Evaluation Of Brain Death Research Articles

Use of neurological criteria to declare death in children.

Accurate determination of death is a necessary responsibility of the medical profession. Brain death, or death by neurological criteria (DNC), can be legally declared after the determination of permanent loss of clinical brain function, including the capacity for consciousness, brainstem reflexes, and the ability to breathe spontaneously. Despite longstanding debates over the exact definition of brain death or DNC and how it is determined, most middle- and high-income countries have compatible medical protocols and legal policies for brain death or DNC. This review summarizes the 2023 updated guidelines for brain death or DNC determination, which integrate adult and pediatric diagnostic criteria. We discuss the clinical challenges related to brain death or DNC determination in infants and young children. We emphasize that physicians must follow the standardized and meticulous evaluation processes outlined in these guidelines to reduce diagnostic error and ensure no false positive determinations. An essential component of the brain death or DNC evaluation is appropriate and transparent communication with families. Ongoing efforts to promote consistency and legal uniformity in the declaration of death are needed.

Apnea Testing on Conventional Mechanical Ventilation During Brain Death Evaluation

IntroductionThe use of continuous positive airway pressure has been shown to improve the tolerance of the apnea test, a critical component of brain death evaluation. The ability to deactivate the apnea backup setting has made apnea testing possible using several conventional mechanical ventilators. Our goal was to evaluate the safety and efficacy of apnea testing performed on mechanical ventilation, compared with the oxygen insufflation technique, for the determination of brain death.MethodsThis was a retrospective study. In 2016, our institution approved a change in policy to permit apnea testing on conventional mechanical ventilation. We examined the records of consecutive adults who underwent apnea testing as part of the brain death evaluation process between 2016 and 2022. Using an apnea test technique was decided at the discretion of the attending physician. Outcomes were successful apnea test and the occurrence of patient instability during the test. This included oxygen desaturation (SpO2) < 90%, hypotension (mean arterial pressure < 65 mm Hg despite titration of vasopressor), cardiac arrhythmia, pneumothorax, and cardiac arrest.ResultsNinety-two adult patients underwent apnea testing during the study period: 58 (63%) with mechanical ventilation, 32 (35%) with oxygen insufflation, and 2 (2%) lacked documentation of technique. Apnea tests could not be completed successfully in 3 of 92 (3%) patients—two patients undergoing the oxygen insufflation technique (one patient with hypoxemia and one patient with hypotension) and one patient on mechanical ventilation (aborted for hemodynamic instability). Hypoxemia occurred in 4 of 32 (12.5%) patients with oxygen insufflation and in zero patients on mechanical ventilation (p = 0.01). Hypotension occurred during 3 of 58 (5%) tests with mechanical ventilation and 4 of 32 (12.5%) tests with oxygen insufflation (p = 0.24). In multivariate analysis, the use of oxygen insufflation was an independent predictor of patient instability during the apnea test (odds ratio 37.74, 95% confidence interval 2.74–520.14).ConclusionsApnea testing on conventional mechanical ventilation is feasible and offers several potential advantages over other techniques.

Neuroimaging in Coma, Brain Death, and Related Conditions

Coma is a state of unresponsiveness to external stimuli, which can be secondary to a variety of CNS alterations affecting essential neuronal pathways, particularly the ascending reticular activating system. A comprehensive clinical evaluation is necessary for assessment of motor function and brainstem reflexes but is often insufficient for determination of the underlying etiology and extent of injury. Diagnostic brain imaging is typically needed for management and decision-making, particularly in acute settings where prompt diagnosis of reversible/treatable conditions is essential, as well as for prognostication. Understanding the pathophysiologic mechanisms leading to coma and comalike states and their imaging manifestations will enable selection of appropriate modalities and facilitate a clinically relevant interpretation. For evaluation of brain death, diagnostic imaging has a supportive role, and when indicated, selection of an ancillary diagnostic test is based on multiple factors, including susceptibility to confounding factors and specificity, in addition to safety, convenience, and availability.Learning objective: To describe the pathophysiology of alterations of consciousness and discuss the role of neuroimaging modalities in the evaluation of coma, brain death, and associated conditions

