Although cerebral arteriography is the gold standard, I have never seen it utilized in 40 years of my pediatric critical care or in any adult patient. Why is that? Dr. Greer, your thoughts, and then Dr. Shutter. Well, that sounds like an aberrancy because it can be used and is really considered the gold standard test. That being said, it's very highly resource intensive. You have to have a team that can do the angiogram. And so that's why people typically go to a radionuclide study first or cranial Doppler. TCD has the luxury of being able to be done at the bedside. That's the only one of those tests that can be. But as I said before, EEG is no longer an acceptable ancillary test. And if you've really got to know and there's equivocality, if that's a word, the gold standard would be a cerebral angiogram. And it can be done in adult and pediatrics. If it's a very small patient, it's technically very difficult to do. But in bigger children, it certainly can be used as an ancillary test as well. Dr. Shutter, any other thoughts? Same, I've actually- Dr. Shutter, any other thoughts? Same, I've actually used it a few times. It actually, when I've asked for it, often the interventionalists are very happy to do it because it's a quick test. And it's the type test that they want experience because it gives them the opportunity. So now it may be at kind of odd hours and we have to facilitate and help getting the patient down there. But I personally have not encountered problems. And I have used it at different times. That sounds good, thank you. I'll go on to the next question. Suppose you have a pediatric patient who does not tolerate the first apnea test, then proceeds to cerebral flow study, nuclear medicine. On this flow study, there is presence of blood flow. Flow study, there is presence of blood flow. In our group's case, we did not proceed with the second brain death test. Is this decision consistent with guidelines? Our group felt that with presence of cerebral flow, brain death could not be confirmed. Thoughts? Laurie, do you wanna go first? The test because they can't tolerate the apnea test and you're using the ancillary test and it shows you cerebral blood flow, then they were right to not proceed with the rest of the exam. That that suggests that there still is, that this patient did not qualify for brain death. Qualify for brain death. Yeah, I totally agree with what Laurie said. Kind of a special circumstances if you think that the patient really is progressing towards brain death and perhaps the flow study was done too early. An example might be a patient that has progressive edema and might progress to brain death. So typically, and I don't think this is in the guidelines, we'll typically wait at least 24 hours and sometimes longer. And either then you can do a clinical determination if they are stable enough to get the apnea test or you repeat a flow study. And sometimes if you had a negative flow study the first time to make absolutely sure, especially in a pediatric patient. But again, those are not in the guidelines, but we really encourage people to err on the side of caution and not rush to a diagnosis of brain death. And so that'd be a very sound practice in that circumstance. That'd be a very sound practice in that circumstance. Sounds good. Going on to the next question. Clinicians have been recommended to undergo an online training program. Is that necessary if you have performed hundreds of brain death exams and served on statewide panel for brain death? We are the rec advisor institution regarding compliance with guidelines. Are you assuming that we have been doing it wrong, not being defensive, but trying to determine whether I need to undergo such online training? I think I addressed that in my talk. I have done hundreds, thousands of these tests and to set this going the test so I will meet all the criteria and then I will be the proctor myself and one of my colleagues, Dr. Joe Darby, who's done even more than I have. The two of us will be able to proctor some of our local people and help with the evidence of competency. I know I can do it. I'm not saying just to meet the new criteria that we are establishing to make sure that people are competent in this. So I think it's my opinion, but I think all of us that are very experienced should set the standard and take the online test. Dr. Greer and Babu, any other addition? Well, I think Dr. Schutter is correct. I think that we want you to be role models and if you have done hundreds, then you're gonna be great at this and you can say, I've even done the course myself and I want you to do it. I've taken it. I think it's really good. Hopefully you say it's really good, but we need people to be champions and cheerleaders in this and what better way to do it than to lead by example. Exactly. I think it's kind of a follow-up to the previous one. How do you get the more arrogant clinicians to follow guidelines? Case in point, the problems with procedural timeouts where people don't really follow them. How do you follow them? How do you get them to adhere? David, I don't know what you're doing. We're actually kind of rewriting our hospital credentialing, which is a much longer process than I realized and we are going to make it a requirement that people have to demonstrate credentials. What you're, for those physicians that may feel this is unnecessary, then if they don't want to take an online test and they have to do an exam with me and I can proctor them