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Introduction The exposure of anesthesiologists to organ recovery procedures and the anesthetic technique used during organ recovery has not been systematically studied in the United States. Methods A retrospective cohort study was conducted on all adult and pediatric patients who were declared brain dead between January 1, 2008, and June 30, 2019, and who progressed to organ donation at Harborview Medical Center. We describe the frequency of directing anesthetic care by attending anesthesiologists, anesthetic technique, and donor management targets during organ recovery. Results In a cohort of 327 patients (286 adults and 41 children), the most common cause of brain death was traumatic brain injury (51.1%). Kidneys (94.4%) and liver (87.4%) were the most common organs recovered. On average, each year, an attending anesthesiologist cared for 1 (range: 1 to 7) brain-dead donor during organ retrieval. The average anesthetic time was 127±53.5 (mean±SD) minutes. Overall, 90% of patients received a neuromuscular blocker, 63.3% an inhaled anesthetic, and 33.9% an opioid. Donor management targets were achieved as follows: mean arterial pressure ≥70 mm Hg (93%), normothermia (96%), normoglycemia (84%), urine output >1 to 3 mL/kg/h (61%), and lung-protective ventilation (58%). Conclusions During organ recovery from brain-dead organ donors, anesthesiologists commonly administer neuromuscular blockers, inhaled anesthetics, and opioids, and strive to achieve donor management targets. While infrequently being exposed to these cases, it is expected that all anesthesiologists be cognizant of the physiological perturbations in brain-dead donors and achieve physiological targets to preserve end-organ function. These findings warrant further examination in a larger multi-institutional cohort.

Secondary insults worsen outcomes after traumatic brain injury (TBI). However, data on intraoperative secondary insults are sparse. The primary aim of this study was to examine the prevalence of intraoperative secondary insults during orthopedic surgery after moderate-severe TBI. We also examined the impact of intraoperative secondary insults on postoperative head computed tomographic scan, intracranial pressure (ICP), and escalation of care within 24 hours of surgery.We reviewed medical records of TBI patients 18 years and above with Glasgow Coma Scale score13 who underwent single orthopedic surgery within 2 weeks of TBI. Secondary insults examined were: systemic hypotension (systolic blood pressure90 mm Hg), intracranial hypertension (ICP20 mm Hg), cerebral hypotension (cerebral perfusion pressure50 mm Hg), hypercarbia (end-tidal CO240 mm Hg), hypocarbia (end-tidal CO230 mm Hg in absence of intracranial hypertension), hyperglycemia (glucose200 mg/dL), hypoglycemia (glucose60 mg/dL), and hyperthermia (temperature38°C).A total of 78 patients (41 [18 to 81] y, 68% male) met the inclusion criteria. The most common intraoperative secondary insults were systemic hypotension (60%), intracranial hypertension and cerebral hypotension (50% and 45%, respectively, in patients with ICP monitoring), hypercarbia (32%), and hypocarbia (29%). Intraoperative secondary insults were associated with worsening of head computed tomography, postoperative decrease of Glasgow Coma Scale score by ≥2, and escalation of care. After Bonferroni correction, association between cerebral hypotension and postoperative escalation of care remained significant (P0.001).Intraoperative secondary insults were common during orthopedic surgery in patients with TBI and were associated with postoperative escalation of care. Strategies to minimize intraoperative secondary insults are needed.

Nutritional adequacy is frequently compromised after brain injury, consequent to initial pathology as well as iatrogenic factors. This also compromises fluid handling, pharmacodynamics, and subsequent wound healing. Early feeding improves outcomes, with the jejunal route offering greater success but more complexity in placement. Motility disorders are common but significantly compromise physiology, while stress gastric erosion remains a significant risk. Refeeding syndrome is a risk in cases of malnutrition. Hyperglycemia has adverse effects, but interventions and the precise thresholds for these remain uncertain. Immune-enhancing formulas can reduce infection rates. Combination therapies of vitamins and trace elements offer possibilities for improvement.

