Śmierć mózgowa – Zapobieganie i profilaktyka

Śmierć mózgowa
Zapobieganie i profilaktyka

Śmierć mózgowa definiowana jest jako całkowite i nieodwracalne ustanie wszystkich funkcji mózgu, w tym pnia mózgu, co odróżnia ją od śpiączki czy stanu wegetatywnego. Zgodnie z Jednolitą Ustawą o Określaniu Śmierci (1981) oraz aktualizowanymi wytycznymi Amerykańskiej Akademii Neurologii (1995, 2010, 2023), śmierć mózgowa jest prawnie i medycznie uznawana za śmierć osoby. Diagnostyka opiera się na badaniu neurologicznym i teście bezdechu (u dorosłych jedno badanie i test, u dzieci dwa badania i testy oddzielone 12-godzinnym interwałem). Nowe wytyczne integrują kryteria dla dorosłych i dzieci oraz uwzględniają szczególne sytuacje, takie jak ciąża czy wsparcie na ECMO. Zgoda pacjenta lub rodziny nie jest wymagana do przeprowadzenia oceny śmierci mózgowej, gdyż stan ten oznacza śmierć biologiczną. Kluczowe jest szybkie rozpoznanie i właściwe zarządzanie potencjalnym dawcą narządów, w tym stosowanie terapii hormonalnych (tyroksyna, T3, kortykosteroidy, insulina) oraz profilaktyki infekcji i zakrzepicy, aby utrzymać narządy w optymalnym stanie do transplantacji.

Zrozumienie śmierci mózgowej

Śmierć mózgowa to stan definiowany jako całkowite i nieodwracalne ustanie wszystkich funkcji mózgu, włącznie z pniem mózgu. Jest to stan końcowy, odmienny od śpiączki czy stanu wegetatywnego. W przeciwieństwie do tych stanów, które charakteryzują się zachowaniem pewnych funkcji mózgu, śmierć mózgowa jest stanem nieodwracalnym i zgodnie z Jednolitą Ustawą o Określaniu Śmierci z 1981 roku (Uniform Determination of Death Act), jest prawnie i medycznie uznawana za śmierć osoby¹²³.

Amerykańska Akademia Neurologii opublikowała kryteria określania śmierci mózgowej, które zostały wydane w 1995 roku i zaktualizowane w 2010 roku, stanowiące obecny standard medyczno-prawny⁴. W 2023 roku opublikowano najnowsze wytyczne dotyczące śmierci mózgowej, które wskazują, że zgoda nie jest wymagana do oceny śmierci, podobnie jak nie poszukuje się zgody podczas osłuchiwania czyjegoś serca i płuc w celu zdiagnozowania śmierci⁵.

Profilaktyka śmierci mózgowej

Profilaktyka śmierci mózgowej koncentruje się głównie na zapobieganiu i leczeniu stanów, które mogą prowadzić do tego nieodwracalnego stanu. Chociaż w wielu przypadkach nie można zapobiec poważnym chorobom lub urazom prowadzącym do śmierci mózgowej, natychmiastowa opieka medyczna może w niektórych przypadkach zapobiec śmierci mózgowej, jeśli pacjent cierpi na poważną chorobę lub uraz wpływający na mózg⁶⁷.

Szybka interwencja medyczna

Kluczowym elementem profilaktyki jest szybka interwencja medyczna w przypadku urazów głowy, udarów i infekcji wpływających na mózg. Badania wykazały, że opóźnienie decyzji o wycofaniu podtrzymywania życia może być korzystne dla niektórych pacjentów z ciężkimi urazami mózgu. Ważne jest, aby podkreślić, że żaden z pacjentów, którzy zmarli w badaniach, nie został uznany za zmarłego z powodu śmierci mózgowej, dlatego wyniki nie mają zastosowania do śmierci mózgowej⁸.

Standardy diagnostyczne

Dokładne diagnozowanie śmierci mózgowej ma kluczowe znaczenie dla zapobiegania fałszywym diagnozom. W badaniu lekarzy wykonujących badania śmierci mózgowej tylko 25% zgłosiło przestrzeganie aktualnych wytycznych praktyki. Polityki szpitalne w Stanach Zjednoczonych dotyczące określania śmierci mózgowej są bardzo zróżnicowane i często niezgodne z aktualnymi wytycznymi praktyki⁹.

Bez sieci zabezpieczeń w postaci znormalizowanych wytycznych fałszywe diagnozy śmierci mózgowej są bardziej prawdopodobne. Zamiast podejścia odgórnego, bardziej niezawodna metoda zapewnienia właściwej diagnozy śmierci mózgowej może pochodzić z wczesnej edukacji przyszłych lekarzy i kształcenia ustawicznego lekarzy praktyków¹⁰.

Edukacja medyczna

Edukacja medyczna na poziomie licencjackim i podyplomowym, a także kształcenie ustawiczne lekarzy, powinna obejmować instruktaż na temat zaburzeń świadomości – śmierci mózgowej, śpiączki, stanu wegetatywnego i stanu minimalnej świadomości. Towarzystwo Opieki Neurokrytycznej (Neurocritical Care Society) oferuje kurs określania śmierci mózgowej w celu standaryzacji diagnozy śmierci mózgowej¹¹.

Dyrektywy zaawansowane i planowanie opieki

Chociaż możemy nie być w stanie zapobiec problemom, które mogą spowodować śmierć mózgową, możemy zaplanować, co chcemy, aby się wydarzyło, jeśli zachorujemy lub doznamy urazu i nastąpi śmierć mózgowa. Można to zrobić, wypełniając dyrektywę zaawansowaną. Jest to dokument prawny, który określa rodzaj opieki, jakiej chcemy w przypadku, gdy nie możemy mówić we własnym imieniu. Na przykład, dyrektywa zaawansowana może stwierdzać, że chcemy przekazać nasze narządy po śmierci, w tym po śmierci mózgowej¹².

Opieka nad potencjalnym dawcą narządów po śmierci mózgowej

Odpowiednie zarządzanie medyczne potencjalnym dawcą narządów jest bardzo ważną kwestią, wymagającą podejścia multidyscyplinarnego zespołu dla udanego przeszczepu narządu. Dla przeżycia przeszczepu po pobraniu, wszystkie dostępne narządy u dawcy muszą być utrzymywane w normalnym stanie fizjologicznym do czasu pobrania narządów¹³.

