scholarly journals Variability Across Countries for Brain Death Determination in Adults

2020 ◽  
Author(s):  
Fang Yuan ◽  
Weijun Zhang ◽  
Wanxin Wen ◽  
Huiping Li ◽  
Shibiao Wu ◽  
...  
Keyword(s):  
Brain Death ◽  
Predictive Value ◽  
Diagnostic Procedures ◽  
Apnea Test ◽  
Ancillary Test ◽  
Brain Death Determination ◽  
Technical Specifications ◽  
Sensitivity Specificity ◽  
Death Determination ◽  
Prospective Database

Abstract Background: Currently there is variability in diagnostic procedures across countries. Our aim was to compare guidelines of brain death determination in adults among five countries: China, UK, US, France, and Germany.Method: This is a retrospective study based on a prospective database of consecutive coma patients who received brain death determination. The technical specifications, completion rates, and positive rates of brain death determination according to criteria of different countries were compared. The accuracy, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of each ancillary test for the identification of brain death diagnosed according to different criteria were investigated.Results: One hundred and ninety-nine patients who received brain death determination from June 2018 to June 2020 were included in this study. One hundred and thirty-one (65.8%) patients were diagnosed with brain death according to French criteria, 132 (66.3%) according to Chinese criteria, and 135 (67.7%) according to criteria of US, UK, and Germany. The sensitivity and PPV of EEG (92.2% - 92.3%) and SLSEP (95.5% - 98.5%) were higher than TCD (84.3% - 86.0%), and all these three tests have a very low specificity and NPV.Conclusions: The duration of apnea test and requirements of ancillary tests vary among countries. The discrepancy in brain death determination between clinical assessments and additional confirmation of ancillary tests is small.

Use of Ancillary Tests When Determining Brain Death in Pediatric Patients in the United States

2017 ◽  
Vol 32 (12) ◽  
pp. 975-980 ◽  
Author(s):  
Ariane Lewis ◽  
Nellie Adams ◽  
Arun Chopra ◽  
Matthew P. Kirschen
Keyword(s):  
United States ◽  
Brain Death ◽  
The United States ◽  
Apnea Test ◽  
Ancillary Test ◽  
Regulatory Bodies ◽  
Brain Death Determination ◽  
Death Determination ◽  
Pediatric Brain ◽  
The Brain

Although pediatric brain death guidelines stipulate when ancillary testing should be used during brain death determination, little is known about the way these recommendations are implemented in clinical practice. We conducted a survey of pediatric intensivists and neurologists in the United States on the use of ancillary testing. Although most respondents noted they only performed an ancillary test if the clinical examination and apnea test could not be completed, 20% of 195 respondents performed an ancillary test for other reasons, including (1) to convince a family that objected to the brain death determination that a patient is truly dead (n = 21), (2) personal preference (n = 14), and (3) institutional requirement (n = 5). Our findings suggest that pediatricians use ancillary tests for a variety of reasons during brain death determination. Medical societies and governmental regulatory bodies must reinforce the need for homogeneity in practice.

scholarly journals Variability in Diagnosing Brain Death at an Academic Medical Center

2017 ◽  
Vol 2017 ◽  
pp. 1-7 ◽  
Author(s):  
Ashutosh Pandey ◽  
Pradeep Sahota ◽  
Premkumar Nattanmai ◽  
Christopher R. Newey
Keyword(s):  
Brain Death ◽  
Medical Center ◽  
Academic Medical Center ◽  
Time Of Death ◽  
Apnea Test ◽  
Hospital Policy ◽  
Strict Adherence ◽  
Ancillary Test ◽  
Brain Death Determination ◽  
Death Determination

Objective. Research continues to highlight variability in hospital policy and documentation of brain death. The aim of our study was to characterize how strictly new guidelines of American Academy of Neurology (AAN) for death by neurological criteria were practiced in our hospital prior to appointment of neurointensivists. Method. This is a retrospective study of adults diagnosed as brain dead from 2011 to 2015. Descriptive statistics compared five categories: preclinical testing, neurological examination, apnea tests, ancillary test, and documentation of time of death. Strict adherence to AAN guidelines for brain death determination was determined. Result. 76 patients were included in this study. Preclinical prerequisites were fulfilled in 53.9% and complete neurological examinations were documented in 76.3%. Apnea test was completed in 39.5%. Ancillary test was completed in 29.8%. Accurate documentation of time of death occurred in 59.2%. Overall, strict adherence to current AAN guidelines for death by neurological criteria was correctly documented in 38.2%. Conclusion. Our study shows wide variability in diagnosing brain death. These findings led us to update our death by neurological criteria policy and increase awareness of brain death determination with the goal of improving our documentation following current AAN guidelines.

scholarly journals The effect of incorporating an arterial pH target during apnea test for brain death determination

2021 ◽  
Vol 9 (1) ◽  
Author(s):  
Ibrahim Migdady ◽  
Moein Amin ◽  
Aaron Shoskes ◽  
Catherine Hassett ◽  
Sung-Min Cho ◽  
...  
Keyword(s):  
Brain Death ◽  
Cleveland Clinic ◽  
Apnea Test ◽  
Arterial Ph ◽  
Common Etiology ◽  
Brain Death Determination ◽  
Blood Gas Analyses ◽  
The Impact ◽  
Death Determination ◽  
Current Guidelines

