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Computed Tomography Angiography (CTA) in Selected Scenarios with Risk of Possible False-Positive or False-Negative Conclusions in Diagnosing Brain Death. LIFE (BASEL, SWITZERLAND) 2022; 12:life12101551. [PMID: 36294986 PMCID: PMC9604663 DOI: 10.3390/life12101551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 09/30/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022]
Abstract
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.
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Thomson D, Joubert I, De Vasconcellos K, Paruk F, Mokogong S, Mathivha R, McCulloch M, Morrow B, Baker D, Rossouw B, Mdladla N, Richards GA, Welkovics N, Levy B, Coetzee I, Spruyt M, Ahmed N, Gopalan D. South African guidelines on the determination of death. SOUTHERN AFRICAN JOURNAL OF CRITICAL CARE 2021; 37:10.7196/SAJCC.2021v37i1b.466. [PMCID: PMC10193841 DOI: 10.7196/sajcc.2021v37i1b.466] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/17/2020] [Indexed: 05/20/2023] Open
Abstract
Summary
Death is a medical occurrence that has social, legal, religious and cultural consequences requiring common clinical standards for its diagnosis
and legal regulation. This document compiled by the Critical Care Society of Southern Africa outlines the core standards for determination
of death in the hospital context. It aligns with the latest evidence-based research and international guidelines and is applicable to the South
African context and legal system. The aim is to provide clear medical standards for healthcare providers to follow in the determination
of death, thereby promoting safe practices and high-quality care through the use of uniform standards. Adherence to such guidelines will
provide assurance to medical staff, patients, their families and the South African public that the determination of death is always undertaken
with diligence, integrity, respect and compassion, and is in accordance with accepted medical standards and latest scientific evidence.
The consensus guidelines were compiled using the AGREE II checklist with an 18-member expert panel participating in a three-round
modified Delphi process. Checklists and advice sheets were created to assist with application of these guidelines in the clinical environment
(https://criticalcare.org.za/resource/death-determination-checklists/). Key points Brain death and circulatory death are the accepted terms for defining death in the hospital context. Death determination is a clinical diagnosis which can be made with complete certainty provided that all preconditions are met. The determination of death in children is held to the same standard as in adults but cannot be diagnosed in children <36 weeks’ corrected
gestation. Brain-death testing while on extra-corporeal membrane oxygenation is outlined. Recommendations are given on handling family requests for accommodation and on consideration of the potential for organ donation. The use of a checklist combined with a rigorous testing process, comprehensive documentation and adequate counselling of the family
are core tenets of death determination. This is a standard of practice to which all clinicians should adhere in end-of-life care.
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Affiliation(s)
- D Thomson
- Division of Critical Care, Department of Surgery, University of Cape Town, Groote Schuur Hospital, Cape Town, South Africa
| | - I Joubert
- Division of Critical Care, Department of Anaesthesia and Peri-operative Medicine, University of Cape Town and Groote Schuur Hospital,
Cape Town, South Africa
| | - K De Vasconcellos
- Department of Critical Care, King Edward VIII Hospital, Durban, South Africa; Discipline of Anaesthesiology and Critical Care, School of Clinical
Medicine, University of KwaZulu-Natal, Durban, South Africa
| | - F Paruk
- Department of Critical Care, University of Pretoria, South Africa
| | - S Mokogong
- Department of Neurosurgery, University of Pretoria, South Africa
| | - R Mathivha
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - M McCulloch
- Paediatric Intensive Care Unit and Transplant Unit, Red Cross War Memorial Children’s Hospital and Faculty of Health Sciences, University of
Cape Town, South Africa
| | - B Morrow
- Department of Paediatrics and Child Health, Faculty of Health Sciences, University of Cape Town, South Africa
| | - D Baker
- Department of Adult Critical Care, Livingstone Hospital and Faculty of Health Sciences, Walter Sisulu University, Port Elizabeth, South Africa
| | - B Rossouw
- Paediatric Intensive Care Unit, Red Cross War Memorial Children’s Hospital and Faculty of Health Sciences, University of Cape Town, South Africa
| | - N Mdladla
- Dr George Mukhari Academic Hospital, Sefako Makgatho University, Johannesburg, South Africa
| | - G A Richards