Purpose of reviewIncreasing numbers of deaths on the transplant waiting list is associated with an expanding supply–demand deficit in transplantable organs. There is consequent interest in reviewing both donor eligibility after death from traumatic brain injury, and subsequent management, to minimiz

Subarachnoid hemorrhage (SAH) is a form of stroke with increasing incidence and significance to practitioners in neuroanesthesia and neurocritical care. Despite the evolution of interventional and surgical treatment technologies, SAH initiates a chain of secondary pathophysiological processes that can materially affect outcome despite successful control of the point of bleeding. Treatment principles must focus on these multisystem processes as well as on the maintenance of cerebrovascular integrity, and the effect of dedicated comprehensive neurocritical care can consequently benefit outcome. Bundled “Triple-H” protocols have been refined to emphasize euvolemia and perfusion, while pharmaceutical treatments of SAH-associated vasospasm have not been shown to be effective. These new perspectives force clinicians to refresh pathophysiological paradigms, and consider new therapeutic strategies.

Medical management of cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) includes hypertensive, hypervolemic, and hemodilution (“triple-H”) therapy. However, there is little information regarding the indications and guidance used to initiate and adjust triple-H therapy. A 43-item questionnaire was e-mailed to 375 members of the Neurocritical Care Society. Questions were designed to investigate the diagnostic approach to cerebral vasospasm and prophylactic and therapeutic administration of triple-H therapy. Completed surveys were received from 167 respondents (45% response proportion). Eighty-six percent of respondents worked in hospitals with neurointensive care units (NICUs). SAH patients in hospitals with a NICU had longer ICU stay (P = 0.037) and had indwelling central venous catheters for longer (P

Death is more than a mere biological occurrence. It has important legal, medical, and social ramifications that make it imperative that those who are responsible for determination of death be accurate and above suspicion. The medical and legal definitions of death have evolved to include consideration of such concepts as loss of integration of the whole organism, loss of autonomy, and loss of personhood. Development of the concept of brain death coincided with advances in medical technology that facilitated artificial ventilation and organ transplantation. More recently, the process of "timed" death with subsequent organ donation (controlled donation after cardiac death transplantation) has raised controversial questions having to do with the limits of treatments that facilitate organ transplant but might hasten death, and the duration of cardiac arrest necessary for declaration of death and the commencement of organ procurement. In this review, we discuss the background and ethical ramifications of the concepts of brain death, and of controversies involved in controlled donation after cardiac death organ transplantation.

Background Perioperative hypothermia has been reported to increase the occurrence of cardiovascular complications. By increasing the activity of sympathetic nervous system, perioperative hypothermia also has the potential to increase cardiac injury and dysfunction associated with subarachnoid hemorrhage. Methods The Intraoperative Hypothermia for Aneurysm Surgery Trial randomized patients undergoing cerebral aneurysm surgery to intraoperative hypothermia (n = 499, 33.3 degrees +/- 0.8 degrees C) or normothermia (n = 501, 36.7 degrees +/- 0.5 degrees C). Cardiovascular events (hypotension, arrhythmias, vasopressor use, myocardial infarction, and others) were prospectively followed until 3-month follow-up and were compared in hypothermic and normothermic patients. A subset of 62 patients (hypothermia, n = 33; normothermia, n = 29) also had preoperative and postoperative (within 24 h) measurement of cardiac troponin-I and echocardiography to explore the association between perioperative hypothermia and subarachnoid hemorrhage-associated myocardial injury and left ventricular function. Results There was no difference between hypothermic and normothermic patients in the occurrence of any single cardiovascular event or in composite cardiovascular events. There was no difference in mortality (6%) between groups, and there was only a single primary cardiovascular death (normothermia). There was no difference between hypothermic and normothermic patients in postoperative versus preoperative left ventricular regional wall motion or ejection fraction. Compared with preoperative values, hypothermic patients had no postoperative increase in cardiac troponin-I (median change 0.00 microg/l), whereas normothermic patients had a small postoperative increase (median change + 0.01 microg/l, P = 0.038). Conclusion In patients undergoing cerebral aneurysm surgery, perioperative hypothermia was not associated with an increased occurrence of cardiovascular events.

