Hyponatremia, volume status and blood pressure following aneurysmal subarachnoid hemorrhage

Patients who survive an aneurysmal subarachnoid hemorrhage (SAH) are endangered by complications, which especially occur during the first weeks after the hemorrhage. These complications have a high mortality and morbidity, and the outcome of patients with SAH will improve if these complications can be prevented or if the neurological deterioration caused by these complications can be reversed. To achieve this, it is of the utmost importance to distinguish between the different causes of deterioration after SAH. For instance, if a patient has an impaired level of consciousness a few days after the initial hemorrhage, while there were no abnormalities during the days before, this patient might have had a rebleed, cerebral ischemia, hydrocephalus or other, less common complications. In our department all such patients were under continuous observation in an intensive care unit. If a deterioration had occurred, the time course was documented, the patient was examined and a CT scan was repeated. The serum sodium levels were also measured in these patients, since it is known that hyponatremia may occur after SAH and can lead to neurological deficits. A low serum sodium level never appeared to be the direct cause of a deterioration, probably because the sodium levels decreased gradually and were never under 120 mmol/liter. However, we had the impression that patients with hyponatremia did worse than others. I decided to investigate whether SAH patients with hyponatremia did indeed have a particularly poor outcome, how and why hyponatremia develops and how it can be prevented. These questions are the subject of this thesis

A Disclosure About Death Disclosure: Variability in Circulatory Death Determination

Introduction. Circulatory-respiratory death declaration is a common duty of physicians, but little is known about the amount of education and physician practice patterns in completing this examination. Methods. We conducted an online survey of physicians evaluating the rate of formal training and specific examination techniques used in the pronouncement of circulatory-respiratory death. Data, including level of practice, training received in formal death declaration, and examination components were collected. Results. Respondents were attending physicians (52.4%), residents (30.2%), fellows (10.7%), and interns (6.7%). The majority of respondents indicated they had received no formal training in death pronouncement, however, most reported self-perceived competence. When comparing examination components used by our cohort, 95 different examination combinations were used for death pronouncement. Conclusions. Formal training in death pronouncement is uncommon and clinical practice varies. Implementation of formal training and standardization of the examination are necessary to improve physician competence and reliability in death declarations

Comparison of 1 vs 2 Brain Death Examinations on Time to Death Pronouncement and Organ Donation: A 12-year Single Center Experience

OBJECTIVE: To fill the evidence gap on the value of a single (SBD) or dual brain death (DBD) exam by providing data on irreversibility of brain function, organ donation consent and transplantation. METHODS: 12-year tertiary hospital and organ procurement organization data on brain death (BD) were combined and outcomes, including consent rate for organ donation and organs recovered and transplanted after SBD and DBD were compared after multiple adjustments for co-variates. RESULTS: two-hundred sixty-six patients were declared BD, 122 after SBD and 144 after DBD. Time from event to BD declaration was longer by an average of 20.9 hours after DBD (p=0.003). Seventy-five (73%) families of patients with SBD and 86 (72%) with DBD consented for organ donation (p=0.79). The number of BD exams was not a predictor for consent. No patient regained brain function during the periods following BD. Patients with SBD were more likely to have at least one lung transplanted (p = 0.033). The number of organs transplanted was associated with the number of exams [beta coefficient, (95% CI) -0.5 (-0.97 to -0.02), p=0.044], along with age (for 5 year increase, -0.36 (-0.43 to -0.29), p\u3c0.001) and PaO2 level (for 10 mmHg increase, 0.026 (0.008 to 0.044), p=0.005) and decreased as the elapsed time to BD declaration increased (p=0.019). CONCLUSIONS: A single neurologic examination to determine brain death is sufficient in patients with non-anoxic catastrophic brain injuries. A second examination is without additional yield in this group and its delay reduces the number of organs transplanted

Donor conversion rates depend on the assessment tools used in the evaluation of potential organ donors

Purpose: It is desirable to identify a potential organ donor (POD) as early as possible to achieve a donor conversion rate (DCR) as high as possible which is defined as the actual number of organ donors divided by the number of patients who are regarded as a potential organ donor. The DCR is calculated with different assessment tools to identify a POD. Obviously, with different assessment tools, one may calculate different DCRs, which make comparison difficult. Our aim was to determine which assessment tool can be used for a realistic estimation of a POD pool and how they compare to each other with regard to DCR. Methods: Retrospective chart review of patients diagnosed with a subarachnoid haemorrhage, traumatic brain injury or intracerebral haemorrhage. We applied three different assessment tools on this cohort of patients. Results: We identified a cohort of 564 patients diagnosed with a subarachnoid haemorrhage, traumatic brain injury or intracerebral haemorrhage of whom 179/564 (31.7%) died. After applying the three different assessment tools the number of patients, before exclusion of medical reasons or age, was 76 for the IBD-FOUR definition, 104 patients for the IBD-GCS definition and 107 patients based on the OPTN definition of imminent neurological death. We noted the highest DCR (36.5%) in the IBD-FOUR definition. Conclusion: The definition of imminent brain death based on the FOUR-score is the most practical tool to identify patients with a realistic chance to become brain dead and therefore to identify the patients most likely to become POD

Imminent brain death: point of departure for potential heart-beating organ donor recognition

Contains fulltext : 88186.pdf (publisher's version ) (Closed access)PURPOSE: There is, in European countries that conduct medical chart review of intensive care unit (ICU) deaths, no consensus on uniform criteria for defining a potential organ donor. Although the term is increasingly being used in recent literature, it is seldom defined in detail. We searched for criteria for determination of imminent brain death, which can be seen as a precursor for organ donation. METHODS: We organized meetings with representatives from the field of clinical neurology, neurotraumatology, intensive care medicine, transplantation medicine, clinical intensive care ethics, and organ procurement management. During these meetings, all possible criteria were discussed to identify a patient with a reasonable probability to become brain dead (imminent brain death). We focused on the practical usefulness of two validated coma scales (Glasgow Coma Scale and the FOUR Score), brain stem reflexes and respiration to define imminent brain death. Further we discussed criteria to determine irreversibility and futility in acute neurological conditions. RESULTS: A patient who fulfills the definition of imminent brain death is a mechanically ventilated deeply comatose patient, admitted to an ICU, with irreversible catastrophic brain damage of known origin. A condition of imminent brain death requires either a Glasgow Coma Score of 3 and the progressive absence of at least three out of six brain stem reflexes or a FOUR score of E(0)M(0)B(0)R(0). CONCLUSION: The definition of imminent brain death can be used as a point of departure for potential heart-beating organ donor recognition on the intensive care unit or retrospective medical chart analysis.1 september 201