Irreversible Cessation Of Brain Function Research Articles

Computed Tomography Angiography as Ancillary Testing for Death Determination by Neurologic Criteria: A Technical Review.

The determination of death by neurological criteria (DNC) stands as a pivotal aspect of medical practice, involving a nuanced clinical diagnosis. Typically, it comes into play following a devastating brain injury, signalling the irreversible cessation of brain function, marked by the absence of consciousness, brainstem reflexes, and the ability to breathe autonomously. Accurate DNC diagnosis is paramount for adhering to the 'Dead donor rule', which permits organ donation solely from deceased individuals. However, complexities inherent in conducting a comprehensive DNC examination may impede reaching a definitive diagnosis. To address this challenge, ancillary testing such as computed tomography angiography (CTA) has emerged as a valuable tool. The aim of our study is to review the technique and interpretation of CTA for DNC diagnoses. CTA, a readily available imaging technique, enables visualization of the cerebral vasculature, offering insights into blood flow to the brain. While various criteria and scoring systems have been proposed, a universally accepted standard for demonstrating full brain circulatory arrest remains elusive. Nonetheless, leveraging CTA as an ancillary test in DNC assessments holds promise, facilitating organ donation and curbing healthcare costs. It is crucial to emphasize that DNC diagnosis should be exclusively entrusted to trained physicians with specialized DNC evaluation training, underscoring the importance of expertise in this intricate medical domain.

The Unified Brain-Based Determination of Death Conceptually Justifies Death Determination in DCDD and NRP Protocols

Organ donation after the circulatory determination of death requires the permanent cessation of circulation while organ donation after the brain determination of death requires the irreversible cessation of brain functions. The unified brain-based determination of death connects the brain and circulatory death criteria for circulatory death determination in organ donation as follows: permanent cessation of systemic circulation causes permanent cessation of brain circulation which causes permanent cessation of brain perfusion which causes permanent cessation of brain function. The relevant circulation that must cease in circulatory death determination is that to the brain. Eliminating brain circulation from the donor ECMO organ perfusion circuit in thoracoabdominal NRP protocols satisfies the unified brain-based determination of death but only if the complete cessation of brain circulation can be proved. Despite its medical and physiologic rationale, the unified brain-based determination of death remains inconsistent with the Uniform Determination of Death Act.

Evolution of the Concept of Death.

The definition of death remains unresolved. To define death, one has to define the characteristics of a living person and to confirm whether an individual with brain death fulfils any of these characteristics. Although the concept of irreversible cessation of brain function is clear, controversy remains on the treatment of individuals with brain death and beating hearts. An individual with brain death but a beating heart is not breathing on his own and is dependent on medications and machines to maintain respiration, heartbeat, and blood pressure. Muslim scholars remain divided over the issue of whether death also means irreversible cessation of brain function. Questions remain on when it is permissible to remove vital organs for organ transplant. Groups have advocated for uniformity in law and medical practice on the definition of brain death.

The evolution from the diagnosis of death to encephalic death

Introduction: Death is a process whose diagnosis has varied throughout history. Objective: Demonstrate the various methods of diagnosing death until brain death is confirmed. Methods: A historical documentary review was conducted on the various methods used to diagnose death. Results: In ancient times, the cessation of breathing was the primary indicator of death. However, with the emergence of clinical death, cardiac activity became the main criterion for diagnosing death. In the late 1950s, European neurologists identified a stage at which the brain ceases to function, exhibiting irreversible damage. However, artificial means can sustain the functions of the heart and lungs. In 1959, professors Mollaret and Goulon from the Claude Bernard Hospital in Paris introduced the term “coma dépassé”' to describe a state beyond coma, where a “dead brain is associated with a living body.” This concept led to the development of brain death and the diagnosis of death through the lens of brain functions. This change facilitated the advancement of organ and tissue transplants. Conclusions: Currently, death can be diagnosed by either the cessation of heart function or the irreversible cessation of brain function

Analysis of the Knowledge of Medicine Students from Mafra-SC About Brain Death and Organs Transplantation