Background Although hypothermia and barbiturates improve neurologic outcomes in animal temporary focal ischemia models, the clinical efficacy of these interventions during temporary occlusion of the cerebral vasculature during intracranial aneurysm surgery (temporary clipping) is not established. Methods A post hoc analysis of patients from the Intraoperative Hypothermia for Aneurysm Surgery Trial who underwent temporary clipping was performed. Univariate and multivariate logistic regression methods were used to test for associations between hypothermia, supplemental protective drug, and short- (24-h) and long-term (3-month) neurologic outcomes. An odds ratio more than 1 denotes better outcome. Results Patients undergoing temporary clipping (n = 441) were assigned to intraoperative hypothermia (33.3 degrees +/- 0.8 degrees C, n = 208) or normothermia (36.7 degrees +/- 0.5 degrees C, n = 233), with 178 patients also receiving supplemental protective drug (thiopental or etomidate) during temporary clipping. Three months after surgery, 278 patients (63%) had good outcome (Glasgow Outcome Score = 1). Neither hypothermia (P = 0.847; odds ratio = 1.043, 95% CI = 0.678-1.606) nor supplemental protective drug (P = 0.835; odds ratio = 1.048, 95% CI = 0.674-1.631) were associated with 3-month Glasgow Outcome Score. The effect of supplemental protective drug did not significantly vary with temperature. The effects of hypothermia and protective drug did not significantly vary with temporary clip duration. Similar findings were made for 24-h neurologic status and 3-month Neuropsychological Composite Score. Conclusion In the Intraoperative Hypothermia for Aneurysm Surgery Trial, neither systemic hypothermia nor supplemental protective drug affected short- or long-term neurologic outcomes of patients undergoing temporary clipping.

Object The authors sought to describe changes in clinical management associated with brain tissue oxygen (PbO2) monitoring and how these changes affected outcomes and resource utilization. Methods The cohort study comprised 629 patients admitted to a Level I trauma center with a diagnosis of severe traumatic brain injury over a period of 3 years. Hospital mortality rate, neurological outcome, and resource utilization of 123 patients who underwent both PbO2 and intracranial pressure (ICP) monitoring were compared with the same measures in 506 patients who underwent ICP monitoring only. The main outcomes were hospital mortality rate, functional independence at hospital discharge, duration of mechanical ventilation, hospital length of stay, and hospital cost. Multivariable regression with robust variance was used to estimate the adjusted differences in the main outcome measures between patient groups. The models were adjusted for patient age, severity of injury, and pathological features seen on head CT scan at admission. Results On average, patients who underwent ICP/PbO2 monitoring were younger and had more severe injuries than patients who received ICP monitoring alone. Relatively more patients treated with PbO2 monitoring received osmotic therapy, vasopressors, and prolonged sedation. After adjustment for baseline characteristics, the hospital mortality rate was, if anything, slightly higher in patients undergoing PbO2-guided management than in patients monitored with ICP only (adjusted mortality difference 4.4%, 95% CI −3.9 to 13%). Patients who underwent PbO2-guided management also had lower adjusted functional independence scores at hospital discharge (adjusted score difference −0.75, 95% CI −1.41 to −0.09). There was a 27% relative increase (95% CI 6–53%) in the median hospital length of stay when the PbO2 group was compared with the ICP-only group. Conclusions The mortality rate in patients with traumatic brain injury whose clinical management was guided by PbO2 monitoring was not reduced in comparison with that in patients who received ICP monitoring alone. Brain tissue oxygen monitoring was associated with worse neurological outcome and increased hospital resource utilization.

