A 360° Rotational Positioning Protocol of Organ Donors May Increase Lungs Available for Transplantation.

OBJECTIVES: To evaluate the improvement in lung donation and immediate lung function after the implementation of a 360° rotational positioning protocol within an organ procurement organization in the Midwest. DESIGN: Retrospective observational study. SETTING: The Midwest Transplant Network from 2005 to 2017. Rotational positioning of donors began in 2008. SUBJECTS: Potential deceased lung donors. INTERVENTIONS: A 360° rotational protocol. Presence of immediate lung function in recipients, change in PaO2:FIO2 ratio during donor management, initial and final PaO2:FIO2 ratio, and proportion of lungs donated were measured. Outcomes were compared between rotated and nonrotated donors. MEASUREMENTS AND MAIN RESULTS: A total of 693 donors were analyzed. The proportion of lung donations increased by 10%. The difference between initial PaO2:FIO2 ratio and final PaO2:FIO2 ratio was significantly different between rotated and nonrotated donors (36 ± 116 vs 104 ± 148; p < 0.001). Lungs transplanted from rotated donors had better immediate function than those from nonrotated donors (99.5% vs 68%; p < 0.001). CONCLUSIONS: There was a statistically significant increase in lung donations after implementing rotational positioning of deceased donors. Rotational positioning significantly increased the average difference in PaO2:FIO2 ratios. There was also superior lung function in the rotated group. The authors recommend that organ procurement organizations consider adopting a rotational positioning protocol for donors to increase the lungs available for transplantation.

Detection of Ventilator Autotriggering by an Esophageal Catheter Used to Monitor the Neural Input and Diaphragm Excitation.

Patient-ventilator synchrony has been the focus of attention in the field of mechanical ventilation for quite some time now. Toward that end, the modern ventilators are equipped with very sensitive pneumatic triggering mechanisms, which allow for minimal wasting of patient effort. The increasingly sensitive pneumatic triggers have the potential to cause autotriggering, where stimuli other than neural signals (eg, cardiac oscillations) can trigger the mechanical breath. Although autotriggering has been well documented in brain-dead patients, its existence is difficult to prove in patients who have the ability to trigger breath through neural diaphragmatic activity. The only way to be sure that the triggered breath is indeed from the neural diaphragmatic activity rather than a spurious change in pressure or flow is to monitor neural signals during triggered mechanical breaths. Autotriggering can have deleterious effects including diaphragmatic atrophy, increased duration on the mechanical ventilator, and increased stay in the intensive care unit. Esophageal catheters, with the ability to measure phrenic nerve and diaphragmatic activity, allow for the detection of the extent of autotriggering. This article demonstrates the hitherto unknown but potentially common occurrence of autotriggering through nonneural stimuli and their amelioration by making the pneumatic autotriggering less sensitive. The full extent of the phenomenon and its deleterious effects remain to be explored in larger patient populations.

What Is the Effect of Organ Donation Authorization Rates When Utilizing a Standardized Effective Request Process?

To determine if implementation of a standardized effective request process (ERP) can increase organ donation authorization rates. DESIGN: A retrospective, observational study was performed using data acquired from the Midwest Transplant Network. chi-square test was used to analyze categorical data, with p value of less than 0.05 deemed significant. SETTING: The Midwest Transplant Network located in Westwood, KS from January 1, 2013 to June 30, 2017. PATIENTS: A total of 1,391 consecutive patients were identified as potential donors based on medical evaluation of the patient's neurologic status, organ function, and established age criteria. INTERVENTIONS: An ERP was used when discussing donation with 733 patients (53%), compared with no ERP usage with 658 patients (47%). MEASUREMENTS AND MAIN RESULTS: A significant increase (30%) in donation rates was observed when an ERP was used. A comparative decrease in donation rates was observed whenever a breakdown in any of the four identified steps occurred. LIMITATIONS: The data analyzed was gathered retrospectively. Due to the retrospective nature of our study, there is no way to determine delay in authorization times versus no delay. Although most population data information about the authorized donors was known, this information was limited in patients who declined. CONCLUSIONS: With proper preparation and planning, the implementation of a standardized ERP may improve organ donation rates and increase the number of life-saving organs for transplant.

