Agonal Phase Research Articles

O istocie gromadkarstwa mazurskiego

After the Reformation Masurians as subjects of the rulers of the first evangelical state in the world became Lutherans. Over time, the inhabitants of the southern areas of Easy Prussia and the so- called Lithuania Minor felt the lack of the deepened spirituality, which they did not find in the evangelical church. Through the settled in Gąbin (Gumbinnen) exiled from the area of Salzburg pietist Evangelists in Masuria, “The six books on True Christianity” by John Arndt appeared. The book, after the Bible and the Small Catechism of Luther became the most popular among people of Masuria. The first piety movements appeared in Masuria in the county of Nidzica and Szczytno at the turn of the 18th and 19th centuries. However their true upturn took place from the 1840s. It manifested itself in running home services, prayer meetings- so-called “beads” and increased activity of travelling preachers. In the seventies and eighties of the nineteenth century, The Gromadkar movement comprised between 30 and 80% of the Masurian population. The centre of the Masurian clusters was located near Szczytno, Pisz and Mrągowo. Registered in 1885 by the Prussian Lithuanian Christopher Kukat , the East Prussian Evangelical Prayers Association which with the help of its bilingual (German Lithuanian) paper Pakajaus Paslas/ Friedens- Bote gave the organizational framework to the East Prussian clusters. At the turn of 19th and 20th centuries, the Gromadkar movement reached its apogee, also spreading among the Mazurian workers’ communities in the Ruhr. Since the First World War, there has been a gradual stifling of the movement, which in the Nazi era entered agonal phase. The key to understanding the world of clusters is the “Six Books on True Christianity” by John Arndt, in which he creates a kind of bridge between Luther’s teachings and the writings of the Rhine mystics of Master Eckhart, John Tauler and Henry Suzo, giving Mazurians directions for spiritual growth. It was supposed to rely on “Six Books” to deny yourself, to reject your own ego, to seek contact with God, indicating as the goal the union with God. The uniqueness of the Gromadkar movement consisted in going beyond the Lutheran principle of “justification by faith” and entering the ground of Christian mysticism unknown to the Evangelical doctrine, which happened through the work of Arndt. An additional aspect that opens up in this context is the Slavic and Lithuanian spirituality and the sensitivity of the crowd, without which undoubtedly it would not be possible to practice mysticism on the basis of the Evangelical religion.

Device therapy in cardiological palliative care situations

There is considerable uncertainty about the management of patients with cardiac implantable electronic devices (CIEDs) threatened by immediate or medium-term death due to heart failure or other disease, for patients and their relatives as well as for physicians and medical staff. Patients can be afraid that they cannot die as long as pacing persists; medical staff may forget to deactivate shock therapies in an agonal phase or may not know how to do this without aprogrammer. For optimal handling of CIEDs in apalliative care situation, patients have to be informed that pacemakers or cardiac resynchronization therapy have no life-prolonging effect in this situation but only limit suffering, particularly due to dyspnea. Palliative care physicians must be informed that ICDs can be temporarily deactivated by magnet application, requiring neither adevice specialist nor aprogrammer. Medical staff has to be trained in empathic discussions about CIED deactivation. An optimal setting for this talk may occur if the patient asks about the course and prognosis of his disease or an advance directive, which includes statements about resuscitation. Palliative care physicians have to understand the different functions of aCIED (antibradycardia pacing, resynchronization, antitachycardia pacing, shock therapy) and the deactivation of each of these components to ensure an appropriate decision; otherwise, CIED management at the end of apatient's life may cause suffering and asense of guilt in relatives and medical staff.

