Expanding controlled donation after the circulatory determination of death: statement from an international collaborative.

A decision to withdraw life-sustaining treatment (WLST) is derived by a conclusion that further treatment will not enable a patient to survive or will not produce a functional outcome with acceptable quality of life that the patient and the treating team regard as beneficial. Although many hospitalized patients die under such circumstances, controlled donation after the circulatory determination of death (cDCDD) programs have been developed only in a reduced number of countries. This International Collaborative Statement aims at expanding cDCDD in the world to help countries progress towards self-sufficiency in transplantation and offer more patients the opportunity of organ donation. The Statement addresses three fundamental aspects of the cDCDD pathway. First, it describes the process of determining a prognosis that justifies the WLST, a decision that should be prior to and independent of any consideration of organ donation and in which transplant professionals must not participate. Second, the Statement establishes the permanent cessation of circulation to the brain as the standard to determine death by circulatory criteria. Death may be declared after an elapsed observation period of 5 min without circulation to the brain, which confirms that the absence of circulation to the brain is permanent. Finally, the Statement highlights the value of perfusion repair for increasing the success of cDCDD organ transplantation. cDCDD protocols may utilize either in situ or ex situ perfusion consistent with the practice of each country. Methods to accomplish the in situ normothermic reperfusion of organs must preclude the restoration of brain perfusion to not invalidate the determination of death.

All human death is brain death: The legacy of the Harvard criteria.

Fifty years ago, the ad hoc committee of the Harvard medical school provided the influential first guidance on confirming death using neurological criteria (DNC). Now 70% of countries have a legal or professional framework enabling DNC. While there is virtually universal acceptance of a three staged approach to the clinical diagnosis of brain death, international variation in practice continues. The need to develop international consensus and standards is essential in the future if public and professional confidence in the diagnosis is to be maintained and increased. The legacy of the Harvard ad hoc committee has been a continuing development of our concepts of human death. There is a growing acceptance that ultimately all human death is brain based whether diagnosed using neurological criteria or using circulatory criteria after cardiac arrest.

Treating delayed gastric emptying in critical illness: metoclopramide, erythromycin, and bedside (cortrak) nasointestinal tube placement.

BACKGROUND: We describe experience using the Cortrak nasointestinal feeding tube and prokinetics in critically ill patients with delayed gastric emptying. METHODS: Patient cohorts fed via a Cortrak electromagnetically guided nasointestinal tube (EGNT) or 14 French-gauge nasogastric tube plus prokinetics were retrospectively compared. RESULTS: Of 69 EGNT placements in 62 patients, 87% reached the small intestine. The median percentage of the enteral nutrition goal increased from 19% pre-EGNT to 80%-100% between days 1 and 10 post-insertion and was greater than in 58 patients prescribed metoclopramide (40%-87%: days 1-2, 5-7, P < or = .018) or 38 patients prescribed erythromycin (48%-98%; days 1 and 5, P < .0084). Up to day 10, the cumulative feeding days lost were lower for EGNT (1.06) than for metoclopramide (2.6, P < .02) or erythromycin (3.1, P < .02). The EGNT group had a lower use of prokinetics and lower treatment cost. CONCLUSION: Most bedside EGNT placements succeed and, compared to nasogastric feeding plus prokinetics, increase enteral nutrition delivery and reduce both cumulative feeding days lost and prokinetic use.