Brain herniation on computed tomography is a poor predictor of whether patients with a devastating brain injury can be confirmed dead using neurological criteria.

Background: It is unclear if the presence of compartmental brain herniation on neuroimaging should be a prerequisite to the clinical confirmation of death using neurological criteria. The World Brain Death Project has posed this as a research question. Methods: The final computed tomography of the head scans before death of 164 consecutive patients confirmed dead using neurological criteria and 41 patients with devastating brain injury who died following withdrawal of life sustaining treatment were assessed by a neuroradiologist to compare the incidence of herniation and other features of cerebral swelling. Results: There was no difference in the incidence of herniation in patients confirmed dead using neurological criteria and those with devastating brain injury (79% vs 76%, OR 1.23 95%, CI 0.56-2.67). The sensitivity and specificity of brain herniation in patients confirmed dead using neurological criteria was 79% and 24%, respectively. The positive and negative predictive value was 81% and 23%, respectively. The most sensitive computed tomography of the head findings for death using neurological criteria were diffuse sulcal effacement (93%) and basal cistern effacement (91%) and the most specific finding was loss of grey-white differentiation (80%). The only features with a significantly different incidence between the death using neurological criteria group and the devastating brain injury group were loss of grey-white differentiation (46 vs 20%, OR 3.56, 95% CI 1.55-8.17) and presence of contralateral ventricular dilatation (24 vs 44%, OR 0.41, 95% CI 0.20-0.84). Conclusions: Neuroimaging is essential in establishing the cause of death using neurological criteria. However, the presence of brain herniation or other signs of cerebral swelling are poor predictors of whether a patient will satisfy the clinical criteria for death using neurological criteria or not. The decision to test must remain a clinical one.

Clinical Practice Guideline for Solid Organ Donation and Transplantation During the COVID-19 Pandemic.

The coronavirus 2019 (COVID-19) pandemic has disrupted health systems worldwide, including solid organ donation and transplantation programs. Guidance on how best to screen patients who are potential organ donors to minimize the risks of COVID-19 as well as how best to manage immunosuppression and reduce the risk of COVID-19 and manage infection in solid organ transplant recipients (SOTr) is needed. METHODS: Iterative literature searches were conducted, the last being January 2021, by a team of 3 information specialists. Stakeholders representing key groups undertook the systematic reviews and generation of recommendations using a rapid response approach that respected the Appraisal of Guidelines for Research and Evaluation II and Grading of Recommendations, Assessment, Development and Evaluations frameworks. RESULTS: The systematic reviews addressed multiple questions of interest. In this guidance document, we make 4 strong recommendations, 7 weak recommendations, 3 good practice statements, and 3 statements of "no recommendation." CONCLUSIONS: SOTr and patients on the waitlist are populations of interest in the COVID-19 pandemic. Currently, there is a paucity of high-quality evidence to guide decisions around deceased donation assessments and the management of SOTr and waitlist patients. Inclusion of these populations in clinical trials of therapeutic interventions, including vaccine candidates, is essential to guide best practices.

X-ray checks of NG tube position: a case for guided tube placement.

OBJECTIVES: Checking nasogastric (NG) tube position by X-ray is too late to prevent 1.5% of blind tube placements entering the lung and results in delays to feeding and drugs. We audit the safety of the tube position and delay incurred by X-ray. METHODS: From Radiology reports, we determined whether tube position was safe for feeding, factors associated with an X-ray request and the time delay from X-ray request to that report. For tubes misplaced into the lung, the distance from the carina to tube tip was measured and compared with that from published records of guided tube placement. RESULTS: From 1 July 2019 to 30 June 2020, 1934 X-rays were done to check NG tube position in 891 patients. Gastric placement was confirmed in 85% but, because of tube proximity to the oesophagus, only 73% were deemed safe to feed. The 2.2% of tubes reported to be in the lung were a median of 18 cm beyond the carina compared to 12 cm and 0 cm for electromagnetic and direct vision methods of guided placement. X-ray checks delayed feed and drug treatment by >2 h in 51% of placements and 33% of patients required >3 X-rays during their enteral episode. CONCLUSION: X-ray checks are common and detect a high percentage of unsafe tube placements, leading to repeated X-ray and delayed delivery of drugs and nutrition. Interpretation can be difficult even when following standard national criteria and post-placement X-ray cannot prevent deep lung placement. Guided or combined methods of confirming tube placement should be investigated. ADVANCES IN KNOWLEDGE: Reports included 27.5% of placements as unsafe, 2.2% in the lung at a median depth of 18 cm beyond the carina and too late to prevent 7 pneumothoraces. X-rays were repeated >3 times in 33% of patients over their enteral course and we are associated with clinically significant delays to drug treatment (and nutrition) in 51%; combined methods of tube confirmation or guided placement may be safer and more efficient.

