Delayed graft function and perfusion parameters of kidneys from uncontrolled donors after circulatory death.

Better preservation and evaluation of kidneys from donors after circulatory death serve to increase the number of kidneys available for transplantation and hypothermic machine perfusion has been shown to decrease ischemia reperfusion injury and delayed graft function. Data on relation between hemodynamic parameters during hypothermic machine perfusion and delayed graft function in kidneys from donors after circulatory death are so far scarce and not univocal. We aimed at assessing whether hemodynamic parameters measured during hypothermic machine perfusion (flow, mean perfusion pressure, and renal resistance) are associated with delayed graft function in 26 kidneys retrieved from uncontrolled donors after circulatory death. In our series, the incidence of delayed graft function was 57.7% (15/26). Recipients who developed delayed graft function had a longer warm ischemic time (p = 0.04). All hemodynamic parameters measured during hypothermic machine perfusion were comparable between recipients with delayed graft function and those without. According to our data, in kidneys from uncontrolled donors after circulatory death, a longer warm ischemic time (that is the overall time of no flow, as the sum of the no-flow and the no-touch period) is associated with delayed graft function. This finding underscores the pivotal role of ischemic injury in terms of absence of flow in affecting graft function. No association was detectable between hemodynamic parameters during hypothermic machine perfusion and the development of delayed graft function in our series.

Utilization rate of uncontrolled donors after circulatory death-a 3-year single-center investigation.

BACKGROUND: Effectiveness of uncontrolled donation after circulatory death (uDCD) has been recently reported to be 75% according to data coming from some European countries in 2016, but few data are to date available on this topic. METHODS: We assessed the utilization rate (as the percentage of donors who were converted into actual donors) in 37 uDCDs consecutively enrolled at our Center (Careggi Teaching Hospital) from June 2016 to June 2019. RESULTS: In three cases, the family did not give consent for donation (3/37, 8.1%). Among the 37 potential uDCDs, 22 became actual donors (22/37, 59%), with 10 livers and 38 kidneys being transplanted, respectively. Fifteen livers were recovered (15/37, 68%), and 10 livers were transplanted (10/15, 67%). Forty-two kidneys were procured and 38 organs transplanted. The overall effectiveness was 78%. CONCLUSIONS: According to our 3-year experience, uncontrolled DCDs do represent an additional means of increasing the number of transplanted organs (kidneys and livers) with an acceptable utilization rate. Research on organ viability assessment (for both livers and kidneys from uDCDs) is still in its infancy, and there is probably space for a further wider use of organs from uDCDs.

Comorbidities and Age in Brain-Dead Donors and Liver Transplantation: A 15-Year Retrospective Investigation.

OBJECTIVES: Although livers from older donors (> 70 y) have been shown to be increasingly more efficiently used for transplant, donor comorbidities are considered additional risk factors. This is quite intriguing as comorbidities are known to increase with advancing age in the donor population. MATERIALS AND METHODS: We assessed whether age and donor comorbidities influenced liver procurement over a 15-year period in a cohort of 1702 brain-dead donors in Tuscany, Italy. RESULTS: Over the study period, age of potential donors significantly increased (P = .02) as well as the proportion of patients who were > 55 years old. The incidence of hypertension, diabetes mellitus, and previously known coronary artery disease also significantly increased. We observed a progressive increase in the number of transplanted livers from donors with advancing age despite an increase in comorbidities. The highest incidences of traumatic brain injury and anoxic brain injury were observed in the youngest donors. Transaminase levels and use of vasoactive drugs were lower in donors who were ≥ 72 years old. CONCLUSIONS: According to our results, criteria for liver donors have already changed. Although age does not seem to be a limiting factor, older donors deserve a more accurate donor selection due to the higher incidence of risk factors (primarily diabetes mellitus).

Epidemiological changes in potential heart donors after brain death: a retrospective 15 year cohort study.

Changes in the causes of brain death may influence the numbers of hearts that can be procured and transplanted. We retrospectively investigated whether the distribution of causes responsible for brain death have changed over a 15-year period in a cohort of 1286 potential heart donor (aged ≤ 60), and whether it influenced heart procurement. Between 2001 and 2016, the age of potential donors significantly increased (p < 0.0001) as well as the relative proportion of postanoxic brain death, while that of traumatic brain injury decreased (p = 0.0007). A significant increase in the use of norepinephrine was detectable. The number of transplanted hearts did not significantly change, with no differences in the age of donors or in the causes of brain death. According to our data, in our 15-year study period, significant changes in the causes of brain death occurred (indicated by a reduction in potential donors following traumatic brain injury) together with an increase in donor age. Nevertheless, the number of transplanted hearts did not change probably thanks to a modified donor management (as inferred by a different use of vasoactive drugs).

