Ancillary Testing in Death
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1 Ancillary Testing in Death MICHAËL CHASSÉ, MD, PHD, FRCPC ASSISTANT PROFESSOR, DEPARTMENT OF ANESTHESIOLOGY AND CRITICAL CARE, UNIVERSITÉ LAVAL INTENSIVIST, DEPARTMENT OF ANESTHESIOLOGY, DIVISION OF CRITICAL CARE, CENTRE HOSPITALIER UNIVERSITAIRE DE QUÉBEC AFFILIATE INVESTIGATOR, THE OTTAWA HOSPITAL RESEARCH INSTITUTE
2 Disclosures I received research funding for research related to the use of ancillary testing in death by: Canadian Institute for Health Research I have collaborations with: Canadian Blood Services Trillium Gift of Life Transplant Québec Canadian National Transplantation Research Program
3 Learning objectives Review the current Canadian recommendations for ancillary testing in death. Review the principal challenges associated with ancillary testing in the neurological determination of death. Understand the limitations of the current evidence regarding ancillary testing in the neurological determination of death.
4 Clinical scenario 48 Found unresponsive beside 2 empty bottles of nortryptilline ROSC 10minutes CPR Usual post CPR care and 3 days clinical observation Day 4: Clinical NDD: consistent with brain death (including apnea test) Day 5: Second clinical exam by independent physician Concerns of confounding CT-angio ordered
5
6 Why use ancillary tests for NDD? Clinical diagnosis is impossible e.g. Severe facial trauma Confounding factor exists e.g. Drug intoxication
7 Which test should I use? Two Categories of ancillary tests Brain blood flow (not about activity ) Conventional 4-vessel angio CT-Angio Nuclear Angio MRI angio Brain activity (so-called neurophysiological tests) EEG Evoked potentials
8 Practice variations (USA) Neurology Jan 22;70(4): Epub 2007 Dec 12.
9 Practice variations (Spain) 42 ICUs 5% clinical Dx only 95% with ancillary test 71% EEG 35% TCD 7.4% Nuclear angio 2.4% CT-Angio 0.5% 4-vessel angio Anaesthesia 2015, 70,
10 Recommended tests (Canadian consensus) Radionuclide angiography CT-angio Conventional 4-vessel angio MR-Angio or Xenon CT Х CT-perfusion Х MR perfusion Х Transcranial Doppler Х EEG Х Evoked potentials
11 Diagnostic criteria (In Canada) Current expert consensus: Must show absence of brain blood flow in cerebral hemispheres and posterior fossa structures: basilar middle cerebral anterior cerebral and posterior cerebral arteries Intracranial Intracerebral Surface of the brain
12 Challenges? The ideal test should: Can J Neurol Sci Sep;35(4):
13 Challenges 1) How accurate are the tests? 2) Are these tests helpful in isolated brainstem death? 3) Residual blood flow?
14 Accuracy 1) Can currently recommended ancillary tests incorrectly classify a patient as brain dead when in fact not brain dead? (False Positive) 2) Can currently recommended ancillary tests incorrectly classify a patient as NOT brain dead when in fact brain dead? (False Negative)
15 4-vessel angio vs clinical Dx Chassé & al. Unpublished data
16 Nuclear scan vs clinical Dx Chassé & al. Unpublished data
17 Accuracy When using ancillary tests, one has to consider that: No test has been validated to confirm not brain dead Should therefore not be used when high suspicion of not dead What they CAN do: Support a high clinical suspicion of brain death With an increased risk of false negative
18 Isolated brainstem death Clinical exam can t differentiate between whole brain death and isolated brainstem death Situations can occur when isolated brainstem death is suspected How to consider those patients with clinical brainstem death but presence of blood flow in the anterior circulation after ancillary test?
19 Isolated brainstem death Clinical diagnosis: Irreversible loss of all brain stem functions CMAJ 2006; 174: S1-30 Determination after ancillary testing Cases of complete and irreversible loss of brainstem function [ ] ancillary testing is performed, brain blood flow to supratentorial regions may be present thus negating the determination of death by neurological criteria Can. J. Neurol. Sci. 2008; 35:
20 Isolated brainstem death Brain death is a concept and is defined by the medical community: In all Canadian provinces and territories, the legal definition of brain death is according to medical standards. Is it medical standard to declare dead a patient with blood flow in the anterior circulation only? No test has been validated to confirm brainstem death. CMAJ 2006; 174: S1-30
21 Residual blood flow? Every clinician who orders ancillary tests will someday be faced with this dilemma What is significant blood flow?
22 What would you do? 1. Repeat the test? 2. Do a different test? 3. Declare dead?
23 Need for more studies Future research should: Prospectively validate in human The absence of flow in clinically brain dead patients with no confounding factors Presence of flow in non-brain-dead patients that are neurologically severely injured Application of novel potential ancillary tests should not be used in practice before appropriate validation? Is there a role for more/less ancillary testing? Future expert/society consensus (maybe not a matter of scientific research) What is significant residual blood flow? What to do with isolated brainstem death?
24 Conclusions There are currently no perfect/robust ancillary test for NDD Brain blood flow tests, when used, can support brain death in patients with an a priori high suspicion Hence the need to perform an as complete as possible clinical exam Not validated in lower likelihood populations How would the tests perform in deeply comatose non-bd patients? Numerous challenges remain Be ready for what you may encounter when ordering one
25 Wijdicks 2010: A case against confirmatory tests If this is the case, why can t that clinical state be extended to include an accurately validated paraclinic definition? Thank you!
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