Curriculum Innovations: High-Fidelity Simulation of Acute Neurology Enhances Rising Resident Confidence

Introduction &amp; Problem Statement The matriculation from internal medicine to neurology residency can be challenging. The most cogent approach to address this transition has yet to be identified. Studies show that simulation is highly effective at reinforcing knowledge and skills while improving learner confidence. We present the design and outcomes of an annual acute neurology simulation program. Objectives We hypothesized that incoming neurology residents would (1) report improved confidence with managing acute neurologic emergencies, (2) cite a high degree of educational value with the program, and (3) demonstrate improvement in their technical knowledge. Methods &amp; Curriculum Description Our military, level 1 trauma institution's simulation laboratory and staff were used to develop and execute simulations for rising neurology residents based on the Accreditation Council for Graduate Medical Education neurology milestones. Three simulations were designed including a case of acute ischemic stroke (AIS), status epilepticus (SE) in an austere environment, and brain death evaluation with family counseling. Residents completed matched pre‐ and post assessments to gauge confidence, technical knowledge, and perceived educational value. Results &amp; Assessment Data Over 3 years, 15 rising neurology residents from 2 training programs completed 3 high-fidelity acute neurology cases. Self-reported confidence with acute neurology skills improved after each simulation. Confidence ratings included assessing for and identifying contraindications to tissue plasminogen activator, identifying AIS, identifying clot retrieval candidates, identifying clinical and electrographic SE, diagnosing and treating SE, identifying contraindications to and confounders of brain death diagnosis, performing the examination, and delivering bad news to families (all p &lt; 0.05). Technical knowledge also statistically improved in the stroke (p = 0.046) and brain death simulation (p = 0.039), but not the SE simulation (p = 0.296). Participants reported an average perceived personal value of 4.8, 4.3, and 4.7 (out of a maximum of 5) for AIS, SE, and brain death simulations, respectively. Discussion &amp; Lessons Learned High-fidelity simulation of neurologic emergencies enhances confidence and knowledge of rising neurology residents. Satisfaction with the simulation cases was high. Academic hospitals can consider incorporating acute neurology simulations into their residency training.

A Taxonomy of Objections to Brain Death Determination.

Family objections to evaluating a patient for death by neurologic criteria, or "brain death," are challenging for the family and the medical team. In this article, we categorize brain death evaluation refusals into a taxonomy: informational objections, emotional objections, and principled objections. We offer suggested approaches for clinicians to respond to refusals on the basis of the category. The category of objection may also be important in considering when accommodation of refusals should be considered. The goal in all such situations is to promote compassionate, ethical, and equitable care for the patient and family.

Outcome After Lung Transplantation From a Donor With Bacterial Pneumonia Under the Japanese Donor Evaluation System

In Japan, a unique medical consultant system for donor evaluation and management has been developed in an effort to maximize the use of extended criteria donor lungs. The aim of this study was to investigate the impact of donor pneumonia (DP) on the outcome after lung transplantation under this system. Clinical data of 85 patients who underwent deceased donor lung transplantation (41 single and 44 bilateral lung transplants) between August 2012 and March 2018 were reviewed. DP was defined as the recognition of pneumonia on imaging with positive bacterial culture in the airway at the time of transplantation. Twenty-three transplanted lung grafts were recognized as having DP (27.1%). Serial chest x-rays at the donor hospital did not show deteriorating infiltration or consolidation. The PaO2/FiO2 ratio at brain death evaluations were similar between the donor pneumonia (DP) negative (-) and donor pneumonia (DP) positive (+) groups. Perioperative antibiotics were effective against 94% of isolated bacteria. The duration of postoperative antibiotics therapy was longer in the DP (+) group (P=.02). The incidence of primary graft dysfunction and acute rejection, intensive care unit stay, chronic lung allograft dysfunction-free survival, and overall survival were similar between the DP (+) and DP (-) groups. Transplantation of donor lung grafts harboring pneumonia but having a similar oxygenation level to those without pneumonia was safely performed and did not affect long-term outcome. Appropriate evaluation of serial imaging at donor hospital and suitable perioperative antibiotic management may be reasons for this outcome.

