Laboratory identification of donor-derived coxsackievirus b3 transmission.

Unexpected donor-to-recipient infectious disease transmission is an important, albeit rare, complication of solid organ transplantation. Greater work and understanding about the epidemiology of these donor-derived transmissions is continually required to further mitigate this risk. Herein we present the first reported case of proven donor-derived transmission of coxsackievirus serogroup-3, an enterovirus, following solid organ transplant. Swift and effective communication between the organ donation agency, treating physicians, laboratory testing and notification ensured a coordinated approach. The resulting clinical syndromes in the organ recipients were mild. This case highlights the requirement for ongoing surveillance over a broad range of infecting pathogens that may present as a donor-derived infection.

International perspective on the diagnosis of death.

There is growing medical consensus in a unifying concept of human death. All human death involves the irreversible loss of the capacity for consciousness, combined with the irreversible loss of the capacity to breathe. Death then is a result of the irreversible loss of these functions in the brain. This paper outlines three sets of criteria to diagnose human death. Each set of criteria clearly establishes the irreversible loss of the capacity for consciousness, combined with the irreversible loss of the capacity to breathe. The most appropriate set of criteria to use is determined by the circumstances in which the medical practitioner is called upon to diagnose death. The three criteria sets are somatic (features visible on external inspection of the corpse), circulatory (after cardiorespiratory arrest), and neurological (in patients in coma on mechanical ventilation); and represent a diagnostic standard in which the medical profession and the public can have complete confidence. This review unites authors from Australia, Canada, and the UK and examines the medical criteria that we should use in 2012 to diagnose human death.

A classification and regression tree to assist clinical decision making in airway management for patients with cervical spinal cord injury.

STUDY DESIGN: This was a prospective observational study. OBJECTIVES: To review airway management of patients with acute cervical spinal cord injury (CSCI) who are admitted to the intensive care unit (ICU) and to develop a classification and regression tree (CART) to direct clinical decision making in airway management. SETTING: This study was carried out in Australia. METHODS: All patients with CSCI who required intubation and mechanical ventilation and who were admitted to ICU in three tertiary hospitals in Melbourne between October 2004 and May 2009 and two other interstate hospitals between December 2004 and December 2005 were included. Airway management was recorded. RESULTS: A total of 114 patients were included. Tracheostomy insertion occurred in 68 patients (59.7%). Using CART analysis, it was found that the variables forced vital capacity, the volume of pulmonary secretion and gas exchange were predictive of airway management on 82.3% occasions with an 8.7% extubation failure rate. CONCLUSION: A CART can be useful in clinical decision making regarding airway management in CSCI.

The acute respiratory management of cervical spinal cord injury in the first 6 weeks after injury: a systematic review.

STUDY DESIGN: Systematic review. OBJECTIVES: Identify, evaluate, and synthesize evidence regarding the effectiveness of various treatment strategies for the respiratory management of acute tetraplegia. SETTING: Melbourne, Australia. METHODS: A search of multiple electronic databases (Medline, Cinahl, EMBASE, Cochrane Library, Web of Science, http://www.guideline.gov and http://www.icord.org/scire) was undertaken accompanied by the reference lists of all relevant articles identified. Methodological quality was assessed using the Newcastle-Ottawa Scale and the PEDro Scale. Descriptive analysis was performed. RESULTS: Twenty-one studies including 1263 patients were identified. The majority of the studies were case series (n = 13). A variety of interventions were used for the management of respiratory complications. Mortality (ARR = 0.4, 95% confidence interval (CI) 0.18, 0.61), the incidence of respiratory complications (ARR = 0.36, 95% CI (0.08, 0.58)), and requirement for a tracheostomy (ARR = 0.18, 95% CI (-0.05, 0.4)) were significantly reduced by using a respiratory protocol. A clinical pathway reduced duration of mechanical ventilation by 6 days 95% CI (-0.56, 12.56), intensive care unit length of stay by 6.8 days 95% CI (0.17-13.77) and costs. Intubation, mechanical ventilation, and tracheostomy are the mainstay of respiratory management for complete injuries above the level of C5. CONCLUSION: This review showed a clinical pathway with a structured respiratory protocol that includes a combination of treatment techniques provided regularly is effective in reducing respiratory complications and cost. The overall study quality was moderate and further studies using specific interventions that target respiratory complications are associated with specific regions of the cervical spine using more methodologically rigorous designs are required.

Continuous hemofiltration for anasarca: recovery of renal function after 71 liters of net ultrafiltration.

We report on a 64-year-old female presenting with anasarca secondary to volume loading in the setting of chronic liver disease, acute on chronic renal failure, circulatory failure and sepsis. Over 37 days, a net negative fluid balance of 71 L was achieved using continuous hemofiltration, with spontaneous recovery of urine output, vasopressor independence and resolution of coagulopathy. This case report underlines the pathophysiological role of tissue edema in the downward spiral of hepato-renal and cardio-renal dysfunction and illustrates that very large volumes of tissue fluid can be safely and effectively removed with continuous renal replacement therapy, thereby permitting recovery of organ function. To our knowledge, there have been no previous reports of such large volume net fluid removal by progressive ultrafiltration in the intensive care unit.

Organ donation after circulatory death in a university teaching hospital.

