Sandralee Blosser

The circulatory-respiratory determination of death in organ donation

Objective:Death statutes permit physicians to declare death on the basis of irreversible cessation of circulatory–respiratory or brain functions. The growing practice of organ donation after circulatory determination of death now requires physicians to exercise greater specificity in circulatory–respiratory death determination. We studied circulatory–respiratory death determination to clarify its concept, practice, and application to innovative circulatory determination of death protocols. Results:It is ethically and legally appropriate to procure organs when permanent cessation (will not return) of circulation and respiration has occurred but before irreversible cessation (cannot return) has occurred because permanent cessation: 1) is an established medical practice standard for determining death; 2) is the meaning of “irreversible” in the Uniform Determination of Death Act; and 3) does not violate the “Dead Donor Rule.” Conclusions:The use of unmodified extracorporeal membrane oxygenation in the circulatory determination of death donor after death is declared should be abandoned because, by restoring brain circulation, it retroactively negates the previous death determination. Modifications of extracorporeal membrane oxygenation that avoid this problem by excluding brain circulation are contrived, invasive, and, if used, should require consent of surrogates. Heart donation in circulatory determination of death is acceptable if proper standards are followed to declare donor death after establishing the permanent cessation of circulation. Pending additional data on “auto-resuscitation,” we recommend that all circulatory determination of death programs should utilize the prevailing standard of 2 to 5 mins of demonstrated mechanical asystole before declaring death.

Do autopsies of critically ill patients reveal important findings that were clinically undetected

OBJECTIVE To determine if autopsies performed on patients who die in the medical intensive care unit (ICU) provide clinically important new information. DESIGN Retrospective review. SETTING A 16-bed medical-coronary ICU. PATIENTS Patients who underwent autopsy during a 1-yr period. INTERVENTIONS Pre mortem diagnoses were determined from the medical record. Autopsy results were obtained from the final pathology report. A panel of three physicians with certification of added qualifications in critical care medicine reviewed the findings. MEASUREMENTS AND MAIN RESULTS These questions were asked: a) Is the primary clinical diagnosis confirmed? b) Are the clinical and pathologic causes of death the same? c) Are new active diagnoses revealed? and d) If the new findings had been known before death, would the clinical management have differed? Forty-one autopsies (31% of deaths) were done that showed: a) the same primary clinical diagnosis and post mortem diagnosis in 34 (83%) patients; b) the same clinical and pathologic cause of death in 27 (66%) patients; c) new active diagnoses in 37 (90%) patients; and d) findings that would have changed medical ICU therapy had the findings been known in 11 (27%) patients. CONCLUSIONS Although the primary clinical diagnosis was accurate in most cases before death, the cause of death was frequently unknown. Almost all autopsies demonstrated new diagnoses, and knowledge of these new findings would have changed medical ICU therapy in many cases. In the critical care setting, autopsies continue to provide information that could be important for education and quality patient care.

Management of the Potential Organ Donor in the ICU: Society of Critical Care Medicine/American College of Chest Physicians/Association of Organ Procurement Organizations Consensus Statement

This document was developed through the collaborative efforts of the Society of Critical Care Medicine, the American College of Chest Physicians, and the Association of Organ Procurement Organizations. Under the auspices of these societies, a multidisciplinary, multi-institutional task force was convened, incorporating expertise in critical care medicine, organ donor management, and transplantation. Members of the task force were divided into 13 subcommittees, each focused on one of the following general or organ-specific areas: death determination using neurologic criteria, donation after circulatory death determination, authorization process, general contraindications to donation, hemodynamic management, endocrine dysfunction and hormone replacement therapy, pediatric donor management, cardiac donation, lung donation, liver donation, kidney donation, small bowel donation, and pancreas donation. Subcommittees were charged with generating a series of management-related questions related to their topic. For each question, subcommittees provided a summary of relevant literature and specific recommendations. The specific recommendations were approved by all members of the task force and then assembled into a complete document. Because the available literature was overwhelmingly comprised of observational studies and case series, representing low-quality evidence, a decision was made that the document would assume the form of a consensus statement rather than a formally graded guideline. The goal of this document is to provide critical care practitioners with essential information and practical recommendations related to management of the potential organ donor, based on the available literature and expert consensus.

ICU Admission, Discharge, and Triage Guidelines: A Framework to Enhance Clinical Operations, Development of Institutional Policies, and Further Research.

