Comparison of 1 vs 2 Brain Death Examinations on Time to Death Pronouncement and Organ Donation: A 12-year Single Center Experience

OBJECTIVE: To fill the evidence gap on the value of a single (SBD) or dual brain death (DBD) exam by providing data on irreversibility of brain function, organ donation consent and transplantation. METHODS: 12-year tertiary hospital and organ procurement organization data on brain death (BD) were combined and outcomes, including consent rate for organ donation and organs recovered and transplanted after SBD and DBD were compared after multiple adjustments for co-variates. RESULTS: two-hundred sixty-six patients were declared BD, 122 after SBD and 144 after DBD. Time from event to BD declaration was longer by an average of 20.9 hours after DBD (p=0.003). Seventy-five (73%) families of patients with SBD and 86 (72%) with DBD consented for organ donation (p=0.79). The number of BD exams was not a predictor for consent. No patient regained brain function during the periods following BD. Patients with SBD were more likely to have at least one lung transplanted (p = 0.033). The number of organs transplanted was associated with the number of exams [beta coefficient, (95% CI) -0.5 (-0.97 to -0.02), p=0.044], along with age (for 5 year increase, -0.36 (-0.43 to -0.29), p\u3c0.001) and PaO2 level (for 10 mmHg increase, 0.026 (0.008 to 0.044), p=0.005) and decreased as the elapsed time to BD declaration increased (p=0.019). CONCLUSIONS: A single neurologic examination to determine brain death is sufficient in patients with non-anoxic catastrophic brain injuries. A second examination is without additional yield in this group and its delay reduces the number of organs transplanted

Snake bite mimicking brain death

A 6 year old girl woke up with pain and increasing swelling over the left hand and difficulty in breathing. On examination, she had swelling of the left forearm and hand, flaccid quadriparesis and was in respiratory failure requiring mechanical ventilation. Two clean puncture wounds were identified on the left thumb. A provisional diagnosis of snake bite with severe envenomation was made and she was given anti snake venom therapy. Over a period of about 4 hours her weakness progressed. She became areflexic, developed internal and external ophthalmoplegia and loss of other brain stem reflexes mimicking brain death. Mechanical ventilation was continued despite features suggestive of brain stem dysfunction. About 36 hours after ventilation she showed a flicker of movement of her fingers and gradually the power improved. She was weaned off the ventilator and extubated after 5 days. External ophthalmoplegia is an established association with cobra envenomation, but, this combination of internal and external ophthalmoplegia can mimic brain death and pose a dilemma to the caregivers regarding continuation of therapy

Cefepime neurotoxicity in the intensive care unit: a cause of severe, underappreciated encephalopathy

INTRODUCTION: Cefepime, a broad spectrum antibiotic, is commonly prescribed in intensive care units (ICU) and may be an overlooked cause of neurologic symptoms such as encephalopathy, myoclonus, seizures, and coma. We aimed to characterize cefepime neurotoxicity in the ICU. METHODS: We performed a retrospective study of adult ICU patients treated with intravenous cefepime for at least 3 days between January 1, 2009 and December 31, 2011. The primary outcome was the development of cefepime neurotoxicity, with the likelihood of causality ascribed via a modified Delphi method. RESULTS: This study included 100 patients. The mean age was 65.8 years (± 12.7 years). The median daily average dose of cefepime was 2.5 (IQR 2.0 to 3.5) grams. The median treatment duration was 6 (IQR 4 to 10) days. Renal failure in any form was present in 84 patients. Chronic kidney disease affected 40 patients, and 77 had acute kidney injury. Cefepime neurotoxicity occurred in 15 patients. Of these, seven were considered definite cases, three probable, and five possible. Neurotoxic symptoms included impaired consciousness (n = 13), myoclonus (n = 11), disorientation (n = 6), and nonconvulsive status epilepticus (n = 1). The dose of cefepime was appropriately adjusted for renal clearance in 64 patients (75.3%) without cefepime neurotoxicity and four patients (28.6%) with neurotoxicity (P = 0.001). Chronic kidney disease was present in 30 patients (35.3%) without neurotoxicity and in 10 (66.7%) of those with neurotoxicity (P = 0.04). CONCLUSIONS: Critically ill patients with chronic kidney disease are particularly susceptible to cefepime neurotoxicity. Myoclonus and impaired consciousness are the predominant clinical manifestations. Neurotoxic symptoms occur more often when the cefepime dose is not adjusted for renal function, but can still occur despite those modifications