A systematic review of autoresuscitation after cardiac arrest*:

Ethical Issues in Uncontrolled Donation After Circulatory Determination of Death: A Scoping Review to Reveal Areas of Broad Consensus, and Those for Future Research

Uncontrolled donation after circulatory determination of death (uDCD) protocols are established in several countries with good outcomes. We reviewed the literature between 1997 and 2024 to identify ethical issues. 33 papers were identified. Several areas of continued ethical debate were delineated: the role of advanced life support techniques; the ethical acceptability of aortic occlusion balloons; the nature and timing of consent to organ preserving techniques; whether best interests can/should extend beyond individual bodily integrity in this context. Further empirical research and ethical analyses are needed in these domains. Broad consensus was identified on several issues including: decisions about termination of resuscitation and entry into a uDCD protocol should be made by different teams; at least 20-30 min of cardio-pulmonary resuscitation is required; a hands-off period of 5-7 min is required alongside continuous monitoring; organ preserving techniques should be as minimally invasive as possible; families should be approached early to discuss organ donation by trained staff; public knowledge and engagement about uDCD is poor and must be improved; transparency and informed consent are essential for potential uDCD organ recipients. To maintain transparency and encourage positive public engagement we propose a name change from uDCD to Organ Donation after Sudden Irreversible Cardiac Arrest (ODASICA).

Review article: Back to life from being declared dead in the Resus Bay: An integrative review of the phenomenon of autoresuscitation and learning for ED

This is a literature review of ED autoresuscitation. The impetus for this review was a case which revealed a lack of understanding about Lazarus syndrome among ED staff. The primary objective was to see the proportion of cases who survived neurologically intact to discharge and the time frame when this occurred after death had been declared. A secondary outcome was to see whether these studies mention whether bedside echo was performed prior to deciding whether to terminate resuscitation. A systematic search of five databases was undertaken with keywords, 'autoresuscitation', 'cardiac arrest' and 'emergency department'. Articles published in the English language were selected for inclusion. No time frame was selected because of the low number of articles. A total of 240 articles were identified, that yielded 26 cases that were relevant and could be synthesised to create a discussion on the current clinical guidelines around resuscitation. Our analysis demonstrates that of the 11 survivors who were discharged neurologically intact, the average age was 42.9 years; otherwise, the average was 62.6 years. The majority (23/26) 88% auto-resuscitated within 10 min after being pronounced dead. Only five patients are mentioned as having had a bedside echo prior to deciding to cease efforts. Under-reporting of autoresuscitation is suspected because of fears of blame. Passive monitoring for 10 min after resuscitation is ceased, is recommended. There is need for more data on this phenomenon to help inform further research on the topic.

Donation After Circulatory Death Heart Transplantation: A Narrative Review

Heart transplantation is the definitive treatment for refractory, end-stage heart failure. The number of patients awaiting transplantation far exceeds available organs. In an effort to expand the donor pool, donation after circulatory death (DCD) heart transplantation has garnered renewed interest. Unlike donation after brain death, DCD donors do not meet the criteria for brain death and are dependent on life-sustaining therapies. Procurement can include a direct strategy or a normothermic regional perfusion, whereby there is restoration of perfusion to the organ before explantation. There are new developments in cold storage and ex vivo perfusion strategies. Since its inception, there has been a steady improvement in post-transplant outcomes, largely attributed to advancements in operative and procurement strategies. In this narrative review, the authors address the unique considerations of DCD heart transplantation, including withdrawal of care, the logistics of procuring and resuscitating organs, outcomes compared with standard donation after brain death, and ethical considerations.

Ethical and Equity Guidance for Transplant Programs Considering Thoracoabdominal Normothermic Regional Perfusion (TA-NRP) for Procurement of Hearts

Donation after circulatory determination of death (DCDD) is an accepted practice in the United States, but heart procurement under these circumstances has been debated. Although the practice is experiencing a resurgence due to the recently completed trials using ex vivo perfusion systems, interest in thoracoabdominal normothermic regional perfusion (TA-NRP), wherein the organs are reanimated in situ prior to procurement, has raised many ethical questions. We outline practical, ethical, and equity considerations to ensure transplant programs make well-informed decisions about TA-NRP. We present a multidisciplinary analysis of the relevant ethical issues arising from DCDD-NRP heart procurement, including application of the Dead Donor Rule and the Uniform Definition of Death Act, and provide recommendations to facilitate ethical analysis and input from all interested parties. We also recommend informed consent, as distinct from typical "authorization," for cadaveric organ donation using TA-NRP.

Do we need standardized management after termination-of-resuscitation attempts? Autoresuscitation in a 67-year-old woman

BACKGROUND

Autoresuscitation is the phenomenon of spontaneous return of circulation after cessation of CPR, also known as the Lazarus phenomenon. Most of the evidence is based on case reports and a few systematic reviews. The occurrence of autoresuscitation may lead to self-reproach and dismay in affected emergency personnel and may rise questions about the correct procedure after terminating resuscitative efforts. In contrast to existing cardiac arrest guidelines there is no standardized approach to terminating resuscitative attempts.

CASE

We report a case of out of hospital autoresuscitation in a 67-year-old female after 60 min of advanced cardiac life support. After shock refractory shockable rhythm, we recorded pulseless electrical activity and fixed pupils, consequently resuscitation was terminated. About 50 min later the patient surprisingly showed signs of life. Due to the suggestive history a coronary angiography was performed, showing severe coronary heart disease which necessitated surgical intervention. After ACBP surgery and intensive care followed by treatment on the cardiological ward, she was finally discharged to neurological rehabilitation.

