Brain Death Protocol Research Articles

Prolonging Support After Brain Death: When Families Ask for More

The manner in which brain death protocols in the United States address family objection to death by neurologic criteria has not been explored. Institutional brain death protocols from hospitals in the United States were reviewed to identify if and how the institution addressed situations in which families object to determination of brain death or discontinuation of organ support after brain death. Protocols from 331 institutions in 25 different states and the District of Columbia were reviewed. There was no mention of how to handle a family's objections in 77.9% (258) of the protocols. Of those that allowed for accommodation, reasons to defer brain death declaration or prolong organ support after brain death declaration included: (1) religion; (2) moral objection; (3) nonspecific social reasons; or (4) awaiting arrival of family. Recommendations to handle these situations included: (1) seek counsel; (2) maintain organ support until cardiac cessation; (3) extubate against the family's wishes; (4) obtain a second opinion; or (5) transfer care of the patient to another practitioner or facility. Protocols differed on indications and length of time to continue organ support, code status while support was continued, and time of death. The majority of protocols reviewed did not mention how to handle circumstances in which families object to determination of brain death or discontinuation of organ support after brain death. The creation of guidelines on management of these complex situations may be helpful to prevent distress to families and hospital staff.

Influence of the duration of brain death protocol on losses of potential donors by cardiac arrest

Organ transplantation is, in many cases, the only therapeutic option for patients with terminal organ dysfunction. Organ donation from deceased donors in brain death (BD) is the main source of organs for transplants. Goal-oriented protocols are associated with reduction of cardiac arrests in potential donors. However, there is not much information about chronological goals and the influence of the length of donor management on the loss of donors by cardiac arrest. The severe inflammatory reaction that occurs from the BD installation tends to amplify over time and could contribute to cardiovascular deterioration and occurrence of cardiac arrest.

Brain death declaration: Practices and perceptions worldwide.

To assess the practices and perceptions of brain death determination worldwide and analyze the extent and nature of variations among countries. An electronic survey was distributed globally to physicians with expertise in neurocritical care, neurology, or related disciplines who would encounter patients at risk of brain death. Most countries (n = 91, response rate 76%) reported a legal provision (n = 63, 70%) and an institutional protocol (n = 70, 77%) for brain death. Institutional protocols were less common in lower-income countries (2/9 of low [22%], 9/18 lower-middle [50%], 22/26 upper-middle [85%], and 37/38 high-income countries [97%], p < 0.001). Countries with an organized transplant network were more likely to have a brain death provision compared with countries without one (53/64 [83%] vs 6/25 [24%], p < 0.001). Among institutions with a formalized brain death protocol, marked variability occurred in requisite examination findings (n = 37, 53% of respondents deviated from the American Academy of Neurology criteria), apnea testing, necessity and type of ancillary testing (most commonly required test: EEG [n = 37, 53%]), time to declaration, number and qualifications of physicians present, and criteria in children (distinct pediatric criteria: n = 38, 56%). Substantial differences in perceptions and practices of brain death exist worldwide. The identification of discrepancies, improvement of gaps in medical education, and formalization of protocols in lower-income countries provide first pragmatic steps to reconciling these variations. Whether a harmonized, uniform standard for brain death worldwide can be achieved remains questionable.

Brain Death: Assessment, Controversy, and Confounding Factors

When brain injury is refractory to aggressive management and is considered nonsurvivable, with loss of consciousness and brain stem reflexes, a brain death protocol may be initiated to determine death according to neurological criteria. Clinical evaluation typically entails 2 consecutive formal neurological examinations to document total loss of consciousness and absence of brain stem reflexes and then apnea testing to evaluate carbon dioxide unresponsiveness within the brain stem. Confounding factors such as use of therapeutic hypothermia, high-dose metabolic suppression, and movements associated with complex spinal reflexes, fasciculations, or cardiogenic ventilator autotriggering may delay initiation or completion of brain death protocols. Neurodiagnostic studies such as 4-vessel cerebral angiography can rapidly document absence of blood flow to the brain and decrease intervals between onset of terminal brain stem herniation and formal declaration of death by neurological criteria. Intracranial pathophysiology leading to brain death must be considered along with clinical assessment, patterns of vital signs, and relevant diagnostic studies.