Rola intensywistów

Intensywiści odgrywają kluczową rolę w zarządzaniu potencjalnymi dawcami narządów poprzez identyfikację potencjalnych dawców, deklarację śmierci mózgowej i właściwą opiekę medyczną, które mogą poprawić wskaźniki przeżycia przeszczepu¹⁴.

Zarządzanie dawcą narządów powinno rozpocząć się natychmiast po wystąpieniu śmierci mózgowej i powinno kontynuować po uzyskaniu zgody rodziny na dawstwo. Dane pokazują, że progresja od śmierci mózgowej do śmierci somatycznej skutkuje utratą 10% do 20% potencjalnych tkanek dawcy, dlatego terminowe leczenie dawcy jest kluczowe¹⁵.

Protokół postępowania

Ścisła intensywna opieka ochronna narządów potencjalnego dawcy narządów jest pierwszym krokiem w kierunku udanego przeszczepu i leczenia przyszłego biorcy narządu. Protokół zaproponowany i dostarczony w liście kontrolnej może pomóc intensywistom zarządzać dawcami narządów po śmierci mózgowej w celu promowania udanego dawstwa narządów i tkanek¹⁶.

Leczenie hormonalne

Zaleca się stosowanie terapii hormonalnych, takich jak tyroksyna, trójjodotyronina (T3), kortykosteroidy i insulina, w celu poprawy stabilności sercowo-naczyniowej. Obecnie takie terapie są uważane za eksperymentalne. Badania dotyczące poziomów ACTH i kortyzolu są niejednoznaczne. Nie jest jasne, czy steroidy przyczyniają się do znaczącej poprawy w zachowaniu narządów¹⁷.

Steroidy pomagają złagodzić odpowiedź zapalną, która następuje po śmierci mózgowej, poprzez hamowanie cytokin i stabilizację błon komórkowych. Wykazano, że steroidy zmniejszają wczesną niewydolność przeszczepu i odrzucenie po transplantacji. SCCM i UNOS zalecają wysokie dawki metyloprednizolonu dla dawców kardiotorakochirurgicznych. Można również stosować hydrokortyzon; w porównaniu z metyloprednizolonem w jednym badaniu, dawcy, którzy otrzymali hydrokortyzon, mieli zmniejszone zapotrzebowanie na insulinę i lepszą kontrolę glikemii¹⁸.

Profilaktyka antybiotykowa

Profilaktyczne antybiotyki są wskazane tylko bezpośrednio przed pobraniem narządów¹⁹. Potencjalny dawca powinien być oceniany klinicznie pod kątem infekcji, a testy przesiewowe na określone infekcje są istotnym elementem zarządzania dawcą²⁰.

Heparyna

Heparyna dożylna jest powszechnie podawana po śmierci mózgowej. Podawanie heparyny przed zaklemowaniem aorty wykazało również pomoc w zapobieganiu powikłaniom zakrzepowym. Dowody na profilaktykę zakrzepicy żył głębokich heparyną są ograniczone. Jednak duże obciążenie zatorem płucnym jest często spotykane u pacjentów podczas pobierania narządów, więc kontynuacja profilaktyki zakrzepicy żył głębokich jest uzasadniona²¹.

Zapobieganie hipotermii

Znacznie łatwiej jest zapobiegać hipotermii niż leczyć ją u pacjenta z śmiercią mózgową. Ważne jest, aby zapobiegać rozwojowi hipotermii²².

Optymalizacja funkcji płuc

Wynik dla biorców płuc, szczególnie we wczesnym okresie po przeszczepie, zależy od stopnia dysfunkcji płuc u dawcy. Ważne jest, aby zapewnić, że wszystkie aspekty funkcji płuc dawcy są jak najlepsze²³.

Z tych powodów zaleca się, aby efekty nadaktywności współczulnej były łagodzone przez leczenie krótko działającą beta-blokadą²⁴.

Stabilność dawcy

Anestezjolog powinien dążyć do utrzymania stabilności u dawcy do momentu zaklemowania aorty. Ma to na celu zapewnienie, że narządy przeznaczone do przeszczepu są w optymalnym stanie podczas usuwania i będą dobrze funkcjonować u biorców po transplantacji²⁵.

Bardzo ważne jest, aby wcześnie rozpoznać i leczyć moczówkę prostą (DI). Hiperosmolalność dawcy była związana z upośledzeniem funkcji narządów u niektórych biorców wątroby²⁶.

Komunikacja z rodzinami

Koncepcja śmierci mózgowej jest trudna do zrozumienia dla wielu rodzin. Jednak ważne jest, aby rodziny zrozumiały, że ich bliski nie żyje, zanim rozpoczną się rozmowy o dawstwie narządów, oczu i tkanek²⁷.

Po deklaracji śmierci mózgowej należy odnieść się do niej jako do śmierci i poinformować rodzinę o czasie zgonu. Pacjent nie jest w śpiączce. Należy odnosić się do respiratora i leków dożylnych jako do sztucznego lub mechanicznego wsparcia²⁸.

Ponadto należy używać słowa „śmierć”. Należy unikać powszechnie używanych eufemizmów (np. odszedł, zniknął, wygasł) w rozmowie o śmierci²⁹.

Wytyczne dla personelu medycznego

W 2023 roku opublikowano nowe wytyczne dotyczące śmierci mózgowej, które integrują wytyczne dla dorosłych i dzieci, aby zapewnić kompleksowy, praktyczny sposób oceny pacjentów z katastrofalnymi obrażeniami mózgu w celu ustalenia, czy spełniają kryteria śmierci mózgowej³⁰.

Jedną z nowości w tych wytycznych jest połączenie kryteriów dla dorosłych i dzieci w jednym dokumencie. Dodano również zalecenia dotyczące szczególnych sytuacji, na przykład oceny kobiet w ciąży pod kątem śmierci mózgowej, wykonywania testu bezdechu i pozostałej oceny u pacjentów wspieranych na VA i VV ECMO³¹.

