Thanks, Lori. These are my disclosures, very similar to Matt and Dave's. So I'm going to 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, in 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 the patient's 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 4-vessel angio. New guidelines also specifically indicate what studies are not allowed. So now we're going to 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 areflexia, 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, every clinician 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 policy should describe the process to resolve disagreements with families who may object to discontinuation of support. Thank you very much.

brain death evaluation

ancillary testing

consent misconceptions

posterior fossa injury

organ support discontinuation