Brain Death Protocol Research Articles

Angiotensin-converting enzyme 2 activation attenuates inflammation and oxidative stress in brain death donor followed by rat lung transplantation

Brain death (BD) provides most of the donor organs destined for lung transplantation (LTx). However, the organs may be affected by inflammatory and oxidative processes. Based on this, we hypothesize that the angiotensin-converting enzyme 2 (ACE2) activation can reduce the lung injury associated with LTx. 3 h after BD induction, rats were injected with saline (BD group) or an ACE2 activator (ACE2a group; 15 mg/kg-1) and kept on mechanical ventilation for additional 3 h. A third group included a control ventilation (Control group) prior to transplant. After BD protocol, left LTx were performed, followed by 2 h-reperfusion. ACE2 activation was associated with better oxygenation after BD management (p = 0.01), attenuating edema (p = 0.05) followed by the reduction in tissue resistance (p = 0.01) and increase of respiratory compliance (p = 0.02). Nrf2 expression was also upregulated in the ACE2a group (p = 0.03). After transplantation, ACE2a group showed lower levels of TNF-α (p = 0.02), IL-6 (p = 0.001), IL-1β (p = 0.01), ROS (p = 0.004) and MDA (p = 0.002), in addition to higher CAT activity (p = 0.04). In conclusion, our study suggests that ACE2 activation improves anti-inflammatory and antioxidant activity in a model of LTx.

Solid Organ Donation Process: Correlation between Pro!le, Learning and Course Indication

Objectives: To understand the pro!le of professionals trained in the solid organ donation process, to analyze the result of their learning before and after the course, and to correlate the pro!le and the performance of the professional with the learning and indication of the course. Methods: Retrospective, quantitative, analytical-descriptive study with participants of the course Processo de Doação de Órgãos Sólidos para Pro!ssionais de Saúde. Online questionnaires were used on professional pro!le, performance in the area of organ donation, knowledge assessment, and course indication. "e analyses and correlations were veri!ed with the McNemar test, Spearman's rank, and the bisserial point. Results: Of the 130 professionals, 62% were nurses, 38% physicians, 35% emergency physicians, 26% intensivists, and 42% had more than 10 years of training. For the pro!le of work in the area of organ donation, the professionals report having participated in up to !ve cases in each of the following stages: 44% were involved in the brain death protocol, 56% in the family interview, and 60% in the organ donation process. "e class knowledge retention rate was 26.7%, with 29.5% for physicians and 24.8% for nurses. "e indication of the course was evaluated following the Net Promoter Score (NPS), being in the promoters zone. "e correlation between the groups was positive and statistically signi!cant for those working in the emergency room, with more than 5 years since graduation and with more than !ve cases reported on the questioned stages of organ donation. No signi!cant correlation was identi!ed between these variables and the indication of the course. Conclusion: "e course contributed to the learning of professionals with more training time, greater previous experience in the stages of the organ donation process, and working in the emergency sector.

The Scenario of organ and Tissue Donation for Post-mortem Transplantation in the 16th Health Region/RS

Introduction: The donation and transplantation of organs and tissues is a topic of multiprofessional interest and an important theme regarding the promotion of public health policies regarding the application of this therapy. Objectives: The objective of this article is to present an analysis of the scenario of organ and tissue donation after death, for transplantation, in the 16th Health Region of Rio Grande do Sul between 2010 and 2020, focusing on evaluating family refusals to donate. Methods: A census survey was carried out of the data referring to the brain death protocols carried out in the period, tabulated in Microsoft Excel, analyzed through the construction of time series and related using the chi-square test. Results: The analysis in the region shows a higher proportion of negatives (57.8 %) concerning acceptances (42.2 %) for organ and tissue donation. However, when only the last years of the period are observed, another reality is seen: from 2017 to 2019, the donation statements corresponded to more than 75 % of the interviewed families. In 2020, however, in an atypical way, no brain death protocols were concluded; therefore, no family underwent the interview for donation. Conclusion: There has been a trend toward an increase in donation percentages over the years, both in the 16th Health Region of Rio Grande do Sul and the rest of the country. However, the number of transplants performed is still lower than the population’s need.