Objectives:To update the Society of Critical Care Medicine’s guidelines for ICU admission, discharge, and triage, providing a framework for clinical practice, the development of institutional policies, and further research. Design:An appointed Task Force followed a standard, systematic, and evidence-based approach in reviewing the literature to develop these guidelines. Measurements and Main Results:The assessment of the evidence and recommendations was based on the principles of the Grading of Recommendations Assessment, Development and Evaluation system. The general subject was addressed in sections: admission criteria and benefits of different levels of care, triage, discharge timing and strategies, use of outreach programs to supplement ICU care, quality assurance/improvement and metrics, nonbeneficial treatment in the ICU, and rationing considerations. The literature searches yielded 2,404 articles published from January 1998 to October 2013 for review. Following the appraisal of the literature, discussion, and consensus, recommendations were written. Conclusion:Although these are administrative guidelines, the subjects addressed encompass complex ethical and medico-legal aspects of patient care that affect daily clinical practice. A limited amount of high-quality evidence made it difficult to answer all the questions asked related to ICU admission, discharge, and triage. Despite these limitations, the members of the Task Force believe that these recommendations provide a comprehensive framework to guide practitioners in making informed decisions during the admission, discharge, and triage process as well as in resolving issues of nonbeneficial treatment and rationing. We need to further develop preventive strategies to reduce the burden of critical illness, educate our noncritical care colleagues about these interventions, and improve our outreach, developing early identification and intervention systems.

Validation of a 5-minute steady state indirect calorimetry protocol for resting energy expenditure in critically ill patients.

OBJECTIVE Numerous protocols are used for indirect calorimetry in research and clinical settings. The objective of the current study was to validate in critically ill patients an abbreviated protocol that uses five consecutive stable 1-minute readings of oxygen consumption (VO2), carbon dioxide production (VCO2), and minute ventilation (VE) in a range of +/- 5%, versus a more standard protocol that uses 30 consecutive stable one minute readings of VO2, VCO2, and VE in a range of +/- 10%. METHODS Indirect calorimetry was performed on resting, mechanically ventilated, critically ill patients. The first 5-minute period in which coefficients of variation for VO2, VCO2, and VE were < or = 5% was compared to the first 30-minute period in which coefficients of variation for these variables were < or = 10%. RESULTS Thirty-four critically ill patients were studied. Twenty four patients (70%) successfully completed both protocols (Success Group). Eighteen percent of subjects completed neither the abbreviated nor the 30 minute protocol, and 12% completed only one protocol (Fail Group). The Success Group was marked by a higher incidence of sedation and/or medical paralysis. There were no significant differences in VE, VO2, VCO2, respiratory quotient, or energy expenditure between the protocols in the Success Group or the Fail Group. Coefficients of determination (R2) for VO2 and VCO2 between the two methods in the Success Group were 0.99. In the Fail Group, R2 values ranged from 0.75 for VCO2 to 0.91 for VO2. CONCLUSION In sedated, mechanically ventilated patients, an indirect calorimetry test of five consecutive 1-minute periods with coefficient of variation < or = 5% is equivalent to a longer test consisting of 30 consecutive 1-minute periods with coefficient of variation < or = 10%.

Relative association of fever and injury with hypermetabolism in critically ill patients

The purpose of this study was to determine the association of injury type (trauma, surgery, medical disease), systemic inflammatory response syndrome (SIRS) and fever with the degree of hypermetabolism in critically ill patients. Medical records of 204 critically ill, mechanically ventilated injured, surgical and medical patients were reviewed for indirect calorimetry and associated data. Analysis of variance and covariance was used to test the effects of injury, fever and SIRS on the degree of hypermetabolism. All injury types were found to be hypermetabolic. Analysis of variance of hypermetabolism with injury type and presence of fever as main effects revealed a significant increase in hypermetabolic response from fever, of similar magnitude across all injury types. Subjects with SIRS were significantly more hypermetabolic than subjects without SIRS. However, analysis of variance indicated no effect for SIRS but a significant effect for fever in increasing the hypermetabolic response. It is concluded that fever portends a magnification of the hypermetabolic response, being similar across injury types. SIRS does not identify hypermetabolic patients independent of fever. The host response to injury, not the injury itself, determines metabolic rate in critically ill patients. Neither SIRS nor injury type should be used to classify hypermetabolic states without stratifying for presence of fever.

Central venous pressure measurements: peripherally inserted catheters versus centrally inserted catheters.

