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Episode 103: HOT TOPICS - Pediatric and adult brain death/death by neurologic criteria consensus practice guideline

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Episode 103: HOT TOPICS - Pediatric and adult brain death/death by neurologic criteria consensus practice guideline

Contributors

  • Ariane Lewis, MD

    Departments of Neurology and Neurosurgery: Division of Neurocritical Care
    Department of Population Health: Division of Medical Ethics
    NYU Langone Medical Center

  • Matthew Kirschen, MD, PhD

    Departments of Anesthesiology and Critical Care Medicine,
    Neurology, and Pediatrics
    Perelman School of Medicine at the University of Pennsylvania
    Children's Hospital of Philadelphia

  • Alexandra Reynolds, MD

    Alexandra Reynolds, MD, is an Assistant Professor of Neurosurgery and Neurology and a board-certified neurointensivist in the Neurocritical Care Unit at The Mount Sinai Hospital. Dr. Reynolds also serves as the Director of TeleNeurocritical Care for the Mount Sinai Health System.

    A native New Yorker, she was educated at Princeton University and the Columbia University College of Physicians & Surgeons before completing a neurology residency at NewYork-Presbyterian/Columbia University Medical Center and a Neurocritical Care fellowship at NewYork-Presbyterian/Columbia University Medical Center and Weill Cornell Medical Center.

    Dr. Reynolds is an expert in the treatment of neurological emergencies such as subarachnoid hemorrhage, intracerebral hemorrhage, status epilepticus, and neurotrauma. Her research centers on assessment, treatment and neurological prognostication of survivors of cardiac arrest and the neurological management of patients in fulminant hepatic failure.

  1. 00:00:19
    Hi, my name is Alex Reynolds and
  2. 00:00:21
    welcome to the Hot Topics Podcast of the
  3. 00:00:23
    Neurocritical Care Society. Today, I'm
  4. 00:00:25
    excited to introduce Dr. Ariane Lewis,
  5. 00:00:28
    Professor of Neurology and Director of
  6. 00:00:30
    NYU Langone's Division of Neurocritical
  7. 00:00:32
    Care, as well as Dr. Matthew Kirschen,
  8. 00:00:35
    Assistant Professor of Anesthesiology
  9. 00:00:37
    and Critical Care and Associate Director
  10. 00:00:39
    of Pediatric Neurocritical Care at the
  11. 00:00:41
    Children's Hospital of Philadelphia They
  12. 00:00:44
    were both involved in the newest
  13. 00:00:46
    guidelines on brain death or death by
  14. 00:00:48
    neurologic criteria that was released in
  15. 00:00:50
    early October as a collaboration between
  16. 00:00:53
    the American Academy of Neurology,
  17. 00:00:55
    American Academy of Pediatrics, Child
  18. 00:00:57
    Neurology Society, and Society of
  19. 00:00:59
    Critical Care Medicine. These
  20. 00:01:01
    guidelines now replace the 2010 AAN
  21. 00:01:03
    guideline for adult determination of
  22. 00:01:05
    brain death and the 2011 AAP, CNS, and
  23. 00:01:09
    SECM guideline for pediatric
  24. 00:01:11
    determination of brain death And they
  25. 00:01:13
    build on the minimum standards for brain
  26. 00:01:15
    death determination established in the
  27. 00:01:16
    World Brain Death Project. So welcome
  28. 00:01:19
    to both of you, Arianne and Matt.
  29. 00:01:22
    Thank you. So I'm really excited to
  30. 00:01:26
    have you guys here because this is a
  31. 00:01:29
    little bit of an insider view on what
  32. 00:01:31
    I'm sure was a very prolonged and
  33. 00:01:33
    tedious process. I'm wondering if one
  34. 00:01:36
    of you can give us a sense of how long
  35. 00:01:38
    it took to generate these newest
  36. 00:01:39
    guidelines and the process that was
  37. 00:01:41
    involved.
  38. 00:01:44
    The process actually took a few years,
  39. 00:01:46
    but actually not as long as A and
  40. 00:01:48
    guidelines have taken in the past. This
  41. 00:01:49
    was actually an expedited version of a
  42. 00:01:51
    guideline process. Wow. And I think,
  43. 00:01:56
    you know, one of the most notable
  44. 00:01:57
    things about these guidelines is that
  45. 00:02:00
    they've combined the determination of
  46. 00:02:03
    brain death in both adults and
  47. 00:02:05
    pediatrics. Can you sort of comment
  48. 00:02:07
    about what the reason was for combining
  49. 00:02:09
    the two of them?
  50. 00:02:12
    So the main reason we wanted to combine
  51. 00:02:14
    adults and peers is because really death
  52. 00:02:16
    determination should be independent. of
  53. 00:02:19
    age. We realized very on that many of
  54. 00:02:22
    the subtle differences between the adult
  55. 00:02:26
    and pediatric guidelines from 2010 and
  56. 00:02:28
    2011 were a bit arbitrary and not
  57. 00:02:31
    evidence-based. They were expert
  58. 00:02:33
    consensus opinion. And so we figured
  59. 00:02:36
    that if we got pediatric and adult
  60. 00:02:38
    experts at the table together reviewed
  61. 00:02:40
    the available evidence that we could
  62. 00:02:42
    actually come to consensus on many of
  63. 00:02:45
    the things that were similar between
  64. 00:02:47
    adults in pediatric brain death
  65. 00:02:49
    determination. And obviously there's
  66. 00:02:51
    some physiological principles that make
  67. 00:02:53
    some components of the brain death
  68. 00:02:55
    determination process in children and
  69. 00:02:57
    infants different than in adults. But
  70. 00:03:00
    we figured for most of the stuff it
  71. 00:03:03
    could actually be similar independent of
  72. 00:03:05
    your age. And some of the differences
  73. 00:03:08
    that it previously existed in the prior
  74. 00:03:10
    guidelines just didn't really make any
  75. 00:03:11
    sense. Like for example, there was a
  76. 00:03:12
    different requirement for the minimum
  77. 00:03:15
    temperature for the evaluation and the
  78. 00:03:17
    wording regarding the apnea testing.
