Determination of Brain Death/Death by Neurologic Criteria: The World Brain Death Project

IMPORTANCE

There are inconsistencies in concept, criteria, practice, and documentation of brain death/death by neurologic criteria (BD/DNC) both internationally and within countries.

OBJECTIVE

To formulate a consensus statement of recommendations on determination of BD/DNC based on review of the literature and expert opinion of a large multidisciplinary, international panel.

PROCESS

Relevant international professional societies were recruited to develop recommendations regarding determination of BD/DNC. Literature searches of the Cochrane, Embase, and MEDLINE databases included January 1, 1992, through April 2020 identified pertinent articles for review. Because of the lack of high-quality data from randomized clinical trials or large observational studies, recommendations were formulated based on consensus of contributors and medical societies that represented relevant disciplines, including critical care, neurology, and neurosurgery.

EVIDENCE SYNTHESIS

Based on review of the literature and consensus from a large multidisciplinary, international panel, minimum clinical criteria needed to determine BD/DNC in various circumstances were developed.

RECOMMENDATIONS

Prior to evaluating a patient for BD/DNC, the patient should have an established neurologic diagnosis that can lead to the complete and irreversible loss of all brain function, and conditions that may confound the clinical examination and diseases that may mimic BD/DNC should be excluded. Determination of BD/DNC can be done with a clinical examination that demonstrates coma, brainstem areflexia, and apnea. This is seen when (1) there is no evidence of arousal or awareness to maximal external stimulation, including noxious visual, auditory, and tactile stimulation; (2) pupils are fixed in a midsize or dilated position and are nonreactive to light; (3) corneal, oculocephalic, and oculovestibular reflexes are absent; (4) there is no facial movement to noxious stimulation; (5) the gag reflex is absent to bilateral posterior pharyngeal stimulation; (6) the cough reflex is absent to deep tracheal suctioning; (7) there is no brain-mediated motor response to noxious stimulation of the limbs; and (8) spontaneous respirations are not observed when apnea test targets reach pH <7.30 and Paco2 ≥60 mm Hg. If the clinical examination cannot be completed, ancillary testing may be considered with blood flow studies or electrophysiologic testing. Special consideration is needed for children, for persons receiving extracorporeal membrane oxygenation, and for those receiving therapeutic hypothermia, as well as for factors such as religious, societal, and cultural perspectives; legal requirements; and resource availability.

CONCLUSIONS AND RELEVANCE

This report provides recommendations for the minimum clinical standards for determination of brain death/death by neurologic criteria in adults and children with clear guidance for various clinical circumstances. The recommendations have widespread international society endorsement and can serve to guide professional societies and countries in the revision or development of protocols and procedures for determination of brain death/death by neurologic criteria, leading to greater consistency within and between countries.

Prevalence of bullying, discrimination and sexual harassment among trainees and Fellows of the College of Intensive Care Medicine of Australia and New Zealand

BACKGROUND

Anecdotal reports about bullying behaviour in intensive care emerged during College of Intensive Care Medicine (CICM) hospital accreditation visits. Bullying, discrimination and sexual harassment (BDSH) in the medical profession, particularly in surgery, were widely reported in the media recently. This prompted the College to formally survey its Fellows and trainees to identify the prevalence of these behaviours in the intensive care workplace.

METHODS

An online survey of all trainees (n = 951) and Fellows (n = 970) of the CICM.

RESULTS

The survey response rate was 51% (Fellows, 60%; trainees, 41%). The overall prevalences of bullying, discrimination and sexual harassment were 32%, 12% and 3%, respectively. The proportions of Fellows and trainees who reported being bullied and discriminated against were similar across all age groups. Women reported a greater prevalence of sexual harassment (odds ratio [OR], 2.97 [95% CI, 1.35-6.51]; P = 0.006) and discrimination (OR, 2.10 [95% CI, 1.39-3.17]; P = 0.0004) than men. Respondents who obtained their primary medical qualification in Asia or Africa appeared to have been at increased risk of discrimination (OR, 1.88 [95% CI, 1.15-3.05]; P = 0.03). Respondents who obtained their degree in Australia, New Zealand or Hong Kong may have been at increased risk of being bullied. In all three domains of unprofessional behaviour, the perpetrators were predominantly consultants (70% overall), and the highest proportion of these was ICU consultants.

