Sam D. Shemie

The circulatory-respiratory determination of death in organ donation

Objective:Death statutes permit physicians to declare death on the basis of irreversible cessation of circulatory–respiratory or brain functions. The growing practice of organ donation after circulatory determination of death now requires physicians to exercise greater specificity in circulatory–respiratory death determination. We studied circulatory–respiratory death determination to clarify its concept, practice, and application to innovative circulatory determination of death protocols. Results:It is ethically and legally appropriate to procure organs when permanent cessation (will not return) of circulation and respiration has occurred but before irreversible cessation (cannot return) has occurred because permanent cessation: 1) is an established medical practice standard for determining death; 2) is the meaning of “irreversible” in the Uniform Determination of Death Act; and 3) does not violate the “Dead Donor Rule.” Conclusions:The use of unmodified extracorporeal membrane oxygenation in the circulatory determination of death donor after death is declared should be abandoned because, by restoring brain circulation, it retroactively negates the previous death determination. Modifications of extracorporeal membrane oxygenation that avoid this problem by excluding brain circulation are contrived, invasive, and, if used, should require consent of surrogates. Heart donation in circulatory determination of death is acceptable if proper standards are followed to declare donor death after establishing the permanent cessation of circulation. Pending additional data on “auto-resuscitation,” we recommend that all circulatory determination of death programs should utilize the prevailing standard of 2 to 5 mins of demonstrated mechanical asystole before declaring death.

Organ donor management in Canada: recommendations of the forum on Medical Management to Optimize Donor Organ Potential

In collaboration with the Canadian Critical Care Society, the Canadian Association of Transplantation and the Canadian Society of Transplantation, the Canadian Council for Donation and Transplantation (CCDT) sponsored a forum entitled „Medical Management to Optimize Donor Organ Potential,” 23–

A systematic review of autoresuscitation after cardiac arrest

Objective:There is a lack of consensus on how long circulation must cease for death to be determined after cardiac arrest. The lack of scientific evidence concerning autoresuscitation influences the practice of organ donation after cardiac death. We conducted a systematic review to summarize the evidence on the timing of autoresuscitation. Data Sources:Electronic databases were searched from date of first issue of each journal until July 2008. Study Selection:Any original study reporting autoresuscitation, as defined by the unassisted return of spontaneous circulation after cardiac arrest, was considered eligible. Reports of electrocardiogram activity without signs of return of circulation were excluded. Data Extraction:For each study case, we extracted patient characteristics, duration of cardiopulmonary resuscitation, terminal heart rhythms, time to unassisted return of spontaneous circulation, monitoring, and outcomes. Data Synthesis:A total of 1265 citations were identified and, of these, 27 articles describing 32 cases of autoresuscitation were included (n = 32; age, 27–94 yrs). The studies came from 16 different countries and were considered of very-low quality (case reports or letters to the editor). All 32 cases reported autoresuscitation after failed cardiopulmonary resuscitation, with times ranging from a few seconds to 33 mins; however, continuity of observation and methods of monitoring were highly inconsistent. For the eight studies reporting continuous electrocardiogram monitoring and exact times, autoresuscitation did not occur beyond 7 mins after failed cardiopulmonary resuscitation. No cases of autoresuscitation in the absence of cardiopulmonary resuscitation were reported. Conclusions:These findings suggest that the provision of cardiopulmonary resuscitation may influence autoresuscitation. In the absence of cardiopulmonary resuscitation, as may apply to controlled organ donation after cardiac death after withdrawal of life-sustaining therapies, autoresuscitation has not been reported. The provision of cardiopulmonary resuscitation, as may apply to uncontrolled organ donation after cardiac death, may influence observation time. However, existing evidence is limited and is consequently insufficient to support or refute the recommended waiting period to determine death after a cardiac arrest, strongly supporting the need for prospective studies in dying patients.

International guideline development for the determination of death.