  79. 00:03:18
    target was slightly different. And
  80. 00:03:20
    there wasn't really any physiologic
  81. 00:03:22
    reason for that. So it made sense to be
  82. 00:03:24
    able to combine and into a single
  83. 00:03:25
    guideline for the whole lifespan. And
  84. 00:03:28
    did you feel that the pediatric group
  85. 00:03:30
    and the adult group sort of seemed to be
  86. 00:03:33
    in agreement for most things? Or was
  87. 00:03:35
    there a lot of debate about the smaller
  88. 00:03:38
    details?
  89. 00:03:40
    I think for the most part, people were
  90. 00:03:41
    in agreement about how to approach brain
  91. 00:03:45
    death As Ariane said, across the
  92. 00:03:48
    lifespan and independent of age, the
  93. 00:03:52
    mechanism of the injury is different in
  94. 00:03:55
    pediatrics than adults. We see more
  95. 00:03:57
    hypoxic ischemic brain injury and
  96. 00:03:59
    pediatrics from either cardiac arrest or
  97. 00:04:02
    shock or respiratory failure, whereas
  98. 00:04:04
    trauma is a bigger component in adults.
  99. 00:04:09
    And one of the things that we had to
  100. 00:04:11
    keep in mind is that infants in
  101. 00:04:14
    particular that have open fontanels and
  102. 00:04:17
    unfuse sutures. that they may not
  103. 00:04:20
    appreciate the consequences of increased
  104. 00:04:24
    intracranial pressure the same as adults.
  105. 00:04:27
    And so they may need slightly longer
  106. 00:04:29
    waiting periods or, I
  107. 00:04:39
    different prerequisite conditions to be
  108. 00:04:41
    met prior to undertaking the brain death
  109. 00:04:45
    determination process.
  110. 00:04:48
    My office name is blocking in and out.
  111. 00:04:51
    Sorry about that.
  112. 00:04:55
    Okay. Obviously he's gonna cut that out.
  113. 00:04:58
    Okay. So one of the biggest changes I
  114. 00:05:01
    think in terms of terminology is the
  115. 00:05:04
    change in one word which is the change
  116. 00:05:07
    in the term irreversible into the term
  117. 00:05:12
    permanent for the reason for
  118. 00:05:15
    neurological injury. Can one of you or
  119. 00:05:17
    maybe both of you comment on the reason
  120. 00:05:19
    for the change in that specific word?
  121. 00:05:22
    Yeah so as you know this is something
  122. 00:05:24
    different. We do have a description at
  123. 00:05:26
    the beginning of the document that
  124. 00:05:27
    defines kind of why we decided to go
  125. 00:05:29
    with the term permanent. Both terms
  126. 00:05:32
    have often been used interchangeably in
  127. 00:05:35
    the same context or in different And we
  128. 00:05:39
    chose to use the word permanent to mean,
  129. 00:05:41
    specifically that function was lost and
  130. 00:05:43
    will not resume spontaneously and
  131. 00:05:45
    medical interventions will not be used
  132. 00:05:47
    to attempt restoration of function.
  133. 00:05:49
    There's been an increase in literature
  134. 00:05:51
    related to the difference between these
  135. 00:05:53
    two terms, specifically coming out of
  136. 00:05:56
    from two authors, Andrew McGee and Dale
  137. 00:05:58
    Gardiner And really, they focus on the
  138. 00:06:02
    fact that I, when you are using the
  139. 00:06:05
    term irreversible, it suggests that
  140. 00:06:07
    literally anything that hypothetically
  141. 00:06:09
    could be done to try and reverse a
  142. 00:06:12
    situation has been done And obviously
  143. 00:06:15
    that that's not done for either the
  144. 00:06:17
    determination of death by neurologic
  145. 00:06:18
    criteria or the determination of death
  146. 00:06:20
    by circulatory respiratory criteria and
  147. 00:06:23
    the term permanent was also used by the
  148. 00:06:24
    world brain death project and by the
  149. 00:06:26
    2023 Canadian guidelines on brain death
  150. 00:06:29
    determination
  151. 00:06:31
    And speaking of the World Brain Death
  152. 00:06:33
    Project. I noticed that there were a
  153. 00:06:35
    lot of new sort of comments on
  154. 00:06:38
    qualifications of examiners, how to
  155. 00:06:41
    demonstrate competence. And I know that
  156. 00:06:43
    this is a guideline primarily for the
  157. 00:06:44
    United States. Do you think this is
  158. 00:06:47
    something that other countries will sort
  159. 00:06:49
    of be commenting on as well?
  160. 00:06:53
    So that's a good question. The World
  161. 00:06:54
    Brain Death Project was intended to be a
  162. 00:06:58
    establishment of the minimum standards
  163. 00:06:59
    for the determination of death by
  164. 00:07:01
    neurologic criteria around the world,
  165. 00:07:03
    not with the intent for any individual
  166. 00:07:05
    country to fully embrace the World Brain
  167. 00:07:07
    Death Project, but rather to use it as
  168. 00:07:09
    a guide to update their country's
  169. 00:07:12
    guidelines or to create new guidelines
  170. 00:07:14
    in their country if they didn't exist.