Impact of a Devastating Brain Injury Pathway on Outcomes, Resources, and Organ Donation: 3 Years' Experience in a Regional Neurosciences ICU.

OBJECTIVE: To assess the impact of introducing a devastating brain injury (DBI) pathway on patient outcome, intensive care unit (ICU) resources, and organ donation practice in the first 3 years of implementation in a regional neurosciences ICU in the South West of England. METHODS: Patients with DBI admitted to our ICU between 2015 and 2018 were identified from our ICU database and their outcomes compared to those of non-DBI patients. Data were also obtained from the national potential donor audit to compare organ donation metrics before and after the introduction of the DBI pathway. Organ donation metrics in DBI patients and non-DBI patients were compared once the pathway had been implemented. RESULTS: We admitted 85 DBI patients (1.3% of all admissions), with a significantly shorter median length of ICU stay than in non-DBI patients, 1.14 versus 2.93 days (p < 0.001). Decisions for withdraw life-sustaining treatments (WLST) were made significantly earlier in DBI patients, median 26.2 versus 84.8 h (p < 0.001). Over 8% of DBI patients survived, while 31% progressed to brain death compared to 7.1% in the general population (p < 0.001), and 25% become solid organ donors compared to 1.3% of the general population (p < 0.001). There was an increase in the proportion of donors after brain death (DBD) to donors after circulatory death (DCD) in the 3 years following the introduction of the DBI pathway (p = 0.024). There was also an increased proportion of DBD donors to DCD donors of 76% versus 24% in the DBI group compared to 62% versus 38% (p = 0,002) in the non-DBI population. Prognostic scoring systems do not provide accurate estimates of survival rate in this population. CONCLUSIONS: Admitting patients with perceived DBI to ICU and avoiding the early WLST allows identification of unexpected survivors and gives families more time in decision making at the end of life. The DBI pathway increases the potential for organ donation and increases the proportion of DBD donors. These benefits outweigh the small impact of a DBI pathway on ICU resources.

Admission to bed 13 in the ICU does not reduce the chance of survival.

PURPOSE: To examine whether admission to bed number 13 on our intensive care unit has any negative impact on the patient's hospital mortality. MATERIALS AND METHODS: We conducted a retrospective cohort study of 1568 patients admitted to our ICU over a two-year period. Observed hospital mortality, predicted mortality using the ICNARC and APACHE II scoring systems and standardised mortality ratios were used to compared patients admitted to bed number 13 with those admitted to beds number 14-24. RESULTS: Of the 1568 patients admitted to ICU, 110 were placed in bed number 13 and 1458 into bed numbers 14-24. Demographics and ICNARC and APACHE II scores were similar between the two groups. There was no significant difference in the ICNARC predicted hospital mortality (mean 21.0%, median8.5% in bed 13 compared with a mean 17.5%, median 6.4% in beds 14-24, p = 0.33), APACHE II predicted hospital mortality (mean 18.4%, median 9.9% in bed 13 compared with mean 18.7%, median 8.9% in beds 14-24, p = 0.74), or observed hospital mortality (20.2% compared with 15.2%, OR 1.41 (CI 0.87 to 2.30), p = 0.17). CONCLUSIONS: Admission to bed number 13 was not associated with a significant increase in hospital mortality when compared to admission to other bed numbers.

Organ donation in adults: a critical care perspective.

