1. Part 1 when the patient is awaiting cardiac arrest = category 3 DCD ; severe brain damage without brain death has occurred; here you would expect brain stem reflexes
2. Part 2 ; After consent from the family, the ventilator is switch off and cardiac arrest is awaited.
YES.
With sever brain damage in category 3 ,It is expected to have brain stem reflexes.
And might be become a DBD donor if mechanical ventilation is prolonged until the criteria for total brain failure have been met. When the ventilator is turned off and determination of death by circulatory criteria in this time expected to have brain stem reflexes.
*Yes , the patient is awaiting cardiac arrest which is category III in Maastricht criteria has already massive brain damage but brain stem is still functioning.so gag reflex may be positive
Yes, while the patient is waiting for cardiac arrest (NHBD category III; serious brain injury without considering him as brain stem dead. we would anticipate brain stem reflexes to be present when the patient is in this state.
Being DCD does not require being DBD for sure. The patient has SAH grade IV which implies severe brain damage not brain death. So, it is expected to have some positive brain stem reflexes.
Yes, because the patient bearing a severe brain damage – irreversible, with poor prognosis, put him on waiting cardiac arrest category class 3. despite this damage ther may some sort of brain stem function.
Andrews PA, Burnapp L, Manas D; British Transplantation Society. Summary of the British Transplantation Society guidelines for transplantation from donors after deceased circulatory death. Transplantation. 2014 Feb 15;97(3):265-70. doi: 10.1097/01.TP.0000438630.13967.c0. PMID: 24448588.
DCD category 3 (controlled )donor is ventilator dependant , may express some brain stem reflexes(So yes) , unable to maintain vital functions , and cardiac arrest is inevitable.
● This is acase of Controlled DCD category 3 with sever irreversible brain damage but he still having brain stem reflexes
● I will go ahead and withdraw treatment after explain the case to his family and the consent had taken
The criteria for the diagnosis and confirmation of death within DCD protocols will need to recognise, where relevant, the possibility of spontaneous return of the circulation as well as clinical interventions that might restore cerebral perfusion whilst the brain retains some sensitivity to the restoration of oxygenation.
BTS
Yes in case of controlled DCD Maastricht Category 3 where brain death didnot occur yet so brain stem reflexes and complex motor activity can be noticed
delay between circulatory arrest and organ preservation may cause acute ischemic injury DCD.
in this scenerio is crucial to know the time of circulatory arest and on the other hand the time of diagnosis of SAH if within 3 days that explain still there is intact brain stem function
referenes Wolfe RA, Ashby VB, Milford EL, Ojo AO, Ettenger RE, Agodoa LY, Held PJ, Port FK: Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med 341: 1725–1730, 1999. [PubMed] [Google Scholar]
a patient with a true gag reflex does not fulfil the criteria of Brain death but grade 4 SAH means stupor. This patient should be evaluated in the context of expected or invertible /awaiting death. At that time, evaluation and discussion with the family should begin.
As this DCD, no DBD, brain stem reflexes can be present. He is not yet brain dead and this will occur after withdrawing treatment, bur he has irreversible brain damage.
DCD donors especially category 3 Maastricht criteria could have brain stem reflexes like gag reflex. This patient is awaiting cardiac arrest.
ahmed saleeh
2 years ago
How do you explain this event?
Category 3 DCD awaiting heart arrest due to severe brain damage
Will you go ahead and withdraw treatment?
I shall proceed with Tx after family consent
Theepa Mariamutu
2 years ago
Reflexes of gag may be present and should not be confused against the diagnosis of brain death. It can present when the patient is awaiting cardiac arrest or severe brain damage without brain death has occurred, additionally, when consent from the family, the ventilator is switch off and cardiac arrest is awaited
Clinical testing for brain death
Coma: Absence of response to noxious stimulus except for spinally mediated reflexes.
Absent brain stem reflexes (a formal evaluation of the brain stem reflexes is undertaken when the patient has had fixed dilated pupils and absent cranial nerve reflexes for more than 4 h).
Apnea test: The aim of this test is to check for the integrity of the brain stem respiratory Centre at high levels of blood carbon dioxide.
Will you go ahead and withdraw treatment?
Yes, after explaining the situation to next of kin
Tahani Ashmaig
2 years ago
▪︎How do you explain this event?
Because this a potential DCD donor , not DBD some reflexes of the brain stem can present .
▪︎Will you go ahead and withdraw treatment?
Yes.
Mu'taz Saleh
2 years ago
this patient is considered category 3 of DCD as he has severe brain damage SAH grade 4 and brain death didn’t occur till now .
He has cardiac arrest not brain death
Patient prognosis should be discussed with the relatives by one who is from outside transplant team and after their consent treatment can be withdrawn waiting for cardiac arrest.
Transplantation from deceased donors after circulatory death, British Transplantation Society Guidelines, 2013
Hinda Hassan
2 years ago
How do you explain this event?
There are a variety of tests a physician can administer in order to diagnose brain death: brain stem reflex assessments, apnea tests, and coma appraisals that determine if a patient has truly passed.14 Examples of tests include searching for an absence of gag reflex, corneal reflex and cough reflex. Other tests look for high body temperature or lack of spontaneous respiratory effort. The time of brain death is marked as a patient’s legal time of death, and then donation after brain death (DBD) can occur. In contrast, cardiac death, or non-heart-beating death, occurs when a patient cannot be legally declared dead due to lingering neurological activity, yet the patient has no chance of recovery.(1)
Will you go ahead and withdraw treatment?
Predicting time to death in controlled donation after circulatory death (cDCD) donors following withdrawal of life-sustaining treatment (WLST) is important but poses a major challenge. In a single-center retrospective study, the data of 92 potential cDCD donors was used. Multivariable regression analysis demonstrated that absent cough-, corneal reflex, lower morphine dosage, and midazolam use were significantly associated with death within 60 minutes (area under the curve [AUC] 0.89; 95% confidenence interval [CI] 0.87-0.91). External validation of the logistic regression models of de Groot et al (AUC 0.86; 95% CI 0.77-0.95), Wind et al (AUC 0.62; 95% CI 0.49-0.76), Davila et al (AUC 0.80; 95% CI 0.708-0.901) and the Cox regression model by Suntharalingam et al (Harrell’s c-index 0.63), exhibited good discrimination and could fairly identify which patients died within 60 minutes. Previous prediction models did not incorporate the process of WLST. (2)
(1)Taylor Sihavong, Organ Transplantation after Cardiac Death(file:///C:/Users/Tecnology/AppData/Local/Packages/Microsoft.MicrosoftEdge_8wekyb3d8bbwe/TempState/Downloads/SJPH+16-17+Taylor+Sihavong%20(1).pdf) (2)Kotsopoulos, AMM, Böing-Messing, F, Jansen, NE, Vos, P, Abdo, WF. External validation of prediction models for time to death in potential donors after circulatory death. Am J Transplant. 2018; 18: 890– 896. https://doi.org/10.1111/ajt.14529
Alyaa Ali
2 years ago
1.controlled CDC category III
cardiac arrest following the withdrawal of life-sustaining treatments but not considered to be brain dead
brain stem still has some function , so gag reflex is positive
2.yes
Hamdy Hegazy
2 years ago
How do you explain this event? He was DCD not DBD so he may still have intact brain stem reflexes like gag reflex. Will you go ahead and withdraw treatment? Withdrawal of treatment can be started.
Nasrin Esfandiar
2 years ago
Q1: DCD donors in category 3 Maastricht criteria could have brain stem reflexes. Q2: In the case of explanation to family and their agreement, we can go ahead and withdraw the treatment.
Heba Wagdy
2 years ago
The patient is considered category 3 of DCD according to Maastricht as he has severe brain damage SAH grade 4 and brain death didn’t occur yet.
Patient prognosis should be discussed with the relatives by one who is from outside transplant team and after their consent treatment can be withdrawn waiting for cardiac arrest.
Transplantation from deceased donors after circulatory death, British Transplantation Society Guidelines, 2013.
Ahmed Abd El Razek
2 years ago
DCD donors can still have intact brainstem reflexes as gag reflex owing to the cause of arrest is primarily cardiac origin.
