- Email: [email protected]
Cost-Benefit-Outcome: Ethical Aspects (IL14)
Abstracts 3. Several retrospective studies have compared established transfusion regimens to more restrictive approaches with hemoglobin (hb) triggers of 7-8 g/dl (vs. 9-10), but no change of mortality was found. The only prospective randomized study in critically ill patients could not identify any bene®cial effect of a liberal transfusion strategy on outcome (2). One large chart analysis in patients with myocardial infarction showed that trans-fusions decrease mortality in patients with hb<10g/dl (3). 4. The term `Critical Hematocrit' has been derived from the critical oxygen delivery de®ning a threshold below which aerobic metabolism becomes directly supply-dependent. However, due to a variety of cofactors, especially cardiovascular disease, this value is different between patients, and cannot easily be assessed by established clinical monitoring tools. Thus, the decision to transfuse should not exclusively be based on a single `critical' value, but rather on evaluation of several factors, such as hemodynamics and clinical judgement.
IL14 COST-BENEFIT-OUTCOME: ETHICAL ASPECTS F.X. Lackner Department of Anesthesiology, and General Intensive Care, University of Vienna, Austria Background and Goal of the Study. As a consequence of the increasing availability of new lifesaving and prolonging therapies, societies are faced with a raising life expectancy on the one hand and augmented ®nancial demand on the other. Material and Methods. The existing literature will be reviewed to identify current trends in allocation and measurements of outcome in order to asses, how their weight is re¯ected in societal perceptions. Results and Discussions. Health care should be seen as a right and therefore delivery governed by ethical principles, rather than a commodity which is solely distributed along economic measures as tools. (1) The purpose of a health delivery system is not to generate revenues ± be it of physicians or pharmaceutical companies ± but to meet societal needs, as health is a determinant of every member of the society's ability to take advantage of its opportunities. That there is imbalance is stressed by the fact that in the USA much of the available funding goes into the last 3 months of life instead of the ®rst 3 months. With the noble goal of `social states', that none of its members is to be deprived of medical treatment for the inability to pay, it becomes quickly obvious, that organ transplantation and intensive care become the bottle necks of adequate care throughout ones life. The dif®culty in determining cost - ef®ciency in the latter discipline lies in the fact, that data on effectiveness are often lacking, patients are complex, there is no standardized approach and typical outcome studies concentrate on short term mortality, rather than long term quality adjusted survival. (2) Data from Europe suggest that 80 % of medical ICU patients including survivors are being cared for in a way, which can exclusively be performed in an ICU. (3) With the hospital mortality of about 15 % the therapeutic intervention scoring system points and costs were higher in this subgroup than in other none active ICU patients. There was also a difference in the length of stay, no association however between cost and measures of severity of illness. Conclusion. Justice demands that access to the ICU is determined by the need of speci®c `active therapy'. Equality calls for a lack of discrimination because of age, income or dispositions like AIDS. In the light of saving public resources to enable implementation of these principles, desirable cost reduction efforts should concentrate on the selection of `appropriate' ICU patients and a reduction of the length of stay. Palliation in some critically ill and patients with cancer is a special problem because cost reduction efforts can only be directed to quality of life, not cure in a reasonable period of time. Autonomy is desirable, life style has repercussions on later disease, but mandates the extent of possible limitation of withdrawal in intensive care at the end of life.
References 1. Kluge EHW. Medical ethics. Ann. N.Y. Ac. Sci. 2000; 913: 23-31. 2. Angus DC, Rubenfeld GD, Roberts MS, et al. Amer. Journ. Respir. Crit. Care. Med. 2002; 165: 540-550. 3. Graf J, Graf C, Janssens U. Int. Care Med. 2002; 28: 324-331.
