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232747_NCS Currents_December_2_eMag

INTERNATIONAL NEUROCRITICAL CARE Implementation of the New Guideline for the Determination of Brain Death in Germany By Katja Wartenberg, MD Following a recommendation of the However, the requirements for the qualifi cation of physicians raise scientifi c forum, the German Medical Board the threshold for all non-academic and smaller hospitals to be (Bundesärztekammer) approved a new able to diagnose patients with irreversible loss of brain function, regulation for the determination of death especially during off-hours and weekends. The German Organ and of the fi nal, irreversible loss of cortical, Donation Organization provides a registry of at least one qualifi ed brain stem, and cerebellar function on physician, usually board-certifi ed in Neurology and Neurocritical March 30, 2015. Care, per state who can be contacted to evaluate patients in hospitals without a qualifi ed physician. The most important and impacting Now a second qualifi ed physician is required. Other questions changes include: • The term “brain death” is replaced by irreversible loss of cerebral function. • The determination of irreversible loss of cerebral function can only be executed by two board certifi ed physicians with experience in management of intensive care patients with acute severe brain injury. At least one physician has to be board certifi ed in Neurology or Neurosurgery, for patients be able to diagnose, execute, and interpret the results of the applied additional diagnostic tools. • The approved additional diagnostic tools include EEG, auditory and somatosensory evoked potentials, transcranial Doppler ultrasonography, SPECT, CT angiography, or cerebral angiography. All assessments of cerebral blood fl ow require a mean arterial pressure (MAP) of greater than 60 mm Hg and are: When is someone qualifi ed? How many determinations of two examinations after a time interval of 30 minutes. irreversible loss of brain function are necessary and should be documented to consider someone qualifi ed enough? Should the • The hospitals that employ qualifying physicians for the training be part of the residency in Neurology and Neurosurgery determination of irreversible loss of brain function are or the fellowship in Neurocritical Care? How do we provide required to provide quality assurance in a standard operating quality control outside of centers with neurocritical care providers? procedure and to participate in quality control registries. • The clinical examination includes the confi rmation of The German societies for Neurology (DGN) and unresponsiveness, dilated and fi xed pupils, bilateral loss NeuroIntensive Care and Emergency Medicine (DGNI) are of the oculocephalic or vestibuloocular refl exes, bilateral currently working on a curriculum including e-learning, loss of corneal refl exes, loss of reactions/refl exes to painful courses, and stimuli in the supply area of the trigeminal nerve and in training offered other areas, loss of the pharyngeal and tracheal refl exes as during the well as loss of respiratory function. If all those items cannot yearly meetings be evaluated during clinical examination, an additional and during diagnostic tool is applied. neurocritical care workshops such • The apnea test requires a baseline pCO2 of 35-45 mmHg as the IGNITE (4.7-6 kPa) measured with temperature correction. summer school. • The protocol for documentation of irreversible loss of brain function has extended and now encompasses documentation of the qualifi cation of the examining physician through the respective board certifi cation and experience. CT angiography is now approved as a diagnostic test to document the absence of cerebral circulation which is easier to obtain than a SPECT scan. 19


232747_NCS Currents_December_2_eMag
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