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1.
Emerg Med Clin North Am ; 39(1): 217-225, 2021 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-33218659

RESUMO

The emergency department is where the patient and potential ethical challenges are first encountered. Patients with acute neurologic illness introduce a unique set of dilemmas related to the pressure for ultra-early prognosis in the wake of rapidly advancing treatments. Many with neurologic injury are unable to provide autonomous consent, further complicating the picture, potentially asking uncertain surrogates to make quick decisions that may result in significant disability. The emergency department physician must take these ethical quandaries into account to provide standard of care treatment.


Assuntos
Lesões Encefálicas Traumáticas/terapia , Assistência Terminal/ética , Manuseio das Vias Aéreas/ética , Manuseio das Vias Aéreas/métodos , Beneficência , Morte Encefálica/diagnóstico , Lesões Encefálicas Traumáticas/diagnóstico , Serviço Hospitalar de Emergência/ética , Procedimentos Endovasculares/ética , Ética Médica , Humanos , Consentimento Livre e Esclarecido/ética , Prognóstico , Acidente Vascular Cerebral/terapia , Obtenção de Tecidos e Órgãos/ética
4.
Artigo em Alemão | MEDLINE | ID: mdl-33180159

RESUMO

In academic and public debate, the meaning of irreversible loss of brain function as a reliable sign of death (brain death criterion) is repeatedly challenged. In the present article, six prototypical theses against the brain death criterion are discussed: 1) the nonsuperiority of brain versus other organs, 2) the unreliability of brain death diagnostics, 3) the preserved perception of pain in brain death, 4) the (spontaneous) sexual maturation and preserved reproductive function in brain death, 5) the symmetry of brain death and embryonic stage, and 6) the equalization of an artificially respired brain-dead body and a living human being.None of these theses withstand critical analysis. In Germany, the whole-brain death criterion is applied. Brain death involves the complete loss of all sensation, consciousness, as well as facial, ocular, lingual and pharyngeal motor, voluntary motor, and sexual function (functional "decapitation"). Other organs or their basic control can be replaced artificially, but not the brain. The brain, not the remaining body, is determinant of the human individual. The equalization of an artificially respired brain-dead organism, that may be considered as a living system from a natural philosophy point of view, and the organism of the same living human being leads, through reducibility of constituting organs, to an obvious absurdity. The irreversible loss of brain function results inevitably in cardiac arrest, spontaneously within minutes, with intensive care usually within days. In the embryo/fetus, malformation of the complete brain also results in (prenatal) death. The statutory guideline of the German Medical Association for the determination of brain death has, by comparison, high diagnostic reliability; no confirmed misdiagnoses have occurred.


Assuntos
Morte Encefálica , Obtenção de Tecidos e Órgãos , Morte Encefálica/diagnóstico , Cuidados Críticos , Morte , Alemanha , Humanos , Reprodutibilidade dos Testes
5.
J Cardiothorac Surg ; 15(1): 295, 2020 Oct 02.
Artigo em Inglês | MEDLINE | ID: mdl-33008478

RESUMO

BACKGROUND: Veno-arterial extracorporeal membrane oxygenation (ECMO) is increasingly being utilized in patients with massive pulmonary embolism (PE). However, the efficacy and the safety remain uncertain. This study aimed to investigate clinical courses and outcomes in ECMO-treated patients with acute PE. METHODS: Twenty-one patients with acute PE rescued by ECMO from January 2012 to December 2019 were retrospectively analysed. Clinical features, laboratory biomarkers, and imaging findings of these patients were reviewed, and the relationship with immediate outcome and clinical course was investigated. RESULTS: Sixteen patients (76.2%) experienced refractory circulatory collapse requiring cardiopulmonary resuscitation (CPR) or ECMO support within 2 h after the onset of cardiogenic shock, and none could receive definitive reperfusion therapy before ECMO initiation. Before or during ECMO support, more than 90% of patients had imaging signs of right ventricular (RV) dysfunction. In normotension patients, the computed tomography (CT) value was a valuable predictor of rapid disease progression compared with cardiac troponin I level. Ultimately, in-hospital death occurred in ten patients (47.6%) and 90% of them died of prolonged CPR-related brain death. Cardiac arrest was a significant predictor of poor prognosis (p = 0.001). CONCLUSIONS: ECMO appears to be a safe and effective circulatory support in patients with massive PE. Close monitoring in intensive care unit is recommended in patients with RV dysfunction and aggressive use of ECMO may reduce the risk of sudden cardiac arrest and improve clinical outcome.