No contraindication for treatment withdrawal after confirmation by neurology team and proper explanation for the relatives.
The donor has suffered a cardiac arrest (DCD) and has sub arachnoid hemorrhage…The donor however has intact brain stem functions as evidenced by positive gag reflex…The patient has controlled cardiac death…He is Masstricht category III – awaiting cardiac arrest…These kind of patients are seen in various CCU, ICU, neurosurgery units on ventilator and are awaiting cardiac arrest when there is severe brain damage….
There is severe brain damage in the patient which will inturn lead on to a cardiac arrest eventually…A multi disciplinary approach involving ICU consultants, nephrologists, neurolgists, neurosurgeons should be discussed and when the consensus for point of no return is obtained we can proceed with withdrawal of treatment
Ramy Elshahat
2 years ago
DCD it means cardiac death so brain stem reflex will be intact
So, yes treatment withdrawal can be started right away.
Wee Leng Gan
2 years ago
This potential donor has severe brain injury, not yet brain death, Category 3 awaiting cardiac death ( Masstricht Category of NHBD ). Hence there is positive gag reflex.
I will go ahead for DCD donor after counseling next of kin. SAH grade 4 has poor prognosis.
Esraa Mohammed
2 years ago
Diagnosis of Death
Death is irreversible and should be regarded as a state in which a patient has
permanently lost the capacity for consciousness and brain stem function. (A1)
Where cardio-respiratory criteria apply, death can be confirmed following five minutes
of continuous cardio-respiratory arrest providing there is no subsequent restoration of
artificial cerebral circulation. (B1)
Where possible, circulatory arrest should be identified by the absence of pulsatile
flow on a correctly functioning arterial line, or by the use of echocardiography if the
expertise is available; or failing that by continuous ECG monitoring. (B1)
DCD organ retrieval protocols should recognise the potential risks around post
mortem interventions that might restore cerebral perfusion. (B1)
The criteria for the diagnosis of death following loss of circulatory function should not
be influenced by the possibility of subsequent organ retrieval. (A1)
4.4 The Decision to Withdraw Futile Life Sustaining Treatments
-The exact definition of death has given rise to significant ethical debate, which is reflected in the variability of definition between societies (1,2). The key ethical principle is that donation should proceed only after death has been established and no prospect of spontaneous auto-
resuscitation exists (5). Similarly, the decision to cease attempts at life preserving treatments should be taken in a manner independent of donation/transplantation considerations and be
based purely on the concept of futility with respect to the prolongation of life. Guidance on the determination and diagnosis of death can be found in the Academy of Royal Colleges Code of Practice for the Diagnosis and Confirmation of death (2008) (4). However, there
remains no statutory definition of death in the UK and the working definition ‘the irreversible loss of the capacity for consciousness combined with irreversible loss of the capacity to breathe’ put forward by the Department of Health seems to have been adopted as the pragmatic approach.
References
1. Controversies in the Determination of Death: A White Paper by the President’s Council
on Bioethics. US Government Printing Office 2011. ISBN 0160879035,
9780160879036.
2. Dhanani S, Hornby L, Ward R, Shemie S. Variability in the determination of death after
cardiac arrest: A review of guidelines and statements. J Intensive Care Med 2012; 27:
238-52.
3. Bernat J, Capron A, Bleck T, et al. The circulatory-respiratory determination of death in
organ donation. Critical Care Medicine 2010; 38: 972-9.
4. Academy of the Medical Royal Colleges. A Code of Practice for the Diagnosis and
Confirmation of Death. London 2008. Available at http://www.aomrc.org.uk/reports.aspx
5. Hornby K, Hornby L, Shemie SD. A systematic review of autoresuscitation after
cardiac arrest. Crit Care Med 2010; 38: 1246-53.
amiri elaf
2 years ago
# How do you explain this event?
A potential DCD donor with SAH Grade 4 has positive gag reflex, still functioning brain stem (maastricht Category 3): Awaiting cardiac arrest Death is inevitable but brain stem death criteria are not fulfilled.
# Will you go ahead and withdraw treatment?
*Yes, I will go a head and withdraw treatment as recommend by BTS guideline:
*The key ethical principle is that donation should proceed only after death has been established and no prospect of spontaneous autoresuscitation exists. Similarly, the decision to cease attempts at life preserving treatments should be taken in a manner independent of donation/transplantation considerations and be based purely on the concept of futility with respect to the prolongation of life.
Transplantation from deceased donors after circulatory death
Compiled by a Working Party of The British Transplantation Society
July 2013
Abhijit Patil
2 years ago
This patient is Maastricht Category 3: Awaiting cardiac arrest.
” Organ donation which follows circulatory arrest. This may be in the context of withdrawal or non-escalation of cardio-respiratory treatments that are considered to be no longer in a patient’s best interests ”
BTS guidelines state that ” Where cardio-respiratory criteria apply, death can be confirmed following five minutes of continuous cardio-respiratory arrest providing there is no subsequent restoration of artificial cerebral circulation.”
So, a DCD donor may have intact brain stem reflexes.
We can inform the next to kin of the deceased donor and proceed.
Last edited 2 years ago by Abhijit Patil
Amit Sharma
2 years ago
How do you explain this event?
A potential DCD donor is not brain dead, hence may retain brainstem reflexes, responsible for the positive gag reflex.
Will you go ahead and withdraw treatment?
As this is a potential DCD donor, we should go ahead and withdraw the treatment, after explaining the scenario to the family members, and getting consent.
Reference:
1) Thuong M, Ruiz A, Evrard P, Kuiper M, Boffa C, Akhtar MZ, Neuberger J, Ploeg R. New classification of donation after circulatory death donors definitions and terminology. Transpl Int. 2016 Jul;29(7):749-59. doi: 10.1111/tri.12776. Epub 2016 May 4. PMID: 26991858.
AMAL Anan
2 years ago
How do you explain this event?
potential donor with DCD (SAH ) grade 4 still with positive gag reflex considered category III according to mastricket classification hello is awaiting for brain death.
Sever brain damage but brain death not occured those patient are usually ventilator dependent after consent can be taken from relatives we can switch off ventilator and wait for cardiac arrest the atonal time is up to 2 hours to avoid damage from hypotension and for liver up to one hour brain stem still not confirmed so gag reflex still preserved.
Will you go ahead and withdraw treatment?
I will proceed with this donor
Rehab Fahmy
2 years ago
Subarachnoid hemorrhage grade 4 by Hunt and Hess grading has survival 20% so it is one of the irreversible brain damage
So it is not yet brain death ,that’s why gag reflex still present
So this is Mastricht category 3 DCD awaiting cardiac arrest ,brain stem death is not fulfilled
So we can proceed for organ retrieval if the family agrees
CARLOS TADEU LEONIDIO
2 years ago
How do you explain this event?
The gag reflex is a type of brainstem reflex, so it is expected to occur in patients with circulatory failure.
Will you go ahead and withdraw treatment?
Yes, because the donor has a damage brain injury that is irreversible that will evolve with DBD.
Dalia Ali
2 years ago
How do you explain this event?
This patient have Maastricht Category 3: Awaiting cardiac arrest which mean that the
Death s inevitable but brain stem death criteria are not fulfilled.
These patients are cared for in many areas within hospitals, but are most commonly identified in neurosurgical and general intensive care units, coronary care units, emergency departments and medical wards
Will you go ahead and withdraw treatment?
The process of organ donation starts with treatment withdrawal, following which the patient’s vital signs, in particular the blood pressure, deteriorate at varying rates until cardiac activity ceases (asystole).
Following the verification of death, organ retrieval begins with perfusion of the donor with cold preservation solution.
Reference
British Transplantation Society Guidelines.
Transplantation from deceased donors after circulatory death
Muntasir Mohammed
2 years ago
How do you explain this event?
As this DCD, no DBD, brain stem reflexes can be present. He is not yet brain dead and this will occur after withdrawing treatment, bur he has terrible irreversible brain damage.
Will you go ahead and withdraw treatment?
Yes. Nothing to worry as his brain activity will be present till withdrawal of treatment.
abosaeed mohamed
2 years ago
– Potential DCD even with severe brain damage , can still have some brain reflexes.
