-
British Journal of Anaesthesia Jan 2012
Topics: Brain Death; Humans; Tissue and Organ Procurement; United Kingdom
PubMed: 22194424
DOI: 10.1093/bja/aer409 -
Clinical Neurophysiology : Official... Nov 2018The widely accepted concept of brain death (BD) comprises the demonstration of irreversible coma in combination with the loss of brainstem reflexes and irreversible... (Review)
Review
The widely accepted concept of brain death (BD) comprises the demonstration of irreversible coma in combination with the loss of brainstem reflexes and irreversible apnea. In some countries the combined clinical finding of coma, apnea, and loss of all tested brainstem reflexes ("brainstem death") is sufficient for diagnosing BD irrespective of the primary location of brain lesion. The present article aims to substantiate the need for ancillary testing in patients with primary infratentorial brain lesions. Anatomically, the "brainstem-death" syndrome can theoretically occur without relevant lesion of the mesopontine tegmental reticular formation (MPT-RF). Thus, a brainstem lesion may cause an apneic total locked-in syndrome, a rare syndrome with preserved capability for consciousness, mimicking "brainstem death". Findings in animals and humans have shown that alpha- or alpha/theta- EEG patterns in case of isolated brainstem lesion indicate intactness of relevant parts of the MPT-RF. In such patients the presence of irreversible coma has to be doubted, and the potential capacity for some degree of consciousness cannot be excluded as long as the EEG activity persists. Consequently the demonstration of either ancillary finding, electro-cortical inactivity or, preferably, cerebral circulatory arrest, is mandatory for diagnosing BD in patients with a primary infratentorial brain lesion.
Topics: Brain Death; Brain Stem; Cerebrovascular Circulation; Diagnosis, Differential; Electroencephalography; Humans
PubMed: 30209020
DOI: 10.1016/j.clinph.2018.08.009 -
Bundesgesundheitsblatt,... Dec 2020In academic and public debate, the meaning of irreversible loss of brain function as a reliable sign of death (brain death criterion) is repeatedly challenged. In the... (Review)
Review
In academic and public debate, the meaning of irreversible loss of brain function as a reliable sign of death (brain death criterion) is repeatedly challenged. In the present article, six prototypical theses against the brain death criterion are discussed: 1) the nonsuperiority of brain versus other organs, 2) the unreliability of brain death diagnostics, 3) the preserved perception of pain in brain death, 4) the (spontaneous) sexual maturation and preserved reproductive function in brain death, 5) the symmetry of brain death and embryonic stage, and 6) the equalization of an artificially respired brain-dead body and a living human being.None of these theses withstand critical analysis. In Germany, the whole-brain death criterion is applied. Brain death involves the complete loss of all sensation, consciousness, as well as facial, ocular, lingual and pharyngeal motor, voluntary motor, and sexual function (functional "decapitation"). Other organs or their basic control can be replaced artificially, but not the brain. The brain, not the remaining body, is determinant of the human individual. The equalization of an artificially respired brain-dead organism, that may be considered as a living system from a natural philosophy point of view, and the organism of the same living human being leads, through reducibility of constituting organs, to an obvious absurdity. The irreversible loss of brain function results inevitably in cardiac arrest, spontaneously within minutes, with intensive care usually within days. In the embryo/fetus, malformation of the complete brain also results in (prenatal) death. The statutory guideline of the German Medical Association for the determination of brain death has, by comparison, high diagnostic reliability; no confirmed misdiagnoses have occurred.
Topics: Brain Death; Critical Care; Death; Germany; Humans; Reproducibility of Results; Tissue and Organ Procurement
PubMed: 33180159
DOI: 10.1007/s00103-020-03245-1 -
Anaesthesia May 2019
Topics: Brain Death; Canada; Critical Care; Humans; Professional Practice; Terminology as Topic; United Kingdom; United States
PubMed: 30671940
DOI: 10.1111/anae.14568 -
Clinics (Sao Paulo, Brazil) 2023Clinical reports associate kidneys from female donors with worse prognostic in male recipients. Brain Death (BD) produces immunological and hemodynamic disorders that...
