© 2010 AMERICAN ACADEMY OF NEUROLOGY Update: Determining Brain Death in Adults Report of the Quality Standards Subcommittee of the American Academy of.

© 2010 AMERICAN ACADEMY OF NEUROLOGY Update: Determining Brain Death in Adults Report of the Quality Standards Subcommittee of the American Academy of Neurology Eelco F. M. Wijdicks, MD, PhD, FAAN; Panayiotis N. Varelas, MD, PhD; Gary S. Gronseth MD, FAAN; David M. Greer, MD, MA

© 2010 AMERICAN ACADEMY OF NEUROLOGY The AAN develops these presentation slides as educational tools for neurologists and other health care practitioners. You may download and retain a single copy for your personal use. Please contact guidelines@aan.com to learn about options for sharing this content beyond your personal use. guidelines@aan.com

© 2010 AMERICAN ACADEMY OF NEUROLOGY Presentation Objectives To present the key findings of the update of the 1995 American Academy of Neurology (AAN) guideline 1 To present evidence-based recommendations

© 2010 AMERICAN ACADEMY OF NEUROLOGY Background The President’s Commission report on “guidelines for the determination of death” 2 culminated in a proposal for a legal definition that led to the Uniform Determination of Death Act (UDDA). The act reads:  “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 must be made with accepted medical standards.” 3

© 2010 AMERICAN ACADEMY OF NEUROLOGY Background, cont. Most US state laws have adopted the UDDA. Several states have added amendments. The UDDA does not define “accepted medical standards.” The American Academy of Neurology (AAN)’s 1995 practice parameter delineated the medical standards for the determination of brain death. 1 Considerable practice variation remains.

© 2010 AMERICAN ACADEMY OF NEUROLOGY Clinical Questions The first step in developing guidelines is to clearly formulate questions to be answered. Questions address areas of controversy, confusion, or variation in practice. Questions must be answerable with data from the literature. Answering the question must have the potential to improve care/patient outcomes.

© 2010 AMERICAN ACADEMY OF NEUROLOGY AAN Classification of Evidence All studies rated Class I, II, III, or IV Five different classification systems:  Therapeutic  Randomization, control, blinding  Diagnostic  Comparison to gold standard  Prognostic  Screening  Causation

© 2010 AMERICAN ACADEMY OF NEUROLOGY AAN Level of Recommendations A = Established as effective, ineffective or harmful (or established as useful/predictive or not useful/predictive) for the given condition in the specified population. B = Probably effective, ineffective or harmful (or probably useful/predictive or not useful/predictive) for the given condition in the specified population. C = Possibly effective, ineffective or harmful (or possibly useful/predictive or not useful/predictive) for the given condition in the specified population. U = Data inadequate or conflicting; given current knowledge, treatment (test, predictor) is unproven. Note that recommendations can be positive or negative.

© 2010 AMERICAN ACADEMY OF NEUROLOGY Translating Class to Recommendations A = Requires at least two consistent Class I studies.* B = Requires at least one Class I study or two consistent Class II studies. C = Requires at least one Class II study or two consistent Class III studies. U = Studies not meeting criteria for Class I through Class III. *In exceptional cases, one convincing Class I study may suffice for an “A” recommendation if 1) all criteria are met, 2) the magnitude of effect is large (relative rate improved outcome >5 and the lower limit of the confidence interval is >2).

© 2010 AMERICAN ACADEMY OF NEUROLOGY Clinical Questions 1. Are there patients who fulfill the clinical criteria of brain death who recover brain function? 2.What is an adequate observation period to ensure that cessation of neurologic function is permanent? 3.Are complex motor movements that falsely suggest retained brain function sometimes observed in brain death? 4.What is the comparative safety of techniques for determining apnea? 5.Are there new ancillary tests that accurately identify patients with brain death?

© 2010 AMERICAN ACADEMY OF NEUROLOGY Methods MEDLINE and EMBASE  January 1996 to May 2009  A secondary bibliography search of all full-text articles  Relevant, fully published, peer-reviewed articles  Search terms included the MeSH term brain death and the text words brain death, irreversible coma, and apnea test.

© 2010 AMERICAN ACADEMY OF NEUROLOGY Methods, cont. At least two authors reviewed each article for inclusion. Risk of bias was determined using the classification of evidence for each study (Classes I–IV). Strength of practice recommendations were linked directly to levels of evidence (Levels A, B, C, and U). Conflicts of interest were disclosed.

