1976 2008 37&years&on& - home - odt...

Organ&Dona)on&Past,&Present&and&Future&&

Diagnosis(of(brain,stem(death(

1(

37&years&on&(

(

1976 2008

Dr Dale Gardiner Adult Intensive Care Consultant, Nottingham Midlands, Clinical Lead for Organ Donation Member of the UK Donation Ethics Committee


(

We are explorers

not inventors.

3(Organ&Dona)on&Past,&Present&and&Future&&


Harvey Cushing describes increased

brain pressure provoking respiratory arrest with preserved

heartbeat.


Brain death: Discovered not Invented (by intensive care)(

1940s Danish medical students hand ventilate polio

victims

Mouth to Mouth Resuscitation gains

prominence & Mechanical Ventilation

becomes possible

1954 1st successful kidney transplant between

identical twins

1959, doctors discover empirical proof by the identification of

mechanically ventilated patients in coma dépassé.


1962 1st successful

deceased donor kidney Tx

1963 1st successful

deceased donor liver &

lung Tx

1966 1st successful

deceased donor pancreas Tx

1968 1st successful

deceased donor heart Tx

1964, Keith Simpson “there is life so long as

circulation of oxygenated blood is maintained to live

brainstem centres”


Modern intensive care

practice grows.

Organ Donation from Brain Dead donors increases

worldwide.

1976 (clarified 1979) UK Criteria for

Diagnosing Death using Neurological Criteria Published.


Growing use of ECMO and other techniques to support the circulation,

establish that it is possible to be alive, without a heart-beat.

2008 UK Criteria for

Circulatory Criteria published for the 1st

time. 5 minutes.

Eugene Bouchut 1846

Rene´ Laennec 1819

UK(Defini<on(of(Death(


“…&irreversible&loss&of&the&capacity&for&consciousness,&combined&with&irreversible&loss&of&the&capacity&to&breathe…&&therefore&irreversible&cessa)on&of&the&integra)ve&func)on&of&the&brainAstem&equates&with&the&death&of&the&individual.”(

2008

UK(Defini<on(of(Death(


All human death is anatomically located

to the brain.

“…&irreversible&loss&of&the&capacity&for&consciousness,&combined&with&irreversible&loss&of&the&capacity&to&breathe…&&therefore&irreversible&cessa)on&of&the&integra)ve&func)on&of&the&brainAstem&equates&with&the&death&of&the&individual.”(

2008


1(death(:(3(sets(of(criteria(

DEATH

Irreversible loss of the capacity for consciousness

Irreversible loss of the capacity to breathe

Neurological(Criteria(

Circulatory(Criteria( Soma<c(Criteria(

Dx(Death(using(Neurological(Criteria(

Organ&Dona)on&Past,&Present&and&Future&& 12(

1.  An(established(

ae)ology&capable(of(causing(structural(

damage(to(the(brain(

which(has(led(to(the(

irreversible(loss(of(

the(capacity(for(

consciousness(

combined(with(the(


the(capacity(to(

breathe.(

•  Cause(tells(you(

irreversibility,(based(on(

the(natural(history(of(

the(disease(

•  Cause(tells(you(how(long(

you(should(observe(

before(tes<ng:(

•  ‘Typical’ (>(6(hours(

•  Hypoxia( (24(hours(

•  Atypical (?(longer(

DEATH




V a l i d a t i o n !

p r o p h e c y


> 10000 patients 10 years

…37 years


D. Alan Shewmon, MD


‘Although(we(were(unable(to(restore(his(consciousness(or(

spontaneous(breathing,(the(boy(lived(several(more(

years.’(((page(195)(



ae)ology(capable(of(causing(structural(




the(capacity(for(

consciousness(

combined(with(the(


the(capacity(to(

breathe.(

2.  An(exclusion(of(reversible(condi<ons(capable(of(mimicking(or(confounding&the(diagnosis(of(death(using(neurological(criteria.(

Dx(Death(using(Neurological(Criteria(

DEATH




•  Clinical(judgement(essen<al(

•  Impossible(to(create(rules(covering(

every(situa<on(

•  Difficul<es(mainly(with(

thiopentone(and(midazolam(

•  Plasma(concentra<ons(not(good(

predictors(of(effect(

•  Use(of((antagonists(

Dx(Death(using(Neurological(Criteria(2.  An(exclusion(of(

reversible(condi<ons(capable(of(mimicking(or(confounding&the(diagnosis(of(death(using(neurological(criteria.(