Assuntos
Oxigenação por Membrana Extracorpórea , Embolia Pulmonar/terapia , Doença Aguda , Adulto , Idoso , Idoso de 80 Anos ou mais , Morte Encefálica , Reanimação Cardiopulmonar , Feminino , Parada Cardíaca/etiologia , Parada Cardíaca/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Embolia Pulmonar/complicações , Reperfusão , Estudos Retrospectivos , Choque Cardiogênico/terapia , Tomografia Computadorizada por Raios X , Disfunção Ventricular Direita/etiologia
6.
Rev Assoc Med Bras (1992) ; 66(9): 1264-1269, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33027456

RESUMO

OBJECTIVE: To analyze the spontaneous knowledge of medical students about organ donation. METHODS: 518 students of a medical school in Sao Paulo city, from the first-year to internship, answered an objective questionnaire applied through electronic media to assess their spontaneous theoretical knowledge and organ donation awareness. RESULTS: Organs that can be donated after brain death, such as the cornea, kidneys, heart, liver, and lung were mentioned by the students. Regarding in-life transplantation, they answered it was possible to donate mainly the kidney (91.3%), part of the liver (81.1%), and bone marrow (79.7%). Although it was not expressive, we also noted that their knowledge gradually increased as they reached the end of the course. CONCLUSIONS: Medical students knowledge on organ donation in life and after death was a little superior to 60%. The students had limited exposure to this subject during the course (<40% of them before the internship). The authors suggest that students should be more exposed to the theme of "organ donation" in the medical curriculum.


Assuntos
Transplante de Órgãos , Estudantes de Medicina , Obtenção de Tecidos e Órgãos , Morte Encefálica , Conhecimentos, Atitudes e Prática em Saúde , Humanos
7.
Einstein (Sao Paulo) ; 18: eAO5448, 2020.
Artigo em Inglês, Português | MEDLINE | ID: mdl-32965298

RESUMO

OBJECTIVE: To characterize the processes of brain death diagnosis and organ donation in a reference trauma center. METHODS: Observational and cross-sectional study with patients notified with brain death at a reference trauma center. Data were obtained through the collection of medical records and brain death declaration forms. RESULTS: One hundred fity-nine patients were notified with brain death, mostly male (82.6%), young adults (97.61%) and victims of brain traumatic injury (93.7%). Median of the total time interval for the diagnosis of brain death was 20.75 hours, with no difference between organ donors and non-donors. We had excessive time intervals on brain death declaration, but without statistical effect on organ donation numbers. CONCLUSION: We had low efficacy in brain death declaration based on longer time intervals, with no impact on organ donation.


Assuntos
Morte Encefálica , Transplante de Órgãos , Obtenção de Tecidos e Órgãos , Estudos Transversais , Humanos , Masculino , Estudos Retrospectivos , Doadores de Tecidos , Centros de Traumatologia , Adulto Jovem
8.
J Card Surg ; 35(10): 2814-2816, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32939787

RESUMO

OBJETIVES: ECMO is progressively being adopted as a last resort to stabilize patients receiving cardiopulmonary resuscitation (ECMO CPR). A significant number of these patients will present recovery of end-organ function, but evolve with brain death, accounting for only 30% of patients discharged from the hospital alive. Harvesting organs from donors on VA ECMO has recently been proposed as a strategy to expand the pool of available organs for transplantation. METHODS: We present a case of combined heart and kidney transplantation from a brain death donor with recent out of hospital cardiac arrest rescued with eCPR. RESULTS: A 31 year old male patient was admitted to local hospital with diagnosis of drowning after seizure episode. Patient received two rounds of CPR for 8 and 30 minutes respectively, and required emergency insertion of VA ECMO. Patient developed compartment syndrome of right lower extremity (RLE) with CPK = 30,720, prompting discontinuation of ECMO support within 48 hours as cardiac function had recovered, reflected on echocardiographic and enzymatic parameters. Patient was declared brain death and became organ donor. Multiple organ procurement was performed. Combined heart and right kidney transplant was then performed on a 61-year-old male with uneventful course, and with normal function of all implanted allografts at 3 months follow up. CONCLUSION: Our experience supports the concept that VA ECMO is not a contraindication for solid organ donation. Individual evaluation of organ function can lead to successful transplantation of multiple organs from donors with recent history of VA ECMO support.


Assuntos
Morte Encefálica , Reanimação Cardiopulmonar/métodos , Afogamento , Oxigenação por Membrana Extracorpórea/métodos , Transplante de Coração/métodos , Transplante de Rim/métodos , Doadores de Tecidos , Coleta de Tecidos e Órgãos/métodos , Obtenção de Tecidos e Órgãos/métodos , Adulto , Síndromes Compartimentais , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento
11.
Pediatrics ; 146(3)2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32868469
12.
JAMA ; 324(11): 1116, 2020 09 15.
Artigo em Inglês | MEDLINE | ID: mdl-32930760
13.
Pediatrics ; 146(Suppl 1): S75-S80, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32737237

