technical assistance for alignment in organ donation- europeaid/131052/d/ser/tr
DESCRIPTION
Key Points in Brain Death Diagnosis Clinical aspects and Confirmation. Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR. Francesco Procaccio ISS – CNT - Rome Neuro Intensive Care Unit University City Hospital, Verona - Italy. What is Brain Death?. - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/1.jpg)
Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR
Key Points in Brain Death Diagnosis
Clinical aspects and ConfirmationFrancesco Procaccio
ISS – CNT - Rome
Neuro Intensive Care Unit
University City Hospital, Verona - Italy
![Page 2: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/2.jpg)
Total Brain Infarct 2
What is Brain Death?
![Page 3: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/3.jpg)
Brain Death is the irreversible loss of capacity for consciousness combined
with the irreversible loss of all brainstem functions including the
capacity to breathe.
The Canadian Neurocritical Care Group, 1999
BD Definition
![Page 4: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/4.jpg)
F Procaccio 2012
Certainty of death: Irreversibility
Karnice-Karnicki, 1896
Brain Death or Brain Dying?
Death is a process
Neurological functions must have ceased
irreversibly
![Page 5: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/5.jpg)
“Irreversible loss of all cerebral functions”
(Brain) Death
![Page 6: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/6.jpg)
Brainstemdeath
6
![Page 7: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/7.jpg)
WhyBrain death is the only
death ?
Pathophysiological reasons
7
![Page 8: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/8.jpg)
When a person is dead?Definitive, irreversible total damage of the
brainCerebral functions are totally lost
Due to two different mechanisms:
1) Respiratory and circulatory arrest causing secondary irreversible damage of brain (non Heart Beating cadaver)
2) Devastating cerebral lesions which cause total irreversible damage of the brain (Brain Death – Heart Beating cadaver)
8
![Page 9: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/9.jpg)
Definition of death (Universal death)
Capron , May 2012 Montreal Forum
Simple uniform reliable concepts & definitions
may increase public confidence and trust
9
![Page 10: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/10.jpg)
Heart, Lung, Liver, Kidneys etc.are vital organs
butcan be supported by technology or replaced by transplantation.
except The Brain
Whyonly Brain death is death ?
10
![Page 11: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/11.jpg)
Who may become brain dead ?
Only patients with acute cerebral lesion under
mechanical ventilation in ICU
Brain injury – Cerebral Hemorrhage Ischemic Stroke – Brain Tumour Anoxia – Cerebral Infection etc.
![Page 12: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/12.jpg)
Determination of deathby neurological criteria
![Page 13: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/13.jpg)
“All the cerebral functions are irreversibly lost”
Clinical
REFLEXES
EEG
Determination of Death by Neurological criteria
CBF
![Page 14: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/14.jpg)
14
![Page 15: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/15.jpg)
Total Brain InfarctAbsence of cerebral blood flow
Death
15
![Page 16: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/16.jpg)
Harvard Criteria - 1968
The Neurological Standard
16
![Page 17: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/17.jpg)
Wijdicks E. N Engl J Med 2001
17
![Page 18: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/18.jpg)
Brain Death Diagnosis Milestones
1. The etiology of the brain lesion is known
2. Exclude all potential confounding factors
3. The neurological examination is complete and all clinical criteria are fulfilled 18
![Page 19: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/19.jpg)
Etiology
19
![Page 20: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/20.jpg)
NMR
20
![Page 21: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/21.jpg)
Clinical examination
![Page 22: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/22.jpg)
Prerequisites
• Etiology must be known• Imaging of irreversible cerebral
damage• Temp. >32 °C (“Normal” BP – SO2 – Na+)• Exclusion of medical confounding
factors • Exclusion of drug effects on CNS• Exclusion of drug effects on clinical
exam (muscle relaxant agents, atropine etc.)
22
![Page 23: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/23.jpg)
The Brainstem
23
![Page 24: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/24.jpg)
II
III
V
VI VII
VIII
X
XI
Light response
Corneal
OculocephalicOculovestibular
Brainstem reflexes:pathways
Painful stimuli
Tracheal
24
![Page 25: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/25.jpg)
25
![Page 26: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/26.jpg)
Pupillary response to lightMethodology & clinical experience
26
![Page 27: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/27.jpg)
APNEA TEST
Absence of respiratory drive 13098
130 78 23
PaCO2 > 60mmHg
100% Oxygen
27
![Page 28: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/28.jpg)
Why brain dead patients may move ?
