Second brain death examination may negatively affect organ donation

Development and validation of a novel score to predict brain death after out-of-hospital cardiac arrest

BACKGROUND AND OBJECTIVES

Brain death (BD) occurs in 9-24% of successfully resuscitated out-of-hospital cardiac arrests (OHCA). To predict BD after OHCA, we developed a novel brain death risk (BDR) score.

METHODS

We identified independent predictors of BD after OHCA in a retrospective, single academic center cohort between 2011 and 2021. The BDR score ranges from 0 to 7 points and includes: non-shockable rhythm (1 point), drug overdose as etiology of arrest (1 point), evidence of grey-white differentiation loss or sulcal effacement on head computed tomography (CT) radiology report within 24 hours of arrest (2 points), Full-Outline-Of-UnResponsiveness (FOUR) score of 0 (2 points), FOUR score 1-5 (1 point), and age <45 years (1 point). We internally validated the BDR score using k-fold cross validation (k = 8) and externally validated the score at an independent academic center. The main outcome was BD.

RESULTS

The development cohort included 362OHCA patients, of whom 18% (N = 58) experienced BD. Internal validation provided an area under the receiving operator characteristic curve (AUC) (95% CI) of 0.931 (0.905-0.957). In the validation cohort, 19.8% (N = 17) experienced BD. The AUC (95% CI) was 0.849 (0.765-0.933). In both cohorts, a BDR score >4 was the optimal cut off (sensitivity 0.903 and 0.882, specificity 0.830 and 0.652, in the development and validation cohorts respectively).

DISCUSSION

The BDR score identifies those at highest risk for BD after OHCA. Our data suggest that a BDR score >4 is the optimal cut off.

Cardiac Oscillations Complicating Brain Death Diagnosis

Death by neurologic criteria (DNC) or brain death is a clinical diagnosis. It is often complicated by variations in policies as well as confounders on examination. We discuss here the case of a 27-year-old male who had a cardiac arrest following toxic gaseous exposure. He ultimately progressed to brain death but was identified as having cardiac oscillations during clinical assessments that complicated the diagnosis. We discuss the case as well as the maneuvers used to clarify that the "triggered breaths" on the ventilator were indeed cardiac oscillations.

Evaluation of organ donation process and affecting factors in COVID-19 pandemic

Objectives: More than six million people worldwide are affected by end-stage organ failure and the COVID-19 pandemic has dramatically changed organ and tissue donation. Methods: The data of patients diagnosed with brain death between July 2018-March 2020 (pre-pandemic period) and April 2020-December 2021 (pandemic period) were analyzed retrospectively. Donor characteristics, laboratory levels, time from intensive care admission to determination of brain death, time to family approval, family approval rates and organ types were analyzed. Results: The mean age of 56 patients with pre-pandemic diagnosis of brain death was 61.82 ± 21.39 years, 37 (63%) patients were donors and 53 organs were obtained. Mean age of 39 patients diagnosed with brain death during the pandemic was 58.26 ± 18.02 years and 38 organs were obtained from 21 (52.5%) donors. Between the two periods, there was a decrease of 30.35% in the diagnosis of brain death, 43.24% in the number of donors and 26.41% in the number of organs supplied. The most common cause of brain death was intracranial hemorrhage during both periods. While the time elapsed between family interview and surgery was 9.33 ± 2.19 hours before the pandemic, it was 15.29 ± 4.28 hours during the pandemic period (p = 0.01). There was a significant difference between C-reactive protein levels at the time of diagnosis of brain death (p &lt; 0.05). Staphylococcus haemolyticus was most frequently seen in blood culture. Conclusions: Brain death and organ donation have decreased significantly during the pandemic period compared to previous years, similar to research conducted in different countries and regions. Due to COVID-19, prolonged stays in the intensive care unit (ICU) may pose a risk of infection in ICU donors, and care should be taken in terms of donor loss.

Computed Tomography Angiography (CTA) in Selected Scenarios with Risk of Possible False-Positive or False-Negative Conclusions in Diagnosing Brain Death

It is widely accepted that brain death (BD) is a diagnosis based on clinical examination. However, false-positive and false-negative evaluation results may be serious limitations. Ancillary tests are used when there is uncertainty about the reliability of the neurologic examination. Computed tomography angiography (CTA) is an ancillary test that tends to have the lowest false-positive rates. However, there are various influencing factors that can have an unfavorable effect on the validity of the examination method. There are inconsistent protocols regarding the evaluation criteria such as scoring systems. Among the most widely used different scoring systems the 4-point CTA-scoring system has been accepted as the most reliable method. Appropriate timing and/or Doppler pre-testing could reduce the number of possible premature examinations and increase the sensitivity of CTA in diagnosing cerebral circulatory arrest (CCA). In some cases of inconclusive CTA, the whole brain computed tomography perfusion (CTP) could be a crucial adjunct. Due to the increasing significance of CTA/CTP in determining BD, the methodology (including benefits and limitations) should also be conveyed via innovative electronic training tools, such as the BRAINDEXweb teaching tool based on an expert system.

A red flag for diagnosing brain death: decompressive craniectomy of the posterior fossa

PURPOSE

Brain death/death by neurologic criteria (BD/DNC) may be determined in many countries by a clinical examination that shows coma, brainstem areflexia, and apnea, provided the conditions causing reversible loss of brain function are excluded a priori. To date, accounts of recovery from BD/DNC in adults have been limited to noncompliance with guidelines.

