Pitfalls and slip-ups in brain death determination

Abstract

Brain death (or brainstem death in the UK) is an uncommon result of a major catastrophic neurologic injury. The determination of brain death proceeds through a comprehensive and stepwise evaluation. There is no room for misinterpretations. Slip ups, however, could occur with brain death determination and this review discusses the most common concerns encountered by physicians. Problems may arise when a multitude of small errors accumulate and this may occur with an inexperienced physician who misjudges confounders, performs an incomplete evaluation, and misinterprets a confirmatory test.

Identification of separation phenomenon during brain death determination of potential organ donor and analysis of relative factors

“…Wijdicks et al, reported that age, cerebral perfusion pressure, type of brain injury, course of disease and operation techniques of confirmatory test were related to separation phenomenon. 11 Our study showed that systolic blood pressure ≥ 140 mmHg, age ≤14 years, primary brain stem injury, spontaneous respiratory arrest time ≤72 h and decompressive craniectomy (unilateral/bilateral) were independent factors of separation phenomenon. For the "pseudocerebral blood flow" caused by high systolic pressure and incomplete skull, further SLSEP examination is recommended to ensure the diagnosis of brain death and avoid further waiting leading to organ donation failure after brain death (the patients with brain death often suffer from cardiac arrest due to unstable circulation); for the primary brain stem injury and children (age ≤ 14 years), re-examination is recommended after 24-72 hours; because of brain stem conduction tract injury or hypoplasia SLSEP test is not recommended for patients; the patients with unstable circulation caused by waiting, can be treated with the "hormone package" (one of effective treatment of our center).…”

Radionuclide Evaluation of Brain Death in the Post-McMath Era

“…Nevertheless, reports in the medical literature do document neurologic function in patients in whom brain death was previously diagnosed, apparently not according to rigorous criteria (52)(53)(54)). In fact, several potential pitfalls have been noted in the clinical determination of brain death (28,(55)(56)(57). A recent global survey on the determination of brain death demonstrated substantial differences in perceptions and practice worldwide (7).…”

“…Reports in the literature persist of patients in whom the physical examination unequivocally demonstrated brain death, yet specific confirmatory tests indicated the presence of blood flow, electrical activity, or other phenomena (15,53,81,96). Although erroneous performance of either the physical examination or the confirmatory test is a possible cause of conflicting findings, Wijdicks believes that the clinical entity of brain death can coexist with preserved blood flow on ancillary examinations and should not deter a physician from declaring patients dead after complete and properly conducted physical examinations and apnea testing (57,97). How to adjudicate situations in which the neurologic and ancillary examinations are discordant is currently unresolved, and a conservative approach should be in order (15).…”

“…Radiographic testing before retrieval of organs from donors who meet clinical brain death criteria might provide conclusive evidence of permanent and irreversible loss of brain function (107), and more-routine use of ancillary brain blood flow analyses might reduce errors (53). A diametrically opposed viewpoint is espoused by Wijdicks, who has suggested that a comprehensive clinical examination, when performed by skilled examiners, should trump any conflicting ancillary examinations (57,97).…”

Simulation Training in Brain Death Determination

“…Material is provided to help learners prepare for the simulation prior to the day of the course. Before our brain death simulation we send the learners the American Academy of Neurology (AAN) brain death guidelines, 9 an article entitled "Pitfalls and Slip-Ups in Brain Death Determination," 18 and a video that comprehensively describes the determination of brain death including how to safely perform the apnea test. 19 An alternative approach is to give a lecture or series of lectures on the day of the simulation in which the learners can review the content they are expected to know to perform well during the simulation.…”