Critics and Brain Death

2017 ◽  
Author(s):  
Eelco F.M. Wijdicks
Keyword(s):  
Brain Death ◽  
Apnea Test ◽  
Life And Death ◽  
Total Brain ◽  
Women And Children ◽  
Brain Dead ◽  
Hypothalamic Function ◽  
Fair Assessment

Matters of life and death—and the physician’s role—invite criticisms and alternate interpretations. Commentaries against the clinical diagnosis of brain death or the concept of brain death have shifted their focus. These range from criticisms of the Harvard Committee (alleging conflict of interest, as shown by the presence of transplant physicians), to clinical examination (alleging injury with the apnea test), to critiques of the total brain necrosis criteria (alleging intact pituitary and hypothalamic function), to critiques on the difficulty of support (alleging long-term support in pregnant “brain-dead” women and children) and, most recently, to critiques on irreversibility (alleging possible recoveries). Philosophical arguments may reach the bedside, which may become consequential. In this chapter, a fair assessment of these criticisms, particularly those regarding determination of brain death, is provided, followed by a rebuttal. Practitioners should be aware of the existing body of literature analyzed herein.

Brain Death and Organ Donation

2018 ◽  
Author(s):  
Thomas I. Cochrane
Keyword(s):  
Brain Death ◽  
Organ Donation ◽  
Cardiac Death ◽  
Donation After Cardiac Death ◽  
Donation After Brain Death ◽  
Brain Death Determination ◽  
Brain Dead ◽  
American Academy Of Neurology ◽  
Death Determination

Brain death is the state of irreversible loss of the clinical functions of the brain. A patient must meet strict criteria to be declared brain dead. They must have suffered a known and demonstrably irreversible brain injury and must not have a condition that could render neurologic testing unreliable. If the patient meets these criteria, a formal brain death examination can be performed. The three findings in brain death are coma or unresponsiveness, absence of brainstem reflexes, and apnea. Brain death is closely tied to organ donation, because brain-dead patients represent approximately 90% of deceased donors and thus a large majority of donated organs. This review details a definition and overview of brain death, determination of brain death, and controversy over brain death, as well as the types of organ donation (living donation versus deceased donation), donation after brain death, and donation after cardiac death. A figure presents a comparison of organ donation after brain death and after cardiac death, and a table lists the American Academy of Neurology Criteria for Determination of Brain Death. This review contains 1 highly rendered figure, 3 table, and 20 references.

Apnea Documentation for Determination of Brain Death in Children

PEDIATRICS ◽  
1984 ◽  
Vol 74 (4) ◽  
pp. 505-508
Author(s):  
Thomas W. Rowland ◽  
Joseph H. Donnelly ◽  
Anthony H. Jackson
Keyword(s):  
Brain Death ◽  
Ventilatory Support ◽  
Respiratory Drive ◽  
Test Protocol ◽  
Apnea Test ◽  
Wide Variability ◽  
Adequate Oxygenation

Discontinuing ventilatory support for determination of respiratory drive is a recognized means of assessing clinical brain death. Methodology must include a means for assuring adequate oxygenation during the test as well as providing sufficient duration for appropriate hypercarbia. Nine patients with other findings of clinical brain death were prospectively assessed with a standardized apnea test protocol. None demonstrated spontaneous respirations. Whereas adequate oxygenation was maintained in each case, wide variability was evident in degree of hypercarbia and acidosis.

Brain Death

2017 ◽  
Author(s):  
Anupamaa Seshadri ◽  
Ali Salim
Keyword(s):  
Brain Death ◽  
Apnea Test ◽  
Brainstem Reflex ◽  
Practice Parameters ◽  
Confirmatory Tests ◽  
History Of ◽  
Pediatric Populations ◽  
Definition Of

The concept of “brain death” is one that has been controversial over time, requiring the development of clear guidelines to diagnose and give prognoses for patients after devastating neurologic injury. This review discusses the history of the definition of brain death, as well as the most recent guidelines and practice parameters on the determination of brain death in both the adult and pediatric populations. We provide specific and detailed instructions on the various clinical tests required, including the brain death neurologic examination and the apnea test, and discuss pitfalls in the diagnosis of brain death. This review also considers the most recent literature and guidelines as to the role of confirmatory tests making this diagnosis.  Key Words: apnea test, brain death, brainstem reflex, death examination

Brain Death in the Newborn

PEDIATRICS ◽  
1989 ◽  
Vol 84 (3) ◽  
pp. 429-437
Author(s):  
Stephen Ashwal ◽  
Sanford Schneider
Keyword(s):  
Blood Flow ◽  
Cerebral Blood Flow ◽  
Brain Death ◽  
Clinical Findings ◽  
Term Infants ◽  
Clinical Criteria ◽  
Brain Dead ◽  
Electroencephalographic Activity ◽  
Radionuclide Uptake

The clinical courses of 18 preterm and term infants less than 1 month of age in whom brain death was diagnosed were retrospectively reviewed. Clinical diagnosis was determined neurologically and included (1) coma, (2) apnea, manifested by inability to sustain respiration, and (3) absent brainstem reflexes. Electroencephalograms were performed in all patients; 17 patients had adequate cerebral blood flow as estimated by radionuclide imaging. The results indicate that (1) neurodiagnostic tests such as electroencephalograms and radionuclide scanning reconfirmed clinically determined brain death in only one half to two thirds of patients; (2) electrocerebral silence in the absence of barbiturates, hypothermia, or cerebral malformations during 24 hours was confirmatory of brain death if the clinical findings remained unchanged; (3) absence of radionuclide uptake associated with initial electrocerebral silence was associated with brain death; (4) term infants clinically brain dead for 2 days and preterm infants brain dead for 3 days did not survive despite electroencephalogram or cerebral blood flow status; and (5) phenobarbital levels > 25 µg/ mL may suppress electroencephalographic activity in this age group. The findings suggest that determination of brain death in the newborn can be made solely by using clinical criteria. Confirmatory neurodiagnostic studies are of value because they can potentially shorten the period of observation.

