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Diagnosis of Death Masterclass. Alex Manara Dale Gardiner Paul Murphy 31 March 2010. “Improving organ donation within your hospital”. 1. 2. Diagnosis of Death Masterclass The six big wins. 3. 2. Increased diagnosis of brain stem death. 3. Increased donation after cardiac death.

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Diagnosis of Death Masterclass

Alex Manara

Dale Gardiner

Paul Murphy

31 March 2010

“Improving organ donation within your hospital”

1


2


Diagnosis of Death MasterclassThe six big wins

3


2. Increased diagnosis of brain stem death

3. Increased donation after cardiac death

Diagnosis of Death Masterclass

4


Incidence of Brainstem Death on ICU

(< 75 years, non-cardiac ICUs)


Incidence of Brainstem Death on ICU

(< 75 years, non-cardiac ICUs)

  • 350 missed potential donors

  • 172 actual donors

  • 619 additional transplanted patients

  • Extra 2.8 donors pmp


Reasons for not testing (approx 350 / year)

Diagnosis of Brainstem Death


Diagnosis of Brainstem Death


Is NHBD organ donation maximised in the UK?

  • The Potential Donor Audit has been assessing the potential for NHBD in the UK for the last five years. The map below shows NHB donor numbers by DTC region for 2009.

  • Significant regional variation

    • Only 50% of suitable patients given the option of NHBD

  • Significant clinical variation

    • Diagnosis of death

    • warm ischaemic times

    • organ retrieval

9


Aims:

Promote national consistency in the use of the criteria used to diagnose death.

You to feel confident in the criteria used to diagnose death whilst being alert to potential pitfalls.

For you to be aware of potential criticisms by colleagues and the literature and have thought about possible counter arguments.

10


Agenda


A Defence of the British Criteria

Dale Gardiner

12


30 years on…

13


Critics

Edmund Pellegrino

Margaret Lock

Alan Shewmon

UK critics

David EvansDavid Hill

Philip Keep

Peter Singer

Rinaldo Bellomo

14


15


= The irreversible cessation of brain-stem function

=> Irreversible unconsciousness + Irreversible apnoea

Criteria for Human Death

=> intra-cranial or extra-cranial cause

=> 5 mins absent cerebral circulation

DO NOT restore Cerebral Circulation

16


17


18


  • Transplant Technique

    • Split livers

    • Marginal Donors

  • Immunosuppressants

    • Tacrolimus

    • Mycophenolate

19


20


The Concept of Brain Death Did Not Evolve to Benefit Organ Transplants.

Transplants

Brain Death

1st Renal auto-Tx

(unsuccessful)

1902

Cushing

Transplants

Transplants

Transplants

Transplants

Transplants

Transplants

Transplants

Transplants

Transplants

21


The Concept of Brain Death Did Not Evolve to Benefit Organ Transplants.

Transplants

Brain Death

1902

  • EEG discovered

  • In electric potential = Death

  • Loss cortical potentials seen in ischaemia

1st xeno-Tx (unsuccessful)

Transplants

Transplants

1st Renal cadaveric Tx

(unsuccessful)

Transplants

Transplants

Transplants

Transplants

Transplants

1950

Transplants

22


The Concept of Brain Death Did Not Evolve to Benefit Organ Transplants.

Transplants

Brain Death

1950

Cessation of brain blood flow = Death

Cortical circulatory arrest seen in coma patients

1st successful live Renal Tx

Transplants

Death of the nervous system = Coma dépassé

Transplants

Transplants

Transplants

1960

Transplants

Transplants

Transplants

23


The Concept of Brain Death Did Not Evolve to Benefit Organ Transplants.

Transplants

Brain Death

1960

1st successful cadaveric Renal Tx

Irreversible cessation of the EEG

= Death

Transplants

Transplants

Transplants

Transplants

Transplants

Transplants

Transplants

24


The Concept of Brain Death Did Not Evolve to Benefit Organ Transplants.

Transplants

Brain Death

1967-68

1st successful Heart Tx

Harvard Criteria

Brain Death = DEATH

Transplants

Transplants

Transplants

Transplants

Transplants

Transplants

Transplants

25


3rd December 1967

26


Ad Hoc Committee of the Harvard Medical SchoolJAMA5th Aug 1968

27


28


‘Our Primary purpose is to define irreversible coma as a new criterion for death……Obsolete criteria for the definition of death can lead to controversy in obtaining organs for transplantation.’

