Randomized trial to evaluate nutritional status and absorption of enteral feeding after brain death.

CONTEXT: Catecholamines and inflammatory mediators, with elevated levels after brain death, are associated with reduced function and survival of transplanted organs. Enteral nutrition reduces tissue damage and may benefit organs. OBJECTIVE: To evaluate the effects of immunomodulating enteral nutrition in organ donors. DESIGN: Prospective, randomized, open-label study. SETTING: Intensive care unit. PATIENTS: Thirty-six brain-dead organ donors. INTERVENTIONS: Donors were randomized to receive enteral nutrition containing omega-3 polyunsaturated fatty acid, antioxidants, and glutamine or standard care (fasting). Donors received hormonal replacement therapy of corticosteroid, levothyroxine, dextrose, and insulin. MAIN OUTCOME MEASURES: Gastrointestinal assimilation (measured by 13 carbon-labeled uracil breath analysis), quantity of organs recovered, resting energy expenditure, urine level of urea nitrogen, and serum levels of albumin, prealbumin, interleukin 6, tumor necrosis factor-α, and C-reactive protein were evaluated. RESULTS: Thirteen patients (36%) assimilated 13C-labeled uracil. Resting energy expenditure was significantly higher than predicted between 10 and 14 hours after baseline in 33 donors (P= .007). Other measures were not conclusively different between fed and fasting groups. No adverse events occurred that were related to the enteral feeding. CONCLUSIONS: About 30% of donors metabolized 13C-labeled uracil, although no difference in oxidation rate was found between fasting and fed donors. Corticosteroid administration lowers plasma levels of interleukin 6 and most likely contributes to greater than predicted resting energy expenditure. Thus energy needs may not be met during fasting if hormones are given. Consequences of this possible energy deficit warrant further study.

Introduction to genetic processes in transplantation.

Recent investigations have explored how analyses of genetic DNA from organ donors and recipients may be helpful during organ allocation so as to reduce graft rejection or improve dosing of immunosuppressive medications. This discussion reviews those data and the processes by which genetic coding controls the production of protein that is important in cellular structure and function during donor and recipient care. Changes in gene structure (polymorphisms or mutations) may occur spontaneously or as a result of cell interactions with environmental factors, and may be associated with recognized diseases or, potentially, could reduce or worsen graft rejection.

Advanced assessment of platelet function during adult donor care.

Abnormal platelet function may complicate the assessment and treatment of continuing blood loss, hypotension, and coagulation disorders during adult donor care. Antiplatelet drugs, such as aspirin, nonsteroidal anti-inflammatory drugs, clopidogrel (Plavix), ticlopidine (Ticlid), prasugrel (Effient), abciximab (ReoPro), eptifibatide (Integrilin), and tirofiban (Aggrastat) are commonly prescribed for older patients. These medications may be part of home therapy or may be given during acute cardiac or cerebrovascular crises that may lead to brain death and organ donation. This discussion reviews normal platelet formation and function, drug actions, methods to evaluate medication effects, pharmacological characteristics, treatment recommendations for platelet transfusion, and risks attendant with those infusions.

Measurement of cardiac output during adult donor care.

Measurement of cardiac output may improve hemodynamic management in donor care. Selected traditional and more recent methods to quantify cardiac output are reviewed. The accuracy or concordance of these newer methods when compared with thermodilution techniques that use a pulmonary artery catheter-the current reference standard-is discussed. Data directly comparing these systems for measuring cardiac output in the donor population are unavailable. However, data from groups of hemodynamically unstable patients favor selection of a measurement method that permits comparison (calibration) with a reference standard. A prospective comparison of all methods against the pulmonary artery catheter thermodilution technique among donors would provide the best data to resolve this clinical and potentially cost-important question.

In my opinion: serum albumin should be maintained during neurocritical care.

