The Use of Predictive Modeling to Compare Prehospital eCPR Strategies.

The duration of low flow prior to initiation of extracorporeal cardiopulmonary resuscitation (eCPR) appears to influence survival. Strategies to reduce the low-flow interval for out-of-hospital cardiac arrest have been focused on expediting patient transport to the hospital or initiating extracorporeal support in the prehospital setting. To date, a direct comparison of low-flow interval between these strategies has not been made. To attempt this comparison, a model was created to predict low-flow intervals for each strategy at different locations across the city of Albuquerque, New Mexico. The data, specific to Albuquerque, suggest that a prehospital cannulation strategy consistently outperforms an expedited transport strategy, with an estimated difference in low-flow interval of 34.3 to 37.2 minutes, depending on location. There is no location within the city in which an expedited transport strategy results in a shorter low-flow interval than prehospital cannulation. It would be rare to successfully initiate eCPR by either strategy in fewer than 30 minutes from the time of patient collapse. Using a prehospital cannulation strategy, the entire coverage area could be eligible for eCPR within 60 minutes of patient collapse. The use of predictive modeling can be a low-cost solution to assist with strategic deployment of prehospital resources and may have potential for real-time decision support for prehospital clinicians.

An Intensivist-Led Extracorporeal Membrane Oxygenation Program: Design, Implementation, and Outcomes of the First Five Years.

We describe the development, implementation, and outcomes of an intensivist-led adult extracorporeal life support (ECLS) program using intensivists both to perform venovenous (V-V), venoarterial (V-A), and extracorporeal cardiopulmonary resuscitation (ECPR) cannulations, and to manage patients on ECLS throughout their ICU course. All adults supported with ECLS at the University of New Mexico Hospital (UNMH) from February 1, 2017 to December 31, 2021 were retrospectively analyzed. A total of 203 ECLS cannulations were performed in 198 patients, including 116 V-A cannulations (including 65 during ECPR) and 87 V-V cannulations (including 38 in patients with COVID-19). UNMH intensivists performed 195 cannulations, with 9 cannulation complications. Cardiothoracic surgeons performed 8 cannulations. Overall survival to hospital discharge or transfer was 46.5%. Survival was 32.3% in the ECPR group and 56% in the non-ECPR V-A group. In the V-V cohort, survival was 66.7% in the COVID-19-negative patients and 34.2% in the COVID-19-positive patients. This large series of intensivist-performed ECLS cannulations-including V-A, V-V, and ECPR modalities-demonstrates the successful implementation of a comprehensive intensivist-led ECLS program. With outcomes comparable to those in the literature, our program serves as a model for the initiation and development of ECLS programs in settings with limited access to local subspecialty cardiothoracic surgical services.

E-CPR in Cardiac Arrest due to Accidental Hypothermia Using Intensivist Cannulators: A Case Series of Nine Consecutive Patients.

Background: Severe accidental hypothermia (AH) accounts for over 1300 deaths/year in the United States. Early extracorporeal life support (ECLS) is recommended for hypothermic cardiac arrest. We describe the use of a rapid-deployment extracorporeal cardiopulmonary resuscitation (E-CPR) team using intensivist physicians (IPs) as cannulators and report the outcomes of consecutive patients cannulated for ECLS to manage cardiac arrest due to AH. Methods: We reviewed all patients managed with veno-arterial (V-A) ECLS for hypothermic cardiac arrest between January 1, 2017 and November 1, 2021. For each patient- age, sex, cause of hypothermia, initial core temperature, initial rhythm, time from arrest to cannulation, cannula configuration, pH, lactate, potassium, cannulation complications, duration of ECLS, hospital length of stay, mortality, and cerebral performance category (CPC) at discharge were reviewed. Results: Nine consecutive patients were identified that underwent V-A ECLS for cardiac arrest due to AH. Seven (78%) were witnessed arrests. Initial rhythm was ventricular fibrillation (VF) in eight patients and pulseless electrical activity (PEA) in one. The mean initial core temperature was 23.8 degrees Celsius. The mean time from arrest to cannulation was 58 min (range 17 to 251 min). There were no complications related to cannulation. The mean duration of ECLS was 39.1 h. All nine patients were discharged alive with a Cerebral Performance score of one or two. Conclusion: In this case series of consecutive patients reporting intensivist-deployed E-CPR for cardiac arrest due to AH, all patients survived to discharge with a favorable neurologic outcome. A rapidly available E-CPR team utilizing intensivist cannulators may improve outcomes in patients with cardiac arrest due to AH.

