Faculty Bibliography

OBJECTIVE: To determine if ischaemia is a mechanism of early brain injury at the time of aneurysm rupture in subarachnoid haemorrhage (SAH) and if early MRI ischaemia correlates with admission clinical status and functional outcome. METHODS: In a prospective, hypothesis-driven study patients with SAH underwent MRI within 0-3 days of ictus (prior to vasospasm) and a repeat MRI (median 7 days). The volume and number of diffusion weighted imaging (DWI) positive/apparent diffusion coefficient (ADC) dark lesions on acute MRI were quantitatively assessed. The association of early ischaemia, admission clinical status, risk factors and 3-month outcome were analysed. RESULTS: In 61 patients with SAH, 131 MRI were performed. Early ischaemia occurred in 40 (66%) with a mean DWI/ADC volume 8.6 mL (0-198 mL) and lesion number 4.3 (0-25). The presence of any early DWI/ADC lesion and increasing lesion volume were associated with worse Hunt-Hess grade, Glasgow Coma Scale score and Acute Physiology and Chronic Health Evaluation II physiological subscores (all p<0.05). Early DWI/ADC lesions significantly predicted increased number and volume of infarcts on follow-up MRI (p<0.005). At 3 months, early DWI/ADC lesion volume was significantly associated with higher rates of death (21% vs. 3%, p=0.031), death/severe disability (modified Rankin Scale 4-6; 53% vs. 15%, p=0.003) and worse Barthel Index (70 vs. 100, p=0.004). After adjusting for age, Hunt-Hess grade and aneurysm size, early infarct volume correlated with death/severe disability (adjusted OR 1.7, 95% CI 1.0 to 3.2, p=0.066). CONCLUSIONS: Early ischaemia is related to poor acute neurological status after SAH and predicts future ischaemia and worse functional outcomes. Treatments addressing acute ischaemia should be evaluated for their effect on outcome.

IMPORTANCE: The disparity between patients awaiting organ transplantation and organ availability increases each year. As a consequence, organ trafficking has emerged and developed into a multibillion-dollar-a-year industry. OBJECTIVE: To identify and address barriers to organ donation in the United States and globally. EVIDENCE REVIEW: Evidence-based peer-reviewed articles, including prospective and retrospective cohort studies, as well as case series and reports were identified in a PubMed search of organ donation, barriers to organ donation, brain death, donation after cardiac death, and organ trafficking. Additional Internet searches were conducted of national and international transplant and organ donation websites and US Department of Health of Health and Human Services websites. Citation publication dates ranged from August 1, 1968, through June 28, 2014. FINDINGS: The lack of standardization of brain death and organ donation criteria worldwide contributes to a loss of potential donors. Major barriers to donation include variable clinical and legal definitions of brain death; inconsistent legal upholding of brain death criteria; racial, ethnic, and religious perspectives on organ donation; and physician discomfort and community misunderstanding of the process of donation after cardiac death. Limited international legislation and oversight of organ donation and transplant has contributed to the dilemma of organ trafficking. CONCLUSIONS AND RELEVANCE: An urgent need exists for a global standard on the definition of brain death and donation after death by cardiac criteria to better regulate organ donation and maximize transplantation rates. Unified standards may have a positive effect on limiting organ trafficking.

BACKGROUND: There are no studies demonstrating that prothrombin complex concentrates (PCC) improves outcome compared FFP in patients with warfarin-associated intracranial hemorrhage. METHODS: A prospective, observational study was conducted of patients who received PCC (Bebulin VH), FFP, or PCC + FFP. All groups received vitamin K 10 mg IV. INR reversal (<1.4), adverse events (venous thromboembolism, myocardial infraction, pulmonary edema), major hemorrhage (new or worsened intracranial hemorrhage, anemia requiring transfusion or GI bleed), and 3-month functional outcome were compared between the groups using Chi squared and logistic regression analysis. RESULTS: Of 64 patients, PCC alone was used in 16 (mean dose 48 IU/kg), FFP alone in 25 (mean dose 12.5 ml/kg), and PCC + FFP in 23 (median doses 47.4 IU/kg and 11.4 ml/kg, respectively). INR correction occurred in 88, 84, and 70 %, respectively. There were no differences in time to INR correction or adverse events between the groups, but FFP alone was associated with more major hemorrhage after administration (52 %, OR 5.0, 95 % CI 1.6-15.4, P = 0.006) and PCC with less (6 %, OR 0.1, 95 % CI 0.01-0.8, P = 0.033). After adjusting for age, admission GCS, initial INR, and bleed type, the use of PCC was associated with a lower risk of death or severe disability at 3-months (adjusted OR 0.02, 95 % CI 0.001-0.8, P = 0.039), while FFP alone was associated with a higher risk (adjusted OR 51.6, 95 % CI 1.2-2163.1, P = 0.039). CONCLUSIONS: PCC adequately corrected INR without any increase in adverse events compared to FFP and was associated with less major hemorrhage and improved 3-month outcomes in patients with warfarin-associated intracranial hemorrhage.

Neurocritical care complications of pregnancy and puerperum such as preeclampsia/eclampsia, hemolysis, elevated liver enzymes, low platelets syndrome, thrombotic thrombocytopenic purpura, seizures, ischemic and hemorrhagic stroke, postpartum angiopathy, cerebral sinus thrombosis, amniotic fluid emboli, choriocarcinoma, and acute fatty liver of pregnancy are rare but can be devastating. These conditions can present a challenge to physicians because pregnancy is a unique physiologic state, most therapeutic options available in the intensive care unit were not studied in pregnant patients, and in many situations, physicians need to deliver care to both the mother and the fetus, simultaneously. Timely recognition and management of critical neurologic complications of pregnancy/puerperum can be life saving for both the mother and fetus.

OBJECTIVE: This review highlights benefits that patients, families and clinicians can expect to realize when palliative care is intentionally incorporated into the PICU. DATA SOURCES: We searched the MEDLINE database from inception to January 2014 for English-language articles using the terms "palliative care" or "end of life care" or "supportive care" and "pediatric intensive care." We also hand-searched reference lists and author files and relevant tools on the Center to Advance Palliative Care website. STUDY SELECTION: Two authors (physicians with experience in pediatric intensive care and palliative care) made final selections. DATA EXTRACTION: We critically reviewed the existing data and tools to identify strategies for incorporating palliative care into the PICU. DATA SYNTHESIS: The Improving Palliative Care in the ICU Advisory Board used data and experience to address key questions relating to: pain and symptom management, enhancing quality of life, communication and decision-making, length of stay, sites of care, and grief and bereavement. CONCLUSIONS: Palliative care should begin at the time of a potentially life-limiting diagnosis and continue throughout the disease trajectory, regardless of the expected outcome. Although the PICU is often used for short term postoperative stabilization, PICU clinicians also care for many chronically ill children with complex underlying conditions and others receiving intensive care for prolonged periods. Integrating palliative care delivery into the PICU is rapidly becoming the standard for high quality care of critically ill children. Interdisciplinary ICU staff can take advantage of the growing resources for continuing education in pediatric palliative care principles and interventions.