Prolongation of the Agonal Phase in the DCD Donor Results in Impairment of Myocardial Contractility Following DCD Heart Resuscitation

Purpose Circulatory arrest follows withdrawal of supportive therapy in the DCD donor. The agonal phase following withdrawal can be prolonged and may be associated with hypoxia and hypotension. Our aim was to evaluate the impact of the duration of the agonal period on the capacity for cardiac resuscitation. Methods Rats (n = 6/group) were subjected to hypoventilation using a mechanical ventilator and exposed to either brief (5 mins), moderate (30 mins) or prolonged (60 mins) hypoxia and hypotension prior to circulatory arrest. This method was used to simulate an agonal phase of varying duration. Following circulatory arrest 15 minutes of warm ischemia was observed prior to reperfusion with extracorporeal membrane oxygenation (ECMO). ECMO reperfusion was followed by cardiac resuscitation. Load independent left ventricular (LV) contractility was assessed at baseline and following resuscitation via the end-systolic pressure volume relationship (ESPVR). Results Hypoventilation was followed by a decrease in oxygen saturation (pre 96% vs post 48%), mean arterial pressure (pre 72 +/- 14 vs. post 41 +/- 5 mm Hg) and pH (pre 7.49 +/- 0.1 vs. post 6.99 +/- 0.1). There was no difference between groups in LV contractility at baseline. Following circulatory arrest and cardiac resuscitation all groups demonstrated a decline in contractile function from baseline. There was marked reduction in LV contractility in animals with a 60-minute agonal phase (ESPVR: 60 minutes; 0.17 +/- 0.08, 30 minutes; 0.66 +/- 0.16, 5 minutes; 0.47 +/- 0.09, p Conclusion Brief or moderate exposure to hypoxia and hypotension prior to circulatory arrest was associated with satisfactory recovery of contractile function. Prolonged exposure to these conditions was associated with a significant decline in LV contractility. In the human DCD donor marked prolongation of the agonal phase may limit cardiac donation.

Factors That Predict the Successful Utilization of Donor Lungs after Ex-Vivo Lung Perfusion

Purpose Ex-vivo lung perfusion (EVLP) has proven effective to identify transplantable lungs retrieved from high-risk donors. However, the relative impact of each donor-related extended criteria on EVLP outcome is unknown. Identifying donor characteristics predictive of EVLP success or failure would help to appropriately select organs with maximized efficiency and benefit. Methods We retrospectively reviewed donor-related variables of all lungs that underwent normothermic EVLP at our institution from September 2008 to December 2017. We then compared variables from accepted lungs to lungs that were ultimately declined for transplantation according to our standard EVLP criteria. Univariate comparisons between groups were performed using Student's t test for continuous variables and Chi2 test or Fisher's exact test for categorical variables. Results During the study period, 373 EVLP procedures were performed, of which 117 (31.3%) were declined for transplantation. Rejected organs showed a trend towards higher Oto donor scores compared to accepted ones (8.1 vs 7.3, p=0.087). 63.4% of declined lungs had scores above 7 in contrast to 48% in transplanted ones (p=0.025). Age and bronchoscopy findings were significantly associated with organ rejection after EVLP: a greater proportion of rejected organs were from donors aged over 60 (29.8% vs 15%, p=0.001) and had major bronchoscopy findings (purulent secretions, blood or aspiration, 46.9% vs 29.3%, p=0.007). Donor P/F ratio was not different between accepted and declined lungs (365.8 vs 343, p=N.S). Chest radiography, smoking history, cause of death, proportion of DCD, agonal phase duration, and days on mechanical ventilation were all not predictive of utilization after EVLP. Conclusion This work does not identify definitive donor characteristics leading to EVLP failure or success. However, our data suggest that lungs retrieved from older donors or those with major bronchoscopy findings may be more susceptible to failure. Clearly, more precise diagnostic measures will be required to improve the precision of selection of donor lungs to treat with EVLP.

