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Gonzalez Cohens FDR, Gonzalez FM. Critical care specialists, the missing link in organ procurement for transplantation. World J Crit Care Med 2024; 13:90274. [PMID: 38855269 PMCID: PMC11155502 DOI: 10.5492/wjccm.v13.i2.90274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 01/23/2024] [Accepted: 05/11/2024] [Indexed: 06/03/2024] Open
Abstract
The procurement process for organ donation begins with the identification of potential organ donors in emergency or critical care units (CCU), followed by their clinical evaluation, diagnostic procedures, and therapeutic interventions, mostly conducted in CCUs. It concludes with the request for organ donation and, if accepted, the retrieval of organs. Despite most interventions occurring in detection units, there has been a neglect of the strategic role played by critical care specialists (CCS) in managing and caring for brain-dead or near-brain-death patients. Questions arise: Are they willing to undertake this responsibility? Do they fully comprehend the nature of organ procurement? Are they aware of the specific interventions required to maintain possible organ donors in optimal physiological condition? Our objective is to examine the role of CCS in organ procurement and propose ways to enhance it, ultimately aiming to increase and enhance organ donation rates.
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Affiliation(s)
| | - Fernando M Gonzalez
- Department of Nephrology, Faculty of Medicine, Universidad de Chile, Santiago 7500922, Chile
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2
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Ökmen K, Balk Ş, Ülker GK. Orbital doppler ultrasound as an ancillary test for diagnosing brain death: A prospective, single blind comparative study. Clin Neurol Neurosurg 2024; 241:108289. [PMID: 38692117 DOI: 10.1016/j.clineuro.2024.108289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2024] [Revised: 04/18/2024] [Accepted: 04/18/2024] [Indexed: 05/03/2024]
Abstract
OBJECTIVE Transcranial Doppler ultrasound (TDUS), computed tomography angiography (CTA), and transcranial Doppler ultrasound to detect cerebral blood flow are among the adjunctive tests in diagnosing brain death. This study aimed to investigate the effectiveness of orbital doppler ultrasound (ODUS). METHODS This prospective, single-blind study included 66 patients for whom brain death was to be diagnosed. Primary outcome measures were ODUS measurements, Ophthalmic artery peak systolic velocity (PSV), end-diastolic velocity (EDV), and resistive indices (RI) measurements recorded during the brain death determination process. Secondary outcome measures were computed tomography angio (CTA), transcranial Doppler ultrasound (TDUS), and demographic data. RESULTS This study investigating the effectiveness of ODUS in diagnosing brain death provided diagnostic success with 100% sensitivity and 93% specificity compared to CT angiography. It was noted that anatomical variations may limit its use. CONCLUSION ODUS was found to have high sensitivity and specificity in the diagnosis of clinical brain death. It may assist in early prognostic assessment and shorten patient follow-up and diagnostic processes.
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Affiliation(s)
- Korgün Ökmen
- Bursa Yuksek Ihtisas Training and Research Hospital, Department of Anesthesiology and Reanimation, Bursa, Turkey.
| | - Şule Balk
- Bursa Yuksek Ihtisas Training and Research Hospital, Department of Anesthesiology and Reanimation, Bursa, Turkey
| | - Gökberk Kürşat Ülker
- Bursa Yuksek Ihtisas Training and Research Hospital, Department of Anesthesiology and Reanimation, Bursa, Turkey
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3
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Wahlster S, Johnson NJ. The Neurocritical Care Examination and Workup. Continuum (Minneap Minn) 2024; 30:556-587. [PMID: 38830063 DOI: 10.1212/con.0000000000001438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
OBJECTIVE This article provides an overview of the evaluation of patients in neurocritical care settings and a structured approach to recognizing and localizing acute neurologic emergencies, performing a focused examination, and pursuing workup to identify critical findings requiring urgent management. LATEST DEVELOPMENTS After identifying and stabilizing imminent threats to survival, including respiratory and hemodynamic compromise, the initial differential diagnosis for patients in neurocritical care is built on a focused history and clinical examination, always keeping in mind critical "must-not-miss" pathologies. A key priority is to identify processes warranting time-sensitive therapeutic interventions, including signs of elevated intracranial pressure and herniation, acute neurovascular emergencies, clinical or subclinical seizures, infections of the central nervous system, spinal cord compression, and acute neuromuscular respiratory failure. Prompt neuroimaging to identify structural abnormalities should be obtained, complemented by laboratory findings to assess for underlying systemic causes. The indication for EEG and lumbar puncture should be considered early based on clinical suspicion. ESSENTIAL POINTS In neurocritical care, the initial evaluation is often fast paced, requiring assessment and management to happen in parallel. History, clinical examination, and workup should be obtained while considering therapeutic implications and the need for lifesaving interventions.
