DNR policy

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>From the really basic point of view, it needs to be obvious.  Print them on
a different type / size of paper from other hospital notes, and give them a
bright coloured border.  You need to be able to see them when you open a
patients notes, not have to go looking for them.  If you have the luxury of
being able to do so, perforate the border, so if can be removed if the DNR
is revoked - then it can be struck though with a large pen, fades into
invisibility with no border, but is still there if later needed.  

Put a review date on them individually for each patient.  Although it is
reasonable to limit the length, it is not realistic to have the same length
on all before review.  

I'm sure others will add more!

Regards,

Stephen.


-----Original Message-----
From: trauma-list-bounces at trauma.org [mailto:trauma-list-bounces at trauma.org]
On Behalf Of Abdullah Al Harthy
Sent: 19 April 2009 18:56
To: Trauma & Critical Care mailing list
Subject: DNR policy


Our hospital is currently in the process of establishing a DNR policy. I do
realize that cultural differences have to be taken in to consideration, but
I would appreciate it if group members would share their current policies or
any advice. 

Abdullah Al- Harthy
Trauma surgeon & Intensivist



On 15 Apr 2009, at 16:15, Karim Brohi <karimbrohi at gmail.com> wrote:

Just to amplify what Tim has said, there's a real problem with using
any lab test to guide therapy because the turn-around time is too long
(30 minutes seems to be the best I've come across) by which time the
patient's physiology has moved on.  Also we'd like to be activating
clotting therapy protocols much earlier than we are currently, so
identifying those patients who are likely to need plasma etc without
wasting buckets of it is difficult. (Hence the interest in
thromboelastometry).

If you're talking about research definitions of TIC/ATC there doesn't
seem to be any real consensus.  Several studies have used >1.5x
normal, but graphs of admission PT/PTT vs blood use or mortality look
linear.  Fibrinogen and platelets appear to be protected early in the
clinical course but decrease with dilution etc.  (Platelet *function*
is another matter entirely!)

Point-of-care devices for PT etc have not been properly validated -
some of them require a certain albumin or haematocrit level to be
accurate - and of course in the bleeding patients this may not be the
case.

K

2009/4/15 Dr Timothy Hardcastle <dr.tchardcastle at absamail.co.za>:
Cat

This is a difficult one: There is a clinical coagulopathy unrelated to
specific numbers that is seen to occur with severe trauma. When the
initial bloods are drawn and the results come back the INR is >1,5, the
TEG is prolonged / abnormal - (often the first sign) and the platelets
progressively drop.

The problem is that the lab does the tests at 37'C, so any effect of
hypotermia is negated, thus giving values that may actually be more normal
than they truly are. The most important thing is a clinical ooze fromt he
patient's wounds.

Hope this helps

Tim
Dr T C Hardcastle
M.B., Ch.B. (Stell); M. Med. (Chir) (Stell); FCS (SA)
Principal Specialist Trauma Surgeon /
Honorary Lecturer University of KwaZulu-Natal Dept Surgery
Deputy Director - IALCH Trauma Service
Durban - South Africa
Dear Traumalist

What are the values for the current defintion of traumatic coagulopathy?

At what values do you consider your trauma-patient coagulopathic, what
INR, what platelet, what fibrinogen, what pH?

Thanks, Cat
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