Ethical and practical considerations in providing critical care to patients with Ebola virus disease.
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ABSTRACT:
SUBMITTER: Torabi-Parizi P
PROVIDER: S-EPMC4451704 | biostudies-literature |
REPOSITORIES: biostudies-literature
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Project description:As of 20 May 2016 there have been 28,646 cases and 11,323 deaths resulting from the West African Ebola virus disease (EVD) outbreak reported to the World Health Organization. There continue to be sporadic flare-ups of EVD cases in West Africa.EVD presentation is nonspecific and characterized initially by onset of fatigue, myalgias, arthralgias, headache, and fever; this is followed several days later by anorexia, nausea, vomiting, diarrhea, and abdominal pain. Anorexia and gastrointestinal losses lead to dehydration, electrolyte abnormalities, and metabolic acidosis, and, in some patients, acute kidney injury. Hypoxia and ventilation failure occurs most often with severe illness and may be exacerbated by substantial fluid requirements for intravascular volume repletion and some degree of systemic capillary leak. Although minor bleeding manifestations are common, hypovolemic and septic shock complicated by multisystem organ dysfunction appear the most frequent causes of death.Males and females have been equally affected, with children (0-14 years of age) accounting for 19 %, young adults (15-44 years) 58 %, and older adults (?45 years) 23 % of reported cases. While the current case fatality proportion in West Africa is approximately 40 %, it has varied substantially over time (highest near the outbreak onset) according to available resources (40-90 % mortality in West Africa compared to under 20 % in Western Europe and the USA), by age (near universal among neonates and high among older adults), and by Ebola viral load at admission.While there is no Ebola virus-specific therapy proven to be effective in clinical trials, mortality has been dramatically lower among EVD patients managed with supportive intensive care in highly resourced settings, allowing for the avoidance of hypovolemia, correction of electrolyte and metabolic abnormalities, and the provision of oxygen, ventilation, vasopressors, and dialysis when indicated. This experience emphasizes that, in addition to evaluating specific medical treatments, improving the global capacity to provide supportive critical care to patients with EVD may be the greatest opportunity to improve patient outcomes.
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Project description:This paper explains the process of developing a scenario involving the use of a robotic platform to enhance the work experience of disabled employees. We outline the challenges involved in revealing the potential unintended consequences of introducing elements of Artificial Intelligence, automation, and robotics into a socially and ethically complex and potentially fragile scenario, and the practical challenges involved in giving a voice to vulnerable users throughout the design process. While an ideal case scenario would involve the disabled employees as much as possible directly in the design process, this can, realistically, be a challenge. In this paper, we detail a methodological and analytic approach that is centered around ethnography and design fictions. It is designed to provide a deeper understanding of all the stakeholders involved in the scenario while encouraging ethical reflection. Based on our findings, we argue that, while it is relatively easy to adopt an a priori ethical stance through notions such as inclusivity and accessibility, there are risks involved in making such a priori prescriptions with respect to the perspectives of different stakeholders in an applied research project. More specifically, we highlight the importance of understanding the broad organizational and bureaucratic characteristics of a business or workplace when devising HRI scenarios and tasks, and of considering elements such as business models, operating philosophy, and organizational hierarchies in the design process.
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Project description:This report describes three patients with Ebola virus disease who were treated in the United States and developed for severe critical illness and multiple organ failure secondary to Ebola virus infection. The patients received mechanical ventilation, renal replacement therapy, invasive monitoring, vasopressor support, and investigational therapies for Ebola virus disease.Patient medical records from three tertiary care centers (Emory University Hospital, University of Nebraska Medical Center, and Texas Health Presbyterian Dallas Hospital).Not applicable.Not applicable.Not applicable.In the severe form, patients with Ebola virus disease may require life-sustaining therapy, including mechanical ventilation and renal replacement therapy. In conjunction with other reported cases, this series suggests that respiratory and renal failure may occur in severe Ebola virus disease, especially in patients burdened with high viral loads. Ebola virus disease complicated by multiple organ failure can be survivable with the application of advanced life support measures. This collective, multicenter experience is presented with the hope that it may inform future treatment of patients with Ebola virus disease requiring critical care treatment.
