Welcome, everybody. I'm Dr. Lori Schutter. I am moderating this session, and we're going to be presenting and discussing the Pediatric and Adult Brain Death, Death by Neurologic Criteria Consensus Practice Guidelines. It's a revised document that has been published recently. We have three presentations, and then I'll talk a little bit about how this impacts on all of us as intensivists, and hopefully we'll have time at the end for a few questions. So we're not going to take questions in the middle. We'll be able to have a discussion at the end. So thank you, everybody, for being here. I am going to please turn down, turn off your cell phones, switch them to vibrate mode. But let's go ahead and get started, and our first speaker today is Dr. Matthew Kirshen. Dr. Kirshen is an assistant professor of anesthesiology and critical care medicine, pediatrics and neurology at Children's Hospital of Philadelphia. He's also the associate director of pediatric neurocritical care at Children's Hospital of Philadelphia, and he's going to be talking to us on why revised guidelines, a little bit of an introduction and the rationale for why we did this. Thank you very much, and thank you for the opportunity to speak today. Here are my disclosures. I have funding which is unrelated to brain death, and you will hear from many of us up here that we do a lot of work for multiple organizations on brain death, but we have no financial stake in its determination. So this is pretty much the outline for the next hour. We are going to talk about the recent consensus guideline that was published. This was a collaborative effort between the American Academy of Neurology, Society of Critical Care Medicine, American Academy of Pediatrics, and the Child Neurology Society. There's a QR code at the bottom that I'll leave the slide up for another second. If you have not seen this document yet, you can click on that QR code, and it will link you to the neurology.org website where you can download for free the actual guideline itself. So one of the big questions we always get asked is, well, why do this guideline, right? Well, death hasn't changed in the past 10 years, but some of the evidence may have. So the adult and the pediatric guidelines were each published more than 10 years ago, and so we wanted to use this opportunity to review data that was available, and we also wanted to acknowledge the fact that death should really be independent of age. And so because of that, we wanted to combine the adult and the pediatric guidelines into a single document, and we also recognized that medical technology has advanced over the past 10 years, and so we wanted to address medical areas that impacted brain death, such as ECMO, therapeutic hypothermia, therapies to treat ICP, pregnancy, and primary infant tentorial injury that were not addressed in either of the two prior guidelines. It will come as no surprise to the people in this room that we don't have a lot of data in the brain death space. When we talk about guidelines, we are not going to have big randomized controlled trials and do typical grade methodology in terms of designing guidelines for brain death as we do for other diseases within our space. And so this is really an evidence-informed process. We use Delphi methodology. And as you look at the document, you will notice that recommendations have three different anchoring verbs. There are musts, shoulds, and mays, and then levels of strength that go with each one of those recommendations. And those fell out of voting from the guideline committee. Let's talk just a little bit about terminology. So we decided to use the hyphenated term brain death, death by neurologic criteria. And we did that in deference to the colloquial term brain death, but also to reinforce that it is not just death of the brain. It is death of the entire person. And it is medically and legally equivalent to cardiopulmonary death. We define children as individuals less than 18 years old. And the panel chose to use the word permanent to describe the extent of the loss of brain function that must be present in an individual in order to determine brain death. And we use permanent. And the definition that we use is we said permanent means that function was lost and it will not resume spontaneously and that medical interventions will not be used to attempt to restore any brain function. Even though it has been 10 years since the last iteration of the guidelines, I think it's important to point out that the fundamental definition of brain death has not changed. It still requires you to have a catastrophic brain injury. The patient has to be observed for a period of time to ensure the brain injury is permanent. And then on a clinical evaluation, you need to demonstrate no evidence of brain function by demonstrating the patient's comatose, has brain stem areflexia, and the absence of respiratory drive with inadequate stimulus. The guideline has 85 recommendations. We are clearly not going to be able to go through all of them today, but we're going to hit a few of the highlights. I'm going to focus first on the key concepts we have to use when talking about approaching a patient that you are suspicious for brain death. Our intent here in these recommendations was to be conservative. We wanted to really minimize the risk of a false positive determination, but at the same time make sure that the recommendations were practical so that they could be implemented in any of our ICUs across the country. While you have a suspicion that the