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Koh S, Park S, Lee M, Kim H, Lee WJ, Lee JM, Choi JY. Assessing the Brain Death/Death by Neurologic Criteria Determination Process in Korea: Insights from 10-Year Noncompleted Donation Data. Neurocrit Care 2024:10.1007/s12028-024-02072-5. [PMID: 39117963 DOI: 10.1007/s12028-024-02072-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 07/09/2024] [Indexed: 08/10/2024]
Abstract
BACKGROUND This study aimed to analyze the current status of brain death/death by neurologic criteria (BD/DNC) determination in Korea over a decade, identifying key areas for improvement in the process. METHODS We conducted a retrospective analysis of data from the Korea Organ Donation Agency spanning 2011 to 2021, focusing on donors whose donations were not completed. The study reviewed demographics, medical settings, diagnoses, and outcomes, with particular emphasis on cases classified as nonbrain death and those resulting in death by cardiac arrest during the BD/DNC assessment. RESULTS Of the 5047 patients evaluated for potential brain death from 2011 to 2021, 361 were identified as noncompleted donors. The primary reasons for noncompletion included nonbrain death (n = 68, 18.8%), cardiac arrests during the BD/DNC assessment process (n = 80, 22.2%), organ ineligibility (n = 151, 41.8%), and logistical and legal challenges (n = 62, 17.2%). Notably, 25 (36.8%) of them failed to meet the minimum clinical criteria, and 7 of them were potential cases of disagreement between the two clinical examinations. Additionally, most cardiac arrests (n = 44, 55.0%) occurred between the first and second examinations, indicating management challenges in critically ill patients during the assessment period. CONCLUSIONS Our study highlights significant challenges in the BD/DNC determination process, including the need for improved consistency in neurologic examinations and the management of critically ill patients. The study underscores the importance of refining protocols and training to enhance the accuracy and reliability of brain death assessments, while also ensuring streamlined and effective organ donation practices.
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Affiliation(s)
- Seungyon Koh
- Department of Brain Science, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon, Gyeonggi-do, Korea
- Department of Neurology, Ajou University School of Medicine, Suwon, Korea
| | - Sungju Park
- Department of Nephrology, Ajou University School of Medicine, Suwon, Korea
| | - Mijin Lee
- Department of Humanities and Social Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Hanki Kim
- Department of Brain Science, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon, Gyeonggi-do, Korea
| | - Won Jung Lee
- Organ Transplantation Center, Ajou University Hospital, Suwon, Korea
| | - Jae-Myeong Lee
- Division of Acute Care Surgery, Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jun Young Choi
- Department of Brain Science, Ajou University School of Medicine, 164, World cup-ro, Yeongtong-gu, Suwon, Gyeonggi-do, Korea.
- Department of Neurology, Ajou University School of Medicine, Suwon, Korea.
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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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Greer DM, Lewis A, Kirschen MP. New developments in guidelines for brain death/death by neurological criteria. Nat Rev Neurol 2024; 20:151-161. [PMID: 38307923 DOI: 10.1038/s41582-024-00929-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/10/2024] [Indexed: 02/04/2024]
Abstract
The declaration of brain death (BD), or death by neurological criteria (DNC), is medically and legally accepted throughout much of the world. However, inconsistencies in national and international policies have prompted efforts to harmonize practice and central concepts, both between and within countries. The World Brain Death Project was published in 2020, followed by notable revisions to the Canadian and US guidelines in 2023. The mission of these initiatives was to ensure accurate and conservative determination of BD/DNC, as false-positive determinations could have major negative implications for the medical field and the public's trust in our ability to accurately declare death. In this Review, we review the changes that were introduced in the 2023 US BD/DNC guidelines and consider how these guidelines compare with those formulated in Canada and elsewhere in the world. We address controversies in BD/DNC determination, including neuroendocrine function, consent and accommodation of objections, summarize the legal status of BD/DNC internationally and discuss areas for further BD/DNC research.
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Affiliation(s)
- David M Greer
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA.
