Transcranial Doppler and Color-Coded Doppler Use for Brain Death Determination in Adult Patients: A Pictorial Essay

Transcranial Doppler (TCD) is a repeatable, at-the-bedside, helpful tool for confirming cerebral circulatory arrest (CCA). Despite its variable accuracy, TCD is increasingly used during brain death determination, and it is considered among the optional ancillary tests in several countries. Among its limitations, the need for skilled operators with appropriate knowledge of typical CCA patterns and the lack of adequate acoustic bone windows for intracranial arteries assessment are critical. The purpose of this review is to describe how to evaluate cerebral circulatory arrest in the intensive care unit with TCD and transcranial duplex color-coded doppler (TCCD).

Brain death as a moral definition and an act of love: the tale of Moon, Nehviel and Fate

The vital status of people with a destroyed brain is one of the most discussed topics in medical literature. According to the current legal narrative, people whose brain is destroyed are dead. Nevertheless, a clear biological rationale to support with certainty such a narrative is still lacking. The purported rationale of the "the brain as the central integrator of the body" has proven to be biologically untenable. Persons with a destroyed brain can be maintained viable for long periods of time, showing clear signs of good biological integration. This fact stirs up a continuous seething of heated discussions among scholars, and generates uncertainty among lay people, loss of trust towards the medical community, and highly controversial cases in the media. To try to settle this unresolved situation, we propose a moral narrative, according to which people whose brain is destroyed should be considered as dead. Defining those people as biologically dead is impossible. Their clinical condition is neither life nor death; it is something in between, an artifice created by modern medicine. Yet, we can well state that the irreversible loss of all brain functions is a clinically and scientifically useful point of no return in the process of dying which can guide sound decisions. Through a personal reinterpretation of the myth of Orpheus and Eurydice, we would like to show that the choice to consider people with a destroyed brain as dead is a sound moral decision and an act of love.

Normothermic Regional Perfusion and Hypothermic Oxygenated Machine Perfusion for Livers Donated After Controlled Circulatory Death With Prolonged Warm Ischemia Time: A Matched Comparison With Livers From Brain-Dead Donors

Prolonged warm ischemia time (WIT) has a negative prognostic value in liver transplantation (LT) using grafts procured after circulatory death (DCD). To assess the value of abdominal normothermic regional perfusion (A-NRP) associated with dual hypothermic oxygenated machine perfusion (D-HOPE) in controlled DCD LT, prospectively collected data on LTs performed between January 2016 and July 2021 were analyzed. Outcome of controlled DCD LTs performed using A-NRP + D-HOPE (n = 20) were compared to those performed with grafts procured after brain death (DBD) (n = 40), selected using propensity-score matching. DCD utilization rate was 59.5%. In the DCD group, median functional WIT, A-NRP and D-HOPE time was 43, 246, and 205 min, respectively. Early outcomes of DCD grafts recipients were comparable to those of matched DBD LTs. In DCD and DBD group, incidence of anastomotic biliary complications and ischemic cholangiopathy was 15% versus 22% (p = 0.73) and 5% versus 2% (p = 1), respectively. One-year patient and graft survival was 100% versus 95% (p = 0.18) and 90% versus 95% (p = 0.82). In conclusion, the association of A-NRP + D-HOPE in DCD LT with prolonged WIT allows achieving comparable outcomes to DBD LT.

Why and how to open intensive care units to family visits during the pandemic

Since the lockdown because of the pandemic, family members have been prohibited from visiting their loved ones in hospital. While it is clearly complicated to implement protocols for the admission of family members, we believe precise strategic goals are essential and operational guidance is needed on how to achieve them. Even during the pandemic, we consider it a priority to share strategies adapted to every local setting to allow family members to enter intensive care units and all the other hospital wards.

How to communicate with families living in complete isolation

IMPORTANCE

During the SARS-CoV-2 pandemic, a complete physical isolation has been worldwide introduced. The impossibility of visiting their loved ones during the hospital stay causes additional distress for families: in addition to the worries about clinical recovery, they may feel exclusion and powerlessness, anxiety, depression, mistrust in the care team and post-traumatic stress disorder. The impossibility of conducting the daily meetings with families poses a challenge for healthcare professionals.

OBJECTIVE

This paper aims to delineate and share consensus statements in order to enable healthcare team to provide by telephone or video calls an optimal level of communication with patient's relatives under circumstances of complete isolation.

