Causes why organ donation was not carried out despite the deceased being positive to donation.

Several studies have shown that over 70% of the population is positive to donate their organs after their death. Despite this it is not unusual for organ donation to be not performed. The aim of this overview was to identify factors that may have an influence on this failure despite the deceased being positive. This is a review of 343 abstracts and 23 scientific publications between 1977 and 2005 dealing with various aspects of donation. In the analysis there were some topics that were associated with the prevention of donation: medical contraindications, inability to identify a potential organ donor and provide optimal medical care, the treatment and care of next of kin, how the question of consent was addressed to the next of kin, the attitude of intensive care unit (ICU) staff toward the process, the behavior of the transplant team during organ recovery. The most crucial act to increase donation is early identification of a potential subject. Early identification and optimal medical care occur more frequent when there is a good, positive attitude of the ICU staff toward the process. A positive attitude of the questioner and good care of the next of kin frequently resulted in a positive attitude when the question of consent was raised. Transplant units could improve the attitude in the ICUs by serving as a good model, giving feedback and education to the ICU staff.

No going back: narratives by close relatives of the braindead patient.

The aim of this narrative study was to illuminate the meaning of being a relative of a patient diagnosed as brain dead. This has so far been explored only to a limited extent. By phenomenological-hermeneutic analysis of 14 narratives, a chronological narrative in 4 steps was identified: the disquieting event; the uncertain vigil; the arduous struggle; and the difficult road ahead. From the analysis, the metaphor of an inner journey emerged, starting from a life situation taken for granted and experienced as safe, and moving towards the unknown, the unfamiliar. During the journey, a series of events of decisive importance in the relative's life were found to take place. Major stages along the road were efforts made to comprehend the reality of death, saying farewell and taking leave of the loved one. The importance of the ICU nurse taking part in the relative's inner journey is discussed in relation to Eriksson's theory of suffering and Martinsen's theory of caring. Implications and suggestions for nursing care activities are discussed.

On the use of narratives in nursing research.

On the use of narratives in nursing research Narratives have always been a path to knowledge in nursing care but are a recent element within nursing research. Therefore, this article deals with the narrative and its use within nursing research. First, the use of narratives in nursing care and nursing research is examined. Second, Paul Ricoeur's narrative theory with its dimensions of interpretation, time, action and ethics is presented as a possible methodological basis. Third, the use of Ricoeur's narrative theory in nursing research is examined, showing that, at present, support mainly comes from Ricoeur's text interpretation theory. Finally, a nursing research approach to the narrative, based on the life-world, is suggested.

Brain death in ICUs and associated nursing care challenges concerning patients and families.

In order to document the incidence and causes of brain death (BD) and the frequency of organ donation (OD) in a Swedish University Hospital, a retrospective review of deaths in a neurosurgical department and in the general intensive care units (ICUs), was carried out for the period 1988-1994. BD diagnosis was established in 197 (10.6%) of all deaths (n = 1843). The hospital records of all BD patients were examined in detail following a specific study plan. The majority of the BD patients (89%) were acute admissions to hospital, and among them 81 were transferred between hospitals often over a long distance. Among the BD patients the total number of OD was 65 (33%). The most common diagnosis leading to BD was spontaneous intracerebral bleeding and traumatic head injury. The BD diagnosis was established by neurological examination (60%) and by cerebral angiography (40%). Of the BD patients, 50% died within 48 hours in the ICU and the majority of requests for OD (67%) were made to the relatives of these patients. The findings are discussed with focus on the workload and psychological stress of ICU nurses when caring for BD patients and their families; a task which includes taking part in processes concerning BD diagnosis information and OD requests.

Haemodynamic changes during epidural caesarean delivery.