Wytyczne zapewniają większą jasność w zakresie przeprowadzania badania neurologicznego. W pediatrii wymagane są dwa badania neurologiczne i dwa testy bezdechu, które są oddzielone interwałem 12 godzin. U dorosłych wymagane jest jedno badanie i jeden test bezdechu³².

To, co panel zdecydował i co zostało zapisane w wytycznych, to obowiązek informowania rodzin o zamiarze przeprowadzenia oceny śmierci mózgowej. Jednak nie trzeba uzyskać zgody na przeprowadzenie oceny, ponieważ lekarze mają obowiązek wiedzieć, czy pacjent, którym się opiekują, jest żywy czy martwy³³.

Jeśli planuje się wykorzystać badania pomocnicze, przed przeprowadzeniem tych badań należy potwierdzić, że całe badanie neurologiczne, które można przeprowadzić, zostało wykonane, a wszystkie wyniki są zgodne ze śmiercią mózgową³⁴.

Wyzwania i problemy etyczne

Pomimo jasnego rządowego zarządzenia, szpitale coraz częściej utrzymują pacjentów z śmiercią mózgową na respiratorach w oddziałach intensywnej terapii dłużej niż to konieczne, tworząc duże obciążenie finansowe i emocjonalne dla rodzin³⁵.

Zarządzenie rządowe z 2020 roku nakazało, aby śmierć mózgowa była deklarowana, jeśli spełnione są określone kryteria, oraz że wszystkie leczenia, w tym podtrzymywanie życia, muszą zostać przerwane po potwierdzeniu śmierci mózgowej. Jednak daremna opieka nadal trwa³⁶.

Problemy etyczne związane z nieadekwatnym zarządzaniem pacjentami ze śmiercią mózgową obejmują: niewłaściwe traktowanie zmarłych, pozbawienie godności, dawanie fałszywej nadziei skutkującej nieufnością, przedłużanie procesu żałoby, podważanie zawodowej odpowiedzialności lekarza, szkoda wynikająca z wynegocjowanego standardu określania śmierci³⁷.

Obecna praktyka niewymagania zgody na badanie śmierci mózgowej opiera się na pojęciu, że pacjent już nie żyje; zgoda na deklarację nie zmienia tego faktu, a zmarli nie mają prawa do autonomii³⁸.

Istnieją argumenty etyczne przemawiające za tym, że świadoma zgoda powinna być przeprowadzona przed określeniem śmierci mózgowej, umożliwiając sprzeciw wobec niej we wszystkich 50 stanach USA³⁹.

Wnioski

Śmierć mózgowa to stan końcowy, który jest prawnie i medycznie uznawany za śmierć osoby. Chociaż w wielu przypadkach nie można zapobiec poważnym chorobom lub urazom prowadzącym do śmierci mózgowej, natychmiastowa opieka medyczna i dokładna diagnostyka mogą w niektórych przypadkach przyczynić się do zmniejszenia ryzyka wystąpienia tego stanu⁴⁰⁴¹.

Edukacja medyczna, standardy diagnostyczne i odpowiednie zarządzanie potencjalnymi dawcami narządów są kluczowe dla zapewnienia właściwej opieki nad pacjentami i ich rodzinami. Jasna komunikacja z rodzinami, przestrzeganie wytycznych i etyczne podejście do deklaracji śmierci mózgowej są niezbędne dla zapewnienia godności i szacunku dla zmarłych oraz ich bliskich⁴²⁴³⁴⁴.

