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The proposed donor heart selection guidelines provide evidence-based and expert-consensus recommendations for the selection of donor hearts following brain death. These recommendations were compiled by an international panel of experts based on an extensive literature review. © 2022 International Society for Heart and Lung Transplantation

PURPOSE OF REVIEW: Brain death, also known as death by neurologic criteria (DNC), is a well-established concept. In this article, we present a short history of the concept and give an overview of recent changes and a practical update on diagnosis and definitions of brain death/DNC. Unresolved issues will be discussed.RECENT FINDINGS: There is variability in brain death/DNC determination worldwide. In recent years, successful attempts have been made to harmonize these criteria and, consequently, to improve public trust in the process and diagnosis. An international multidisciplinary collaboration has been created and it has published minimum criteria, provided guidance for professionals and encouragement to revise or develop guidelines on brain death/DNC worldwide.SUMMARY: There are two sets of criteria for declaration of death. First, if there is neither cardiac output nor respiratory effort, then cardiopulmonary criteria are used. Second, if both the cerebrum and brainstem have completely and permanently lost all functions, and there is a persistent coma, absent brainstem reflexes and no spontaneous respiratory effort, death can be declared on the basis of brain death/DNC. Although attempts to formulate uniform criteria are ongoing, consensus has been reached on the minimum criteria. Some inconsistencies and questions remain.

Donor brain death-induced lung injury may compromise graft function after transplantation. Establishing strategies to attenuate lung damage remains a challenge because the underlying mechanisms remain uncertain. The effects of tacrolimus pretreatment were evaluated in an experimental model of brain death-induced lung injury. Brain death was induced by slow intracranial infusion of blood in anesthetized pigs after randomization to tacrolimus (orally administered at 0.25 mg. kg-1 BID the day before the experiment and intravenously at 0.05 mg. kg-1 one hour before the experiment; n=8) or placebo (n=9) pretreatment. Hemodynamic measurements were performed 1, 3, 5 and 7 hours after brain death. After euthanasia of the animals, lung tissue was sampled for pathobiological and histological analysis, including lung injury scoring (LIS). Tacrolimus pretreatment prevented increases in pulmonary artery pressure, pulmonary vascular resistance and pulmonary capillary pressure and decreases in systemic artery pressure and thermodilution cardiac output associated with brain death. After brain death, the ratio of the partial arterial O2 pressure to the inspired O2 fraction (PaO2/FiO2) decreased, which was prevented by tacrolimus. Tacrolimus pretreatment prevented increases in the interleukin (IL)-6-to-IL-10 ratio, vascular cell adhesion molecule-1, circulating levels of IL-1β, IL-6-to-IL-10 ratio and glycocalyx-derived molecules. Tacrolimus partially decreased apoptosis [Bax-to-Bcl2 ratio (p=0.07) and the number of apoptotic cells in the lungs (p

An increased number of older recipients underwent liver transplantation in recent years, and consequently needing to obtain more liver grafts. In order to increase this pool, in 2006, we initiated the use of livers from uncontrolled circulatory death (uDCD). We analyzed the use of uDCD livers in sexagenarian recipients and their effect on overall survival.A retrospective and comparative study was performed among 4 groups according to recipient age (less or greater than 60 years) and donor type (donor brain death [DBD] or uDCD): Group A: DBD livers in recipients aged60 years (n = 169); Group B: uDCD livers in recipients aged60 years (n = 36); Group C: DBD livers in recipients aged60 years (n = 96); and Group D: uDCD livers in recipients aged60 years(n = 39).Intraoperative transfusion, biliary complications, primary non-function, acute rejection, chronic renal dysfunction, retransplantation, and mortality during follow-up (cardiovascular diseases in 3 patients, hepatitis C virus recurrence in 4 patients, and de novo malignancies in 3 patients) were significantly higher, and 5-year patient and graft survival was significantly lower in sexagenarian recipients. Bilirubin and packed red blood cells transfusion were risk factors for patient survival, whereas hepatocelular carcinoma, creatinine, and packed red blood cells transfusion were risk factors for patient survival. Recipient age (60 years) was confirmed as protective factor for patient and graft survival, whereas the use of uDCD was not a risk factor for patient or graft survival.Use of a uDCD liver did not demonstrate as a risk factor for patient and graft survival, and recipient age (60 years) was a protective factor for patient and graft survival.

PURPOSE OF REVIEW: Brain death, also known as death by neurologic criteria (DNC), is a well-established concept. In this article, we present a short history of the concept and give an overview of recent changes and a practical update on diagnosis and definitions of brain death/DNC. Unresolved issues will be discussed. RECENT FINDINGS: There is variability in brain death/DNC determination worldwide. In recent years, successful attempts have been made to harmonize these criteria and, consequently, to improve public trust in the process and diagnosis. An international multidisciplinary collaboration has been created and it has published minimum criteria, provided guidance for professionals and encouragement to revise or develop guidelines on brain death/DNC worldwide. SUMMARY: There are two sets of criteria for declaration of death. First, if there is neither cardiac output nor respiratory effort, then cardiopulmonary criteria are used. Second, if both the cerebrum and brainstem have completely and permanently lost all functions, and there is a persistent coma, absent brainstem reflexes and no spontaneous respiratory effort, death can be declared on the basis of brain death/DNC. Although attempts to formulate uniform criteria are ongoing, consensus has been reached on the minimum criteria. Some inconsistencies and questions remain.

Late-phase images on computed tomography angiography (CTA), traditionally used for assessing cerebral circulatory arrest in brain death, suffer from suboptimal diagnostic yield due to stasis filling. Herein, we assessed contrast filling in individual intracranial arteries and veins in the early and late phases of CTA in patients with clinically confirmed brain death.Contrast opacification within 28 arterial/venous segments was evaluated in both phases of CTA in 79 patients. This information was combined with reports in the literature to calculate prevalence of contrast filling in different intracranial vessels. Additionally, diagnostic sensitivity of 4-point, 7-point, and 10-point scores defined for brain death were compared among ratings based on early, late, and both phases (arteries rated on early, veins rated on late phase) of imaging.The median (IQR) number of vessel segments with contrast opacification was 0 (0-2) in early phase and 6 (0-10) in late phase. All segments showed increased prevalence of opacification when evaluated in late phase (p 0.05). The M4 segments of MCA, internal cerebral veins, and vein of Galen had the lowest percentage of opacification in both phases. The sensitivity of 4-, 7-, and 10-point scoring algorithms increased from 59-91% to 94-99% when ratings were performed using early-phase images rather than based solely on late-phase images.The incorporation of early-phase images might be considered as a strategy to improve the sensitivity of CTA as an ancillary test in confirming brain death, especially in patients without missing or questionable elements in clinical examination.

Voluntary contribution has become the only source of donor lungs in China since 2015. To elaborate the outcomes of patients awaiting lung transplantation (LTx) after the implementation of donation after brain death, we performed a retrospective study that encompassed 205 patients with end-stage lung disease who registered for LTx at Shanghai Pulmonary Hospital from January 1, 2015 to January 1, 2021. A total of 180 patients were enrolled in the study. The median waiting time was 1.25 months. Interstitial lung disease (ILD) (103/180, 57.2%) and chronic obstructive pulmonary disease (COPD) (56/180, 31.1%) were the most common diseases in our study population. The mean pulmonary artery pressure (mPAP) of patients in the died-waiting group was higher than that of the survivors (53.29±21.71 mmHg vs. 42.11±18.58 mmHg, P=0.002). The mortality of patients with ILD (34/103, 33.00%) was nearly twice that of patients with COPD (10/56, 17.86%) while awaiting LTx (P=0.041). In the died-waiting group, patients with ILD had a shorter median waiting time than patients with COPD after being listed (0.865 months vs. 4.720 months, P=0.030). ILD as primary disease and mPAP35 mmHg were two significant independent risk factors for waitlist mortality, with hazard ratios (HR) of 3.483 (95% CI 1.311-9.111; P=0.011) and 3.500 (95% CI 1.435-8.536; P=0.006). Hence, LTx is more urgently needed in patients with ILD and pulmonary hypertension.

Despite the benefits of abdominal normothermic regional perfusion (A-NRP) for abdominal grafts in controlled donation after circulatory death (cDCD), there is limited information on the effect of A-NRP on the quality of the cDCD lungs. We aimed to study the effect of A-NRP in lungs obtained from cDCD and its impact on recipients´ outcomes. This is a study comparing outcomes of lung transplants (LT) from cDCD donors (September 2014 to December 2021) obtained using A-NRP as the abdominal preservation method. As controls, all lung recipients transplanted from donors after brain death (DBD) were considered. The primary outcomes were lung recipient 3-month, 1-year, and 5-year survival. A total of 269 LT were performed (60 cDCD and 209 DBD). There was no difference in survival at 3 months (98.3% cDCD vs. 93.7% DBD), 1 year (90.9% vs. 87.2%), and 5 years (68.7% vs. 69%). LT from the cDCD group had a higher rate of primary graft dysfunction grade 3 at 72 h (10% vs. 3.4%; p .001). This is the largest experience ever reported with the use of A-NRP combined with lung retrieval in cDCD donors. This combined method is safe for lung grafts presenting short-term survival outcomes equivalent to those transplanted through DBD.