Evaluation of Brain Death in Children in a Tertiary Pediatric Intensive Care Unit

Evaluation of Brain Death in Children in a Tertiary Pediatric Intensive Care Unit

Evaluation of Pediatric Brain Death and Organ Donation: 10-Year Experience in a Pediatric Intensive Care Unit in Turkey.

Objective:We aimed to investigate the rate of brain death (BD) determinations and organ donations (OD) in our tertiary pediatric intensive care unit (PICU), and to report the data on the demographic pattern and supplementary descriptive data on BD declarations.Methods: The study was designed as a retrospective, single-center, descriptive cohort study. We evaluated all children who were determined to meet the criteria for BD in our tertiary PICU between January 2011 and December 2020.Results:During study period, BD was identified in 24 patients among 225 total deaths (10.7%). Their median age was 85 months (8-214) and the male-to-female ratio was 1 : 1. The most common diagnosis was meningoencephalitis in 25%, followed by traumatic intracranial hemorrhage (16.7%). The median time from admission to PICU until BD diagnosis was 6.5 days. The time from the first BD physical examination to the declaration of BD was 27.5 hours. There was no statistically important difference between donors and non-donors. The apnea test (AT) was the most performed ancillary method (100%), followed by electroencephalogram (EEG) (66.7%), and magnetic resonance angiography or computed tomography angiography (MRA/CTA) (54.2%). Hyperglycemia developed in 79.2% of the cases, and 70.8% developed diabetes insipidus (DI). Five patients (20.8%) were organ donors in study group. In the study, 13 solid organ and 4 tissue transplantations were performed after OD.Conclusion:Awareness of the incidence and etiology may contribute to the timely diagnosis and declaration of brain death, and with the help of good donor care, may help in increasing OD rates in the pediatric population.

Current situation and advancement of brain death determination in China

China's "Criteria and practical guidance for determination of brain death (BD)" based on medicine was launched eight years ago. After joining the writing and publishing work of "The World Brain Death Project-Determination of Brain Death/Death by Neurologic Criteria", China has accelerated the process of internationalization. For this reason, the author expressed his own opinions on the related work progress and existing problems. (1) Although the criteria of BD in different countries are different due to various national conditions, cultures, religions and laws, we can seek common ground while reserving differences, such as the unification of the minimum criteria and the choice of confirmatory tests. (2) Although there are differences in the executive force of BD evaluation among countries around the world due to whether legislation or not, all walks of life and the public can respect the development of medicine. (3) Although there are still life support and organ donation problems to be solved after the determination of BD, they will be solved one by one through medical practice. In a word, we believe that the specification of BD determination in China will continue to advance orderly and rapidly.

Metabolic values precluding clinical death by neurologic Criteria/Brain death: Survey of neurocritical care society physicians

BackgroundThere are no established ranges for metabolic values prior to death by neurologic criteria/brain death determination (DNC/BD) and the thresholds required by institutional protocols and accepted by neurointensivists is unknown. MethodsWe designed a survey that addressed 1) the metabolic tests required in institutional guidelines prior to brain death determination, 2) the metabolic tests the respondent reviewed prior to brain death determination, and 3) the metabolic test thresholds for laboratory tests that were perceived to preclude or permit clinical DNC/BD determination. The survey was distributed online to physicians in the Neurocritical Care Society from September to December 2019. Respondents were dichotomized based on the number of brain death evaluations they had performed (≤20 vs. > 20) and responses were compared between groups. ResultsThe survey was completed by 84 physicians. Nearly half (47.6%) of respondents did not believe their institutions required metabolic testing. The metabolic testing for which institutions most commonly provided a defined threshold were arterial pH (34.5%, 29/84), sodium (28.6%, 24/84), and glucose (15.5%, 13/84). Nearly all (97.6%) respondents routinely reviewed metabolic tests prior to brain death evaluation, the most common of which were: sodium (91.7%, 77/84), arterial pH (83.3%, 70/84), and glucose (79.8%, 67/84). Respondents who had performed > 20 evaluations were less likely to check thyroxine and total bilirubin (3.6%, 2/55 vs. 20.7%, 6/29 (p = 0.011) and 12.7%, 7/55 vs. 31%, 9/29 (p = 0.042), respectively), and had a more liberal upper limit of potassium (6.3 mEq/L vs 6.0 mEq/L, p = 0.045). ConclusionPrior to brain death evaluation, neurocritical care providers commonly review similar metabolic tests and have similar thresholds regarding values that would preclude clinical brain death determination. This finding is independent of experience with brain death determination.

