Brain Death Simulation Workshop November 8

Report
Brain Death: An Update on New
Important Initiatives
Community of Practice Action Leader Meeting
Organ Donation & Transplantation Alliance
Nashville, TN
March 19, 2013
You must be one of
Dr. Frank’s patients!
Jeffrey I. Frank, MD, FAAN, FAHA
Professor of Neurology and
Neurosurgery
Director, Neurocritical Care
University of Chicago Medicine
Disclaimer
 I am NOT a passionate about organ donation advocate
 My presence at this meeting IS NOT about enhancing
organ donation
 My passion and presence IS about my role in:
 Improving contemporary understanding of brain death
 Assuring integrity in brain death diagnosis and
patient/family management through better education of
physicians and nurses, and better uniformity of policies
 Implications for organ donation but it NOT ABOUT organ
donation (ODMT: DDWG)
Pre-Ventilator Era
Any process that arrested breathing led to asystole
and a cold, blue corpse
Apnea
Asystole
Ventilator Era (1960’s)
?
1928
1952
1972
Now patients with severe brain dysfunction were on ventilators!
Spectrum of Brain Injury
With Mechanical Ventilation
Moderate:
Awake or
drowsy with
disability
Major:
Coma with
some brain
function
Extreme:
No discernible
brain function
Required
Definition
Brain Death History
Harvard
(1968)
NIH Collaborative Study
(1977)
“Irreversible Coma”
No brainstem reflexes
“Flat” EEG
Proposed brain death
Defined the futility of
brain death
President’s Commission Report
(1980)
Affirmed the validity
of brain death
Proposed
guidelines on how
to approach brain
death diagnosis
Declaration of Death Act
Uniform Declaration of Death Act (1980)
 Basis for Brain Death Law
 Dead if irreversible cessation of either:
– Circulatory and respiratory functions, or
– All functions of the entire brain, including brain-
stem (brain death)
BRAIN DEATH IS THE IRREVERSIBLE CESSATION OF
WHOLE BRAIN FUNCTION
(HEMISPHERES AND BRAINSTEM)
1995
AAN Creates Practice Parameter:
Guideline
Brain Death in the U.S.
Harvard
Report
1920
NIH
Study
President’s
Commission
Report
UDDA
1965
2012
Transplant
Reality
Iron Lung
Invented
Modern mechanical
ventilation (critical care)
CT Scanner
Invented
Societal Evolution and Acceptance (death with a heart beat)
Irreversible cessation of whole brain function = Death
Real mechanism of death
Can be reliably diagnosed
Paradigm Shift
Brain Death Today
 Mechanism of death: Widely accepted
 Diagnosis: Important; Independent of OD
 Contemporary Imperative