The dead donor rule is fundamental to transplant ethics. The rule states that organ procurement must not commence until the donor is both dead and formally pronounced so, and by the same token, that procurement of organs must not cause the death of the donor. In a separate area of medical practice, there has been intense controversy around the participation of physicians in the execution of capital prisoners. These two apparently disparate topics converge in a unique case: the intimate involvement of transplant surgeons in China in the execution of prisoners via the procurement of organs. We use computational text analysis to conduct a forensic review of 2838 papers drawn from a dataset of 124 770 Chinese-language transplant publications. Our algorithm searched for evidence of problematic declarations of brain death during organ procurement. We find evidence in 71 of these reports, spread nationwide, that brain death could not have properly been declared. In these cases, the removal of the heart during organ procurement must have been the proximate cause of the donor's death. Because these organ donors could only have been prisoners, our findings strongly suggest that physicians in the People's Republic of China have participated in executions by organ removal.

Background: Right ventricular (RV) dysfunction remains a major problem after heart transplantation and may be associated with brain death (BD) in a donor. A calcineurin inhibitor tacrolimus was recently found to have beneficial effects on heart function. Here, we examined whether tacrolimus might prevent BD-induced RV dysfunction and the associated pathobiological changes. Methods: After randomized tacrolimus (n = 8; 0.05 mg·kg−1·day−1) or placebo (n = 9) pretreatment, pigs were assigned to a BD procedure and hemodynamically investigated 1, 3, 5, and 7 h after the Cushing reflex. After euthanasia, myocardial tissue was sampled for pathobiological evaluation. Seven pigs were used as controls. Results: Calcineurin inhibition prevented increases in pulmonary vascular resistance and RV-arterial decoupling induced by BD. BD was associated with an increased RV pro-apoptotic Bax-to-Bcl2 ratio and RV and LV apoptotic rates, which were prevented by tacrolimus. BD induced increased expression of the pro-inflammatory IL-6-to-IL-10 ratio, their related receptors, and vascular cell adhesion molecule-1 in both the RV and LV. These changes were prevented by tacrolimus. RV and LV neutrophil infiltration induced by BD was partly prevented by tacrolimus. BD was associated with decreased RV expression of the β-1 adrenergic receptor and sarcomere (myosin heavy chain [MYH]7-to-MYH6 ratio) components, while β-3 adrenergic receptor, nitric oxide-synthase 3, and glucose transporter 1 expression increased. These changes were prevented by tacrolimus. Conclusions: Brain death was associated with isolated RV dysfunction. Tacrolimus prevented RV dysfunction induced by BD through the inhibition of apoptosis and inflammation activation.

Introduction: Ancillary tests can be used for the diagnosis of brain death in cases wherein uncertainty exists regarding the neurological examination and apnoea test cannot be performed. Transcranial Doppler ultrasonography (TCD) is a useful, valid, non-invasive, portable, and repeatable ancillary test for the confirmation of brain death. The purpose of this case is to represent the utility of transcranial Doppler as an ancillary test in brain death confirmation. Case: A 32-year-old male patient was admitted to intensive care unit after DSA intervention due to middle cerebral artery (MCA) aneurysm. In the intensive care follow-ups, sedation vacation attempted, however his brain stem reflexes were absent, he had no respiratory effort, GCS score was 3, pupils were fixed dilated. The patient’s hemodynamic status remained stable throughout the ICU stay, only requiring low-dose norepinephrine for less than 12 hour. Neurological examination showed the absence of the corneal, gag, oculovestibular, and cough cranial reflexes. The apnea test was positive and then secondly TCD performed. Cerebral blood flow cessation detected and oscillating flow waves observed in MCA, anterior cerebral artery (ACA), posterior cerebral artery (PCA), basilar and vertebral arteries. We determined when to perform CT angiography (CTA) with light of TCD. Brain death was confirmed according to CTA results. Discussion: TCD ultrasonography, one of the ancillary bedside tests for brain death, is a non-invasive, reproducible method. Despite its limitations, TCD helps solve common diagnostic problems, avoids the unnecessary consumption of resources. It is inevitable that intensivists will gradually increase the use of TCD ultrasonography in the diagnosis of brain death in the near future due to its advantages. Keywords: Transcranial doppler USG, brain death, CT angiography, cerebral blood flow

One of the leading directions of the development of Ukrainian medicine during the last few years is organ transplantation, because it is a treatment method that remains the last hope when all other methods are already ineffective. However, despite the successes in this area, there are also problematic moments, the main of which is the lack of donor organs. And the reason for this shortage is considered to be the disapproval of relatives for the removal of organs, due to the low level of awareness of the procedure for establishing brain death. But, despite this, as well as in spite of the difficult working conditions during the war, Ukrainian transplantology is constantly developing, as evidenced by the data of the Ministry of Health and the Ukrainian Center for Transplant Coordination. A significant success in the field of transplantology is the second lung transplant recently carried out in Ukraine and the first carried out independently by Ukrainian doctors., Одним з провідних напрямків розвитку української медицини впродовж останніх декількох років є трансплантація органів, адже це метод лікування, який залишається останньою надією на порятунок, коли будь-які інші методи вже неефективні. Та, попри успіхи у цій сфері, виникають і проблемні моменти, основний з яких – нестача донорських органів. Головною причиною даного дефіциту вважається незгода родичів на вилучення органів, у зв’язку з низьким рівнем інформованості населення щодо процедури констатації смерті мозку. Та, не зважаючи на це, а також попри тяжкі умови праці в часі війни, українська трансплантологія безупинно розвивається, про що свідчать дані МОЗ та Українського центру трансплант-координації. Значним успіхом у сфері трансплантології є нещодавно проведена друга в Україні та перша, здійснена самостійно українськими лікарями, трансплантація легень.

The diagnosis of brain death is primarily clinical. Sometimes ancillary tests are needed.This study compared sensitivity and interobserver agreement of the 10-, 7- and 4-point CT angiography scoring systems for the diagnosis of brain death in children.CT angiography examinations of 50 pediatric patients with a clinical diagnosis of brain death were evaluated according to 10-, 7- and 4-point scoring systems. Images were evaluated by two radiologists who considered the vessel opacification first in the arterial phase (AUsing the clinical exam as the reference standard, we found sensitivities for 10-, 7- and 4-point scoring systems to be 70%, 88% and 92% in the AJust as in adult age groups, in children the 4-point scale appears to be more sensitive than the 10- and 7-point scales for CT angiography-based assessment of brain death. Because the scoring systems have similar sensitivities, they could be used as ancillary tests in pediatric cases.

In this article I examine the question of how a liberal state should go about defining death. Plausible standards for a definition of death include a somatic one based on circulatory criteria, death by neurologic criteria (DNC), and higher brain death. I will argue that Rawlsian "burdens of judgment" apply in this process: that is, reasonable disagreement should be expected on important topics, and such disagreement ought not be resolved via the coercive powers of the state. Nevertheless, the state must legislate a definition of death, and in doing so faces a "neutralist dilemma," that is, when there are multiple reasonable ways to move forward, only one can be chosen. I will examine a possible way to exit this neutralist dilemma. Finally, I will argue for DNC as the normatively preferred default definition of death. To do this, I will employ the Rawlsian heuristic of the "original position" and offer public reasons in favor of using DNC as the preferred default definition of death.

The conventional historical account of the concept of brain death credits developments and discoveries of the twentieth century with its inception, emphasizing the role of technological developments and professional conferences, notably the 1968 Ad Hoc Committee of the Harvard Medical School to Examine the Definition of Brain Death. This essay argues that the French physician Eugène Bouchut anticipated the concept of brain death as early as 1846. Correspondence with Bouchut’s understanding of brain death and one important contemporary concept of brain death is established then contrasted with current trends of defining death as the death of the brain. The philosophical factors that influenced Bouchut and the later developments of concepts of brain death are considered, with special reference to mechanistic philosophy and vitalism.

Donor hepatic artery thrombosis (dHAT) identified during liver procurement and backtable is a rare and little-reported event that can make liver transplants unfeasible.This is a retrospective study of dHAT identified during liver grafts procurements or backtable procedures. All grafts were recovered from brain-dead donors. The demographic characteristics of the donors and the incidence of dHAT were analyzed. The data were also compared to a cohort of donors without dHAT.There was a total of 486 donors during the study period. The incidence of dHAT was 1.85% (n = 9). The diagnosis of dHAT was made during procurement in 5 cases (55.5%) and during the backtable in 4 (44.4%). Most donors were female (n = 5), with an average BMI of 28.14 ± 6.9 kg/mThe occurrence of dHAT before liver procurement is a rare event, however it may become a treacherous pitfall if the diagnosis is late. Grafts with anatomic variations recovered from women with brain death due to stroke and with past history of hypertension seem to be at a higher risk of presenting dHAT.