BACKGROUND
Clinical reports associate kidneys from female donors with worse prognostic in male recipients. Brain Death (BD) produces immunological and hemodynamic disorders that affect organ viability. Following BD, female rats are associated with increased renal inflammation interrelated with female sex hormone reduction. Here, the aim was to investigate the effects of sex on BD-induced Acute Kidney Injury (AKI) using an Isolated Perfused rat Kidney (IPK) model.
METHODS
Wistar rats, females, and males (8 weeks old), were maintained for 4h after BD. A left nephrectomy was performed and the kidney was preserved in a cold saline solution (30 min). IPK was performed under normothermic temperature (37°C) for 90 min using WME as perfusion solution. AKI was assessed by morphological analyses, staining of complement system components and inflammatory cell markers, perfusion flow, and creatinine clearance.
RESULTS
BD-male kidneys had decreased perfusion flow on IPK, a phenomenon that was not observed in the kidneys of BD-females (p < 0.0001). BD-male kidneys presented greater proximal (p = 0.0311) and distal tubule (p = 0.0029) necrosis. However, BD-female kidneys presented higher expression of eNOS (p = 0.0060) and greater upregulation of inflammatory mediators, iNOS (p = 0.0051), and Caspase-3 (p = 0.0099). In addition, both sexes had increased complement system formation (C5b-9) (p=0.0005), glomerular edema (p = 0.0003), and nNOS (p = 0.0051).
CONCLUSION
The present data revealed an important sex difference in renal perfusion in the IPK model, evidenced by a pronounced reduction in perfusate flow and low eNOS expression in the BD-male group. Nonetheless, the upregulation of genes related to the proinflammatory cascade suggests a progressive inflammatory process in BD-female kidneys.
Topics: Rats; Female; Male; Animals; Brain Death; Rats, Wistar; Kidney; Kidney Transplantation; Acute Kidney Injury; Perfusion
PubMed: 37257364
DOI: 10.1016/j.clinsp.2023.100222 -
The Western Journal of Medicine Apr 1984
Topics: Brain Death; Ethics, Medical; Humans
PubMed: 6719913
DOI: No ID Found -
Minerva Anestesiologica Jul 2019Death by neurologic criteria is an irreversible sequence of events culminating in permanent cessation of cerebral functions. In this context, there are no responses... (Review)
Review
Death by neurologic criteria is an irreversible sequence of events culminating in permanent cessation of cerebral functions. In this context, there are no responses arising from the brain, no cranial nerve reflexes nor motor responses to pain stimuli, and no respiratory drive. The diagnosis of death by neurologic criteria implies that there is clinical evidence of the complete and irreversible cessation of brainstem and cerebral functions. The diagnosis, confirmation, and certification of death are core skills for medical practitioners. The aim of this review is to discuss the pathophysiology and definition of death by neurological criteria, describing the clinical assessment, and the use of ancillary tests for the diagnosis of brainstem death.
Topics: Apnea; Brain; Brain Death; Brain Injuries; Brain Stem; Coma; Death; Diabetes Insipidus; Diagnosis, Differential; Disease Progression; Electrodiagnosis; Heart Arrest; Hemodynamics; Hypothalamo-Hypophyseal System; Neuroimaging; Neurologic Examination; Reflex, Abnormal; Reflex, Pupillary; Sympathetic Nervous System
PubMed: 30871303
DOI: 10.23736/S0375-9393.19.13338-X -
Anaesthesia Sep 2020Organ donation after brain death remains the deceased organ donation pathway of choice. In the UK, the current identification and referral rate for potential donation... (Review)
Review
Organ donation after brain death remains the deceased organ donation pathway of choice. In the UK, the current identification and referral rate for potential donation after brain death donors is 99%, the testing rate for determining death using neurological criteria is 86% and the approach to families for donation is 91%. Increasing donation after brain death donation will primarily require a large increase in the current consent rate of 72% to one matching the consent rate of 80-90% achieved in other European countries. Implementing the use of evidence-based donor optimisation bundles may increase the number of organs available for transplantation. Alternatively, the UK will need to look at more challenging ways of increasing the pool of potential donors after brain death. The first would be to delay the withdrawal of life-sustaining treatment in patients with devastating brain injury to allow progression to brain death after the family have given consent to organ donation and with their consent to this delay. Even more challenging would be the consideration of re-introducing intensive care to facilitate organ donation programmes that have been so successful at increasing the number of organ donors elsewhere.