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Kirschen MP, Lewis A, Rubin MA, Varelas PN, Greer DM. Beyond the Final Heartbeat: Neurological Perspectives on Normothermic Regional Perfusion for Organ Donation after Circulatory Death. Ann Neurol 2024; 95:1035-1039. [PMID: 38501716 DOI: 10.1002/ana.26926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 02/28/2024] [Accepted: 03/09/2024] [Indexed: 03/20/2024]
Abstract
Normothermic regional perfusion (NRP) has recently been used to augment organ donation after circulatory death (DCD) to improve the quantity and quality of transplantable organs. In DCD-NRP, after withdrawal of life-sustaining therapies and cardiopulmonary arrest, patients are cannulated onto extracorporeal membrane oxygenation to reestablish blood flow to targeted organs including the heart. During this process, aortic arch vessels are ligated to restrict cerebral blood flow. We review ethical challenges including whether the brain is sufficiently reperfused through collateral circulation to allow reemergence of consciousness or pain perception, whether resumption of cardiac activity nullifies the patient's prior death determination, and whether specific authorization for DCD-NRP is required. ANN NEUROL 2024;95:1035-1039.
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Affiliation(s)
- Matthew P Kirschen
- Departments of Anesthesiology and Critical Care Medicine, Neurology, and Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Ariane Lewis
- Departments of Neurology and Neurosurgery, New York University, Langone Medical Center, New York, NY, USA
| | - Michael A Rubin
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | - David M Greer
- Department of Neurology, Boston University Chobanian and Avedisian School of Medicine and Boston Medical Center, Boston, MA, USA
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DeCamp MW, Snyder Sulmasy L. NRP: Neither Perfusion nor Regional. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2024; 24:50-53. [PMID: 38829588 DOI: 10.1080/15265161.2024.2337427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
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6
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Salih F, Lambeck J, Günther A, Ferse C, Hoffmann O, Dimitriadis K, Finn A, Brandt SA, Hotter B, Masuhr F, Schreiber S, Weissinger F, Rocco A, Schneider H, Niesen WD. Brain death determination in patients with veno-arterial extracorporeal membrane oxygenation: A systematic study to address the Harlequin syndrome. J Crit Care 2024; 81:154545. [PMID: 38395004 DOI: 10.1016/j.jcrc.2024.154545] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 02/06/2024] [Accepted: 02/15/2024] [Indexed: 02/25/2024]
Abstract
PURPOSE The Harlequin syndrome may occur in patients treated with venoarterial extracorporal membrane oxygenation (VA-ECMO), in whom blood from the left ventricle and the ECMO system supply different parts of the body with different paCO2-levels. The purpose of this study was to compare two variants of paCO2-analysis to account for the Harlequin syndrome during apnea testing (AT) in brain death (BD) determination. MATERIALS AND METHODS Twenty-seven patients (median age 48 years, 26-76 years; male n = 19) with VA-ECMO treatment were included who underwent BD determination. In variant 1, simultaneous arterial blood gas (ABG) samples were drawn from the right and the left radial artery. In variant 2, simultaneous ABG samples were drawn from the right radial artery and the postoxygenator ECMO circuit. Differences in paCO2-levels were analysed for both variants. RESULTS At the start of AT, median paCO2-difference between right and left radial artery (variant 1) was 0.90 mmHg (95%-confidence intervall [CI]: 0.7-1.3 mmHg). Median paCO2-difference between right radial artery and postoxygenator ECMO circuit (variant 2) was 3.3 mmHg (95%-CI: 1.5-6.0 mmHg) and thereby significantly higher compared to variant 1 (p = 0.001). At the end of AT, paCO2-difference according to variant 1 remained unchanged with 1.1 mmHg (95%-CI: 0.9-1.8 mmHg). In contrast, paCO2-difference according to variant 2 increased to 9.9 mmHg (95%-CI: 3.5-19.2 mmHg; p = 0.002). CONCLUSIONS Simultaneous paCO2-analysis from right and left distal arterial lines is the method of choice to reduce the risk of adverse effects (e.g. severe respiratory acidosis) while performing AT in VA-ECMO patients during BD determination.