Semen Collection Requirement From Multiple-Organs Brain-Dead Donors: Report of Two Cases and Analysis of the Available Brazilian Legislation

Along with developments in transplantation there have been major breakthroughs in the techniques of assisted reproduction. The areas of common interest include requesting semen collection from organ donors with a diagnosis of brain death. After the recent report of two cases in the Search Service of Organs and Tissues, we analyzed legislation in our country, which still lacks specific guidance in such situations. Organ transplantation progressively established itself as an effective therapeutic option in our country since the 1960s. It represents viable alternative to improve both the quality and length of life as well as to decrease long-term costs of patients with severe end-stage organ failure. These programs have specific rules and laws that are necessary to guide all stages of transplantation: donor identification, authorization and execution as well as recipients selection of implantation techniques. Assisted reproduction also needs legislation specific for human infertility, a public health problem that affects medical, psychological, and legitimate desires of people. The World Health Organization estimates that infertility reaches 20% of the population demanding the development and use of techniques for its treatment. Brazilian legislation includes regulations for transplantation of organs and tissues in law no. 9434 of February 04, 1997; it provides for the removal of organs, tissues, and human body parts for transplantation and other treatments. This law is regulated by Decree no. 2268 of June 30, 1997, establishing the National Transplant System, which standardizes these processes. The postmortem organ and tissue provision must be preceded by a diagnosis of via the Brain Death Protocol (Federal Council of Medicine-Brazil). The sole paragraph of Article 1 makes clear that its provisions do not apply to blood, sperm, or ovules as confirmed by the sole paragraph of Article 1 in the Decree 2.268/97 regulation. Since there is no specific legislation, assisted reproduction in our country is also regulated by The Federal Council of Medicine resolution, which was recently updated (Resolution no. 1957 December 15, 2010 in item VIII), which provides ethical standards for the use of assisted reproduction techniques provides that “It is unlawful ethical assisted reproduction postmortem since there is specific prior authorization of (a) late (a) to the use of cryopreserved biological material, in accordance with current legislation.” Standardization is specific to material collected before the diagnosis of brain death, including being subject to expressed and informed consent of both spouses (item 3, item 1, attached single Resolution 1.957/2010 Federal Council of Medicine). We cannot yet find support in these legal provisions even after brain death for postmortem collection of sperm or ovules. Despite the evolution of the assisted reproduction techniques and the recognition of people's rights and wishes to procreate, this matter still creates complicated ethical and legal issues that seem to be far from being solved in our country.

Morte encefálica e cuidados na manutenção do potencial doador de órgãos e tecidos para transplante

This is an exploratory-descriptive study performed using a quantitative approach and prospective data, with the objective to identify the knowledge of nursing professionals regarding brain death (BD) and maintaining the Potential Donor (PD). The study population consisted of 55 nursing professionals, mostly nursing technicians (74.5%); 78.2% reported having worked with PDs and 50.9% stated being prepared to take care of those patients. Among the conditions considered indispensible to open a BD protocol, 49.1% made a wrong statement of body temperature above 36oC. Regarding the management of hydroelectrolytic disorders, 50.9% made a wrong choice concerning the reposition of sodium, potassium and magnesium. Regarding cornea care, 58.2% made a wrong decision about the protection using gauzes. Furthermore, 52.7% made the correct statement that the PD can be reanimated. It was observed that the subjects had insufficient knowledge regarding the diagnosis of BD and PD maintenance, thus requiring education on the topic in order to increase the offer of organs/tissue for transplants. Descriptors: Nursing; Brain Death; Transplantation; Intensive Care Units.