patient will meet criteria for brain death, the presumption is that the patient does not meet brain death criteria, and your goal when walking into that room is to disprove that presumption. What this does is this takes our bias from going into the room to prove the patient's dead versus going into the room to say, I'm going to do the most standardized, protocolized, comprehensive neurologic assessment that we know how to do in order to look for any evidence of brain function. And if we do not find any evidence of brain function, then it means the patient meets criteria for death. It is important within this space that we need to provide support and guidance for families as they face these difficult end-of-life decisions. Our communication needs to be clear, concise, and supportive by using simple terminology that our families can understand. And it may be helpful for us to provide the opportunity for families to observe the evaluation, including the clinical exam and the apnea test, and it may help them come to terms with the gravity and the irreversibility of the brain injury in the situation. Who is a qualified examiner? It must be an attending physician, and that attending physician must be adequately trained and competent in the brain death evaluation. That competence can be achieved by a supervised evaluation in a clinical setting, and there's in-person and online courses which can help supplement that. Trainees must be directly supervised. In most situations, APPs should also be directly supervised, however, there are some states where APPs are allowed to do brain death evaluations independently, and if it is allowed in your state and per your institutional policy and guidelines, then that is permissible. The last thing I'm going to talk about are the prerequisites, and I think that this is probably the most important part. Don't tell Dave and Ariane that we're coming next, but probably the most important part of the brain death evaluation process, and in many of the cases where people have woken up from brain death, it is because the prerequisites were not meticulously evaluated. So we must know the mechanism of the brain injury. You have to know that they've sustained a catastrophic permanent brain injury, and you've got to know the mechanism of injury. Typically that's trauma, hypoxemic brain injury from cardiac arrest, intracranial hemorrhage, et cetera. If you have a patient who is comatose with no brain stem reflexes on their exam and you do not know the mechanism of the brain injury, you must do further diagnostic testing in order to figure out the cause of the injury prior to proceeding with the evaluation. Neuroimaging is not required, although it is performed in most cases, and if you do have neuroimaging, it should be consistent with the mechanism and the severity of the injury. There is a lot of discussion around the amount of time that you need to observe somebody after the injury has occurred before we feel confident saying that the injury is irreversible or permanent and that it is OK to proceed with the evaluation. Now we do not have great data on how long that observation period should be. However, we do feel strongly that it should be based on the pathophysiology of the brain injury leading to the clinical state of the patient. In patients less than two years old, it is recommended that you observe the patient for at least 48 hours prior to proceeding with the evaluation, and that has to do with the fact that infants have open fontanelles and unfused sutures and may not experience the same sequelae of refractory intracranial hypertension as somebody with an intact calvarium and also because the brain stem in young infants is more resistant to hypoxic ischemic injury, which is the predominant mechanism in that age group. If you are older than two years old, after hypoxic ischemic brain injury in particular, we recommend waiting 24 hours. The last point I'll measure here is if you do some sort of intervention for neuroprotection or neuroresuscitation, say doing something to decrease your intracranial pressure, it is important to then give a sufficient amount of time to see whether that intervention worked prior to saying that the brain injury is permanent. So if you put in an EVD, if you do a hemicraniectomy, if you give hyperosmolar therapy, give an appropriate amount of time to see whether your interventions worked prior to saying the injury is permanent. The last thing, and this is maybe the most important slide that I have up here, is that is you need to exclude confounding factors. There's toxins and medications that can impact the ability for you to interpret your neurologic exam. If you're hypothermic, that can impact your ability to interpret your exam. The same with hypotension and metabolic factors. We do not have time today to go through all of these in great detail, but please make sure that medications are adequately cleared out of the system. Your core body temperature is greater than 36 degrees. You are normotensive for age, and metabolic factors have been excluded. There are comprehensive tables in the appendices of the guidelines that go through recommended goal ranges for the metabolic laboratory values as well as medication data and metabolism and clearance of those medications that is broken down by age group and has additional commentary if you have hepatic or renal failure. And there's a QR code there if you want direct access to those tables. So in summary from this first part, be knowledgeable and be prepared. Please