Ancillary testing for Neurological Death Determination: A survey of Canadian Intensivists
CCCF ePoster library. Chassé M. Nov 7, 2018; 233347; 31
Dr. Michaël Chassé
Dr. Michaël Chassé
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Background: There is disagreement between physicians and wide variations in policy and practice across hospitals and countries regarding neurological death criteria. These include varying clinical criteria and indications for ancillary testing that may undermine public or professional understanding and trust toward neurological death determination(NDD)1–4. While most North American guidelines recommend ancillary testing only when NDD is impossible to confirm by clinical exam5, the specific indications for when to employ these tests are highly variable.

Objective: To investigate beliefs and attitudes of Canadian intensive care physicians toward their practices regarding deceased donation.

Methods: We conducted a cross-sectional survey of Canadian intensivists. We followed a standardized approach suggested for the design and conduct of self-administered survey of clinicians6. Our sampling frame included all intensivists that practice in an institution that provides care for potential organ donors. The intensivists were identified by merging lists obtained in collaboration with Canadian Blood Services, the Canadian Critical Care Society and manual searches from publicly available sources. The survey was administered using an online platform (Limesurvey) with two e-mail reminders. Survey responses are reported using descriptive statistics.

Results: A total of 550 intensive care physicians were identified from our combined lists. Twenty-one participants did not meet inclusion criteria and one participant declined consent, leaving 529 eligible participants. The response rate to the survey was 49.7% (263/529) and the completion rate 89.4% (235/263). Most respondents (85.6%) agreed or strongly agreed that an ancillary test should always be conducted when a complete clinical evaluation is impossible. A total of 45.7% agreed or strongly agreed that the use of ancillary tests helps families accept neurological death. The indication for use of an ancillary test was not affected by the primary cause of brain injury. A total of 70.8% believed that an ancillary test should always be conducted when the primary cause of brain injury was unclear and 88.9% when there was a possibility of residual effect of sedative. Respondents strongly agreed or agreed that currently recommended ancillary tests are useful for NDD including 85% for conventional 4-vessel angiography, 74% for nuclear imaging, and 65% for Angio-CT. CT-Perfusion was considered useful as an ancillary test by 55% of respondents. Depending on the exam, between 10% and 20% of respondents considered electroencephalogram, functional MRI, somato-sensory evoked potentials, or transcranial Doppler to be useful for NDD.

Conclusion: According to Canadian intensivists, ancillary testing is clinically useful in the context of NDD, and half believe these tests help families accept NDD. A majority of intensivists believe that the currently recommended ancillary tests are useful for NDD, including novel non-validated tests such as CT-Perfusion. A minority of intensivists did not consider ancillary tests to be mandatory, even in the presence of confounding factors or unknown brain injury. A significant proportion of respondents also considered several tests not currently recommended for NDD to be clinically useful. Given the perceived importance of ancillary tests for NDD by Canadian intensive care physicians, and their use in practice without appropriate validation, it is important to conduct rigorous studies to validate appropriate ancillary tests for NDD.

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