Evaluation of a Disposable Vascular Pressure Device for Pre- and Postmembrane Pressure Monitoring During Venovenous Extracorporeal Membrane Oxygenation.

Membrane pressure monitoring during extracorporeal membrane oxygenation (ECMO) is integral to monitoring circuit health. We compared a disposable vascular pressure device (DVPD) to the transducer pressure bag arterial line (TPBAL) monitoring system to determine whether the DVPD can reliably and accurately monitor membrane pressures during venovenous extracorporeal membrane oxygenation (VV ECMO). We analyzed existing quality assurance data collected at a single center as part of routine circuit performance monitoring and process improvement on a convenience sample of four VV ECMO circuits. We placed and zeroed a DVPD in line with the pre- and postmembrane TPBAL setups in coordination with a standard transducer setup. We recorded DVPD and TPBAL pressure measurements every 4 hours for 2.5 days on the four separate VV ECMO circuits. We compared the standard and DVPD pressures using Bland-Altman plots and methods that accounted for repeated measures in the same subject. We recorded 58 pre/postmembrane pressures. Mean membrane pressure values were similar in the DVPD (pre: 208 mmHg [SD, 50.8]; post: 175 mmHg [46.3]) compared to the standard TPBAL setup (pre: 205 mmHg [52.0]; post: 177 mmHg [46.3]). Using Bland-Altman methods, premembrane pressures were found to be 2.2 mmHg higher (95% confidence interval [CI]: -5.3 to 9.7) in the standard TPBAL setup compared to DVPD and 1.8 mmHg higher (95% CI: -5.3 to 8.9) than the postmembrane pressures. The DVPD provided an accurate measurement of circuit pressure as compared to the TPBAL setup. Across the range of pre- and postmembrane pressures, both methods reliably agreed. Future trials should investigate DVPD accuracy in different environments such as prehospital field cannulation or critical care transport of ECMO patients.

Transesophageal Echocardiography Performed by Intensivist and Emergency Physicians-A 5-Year, Single-Center Experience.

Purpose: Data on the use of transesophageal echocardiography (TEE) by intensivist physicians (IP) and emergency physicians (EP) are limited. This study aims to characterize the use of TEE by IPs and EPs in critically ill patients at a single center in the United States. Materials and Methods: Retrospective chart review of all critical care TEEs performed from January 1, 2016 to January 31, 2021. The personnel performing the exams, location of the exams, characteristics of exams, complications, and outcome of the patients were reviewed. Results: A total of 396 examinations was reviewed. TEE was performed by IPs (92%) and EPs (9%). The location of TEE included: intensive care unit (87%), emergency department (11%), and prehospital (2%) settings. The most common indications for TEE were: hemodynamic instability/shock (44%), cardiac arrest (23%), and extracorporeal membrane oxygenation (ECMO) facilitation, adjustment, or weaning (21%). The most common diagnosis based on TEE were: normal TEE (25%), left ventricular dysfunction (19%), and vasodilatory shock (15%). A management change resulted from 89% of exams performed. Complications occurred in 2% of critical care TEEs. Conclusion: TEE can be successfully performed by IPs and EPs on critically ill patients in multiple clinical settings. TEE frequently informed management changes with few complications.