Object The goal of this study was to assess the accuracy of the routine clinical use of transcranial Doppler (TCD) ultrasonography and SPECT in predicting angiographically demonstrated vasospasm. Methods Following receipt of institutional review board approval, the authors reviewed the records of patients with subarachnoid hemorrhage who had been admitted between 2004 and 2005 and underwent TCD ultrasonography and SPECT evaluations within 24 hours of cerebral angiography. Patients were categorized based on the presence or absence of vasospasm and/or hypoperfusion in the anterior cerebral arteries (ACAs), middle cerebral arteries (MCAs), and basilar arteries (BAs) or posterior cerebral arteries (PCAs) according to each imaging modality. Logistic regression was used to estimate the odds ratio (OR) of an angiographically demonstrated vasospasm also detected on TCD ultrasonography and SPECT. Results One hundred fifty-two patients (101 women) with a mean age (± standard deviation) of 53 ± 13 years were included in the study. In the ACA, the OR of a vasospasm on TCD ultrasonography was 27 (95% confidence interval [CI] 3–243) and on SPECT 0.97 (95% CI 0.36–2.6); in the MCA, 17 (95% CI 5.4–55) and 2.0 (95% CI 0.71–5.5), respectively; in the BA, 4.4 (95% CI 0.72–27) and 5.6 (95% CI 0.89–36), respectively. There was no substantial change in the relative odds of a vasospasm when the findings on TCD ultrasonography and SPECT were considered jointly. Conclusions Transcranial Doppler ultrasonography appears to be highly predictive of an angiographically demonstrated vasospasm in the MCA and ACA; however, its diagnostic accuracy was lower with regard to vasospasm in the BA. Single-photon emission computed tomography was not predictive of a vasospasm in any of the vascular territories assessed.

Devastating brain injuries (DBIs) profoundly damage cerebral function and frequently cause death. DBI survivors admitted to critical care will suffer both intracranial and extracranial effects from their brain injury. The indicators of quality care in DBI are not completely defined, and despite best efforts many patients will not survive, although others may have better outcomes than originally anticipated. Inaccuracies in prognostication can result in premature termination of life support, thereby biasing outcomes research and creating a self-fulfilling cycle where the predicted course is almost invariably dismal. Because of the potential complexities and controversies involved in the management of devastating brain injury, the Neurocritical Care Society organized a panel of expert clinicians from neurocritical care, neuroanesthesia, neurology, neurosurgery, emergency medicine, nursing, and pharmacy to develop an evidence-based guideline with practice recommendations. The panel intends for this guideline to be used by critical care physicians, neurologists, emergency physicians, and other health professionals, with specific emphasis on management during the first 72-h post-injury. Following an extensive literature review, the panel used the GRADE methodology to evaluate the robustness of the data. They made actionable recommendations based on the quality of evidence, as well as on considerations of risk: benefit ratios, cost, and user preference. The panel generated recommendations regarding prognostication, psychosocial issues, and ethical considerations.

The pharmacologic profile of the alpha-2 agonist dexmedetomidine (Dex) suggests that it may be an ideal sedative drug for deep brain stimulator (DBS) implantation. We performed a retrospective chart review of anesthesia records of patients who underwent DBS implantation from 2001 to 2004. In 2003, a clinical protocol with Dex sedation for DBS implantation was initiated. Demographic data, use of antihypertensive medication, and duration of mapping were compared between patients who received Dex (11 patients/13 procedures) and patients who did not receive any sedation (controls: 8 patients/9 procedures). There were no differences in severity of illness between the two groups. Dex provided patient comfort and surgical satisfaction with mapping in all cases, and significantly reduced the use of antihypertensive medication (54% in the Dex group, versus 100% in controls, P = 0.048). In DBS implantation, sedation with Dex did not interfere with electrophysiologic mapping, and provided hemodynamic stability and patient comfort. Routine use of Dex in these procedures may be indicated.

Decrire l’hyperemie cerebrale et l ’autoregulation cerebrale alteree documentees par le Doppler transcrânien (DTC) chez un adulte atteint d’acidocetose diabetique (ACD) et de septicemie admis pour une intervention chirurgicale. La vitesse du flux de l’artere cerebrale moyenne a augmente en relation avec la PaCO2 (Vacm a 52 cm·sec-1; PaCO2 de 22 mmHg) et l’index d’autoregulation (IAR) etait de 0 avant l’intervention chirurgicale. Vingt heures apres l’admission et le traitement, l’hyperemie cerebrale etait stoppee (Vmca a 52 cm·sec-1; PaCO2 de 35 mmHg) et l’autoregulation cerebrale revenue a la normale (IAR de 0,91). Selon nous, c’est la premiere description d’autoregulation cerebrale alteree chez un adulte atteint d’ACD. Nos observations suggerent une relation entre l’hyperemie cerebrale et l’autoregulation cerebrale alteree en cas d’ACD.