and we'll establish a certain number and then I can sign off on their credentials. But there has to be something officially through our credentialing offices, has to be something officially through our credentialing offices to say that somebody is competent. So I grew up in Florida where there were a lot of sharks and the old adage was, if a shark is trying to attach you, you punch it in the nose. And so an arrogant clinician who's gonna be doing something like this wrong, where the stakes are so high, you have to take it head on, in my opinion. And maybe that's a situation where you talk to your chief medical officer and say, hey, I have concerns about this anonymously. Perhaps you do stand on the sidelines and say, oh, that person's just arrogant. Maybe we'll get them next time. No, we can't do this wrong. We have to be right about this 100% of the time. And if somebody is so arrogant that they're not willing to listen to reason or follow guidelines particularly, that's an unsafe position. Follow guidelines particularly, that's an unsafe position. Our clinician, they should be called out for it. I agree. And I think also our societies, our respective societies can also hopefully help promote consistency and standardization as well. I know we're more focused on kind of trauma CME and sort of how do we approach the whole issue of keeping training related to neurotrauma consistent. But I think this is certainly a valuable aspect that really anyone can learn pearls from even with a refresher. The next question in Idaho seems out of date. Considering the present standard of telehealth community, do you have any comments on that? All I can say is that I based that information off the reference that I listed and it was a 2016 reference. So it is eight years old. That was the only thing ideas, which is why I really encourage people to look at your own state regulations. Now, don't be surprised if your state legislature has not changed things in eight years because they may not have recognized the implication of what their law says relative to things they've changed regarding telemedicine. Implication of what their law says relative to things they've changed regarding telemedicine services. And if they haven't, if that is still the law in Idaho, then maybe it's time to work with legislatures and change it. But that's the information I found from a 2016 document. That's the information I found from a 2016 document. I did not take the time to go to each state individually and look up if their laws were still the same from that reference. I'll just chime in that Dr. Arian Lewis is really leading an effort, a national effort to try to get the joint commission or to try to get the joint commission to make sure that individual hospitals have up-to-date policies regarding brain death determination. It's an opportunity for places such as Idaho that use a lot of telemedicine to incorporate that into their specific guidelines because all hospitals have an up-to-date hospital policy because all hospitals have an up-to-date hospital policy that is consistent with the AAN slash SCCM guidelines. So I think that'll be an opportunity for everybody to look at it and make sure that things like that, the telehealth aspects of this, if that's a big part of your practice, that's the opportunity to do it. I do have a comment here that having practiced in Idaho doing brain death exams recently, I can tell you everything there is out of date. I think the next question we, I want to say about the maintenance of certification and training and experience. The next question is regarding neuroimaging being consistent with the mechanism of brain death being consistent with the mechanism and severity of brain injury. How does this apply to patients with exams consistent with neurological death? However, the CT head is negative. So I'll take that one. We're actually doing a current study right now, starting with cardiac arrest patients to look at what should be the neuroradiologic criteria that have to be in place. And it's surprising how many patients don't get a CAT scan or an MRI proximate to the time, a CAT scan or an MRI proximate to the time that they're getting their brain death determination. Cardiac arrest is a great example where the initial CAT scan is often normal, and then they progress to brain death. They're probably, not probably, they're very, very likely brain dead, but there isn't another CAT scan. And that's really something that we, in the new guide, in the eye of the beholder, would be compatible with what I like to call cerebral circulatory arrest, that there's no way that blood would get into that skull. That's currently in the eye of the beholder, and it always has been. Can we codify this and come up with formal criteria? Yes, we're working on it. Stay tuned. It's probably another year or so away, but that's a really essential next step for us to do to make sure that we are providing strict guidance, not just for neurologists, but actually also for neuroradiologists who are reading these scans. Dr. Babu and Dr. Schatter, any other thoughts? Agree. Yeah, I was gonna say, I mean, I think one challenge with bringing neuroradiology into the mixed is, of course, the report and the interpretation. So I'm heartened to hear what you're saying, Dr. Greer, about involving radiology-specific guidelines. I mean, that's a, I think, at least, may be able to interpret the images, but in terms of what the report may or may not suggest, certainly