Protocolized Whole-Body Computed Tomography Imaging After Extracorporeal Membrane Oxygenation (ECMO) Cannulation for Cardiac Arrest.

Evaluate the utility of whole-body computed tomography (WBCT) imaging in detecting clinically significant findings in patients who have undergone extracorporeal membrane oxygenation (ECMO) cannulation for cardiac arrest (extracorporeal cardiopulmonary resuscitation or "eCPR"). Single-center retrospective review of 52 consecutive patients from 2017 to 2019 who underwent eCPR and received concomitant WBCT imaging. WBCT images were reviewed for clinically significant findings (compression-related injuries, cannulation-related complications, etiology of cardiac arrest, incidental findings, and evidence of hypoxic brain injury) as well as the frequency of interventions performed as a direct result of such findings. Thirty-eight patients met inclusion criteria for analysis. Clinically significant WBCT findings were present in 37/38 (97%) of patients with 3.3 ± 1.7 findings per patient. An intervention as a direct result of WBCT findings was performed in 54% (20/37) of patients with such findings. Evidence of hypoxic brain injury on WBCT was associated with clinical brain death as compared with those without such findings (10/15 [67%] vs 1/22 [4%], P < 0.001), respectively. WBCT scan after eCPR frequently detects clinically significant findings which commonly prompt an intervention directly affecting the patient's clinical course. We advocate for protocolized use of WBCT imaging in all eCPR patients.

Models for plasma kinetics during simultaneous therapeutic plasma exchange and extracorporeal membrane oxygenation.

This paper focuses on the derivation and simulation of mathematical models describing new plasma fraction in blood for patients undergoing simultaneous extracorporeal membrane oxygenation and therapeutic plasma exchange. Models for plasma exchange with either veno-arterial or veno-venous extracorporeal membrane oxygenation are considered. Two classes of models are derived for each case, one in the form of an algebraic delay equation and another in the form of a system of delay differential equations. In special cases, our models reduce to single compartment ones for plasma exchange that have been validated with experimental data (Randerson et al., 1982, Artif. Organs, 6, 43-49). We also show that the algebraic differential equations are forward Euler discretizations of the delay differential equations, with timesteps equal to transit times through model compartments. Numerical simulations are performed to compare different model types, to investigate the impact of plasma device port switching on the efficiency of the exchange process, and to study the sensitivity of the models to their parameters.

Safety of Transesophageal Echocardiography Performed by Intensivists and Emergency Physicians in Critically Ill Patients With Coagulopathy and Thrombocytopenia: A Single-Center Experience.

INTRODUCTION: The use of transesophageal echocardiography (TEE) by intensivist physicians (IPs) and emergency physicians (EPs) in critically ill patients is increasing in the intensive care unit, emergency department, and prehospital environments. Coagulopathy and thrombocytopenia are common in critically ill patients. The risk of performing TEE in these patients is unknown. The goal of this study was to assess whether TEE is safe when performed by IPs or EPs in critically ill patients with high bleeding risk (HBR). METHODS: All TEEs performed by an IP or EP between January 1, 2016, and July 31, 2019, were reviewed as part of a quality assurance database. A TEE performed on a patient was deemed HBR if the patient met at least one of the following criteria: undergoing therapeutic anticoagulation, had an INR > 2, activated partial thromboplastin time >40 seconds, fibrinogen <150 mg/dL, and/or platelet count <50 000/µL. The medical record was reviewed on each patient to determine whether upper esophageal bleeding, oropharyngeal bleeding, esophageal perforation, or dislodgement of an artificial airway occurred during or after the TEE. RESULTS: A total of 228 examinations were reviewed: 80 in the high-risk group and 148 in the low-risk group (LBR). There were complications potentially attributable to TEE in 8 (4%) of the 228 exams. Total complications were not different between groups: 4 (5%) in the HBR group versus 4 (3%) in the LBR group (odds ratio [OR] = 1.89 [0.34-10.44], P =.368). Upper esophageal bleeding occurred in 5 total examinations (2%), which was not different between groups: 3 (4%) in the HBR group and 2 (1%) in the LBR group (OR = 2.84 [0.31-34.55], P = .238). There were no deaths attributable to TEE in either group. CONCLUSION: Transesophageal echocardiography can be safely performed by IPs and EPs in critically ill patients at high risk of bleeding with minimal complications.