  171. 00:07:16
    And so that's the way that we used it.
  172. 00:07:18
    We used it as a foundation, as a sort
  173. 00:07:20
    of a springboard in terms of thought
  174. 00:07:22
    processes related to the revisions when
  175. 00:07:25
    we combine the two guidelines. And
  176. 00:07:26
    going forwards, I think that, you know,
  177. 00:07:29
    the ANs guidelines have always been,
  178. 00:07:32
    cited by many countries around the world
  179. 00:07:34
    and obviously the AN is a large
  180. 00:07:37
    international organization. And so I
  181. 00:07:39
    think that it certainly has the
  182. 00:07:40
    potential for other countries to embrace
  183. 00:07:43
    this guideline as has been the case
  184. 00:07:45
    previously. When looking at
  185. 00:07:47
    international protocols for the
  186. 00:07:49
    determination of death by neurologic
  187. 00:07:50
    criteria, there were a few countries
  188. 00:07:52
    that indicated that they use the AN
  189. 00:07:54
    guidelines as their national standards.
  190. 00:07:56
    And so I anticipate that that will
  191. 00:07:58
    continue to be the case going forwards
  192. 00:07:59
    now.
  193. 00:08:03
    I would, I want to make sure that I
  194. 00:08:05
    sort of make it clear before we keep
  195. 00:08:07
    going that we're not going to use this
  196. 00:08:10
    podcast to sort of go through the nitty
  197. 00:08:12
    gritty of changes between the old
  198. 00:08:15
    guidelines and the new. I would
  199. 00:08:16
    encourage people to look at the
  200. 00:08:19
    neurology clinical practice paper that
  201. 00:08:22
    both of you wrote with David Greer that
  202. 00:08:24
    sort of highlights I think the very
  203. 00:08:26
    nicely the the changes and the additions.
  204. 00:08:29
    Um, and I would also encourage everyone
  205. 00:08:31
    to read the actual guidelines, uh,
  206. 00:08:33
    tedious as it may be, um, because I
  207. 00:08:35
    think this is really important stuff and,
  208. 00:08:37
    um, I, you know, I think we're going
  209. 00:08:40
    to need to get our, our hospitals
  210. 00:08:42
    potentially up to speed on some of the,
  211. 00:08:44
    the changes that have been made, both
  212. 00:08:46
    in terms of the sort of, uh, criteria
  213. 00:08:50
    for that you must sort of pass in order
  214. 00:08:52
    to declare death by neurologic criteria,
  215. 00:08:55
    but also the, the specifics of, you
  216. 00:08:57
    know, prerequisites to brain death
  217. 00:08:59
    determination and ancillary testing.
  218. 00:09:02
    And we will kind of highlight a few of
  219. 00:09:04
    those things, but I do want to
  220. 00:09:05
    encourage the readers to kind of go back
  221. 00:09:07
    and read everything themselves. Um,
  222. 00:09:10
    and I also want to highlight that, uh,
  223. 00:09:12
    one of my favorite parts was the
  224. 00:09:13
    e-tables that come with the guidelines,
  225. 00:09:17
    mostly because for, and I'm sure the
  226. 00:09:19
    pharmacists are going to salivate over
  227. 00:09:21
    e-table number two. Um, but I thought
  228. 00:09:24
    it was great that you guys included sort
  229. 00:09:27
    of a pharmacokinetic table for
  230. 00:09:29
    medications that depress the central
  231. 00:09:30
    nervous system. And you specifically
  232. 00:09:32
    mentioned, well, you mentioned that
  233. 00:09:36
    tendobarbitol levels should just not be
  234. 00:09:37
    detectable at all, and that other
  235. 00:09:39
    medication levels should really be
  236. 00:09:41
    within the therapeutic or some
  237. 00:09:42
    therapeutic range. And I'm sort of
  238. 00:09:43
    wondering, is that something that you
  239. 00:09:47
    went in sort of feeling was a deficit in
  240. 00:09:49
    the previous iterations of guidelines?
  241. 00:09:52
    And how did you get pharmacy to sort of,
  242. 00:09:56
    or pharmacist colleagues to weigh in and
  243. 00:09:59
    help with that?
  244. 00:10:02
    So what does - Go ahead Ariane. Part of
  245. 00:10:05
    the thought process in writing the new
  246. 00:10:07
    guidelines was that we wanted to ensure
  247. 00:10:09
    that we were addressing the many
  248. 00:10:11
    questions that have come up towards us
  249. 00:10:13
    in the past about the prior guidelines.
  250. 00:10:16
    And so one area of questions has been
  251. 00:10:18
    related to testing after administration
  252. 00:10:22
    of drugs and how long it's necessary to
  253. 00:10:23
    wait. Another area that's come up is
  254. 00:10:26
    questions about electrolytes and other
  255. 00:10:29
    laboratory values and whether certain
  256. 00:10:32
    specific derangements are acceptable or
  257. 00:10:33
    unacceptable with the evaluation process.