CLINICAL FEATURES

We report the case of a 72-yr-old man with a combined primary infratentorial (hemorrhagic) and secondary global (anoxic) brain lesion in whom decompressive craniectomy of the posterior fossa and six-hour therapeutic hypothermia (33-34°C) followed by 8-hour rewarming to ≥ 36°C were conducted. Thirteen hours later, clinical findings of brain function loss were documented in addition to guideline-compliant exclusion of reversible causes (arterial hypotension, intoxication, depressant drug effects, relevant metabolic or endocrine disequilibrium, chronic hypercapnia, neuromuscular disorders, and administration of a muscle relaxant). Since a primary infratentorial brain lesion was present, German guidelines required further ancillary testing. Doppler ultrasonography revealed some preserved cerebral circulation, and BD/DNC was not diagnosed. Approximately 24 hr after rewarming to ≥ 36°C, the patient exhibited respiratory efforts. He continued with assisted respiration until final asystole/apnea, without regaining additional brain function other than mild signs of hemispasticity. Follow-up computed tomography showed partial herniation of the cerebellum through the craniectomy gap of the posterior fossa, alleviating caudal brain stem compression.

CONCLUSIONS

Therapeutic decompressive craniectomy of the posterior fossa may allow for delayed reversal of apnea. In these patients, proof of cerebral circulatory arrest should be mandatory for diagnosing BD/DNC.

Building a Fence Around Brain Death: The Shielded-Brain Formulation

The concept of brain death was proposed more than 50 years ago, and it has been incorporated in laws and clinical practice, but it remains a source of confusion, debate, and litigation. Because of persistent variability in clinical standards and ongoing controversies regarding policies, the Uniform Law Commission, which drafted the Uniform Determination of Death Act in 1980, has appointed a committee to study whether the act should be revised. This article reviews the history of the concept of brain death and its philosophical underpinnings, summarizes the objections that have been raised to the prevailing philosophical formulations, and proposes a new formulation that addresses those objections while preserving current practices.

Correlation of Organ Donors' Age With Duration Between Admission and First Brain Death Examination: A Five-Year Study in South Korea

BACKGROUND

Deceased organ donation can be performed only with the consent of the donor or their family members. The aim of this study was to determine whether donor age is related to families' decision-making regarding consent for organ donation.

METHODS

We obtained the data of 2451 organ donors with brain death (men 1645, women 806; mean age, 46.5 ± 16.2 years) registered with the Korean Network for Organ Sharing for the period between December 2012 and December 2017. The duration between the admission of the patient and the first brain death assessment was determined.

RESULTS

The mean duration from admission to the first brain death examination was significantly longer in the 0 to 30 age group (16.23 ± 6.01 days) compared with the 31 to 83 age group (6.7 ± 1.07 days) (P < .001). There was a strong negative correlation (r = 0.795, P = .010) between age and the mean duration from admission to the first brain death examination.

CONCLUSION

Because the family members of younger potential organ donors needed more time to provide consent, the first brain death examination and, therefore, the donation process was delayed in cases of young donors.

Comparison of 1 vs 2 Brain Death Examinations on Time to Death Pronouncement and Organ Donation: A 12-Year Single Center Experience

OBJECTIVE

To fill the evidence gap on the value of a single brain death (SBD) or dual brain death (DBD) examination by providing data on irreversibility of brain function, organ donation consent, and transplantation.

METHODS

Twelve-year tertiary hospital and organ procurement organization data on brain death (BD) were combined and outcomes, including consent rate for organ donation and organs recovered and transplanted after SBD and DBD, were compared after multiple adjustments for covariates.

RESULTS

A total of 266 patients were declared BD, 122 after SBD and 144 after DBD. Time from event to BD declaration was longer by an average of 20.9 hours after DBD (p = 0.003). Seventy-five (73%) families of patients with SBD and 86 (72%) with DBD consented for organ donation (p = 0.79). The number of BD examinations was not a predictor for consent. No patient regained brain function during the periods following BD. Patients with SBD were more likely to have at least 1 lung transplanted (p = 0.031). The number of organs transplanted was associated with the number of examinations (β coefficient [95% confidence interval] -0.5 [-0.97 to -0.02]; p = 0.044), along with age (for 5-year increase, -0.36 [-0.43 to -0.29]; p < 0.001) and PaO₂ level (for 10 mm Hg increase, 0.026 [0.008-0.044]; p = 0.005) and decreased as the elapsed time to BD declaration increased (p = 0.019).

CONCLUSIONS

A single neurologic examination to determine BD is sufficient in patients with nonanoxic catastrophic brain injuries. A second examination is without additional yield in this group and its delay reduces the number of organs transplanted.

[Diagnostics of irreversible brain death : Limitations and potential for improvement from the perspective of transplantation officials]

BACKGROUND

In Germany, postmortem organ donation requires a diagnosis of irreversible brain death (BD) in strict compliance with the guidelines of the German Medical Association.

OBJECTIVE

Identification of factors that have a limiting effect on the initiation and execution of BD diagnostics. Identification of potential for improvement.

MATERIAL AND METHODS

Anonymous survey of transplantation officials in hospitals in Berlin, Brandenburg and Mecklenburg-Western Pomerania.

RESULTS

There is considerable heterogeneity with respect to the frequency of BD diagnostics and hospital-specific procedures, including the use of an existing consultation service. The local availability of qualified doctors and of suitable ancillary diagnostic tests has a structurally limiting effect. This is especially true for pediatric patients. Potential for improvement was seen in the identification of affected patients, the motivation of staff and the role of transplantation officials.

CONCLUSION

According to the recently amended German Transplantation Act, a centrally organized consultation service for BD diagnostics must be implemented as soon as 2021. Recommendations can be derived from the present survey and from the experience of the regionally established consultation service. In addition to neurological and neurosurgical expertise, qualified pediatricians and mobile ancillary instrumental diagnostics should also be provided. Expert advice from neurointensive care physicians should be available at an early stage in order to identify potentially affected patients. The highly variable participation of hospitals in organ donation, despite the availability of an expert diagnostic service free of charge, points to an important role of additional factors, some of which may be nonmedical in nature.