EVIDENCE REVIEW

PubMed, Cochrane Database of Systematic Reviews, Database of Abstracts and Reviews of Effectiveness and the AHCPR Clinical Guidelines and Evidence Reports were explored from 1999 to 2019. Exclusion criteria were: poor or absent relevance regarding the aim of the consensus statements, studies prior to 1999, non-English language. Since the present pandemic context is completely new, unexpected and unexplored, there are not randomised controlled trials regarding clinical communication in a setting of complete isolation. Thus, a multiprofessional taskforce of physicians, nurses, psychologists and legal experts, together with some family members and former intensive care unit patients was established by four Italian national scientific societies. Using an e-Delphi methodology, general and specific questions were posed, relevant topics were argumented, until arriving to delineate position statements and practical checklist, which were set and evaluated through an evidence-based consensus procedure.

FINDINGS

Ten statements and two practical checklists for phone or video calls were drafted and evaluated; they are related to who, when, why and how family members must be given clinical information under circumstances of complete isolation.

CONCLUSIONS AND RELEVANCE

The statements and the checklists offer a structured methodology in order to ensure a good-quality communication between healthcare team and family members even in isolation, confirming that time dedicated to communication has to be intended as a time of care.

Rationing in a Pandemic: Lessons from Italy

In late February and early March 2020, Italy became the European epicenter of the COVID-19 pandemic. Despite increasingly stringent containment measures enforced by the government, the health system faced an enormous pressure, and extraordinary efforts were made in order to increase overall hospital beds' availability and especially ICU capacity. Nevertheless, the hardest-hit hospitals in Northern Italy experienced a shortage of ICU beds and resources that led to hard allocating choices. At the beginning of March 2020, the Italian Society of Anesthesia, Analgesia, Resuscitation, and Intensive Care (SIAARTI) issued recommendations aimed at supporting physicians in prioritizing patients when the number of critically ill patients overwhelm the capacity of ICUs. One motivating concern for the SIAARTI guidance was that, if no balanced and consistent allocation procedures were applied to prioritize patients, there would be a concrete risk for unfair choices, and that the prevalent "first come, first served" principle would lead to many avoidable deaths. Among the drivers of decision for admission to ICUs, age, comorbidities, and preexisting functional status were included. The recommendations were criticized as ageist and potentially discriminatory against elderly patients. Looking forward to the next steps, the Italian experience can be relevant to other parts of the world that are yet to see a significant surge of COVID-19: the need for transparent triage criteria and commonly shared values give the Italian recommendations even greater legitimacy.

[Clinical ethics recommendations for the allocation of intensive care treatments, in exceptional, resource-limited circumstances.]

On February 21st, 2020 the first case of severe acute respiratory syndrome due to the coronavirus 2 (SARS-CoV-2) causing the CoViD-19 disease, was identified in Italy. In the following days, despite the restrictive public health measures aimed to avoid the infection's spread, the number of cases increased. As of March 8th, 2020, Italy is the 2nd most affected country in the world. As of March 6th, 2020, the Italian Society of Anesthesia Analgesia Resuscitation and Intensive Care (SIAARTI) published operational recommendations and ethical considerations to support the clinicians involved in the care of critically-ill CoViD-19 patients, in regard a probable scenario where an imbalance between supply and demand of ICU beds, is put in place by a steadily rising number of these patients.

[Open doors, closed ports: can medicine suggest something to society?]

Western countries are today experiencing a profound mutation of their immigration policies. Integration and hospitality have been taken over by closure and rejections. The policy of "closed ports" gained ground as never before. Traditionally, hospitals have imposed rules and restrictions to patients and visitors, ruling and limiting the space and the time offered. In the last two decades, though, a radical change in perspectives of some medical centres allowed a profound transformation of hospitals from closed realms to open spaces where communication and interaction with visitors is desired and encouraged. The policy of "open doors" became widespread and showed benefits in a lot of ways. Noticeably, a profound asymmetry exists between the idea of "closed ports" and "open doors", both representing - albeit in different contexts - opposite solutions for similar issues. It is possible to make a comparison? Can medicine suggest something to society?

Forgoing life-sustaining treatments in the ICU. To withhold or to withdraw: is that the question?

In the last decades, mortality from severe acute illnesses has considerably declined thanks to the advances in intensive care medicine. Meanwhile, critical care physicians realized that life-sustaining treatments (LST) may not be appropriate for every patient, and end-of-life care in the Intensive Care Unit (ICU) started to receive growing attention. Most deaths occurring in the ICU now follow a decision to forgo life-sustaining treatments (DFLST), which can be implemented either by withdrawing (WDLST) or withholding (WHLST) life-sustaining treatments. Despite the broad consensus about the equivalence of the two practices from an ethical point of view, the issue of the best option between WDLST and WHLST constantly gives rise to controversies in clinical practice. This review is not intended to take a stand for or against WDLST or WHLST. Based on available evidence, the definitions of the two practices are first presented. Secondly, the preferences of ICU physicians towards WDLST and WHLST are examined. Finally, some arguments are offered outlining pros and cons of WDLST and WHLST, stressing that the clinician's attention should focus on an early and thorough recognition of patients in need of a DFLST, rather than on the theoretical strength and weakness of the two practices. This approach will enable physicians to make informed decisions on how to implement the limitation of LSTs, considering the patients' clinical conditions and preferences, the circumstances and needs of their families.