  258. 00:10:36
    So with that in mind, we did create two
  259. 00:10:38
    tables that address this issue. First,
  260. 00:10:41
    as you mentioned, the pharmacokinetics
  261. 00:10:43
    table, which was created in conjunction,
  262. 00:10:46
    Matt created in conjunction with a
  263. 00:10:49
    PharmD at his institution And then
  264. 00:10:51
    second is the table of suggested
  265. 00:10:55
    metabolic values prior to the evaluation,
  266. 00:10:58
    recognizing that there's no scientific
  267. 00:11:01
    evidence that, for example, a sodium
  268. 00:11:03
    of 161 is unacceptable, but a sodium of
  269. 00:11:06
    159 is acceptable. But we actually took
  270. 00:11:09
    information based upon a survey study
  271. 00:11:12
    that David Lerner had done a couple of
  272. 00:11:13
    years ago with members of NCS about
  273. 00:11:16
    their perspectives as to acceptable and
  274. 00:11:18
    unacceptable lab values. when doing the
  275. 00:11:21
    evaluation and incorporated that into
  276. 00:11:23
    this table so that there were some
  277. 00:11:25
    recommendations on this topic. One of
  278. 00:11:28
    the other reasons why I think those
  279. 00:11:30
    tables are so important is because we
  280. 00:11:32
    really wanted to emphasize that
  281. 00:11:34
    determination of brain death is really a
  282. 00:11:37
    clinical determination. And we wanted
  283. 00:11:40
    to give people all of the tools
  284. 00:11:43
    available so that they could go through
  285. 00:11:46
    all of their prerequisites, exclude all
  286. 00:11:48
    potential confounders, and proceed with
  287. 00:11:52
    the clinical examination preferentially
  288. 00:11:56
    rather than use ancillary testing. We
  289. 00:11:58
    really tried to narrow the indications
  290. 00:12:00
    for ancillary testing such that if you
  291. 00:12:02
    could collect, correct an electrolyte
  292. 00:12:04
    abnormality, if you could wait longer
  293. 00:12:06
    for a medication to be metabolized and
  294. 00:12:09
    cleared from the body, that that was
  295. 00:12:11
    really the preferred way to make a
  296. 00:12:13
    clinical determination of brain death.
  297. 00:12:15
    And we wanted to give people as many
  298. 00:12:17
    tools as possible in order to be able to
  299. 00:12:20
    do that effectively.
  300. 00:12:22
    So that's a great point. And I think,
  301. 00:12:24
    you know, having read through and
  302. 00:12:26
    especially, you know, specifics about
  303. 00:12:28
    how long to wait after a cardiac arrest,
  304. 00:12:31
    how long to wait after cooling. I think
  305. 00:12:34
    some people may feel that brain death
  306. 00:12:39
    determination is going to be sort of
  307. 00:12:40
    delayed and that things are gonna take
  308. 00:12:42
    longer before you can, you know, sort
  309. 00:12:45
    of clinically diagnose. And I wonder
  310. 00:12:48
    what your response would be to people
  311. 00:12:50
    who sort of are unhappy with having to
  312. 00:12:52
    wait a little longer. We're more than
  313. 00:12:54
    okay with their unhappiness about that.
  314. 00:12:56
    The goal in the evaluation process and
  315. 00:12:58
    writing the guidelines was to be as
  316. 00:13:00
    conservative as possible. Nobody ever
  317. 00:13:02
    wants to find themselves in a
  318. 00:13:03
    circumstance where they've made a
  319. 00:13:05
    determination of death and then they
  320. 00:13:07
    have to subsequently go back and say,
  321. 00:13:08
    whoops, I made a mistake. So the goal
  322. 00:13:11
    in creating the guidelines was to ensure
  323. 00:13:13
    that as much conservatism as possible
  324. 00:13:16
    was being employed throughout all
  325. 00:13:18
    aspects of the determination process.
  326. 00:13:20
    And that's also why I don't like the
  327. 00:13:22
    word delay. We are not delaying the
  328. 00:13:26
    determination of death. We are
  329. 00:13:28
    advocating for an appropriate
  330. 00:13:31
    observation period to determine
  331. 00:13:33
    permanency and irreversibility of the
  332. 00:13:36
    brain injury. And we have lengthened
  333. 00:13:40
    that period of time for some specific
  334. 00:13:43
    ideologies like hypoxic ischemic brain
  335. 00:13:45
    injury and in younger infants and
  336. 00:13:48
    children in particular, but one of the
  337. 00:13:50
    other things that we emphasized is if
  338. 00:13:54
    the patient undergoes an intervention in
  339. 00:13:57
    order to try to promote neuro-recovery
  340. 00:14:01
    or neuro-protection if they were treated
  341. 00:14:03
    with therapeutic hypothermia, if they
  342. 00:14:06
    had medical or surgical interventions to
  343. 00:14:09
    lower ICP, then we advocated that you
  344. 00:14:12
    actually need to give time to see if
  345. 00:14:14
    those interventions were effective So
  346. 00:14:16
    you can't give a dose of hypertonic
  347. 00:14:18
    saline. and then proceed to your
  348. 00:14:21
    brain-death evaluation. You need to
  349. 00:14:22
    give your hypotonic saline, give it an
  350. 00:14:25
    appropriate period of time to see
  351. 00:14:27
    whether it was effective or not, and
  352. 00:14:28
    did the patient have any recovery of
  353. 00:14:30
    neurologic function, and then proceed
  354. 00:14:32
    with your brain-death evaluation. So we
  355. 00:14:35
    don't consider it delaying the
  356. 00:14:36
    evaluation, we consider it observing
  357. 00:14:39
    the patient for an appropriate period of
  358. 00:14:41
    time to ensure the permanency of the
  359. 00:14:43
    injury. And once you have done that,
  360. 00:14:45
    then proceed with your clinical
  361. 00:14:46
    evaluation. The message that we always
  362. 00:14:48
    reinforce when we're teaching classes
  363. 00:14:50
    about brain death determination is that
  364. 00:14:52
    it should never be a rush to make a
  365. 00:14:54
    determination of death.