Brain Death Evaluation in Children With Suspected or Confirmed Coronavirus Disease 2019.

Objectives:To discuss the challenges of conducting a death by neurologic criteria or brain death evaluation in the coronavirus disease 2019 era and provide guidance to mitigate viral transmission risk and maintain patient safety during testing.Design:Not applicable.Setting:Not applicable.Patients:Children with suspected or confirmed coronavirus disease 2019 who suffer catastrophic brain injury due to one of numerous neurologic complications or from an unrelated process and require evaluation for death by neurologic criteria.Interventions:Not applicable.Measurements and Main Results:There is a risk to healthcare providers from aerosol generation during the neurologic examination and apnea test for determination of death by neurologic criteria. In this technical note, we provide guidance to mitigate transmission risk and maintain patient safety during each step of the death by neurologic criteria evaluation. Clinicians should put on appropriate personal protective equipment before performing the death by neurologic criteria evaluation. Risk of aerosol generation and viral transmission during the apnea test can be mitigated by using continuous positive airway pressure delivered via the ventilator as a means of apneic oxygenation. Physicians should assess the risk of transporting coronavirus disease 2019 patients to the nuclear medicine suite to perform a radionucleotide cerebral blood flow study, as disconnections to and from the ventilator for transport and inadvertent ventilator disconnections during transport can increase transmission risk.Conclusions:When conducting the neurologic examination and apnea test required for death by neurologic criteria determination in patients with suspected or confirmed coronavirus disease 2019, appropriate modifications are needed to mitigate the risk of viral transmission and ensure patient safety.

Non-invasive Evaluation of Brain Death Caused by Traumatic Brain Injury by Ultrasound Imaging.

ObjectivesTo investigate the clinical value of non-invasive ultrasound imaging in the evaluation of brain death caused by traumatic brain injury.MethodsThirty-four patients with acute severe traumatic brain injury were admitted to hospital within 48 h after injury. All patients were monitored intracranial pressure, transcranial Doppler, echocardiography examination, collection intracranial pressure, MCA-Vs, MCA-Vd, MCA-Vm, EF, LVMPI, RVMPI and other indicators, and combined with clinical conditions and other related data for comparative study and statistical analysis.ResultsThe blood flow spectrum was characterized by diastolic retrograde blood flow spectrum pattern and nail waveform spectrum shape when the patient had clinical brain death. For the parameters of transcranial Doppler, there were significant differences in MCA-Vm and PI between clinical brain death group and normal control group (P < 0.05). For the parameters of echocardiography, there were statistically significant differences in EF, LVMPI, and RVMPI between clinical brain death group and normal control group (P < 0.05).ConclusionNon-invasive dynamic monitoring of cerebral hemodynamics and cardiac function parameters in patients with severe craniocerebral injury can provide a high accuracy and reliability for the preliminary diagnosis of brain death in patients with severe craniocerebral injury. It is helpful for early evaluation of prognosis and provides effective monitoring methods and guidance for clinical treatment.

Special considerations in the assessment of catastrophic brain injury and determination of brain death in patients with SARS-CoV-2