Success of Another Hispanic Donation Model: The Puerto Rico Experience

Introduction: The Spanish model for increasing organ donation has proven to be effective, based on the involvement of trained health care personnel in the care of potential donors and their families early in the process. This model has been applied in other countries also. Donation through an OPO was started in Puerto Rico in 1994 by LifeLink Foundation. Donors per million (dpm) have increased from an average of 3 (1994-7) to 28 (2007-11). Aim: To identify factors that have resulted in the significant increase in organ donors. Methods: Review of strategies, specific measures, changes implemented and significant events as they correlate with the number of donors per study period. Five time periods were identified according to the increment in number of donors. Results: For the initial period of 1994-97, aggressive public education, OPO-hospital contracts, recruitment of local executive director, and agreement with Medical Examiner were the main factors, resulting in average of 3 dpm. At this time, only kidney transplant was done in the island. From 1998-2000, dpm grew to 10.2. In this period, support from the federal and state governments, emphasis on brain death declaration, huge media exposure and a new heart transplant program were crucial. For 2001-3, 16.9 dpm were achieved. Staff growth, training of local kidney recovery surgeons, and endorsement by the Health Department were instrumental. From 2004-6, dpm rose to 22.5. Internal restructuring, uniform brain death protocol adopted by hospitals, identification and development of high donor potential hospitals, “Zero denial by ME” policy, training of local liver recovery surgeon, implementation of collaborative project with clinical triggers and management protocols, recruitment of critical care specialists for donor management, fulltime in-house public affairs specialist and active volunteer program were salient actions. The most recent growth to 28 dpm occurred from 2007-11. Measures included designated requestor, in-house coordinator, hospital standard support orders, Donor Advisory Committees, first responders, first kidney-pancreas transplant and implementation of electronic Donor Registry. Through out, a continued emphasis on physician education, brain death declaration and culturally sensitive public awareness campaign have been sustained. Conclusions: Creating a culturally sensitive process that includes highly trained DRs, focused education efforts, appealing public campaigns, addition of in-house coordinators, and development of local transplant centers have contributed to the increase in organ donors in spite of limited health care infrastructure and resources. Our experience supports the implementation of the Spanish approach of organizational strategies to increasing organ donation.

Success of Another Hispanic Donation Model: The Puerto Rico Experience

Introduction: The Spanish model for increasing organ donation has proven to be effective, based on the involvement of trained health care personnel in the care of potential donors and their families early in the process. This model has been applied in other countries also. Donation through an OPO was started in Puerto Rico in 1994 by LifeLink Foundation. Donors per million (dpm) have increased from an average of 3 (1994-7) to 28 (2007-11). Aim: To identify factors that have resulted in the significant increase in organ donors. Methods: Review of strategies, specific measures, changes implemented and significant events as they correlate with the number of donors per study period. Five time periods were identified according to the increment in number of donors. Results: For the initial period of 1994-97, aggressive public education, OPO-hospital contracts, recruitment of local executive director, and agreement with Medical Examiner were the main factors, resulting in average of 3 dpm. At this time, only kidney transplant was done in the island. From 1998-2000, dpm grew to 10.2. In this period, support from the federal and state governments, emphasis on brain death declaration, huge media exposure and a new heart transplant program were crucial. For 2001-3, 16.9 dpm were achieved. Staff growth, training of local kidney recovery surgeons, and endorsement by the Health Department were instrumental. From 2004-6, dpm rose to 22.5. Internal restructuring, uniform brain death protocol adopted by hospitals, identification and development of high donor potential hospitals, “Zero denial by ME” policy, training of local liver recovery surgeon, implementation of collaborative project with clinical triggers and management protocols, recruitment of critical care specialists for donor management, fulltime in-house public affairs specialist and active volunteer program were salient actions. The most recent growth to 28 dpm occurred from 2007-11. Measures included designated requestor, in-house coordinator, hospital standard support orders, Donor Advisory Committees, first responders, first kidney-pancreas transplant and implementation of electronic Donor Registry. Through out, a continued emphasis on physician education, brain death declaration and culturally sensitive public awareness campaign have been sustained. Conclusions: Creating a culturally sensitive process that includes highly trained DRs, focused education efforts, appealing public campaigns, addition of in-house coordinators, and development of local transplant centers have contributed to the increase in organ donors in spite of limited health care infrastructure and resources. Our experience supports the implementation of the Spanish approach of organizational strategies to increasing organ donation.