Status of Brain Death Diagnosis in Brazil: The Role of Transcranial Doppler Ultrasonography

Transcranial Doppler Ultrasonography (TCDU) comprises an indispensable tool for brain death (BD) protocol closure due to its practicality and low cost. In Brazil, it is used in most organ procurement organization (OPO) centers for this purpose. The evaluation of its importance in the diagnosis of BD in Brazil nowadays constitutes the main scope of this work. Objectives:analysis of the results of TCDU from a series of 100 consecutive patients with clinical diagnosis of BD, with calculation of sensitivity and time intervals for closure of protocols. Evaluation of the variables gender, age, diseases causing death and presence of decompressive cranial surgery in relation to time to death. Methods: evaluation of CT scans, TCDU and medical records of patients on BD protocol with statistical analysis of the sample. Results: 145 TCDU examinations in 100 patients (62% male) were evaluated. Systolic spicules were found in 40.1%, reduced flow velocity in 12.9%, diastolic reversal in 8.3%, no flow in 5.2% and normal flow in 3.5%. Sensitivity ranged from 69% to 90.5% when repeated serially. The mean time to complete the protocols was 35.4 hours (SD=±48.2h), with the majority (59.5%) within 24 hours. There was no statistically significant correlation between gender, age or diagnostic variables, presence of decompressive craniectomy and time to death. Conclusion: most TCDU confirmed the status of BD, but a small percentage (9.5%) did not complete the diagnosis, delaying the protocol in these cases.

Qualitative Evaluation of Intracranial Pressure Slopes in Patients Undergoing Brain Death Protocol

Due to the importance of not mistaking when determining the brain death (BD) diagnostic, reliable confirmatory exams should be performed to enhance its security. This study aims to evaluate the intracranial pressure (ICP) pulse morphology behavior in brain-dead patients through a noninvasive monitoring system. A pilot case-control study was conducted in adults that met the BD national protocol criteria. Quantitative parameters from the ICP waveforms, such as the P2/P1 ratio, time-to-peak (TTP) and pulse amplitude (AMP) were extracted and analyzed comparing BD patients and health subjects. Fifteen patients were included, and 6172 waveforms were analyzed. ICP waveforms presented substantial differences amidst BD patients when compared to the control group, especially AMP, which had lower values in patients diagnosed with BD (p < 0.0001) and the TTP median (p < 0.00001), but no significance was found for the P2/P1 ratio (p = 0.8). The area under curve for combination of parameters on the BD prediction was 0.77. In this exploratory study, noninvasive ICP waveforms have shown potential as a screening method in patients with suspected brain death. Future studies should be carried out in a larger population.

Brain death and organ and tissue donor management in the Intensive Care Unit

Introduction: brain death is defined as the irreversible cessation of all brain and brainstem functions. The timely management and maintenance of these vital functions and correction of the physiopathological alterations of the potential donor make organ donation possible, providing a second chance to patients who depend on a transplant. Aim: to describe the concept of encephalic death in the patient and its current management as a potential organ and tissue donor in the intensive care unit. Methodology: a non-experimental, descriptive, literature review study was carried out.Results: the process of organ and tissue donation after encephalic death is a challenge in terms of diagnosis and subsequent hemodynamic management with the aim of maintaining tissue perfusion so that these have vitality and viability to be transplanted to the recipient patient.Conclusions: it is recommended to use an established brain death protocol and apply it correctly, to avoid legal problems. Once the diagnosis has been made, it is possible to carry out the evaluation to establish whether the patient is a donor candidate or not. The pathophysiological changes that appear in the process of BD make these critical patients to be managed with extreme care. Donor maintenance is a major challenge for all health personnel in the intensive care area, since its treatment is extremely complex and the availability of donors is limited compared to the high demand of recipient patients waiting for an organ

Assessment of physicians' knowledge about brain death and organ donation and associated factors.