review the updated guidelines. We've talked about the general principles and the prerequisites, and Dr. Greer is now going to talk about the exam and the apnea test. Remember to meticulously review prerequisite and confounding conditions. And when in doubt, please stop and ask for help. Brain death is one of the few domains in medicine where we've got to be 100% right 100% of the time. Thank you very much. Thank you. If people didn't realize, we actually have the three lead authors for this guideline presenting today. So you are getting to hear from the true experts in this area. The next talk is hopefully, yep. So the next one is the actual determination of death, and that's going to be presented by Dr. David Greer. He is a professor and chair of the Department of Neurology at Boston University School of Medicine, and the Richard B. Slivka Chief of Neurology at Boston Medical Center. His research interest has been in the area of death by neurologic criteria for a long time in prognostication, and he was instrumental in moving this forward for us. So I'm thrilled to have Dr. Greer here to present on probably one of his favorite topics, is how to do this exam properly. Thanks, Laurie. Thanks for coming, everybody. Great to see you. Here are my disclosures. None of these are pertinent to today's talk. I am going to show a number of patient videos. I would kindly request that you not take pictures or videos of the videos themselves. These are with the express permission of the families of these patients to whom we're very indebted, so please do respect that. Picking up where Matt left off, how many examinations are required? So there was a lot of debate about this, but we settled on at least one, of course, in adults, and two is probably better. When you think about a disease like this where we really have to be right 100% of the time, I strongly advocate for having two. And in fact, I think the best way to do it is to be blinded of each other, totally separate and independent. That's the soundest way to do it. In children, it is still two examinations for every patient, including two apnea tests. So that's a very big distinction between the two. And in children, you have to have an intervening period of 12 hours. It is arbitrary. The most important waiting period is before any evaluation for brain death. Please keep that in mind. If you have any question about the permanence of the condition, you shouldn't be doing any brain death evaluations in that patient. So in order to satisfy the pediatric community, which is reasonable that we put in a 12-hour intervening waiting period, but again, the most important waiting period is before any evaluation. I've gotten calls from different places around the country where an OPO representative has said, oh my gosh, they're going straight to SPECT again. Can you please do something? Please do not go straight to ancillary testing. If you suspect the patient might be brain dead, clinical evaluation is really going to be the most important way to determine somebody. And ancillary testing should not be a crutch. In fact, even when you know that you're going to have to do ancillary testing because of some confounding in that patient, you still do all of the clinical examination that you can, including the apnea test, if you can. Because if you find signs of life on that, there is no indication to get an ancillary test. So always test everything that you can when you can to the degree that you can. All right, the clinical evaluation. Let's talk about the neuro exam. And this will probably be a review for everybody here. But I'm going to tell you a few things about technique that may be helpful. This should sound familiar. Three things in brain death. Coma, no brain stem reflexes, and apnea in the setting of a carbon dioxide challenge. Coma means no responsiveness to any kind of stimulation. Visual, auditory, tactile stimulation. The tactile stimulation should only give you spinally mediated responses, nothing that looks cerebrally mediated. You have to stimulate in all four limbs and on the cranium. Somebody may have a c-spine injury or a bad peripheral neuropathy. And so you have to stimulate on the cranium also. How do you do that? Well, I want you to take your index finger and touch your eyebrow. Go with me. Humor me for a second. Go about 2 3rds of the way out, and you're going to feel your superorbital notch. If you press right there, that's your superorbital nerve. It hurts like the Dickens, right? Don't press too hard. That's a great place to give noxious stimulation on the cranium. Another one is bilateral TMJ pressure. You don't have to press that hard for it to be noxious. And then there's the old nasal tickle, the COVID swab that we all see nowadays. And that's also very stimulatory. Sometimes you'll see a movement, and you're not sure if it came from the brain or the spinal cord. Phone a friend. Bring in somebody to take a look who has more experience, perhaps. And if you're still not sure, then you may need to get an ancillary test in that situation. There are a number of spinally mediated reflexes that have been published. This is from the guidelines themselves. I'm not going to go through these in any detail, but keep in mind that they have been described. And that may be helpful for you to say, oh, somebody else has described that before as a spinal reflex. Let's show how to do a blink to visual threat. So you hold the eyes open, and you come in with your hand flat. And you come right down the center and from the