The cardiovascular changes during epidural caesarean delivery were studied, using a non-invasive cardiac output monitor (BoMed NCCOM3-R7). Two different regimens were used to control hypotension (A = 15 ml/kg of 3% dextran 70, B = 7.5 ml/kg of 3% dextran 70 followed by an infusion of 17.5 mg of ephedrine). Cardiac index (CI) and heart rate (HR) increased after delivery and oxytocin administration (P < 0.001) and maximum values were recorded 1-1.5 min after administration of oxytocin. The maximum increase in CI was 76% (A) and 117% (B), in HR 42% (A) and 56% (B), and in SI 23% (A) and 47% (B) compared with values before anaesthesia. The increase in cardiac output after delivery was greater than that measured previously, which might be because impedance cardiac output is a continuous method. It is also suggested that the most pronounced changes are augmented by the use of a bolus injection of 10 units oxytocin i.v.

Cardiac risk and peripheral vascular surgery: new approach based on a multifactorial risk index.

An inexpensive approach to stratification of patients admitted for arterial surgery into groups of high and low cardiac risk has been prospectively evaluated in 235 consecutive patients. The Goldman and Detsky indices, assessed by a nurse the day before surgery, both identified patient groups with increased risk of lethal or potentially lethal (myocardial infarction, pulmonary oedema) cardiac events within 30 days after peripheral vascular surgery. The Goldman index was the more sensitive predictor of cardiac death (overall frequency 3.1 per cent) while the Detsky index was superior for prediction of non-lethal cardiac events (overall frequency 5.9 per cent). The simplest and yet most effective stratification into high and low cardiac risk was achieved using a Detsky score of 10 as the cut-off. It is concluded that multifactorial risk index-based preoperative screening can identify low-risk patients (Detsky score < or = 10), who may be accepted for vascular surgery (aortic aneurysm surgery excluded) without additional cardiac testing.

Colloid (3% Dextran 70) with or without ephedrine infusion for cardiovascular stability during extradural caesarean section.

Using a non-invasive cardiac output monitor (Bo-Med NCCOM 3-R7), we have compared cardiovascular responses, degree of haemodilution and incidence of nausea during extradural Caesarean section in healthy non-labouring mothers given either ephedrine 17.5 mg and 3% Dextran 70 7.5 ml kg-1 before delivery (group A) or volume loading with Dextran 15 ml kg-1 without infusion of ephedrine (group B). Smallest systolic arterial pressures before delivery were 114 (SEM 4) mm Hg (group A) and 105 (5) (group B). There were no significant differences between the groups in mean arterial pressure, heart rate, systemic vascular resistance or central venous pressure, while cardiac output increased more with the ephedrine infusion (P less than 0.05). Haemodilution was 8% in group A and 16% in group B at the time of delivery. Ephedrine infusion was associated with a smaller incidence of nausea (P less than 0.01). Umbilical arterial pH values were not different between the two groups. We conclude that infusion of ephedrine, combined with low volume colloid administration, is a safe alternative to more extensive colloid volume expansion for control of hypotension and provides effective prophylaxis against nausea during extradural Caesarean section in healthy non-labouring mothers.

Comparison of Ringer's acetate with 3% dextran 70 for volume loading before extradural caesarean section.

We have studied haemodilution and cardiovascular responses to i.v. hydration with either 3% dextran 70 (Dx70) or Ringer's acetate using a non-invasive cardiac output monitor (BoMed NCCOM3-R7) in 40 healthy parturients undergoing Caesarean section under extradural anaesthesia. Haemodilution was more pronounced, and central venous pressure, mean arterial pressure and cardiac index maintained at greater values, after treatment with Dx70. Colloid osmotic pressures (COP) decreased by 1.7 mm Hg after loading with 3% Dx70, and by 5.6 mm Hg in mothers treated with Ringer's acetate (P less than 0.001). The transthoracic fluid index decreased more after hydration with Ringer's acetate (P less than 0.001), indicating an increase in lung water. In spite of these maternal changes, there were no differences in neonatal bioimpedance or values of haemoglobin, PCV, albumin and COP in umbilical cord blood, and only one case of respiratory distress. We conclude that colloids may be preferable to crystalloids for circulatory preload for extradural Caesarean section, as greater haemodynamic stability was maintained and increases in lung water avoided.