Precocity and assertiveness when diagnosing brain death are essential for identifying potential donors. To assess the knowledge of physicians about brain death and organ donation, cross-sectional web-based survey was carried out with physicians from different specialties. The knowledge about brain death and organ donation was assessed by a questionnaire with 12 multiple-choice or multiple-answer questions (possible range from 0 to 12). The nonparametric Mann–Whitney and Kruskal–Wallis tests were performed to verify the association between the physicians’ knowledge and others variables. The project was approved by the Research Ethics Committee of the Hospital das Clínicas, Faculty of Medicine of Ribeirão Preto, University of São Paulo, under number 4.022.657, and all patients agreed to participate and provided free prior-informed consent. Three hundred sixty physicians were included in this study, most of them have postgraduate (55%) and 59.2% were intensive care physicians. The median of responses was 5 (obtained range from 0 to 10). The participants were classified in 2 groups: with satisfactory knowledge (scores above 5) or without satisfactory knowledge (scores equal/below 5). There was better performance among participants who: completed graduation between 6 and 10 years (P < .012); were intensive care physicians (P < .002); had participated in training courses (P < .001); and those who had worked in intensive care unit (ICU) from 6 to 10 years (P < .023); had performed over 10 brain death protocols (P < .001), and felt safe to talk to family members about brain death (P < .001). The results showed that the participants had low knowledge about diagnosis of brain death and organ donation protocols despite the majority working in ICUs. Be an intensive care physician, had large time experience in ICU, and had performed brain death protocols were associated with unsatisfactory knowledge concerning the subject.

MORTE ENCEFÁLICA: VIVÊNCIA DA EQUIPE DE SAÚDE JUNTO AOS PAIS DE CRIANÇAS E ADOLESCENTES

ABSTRACT Objective to understand the health team’s experience with parents of children and adolescents during the brain death protocol stages. Method a qualitative and exploratory research developed in two health institutions of high complexity and reference in the care of children and adolescents with polytrauma. Participants were health professionals from critical patient units. Data collection took place between October and December 2019 through semi-structured interviews. For content analysis, we used the software Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires as support. Results twenty-one professionals (physicians, nurses and nursing technicians) participated in the study. The general corpus consisted of 21 texts, separated into 123 segments, with the emergence of four classes. The study shows feelings of support and compassion at all brain death protocol stages. In the protocol opening stage, the team’s emotions are focused on the actions of clarifying and revealing information in this process, in addition to pointing out the need for the team to detail the step by step of the exams to be performed. In the communication of death stage, the feeling of being, caring for and welcoming the family relates to other feelings experienced by them. Conclusion the study reveals that the health team experiences unique feelings during the brain death protocol in the reality of children and adolescents, revealing the team’s concern with being with the family, paying attention and caring for the pain of loss.

Variability in Pediatric Brain Death Protocols in the United States (1173)

Variability in Pediatric Brain Death Protocols in the United States (1173)