Short-Term Effects of Hydroxyethylstarch Resuscitation on Systemic and Regional Hemodynamics and Metabolism in a Brain-Dead Canine Model

Hydroxyethylstarch (HES) is a synthetic polymer of glucose that has been suggested for therapeutic use in long-term plasma expansion. The aim of this study was to test the hypothesis that the infusion of a small volume of HES may provide benefits in systemic and regional hemodynamics and metabolism in a brain-dead canine model compared with large volume crystalloid resuscitation. Fourteen mongrel dogs were subjected to a brain-death protocol by consecutive insufflations of a balloon catheter in the epidural space. One hour after induction of brain-death, the animals were randomly assigned to two groups: NS (0.9% NaCl, 33 mL/kg), and HES (6%HES 450/0.7, 17 mL/Kg). Systemic and regional hemodynamics were evaluated using Swan-Ganz, ultrasonic flowprobes, and arterial catheters. Serial blood samples were collected for blood gas, electrolyte, and serum chemistry analysis. Systemic, hepatic, and splanchnic O(2)-derived variables were also calculated. Epidural balloon insufflations induced a significant increase in mean arterial pressure, cardiac output (MAP and CO, respectively), regional blood flow, and systemic vascular resistance. Following the hyperdynamic phase, severe hypotension with normalization of systemic and regional blood flow was observed. Fluid resuscitation induced a prompt increase in MAP, CO, and portal vein blood flow, and a significant reduction in systemic and pulmonary vascular resistance. There were no differences between groups in metabolic indices, liver function tests (LFTs), or renal function tests. HES was more effective than NS in restoring cardiac performance in the first 2h after fluid resuscitation (P < 0.05). Both tested solutions partially and temporarily restored systemic and regional oxygen delivery. Small volumes of 6% HES 450/0.7 improved cardiovascular performance and provided the same regional hemodynamic and metabolic benefits of large volumes of isotonic crystalloid solutions.

Must the entire brain be dead to diagnose brain death?

To the Editor: The June 2006 issue of the Canadian Journal of Anesthesia contains four excellent articles dealing with brain death.1–4 In 1981 the President’s Commission for the Study of Ethical Problems in Medicare and Biomedical and Behavioral Research published a landmark report intended to establish a common ground for American law related to brain death.5 The commission defined brain death as the “irreversible cessation of all functions of the entire brain, including the brain stem”. Since that time, this seminal report has been used as the basis for much of the discourse on brain death, especially in the United States. Similarly, the World Medical Association has written that “it is essential to determine the irreversible cessation of all functions of the entire brain, including the brain stem”.6 The purpose of this letter is to point out that, while these bodies have defined brain death in terms of “irreversible cessation of all functions of the entire brain,” in the years since this definition has been widely adopted it has become very clear that many (perhaps most) patients diagnosed with brain death do not actually meet this requirement. In particular, many patients diagnosed with brain death still synthesize arginine vasopressin (which regulates serum osmolality), implying the presence of residual function in the hypothalmus. Indeed, evaluation of hypothalamic function is not part of any brain death protocol with which I am familiar. It may be time for the World Medical Association and other authorities to reformulate the definition of brain death to reflect current clinical realities.

Emotional considerations and attending involvement ameliorates organ donation in brain dead pediatric trauma victims.

The purpose of this study was to ascertain a strategy for maximizing parental consent for organ donation in traumatically injured children suffering from brain death. Our hypothesis was that appropriate attending surgeon involvement and delay in evaluating children for brain death leads to an increased percentage of organ donors. From January 1993 to August 1999, the records of all children who died in a Level I trauma center were evaluated. Those children suffering brain death that were suitable for organ donation were entered into the study. Cases were reviewed for patient demographics, time to entry into brain death protocol (measured from time of admission), time to parent notification about brain death (measured from time of admission), specific attending involved in the case (with level of involvement), and success of organ donation request. In all, 43 charts were reviewed. Of 43 deaths, 33 were deemed suitable for donation. Age of suitable donors ranged from 1 month to 18 years. In all, 11 attending physicians were involved in the care of these children. Overall, 20 of 33 were organ donors (60%). When the attending surgeon was involved, donation success for organ retrieval was 86%, whereas if the attending was not involved personally, the success rate dropped to 23% (p < 0.04). One senior pediatric surgeon obtained a success rate of 12 of 12 children. It was this surgeon's policy to not initiate brain death protocols in children immediately on entry into the emergency room, but rather to delay initiation until family could be gathered and spend time with the affected child in order that the family could recover from the initial shock of trauma (always at least overnight). When time to initiation of brain death protocol was examined, success was obtained when a delay of 15.5 hours was respected, versus 7.0 hours when donation was requested but denied (p < 0.03). These data indicate that attending involvement is important when parents of brain dead children are asked about organ retrieval (p < 0.04). Delay in initiating brain death protocols in order for family members to deal with the shock of the initial trauma appears to increase willingness to participate in organ donation.