Clinical ethics: what the anesthesiologist and the intensivist need to know

Clinical ethics if often perceived as an intuitive understanding of what is right versus wrong. This is insufficient for healthcare workers in general, but particularly for anesthesiologists and intensivists, who often must weigh up complex and emergent life or death decisions and subsequently justify these decisions to their team and patients, as well as patient's families. Articulating the rationale for such decisions is an arduous task. Thus, a brief introduction to the basic conceptual framework and vocabulary of clinical ethics may be useful to this population of physicians. The most important concept is that interventions offered should be both clinically appropriate and ethically proportionate, desirable by both the patient and the medical team, and offering a meaningful benefit to the patient within the context of his or her own life narrative. This puts an emphasis on understanding, from the patient or his/her proxies, not just who the patient is biologically but also biographically: that is what gives meaning to his/her life subjectively, and what quality of life would be compatible with this level of functioning, as well as when he/she would wish life sustaining therapy to be withheld or withdrawn.

Making a case for controlled organ donation after cardiac death: the story of Italy's first experience

Donation after circulatory death (DCD) is a valuable option for the procurement of organs for transplantation. In Italy, organ procurement after controlled DCD is legally and ethically conceivable within the current legislative framework. However, although formal impediments do not exist, the health care team is faced with many obstacles that may hinder the implementation of such programs. We report the case of Italy's first controlled DCD, specifically discussing the role of the patient's family in the shared decision-making process. In our case, the death of the patient subsequent to the withdrawal of life-sustaining therapies was consistent with the patient's wishes, showing respect for his dignity and honoring his autonomy, as expressed to his family previously. By making donation possible, the medical team was able to fulfill the family's last request on behalf of the patient. This case should stimulate deliberation regarding the potential to shorten the 20-minute no-touch period currently in place in Italy. Such an action would not have injured this patient and would certainly have increased the quality of the procured organs.

Efficacy and safety of a low-flow veno-venous carbon dioxide removal device: results of an experimental study in adult sheep

Introduction

Extracorporeal lung assist, an extreme resource in patients with acute respiratory failure (ARF), is expanding its indications since knowledge about ventilator-induced lung injury has increased and protective ventilation has become the standard in ARF.

Methods

A prospective study on seven adult sheep was conducted to quantify carbon dioxide (CO₂) removal and evaluate the safety of an extracorporeal membrane gas exchanger placed in a veno-venous pump-driven bypass. Animals were anaesthetised, intubated, ventilated in order to reach hypercapnia, and then connected to the CO₂ removal device. Five animals were treated for three hours, one for nine hours, and one for 12 hours. At the end of the experiment, general anaesthesia was discontinued and animals were extubated. All of them survived.

Results

No significant haemodynamic variations occurred during the experiment. Maintaining an extracorporeal blood flow of 300 ml/minute (4.5% to 5.3% of the mean cardiac output), a constant removal of arterial CO₂, with an average reduction of 17% to 22%, was observed. Arterial partial pressure of carbon dioxide (PaCO₂) returned to baseline after treatment discontinuation. No adverse events were observed.

Conclusion

We obtained a significant reduction of PaCO₂ using low blood flow rates, if compared with other techniques. Percutaneous venous access, simplicity of circuit, minimal anticoagulation requirements, blood flow rate, and haemodynamic impact of this device are more similar to renal replacement therapy than to common extracorporeal respiratory assistance, making it feasible not only in just a few dedicated centres but in a large number of intensive care units as well.

[NMR in the diagnosis and treatment of neurologic lesions in decompression sickness]

The case of a decompression sickness in woman, diving to 26 meter depth is reported. The patient was helped by instructor's computer (error!) and she presented risk factors for embolic disease (obesity, smoke, estroprogestinic therapy). She presented with many symptoms of decompression sickness during immersion and during re-ascent (headache, vertigoes and paresthesias). She was not treated on the place of incident, but only 36 hours later at our center of hyperbaric medicine. Her Magnetic Resonance imaging showed hyperintensity lesions of white matter.