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Affiliation(s)
- Farid Salih
- Dept. of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 13353 Berlin, Germany.
| | - Johann Lambeck
- Dept. of Neurology and Clinical Neurophysiology, University Medical Center Freiburg, Breisacher Straße 64, 79106 Freiburg, Germany
| | - Albrecht Günther
- Dept. of Neurology, Jena University Hospital, Am Klinikum 1, 07747 Jena, Germany
| | - Caroline Ferse
- Dept. of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Olaf Hoffmann
- Dept. of Neurology, St. Josefs-Krankenhaus, Allee nach Sanssouci 7, 14471 Potsdam, Germany; Medizinische Hochschule Brandenburg Theodor Fontane, Fehrbelliner Straße 38, 16816 Neuruppin, Germany
| | | | - Andre Finn
- Dept. of Nephrology and Medical Intensive Care, Charité-Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany
| | - Stephan A Brandt
- Dept. of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 13353 Berlin, Germany
| | - Benjamin Hotter
- Dept. of Neurology and Experimental Neurology, Charité-Universitätsmedizin Berlin, Charitéplatz 1, 13353 Berlin, Germany
| | - Florian Masuhr
- Dept. of Neurology, Bundeswehrkrankenhaus Berlin, Scharnhorststraße 13, 10115 Berlin, Germany
| | - Stephan Schreiber
- Dept. of Neurology, Asklepios Fachklinikum, Anton-Saefkow-Allee 2, 14772, Brandenburg, Germany
| | - Florian Weissinger
- Dept. of Neurology, Vivantes Humboldt-Klinikum, Am Nordgraben 2, 13509 Berlin, Germany
| | - Andrea Rocco
- Dept. of Neurology, Klinikum Ernst von Bergmann, Charlottenstraße 72, 14467 Potsdam, Germany
| | - Hauke Schneider
- Dept. of Neurology, University Hospital Augsburg, Stenglinstr. 2, 86156 Augsburg, Germany
| | - Wolf-Dirk Niesen
- Dept. of Neurology and Clinical Neurophysiology, University Medical Center Freiburg, Breisacher Straße 64, 79106 Freiburg, Germany
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Plante V, Basu M, Gettings JV, Luchette M, LaRovere KL. Update in Pediatric Neurocritical Care: What a Neurologist Caring for Critically Ill Children Needs to Know. Semin Neurol 2024. [PMID: 38788765 DOI: 10.1055/s-0044-1787047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Currently nearly one-quarter of admissions to pediatric intensive care units (PICUs) worldwide are for neurocritical care diagnoses that are associated with significant morbidity and mortality. Pediatric neurocritical care is a rapidly evolving field with unique challenges due to not only age-related responses to primary neurologic insults and their treatments but also the rarity of pediatric neurocritical care conditions at any given institution. The structure of pediatric neurocritical care services therefore is most commonly a collaborative model where critical care medicine physicians coordinate care and are supported by a multidisciplinary team of pediatric subspecialists, including neurologists. While pediatric neurocritical care lies at the intersection between critical care and the neurosciences, this narrative review focuses on the most common clinical scenarios encountered by pediatric neurologists as consultants in the PICU and synthesizes the recent evidence, best practices, and ongoing research in these cases. We provide an in-depth review of (1) the evaluation and management of abnormal movements (seizures/status epilepticus and status dystonicus); (2) acute weakness and paralysis (focusing on pediatric stroke and select pediatric neuroimmune conditions); (3) neuromonitoring modalities using a pathophysiology-driven approach; (4) neuroprotective strategies for which there is evidence (e.g., pediatric severe traumatic brain injury, post-cardiac arrest care, and ischemic stroke and hemorrhagic stroke); and (5) best practices for neuroprognostication in pediatric traumatic brain injury, cardiac arrest, and disorders of consciousness, with highlights of the 2023 updates on Brain Death/Death by Neurological Criteria. Our review of the current state of pediatric neurocritical care from the viewpoint of what a pediatric neurologist in the PICU needs to know is intended to improve knowledge for providers at the bedside with the goal of better patient care and outcomes.