RESUMO

Death is defined biologically as the irreversible loss of the functioning of the organism as a whole, which typically occurs after the loss of cardiorespiratory function. In 1968, a Harvard committee proposed that death could also be defined neurologically as the irreversible loss of brain function. Brain death has been considered to be equivalent to cardiorespiratory arrest on the basis of the belief that the brain is required to maintain functioning of the organism as a whole and that without the brain, cardiorespiratory arrest and biological death are both rapid and certain. Over the past 20 years, however, this equivalence has been shown to be false on the basis of numerous cases of patients correctly diagnosed as brain-dead who nevertheless continued to survive for many years. The issue reached national attention with the case of Jahi McMath, a young woman diagnosed as brain-dead after a surgical accident, who survived for almost 5 years, mostly at home, supported with a ventilator and tube feedings. The fact that brain death is not biological death has many implications, notably including the concern that procurement of organs from brain-dead donors may not comply with the so-called dead donor rule, which requires that vital organs be procured from patients only after they are dead. In this article, I conclude with an analysis of options for moving forward and among them advocate for reframing brain death as a "social construct," with implicit societal acceptance that patients diagnosed as brain-dead may be treated legally and ethically the same as if they were biologically dead.


Assuntos
Morte Encefálica , Morte , Parada Cardíaca , Adolescente , Atitude Frente a Morte , Morte Encefálica/diagnóstico , Morte Encefálica/legislação & jurisprudência , Morte Encefálica/fisiopatologia , Feminino , Parada Cardíaca/diagnóstico , Parada Cardíaca/etiologia , Parada Cardíaca/fisiopatologia , História do Século XXI , Humanos , Neuroimagem/métodos , Neurologia/normas , Hemorragia Pós-Operatória/complicações , Guias de Prática Clínica como Assunto , Respiração Artificial , Sobrevivência , Fatores de Tempo , Inconsciência , Estados Unidos
14.
Pediatrics ; 146(Suppl 1): S81-S85, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32737238

RESUMO

Jahi McMath's story has been an important reference in medicine and ethics as the landscape of the understanding of death by neurologic criteria is shifting, with families actively questioning the once-firm criterion. Palliative care providers have a role in seeking understanding and collaborating with families and clinical teams to navigate the many challenges that arise when a medical team has determined that a child has died, and their parents disagree. In this case-based narrative discussion we consider the complexity of the family experience of brain death.


Assuntos
Morte Encefálica/diagnóstico , Família , Cuidados Paliativos , Religião e Medicina , Adolescente , Cura pela Fé/psicologia , Feminino , História do Século XXI , Humanos , Comportamento Materno , Exame Neurológico , Relações Profissional-Família , Prognóstico
15.
J Stroke Cerebrovasc Dis ; 29(9): 104913, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32807410

RESUMO

Introduction and Case Presentation: Brain death can be associated with limb movements that are attributed to spinal reflexes. Although head/face movements have been rarely reported, no case of overt eye movements in brain death has been documented. We report a case of a patient with subtle eye movements whose exam was otherwise consistent with brain death. The presence of eye movements delayed pronouncing the patient as brain dead and delayed organ donation. We agree with American Academy of Neurology Position statement from 2019 that brain death does not mean demise of every neuron. Discussion: This case raises important questions about the types of movements that should be "allowed" during the determination of brain death to avoid delays in diagnosis.


Assuntos
Morte Encefálica/fisiopatologia , Morte Súbita Cardíaca/etiologia , Movimentos Oculares , Morte Encefálica/diagnóstico , Diagnóstico Tardio , Humanos , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Fatores de Tempo , Doadores de Tecidos , Coleta de Tecidos e Órgãos
16.
Clin Nucl Med ; 45(10): e433-e434, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32804770

RESUMO

Brain death is the complete, irreversible cessation of brain function, including the capacity for brainstem, respiratory, and vegetative activities. It is a clinical diagnosis that can be supplemented with brain perfusion imaging. Absent cerebral blood flow can be visualized with CT angiography or perfusion scintigraphy. F-FDG PET/CT, visualizing glucose uptake, is another approach that has been shown to indicate brain death in small case series. We here present a case with unsuspected absent F-FDG uptake and thus no metabolic activity, in the brain. The patient was declared brain dead later the same day.


Assuntos
Morte Encefálica/diagnóstico por imagem , Morte Encefálica/metabolismo , Encéfalo/diagnóstico por imagem , Encéfalo/metabolismo , Fluordesoxiglucose F18/metabolismo , Tomografia Computadorizada com Tomografia por Emissão de Pósitrons , Transporte Biológico , Humanos
18.
JAMA ; 324(11): 1078-1097, 2020 Sep 15.
Artigo em Inglês | MEDLINE | ID: mdl-32761206

RESUMO

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.


Assuntos
Apneia/diagnóstico , Morte Encefálica/diagnóstico , Coma/diagnóstico , Fenômenos Fisiológicos do Sistema Nervoso , Pesquisa Biomédica , Morte Encefálica/fisiopatologia , Tronco Encefálico/fisiopatologia , Diagnóstico Diferencial , Humanos
20.
Pediatr Crit Care Med ; 21(8): 782-783, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32769948
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