IL15 METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA) IN NURSING HOMES: A DANGER FOR INTENSIVE CARE UNITS? W. Lingnau, N. Treml, F. Allerberger* Dept. of Anaesthesiology and Critical Care Medicine and *Institute of Hygiene, Leopold-Franzens-University, Anichstr. 35, A-6020 Innsbruck, Austria Background and Goal of Study. Shifting population demographics with a growing segment of late middle-aged and elderly persons result in a trend toward older, sicker, and more complex patients in hospital wards and intensive care units (ICUs). Our goal is to evaluate the prevalence of nasal colonisation with Staphylococcus aureus (SA) and corresponding risk factors in community nursing homes in Innsbruck, Austria Patients and Methods. The Ethics Committee approved this study at the University of Innsbruck. We took nasal swabs from nursing home residents and processed them in the microbiological laboratory within two hours. Cultures were performed on selective agar plates. We performed antimicrobial susceptibility testing according to the guidelines of National Committee for Clinical Laboratory Standards (NCCLS). Results and Discussion. We screened 623 residents (mean age 85.068.9 yr., male 17.2%) in ®ve community nursing homes for nasal carriage of S. aureus. Among these residents 311 (49.9%) were colonised with S. aureus, 39 of them were MRSA (12.5%). We found signi®cantly more male residents colonised with MRSA (male 20.0% vs. female 10.5%; p<0.05). Other risk factors were the presence of cardiovascular diseases (14.9% vs. 0.0%), diabetes (26.0% vs. 7.7%), bedsore (50.0% vs. 11.7%), a history of bacterial infection during the past two months (pulmonary 42.9%, urinary 27.8%, none 10.1%), or recent treatment at the university medical centre (18.6% vs. 10.5%). There was a linear correlation between the category of nursing intensity and MRSA-prevalence (A: 0,0%; B: 5.9%; C: 8.3%; D: 15.6%; E: 20.4%). Resistance of colonising MRSA to other antimicrobials: cipro¯oxacin 100%, imipenem 91.7%, mupirocin 29.2%, cotrimoxazol 8.7%, fusidinic acid and vancomycin 0%. Conclusion. The prevalence of MRSA is higher in nursing homes than in average. It is pivotal to stop the spread of resistance by screening for and eradication of colonising MRSA in concert with hygienic measures.
IL16 PUMP FAILURE AND PHARMACOLOGICAL SUPPORT H. Metzler, W. Toller Department of Anesthesiology, University Hospital of Graz, Auenbruggerplatz 29, A-8036 Graz, Austria While positive inotropic drugs, including catecholamines and phosphodiesterase (PDE) inhibitors clearly represent the mainstay of pharmacological therapy of acute myocardial pump failure, the choice of agent or combination of substances is less clear and primarily depends on the underlying pathophysiologic alteration causing pump failure. Stimulation of b1-adrenergic receptors with dobutamine will particularly increase myocardial contractility without signi®cantly alterating systemic and pulmonary vascular resistances and may currently be the agent of choice during states of post-infarction myocardial pump failure. During persistent states of low cardiac output despite therapy with dobutamine, PDEinhibitors or epinephrine may transiently be added. Stimulation of a1adrenergic receptors with norepinephrine will increase systemic vascular
Downloaded from http://bja.oxfordjournals.org/ at Sussex Language Institute on July 17, 2015
References: 1. Kulier et al.: Anaesthesist 2001; 50,73-86 2. Hebert et al.: NEJM 1999; 340, 409-17 3. Wu et al.: NEJM 2001; 345, 1230-6
9
IL14 COST-BENEFIT-OUTCOME: ETHICAL ASPECTS F.X. Lackner Department of Anesthesiology, and General Intensive Care, University of Vienna, Austria Background and Goal of the Study. As a consequence of the increasing availability of new lifesaving and prolonging therapies, societies are faced with a raising life expectancy on the one hand and augmented ®nancial demand on the other. Material and Methods. The existing literature will be reviewed to identify current trends in allocation and measurements of outcome in order to asses, how their weight is re¯ected in societal perceptions. Results and Discussions. Health care should be seen as a right and therefore delivery governed by ethical principles, rather than a commodity which is solely distributed along economic measures as tools. (1) The purpose of a health delivery system is not to generate revenues ± be it of physicians or pharmaceutical companies ± but to meet societal needs, as health is a determinant of every member of the society's ability to take advantage of its opportunities. That there is imbalance is stressed by the fact that in the USA much of the available funding goes into the last 3 months of life instead of the ®rst 3 months. With the noble goal of `social states', that none of its members is to be deprived of medical treatment for the inability to pay, it becomes quickly obvious, that organ transplantation and intensive care become the bottle necks of adequate care throughout ones life. The dif®culty in determining cost - ef®ciency in the latter discipline lies in the fact, that data on effectiveness are often lacking, patients are complex, there is no standardized approach and typical outcome studies concentrate on short term mortality, rather than long term quality adjusted survival. (2) Data from Europe suggest that 80 % of medical ICU patients including survivors are being cared for in a way, which can exclusively be performed in an ICU. (3) With the hospital mortality of about 15 % the therapeutic intervention scoring system points and costs were higher in this subgroup than in other none active ICU patients. There was also a difference in the length of stay, no association however between cost and measures of severity of illness. Conclusion. Justice demands that access to the ICU is determined by the need of speci®c `active therapy'. Equality calls for a lack of discrimination because of age, income or dispositions like AIDS. In the light of saving public resources to enable implementation of these principles, desirable cost reduction efforts should concentrate on the selection of `appropriate' ICU patients and a reduction of the length of stay. Palliation in some critically ill and patients with cancer is a special problem because cost reduction efforts can only be directed to quality of life, not cure in a reasonable period of time. Autonomy is desirable, life style has repercussions on later disease, but mandates the extent of possible limitation of withdrawal in intensive care at the end of life.