Background: A guideline to determine pediatric brain death was updated in 2011. It is unknown how pediatric intensivists have accepted and adopted the revised guideline into clinical practice. Methods: We surveyed US pediatric critical care attending physicians July 2013 to September 2013 and February 2020 to May 2020. Brain death testing practices and utilization of the 2011 pediatric and neonatal brain death guideline were assessed. Results: The 2020 respondents found that the revised pediatric brain death guideline were useful in clinical practice (93.7% vs 83.3%, P = .0484) and provided more consistency and clarity (73.2% vs 63.1%, P = .0462) when compared to 2013 respondents. Conclusion: This study demonstrates that with defined criteria, survey participants reported increased clarity and consistency. Findings from our study indicate that in clinical practice there is no significant deviation from the minimum requirements to determine brain death in children as outlined in the 2011 guideline.

To detect the cerebral blood vessels and perfusion using neuroimaging modalities including computed tomography angiography (CTA), computed tomography perfusion (CTP), and arterial spin labeling (ASL) in children with brain death (BD).According to the current children's BD criteria, 5 children (3 males, 2 females, mean age of 5.65 years) with BD were enrolled from January 2019 to December 2020. The imaging features of CTA, CTP, and ASL were evaluated to analyze the visualization of important intracranial blood vessels and the states of the cerebral blood flow (CBF) and cerebral blood volume (CBV) related to the region of interest (ROI) brain tissue during the two clinical assessments for BD.The "4-point scale" scoring system of CTA was applied to evaluate BD and no negative results were detected. The CTP results of the 5 children suggested the cessation of cerebral circulation with 100% positive results. The ranges of CBF and CBV were 0.00-9.52 ml/100 g/min (mean value 4.95 ± 1.69 ml/100 g/min) and 0.00-1.34 ml/100 g (mean value 0.36 ± 0.20 ml/100 g), respectively. One patient also underwent ASL examination, which demonstrated a significant reduction in whole brain perfusion, indicating the absence of cerebral circulation. The CBF values of the brainstem, basal ganglia, and prefrontal lobe were 11.61 ± 1.49 ml/100 g/min, 7.81 ± 2.42 ml/100 g/min, and 9.94 ± 2.01 ml/100 g/min, respectively.Neuroimaging examinations particularly CTA and CTP reveal well the hemodynamic and cerebral blood vessels changes of BD, which can be used as supplementary supportive evidence for the declaration of brain death in children.

Summary Background Bone allografts are harvested and transplanted under sterile conditions. However, the risk of bacterial contamination of grafts during these processes is a health concern. Bioburden testing and bacterial contamination detection are conducted to ensure allograft sterility. Aim The present study aimed to determine the incidence of bacterial contamination in bone allografts based on different classifications. Methods PROSPERO registration number was received for the study. Systematic searches were conducted in PubMed and EMBASE databases with relevant keywords from January 2000 to March 2021. After choosing related studies according to the PRISMA flow diagram, Stata software was used for data analysis. We considered I 2 ˃ 50% as heterogeneity between studies. Findings The overall incidence of bacterial contamination was 12.6% (95% CI 0.100, 0.152) among 19,805 bone allografts of 17 studies. The bacterial contamination rate among bone allografts was 10.8% before 2010 and 14.7% in 2010-March 2021. The contamination frequency in Asia, Europe, and Australia was 11.5%, 14.3%, and 5.2%, respectively. Bone contamination rates were higher in cadaver donors (19.9%), retrieval time sampling (13.5%), and swab samples (13.2%) compared to those in living donors (7.5%), implantation time sampling (6.9%), and bone fragments cultures (6.3%). Bacterial contamination was recovered 24.4%, 19.7%, 13.2%, and 21% from tibia, fibula, femoral, and other bones, respectively. Staphylococcus spp. was the predominant isolated bacteria from bones (63.2% of all isolated genera), followed by Propionibacterium spp. (10.6%). Conclusion The high contamination of bone allografts is a health concern, indicating the need for more health monitoring and improvement of standards.

One of the important tasks of a modern hospital, in addition to treatment, prevention, and education, is the activity in the field of donating organs from deceased and living donors. In July 2010, the Polish Transplantation Coordination Center Poltransplant (the national transplantation organization and the authority responsible for organ donation and transplantation), thanks to the funds of the Ministry of Health, under the National Program for the Development of Transplant Medicine, initiated the project of building a network of coordinators by employing hospital transplantation coordinators in selected hospitals, where it is possible to identify potential deceased donors, perform the brain death diagnostic procedure, and where the conditions are met and it is possible to collect organs (they have an intensive care unit and operating theater in their structures). In Poland, these conditions are met by 388 hospitals with a donation potential.The aim of the work is to present the functioning of the system of transplant coordinators in Poland.The work presents the system of employment and tasks of transplant coordinators at various levels: hospital coordinators for donating organs from deceased donors, living donation and transplant coordinators, coordinators of hematopoietic cell collection and transplantation, central coordinators of Poltransplant, and organ procurement and transplant coordinators associated with transplant centers.

Static cold preservation remains the cornerstone for storing donor livers following procurement; however, the choice between University of Wisconsin solution (UW) and histidine-tryptophan-ketoglutarate solution (HTK) remains controversial. Recent International Liver Transplantation Society (ILTS) guidelines have recommended avoiding HTK for donation after circulatory death (DCD) grafts based on older reports. We studied the latest US adult graft outcomes in three recent eras (2006-2010, 2011-2015, 2016-2020) comparing HTK and UW among 5956 DCD LTs: 3873 (65.0%) used UW and 1944 (32.7%) used HTK. In a total of 82,679 donation after brain death (DBD) liver transplantations (LTs), 63,511 (76.8%) used UW and 15,855 (19.2%) used HTK. The HTK group had higher 1-year and 5-year graft survival rates of 89.7% and 74.3%, respectively, compared with 85.9% and 70.8% in the UW group in the 2016-2020 era (p = 0.005). This difference remained when adjusted for important potential confounders (hazard ratio, 0.78; 95% confidence interval: 0.60, 0.99). There were no differences between groups among DCD LTs in the earlier eras or among DBD LTs in all eras (all p values0.05). The latest US data suggest that HTK is at least noninferior to UW for preserving DCD livers. These data support HTK use in DCD LT and contradict ILTS guidance.

Organ shortage is the main limiting factor for further dissemination of organ transplantation therapies; implementation of brain-death (BD) criteria for organ donation purposes is essential for overcoming this limitation. Investigating and characterizing the effects of this intervention on organ availability and subsequent orthotopic organ transplantation in Asia, the world's most populous continent, should shed light on a global issue. The aim of this study was to describe temporal trends in brain-death donors (BDDs) and deceased-donor transplants (DDTs) in the Asian continent.We used data from the Global Observatory on Donation and Transplantation (GODT), the world's most comprehensive source of data relating to organ donation and transplantation activities. Available data on the number of BDDs and DDTs in 48 Asian countries was collated and analyzed for the years 2000-2019.The number of BDDs in Asia increased progressively, from 25 BBDs in 2000 to 5357 in 2019. The number of DDTs increased concomitantly, albeit with an initial decline between 2004 and 2008, with an exponential increase in the number of kidney and liver transplants, followed by heart and lung transplants. Data from the latest year with complete data (2019) demonstrated 25,557 deceased-donor organs were transplanted, representing a3-fold increase in the number of transplanted organs compared with the nadir in 2008.Although the Asian continent has noticed a rapid increase in BD transplantation activities during the past 2 decades, it is self-evident that further dissemination and adoption of BD donation are fundamental to reducing organ shortage gap.

The increase in the number of patients on the kidney transplant waiting list has led to an attempt to increase the number of potential donors by incorporating candidates that previously would not have been considered optimal, including donors after cardiac death (DCD) and those with "expanded" criteria (ECD). Recipients of controlled DCD (cDCD) grafts suffer more delayed graft function (DGF), but have a long-term evolution comparable to those of brain-dead donors, which has allowed an increase in the number of cDCD transplants in different countries in recent years. In parallel, the use of cDCD with expanded criteria (cDCD/ECD) has increased in recent years in different countries, allowing the waiting list for kidney transplantation to be shortened. The use of these grafts, although associated with a higher frequency of DGF, offers similar or only slightly lower long-term graft survival than those of brain death donors with expanded criteria. Different studies have observed that cDCD/ECD graft recipients have worse kidney function than cDCD/standard and brain death/ECD. Mortality associated with cDCD/ECD graft transplantation mostly relates to the recipient age. Patients who receive a cDCD/≥60 graft have better survival than those who continue on the waiting list, although this fact has not been demonstrated in recipients of cDCD/65 years. The use of this type of organ should be accompanied by the optimization of surgical times and the shortest possible cold ischemia.