Mandatory, accurate, and expeditious diagnosis
Respect for process



Proactive management of physiology
Thoughtful interaction with family/surrogates
Thoughtful sequencing of involvement of health care teams
and OPOs
 Profound variability in policy and practice
Guideline performance
Pre-clinical testing
Clinical examination
Apnea testing
Ancillary testing
Physicians Responsible for
Brain Death Diagnosis
11%
36%
43%
10%
Intensivist
Primary Attending
No mention
N/NS
71%
63%
60%
50%
45%
Endocrine
Disorders
Absent
70%
Acid-base
Disorders
Absent
72%
Sedatives and
Paralytics
Absent
80%
Established
Cause
81%
Shock Absent
89%
Electrolyte
Disorders
Absent
90%
Sedatives
Absent
100%
Hypothermia
Absent
Preclinical Testing:
Compliance with AAN Guidelines
55%
42%
40%
30%
20%
10%
0%
Clinical Exam:
Compliance with AAN Guidelines
100%
100%100% 97% 95%
90%
87% 87% 87%
82%
80%
70%
60%
42%
50%
40%
27%
30%
18%
20%
10%
Jaw Jerk
Absence of
Pain in
Cranium
Cough
Absence of
Pain in Body
Corneal
Coma
0%
55%
50%
40%
48%
30%
20%
Repeat if
inconclusive
60%
hypotension,
desat and
arrhythmia
pCO2 rise
above
baseline
76% 71%
66%
Use of suppl
02
ABG prior to
test
70%
Stop if
unstable
80%
Preoxygenation
87%
Absence of
respirations
90%
Final pCO2
spec.
100%
Apnea Testing:
Compliance with AAN
Guidelines
87%
39%
16%
10%
0%
Ancillary Testing
100%
84%
90%
80%
70%
74%
66%
66%
60%
50%
40%
30%
20%
10%
0%
33%
42%
21%
29%
21% 24% 18% 24%
Variability in BD Determination Practice:
a review of 226 brain dead organ donors (2011)
Claire Shappell MS2, Jeffrey Frank MD
AAN Approach to Determining
Brain Death
Part 1
Coma
Known Cause
Irreversible
“Pre-Requisites”
Neuroimaging
compatible
Part 2
Absent
Reflexes
Pupillary
Doll’s Eyes
Cold Water Calorics
Corneal
Gag
Cough
Motor
Part 3
Apnea
Loss of respiratory
drive
Specific method of
testing for apnea
Rise in CO2 with
no breaths
observed
Sometimes, Part 4
Ancillary Tests
 Nuclear Medicine Blood Flow Study
 Electroencephalography (EEG)
 CT Angiography
 Conventional Angiography
Required ONLY if clinical examination or apnea testing
cannot be fully performed
Results: Overview and Part 1
Total Patients
226
Age, mean (SD), y
46 (16)
Male Sex, No. (%)
115 (51)
Cause of Death, No. (%)
Intracranial Hemorrhage
95 (42)
Trauma
59 (26)
Anoxia
44 (19)
Unknown
9 (4)
Ischemic Stroke
8 (4)
Other
8 (4)
Results: Brain Stem Reflexes
100%
99%
96%
95%
94%
80%
80%
69%
66%
Cough
Calorics
60%
40%
20%
0%
Pupillary
Corneal
Motor
Gag
Doll's Eyes
Mean # of reflexes documented: 6 ±1.2
All reflexes documented (7 of 7): 101 (44.7%)
Apnea and Ancillary Studies
Apnea Test
Completed
# Donors (%)
162 (71.7)
Aborted
12 (5.3)
Not Performed
46 (20.4)
100%
80%
60%
40%
35%
28%
13%
20%
0%
NM
EEG
CTA
2%
2%
TCD
Angio
8%
Other
Putting it all together
All Brain Dead
Organ Donors
n=226
Coma
Cause Known
n=217
67%
69%
81%
96%
100%
Normothermic
(≥36°C)
n=184
Reflexes Absent
± Redundant
n=157
Apnea Test OR
Ancillary Study
n= 151
Conclusions
 36.7% documented adherence to all AAN practice
recommendations for brain death diagnosis
 66.8% documented adherence to AAN
recommendations with weaker brain stem reflex
standard (± redundant reflexes)
 At least 1/3 of brain death determinations do NOT
have documentation of necessary features of brain
death
What are we doing to improve
the field?
 Educational/training endeavors
 Web-based training: Acute Review (CCF, Prpvencio)
 Webinars: Frank, Greer, Goldenberg, Provencio
 Simulation training:
 Basic training (Yale, Greer)
 “Champions”: Training Leaders (UofC, Frank, Goldenberg)
Brain Death Simulation Training
November 12, 2012
Second International Brain Death
Simulation Workshop: Training
Future Leaders
BD
Clinical Cases
Dummy
Simulation
Station
Intoxication
DDNC
Isolated BS
Injury
Apnea Test
Post CA w/o CE
Grade V SAH
Catastrophic
Brain Injury
Physiological
Management
Station
Ancillary Tests
Station
Involuntary
Movements
Station
MD/Family
Interaction
Station
What are we doing to improve
the field?
 Educational/training endeavors
 Web-based training: Acute Review
 Simulation training: Basic training
 “Champions”: Training Leaders
 Creation of a national/international standard
 Re-evaluate protocols since the 2010 AAN Practice
Parameters (WE NEED YOUR HELP)
 Lobby at a national level for uniformity
 Brain Death Ethics Subcommittee of NCS
 Taking leadership/ownership regarding Brain Death
 Education, Advocacy, Policy
Adaptation to Technology
End-Stage
Cardiomyopathy
Perioperative
MI and
Cardiac Arrest
VAD
Insertion
Death of Heart
Muscle: Permanent
Asystole
Post-Event Scenario
Continuous Flow
Ventricular Assist
Device
Heart Stops = Dead
•Permanent asystole
•Maintained perfusion through VAD
•Brain with continued blood flow
Brain Death = Dead
•Systemic perfusion
•No heart beating
Heart stops but
device maintained
systemic perfusion
= Alive
Summary
 Brain Death is an Important Diagnosis
 Shift in accountability and responsibility for the
integrity of brain death diagnosis, patient/family
management, and policies/advocacy
 Educational efforts
 Academic efforts
 Policy change
 Better uniformity
“Growth means change and
change involves risk,
stepping from the known to
the unknown”

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