CONCLUSION

As already proposed by existing literature, there should be at least a 10-min interval of close monitoring after abandoning CPR. Transport of a deceased patient should only take place after secure signs of death can be detected. Further investigation is needed to determine which patients are most likely to benefit from an extended observation period. Our case reports highlights the difficulties in death declaration and the importance of close monitoring after abandoning CPR.

From flatline to lifeline: A scoping review of the Lazarus phenomenon

BACKGROUND

The Lazarus phenomenon or autoresuscitation (autoROSC) is the return of spontaneous circulation (ROSC) after the termination of the cardiopulmonary resuscitation (CPR) efforts.

PURPOSE

The purpose of the current scoping review is to present the available data in the literature regarding autoROSC.

METHODS

We reviewed four scientific databases to identify all studies which reported autoROSC cases in patients who underwent CPR. We then extracted all information relevant to CPR and autoROSC. The review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews.

RESULTS

We identified 66 studies describing 76 autoROSC cases. The majority of cardiac arrests were in-hospital (44, 57.89%). Median time from termination of CPR to autoROSC was 5 min. Regarding the outcome, 52 (77.61%) patients died and 11 (14.47%) patients had intact neurological outcome. A higher mortality rate was identified in patients with respiratory comorbidities. Overall, 24 (31.58%) patients survived.

CONCLUSION

AutoROSC is probably an under-reported event in the medical community. Healthcare professionals should be aware of the phenomenon and actively monitor for it, when appropriate.

Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation

AIM OF THE REVIEW

Improving rates of organ donation among patients with out-of-hospital cardiac arrest who do not survive is an opportunity to save countless lives. The objectives of this scientific statement were to do the following: define the opportunity for organ donation among patients with out-of-hospital cardiac arrest; identify challenges and opportunities associated with organ donation by patients with cardiac arrest; identify strategies, including a generic protocol for organ donation after cardiac arrest, to increase the rate and consistency of organ donation from this population; and provide rationale for including organ donation as a key clinical outcome for all future cardiac arrest clinical trials and registries.

METHODS

The scope of this International Liaison Committee on Resuscitation scientific statement was approved by the International Liaison Committee on Resuscitation board and the American Heart Association, posted on ILCOR.org for public comment, and then assigned by section to primary and secondary authors. A unique literature search was completed and updated for each section.

RESULTS

There are a number of defining pathways for patients with out-of-hospital cardiac arrest to become organ donors; however, modifications in the Maastricht classification system need to be made to correctly identify these donors and to report outcomes with consistency. Suggested modifications to the minimum data set for reporting cardiac arrests will increase reporting of organ donation as an important resuscitation outcome. There are a number of challenges with implementing uncontrolled donation after cardiac death protocols, and the greatest impediment is the lack of legislation in most countries to mandate organ donation as the default option. Extracorporeal cardiopulmonary resuscitation has the potential to increase organ donation rates, but more research is needed to derive neuroprognostication rules to guide clinical decision-making about when to stop extracorporeal cardiopulmonary resuscitation and to evaluate cost-effectiveness.

CONCLUSIONS

All health systems should develop, implement, and evaluate protocols designed to optimize organ donation opportunities for patients who have an out-of-hospital cardiac arrest and failed attempts at resuscitation.

Organ Donation After Out-of-Hospital Cardiac Arrest: A Scientific Statement From the International Liaison Committee on Resuscitation

AIM OF THE REVIEW

Improving rates of organ donation among patients with out-of-hospital cardiac arrest who do not survive is an opportunity to save countless lives. The objectives of this scientific statement were to do the following: define the opportunity for organ donation among patients with out-of-hospital cardiac arrest; identify challenges and opportunities associated with organ donation by patients with cardiac arrest; identify strategies, including a generic protocol for organ donation after cardiac arrest, to increase the rate and consistency of organ donation from this population; and provide rationale for including organ donation as a key clinical outcome for all future cardiac arrest clinical trials and registries.

METHODS

The scope of this International Liaison Committee on Resuscitation scientific statement was approved by the International Liaison Committee on Resuscitation board and the American Heart Association, posted on ILCOR.org for public comment, and then assigned by section to primary and secondary authors. A unique literature search was completed and updated for each section.

RESULTS

There are a number of defining pathways for patients with out-of-hospital cardiac arrest to become organ donors; however, modifications in the Maastricht classification system need to be made to correctly identify these donors and to report outcomes with consistency. Suggested modifications to the minimum data set for reporting cardiac arrests will increase reporting of organ donation as an important resuscitation outcome. There are a number of challenges with implementing uncontrolled donation after cardiac death protocols, and the greatest impediment is the lack of legislation in most countries to mandate organ donation as the default option. Extracorporeal cardiopulmonary resuscitation has the potential to increase organ donation rates, but more research is needed to derive neuroprognostication rules to guide clinical decision-making about when to stop extracorporeal cardiopulmonary resuscitation and to evaluate cost-effectiveness.

CONCLUSIONS

All health systems should develop, implement, and evaluate protocols designed to optimise organ donation opportunities for patients who have an out-of-hospital cardiac arrest and failed attempts at resuscitation.