Elevated levels of 8-oxoGuo and 8-oxodG in individuals with severe mental illness – An autopsy-based study

Elevated systemic oxidative stress levels of 8-oxoGuo and 8-oxodG have been reported in individuals with severe mental illness (SMI). As no previous studies have addressed the link between local levels of 8-oxoGuo and 8-oxodG in the central nervous system (CNS), measured in cerebrospinal fluid (CSF), and urinary systemic levels, we employed autopsy-based material to elucidate this aspect. Additionally, we investigated the impact of 8-oxoGuo and 8-oxodG levels on the prevalence of somatic co-morbidities.Based on post mortem samples from deceased individuals with SMI (N = 107), we found significantly elevated urinary levels of both 8-oxoGuo and 8-oxodG compared to mentally healthy living controls. While we found an association between urinary and CSF 8-oxodG levels (r = 0.50, P < 0.001), a similar correlation was not evident for 8-oxoGuo (r = 0.15, P = 0.16). Additionally, the two r-values were significantly different (P < 0.001). Neither marker in urine or CSF was associated with obesity-related variables, metabolic syndrome or type 2 diabetes. The post mortem interval did not affect the results, but the agonal phase seemingly introduced bias.This study provided novel insights into the cellular oxidative stress levels in individuals with SMI. We demonstrated that increased oxidative stress locally and systemically is correlated and is a clear phenomenon in SMI. Although post mortem measurements contain some weaknesses, our study indicates DNA as the main site of oxidative stress modifications in the CNS in SMI. This may provide novel opportunities for treatment modalities. Additionally, our study demonstrated the applicability of post mortem material investigating systemic and local 8-oxoGuo and 8-oxodG levels.

Influence of lung donor agonal and warm ischemic times on early mortality: Analyses from the ISHLT DCD Lung Transplant Registry.

In this study we aimed to assess the impact of agonal time and warm ischemic time on early survival in Category III donation-after-circulatory-death (DCD) donor lung transplants (LTxs) using data reported to the International Society for Heart and Lung Transplantation (ISHLT) DCD Lung Transplant Registry. In this retrospective study, data were analyzed for 507 DCD LTxs done between January 2005 and June 2015. DCD lung donor agonal time (defined as withdrawal of life support to cessation of cardiac output) andwarm ischemic time (WIT; defined as donor systolic blood pressure <50 mm Hg to cold pulmonary artery flush) were divided into 3 clinical timing categories (<30 minutes, 30 to 60 minutes, >60 minutes) and 3 tertiles. Univariate analysis was undertaken for all categorizations, and Day 30/Day 365 Kaplan‒Meier survival rates were calculated and compared. Multivariable analysis included Cox proportional hazards regression models to estimate hazard of 365-day mortality. Four hundred sixty-five and 301 DCD LTxs had data to analyze in the agonal and warm ischemic time groups, respectively. Day 30 and Day 365 post-transplant survival overall were 96% and 90%, respectively, and not statistically different according to agonal or WIT category or tertile. Current experience with DCD Category III LTx does not show a relationship between the duration of donor agonal phase or warm ischemic time up to 60 minutes and early survival. These results suggest the true limits of clinical DCD allograft warm ischemic times may not yet be reached. Global variations in clinical DCD practice are apparent. Continued accurate recording and analyses of DCD processes is warranted.

Onset of Donor Warm Ischemia Time in Donation After Circulatory Death Liver Transplantation: Hypotension or Hypoxia?

The aim of this study was to investigate the impact of hypoxia and hypotension during the agonal phase of donor warm ischemia time (DWIT) on hepatic ischemia/reperfusion injury (IRI) and complications in donation after circulatory death (DCD) liver transplantation. A retrospective single‐center study of 93 DCD liver transplants (Maastricht type III) was performed. DWIT was divided into 2 periods: the agonal phase (from withdrawal of treatment [WoT] until circulatory arrest) and the asystolic phase (circulatory arrest until cold perfusion). A drop to <80% in peripheral oxygenation (SpO2) was considered as hypoxia in the agonal phase (SpO2‐agonal) and a drop to <50 mm Hg as hypotension in the agonal phase (SBP‐agonal). Peak postoperative aspartate transaminase level >3000 U/L was considered as severe hepatic IRI. SpO2 dropped within 2 minutes after WoT <80%, whereas the systolic blood pressure dropped to <50 mm Hg after 9 minutes, resulting in a longer SpO2‐agonal (13 minutes) than SBP‐agonal (6 minutes). In multiple logistic regression analysis, only duration of SpO2‐agonal was associated with severe hepatic IRI (P = 0.006) and not SBP‐agonal (P = 0.32). Also, recipients with long SpO2‐agonal (>13 minutes) had more complications with a higher Comprehensive Complication Index during hospital admission (43.0 versus 32.0; P = 0.002) and 90‐day graft loss (26% versus 6%; P = 0.01), compared with recipients with a short SpO2‐agonal (≤13 minutes). Furthermore, Cox proportional hazard modeling identified a long SpO2‐agonal as a risk factor for longterm graft loss (hazard ratio, 3.30; 95% confidence interval, 1.15‐9.48; P = 0.03). In conclusion, the onset of hypoxia during the agonal phase is related to the severity of hepatic IRI and postoperative complications. Therefore, SpO2 <80% should be considered as the start of functional DWIT in DCD liver transplantation.