Abstract Background Persistent apnea despite an adequate rise in arterial pressure of CO2 is an essential component of the criteria for brain death (BD) determination. Current guidelines vary regarding the utility of arterial pH changes during the apnea test (AT). We aimed to study the effect of incorporating an arterial pH target < 7.30 during the AT (in addition to the existing PaCO2 threshold) on brain death declarations. Methods We performed retrospective analysis of consecutive adult patients who were diagnosed with BD and underwent AT at the Cleveland Clinic over the last 10 years. Data regarding baseline and post-AT blood gas analyses were collected and analyzed. Results Ninety-eight patients underwent AT in the study period, which was positive in 89 (91%) and inconclusive in 9 (9%) patients. The mean age was 50 years old (standard deviation [SD] 16) and 54 (55%) were female. The most common etiology BD was hypoxic ischemic brain injury (HIBI) due to cardiac arrest (42%). Compared to those with positive AT, patients with inconclusive AT had a higher post-AT pH (7.24 vs 7.17, p = 0.01), lower PaO2 (47 vs 145, p < 0.01), and a lower PaCO2 (55 vs 73, p = 0.01). Among patients with a positive AT using PaCO2 threshold alone, the frequency of patients with post-AT pH < 7.30 was 95% (83/87). Conclusion Implementing a BD criteria requiring both arterial pH and PaCO2 thresholds reduced the total number of positive ATs; these inconclusive cases would have required longer duration of AT to reach both targets, repeated ATs, or ancillary studies to confirm BD. The impact of this on the overall number BD declarations requires further research.

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.

744: Sensitivity of Arterial pH Changes During Apnea Test for Brain Death Determination

2020 ◽  
Vol 49 (1) ◽  
pp. 368-368
Author(s):  
Ibrahim Migdady ◽  
Moein Amin ◽  
Aaron Shoskes ◽  
Catherine Hassett ◽  
Sung-Min Cho ◽  
...  
Keyword(s):  
Brain Death ◽  
Apnea Test ◽  
Ph Changes ◽  
Arterial Ph ◽  
Brain Death Determination ◽  
Death Determination

scholarly journals Computed tomography angiography as a confirmatory test for the diagnosis of brain death

2018 ◽  
Vol 128 (2) ◽  
pp. 639-644 ◽  
Author(s):  
Mark P. Garrett ◽  
Richard W. Williamson ◽  
Michael A. Bohl ◽  
C. Roger Bird ◽  
Nicholas Theodore
Keyword(s):  
Blood Flow ◽  
Brain Death ◽  
Clinical Examination ◽  
Predictive Value ◽  
Gold Standard ◽  
Confirmatory Test ◽  
Apnea Test ◽  
Clinical Criteria ◽  
Test Characteristics ◽  
Ancillary Test

OBJECTIVEFor a diagnosis of brain death (BD), ancillary testing is performed if patient factors prohibit a complete clinical examination and apnea test. The American Academy of Neurology (AAN) guidelines identify cerebral angiography (CA), cerebral scintigraphy, electroencephalography, and transcranial Doppler ultrasonography as accepted ancillary tests. CA is widely considered the gold standard of these, as it provides the most reliable assessment of intracranial blood flow. CT angiography (CTA) is a noninvasive and widely available study that is also capable of identifying absent or severely diminished intracranial blood flow, but it is not included among the AAN's accepted ancillary tests because of insufficient evidence demonstrating its reliability. The objective of this study was to assess the statistical performance of CTA in diagnosing BD, using clinical criteria alone or clinical criteria plus CA as the gold-standard comparisons.METHODSThe authors prospectively enrolled 22 adult patients undergoing workup for BD. All patients had cranial imaging and clinical examination results consistent with BD. In patients who met the AAN clinical criteria for BD, the authors performed CA and CTA so that both tests could be compared with the gold-standard clinical criteria. In cases that required ancillary testing, CA was performed as a confirmatory study, and CTA was then performed to compare against clinical criteria plus CA. Radiographic data were evaluated by an independent neuroradiologist. Test characteristics for CTA were calculated.RESULTSFour patients could not complete the standard BD workup and were excluded from analysis. Of the remaining 18 patients, 16 met AAN criteria for BD, 9 of whom required ancillary testing with CA. Of the 16 patients, 2 who also required CA ancillary testing were found to have persistent intracranial flow and were not declared brain dead at that time. These patients also underwent CTA; the results were concordant with the CA results. Six patients who were diagnosed with BD on the basis of clinical criteria alone also underwent CA, with 100% sensitivity. For all 18 patients included in the study, CTA had a sensitivity of 75%, a specificity of 100%, a positive predictive value of 100%, and a negative predictive value of 33%.CONCLUSIONSClinical examination with or without CA remains the gold standard in BD testing. Studies assessing the statistical performance of CTA in BD testing should compare CTA to these gold standards. The statistical performance of CTA in BD testing is comparable to several of the nationally accepted ancillary tests. These data add to the growing medical literature supporting the use of CTA as a reliable ancillary test in BD testing.

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