sides. The reason why my hand is flat, if you take your hand and go like this, you're creating a wind wave, and you're testing a corneal reflex. I don't want to test a corneal reflex yet. I'll test it when I'm ready. So that's how you test a blink to visual threat. Here's motor testing. You stimulate on the nail bed. You can see that this patient is not in coma. He opens his eyes, and he has some head turning with this. He has a little bit of extensor versus flexor posturing. Again, you always pinch immediately on the arm also. If you move towards a noxious stimulus, that's always pathological. You should move away. Stimulating on the legs is the same principle. You're going to stimulate typically at the great toe, right at the base of the nail, not on the skin, because it's easy to cause skin breakdown there. And you see this looks like triple flexion. But when I pinch him on the knees immediately, he has more complex movement of the legs that looks maybe triple flexion, but on the right leg it looks maybe purposeful. So you just write down what you see when you see it. Pupillary reactivity is obviously extremely important to test for. The pupils in brain death should be typically four to six millimeters. They can be anywhere two to nine millimeters. If they're less than two millimeters, you have to worry about drug intoxication, particularly with opioids. A magnifying glass can be helpful, or pupilometers can be helpful with this as well. I don't own any stock in the companies. This is my hardware store flashlight with a magnifying glass. That's my own pupilometer. It costs about $6. This one costs about $4,500. This is an automated pupilometer. But the nice thing about these is that they automatically check a second time. They do not like to not get a reaction on the pupil. And so one, two, three, boom. Oh, I missed it. Boom, there it goes. It shines a light again. It's always automatically going to check a second time as well. All right, who here, show of hands, who uses a saline squirt or a sterile water to check a corneal reflex? Anybody? I do. I do it all the time, every day, multiple times a day. If you get a corneal reflex to that, they've got a corneal. So you're good, and you haven't injured the cornea in any way. But that's not a potent enough stimulus to be definitive in brain death or post-cardiac arrest. And where you touch on the eye is important also. This is a heat map from over 900 intensivists and neurologists saying, where do you touch on the eye? And a lot of people were pretty far lateral. Some people miss the eye entirely, which is sad. But the farther you get out on the sclera, the less sensitive the eye is. So you really want to go right at the border. Sorry. I didn't want to do that. Help. I'm working on it. You go right at the border of the iris right here. And I'll show you what it looks like. And you want to give some pressure. So this looks gross. You are not going to injure the patient. But this is how you know that you've given a potent enough stimulus that the patient does not have a corneal reflex. That's how you test it properly. What are doll's eyes? Somebody writes dolls plus in the chart. Is it an old doll? Is it a new doll? The eye is supposed to move. It should be called the oculocephalic reflex. And it's tested only when you have integrity of the c-spine and an intact skull base as well. You briskly rotate the head horizontally. You should see no eye movements in a brain dead patient. You want to stabilize the endotracheal tube, as you see me doing now, and hold the eyes open with the other hand. And you move your hands in unison so you do not dislodge the ET tube. Again, in brain dead, there is no movement. This is what it looks like in a normal patient. This is my friend Fernando, who has a very nice brain stem. If you can't test the oculocephalics because of the c-spine or the skull base, it's the one thing you can skip, provided that you can still do the oculovestibular or the cold calorics. That's an important thing to remember. This is the one test that you can skip. How do you test the oculovestibular test correctly? So first of all, look in the ear to make sure you've got a clean path to the tympanic membrane and that the tympanic membrane is intact. You elevate the head of the bed to 30 degrees. You irrigate one ear at a time with ice cold water. And you're observing for one minute to see if there's any eye movements. Again, in brain death, there should be no eye movements. You see, it's a two person operation. Somebody's helping me to hold the eyes open while I instill the water in one ear at a time. And you wait five minutes before testing the other ear. Confounders for these tests include ototoxic drugs, as you can see listed here. More commonly, like in a TBI patient, you're gonna have a restrictive defect because they've got trauma and edema on their face and their eyes just simply can't move. Again, you test what you can when you can, but you're gonna need to get an ancillary test in that situation. You should see no facial movement to noxious stimulation. We talked about the places to stimulate. You can get facial myokinemias, which are spontaneous discharges of the facial nerve, but should not happen in response to anything you do to the patient. They should have an absent gag and an absent cough, and they should not be over-breathing the ventilator. You guys all know what a nasal tickle looks like. You can see this on both sides here. Here's a gag reflex. Sorry. Oh, what did I do? Oh, no. No. This is very