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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

Diagnosis of Death Masterclass

Alex Manara

Dale Gardiner

Paul Murphy

31 March 2010

“Improving organ donation within your hospital”

1

slide4

2. Increased diagnosis of brain stem death

3. Increased donation after cardiac death

Diagnosis of Death Masterclass

4

slide5

Incidence of Brainstem Death on ICU

(< 75 years, non-cardiac ICUs)

slide6

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
slide9

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

slide10

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

slide14

Critics

Edmund Pellegrino

Margaret Lock

Alan Shewmon

UK critics

David EvansDavid Hill

Philip Keep

Peter Singer

Rinaldo Bellomo

14

criteria for human death

= 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

slide19

Transplant Technique

    • Split livers
    • Marginal Donors
  • Immunosuppressants
    • Tacrolimus
    • Mycophenolate

19

slide21

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

slide22

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

slide23

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

slide24

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

slide25

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

slide29

‘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

slide30

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

slide35

Whole Brain Death

Rest of the World

Brain Stem Death

UK

Higher Brain Death

Philosophers

35

slide36

Higher Brain Death

Philosophers

Peter Singer

36

slide37

Whole Brain Death

Rest of the World

Rinaldo Bellomo

ICM 2004

37

slide39

Whole Brain Death

Rest of the World

39

slide40

Whole Brain Death

Rest of the World

40

slide41

Whole Brain Death

Rest of the World

41

slide46

DEAD

ALIVE

46

slide58

Whole Brain Death

Rest of the World

58

slide60

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

slide63

Whole Brain Death

Rest of the World

63

criteria for human death1

= The irreversible cessation of brain-stem function

=> Irreversible unconsciousness + Irreversible apnoea

Criteria for Human Death

64

slide66

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

66

slide69

trauma unit

PET scan brain

United Regional

Healthcare System

Wichita Falls, Texas

no blood flowing

69

slide72

USA Trauma Center

Level I - Highest

to

Level III - Lowest

72

slide74

>

74

criteria for human death2

= 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

slide80

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

slide84

DEAD

ALIVE

84

slide88

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

slide89

Question 2

The ventilator registers the patient as making spontaneous respirations?

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

89

slide90

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

slide91

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

slide92

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

slide93

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

slide94

How are you going?

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

94

slide95

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

slide96

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

slide97

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

slide98

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

slide99

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

The Confirmation of Death

Alex ManaraICU Frenchay Hospital

100

slide103

Confirming Death

  • Cessation of heart beat
  • Cessation of breathing
  • Unresponsiveness
  • Relatively easy to make
  • Reproducible
  • Recognizable

103

slide105

Confirming Death: Most doctors.

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

105

slide106

Confirming Death: Neurosurgeons...

“YOU’RE DEAD WHEN YOUR BRAIN IS DEAD”

106

slide107

Confirming Death: Orthopods...

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

107

slide108

Confirming Death: What the public think...

“YOU’RE DEAD WHEN YOUR HEART STOPS”

108

slide109

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

slide112

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

slide113

All Death is Brain Death

  • 1. Cardio-respiratory determination of death
  • 2. Neurological determination of death
  • 3. Somatic determination of death

113

slide114

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

slide115

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

slide116

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

slide117

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

slide118

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

slide119

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

slide120

Post mortem Interventions

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

120

slide121

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

slide122

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

slide124

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

slide125

UK Deceased Organ Donors

In past 10 years there have been 1138 NHBDs

125

slide126

Organ Donation USA

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

126

slide127

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

slide129

History

  • Improved ICU care of comatose patients
  • Coma depassé described in Paris in 1959
  • Deep irreversible coma
  • Nearly always followed by cardiac arrest

129

slide130

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

slide131

Rationale for New Guidelines

  • Variable practice when guidelines not specific
  • Guidelines not always followed even when specific

131

slide132

New Guidelines

  • Published 2008
  • Attempts further standardisation
  • Primarily a clinical diagnosis
  • Clinical judgement still required

132

slide133

Neurological Determination of Death in UK

1. Patient in deep apnoeic coma

133

slide134

Neurological Determination of Death in UK

2. Known cause capable of causing ND

134

slide135

Neurological Determination of Death in UK

3. No reversible causes / confounding factors

  • Primary hypothermia
  • Metabolic disturbances
  • Alcohol
  • Depressant drugs
  • Muscle relaxants

135

slide136

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

slide137

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

slide138

Neurological Determination of Death in UK

4. Absent brainstem reflexes

138

slide139

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

slide140

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

slide141

Whole Brain Death ?

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

141

slide142

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

slide144

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

slide145

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

slide146

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

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