  366. 00:14:57
    I think that's a great way of framing it.
  367. 00:14:59
    And obviously there are societal
  368. 00:15:03
    concerns about the idea of brain death
  369. 00:15:05
    and suspicions. And so I think that
  370. 00:15:08
    there's nothing more permanent than the
  371. 00:15:11
    declaration of death. So we should be
  372. 00:15:14
    100 certain when we're doing it. I did
  373. 00:15:17
    want to talk a little bit about
  374. 00:15:18
    ancillary testing because I do know one
  375. 00:15:20
    that ancillary testing, you know,
  376. 00:15:22
    sometimes is used to sort of bypass the
  377. 00:15:24
    clinical test, but also there was a
  378. 00:15:27
    very important change in use of
  379. 00:15:29
    ancillary testing. So EEG has now been
  380. 00:15:32
    taken out as an appropriate ancillary
  381. 00:15:35
    test, and I think most people would
  382. 00:15:37
    probably agree that technically it's
  383. 00:15:39
    very challenging to do an EEG as an
  384. 00:15:42
    ancillary test without
  385. 00:15:45
    any,
  386. 00:15:50
    what's the word, technically it's very,
  387. 00:15:52
    yes, technically it's very challenging
  388. 00:15:55
    to do an EEG in an ICU without any
  389. 00:15:58
    artifacts and get an appropriate result
  390. 00:16:02
    that would be consistent. But I'm
  391. 00:16:03
    wondering what were the other
  392. 00:16:05
    conversations surrounding removing EEG
  393. 00:16:07
    as an ancillary test? Yeah, so first,
  394. 00:16:10
    you know, we really wanted to ensure in
  395. 00:16:12
    describing the purpose for ancillary
  396. 00:16:14
    testing that we were very clear that
  397. 00:16:16
    ancillary testing should not be used as
  398. 00:16:18
    a replacement for the clinical
  399. 00:16:20
    evaluation. And that first and foremost,
  400. 00:16:23
    brain death determination is a clinical
  401. 00:16:24
    determination. And I all portions of
  402. 00:16:28
    the evaluation that can be completed,
  403. 00:16:29
    including the apnea test must be
  404. 00:16:31
    completed before thinking about going
  405. 00:16:33
    towards ancillary testing. In terms of
  406. 00:16:36
    the specific tests that were noted to be
  407. 00:16:39
    acceptable tests, as you mentioned,
  408. 00:16:41
    the EEG has now fallen out of favor.
  409. 00:16:44
    And now is no longer included as an
  410. 00:16:46
    acceptable test in the guidelines. And
  411. 00:16:48
    similarly, this is the case in the
  412. 00:16:50
    World Brain Death Project, and also in
  413. 00:16:52
    the Canadian guidelines. And while, as
  414. 00:16:55
    you mentioned, there are as the
  415. 00:16:56
    potentials for artifact in the ICU
  416. 00:16:58
    environment, that actually wasn't
  417. 00:17:00
    really the main factor that contributed
  418. 00:17:01
    to eliminating this as an ancillary test,
  419. 00:17:04
    rather the concern is that an EEG does
  420. 00:17:07
    not evaluate brain STEM activity, and
  421. 00:17:10
    when it comes down to it. much of the
  422. 00:17:12
    evaluation for brain death determination
  423. 00:17:14
    involves the evaluation for brain stem
  424. 00:17:16
    reflexes and also the ability to breathe
  425. 00:17:19
    spontaneously, which is coming from the
  426. 00:17:20
    brain stem. And so therefore, if we're
  427. 00:17:22
    just the evaluating the cortex with our
  428. 00:17:24
    ancillary test, then that's not really
  429. 00:17:26
    a suitable ancillary test.
  430. 00:17:32
    And speaking of the apnea test, I do
  431. 00:17:34
    think it's remarkable that you all
  432. 00:17:36
    commented specifically on obtaining
  433. 00:17:39
    consent for evaluation of death by
  434. 00:17:42
    neurologic criteria. And I imagine in
  435. 00:17:45
    pediatrics it's probably even harder
  436. 00:17:47
    than in adults, but I wonder if either
  437. 00:17:50
    of both of you wanted to comment a
  438. 00:17:51
    little bit about the reason for
  439. 00:17:53
    specifically putting that in. So first,
  440. 00:17:56
    just for clarification in terms of what
  441. 00:17:57
    the guidance is, the guidance is that
  442. 00:17:59
    it's not necessary to obtain consent
  443. 00:18:01
    prior to the evaluation, that all
  444. 00:18:04
    efforts should be made to notify a
  445. 00:18:05
    family of the intent to perform a
  446. 00:18:07
    brain-death evaluation, but it's not
  447. 00:18:09
    necessary to seek consent. And this is
  448. 00:18:11
    consistent with guidance that was put
  449. 00:18:13
    forth previously by AN in a position
  450. 00:18:17
    statement a couple of years ago that
  451. 00:18:19
    focuses on accommodation or how to
  452. 00:18:21
    accommodate or whether to accommodate
  453. 00:18:24
    objections to the determination of death
  454. 00:18:26
    by neurologic So we wanted to reinforce
  455. 00:18:28
    that message that consent is not
  456. 00:18:31
    required, particularly because this is
  457. 00:18:33
    something that's been kind of highly
  458. 00:18:35
    debated in the literature, but, you
  459. 00:18:37
    know, over three quarters of
  460. 00:18:38
    neurologists indicate that they in
  461. 00:18:41
    surveys that they do not obtain consent
  462. 00:18:43
    that they do not think consent should be
  463. 00:18:45
    needed and so we just wanted to really
  464. 00:18:46
    clarify that for sure in the guidelines
  465. 00:18:49
    themselves
  466. 00:18:52
    Thank you for clarifying exactly what I
  467. 00:18:55
    meant by the consent issue.
