Hypothalamic function in patients diagnosed as brain dead and its practical consequences

Nair‐Collins, Michael; Joffe, Ari R.

doi:10.1016/b978-0-12-819973-2.00029-0

Cited by 15 publications

(10 citation statements)

References 86 publications

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“…4,15 Antidiuretic hormone (ADH) is the most frequently discussed neurosecretory hormone in the context of BD/DNC, but the hypothalamus controls secretion of several other hormones including adrenocorticotropic hormone (ACTH), follicle-stimulating hormone (FSH), growth hormone (GH), luteinizing hormone (LH), oxytocin, prolactin, and thyroid-stimulating hormone (TSH). 16 A review of hypothalamic neurosecretory hormone levels at the time of BD/DNC determination demonstrated normal levels are common: ACTH (48% of 65 patients), ADH (50% of 2,546 patients), and TSH (78% of 347 patients). 16 Both a 2019 AAN position statement on management of objections to BD/DNC determination and the WBDP acknowledge that hypothalamic neurosecretory function does not preclude BD/DNC determination.…”

Section: Introductionmentioning

confidence: 99%

“…16 A review of hypothalamic neurosecretory hormone levels at the time of BD/DNC determination demonstrated normal levels are common: ACTH (48% of 65 patients), ADH (50% of 2,546 patients), and TSH (78% of 347 patients). 16 Both a 2019 AAN position statement on management of objections to BD/DNC determination and the WBDP acknowledge that hypothalamic neurosecretory function does not preclude BD/DNC determination. 11,17 If the rUDDA stipulates that cessation of hypothalamic neurosecretory function is required for BD/DNC determination, BD/DNC guidelines would need to be revised to comply with the law.…”

Section: Introductionmentioning

confidence: 99%

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Potential Threats and Impediments to the Clinical Practice of Brain Death Determination

Lewis

Kirschen

2023

Neurology

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The Uniform Determination of Death Act (UDDA) revision series in Neurology® originated in response to the Uniform Law Commission’s plan to create a revised Uniform Determination of Death Act (rUDDA) to address contemporary controversies associated with brain death/death by neurologic criteria (BD/DNC) determination. This article contextualizes these, and other, controversies and reviews the extent to which they represent potential threats and impediments to the clinical practice of BD/DNC determination. It also explains the reasons that our rapidly evolving understanding of the brain’s ability to recover from injury should not influence the clinical practice of BD/DNC determination. Finally, it explores the myriad ways in which the American Academy of Neurology has addressed potential threats and impediments to the clinical practice of BD/DNC determination and the implications potential changes to the UDDA may have on the future of the clinical practice of BD/DNC determination.

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Section: Introductionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Potential Threats and Impediments to the Clinical Practice of Brain Death Determination

Lewis

Kirschen

2023

Neurology

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“…One is potentially reversible high cervical spinal cord injury, present in most BD patients at autopsy, secondary to brain herniation (3). Another is central thyroid and/or adrenal insufficiency secondary to hypothalamic and/or pituitary damage, which can cause coma and decreased Pa co 2 responsiveness (4). A systematic review found these endocrine deficiencies were present in 16% and 29% of BD patients, respectively (4).…”

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confidence: 99%

Consent for the Apnea Test: Asking the Wrong Question*

Joffe

2023

Pediatric Critical Care Medicine

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I n this issue of Pediatric Critical Care Medicine, Sveen et al (1) wrote that "some parents and providers have asserted informed consent is required for [the apnea test] AT due to the risk of serious adverse events" and concluded that their study's "findings may inform the ongoing debate regarding whether specific informed consent should be required for AT. " They based this on their empirical findings of adverse event rates that occurred during the apnea test (AT), and the "general consent for medical treatment" upon admission to the hospital (1).The authors report a retrospective study of all 105 ATs done in 58 patients at Cincinnati Children's Hospital Medical Center from July 2013 to June 2020. Adverse events during the AT were defined as hypotension (mean arterial pressure < 5th percentile for age), hypoxia (pulse oximetry saturation < 85%), new or increased pneumothorax, arrhythmia, new intracranial hypertension (intracranial pressure [ICP] > 20 mm Hg), or cardiac arrest. No patients had arrhythmia, new intracranial hypertension (because all had this prior to the AT), or cardiac arrest. Adverse events (hypotension, hypoxia, and/or pneumothorax) occurred in 21 of 105 AT (20%), and led to premature termination of the AT in five of 105 (5%), with the rest "managed medically… with transient increase in vasoactive support, or with completion of the AT" (1). The "transient" increases in vasoactive support lasted "less than 1 hour" (1). The six or seven patients monitored had 15 AT with no change in ICP from pre-AT (median, 72 mm Hg; interquartile range [IQR], 61-82 mm Hg) to post-AT (median, 72 mm Hg; IQR, 60-83 mm Hg). One patient had absent breathing on the second AT but spontaneous breathing on the third AT. There were no "vital sign changes consistent with herniation" identified, although presumably, most patients had brain herniation as part of the usual pathophysiology of brain death (BD) (1).Limitations of the study discussed by the authors included that the study was single center and retrospective, that it was possible AT was deferred in some patients felt to be at high risk of decompensation, and that the few patients with ICP monitoring had severe intracranial hypertension at baseline "preventing any assessment regarding potential AT effects on cerebral perfusion" (1). In these patients, the cerebral perfusion pressure (CPP) was likely already above the critical closing pressure of cerebral vessels pre-AT. There was a lack of arterial access during 20 AT, making accurate assessment of transient hypotension in those patients impossible. Nevertheless, given that adverse events occurred in only 20% of AT and "resolved with medical care" or premature termination of the AT "without further intervention, " the findings "may inform the ongoing debate regarding whether specific consent should be required for AT" (1). *See also p. 399.

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“…Up to 50% of patients who are declared dead by neurologic criteria have some preserved hypothalamic function, as evidenced by the absence of central diabetes insipidus. 2 Therefore, some brain function continues in some patients who are declared dead by neurologic criteria. These are false-positive declarations of death.…”

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confidence: 99%

Hypothalamic function in patients diagnosed as brain dead and its practical consequences

Cited by 15 publications

References 86 publications

Potential Threats and Impediments to the Clinical Practice of Brain Death Determination

Potential Threats and Impediments to the Clinical Practice of Brain Death Determination

Consent for the Apnea Test: Asking the Wrong Question*

Must Hypothalamic Neurosecretory Function Cease for Brain Death Determination? Yes

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