1976 2008 37&years&on& - home - odt...
TRANSCRIPT
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
Organ&Dona)on&Past,&Present&and&Future&&
(
We are explorers
not inventors.
3(Organ&Dona)on&Past,&Present&and&Future&&
4(Organ&Dona)on&Past,&Present&and&Future&&
Harvey Cushing describes increased
brain pressure provoking respiratory arrest with preserved
heartbeat.
5(Organ&Dona)on&Past,&Present&and&Future&&
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.
6(Organ&Dona)on&Past,&Present&and&Future&&
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”
7(Organ&Dona)on&Past,&Present&and&Future&&
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.
8(Organ&Dona)on&Past,&Present&and&Future&&
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(
9(Organ&Dona)on&Past,&Present&and&Future&&
“…&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(
10(Organ&Dona)on&Past,&Present&and&Future&&
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
Organ&Dona)on&Past,&Present&and&Future&&
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(
irreversible(loss(of(
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
Irreversible loss of the capacity for consciousness
Irreversible loss of the capacity to breathe
Organ&Dona)on&Past,&Present&and&Future&&
V a l i d a t i o n !
p r o p h e c y
Organ&Dona)on&Past,&Present&and&Future&&
> 10000 patients 10 years
…37 years
Organ&Dona)on&Past,&Present&and&Future&&
D. Alan Shewmon, MD
Organ&Dona)on&Past,&Present&and&Future&&
‘Although(we(were(unable(to(restore(his(consciousness(or(
spontaneous(breathing,(the(boy(lived(several(more(
years.’(((page(195)(
Organ&Dona)on&Past,&Present&and&Future&&
Organ&Dona)on&Past,&Present&and&Future&& 18(
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(
irreversible(loss(of(
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
Irreversible loss of the capacity for consciousness
Irreversible loss of the capacity to breathe
Organ&Dona)on&Past,&Present&and&Future&& 19(
• 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
Irreversible loss of the capacity for consciousness
Irreversible loss of the capacity to breathe
Organ&Dona)on&Past,&Present&and&Future&& 20(
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(
irreversible(loss(of(
the(capacity(to(
breathe.(
3. A(clinical(examina)on&of(the(pa<ent,(which(
demonstrates(
profound(coma,(
apnoea(and(absent(
brainstem(reflexes.((
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
Irreversible loss of the capacity for consciousness
Irreversible loss of the capacity to breathe
Brain,stem(reflexes (
Organ&Dona)on&Past,&Present&and&Future&& 21(
! 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 (
Organ&Dona)on&Past,&Present&and&Future&& 22(
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(
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(
irreversible(loss(of(
the(capacity(to(
breathe.(
3. A(clinical(examina)on&of(the(pa<ent,(which(
demonstrates(
profound(coma,(
apnoea(and(absent(
brainstem(reflexes.((
Dx(Death(using(Neurological(Criteria(2. An(exclusion(of(
reversible(condi<ons(capable(of(mimicking(or(confounding&the(diagnosis(of(death(using(neurological(criteria.(
In 2012,1238 tests performed, death confirmed in 1220 = 98.5%
DEATH
Irreversible loss of the capacity for consciousness
Irreversible loss of the capacity to breathe
Tes<ng(for(Brain,stem(Death (
Organ&Dona)on&Past,&Present&and&Future&& 24(
“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&
Organ&Dona)on&Past,&Present&and&Future&& 25(
Organ&Dona)on&Past,&Present&and&Future&&
WHY(TEST?(
Organ&Dona)on&Past,&Present&and&Future&&
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(
(
Organ&Dona)on&Past,&Present&and&Future&&
diagnosis((((((((((((((((((decision(
Organ&Dona)on&Past,&Present&and&Future&&
((((((Brainstem(death(in(the(
Organ&Dona)on&Past,&Present&and&Future&&
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.
Organ&Dona)on&Past,&Present&and&Future&&
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(
Organ&Dona)on&Past,&Present&and&Future&&
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(
=(2(TESTS((regardless(of(organ(dona<on)((
Legal(support(from(case(law(
&(Bolam(&(Bolithio(tests(
Organ&Dona)on&Past,&Present&and&Future&&
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(
=(2(TESTS((regardless(of(organ(dona<on)((
Legal(support(from(case(law(
&(Bolam(&(Bolithio(tests(
Time(
of(
Death(
Organ&Dona)on&Past,&Present&and&Future&&
2008 1976
Lesson 1
Organ&Dona)on&Past,&Present&and&Future&&
Lesson 2
Organ&Dona)on&Past,&Present&and&Future&&
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
Organ&Dona)on&Past,&Present&and&Future&&
Lesson 4 Induced hypothermia has unpredictable consequences See Lesson 3
Advice: warm to normothermia and then wait 24 hours
Organ&Dona)on&Past,&Present&and&Future&&
Lesson 5 NO EEG
Organ&Dona)on&Past,&Present&and&Future&&
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?’
Organ&Dona)on&Past,&Present&and&Future&&
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Gardiner, Shemie, Manara & Opdam International Perspective on the Diagnosis of Death Br J Anaesthesia Supplement January 2012
www.odt.nhs.uk