IntroductionThe coronavirus disease 2019 (Covid-19) pandemic has led to challenges in provision of care, clinical assessment and communication with families. The unique considerations associated with evaluation of catastrophic brain injury and death by neurologic criteria in patients with Covid-19 infection have not been examined. MethodsWe describe the evaluation of six patients hospitalized at a health network in New York City in April 2020 who had Covid-19, were comatose and had absent brainstem reflexes. ResultsFour males and two females with a median age of 58.5 (IQR 47–68) were evaluated for catastrophic brain injury due to stroke and/or global anoxic injury at a median of 14 days (IQR 13–18) after admission for acute respiratory failure due to Covid-19. All patients had hypotension requiring vasopressors and had been treated with sedative/narcotic drips for ventilator dyssynchrony. Among these patients, 5 had received paralytics. Apnea testing was performed for 1 patient due to the decision to withdraw treatment (n = 2), concern for inability to tolerate testing (n = 2) and observation of spontaneous respirations (n = 1). The apnea test was aborted due to hypoxia and hypotension. After ancillary testing, death was declared in three patients based on neurologic criteria and in three patients based on cardiopulmonary criteria (after withdrawal of support (n = 2) or cardiopulmonary arrest (n = 1)). A family member was able to visit 5/6 patients prior to cardiopulmonary arrest/discontinuation of organ support. ConclusionIt is feasible to evaluate patients with catastrophic brain injury and declare brain death despite the Covid-19 pandemic, but this requires unique considerations.

Brain death evaluation during the pandemic.

Coronavirus disease 2019 (COVID-19) may pose unique challenges to clinicians attempting to diagnose brain death in patients infected with the SARS-CoV-2. Among these challenges is the risk of aerosol generation during the traditional apnea testing using the insufflation technique in addition to the risk of complications due to SARS-CoV-2-related lung disease. In this article, we discuss these challenges and provide further guidance to minimize such risks to ensure safety of healthcare professionals and other patients. We also emphasize the importance of maintaining the standards of brain death determination in this critical time.

Editors' note: Variability in reported physician practices for brain death determination

In “Variability in reported physician practices for brain death determination,” Braksick et al. reported that a survey of physicians at 3 academic medical centers demonstrated variability in performance of brain death evaluations. For example, many respondents reported that they perform ancillary tests for indications outside those described in the 2010 AAN Practice Parameter, including institutional mandates, protection from liability, and following the observation that a patient breathes during apnea testing. In their comments, Sethi and Machado reinforce their finding that ancillary tests are often ordered for indications outside the AAN Practice Parameter recommendations and note that it is imperative to remember that (1) brain death is a clinical determination and (2) ancillary tests can have both false positives and false negatives. Machado also suggests that the AAN criteria be revised to require an ancillary test to reduce variability in brain death policies. Braksick et al. disagree with this proposal, noting that the value of ancillary tests is “extremely questionable.” Furthermore, with respect to Machado's argument that implementing universal mandatory ancillary testing would reduce variability in brain death policies, in light of the fact that he also noted that only 6.5% of policies mandate ancillary testing, it would clearly be more reasonable for these policies to change to conform to the current AAN Practice Parameter than for the other 93.5% of protocols to start mandating ancillary testing. To reinforce awareness about the indications for ancillary testing, Braksick et al. advocate for formal education about brain death determination for all clinicians performing brain death evaluations. They, unfortunately, found that 76% of respondents did not receive formal training on performance of this evaluation. Accordingly, to decrease variability in brain death determination, the Neurocritical Care Society has recently released a training module on brain death.[1][1] Machado further comments that he recently proposed a new disorder of consciousness, based on the case of Jahi McMath, which exists when a patient meets clinical criteria for brain death but has ancillary tests that conflict with the clinical findings. Further discussion of this interesting case and the questions it generated can be found elsewhere.[2][2] In “Variability in reported physician practices for brain death determination,” Braksick et al. reported that a survey of physicians at 3 academic medical centers demonstrated variability in performance of brain death evaluations. For example, many respondents reported that they perform ancillary tests for indications outside those described in the 2010 AAN Practice Parameter, including institutional mandates, protection from liability, and following the observation that a patient breathes during apnea testing. In their comments, Sethi and Machado reinforce their finding that ancillary tests are often ordered for indications outside the AAN Practice Parameter recommendations and note that it is imperative to remember that (1) brain death is a clinical determination and (2) ancillary tests can have both false positives and false negatives. Machado also suggests that the AAN criteria be revised to require an ancillary test to reduce variability in brain death policies. Braksick et al. disagree with this proposal, noting that the value of ancillary tests is “extremely questionable.” Furthermore, with respect to Machado's argument that implementing universal mandatory ancillary testing would reduce variability in brain death policies, in light of the fact that he also noted that only 6.5% of policies mandate ancillary testing, it would clearly be more reasonable for these policies to change to conform to the current AAN Practice Parameter than for the other 93.5% of protocols to start mandating ancillary testing. To reinforce awareness about the indications for ancillary testing, Braksick et al. advocate for formal education about brain death determination for all clinicians performing brain death evaluations. They, unfortunately, found that 76% of respondents did not receive formal training on performance of this evaluation. Accordingly, to decrease variability in brain death determination, the Neurocritical Care Society has recently released a training module on brain death.1 Machado further comments that he recently proposed a new disorder of consciousness, based on the case of Jahi McMath, which exists when a patient meets clinical criteria for brain death but has ancillary tests that conflict with the clinical findings. Further discussion of this interesting case and the questions it generated can be found elsewhere.2 [1]: #ref-1 [2]: #ref-2