Although organ transplantation is well established for end-stage organ failure, many patients die on waiting lists due to insufficient donor numbers. Recently, there has been renewed interest in donation after circulatory death (DCD). In a retrospective observational study we reviewed the screening of patients considered for DCD between March 2007 and December 2012 in our hospital. Overall, 148 patients were screened, 17 of whom were transferred from other hospitals. Ninety-three patients were excluded (53 immediately and 40 after review by donation staff). The 55 DCD patients were younger than those excluded (P=0.007) and they died from hypoxic brain injury (43.6%), intraparenchymal haemorrhage (21.8%) and subarachnoid haemorrhage (14.5%). Antemortem heparin administration and bronchoscopy occurred in 50/53 (94.3%) and 22/55 (40%) of cases, respectively. Forty-eight patients died within 90 minutes and proceeded to donation surgery. Associations with not dying in 90 minutes included spontaneous ventilation mode (P=0.022), absence of noradrenaline infusion (P=0.051) and higher PaO2:FiO2 ratio (P=0.052). The number of brain dead donors did not decrease over the study period. The time interval between admission and death was longer for DCD than for the 45 brain dead donors (5 [3-11] versus 2 [2-3] days; P<0.001), and 95 additional patients received organ transplants due to DCD. Introducing a DCD program can increase potential organ donors without reducing brain dead donors. Antemortem investigations appear to be acceptable to relatives when included in the consent process.

A before and after trial of the effect of a high-dependency unit on post-operative morbidity and mortality.

OBJECTIVE: It has been suggested that the availability of a high-dependency unit (HDU), to facilitate graded admission to, and discharge from, an intensive care unit (ICU), might decrease post-operative morbidity. We wished to determine whether the addition of a 4-bed HDU to a tertiary 17-bed ICU facility at a University-affiliated hospital would decrease post-operative morbidity and mortality. PATIENTS AND METHODS: A prospective controlled before-and-after trial was performed with the opening of a 4-bed HDU. Consecutive patients admitted to hospital for major surgery during a 4-month control (pre-HDU) phase and during a 4-month intervention (HDU) phase were studied for the incidence of serious adverse events (SAEs), mortality after major surgery and mean duration of hospital stay. RESULTS: There were 1319 operations performed in 1125 patients during the pre-HDU period and 1369 operations performed in 1127 patients during the HDU period. During the HDU period there was an excess in unscheduled surgery cases (674 during HDU vs. 531 during the pre-HDU period; p < 0.0001). In the pre-HDU period, there were 414 SAEs in 190 patients compared with 456 SAEs in 209 patients during the HDU period (NS). There were no significant changes in any of the individual SAEs measured except for the incidence of post-operative acute pulmonary edema, which increased from 19 cases to 46 during the HDU period (p = 0.028). This increase was associated with a greater number of patients requiring re-intubation (52 vs. 75 cases; p = 0.044). The introduction of an HDU had no effect on mortality (80 deaths vs. 76; NS) and failed to reduce mean hospital length of stay (21.8 vs. 24 days; NS). CONCLUSIONS: The introduction of a 4-bed HDU in a teaching hospital was associated with a marked increase in unscheduled surgery and failed to reduce the incidence of post-operative SAEs, post-operative mortality, and mean duration of hospital stay.

A new tremor balance-transducer.

A new tremor-measuring device has been developed. It is constructed as a beam balance and measures principally in a vertical direction. Both arms of the beam contain a ceramic crystal; one of the arms has an extension that rests on the object to be measured. In this way, problems associated with mounting the transducer to the object are eliminated. The balance-transducer performs a well defined rotational movement in contrast to the frequently used transducers with a single sensor which are mounted to the object. The tremor movement of the limb and/or inadequate mounting causes unknown variation in the influence of the gravity component on the sensor; this can cause substantial errors. This tremor-transducer eliminates this problem. The static load of the balance-transducer on the object can be adjusted to less than 0.5 X 10(-3) kg(0.005 N). Even in the case of finger tremor, the balance-transducer does not influence the tremor phenomenon significantly. The principle of the balance-transducer is suited to measurements of postural, intention and limited action tremor of the finger, hand, forearm and jaw.

Oxygen consumption and lactate release by the lung after cardiopulmonary bypass and during septic shock.

OBJECTIVE: We sought to determine whether a correlation exists between lung lactate release and lung oxygen consumption by studying adult intensive care patients, either after cardiopulmonary bypass (CPB) or with septic shock. METHODS: A prospective observational study of six post cardiopulmonary bypass patients and seven patients with septic shock was performed in an intensive care unit of a major teaching hospital. Pulmonary oxygen consumption was estimated by subtracting oxygen consumption calculated using the reverse Fick equation (V O2Fick) from that measured by indirect calorimetry (V O2meas). Pulmonary lactate release was derived from the difference between arterial and mixed-venous lactate, multiplied by cardiac output. RESULTS: Pulmonary oxygen consumption comprised a substantial component of total oxygen consumption (CPB-median: 20.6%; interquartile range (IQR): 15.4 - 27.3%; septic shock-median: 32.3%; IQR: -4.0 - 35.4%). Lung lactate release occurred both after CPB (median: 27.5 mmol/hr; IQR: 24.8-64.1 mmol/hr) and with septic shock (median: 55.4 mmol/hr; IQR: 24.3 - 217.6 mmol/hr). Although no correlation was found between lung lactate release and pulmonary oxygen consumption, lactate release correlated with V O2meas and V O2Fick in septic patients (p < 0.005). CONCLUSIONS: We conclude that lung oxygen consumption and lactate release are substantial in conditions associated with lung inflammation. Lactate release and lung oxygen consumption may not share a common pathogenesis, however there is an association between lung lactate release and systemic oxygen consumption in sepsis.