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Nottingham, United Kingdom

Birchley G.,Paediatric Intensive Care Unit
Journal of Medical Ethics | Year: 2012

The value of conscience in healthcare ethics is widely debated. While some sources present it as an unquestionably positive attribute, others question both the veracity of its decisions and the effect of conscientious objection on patient access to health care. This paper argues that the right to object conscientiously should be broadened, subject to certain previsos, as there are many benefits to healthcare practice in the development of the consciences of practitioners. While effects such as the preservation of moral integrity are widely considered to benefit practitioners, this paper draws on the work of Hannah Arendt to offer several original arguments in defence of conscience that may more directly benefit patients, namely that a pang of conscience may be useful in rapidly unfolding situations in which there is no time to reflect satisfactorily upon activities and that, given the hierarchical nature of healthcare institutions, a right to defy authority on the basis of conscience may benefit junior staff who lack the institutional power to challenge the orders of superiors.

Anderson B.J.,Paediatric Intensive Care Unit
Paediatric Anaesthesia | Year: 2012

The pharmacokinetic (PK) parameters that are important for dosing (e.g., clearance and volume) are well known. They are used in universal mathematical formulae that describe the time course of drug concentration. Additional formulae can be used to describe major covariate effects in children, such as size and maturation. PK parameters describing the time-concentration profile of a drug after administration are those for a typical individual in a population. These parameters are associated with variability. Further, any one individual may not be typical of the population studied. While size and maturation are two important considerations in children and assist with dosing estimation, there are also a number of additional PK covariates (e.g., organ function, disease, drug interactions, pharmacogenetics), and identifying these sources of variability allows us to individualize drug dose. Pharmacology is not simply an application of PK, and determinants of drug dose also require an understanding of the variability associated with pharmacodynamic response and a balancing of beneficial effects against unwanted effects. Each child is unique in this respect. © 2012 Blackwell Publishing Ltd.

Scholefield B.,Paediatric Intensive Care Unit
Cochrane database of systematic reviews (Online) | Year: 2013

Cardiopulmonary arrest in paediatric patients often results in death or survival with severe brain injury. Therapeutic hypothermia, lowering of the core body temperature to 32°C to 34°C, may reduce injury to the brain in the period after the circulation has been restored. This therapy has been effective in neonates with hypoxic ischaemic encephalopathy and adults after witnessed ventricular fibrillation cardiopulmonary arrest. The effect of therapeutic hypothermia after cardiopulmonary arrest in paediatric patients is unknown. To assess the clinical effectiveness of therapeutic hypothermia after paediatric cardiopulmonary arrest. We searched the Cochrane Anaesthesia Review Group Specialized Register; Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 11); Ovid MEDLINE (1966 to December 2011); Ovid EMBASE (1980 to December 2011); Ovid CINAHL (1982 to December 2011); Ovid BIOSIS (1923 to December 2011); and Web of Science (1945 to December 2011). We searched the trials registry databases for ongoing trials. We also contacted international experts in therapeutic hypothermia and paediatric critical care to locate further published and unpublished studies. We planned to include randomized and quasi-randomized controlled trials comparing therapeutic hypothermia with normothermia or standard care in children, aged 24 hours to 18 years, after paediatric cardiopulmonary arrest. Two authors independently assessed articles for inclusion. We found no studies that satisfied the inclusion criteria. We found four on-going randomized controlled trials which may be available for analysis in the future. We excluded 18 non-randomized studies. Of these 18 non-randomized studies, three compared therapeutic hypothermia with standard therapy and demonstrated no difference in mortality or the proportion of children with a good neurological outcome; a narrative report was presented. Based on this review, we are unable to make any recommendations for clinical practice. Randomized controlled trials are needed and the results of on-going trials will be assessed when available.

Murphy P.J.,Paediatric Intensive Care Unit
British Journal of Anaesthesia | Year: 2012

Summary Achieving good health outcomes for patients is the fundamental purpose of healthcare. What really matters to patients is the outcome of an intervention and the effect it will have on their wellbeing and life expectancy. After media coverage, and public enquiry into high mortality rates for paediatric cardiac surgery at the Bristol Royal Infirmary during the early 1990s, mortality rates for paediatric cardiac surgical procedures decreased dramatically both in Bristol and nationally. There can be little doubt that one of the prime 'drivers for change' was the placement of outcome data into the public domain. After events in Bristol, the Society for Cardiothoracic Surgery in Britain and Ireland (SCTS) has taken the lead in measuring and publishing clinical outcome data. It has also discussed how outcome data could be used to assess an individuals clinical performance and how, in the future, this might be linked to continuing professional development, appraisal, and revalidation. Measuring quality and outcome in healthcare is complex. Ideal outcome measures should be specific, sensitive, reliable, responsive, validated, timely, and easy to measure. Monitoring of outcomes can be 'process' orientated or 'clinically' orientated. The 2010 National Health Service (NHS) White Paper aimed for an NHS which 'moves away from centrally driven process targets and focuses on delivering outcomes which matter to people'. Measuring outcome in anaesthesia is problematic. There are issues around clinical coding, risk adjustment, the influence of clinical teamworking, and environmental factors. The National Institute of Academic Anaesthesia (NIAA) has identified that the description of clinical practice in anaesthesia and perioperative medicine is currently limited by a lack of valid, reliable quality measures. The NIAA suggests that there is a requirement for further research into identifying the anaesthetic outcome indicators which are most relevant to patients, and then benchmarking the performance of anaesthetic departments and anaesthetists. © The Author [2012].

Cove M.E.,National University of Singapore | MacLaren G.,National University of Singapore | MacLaren G.,Paediatric Intensive Care Unit
Critical Care | Year: 2010

Acute myocardial infarction is one of the 10 leading reasons for admission to adult critical care units. In-hospital mortality for this condition has remained static in recent years, and this is related primarily to the development of cardiogenic shock. Recent advances in reperfusion therapies have had little impact on the mortality of cardiogenic shock. This may be attributable to the underutilization of life support technology that may assist or completely supplant the patient's own cardiac output until adequate myocardial recovery is established or long-term therapy can be initiated. Clinicians working in the intensive care environment are increasingly likely to be exposed to these technologies. The purpose of this review is to outline the various techniques of mechanical circulatory support and discuss the latest evidence for their use in cardiogenic shock complicating acute myocardial infarction. © 2010 BioMed Central Ltd.

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