Hypoalbuminemia is common among critically ill/injured patients and is strongly associated with increased morbidity and mortality in the patients with and without neurological conditions. Normal serum albumin is important as the primary intravascular antioxidant, in transporting a variety of hormones, medications and electrolytes, in providing colloid osmotic pressure during trans-compartmental fluid movement, in enhancing organ and tissue blood flow, and in supporting acid-base balance. Studies of albumin administration during intravascular resuscitation have not addressed potential longer term benefits to sustaining serum albumin concentrations during critical care. Evidence for such benefit is present although additional prospective studies are needed.

Takotsubo cardiomyopathy: its possible impact during adult donor care.

Takotsubo cardiomyopathy, the syndrome caused by an extreme release and circulation of catecholamines, shares several histopathological and clinical similarities with cardiac changes after brain death noted in animal investigations and human observation. Overwhelming stimulation of myocardial inotropic ß receptors may alter their responsiveness and induce other biochemical processes, producing reduced cardiac contractility. Treatment methods in Takotsubo cardiomyopathy that use extracorporeal circulatory support and medications that do not rely on ß-receptor stimulation and preemptive blockade of ß receptors or calcium channels before brain death may be relevant to donor care.

Differential lung ventilation during adult donor care.

Differential lung ventilation may be required when one lung is injured or affected more than the other lung following, for example, aspiration, crush injury, or selective pneumonia, or if lung rupture results in formation of a bronchopleural fistula. Unilateral lung failure causes increased ventilation-perfusion mismatching that often leads to severe hypoxemia. Treatment may include careful attention to ventilator parameters to avoid overdistention of the less-affected lung or lateral decubitus positioning of the donor with the less-affected lung down (gravitationally dependent position). Under extreme conditions, use of a specialized double-lumen endotracheal tube and separate ventilators with individualized parameters for each lung is required to provide adequate oxygenation and ventilation for organ preservation.

Airway pressure release ventilation during adult donor care.

Airway pressure release ventilation is most commonly used during donor care to treat hypoxemia and to avoid high peak airway pressure. The traditional concept of cyclic inhalation/exhalation is replaced by a continuous positive airway inflation interspersed by brief episodes in which the positive pressure is reduced. The variables, Pressure-high, Pressure-low, Time-high, and Time-low, are manipulated to ensure adequate donor oxygenation and carbon dioxide removal. Organ procurement coordinators may find this method of mechanical ventilation in place when donor care is assumed or initiate it as a useful tool in providing donor support.

Thromboelastography during adult donor care.

Thromboelastography is a test of blood coagulation used to evaluate all components of clot formation and possible abnormal clot dissolution. It supplements traditional laboratory testing by demonstrating the integration of coagulation factors, platelets (number and function), and other factors during coagulation. Analysis of abnormalities demonstrated by thromboelastography can guide organ procurement coordinators in titrating appropriate quantities of fresh frozen plasma, cryoprecipitate, or platelet transfusions during treatment of coagulation in adult donors.

Technical aspects of intravascular pressure monitoring during donor care.

Many biological signals must be measured and interpreted accurately to titrate therapy properly during donor care. Although the technological aspects of intravascular pressure monitoring are usually delegated to bedside nursing colleagues, organ procurement coordinators should be familiar with those devices and methods. The equipment, supplies, and procedures used for arterial and central venous pressure monitoring are reviewed. Transducer leveling and zeroing plus maintenance of the hydraulic tubing system between the transducer and bedside monitor are especially important. These variables may greatly influence the accuracy of the displayed pressures and, therefore, must be considered during donor assessment as treatment is considered.

Sperm retrieval during critical illness.

Objective of this study is to review technical methods to retrieve sperm from critically ill/injured patients after an appropriate family request, possible harmful effects on sperm production/function by ICU medications or concurrent illnesses, and ethical considerations for hospitals and care providers in providing this resource. Design used for this study includes: literature review, PubMed 1998-2009, and authors' files. There are no interventions. In conclusion, although successful and unsuccessful pregnancies following sperm removal from critically-ill patients are reported, no firm probability predictions for either result are known. Acute and chronic diseases that effect the hypothalamic-pituitary-gonadal axis and multiple medications common to the ICU may reduce sperm production or function. Retrieval methods before and after cardio-respiratory death differ and often require intracytoplasmic sperm injection or other in vitro fertilization techniques to achieve a subsequent pregnancy. The proactive development of a collaborative policy/procedure to identify appropriate roles for the hospital, its employees, and affiliated critical care and urology physicians is strongly recommended.