– To go ahead & withdraw the treatment , it depends on the family agreement & consent , if they agreed for donation & consented , yes I will go ahead .
Zahid Nabi
2 years ago
A DCD donor can have severe brain injury with intact brain stem reflexes so this doesn’t stop donation. This patient has SAH grade 4 so he can have a positive gag .
Sahar elkharraz
2 years ago
This case is donor circulating death with severe brain damage but still brain stem functioning.
Yes i will go a head
Mohammed Sobair
2 years ago
Brain death not damage cause loss of gag reflexes.
Brain death confirmation needs loss of brain stem reflexes, including:
CN II: Loss of pupillary reflex (light reflex): Pupils should be fixed in mid-size or
dilated (4 to 9 mm) and not reactive to light; a magnifying glass can be used to
evaluate further.
CN III, IV, VI: Eye motion is lost in reaction to head movement “doll’s eye”).
CN V, VII: Loss of corneal reflex determined by using a cotton swab or drops of water/normal saline.
CN VIII: Loss of oculovestibular reflex (Caloric test). The test requires a cervical
spine integrity check and head elevation at 30 degrees. Irrigation of each ear by
50 to 60 ml of ice water won’t move the eyes towards the irrigated side within 1
minute of the test performed. Each ear should be irrigated after a pause of a
couple of minutes.
CN IX: Loss of gag reflex confirmed after stimulation of bilateral posterior
pharyngeal membranes.
CN X: Loss of cough reflex confirmed after tracheal suctioning.(1)
In Category III Maastricht classification patient who Awaiting circulatory death those patients for whom circulatory death occurs after a planned withdrawal of life-sustaining therapies (WLST), mainly cardiorespiratory support including inotropic and ventilatory support . Cardiac arrest is expected and the medical decision of withdrawal is taken in a multi-disciplinary approach, consistent with local/national legal requirements, by the clinical team together with the family, where further treatment is considered futile. In the initial description, the term “controlled” meant that the ischaemia time was short enough to consider recovery of liver, kidneys, pancreas and lungs.
In this period some brain tests reflexes can be there.
Decision to go a head and withdraw treatment is depends on local/national legal requirements
Manal Malik
2 years ago
follow the below
Iwill explain this event that it is early post circulatory death so ischemic injury of the brain stem not take place
iIwll go ahead and will not withdrawal treatment
Manal Malik
2 years ago
delay between circulatory arrest and organ preservation may cause acute ischemic injury DCD.
in this scenerio is crucial to know the time of circulatory arest and on the other hand the time of diagnosis of SAH if within 3 days that explain still there is intact brain stem function
referenes Wolfe RA, Ashby VB, Milford EL, Ojo AO, Ettenger RE, Agodoa LY, Held PJ, Port FK: Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med 341: 1725–1730, 1999. [PubMed] [Google Scholar]
Ahmed Fouad Omar
2 years ago
How do you explain this event?
We are dealing here with a controlledDCD donor category- maastricht category 3 , with SAH grade 4(severe brain injury) who is awaiting cardiac arrest.
The presence of marked brain damage does not preclude the presence of functioning brain Stem reflexes like the positive Gag reflex
Will you go ahead and withdraw treatment?
Yes I will proceed to withdraw treatment.
The decision to stop the attempts of life-preserving treatments should be completely independent of donation/transplantation considerations and be based purely on the concept of futility of that treatment with respect to the prolongation of life.
A meeting should be arranged with the family members to decide about the futility of that treatment and exploring any previous donor wishes. If they agreed about donation, they should be consented ,then proceeding with the termination of the ventilator support and the donation process.
Reference: BTS guidelines 2013 Transplantation from deceased donors after circulatory death
MICHAEL Farag
2 years ago
How do you explain this event?
this patient has SAH grade 4, and still no brain stem death so brain stem reflexes are expected; however, this patient has a very poor prognosis
Will you go ahead and withdraw treatment?
Yes I will go ahead after a discussion with the patient’s family
Reference: – BTS/Transplantation from deceased donors after circulatory death
Mohamed Ghanem
2 years ago
How do you explain this event? Our Potential donor is a DCD category 3 ( awaiting for cardiac arrest ) >> Controlled’ DCD donor.
that leads to Marked incomplete brain damage But still functioning Brain Stem ( Positive Gag reflex ).
Will you go ahead and withdraw treatment? The decision to stop attempts for life-saving treatments should be taken in a way independent of donation/transplantation respect. and confirming irreversible disability for consciousness combined with irreversible loss of the ability to breathe depending on MDT of (nephrology, Urology, Neurology, Radiology, and ICU teams ) and after ethical written consent from his relatives’ withdrawal treatment can be done.
Controlled DCD entails a period of time during which supportive treatment, often mechanical ventilation and inotropic cardiac support, are withdrawn. Best practice must reflect these ethical standpoints and local protocols should provide them.
References
Dhanani S, Hornby L, Ward R, Shemie S. Variability in the determination of death after
cardiac arrest: A review of guidelines and statements. J Intensive Care Med 2012; 27:
238-52.
Hornby K, Hornby L, Shemie SD. A systematic review of autoresuscitation after
cardiac arrest. Crit Care Med 2010; 38: 1246-53.
Nahla Allam
2 years ago
Clinical tests for brain death: Absent pupillary light reflex Afferent II cranial nerve, efferent III nerve Absent corneal reflex Afferent V nerve, efferent VII nerve Absent reflexes in the face and maxillary region Area supplied by V cranial nerve (trigeminal) Absent oculo-cephalic reflex Afferent VIII, efferent III and VI. Lateral 90° movements of the neck result in deviation of the eyes in an opposite direction with an intact brain stem. Cervical spine injury must be ruled out prior to testing Absent oculo-vestibular reflex The afferent is the VIII and efferent III and VI cranial nerves. With the patient at a 30° head up position (lateral semicircular canal becomes vertical), 50 ml of ice-cold saline is injected into the ear. Nystagmus with a slow component toward the side of injection is seen with a functioning brain stem (confirm intact tympanic membrane. Allow 5 min to elapse prior to testing the other ear) Absent pharyngeal (gag) and laryngeal (cough) reflex) Afferent IX and efferent X cranial nerves
Absent gag reflex is criteria of brain death .if present wait for cardiac arrest
Reference :
Journal of Anaesthesiology Clinical Pharmacology | April-June 2016 | Vol 32 | Issue 2
Reem Younis
2 years ago
How do you explain this event?
This potential donor is controlled DCD, maastricht category 3: Awaiting cardiac arrest. His condition is associated with brain damage, but not complete brain death, so he maintains some brain reflexes like the gag reflex. Will you go ahead and withdraw treatment?
-Yes, I will go ahead and withdraw treatment, and is best done in the operating theatre complex wherever possible after counseling his family. Reference:
– BTS/Transplantation from deceased donors after circulatory death
Asmaa Khudhur
2 years ago
How do you explain this event?
A potential donor with SAH grade 4 with gag reflex present is a controlled DCD category- maastricht 3 (awaiting cardiac arrest).with intact brain stem reflexes.
Will you go ahead and withdraw treatment?
Yes I will go ahead and withdraw treatment after explaining to the family the unusfullness of continuing treatment and getting a signed consent, then confirm brain death and then starting retrievals by 2 independent doctors from the donation/transplantation process.
death can be diagnosed when
1. Asystole has occurred, and
2. Brain function has been lost, and
3. The possibility of spontaneous return of cardiac function has passed, providing that
4. There will be no subsequent intervention that restores cerebral perfusion whilst the brain remains responsive to such restoration.
DCD organ retrieval protocols should recognise the potential risks around post mortem interventions that might restore cerebral perfusion
The criteria for the diagnosis and confirmation of death within DCD protocols will need to recognise, where relevant, the possibility of spontaneous return of the circulation as well as clinical interventions that might restore cerebral perfusion whilst the brain retains some sensitivity to the restoration of oxygenation.
BTS
Doaa Elwasly
2 years ago
-This donor is considered controlled DCD Maastricht Category 3 indicating that he is awaiting cardiac arrest with SAH grade 4 leading to severe brain damage but brain death did not occur yet so some brain stem reflexes including gag reflex can be maintained post cardiac arrest .