Mathematical modeling of the impact of recirculation on exchange kinetics in tandem extracorporeal membrane oxygenation and therapeutic plasma exchange.

Vascular access connection configurations during tandem extracorporeal membrane oxygenation (ECMO) and therapeutic plasma exchange (TPE) may impact exchange kinetics. In these tandem procedures, typically the TPE inlet line is proximal to the TPE return line with respect to blood flow in the ECMO device, maximizing the opportunity for replacement fluid homogenization within the ECMO circuit. However, if TPE inlet and return line connections are switched, recirculation-a phenomenon in which replacement fluid leaving the TPE return line is prematurely drawn into the TPE inlet line prior to satisfactory homogenization within the ECMO circuit-will occur. Such recirculation could diminish TPE efficacy in patients on ECMO and mitigate therapeutic benefits. Using a mathematical model of recirculation in tandem ECMO and TPE, we demonstrate that the predicted impact of recirculation is negligible and vascular access connection positioning does not appear to be a point of clinical concern with regard to TPE kinetics.

Accuracy and Reliability of a Disposable Vascular Pressure Device for Arterial Pressure Monitoring in Critical Care Transport.

OBJECTIVE: Arterial catheterization is a commonly performed procedure in intensive care units to guide the management of critically ill patients who require precise hemodynamic monitoring; however, this technology is not always available in the transport setting because of cumbersome and expensive equipment requirements. We compared the accuracy and reliability of a disposable vascular pressure device (DVPD) with the gold standard (ie, the transducer pressure bag invasive arterial monitoring system) used in intensive care units to determine if the DVPD can be reliably used in place of the traditional pressure transducer setup. METHODS: This study was a single-center, prospective, observational study performed in the adult intensive care unit of a large academic university hospital. A convenience cohort of hemodynamically stable, adult critically ill patients with femoral, brachial, or radial arterial catheters was recruited for this study. The Compass pressure device (Centurion Medical Products, Williamston, MI) is a disposable vascular pressure-sensing device used to assure venous access versus inadvertent arterial access during central line placement. The DVPD was attached to an in situ arterial catheter and measures the mean intravascular pressure via an embedded sensor and displays the pressure via the integrated LCD screen. Using a 3-way stopcock, the DVPD was compared with the standard arterial setup. We compared the mean arterial pressure (MAP) in the standard setup with the DVPD using Bland-Altman plots and methods that accounted for repeated measures in the same subject. RESULTS: Data were collected on 14 of the 15 subjects enrolled. Five measurements were obtained on each patient comparing the DVPD with the standard arterial setup at 1-minute intervals over the course of 5 minutes. A total of 70 observations were made. Among the 15 subjects, most (10 [67%]) were radial or brachial sites. The average MAP scores and standard deviation values obtained by the standard setup were 83.5 mm Hg (14.8) and 81.1 mm Hg (19.3) using the DVPD. Just over half (51.4%) of the measurements were within a ± 5-mm Hg difference. Using Bland-Altman plotting methods, standard arterial measurements were 2.4 mm Hg higher (95% confidence interval, 0.60-4.1) than with the DVPD. Differences between the 2 devices varied significantly across MAP values. The standard arterial line measurements were significantly higher than the DVPD at low MAP values, whereas the DVPD measurements were significantly higher than the standard arterial line at high MAP values. CONCLUSION: The DVPD provides a reasonable estimate of MAP and may be suitable for arterial pressure monitoring in settings where standard monitoring setups are not available. The DVPD appears to provide "worst-case" values because it underestimates low arterial blood pressure and overestimates high arterial blood pressure. Future trials should investigate the DVPD under different physiological conditions (eg, hypotensive patients, patients with ventricular assist devices, and patients on extracorporeal membrane oxygenation), different patient populations (such as pediatric patients), and in different environments (prehospital, air medical transport, and austere locations).

