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Shemie SD, Wilson LC, Hornby L, Basmaji J, Baker AJ, Bensimon CM, Chandler JA, Chassé M, Dawson R, Dhanani S, Mooney OT, Sarti AJ, Simpson C, Teitelbaum J, Torrance S, Boyd JG, Brennan J, Brewster H, Carignan R, Dawe KJ, Doig CJ, Elliott-Pohl K, Gofton TE, Hartwick M, Healey A, Honarmand K, Hornby K, Isac G, Kanji A, Kawchuk J, Klowak JA, Kramer AH, Kromm J, LeBlanc AE, Lee-Ameduri K, Lee LA, Leeies M, Lewis A, Manara A, Matheson S, McKinnon NKA, Murphy N, Briard JN, Pope TM, Sekhon MS, Shanker JJS, Singh G, Singh J, Slessarev M, Soliman K, Sutherland S, Weiss MJ, Shaul RZ, Zuckier LS, Zorko DJ, Rochwerg B. A brain-based definition of death and criteria for its determination after arrest of circulation or neurologic function in Canada: a 2023 clinical practice guideline. Can J Anaesth 2023; 70:483-557. [PMID: 37131020 PMCID: PMC10203028 DOI: 10.1007/s12630-023-02431-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 12/13/2022] [Accepted: 12/19/2022] [Indexed: 05/04/2023] Open
Abstract
This 2023 Clinical Practice Guideline provides the biomedical definition of death based on permanent cessation of brain function that applies to all persons, as well as recommendations for death determination by circulatory criteria for potential organ donors and death determination by neurologic criteria for all mechanically ventilated patients regardless of organ donation potential. This Guideline is endorsed by the Canadian Critical Care Society, the Canadian Medical Association, the Canadian Association of Critical Care Nurses, Canadian Anesthesiologists' Society, the Canadian Neurological Sciences Federation (representing the Canadian Neurological Society, Canadian Neurosurgical Society, Canadian Society of Clinical Neurophysiologists, Canadian Association of Child Neurology, Canadian Society of Neuroradiology, and Canadian Stroke Consortium), Canadian Blood Services, the Canadian Donation and Transplantation Research Program, the Canadian Association of Emergency Physicians, the Nurse Practitioners Association of Canada, and the Canadian Cardiovascular Critical Care Society.
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Affiliation(s)
- Sam D Shemie
- McGill University Health Centre, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada.
- McGill University, Montreal, QC, Canada.
- MUHC Research Institute, Montreal, QC, Canada.
- Canadian Blood Services, Ottawa, ON, Canada.
| | | | | | | | - Andrew J Baker
- Unity Health Toronto, Toronto, ON, Canada
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | | | | | | | | | - Sonny Dhanani
- University of Ottawa, Ottawa, ON, Canada
- Children's Hospital of Eastern Ontario, Ottawa, ON, Canada
| | - Owen T Mooney
- University of Manitoba, Winnipeg, MB, Canada
- Transplant Manitoba Gift of Life Program, Winnipeg, MB, Canada
- St. Boniface Hospital, Winnipeg, MB, Canada
| | - Aimee J Sarti
- University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
- Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Christy Simpson
- Canadian Blood Services, Ottawa, ON, Canada
- Dalhousie University, Halifax, NS, Canada
| | - Jeanne Teitelbaum
- McGill University Health Centre, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
- McGill University, Montreal, QC, Canada
| | | | - J Gordon Boyd
- Kingston General Hospital, Kingston, ON, Canada
- Queen's University, Kingston, ON, Canada
| | | | | | | | - Kirk J Dawe
- Eastern Health, St. John's, NL, Canada
- Memorial University of Newfoundland, St. John's, NL, Canada
| | - Christopher J Doig
- University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Edmonton, AB, Canada
| | | | | | - Michael Hartwick
- University of Ottawa, Ottawa, ON, Canada
- Ontario Health (Trillium Gift of Life Network), Toronto, ON, Canada
| | - Andrew Healey
- Ontario Health (Trillium Gift of Life Network), Toronto, ON, Canada
- McMaster University, Hamilton, ON, Canada
- William Osler Health System, Brampton, ON, Canada
| | - Kimia Honarmand
- Western University, London, ON, Canada
- London Health Sciences Centre, London, ON, Canada
| | | | - George Isac
- University of British Columbia, Vancouver, BC, Canada
| | - Aly Kanji
- McGill University Health Centre, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada
- McGill University, Montreal, QC, Canada
| | - Joann Kawchuk
- Saskatchewan Health Authority, Saskatoon, SK, Canada
| | | | - Andreas H Kramer
- University of Calgary, Calgary, AB, Canada
- Southern Alberta Organ & Tissue Donation Program, Calgary, AB, Canada
| | - Julie Kromm
- University of Calgary, Calgary, AB, Canada
- Alberta Health Services, Edmonton, AB, Canada
| | - Allana E LeBlanc
- University of British Columbia, Vancouver, BC, Canada
- Vancouver Coastal Health, Vancouver, BC, Canada
- Canadian Association of Critical Care Nurses, London, ON, Canada
| | - Katarina Lee-Ameduri
- University of Manitoba, Winnipeg, MB, Canada
- St. Boniface Hospital, Winnipeg, MB, Canada
| | - Laurie A Lee
- University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital, Calgary, AB, Canada
| | - Murdoch Leeies
- University of Manitoba, Winnipeg, MB, Canada
- Transplant Manitoba Gift of Life Program, Winnipeg, MB, Canada
- Canadian Critical Care Society, Markham, ON, Canada
| | - Ariane Lewis
- NYU Langone Medical Center, New York City, NY, USA
| | | | | | - Nicole K A McKinnon
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Hospital for Sick Children, Toronto, ON, Canada
- Peter Gilgan Center for Research and Learning, Toronto, ON, Canada
| | | | | | - Thaddeus M Pope
- University of Ottawa, Ottawa, ON, Canada
- Mitchell Hamline School of Law, Saint Paul, MN, USA