- Department of Critical Care, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - N Welkovics
- Netcare Unitas Hospital, Centurion, South Africa
| | - B Levy
- Netcare Rosebank Hospital, Johannesburg, South Africa
| | - I Coetzee
- Department of Nursing Science, University of Pretoria, South Africa
| | - M Spruyt
- Busamed Bram Fischer International Airport Hospital, Bloemfontein, South Africa
| | - N Ahmed
- Consolidated Critical Care Unit, Tygerberg Hospital, Department of Surgical Sciences, Department of Anaesthesiology and Critical Care, Faculty
of Medicine and Health Sciences, Stellenbosch University, Cape Town
| | - D Gopalan
- Discipline of Anaesthesiology and Critical Care, School of Clinical Medicine, University of KwaZulu-Natal, Durban, South Africa
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Analysis of factors involved in brain-death donor processing for face transplantation in Korea: How much time is available from brain death to transplantation? Arch Plast Surg 2019; 46:405-413. [PMID: 31462025 PMCID: PMC6759447 DOI: 10.5999/aps.2019.00150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 07/03/2019] [Indexed: 11/23/2022] Open
Abstract
Background Face transplantation has naturally evolved from reconstructive procedures. However, few institutions perform face transplantations, because it is time-consuming and it is necessary to justify non-vital organ transplantation. We investigated the process of organ donation from brain-dead patients and the possibility of incorporating face transplantation into the donation process. Methods A retrospective review was performed of 1,074 brain-dead patients from January 2015 to December 2016 in Korea. We analyzed the time intervals from admission to brain death decisions (first, second, and final), the causes of brain death, and the state of the transplanted organs. Results The patient base (n=1,074) was composed of 747 males and 327 females. The average period between admission to the first brain death decision was 8.5 days (±15.3). The average time intervals between the first brain death decision and medical confirmation using electroencephalography and between the first brain death decision and the final determination of brain death were 16 hours 58 minutes (±14 hours 50 minutes) and 22 hours 57 minutes (±16 hours 16 minutes), respectively. The most common cause of brain death was cerebral hemorrhage/stroke (42.3%), followed by hypoxia (30.1%), and head trauma (25.2%). Conclusions When face transplantation is performed, the transplantation team has 22 hours 57 minutes on average to prepare after the first brain death decision. The cause of brain death was head trauma in approximately one-fourth of cases. Although head trauma does not always imply facial trauma, surgeons should be aware that the facial tissue may be compromised in such cases.
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Variability in Diagnosing Brain Death at an Academic Medical Center. NEUROSCIENCE JOURNAL 2017; 2017:6017958. [PMID: 28352638 PMCID: PMC5352905 DOI: 10.1155/2017/6017958] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/09/2016] [Accepted: 02/13/2017] [Indexed: 11/18/2022]
Abstract
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.
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Yu YD, Kim SJ, Jang YS, Jung SW, Han JH, Jun H, Jung CW, Kim DS. Factors Delaying Organ Procurement After Declaration of Brain Death in Korea. Transplant Proc 2016; 48:2403-2406. [DOI: 10.1016/j.transproceed.2016.02.095] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 02/02/2016] [Indexed: 11/15/2022]
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Cameron EJ, Bellini A, Damian MS, Breen DP. Confirmation of brainstem death. Pract Neurol 2016; 16:129-35. [DOI: 10.1136/practneurol-2015-001297] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2015] [Indexed: 11/03/2022]
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Youn TS, Greer DM. Brain death and management of a potential organ donor in the intensive care unit. Crit Care Clin 2015; 30:813-31. [PMID: 25257743 DOI: 10.1016/j.ccc.2014.06.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The concept of brain death developed with the advent of mechanical ventilation, and guidelines for determining brain death have been refined over time. Organ donation after brain death is a common source of transplant organs in Western countries. Early identification and notification of organ procurement organizations are essential. Management of potential organ donors must take into consideration specific pathophysiologic changes for medical optimization. Future aims in intensive and neurocritical care medicine must include reducing practice variability in the operational guidelines for brain death determination, as well as improving communication with families about the process of determining brain death.
