Brain Death: Ongoing Threats

David M. Greer MD, MADepartment of Neurology

Boston University School of Medicine

DISCLOSURES

• I receive research support as PI of R01NS102574-01A1

• I receive research support from Bard Medical, Inc. for the INTREPID Study (NCT02996266)

• I serve as editor-in-chief for Seminars in Neurology

Practice Parameters published in 1995, based on the Uniform

Determination of Death Act (UDDA): “An individual who has

sustained either 1) irreversible cessation of circulatory and

respiratory functions, or 2) irreversible cessation of all functions

of the entire brain, including the brain stem, is dead. A

determination of death is made with acceptable medical

standards.”

Uniform Determination of Death Act, 12 uniform laws annotated 589 (West 1993 and West suppl

1997)

More recent data…

Basic Stats

•508 individual policies obtained

• (likely many policies shared within a health system, so 508 is an underestimate of the total hospitals represented)

Hilary H. Wang, MD

Panayiotis N. Varelas,

MD, PhD

Galen V. Henderson, MD

Eelco F.M. Wijdicks,

MD, PhD

David M. Greer, MD,

MA

Correspondence to

Dr. Greer:

david.greer@yale.edu

Improving uniformity in braindeath determination policiesover time

ABSTRACT

Objective: To demons t rate that progres s has been made in unifying brain dea th de termination

guide lines in the las t decade by direc tly comparing the policies of t he US News and World Re-

port’s top 5 0 ranked neurologic institu tions from 2 0 0 6 and 2 0 1 5 .

Methods: We s olicited official hospita l guidelines in 2 0 1 5 from the se top 5 0 ins t itutions, gener-

a te d summary s ta t ist ics of their crite ria as benchmarked against the American Academy of

Neurology Prac tice Paramete rs (AANPP) and the comparison 2 0 0 6 cohort in 5 key ca te gories,

and s ta t ist ically compared the 2 cohorts ’compliance with the AANPP.

Results: From 2 0 0 8 to 2 0 1 5 , hospita l policies exhibited significant improvement (p 5 0 .0 0 5 ) in

compliance with official guide lines, part icularly with resp ec t to crite ria re lated to apnea tes t ing

(p 5 0 .0 0 9) and appropriate ancillary te sting (p 5 0 .0 0 0 6). However, variability re mains in other

port ions of t he policies, bo th those with spec ific recommendat ion from the AANPP (e .g., sp ec ifics

for ancillary tes ts) and those without firm guidance (e .g., the leve l of involvement of neurologists,

neurosurgeons, or physicians with educa tion/tra ining sp ec ific to bra in dea th in the de termina tion

proce ss).

Conclusions: While the 2 0 1 0 AANPP upda te see ms to be concordant with progre ss in achieving

grea ter uniformit y in guide lines a t the top 5 0 neurologic inst itu tions, more needs to be done.

Whe ther further interven tions come as gras s roo ts initia tives tha t leverage technologica l advan-

ces in promot ing adopt ion of new guidelines or as top-down regulatory rulings to manda te s peed-

ier approva l p roce sses , th is s tudy s hows tha t so lely re lying on volun tary upda te s to profes s ional

society guide lines is not enough. Neurology® 2 0 1 7 ;88 :1–7

47

55

60

20

10

11

00

1

2013

2007

2015

20062005

2014

20122011201020092008

2004

200120022003

AANPP Updated June

2010

The majority of institutions (71%) have updated their

policies at a date after the June 2010 update to the

AANPP, while 16% did not, and 13% made no mention

of revision date, suggesting most institutions had an

opportunity to review the official guidelines prior to

adopting their current policies

Year of most recent policy update/revision

Prereqprior to testing

95% 97%

Estabcause

63%

89%

Absent hypo-

thermia

89%97%

Absent shock

82%71%

95%81%

Absence of drugs

92%

72%

Absent confoun-

ders

20062015

The majority of 2015 policies (95%)

required prerequisites, and named

individual prerequisites at a consistently

higher rate than in 2006 (e.g. 89% of

2015 policies looked for cause of coma

vs only 63% in 2006)

Prerequisites for testing

Electrolyte disorder absent

Acid-basedisorder

absent

Endocrinedisorder absent

3%

3%0%

80%

9%

0%

0%

2015*

Prerequisite absence of confounding disorders

[A] The absence of

confounding medical

conditions were specified

more frequently in 2015 than

2006 for electrolyte

disorders (92% vs 72%),

acid-base disorders (92% vs

45%), and endocrine

disorders (80% vs 42%). [B]

Most commonly in the 2015

policies, the three conditions

were named together as a

group of possible

confounders, with a

smattering of other

disorders, such as nutritional

deficits, listed additionally.

42%

Electrolyte disorder absent

92%

72%

45%

92%

80%

Endocrine disorder absent

Acid-base

disorder absent

2015 2006 *8% “other” :“nutritional”

PO2 < 50

A B

97%

Coma

100%

Pupil

100%97%97% 97%

Corneal

2015

2006

Clinical examination compliance with AANPP, 2015 vs 2006

A B C

97%

OVR

95%

OCR

82%97%

Pain body

87%97%

87%92%

Cough

E F G

89%

Gag

87%

42%

Pain cranium

53%

D

H

27%

No spontresp

42%

26%18%

Jaw Jerk

I J K

[A] to [H] show consistent,

good compliance to the

majority of the clinical

examination, with additional

specificity for pupil size in

45% of policies; [I] to [K]

highlight areas of notably

poor adherence in 2006 &

2015

29%No

8%

"mid to dilated"

55%

8%

4-9mm

"Yes"

Specific pupil size?