Lazarus Phenomenon or the Return from the Afterlife-What We Know about Auto Resuscitation

Autoresuscitation is a phenomenon of the heart during which it can resume its spontaneous activity and generate circulation. It was described for the first time by K. Linko in 1982 as a recovery after discontinued cardiopulmonary resuscitation (CPR). J.G. Bray named the recovery from death the Lazarus phenomenon in 1993. It is based on a biblical story of Jesus' resurrection of Lazarus four days after confirmation of his death. Up to the end of 2022, 76 cases (coming from 27 countries) of spontaneous recovery after death were reported; among them, 10 occurred in children. The youngest patient was 9 months old, and the oldest was 97 years old. The longest resuscitation lasted 90 min, but the shortest was 6 min. Cardiac arrest occurred in and out of the hospital. The majority of the patients suffered from many diseases. In most cases of the Lazarus phenomenon, the observed rhythms at cardiac arrest were non-shockable (Asystole, PEA). Survival time after death ranged from minutes to hours, days, and even months. Six patients with the Lazarus phenomenon reached full recovery without neurological impairment. Some of the causes leading to autoresuscitation presented here are hyperventilation and alkalosis, auto-PEEP, delayed drug action, hypothermia, intoxication, metabolic disorders (hyperkalemia), and unobserved minimal vital signs. To avoid Lazarus Syndrome, it is recommended that the patient be monitored for 10 min after discontinuing CPR. Knowledge about this phenomenon should be disseminated in the medical community in order to improve the reporting of such cases. The probability of autoresuscitation among older people is possible.

Autoresuscitation after circulatory arrest: an updated systematic review

PURPOSE

Current practice in organ donation after death determination by circulatory criteria (DCD) advises a five-minute observation period following circulatory arrest, monitoring for unassisted resumption of spontaneous circulation (i.e., autoresuscitation). In light of newer data, the objective of this updated systematic review was to determine whether a five-minute observation time was still adequate for death determination by circulatory criteria.

SOURCE

We searched four electronic databases from inception to 28 August 2021, for studies evaluating or describing autoresuscitation events after circulatory arrest. Citation screening and data abstraction were conducted independently and in duplicate. We assessed certainty in evidence using the GRADE framework.

PRINCIPAL FINDINGS

Eighteen new studies on autoresuscitation were identified, consisting of 14 case reports and four observational studies. Most studies evaluated adults (n = 15, 83%) and patients with unsuccessful resuscitation following cardiac arrest (n = 11, 61%). Overall, autoresuscitation was reported to occur between one and 20 min after circulatory arrest. Among all eligible studies identified by our reviews (n = 73), seven observational studies were identified. In observational studies of controlled withdrawal of life-sustaining measures with or without DCD (n = 6), 19 autoresuscitation events were reported in 1,049 patients (incidence 1.8%; 95% confidence interval, 1.1 to 2.8). All resumptions occurred within five minutes of circulatory arrest and all patients with autoresuscitation died.

CONCLUSION

A five-minute observation time is sufficient for controlled DCD (moderate certainty). An observation time greater than five minutes may be needed for uncontrolled DCD (low certainty). The findings of this systematic review will be incorporated into a Canadian guideline on death determination.

STUDY REGISTRATION

PROSPERO (CRD42021257827); registered 9 July 2021.

Practice and challenges for organ donation after medical assistance in dying: A scoping review including the results of the first international roundtable in 2021

The procedure combining medical assistance in dying (MAiD) with donations after circulatory determination of death (DCDD) is known as organ donation after euthanasia (ODE). The first international roundtable on ODE was held during the 2021 WONCA family medicine conference as part of a scoping review. It aimed to document practice and related issues to advise patients, professionals, and policymakers, aiding the development of responsible guidelines and helping to navigate the issues. This was achieved through literature searches and national and international stakeholder meetings. Up to 2021, ODE was performed 286 times in Canada, the Netherlands, Spain, and Belgium, including eight cases of ODE from home (ODEH). MAiD was provided 17,217 times (2020) in the eight countries where ODE is permitted. As of 2021, 837 patients (up to 14% of recipients of DCDD donors) had received organs from ODE. ODE raises some important ethical concerns involving patient autonomy, the link between the request for MAiD and the request to donate organs and the increased burden placed on seriously ill MAiD patients.

Ethical Issues Related to Donation and Transplantation of Donation After Circulatory Determination of Death Donors

With the continuing disparity between organ supply to match the increasing demand for kidney transplants in patients with renal failure, donation after the circulatory determination of death (DCDD) has become an important and increasing global source of kidneys for clinical use. The concern that the outcomes of controlled DCDD donor kidney transplants were inferior to those obtained from donors declared dead by neurologic criteria has largely diminished because large-scale registry and single-center reports consistently have reported favorable outcomes. For uncontrolled DCDD kidney transplants, outcomes are correspondingly acceptable, although there is a greater risk of primary nonfunction. The potential of DCDD remains unrealized in many countries because of the ethical concerns and resource implications in the utilization of these donor kidneys for transplantation. In this review, we discuss the origin and definitions of DCDD donors, and examine the long-term outcomes of transplants from DCDD donor kidneys. We discuss the controversies, challenges, and ethical and legal barriers in the acceptance of DCDD, including the complexities of implementing and sustaining controlled and uncontrolled DCDD donor programs. The lessons learned from global leaders will assist a wider international recognition, acceptance, and development of DCDD transplant programs that will noticeably facilitate and address the global shortages of kidneys for transplantation, and ensure the opportunity for people who had indicated their desires to become organ donors fulfill their final wishes.

A Disclosure About Death Disclosure: Variability in Circulatory Death Determination

Introduction

Circulatory-respiratory death declaration is a common duty of physicians, but little is known about the amount of education and physician practice patterns in completing this examination.