Interet du doppler transcranien dans l'etat de mort cerebrale

Background and purpose: Oscillating flow or systolic spikes are typical Doppler-sonographic flow signals found in the presence of cerebral circulatory arrest, which if irreversible, results in brain death. The Neurosonology Research Group (NSRG) of the World Federation of Neurology (WFN) created a Task Force Group in order to evaluate the role of Doppler-sonography as a confirmatory test for determining brain death. Methods: The available evidence from the literature has been reviewed and discussed by a group of experts, the members of the Task Force Group on cerebral death of the NSRG. Results and conclusions: Extra- and intracranial Doppler-sonography is a useful confirmatory test to establish irreversibility of cerebral circulatory arrest as optional part of a brain death protocol. Doppler-sonography is of special value when the therapeutic use of sedative drugs renders electroencephalography unreliable. Doppler-sonographic criteria are defined and guidelines for the use of Doppler-sonography in this setting are presented.

Confirmation of Brain Death Using 99m Tc HM-PAO

Because 99m Tc HM-PAO is simple to use, noninvasive and readily available, it appears to satisfy most criteria for the use of radionuclide cerebral imaging in the confirmation of brain death. Waiting periods, which are often included in brain death protocols, delay the diagnosis of brain death. 99m Tc HM-PAO has proven to be a useful test to confirm brain death.

UTILIZATION OF TRAUMA-RELATED DEATHS FOR ORGAN AND TISSUE HARVESTING

A randomized retrospective analysis of patients who suffered trauma-related deaths over 36 months (May 1987-April 1990) was performed to study their utilization as candidates for organ and tissue harvesting. There were a total of 108 patients: 79 males, 29 females. The average age was 46.2 years; 38 (36%) of these patients were 65 years of age or older. Over 50% of fatalities were the result of motor vehicle crashes. There were 61 potential tissue donors. Forty-three were lost without documentation of a request for organ procurement. There were 23 patients with potentially salvageable organs: one candidate was lost without documentation of a request for organ procurement. Twenty-eight (26%) of the patients had support withdrawn; 16 were 65 years old or older. Brain death protocol was instituted in 17 (20%); organs were obtained from 70% of these patients. Reasons for failure of procurement after request by a physician included family refusal in seven cases, cardiopulmonary arrest during brain death protocol in two cases, and religious bias in one candidate. Twelve patients were organ donors: 10 patients were tissue donors. We conclude that the greatest source of underutilization lies in the failure to request tissue for harvesting, since there were no isolated tissue donors. Pertinent information should be more widely distributed to physicians regarding candidacy for tissue donation. Further consideration of the adequacy of organs or tissue in relation to the candidates' age should be given, since patients aged 65 years and older can be a significant source of potential donor candidates.(ABSTRACT TRUNCATED AT 250 WORDS)

Editorial

AnaesthesiaVolume 36, Issue 3 p. 253-255 Free Access Editorial J.F. Searle, J.F. SearleSearch for more papers by this author J.F. Searle, J.F. SearleSearch for more papers by this author First published: March 1981 https://doi.org/10.1111/j.1365-2044.1981.tb10194.xAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat References 1 Jennett B, Gleave J, Wilson P. Brain deaths in three neurosurgical units. British Medical Journal, 282, 533– 9. 2 Conference Of Medical Royal Colleges and Their Faculties. Diagnosis of brain death. British Medical Journal 1976; ii: 1187– 8. 3 Pallis C. Medicine and the media. British Medical Journal 1980; 281: 1064. 4 Pallis C. Brain death and the BBC. Lancet 1980; ii: 911. 5 Searle J, Collins C. A brain death protocol. Lancet 1980; i: 641– 3. 6 Hopkins A, Cattell WR. Brain death. Lancet 1980; i: 1194. 7 Department of Health and Social Security. The removal of cadaveric organs for transplantation. A Code of Practice. London : HMSO, 1979. 8 Conference of Medical Royal Colleges and their Faculties. Statement on BBC brain death programme. British Medical Journal 1980; 281: 1291. Volume36, Issue3March 1981Pages 253-255 ReferencesRelatedInformation