December 2015

December 2015 CME papers Dr I Tweedie   For this months review I looked through recent 2015 editions of the following journals:

Neurocritical care Intensive Care Medicine Critical care Medicine Critical care forum JNSA BJNS Journal of Neurosurgery

The papers presented are around two themes: prognostication and outcome, and organ donation.   Souter MJ, Blissitt P, Blosser S et al. Recommendations for the Critical Care Management of Devastating Brain Injury: Prognostication, Psychosocial, and Ethical Management. A position statement for health care professionals from the Neurocritical Care Society. Neurocritical Care 2015; 23: 4-13. It is increasingly recognised that prognostication for severe brain injury is very difficult and we will get the occasional patient with a seemingly hopeless brain injury that will ‘go home’ reasonably intact. The nihilistic attitude therefore has to be questioned as being appropriate in the early period after a severe brain injury. The recent positional paper from the Neurocritical Care Society makes a firm statement that we should not be making such judgments for a minimum of 72 hours, with repeated reassessments of the neurological state whilst in the meantime giving appropriate critical care support to avoid self fulfilling nihilism. It presents evidence as to how poor our predictions can be when based on signs within the first 24+hours, and how later assessments have better prognostic accuracy. It also looks at the other benefits of a delay in prognosticating, such as allowing families’ time to come to terms with the situation, the value of clear communication and the added potential benefit of an increased likelihood for organ donation. It also proposes a simple definition for devastating brain injury as “an immediate threat to life from neurological cause upon presentation to hospital.” Overall this is a paper all those doing critical care and in particular neuro-critical care should be reading, as well as neurosurgeons. Should this become the norm?    Sandroni C, Soar J, Friberg H. Does this Comatose Survivor of Cardiac Arrest have a Poor Prognosis? Intensive Care Medicine 2016; 42: 104-106. Continuing the same theme, a case report in Intensive Care Medicine reviews the case of a man who suffered a witnessed cardiac arrest and had fixed dilated pupils, but they followed a logical protocol despite things looking very bleak. He eventually went home and so it reminds us of prognostication difficulties in these patients. However, following a timed protocol with repeated observations gave a clearer view of the likely outcome. The case report includes a prognostic algorithm.   Williamson CA, Sheehan KM, Tipireni R, et al. The Association Between Spontaneous Hyperventilation, Delayed Cerebral Ischemia, and Poor Neurological Outcome in Patients with Subarachnoid Hemorrhage. Neurocrit Care 2015; 23: 330-338.  One of the problems we have is, what are reliable signs of prognostic significance? A paper from the University of Michigan may give a further sign to look for, when considering the potential outcome for patients after subarachnoid haemorrhage (SAH). They reviewed data from their prospectively gathered database about all the admissions from 2010 – 2014 with the diagnosis of SAH. They looked for evidence of spontaneous hyperventilation, which they then graded into moderate and severe, based on ABGS. Outcomes were recorded and they found that those with both moderate and severe hyperventilation had an increased odds ratios (>3 and >4 respectively) of developing signs of delayed cerebral ischaemia (DCI). However, only those with severe hyperventilation had a strongly significant association with poor neurological outcome. They also looked at how confounders such as WFNS scores, blood load, SIRs etc. may have affected the result, but statistically the hyperventilation remained an independent variable with regard to outcome. They postulate that if the observation is correct then the observed worse outcome may be enhanced due to the ischaemic insult from the consequent cerebral vasoconstriction, however, they do point out that this study does not look at causality. Even so, they discuss as to whether there would therefore be value in controlling the hyperventilation, with the hope of improved outcomes in this group.   Zamperetti N, Bellomo R, Latronico N. Heart donation and transplantation after circulatory death: ethical issues after Europe’s first case. Intensive Care Med 2016; 42: 93-95. Organ donation is very much part of neurocritical care work and the regularity of retrieval procedures means that most neuroanaesthetists will also be involved at some time. The recent Papworth case of donation after cardiac death (DCD) of a heart has lead the medical world to review the ethics of this. The commentary from Intensive Care Medicine provides a quick overview of this issue and includes discussion about the different thresholds around the world for the time between mechanical Asystole and when death can be certified, with thoughts about the dying process. I feel that this is also a paper worthy of the attention of all intensivists and anaesthetists, and it only takes 5 minutes to read.   Ortega-Deballon I, Hornby L, Shemie SD. Protocols for uncontrolled donation after circulatory death: a systematic review of international guidelines, practices and transplant outcomes. Critical Care 2015; 19: 268. In addition to the above commentary I found a paper from Sam Shemie reviewing protocols for uncontrolled DCD, which for those directly involved with organ donation such as CLODs, RCLODs, and SNODs will be of interest. I include it for completeness for the organ donation theme part of this CME review.