Methods

An online survey of physicians was conducted evaluating the rate of formal training and specific examination techniques used in the pronouncement of circulatory-respiratory death. Data, including the level of practice, training received in a formal death declaration, and examination components, were collected.

Results

Respondents were attending physicians (52.4%), residents (30.2%), fellows (10.7%), and interns (6.7%). Most respondents indicated they had received no formal training in death pronouncement; however, most reported self-perceived competence. When comparing examination components used by the study’s cohort, 95 different examination combinations were used for death pronouncement.

Conclusions

Formal training in death pronouncement was uncommon and clinical practice varied. Implementation of formal training and standardization of the examination are necessary to improve physician competence and reliability in death declarations.

Lazarus Phenomenon: Return of Spontaneous Circulation After Cessation of Prolonged Cardiopulmonary Resuscitation in a Patient With COVID-19

The pandemic caused by the SARS-CoV-2 or COVID-19 infection has had an unimaginable impact on health systems worldwide. Cardiorespiratory arrest remains a potentially reversible medical emergency that requires the performance of a set of maneuvers designed to replace and restore spontaneous breathing and circulation. Suspending cardiopulmonary resuscitation (CPR) usually corresponds to an ethical-clinical dilemma that the health professional in charge must assume. The “Lazarus phenomenon” is an unusual syndrome with a difficult pathophysiological explanation, defined as the spontaneous return of circulation in the absence of any life support technique or after the cessation of failed CPR maneuvers.

We present the case of a 79-year-old patient hospitalized in the intensive care unit for septic shock of pulmonary origin associated with COVID-19 infection who presented cardiorespiratory arrest that required unsuccessful resuscitation maneuvers for 40 minutes, declared deceased. After 20 minutes of death, he presented a return to spontaneous circulation.

The pathophysiological changes of the Lazarus phenomenon remind us of the limitations we have in determining when to end cardiopulmonary resuscitation and that its interruption must be approached with more caution, especially in the context of the COVID-19 pandemic.

Pronounced Dead Twice: What Should an Attending Physician Do in Between?

Patient: Female, 39-year-old

Final Diagnosis: Acute Fentanyl toxicity due to a Fentanyl injection in the hospital

Symptoms: Unresponsive

Medication: Fentanyl

Clinical Procedure: Endovascular coiling for the ruptured berry aneurysm

Specialty: Neurosurgery

Autoresuscitation and pheochromocytoma multisystem crisis in a dog

OBJECTIVE

To describe the clinical course of a dog with a pheochromocytoma multisystem crisis that exhibited autoresuscitation after cardiac arrest.

CASE SUMMARY

An approximately 10-year-old male neutered terrier mix dog presented for collapse. Abdominal imaging was suggestive of a pheochromocytoma, and clinical pathology data and thoracic imaging suggested the presence of a multisystem crisis. The dog developed cardiopulmonary arrest that was followed by autoresuscitation.

NEW OR UNIQUE INFORMATION PROVIDED

To the authors' knowledge, this is the first report of autoresuscitation in a dog. The phenomenon may have been associated with a pheochromocytoma multisystem crisis.

South African guidelines on the determination of death

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.

Resumption of Cardiac Activity after Withdrawal of Life-Sustaining Measures

BACKGROUND

The minimum duration of pulselessness required before organ donation after circulatory determination of death has not been well studied.

METHODS

We conducted a prospective observational study of the incidence and timing of resumption of cardiac electrical and pulsatile activity in adults who died after planned withdrawal of life-sustaining measures in 20 intensive care units in three countries. Patients were intended to be monitored for 30 minutes after determination of death. Clinicians at the bedside reported resumption of cardiac activity prospectively. Continuous blood-pressure and electrocardiographic (ECG) waveforms were recorded and reviewed retrospectively to confirm bedside observations and to determine whether there were additional instances of resumption of cardiac activity.

RESULTS

A total of 1999 patients were screened, and 631 were included in the study. Clinically reported resumption of cardiac activity, respiratory movement, or both that was confirmed by waveform analysis occurred in 5 patients (1%). Retrospective analysis of ECG and blood-pressure waveforms from 480 patients identified 67 instances (14%) with resumption of cardiac activity after a period of pulselessness, including the 5 reported by bedside clinicians. The longest duration after pulselessness before resumption of cardiac activity was 4 minutes 20 seconds. The last QRS complex coincided with the last arterial pulse in 19% of the patients.

CONCLUSIONS

After withdrawal of life-sustaining measures, transient resumption of at least one cycle of cardiac activity after pulselessness occurred in 14% of patients according to retrospective analysis of waveforms; only 1% of such resumptions were identified at the bedside. These events occurred within 4 minutes 20 seconds after a period of pulselessness. (Funded by the Canadian Institutes for Health Research and others.).

Controlled Donation After Circulatory Determination of Death: A Scoping Review of Ethical Issues, Key Concepts, and Arguments

Controlled donation after circulatory determination of death (cDCDD) is an important strategy for increasing the pool of eligible organ donors.