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Affiliation(s)
- Virginie Plante
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Meera Basu
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | | | - Matthew Luchette
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
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8
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Feldman R, Theobald J, Stanton M, Stolbach A, Tormoehlen L. Reader Response: Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline: Report of the AAN Guidelines Subcommittee, AAP, CNS, and SCCM. Neurology 2024; 102:e209363. [PMID: 38648601 DOI: 10.1212/wnl.0000000000209363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024] Open
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9
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Greer DM, Lewis A, Kirschen MP, Rae-Grant A, Halperin JJ. Author Response: Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline: Report of the AAN Guidelines Subcommittee, AAP, CNS, and SCCM. Neurology 2024; 102:e209368. [PMID: 38648599 DOI: 10.1212/wnl.0000000000209368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024] Open
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10
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DeCock CA, Giordano J, Donovan GK, Tornatore CS. Reader Response: Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline: Report of the AAN Guidelines Subcommittee, AAP, CNS, and SCCM. Neurology 2024; 102:e209369. [PMID: 38648606 DOI: 10.1212/wnl.0000000000209369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024] Open
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11
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Greer DM, Lewis A, Kirschen MP. Author Response: Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline: Report of the AAN Guidelines Subcommittee, AAP, CNS, and SCCM. Neurology 2024; 102:e209364. [PMID: 38648604 DOI: 10.1212/wnl.0000000000209364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024] Open
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12
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Machado C. Reader Response: Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline: Report of the AAN Guidelines Subcommittee, AAP, CNS, and SCCM. Neurology 2024; 102:e209367. [PMID: 38652876 DOI: 10.1212/wnl.0000000000209367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024] Open
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13
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Lewis A, Kirschen MP, Greer DM. Author Response: Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline: Report of the AAN Guidelines Subcommittee, AAP, CNS, and SCCM. Neurology 2024; 102:e209370. [PMID: 38648607 DOI: 10.1212/wnl.0000000000209370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024] Open
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14
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Toossi S, Shen T, Dragomer D, Nurok M. Reader Response: Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline: Report of the AAN Guidelines Subcommittee, AAP, CNS, and SCCM. Neurology 2024; 102:e209365. [PMID: 38648603 DOI: 10.1212/wnl.0000000000209365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/25/2024] Open
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15
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Oakley CI, Chou CZ, Wiste R, Lugassy M. Communicating About Death by Neurologic Criteria #479. J Palliat Med 2024; 27:702-703. [PMID: 38728084 DOI: 10.1089/jpm.2024.0060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024] Open
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16
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DeCamp M, Carney JK, Snyder Sulmasy L. Standards and Ethics Issues in the Determination of Death. Ann Intern Med 2024; 177:690-691. [PMID: 38768489 DOI: 10.7326/l24-0128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/22/2024] Open
Affiliation(s)
- Matthew DeCamp
- University of Colorado Anschutz Medical Campus, Denver, Colorado
| | - Jan K Carney
- Larner College of Medicine at the University of Vermont, Burlington, Vermont, and Center for Ethics and Professionalism, American College of Physicians, Philadelphia, Pennsylvania
| | - Lois Snyder Sulmasy
- Center for Ethics and Professionalism, American College of Physicians, Philadelphia, Pennsylvania
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17
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Lewis A. An Update on Brain Death/Death by Neurologic Criteria since the World Brain Death Project. Semin Neurol 2024. [PMID: 38621707 DOI: 10.1055/s-0044-1786020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