Topics: Brain Death; Humans; Organ Transplantation; Tissue and Organ Procurement; United Kingdom
PubMed: 32430995
DOI: 10.1111/anae.15038 -
Journal of Medical Ethics Apr 2002Refusal of organ donation is common, and becoming more frequent. In Australia refusal by families occurred in 56% of cases in 1995 in New South Wales, and had risen to... (Review)
Review
Refusal of organ donation is common, and becoming more frequent. In Australia refusal by families occurred in 56% of cases in 1995 in New South Wales, and had risen to 82% in 1999, becoming the most important determinant of the country's very low organ donation rate (8.9/million in 1999). Leading causes of refusal, identified in many studies, include the lack of understanding by families of brain death and its implications, and subsequent reluctance to relegate the body to purely instrumental status. It is an interesting paradox that surveys of the public continue to show considerable support for organ donation programmes--in theory we will, in practice we won't (and don't). In this paper we propose that the Australian community may, for good reason, distrust the concept of and criteria for "whole brain death", and the equation of this new concept with death of the human being. We suggest that irreversible loss of circulation should be reinstated as the major defining characteristic of death, but that brain-dead, heart-beating entities remain suitable organ donors despite being alive by this criterion. This presents a major challenge to the "dead donor rule", and would require review of current transplantation legislation. Brain dead entities are suitable donors because of irreversible loss of personhood, accurately and robustly defined by the current brain stem criteria. Even the dead are not terminally ill any more.
Topics: Attitude to Death; Australia; Brain Death; Family; Health Knowledge, Attitudes, Practice; Humans; Organ Transplantation; Tissue Donors
PubMed: 11934936
DOI: 10.1136/jme.28.2.89 -
AJNR. American Journal of Neuroradiology Mar 2016Transcranial Doppler is a useful ancillary test for brain death confirmation because it is safe, noninvasive, and done at the bedside. Transcranial Doppler confirms... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND AND PURPOSE
Transcranial Doppler is a useful ancillary test for brain death confirmation because it is safe, noninvasive, and done at the bedside. Transcranial Doppler confirms brain death by evaluating cerebral circulatory arrest. Case series studies have generally reported good correlations between transcranial Doppler confirmation of cerebral circulatory arrest and clinical confirmation of brain death. The purpose of this study is to evaluate the utility of transcranial Doppler as an ancillary test in brain death confirmation.
MATERIALS AND METHODS
We conducted a systematic review of the literature and a diagnostic test accuracy meta-analysis to compare the sensitivity and specificity of transcranial Doppler confirmation of cerebral circulatory arrest, by using clinical confirmation of brain death as the criterion standard.
RESULTS
We identified 22 eligible studies (1671 patients total), dating from 1987 to 2014. Pooled sensitivity and specificity estimates from 12 study protocols that reported data for the calculation of both values were 0.90 (95% CI, 0.87-0.92) and 0.98 (95% CI, 0.96-0.99), respectively. Between-study differences in the diagnostic performance of transcranial Doppler were found for both sensitivity (I(2) = 76%; P < .001) and specificity (I(2) = 74.3%; P < .001). The threshold effect was not significant (Spearman r = -0.173; P = .612). The area under the curve with the corresponding standard error (SE) was 0.964 ± 0.018, while index Q test ± SE was estimated at 0.910 ± 0.028.
CONCLUSIONS
The results of this meta-analysis suggest that transcranial Doppler is a highly accurate ancillary test for brain death confirmation. However, transcranial Doppler evaluates cerebral circulatory arrest rather than brain stem function, and this limitation needs to be taken into account when interpreting the results of this meta-analysis.
Topics: Brain Death; Female; Humans; Sensitivity and Specificity; Ultrasonography, Doppler, Transcranial
PubMed: 26514611
DOI: 10.3174/ajnr.A4548