Professional Development Programme for Organ Donation Diagnosis of Death Masterclass Alex Manara...

Professional Development Programme for Organ Donation

Diagnosis of Death Masterclass

Alex ManaraDale GardinerPaul Murphy

31 March 2010

“Improving organ donation within your hospital”

1

Professional Development Programme for Organ Donation2


Diagnosis of Death MasterclassThe six big wins


Diagnosis of Death Masterclass

2. Increased diagnosis of brain stem death

3. Increased donation after cardiac death


20461928

17161628 1575

14951370 1338

1243 12681161 1165

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500

1000

1500

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2500

2003/04 2004/05 2005/06 2006/07 2007/8 2008/9

BSD possible diagnosis Patient confirmed BSD

Incidence of Brainstem Death on ICU(< 75 years, non-cardiac ICUs)


20461928

17161628 1575

14951370 1338

1243 12681161 1165

0

500

1000

1500

2000

2500

2003/04 2004/05 2005/06 2006/07 2007/8 2008/9

BSD possible diagnosis Patient confirmed BSD

Incidence of Brainstem Death on ICU(< 75 years, non-cardiac ICUs)

• 350 missed potential donors

• 172 actual donors

• 619 additional transplanted patients

• Extra 2.8 donors pmp


Diagnosis of Brainstem Death

Reasons for not testing (approx 650 / year)

30.4

28.1

14.6

11

8.4

6.1

0.7

0.7

0 10 20 30 40

cardiovascular instability

unknow n

residual neurological function

family-related

problems w ith testing

contra-indication to donation (including age)

coroner

others

% total

Reasons for not testing (approx 350 / year)


Diagnosis of Brainstem Death

Difficulties with BSD testing

0

2

4

6

8

10

12

preconditions drugs biochemicaldisturbances

hypothermia apnoea

% t

ota

l re

as

on

s f

or

no

t te

sti

ng

all

ICH

trauma


• Significant regional variation

– Only 50% of suitable patients given the option of NHBD

• Significant clinical variation

– Diagnosis of death

– warm ischaemic times

– organ retrieval

Is NHBD organ donation maximised in the UK?

9

The Potential Donor Audit has been assessing the potential for NHBD in the UK for the last five years. The map below shows NHB donor numbers by DTC region for 2009.


Aims:

1. Promote national consistency in the use of the criteria used to diagnose death.

2. You to feel confident in the criteria used to diagnose death whilst being alert to potential pitfalls.

3. For you to be aware of potential criticisms by colleagues and the literature and have thought about possible counter arguments.


Agenda

1 Introduction 09.30-09.45

2 Diagnosis of Death: A defence of the British criteria 09.45-10.15

3 Quiz: Dead or not dead? 10.15-10.30

Break 10.30-10.40

4 The confirmation of death 10.40-11.15

5 Case study activity 11.15-12.15

6 Questions 12.15-12.25

7 Summary & close 12.25-12.30

11

A Defence of the British Criteria

Dale Gardiner

12


30 years on…


UK criticsDavid EvansDavid HillPhilip Keep

Critics

Rinaldo Bellomo

Margaret Lock

Alan Shewmon

14

Edmund Pellegrino

Peter Singer



Criteria for Human Death

= The irreversible cessation of brain-stem function

=> Irreversible unconsciousness + Irreversible apnoea

=> intra-cranial or extra-cranial cause

DO NOT restore Cerebral Circulation

=> 5 mins absent cerebral circulation




Transplant Technique• Split livers• Marginal Donors

Immunosuppressants• Tacrolimus• Mycophenolate



Brain Death

Cushing1st Renal auto-Tx(unsuccessful)

TransplantsTransplantsTransplants

Transplants

TransplantsTransplantsTransplantsTransplantsTransplants

Transplants

1902

The Concept of Brain Death Did Not Evolve to Benefit Organ Transplants.