bad. Okay, here it goes. So this patient had a very large tongue, and I had to squeak the Q-tip past the tongue and stimulate both sides of the soft palate, and a cough reflex. Everybody knows how to do inline suctioning, so I'm not gonna show you how to do that. This is the auditory response by. Sorry. This is a video from the New England Journal that we published a couple years ago that goes through all of this in five minutes. If you haven't done a brain death evaluation in a while, and you're going in to do one, this can be very helpful for you. Five minutes, free on New England Journal's website. Just search brain death on NEJM. All right, apnea testing. Coming to the close here. So apnea testing should only be done in a controlled environment in the ICU by skilled providers who know what they're doing. Prerequisites, they have to be normotensive, which means now not only is systolic greater than or equal to 100, but a MAP also of 75 or greater. In PEDS, it's above the fifth percentile. They have to be normothermic, and they have to be euvolemic. In patients who've had DI, they may be hypovolemic, and they be at risk for getting hypotension during the exam. You wanna establish eucapnea unless they're a known CO2 retainer. I'll get back to that in just a second. And a normal pH. And I recommend getting a functioning A-line for every patient. What if they're a CO2 retainer? Well, if you know what their baseline is for their CO2, that's the baseline that you start with for the test, and you're gonna go for 20 points above that elevated baseline. If you suspect it, but you don't know what their baseline is, then you can estimate going above a certain level, maybe trying to get a PCO2 of 70, but you have to get a ancillary test in that situation. So that's the new guidance regarding CO2 retention. Everybody gets pre-oxygenated, you establish eucapnea, and you disconnect the patient from the ventilator. There's no question then whether the patient took a breath or not. That's at least in adults. In children, they do it differently. You wanna provide oxygen to the level of the carina at a flow rate of no faster than four to six liters per minute. Faster than that, you can cause barotrauma and wash out CO2. There are alternative methods that can be used, including a flow-inflating resuscitation bag with a functioning PEEP valve. That's commonly done in children. You typically observe for eight to 10 minutes. You can send ABGs along the way. What you're looking for is an absence of respiratory effort. You bear the chest and the abdomen. Look for any respiratory effort. And you want the PCO2 to be above, I'm sorry, 60 or above and 20 above. That and is new. It used to be or. It's and, it's both. And especially in an elevated baseline. And you have to have the pH now less than 7.3. That's new also. You can go for longer. But you, again, have to re-establish hyperoxygenation and normal carbia. You abort the test if they breathe, obviously. If they drop their blood pressure. If they have a progressive O2 sat less than 85%. Cardiac arrhythmia is with hemodynamic instability. But get an ABG right before you reconnect them to the ventilator. I recommend hyperventilating everybody, whether or not they got hypotensive. The patient is acidotic. You caused an acidosis. That's the whole point. To rapidly correct that, you can do gentle hyperventilation. We do provide new guidance for apnea testing on ECMO. And this is very important. There's two different kinds of ECMO, obviously. And so whether they're on VA or VV ECMO, we have blood pressure targets. And we have the places that you need to sample the arterial blood gases from to make sure that you're consistent with what the brain is seeing. So take home messages from my portion of the talk. Use meticulous technique. This is a matter of life and death, literally. So please do it correctly. Always perform everything you can, when you can. Do not go straight to ancillary testing. The only part of the clinical exam you can skip is the oculocephalic. Only if contraindicated. And only if you can do the oculovestibular. Please be aware of the new blood pressure goals for adults and children. And the new guidance regarding CO2 retention and patients on ECMO. And practice, practice, practice. This is a great place to use simulators to get really good at your exam and to go through scenarios. So I think that's it. Thank you very much for your attention. And remember, we will have time for discussion. Everybody's doing a great job of staying on schedule. Thank you guys. So our next speaker, bringing up will be Dr. Arianne Lewis. She is a professor in the departments of neurology and neurosurgery. And the director of the division of neurocritical care at NYU Langode Medical Center. She also was a major contributor and lead on this effort. And she's gonna be speaking to us on ancillary testing and special considerations for brain death DNC evaluation. Thanks. Thanks, Lori. These are my disclosures, very similar to Matt and Dave's. So I'm gonna be talking first about ancillary testing for the brain death evaluation. Prior studies over the past few years have demonstrated that there's variabilities in the perspectives of providers on when they should be employing ancillary testing as part of the brain death evaluation. The new guidelines provide clear guidance about when ancillary testing should be used. Ancillary testing should be performed when the full exam or the apnea test can't be fully completed, or the findings can't be interpreted