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Lewis A. An Update on Brain Death/Death by Neurologic Criteria since the World Brain Death Project. Semin Neurol 2024; 44:236-262. [PMID: 38621707 DOI: 10.1055/s-0044-1786020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
The World Brain Death Project (WBDP) is a 2020 international consensus statement that provides historical background and recommendations on brain death/death by neurologic criteria (BD/DNC) determination. It addresses 13 topics including: (1) worldwide variance in BD/DNC, (2) the science of BD/DNC, (3) the concept of BD/DNC, (4) minimum clinical criteria for BD/DNC determination, (5) beyond minimum clinical BD/DNC determination, (6) pediatric and neonatal BD/DNC determination, (7) BD/DNC determination in patients on ECMO, (8) BD/DNC determination after treatment with targeted temperature management, (9) BD/DNC documentation, (10) qualification for and education on BD/DNC determination, (11) somatic support after BD/DNC for organ donation and other special circumstances, (12) religion and BD/DNC: managing requests to forego a BD/DNC evaluation or continue somatic support after BD/DNC, and (13) BD/DNC and the law. This review summarizes the WBDP content on each of these topics and highlights relevant work published from 2020 to 2023, including both the 192 citing publications and other publications on BD/DNC. Finally, it reviews questions for future research related to BD/DNC and emphasizes the need for national efforts to ensure the minimum standards for BD/DNC determination described in the WBDP are included in national BD/DNC guidelines and due consideration is given to the recommendations about social and legal aspects of BD/DNC determination.
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Affiliation(s)
- Ariane Lewis
- Division of Neurocritical Care, Department of Neurology and Neurosurgery, NYU Langone Medical Center, New York
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Gambardella I, Nappi F, Worku B, Tranbaugh RF, Ibrahim AM, Balaram SK, Bernat JL. Taking the pulse of brain death: A meta-analysis of the natural history of brain death with somatic support. Eur J Neurol 2024; 31:e16243. [PMID: 38375732 DOI: 10.1111/ene.16243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 10/02/2023] [Accepted: 01/30/2024] [Indexed: 02/21/2024]
Abstract
BACKGROUND AND PURPOSE The conceptualization of brain death (BD) was pivotal in the shaping of judicial and medical practices. Nonetheless, media reports of alleged recovery from BD reinforced the criticism that this construct is a self-fulfilling prophecy (by treatment withdrawal or organ donation). We meta-analyzed the natural history of BD when somatic support (SS) is maintained. METHODS Publications on BD were eligible if the following were reported: aggregated data on its natural history with SS; and patient-level data that allowed censoring at the time of treatment withdrawal or organ donation. Endpoints were as follows: rate of somatic expiration after BD with SS; BD misdiagnosis, including "functionally brain-dead" patients (FBD; i.e. after the pronouncement of brain-death, ≥1 findings were incongruent with guidelines for its diagnosis, albeit the lethal prognosis was not altered); and length and predictors of somatic survival. RESULTS Forty-seven articles were selected (1610 patients, years: 1969-2021). In BD patients with SS, median age was 32.9 years (range = newborn-85 years). Somatic expiration followed BD in 99.9% (95% confidence interval = 89.8-100). Mean somatic survival was 8.0 days (range = 1.6 h-19.5 years). Only age at BD diagnosis was an independent predictor of somatic survival length (coefficient = -11.8, SE = 4, p < 0.01). Nine BD misdiagnoses were detected; eight were FBD, and one newborn fully recovered. No patient ever recovered from chronic BD (≥1 week somatic survival). CONCLUSIONS BD diagnosis is reliable. Diagnostic criteria should be fine-tuned to avoid the small incidence of misdiagnosis, which nonetheless does not alter the prognosis of FBD patients. Age at BD diagnosis is inversely proportional to somatic survival.