Kolejne rozdziały

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Materiały źródłowe

#1 Understanding and Coping With Brain Death | University of Utah Health
https://healthcare.utah.edu/healthfeed/2014/01/understanding-and-coping-brain-death
According to the Uniform Determination of Death Act of 1981, an individual is declared dead when he or she „has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem.” […] The American Academy of Neurology has published criteria for determining brain death that were released in 1995 and updated in 2010 that are the current medico-legal standard. […] Once brain death has been confirmed by these criteria, the idea that the patient is on life support is a misnomer simply because there is no life left to support. The idea that machines and mechanical body support can somehow bring a person back to life when they are brain dead has lead to major misconceptions that lead to false hope, and prolongs the end-of-life process.
#2
https://npistanbul.com/en/what-is-brain-death
Brain death is different from coma or vegetative state; it is considered a definitive state of death. […] Brain death, an ideal condition for organ donation, offers an opportunity for life-saving donations. However, in Turkey, organ donation requires family consent after the diagnosis of brain death. Raising awareness about the importance of brain death and organ donation contributes to saving more lives. […] Lack of understanding of the differences between brain death and coma or vegetative state may increase hesitation about organ donation. Brain death is irreversible, whereas in coma and vegetative state, some brain functions may still be active. Therefore, it is important that health professionals and public authorities provide accurate information on this issue through awareness campaigns.
#3 The Facts: Brain death, circulatory death and comas – Gift of Life Michigan
https://giftoflifemichigan.org/blog/the-facts-brain-death-circulatory-death-and-comas
Brain death is legally and medically recognized as death. […] Brain death is determined by the patients medical team at the hospital. […] Organ donation does not take place until brain death is declared by the patients medical team at the hospital and a time of death is noted. […] If the patient is a registered organ donor, their body is kept on a ventilator until the organ recovery can take place. The ventilator keeps blood and oxygen flowing to their organs. Brain death is not reversible.
#4 Understanding and Coping With Brain Death | University of Utah Health
https://healthcare.utah.edu/healthfeed/2014/01/understanding-and-coping-brain-death
According to the Uniform Determination of Death Act of 1981, an individual is declared dead when he or she „has sustained either (1) irreversible cessation of circulatory and respiratory functions, or (2) irreversible cessation of all functions of the entire brain, including the brain stem.” […] The American Academy of Neurology has published criteria for determining brain death that were released in 1995 and updated in 2010 that are the current medico-legal standard. […] Once brain death has been confirmed by these criteria, the idea that the patient is on life support is a misnomer simply because there is no life left to support. The idea that machines and mechanical body support can somehow bring a person back to life when they are brain dead has lead to major misconceptions that lead to false hope, and prolongs the end-of-life process.
#5 Leading Insights
https://currents.neurocriticalcare.org/Leading-Insights/Article/consent-for-brain-death-determination-the-ends-justify-the-means-or-it-does-not
Ms. D.R. was a 60-year-old woman who presented to the Neurointensive Care Unit with a catastrophic non-traumatic intracerebral hemorrhage. […] Family was informed that her neurologic exam was consistent with progression to brain death and that the primary team would proceed with clinical bedside testing and an apnea test to confirm the diagnosis of brain death, as per hospital protocols. […] The newest 2023 brain death guidelines published by the AAN state that consent is not required to evaluate for death, in the same way that consent is not sought when auscultating someones heart and lungs in order to diagnose death. […] Instead of consent, current guidelines stipulate that health care providers are required to make reasonable efforts to inform the patients family/surrogates that there is a suspicion of brain death, and that testing will be performed to confirm the diagnosis.
#6 Brain Death: What It Is, Stages & Criteria
https://my.clevelandclinic.org/health/diseases/brain-death
No, you cant because you may not be able to prevent any of the serious illnesses or injuries that lead to brain death. […] In some cases, immediate medical care may keep brain death from happening if you have a serious illness or an injury that affects your brain. […] But once your brain stops working, there isnt a treatment that can prevent brain death from happening. […] While you may not be able to prevent issues that can cause brain death, you can plan for what you want to happen if youre sick or injured and you have brain death. […] You do that by completing an advance directive. This is a legal document that outlines the kind of care you want in the event you cant speak for yourself. For example, your advance directive could state you want to donate your organs after death, including brain death.
#7 Brain Death: Causes, Symptoms and Treatment
https://www.medicoverhospitals.in/diseases/brain-death/
Preventing brain death involves addressing its underlying causes: […] Brain death prevention is primarily through prompt treatment of severe head injuries, strokes, and infections that affect the brain.
#8 Study Reveals Patients with Brain Injuries Who Died After Withdrawal of Life Support May Have Recovered | Mass General Brigham
https://www.massgeneralbrigham.org/en/about/newsroom/press-releases/study-reveals-patients-with-brain-injuries-who-died-after-withdrawal-of-life-support-may-have-recovered
Severe traumatic brain injury (TBI) is a major cause of hospitalizations and deaths around the world, affecting more than five million people each year. […] These findings suggest that delaying decisions on withdrawing life support might be beneficial for some patients. […] Importantly, none of the patients who died in this study were pronounced brain dead, and thus the results are not applicable to brain death. […] Our findings support a more cautious approach to making early decisions on withdrawal of life support, said corresponding author Yelena Bodien, PhD, of the Department of Neurologys Center for Neurotechnology and Neurorecovery at Massachusetts General Hospital and of the Spaulding-Harvard Traumatic Brain Injury Model Systems. Delaying decisions regarding life support may be warranted to better identify patients whose condition may improve.
#9 How Educators Can Help Prevent False Brain Death Diagnoses | Journal of Ethics | American Medical Association
https://journalofethics.ama-assn.org/article/how-educators-can-help-prevent-false-brain-death-diagnoses/2020-12
It is critical for brain death diagnosis to be accurate. […] Using a case-based approach, this article demonstrates what tends to go wrong in erroneous brain death diagnoses and clarifies what physicians and educators should do to help avoid these errors. […] In a survey of physicians who perform brain death examinations, only 25% reported compliance with current practice guidelines. […] Although the diagnosis of brain death and prognosis of neurological recovery after brain injury are well-defined in the literature, hospital policies in the United States for the determination of brain death are highly variable and often not in line with current practice guidelines. […] Without the safety net of standardized guidelines, false diagnoses of brain death are more likely to occur. […] Rather than a top-down approach, a more fail-safe method of ensuring appropriate diagnoses of brain death might well come from early education of future physicians and continuing education of physicians in practice.
#10 How Educators Can Help Prevent False Brain Death Diagnoses | Journal of Ethics | American Medical Association
https://journalofethics.ama-assn.org/article/how-educators-can-help-prevent-false-brain-death-diagnoses/2020-12