Central venous oxygen saturation monitoring: role in adult donor care?

Monitoring oxygen saturation of blood drawn from a catheter placed within the superior vena cava (Scvo2) has recently been promoted as a substitute for evaluating oxygen saturation of mixed venous blood drawn from the pulmonary artery (Svo2). The Svo2 reflects the balance between oxygen delivery and oxygen consumption throughout the body and, among critically ill patients, may be helpful for assessing resuscitation, cardiac function, or oxygen homeostasis end points. Use of Scvo2 instead has been promoted because of its easier access and recent use during resuscitation of patients with severe infections. Although data from healthy subjects and critically ill patients are available, no study has been done among organ donors to evaluate customary values for either Scvo2 or Svo2 or how well the values correspond. After loss of oxygen consumption in the brain following brain death, the customary values for these variables may be different from values in other groups of patients. Therefore, until donor-specific normative values for these important parameters are identified, we do not recommend that Scvo2 be used to evaluate the balance between donor oxygen consumption and delivery or as a variable to guide treatment.

An introduction to the electrocardiogram during adult donor care.

Organ procurement coordinators use continuous monitoring of the electrocardiographic rhythm from the donor's heart during bedside care. Similarly, organ procurement coordinators are often asked to report interpretations of 12-lead electrocardiograms provided by hospital cardiologists. To aid in these important functions, this article describes the biochemical bases of electrocardiograms and alterations in electrocardiograms caused by common electrolyte disorders, hypothermia, and myocardial ischemia that may occur during donor care.

An occlusal guard for preventing and treating self-inflicted tongue trauma in a comatose patient: a clinical report.

This clinical report describes the treatment of a 48-year-old patient who demonstrated neuropathologic and reflex mastication of her tongue after an intracerebral hemorrhage. Standard medical interventions failed to address the oral condition, and the attending neurosurgeon consulted the dental team. A provisional soft occlusal guard was initially placed, followed by fabrication of a heat-polymerized, acrylic resin occlusal guard. The tongue injury improved after placement of the oral device and administration of systemic hydrocortisone.

Adrenal insufficiency following traumatic brain injury in adults.

PURPOSE OF REVIEW: Hypoadrenalism occurs in approximately 25% of patients soon after traumatic brain injury. Neurosurgeons or critical care physicians should be prepared to diagnose and treat this and other related hormonal deficiencies. RECENT FINDINGS: The severity of traumatic brain injury, location of basilar skull fractures and edema or hemorrhage within the hypothalamic-pituitary axis appear correlated with secondary adrenal failure. Primary hypoadrenalism also may occur due to injury-related systemic inflammation. Hypotension requiring vasoactive drug support, hyponatremia and hypoglycemia may be corresponding clinical signs. Evaluation of either primary or secondary hypoadrenalism should include measurement of basal and post-adrenocorticotropin stimulation cortisol blood concentrations. If the basal cortisol is under 15 microg/dl or increases by over 9 microg/dl after stimulation treatment should be considered. Intravenous hydrocortisone at 50-100 mg every 8 h or by continuous infusion is usually sufficient but may be supplemented with a mineralocorticoid if hyponatremia persists. All patients sustaining severe traumatic brain injury should be tested for endocrine failure (adrenal, thyroid and growth hormone) 3 months after injury. SUMMARY: Adrenal gland failure or the inability to produce adrenocorticotropin and other pituitary hormones may occur early after traumatic brain injury. Acute treatment of either cause of hypoadrenalism may correct associated hypotension, hypoglycemia, or hyponatremia.

Thrombocytosis in the NICU.