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Affiliation(s)
- Teddy S Youn
- Department of Neurology, Yale University School of Medicine, LLCI 912, 15 York Street, New Haven, CT 06520, USA
| | - David M Greer
- Department of Neurology, Yale University School of Medicine, LLCI 912, 15 York Street, New Haven, CT 06520, USA.
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International perspectives in the diagnosis of brain death in adults. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2012. [DOI: 10.1016/j.tacc.2011.11.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Bohatyrewicz R, Bohatyrewicz A, Zukowski M, Marzec-Lewenstein E, Biernawska J, Solek-Pastuszka J, Sienko J, Sulikowski T. Reversal to whole-brain death criteria after 15-year experience with brain stem death criteria in Poland. Transplant Proc 2010; 41:2959-60. [PMID: 19857649 DOI: 10.1016/j.transproceed.2009.07.079] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Polish brain-death criteria, similar to the original Harvard criteria, were published in 1984. In 1990, they were converted to brainstem death criteria, and were revised twice, in 1994 and in 1996. However, they could not be used in many complicated clinical situations such as intoxication, metabolic alterations, major facial injury, infratentorial lesions, and cervical spinal cord injury. The new Polish Transplant Act, passed by the Polish Parliament in 2005, recommends implementation of criteria for whole-brain death for brain-death diagnosis. In 2007, the Polish Ministry of Health Commission outlined new Polish brain-death criteria. Optional use of instrumental confirmatory tests was implemented in the new Polish national code of practice for the diagnosis of brain death in adults. In children up to age 2 years, instrumental tests are obligatory. Initially, there were problems in understanding the new, slightly more complicated classifications of primary and secondary brain injuries, infratentorial and supratentorial processes, modified apnea test. A broad commentary that addressed the most frequently asked questions was published in Anesthesiology and Intensive Therapy, the official journal of the Polish Society of Anaesthesiology and Intensive Therapy. This article dealt with most of the problems associated with implementation of the new criteria for diagnosis of brain death.
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Affiliation(s)
- R Bohatyrewicz
- Department of Anaesthesiology and Intensive Care, Pomeranian Medical University, ul. Unii Lubelskiej 1, 71-252 Szczecin, Poland.
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Seth AK, Nambiar P, Joshi A, Ramprasad R, Choubey R, Puri P, Murthy M, Naidu S, Saha A, Bhatoe H. First prospective study on brain stem death and attitudes toward organ donation in India. Liver Transpl 2009; 15:1443-7. [PMID: 19877266 DOI: 10.1002/lt.21912] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Organ donation following brain stem death is infrequent in India. There is no prospective study on prevalence of brain stem death and causes of non-donation. Consecutive patients admitted to intensive care unit from Sep 2006 to Sep 2008 were studied prospectively. Families of those with brain stem death were approached for organ donation by transplant coordinator. Extensive awareness drive was launched. Reasons for non-donation, if any, were documented. Of 2820 patients admitted, 994 (35%) were on mechanical ventilator and 657 (23%) died. Brain stem death could be diagnosed in 55, 37 males, median age 46 years (range 7 to 87 years) i.e., 1.9% of all admissions and 8.3% of all deaths. Among neurology and neurosurgery patients brain stem death was seen in 45 of 1037 (4.3%) admissions and 45 of 161 (27.9%) deaths. Complications of brain stem death were hypotension in 49, diabetes insipidus in 17 and hypertension in 5 patients. Of 33 families counselled, 16(48%) consented to organ donation. In 14(42%), organs and tissues retrieved and transplanted included 13 livers, 23 kidneys, 25 corneas and 5 cardiac valves. Consent was more likely in females (10 of 14 as compared to 6 of 19 males, p = 0.037). Consent did not correlate with age of donor or medico-legal issues (p = 0.227 & 0.579 respectively). Trained staff with requisite systems in place produced significant organ donation rates. Religious issues and medico legal concerns were not a major hurdle towards organ donation. Female patients with brain stem were more likely to become organ donors.