we don't wanna leave anything to misinterpretation or deviate from what the intent is with the guidelines. Certainly, yeah, yeah. Our next question that we have here, with regards to weighting, next question that we have here, with regards to weighting five half-lives of medications that have been given, specific medicines that are listed such as Keppra and lorazepam, is there a real true concern that a single dose of these medications would alter mental status enough to be confused as to mimic brain death? We have had to make changes to timing after one dose with the new guidelines. What thoughts do you have on those? Well, I think if you give a therapeutic dose of something like Keppra, that's not gonna get you super therapeutic. You're probably fine with that. I think it becomes more murky when it comes to benzodiazepines based on the dose and the person's metabolism. So we do leave it to the clinician's discretion. And we ask you again to err on the side of conservative. If you think it could be something that isn't metabolized in a given patient based on, wasn't metabolized in a given patient based on whatever their milieu is, then give it time until you are comfortable with that. It's very hard to put numbers to that. And everybody would love to say, oh, I have to wait six hours, 12 hours, whatever. But everybody's metabolism is different. We do talk about many of the very commonly used medications, their half-lives, when to take in consideration the age of the patient, very old or very young, the renal or hepatic metabolism. So we try to help people. And I shouldn't forget about the body habitus also because some patients have a very large BMI and a different volume and distribution. But there has to be some clinician discretion in this because there's just too much that can go into the equation. I would strongly, the last thing I'll say is I'd strongly advocate for getting your clinical pharmacist involved also. They are typically very helpful when you're trying to calculate in a given patient how long you might need to wait. Sure. So I think you could throw out the knee-jerk response of saying, well, just measure a level. But a lot of places, you're not gonna get a level back on Keppra, not a good answer. What I would say is, in my mind, it's different if they've been given a routine dose of like one gram of Keppra. But if they came in with concern for status and they were loaded completely and they got 4.5 grams, the maximum loading dose, 60 milligrams per kilo, because you thought you were treating status, in that situation, you have to be cautious because that's often done before you even know what renal function is. And heaven knows how long that can hang around. But if it had been a single 500 milligrams, 1,000 milligram dose, I agree, that should not really impact, mimic brain death significantly. I would feel more comfortable. So each situation is unique. I love the idea of bringing in your clinical pharmacist, looking at this, but use your good judgment. The revised guidelines are meant to give you guidance and to, guidelines are meant to give you guidance and to try to standardize things and to give a little bit of structure. But they still are, like anything, they are recommendations for care, but use your clinical judgment. Definitely. Dr. Babu, anything you'd like to add to these comments? Yeah, just, I absolutely agree. I think for me, it's, I'm certainly err on the side of caution. And I do feel, especially at least in the, my clinical bent is more on the trauma side, drugs of use or abuse, depending on how you look at it, might be in a person's system. I do feel like waiting and if there's any concern is certainly very reasonable because, especially nowadays, we really don't know oftentimes what all might be present. So I think certainly having that comfort in a sense of being conservative as a promoted rationale, I think is appropriate. Just one other comment is, if you're still not sure and you still can't feel absolutely 100% certain about residual confounding, feel absolutely 100% certain about residual confounding, then still do your complete examination, including the apnea test, but you may need to get an ancillary test in that situation. If your clinical exam or your apnea test is not positive, meaning is not compatible with brain death, then you don't get an ancillary test. Yeah, perfect. The American College of Medical Toxicology issued a position statement warning against the use of drug screens and clearance kinetics for the determination of brain death, yet they seem to be incorporated in the current guidelines. Any thoughts on that? Well, I think they kind of missed the boat a little bit on that. We weren't on that. We weren't saying, you know, not to take a conservative approach. In fact, it was quite the opposite that we said, you can use these things, but there are some things that are not measured in a tox screen, and you have to be vigilant for that. And we also, again, emphasize the use of neuroimaging, and we also, again, emphasize the use of neuroimaging to make sure that you have a scan that is compatible with brain death too. So I didn't really, I would say, fully appreciate that statement, and I think it was a little bit inflammatory to be on that statement, and I think it was a little bit inflammatory to be honest with you. Got it, got it. Any other comments? I have a few other questions here. What is your strategy? We know we don't need informed consent for brain