1. Brain-stem death testing audit Dr Paul Murphy National Clinical Lead for Organ Donation 1

2. Background Challenges to neurological determination of death by organ retrieval teams –P a CO 2 prior to disconnection –interval between apnoea tests –serum Na Disruptive –Delays in retrieval –? loss of cardiothoracic organs –Loss of goodwill

3. NORS standards for Organ Retrieval

4. Background Challenges to neurological determination of death by organ retrieval teams –P a CO 2 prior to disconnection –interval between apnoea tests –serum Na Disruptive –Delays in retrieval –? loss of cardiothoracic organs –Loss of goodwill

6. Apnoea test (AoMRC 2008) The apnoea test should be the last brain-stem reflex to be tested and should not be performed if any of the preceding tests confirm the presence of brain-stem reflexes New guidance –Eliminate the risk of the development of significant hypoxia –Minimise the risk of the development of excessive hypercarbia and/or rapid changes in carbon dioxide tension –Minimise the development of changes in mean arterial pressure and as a result, minimise the risk of further injury to potentially recoverable brain tissue, in case death of the brain-stem has not actually occurred.

7. Apnoea test (AoMRC 2008) Increase the patient’s FiO2 to 1.0 –Check arterial blood gases to confirm that the measured PaCO2 and SaO2 correlate with the monitored values With SaO 2 > 95%, reduce MV to allow a slow rise in E T CO 2 Once E T CO 2 > 6.0 kPa, check ABG to confirm P a CO 2 ≥ 6.0kPa and pH < 7.40 If cardiovascular stability is maintained, disconnect from ventilator and apply O 2 via an endotracheal catheter; observe for five minutes If, after five minutes, there has been no spontaneous respiratory response, a presumption of no respiratory centre activity will be documented. Confirm that P 2 CO 2 has increased by more than 0.5KPa

8. Apnoea test (AoMRC 2008) The aim should be to ensure that this, and not a substantially greater, degree of hypercarbia and acidaemia is achieved for those with no previous history of respiratory disease or bicarbonate administration –The aim should also be to ensure that the respiratory centre is exposed to an adequate respiratory acidosis for a minimum of 5 minutes The diagnosis of death by brain-stem testing should be made by at least two medical practitioners. –Testing should be undertaken by the nominated doctors acting together and must always be performed on two occasions. –A complete set of tests should be performed on each occasion, i.e., a total of two sets of tests will be performed.

9. Audit of BSD apnoea testing retrospective audit of DBD donor care files Jan-Mar 2015 –All 12 ODT teams, –n = 185 Data fields –Blood gas data relating to apnoea tests where available –Nature of form used to record NDD Analysis –PM / DG / AM

10. Availability of data OD teamComplete acid-base data South East 17/17 Northern Ireland 0/11 South West 7/9 Eastern 8/20 North West 19/22 South Central 14/15 London 14/20 Yorkshire 7/22 Northern 10/10 South Wales 8/10 Scotland 11/11 Midlands 7/18

11. Deviation from Academy guidance OD teamComplete acid- base data Deviation from AoMRC Significant concern South East 17/17 3/171/17 Northern Ireland 0/11 7/111/11 South West 7/9 1/90/9 Eastern 8/20 3/20 North West 19.22 5/221/22 South Central 14/15 1/150/15 London 14/20 5/202/20 Yorkshire 7/22 4/221/22 Northern 10/10 1/100/10 South Wales 8/10 2/100/10 Scotland 11/11 Midlands 7/18 5/182/18 Total 42/1749/174

12. Significant concern, all regions pre-disconnectionend of apnoea testpre-disconnectionend of apnoea test 6.110.15.36.7 46.969.6 5.28.44.87.6 4.578.144.737.79 4.16.865.277.04 4.56.55.67.02 4.397.155.057.42 + 2 cases of single apnoea tests

14. http://www.ics.ac.uk/ics-homepage/guidelines-and-standards/

17. NDD forms – UK summary

18. NDD forms – regional usage

19. NDD forms – available acid-base status Deviation from AoMRC Significant concern 3/171/17 7/111/11 1/90/9 8/203/20 5/221/22 1/150/15 5/202/20 4/221/22 1/100/10 2/100/10 5/182/18 42/1749/174

20. Impact of form All non-compliance ICS / FICMAoMRCHospitale-form Compliant6512132 Non-compliant163145 Insufficient data515216 Total86304813 Non compliance: deviation from physiological ranges as per AoMRC guidance. Excludes Scotland.

21. Significant concern Type of form Apnoea test 1Apnoea test 2 beforeafterbeforeafter ICS / FICM6.110.15.36.7 ICS / FICM46.969.6 ICS / FICM5.28.44.87.6 Hosp4.578.144.737.79 Hosp4.16.865.277.04 e-form4.56.55.67.02 AoMRC4.397.155.057.42 Significant concern: < 5 minutes adequate respiratory acidosis. Excludes Scotland.

22. Scottish data

23. Summary Retrospective audit –Incomplete data –Selected group (consented DBD donors) Wide variation in documentation –Data collected by SN-ODs makes up for limitations of forms –Form now approved by ICS / FICM 5% of apnoea tests ‘significant concern’ –?? Single apnoea tests Impact of forms –No form ‘immune’ –bespoke and e-forms may be particularly problematic –ICS / FICM form improves auditability

24. Actions??

25. Recommendations from NODC Consistency –Nationwide adoption of the ICS / FICM form –Promoted through regional CLODs and Collaboratives Compliance –Simulation training for advanced ICM trainees –Best practice guidance on neurological determination of death, including AV guide