Brain Death, Organ Donation, and Transplantation

2018 ◽  
pp. 276-285
Author(s):  
Hilary H. Wang ◽  
David M. Greer
Keyword(s):  
Brain Death ◽  
Organ Donation ◽  
The United States ◽  
Apnea Test ◽  
Unit Management ◽  
Legal Context ◽  
History Of ◽  
Brain Death Determination ◽  
Brain Dead ◽  
Death Determination

This chapter reviews the history of brain death determination, current guidelines for performing the brain death examination including the apnea test, details of apnea testing, the role of brain dead donors in organ donation, physiologic changes seen in brain dead patients, and the relevant challenges in intensive care unit management of such patients for donor organ optimization. The goal of this chapter is to provide clear guidance for a critical care provider to perform an accurate and thorough brain death examination and to further the reader’s understanding of the historical and legal context surrounding brain death and organ donation in the United States.

scholarly journals Complications associated with the apnea test in the determination of the brain death

2008 ◽  
Vol 121 (13) ◽  
pp. 1169-1172 ◽  
Author(s):  
Xiao-liang WU ◽  
Qiang FANG ◽  
Li LI ◽  
Yun-qing QIU ◽  
Ben-yan LUO
Keyword(s):  
Brain Death ◽  
Apnea Test ◽  
The Brain

Brain Death?

PEDIATRICS ◽  
1987 ◽  
Vol 79 (6) ◽  
pp. 1057-1057
Author(s):  
JEFFREY P. MORRAY ◽  
ELLIOT J. KRANE ◽  
ANNE M. LYNN ◽  
DONALD C. TYLER
Keyword(s):  
Brain Death ◽  
Critical Issue ◽  
Recent Experience ◽  
Diagnosis Of Death

To the Editor.— Because we are now able to provide long-term cardio-pulmonary support, the determination of cerebral death in children is a critical issue, both to provide an unambiguous diagnosis of death and, when appropriate, to allow recovery of organs for transplantation. Perhaps this latter issue provided the impetus for Drake et al1 to evaluate their recent experience at Loma Linda and to present a protocol for the determination of brain death in children.

Apnea testing for the determination of brain death: a modified protocol

1992 ◽  
Vol 76 (6) ◽  
pp. 1029-1031 ◽  
Author(s):  
Edward C. Benzel ◽  
Jay P. Mashburn ◽  
Steven Conrad ◽  
Denise Modling
Keyword(s):  
Brain Death ◽  
Apnea Test ◽  
Content Type ◽  
Group I ◽  
The Mean ◽  
Group Ii ◽  
Safe Approach ◽  
Apnea Testing ◽  
Fine Print

✓ The absence of spontaneous respirations at a PaCO2 of 60 mm Hg or above has traditionally been accepted as the respiratory criteria for the determination of brain death. The testing of patients for the presence or absence of apnea has been complicated because the rate of PaCO2 elevation may vary substantially from patient to patient, and a nonlinear relationship exists between the rate of PaCO2 increase and the duration of apnea. In an attempt to refine the apnea test and to further elucidate the physiology of hypercapnia in humans, 11 patients who met all but the respiratory criteria for brain death were evaluated using a modification of a previously utilized apnea testing protocol. All patients were brought to a PaCO2 of 40 mm Hg or above prior to the apnea test. Baseline PaCO2 ranged from 40 to 45 mm Hg in six patients (Group I) and from 46 to 51 mm Hg in five patients (Group II). The mean rate of PaCO2 increase was 5.1 ± 1.4 mm Hg/min in Group I and 6.7 ± 3.1 mm Hg/min in Group II. No problems with cardiovascular instability or hypoxia were encountered during testing in this series. This refinement of the apnea test allows for a streamlined and safe approach to brain death detection.

Challenges to the Determination of Death by Neurological Criteria

2019 ◽  
Vol 19 (4) ◽  
pp. 583-599
Author(s):  
Tadeusz Pacholczyk ◽  
Stephen Hannan ◽  
Keyword(s):  
Brain Death ◽  
Determination Of Death ◽  
Ethical Concerns ◽  
Diagnostic Practices ◽  
Testing Potential ◽  
Brain Dead ◽  
Testing Protocols ◽  
The Brain ◽  
Apnea Testing

Ethical concerns regarding the conceptual framework for the determination of death by neurological criteria, including several clinical and diagnostic practices, are addressed. The significance of a diagnosis of brain death, diagnostic criteria, and certain technical aspects of the brain-death exam are presented. Standard and ancillary tests that typically help achieve prudential certitude that an individual has died are indicated. Ethical concerns surrounding interinstitutional variability of testing protocols are evaluated and considered, as are potential apnea-testing confounders such as hypotension, hypoxemia, hypercarbia, and penumbra effects during ancillary testing. Potential adjustments to apnea-testing protocols involving capnography, thoracic impedance monitors, or spirometers to assess respiratory efforts are discussed. Situations in which individuals determined to be brain dead “wake up,” or fail to manifest the imminent cessation of somatic functioning typically seen when supported only by a ventilator, are also briefly reviewed.

482: APNEA TEST FOR DETERMINATION OF BRAIN DEATH IN A CHILD ON VENOARTERIAL ECMO

2018 ◽  
Vol 46 (1) ◽  
pp. 225-225
Author(s):  
Haitham Al Wahab ◽  
Vandana Thapar ◽  
Myron Allukian ◽  
Konstantinos Boukas
Keyword(s):  
Brain Death ◽  
Apnea Test
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