-Yes I will proceed with withdrawing the treatment in a manner independent of donation considerations and solely based on the concept of futility with respect to the prolongation of life along with counselling the family and taking an ethical consent with involving of the retrieval team.
Reference
Professor Halaw’s lecture.
BTS guidelines 2013
Abdul Rahim Khan
2 years ago
How do you explain this event? A potential donor -DCD with SAH Grade 4 has positive gag reflex. There is brain damage which is irreversible but intact brain stem function-positive Gag reflex. This is controlled DCD- Category 3. Will you go ahead and withdraw treatment?
I will withdraw treatment after detailed counselling the family. There will be no benefit of continuing the treatment. Treatment withdrawal only after written informed consent.
The decision should be taken after a multimodality discussion involving radiologist, neurologist and intensivist.
Continue hemodynamic support to maintain organ perfusion.
Death should be confirmed by two clinicians which are not member of transplant team. One should be a Consultant on Specialist register and other clinician should be registered with GMC for at least 5 years.
Organ retrieval can done after this due process.
References-
Deceased Donor transplantation- Lecture by Prof Ahmed Halawa
BTS Huidelines-Transplantation from deceased donor after circulatory death- July 2013
Huda Al-Taee
2 years ago
How do you explain this event?
The patient is a controlled DCD, still having a functional brain stem, so the gag reflex is still preserved.
Will you go ahead and withdraw treatment?
Yes, after explaining the state to the family.
the decision to cease attempts at life-preserving treatments should be taken in a manner independent of donation/transplantation considerations and be based purely on the concept of futility with respect to the prolongation of life.
Reference:
BTS guidelines 2013 Transplantation from deceased donors after circulatory death.
Batool Butt
2 years ago
How do you explain this event?
A potential donor with SAH grade 4 with gag reflex present indicating intact brain stem function is a controlled DCD category- maastricht 3 (awaiting cardiac arrest). While a patient with DBD should have negative gag reflex. Will you go ahead and withdraw treatment?
Yes ,but after discussing the case in detail in meeting with the critical care specialist ,neurosurgeon and radiologist and also counselling of the patient ‘s family regarding no benefit from further continuation of management and withdrawing from treatment after getting signed informed consent from the family members ,and then confirmation of brain death after agonal period observation, by two clinicians which are not member of the transplant team ,followed by organ retrieval .
REFERENCE:
Deceased Donor Transplantation Lecture By, professor, Ahmed Halawa
Mohammad Alshaikh
2 years ago
Just before multiorgan retrieval, a potential DCD donor (SAH grade 4) has a positive gag reflex. How do you explain this event?
The patient in the scenario, with massive brain damage-irriversible, with residual brain stem function (positive gag reflex), it is a controlled DCD category- maastricht 3 (awaiting cardiac arrest).
Will you go ahead and withdraw treatment?
Yes, i will withdraw treatment after discussing the case in a multidisciplinary team- intensivist, radiologist, neurologist and neurosurgeon, to declare the useless further management in this case.
A trained nurse will continue on preserving organs by resuscitation- keeping good hemodynamics to have viable organs.
Counseling patients family about futility (useless management) in his situation, knowing the patient well to donate organs, and to have a written consent from family in order to stop ventilator support and further management.
If all are OK and the consent forms taken, then at operating room, scrubed team available to have the kidneys.
Reference: Andrews PA, Burnapp L, Manas D; British Transplantation Society. Summary of the British Transplantation Society guidelines for transplantation from donors after deceased circulatory death. Transplantation. 2014 Feb 15;97(3):265-70. doi: 10.1097/01.TP.0000438630.13967.c0. PMID: 24448588.
SAH grade 4 >>> severe brain injury classified as poor grade
positive gag reflex >>> remaining brain stem function
How do you explain this event?
This is Maastricht Category 3: Awaiting cardiac arrest
Death is inevitable but brain stem death criteria are not fulfilled. These patients are cared for in many areas within hospitals, but are most commonly identified in neurosurgical and general intensive care units, coronary care units, emergency departments and medical wards.
Categories 3 and 4 are also referred to as ‘Controlled’ DCD donors.
Controlled donation occurs when treatment is withdrawn on an intensive care unit (ICU) or emergency department (ED) and death follows.
Will you go ahead and withdraw treatment?
Yes I will go ahead and withdraw treatment
A decision that continued active management of a patient is futile follows confirmation by both examination and investigation that patient has sustained a catastrophic and irreversible brain injury.
At this point, formal testing of brain stem function should be performed to establish whether the criteria are fulfilled for a diagnosis of brain stem death. This recommendation is in line with those made in the Organ Donation Task Force report of 2008 . If some residual function remains as in our case , the supervising ICU or ED clinician may decide that there is no hope of recovery and that further treatment would be futile. If this opinion is based on the interpretation of CT or MR images of the head
>>> a written opinion is required from the neurologist or neurosurgeon involved prior to the declaration of futility.
Reference
British Transplantation Society Guidelines July 2013
How do you explain this event?
a) Gag reflex or cough reflex are signs of viable brainstem, may be present even in severe brain damage in a critically ill patient awaiting cardiac arrest(Maastricht 3). b) This patient needs to continue management and arrangement for organ retrieval as per protocol.
Will you go ahead and withdraw treatment?
I will go ahead in the process of organ retrieval. This is DCD and not DBD.
How do you explain this event? It is legally required to confirm the absence of a gag reflex in patients who are declared brain dead (DBD) & the presence ofa gag reflex (positive gag reflex) would indicate functioning brainstem & thus disprove brain death. The gag reflex is a highly specific test in this situation. Actually, the only rational use of the gag reflex appears to be certification of brain death. However, here, the scenario is a one of DCD, not DBD, which has different criteria.
The Institute of Medicine–American National Academy of Sciences proposed a clarification of the terms (DCD, DBD, etc) to specify that death can be declared or determined by a physician by the use of either neurologic criteria or by circulatory criteria. ==================== Will you go ahead and withdraw treatment?
This scenario is category III, DCD not DBD
Cardiac arrest awaited. The patient is not brain dead.
I will continue treatment treatment to preserve organs. The Maastricht categories of NHBD Category I. Dead on arrival at hospital Category II. Death with Unsuccessful resuscitation Category III. Awaiting cardiac death Category IV. Cardiac arrest while brain dead References 1.Josh Farkas.The gag reflex shouldn’t be tested in living patients. PulmCrit (EMCrit). July 4, 20172. Marie Thuong et al. REVIEW New classification of donation after circulatorydeath donors definitions and terminology. Transplant International2016; 29: 749–759
In the above mentioned scenario, it is case of potential DCD donor. Here there could be two possibilities:
Cardiac death has already happened – In that case gag reflex is not possible.
Patient is awaiting cardiac arrest. This comes under category III of Maastricht criteria. So there is massive brain injury hence gag reflex is possible.
So, if patient is in stage of point 1, then I will reject donation.
The best way to explain that event is to re-evaluate the patient. In this case, the members of the transplant team must be out of the re-evaluation, and bias or unfairness may be present. To prevent such a different group of physicians should be the ones to access the potential donor. The brain stem test must be performed to ensure there is no activity. If the physician observes that there is no activity, then they can consider the patient brain dead. If there is a gag present, then the patient is not brain dead. Since the patient is not brain dead but due to the intense brain lesion there will be at some point circulatory problem that can lead to cardiac arrest. The situation must be explained to family members and health workers and social services to ensure it is a forceful decision.
Once the case has been analyzed and discussed with the family members and they are in agreement then the other steps must be proceeding with care and timely. The patient can then be used as a donor once there is cardiac arrest and ventilator support has been stopped. Consent or legal documents must ensure they are signed by witnesses.
Thank you, Marius See my question above. Are you expecting this donor to have a gag reflex or not?