Apnea Test Safety in Brain Death: A Single-Center Retrospective Cohort Analysis

Background: The apnea test, which is considered positive when no spontaneous breathing movements are observed following maximal hypercapnia (PaCO 2 &gt; 55 mm Hg) respiratory center stimulation, was critically evaluated in this study by assessment of blood gas analyses performed during brain death protocols from 2010 to 2017, in the intensive care units of the Universidade Estadual de Campinas (UNICAMP). Methods: A retrospective cohort analysis based on the intensive care unit and Transplant Organ Search Organization data banks. Blood gas analyses before (pre-first and -second apnea tests) as after (after-first and -second apnea tests) were assessed. Descriptive statistical analyses of the numerical variables (such as pH, PaO 2 , PaCO 2 , HCO 3, SatO 2 ) with mean values and standard deviation, medians, and quartiles were performed. The Student’s t -test was used for pairwise group comparisons. A P &lt; 0.05 level was adopted for significance. Results: Eighty-seven protocols were evaluated. The mean apnea test duration was 11 min. All of the patients were under vasoactive drugs. Only five apnea tests were interrupted before the end at 10 min due to rapid desaturation (SatO 2 &lt; 90%), with no invalidated apnea test. Mean and standard deviation of blood gas tests assessed before the first apnea test were: pH 7.35(± 0.10), PaO 2 252.15 mm Hg (± 114.11), PaCO 2 42.78 mm Hg (± 10.84); after the first apnea test: pH 7.11(± 0.08), PaO 2 208.39 mm Hg (± 112), PaCO 2 82.43 mm Hg (± 16.91); before the second test: pH 7.33 (± 0.09), PaO 2 253.56 mm Hg (± 105.36), PaCO 2 43.76 mm Hg (± 9.67); following the second apnea test: pH 7.11 (± 0.10), PaO 2 200.1 mm Hg (± 116.45), PaCO 2 84.98 mm Hg (± 20.21). The pH, PaO 2 , and PaCO 2 values before and after the first and second apnea tests have shown statistically significant differences (P &lt; 0.0001). Conclusions: The apnea test was safe, blood gas test results are similar to those described in the literature, severe hypoxemias were prevented by a quick reconnection to the mechanical ventilation; and marked hypercapnia and acidemia following the apnea test were found, but no test was invalidated. J Neurol Res. 2021;11(1-2):14-19 doi: https://doi.org/10.14740/jnr646

Apnea Test Safety in Brain Death: A Single-Center Retrospective Cohort Analysis

Background: The apnea test, which is considered positive when no spontaneous breathing movements are observed following maximal hypercapnia (PaCO 2 > 55 mm Hg) respiratory center stimulation, was critically evaluated in this study by assessment of blood gas analyses performed during brain death protocols from 2010 to 2017, in the intensive care units of the Universidade Estadual de Campinas (UNICAMP). Methods: A retrospective cohort analysis based on the intensive care unit and Transplant Organ Search Organization data banks. Blood gas analyses before (pre-first and -second apnea tests) as after (after-first and -second apnea tests) were assessed. Descriptive statistical analyses of the numerical variables (such as pH, PaO 2 , PaCO 2 , HCO 3, SatO 2 ) with mean values and standard deviation, medians, and quartiles were performed. The Student’s t -test was used for pairwise group comparisons. A P < 0.05 level was adopted for significance. Results: Eighty-seven protocols were evaluated. The mean apnea test duration was 11 min. All of the patients were under vasoactive drugs. Only five apnea tests were interrupted before the end at 10 min due to rapid desaturation (SatO 2 < 90%), with no invalidated apnea test. Mean and standard deviation of blood gas tests assessed before the first apnea test were: pH 7.35(± 0.10), PaO 2 252.15 mm Hg (± 114.11), PaCO 2 42.78 mm Hg (± 10.84); after the first apnea test: pH 7.11(± 0.08), PaO 2 208.39 mm Hg (± 112), PaCO 2 82.43 mm Hg (± 16.91); before the second test: pH 7.33 (± 0.09), PaO 2 253.56 mm Hg (± 105.36), PaCO 2 43.76 mm Hg (± 9.67); following the second apnea test: pH 7.11 (± 0.10), PaO 2 200.1 mm Hg (± 116.45), PaCO 2 84.98 mm Hg (± 20.21). The pH, PaO 2 , and PaCO 2 values before and after the first and second apnea tests have shown statistically significant differences (P < 0.0001). Conclusions: The apnea test was safe, blood gas test results are similar to those described in the literature, severe hypoxemias were prevented by a quick reconnection to the mechanical ventilation; and marked hypercapnia and acidemia following the apnea test were found, but no test was invalidated. J Neurol Res. 2021;11(1-2):14-19 doi: https://doi.org/10.14740/jnr646