CONCLUSIONS

The occurrence of BDSH appears to be common in the intensive care environment in Australia and New Zealand.

Ventilation strategies in paediatric inhalation injury

Inhalation injury increases morbidity and mortality in burns victims. While the diagnosis remains largely clinical, bronchoscopy is also helpful to diagnose and grade the severity of any injury. Inhalation injury results from direct thermal injury or chemical irritation of the respiratory tract, systemic toxicity from inhaled substances, or a combination of these factors. While endotracheal intubation is essential in cases where upper airway obstruction may occur, it has its own risks and should not be performed prophylactically in all cases of inhalation injury. The evidence-base informing the selection of optimal ventilation strategy in inhalation injury is sparse, and most recommendations are based on extrapolation from (largely adult) studies in acute respiratory distress syndrome (ARDS). Conventional ventilation using a lung-protective approach (i.e. low tidal volume, limited plateau pressure, and permissive hypercarbia) is recommended as the initial approach if invasive ventilation is required; various rescue strategies may become necessary if there is a poor response. The efficacy of many widely used pharmacologic adjuncts in inhalation injury remains uncertain. Further research is urgently required to address these gaps in our knowledge.

Magnesium should be given to all children presenting to hospital with acute severe asthma

Asthma is one of the most prevalent chronic condition affecting children worldwide and acute exacerbations requiring emergency medical management are common. In addition to corticosteroids, a number of drugs may be used in the management of acute severe asthma aiming to reverse bronchoconstriction. Magnesium sulphate - either inhaled or intravenous - may be added to conventional therapy of children with acute severe asthma. Despite its safety profile and effectiveness, the use of magnesium sulphate has been inconsistent due to lack of consensus. The authors believe that the accumulating evidence of a favorable 'cost benefit' profile justifies the use of magnesium for all children presenting with acute severe asthma.

Hypoplastic left heart syndrome in context

Hypoplastic left heart syndrome is a rare condition requiring major cardiac surgery during the neonatal period to sustain life, with subsequent procedures culminating in completion of the Fontan circulation - the common pathway for all 'single ventricle' conditions. Algorithms for care of these children are now well defined with predictable medium-term outcomes with the majority achieving a Fontan circulation. Hypoplastic left heart syndrome is one of a group of conditions that require complex surgery as a neonate and require a similar perioperative approach. Antenatal diagnosis is common in this patient subgroup, and there is a significant body of work that can be drawn on to inform parental choice.

Withdrawal and limitation of life-sustaining treatments in a paediatric intensive care unit and review of the literature

OBJECTIVES

To examine withdrawal and limitation of life-sustaining treatment (WLST) in an Australian paediatric intensive care unit (PICU) and to compare this experience with published data from other countries.

DESIGN

Retrospective chart review and literature review.

SOURCE OF DATA

Review of 12 months of patient records from a tertiary Australian children's teaching hospital. Medline search using relevant key words focusing on death and PICU.

RESULTS

Twenty of 27 deaths (74%) followed either WLST (n = 16) or Do Not Resuscitate (DNR) orders (n = 4); five children failed cardiopulmonary resuscitation (CPR); and two children were brain-dead. Meetings between the medical team and family were documented for 15 of 16 children (93.8%) before treatment was withdrawn. The average time between withdrawal of life support and death was 13 min. A review of the English-language literature revealed that 18-65% occurring in PICUs worldwide follow WLST and/or institution of DNR orders. Rates were higher (30-65%) in North America and Europe than elsewhere. Most PICU deaths occurred within 3 days of admission. North American and British parents appear to be involved in decisions regarding withdrawal and limitation of treatment more often than parents in other countries.

CONCLUSIONS

Withdrawal and limitation of life-sustaining treatment was more common in an Australian children's hospital ICU than has been reported from other countries. Details of discussion with parents, including the basis for any decision to WLST, were almost always documented in the patient's medical record.

Spinal muscular atrophy type 1: is long-term mechanical ventilation ethical?