The Impact of Combined Warm Ischemia Time on Development of Acute Kidney Injury in Donation After Circulatory Death Liver Transplantation: Stay Within the Golden Hour.

Acute kidney injury (AKI) is a common complication after liver transplantation and more frequently observed when high-risk grafts, such as donation after circulatory death (DCD) grafts are used. Our aim was to investigate the impact of the ischemia periods on development of AKI in DCD liver transplantation. We performed a 2-center retrospective study with 368 DCD graft-recipients. Donor warm ischemia time (DWIT) was divided into agonal phase (withdrawal of life support-cardiac arrest) and asystolic phase (cardiac arrest-start cold perfusion). We introduced a new period of warm ischemia: the combined warm ischemia time (combined WIT), which was defined as the sum of DWIT and recipient WIT. AKI was observed in 65% of the recipients and severe AKI in 41% (KDIGO stage 2/3). The length of combined WIT increased significantly with AKI severity: 61 minutes in recipients without AKI up to 69 minutes in recipients with the most severe form of AKI (P < 0.001). On multivariable analysis, increasing duration of the combined WIT was associated with an increased risk of developing severe AKI (odds ratio, 1.032 per every extra minute; 95% confidence interval, 1.014-1.051; P < 0.001). No relation was observed between length of cold ischemia time and severe AKI. Combined WIT is a newly defined period of warm ischemia in DCD liver transplantation. Length of combined WIT is associated with severity of postoperative AKI and should ideally not exceed 60 minutes.

DCD donor hemodynamics as predictor of outcome after kidney transplantation.

Insufficient hemodynamics during agonal phase-ie, the period between withdrawal of life-sustaining treatment and circulatory arrest-in Maastricht category III circulatory-death donors (DCD) potentially exacerbate ischemia/reperfusion injury. We included 409 Dutch adult recipients of DCD donor kidneys transplanted between 2006 and 2014. Peripheral oxygen saturation (SpO2-with pulse oximetry at the fingertip) and systolic blood pressure (SBP-with arterial catheter) were measured during agonal phase, and were dichotomized into minutes of SpO2>60% or SpO2<60%, and minutes of SBP > 80mmHg or SBP < 80mmHg. Outcome measures were and primary non-function (PNF), delayed graft function (DGF), and three-year graft survival. Primary non-function (PNF) rate was 6.6%, delayed graft function (DGF) rate was 67%, and graft survival at threeyears was 76%. Longer periods of agonal phase (median 16min [IQR 11-23]) contributed significantly to an increased risk of DGF (P=.012), but not to PNF (P=.071) and graft failure (P=.528). Multiple logistic regression analysis showed that an increase from 7 to 20minutes in period of SBP < 80mmHg was associated with 2.19 times the odds (95% CI 1.08-4.46, P=.030) for DGF. In conclusion, duration of agonal phase is associated with early transplant outcome. SBP < 80mmHg during agonal phase shows a better discrimination for transplant outcome than SpO2<60% does.