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Affiliation(s)
| | - Francesco Nappi
- Cardiac Surgery Center, Cardiologique du Nord de Saint-Denis, Paris, France
| | - Berhane Worku
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Robert F Tranbaugh
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - Aminat M Ibrahim
- Department of Biomedical Engineering, Cornell University, Ithaca, New York, USA
| | - Sandhya K Balaram
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, New York, USA
| | - James L Bernat
- Department of Neurology, Dartmouth Geisel School of Medicine, Hanover, New York, USA
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Deana C, Biasucci DG, Aspide R, Brasil S, Vergano M, Leonardis F, Rica E, Cammarota G, Dauri M, Vetrugno G, Longhini F, Maggiore SM, Rasulo F, Vetrugno L. Transcranial Doppler and Color-Coded Doppler Use for Brain Death Determination in Adult Patients: A Pictorial Essay. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:979-992. [PMID: 38279568 DOI: 10.1002/jum.16421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 01/02/2024] [Accepted: 01/15/2024] [Indexed: 01/28/2024]
Abstract
Transcranial Doppler (TCD) is a repeatable, at-the-bedside, helpful tool for confirming cerebral circulatory arrest (CCA). Despite its variable accuracy, TCD is increasingly used during brain death determination, and it is considered among the optional ancillary tests in several countries. Among its limitations, the need for skilled operators with appropriate knowledge of typical CCA patterns and the lack of adequate acoustic bone windows for intracranial arteries assessment are critical. The purpose of this review is to describe how to evaluate cerebral circulatory arrest in the intensive care unit with TCD and transcranial duplex color-coded doppler (TCCD).
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Affiliation(s)
- Cristian Deana
- Department of Anesthesia and Intensive Care, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Daniele G Biasucci
- Department of Clinical Science and Translational Medicine, "Tor Vergata" University, Rome, Italy
- Emergency Department, "Tor Vergata" University Hospital, Rome, Italy
- Catholic University of the Sacred Heart (UCSC), Rome, Italy
| | - Raffaele Aspide
- Anesthesia and Neurointensive Care Unit, Istituto delle Scienze Neurologiche IRCCS, Bologna, Italy
| | - Sergio Brasil
- Neurosurgical Division, Department of Neurology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Marco Vergano
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Torino, Italy
| | - Francesca Leonardis
- Emergency Department, "Tor Vergata" University Hospital, Rome, Italy
- Department of Surgical Science, "Tor Vergata" University, Rome, Italy
| | - Ermal Rica
- Department of Anesthesia and Intensive Care, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Gianmaria Cammarota
- Department of Anesthesiology and Intensive Care, Azienda Ospedaliero-Universitaria "Maggiore della Carità", Novara, Italy
- Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Novara, Italy
| | - Mario Dauri
- Department of Clinical Science and Translational Medicine, "Tor Vergata" University, Rome, Italy
- Emergency Department, "Tor Vergata" University Hospital, Rome, Italy
| | - Giuseppe Vetrugno
- Catholic University of the Sacred Heart (UCSC), Rome, Italy
- Risk Management, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Federico Longhini
- Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Salvatore Maurizio Maggiore
- Department of Innovative Technologies in Medicine & Dentistry, Section of Anesthesia and Intensive Care, "G. D'Annunzio" University, "SS. Annunziata" Hospital, Chieti, Italy
- Department of Anesthesiology, Critical Care Medicine and Emergency, "SS. Annunziata" Hospital, Chieti, Italy
| | - Frank Rasulo
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Luigi Vetrugno
- Department of Anesthesiology, Critical Care Medicine and Emergency, "SS. Annunziata" Hospital, Chieti, Italy
- Department of Medical, Oral and Biotechnological Science, "G. d'Annunzio" Chieti-Pescara University, Chieti, Italy
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Arslan K, Sahin AS. Evaluation of patients diagnosed with brain death in the intensive care unit: 10 years of tertiary center experience in Istanbul. North Clin Istanb 2024; 11:127-132. [PMID: 38757109 PMCID: PMC11095337 DOI: 10.14744/nci.2023.06937] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 07/15/2023] [Indexed: 05/18/2024] Open
Abstract
OBJECTIVE Early and accurate diagnosis of brain death in intensive care units (ICU) is essential for organ transplantation. This study aimed to evaluate the cases diagnosed with brain death in the ICU of a tertiary center in Istanbul. METHODS The cases diagnosed as brain death in the ICU during the ten years between January 2013 and September 2022 were evaluated retrospectively. The demographic characteristics of the patients, the diagnosis of hospitalization in the ICU, the time from arrival to the ICU until the diagnosis of brain death, the somatic survival time after the diagnosis of brain death, the acceptance rate of organ donation by the families and the organs removed were evaluated. RESULTS A total of 44 patients were diagnosed with brain death. The mean age of the cases was 39.7±17.4 years, and 63% were male. The most common hospitalization diagnosis was intracranial hemorrhage (81.8%). Traffic accidents, hypertensive and aneurysm-related hemorrhages, gunshot wounds, and falls from height were the most common causes of intracranial hemorrhage. Patients were admitted to the ICU most frequently from the emergency department (54%). The mean time to brain death was 7.9±6.2 days, and the somatic survival time was 1.9±1.9 days in patients who did not receive organ transplantation. While the apnea test was positive in 91% of the cases, the apnea test could not be completed in 9% of the cases. While relatives of 7% (n=3) of the cases accepted organ donation, a patient was not allowed to be an organ donor for medical reasons. Organ transplantation was performed in two patients (5%). CONCLUSION As in the whole world, getting treatment as soon as possible for the patients waiting on the organ transplant list in Turkiye by increasing the number of organs to be obtained from cadavers. In cases with suspected brain death in the ICU, diagnosing brain death as soon as possible and conducting family interviews with trained organ transplant coordinators will increase the number of cadaver donors. However, we think policies should be developed to ensure that society is informed and encouraged about brain death and organ donation.
