Explore the vast range of titles available.

Acknowledging this variation in the recognition, diagnosis and documentation of neurological death, the Canadian Council for Donation and Transplantation sponsored a national forum of experts to create a set of recommendations that will have significant implications for organ donation in Canada. Severe brain injury is a prerequisite for neurological determination of death (NDD); and NDD, commonly referred to as brain death, is a prerequisite for cadaveric organ donation. The right to entertain the option of organ and tissue donation is increasingly supported by society and will become legislated in some Canadian jurisdictions. Collaborative efforts are required to optimize the care of patients who may become eligible for donation and to ensure consistent and ethical conduct in care. This comprehensive national collaboration is the first of its kind in Canada in this domain. Each of the 3 main areas of focus - recommendations for a Canadian definition, criteria and minimum testing requirements for NDD; recommendations concerning the incidence and reporting of NDD and legal issues; and recommendations associated with the management of patients with severe brain injury from the emergency department to the intensive care unit - was addressed using the following process. Presentations by experts were followed by plenary discussions supported by fact sheets that summarized preceding American8 and Canadian guidelines7 and by substantial background papers9-11 and surveys12 provided by the planning committee in advance of the forum. Small-group discussions then focused on specific questions related to the processes of care. The Forum Recommendations Group (FRG) and the Pediatric Reference Group (PRG) reviewed the results of the small-group discussions, developed unanimous recommendations for adults and children and returned these for plenary discussion. A Neonatal Reference Group met subsequent to the forum to develop neonatal age-adjusted recommendations. (See Appendix 1 for a list of members of these groups.) Clinical checklists are included in Appendix 4. From Division of Pediatric Critical Care, Montreal Children's Hospital, McGill University Health Centre, Montréal, Que. (Shemie), Adult Critical Care, Foothills Hospital, University of Calgary, Calgary, Alta. (Doig), Faculty of Law, Joint Centre for Bioethics, University of Toronto, Toronto, Ont. ([Bernard Dickens]), John Dossetor, Health Ethics Centre and Department of Pediatrics, University of Alberta, Edmonton, Alta. ([Paul Byrne]), Neonatal Intensive Care Unit, Stollery Children's Hospital (Byrne), Dalhousie University, Queen Elizabeth II Health Sciences Centre, Halifax, NS (Rocker), Trauma and Neurosurgery Intensive Care Unit, St. Michael's Hospital, University of Toronto, Toronto, Ont. (Baker), Department of Critical Care Medicine, Sunnybrook and Women's College Health Sciences Centre, University of Toronto, Toronto, Ont. (Guest), Emergency Medicine, St. Michael's Hospital, Toronto, Ont. ([Dan Cass]), ICU, Children's and Women's Health Centre of British Columbia, Vancouver, BC ([Rosella Jefferson]), Montreal Neurological Institute and Hospital, McGill University, Montréal, Que. (Teitelbaum), Maisonneuve-Rosemount Hospital, University of Montreal, Montréal, Que. (Teitelbaum), Trillium Gift of Life Network (Baker, Guest), Canadian Critical Care Society (Shemie, Doig, Rocker, Baker), Canadian Council for Donation and Transplantation (Shemie, Doig, Young), Canadian Neurosurgical Society ([Brian Wheelock]), Canadian Anesthesiologists' Society (Baker), College of Physicians and Surgeons of British Columbia (Seland), Canadian Association of Emergency Physicians (Cass), Canadian Association of Critical Care Nurses (Jefferson), Canadian Association of Transplantation (Young), Canadian Neurocritical Care Group ([Jeanne Teitelbaum]).

Brain function during the dying process and around the time of cardiac arrest is poorly understood. To better inform the clinical physiology of the dying process and organ donation practices, we performed a scoping review of the literature to assess time to loss of brain function and activity after circulatory arrest. Medline and Embase databases were searched from inception to June 2014 for articles reporting the time interval to loss of brain function or activity after loss of systemic circulation. Thirty-nine studies met selection criteria. Seven human studies and 10 animal studies reported that electroencephalography (EEG) activity is lost less than 30seconds after abrupt circulatory arrest. In the setting of existing brain injury, with progressive loss of oxygenated circulation, loss of EEG may occur before circulatory arrest. Cortical evoked potentials may persist for several minutes after loss of circulation. The time required to lose brain function varied according to clinical context and method by which this function is measured. Most studies show that clinical loss of consciousness and loss of EEG activity occur within 30seconds after abrupt circulatory arrest and may occur before circulatory arrest after progressive hypoxia-ischemia. Prospective clinical studies are required to confirm these observations.