Brain Death


Transplants

TransplantsTransplantsTransplantsTransplants

Transplants

1902


1st xeno-Tx (unsuccessful)

EEG discovered In electric potential =

Death

Loss cortical potentials seen in ischaemia1st Renal cadaveric Tx

(unsuccessful)1950


Brain Death


Transplants


Transplants


1950 Cessation of brain blood flow = Death

Cortical circulatory arrest seen in coma patients

1st successful live Renal Tx

1960Death of the nervous system

= Coma dépassé


Brain Death


Transplants


Transplants


19601st successful

cadaveric Renal Tx

Irreversible cessation of the EEG= Death


Brain Death


Transplants


Transplants


1967-68

1st successful Heart Tx

Harvard CriteriaBrain Death = DEATH


3rd December 1967


Ad Hoc Committee of the Harvard Medical SchoolJAMA

5th Aug 1968



‘Our Primary purpose is to define irreversible coma as a new criterion for death…

…Obsolete criteria for the definition of death can lead to controversy in obtaining organs for transplantation.’


Brain Death


Transplants

TransplantsTransplantsTransplantsTransplantsTransplants

Transplants


Future

1st xeno Tx

1st lab grown organ Tx

Brain Death = DEATH




diagnosis decision



Brain Stem Death

UK

Whole Brain Death

Rest of the World

Higher Brain DeathPhilosophers


Higher Brain DeathPhilosophers

Peter Singer


Whole Brain Death

Rest of the World

Rinaldo BellomoICM 2004


Brain Stem Death UK


Whole Brain DeathRest of the World






Brain Stem Death UK



NEJM 2010



ALIVE DEAD


Brain Stem DeathUK


Brain Stem DeathUK


Brain Stem DeathUK




D. Alan Shewmon, MD





Doctors fight to save brain-dead mom’s foetus...

… for 3½ months





Brain Stem Death UK


The inferior hypophysial artery is an artery supplying the posterior pituitary gland. It is a branch of the cavernous carotid artery (internal carotid artery) which is extradural at this point.










Alan Shewmon MD


‘Although we were unable to restore his consciousness or spontaneous breathing, the boy lived several more years.’

(page 195)


Brain Stem DeathUK



trauma unit PET scan brainno blood flowingUnited Regional

Healthcare System Wichita Falls, Texas



Regions only Level III Trauma Centre


USA Trauma Center Level I - Highest toLevel III - Lowest









=> intra-cranial or extra-cranial cause

DO NOT restore Cerebral Circulation

=> 5 mins absent cerebral circulation


75 seconds, 2 minutes, 5 minutes

2 minutes

5 minutes


Dr Michael DeVitaUniversity of Pittsburgh


3.7 days old donor

Taken to the operating room

Lined and given heparin

Extubated & sedated

Waited 75 seconds of PEA

“Best interests of the recipient”




One Thousand One Hundred and Seven NHBD


ALIVE DEAD



Questions?

Quiz: Dead or not Dead?

87


Question 1

1. The patient flexes their arm at the elbow following

imposition of a painful stimulus to the nail bed on that

side?

Dead - May represent a spinal reflex


Question 2

2. The ventilator registers the patient as making

spontaneous respirations?

Dead - May represent the heart beat creating flow

that is triggering ventilation


Question 3

3. The patient has a generalised tonic clonic seizure?

NOT brain stem dead – the patient must have intact

neural connections to have a grand mal fit


Question 4

4. The patient’s pulse increases from 70bpm to 110 bpm

during apnoea testing?

Dead - Hypercarbia (which occurs during apnoea

testing) results in endogenous adrenaline release.


Question 5

5. There is slow drift of one eye away from the ear in which

cold water is injected?

NOT brain stem dead – any eye movements in

response to caloric testing signifies the presence of

some reflex brain stem arc function.


Question 6

6. The patient sits up during apnoea testing (Lazarus sign)?

Dead - A spinal reaction to the acidosis which

follows hypercarbia. Very unsettling and disturbing!


How are you going?

These six questions were asked in the Australian JFICM

exam 2008 and the pass rate was only 65%!


Question 7

7. During an apnoea test on a mechanical ventilator after

20 seconds the patient starts to breathe and then

continues to breathe at 16 breaths per minute?

Dead – ventilator apnoea ventilation has kicked in.