References 1. Kluge EHW. Medical ethics. Ann. N.Y. Ac. Sci. 2000; 913: 23-31. 2. Angus DC, Rubenfeld GD, Roberts MS, et al. Amer. Journ. Respir. Crit. Care. Med. 2002; 165: 540-550. 3. Graf J, Graf C, Janssens U. Int. Care Med. 2002; 28: 324-331.
IL15 METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS (MRSA) IN NURSING HOMES: A DANGER FOR INTENSIVE CARE UNITS? W. Lingnau, N. Treml, F. Allerberger* Dept. of Anaesthesiology and Critical Care Medicine and *Institute of Hygiene, Leopold-Franzens-University, Anichstr. 35, A-6020 Innsbruck, Austria Background and Goal of Study. Shifting population demographics with a growing segment of late middle-aged and elderly persons result in a trend toward older, sicker, and more complex patients in hospital wards and intensive care units (ICUs). Our goal is to evaluate the prevalence of nasal colonisation with Staphylococcus aureus (SA) and corresponding risk factors in community nursing homes in Innsbruck, Austria Patients and Methods. The Ethics Committee approved this study at the University of Innsbruck. We took nasal swabs from nursing home residents and processed them in the microbiological laboratory within two hours. Cultures were performed on selective agar plates. We performed antimicrobial susceptibility testing according to the guidelines of National Committee for Clinical Laboratory Standards (NCCLS). Results and Discussion. We screened 623 residents (mean age 85.068.9 yr., male 17.2%) in ®ve community nursing homes for nasal carriage of S. aureus. Among these residents 311 (49.9%) were colonised with S. aureus, 39 of them were MRSA (12.5%). We found signi®cantly more male residents colonised with MRSA (male 20.0% vs. female 10.5%; p<0.05). Other risk factors were the presence of cardiovascular diseases (14.9% vs. 0.0%), diabetes (26.0% vs. 7.7%), bedsore (50.0% vs. 11.7%), a history of bacterial infection during the past two months (pulmonary 42.9%, urinary 27.8%, none 10.1%), or recent treatment at the university medical centre (18.6% vs. 10.5%). There was a linear correlation between the category of nursing intensity and MRSA-prevalence (A: 0,0%; B: 5.9%; C: 8.3%; D: 15.6%; E: 20.4%). Resistance of colonising MRSA to other antimicrobials: cipro¯oxacin 100%, imipenem 91.7%, mupirocin 29.2%, cotrimoxazol 8.7%, fusidinic acid and vancomycin 0%. Conclusion. The prevalence of MRSA is higher in nursing homes than in average. It is pivotal to stop the spread of resistance by screening for and eradication of colonising MRSA in concert with hygienic measures.
IL16 PUMP FAILURE AND PHARMACOLOGICAL SUPPORT H. Metzler, W. Toller Department of Anesthesiology, University Hospital of Graz, Auenbruggerplatz 29, A-8036 Graz, Austria While positive inotropic drugs, including catecholamines and phosphodiesterase (PDE) inhibitors clearly represent the mainstay of pharmacological therapy of acute myocardial pump failure, the choice of agent or combination of substances is less clear and primarily depends on the underlying pathophysiologic alteration causing pump failure. Stimulation of b1-adrenergic receptors with dobutamine will particularly increase myocardial contractility without signi®cantly alterating systemic and pulmonary vascular resistances and may currently be the agent of choice during states of post-infarction myocardial pump failure. During persistent states of low cardiac output despite therapy with dobutamine, PDEinhibitors or epinephrine may transiently be added. Stimulation of a1adrenergic receptors with norepinephrine will increase systemic vascular
Downloaded from http://bja.oxfordjournals.org/ at Sussex Language Institute on July 17, 2015
References: 1. Kulier et al.: Anaesthesist 2001; 50,73-86 2. Hebert et al.: NEJM 1999; 340, 409-17 3. Wu et al.: NEJM 2001; 345, 1230-6
9