An elevated platelet count may occur during care of neurology/neurosurgical patients and is usually due to reactive or secondary thrombocytosis (ST) caused by inflammation or infection. Primary (clonal) thrombocythemia or essential thrombocythemia associated with myeloproliferative disorders is usually known before or during early patient assessment. Rarely, paraneoplastic causes of thrombocytosis may be discovered. Although no single test differentiates primary from secondary etiologies, laboratory tests that show increased acute phase responses, such as C-reactive protein, fibrinogen, erythrocyte sedimentation rate, and interleukin-6, may be useful in diagnosing ST. Thrombosis due to ST is rare in any platelet count. ST, however, should be considered within the overall risk assessment for thromboembolism in any patient. If treatment is initiated, low-dose aspirin is sufficient.

Postmortem intubation training: patient and family opinion.

OBJECTIVE: Endotracheal intubation is a life-saving skill which requires training to master. Learning opportunities for endotracheal intubation must be balanced with patient rights and intentions. This study was conducted to explore patient and family opinions about postmortem endotracheal intubation training. METHODS: We carried out an observational, cross-sectional survey study in an urban, teaching hospital, on the day of hospital discharge. Subjects were neurologically unimpaired neurosurgical patients discharged from hospital in 2004-2005, and their relatives. We carried out interviews using a standardised script to determine whether subjects would permit postmortem intubation training on themselves or relatives, and whether permission should be granted by relatives before training. RESULTS: A total of 85% of patient and family respondents would allow intubation training after death on themselves, 76% would allow endotracheal intubation to be practised on a relative, and 81% felt the deceased's next-of-kin should be asked for permission prior to endotracheal intubation training. Subjects responded consistently as to what they would allow on self and family. Knowledge that the deceased person would have agreed to his or her body being used in endotracheal intubation training increased their likelihood of granting permission for training (P = 0.008). White subjects were 4.6 times more likely than non-Whites to allow intubation training on themselves (P = 0.01). CONCLUSIONS: Patients and families are agreeable to postmortem intubation training; however, most expect to be asked for permission. Utilising existing mechanisms which communicate desired treatment, such as advance directives, hospital admissions documents, donor registries or community health fairs may facilitate training opportunities and altruistic patient intentions.

Hyponatremia and comparison of NT-pro-BNP concentrations in blood samples from jugular bulb and arterial sites after traumatic brain injury in adults: a pilot study.

BACKGROUND: Hyponatremia after traumatic brain injury (TBI) may influence neurological function and treatment. A causal relationship between elevated serum concentrations of Type B natriuretic peptide (BNP) and hyponatremia has been implied after subarachnoid hemorrhage and other neurosurgical disorders, although the source of BNP has not been identified. We evaluated if hyponatremia and increased BNP occur after TBI and if BNP is produced/released by the brain within 24 h after injury. RESULTS: NT-proBNP was measured in concomitant jugular venous and arterial blood samples within 24 h after TBI. NT-proBNP was elevated in both samples in six patients (24%). One patient (4%) showed an increased jugular NT-proBNP concentration above a normal arterial concentration, suggesting a brain source. In the other 24 patients the difference between jugular and arterial NT-proBNP was not statistically significant. Hyponatremia (< or =136 mEq/l) also occurred in six patients (24%), but only two (8%) had both increased arterial NT-proBNP and hyponatremia. In both the urine sodium was slightly elevated above normal, but not statistically different from other patients. The difference in serum sodium between hypo- and normo-natremic groups was significant, but mean NT-proBNP and jugular:arterial NT-proBNP differences were not. CONCLUSIONS: In this pilot study BNP is elevated within 24 h after TBI in some patients. However, it does not originate from the brain and increased NT-proBNP concentrations are not consistently associated with hyponatremia or increased urinary sodium loss.

Advanced practice organ procurement techniques: placement of pulmonary artery catheters.

Insertion of pulmonary artery catheters by organ procurement coordinators may be incorporated into donor management to optimize organ perfusion. As invasive procedures are added to coordinator roles, the organ procurement organization must include didactic instruction and supervised clinical experience as part of any training program. Policies and procedures guiding the use of the pulmonary artery catheter and the measurements obtained must be provided by the organization to guide practitioners. This article focuses on methods for insertion and basic troubleshooting of a pulmonary artery catheter.