First report of transiently reversible brain death after induced hypothermia (Crit Care Med) - PulmCCM
Dec 262011

Webb and Samuels (Emory neuro-intensivists) report on a brain-injured patient who, after induced hypothermia and rewarming, had absent brainstem function and a confirmatory apnea test. However, in the O.R. for organ donation 24 hours later, brainstem function transiently returned and the surgery had to be aborted. They urge caution to the rest of us in declaring brain death after induced hypothermia. Crit Care Med 2011;39:1538-1542.

For Dr. Webb's personal comments on this experience (or to add your own), click the "Responses" icon in the upper right of this post.

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  3 Responses to “First report of transiently reversible brain death after induced hypothermia (Crit Care Med)”

  1. This case has been a humbling experience and one that we thought very important to share with the critical care community. With the widespread use of targeted temperature management in comatose survivors of cardiac arrest, this will become an increasingly important issue. Hypothermia greatly alters both the progression of brain injury after global ischemia as well as the clearance of commonly used sedatives and analgesics. Though only a small fraction of these patients suffer injury severe enough to progress to brain death, our current clinical criteria and process for the determination of brain death is not adequate for these patients. Careful consideration should be made for the use of confirmatory testing in addition to standard clinical examinations.

    • Dr. Webb: I’m curious as to what you mean by “confirmatory testing in addition to standard clinical examinations?”

      Reading the paper, it sounds like you all did everything by the book (with an apnea test that confirmed brain death). After all, you’re who we often consult to make sure we’re doing everything properly for cases of possible brain death in the MICU.

      What additional testing do you suggest? Or, short of suggesting, would you share with us what you else you plan to do the next time you have a brain death examination after therapeutic hypothermia / targeted temperature management?

      Thanks for your comment and for sharing your experience.

      • Apnea testing is part of the clinical brain death exam and is not a confirmatory test.

        Confirmatory tests for brain death as stated in the American Academy of Neurology guidelines include EEG showing absence of cerebral cortical electrical activity, Transcranial doppler showing reversal of or absent diastolic cerebral blood flow, conventional cerebral angiography and Nuclear Medicine cerebral blood flow studies. The latter is by far the most common and preferred.

        Confirmatory testing should be done in any patient who cannot undergo full clinical brain death testing (i.e. too unstable for an apnea test) or in a patient in whom you cannot completely exclude confounding factors (i.e. has been on a barbiturate infusion for ICP).

        We are suggesting in this report that targeted temperature management after cardiac arrest should be considered a confounding factor regardless of if the patient is now normothermic or how long the patient has been off sedatives as we simply cannot predict the effects.

        Your point about calling the neuro-ICU team is an important one. First, brain death testing should only be done by those familiar with brain death, protocols and guidelines. Many intensivists are but many are not. This case shows us how difficult brain death determinations can be even when performed by those who do this every day. It is something that for obvious reasons we have to get right every time.