death exam. If a patient's surrogate refuses the exam from before, what is your strategy to address such a situation? You know, the brain death exam is my clinical exam. For somebody in a coma, that is the exam. And I also, the only difference would be the apnea test, and I prepare them for that. And as I said, I am adamant all the time that I am trying to prove life. You know, I don't use the term that, I try to avoid that term, that I wanna show that they're brain dead. I'll say, I wanna show that your loved one is still alive. I want you to be in here and you watch. One is still alive. I want you to be in here and you watch, and you see any movement, because they might understand it a little better. But in all honesty, they really, it's part of a standard exam. I have at times said, do you want someone else to exam? Part of our routine neurologic examination. You tell me who you want me to ask to come in and examine. And I try to get them engaged in the discussion as much as possible so they recognize it. And I've just reiterated over and over again, emphasizing that I'm trying to prove life, not death. Helpful to talk about trying to prove life and not doing a brain death exam per se, but to focus on the presence of life. Any other thoughts, Dr. Gray? Yeah, I would just add, if you have a situation like that, you're gonna wanna get your hospital administration aware and because those often can cascade into a denial of the diagnosis of brain death. I fully agree with Lori. Brain death is a medical diagnosis like any other. It has taken place. It needs to be determined and documented, irrespective of whether they're gonna be an organ donor or not. It is a medical diagnosis and it is a medical or not. It is a medical diagnosis and it is a medical and legal time that they are dead. And that has repercussions as well. So we have an obligation in the medical field to make a diagnosis when it has taken place. We can't stick our heads in the sand and say, they may or may not be that, but I'm not allowed to medicine the way that we've been trained to do so and make diagnoses when they've taken place. Yes, if I can weigh in too, I think obviously as much as we can communicate, we try. I think the question is really getting at those really challenging situations where obviously family decisions, where obviously family decision makers have really dug in. And I think in terms of real world challenges, I think, and actually just dealt with something related to this. And I think this is so vexing in terms of, for clinicians, we obviously, these are very challenging situations. And I think we approach them with a lot of respect for the process and wanting to make the best possible determination. And it's very difficult when you're dealing with significant hostility and sometimes even threats and intimidation and all the things that go along with all the complex emotions that family. I would say in addition to the suggestions from the other panelists, as much as we can engage obviously groups outside of our specialty, in my case, palliative care, trauma surgery, the language of maybe the processing of the background specialties, and that might be an approach. Folks have mentioned ethics committees, I mean, obviously plus minus and those decisions can take a long time, but I do think having multiple parties involved at least helps perhaps mitigate some of those concerns. And I think too, what's challenging that I've observed more recently, and I don't know if other folks have seen it, is obviously this is really strictly talking about brain death, but having the discussions of organ donation often are in parallel to the discussions we have with patients and family, to the discussions we have with patients and family. And I just became very sensitive to that recently, and we don't necessarily control those because those are not from our clinical staff. So it can be very challenging in terms of what exactly our family's hearing in terms of the process. So at least what I try to communicating in their own way, and maybe can emphasize and reiterate the message. You know, Maya, I really appreciate that idea. I think bringing in palliative is a great idea. And I also just literally had a situation where we were parallel with the family until a declaration is made. So I had a recent situation where we had talked to the family. Her medical status was such that I did not see how I was going to be able to safely do an apnea test on this woman. And I've done lots of them, and I didn't see how it was gonna happen. And her family wanted to make her CMO. Then our OPO approached and made them think that, oh, give her a little more time and she'll progress to brain death, and then you have all these options. And it's like, wait a minute. So in my talk, I like, wait a minute. So in my talk, I actually mentioned that that was what initiated my goal right now is to actually develop a checklist for my OPO to say, look at the labs, look at the hemodynamics. And if you see these things, then medically stable enough for us to do an exam, even though you think the heart rate looks fine, they are not because their pH is still 6.9, no matter how hard I've tried to fix it, right? So trying to make sure you keep that separation with your OPO and what you're doing and why they get triggered to get involved, fear to not let them get too involved until certain criteria get met. But it's challenging. And I'd love to hear other people's thoughts and how you deal