29


The Concept of Brain Death Did Not Evolve to Benefit Organ Transplants.

Transplants

Brain Death

Future

1st xeno Tx

1st lab grown organ Tx

Brain Death = DEATH

Transplants

Transplants

Transplants

Transplants

Transplants

Transplants

Transplants

Transplants

Transplants

30


31


32


diagnosis decision

33


34


Whole Brain Death

Rest of the World

Brain Stem Death

UK

Higher Brain Death

Philosophers

35


Higher Brain Death

Philosophers

Peter Singer

36


Whole Brain Death

Rest of the World

Rinaldo Bellomo

ICM 2004

37


Brain Stem Death

UK

38


Whole Brain Death

Rest of the World

39


Whole Brain Death

Rest of the World

40


Whole Brain Death

Rest of the World

41


Brain Stem Death

UK

42


43


NEJM 2010

44


45


DEAD

ALIVE

46


Brain Stem Death

UK

47


Brain Stem Death

UK

48


Brain Stem Death

UK

49


50


51


D. Alan Shewmon, MD

52


53


54


55


Doctors fight to save brain-dead mom’s foetus...… for 3½ months

56


57


Whole Brain Death

Rest of the World

58


Brain Stem Death

UK

59


The inferior hypophysial artery is an artery supplying the posterior pituitary gland. It is a branch of the cavernous carotid artery (internal carotid artery) which is extradural at this point.

60


61


62


Whole Brain Death

Rest of the World

63


= The irreversible cessation of brain-stem function

=> Irreversible unconsciousness + Irreversible apnoea

Criteria for Human Death

64


Alan Shewmon MD

65


‘Although we were unable to restore his consciousness or spontaneous breathing, the boy lived several more years.’ (page 195)

66


Brain Stem Death

UK

67


68


trauma unit

PET scan brain

United Regional

Healthcare System

Wichita Falls, Texas

no blood flowing

69


70


Regions only Level III Trauma Centre

71


USA Trauma Center

Level I - Highest

to

Level III - Lowest

72


73


>

74


75


76


= The irreversible cessation of brain-stem function

=> Irreversible unconsciousness + Irreversible apnoea

Criteria for Human Death

=> intra-cranial or extra-cranial cause

=> 5 mins absent cerebral circulation

DO NOT restore Cerebral Circulation

77


75 seconds, 2 minutes, 5 minutes

2 minutes

5 minutes

78


Dr Michael DeVitaUniversity of Pittsburgh

79


3.7 days old donor

Taken to the operating room

Lined and given heparin

Extubated & sedated

Waited 75 seconds of PEA

“Best interests of the recipient”

80


81


82


One Thousand One Hundred and Seven NHBD

83


DEAD

ALIVE

84


85


Questions?

86


Quiz: Dead or not Dead?

87


Question 1

The patient flexes their arm at the elbow following imposition of a painful stimulus to the nail bed on that side?

  • Dead - May represent a spinal reflex

88


Question 2

The ventilator registers the patient as making spontaneous respirations?

  • Dead - May represent the heart beat creating flow that is triggering ventilation

89


Question 3

The patient has a generalised tonic clonic seizure?

  • NOT brain stem dead – the patient must have intact neural connections to have a grand mal fit

90


Question 4

The patient’s pulse increases from 70bpm to 110 bpm during apnoea testing?

  • Dead - Hypercarbia (which occurs during apnoea testing) results in endogenous adrenaline release.

91


Question 5

There is slow drift of one eye away from the ear in which cold water is injected?

  • NOT brain stem dead – any eye movements in response to caloric testing signifies the presence of some reflex brain stem arc function.

92


Question 6

The patient sits up during apnoea testing (Lazarus sign)?

  • Dead - A spinal reaction to the acidosis which follows hypercarbia. Very unsettling and disturbing!

93


How are you going?

These six questions were asked in the Australian JFICM exam 2008 and the pass rate was only 65%!

94


Question 7

During an apnoea test on a mechanical ventilator after 20 seconds the patient starts to breathe and then continues to breathe at 16 breaths per minute?

  • Dead – ventilator apnoea ventilation has kicked in. Are you convinced not to do your apnoea tests still connected to the ventilator?

95


Question 8

Supra-orbital painful stimulus leads to movement in one of the arms?

  • Not dead – although one primarily looks for movement in the cranial nerve distribution one must actively ensure (by repetition) that this was a coincidental spinal reflex but until proven this may represent the patient is not brain stem dead.

