Brainstem Death Testing Research Articles

Guillain-Barré Syndrome Mimicking Brainstem Death Following Traumatic Intracerebral Hemorrhage (P12-7.006)

<h3>Objective:</h3> NA <h3>Background:</h3> NA <h3>Design/Methods:</h3> NA <h3>Results:</h3> A 73-year-old man attended the ED following an assault where he sustained multiple traumatic blows to the head. He was alert, complained of headache but provided a detailed account. There were facial injuries but no clinical signs of cranial or skull base fractures. There was injury to the right eye, in which he had pre-existing visual impairment from previous injury. Vision was normal in the left. Right pupillary light reflex was absent but left was normal. The remainder of the neurological examination was unremarkable. CT-Head identified a small traumatic subarachnoid hemorrhage over the left cerebral convexity and a small contusion in the left temporo-parietal region. Vitreous hemorrhage was evident in the right eye. Clinically stable, follow-up CT on day 3 showed small intra-cerebral haemorrhage within the contusion, with minimal mass effect. However, on day 8, his GCS dropped and he was admitted to the ITU for airway management. Both pupils were non-responsive to light. Expansion of haemorrhage was suspected, however repeat CT was stable. EEG showed slowing over the left hemisphere without epileptiform activity. MRI excluded alternative causes for his neurological status such as brainstem ischaemia. With no clinical improvement, formal brainstem death testing was initiated. No potential confounders were recognised. The pupillary, corneal, oculocephalic, cough and gag reflexes were absent. Unexpectedly, deep tendon reflexes were absent in all limbs. A peripheral nerve stimulator using a train-of-four test protocol found no response. Post-traumatic Guillain-Barré syndrome (GBS) was suspected. Intravenous immunoglobulin was commenced. Nerve conduction studies found absent motor and sensory responses in all limbs. EMG showed fibrillation potentials and sharp waves. These findings were consistent with acute motor-sensory axonal neuropathy (AMSAN) variant of GBS. Serum Anti-GM1 antibodies were identified. After multiple rounds of plasmapheresis the patient was weaned from the ventilator. Nevertheless, severe neurological disability remained. <h3>Conclusions:</h3> NA <b>Disclosure:</b> Dr. Finegan has nothing to disclose. Dr. Ryan has nothing to disclose. Michael J. Hennessy has nothing to disclose. Kevin Murphy has nothing to disclose. Dr. Crowley has nothing to disclose. Dr. Elamin has received personal compensation in the range of $500-$4,999 for serving on a Scientific Advisory or Data Safety Monitoring board for Roche .

Apparent ventilator triggering in a brainstem dead patient

Ventilator auto-triggering is a potential confounding factor in brainstem death with implications in delaying brainstem death testing. We report a case of a brainstem dead patient with extensive intracranial haemorrhage, tonsillar herniation and an absence of intracranial perfusion. Prior to brainstem death testing, there was apparent triggering of the ventilator mimicking spontaneous respiratory efforts which raised the possibility of residual brain activity. Further analysis revealed ventilator auto-triggering as the cause and the patient was certified brainstem dead.

Determination of brain stem death

This article will focus on a step by step description of the process of brain stem death testing as per Indian Society of Critical Care Medicine (ISCCM) guidelines. This will be followed by a narrative on how the testing criteria differ among the various international guidelines. The importance of identifying a potential brain stem dead patient and confirming the same, zeroes down to two reasons. First and foremost, confirmation of death is needed for both the treating team of doctors and relatives to make informed decisions regarding ongoing care, including futility. The second is that it opens the opportunity to discuss the possibility of organ donation with the relatives. The criteria to diagnose brain stem death follows a stringent protocol and is laid in a fool proof manner so that the chances of making an error is infinistically minimal.

What Intensivists Say About an Opt-Out System for Organ Donation

BackgroundSingapore has had an opt-out organ donation system since the inception of the Human Organ Transplant Act in 2009. This law allows all Singapore citizens and permanent residents to donate their organs after confirmation of brain death, usually in the setting of devastating brain injury or stroke in an intensive care unit (ICU) setting, and such cases are referred to the National Organ Transplant Unit team by intensivists after the presumed clinical brain stem death testing. The further confirmatory tests, coordination with surgeons to find suitable recipients, and communication with family members is then carried out by the transplant coordinators from the National Organ Transplant Unit and not the clinicians. Despite a decade of the institution of the Act, the rates of organ donation remain low. This survey is the first aimed to assess the concerns and recommendations of the intensivists in Singapore. MethodsThis was an anonymous survey sent to 120 intensivists registered in Singapore with a 58% response rate. The survey included 14 open-ended questions. The respondents included both private and public sector intensivists. A qualitative analysis was carried out to analyze the emergent themes from the survey. ResultsA total of 79% of the respondents mentioned raising awareness through publicity, education, and advertising; 34% mentioned educating physicians and engaging ICU physicians in further planning of the organ transplant program in Singapore; 35% felt that publicizing more real stories of recipients would help. Generally, there was unease at the opt-out system infringing basic rights. ConclusionThis is the first survey to elicit the responses of the referring physicians for organ transplant. Their opinions suggest that a wider awareness and buy-in is needed both by the public and the ICU physicians, and addressing their valid moral concerns is essential in bridging this gap.