  468. 00:19:00
    I think one of the other sort of
  469. 00:19:02
    interesting in inclusions which had been
  470. 00:19:05
    sort of spoken about a little bit
  471. 00:19:09
    in the World Brain Death Project is the
  472. 00:19:09
    inclusion of patients who are on ECMO
  473. 00:19:12
    And I'm sure that there was a
  474. 00:19:15
    recognition that patients are
  475. 00:19:16
    increasingly placed on ECMO with results
  476. 00:19:19
    in catastrophic neurological injury What
  477. 00:19:23
    was the discussion in terms of
  478. 00:19:26
    performing apnea testing on ECMO and was
  479. 00:19:30
    there much of a debate or was it pretty
  480. 00:19:32
    sort of well established what the
  481. 00:19:35
    guidelines were going to be?
  482. 00:19:41
    Matt, you're muted.
  483. 00:19:45
    Sorry, I was trying to cut out
  484. 00:19:46
    background noise. So prior to
  485. 00:19:51
    producing these guidelines, there were
  486. 00:19:53
    several institutions that had published
  487. 00:19:55
    their protocol for how to do apnea
  488. 00:19:58
    testing on ECMO. And from a physiologic
  489. 00:20:01
    standpoint, it is not different to do
  490. 00:20:05
    apnea testing on ECMO than it is off of
  491. 00:20:08
    ECMO The same principles are followed,
  492. 00:20:12
    where you normalize the pH and the PSCO2
  493. 00:20:14
    prior to beginning. You pre-oxygenate
  494. 00:20:17
    the patient. In the case of being on
  495. 00:20:19
    ECMO, you would pre-oxygenate both
  496. 00:20:21
    through the ventilator and through the
  497. 00:20:23
    ECMO circuit. And then when you are
  498. 00:20:26
    going to begin the apnea test, you're
  499. 00:20:29
    following the same procedure as you do
  500. 00:20:31
    when the patient is not on ECMO, that
  501. 00:20:33
    you remove the patient from intermittent
  502. 00:20:35
    mechanical
  503. 00:20:38
    And then during that time, you need to
  504. 00:20:39
    provide apnic oxygenation. So there are
  505. 00:20:43
    multiple different ways to do that.
  506. 00:20:45
    Some that are preferred in pediatrics
  507. 00:20:47
    because of their limited pulmonary
  508. 00:20:49
    reserve. And you actually have an
  509. 00:20:51
    advantage on ECMO that you can actually
  510. 00:20:54
    provide apnic oxygenation through the
  511. 00:20:56
    ECMO circuit, which may provide a
  512. 00:20:59
    margin of safety. And then you have to
  513. 00:21:02
    allow time for the CO2 to rise to
  514. 00:21:05
    stimulate the medullary chemo receptors,
  515. 00:21:07
    to see if you have any respiratory
  516. 00:21:09
    effort. When you are not on ECMO,
  517. 00:21:13
    simply taking the patient off the
  518. 00:21:14
    ventilator. If the patient is not
  519. 00:21:17
    having spontaneous respirations, will
  520. 00:21:19
    allow the CO2 to rise. When you
  521. 00:21:23
    are on ECMO, you need to decrease the
  522. 00:21:24
    sweep flow, usually to somewhere
  523. 00:21:27
    between 05 and one in order to allow the
  524. 00:21:30
    CO2 to rise. Sometimes after doing that,
  525. 00:21:33
    you do not get adequate CO2 rise because
  526. 00:21:36
    of the efficiency. of the membranes
  527. 00:21:40
    that are now used for ECMO. So
  528. 00:21:41
    sometimes CO2 needs to be added into the
  529. 00:21:44
    circuit in order to get it to rise to
  530. 00:21:46
    the appropriate level. The other thing
  531. 00:21:49
    that needs to be kept in mind when you
  532. 00:21:51
    were on VA ECMO in particular is where
  533. 00:21:54
    you sample your blood gases from because
  534. 00:21:56
    you actually want
  535. 00:22:00
    the CO2 that is being seen in the
  536. 00:22:02
    cerebral circulation rather than in the
  537. 00:22:05
    systemic circulation And if you have
  538. 00:22:07
    native myocardial output and you have
  539. 00:22:11
    ECMO flow depending on where your ECMO
  540. 00:22:14
    canula is, then the blood going to the
  541. 00:22:16
    brain is going to be some mixture of the
  542. 00:22:20
    blood from the native myocardium as well
  543. 00:22:23
    as from the ECMO flow. And so in order
  544. 00:22:26
    to best estimate what CO2 is being seen
  545. 00:22:32
    in the cerebral arterial circulation,
  546. 00:22:36
    check blood gases from both the ECMO
  547. 00:22:38
    circuit post oxygenator
  548. 00:22:42
    and from the patient's arterial line.
  549. 00:22:45
    And where the patient's arterial line is
  550. 00:22:47
    relative to the ECMO cannula needs to be
  551. 00:22:50
    taken into consideration. So the best
  552. 00:22:53
    approximate the CO2 and the cerebral
  553. 00:22:55
    circulation.
  554. 00:22:58
    I love the specificity and the detail.