Perfusion Parameters of Donation After Cardiac Death Kidneys Predict Early Transplant Outcomes Based on Expanded Criteria Donor Designation

BackgroundDonation after cardiac death is the only source of the deceased donor in China at present. Hypothermic machine perfusion has been used increasingly over the years. We determined the hypothermic machine perfusion parameters associated with early transplant outcomes based on the expanded criteria donor (ECD) designation. MethodsThere were 446 consecutive kidneys donated after cardiac death and preserved by hypothermic machine perfusion (LifePort) in our center that were included in this study. The database was divided into 2 groups: ECD and non-ECD groups. LifePort parameters and other pretransplant factors were analyzed. Logistic regression analysis was used to determine the significant factors for delayed graft function (DGF). Recovery time for renal function and 6-months serum creatinine were investigated. ResultsThe DGF rates were 20.25% and 11.72% in ECD and non-ECD group by our definition, respectively (P = .042). Higher pressures allowed comparable increases of flow in ECD kidneys despite still greater resistance. For non-ECD kidneys with an initial flow of ≤80 mL/min, the DGF rate of the subgroup with a terminal flow of ≥100 mL/min was significantly lower compared with that of other terminal flow subgroups (≤80 and 90–100 mL/min; P < .05), and showed a trend toward significance when compared with the terminal flow subgroup of 80 to 90 mL/min (P = .098). Terminal resistance was the most significant parameter predicting DGF (odds ratio 2.44; P < .001), and remained significant after adjusted for other relevant pretransplant variables. Logistic model for DGF (model: terminal resistance, hypotension in agonal phase, terminal serum creatinine, and cause of death) had good predictive ability (c-statistic 0.851; 95% confidence interval, 0.799–0.903). ConclusionsLifePort parameters provided a granular measurement easily accessible in evaluating the quality of kidneys donated after cardiac death that added information to ECD criterion.

Dual chamber stent prevents organ malperfusion in a model of donation after cardiac death

The paradigm for donation after cardiac death subjects donor organs to ischemic injury. A dual-chamber organ perfusion stent would maintain organ perfusion without affecting natural cardiac death. A center lumen allows uninterrupted cardiac blood flow, while an external chamber delivers oxygenated blood to the visceral vessels. A prototype organ perfusion stent was constructed from commercial stents. In a porcine model, the organ perfusion stent was deployed, followed by a simulated agonal period. Oxygenated blood perfused the external stent chamber. Organ perfusion was compared between controls (n=3) and organ perfusion stent (n=6). Finally, a custom, nitinol, dual chamber organ perfusion stent was fabricated using a retrievable "petal and stem" design. Endovascular organ perfusion stent deployment achieved visceral isolation without adverse impact on cardiac parameters. Visceral oxygen delivery was 4.8-fold greater compared with controls. During the agonal period, organs in organ perfusion stent-treated animals appeared well perfused in contrast with the malperfused controls. A custom nitinol and polyurethane organ perfusion stent was recaptured easily with simple sheath advancement. An organ perfusion stent maintained organ perfusion during the agonal phase in a porcine model of donation after cardiac death organ donation without adversely affecting cardiac function. Ultimately, the custom retrievable design of this study may help resolve the critical shortage of donor organs for transplant.

