Comparison of 1 vs 2 Brain Death Examinations on Time to Death Pronouncement and Organ Donation: A 12-year Single Center Experience

OBJECTIVE: To fill the evidence gap on the value of a single (SBD) or dual brain death (DBD) exam by providing data on irreversibility of brain function, organ donation consent and transplantation. METHODS: 12-year tertiary hospital and organ procurement organization data on brain death (BD) were combined and outcomes, including consent rate for organ donation and organs recovered and transplanted after SBD and DBD were compared after multiple adjustments for co-variates. RESULTS: two-hundred sixty-six patients were declared BD, 122 after SBD and 144 after DBD. Time from event to BD declaration was longer by an average of 20.9 hours after DBD (p=0.003). Seventy-five (73%) families of patients with SBD and 86 (72%) with DBD consented for organ donation (p=0.79). The number of BD exams was not a predictor for consent. No patient regained brain function during the periods following BD. Patients with SBD were more likely to have at least one lung transplanted (p = 0.033). The number of organs transplanted was associated with the number of exams [beta coefficient, (95% CI) -0.5 (-0.97 to -0.02), p=0.044], along with age (for 5 year increase, -0.36 (-0.43 to -0.29), p\u3c0.001) and PaO2 level (for 10 mmHg increase, 0.026 (0.008 to 0.044), p=0.005) and decreased as the elapsed time to BD declaration increased (p=0.019). CONCLUSIONS: A single neurologic examination to determine brain death is sufficient in patients with non-anoxic catastrophic brain injuries. A second examination is without additional yield in this group and its delay reduces the number of organs transplanted

Variability of Brain Death Policies in the United States

IMPORTANCE: Brain death is the irreversible cessation of function of the entire brain, and it is a medically and legally accepted mechanism of death in the United States and worldwide. Significant variability may exist in individual institutional policies regarding the determination of brain death. It is imperative that brain death be diagnosed accurately in every patient. The American Academy of Neurology (AAN) issued new guidelines in 2010 on the determination of brain death. OBJECTIVE: To evaluate if institutions have adopted the new AAN guidelines on the determination of brain death, leading to policy changes. DESIGN, SETTING, AND PARTICIPANTS: Fifty-two organ procurement organizations provided US hospital policies pertaining to the criteria for determining brain death. Organizations were instructed to procure protocols specific to brain death (ie, not cardiac death or organ donation procedures). Data analysis was conducted from June 26, 2012, to July 1, 2015. MAIN OUTCOMES AND MEASURES: Policies were evaluated for summary statistics across the following 5 categories of data: who is qualified to perform the determination of brain death, what are the necessary prerequisites for testing, details of the clinical examination, details of apnea testing, and details of ancillary testing. We compared these data with the standards in the 2010 AAN update on practice parameters for brain death. RESULTS: A total of 508 unique hospital policies were obtained, representing the majority of hospitals in the United States that would be eligible and equipped to evaluate brain death in a patient. Of these, 492 provided adequate data for analysis. Although improvement with AAN practice parameters was readily apparent, there remained significant variability across all 5 categories of data, such as excluding the absence of hypotension (276 of 491 policies [56.2%]) and hypothermia (181 of 228 policies [79.4%]), specifying all aspects of the clinical examination and apnea testing, and specifying appropriate ancillary tests and how they were to be performed. Of the 492 policies, 163 (33.1%) required specific expertise in neurology or neurosurgery for the health care professional who determines brain death, and 212 (43.1%) stipulated that an attending physician determine brain death; 150 policies did not mention who could perform such determination. CONCLUSIONS AND RELEVANCE: Hospital policies in the United States for the determination of brain death are still widely variable and not fully congruent with contemporary practice parameters. Hospitals should be encouraged to implement the 2010 AAN guidelines to ensure 100% accurate and appropriate determination of brain death

Indicators of Subarachnoid Hemorrhage as a Cause of Sudden Cardiac Arrest

Subarachnoid hemorrhage (SAH) may present with cardiac arrest (SAH-CA). We report a case of SAH-CA to assist providers in distinguishing SAH as an etiology of cardiac arrest despite electrocardiogram findings that may be suggestive of a cardiac etiology. SAH-CA is associated with high rates of return of spontaneous circulation, but overall poor outcome. An initially non-shockable cardiac rhythm and the absence of brain stem reflexes are important clues in indentifying SAH-CA

Indicators of Subarachnoid Hemorrhage as a Cause of Sudden Cardiac Arrest

Subarachnoid hemorrhage (SAH) may present with cardiac arrest (SAH-CA). We report a case of SAH-CA to assist providers in distinguishing SAH as an etiology of cardiac arrest despite electrocardiogram findings that may be suggestive of a cardiac etiology. SAH-CA is associated with high rates of return of spontaneous circulation, but overall poor outcome. An initially non-shockable cardiac rhythm and the absence of brain stem reflexes are important clues in indentifying SAH-CA

Brain death declaration

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