Evidence-based guideline update: Determining brain death in adults
Joseph S.Jeret, MD, FAAN, 220 Maple Avenue, suite 101,Brainsrus2@aol.com
Rockville Centre, NY 11570
Submitted August 31, 2010
The recent AAN Quality Standards Subcommittee authored by Wijdicks et al. [1] outlined several dilemmas facing practicing neurologists who must deal with the determination of brain death. Unfortunately, by limiting the literature search to articles published after 1995, only four safety studies were identified and a large, earlier study was not included.
In June 1994, I co-authored a study of 70 apnea tests attempted on 61 comatose patients as part of the determination of brain death. [6] The technique we used for oxygenation in the 1990s was identical to the 2010 recommendations currently advocated. As an aside, the study was motivated by the death of one patient during apnea testing.
We found that 33% of patients developed marked hypotension (> 15% drop in MAP) and 6% required prophylactic manipulation of vasopressors. We concluded that apnea testing can pose a significant risk of hypotension. [2] In a letter to the editor, Wijdicks wrote, “That hypotension develops during apnea testing in certain patients who otherwise fulfill the clinical criteria of brain death is well recognized.” [7] Over a decade later, in the largest safety study to date, Wijdicks et al [8] aborted apnea testing in 3% due to hypotension but 7% were judged medically unstable for the testing. The lower incidence of complications compared to our prior study was attributed to stricter, subsequently-developed guidelines.
The legal and moral question of performing a potentially dangerous apnea test with no therapeutic implications for the individual has been discussed. [9] Is informed consent needed—whether the risk is 3% of 33%? If time of death is the conclusion of the apnea test or ancillary test, as recently stated, [1] these comatose patients should be accorded all the moral and legal protections of any other living human being. It is a shame that these issues were not addressed in the recent review or similar policy statements.
References
6. Jeret JS, Benjamin JL. Risk of hypotension during apnea testing. Arch Neurol 1994; 51:595-599.
7. Wijdicks EFM. In search of a safe apnea test in brain death: Is the procedure really more dangerous than we think? (letter) Arch Neurol 1995; 52:338.
8. Wijdicks EFM, Rabenstein AA, Manno EM, Atkinson JD. Pronouncing brain death: contemporary practice and safety of the apnea test. Neurology 2008; 71: 1240-1244.
9. Jeret JS, Benjamin JL. In search of a safe apnea test in brain death: Is the procedure really more dangerous than we think? In response. (letter) Arch Neurol 1995;52:338-339.
Disclosure: Dr. Jeret seves on the speakers' bureau of Forest Pharmaceuticals, Inc.
The recent AAN Quality Standards Subcommittee authored by Wijdicks et al. [1] outlined several dilemmas facing practicing neurologists who must deal with the determination of brain death. Unfortunately, by limiting the literature search to articles published after 1995, only four safety studies were identified and a large, earlier study was not included.
In June 1994, I co-authored a study of 70 apnea tests attempted on 61 comatose patients as part of the determination of brain death. [6] The technique we used for oxygenation in the 1990s was identical to the 2010 recommendations currently advocated. As an aside, the study was motivated by the death of one patient during apnea testing.
We found that 33% of patients developed marked hypotension (> 15% drop in MAP) and 6% required prophylactic manipulation of vasopressors. We concluded that apnea testing can pose a significant risk of hypotension. [2] In a letter to the editor, Wijdicks wrote, “That hypotension develops during apnea testing in certain patients who otherwise fulfill the clinical criteria of brain death is well recognized.” [7] Over a decade later, in the largest safety study to date, Wijdicks et al [8] aborted apnea testing in 3% due to hypotension but 7% were judged medically unstable for the testing. The lower incidence of complications compared to our prior study was attributed to stricter, subsequently-developed guidelines.
The legal and moral question of performing a potentially dangerous apnea test with no therapeutic implications for the individual has been discussed. [9] Is informed consent needed—whether the risk is 3% of 33%? If time of death is the conclusion of the apnea test or ancillary test, as recently stated, [1] these comatose patients should be accorded all the moral and legal protections of any other living human being. It is a shame that these issues were not addressed in the recent review or similar policy statements.
References
6. Jeret JS, Benjamin JL. Risk of hypotension during apnea testing. Arch Neurol 1994; 51:595-599.
7. Wijdicks EFM. In search of a safe apnea test in brain death: Is the procedure really more dangerous than we think? (letter) Arch Neurol 1995; 52:338.
8. Wijdicks EFM, Rabenstein AA, Manno EM, Atkinson JD. Pronouncing brain death: contemporary practice and safety of the apnea test. Neurology 2008; 71: 1240-1244.
9. Jeret JS, Benjamin JL. In search of a safe apnea test in brain death: Is the procedure really more dangerous than we think? In response. (letter) Arch Neurol 1995;52:338-339.
Disclosure: Dr. Jeret seves on the speakers' bureau of Forest Pharmaceuticals, Inc.