Background Volume expansion and hypertension are widely used for the hemodynamic management of patients with subarachnoid hemorrhage. Objective To investigate the feasibility, adherence, and retention in a trial of volume expansion and blood pressure manipulation to prevent delayed cerebral ischemia. Methods A randomized pilot trial using a 2-way factorial design allocating patients within 72 hours of subarachnoid hemorrhage to either normovolemia (NV) or volume expansion (HV) and simultaneously to conventional (CBP) or augmented blood pressure (ABP) for 10 days. The study endpoints were protocol adherence and retention to follow-up. The quality of endpoints for a larger trial were 6-month modified Rankin Scale score, comprehensive neurobehavioral assessment, delayed cerebral ischemia, new stroke, and discharge disposition. Results Twenty patients were randomized and completed follow-up. The overall difference in daily mean intravenous fluid intake was 2099 mL (95% confidence interval [CI]: 867, 3333), HV vs NV group. The overall mean systolic blood pressure difference was 5 mm Hg (95% CI: -4.65, 14.75), ABP vs CBP group. Adverse events included death (n=1), delayed cerebral ischemia (n=1), and pulmonary complications (n=3). There were no differences in modified Rankin Scale score between HV and NV (difference 0.1; 95% CI: -1.26, 1.46, P=.87) or between ABP and CBP groups (-0.5, 95% CI: -1.78, 0.78, P=.43). Neuropsychological scores were similar between HV vs NV, but tended to be worse in ABP (57±27) vs CBP group (85±21, P=.04). Conclusion This pilot study showed adequate feasibility and excellent retention to follow-up. Given the suggestion of possible worse neurobehavioral outcome with ABP, a larger trial to determine the optimal blood pressure management in this patient population is warranted. (ClinTrials.gov NCT01414894.)

Systemic lupus erythematosus is a multifactorial autoimmune disease of complex etiology, which may be associated with cognitive dysfunction, seizures, and headache. The authors present an unusual presentation of systemic lupus erythematosus complicated by global cerebral edema and subarachnoid hemorrhage secondary to rupture of a cerebral aneurysm. The complicated patient management issues are discussed.

Cognitive and behavioral deficits after brain insult and injury can significantly compromise nutritional status, consequent to the development of nausea, anorexia, vomiting, and feeding intolerance. Over 60% of patients requiring rehabilitation for brain injury demonstrate problems with swallowing, resulting in an incidence of aspiration exceeding 40%.

Conivaptan is an arginine-vasopressin-receptor antagonist approved for the treatment of hyponatremia. We hypothesized that administration of conivaptan to normonatremic patients with traumatic brain injury (TBI) is safe and could reduce intracranial pressure (ICP).Open-label, randomized, controlled trial enrolling 10 subjects within 24 h of severe TBI to receive a single 20 mg dose of conivaptan (n = 5) or usual care (n = 5). The primary endpoint was the evaluation of the safety profile defined by serum sodium increases averaging1 mEq/h when measured every 4 h and any adverse events. Secondary endpoints were 48-h serum sodium, sodium load, change in ICP, and urine output.Ten patients were included in the intention-to-treat analysis. Three patients (2 conivaptan, 1 usual care group) experienced brief sodium increases averaging1 mEq/h, with no patients achieving Na160 mEq/l. There were no drug-related serious adverse events. At 48 h, the mean sodium was 142 ± 6 mEq/l (conivaptan) and 144 ± 10 mEq/l (usual care, P = 0.71). 48-h sodium load was 819 ± 724 mEq in the conivaptan and 1,137 ± 1,165 mEq in the usual care group (P = 0.62). At 4 h, serum sodium was higher (P = 0.02) and ICP was lower (P = 0.046) in the conivaptan compared with usual care group. 24-h but not 48-h urine output was different between the two groups (P0.01 and P = 0.20, respectively).These data suggest that a single dose conivaptan is safe in non-hyponatremic patients with severe TBI and may reduce ICP. Further studies are needed to establish the effect of conivaptan on clinically relevant endpoints, and its role in the management of intracranial hypertension.

