Intensiivravi limiteerimine Mari-Liis Ilmoja SA Tallinna Lastehaigla Pärnu, 2007

„Keeldu ravimast haigeid kelle üle haigus on võimust võtnud, tunnistades, et siin on meditsiin jõuetu.” „Keeldu ravimast haigeid kelle üle haigus on võimust võtnud, tunnistades, et siin on meditsiin jõuetu.” Hippocrates Hippocrates

“Me kõik kardame valu, keegi meist ei taha jääda ka lutitatavaks-potitatavaks. Ma ei saa sinna midagi parata, et minu sisetunde järgi on aeglases suremises midagi piinlikku ja vääritut. Ka siis, ja võib-olla just eriti siis, kui su põetajad on kõige armsamad inimesed.” “Me kõik kardame valu, keegi meist ei taha jääda ka lutitatavaks-potitatavaks. Ma ei saa sinna midagi parata, et minu sisetunde järgi on aeglases suremises midagi piinlikku ja vääritut. Ka siis, ja võib-olla just eriti siis, kui su põetajad on kõige armsamad inimesed.” Enn Vetemaa, EPL

Moraalsed ja eetilised küsimused vastsündinute intensiivravis Moraalsed ja eetilised küsimused vastsündinute intensiivravis Duff RS, Campbell AGM NEJM – 81% intensiivravil surnud vastsündinutest on elu alalhoidvad ravimeetodid lõpetatud 58 – 81% intensiivravil surnud vastsündinutest on elu alalhoidvad ravimeetodid lõpetatud Wilkinson DJ ADC 2006 Põhja-Ameerika ja Euroopa laste intensiivravi osakondades surnud lastest on 28 – 65% juhul ravi piiratud Põhja-Ameerika ja Euroopa laste intensiivravi osakondades surnud lastest on 28 – 65% juhul ravi piiratud Ten Berge J BMC Pediatrics 2006

Ravi piiramine Elustamiskatsete lõpetamine vastsündinul on näidustatud, kui 20 min. adekvaatse elustamise jooksul ei ole taastunud spontaanne vereringe 20 min. adekvaatse elustamise jooksul ei ole taastunud spontaanne vereringe Elustamist võib mitte alustada, kui Sünnieelselt on diagnoositud anentsefaalia, kinnitunud trisoomia 13 või 18 diagnoos Sünnieelselt on diagnoositud anentsefaalia, kinnitunud trisoomia 13 või 18 diagnoos Tegemist on < 23 nädala või < 500 g vastsündinuga Tegemist on < 23 nädala või < 500 g vastsündinuga EPS juhised, mai 2002 EPS juhised, mai

End-of life decisions in the Neonatal and Pediatric Intensive Care Unit. Mari-Liis Ilmoja 1, Tuuli Metsvaht 2 1 Tallinn Children`s Hospital, 2 Tartu University Clinics Estonia

Aim of the study : Aim of the study : to evaluate the mode of death in Neonatal and Pediatric Intensive Care Units of Estonia to evaluate the mode of death in Neonatal and Pediatric Intensive Care Units of Estonia Methods: Methods: retrospective chart review of all deaths from 2002 to 2006 retrospective chart review of all deaths from 2002 to 2006

Methods 5 groups: Total care ( TC) Total care ( TC) Brain death (BD) Brain death (BD) Treatment withdrawal (WD) Treatment withdrawal (WD) Treatment witholding (WH) Treatment witholding (WH) Unsuccessful resuscitation (UNS) Unsuccessful resuscitation (UNS)

Results 3528 patients were admitted 3528 patients were admitted 1846 of them were neonates 1846 of them were neonates 247 died ( 7,02%) 247 died ( 7,02%) 176 newborns died (9,5%) 176 newborns died (9,5%)

Results: Mode of death

Mode of death

Mode of death in newborn

Diagnosis of newborns in withdrawal or withholding group IVH + IPH 13 IVH + IPH 13 Congenital anomalies 10 Congenital anomalies 10 Asphyxia 8 Asphyxia 8 Cardiac malformations 7 Cardiac malformations 7 Necrosis of bowel 3 Necrosis of bowel 3 Other complications of prematurity 3 Other complications of prematurity 3

The reason for withdrawal or witholding

Mode of withdrawal

EPICURE 2 <24 n 24 n 25 n 1995.a. (n) Elulemus 28.p (%) 37(28)111(45)177(61) 2006.a. (n) Elulemus28.p(%)55(37)129(55)211(71) Elulemuse tõus (%) 9,49,810,4 Costeloe K; EPICURE 2: Early survival; ESPR meeting,2007

EPICURE 1: 30. elukuu

EPICURE 1: 6-aastased

Limits of viability > 25 weeks:...high rate of survival... low risk of disability > 25 weeks:...high rate of survival... low risk of disability 24 weeks:...start intensive care....unless the parents and the clinicians are agreed that in the light of the baby`s condition it is not his best interest 24 weeks:...start intensive care....unless the parents and the clinicians are agreed that in the light of the baby`s condition it is not his best interest 23 weeks:...when the condition of a baby indicates that he will not survive for long, clinicians are not obliged to proceed with treatment weeks:...when the condition of a baby indicates that he will not survive for long, clinicians are not obliged to proceed with treatment... Nuffield council of ethics: Critical care decisions in fetal and neonatal medicine, 2006

Survival of S-treated infants (Tartu+Tallinn, n=525)

Vastsündinute koguarv 2006.a. TLH-s: 238; enneaegseid 139 ja ajalisi 99.

 500g* or <23wk Gray Zone /7 wk and g  600g or  25wks Heart rate Low or Absent Present; >40-50 Bag /Intubate Can’t intubate or Poor response HR < 60/min for 5mins Discontinue interventions Initiate comfort care measures HR Consider brief CPR, drugs & bolus fluids x1 Poor response HR > 100/min Give surfactant, insert lines, check ABG start fluids good response Transfer to NICU NICU Care HUS ECHO Parents desire active management; carry on and set limits No resuscitation Initiate comfort care measures Initiate resuscitation. Clinical course will dictate management Poor clinical status * The occasional infant <500g BW (usually IUGR), who is vigorous at birth may warrant active intervention

Gray Zone /7 wk and g Heart rate Present; >40-50 Bag /Intubate Can’t intubate or Poor response HR < 60/min for 5mins Discontinue interventions Initiate comfort care measures HR Consider brief CPR, drugs & bolus fluids x1 Poor response HR > 100/min Give surfactant, insert lines, check ABG start fluids good response Transfer to NICU NICU Care HUS ECHO Parents desire active management; carry on and set limits Poor clinical status * The occasional infant <500g BW (usually IUGR), who is vigorous at birth may warrant active intervention

Gray Zone /7 wk and g Heart rate Present; >40-50 Bag /Intubate Discontinue interventions Initiate comfort care measures HR Consider brief CPR, drugs & bolus fluids x1 Poor response HR > 100/min Give surfactant, insert lines, check ABG start fluids good response Transfer to NICU

“Kui sa vaatad öist taevast, siis seepärast, et mina elan ühel neist tähtedest, seepärast, et mina naeran ühel neist, siis on otsekui naeraksid sulle kõik tähed. Sina saad endale tähed, mis oskavad naerda!” A de Saint-Exupéry “Väike prints”

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