Reliability of the Telemedicine Examination in the Neurologic Diagnosis of Death.

To determine whether telemedicine technology can be used to reliably determine the neurologic diagnosis of death (NDD) in patients with catastrophic brain injury (CBI). We included a convenience sample of patients with CBI at a single academic medical center from November 2016 through June 2018. We simultaneously performed brain death evaluation at the bedside and remotely via telemedicine. Remote examiners were neurointensivists who were experienced and knowledgeable in the NDD. In addition to standard clinical examination, we used quantitative pupillometry to evaluate pupil size and reactivity. We determined the proportion of agreement for each NDD examination element and the overall diagnosis of brain death between bedside and remote examiners. Twenty-nine patients with mean age 46 ± 18 years underwent 30 paired NDD examinations. Twenty-eight (97%) patients met the NDD criteria and were pronounced dead. One patient did not meet the NDD criteria and died after withdrawal of life support. With the exception of qualitative assessment of pupillary reactivity, we observed excellent agreement (97%-100% across NDD examination elements) between bedside and remote examiners and 97% agreement on the overall diagnosis of brain death. Unlike qualitative pupillary assessment, quantitative pupillometry was consistently interpretable by remote examiners. Our results suggest that remote telemedicine technology can be used to verify the findings of bedside examiners performing NDD examinations when a pupillometer is used to assess pupillary reactivity. When performed by neurocritical care experts, the telemedicine NDD examination has potential to facilitate timely and accurate certification of brain death in patients with CBI. This study provides Class IV evidence on the concordance of neurologic diagnosis of death by telemedicine and bedside examiners.

Noninvasive and Wearable Optical Monitoring of Brain Death with Aid of a Protocol at Differentiated Fractions of Oxygen Inspired