We describe institutional vasopressor usage, and examine the effect of vasopressors on hemodynamics: heart rate (HR), mean arterial blood pressure (MAP), intracranial pressure (ICP), cerebral perfusion pressure (CPP), brain tissue oxygenation (PbtO(2)), and jugular venous oximetry (SjVO(2)) in adults with severe traumatic brain injury (TBI).We performed a retrospective analysis of 114 severely head injured patients who were admitted to the neurocritical care unit of Level 1 trauma center and who received vasopressors (phenylephrine, norepinephrine, dopamine, vasopressin or epinephrine) to increase blood pressurePhenylephrine was the most commonly used vasopressor (43%), followed by norepinephrine (30%), dopamine (22%), and vasopressin (5%). Adjusted for age, gender, injury severity score, vasopressor dose, baseline blood pressure, fluid administration, propofol sedation, and hypertonic saline infusion, phenylephrine use was associated with 8 mmHg higher mean arterial pressure (MAP) than dopamine (P = 0.03), and 12 mmHg higher cerebral perfusion pressure (CPP) than norepinephrine (P = 0.02) during the 3 h after vasopressor start. There was no difference in ICP between the drug groups, either at baseline or after vasopressor treatment.Most severe TBI patients received phenylephrine. Patients who received phenylephrine had higher MAP and CPP than patients who received dopamine and norepinephrine, respectively.

OBJECTIVE: We examined the incidence of perioperative fever and its relationship to outcome among patients enrolled in the Intraoperative Hypothermia for Aneurysm Surgery Trial. METHODS: One thousand patients with initial World Federation of Neurological Surgeons grades of I to III undergoing clipping of intracranial aneurysms after subarachnoid hemorrhage were randomized to intraoperative normothermia (36 degrees C-37 degrees C) or hypothermia (32.5 degrees C-33.5 degrees C). Fever (> or =38.5 degrees C) and other complications (including infections) occurring between admission and discharge (or death) were recorded. Functional and neuropsychologic outcomes were assessed 3 months postoperatively. The primary outcome variable for the trial was dichotomized Glasgow Outcome Scale (good outcome versus all others). RESULTS: Fever was reported in 41% of patients. In 97% of these, fever occurred in the postoperative period. The median time from surgery to first fever was 3 days. All measures of outcome were worse in patients who developed fever, even in those without infections or who were World Federation of Neurological Surgeons grade I. Logistic regression analyses were performed to adjust for differences in preoperative factors (e.g., age, Fisher grade, initial neurological status). This demonstrated that fever continued to be significantly associated with most outcome measures, even when infection was added to the model. An alternative stepwise model selection process including all fever-related measures from the preoperative and intraoperative period (e.g., hydrocephalus, duration of surgery, intraoperative blood loss) resulted in the loss of significance for dichotomized Glasgow Outcome Scale, but significant associations between fever and several other outcome measures remained. After adding postoperative delayed ischemic neurological deficits to the model, only worsened National Institutes of Health Stroke Scale score, Barthel Activities of Daily Living index, and discharge destination (home versus other) remained independently associated with fever. CONCLUSION: These findings suggest that fever is associated with worsened outcome in surgical subarachnoid hemorrhage patients, although, because the association between fever and the primary outcome measure for the trial is dependent on the covariates used in the analysis (particularly operative events and delayed ischemic neurological deficits), we cannot rule out the possibility that fever is a marker for other events. Only a formal trial of fever treatment or prevention can address this issue.

We describe the incidence and etiology of fever and the relationship between fever characteristics and outcome in children with severe traumatic brain injury (TBI). We conducted a retrospective study of children

The validity of Transcranial Doppler cerebral blood flow velocity (TCD) as an index of cerebral blood flow hinges on the assumption that the insonated cerebral vessel diameters do not change (outside the circumstances of vasospasm). This assumption has been challenged 1 particularly when considering the sensitivity and specificity of TCD to pathological and anesthesia induced changes in CBF. Accordingly we examined changes in both TCD flow velocities and angiographically derived cerebral artery diameters, in patients undergoing elective cerebral artery aneurysmal coiling, with crossover from a vasoconstrictor to a vasodilator anesthetic.