with that. But I really like the idea of bringing palliative in. I think that can often help the situation. I think the checklist sounds like a good idea because it's very challenging when we have approached and then there's a lot of confounders in the conversation moving forward. Going on to the next question. Recently on my first day in the unit, I was asked to do a brain death exam on a young kid. I was asked to do a brain death exam on a young overdose patient with radiographic signs of anoxic brain injury, who had subsequently developed severe DI and a sodium level of 179. What is the appropriate timeframe to reduce the sodium level with fluids to less that exam in the setting of the severe electrolyte abnormality? Well, I'll take a stab at that. I mean, that's an interesting question. If there's a concern of lowering the sodium too quickly because you could hurt the patient, then you're not talking about the right patient, right? Because all of these patients should have a very high pretest catastrophic brain injury if their sodium is in the 170s because of DI, that's very convincing evidence that that's actually a patient with a very high likelihood of brain death. So the reason why you wouldn't wanna lower the sodium too quickly would be because you would worsen cerebral edema in a usual cerebral edema in a usual patient. But in a patient like this, where you think that they are in the state that they are, because they are very likely brain dead, I think you could probably bring them down fairly quickly. What does fairly quickly mean after I've just said it? I don't know, maybe within a day, so very likely brain dead. I think you could probably bring them down fairly quickly. What does fairly quickly mean after I've just said it? I don't know, maybe within a day, something like that to get them less than 160, but that's arbitrary. You could say faster, you could say slower. The other thing that gives me caution about your case, how I've been more and more common these days, and we don't often know what people are overdosing on. And so if you think that there may be unmeasured stuff in the talk screen, then you probably can and should take your time in that patient regardless and give it a few days. So you can normalize the sodium over one, two, three days, something like that. Make sure you're feeling comfortable with follow-up neuroimaging and getting your toxicologist involved. And even considering after you've done your clinical testing, again, getting an ancillary test to make absolutely sure. That's probably absolutely sure. That's probably how I would approach that case. David, I agree with many aspects of that. I think what struck me with that case is why wasn't somebody addressing the sodium before they kind of hand it off to you? Isn't part of the process that we're sidelined is these are the criteria you need to meet. These are the standardizations. If you have a local policy saying you cannot do the exam until these criteria are met, then as intensivists, it's our responsibility to treat the abnormalities we see so we can safely perform, abnormalities we see so we can safely perform a examination to determine death based on neurologic criteria. So this, I would go back and really spend some time educating my colleagues kind of why didn't you address this before and just leave it to me? Because you can't do the exam. You have to get it fixed and you have to fix it in the timeframe that you feel is safe. So my pushback with that is by standardizing this, hopefully people will begin to realize if you have had to be, then hopefully us as intensivists will address that and do the interventions that are needed to get the laboratory values in the range where we can appropriately do the exam. That's a great point, Dr. Schatter, the case that was presented. No, thank you. Our next question is looking for some clarity when it comes to what would be an appropriate observation time after interventions for elevated ICP before initiating a brain death or ICP before initiating a brain death or death by neurological criteria evaluation? It's 24 hours too short. What are your thoughts? Dr. Bhatia, you're our trauma expert. Why don't you take this one? Thank you. Yeah, to be honest, to be honest, that is a really great question. So I struggle with that question because it's implying that there, I would assume that if you tried intracranial pressure, reducing techniques, mannitol, hypertonic saline, et cetera, and possibly, I guess this question maybe was focused on final fluid diversion, placement of an external ventricular drain, all those things, you thought that there was some salvageable function, presumably. So I think the question really is how long do you wait based upon that underlying assumption? And I would say if you use hyperosmolar therapy, for instance, or any intervention to reduce ICP, the question is what changed in terms of your belief system of the patient possibly having salvageable function? If it's just, you were kind of throwing the kitchen sink at it, hail Mary, fair enough. Maybe in that case, I would say, I would say at a minimum, probably three days off of those adjuncts to see if there's any response. But I guess it really depends. If it's truly a hail Mary, I guess two to three days would be reasonable. If there seemed to be some function and maybe a deterioration, then I would probably wait longer because the question is, essentially what changed? I think I might answer that a little bit