© 2010 AMERICAN ACADEMY OF NEUROLOGY Literature Review 38 articles 367 abstracts Exclusion criteria: - Articles that studied patients younger than 18 years - Articles that confirmed prior observations - Review articles, bioethical reviews, articles without description of a brain death examination - Articles with questionable practices or describing rarely used ancillary technology

© 2010 AMERICAN ACADEMY OF NEUROLOGY AAN Classification of Evidence for Diagnostic Accuracy Class I: A cohort study with prospective data collection of a broad spectrum of persons with the suspected condition, using an acceptable reference standard for case definition. The diagnostic test is objective or performed and interpreted without knowledge of the patient’s clinical status. Study results allow calculation of measures of diagnostic accuracy. Class II: A case control study of a broad spectrum of persons with the condition established by an acceptable reference standard compared to a broad spectrum of controls or a cohort study where a broad spectrum of persons with the suspected condition where the data was collected retrospectively. The diagnostic test is objective or performed and interpreted without knowledge of disease status. Study results allow calculation of measures of diagnostic accuracy.

© 2010 AMERICAN ACADEMY OF NEUROLOGY AAN Classification of Evidence for Diagnostic Accuracy, cont. Class III: A case control study or cohort study where either persons with the condition or controls are of a narrow spectrum. The condition is established by an acceptable reference standard. The reference standard and diagnostic test are objective or performed and interpreted by different observers. Study results allow calculation of measures of diagnostic accuracy. Class IV: Studies not meeting Class I, II or III criteria including consensus, expert opinion or a case report.

© 2010 AMERICAN ACADEMY OF NEUROLOGY AAN Classification of Evidence for Screening Studies Class I: A statistical, population-based sample of patients studied at a uniform point in time (usually early) during the course of the condition. All patients undergo the intervention of interest. The outcome, if not objective, is determined in an evaluation that is masked to the patients’ clinical presentations. Class II: A statistical, non-referral-clinic-based sample of patients studied at a uniform point in time (usually early) during the course of the condition. Most patients undergo the intervention of interest. The outcome, if not objective, is determined in an evaluation that is masked to the patients’ clinical presentations.

© 2010 AMERICAN ACADEMY OF NEUROLOGY AAN Classification of Evidence for Screening Studies, cont. Class III: A sample of patients studied during the course of the condition. Some patients undergo the intervention of interest. The outcome, if not objective, is determined in an evaluation by someone other than the treating physician. Class IV: Studies not meeting Class I, II or III criteria including consensus, expert opinion or a case report.

© 2010 AMERICAN ACADEMY OF NEUROLOGY Conclusion/Recommendation Conclusion: In adults, recovery of neurologic function has not been reported after the clinical diagnosis of brain death has been established using the criteria given in the 1995 AAN practice parameter. Recommendation : The criteria for the determination of brain death given in the 1995 AAN practice parameter have not been invalidated by published reports of neurological recovery in patients who fulfill these criteria (Level U).

© 2010 AMERICAN ACADEMY OF NEUROLOGY Conclusion/Recommendation Conclusion: There is insufficient evidence to determine the minimally acceptable observation period to ensure that neurologic functions have ceased irreversibly. Recommendation : There is insufficient evidence to determine the minimally acceptable observation period to ensure that neurologic functions have ceased irreversibly (Level U).

© 2010 AMERICAN ACADEMY OF NEUROLOGY Conclusion/Recommendation Conclusion: For some patients diagnosed as brain dead, complex, non-brain-mediated spontaneous movements can falsely suggest retained brain function. Additionally, ventilator autocycling may falsely suggest patient-initiated breathing. Recommendation: Complex–spontaneous motor movements and false- positive triggering of the ventilator may occur in patients who are brain dead (Level C).

© 2010 AMERICAN ACADEMY OF NEUROLOGY Conclusion/Recommendation Conclusion: Apneic oxygenation diffusion to determine apnea is safe, but there is insufficient evidence to determine the comparative safety of techniques used for apnea testing. Recommendation: There is insufficient evidence to determine the comparative safety of techniques used for apnea testing (Level U).