The World Brain Death Project (WBDP) is a 2020 international consensus statement that provides historical background and recommendations on brain death/death by neurologic criteria (BD/DNC) determination. It addresses 13 topics including: (1) worldwide variance in BD/DNC, (2) the science of BD/DNC, (3) the concept of BD/DNC, (4) minimum clinical criteria for BD/DNC determination, (5) beyond minimum clinical BD/DNC determination, (6) pediatric and neonatal BD/DNC determination, (7) BD/DNC determination in patients on ECMO, (8) BD/DNC determination after treatment with targeted temperature management, (9) BD/DNC documentation, (10) qualification for and education on BD/DNC determination, (11) somatic support after BD/DNC for organ donation and other special circumstances, (12) religion and BD/DNC: managing requests to forego a BD/DNC evaluation or continue somatic support after BD/DNC, and (13) BD/DNC and the law. This review summarizes the WBDP content on each of these topics and highlights relevant work published from 2020 to 2023, including both the 192 citing publications and other publications on BD/DNC. Finally, it reviews questions for future research related to BD/DNC and emphasizes the need for national efforts to ensure the minimum standards for BD/DNC determination described in the WBDP are included in national BD/DNC guidelines and due consideration is given to the recommendations about social and legal aspects of BD/DNC determination.
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Affiliation(s)
- Ariane Lewis
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, NYU Langone Medical Center, New York
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18
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Varelas P, Greer D. The authors reply. Crit Care Med 2024; 52:e214-e215. [PMID: 38483237 DOI: 10.1097/ccm.0000000000006208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/24/2024]
Affiliation(s)
| | - David Greer
- Department of Neurology, Boston University, Boston, MA
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19
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Shewmon DA. The Fundamental Concept of Death-Controversies and Clinical Relevance: The UDDA Revision Series. Neurology 2024; 102:e209196. [PMID: 38408293 DOI: 10.1212/wnl.0000000000209196] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Accepted: 12/18/2023] [Indexed: 02/28/2024] Open
Abstract
When the Uniform Law Commission (ULC) was recently in the process of revising the Uniform Determination of Death Act (UDDA), Neurology® ran a series of debates over certain controversial issues being deliberated. Omitted was a debate over the fundamental concept underlying brain death. In his introductory article, Bernat offered reasons for this omission: "It is not directly relevant to practicing neurologists who largely accept brain death, do not question its conceptual basis, …." In this article I argue the opposite: the fundamental concept of death is highly relevant to the clinical criteria and tests used to diagnose it. Moreover, most neurologists in fact disagree with the conceptual basis articulated by Bernat. Basically, there are 3 competing concepts of death: (1) biological: cessation of the integrative unity of the organism as a whole (endorsed by Bernat and the 1981 President's Commission), (2) psychological: cessation of the person, equated with a self-conscious mind (endorsed by half of neurologists), and (3) the vital work concept proposed by the 2008 President's Council on Bioethics. The first actually corresponds to a circulatory, not a neurologic, criterion. The second corresponds to a "higher brain" criterion. The third corresponds loosely to the UK's "brainstem death" criterion. In terms of the biological concept, current diagnostic guidelines entail a high rate of false-positive declarations of death, whereas in terms of the psychological concept, the same guidelines entail a high rate of false-negative declarations. Brainstem reflexes have nothing to do with any death concept (their role is putatively to guarantee irreversibility). By shining a spotlight on the deficiencies of the UDDA through attempting to revise it, the ULC may have unwittingly opened a Pandora's box of fresh scrutiny of the concept of death underlying the neurologic criterion-particularly on the part of state legislatures with irreconcilably opposed worldviews.
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Affiliation(s)
- D Alan Shewmon
- From the Departments of Neurology and Pediatrics, David Geffen School of Medicine at UCLA
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20
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Lewis A. The Quest to Revise the Uniform Determination of Death Act: Why We Tried, Why We Failed, and Where We Go from Here. Neurocrit Care 2024:10.1007/s12028-024-01964-w. [PMID: 38512640 DOI: 10.1007/s12028-024-01964-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 02/16/2024] [Indexed: 03/23/2024]
Affiliation(s)
- Ariane Lewis
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, New York University Langone Medical Center, 530 First Avenue, Skirball-7R, New York, 10016, NY, USA.