DEATH









the(capacity(for(

consciousness(

combined(with(the(


the(capacity(to(

breathe.(

3.  A(clinical(examina)on&of(the(pa<ent,(which(

demonstrates(

profound(coma,(

apnoea(and(absent(

brainstem(reflexes.((



DEATH



Brain,stem(reflexes (


!  Pupils((II,(III)(

!  Corneals((V,(VII)(

!  Pain((V,(VII)(

!  Gag((IX,(X)(

!  Cough((IX,(X)(

!  Oculoves<bular((III,(VI,(VIII)(

"  Oculocephalic(

"  Suck(( }(Paediatric(

Wijdicks EFM. The diagnosis of brain death. N Engl J Med 2001;344:1215-1221 + AoMRC (2008)

Consciousness Ascending reticular activity system Breathe Medulla Oblongata (

Apnoea(Test (


Recommended&method:&Aeer(pre,oxygena<on,(disconnect(the(pa<ent(from(the(ven<lator(and(administer(oxygen(via(a(suc<on(catheter(in(the(

endotracheal(tube(at(a(rate(of(>6(L/minute.(If(oxygena<on(is(a(problem,(

consider(the(use(of(a(CPAP(circuit((eg(Mapleson(B).((

The&apnoea&test&is&performed&only&twice&in&total.&&

Stopping:((5(minutes(observa<on(

(((((((paCO2(rise(>(0.5(KPa(

Star<ng:&(paCO2(>(6.0(Kpa(

(((((pH((<7.4(






the(capacity(for(

consciousness(

combined(with(the(


the(capacity(to(

breathe.(

3.  A(clinical(examina)on&of(the(pa<ent,(which(

demonstrates(

profound(coma,(

apnoea(and(absent(

brainstem(reflexes.((



In 2012,1238 tests performed, death confirmed in 1220 = 98.5%

DEATH



Tes<ng(for(Brain,stem(Death (


“This(form(is(consistent(with(and(should(be(used(in(conjunc<on(with,(the(

AoMRC((2008)(A"Code"of"Prac,ce"for"the"Diagnosis"and"Confirma,on"of"Death(and(has(been(endorsed(for(use(by(the(following(ins<tu<ons:(Faculty(of(

Intensive(Care(Medicine,(Intensive(Care(Society(and(the(Na<onal(Organ(

Dona<on(Commimee.”((

((

(

Full&Abbreviated&


WHY(TEST?(


WHY(TEST?(

1.  To(eliminate(all(possible(doubt(

regarding(survivability(

2.  To(confirm(diagnosis(for(families(

3.  To(protect(doctors(in(cases(subject(to(medico,legal(scru<ny(

4.  To(provide(choice(regarding(organ(dona<on(

(


diagnosis((((((((((((((((((decision(


((((((Brainstem(death(in(the(


TWO(TESTS(not(ONE(1976 1983 1998 2008

‘customary’ to repeat the tests

if the tests confirm brain death they

should nevertheless be repeated

two sets of tests should always be performed

must always be performed

on two occasions

Gardiner D, Danbury C & Manara A (2013) “Confirming death using neurological criteria: are two sets of tests better than one?” JICS 14(1):6-7.


TWO(TESTS(not(ONE(

ALIVE((

Test(1(

(

ALIVE(

(

Test(2((

DECEASED(

2008

=(2(TESTS((regardless(of(organ(dona<on)((

Legal(support(from(case(law(

&(Bolam(&(Bolithio(tests(

Dr(A(performs((

Dr(B(observes(

(

SWAP&(

Dr(B(performs(

Dr(A(observes(


TWO(TESTS(not(ONE(

ALIVE((

Test(1(

(

ALIVE(

(

Test(2((

DECEASED(

2008 Dr(A(performs((

Dr(B(observes(

(

SWAP&(

Dr(B(performs(

Dr(A(observes(





TWO(TESTS(not(ONE(

ALIVE((

Test(1(

(

ALIVE(

(

Test(2((

DECEASED(

2008 Dr(A(performs((

Dr(B(observes(

(

SWAP&(

Dr(B(performs(

Dr(A(observes(




Time(

of(

Death(


2008 1976

Lesson 1


Lesson 2


Lesson 3 Take your time • Slow down (minimum 6 hours)

• Don’t over-read coning on CT

• Atypical presentation = wait

• Hypoxic brain injury >24 hours


Lesson 4 Induced hypothermia has unpredictable consequences See Lesson 3

Advice: warm to normothermia and then wait 24 hours


Lesson 5 NO EEG


Lesson 6 Start with Lesson 2 = use your brain and examine your patient

1.  Clinical brain death + NO flow = Death

2.  Clinical brain death + flow = Wait See Lesson 3 = take your time and ask ‘Is reversibility possible?’


www.clodlog.com

Gardiner, Shemie, Manara & Opdam International Perspective on the Diagnosis of Death Br J Anaesthesia Supplement January 2012

www.odt.nhs.uk

1976 2008 37&years&on& - home - odt...

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