Ethical and medical management of a pregnant woman with brain stem death resulting in delivery of a healthy child and organ donation.

Maternal brain death during pregnancy remains an exceedingly complex situation that requires not only a well-considered medical management plan, but also careful decision-making in a legally and ethically delicate situation. Management of brain dead pregnant patients needs to adhere to special strategies that support the mother in a way that she can deliver a viable and healthy child. Brain death in pregnant women is very rare, with only a few published cases. We present a case of a pregnant woman with previously diagnosed multiple brain cavernomas that led to intracranial hemorrhage and brain stem death during the 21st week of pregnancy. The condition that can be proven unequivocally, using tests that do not endanger viability of the fetus, is brain stem death, diagnosed through absence of cranial reflexes. The patient was successfully treated until delivery of a healthy female child at 29weeks of gestation. The patient received continuous hormone substitution therapy, fetal monitoring and extrinsic regulation of maternal homeostasis over 64days. After delivery, the final diagnosis of brain death was established through multi-slice computerized tomography pan-angiography. This challenging case discusses ethical and medical circumstances arising from a diagnosis of maternal brain death, while showing that prolongation of somatic life support in a multidisciplinary setting can result in a successful pregnancy outcome.

Transcranial Doppler in brain death confirmation in clinical practice.

PURPOSE: Transcranial Doppler (TCD) can be used as a confirmatory test in brain death. The aim was to present the usefulness of TCD in brain death confirmation. MATERIALS AND METHODS: Forty-four patients with severe brain lesions leading to brain death were treated over a 4-year period. After the clinical diagnosis of brain death was made, the appropriate confirmatory test was chosen according to patient condition, taking into consideration the restrictions of the test protocol. Due to the inconclusive test results, some patients underwent repeat testing. RESULTS: Among 44 patients, 19 had neurotrauma, 11 massive aneurysmal subarachnoidal hemorrhages, 1 arteriovenous subarachnoidal and parenchymal hemorrhage, 12 hypertensive parenchymal hemorrhages, and 1 ischemic stroke. As a primary test, TCD was used in 30, brain scintigraphy in 2, multislice CT angiography (CTA) in 10, and cerebral angiography in 2 patients, and the diagnosis was confirmed in 26, 3, 9 and 2 patients, respectively. Due to inconclusive results CTA was repeated in five patients. In patients in whom TCD was applied, the time to confirm the diagnosis was the shortest, and in most (61 %) cerebral circulatory arrest was confirmed within 2 hours of clinical diagnosis. CONCLUSION: TCD is a favorable confirmatory test for cerebral circulatory arrest in brain death diagnosis.

Tocolysis with ritodrine worsens cerebral oedema in a patient with brain injury.

In a 33-weeks pregnant patient with a head injury, neurological status severely deteriorated after introduction of tocolytic treatment with ritodrine. On admission to the intensive care unit she scored 10 points on the Glasgow coma scale. She gradually recovered and on day 7 there was no neurological deficit, apart from slight confusion. The same day tocolytic treatment with ritodrine was recommended because of imminent premature labour. Fourteen hours after ritodrine infusion was started, the neurological status deteriorated severely. Urgent CT scan showed signs of transtentorial herniation. Ritodrine infusion was stopped and therapy for brain oedema was introduced. The patient made a good neurological recovery. A caesarean section was performed on day 11, because of placenta praevia, and a healthy girl was delivered. The patient was discharged without neurological sequelae. The clinical course and CT findings imply that tocolytic treatment with ritodrine can worsen brain oedema in a patient with a disrupted blood-brain barrier, as in head injury. The mechanism is probably analogous to the one by which ritodrine causes pulmonary oedema, a well-known complication.

The effect of implementation of guidelines for the management of severe head injury on patient treatment and outcome.

The authors retrospectively analysed two groups of consecutive patients who were similarly matched for brain injury severity. From a total of 39 severe head injury patients, 23 were treated according to the Guidelines for the Management of Severe Head Injury with intracranial pressure (ICP) monitoring ("Guidelines group"). Such an approach allowed the maintenance of ICP within normal values, especially in patients with intraventricular ICP monitoring allowing the release of cerebrospinal fluid (CSF) from the ventricular system. In the Guidelines group only two patients were administered barbiturates, after all other means of ICP lowering had been exhausted. The second group consisted of 16 patients who were not monitored for ICP ("non-Guidelines group"). In this group, management consisted of the prophylactic administration of barbiturates, high dose osmotic diuretics and hyperventilation usually at levels below 25 mm Hg. In the Guidelines group the mortality rate was 30% compared to 44% in the non-Guidelines group. Almost twice as many patients achieved a "favourable" (good recovery and moderate disability) outcome (49%) compared to the non-Guidelines treated patients (25%). Furthermore, there was a 32% decrease in severe neurological disabilities in those patients in the Guidelines group. It seems that the implementation of "Guidelines" in the treatment of severe head injury, based on the result of our clinical study, reduces death and disability rates in patients with severe head injury. The administration of therapy based on the "Guidelines principles" and monitoring of ICP, can minimise the application of those therapeutic modalities (barbiturate coma and prolonged hyperventilation) which, in addition to favourable effects, may also have harmful effects on patients with severe head injury.