Assessment of Organ Donation Potential From Brain-Dead Donors in Polish Hospitals Using Quality Systems: System Of Donor Hospital Transplant Coordinators and Web-Tooled System of Monitoring Intensive Care Unit Deaths

IntroductionIn 2010 Poltransplant organized a national network of donor hospital transplant coordinators involved in the recruitment of potential deceased organ donors. One of the employed coordinators’ tasks is monitoring donation potential at hospitals and reporting their results with the use of a tele-information tool www.koordynator.net. BackgroundThe aim of our study was to evaluate the organ donation potential at hospitals in 2018 based on the analysis of reports and on the comparison of these results with organ donation indicators elaborated within the European Commission project entitled Improving the Knowledge and Practices in Organ Donation (DOPKI). MethodsReports concerning deaths were applied to a retrospective analysis regarding a possibility to diagnose deaths according to neurologic criteria and to detect possible donations. In total, 1214 reports from 116 hospitals were delivered to the tele-information system during 2018. The analysis was made based on 840 full monthly reports from 70 hospitals. Numbers and indicators connected to the organ donation potential, both in the hospital and the intensive care unit (ICU) scales, have been calculated: numbers of beds and admissions, total number of deaths, deaths due to reasons frequently leading to death according to neurologic criteria, number of brain death diagnoses, and number of organ donations. ResultsIn the scales of hospital and ICU the studied indices showed the following: 1. distinctly lower ratios related to brain death determination in the total number of beds, admissions, deaths, and deaths with selected International Classification of Diseases and Related Health Problems (ICD) codes in comparison with DOPKI results and 2. distinctly higher ratio of donations in the total number of brain deaths confirmed (69%) in comparison with DOPKI (42%). ConclusionsBased on obtained data from respective hospitals, the analysis showed the following in comparison with data coming from international European study (DOPKI): 1. low frequency of brain death determination procedures in the total number of deaths in Polish hospitals and ICUs, probably also in cases where such mechanism of death has occurred (the discrepancy may reach 1974 cases per year) and 2. high percentage of donations in the total number of brain-dead persons (conversion index), which may be caused by successful authorization of donation and acceptance of risky donors and organs by transplant teams but (what is more probable) may be explained by the ICUs’ habit that procedures of brain death protocol is implemented only in cases when donation is expected.

Incidência de protocolos de morte encefálica, captações e fatores que influenciam o processo de doação de órgãos em um Complexo Hospitalar Regional

Objetivo: Apontar fatores que segundo os profissionais de saúde envolvidos no cuidar do potencial doador, podem influenciar no processo de captações de órgãos. Além de apresentar dados de incidência de Protocolos de Morte Encefálica, de captações de órgãos ocorridos nos anos de 2017 e 2018 do Complexo Hospitalar Regional de Cacoal (COHREC). Métodos: Pesquisa transversal, de caráter descritivo, com abordagem quantitativa e qualitativa. O levantamento de dados ocorreu por meio de um questionário aplicado aos profissionais atuantes há mais de seis meses na sala vermelha e nas Unidades de Terapia Intensiva (UTI) do COHREC. Resultados: Foi possível constatar que os principais fatores que os profissionais citaram foram a não observação ou não participação de alguma captação de órgão, a falta de profissionais, a falta de capacitação dos profissionais, a falta de equipamentos e a falta de estrutura. Conclusão: Deve-se buscar a qualificação multiprofissional, não só para diagnóstico e manutenção do potencial doador, mas para desenvolvimento de habilidades relacionadas à comunicação entre os profissionais, a comunicação para com os familiares e proporcionar ao profissional apoio psicológico e condições dignas de trabalho.

Update of the diagnostic criteria of brain death: application and training of physicians.