  555. 00:23:02
    And it sounds like
  556. 00:23:07
    I'm -
  557. 00:23:13
    I like to hold on one second because
  558. 00:23:14
    it's crazy feedback, but I don't know
  559. 00:23:16
    where it's from. Is that from you again?
  560. 00:23:20
    No, no, I can't figure it out. Hold
  561. 00:23:22
    on
  562. 00:23:27
    Sorry Alex. No, that's totally cool.
  563. 00:23:30
    What was the last thing
  564. 00:23:34
    you guys heard? You said you were
  565. 00:23:36
    talking about the specificity. Yeah.
  566. 00:23:38
    Oh, okay. Cool. Okay. So I'll just
  567. 00:23:39
    start over from there. I saw all you
  568. 00:23:42
    guys smiling and I was like, I can't
  569. 00:23:43
    possibly be saying anything that funny.
  570. 00:23:46
    Oh, actually I was smiling at what you
  571. 00:23:47
    were saying. Okay. And then the sound
  572. 00:23:49
    started. And then you were just making
  573. 00:23:51
    fun of me. Got it
  574. 00:23:53
    So we'll start over after Matt says his
  575. 00:23:57
    thing. And I'm going to say, I do love
  576. 00:24:00
    the amount of detail and the specificity
  577. 00:24:02
    that went into not only
  578. 00:24:05
    describing how to do the apnea test and
  579. 00:24:08
    apnea testing on ECMO, but even the
  580. 00:24:10
    clinical exam. And I think that that
  581. 00:24:12
    sort of specificity, even though it can
  582. 00:24:14
    be challenging to read, is important
  583. 00:24:17
    for ensuring that everyone's sort of
  584. 00:24:20
    doing this the same way So I appreciate
  585. 00:24:23
    that and I wonder sort of how might we
  586. 00:24:27
    ensure that hospitals are going to be in
  587. 00:24:31
    compliance with these new guidelines?
  588. 00:24:33
    Was there any discussion about that?
  589. 00:24:37
    Yeah, so that's a great question. As
  590. 00:24:39
    you alluded to earlier, it's incredibly
  591. 00:24:41
    important that everyone who listens to
  592. 00:24:43
    this podcast, everybody who reads the
  593. 00:24:45
    guidelines will go back to their own
  594. 00:24:47
    guidelines in their hospital and update
  595. 00:24:49
    them to be in accord with the new
  596. 00:24:51
    guidelines. As we've seen from prior
  597. 00:24:55
    studies looking at hospital protocols on
  598. 00:24:57
    the determination of death, we see that
  599. 00:24:59
    there is variability from hospital to
  600. 00:25:01
    hospital and that there's variability in
  601. 00:25:03
    comparison to the accepted guidelines.
  602. 00:25:05
    And so we're hoping that with these new
  603. 00:25:07
    guidelines that everyone will be more
  604. 00:25:10
    proactive about reviewing their hospital
  605. 00:25:13
    standards in more detail to ensure that
  606. 00:25:15
    they are consistent. In terms of any
  607. 00:25:18
    sort of regulation to ensure that
  608. 00:25:20
    hospital protocols are in line with the
  609. 00:25:23
    new guidelines. We have been discussing
  610. 00:25:26
    getting JCO involved to see if there is
  611. 00:25:29
    the ability to provide some oversight in
  612. 00:25:30
    that capacity. But that's not something
  613. 00:25:32
    that's in place as of yet. One of the
  614. 00:25:34
    things that was in our mind as we
  615. 00:25:36
    composed the document for the guideline
  616. 00:25:39
    itself was to try to make it as easy as
  617. 00:25:42
    possible for institutions to adopt these
  618. 00:25:45
    guidelines. The ancillary tables were
  619. 00:25:48
    designed in a way that hopefully they
  620. 00:25:50
    can just be included in hospital
  621. 00:25:51
    protocols In addition, one of the other
  622. 00:25:54
    appendices to the document was a
  623. 00:25:57
    checklist that institutions could either
  624. 00:26:00
    use as is or could adopt into a smart
  625. 00:26:05
    phrase to be used in their electronic
  626. 00:26:07
    medical record system The other thing
  627. 00:26:11
    that I will note is on the AAN website,
  628. 00:26:14
    there is a digital interactive tool that
  629. 00:26:17
    will actually for an individual patient
  630. 00:26:19
    take you through the flowchart or the
  631. 00:26:22
    path. of how to do a brain death
  632. 00:26:24
    determination for that individual
  633. 00:26:26
    patient. It will take you through all
  634. 00:26:28
    of the prerequisites, through the exams,
  635. 00:26:31
    it will give you the questions to
  636. 00:26:33
    indicate whether the patient needs an
  637. 00:26:35
    ancillary test, it will give you the
  638. 00:26:37
    option of doing two exams for adults,
  639. 00:26:39
    the mandated two exams with the waiting
  640. 00:26:41
    period for children, and then advise
  641. 00:26:46
    you on the time of death determination
  642. 00:26:48
    at the end So that is a very valuable
  643. 00:26:51
    tool that people can use on their own
  644. 00:26:55
    personal device at the bedside in order
  645. 00:26:57
    to guide them through doing a brain
  646. 00:26:59
    death determination. Yeah, that was
  647. 00:27:02
    really incredible to go through. And
  648. 00:27:04
    for those of us who are maybe not as
  649. 00:27:06
    tech savvy, there is also a printable
  650. 00:27:09
    criteria checklist in one of the
  651. 00:27:12
    appendices. If you're more used to
  652. 00:27:15
    checking things with pen and paper. On
  653. 00:27:17
    a related note,
  654. 00:27:20
    the Uniform Law Commission was looking
  655. 00:27:22
    to make some updates on the uniform
  656. 00:27:24
    determination of death after the UDDA.