© 2010 AMERICAN ACADEMY OF NEUROLOGY Conclusion/Recommendation Conclusion : Because of a high risk of bias and inadequate statistical precision, there is insufficient evidence to determine if any new ancillary tests accurately identify brain death. Recommendation : There is insufficient evidence to determine if newer ancillary tests accurately confirm the cessation of function of the entire brain (Level U).

© 2010 AMERICAN ACADEMY OF NEUROLOGY Clinical Context Much of the framework necessary for the development of “accepted medical standards” for the declaration of brain death is based on straightforward principles. These principles can be derived from the definition of brain death provided by the UDDA. Note: Clinical Context slightly abridged. See published guideline for complete text.

© 2010 AMERICAN ACADEMY OF NEUROLOGY To determine “cessation of all functions of the entire brain, including the brain stem,” physicians must:  determine the presence of unresponsive coma  determine the absence of brainstem reflexes  determine the absence of respiratory drive after a CO 2 challenge To ensure that the cessation of brain function is “irreversible,” physicians must:  determine the cause of coma  exclude mimicking medical conditions  observe the patient for a period of time to exclude the possibility of recovery Note: Clinical Context slightly abridged. See published guideline for complete text. Clinical Context, cont.

© 2010 AMERICAN ACADEMY OF NEUROLOGY Future Research Future prospective studies of brain death determination are needed. Areas of future research include:  examining the safety of the apnea test  seeking alternative methods of apnea testing  performing an audit of adequate documentation  studying the competence of examiners Details of the neurologic examination may be subjected to an expert panel review, possibly including international organizations.

© 2010 AMERICAN ACADEMY OF NEUROLOGY Practical Guidance for Determining Brain Death Many of the details of the clinical neurological examination to determine brain death cannot be established by evidence-based methods. The detailed brain death evaluation protocol that follows is intended as a useful tool for clinicians. It must be emphasized that this guidance is opinion-based. Alternative protocols may be equally informative. Note: Practical Guidance slightly abridged. See published guideline for complete text.

© 2010 AMERICAN ACADEMY OF NEUROLOGY Practical Guidance for Determining Brain Death, cont. 1. The clinical evaluation (prerequisites).  Establish irreversible and proximate cause of coma. –The cause of coma can usually be established by history, examination, neuroimaging, and laboratory tests. –Exclude the presence of a CNS-depressant drug effect by history, drug screen, calculation of clearance using 5 times the drug’s half-life, or drug plasma levels below the therapeutic range. Prior use of hypothermia may delay drug metabolism. The legal alcohol limit for driving is a practical threshold below which an examination to determine brain death could reasonably proceed. –There should be no recent administration or continued presence of neuromuscular blocking agents (this can be defined by the presence of a train of four twitches with maximal ulnar nerve stimulation). –There should be no severe electrolyte, acid-base, or endocrine disturbance (defined by severe acidosis or laboratory values markedly deviated from the norm). Note: Practical Guidance slightly abridged. See published guideline for complete text.

© 2010 AMERICAN ACADEMY OF NEUROLOGY Practical Guidance for Determining Brain Death, cont.  Achieve normal core temperature. –In most patients, a warming blanket is needed to raise the body temperature and maintain a normal or near-normal temperature (>36°C). After the initial equilibration of arterial carbon dioxide with mixed central venous carbon dioxide the PaCO 2 rises steeply, but then more slowly when the body metabolism raises PaCO 2.To avoid delaying an increase in PaCO 2, normal or near-normal core temperature is preferred during the apnea test.  Achieve normal systolic blood pressure. –Hypotension from loss of peripheral vascular tone or hypovolemia (diabetes insipidus) is common; vasopressors or vasopressin are often required. Neurologic examination is usually reliable with a systolic blood pressure ≥100 mm Hg. Note: Practical Guidance slightly abridged. See published guideline for complete text.

© 2010 AMERICAN ACADEMY OF NEUROLOGY Practical Guidance for Determining Brain Death, cont.  Perform one neurologic examination (sufficient to pronounce brain death in most US states. –If a certain period of time has passed since the onset of the brain insult to exclude the possibility of recovery (in practice, usually several hours), one neurologic examination should be sufficient to pronounce brain death. However, some US state statutes require two examinations. –Legally, all physicians are allowed to determine brain death in most US states. Neurologists, neurosurgeons, and intensive care specialists may have specialized expertise. It seems reasonable to require that all physicians making a determination of brain death be intimately familiar with brain death criteria and have demonstrated competence in this complex examination. Brain death statutes in the US do differ by state and institution. Some US state or hospital guidelines require the examiner to have certain expertise. Note: Practical Guidance slightly abridged. See published guideline for complete text.