Are you convinced not to do your apnoea tests still

connected to the ventilator?


Question 8

8. Supra-orbital painful stimulus leads to movement in one

of the arms?

Not dead – although one primarily looks for

movement in the cranial nerve distribution one must

actively ensure (by repetition) that this was a

coincidental spinal reflex but until proven this may

represent the patient is not brain stem dead.


Question 9

9. During the second set of brain stem testing the second

clinician finds the ears full of wax and can't visualise the

drum?

Not dead – this finding may invalidate the first

oculovestibular test and thus the patient may not be

dead.


Question 10

10.Due to left orbital trauma you can't visualise or observe

the left eye?

Dead – may still be dead even if one can’t carry out

the full test. Some of the options we discuss in our

case based discussions after morning tea.


Question 11

10.After a complete set of brain stem tests, confirming

clinical brain stem death, your colleague organises a CT

angiogram which reveals persisting intracerebral blood

flow?

Dead – Brain Stem Death is the UK Criteria

The Confirmation of Death

Alex ManaraICU Frenchay Hospital

100


Confirmation vs. Certification


600,000 UK deaths per annum


Confirming Death

• Cessation of heart beat

• Cessation of breathing

• Unresponsiveness

• Relatively easy to make

• Reproducible

• Recognizable


Confirming Death


Confirming Death: Most doctors.


Confirming Death: Neurosurgeons...


Confirming Death: Orthopods...


Confirming Death: What the public think...


The Law

• There is no statutory definition of death in the United Kingdom

(Unlike USA)

• The determination of death using neurological criteria has been

accepted by the courts of England and Wales.

• Otherwise you’re dead when a doctor says so = accepted medical

practice


Variation in Practice


What is accepted medical practice?


Definition of death

“The irreversible loss of those essential characteristics which are necessary to the existence of a living human person”

=

“The irreversible loss of the capacity for consciousness, combined with the irreversible loss of the capacity to breathe”


All Death is Brain Death

1. Cardio-respiratory determination of death

2. Neurological determination of death

3. Somatic determination of death


Cardio-respiratory criteria

“The heart and lung are not important as basic prerequisites to continue

life but rather because the irreversible cessation of their functions shows

that the brain has ceased functioning”


Cardio-respiratory criteria

• Need to be applicable to primary care / out of hospital setting

• Simultaneous and irreversible onset of apnoea, and

unconsciousness in the absence of a circulation.

• Irreversible cessation of brain stem function rapidly follows


Preconditions for cardiac criteria

• Decision made to abandon CPR

• The individual meets the criteria for not attempting CPR (ROLE)

• Active treatment is being withdrawn as declared not in the patient’s

best interests

• Patient has an advance directive refusing CPR


At “asystole”

• Person confirming death present and continuously observes apnoea,

asystole and unresponsiveness for a minimum of 5 minutes

• Absent circulation confirmed clinically or with monitors

• Return of circulation or respiration prompts start of a further 5

minutes from point of next cardio-respiratory arrest

• Confirm absent pupillary and corneal reflexes and no central

response to pain


At “asystole”

• Person confirming death present and continuously observes apnoea,

asystole and unresponsiveness for a minimum of 5 minutes

• Absent circulation confirmed clinically or with monitors

• Return of circulation or respiration prompts start of a further 5

minutes from point of next cardio-respiratory arrest

• Confirm absent pupillary and corneal reflexes and no central

response to pain


Irreversibility

• Heart will not be restarted because patient not for CPR

• Cardiac activity will not resume spontaneously

• Cannot be restarted even with CPR

No post-mortem procedures that have the potential to restore cerebral perfusion


Post mortem Interventions

http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/documents/digitalasset/dh_108827.pdf


Post Mortem Interventions

Anything that places the person at risk of serious harm or distress is

unlikely ever to be in the person’s best interests. (CPR, femoral

cannulation, heparinisation)


International Differences

• 2 minutes

Pittsburgh protocol 1993

ANZICS

• Minimum of 2 minutes, no more than 5 minutes recommended

Society of Critical Care Medicine, USA

• Minimum of 5 minutes:

Academy of Medical Royal Colleges UK

Intensive Care Society, UK

Institute of Medicine, USA

Canadian Council for Donation and Transplantation

• Minimum of 10 minutes

Maastricht Conference, Holland



80 year old male with pancreatitis, cerebral infarction and MRSA sepsisCPR abandoned - Doctor went to showerIPPV continuedROSC noted on return at 5 minutesPatient died 2 days later


UK Deceased Organ Donors


Organ Donation USA


Lazarus?