Cardiac output determinations in the pig--thoracic electrical bioimpedance versus thermodilution.

The accuracy of transthoracic electrical bioimpedance (TEB) for continuous, noninvasive measurement of cardiac output (Qt) in pigs was assessed in comparison with the thermodilution (TD) technique. Using the TEB technique, the different thoracic habitus of the pig had to be corrected for A good correlation with the TD technique was obtained (r = .87; p less than .001; n = 86) using thoracic length value (the measured value plus 25%) in an NCCOM3-R6 cardiodynamic computer for Qt values ranging from 2.9 to 9.8 L/min in pigs weighing from 40 to 75 kg. However, the Qt values given by the NCCOM3 were systematically 11% to 15% higher over the full range of values than the average of NCCOM-3 and TD Qt values. On the basis of the good agreement in the present study between the TEB and TD techniques over a broad range of Qt values, we conclude that TEB offers a valuable continuous, noninvasive alternative to TD for Qt determinations in experimental porcine models.

A porcine model for acute distal aortic occlusion.

Periarterial and intramural nerves and lymphatics as well as the vascular endothelium may influence pathophysiologic responses to acute arterial occlusion. For study of such pathophysiologic patterns, experimental models resembling the clinical situation are therefore preferable. In this porcine study acute distal aortic occlusion was mimicked by use of a balloon catheter introduced via a vascular graft anastomosed to the lateral aortic wall. Peripheral circulatory disturbance was assessed by measurements of femoral vein blood flow, skin blood flow in the hind foot and oxygen tension in the calf muscle, which verified the degree of ischemia. During the 4-hour ischemic period, repeated arterial and venous blood gas analyses showed increasing acidosis in effluent venous blood from the hind limbs, which after reperfusion slowly normalized. As highly reproducible conditions are achievable with the present experimental model, it can be used for studies of pathophysiologic responses to acute distal aortic occlusion.

Cardiac output in patients with acute lower limb ischaemia of presumed embolic origin--a predictor of severity and outcome?

Cardiodynamic studies using a non-invasive computerised thoracic electrical bioimpedance (TEB) equipment were performed in 35 patients presenting with acute lower limb ischaemia of presumed embolic origin, and in 36 age-matched control patients without emboli. Patients who presented with imminent gangrene were promptly operated upon, whereas those who had less severe ischaemia were treated initially with heparin only. In the former group, cardiac output and myocardial contractility were very low on admission, while systemic vascular resistance was high. Cardiac output was further decreased when measured immediately after revascularisation, whereas it had become normal 2 days later. In patients with less severe acute ischaemia, cardiac output and myocardial contractility values on admission were similar to those of control patients, and no changes were observed after 2 days of conservative treatment. Overall, cardiac output on admission was significantly related to the simultaneously observed severity of the limb ischaemia. A low cardiac output (less than 1.7 l/min m2) on admission was found to predict severe cardiac complications (60% mortality within 10 days), whereas clinical assessment of cardiac failure on admission was poorly related to outcome. We conclude that patients with acute lower limb ischaemia of presumed embolic origin often have unrecognised poor cardiac function, which is related to the severity of the limb ischaemia and to outcome. By routine non-invasive TEB cardiodynamic measurements, high risk patients can rapidly be identified and proper treatment regimes be instituted in each individual patient.

Disturbances of blood-flow velocity in the dorsal veins of the hand after vein cannulation and cannula fixation in the anaesthetised patient.

