Intensivist-led management of brain-dead donors is associated with an increase in organ recovery for transplantation

The disparity between the number of patients in need of organ transplantation and the number of available organs is steadily rising. We hypothesized that intensivist-led management of brain dead donors would increase the number of organs recovered for transplantation. We retrospectively analyzed data from all consented adult brain dead patients in the year before (n = 35) and after (n = 43) implementation of an intensivist-led donor management program. Donor characteristics before and after implementation were similar. After implementation of the organ donor support team, the overall number of organs recovered for transplantation increased significantly (66 out of 210 potentially available organs vs. 113 out of 258 potentially available organs, p = 0.008). This was largely due to an increase in the number of lungs (8 out of 70 potentially available lungs vs. 21 out of 86 potentially available lungs; p = 0.039) and kidneys (31 out of 70 potentially available kidneys vs. 52 out of 86 potentially available kidneys; p = 0.044) recovered for transplantation. The number of hearts and livers recovered for transplantation did not change significantly. Institution of an intensivist-led organ donor support team may be a new and viable strategy to increase the number of organs available for transplantations.

International organizations and communications

Multidisciplinary critical care evolved from the work of Bjorn Ibsen in 1952, and from his international links, developed international organizations, and regional federations and societies. Today the international critical care community is increasingly communicating through the Internet.

Pharmacologic treatment of brain failure and delirium

The critical care unit is a place where multiple organ system failure can be effectively reversed by highly technologic treatment innovations. That same technology can confer a great deal of stress on the patient, leading to the unique syndrome of integrative brain failure. Exacerbating factors, such as pain, anxiety, and discomfort, can ultimately result in severe agitation syndromes. This article outlines uniquely specialized treatments for these syndromes and the outlook for future therapies.

Regionalization of critical care medicine: task force report of the American College of Critical Care Medicine

OBJECTIVES

To review the existing literature and task force opinions on regionalization of critical care services, and to synthesize a judgement on possible costs, benefits, disadvantages, and strategies.

DATA SOURCES

Pertinent literature in the English language.

STUDY SELECTION

One hundred forty-six English language papers were studied to determine possible ramifications of regionalization of critical care or other similar services.

DATA EXTRACTION

Information on possible influence on the care of the critically ill was sought and integrated with the opinions of task force members. Possible costs, benefits, as well as disadvantages to the patient, transferring and receiving institutions, and region as a whole were sought.

DATA SYNTHESIS

Regionalization of critical care services was thought to be advantageous to the patient. The larger academic institutions tend to have more resources, better subspecialty availability, and expertise in the care of the critically ill. Efficiency and safety during transport need to be in place. Disadvantages of overutilization, possible costliness to both the referring institution as well as to the receiving institution were outlined. It was agreed that pediatric critical care medicine was a separate issue.

CONCLUSIONS

Regionalization of critical care medicine probably is beneficial and the concept should be explored.

Neurologic monitoring in the intensive care unit

Aggressive methods of decreasing oxygen consumption, such as therapeutic musculoskeletal paralysis, are used in patients with marginal oxygen delivery associated with cardiac and respiratory insufficiency. This is especially true of new mechanical ventilation methods designed to decrease tidal volume and peak airway pressures. Agitation and delirium associated with brain failure also have become an important source of abnormally increased oxygen consumption in ICU patients. Hemodynamic deterioration from the effects of musculoskeletal hyperactivity can precipitate angina, heart failure, and cardiac arrhythmias by increasing myocardial work and oxygen consumption in the face of a fixed coronary artery output. Escalated doses of sedatives, followed by oppressive hemodynamic and ventilatory side-effects, sometimes indicate the need for therapeutic musculoskeletal paralysis to quickly control life-threatening agitation syndromes. Cerebral-function monitoring with portable, noninvasive, computer-processed monitors allows quick recognition of brain functions under titrated, suspended animation in real time, facilitating modulation of therapy when the visual clues of neuronal function disappear.

The role of sedation in the ICU patient with pain and agitation

Aside from being hard for physicians and staff to cope with, ICU agitation syndromes result in deterioration of hemodynamics and must be handled effectively. The interaction between pain and delirium is examined, as well as hemodynamic and metabolic syndromes that cause agitation in the ICU setting. The various medications useful in the treatment of pain and delirium are reviewed and new regimens discussed. Comprehensive treatment plans are reviewed for the profoundly agitated patient.

Cost and survival results of critical care regionalization for Medicare patients

A ground-based mobile ICU, two medical evacuation helicopters, and a specially equipped fixed wing aircraft were utilized by a critical care transport team, staffed by a critical care physician, ICU nurse, critical care technologist, and respiratory therapist to facilitate regionalization of critical care services from small community hospitals to a central tertiary care facility. Survival, length of stay, age, actual hospital cost, and reimbursement were evaluated retrospectively for 81 Medicare patients transported by the team to a tertiary care facility during a 33-month period. All patients had acute, nontraumatic, medical/surgical illnesses, primarily cardiac. Forty-four (54%) patients were discharged home alive. Average hospital cost per patient was $36,059.00, average Medicare reimbursement was $13,802.00, and average hospital loss was $22,256.00. We show that regionalization to tertiary care facilities can facilitate access to critical care technology, but the Medicare reimbursement system of diagnosis-related groups makes this concept financially prohibitive for the tertiary care hospital.

Emergency medicine redux: the rise and fall of a community medical specialty

The specialty of Emergency Medicine has evolved circuitously . The poor relation of medicine, previously the domain of moonlighting dermatologists and semi-retired physicians, we considered it a diamond in the rough, a wealth of opportunity hidden by the prejudice of established specialties . We tailored the discipline to meet our needs and desires. As we created form from void, we generated an interest in a practical area of medicine previously indulged only theoretically. Now we are enlarging geometrically as a specialty and have discovered that our actual role as practicing physicians in the community hospital setting has turned out differently than we had conceived in training. As we overpower the available market by expanding our numbers, we are learning about some practical realities that are only now becoming apparent.