What factors influence a family's decision to agree to organ donation? A critical literature review.

Background:There is a shortage of organs for transplantation in the UK. However, whilst 82% of the population consider donating their organs, only 35% of people have joined the NHS Organ Donor Register. Although the Human Tissue Acts (2004, 2006) and Human Transplantation (Wales) Act (2013) state that the wishes of the deceased cannot be vetoed, it is unlikely that healthcare teams will continue with the retrieval process without the family’s agreement to proceed.Aim:To understand what influences the decision of families to donate in order to guide clinical practice, education, training and increase donation rates to 80% in line with the NHS Blood and Transplant – Taking Organ Donation to 2020 strategy. Method: A literature review of published research. Results: Seven papers met the inclusion criteria. Several significant factors were identified that influence family decisions, including prior knowledge of the deceased’s wishes (e.g. carrying a donor card), presence at the time of the donor’s injury, understanding of brain stem death testing, ‘personal realisation’ of death and hospital related factors (e.g. information, communication and care). These were organised to form the acronym DONATE that serves as a useful mnemonic to guide the requester prior to discussing organ donation. Conclusions: Rates of donation of organ donation may increase through understanding family decision-making.

Understanding brainstem death testing

Caring for a patient with suspected brain stem death is said to be one of the most challenging nursing roles. There are preconditions a patient must fulfil before brain stem death testing is carried out; different countries have their own brain stem death-testing guidelines. Potentially reversible causes of coma, including metabolic disturbance, hypothermia and depressant drugs, must be excluded, as must high cervical-cord injury if a head injury is suspected. Brain stem reflexes are tested to support the diagnosis and confirmation of brain stem death. Providing relatives with information on brain stem death testing can help reduce the emotional burden on both practitioners and family members. A plan to perform brain stem death testing should trigger urgent referral to the hospital's on-call specialist nurse–organ donation; when relatives are approached about donation by such a specialist practitioner, donation rates are higher. Nurses need to see organ and tissue donation as a normal part of end-of-life care following the death of a patient.

Seeing for themselves - healthcare professionals' views about the presence of family members during brainstem death testing.

To provide an insight into the views of healthcare professionals on the presence of family members during brainstem death testing. Brainstem death presents families with a paradoxical death that can be difficult to define. International research suggests families should be given the choice to be present at brainstem death testing, yet it appears few units offer families the choice to be present and little attention has been paid to developing practice to enable effective facilitation of choice. A qualitative, exploratory design was adopted to understand the perceptions of healthcare professionals. Individual semi-structured interviews were audio-taped and carried out over two months. A purposive sample of 10 nurses and 10 doctors from two tertiary intensive care units in the United Kingdom was interviewed, and transcripts were analysed using content analysis to identify emergent categories and themes. Healthcare professionals indicated different perceptions of death in the context of catastrophic brainstem injury. The majority of participants favoured offering families the choice to be present while acknowledging the influence of organisational culture. Identified benefits included acceptance, closure and better understanding. Suggested challenges involved the assumption of trauma or disruption and sense of obligation for families to accept if choice was offered. Key issues involved improving knowledge and communication skills to individually tailor support for families involved. If families are to be offered the choice of witnessing brainstem death testing, considering that needs and conventions will differ according to global cultural backgrounds, then key needs must be met to ensure that effective care and support is provided to families and clinicians. A proactive approach to facilitating family choice to be present at testing requires the development of guidelines that accommodate cultural and professional variations to provide excellence in end-of-life care.