Introduction and MethodsThis report summarizes the results of the first phase in the development of international guidelines for death determination, focusing on the biology of death and the dying process, developed by an invitational forum of international content experts and representatives of a number of professional societies.Results and ConclusionsPrecise terminology was developed in order to improve clarity in death discussion and debate. Critical events in the physiological sequences leading to cessation of neurological and/or circulatory function were constructed. It was agreed that death determination is primarily clinical and recommendations for preconditions, confounding factors, minimum clinical standards and additional testing were made. A single operational definition of human death was developed: ‘the permanent loss of capacity for consciousness and all brainstem functions, as a consequence of permanent cessation of circulation or catastrophic brain injury’. In order to complete the project, in the next phase, a broader group of international stakeholders will develop clinical practice guidelines, based on comprehensive reviews and grading of the existing evidence.

Medical management to optimize donor organ potential: review of the literature.

PurposeOver the past two decades, the demand for donor organs continues to outpace the number of organs available for transplantation. Parallel with this has been a change in the demographics of organ donors with an increase in older donors and donors with marginal organs as a proportion of the total organ donor pool. Consequently, efforts have been made to improve the medical care delivered to potential organ donors to improve the conversion rate and graft survival of available organs. The purpose of this literature review is to provide updated recommendations for the contemporary management of organ donors after the neurological determination of death in order to maximize the probability of recipient graft survival.SourcesA comprehensive review of the literature obtained through searches of MEDLINE/PubMed, and personal reference files.Principal findingsContemporary management of the organ donor after neurological determination of death includes therapies to prevent the detrimental effects of the autonomic storm, the use of invasive hemodynamic monitoring and aggressive respiratory therapy including therapeutic bronchoscopy in marginal heart and lung donors, and the use of hormonal therapy including vasopressin, corticosteroids, triiodothyronine or thyroxine, and insulin for the pituitary failure and inflammation seen in brain dead organ donors. The importance of normalizing donor physiology to optimize all available organs is stressed.ConclusionAggressive hemodynamic and respiratory management of solid organ donors, coupled with the use of hormonal therapy improves the rate of conversion and graft survival in solid organ recipients.RésuméObjectifDepuis plus de deux décennies, il y a une disproportion croissante entre les demandes de transplantation et la pénurie d’organes disponibles. En même temps, les données démographiques des donneurs ont changé, car une partie de leur nombre total compte plus de gens âgés dont les organes sont marginaux. Par conséquent, on tente d’améliorer les soins médicaux prodigués aux donneurs potentiels pour augmenter le taux de conversion et la survie du greffon des organes disponibles. Notre revue visait la mise à jour de recommandations de traitement aux donneurs d’organes, chez qui la mort neurologique a été établie, pour maximiser la probabilité de survie du greffon chez le receveur.SourcesUne revue documentaire étendue obtenue par des recherches dans MEDLINE/PubMed et des fichiers de référence personnels.Constatations principalesLe traitement actuel du donneur d’organe, après la détermination de la mort neurologique, comprend la prévention d’effets nuisibles du choc subi par le système nerveux autonome, l’usage d’un monitorage hémodynamique effractifet une thérapie respiratoire énergique dont la bronchoscopie thérapeutique chez des donneurs marginaux de cœur et de poumons et l’usage d’hormonothérapie dont la vasopressine, les corticostéroïdes, la triiodothyronine ou thyroxine et l’insuline pour la défaillance hypophysaire et l’inflammation observée lors de la mort encéphalique des donneurs. L’accent est mis sur la normalisation physiologique du donneur afin de mieux protéger tout organe disponible.ConclusionLe traitement hémodynamique et respiratoire énergique des donneurs d’organes pleins, couplé à l’usage d’hormonothérapie, améliore le taux de conversion et la survie du greffon chez les receveurs.