Is auto-resuscitation a result of not having a standardised way of

confirming death and also defining what can and cannot happen after

death?


Neurological Determination of Death in UK


History

• Improved ICU care of comatose

patients

• Coma depassé described in

Paris in 1959

• Deep irreversible coma

• Nearly always followed by

cardiac arrest


Cardiac Prognosis After NDD

Pallis 1987:

1300 patients all developed cardiorespiratory arrest even with full

support

Hung et al 1995:

•73 adults and children

• Full and continued CVS support

• All became asystolic; within 10 days


Rationale for New Guidelines

• Variable practice when

guidelines not specific

• Guidelines not always followed

even when specific


New Guidelines

• Published 2008

• Attempts further standardisation

• Primarily a clinical diagnosis

• Clinical judgement still required



1. Patient in deep apnoeic coma



2. Known cause capable of causing ND



• Primary hypothermia

• Metabolic disturbances

• Alcohol

• Depressant drugs

• Muscle relaxants

3. No reversible causes / confounding factors



• Temperature > 34o C

• Na+ < 160 mmol/L

• K+ > 2 mmol/L

• Glucose > 3 mmol/L < 20mmol/L

• Phosphate > 0.5 mmol/L < 3 mmol/L

• Magnesium

3. No reversible causes / confounding factors - Metabolic

Serum Na+ > 115mmol/L?



• Clinical judgement essential

• Impossible to create rules covering every situation

• Difficulties mainly with thiopentone and midazolam

• Plasma concentrations not good predictors of effect

• Use of antagonists may help

• Ideally use non cumulative drugs – propofol, remifentanil

3. No reversible causes / confounding factors - Sedatives



4. Absent brainstem reflexes



• Must be done last after other reflexes absent

• Undertaken no more than twice

• Achieve CVS stability at PaCO2 > 6kPa before disconnection

• Disconnect for 5 minutes

• Return PaCO2 to normal on reconnection

Apnoea Test



• 4 vessel cerebral angiography

• CT angiography

• MRI angiography

• EEG

• TCD

• SPECT

• Brain stem evoked potentials

• Response to 2mg atropine

• ICP > MAP

5. Ancillary Tests


Whole Brain Death ?

http://video.bloodservices.ca/Streaming/nddvideo/


Reducing Variability in Practice

• Guidelines – Helpful but limited value

• CLODs – Professional Development Programme

• Development of international approach to confirmation

• Prospective observational studies on onset of asystole

Case Study Activity

143


Case Study Exercise

• We have 2 case studies which we would like you to discuss and

respond to in your table groups

• You each have a handout of the 2 case studies which provide a case

context and a series of questions

• We will spend 30 mins total on each case study, 15mins to discuss &

answer questions and15 mins to feedback as a wider group

• This part of the session will take an hour to complete and will be

followed by a more general Q&A


Case Study 1

A middle-aged woman presents to your Emergency Department at 1600

after collapsing at home. She has fixed pupils and is intubated without

drugs. CT head reveals catastrophic subarachnoid haemorrhage.

Neurosurgical opinion is that this is an unsurvivable situation and

withdrawal of life sustaining treatment is advised. The family approach

the ED staff suggesting their relative would wish to be an organ donor.

Brain death is suspected.


Case Study 2

A young man is admitted to your neuro-critical care unit with severe

traumatic brain injury. Despite aggressive treatment his pupils fix after

four days and irreversible cessation of brain stem function (brain stem

death) is suspected.

He has received substantial doses of sedatives (midazolam, alfentanil

and propofol).

Questions???

147

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