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Affiliation(s)
- Kadir Arslan
- Department of Anesthesiology and Reanimation, University of Health Sciences, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkiye
| | - Ayca Sultan Sahin
- Department of Anesthesiology and Reanimation, University of Health Sciences, Kanuni Sultan Suleyman Training and Research Hospital, Istanbul, Turkiye
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Parent B, Gelb B, Latham S, Lewis A, Kimberly LL, Caplan AL. The ethics of testing and research of manufactured organs on brain-dead/recently deceased subjects. JOURNAL OF MEDICAL ETHICS 2020; 46:199-204. [PMID: 31563872 DOI: 10.1136/medethics-2019-105674] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 09/06/2019] [Accepted: 09/17/2019] [Indexed: 06/10/2023]
Abstract
Over 115 000 people are waiting for life-saving organ transplants, of whom a small fraction will receive transplants and many others will die while waiting. Existing efforts to expand the number of available organs, including increasing the number of registered donors and procuring organs in uncontrolled environments, are crucial but unlikely to address the shortage in the near future and will not improve donor/recipient compatibility or organ quality. If successful, organ bioengineering can solve the shortage and improve functional outcomes. Studying manufactured organs in animal models has produced valuable data, but is not sufficient to understand viability in humans. Before risking manufactured organ experimentation in living humans, study of bioengineered organs in recently deceased humans would facilitate evaluation of the function of engineered tissues and the complex interactions between the host and the transplanted tissue. Although such studies do not pose risk to human subjects, they pose unique ethical challenges concerning the previous wishes of the deceased, rights of surviving family members, effective operation and fair distribution of medical services, and public transparency. This article investigates the ethical, legal and social considerations in performing engineered organ research on the recently deceased.
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Affiliation(s)
- Brendan Parent
- Division of Medical Ethics, New York University School of Medicine, New York City, New York, USA
| | - Bruce Gelb
- Transplant Institute, New York University School of Medicine, New York City, New York, USA
| | - Stephen Latham
- Interdisciplinary Center for Bioethics, Yale University, New Haven, Connecticut, USA
| | - Ariane Lewis
- Division of Medical Ethics, New York University School of Medicine, New York City, New York, USA
| | - Laura L Kimberly
- Division of Medical Ethics, New York University School of Medicine, New York City, New York, USA
- Hansjörg Wyss Department of Plastic Surgery, NYU School of Medicine, New York City, New York, USA
| | - Arthur L Caplan
- Division of Medical Ethics, New York University School of Medicine, New York City, New York, USA
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Gabbay E, Fins JJ. Go in Peace: Brain Death, Reasonable Accommodation and Jewish Mourning Rituals. JOURNAL OF RELIGION AND HEALTH 2019; 58:1672-1686. [PMID: 31280412 DOI: 10.1007/s10943-019-00874-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Religious objections to brain death are common among Orthodox Jews. These objections often lead to conflicts between families of patients who are diagnosed with brain death, and physicians and hospitals. Israel, New York and New Jersey (among other jurisdictions) include accommodation clauses in their regulations or laws regarding the determination of death by brain-death criteria. The purpose of these clauses is to allow families an opportunity to oppose or even veto (in the case of Israel and New Jersey) determinations of brain death. In New York, the extent and duration of this accommodation period are generally left to the discretion of individual institutions. Jewish tradition has embraced cultural and psychological mechanisms to help families cope with death and loss through a structured process that includes quick separation from the physical body of the dead and a gradual transition through phases of mourning (Aninut,Kriah, timely burial, Shiva, Shloshim, first year of mourning). This process is meant to help achieve closure, acceptance, support for the bereaved, commemoration, faith in the afterlife and affirmation of life for the survivors. We argue that the open-ended period of contention of brain death under the reasonable accommodation laws may undermine the deep psychological wisdom that informs the Jewish tradition. By promoting dispute and conflict, the process of inevitable separation and acceptance is delayed and the comforting rituals of mourning are deferred at the expense of the bereft family. Solutions to this problem may include separating discussions of organ donation from those concerning the diagnosis of brain death per se, allowing a period of no escalation of life-sustaining interventions rather than unilateral withdrawal of mechanical ventilation, engagement of rabbinical leaders in individual cases and policy formulations that prioritize emotional support for families.