Deterioration of Lung Function in a Pig Model of Uncontrolled Cardiac Death

IntroductionUncontrolled donors after circulatory determination of death (uDCDD) represent a yet unexplored pool of organs potentially available for transplantation. The aims of this study were to validate a protocol of cardiac death in the pig and to investigate lung function during the process. Materials and MethodsCardiac death was induced in preanesthetized animals with an injection of 600 mg propofol; once systolic blood pressure was <50 mm Hg (Agonal Phase), a 20 mEq bolus of KCl was given and, after asystolia was documented, cardiopulmonary resuscitation (CPR) started, followed by 5 minutes no touch (end-CPR). Invasive blood pressure (BP) and heart rate (HR) were recorded; blood samples taken at baseline, 15 minutes after CPR, and after the no touch period (end-CPR). Computed tomography (CT) scans were taken at baseline and at end-CPR. ResultsAgonal phase was reached in 6 ± 1 minutes and lasted 3 ± 1 minutes; average HR was 49 ± 16 beats/min, and BP was 41 ± 12 mm Hg. CPR lasted 35 ± 3 minutes; average HR and BP were 113 ± 32 beats/min and 86 ± 63 mm Hg, respectively. PaO2/FiO2 decreased from 442 ± 31 mm Hg at baseline to 63 ± 36 at end-CPR (P < .001). pH decreased from 7.378 ± 0.045 to 6.931 ± 0.042 (P < .001), with a corresponding increase of lactate from 0.9 ± 0.2 to mmol/L to 12.8 ± 2.1 (P < .001). As assessed using CT scan, total lung volume decreased (baseline vs end-CPR 1107 ± 106 mL vs 617 ± 95; P < .001), whereas noninflated tissue (ie, atelectasis) significantly increased (46 ± 10 g vs 131 ± 89; P = .008). ConclusionsLung function greatly deteriorated after cardiac death. The model we set may constitute a reproducible platform for future investigations on lung uDCDD.

Nutrition et hydratation en fin de vie : une mise en œuvre pas toujours bientraitante

At the end of life the pleasure function of alimentation is to be preferred to its nutritive function. Artificial nutrition and hydration in an enteral or parenteral way are artificial life support techniques. Artificial nutrition and hydration are systematically justified for patients in curative phase that require it but not for patients in a terminal or agonal phase. The fear of death from hunger and thirst is not justified. It is more relevant of a symbolic and phantasmic dimension than of an objective reality. The practice of oral care is much more effective than installing an artificial hydration to improve the comfort of a patient at the very end of life. Withdrawing or withholding an artificial nutrition and hydration can prevent an unreasonable obstinacy prohibited by law.

Characterizing Cardiac Donation After Circulatory Death: Implications for Perfusion Preservation

Donation after circulatory determination of death (DCDD) involves variable definitions of death among hospitals, and DCDD hearts are not generally considered for transplantation. The definition can affect ischemic times, and machine perfusion preservation appears promising for recovery of DCDD hearts. The purpose of the current study was to investigate the agonal phase of DCDD donors and evaluate retrograde perfusion preservation of DCDD donor hearts in a large animal model of cardiac transplantation. Ten canines were anesthetized and then disconnected from mechanical ventilation. Time to loss of pulse (systolic blood pressure <50 mm Hg), loss of pressure, and asystole or fibrillation were recorded. Five minutes after asystole, hearts were exposed and arrested with 1 L of University of Wisconsin Machine Perfusion Solution. Eight hearts were cold preserved for 4 hours by retrograde machine perfusion or static storage (n= 4/group), then reimplanted and reperfused for 6 hours. Thepreload recruitable stroke work was used to measure myocardial function. The agonal phase was similar between groups. Loss of pulse and pressure were consistent between animals (7.9 ± 0.5 minutes [range, 5 to 11 minutes], 10.2 ± 0.4 minutes [range, 9 to 13 minutes], respectively). Electrical silence wasvariable at 26.9 ± 3.8 minutes (range, 11 to 43 minutes). All perfused hearts separated and remained off cardiopulmonary bypass. Three of four static hearts initially separated from cardiopulmonary bypass, but two returned by the end of the reperfusion period. The preload recruitable stroke work was significantly higher in perfused hearts. Protocols for DCDD have implications on ischemic times of donor hearts. Machine perfusion preservation can recover DCDD hearts more consistently than static storage.