It is critical for brain death diagnosis to be accurate. […] Using a case-based approach, this article demonstrates what tends to go wrong in erroneous brain death diagnoses and clarifies what physicians and educators should do to help avoid these errors. […] In a survey of physicians who perform brain death examinations, only 25% reported compliance with current practice guidelines. […] Although the diagnosis of brain death and prognosis of neurological recovery after brain injury are well-defined in the literature, hospital policies in the United States for the determination of brain death are highly variable and often not in line with current practice guidelines. […] Without the safety net of standardized guidelines, false diagnoses of brain death are more likely to occur. […] Rather than a top-down approach, a more fail-safe method of ensuring appropriate diagnoses of brain death might well come from early education of future physicians and continuing education of physicians in practice.
#11 How Educators Can Help Prevent False Brain Death Diagnoses | Journal of Ethics | American Medical Association
https://journalofethics.ama-assn.org/article/how-educators-can-help-prevent-false-brain-death-diagnoses/2020-12
Undergraduate and graduate medical education, as well as continuing medical education, should include instruction on the disorders of consciousnessâbrain death, coma, vegetative state, and minimally conscious state. […] The Neurocritical Care Society provides a brain death determination course to standardize brain death diagnosis.
#12 Brain Death: What It Is, Stages & Criteria
https://my.clevelandclinic.org/health/diseases/brain-death
No, you cant because you may not be able to prevent any of the serious illnesses or injuries that lead to brain death. […] In some cases, immediate medical care may keep brain death from happening if you have a serious illness or an injury that affects your brain. […] But once your brain stops working, there isnt a treatment that can prevent brain death from happening. […] While you may not be able to prevent issues that can cause brain death, you can plan for what you want to happen if youre sick or injured and you have brain death. […] You do that by completing an advance directive. This is a legal document that outlines the kind of care you want in the event you cant speak for yourself. For example, your advance directive could state you want to donate your organs after death, including brain death.
#13 Medical Management of Brain-Dead Organ Donors
https://www.accjournal.org/journal/view.php?doi=10.4266/acc.2019.00430
With this increasing demand, the responsibility with regard to caring for potential organ donors is also rising. Appropriate medical management of a potential organ donor is a very important issue, requiring a multidisciplinary team approach for successful organ transplantation. For graft survival after donation, all available organs in the donor need to be maintained at their normal physiological condition until the time of organ retrieval. Intensivists play a vital role in the management of potential organ donors through the identification of potential donors, declaration of brain death, and proper medical care all of which can improve the rates of graft survival. […] Organ donor management should be started immediately after brain death occurs and should continue once consent from the family for donation is obtained. Data shows that progression from brain death to somatic death results in the loss of 10% to 20% of potential donor tissues, therefore timely treatment of the donor is very crucial. Strict organ-protective intensive care of the potential organ donor is therefore the first step towards a successful transplant and in the treatment of the future organ recipient. […] The protocol we have proposed and provided in the checklist may help intensivists manage brain-dead organ donors to promote successful organ and tissue donations.
#14 Medical Management of Brain-Dead Organ Donors
https://www.accjournal.org/journal/view.php?doi=10.4266/acc.2019.00430
With this increasing demand, the responsibility with regard to caring for potential organ donors is also rising. Appropriate medical management of a potential organ donor is a very important issue, requiring a multidisciplinary team approach for successful organ transplantation. For graft survival after donation, all available organs in the donor need to be maintained at their normal physiological condition until the time of organ retrieval. Intensivists play a vital role in the management of potential organ donors through the identification of potential donors, declaration of brain death, and proper medical care all of which can improve the rates of graft survival. […] Organ donor management should be started immediately after brain death occurs and should continue once consent from the family for donation is obtained. Data shows that progression from brain death to somatic death results in the loss of 10% to 20% of potential donor tissues, therefore timely treatment of the donor is very crucial. Strict organ-protective intensive care of the potential organ donor is therefore the first step towards a successful transplant and in the treatment of the future organ recipient. […] The protocol we have proposed and provided in the checklist may help intensivists manage brain-dead organ donors to promote successful organ and tissue donations.
#15 Medical Management of Brain-Dead Organ Donors
https://www.accjournal.org/journal/view.php?doi=10.4266/acc.2019.00430
With this increasing demand, the responsibility with regard to caring for potential organ donors is also rising. Appropriate medical management of a potential organ donor is a very important issue, requiring a multidisciplinary team approach for successful organ transplantation. For graft survival after donation, all available organs in the donor need to be maintained at their normal physiological condition until the time of organ retrieval. Intensivists play a vital role in the management of potential organ donors through the identification of potential donors, declaration of brain death, and proper medical care all of which can improve the rates of graft survival. […] Organ donor management should be started immediately after brain death occurs and should continue once consent from the family for donation is obtained. Data shows that progression from brain death to somatic death results in the loss of 10% to 20% of potential donor tissues, therefore timely treatment of the donor is very crucial. Strict organ-protective intensive care of the potential organ donor is therefore the first step towards a successful transplant and in the treatment of the future organ recipient. […] The protocol we have proposed and provided in the checklist may help intensivists manage brain-dead organ donors to promote successful organ and tissue donations.
#16 Medical Management of Brain-Dead Organ Donors
https://www.accjournal.org/journal/view.php?doi=10.4266/acc.2019.00430
With this increasing demand, the responsibility with regard to caring for potential organ donors is also rising. Appropriate medical management of a potential organ donor is a very important issue, requiring a multidisciplinary team approach for successful organ transplantation. For graft survival after donation, all available organs in the donor need to be maintained at their normal physiological condition until the time of organ retrieval. Intensivists play a vital role in the management of potential organ donors through the identification of potential donors, declaration of brain death, and proper medical care all of which can improve the rates of graft survival. […] Organ donor management should be started immediately after brain death occurs and should continue once consent from the family for donation is obtained. Data shows that progression from brain death to somatic death results in the loss of 10% to 20% of potential donor tissues, therefore timely treatment of the donor is very crucial. Strict organ-protective intensive care of the potential organ donor is therefore the first step towards a successful transplant and in the treatment of the future organ recipient. […] The protocol we have proposed and provided in the checklist may help intensivists manage brain-dead organ donors to promote successful organ and tissue donations.
#17 Standard Treatment Guidelines for Brain Death And ICU Management
https://speciality.medicaldialogues.in/standard-treatment-guidelines-for-brain-death-and-icu-management