A metabolic approach during normothermic regional perfusion in uncontrolled donors after circulatory death-A pilot study.

The use of donation after circulatory death (DCD) has increased significantly to face the persistent mismatch between supply and demand of organs for transplantation. While controlled (c) DCDs have warm ischemic time (WIT) that can be estimated, the WIT is often inexact and extended in uncontrolled DCD (uDCD), making assessment of injury difficult. We aimed at investigating the effects of cold ischemia on potential donor organ damage in the course of nRP by assessing the dynamic variations of transaminases and creatinine values in 17 uDCD donors. In our series, lactate values did not show significant changes during the study period (P = 0.147). Creatinine values did not significantly changed while transaminases progressive increased throughout the study period, even if it was significant only for AST (P = 0.035). According to our data, nRP duration affects splanchnic organs, being the liver sensitive to hypoperfusion, and serial biochemical measurements could help in detecting organ functional status.

Is brain computed tomography combined with somatosensory evoked potentials useful in the prediction of brain death after cardiac arrest?

BACKGROUND: Brain death (BD) in coma after cardiac arrest (CA) is difficult to predict. Basal ganglia gray matter/white matter (GM/WM) ratio density and somatosensory evoked potentials (SEPs) may differentiate patients evolving toward BD. METHODS: We used SEPs and brain computed tomography (CT) after coma onset, within the first 24hours. RESULTS: Of the 160 patients included in the study, 22 (14%) evolved toward BD. SEP patterns predicted BD (ROC area=0.82, P<0.0001). The combination of SEP patterns, bilaterally absent (AA) and absent on one hemisphere and pathological on the other (AP), predicted BD with a sensitivity of 100% and a specificity of 62.3%, with a positive likelihood ratio of 2.65. The GM/WM ratio predicted BD (ROC area=0.68, P=0.01). A GM/WM ratio <1.07 had a sensitivity of 30.4%, a specificity of 94.9%, and a positive likelihood ratio of 6.27. The combination of SEP and CT findings did not increase the prediction of BD. CONCLUSION: SEPs and brain CT within 24hours predicted BD after CA. Severe SEP findings (SEP patterns: AA, AP) identified a subset of patients in whom BD could occur. Brain CT (GM/WM ratio in basal ganglia) predicted an early evolution toward BD with high specificity but lower sensitivity.

A Case of Insect Colonization Before the Death.

Forensic entomology is a branch of forensic science in which insects are used as evidence in legal investigations relating to humans, domestic animals and wildlife. One of the theoretical pillars on which the discipline is based concerns the fact that flies colonize a body after death. However in cases of myiasis, maggots are present before death, with consequences in the correct estimation of the minimum postmortem interval (mPMI). We report here the case of a woman, largely colonized by fly larvae, who has lain alive in her garden for four days prior to being rescued. Larvae were found on the conjunctivae, the bronchi, the rectum and vagina. The woman's death, two months later, was caused by tetanus. The consequences of myiasis on mPMI estimation are here discussed. In fact, despite she was still alive larvae, indicated and estimated age of 1.5-2.5 days, based on environmental and body temperature.

Predictive patterns of sensory evoked potentials in comatose brain injured patients evolving to brain death.

OBJECTIVE: To assess whether Somatosensory Evoked Potentials (SEPs), recorded within 24h after ICU admission, are reliable predictors of brain death (BD) in comatose patients with acquired brain injury of various aetiologies. METHODS: SEPs were classified as absent (A), pathological (P), and normal (N). Considering SEP recordings from both hemispheres, 6 patterns were identified: NN, NP, PP, NA, AP, and AA. The final endpoint was BD. RESULTS: Of the 203 patients included in the study, 70 (34%) evolved toward BD. The survival analysis indicated that the combination of SEP patterns in a two-graded scale (grade 1: NN-NP-PP-NA, and grade 2: AP-AA), allowed for prediction of BD with the best accuracy. This aggregation predicted BD with a sensitivity of 75.7% (CI: 64-84), a specificity of 76.6% (CI: 68-83), a positive predictive value of 64.2% (CI: 53-74) and a negative predictive value of 84.3% (CI: 77-90) in overall patients, and with a sensitivity of 75.0% (CI: 63-84), a specificity of 84.9% (CI: 75-90), a positive predictive value of 77.5% (CI: 63-88) and a negative predictive value of 84.3% (CI: 74-91) when excluding cardiac arrest. CONCLUSION: It is worth including SEPs, in association with other investigations and clinical signs, in prognostic scores of BD. The early identification of patients at high risk of evolving towards BD could help physicians to optimise management.

Extracorporeal life support and multiorgan donation in a severe polytrauma patient: A case report.