Brain death is a permanent loss of all brain function [1]. Current clinical organ transplantations mostly depend on the organs from brain-dead patients [2]. And of note, a lot of blood deases are easy to cause cerebral haemorrhage, which is quite of danger and usually induce brain death if not detected and treated in time. Thus prompt evaluation of brain death is of great significance for saving medical resources and reducing economic burden of the patients' families. Current guide for diagnosing brain death required to perform a list of &gt;30 hours neurological examninations, some of which are even invasive, not in time and easily hampered by many confounding factors. An ideal ancillary test to assess brain death is highlighted to be noninvasive, sensitive, universally available, timely, and easy to perform at the bedside. Near infrared spectroscopy ( NIRS ) is capable of monitoring hemodynamics in response to brain activity noninvasively, conveniently, continually, and relatively inexpensively, evidented by a series of clinical cerebral studies recently. Weigl et al newly reported to use a time resolved NIRS to detect the fluorescence photons excited in the indocyanine green ( ICG ) for cerebral perfusion detection. It provided a novel optical ancillary tool to assess brain death, while its accuracy was only 69.2%, which did not reach the level of brain death confirmation. Plus, it was invasive, requiring injection of optical contrast agent. We attempted to assess brain death completely in nonivasive way with just a custom wearable NIRS device developed in our lab [3] ( fig.1 a ). We novelly incororate a protocol at markedly but safely varied fractions of oxygen respiration. Firstly, Monte Carlo modeling were carried out to test the difference in photon transport within human brain at different oxygen concentrations induced by varied fractions of oxygen respiration ( FIO2 ) [4]. 18 healthy subjects ( 41 ± 11 years old ) and 17 brain dead patients were recruited from the intensive care unit (ICU) in Sichuan Academy of Medical Sciences &amp; Sichuan Provincial People's Hospital. No significant difference in age was found between patients and healthy groups ( p &gt;0.413 ). These patients were finally clinically diagnosed by the international standards of brain death. Two protocols were used ( fig.1 b). One is consisted of 1 hour resting, 3-minute baseline measure, half-hour measurement at 60% FIO2 ( phase I, high oxygen ),a half hour measure at 40% FIO2 ( phase II, low oxygen ), and a half hour measure at 60% FIO2 ( phase III, high oxygen ). The other is low, high, and low. The Δ[Hb] and Δ[HbO2] time courses were recorded by NIRS in real time with related signal processing ( fig.1 c ). Statistical analysis were focus on the sensitivity and specificiy of our proposed methodology at combination of NIRS and above protocol, as well as which protocol act better. Fig.1 ( c right ) showed that the detected light signal profile dramatically differed among varied oxygen concentrations in human brain. Plus the hemodynamic responses varied clearly between two subject groups among varied FIO2 in both protocols ( fig1. d ). The ' II-III ' phase act more distinct in differing two groups than ' I-II ' phase. And the low-high-low protocol acted almost perfect in accessing brain death with highest sensitivity and specificity. Over all, the novel incorporation of NIRS and a low-high-low varied FIO2 protocol was shown to a be most sensitive, highly specific, noninvasive and real time way to assess brain death and promptly offer quality assured donor organs. [1] E. F. M. Wijdicks, P. N. Varelas, G. S. Gronseth, D. M. Greer, Evidence-based guideline update: Determining brain death in adults report of the quality standards subcommittee of the American Academy of Neurology, Neurology, vol. 74, no. 23, pp. 1911-1918, 2010 [2] K. Singbartl, R. Murugan, A. M. Kaynar, D. W. Crippen, S. A. Tisherman, K. Shutterly, S. A. Stuart, R. Simmons, Intensivist-led management of brain-dead donors is associated with an increase in organ recovery for transplantation, J. M. Darby, Am. J. Transplant., vol. 11, no. 7, pp. 1517-1521, 2011 [3] T. Li, M. Duan, Y. Zhao, G. Yu, Z. Ruan. Bedside monitoring of patients with shock using a portable spatially-resolved near-infrared spectroscopy. Biomed. Opt. Express, vol. 6, no. 9, pp. 3431-3436, 2015 [4] B. Pan, C. Huang, X. Fang, X. Huang, T. Li*, Noninvasive and Sensitive Optical Assessment of Brain Death, J. Biophotonics, vol. 12, no. 3, pp. e201800240, 2018 Disclosures No relevant conflicts of interest to declare.

Evaluation of Brain Death in Laying Hens During On-Farm Killing by Cervical Dislocation Methods or Pentobarbital Sodium Injection.

This study investigated changes in the electroencephalograph (EEG) power spectrum as well as physiological and behavioral responses to on-farm killing via mechanical cervical dislocation (MCD), manual cervical dislocation (CD) or intravenous pentobarbital sodium administration in lightly anesthetized laying hens, to evaluate the welfare impact of each method. A mixed group of 44 white Leghorn and Smoky Joe laying hens (60 weeks-old) were anesthetized with isoflurane in oxygen and maintained at 1.5–2% isoflurane/O2 until the killing method was applied. Birds were randomly assigned to one of three experimental groups on each trial day. The EEG was recorded bilaterally in a four-electrode montage. After recording a 5-min baseline, the killing method was applied and EEGs and other behavioral and physiological responses, including convulsions, gasping, cessation of body movements and feather erection were recorded for 5 min. Changes in EEG frequency bands (alpha, beta, delta, theta), median frequency (F50), 95% spectral edge frequency (F95), and total power (Ptot) were used to assess the quality of the on-farm killing event. Within 15 s after administration of pentobarbital sodium, there were significant decreases in mean frequency bands, increases in mean F50 and F95, and decreases in Ptot, suggesting brain death. In addition, birds presented a shorter latency to cessation of movement after pentobarbital sodium injection compared to MCD and CD (22 vs. 115 s and 136 s, respectively). There were significant increases in F95 and decreases in Ptot at 120 s after application of CD; and a concomitant decrease in the frequency bands at 135 s and isoelectric EEG at 171 ± 15 s. Changes consistent with brain death after MCD included isoelectric EEG at 207 ± 23 s and a significant decreases in some frequency bands at 300 s post-application. No other significant spectrum frequency changes were observed in the MCD group, suggesting brain death likely occurred near the 5-min endpoint. There was no clear association between behavioral, physiological, and EEG responses within CD and MCD treatments. The data demonstrate that pentobarbital sodium induced a rapid death with minimal behavioral and physiological responses regardless of strain of hens. In comparison, use of CD and MCD resulted in a slow onset of brain death in hens.