If the patient is a potential organ donor, he should be transferred to a tertiary level centre that is certified by the competent authority and is capable of supporting the brain dead organ donor. […] The use of hormonal replacement therapy, Thyroxin, triiodothyronine (T3), corticosteroid and insulin, has been advocated to improve cardiovascular stability. At present, such therapies are regarded as experimental. Studies regarding ACTH and cortisol levels inconclusive. Unclear whether steroids make any significant improvement in organ preservation. […] Prophylactic antibiotics are indicated only immediately prior to organ retrieval.
#18 Management of Organ Donors after Brain Death (Part II) â ResusNation
https://criticalcarenow.com/management-of-organ-donors-after-brain-death-part-2/
The Pre-brief: Today, weâll continue with part II of organ donation after brain death. As critical care practitioners, we should be honoring organ donors by doing justice to the gifts they give so many â their vital organs. Which medications should we be using to maintain viability of organs and why? […] Management: Heparin: Heparin IV is commonly administered after brain death. Administering heparin before cross clamping the aorta has also been shown to help prevent thrombotic complications. Evidence for DVT prophylaxis with heparin is limited. However, a high pulmonary emboli burden is frequently found in patients during organ procurement so continuing DVT prophylaxis is reasonable. […] Management: Steroids: Steroids help attenuate the inflammatory response which ensues after brain death by inhibiting cytokines and stabilizing cell membranes. Steroids have been shown to decrease early graft failure and rejection following transplantation. SCCM and UNOS recommend high dose methylprednisolone for cardiothoracic donors. Hydrocortisone can also be used; when compared to methylprednisolone in one study, donors who received hydrocortisone had decreased insulin requirements and better glycemic control.
#19 Standard Treatment Guidelines for Brain Death And ICU Management
https://speciality.medicaldialogues.in/standard-treatment-guidelines-for-brain-death-and-icu-management
If the patient is a potential organ donor, he should be transferred to a tertiary level centre that is certified by the competent authority and is capable of supporting the brain dead organ donor. […] The use of hormonal replacement therapy, Thyroxin, triiodothyronine (T3), corticosteroid and insulin, has been advocated to improve cardiovascular stability. At present, such therapies are regarded as experimental. Studies regarding ACTH and cortisol levels inconclusive. Unclear whether steroids make any significant improvement in organ preservation. […] Prophylactic antibiotics are indicated only immediately prior to organ retrieval.
#20
https://link.springer.com/article/10.1007/s00134-019-05551-y
To provide a practical overview of the management of the potential organ donor in the intensive care unit. […] The potential donor should be assessed clinically for infections, and screening tests for specific infections are an essential part of donor management. […] However, new antiviral drugs and strategies now allow organ donation from certain infected donors to be done safely. […] The indications and controversies regarding endocrine therapies, in particular thyroid hormone replacement therapy, and corticosteroid therapy, are discussed. […] Corticosteroids in the management of brain-dead potential organ donors: a systematic review. […] Interest of low-dose hydrocortisone therapy during brain-dead organ donor resuscitation: the CORTICOME study. […] High prevalence of decreased cortisol reserve in brain-dead potential organ donors.
#21 Management of Organ Donors after Brain Death (Part II) â ResusNation
https://criticalcarenow.com/management-of-organ-donors-after-brain-death-part-2/
The Pre-brief: Today, weâll continue with part II of organ donation after brain death. As critical care practitioners, we should be honoring organ donors by doing justice to the gifts they give so many â their vital organs. Which medications should we be using to maintain viability of organs and why? […] Management: Heparin: Heparin IV is commonly administered after brain death. Administering heparin before cross clamping the aorta has also been shown to help prevent thrombotic complications. Evidence for DVT prophylaxis with heparin is limited. However, a high pulmonary emboli burden is frequently found in patients during organ procurement so continuing DVT prophylaxis is reasonable. […] Management: Steroids: Steroids help attenuate the inflammatory response which ensues after brain death by inhibiting cytokines and stabilizing cell membranes. Steroids have been shown to decrease early graft failure and rejection following transplantation. SCCM and UNOS recommend high dose methylprednisolone for cardiothoracic donors. Hydrocortisone can also be used; when compared to methylprednisolone in one study, donors who received hydrocortisone had decreased insulin requirements and better glycemic control.
#22 Organ Donation New Zealand | 4 | Physiological support after brain death
https://donor.co.nz/healthcare-professionals/intensive-care-unit-guidelines/4-physiological-support-after-brain-death/
To enable brain death to be determined. […] To preserve the option of donation of the maximum number of organs for transplantation. […] To ensure that any organs that are donated will be in optimal condition when retrieved and will function well in recipients after transplantation. […] It is much easier to prevent hypothermia than to treat it in the brain dead patient. It is important to prevent hypothermia developing. […] The outcome for lung recipients, especially in the early post-transplant period, is dependent on the degree of lung dysfunction in the donor. It is important to ensure that all aspects of lung function of the donor are as good as possible. […] For these reasons it is recommended that the effects of sympathetic hyperactivity should be blunted by treatment with short-acting beta-blockade.
#23 Organ Donation New Zealand | 4 | Physiological support after brain death
https://donor.co.nz/healthcare-professionals/intensive-care-unit-guidelines/4-physiological-support-after-brain-death/
To enable brain death to be determined. […] To preserve the option of donation of the maximum number of organs for transplantation. […] To ensure that any organs that are donated will be in optimal condition when retrieved and will function well in recipients after transplantation. […] It is much easier to prevent hypothermia than to treat it in the brain dead patient. It is important to prevent hypothermia developing. […] The outcome for lung recipients, especially in the early post-transplant period, is dependent on the degree of lung dysfunction in the donor. It is important to ensure that all aspects of lung function of the donor are as good as possible. […] For these reasons it is recommended that the effects of sympathetic hyperactivity should be blunted by treatment with short-acting beta-blockade.
#24 Organ Donation New Zealand | 4 | Physiological support after brain death
https://donor.co.nz/healthcare-professionals/intensive-care-unit-guidelines/4-physiological-support-after-brain-death/
To enable brain death to be determined. […] To preserve the option of donation of the maximum number of organs for transplantation. […] To ensure that any organs that are donated will be in optimal condition when retrieved and will function well in recipients after transplantation. […] It is much easier to prevent hypothermia than to treat it in the brain dead patient. It is important to prevent hypothermia developing. […] The outcome for lung recipients, especially in the early post-transplant period, is dependent on the degree of lung dysfunction in the donor. It is important to ensure that all aspects of lung function of the donor are as good as possible. […] For these reasons it is recommended that the effects of sympathetic hyperactivity should be blunted by treatment with short-acting beta-blockade.
#25 Organ Donation New Zealand | 4 | Physiological support after brain death
https://donor.co.nz/healthcare-professionals/intensive-care-unit-guidelines/4-physiological-support-after-brain-death/