Survey of the Knowledge, Perception, and Attitude of Medical Students at the University of Leeds Toward Organ Donation and Transplantation

BackgroundThe shortage of organ donors is the key rate-limiting factor for organ transplantation in the United Kingdom. Many strategies have been proposed to increase donation; one strategy aims to improve awareness of organ donation and transplantation (ODT) among medical students. This survey seeks to investigate the knowledge, perceptions, and attitudes of the medical students in the United Kingdom toward ODT and the curriculum content. MethodsA 32-item online questionnaire was distributed to 957 medical students at the University of Leeds (October to December 2012). ResultsThere were 216 (22.6%) respondents. Students were aware of kidney, heart, and liver transplantation (91.6%, 88.8%, and 86.5%). Awareness of small intestine (36.7%) and islet of Langerhans (33.0%) transplantation was poor. Students understood the term “brain stem death” (82.3%); however, they lacked understanding of criteria used for brain stem death testing (75.8%). Their perceptions and attitudes were favorable toward ODT; 43.3% of the students were unhappy with their current knowledge, and 87.6% of the students agree that ODT teaching should be included in the curriculum. ConclusionsStudents have a basic understanding of ODT but lack detailed knowledge. They accept its importance and desire further teaching to supplement their current knowledge to be able to understand the issues related to ODT.

The Presence of Relatives during Brainstem Death Testing in an Intensive Care Unit

The issue of allowing relatives to witness brainstem death testing has sparked debate between all members of the multidisciplinary team working in intensive care. A literature search was carried out, highlighting the advantages and disadvantages of relatives observing brainstem death testing. Databases searched were the NHS Knowledge Network, OVID, CINAHL, the Cochrane Library, and Medline. Search items included: brainstem death, brainstem death testing, brain death, intensive care, relatives, families and witnessed cardiopulmonary resuscitation. Articles which were under ten years old were included; however articles which were pertinent to the topic were not excluded if outside this timeframe.

Barriers to brainstem death testing and organ donation can be addressed

Barriers to brainstem death testing and organ donation can be addressed

Survey of Family-Witnessed Brain Stem Death Testing in Intensive Care Units

It is not currently known how often relatives are present during brain stem death (BSD) testing. A telephone survey of a selection of UK intensive care units (ICUs) was therefore performed asking about their experience with family-witnessed BSD testing. Forty-eight ICUs participated. Relatives were allowed to witness BSD testing in 21 ICUs (44%). Despite initial concerns by some ICU staff, none had experienced any problems with the family being present during the testing procedure.

Residual sedation and brain stem death testing

Residual sedation and brain stem death testing

Brain stem death testing after thiopental use: a survey of UK neuro critical care practice*

A postal survey was conducted to determine how thiopental is used in UK neurosurgery critical care units. Thirty units were contacted and 26 replied. Thiopental is used in 23 units. The majority (60%) of these units govern the use of thiopental with protocols or guidelines and 74% use cerebral monitoring to guide dosage. When patients have had thiopental, 20 units delay brain stem testing, two will not perform tests and one unit incorporates cerebral angiography into their protocol. Twelve units use serum thiopental assays in their brain stem testing procedures, but there is wide variation in the interpretation of the results. We found inconsistency and confusion surrounding brain stem testing in this patient group, raising the possibility of misdiagnosis of brain stem death.

Experiences of families when a relative is diagnosed brain stem dead: understanding of death, observation of brain stem death testing and attitudes to organ donation

Brain stem death may be a difficult concept for relatives to understand. Our ITU practice follows published recommendations that the use of explanatory leaflets showing CT scans and observing brain stem death testing in some cases may help relatives to understand that death has occurred. Using this strategy, we interviewed 27 relatives 12 months after bereavement following certification by brain stem testing, investigating their understanding of brain stem death, subsequent attitudes to organ donation, grief reactions and attitudes of those who had observed the tests. Most relatives understood that the brain stem death tests indicated that survival was not possible, although three relatives had not fully understood this and valued the opportunity to discuss it again. Only five relatives observed the tests, all were pleased that they had done so as this had confirmed their understanding that death had occurred; however, these relatives had more evidence of psychological distress. No relatives who agreed to organ donation regretted this but three who did not allow donation subsequently expressed regret. Several relatives thought that observing the tests would have helped them to understand that death had occurred, making easier the decision to allow organ donation.

Hypoxaemia during open‐airway apnoea: a computational modelling analysis

Hypoxaemia during open-airway apnoea, e.g. during brainstem death testing, may cause organ damage. The effect of ambient oxygen fraction on the extent of hypoxaemia has not been established. We validated the Nottingham Physiology Simulator in this context by reproducing the methodologies and results of four published clinical studies. We then used the simulator to examine the effects of different ambient oxygen fractions (0.21-1.0) and shunt fractions (1-30% of cardiac output) during apnoea. Increasing ambient oxygen fraction from 0.9 to 1.0 more than doubled the time to haemoglobin desaturation at all shunt fractions, and extended apnoea longer than when the ambient oxygen fraction was increased from 0.21 to 0.9. When ambient oxygen fraction and shunt fraction were large, arterial oxygen tension transiently increased during apnoea. A very high ambient oxygen fraction and a patent airway are likely to delay dangerous hypoxaemia during apnoea.