Introduction: Organ transplantation (OT) is a historical advance in medicine as result of the evolution of surgical techniques and immunosuppressive drugs. Brain death (BD) which is defined as the total and irreversible cessation of brain functions, closely related to OT, as these patients are potential organ donors. Objective: This study aims to evaluate the knowledge from Universidade do Contestado’s medical students regarding brain death and organ transplantation. Materials and methods: This is a prospective, analytical and descriptive study, carried out with Universidade do Contestado’s medical students, where questionnaires were applied to evaluate their knowledge on the addressed topic. In the research 139 students participated from the first to the ninth phase of the medical course, being 68.6 % feminine and 31.4 % masculine. Of these, 62.6 % have already participated in a class on ME and 44.6 % in a class on OT. 84.2 % of students do not feel able to make the diagnosis of BD, and about 51.8 % assess their knowledge of the research topics as regular, 38.8 % as poor and only 9.4 % assess it as being good. Still about BD, 69.8 % of the participants know its concept, but when asked about BD criteria, exams needed for its diagnosis and about the Brazilian legislation necessary for the donation to occur, the answers were divergent. In the study, 79.9 % of the participants intend to donate their organs. Conclusion:Most students presented knowledge around BD and OT but do not feel capable of making BD diagnosis. The study also showed that most participants would like to be organ donors

Understanding the Brain-based Determination of Death When Organ Recovery Is Performed With DCDD In Situ Normothermic Regional Perfusion.

Understanding the Brain-based Determination of Death When Organ Recovery Is Performed With DCDD In Situ Normothermic Regional Perfusion.

The Understanding of Human Death by Polish Early Career Pre-Specialist Physicians.

Despite the legal classification of cerebral death as the actual death of a human being and the continuous clarification of neurological criteria, the subject of death, particularly, when exactly it occurs, has been the subject of debate not only in the medical environment but also in other scientific communities for over sixty years. This issue is also present in social discourse. In Poland, as well as in other countries, the concepts of "death" and "cerebral death" have a legal basis. Considerations devoted to death are also important for tanatopedagogics, which focuses primarily on mortality. Indeed, the quality of relationships with other people depends to a large extent on the awareness of death. The study involved 113 pre-specialist physicians employed in various medical centers in Poland. An original questionnaire was used to study the understanding of human death in the light of legal and medical acts that came into force between 2007 and 2019. The study showed that only 7.08% of pre-specialist physicians could fully and correctly identify the basis for declaring a patient dead after diagnosing the irreversible cessation of brain function, and only 33.63% of all respondents understood death in accordance with legal acts currently in force in Poland. Moreover, nearly half of the study participants (47.79%) indicated that irreversible loss of consciousness is not adequate grounds for determining a patient's death, while 56.64% felt that cerebral death is equal to the biological death of a human being. Women were significantly more likely to understand the concept of death (p = 0.028) as defined by current documents and to perceive the irreversible loss of consciousness as an insufficient basis for determining a patient's death (p = 0.040) and also to correctly indicate on what basis cerebral death is identified with human death (p = 0.003), as expressed by current legal regulations in Poland.

Heart Transplantation after Circulatory Death: It Is Time to Redefine Death According to Irreversible Cessation of the Circulation and Reconcile It with Irreversible Cessation of Brain Function

In this article, we examine whether organ procurement of the heart and transplantation contravenes the dead donor rule and Australian legislative definitions of death as an irreversible cessation of the circulation. We contend that this practice upholds a long-held belief that donors of any organs after cessation of the circulation are not actually dead at the time of procurement – principally because of insufficient time lapse between cessation of the circulation and procurement of organs. Moreover, the fact that the transplanted heart functions in a recipient proves the donor’s circulation had never actually ceased irreversibly. Nonetheless, we suggest that this practice may be legitimised by amending legislation to redefine death as an irreversible cessation of brain function preceded by cessation of the circulation and requiring medical proof that the donor’s cortical brain function has ceased function before organ procurement.

Use of duplex echoencephalography to evaluate brain death in children: A novel approach to the diagnosis.