adequately. As Dave mentioned, ancillary testing is not a substitute for the clinical examination as a whole. This brain death evaluation as general is a primarily clinical process. And so you should not be employing ancillary testing instead of doing a clinical exam. When thinking about when to do ancillary testing, it's if there's inability to correct the metabolic derangements adequately, but the exam and apnea test is consistent with brain death. If there's inability to perform some components of the evaluation, such as if there's a cervical fracture or facial injury, inability to interpret what the exam findings indicate in terms of whether they're spinally mediated or brain mediated findings. If the apnea test can't be completed due to instability, or if there's knowledge or suspicion of hypercarbia without knowledge of the chronic baseline, PaCO2, since there's specific guidance in terms of what the target should be for those patients. The guidelines also provide information about contraindications for ancillary testing. So ancillary testing should not be used as part of the exam or as part of the evaluation if there's any prerequisite that's not been met. So for example, if there's patients hypothermic, you shouldn't use ancillary testing as a substitute for rewarming them adequately. You shouldn't use ancillary testing if there's high levels of sedating medications. You shouldn't use ancillary testing as a substitute for any testable element of the brain death evaluation. Or if there's any finding in the evaluation that's consistent with life, then ancillary testing should not be employed. The patient is not brain dead, the patient is alive. And then also the guidelines specifically note that ancillary testing is not indicated just because there's an open fontanelle or a skull fracture or skull defect. Prior studies also have demonstrated that institutional policies vary with respect to the recommended ancillary studies. The new guidelines clearly indicate the accepted ancillary studies are TCDs in adults only, a radionucleotide cerebral blood flow scan or four vessel angio. The new guidelines also specifically indicate what studies are not allowed. So now we're gonna talk about special considerations for the brain death evaluation. There's been a lot of controversy over the past few years, particularly in the literature about whether consent should be required for brain death evaluation. And some of this has made its way to the public media, particularly secondary to lawsuits. There are arguments both for and against the need for consent prior to brain death evaluation. In surveys of pediatric and adult neurologists and intensivists demonstrate that about three quarters of us feel that consent should not be required. The new guidelines clearly indicate that it's necessary to make a reasonable attempt to inform the patient's family of the plan to perform the evaluation and to provide them with education about brain death. This requires communication, including an explanation of the concern for the brain death, an explanation of the legal equivalence between brain death and death by circulatory respiratory criteria, the intent to perform an evaluation, noting that the goal is to evaluate for any signs of life. As Matt noted, it should not be specified that the purpose of doing the brain death evaluation is to prove that you indeed are correct, the patient is brain dead. Rather, the purpose of doing the brain death evaluation is to look to see if there's any evidence of signs of life. And also to note during this discussion that it's possible that there could be reflexive movement due to spinal or muscular or nerve activity. Families should be invited to observe the evaluation, but there's no obligation to obtain consent unless it's stipulated in institutional policy or state laws or regulations. And notably, there's no state that actually has a legal requirement to obtain consent prior to the evaluation. The guidelines also address the situation as to whether or not preservation of neuroendocrine function should impact the evaluation process. This is something that also has been debated. As is noted here, studies demonstrate that diabetes insipidus is present anywhere between nine and 90% of the time when brain death is declared. However, there are some who argue that diabetes insipidus should always be present when declaring brain death. The new guidelines specify that evidence of neuroendocrine function does not preclude the brain death evaluation, noting that irreversible cessation of all functions of the entire brain, including the brainstem, which is part of the legal definition of death in the Uniform Determination of Death Act, should be interpreted to mean loss of function of the brain as a whole resulting in coma, brainstem areoflexia, and apnea in the setting of inadequate stimulus. The new guidelines also provide information about how to handle brain death evaluation in a patient who has a primary posterior fossa injury. The majority of the time when brain death is being considered, patients have primary supratentorial injury that leads to downwards herniation. However, studies demonstrate that between 2% and 16% of the time when brain death is being declared, this starts as a primary infratentorial injury, and that some of these patients may not actually have supratentorial injury due to upwards herniation. So in order to ensure that there is loss of function of the whole brain, the new guidelines specify that patients must have imaging that demonstrates