Metabolic values precluding clinical death by neurologic Criteria/Brain death: Survey of neurocritical care society physicians

David P Lerner; Ribal Bassil; Aleksey Tadevosyan; Anil Ramineni; Joseph D Burns; James A Russell; Panayiotis N Varelas; Ariane Lewis

doi:10.1016/j.jocn.2021.03.021

Metabolic values precluding clinical death by neurologic Criteria/Brain death: Survey of neurocritical care society physicians

J Clin Neurosci. 2021 Jun:88:16-21. doi: 10.1016/j.jocn.2021.03.021. Epub 2021 Mar 29.

Authors

David P Lerner¹, Ribal Bassil², Aleksey Tadevosyan³, Anil Ramineni⁴, Joseph D Burns⁵, James A Russell⁶, Panayiotis N Varelas⁷, Ariane Lewis⁸

Affiliations

¹ Department of Neurology Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA; Department of Neurology Tufts University Medical Center, 800 Washington Street, Boston, MA 02111, USA. Electronic address: david.lerner@lahey.org.
² Department of Neurology Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA; Department of Neurology Tufts University Medical Center, 800 Washington Street, Boston, MA 02111, USA. Electronic address: ribal.bassil@lahey.org.
³ Department of Neurology Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA; Department of Neurology Tufts University Medical Center, 800 Washington Street, Boston, MA 02111, USA. Electronic address: aleksey.tadevosyan@lahey.org.
⁴ Department of Neurology Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA; Department of Neurology Tufts University Medical Center, 800 Washington Street, Boston, MA 02111, USA. Electronic address: anil.ramineni@lahey.org.
⁵ Department of Neurology Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA; Department of Neurology Tufts University Medical Center, 800 Washington Street, Boston, MA 02111, USA; Department of Neurosurgery Tufts University Medical Center, 800 Washington Street, Boston, MA 02111, USA. Electronic address: joseph.d.burns@lahey.org.
⁶ Department of Neurology Lahey Hospital and Medical Center, 41 Mall Road, Burlington, MA 01805, USA; Department of Neurology Tufts University Medical Center, 800 Washington Street, Boston, MA 02111, USA. Electronic address: james.a.russell@lahey.org.
⁷ Department of Neurology Albany Medical Center Albany, NY 12208, USA. Electronic address: varelap@amc.edu.
⁸ NYU Langone Medical Center Departments of Neurology and Neurosurgery New York, NY 10016, USA.

PMID: 33992178
DOI: 10.1016/j.jocn.2021.03.021

Abstract

Background: There are no established ranges for metabolic values prior to death by neurologic criteria/brain death determination (DNC/BD) and the thresholds required by institutional protocols and accepted by neurointensivists is unknown.

Methods: We designed a survey that addressed 1) the metabolic tests required in institutional guidelines prior to brain death determination, 2) the metabolic tests the respondent reviewed prior to brain death determination, and 3) the metabolic test thresholds for laboratory tests that were perceived to preclude or permit clinical DNC/BD determination. The survey was distributed online to physicians in the Neurocritical Care Society from September to December 2019. Respondents were dichotomized based on the number of brain death evaluations they had performed (≤20 vs. > 20) and responses were compared between groups.

Results: The survey was completed by 84 physicians. Nearly half (47.6%) of respondents did not believe their institutions required metabolic testing. The metabolic testing for which institutions most commonly provided a defined threshold were arterial pH (34.5%, 29/84), sodium (28.6%, 24/84), and glucose (15.5%, 13/84). Nearly all (97.6%) respondents routinely reviewed metabolic tests prior to brain death evaluation, the most common of which were: sodium (91.7%, 77/84), arterial pH (83.3%, 70/84), and glucose (79.8%, 67/84). Respondents who had performed > 20 evaluations were less likely to check thyroxine and total bilirubin (3.6%, 2/55 vs. 20.7%, 6/29 (p = 0.011) and 12.7%, 7/55 vs. 31%, 9/29 (p = 0.042), respectively), and had a more liberal upper limit of potassium (6.3 mEq/L vs 6.0 mEq/L, p = 0.045).

Conclusion: Prior to brain death evaluation, neurocritical care providers commonly review similar metabolic tests and have similar thresholds regarding values that would preclude clinical brain death determination. This finding is independent of experience with brain death determination.

Keywords: Brain death; Coma; Hypernatremia; Hyponatremia; Sedation.

MeSH terms

Adult
Aged
Blood Chemical Analysis
Brain Death / blood*
Brain Death / diagnosis*
Critical Care / standards*
Female
Guidelines as Topic*
Humans
Male
Middle Aged
Physicians
Reference Values
Surveys and Questionnaires