Anesthetic Considerations During Heart Transplantation Using Donation After Circulatory Death

Worldwide, the majority of heart transplant organs are from donation after brain death. However, the shortage of suitable donors places severe limitations on this route. One option to increase the donor pool is to use organs from donation after circulatory death (DCD). Transplant centers for solid organs have been using DCD organs for years. At this time, 40% of solid organ transplantation in the United Kingdom uses organs from DCD. Use of DCD for solid organ transplants in Canada is also rising. Recently, there has been interest in using DCD organs for heart transplantation. The authors will discuss their experience of 4 heart transplants with organs from DCD donors after normothermic regional perfusion (NRP). The authors' first heart transplant using a DCD organ was in January 2020, and the fourth was in March 2020, just before the coronavirus disease 2019 (COVID-19) pandemic. The authors' protocol using NRP allows adequate evaluation of the donor heart to confidently determine organ acceptance. The co-location of the donor and the recipient in neighboring operating rooms limits ischemic times. Avoidance of an expensive ex vivo organ perfusion machine is an additional benefit for programs that may not have the resources required to purchase and maintain the machine. Some hospitals may not have the resources and space to be able to co-locate both the donor and recipient. Use of cold storage may be an option to transport the procured organ, similar to donation after brain death organs. The authors hope that this technique of NRP in DCD donors can help further increase the donor pool for heart transplantation in the United States.

Determination of Death in Mountain Rescue: Recommendations of the International Commission for Mountain Emergency Medicine (ICAR MedCom)

Determination of death requires specific knowledge, training, and experience in most cases. It can be particularly difficult when external conditions, such as objective hazards in mountains, prevent close physical examination of an apparently lifeless person, or when examination cannot be accomplished by an authorized person. Guidelines exist, but proper use can be difficult. In addition to the absence of vital signs, definitive signs of death must be present. Recognition of definitive signs of death can be problematic due to the variability in time course and the possibility of mimics. Only clear criteria such as decapitation or detruncation should be used to determine death from a distance or by laypersons who are not medically trained. To present criteria that allow for accurate determination of death in mountain rescue situations, the International Commission for Mountain Emergency Medicine convened a panel of mountain rescue doctors and a forensic pathologist. These recommendations are based on a nonsystematic review of the literature including articles on determination of death and related topics.

When a Dead Patient Is Not Really Dead: Lazarus Phenomenon

Lazarus phenomenon refers to autoresuscitation of a patient declared dead after cessation of cardiopulmonary resuscitation (CPR). The Lazarus phenomenon is rarely encountered and pathophysiology is not very well understood, but physicians need to be aware of this phenomenon. It is prudent that a physician leading a CPR effort waits for some time and monitors the patient further using blood pressure and electrocardiogram before confirming that a patient is actually dead.

Autoresuscitation (Lazarus phenomenon) after termination of cardiopulmonary resuscitation - a scoping review

BACKGROUND

Autoresuscitation describes the return of spontaneous circulation after termination of resuscitation (TOR) following cardiac arrest (CA). We aimed to identify phenomena that may lead to autoresuscitation and to provide guidance to reduce the likelihood of it occurring.

MATERIALS AND METHODS

We conducted a literature search (Google Scholar, MEDLINE, PubMed) and a scoping review according to PRISMA-ScR guidelines of autoresuscitation cases where patients undergoing CPR recovered circulation spontaneously after TOR with the following criteria: 1) CA from any cause; 2) CPR for any length of time; 3) A point was reached when it was felt that the patient had died; 4) Staff declared the patient dead and stood back. No further interventions took place; 5) Later, vital signs were observed. 6) Vital signs were sustained for more than a few seconds, such that staff had to resume active care.

RESULTS

Sixty-five patients with ROSC after TOR were identified in 53 articles (1982-2018), 18 (28%) made a full recovery.

CONCLUSIONS

Almost a third made a full recovery after autoresuscitation. The following reasons for and recommendations to avoid autoresuscitation can be proposed: 1) In asystole with no reversible causes, resuscitation efforts should be continued for at least 20 min; 2) CPR should not be abandoned immediately after unsuccessful defibrillation, as transient asystole can occur after defibrillation; 3) Excessive ventilation during CPR may cause hyperinflation and should be avoided; 4) In refractory CA, resuscitation should not be terminated in the presence of any potentially-treatable cardiac rhythm; 5) After TOR, the casualty should be observed continuously and ECG monitored for at least 10 min.

New physiological insights in ventilation during cardiopulmonary resuscitation

PURPOSE OF REVIEW

In the setting of cardiopulmonary resuscitation (CPR), classical physiological concept about ventilation become challenging. Ventilation may exert detrimental hemodynamic effects that must be balanced with its expected benefits. The risks of hyperventilation have been thoroughly addressed, even questioning the need for ventilation, emphasizing the need to prioritize chest compression quality. However, ventilation is mandatory for adequate gas exchange as soon as CPR is prolonged. Factors affecting the capability of chest compressions to produce alveolar ventilation are poorly understood. In this review, we discuss the conventional interpretation of interactions between ventilation and circulation, from the perspective of novel physiological observations.

RECENT FINDINGS

Many patients with cardiac arrest exhibit 'intrathoracic airway closure.' This phenomenon is associated with lung volume reduction, impedes chest compressions to generate ventilation and overall limits the delivered ventilation. This phenomenon can be reversed by the application of small levels of positive end-expiratory pressure. Also, a novel interpretation of the capnogram can rate the magnitude of this phenomenon, contributing to clarify the physiological meaning of exhaled CO2 and may help assess the real amount of delivered ventilation.

SUMMARY

Recent advances in the understanding of ventilatory physiology during CPR shows that capnogram analysis not only provides information on the quality of resuscitation but also on the amount of ventilation produced by chest compressions and on the total amount of ventilation.