The anaesthetist should aim to maintain stability in the donor until aortic cross-clamp. This is to ensure the organs being donated for transplantation are in optimal condition when removed and will function well in recipients following transplantation. […] It is very important to recognise and treat DI early. […] Donor hyperosmolality has been associated with impaired organ function in some liver recipients.
#26 Organ Donation New Zealand | 4 | Physiological support after brain death
https://donor.co.nz/healthcare-professionals/intensive-care-unit-guidelines/4-physiological-support-after-brain-death/
The anaesthetist should aim to maintain stability in the donor until aortic cross-clamp. This is to ensure the organs being donated for transplantation are in optimal condition when removed and will function well in recipients following transplantation. […] It is very important to recognise and treat DI early. […] Donor hyperosmolality has been associated with impaired organ function in some liver recipients.
#27 Families Understanding Brain Death | Donor Network of Arizona
https://www.dnaz.org/partners/hospital/brain-death/
Families Understanding Brain Death The concept of brain death is difficult for many families to comprehend. However, it is important for families to understand their loved one is dead before conversations about organ, eye and tissue donation occur. The following communication points may be useful in helping families understand brain death. […] After declaration, refer to brain death as death, and tell the family the time of death. The patient is not in a coma. Refer to the ventilator and intravenous medications as artificial or mechanical support. […] Use the word death. Avoid commonly used euphemisms (e.g. passed away, gone, expired) in your conversation about the death.
#28 Families Understanding Brain Death | Donor Network of Arizona
https://www.dnaz.org/partners/hospital/brain-death/
Families Understanding Brain Death The concept of brain death is difficult for many families to comprehend. However, it is important for families to understand their loved one is dead before conversations about organ, eye and tissue donation occur. The following communication points may be useful in helping families understand brain death. […] After declaration, refer to brain death as death, and tell the family the time of death. The patient is not in a coma. Refer to the ventilator and intravenous medications as artificial or mechanical support. […] Use the word death. Avoid commonly used euphemisms (e.g. passed away, gone, expired) in your conversation about the death.
#29 Families Understanding Brain Death | Donor Network of Arizona
https://www.dnaz.org/partners/hospital/brain-death/
Families Understanding Brain Death The concept of brain death is difficult for many families to comprehend. However, it is important for families to understand their loved one is dead before conversations about organ, eye and tissue donation occur. The following communication points may be useful in helping families understand brain death. […] After declaration, refer to brain death as death, and tell the family the time of death. The patient is not in a coma. Refer to the ventilator and intravenous medications as artificial or mechanical support. […] Use the word death. Avoid commonly used euphemisms (e.g. passed away, gone, expired) in your conversation about the death.
#30 Updated Brain Death Guidance: What Care Teams Need to Know | SCCM
https://www.sccm.org/communications/sccm-podcast/sccm-podcast-all-episodes/sccm-pod-533-ccm-updated-brain-death-guidance-what-critical-care-teams-need-to-know
Host Diane C. McLaughlin, DNP, AGACNP-BC, CCRN, FCCM, welcomes Matthew Kirschen, MD, PhD, FAAN, FNCS, to discuss what critical care professionals need to know about determining brain death/death by neurologic criteria (BD/DNC). […] The guideline integrated guidance for adults and children to provide a comprehensive, practical way to evaluate patients with catastrophic brain injuries to determine whether they meet the criteria for brain death. […] The big thing in this set of guidelines is that we amalgamated the adult criteria and the pediatric criteria into one document. […] One of the things that we did is we added recommendations for special situations, for example, evaluating pregnant persons for brain death, doing the apnea test, and the rest of the evaluation in patients supported on VA and VV ECMO.
#31 Updated Brain Death Guidance: What Care Teams Need to Know | SCCM
https://www.sccm.org/communications/sccm-podcast/sccm-podcast-all-episodes/sccm-pod-533-ccm-updated-brain-death-guidance-what-critical-care-teams-need-to-know
Host Diane C. McLaughlin, DNP, AGACNP-BC, CCRN, FCCM, welcomes Matthew Kirschen, MD, PhD, FAAN, FNCS, to discuss what critical care professionals need to know about determining brain death/death by neurologic criteria (BD/DNC). […] The guideline integrated guidance for adults and children to provide a comprehensive, practical way to evaluate patients with catastrophic brain injuries to determine whether they meet the criteria for brain death. […] The big thing in this set of guidelines is that we amalgamated the adult criteria and the pediatric criteria into one document. […] One of the things that we did is we added recommendations for special situations, for example, evaluating pregnant persons for brain death, doing the apnea test, and the rest of the evaluation in patients supported on VA and VV ECMO.
#32 Updated Brain Death Guidance: What Care Teams Need to Know | SCCM
https://www.sccm.org/communications/sccm-podcast/sccm-podcast-all-episodes/sccm-pod-533-ccm-updated-brain-death-guidance-what-critical-care-teams-need-to-know
We provide a little bit of additional clarity in terms of doing the neurologic examination. […] In pediatrics, we’re required to have two neurologic examinations and two apnea tests, and those are separated by an interval of 12 hours. […] In adults, one exam and one apnea test are required. […] The way I look at it is that this is one of the few decisions in medicine that we can’t take back, right? […] One of the things that we emphasize in the guidelines that were published at the end of last year is that practitioners who perform the evaluation should be adequately trained and competent in performing the evaluation. […] In the United States, the legal basis for brain death stems from the UDDA, the Uniform Determination of Death Act, which was enacted in 1981 in the United States.
#33 Updated Brain Death Guidance: What Care Teams Need to Know | SCCM
https://www.sccm.org/communications/sccm-podcast/sccm-podcast-all-episodes/sccm-pod-533-ccm-updated-brain-death-guidance-what-critical-care-teams-need-to-know
What the panel decided and what has been written into the guidelines is that you have a duty to inform families that you are going to proceed with a brain death evaluation. […] However, you do not need to obtain consent for doing the evaluation, that we have an obligation as clinicians to know whether the patient who we are taking care of in front of us is alive or dead. […] If you are going to use ancillary testing, prior to doing that ancillary testing, you must confirm that the entire neurologic exam that you are able to do has been performed and all the findings are consistent with brain death. […] I think we need to think of this in a variety of action items. Hospitals need to take the guidelines and they need to revise their institutional protocols to be consistent with the guidelines, keeping in mind state and local laws and regulations that also need to be adhered to.
#34 Updated Brain Death Guidance: What Care Teams Need to Know | SCCM
https://www.sccm.org/communications/sccm-podcast/sccm-podcast-all-episodes/sccm-pod-533-ccm-updated-brain-death-guidance-what-critical-care-teams-need-to-know
What the panel decided and what has been written into the guidelines is that you have a duty to inform families that you are going to proceed with a brain death evaluation. […] However, you do not need to obtain consent for doing the evaluation, that we have an obligation as clinicians to know whether the patient who we are taking care of in front of us is alive or dead. […] If you are going to use ancillary testing, prior to doing that ancillary testing, you must confirm that the entire neurologic exam that you are able to do has been performed and all the findings are consistent with brain death. […] I think we need to think of this in a variety of action items. Hospitals need to take the guidelines and they need to revise their institutional protocols to be consistent with the guidelines, keeping in mind state and local laws and regulations that also need to be adhered to.
