1. ACOT Meeting February 28, 2012 Circulatory Death Determination in Uncontrolled Organ Donors ACOT Meeting February 28, 2012 James L. Bernat, M.D. Louis and Ruth Frank Professor of Neuroscience Professor of Neurology and Medicine Dartmouth Medical School

2. Overview Foundational principlesFoundational principles Concepts of uncontrolled donation after the circulatory determination of death (uDCDD)Concepts of uncontrolled donation after the circulatory determination of death (uDCDD) Application of the foundational principles to uDCDDApplication of the foundational principles to uDCDD The relationship between cessation of systemic circulation and cessation of brain functionsThe relationship between cessation of systemic circulation and cessation of brain functions

3. Foundational Principles Why cessation of systemic circulation causes deathWhy cessation of systemic circulation causes death Permanent vs. irreversible cessation of circulatory functionPermanent vs. irreversible cessation of circulatory function Necessary conditions for permanent cessation of circulatory functionNecessary conditions for permanent cessation of circulatory function Interference by resuscitation technologiesInterference by resuscitation technologies Differences in death determination in organ donorsDifferences in death determination in organ donors

4. Concepts of uDCDD Four clinical circumstancesFour clinical circumstances Two studies failed to recruit donorsTwo studies failed to recruit donors Prior reports were consented BD or DCD donorsPrior reports were consented BD or DCD donors Hard to extrapolate European experience to the United StatesHard to extrapolate European experience to the United States

5. Applications of Principles to uDCDD UDCDD donor must have permanent cessation of circulationUDCDD donor must have permanent cessation of circulation Auto-resuscitation is an empirical questionAuto-resuscitation is an empirical question Permanent cessation of circulation is death because it destroys the brainPermanent cessation of circulation is death because it destroys the brain Reperfusion technologies can retroactively invalidate the death determination unless the brain is not perfusedReperfusion technologies can retroactively invalidate the death determination unless the brain is not perfused

6. Relationship between Circulation and Brain Function Circulatory-respiratory criterion of death is a hybrid of circulatory and brain functionsCirculatory-respiratory criterion of death is a hybrid of circulatory and brain functions Brain circulation stops when systemic circulation stopsBrain circulation stops when systemic circulation stops Cessation of breathing is tightly linked to cessation of circulation in the absence of resuscitationCessation of breathing is tightly linked to cessation of circulation in the absence of resuscitation TimelineTimeline

7. Time 1 T1T2T3T4T5T6 Event Circulation ceases clinically Brain functions cease clinically Circulation ceases permanently Brain functions cease permanently Circulation ceases irreversibly Brain functions cease irreversibly Prerequisite NoneNo brain circulation Auto-resuscitation impossible; CPR will not be performed 2 No brain circulation Auto-resuscitation impossible; CPR would be unsuccessful if attempted 2 No brain circulation or no brain function if brain circulation is restored Evidence No pulse or heartbeatUnresponsiveness Apnea Pupils, corneals, other brain stem reflexes absent Absent systolic wave forms by A-line; or no aortic valve opening on echocardiogram; electrical asystole is sufficient but not necessary Unresponsiveness Apnea Pupils, corneals, other brain stem reflexes absent Absent EEG activity Absent evoked potentials Same as T3 with electrical asystole “Brain death” tests fulfilled Circulatory Cessation to Death