Objective: To evaluate the educational impact of a pilot MOOC (Massive Open Online Course), validated by the French College of Urology Teachers (FCUT), on the surgical technique of kidney transplantation.Materials and methods: We developed a MOOC on the surgical technique of kidney transplantation, based on a video of a surgical procedure, performed by an expert surgeon. The MOOC has been validated by the FCUT. We have created 2 student groups: 1) MOOC-pre-QCM group: visualization of the MOOC then answer to the MCQs and satisfaction questions; 2) MOOC-post-QCM group: answer to the MCQs then visualization of the MOOC then answers to the satisfaction questions. In total, 20 MCQs on the kidney transplantation technique were completed by the 2 groups. The answers were anonymous.Results: A total of 142 people answered the MCQs (MOOC-pre-QCM group (n=66) and MOOC-post-QCM group (n=76)). Twenty-nine percent (41/142) of the participants were fellows and 71 % (101/142) were residents. The proportion of fellows and residents was identical between the 2 groups. The rate of correct answers to the 20 MCQs was statistically higher in the MOOC-pre-QCM group, compared to the MOOC-post-QCM group (88.6 % versus 73.3 %, P, ObjectifÉvaluer l’impact pédagogique d’un MOOC (Massive Open Online Course) pilote, validé par le Collège français des enseignants en urologie (CFEU), sur la technique chirurgicale de transplantation rénale.Matériel et méthodesNous avons réalisé un MOOC sur la technique chirurgicale de transplantation rénale, à partir d’une vidéo d’une intervention chirurgicale, réalisée par un chirurgien expert. Le MOOC a été validé par le CFEU. Nous avons créé 2 groupes d’étudiants : 1) groupe MOOC-pré-QCM : visualisation du MOOC, puis réponse aux QCM et aux questions de satisfaction ; 2) groupe MOOC-post-QCM : réponse aux QCM, puis visualisation du MOOC, puis réponse aux questions de satisfaction. Au total, 20 QCM sur la technique transplantation rénale ont été remplis par les 2 groupes. Les réponses étaient anonymes.RésultatsAu total, 142 personnes ont répondu aux QCM (groupe MOOC-pré-QCM (n = 66) et groupe MOOC-post-QCM (n = 76)). 29 % (41/142) des participants étaient des CCA ou assistants et 71 % (101/142) étaient des internes. La proportion de CCA/assistants et d’internes était identique entre les 2 groupes. Le taux de réponses correctes aux 20 QCM était statistiquement supérieur dans le groupe MOOC-pré-QCM, en comparaison au groupe MOOC post-QCM (88,6 % contre 73,3 %, p < 0,0001). Au total, 91 % des étudiants ont trouvé le MOOC « Très Utile » ou « Utile ». La médiane de la note du MOOC, donnée par les étudiants, était de 8/10.ConclusionCette étude a montré un impact positif du MOOC sur les connaissances théoriques de la technique chirurgicale de transplantation rénale. Ce MOOC pourrait servir de projet pilote pour le développement d’autres MOOC sur la chirurgie urologique.Niveau3.

OBJECTIVE: To identify optimal conditions for recovering viable inner ear tissues from deceased organ donors. SETTING: Tertiary recovery hospitals and Donor Network West Organ Recovery Center. INTERVENTIONS: Recovering bilateral inner ear tissues and immunohistological analysis. MAIN OUTCOME MEASURES: Immunohistochemical analysis of utricles from human organ donors after brain death (DBD) or donors after cardiac death (DCD). RESULTS: Vestibular tissues from 21 organ donors (39 ears) were recovered. Of these, 18 donors (33 utricles) were examined by immunofluorescence. The sensory epithelium was present in 7 utricles (two from DBD and five from DCD). Relative to DBD utricles, DCD organs more commonly displayed dense populations of hair cells and supporting cells. Relative to DBD, DCD had significantly shorter postmortem interval time to tissue recovery (less than 48 hours). Compared to donors with no sensory epithelium, donors with intact and viable sensory epithelium (both DCD and DBD) had significantly shorter lag time to resuscitation prior to hospital admission (6.4±9.2 versus 35.6±23.7 minutes, respectively) as well as a shorter time between pronouncement of death to organ recovery (22.6±30.4 versus 64.8 ±22.8 hours, respectively). CONCLUSIONS: Organ donors are a novel resource for bilateral inner ear organs. Selecting tissue donors within defined parameters can optimize the quality of recovered inner ear tissues, thereby facilitating future research investigating sensory and non-sensory cells.

There are increasing calls to reject the dead-donor rule and permit organ donation euthanasia in organ transplantation. I argue that the fundamental problem with this proposal is that it would bestow more worth on the organs than on the donor who possesses them. What is at stake is the basis of human equality, which, I argue, should be based on an ineliminable dignity that each of us has in virtue of having a rational nature. To allow mortal harvesting would be to make our worth contingent upon variable quality-of-life judgments that can be based only on properties that come in degrees. Thus, rejecting the dead-donor rule comes at the expense of egalitarian principles with respect to the value each individual human life has in relation to the protections against killing.

The specific effect of donation after circulatory death (DCD) liver grafts on fibrinolysis, blood loss, and transfusion requirements after graft reperfusion is not well known. The aim of this study was to determine whether transplantation of controlled DCD livers is associated with an elevated risk of hyperfibrinolysis, increased blood loss, and higher transfusion requirements upon graft reperfusion, compared with livers donated after brain death (DBD).A retrospective single-center analysis of all adult recipients of primary liver transplantation between 2000 and 2019 was performed (total cohort n = 628). Propensity score matching was used to balance baseline characteristics for DCD and DBD liver recipients (propensity score matching cohort n = 218). Intraoperative and postoperative hemostatic variables between DCD and DBD liver recipients were subsequently compared. Additionally, in vitro plasma analyses were performed to compare the intraoperative fibrinolytic state upon reperfusion.No significant differences in median (interquartile range) postreperfusion blood loss (1.2 L [0.5-2.2] versus 1.3 L [0.6-2.2]; P = 0.62), red blood cell transfusion (2 units [0-4] versus 1.1 units [0-3]; P = 0.21), or fresh frozen plasma transfusion requirements (0 unit [0-2.2] versus 0 unit [0-0.9]; P = 0.11) were seen in DCD compared with DBD recipients, respectively. Furthermore, plasma fibrinolytic potential was similar in both groups.Transplantation of controlled DCD liver grafts does not result in higher intraoperative blood loss or more transfusion requirements, compared with DBD liver transplantation. In accordance with this, no evidence for increased hyperfibrinolysis upon reperfusion in DCD compared with DBD liver grafts was found.

RESUMO Objetivo: Descrever o conhecimento de profissionais de saúde relacionado com doação de pulmão e manejo do doador. Métodos: Realizou-se estudo descritivo, transversal, com base em levantamento anônimo conduzido entre março e setembro de 2019 envolvendo profissionais de saúde registrados na Sociedad Argentina de Terapia Intensiva. Resultados: Dentre os 736 participantes, a média de idade foi de 30,5 anos (desvio-padrão de 8,9), sendo 61,3% do sexo feminino. Dentre os participantes, 60% eram médicos, 21,5% enfermeiros e 17,9% fisioterapeutas. Dentre os participantes, 68% se consideravam adequadamente informados com relação à procura de órgãos, e 79,8% afirmaram estar cientes do manejo de um potencial doador sob terapia intensiva. Os critérios relativos a um doador de pulmão foram respondidos corretamente por 71,3% dos participantes. Entretanto, após a morte cerebral do doador, 51% dos participantes não fariam modificações nos parâmetros de ventilação mecânica, 22,9% não sabiam quais parâmetros reprogramar, e 44,5% escolheriam um volume corrente de 6 - 8mL/kg e pressão positiva expiratória final de 5cmH2O. Para 85% dos profissionais de saúde, o tipo de teste de apneia escolhido foi desconexão do ventilador, e apenas 18,5% utilizariam um protocolo de controle. As intervenções mais frequentemente utilizadas no caso de pressão parcial de oxigênio/fração inspirada de oxigênio < 300 foram titulação da pressão positiva expiratória final, aspiração traqueal em circuito fechado e manobras de recrutamento. Conclusão: Os profissionais de saúde que participaram deste levantamento na Argentina responderam corretamente à maior parte das questões relacionadas aos critérios para o doador de pulmão. Contudo, faltou-lhes um conhecimento detalhado relativo aos parâmetros ventilatórios, às estratégias ventilatórias e aos protocolos para doadores de pulmão. Programas educacionais são fundamentais para otimizar a doação de múltiplos órgãos e devem focalizar a proteção dos pulmões do doador, com objetivo de incrementar o número de órgãos disponíveis para transplante. ABSTRACT Objective: To describe health care providers’ knowledge about lung donation and donor lung management. Methods: A descriptive, cross-sectional study based on an anonymous survey was conducted between March and September 2018 among health care professionals registered to Sociedad Argentina de Terapia Intensiva. Results: Of the 736 respondents, the mean age was 40.5 years (standard deviation 8.9), and 61.3% were female. Sixty percent were physicians, 21.5% were nurses, and 17.9% were physiotherapists. Seventy-eight percent considered themselves appropriately informed about organ procurement, and 79.8% stated that they knew potential organ donor critical care management. The lung donor criteria were answered correctly by 71.3% of the respondents. However, after the donor’s brain death, 51% made no changes to ventilator parameters, 22.9% were not aware of which parameters to reprogram, and 44.5% selected tidal volume of 6 - 8mL/kg and positive end expiratory pressure of 5cmH2O. For 85% of the health care providers, the type of apnea test chosen was disconnection from the ventilator, and only 18.5% used a lung management protocol. The most frequent interventions used in the case of arterial oxygen partial pressure/fractional inspired oxygen < 300 were positive end expiratory pressure titration, closed-circuit endotracheal suctioning, and recruitment maneuvers. Conclusion: Health care professionals surveyed in Argentina correctly answered most of the questions related to lung donor criteria. However, they lacked detailed knowledge about ventilatory settings, ventilatory strategies, and protocols for lung donors. Educational programs are key to optimizing multiorgan donation and should be focused on protecting the donor lungs to increase the numbers of organs available for transplantation.