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21
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Greer DM, Lewis A, Kirschen MP. New developments in guidelines for brain death/death by neurological criteria. Nat Rev Neurol 2024; 20:151-161. [PMID: 38307923 DOI: 10.1038/s41582-024-00929-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2024] [Indexed: 02/04/2024]
Abstract
The declaration of brain death (BD), or death by neurological criteria (DNC), is medically and legally accepted throughout much of the world. However, inconsistencies in national and international policies have prompted efforts to harmonize practice and central concepts, both between and within countries. The World Brain Death Project was published in 2020, followed by notable revisions to the Canadian and US guidelines in 2023. The mission of these initiatives was to ensure accurate and conservative determination of BD/DNC, as false-positive determinations could have major negative implications for the medical field and the public's trust in our ability to accurately declare death. In this Review, we review the changes that were introduced in the 2023 US BD/DNC guidelines and consider how these guidelines compare with those formulated in Canada and elsewhere in the world. We address controversies in BD/DNC determination, including neuroendocrine function, consent and accommodation of objections, summarize the legal status of BD/DNC internationally and discuss areas for further BD/DNC research.
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Affiliation(s)
- David M Greer
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
- Boston Medical Center, Department of Neurology, Boston, MA, USA.
| | - Ariane Lewis
- NYU Langone Medical Center, Departments of Neurology and Neurosurgery, New York, NY, USA
| | - Matthew P Kirschen
- The Children's Hospital of Philadelphia, Department of Anaesthesiology and Critical Care Medicine, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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22
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Chang CWJ. Seeking Harmony-Determining Brain Death/Death by Neurologic Criteria Circa 2023. Crit Care Med 2024; 52:495-497. [PMID: 38381009 DOI: 10.1097/ccm.0000000000006127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
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23
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Kirschen MP, Lewis A, Greer DM. The 2023 American Academy of Neurology, American Academy of Pediatrics, Child Neurology Society, and Society of Critical Care Medicine Pediatric and Adult Brain Death/Death by Neurologic Criteria Determination Consensus Guidelines: What the Critical Care Team Needs to Know. Crit Care Med 2024; 52:376-386. [PMID: 37921516 DOI: 10.1097/ccm.0000000000006099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
Guidelines for brain death/death by neurologic criteria (BD/DNC) determination were revised to provide a consistent and updated approach to BD/DNC evaluation across all ages by the American Academy of Neurology, American Academy of Pediatrics, Child Neurology Society, and Society of Critical Care Medicine. This article is intended to complement the guidelines and highlight aspects relevant to the critical care community; the actual guidelines should be used to update hospital protocols and dictate clinical practice. Because BD/DNC evaluations are conducted in the ICU, it is essential for members of the critical care community to familiarize themselves with these guidelines. The fundamental concept of BD/DNC has not changed; BD/DNC is permanent loss of function of the brain as a whole, including the brain stem, resulting in coma, brainstem areflexia, and apnea in the setting of an adequate stimulus. The BD/DNC evaluation requires a sufficient observation period to ensure there is no chance of recovery, followed by exclusion of potentially confounding conditions like hypothermia, hypotension, severe metabolic disturbances, or medication effects. Specific guidance is provided for patients who were treated with therapeutic hypothermia or medical or surgical interventions to manage intracranial hypertension. The guidelines outline a structured and meticulous neurologic examination and detail the responses consistent with BD/DNC. A protocol is provided for how to safely perform apnea testing, including modifications needed for patients on extracorporeal membrane oxygenation. Controversial issues such as consent, BD/DNC evaluation in pregnancy, preservation of neuroendocrine function, and primary posterior fossa injuries are addressed. The ultimate goal is to ensure a consistent and accurate approach to BD/DNC evaluation in patients of all ages, fostering public trust in the medical community's ability to determine death. By adhering to these guidelines, critical care clinicians can confidently navigate the challenging aspects of BD/DNC determination.