Global Scientific Outputs of Brain Death Publications and Evaluation According to the Religions of Countries.

In 1950s, the concept of brain death, which began to be discussed primarily in terms of medicine and then in terms of religion, law, and ethics, became a central topic in all world countries as it was an early diagnosis of death. Despite the fact that brain death (BD) diagnosis is of importance for benefitting from organ and tissue transplantation of patients in the world, the literature still involves no bibliometric studies that made a holistic evaluation of the publications about this issue. The present study aims to investigate the top-cited articles about BD published between 1980 and 2018, identify the citation collaboration of the journals, demonstrate the collaboration between the countries, define the relationship between organ transplantation and BD, and reveal the latest developments and trend topics about this issue. In addition, this study aims to investigate the relationship between religions of countries and brain death publication productivity. Documents for bibliometric analysis were downloaded from Web of Science. The literature search was performed using the keywords "brain death/dead" during 1980-2018. The correlations between gross domestic product (GDP), Human Development Index (HDI) and publication productivity of the countries on BD were investigated with Spearman's correlation coefficient. There was a high-level, statistically significant correlation between the number of publications and GDP, and HDI and the number of publications about BD (r = 0.761, p < 0.001; r = 0.703, p < 0.001). The USA was the top country in terms of publication productivity, which was followed by developed countries such as Germany, Japan, France, and Spain. However, the contribution of the undeveloped or developing countries such as China, Brazil, Turkey, Iran, and South Africa was found to be considerably important. While many people in the world die with undamaged organs, many other people die needing those organs. Therefore, it is considered that the collaborations and thus multidisciplinary studies about BD should be increased in the world countries, and the countries should be involved in bigger collaborations instead of little clusters. Especially, Muslim countries should be encouraged to do research and publish studies about the issues of brain death and organ transplantation.

Assessing and Improving Documentation of Pediatric Brain Death Determination within an Electronic Health Record.

Pediatric brain death determination (BDD) can be subject to interprovider variability of documentation, resulting in diagnosis credibility. The aim of this study was to describe our approach to assessing pediatric BDD documentation and documentation variation in the electronic health record (EHR). This was a single institution cross-sectional review of pediatric patients younger than 18 years determined to meet brain death criteria. We assessed electronic documentation and evaluated for the presence of contributing factors that can interfere with the brain death documentation based on our institutional brain death evaluation policy (core body temperature, systolic blood pressure within an acceptable range, sedative/analgesic drug effects, and neuromuscular blockade). In total, 33 pediatric brain death patients were identified. This review revealed pediatric BDD documentation consistency (n, %) as follows: performance of the first pediatric brain death clinical examination with temperature above 36°C (27, 81.8%), systolic blood pressure above the defined range (29, 87.9%), more than 24 hours following admission (28, 84.8%); performance of the second pediatric brain death clinical examination with temperature above 36°C (32, 97%), more than 12 hours following the first examination (26, 89.7%); and ensuring sedative infusions were discontinued within the recommended cutoff period prior to pediatric BDD (28, 84.8%). Clinical neurologic examinations were fully documented. Pediatric BDD is a rare process subject to documentation omissions and error. Our findings highlight the variability of pediatric BDD electronic documentation among different providers and specialties at our institution. An approach to improving pediatric BDD documentation may start with completing a standardized electronic brain death document.