differently. I agree with like thinking about medical versus surgical. For a medical intervention, which could include hyperosmolar therapy, either mannitol or hypertonic saline, and you're looking for an effect, you should see that effect within six to 12 hours, right? Six to 12 hours, right? And assuming that, well, I guess you can't assume that you have an intracranial pressure monitor, but I guess you can't assume that you have an intracranial pressure monitor, but maybe you do. And you can see what the ICP is doing. And if your ICP remains higher than your mean arterial pressure, then you're good to go from a brain death standpoint. If you're putting in a ventriculostomy, you might want to wait for longer because you might have a patient deviating to their clinical state. So maybe that would be 12 to 24 hours. That's left to your discretion. If you're doing a decompressive craniectomy, then you might want to wait for days because that might be more delayed. So those are just kind of my general rules of thumb. I think a medical therapy, you should be able to know within six to 12 hours. If you're going to take the time and effort to do one of those things, especially a decompressive crani, I'd probably give it a couple of days. I don't know, Lori, I'm very interested in your thoughts. I would challenge a little bit. While I agree that mannitol and hypertonic saline, you should see an effect. And if you have refractory ICP, then it's see an effect. And if you have refractory ICP, then that's telling you that the patient's progressing to brain death. My concern is that usually in getting to that point, particularly in like subarachnoid hemorrhage and TBI patients that also means they've been maxed out on propofol. They may have been on potentially, they've got all these other agents that you're doing sedation and analgesia to try to treat the ICP. And while mannitol and hypertonic saline may have its effects are gone in an hour, or in four hours, or while. And then you have to take the time to either just stone cold stop your propofol, fentanyl, morphine, Versed, whatever you've been on, or wean it down. And then you need all the time to get that out of the system. So mannitol, hypertonic saline, I think six, 12 hours, you're fine with that. But you have to make sure you're looking at what all the other agents that have been used to treat that ICP. You know, what about the fact that maybe they made them cold? Maybe they've had a body temperature of 35 degrees for the last two days. And now you need to, just like with cardiac arrest, warm them up again and give them a certain amount of, and now you need to, just like with cardiac arrest, warm them up again and give them a certain amount of time of being at normal body temperature. So there's not a great answer for how long you have to wait. I think you can go a little faster with medical than the surgical interventions, but with the medical, look at everything you've done to them not just what hypertonic and mannitol agents you gave. Those are great, great points. I have two questions kind of related on apnea testing. During apnea testing, if there is hypoxemia or hypotetemporize before aborting the apnea test, I guess how long can we wait is probably the question they're getting at. Could be tried to blood pressure and the oxygenation. No, you can't wait. And we have pretty firm stopping rules for that. I mean, you can draw an AVG as you're getting them reconnected to the ventilator and your pressure back up, but don't risk the patient developing hemodynamic compromise. You don't want the patient getting hypoxic ever during the apnea test. That's not gonna be the drive for them to breathe. And the hypotension, you might invalidate the test also because you don't have enough cerebral perfusion. So you're still ever during the apnea test. That's not gonna be the drive for them to breathe. And the hypotension, you might invalidate the test also because you don't have enough cerebral perfusion. So there's still wiggle room on that one. I'm sorry, but if they are passing the thresholds for the SATs or the blood pressure, you abort the test, period. Can, when I have all my assigned roles, I usually assign a nurse to be standing next to the Levo. And it's like, this is my pressure. I don't want my mat below this. I don't want my systolic below this. You see my systolic or my mat get at 10 points above my floor through the test. So I can fix the hypotension. The hypoxia is harder. And I think many times the hypoxia happens if people have not done adequate pre-oxygenation. Not always, many times people have pulmonary contusions. They have neurogenic pulmonary COVID. There may be reasons why you cannot address it. But if the lungs have started out relatively healthy, there is nothing wrong with putting them on 100% FiO2 with 10 a peep for four hours before the test. Get the PaO2 up to four hours before the test. Get the PaO2 up to 250, 300 to start. And that way you have some wiggle room as you're going down through your apnea test. What's going to cause problems during your apnea test is the hypotension and the hypoxia. Pre-oxygenate them adequately beforehand. You will encounter less problems during the test. And also, don't start with a PaCO2 of 32. Can't tell you how often I see people start there because they've been hyperventilating somebody. Get their PaCO2 around 40 so that you're not taking forever, many times with a PaCO2 of 44 to give me a little more room. You have