To identify clinical and radiological factors associated to early evolution to brain death (BD), defined as occurring within the first 24 hours.A retrospective cohort study was made covering the period 2015-2017.An adult Intensive Care Unit (ICU).Epidemiological, clinical and imaging (CT scan) parameters upon admission to the ICU in patients evolving to BD.A total of 166 patients with BD (86 males, mean age 62.7 years) were analyzed. Primary cause: intracerebral hemorrhage 42.8%, subarachnoid hemorrhage 18.7%, traumatic brain injury 17.5%, anoxia 9%, stroke 7.8%, other causes 4.2%. Epidemiological data: arterial hypertension 50%, dyslipidemia 34%, smoking 33%, antiplatelet medication 21%, alcoholism 19%, anticoagulant therapy 15%, diabetes 15%. The Glasgow Coma Score (GCS) upon admission was 3 in 68.8% of the cases in early BD versus in 38.2% of the cases in BD occurring after 24 h (p = 0.0001). Eighty-five patients presented supratentorial hematomas with a volume of 90.9 ml in early BD versus 82.7 ml in BD 24 h (p = 0.54). The mean midline shift was 10.7 mm in early BD versus 7.8 mm in BD 24 h (p = 0.045). Ninety-one patients presented ventriculomegaly and 38 additionally ependymal transudation (p = 0.021). Thirty-six patients with early BD versus 24 with BD 24 h presented complete effacement of basal cisterns (p = 0.005), sulcular effacement (p = 0.013), loss of cortico-subcortical differentiation (p = 0.0001) and effacement of the suprasellar cistern (p = 0.005). The optic nerve sheath measurements showed no significant differences between groups.Early BD (24 h) was associated to GCS 5, midline shift, effacement of the basal cisterns, cerebral sulci and suprasellar cistern, and ependymal transudation.

Clinical Image on "Global Cerebral Infarction After Hospital Cardiac Arrest" presented in volume 4 issue 1 of 2023 of Ictus.

Background and Objectives: The inflammatory cells released after intracranial hemorrhage, such as monocytes, macrophages, and neutrophils, activate the inflammatory system. These parameters can be used to evaluate the clinical course of diseases. This study aims to evaluate these parameters as possible predictors for evaluating the development of brain death. Materials and Methods: Patients with a Glasgow coma scale score below 7 were assigned to Group BD (patients with brain death) and Group ICH (intracranial hemorrhage). The neutrophil, lymphocyte, platelet, monocyte counts, neutrophil-to-lymphocyte ratio (NLR), platelet-to-lymphocyte ratio (PLR), lymphocyte-to-monocyte ratio (LMR), and platelet-to-neutrophil ratio (PNR) were measured at admission. Results: A high WBC count, neutrophil count, NLR, and PLR and a low lymphocyte count, LMR, and PNR were found to be significant for determining brain death. The area under the curve (AUC) values of NLR, PNR, PLR, and LMR to discriminate brain death were 0.63, 0.61, 0.56, and 0.61, respectively. Conclusion: NLR, PNR, PLR, and LMR are easily accessible and reliable parameters that can be used to predict the development of brain death and can be estimated by a simple complete blood count test.

[cat] L’objectiu d’aquesta tesi és abordar, en primer lloc, la irrupció del biopoder en l’obra de Foucault, i, en segon lloc, analitzar el cas de la sida com a malaltia model del nostre present. Aquesta investigació està dividida en quatre parts. A la primera part, s’hi delimita el marc teòric de la investigació i s’introdueixen i se situen els conceptes principals de l’obra filosòfica de Foucault. A la segona part, s’hi exposa el pas del poder sobirà al poder disciplinari i, a continuació, s’analitza el poder disciplinari, de manera exhaustiva. La tercera part està dedicada al biopoder i està dividida en quatre apartats. Al primer apartat, s’hi aborda l’objecte sexualitat, que és el que va obrir la porta a la irrupció del biopoder. El segon apartat tracta del concepte de biopoder, des de la seva aparició, fins a les seves paradoxes; amb les característiques, conseqüències i nous personatges que comporta. El tercer apartat està dedicat al canvi d’estatut de la mort, amb una anàlisi de la mort com a límit del poder, com a lloc on el biopoder troba les seves contradiccions més importants; i s’hi tracta el cas de la mort cerebral. Finalment, el quart apartat està dedicat a examinar el dispositiu de seguretat, que és com Foucault anomena aquest nou repartiment del poder i del saber, i que apareix després del poder disciplinari. La quarta part està dedicada al cas de la malaltia de la sida i és analitzada d’acord amb l’esquema d’anàlisi de les malalties proposat per Foucault. Aquesta part està dividida en cinc apartats. El primer apartat està centrat en la irrupció de la malaltia. Al segon apartat, s’hi tracta la investigació científica que en va sorgir, des de la seva aparició i durant els primers anys de l’epidèmia. Al tercer apartat, s’hi analitzen les condicions de possibilitat que van permetre l’aparició de la malaltia. Es tracta, al quart apartat, el tema del risc de la sida. Finalment, al cinquè i últim apartat, s’hi considera la normalització que va lligada a la malaltia., [eng] The aim of this thesis is firstly to address the emergence of biopower in Foucault’s work, and secondly to analyze the case of AIDS as a model disease of our time. This research is divided into four parts. In the first part, the theoretical framework of the research is defined and the main concepts of Foucault's philosophical work are introduced and contextualized. In the second part, the transition from sovereign power to disciplinary power is presented, and then disciplinary power is exhaustively analyzed. The third part is dedicated to biopower and is divided into four sections. In the first section, the object addressed is sexuality, which opened the door to the emergence of biopower. The second section deals with the concept of biopower, from its appearance to its paradoxes, and with the features, consequences and new cast of characters which it entails. The third section is dedicated to the change in the status of death, with an analysis of death as a limitation of power, as a place where biopower encounters its most important contradictions; this section also deals with the case of brain death. Finally, the fourth section is dedicated to examining the security device, which is what Foucault calls the new distribution of power and knowledge, that appears after disciplinary power. The fourth part of this research is dedicated to the case of the AIDS disease, which is analyzed in accordance with the scheme of disease analysis proposed by Fouacult. This part is divided into five sections. The first section is focused on the emergence of the disease. The second section deals with the scientific research that arose from it, starting from its appearance and during the first years of the epidemic. In the third section, the conditions of possibility that allowed the emergence of the disease are analyzed. The fourth section deals with the issue of AIDS risk. Finally, the fifth and last section considers the normalization linked to this disease.

Moždana smrt predstavlja trajni gubitak svijesti te ireverzibilnu disfunkciju mozga i moždanog debla. Čini 1-2% svih smrti. Moždano mrtvi pacijenti najbolji su kandidati za donore organa stoga je vrlo bitno poznavati postupak dijagnosticiranja moždane smrti. Postupak utvrđivanja moždane smrti može započeti samo ako je utvrđen i objektivno dokumentiran ireverzibilni uzrok kome. Reverzibilni uzroci kome koji mogu oponašati moždanu smrt moraju biti isključeni. Moždana smrt predstavlja prvenstveno kliničku dijagnozu. Fizikalnim pregledom utvrđuju se klinički znakovi moždane smrti. Potrebno je zadovoljiti tri klinička kriterija: duboka koma, odsutnost refleksa moždanog debla i pozitivan apneja test. Moždano mrtvi pacijenti u dubokoj komi imaju GCS 3. Svi refleksi moždanog debla su odsutni. Ispituje se: reaktivnost zjenica na svjetlo, kornealni refleks, reakcija na bolni podražaj u području inervacije trigeminalnog živca, okulocefalični i okulovestibularni refleks, faringealni i trahealni refleks, atonija muskulature te atropinski test. Apneja test neće potaknuti spontanu respiratornu aktivnost. Test se smatra pozitivnim ako PaCO2 postane veći od 60mmHg ili se PaCO2 povisi za 20mmHg na referentnu vrijednost. Fizikalni pregled uputno je dopuniti minimalno jednim potvrdnim parakliničkim testom, pogotovo ako postoji sumnja u kliničku dijagnozu moždane smrti. Najčešće se izvode EEG, evocirani moždani potencijali, angiografija mozga i transkranijalna Doppler sonografija. Moždana smrt proglašava se nakon dva uzastopna fizikalna pregleda. Preglede obavlja povjerenstvo sastavljano od minimalno dva liječnika specijalista. Daljnji dijagnostički i terapijski postupci su neprikladni i nepotrebni nakon proglašenja moždane smrti. Jedinu iznimku čine darovatelji dijelova tijela za transplantaciju., Brain death is defined as a permanent loss of consciousness and irreversible dysfunction of the brain and the brainstem. It is diagnosed in 1-2% of all deaths. Brain-dead patients are the best candidates for organ transplantation so it is very important to know the procedure of brain death diagnosis. Irreversible cause of coma must be identified and objectively documented to start the process of brain death determination. Reversible causes of coma that may mimic brain death must be ruled out. Brain death is primarily a clinical diagnosis. Physical examination reveals clinical signs of brain death. Three clinical criteria need to be met: deep coma, absence of brainstem reflexes and positive apnea test. Brain-dead patients are in deep coma when the Glasgow Coma score is 3. Secondly, all brainstem reflexes are absent. The following reflexes are examined: pupillary response to light, corneal reflex, facial movement in response to noxious stimuli, oculocephalic and oculovestibular reflexes, gag and reflexes, muscular atonia and atropine test. Apnea test includes absence of spontaneous respiratory efforts. The test is considered positive if PaCO2 becomes greater than 60mmHg or PaCO2 rises by 20 mmHg above baseline. At least one ancillary test is recommended to overcome any doubt about the accuracy of a clinical diagnosis of brain death. The most commonly performed ancillary tests are EEG, multimodal evoked potentials, brain angiography and transcranial Doppler sonography. The two examinations must be performed by at least two specialists. Further diagnostic and therapeutic procedures are inappropriate and unnecessary after declaring brain death. The only exception for maintaining life support is to preserve organs for transplantation.