Akram Abdullah
2 years ago
It occurred in category 3, braindead donor. controlled donor ( awaiting cardiac arrest in severe brain damage ) with some reflexes, A potential cadaveric donor needs a family approach & apnea test with 2 consultants’ approval.
this patient fit the classification of controlled DCD category3, awaiting cardiac arrest but still has some brain steam function in his case we should meet the family members and discuss the futility of continuing the ventilatory support, this preferred to be done by consultant members not part of the transplant team and once agreed and consented for donation then we can proceed with the termination of treatment and the donation process
references
1. British Transplantation Society Guidelines Transplantation from deceased donors 2013 .
_ DCD donor can have some Brain stem reflexes as gag reflex. However, he is completely ventilator dependent (category 3, extensive brain damage without brain stem death ).
_ discontinuation of ventilator and care after approval and discussion with the family is appropriate and no value of waiting.
This patient is category III Maastricht of DCD, who is awaiting cardiac death in intensive care controlled settings.Being DCD does not require being DBD for sure. The patient has SAH grade IV which implies severe brain damage not brain death. So, it is expected to have some positive brain stem reflexes.
Thank you for your reply
Will you expect a DCD donor (awaiting cardiac arrest) to have brain stem reflexes?
This a trap question.
I agree, Dr Benlomatayo
Thank you, prof
YES.
With sever brain damage in category 3 ,It is expected to have brain stem reflexes.
And might be become a DBD donor if mechanical ventilation is prolonged until the criteria for total brain failure have been met.
When the ventilator is turned off and determination of death by circulatory criteria in this time expected to have brain stem reflexes.
I agree
testing of brain death:-
1. Coma (unresponsiveness)
2. Absent brain stem reflexes (all of the below)
3- Apnea over 8 minutes with PC02 > 60 mm Hg.
Certificates after a pateint brain death.
I agree,Dr Wadi
*Yes , the patient is awaiting cardiac arrest which is category III in Maastricht criteria has already massive brain damage but brain stem is still functioning.so gag reflex may be positive
Very good
As this DCD donor awaiting cardiac arrest, may have some brain stem reflexes.
Yes, while the patient is waiting for cardiac arrest (NHBD category III; serious brain injury without considering him as brain stem dead. we would anticipate brain stem reflexes to be present when the patient is in this state.
Being DCD does not require being DBD for sure. The patient has SAH grade IV which implies severe brain damage not brain death. So, it is expected to have some positive brain stem reflexes.
no, but we should wait for brain stem reflexes loss
I disagree with you, Riham. DCD would have some brain stem reflexes
Yes, because the patient bearing a severe brain damage – irreversible, with poor prognosis, put him on waiting cardiac arrest category class 3. despite this damage ther may some sort of brain stem function.
Andrews PA, Burnapp L, Manas D; British Transplantation Society. Summary of the British Transplantation Society guidelines for transplantation from donors after deceased circulatory death. Transplantation. 2014 Feb 15;97(3):265-70. doi: 10.1097/01.TP.0000438630.13967.c0. PMID: 24448588.
Dear professor ,
DCD category 3 (controlled )donor is ventilator dependant , may express some brain stem reflexes(So yes) , unable to maintain vital functions , and cardiac arrest is inevitable.
Thank you, All.
Yes, still have a functional brain stem
● This is acase of Controlled DCD category 3 with sever irreversible brain damage but he still having brain stem reflexes
● I will go ahead and withdraw treatment after explain the case to his family and the consent had taken
The criteria for the diagnosis and confirmation of death within DCD protocols will need to recognise, where relevant, the possibility of spontaneous return of the circulation as well as clinical interventions that might restore cerebral perfusion whilst the brain retains some sensitivity to the restoration of oxygenation.
BTS
Yes in case of controlled DCD Maastricht Category 3 where brain death didnot occur yet so brain stem reflexes and complex motor activity can be noticed
delay between circulatory arrest and organ preservation may cause acute ischemic injury DCD.
in this scenerio is crucial to know the time of circulatory arest and on the other hand the time of diagnosis of SAH if within 3 days that explain still there is intact brain stem function
referenes
Wolfe RA, Ashby VB, Milford EL, Ojo AO, Ettenger RE, Agodoa LY, Held PJ, Port FK: Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med 341: 1725–1730, 1999. [PubMed] [Google Scholar]
a patient with a true gag reflex does not fulfil the criteria of Brain death but grade 4 SAH means stupor. This patient should be evaluated in the context of expected or invertible /awaiting death. At that time, evaluation and discussion with the family should begin.
yes the patient is caticorey 3 in Maastricht criteria
DCD patients may have some brainstem reflexes
As this DCD, no DBD, brain stem reflexes can be present. He is not yet brain dead and this will occur after withdrawing treatment, bur he has irreversible brain damage.
Yes
considered category III according to Maastricht classification where there is sever brain damage but still brain stem test not confirmed
Yes.
A DCD donor is not brain-dead, hence may have brainstem reflexes.
DCD donors especially category 3 Maastricht criteria could have brain stem reflexes like gag reflex. This patient is awaiting cardiac arrest.
How do you explain this event?
Category 3 DCD awaiting heart arrest due to severe brain damage
I shall proceed with Tx after family consent
Reflexes of gag may be present and should not be confused against the diagnosis of brain death. It can present when the patient is awaiting cardiac arrest or severe brain damage without brain death has occurred, additionally, when consent from the family, the ventilator is switch off and cardiac arrest is awaited
Clinical testing for brain death
Coma: Absence of response to noxious stimulus except for spinally mediated reflexes.
Absent brain stem reflexes (a formal evaluation of the brain stem reflexes is undertaken when the patient has had fixed dilated pupils and absent cranial nerve reflexes for more than 4 h).
Apnea test: The aim of this test is to check for the integrity of the brain stem respiratory Centre at high levels of blood carbon dioxide.
Will you go ahead and withdraw treatment?
Yes, after explaining the situation to next of kin
▪︎How do you explain this event?
Because this a potential DCD donor , not DBD some reflexes of the brain stem can present .
▪︎Will you go ahead and withdraw treatment?
Yes.
this patient is considered category 3 of DCD as he has severe brain damage SAH grade 4 and brain death didn’t occur till now .
He has cardiac arrest not brain death
Patient prognosis should be discussed with the relatives by one who is from outside transplant team and after their consent treatment can be withdrawn waiting for cardiac arrest.
Transplantation from deceased donors after circulatory death, British Transplantation Society Guidelines, 2013
There are a variety of tests a physician can administer in order to diagnose brain death: brain stem reflex assessments, apnea tests, and coma appraisals that determine if a patient has truly passed.14 Examples of tests include searching for an absence of gag reflex, corneal reflex and cough reflex. Other tests look for high body temperature or lack of spontaneous respiratory effort. The time of brain death is marked as a patient’s legal time of death, and then donation after brain death (DBD) can occur. In contrast, cardiac death, or non-heart-beating death, occurs when a patient cannot be legally declared dead due to lingering neurological activity, yet the patient has no chance of recovery.(1)
Predicting time to death in controlled donation after circulatory death (cDCD) donors following withdrawal of life-sustaining treatment (WLST) is important but poses a major challenge. In a single-center retrospective study, the data of 92 potential cDCD donors was used. Multivariable regression analysis demonstrated that absent cough-, corneal reflex, lower morphine dosage, and midazolam use were significantly associated with death within 60 minutes (area under the curve [AUC] 0.89; 95% confidenence interval [CI] 0.87-0.91). External validation of the logistic regression models of de Groot et al (AUC 0.86; 95% CI 0.77-0.95), Wind et al (AUC 0.62; 95% CI 0.49-0.76), Davila et al (AUC 0.80; 95% CI 0.708-0.901) and the Cox regression model by Suntharalingam et al (Harrell’s c-index 0.63), exhibited good discrimination and could fairly identify which patients died within 60 minutes. Previous prediction models did not incorporate the process of WLST. (2)
(1)Taylor Sihavong, Organ Transplantation after Cardiac Death(file:///C:/Users/Tecnology/AppData/Local/Packages/Microsoft.MicrosoftEdge_8wekyb3d8bbwe/TempState/Downloads/SJPH+16-17+Taylor+Sihavong%20(1).pdf)
(2)Kotsopoulos, AMM, Böing-Messing, F, Jansen, NE, Vos, P, Abdo, WF. External validation of prediction models for time to death in potential donors after circulatory death. Am J Transplant. 2018; 18: 890– 896. https://doi.org/10.1111/ajt.14529
1.controlled CDC category III
cardiac arrest following the withdrawal of life-sustaining treatments but not considered to be brain dead
brain stem still has some function , so gag reflex is positive
2.yes
How do you explain this event?
