Benefits, shortcomings, and costs of EEG monitoring.

A 5-year experience with 562 carotid endarterectomies, using electroencephalogram (EEG) monitoring and selective shunting, was reviewed. EEG changes occurred in 102 patients (18%). The frequency of EEG changes, as related to cerebral vascular symptoms, was as follows: transient ischemic attacks, seven per cent (19/259); completed strokes, 37% (36/98); vertebral basilar insufficiency, 24% (32/135); asymptomatic, 21% (15/71). Patients with contralateral carotid occlusion exhibited EEG changes in 37% (28/76) of operations. Fifteen patients suffered perioperative strokes (2.6%). Nine of the 15 were associated with a technical problem of either thrombosis of the internal carotid artery (five) or emboli (four). Technical problems were more common when shunts were used (five per cent) than when they were not (0.9%). Patients who suffered strokes prior to surgery were more at risk to develop a perioperative stroke (three per cent) than those not suffering prior strokes (0.3%). The EEG did not change in three patients who had lacunar infarcts prior to surgery and who awoke with a worsened deficit. Our series does not clearly establish the advantages of EEG monitoring, which is expensive (+375/patient) and may not detect ischemia in all areas of the brain. However, the use of shunts may introduce a risk of stroke due to technical error that is equal or greater than the risk of stroke due to hemodynamic ischemia. Since the need for protection is unpredictable by angiographic or clinical criteria, the benefit of EEG monitoring may be in reducing the incidence of shunting in those patients whose tracing remains normal after clamping. The decision to shunt, however, when there is electrical dysfunction after carotid clamping should be based not only on the EEG but also on the clinical signs and computed tomography (CT) scan. Our data does not show a net benefit in selective shunting unless the patient has sustained a stroke prior to surgery.

Health care in the Soviet Union.

More nurses today have the opportunity to visit other countries and broaden their ideas of health care and nursing. Several colleagues and I have prepared a series of three articles that describe visits to the Soviet Union, China and Africa by nurses participating in exchange tours conducted by Professional Seminar Consultants of Albuquerque, New Mexico. During these two-week trips, American nurses were able to observe health care facilities and talk to health care providers in other countries. Although short visits such as these are not able to provide in-depth understanding of the health care systems or cultures involved, they have provided provocative ideas about how our own health care system differs from others. In some instances, our health care system seems the better one, but in many instances we were able to gain insights from our observations that may help us improve our own system of nursing and health care. This is the first in a series of three articles reporting professional exchange tours between American nurses and nurses of other countries. In this article, the health care system of the Soviet Union is discussed and compared to the United States' system of health care. From this comparison come several insights into ways for improving health care delivery.

Kidney donation: needs and possibilities.

The need for cadaver kidney donors far surpasses the present supply. The subject of how to increase the number of donors is extremely complex, involving not only the medical issue of determination of brain death, but also philosophical, religious, legal, political, psychological, and economic considerations and the opinions of leaders and lay groups. It now seems that the physician can rapidly and unequivocally ascertain brain death, that the law not only recognizes this but can facilitate organ retrieval, that adequate numbers of potential donors should be available, and that both the public and physicians generally favor retrieval. Our survey of patients seeking aid in the emergency room revealed that 19% had signed the donor statement on their driving license. Of the neurosurgeons and neurologists who responded to a questionnaire, 74% had requested donation and 37% had obtained permission for organ retrieval. Review of our case material revealed that 60% of individuals with head injuries alone who were hospitalized for over 3 days were suitable donors. Of the 54 kidneys retrieved during a 6-month period, 49 (90%) were transplanted. Because most potential donors come to the attention of neurosurgeons and neurologists and because it seems ethically appropriate for physicians to consider transplantation when death is certain, we suggest that an organized effort be undertaken to develop a liaison with transplantation services to facilitate the process of obtaining adequate numbers of cadaver kidneys.