Retrospective analysis of the apnea test and ancillary test in determining brain death

Objective

We investigated the frequency of apnea tests, and the use of ancillary tests in the diagnosis of brain death in our hospital, as well as the reasons for not being able to perform apnea testing and the reasons for using ancillary tests.

Methods

In this retrospective study, the files of patients diagnosed with brain death between 2012 - 2018 were examined. The preferred test was determined if an ancillary test was performed in the diagnosis of brain death. The rate and frequency of use of these tests were analyzed.

Results

During the diagnosis of brain death, an apnea test was performed on 104 (61.5%) patients and was not or could not be performed on 65 (38.5%) patients. Ancillary tests were performed on 139 (82.8%) of the patients. The most common ancillary test was computed tomography angiography (79 patients, 46.7%). Approval for organ donation was received in the meetings with the family following the diagnosis of brain death for 55 (32.5%) of the 169 patients.

Conclusion

We found an increase in the rate of incomplete apnea tests and concordantly, an increase in the use of ancillary tests in recent years. Ancillary tests should be performed on patients when there is difficulty in reaching a decision of brain death, but it should not be forgotten that there is no worldwide consensus on the use of ancillary tests.

Analysis of brain death declaration process and its impact on organ donation in a reference trauma center

Objective

To characterize the processes of brain death diagnosis and organ donation in a reference trauma center.

Methods

Observational and cross-sectional study with patients notified with brain death at a reference trauma center. Data were obtained through the collection of medical records and brain death declaration forms.

Results

One hundred fity-nine patients were notified with brain death, mostly male (82.6%), young adults (97.61%) and victims of brain traumatic injury (93.7%). Median of the total time interval for the diagnosis of brain death was 20.75 hours, with no difference between organ donors and non-donors. We had excessive time intervals on brain death declaration, but without statistical effect on organ donation numbers.

Conclusion

We had low efficacy in brain death declaration based on longer time intervals, with no impact on organ donation.

Evaluation of Computed Tomography Angiography as an Ancillary Test to Reduce Confusion After Clinical Diagnosis of Brain Death

BACKGROUND

The diagnosis of brain death (BD) is mainly a clinical diagnosis. Ancillary tests may be used in confusing situations. Although computed tomography angiography (CTA) has high sensitivity and specificity, it can give false-positive results in cases with craniotomy.

OBJECTIVE

The aim of this study is to emphasize the importance of accurate and detailed clinical diagnosis and to reveal that there is organ loss as a result of prolonged supportive tests, especially in developing countries.

MATERIAL AND METHODS

This retrospective study included patients who were diagnosed with BD in the intensive care unit of Van Yüzüncü Yıl University, between September 2014 and August 2017 in Turkey. The study included 14 male and 8 female patients. Patients who did not show any spontaneous respiratory symptoms after the apnea test were diagnosed with clinical BD. Patients on neurodepressant medications who were hypothermic or hypoxic or had a severe endocrine or metabolic disorder were excluded from the study. CTA was used as an ancillary test in compliance with legal requirements. Age, sex, hospitalization days, day of clinical diagnosis of BD, first radiologic evaluation by CTA, clinical diagnosis, and radiologic evaluation were recorded for all patients.

RESULTS

Radiologic evaluation was not compatible with the clinical evaluation in 5 patients. Although 2 of these 5 patients had BD diagnosis clinically, blood flow could be expected during CTA because of cranial injury. Unlike in the literature, false positivity was found in 3 patients with hypoxic ischemic encephalopathy in the present study.

CONCLUSIONS

Proper management of limited resources and the facilitation of cadaver organ donation in developing countries are important and humanitarian global responsibilities. Revision of the country's legal regulations is important and is warranted in this regard.

Outcomes and implications of a single brain death examination policy on organ donation outcomes at a high-volume trauma center

BACKGROUND

Despite current neurological guidelines that a single brain death examination (SBDE) is sufficient to determine brain death, a vast majority of hospitals still use a two brain death examination (TBDE) policy based on historical practice. The purpose of this study was to analyze the outcomes and implications of an SBDE policy compared with a TBDE policy with respect to organ donation outcomes.

METHODS

We retrospectively reviewed all adult patients declared dead by neurological criteria between 2010 and 2018 at a high-volume trauma center. The study population was divided into SBDE and TBDE cohorts. Primary outcomes included time to organ donation, terminal donor creatinine and bilirubin, and number of procured and transplanted organs.

RESULTS

A total of 327 patients comprised the study population: 66.7% SBDE (n = 218 of 327 patients) and 33.3% TBDE (n = 109 of 327 patients). The SBDE group had a shorter median time from examination to procurement (38 vs. 44 hours, p = 0.02) as well as lower terminal donor creatinine (1.1 vs. 1.35 mg/dL, p = 0.004) and bilirubin (0.8 vs. 1.1 mg/dL, p = 0.04). Furthermore, the SBDE group had a significantly greater proportion of kidneys (90.6% vs. 81.6%, p = 0.02), lungs (11.8% vs. 4.6%, p = 0.02), and total organs (58.2% vs. 46.6%; p = 0.0001) procured with intent to transplant and a greater proportion of total organs transplanted (53.1% vs. 42.4%, p = 0.0004). Multivariable regression analysis confirmed that SBDE was independently associated with a shorter time to procurement, lower terminal creatinine, and increased number of procured organs.

CONCLUSION

These data highlight the potential benefit of an SBDE policy with regards to organ donation outcomes at a high-volume trauma center and should facilitate future randomized prospective studies to more rigorously test this hypothesis.

LEVEL OF EVIDENCE

Therapeutic/Care Management, level IV.

Diagnostic accuracy of a revised computed tomography angiography score for brain death confirmation, combining supra-tentorial arteries and infra-tentorial veins

PURPOSE

The 4-point score is the corner stone of brain death (BD) confirmation using computed tomography angiography (CTA). We hypothesized that considering the superior petrosal veins (SPVs) may improve CTA diagnosis performance in BD setting. We aimed at comparing the diagnosis performance of three revised CTA scores including SPVs and the 4-point score in the confirmation of BD.