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Affiliation(s)
- Ezra Gabbay
- Hospital Medicine Section, Division of General Internal Medicine, Department of Medicine, Weill-Cornell Medicine, 525 East 68th Street, Box 331, New York, NY, 10065, USA.
| | - Joseph J Fins
- Division of Medical Ethics, Department of Medicine, Weill-Cornell Medicine, New York, NY, USA
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Özmert S, Sever F, Ayar G, Yazıcı MU, Öztaş DK. Brain Death and Organ Donation in Paediatric Intensive Care Unit. Turk J Anaesthesiol Reanim 2019; 47:55-61. [PMID: 31276112 DOI: 10.5152/tjar.2019.43726] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2018] [Accepted: 10/16/2018] [Indexed: 11/22/2022] Open
Abstract
Objective The purpose of the present study was to retrospectively analyse the brain death (BD) cases that were specified within the last 8 years in the paediatric intensive care unit of our hospital. Methods Archive files and computer records of 23 paediatric cases were analysed. Data on age, gender, conditions that caused BD, paediatric risk of mortality (PRISM III) scores, time between suspicion of BD and issuing of BD report, confirmatory tests used, complications that occurred following the diagnosis of BD and time to cardiac arrest development after diagnosis of BD were recorded. Results The average age of the patients was 6.8±5.5 years. The most frequent cause of BD was intracranial haemorrhage (30.4%). The mean time to diagnosis after BD suspicion was 5.9±6.2 days. Electroencephalography was performed in 61% of the patients in addition to the apnoea test. Radiological imaging methods were used in 39% of the patients (n=9). Of the cases, 34.7% developed hypothermia, and 4.3% developed diabetes insipidus (DI). Among them, 43.4% had both DI and hypothermia. The mean PRISM score was calculated as 22±9.2. The donation rate of the families was 17%. The mean time to cardiac arrest development after diagnosis of BD was 6.9±7.4 days in non-donor cases where medical support had been reduced. Conclusion Any patient with a neurologically poor prognosis in the intensive care unit should be considered to develop BD and diagnosed with BD without delay. The donation rate will increase if family interviews are done by an experienced and educated coordinator.