to get over 60 or 20 over the baseline if they're a known CO2 retainer. So start them at their normal baseline level, not what you've been doing to hyperventilate them. That's a very important point about it's not paid attention to the baseline before they start the test. Dr. Babu, any other thoughts on this? No, you can move on. Thank you. A next question on our question box. If a patient has been greater than 36 degrees centigrade since admission, admission being multiple days, but goes for... Since admission, admission being multiple days, but goes for ancillary testing. And in the process of getting the testing, their temp drops to 35.5. Should we still wait for a full 24 hours of temp being greater than 36 to test patient's status? Smiling, because I don't know where these questions come from sometimes, but they're very interesting. I guess people can cool off as they're traveling through the hallways and the ambient air might bring them down. I don't think that we really intended for it to influence an ancillary test finding to be slightly hypothermic like that. And especially if it's a flow study that really shouldn't be impacted by going down to 35.5. And that really is the threshold right there, less than 35.5, then you have to rewarm them away 24 hours for the clinical exam. But for an ancillary test, as it was while they were traveling forward and they were normal thermic tests, as it was while they were traveling forward and they were normal thermic heading towards it, I don't know, I wouldn't... I'm interested to hear what the other speakers would do, but that wouldn't invalidate it for me. Wouldn't invalidate it for me. And I strongly encourage my nurses to carry blankets with them and put it over the patients because they'll keep them comfortable as you're going down. But it would not invalidate it because I've already done my clinical exam. And for some reason I need an ancillary test to support something because maybe it's a trauma patient and I can't do all the cranial nerves because of the trauma. So as I possibly can, and then I would not invalidate that for a 30 minute, one hour of being at 35.5 just for an ancillary test. Dr. Babu, anything to add to this? Yeah, I agree. Would not invalidate. The next question is regarding patients on ECMO and the suite flow. So when we do apnea testing in them, I've noticed that on ECMO, even a small amount of suite flow can impair the elevation of PACO2. What thoughts or suggestions do you have for doing apnea testing in these patients? Suggestions do you have for doing apnea testing in these patients? So that can be a little tricky because some patients just don't generate enough CO2 or it gets washed out, as you said, with a suite gas flow rate. Some people have added exogenous carbogen in situations like that to make sure that they're also getting acidotic. That's why we have the addition of the pH goal in the newest iteration of the guidelines because it's really the acidosis that's going to trigger them to breathe if their medulla is intact. So it's not just the PCO2 goal, but you've got to get the pH down also, which doesn't always happen with carbogen. Dr. Schatter and Dr. Bago, any other thoughts? No additions to that. Sounds good. Now we've moved on to just a, I want to say I have two more questions here on mostly about processes. The detailed elaborate evaluation, the detailed elaborate evaluation process for brain death and D&C can be difficult for institutions or hospitals with less resources to implement. Do you have any suggestions on how to navigate this concern? I had read that question when you sent it in and I was trying to figure out what, and then they should be able to do that. If it's related to having the people trained, then that might be a place to use some type of remote support to help people do testing. And as long as you have one or two champions at your location, kind of what they were referring to as far as resources, is it people resources? Is it equipment for ancillary testing? Yeah, the question and how does that qualify people to do the exam? But I agree, it was similar to the talk that you had given earlier, Dr. Schatter, about having some remote help to help with the exam. Yeah. Now, one thing I am absolutely concerned about and worried about, the ancillary tests now are limited and people may not have those available. And then if they aren't, does that require a transfer to a facility that can do the testing? I think it's something that people have to grapple with at their local levels and decide as to what the options would be if they should wear an ancillary test is required. Recognize that, hopefully those aren't very often. David, do you wanna weigh in on that, any at all? No, I think you'd answered it very well, Lori. I don't have anything to add to it. Yeah, I would just say I primarily, yes, ancillary testing may not be accessible as Dr. Schatter was mentioning. And I think having a strategy upfront, whether it's built into your hospital-based protocols is really important. Certainly you can rely on telehealth, but I think it is gonna be a challenge going forward, especially thinking about perhaps rural settings where presumably these types of tests can and do occur. So I think having at least some type of a network that you can plug into for questions and remoting in is helpful.

brain death examinations

protocols

intracranial pressure

apnea testing

ECMO patients

palliative care

family refusal

certification