Heart transplantation from donation after circulatory death donors: Present and future

The first successful human heart transplantation was reported on 3 December 1967, by Christiaan Barnard in South Africa. Since then this life-saving procedure has been performed in over 120 000 patients. A limitation to the performance of this procedure is the availability of donor hearts with as many as 20% of patients dying before a donor's heart is available for transplant. Today, hearts for transplantation are procured from individuals experiencing donation after brain death (DBD). Interestingly, this, however, was not always the case as the first heart transplants occurred after circulatory death. Revisiting the availability of hearts for transplant from those experiencing donation after circulatory death (DCD) could further expand the number of hearts suitable for transplantation. There are several considerations pertinent to transplanting hearts from those undergoing circulatory death. In this review, we summarize the main distinctions between DBD and DCD heart donation and discuss the research relevant to increasing the number of hearts available for transplantation by including individual's hearts that experience circulatory death.

Intrathoracic Airway Closure Impacts CO2 Signal and Delivered Ventilation during Cardiopulmonary Resuscitation

RATIONALE

End-tidal CO₂ (EtCO₂) is used to monitor cardiopulmonary resuscitation (CPR), but it can be affected by intrathoracic airway closure. Chest compressions induce oscillations in expired CO₂, and this could reflect variable degrees of airway patency.

OBJECTIVES

To understand the impact of airway closure during CPR, and the relationship between the capnogram shape, airway closure, and delivered ventilation.

METHODS

This study had three parts: 1) a clinical study analyzing capnograms after intubation in patients with out-of-hospital cardiac arrest receiving continuous chest compressions, 2) a bench model, and 3) experiments with human cadavers. For 2 and 3, a constant CO₂ flow was added in the lung to simulate CO₂ production. Capnograms similar to clinical recordings were obtained and different ventilator settings tested. EtCO₂ was compared with alveolar CO₂ (bench). An airway opening index was used to quantify chest compression-induced expired CO₂ oscillations in all three clinical and experimental settings.

MEASUREMENTS AND MAIN RESULTS

A total of 89 patients were analyzed (mean age, 69 ± 15 yr; 23% female; 12% of hospital admission survival): capnograms exhibited various degrees of oscillations, quantified by the opening index. CO₂ value varied considerably across oscillations related to consecutive chest compressions. In bench and cadavers, similar capnograms were reproduced with different degrees of airway closure. Differences in airway patency were associated with huge changes in delivered ventilation. The opening index and delivered ventilation increased with positive end-expiratory pressure, without affecting intrathoracic pressure. Maximal EtCO₂ recorded between ventilator breaths reflected alveolar CO₂ (bench).

CONCLUSIONS

During chest compressions, intrathoracic airway patency greatly affects the delivered ventilation. The expired CO₂ signal can reflect CPR effectiveness but is also dependent on airway patency. The maximal EtCO₂ recorded between consecutive ventilator breaths best reflects alveolar CO₂.

Lazarus phenomenon in trauma

Lazarus phenomenon embodies auto-resuscitation, aka the return of spontaneous circulation following termination of cardiopulmonary resuscitation. Limited or no literature exists that describes auto-resuscitation in trauma. In the current report, we describe a case of an older woman that presented with poly-traumatic injuries following a motor vehicle collision. The aggressive resuscitation efforts failed, and the patient witnessed a pulseless electrical activity; however, nine-minutes after cessation of resuscitation efforts, the patient experienced auto-resuscitation. In addition to the sequel of events following the presentation, the report highlights the management dilemma and ethical implications relating to the observation period for auto-resuscitation in cases of donation after circulatory death, where the urgency to harvest the organs to ensure maximum viability is in direct opposition to ensuring enough time has elapsed to rule out auto-resuscitation. Guidelines on an appropriate period for observation in auto-resuscitation patients queued for organ donation are warranted, keeping in lieu viability of organs following death.

Donation After the Circulatory Determination of Death: Some Responses to Recent Criticisms

This article defends the criterion of permanence as a valid criterion for declaring death against some well-known recent objections. We argue that it is reasonable to adopt the criterion of permanence for declaring death, given how difficult it is to know when the point of irreversibility is actually reached. We claim that this point applies in all contexts, including the donation after circulatory determination of death context. We also examine some of the potentially unpalatable ramifications, for current death declaration practices, of adopting the irreversibility criterion.

Relating Clinical and Electrophysiological Parameters in Death Determination in a Laboratory Model of Progressive Hypoxemia

BACKGROUND

Death after withdrawal of mechanical ventilation frequently follows the sequence of progressive hypoxemia and hypotension leading to cardiac arrest. Accurate timing of the determination of death is fundamental to trust in controlled donation after circulatory death (cDCD) programs and is generally based on cessation of circulation (pulselessness), brain function (apnea), and the passage of time. If death is understood to be the unresuscitatable loss of brain function, the clinical determination that death following apnea and pulselessness has occurred is largely inferential. We sought to elucidate the relationship between the available clinical variables and the loss of brain function and its inability to be resuscitated.

METHODS

We developed a rat model of progressive hypoxia resulting in apnea and circulatory failure. We monitored clinical physiological variables including heart rate, respiration, and arterial pulse pressure. In addition, we simultaneously monitored spontaneous and evoked brain activity within the hippocampus through microelectrode field potential recordings. We also examined neurological function following restoration of pulmonary and circulatory function.

RESULTS

Our data provide evidence that in a model of progressive hypoxemia, loss of spontaneous and evoked brain activity preceded the loss of circulation. Importantly, the data suggest that the loss of brain function, in the presence of restored cardiopulmonary indices, occurred at a time point after apnea but before the loss of detectable arterial pulse pressure.

CONCLUSIONS

These are important data that act as a conceptual reference point when clinicians undertake the inferential activity of identifying the time prior to which a patient has died following progressive hypoxemia and while observing apnea and pulselessness.