He was DCD not DBD so he may still have intact brain stem reflexes like gag reflex.
Will you go ahead and withdraw treatment?
Withdrawal of treatment can be started.
Q1: DCD donors in category 3 Maastricht criteria could have brain stem reflexes.
Q2: In the case of explanation to family and their agreement, we can go ahead and withdraw the treatment.
The patient is considered category 3 of DCD according to Maastricht as he has severe brain damage SAH grade 4 and brain death didn’t occur yet.
Patient prognosis should be discussed with the relatives by one who is from outside transplant team and after their consent treatment can be withdrawn waiting for cardiac arrest.
Transplantation from deceased donors after circulatory death, British Transplantation Society Guidelines, 2013.
DCD donors can still have intact brainstem reflexes as gag reflex owing to the cause of arrest is primarily cardiac origin.
No contraindication for treatment withdrawal after confirmation by neurology team and proper explanation for the relatives.
Reference:
A CODE OF PRACTICE FOR THE DIAGNOSIS AND CONFIRMATION OF DEATH
Copyright © Academy of Medical Royal Colleges 2008
The donor has suffered a cardiac arrest (DCD) and has sub arachnoid hemorrhage…The donor however has intact brain stem functions as evidenced by positive gag reflex…The patient has controlled cardiac death…He is Masstricht category III – awaiting cardiac arrest…These kind of patients are seen in various CCU, ICU, neurosurgery units on ventilator and are awaiting cardiac arrest when there is severe brain damage….
There is severe brain damage in the patient which will inturn lead on to a cardiac arrest eventually…A multi disciplinary approach involving ICU consultants, nephrologists, neurolgists, neurosurgeons should be discussed and when the consensus for point of no return is obtained we can proceed with withdrawal of treatment
DCD it means cardiac death so brain stem reflex will be intact
So, yes treatment withdrawal can be started right away.
This potential donor has severe brain injury, not yet brain death, Category 3 awaiting cardiac death ( Masstricht Category of NHBD ). Hence there is positive gag reflex.
I will go ahead for DCD donor after counseling next of kin. SAH grade 4 has poor prognosis.
Diagnosis of Death
Death is irreversible and should be regarded as a state in which a patient has
permanently lost the capacity for consciousness and brain stem function. (A1)
Where cardio-respiratory criteria apply, death can be confirmed following five minutes
of continuous cardio-respiratory arrest providing there is no subsequent restoration of
artificial cerebral circulation. (B1)
Where possible, circulatory arrest should be identified by the absence of pulsatile
flow on a correctly functioning arterial line, or by the use of echocardiography if the
expertise is available; or failing that by continuous ECG monitoring. (B1)
DCD organ retrieval protocols should recognise the potential risks around post
mortem interventions that might restore cerebral perfusion. (B1)
The criteria for the diagnosis of death following loss of circulatory function should not
be influenced by the possibility of subsequent organ retrieval. (A1)
4.4 The Decision to Withdraw Futile Life Sustaining Treatments
-The exact definition of death has given rise to significant ethical debate, which is reflected in the variability of definition between societies (1,2). The key ethical principle is that donation should proceed only after death has been established and no prospect of spontaneous auto-
resuscitation exists (5). Similarly, the decision to cease attempts at life preserving treatments should be taken in a manner independent of donation/transplantation considerations and be
based purely on the concept of futility with respect to the prolongation of life. Guidance on the determination and diagnosis of death can be found in the Academy of Royal Colleges Code of Practice for the Diagnosis and Confirmation of death (2008) (4). However, there
remains no statutory definition of death in the UK and the working definition ‘the irreversible loss of the capacity for consciousness combined with irreversible loss of the capacity to breathe’ put forward by the Department of Health seems to have been adopted as the pragmatic approach.
References
1. Controversies in the Determination of Death: A White Paper by the President’s Council
on Bioethics. US Government Printing Office 2011. ISBN 0160879035,
9780160879036.
2. Dhanani S, Hornby L, Ward R, Shemie S. Variability in the determination of death after
cardiac arrest: A review of guidelines and statements. J Intensive Care Med 2012; 27:
238-52.
3. Bernat J, Capron A, Bleck T, et al. The circulatory-respiratory determination of death in
organ donation. Critical Care Medicine 2010; 38: 972-9.
4. Academy of the Medical Royal Colleges. A Code of Practice for the Diagnosis and
Confirmation of Death. London 2008. Available at http://www.aomrc.org.uk/reports.aspx
5. Hornby K, Hornby L, Shemie SD. A systematic review of autoresuscitation after
cardiac arrest. Crit Care Med 2010; 38: 1246-53.
# How do you explain this event?
A potential DCD donor with SAH Grade 4 has positive gag reflex, still functioning brain stem (maastricht Category 3): Awaiting cardiac arrest Death is inevitable but brain stem death criteria are not fulfilled.
# Will you go ahead and withdraw treatment?
*Yes, I will go a head and withdraw treatment as recommend by BTS guideline:
*The key ethical principle is that donation should proceed only after death has been established and no prospect of spontaneous autoresuscitation exists. Similarly, the decision to cease attempts at life preserving treatments should be taken in a manner independent of donation/transplantation considerations and be based purely on the concept of futility with respect to the prolongation of life.
Transplantation from deceased donors after circulatory death
Compiled by a Working Party of The British Transplantation Society
July 2013
This patient is Maastricht Category 3: Awaiting cardiac arrest.
” Organ donation which follows circulatory arrest. This may be in the context of withdrawal or non-escalation of cardio-respiratory treatments that are considered to be no longer in a patient’s best interests ”
BTS guidelines state that ” Where cardio-respiratory criteria apply, death can be confirmed following five minutes of continuous cardio-respiratory arrest providing there is no subsequent restoration of artificial cerebral circulation.”
So, a DCD donor may have intact brain stem reflexes.
We can inform the next to kin of the deceased donor and proceed.
A potential DCD donor is not brain dead, hence may retain brainstem reflexes, responsible for the positive gag reflex.
As this is a potential DCD donor, we should go ahead and withdraw the treatment, after explaining the scenario to the family members, and getting consent.
Reference:
1) Thuong M, Ruiz A, Evrard P, Kuiper M, Boffa C, Akhtar MZ, Neuberger J, Ploeg R. New classification of donation after circulatory death donors definitions and terminology. Transpl Int. 2016 Jul;29(7):749-59. doi: 10.1111/tri.12776. Epub 2016 May 4. PMID: 26991858.
potential donor with DCD (SAH ) grade 4 still with positive gag reflex considered category III according to mastricket classification hello is awaiting for brain death.
Sever brain damage but brain death not occured those patient are usually ventilator dependent after consent can be taken from relatives we can switch off ventilator and wait for cardiac arrest the atonal time is up to 2 hours to avoid damage from hypotension and for liver up to one hour brain stem still not confirmed so gag reflex still preserved.
I will proceed with this donor
Subarachnoid hemorrhage grade 4 by Hunt and Hess grading has survival 20% so it is one of the irreversible brain damage
So it is not yet brain death ,that’s why gag reflex still present
So this is Mastricht category 3 DCD awaiting cardiac arrest ,brain stem death is not fulfilled
So we can proceed for organ retrieval if the family agrees
The gag reflex is a type of brainstem reflex, so it is expected to occur in patients with circulatory failure.
Yes, because the donor has a damage brain injury that is irreversible that will evolve with DBD.
This patient have Maastricht Category 3: Awaiting cardiac arrest which mean that the
Death s inevitable but brain stem death criteria are not fulfilled.
These patients are cared for in many areas within hospitals, but are most commonly identified in neurosurgical and general intensive care units, coronary care units, emergency departments and medical wards
The process of organ donation starts with treatment withdrawal, following which the patient’s vital signs, in particular the blood pressure, deteriorate at varying rates until cardiac activity ceases (asystole).
Following the verification of death, organ retrieval begins with perfusion of the donor with cold preservation solution.
Reference
British Transplantation Society Guidelines.