A Case of Fatal Serotonin Syndrome-Like Human Rabies Caused by Tricolored Bat-Associated Rabies Virus.

Human rabies is a fatal disease, transmitted by saliva of infected animals, and the diagnosis requires a high index of suspicion. Very few cases are reported annually in the United States. We present a case of human rabies without a clear exposure history that masqueraded as serotonin syndrome.

Peritoneal dialysis first: rationale.

The use of peritoneal dialysis (PD) has become wide spread since the introduction of continuous ambulatory PD more than 25 years ago. Over this time, many advances have been made and PD is an alternative to hemodialysis (HD), with excellent comparable survival, lower cost, and improved quality of life. The percentage of prevalent PD patients in the United States is approximately 7%, which is significantly lower compared with the 15% PD prevalence from the mid-1980s. Despite comparable survival of HD and PD and improved PD technique survival over the last few years, the percentage of patients performing PD in the United States has declined. The increased numbers of in-center HD units, physician comfort with the modality, perceived superiority of HD, and reimbursement incentives have all contributed to the underutilization of PD. In addition to a higher transplantation rate among patients treated with PD in the United States, an important reason for the low PD prevalence is the transfer to HD. There are various reasons for the transfer (e.g., episodes of peritonitis, membrane failure, patient fatigue, etc.). This review discusses the various factors that contribute to PD underutilization and the rationale and strategies to implement "PD first" and how to maintain it. The PD first concept implies that when feasible, PD should be offered as the first dialysis modality. This concept of PD first and HD second must not be seen as a competition between therapies, but rather that they are complementary, keeping in mind the long-term goals for the patient.

In Peritoneal Dialysis, Is There Sufficient Evidence to Make "PD First" Therapy?

Since its introduction more than 3 decades ago, the use of peritoneal dialysis (PD) has increased greatly due to its simplicity, convenience, and low cost. Advances in technique, antibiotic prophylaxis, and the introduction of newer solutions have improved survival, quality of life, and reduced rate of complications with PD. In Hong Kong, approximately 80% end-stage renal disease (ESRD) patients perform PD; in others, that is, Canada, Australia, and New Zealand, 20%-30% patients use PD. However, in the United States, the annual rate of prevalent patients receiving PD has reduced to 8% from its peak of 15% in mid-1980s. PD as the initial modality is being offered to far less patients than hemodialysis (HD), resulting in the current annual incidence rate of less than 10% in USA. There are many reasons preventing the PD first initiative including the increased numbers of in-center hemodialysis units, physician comfort with the modality, perceived superiority of HD, risk of peritonitis, achieving adequate clearances, and reimbursement incentives to providers. Patient fatigue, membrane failure, and catheter problems are other reasons which discourage PD utilization. In this paper, we discuss the available evidence and provide rationale to support PD as the initial renal replacement modality for ESRD patients.

Postprostatectomy seizures: A case report.

A 75-year-old Caucasian male presented with generalized seizures half-hour post-transurethral resection of the prostate surgery. The intra-operative course was complicated by perforation of the posterior wall of the bladder neck during a difficult Foley catheter placement. This resulted in intraperitoneal extravasation of the glycine containing bladder irrigation fluid. An emergent laparotomy was performed, and 3.5-4 L of fluid was drained from the peritoneal cavity. Postoperative course was complicated by two seizures within a short interval. Patient developed profound hyponatremia (Na of 109 mEq/L). However, measured serum osmolality was normal (283 mOsm/kg). The serum osmolality remained relatively stable, indicating that the absorbed glycine and its metabolites remained osmotically active in the intravascular space (until they were dialyzed as mentioned later), making the hyponatremia less pernicious and an unlikely cause of patient's symptoms. The encephalopathy and seizures were ascribed to accumulation of toxic metabolites of glycine, especially ammonia (serum level -1261 mcmol/L). During a complicated postoperative period, patient developed oligo-anuric renal failure, and was started on slow low-efficiency dialysis for 8 hours resulting in rapid lowering of serum ammonia levels and glycine with reversal of encephalopathy including seizures. There was no recurrence of encephalopathy, seizures, or metabolic acidosis. Although rare, glycine toxicity may be life threatening. The pathophysiology, need for early detection and the role of early use of renal replacement therapy in acute glycine toxicity is discussed below.