#35 Hospitals in Kerala prolong life support for brain-dead patients despite government directive
https://www.newindianexpress.com/states/kerala/2025/Feb/15/hospitals-in-kerala-prolong-life-support-for-brain-dead-patients-despite-government-directive
Despite a clear government directive to the contrary, hospitals are increasingly keeping brain-dead patients on ventilators in intensive care units (ICUs) longer than necessary, creating a heavy financial and emotional burden on families. […] The 2020 directive made brain death certification mandatory and barred the treatment of such patients. […] The state government order mandated that brain death be declared if certain criteria are met, and that all treatment, including life support, must stop once brain death is confirmed. But futile care continues. […] Mistreatment of the dead, deprivation of dignity, provision of false hope with resultant distrust, prolongation of the grieving process, undermining the professional responsibility of the physician, harm arising from a negotiated standard of death determination. […] All treatment support must be discontinued after the declaration.
#36 Hospitals in Kerala prolong life support for brain-dead patients despite government directive
https://www.newindianexpress.com/states/kerala/2025/Feb/15/hospitals-in-kerala-prolong-life-support-for-brain-dead-patients-despite-government-directive
Despite a clear government directive to the contrary, hospitals are increasingly keeping brain-dead patients on ventilators in intensive care units (ICUs) longer than necessary, creating a heavy financial and emotional burden on families. […] The 2020 directive made brain death certification mandatory and barred the treatment of such patients. […] The state government order mandated that brain death be declared if certain criteria are met, and that all treatment, including life support, must stop once brain death is confirmed. But futile care continues. […] Mistreatment of the dead, deprivation of dignity, provision of false hope with resultant distrust, prolongation of the grieving process, undermining the professional responsibility of the physician, harm arising from a negotiated standard of death determination. […] All treatment support must be discontinued after the declaration.
#37 Hospitals in Kerala prolong life support for brain-dead patients despite government directive
https://www.newindianexpress.com/states/kerala/2025/Feb/15/hospitals-in-kerala-prolong-life-support-for-brain-dead-patients-despite-government-directive
Despite a clear government directive to the contrary, hospitals are increasingly keeping brain-dead patients on ventilators in intensive care units (ICUs) longer than necessary, creating a heavy financial and emotional burden on families. […] The 2020 directive made brain death certification mandatory and barred the treatment of such patients. […] The state government order mandated that brain death be declared if certain criteria are met, and that all treatment, including life support, must stop once brain death is confirmed. But futile care continues. […] Mistreatment of the dead, deprivation of dignity, provision of false hope with resultant distrust, prolongation of the grieving process, undermining the professional responsibility of the physician, harm arising from a negotiated standard of death determination. […] All treatment support must be discontinued after the declaration.
#38 Leading Insights
https://currents.neurocriticalcare.org/Leading-Insights/Article/consent-for-brain-death-determination-the-ends-justify-the-means-or-it-does-not
The current practice of not requiring consent for brain death testing is based on a notion that the patient is already dead; consenting to the declaration does not change that fact and the dead do not have rights to autonomy. […] We argue that there is an ethical case to be made that informed consent should be conducted prior to brain death determination, allowing for objections to it in all 50 states.
#39 Leading Insights
https://currents.neurocriticalcare.org/Leading-Insights/Article/consent-for-brain-death-determination-the-ends-justify-the-means-or-it-does-not
The current practice of not requiring consent for brain death testing is based on a notion that the patient is already dead; consenting to the declaration does not change that fact and the dead do not have rights to autonomy. […] We argue that there is an ethical case to be made that informed consent should be conducted prior to brain death determination, allowing for objections to it in all 50 states.
#40 Brain Death: What It Is, Stages & Criteria
https://my.clevelandclinic.org/health/diseases/brain-death
No, you cant because you may not be able to prevent any of the serious illnesses or injuries that lead to brain death. […] In some cases, immediate medical care may keep brain death from happening if you have a serious illness or an injury that affects your brain. […] But once your brain stops working, there isnt a treatment that can prevent brain death from happening. […] While you may not be able to prevent issues that can cause brain death, you can plan for what you want to happen if youre sick or injured and you have brain death. […] You do that by completing an advance directive. This is a legal document that outlines the kind of care you want in the event you cant speak for yourself. For example, your advance directive could state you want to donate your organs after death, including brain death.
#41 Brain Death: Causes, Symptoms and Treatment
https://www.medicoverhospitals.in/diseases/brain-death/
Preventing brain death involves addressing its underlying causes: […] Brain death prevention is primarily through prompt treatment of severe head injuries, strokes, and infections that affect the brain.
#42 How Educators Can Help Prevent False Brain Death Diagnoses | Journal of Ethics | American Medical Association
https://journalofethics.ama-assn.org/article/how-educators-can-help-prevent-false-brain-death-diagnoses/2020-12
It is critical for brain death diagnosis to be accurate. […] Using a case-based approach, this article demonstrates what tends to go wrong in erroneous brain death diagnoses and clarifies what physicians and educators should do to help avoid these errors. […] In a survey of physicians who perform brain death examinations, only 25% reported compliance with current practice guidelines. […] Although the diagnosis of brain death and prognosis of neurological recovery after brain injury are well-defined in the literature, hospital policies in the United States for the determination of brain death are highly variable and often not in line with current practice guidelines. […] Without the safety net of standardized guidelines, false diagnoses of brain death are more likely to occur. […] Rather than a top-down approach, a more fail-safe method of ensuring appropriate diagnoses of brain death might well come from early education of future physicians and continuing education of physicians in practice.
#43 How Educators Can Help Prevent False Brain Death Diagnoses | Journal of Ethics | American Medical Association
https://journalofethics.ama-assn.org/article/how-educators-can-help-prevent-false-brain-death-diagnoses/2020-12
Undergraduate and graduate medical education, as well as continuing medical education, should include instruction on the disorders of consciousnessâbrain death, coma, vegetative state, and minimally conscious state. […] The Neurocritical Care Society provides a brain death determination course to standardize brain death diagnosis.
#44 Families Understanding Brain Death | Donor Network of Arizona
https://www.dnaz.org/partners/hospital/brain-death/
Families Understanding Brain Death The concept of brain death is difficult for many families to comprehend. However, it is important for families to understand their loved one is dead before conversations about organ, eye and tissue donation occur. The following communication points may be useful in helping families understand brain death. […] After declaration, refer to brain death as death, and tell the family the time of death. The patient is not in a coma. Refer to the ventilator and intravenous medications as artificial or mechanical support. […] Use the word death. Avoid commonly used euphemisms (e.g. passed away, gone, expired) in your conversation about the death.