In collaboration with the Canadian Critical Care Society, the Canadian Association of Transplantation and the Canadian Society of Transplantation, the Canadian Council for Donation and Transplantation (CCDT) sponsored a forum entitled \"Medical Management to Optimize Donor Organ Potential,\" 23-25 Feb. 2004, to develop guidelines and recommendations for organ donor management in Canada. Discussions were restricted to the interval of care that begins with neurological determination of death (NDD), commonly called \"brain death,\" and consent to organ donation, and culminates in surgical organ procurement. This period presents a significant opportunity to enhance multi-organ function and improve organ utilization. From Division of Pediatric Critical Care, Montreal Children's Hospital, McGill University Health Centre, Montréal, Que. (Shemie), Cardiac Transplant Program, Toronto General Hospital, University Health Network ([Heather Ross]), GI Transplant Program, Toronto General Hospital, University Health Network ([Paul D. Greig]), General Surgery, ICU and Organ and Tissue Donation Program, The Ottawa Hospital ([Joe Pagliarello]), Trauma and Neurosurgery Intensive Care Unit, St. Michael's Hospital, University of Toronto, Toronto, Ont. ([Andrew J. Baker]), Adult Critical Care, Foothills Hospital, Calgary, Alta. ([Christopher Doig]), Trillium Gift of Life Network (Baker), Canadian Critical Care Society ([Sam D. Shemie], Pagliarello, Baker, Doig, Guest), Canadian Anesthesiologists' Society (Baker), Canadian Organ Replacement Register (Greig), Canadian Society of Transplantation (Greig, Ross, [Sandra Cockfield], Keshavjee, [Vivek Rao], [Peter Nickerson]), Canadian Association of Transplantation ([Tracy Brand], [Kimberly Young]), Kidney Transplant Program, University of Alberta Hospital, Edmonton, Alta. (Cockfield), Toronto Lung Transplant Program, University Health Network, University of Toronto, Toronto, Ont. (Keshavjee), Immunogenetics Laboratory, University of Manitoba Health Services Centre, Winnipeg, Man. (Nickerson), Cardiac Transplant Program, University Health Network, University of Toronto, Toronto, Ont. (Rao), Department of Critical Care Medicine, Sunnybrooke and Women's College Hospital, Toronto, Ont. (Guest), Canadian Council for Donation and Transplantation (Shemie, Young, Doig), Saskatchewan Transplant Program (Brand).

Introduction Family members of critically ill patients suffer from high levels of anxiety and depression in the ICU, and are at risk of developing post-ICU syndrome following ICU discharge. In the case of brain death, and potential organ donation, the family is at the center of the decision process: within a limited time frame, the family will be informed that the patient is brain-dead and will be approached about potential organ donation. Materials and methods Family experience with organ donation has been the topic of several research papers allowing one to gain knowledge about family members’ experience of organ donation, emphasizing specific needs, adequate support, and pointing out gaps in current delivery of family-centered care. In this narrative review, experts, clinicians, and researchers present the various legal systems regarding family implication in organ donation decisions; describe factors that influence the decision-making process; highlight family perspectives of care and respect for potential donors in the ICU environment; describe the impact of organ donation discussions and decisions on post-ICU syndrome; and suggest communication skills and support to be developed in the future. A research agenda for the next decade is also encouraged. Conclusion Overall, challenges remain and concern all persons involved in the process, ICU doctors and nurses, the organ procurement organization, family members, and, in some cases, the patients themselves. Looking at the big picture will provide opportunities for further improvements.