![Page 29: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/29.jpg)
Spinal reflexes in Brain Death
Brain infarct
Spine without superior control
SpinalShock
Spinal function recovery
Hyperexcitability
1
2
329
![Page 30: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/30.jpg)
Are there factors that may cause unreliable brain death
diagnosis?
![Page 31: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/31.jpg)
CONFOUNDING FACTORSSevere derangement in temperature,
blood pressure, oxygenation, electrolytes, glusose, cortisol, T4)
Drugs (sedative/anesthetic - barbiturates ! – muscle relaxants )
Facial trauma – Cranial nerves lesions31
![Page 32: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/32.jpg)
Facial Trauma
32
![Page 33: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/33.jpg)
If potentially confounding factors
may be present confirmatory tests
must be used
![Page 34: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/34.jpg)
The absence of cerebral perfusion is a simple,
clear, acceptable criteria, easily to be
understood and demonstrated.
![Page 35: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/35.jpg)
Cerebral angiogram. Arch injection
Wijdicks, 200135
![Page 36: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/36.jpg)
36
![Page 37: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/37.jpg)
TCD
Brain Deathpatterns
Trans Cranial Doppler
37
![Page 38: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/38.jpg)
F Procaccio 2012
Girlanda
R
Angio-CT scan
BD standard – no confounding factors
![Page 39: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/39.jpg)
Persistence of cerebral blood “flow” after brain death
Flowers WM et al. Southern Medical Journal 93:364,2000
• Decompressing fractures• Ventricular shunts• Reperfusion (post-anoxic !)• Decompressive Hemicraniectomy
39
![Page 40: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/40.jpg)
F Procaccio 2012
Possible Pitfalls in BD diagnosis
1. the BD declared patient is not Deadzero mistake must be ensured
2. the BD person is not BD declaredsilent BD – Death is not equal - missing PODs
![Page 41: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/41.jpg)
Mimicking Disorders
• Hypothermia• Barbiturates• Acute poisoning• Endocrine crisis
(glucose – cortisol – T4)
• neurological diseases41
![Page 42: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/42.jpg)
“Neurological” conditions that may be confused with Brain
Death• Locked-in syndrome• Guillain-Barré syndrome• Demyelinating conditions • Post-anoxic coma• Brainstem encephalitis• “Medulla man”
42
![Page 43: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/43.jpg)
The Medulla Man
Wijdicks E. J Neurol Neurosurg Psych 200143
![Page 44: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/44.jpg)
F Procaccio 2012
![Page 45: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/45.jpg)
Post-anoxic BD
Neuro ICU, Verona - 2005
swelling “flow”6 hours
45
![Page 46: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/46.jpg)
46
![Page 47: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/47.jpg)
F Procaccio 2012
Possible Pitfalls in BD diagnosis
1. the BD declared patient is not Deadzero mistake must be ensured
2. the BD person is not BD declared
![Page 48: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/48.jpg)
![Page 49: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/49.jpg)
49
Brain Death Declaration
Certain diagnosis
plus
Legal procedures
![Page 50: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/50.jpg)
Clinical Diagnosis simple and reliable
Must be complete
methodicalrigorous
50
![Page 51: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/51.jpg)
Deceased Organ Donation Dead Donor Rule
Death determination (diagnosis)
• Threshold of irreversibility• Clinical standard• Confirmatory tests
Dying process
(legal) Death declaration• Adherence to guidelines• Legal procedures • The moment of Death
51
![Page 52: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/52.jpg)
Brain death diagnosis (clinical criteria)
etiology
ComaBrainstemreflexes
+apnea
MandatoryEEG
MandatoryCBF
CBFIn
DefinedConditions children
All pts or only potential donors?
other
x x x no x x all >24hrs anoxic
BD declaration (legal procedures)
Observationperiod
N° MD
Repeated clincial tests
RepeatedEEG
Repeated CBF Children
All ptsOr only
Potential Donors?