METHODS

In this retrospective study, 69 consecutive adult-patients admitted in a French University Hospital meeting clinical brain death criteria and receiving at least one CTA were included. CTA images were reviewed by two blinded neuroradiologists. A first analysis compared the 4-point score, considered as the reference and three non-opacification scores: a "Toulouse score" including SPVs and middle cerebral arteries, a "venous score" including SPVs and internal cerebral veins and a "7-score" including all these vessels and the basilar artery. Psychometric tools, observer agreement and misclassification rates were assessed. A second analysis considered clinical examination as the reference.

RESULTS

Brain death was confirmed by the 4-score in 59 cases (89.4 %). When compared to the 4-score, the Toulouse score displayed a 100 % positive predictive value, a substantial observer agreement (0.77 [0.53; 1]) and the least misclassification rate (3.03 %). Results were similar in the craniectomy subgroup. The Toulouse score was the only revised test that combined a sensitivity close to that of the 4-score (86.4 % [75.7; 93.6] and 89.4 % [79.4; 95.6], p-value < 0.001, respectively) and a substantial observer agreement.

CONCLUSIONS

A score including SPVs and middle cerebral arteries is a valid method for BD confirmation using CTA even in patients receiving craniectomy.

Criteria to Identify a Potential Deceased Organ Donor: A Systematic Review

OBJECTIVES

To systematically review the global published literature defining a potential deceased organ donor and identifying clinical triggers for deceased organ donation identification and referral.

DATA SOURCES

Medline and Embase databases from January 2006 to September 2017.

STUDY SELECTION

All published studies containing a definition of a potential deceased organ donor and/or clinical triggers for referring a potential deceased organ donor were eligible for inclusion. Dual, independent screening was conducted of 3,857 citations.

DATA EXTRACTION

Data extraction was completed by one team member and verified by a second team member. Thematic content analysis was used to identify clinical criteria for potential deceased organ donation identification from the published definitions and clinical triggers.

DATA SYNTHESIS

One hundred twenty-four articles were included in the review. Criteria fell into four categories: Neurological, Medical Decision, Cardiorespiratory, and Administrative. Distinct and globally consistent sets of clinical criteria by type of deceased organ donation (neurologic death determination, controlled donation after circulatory determination of death, and uncontrolled donation after circulatory determination of death) are reported.

CONCLUSIONS

Use of the clinical criteria sets reported will reduce ambiguity associated with the deceased organ donor identification and the subsequent referral process, potentially reducing the number of missed donors and saving lives globally through increased transplantation.

Impact of nighttime procedures on outcomes after liver transplantation

Background

Sleep deprivation is a well-known risk factor for the performance of medical professionals. Solid organ transplantation (especially orthotopic liver transplantation (oLT)) appears to be vulnerable since it combines technically challenging operative procedures with an often unpredictable start time, frequently during the night. Aim of this study was to analyze whether night time oLT has an impact on one-year graft and patient survival.

Material and methods

Deceased donor oLTs between 2006 and 2017 were retrospectively analyzed and stratified for recipients with a start time at day (8 a.m. and 6 p.m.) or at night (6 p.m. to 8 a.m.). We examined donor as well as recipient demographics and primary outcome measure was one-year patient and graft survival.

Results

350 oLTs were conducted in the study period, 154 (44%) during daytime and 196 (56%) during nighttime. Donor and recipient variables were comparable. One-year patient survival (daytime 75.3% vs nighttime 76.5%, p = 0.85) as well as graft survival (daytime 69.5% vs nighttime 73.5%, p = 0.46) were similar between the two groups. Frequencies of reoperation (daytime 53.2% vs nighttime 55.1%, p = 0.74) were also not significantly different.

Conclusion

Our retrospective single center data derived from a German transplant center within the Eurotransplant region provides evidence that oLT is a safe procedure irrespective of the starting time. Our data demonstrate that compared to daytime surgery nighttime liver transplantation is not associated with a greater risk of surgical complications. In addition, one-year graft and patient survival do not display inferior results in patients undergoing nighttime transplantation.

Understanding of Brain Death Among Health-Care Professionals at a Transplant Center

Introduction:

There is considerable variation in brain death understanding and policies between medical institutions, however, studies have not yet compared different health-care professionals working in the same hospital.

Research Questions:

The overall aim of this study was to evaluate understanding of brain death among health-care professionals within intensive care units (ICUs) at a single institution.

Design:

Study participants included 217 attending physicians, residents, nurses, medical students, and other ICU team members in 6 ICUs. Participants completed a 21-question survey pertaining to knowledge of brain death and related institutional policies as well as opinions about brain death.

Results:

We found a wide range of brain death understanding among health-care professionals in ICUs. Attending physicians have the greatest understanding (94.7%), followed by nurses (72.4%). In contrast, approximately half of the students and residents do not have a basic understanding of brain death. Brain death understanding was correlated to health-care role, years of experience, and whether the participant had formal training in brain death. Although most participants had been involved in cases of brain death, a much smaller number had received formal training on death by neurological criteria.

Discussion:

The present study observed a paucity of clinical training in brain death among health-care professionals in the study ICUs. There is an opportunity for improved clinical education on brain death that could improve communication with families about brain death and potentially increase the number of organs transplanted.

The weekend effect in liver transplantation

Background

The weekend effect describes a phenomenon whereby patients admitted to hospitals on weekends are at higher risk of complications compared to those admitted during weekdays. However, if a weekend effect exists in orthotopic liver transplantation (oLT).

Methods

We analyzed oLT between 2006 and 2016 and stratified patients into weekday (Monday to Friday) and weekend (Saturday, Sunday) groups. Primary outcome measures were one-year patient and graft survival.