Transplantation from deceased donors after circulatory death
As this DCD, no DBD, brain stem reflexes can be present. He is not yet brain dead and this will occur after withdrawing treatment, bur he has terrible irreversible brain damage.
Yes. Nothing to worry as his brain activity will be present till withdrawal of treatment.
– Potential DCD even with severe brain damage , can still have some brain reflexes.
– To go ahead & withdraw the treatment , it depends on the family agreement & consent , if they agreed for donation & consented , yes I will go ahead .
A DCD donor can have severe brain injury with intact brain stem reflexes so this doesn’t stop donation. This patient has SAH grade 4 so he can have a positive gag .
This case is donor circulating death with severe brain damage but still brain stem functioning.
Yes i will go a head
Brain death not damage cause loss of gag reflexes.
Brain death confirmation needs loss of brain stem reflexes, including:
evaluate further.
pharyngeal membranes.
Yes ,with consent of family.
References:
1- Mostafa Abubaker .Brain Death Criteria. StatPearls Publishing; 2022 Jan.
In Category III Maastricht classification patient who Awaiting circulatory death those patients for whom circulatory death occurs after a planned withdrawal of life-sustaining therapies (WLST), mainly cardiorespiratory support including inotropic and ventilatory support . Cardiac arrest is expected and the medical decision of withdrawal is taken in a multi-disciplinary approach, consistent with local/national legal requirements, by the clinical team together with the family, where further treatment is considered futile. In the initial description, the term “controlled” meant that the ischaemia time was short enough to consider recovery of liver, kidneys, pancreas and lungs.
In this period some brain tests reflexes can be there.
Decision to go a head and withdraw treatment is depends on local/national legal requirements
follow the below
Iwill explain this event that it is early post circulatory death so ischemic injury of the brain stem not take place
iIwll go ahead and will not withdrawal treatment
delay between circulatory arrest and organ preservation may cause acute ischemic injury DCD.
in this scenerio is crucial to know the time of circulatory arest and on the other hand the time of diagnosis of SAH if within 3 days that explain still there is intact brain stem function
referenes
Wolfe RA, Ashby VB, Milford EL, Ojo AO, Ettenger RE, Agodoa LY, Held PJ, Port FK: Comparison of mortality in all patients on dialysis, patients on dialysis awaiting transplantation, and recipients of a first cadaveric transplant. N Engl J Med 341: 1725–1730, 1999. [PubMed] [Google Scholar]
How do you explain this event?
We are dealing here with a controlled DCD donor category- maastricht category 3 , with SAH grade 4(severe brain injury) who is awaiting cardiac arrest.
The presence of marked brain damage does not preclude the presence of functioning brain Stem reflexes like the positive Gag reflex
Will you go ahead and withdraw treatment?
Yes I will proceed to withdraw treatment.
The decision to stop the attempts of life-preserving treatments should be completely independent of donation/transplantation considerations and be based purely on the concept of futility of that treatment with respect to the prolongation of life.
A meeting should be arranged with the family members to decide about the futility of that treatment and exploring any previous donor wishes. If they agreed about donation, they should be consented ,then proceeding with the termination of the ventilator support and the donation process.
Reference:
BTS guidelines 2013 Transplantation from deceased donors after circulatory death
this patient has SAH grade 4, and still no brain stem death so brain stem reflexes are expected; however, this patient has a very poor prognosis
Yes I will go ahead after a discussion with the patient’s family
Reference:
– BTS/Transplantation from deceased donors after circulatory death
How do you explain this event?
Our Potential donor is a DCD category 3 ( awaiting for cardiac arrest ) >> Controlled’ DCD donor.
that leads to Marked incomplete brain damage But still functioning Brain Stem ( Positive Gag reflex ).
Will you go ahead and withdraw treatment?
The decision to stop attempts for life-saving treatments should be taken in a way independent of donation/transplantation respect.
and confirming irreversible disability for consciousness combined with irreversible loss of the ability to
breathe depending on MDT of (nephrology, Urology, Neurology, Radiology, and ICU teams )
and after ethical written consent from his relatives’ withdrawal treatment can be done.
Controlled DCD entails a period of time during which supportive treatment, often mechanical
ventilation and inotropic cardiac support, are withdrawn.
Best practice must reflect these ethical standpoints and local protocols should provide them.
References
Dhanani S, Hornby L, Ward R, Shemie S. Variability in the determination of death after
cardiac arrest: A review of guidelines and statements. J Intensive Care Med 2012; 27:
238-52.
Hornby K, Hornby L, Shemie SD. A systematic review of autoresuscitation after
cardiac arrest. Crit Care Med 2010; 38: 1246-53.
Clinical tests for brain death:
Absent pupillary light reflex Afferent II cranial nerve, efferent III nerve
Absent corneal reflex Afferent V nerve, efferent VII nerve
Absent reflexes in the face and maxillary region Area supplied by V cranial nerve (trigeminal)
Absent oculo-cephalic reflex Afferent VIII, efferent III and VI. Lateral 90° movements of the neck result in deviation of the eyes in an opposite direction with an intact brain stem. Cervical spine injury must be ruled out prior to testing
Absent oculo-vestibular reflex The afferent is the VIII and efferent III and VI cranial nerves. With the patient at a 30° head up position (lateral semicircular canal becomes vertical), 50 ml of ice-cold saline is injected into the ear. Nystagmus with a slow component toward the side of injection is seen with a functioning brain stem (confirm intact tympanic membrane. Allow 5 min to elapse prior to testing the other ear)
Absent pharyngeal (gag) and laryngeal (cough) reflex) Afferent IX and efferent X cranial nerves
Absent gag reflex is criteria of brain death .if present wait for cardiac arrest
Reference :
Journal of Anaesthesiology Clinical Pharmacology | April-June 2016 | Vol 32 | Issue 2
How do you explain this event?
This potential donor is controlled DCD, maastricht category 3: Awaiting cardiac arrest. His condition is associated with brain damage, but not complete brain death, so he maintains some brain reflexes like the gag reflex.
Will you go ahead and withdraw treatment?
-Yes, I will go ahead and withdraw treatment, and is best done in the operating theatre complex wherever possible after counseling his family.
Reference:
– BTS/Transplantation from deceased donors after circulatory death
How do you explain this event?
A potential donor with SAH grade 4 with gag reflex present is a controlled DCD category- maastricht 3 (awaiting cardiac arrest).with intact brain stem reflexes.
Will you go ahead and withdraw treatment?
Yes I will go ahead and withdraw treatment after explaining to the family the unusfullness of continuing treatment and getting a signed consent, then confirm brain death and then starting retrievals by 2 independent doctors from the donation/transplantation process.
death can be diagnosed when
1. Asystole has occurred, and
2. Brain function has been lost, and
3. The possibility of spontaneous return of cardiac function has passed, providing that
4. There will be no subsequent intervention that restores cerebral perfusion whilst the brain remains responsive to such restoration.
DCD organ retrieval protocols should recognise the potential risks around post mortem interventions that might restore cerebral perfusion
The criteria for the diagnosis and confirmation of death within DCD protocols will need to recognise, where relevant, the possibility of spontaneous return of the circulation as well as clinical interventions that might restore cerebral perfusion whilst the brain retains some sensitivity to the restoration of oxygenation.
BTS
-This donor is considered controlled DCD Maastricht Category 3 indicating that he is awaiting cardiac arrest with SAH grade 4 leading to severe brain damage but brain death did not occur yet so some brain stem reflexes including gag reflex can be maintained post cardiac arrest .
-Yes I will proceed with withdrawing the treatment in a manner independent of donation considerations and solely based on the concept of futility with respect to the prolongation of life along with counselling the family and taking an ethical consent with involving of the retrieval team.
Reference
Professor Halaw’s lecture.
BTS guidelines 2013
How do you explain this event?
A potential donor -DCD with SAH Grade 4 has positive gag reflex. There is brain damage which is irreversible but intact brain stem function-positive Gag reflex.
This is controlled DCD- Category 3.
Will you go ahead and withdraw treatment?
I will withdraw treatment after detailed counselling the family. There will be no benefit of continuing the treatment. Treatment withdrawal only after written informed consent.