Brain death is defined as the irreversible cessation of brain function with a known etiology. This study aims to establish the value of duplex echoencephalography (DEG) in children fulfilling clinical brain death diagnostic criteria. DEG must show intracranial brain structures. Power Doppler is used to assess venous flow when feasible. Color Doppler patterns in all major arteries are assessed. Spectral analysis of arterial flow is divided into four grades: grade 1: inverted flow during entire diastole with time average peak velocity (TAPV) less or equal to zero; grade 2: disappearance of the inverted diastolic flow at the end of diastole; grade 3: oscillating pattern in early diastole; and grade 4: no diastolic flow with systolic blip. To fulfill diagnosis of brain death, brain perfusion must be lost for 30 minutes. DEG is performed in 41 pediatric patients. In infants, loss of venous flow occurs regardless of the etiology. Grade 1 is the most common arterial color flow pattern and TAPV is always below zero. A pulsatile color flow is associated with three other types of flow patterns (grades 2-4). TAPV is not calculated, when there is loss of diastolic flow. Diagnosis of brain death is validated using nuclear brain scan in 4patients. Two have a grade 1 flow pattern, while the other two have a grade 4 flow pattern. In children, DEG following a strict protocol can be used to confirm diagnosis of brain death in the appropriate clinical setting.

A Case Study of Child with Acute Lymphoblastic Leukemia Treated in Intensive Care

Abstract The most common childhood cancer is acute lymphoblastic leukemia, which, thanks to medical progress, achieves up to 95% of complete remission and 80% of cures with appropriate treatment among patients diagnosed with ALL. A less than three-year-old boy treated for an infectious disease and progressively worsening symptoms was transferred by the Emergency Department to the Department of Hematology and Oncology of Children after revealing leukocytosis and thrombocytopenia. In a short time, the child’s condition deteriorated, and it was decided to transfer the patient to the Children’s Intensive Care Unit. Due to respiratory failure, the boy was intubated, and mechanical ventilation was started. Catecholamines and sedatives were introduced. Due to increasing edema and anuria, diuretics were administered without diuresis. Hemodialysis was used. In spite of transfused group compatible blood products and exchange transfusion, coagulation disorders occurred. On the tenth day of hospitalization in the intensive care unit, the procedure of confirming brain death was performed. Both the prevention and treatment of hyperleukocytosis syndrome and the development of treatment methods do not reduce the risk of this syndrome among children diagnosed with acute lymphoblastic leukemia. The determination of permanent and irreversible cessation of brain function is possible only after the proper execution of the procedure for determining brain death.

Understanding of Brazilian Nursing Assistants and Technicians of Brain Death

Brain death (BD) is defined as the total and irreversible cessation of brain functions including the brain stem. The team that assists the patient in this situation is made up of higher-level and technical health professionals. Our objective was to analyze the understanding of nursing assistants and technicians of BD. Descriptive and exploratory research with a qualitative approach was carried out with nursing assistants and technicians who were members of the Regional Nursing Council of São Paulo, Brazil. After collection, the data were submitted to the thematic-category content analysis technique. From the analysis, the following categories emerged: an understanding of BD; religiosity and hope in the reversal of BD; and "brain death associated with the possibility of organ donation." This study reinforces the need to train professionals at a technical nursing level on the subject in order to improve nursing care and avoid mistaken beliefs that can negatively influence the process of donating organs and tissues for transplantation.

A Framework for Revisiting Brain Death: Evaluating Awareness and Attitudes Toward the Neuroscientific and Ethical Debate Around the American Academy of Neurology Brain Death Criteria.

