Walter U, Brüderlein U, Gloger M, Mann S, Walther U
Klinik und Poliklinik für Neurologie, Universitätsmedizin Rostock, Gehlsheimer Str. 20, 18147, Rostock, Deutschland,
Med Klin Intensivmed Notfmed. 2015 Apr;110(2):145-9. doi: 10.1007/s00063-014-0416-6. Epub 2014 Sep 26.
Before the clinical diagnosis of brain death is made, toxicological analyses are often performed for the exclusion of effective serum levels of previously applied sedating drugs. For propofol and sufentanil there are no uniform recommendations for the usage of toxicology test results.
To develop a standard practice in the diagnosis of brain death after therapeutic application of one of these drugs.
Based on the current literature and the available analytical assays, an ad hoc working group consisting of specialists in toxicology and intensive care medicine compiled recommendations for the usage of toxicological analytics in the diagnosis of brain death at the Rostock University Hospital.
For propofol, current analytical assays allow the quantification of serum concentrations of 0.2 μg/ml and lower; the execution of clinical brain death diagnostics is recommended by the ad hoc group only at propofol serum levels lower than 0.4 μg/ml. For sufentanil, the currently prevalent assays set lower determination limits of about 0.2 ng/ml in serum and 0.1 ng/ml in urine, which is above the cautiously adopted lower therapeutic serum concentration of 0.02 ng/ml. Therefore after negative determination of sufentanil (< 0.2 ng/ml) in blood serum, the following alternative procedures are recommended: (1) the execution of clinical brain death diagnostics under administration of naloxone; or (2) at intact renal function the additional negative determination of sufentanil in urine (< 0.1 ng/ml). If an assay allowing the detection of sufentanil at ≤ 0.01 ng/ml is available, brain death diagnostics should be carried out only at a serum level lower than 0.02 ng/ml.
These recommendations may serve as a proposal for similar standards in other hospitals.
在做出脑死亡的临床诊断之前，通常会进行毒理学分析，以排除先前使用的镇静药物的有效血清水平。对于丙泊酚和舒芬太尼，毒理学检测结果的使用没有统一的建议。
制定在使用这些药物之一进行治疗后诊断脑死亡的标准做法。
基于当前文献和可用的分析方法，由毒理学和重症医学专家组成的特设工作组编制了罗斯托克大学医院在脑死亡诊断中使用毒理学分析的建议。
对于丙泊酚，当前的分析方法能够定量血清浓度低至0.2μg/ml；特设小组建议仅在丙泊酚血清水平低于0.4μg/ml时进行临床脑死亡诊断。对于舒芬太尼，目前普遍使用的检测方法设定血清中约0.2ng/ml和尿液中0.1ng/ml的较低测定限，这高于谨慎采用的0.02ng/ml的较低治疗血清浓度。因此，在血清中舒芬太尼测定为阴性（<0.2ng/ml）后，建议采用以下替代程序：（1）在使用纳洛酮的情况下进行临床脑死亡诊断；或（2）在肾功能正常时，额外检测尿液中舒芬太尼阴性（<0.1ng/ml）。如果有能够检测≤0.01ng/ml舒芬太尼的检测方法，仅应在血清水平低于0.02ng/ml时进行脑死亡诊断。
这些建议可作为其他医院类似标准的提议。