Einleitung: Das Intensivpflegepersonal spielt eine essenzielle Rolle bei der Pflege hirntoter Patient*innen und derer Angehörigen, welche ein hohes Maß an Verantwortung, Wissen und Kompetenz seitens der Pflegekräfte benötigt. Der Betreuungsprozess hirntoter Patient*innen ist für einige Intensivpflegepersonen anstrengend, emotional belastend und herausfordernd. Daher ist die Anwendung von Bewältigungsstrategien für Stress- und Belastungssituationen hilfreich, um einerseits die Gesundheit der Intensivpfleger*innen aufrechtzuerhalten und andererseits die höchste Qualität bei der Versorgung potenziell hirntoter Organspender*innen gewährleisten zu können. Methodik: Für diese wissenschaftliche Arbeit wurde eine systematische Literaturrecherche nach Kleibel & Mayer (2011) durchgeführt. Die Literaturrecherche erfolgte in fünf unterschiedlichen wissenschaftlichen Datenbanken, in der Onlinebibliothek des FH Campus Wiens und der Universität Wiens sowie mithilfe des Schneeballverfahrens. Die Qualität der identifizierten Literatur wurde anhand der Bewertungsinstrumente von Brandenburg, Panfil und Mayer (2018) kritisch bewertet. Infolgedessen wurden zur weiteren Bearbeitung der Forschungsfrage zehn qualitative Studien und zwei systematische Reviews herangezogen. Ergebnisse: Aus den Ergebnissen der miteingeschlossenen Literatur konnten drei Hauptkategorien und sechs Subkategorien gebildet werden, welche pflegerische Belastungsfaktoren bei der Betreuung hirntoter Patient*innen bis zur Organexplantation beschreiben sollen: „Belastungserleben“, „Angehörigenbetreuung“ und „Bewältigungsstrategien“. Viele Intensivpflegekräfte erleben einige belastende und stressige Situationen während des Betreuungsprozesses potenziell hirntoter Organspender*innen und derer Angehörigen, wobei sich die Anwendung von Bewältigungsstrategien positiv auf die Vermeidung deren Belastungserlebens auswirken kann. Schlussfolgerung: Psychologische und soziale Unterstützungsmöglichkeiten, Schulungen sowie Fort- und Weiterbildungen im Bereich der Ethik, des Organspendeprozesses und dem Hirntod müssen optimiert werden, um das Belastungserleben des Intensivpflegepersonals während der Pflege hirntoter Patient*innen minimieren beziehungsweise vermeiden und um deren emotionale Stabilität dabei steigern zu können. Es erscheint als nützlich Intensivpflegepersonen erweiterte und angemessene Kompetenzen und Kenntnisse über den Betreuungsprozess potenziell hirntoter Organspender*innen zu übermitteln und zu lehren, um die bestmögliche pflegerische Versorgung hirntoter Patient*innen gewährleisten zu können. Introduction: Intensive care staff plays an essential role in the care of brain-dead patients and their families which requires a high level of responsibility, knowledge and competence from the nurses. The process of caring for brain dead patients is stressful, emotionally draining and challenging for many intensive care nurses. Therefore, the use of coping strategies for stressful nursing situations is helpful in order to maintain the health of the intensive care staff on the one hand and on the other hand to be able to ensure the highest quality of care for potentially brain-dead organ donors. Methodology: For this scientific work a systematic literature search was conducted according to Kleibel & Mayer (2011). The literature search was carried out in five different scientific databases, in the online library of the FH Campus Wien and the University of Vienna and through the snowball method. The quality of the identified literature was critically evaluated using the assessment tool of Brandenburg et al. (2018). As a result, ten qualitative studies and two systematic reviews were used to further address the research question. Results: From the results of the included literature three main categories and six subcategories could be formed to describe nursing stress factors during the care of brain-dead patients until organ explantation: "Experience of stress", "Care of relatives" and "Coping strategies". Many intensive care nurses experienced some distressing and stressful situations during the process of caring for potentially brain-dead organ donors and their families and the use of coping strategies could have a positive impact on avoiding these stressful experiences. Conclusion: Psychological and social support, training and education about ethic, the organ donation process and brain death need to be optimised in order to minimise or avoid stressful experience of intensive care staff during the care of brain-dead patients and to increase their emotional stability. It seems useful to provide and teach intensive care nurses advanced and appropriate competencies and knowledge about the care process of potentially brain-dead organ donors to provide the best possible nursing care for brain-dead patients.

Poremećaji stanja svijesti djece uzrokovani su različitim poremećajima, od hipoglikemije do traumatskih intrakranijalnih krvarenja. Mogu trajati od nekoliko sekunda, poput sinkope, nekoliko dana i tjedana, pa sve do doživotnog stanja s protrahiranim poremećajima svijesti kao što su minimalno svjesno stanje ili perzistentno vegetativno stanje. Dobro poznavanje neuroanatomije i dobra vještina primjene tog znanja na ispitivanje neurološkog statusa omogućuje međusobno razlikovanje različitih stanja poremećaja svijesti te rano prepoznavanje uzroka. Ascendentni retikularni aktivacijski sustav moždanog debla, koji sadrži glavne strukture za regulaciju budnosti i spavanja, smješten je blizu jezgara čija se funkcija može klinički ispitati čak i u djece bez svijesti, što omogućuje lokalizaciju lezije i procjenu oštećenja. Radiološke, laboratorijske i elektrofiziološke pretrage služe daljnjem prepoznavanju različitih uzroka poremećaja svijesti. Ovaj rad ima za cilj dati kratak pregled uzroka poremećaja stanja svijesti, patofiziologije oštećenja koja stvaraju, specifičnosti kliničke prezentacije na osnovi kojih se mogu razlikovati i temeljna načela dijagnostičkog i terapijskog pristupa djetetu s akutnim poremećajem stanja svijesti., Disturbances of consciousness in children can be caused by various disorders, from hypoglycemia to traumatic intracranial hemorrhages. The duration of periods of impaired consciousness varies from less than a minute, such as syncope, days and weeks, to a lifetime of disordered consciousness in certain patients, such as a minimally conscious state or a persistent vegetative state. A knowledge of neuroanatomy and its skilful application enables properly differentiating between these states and recognizing their causes. The ascending reticular activating system of the brainstem, the main pathway regulating wakefulness and sleep, lies in close proximity to certain nuclei whose function can be clinically tested even in unconscious patients, allowing for localization of a potential focal lesion and assessment of damage. Neuroimaging, laboratory testing and electrophysiological studies can further identify different levels and causes of consciousness disorders. This paper aims to give a brief overview of the causes of disorders of consciousness, the pathophysiology of the damage they cause, the specifics of the clinical presentation that can be used to differentiate between them, and the basic principles of the diagnostic and therapeutic approach to a child with an acute disorder of the state of consciousness.