© 2010 AMERICAN ACADEMY OF NEUROLOGY Practical Guidance for Determining Brain Death, cont. 2. The clinical evaluation (neurologic assessment).  Coma. –Patients must lack all evidence of responsiveness. o Eye opening or eye movement to noxious stimuli is absent. Noxious stimuli should not produce a motor response other than spinally mediated reflexes. The clinical differentiation of spinal responses from retained motor responses associated with brain activity requires expertise.  Absence of brainstem reflexes. –Absence of pupillary response to a bright light is documented in both eyes. o Usually the pupils are fixed in a midsize or dilated position (4–9 mm). Constricted pupils suggest the possibility of drug intoxication. When uncertainty exists a magnifying glass should be used. Note: Practical Guidance slightly abridged. See published guideline for complete text.

© 2010 AMERICAN ACADEMY OF NEUROLOGY Practical Guidance for Determining Brain Death, cont. –Absence of ocular movements using oculocephalic testing and oculovestibular reflex testing. o Once the integrity of the cervical spine is ensured, the head is briskly rotated horizontally and vertically. There should be no movement of the eyes relative to head movement. The oculovestibular reflex is tested by irrigating each ear with ice water (caloric testing) after the patency of the external auditory canal is confirmed. The head is elevated to 30 degrees. Each external auditory canal is irrigated (one ear at a time) with approximately 50 cc of ice water. Movement of the eyes should be absent during 1 minute of observation. Both sides are tested, with an interval of several minutes. –Absence of corneal reflex. o Absent corneal reflex is demonstrated by touching the cornea with a piece of tissue paper, a cotton swab, or squirts of water. No eyelid movement should be seen. Note: Practical Guidance slightly abridged. See published guideline for complete text.

© 2010 AMERICAN ACADEMY OF NEUROLOGY Practical Guidance for Determining Brain Death, cont. –Absence of facial muscle movement to a noxious stimulus. o Deep pressure on the condyles at the level of the temporomandibular joints and deep pressure at the supraorbital ridge should produce no grimacing or facial muscle movement. –Absence of the pharyngeal and tracheal reflexes. o The pharyngeal or gag reflex is tested after stimulation of the posterior pharynx with a tongue blade or suction device. The tracheal reflex is most reliably tested by examining the cough response to tracheal suctioning. The catheter should be inserted into the trachea and advanced to the level of the carina followed by one or two suctioning passes.  Apnea. –Absence of a breathing drive. o Absence of a breathing drive is tested with a CO 2 challenge. Documentation of an increase in (partial pressure of carbon dioxide [PaCO 2 ] above normal levels is typical practice. It requires preparation before the test. Note: Practical Guidance slightly abridged. See published guideline for complete text.

© 2010 AMERICAN ACADEMY OF NEUROLOGY Practical Guidance for Determining Brain Death, cont. –Prerequisites. o Normotension o Normothermia o Euvolemia o Eucapnia (PaCO 2 35–45 mm Hg) o Absence of hypoxia o No prior evidence of CO 2 retention (i.e., chronic obstructive pulmonary disease, severe obesity) Note: Practical Guidance slightly abridged. See published guideline for complete text.

© 2010 AMERICAN ACADEMY OF NEUROLOGY Practical Guidance for Determining Brain Death, cont. –Procedure. o Adjust vasopressors to a systolic blood pressure ≥100 mm Hg. o Preoxygenate for at least 10 minutes with 100% oxygen to a PaO 2 >200 mm Hg. o Reduce ventilation frequency to 10 breaths per minute to eucapnia. o Reduce positive end-expiratory pressure (PEEP) to 5 cm H 2 O (oxygen desaturation with decreasing PEEP may suggest difficulty with apnea testing). o If pulse oximetry oxygen saturation remains >95%, obtain a baseline blood gas (partial pressure of oxygen [PaO 2 ], PaCO 2, pH, bicarbonate, base excess). o Disconnect the patient from the ventilator. o Preserve oxygenation (e.g., place an insufflation catheter through the endotracheal tube and close to the level of the carina and deliver 100% O 2 at 6 L/min). o Look closely for respiratory movements for 8–10 minutes. Respiration is defined as abdominal or chest excursions and may include a brief gasp. Note: Practical Guidance slightly abridged. See published guideline for complete text.