PURPOSE: The shortage of organs for transplantation is an important medical and societal problem because transplantation is often the best therapeutic option for end-stage organ failure. METHODS: We review the potential deceased organ donation pathways in adult ICU practice, i.e. donation after brain death (DBD) and controlled donation after circulatory death (cDCD), which follows the planned withdrawal of life-sustaining treatments (WLST) and subsequent confirmation of death using cardiorespiratory criteria. RESULTS: Strategies in the ICU to increase the number of organs available for transplantation are discussed. These include timely identification of the potential organ donor, optimization of the brain-dead donor by aggressive management of the physiological consequence of brain death, implementation of cDCD protocols, and the potential for ex vivo perfusion techniques. CONCLUSIONS: Organ donation should be offered as a routine component of the end-of-life care plan of every patient dying in the ICU where appropriate, and intensivists are the key professional in this process.

A case for stopping the early withdrawal of life sustaining therapies in patients with devastating brain injuries.

Early prognostication in patients with a devastating brain injury is not always accurate and can lead to inappropriate decisions. We present case histories to support the recent recommendations of the Neurocritical Care Society that treatment withdrawal decisions should be delayed by up to 72 h in these patients. Development of pathways incorporating these recommendations can improve prognostication, enhance end of life care given to these patients and their families, and increase the opportunities to explore the donation wishes of more patients. They may also standardise the approach to decision making in the same way as the recommendations for management of patients after out of hospital cardiac arrest have done.

Ocular microtremor during general anesthesia: results of a multicenter trial using automated signal analysis.

Ocular microtremor (OMT) is a fine physiologic tremor of the eye related to neuronal activity in the reticular formation of the brainstem. The frequency of OMT is suppressed by propofol and sevoflurane and predicts the response to command at emergence from anesthesia. Previous studies have relied on post hoc computer analysis of OMT wave forms or on real-time measurements confirmed visually on an oscilloscope. Our overall aim was to evaluate an automated system of OMT signal analysis in a diverse patient population undergoing general anesthesia. In a multicenter trial involving four centers in three countries, we examined the accuracy of OMT to identify the unconscious state and to predict movement in response to airway instrumentation and surgical stimulation. We also tested the effects of neuromuscular blockade and patient position on OMT. We measured OMT continuously by using the closed-eye piezoelectric technique in 214 patients undergoing extracranial surgery with general anesthesia using a variety of anesthetics. OMT decreased at induction in all patients, increased transiently in response to surgical incision or airway instrumentation, and increased at emergence. The frequency of OMT predicted movement in response to laryngeal mask airway insertion and response to command at emergence. Neuromuscular blockade did not affect the frequency of OMT but decreased its amplitude. OMT frequency was unaffected by changes in patient position. We conclude that OMT, measured by an automated signal analysis module, accurately determines the anesthetic state in surgical patients, even during profound neuromuscular blockade and after changes in patient position.

Microendoscopic nasointestinal feeding tube placement in mechanically ventilated patients with gastroparesis.

Gastroparesis often precludes gastric enteral nutrition (EN) in critically ill patients. Our aim was to determine the feasibility of bedside microendoscopic placement of nasointestinal feeding tubes to facilitate enteral nutrition in critically ill patients with poor gastric emptying. Nine mechanically ventilated patients with proven gastroparesis underwent 10 nasointestinal intubations using a microendoscope. These were compared with 35 patients who underwent pH sensor-guided intubation. Blind pH-guided intubation was faster than microendoscopic placement (21.4 +/- 10.7 v 32 +/- 11.6 min, P = 0.016) and cheaper in terms of disposables [87 pounds sterling (132 dollars) vs 222 pounds sterling (337 dollars) per intubation, P < 0.0001]. Depth of placement (postpyloric: 64% vs 50% including 32% vs 50% reaching duodenum part 3, 4, or jejunum, both NS) was similar. We conclude that microendoscopy failed to improve transpyloric intubation due to poor visualization of gastrointestinal anatomy and difficulty maneuvering the tube-endoscope ensemble. However, when successful, transpyloric placement was always deep, permitting immediate and full EN. To date, the technique and equipment is not superior to pH-guided placement and is not suitable for use by personnel with minimal training.