Prediction of the Evolution to Brain Death in the Neurocritical Patient: SPN Model Showed Better Performance Than Simplified Acute Physiology Score II and Acute Physiology and Chronic Health Evaluation II.

The detection of brain death (BD) plays a fundamental role in the management of hospital donation. Delayed diagnosis of BD is the main cause of donor loss. A tool for monitoring and prognosis in the neurocritical patient is essential to meet these objectives. The most used prognostic scores in intensive care units are Simplified Acute Physiology Score (SAPS) II and Acute Physiology and Chronic Health Evaluation (APACHE) II. A predictive model of good performance (ModSPN) in predicting BD in neurocritical patients with Glasgow Coma Scale score < 8 was published in 2014. With the objective of analyzing the predictive capacity of ModSPN and comparing it with SAPS II and APACHE II, 2307 patients admitted to the neurocritical patient monitoring (SPN) program of the INDT were analyzed. The predictive capacity for death and brain death of SAPS II, APACHE II, and ModSPN was compared using receiver operating characteristic curves. The area under the curve showed a better APACHE II performance for the prediction of death and the ModSPN being a better predictor of the probability of dying in BD. Therefore, for the prediction of death in the neurocritical patient, APACHE II was superior, but for the prediction of encephalic death, the ModSPN presented the best predictive power for all causes of brain injury.

Epidemiologic and Evolutionary Profile of Patients With Subarachnoid Hemorrhage With Glasgow Coma Scale Score of 8 or Less Who Entered the Follow-Up Program of the National Institute of Donation and Transplantation.

INTRODUCTION: The improvement in understanding the process that determines the death of an individual and his or her evolution toward brain death allows organization and planning of health policies, optimization of clinical activity and management of organ and tissue procurement processes for transplantation. OBJECTIVE: This study sought to analyze the epidemiological and evolutionary profile of patients with spontaneous subarachnoid hemorrhage (SAH) with a Glasgow Coma Scale score (GCS) ≤8 who entered follow-up in the Neurocritical Patient Monitoring Program (SPN) of Instituto Nacional de Donación y Trasplante (INDT), Uruguay. MATERIALS AND METHODS: SPN, a monitoring and follow-up program for neurocritical patients with GCS ≤ 8, prospectively collected data from 5 public and private intensive care units. A total of 160 patients with SAH with GCS ≤8 in 10 years were identified and analyzed using a 2-step nested model. Firstly, independent risk factors for mortality were identified, tested in different combinations, and one of them was selected using the best correct classification rate. In the second step, risk factors for evolution to brain death were investigated. RESULTS: The mortality of patients with SAH with GCS ≤8 was 68%. Mortality for GCS 3 was 82%, significantly higher than for other values on the scale (P = .0025). Female sex (P = .011) and arterial hypertension (P = .017) were associated with higher mortality. There was no significant association between mortality and age, Acute Physiology and Chronic Health Evaluation score, and Simplified Acute Physiologic Score II. Administration of analgesia and/or sedation was a protective factor (P < .0001). Of the patients who died, 50% were in brain death. We did not find clinical elements capable of identifying an increased probability of developing brain death. CONCLUSIONS: Based on epidemiological data, models capable of improving the understanding of the complex process of death and particularly brain death can be generated. More studies are needed to explore the differential evolutionary behavior of critical neurological illness.

Donation rates: what matters?

INTRODUCTION: The increase in the number of donors is the main objective of all transplantation organizations around the world. Further understanding of the factors involved in increasing donation rates is very important for planning future strategies to improve outcomes in each country. OBJECTIVE AND METHOD: With this purpose we analyzed the relationship between social and economic factors of the countries and organizational aspects of health systems and institutions dedicated to transplantation in relation to the number of actual donors per million population. We analyzed rates of deceased donors per million population of Latin America, North America, and Europe (20 countries) and correlated them with the human development index and its most important indicators. We also studied the correlation with spending on health and organizational aspects of the health system. RESULTS: On the one hand, we found that donation rates (DRs) per million population (pmp) were not statistically significantly correlated with the human development index (significant correlation 0.61 and 0.181). There is a correlation, albeit weak, between observed donation rates and gross domestic product (GDP) of each country (significance, 0.04; correlation, 0.46). On the other hand, there exists a strong correlation between the percentage of GDP spent on health and DRs pmp (significance, 0.01; correlation, 0.53). Those countries with an integrated national health system (P = .01) and a higher percentage of hospitals with intrahospital transplantation coordinators (P = .001) had higher DRs pmp. CONCLUSIONS: The best DRs are closely linked to organizational aspects of the donation system in particular and the health system in general. There is a weak correlation between observed DRs and socio-economic and development indicators of countries. These data should be taken into account in planning future strategies to increase DRs, health plan policies, and investments.

A model to predict progression in brain-injured patients.

INTRODUCTION: The study of brain death (BD) epidemiology and the acute brain injury (ABI) progression profile is important to improve public health programs, organ procurement strategies, and intensive care unit (ICU) protocols. The purpose of this study was to analyze the ABI progression profile among patients admitted to ICUs with a Glasgow Coma Score (GCS) ≤8, as well as establishing a prediction model of probability of death and BD. MATERIALS AND METHODS: This was a retrospective analysis of prospective data that included all brain-injured patients with GCS ≤8 admitted to a total of four public and private ICUs in Uruguay (N = 1447). The independent predictor factors of death and BD were studied using logistic regression analysis. A hierarchical model consisting of 2 nested logit regression models was then created. With these models, the probabilities of death, BD, and death by cardiorespiratory arrest were analyzed. RESULTS: In the first regression, we observed that as the GCS decreased and age increased, the probability of death rose. Each additional year of age increased the probability of death by 0.014. In the second model, however, BD risk decreased with each year of age. The presence of swelling, mass effect, and/or space-occupying lesion increased BD risk for the same given GCS. In the presence of injuries compatible with intracranial hypertension, age behaved as a protective factor that reduced the probability of BD. CONCLUSIONS: Based on the analysis of the local epidemiology, a model to predict the probability of death and BD can be developed. The organ potential donation of a country, region, or hospital can be predicted on the basis of this model, customizing it to each specific situation.