ObjectiveTo evaluate the medical knowledge regarding the application of the diagnostic criteria for brain death and to correlate it with training parameters for this diagnosis according to Federal Council of Medicine resolution 2,173 of 2017.MethodWe interviewed 174 physicians with experience with comatose patients. A structured questionnaire adapted from previous studies was used. The associations of the variables were tested using the chi-square test for independence. A multivariate logistic model was fitted for associations with p values ≤ 0.20.ResultsAmong the interviewees, 40% had been working for more than 1 year in intensive care, and 23% had initiated ten or more brain death protocols complying with the new resolution. Forty-five percent of the interviewees reported having difficulty following the criteria, 94% acknowledged the need for complementary tests for diagnosis, and 8% of them reported the existence of incorrect tests. The difficulty with these criteria decreased with an increase in the number of years of medical training (OR = 0.487; p = 0.045; 95%CI 0.241 - 0.983) and with a higher number of initiated brain death protocols (OR = 0.223; p = 0.0001; 95%CI 0.117 - 0.424).ConclusionsDifficulties in the application of brain death criteria were identified by a significant portion of the sample. However, among other factors, more years of training and a greater number of initiated brain death protocols were associated with greater ease in the application of brain death criteria according to the guidelines provided in Resolution 2,173 of the Federal Council of Medicine.

Determining Brain Death: Basic Approach and Controversial Issues.

Determining Brain Death: Basic Approach and Controversial Issues.

Planning for Deceased Organ Donation in Ethiopia

Introduction Living donor kidney transplantation began in Ethiopia at Saint Paul’s Hospital Millennium Medical College (SPHMMC) in September 2015. At the request of the Federal Democratic Republic of Ethiopia Ministry of Health, preparations for recovery of organs from deceased donors (DD) began in November 2015. Methods AaBET Hospital (AH), the trauma center associated with SPHMMC, was selected as the site to initiate DD. Collaborations with the University of Michigan (UM), University of Barcelona’s Donation and Transplantation Institute (DTI), and Hospital do Rim (HR) in Sao Paulo, Brazil, were established. Six areas of planning were identified: (1) engaging experienced collaborating institutions to support and train Ethiopian personnel, (2) updating Ethiopia’s brain death (BD) laws, (3) designing a program for professional and public education, (4) establishing BD protocols at AH and SPHMMC, (5) training physicians and staff in the management of potential donors and recovery of DD organs, and (6) training faculty and staff to organize, lead, and operate a hospital-based organ procurement organization (OPO). Results Training of four SPHMMC surgeons in kidney transplantation by UM kidney transplant surgeons began in July 2015. Teams from UM and the DTI made site visits in March 2016 to assess the feasibility of establishing DD at SPHMMC and AH. Beginning that month, working groups were established at SPHMMC and AH to guide the DD development process. In September 2016, two surgical fellows from SPHMMC traveled to the HR for training that included DD management and organ recovery. Two AH faculty members and a SPHMMC administrator enrolled in DTI master level courses in November 2016 for training in DD and OPO administration. An additional site visit by faculty from DTI and UM in January 2017, focused on protocol development, staff recruitment and training, and legislation. Timelines and prototype BD protocols and legislative language will be presented, as will perspectives on the imperative for establishing brain death protocols, even in the absence of active DD. Conclusion Pragmatic BD definitions and protocols are necessary for the operation of modern hospitals. DD under conditions of restrained resources is possible and practical. Successful introduction of these practices requires methodical planning and preparation, and critical support and leadership by hospital administration and governmental agencies.

Somatic support following cardiac arrest for 90 days leading to a healthy baby boy: A case report

Due to a lack of published case reports regarding the somatic support of brain dead pregnant patients, each one adds to the limited knowledge that directs care for this patient population. A young woman experienced a cardiac arrest and was subsequently determined to be approximately 20 weeks pregnant following cardio pulmonary resuscitation. Soon after, she was diagnosed as brain dead, but her family chose to keep her supported in hopes of the delivery of a healthy child. She was transferred to our facility, where she was supported after being diagnosed as brain dead for a total of 90 days and delivered a healthy baby boy at almost 32 weeks gestational age. Following delivery, the pregnant patient expired per brain death protocol. The following case report outlines the details of her care and the outcome of our somatic support to share and collaborate with other healthcare professionals caring for this rare patient population.