Modifications of the mean blood-flow velocity in the dorsal veins of the hand were assessed semi-quantitatively with continuous wave (CW) Doppler equipment in 32 anaesthetised patients (17 men and 15 women), 23-78 (median = 56) years of age, before and after venous catheterisation with cannula fixation to the skin. Cannulation of the vein caused a 48% reduction in the mean blood-flow velocity and made it impossible to detect any flow with the equipment used in 22% of the patients. A 10% further reduction in the mean blood-flow velocity and in the number of subjects with undetectable blood flow was observed after fixation of the cannulae. Age, small vein diameter, and hyperventilation (end-tidal carbon dioxide less than or equal to 3.5 volume % appeared to be significant factors reducing blood-flow velocities in the cannulated veins. It is concluded that venous catheterisation and fixation of the cannula induce a significant reduction in the blood-flow velocity.

Continuous conjunctival oxygen tension (PcjO2) monitoring for assessment of cerebral oxygenation and metabolism during carotid artery surgery.

The clinical value of noninvasive continuous monitoring of conjunctival oxygen tension for assessment of cerebral perfusion during carotid endarterectomy performed under general anaesthesia has been evaluated. The patients (n = 17; mean age 62.5 +/- 1.7 years) were monitored as follows: conjunctival oxygen tension (PcjO2); internal jugular venous oxygen tension at the skull base level (PcijvO2); arterial blood pressure; arterial and internal jugular venous blood gases; acid-base data and lactate, pyruvate levels; end-tidal CO2 concentration. The mean preanaesthetic PcjO2 level of 4.86 +/- 0.40 kPa was significantly lower than PaO2(PcjO2)/PaO2 ratio of 0.48). Following anaesthesia, a larger PcjO2-PaO2 gradient (ratio 0.32) was seen in spite of the hyperoxic situation (FiO2 = 0.40) due to vasoconstriction induced by slight hypocapnia (reduction of PaCO2 from 5.13 +/- 0.08 to 4.64 +/- 0.10 kPa). The carotid artery crossclamping resulted in a rapid and pronounced decrease of PcjO2, while PcijvO2 remained unchanged. No relationship between PcjO2 and stump pressure was found, while a significant correlation (P less than 0.02) between PcjO2 and lactate in effluent venous blood from the brain was demonstrable. It is concluded that PcjO2 monitoring seems a clinically useful trend indicator of cerebral perfusion in the individual patient. Due to large interindividual variations in basal PcjO2 readings and in PcjO2 changes during carotid artery clamping, however, transconjunctival oxygen tension monitoring does not seem to allow early and accurate recognition of impending cerebral ischaemia during carotid endarterectomy, and its routine use therefore seems of limited value.

[Effects of hyperbaric oxygenation on tumor growth]. / Vliianie giperbaricheskoi oksigenatsii na opukholevyi rost.

The study failed to show a stimulating effect of hyperbaric oxygen on growth and metastatic spreading of sarcoma 37 transplanted subcutaneously or intravenously to female SHR mice, melanoma B16 intramuscularly transplanted to female C57/Bl mice and methylcholanthrene-induced tumors in female albino noninbred rats. An insignificant inhibitory effect of hyperbaric oxygen on transplantable tumor growth and development of inducible ones in experimental animals was observed.

Epidural vs general anaesthesia and leg blood flow in patients with occlusive atherosclerotic disease.

Total leg blood flow (plethysmography), skin blood flow (laser-Doppler flowmetry), and haemodynamic stability (MAP, HR, RPP) were studied in vascular (ABI less than 1.0; n = 31) and in non-vascular (ABI greater than 1.0; n = 24) surgical patients during epidural or fentanyl-supplemented general anaesthesia. During epidural anaesthesia significant increases in total leg blood flow were observed in vascular (from 1.9 +/- 0.2 to about 3 ml/100 ml tissue/min) as well as in non-vascular (from 2.5 +/- 0.6 to about 7 ml/100 ml tissue/min) patients and leg blood flow remained high in the postanaesthetic period. During general anaesthesia total leg blood did not increase, either in vascular or in non-vascular patients, and in the postanaesthetic period blood flow values even lower than the initial ones were observed. Skin blood flow increased about 4-fold in vascular as well as in non-vascular patients following both types of anaesthesia. In the immediate postanaesthetic period low flow values were again observed but only in the general anaesthesia groups. In vascular patients no critical redistribution of blood flow within the limb was observed irrespective of the type of anaesthesia. Good haemodynamic stability could only be maintained in the epidural group. It is concluded that epidural anaesthesia seems to offer considerable advantages over general anaesthesia for high-risk vascular patients during arterial reconstructions since better haemodynamic stability and higher leg blood flow can be achieved.