96


Question 9

During the second set of brain stem testing the second clinician finds the ears full of wax and can't visualise the drum?

  • Not dead – this finding may invalidate the first oculovestibular test and thus the patient may not be dead.

97


Question 10

Due to left orbital trauma you can't visualise or observe the left eye?

  • Dead – may still be dead even if one can’t carry out the full test. Some of the options we discuss in our case based discussions after morning tea.

98


Question 11

After a complete set of brain stem tests, confirming clinical brain stem death, your colleague organises a CT angiogram which reveals persisting intracerebral blood flow?

  • Dead – Brain Stem Death is the UK Criteria

99


The Confirmation of Death

Alex ManaraICU Frenchay Hospital

100


Confirmation vs. Certification

101


600,000 UK deaths per annum

102


Confirming Death

  • Cessation of heart beat

  • Cessation of breathing

  • Unresponsiveness

  • Relatively easy to make

  • Reproducible

  • Recognizable

103


Confirming Death

104


Confirming Death: Most doctors.

“YOU’RE DEAD WHEN YOU’VE GOT NO HEART SOUNDS, NO BREATHE SOUNDS AND FIXED DILATED PUPILS”

105


Confirming Death: Neurosurgeons...

“YOU’RE DEAD WHEN YOUR BRAIN IS DEAD”

106


Confirming Death: Orthopods...

“YOU’RE DEAD WHEN YOU’RE COLD, BLUE AND STIFF”

107


Confirming Death: What the public think...

“YOU’RE DEAD WHEN YOUR HEART STOPS”

108


The Law

  • There is no statutory definition of death in the United Kingdom (Unlike USA)

  • The determination of death using neurological criteria has been accepted by the courts of England and Wales.

  • Otherwise you’re dead when a doctor says so = accepted medical practice

109


Variation in Practice

110


What is accepted medical practice?

111


Definition of death

“The irreversible loss of those essential characteristics which are necessary to the existence of a living human person”

=

“The irreversible loss of the capacity for consciousness, combined with the irreversible loss of the capacity to breathe”

112


All Death is Brain Death

  • 1. Cardio-respiratory determination of death

  • 2. Neurological determination of death

  • 3. Somatic determination of death

113


Cardio-respiratory criteria

“The heart and lung are not important as basic prerequisites to continue life but rather because the irreversible cessation of their functions shows that the brain has ceased functioning”

114


Cardio-respiratory criteria

  • Need to be applicable to primary care / out of hospital setting

  • Simultaneous and irreversible onset of apnoea, and unconsciousness in the absence of a circulation.

  • Irreversible cessation of brain stem function rapidly follows

115


Preconditions for cardiac criteria

  • Decision made to abandon CPR

  • The individual meets the criteria for not attempting CPR (ROLE)

  • Active treatment is being withdrawn as declared not in the patient’s best interests

  • Patient has an advance directive refusing CPR

116


At “asystole”

  • Person confirming death present and continuously observes apnoea, asystole and unresponsiveness for a minimum of 5 minutes

  • Absent circulation confirmed clinically or with monitors

  • Return of circulation or respiration prompts start of a further 5 minutes from point of next cardio-respiratory arrest

  • Confirm absent pupillary and corneal reflexes and no central response to pain

117


At “asystole”

  • Person confirming death present and continuously observes apnoea, asystole and unresponsiveness for a minimum of 5 minutes

  • Absent circulation confirmed clinically or with monitors

  • Return of circulation or respiration prompts start of a further 5 minutes from point of next cardio-respiratory arrest

  • Confirm absent pupillary and corneal reflexes and no central response to pain

118


Irreversibility

  • Heart will not be restarted because patient not for CPR

  • Cardiac activity will not resume spontaneously

  • Cannot be restarted even with CPR

No post-mortem procedures that have the potential to restore cerebral perfusion

119


Post mortem Interventions

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_108827.pdf

120


Post Mortem Interventions

Anything that places the person at risk of serious harm or distress is unlikely ever to be in the person’s best interests. (CPR, femoral cannulation, heparinisation)

121


International Differences

  • 2 minutes

    • Pittsburgh protocol 1993

    • ANZICS

  • Minimum of 2 minutes, no more than 5 minutes recommended

    • Society of Critical Care Medicine, USA

  • Minimum of 5 minutes:

    • Academy of Medical Royal Colleges UK

    • Intensive Care Society, UK

    • Institute of Medicine, USA

    • Canadian Council for Donation and Transplantation

  • Minimum of 10 minutes

    • Maastricht Conference, Holland

122


123


80 year old male with pancreatitis, cerebral infarction and MRSA sepsis

CPR abandoned - Doctor went to shower

IPPV continued

ROSC noted on return at 5 minutes

Patient died 2 days later

124


UK Deceased Organ Donors

In past 10 years there have been 1138 NHBDs

125


Organ Donation USA

In USA approx 3000 NHBDs (2 min – 5 min)

126


Lazarus?