© 2010 AMERICAN ACADEMY OF NEUROLOGY Practical Guidance for Determining Brain Death, cont. o Abort if systolic blood pressure decreases to <90 mm Hg. o Abort if oxygen saturation measured by pulse oximetry is 30 seconds. Retry procedure with T-piece, continuous positive airway pressure (CPAP) 10 cm H 2 O, and 100% O 2 12 L/minute. o If no respiratory drive is observed, repeat blood gas (PaO 2, PaCO 2, pH, bicarbonate, base excess) after approximately 8 minutes. o If respiratory movements are absent and arterial PCO 2 is ≥60 mm Hg (or 20 mm Hg increase in arterial PCO 2 over a baseline normal arterial PCO 2 ), the apnea test result is positive (i.e., supports the clinical diagnosis of brain death). o If the test is inconclusive but the patient is hemodynamically stable during the procedure, it may be repeated for a longer period of time (10–15 minutes) after the patient is again adequately preoxygenated. Note: Practical Guidance slightly abridged. See published guideline for complete text.

© 2010 AMERICAN ACADEMY OF NEUROLOGY Practical Guidance for Determining Brain Death, cont. Ancillary tests.  In clinical practice, EEG, cerebral angiography, nuclear scan, transcranial Doppler (TCD), CT angiography (CTA), and MRI/magnetic resonance angiography (MRA) are currently used ancillary tests in adults (see appendix 1 of the published guideline). Most hospitals will have the logistics in place to perform and interpret an EEG, nuclear scan, or cerebral angiogram, and these three tests may be considered the preferred tests. Ancillary tests can be used when uncertainty exists about the reliability of parts of the neurologic examination or when the apnea test cannot be performed. In some protocols, ancillary tests are used to shorten the duration of the observation period. Note: Practical Guidance slightly abridged. See published guideline for complete text.

© 2010 AMERICAN ACADEMY OF NEUROLOGY Practical Guidance for Determining Brain Death, cont.  The interpretation of each of these tests requires expertise. In adults, ancillary tests are not needed for the clinical diagnosis of brain death and cannot replace a neurologic examination. Physicians ordering ancillary tests should appreciate the disparities between tests and the potential for false positives (i.e., the test suggests brain death, but the patient does not meet clinical criteria). Rather than ordering ancillary tests, physicians may decide not to proceed with the declaration of brain death if clinical findings are unreliable. Note: Practical Guidance slightly abridged. See published guideline for complete text.

© 2010 AMERICAN ACADEMY OF NEUROLOGY Practical Guidance for Determining Brain Death, cont. Documentation.  The time of brain death is documented in the medical records. Time of death is the time the arterial PCO 2 reached the target value. In patients with an aborted apnea test, the time of death is when the ancillary test has been officially interpreted. A checklist is filled out, signed, and dated (see appendix 2 of the published guideline). Federal and state law requires the physician to contact an organ procurement organization following determination of brain death. 4,5 Note: Practical Guidance slightly abridged. See published guideline for complete text.

© 2010 AMERICAN ACADEMY OF NEUROLOGY References 1.Practice parameters for determining brain death in adults (summary statement). The Quality Standards Subcommittee of the American Academy of Neurology. Neurology 1995;45:1012  1014. 2.Guidelines for the determination of death. Report of the medical consultants on the diagnosis of death to the President’s commission for the study of ethical problems in medicine and biochemical and behavioral research. JAMA 1981;246:2184  2186. 3.Uniform Determination of Death Act, 12 uniform laws annotated 589 (West 1993 and West supp 1997). 4. Title 42 CFR 482.45 (Condition of participation: Organ, tissue, and eye procurement). 5. Title 42 USC § 1320b-8 (Hospital protocols for organ procurement and standards for organ procurement agencies).

© 2010 AMERICAN ACADEMY OF NEUROLOGY Update: Determining Brain Death in Adults Report of the Quality Standards Subcommittee of the American Academy of.

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© 2010 AMERICAN ACADEMY OF NEUROLOGY Update: Determining Brain Death in Adults Report of the Quality Standards Subcommittee of the American Academy of.

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