[Recent modalities in the treatment of severe head injuries]. / Suvremeni principi u lijecenju teske ozljede mozga.

Intracranial pressure (ICP) monitoring represents today a critical point in the treatment of patients with severe head injuries. Medical therapy depends on the intracranial pressure level. The most important in therapy is to maintain the cerebral prefusion pressure at the level of 70 mmHg or above. The use of corticosteroids, prophylactic hyperventilation and prophylactic antiseizures drugs for the late posttraumatic seizures, is not recommended. High dose barbiturates can be used only in patients in whom other treatment modalities failed to decrease the raised intracranial pressure.

Clinical course in 52 severely wounded patients treated in the intensive care unit during the war in Croatia.

Fifty-two severely wounded patients, admitted directly from a battlefield or after surgical treatment in a war hospital, were treated in the Surgical Intensive Care Unit of the 'Sisters of Mercy' University Hospital in Zagreb during the 1991 war in Croatia. Considering the severity of the wounds, blood loss was not as severe as expected. This can be attributed to the nature of the injuries as most of the patients were wounded by fragments of explosive devices which cause less tissue destruction than military bullets. Low serum potassium levels, metabolic acidosis, low total protein levels and consequently low serum calcium levels correlated with wound severity. Low serum potassium levels were caused by its redistribution. Reperfusion liver injury was also present. Consumption coagulopathy was one of the characteristic disturbances in this type of injury. There was a relatively big difference between fluid input and output caused by fluid loss through drain sites and large open wound surfaces. The low mortality of the severely wounded was due to their young age and the well-organized military medical service which was developed from the civilian medical service in a short time.

Comparison of the postoperative fibrinogen, alpha-1-antitrypsin and alpha-2- macroglobulin concentrations in the blood of wounded soldiers of Croatian Army and peacetime injured civilians.

In 10 wounded Croatian Army soldiers and in 10 civilians with accidental musculosceletal traumatisation, blood concentrations of the 3 acute phase proteins: fibrinogen, alpha-1-antitrypsin and alpha-2-macroglobulin on the 1st, 5th and 10th postoperative day were assessed. On the 5th day after injury, increased concentrations of all 3 acute phase proteins (APP) were found in all patients. The rise of the fibrinogen concentrations in the wounded soldiers was the steepest. On the 10th day after wounding, fibrinogen concentrations in the gorup of wounded soldiers were significantly lower than those in the group of injured civilians. On the 10th day after wounding there were no differences between the 2 groups in the concentrations of alpha-1-antitrypsin and of alpha-2-macroglobulin. The lower fibrinogen concentrations in the wounded soldiers could be explained by the modulation of the general reactivity of the organism to injury, proposed by Woloski, which is induced by stress and microtrauma on battlefield before the wounding.

Hyperdynamic beta-adrenergic syndrome among Croatian soldiers engaged in battle.

A group of 1592 male Croatian soldiers (average age 32 +/- 9, ranging from 19 to 54) were examined by an internist at the war hospital. Elevated blood pressure was found in 80 men (5%); 61 of them had no history of hypertension (Group A), while in 19 patients hypertensive disease had been diagnosed before (Group B). In group A, systolic blood pressure (BPS in mm Hg), diastolic blood pressure (BPD in mm Hg) and heart rate (HR) were 182 +/- 13, 111 +/- 10, and 115 +/- 9; in group B, the values were 184 +/- 12, 108 +/- 8, 85 +/- 11. Electrocardiograms (ECG) and thorax roentgenograms of group A did not reveal any hypertension-caused signs, neither did the examination of the fundus, nor the serum creatinine values yield any abnormal results. The ECG test showed sinus tachycardia (heart rate > 100/min) but an otherwise normal function in group A. In group B, at least one of the laboratory examinations confirmed the previously diagnosed hypertension. Group A was treated with the cardioselective beta-blocker Atenolol (100 mg daily), while in group B, the previous antihypertensive medication was modified and/or increased. All patients were sent back to the front-line. Three days later, blood pressure and heart rate in group A were: BPS 139 +/- 9, BPD 87 +/- 6 and HR 77 +/- 8; and in group B: 156 +/- 11, 95 +/- 8, 75 +/- 7. A significant decrease in systolic and diastolic blood pressure (p < 0.0001) was found in both groups.(ABSTRACT TRUNCATED AT 250 WORDS)