  657. 00:27:26
    Where are we with that and how does this
  658. 00:27:28
    fit in? Yeah, so that's been a
  659. 00:27:31
    three-year process to try and revise
  660. 00:27:35
    the UDDA because of a number of
  661. 00:27:36
    different concerns with the language of
  662. 00:27:38
    the UDDA that I won't get into here,
  663. 00:27:40
    but are addressed in a couple of
  664. 00:27:42
    publications I've had in neuro-critical
  665. 00:27:44
    care But most recently,
  666. 00:27:49
    there was a drafting committee to
  667. 00:27:50
    discuss specific textual revisions to
  668. 00:27:53
    the UDDA and after the drafting
  669. 00:27:55
    committee met for two years to discuss
  670. 00:27:57
    revisions, this summer, those
  671. 00:28:00
    revisions were brought before the full
  672. 00:28:03
    uniform law commission in Hawaii to talk
  673. 00:28:06
    about both those specific revisions and
  674. 00:28:08
    the general concept of revising the UDDA
  675. 00:28:11
    further. And after that meeting, it
  676. 00:28:14
    was ultimately determined by the uniform
  677. 00:28:16
    law commission that. At present, this
  678. 00:28:18
    issue is too controversial in terms of
  679. 00:28:21
    what language should be employed in the
  680. 00:28:23
    revisions. And therefore, we are now
  681. 00:28:25
    in a pause, which I'm considering an
  682. 00:28:27
    indefinite pause to the drafting process.
  683. 00:28:31
    I do have a paper in our critical care
  684. 00:28:33
    that addresses comments that the ULC
  685. 00:28:36
    received from medical societies, from
  686. 00:28:40
    organ procurement organizations and from
  687. 00:28:42
    advocacy organizations that addresses
  688. 00:28:45
    the textual thematic content of these
  689. 00:28:49
    comments in terms of what they would
  690. 00:28:51
    like to see versus what they would not
  691. 00:28:53
    like to see in a UDDA revision. And in
  692. 00:28:56
    reading the paper, you'll see that
  693. 00:28:58
    there's a lot of different perspectives
  694. 00:29:00
    from these different stakeholders. And
  695. 00:29:02
    this is what contributed to the ULC
  696. 00:29:04
    deciding to table this issue. Wow, so
  697. 00:29:08
    even more reading for our listeners,
  698. 00:29:11
    check out Dr. Lewis's latest in
  699. 00:29:13
    neurocritical care. Is there anything
  700. 00:29:16
    else that we haven't really talked about
  701. 00:29:18
    that you think is important to emphasize?
  702. 00:29:22
    And no, I think you've really covered
  703. 00:29:23
    it. Thank you so much for having us on.
  704. 00:29:25
    And I think, as you reiterated, it's
  705. 00:29:27
    important to ensure that everybody goes
  706. 00:29:29
    back and reads the guidelines, reads
  707. 00:29:32
    the comparison document, and then
  708. 00:29:33
    reviews their institutional else
  709. 00:29:34
    everyone and you of both to Thanks.
  710. 00:29:34
    accordingly it updates and protocols
  711. 00:29:41
    who was on the committee who spent years
  712. 00:29:43
    trying to update this And
  713. 00:29:47
    thanks a lot for your time coming on the
  714. 00:29:49
    podcast today. Just remember everyone,
  715. 00:29:52
    you can access the NCS podcast wherever
  716. 00:29:54
    you get your pods, add us to your
  717. 00:29:56
    favorites and be sure never to miss an
  718. 00:29:58
    episode. NCS also offers free
  719. 00:30:00
    continuing education credits for
  720. 00:30:02
    listening to select episodes. Listen
  721. 00:30:04
    via the NCS Learning Center and complete
  722. 00:30:06
    a short survey to receive your free
  723. 00:30:08
    credits. Thanks everyone, see you next
  724. 00:30:10
    time.
  725. 00:30:12
    Cut. All right, great Thank you guys
  726. 00:30:14
    so much. This was really interesting.
  727. 00:30:17
    Hey, Alex, the answer I gave at the
  728. 00:30:19
    very beginning about the Pete's thing,
  729. 00:30:21
    where I stumbled a little bit at the end,
  730. 00:30:23
    'cause I didn't want to bring up some of
  731. 00:30:26
    the differences. Will you just make
  732. 00:30:27
    sure that sounds okay when they edit it?
  733. 00:30:29
    Yeah, yeah, usually that's me
  734. 00:30:30
    listening to it before we release it.
  735. 00:30:33
    And I'll let you guys know when we
  736. 00:30:35
    release it, or the day before we
  737. 00:30:36
    release it or something, 'cause I'm
  738. 00:30:38
    sure. All right, I just want to make
  739. 00:30:39
    sure I don't say, it doesn't come out
  740. 00:30:42
    egregiously bad. I thought what you
  741. 00:30:44
    said was fine, though I thought it was
  742. 00:30:45
    great, but I don't know anything about
  743. 00:30:48
    children, so you could say all sorts of
  744. 00:30:50
    things, and I wouldn't know the
  745. 00:30:51
    difference. Awesome, thank you guys so
  746. 00:30:54
    much. I know this is like a ton of your
  747. 00:30:56
    time, I really appreciate it, and yeah.
  748. 00:31:00
    No problem, we're happy to highlight
  749. 00:31:01
    the new guidelines. Cool. Thank you
  750. 00:31:03
    guys. Awesome, thank you too, bye