Update of a Systematic Review of Autoresuscitation After Cardiac Arrest

OBJECTIVES

There has been a growth in publications focusing on the phenomena of autoresuscitation in recent years. In 2010, we systematically reviewed the medical literature with the primary objective of summarizing the evidence on the timing of autoresuscitation. Healthcare professionals have continued to voice concerns regarding the potential for autoresuscitation. With this in mind, the objective of this brief report is to update the results of our original review of autoresuscitation.

DATA SOURCES

We applied the same search strategy described in our original article to update our findings to include articles published from January 2009 to September 2016.

STUDY SELECTION AND DATA EXTRACTION

We screened an additional 1,859 citations, after duplicates were removed, and then assessed 46 full-text articles for eligibility, from which 15 studies were included for data extraction.

DATA SYNTHESIS

During the time period of this review, there have been 1) 10 additional adult and three pediatric case reports of autoresuscitation in patients after cessation of cardiopulmonary resuscitation; in those cases with continuous monitoring and confirmation of circulation, the longest events are reported to be 10 and 2 minutes, respectively for adults and children; 2) six adults (4%, total n = 162) with autoresuscitation events reported from two observational studies and one chart review of patients undergoing withdrawal of life-sustaining therapy; the longest time reported to be 89 seconds with electrocardiogram and invasive arterial blood pressure monitoring and 3 minutes with electrocardiogram monitoring only; 3) 12 pediatric patients studied with vital sign monitoring during withdrawal of life-sustaining therapy without any reports of autoresuscitation.

CONCLUSIONS

Although case reports of autoresuscitation are hampered by variability in observation and monitoring techniques, autoresuscitation has now been reported in adults and children, and there appears to be a distinction in timing between failed cardiopulmonary resuscitation and withdrawal of life-sustaining therapy. Although additional prospective studies are required to clarify the frequency and predisposing factors associated with this phenomenon, clinical decision-making regarding patient management under uncertainty is required nonetheless. Both adult and pediatric healthcare professionals should be aware of the possibility of autoresuscitation and monitor their patients accordingly before diagnosing death.

When are you dead enough to be a donor? Can any feasible protocol for the determination of death on circulatory criteria respect the dead donor rule?

The basic question concerning the compatibility of donation after circulatory death (DCD) protocols with the dead donor rule is whether such protocols can guarantee that the loss of relevant biological functions is truly irreversible. Which functions are the relevant ones? I argue that the answer to this question can be derived neither from a proper understanding of the meaning of the term "death" nor from a proper understanding of the nature of death as a biological phenomenon. The concept of death can be made fully determinate only by stipulation. I propose to focus on the irreversible loss of the capacity for consciousness and the capacity for spontaneous breathing. Having accepted that proposal, the meaning of "irreversibility" need not be twisted in order to claim that DCD protocols can guarantee that the loss of these functions is irreversible. And this guarantee does not mean that reversing that loss is either conceptually impossible or known to be impossible with absolute certainty.

Circulatory Arrest, Brain Arrest and Death Determination

Technological advances, particularly in the capacity to support, replace or transplant failing organs, continue to challenge and refine our understanding of human death. Given the ability to reanimate organs before and after death, both inside and outside of the body, through reinstitution of oxygenated circulation, concepts related to death of organs (e.g. cardiac death) are no longer valid. This paper advances the rationale for a single conceptual determination of death related to permanent brain arrest, resulting from primary brain injury or secondary to circulatory arrest. The clinical characteristics of brain arrest are the permanent loss of capacity for consciousness and loss of all brainstem functions. In the setting of circulatory arrest, death occurs after the arrest of circulation to the brain rather than death of the heart. Correspondingly, any intervention that resumes oxygenated circulation to the brain after circulatory arrest would invalidate the determination of death.

Canadian Guidelines for Controlled Pediatric Donation After Circulatory Determination of Death-Summary Report

OBJECTIVES

Create trustworthy, rigorous, national clinical practice guidelines for the practice of pediatric donation after circulatory determination of death in Canada.

METHODS

We followed a process of clinical practice guideline development based on World Health Organization and Canadian Medical Association methods. This included application of Grading of Recommendations Assessment, Development, and Evaluation methodology. Questions requiring recommendations were generated based on 1) 2006 Canadian donation after circulatory determination of death guidelines (not pediatric specific), 2) a multidisciplinary symposium of national and international pediatric donation after circulatory determination of death leaders, and 3) a scoping review of the pediatric donation after circulatory determination of death literature. Input from these sources drove drafting of actionable questions and Good Practice Statements, as defined by the Grading of Recommendations Assessment, Development, and Evaluation group. We performed additional literature reviews for all actionable questions. Evidence was assessed for quality using Grading of Recommendations Assessment, Development, and Evaluation and then formulated into evidence profiles that informed recommendations through the evidence-to-decision framework. Recommendations were revised through consensus among members of seven topic-specific working groups and finalized during meetings of working group leads and the planning committee. External review was provided by pediatric, critical care, and critical care nursing professional societies and patient partners.

RESULTS

We generated 63 Good Practice Statements and seven Grading of Recommendations Assessment, Development, and Evaluation recommendations covering 1) ethics, consent, and withdrawal of life-sustaining therapy, 2) eligibility, 3) withdrawal of life-sustaining therapy practices, 4) ante and postmortem interventions, 5) death determination, 6) neonatal pediatric donation after circulatory determination of death, 7) cardiac and innovative pediatric donation after circulatory determination of death, and 8) implementation. For brevity, 48 Good Practice Statement and truncated justification are included in this summary report. The remaining recommendations, detailed methodology, full Grading of Recommendations Assessment, Development, and Evaluation tables, and expanded justifications are available in the full text report.