- Queensland University of Technology, Brisbane, Qld, Australia
- Albany Medical College, Albany, NY, USA
- University of Minnesota Center for Bioethics, Minneapolis, MN, USA
| | - Mypinder S Sekhon
- University of British Columbia, Vancouver, BC, Canada
- Vancouver General Hospital, Vancouver, BC, Canada
| | | | - Gurmeet Singh
- Mazankowski Alberta Heart Institute, Edmonton, AB, Canada
- University of Alberta, Edmonton, AB, Canada
| | - Jeffrey Singh
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Ontario Health (Trillium Gift of Life Network), Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
| | - Marat Slessarev
- Western University, London, ON, Canada
- Ontario Health (Trillium Gift of Life Network), Toronto, ON, Canada
| | - Karim Soliman
- Queen's University, Kingston, ON, Canada
- Ontario Health (Trillium Gift of Life Network), Toronto, ON, Canada
- Lakeridge Health, Oshawa, ON, Canada
| | | | - Matthew J Weiss
- Transplant Québec, Montreal, QC, Canada
- CHU de Québec - Université Laval, Quebec City, QC, Canada
- Université Laval, Quebec City, QC, Canada
| | - Randi Zlotnik Shaul
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Hospital for Sick Children, Toronto, ON, Canada
| | - Lionel S Zuckier
- University of Ottawa, Ottawa, ON, Canada
- The Ottawa Hospital, Ottawa, ON, Canada
| | - David J Zorko
- St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
- Hospital for Sick Children, Toronto, ON, Canada
| | - Bram Rochwerg
- McMaster University, Hamilton, ON, Canada
- Canadian Critical Care Society, Markham, ON, Canada
- Canadian Critical Care Trials Group, Markham, ON, Canada
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Shemie SD, Briard JN, Boyd JG, Gofton T, Kramer A, Chassé M, Taran S, Gros P, Singh JM. Infratentorial brain injury and death by neurologic criteria in Canada: a narrative review. Can J Anaesth 2023; 70:781-787. [PMID: 37138155 PMCID: PMC10203019 DOI: 10.1007/s12630-023-02427-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 01/04/2023] [Accepted: 01/06/2023] [Indexed: 05/05/2023] Open
Abstract
There are two anatomic formulations of death by neurologic criteria accepted worldwide: whole-brain death and brainstem death. As part of the Canadian Death Definition and Determination Project, we convened an expert working group and performed a narrative review of the literature. Infratentorial brain injury (IBI) with an unconfounded clinical assessment consistent with death by neurologic criteria represents a nonrecoverable injury. The clinical determination of death cannot distinguish between IBI and whole-brain cessation of function. Current clinical, functional, and neuroimaging assessments cannot reliably confirm the complete and permanent destruction of the brainstem. No patient with isolated brainstem death has been reported to recover consciousness and all patients have died. Studies suggest a significant majority of isolated brainstem death will evolve into whole-brain death, influenced by time/duration of somatic support and impacted by ventricular drainage and/or posterior fossa decompressive craniectomy. Acknowledging variability in intensive care unit (ICU) physician opinion on this matter, a majority of Canadian ICU physicians would perform ancillary testing for death determination by neurologic criteria in the context of IBI. There is currently no reliable ancillary test to confirm complete destruction of the brainstem; ancillary testing currently includes evaluation of both infratentorial and supratentorial flow. Acknowledging international variability in this regard, the existing evidence reviewed does not provide sufficient confidence that the clinical exam in IBI represents a complete and permanent destruction of the reticular activating system and thus the capacity for consciousness. On this basis, IBI consistent with clinical signs of death by neurologic criteria without significant supratentorial involvement does not fulfill criteria for death in Canada and ancillary testing is required.
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Affiliation(s)
- Sam D Shemie
- Division of Pediatric Critical Care, Department of Pediatrics, Montreal Children's Hospital, McGill University, Montreal, QC, Canada.
- MUHC Research Institute, 1001 Decarie Blvd, Montreal, QC, H4A 3J1, Canada.
- System Development, Canadian Blood Services, Ottawa, ON, Canada.
| | - Joel Neves Briard
- Department of Neuroscience, Université de Montréal, Montreal, QC, Canada
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada
| | - J Gordon Boyd
- Departments of Medicine (Neurology) and Critical Care Medicine, Queen's University, Kingston, ON, Canada
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada
| | - Tenielle Gofton
- Department of Clinical Neurological Sciences, Schulich School of Medicine and Dentistry, Western University, London, ON, Canada
| | - Andreas Kramer
- Departments of Critical Care Medicine and Clinical Neurosciences, University of Calgary and Southern Alberta Organ and Tissue Donation Program, Calgary, AB, Canada
| | - Michaël Chassé
- Centre de recherche du Centre hospitalier de l'Université de Montréal (CRCHUM), Montreal, QC, Canada
- Department of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Shaurya Taran
- Division of Neurology, Department of Medicine, University Health Network, Toronto, ON, Canada
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
| | - Priti Gros
- Division of Neurology, Department of Medicine, University Health Network, Toronto, ON, Canada
| | - Jeffrey M Singh
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada
- Ontario Health (Trillium Gift of Life Network), Toronto, ON, Canada
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