Family presence during brain death evaluation: a randomized controlled trial*.

OBJECTIVE: To evaluate if a family presence educational intervention during brain death evaluation improves understanding of brain death without affecting psychological distress. DESIGN: Randomized controlled trial. SETTING: Four ICUs at an academic tertiary care center. SUBJECTS: Immediate family members of patients suspected to have suffered brain death. INTERVENTIONS: Subjects were group randomized to presence or absence at bedside throughout the brain death evaluation with a trained chaperone. All randomized subjects were administered a validated "understanding brain death" survey before and after the intervention. Subjects were assessed for psychological well-being between 30 and 90 days after the intervention. MEASUREMENTS AND MAIN RESULTS: Follow-up assessment of psychological well-being was performed using the Impact of Event Scale and General Health Questionnaire. Brain death understanding, Impact of Event Scale, and General Health Questionnaire scores were analyzed using Wilcoxon nonparametric tests. Analyses were adjusted for within family correlation. Fifty-eight family members of 17 patients undergoing brain death evaluation were enrolled: 38 family members were present for 11 brain death evaluations and 20 family members were absent for six brain death evaluations. Baseline understanding scores were similar between groups (median 3.0 [presence group] vs 2.5 [control], p = 0.482). Scores increased by a median of 2 (interquartile range, 1-2) if present versus 0 (interquartile range, 0-0) if absent (p < 0.001). Sixty-six percent of those in the intervention group achieved perfect postintervention "understanding" scores, compared with 20% of subjects who were not present (p = 0.02). Median Impact of Event Scale and General Health Questionnaire scores were similar between groups at follow-up (Impact of Event Scale: present = 20.5, absent = 23.5, p = 0.211; General Health Questionnaire: present = 13.5, absent = 13.0, p = 0.250). CONCLUSIONS: Family presence during brain death evaluation improves understanding of brain death with no apparent adverse impact on psychological well-being. Family presence during brain death evaluation is feasible and safe.

Do medical students understand brain death? A survey study.

BACKGROUND: A lack of understanding of brain death has been demonstrated among physicians, and may stem from knowledge deficits at the medical school level. The authors sought to evaluate current understanding of brain death and knowledge gaps among U.S. medical students at a single center. METHODS: Using a validated "Understanding Brain Death" survey tool, the authors surveyed the student body at an accredited four year medical school. A score of 5/5 on this scale indicated an expert level of understanding. The investigators identified areas of knowledge gaps, and compared brain death expertise throughout the curriculum progression. RESULTS: The overall response rate was 69% (212 of 306 students). Mean scores were 3.1, 3.9, 4.1, and 4.0 (out of 5) among first through fourth year classes respectively. Understanding of brain death differed across the medical school classes (p <0.0001). 33% (N=70) of all students attained scores of 5 indicating an expert level of understanding brain death. By class; 18% of first year students demonstrated expert levels of understanding, compared to 31% of second year students, 48% of third year students, and 39% of fourth year students. CONCLUSIONS: The level of understanding of brain death is low among the student body in a four year accredited U.S. medical school. This knowledge gap persists among graduating students as most do not attain an expert understanding of brain death. A more comprehensive brain death curriculum should be implemented in order to adequately equip physicians with this fundamental knowledge.

Ultrasound determination of chest wall thickness: implications for needle thoracostomy.