Background:There remains a lack of awareness around the American Academy of Neurology (AAN) procedural criteria for brain death and the surrounding controversies, leading to significant practice variability. This survey study assessed for existing knowledge and attitude among healthcare professionals regarding procedural criteria and potential change after an educational intervention.Methods:Healthcare professionals with increased exposure to brain injury at Mayo Clinic hospitals in Arizona and Florida were invited to complete an online survey consisting of 2 iterations of a 14-item questionnaire, taken before and after a 30-minute video educational intervention. The questionnaire gathered participants’ opinion of (1) their knowledge of the AAN procedural criteria, (2) whether these criteria determine complete, irreversible cessation of brain function, and (3) on what concept of death they base the equivalence of brain death to biological death.Results:Of the 928 people contacted, a total of 118 and 62 participants completed the pre-intervention and post-intervention questionnaire, respectively. The results show broad, unchanging support for the concept of brain death (86.8%) and that current criteria constitute best practice. While 64.9% agree further that the loss of consciousness and spontaneous breathing is sufficient for death, contradictorily, 37.6% believe the loss of additional integrated bodily functions such as fighting infection is necessary for death. A plurality trusts these criteria to demonstrate loss of brain function that is irreversible (67.6%) and complete (43.6%) at baseline, but there is significantly less agreement on both at post-intervention.Conclusion:Although there is consistent support that AAN procedural criteria are best for clinical practice, results show a tenuous belief that these criteria determine irreversible and complete loss of all brain function. Despite support for the concept of brain death first developed by the President’s Council, participants demonstrate confusion over whether the loss of consciousness and spontaneous breath are truly sufficient for death.

Muerte Cerebral, revisión de tema.


 El término muerte cerebral se entiende como el cese irreversible de las funciones cerebrales incluidas las del tronco encefálico. El determinar el fallecimiento de una persona cuando todavía presenta signos vitales genera gran controversia con respecto al tema de donación de órganos y la fiabilidad del diagnóstico certero. Hasta este momento ninguna prueba de gabinete ha demostrado ser completamente adecuada y aunque son muchos las pruebas que se utilizan mundialmente, ninguna ha sido adoptada dentro de una guía oficial.

Organ Donation - Management from Donor Identification to Organ Procurement

According to the Transplantation Act (TPG), clinics and transplant commissaries (TxB) are obliged to ensure quality in donor evaluation. They are supervised. TxBs exist in every hospital that carries out organ harvesting and are always available. They are responsible for the conception of the organ donation process and should manage each individual case from the evaluation to the implementation of the patient's wishes.The evaluation for potential organ donors should be routine and supported by IT technology. The intensive care team must inform the TxB about living patients who "come into consideration" as organ donors. Reasons for exclusion can be known rejection, absolute medical contraindications and loss of function of all transplant organs. ICBF (irreversible cessation of brain function) deceased without reasons for exclusion must be reported to the DSO immediately. Talks with relatives about the neurological outcome, the ICBF diagnostics and organ donation are of fundamental importance for the implementation of the (presumed) wish of the potential organ donor and the relatives. The aim of the talks should be a sound decision with which the relatives can conclude. The TxBs support the ICU team to achieve this.Organ donation should be handled like an emergency. Typical bottlenecks are the instrument-based examinations and the availability of the operating room. The TxBs should draw up a schedule, communicate this to the interfaces and be available at all times during the entire organ donation process. Documentation of all details is important, as the TxBs must prepare detailed individual case analyses for quality assurance purposes and forward them to the clinic management and the DSO. Quality circles and especially peer review procedures are used and recommended as further QM tools.

Donors After Circulatory Death: Theme of Present or a Future? The Research in West Poland

The most urgent issue in transplantology nowadays is to increase the number of donors as replacement of lungs, heart, and liver in end-stage disease remains the only available method to save patients. Donors after brain death (DBD), these after irreversible cessation of brain function, represent 95% of all donors. On the contrary, donors after circulatory death (DCD), namely donors after irreversible detention of circulation, a group of great potential, is totally unused. The survey was done among 500 people from the medical staff of the intensive care unit and intensive cardiological care where the probability of receiving anonymous donation after circulatory death is the highest, yet only 368 people had completed the survey and their cases were taken into consideration as far as the study was concerned. The survey was conducted in the form of a self-projected questionnaire based on the Hospital Attitude Survey. The study showed that 98.4% of respondents accept the transplant. As many as 93.1% of people did not know the Maastricht classification, and 57.5% claimed that in Poland there is permission to take organs from people with a nonbeating heart. Ninety percent of respondents expressed their willingness to participate in training, and 70% of them were interested in the subject of the training presented in the questionnaire. At a time of such immense need for organs and such a huge disparity in the number of donors and recipients, DCD type of transplantation may be an alternative for patients whose waiting time for donation from a DBD would total a few years.