ObjectiveTo determine whether central venous pressure measurements taken from a peripherally inserted central catheter (PICC) correlate with those from a centrally inserted central catheter (CICC). DesignA pilot bench study followed by a prospective, nonblinded, clinical comparison. SettingA 16-bed medical coronary intensive care unit and a 30-bed surgical intensive care unit at a university hospital. PatientsSeven surgical intensive care unit patients and five medical coronary intensive care unit patients. InterventionsDuring the bench study, a simple manometer system was set up to test the catheters. During the clinical study, measurements of central venous pressure were recorded from patients who had an indwelling CICC and PICC concomitantly. Positions of the catheter tips in the chest were verified by radiography. Paired central venous pressure measurements were taken from 19-gauge dual-lumen PICCs and from 7-Fr, 16-gauge, 18-gauge, and pulmonary artery catheter CICCs, all with continuous pressure infusion devices. Measurements and Main ResultsBench work showed that PICCs, because of their longer length and narrower lumen, have a higher inherent resistance, which can be overcome with a continuous infusion device. During the clinical study, three to 12 paired, digital, central venous pressure measurements were recorded from each of 12 patients for a total of 77 data pairs. Measurements were recorded at end-expiration. Mean central venous pressure from the CICCs was 11 ± 7 mm Hg, and from the PICCs was 12 ± 7 mm Hg. PICC pressure versus CICC pressure correlated (r = 0.99) for all data pairs. Analysis by repeated measures showed PICC central venous pressure more than CICC central venous pressure by 1.0 ± 3.2 mm Hg (p = 0.02). ConclusionsPICCs can be used to measure central venous pressure and to follow trends in a clinical setting when used with a pressure infusion device to overcome the natural resistance of the PICC. Central venous pressure recorded via PICCs is slightly higher, but the difference is clinically insignificant.

Circulatory Death Determination in Uncontrolled Organ Donors: A Panel Viewpoint

One barrier for implementing programs of uncontrolled organ donation after the circulatory determination of death is the lack of consensus on the precise moment of death. Our panel was convened to study this question after we performed a similar analysis on the moment of death in controlled organ donation after the circulatory determination of death. We concluded that death could be determined by showing the permanent or irreversible cessation of circulation and respiration. Circulatory irreversibility may be presumed when optimal cardiopulmonary resuscitation efforts have failed to restore circulation and at least a 7-minute period has elapsed thereafter during which autoresuscitation to restored circulation could occur. We advise against the use of postmortem organ support technologies that reestablish circulation of warm oxygenated blood because of their risk of retroactively invalidating the required conditions on which death was declared.

Recommendations for the Critical Care Management of Devastating Brain Injury: Prognostication, Psychosocial, and Ethical Management

Devastating brain injuries (DBIs) profoundly damage cerebral function and frequently cause death. DBI survivors admitted to critical care will suffer both intracranial and extracranial effects from their brain injury. The indicators of quality care in DBI are not completely defined, and despite best efforts many patients will not survive, although others may have better outcomes than originally anticipated. Inaccuracies in prognostication can result in premature termination of life support, thereby biasing outcomes research and creating a self-fulfilling cycle where the predicted course is almost invariably dismal. Because of the potential complexities and controversies involved in the management of devastating brain injury, the Neurocritical Care Society organized a panel of expert clinicians from neurocritical care, neuroanesthesia, neurology, neurosurgery, emergency medicine, nursing, and pharmacy to develop an evidence-based guideline with practice recommendations. The panel intends for this guideline to be used by critical care physicians, neurologists, emergency physicians, and other health professionals, with specific emphasis on management during the first 72-h post-injury. Following an extensive literature review, the panel used the GRADE methodology to evaluate the robustness of the data. They made actionable recommendations based on the quality of evidence, as well as on considerations of risk: benefit ratios, cost, and user preference. The panel generated recommendations regarding prognostication, psychosocial issues, and ethical considerations.

Recommendations for the critical care management of devastating brain injury: prognostication, psychosocial, and ethical management : a position statement for healthcare professionals from the neurocritical care society

Devastating brain injuries (DBIs) profoundly damage cerebral function and frequently cause death. DBI survivors admitted to critical care will suffer both intracranial and extracranial effects from their brain injury. The indicators of quality care in DBI are not completely defined, and despite best efforts many patients will not survive, although others may have better outcomes than originally anticipated. Inaccuracies in prognostication can result in premature termination of life support, thereby biasing outcomes research and creating a self-fulfilling cycle where the predicted course is almost invariably dismal. Because of the potential complexities and controversies involved in the management of devastating brain injury, the Neurocritical Care Society organized a panel of expert clinicians from neurocritical care, neuroanesthesia, neurology, neurosurgery, emergency medicine, nursing, and pharmacy to develop an evidence-based guideline with practice recommendations. The panel intends for this guideline to be used by critical care physicians, neurologists, emergency physicians, and other health professionals, with specific emphasis on management during the first 72-h post-injury. Following an extensive literature review, the panel used the GRADE methodology to evaluate the robustness of the data. They made actionable recommendations based on the quality of evidence, as well as on considerations of risk: benefit ratios, cost, and user preference. The panel generated recommendations regarding prognostication, psychosocial issues, and ethical considerations.