catastrophic supratentorial injury prior to conducting a brain death evaluation. So there must be catastrophic injury both supratentorially and infratentorially when the evaluation is being conducted in patients who have primary infratentorial injury. The new guidelines also provide information about brain death evaluation in a patient who is pregnant. Prior studies had demonstrated that there's lack of guidance in US hospital policies for brain death determination about how to handle pregnancy. So the new guidelines specifically note that pregnancy is not a contraindication to brain death evaluation. Additionally, they note that after brain death determination in a pregnant patient, clinicians should provide care and clinicians with expertise in MFM, child neurology, neonatology should educate surrogate decision makers about the risks and benefits of continuing organ support to the fetus and allowing them to make decisions about how to proceed. The new guidelines also specify the time of death and provide information about discontinuation of organ support after brain death determination. With respect to the time of death, the guidelines indicate that the time of death is the time the arterial blood gas at the end of apnea testing results are consistent with brain death or if ancillary testing is employed, then the time when an attending clinician reads the study and documents that the results are consistent with brain death. With respect to discontinuation of organ support after brain death determination, the new guidelines indicate that support may be continued for a period after brain death determination for a duration that's deemed appropriate by the attending and institutional policy if it's necessary to provide the family with a reasonable but limited time prior to discontinuation of support. And the guidelines also specify that institutional policies should describe the process to resolve disagreements with families who may object to discontinuation of support. Thank you very much. »» All right. So I get the pleasure of wrapping this up by spending some time talking about how does this actually impact on us as intensivists. This guideline has come out. What do we need to do? Disclosures fairly similar, no financial ones, but I have been part of the working group and was the liaison and representative of FCCM on the group. So some general thoughts for intensivists. Determination of death based on neurologic criteria is done in the critical care setting. Thus, all intensivists must be familiar. That's the greatest impact. You all need to know this. This is your job, okay? Show of hands, how many in this audience have been part of a brain death exam in the last three months? Good. So we all know that this is important. Another major issue is we wanted to standardize language within institutions, across institutions. We wanted to have a consistent approach to how you determine brain death so that we can build public trust in this area. Just today I heard somebody use the term essentially brain dead. We need to strike that language from our vocabulary. You're either brain dead or you are not. We cannot use inaccurate terms in this situation. We have to manage care appropriately. We have to prognosticate appropriately. We have to declare death in patients with this level of injury appropriately. So death is death. And we need to be 100% accurate 100% of the time. So what do you need to do? This guideline is out now. Review it. And review your local policy. When was the last time it was updated? Do you need to change this? What are your own state laws? Because they vary. Does your institution have overarching policies? Some of the institutions that have religious affiliations may have overarching policies that vary from state. Do you have separate policies for adult and pediatrics? We did. We're now going to combine them all together. So UPMC is going to have one policy for all age. What updates do you need to do? Be prepared for that. And who will be overseeing these policy updates? Who's going to have some comments about this? I am not going to get into issues regarding the UDDA and efforts to update that. It is still in place, and we're going to follow that practice. So a few state laws. This gives you a breakdown of which states use the UDDA, which states have enacted it, but also have other variations. The brain death concept only applies when artificial life support is used. I think most of the patients are on artificial life support. So light blue should be the same as the dark blue. The gray, brain death is a criteria for death is permissive, but it's not required. And then black areas, brain death must be accompanied by the loss of spontaneous respiratory function in order to constitute death. Well, that's the apnea test. So be aware of your own laws and be able to address them. There's other special considerations. There are certain states that require unique things, that you accommodate religious or moral objections, that you have a specialist in neuroscience doing this rather than an intensivist. So be familiar if you have special considerations by the laws in your particular states. Then know about pregnancy. In preparing for this, I actually wasn't aware of some of the state laws regarding pregnancy. And it turns out that if you happen to be in Texas, and even if you have advanced directives that say what you want done in the event of a catastrophic neurologic event, if you are pregnant, those don't count anymore. Your advanced directives as a