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Affiliation(s)
- Avnish Kumar Seth
- Armed Forces Organ Retrieval and Transplantation Authority, Army Hospital (Research and Referral), New Delhi, India.
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Brain death and the cervical spinal cord: a confounding factor for the clinical examination. Spinal Cord 2009; 48:2-9. [PMID: 19736557 DOI: 10.1038/sc.2009.115] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
STUDY DESIGN This study is a systematic review. OBJECTIVES Brain death (BD) is a clinical diagnosis, made by documenting absent brainstem functions, including unresponsive coma and apnea. Cervical spinal cord dysfunction would confound clinical diagnosis of BD. Our objective was to determine whether cervical spinal cord dysfunction is common in BD. METHODS A case of BD showing cervical cord compression on magnetic resonance imaging prompted a literature review from 1965 to 2008 for any reports of cervical spinal cord injury associated with brain herniation or BD. RESULTS A total of 12 cases of brain herniation in meningitis occurred shortly after a lumbar puncture with acute respiratory arrest and quadriplegia. In total, nine cases of acute brain herniation from various non-meningitis causes resulted in acute quadriplegia. The cases suggest that direct compression of the cervical spinal cord, or the anterior spinal arteries during cerebellar tonsillar herniation cause ischemic injury to the cord. No case series of brain herniation specifically mentioned spinal cord injury, but many survivors had severe disability including spastic limbs. Only two pathological series of BD examined the spinal cord; 56-100% of cases had upper cervical spinal cord damage, suggesting infarction from direct compression of the cord or its arterial blood supply. CONCLUSIONS Upper cervical spinal cord injury may be common after brain herniation. Cervical spinal cord injury must either be ruled out before clinical testing for BD, or an ancillary test to document lack of brainstem blood flow is required in all cases of suspected BD. BD may not be a purely clinical diagnosis.
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Pitfalls in the Diagnosis of Brain Death. Neurocrit Care 2009; 11:276-87. [DOI: 10.1007/s12028-009-9231-y] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2009] [Accepted: 04/28/2009] [Indexed: 11/25/2022]
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Wang K, Yuan Y, Xu ZQ, Wu XL, Luo BY. Benefits of combination of electroencephalography, short latency somatosensory evoked potentials, and transcranial Doppler techniques for confirming brain death. J Zhejiang Univ Sci B 2009; 9:916-20. [PMID: 18988311 DOI: 10.1631/jzus.b0820123] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Optimization of combining electroencephalography (EEG), short latency somatosensory evoked potentials (SLSEP) and transcranial Doppler (TCD) techniques to diagnose brain death. METHODS One hundred and eleven patients (69 males, 42 females) from the major hospitals of Zhejiang Province were examined with portable EEG, SLSEP and TCD devices. Re-examinations occurred < or =12 h later. RESULTS The first examination revealed that the combination of SLSEP and EEG led to more sensitive diagnoses than the combination of SLSEP and TCD. Re-examination confirmed this and also revealed that the combination of TCD and EEG was the most sensitive. CONCLUSION The results show that using multiple techniques to diagnose brain death is superior to using single method, and that the combination of SLSEP and EEG is better than other combinations.
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Affiliation(s)
- Kang Wang
- Department of Neurology, the First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou 310003, China
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