OBJECTIVE: Computed tomography measurements of chest wall thickness (CWT) suggest that standard-length angiocatheters (4.5 cm) may fail to decompress tension pneumothoraces. We used an alternative modality, ultrasound, to measure CWT. We correlated CWT with body mass index (BMI) and used national data to estimate the percentage of patients with CWT greater than 4.5 cm. METHODS: This was an observational, cross-sectional study of a convenience sample. We recorded standing height, weight, and sex. We measured CWT with ultrasound at the second intercostal space, midclavicular line and at the fourth intercostal space, midaxillary line on supine subjects. We correlated BMI (weight [in kilograms]/height(2) [in square meters]) with CWT using linear regression. 95% Confidence intervals (CIs) assessed statistical significance. National Health and Nutrition Examination Survey results for 2007-2008 were combined to estimate national BMI adult measurements. RESULTS: Of 51 subjects, 33 (65%) were male and 18 (35%) were female. Mean anterior CWT (male, 2.1 cm; CI, 1.9-2.3; female, 2.3 cm; CI, 1.7-2.7), lateral CWT (male, 2.4 cm; CI, 2.1-2.6; female, 2.5 cm; CI 2.0-2.9), and BMI (male, 27.7; CI, 26.1-29.3; female, 30.0; CI, 25.8-34.2) did not differ by sex. Lateral CWT was greater than anterior CWT (0.2 cm; CI, 0.1-0.4; P < .01). Only one subject with a BMI of 48.2 had a CWT that exceeded 4.5 cm. Using national BMI estimates, less than 1% of the US population would be expected to have CWT greater than 4.5 cm. CONCLUSIONS: Ultrasound measurements suggest that most patients will have CWT less than 4.5 cm and that CWT may not be the source of the high failure rate of needle decompression in tension pneumothorax.

Ultrasonographic determination of pubic symphyseal widening in trauma: the FAST-PS study.

BACKGROUND: The focused abdominal sonography in trauma (FAST) examination is a routine component of the initial work-up of trauma patients. However, it does not identify patients with retroperitoneal hemorrhage associated with significant pelvic trauma. A wide pubic symphysis (PS) is indicative of an open book pelvic fracture and a high risk of retroperitoneal bleeding. STUDY OBJECTIVES: We hypothesized that an ultrasound image of the PS as part of the FAST examination (FAST-PS) would be an accurate method to determine if pubic symphysis diastasis was present. METHODS: This is a comparative study of a diagnostic test on a convenience sample of 23 trauma patients at a Level 1 Trauma Center. The PS was measured sonographically in the Emergency Department (ED) and post-mortem (PM) at the State Medical Examiner. The ultrasound (US) measurements were then compared with PS width on anterior-posterior pelvis radiograph. RESULTS: Twenty-three trauma patients were evaluated with both plain radiographs and US (11 PM, 12 ED). Four patients had radiographic PS widening (3 PM, 1 ED) and 19 patients had radiographically normal PS width; all were correctly identified with US. US measurements were compared with plain X-ray study by Bland-Altman plot. With one exception, US measurements were within 2 standard deviations of the radiographic measurements and, therefore, have excellent agreement. The only exception was a patient with pubic symphysis wider than the US probe. CONCLUSION: Bedside ultrasound examination may be able to identify pubic symphysis widening in trauma patients. This potentially could lead to faster application of a pelvic binder and tamponade of bleeding.

Impact of positive pressure ventilation on thoracostomy tube removal.