(246) - Length of the Agonal Phase in Donors After Cardiac Death Influences Donor Lung Function After Reperfusion in a Rat Model

(246) - Length of the Agonal Phase in Donors After Cardiac Death Influences Donor Lung Function After Reperfusion in a Rat Model

Donation after circulatory death

Donor shortage has forced transplant teams to explore new methods to increase the potential donor pool. Donation after circulatory death (DCD) has opened new perspectives and could be a valuable option to expand the brain-dead donors. The purpose of this review is to provide an overview of current practice and to identify remaining questions related to ethical and medical issues that should be further addressed in the future. Recent findings demonstrate acceptable outcomes after DCD kidney and lung transplantation but inferior graft survival for liver transplantation. The impact and importance of the agonal phase following withdrawal of treatment in controlled DCD is increasingly recognized. Premortem interventions are currently under debate related to preservation strategies or comfort therapy. New preservation strategies using in-situ/in-vivo extracorporeal membrane oxygenation or ex-vivo machine perfusion have large potential in the future. Finally, organizations and institutions are reporting more uniform guidelines related to declaration of death and DCD organ procurement. DCD donation has regained much attention during the last decade and is now part of standard clinical practice albeit this type of donation should not be regarded as an equally acceptable alternative for donation after brain death. It will be important to further explore the potential of DCD, to monitor the long-term outcomes and to further optimize the quality of these grafts. Development and implementation of uniform guidelines will be necessary to guarantee the clinical use of these donor pools.

Characterizing the Agonal Phase of the Non-Heart Beating Donor in Canines – Implications for Utilization of DCD Hearts for Transplantation

Purpose Donation after cardiac death (DCD) has increased the donor pool for abdominal organ and lung transplantation but is not generally considered for cardiac transplantation. In the United States, the definition of cardiac death varies widely among hospitals but most commonly is defined as loss of pulse/heart sounds, loss of arterial wave form, or loss of electrical activity. The purpose of the current study was to investigate the agonal phase of DCD donation in a large animal model to evaluate the time to cardiac death using these definitions and assess potential implications for heart transplantation. Methods and Materials Adult mongrel dogs (n=5) were anesthetized and instrumented with a left ventricular catheter. Baseline hemodynamic data were obtained. Animals were then disconnected from the ventilator. Hemodynamic data were then collected at two minute intervals until flat line of the LV catheter. Time to loss of pulse, loss of pressure wave form and cessation of electrical activity/ventricular fibrillation were measured. Data are reported as mean ± standard error of the mean. Results Hearts experienced an initial period of tachycardia and hypertension after cessation of ventilation. This was followed by a rapid decline in left ventricular pressure. Loss of pulse and the pressure wave form were relatively consistent between animals occurring at 7.4±.7 min (range 5-9 min) and 9.8±.5 min (range 9-11 min), respectively. Electrical silence was variable and occurred at 30.1±7.3 min (range 11-43 min). Conclusions The definition of cardiac death may have important implications for recovery of DCD hearts for transplantation. Loss of pulse is an early event associated with ongoing cardiac contractile function and has the greatest potential for organ recovery. Flat line of the pressure wave is a later but relatively predictable event. Electrical activity can persists for a long periods of warm ischemia and likely will not yield acceptable hearts for transplantation using conventional preservation techniques.

Injury evolution and classified treatment in survival process of penetrating cardiac trauma

Objective To analyze the pathophysiological variation in patients with penetrating cardiac trauma (PCT) and discuss the classified treatment strategies.Methods A retrospective analysis was conducted on pathogenetic condition,medical interventions and other clinical information of 133 PCT patients.The patients were divided into four groups in accordance with their symptom classification on arrival at emergency department,including sub-clinic type,cardiac tamponade type,hemorrhagic shock type and agonal type.Meanwhile,the patients were classified into three groups according to their pathogenesis phase,including sub-clinical phase,clinical phase and agonal phase.Development characteristic of patients' condition in each group was investigated in each time point by survival analysis.Impacts of medical interventions on prognosis of those patients were analyzed,such as pericardial space exploration,emergency room thoracotomy (ERT),operating room thoracotomy (ORT).Results Some patients at sub-clinical phase were aggravated into clinical phase or agonal phase,as well as some patients at clinical phase were aggravated into agonal phase during in-hospital treatment.There were significance differences of posttraumatic suvival course among the four groups,namely sub-clinical type,cardiac tamponade type,hemorrhagic shock type and agonal type (P ＜ 0.01).The differences of posttraumatic survival course were also significant among the three groups,namely sub-clinical phase,clinical phase and agonal phase (P ＜ 0.01).Conclusion Clinical symptom classification (or pathogenesis phase) of PCT may not be always unchangeable,thus it is recommended that PCT patients should be treated based on their clinical symptom classification or patbogenesis phase at consultation. Key words: Heart injuries; Classification ; Prognosis