Is auto-resuscitation a result of not having a standardised way of confirming death and also defining what can and cannot happen after death?

127


Neurological Determination of Death in UK

128


History

  • Improved ICU care of comatose patients

  • Coma depassé described in Paris in 1959

  • Deep irreversible coma

  • Nearly always followed by cardiac arrest

129


Cardiac Prognosis After NDD

  • Pallis 1987: 1300 patients all developed cardiorespiratory arrest even with full support

  • Hung et al 1995:

  • 73 adults and children

  • Full and continued CVS support

  • All became asystolic; within 10 days

130


Rationale for New Guidelines

  • Variable practice when guidelines not specific

  • Guidelines not always followed even when specific

131


New Guidelines

  • Published 2008

  • Attempts further standardisation

  • Primarily a clinical diagnosis

  • Clinical judgement still required

132


Neurological Determination of Death in UK

1. Patient in deep apnoeic coma

133


Neurological Determination of Death in UK

2. Known cause capable of causing ND

134


Neurological Determination of Death in UK

3. No reversible causes / confounding factors

  • Primary hypothermia

  • Metabolic disturbances

  • Alcohol

  • Depressant drugs

  • Muscle relaxants

135


Neurological Determination of Death in UK

3. No reversible causes / confounding factors - Metabolic

  • Temperature > 34o C

  • Na+ < 160 mmol/L

  • K+ > 2 mmol/L

  • Glucose > 3 mmol/L < 20mmol/L

  • Phosphate > 0.5 mmol/L < 3 mmol/L

  • Magnesium

  • Serum Na+ > 115mmol/L?

136


Neurological Determination of Death in UK

3. No reversible causes / confounding factors - Sedatives

  • Clinical judgement essential

  • Impossible to create rules covering every situation

  • Difficulties mainly with thiopentone and midazolam

  • Plasma concentrations not good predictors of effect

  • Use of antagonists may help

  • Ideally use non cumulative drugs – propofol, remifentanil

137


Neurological Determination of Death in UK

4. Absent brainstem reflexes

138


Neurological Determination of Death in UK

Apnoea Test

  • Must be done last after other reflexes absent

  • Undertaken no more than twice

  • Achieve CVS stability at PaCO2 > 6kPa before disconnection

  • Disconnect for 5 minutes

  • Return PaCO2 to normal on reconnection

139


Neurological Determination of Death in UK

5. Ancillary Tests

  • 4 vessel cerebral angiography

  • CT angiography

  • MRI angiography

  • EEG

  • TCD

  • SPECT

  • Brain stem evoked potentials

  • Response to 2mg atropine

  • ICP > MAP

140


Whole Brain Death ?

http://video.bloodservices.ca/Streaming/nddvideo/

141


Reducing Variability in Practice

  • Guidelines – Helpful but limited value

  • CLODs – Professional Development Programme

  • Development of international approach to confirmation

  • Prospective observational studies on onset of asystole

142


Case Study Activity

143


Case Study Exercise

  • We have 2 case studies which we would like you to discuss and respond to in your table groups

  • You each have a handout of the 2 case studies which provide a case context and a series of questions

  • We will spend 30 mins total on each case study, 15mins to discuss & answer questions and15 mins to feedback as a wider group

  • This part of the session will take an hour to complete and will be followed by a more general Q&A

144


Case Study 1

  • A middle-aged woman presents to your Emergency Department at 1600 after collapsing at home. She has fixed pupils and is intubated without drugs. CT head reveals catastrophic subarachnoid haemorrhage. Neurosurgical opinion is that this is an unsurvivable situation and withdrawal of life sustaining treatment is advised. The family approach the ED staff suggesting their relative would wish to be an organ donor. Brain death is suspected.

145


Case Study 2

  • A young man is admitted to your neuro-critical care unit with severe traumatic brain injury. Despite aggressive treatment his pupils fix after four days and irreversible cessation of brain stem function (brain stem death) is suspected.

  • He has received substantial doses of sedatives (midazolam, alfentanil and propofol).

146


Questions???

147


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