Ankle-brachial index (ABI) and leg blood flow following epidural anaesthesia.

The influence of the severity of occlusive arterial disease, as evaluated from the ankle-brachial index (ABI) values, on blood flow and the distribution of blood flow within the lower limb following epidural block to the level of Th 4 to 6 was studied in 48 patients (ABI values ranging from 0.45-1.62). Leg (LBF) and foot (FBF) blood flows were measured with plethysmography and skin blood flow (SBF) was evaluated from laser-Doppler flowmetry and temperature recordings. The resting control LBF, FBF and SBF values were similar for all patients. Following the epidural block mean arterial blood pressure (MAP) decreased by about 20 mmHg. LBF, FBF and SBF all increased. There were significant correlations between the ABI values and the changes following the epidural block in LBF and FBF but not between ABI and SBF changes as evaluated from laser-Doppler flowmetry.

[Analgesic therapy of cancer outpatients]. / Protivobolevaia terapiia u onkologicheskikh bol'nykh v ambulatornykh usloviiakh.

The results of treatment of 164 out-patients with far advanced malignancies for chronic pain syndrome are discussed. It was found that subarachnoid, peridural and sacral blocks with alcohol, phenol glycerine and carbolic acid can relieve pain for a long time, improve general condition and save narcotic analgetics. The most effective proved to be peridural block by phenolglycerine which induced analgesia in 67% of cases and maintained it for 45 days.

Anaesthesia and development of some experimental tumours.

Present work is based on the data of experimental studies on the influence of inhalatory (ether, chloroform, halothane and methoxyfluorane) and intravenous anaesthesia (neurovegetative block and neuroleptoanalgesia) upon the tumour growth and metastasization as well as the level of corticosteronemia in surgical trauma. It has been revealed that the narcosis may change the course of the tumorous process both by means of its action on the endocrine part of the organism-tumour system and immediately (halothane) due to its cytostatic action. Obviously, anaesthesia may appear one of the factors influencing the results of multifactoral therapy of tumorous diseases.

[Blood prolactin level of breast and endometrial cancer patients during surgical intervention]. / Uroven' prolaktina krovi u bol'nykh rakom molochnoi zhelezy i éndometriia vo vremia khirurgicheskogo vmeshatel'stva.

Abundant experimental data suggest the potentiating influence of hyperprolactinemia on the development, progression and dissemination of breast cancer, whereas hypophysectomy, immunologically- and pharmacologically-induced inhibition of prolactin has an antitumor effect. Moreover, hyperprolactinemia is caused by any kind of stress (surgical one included) as well as phenothiazine and butyrophenone treatment for neuroleptanalgesia. These findings encouraged intraoperative radioimmunologic assays of blood-prolactin levels in endometrial and breast cancer patients. The advantages offered by treatment with specific inhibitors of prolactin secretion aimed at reducing hyperprolactinemia on the day of surgery are discussed.

[Effect of anesthesia on a neoplastic process in an experiment]. / Vliianie narkoza na opukholevyi protsess v éksperimente.

The modifying influence of anaestesia on tumourigenic process (its stimulative or inhibitory effect upon tumour and metastasis growth) was established. It may occur indirectly, i.e. through endocrine link of the host-tumour system, and due to cytostatic effect of the anaesthetic drug (fluothane in particular).