Sedación paliativa en un Hospital Universitario: experiencia tras la puesta en marcha de un protocolo específico

A descriptive prospective study of palliative sedation (PS) records during a one year period after starting the PS protocol. Patients included in the PS protocol and those who had completed the "data registry form". Registry forms included in the PS protocol as Annex 5 (included as Annex 1 in this study). Personal data, data regarding basal disease, prognosis, level of information. Refractory symptoms: type, time of evolution and treatments employed. Involvement of the patient and/or representatives in decision making. Type of sedation, continuity, depth, employed, duration and results, and readjustment of other therapeutic measures. The SPSS 14.0 was used. For qualitative variables we studied absolute frequencies and proportions. For quantitative variables with normal distribution, we used means and standard deviations, and for non-normal distribution, medians and ranges. In the study period 90 cases of PS were counted. This represented 27.6% of the patients treated in the hospital palliative care support team (PCST), and 7.03% of the total deceased patients in our hospital. Mean age of patients undergoing PS was 59.22 years old, range between 40.86 and 77.58 years, and 68.1% were men. All patients were in an advanced or terminal stage of their condition, and 49.5% in an agonal phase. In 90.4% of the cases, the main pathology was oncological. Regarding PS indication, this was jointly made between the PCST physician and the patient's usual doctor in 60 cases (66.6%). Symptoms leading to sedation were mainly dyspnea, delirium and pain. The Ethics committee was consulted in five cases. Mean time under sedation was 134.02 hours (5.5 days). In 90% of the cases, duration ranged from 50 to 218.04 hours (2-9 days). Depth of PS after induction was registered in 88.8% of the cases. Informed consent (IC) was explicit in 11.2% of the cases,and given prior to the appearance of refractory symptoms and/or agonal phase. In 88.8% of sedation cases, the IC was given by a representative. Midazolam was the most used drug of choice in 87.8% of the cases, and levomepromazine in 10.2%. Up to 15% of sedations required drug changes or combinations. 1) The application of a PS Protocol and the availability of a hospital PCST and an Ethical Care Committee favored a safe (correct) use of PS in a hospital lacking a palliative care unit (PCU), and a homogeneous data registry for their analysis, with quality criteria similar to those offered by a PCU. 2) We have detected areas of improvement that will be applied in the second version of our protocol.

Outcomes of simultaneous pancreas–kidney transplantation from brain-dead and controlled circulatory death donors

Organ scarcity has prompted increased use of organs from donation after circulatory death (DCD) donors. An early single-centre experience of simultaneous pancreas-kidney (SPK) transplantation from controlled DCD donors is described here. Outcomes of SPK transplants from DCD and donation after brain death (DBD) donors between August 2008 and January 2011 were reviewed retrospectively. SPK transplants from 20 DCD and 40 DBD donors were carried out. Donor and recipient characteristics were similar for both groups, although pancreas cold ischaemia times were shorter in DCD recipients: median (range) 8·2 (5·9-10·5) versus 9·5 (3·8-12·5) h respectively (P = 0·004). Median time from treatment withdrawal to cold perfusion was 24 (range 16-110) min for DCD donors. There were no episodes of delayed pancreatic graft function in either group; the graft thrombosis rates were both 5 per cent. Similarly, there were no differences in haemoglobin A1c level at 12 months: median (range) 5·4 (4·9-7·7) per cent in DCD group versus 5·4 (4·1-6·2) per cent in DBD group (P = 0·910). Pancreas graft survival rates were not significantly different, with Kaplan-Meier 1-year survival estimates of 84 and 95 per cent respectively (P = 0·181). DCD SPK grafts had comparable short-term outcomes to DBD grafts, even when procured from selected donors with a prolonged agonal phase.