Impact of diaphragmatic paralysis after cardiothoracic surgery in children

OBJECTIVES We sought to determine the prevalence and clinical impact of diaphragmatic paralysis caused by phrenic nerve injury after cardiothoracic surgery in children. METHODS A search of cardiology, radiology, and hospital databases identified 170 episodes of diaphragmatic paralysis after cardiothoracic surgery in 168 children operated on from 1985 to 1997. Medical records were reviewed to determine demographics, details of the operation and postoperative course, diagnostic features and management of diaphragmatic paralysis, and follow-up status. RESULTS The prevalence of diaphragmatic paralysis was 1.6% (95% confidence interval 1.4%-1.8%). Median age at operation was 6 months (range <1 day-14.4 years). Median time from the operation to the initial investigation was 5 days (range <1 day-61 days), with 57% of patients receiving mechanical ventilation at diagnosis. Diaphragmatic plication was performed in 40% of the patients at a median interval from the initial investigation of 15 days (range 3 days-11.1 months). Significant independent factors associated with increased postoperative hospital stay were lower patient weight at operation, previous cardiothoracic operations, bilateral diaphragmatic paralysis, increased interval from operation to investigation, mechanical ventilation at the time of investigation, and diaphragmatic plication. Confirmed recovery of diaphragmatic function was noted before hospital discharge in only 15 episodes. CONCLUSIONS Diaphragmatic paralysis complicating cardiothoracic surgery continues to occur in the current era, with a significant impact on morbidity. Smaller patients with bilateral hemidiaphragmatic paralysis, requiring mechanical ventilation, may represent a higher risk subgroup to target for increased diagnostic suspicion and more aggressive management; early spontaneous recovery is rare.

Prognosis of pediatric bone marrow transplant recipients requiring mechanical ventilation

OBJECTIVES To assess the prognosis of pediatric bone marrow transplant recipients requiring mechanical ventilation and to identify risk factors for mortality. DESIGN Retrospective chart review. SETTING Pediatric intensive care unit (PICU), tertiary care center. PATIENTS Inclusion criteria were endotracheal intubation and mechanical ventilation after bone marrow transplantation; patients with perioperative ventilation were excluded. Outcome measures were extubation, PICU discharge, and 6-month survival. The 39 patients who met the inclusion criteria were ventilated on 41 occasions. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Overall survival rate to PICU discharge was 44% (17 of 39 patients). Six months after PICU discharge, 14 of these children were still alive, for a medium-term survival rate of 36%. Preexisting conditions (primary disease, bone marrow engraftment, or graft-vs.-host disease) had no significant effect on survival. Multiple organ failure, especially pulmonary failure and neurologic deterioration, were significant determinants of patient survival. CONCLUSIONS The observed prognosis is improved over previous reports. Early initiation of aggressive intensive care treatment is warranted in this patient group. Decisions regarding intensity of treatment must be based on aspects of the acute illness rather than on the primary conditions.

Brief review : The role of ancillary tests in the neurological determination of death