© 2023 The Authors. European Journal of Neurology published by John Wiley & Sons Ltd on behalf of European Academy of Neurology. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made., Background and purpose: Cerebral venous sinus thrombosis due to vaccine-induced immune thrombotic thrombocytopenia (CVST-VITT) is an adverse drug reaction occurring after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) vaccination. CVST-VITT patients often present with large intracerebral haemorrhages and a high proportion undergoes decompressive surgery. Clinical characteristics, therapeutic management and outcomes of CVST-VITT patients who underwent decompressive surgery are described and predictors of in-hospital mortality in these patients are explored. Methods: Data from an ongoing international registry of patients who developed CVST within 28 days of SARS-CoV-2 vaccination, reported between 29 March 2021 and 10 May 2022, were used. Definite, probable and possible VITT cases, as defined by Pavord et al. (N Engl J Med 2021; 385: 1680-1689), were included. Results: Decompressive surgery was performed in 34/128 (27%) patients with CVST-VITT. In-hospital mortality was 22/34 (65%) in the surgical and 27/94 (29%) in the non-surgical group (p < 0.001). In all surgical cases, the cause of death was brain herniation. The highest mortality rates were found amongst patients with preoperative coma (17/18, 94% vs. 4/14, 29% in the non-comatose; p < 0.001) and bilaterally absent pupillary reflexes (7/7, 100% vs. 6/9, 67% with unilaterally reactive pupil, and 4/11, 36% with bilaterally reactive pupils; p = 0.023). Postoperative imaging revealed worsening of index haemorrhagic lesion in 19 (70%) patients and new haemorrhagic lesions in 16 (59%) patients. At a median follow-up of 6 months, 8/10 of surgical CVST-VITT who survived admission were functionally independent. Conclusions: Almost two-thirds of surgical CVST-VITT patients died during hospital admission. Preoperative coma and bilateral absence of pupillary responses were associated with higher mortality rates. Survivors often achieved functional independence., This research was funded by the Netherlands Organization for Health Research and Development (ZonMw, grant number 10430072110005) and the Dr C.J. Vaillant Foundation.

The present effort offers students the opportunity to become familiar with approaches that are related both to the basic issues and dilemmas of the interdisciplinary subject of Bioethics, and to the approach through narrative, especially the "stories" of the Bible, which reflect various traditions of the Mediterranean peoples and have had an indelible influence on European culture. The bioethical issues addressed in the six chapters concern the beginning, duration and end of human life., Η παρούσα προσπάθεια προσφέρει στους φοιτητές τη δυνατότητα να εξοικειωθούν με προσεγγίσεις οι οποίες σχετίζονται τόσο με τα βασικά ζητήματα και διλήμματα του διεπιστημονικού γνωστικού αντικειμένου της Βιοηθικής, όσο και με την προσέγγιση μέσω της αφήγησης, ιδίως των «ιστοριών» της Βίβλου, οι οποίες αντικατοπτρίζουν ποικίλες παραδόσεις των λαών της Μεσογείου και έχουν επηρεάσει ανεξίτηλα τον ευρωπαϊκό πολιτισμό. Τα βιοηθικά θέματα, τα οποία εξετάζονται στα έξι κεφάλαια, αφορούν την αρχή, τη διάρκεια και το τέλος της ανθρώπινης ζωής.

Bakgrund: Varje år dör folk i väntan på organ- och vävnadsdonation. När en person avlider av total hjärninfarkt blir denne under rätt förutsättningar en möjlig donator. Organ- och vävnadsdonationsprocessen är en process som oftast ses som plötslig och främmande för de närstående. Närstående är involverade under hela donationsprocessen och de blir en del av omvårdnaden, något sjuksköterskan måste ta i beaktande. Syfte: Att belysa närståendes upplevelser av donationsprocessen. Metod: En litteraturöversikt baserad på kvalitativa artiklar där tio vetenskapliga originalartiklar analyserades. Resultat: Resultatet presenteras i två huvudteman: Yttre faktorer och Inre faktorer med två subteman tillhörande vardera huvudtema: vårdmiljö och tid, socialt stöd, bristande förståelse och att känna sig bortglömd. Konklusion: Närstående upplevde donationsprocessen som en svår tid med både positiva och negativa känslor. Yttre och inre faktorer präglar de närståendes upplevelser. Behovet av utveckling av vårdandet för de närstående kvarstår och behöver förbättras. Background: Every year people die waiting for organ and tissue donation. When a person dies of a total cerebral infarction, he becomes a possible donor under the right conditions. The organ and tissue donation process is a process that often is seen as sudden and foreign to the relatives. Relatives are involved throughout the donation process and they become part of the care, something the nurses must take into account. Aim: To shed light on relatives’ experiences of the donation process. Method: A literature review based on ten qualitative original articles were analysed. Findings: The results revealed two main themes: External factors and Internal factors with two subthemes belonging to each main theme: care environment and time, social support, lack of understanding and to feel forgotten. Conclusion: Relatives experienced the donation process as a difficult time with both positive and negative emotions. External and internal factors shape the experiences of those close to you. The need for development of care for the next of kin remains and needs to be improved.

In an attempt to address the organ shortages in heart transplantation, USA centres have begun utilizing donation after cardiac death (DCD) as an alternative to traditional donation after brain death (DBD). As this paradigm continues to expand, there is a need to address the medico-legal and ethical aspects of DCD donation, which is the focus of the current review.Current protocols use criteria established by the Uniform Determination of Death Act (UDDA), which is explicit in defining the irreversibility of circulation and brain function in determining death. By the nature of DCD, the patient may not meet death criteria from a biological systems perspective of irreversibility, and thus, the moral dilemma ensues on whether removing vital organs violates our legal and moral obligations to the patient.In the current article, we review the ethical issues raised with DCD and define DCD protocols and their ability to comply with established regulatory guidelines while respecting the wishes of patients and their surrogates through informed decisions making about organ donation and end-of-life care.

In 2019 a total of 756 people died in Germany while registered on the waiting list for an organ transplantation. With 10.8 organ donors/million inhabitants in 2019, Germany belongs to the bottom group in the Eurotransplant foundation as well as worldwide. All political attempts to increase the number of organ donations have so far been unsuccessful. Furthermore, the pandemic triggered by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) led to a further decline in organ donations. Critical care physicians play an important role in the identification of potential doners and are also the main point of contact for relatives; however, multiple uncertainties exist regarding the process of organ donation not only in discussions in the media and society but also among physicians involved in intensive care medicine. Many assumptions and hypotheses, which have been associated with the low number of donors, lack scientific evidence and are discussed in this article.Im Jahr 2019 starben in Deutschland 756 Menschen, während sie auf der Warteliste für ein Spenderorgan standen. Sowohl im Eurotransplant-Verbund als auch weltweit gehört Deutschland mit 10,8 Organspendern/Mio. Einwohner im Jahr 2019 zur Schlussgruppe. Sämtliche politischen Versuche, die Spenderzahlen zu steigern, scheinen bislang ohne Effekt geblieben zu sein. Darüber hinaus hat die durch das „severe acute respiratory syndrome coronavirus 2“ (SARS-CoV-2) ausgelöste Pandemie zum weiteren Rückgang der Spenderzahlen geführt. Der Intensivmedizinerin kommt im Prozess der Erkennung möglicher Spender sowie als erste Ansprechpartnerin für die Angehörigen eine zentrale Rolle zu. Jedoch existieren nicht nur in den gesellschaftlichen und medialen Diskussionen um das Thema Organspende viele Unklarheiten, sondern auch bei den intensivmedizinisch tätigen Ärzten. Viele Annahmen und Hypothesen, die mit den niedrigen Spenderzahlen in einen Zusammenhang gebracht werden, lassen sich wissenschaftlich jedoch nicht belegen und sollen in diesem Beitrag diskutiert werden.

Current risk-adjusted models for donor lung use and lung graft survival do not include donor critical care data. We sought to identify modifiable donor physiologic and mechanical ventilation parameters that predict donor lung use and lung graft survival. This is a prospective observational study of donors after brain death (DBDs) managed by 19 Organ Procurement Organizations from 2016 to 2019. Demographics, mechanical ventilation parameters, and critical care data were recorded at standardized time points during donor management. The lungs were transplanted from 1811 (30%) of 6052 DBDs. Achieving ≥7 critical care endpoints was a positive predictor of donor lung use. After controlling for recipient factors, donor blood pH positively predicted lung graft survival (OR 1.48 per 0.1 unit increase in pH) and the administration of dopamine during donor management negatively predicted lung graft survival (OR 0.19). Tidal volumes ≤8 ml/kg predicted body weight (OR 0.65), and higher positive end-expiratory pressures (OR 0.91 per cm H2 O) predicted decreased donor lung use without affecting lung graft survival. A randomized clinical trial is needed to inform optimal ventilator management strategies in DBDs.

BackgroundSocio-cultural perceptions surrounding death have profoundly changed since the 1950s with development of modern intensive care and progress in solid organ transplantation. Despite broad support for organ transplantation, many fundamental concepts and practices including brain death, organ donation after circulatory death, and some antemortem interventions to prepare for transplantation continue to be challenged. Attitudes toward the ethical issues surrounding death and organ donation may influence support for and participation in organ donation but differences between and among diverse populations have not been studied.ObjectivesIn order to clarify attitudes toward brain death, organ donation after circulatory death and antemortem interventions in the context of organ donation, we conducted a scoping review of international English-language quantitative surveys in various populations.Study appraisalA search of literature up to October 2020 was performed, using multiple databases. After screening, 45 studies were found to meet pre-specified inclusion criteria.Results32 studies examined attitudes to brain death, predominantly in healthcare professionals. In most, around 75% of respondents accepted brain death as equivalent to death of the person. Less common perspectives included equating death with irreversible coma and willingness to undertake organ donation even if itcauseddeath. 14 studies examined attitudes to organ donation following circulatory death. Around half of respondents in most studies accepted that death could be confidently diagnosed after only 5 min of cardiorespiratory arrest. The predominant reason was lack of confidence in doctors or diagnostic procedures. Only 6 studies examined attitudes towards antemortem interventions in prospective organ donors. Most respondents supported minimally invasive procedures and only where specific consent was obtained.ConclusionsOur review suggests a considerable proportion of people, including healthcare professionals, have doubts about the medical and ethical validity of modern determinations of death. The prognosis of brain injury was a more common concern in the context of organ donation decision-making than certainty of death.