Endotoxin is a primary trigger of the inflammatory processes that lead to shock, multiorgan failure, and purpura fulminans in meningococcal sepsis. Bactericidal/permeability-increasing protein (BPI) is a natural protein, stored within the neutrophil granules, that binds to and neutralises the effects of endotoxin in vitro, in laboratory animals, and in humans. To establish whether a recombinant 21-kDa modified fragment of human BPI (rBPI 21), containing the active antimicrobial and endotoxin-neutralising moiety, would decrease death and long-term disability from meningococcal sepsis, we did a randomised, double-blind, placebo-controlled trial of rBPI21 in children with severe meningococcal sepsis. We enrolled children (2 weeks to 18 years of age) presenting to 22 centres in the UK and the USA with a clinical picture suggestive of meningococcal sepsis, and with evidence of severe disease. Children were randomly assigned rBPI 21 (2 mg/kg over 30 min followed by 2 mg/kg over 24 h) or placebo (0·2 mg/mL human albumin solution) in addition to conventional medical therapy. Primary outcome variables were mortality, amputations, and change in paediatric overall performance category (POPC) from before illness to day 60. Analysis was by intention to treat. Of 1287 patients screened, 892 were excluded, including 57 patients who died or who met criteria for imminent death before receiving the study drug. 190 patients received rBPI21, and 203 placebo. 34 (8·7%) of 393 patients died during the study: 14 (7·4%) in the rBPI21 group and 20 (9·9%) in the placebo group (odds ratio 1·31 [95% Cl 0·62–2·74], p=0·48). Compared with patients randomised to placebo, fewer patients treated with rBPI21 had multiple severe amputations (six of 190 [3·2%] vs 15 of 203 [7·4%], odds ratio 2·47 [0·94–6·51], p=0·067), and more had a functional outcome similar to that before illness (as measured by the POPC scale) at day 60 (136 of 176 [77·3%] vs 126 of 190 [66·3%], p=0·019). Because most deaths occurred in the interval between identification of patients and study drug administration, the mortality rate in the placebo group was substantially lower than predicted. The trial was therefore underpowered to detect significant differences in mortality. However, patients receiving rBPI21 had a trend towards improved outcome in all primary outcome variables. Given the excellent severity match between placebo and rBPI21 groups at study entry, the results overall indicate that rBPI21 is beneficial in decreasing complications of meningococcal disease.

Background: Ancillary tests are indicated to diagnose death by neurological criteria whenever clinical neurological examination is unreliable, but their use is variable and subject to debate. Methods: Survey of Canadian intensivists providing care for potential organ donors. We included closed-ended questions and different clinical scenarios regarding the use of ancillary tests. Results: Among 550 identified intensivists, 249 completed the survey. Respondents indicated they would be comfortable diagnosing death based on neurological examination without ancillary tests in the following scenarios: movement in response to stimulation (48%), spontaneous peripheral movement (31%), inability to evaluate upper/lower extremity responses (34%) or both oculocephalic and oculo-caloric reflexes (17%), presence of high cervical spinal cord injury (16%) and within 24 hours of hypoxemic-ischemic brain injury (15%). Furthermore, 93% agreed that ancillary tests should always be conducted when a complete neurological examination is impossible, 89% if there remains possibility of residual sedative effect and 59% in suspected isolated brainstem death. Conclusions: Our findings suggest that Canadian intensivists have different perceptions on what constitutes a complete and reliable clinical neurological examination for determining death by neurologic criteria. Some self-reported practices also diverge from national recommendations. Further investigation and education are required to align and standardize medical practice across physicians and systems.

To compare the effect of the proneposition (PP) vs supine position (SP) on oxygenation in children withacute respiratory failure (ARF). Prospective, randomized controlled trial. A 36-bedpediatric critical-care unit in a tertiary-care, university-basedchildren's hospital. Ten children (mean[SD] age, 5 ± 3.6 years) with ARF with a baseline oxygenationindex (OI) of 22 ± 8.5. Following a period of stabilization in the SP, baseline data werecollected and patients were randomized to one of two groups in atwo-crossover study design: group 1, supine/prone sequence; group 2,prone/supine sequence. Each position was maintained for 12 h. Lungmechanics and acute response to inhaled nitric oxide were examined ineach position. OI wassignificantly better in the PP compared to the SP over the 12-h period(analysis of variance, p = 0.0016). When patients were prone, asignificant improvement in OI was detected (7.9 ± 5.3; p = 0.002);this improvement occurred early (within 2 h in 9 of 10 patients)and was sustained over the 12-h study period. Static respiratory systemcompliance and resistance were not significantly affected by theposition change. Inhaled nitric oxide had no effect on oxygenation ineither position. Urine output increased while prone, resulting in asignificantly improved fluid balance (+ 6.6 ± 15.2 m, L/kg/12 h in PPvs + 18.9 ± 13.6 m, L/kg/12 h in SP; p = 0.041). No serious adverseeffects were detected in the PP. Inchildren with ARF, oxygenation is significantly superior in the PP thanin the SP. This improvement occurs early, remains sustained for a 12-hperiod, and is independent of changes in lungmechanics.

After planned withdrawal of life support and determination of death by cardiac criteria, 14% of 480 patients had one or more cycles of a return of blood pressure of more than 5 mm Hg detected by arterial catheter monitoring after a period of pulselessness, all occurring within 5 minutes.