Brain Stem Testing in Neurointensive Care: To Test or Not?

1. To Test or Not? NHSBT Regional Collaborative 13th November 2014 Roger Lightfoot

2. Objectives • Generate Discussion • Present 2 Cases • Ask audience whether to confirm death by completing Brain Stem Tests or not?

3. Curriculum Vitae • Consultant – Neurointensive Care • August 2004 – present • Director of Neurointensive Care • June 2014 - Present • Clinical Lead Organ Donation Neurointensive Care • November 2012 – present

4. My own views “If a patient is close to death and their views cannot be determined, you should be prepared to explore with those close to them whether they had expressed any views about organ or tissue donation, ifdonation is likely to be a possibility.” GMC 2010 …it was important to separate completely the diagnosis and confirmation of death from anything to do with the issues surrounding organ donation and transplantation. 2008 ..Suggested practice could involve testing before end-of-life discussions… Club 32 Meeting Sept ‘13

5. Neurointensive Care Data

6. Neurointensive Care Data

7. Case 1 • 52 yr female • Previous TIAs • Occluded basilar artery • Cerebellar infarct • No interventions

8. Case 1 • 2 days after admission • 14:00 my first involvement • Dilated unreactive pupils from 02:00 • Cardiovascular instability • Sedation stopped at 11:00 (fentanyl/propofol) • Talk of “living will” • In back of husbands car • Caring and close family

9. Case 1 • Futility of continued treatment confirmed • Influences on BS Testing: • Timing • Consensus was following morning • Influence of “living will” • No experience

10. Case 1 • Comprehensive • Disability • Prolongation of life • Interventions • Not for organ donation • Signed by 3rd party • Confirmed with NOK Compassionindying.org.uk

11. To Test or Not?

12. Outcome • I did not proceed to BSD testing • Living Will facilitated wishes • Insight into person • Extubated in evening • Family drinking champagne before extubation

13. Case 2 • 53 yr old female • Previous Ca Breast • Mastectomy and radiotherapy • ICH and MCA aneurysm

14. Case 2 • Day 3 post op • Worsening vasospasm • Fixed Dilated pupils 04:00 • Sedation stopped 09:00 • Discussion with SNOD • Cancer Hx contraindication to organ donation • My involvement 14:00

15. Case 2 • Futility of continued treatment confirmed • Ancillary imaging techniques • Factors influencing testing: • Sedation • PMHx contraindication to organ donation

16. To Brain Stem Test or Not?

17. Outcome • 14:45 –Discussion with family • I did not proceed to BSD Testing • Withdrawal of care at 19:12 • Verification of death at 19:36

18. Objectives • Generate Discussion • Present 2 Cases • Ask audience whether to confirm death by completing Brain Stem Tests or not?

21. Time Between Tests • Patient not dead until second test is done • Timing: • No specified time delay in UK • USA observation ~ 19 hrs • ANZICS now no minimum time • Time of first tests is the important decision “Confirming death using neurological criteria: are two sets of tests better than one?” Gardiner D, Danbury C & Manara A (2013) JICS 14(1):6-7.

22. Ancillary Tests • Clinical • Dolls eyes movements • Electrophysiological • EEG • AEP • Cerebral Flow • Cerebral angiography • CTA, MRA, TCDs • Cerebral Perfusion • PET, Xenon CT, HMPAO SPECT

23. Ancillary Tests A survey of current practice and attitudes surrounding the use of ancillary tests in the diagnosis of brainstem death in neurocritical care units in the UK JICS Volume 14, Number 3, July 2013 • Variation in practice in neurocritical care units in UK • Confidence • Availability • Timing after sedatives stopped • Recommend guidance on use of tests.

24. Ancillary Testing - Angiography • 19 yr Female • DKA • GCS 3/15 • EVD inserted • Bilateral Fixed dilated pupils • Cerebral angiogram • BSD Testing ✔ • Central Line • Fluid resuscitation • Vasopressors • DDAVP