Diagnosis of irreversible loss of brain function ("brain death")-what is new?

The determination of the irreversible cessation of brain function (ICBF) is conducted in Germany according to the guideline of the German Medical Association, which is currently its fourth update issued in July 2015. This article provides an assessment of the current situation including an international comparison. International case reports with allegedly incorrect ICBF diagnosis are reviewed from the point of view of the German guideline. These case reports underpin the validity of the German guideline, especially its following provisions: (1)in patients with known or suspected adaptation to chronic hypercapnia, apnea cannot be diagnosed as usual; therefore in such acase the proof of cerebral circulatory arrest is mandatory; (2) if perfusion scintigraphy is used for proof of cerebral circulatory arrest, only validated lipophilic radiopharmaceuticals are allowed. This is compatible with new research data which indicate that cellular function can be reactivated for several hours after circulatory arrest but not the brain function. The recently updated recommendations of the German Society for Clinical Neurophysiology and Functional Imaging (DGKN) for ancillary testing include editorial adaptations (e.g., the more precise specification of the electrode positions for electroencephalography), standards of display screen with digital electroencephalography and age-related minimum values of mean arterial pressure for Doppler and duplex sonography in children. The novel requirements regarding the institutional organization of ICBF diagnostics in Germany issued in the "Second law on the amendment of transplantation law-improvement of the cooperation and the framework for organ donation" that became effective recently are presented and discussed critically in this review.

Determination of Death in Execution by Lethal Injection in China

Since 1997, execution in China has been increasingly performed by lethal injection. The current criteria for determination of death for execution by lethal injection (cessation of heartbeat, cessation of respiration, and dilated pupils) neither conform to current medical science nor to any standard of medical ethics. In practice, death is pronounced in China within tens of seconds after starting the lethal injection. At this stage, however, neither the common criteria for cardiopulmonary death (irreversible cessation of heartbeat and breathing) nor that of brain death (irreversible cessation of brain functions) have been met. To declare a still-living person dead is incompatible with human dignity, regardless of the processes following death pronouncement. This ethical concern is further aggravated if organs are procured from the prisoners. Analysis of postmortem blood thiopental level data from the United States indicates that thiopental, as used, may not provide sufficient surgical anesthesia. The dose of thiopental used in China is kept secret. It cannot be excluded that some of the organ explantation surgeries on prisoners subjected to lethal injection are performed under insufficient anesthesia in China. In such cases, the inmate may potentially experience asphyxiation and pain. Yet this can be easily overlooked by the medical professionals performing the explantation surgery because pancuronium prevents muscle responses to pain, resulting in an extremely inhumane situation. We call for an immediate revision of the death determination criteria in execution by lethal injection in China. Biological death must be ensured before death pronouncement, regardless of whether organ procurement is involved or not.

Determination of Brain Death: An Overview with a Special Emphasis on New Ultrasound Techniques for Confirmatory Testing

Progress in resuscitation medicine and the widespread success of cardiopulmonary support in intensive care medicine called for new standards for determining a patients death. Following a worldwide discussion on the medical, ethical, and legal aspects of death, the term brain death is now a generally accepted criterion for death. Brain death, defined as complete and irreversible cessation of brain function was established to describe an individuals death even during artificial ventilation and a temporary maintenance of cardiac function in the ICU setting. The determination of brain death requires adequate prerequisites, as well as clinical findings verifying a complete loss of function of the entire brain, and a confirmation of its irreversibility. Most countries have national guidelines aimed at providing a high-quality medical standard and to exclude any conflicts of interest. On confirmation of brain death, life-sustaining therapies are discontinued in accordance with the declared or assumed will of the dead individual. Only in cases of an intended organ donation, organ protective measures need to be continued until surgery. In this overview, we aim to outline the components of determining clinical brain death with a special emphasis on new ultrasound techniques for confirmatory testing.