Results

364 deceased donor livers were transplanted into 329 patients with 246 weekday (74.77%) and 83 weekend (25.23%) patients. Potential confounders (e.g. age, ischemia time, MELD score) were comparable. One-year patient and graft survival were similar. Frequencies of rejections, primary-non function or re-transplantation were not different. The day of transplantation was not associated with one-year patient and graft survival in multivariate analysis.

Conclusions

We provide the first data for the Eurotransplant region on oLT stratified for weekend and weekday procedures and our findings suggest there was no weekend effect on oLT. While we hypothesize that the absent weekend effect is due to standardized transplant procedures and specialized multidisciplinary transplant teams, our results are encouraging showing oLT is a safe and successful procedure, independent from the day of the week.

Brain Death

Death determined by neurologic criteria, commonly referred to as "brain death," occurs when function of the entire brain ceases, including the brain stem. Diagnostic criteria for brain death are explicit but controversy exists regarding nuances of the evaluation and potential confounders of the examination. Hospitals and ICU teams should carefully consider which clinicians will perform brain death testing and should use standard processes, including checklists to prevent diagnostic errors. Proper diagnosis is essential because misdiagnosis can be catastrophic. Timely, accurate brain death determination and aggressive physiologic support are cornerstones of both good end-of-life care and successful organ donation.

Medical Training and the Brain Death Exam: A Single Institution's Experience

BACKGROUND

Clinicians may have limited opportunities to perform neurological determination of death (NDD, or brain death) certification during their training. This study aimed to evaluate the level of resident exposure to the brain death exam at a large-volume donor hospital.

METHODS

In March 2014, we adapted a dual-physician model for NDD certification at our institution to improve resident education regarding NDD. To evaluate the incidence of resident exposure, we collected examiner information from all brain death exams conducted between January 2014 and July 2015. Organ procurement, family authorization, and brain death intervals were also collected to evaluate the impact of NDD timeliness on organ donation.

RESULTS

A total of 68 patients who met NDD criteria were included in this study. For these patients, 127 brain death exams were performed, 108 (85%) by a critical care attending physician or fellow, 9 (7%) by a neurology resident, and 7 (6%) by a neurosurgery resident. Exposure rates for neurology and neurosurgery residents were approximately 0.22 and 0.20 exams/resident/year, respectively. The median brain death interval between exams was 1.0 hours (interquartile range, 0.0-2.5) hours. Resident involvement, time between exams, and dual exams were all found to be nonsignificant correlates of organ authorization and family refusal.

CONCLUSIONS

Neurology and neurosurgery residents may be limited in their exposure to the brain death exam during training. High-volume donor hospitals may be able to complete 2 exams for NDD certification in a timely manner without detrimentally influencing organ authorization or family refusal rates.

Current controversies in brain death determination

Although the concept of brain death is accepted by the majority of physicians, lawyers, ethicists and society at large, controversies about determination of death by neurological criteria persist, and often reach the public eye. In this article, we examine four prominent controversial brain death cases from 2013-2016. We review current controversies, including protocol variability, recognition of the American Academy of Neurology (AAN) criteria for brain death as an accepted medical standard, and management of objections to discontinuation of organ support after determination of brain death. Brain death remains conceptually and legally valid, and it is vital that these issues are solved. We argue that medical societies and governmental regulatory bodies must support the AAN criteria in order to decrease protocol variability, and must fully endorse the validity of these criteria as accepted medical standards.

Optic Nerve Sheath Diameter Ultrasound Evaluation in Intensive Care Unit: Possible Role and Clinical Aspects in Neurological Critical Patients' Daily Monitoring

Background. The increase of the optic nerve sheath diameter (ONSD) is a reliable, noninvasive sonographic marker of intracranial hypertension. Aim of the study was to demonstrate the efficacy of ONSD evaluation, when monitoring neurocritical patients, to early identify malignant intracranial hypertension in patients with brain death (BD). Methods. Data from ultrasound ONSD evaluation have been retrospectively analyzed in 21 sedated critical patients with neurological diseases who, during their clinical course, developed BD. 31 nonneurological controls were used for standard ONSD reference. Results. Patients with neurological diseases, before BD, showed higher ONSD values than control group (CTRL: RT 0.45 ± 0.03 cm; LT 0.45 ± 0.02 cm; pre-BD: RT 0.54 ± 0.02 cm; LT 0.55 ± 0.02 cm; p < 0.000) even without intracranial hypertension, evaluated with invasive monitoring. ONSD was further significantly markedly increased in respect to the pre-BD evaluation in neurocritical patients after BD, with mean values above 0.7 cm (RT 0.7 ± 0.02 cm; LT 0.71 ± 0.02 cm; p < 0.000), with a corresponding dramatic raise in intracranial pressure. Logistic regression analysis showed a strong correlation between ONSD and ICP (R 0,895, p < 0.001). Conclusions. ONSD is a reliable marker of intracranial hypertension, easy to be performed with a minimal training. Routine ONSD daily monitoring could be of help in Intensive Care Units when invasive intracranial pressure monitoring is not available, to early recognize intracranial hypertension and to suspect BD in neurocritical patients.

Variability in Diagnosing Brain Death at an Academic Medical Center

Objective. Research continues to highlight variability in hospital policy and documentation of brain death. The aim of our study was to characterize how strictly new guidelines of American Academy of Neurology (AAN) for death by neurological criteria were practiced in our hospital prior to appointment of neurointensivists. Method. This is a retrospective study of adults diagnosed as brain dead from 2011 to 2015. Descriptive statistics compared five categories: preclinical testing, neurological examination, apnea tests, ancillary test, and documentation of time of death. Strict adherence to AAN guidelines for brain death determination was determined. Result. 76 patients were included in this study. Preclinical prerequisites were fulfilled in 53.9% and complete neurological examinations were documented in 76.3%. Apnea test was completed in 39.5%. Ancillary test was completed in 29.8%. Accurate documentation of time of death occurred in 59.2%. Overall, strict adherence to current AAN guidelines for death by neurological criteria was correctly documented in 38.2%. Conclusion. Our study shows wide variability in diagnosing brain death. These findings led us to update our death by neurological criteria policy and increase awareness of brain death determination with the goal of improving our documentation following current AAN guidelines.