The decision should be taken after a multimodality discussion involving radiologist, neurologist and intensivist.
Continue hemodynamic support to maintain organ perfusion.
Death should be confirmed by two clinicians which are not member of transplant team. One should be a Consultant on Specialist register and other clinician should be registered with GMC for at least 5 years.
Organ retrieval can done after this due process.
References-
Deceased Donor transplantation- Lecture by Prof Ahmed Halawa
BTS Huidelines-Transplantation from deceased donor after circulatory death- July 2013
The patient is a controlled DCD, still having a functional brain stem, so the gag reflex is still preserved.
Yes, after explaining the state to the family.
the decision to cease attempts at life-preserving treatments should be taken in a manner independent of donation/transplantation considerations and be based purely on the concept of futility with respect to the prolongation of life.
Reference:
BTS guidelines 2013 Transplantation from deceased donors after circulatory death.
How do you explain this event?
A potential donor with SAH grade 4 with gag reflex present indicating intact brain stem function is a controlled DCD category- maastricht 3 (awaiting cardiac arrest). While a patient with DBD should have negative gag reflex.
Will you go ahead and withdraw treatment?
Yes ,but after discussing the case in detail in meeting with the critical care specialist ,neurosurgeon and radiologist and also counselling of the patient ‘s family regarding no benefit from further continuation of management and withdrawing from treatment after getting signed informed consent from the family members ,and then confirmation of brain death after agonal period observation, by two clinicians which are not member of the transplant team ,followed by organ retrieval .
REFERENCE:
Deceased Donor Transplantation Lecture By, professor, Ahmed Halawa
Just before multiorgan retrieval, a potential DCD donor (SAH grade 4) has a positive gag reflex.
How do you explain this event?
The patient in the scenario, with massive brain damage-irriversible, with residual brain stem function (positive gag reflex), it is a controlled DCD category- maastricht 3 (awaiting cardiac arrest).
Will you go ahead and withdraw treatment?
Yes, i will withdraw treatment after discussing the case in a multidisciplinary team- intensivist, radiologist, neurologist and neurosurgeon, to declare the useless further management in this case.
A trained nurse will continue on preserving organs by resuscitation- keeping good hemodynamics to have viable organs.
Counseling patients family about futility (useless management) in his situation, knowing the patient well to donate organs, and to have a written consent from family in order to stop ventilator support and further management.
If all are OK and the consent forms taken, then at operating room, scrubed team available to have the kidneys.
Reference:
Andrews PA, Burnapp L, Manas D; British Transplantation Society. Summary of the British Transplantation Society guidelines for transplantation from donors after deceased circulatory death. Transplantation. 2014 Feb 15;97(3):265-70. doi: 10.1097/01.TP.0000438630.13967.c0. PMID: 24448588.
Thank you
We have potential DCD donor
This is Maastricht Category 3: Awaiting cardiac arrest
Death is inevitable but brain stem death criteria are not fulfilled. These patients are cared for in many areas within hospitals, but are most commonly identified in neurosurgical and general intensive care units, coronary care units, emergency departments and medical wards.
Categories 3 and 4 are also referred to as ‘Controlled’ DCD donors.
Controlled donation occurs when treatment is withdrawn on an intensive care unit (ICU) or emergency department (ED) and death follows.
Yes I will go ahead and withdraw treatment
A decision that continued active management of a patient is futile follows confirmation by both examination and investigation that patient has sustained a catastrophic and irreversible brain injury.
At this point, formal testing of brain stem function should be performed to establish whether the criteria are fulfilled for a diagnosis of brain stem death. This recommendation is in line with those made in the Organ Donation Task Force report of 2008 .
If some residual function remains as in our case , the supervising ICU or ED clinician may decide that there is no hope of recovery and that further treatment would be futile. If this opinion is based on the interpretation of CT or MR images of the head
>>> a written opinion is required from the neurologist or neurosurgeon involved prior to the declaration of futility.
Reference
British Transplantation Society Guidelines July 2013
Thank you
How do you explain this event?
a) Gag reflex or cough reflex are signs of viable brainstem, may be present even in severe brain damage in a critically ill patient awaiting cardiac arrest(Maastricht 3).
b) This patient needs to continue management and arrangement for organ retrieval as per protocol.
Will you go ahead and withdraw treatment?
I will go ahead in the process of organ retrieval. This is DCD and not DBD.
Thank you,
How do you explain this event?
It is legally required to confirm the absence of a gag reflex in patients who are declared brain dead (DBD) & the presence of a gag reflex (positive gag reflex) would indicate functioning brainstem & thus disprove brain death.
The gag reflex is a highly specific test in this situation. Actually, the only rational use of the gag reflex appears to be certification of brain death.
However, here, the scenario is a one of DCD, not DBD, which has different criteria.
The Institute of Medicine–American National Academy of Sciences proposed a clarification of the terms (DCD, DBD, etc) to specify that death can be declared or determined by a physician by the use of either neurologic criteria or by circulatory criteria.
====================
Will you go ahead and withdraw treatment?
This scenario is category III, DCD not DBD
Cardiac arrest awaited. The patient is not brain dead.
I will continue treatment treatment to preserve organs.
The Maastricht categories of NHBD
Category I. Dead on arrival at hospital
Category II. Death with Unsuccessful resuscitation
Category III. Awaiting cardiac death
Category IV. Cardiac arrest while brain dead
References
1.Josh Farkas.The gag reflex shouldn’t be tested in living patients. PulmCrit (EMCrit). July 4, 20172. Marie Thuong et al. REVIEW New classification of donation after circulatorydeath donors definitions and terminology. Transplant International2016; 29: 749–759
Thank you.
In the above mentioned scenario, it is case of potential DCD donor. Here there could be two possibilities:
So, if patient is in stage of point 1, then I will reject donation.
Thank you, when we say a DCD donor, this means he is awaiting cardiac arrest.
But sir uncontrolled donors of Maastricht Category 2: Unsuccessful resuscitation. In these cases cardiac arrest has already happened
DCD patient may have positive gag reflex as it is a brain stem reflex.
After explaining this to patient family member and after taking consent I will proceed for organ retrieval.
Thank you,
The best way to explain that event is to re-evaluate the patient. In this case, the members of the transplant team must be out of the re-evaluation, and bias or unfairness may be present. To prevent such a different group of physicians should be the ones to access the potential donor. The brain stem test must be performed to ensure there is no activity. If the physician observes that there is no activity, then they can consider the patient brain dead. If there is a gag present, then the patient is not brain dead. Since the patient is not brain dead but due to the intense brain lesion there will be at some point circulatory problem that can lead to cardiac arrest. The situation must be explained to family members and health workers and social services to ensure it is a forceful decision.
Once the case has been analyzed and discussed with the family members and they are in agreement then the other steps must be proceeding with care and timely. The patient can then be used as a donor once there is cardiac arrest and ventilator support has been stopped. Consent or legal documents must ensure they are signed by witnesses.
Thank you, Marius
See my question above. Are you expecting this donor to have a gag reflex or not?
It occurred in category 3, braindead donor. controlled donor ( awaiting cardiac arrest in severe brain damage ) with some reflexes, A potential cadaveric donor needs a family approach & apnea test with 2 consultants’ approval.
Thank you
this patient fit the classification of controlled DCD category3, awaiting cardiac arrest but still has some brain steam function in his case we should meet the family members and discuss the futility of continuing the ventilatory support, this preferred to be done by consultant members not part of the transplant team and once agreed and consented for donation then we can proceed with the termination of treatment and the donation process
references
1. British Transplantation Society Guidelines Transplantation from deceased donors 2013 .
Thank you
_ DCD donor can have some Brain stem reflexes as gag reflex. However, he is completely ventilator dependent (category 3, extensive brain damage without brain stem death ).
_ discontinuation of ventilator and care after approval and discussion with the family is appropriate and no value of waiting.
Thank you
This patient is category III Maastricht of DCD, who is awaiting cardiac death in intensive care controlled settings.Being DCD does not require being DBD for sure. The patient has SAH grade IV which implies severe brain damage not brain death. So, it is expected to have some positive brain stem reflexes.
I will proceed with transplantation
I agree