Brain Death Diagnosis for Potential Organ Donors During the Covid-19 Pandemic.

Formal brainstem reflex testing remains one of the most important procedures in identification and evaluation of patients who meet clinical criteria for brainstem death. Early identification of such patients is critical since willing donors may contribute to the organ donation process. During the first two waves of the coronavirus disease of 2019 (COVID-19) pandemic, organ transplantation from brainstem dead donors has declined significantly due to several reasons, including perceived increased risk of virus transmission to both physicians as well as patients as well as lack of awareness regarding donor workup in the context of the COVID-19 pandemic.

Challenges in Brain Death Determination and Apnea Testing for Patients with COVID-19.

INTRODUCTION: Apnea testing remains essential for the clinical evaluation of brain death determination. In patients who test positive for SARS-CoV-2, disconnecting the patient from the ventilator and introducing high flow oxygen into the endotracheal tube increases the risk for aerosolization of airway secretions and exposure of the examiner. METHODS: Case report of a patient with an intracerebral hemorrhage that evolved to significant cerebral edema and herniation, who underwent apnea test using a method involving a t-piece and an HME filter. RESULTS: Patient successfully pronounced brain dead using a safe method to minimize exposure to SARS-CoV-2. CONCLUSION: At a time where healthcare workers are at high risk of exposure to COVID-19, the above described method is a safe process for apnea testing in declaration of brain death.

Special considerations in the assessment of catastrophic brain injury and determination of brain death in patients with SARS-CoV-2.

INTRODUCTION: The coronavirus disease 2019 (Covid-19) pandemic has led to challenges in provision of care, clinical assessment and communication with families. The unique considerations associated with evaluation of catastrophic brain injury and death by neurologic criteria in patients with Covid-19 infection have not been examined. METHODS: We describe the evaluation of six patients hospitalized at a health network in New York City in April 2020 who had Covid-19, were comatose and had absent brainstem reflexes. RESULTS: Four males and two females with a median age of 58.5 (IQR 47-68) were evaluated for catastrophic brain injury due to stroke and/or global anoxic injury at a median of 14 days (IQR 13-18) after admission for acute respiratory failure due to Covid-19. All patients had hypotension requiring vasopressors and had been treated with sedative/narcotic drips for ventilator dyssynchrony. Among these patients, 5 had received paralytics. Apnea testing was performed for 1 patient due to the decision to withdraw treatment (n = 2), concern for inability to tolerate testing (n = 2) and observation of spontaneous respirations (n = 1). The apnea test was aborted due to hypoxia and hypotension. After ancillary testing, death was declared in three patients based on neurologic criteria and in three patients based on cardiopulmonary criteria (after withdrawal of support (n = 2) or cardiopulmonary arrest (n = 1)). A family member was able to visit 5/6 patients prior to cardiopulmonary arrest/discontinuation of organ support. CONCLUSION: It is feasible to evaluate patients with catastrophic brain injury and declare brain death despite the Covid-19 pandemic, but this requires unique considerations.

Brain death evaluation during the pandemic.

Coronavirus disease 2019 (COVID-19) may pose unique challenges to clinicians attempting to diagnose brain death in patients infected with the SARS-CoV-2. Among these challenges is the risk of aerosol generation during the traditional apnea testing using the insufflation technique in addition to the risk of complications due to SARS-CoV-2-related lung disease. In this article, we discuss these challenges and provide further guidance to minimize such risks to ensure safety of healthcare professionals and other patients. We also emphasize the importance of maintaining the standards of brain death determination in this critical time.