INTRODUCTION: Organ availability represents a key factor in transplants due to an almost universal shortage of deceased donors. PRESENTATION OF CASE: We present the case of a 41-year-old patients with severe polytrauma, where extracorporeal life support (ECLS) allowed brain death (BD) declaration and multiorgan retrieval and transplantation. DISCUSSION: Organ procurement is of utmost importance for transplant procedures. The presented case could rise ethical doubts as ECLS could be viewed as a tool for organ preservation instead of patient support. Nonetheless, it is obvious how organ preservation represents the necessary condition for patient preservation. CONCLUSION: Besides it' role in non heart beating donors, ECLS is emerging as an adjunctive tool for brain dead donors management when standard treatment fails, potentially allowing a substantial increase in organ availability.

Upper G.I. hemorrhage from glass fragments' ingestion in a patient with jejunal diverticula - Case report.

INTRODUCTION: Acute upper gastrointestinal bleeding is a common emergency. The ingestion of foreign bodies represents a less frequent cause of bleeding, but it is equally life-threatening, especially if the patient does not report the incident. PRESENTATION OF CASE: We are reporting the case of a 77-year-old patient with a bleeding caused by ingestion of glass fragments with co-existing jejunal diverticula. DISCUSSION: The ingestion of foreign bodies is a rare, mostly accidental event. Another possible source of upper G.I. bleeding is jejunal diverticula; in this case, the examination of the specimens showed evidence of glass ingestion fragments as the likely cause of bleeding. CONCLUSION: Surgeons should be aware that patients may fail to report correctly on the possible causes of bleeding, misleading the diagnosis, and delaying the diagnostic routes.

Early intra-intensive care unit psychological intervention promotes recovery from post traumatic stress disorders, anxiety and depression symptoms in critically ill patients.

INTRODUCTION: Critically ill patients who require intensive care unit (ICU) treatment may experience psychological distress with increasing development of psychological disorders and related morbidity. Our aim was to determine whether intra-ICU clinical psychologist interventions decrease the prevalence of anxiety, depression and posttraumatic stress disorder (PTSD) after 12 months from ICU discharge. METHODS: Our observational study included critical patients admitted before clinical psychologist intervention (control group) and patients who were involved in a clinical psychologist program (intervention group). The Hospital Anxiety and Depression Scale (HADS) and Impact of Event Scale-Revised questionnaires were used to assess the level of posttraumatic stress, anxiety and depression symptoms. RESULTS: The control and intervention groups showed similar demographic and clinical characteristics. Patients in the intervention group showed lower rates of anxiety (8.9% vs. 17.4%) and depression (6.5% vs. 12.8%) than the control group on the basis of HADS scores, even if the differences were not statistically significant. High risk for PTSD was significantly lower in patients receiving early clinical psychologist support than in the control group (21.1% vs. 57%; P < 0.0001). The percentage of patients who needed psychiatric medications at 12 months was significantly higher in the control group than in the patient group (41.7% vs. 8.1%; P < 0.0001). CONCLUSIONS: Our results suggest that that early intra-ICU clinical psychologist intervention may help critically ill trauma patients recover from this stressful experience.

Diagnosis of carotid arterial injury in major trauma using a modification of Memphis criteria.

BACKGROUND: Incidence of Blunt Cerebrovascular Injuries (BCVI) after head injury has been reported as 0.5-1% of all admissions for blunt trauma, with a high stroke and mortality rate. The purpose of this study is to evaluate if a modification of Memphis criteria could improve the rate of BCVI diagnosis. METHODS: Trauma patients consecutively admitted to Intensive Care Unit (ICU) from Jan 2008 to Oct 2009 were considered for the study. Memphis criteria comprehend: basilar skull fracture with involvement of the carotid canal, cervical spine fracture, neurological exam not explained by brain imaging, Horner's syndrome, LeFort II-III fractures, and neck soft tissue injury. As single criteria modification, we included all patients with petrous bone fracture, even without carotid canal involvement. In all patients at risk of BCVI, 64-slice angio-CT-scans was performed. RESULTS: During the study period, 266 patients were admitted to the ICU for blunt major trauma. Among them, 162 presented traumatic brain injury or cervical spine fracture. In accordance with the proposed modified-Memphis criteria, 53 patients showed risk factors for BCVI compared to 45 using the original Memphis criteria. Among the 53 patients, 6 resulted as having carotid lesions (2.2% of all blunt major traumas; one patient more than when using Memphis criteria). Anticoagulant therapy with low molecular weight heparin was administered in all patients. No stroke or hemorrhagic complications occurred. Clinical examination at 6-months showed no central neurological deficit. CONCLUSION: A modification of a single criteria of Memphis screening protocol might permit the identification of a higher percentage of BCVI. Limited by sample size, this study needs to be validated.