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Affiliation(s)
- Matthew P Kirschen
- Department of Anesthesiology, The Children's Hospital of Philadelphia, Philadelphia, PA
- Department of Critical Care Medicine, Neurology, and Pediatrics, The Children's Hospital of Philadelphia, Philadelphia, PA
| | - Ariane Lewis
- Department of Neurology, NYU Langone Medical Center, New York, NY
- Department of Neurosurgery, NYU Langone Medical Center, New York, NY
| | - David M Greer
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, Boston, MA
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Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Guideline: Report of the AAN Guidelines Subcommittee, AAP, CNS, and SCCM. Neurology 2024; 102:e208108. [PMID: 38175986 DOI: 10.1212/wnl.0000000000208108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024] Open
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Moynihan KM, Taylor LS, Siegel B, Nassar N, Lelkes E, Morrison W. "Death as the One Great Certainty": ethical implications of children with irreversible cardiorespiratory failure and dependence on extracorporeal membrane oxygenation. Front Pediatr 2024; 11:1325207. [PMID: 38274466 PMCID: PMC10808631 DOI: 10.3389/fped.2023.1325207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 12/22/2023] [Indexed: 01/27/2024] Open
Abstract
Introduction Advances in medical technology have led to both clinical and philosophical challenges in defining death. Highly publicized cases have occurred when families or communities challenge a determination of death by the irreversible cessation of neurologic function (brain death). Parallels can be drawn in cases where an irreversible cessation of cardiopulmonary function exists, in which cases patients are supported by extracorporeal cardiopulmonary support, such as extracorporeal membrane oxygenation (ECMO). Analysis Two cases and an ethical analysis are presented which compare and contrast contested neurologic determinations of death and refusal to accept the irreversibility of an imminent death by cardiopulmonary standards. Ambiguities in the Uniform Determination of Death Act are highlighted, as it can be clear, when supported by ECMO, that a patient could have suffered the irreversible cessation of cardiopulmonary function yet still be alive (e.g., responsive and interactive). Parallel challenges with communication with families around the limits of medical technology are discussed. Discussion Cases that lead to conflict around the removal of technology considered not clinically beneficial are likely to increase. Reframing our goals when death is inevitable is important for both families and the medical team. Building relationships and trust between all parties will help families and teams navigate these situations. All parties may require support for moral distress. Suggested approaches are discussed.
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Affiliation(s)
- Katie M. Moynihan
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
- Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, NSW, Australia
| | - Lisa S. Taylor
- Office of Ethics, Boston Children’s Hospital, Boston, MA, United States
| | - Bryan Siegel
- Department of Pediatrics, Harvard Medical School, Boston, MA, United States
- Department of Cardiology, Boston Children’s Hospital, Boston, MA, United States
| | - Natasha Nassar
- Clinical and Population Translational Health, Children’s Hospital at Westmead Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Efrat Lelkes
- Department of Pediatrics, MaineGeneral Medical Center, Augusta, ME, United States
| | - Wynne Morrison
- Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
- Divisions of Critical Care and Palliative Care, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
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Kida S, Nagata I, Takei T, Yoshizawa K, Suzuki T, Yamada H, Nakayama Y. Respiratory-like movements during an apnea test. Acute Med Surg 2024; 11:e959. [PMID: 38665594 PMCID: PMC11043618 DOI: 10.1002/ams2.959] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Revised: 04/02/2024] [Accepted: 04/12/2024] [Indexed: 04/28/2024] Open
Abstract
Background Despite the possible occurrence of spontaneous movements during an apnea test, respiratory-like movements are rare. Case Presentation A 51-year-old man was transferred to our hospital when a sudden disturbance of consciousness developed into cardiac arrest. After spontaneous circulation returned, we diagnosed bilateral cerebellar hemorrhage. He remained comatose with dilated pupils, absent brainstem reflexes, spontaneous breathing, and electrocerebral activity. After being considered brain dead, his family opted for organ donation. The first legal brain death examination on day 5 was aborted because of respiratory-like movements mimicking repetitive abdominal respiration during the apnea test. However, an enhanced magnetic resonance image of the head indicated no blood flow and somatosensory evoked potential testing revealed no brain-derived potentials. Conclusion Respiratory-like movements can occur during the apnea test in patients considered brain dead. Further research is required to understand this phenomenon.