Organ donation protocols

Organ transplantation improves survival and quality of life in patients with end-organ failure. Waiting lists continue to grow across the world despite remarkable advances in the transplantation process, from the creation of public engagement campaigns to the development of critical pathways for the timely identification, referral, approach, and treatment of the potential organ donor. The pathophysiology of dying triggers systemic changes that are intimately related to organ viability. The intensive care management of the potential organ donor optimizes organ function and improves the donation yield, representing a significant step in reducing the mismatch between organ supply and demand. Different beliefs and cultures reflect diverse legislations and donation practices amongst different countries, creating a challenge to standardized practices. Maintaining public trust is necessary for continued progress in organ donation and transplantation, hence the urge for a joint effort in creating uniform protocols that ensure transparent practices within the medical community.

[Non-heart-beating donors are ineligible]

The death of the donor is a mandatory prerequisite for organ transplantation (dead donor rule) worldwide. It is a medical, legal and ethical consensus to accept the concept of brain death, as first proposed in 1968 by the ad hoc committee of the Harvard Medical School, as a certain criterion of death. In isolated cases where the diagnosis of brain death was claimed to be wrong, it could be demonstrated that the diagnostic procedure for brain death had not been correctly performed. In March 2014 a joint statement by the German neuromedical societies emphasized that 1) the diagnosis of brain death is one of the safest diagnoses in medicine if performed according to accepted medical standards and criteria and 2) the concept of non-heart-beating donors (NHBD, i. e. organ donation after an arbitrarily defined duration of circulatory and cardiac arrest) practiced in some European countries must be absolutely rejected because it implicates a high risk of diagnostic error. According to the current literature it is unclear at what time cardiac and circulatory arrest is irreversible and leads to irreversible cessation of all functions of the entire brain including the brainstem, even though clinical signs of cessation of brain functions are always found after 10 min. Furthermore, is it often an arbitrary decision to exactly define the duration of cardiac arrest if continuous echocardiographic monitoring has not been carried out from the very beginning. Last but not least there are ethical concerns against the concept of NHBD because it might influence therapeutic efforts to resuscitate a patient with cardiac arrest. Therefore, the German Medical Council (BÄK) has repeatedly rejected the concept of NHBD for organ transplantation since 1995.

Recovery from a possible cytomegalovirus meningoencephalitis-induced apparent brain stem death in an immunocompetent man: a case report

BACKGROUND

Recovery from cytomegalovirus meningoencephalitis with brain stem death in an immunocompetent patient is almost impossible. We present a remarkable recovery from a possible cytomegalovirus infection in an immunocompetent man who had severe neurological syndromes, suggesting brain stem death complicated by pneumonia and pleural effusion.

CASE PRESENTATION

A 19-year-old Asian man presented at our hospital's emergency department with reduced consciousness and seizures following high fever, headache, confusion, and vomitus within a week before arrival. He was intubated and sent to our intensive care unit. He had nuchal rigidity and tetraparesis with accentuated tendon reflexes. Electroencephalography findings suggested an acute structural lesion at his right temporal area or an epileptic state. A cerebral spinal fluid examination suggested viral infection. A computed tomography scan was normal at the early stage of disease. Immunoglobulin M, immunoglobulin G anti-herpes simplex virus, and immunoglobulin M anti-cytomegalovirus were negative. However, immunoglobulin G anti-cytomegalovirus was positive, which supported a diagnosis of cytomegalovirus meningoencephalitis. His clinical condition deteriorated, spontaneous respiration disappeared, cranial reflexes became negative, and brain stem death was suspected. Therapy included antivirals, corticosteroids, antibiotics, anticonvulsant, antipyretics, antifungal agents, and a vasopressor to maintain hemodynamic stability. After 1 month, he showed a vague response to painful stimuli at his supraorbital nerve and respiration started to appear the following week. After pneumonia and pleural effusion were resolved, he was weaned from the ventilator and moved from the intensive care unit on day 90.

CONCLUSIONS

This case highlights several important issues that should be considered. First, the diagnosis of brain stem death must be confirmed with caution even if there are negative results of brain stem death test for a long period. Second, cytomegalovirus meningoencephalitis should be considered in the differential diagnosis even for an immunocompetent adult. Third, accurate therapy and simultaneous intensive care have very important roles in the recovery process of patients with cytomegalovirus meningoencephalitis.

Brain death and true patient care

The "brain death" standard as a criterion of death is closely associated with the need for transplantable organs from heart-beating donors. Are all of these potential donors really dead, or does the documented evidence of patients destined for organ harvesting who improve, or even recover to live normal lives, call into question the premise underlying "brain death"? The aim of this paper is to re-examine the notion of "brain death," especially its clinical test-criteria, in light of a broad framework, including medical knowledge in the field of neuro-intensive care and the traditional ethics of the medical profession. I will argue that both the empirical medical evidence and the ethics of the doctor-patient relationship point to an alternative approach toward the severely comatose patient (potential brain-dead donor). Lay Summary: Though legally accepted and widely practiced, the "brain death" standard for the determination of death has remained a controversial issue, especially in view of the occurrence of "chronic brain death" survivors. This paper critically re-evaluates the clinical test-criteria for "brain death," taking into account what is known about the neuro-critical care of severe brain injury. The medical evidence, together with the understanding of the moral role of the physician toward the patient present before him or her, indicate that an alternative approach should be offered to the deeply comatose patient.