Capnography: Clinical Aspects

Capnography: Clinical Aspects

Organ and tissue donation: a survey of nurse's knowledge and educational needs in an adult ITU

The aim of this paper is to present the results of a survey that was undertaken to assess nurses' knowledge and educational needs towards organ donation within one adult general intensive care unit. The survey consists of 31 registered nurses who completed a confidential questionnaire that aimed to assess their existing knowledge and deficits in organ and tissue donation. The survey highlights the sample lacked confidence in approaching relatives for donation consent, deficits in brain stem death testing and donor criteria. It was also apparent that a significant number of nurses could not identify which tissues can be donated and the contraindications for tissue donation. A majority of the sample stated their knowledge of donation issues would improve if an educational programme were developed on organ donation. This is further supported by previous work by [Bidigare S, Oermann M, 1991. Attitudes and knowledge of nurses regarding organ procurement. Heart & lung 1:20-3; Smith-Brew S, Yanai L, 1996. The organ donation process through a review of the literature. Part 1. Accident & emergency nursing 4:5-11; Roark D, 2000. Overhauling the organ donation system. Am J Nurs 6:44-9] who suggest that educational programmes covering donation issues should enhance nurses' knowledge and confidence in the organ donation process and ultimately increase the number of potential donors.

An evaluation of brainstem death documentation: the importance of full documentation

With the introduction of the concept of brainstem death as acceptable proof that life has ended, rather than cessation of the beating heart, the process of determining brain death has to be rigorous to ensure maintenance of confidence in the definition. A recent study from South Thames in the UK revealed that only 44% of brainstem death documentation was complete at the time of referral to the transplant coordinator. The aim of our study was to see whether our documentation of brainstem death in paediatric practice complied with the UK Royal College's guidelines and to determine whether any changes are required to be instituted. We studied retrospectively the case notes of children who underwent brainstem testing over a 3-year period (1994-1997) at two tertiary referral children's hospitals. The results of the audit were disseminated and a reaudit was performed over a 3-year period (1998-2001). A proforma was completed in 61% of cases and in only 54% of cases was the ideal standard of two tests by two doctors documented. Of the 26 sets of case notes studied, the cause of coma was not stated in 85% of cases and exclusion of other causes was stated in 54%. For the reaudit, 32 sets of case notes were studied and the proforma was completed in 100% of cases. In 91% of cases, the cause of coma was stated and in 94%, exclusion of other causes was documented. In 94% of cases two tests were performed by two doctors. Documentation of adherence to the Royal Colleges, guidelines on brainstem death testing improved significantly between the two study periods as a consequence of major changes in practice within the PICU. With the appointment of dedicated intensive care consultants, care became largely consultant intensivist led and emphasis was placed on the documentation and completion of a single validated brainstem death proforma. It is essential to improve and maintain the quality of brainstem death test documentation in order to ensure the integrity of the process.

Brainstem death testing in the UK'time for reappraisal?

A diagnosis of brainstem death in the UK is based on clinical assessment rather than technical investigations, but is considered rigorous enough to be legally synonymous with death. A questionnaire in five sections concerning clinician details, initiation of support, criteria for testing, conduct of the tests, and the process of organ donation, was sent to all members of the Neuroanaesthesia Society. The survey reveals evidence of failure to apply existing guidelines accurately and a wide variation in practice where the recommendations are not specific. In an era of scrutiny of medical process, it is timely to consider whether the current guidelines should be revisited. Clarification of the approach to biochemical derangement, and the role of confirmatory tests when the residual effect of sedative agents cannot be excluded, are two areas worthy of debate.

The presence of family during brain stem death testing.

It is established practice in intensive care units (ICU) for relatives to be excluded from brain stem death testing. However, times are changing and this is evident in other areas of health care, where fathers are now present during childbirth and relatives may be given the choice of being present during cardiopulmonary resuscitation (CPR). In Part One of this serial, it was suggested that with relatives now being present during resuscitation it will only be a matter of time before requests to witness brain stem death testing are made. This article will focus on the barriers that inhibit the presence of family during brain stem death testing. A strategy that aims to facilitate their presence will then be proposed.