Livers procured via donation after cardiac death have produced good outcomes. Some centers use only aortic perfusion; others add portal perfusion.We report a series of organ procurements in which portal perfusion was performed via cannulation of the splenic vein instead of the inferior mesenteric vein in 4 donors after cardiac death and 2 donors after brain death.After declaration of death, donors were brought to the operating room and prepared and draped. During procurement, first the aorta was cannulated, and then the atrium or inferior vena cava was opened and perfusion was started.The spleen was mobilized, the splenic vein was dissected out and cannulated, and portal perfusion was performed with 2 L of University of Wisconsin solution. Five liver allografts were transplanted: 3 at our center, and 2 at outside centers. One liver from a donor after cardiac death was declined because of a high fat content. All 5 transplanted grafts showed good initial function; there was no sign of primary nonfunction, and no vascular or biliary complications developed.For livers from donors after cardiac death, cannulation of the splenic vein was easier than access via the inferior mesenteric vein. For donors after brain death, we also found this technique was suitable for livers with intra-abdominal adhesions or a small inferior mesenteric vein. Graft outcomes in this series were excellent.

Death by neurologic criteria is a diagnosis that has presented complexities since its inception and pediatric cases are no exception. While rare, families may request accommodation to deviate from the traditionally defined diagnostic pathway based on their beliefs, mistrust of the diagnosis, or other complex reasons. Palliative care consultation offers a unique clinical perspective to complement the work of intensivists to support families through the diagnosis and possible resolution around accommodation requests. With misinformation and high-profile cases widely visible to the public through the media, these requests require a thoughtful and informed clinical approach by all members of the interdisciplinary clinical team. Common themes in many of these cases are trauma, bias and their impact on caregivers. We use a case-based approach to explore these complexities and clinical tools.

BACKGROUND Despite well-defined American Academy of Neurology guidelines for death by whole brain criteria (brain death), there is marked variability in national practice, which some have attributed to lack of formal education. Further, communication with surrogates and families about brain death is integral to brain death declaration. As such, we developed a targeted brain death curriculum combining didactics and simulation-based education to improve examination and subsequent communication skills with families. METHODS Multidisciplinary critical care fellows participated in (1) didactic and case-based curriculum, (2) brain death simulated examination (SimMan3G mannequin), and (3) a standardized family scenario with delivery of a brain death diagnosis to a surrogate "family member". Fellows completed a precurriculum and postcurriculum multiple choice knowledge test and survey (Likert 1 to 10 scale) evaluating measures regarding diagnosis and communication of brain death. t Test and 2-tailed Wilcoxon signed rank test were used for statistical analysis (P

The hemodynamic maintenance of brain-dead donors will influence the quality of the organs procured for transplantation, including the intestine. Although norepinephrine (NE) and dopamine (DA) are commonly used to sustain mean arterial pressure in humans, there are no standardized protocols for their use during maintenance of brain-dead donors. Our aim was to compare the effects of each drug, in the intestinal graft quality using a rat brain-dead donation model.Wistar rats (N = 17) underwent brain death (BD) for 2 hours with NE (NE group) or with DA (DA group) administration; the control group was mechanically ventilated for 2 hours without BD. Jejunum biopsies were obtained at the end of the maintenance period. Histological damage was evaluated using Park-Chiu scale. Villi/crypt ratio, mucosal thickness, Goblet cell count, and villi density were evaluated using ImageJ software (US National Institutes of Health, Bethesda, MD). Barrier damage was assessed by bacterial translocation culture counting on liver samples. The inflammatory status of the intestine was evaluated by CD3+ counting by immunohistochemistry and gene expression analysis of interleukin (IL)-6, IL-22, and CXCL10.Norepinephrine-treated donors had higher focal ischemic injury in the intestinal mucosa without a substantial modification of morphometrical parameters compared with DA-treated donors. CD3+ mucosal infiltration was greater in intestines procured from brain-dead donors, being highest in NE (p ˂ 0.001). Local inflammatory mediators were affected in BD: DA and NE groups showed a trend to lower expression of IL-22, whereas CXCL10 expression was higher in NE versus control group. Brain death promoted intestinal bacterial translocation, but the use of NE resulted in the highest bacterial counting in the liver (p ˂ 0.01).Our results favor the use of DA instead of NE as main vasoactive drug to manage BD-associated hemodynamic instability. Dopamine may contribute to improve the quality of the intestinal graft, by better preserving barrier function and lowering immune cell infiltration.The hemodynamic maintenance of brain-dead donors will influence the quality of the organs procured for transplantation, including the intestine. Although norepinephrine (NE) and dopamine (DA) are commonly used to sustain mean arterial pressure in humans, there are no standardized protocols for their use during maintenance of brain-dead donors. Our aim was to compare the effects of each drug, in the intestinal graft quality using a rat brain-dead donation model.Wistar rats (N = 17) underwent brain death (BD) for 2 hours with NE (NE group) or with DA (DA group) administration; the control group was mechanically ventilated for 2 hours without BD. Jejunum biopsies were obtained at the end of the maintenance period. Histological damage was evaluated using Park-Chiu scale. Villi/crypt ratio, mucosal thickness, Goblet cell count, and villi density were evaluated using ImageJ software (US National Institutes of Health, Bethesda, MD). Barrier damage was assessed by bacterial translocation culture counting on liver samples. The inflammatory status of the intestine was evaluated by CD3+ counting by immunohistochemistry and gene expression analysis of interleukin (IL)-6, IL-22, and CXCL10.Norepinephrine-treated donors had higher focal ischemic injury in the intestinal mucosa without a substantial modification of morphometrical parameters compared with DA-treated donors. CD3+ mucosal infiltration was greater in intestines procured from brain-dead donors, being highest in NE (p ˂ 0.001). Local inflammatory mediators were affected in BD: DA and NE groups showed a trend to lower expression of IL-22, whereas CXCL10 expression was higher in NE versus control group. Brain death promoted intestinal bacterial translocation, but the use of NE resulted in the highest bacterial counting in the liver (p ˂ 0.01).Our results favor the use of DA instead of NE as main vasoactive drug to manage BD-associated hemodynamic instability. Dopamine may contribute to improve the quality of the intestinal graft, by better preserving barrier function and lowering immune cell infiltration.

Jahi McMath was diagnosed brain dead on 12/12/2013 in strict accordance with both the pediatric and adult Guidelines, reinforced by 4 isoelectric electroencephalograms and a radionuclide scan showing intracranial circulatory arrest. Her magnetic resonance imaging scan 9 1/2 months later surprisingly showed gross integrity of cortex, basal ganglia, thalamus, and upper brainstem. The greatest damage was in the white matter, which was extensively demyelinated and cystic, and in the lower brainstem, most likely from partial herniation that resolved. The apparent integrity of gray matter and the ascending reticular activating system may have provided a potential structural basis for the reemergence of some limited brain functions, while the white matter and lower brainstem lesions would have caused severe motor disability, brainstem areflexia and apnea. The findings indicate that there could never have been a period of sustained intracranial circulatory arrest. Rather, at the time of brain death diagnosis, low blood flow below the detection threshold of the radionuclide scan was sufficient to maintain widespread neuronal viability, though insufficient to support synaptic function. Her case represents the first indirect confirmation of the reality and clinical relevance of global ischemic penumbra, hypothesized in 1999 as a generally unacknowledged and possibly common brain death mimic.

There are concerns that simultaneous pancreas-kidney (SPK) transplants from donation after circulatory death (DCD) donors have a higher risk of graft failure than those from donation after brain death (DBD) donors. A UK registry analysis of SPK transplants between 2005 and 2018 was performed. Pancreas survivals of those receiving organs from DCD or DBD donors were compared. Multivariable analyses were used to adjust for baseline differences between the two groups and to identify factors associated with pancreas graft loss. A total of 2228 SPK transplants were implanted; 403 (18.1%) were from DCD donors. DCD donors were generally younger, slimmer, less likely to have stroke as a cause of death, with lower terminal creatinines and shorter pancreas cold ischemic times than DBD donors. Median (IQR) follow-up was 4.2 (1.6-8.1) years. On univariable analysis, there were no statistically significant differences in 5-year death-censored pancreas graft survival between the two donor types (79.5% versus 80.4%; p = .86). Multivariable analysis showed no statistically significant differences in 5-year pancreas graft loss between transplants from DCD (n = 343) and DBD (n = 1492) donors (hazard ratio 1.26, 95% CI 0.76-1.23; p = .12). The findings from this study support the increased use of SPK transplants from DCD donors.