We present a baby with spinal muscular atrophy type 1, an inherited disorder causing progressive weakness, leading to complete paralysis of respiratory, facial and limb muscles. Without intervention, death occurs in infancy due to respiratory failure. Mechanical ventilatory support can prolong life, but the child's quality of life is highly debatable. We discuss the appropriateness of initiating and continuing intensive care for this child and others in a similar position.

Levosimendan for low cardiac output: a pediatric experience

This was a retrospective observational study in a pediatric intensive care unit, in which 19 patients received levosimendan. There were no adverse events attributable to levosimendan and no instances where the clinical condition worsened after administration. Arterial lactate levels decreased significantly following levosimendan administration during cardiopulmonary bypass for anticipated low cardiac output. In those with established low cardiac output, trends toward improved hemodynamics were seen, with heart rate reduction, an increase in mean blood pressure, a reduction in arterial lactate, and reduced conventional inotrope use. Levosimendan was safely used in a small number of pediatric patients with established low cardiac output state who demonstrated improved hemodynamics and tissue perfusion, with a tendency to reduced conventional inotrope usage, and this warrants its evaluation as an inotrope in the pediatric population.

The mortality index for neonatal transportation score: a new mortality prediction model for retrieved neonates

OBJECTIVE

To develop a mortality prediction score for retrieved neonates based on the information given at the first telephone contact with a retrieval service.

METHODS

Data from the New South Wales Newborn and Pediatric Emergency Transport Service database were examined. Analysis was performed with the results for 2504 infants (median gestational age: 36 weeks; range: 24-43 weeks) who were <72 hours of age at the time of referral and whose outcome (neonatal death or survival) was known. The study population was divided randomly into 2 halves, the derivation and validation cohorts. Univariate analysis was performed to identify variables in the derivation cohort related to neonatal death. The variables were entered into a multivariate logistic regression analysis with neonatal death as the outcome. Receiver operator characteristic (ROC) curves were constructed with the regression model and data from the derivation cohort and then the validation cohort. The results were used to generate an integer-based score, the Mortality Index for Neonatal Transportation (MINT) score. ROC curves were constructed to assess the ability of the MINT score to predict perinatal and neonatal death.

RESULTS

A 7-variable (Apgar score at 1 minute, birth weight, presence of a congenital anomaly, and infant's age, pH, arterial partial pressure of oxygen, and heart rate at the time of the call) model was constructed that generated areas under ROC curves of 0.82 and 0.83 for the derivation and validation cohorts, respectively. The 7 variables were then used to generate the MINT score, which gave areas under ROC curves of 0.80 for both neonatal and perinatal death.

CONCLUSION

Data collected at the first telephone contact by the referring hospital with a regionalized transport service can identify neonates at the greatest risk of dying.

An illness severity score and neonatal mortality in retrieved neonates

The Clinical Risk Index for Babies (CRIB) score is a simple tool to measure clinical risk and illness severity in very low birth weight infants. The aim of this study was to determine if a modified CRIB score (MCRIB) used at first telephone contact with a transport service differentiated between retrieved infants who did or did not die in the neonatal period and hence might be a useful triage tool. A retrospective cohort study of 2504 infants, median gestational age 36 weeks and birth weight 2782 g, transported by the New South Wales Newborn and Paediatric Emergency Transport Service (NETS) was performed. MCRIB was calculated at four time points during the retrieval process. The MCRIB score at the time of the first call and the change in the MCRIB score over the retrieval process were related to outcome (neonatal death or survival). The mean MCRIB score at the time of first call was higher in those infants who died during the neonatal period (4.37) than in those who survived (2.63), (P < 0.0001). MCRIB performed better (area under the receiver operator characteristic curves of 0.72) with regard to predicting mortality than gestational age (0.56) or birth weight (0.52). The mean MCRIB score fell progressively from the time of first call to admission at the accepting NICU (P < 0.0001); infants whose MCRIB score increased were more likely to die (P < 0.0001).

CONCLUSION

these results suggest an illness severity score, applied at the time of first call to a transport service would be helpful in setting priorities for retrievals.