Brain tissue oxygen tension in clinical brain death: a case series.

OBJECTIVES: Brain death is a clinical diagnosis often confirmed with supplementary tests. In this study, we examined the relationship between brain death and the partial pressure of brain tissue oxygen (PbtO(2)). We hypothesized that a sustained PbtO(2) of 0 is associated with brain death. METHODS: One hundred and twenty-six patients (Glasgow coma scale < or = 8, median age: 50 years) who underwent PbtO(2) monitoring were studied prospectively during a 2 year period in the neurointensive care unit at a university-based level I trauma center. PbtO(2), intracranial pressure (ICP), mean arterial pressure (MAP), cerebral perfusion pressure (CPP) and brain temperature (BT) were compared before and after the diagnosis of brain death. RESULTS: Six patients (median age: 52 years) experienced brain death. In these patients, PbtO(2) decreased toward 0 mmHg as ICP increased and CPP decreased. PbtO(2) reached 0 only when there was clinical evidence for brain death. During the subsequent 12 hours until the second brain death examination, PbtO(2) remained 0 mmHg and did not respond to oxygen challenge. In addition, TCD examination demonstrated a 'to and fro' pattern consistent with brain death and cerebral circulatory arrest. PbtO(2) of 0 mmHg was observed in five non-brain dead patients. These episodes were transient (>30 minutes) and responded to an oxygen challenge, directed treatment or catheter replacement. DISCUSSION: A sustained (>30 minutes) brain PbtO(2) of 0 is consistent with brain death. We suggest that a sustained 'zero' PbtO(2) may be used to determine when a brain death examination is appropriate in the pharmacologically suppressed patient.

Report of the ASHP Task Force on Caring for Patients Served by Specialty Suppliers.

Task Force recommendations are discussed in more detail in eAppendix A (available at www.ajhp.org). What follows is a brief summary of those recommendations. In very abbreviated terms, the Task Force suggested that ASHP: 1. Consider creating and maintaining a Web resource center on ASHP's website to provide information about restricted drug distributions systems (RDDSs), risk evaluation and mitigation strategies (REMSs), risk assessment and minimization plans (RiskMAPs), and specialty suppliers and products. 2. Provide comprehensive education to members, other health professionals, regulators, third-party payers, patients, and other stakeholders about RDDSs, REMSs, RiskMAPs, and specialty suppliers and products. 3. Develop policies to advocate that a. Pharmacists serve as the institutional leaders in compliance and utilization challenges of safely managing externally supplied medications and related drug administration devices, b. Agencies, organizations, and associations that influence the distribution, sale, and dispensing of medications under these alternative distribution models address issues these models create in continuity of care, reimbursement, and patient safety, c. The Centers for Medicare and Medicaid Services and the Joint Commission develop standards and interpretations that accommodate hospital use of these products and devices when currently available technology (e.g., cold-chain storage, e-pedigree) is used to ensure patient safety, d. Group purchasing organizations negotiate contractual arrangements for specialty pharmaceuticals for both acquisition costs and distribution arrangements, and e. Information technology (IT) be used to resolve issues created by alternative distribution models and that ASHP work with IT vendors to ensure that programs are designed to meet the needs of these evolving models. 4. Quantify through research, perhaps in cooperation with entities such as the Agency for Healthcare Research and Quality, the Institute of Medicine, and the Institute for Safe Medication Practices, the impact of alternative distribution models on financial, safety, clinical, and humanistic patient outcomes. 5. Develop multidisciplinary tools and best practices that assist health care practitioners address the challenges created by alternative distribution models, from patient intake and referral to hospital discharge.