BACKGROUND: Little data exist examining the impact of positive pressure ventilation on safe thoracostomy tube removal. We sought to evaluate the impact of positive-pressure ventilation (PPV) on recurrent pneumothoraces (PTX) after removal of thoracostomy tubes (TT). METHODS: A retrospective cohort analysis was performed evaluating all trauma patients requiring TT drainage of PTX or hemothoraces during a 3-year period. All chest radiographs before and after TT removal were reviewed to identify PTX recurrence. The principle outcome was recurrent PTX after TT removal. The 95% confidence intervals were calculated to assess for significance. RESULTS: We studied 234 TT removals in 190 patients. One hundred thirty-six (58%) TTs were removed under PPV. PTX recurred in 15 (11%) and 6 (4%) required reinsertion. In 10 patients (7.4%), there was a radiographically stable small PTX before and after removal not requiring TT reinsertion. In comparison, 98 (42%) TTs were removed under spontaneous ventilation. PTX recurred in 16 (16%) and 3 (3%) required reinsertion. There were 25 (25.5%) stable small PTXs before and after removal. The overall recurrence rate difference was -5.3% (confidence interval: -14.8 to 3.5) and reinsertion rate difference was 1.35% (confidence interval: -4.7 to 6.6). CONCLUSIONS: The rate of recurrent PTX or TT replacement after removal is not associated with PPV status. The slightly lower recurrence rate on PPV combined with the smaller proportion of patients with stable small PTX before removal may reflect more careful clinician selection of ideal patients or technique of TT removal among patients on PPV. Prospective data are needed to clarify these associations.

Development and validation of a tool for assessing understanding of brain death.

BACKGROUND: Death by neurological criteria is often misunderstood by laypersons even though they make decisions about withdrawal of care and organ donation. No validated questionnaire for determining laypersons' understanding of brain death exists. Such a tool could be useful in clinical, educational, and research settings. METHODS: Brain death experts and a focus group of laypersons were used to develop a 5-item questionnaire with face validity. The questionnaire explores 3 concepts: apnea, irreversibility, and differentiation between cardiac death, brain death, and persistent vegetative state. The questionnaire was administered to separate groups of laypersons and experts and was readministered 7 to 10 days later. Test-retest reliability for individual items and overall score was measured by using Spearman rank correlation. Internal consistency of the questionnaire was measured by using Cronbach alpha. Utility of the questionnaire in discriminating between scores of laypersons and experts was evaluated by using a t test. RESULTS: Twelve laypersons and 13 experts participated. The test-retest correlation was significant for all questions (Spearman p range, 0.43-0.94) and raw score (Spearman p=0.91, P<.001). Internal consistency was fair (Cronbach alpha=0.64). The questionnaire enabled discrimination of laypersons from experts, with mean (SD) raw scores of 3.0 (1.1) vs 4.8 (0.6), respectively (t test, P<.001). Removal of 1 item improved internal consistency (Cronbach alpha=0.70), but with a corresponding decrease in discriminatory ability. CONCLUSIONS: This simple 5-item questionnaire for evaluating understanding of brain death has test-retest reliability, internal consistency, and can be used to discriminate between persons who do and do not understand brain death.

HBOC-201 use in traumatic brain injury: case report and review of literature.

BACKGROUND: The first use of HBOC-201 in severe traumatic brain injury (TBI) is presented. The use of noninvasive cerebral oximetric devices to follow clinical progress in a patient infused with HBOC-201 is reported and the literature of hemoglobin-based oxygen carriers (HBOCs) in brain injury is reported. CASE REPORT: A 21-year-old Jehovah's Witness who was hit and dragged by a motor vehicle was admitted to the University of New Mexico Hospital Level 1 Trauma Center Trauma Surgical Intensive Care Unit with severe TBI and extensive soft tissue loss resulting in profound anemia. The patient received infusion of HBOC-201 with regional and global oximetric monitoring. RESULTS: Chart abstraction was performed to identify clinically relevant physiologic markers of patient progress. We observed a marked increase in brain tissue oxygen saturations, central venous oxygen saturation, and hemodynamic variables after administration of HBOC-201. The patient subsequently suffered massive cerebral edema and died. CONCLUSIONS: Major HBOC trials to date have excluded severe TBI. We report the first use of an HBOC in severe TBI to correct profound anemia. The HBOC-201 rapidly corrected cerebral venous and central venous oxygen saturations. The patient's death may have been due to massive reperfusion injury from delayed repayment of cerebral oxygen debt in a severely ischemic brain.