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Affiliation(s)
- Shinichi Kida
- Department of Emergency and Critical Care MedicineYokohama City Minato Red Cross HospitalYokohamaJapan
| | - Isao Nagata
- Department of Emergency and Critical Care MedicineYokohama City Minato Red Cross HospitalYokohamaJapan
| | - Tetsuhiro Takei
- Department of Emergency and Critical Care MedicineYokohama City Minato Red Cross HospitalYokohamaJapan
| | - Kazuhiro Yoshizawa
- Department of Emergency and Critical Care MedicineYokohama City Minato Red Cross HospitalYokohamaJapan
| | - Taketo Suzuki
- Department of Emergency and Critical Care MedicineYokohama City Minato Red Cross HospitalYokohamaJapan
| | - Hiroyuki Yamada
- Department of Emergency and Critical Care MedicineYokohama City Minato Red Cross HospitalYokohamaJapan
| | - Yusuke Nakayama
- Department of Emergency and Critical Care MedicineYokohama City Minato Red Cross HospitalYokohamaJapan
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Lewis A. Response to Open Peer Commentaries Re: Medicolegal Challenges to Death by Neurologic Criteria in the United Kingdom and USA. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2024; 24:W1-W3. [PMID: 38236884 DOI: 10.1080/15265161.2023.2284289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/23/2024]
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Lazaridis C, Wolf M, Roth WH, Fan T, Mansour A, Goldenberg FD. Apnea Test: The Family in the Room. Neurocrit Care 2023:10.1007/s12028-023-01906-y. [PMID: 38158482 DOI: 10.1007/s12028-023-01906-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 11/20/2023] [Indexed: 01/03/2024]
Affiliation(s)
- Christos Lazaridis
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, MacLean Center for Clinical Medical Ethics, The University of Chicago Medicine, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA.
| | - Mary Wolf
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, MacLean Center for Clinical Medical Ethics, The University of Chicago Medicine, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA
| | - William H Roth
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, MacLean Center for Clinical Medical Ethics, The University of Chicago Medicine, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA
| | - Tracey Fan
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, MacLean Center for Clinical Medical Ethics, The University of Chicago Medicine, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA
| | - Ali Mansour
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, MacLean Center for Clinical Medical Ethics, The University of Chicago Medicine, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA
| | - Fernando D Goldenberg
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, MacLean Center for Clinical Medical Ethics, The University of Chicago Medicine, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA
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Pope TM, Ruck Keene A, Chandler J. No consent for brain death testing. JOURNAL OF MEDICAL ETHICS 2023:jme-2023-109797. [PMID: 38154918 DOI: 10.1136/jme-2023-109797] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Accepted: 12/16/2023] [Indexed: 12/30/2023]
Abstract
The overwhelming weight of legal authority in the USA and Canada holds that consent is not required for brain death testing. The situation in England and Wales is similar but different. While clinicians in England and Wales may have a prima facie duty to obtain consent, lack of consent has not barred testing. In three recent cases where consent for brain death testing was formally presented to the court, lack of consent was not determinative, and in one case the court questioned whether the clinicians were even required to seek consent from the parents of a child at all.
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Affiliation(s)
| | - Alexander Ruck Keene
- 39 Essex Chambers, London, UK
- Dickson Poon School of Law, Kings College London, London, UK
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Truog RD, Magnus DC. The Unsuccessful Effort to Revise the Uniform Determination of Death Act. JAMA 2023; 330:2335-2336. [PMID: 38060232 DOI: 10.1001/jama.2023.24475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/08/2023]
Abstract
This Viewpoint summarizes the major issues that led to the decision to draft a revision of the Uniform Determination of Death Act, the alternatives that were considered, why there was failure to reach consensus, and what this means for the future.
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Affiliation(s)
- Robert D Truog
- Department of Anesthesiology, Critical Care, and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Center for Bioethics, Department of Global Health and Social Medicine, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts
| | - David C Magnus
- Stanford Center for Biomedical Ethics, Stanford University, Palo Alto, California
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