Department of Neurology, Neuroscience Critical Care, Emory University School of Medicine, Atlanta, GA, USA.
Crit Care Med. 2011 Jun;39(6):1538-42. doi: 10.1097/CCM.0b013e3182186687.
To describe a patient with transient reversal of findings of brain death after cardiopulmonary arrest and attempted therapeutic hypothermia.
Case report.
Intensive care unit of an academic tertiary care hospital.
A 55-yr-old man presented with cardiac arrest preceded by respiratory arrest. Cardiopulmonary resuscitation was performed, spontaneous perfusion restored, and therapeutic hypothermia was attempted for neural protection. After rewarming to 36.5°C, neurologic examination showed no eye opening or response to pain, spontaneous myoclonic movements, sluggishly reactive pupils, absent corneal reflexes, and intact gag and spontaneous respirations. Over 24 hrs, remaining cranial nerve function was lost. The neurologic examination was consistent with brain death. Apnea test and repeat clinical examination after a duration of 6 hrs confirmed brain death. Death was pronounced and the family consented to organ donation. Twenty-four hrs after brain death pronouncement, on arrival to the operating room for organ procurement, the patient was found to have regained corneal reflexes, cough reflex, and spontaneous respirations. The care team faced the challenge of offering an adequate explanation to the patient's family and other healthcare professionals involved.
Induced hypothermia and brain death determination.
This represents the first published report in an adult patient of reversal of a diagnosis of brain death made in full adherence to American Academy of Neurology guidelines. Although the reversal was transient and did not impact the patient's prognosis, it impacted his eligibility for organ donation and cast doubt about the ability to determine irreversibility of brain death findings in patients treated with hypothermia after cardiac arrest.
We strongly recommend caution in the determination of brain death after cardiac arrest when induced hypothermia is used. Confirmatory testing should be considered and a minimum observation period after rewarming before brain death testing ensues should be established.
描述 1 例心肺复苏后及尝试低温治疗后出现脑死亡表现短暂逆转的患者。
病例报告。
学术性三级医院重症监护病房。
1 例 55 岁男性，因呼吸心跳骤停就诊，心肺复苏后自主循环恢复，为神经保护尝试低温治疗。复温至 36.5°C 后，神经系统检查发现患者无睁眼或疼痛反应，自发肌阵挛，瞳孔反应迟钝，角膜反射消失，咽反射和自主呼吸正常。24 小时后，其他颅神经功能丧失。神经系统检查符合脑死亡表现。随后进行的窒息试验和持续 6 小时后的重复临床检查均证实脑死亡。宣告患者死亡后，其家属同意进行器官捐献。脑死亡宣告后 24 小时，在到达手术室进行器官获取时，患者出现了角膜反射、咳嗽反射和自主呼吸恢复。这给患者的家属和其他参与的医护人员解释造成了困难。
诱导性低温和脑死亡判断。
这是首例在完全遵循美国神经病学学会指南的情况下，报告成人患者脑死亡诊断逆转的病例。尽管逆转是短暂的，并未影响患者预后，但它影响了患者接受器官捐献的资格，并对低温治疗后心跳骤停患者脑死亡发现的不可逆转性判断能力产生了怀疑。
我们强烈建议在使用诱导性低温治疗后判断心跳骤停患者的脑死亡时应保持谨慎。应考虑进行确认性检查，并在进行脑死亡检测前建立复温后至少观察一段时间的标准。