6 hrs 3 2 2 no x all Italy
Law –Decree ? !x!National Guidelines ? !x! Country: Italy
Death determination by neurological criteria
52
![Page 53: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/53.jpg)
ICU Admission Vegetative
Storm(coning)
Brain DeathDeclaration
1 2 3 4
Patient treatment
Timing in Death declaration
BDcriteria observation
Death53
![Page 54: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/54.jpg)
Common Principles for present/future ?
Citizens equal in death: Death declaration independent from organ donation
Clear, simple and acceptable definitions, criteria and procedures in death diagnosis
A «Universal death» independent from clinical and (new) technical aspects
Clear legal procedures for death declaration
54
![Page 55: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/55.jpg)
1. Treating physicians (Intensivists!) should be more involved in BD diagnosis and potential donor identification.
2. BD Pathophysiology based guidelines should guide BD diagnosis and donor treatment.
3. Law and decrees should have (few) technical details aimed to BD (legal) declaration
Suggestions
55
![Page 56: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/56.jpg)
1. Specific education and common language are needed.
2. Quality of critical care may facilitate BD diagnosis.
3. The probability of success in organ donation reflects the capacity of declaring brain death in all the patients fulfilling BD criteria.
Key factors
56
![Page 57: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/57.jpg)
57
Case study
Reversible Brain Death
![Page 58: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/58.jpg)
A 55-yr-old man presented with cardiac arrest preceded by respiratory arrest.
Cardiopulmonary resuscitation was performed, spontaneous perfusion restored, and therapeutic hypothermia was attempted for neural protection.
After rewarming to 36.5°C, neurologic examination showed no eye opening or response to pain, spontaneous myoclonic movements, sluggishly reactive pupils, absent corneal reflexes, and intact gag and spontaneous respirations.
![Page 59: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/59.jpg)
Day 1Facial Myoclonus
![Page 60: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/60.jpg)
Over 24 hours, remaining cranial nerve function was lost.
The neurologic examination was consistent with brain death.
Apnea test and repeat clinical examination after a duration of 6 hrs confirmed brain death.
Death was pronounced and the family consented to organ donation.
![Page 61: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/61.jpg)
Are there factors that may cause unreliable brain death
diagnosis?
![Page 62: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/62.jpg)
Twenty-four hrs after brain death pronouncement, on arrival to the operating room for organ procurement, the patient was found to have regained corneal reflexes, cough reflex, and spontaneous respirations.
The care team faced the challenge of offering an adequate explanation to the patient's family and other healthcare professionals involved.
![Page 63: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/63.jpg)
63
![Page 64: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/64.jpg)
![Page 65: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/65.jpg)
![Page 66: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/66.jpg)
66
Would you consider propofol/fentanyl a potential confounding factor at hour 80 ?
1) Yes2) No3) maybe
![Page 67: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/67.jpg)
The ideal practice is to use confirmatory tests
only if necessary to confirm the clinical examination.
Physicians should not go far as to place blind faith in machinery and
the clinical diagnosis remains a sacrosant principle.
EFM Wijdicks, 2001
67
![Page 68: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/68.jpg)
68
Is an ancillary test
1) Useful
2) Mandatory
3) Unreliable
![Page 69: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/69.jpg)
F Procaccio 2012
SEPs NMR CBF CCA
170
195 200 202
venti
latio
nw
ithdr
awal
Ope
ratin
g ro
om
1°- 2
° clin
ical
exa
m +
apn
ea te
st
HypothermiaSedation
![Page 70: Technical Assistance for Alignment in Organ Donation- EuropeAid/131052/D/SER/TR](https://reader035.vdocument.in/reader035/viewer/2022062814/5681672c550346895ddbcd30/html5/thumbnails/70.jpg)
Although the reversal was transient and did not impact the patient's prognosis, it impacted his eligibility for organ donation and cast doubt about the ability to determine irreversibility of brain death findings in patients treated with hypothermia after cardiac arrest.
CONCLUSIONS:
We strongly recommend caution in the determination of brain death after cardiac arrest when induced hypothermia is used. Confirmatory testing should be considered and a minimum observation period after rewarming before brain death testing ensues should be established.