Brain Death: Knowledge of Future Brazilian Physicians

BackgroundThousands of people die on the waiting list for transplants. The shortage of organs and tissues for transplantation is considered a serious global problem. Brain death (BD) is the main source of organs for transplantations. ObjectiveGiven that BD is assessed by medical staff and that this diagnosis is ethically relevant, the goal of this work was to analyze the knowledge of 5th- and 6th-year medical students of Southern Brazil regarding the process of determining BD. MethodThis observational, cross-sectional study was conducted between September 2013 and March 2014. ResultsA total of 635 students participated in the study, with 337 (53.1%) from public and 298 (46.9%) from private schools. Approximately 333 (52.4%) attended the 6th year of the medical program. The mean age of the students was 25.4 ± 3.56 years, with a prevalence of females of 54.6% (347) and a prevalence of Catholic religion of 61.7% (392); 84.2% of the students reported not feeling confident performing the BD protocol. A low percentage (15.7%) correctly answered 75% or more of the questions about BD, a criterion used to determine sufficient knowledge of BD. Approximately 45% (282) of respondents were not able to identify the patients who were candidates for the BD protocol. Analyzing the medical students' knowledge at the end of the program can provide information about the quality of undergraduate education on the topic of determining BD. ConclusionIt was concluded that 5th- and 6th-year medical students of Paraná State have little knowledge about the BD protocol.

The effect of brain death protocol duration on potential donor losses due to cardiac arrest.

The severe inflammatory reaction that occurs after brain death (BD) tends to amplify over time, contributing to cardiovascular deterioration and occurrence of cardiac arrest (CA). Our purpose is to evaluate the effect of BD protocol duration (BDPD) on potential donor losses due to CA. This retrospective analysis included potential donors reported during the period from May 2012 to April 2014. The risk of losses due to CA was analyzed to identify the chronological threshold at which the probability of loss due to CA increases. Three hundred and eighty-four potential donors were analyzed. There was a greater chance of CA after a 30-hour threshold (OR 1.67, 95% CI: 1.38-1.83), and the lowest risk of was identified for the range from 12 to 30hours (OR 0.32, 95% CI: 0.19-0.52). Multivariate analysis identified the following variables as being associated with lower occurrence of CA: BDPD between 12 and 30hours, management of a potential donor inside the intensive care unit, and the adherence to a goal-directed protocol. A long duration between the first clinical test for BD diagnosis and the procurement of organs may be an important risk factor for the occurrence of cardiac arrest in deceased potential donors.

Pregnancy and Brain Death: Lack of Guidance in U.S. Hospital Policies

Objective The death of Marlise Muñoz, a pregnant woman who suffered an anoxic brain injury in November 2013, highlights the social, ethical, legal, and medical controversies associated with brain death in pregnancy. We sought to evaluate whether institutions in the United States have policies in place for situations in which a pregnant woman is declared brain dead. Study Design Institutional brain-death protocols from hospitals in the United States were obtained in cooperation with local and regional organ procurement agencies. Each protocol was reviewed to determine if and how it addressed brain death in pregnancy. Results We reviewed 317 unique brain-death protocols. In eight protocols (2.5%), it was noted that a pregnant patient could not be evaluated for brain death if the fetus could be preserved. Of the protocols that permitted brain-death evaluation, 289 (93.8%) did not include guidance about fetal management after maternal brain death and 305 (99%) did not indicate who was responsible for making decisions for the fetus. Conclusion Very few institutional brain-death policies address the issue of pregnancy. The creation of guidelines on management of the social and ethical challenges associated with brain death in pregnancy may be helpful.