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Project description:The 2013-16 Ebola virus disease outbreak in west Africa was associated with unprecedented challenges in the provision of care to patients with Ebola virus disease, including absence of pre-existing isolation and treatment facilities, patients' reluctance to present for medical care, and limitations in the provision of supportive medical care. Case fatality rates in west Africa were initially greater than 70%, but decreased with improvements in supportive care. To inform optimal care in a future outbreak of Ebola virus disease, we employed the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology to develop evidence-based guidelines for the delivery of supportive care to patients admitted to Ebola treatment units. Key recommendations include administration of oral and, as necessary, intravenous hydration; systematic monitoring of vital signs and volume status; availability of key biochemical testing; adequate staffing ratios; and availability of analgesics, including opioids, for pain relief.
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Project description:Improving the provision of supportive care for patients with Ebola is an important quality improvement initiative. We designed a simulated Ebola Treatment Unit (ETU) to assess performance and safety of healthcare workers (HCWs) performing tasks wearing personal protective equipment (PPE) in hot (35 °C, 60% relative humidity) or thermo-neutral (20 °C, 20% relative humidity) conditions. In this pilot phase to determine the feasibility of study procedures, HCWs in PPE were non-randomly allocated to hot or thermo-neutral conditions to perform peripheral intravenous (PIV) and midline catheter (MLC) insertion and endotracheal intubation (ETI) on mannequins. Eighteen HCWs (13 physicians, 4 nurses, 1 nurse practitioner; 2 with prior ETU experience; 10 in hot conditions) spent 69 (10) (mean (SD)) minutes in the simulated ETU. Mean (SD) task completion times were 16 (6) min for PIV insertion; 33 (5) min for MLC insertion; and 16 (8) min for ETI. Satisfactory task completion was numerically higher for physicians vs. nurses. Participants' blood pressure was similar, but heart rate was higher (p = 0.0005) post-simulation vs. baseline. Participants had a median (range) of 2.0 (0.0-10.0) minor PPE breaches, 2.0 (0.0-6.0) near-miss incidents, and 2.0 (0.0-6.0) health symptoms and concerns. There were eight health-assessment triggers in five participants, of whom four were in hot conditions. We terminated the simulation of two participants in hot conditions due to thermal discomfort. In summary, study tasks were suitable for physician participants, but they require redesign to match nurses' expertise for the subsequent randomized phase of the study. One-quarter of participants had a health-assessment trigger. This research model may be useful in future training and research regarding clinical care for patients with highly infectious pathogens in austere settings.
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Project description:The 2013-2016 Ebola Zaire virus (EBV) outbreak in West Africa resulted in over 28,000 cases and 11,000 deaths. Ebola virus disease (EVD) is a highly virulent systemic disease with a high case fatality rate of ~ 50%. EVD results in hemorrhagic fever marked by an exaggerated systemic inflammatory response, and impaired vascular and coagulation systems. The immune response of patients who either survived or died is characterized by strong differences. Notably, fatalities showed a diminished capacity to mount an appropriate immune response, resulting in high viremia and increased pro-inflammatory cytokine production. In this study, we analyzed 38 sequential samples collected from 12 patients: 8 survivors and 4 fatalities. Our analytical strategy combined three protein-based platforms covering three different fractions of the plasma proteome: the undepleted classical plasma proteome, the depleted plasma proteome, and cytokines/chemokines, using LC/MS- and antibody-based assays, resulting in over 1000 quantified host and pathogen proteins. For depletion of the most abundant plasma proteins, we advanced a perchloric acid-based precipitation method. This method is low cost, high-throughput and robust.
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