- Boston Medical Center, Department of Neurology, Boston, MA, USA.
| | - Ariane Lewis
- NYU Langone Medical Center, Departments of Neurology and Neurosurgery, New York, NY, USA
| | - Matthew P Kirschen
- The Children's Hospital of Philadelphia, Department of Anaesthesiology and Critical Care Medicine, Philadelphia, PA, USA
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Sahin M, Altinay M, Cinar AS, Yavuz H. Retrospective Analysis of Patients Diagnosed with Brain Death in Our Hospital in the Last 15 Years. SISLI ETFAL HASTANESI TIP BULTENI 2023; 57:526-530. [PMID: 38268659 PMCID: PMC10805059 DOI: 10.14744/semb.2023.65928] [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: 05/25/2023] [Accepted: 08/18/2023] [Indexed: 01/26/2024]
Abstract
Objectives Retrospective analysis of cases diagnosed with brain death in our hospital in the last 15 years. Methods The files and computer records of the cases diagnosed with brain death in the intensive care units of our hospital between January 2008 and January 2023 were evaluated retrospectively. The demographic data of the cases, the primary disease leading to brain death, the complementary tests used in the diagnosis of brain death, the day on which brain death was diagnosed in the intensive care unit, and the donor status were examined. Results A total of 228 cases diagnosed as brain death were detected. Seven patients with missing data were excluded from the study. 61.99% of the cases were male, 38.01% were female, 14.02% were under 18 years old, 68.34% were between 18 and 65 years old, 17.64% were over 65 years old. Brain death was diagnosed in 69.69% of the patients admitted to the intensive care unit in the first 7 days, 22.17% in 7-14 days, and 8.14% after 14 days. The primary disease causing brain death was found to be 47% hemorrhagic cerebral injury, 21% traumatic hemorrhagic injury, 18% ischemic cerebral injury, and 14% hypoxic cerebral injury. No ancillary testing was used in 38% of the cases. Carotid doppler ultrasound was used in 36%, computed tomography angiography was used in 22%, and transcranialdoppler was used in 4%. Families agreed to be organ transplant donors in 28.95% of the cases. 71.05% family members refused to be organ transplant donors. Conclusion The number of organ donations and the diagnosis of brain death has decreased rapidly with the covid-19 pandemic. In order to increase organ donation, we think that the necessary education should be given at an early age to increase organ donation awareness and social awareness.
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Affiliation(s)
- Murat Sahin
- Department of Anaesthesia and Intensive Care, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Mustafa Altinay
- Department of Anaesthesia and Intensive Care, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Ayse Surhan Cinar
- Department of Anaesthesia and Intensive Care, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
| | - Hanife Yavuz
- Department of Organ and Tissue Transplantation, University of Health Sciences Türkiye, Sisli Hamidiye Etfal Training and Research Hospital, Istanbul, Türkiye
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Moguillansky N, Mathelier M, Tuna IS. Brain Dead and Pregnant. Cureus 2023; 15:e44172. [PMID: 37753021 PMCID: PMC10519615 DOI: 10.7759/cureus.44172] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2023] [Indexed: 09/28/2023] Open
Abstract
The presence of pregnancy in a brain-dead woman is a rare circumstance. We present a case of a 31-year-old woman who was 22 weeks pregnant at the time of diagnosis of brain death after intracranial and subarachnoid hemorrhage. After a multidisciplinary approach, the decision was made to continue somatic support to maintain the pregnancy until optimal fetus viability. Cesarean section was performed after 11 weeks (33 weeks gestational age) of brain-death diagnosis with a successful delivery of a live infant. Management of brain-death complications during pregnancy is described.
