CAEP, CCCS, and CNSF Position Statement – Management of devastating brain injuries in the emergency department: Enhancing neuroprognostication and maintaining the opportunity for organ and tissue donation

Healey, Andrew; Leeies, Murdoch; Hrymak, Carmen; Chochinov, Alecs; Grunau, Brian; Paunovic, Bojan; Teitelbaum, Jeanne; Wilson, Lindsay; Shemie, Sam D.

doi:10.1017/cem.2020.357

Cited by 10 publications

(3 citation statements)

References 7 publications

(14 reference statements)

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“…12 These pathways are now recommended practice by professional bodies in the United Kingdom, 13 the United States 14 and Canada. 15 In patients with DBI admitted to our ICU in the first 3 years after the implementation of a DBI pathway, death was confirmed using neurological criteria in 31% of patients and followed the WLST in a further 51%. 7 This was the reason for selecting the patients undergoing WLST from our DBI pathway as a suitable group to compare to those confirmed DNC.…”

Section: Discussionmentioning

confidence: 96%

Brain herniation on computed tomography is a poor predictor of whether patients with a devastating brain injury can be confirmed dead using neurological criteria

Ray

Manara

Mortimer

et al. 2021

Journal of the Intensive Care Society

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Background It is unclear if the presence of compartmental brain herniation on neuroimaging should be a prerequisite to the clinical confirmation of death using neurological criteria. The World Brain Death Project has posed this as a research question. Methods The final computed tomography of the head scans before death of 164 consecutive patients confirmed dead using neurological criteria and 41 patients with devastating brain injury who died following withdrawal of life sustaining treatment were assessed by a neuroradiologist to compare the incidence of herniation and other features of cerebral swelling. Results There was no difference in the incidence of herniation in patients confirmed dead using neurological criteria and those with devastating brain injury (79% vs 76%, OR 1.23 95%, CI 0.56–2.67). The sensitivity and specificity of brain herniation in patients confirmed dead using neurological criteria was 79% and 24%, respectively. The positive and negative predictive value was 81% and 23%, respectively. The most sensitive computed tomography of the head findings for death using neurological criteria were diffuse sulcal effacement (93%) and basal cistern effacement (91%) and the most specific finding was loss of grey-white differentiation (80%). The only features with a significantly different incidence between the death using neurological criteria group and the devastating brain injury group were loss of grey-white differentiation (46 vs 20%, OR 3.56, 95% CI 1.55–8.17) and presence of contralateral ventricular dilatation (24 vs 44%, OR 0.41, 95% CI 0.20–0.84). Conclusions Neuroimaging is essential in establishing the cause of death using neurological criteria. However, the presence of brain herniation or other signs of cerebral swelling are poor predictors of whether a patient will satisfy the clinical criteria for death using neurological criteria or not. The decision to test must remain a clinical one.

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Section: Discussionmentioning

confidence: 96%

Brain herniation on computed tomography is a poor predictor of whether patients with a devastating brain injury can be confirmed dead using neurological criteria

Ray

Manara

Mortimer

et al. 2021

Journal of the Intensive Care Society

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“…On the other end of this spectrum, delivering maximal therapy targeting survival to patients with devastating spontaneous intracranial hemorrhages may prevent in-hospital deaths in 65% of cases, although enduring such a journey may be regarded as a torment if nearly all survivors would ultimately die in the subsequent 12 months or be rendered severely disabled 2 . This is so important that multiple societies have put forth position statements defining futile and potentially inappropriate interventions for patients who are critically ill, 3 providing guidance on how to manage intractable treatment conflicts 4 and centering on the outcome prediction and psychosocial and ethical management of devastating brain injuries 5-7 …”

Section: Impact Of Neuroprognosticationmentioning

confidence: 99%

Neurologic Outcome Prediction in the Intensive Care Unit

Maciel¹

2021

CONTINUUM: Lifelong Learning in Neurology

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PURPOSE OF REVIEW The burden of severe and disabling neurologic injury on survivors, families, and society can be profound. Neurologic outcome prediction, or neuroprognostication, is a complex undertaking with many important ramifications. It allows patients with good prognoses to be supported aggressively, survive, and recover; conversely, it avoids inappropriate prolonged and costly care in those with devastating injuries. RECENT FINDINGS Striving to maintain a high prediction performance during prognostic assessments encompasses acknowledging the shortcomings of this task and the challenges created by advances in medicine, which constantly shift the natural history of neurologic conditions. Embracing the unknowns of outcome prediction and the boundaries of knowledge surrounding neurologic recovery and plasticity is a necessary step toward refining neuroprognostication practices and improving the accuracy of prognostic impressions. The pillars of modern neuroprognostication include comprehensive characterization of neurologic injury burden (primary and secondary injuries), gauging cerebral resilience and estimated neurologic reserve, and tying it all together with individual values surrounding the acceptable extent of disability and the difficulties of an arduous convalescence journey. SUMMARY Comprehensive multimodal frameworks of neuroprognostication using different prognostic tools to portray the burden of neurologic injury coupled with the characterization of individual values and the degree of cerebral reserve and resilience are the cornerstone of modern outcome prediction.

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“…Other countries-e.g. Australia [6], Canada [7], France [8], the Netherlands [9], the United Kingdom [10] and the United States [11]-have implemented similar policies, based on delaying WLST, to preserve the option of progressing to DNC. However, Spanish legislation and the ICOD national protocol permit the initiation of intensive measures, whilst several other national systems only accept their continuation [12][13][14].…”

Section: Introductionmentioning

confidence: 99%

Assessing Outcomes of Patients Subject to Intensive Care to Facilitate Organ Donation: A Spanish Multicenter Prospective Study

Pérez-Blanco,

Acevedo,

Padilla

et al. 2024

Transpl Int

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Intensive Care to facilitate Organ Donation (ICOD) consists of the initiation or continuation of intensive care measures in patients with a devastating brain injury (DBI) in whom curative treatment is deemed futile and death by neurological criteria (DNC) is foreseen, to incorporate organ donation into their end-of-life plans. In this study we evaluate the outcomes of patients subject to ICOD and identify radiological and clinical factors associated with progression to DNC. In this first prospective multicenter study we tested by multivariate regression the association of clinical and radiological severity features with progression to DNC. Of the 194 patients, 144 (74.2%) patients fulfilled DNC after a median of 25 h (95% IQR: 17–44) from ICOD onset. Two patients (1%) shifted from ICOD to curative treatment, both were alive at discharge. Factors associated with progression to DNC included: age below 70 years, clinical score consistent with severe brain injury, instability, intracranial hemorrhage, midline shift ≥5 mm and certain types of brain herniation. Overall 151 (77.8%) patients progressed to organ donation. Based on these results, we conclude that ICOD is a beneficial and efficient practice that can contribute to the pool of deceased donors.

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CAEP, CCCS, and CNSF Position Statement – Management of devastating brain injuries in the emergency department: Enhancing neuroprognostication and maintaining the opportunity for organ and tissue donation

Abstract: The primary purpose of this statement is to improve neuroprognostication after devastating brain injury (DBI), with a secondary benefit of potential organ and tissue donation.

Cited by 10 publications

References 7 publications

Brain herniation on computed tomography is a poor predictor of whether patients with a devastating brain injury can be confirmed dead using neurological criteria

Brain herniation on computed tomography is a poor predictor of whether patients with a devastating brain injury can be confirmed dead using neurological criteria

Neurologic Outcome Prediction in the Intensive Care Unit

Assessing Outcomes of Patients Subject to Intensive Care to Facilitate Organ Donation: A Spanish Multicenter Prospective Study

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