woman in the state of Texas if you are pregnant are null and void. So be aware of these laws. Revising your own policy, coordinate efforts, please. Identify your stakeholders, not only in your hospital, but in your community. Who is going to have some input on this? Who may have some thoughts? Intensivists, neurosurgery, neurology, common stakeholders. But what about other services? Do you have a post-cardiac arrest team? Do you have an organ donation support team? Your local organ procurement agency. Are there providers that will contribute to this, radiology, interventionalists? They need to be on board if they're going to be part of the testing. And I already mentioned your community groups. Know your local resources. What do you have available? You notice that EEG is now not an ancillary test anymore. So what is available at your location? Both providers, do you have adequate number of providers that are competent in doing this and have training and credentialing? Do you have backup options in place to get extra assistance? And what are your ancillary testing options locally that you have? Regarding remote locations, Dr. Joe Darby was the lead on this. He's one of my colleagues at UPMC, and we actually did a small study but looked at using tele-ICU to support providers in remote locations. So if they hadn't done a brain death exam for an extended time period, we didn't want to transport the patient all the way down to our helicopter ride to do this exam. Could we provide support and help do the exam and talk people through it remotely? Please look at this. It actually was only 29 patients, but we did 30 exams, and there was anywhere between 97 to 100 percent agreement. The 97 was usually when it came to pupils, and it was dark eyes, and you couldn't see the pupils well. So we actually started using pupillometry and made that a requirement because the pupillometry was accurate in that situation. Standardization of doing your exam. If you don't have checklists, do it. We're in the process of creating a checklist for preparation for doing the exam. How do we script this? How do we discuss it? How do we make sure that everybody's on board to do this properly? And then what are the examination steps? Dr. Greer did a great job of walking you all through it, but if it's been a little while, make sure you have the steps available so you don't skip anything. There is no cutting corners on this exam. So develop these. Have them available. If you need help getting started, there are tools available to you. The American Academy of Neurology has this option that you can go in and there is a link and it will actually walk you through the process of doing this evaluation. There are a number of options available to assist you in making sure that you are doing this correctly. There is standardization training. The Neurocritical Care Society has the brain death toolkit. There is also a brain death determination course that is being revised to reflect the current revised guidelines. But these are in place to help people so you can get adequate training and develop a local credentialing process in your own institution to make sure people doing this test know how to do it right and are competent to do it. I also want to make sure just to emphasize, and this is my last area of focusing on, communication and accuracy. Communicate to your staff. Work as a team, okay? Respect each other and recognize there may be unspoken needs. This is often uncomfortable for people to go through. Families have a hard time understanding this. Use your team as a group to help make sure that we've identified if there are any people that need assistance with this or are uncomfortable with it. And then communication to family. I want to end with something Dr. Kirshen actually talked about that's so important. Empathy, respect, body language when you're talking to families. Be aware of potential cultural differences. Address them up front. Let families know what you're going to do. And watch your word choices, okay? After the patient has been declared, don't send mixed messages. The patient is no longer on life support. They are dead. They are now on organ support. Don't examine the patient again once you've declared them dead. If you walk in the room to see them, I've put my hand on a family member's shoulder. I talk to the family members. If I do anything to the patient, it's usually just resting my hand on their hand in a calm type of way. But I don't examine the patient again. Don't send mixed messages. And make sure you use all support systems in your hospital. The family will need assistance. Chaplains, social workers, whatever the family needs, help them through this so that they feel comforted through the most horrific experience they're going to ever encounter. So in summary, intensivists need to be familiar with this process. There is a revised guideline. There are state laws that vary. Cultures differ. Be aware of those differences. Evaluate your local policies. If you have not done it, go back and start doing it right now. Standardize your test. Make sure people know how to do the test properly. Maintain your own competency. And then choose your words. Let's be accurate 100% of the time. And with that, we now have lots of time that we can answer questions, discuss different things. And I'm going to open this up to discussion.

Brain Death Guidelines

Pediatric and Adult

Neurologic Criteria

Medical Technology

Ancillary Testing

Evaluation Process

Policy and Communication

Consensus Practice