General Anesthesia for Surgical Procurement in Non-Heart-Beating Organ Donation

To the Editor The Uniform Determination of Death Act defines death as a singular phenomenon by irreversible cessation either of circulatory and respiratory functions or of all brain and brainstem functions.1 Growing demand for transplantable organs has refocused attention on the circulatory standard of declaring death in non-heart-beating donation (NHBD).2 Variable (75 seconds to 5 minutes) cardiac mechanical asystole (or absent arterial pulse) is the United States' circulatory standard.2 This standard is based on expert opinion of zero chance of spontaneous recovery of heart and brain functions after 65 seconds of mechanical asystole.3 Hearts recovered from donors may have normal native mechanical and electrical functions after transplantation3; therefore, mechanical asystole can be reversed. Others conceded that donors in NHBD might not necessarily be dead, either by cardiorespiratory (circulatory standard) or brain (neurological standard) criteria.4 We argued that antemortem and postmortem interventions performed for organ preservation in donors are neuroprotective, preventing rapid deterioration or irreversible cessation of brain functions after mechanical asystole.5 Auyong et al. provided compelling evidence for studying brain function in donors declared dead in NHBD.6 In 3 non-heart-beating donors, the authors demonstrated reproducible surges in Bispectral Index scores from real-time electroencephalograms. Chawla et al.7 reported similar Bispectral Index score surges in 7 cases within minutes after being declared dead, i.e., pulseless, motionless, and asystolic on the electrocardiogram. The clinical and neurological significance of delayed surges of brain electric activity after mechanical asystole is unknown. However, nocioception and awareness are real concerns during surgical procurement in NHBD. General anesthesia is not administered to donors because they are assumed dead with no discernable brain functions. This is of particular concern because age eligibility for NHBD starts from newborn and includes donors with normal brain function before sustaining mechanical asystole (e.g., end-stage musculoskeletal disease, pulmonary disease, and high spinal cord injury) (available at http://optn.transplant.hrsa.gov/policiesAndBylaws/bylaws.asp; accessed March 20, 2010).8 We agree with Auyong et al. that donors should be routinely monitored with electroencephalogram for dosing of anesthetic and opioids drugs during surgical procurement. Mohamed Y. Rady, MD, PhD, FCCM Joseph L. Verheijde, PhD, MBA, PT Department of Critical Care Medicine Departments of Biomedical Ethics, Physical Medicine, and Rehabilitation Mayo Clinic Phoenix, Arizona School of Life Sciences Center for Biology and Society Arizona State University Tempe, Arizona [email protected]

The diagnosis of brain death: medical and legal aspects with special reference to the German Transplantation Law (TPG)

The diagnosis of brain death following total and irreversible cessation of all cerebral functions is based on anthropological assumptions and conventions as well as on the exact medical diagnosis of total loss of brain function. The question whether individual life ends after cerebral function is irreversibly lost cannot be answered by medical definition alone. Clear and unrefutable legal definitions of death and the cessation of the rights of the individual must be provided before organs may be harvested from brain dead individuals. Acceptance of these definitions by the general population is of paramount importance for the practice of organ donation. In the first part of this article, the legal definition of death and the provisions of the German transplantation law are critically reviewed. The legal statements deal with the question of the definition of death and how death can be detected. The provisions of the German transplantation law are referenced with special attention to the provision of prior consent to the removal of organs following after the diagnosis of brain death. The provisions of the German constitution with respect to the preservation of the personal rights of the individual are discussed in the light of organ harvesting. The second part deals with the medical procedure of determining brain death in adults. The medical statements pertain to the diagnostic steps to be taken in the diagnosis and determination of brain death. The prerequisites for entering the diagnostic procedure to determine brain death are described. The clinical signs of total and irreversible cessation of brain function are listed, and the technical examinations to corroborate the clinical signs of brain death as accepted in Germany are delineated. In the perspective of the authors, individuals having suffered brain death still possess the protection of their personal human rights according to the German constitution since it cannot be conclusively demonstrated that total loss of brain function alone constitutes the cessation of life in the sense of the German constitution.