Procedural aspects of compassionate care such as the terminal extubation are understudied. We used machine learning methods to determine factors associated with the decision to extubate the critically ill patient at the end of life, and whether the terminal extubation shortens the dying process. We performed a secondary data analysis of a large, prospective, multicentre, cohort study, death prediction and physiology after removal of therapy (DePPaRT), which collected baseline data as well as ECG, pulse oximeter and arterial waveforms from WLST until 30 min after death. We analysed a priori defined factors associated with the decision to perform terminal extubation in WLST using the random forest method and logistic regression. Cox regression was used to analyse the effect of terminal extubation on time from WLST to death. A total of 616 patients were included into the analysis, out of which 396 (64.3%) were terminally extubated. The study centre, low or no vasopressor support, and good respiratory function were factors significantly associated with the decision to extubate. Unadjusted time to death did not differ between patients with and without extubation (median survival time extubated vs. not extubated: 60 [95% CI: 46; 76] vs. 58 [95% CI: 45; 75] min). In contrast, after adjustment for confounders, time to death of extubated patients was significantly shorter (49 [95% CI: 40; 62] vs. 85 [95% CI: 61; 115] min). The decision to terminally extubate is associated with specific centres and less respiratory and/or vasopressor support. In this context, terminal extubation was associated with a shorter time to death.
BACKGROUND: The minimum duration of pulselessness required before organ donation after circulatory determination of death has not been well studied. METHODS: We conducted a prospective observational study of the incidence and timing of resumption of cardiac electrical and pulsatile activity in adults who died after planned withdrawal of life-sustaining measures in 20 intensive care units in three countries. Patients were intended to be monitored for 30 minutes after determination of death. Clinicians at the bedside reported resumption of cardiac activity prospectively. Continuous blood-pressure and electrocardiographic (ECG) waveforms were recorded and reviewed retrospectively to confirm bedside observations and to determine whether there were additional instances of resumption of cardiac activity. RESULTS: A total of 1999 patients were screened, and 631 were included in the study. Clinically reported resumption of cardiac activity, respiratory movement, or both that was confirmed by waveform analysis occurred in 5 patients (1%). Retrospective analysis of ECG and blood-pressure waveforms from 480 patients identified 67 instances (14%) with resumption of cardiac activity after a period of pulselessness, including the 5 reported by bedside clinicians. The longest duration after pulselessness before resumption of cardiac activity was 4 minutes 20 seconds. The last QRS complex coincided with the last arterial pulse in 19% of the patients. CONCLUSIONS: After withdrawal of life-sustaining measures, transient resumption of at least one cycle of cardiac activity after pulselessness occurred in 14% of patients according to retrospective analysis of waveforms; only 1% of such resumptions were identified at the bedside. These events occurred within 4 minutes 20 seconds after a period of pulselessness. (Funded by the Canadian Institutes for Health Research and others.).
- MeSH
- dospělí MeSH
- elektrokardiografie MeSH
- extubace MeSH
- funkční vyšetření srdce MeSH
- krevní tlak fyziologie MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladiství MeSH
- mladý dospělý MeSH
- nenasazení léčby * MeSH
- prospektivní studie MeSH
- pulz * MeSH
- resuscitační péče MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- smrt MeSH
- srdce fyziologie MeSH
- srdeční zástava * MeSH
- Check Tag
- dospělí MeSH
- lidé středního věku MeSH
- lidé MeSH
- mladiství MeSH
- mladý dospělý MeSH
- mužské pohlaví MeSH
- senioři nad 80 let MeSH
- senioři MeSH
- ženské pohlaví MeSH
- Publikační typ
- časopisecké články MeSH
- multicentrická studie MeSH
- pozorovací studie MeSH
- práce podpořená grantem MeSH
Importance: There are inconsistencies in concept, criteria, practice, and documentation of brain death/death by neurologic criteria (BD/DNC) both internationally and within countries. Objective: To formulate a consensus statement of recommendations on determination of BD/DNC based on review of the literature and expert opinion of a large multidisciplinary, international panel. Process: Relevant international professional societies were recruited to develop recommendations regarding determination of BD/DNC. Literature searches of the Cochrane, Embase, and MEDLINE databases included January 1, 1992, through April 2020 identified pertinent articles for review. Because of the lack of high-quality data from randomized clinical trials or large observational studies, recommendations were formulated based on consensus of contributors and medical societies that represented relevant disciplines, including critical care, neurology, and neurosurgery. Evidence Synthesis: Based on review of the literature and consensus from a large multidisciplinary, international panel, minimum clinical criteria needed to determine BD/DNC in various circumstances were developed. Recommendations: Prior to evaluating a patient for BD/DNC, the patient should have an established neurologic diagnosis that can lead to the complete and irreversible loss of all brain function, and conditions that may confound the clinical examination and diseases that may mimic BD/DNC should be excluded. Determination of BD/DNC can be done with a clinical examination that demonstrates coma, brainstem areflexia, and apnea. This is seen when (1) there is no evidence of arousal or awareness to maximal external stimulation, including noxious visual, auditory, and tactile stimulation; (2) pupils are fixed in a midsize or dilated position and are nonreactive to light; (3) corneal, oculocephalic, and oculovestibular reflexes are absent; (4) there is no facial movement to noxious stimulation; (5) the gag reflex is absent to bilateral posterior pharyngeal stimulation; (6) the cough reflex is absent to deep tracheal suctioning; (7) there is no brain-mediated motor response to noxious stimulation of the limbs; and (8) spontaneous respirations are not observed when apnea test targets reach pH <7.30 and Paco2 ≥60 mm Hg. If the clinical examination cannot be completed, ancillary testing may be considered with blood flow studies or electrophysiologic testing. Special consideration is needed for children, for persons receiving extracorporeal membrane oxygenation, and for those receiving therapeutic hypothermia, as well as for factors such as religious, societal, and cultural perspectives; legal requirements; and resource availability. Conclusions and Relevance: This report provides recommendations for the minimum clinical standards for determination of brain death/death by neurologic criteria in adults and children with clear guidance for various clinical circumstances. The recommendations have widespread international society endorsement and can serve to guide professional societies and countries in the revision or development of protocols and procedures for determination of brain death/death by neurologic criteria, leading to greater consistency within and between countries.
- MeSH
- apnoe diagnóza MeSH
- biomedicínský výzkum MeSH
- diferenciální diagnóza MeSH
- kóma diagnóza MeSH
- lidé MeSH
- mozková smrt diagnóza patofyziologie MeSH
- mozkový kmen patofyziologie MeSH
- nervový systém - fyziologické jevy * MeSH
- Check Tag
- lidé MeSH
- Publikační typ
- časopisecké články MeSH
- konsensus - konference MeSH
- směrnice pro lékařskou praxi MeSH
CMAJ, ISSN 0820-3946 vol. 174, no. 6, suppl, 2006
30 s. : tab. ; 28 cm
- MeSH
- dárci tkání MeSH
- management péče o pacienta MeSH
- mozková smrt klasifikace MeSH
- poranění mozku MeSH
- směrnice pro lékařskou praxi jako téma MeSH
- Publikační typ
- směrnice MeSH
- Geografické názvy
- Kanada MeSH
- Konspekt
- Patologie. Klinická medicína
- NLK Obory
- neurologie