CONCLUSIONS

This process showed that rigorous, transparent clinical practice guideline development is possible in the domain of pediatric deceased donation. Application of these recommendations will increase access to pediatric donation after circulatory determination of death across Canada and may serve as a model for future clinical practice guideline development in deceased donation.

Probucol Protects Rats from Cardiac Dysfunction Induced by Oxidative Stress following Cardiopulmonary Resuscitation

Objective

To investigate the protective effect of probucol on induced cardiac arrest (CA) rats and possible mechanisms.

Methods

Sprague Dawley rats were orally administrated with probucol at different dosage or vehicle for 5 days and subjected to a CA model by electrical stimulation, followed by cardiopulmonary resuscitation (CPR). The return of spontaneous circulation (ROSC) rate, antioxidant enzyme activities, and lipid oxidation markers were measured in serum and myocardium. Hemodynamic parameters and myocardial functions of animals were analyzed. Expression of erythroid-derived 2-like 2 (NFE2L2) and Kelch-like ECH-associated protein 1 (KEAP1) in the myocardium were examined with immunohistochemistry.

Results

Probucol treatment significantly increased the ROSC rate and survival time of CA-induced rats. After ROSC, levels of oxidation-specific markers were decreased, while activities of antioxidant enzymes were increased significantly in probucol treatment groups. The probucol treatment improves hemodynamic parameters and myocardial functions. These parameter changes were in a dose-dependent manner. In the probucol treatment groups, the expression of KEAP1 was downregulated, while that of NFE2L2 was upregulated significantly.

Conclusion

In the CA-induced rat model, probucol dose dependently improved the ROSC rate, prolonged survival time, alleviated oxidative stress, and improved cardiac function. Such protective effects are possibly through regulations of the KEAP1-NFE2L2 system.

In-hospital logistics: what are the key aspects for succeeding in each of the steps of the process of controlled donation after circulatory death?

Donation after circulatory death (DCD) donors are becoming an increasingly important population of organ donors in Europe and worldwide. We report the state of the art regarding controlled DCD donation describing the organizational and technical aspects of establishing a controlled DCD programme and provide recommendations regarding the introduction and development of this type of programme.

The Lazarus phenomenon: spontaneous cardioversion after termination of resuscitation in a Scottish hospital

A 66-year-old man suffered a ventricular fibrillation cardiac arrest after an episode of chest pain. Despite advanced life support, his condition deteriorated; the situation was considered irrecoverable and resuscitation was discontinued. The patient was observed for about 5 min with irregular agonal gasping respirations evident but no palpable pulse. A gradual increase in the regularity of breathing pattern heralded the return of spontaneous circulation. An inferior myocardial infarction was diagnosed. Primary percutaneous coronary intervention was performed. The patient was discharged from hospital after 9 days with no neurological sequelae. There are several possible mechanisms to explain the Lazarus phenomenon including auto-positive end expiratory pressure and delayed drug actions, but cases are rarely reported in the medical literature. After discontinued resuscitation, we suggest consideration should be given to a period of continued monitoring. However, evidence is limited and prospective studies would be welcome to allow firmer recommendations.

Donation after brain circulation determination of death

Background

The fundamental determinant of death in donation after circulatory determination of death is the cessation of brain circulation and function. We therefore propose the term donation after brain circulation determination of death [DBCDD].

Results

In DBCDD, death is determined when the cessation of circulatory function is permanent but before it is irreversible, consistent with medical standards of death determination outside the context of organ donation. Safeguards to prevent error include that: 1] the possibility of auto-resuscitation has elapsed; 2] no brain circulation may resume after the determination of death; 3] complete circulatory cessation is verified; and 4] the cessation of brain function is permanent and complete. Death should be determined by the confirmation of the cessation of systemic circulation; the use of brain death tests is invalid and unnecessary.

Because this concept differs from current standards, consensus should be sought among stakeholders. The patient or surrogate should provide informed consent for organ donation by understanding the basis of the declaration of death.

Conclusion

In cases of circulatory cessation, such as occurs in DBCDD, death can be defined as the permanent cessation of brain functions, determined by the permanent cessation of brain circulation.

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.

Uncontrolled Donation After Circulatory Determination of Death: A Systematic Ethical Analysis

Uncontrolled donation after circulatory determination of death (uDCDD) refers to organ donation after a refractory cardiac arrest. We analyzed ethical issues raised by the uDCDD protocols of France, Madrid, and New York City. We recommend: (1) Termination of resuscitation (TOR) guidelines need refinement, particularly the minimal duration of resuscitation efforts before considering TOR; (2) Before enrolling in an uDCDD protocol, physicians must ascertain that additional resuscitation efforts would be ineffective; (3) Inclusion in an uDCDD protocol should not be made in the outpatient setting to avoid error and conflicts of interest; (4) The patient's condition should be reassessed at the hospital and reversible causes treated; (5) A no-touch period of at least 10 minutes should be respected to avoid the risk of autoresuscitation; (6) Once death has been determined, no procedure that may resume brain circulation should be used, including cardiopulmonary resuscitation, artificial ventilation, and extracorporeal membrane oxygenation; (7) Specific consent is required prior to entry into an uDCDD protocol; (8) Family members should be informed about the goals, risks, and benefits of planned uDCDD procedures; and (9) Public information on uDCDD is desirable because it promotes public trust and confidence in the organ donation system.