Renal and Transplant Surgery
http://hdl.handle.net/20.500.12904/15475
2024-03-28T17:34:50Z
2024-03-28T17:34:50Z
Cost-effectiveness of adrenaline for out-of-hospital cardiac arrest
Gardiner, Dale C.
http://hdl.handle.net/20.500.12904/17142
2023-06-06T02:47:50Z
2020-01-01T00:00:00Z
Cost-effectiveness of adrenaline for out-of-hospital cardiac arrest
Gardiner, Dale C.
BACKGROUND: The 'Prehospital Assessment of the Role of Adrenaline: Measuring the Effectiveness of Drug Administration In Cardiac Arrest' (PARAMEDIC2) trial showed that adrenaline improves overall survival, but not neurological outcomes. We sought to determine the within-trial and lifetime health and social care costs and benefits associated with adrenaline, including secondary benefits from organ donation. METHODS: We estimated the costs, benefits (quality-adjusted life years (QALYs)) and incremental cost-effectiveness ratios (ICERs) associated with adrenaline during the 6-month trial follow-up. Model-based analyses explored how results altered when the time horizon was extended beyond 6 months and the scope extended to include recipients of donated organs. RESULTS: The within-trial (6 months) and lifetime horizon economic evaluations focussed on the trial population produced ICERs of 1,693,003 (1,946,953) and 81,070 (93,231) per QALY gained in 2017 prices, respectively, reflecting significantly higher mean costs and only marginally higher mean QALYs in the adrenaline group. The probability that adrenaline is cost-effective was less than 1% across a range of cost-effectiveness thresholds. Combined direct economic effects over the lifetimes of survivors and indirect economic effects in organ recipients produced an ICER of 16,086 (18,499) per QALY gained for adrenaline with the probability that adrenaline is cost-effective increasing to 90% at a 30,000 (34,500) per QALY cost-effectiveness threshold. CONCLUSIONS: Adrenaline was not cost-effective when only directly related costs and consequences are considered. However, incorporating the indirect economic effects associated with transplanted organs substantially alters cost-effectiveness, suggesting decision-makers should consider the complexity of direct and indirect economic impacts of adrenaline. TRIAL REGISTRATION: ISRCTN73485024 . Registered on 13 March 2014.
2020-01-01T00:00:00Z
Resumption of cardiac activity after withdrawal of life-sustaining measures
Gardiner, Dale C.
http://hdl.handle.net/20.500.12904/17140
2023-06-05T13:42:03Z
2021-01-01T00:00:00Z
Resumption of cardiac activity after withdrawal of life-sustaining measures
Gardiner, Dale C.
BACKGROUND: The minimum duration of pulselessness required before organ donation after circulatory determination of death has not been well studied. METHODS: We conducted a prospective observational study of the incidence and timing of resumption of cardiac electrical and pulsatile activity in adults who died after planned withdrawal of life-sustaining measures in 20 intensive care units in three countries. Patients were intended to be monitored for 30 minutes after determination of death. Clinicians at the bedside reported resumption of cardiac activity prospectively. Continuous blood-pressure and electrocardiographic (ECG) waveforms were recorded and reviewed retrospectively to confirm bedside observations and to determine whether there were additional instances of resumption of cardiac activity. RESULTS: A total of 1999 patients were screened, and 631 were included in the study. Clinically reported resumption of cardiac activity, respiratory movement, or both that was confirmed by waveform analysis occurred in 5 patients (1%). Retrospective analysis of ECG and blood-pressure waveforms from 480 patients identified 67 instances (14%) with resumption of cardiac activity after a period of pulselessness, including the 5 reported by bedside clinicians. The longest duration after pulselessness before resumption of cardiac activity was 4 minutes 20 seconds. The last QRS complex coincided with the last arterial pulse in 19% of the patients. CONCLUSIONS: After withdrawal of life-sustaining measures, transient resumption of at least one cycle of cardiac activity after pulselessness occurred in 14% of patients according to retrospective analysis of waveforms; only 1% of such resumptions were identified at the bedside. These events occurred within 4 minutes 20 seconds after a period of pulselessness. (Funded by the Canadian Institutes for Health Research and others.). Copyright © 2021 Massachusetts Medical Society.
Available to read on the publisher's website here: https://www.nejm.org/doi/full/10.1056/NEJMoa2022713. For personal use only.
2021-01-01T00:00:00Z
Chapter 3.12 Organ donation
Gardiner, Dale C.
http://hdl.handle.net/20.500.12904/17009
2023-05-18T02:02:52Z
2022-01-01T00:00:00Z
Chapter 3.12 Organ donation
Gardiner, Dale C.
2022-01-01T00:00:00Z
Organ donation and transplantation
Gardiner, Dale C.
http://hdl.handle.net/20.500.12904/17008
2023-05-17T09:40:50Z
2020-01-01T00:00:00Z
Organ donation and transplantation
Gardiner, Dale C.
An ethical organ donation and transplantation program regarding deceased patients donors would balance the needs of the organ recipient with the needs of the organ donor and his or her family. The solution to achieve ethical balance is not easy. The donation community leans toward Kantian ethics to justify actions on the donor, while the transplant community tends toward utilitarian justifications that focus on recipient outcomes. Yet the responsibility to achieve balance lies with both communities (and their wider healthcare colleagues) to work together so that good end-of-life care for donors is achieved while simultaneously increasing the number and quality of deceased organ transplants. This chapter will use our personal knowledge of the British and Spanish organ donation and transplantation systems to ask if organ transplantation fosters or threatens end-of-life care in critical care and emergency medicine. Our conclusion is that by adopting a rule utilitarianism approach, ethical balance is more likely to be achieved. We propose three rules for any donation and transplantation program: (1) The exploration of organ donation for all patients dying in critical care and emergency medicine should be pursued, as organ donation might improve end-of-life care and can honor the ideal of a “good death”; (2) Organ donation must never compromise a “good death”; and (3) All parties should seek to build institutional trustworthiness.
2020-01-01T00:00:00Z