Pediatric Deceased Donation-A Report of the Transplantation Society Meeting in Geneva

The Ethics Committee of The Transplantation Society convened a meeting on pediatric deceased donation of organs in Geneva, Switzerland, on March 21 to 22, 2014. Thirty-four participants from Africa, Asia, the Middle East, Oceania, Europe, and North and South America explored the practical and ethical issues pertaining to pediatric deceased donation and developed recommendations for policy and practice. Their expertise was inclusive of pediatric intensive care, internal medicine, and surgery, nursing, ethics, organ donation and procurement, psychology, law, and sociology. The report of the meeting advocates the routine provision of opportunities for deceased donation by pediatric patients and conveys an international call for the development of evidence-based resources needed to inform provision of best practice care in deceased donation for neonates and children.

[Access to brain death diagnostics]

BACKGROUND AND OBJECTIVES

In Germany the diagnosis of brain death must strictly adhere to the expert guidelines of the German chamber of physicians. For patients with primary supratentorial or hypoxic brain injury aged 2 years or more, repeat clinical examinations or one complete examination combined with an ancillary test are equally accurate. This study aimed to identify factors with potential impact on whether and by which means a formal brain death examination is pursued.

MATERIAL AND METHODS

A retrospective analysis was carried out of recorded data of all patients who died in the acute phase after severe brain injury during mechanical ventilation in an intensive care unit and who were registered at the north east regional bureau of the German organ procurement organization (Deutsche Stiftung Organtransplantation) between 2001 and 2010.

RESULTS

Of 5988 reported patients, a protocol-specified brain death examination was initiated in 3023, leading to a diagnosis of brain death in 2592. All other patients died due to permanent cardiac arrest. Patients were less likely to undergo brain death examinations in the presence of one or more of the following characteristics: perceived medical contraindication for organ donation, patient age greater than 69 years, hypoxic brain damage, treatment in a hospital without neurological and neurosurgical departments and death on a weekend or public holiday. In 2192 patients (72.5%), neurologists or neurosurgeons participated in the diagnostic procedures and in 926 of these cases members of specialized external diagnostic expert teams were involved. Ancillary tests were rarely used by physicians based at the treating hospitals (31.1%) but on a regular basis by members of the external teams (93.4%). The risk of death due to permanent cardiac arrest before completion of the brain death examination was increased approximately 7-fold when a neurological or neurosurgical consultation with ancillary studies was not performed.

DISCUSSION

Access to neurological expertise and to ancillary tests has a significant impact on the provision of guideline-specified diagnostic procedures for suspected brain death. Centralized diagnostic teams offer an effective means to support qualified brain death examinations.

Renaissance of criticism on the concept of brain death--the role of legal medicine in the context of the interdisciplinary discussion

BACKGROUND

In the practice of legal medicine in Germany, the assessment of brain death is of minor importance and attracts little attention. However, since several years, international criticism on the concept of brain death has culminated. By reviewing literature and the results of a questionnaire distributed among the participants of the 93rd Annual Congress of the Germany Society of Legal Medicine, the state of knowledge and the current views on brain death were evaluated.

MATERIALS AND METHODS

Literature search of recent publications regarding brain death was performed (PubMed database, references of legal medicine, Report of the President's Council on Bioethics, USA 2008). A questionnaire was developed and distributed among the participants of the Congress.

RESULTS

The assumption that individual and brain death are synonymous is criticized. Internationally, there are trends to harmonize the very different clinical criteria to assess brain death. The diagnostic advantage of novel techniques such as CT angiography is controversially discussed. It becomes apparent that procedures which record the blood flow and perfusion of the brain will be applied more in the future. Regrettably, these developments are not described in the literature of legal medicine. Moreover, among German forensic scientists, different views concerning brain death exist. The majority favors its equivalent treatment with individual death. The thanatological background can be improved concerning certain aspects of brain death as well as its legal implications.

CONCLUSION

Teaching and research in legal medicine should include the subject brain death. Expertise in forensic science may contribute to the interdisciplinary discussion on brain death. The transfer of actual knowledge, also on disputed ethical aspects of thanatology, to physicians of all disciplines is of great importance.

The use of transcranial Doppler ultrasound in confirming brain death in the setting of skull defects and extraventricular drains

BACKGROUND

Transcranial Doppler ultrasound (TCD) has been used as a confirmatory test for the diagnosis of brain death (BD), but may be inaccurate in patients with a skull defect or extraventricular drain (EVD).

METHODS AND RESULTS

We report three cases of patients with a skull defect or EVD in whom TCD supported a diagnosis of BD but in which the clinical examination later refuted the diagnosis.

CONCLUSION

We caution against the use of TCD to confirm the diagnosis of BD in the presence of a skull defect or EVD.

Brain-dead patients are not cadavers: the need to revise the definition of death in Muslim communities

The utilitarian construct of two alternative criteria of human death increases the supply of transplantable organs at the end of life. Neither the neurological criterion (heart-beating donation) nor the circulatory criterion (non-heart-beating donation) is grounded in scientific evidence but based on philosophical reasoning. A utilitarian death definition can have unintended consequences for dying Muslim patients: (1) the expedited process of determining death for retrieval of transplantable organs can lead to diagnostic errors, (2) the equivalence of brain death with human death may be incorrect, and (3) end-of-life religious values and traditional rituals may be sacrificed. Therefore, it is imperative to reevaluate the two different types and criteria of death introduced by the Resolution (Fatwa) of the Council of Islamic Jurisprudence on Resuscitation Apparatus in 1986. Although we recognize that this Fatwa was based on best scientific evidence available at that time, more recent evidence shows that it rests on outdated knowledge and understanding of the phenomenon of human death. We recommend redefining death in Islam to reaffirm the singularity of this biological phenomenon as revealed in the Quran 14 centuries ago.

