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.

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.

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 β 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 β-receptor stimulation and preemptive blockade of β receptors or calcium channels before brain death may be relevant to donor care.

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.

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.

Tetraspanin CD9 in cell migration.

Tetraspanin CD9 is associated with integrin adhesion receptors and it was reported that CD9 regulates integrin-dependent cell migration and invasion. Pro- and anti-migratory effects of CD9 have been linked to adhesion-dependent signalling pathways, including phosphorylation of FAK (focal adhesion kinase) and activation of phosphoinositide 3-kinase, p38 MAPK (mitogen-activated protein kinase) and JNK (c-Jun N-terminal kinase). In the present paper, we describe a novel mechanism whereby CD9 specifically controls localization of talin1, one of the critical regulators of integrin activation, to focal adhesions: CD9-deficiency leads to impaired localization of talin1 to focal adhesions and correlates with increased motility of breast cancer cells.

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.

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.

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.

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).

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.

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.

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.

Increased plasma interleukin-6 in donors is associated with lower recipient hospital-free survival after cadaveric organ transplantation.

Objectives: Brain death induces a massive inflammatory response. However, the influence of this inflammatory response on organ procurement, transplantation, and recipient outcome is unknown. We describe the inflammatory response characteristics in brain-dead organ donors and examine associations with organ transplantation and recipient survival.

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.

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.

Bacterial infection during adult donor care.

Assessment, prevention, and treatment of bacterial infection in donors are critically important to the welfare of grafts and recipients after transplantation. Transmission of bacterial, viral, fungal, and protozoan infections from a donor to recipient(s) has been documented to have serious or fatal consequences. This article reviews issues of bacterial infection only.

Feasibility study of cytokine removal by hemoadsorption in brain-dead humans.

Background: Inflammatory cytokines occur in the circulation and in the tissues after brain death and have been associated with dysfunction of donor organs before and after transplantation.

Objective: To determine the feasibility of removing cytokines using a hemoadsorption device.

Design: Two-center, randomized, open-label, feasibility study in which brain-dead subjects were randomized to two treatment groups.

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.

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.