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Affiliation(s)
- Sengül Özmert
- Department of Anaesthesiolgy and Reanimation, University of Health Sciences Ankara Child Health and Diseases Haematology Oncology Training and Research Hospital, Ankara, Turkey
| | - Feyza Sever
- Department of Anaesthesiolgy and Reanimation, University of Health Sciences Ankara Child Health and Diseases Haematology Oncology Training and Research Hospital, Ankara, Turkey
| | - Ganime Ayar
- Department of Paediatric Intensive Care Unit, University of Health Sciences Ankara Child Health and Diseases Haematology Oncology Training and Research Hospital, Ankara, Turkey
| | - Mutlu Uysal Yazıcı
- Department of Paediatric Intensive Care Unit, Hacettepe University İhsan Dogramacı Children's Hospital, Ankara, Turkey
| | - Dilek Kahraman Öztaş
- Department of Public Health, Yıldırım Beyazıt University School of Medicine, Ankara Atatürk Training and Research Hospital, Ankara, Turkey
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Nakamura MT, Rodio GE, Tchaicka C, Padilha EF, Jorge AC, Duarte PAD. Predictors of Organ Donation Among Patients With Brain Death in the Intensive Care Unit. Transplant Proc 2018; 50:1220-1226. [PMID: 29731163 DOI: 10.1016/j.transproceed.2018.02.069] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Revised: 02/19/2018] [Accepted: 02/20/2018] [Indexed: 10/17/2022]
Abstract
INTRODUCTION Despite the improved care of potential organ donors with probable brain death (BD) in the intensive care unit (ICU), few epidemiologic and clinical data are available in developing countries. OBJECTIVES To evaluate ICU patients with suspected BD aiming to identify factors possibly related to success (organ donation) or failure (nondonation). METHODS Retrospective cohort study, from the patient records of an adult ICU of a Brazilian teaching hospital for 12 months. Data were tabulated, and descriptive statistics and univariate and multivariate analyses were performed. RESULTS During the study period, 85 patients with acute neurologic diseases and suspected BD were admitted to the ICU and included for analysis. Of these, there were 9 organ donors (7 liver and 9 kidney donors); 77.7% were men, with a mean age of 39.6 years and admission Acute Physiology and Chronic Health Evaluation II of 25.5. Two-thirds of the patients were victims of trauma. The mean time between acute neurologic event and organ withdrawal was 269 hours. The main prognostic factors related to the success of organ donation were the maximum serum lactate and creatinine levels during ICU admission. CONCLUSIONS The main clinical factors correlated with nonevolution for organ donation among ICU patients with clinical suspicion of BD were related to patient severity and organic dysfunction: serum lactate and creatinine level. Clinical care and monitoring are emphasized to improve the efficiency of the donation process.
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Affiliation(s)
- M T Nakamura
- Hospital Universitário do Oeste do Paraná, Cascavel, Brazil
| | - G E Rodio
- Hospital Universitário do Oeste do Paraná, Cascavel, Brazil
| | - C Tchaicka
- General ICU, Hospital Universitário do Oeste do Paraná, Cascavel, Brazil.
| | - E F Padilha
- Transplantation and Organ Donation Committee, Hospital Universitário do Oeste do Paraná, Cascavel/PR, Brazil
| | - A C Jorge
- General ICU, Hospital Universitário do Oeste do Paraná, Cascavel, Brazil
| | - P A D Duarte
- General ICU, Hospital Universitário do Oeste do Paraná, Cascavel, Brazil
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Early declaration of death by neurologic criteria results in greater organ donor potential. J Surg Res 2017; 218:29-34. [PMID: 28985863 DOI: 10.1016/j.jss.2017.05.032] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Revised: 03/20/2017] [Accepted: 05/05/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND Aggressive management of patients prior to and after determination of death by neurologic criteria (DNC) is necessary to optimize organ recovery, transplantation, and increase the number of organs transplanted per donor (OTPD). The effects of time management are understudied but potentially pivotal component. The objective of this study was to analyze specific time points (time to DNC, time to procurement) and the time intervals between them to better characterize the optimal timeline of organ donation. METHODS Using data over a 5-year time period (2011-2015) from the largest US OPO, all patients with catastrophic brain injury and donated transplantable organs were retrospectively reviewed. Active smokers were excluded. Maximum donor potential was seven organs (heart, lungs [2], kidneys [2], liver, and pancreas). Time from admission to declaration of DNC and donation was calculated. Mean time points stratified by specific organ procurement rates and overall OTPD were compared using unpaired t-test. RESULTS Of 1719 Declaration of Death by Neurologic Criteria organ donors, 381 were secondary to head trauma. Smokers and organs recovered but not transplanted were excluded leaving 297 patients. Males comprised 78.8%, the mean age was 36.0 (±16.8) years, and 87.6% were treated at a trauma center. Higher donor potential (>4 OTPD) was associated with shorter average times from admission to brain death; 66.6 versus 82.2 hours, P = 0.04. Lung donors were also associated with shorter average times from admission to brain death; 61.6 versus 83.6 hours, P = 0.004. The time interval from DNC to donation varied minimally among groups and did not affect donation rates. CONCLUSIONS A shorter time interval between admission and declaration of DNC was associated with increased OTPD, especially lungs. Further research to identify what role timing plays in the management of the potential organ donor and how that relates to donor management goals is needed.
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