PurposeThe acceptance of brain death by society has allowed for the discontinuation of “life support” and the transplantation of organs. In Canada we accept the clinical criteria for brain death (essentially brain stem death) when they can be legitimately applied. Ancillary tests are needed when these clinical criteria cannot be applied or when there are confounders. Ancillary tests include tests of intracranial blood circulation, electrophysiological tests, metabolic studies and tests for residual vagus nerve function. The ideal confirmatory test is one which, when positive, would be incompatible with recoverable brain function (i.e., has no false positives), is not influenced by drugs or metabolic disturbances and which can be readily applied. A critical review of the various ancillary tests used to support the neurological determination of death (brain death) was undertaken.MethodsA literature review based on a MEDLINE search of relevant articles published between January 1966 to January 2005 was undertaken.ResultsTests of whole brain perfusion/intracranial blood circulation are the only ones that meet stated criteria.ConclusionsAt present only cerebral angiography and nuclear medicine tests of perfusion are accepted by Canadian standards, but computed tomography and magnetic resonance angiography should prove to be suitable. Transcranial Doppler studies may be suitable for specific cases once appropriate guidelines are established.RésuméObjectifĽacceptation de la mort encéphalique par la société a permis ľinterruption du «maintien des fonctions vitales» et la transplantation ďorganes. Au Canada, nous acceptons les critères cliniques de la mort encéphalique (essentiellement, mort du tronc cérébral) quand ils peuvent légitimement s’appliquer. Des tests auxiliaires sont nécessaires quand ces critères ne peuvent être appliqués ou quand ils sont confondants. Ils comprennent les tests de circulation sanguine intracrânienne, les épreuves électrophysiologiques, les études métaboliques et les tests de fonction résiduelle du nerf vague. Le test de confirmation idéal est celui qui, s’il est positif, est incompatible avec une récupération de la fonction cérébrale (donc, sans faux positifs), n’est pas modifié par les médicaments ou les désordres métaboliques et peut être facilement réalisé. Nous avons fait une revue critique des différents tests accessoires utilisés lors de la détermination neurologique de la mort (mort encéphalique).MéthodeNous avons recherché les articles pertinents de MEDLINE publiés entre janvier 1966 et janvier 2005.RésultatsLes tests de perfusion cérébrale totale/de circulation sanguine intracrânienne sont les seuls qui répondent aux critères convenus.ConclusionÀ présent, les seuls tests acceptés par les normes canadiennes sont ľangiographie cérébrale et les tests de perfusion de la médecine nucléaire. La tomodensitométrie et ľangiographie par résonance magnétique devraient se révéler appropriés. Dans des cas spécifiques, les examens de doppler transcrânien peuvent convenir une fois établies les directives appropriées.

Resolution of mucus plugging and atelectasis after intratracheal rhDNase therapy in a mechanically ventilated child with refractory status asthmaticus

Objective: To report the dramatic resolution of unilateral mucus plugging and atelectasis in a mechanically ventilated child with refractory status asthmaticus after intratracheal recombinant human DNase (rhDNase) therapy. Design: Case report. Setting: Critical care unit. Patient: A 7‐yr‐old boy with status asthmaticus, severe respiratory failure and barotrauma unresponsive to conventional therapy. Fiberoptic bronchoscopy confirmed widespread mucus impaction of the subsegmental bronchi of the left lung without response to bronchoscopic lavage. Interventions: Two 10‐mg doses of intratracheal rhDNase were administered 8 hrs apart. Main Results: The left‐sided atelectasis resolved 3 hrs after the first dose of rhDNase. Improvements in gas exchange and tidal volumes were sustained and particularly noticeable after the second dose. The patient was successfully extubated 26 hrs after receiving the rhDNase treatment without any adverse effects. Conclusions: rhDNase should be considered as a potential therapy for refractory mucus plugging and atelectasis in intubated patients with status asthmaticus.

An Official American Thoracic Society/International Society for Heart and Lung Transplantation/Society of Critical Care Medicine/Association of Organ and Procurement Organizations/United Network of Organ Sharing Statement: Ethical and Policy Considerations in Organ Donation after Circulatory Determination of Death

RATIONALE Donation after circulatory determination of death (DCDD) has the potential to increase the number of organs available for transplantation. Because consent and management of potential donors must occur before death, DCDD raises unique ethical and policy issues. OBJECTIVES To develop an ethics and health policy statement on adult and pediatric DCDD relevant to critical care and transplantation stakeholders. METHODS A multidisciplinary panel of stakeholders was convened to develop an ethics and health policy statement. The panel consisted of representatives from the American Thoracic Society, Society of Critical Care Medicine, International Society for Heart and Lung Transplantation, Association of Organ Procurement Organizations, and the United Network of Organ Sharing. The panel reviewed the literature, discussed important ethics and health policy considerations, and developed a guiding framework for decision making by stakeholders. RESULTS A framework to guide ethics and health policy statement was established, which addressed the consent process, pre- and post mortem interventions, the determination of death, provisions of end-of-life care, and pediatric DCDD. CONCLUSIONS The information presented in this Statement is based on the current evidence, experience, and clinical rationale. New clinical research and the development and dissemination of new technologies will eventually necessitate an update of this Statement.