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Brain-stem death testing audit

Brain-stem death testing audit. Dr Paul Murphy National Clinical Lead for Organ Donation. 1. Challenges to neurological determination of death by organ retrieval teams P a CO 2 prior to disconnection interval between apnoea tests serum Na Disruptive Delays in retrieval

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Brain-stem death testing audit

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  1. Brain-stem death testing audit Dr Paul Murphy National Clinical Lead for Organ Donation 1

  2. Challenges to neurological determination of death by organ retrieval teams PaCO2 prior to disconnection interval between apnoea tests serum Na Disruptive Delays in retrieval ? loss of cardiothoracic organs Loss of goodwill Background

  3. NORS standards for Organ Retrieval

  4. Challenges to neurological determination of death by organ retrieval teams PaCO2 prior to disconnection interval between apnoea tests serum Na Disruptive Delays in retrieval ? loss of cardiothoracic organs Loss of goodwill Background

  5. Apnoea test (AoMRC 2008) • The apnoea test should be the last brain-stem reflex to be tested and should not be performed if any of the preceding tests confirm the presence of brain-stem reflexes • New guidance • Eliminate the risk of the development of significant hypoxia • Minimise the risk of the development of excessive hypercarbia and/or rapid changes in carbon dioxide tension • Minimise the development of changes in mean arterial pressure and as a result, minimise the risk of further injury to potentially recoverable brain tissue, in case death of the brain-stem has not actually occurred.

  6. Apnoea test (AoMRC 2008) • Increase the patient’s FiO2 to 1.0 • Check arterial blood gases to confirm that the measured PaCO2 and SaO2 correlate with the monitored values • With SaO2 > 95%, reduce MV to allow a slow rise in ETCO2 • Once ETCO2 > 6.0 kPa, check ABG to confirm PaCO2 ≥ 6.0kPa and pH < 7.40 • If cardiovascular stability is maintained, disconnect from ventilator and apply O2 via an endotracheal catheter; observe for five minutes • If, after five minutes, there has been no spontaneous respiratory response, a presumption of no respiratory centre activity will be documented. Confirm that P2CO2 has increased by more than 0.5KPa

  7. Apnoea test (AoMRC 2008) • The aim should be to ensure that this, and not a substantially greater, degree of hypercarbia and acidaemia is achieved for those with no previous history of respiratory disease or bicarbonate administration • The aim should also be to ensure that the respiratory centre is exposed to an adequate respiratory acidosis for a minimum of 5 minutes • The diagnosis of death by brain-stem testing should be made by at least two medical practitioners. • Testing should be undertaken by the nominated doctors acting together and must always be performed on two occasions. • A complete set of tests should be performed on each occasion, i.e., a total of two sets of tests will be performed.

  8. Audit of BSD apnoea testing • retrospective audit of DBD donor care files • Jan-Mar 2015 • All 12 ODT teams, • n = 185 • Data fields • Blood gas data relating to apnoea tests where available • Nature of form used to record NDD • Analysis • PM / DG / AM

  9. Availability of data

  10. Deviation from Academy guidance

  11. Significant concern, all regions + 2 cases of single apnoea tests

  12. http://www.ics.ac.uk/ics-homepage/guidelines-and-standards/

  13. NDD forms – UK summary

  14. NDD forms – regional usage

  15. NDD forms – available acid-base status

  16. Impact of formAll non-compliance Non compliance: deviation from physiological ranges as per AoMRC guidance. Excludes Scotland.

  17. Significant concernType of form Significant concern: < 5 minutes adequate respiratory acidosis. Excludes Scotland.

  18. Scottish data

  19. Summary • Retrospective audit • Incomplete data • Selected group (consented DBD donors) • Wide variation in documentation • Data collected by SN-ODs makes up for limitations of forms • Form now approved by ICS / FICM • 5% of apnoea tests ‘significant concern’ • ?? Single apnoea tests • Impact of forms • No form ‘immune’ • bespoke and e-forms may be particularly problematic • ICS / FICM form improves auditability

  20. Actions??

  21. Recommendations from NODC • Consistency • Nationwide adoption of the ICS / FICM form • Promoted through regional CLODs and Collaboratives • Compliance • Simulation training for advanced ICM trainees • Best practice guidance on neurological determination of death, including AV guide

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