patients receive sedation and neuromuscular blockers (NMBs) during high-frequency oscillatory ventilation (HFOV).OBJECTIVE:
To describe analgo-sedation and NMB use prior to and during HFOV in adults with acute respiratory distress syndrome.METHODS:
Retrospective single-center study of 131 consecutive adults whose care was managed with HFOV from 2002 to 2011.RESULTS:
During the first 4 days of HFOV, 89% and 95% of patients received sedation and opioids, respectively. Upon HFOV initiation, 119 (90.8%) patients received fentanyl doses higher than 200 µg/h; of these, 48 also received more than 20 mg/h of midazolam. Analgo-sedation doses increased significantly over time such that doses were double by day 3. Factors independently associated with fentanyl doses higher than 200 µg/h were NMB ever used (OR 4.43; 95% CI 1.26-15.65, p = 0.02), pH less than 7.15 (OR 2.08; 95% CI 1.22-3.5, p = 0.007), worsening partial pressure of oxygen/fraction of inspired oxygen (OR 1.05; 95% CI 1.00-1.10, p = 0.04), and Acute Physiology and Chronic Health Evaluation (APACHE) II score (OR 0.87; 95% CI 0.79-0.97, p = 0.009).Deep sedation was commonly administered when NMBs were not being used, with 99.2% of sedation-agitation scores of 1 or 2. Eighty-six patients (65.6%) received NMBs and use was greatest on day 1 (59.5%). Train-of-Four was measured every hour for 53.4% of patients; 29.2% of the measurements were 0 of 4. NMB use declined over the 10-year study period.
CONCLUSIONS:
High analgo-sedation doses were associated with APACHE II scores, worsening gas exchange, and NMB use.Two thirds of patients received NMBs; use was highest on day 1 and subsequently declined.
The percentage of patients who received NMB during HFOV in our study was lower than that previously reported.
Future research should evaluate patient outcomes with and without use of NMBs, as well as the potential to manage patients with less sedation.
KEYWORDS:
high frequency oscillatory ventilation, intensive care unit, neuromuscular blockers, sedation
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