Pitfalls and slip-ups in brain death determination

Brain death (or brainstem death in the UK) is an uncommon result of a major catastrophic neurologic injury. The determination of brain death proceeds through a comprehensive and stepwise evaluation. There is no room for misinterpretations. Slip ups, however, could occur with brain death determination and this review discusses the most common concerns encountered by physicians. Problems may arise when a multitude of small errors accumulate and this may occur with an inexperienced physician who misjudges confounders, performs an incomplete evaluation, and misinterprets a confirmatory test.

Transparency and accountability in mass media campaigns about organ donation: a response to Morgan and Feeley

We respond to Morgan and Feeley's critique on our article "Mass Media in Organ Donation: Managing Conflicting Messages and Interests." We noted that Morgan and Feeley agree with the position that the primary aims of media campaigns are: "to educate the general public about organ donation process" and "help individuals make informed decisions" about organ donation. For those reasons, the educational messages in media campaigns should not be restricted to "information from pilot work or focus groups" but should include evidence-based facts resulting from a comprehensive literature research. We consider the controversial aspects about organ donation to be relevant, if not necessary, educational materials that must be disclosed in media campaigns to comply with the legal and moral requirements of informed consent. With that perspective in mind, we address the validity of Morgan and Feeley's claim that media campaigns have no need for informing the public about the controversial nature of death determination in organ donation. Scientific evidence has proven that the criteria for death determination are inconsistent with the Uniform Determination of Death Act and therefore potentially harmful to donors. The decision by campaign designers to use the statutory definition of death without disclosing the current controversies surrounding that definition does not contribute to improved informed decision making. We argue that if Morgan and Feeley accept the important role of media campaigns to enhance informed decision making, then critical controversies should be disclosed. In support of that premise, we will outline: (1) the wide-spread scientific challenges to brain death as a concept of death; (2) the influence of the donor registry and team-huddling on the medical care of potential donors; (3) the use of authorization rather than informed consent for donor registration; (4) the contemporary religious controversy; and (5) the effects of training desk clerks as organ requestors at the Department of Motor Vehicles offices. We conclude that organ donation is a medical procedure subject to all the ethical obligations that the medical profession must uphold including that of transparency and truthfulness.

Non confirmatory electroencephalography in patients meeting clinical criteria for brain death: scenario and impact on organ donation

OBJECTIVE

To describe the causes and outcome of adult patients with preserved electroencephalographic activity despite clinical findings suggesting brain death (BD), and its impact on organ donation.

METHODS

Retrospective study of the clinical and electroencephalography (EEG) data of all adult patients admitted to our hospital between January 2001 and December 2011 in whom a comprehensive clinical diagnosis of BD was reached following absence of brainstem reflexes and confirmatory apnea tests, were obtained. All patients with clinical findings suggesting BD and an EEG showing brain activity were selected for the analysis. We calculated the brain death interval (BDI) as the time between the first complete clinical examination and confirmatory ancillary test, or the time between the first and second complete clinical examination for BD, in order to analyze the impact on family consent for organ donation.

RESULTS

A complete clinical examination and EEG were diagnostic in 289 patients. In 279 (96.5%), the first EEG showed electrocerebral inactivity corroborating the clinical findings of BD. The mean BDI in this group was 4.2 ± 5.8h (median; 1.8[1.0-3.5]). This value was significantly lower than in the group in which only two full clinical evaluations were performed (p<0.0001). In 10 out 289 (3.5%), the first EEG showed at least some brain activity. The mean BDI in this group was 27.2 ± 13.8h (median; 22.9 [19.1-31.2]). In two cases, a third EEG was necessary before obtaining electrocerebral inactivity. A BDI>6h, was positively associated with a family refusal for organ donation (p=0.02).

CONCLUSIONS

The rate of EEGs with electrocerebral activity despite clinical findings suggesting BD was only 3.5%. It occurred most frequently with severe brainstem damage. Although in this small percentage of patients, BD diagnosis was notably delayed, in the great majority of cases the use of EEG shortened the BDI. In our series, a BD diagnosis delay >6h negatively affected consent for organ donation.

SIGNIFICANCE

The use of EEG can decrease the time interval for brain death diagnosis.

Consent to organ donation: a review

Successful transplant medicine hinges on consent to deceased organ donation. Yet rates of consent remain suboptimal. To increase the availability of transplantable organs, several policy strategies along with a rich body of evidence aimed at identifying best practices for obtaining consent have accumulated. This review describes past and current policies and practices, presents evidence illustrating the impact of these policies and practices on consent, and summarizes future directions and recommendations for the field. Key findings include evidence that although past policies such as required request have been unsuccessful, the recent policy, first-person authorization, shows promise. Additionally, practices such as decoupling and detailed discussions of brain death are unwarranted. On the other hand, the Organ Donation Breakthrough Collaboration was successful. We also underscore the impact of alternative procedures such as donation after cardiac death. Last, effective communication that is delivered by trained, caring requesters at the appropriate time, in a supportive environment, and allows sufficient time for families to make an informed decision, optimizes the request process. Organ procurement organizations' adoption of such request practices, implementation of evidence-based policies regarding donation after cardiac death, and further investigations of the medical basis for dual brain death examinations are recommended.

Controversies in defining and determining death in critical care

Circulatory-respiratory or brain tests are widely accepted for definition and determination of death, but have several controversial issues. Both determinations have been stimulated by organ donation, but must be valid independently of this process. Current controversies in brain death include whether the definition is conceptually coherent, whether the whole-brain or brainstem criterion is correct, whether one neurological examination or two should be required, and when to conduct the examination following therapeutic hypothermia. Controversies about the circulatory determination of death include the minimum duration of asystole that is sufficient for death to be declared, and whether the distinction between permanent and irreversible cessation of circulatory functioning is important. In addition, the goal of organ donation raises issues such as the optimal way to time and conduct the request conversation with family members of the patient, and whether the Dead Donor Rule should be abandoned.