87%

95%

87%

Absent resps

95%

76%

84%

71%

Use of suppl

O2

55%

66%

pCO2 rise

above BL

89%

Final pCO2 stated

74%

39%

76%

Pre-ox spec

ABGs before starting

Repeat if inconclusive

Stop if unstable

71%

16%11%

20062015

2-6L

How many liters/min

O2?

8L

4%

11%

4%

7%

100L

6L

4L

4%

4%7%

4-10L

54%

10L

8-10L

7%8-12L

60mmHg (97%)

55mmHg (3%)

+20mmHg (100%

policies)

Cannula inside ETT/Trach (90%)

Ventilator,no breaths (10%)

B

Apnea testing compliance with AANPP, 2015 vs 2006

Apnea testing criteriaappear to trendtowards less variabilityfrom 2006 to 2015,with a notably higherproportion of policiesrequiring ABGs beforebeginning apneatesting (89% vs 66%)and a pCO2 rise of20mmHg abovebaseline for the test toqualify as positive (76%vs 39%). However, widevariability is seen in therecommendedliters/min rate ofsupplemental oxygen.

Hypotension

DesatsArrhyth/

50%15%12%

8%

0%4%

0%

Stopfor what?

Jahi McMath, California, 2013-18

ADEN HAILU, NEVADA, 2015-16

ISRAEL STINSON, CALIFORNIA, 2016

A CHILD, UNITED KINGDOM, 2015

ALLEN CALLAWAY, MONTANA, 2016

MIRRANDA GRACE LAWSON, VIRGINIA, 2016

ALEX PIERCE, CALIFORNIA, 2016

TAQUISHA MCKITTY, ONTARIO, 2017-18

SHALOM OUANOUNOU, ONTARIO, 2017-18

AREEN CHAKRABARTI, PENNSYLVANIA, 2018

JAYDEN AUYEUNG, PENNSYLVANIA, 2018

Important Peds – Adults Guideline Differences

PEDS

• Minimum temp 35C

• 2 exams

• Observation period, varies by age

• Some procedural details lacking

• Different ancillary tests, indications

• Multiple different age groups with different rules

ADULTS

• Minimum temp 36C

• 1 vs. 2 exams

• No observation period (sort of)

• Most procedural details present

• Different ancillary tests, indications

• Aspects can be tightened for both groups of patients.• Most aspects can be unified as general principles that pertain to both groups.• There will be a natural “carve out” for peds (e.g. BP for age, cranial physiology

below 2 years of age, etc.)

What are we doing to improve the field?• Educational/training endeavors

•Online training and certification• Simulation training• “Champions”

• Creation of a national/international standard• Lobby at a national level for ONE STANDARD•Nevada is already there

•AAN position statement on accommodation and pregnancy

• Potential merging of adult and child guidelines

• Brain Death Toolkit: https://www.pathlms.com/ncs-ondemand/courses/1223• Or just search “brain death toolkit”

• World Brain Death Project

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Objectives:

• To consolidate and summarize the knowledge base surrounding the concept and practice of brain death, with a goal of establishing international professional consensus regarding the underlying principles and clinical practice.

• To serve as a framework of understanding for the current model of brain death, and help guide future developments in the field.

World Brain Death Project

Gene Yong Sung, MDAssistant Professor of Clinical Neurology, Director of Neuro Critical Care, LAC+USC Medical Center Inpatient Chief

David M. Greer, MDProfessor and Chairman,Department of Neurology,Boston University School of Medicine

Sam D. Shemie, MDCritical Care Physician, Montreal Children’s Hospital; Professor of Pediatrics, McGill University

Ariane K Lewis, MDNeurocritical CareNew York University

Sylvia TorranceCenter for InnovationCanadian Blood Services

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Topics:

• History of Brain Death

• Legal Issues

• Conceptual/Religious Issues

• Worldwide Variance

• Epidemiology, Clinical Settings, Etiology

• Pathophysiology

• Clinical Determination:

o Prerequisites, Neurological Examination, Apnea Testing, Ancillary Testing

• Pediatric & Neonatal

• Modern Issues:

o ECMO

o Somatic Support

o Non-acceptance & accommodation

o Brainstem vs. Whole Brain

o TTM

• Documentation and Communication

• Education

• Future Research

25

World Project

Contributors

1. European Society of Intensive Care Medicine (ESICM)

2. China Brain Injury Evaluation Quality Control Centre

3. International Pan-Arab Critical Care (IPACCMS)

4. Neurocritical Care Society5. Australia-New Zealand Intensive Care

Society (ANZICS)

Collaborating Organizations6. World Federation of Critical Care Nurses

(WFCCN)7. World Federation of Neurology (WFN)8. World Federation of Neurosurgical

Societies (WFNS)9. World Federation of Pediatric Intensive &

Critical Care Societies (WFPICCS)10. World Federation of Societies of Intensive

and Critical Care Medicine (WFSICCM)

26

World Project

Process

Planning Literature search

Review of evidence

Drafting of consensus statements

Consensus forum

Revisions External review

Publication Knowledge translation

AANESICM

IPACCMS NCS

WFCCNWFN

WFNSWFPICCSWFSICCM

World Congress of Intensive and Critical Care

MedicineNov 2017Rio, Brazil