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Affiliation(s)
- Natalia Moguillansky
- Department of Medicine, Division of Pulmonary Critical Care and Sleep Medicine, University of Florida Health, Gainesville, USA
| | - Michael Mathelier
- Department of Emergency Medicine, University of Florida College of Medicine, Gainesville, USA
| | - Ibrahim S Tuna
- Department of Radiology, University of Florida College of Medicine, Gainesville, USA
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Abstract
PURPOSE OF REVIEW Brain death, also known as death by neurologic criteria (DNC), is a well-established concept. In this article, we present a short history of the concept and give an overview of recent changes and a practical update on diagnosis and definitions of brain death/DNC. Unresolved issues will be discussed. RECENT FINDINGS There is variability in brain death/DNC determination worldwide. In recent years, successful attempts have been made to harmonize these criteria and, consequently, to improve public trust in the process and diagnosis. An international multidisciplinary collaboration has been created and it has published minimum criteria, provided guidance for professionals and encouragement to revise or develop guidelines on brain death/DNC worldwide. SUMMARY There are two sets of criteria for declaration of death. First, if there is neither cardiac output nor respiratory effort, then cardiopulmonary criteria are used. Second, if both the cerebrum and brainstem have completely and permanently lost all functions, and there is a persistent coma, absent brainstem reflexes and no spontaneous respiratory effort, death can be declared on the basis of brain death/DNC. Although attempts to formulate uniform criteria are ongoing, consensus has been reached on the minimum criteria. Some inconsistencies and questions remain.
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Minimum Criteria for Brain Death Determination: Consensus Promotion and Chinese Practice. Neurocrit Care 2022; 37:479-486. [PMID: 35538297 DOI: 10.1007/s12028-022-01508-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 04/04/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Brain death (BD), the irreversible cessation of function in the whole brain, is a well-known condition in most countries. The criteria and practical guidelines for brain death determination (BDD) in China were issued by the Brain Injury Evaluation Quality Control Center (BQCC) of the National Health and Family Planning Commission in 2013. Thereafter, we proposed a plan called the three-step quality control plan (three-step QCP) to ensure the safety and consistency of the clinical judgments regarding BD. By retrospectively reviewing this plan, we aimed to identify problems during its implementation and to provide suggestions for future work on quality control for BDD. METHODS Data were retrieved from the BQCC database. The characteristics and test results of physicians undergoing a BDD training course and the BD case records submitted by hospitals before and after receiving accreditation were analyzed. RESULTS In the first step of the plan, the error rate for physicians undergoing the BDD paper test was highest for limb movement discrimination (26.29%); this error rate was correlated with age (per 10-year increase) (odds ratio = 1.262, 95% confidence interval 1.067-1.491, P = 0.007) but was nonsignificantly associated with sex, specialty category, professional level, and hospital level (P > 0.05). During the second step of the plan, the highest percentage of problems was associated with apnea testing (22.75%), followed by ancillary testing of BDD (16.17%). In the last step, the highest percentage of problems in the case records was associated with apnea testing (41.73%). CONCLUSIONS The three-step QCP is of significant utility for ensuring accuracy and appropriateness in BDD. Simultaneously, this study provides important evidence for advancing quality control for BDD in the next stage.
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Lewis A, Kumpfbeck A, Liebman J, Shemie SD, Sung G, Torrance S, Greer D. Barriers to the Use of Neurologic Criteria to Declare Death in Africa. Am J Hosp Palliat Care 2021; 39:243-249. [PMID: 33783232 DOI: 10.1177/10499091211006921] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
There are varying medical, legal, social, religious and philosophical perspectives about the distinction between life and death. Death can be declared using cardiopulmonary or neurologic criteria throughout much of the world. After solicitation of brain death/death by neurologic criteria (BD/DNC) protocols from contacts around the world, we found that the percentage of countries with BD/DNC protocols is much lower in Africa than other developing regions. We performed an informal review of the literature to identify barriers to declaration of BD/DNC in Africa. We found that there are numerous medical, legal, social and religious barriers to the creation of BD/DNC protocols in Africa including 1) limited number of healthcare facilities, critical care resources and clinicians with relevant expertise; 2) absence of a political and legal framework codifying death; and 3) cultural and religious perspectives that present ideological conflict with the idea of BD/DNC, in particular, and between traditional and Western medicine, in general. Because there are a number of unique barriers to the creation of BD/DNC protocols in Africa, it remains to be seen how the World Brain Death Project, which is intended to create minimum standards for BD/DNC around the world, will impact BD/DNC determination in Africa.
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Affiliation(s)
| | | | | | - Sam D Shemie
- Montreal Children's Hospital, McGill University, Montreal, Canada.,Canadian Blood Services, Ottawa, Canada
| | - Gene Sung
- LAC and USC Medical Center, Los Angeles, CA, USA
| | | | - David Greer
- Boston University School of Medicine, Boston, MA, USA
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